بسم الله الرحمن الرحيم

CHRONIC OTITIS MEDIA

Classification of Chronic Otitis Media Chronic Non Suppurative Otitis Media Otitis media with effusion “OME” Adhesive otitis media Chronic Suppurative Otitis Media “CSOM” Tubotympanic (Safe) Atticoantral (Unsafe)

OTITIS MEDIA WITH EFFUSION

DEFINITION Presence of non-purulent fluid within the middle ear cleft

SYNONYMS Secretory otitis media Middle ear effusion Sero-mucinous otitis media Catarrhal otitis media Glue ear Serous otitis media Non-suppurative otitis media

PREVALENCE Between 20% and 50% of children do have OME at some time between 3 and 10 years of age Two peaks at 2 and 5 years of age

RISK FACTORS Race Age Gender Season Nasopharyngeal anatomical abnormalities Cleft palate Smoking ? Allergy

HISTOPATHOLOGY Changes in the mucosa Vasodilatation & mononuclear cell infiltration Metaplasia of the epithelium to ciliated columnar Mucus secreting gland formation Formation of fluid in the middle ear Transudate Exudate Secretion

ETIOPATHOLOGY Eustachian tube dysfunction Chronic inflammation

ETIOLOGY Eustachian tube dysfunction Infections Poor muscular function Adenoids Barotrauma Others Infections Unresolved AOM Adenoiditis and other URTIs

SYMPTOMS Hearing impairment ± Otalgia Fluid sensation

Diagnosis

DIAGNOSIS

DIAGNOSIS Otoscopy Tuning fork tests

DIAGNOSIS Otoscopy Tuning fork tests PTA

DIAGNOSIS Otoscopy Tuning fork tests PTA Tympanometry

DIAGNOSIS Otoscopy Tuning fork tests PTA Tympanometry Myringotomy

TREATMENT Treatment of the cause if feasible Observation Medical treatment Antibiotics Decongestants, ?Auto-inflation ?Steroids Surgical Myringotomy Ventilation tubes (grommets)

COMPLICATIONS OF VENTILATION TUBES INSERTION Infection Blockage Extrusion Tympanosclerosis Perforation

Iatrogenic Cholesteatoma

FACTORS AFFECTING TREATMENT Age Duration Unilateral or bilateral Degree of hearing impairment Previous treatment Associated conditions Tympanic membrane changes Others

SEQUELAE Spontaneous resolution Tympanosclerosis 50% resolve within 3 months. Only 5% persists for more than 12 months Tympanosclerosis Scarring, retraction and atelectasis Cholesteatoma

Conclusion OME is very common in children Etiology is associated with ET dysfunction and or chronic infection In adults: Nasopharyngeal pathology should be considered Most cases resolve spontaneously Conservative treatment is of doubtful value VT insertion restore hearing in the selected cases

Classification of Chronic Otitis Media Chronic Non Suppurative Otitis Media Otitis media with effusion “OME” Adhesive otitis media Chronic Suppurative Otitis Media “CSOM” Tubo-tympanic (Safe) Attico-antral (Unsafe)

Chronic Adhesive Otitis Media Formation of adhesion in the middle ear after reactivation and subsequent healing of either CSOM or OME

Clinical Features History of CSOM or OME Deafness is usually the only symptoms TM shows various structural changes

Treatment Observation Surgical treatment Hearing aid

Classification of Chronic Otitis Media Chronic Non Suppurative Otitis Media Otitis media with effusion “OME” Adhesive otitis media Chronic Suppurative Otitis Media “CSOM” Tubo-tympanic (Safe) Attico-antral (Unsafe)

CHRONIC SUPPURATIVE OTITIS MEDIA

ETIOLOGY Environmental Genetic Previous OM Upper respiratory tract infections Eustachian tube dysfunction

CLINICO-PATHOLOGICAL TYPES Tubo-tympanic Attico-antral

PATHOLOGY Signs of suppurative infection Signs of healing attempts Discharge & perforation Chronic inflammatory reaction in the mucosa and the bone (ostietis) Signs of healing attempts Granulation tissue & polyps Fibrosis & tympanosclerosis Cholesteatoma (attico-antral type)

CHOLESTEATOMA

DEFINITION The presence of a desquamating stratified squamous epithelium in the middle ear

PATHOGENESIS OF CHOLESTEATOMA Implantation (congenital or acquired) Metaplasia Epithelial migration

CLASSIFICATION OF CHOLESTEATOMA Congenital Acquired Primary Secondary

Effect of Cholesteatoma Keratin encourages persistence of the infection Matrix causes bone erosion

Clinical Features of CSOM

CLINICO-PATHOLOGICAL TYPES Tubo-tympanic Attico-antral (cholesteatoma)

SYMPTOMS OF CSOM Otorrhea Deafness Tinnitus Intermittent, profuse & odorless in TT type Persistent, scanty & malodorous in AA type Deafness Tinnitus N.B. Any other symptom means complication

OTOSCOPIC EXAMINATION Discharge Present in TT type if active but may be absent Usually is present in AA type Perforation Central: in TT type Marginal or attic in AA type with cholesteatoma

PERFORATION IN TT CSOM

PERFORATION IN AA CSOM

OTOSCOPIC EXAMINATION Discharge Present in TT type if active but may be absent Usually is present in AA type Perforation Central: in TT type Marginal or attic in AA type with cholesteatoma Polyps, granulation tissue, tympanosclerosis

Bacteriology

INVESTIGATIONS Audiometry Bacteriology Imaging

Congenital Cholesteatoma

Cloudy middle ear in CSOM

Cholesteatoma with attic erosion

TREATMENT OF CHRONIC SUPPURATIVE OTITIS MEDIA Depends on the type and presentation

Active TT type Inactive TT type Attico-antral type (usually active)

Conservative Treatment Active TT type Inactive TT type Conservative Treatment Treat any predisposing factor Keep the ear dry Ear toilet Antibiotics Removal of polyps and granulations TYMPANOPLASTY

TYMPANOPLASTY An operation performed to eradicate disease in the middle ear cavity and to reconstruct the hearing mechanism

MYRINGOPLASTY An operation performed to repair the tympanic membrane

AIMS OF TYMPANOPLASTY To close the perforation To prevent re-infection To improve hearing

TREATMENT OF ATTICO-ANTRAL CSOM Removal of cholesteatoma by mastoid operation

RADICAL MASTOIDECTOMY An operation in which the mastoid antrum and air cells, attic and middle ear are converted into common cavity, exteriorized to the external canal. The tympanic membrane, malleus and incus are removed leaving only the stapes in situ.

MODIFIED RADICAL MASTOIDECTOMY An operation in which the mastoid antrum and air cells, attic and middle ear are converted into common cavity, exteriorized to the external canal. The tympanic membrane and ossicles remnants are retained

AIMS OF RADICAL & MODIFIED RADICAL MASTOIDECTOMY Safety Dry ear Preserve hearing

Conclusion In TT type the discharge is usually copious, intermittent and odorless. The perforation is central. Treatment is conservative (if there is active infection) followed by tympanoplasty to prevent re-infection and improve hearing. In the AA type the discharge is usually scanty, persistent and of bad odor. The perforation is attic or marginal with cholesteatoma. Treatment is by mastoidectomy to provide safety and dry ear

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