2. Hiroshima 1945

3. Chronic Suppurative Otitis Media (CSOM)
Persistent disease, insidious in onset manifested clinically as long standing painless aural discharge with deafness. It is grouped into two clinical types;
Tubotympanic (safe).
Atticoantral (dangerous) disease.

4. Tubotympanic Disease Benign.
Rarely gives rise to any serious complications.
Why it is called TUBOTYMPANIC ?
Because the persisting or recurring infection spread via the ET to the tympanic cavity

5. Aetiology
It is a complication of AOM where there is persisting perforation of the TM.
It therefore usually starts in infancy and early childhood.
Reinfection either through
the nasopharynx (tonsillitis, adenoid hypertrophy and sinusitis)
perforation allows active infection to persist or to recur.

6. Bacteriology gram negative (high incidence) proteus
pseudomonas aeroginosa.
Anaerobic

7. Pathology
Central perforation
Polyp

8. Clinical Picture
Mucoid or mucopurulent discharge …intermittent or persistent.
CHL

9. Examination Otoscopy: Central TM perforation in the pars tensa.
Tuning fork tests
CHL.

10. Investigations PTA: CHL.
X-ray and CT scan shows sclerosis with clouding of the mastoid air cells.
Swab of the aural discharge for c/s.

11. Treatment Elimination of URTI Medical Treatment Aural toilet
Local antibiotic /steroid drops
Systemic antibiotics
Surgical treatment
Removal of polyps and granulation tissue
Myringoplasty

12. Atticoantral Disease
The bone of the attic, mastoid antrum and air cells are involved as well as the mucosa of the middle ear cleft (therefore called atticoantral disease).
Erosion of bone may extend to adjacent vital structures danger of serious complications; both intra- and extracranial. This type of infection is usually associated with cholesteatoma.

13. Cholesteatoma It is a skin in Sac of keratinizing sq. epithelium
Surrounded by granulation tissue
The surface layers of epithelium keep producing keratin leading to thin-walled sac containing cheesy material.
The granulation tissue on the outside of the sac produces lysozymes and this gradually erodes the ossicles, ear drum and mastoid bone.
The suffix “oma” may suggest that it is a tumour, this is not the case, though if untreated it will continue to expand and destroy surrounding structure.
It is a skin in
wrong place

14. Theories of origin of cholesteatoma
1. Congenial:
This is unrelated to CSOM as it arises from embryonic epithelial tissue and occurs in the temporal bone and in the middle ear.
2. Acquired
Invagination theory
Emigration theory
Metaplasia theory:

15. Clinical picture of Atticoantral disease
Insidious onset.
Persistent or recurrent offensive purulent aural discharge
CHL
Bleeding from the ear
Headache, vertigo and facial paralysis/complication.

16. Examination
Otoscopy
Tuning fork test: CHL
Fistula sign

17. Investigations PTA: CHL.
X-ray and CT scan of mastoid; Cholesteatoma appears as an area of translucency with a clearly out lined bony margin.
Swab of the aural discharge for c/s.

19. Treatment Conservative:
no complications
cholesteatoma is small and accessible
removal of cholesteatoma and granulation tissue by fine crocodile forceps and suction clearance under magnification.
Surgical: In most cholesteatoma surgical treatment is required.

20. Primarily the objective of surgical treatment
Eradication of potentially dangerous disease by mastoidectomy.
Reconstruction of hearing mechanism

21. Complications of otitis media
(Infective process spreads beyond the confines of the middle ear).

22. Types of Complications
Extracranial
Mastoiditis.
Labyrinthitis
Petrositis
Facial nerve paralysis.
Intracranial
Extradural abscess.
Subdural abscess.
Lateral (sigmoid) sinus thrombosis.
Meningitis.
Brain abscess.
Otitic hydrocephalus.

24. Acute Mastoiditis
Acute infection of the mastoid antrum and air cells by virtue of the mucosal continuity between the middle ear cleft and mastoid process. The pus may break through the superficial cortex forming postauricular subperiosteal abscess.

25. Aetiology Complication of AOM
It can be superimposed on a chronic atticoantral disease in which the cholesteatoma has invaded the mastoid bone.

26. Clinical picture children > adults.
..looks ill with fever and tachycardia.
Earache aural discharge with relief of pain cessation of discharge and recurrence of pain with pyrexia.
If the disease continues uncontrolled the pus may break through the superficial cortex and forms postauricular abscess.

27. Examination Retroauricular swelling and tenderness (+fluctuation
if postauricular abscess forms)
Soft tissue oedema with displacement of the auricle downwards and outwards. The postauricular sulcus tends to be retained.
Narrowing of the EAM due to sagging of the posterosuperior meatal wall

28. Differential diagnosis Frunculosis /Infected sebaceous cyst.
Mastoiditis
Furuncle 1
Preceding history of OM
No such history 2
Deafness is present
No deafness until the canal is occluded 3
TM shows signs of OM
TM is normal 4
Tenderness on pressure over the mastoid
Tenderness on moving the auricle 5
Postauricular sulcus tends to remain
Postauricular sulcus tends to be obliterated with forward displacement. 6
Radiographic changes in mastoid
No radiographic changes in mastoid

29. Investigations
X-ray and CT scan shows opacity of the mastoid air cells.

30. Treatment Medical Admission to hospital
Antibiotic (in full dose): IV antibiotic according to c/s if there is discharge.
If not IV penicillin for 48 h ,followed by oral antibiotic for a week.
Surgical
Indications:
fluctuant area.
pyrexia and tenderness continue.
abscess drainage with or without cortical mastoidectomy - c/s -antibiotic for a week.

31. وآخر دعوانا أن الحمد لله رب العالمين
والسلام عليكم ورحمة الله وبركاته