1. Chronic otitis media İlhan TOPALOĞLU M.D Otolaryngology Department
Yeditepe University, School of Medicine

2. Definition
COM: unresolved inflammatory process of the middle ear and mastoid associated with TM perforation, otorrhea and hearing loss.

3. Etiology Unresolved middle ear infection
Dysfunction of Eustachian tube
Chronic inflammation in nose and pharynx
Dysfunction of immune system

4. Etiology Dysfunction of Eustachian tube
Chronic inflammation in nose and pharynx
Dysfunction of immune system

5. TYPES OF C.S.O.M.
Tubo tympanic s.o.m. Safe
Attico antral Unsafe

6. TYPES OF TUBO TYMPANIC C.S.O.M.
Active Tubo Tympanic C.S.O.M.
Inactive Tubo Tympanic C.S.O.M.

7. TUBO TYMPANIC C.S.O.M
Deafness
Discharge
Central perforation

8. TUBO TYMPANIC C.S.O.M Patency of Eustachian tube
Nidus of infection in U.R.T.I.
Immune status of patient
Aerobic and Anaerobic

9. ATTICO ANTRAL C.S.O.M. Cholesteatoma Keratinizing Squamous Epithelium.
A small sac
May involve whole middle ear cleft

10. Pathology
Middle ear mucosa is lined by secretory epithelium forming glandlike structure.
Hyalinization or tympanosclerosis
A healing response
It occurs during quiescent periods
It is formed by fused collagenous fibers
It is hardened by the deposition of calcium and phosphate crystals
Conductive hearing loss is associated with masses restricting ossicular mobility

11. Pathology Ossicular erosion is frequent in COM
Infection process per se
Necrosis following vascular thrombosis
It most commonly affect the lenticular process of the incus and head of the stapes

12. Pathology Cholesterol granulomas
Presence of yellowish masses surrounded by granulation tissue, edematous mucosa and fibrous tissue
It contains many cholesterol crystals and foreign body giant cells.

13. Pathology
Cholesteatoma: cystlike, expanding lesions of the temporal bone, lined by stratified epithelium and containing desquamated keratin and purulent material.
Classification
Congenital cholesteatoma
Acquired cholesteatoma

14. Pathology
Mechanics of mucosal transformation and epithelial ingrowth have been the focal point of cholesteatoma
Pocket retraction: dysfunction of Eustachian tube

15. Pathology Epithelial migration: the edge of a peripheral perforation
Inward growth of the surface epithelium follows papillary proliferation of the germinative layer of the pars flaccida.
Metaplasia from pseudostratified ciliated columnar epithelium

17. Cholesteatoma Formation

18. Cholesteatoma Formation

19. Pathology Pathogenesis of congenital cholesteatoma:
Ectodermal epithelial in proximity of the geniculate ganglion, medial to the neck of the malleus

20. Pathology Diagnosis criteria:
Patients without previous history of ear disease, with normal and intact TM
The temporal bone pneumatization should be normal

21. Clinical presentations
Otorrhea
Malodorous associated with cholesteatoma
Hearing loss
Air conduction threshold is within 40 dB means TM proferation with intact ossicular chain
If air-bone gap is more than 40 dB is associated with discontinuity of ossicular chain

22. Clinical presentations
Physical findings
Defect in the pars tensa of TM or the pars flaccida or both
Atelectatic lesions in tensa or flaccida pars
Squamous epithelial invasion may invade middle ear
Granumoms, polyps, tympanosclerotic plaques in middle ear

23. Radiographic evaluation
Indications for image study
Uncontrollable aural discharge
Complications such as facial paralysis, labyrinthitis
When central nervous stystem involvement is suspected, MRI should be considered.
Coronal CT scan is perferred

24. RADIOLOGICAL ASSESSMENT
X-rays mastoid

26. Differential diagnosis
Tuberculous otitis media
Hematogenous route
Multiple perforation and fetid
Creamy aural discharge
Active pulmonary disease
Multiple antituberculosis agents

27. Differential diagnosis
Middle ear carcinoma
Middle age patient
Long term otorrhea with blood
Otalgia
Neoplasm in tympanum
CT scan showed temporal bone destruction

28. Managements Medical treatment Goals
Infection control
Stabilization of process
Prevention of irreversible damage and development of serious complications
3%H202 clears up pus then antibiotics ear drops is used.
With the decrease of pus, 3% boric glycerin, 3% boric alcohol can be used
No aminoglycoside ear drops
No powders containing antibiotic and erosion ear drugs

29. Managements Surgery Goals classification Safe ear: lesion removal
Dry ear
Hearing ear: reconstruction of ossiclar chain
classification
Myrigoplasty
Tympanoplasty
Tympanoplasty with mastoidectomy