1. Chronic Otitis Media (COM) with and without Cholesteatoma Pathophysiology, Diagnosis, and Management.
Abraham Jacob, MD
Otolaryngology – Head and Neck Surgery
Otology, Neurotology, and Cranial Base Surgery
The Ohio State University
Images used in this lecture were obtained from the presenter’s collection, various textbooks and internet websites. Their use is for educational purposes only.

2. Objectives
To define the normal anatomy and physiology of the ear, Eustachian tube, and lateral skull base.
To understand the role of Eustachian tube dysfunction in the development of chronic ear disease.
To define chronic otitis media (COM) with and without cholesteatoma.
To define the various types of cholesteatoma and how they develop.
To understand the clinical presentation and diagnostic evaluation of COM.
To provide an overview of the surgical management of COM.

3. Anatomy of the Ear and Temporal Bone

4. The Ear – Anatomic Overview

5. The mastoid is a part of the petrous bone.
The Temporal Bone
Made up of the squamous bone, the petrous bone, the tympanic bone, and the styloid process.
The mastoid is a part of the petrous bone.

6. The Middle Ear

7. The Eustachian Tube

8. The Eustachian Tube
Connection between middle ear (ME) & nasopharynx (NP)
Medial 2/3 fibro-cartilage; lateral 1/3 bony
Equalizes ME pressure with atmospheric pressure
Allows air into the middle ear and mastoid to spur air cell development
Lined with respiratory epithelium
Mucociliary clearance towards the NP – drains fluid from ME
Usually closed to prevent reflux of NP contents into ME
13 birth; 36 mm in adulthood
More horizontal at birth; elongates and descends over time

9. Eustachian Tube Embryology
ET and middle ear develop from the first pharyngeal pouch (endoderm)
The external ear canal develops from the first branchial cleft (ectoderm)
The ossicles develop from the 1st and 2nd branchial arches
The interface between the first pharyngeal pouch and the first branchial cleft is the tympanic membrane

10. Eustachian Tube Dysfunction
Abnormal cranial base anatomy
Bony anatomy
Abnormal musculature
Tensor veli palatini and/or levator veli palatini
Inflammation/edema
Physical obstruction
Usually “too closed” but can also be “too open” (patulous Eustachian tube)

11. Eustachian Tube Dysfunction
ETD is central to the development of otitis media
Acute otitis media
Recurrent acute otitis media (ROM)
Otitis media with effusion (chronic non-suppurative otitis media)
Middle ear atelectasis
Chronic suppurative otitis media
Without cholesteatoma
With cholesteatoma

12. Middle Ear Disease

13. Acute Otitis Media (AOM)
The diagnosis of AOM requires:
History of acute onset signs and symptoms
Presence of middle ear effusion (MEE)
Signs and symptoms of middle ear inflammation
The presence of MEE is indicated by:
A bulging tympanic membrane
Limited or absent tympanic membrane mobility
Air-fluid level behind the TM
- Otorrhea (drainage from the ear)
Signs of middle ear inflammation include:
Erythema of the tympanic membrane
- Otalgia (ear pain)

14. Acute Otitis Media (AOM)

15. Etiology of Acute Otitis Media
S. pneumoniae %
H. influenzae %
M. catarrhalis %
S. pyogenes (gr. A) 2%
S. aureus %
No growth up to 35%

16. Recurrent Acute Otitis Media
Multiple bouts of acute otitis media with complete resolution between episodes
4 episodes in 6 months or 6 episodes in 1 year is an indication for tympanostomy tube placement

17. Otitis Media with Effusion (Chronic non-suppurative Otitis Media)
Middle ear filled with serous or mucoid fluid
No purulence
Often present after acute otitis media is treated appropriately with antibiotics
Most will clear within 3 months

18. Etiology of OME 50% sterile to culture
Molecular techniques find bacterial products
When culture +, similar to AOM

19. Medical Treatment of OME
Observation – many European countries wait 6-9 months prior to placement of ear tubes
Antibiotics
Meta-analysis shows beneficial short-term resolution of OME
Unclear long-term impact
Audiogram at 3 months with persistent effusion to determine impact on hearing

20. Tympanostomy Tubes
In the US, chronic OME >3mos with hearing loss and/or speech delay is an indication for tympanostomy tube placement
Not just there to “drain fluid”
Bypass Eustachian tube to ventilate middle ear

21. Middle Ear Atelectasis
Lack of middle ear ventilation results in negative pressure within the tympanic cavity
The ear drum retracts onto structures within the middle ear
The result of long standing Eustachian tube dysfunction
The drum loses structural integrity and becomes flaccid
Contact between the drum and the incus or stapes can cause bone erosion at the IS joint
Can sometimes be treated with tympanostomy tubes

22. Middle Ear Atelectasis

23. Middle Ear Atelectasis
Patient is at risk for cholesteatoma due to skin accumulation within retraction pockets
Drum contact with the incus and/or stapes cause erosion of the incudostapedial (IS) joint
TM is flaccid and non-vibratory – affects hearing
Early atelectasis may be treatable with tympanostomy tubes
Severe atelectasis requires removal of the flaccid ear drum and replacement using cartilage (cartilage tympanoplasty)
This adds rigidity to the drum at the expense of vibratory capacity

24. Chronic suppurative otitis media with and without cholesteatoma

25. Chronic suppurative otitis media without cholesteatoma
Chronic infection of the middle ear with a non-healing perforation of the tympanic membrane
Otorrhea (ear drainage) for 6-12 weeks
Middle ear mucosa becomes edematous, polypoid, or ulcerated
The tympanic cavity usually contains granulation tissue
Most common infecting organisms are Pseudomonas aeruginosa, Staphylococcus aureus, Proteus species, Klebsiella pneumoniae, and diphteroids
Annual incidence approximately 40 cases/100,000 population

26. Chronic suppurative otitis media without cholesteatoma
Patients present with hearing loss and otorrhea
Pain, vertigo, fevers, facial nerve palsy, mental status changes or fetid drainage signify impending intra-temporal or intra-cranial complications

27. Near Total TM Perforation
These more severe perforations. The middle ear structures can be easily seen. Note the malleus handle, umbo, incudostapedial joint, stapedius muscle, stapes in the oval window, and round window. A perforation of this size is likely to require surgical repair.

28. Cholesteatoma

29. Cholesteatoma
Cholesteatomas are epidermal inclusion cysts of the middle ear and/or mastoid with a squamous epithelial lining
Contain keratin and desquamated epithelium
Term “cholesteatoma” coined by Johannes Muller in 1838
Misnomer because the cysts don’t contain cholesterol
Can be congenital or acquired
Natural history is progressive growth with erosion of surrounding bone due to pressure effects and osteoclast activation

30. Cholesteatoma

31. Cholesteatoma Annual incidence is unknown
In 1978, there were 4.2 hospital discharges per 100,000 with cholesteatoma
(Ruben RJ: The disease in society: evaluation of chronic otitis media in general and cholesteatoma in particular. In Sadé J, editor: Cholesteatoma and mastoid surgery, Amsterdam, 1982, Kugler Publishing)
Harker and coworkers estimated the incidence at 6/100,000
(Harker LA: Cholesteatoma: an incidence study. In McCabe BF, Sadé J, Abramson M, editors: Cholesteatoma: first international conference, Birmingham, Alabama, 1977, Aesculapius Publishing)
Tos and colleagues found 3/100,000 in children and 12.6 per 100,000 in adults
(Tos M: Incidence, etiology and pathogenesis of cholesteatoma in children, Ann Otol Rhinol Laryngol 40:110, 1988)

32. Congenital cholesteatoma
Epidermal inclusion cysts usually present in the anterior superior quadrant of the middle ear near the Eustachian tube orifice
Michaels found epidermoid formation in 37 of 68 temporal bones of fetuses at 10 to 33 weeks' gestation.
(Michaels L: An epidermoid formation in the developing middle ear; possible source of cholesteatoma, Otolaryngol 15:169, 1986)
Diagnosed as a pearly white mass behind an intact tympanic membrane in a child who does not have a history of chronic ear disease

33. Acquired Cholesteatoma
Pathogenesis
Invagination
Basal cell hyperplasia
Migration (through a perforation)
Squamous metaplasia

34. Primary acquired cholesteatoma
Retraction pocket cholesteatoma usually within the pars flaccida or posterior superior tympanic membrane (invagination Theory)
Secondary to ETD
Keratin debris collects within a retraction pocket
Mucoid effusion and primary
acquired cholesteatoma
Mesotympanic cholesteatoma
Normal TM

35. Primary acquired cholesteatoma

36. Secondary Acquired Cholesteatoma
Migration Theory – most accepted
Originates from a tympanic membrane perforation
As the edges of the TM try to heal, the squamous epithelium migrates into the middle ear

37. COM with and without cholesteatoma Diagnosis

38. COM with and without cholesteatoma Diagnosis
History, physical examination, high resolution CT scan of the temporal bone
Axial Section
Coronal Section

39. Cholesteatoma Imaging

40. Cholesteatoma Imaging

41. COM with and without Cholesteatoma Treatment

42. Chronic suppurative otitis media without cholesteatoma
Ototopical antibiotics
Surgical repair of the TM perforation
Repair of the ossicular chain if necessary

43. Ototopical Medications
Antibiotic only otic drops
Floxin (ofloxacin)
Antibiotic with steroid otic drops
Ciprodex (ciprofloxin and dexamethasone)
Cipro HC (ciprofloxin and hydrocortisone)
Cortisporin (neomycin, polymyxin, and hydrocortisone)
Ophthalmic antibiotic preparations
Tobradex (tobramycin and dexamethasone)
The concentration of antibiotic in ototopical drops is x greater than what can be achieved systemically.

44. Tympanoplasty Paper patch myringoplasty Fat myringoplasty
Underlay tympanoplasty (medial graft technique)

45. Underlay Tympanoplasty

46. Ossicular Chain Reconstruction

47. Chronic suppurative otitis media with cholesteatoma
Ototopical antibiotics
Surgical repair of the TM perforation
Repair of the ossicular chain if necessary
Often requires mastoidectomy

48. Mastoidectomy Intact (bony ear) canal wall mastoidectomy
Canal wall down mastoidectomy
Radical Mastoidectomy
Modified Radical Mastoidectomy

49. Mastoidectomy
Tympanoplasty with mastoidectomy and hydroxyapatite bone cement ossicular reconstruction

50. COM with and without Cholesteatoma Complications

51. Complications of Otitis Media
Acute mastoiditis
Sub-periosteal abscess
Cholesteatoma
Labyrinthitis
Facial paralysis
Meningitis
Epidural/subdural abscess
Brain abscess
Sigmoid sinus thrombosis
Otitic Hydrocephalus

52. Complications of Otitis Media
Due to antibiotics, the incidence of complications has greatly declined.
Complications are usually associated with some degree of bone destruction, granulation tissue formation, or the presence of a cholesteatoma.
Complications arise most commonly by infection spreading by direct extension from the middle ear or mastoid cavity to adjacent structures.

53. Acute mastoiditis with sub-periosteal abscess
Infection in the mastoid has eroded through the mastoid cortex forming a “subperiosteal abscess.” This condition requires antibiotics and surgical drainage.

54. Brain Abscess

55. Complications of Otitis Media
Patients appear more ill than expected
fever, new onset vertigo, sensorineural hearing loss, fetid drainage, facial nerve weakness, proptotic ear
lethargy and mental status changes
CT and MRI are indicated
CT is superior for evaluating the bony details of the middle ear and mastoid space
MRI is more sensitive for diagnosing suspected intracranial complications.
Broad spectrum antibiotics and surgery are required

56. Summary
Eustachian tube dysfunction is central to the development of ear disease
Chronic otitis media without cholesteatoma is defined as prolonged otorrhea thru a non-healing TM perforation
Cholesteatomas are bone destructive epithelial cysts that require surgical removal
The temporal bone is a complex anatomic region with close proximity to a variety of critical structures. These structures are at risk during both acute and chronic otitis media