1. Department of Otorhinolaryngology

2. Chronic Suppurative Otitis Media Attico-Antral Type
CHOLESTEATOMA
Chronic Suppurative Otitis Media
Attico-Antral Type

3. It is skin in wrong place
Cholesteatoma
Is epidermal cyst of the middle ear and/or Temporal bone with a squamous epithelial lining.
Contain keratin and desquamated epithelium.
Can be congenital or acquired
Natural history is progressive growth with erosion of surrounding bone due to pressure effects and osteoclast activation.
It is skin in wrong place

4. Cholesteatoma It erodes bone by: 1.Enzymatic activity.
2.Pressure necrosis (expansion of the sac).
This may open pathways for spread of infection (Bony or Unsafe type o CSOM)

5. Pathogenesis of Cholesteatoma
Congenital Cholesteatoma:
Arises from embryonic epithelial tissue in the temporal bone ( may be in ME cavity or temporal bone especially the petrous apex).
Epidermal cysts usually present in the anterior superior quadrant of the middle ear near the Eustachian tube orifice.

6. Congenital Cholesteatoma:
Diagnosed as a pearly white mass behind an intact tympanic membrane in a child with no history of chronic ear disease.

7. Acquired Cholesteatoma
Pathogenesis
Squamous epithelium may be found in the middle ear as a result of:
Invagination
Migration (through a perforation)
Squamous metaplasia

8. Acquired Cholesteatoma Pathogenesis

9. Acquired Cholesteatoma
1) Invagination Theory ( primary acquired )
Prolonged ET obstruction creates negative ME pressure leading to retraction of pars flaccida (or the superior part of the membrana tensa) which becomes an invaginated into the ME (retraction pocket) and gradually distend with accumulated keratin and later on separate from the drum membrane.

11. Primary acquired cholesteatoma
Primary acquired (M Flaccida)
Normal TM

12. Primary acquired cholesteatoma
Normal TM
Mesotympanic Type (primary)

13. Primary acquired cholesteatoma

14. Pathogenesis Of Cholesteatoma (cont.)
2) Migration Theory (Secondry acquired) The stratified squamous epithelium of the deep external auditory meatus grows through a marginal perforation into the middle ear cavity. 3) Metaplasia Theory Long standing suppuration can stimulate metaplasia of the simple squamous epithelium of the middle ear to stratified squamous epithelium.

15. 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

16. Clinical Picture symptoms Signs 1) Hearing loss (marked) and tinnitus.
Sometimes HL is minimal as the sac may bridges the gap between the necrosed ossicles.
2) Foul smelling ear discharge.
Signs
1- Fetid scanty purulent ear discharge
2- Perforated DM with cholesteatoma debris
3- Conductive or mixed HL

17. Clinical Picture
Mass behind intact tympanic membrane in cases of congenital cholesteatoma
Sometimes the first presentation is with one of complications e.g. facial nerve paralysis or lateral sinus thrombophlebitis
Granulation tissue or aural polyp may fill the ear canal with bloody ear discharge

19. Investigations
1- Culture and Sensitivity: of the ear discharge. 2- Audiological assessment - CHL, mixed HL or dead ear 3- Imaging of the temporal bone: Only in cases with - Suspected or presence of complications, - Congenital cholesteatoma or - History of previous ear surgery

20. Imaging of Temporal
Axial Section
Coronal Section

21. Cholesteatoma Imaging

22. Treatment of Cholesteatoma
Is Surgical, No role for medical treatment except for active ear infection (ototopical drops) Tympanoplasty with Mastoidectomy is the standard surgical procedure In cases with total HL radical mastoidectomy is indicated

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

24. Cholesterol Granuloma
CGs, first reported in the mastoid and middle ear in 1894, may occur anywhere in the air cell system of temporal bone when eustachian tube obstruction, mucosal edema, temporal bone fracture, cholesteatoma, chronic otitis media or any another process blocks the air cell tracts.

25. Cholesterol Granuloma
Cholesterol granuloma is a histological term used for the description of a tissue response to a foreign body such as cholesterol crystals released by the breakdown of blood and local tissue.
It may arise any portion of the pneumatized temporal bone but most frequently involves the petrous apex

26. Cholesterol Granuloma
CG can be a perfectly localized and isolated mass in any pneumatized area in the temporal bone, the middle ear cavity, mastoid antrum, external auditory canal and the petrous apex.

27. Cholesterol Granuloma
Cholesterol granuloma (CG) of the middle ear typically presents with a conductive hearing loss and a blue eardrum; those at the petrous apex either manifest with side-effects from bony erosion (with sensorineural hearing loss, tinnitus, vertigo or cranial nerve impairment), or are identified as incidental findings.

28. OTORRHOEA
Definition: Discharge of abnormal material through the external ear canal Ear Wax is considered as normal external ear secretion not discharge

29. OTORRHOEA
Description Amount: Scanty or profuse Nature: Watery, mucoid (& muco-purulent), purulent or bloody (sanginous) Smell: Cholesteatoma & external otitis

30. OTORRHOEA
The source of ear discharge: 1- External ear 2- Middle ear 3- Intracranial (CSF)

31. WATERY OTORRHOEA CSF Otorrhoea: Mostly traumatic
Skull base fracture (commonly the longitudinal type)
Iatrogenic (post-operative)
Rarely, malignant neoplasm eroding the skull base

32. Bloody Otorrhoea Traumatic:
Trauma of the external, middle ear and skull base
Inflammatory:
Bullous myringitis, acute and chronic otitis media
Neoplastic:
glomus , carcinoma of external or middle ear

33. Mucopurulent Otorrhoea
Always from middle ear; Acute and chronic otitis media Pulsating ear discharge: Acute or acute on top of chronic suppurative otitis media with small perforation of drum membrane Intra-cranial complications of suppurative otitis media ( extra-dural abscess)

34. Muc-opurulent Otorrhoea
Reservoir Sign: Rapid recollection of discharge in the external ear canal which indicates coalescent mastoiditis

35. PURULENT OTORRHOEA
External otitis and cholesteatoma Usually smelly (fetid) Management of cases of ear discharge is according to the cause N.B. No packing of external ear in suspected cases of CSF otorrhoea.