1. C.S.O.M.: Investigations & Treatment
Dr. Vishal Sharma

2. Investigations for T.T.D.
Examination under microscope
Ear discharge swab: for culture sensitivity
Pure tone audiometry
Patch test
X-ray mastoid: B/L 300 lateral oblique (Schuller) Done when cortical mastoidectomy is required in ear discharge refractory to antibiotics

3. Uses of Audiometry Presence of hearing loss Degree of hearing loss
Type of hearing loss
Hearing of other ear
Record to compare hearing post-operatively
Medico legal purpose

4. Patch Test Done when deafness = 40-50 dB
Do pure tone audiometry: for hearing threshold
Put Aluminum foil patch over T.M. perforation
Repeat pure tone audiometry:
Hearing improved = ossicular chain intact & mobile
Hearing same / worse = oss. chain broken or fixed

5. Investigations for A.A.D.
Examination under microscope
Ear discharge swab: for culture sensitivity
Pure tone audiometry
X-ray mastoid: B/L 300 lateral oblique (Schuller)
CT scan: revision surgery, complications, children

6. Uses of E.U.M. Confirmation of otoscopy findings
Epithelial migration at perforation margin
Cholesteatoma & granulations
Adhesions & tympanosclerosis
Assesment of ossicular chain integrity
Collection of discharge for culture sensitivity

7. Uses of X-ray mastoid
1. Position of dural & sinus plates: helps in surgery
2. Type of pneumatization:
a. Cellular (80%): plenty of air cells
b. Sclerotic (20%): small antrum, air cells absent
c. Diploetic (<1%): bone marrow within few air cells
3. Cholesteatoma (cotton wool appearance)
4. Bone destruction: presence & extent
5. Mastoid cavity

8. Dural & sinus plates

9. Cellular mastoid

10. Sclerotic mastoid

11. Diploetic mastoid

12. Attic bone erosion

13. Causes for mastoid cavity
Cholesteatoma erosion
Mastoidectomy cavity
Tubercular mastoiditis
Coalescent mastoiditis
Malignancy
Eosinophilic granuloma
Mega-antrum
Large emissary vein

14. Posterior canal wall erosion
C.T. scan temporal bone
Posterior canal wall erosion

15. Mastoid cholesteatoma
C.T. scan temporal bone
Mastoid cholesteatoma

16. Treatment for Tubo-tympanic Disease

17. Non-surgical Treatment
Precautions
Aural toilet
Antibiotics: Systemic & Topical
Antihistamines: Systemic & Topical
Nasal decongestant: Systemic & Topical
Treatment of respiratory infection & allergy
Tympanic membrane patcher

18. Precautions
Encourage breast feeding with child’s head raised. Avoid bottle feeding.
Avoid forceful nose blowing
Plug E.A.C. with Vaseline smeared cotton while bathing & avoid swimming
Avoid putting oil & self-cleaning of E.A.C.

19. Aural Toilet Done only for active stage Dry mopping with cotton swab
Suction clearance: best method
Gentle irrigation (wet mopping)
 1.5% acetic acid solution used T.I.D.
 Removes accumulated debris
 Acidic pH discourages bacterial growth

20. Antibiotics Topical Antibiotics:
Antibiotics: Ciprofloxacin, Gentamicin, Tobramycin
Antibiotics + Steroid: for polyps, granulations
Neosporin + Betamethasone / Hydrocortisone
Oral Antibiotics: for severe infections
Cefuroxime, Cefaclor, Cefpodoxime, Cefixime

21. Antihistamines & Decongestants
Antihistamines Systemic decongestants
 Chlorpheniramine  Pseudoephedrine
 Cetirizine  Phenylephrine
 Fexofenadine Topical decongestants
 Loratidine  Oxymetazoline
 Levo-cetrizine  Xylometazoline
 Azelastine (topical)  Hypertonic saline

22. Kartush T.M. Patcher Indicated in: Perforation in only hearing ear
Patient refuses surgery
Patient unfit for surgery
Age < 7 years

23. Surgical Treatment Indicated in inactive or quiescent stage
Myringoplasty
Tympanoplasty
Indicated in active stage
Cortical Mastoidectomy
Aural polypectomy

24. Methods to close perforation
T.M. perforation < 2 mm
Chemical cautery with silver nitrate
Fat grafting
Myringoplasty if these measures fail
T.M. perforation > 2 mm
Tympanic membrane patcher
Myringoplasty

25. Chemical cautery

26. Approaches to middle ear

27. Wilde’s post-aural incision

28. Lempert’s end-aural incision

29. Rosen’s permeatal incision

30. Hearing Restoration Myringoplasty: Ossiculoplasty: Tympanoplasty:
surgical closure of tympanic membrane perforation
Ossiculoplasty:
surgical reconstruction of ossicular chain
Tympanoplasty:
Surgical removal of disease + reconstruction of
hearing mechanism without mastoid surgery

31. Principles of hearing restoration
Intact tympanic membrane
Intact ossicular chain
Functioning receiving & relieving windows
Acoustic separation of these windows
Functioning Eustachian tube
Absence of sensori-neural hearing loss
Absence of active infection / allergy in middle ear cleft

32. Myringoplasty

33. Aims Permanently stop ear discharge: dry, safe ear
Improve hearing: provided: 1. ossicles are intact +
mobile; 2. absence of sensori-neural deafness
Prevention of: tympanosclerosis, adhesions, vertigo, S.N.H.L. (cochlear exposure to loud sound)
Wearing of hearing aid
Occupational: military, pilots
Recreation: swimming, diving

34. Contraindications Purulent ear discharge Otitis externa
Respiratory allergy
Age < 7 yr (Eustachian tube not fully developed)
Only hearing ear
Cholesteatoma

35. Methods Techniques: Underlay: graft placed medial to fibrous annulus
Overlay: graft placed lateral to fibrous annulus
Grafts used:
Temporalis fascia, Tragal perichondrium, Vein graft, Fascia lata, Dura mater

36. Underlay myringoplasty

37. Overlay myringoplasty

38. Steps of underlay myringoplasty

39. Tympanomeatal flap raised

40. Placement of graft

41. Tympanomeatal flap replaced

42. Tympanomeatal flap replaced

44. Why temporalis fascia?
Basal metabolic rate lowest (best survival rate)
Easily harvested by post-aural incision
Its an autograft, so no rejection
Same thickness as normal tympanic membrane
Large size graft can be harvested
Good resistance to infection

45. Onlay Underlay Graft cholesteatoma No
Blunting of anterior tympano-meatal angle
Lateralization of graft
Delayed healing time (6 wk)
3-4 weeks
No middle ear inspection
Possible
Difficult & takes more time
Easier & quicker

46. Advantages of Local Anesthesia
Minimal bleeding
Hearing results can be tested on table
Facial palsy detected immediately
Labyrinthine stimulation detected immediately
No complications of General anesthesia

47. Tympanoplasty

48. Types

49. Type Pathology Graft placed on I II III IV V VI
Ear drum perforation only
Malleus handle II
Malleus handle eroded
Incus
III
Malleus + Incus eroded
Stapes head IV
Only footplate remains: mobile
Round window (Footplate exposed) V
Only stapes remains: fixed
Lateral SCC opening VI
Stapes Footplate

50. Malleus / Incus Autografts

54. Thank You