1. C.S.O.M.: Clinical Features
Dr. Vishal Sharma

2. Definition
Chronic (> 3 months) pyogenic infection of middle ear cleft mucosa, characterized by persistent perforation of tympanic membrane, ear discharge & decreased hearing
Prevalence in Nepal: 7.2 %

3. Types of C.S.O.M. Tubo-tympanic: chronic pyogenic infection of
middle ear cleft mucosa with persistent perforation
in pars tensa
Attico-antral: chronic pyogenic infection of middle
ear cleft with cholesteatoma & granulations in attic
or postero-superior quadrant of pars tensa

4. Middle ear cleft

5. Tubo-tympanic vs. Attico-antral

6. Tympanic Membrane Perforations

7. Types Perforation of Pars Tensa 1. Central  tubo-tympanic
 Small  Medium  Large  Subtotal
2. Central with ingrowing epithelium  attico-antral
3. Marginal  attico-antral
4. Total  attico-antral
Perforation of Pars Flaccida
1. Attic  attico-antral

8. 4 quadrants of T.M.
umbo

9. Small perforation
Involves only
one quadrant or
< 10% of pars
tensa

10. Medium perforation
Involves two
quadrants or
10 – 40 % of
pars tensa

11. Medium perforation

12. Large perforation Involves 3 or 4 quadrants with wide T.M. remnant or
> 40 % of pars
tensa

13. Subtotal perforation Involves all 4 quadrants & reaches up to annulus
fibrosus

14. In growing epithelium T.M. perforation with inward migration of

15. Marginal perforation Erodes annulus fibrosus & one margin is formed by
bony tympanic

16. Marginal perforation

17. Total perforation
Total erosion
of pars tensa
& anulus
fibrosus

18. Attic perforation
Involves
pars
flaccida

19. Tympanic Membrane Retractions

20. Grade 1 retraction Dull, lustreless T.M. Prominent annulus
Cone of light absent
Handle medialized
Prominent lateral process
Malleolar folds sickle shaped

21. Grade 2 retraction
Eardrum
touches
incus

22. Grade 3 retraction TM touches promontory (atelectasis) but mobile on
Valsalva
maneuver or
Siegalization

23. Grade 4 retraction TM firmly adherent to promontory & immobile on
Valsalva
maneuver or
Siegalization

24. PSQ retraction pocket

25. Attic retraction pocket

26. Otological examination
1. Pre-auricular region: sinus, lymph node
2. Pinna: size, position, deformity, swelling
3. Post-auricular region: surgical scar, swelling, fistula, lymph node
4. External auditory canal: meatal opening, otitis externa, wax, fungal debris, ear discharge

27. Otological examination
5. Tympanic membrane:
intact: colour, position, mobility, tympanosclerosis, retraction pocket
perforated: type, site, size & margin of perforation handle of malleus; middle ear cavity (mucosa, ear discharge, polyp, granulations, cholesteatoma flakes); pars flaccida

28. Otological examination
6. Mastoid cavity: size, facial ridge, discharge,
epithelialization, granulations, polyps
7. Tragal tenderness: associated otitis externa
8. Mastoid tenderness: cymba conchae, mastoid
body + tip & posterior zygoma root
9. Fistula sign Facial nerve function
11. Tuning Fork Tests

29. Tubo-tympanic Disease

30. Predisposing factors Upper respiratory tract infection (recurrent)
Upper respiratory tract allergy
Pre-existing otitis media with effusion
Cleft palate
Immune deficiency: diabetes, AIDS
Poor socio-economic status

31. Bacteria responsible Staphylococcus aureus Pseudomonas aeruginosa
Klebsiella
Proteus
Streptococcus
Bacteroides

32. Routes of infection
Via Eustachian tube: U.R.T.I., nose blowing, regurgitation of milk
Via tympanic membrane perforation: following A.S.O.M. or post-traumatic
Haematogenous (rare): viral exanthematous fevers

33. Pathological Changes 1. Eardrum: central perforation; myringosclerosis
2. Ossicles: Destruction (hyperaemic decalcification)
Tympanoslerosis
Fibrosis + Adhesions
3. Middle ear mucosa: edematous, pale pink
4. Mastoid bone: sclerosis

34. Clinical Features Ear discharge: profuse, mucoid / muco-purulent,
intermittent, odourless, not blood-stained
Hearing Loss:  usually conductive (25-50 dB)
 absent in small, dry perforations
 round window shielding by ear
discharge leads to better hearing
Tympanic membrane: central perforation

35. Stages of Tubotympanic disease
Otorrhoea
Eardrum perforation
Last ear discharge
Active
Present -
Quiescent
Absent
< 6 months
Inactive
> 6 months
Healed

36. Attico-antral disease

37. Cholesteatoma Term used by Johannes Müller in 1858
Three dimensional sac lined by matrix of keratinizing stratified squamous epithelium which rests on a thin layer of fibrous tissue
Contains desquamated keratin debris
Grows at the expense of surrounding bone
Not a tumor & has no cholesterol
Epidermosis is a better term

38. Cholesteatoma

39. Histopathology

40. Causes of bone destruction
1. Hyperaemic decalcification
2. Osteoclastic bone resorption due to:
 Acid phosphatase  Collagenase
 Acid proteases  Proteolytic enzymes
 Leukotrienes  Cytokines
3. Pressure necrosis: No role
4. Bacterial toxins: No role

41. Types of Cholesteatoma
Congenital (McKenzie)
Primary Acquired Secondary Acquired
1. Retraction pocket Squamous metaplasia
(Wittmaack) 2. Epithelial migration
2. Basal cell hyperplasia (Habermann)
(Ruedi) Tertiary Acquired
3. Squamous metaplasia 1. Post-traumatic
(Sade) 2. Post-tympanoplasty

42. Congenital cholesteatoma
Persistence of congenital cell rests in middle ear, petrous apex, cerebello-pontine angle

43. Congenital cholesteatoma

44. Retraction pocket formation
Retraction pocket in pars flaccida or Postero-superior
quadrant pars tensa due to E.T. dysfunction

45. Basal cell hyperplasia
Hyperplasia of basal cells in epithelial layer of T.M. & their invasion of sub-epithelial tissues

46. Primary squamous metaplasia
Transformation of middle ear mucosa into squamous
epithelium due to infection, with no T.M. perforation

47. Secondary squamous metaplasia
Transformation of middle ear mucosa into squamous
epithelium due to infection via T.M. perforation

48. Epithelial migration
Migration of epithelium via T.M. perforation into middle ear

49. Post-traumatic cholesteatoma
Mechanisms:
1. Epithelial entrapment in fracture line
2. In growth of epithelium through fracture line
3. Traumatic implantation of epithelium into middle ear
4. Trapping of epithelium medial to E.A.C. stenosis

50. Pathological Changes 1. T.M. perforation: marginal or attic
2. T.M. retraction pocket: attic or P.S.Q.
3. Cholesteatoma formation
4. Ossicles: destruction
5. Middle ear mucosa: edematous, red
6. Aural polyp: red, fleshy
7. Osteitis & granulation tissue formation
8. Mastoid bone: erosion, sclerosis

51. Clinical Features Ear discharge: scanty, purulent, continuous, foul-
smelling, blood-stained
Hearing Loss: conductive or sensori-neural
T.M. perforation: marginal or attic or total
T.M. retraction pocket: attic or P.S.Q.
Cholesteatoma flakes
Aural polyp, osteitis & granulation tissue

52. Features of Complications
Severe otalgia, painful swelling around ear
Vertigo, nausea, vomiting
Headache + blurred vision + projectile vomiting
Fever + neck rigidity + irritability / drowsiness
Facial asymmetry
Gradenigo syndrome (apex petrositis)
Ataxia

53. Otorrhoea & aural polyp

54. Attic cholesteatoma

55. Attic cholesteatoma

56. PSQ cholesteatoma & granulation tissue

57. Attico-antral Tubo-tympanic Otorrhoea: Scanty Profuse Continuous
Intermittent
Purulent
Mucoid
Blood-stained No
Foul smelling
Attic / marginal perforation, retraction pocket
Central perforation
Cholesteatoma, granulation

58. Tuberculous Otitis Media
Painless, odorless otorrhoea refractory to antibiotics
Multiple TM perforations  large perforation
Middle ear mucosa pale (congestion around E.T.O.)
Pale granulations in mastoid & middle ear
Severe deafness with bony necrosis (caries)
Facial palsy & labyrinthitis
Tx: Anti-TB therapy + cortical mastoidectomy

59. Multiple T.M. perforations

60. Thank You