1. Cholesteatoma and chronic suppurative otitis media

2. CHOLESTEATOMA Normally middle ear cleft linings:
Ciliated columnar in anterior and inferior part.
Cuboidal in middle part.
There is nowhere lined by keratinising squamous epithelium in middle ear cleft.
Presence of this epithelium in middle ear is called cholesteatoma(skin in the wrong place)

4. Origin of cholesteatoma
1)Presence of congenital cell rests.
2)Invagination TM from attic or posterosuperior part of pars tensa in the form of retraction pockets(wittmacck’s theory).
3)Basal cell hyperplasia(Rueid’s theory)
4)Epithelial invasion(Habermann’s theory)
5)Metaplasia(Sade’s theory)
Origin of cholesteatoma

5. CLASSIFICATION OF CHOLESTEATOMA
1.CONGENITAL
2.ACQUIRED,PRIMARY
3.ACQUIRED,SECONDARY

6. EUSTACHIAN TUBE OBSTRUCTION
PERSISTENT NEGATIVE PRESSURE IN MIDDLE EAR
ATTIC OR POSTERIOSUPERIOR RETRACTION POCKET
PROLIFERATION OF BASAL LAYER
METAPLASIA OF MIDDLE EAR MUCOSA
PRIMARY ACQUIRED CHOLESTEATOMA
SUBCLINICAL INFECTIONS OF MIDDLE EAR

7. SECONDARY ACQUIRED CHOLESTEATOMA
ACUTE NECROTIZING OTITIS MEDIA
REPEATED INFECTION THROUGH PERFORATION
LARGE CENTRAL OR MARGINAL PERFORATION
METAPLASIA OF MIDDLE EAR MUCOSA
EPITHELIAL MIGRATION THROUGH PERFORATION
SECONDARY ACQUIRED CHOLESTEATOMA

9. Expansion of cholesteatoma and destruction of bone
Once cholestetoma enters middle ear cleft , it invades surrounding structures,first by following the path of least resistance, and then by enzymatic bone destruction which is caused by collagenase , acid phosphatase and proteolytic enzymes which are liberated by osteoclasts and mononuclear inflammatory cells.

10. Chronic suppurative otitis media
It is long standing infection of a part or whole of the middle ear cleft , characterised by ear discharge and permanent perforation .
Epidemiology:
Higher incidence in developing countries.
Both sexes and all age group s are affected.
Singlemost imp. Cause of hearing loss.

11. Types of CSOM
A)Tubotympanic : Also called safe or benign type . Involves antero inferior part with central perforation.
B)Atticoantral : Also called unsafe or dangerous type . Involves the posterosuperior part and is associated with an attic or marginal perforation . Often associated with bone eroding process.

12. A)Tubotympanic type Pathology: 1)Perforation of pars tensa
2)Middle ear mucosa
3)Polyp
4)Ossicular chain
5)Tympanosclerosis
6)Fibrosis and adhesions

14. Bacteriology
Pseudomonas aeruginosa , proteus , E.coli and staph aerus.
Bacteroides fragilis and streptococci.

15. Clinical Features:
1)Ear discharge : non offensive mucoid or mucopurulent.
2)Hearing loss
3)Perforation
4)Middle ear mucosa:Red oedematous and swollen.

17. Investigations: 1)Examination under microscope 2)Audiogram
3)Culture and sensitivity of ear discharge
4)Mastoid X-rays.

18. Treatment: Aural Toilet. Ear drops. Systemic antibiotics. Precautions.
Treatment of contributory causes.
Surgical treatment.
Reconstructive surgery.

19. B)Atticoantral Type Pathology: Cholesteatoma
Osteitis and granulation tissue
Ossicular necrosis
Cholesterol granuloma

20. SYMPTOMS:
Ear discharge.
Hearing loss.
Bleeding.
SIGNS:
Perforation.
Retraction pocket.
Cholesteatoma

21. Investigations: 1)Tunning fork test 2)Audiogram
3)X-ray mastoids and CT scan of temporal bone.
4)Culture and sensitivity of ear discharge.

23. Treatment: 1)Surgical: 2)Reconstructive surgery:
3)Conservative Treatment:

24. Tubercular otitis media SYPHILITIC OTITIS MEDIA

25. WILL BE CONTINUED AFTER 10 MIN BREAK