CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM)

Name: Mrs. XYZ

Age: 64 years

Gender: Female

Occupation: Farmer

Address: KEB Circle, Hoskote

SES: Class IV (Kuppuswamy scale)

Date of admission: 21 Feb, 2020

Date of examination: 21 Feb, 2020

Chief complaints:

1. Decreased hearing in right ear since 6 months

2. Discharge in right ear since 6 months

(Q: Causes of decreased hearing?

A: It can be CHL or SNHL which can further be sudden or delayed in onset.

Causes for decreased hearing here?

(a) Otosclerosis
(b) Cholesteatoma
(c) CSOM
(d) SOM)

HOPI:

Patient was apparently normal 6 months back after which she noticed decreased hearing in right ear
which was insidious in onset, gradually progressive. She used to hear better when spoken to loudly.
No aggravating or relieving factors.

(Q: Patient is 64 years of age, so can also have presbycusis which is SNHL, another ddx is CSOM which is
CHL, how will you differentiate the two based on history?

A: Presbycusis will be B/L and not associated with any discharge. Also, in presbycusis the ability to
comprehend is decreased (i.e. will hear you but not understand you) whereas in CHL patient will be able
to hear when spoken to loudly.)

(Q: Cholesteatoma hearer?

A: Although there is ossicular destruction, the cholesteatoma bridges the ossicular chain and even in the
presence of CHL patient hears better.

Q: Round window shielding effect?

A: In some patients hearing will improve with discharge because discharge will shield the round window.
This happens because the discharge will maintain the phase difference between round and oval
windows.)

The patient also complains of discharge from right ear since 6 months which was insidious in onset,
gradually progressive, continuous, scanty and foul smelling, yellow in color, mucopurulent in
consistency. It was blood tinged when patient tried to clean his ear or during itching. No aggravation
on seasonal changes or cold weather. No relieving factors.

(Q: Types of discharge you know of?

Watery—CSF Otorrhoea

Serous—Otitis externa

Blood-tinged

(A) Causes of external ear

(i) Traumatic- RTA leading to laceration of EAC skin, Instrumentation
(ii) Infectious- Ruptured furuncle, Malignant Otitis Externa
(iii) Malignant
(B) Causes of tympanic membrane and middle ear
(i) Traumatic- Traumatic perforation
(ii) Infectious- ASOM:Suppurative stage, Unsafe CSOM
(iii) Malignant

Mucoid to Mucopurulent—Middle ear infections like ASOM, CSOM; the discharge here is mucoid
because the lining had mucus producing goblet cells.

Q: How do you quantify ear discharge?

A: Scanty, moderate, profuse/copious

Scanty—ear discharge that can be cleaned with an ear bud

Moderate—ear discharge comes out of the ear but does not wet bed spread

Copious—ear discharge comes out of the ear and wets the bed spread

Another method of quantifying is by the patient’s use of ear buds:

1-2 - scanty

2-4 - moderate

>5 - copious
Yellow colored discharge-- Staphylococcus aureus, Streptococcus pneumoniae

Green colored discharge—Pseudomonas

Brown colored discharge—normal wax or fungal (Aspergillus flavus, Aspergillus fumigatus)

Black colored discharge—Aspergillus niger

Curdy white discharge—Candida

Q: Ddx at this point?

A: Atticoantral CSOM

Q: Why is it foul smelling?

A: Due to osteitis

Q: Ddx of foul smelling discharge?

A: Otomycosis, Malignant Otitis Externa-late stage, Keratosis obturans)

No h/o pain (CSOM is painless otorrhoea)

Pain is felt in complications of CSOM like mastoiditis, petrositis etc

No h/o fluctuation in hearing

(Q: What would you expect is patient had fluctuant hearing?

(a) Recurrent SOM—hearing fluctuates with fluid fluctuation

(b) Meniere’s disease—diplacusis or distorted hearing
(c) Autoimmune inner ear disorders like Vogt-Koyanagi-Harada disorder (most noticeable symptom
is rapid loss of vision)

No h/o tinnitis (points towards SNHL)

Pulsatile tinnitis—Glomus tumor, AV malformations

No h/o vertigo (to rule out labyrinthitis)

No h/o fever (to rule out intracranial complications, abscesses)

No h/o nausea and vomiting (to rule out raised ICP)

No h/o giddiness

No h/o headache

No h/o swelling around the ear (to rule out mastoiditis, mastoid abscesses)

No h/o facial weakness (to rule out facial nerve complications)

No h/o irritability or neck rigidity

No h/o visual defects or diplopia (to rule out petrositis)

(Q: Gradenigo’s Syndrome?

(a) Diplopia due to CN VI involvement (passes through Dorello’s canal)

(b) Persistent copious ear discharge
(c) Deep seated retro-orbital pain)

No h/o trauma and surgery

No h/o URTI

No h/o throat pain

PAST HISTORY

- Patient is a known case of DM since 5 years and is under regular medication

- No h/o HTN, asthma or any chronic illness
- The patient had similar complaints in the past (1 year back)
- No h/o trauma or surgery

FAMILY HISTORY

- No significant family history (to rule out congenital causes)

- No history of deafness in family
- No history of consanguineous marriage

PERSONAL HISTORY

- Diet: mixed
- Appetite: normal
- Sleep: adequate
- Bowel and bladder habits: regular
- No ill habits (Smoking predisposes to CSOM because it hampers mucociliary clearance leading
to ET blocking, if you’re planning surgery, patient has to stop smoking for 2 weeks prior to Sx
and 2-3 weeks after Sx also→ continues to smoke, ET blocked again

SUMMARY

This is a case of a female farmer of 64 years of age who is a known case of diabetes presenting with
the complaint of decreased hearing in the right ear since 6 months and discharge in right ear since 6
months.

Most probable diagnosis—CSOM

Keeping in mind, scanty and foul-smelling discharge—Attico-antral type

GENERAL PHYSICAL EXAMINATION

- Patient aged about 64 years conscious, cooperative and well-oriented to time, place and
person.
- Well built and nourished
- Height- 154cm, Weight- 65kg, BMI- 27.3 kg/m2
- No pallor, icterus, clubbing, cyanosis, lymphadenopathy or edema

(Q: Anemia (pallor) + ear pathology, what do you suspect?

A: Lateral sinus thrombophlebitis since it leads to consumption coagulopathy

Q: Anemia in ENT?

A: Malignancies, Plummer Vincent Syndrome (Dysphagia→ Anemia), Juvenile Nasopharyngeal

Angiofibroma)

VITALS

- Pulse: 76bpm
- BP: 120/80 mmHg in the left arm, sitting position
- RR: 17 cycles/min, thoraco-abdominal type
- Afebrile

SYSTEMIC EXAMINATION

- CVS: S1, S2 heard, no murmurs

- RS: Normal vesicular breath sounds heard
- Abdominal examination: No mass per abdomen, no organomegaly
- CNS examination: No neurological deficit present, no neck rigidity, no facial nerve palsies (also
tell about 8th nerve examination)

LOCAL EXAMINATION OF EAR (columns for Rt and Lt ear)

- Pre-auricular region normal on both sides

- Pinna normal on both sides
- Post-auricular region normal on both sides
- Elicit Tragal sign (press tragus inwards, if patient has otitis externa or any furuncle, patient
will cry out in pain)
- External auditory canal (without speculum): Normal on the left and right sides but
presence of scanty muco-purulent secretion which is blood tinged, no exostosis or
granulation tissue seen

(Q: What do you look for in the pre-auricular region?

(a) Pre-auricular sinus (development anomaly-failure in merging first and second

branchial clefts that form the ear)
(b) Skin tags
(c) Surgical marks
 (d) Parotid swellings
(e) Pre-auricular lymph node enlargement

Q: What do you look for in the pinna?

(a) Any developmental anomaly like microtia, anotia

(b) Keloid
(c) Bat ear (absence of anti-helix in the ear)
(d) Boxer’s ear or Cauliflower ear or Wrestler’s ear

Q: What do you look for in post-auricular region?

(a) Scar from previous surgeries

(b) Appearance of mastoid (Ironed out mastoid- mastoiditis)
(c) Grisinger’s sign (non-tender edema of mastoid seen in sigmoid or lateral sinus thrombophlebitis
due to thrombophlebitis of mastoid emissary vein)
(d) Battle’s sign (ecchymosis of post-auricular region seen in middle cranial fossa fractures)

Q: Gradenigo’s triad?

(a) Otorrhoea (associated with bacterial otitis media with apex involvement of the petrous part of
temporal bone)
(b) Diplopia due to 6th nerve involvement
(c) Peri-orbital pain due to 5th nerve involvement

Q: Swimmer’s ear—Otitis externa

Surfer’s ear—exostosis)

6. Tympanic membrane (on Bull’s eye lamp)

• Right— Pars tensa: TM dull because there’sno cone of light, handle of malleus
not clearly visible, rest of pars tensa is normal; anterior and posterior
malleolar folds are normal; single small sized round attic perforation in pars
flaccida
• Left—Pearly white in color, cone of light normal, handle of malleus visible, the
anterior and posterior malleolar folds are normal, pars flaccida normal

(# Description of Left TM with subtotal perforation:

There is a subtotal perforation involving all four quadrants, margins are clearly visible, rest of the pars
tensa is congested/normal, handle of malleus is foreshortened, anterior and posterior malleolar folds
are more prominent, lateral process of malleus is more prominent

Q: When do you get multiple perforations in TM?

(a) Trauma (blast trauma)

(b) TB
# Round margins—CSOM

# Irregular margins—Traumatic perforation

Q: How is handle of malleus kept in position and why is it foreshortened after perforation?

A: Handle of malleus is kept in position with the help of TM and tensor tympani, after perforation it gets
pulled in due or handle of malleus more horizontal than normal to unopposed action of tensor
tympani→ anterior and posterior malleolar folds + lateral process of malleus become more prominent

7. Middle ear not visible

Q: What all will be visible in the middle ear through a large perforation through an otoscope?

(a) Middle ear mucosa

(b) Bulge of the promontory
(c) ET opening in the antero-inferior part
(d) Incudo-stapedial joint in the postero-superior part
(e) Round window niche (NOT membrane; niche—shelf-like projection that covers the round
window)

8. Mastoid normal

(Q: How to elicit mastoid tenderness?

A: We use three fingers:

• Index finger is applied over mastoid process—tenderness indicates mastoiditis

• Middle finger is applied over well of concha—tenderness indicates inflammation over the
mastoid antrum area
• Thumb is used to apply pressure over mastoid process—tenderness indicates mastoid emissary
vein thrombophlebitis
9. Facial nerve normal
10. ET—Valsalva: cracking sound heard on the right side: ET patent

FUNCTIONAL EXAMINATION OF EAR

RIGHT LEFT
Rinne’s test BC>AC AC>BC
Weber’s test Lateralized to the right ear
ABC Same as examiner Same as
examiner
Fistula Sign Negative Negative
Nystagmus Not present Not present
(Q: Rinne equivocal?

A: AC=BC, seen in mild CHL

Q: False negative Rinne’s?

A: Seen in severe U/L SNHL due to transcranial transmission of sound waves.

Q: False positive Fistula sign?

A: Hennebert’s Sign—positive fistula test in the absence of labyrinthine fistula.

(a) Meniere’s disease: fibrosis between stapes footplate and utricle

(b) Hyper mobile stapes footplate: Congenital Syphilis or idiopathic
(c) Superior semicircular canal dehiscence

Q: False negative Fistula sign?

(a) Dead labyrinth

(b) Fistula bridged by choleateatoma sack

NOSE:-

- External nasal framework: normal

- Tip raising test:
(a) Ala normal
(b) Columella normal
(c) Vestibule normal
- Anterior Rhinoscopy
(a) Septum: present in the midline
(b) Turbinates: no hypertrophy
- Functional examination
(a) Cold spatula test: fogging equal on both sides
(b) Cotton wool test: movement is B/L equal
(c) Post. Nasal examination: not done
- Sinus tenderness: absent

ORAL CAVITY:-

- Oral hygiene: good

- Mouth opening: adequate
- Lips: normal
- Tongue: normal
- Floor of mouth: normal
- Buccal mucosa: normal
- Gingivo-buccal sulcus: normal
- Dentition: normal
- Retromolar trigone: normal
- Hard palate: normal
OROPHARYNX:-

- Uvula: midline and normal

- Soft palate: normal

RIGHT LEFT
B/L anterior pillars Normal Normal
Tonsils Normal in size, Normal in size,
shape and position shape and position

B/L posterior pillars Normal Normal

Posterior pharyngeal wall Normal Normal

- Indirect laryngoscopy: not done

NECK:-

- Boccas sign: positive (Laryngeal crepitus; absent in posterior cricoid malignancy,

retropharyngeal abscess)
- Trachea: appears to be midline
- B/L carotids: palpable
- No palpable mass or swellings in neck
- No lymphadenopathy

(Q: What can be the findings in neck in CSOM?

(a) Bezold abscess

(b) Citelli’s abscess
(c) Crowe Beck Sign (lateral sinus thrombosis→ IJV→ tenderness in neck)

PROVISIONAL DIAGNOSIS:-

(a) Right-sided
(b) CSOM
(c) Active (mucosal: inactive after 6months, squamosal/attico-antral: active unless proven
otherwise)
(d) Squamosal type (based on the type of discharge and perforation)
(e) with CHL
(f) no complications (since no history suggestive of complications)

(Q: How to proceed further?

1. EUM (Examination under microscopy)

2. Swab for culture
3. X Ray: Schuller’s view (lateral radiographic view of skull used for viewing mastoid air
cells- look for
(a) Any bony destruction due to cholesteatoma
(b) Level of dural and sinus plates
(c) Dura
 (d) Sigmoid sinus
(e) Any cavity in mastoid
4. PTA (type and amount of HL, for post-op comparison, medico-legal document) #There
will be post-op HL due to the radical Sx
5. HRCT: Temporal Bone (to look for existing or impending complications, to plan the
mastoid exploration)
6. Investigations needed for undergoing Sx

Q: Ddx for any cavity in mastoid in X-Ray?

(a) Mastoiditis→ mastoid abscess

(b) Previous Sx (mastoidectomy)
(c) Cholesteatoma cavity
(d) Physiological mega-antrum
(e) Histiocytosis x
(f) Multiple myeloma

Q: How to differentiate if the cavity is due to cholesteatoma or post-op cavity?

A: Post-op: spicules present because bone is trying to heal

Cholesteatoma: smooth lined cavity

Q: What Rx?

A: Modified Radical Mastoidectomy (MRM) with tympanoplasty

Indications for MRM:

1. Cholesteatoma
2. Approach to Facial Nerve for decompression
3. Unsafe CSOM with intracranial complications

Indications for Cortical mastoidectomy Schwartz (wasn’t the first to do it but first to popularize)
operation, Simple mastoidectomy, Complete mastoidectomy, Canal wall up mastoidectomy):

1. Infective—
(a) CSOM, mucosal type, not controlled by conservative treatment
(b) ASOM with complications
(c) Otitis Media with Effusion (last reserve)
(d) CSOM with complications like mastoiditis (all sorts- acute
mastoiditis not controlled by medicines, coalescent mastoiditis,
masked mastoiditis)
2. Non-infective—
(a) Approach to cochlear implant surgery
(b) To decompress only the vertical part of facial nerve
(c) Endolymphatic sac decompression (for intractable and resistant
Meniere’s disease)
 (d) Labyrinthectomy
(e) Approach to CT angle

Q: Define cortical mastoidectomy.

A: It is a surgical procedure wherein we exenterate (drill) all the accessible (inaccessible mastoid air
cells—petrous, tubal) mastoid air cells and we reach the antrum, establish the patency of aditus
without destroying the posterior bony EAC.

Q: Define MRM.

A: It is a surgical procedure wherein we exenterate (drill) all the accessible mastoid air cells and we
convert the mastoid aditus and middle ear into one single cavity then we exenterate the cavity to the
exterior by doing wide conchomeatoplasty.

Inactive Mucosal Type of CSOM: Tympanoplasty

Active Mucosal Type of CSOM: Medical treatment, culture sensitivity→ dry: plan for Tympanoplasty, if
not→ cortical mastoidectomy + Tympanoplasty