CSOM

PRESENTER
M.ISMAIL.DARS
MOIZ

CSOM is a long standing

infection of a part or
whole of middle ear cleft
characterized byEar discharge
And a permanent
perforation

EPIDEMIOLOGY
Incidence is higher in developing
countries
Affects both sexes and all age
groups
Most important cause of hearing
impairment in rural population

TYPES
Clinically it is divided into
two types
1.Tubotympanic
2.Atticoantral

TUBOTYMPANIC
It involves anteroinferior part of middle
ear cleft (eustachian tube,
mesotympanum) and is associated with a
central perforation
Safe/benign type
No risk of serious complications

Atticoantarl
It involves posterosuperior part of
the cleft (attic ,antrum,mastoid)
Associated with an attic or marginal
perforation
It is often associated with bone
eroding process such as
cholesteatoma,granulations or osteitis
Risk of complications is high
Unsafe/dangerous type

property

Tubotympanic

Atticoantral

Discharge

Profuse,mucoid,
odourless

Scanty,purulent,
foul smelling

Perforation

Central

Marginal

Granulations Uncommon

Common

Polyp

Pale

Red and fleshy

Cholesteato
ma

Absent

Present

Complicatio
ns

Rare

Common

Audiogram

Mild to
moderate
conductive
deafness

Conductive or mixed
deafness

1.TUBOTYMPANIC
1.AETIOLOGY
The disease starts in childhood and is
common in that age group
Sequela of acute otitis media usually
following exanthematous fever and leaving
behind a large central perforation
Ascending infections via eustachian
tube causes persistent and recurring
otorrhoea
Allergy to ingestants (milk,egg) causes
persistent mucoid otorrhoea

2.PATHOLOGICAL CHANGES
Perforation of pars tensa-it is a central
perforation, size and position varies
Middle ear mucosa-disease is
quiescent/inactive- normal mucosa
disease active- oedematous and velvety
mucosa
Polyp-pale to pink
Ossicular chain- intact , mobile but shows
some degree of necrosis( long process of incus)
Tympanosclerosis-hyalinization and
subsequent calcification of subepithelial
connective tissue.. Causes conductive deafness
Fibrosis and adhesions- result of healing
process
impair mobility of ossicular chain/block
eustachian
tube

3.BACTERIOLOGY
Pus culture in both aerobic and anaerobic types of
csom show multiple organisms
Aerobes

Anaerobes

Pseudomonas
aeruginosa

Bacteroides fragilis

Proteus

Anaerobic streptococci

Escherichia coli
Staphylococcus aureus

4.Alternative classification of Chronic

otitis media

Mucosal disease-tubotympanic disease:

Squamous disease-atticoantral disease;

Tubotympanic

Atticoantral

Mucosal disease with no

evidence of invasion of
squamous epi.

Squamous disease of middle ear

Active-perforation of pars
tensa with inflammation of
mucosa and mucopurulent
discharge

Active-presence of
cholesteatoma in posterosuperior
part of pars tensa/in pars
flaccida. Erodes bone ,form
granulation tissue,has purulent
offensive discharge

Inactive- permanent
perforation of pars tensa but
middle ear mucosa isnt
inflamed & theres no
discharge.

Inactive-retraction in pars
tensa/pars flaccida,no discharge

Healed-tm is healed (by 2

layers)is atrophic,easily
retracted if ve pressure in
middle ear

Clinical features
Ear discharge-nonoffensive , mucoid/mucopurulent
,constant/intermittent.
Appears at the time of URT infection or on accidental
entry of
water into ear
Hearing loss-conductive type (rarely exceeds 50dB)
Perforation- always central ! May lie
ant./post./inferior to handle of malleus. Can be
small/med./large
Middle ear mucosa- seen when perforation is large.
normally-pale pink & moist
inflamed-red , edematous
occasionally polyp is seen

INVESTIGATIONS
Examination under microscope
Audiogram
Culture and sensitivity of ear
discharge
Mastoid xrays/ct scan temporal
bone

TREATMENT
Aural toilet- dry mopping with absorbent cotton buds
suction clearance under microscope

irrigation with sterile normal saline

Ear drops- antibiotic ear drops containing
neomycin,polymyxin,or gentamycin are used).Often
combined with steroids
Systemic antibiotics- in case of acute exacerbation
Precautions- keep water out of ear during bathing.(rubber
inserts) hard nose blowing should be avoided
Surgical treatment
Reconstructive surgery

2.Atticoantral
1.Aetiology
It is seen in sclerotic
mastoid
cholesteatoma

2.Pathology
It is associated with the following
pathological processes
Cholesteatoma-skin in wrong place
It is presence of keratinized squamous
epithelium in the middle ear or mastoid
Osteitis and granulation tissueinvolves outer attic wall and
posteriosuperior margin of tympanic ring
Ossicular necrosis- hearing loss
Cholesterol granuloma- mass of
granulation tissue with foreign body giant
cells surrounding the cholesterol crystals

3.Symptoms
Ear discharge- scanty but foul
smelling due to bone destruction,
purulent
Hearing loss- hearing is normal
when ossicular chains are intact or
when cholesteatoma (cholesteatoma
hearer) conductive/mixed deafness
Bleeding from granulation/polyp

4.Signs
Perforation- attic/posterosuperior marginal type
Retraction pocket an invagination of tympanic
membrane is seen in attic/posterosuperior area of
pars tensa.
Stages:a) Stage 1 tympanic membrane is retracted
but doesnt contact incus (MILD RETARCTION)
b) STAGE 2- tympanic memb. Is retracted deep
& it contacts the incus; middle ear mucosa isnt
affected.
c) Stage3 middle ear atelectasis : middle ear
comes to lie on promontory & ossicles
d) Stage 4- adhesive otitis medi : TM is very thin;
wraps promontory & ossicles; no middle ear
space; mucosal lining of middle ear is absent;
retraction pockets formed; erosion of long process
of incus stapes superstructure

3. Cholesteatoma pearly white flakes of

cholesteatoma can be sucked from retraction
pockets

5.INVESTIGATIONS
Examination under microscope- imp.
Part of clinical assessment of any type
of CSOM
Tuning fork test and audiogram
Xray mastoids/CT scan of temporal
bone for extent of bone destruction
and degree of mastoid pneumatization
Culture and sensitivity of ear discharge

6.Features indicating
complications in CSOM
Pain- uncommon in uncomplicated CSOM.
Persence of pain indicates
extardural,perisinis or brain abscess
Vertigo-indicates erosion of lateral
semicircular canal , may progress to
labyrinthis/meningitis
Persistent headache-suggestive of
intracranial complications
Facial weakness- erosion of facial canal

 A listless child refusing to take feeds and

easily going to sleep (extradural abscess)
Fever ,nausea & vomiting- intacranial
infection
Irritability and neck rigidity-meningitis
Diplopia (Gradenigo syndrome)petrositis
Ataxia (labyrinthitis or cerebellar abscess)
Abscess around ear (mastoiditis)

7.Treatment
I. Surgical- mainstay treatment
(!)primary aim- remove the disease & render the ear safe
(!!)2nd aim- to preserve/reconstruct hearing

Two types of surgical are done to deal with cholesteatoma:

1. Canal wall down procedure- they leave the mastoid
cavity open in external auditory canal so that the diseased
area is fully exteriorized.
*atticotomy
*modified radical mastoidectomy
*radical mastoidectomy
2. Canal wall up procedures- disease is removed by
combined approach through mastoid and meatus but
retaining the posterior bony meatal wall intact thus
avoiding an open mastoid cavity

II.Reconstructive surgery
hearing can be restored by myringoplasty or
tympanoplasty

III.Conservative treatment-

done
when cholesteatoma is small and easily
accessible to suction clearance under
operating microscope

Thank you