Chronic Suppurative Otitis

Media
(C.S.O.M.)(COM)
Khalid Hussain Mahida
Department of ORL-HNS
Ziauddin University Karachi Pakistan
 History
 A 32 year old male reported to ENT OPD with long
standing ear discharge and decreased hearing from
Left ear,
 The problem is intermittent and always started
following upper RTI or after swimming.
 It resolved after a course of antibiotics and ear drops
advised by his GP
 He desired a permanent solution for this problem
 Exam.
 The Right ear is normal

 The left ear examination reveals a large central perforation

 Hearing loss was of conductive type

demonstrate by Tuning fork test

 Rest of the nose, throat ,Vestibular and limited

neurological examination were normal
 Investigations
 Pure Tone audiometry shows moderate
conductive hearing loss

 Pus c/s shows growth of Pseudomonas

aerugenosa sensitive to Quinolones and amino
glycosides group
 Treatment
 Tab Ciprofloxacin 250mg BD for 10 days

 Tobaramycin- Dexamethasone ear drops twice daily

 Water precautions

 Follow-up after 10 days if Inactive then date

for Tympanoplasty
 C.S.O.M.
 Chronic inflammation of Middle ear
 Irreversible changes in Mucosa
 Disease extends beyond mucosa to underlying
bone
 Basically a surgical disease
 C.S.O.M.-Definition

It is a persistent disease of the middle ear cleft,

insidious in onset, capable of causing sever
destruction and irreversible sequelae, and
clinically manifests with deafness and
discharge
 C.S.O.M.- Classification

C.S.O.M.

Tubo-Tympanic Attico-Antral

Active Inactive Active Inactive

 Diagnostic Categories on the
basis of Otomicroscopy

 Healed COM
 Inactive mucosal COM
 Active Mucosal COM
 Inactive (squamous) retractions
 Active (Squamous )Cholesteatoma
Healed COM
Healed COM
Inactive Mucosa;
Active Mucosal
Active Mcosal
Inactive (squamous) retractions
 Active
(Squamous)Cholesteatoma
 C.S.O.M.- Tubotympanic
 Also called as Safe type of CSOM
 H/O long standing uni/bilateral ear discharge
associated with deafness
 Active , when the ear is discharging
 Inactive , when the ear is dry
 C.S.O.M.- Tubotympanic-Active

 Preceding URTI/swimming
 Anterior pulsatile, profuse, mucoid or
mucopurulent non-odorous ear discharge
 Nidus of infection in URT
 Perforation is central
 C.S.O.M.- Tubotympanic-Inactive

 Symptom free
 Mild to moderate conductive hearing loss
 Dry central perforation
 C.S.O.M.- Attico Antral

 Cholesteatoma
 Unsafe CSOM, dangerous type
 Ear discharge is scanty(profuse in mixed
infection)
 Discharge is malodorous
 The ear is seldom dry
 Deafness is conductive
 Cholesteatoma
 A cholesteatoma is a three-dimensional
epidermal structure exhibiting independent
growth, replacing middle ear mucosa,
resorbing underlying bone and tending to recur
after removal.
 Simply it is bad skin in the middle ear
 C.S.O.M.- Attico Antral

 Presence of following indicates complications

* blood stained discharge
* facial palsy
* pain
* vertigo
* Headach
 Pathology and Classification
 Non-neoplastic accumulation of keratinizing
stratified squamous epithelium with
desquamated keratin debris
 Subepithelial fibroconnective tissue
 Granulation tissue
 Bone destruction
 Elaboration of collagenase and other
inflammatory mediators
 C.S.O.M.- Evaluation
 History-long h/o ear
complaints
 Physical examination-

-otoscopy
-otomicroscopy
 Hearing Assessment

 Pus C/S
Otomicroscopy
 C.S.O.M.- Evaluation

 Imaging-
 assessment of mastoid disease,

-X-ray mastoid
-CT Scan
 C.S.O.M.- Evaluation
 Bacteriology
* Pseudomonas aerugenosa
* Proteus mirabilis
* E coli
* S.aureus
* G-ve/anaerobes
 C.S.O.M.- Evaluation
Audiology-CHL
-PTA/Speech
Audiometry
 C.S.O.M.- Tubotympanic Management
Ciprofloxacin
 Aural toilet- Ofloxacin
 Antimicrobial agents Gentamycin Hydrocortisone
 Eliminate any nidus of infection in UR
 Prevent water from gaining access in to the ear
 Myringo/Tympanoplasty/ossiculoplasty, if the
ear becomes inactive
Modified radical mastoidectomy
Combine approach
tympanoplasty