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CHRONIC OTITIS MEDIA

Classification of Chronic Otitis Media
• Chronic Non Suppurative Otitis Media
– Otitis media with effusion “OME” – Adhesive otitis media

• Chronic Suppurative Otitis Media “CSOM”
– Tubotympanic (Safe) – Atticoantral (Unsafe)

OTITIS MEDIA WITH EFFUSION

DEFINITION Presence of non-purulent fluid within the middle ear cleft .

SYNONYMS • • • • • • • Secretory otitis media Middle ear effusion Sero-mucinous otitis media Catarrhal otitis media Glue ear Serous otitis media Non-suppurative otitis media .

PREVALENCE • Between 20% and 50% of children do have OME at some time between 3 and 10 years of age • Two peaks at 2 and 5 years of age .

RISK FACTORS • • • • • • • • Race Age Gender Season Nasopharyngeal anatomical abnormalities Cleft palate Smoking ? Allergy .

HISTOPATHOLOGY • Changes in the mucosa – Vasodilatation & mononuclear cell infiltration – Metaplasia of the epithelium to ciliated columnar – Mucus secreting gland formation • Formation of fluid in the middle ear – Transudate – Exudate – Secretion .

ETIOPATHOLOGY • Eustachian tube dysfunction • Chronic inflammation .

ETIOLOGY • Eustachian tube dysfunction – Poor muscular function – Adenoids – Barotrauma – Others • Infections – Unresolved AOM – Adenoiditis and other URTIs .

SYMPTOMS • Hearing impairment • ± Otalgia • Fluid sensation .

Diagnosis .

DIAGNOSIS .

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DIAGNOSIS • Otoscopy • Tuning fork tests .

DIAGNOSIS • Otoscopy • Tuning fork tests • PTA .

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DIAGNOSIS • Otoscopy • Tuning fork tests • PTA • Tympanometry .

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DIAGNOSIS • Otoscopy • Tuning fork tests • PTA • Tympanometry • Myringotomy .

?Auto-inflation – ?Steroids • Surgical – Myringotomy – Ventilation tubes (grommets) .TREATMENT • Treatment of the cause if feasible • Observation • Medical treatment – Antibiotics – Decongestants.

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COMPLICATIONS OF VENTILATION TUBES INSERTION • Infection • Blockage • Extrusion • Tympanosclerosis • Perforation .

Iatrogenic Cholesteatoma .

FACTORS AFFECTING TREATMENT • • • • • • • • Age Duration Unilateral or bilateral Degree of hearing impairment Previous treatment Associated conditions Tympanic membrane changes Others .

Only 5% persists for more than 12 months • Tympanosclerosis • Scarring. retraction and atelectasis • Cholesteatoma .SEQUELAE • Spontaneous resolution – 50% resolve within 3 months.

Conclusion • OME is very common in children • Etiology is associated with ET dysfunction and or chronic infection • In adults: Nasopharyngeal pathology should be considered • Most cases resolve spontaneously • Conservative treatment is of doubtful value • VT insertion restore hearing in the selected cases .

Classification of Chronic Otitis Media • Chronic Non Suppurative Otitis Media – Otitis media with effusion “OME” – Adhesive otitis media • Chronic Suppurative Otitis Media “CSOM” – Tubo-tympanic (Safe) – Attico-antral (Unsafe) .

Chronic Adhesive Otitis Media
• Formation of adhesion in the middle ear after reactivation and subsequent healing of either CSOM or OME

Clinical Features
• History of CSOM or OME • Deafness is usually the only symptoms • TM shows various structural changes

Treatment
• Observation • Surgical treatment • Hearing aid

Classification of Chronic Otitis Media • Chronic Non Suppurative Otitis Media – Otitis media with effusion “OME” – Adhesive otitis media • Chronic Suppurative Otitis Media “CSOM” – Tubo-tympanic (Safe) – Attico-antral (Unsafe) .

CHRONIC SUPPURATIVE OTITIS MEDIA .

ETIOLOGY • Environmental • Genetic • Previous OM • Upper respiratory tract infections • Eustachian tube dysfunction .

CLINICO-PATHOLOGICAL TYPES Tubo-tympanic Attico-antral .

PATHOLOGY • Signs of suppurative infection – Discharge & perforation – Chronic inflammatory reaction in the mucosa and the bone (ostietis) • Signs of healing attempts – Granulation tissue & polyps – Fibrosis & tympanosclerosis • Cholesteatoma (attico-antral type) .

CHOLESTEATOMA .

DEFINITION • The presence of a desquamating stratified squamous epithelium in the middle ear .

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PATHOGENESIS OF CHOLESTEATOMA • Implantation (congenital or acquired) • Metaplasia • Epithelial migration .

CLASSIFICATION OF CHOLESTEATOMA • Congenital • Acquired – Primary – Secondary .

Effect of Cholesteatoma • Keratin encourages persistence of the infection • Matrix causes bone erosion .

Clinical Features of CSOM .

CLINICO-PATHOLOGICAL TYPES Tubo-tympanic Attico-antral (cholesteatoma) .

SYMPTOMS OF CSOM • Otorrhea – Intermittent. Any other symptom means complication . profuse & odorless in TT type – Persistent.B. scanty & malodorous in AA type • Deafness • Tinnitus N.

OTOSCOPIC EXAMINATION • Discharge – Present in TT type if active but may be absent – Usually is present in AA type • Perforation – Central: in TT type – Marginal or attic in AA type with cholesteatoma .

PERFORATION IN TT CSOM .

PERFORATION IN AA CSOM .

granulation tissue. tympanosclerosis .OTOSCOPIC EXAMINATION • Discharge – Present in TT type if active but may be absent – Usually is present in AA type • Perforation – Central: in TT type – Marginal or attic in AA type with cholesteatoma • Polyps.

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Bacteriology B A P S P K e r o b s e t a r o le u e s d a c t e A r io l o n a e g y r o b e s ea s c u p t ia o m o n a s p h y lo c o c c u t e u s b s i e ll a a n d a e a r c u t ge ir n o oi d s B s P a e u p r t eo uc so c P e p t o s t r e E s c h e r ic h .

INVESTIGATIONS • Audiometry • Bacteriology • Imaging .

Congenital Cholesteatoma .

Cloudy middle ear in CSOM .

Cholesteatoma with attic erosion .

TREATMENT OF CHRONIC SUPPURATIVE OTITIS MEDIA • Depends on the type and presentation .

Active TT type Inactive TT type Attico-antral type (usually active) .

Conservative treatment Active TT type Inactive TT type Conservative Treatment •Treat any predisposing factor •Keep the ear dry TYMPANOPLASTY •Ear toilet •Antibiotics •Removal of polyps and granulations .

TYMPANOPLASTY An operation performed to eradicate disease in the middle ear cavity and to reconstruct the hearing mechanism .

MYRINGOPLASTY An operation performed tympanic membrane to repair the .

AIMS OF TYMPANOPLASTY • To close the perforation • To prevent re-infection • To improve hearing .

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TREATMENT OF ATTICOANTRAL CSOM Removal of cholesteatoma by mastoid operation .

malleus and incus are removed leaving only the stapes in situ.RADICAL MASTOIDECTOMY An operation in which the mastoid antrum and air cells. . The tympanic membrane. attic and middle ear are converted into common cavity. exteriorized to the external canal.

attic and middle ear are converted into common cavity. exteriorized to the external canal.MODIFIED RADICAL MASTOIDECTOMY An operation in which the mastoid antrum and air cells. The tympanic membrane and ossicles remnants are retained .

AIMS OF RADICAL & MODIFIED RADICAL MASTOIDECTOMY • Safety • Dry ear • Preserve hearing .

Treatment is conservative (if there is active infection) followed by tympanoplasty to prevent re-infection and improve hearing. intermittent and odorless. The perforation is attic or marginal with cholesteatoma.Conclusion • In TT type the discharge is usually copious. Treatment is by mastoidectomy to provide safety and dry ear . • In the AA type the discharge is usually scanty. persistent and of bad odor. The perforation is central.