Chronic Otitis Media

Lecture 5
Chronic otitis media
Repeated or proloned bouts of acute otitis media ,often in childhood,can cause damage to the tympanic membrane and a non-healing perforation can occur,the perforation may occupy either the pars flaccida or the pars tensa.
The perforation may be further described as central or marginal depending to their position relative to the annulus of the drum
Pathological classification
Inactive mucosal COM (dry type)?
There is permanent perforation of the pars tensa ,but the middle ear and mastoid
mucosa is not inflamed
Active mucosal COM (perforation with otorrhoea)?
There is chronic inflammation within the mucosa of the middle ear and mastoid ,with varying degree of oedema,submucosal fibrosis,hypervascularity,and infiltration with lymphocyte,plasma cells and hiseocyt, thus simple closure of perforation in active mucosal COM without surgical removal of infected mucosa and granulation tissue from the mastoid is fraught with failure to control the disease Active mucosal COM is often associated with resorption of parts or all of the oscular chain(resorptive osteitis)
Healed COM
Thinning and/or local or generalized opacification of the pars tensa without perforation or retraction
Chalk patches tympanosclerosis plaques or definition of healed otitis media are thin replacement membrane,usually circular in outline and suggestive of an old perforation

?Inactive squamous epithelial COM (retraction,atelectasis and epidermization)
Negative static middle ear pressure can result in retraction (atelectasis) of the tympanic membrane,a retraction pocket consists of an invagination into the middle ear space of a part of the ear drum,and may be fixed when it is adherent to structures of the middle ear or free when it can move madially or laterally .
epidermizatin is a more advance type of the retraction and refers to replacement of the middle ear mucosa by keratinizing squamous epithelium without retention of keratin debris,the area of epidermization may involve part or all of the middle ear cavity.it doesnot progress to cholesteotoma or active suppuration .therefore epidermization in itself not an indication for surgical intervention.

Active squamous epithelium COM (cholesteatoma)?
Cholesteatoma ia a poor name since this condition is not a tumour and nothing to do with cholesterol infact it is acyst or sac of keratinized squamous epithelium (skin) and most commonly occur in the attic or epitympanum part of the middle ear the name keratoma will be more correct because it is retention of keratin debris so it is a cyst or sac filled with keratin and be quite dry or associated with active bacterial infection leading to profuse malodorous otorrhoea .
Cholesteatoma are potentially dangerous because of their potential to incite resorption of bone leading to intratemporal or intracranial complications.
Symptoms and signs of cholesteatoma
1 foul smelling discharge
2conductive hearing loss
3attic retraction filled with squamous debris
4Discharging attic perforation
5 attic aural polyp
Patient may present with complication of cholesteatoma
1 facial palsy
2vertigo
3intracranial sepsis
Cholesteatoma are rarely congenital,and these are though to arise from squamous rest cell within the middle ear .
Aetiology
The exact aetiology is unknown ,negativre pressure within the middle ear has a maximal effect on the thin pars flaccida of the TM ,this will ballon backwards forming a so-called retraction pocket
The migratory epithelium of the outer layer of the TM may now fall into this pocket and in some cases cannot escape.
This ball of squamous debris slowly enlarges and invariably becomee infected with pseudomonas,hence the foul otorrhea.
It tends to grow upards into the attic and backwards into the mastoid.
Cholesteatoma is able to erode bone and therefore can damage any of the important structures in or around the middle ear and mastoid like
1 ossicles lead to conductive deafness
2facial nerve lead to facial palsy
3labyrinth lead to vertigo
4Tegman tympeni (roof of the middle ear) erosion lead to intracranial sepsis
Treatment
Surgical removal,the operation required depends on the size and extent of the disease
Aetiology of COM
Why some individuals progress from acute otitis media to COM is not clear but some risk factors are envolved
1 Genetic and race
There is high incidence of COM in native Americans
2 Environment
COM is higher in lower socioeconomic groups the reason is multifactorial like general health scores,maternal smoking, and day care attendance,the effect of breast feeding is weak and doesn’t show statistical significant and there is decrease in prevalence due to improvement of health care and in housing condition
3 Eustachian tube dysfunction
ETD is more common in COM than in normal individuals,it is not known however if the Eustachian tube dysfunction is the intiating factor in COM or whether it is a result of COM
4Gastro-oesophageal reflux
Recently there is a role of GERD in ear disease
5 Craniofacial abnormalities
The incidence of COM in cleft palate is high ,the tensor veli palatine muscle is hypoplastic in cleft palate childrena and may predispose to ETD
6Autoimmune disease
One study present 29% of patient with ankylosing spondylitis present with COM
7 Immune difficiency
There is no evidence that AIDS patient have higher risk of COM although they have higher risk of aural poyp.

Diagnosis and assessment
Otoscopy with the aid of microscope is the gold standered for the diagnosis of COM
Otoscopy done for the patient and microscopic magnification to be used with an appropriately sized speculum to held the EUM open with facilities of aural toilet like suction,irrigation,mopping and instrumental removal.
Rigid endoscopy can give a good general overall view of anatomy and pathology and be helpful in viewing the anterior recess of the tympanic membrane which is often blocked from view by an anterior canal bulge,and it is good for teaching and to assess pathology and finer ear anatomy but its resolution and colour is not as good as microscope.
Prior to otoscopy operation scars will be looked for,endaural scar and postauricular scarAnatomicaly the pars tensa can be divided into four quadrants but pathologically yhe perforation could be anterior,posterior or inferior hence division into thirds rather than quadrants is preferred, percentage are preferred to non defined terms such as smal,large or subtotal.
All perforations of the pars tensa are central indicative of tubotympanic disease.
The pars flaccida in the attic has always be cleared to assess pathology which may occur alone or with pars tensa disease. All attic disease is attico-antral and marginal , the term marginal goes along with the absence of an annulus,which is not normally in attic pars flaccida ,if the term marginal is applied to pars tensa pathology ,its interpretation becomes confusing and should be avoided.
Otoscopy Inactive (mucosal) COM
Permanent perforation of the pars tensa but the middle ear mucosa is not inflamed
The diagnosis implies permanent perforation of the pars tensa and the middle ear

mucosa that seen through the perforation is inactive
Otoscopy Active (mucosal) COM
Permanent defect of the pars tensa with an inflamed middle ear mucosa which produces mucopus that may discharge ,activity is evident usually with generally inflamed middle ear mucosa ,but sometime with granulation tissue that is localized
and may become polypoidal
Otoscopy Inactive (squamous epithelial) COM
Retraction of the pars flaccida or pars tensa .pars tensa retractions are primarly of the posterior TM ,many classifications used to document their degree like Sade and Berco.
The rtraction of pars tensa may be totally in view or there may be area out of view.
Pars flaccida retraction was clssified by Tos et al into four stages Otoscopy Active (squamous)COM
Retraction of the pars flaccida or tensa that has retained squamous epithelial debris and is associated with inflammation and the production of pus,often from adjacent mucosa Cholesteatoma are the end stage retraction of pars tensa or flaccida Management of csom
Active mucosal CSOM
Two main symptoms which is otorrhea and hearing impairment.
It may remain active,become inactive,or progress to complication.continuing activity may be the result of infection with a particularly virulent or persistent organism ,commonly pseudomonas,impaired immunity group and deprived communities in the developing world should be kept in mind.
Continuing activity of CSOM is likely to result in damage to the ossicular chain and potentially to the inner ear (relatively rare) ,this due to infected with multiple organism,and due to inflammatory reaction in the middle ear associated with granulation tissue which is most likely factor in ossicular damage this will result in nonspecific changes in bone with osteoclastic and osteoblastic activity which result in resorption and remodeling of the bone mainly to the long process of incus and stapes super structure
Aural toilet
Suction clearance with otoscopic aid or microscope,some clinitian use gentle syringing with saline or antiseptic agent cotton ,aural toilet may be carried with cotton wall on probe,but now it is not effective only effective for patient to clean his or her own ear perior to insertion of topical medication

Topical medication
topical antibiotic is the most effective means of treatment of active otorrhea in active CSOM
Topical antibiotic are more effective than oral or intramuscular (meta -analysis of randomized controlled trails )
Topical antibiotics with steroid are commonly used ,gentamicine or neomycin with hydrocortisone is most popular agent used for many years ,other combination is topical quinolone (ciprofluxacine,ofloxacine),topical combination polymyxine B,neomycine,and HC (otosporine)
Aminoglycoside is ototoxic in parenteral admistration and some anecdotal repots of ototoxic effect in topical use in human,but it is difficult to separate the effects of treatment from the effects of the disease itself
Although quinolones are less effective in reducing otorrhea than aminoglycoside but quinolones are preferable to aminoglycoside in active CSOM
Reccurance of activity 4-6 weeks after completion of treatment was reported in 5-43%
Surgery
In those cases that do not become inactive on medical treatment
Cortical mastoidectomy with myringoplasty ,maryngoplasty alone can be done when make active ear inactive
In some cases aural polyps are found protruding from the middle ear ,this can be removed or partially removed ULA or UGA remembering that polyp can be attached to stapes superstructure or facial nerve.
Cauterization of polyp with silver nitrate on a astick is helpful
Laser used in removal of aural polyp to reduce bleeding on removal
Inactive mucosal COM
Surgery
Myringoplasty….reconstruction of TM and/or ossicular chain,myringoplasty is tympanoplasty without ossiculoplasty
Underlay graft of temporalis fascia or prechonderium,
In spite of that thedegree of hearing loss depend on size of perforation Myringoplasty has a small improvement in hearing it does not make the ear the normal ear ,Air bone gap of 35dB or more is due to erosion or fixation of ossicular chain
Ossiculoplasty
Put a prosthesis between handle of malleus and head of stapes,when stapes overstructure is missing the handle of malleus is connected to the stapes footplate
2 hearing aid
Inactive squamous COM
Retraction of the pars tensa or pars flaccida with a potential to be active with retained debris (cholesteatoma)
1Aural toilet
Small retraction pocket can be managed by regular suction
2Management of nasal disease
Ther is evidence that a poorly function ET plays a role in the pathogenesis ot tympanic retraction ,so we have to look for sinonasal diseases like allergy and infection
3 surgery
Surgery for the TM,surgery for ventilating the middle ear
Restore the normal anatomical appearance of TM A excision without graft
B excision with myringoplasty
C excision with myringoplasty and cortical mastoidectomy
Ventilation of the middle ear

Active squqmous AOM
Surgical removal is the only effective treatment in cholesteatoma

Healed otitis media
HA
Young patient need ossiculoplasty success rate is limited

Complications of COM,OM,
Complication occur when the infection spread outside the middle ear
It is either extracranial or intracranial ….
………
Extracranial
1 Sensoryneural hearing loss
2 Labrynthine complication Acute bacterial labrynthitis
3 Facial nerve complication
Intracranial
1 meningitis
2 Intracranial abscess
3 Lateral venous sinus thrombosis
4 Otitic hydrocephalus