Prof.Dr. Mohamed Talaat EL.

Ghonemy
 CONGENITAL ANOMALIES

-Dehiscence of the bony facial canal

(horizontal part) predisposes to facial
paralysis during attacks of acute otitis
media, cholesteatoma and ear surgical
trauma.
-Fixation or absence of ossicles causing
conductive deafness.
-Dehiscence of the floor of the tympanic
cavity predisposes to injury of the jugular
bulb during tympanoplasty leading to
severe hemorrhage.
TRAUMA OF THE MIDDLE EAR

Traumatic rupture of the drum:

Causes:
-Indirect trauma: Slap, blast or
otitic barotrauma.
-F.B. or during its removal, clumsy
ear wash, fracture base of the
skull.
Symptoms:
-Slight pain.
-Mild deafness and tinnitus.
-Minimal bleeding.
Signs and Differential Diagnosis

Traumatic Pathologic
History trauma otitis
media
Discharge Absent Present
Blood may be absent
Perforation
site pars tensa anywhere
type central anywhere
size small any size
shape irregular rounded
edges thin thick
Treatment

-Keep the ear dry: no drops and water.

-Antibiotics, analgesics and nasal
decongestive drops.
-The perforation usually heals in three to
six weeks.
-Myringoplasty after three months if the
perforation fails to heal.
Otitic Barotrauma
Non infective inflammation of the
middle ear due to relatively
negative intratympanic pressure
caused by Eustachian tube
obstruction.
 Predisposing factors:
-Eustachian tube pathology e.g.
allergy, inflammation, or
adenoids.
-Eustachian obstruction due to rapid
descent in a no pressurized
airplane or sea divers.
 Pathology:
-Congestion and effusion in the
middle ear due to negative
pressure.
Symptoms:
-Deafness, tinnitus, pain and autophony.
Signs:
-Retracted congested drum.
-Fluid and bubbles in the middle ear.
-The drum may be traumatically perforated.
Prophylaxis:
-Avoid flying when having upper respiratory infection.
-Avoid sleeping during flight descent (Eustachian tube is
closed at rest).
-Opening the Eustachian tube by nasal drops, chewing
gum and auto-inflation by performing Vasalva's method.
Treatment:
-Antibiotics, analgesics and nasal decongestive drops.
-Myringotomy to allow air in and drain fluid out.
 Fracture Base of Skull
-Longitudinal fracture passes in the long axis of the
petrous temporal bone through the middle ear, drum
and external ear. It causes conductive deafness,
bleeding from the ear and cerebrospinal otorrhea. It
is more frequent than the transverse fracture.

-Transverse fracture (at right angle to the long axis

of the petrous bone) usually affects the inner ear
and the facial nerve. It causes sensorineural
deafness, vertigo and facial paralysis.
Ossicles disconnection
Causes: head injury, fracture skull
base, ear surgery or impacted
foreign body.
It causes conductive deafness and
the drum may be intact.
The incudostapedial joint is the
most common affected.
Treatment: middle ear exploration
and ossiculoplasty.
Audiogram (air bone gap more than 50db) Tympanometery (Ad curve)
INFLAMMATIONS OF THE MIDDLE EAR

Acute otitis media

An acute inflammation of the mucoperiosteal lining of the middle
ear cleft.
 Causative organisms:
-Bacterial as Haemophilus influenza, streptococci and
staphylococci.
-Viral as influenza.
 Routes of infection:
Through the Eustachian tube: In diseases of:
-Acute rhinitis, acute sinusitis, acute pharyngitis.
-Acute tonsillitis and adenoiditis, common cold.
-Post-nasal pack.
-Milk regurge during suckling in infants.

Through drum perforation: During swimming and bathing.

Pathology:
Stage of acute salpingitis:
Eustachian tubal occlusion and
inflammation.
Symptoms: Deafness, tinnitus, pain and
autophony.
Signs: Retracted congested drum. Fluid and
bubbles in the middle ear.
Stage of acute tympanitis:
Inflammation extends to the middle ear with
serous exudation.
Symptoms: Deafness, tinnitus, pain.
Signs: Congested drum; congestion begins
around handle of malleus then to the
periphery and then the whole drum.
Stage of acute suppurative otitis media:
The exudation in the middle ear becomes
mucopurulent or purulent. The drum
bulges then perforates.
Treatment of acute otitis media
-Antibiotics, analgesics and nasal decongestive
drops.
-Myringotomy to allow drainage before perforation.

Complications of acute otitis media:

-Cranial: Mastoiditis, facial paralysis.

-Intracranial: rare
 Sequelae of acute otitis media:
-Healing: arrest of discharge, normal drum and normal hearing.
-Non-resolution: is due to inadequate treatment, virulent
organisms and low resistance of the patient. This may
manifest by:
A) Residual deafness due to:
-Secretory otitis media: Fluid collects in the middle ear due to
Eustachian tube obstruction or mild infection. Treated with
myringotomy and ventilation tube (Grommet's tube).
-Residual perforation: treated with myringoplasty.
B) Residual discharge due to:
-Persistence of the cause: treated with tonsillectomy and
adenoidectomy.
-Masked mastoiditis: treated with cortical mastoidectomy.
 ACUTE OTITIS MEDIA IN INFANTS
Otitis media is more common in infants than in adults because
children are more susceptible to infection than adults due to their
low resistance as a result of teething, gastrointestinal troubles and
artificial feeding.

a) Adenotonsillitis and recurrent upper respiratory tract

infections.
b) Milk regurge during suckling enters the Eustachian
tube when the child suckles in the supine position.
c) The Eustachian tube is shorter, more horizontal and
wider than in adults.
Symptoms: Mainly general.
-Fever, vomiting and diarrhea.
-Child cries, restless, moves his head and
pulls his ears.
Signs:
-The drum is congested. Bulging is late as the
drum is thicker and more oblique than in
adults.
Treatment:
- Antibiotics, analgesics and nasal
decongestive drops.
-Myringotomy under general anesthesia is
done if not resolved.
VIRAL OTITIS MEDIA
Otitis media complicating
influenza: manifested by
hemorrhagic bullae on the
drum and non-purulent
hemorrhagic exudates in
the middle ear.
Otitis media complicating
exanthemata: as in
measles and chickenpox
which are usually
accompanied by secondary
infection.
 CHRONIC SUPPURATIVE OTITIS MEDIA (C.S.O.M)
Chronic infection of the middle ear: causing conductive deafness and

discharge from a perforated drum .

Clinical types:

1. Tubotympanic disease: Safe ear

It is a safe mucosal affection of
Eustachian tube and tympanic cavity.
It is due to inefficient treatment,
inadequate drainage, low resistance
of the patient or high virulence of the
organism in cases of repeated attacks
of acute otitis media.
2. Attico-antral (Cholesteatoma):
Unsafe ear
It is unsafe bony affection of the attic,
antrum and bony walls of the mastoid
air cells.
 CHOLESTEATOMA:
Cholesteatoma is a bag-like, cystic, foul smelling
mass. It is formed of keratinizing desquamated
squamous epithelium, pus, cholesterol crystals
and proteolytic enzymes.
It erodes bone by chemical (proteolytic enzymes)
and bacterial action (secondary infection). The
abnormal presence of the squamous epithelium
in the middle ear is either congenital or acquired.
 Theories of cholesteatoma
a) Congenital cholesteatoma arises from embryonic epithelial
rests in of the petrous bone. It could be arise at
cerebellopontine angle (CPA) or middle ear. In CPA, it may
present with facial nerve paralysis, nerve deafness and vertigo
while in the middle ear it leads to conductive deafness behind
an intact drum.

b) Acquired cholesteatoma may be due to:

 Primary acquired cholesteatoma: Invagination of pars flaccida
(attic retraction) in repeated prolonged Eustachian obstruction.
The flaccid part of the drum is sucked and is separated as a
sac filled with squamous epithelium in the attic.
 Secondary acquired cholesteatoma:
-Invasion of middle ear by the skin of the external canal through a
marginal perforation (migration).
-Metaplasia of the flattened epithelium of the middle ear by
infection into stratified squamous epithelium.
Attic cholesteatoma
 Symptoms of C.S.O.M.:
1. Deafness.
2. Discharge.
Signs of C.S.O.M.:
1. Perforation 2. Granulations
3. Polypi. 4. Conductive deafness.
Signs Safe ear Unsafe ear
1. Deafness Conductive and not severe Conductive and severe
2. Discharge Mucopurulent,profuse,odourless Purulent, scanty,foul odour
3. Perforation Central Marginal or attic
4. Granulations Uncommon Common

5. Polypi Pale and edematous Fleshy and granular

6.Cholesteatoma Very uncommon Very common
Investigations:
-X-ray and CT scan of the mastoids.
-Culture and sensitivity test for the discharge.
-Audiological assessment.
Treatment:
-Tubotympanic type: (Safe type)
Tympanoplasty in done after trials to make the ear dry by
conservative treatment using antibiotics, suction, ear drops
and removal of the source of infection as tonsils and
adenoids.
-Atticoantral Cholesteatoma: (Unsafe type)
a) Atticotomy when it is limited to the attic.
b) Modified radical mastoidectomy if it is localized to the attic
and antrum.
c) Radical mastoidectomy for extensive cholesteatoma or the
Cholesteatoma matrix Pinpoint perforation
Unsafe CSOM with granulations Unsafe CSOM with aural polyp
Rt subtotal perforartion Lt subtotal perforation
Rt posterior perforation Lt subtotal perforation with
with tympanosclerosis middle ear cholesteatoma
TUMOURS OF THE MIDDLE EAR
Benign : Glomus tumour:
It is the most common benign tumour of the
middle ear. It is of two types.
 -Glomus tympanicum arises from the tympanic
branch of 9th cranial nerve (Jacobson) on the
promontory.
 -Glomus jugulare arises from the para-
ganglionic tissue related to auricular branch of
10th cranial nerve (Arnold) on the jugular bulb.
Symptoms and signs
-Pulsating tinnitus is the early manifestation.
-Red mass behind an intact drum: sun rise
appearance.
- Bleeding polyp or mass when the tumour
erodes the drum.
-Conductive deafness then becomes mixed
when the tumour invades the inner ear
-Paralysis of the lower four cranial nerves
(jugular foramen syndrome).
-Facial nerve paralysis.
Investigations:
- CT scan and MRI show extension of the tumour.
-Angiography show feeding vessels for
preoperative embolization.
Treatment:
-Glomus tympanicum through tympanotomy or
radical mastoidectomy.
-Glomus jugulare through infratemporal skull base
approaches.
Malignant
Squamous cell carcinoma is the most common
malignant tumour of the middle ear.
Long standing chronic otitis media may be a
predisposing factor.
Bleeding polyp in the external ear canal is usually
a presenting sign.
Treated by petrosecctomy and radiotherapy.
Thank you