Dr.

Haider Salih Ibrahim

Chronic Suppurative Otitis Media (CSOM):

o Long-standing infection of a part or whole of the middle ear cleft

characterised by ear discharge and a permanent perforation.
o Persistent (>6 weeks) or recurrent drainage from infection of the
middle ear and/or mastoid in the presence of a TM perforation (or
ventilation tube).

 Pathophysiology:
- Chronically inflamed or infected middle ear space or mastoid
secondary to:
o Poor aeration (chronic eustachian tube dysfunction),
o Chronic perforation <History of immunological disorders (especially IgA and IgG
subclass 2 and 3 deficiencies)
o Presence of a Cholesteatoma.

 Pathogens:
- Mixed infections:
• Gram-negative bacilli (Pseudomonas, Klebsiella, Proteus, E.
coli,). Pseudomonas (most common aerobe)
• Staphylococcus aureus
o Anaerobes “anaerobic Streptococci ( most common anaerobe)
and Bacteroides fragilis “

 Risk Factors:
1. Abnormal Eustachian tube function:
o Cleft palate
o Down syndrome
2. Immune deficiency
3. Ciliary dysfunction:
o Kartagener syndrome.
4. Gastroesophageal reflux

 Clinical presentation:
o Otorrhea (mucopurulent, odorous)
o TM perforation
o Inflamed middle ear mucosa
o Conductive hearing loss

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Dr.Haider Salih Ibrahim

 Types of CSOM:
- Clinically, it is divided into two types:

1. Tubo-tympanic TT:
- Safe type.
- Involves Antero-inferior part of middle ear cleft (Eustachian tube and
Mesotympanum).
- Central perforation.
- No risk of serious complications.

2. Attico-antral AA:
- Unsafe type
- Involves Postero-superior part of middle ear cleft (Attic, Antrum and
mastoid).
- Attic or Marginal perforation.
- Associated with a bone-eroding process such as Cholesteatoma,
Granulations or Osteitis.
- High risk of serious complications.

 Tubotympanic CSOM:

- Mucosal disease of middle ear cleft with no evidence of invasion of

squamous epithelium.

- Healed chronic otitis media:

o Adhesive otitis media.
o Healed TM (usually by two layers), atrophic and easily
retracted.
o Tympanosclerosis
o Fibrotic tissue may appear in middle ear.
o Always associated with some degree of conductive hearing loss.

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Dr.Haider Salih Ibrahim

- Etiology:
o Starts in childhood and is therefore common in that age group.
1. Sequel of Acute otitis media:
o Following fever and leaving behind a large central perforation.
o Perforation becomes permanent and permits repeated
infection from the external ear.
2. .Ascending infections via the eustachian tube:
o Infection from tonsils, adenoids and infected sinuses may be
responsible for persistent or recurring otorrhoea.
3. Persistent mucoid otorrhoea is sometimes the result of allergy to
ingestants.

- Pathology:
o Disease localized to the mucosa.
o Mostly involves Antero-inferior part of the middle ear cleft.
o Processes of healing and destruction, depending on the virulence of
organism and resistance of the patient.
o Acute exacerbations are common.

- Pathological changes seen in Tubotympanic CSOM:

1. Perforation of pars tensa:
o Central perforation
2. Middle ear mucosa:
o Normal when disease is inactive.
o Edematous when disease is active.
3. Polyp:
o Smooth mass of edematous and inflamed mucosa protruded
through a perforation and presents in the external canal.

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Dr.Haider Salih Ibrahim

4. Ossicular chain:
o Intact and mobile.
5. Tympanosclerosis:
6. granulation tissue
7. Fibrosis and Adhesions:

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Dr.Haider Salih Ibrahim

- Clinical Features:
1. Ear discharge
o Non-offensive, mucoid or mucopurulent, constant or
intermittent.
o Appears mostly at time of URTI or on accidental entry of water
into the ear.
2. Hearing loss
o CHL
3. Perforation
o Always central, it may lie anterior, posterior or inferior to the
handle of malleus.
4. Middle ear mucosa
o Seen through large perforation.
o Normally, it is pale pink and moist.
o When inflamed it looks red, oedematous and swollen.
o Polyp may be seen.

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Dr.Haider Salih Ibrahim

- Investigations:
1. Examination under Microscope:
o Provides useful information regarding :-
- Granulations
- Growth of squamous epithelium from the edges of
perforation
- Status of ossicular chain
- Tympanosclerosis
- Adhesions.

2. Audiogram:
o Assess degree of hearing loss and its type.
o Usually, CHL
3. Culture and sensitivity of ear discharge:
o To select proper antibiotic ear drops.
4. CT scan temporal bone:
o Mastoid is usually sclerotic but may be pneumatised with
clouding of air cells.
o No evidence of bone destruction.

- Treatment of Tubotympanic CSOM:

- Aim of the management:
o Control infection
o Eliminate ear discharge
o Correct the hearing loss by surgical means.

1. Aural toilet:
o Remove all discharge and debris from the ear.
o Done by dry mopping with absorbent cotton buds, suction
clearance under microscope or

2. Ear drops:

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Dr.Haider Salih Ibrahim
o Combined with steroids which have local anti-inflammatory
effect.

3. Systemic antibiotics:
o Role of systemic antibiotics in the treatment of CSOM is limited.
o Useful in Acute exacerbation

4. Precautions:
o Keep water out of the ear during bathing, swimming and hair
wash.
o Rubber inserts can be used.
o Hard nose-blowing can also push the infection from
nasopharynx to middle ear and should be
avoided.

5. Treatment of contributory causes:

o Treat concomitantly infected tonsils, adenoids, sinuses and nasal
allergy.

6. Surgical treatment:
o Aural polyp or granulations, if present, should be removed
before local treatment with antibiotics.
o It will facilitate ear toilet and permit ear drops to be used
effectively.

7. Reconstructive surgery:
o Once ear is dry, Tympanoplasty with or without ossicular
reconstruction can be done to restore hearing.
o Closure of perforation will also check repeated infection from the
external canal.
o Ideally, an ear with a tympanic membrane perforation should be
free from infection for 3 months before tympanoplasty.

 Atticoantral CSOM:

- Squamosal disease of middle ear.

- Active disease:
o Presence of cholesteatoma of posterosuperior region of pars
tensa or in the pars flaccida.
o Erodes bone, forms granulation tissue and has purulent
offensive discharge.
- Inactive disease:
o Atelactatic ear.
o Retraction pockets in pars tensa (usually the posterosuperior
region) or pars flaccida.

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Dr.Haider Salih Ibrahim

- Atticoantral diseases is associated with the following

pathological processes:
1. Cholesteatoma
2. Osteitis and granulation tissue
o Osteitis involves outer attic wall and Postero-superior margin of
tympanic ring.
o A fleshy red polypus may be seen filling the meatus.
3. Aural polyp
o Infected cholesteatoma sometimes manifests as an “aural polyp.

4. Ossicular necrosis:
o Common in Atticoantral disease.
o Destruction may be limited to long process of incus or may also
involve stapes superstructure, handle of malleus or the entire
ossicular chain.

5. Cholesterol granuloma:
o Mass of granulation tissue with foreign body giant cells
surrounding the cholesterol crystals.

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Dr.Haider Salih Ibrahim

- Symptoms
1. Ear discharge:
o Usually scanty, patient may not even be aware of it.
o Always foul-smelling due to bone destruction.
2. Hearing loss:
o Hearing is normal when ossicular chain is intact or when
cholesteatoma, having destroyed the ossicles, bridges the gap
caused by destroyed ossicles (cholesteatoma hearer).
o Mostly CHL
3. Bleeding:
o From granulations or the polyp when cleaning the ear.

- Signs:
1. Perforation:
o Either Attic or Postero-superior marginal type.
2. Retraction pocket:
o Invagination of tympanic membrane is seen in the attic or
Postero-superior area of pars tensa.
3. Cholesteatoma:
o Pearly-white flakes of cholesteatoma can be sucked from the
retraction pockets.

- Investigations:
1. Examination under microscope:
o All patients of chronic middle early disease should be examined
under microscope.
o Suction clearance and examination under Microscope forms an
important part of clinical examination of any type of CSOM.
2. Tuning fork tests and audiogram:
o Pre-operative assessment and to confirm degree and type of HL.
3. CT scan temporal bone:
o Indicate extent of bone destruction and degree of mastoid
pneumatisation.
4. Culture and sensitivity of ear discharge:
o Helps to select proper antibiotic for local or systemic use

- Complications of COM with cholesteatoma in order of

frequency:
1. HL “conductive, sensorineural, mixed type” – Ossicular chain
disruption in up to 30%
2. Inner Ear Fistula – 10% of cases, mainly HSCC, rarely Cochlea
3. Extradural or Perisinus Abscess
4. Labyrinthitis – Serous or Suppurative
5. Facial Nerve Paralysis – Acute (infection) or Chronic (slow
expansion)
6. Meningitis secondary to Tegmen Erosion
7. Subdural or Intraparenchymal Brain Abscess
8. Sigmoid Sinus Thrombosis/Phlebitis
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Dr.Haider Salih Ibrahim
9. Subperiosteal Abscess/Bezold’s Abscess due to erosion of Mastoid
Cortex
10. Recurrent Cholesteatoma

 Cholestatoma:

- Cystlike, “epidermal inclusion cysts” expansile lesions of the temporal

bone lined by stratified squamous epithelium “ matrix” that contain
desquamated keratin.
- Presence of keratinising squamous epitheliumin in the middle ear or
mastoid (Skin in the wrong place) .

- Normally, middle ear cleft is lined by different types of epithelium in

different regions.
o Ciliated columnar in the anterior and inferior part.
o Cuboidal in the middle part
o Pavement-like in the attic.
o No where lined by keratinising squamous epithelium.

- Cholesteatoma consists of two parts:

1. Matrix:
o Made up of keratinising squamous
epithelium resting on a thin stroma
of fibrous tissues.
2. Keratin mass:
o Central white mass consisting of
keratin debris produced by the
matrix.

Most common aerobic bacteria

 Pseudomonas aeruginosa.
 Staphylococcus aureus
o Most common anaerobic microorganisms are anaerobic cocci
 Peptococcus/Peptostreptococcus
 Bacteroides

- Mechanisms of Bone erosion (faster in active infection):

1. Mechanical: Pressure from expansile mass.
2. Biochemical:
- Bacterial (Endotoxins)
3. Cellular:
- Osteoclastic activity (Acid phosphate, Acid Proteases
,Collagenase other protolytic enzymes)

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Dr.Haider Salih Ibrahim

- Classification of Cholesteatoma:
1. Congenital
2. Acquired, Primary.
3. Acquired, Secondary.

Congenital Cholesteatoma:
- Theory:
o Arises from Embryonic epithelial cells rests in the middle ear
cleft or temporal bone.
o Failure of involution and continued growth of the Epidermoid
Formation, derived from 1st branchial groove ectoderm

It causes CHL.
- Sometimes discovered on routine examination of children or at the
time of myringotomy.

Acquired Cholesteatoma:
- The common factor of all acquired cholesteatomas is that the
keratinizing squamous epithelium has grown beyond its normal limits.

 Two types of Acquired Cholesteatoma

o Primary Acquired:
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Dr.Haider Salih Ibrahim
o Retraction Pocket cholesteatoma
o NOT secondary to infection, develop within a retraction pocket
o Secondary Acquired:
o Secondary to perforation from infection, surgery or trauma

- Acquired Primary Cholesteatoma:

- NOT associated with pre-existing perforation.
1. Invagination Theory (Retraction pocket):
o Prolonged Eustachian tube obstruction.
o Persistent Negative pressure in Middle ear.
o Invagination of TM from the Pars Flaccisa (due
to lack of fibrous layer) or Postero-Superior part of pars tensa
in the form of Retraction pockets.

2. Basal cell hyperplasia Theory:

o Cone-like extension of the basal layer of
epidermis can become invasive as a result of
infections.

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Dr.Haider Salih Ibrahim

Acquired Secondary Cholesteatoma:

- There is already a pre-existing perforation in pars tensa from
infection, surgery or trauma

1. Epithelial invasion (Migration) Theory:

o Most accepted theory.
o Keratinized stratified squamous epithelium from the meatus or
outer drum surface grows into the middle ear through a pre-
existing perforation especially of the marginal type where part
of annulus tympanicus has already been destroyed.

2. Implantation Theory:
o Iatrogenic implantation of skin into TM or middle ear.

3. Metaplasia Theory:
o Transformation of columnar epithelium to keratinized stratified
squamous epithelium.

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Dr.Haider Salih Ibrahim

- Radiological investigations:
- CT Temporal bone:
o Allows for evaluation of
anatomy, extent of the disease
and as screen for
complications.

- Diffusion-weighted MRI Temporal bone:

 Management:
- Cholesteatoma must come out surgically unless:
o Too old or too sick “ unfit”
o Small and easily accessible
not infected cholesteatoma
to suction clearance under
operating microscope
o Risks of surgery may not
outweigh the benefits in some
patients with only-hearing ears.
o Patients refusing surgery.

- Surgical intervention:
- Dry ears are much easier to operate on than wet,
infected ears.
- While it is not always possible to dry
a chronically infected ear with
medical therapy

- Surgical Management:
- Mainstay of treatment.

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Dr.Haider Salih Ibrahim

o Types of Mastoidectomy

- Canal-wall-up (Intact wall):

o Simple mastoidectomy

- Canal-wall-down:
o Radical mastoidectomy
o Modified radical mastoidectomy (MRM)

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