THE Middle EAR

Chronic Diseases

Horatiu Stefanescu MD, PhD

C.S.O.M.
Definition
 Chronic (>3 months) pyogenic infection of middle

ear cleft mucosa, characterized by:

 persistent perforation of TM,

 ear discharge ,

 hearing loss
Types

Tubo-tympanic: chronic pyogenic infection of

ME mucosa with persistent perforation in pars tensa

Attico-antral: chronic pyogenic infection of ME mucosa

with cholesteatoma & granulations in attic or postero-superior

quadrant of pars tensa

Middle Ear Cleft
Types
Tympanic Membrane
Perforations

Clinical Features
Types
Perforation of Pars Tensa
1. Central  tubo-tympanic
 Small  Medium  Large  Subtotal
2. Central with ingrowing epithelium  attico-antral
3. Marginal  attico-antral
4. Total  attico-antral

Perforation of Pars Flaccida

1. Attic  attico-antral
Quadrants
Small Perforation

Involves only one

quadrant or < 10% of
pars tensa
Medium Perforation

Involves two
quadrants
or 10 – 40 %
of pars tensa
Large Perforation

Involves 3 or 4
quadrants with
wide T.M. remnant
or > 40 % of pars
tensa
Subtotal Perforation

Involves all 4

quadrants &

reaches up to

annulus fibrosus
In-growing Epithelium

T.M. perforation
with inward
migration of
epithelium
Marginal Perforation

Erodes annulus
fibrosus & one
margin is formed by
bony tympanic annulus
Total Perforation

Total erosion of
pars tensa & anulus
fibrosus
Attic Perforation

Involves

pars flaccida
Tympanic Membrane
Retractions
Grade I
-Dull, lustreless T.M.
-Prominent annulus
-Cone of light absent
-Handle medialized
-Prominent lateral
process
-Malleolar folds sickle
shaped
Grade II

Eardrum

touches incus
Grade III

TM touches
Promontory
(atelectasis)
but mobile on
Valsalva maneuver
Grade IV

TM firmly adherent
to
promontory &
immobile on
Valsalva Maneuver
Retraction Pocket
Tubo-tympanic Disease
Risk Factors

 Upper respiratory tract infection (recurrent)

 Upper respiratory tract allergy
 Pre-existing otitis media with effusion
 Cleft palate
 Immune deficiency: diabetes, AIDS
 Poor socio-economic status
Microbiology

 Pseudomonas aeruginosa

 Staphylococcus aureus

 Klebsiella

 Proteus

 Streptococcus

 Bacteroides
Routes

1. Via Eustachian tube:

U.R.T.I., nose blowing, regurgitation
of milk

2. Via tympanic membrane perforation:

following A.S.O.M. or post-traumatic

3. Haematogenous (rare):
viral exanthematous fevers
Pathology

1. Eardrum: central perforation; myringosclerosis

2. Ossicles: Destruction (hyperaemic decalcification)

Tympanoslerosis

Fibrosis + Adhesions

3. Middle ear mucosa: edematous, pale pink

4. Mastoid bone: sclerosis

Features

Ear discharge: profuse, mucoid / muco-purulent,

intermittent, odourless, not blood-stained
Hearing Loss:  usually conductive (25-50 dB)
 absent in small, dry perforations
 round window shielding by ear
discharge leads to better hearing
Tympanic membrane: central perforation
Stages
Attico-antral disease
Cholesteatoma
 Term used by Johannes Müller in 1858
 Sac lined by matrix of keratinizing stratified squamous
epithelium which rests on a thin layer of fibrous tissue
 Contains desquamated keratin debris
 Grows at the expense of surrounding bone
 Not a tumor & has no cholesterol
 Epidermosis is a better term
Cholesteatoma
Bone Distruction
1. Hyperaemic decalcification
2. Osteoclastic bone resorption due to:
 Acid phosphatase  Collagenase
 Acid proteases  Proteolytic enzymes
 Leukotrienes  Cytokines
3. Pressure necrosis: No role
4. Bacterial toxins: No role
Types
Congenital (McKenzie)
Primary Acquired Secondary Acquired
1. Retraction pocket 1. Squamous metaplasia
(Wittmaack) 2. Epithelial migration
2. Basal cell hyperplasia (Habermann)
(Ruedi) Tertiary Acquired
3. Squamous metaplasia 1. Post-traumatic
(Sade) 2. Post-tympanoplasty
Congenital Cholesteatoma
Persistence of congenital cell
rests in middle ear, petrous
apex, cerebello-pontine angle
Retraction Pocket Formation

Retraction pocket in pars flaccida or Postero-superior

quadrant pars tensa due to E.T. dysfunction
Basal cell hyperplasia

Hyperplasia of basal cells in epithelial layer of

T.M. & their invasion of sub-epithelial
tissues
Primary squamous metaplasia

Transformation of middle ear mucosa into squamous

epithelium due to infection, with no T.M. perforation
Secondary squamous metaplasia

Transformation of middle ear mucosa into squamous

epithelium due to infection via T.M. perforation
Epithelial Migration

Migration of epithelium via T.M. perforation into middle ear

Post-traumatic cholesteatoma

Mechanisms:

1. Epithelial entrapment in fracture line

2. In growth of epithelium through fracture line

3. Traumatic implantation of epithelium into middle ear

4. Trapping of epithelium medial to EAC stenosis

Pathology

1. TM perforation: marginal or attic

2. TM retraction pocket: attic or PSQ
3. Cholesteatoma formation
4. Ossicles: destruction
5. Middle ear mucosa: edematous, red
6. Aural polyp: red, fleshy
7. Osteitis & granulation tissue formation
8. Mastoid bone: erosion, sclerosis
Features

1. Ear discharge: scanty, purulent, continuous,

foul- smelling, blood-stained
2. Hearing Loss: conductive or mixt
3. TM perforation: marginal or attic or total
4. TM retraction pocket: attic or PSQ
5. Cholesteatoma flakes
6. Aural polyp, osteitis & granulation tissue
Discharge/ Polip
Attic cholesteatoma
PQ Cholesteatoma
AA vs TT
D/D - Tuberculous OM

 Painless, odorless otorrhoea refractory to AB

 Multiple TM perforations  large perforation
 Middle ear mucosa pale (congestion around ET)
 Pale granulations in mastoid & middle ear
 Severe deafness with bony necrosis (caries)
 Facial palsy & labyrinthitis
 Tx: Anti-TB therapy + cortical mastoidectomy
Tuberculous OM
D/D – ME Carcinoma

 Middle ear carcinoma

 Middle age patient
 Long term otorrhea with blood
 Otalgia
 Neoplasm in tympanum
 CT scan showed temporal bone destruction
 CSOM
Investigations &
Treatment
Investigations in TT

 Examination under microscope

 Ear discharge swab: for culture sensitivity
 Pure tone audiometry
 Patch test
 X-ray mastoid: B/L 300 lateral oblique (Schuller)
(when cortical mastoidectomy is required)
Audiometry

 Presence of hearing loss

 Degree of hearing loss
 Type of hearing loss
 Hearing of other ear
 Record to compare hearing post-operatively
 Medico legal purpose
Patch Test

When hearing loss = 40-50 dB

 Do pure tone audiometry: for hearing threshold

 Put Aluminum foil patch over T.M. perforation

 Repeat pure tone audiometry:

Hearing improved = ossicular chain intact & mobile

Hearing same / worse = oss. chain broken or fixed

Investigations for AA

 Examination under microscope

 Ear discharge swab: for culture sensitivity

 Pure tone audiometry

 X-ray mastoid: B/L 300 lateral oblique (Schuller)

 CT scan: revision surgery, complications, children

X-Ray
1. Position of dural & sinus plates: helps in surgery
2. Type of pneumatization:
a. Cellular (80%): plenty of air cells
b. Sclerotic (20%): small antrum, air cells absent
c. Diploetic (<1%): bone marrow within few air cells
3. Cholesteatoma (cotton wool appearance)
4. Bone destruction: presence & extent
5. Mastoid cavity
Dura & sinus plates
Cellular
Sclerotic
Diploetic
Attic erosion
Cavity
CT

Posterior canal wall erosion

CT

Mastoid cholesteatoma
Tubo-Tympanic Disease
Treatment
Non-Surgical

 Precautions
 Aural toilet
 Antibiotics: Systemic & Topical
 Antihistamines: Systemic & Topical
 Nasal decongestant: Systemic & Topical
 Treatment of respiratory infection & allergy
Precautions

 Encourage breast feeding with child’s head raised.

Avoid bottle feeding.

 Avoid forceful nose blowing

 Plug EAC with Vaseline smeared cotton while

bathing & avoid swimming

 Avoid putting oil & self-cleaning of EAC

Aural toilet

Done only for active stage

 Dry mopping with cotton swab - sterile
 Suction clearance: best method
 Gentle irrigation (wet mopping)

 1.5% acetic acid solution used T.I.D.

 Removes accumulated debris

 Acidic pH inhibits bacterial growth

Antibiotics
Topical Antibiotics:
Antibiotics:
Ciprofloxacin, Chloramphenicol, Polymixin, Tobramycin
Antibiotics + Steroid: for polyps, granulations

Neosporin + Betamethasone / Hydrocortisone

Oral Antibiotics:
for severe infections
Cefuroxime, Cefaclor, Cefpodoxime, Cefixime
Antihistamines & Decongestants

Antihistamines Systemic decongestants

 Chlorpheniramine  Pseudoephedrine
 Cetirizine  Phenylephrine
 Fexofenadine Topical decongestants
 Loratidine  Oxymetazoline
 Levo-cetrizine  Xylometazoline
 Azelastine (topical)  Hypertonic saline
Surgical

Inactive or quiescent stage

 Tympanoplasty
 Tympanomastoidectomy

Active stage
 Cortical Mastoidectomy
 Aural polypectomy
TM Perforation

T.M. perforation < 2 mm

 Chemical cautery with silver nitrate
 Fat grafting
 Myringoplasty if these measures fail
T.M. perforation > 2 mm
 Tympanic membrane patcher
 Myringoplasty
Myringoplasty
Aims
 Permanently stop ear discharge: dry, safe ear
 Improve hearing provided:
 1. ossicles are intact + mobile;
 2. absence of SNHL
 Prevention of: tympanosclerosis, adhesions,
vertigo, SNHL (cochlear exposure to loud sound)
 Wearing of hearing aid
 Occupational: military, pilots
 Recreation: swimming, diving
Contraindications

 Purulent ear discharge

 Otitis externa
 Respiratory allergy (?)
 Age < 7yrs (??)
 Only hearing ear
 Cholesteatoma
Methods
Techniques:

 Underlay: graft medial to fibrous annulus

 Overlay: graft lateral to fibrous annulus

Grafts used:
 Temporalis fascia,

 Tragal perichondrium,

 Cartilage – full thickness/split

 Vein graft,

 Fascia lata,
Underlay
Overlay
Comparison
Types
Types
Ossicular reconstruction
Ossicular reconstruction
Ossicular reconstruction
Cortical Mastoidectomy
Schwartze’s Technique
Cortical Mastoidectomy
Cortical Mastoidectomy
Cavity Boundaries

 Superior: Dural or Tegmen plate

 Anterior: Posterior wall of EAC

 Inferior: Digastric ridge

 Posterior: Sigmoid sinus plate

 Medially: Lateral semicircular canal

MacEwan’s triangle
Cortical Mastoidectomy
Indications
1. Coalescent mastoiditis & Masked mastoiditis
2. CSOM T.T.D. active refractory to antibiotics
3. Secretory otitis media refractory to antibiotics
4. Approach to:
 Endolymphatic sac surgery
 Facial nerve decompression
 Vestibulo-cochlear nerve section
 Translabyrinthine approach for C.P. angle
 Cochlear implant surgery
 Combined approach tympanoplasty
Atico-Antral Disease
Treatment
Non-Surgical
Topical ear drops + frequent suction clearance

Indications:

1. Early disease with shallow retraction pocket

2. Only hearing ear with cholesteatoma

3. Elderly patients

4. Patients not fit for surgery under G.A.

5. Patients who can regularly come for follow up?

Surgical
Canal Wall down:

 Attico-antrostomy

 Modified Radical Mastoidectomy (MRM)

 Radical Mastoidectomy

Canal Wall up:

 Combined Approach Tympanoplasty (CAT)

CWU
CWD
Atico-Antrostomy
MRM
MRM - steps
 Perform cortical mastoidectomy

 Lower facial ridge & break facial bridge

 Remove cholesteatoma & granulations from mastoid air

cells & middle ear cavity

 Preserve healthy mucosa, TM remnant & ossicles

 Mastoid cavity & EAC become a single cavity

 Perform tympanoplasty.

 Perform concho-meatoplasty.
MRM Cavity+ossicles
FN injury
Radical Mastoidectomy
Steps

 Perform cortical mastoidectomy.

 Lower facial ridge & break facial bridge.

 Remove cholesteatoma & granulations from mastoid & ME.

 Remove ME mucosa, TM & ossicles(except stapes footplate).

 Close Eustachian tube opening.

 No tympanoplasty done. Concho-meatoplasty performed.

 Mastoid, EAC & middle ear become single cavity.

Indications

1. CSOM attico-antral disease with

 Intra-cranial complication

 Recurrence after MR mastoidectomy

 Profound sensori-neural hearing loss

2. Limited malignancy of middle ear

3. Glomus jugulare

4. Osteomyelitis of temporal bone

Persistent Draining Cavity
1. Inadequate concho-meatoplasty !!!
2. High facial ridge !!
3. Insuficient cell removal !
4. Persistent infection: petrositis, T.B., sinusitis
5. Residual cholesteatoma: anterior + posterior buttress,
mastoid tip, sinus tympani, anterior epitympanum
6. Recurrence of cholesteatoma
7. Persistent allergy
8. Retained foreign body: cotton ball
9. Persistent extra-dural abscess
Concho-Meatoplasty
CAT steps

1. Cortical Mastoidectomy

2. Anterior tympanotomy: via tympano-meatal

flap

3. Posterior tympanotomy: via facial recess

4. Tympanoplasty
CAT
CAT
CAT
 CSOM
COMPLICATIONS
Features

 Severe otalgia, painful swelling around ear

 Vertigo, nausea, vomiting
 Headache + blurred vision + vomiting
 Fever + neck rigidity + irritability / drowsiness
 Facial asymmetry
 Otorrhoea + Retro-orbital pain + diplopia
 Ataxia
Classification

 Intra-cranial

 Extra-cranial, Intra-temporal

 Extra-cranial, Extra-temporal

 Systemic: septicemia
Classification
Intra-cranial

1. Extra-dural abscess

2. Subdural abscess

3. Meningitis

4. Brain abscess

5. Lateral Sinus thrombophlebitis

6. Otitic hydrocephalus

7. Brain fungus (fungus cerebri)

Intra-temporal

 Acute mastoiditis

 Coalescent mastoiditis

 Masked mastoiditis

 Facial nerve palsy

 Labyrinthitis

 Labyrinthine fistula

 Apex Petrositis (Gradenigo syndrome)

Extra-temporal

1. Post-auricular abscess

2. Bezold abscess

3. Citelli abscess

4. Luc abscess

5. Zygomatic abscess

6. Retro-mastoid abscess
Risk Factors
Pathogen Factors Patient Factors

 High virulence bacteria  Young age

 Antimicrobial resistance  Poor immune status

 Chronic disease (DM, TB)

Physician Factors  Poor socio-economic status

 Non-availability

 Injudicious antibiotic use

 Error in recognizing dangerous symptoms & signs

Routes
1. Bony erosion (cholesteatoma destruction, osteitis)

2. Retrograde Thrombophlebitis

3. Anatomical pathway: OW, RW, IAC, suture line, cochlear &

vestibular aqueduct

4. Congenital bony defects: facial canal, tegmen plate

5. Acquired bony defects: fracture, neoplasm, stapedectomy

6. Peri-arteriolar space of Virchow-Robin: spread into brain

Labyrinthitis
Inflammation of endosteal layer of bony labyrinth
Route of infection:
 Round window membrane
 Pre-formed opening (Stapedectomy)
 Retrograde spread of meningitis via IAC / aqueducts
Clinical forms:
1. Circumscribed (labyrinthine fistula)
2. Diffuse serous
3. Diffuse suppurative
Types
 Circumscribed:
 Fistula commonly involves lateral SCC.

 transient vertigo & positive fistula test  I/L nystagmus with +ve

pressure; C/L nystagmus with -ve pressure

 Serous:
 Reversible, non-purulent, mild vertigo,

 I/L nystagmus, mild sensori-neural hearing loss

 Purulent:
 Irreversible, purulent, severe vertigo,

 C/L nystagmus, severe / profound hearing loss

Treatment
 Bed rest (affected ear up). Avoid head movement.
 Labyrinthine sedative: Prochlorperazine, Cinnarizine
 Broad spectrum I.V. antibiotics
 Modified Radical Mastoidectomy: removes infection
 Open labyrinthine fistula: cover with temporalis fascia
 Fistula covered with cholesteatoma matrix
 < 2 mm: remove matrix & cover with temporalis fascia
 > 2 mm / multiple / over promontory: leave it
 Rehabilitation by Cawthorne-Cooksey Exercises
LSC fistula
Facial Nerve Paralysis
 Within 1st wk: due to nerve sheath edema

 After 2 wks: due to bone erosion

 Lower motor neuron palsy

 Common in tubercular otitis media

Treatment:

 Modified Radical Mastoidectomy

 Facial nerve decompression seldom required

Menyngitis
 High grade persistent fever with rigors
 Severe headache & neck stiffness
 Irritability  drowsiness  confusion  coma
 Neck rigidity positive
 Kernig sign positive; Brudzinski sign positive
 Papilloedema
 Lumbar Puncture:  cell count,  protein,  sugar
 I.V. Ceftriaxone + Metronidazole + Gentamicin
 Radical Mastoidectomy once patient is stable
Otogenic Brain Abscess
 50-75 % in adult & 25% in children = otogenic

 Temporal abscess : Cerebellar abscess = 2:1

 Route of infection:

 1. Retrograde thrombophlebitis

 2. Direct spread:

 via Tegmen plate: Temporal abscess

 via Trautmann’s triangle: Cerebellar abscess

Trautmann’s Triangle

Pathway to posterior cranial fossa from mastoid cavity

Stages

1. Invasion or Encephalitis (1-10 days)

2. Localization or Latent Abscess (10-14 days)

3. Expansion or Manifest Abscess (> 14 days):

leads to raised intracranial tension & focal signs

4. Termination or Abscess rupture: leads to fatal

meningitis
Stages
Cranial Hypertension

Seen more in cerebellar abscess

 Severe persistent headache, worse in morning
 Projectile vomiting
 Blurring of vision & Papilloedema
 Lethargy  drowsiness  confusion  coma
 Bradycardia
 Subnormal temperature
Focal neurological signs
Temporal Lobe Cerebellum
 Nominal aphasia  I/L nystagmus
 Quadrantic homonymous  I/L weakness
hemianopsia (C/L)  I/L hypotonia
 Epileptic seizures  I/L ataxia
 Pupillary dilatation  Intention tremor
 Hallucination (smell & taste)  Past-pointing
 C/L hemiplegia  Dysdiadochokinesia
Bacteriology
 Anaerobic streptococci

 Streptococcus pneumoniae

 Staphylococci

 Proteus

 E. coli

 Pseudomonas

 Bacteroidis fragilis
Investigations
 CT scan of brain & temporal bone with contrast
 Site, size & staging of abscess
 Observe progression of brain abscess
 Associated intra-cranial complications

 MRI brain
 D/D: pus, abscess capsule, edema & normal brain
 Spread to ventricles & subarachnoid space

 Avoid lumbar puncture to prevent coning

CT Brain Abscess
CT Cerebellar Abscess
Medical Treatment

• High dose broad spectrum I.V. antibiotics:

Ceftriaxone + Metronidazole + Gentamicin

• I.V. Dexamethasone 4mg 6Hr-ly: es oedema

• I.V. 20% Mannitol (0.5 gm/kg): es I.C.T.

• Anti-epileptics: Phenytoin sodium

• Antibiotic ear drops & aural toilet

Surgical treatment

• Repeated burr hole aspirations

• Excision of brain abscess with capsule: best Tx

• Open incision & evacuation of pus

• Radical mastoidectomy after pt becomes stable

Lateral Sinus Thrombophlebitis
Pathogenesis
Lateral sinus=Sigmoid sinus+Transverse sinus

Erosion of sigmoid sinus plate 

peri-sinus abscess 

inflammation of outer wall 

endophlebitis 

mural thrombus 

occlusion of sinus lumen 

intra-sinus abscess 

propagating infected thrombus

Pathogenesis
Spread of thrombus
Proximal:

1. To superior sagittal sinus via torcula Hierophili 

hydrocephalus

2. To cavernous sinus  proptosis

3. To mastoid emissary vein  Griesinger’s sign

Distal:

To internal jugular vein & subclavian vein  pulmonary

thrombo-embolism & septicaemia
Features
 Remittent high fever with rigors (picket fence)

 Oedema over retro-mastoid area & occipital bone due

to mastoid emissary vein thrombosis (Griesinger’s
sign)

 Tenderness along Internal Jugular Vein

 Headache

 Anaemia
Fever

Brain
abscess

Meningitis

Lateral
Sinus
Thrombophlebitis
Special tests
 Queckenstedt or Tobey-Ayer test:
 compression of I.J.V.  rapid rise of C.S.F. pressure (50
– 100 mm water  rapid fall on release of compression.
 In L.S.T. no rise / rise by only 10 – 20 mm water.

 Lillie – Crowe - Beck test:

 pressure on I.J.V. on normal side  engorgement of
retinal veins + papilloedema seen in fundoscopy due to
L.S.T. on opposite side.
Investigations

 Lumbar puncture: to rule out meningitis

 CT brain with contrast: Delta sign or

 MRI brain with contrast: Empty triangle sign

 MR angiography

 Blood culture

 Culture & sensitivity of ear discharge

Delta Sign
Treatment
1. Radical mastoidectomy: Removal of disease +
needle aspiration to confirm diagnosis. Sinus wall
incised. Infected clots removed & abscess drained.

2. I.V. Ceftriaxone + Metronidazole + Gentamicin

3. Anticoagulants: in cavernous sinus thrombosis

4. Internal jugular vein ligation: for embolism not

responding to antibiotics & surgery

5. Blood transfusion: for anaemia

Extra-Dural Abscess

Commonest otogenic
intra-cranial complication

Collection of pus b/w skull

bone & dura of middle or
posterior cranial fossa
Extra-Dural Abscess
 Majority asymptomatic.
 Suspected in case of:
 Profuse, intermittent, pulsatile, purulent, otorrhoea
 Low grade fever
 I/L Persistent headache
 Recurring meningococcal meningitis
 CT scan brain shows extra-dural abscess
 Tx:
 I.V. Ceftriaxone + Metronidazole + Gentamicin
 Modified Radical mastoidectomy
 Drill tegmen or sinus plate  pus drained
Extra-Dural Abscess
Sub-Dural Abscess
Subdural Abscess
 Collection of pus b/w dura & arachnoid by:
 erosion of bone & dura mater or

 retrograde thrombophlebitis

 Symptoms of raised intra-cranial tension & meningeal

irritation develop quickly

 CT scan brain shows subdural abscess

 Tx:
 I.V. Ceftriaxone + Metronidazole + Gentamicin

 Burr hole evacuation of pus

 Radical mastoidectomy after pt becomes stable

Otitic Hydrocephalus
 Synonym:
 Symond’s syndrome

 Etiology:
 Associated L.S.T.  obstruction of cerebral venous return.
 Superior sagittal sinus thrombosis  ed C.S.F. absorption

 Clinical Features:
 Severe headache, vomiting
 Blurred vision, papilloedema, optic atrophy
 Abducens palsy & diplopia due to raised intra-cranial tension

(False localizing sign)

Otitic Hydrocephalus
1. Lumbar puncture:  CSF pressure (> 300 mm H2O).
Biochemistry & bacteriology normal
2. CT scan brain: normal ventricles
3. Treatment:
a. Tx of L.S.T.: I.V. antibiotics & MRM
b.  CSF pressure (prevents optic atrophy) by:
 I.V. Dexamethasone 4mg/6hrs
 I.V. 20% Mannitol 0.5 gm/kg
 Repeated lumbar puncture / lumbar drain
Brain Fungus
 Prolapse of brain into ME cavity / mastoid cavity due to
erosion of dural plate.
 Common in pre-antibiotic era. Rarely seen now in
resistant infections.
 Diagnosis: C.T. scan temporal bone.
 Treatment:
 Removal of necrotic tissue,
 replacement of healthy prolapsed brain into cranial cavity
 repair of bone defect.
Brain Fungus