Chronic Otitis Media

Etiology, pathology,complications
And management

DOHA, 2017
 Chronic Otitis Media
Types
Tubotympanic Chronic Active
Attico-antral Chronic Inactive
 Chronic Otitis Media
Surgical Strategy
Patient
Surgeon
Pathology
 Chronic Otitis Media
PATHOLOGICAL VARIANTS

 Eardrum perforation
 Atelectatic eardrum
 Tympanosclerosis
 Middle ear fibrosis
 Cholesterol granuloma
 Chronic Serous Mastoiditis.
 Cholesteatoma
 Chronic Otitis Media
 Obviously the results of chronic ear surgery varies
widely in these different pathological variants
 A combination of lesions may be present in one case
EARDRUM PERFORATION
Office Examination

Bridging the Gap

Office Examination

Bridging the Gap

Multislice CT
Coronal Sagittal Reconstruction

Bridging the Gap

Virtual Otoendoscopy

Bridging the Gap

 EARDRUM PERFORATION
Goals of surgery
 Repair of eardrum defect
 Removal of squamous
epithelium
 Checkup of ossicular
chain
 Myringoplasty
Underlay/Overlay
OVERLAY MYRINGOPLASTY

7 years P/O
Blunting
Lateralization
FAT MYRINGOPLASTY
Tissue engineering
CELLS
- stem
(adult, embryonic)
- somatic
- culture method

SCAFFOLDS SIGNALS
- natural - proliferation
- synthetic - differentiation
- vascularization - drug delivery
The current project: myringoplasty in rats using stem cells
Fibrin glue scaffold Stem cell complex
Multipotent :which can
give rise only to tissues
belonging to one embryonic
germ layer (ectoderm,
mesoderm or endoderm).
 ATELECTATIC EARDRUM
 Atrophy of the fibrous layer
of the eardrum
 Collapse of the eardrum on
the medial wall of the
mioddle ear
 Adhesions due to bouts of
OM
Atelectatic Eardrum
ATELECTATIC EARDRUM
Staging Management
Only if associated with:
 Severe conductive Hearing
loss
 Recurrent infections
 Starting cholesteatoma
 ATELECTATIC EARDRUM
Goals of surgery
 Ventilation tubes in
earlycases
 Reconstruction of
new rigid eardrum
 Areation :Tympano-
mastoidectomy
 TYMPANOSCLEROSIS

 Ischemia  Tympanic
 Calciun deposition,  Ossicular
hyalinization and ossification
 TYMPANOSCLEROSIS
Goals of Surgery
 Removal of large TS
patches
 Ossicular
reconstruction
Ossiculoplasty
 Management of I-S Defects

Bridging the Gap Mahmoud

Reda,MD
Incus Interposition

Bridging the Gap

Cartilage Interposition

Bridging the Gap

Joint Prosthesis

Applebaum® ISJ Prosthesis

Bridging the Gap

Joint Prosthesis

KURZ® ISJ Prosthesis

Bridging the Gap

Joint Prosthesis

KURZ® Incus Bridge Prosthesis

Bridging the Gap

Joint Prosthesis

KRAUS K-Helix® ISJ Prosthesis

Bridging the Gap

PORPs

Bridging the Gap

Bone Cements & Tissue Adhesives

Glass Ionomer Cement (GIC)

Hydroxyapatite Cement

Fibrin Glue

Bridging the Gap

 Glass Ionomer Cement (GIC)
Calcium aluminium
fluorosilicate
(Powder)
+
Maleic acid
(Liquid)

GIC
Working time: 3 to 5 min
Setting : 7 to 10 min

Bridging the Gap

 Glass Ionomer Cement (GIC)
Properties:
• Histopathological : Biocompatible

• Physical : Adhesion to bone

• Application : Easy to use

• Audiological : Efficient

• Durability : Long-lasting

• Financial : Economic

Bridging the Gap

 Glass Ionomer Cement (GIC)

Bridging the Gap

 Glass Ionomer Cement (GIC)

Bridging the Gap

 What is the best
modality ???

Bridging the Gap

 3 Logic Answers

No modality is suitable for every IS defect

We need a Staging system

Bridging the Gap

Classification of Ossicular Defects
Austin 1972 Kartush 1994

Bridging the Gap

Staging of IS Defects

Bridging the Gap

Classification of IS Defects

Bridging the Gap

Importance of Staging System

Stage-specific
technique

Reliable comparing of
results

Bridging the Gap Mahmoud

Reda,MD
Stage-Specific Technique
1st choice 2nd choice 3rd choice
Type 1
Cement bridging Cartilage interposition _

Type 2
Cement bridging I-S Joint prosthesis Incus interposition
(Applebaum)

Type 3
Cement bridging Incus interposition PORP

Type 4
Incus interposition PORP _

Bridging the Gap

 Message
IS Defects are commonly encountered

New staging System & stage-specific reconstructive

technique
gives the best functional results

GIC Bridging Technique is a safe and efficient in

reconstruction of
most of IS defects
OSSICULOPLASTY

Incus Autograft
6 years P/O
Autograft Incus
OSSICULOPLASTY
Homograft Incus

Malleus homograft
1year P/O
OSSICULOPLASTY

Tragal autograft
3 years P/O
OSSICULOPLASTY
Plastipore TORP x 20
Plastipore SEM x 200
Plastipore TEM
CHOLESTEROL GRANULOMA
Pathogenesis: Gold Flecks
Chronic eustachian
dysfunction
Bleeding and effusion
RBCs disentigration
Cholesterol crystalls
release
FB resction and
granuloma formation in
middle ear and mastoid
 CHOLESTEROL GRANULOMA
Goals of surgery
 Removal of
granuloma:ICW
Mastoidectomy
 Muco-lined, air-filled
middle ear:
Tympanoplasty
 MIDDLE EAR FIBROSIS
Pathogenesis:
Recurrent otitis media
Fibrosis, cyst formation
and ossification in the
middle ear
Fibrocystic and fibro-
osseous otitis media
 MIDDLE EAR FIBROSIS
Pathology
Airless middle ear space
Thickened retracted
eardrum
Fixation of
malleus/incus in the
epitympanum
 MIDDLE EAR FIBROSIS

Goals of Surgery Surgical Technique

Mucosa-lined air-filled  2 stage operation
middle ear  1st, lysis of adhesions, silastic
Hearing aids are an sheet
alternative  2nd, ossiculoplasty
 Chronic Serous Mastoiditis

Pathology
 Metaplasia of the lining
mucosa of the middle ear and
mastoid
 Recurrent ME effusions
 Chronic Serous Mastoiditis

Goals of surgery Surgical Technique

Stripping of tympano-  ICW mastoidectomy with
mastoid mucosa obliteration
 Tympanoplasty with silastic
sheeting of the middle ear
 CHOLESTEATOMA
Definition: Wrong Skin:
Wrong skin in the wrong No hair follicles
place No sweat glands
No stratified layer

Wrong place
Tympanomastoid
Petrous Bone
Cerebellopontine angle
 CHOLESTEATOMA
Etiology: Staging:
Congenital
Primary acquired
Secondary acquired
CONGENITAL CHOLESTEATOMA
 CONGENITAL CHOLESTEATOMA
Without eardrum perforation
No relation to pars flaccida
Surounding ME mucosa is normal
In relation to pars tensa
 CONGENITAL CHOLESTEATOMA
 Origin: mesotympanum either anterior to the malleus
handle (Type A1) or posterior over the incudo-
stapedial joint(Type A2)
 Spread: equal in all directions
 Eardrum: intact
 Middle Ear: involved early and extensively
 Mastoid: pneumatized and involved early
 Surgery: ICW, multiple stages
PRIMARY ACQUIRED CHOLESTEATOMA
PRIMARY ACQUIRED CHOLESTEATOMA
 Origin: epitympanum
 Spread: upwards and backwards
 Eardrum: attic perforation
 Middle ear: free meso-and hypotympanum
 Mastoid: involved early
 Surgery: modified radical if intact ossicles & sclerosed
mastoid. Open mastoid tympanoplasty, one or more
stages
SECONDARY ACQUIRED CHOLESTEATOMA
SECONDARY ACQUIRED CHOLESTEATOMA
 Origin: Mesotympanum
 Spread: downwards and forwards
 Eardrum: marginal or total perforation
 Middle ear: involved early and extensively
 Mastoid: involved late
 Surgery: ICW mastoidectomy, one or more stages
 Complications of COM
Cranial
Intracranial
Extracranial
 Cranial Complications
Labyrinthine fistula
Facial paralysis
Sensorineural hearing loss
Endolymphatic hydrops
 IntraCranial Complications
Sinus thrombophlebitis
Meningitis
Brain abscess
Otitic hydrocephalus
 ExtraCranial Complications
Mastoiditis with subperiosteal abscess
Postauricular
Zygomatic
Bezold,s
Petrositis