Chronic Suppurative Otitis Media Overview

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Questions and Answers

What is the primary characteristic that defines chronic suppurative otitis media (CSOM)?

Persistent or intermittent infected discharge through a nonintact tympanic membrane.

What are the symptoms commonly associated with chronic suppurative otitis media?

Discharge, decreased hearing, pain, and possibly granulation tissue.

Which pathogens are commonly involved in chronic suppurative otitis media?

Pseudomonas aeruginosa, Staphylococcus aureus, and Proteus species.

How does chronic perforation of the tympanic membrane differ from inactive CSOM?

Chronic perforation can occur without suppuration, categorized as inactive CSOM. Signup and view all the answers

Describe the two types of chronic suppurative otitis media classification.

Tubo-tympanic type (safe) and Attico-antral type (unsafe). Signup and view all the answers

What role do special tests such as imaging play in diagnosing CSOM?

Imaging techniques like CT scans and MRIs help assess the extent of the disease. Signup and view all the answers

What may cause the tympanic membrane to fail to heal in cases of CSOM?

Recurrent episodes of acute otitis media and failure of ventilation tube healing. Signup and view all the answers

Why is chronic suppurative otitis media often considered clinically diagnosed?

It typically presents with clear symptoms and physical examination findings. Signup and view all the answers

What is the primary imaging method used to diagnose acute mastoiditis?

CT scan Signup and view all the answers

Name two treatment options for mastoiditis.

Antibiotics and surgery Signup and view all the answers

What mechanism can lead to facial nerve paralysis in cases of otitis media?

Bacterial toxins or direct pressure on the nerve Signup and view all the answers

What symptoms characterize suppurative labyrinthitis?

Sudden sensorineural hearing loss, severe vertigo, and nausea Signup and view all the answers

Which imaging study is essential for evaluating intracranial complications related to acute otitis media?

MRI of the brain Signup and view all the answers

What are the classic symptoms of meningitis that may develop from acute otitis media?

Headaches, photophobia, neck stiffness, and altered consciousness Signup and view all the answers

Explain the potential route for the development of meningitis due to acute otitis media.

Hematogenous spread or direct extension from the middle ear Signup and view all the answers

What should be performed after initiating antibiotic therapy for meningitis secondary to acute otitis media?

A myringotomy Signup and view all the answers

What is a critical step before considering surgical management for a patient with chronic otitis media and meningitis?

The patient should be fully stabilized. Signup and view all the answers

List two commonly cultured organisms associated with intracranial abscesses due to chronic otitis media.

Streptococci and S pneumoniae. Signup and view all the answers

What is the urgency of surgical intervention for a brain abscess compared to the treatment of associated ear diseases?

Urgent intervention is needed for the brain abscess, while ear disease surgery is planned for when the patient stabilizes. Signup and view all the answers

Explain the location of a subdural abscess in relation to the meningeal layers.

It forms between the dura mater and the arachnoid mater. Signup and view all the answers

What are the main symptoms of an extradural abscess?

Headache and fever. Signup and view all the answers

Describe the method of drainage for an extradural abscess.

It can usually be drained through a mastoidectomy approach. Signup and view all the answers

What condition results from thrombus formation in the lateral or sigmoid sinus?

Lateral sinus thrombosis. Signup and view all the answers

What tissue type characterizes a cholesteatoma?

Squamous epithelium. Signup and view all the answers

What are the two types of chronic suppurative otitis media, and how do they differ in terms of discharge characteristics?

The two types are Tubotympanic (safe) with intermittent, non-offensive, non-bloody discharge, and Attico-antral (unsafe) with chronic, scanty, offensive, and bloody discharge. Signup and view all the answers

List the four primary goals of treating chronic suppurative otitis media.

The goals are to eliminate infection, prevent further infection, restore normal middle ear function, and prevent complications. Signup and view all the answers

What is the significance of aural toilet in the nonsurgical management of chronic suppurative otitis media?

Aural toilet helps in cleaning the ear to remove debris and discharge, facilitating better healing and effectiveness of other treatments. Signup and view all the answers

Differentiate between tympanoplasty and myringoplasty.

Myringoplasty is the repair of the perforated tympanic membrane, while tympanoplasty includes myringoplasty and ossicular reconstruction. Signup and view all the answers

What are the two types of mastoidectomy and how do they differ?

The two types are Canal Wall Up (CWU) and Canal Wall Down (CWD), differing in the maintenance of the ear canal wall structure. Signup and view all the answers

Describe the initial indicators of mastoiditis in children.

Initial indicators include pain and tenderness over the mastoid process, along with potential swelling and redness of the postauricular soft tissues. Signup and view all the answers

What is the aim of medical treatment for chronic suppurative otitis media before considering surgical options?

The aim is to shift the condition from an active to an inactive form, potentially resolving the issue without surgery. Signup and view all the answers

Explain what cholesteatoma surgery typically involves.

Cholesteatoma surgery usually involves mastoidectomy to remove the cholesteatoma and any infected tissue. Signup and view all the answers

What characterizes congenital cholesteatoma based on Levenson criteria?

A white mass medial to the normal tympanic membrane with no history of otorrhea or perforations. Signup and view all the answers

What is the primary cause of primary acquired cholesteatoma?

Eustachian tube dysfunction leading to poor aeration of the epitympanic space. Signup and view all the answers

Describe the role of metaplasia in secondary acquired cholesteatoma.

Metaplasia involves the transformation of cuboidal epithelium to squamous epithelium due to chronic infection. Signup and view all the answers

List three common symptoms associated with cholesteatoma.

Hearing loss, otorrhea, and tinnitus. Signup and view all the answers

What physical examination findings are indicative of cholesteatoma?

Posterosuperior retraction pocket with squamous debris and granulation tissue from diseased bone. Signup and view all the answers

What imaging study is essential in the evaluation of cholesteatoma, particularly in revision cases?

CT temporal bone. Signup and view all the answers

What are the main objectives of managing cholesteatoma surgically?

To remove the disease for a safe, dry ear and to restore or maintain hearing capacity. Signup and view all the answers

What factors are considered in the treatment of cholesteatoma?

Each case is treated individually based on the extent and location of the disease. Signup and view all the answers

Study Notes

Chronic Suppurative Otitis Media (CSOM)

CSOM is defined as persistent or intermittent infected discharge through a non-intact tympanic membrane (perforation or tympanostomy tube).
Inactive CSOM occurs when chronic perforation exists but without suppuration.
CSOM usually occurs after an episode of acute otitis media (AOM) with perforation, failing to heal.
CSOM can also occur after ventilation tube insertion if the tympanic membrane fails to heal.
Traumatic perforations can also lead to CSOM.

Pathogenesis of CSOM

Most commonly, CSOM occurs as a consequence of AOM with perforation, and failure of healing.

Bacteriology of CSOM

The most common bacterial culprits include:
- Pseudomonas aeruginosa
- Staphylococcus aureus
- Proteus species
- Anaerobic bacteria

Symptoms and Signs of CSOM

Discharge (Active or Inactive)
Decreased hearing
Pain during exacerbations
Associated otitis externa
Perforated tympanic membrane
Granulation tissue
Polyp

Special Tests for CSOM

CSOM is clinically diagnosed
Swab for culture and sensitivity
Audiological test
Imaging:
- CT scan
- MRI

Classification of CSOM

Tubo-tympanic type (Safe):
- Simple perforation
- Intermittent, non-offensive, non-bloody ear discharge
- Central perforation on examination
Attico-antral (Unsafe):
- Chronic, scanty, offensive, and bloody ear discharge
- Marginal perforation on examination
- More likely to develop cholesteatoma

Treatment of CSOM

Goals of Treatment:
- Eliminate infection
- Prevent further infection
- Restore normal middle ear function
- Prevent complications
Non-Surgical Measures:
- Aural toilet (ear cleaning)
- Topical antibiotics
- Systemic antibiotics
- Water precautions
Surgical Measures:
- Tympanoplasty
- Tympanomastoid surgery:
  - Mastoidectomy (Canal Wall Up and Canal Wall Down)

Surgical Repair of Tympanic Membrane Perforation

Myringoplasty: Repair of a perforated membrane
Tympanoplasty: Myringoplasty + ossicular reconstruction

Ossicular Chain Reconstruction

Using cartilage or prosthesis

Cholesteatoma Surgery

Mastoidectomy (Canal Wall Up and Canal Wall Down)

Complications of Otitis Media

Intratemporal Complications

Mastoiditis:
- Pain and tenderness over the mastoid process
- Edema and erythema of the postauricular soft tissues
- Loss of the postauricular crease
- Anteroinferior displacement of the pinna
- Fluctuance in the postauricular area (subperiosteal abscess)
- CT scan is the preferred radiologic investigation
Treatment:
- Antibiotics
- Surgery
Facial Nerve Paralysis:
- Bacterial toxins or pressure from cholesteatoma or granulation tissue
Suppurative Labyrinthitis:
- Direct bacterial invasion of the inner ear, usually via the round window
- Sudden sensorineural hearing loss, severe vertigo, nystagmus, nausea, and vomiting
- Increased risk of meningitis due to cochlear aqueduct communication with cerebrospinal fluid

Intracranial Complications

Meningitis:
- Most common cause of bacterial meningitis
- Hematogenous blood spread or direct extension from the middle ear
- Commonly caused by S. pneumoniae and H. influenzae type B
- Classic presentation: headaches, photophobia, neck stiffness, and fluctuating consciousness
- MRI of the brain to rule out other intracranial complications
- Lumbar puncture
Treatment:
- Antibiotics
- Myringotomy
Intracranial Abscess:
- Most commonly associated with CSOM
- Temporal lobe or cerebellum
- Urgent neurosurgical intervention
Subdural Abscess:
- Forms between the dura mater and the arachnoid mater
- Symptoms develop rapidly
- Drainage of the abscess is the mainstay of treatment
Extradural Abscess:
- Forms between the dura mater and the thin bony plate of the tegmen
- Headache and fever are the most common features
- Usually drained through a mastoidectomy approach
Lateral Sinus Thrombosis:
- Thrombus formation in the lateral or sigmoid sinus
- Symptoms: intermittent fever
- MRI for diagnosis
- Treatment: Anti-coagulation

Cholesteatoma

Squamous epithelium in the middle ear or mastoid.
Coined (1838) "a pearly tumor of fat...among sheets of polyhedral cells.”
Independent growth, replaces mucosa, and resorbs bone

Classification of Cholesteatoma

Congenital:
- Arise from embryonal rests of epithelial cells
- Location: petrous pyramid, mastoid, and middle ear cleft
Acquired:
- Primary Acquired (Retraction Pocket):
- Eustachian tube dysfunction
- Poor aeration of the epitympanic space
- Retraction of the pars flaccida
- Altered normal migratory pattern
- Keratin accumulation and sac enlargement
- Secondary Acquired:
- Implantation: surgery, foreign body, blast injury
- Metaplasia: transformation of cuboidal epithelium to squamous epithelium due to chronic infection
- Invasion/Migration: medial migration along a permanent TM perforation

Evaluation of Cholesteatoma

History:
Hearing loss, otorrhea, otalgia (earache), tinnitus, vertigo, and nasal obstruction.
Previous history of CSOM, tympanic membrane perforation, or otologic surgery
Progressive unilateral hearing loss with chronic fetid otorrhea is suspicious.
Physical Examination:
- Otomicroscopy:
  - Posterosuperior retraction pocket with squames
  - Granulation from diseased bone
  - Aural polyps.
- Pneumatic otoscopy: Positive fistula response suggests erosion into the labyrinth, which can cause vertigo
- Cultures should be obtained from infected ears
Audiology: Usually conductive loss, but can vary greatly
Imaging:
CT temporal bone:
- Definitively obtained for revision cases
- Complications of CSOM
- Sensorineural hearing loss
- Vestibular symptoms
- Other complications of cholesteatoma

Management of Cholesteatoma

Surgical disease with specific objectives:
- Remove the disease for a safe, dry ear
- Restore or maintain functional capacity of the ear (i.e. hearing)
- Maintain normal anatomy whenever possible
- Management of complications takes priority
Each case treated individually based on the extent and location of the disease.
Preoperative counseling:
Although hearing difficulty is usually the main presenting symptom, it is essential to fully educate the patient about the condition and the potential risks involved.

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Description

This quiz focuses on Chronic Suppurative Otitis Media (CSOM), covering its definition, pathogenesis, common bacteria involved, and symptoms. Test your knowledge on how CSOM develops after episodes of acute otitis media and its implications. Ideal for students in medical or health-related fields.