Chronic Suppurative Otitis Media Overview

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Questions and Answers

Which of the following is NOT a characteristic of a Bezold's abscess?

It occurs when pus from the mastoid extends along the sternomastoid muscle

It is an abscess in the neck

It is a subperiosteal abscess (correct)

It can be a complication of mastoiditis

What is the most common intracranial complication of suppurative otitis media?

Otic meningitis (correct)

Lateral sinus thrombophlebitis

Subdural abscess

Brain abscess

What is the triad of symptoms associated with Gradenigo's syndrome?

Otorrhea, facial pain, and vertigo

Otorrhea, facial paralysis, and headache

Otorrhea, tinnitus, and hearing loss

Otorrhea, facial pain, and diplopia (correct)

What is the clinical feature that distinguishes a serous labyrinthitis from a suppurative labyrinthitis?

Presence of pus in labyrinth fluid (D) Signup and view all the answers

Which of the following statements is TRUE regarding otic hydrocephalus?

It is caused by reduced CSF reabsorption (C) Signup and view all the answers

What is the most likely cause of facial nerve paralysis in a patient with suppurative otitis media?

Infection extending into the falopian canal (B) Signup and view all the answers

Which of the following is NOT a typical symptom of an intracranial complication of suppurative otitis media?

Hearing Loss (D) Signup and view all the answers

What is the role of a neurosurgeon in managing complications of suppurative otitis media?

To treat intracranial complications (D) Signup and view all the answers

What is the primary outcome of the retraction pocket theory in relation to cholesteatoma formation?

It results from Eustachian tube dysfunction. (D) Signup and view all the answers

Which clinical feature is most indicative of the presence of cholesteatoma in the middle ear?

Thick malodourous discharge (B) Signup and view all the answers

What is the main goal of surgical treatment for cholesteatoma?

To create a safe ear and improve hearing. (B) Signup and view all the answers

In the context of chronic otitis media with cholesteatoma, which complication may occur when the infection spreads beyond the middle ear?

Intracranial complications (B) Signup and view all the answers

Which type of surgery is performed specifically to eradicate cholesteatoma?

Mastoidectomy (A) Signup and view all the answers

What is a defining characteristic of Tubo-tympanic CSOM?

Central TM perforation (B) Signup and view all the answers

Which of the following is NOT considered a route of entry for Tubo-tympanic CSOM?

Direct infection through the mastoid (C) Signup and view all the answers

Which predisposing factor is associated with an increased risk for CSOM?

Ciliary dysfunction (A) Signup and view all the answers

What type of bacteria is most commonly associated with CSOM infections?

Gram-negative bacteria (D) Signup and view all the answers

Which imaging technique is commonly used to evaluate complications of CSOM?

CT scan/MRI (D) Signup and view all the answers

What surgical option is typically performed for the management of Attico Antro CSOM?

Mastoidectomy (D) Signup and view all the answers

Which of the following best describes cholesteatoma?

Ectopic presence of keratinizing squamous epithelium (D) Signup and view all the answers

What is the primary characteristic of Attico Antro CSOM?

It is associated with a cholesteatoma (D) Signup and view all the answers

Study Notes

Chronic Suppurative Otitis Media (CSOM)

CSOM is a long-standing infection of the middle ear mucoperiosteum.
Characterized by ear discharge and TM perforation.
Duration: 2 weeks to 3 months.

Types of CSOM

Tubo-tympanic: Chronic inflammation of the anterior inferior mucoperiosteum, often with a central TM perforation. Considered safe.
Attico-antral: Inflammation involving the posterosuperior region, often associated with cholesteatoma. Considered unsafe or dangerous.

Route of Entry

Ascending from the Eustachian tube.
Through a TM perforation.
Haematogenous spread.

Predisposing Factors

Mechanical obstruction of the Eustachian tube (e.g., adenoid hypertrophy).
Immunodeficiency.
Allergies.
Ciliary dysfunction (e.g., cystic fibrosis).
Laryngopharyngeal reflux.
Genetic predisposition (e.g., certain ethnic groups).
History of recurrent acute otitis media (AOM).
Parent with CSOM.
Craniofacial anomalies.
Inadequate treatment of AOM.

Pathology

Thickened, edematous, occasionally polypoid mucosa.
Granulation tissue.
TM perforation.
Osteitis and ossicular necrosis.
Mucopurulent discharge.

Microbiology

Gram-negative bacteria (59.7%).
Gram-positive bacteria (25.6%).
Fungi (14.7%, e.g., Aspergillus).
Various bacterial species are commonly present (K. pneumoniae, E. coli, Pseudomonas aeruginosa, Staphylococcus, Proteus, MTB).
Multibacterial in most cases.

Investigations

Pus swab for culture and sensitivity.
Audiological tests (e.g., PTA).
Imaging:
- X-ray (for mastoiditis and adenoid hypertrophy).
- CT scan/MRI.
- FBP (likely a blood test).

Treatment

Aural toilet.
Medical treatment (local antibiotics, e.g., Ciprofloxacin ear drops, systemic antibiotics).
Surgical treatment (Mastoidectomy, Adenoidectomy, Tympanoplasty).

Attico-antral CSOM

Inflammation involving the posterosuperior region, often with cholesteatoma.
Characterized by marginal or attic TM perforation.
Considered unsafe or dangerous.

Cholesteatoma

Presence of keratinizing squamous epithelium in an ectopic site (e.g., middle ear, brain).

Site of Attico-antral CSOM

Located in the epitympanum (attic) and mastoid antrum.

Aetiology Theories

Congenital theory.
Metaplasia theory.
Migration theory.
Retraction pocket theory.

Congenital Theory

Persistence of embryonic epidermal rest cells of epithelial origin in the middle ear or temporal bone.
Eventually forms cholesteatoma.

Squamous Metaplasia Theory

Middle ear respiratory epithelium transforms into keratinising squamous epithelium.
Due to chronic inflammation.

Migration Theory

AKA Invasion theory.
Movement of squamous epithelium from the external auditory canal into the middle ear.
Occurs through a drum perforation.

Retraction Pocket (Invagination) Theory

Eustachian tube dysfunction leads to negative middle ear pressure causing retraction pocket on the tympanic membrane.
The pocket draws squamous cells into the middle ear.
Cells multiply to form a keratinised mass (cholesteatoma).

Clinical Features

Otorrhoea (thick, malodorous discharge, potentially with white, blotting-paper-like cholesteatoma material).
TM perforation.
Hearing loss.
Earache.
Bleeding (if associated granulation tissue is traumatized).
Vertigo (if horizontal semicircular canal is involved).
Tinnitus.
Headache (suggests pending intracranial complications).

Intracranial Complications

Meningitis.
Brain abscess.
Subdural abscess.
Epidural abscess.
Lateral sinus thrombosis.
Otic hydrocephalus.

Extracranial Complications

Mastoiditis.
Petrositis.
Facial nerve paralysis.
Labyrinthitis
Labyrinthine fistula.

Mastoiditis

Destruction of mastoid air cells by inflammatory exudate under pressure.
Subperiosteal abscess (post-auricular abscess) may occur.
Pus may extend along the sternomastoid muscle to the neck (Bezold's abscess).

Petrositis

Inflammation of the petrous pyramid involving adjacent structures (trigeminal and abducent nerves).
Triad of symptoms: otorrhoea, diplopia, facial pain (Gradenigo's syndrome).

Facial Nerve Paralysis

Infection extends into the fallopian canal, through bone erosion or dehiscence.

Labyrinthitis

Serous type: Labyrinth hyperemia
Suppurative type: Infections directly entering labyrinth fluid, causing pus.
Clinical features: Hearing loss, vertigo, tinnitus, spontaneous horizontal nystagmus.

Management of Complications

Management depends on the type of complication.
Mastoidectomy is often indicated to control the aural infection.
Neurosurgeon involvement is critical for intracranial complications.
Chemotherapy must consider gram-negative bacillus and anaerobic bacteria.

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Description

This quiz covers the key aspects of Chronic Suppurative Otitis Media (CSOM), including its types, routes of entry, and predisposing factors. Understand the differences between tubo-tympanic and attico-antral CSOM, as well as common causes and complications associated with this condition.