Chronic Suppurative Otitis Media PDF

Chronic suppurative otitis media Dr. Abdullah Alkhalil MRCS-ENT(UK), DOHNS(London) Higher specialty(JUST), Jordanian Board. puesttfwmwfoeffeg.fr  Chronic suppurative otitis media Chronic suppurative otitis media is defined as a persistent or intermi...

Chronic suppurative otitis media Dr. Abdullah Alkhalil MRCS-ENT(UK), DOHNS(London) Higher specialty(JUST), Jordanian Board. puesttfwmwfoeffeg.fr  Chronic suppurative otitis media Chronic suppurative otitis media is defined as a persistent or intermittent infected discharge through a nonintact tympanic membrane (ie, perforation or tympanostomy tube). Chronic perforation of the tympanic membrane can occur without suppuration and is often referred to as “inactive” CSOM. essenladfanda hi.at ah.TMperetf ESSENTIALS OF DIAGNOSIS A Chokken Chronic or recurrent otorrhea or both. Tymphets Rent e Hearing loss. Tympanic membrane perforation. he 3105 Active Inactive NO Otorley DUST  of Pathogenesis loneauence A0 trauma failureof TYMEftektd.EE e In most cases, CSOM occurs as a consequence of an episode of AOM with perforation, with subsequent failure of the perforation to heal. Failure of tympanic membrane to heal after ventilation tube insertion. Traumatic perforation 2 1 11 Bacteriology P aeruginosa PYYI.IQ in S aureus Proteus species. Anaerobe  Discharge SYMPTOMS AND SIGNS Effy Discharge. (Active vs inactive) Decreased hearing. 0 Pain !!! Exacerbations Associated otitis externa. Perforated tympanic membrane Granulation tissue. 00 Polyp  Specialists SPECIAL TESTS CSOM is clinically diagnosed condition. Swab for C & S Audiological test Imaging - CT scan - MRI SPECIAL TESTS Complete oppacification  Chronic suppurative otitis media Classification : Chronic suppurative otitis media Tubo-tympanic type (safe) Attico- antral (un safe) AT Attic means epitympanum (space above tympanic membrane) This was the old classification Atrium is the tympanic space. bcz no CSOM is safe Mastoid antrum is the entry to mastoid cavity  Chronic suppurative otitis media A- Tubotympanic type (Safe) : Simple perforation. Intermittent non offensive non bloody ear discharge. of On examination (central perforation ).  Chronic suppurative otitis media Choked B- Attico-antral (unsafe) : Chronic ,Scanty, offensive and bloody ear discharge. On examination marginal perforation. More likely to develop You may see cholesteatoma. defeats each behing 28 8 Treatment Goals: 1. Eliminate infection. 2. Prevent further infection. 3. Restore normal functioning to the middle ear. 4. Prevent complication. Treatment NONSURGICAL MEASURES 1. Aural toilet 2. Topical antibiotics 3. Systemic antibiotics 4. Water precautions Aim of medical treatment is to shift from active to inactive form for surgery bcz almost always requires surgical treatment Treatment SURGICAL MEASURES Some cases of CSOM resolve with medical treatment, and if the patient is asymptomatic, then no further intervention is required. However, if otorrhea recurs or persists despite medical treatment or if the patient feel handicapped by a residual conductive hearing loss, surgical therapy should be considered. Treatment SURGICAL MEASURES 1. Tympanoplasty 2. Tympanomastoid surgery Mastoidectomy (CWU & CWD) Canal wall up, canal wall down  Chronic suppurative otitis media B — Surgical repair of the TM perforation : Myringplasty = Repair of perforated membrane Tympanoplasty = myringoplasty + ossicular reconstruction Chronic suppurative otitis media — Ossicular Chain Reconstruction : By cartilage or prothesis Cholesteatoma Surgery : Mastoidectomy ( CWU & CWD )  Complication of otitis media Intratemporal Complications 1. Mastoiditis: Typically, acute mastoiditis presents as a complication of AOM in a child. Pain and tenderness over the mastoid process are the initial indicators of mastoiditis. As the infection progresses, edema and erythema of the postauricular soft tissues with loss of the postauricular crease develop. These changes result in anteroinferior displacement of the pinna. If a subperiosteal abscess has developed, fluctuance may be elicited in the postauricular area. Mastoiditis ñ Once the diagnosis of acute mastoiditis is suspected, the radiologic investigation of choice is a CT scan, which provide information about the extent of the opacification of the mastoid air cells, the formation of subperiosteal abscess, and the presence of intracranial complications. Mastoiditis it Mastoiditis Treatment: 1. Antibiotics 2. Surgery o  Complication of otitis media Intratemporal Complications Aom bacterialtoxins pressureby chronic granulation 2. Facial Nerve Paralysis eholewtomn Facial nerve palsy can occur as a result of either acute or chronic OM. There are two mechanisms by which OM can result in facial nerve paralysis: (1) as a result of the locally produced bacterial toxins or (2) from direct pressure applied to the nerve by cholesteatoma or granulation tissue. Facial Nerve Paralysis Treatment ?  Complication of otitis media Intratemporal Complications Caine 3.Suppurative Labyrinthitis Infection of the middle ear can lead to direct bacterial invasion of the inner ear, usually via the round window, resulting in acute suppurative labyrinthitis. Suppurative Labyrinthitis Suppurative labyrinthitis presents with sudden sensorineural hearing loss, severe vertigo, nystagmus, and nausea and vomiting. The cochlear aqueduct provides a direct communication between the perilymph and the cerebrospinal fluid; therefore, there is a significant risk of developing meningitis. Treatment  Complication of otitis media Intracranial Complications Reduced in incidence Have high mortality Persistent headache and fever are alarming signs. MRI investigation of choice  Intracranial Complications 1. Meningitis: Acute otitis media is the most common cause of bacterial meningitis. in blood or directly It can occur as a result of hematogenous spread, of direct extension from the middle ear. S pneumoniae and H influenzae type B are responsible microbs. The classic presentation is with headaches, photophobia, neck stiffness, and fluctuating levels of consciousness. The evaluation should include an MRI of the brain to rule out other intracranial complications as well as a lumbar puncture Meningitis If meningitis is secondary to AOM, then a myringotomy should be performed once antibiotic therapy has been initiated. In the case of CSOM resulting in meningitis, the patient should be fully stabilized before considering surgical management of the chronic ear disease. 1  Complication of otitis media Intracranial Complications Intracranial Abscess Intracranial abscesses are usually caused by multiple aerobic and anaerobic bacteria. Commonly cultured organisms include streptococci, S aureus, S pneumoniae, H influenzae, P aeruginosa, Bacteroides fragilis, and Proteus species. Most commonly associated with chronic otitis media Intracranial Complications BRAIN ABSCESS Temporal lobe or cerebellum. The progression of symptoms from a brain abscess can be gradual. Once a brain abscess has been diagnosed, urgent neurosurgical intervention is indicated to drain the abscess. Surgery for the associated ear disease is less urgent and should be planned when the patient’s condition is more stable. Intracranial Complications SUBDURAL ABSCESS A subdural abscess forms between the dura mater and the arachnoid mater. Symptoms and signs tend to progress much more rapidly than those seen with a brain abscess. Drainage of the abscess is the mainstay of treatment. Dura Arachnoid Pia matter Intracranial Complications EXTRADURAL ABSCESS Extradural abscesses are typically formed in the middle fossa between the dura mater and the thin bony plate of the tegmen. As with other intracranial complications, headache and fever are the most common features. Because of its location, an extradural abscess can usually be drained through a mastoidectomy approach while treating the underlying middle ear disease. Intracranial Complications Lateral Sinus Thrombosis Thrombus formation in the lateral or sigmois sinus. Symptoms: intermittent fever MRI for diagnosis Treatment  Cholesteatoma Dr. Abdullah Alkhalil MRCS-ENT(UK), DOHNS(London) Higher specialty(JUST), Jordanian Board. Cholesteatoma Squamous epithelium in the middle ear or mastoid. Johannes Müller (1838) coined the term “a pearly tumor of fat…among sheets of polyhedral cells” Exhibits independent growth, replaces mucosa, resorbs bone Classification Congenital Acquired – Primary acquired (retraction pocket) – Secondary acquired Pathogenesis Congenital – Arise from embryonal rests of epithelial cells – Location (petrous pyramid, mastoid and middle ear cleft) – Levenson criteria White mass medial to normal TM Normal pars flaccida and tensa No history of otorrhea or perforations No prior otologic procedures Congenital cholesteatoma  Pathogenesis Primary acquired – Eustachian tube dysfunction – Poor aeration of the epitympanic space – Retraction of the pars flaccida – Normal migratory pattern altered – Accumulation of keratin, enlargement of sac Primary acquired cholesteatoma  Pathogenesis Secondary acquired – Implantation – surgery, foreign body, blast injury – Metaplasia – transformation of cuboidal epithelium to squamous epithelium from chronic infection – Invasion/Migration – medial migration along permanent perforation of TM  Evaluation O Similar to CSOM History – Hearing loss, otorrhea, otalgia, tinnitus, vertigo and nasal obstruction – Previous history of chronic otitis media, tympanic membrane perforation or otologic surgery – Progressive unilateral hearing loss with chronic fetid otorrhea suspicious  Evaluation Physical Examination – Otomicroscopy – Posterosuperior retraction pocket with squam – Granulation from diseased bone – Aural polyps – Pneumatic otoscopy – positive fistula response suggests erosion into labyrinth Induces vertigo – Cultures should be obtained in infected ears  Evaluation 2 Audiology – usually conductive loss, may vary greatly; confirm with tuning forks Imaging – CT temporal bone – definitely obtain for revision cases, complications of chronic suppurative otitis media, sensorineural hearing loss, vestibular symptoms, other complications of cholesteatoma  Management Surgical disease with definite objectives: – Removal of disease for safe, dry ear – Restore or maintain functional capacity of ear, i.e., hearing – Maintain normal anatomy if possible – Management of complications takes priority Each case treated individually according to extent/location of disease Preoperative counseling Although hearing difficulty is main presenting symptoms. Main goal is dry ear, so tell the patient that hearing might not return or even worsen (e.g removal of affected ossicles by infection & erosion)  Management Medical – Aural toilet, local care, – patients with unacceptable anesthesia risks Preventive – Tympanostomy tube for early retraction pockets – Surgical exploration for persistence