Chronic Suppurative Otitis Media (CSOM) PDF

CHRONIC-SUPPURATIVE OTITIS MEDIA (CSOM) and ITS COMPLICATIONS DEFINITION: Is the long standing infection causing inflammation of the mucoperiosteum of the middle ear cleft characterized by ear discharge and TM perforation. 2 weeks – 3 months duration. Types of CSOM (a) Tubo-tympanic...

CHRONIC-SUPPURATIVE OTITIS MEDIA (CSOM) and ITS COMPLICATIONS DEFINITION: Is the long standing infection causing inflammation of the mucoperiosteum of the middle ear cleft characterized by ear discharge and TM perforation. 2 weeks – 3 months duration. Types of CSOM (a) Tubo-tympanic SOM (b) Attico Antro SOM  Types of CSOM Tubo tympanic C.S.O.M. Characterized by chronic inflammation of anterior inferior mucoperiosteum, a/w central TM perforation. Regarded as safe.  Route of Entry (1) Ascending from Eustachian tube (2) Through TM perforation (3) Haematogenous spread. Predisposing factors Mechanical obstruction of ET ie Adenoid hypertrophy and Nasopharyngeal tumours Immunodeficiency Allergy Cilliary dysfunction ie Cystic fibrosis Laryngopharyngeal refluxes Genetic predisposition ie Eskimos, American Indians, aborigenes Hx of recurrent AOM Parent with CSOM Craniofacial anomalies Inadequate Treatment of AOM  Pathology (a) Thickened, oedematous occasionally polypoid mucosa. (b) Granulation tissue (c) TM perforation (d) Osteitis and Ossicular necrosis (e) Mucopurulent discharge Microbiology G –ve bacteria 59.7% G +ve bacteria 25.6% Fungi 14.7% ie Aspergillus Bacteria ◦ K.pneumoniae ◦ E.coli ◦ Pseudomonas aureginosa ◦ Staphylococcus ◦ Proteus ◦ MTB NB; It’s a multibacterial in most settings  Investigations (1) Pus swab for Culture and sensitivity (2) Audiological tests ie PTA (3) Imaging (1) X-ray ie for mastoiditis and Adenoid hypertrophy (2) CT scan/MRI (4) FBP  TREATMENT (1) Aural Toilet (2) Medical Rx I. Local antibiotics ie Ciprofloxacin ear drops II. Systemic antibiotic (3) Surgical Rx I. Mastoidectomy II. Adenoidectomy III. Tympanoplasty ATTICO ANTRO CSOM DEFINITION Inflammation involving the posterosuperior region, a/w cholesteatoma. Characterized by marginal or attic TM perforation. Regarded as unsafe or dangerous CHOLESTEATOMA: This is the presence of Keratinizing squamous epithelium in an ectopic site (e.g. middle ear or brain). Ie keratoma CHOLESTEATOMA: SITE Attico antro COM occurs in the epitympanum (attic) and mastoid antrum. AETIOLOGY Congenital theory. Metaplasia theory. Migration theory. Retraction pocket theory CONGENITAL Persistence of Embryonic epidermal rest cells of Epithelial origin; in middle ear or temporal bone. These eventually forms cholesteatoma  Squamous metaplasia theory Middle ear respiratory epithelium transforms into keratinizing squamous epithelium. Due to chronic inflammation MIGRATION THEORY A.KA invasion theory Movement of squamous epithelium from the E.A.C. into the middle ear through a drum perforation. RETRACTION POCKET THEORY (INVAGINATION THEORY) Eustachian tube dysfuction leads to negative middle ear pressure, this leads to a tympanic membrane retraction pocket. The pocket draws squamous cells into the middle ear. The squamous cells multiply and forms a ball containing keratine (cholesteatoma). Clinical features 1. Otorrhoea: Thick malodourous discharge with white blotting paper like material, (cholesteatoma) may be seen in the middle ear. 2. TM perforation,Most commonly occur in the pars flaccida or posterior upper quadrant. Clinical features... 3. Hearing loss: may be mild or severe 4. Ear ache: occur if there is associated otitis externa 5. Bleeding: may occur if associated granulation tissue is traumatized. 6. Vertigo: occurs if the horizontal semicircular canal is involved. 7. Tinnitus 8. Headache: This symptom suggests pending intracranial complications. INVESTIGATIONS As for tubo tympanic CSOM  TREATMENT This disease is more often associated with complications than tubotympanic CSOM. Treatment is surgical unless there are contraindications to surgery. Aim of surgery (1) Create a safe ear (2) Hearing improvement procedures can follow control of the infection.  Types of Surgery 1) Mastoidectomy: (opening into the mastoid antrum) This is done to eradicate the cholesteatoma 2) Tympanoplasty ( repair of the TM membrane and ossicular chain) This is a procedure done to improve the hearing of the patient. COMPLICATIONS OF CSOM with/without cholesteatoma Complications occur when the infection spread beyond the mucoperiosteum of the middle ear cavity. Types of complications Intracranial Extracranial Meningitis Mastoiditis Brain abscess Petrositis Subdural abscess Facial nerve Epidural abscess paralysis Lateral sinus Labyrinthitis thrombosis Labyrinthine fistula Otitic hydrocephalus  Complications of suppurative otitis media EXTRACRANIAL COMPLICATIONS Mastoiditis Facial nerve paralysis Labyrinthitis Petrositis  MASTOIDITIS Destruction of mastoid air cells by inflammatory exudate under pressure occurs. (i) A sub periosteal abscess may occur (Post auricular abscess). (ii) Pus from the mastoid may extend along the sternomastoid muscle forming an abscess in the neck. (Bezolds abscess) PETROSITIS This is inflammation of the petrous pyramid. Such inflammation may involve adjacent structures i.e. the trigeminal Nerve ganglion, and the abducent nerve leading to a triad of symptoms.ie. Otorrhea Diplopia & Facial pain (GRADENIGO’S SYNDROME) FACIAL NERVE PARALYSIS Facial nerve paralysis occurs when infection extends into the falopian canal, through bone erosion or dehiscence.  LABYRINTHITIS Serous type: Hyperaemia of the labyrinth. Suppurative type: Infection has directly entered the labyrinth fluid causing pus. Clinical features Hearing loss Vertigo Tinnitus Spontaneous horizontal nystagmus INTRA-CRANIAL COMPLICATIONS 1 Extradural abscess 2 Subdural abscess 3 Brain abscess The above will present with: Head ache,otorrhea ,fever and papiloedema. impairment of consciousness Convulsions and other neurologic signs.  Complications CT. 4. Otic meningitis Most common intracranial complication 5. Lateral sinus thrombophlebitis This usually follows chronic mastoiditis 6. Otic hydrocephalus May follow reduced CSF reabsoption.  Management of the complications (a) This depends on the type of complication however mastoidectomy is indicated to control the aural infection. (b) A neurosurgeon is involved to handle the intracranial complications. (c) Chemotherapy must take into account gram negative bacillus and anerobic bacteria. The end