Chronic Suppurative Otitis Media: Tubotympanic Type (CSOM TT) is an important topic for MBBS and MS ENt students. Dr Krishna Koirala will be explaining this topic in a simplified way.

1. Chronic Suppurative Otitis Media:
Tubotympanic Disease (CSOM TT,
COM Mucosal type)
Dr. Krishna Koirala
2016-05-03

2. Definition
• Pyogenic infection of middle ear cleft mucosa
lasting for more than 3 months characterized
by persistent perforation of pars tensa of
tympanic membrane, ear discharge and
decreased hearing

3. Tubo-tympanic vs. Attico-antral

4. Perforations of Pars Tensa in CSOM TT

5. Involves only one quadrant or < 10% of pars tensa
Small perforation

6. Medium perforation
Involves two quadrants or 10 – 40 % of pars tensa

7. Large perforation

8. Retraction of pars Tensa of TM

9. Grade I retraction
• Dull, lusterless T.M.
• Prominent annulus
• Cone of light absent
• Prominent lateral process
• Handle of malleus medialized
• Malleal folds sickle shaped

10. Grade II retraction
TM touches the incus

11. Grade III retraction
TM touches the promontory (atelectasis) but mobile
on Valsalva maneuver or Siegelization

12. Grade IV retraction
TM firmly adherent to promontory & immobile on Valsalva
maneuver or Siegelization

13. Predisposing factors for CSOM TT
• Upper respiratory tract infection (recurrent)
• Upper respiratory tract allergy
• Pre-existing otitis media with effusion
• Cleft palate
• Immune deficiency: diabetes, AIDS
• Poor socio-economic status

14. Bacteria responsible
• Staphylococcus aureus
• Pseudomonas aeruginosa
• Klebsiella
• Proteus
• Streptococcus
• Bacteroides

15. Routes of infection
1. Via Eustachian tube
– U.R.T.I., nose blowing, regurgitation of milk
2. Via tympanic membrane perforation
– Following A.S.O.M. or post-traumatic
3. Haematogenous (rare): exanthematous fever

16. Pathological Changes
1. Eardrum
– Central perforation; myringosclerosis
2. Ossicles
– Destruction (hyperemic decalcification)
– Tympanosclerosis, Fibrosis + Adhesions
3. Middle ear mucosa: edematous, pale, congested
4. Mastoid bone: sclerosis

17. Clinical Features
• Ear discharge: intermittent, profuse, mucoid to muco-
purulent, whitish, odorless, not blood-stained
• Hearing Loss:
– Usually conductive (25-50 dB) but might be normal
in small, dry perforations
– Round window shielding by ear discharge leads to
better hearing in acute exacerbations
• Tympanic membrane: central perforation

18. Stages of Tubotympanic disease
Stage Otorrhoea Eardrum
perforation
Last ear
discharge
Active Present Present -
Quiescent Absent Present < 6 months
Inactive Absent Present > 6 months
Healed Absent Absent -

19. Investigations for CSOM TTD
• Examination under microscope
• Ear discharge swab: for culture sensitivity
• Pure tone audiometry
• Patch test
• X-ray mastoid: B/L 300 lateral oblique (Schuller)
(Done when cortical mastoidectomy is required in
CSOM TT not responding to antibiotics)

20. Examination under microscope
• Confirmation of otoscopic findings
• Epithelial migration at perforation
margin
• Cholesteatoma & granulations
• Adhesions & Tympanosclerosis
• Assessment of Ossicular chain
integrity
• Collection of discharge for culture
sensitivity

21. Pure Tone Audiometry
• Uses
– Presence of hearing loss
– Degree of hearing loss
– Type of hearing loss
– Hearing of other ear
– Record to compare hearing post-operatively
– Medico legal purpose

22. Patch Test
• Performed when deafness is around 40-50 dB
– Do pure tone audiometry: for hearing threshold
– Put Aluminum foil patch over T.M. perforation
– Repeat pure tone audiometry
• Hearing improved  Ossicular chain intact &
mobile
• Hearing same / worse  Ossicular chain
broken or fixed

23. Treatment of CSOM Tubo-tympanic
Disease

24. Non-surgical Treatment
• Precautions
• Aural toilet
• Antibiotics : Systemic & Topical
• Antihistamines : Systemic & Topical
• Nasal decongestants : Systemic & Topical
• Treatment of respiratory infection & allergy
• Tympanic membrane patcher

25. Precautions
• Encourage breast feeding with child’s head raised.
Avoid bottle feeding
• Avoid forceful nose blowing
• Plug E.A.C. with Vaseline smeared cotton while
bathing & avoid swimming
• Avoid putting oil , water or self-cleaning of ear

26. • Done only for active stage
• Dry mopping with cotton swab
• Suction clearance: best method
• Gentle irrigation (wet mopping)
• 1.5% acetic acid solution used T.I.D.
• Removes accumulated debris
• Acidic pH discourages bacterial growth
Aural Toilet

27. Antibiotics
• Topical Antibiotics:
• Ciprofloxacin, Gentamicin, Tobramycin
• Antibiotics + Steroid: for polyps, granulations
• Neosporin + Betamethasone / Hydrocortisone
• Oral Antibiotics: for severe infections
• Cefuroxime, Cefaclor, Cefpodoxime, Cefixime

28. Antihistamines and Decongestants
• Antihistamines
– Chlorpheniramine
– Cetirizine
– Fexofenadine
– Loratadine
– Levocetrizine
– Azelastine (topical)
• Systemic Decongestants
– Pseudoephedrine
– Phenylephrine
• Topical Decongestants
– Oxymetazoline
– Xylometazoline
– Hypertonic saline

29. Kartush T.M. Patcher
• Indicated in:
– Perforation in only hearing ear
– Patient refuses surgery
– Patient unfit for surgery
– Age < 7 years

30. Surgical Treatment
• Indicated in inactive or quiescent stage
–Myringoplasty
–Tympanoplasty
• Indicated in active stage
–Cortical Mastoidectomy
–Aural polypectomy

31. Methods to close perforation
• T.M. perforation < 2 mm
– Chemical cautery with silver nitrate
–Fat grafting
(Myringoplasty if these measures fail)
• T.M. perforation > 2 mm
– Tympanic membrane patcher
– Myringoplasty

32. Chemical cautery

33. Surgical Approaches to the
middle ear

34. Wilde’s post-aural incision

35. Lempert’s end-aural incision

36. Rosen’s permeatal incision

37. Hearing Restoration
• Myringoplasty
– Surgical closure of tympanic membrane
perforation
• Ossiculoplasty
– Surgical reconstruction of ossicular chain
• Tympanoplasty
– Surgical removal of disease + reconstruction of
hearing mechanism without mastoid surgery

38. Principles of hearing restoration
• Intact tympanic membrane
• Intact ossicular chain
• Functioning receiving & relieving windows
• Acoustic separation of these windows
• Functioning Eustachian tube
• Absence of sensorineural hearing loss
• Absence of active infection / allergy in middle ear cleft

39. Myringoplasty
Surgical closure of perforation of pars
tensa of Tympanic membrane without
ossicular reconstruction

40. Aims
• Permanently stop ear discharge : make the ear dry and
safe
• Improve hearing if ossicles are intact and mobile and there
is absence of sensori-neural deafness
• Prevention of ongoing complications like further hearing
loss, tympanosclerosis, adhesions, mucosal bands, vertigo
• Wearing of hearing aid
• Occupational: military, pilots
• Recreation: swimming, diving

41. Contraindications
• Purulent ear discharge
• Otitis externa
• Respiratory allergy
• Age < 7 yr (Eustachian tube not fully developed)
• Only hearing ear
• Cholesteatoma

42. Methods
Techniques
• Underlay: graft placed medial to fibrous annulus
• Overlay: graft placed lateral to fibrous annulus
Grafts used
• Temporalis fascia, Tragal perichondrium, Vein
graft, Fascia lata, Dura mater

43. Overlay Myringoplasty

44. Underlay Myringoplasty

46. Steps of underlay
Myringoplasty

47. Tympanomeatal flap raised

48. Placement of graft

49. Tympanomeatal flap replaced

50. Why temporalis fascia?
• Basal metabolic rate lowest (best survival rate)
• Easy to harvest
• Large size graft can be harvested
• Autograft, so no rejection
• Same thickness as normal tympanic membrane
• Good resistance to infection

51. Onlay Underlay
Graft cholesteatoma No
Blunting of anterior tympano-
meatal angle
No
Lateralization of graft No
Delayed healing time (6 wk) 3-4 weeks
No middle ear inspection Possible
Difficult & takes more time Easier & quicker

52. Advantages of Local Anesthesia
• Minimal bleeding
• Hearing results can be tested on table
• Facial palsy detected immediately
• Labyrinthine stimulation detected immediately
• No complications of General anesthesia

53. Tympanoplasty

54. Types

55. Type Pathology Graft placed on
I Ear drum perforation only Malleus handle
II Malleus handle eroded Incus
III Malleus + Incus eroded Stapes head
IV Only footplate remains: mobile Footplate exposed
V Only stapes remains: fixed Lateral SCC
opening
VI Only footplate remains: mobile Round window
exposed (Sono
inversion )

56. Ossiculoplasty
• Ossicular graft material
– Autograft
• Ossicles : incus/malleus
• Cartilage : Tragal/ conchal
• Bone : spine of Henle/mastoid
– Homograft: ossicles/cartilage/bone
– Biomaterials: plastic(polyethylene)/ceramic/ teflon/gold
(Biomaterials available as PORP and TORP)