1.
CSOM in Children
Challenges in Management
Prahlada N.B
MBBS, MS, MBA, MHA
Karnataka ENT Hospital & Research Center,
Chitradurga, Karnataka, India
Oration delivered during SAARC ENT Congress 2014, Held at Colombo, Srilanka

2.
Challenges
• Socio-economic
• Anatomical
• Pathological
• Clinical
• Surgical

3.
Socio-economic factors
• Male gender
• Low socio-economic status
• Early onset of AOM (6 months – 24 months)
• Sibling history
• Formula feeding in infancy

4.
Socio-economic factors
• Day care attendance
• Ethinicity (Natives, Aborigines)
• Passive smoking
• Pacifier use
• Seasonal changes

5.
Anatomical challenges
• Natural
• Eustachian tube
• Congenital
• Craniofacial anomaly
• Acquired
• Adenoids
• Nasopharyngeal mass
• Infectious or inflammatory

6.
Eustachian tube
Anatomic features of the Eustachian Tube Compared with the
Adult’s the infant’s is
Length of tube Shorter Sadler-Kimes et al., 1989
Angle of tube to horizontal plane 10’ vs 45’ Proctor 1967
Angle of tensor veli palatine muscle to cartilage Variable vs stable Swarts and Rood 1993
Cartilage cell density Greater Yamaguchi et al 1990
Elastic at hinge portion of Cartilage Less Mastume et al 1993
Oatmann fat pad Heavily wider Aoki et al, 1994
C.Bluestone

7.
Eustachian tube

8.
Clinical challenges
• Making the diagnosis in children is often a difficult task:
• In-ability to express
• Paucity of symptoms.
• Difficulty in examination.
• Small, tortuous ear canals.
• Previous antibiotic use
• Previous oitits media
• Failure to follow-up

9.
Pathological challenges
• Middle ear pathology
• Associated pathology
• Congenital
• Acquired

10.
Pathological challenges – Middle ear
• More prevalent in children than in adults
• The more forceful nature of otitis media
• More aggressive and persistent otitis media
• A higher rate of complications of this disease
• High rate of Persistent ME inflammation after TN repair.

11.
Pathological challenges – Middle ear
• High Rate of Failure of tympanic membrane repair
• May also reflect the higher prevalence of pars tensa atrophy
• The patterns of cholesteatoma development are different.
• The pattern of cholesteatoma spread is also different.
• High recurrence rate of cholesteatoma after ICW mastoidectomy.
• Surgeon faces a more difficult task

12.
Pathological challenges - Associated
• Congential
• Specific ethnic groups
• Cleft palate
• Craniofacial syndroms – Down, Crouzon, Apert’s. Turner’s & Pierre
Robin.
• Immune disorders – Severe combined Inmmune dieficeincy, X-
linked agammaglobulinemia and others.
• Ciliary dyskinesias – Kartagener’s syndrome & Cystic fibrosis

13.
Pathological challenges - Associated
• Acquired
• Allergy
• Acquired immunodeficiency syndrome
• Nasal pathology
• Sinus pathology
• Throat pathology
• Gastroesophageal reflux disease
• Biofilm formation in the middle ear
and mastoid

14.
Pathology – common entities
• CSOM with Perforation
• TM Atrophy with Pars Tensa retraction
• Attic retraction
• Cholesteatoma

15.
CSOM with Perforation

16.
Tympanic Membrane Atrophy
and Retraction Pockets: Pars Tensa

17.
Attic retraction

18.
Cholesteatoma

19.
Summary
• COM is more aggressive and persistent.
• Management difficult in children.
• common in low socio-economic state population.
• The success rate for surgical closure of perforations rises with the
age of the child, between 6 and 13 years.
• Pars tensa atrophy is commoner in children than in adults.

20.
Summary
• Cholesteatoma tends to be more aggressive.
• Surgical techniques may need to be different .
• Surgical reconstruction of the ossicular chain worthwhile .
• Complications of CSOM do occur in children.

21.
Thank you