Chronic otitis media Chronic otitis media

Chunfu Dai M.D & Ph. DChunfu Dai M.D & Ph. D

Otolaryngology DepartmentOtolaryngology DepartmentEye Ear Nose and Throat Hospital Eye Ear Nose and Throat Hospital

Fudan UniversityFudan University

Definition Definition

COM: unresolved inflammatory process COM: unresolved inflammatory process of the middle ear and mastoid associateof the middle ear and mastoid associated with TM perforation, otorrhea and head with TM perforation, otorrhea and hearing loss.ring loss.

Etiology Etiology

Unresolved middle ear infection.Unresolved middle ear infection.1.1. Uncomplicated inflammatory process of the midUncomplicated inflammatory process of the mid

dle ear may evolve over time to produce persistedle ear may evolve over time to produce persistent effusion and irreversible mucosal changent effusion and irreversible mucosal change

2.2. Fluid contains enzymes to alter the mucosal lininFluid contains enzymes to alter the mucosal lining of the middle ear, it results in collapse or chronig of the middle ear, it results in collapse or chronic perforationc perforation

3.3. Obstruction of narrow communication between tObstruction of narrow communication between the antrum and the attic, the aditus.he antrum and the attic, the aditus.

Etiology Etiology

Dysfunction of Eustachian tubeDysfunction of Eustachian tube Chronic inflammation in nose and pharyChronic inflammation in nose and phary

nxnx Dysfunction of immune systemDysfunction of immune system

Bacteriology Bacteriology

Pseudomonas aeruginosa (40-60%)Pseudomonas aeruginosa (40-60%) Straphylococus aureus (10-20%)Straphylococus aureus (10-20%) Anaerobic bacteriaAnaerobic bacteria

Pathology Pathology

Middle ear mucosa is lined by secretory epitheMiddle ear mucosa is lined by secretory epithelium forming glandlike structure.lium forming glandlike structure.

Hyalinization or tympanosclerosisHyalinization or tympanosclerosis A healing responseA healing response It occurs during quiescent periodsIt occurs during quiescent periods It is formed by fused collagenous fibersIt is formed by fused collagenous fibers It is hardened by the deposition of calcium and phoIt is hardened by the deposition of calcium and pho

sphate crystalssphate crystals Conductive hearing loss is associated with masses rConductive hearing loss is associated with masses r

estricting ossicular mobilityestricting ossicular mobility

PathologyPathology Ossicular erosion is frequeOssicular erosion is freque

nt in COMnt in COM Infection process per seInfection process per se Necrosis following vascular tNecrosis following vascular t

hrombosishrombosis It most commonly affect the It most commonly affect the

lenticular process of the inculenticular process of the incus and head of the stapess and head of the stapes

PathologyPathology

Cholesterol granulomasCholesterol granulomas Presence of yellowish masses surrounded bPresence of yellowish masses surrounded b

y granulation tissue, edematous mucosa any granulation tissue, edematous mucosa and fibrous tissued fibrous tissue

It contains many cholesterol crystals and forIt contains many cholesterol crystals and foreign body giant cells.eign body giant cells.

PathologyPathology

Cholesteatoma: cystlike, expanding lesiCholesteatoma: cystlike, expanding lesions of the temporal bone, lined by strations of the temporal bone, lined by stratified epithelium and containing desquamfied epithelium and containing desquamated keratin and purulent material.ated keratin and purulent material.

Classification Classification Congenital cholesteatomaCongenital cholesteatoma Acquired cholesteatomaAcquired cholesteatoma

PathologyPathology

Mechanics of mucosMechanics of mucosal transformation anal transformation and epithelial ingrowth d epithelial ingrowth have been the focal have been the focal point of cholesteatopoint of cholesteatomama Pocket retraction: dysPocket retraction: dys

function of Eustachiafunction of Eustachian tube n tube

PathologyPathology

Epithelial migration: the eEpithelial migration: the edge of a peripheral perfordge of a peripheral perforationation

Inward growth of the surfInward growth of the surface epithelium follows paace epithelium follows papillary proliferation of the pillary proliferation of the germinative layer of the pgerminative layer of the pars flaccida.ars flaccida.

Metaplasia from pseudostMetaplasia from pseudostratified ciliated columnar ratified ciliated columnar epitheliumepithelium

Cholesteatoma Formation

Cholesteatoma Formation

Pathology Pathology

Pathogenesis of congenital cholesteatoPathogenesis of congenital cholesteatoma:ma: Ectodermal epithelial in proximity of the geEctodermal epithelial in proximity of the ge

niculate ganglion, medial to the neck of the niculate ganglion, medial to the neck of the malleusmalleus

PathologyPathology

Diagnosis criteria:Diagnosis criteria: Patients without prevPatients without prev

ious history of ear disious history of ear disease, with normal anease, with normal and intact TMd intact TM

The temporal bone pThe temporal bone pneumatization shoulneumatization should be normald be normal

Clinical presentations Clinical presentations

Otorrhea Otorrhea Malodorous associated with cholesteatomaMalodorous associated with cholesteatoma

Hearing loss Hearing loss Air conduction threshold is within 40 dB meAir conduction threshold is within 40 dB me

ans TM proferation with intact ossicular chaans TM proferation with intact ossicular chainin

If air-bone gap is more than 40 dB is associaIf air-bone gap is more than 40 dB is associated with discontinuity of ossicular chain ted with discontinuity of ossicular chain

Clinical presentationsClinical presentations

Physical findingsPhysical findings Defect in the pars tensa of TM or the pars flaDefect in the pars tensa of TM or the pars fla

ccida or bothccida or both Atelectatic lesions in tensa or flaccida parsAtelectatic lesions in tensa or flaccida pars Squamous epithelial invasion may invade mSquamous epithelial invasion may invade m

iddle eariddle ear Granumoms, polyps, tympanosclerotic plaqGranumoms, polyps, tympanosclerotic plaq

ues in middle earues in middle ear

Radiographic evaluationRadiographic evaluation

Indications for image stIndications for image study udy Uncontrollable aural discUncontrollable aural disc

hargeharge Complications such as facComplications such as fac

ial paralysis, labyrinthitis ial paralysis, labyrinthitis When central nervous stysWhen central nervous stys

tem involvement is suspetem involvement is suspected, MRI should be consicted, MRI should be considered.dered.

Coronal CT scan is perferrCoronal CT scan is perferreded

Differential diagnosisDifferential diagnosis

Tuberculous otitis mediaTuberculous otitis media Hematogenous routeHematogenous route Multiple perforation and fetidMultiple perforation and fetid Creamy aural dischargeCreamy aural discharge Active pulmonary diseaseActive pulmonary disease Multiple antituberculosis agentsMultiple antituberculosis agents

Differential diagnosisDifferential diagnosis

Middle ear carcinomaMiddle ear carcinoma Middle age patientMiddle age patient Long term otorrhea with bloodLong term otorrhea with blood OtalgiaOtalgia Neoplasm in tympanumNeoplasm in tympanum CT scan showed temporal bone destructionCT scan showed temporal bone destruction

Managements Managements

Medical treatment Medical treatment GoalsGoals

Infection controlInfection control Stabilization of processStabilization of process Prevention of irreversible damage and development of serious cPrevention of irreversible damage and development of serious c

omplicationsomplications 3%H202 clears up pus then antibiotics ear drops is used.3%H202 clears up pus then antibiotics ear drops is used. With the decrease of pus, 3% boric glycerin, 3% boric alcohol With the decrease of pus, 3% boric glycerin, 3% boric alcohol

can be usedcan be used No aminoglycoside ear dropsNo aminoglycoside ear drops No powders containing antibiotic and erosion ear drugsNo powders containing antibiotic and erosion ear drugs

Managements Managements

Surgery Surgery GoalsGoals

Safe ear: lesion removal Safe ear: lesion removal Dry earDry ear Hearing ear: reconstruction of ossiclar chainHearing ear: reconstruction of ossiclar chain

classificationclassification Myrigoplasty Myrigoplasty TympanoplastyTympanoplasty Tympanoplasty with mastoidectomyTympanoplasty with mastoidectomy