Chronic otitis media with cholesteatoma

Chronic otitis media with cholesteatomaDefinition of cholesteatomaOsteoclastic inflammation of the mucosal spaces in the middle ear.Often coexsting infection is presentCharacteristic:Keratinizing squamous epithelium is found in bony spaces at an abnormal locationBone is destroyed through an inflammatory osteoclastic processTypes of cholesteatoma:Congenital cholesteatoma:Very RareUsually found behind an intact tympanic membraneAcquired cholesteatoma:Primary acquired cholesteatoma(pars flaccida cholesteatoma): develops from squamous epithelial pocket in the pars flaccida and expands in the epitympanum -> tends to destroy the lateral attic wall. Secondary acquired cholesteatoma(pars tensa cholesteatoma): originate from perforation of the pars tensa with destruction of the fibrocartilaginous ring or from a retraction pocket in the pars tensa. Initially develops in the mesotympanum expanding into the epitympanum.

Clinical aspects of cholesteatomaEpidemiology: any age group but rare in small childrenPathogenesis:Impairment of middle ear ventilationEustachian tube dysfunctionNegative pressure in the middle ear countinuouslyRetraction pocket forms in tympanic membranePocket is lined by squamous epitheliumMigrate on the tympanic membrane and external canalEntering the middle ear and cause inflammation and bone resorptionSymptoms:Chronic otitis mediaDry, uninfected cholesteatomaDoes not cause otalgia or otorrheaAural pressure: hearing loss -> facial nerve palsy, signs of vestibular dysfunctionInfected cholesteatoma(more common)DischargeHearing lossPainFunctional deficitAbcess formation and meningitis

Diagnostic work up:Establishing the diagnosis:Otoscopy: white epithelial debris on tympanic membrane, bone erosion on the posterosuperior canal wall close to tympanic membraneDry cholesteatoma shows brownish black crusts on superior canal wallInflammation changes make hard to interpret by otoscopyScreening for complications:Hearing test show conductive hearing lossSensorineural hearing loss indicates complicationFacial nerve function testLabyrinthine fistula: fistula sign(vertigo, nystagmus)Imgaing: define extent of bone destruction, detect intracranial complications,Evidence of labyrithine fistula,Degree of pneumatization of the temporal boneCT scan contrast if complication is suspectedCourse and complications: without treatment, bone destruction progresses, labyrinthine fistula, facial nerve palsy, intracranial process.Treatment(surgical) to:Prevent further bone destructionGoal is to eradicate destructive inflammatory process in the mastoid and tympanic cavityImprove hearing by tympanoplastyAcute inflammatory changes treated with local treatment

Otogenic complications of otitisMay originate from the external ear or middle ear.Otologic emergencies and should be treated immediatelyThe earlier surgery is performed, the better the chance of curing, prevent further complicationsComplications are:MastoiditisIntracranial complicationLabyrinthitisCranial nerve deficitsMastoiditis Definition: inflammation of the air cells in the mastoid process focused on the mucous membranes and bony structures of the mastoid.Etiopathogenesis:Infection of the middle earPathogenic factors:Degree of mastoid pneumatizationVirulence of the infecting organismHost immune statusInadequate treatment of otitis mediaSymptoms:FeverLocal painMalaiseanorexiadiagnosis:Prominent auricle with retroauricular swellingTenderness over the mastoidOtorrheaOtitis media that lasts more than 2-3weeksOtoscopy: acute or subacute otitis media with or without TM perforationPosterior wall diagnosis:Prominent auricle with retroauricular swellingTenderness over the mastoidOtorrheaOtitis media that lasts more than 2-3weeksOtoscopy: acute or subacute otitis media with or without TM perforationPosterior wall of external canal may be erythematous and swollenCT scan: clouding of mastoid air cell and middle ear spaces, erosion of mastoid bone structureLab: WBC, CRP, ESR markedly elevated

Complications:

Treatment:MastoidectomyCulture-directed intravenous antibioticsMyringotomy tube to decompress the middle earEarly stage of mastoiditis can be treated with antibiotics with inpatient observation

Intracranial complicationsMeningitis:Usually result from OM with cholesteatomaCan also arise from occult process involving the lateral skill baseSpread from middle er infection, osteitis or cholesteatomaSymptoms: severe headache. Fever, clouding of the consciousness, nuchal stiffness, inner ear dysfunction to bilateral deafnessDiagnostic by CT scan with contrastTreatment: antibiotic and steroidSurgical indicated if involves middle ear or lateral skull base

Intracranial abscesses:Epidural abscessSubdural abscessIntracranial abscess

Treatment: otosurgical and neurosurgical approach.

Cranial nerve deficitFacial nerve is the most frequent cranial nerve complication due to the inflammation of peripheral nerve.Petrous apex syndrome: lesion of petrous apex causing trigeminal symptoms and abducens nerve palsy accompanied by otologic symptoms.

Characteristic of cholesteatoma exceptKeratinizing squamous epitheliumBone destructionnecrosis of the external ear canal

what is the use of CT scan on cholesteatoma?To diagnoseTo observe whether cholesteatoma is presentTo see the type of cholesteatomaTo define the extent of bone destructionWhich one of these does not have to do surgical treatment?Mastoiditis chronicSinusitisMeningitisCranial nerve deficitsWhich cranical nerve deficits less likely to be found on otogenic complication?Facial nerveTrigeminal nerveHypoglosseal nerveAbducens nerve