C.S.O.M.: Investigations &
TreatmentDr. Vishal Sharma
Investigations for T.T.D.• 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 ear discharge refractory to antibiotics
Uses of Audiometry• 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
Patch TestDone when deafness = 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 = oss. chain broken or fixed
Investigations for A.A.D.• Examination under microscope
• Ear discharge swab: for culture sensitivity
• Pure tone audiometry
• X-ray mastoid: B/L 300 lateral oblique (Schuller)
• CT scan: revision surgery, complications, children
Uses of E.U.M.• Confirmation of otoscopy findings
• Epithelial migration at perforation margin
• Cholesteatoma & granulations
• Adhesions & tympanosclerosis
• Assesment of ossicular chain integrity
• Collection of discharge for culture sensitivity
Uses of X-ray mastoid1. Position of dural & sinus plates: helps in surgery
2. Type of pneumatization:
a. Cellular (80%): plenty of air cells
b. Sclerotic (20%): small antrum, air cells absent
c. Diploetic (<1%): bone marrow within few air cells
3. Cholesteatoma (cotton wool appearance)
4. Bone destruction: presence & extent
5. Mastoid cavity
Dural & sinus plates
Cellular mastoid
Sclerotic mastoid
Diploetic mastoid
Attic bone erosion
Causes for mastoid cavity• Cholesteatoma erosion• Mastoidectomy cavity• Tubercular mastoiditis• Coalescent mastoiditis• Malignancy• Eosinophilic granuloma• Mega-antrum• Large emissary vein
C.T. scan temporal bone
Posterior canal wall erosion
C.T. scan temporal bone
Mastoid cholesteatoma
Treatment for Tubo-tympanic
Disease
Non-surgical Treatment• Precautions• Aural toilet• Antibiotics: Systemic & Topical• Antihistamines: Systemic & Topical• Nasal decongestant: Systemic & Topical• Treatment of respiratory infection & allergy• Tympanic membrane patcher
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 & self-cleaning of E.A.C.
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
AntibioticsTopical Antibiotics:
Antibiotics: Ciprofloxacin, Gentamicin, Tobramycin
Antibiotics + Steroid: for polyps, granulations
Neosporin + Betamethasone / Hydrocortisone
Oral Antibiotics: for severe infections
Cefuroxime, Cefaclor, Cefpodoxime, Cefixime
Antihistamines & Decongestants Antihistamines Systemic decongestants
Chlorpheniramine Pseudoephedrine
Cetirizine Phenylephrine
Fexofenadine Topical decongestants
Loratidine Oxymetazoline
Levo-cetrizine Xylometazoline
Azelastine (topical) Hypertonic saline
Kartush T.M. PatcherIndicated in:
• Perforation in only
hearing ear
• Patient refuses surgery
• Patient unfit for surgery
• Age < 7 years
Surgical TreatmentIndicated in inactive or quiescent stage
• Myringoplasty
• Tympanoplasty
Indicated in active stage
• Cortical Mastoidectomy
• Aural polypectomy
Methods to close perforationT.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
Chemical cautery
Approaches to middle ear
Wilde’s post-aural incision
Lempert’s end-aural incision
Rosen’s permeatal incision
Hearing RestorationMyringoplasty: • surgical closure of tympanic membrane perforation
Ossiculoplasty: • surgical reconstruction of ossicular chain
Tympanoplasty: • Surgical removal of disease + reconstruction of
hearing mechanism without mastoid surgery
Principles of hearing restoration• Intact tympanic membrane• Intact ossicular chain• Functioning receiving & relieving windows• Acoustic separation of these windows• Functioning Eustachian tube• Absence of sensori-neural hearing loss• Absence of active infection / allergy in
middle ear cleft
Myringoplasty
Aims• Permanently stop ear discharge: dry, safe ear• Improve hearing: provided: 1. ossicles are intact +
mobile; 2. absence of sensori-neural deafness• Prevention of: tympanosclerosis, adhesions,
vertigo, S.N.H.L. (cochlear exposure to loud sound)• Wearing of hearing aid• Occupational: military, pilots• Recreation: swimming, diving
Contraindications• Purulent ear discharge• Otitis externa• Respiratory allergy• Age < 7 yr (Eustachian tube not fully developed)
• Only hearing ear• Cholesteatoma
MethodsTechniques:
• 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
Underlay myringoplasty
Overlay myringoplasty
Steps of underlay myringoplasty
Tympanomeatal flap raised
Placement of graft
Tympanomeatal flap replaced
Tympanomeatal flap replaced
Why temporalis fascia?• Basal metabolic rate lowest (best survival rate)
• Easily harvested by post-aural incision
• Its an autograft, so no rejection
• Same thickness as normal tympanic membrane
• Large size graft can be harvested
• Good resistance to infection
Onlay UnderlayGraft 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
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
Tympanoplasty
Types
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
Round window (Footplate exposed)
V Only stapes remains: fixed Lateral SCC opening
VI Only footplate remains: mobile
Stapes Footplate
Malleus / Incus Autografts
Thank You