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Department of Otorhinolaryngology. CHOLESTEATOMA. Chronic Suppurative Otitis Media Attico-Antral Type. Cholesteatoma. Is epidermal cyst of the middle ear and/or Temporal bone with a squamous epithelial lining. Contain keratin and desquamated epithelium. Can be congenital or acquired

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Department of otorhinolaryngology

Department of Otorhinolaryngology


Cholesteatoma

CHOLESTEATOMA

Chronic SuppurativeOtitis Media

Attico-Antral Type


Cholesteatoma1

Cholesteatoma

  • Is epidermalcystof the middle ear and/or Temporal bone with a squamous epithelial lining.

  • Contain keratinand desquamated epithelium.

  • Can be congenital or acquired

  • Natural history is progressive growth with erosion of surrounding bone due to pressure effects and osteoclast activation.

    It is skin in wrong place


Department of otorhinolaryngology

Cholesteatoma

It erodes bone by:

1.Enzymatic activity.

2.Pressure necrosis (expansion of the sac).

This may open pathways for spread of infection (Bony or Unsafe type o CSOM)


Pathogenesis of cholesteatoma

Pathogenesis of Cholesteatoma

Congenital Cholesteatoma:

Arises from embryonic epithelial tissue in the temporal bone ( may be in ME cavity or temporal bone especially the petrous apex).

Epidermal cysts usually present in the anterior superior quadrant of the middle ear near the Eustachian tube orifice.


Congenital cholesteatoma

Congenital Cholesteatoma:

Diagnosed as a pearly white mass behind an intact tympanic membrane in a child with no history of chronic ear disease.


Acquired cholesteatoma

Acquired Cholesteatoma

Pathogenesis

Squamous epithelium may be found in the middle ear as a result of:

  • Invagination

  • Migration (through a perforation)

  • Squamous metaplasia


Acquired cholesteatoma pathogenesis

Acquired CholesteatomaPathogenesis


Acquired cholesteatoma1

Acquired Cholesteatoma

1) Invagination Theory ( primary acquired )

Prolonged ET obstruction creates negative ME pressure leading to retraction of pars flaccida (or the superior part of the membrana tensa) which becomes aninvaginated into the ME (retraction pocket) and gradually distend with accumulated keratin and later on separate from the drum membrane.


Primary acquired cholesteatoma

Primary acquired cholesteatoma

Normal TM

Primary acquired (M Flaccida)


Primary acquired cholesteatoma1

Primary acquired cholesteatoma

Normal TM

Mesotympanic Type (primary)


Primary acquired cholesteatoma2

Primary acquired cholesteatoma


Pathogenesis of cholesteatoma cont

Pathogenesis Of Cholesteatoma(cont.)

2) Migration Theory (Secondry acquired)

The stratified squamous epithelium of the deep external auditory meatus grows through a marginal perforation into the middle ear cavity.

3) Metaplasia Theory

Long standing suppuration can stimulate metaplasia of the simple squamous epithelium of the middle ear to stratified squamous epithelium.


Secondary acquired cholesteatoma

Secondary Acquired Cholesteatoma

  • Migration Theory – most accepted

  • Originates from a tympanic membrane perforation

  • As the edges of the TM try to heal, the squamous epithelium migrates into the middle ear


Clinical picture

Clinical Picture

symptoms

1) Hearing loss (marked) and tinnitus.

Sometimes HL is minimal as the sac may bridges the gap between the necrosedossicles.

2) Foul smelling ear discharge.

Signs

1- Fetid scanty purulent ear discharge

2- Perforated DM with cholesteatoma debris

3- Conductive or mixed HL


Clinical picture1

Clinical Picture

  • Mass behind intact tympanic membrane in cases of congenital cholesteatoma

  • Sometimes the first presentation is with one of complications e.g. facial nerve paralysis or lateral sinus thrombophlebitis

  • Granulation tissue or aural polyp may fill the ear canal with bloody ear discharge


Investigations

Investigations

1- Culture and Sensitivity: of the ear discharge.

2- Audiological assessment

- CHL, mixed HL or dead ear

3- Imaging of the temporal bone: Only in cases with

- Suspected or presence of complications,

- Congenital cholesteatoma or

- History of previous ear surgery


Imaging of temporal

Imaging of Temporal

Axial Section

Coronal Section


Cholesteatoma imaging

Cholesteatoma Imaging


Treatment of cholesteatoma

Treatment of Cholesteatoma

Is Surgical, No role for medical treatment except for active ear infection (ototopical drops)

Tympanoplasty with Mastoidectomy is the standard surgical procedure

In cases with total HL radical mastoidectomy is indicated


Mastoidectomy

Mastoidectomy

  • Intact (bony ear) canal wall mastoidectomy

  • Canal wall down mastoidectomy

    • Radical Mastoidectomy ( dead ear)

    • Modified Radical Mastoidectomy


Cholesterol granuloma

Cholesterol Granuloma

CGs, first reported in the mastoid and middle ear in 1894, may occur anywhere in the air cell system of temporal bone when eustachian tube obstruction, mucosal edema, temporal bone fracture, cholesteatoma, chronic otitis media or any another process blocks the air cell tracts.


Cholesterol granuloma1

Cholesterol Granuloma

  • Cholesterol granuloma is a histological term used for the description of a tissue response to a foreign body such as cholesterol crystals released by the breakdown of blood and local tissue.

  • It may arise any portion of the pneumatized temporal bone but most frequently involves the petrous apex


Cholesterol granuloma2

Cholesterol Granuloma

CG can be a perfectly localized and isolated mass in any pneumatized area in the temporal bone, the middle ear cavity, mastoid antrum, external auditory canal and the petrous apex.


Cholesterol granuloma3

Cholesterol Granuloma

Cholesterol granuloma (CG) of the middle ear typically presents with a conductive hearing loss and a blue eardrum; those at the petrous apex either manifest with side-effects from bony erosion (with sensorineural hearing loss, tinnitus, vertigo or cranial nerve impairment), or are identified as incidental findings.


Otorrhoea

OTORRHOEA

Definition:

Discharge of abnormal material through the external ear canal

Ear Wax is considered as normal external ear secretion not discharge


Otorrhoea1

OTORRHOEA

Description

Amount:

Scanty or profuse

Nature:

Watery, mucoid (& muco-purulent), purulent or bloody (sanginous)

Smell:

Cholesteatoma & external otitis


Otorrhoea2

OTORRHOEA

The source of ear discharge:

1- External ear

2- Middle ear

3- Intracranial (CSF)


Watery otorrhoea

WATERY OTORRHOEA

CSF Otorrhoea: Mostly traumatic

  • Skull base fracture (commonly the longitudinal type)

  • Iatrogenic (post-operative)

  • Rarely, malignant neoplasm eroding the skull base


Bloody otorrhoea

Bloody Otorrhoea

  • Traumatic:

    Trauma of the external, middle ear and skull base

  • Inflammatory:

    Bullous myringitis, acute and chronic otitis media

  • Neoplastic:

    glomus , carcinoma of external or middle ear


Mucopurulent otorrhoea

Mucopurulent Otorrhoea

Always from middle ear;

Acute and chronic otitis media

Pulsating ear discharge:

Acute or acute on top of chronic suppurative otitis media with small perforation of drum membrane

Intra-cranial complications of suppurative otitis media ( extra-dural abscess)


Muc opurulent otorrhoea

Muc-opurulent Otorrhoea

Reservoir Sign:

Rapid recollection of discharge in the external ear canal which indicates coalescent mastoiditis


Purulent otorrhoea

PURULENT OTORRHOEA

External otitis and cholesteatoma

Usually smelly (fetid)

Management of cases of ear discharge is according to the cause

N.B.No packing of external ear in suspected cases of CSF otorrhoea.


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