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
Chronic SuppurativeOtitis Media
It is skin in wrong place
It erodes bone by:
2.Pressure necrosis (expansion of the sac).
This may open pathways for spread of infection (Bony or Unsafe type o CSOM)
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.
Diagnosed as a pearly white mass behind an intact tympanic membrane in a child with no history of chronic ear disease.
Squamous epithelium may be found in the middle ear as a result of:
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 (M Flaccida)
Mesotympanic Type (primary)
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.
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.
1- Fetid scanty purulent ear discharge
2- Perforated DM with cholesteatoma debris
3- Conductive or mixed HL
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
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
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.
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 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.
Discharge of abnormal material through the external ear canal
Ear Wax is considered as normal external ear secretion not discharge
Scanty or profuse
Watery, mucoid (& muco-purulent), purulent or bloody (sanginous)
Cholesteatoma & external otitis
The source of ear discharge:
1- External ear
2- Middle ear
3- Intracranial (CSF)
CSF Otorrhoea: Mostly traumatic
Trauma of the external, middle ear and skull base
Bullous myringitis, acute and chronic otitis media
glomus , carcinoma of external or middle ear
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)
Rapid recollection of discharge in the external ear canal which indicates coalescent mastoiditis
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.