C.S.O.M.: Investigations & Treatment

1. C.S.O.M.: Investigations & Treatment Dr. Vishal Sharma

2. 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

3. 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

4. Patch Test Done 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

5. 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

6. 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

7. Uses of X-ray mastoid 1. 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

8. Dural & sinus plates

9. Cellular mastoid

10. Sclerotic mastoid

11. Diploetic mastoid

12. Attic bone erosion

13. Causes for mastoid cavity • Cholesteatoma erosion • Mastoidectomy cavity • Tubercular mastoiditis • Coalescent mastoiditis • Malignancy • Eosinophilic granuloma • Mega-antrum • Large emissary vein

14. C.T. scan temporal bone Posterior canal wall erosion

15. C.T. scan temporal bone Mastoid cholesteatoma

16. Treatment for Tubo-tympanic Disease

17. Non-surgical Treatment • Precautions • Aural toilet • Antibiotics: Systemic & Topical • Antihistamines:Systemic & Topical • Nasal decongestant: Systemic & Topical • Treatment of respiratory infection & allergy • Tympanic membrane patcher

18. 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.

19. Aural Toilet 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

20. Antibiotics Topical Antibiotics: Antibiotics:Ciprofloxacin, Gentamicin, Tobramycin Antibiotics + Steroid: for polyps, granulations Neosporin + Betamethasone / Hydrocortisone Oral Antibiotics:for severe infections Cefuroxime, Cefaclor, Cefpodoxime, Cefixime

21. Antihistamines & Decongestants Antihistamines Systemic decongestants  Chlorpheniramine  Pseudoephedrine  Cetirizine Phenylephrine  FexofenadineTopical decongestants  Loratidine Oxymetazoline  Levo-cetrizine Xylometazoline  Azelastine (topical) Hypertonic saline

22. Kartush T.M. Patcher Indicated in: • Perforation in only hearing ear • Patient refuses surgery • Patient unfit for surgery • Age < 7 years

23. Surgical Treatment Indicated in inactive or quiescent stage • Myringoplasty • Tympanoplasty Indicated in active stage • Cortical Mastoidectomy • Aural polypectomy

24. Methods to close perforation T.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

25. Chemical cautery

26. Approaches to middle ear

27. Wilde’s post-aural incision

28. Lempert’s end-aural incision

29. Rosen’s permeatal incision

30. Hearing Restoration Myringoplasty: • surgical closure of tympanic membrane perforation Ossiculoplasty: • surgical reconstruction of ossicular chain Tympanoplasty: • Surgical removal of disease + reconstruction of hearing mechanism without mastoid surgery

31. 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

32. Myringoplasty

33. 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

34. Contraindications • Purulent ear discharge • Otitis externa • Respiratory allergy • Age < 7 yr (Eustachian tube not fully developed) • Only hearing ear • Cholesteatoma

35. Methods Techniques: • 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

36. Underlay myringoplasty

37. Overlay myringoplasty

38. Steps of underlay myringoplasty

39. Tympanomeatal flap raised

40. Placement of graft

41. Tympanomeatal flap replaced

42. Tympanomeatal flap replaced

44. 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

46. 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

47. Tympanoplasty

48. Types

50. Malleus / Incus Autografts