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

C.S.O.M.: Investigations & Treatment. Dr. Vishal Sharma. Investigations for T.T.D. Examination under microscope Ear discharge swab: for culture sensitivity Pure tone audiometry Patch test

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

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  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

  43. 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

  44. 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

  45. Tympanoplasty

  46. Types

  47. Malleus / Incus Autografts

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