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Chronic otitis media

Chronic otitis media. Definition. COM: unresolved inflammatory process of the middle ear and mastoid associated with TM perforation, otorrhea and hearing loss. Etiology. Unresolved middle ear infection.

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Chronic otitis media

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  1. Chronic otitis media

  2. Definition • COM: unresolved inflammatory process of the middle ear and mastoid associated with TM perforation, otorrhea and hearing loss.

  3. Etiology • Unresolved middle ear infection. • Uncomplicated inflammatory process of the middle ear may evolve over time to produce persistent effusion and irreversible mucosal change • Fluid contains enzymes to alter the mucosal lining of the middle ear, it results in collapse or chronic perforation • Obstruction of narrow communication between the antrum and the attic, the aditus.

  4. Etiology • Dysfunction of Eustachian tube • Chronic inflammation in nose and pharynx • Dysfunction of immune system

  5. Bacteriology • Pseudomonas aeruginosa (40-60%) • Straphylococus aureus (10-20%) • Anaerobic bacteria

  6. Pathology • Middle ear mucosa is lined by secretory epithelium forming glandlike structure. • Hyalinization or tympanosclerosis • A healing response • It occurs during quiescent periods • It is formed by fused collagenous fibers • It is hardened by the deposition of calcium and phosphate crystals • Conductive hearing loss is associated with masses restricting ossicular mobility

  7. Pathology • Ossicular erosion is frequent in COM • Infection process per se • Necrosis following vascular thrombosis • It most commonly affect the lenticular process of the incus and head of the stapes

  8. Pathology • Cholesterol granulomas • Presence of yellowish masses surrounded by granulation tissue, edematous mucosa and fibrous tissue • It contains many cholesterol crystals and foreign body giant cells.

  9. Pathology • Cholesteatoma: cystlike, expanding lesions of the temporal bone, lined by stratified epithelium and containing desquamated keratin and purulent material. • Classification • Congenital cholesteatoma • Acquired cholesteatoma

  10. Pathology • Mechanics of mucosal transformation and epithelial ingrowth have been the focal point of cholesteatoma • Pocket retraction: dysfunction of Eustachian tube

  11. Pathology • Epithelial migration: the edge of a peripheral perforation • Inward growth of the surface epithelium follows papillary proliferation of the germinative layer of the pars flaccida. • Metaplasia from pseudostratified ciliated columnar epithelium

  12. Cholesteatoma Formation

  13. Cholesteatoma Formation

  14. Pathology • Pathogenesis of congenital cholesteatoma: • Ectodermal epithelial in proximity of the geniculate ganglion, medial to the neck of the malleus

  15. Pathology • Diagnosis criteria: • Patients without previous history of ear disease, with normal and intact TM • The temporal bone pneumatization should be normal

  16. Clinical presentations • Otorrhea • Malodorous associated with cholesteatoma • Hearing loss • Air conduction threshold is within 40 dB means TM proferation with intact ossicular chain • If air-bone gap is more than 40 dB is associated with discontinuity of ossicular chain

  17. Clinical presentations • Physical findings • Defect in the pars tensa of TM or the pars flaccida or both • Atelectatic lesions in tensa or flaccida pars • Squamous epithelial invasion may invade middle ear • Granumoms, polyps, tympanosclerotic plaques in middle ear

  18. Radiographic evaluation • Indications for image study • Uncontrollable aural discharge • Complications such as facial paralysis, labyrinthitis • When central nervous stystem involvement is suspected, MRI should be considered. • Coronal CT scan is perferred

  19. Differential diagnosis • Tuberculous otitis media • Hematogenous route • Multiple perforation and fetid • Creamy aural discharge • Active pulmonary disease • Multiple antituberculosis agents

  20. Differential diagnosis • Middle ear carcinoma • Middle age patient • Long term otorrhea with blood • Otalgia • Neoplasm in tympanum • CT scan showed temporal bone destruction

  21. Managements • Medical treatment • Goals • Infection control • Stabilization of process • Prevention of irreversible damage and development of serious complications • 3%H202 clears up pus then antibiotics ear drops is used. • With the decrease of pus, 3% boric glycerin, 3% boric alcohol can be used • No aminoglycoside ear drops • No powders containing antibiotic and erosion ear drugs

  22. Managements • Surgery • Goals • Safe ear: lesion removal • Dry ear • Hearing ear: reconstruction of ossiclar chain • classification • Myrigoplasty • Tympanoplasty • Tympanoplasty with mastoidectomy

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