Chronic otitis media

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Chronic otitis media

• Chunfu Dai M.D Ph. D
• Otolaryngology Department
• Eye Ear Nose and Throat Hospital
• Fudan University

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Definition

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

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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.

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Etiology

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

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Bacteriology

• Pseudomonas aeruginosa (40-60)
• Straphylococus aureus (10-20)
• Anaerobic bacteria

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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

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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

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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.

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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

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Pathology

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

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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

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Cholesteatoma Formation
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Cholesteatoma Formation
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Pathology

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

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Pathology

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

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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

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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

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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

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Differential diagnosis

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

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Differential diagnosis

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

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Managements

• Medical treatment
• Goals
• Infection control
• Stabilization of process
• Prevention of irreversible damage and development
  of serious complications
• 3H202 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

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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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