بسم الله الرحمن الرحيم
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Transcript of بسم الله الرحمن الرحيم
الرحيم الرحمن الله بسم
CHRONIC OTITIS MEDIA
Classification of Chronic Otitis Media
• Chronic Non Suppurative Otitis Media
– Otitis media with effusion “OME”
– Adhesive otitis media
• Chronic Suppurative Otitis Media “CSOM”
– Tubotympanic (Safe)
– Atticoantral (Unsafe)
OTITIS MEDIA WITH EFFUSION
DEFINITION
Presence of non-purulent fluid within the
middle ear cleft
SYNONYMS
• Secretory otitis media
• Middle ear effusion
• Sero-mucinous otitis media
• Catarrhal otitis media
• Glue ear
• Serous otitis media
• Non-suppurative otitis media
PREVALENCE
• Between 20% and 50% of children do have
OME at some time between 3 and 10 years
of age
• Two peaks at 2 and 5 years of age
RISK FACTORS
• Race• Age• Gender• Season• Nasopharyngeal anatomical abnormalities• Cleft palate• Smoking• ? Allergy
HISTOPATHOLOGY
• Changes in the mucosa– Vasodilatation & mononuclear cell infiltration– Metaplasia of the epithelium to ciliated columnar– Mucus secreting gland formation
• Formation of fluid in the middle ear– Transudate– Exudate– Secretion
ETIOPATHOLOGY
• Eustachian tube dysfunction
• Chronic inflammation
ETIOLOGY
• Eustachian tube dysfunction– Poor muscular function– Adenoids– Barotrauma– Others
• Infections– Unresolved AOM– Adenoiditis and other URTIs
SYMPTOMS
• Hearing impairment
• ± Otalgia
• Fluid sensation
Diagnosis
DIAGNOSIS
DIAGNOSIS
• Otoscopy
• Tuning fork tests
DIAGNOSIS
• Otoscopy
• Tuning fork tests
• PTA
DIAGNOSIS
• Otoscopy
• Tuning fork tests
• PTA
• Tympanometry
DIAGNOSIS
• Otoscopy
• Tuning fork tests
• PTA
• Tympanometry
• Myringotomy
TREATMENT
• Treatment of the cause if feasible
• Observation
• Medical treatment– Antibiotics– Decongestants, ?Auto-inflation– ?Steroids
• Surgical– Myringotomy– Ventilation tubes (grommets)
COMPLICATIONS OF VENTILATION TUBES INSERTION
• Infection
• Blockage
• Extrusion
• Tympanosclerosis
• Perforation
Iatrogenic Cholesteatoma
FACTORS AFFECTING TREATMENT
• Age• Duration• Unilateral or bilateral• Degree of hearing impairment• Previous treatment• Associated conditions• Tympanic membrane changes• Others
SEQUELAE
• Spontaneous resolution– 50% resolve within 3 months.
Only 5% persists for more than 12 months
• Tympanosclerosis
• Scarring, retraction and atelectasis
• Cholesteatoma
Conclusion
• OME is very common in children• Etiology is associated with ET dysfunction and
or chronic infection• In adults: Nasopharyngeal pathology should be
considered• Most cases resolve spontaneously• Conservative treatment is of doubtful value• VT insertion restore hearing in the selected
cases
Classification of Chronic Otitis Media
• Chronic Non Suppurative Otitis Media
– Otitis media with effusion “OME”
– Adhesive otitis media
• Chronic Suppurative Otitis Media “CSOM”
– Tubo-tympanic (Safe)
– Attico-antral (Unsafe)
Chronic Adhesive Otitis Media
• Formation of adhesion in the middle ear
after reactivation and subsequent healing of
either CSOM or OME
Clinical Features
• History of CSOM or
OME
• Deafness is usually the
only symptoms
• TM shows various
structural changes
Treatment
• Observation
• Surgical treatment
• Hearing aid
Classification of Chronic Otitis Media
• Chronic Non Suppurative Otitis Media
– Otitis media with effusion “OME”
– Adhesive otitis media
• Chronic Suppurative Otitis Media “CSOM”
– Tubo-tympanic (Safe)
– Attico-antral (Unsafe)
CHRONIC SUPPURATIVE OTITIS MEDIA
ETIOLOGY
• Environmental
• Genetic
• Previous OM
• Upper respiratory tract infections
• Eustachian tube dysfunction
Tubo-tympanic
CLINICO-PATHOLOGICAL TYPES
Attico-antral
PATHOLOGY
• Signs of suppurative infection
– Discharge & perforation
– Chronic inflammatory reaction in the mucosa and the
bone (ostietis)
• Signs of healing attempts
– Granulation tissue & polyps
– Fibrosis & tympanosclerosis
• Cholesteatoma (attico-antral type)
CHOLESTEATOMA
DEFINITION
• The presence of a desquamating stratified
squamous epithelium in the middle ear
PATHOGENESIS OF CHOLESTEATOMA
• Implantation (congenital or
acquired)
• Metaplasia
• Epithelial migration
CLASSIFICATION OF CHOLESTEATOMA
• Congenital
• Acquired– Primary
– Secondary
Effect of Cholesteatoma
• Keratin encourages
persistence of the infection
• Matrix causes bone erosion
Clinical Features of CSOM
Tubo-tympanic
CLINICO-PATHOLOGICAL TYPES
Attico-antral (cholesteatoma)
SYMPTOMS OF CSOM
• Otorrhea
– Intermittent, profuse & odorless in TT type
– Persistent, scanty & malodorous in AA type
• Deafness
• Tinnitus
N.B. Any other symptom means complication
OTOSCOPIC EXAMINATION
• Discharge– Present in TT type if active but may be absent– Usually is present in AA type
• Perforation– Central: in TT type– Marginal or attic in AA type with
cholesteatoma
PERFORATION IN TT CSOM
PERFORATION IN AA CSOM
OTOSCOPIC EXAMINATION
• Discharge– Present in TT type if active but may be absent– Usually is present in AA type
• Perforation– Central: in TT type– Marginal or attic in AA type with
cholesteatoma
• Polyps, granulation tissue, tympanosclerosis
Bacteriology
P seu d om on as aeru g in osaS tap h ylococcu s au reu sP ro teu sK leb s ie lla an d E sch erich ia co li
A erob es
B ac te ro id esP ep tococcu sP ep tos trep tococcu s
A n aerob es
B ac te rio log y
INVESTIGATIONS
• Audiometry
• Bacteriology
• Imaging
Congenital Cholesteatoma
Cloudy middle ear in CSOM
Cholesteatoma with attic erosion
TREATMENT OF CHRONIC SUPPURATIVE OTITIS
MEDIA
• Depends on the type and presentation
Active TT type Inactive TT type
Attico-antral type
(usually active)
Active TT type Inactive TT type
Conservative treatment
Conservative Treatment•Treat any predisposing factor•Keep the ear dry•Ear toilet•Antibiotics•Removal of polyps and granulations
TYMPANOPLASTY
TYMPANOPLASTY
An operation performed to eradicate disease
in the middle ear cavity and to reconstruct the
hearing mechanism
MYRINGOPLASTY
An operation performed to repair the tympanic membrane
AIMS OF TYMPANOPLASTY
• To close the perforation
• To prevent re-infection
• To improve hearing
TREATMENT OF ATTICO-ANTRAL CSOM
Removal of cholesteatoma by mastoid operation
RADICAL MASTOIDECTOMY
An operation in which the mastoid antrum
and air cells, attic and middle ear are
converted into common cavity, exteriorized to
the external canal. The tympanic membrane,
malleus and incus are removed leaving only
the stapes in situ.
MODIFIED RADICAL MASTOIDECTOMY
An operation in which the mastoid antrum
and air cells, attic and middle ear are
converted into common cavity, exteriorized to
the external canal. The tympanic membrane
and ossicles remnants are retained
AIMS OF RADICAL & MODIFIED RADICAL MASTOIDECTOMY
• Safety
• Dry ear
• Preserve hearing
Conclusion
• In TT type the discharge is usually copious, intermittent and odorless. The perforation is central. Treatment is conservative (if there is active infection) followed by tympanoplasty to prevent re-infection and improve hearing.
• In the AA type the discharge is usually scanty, persistent and of bad odor. The perforation is attic or marginal with cholesteatoma. Treatment is by mastoidectomy to provide safety and dry ear
THANK YOU