C.S.O.M.: Clinical Features

Dr. Vishal Sharma

Definition

• Chronic (> 3 months) pyogenic infection of

middle ear cleft mucosa, characterized by

persistent perforation of tympanic membrane,

ear discharge & decreased hearing

• Prevalence in Nepal: 7.2 %

Types of C.S.O.M.Tubo-tympanic: chronic pyogenic infection of

middle ear cleft mucosa with persistent perforation

in pars tensa

Attico-antral: chronic pyogenic infection of middle

ear cleft with cholesteatoma & granulations in attic

or postero-superior quadrant of pars tensa

Middle ear cleft

Tubo-tympanic vs. Attico-antral

Tympanic Membrane Perforations

TypesPerforation of Pars Tensa

1. Central tubo-tympanic

Small Medium Large Subtotal

2. Central with ingrowing epithelium attico-antral

3. Marginal attico-antral

4. Total attico-antral

Perforation of Pars Flaccida

1. Attic attico-antral

4 quadrants of T.M.

umbo

Small perforation

Involves only

one quadrant

or

< 10% of pars

tensa

Medium perforation

Involves two

quadrants

or

10 – 40 %

of

pars tensa

Medium perforation

Large perforationInvolves 3 or 4

quadrants with

wide T.M.

remnant

or

> 40 % of pars

tensa

Subtotal perforation

Involves all 4

quadrants &

reaches up to

annulus

fibrosus

In growing epithelium

T.M.

perforation

with

inward

migration of

epithelium

Marginal perforation

Erodes

annulus

fibrosus & one

margin is

formed by

bony tympanic

annulus

Marginal perforation

Total perforation

Total erosion

of pars tensa

& anulus

fibrosus

Attic perforation

Involves

pars

flaccida

Tympanic Membrane Retractions

Grade 1 retraction• Dull, lustreless T.M.

• Prominent annulus

• Cone of light absent

• Handle medialized

• Prominent lateral

process

• Malleolar folds

sickle shaped

Grade 2 retraction

Eardrum

touches

incus

Grade 3 retractionTM touches

promontory

(atelectasis)

but mobile on

Valsalva

maneuver or

Siegalization

Grade 4 retraction

TM firmly

adherent to

promontory &

immobile on

Valsalva

maneuver or

Siegalization

PSQ retraction pocket

Attic retraction pocket

Otological examination

1. Pre-auricular region: sinus, lymph node

2. Pinna: size, position, deformity, swelling

3. Post-auricular region: surgical scar, swelling,

fistula, lymph node

4. External auditory canal: meatal opening, otitis

externa, wax, fungal debris, ear discharge

5. Tympanic membrane:

intact: colour, position, mobility, tympanosclerosis,

retraction pocket

perforated: type, site, size & margin of perforation

handle of malleus; middle ear cavity (mucosa, ear

discharge, polyp, granulations, cholesteatoma

flakes); pars flaccida

Otological examination

Otological examination6. Mastoid cavity: size, facial ridge, discharge,

epithelialization, granulations,

polyps

7. Tragal tenderness: associated otitis externa

8. Mastoid tenderness: cymba conchae, mastoid

body + tip & posterior zygoma root

9. Fistula sign 10. Facial nerve function

11. Tuning Fork Tests

Tubo-tympanic Disease

Predisposing factors• Upper respiratory tract infection (recurrent)

• Upper respiratory tract allergy

• Pre-existing otitis media with effusion

• Cleft palate

• Immune deficiency: diabetes, AIDS

• Poor socio-economic status

Bacteria responsible

• Staphylococcus aureus

• Pseudomonas aeruginosa

• Klebsiella

• Proteus

• Streptococcus

• Bacteroides

Routes of infection

1. Via Eustachian tube:

U.R.T.I., nose blowing,

regurgitation of milk

2. Via tympanic membrane perforation:

following A.S.O.M. or post-traumatic

3. Haematogenous (rare):

viral exanthematous fevers

Pathological Changes

1. Eardrum: central perforation; myringosclerosis

2. Ossicles: Destruction (hyperaemic decalcification)

Tympanoslerosis

Fibrosis + Adhesions

3. Middle ear mucosa: edematous, pale pink

4. Mastoid bone: sclerosis

Clinical Features

Ear discharge: profuse, mucoid / muco-purulent,

intermittent, odourless, not blood-stained

Hearing Loss: usually conductive (25-50 dB)

absent in small, dry perforations

round window shielding by ear

discharge leads to better hearing

Tympanic membrane: central perforation

Stages of Tubotympanic diseaseOtorrhoea Eardrum

perforationLast ear

discharge

Active Present Present -

Quiescent Absent Present < 6 months

Inactive Absent Present > 6 months

Healed Absent Absent -

Attico-antral disease

Cholesteatoma• Term used by Johannes Müller in 1858

• Three dimensional sac lined by matrix of

keratinizing stratified squamous epithelium

which rests on a thin layer of fibrous tissue

• Contains desquamated keratin debris

• Grows at the expense of surrounding bone

• Not a tumor & has no cholesterol

• Epidermosis is a better term

Cholesteatoma

Histopathology

Causes of bone destruction1. Hyperaemic decalcification

2. Osteoclastic bone resorption due to:

Acid phosphatase Collagenase

Acid proteases Proteolytic enzymes

Leukotrienes Cytokines

3. Pressure necrosis: No role

4. Bacterial toxins: No role

Congenital (McKenzie)

Primary Acquired Secondary Acquired

1. Retraction pocket 1. Squamous

metaplasia

(Wittmaack) 2. Epithelial migration

2. Basal cell hyperplasia (Habermann)

(Ruedi) Tertiary Acquired

3. Squamous metaplasia 1. Post-traumatic

(Sade) 2. Post-tympanoplasty

Types of Cholesteatoma

Congenital cholesteatoma

Persistence of congenital cell rests in middle ear, petrous apex, cerebello-pontine angle

Congenital cholesteatoma

Retraction pocket formation

Retraction pocket in pars flaccida or Postero-superior

quadrant pars tensa due to E.T. dysfunction

Basal cell hyperplasia

Hyperplasia of basal cells in epithelial layer of T.M. & their invasion of sub-

epithelial tissues

Primary squamous metaplasia

Transformation of middle ear mucosa into squamous

epithelium due to infection, with no T.M. perforation

Secondary squamous metaplasia

Transformation of middle ear mucosa into squamous

epithelium due to infection via T.M. perforation

Epithelial migration

Migration of epithelium via T.M. perforation into middle ear

Post-traumatic cholesteatoma

Mechanisms:

1. Epithelial entrapment in fracture line

2. In growth of epithelium through fracture line

3. Traumatic implantation of epithelium into middle ear

4. Trapping of epithelium medial to E.A.C. stenosis

Pathological Changes1. T.M. perforation: marginal or attic

2. T.M. retraction pocket: attic or P.S.Q.

3. Cholesteatoma formation

4. Ossicles: destruction

5. Middle ear mucosa: edematous, red

6. Aural polyp: red, fleshy

7. Osteitis & granulation tissue formation

8. Mastoid bone: erosion, sclerosis

Clinical FeaturesEar discharge: scanty, purulent, continuous, foul-

smelling, blood-stained

Hearing Loss: conductive or sensori-neural

T.M. perforation: marginal or attic or total

T.M. retraction pocket: attic or P.S.Q.

Cholesteatoma flakes

Aural polyp, osteitis & granulation tissue

Features of Complications• Severe otalgia, painful swelling around ear

• Vertigo, nausea, vomiting

• Headache + blurred vision + projectile vomiting

• Fever + neck rigidity + irritability / drowsiness

• Facial asymmetry

• Gradenigo syndrome (apex petrositis)

• Ataxia

Otorrhoea & aural polyp

Attic cholesteatoma

Attic cholesteatoma

PSQ cholesteatoma & granulation tissue

Attico-antral Tubo-tympanic

Otorrhoea: Scanty Profuse

Continuous Intermittent

Purulent Mucoid

Blood-stained No

Foul smelling No

Attic / marginal perforation, retraction pocket

Central perforation

Cholesteatoma, granulation No

Tuberculous Otitis Media• Painless, odorless otorrhoea refractory to antibiotics

• Multiple TM perforations large perforation

• Middle ear mucosa pale (congestion around E.T.O.)

• Pale granulations in mastoid & middle ear

• Severe deafness with bony necrosis (caries)

• Facial palsy & labyrinthitis

• Tx: Anti-TB therapy + cortical mastoidectomy

Multiple T.M. perforations

Thank You