Csom

CHRONIC SUPPURATIVE OTITIS MEDIA

• CSOM can be classified according to the degree of involvement of the structures of the middle ear 

TUBOTYMPANIC TYPE OF CSOM(SAFE OR BENIGN TYPE)

• It  involves the anterior inferior part of middle ear cleft (eustachian tube and mesotympanum).
• Tubotympanic type is also called safe or benign type as there is no risk of serious complicatiions.

Etiology:

• Residue of an Acute Otits Media during childhood.
• Acute necrotizing Otits Media
• Repeated infections from the Eustachian Tube
• Large sized traumatic perforation.

Involvement of disease

• Perforation-usually in the form of central perforation situated exclusively in the pars tensa.
• In long standing disease,erosion of ossicles,particularly of long process of Incus may occur.
• Polyp or granulations may be seen if few cases.
• Cholesteatoma is not seen.

Clinical features:

• Discharge:Mucoid,copius and non-foul smelling.It becomes profus during an upper respiratory tract infection.
• Deafness-is conductive in type.Degree varies with the position and size of perforation and involvement of ossicles.
• Round window shielding effect — patient hears better in the presence of discharge than when the ear is dry.

Treatment:

• Conservative management is the treatment of choice.
• Aural toilet,Antibiotic Ear drops,treatment of focii of infection like tonsilitis,sinusitis.
• Removal of polyp or granulation tissue-if present in the middle ear.
• Myringoplasty in case of persistent perforation,Tympanoplast-in case of persistent perforation with ossicular involvement. 

ATTICO-ANTRAL TYPE OF CSOM(UNSAFE OR DANGEROUS TYPE)

• It involves postero-superior part of middle ear cleft (attic, antrum and mastoid).
• Risk of intracranial extension of infection, and thus the risk of complication, is very high, therefore it is called dangerous or unsafe ear.
• It is associated with Cholesteatoma.
• Cholesteatoma is a sac lined by keratinizing stratified squamous epithelium in the middle ear cleft .

Cause of Cholesteatoma:

• Congenital

Acquired:

• Primary:Retaction pockets.
• Secondary:Migration,Metaplasia

 Clinical Features:

• Ear Discharge-scanty,foul smelling,painless and sometimes blood stained.
• Deafness-It is of conductive type but if complications like labyrinthitis intervene, SNHL may also be seen.
• Otalgia is not seen in case of cholesteatoma.
• Complications;may cause symptoms of headache,vertigo,facial palsy or ear ache.

Involvement of disease

• Perforation is situated either in pars flaccida or marginally in the posterior superior quadrant of the pars tensa.
• Perforation of tympanic membrane with destruction of tympanic annulus is called Marginal perforation.
• Cholesteatoma is visible with the perforation and the greyish white or pearly sheets of keratin are easily recognised.
• Polyps and Granulations may be seen.
• Ossicles may be affected.

Treatment:

• Surgery is the treatment of Choice.
• Tympanomastoid exploration is required which may be Atticotomy,Modified radical mastoidectomy or Radical Mastoidectomy in rare cases or combined approach tympanoplasty
• Modified Radical Mastoidectomy is the treatment of choice.
• In case of symptoms suggestive of complications like Vertigo,Facial palsy,Immediate Mastoid exploration is required.