Tag: Csom

Csom

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.

MICROBIOLOGY OF CSOM

  • Pus culture in CSOM may show multiple organisms.
  • Most commonly isolated organisms are gram negative bacilli, i.e., Pseudomonas, proteus, E.coli.
  • These organisms are not commonly found in the respiratory tract, while commonly found in the skin of external ear.
Exam Question
 
  • Most common organism cultured in CSOM is Pseudomonas seruginosa.
  • Treatment of choice in a patient of CSOM has choleastatoma and presenting with vertigo or Facial Palsy is immediate Mastoid Exploration.
  • Perforation of pars flaccida is associated with cholesteatoma.
  • Perforation of tympanic membrane with destruction of tympanic annulus is called Marginal perforation.
  • Treatment of choice for Perforation in pars flaccida of the tympanic membrane with cholesteatoma is Modified Radical Mastoidectomy.
  • Cholesteotoma is seen in Attico-antral CSOM.
  • Ossicle M/C involved in CSOM is Long process of Incus.
  • CSOM is caused by multiple bacteria.
  • Conservative management is the treatment of choice in central,safe tympanic membrane perforation.
  • Treatment of choice in case of Attico-antral Cholesteatoma is Modified radical Mastoidectomy/Tympano-mastoid exploration.
  • Cholesteatoma is associated with scanty,foul smelling,painless discharge.
  • 7 th cranial nerve is most commonly involved in CSOM.
Don’t Forget to Solve all the previous Year Question asked on Csom

Csom

CSOM

Q. 1

A child presents with left ear hearing loss of three month duration. On examination, foul smelling purulent discharge is seen with perforation in pars flaccida. What is the most appropriate management?

 A

Topical antibiotics and decongestants for 4 weeks.

 B

Aural toileting

 C

Tympano-mastoid exploration

 D

Type I tympanoplasty

Q. 1

A child presents with left ear hearing loss of three month duration. On examination, foul smelling purulent discharge is seen with perforation in pars flaccida. What is the most appropriate management?

 A

Topical antibiotics and decongestants for 4 weeks.

 B

Aural toileting

 C

Tympano-mastoid exploration

 D

Type I tympanoplasty

Ans. C

Explanation:

 

  • Foul smelling discharge and perforation in the Pars flaccida suggest CSOM of the unsafe type (Atticoantral type)
  • This type of CSOM is often associated with a bone eroding process such as cholesteatoma, granulations or osteitis. Risk of complications is high
  • Surgery is the mainstay of treatment.
  • The primary aim is to remove the disease process by tympano-mastoid exploration and render the ear safe.
  • Tympano-mastiod exploration can be done through various procedures.

1. Canal wall down procedures

– Atticotomy, modified radical mastoidectomy and rarely radical mastoidectomy.

2. Canal wall up procedures

  • Tympanoplasty is a surgical procedure that repairs or reconstructs the hearing mechanism.

‘Type I Defect is perforation of tympanic membrane which is

repaired with a graft. It is also called myringoplasty.

-Type II Defect is perforation of tympanic membrane with erosion of malleus. Graft is placed on the incus or remnant of malleus.

‘Type III Malleus and incus are absent. Graft is placed directly on the stapes head. It is also myringostapediopexy or columella tympanoplasty.

-Type IV Only the footplate of stapes is present. It is exposed to the external ear, and graft is placed between the oval and round windows. A narrow middle ear (cavum minor) is thus created, to have an air pocket around the round window. A mucosa-lined space extends from the eustachian tube to the round window. Sound waves in this case act directly on the footplate while the round window has been shielded.

Type V Stapes footplate is fixed but round window is functioning. In such cases, another window is created on horizontal semicircular canal and covered with a graft. Also called fenestration operation.


Q. 2

A 30-year-old,lady, with a history of chronic otitis and sinusitis is found to have a low serum IgA level. All other immunoglobulin classes are found to be normal. Which of the following statements is correct?

 A

She may suffer an anaphylactic reaction following the administration of blood products

 B

Not associated with other autoimmune disorders

 C

Intravenous immunoglobulin (IVIG) is the treatment of choice

 D

All of the above

Q. 2

A 30-year-old,lady, with a history of chronic otitis and sinusitis is found to have a low serum IgA level. All other immunoglobulin classes are found to be normal. Which of the following statements is correct?

 A

She may suffer an anaphylactic reaction following the administration of blood products

 B

Not associated with other autoimmune disorders

 C

Intravenous immunoglobulin (IVIG) is the treatment of choice

 D

All of the above

Ans. A

Explanation:

The patient is suffering from isolated IgA deficiency.

 
IgA deficiency is the most common PID.
It is asymptomatic in most cases; however, individuals may present with increased numbers of acute and chronic respiratory infections that may lead to bronchiectasis.
In addition, over their lifetime, these patients experience an increased susceptibility to drug allergies, atopic disorders, and autoimmune diseases.
Serum antibodies to IgA are reported in as many as 44% of patients with selective IgA deficiency.
If these antibodies are of the IgE isotype, they can cause severe or fatal anaphylactic reactions after intravenous administration of blood products containing IgA.
 
Administration of intravenous immunoglobulin (IVIG), which is >99% IgG, is not indicated because most IgA-deficient patients make IgG antibodies normally. Many IVIG preparations contain sufficient IgA to cause anaphylactic reactions.

Q. 3

Which of the following condition is most commonly associated with cholesteatoma formation?

 A

Central perforation

 B

Attico-antral perforation

 C

Tubo-tympanic disease

 D

Otosclerosis

Q. 3

Which of the following condition is most commonly associated with cholesteatoma formation?

 A

Central perforation

 B

Attico-antral perforation

 C

Tubo-tympanic disease

 D

Otosclerosis

Ans. B

Explanation:

Atticoantral type of CSOM is most commonly associated with cholesteatoma, granulations or osteitis. It is associated with an attic or marginal perforation.

Tubotympanic type of CSOM is associated with central perforation.


Q. 4

A 10 year boy presents with discharge and hearing disturbance in the left ear. On examination of the left ear, a central perforation is noted. Which of the following is the surgical management of choice in this patient?

 A

Myringoplasty

 B

Modified radical mastoidectomy

 C

Radical mastoidectomy

 D

Clearance and antibiotics

Q. 4

A 10 year boy presents with discharge and hearing disturbance in the left ear. On examination of the left ear, a central perforation is noted. Which of the following is the surgical management of choice in this patient?

 A

Myringoplasty

 B

Modified radical mastoidectomy

 C

Radical mastoidectomy

 D

Clearance and antibiotics

Ans. A

Explanation:

Q. 5

A man presented with complaints of scanty, foul smelling, painless discharge from the ear. It is characteristic feature of the following lesion:

 A

ASOM

 B

Cholesteatoma

 C

Central perforation

 D

Otitis externa

Q. 5

A man presented with complaints of scanty, foul smelling, painless discharge from the ear. It is characteristic feature of the following lesion:

 A

ASOM

 B

Cholesteatoma

 C

Central perforation

 D

Otitis externa

Ans. B

Explanation:

Patients with acquired cholesteatomas typically present with recurrent or persistent purulent otorrhea and hearing loss. The discharge is scanty & always foul-smelling due to bone destruction. Facial nerve twitching, palsy, or paralysis can also result from the inflammatory process or from mechanical compression of the nerve. 
 
Ref: Chang C. (2012). Chapter 50. Cholesteatoma. In A.K. Lalwani (Ed), CURRENT Diagnosis & Treatment in Otolaryngology—Head & Neck Surgery, 3e.

Q. 6

Which of the following is the treatment of choice for atticoantral variety of chronic suppurative otitis media?

 A

Mastoidectomy

 B

Medical management

 C

Underlay myringoplasty

 D

Insertion of ventilation lube

Q. 6

Which of the following is the treatment of choice for atticoantral variety of chronic suppurative otitis media?

 A

Mastoidectomy

 B

Medical management

 C

Underlay myringoplasty

 D

Insertion of ventilation lube

Ans. A

Explanation:

Atticoantral type of CSOM involves the attic of the tympanic membrane and is often associated with cholesteatoma formation.

In this type, a retraction pocket develops in the pars flaccida and a cholesteatoma develops if the squamous epithelium cannot migrate out of this pocket.

It is associated with a number of complications and the surgery is the primary modality of treatment.

Surgical procedures indicated in this condition are atticotomy, mastoidectomy or combined approach tympanoplasty.

 
Tubotympanic type of CSOM involves the anteroinferior part of the middle ear cleft and is associated with a permanent central perforation. It is not associated with serious complications and it is called safe or benign CSOM.
 

Q. 7

Ossicle M/C involved in CSOM:

 A

Stapes

 B

Long process of incus

 C

Head of malleus

 D

Handle of malleus

Q. 7

Ossicle M/C involved in CSOM:

 A

Stapes

 B

Long process of incus

 C

Head of malleus

 D

Handle of malleus

Ans. B

Explanation:

Q. 8

True about safe CSOM:

 A

Etiology is multiple bacteria

 B

Oral antibiotics are not affective

 C

Ear drops have no role

 D

Ottic hydrocephalus is a known complication

Q. 8

True about safe CSOM:

 A

Etiology is multiple bacteria

 B

Oral antibiotics are not affective

 C

Ear drops have no role

 D

Ottic hydrocephalus is a known complication

Ans. A

Explanation:

 

CSOM is caused by multiple bacteria – both aerobic and anaerobic.

Their is no sex predilection in CSOM – both sexes are affected equally.                              

Treatment of Tubotympanic type of CSOM is aural toileting and antibiotic ear drops. Dhingra 5th/ed


Q. 9

Treatment of choice in central safe perforation is:

 A

Modified mastoidectomy

 B

Tympanoplasty

 C

Myringoplasty

 D

Conservative management

Q. 9

Treatment of choice in central safe perforation is:

 A

Modified mastoidectomy

 B

Tympanoplasty

 C

Myringoplasty

 D

Conservative management

Ans. D

Explanation:

Q. 10

Cholesteatoma is commonly caused by:

 A

Attico-antral perforation

 B

Tubotympanic disease

 C

Central perforation of tympanic membrane

 D

Meniere’s disease

Q. 10

Cholesteatoma is commonly caused by:

 A

Attico-antral perforation

 B

Tubotympanic disease

 C

Central perforation of tympanic membrane

 D

Meniere’s disease

Ans. A

Explanation:

 

Tubotympanic type (safe or benign type)

  • It is associated with central perforation of tympanic membrane and involves the anterior inferior part of middle ear cleft (eustachian tube and mesotympanum).
  • There is no association with cholesteatoma.
  • Tubotympanic type is also called safe or benign type as there is no risk of serious complicatiions.

Attico-antral type (unsafe or dangerous type)

  • It is associated with an attic or a marginal perforation of the tympanic membrane and involves postero-superior part of middle ear cleft (attic, antrum and mastoid).
  • The attico-antral disease is characterized with cholesteatoma which erodes the bone.
  • Risk of intracranial extension of infection, and thus the risk of complication, is very high, therefore it is called dangerous or unsafe ear.

Q. 11

Cholesteatoma occurs in:

 A

CSOM with central perforation

 B

Masked mastoiditis

 C

Coalescent mastoiditis

 D

Acute necrotizing otitis media

Q. 11

Cholesteatoma occurs in:

 A

CSOM with central perforation

 B

Masked mastoiditis

 C

Coalescent mastoiditis

 D

Acute necrotizing otitis media

Ans. D

Explanation:

Q. 12

Cholesteotoma is seen in:

 A

ASOM

 B

CSOM

 C

Secretory ottitis media 

 D

Osteosclerosis

Q. 12

Cholesteotoma is seen in:

 A

ASOM

 B

CSOM

 C

Secretory ottitis media 

 D

Osteosclerosis

Ans. B

Explanation:

Q. 13

Perforation of tympanic membrane with destruction of tympanic annulus is called:

 A

Attic

 B

Marginal

 C

Subtotal

 D

Total

Q. 13

Perforation of tympanic membrane with destruction of tympanic annulus is called:

 A

Attic

 B

Marginal

 C

Subtotal

 D

Total

Ans. B

Explanation:

Q. 14

What is true in case of perforation of pars flaccida?

 A

CSOM is a rare cause

 B

Associated with cholesteatoma

 C

Usually due to trauma

 D

All of the above

Q. 14

What is true in case of perforation of pars flaccida?

 A

CSOM is a rare cause

 B

Associated with cholesteatoma

 C

Usually due to trauma

 D

All of the above

Ans. B

Explanation:

 

Tympanic membrane can be divided in 2 parts:

Pars tensa  : It forms most of the tympanic membrane. Its periphery is thickened to form fibro cartilaginous ring called as annulus tympanicus.

Pars Flaccida : It is situated above the lateral process of malleus between the notch of Rivinus and the anterior and posterior malleolar fold.


 

 


Q. 15

Prior H/O ear surgery and Scanty, foul smelling, painless discharge from the ear is characteristic feature of which of the following lesions:

 A

ASOM

 B

Cholesteatoma

 C

Central perforation

 D

Otitis externa

Q. 15

Prior H/O ear surgery and Scanty, foul smelling, painless discharge from the ear is characteristic feature of which of the following lesions:

 A

ASOM

 B

Cholesteatoma

 C

Central perforation

 D

Otitis externa

Ans. B

Explanation:

 

Cholesteatoma / attico antral type of CSOM / marginal perforation is characterised by scanty foul smelling, painless discharge from the ear.

The foul smell is due to saprophytic infection and osteitis


Q. 16

Which is true about Cholesteatoma (Atticoantral)?

 A

Scanty, malodorous discharge

 B

Otalgia

 C

Central perforation

 D

All

Q. 16

Which is true about Cholesteatoma (Atticoantral)?

 A

Scanty, malodorous discharge

 B

Otalgia

 C

Central perforation

 D

All

Ans. A

Explanation:

 

  • Cholestatoma is associated with atticoantral type of CSOM / atticoantral or marginal perforation (and not central perforation).
  • Cholesteatoma leads to destruction of bones therefore there is scanty foul smelling discharge and ossicular necrosis.
  • Hearing loss occurs if ossicles are involved.
  • It is of conductive type but if complications like labyrinthitis intervene, SNHL may also be seen.
  • Bleeding may occur from granulations or polyp.
  • Otalgia is not seen in case of cholesteatoma.



Q. 17

The treatment of choice for atticoantral variety of chronic suppurative otitis media is:

 A

Mastoidectomy

 B

Medical management

 C

Underlay myringoplasty

 D

Insertion of ventilation tube

Q. 17

The treatment of choice for atticoantral variety of chronic suppurative otitis media is:

 A

Mastoidectomy

 B

Medical management

 C

Underlay myringoplasty

 D

Insertion of ventilation tube

Ans. A

Explanation:

Q. 18

Treatment of choice for Perforation in pars flaccida of the tympanic membrane with cholesteatoma is: 

 A

Myringoplasty

 B

 Modified Radical Mastoidectomy [MRM]

 C

Antibiotics

 D

Radical mastoidectomy

Q. 18

Treatment of choice for Perforation in pars flaccida of the tympanic membrane with cholesteatoma is: 

 A

Myringoplasty

 B

 Modified Radical Mastoidectomy [MRM]

 C

Antibiotics

 D

Radical mastoidectomy

Ans. B

Explanation:

Q. 19

A child presents with ear infection with foul smelling discharge. On further exploration, a small perforation is found in the pars flaccida of the tympanic membrance. Most appropriate next step in the management would be:

 A

Topical antibiotics and decongestants for 4 weeks

 B

IV antibiotics and follow up after a month

 C

Tympanoplasty

 D

Tympano-mastoid exploration

Q. 19

A child presents with ear infection with foul smelling discharge. On further exploration, a small perforation is found in the pars flaccida of the tympanic membrance. Most appropriate next step in the management would be:

 A

Topical antibiotics and decongestants for 4 weeks

 B

IV antibiotics and follow up after a month

 C

Tympanoplasty

 D

Tympano-mastoid exploration

Ans. D

Explanation:

 

  • Tympano-mastiod exploration can be done through various procedures: – Canal wall down procedures
  • Atticotomy, and rarely radical mastoidectomy. – Canal wall up procedures
  • Cortical mastoidectomy

Q. 20

Treatment of choice for CSOM with vertigo and facial nerve palsy is:

 A

Antibiotics and labyrinthine sedative

 B

Myringoplasty

 C

Immediate mastoid exploration

 D

Labyrinthectomy

Q. 20

Treatment of choice for CSOM with vertigo and facial nerve palsy is:

 A

Antibiotics and labyrinthine sedative

 B

Myringoplasty

 C

Immediate mastoid exploration

 D

Labyrinthectomy

Ans. C

Explanation:

Q. 21

A patient of CSOM has choleastatoma and presents with vertigo . Treatment of choice would be:

 A

Antibiotics and labyrinthine sedative

 B

Myringoplasty

 C

Immediate mastoid exploration

 D

Labyrinthectomy

Q. 21

A patient of CSOM has choleastatoma and presents with vertigo . Treatment of choice would be:

 A

Antibiotics and labyrinthine sedative

 B

Myringoplasty

 C

Immediate mastoid exploration

 D

Labyrinthectomy

Ans. C

Explanation:

 

The patient is presenting with CSOM and vertigo which means cholesteatoma has led to fistula formation involving semicircular canals which in turn has caused vertigo.

So the management is immediate mastoid exploration to remove the cholesteatoma.



Q. 22

A patient of CSOM with cholesteatoma present with acute onset of vertigo. Treatment is: 

 A

Immediate exploration

 B

Antibiotics + steroids

 C

Labyrinthine sedatives + antibiotics

 D

Labyrinthine sedatives only

Q. 22

A patient of CSOM with cholesteatoma present with acute onset of vertigo. Treatment is: 

 A

Immediate exploration

 B

Antibiotics + steroids

 C

Labyrinthine sedatives + antibiotics

 D

Labyrinthine sedatives only

Ans. A

Explanation:

Q. 23

Most common organism cultured in CSOM is ‑

 A

Staphylococcus aureus

 B

Staphylococcus epidermidis

 C

Streptococcus pneumonia

 D

Pseudomonas seruginosa

Q. 23

Most common organism cultured in CSOM is ‑

 A

Staphylococcus aureus

 B

Staphylococcus epidermidis

 C

Streptococcus pneumonia

 D

Pseudomonas seruginosa

Ans. D

Explanation:

Ans. is ‘d’ i.e., Pseudomonas aeruginosa

Microbiology of CSOM

  • Pus culture in both types of aerobic and anaerobic CSOM may show multiple organisms.
  • Most commonly isolated organisms are gram negative bacilli, i.e., Pseudomonas, proteus, E.coli.
  • These organisms are not commonly found in the respiratory tract, while commonly found in the skin of external ear.

Q. 24

Most common cranial nerve involved in CSOM is ‑

 A

V

 B

VII

 C

IX

 D

XI

Q. 24

Most common cranial nerve involved in CSOM is ‑

 A

V

 B

VII

 C

IX

 D

XI

Ans. B

Explanation:

Ans. is ‘b’ i.e., VII



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