Chronic otitis media

Question 1

What is Chronic suppurative otitis media (CSOM)?

also called Chronic otitis media

Answer 1

Chronic inflammation of the middle ear. It is characterised by persistent or recurrent ear discharge.

https://teachmesurgery.com/ent/ear/chronic-squamous-otitis-media/

Question 2

Most classifications now separate chronic otitis media into two distinct types:

Answer 2

• Squamous – occurs due to retraction of the tympanic membrane and is associated with the formation of cholesteatoma
• Mucosal – occurs due to tympanic membrane perforation and subsequent inflammation of the middle ear mucosa; it is also known as chronic suppurative otitis media

Question 3

Features of COM?

Answer 3

• Ear discharge (for at least 2 weeks) without pain or fever (resistant to ear drops_
• history of AOM (ear pain, fever, and irritability), a history of ear trauma, or a previous glue ear and grommet insertion.
• Possible hearing loss (conductive - cholesteoma).
• Bony destruction of cochlear - sensoneurial component to hearing loss, tinnitus, vertigo, or facial nerve palsy.
• painless ear examination - NO OTALGIA (unlike AOM or acute otitis externa), with evidence of tympanic membrane perforation.

Question 4

RF for Chronoic otitis media?

Answer 4

• Recurrent acute otitis media
• Eustachian tube dysfunction
• prior otological surgery
• ABove are all known risk factors for cholesteatoma.
• The diseas is more aggressive in children.

Question 5

Causes of COM?

Answer 5

Assumed to be complication of AOM

Question 6

Pathophysiology of Squamous COM?

Answer 6

• congenital or acquired- majority are acquired.

acquired
* chronic negative middle ear pressure from Eustachian tube dysfunction.
* pocket of space being left, termed a retraction pocket
* pockets are initially self-cleansing, but some may narrow, and trap keratinised squamous cell debris, leading to the formation of a cyst-like structure which may evolve into a cholesteatoma

Question 7

Complications of COM?

Answer 7

*Infection may spread extracranially (causing facial paralysis or mastoiditis)
*or intracranially (causing meningitis or cerebral abscess)

Question 8

Treatment of COM?

Answer 8

Referral to ENT
In primary care: Do NOT swab the ear
Treatment should NOT be initiated
Reassurance that hearing loss will return when perforation heals.

Question 9

DDx of COM

Answer 9

Otitis externa- inflamed eczematous canal without a perforation
Foreign body
Impacted ear wax
Neoplasm- ear canal swelling that bleeds on contact

Question 10

How do we class chronic otitis media (COM) (workbook)

Answer 10

First divide into - ACTIVE or INACTIVE (based on whether ear is discharging or not)

THEN it is subdivided into:
- Mucosal disease
or
- Squamous disease

Question 11

In chronic otitis media what are the following also known as?

1. active squamous disease
2. inactive squamous disease

Answer 11

1. active squamous disease = Cholesteatoma
2. inactive squamous disease = a retraction pocket which may develop into cholesteatoma

Question 12

What is active and inactive mucosal disease in chronic otitis media?

Answer 12

1. Active mucosal disease - chronic discharge from the middle ear through a tympanic membrane perforation
2. Inactive mucosal disease - tympanic membrane perforation but no active discharge or infection

Question 13

When is a mastoidectomy indicated in chronic otitis media?

Answer 13

If there is a cholesteatoma present (squamous disease)

cholesteatoma grows from middle ear into mastoid

https://teachmesurgery.com/ent/ear/chronic-squamous-otitis-media/

Question 14

If there is no cholesteatoma (squamous disease) how should this form of chronic otitis media be treated?

Answer 14

Medical treatment topical antibiotic drops and aural toilet (ear cleaning)

Question 15

Management of Chronic otitis media
How should you treat a chronically discharging ear when you are not sure if a cholesteatoma is present ?

Answer 15

medically first

if fails to respond = surgery (mastoidectomy) should be carried out

Surgery: repair perforation, ensure ventilation of middle ear and mastoid bone. If there is a cholesteatoma ever trace of disease should be removed.

Question 16

What are some complications of mastoid surgery?

Answer 16

facial nerve palsy
altered taste (damage to chordae tympani
CSF leak
tinnitus
vertigo
complete loss of hearing in operated ear

Question 17

Investigations for COM?

Answer 17

• pure-tone audiogram to objectively determine the extent and type of hearing loss.
• A CT scan of the petrous temporal bone must be performed to guide clinical suspicion and for pre-operative surgical planning

Question 18

What would you see in a squamous chronic otitis media on otoscopy?

Answer 18

• pearly, keratinized, or waxy mass in the attic region is seen on otoscopy
• These are best seen when a perforation of the tympanic membrane is present, providing a window into the middle ear.