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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
Types
Perforation 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 perforation
Involves 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 retraction
TM 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
Otological examination
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
6. 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 disease
Otorrhoea
Eardrum
perforation
Last 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 destruction
1. 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
Types of Cholesteatoma
Congenital (McKenzie)
Primary Acquired
Secondary Acquired
1. Retraction pocket
1. Squamous metaplasia
(Wittmaack)
2. Basal cell hyperplasia
(Ruedi)
3. Squamous metaplasia
(Sade)
2. Epithelial migration
(Habermann)
Tertiary Acquired
1. Post-traumatic
2. Post-tympanoplasty
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 Changes
1. 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 Features
Ear discharge: scanty, purulent, continuous, foulsmelling, 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
Otorrhoea: Scanty
Tubo-tympanic
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