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C.S.O.M.:
Investigations &
Treatment
Dr. Vishal Sharma
Investigations for T.T.D.
• Examination under microscope
• Ear discharge swab: for culture sensitivity
• Pure tone audiometry
• Patch test
• X-ray mastoid: B/L 300 lateral oblique (Schuller)
Done when cortical mastoidectomy is required
in ear discharge refractory to antibiotics
Uses of Audiometry
• Presence of hearing loss
• Degree of hearing loss
• Type of hearing loss
• Hearing of other ear
• Record to compare hearing post-operatively
• Medico legal purpose
Patch Test
Done when deafness = 40-50 dB
•
Do pure tone audiometry: for hearing threshold
•
Put Aluminum foil patch over T.M. perforation
•
Repeat pure tone audiometry:
Hearing improved = ossicular chain intact & mobile
Hearing same / worse = oss. chain broken or fixed
Investigations for A.A.D.
• Examination under microscope
• Ear discharge swab: for culture sensitivity
• Pure tone audiometry
• X-ray mastoid: B/L 300 lateral oblique (Schuller)
• CT scan: revision surgery, complications, children
Uses of E.U.M.
• Confirmation of otoscopy findings
• Epithelial migration at perforation margin
• Cholesteatoma & granulations
• Adhesions & tympanosclerosis
• Assesment of ossicular chain integrity
• Collection of discharge for culture sensitivity
Uses of X-ray mastoid
1. Position of dural & sinus plates: helps in surgery
2. Type of pneumatization:
a. Cellular (80%): plenty of air cells
b. Sclerotic (20%): small antrum, air cells absent
c. Diploetic (<1%): bone marrow within few air cells
3. Cholesteatoma (cotton wool appearance)
4. Bone destruction: presence & extent
5. Mastoid cavity
Dural & sinus plates
Cellular mastoid
Sclerotic mastoid
Diploetic mastoid
Attic bone erosion
Causes for mastoid cavity
• Cholesteatoma erosion
• Mastoidectomy cavity
• Tubercular mastoiditis
• Coalescent mastoiditis
• Malignancy
• Eosinophilic granuloma
• Mega-antrum
• Large emissary vein
C.T. scan temporal bone
Posterior canal wall erosion
C.T. scan temporal bone
Mastoid cholesteatoma
Treatment for
Tubo-tympanic
Disease
Non-surgical Treatment
• Precautions
• Aural toilet
• Antibiotics: Systemic & Topical
• Antihistamines: Systemic & Topical
• Nasal decongestant: Systemic & Topical
• Treatment of respiratory infection & allergy
• Tympanic membrane patcher
Precautions
• Encourage breast feeding with child’s head
raised. Avoid bottle feeding.
• Avoid forceful nose blowing
• Plug E.A.C. with Vaseline smeared cotton
while bathing & avoid swimming
• Avoid putting oil & self-cleaning of E.A.C.
Aural Toilet
Done only for active stage
– Dry mopping with cotton swab
– Suction clearance: best method
– Gentle irrigation (wet mopping)
 1.5% acetic acid solution used T.I.D.
 Removes accumulated debris
 Acidic pH discourages bacterial growth
Antibiotics
Topical Antibiotics:
Antibiotics: Ciprofloxacin, Gentamicin, Tobramycin
Antibiotics + Steroid: for polyps, granulations
Neosporin + Betamethasone / Hydrocortisone
Oral Antibiotics: for severe infections
Cefuroxime, Cefaclor, Cefpodoxime, Cefixime
Antihistamines & Decongestants
Antihistamines
Systemic decongestants
 Chlorpheniramine
 Pseudoephedrine
 Cetirizine
 Phenylephrine
 Fexofenadine
Topical decongestants
 Loratidine
 Oxymetazoline
 Levo-cetrizine
 Xylometazoline
 Azelastine (topical)
 Hypertonic saline
Kartush T.M. Patcher
Indicated in:
• Perforation in only
hearing ear
• Patient refuses surgery
• Patient unfit for surgery
• Age < 7 years
Surgical Treatment
Indicated in inactive or quiescent stage
• Myringoplasty
• Tympanoplasty
Indicated in active stage
• Cortical Mastoidectomy
• Aural polypectomy
Methods to close perforation
T.M. perforation < 2 mm
 Chemical cautery with silver nitrate
 Fat grafting
 Myringoplasty if these measures fail
T.M. perforation > 2 mm
 Tympanic membrane patcher
 Myringoplasty
Chemical cautery
Approaches to
middle ear
Wilde’s post-aural incision
Lempert’s end-aural incision
Rosen’s permeatal incision
Hearing Restoration
Myringoplasty:
• surgical closure of tympanic membrane perforation
Ossiculoplasty:
• surgical reconstruction of ossicular chain
Tympanoplasty:
• Surgical removal of disease + reconstruction of
hearing mechanism without mastoid surgery
Principles of hearing restoration
• Intact tympanic membrane
• Intact ossicular chain
• Functioning receiving & relieving windows
• Acoustic separation of these windows
• Functioning Eustachian tube
• Absence of sensori-neural hearing loss
• Absence of active infection / allergy in
middle ear cleft
Myringoplasty
Aims
• Permanently stop ear discharge: dry, safe ear
• Improve hearing: provided: 1. ossicles are intact +
mobile; 2. absence of sensori-neural deafness
• Prevention of: tympanosclerosis, adhesions,
vertigo, S.N.H.L. (cochlear exposure to loud sound)
• Wearing of hearing aid
• Occupational: military, pilots
• Recreation: swimming, diving
Contraindications
• Purulent ear discharge
• Otitis externa
• Respiratory allergy
• Age < 7 yr (Eustachian tube not fully developed)
• Only hearing ear
• Cholesteatoma
Methods
Techniques:
• Underlay: graft placed medial to fibrous annulus
• Overlay: graft placed lateral to fibrous annulus
Grafts used:
• Temporalis fascia, Tragal perichondrium, Vein
graft, Fascia lata, Dura mater
Underlay myringoplasty
Overlay myringoplasty
Steps of underlay
myringoplasty
Tympanomeatal flap raised
Placement of graft
Tympanomeatal flap replaced
Tympanomeatal flap replaced
Why temporalis fascia?
• Basal metabolic rate lowest (best survival rate)
• Easily harvested by post-aural incision
• Its an autograft, so no rejection
• Same thickness as normal tympanic membrane
• Large size graft can be harvested
• Good resistance to infection
Onlay
Underlay
Graft cholesteatoma
No
Blunting of anterior tympanomeatal angle
Lateralization of graft
No
Delayed healing time (6 wk)
3-4 weeks
No middle ear inspection
Possible
Difficult & takes more time
Easier & quicker
No
Advantages of Local
Anesthesia
• Minimal bleeding
• Hearing results can be tested on table
• Facial palsy detected immediately
• Labyrinthine stimulation detected
immediately
• No complications of General anesthesia
Tympanoplasty
Types
Type
Pathology
Graft placed on
I
Ear drum perforation only
Malleus handle
II
Malleus handle eroded
Incus
III
Malleus + Incus eroded
Stapes head
IV
V
VI
Only footplate remains:
Round window
mobile
(Footplate exposed)
Only stapes remains: fixed Lateral SCC opening
Only footplate remains:
mobile
Stapes Footplate
Malleus / Incus Autografts
Thank You