Q. WHAT ARE THE CAUSES OF BLOOD STAINED EAR DISCHARGE?
Trauma
Granulation
Malignant OE
EAC tumour
ASOM
COM squamous
Q. WHAT ARE THE CAUSES OF FOUL SMELLING EAR DISCHARGE?
Foul smelling discharge is secondary to saprophytic anerobic bacteria and osteititis . The causes are:
Cholesteatoma
Granulomatous condition
Myiasis
Foreign body
Malignancy with econdary infection
Q. WHAT DOES SAGGING OF POSTERIOR BONY MEATAL WALL INIDCATE?
Acute mastoiditis
Cholesteatoma
Q. WHAT ARE THE INFECTIOUS AND NON- INFECTIOUS SEQUELAE OR COMPLICATION OF COM?
INFECTIOUS COMPLICATIONS:
Acute and chronic mastoiditis
Petrositis
Intracranial infections
NON-INFECTIOUS COMPLICATIONS:
Chronic perforation of TM
Ossicular erosion
Labyrinthine erosion
Tympanosclerosis
Hearing loss
Q. WHAT ARE THE THEORIES OF MASTOID PNEUMATIZATION?
THE HEREDITARY THEORY: Children with hypo-aeration of the middle ear are prone to OME
ENVIRONMENTAL THEORY: Chronic otitis media with effusion results in hypo-pneumatization of the mastoid.
Q. WHAT IS THE CAUSE OF RETRACTION OF TM?
Repeated bouts of AOM results in weakening and thinning of the tympanic membrane by destroying the collagen containing fibrous layer of TM which results in displacement causing retraction.
Q. WHAT ARE THE FEATURES OF RETRACTED TM?
Lateral process of malleus becomes prominent.
Absence of cone of light.
Mobility of TM is restricted.
Prominent anterior and posterior malleolar folds.
Handle of malleus is foreshortened and rotated and is drawn backward which in turn brings umbo in the upper half of the membrane which displaces the light reflex ( Absent of light reflex).
Q. WHAT ARE THE DIFFERENT STAGES OF PARS TENSA RETRACTION?
According to Jacob Sade & Berco, the different stages are:
STAGE I: Retracted TM
STAGE II: Retracted TM has contact onto INCUS
STAGE III: Middle ear atelectasis ( Reverisible with VT)
STAGE IV: Adhesive Otitis Media
Q. WHAT IS TOS & POULSEN CLASSIFICATION OF PARS FLACCIDA RETRACTION?
STAGE I: Pars flaccida is dimpled and more retracted than the normal but not adhered to the malleus.
STAGE II: The retraction pocket is adherent to the handle of malleus and the full extension of the retraction pocket can be seen clearly.
STAGE III: The full extent of retraction pocket is not seen and there is an erosion of the outer attic wall (scutum)
STAGE IV: There is definite erosion of the outer attic wall and the extent of the retraction pocket cannot be seen clearly as most of it are hidden from the view.
STAGE V: Attic cholesteatoma (poulsen)
Q. WHAT ARE THE CAUSES OF SNHL IN COM?
Secondary to suppurative labyrinthitis
Ototoxicity due to use of antibiotics frequently.
Cochlear hair cell loss adjacent to cholesteatoma
Q. HOW WILL YOU IRRIGATE THE EAR TO KEEP CHOLESTEATOMA STABLE ?
Irrigation is done by 1: 1:1 mixture of distilled white vinegar + distilled water + 70 % isopropyl alcohol
Q. WHAT IS THE BACTERIOLOGY OF THE INFECTED CHOLESTEATOMA?
AEROBIC:
Pseudomonas aeruginosa
P. fluorescens
Streptococcus
Proteus
E.coli
Kliebsiella
Staphylococcus epidermidis and aureus
ANAEROBIC:
Bacteroides
Peptococcus
Fusobacterium
Q. WHY IS THE DISCHARGE FROM THE INFECTED CHOLESTEATOMA MALODOROUS?
The discharge from the ear with cholesteatoma is malodorous because of frequent super-infection with anaerobic bacteria.
Q.WHAT IS THE RATE OF OCCURRENCE OF CHLESTEATOMA?
Ear with perforation: 36%
Ear without perforation : 4 %
Q. WHAT IS POTSIC & COLLEAGUES STAGING OF CONGENITAL CHOLESTEATOMA?
STAGE I: cholesteatoma limited to one quadrant
STAGE II: Involving multiple quadrant without ossicular involvement
STAGE III: Ossicular involvement without Mastoid extension
STAGE IV: Mastoid involvement ( It carries 67% risk of residual cholesteatoma)
Q. WHAT IS NELSONS STAGING OF CONGENITAL CHOLESTEATOMA?
TYPE I: Involvement of mesotympanum without involvement of Incus or stapes.
TYPE II: Involvement of mesotympanum, attic along with erosion of ossicles without extension into mastoid cavity.
TYPE III: Involvement of mesotympanum and mastoid extension.
Q. WHAT ARE THE DIFFERENT PATHOPHYSIOLOGICAL FEATURES THAT INFLUENCES THE DEVELOPMENT AND BEHAVIOR OF COM?
Disorder of Ventilation
Mucosal Factor: Reaction of the muco-periosteal lining
Keratinizing factors/ cholesteatoma: Infiltration by keratinized squamous epithelium
Secondary infection by Saprophytic/ Pyogenic organisms
Bone reactions: erosin, necrosis or sclerosis.
Q. WHAT ARE THE CLASSICAL SYMPTOMS OF UNCOMPLICATED COM?
Otorrhoea (discharging ear)
Hearing loss
Q. WHAT ARE THE FEATURES OF COMPLICATED COM?
Severe pain
Facial palsy
Vertigo
Headache
Q. WHAT ARE THE MUCOSAL LINING PATTERN OF MIDDLE EAR CLEFT?
Cuboidal epithelium is found in :
Mastoid
Attic
Posterior Tympanum
Ciliated columnar epithelium is found in:
Eustachian tube
Hypotympanum
Anterior Mesotympanu
Q. HOW DOES NORMAL MIDDLE EAR MUCOSA APPEAR?
Thin
Pale pink in color
Barely moist
No focus of granulation or keratinization
Q. WHAT ARE THE DIFFERENT ROUTES BY WHICH INFECTION CAN REACH TO THE MIDDLE EAR?
Via Eustachian Tube
Via external meatus through perforation
Q. WHAT IS CHOLESTEROL GRANULOMA?
Cholesterol granuloma is a non-specific entity occuriing on any situation where there is stasis and haemorrhage. It composes of :
Cholesterol crystals
Foreign body giant cells
Fibrous granulation tissue
Blood Pigment (Haemosiderins)
Q. DESCRIBE THE PATTERN OF HEARING LOSS IN COM MUCOSAL?
Hearing loss tend to be slight with an anterior perforations but more with posterior extension of the defect due to loss of sound protection for the round window.
Hearing is better when the ear is discharging as the discharge closes the perforation and also loads the round window.
Q. HOW CAN YOU SAY IF OSSICULAR CHAIN AND LABYRINTHINE WINDOWS ARE FUNCTIONALLY INTACT PRE-OPERATIVELY BY ASSESSING HEARIING?
Hearing should improve noticeably when perforation is closed with prostheis e.g. Cotton soaked with liquid paraffin or Filter paper.
If this hearing improvement is absent: Ossicular fixation (tympanosclerosis) has to be suspected.
Q. WHAT ARE THE POINTS FORE AND AGAINST MYRINGOPLASTY OR TYMPANOPLASTY IN COM?
Recurrent otitis media should be controlled if re-infection has been occurring mainly via the external auditory meatus.
If observation and history suggest that infection is mainly via Eustachian tube then the causes in the nose and paranasal sinuses has to be corrected.
To insist that the child must not get water in the ear and to forbid swimming is difficult and makes the child fraustated. So correction of TM perforation prevents this case.
The hearing will be further impaired by the recurrent infection over years.
It is desirable but not essential that the ear has to be free of infection for several months before the surgery.
Age is not an absolute consideration and each case must be considered on its own merits. We should be aware that the cases below the age of 10 years are more in risk of recurrent tubal infection and in the age groups above 60 years, the cochlear function may be very intolerant of even minor non-operative trauma.
With modern techniques, the prospect of successful long- term healing after myringoplasty are excellent.
Q. WHAT ARE THE TYPES OF PERSISTENT MUCOSAL DISEASE AND THEIR CHARACTERISTICS?
Tubal:
– Usually in catarrhal child of lower social status
-Persistent or recurrent profuse mucopurulent otorrhoea.
Tympanic
-Scanty but persistent and frequent non-foetid discharge but exposure ti cold or water may result in profuse discharge.
Tympanomastoid:
– Purulent pulsatile discharge
– More active and Malodorous
-No satisfactory response to aural care
Q. WHAT ARE THE DIFFERENT METHODS OF AURAL TOILET WHICH ARE COMMONLY USED?
SUCTION
-Sterile angled canunulae of 16 or 18 Gauze is used
-It’s main advantage is it avoids the cross infection
-The main disadvantage is the nose which may make patient uncomfortable
-Precaution: Do only for short duration
DRY MOPPING
-Minimal discomfort
-Preferred method in children
WET TOILET BY SYRINGING
-It has to be done in proper postero-superior direction.
-It must be followed by dry mopping.
OTHER METHODS FOR PERSISTENT CASES:
-Zinc ionization using 1 % zinc sulphate is done for the large perforations and chronic infection of exposed mucosa
-Boric powder containing 1 % iodine was used.
-Acetic acid
Q. WHAT ARE THE DIFFERENT TERMS USED FOR CHOLESTEATOM?
Cholesteatosis ( Young)
Epidermosis (Tumarkin)
Keratosi (McGuckin)
Q. WHAT ARE THE CONDITION WHERE SURGERY FOR COM IS NOT ADVISABLE?
Medically unfit patient for surgery
Only hearing ear
Q. WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF CANAL WALL UP AND CANAL DOWN PROCEDURES?
CANAL WALL UP
ADVANTAGES:
It maintains the physiological position of TM
There is adequate middle ear space
There is no mastoid cavity problem
DISADVANTAGES:
Residual (11-27%) and Recurrent ( 5-13 %) cholesteatoma may occur.
Incomplete exteriorization of facial recess.
Second stage operation often required.
CANAL WALL DOWN
ADVANTAGES:
Residual cholesteatoma easily found on the follow up evaluation.
Recurrent cholesteatoma rare ( 2-10 %).
Total exteriorization of facial recess.
DISADVANTAGES:
Mastoid cavity problems.
Shallow middle ear which is difficult to reconstruct.
Position of pinna may be altered.
Second stage operation sometimes required.
Q. WHAT ARE THE FACTORS FOR DETERMINATION OF TREATMENT OF COM?
Extent of disease
Presence of complication
Hearing states of both ears
Eustachian tube function
Mastoid pneumatization
Patient’ factor: Age, Occupation, Medical conditions and reliability
Surgeon’s skill
Q. WHAT ARE THE MANAGEMENT OPTIONS FOR COM WITH CHOLESTEATOMA?
CONSERVATIVE TREATMENT:
Removal of entrapped keratin: direct irrigation with 1: 1: 1 distilled white vinegar+ distilled water + 70 % isopropyl alcohol for stabilization
SURGICAL APPROACHES:
Atticotomy: transcanal
Simple mastoidectomy
Canal wall -up procedures
Canal wall down procedures
Q. WHAT ARE THE PATHOLOGICAL FINDINGS IN THE TEMPORAL BONES WITH COM?
Granulation tissue
Ossicular changes
Tympanosclerosis
Cholesterol granuloma
Cholesteatoma
Q. WHAT ARE THE MOST COMMON SITES OF TYMPANOSCLEROSIS IN THE MIDDLE EAR?
Protection