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CHRONIC OTITIS MEDIA CASE : QUESTIONS AND ANSWERS

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Q. WHAT ARE THE CAUSES OF BLOOD STAINED EAR DISCHARGE?

  1. Trauma
  2. Granulation
  3. Malignant OE
  4. EAC tumour
  5. ASOM
  6. 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:
  1. Cholesteatoma
  2. Granulomatous condition
  3. Myiasis
  4. Foreign body
  5. Malignancy with econdary infection

Q. WHAT DOES SAGGING OF POSTERIOR BONY MEATAL WALL INIDCATE?

  1. Acute mastoiditis
  2. Cholesteatoma

Q. WHAT ARE THE INFECTIOUS AND NON- INFECTIOUS SEQUELAE OR COMPLICATION OF COM?

INFECTIOUS COMPLICATIONS:

  1. Acute and chronic mastoiditis
  2. Petrositis
  3. Intracranial infections

NON-INFECTIOUS COMPLICATIONS:

  1. Chronic perforation of TM
  2. Ossicular erosion
  3. Labyrinthine erosion
  4. Tympanosclerosis
  5. Hearing loss

Q. WHAT ARE THE THEORIES OF MASTOID PNEUMATIZATION?

  1. THE HEREDITARY THEORY: Children with hypo-aeration of the middle ear are prone to OME
  2. 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?

  1. Lateral process of malleus becomes prominent.
  2. Absence of cone of light.
  3. Mobility of TM is restricted.
  4. Prominent anterior and posterior malleolar folds.
  5. 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

sade's staging of retraction of pars tensa

 

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)

 

tos staging of pars flaccida retraction

Q. WHAT ARE THE CAUSES OF SNHL IN COM?

  1. Secondary to suppurative labyrinthitis
  2. Ototoxicity due to use of antibiotics frequently.
  3. 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:
  1. Pseudomonas aeruginosa
  2. P. fluorescens
  3. Streptococcus
  4. Proteus
  5. E.coli
  6. Kliebsiella
  7. Staphylococcus epidermidis and aureus
  • ANAEROBIC:
  1. Bacteroides
  2. Peptococcus
  3. 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?

  1. Disorder of Ventilation
  2. Mucosal Factor: Reaction of the muco-periosteal lining
  3. Keratinizing factors/ cholesteatoma: Infiltration by keratinized squamous epithelium
  4. Secondary infection by Saprophytic/ Pyogenic organisms
  5. Bone reactions: erosin, necrosis or sclerosis.

Q. WHAT ARE THE CLASSICAL SYMPTOMS OF UNCOMPLICATED COM?

  1. Otorrhoea (discharging ear)
  2. Hearing loss

Q. WHAT ARE THE FEATURES OF COMPLICATED COM?

  1. Severe pain
  2. Facial palsy
  3. Vertigo
  4. Headache

Q. WHAT ARE THE MUCOSAL LINING PATTERN OF MIDDLE EAR CLEFT?

  • Cuboidal epithelium is found in :
  1. Mastoid
  2. Attic
  3. Posterior Tympanum
  • Ciliated columnar epithelium is found in:
  1. Eustachian tube
  2. Hypotympanum
  3. 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?

  1. Via Eustachian Tube
  2. 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 :
  1. Cholesterol crystals
  2. Foreign body giant cells
  3. Fibrous granulation tissue
  4. Blood Pigment (Haemosiderins)

Q. DESCRIBE THE PATTERN OF HEARING LOSS IN COM MUCOSAL?

  1. 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.
  2. It is conductive type of around 20-45 dB
  3. 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?

  1. Recurrent otitis media should be controlled if re-infection has been occurring mainly via the external auditory meatus.
  2. 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.
  3. 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.
  4. The hearing will be further impaired by the recurrent infection over years.
  5. It is desirable but not essential that the ear has to be free of infection for several months before the surgery.
  6. 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.
  7. 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?

  1. Tubal:
    – Usually in catarrhal child of lower social status
    -Persistent or recurrent profuse mucopurulent otorrhoea.
  2. Tympanic
    -Scanty but persistent and frequent non-foetid discharge but exposure ti cold or water may result in profuse discharge.
  3. 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?

  1. 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
  2. DRY MOPPING
    -Minimal discomfort
    -Preferred method in children
  3. WET TOILET BY SYRINGING
    -It has to be done in proper postero-superior direction.
    -It must be followed by dry mopping.
  4. 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?

  1. Cholesteatosis ( Young)
  2. Epidermosis (Tumarkin)
  3. Keratosi (McGuckin)

Q. WHAT ARE THE CONDITION WHERE SURGERY FOR COM IS NOT ADVISABLE?

  1. Medically unfit patient for surgery
  2. Only hearing ear

Q. WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF CANAL WALL UP AND CANAL DOWN PROCEDURES?

CANAL WALL UP

ADVANTAGES:

  1. It maintains the physiological position of TM
  2. There is adequate middle ear space
  3. There is no mastoid cavity problem

DISADVANTAGES:

  1. Residual (11-27%) and Recurrent ( 5-13 %) cholesteatoma may occur.
  2. Incomplete exteriorization of facial recess.
  3. Second stage operation often required.

CANAL WALL DOWN

ADVANTAGES:

  1. Residual cholesteatoma easily found on the follow up evaluation.
  2. Recurrent cholesteatoma rare ( 2-10 %).
  3. Total exteriorization of facial recess.

DISADVANTAGES:

  1. Mastoid cavity problems.
  2. Shallow middle ear which is difficult to reconstruct.
  3. Position of pinna may be altered.
  4. Second stage operation sometimes required.

Q. WHAT ARE THE FACTORS FOR DETERMINATION OF TREATMENT OF COM?

  1. Extent of disease
  2. Presence of complication
  3. Hearing states of both ears
  4. Eustachian tube function
  5. Mastoid pneumatization
  6. Patient’ factor: Age, Occupation, Medical conditions and reliability
  7. 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:

  1. Atticotomy: transcanal
  2. Simple mastoidectomy
  3. Canal wall -up procedures
  4. Canal wall down procedures

Q. WHAT ARE THE PATHOLOGICAL FINDINGS IN THE TEMPORAL BONES WITH COM?

  1. Granulation tissue
  2. Ossicular changes
  3. Tympanosclerosis
  4. Cholesterol granuloma
  5. Cholesteatoma

Q. WHAT ARE THE MOST COMMON SITES OF TYMPANOSCLEROSIS IN THE MIDDLE EAR?

  1. TM
  2. Ossicles: Head of malleus
  3. Submucosa of Middle ear

 

 

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