C.S.O.M.: Investigations & Treatment

Dr. Vishal Sharma

Investigations for T.T.D.

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Examination under microscope

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Ear discharge swab: for culture sensitivity

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Pure tone audiometry

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Patch test

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X-ray mastoid: B/L 30 0 lateral oblique (Schuller) Done when cortical mastoidectomy is required in ear discharge refractory to antibiotics

Uses of Audiometry

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Presence of hearing loss

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Degree of hearing loss

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Type of hearing loss

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Hearing of other ear

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Record to compare hearing post-operatively

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Medico legal purpose

Patch Test

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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.

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Examination under microscope

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Ear discharge swab:

for culture sensitivity •

Pure tone audiometry

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X-ray mastoid: B/L 30 0 lateral oblique (Schuller)

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CT scan:

revision surgery, complications, children

Uses of E.U.M.

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Confirmation of otoscopy findings

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Epithelial migration at perforation margin

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Cholesteatoma & granulations

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Adhesions & tympanosclerosis

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Assesment of ossicular chain integrity

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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

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Cholesteatoma erosion

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Mastoidectomy cavity

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Tubercular mastoiditis

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Coalescent mastoiditis

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Malignancy

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Eosinophilic granuloma

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Mega-antrum

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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

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Precautions

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Aural toilet

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Antibiotics: Systemic & Topical

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Antihistamines: Systemic & Topical

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Nasal decongestant: Systemic & Topical

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Treatment of respiratory infection & allergy

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Tympanic membrane patcher

Precautions

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Encourage breast feeding with child’s head raised. Avoid bottle feeding.

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Avoid forceful nose blowing

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Plug E.A.C. with Vaseline smeared cotton while bathing & avoid swimming

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Avoid putting oil & self-cleaning of E.A.C.

Aural Toilet Done only for active stage

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Dry mopping with cotton swab

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Suction clearance: best method

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Gentle irrigation (wet mopping)

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1.5% acetic acid solution used T.I.D.

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Removes accumulated debris

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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

 Chlorpheniramine  Cetirizine  Fexofenadine  Loratidine  Levo-cetrizine  Azelastine (topical)

Systemic decongestants

 Pseudoephedrine  Phenylephrine

Topical decongestants

 Oxymetazoline  Xylometazoline  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

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Intact tympanic membrane

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Intact ossicular chain

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Functioning receiving & relieving windows

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Acoustic separation of these windows

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Functioning Eustachian tube

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Absence of sensori-neural hearing loss

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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:

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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?

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Basal metabolic rate lowest (best survival rate)

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Easily harvested by post-aural incision

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Its an autograft, so no rejection

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Same thickness as normal tympanic membrane

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Large size graft can be harvested

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Good resistance to infection

Onlay Graft cholesteatoma Blunting of anterior tympano meatal angle Lateralization of graft Delayed healing time (6 wk) No middle ear inspection Difficult & takes more time Underlay No No No 3-4 weeks Possible Easier & quicker

Advantages of Local Anesthesia

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Minimal bleeding

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Hearing results can be tested on table

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Facial palsy detected immediately

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Labyrinthine stimulation detected immediately

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No complications of General anesthesia

Tympanoplasty

Types

Type I Pathology

Ear drum perforation only

II III IV V VI

Malleus handle eroded Malleus + Incus eroded Only footplate remains: mobile Only stapes remains: fixed Only footplate remains: mobile

Graft placed on

Malleus handle Incus Stapes head Round window (Footplate exposed) Lateral SCC opening Stapes Footplate

Malleus / Incus Autografts

Thank You