Chronic suppurative otitis media(CSOM)

Def : Chronic infective inflammatory condition of the mucoperiosteum of the middle ear cleft characterized by perforation of the tympanic membrane, hearing loss and discharge
.
Types :
1.Tubo-tympanic
2. Attico-antral
Tubo-tympanic types :
Area involve in T-T Type- Antero-inferior portion of middle ear cleft
Etiology -  As a complication of post-perforative type of acute suppurative otitis media usually acquired in infancy and early childhood
- Often associated with acute infectious disease
Predisposing factors :

1.ET dysfunction :

- Age
- Rhinitis
- DNS
- Cleft palate
- Primary mucociliary impaired function
2. Socio-economic condition : Damp, over/poor ventilated housing, over crowding, poor nutrition
3.Bathing habit
4.Self cleaning of the ears
5. Environmental pollution
6. Smoking (active/passive)
Routes of entry of Bacteria :

1.Through perforation

2.Through ET

Organisms :
Always mixed organisms- Gram negative, Gram positive, Anaerobic (e.g. bacteroids)
Pathology :

         I.Central perforation with healed margin

        II.Chronic inflammatory cells deposit in tissues

        III.Hyaline degeneration

        IV.Dystrophic calcification

        V.Fibrosis

       VI.Mucous polyp formation

      VII. Hypertrophy and hyperplasia of glandular structures with increased secretions
VIII. Absorption of toxic materials in inner ear mainly through round window
IX. Erosion of ossicles
X. Fixation of ossicular joints
Symptoms :

I.Profuse, intermittent, mucoid or mucopurulent, non-odourous, non-blood stained aural discharge

II.Hearing loss (more in posterior perforation)

III.Tinnitus may or may not

Signs :

I.Discharge- profuse,intermittent, non-odourous, non-blood stained

II.TM – Central perforation

III.Middle ear mucosa- velvety and pink, may be oedematous( In active stage)

IV.Ossicles- can be seen, usually intact

V.Tuning fork test- normal

VI.Facial nerve intact

VII.Fistula test- negative

Investigations :

I.Pus for C/S

II.Pure tone audiometry

III.Xray Mastoid Town’s view/ Stenver’s view

IV.To exclude other sources of infection

Stages of the disease:

1.Active (Discharging ear)

2.Dry ear (No discharge)- Only perforation

Active stage :

I.Aural toileting

II.Drugs

III.Advices

IV.To remove source of infection, if any

Descriptions:

I.Aural toileting :

- Better to be done by aseptic suction clearance under microscope or dry mopping
II. Drugs :
- Local antibiotic drops : Gentamycin/ Neomycin/ Bacitracin/ Polymyxin B/ Chloramphenicol + steroid mixture
3 drops 3 times daily in the affected ear for 10-14 days

-Systemic antibiotics : Indications for using systemic antibiotics-

I. If discharge is profuse and
purulent
II. If disease is associated with
URTI
- Local decongestants
Xylometazoline / Oxymetazoline / Ephedrine Nose drop
- Systemic decongestants
Psedoephedrine/ Antihistamine
Treatment of predisposing factors if any
e.g. Adenoidectomy, Tonsillectomy etc.
Treatment of Dry ear :
Only advises
Surgery for tubo-tympanic disease :

a)To remove source of infection

b)To repair perforation

- Myringoplasty
c) Cortical mastoidectoomy- if mastoid air cells act as reservoir of infections
d) Ossiculoplasty if ossicle is eroded
Complications :

1.Slowly progressive hearing loss

2.Mucous polyp formation

3. Otitis externa

4. Otogenic tetanus

5. Carcinoma middle ear- in long standing cases

6. Cholesteatoma formation