Chronic otitis media

Chunfu Dai M.D & Ph. D

Otolaryngology Department
Eye Ear Nose and Throat Hospital
Fudan University

Definition
COM: unresolved inflammatory process of
the middle ear and mastoid associated
with TM perforation, otorrhea and hearing
loss.
Etiology
Unresolved middle ear infection.
1. Uncomplicated inflammatory process of the middle
ear may evolve over time to produce persistent
effusion and irreversible mucosal change
2. Fluid contains enzymes to alter the mucosal lining
of the middle ear, it results in collapse or chronic
perforation
3. Obstruction of narrow communication between the
antrum and the attic, the aditus.

Etiology
Dysfunction of Eustachian tube
Chronic inflammation in nose and pharynx
Dysfunction of immune system

Bacteriology
Pseudomonas aeruginosa (40-60%)
Straphylococus aureus (10-20%)
Anaerobic bacteria
Pathology
Middle ear mucosa is lined by secretory
epithelium forming glandlike structure.
Hyalinization or tympanosclerosis
A healing response
It occurs during quiescent periods
It is formed by fused collagenous fibers
It is hardened by the deposition of calcium and
phosphate crystals
Conductive hearing loss is associated with masses
restricting ossicular mobility
Pathology
Ossicular erosion is frequent
in COM
Infection process per se
Necrosis following vascular
thrombosis
It most commonly affect the
lenticular process of the incus
and head of the stapes
Pathology
Cholesterol granulomas
Presence of yellowish masses surrounded by
granulation tissue, edematous mucosa and
fibrous tissue
It contains many cholesterol crystals and
foreign body giant cells.

Pathology
Cholesteatoma: cystlike, expanding lesions
of the temporal bone, lined by stratified
epithelium and containing desquamated
keratin and purulent material.
Classification
Congenital cholesteatoma
Acquired cholesteatoma

Pathology
Mechanics of mucosal
transformation and
epithelial ingrowth
have been the focal
point of
cholesteatoma
Pocket retraction:
dysfunction of
Eustachian tube
Pathology
Epithelial migration: the
edge of a peripheral
perforation
Inward growth of the
surface epithelium follows
papillary proliferation of
the germinative layer of
the pars flaccida.
Metaplasia from
pseudostratified ciliated
columnar epithelium

Cholesteatoma Formation
Cholesteatoma Formation
Pathology
Pathogenesis of congenital cholesteatoma:
Ectodermal epithelial in proximity of the
geniculate ganglion, medial to the neck of the
malleus

Pathology
Diagnosis criteria:
Patients without
previous history of ear
disease, with normal
and intact TM
The temporal bone
pneumatization should
be normal

Clinical presentations
Otorrhea
Malodorous associated with cholesteatoma
Hearing loss
Air conduction threshold is within 40 dB
means TM proferation with intact ossicular
chain
If air-bone gap is more than 40 dB is
associated with discontinuity of ossicular
chain
Clinical presentations
Physical findings
Defect in the pars tensa of TM or the pars
flaccida or both
Atelectatic lesions in tensa or flaccida pars
Squamous epithelial invasion may invade
middle ear
Granumoms, polyps, tympanosclerotic
plaques in middle ear
Radiographic evaluation
Indications for image
study
Uncontrollable aural
discharge
Complications such as
facial paralysis, labyrinthitis
When central nervous
stystem involvement is
suspected, MRI should be
considered.
Coronal CT scan is
perferred

Differential diagnosis
Tuberculous otitis media
Hematogenous route
Multiple perforation and fetid
Creamy aural discharge
Active pulmonary disease
Multiple antituberculosis agents

Differential diagnosis
Middle ear carcinoma
Middle age patient
Long term otorrhea with blood
Otalgia
Neoplasm in tympanum
CT scan showed temporal bone destruction


Managements
Medical treatment
Goals
Infection control
Stabilization of process
Prevention of irreversible damage and development of serious
complications
3%H202 clears up pus then antibiotics ear drops is used.
With the decrease of pus, 3% boric glycerin, 3% boric alcohol
can be used
No aminoglycoside ear drops
No powders containing antibiotic and erosion ear drugs

Managements
Surgery
Goals
Safe ear: lesion removal
Dry ear
Hearing ear: reconstruction of ossiclar chain
classification
Myrigoplasty
Tympanoplasty
Tympanoplasty with mastoidectomy