Lec 4

Question 1

Talk about CSOM ?

Answer 1

(2)
- chronic inflammation affects the mucoperiosteal lining the ME cleft characterized by perforation , discharge ( persistent or intermittent due to type )

• types :
  Safe
  Unsafe

Question 2

Talk about safe type

Answer 2

(6)
1- tubotympanic
2- mucosal CSOM
3- aetilogy : AOM ~> safe csom
Due to
- inappropriate treatment by
• inaffective antibiotic
• short course of treatment
• inadequate drainage

• • virulance
• (-) immunity

4- clinical picture :
Symptoms:
Deafness and tinnitus
Intermittent discharge

Signs
Otoscope :-
Discharge : profuse , mucoprulent , odorless
Perforted area is central in pars tensa ( there is rim all around it ) ( not reaching the annulus )
Me mucosa :
Thin pale dry : inactive
Congested edemtic : active
Granulation tissue : reddish bleeds on touch
Polyps : pedinculated odematous passing through perforated area in drum

Tuning fork : CHL

5- investigations
PTA : chl
Culture and sensitivity: when there is discharge

6- treatment
Medical
- general
Systemic antibiotics

• local
  Local antibiotic ear drop
  Aural toilet by suction or dry mopping the ear
• prevention of re infection
  Avoid getting it wet
  Control upper respiratory infection as common cold

Surgical
Tympanoplasty with or without cortical mastoidectomy
( if medical treatment failed with treating the discharge then its with cortical mastoidectomy if not its tympanplasty ( myringoplasty

Question 3

Talk about unsafe type ?

Answer 3

(7)
1- anttico antral
2- bony csom
3- cholestatoma

4- types
•Aquired
-Primary
Not perceded by otits media
Aetiology :
retraction pocket theory : prolonged ET obstruction ~> -ve me pressure ~> invagination of the weakest part of drum ( posterosuperior part or the pars flaccida ) forming retraction pocket ~> this pocket filled with keratin ~> cholestatoma

• secondary
  Perceded by severe otitis media

Aetiology:
Metaplasia : squamous metaplasia of ME following irritant CSOM
Migration : epithelial migration from EAC to ME through perforation

5- clinical picture
Symptoms : (2)
Deafness , tinnitus
Persistent discharge

Signs :
Otoscope : (5)
-Discharge : scanty , purulent , offensive ( due bone necrosis )
-Perforated area : marginal ( no rim all around it ) ( reaching the annulus ) or attic in pars flaccida
-Retracted pocket can be seen during cholestetoma formation
- cholestatoma is seen whitish epithelial mass
- ME mucosa : granulation tissue ,or polyps ( more common in unsafe than safe due persistent irritation)

Tuning fork :
Chl except if cholestiatoma causes bone erosion to inner ear ~> mixed

6- investigations
PTA : chl
Culture and sensitivity
CT : if complications were suspected , shows bone erosion too

7- treatment
Surgical
Radical mastoidectomy is the classic treatment
( there is 2 lines of operations of cholestatoma)
- canal wall up ( closed) technique: should be looked up for 6 months for recurrence

• canal wall down ( opened ) technique : ( radical mastoidectomy )

Question 4

Talk about cholesteatoma in general ?

Answer 4

(8)
1- mis name : it may have cholestrol , not a tumour
2- sac lined with keratinized stratified squamous epithelium ( skin )
3- called matrix sac filled with keratinous material
4- +- cholestrol
5- secretes osteolytic enzymes and causes infection ( anaerobic bacteria as there is no air )
6- types
- Congenital
- aquired
Primary , secondary
7- congenital (4)
• epidermoid cyst
• site : one of the following
Petrous apex
CPA
middle ear
• presented clinicaly by
Trigiminal facial pain : petrous
Chl : middle ear
Facial tics then paralysis + SNHL and vertigo : CPA
• INTACT DRUM

8- sequalae of cholesteatoma (4)
1-expansion: due to recurrent infection , keratin secretion
2- bone erosion :
Mastoid ~> natural cavity
Ossicles ~> hearing loss
( the commonest place to grt involved is long process of incus ( more slender less vascularised)

3- mastoid sclerosis : mastoid air cells become acellular ( sclerotic )

4- complications may occur