1. Chronic Suppurative Otitis
Media: Attico - antral disease
(CSOM-AAD)
(COM-Squamous)
Dr. Krishna Koirala
2023-05-16

2. Definition:
• Chronic pyogenic infection of the middle ear cleft
lasting for >3 months with cholesteatoma &
granulation tissue in attic or postero-superior
quadrant of pars tensa
• Unsafe/ Dangerous : Higher chances of
complication due to bone erosion
• Hallmark of Disease : Cholesteatoma/granulations

4. Cholesteatoma
• Johannes Muller (1858)
• Defined as a three-dimensional sac lined by
matrix of keratinizing stratified squamous
epithelium that rests on a thin layer of fibrous
tissue and contains desquamated keratin debris
which grows at the expense of surrounding bone
• Not a tumor and has no cholesterol
• Better term : Epidermosis

5. Cholesteatoma

6. Causes of bone destruction
• Hyperemic decalcification
• Osteoclastic bone resorption
– Acid phosphatase ,collagenase, acid proteases
proteolytic enzymes, leukotrienes, cytokines
• Bacterial toxins
• Pressure necrosis

7. • Congenital (McKenzie)
• Primary Acquired
– Retraction pocket (Wittmaack)
– Basal cell hyperplasia (Ruedi)
– Squamous metaplasia (Sade)
• Secondary Acquired
– Squamous metaplasia
– Epithelial migration (Habermann)
• Tertiary Acquired : Post-traumatic , post-tympanoplasty
Types of Cholesteatoma

8. Congenital Cholesteatoma
• Persistence of congenital epithelial cell rests in
middle ear, petrous apex, cerebello-pontine angle
• Diagnostic criteria
– Intact TM
– No previous history of otitis media
– Origin from embryonal inclusion of squamous
epithelium

10. Acquired Cholesteatoma
• One of the primary mechanism of cholesteatoma
formation
• Develops in posterosuperior quadrant of Pars
tensa /attic with adjacent canal wall erosion
1. Invagination / Retraction pocket
(Wittmack’s Theory)

11. Retraction pocket in pars flaccida or Postero-superior
quadrant of pars tensa due to E.T. dysfunction

12. 2. Basal cell hyperplasia (Ruedi)
Hyperplasia of basal cells in epithelial layer of T.M. &
their invasion of sub-epithelial tissues

13. 3. Primary squamous metaplasia (Sade)
Transformation of middle ear mucosa into squamous
epithelium without TM perforation

14. 4. Secondary squamous metaplasia
Transformation of middle ear mucosa into squamous
epithelium due to infection via T.M. perforation

15. 5. Epithelial migration
Migration of epithelium via T.M. perforation into
middle ear

16. 6. Tertiary / Post-traumatic cholesteatoma
Mechanisms:
1. Epithelial entrapment in fracture line
2. Ingrowth of epithelium through fracture line
3. Traumatic implantation of epithelium into middle
ear
4. Entrapment of epithelium medial to E.A.C.
stenosis

17. Pathological Changes (Pathology)
1. T.M. retraction pocket (attic or P.S.Q.)
2. T.M. perforation (marginal or attic)
3. Cholesteatoma formation
4. Osteitis & granulation tissue formation
5. Ossicles: destruction
6. Middle ear mucosa: edematous, red, polypoid
7. Aural polyp: red, fleshy
8. Mastoid bone: erosion, sclerosis

18. Clinical Features
• Ear discharge : scanty, purulent, continuous,
whitish to yellowish, foul-smelling, occasionally.
blood-stained
• Hearing Loss: conductive or sensori-neural
• T.M. retraction pocket: attic or P.S.Q.
• T.M. perforation: marginal /attic /total
• Cholesteatoma flakes
• Aural polyp, granulation tissue

19. Features of Complications
• Severe otalgia, painful swelling around the ear
• Headache/retro-orbital pain (apex petrositis)
• Facial asymmetry
• Vertigo, nausea, vomiting, ataxia
• Fever + neck stiffness + irritability / drowsiness
• Headache + blurred vision + projectile vomiting

20. Attic cholesteatoma

21. Cholesteatoma & granulation tissue

22. Differences between CSOM AA and TTD
Attico-antral (COM-
Sqamous)
Tubo –Tympanic (COM–
Mucosal)
Otorrhea Scanty, continuous,
purulent,
blood stained , foul
smelling
Profuse, intermittent,
mucoid, not blood stained
and non foul smelling
Perforation Attic / marginal,
retraction pocket
Central perforation
Cholesteat
oma/
granulation
Yes No
Disease
categorizat
ion
Unsafe Safe disease
Complicati
ons
Common Rare

23. Investigations
• Examination under microscope ( EUM)
• Ear discharge swab: for culture and sensitivity ???
• Pure Tone audiometry
• X-ray mastoid : B/L 300 lateral oblique (Schuller)
• CT scan: revision surgery, complications, children

24. Advantages of E.U.M.
• Confirmation of otoscopic findings
• Epithelial migration from margin of perforation
• Cholesteatoma & granulations
• Adhesions & tympanosclerosis
• Assessment of ossicular chain integrity
• Collection of discharge for culture sensitivity

25. Uses of X-ray mastoid
1. Position of dural & sinus plates
2. Type of pneumatization : Cellular (80%), Diploic
(<1%), Sclerotic (20%)small antrum, air cells absent
3. Cholesteatoma (cotton wool appearance)
4. Bone destruction: presence & extent
5. Mastoid cavity

26. Dural & sinus plates

27. Cellular mastoid

28. Sclerotic mastoid

29. Diploic mastoid

30. Attic bone erosion

31. Causes of big mastoid cavity
• Cholesteatoma erosion
• Mastoidectomy cavity
• Tubercular mastoiditis
• Coalescent mastoiditis
• Malignancy
• Eosinophilic granuloma
• Mega-antrum
• Large mastoid emissary
vein

32. C.T. scan of temporal bone
Posterior canal wall erosion Mastoid cholesteatoma

33. Medical - Conservative
• Topical ear drops and frequent suction clearance
• Indications:
– Early disease with shallow retraction pocket
– Only hearing ear with cholesteatoma
– Elderly patients
– Pts who are not fit for surgery under G.A.
– Pts who can regularly come for follow up
Treatment Options

34. • Canal Wall down
– Attico-antrostomy
– Modified Radical Mastoidectomy (MRM)
– Radical Mastoidectomy
• Canal Wall up
– Combined Approach Tympanoplasty (CAT)
Surgical Treatment - Mainstay