Overview of Chronic Suppurative Otitis Media (CSOM)

Overview

Chronic Suppurative Otitis Media (CSOM) is a chronic infection of the middle ear cleft, characterized by a persistent or recurrent discharge from the ear through a perforation in the tympanic membrane. The middle ear cleft consists of the middle ear or tympanic cavity, Eustachian tube, additus ad antrum. and the mastoid cavity and air-cell systems.

Epidemiology

1. Prevalence: CSOM affects approximately 2-5% of the global population.

2. Age: CSOM can occur at any age, but it's more common in children and young adults.

3. Socioeconomic factors: CSOM is more prevalent in low-income communities with poor sanitation and limited access to healthcare.

Pathological Types

The different types include the following:

Tubotympanic Type

1. Characterized by: Infection of the middle ear cleft via the Eustachian tube.

2. Perforation: Central perforation of the tympanic membrane.

Cholesteatoma Type

1. Characterized by: Presence of a cholesteatoma, a cyst-like structure filled with keratin debris.

2. Perforation: Marginal or attic perforation of the tympanic membrane.

Symptoms and Signs (Tubotympanic Type)

Active Stage

1. Discharge: Purulent discharge from the ear at the time of examination. Middle ear mucosa inflamed and oedematous.

2. Hearing loss: Conductive hearing loss.

3. Pain: Ear pain or discomfort.

Quiescent Stage

1. Discharge: In the recent past, discharge present but there is no discharge now. Middle ear mucosa may be oedematous.

2. Hearing loss: Persistent conductive hearing loss.

Inactive Stage

1. Discharge: No discharge for 3-6 months. Dry ear. Middle ear mucosa not inflamed.

2. Hearing loss: Persistent conductive hearing loss.

Healed Stage

1. Tympanic membrane: Intact tympanic membrane.

2. Hearing: Normal hearing

3. Infection: Permanently controlled middle ear infection.

Cholesteatoma

Theories of Formation

1. Epithelial Migration ( Immigration ) Theory

Skin cells migrate into the middle ear through a perforation.
2. Squamous Metaplasia Theory

Middle ear mucosa undergoes metaplastic changes to form into keratinizing epithelium or skin cells, which then forms a cholesteatoma.
3. Retraction pocket ( Invagination theory )

This theory suggests that cholesteatoma develops when a retraction pocket, formed due to eustachian tube dysfunction and negative pressure in the middle ear, traps squamous epithelium and keratin debris.
4. Congenital

This theory holds that small Inflammatory injury of the tympanic membrane near the neck of the malleus causes invagination of the epithelium that progresses to form a congenital cholesteatoma. This event may occur in utero during childhood development. The retracted tympanic membrane is adherent to the malleus or incus.

Complications of CSOM

1. Mastoiditis: Infection of the mastoid bone.

2. Petrous apicitis: Infection of the petrous apex.

3. Cranial nerve involvement: Infection can affect nearby cranial nerves.

4. Intracranial complications: Meningitis, brain abscess, or lateral sinus thrombosis.

4. Hearing loss: Permanent conductive, sensorineural or mixed hearing loss.

5. Facial: nerve paralysis

6. Labyrinthitis

Management of CSOM

1. Aural toilet: Cleaning of the ear canal and removal of debris.

2. Antibiotics: Topical or systemic antibiotics to control infection.

3. Tympanoplasty: Surgical repair of the tympanic membrane and middle ear.

4. Mastoidectomy: Surgical removal of infected mastoid bone.

5. Hearing rehabilitation: Hearing aids or cochlear implants to manage hearing loss.

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