Supervised by:

Dr. Ahmed Mehana

 Presented by:
Asmaa Hassan
MIDDLE EAR CLEFT CONSIST
OF :
a- the middle ear
cavity(tympanic cavity)
b-the Eustachian tube
c- the mastoid air cells
A-THE MIDDLE EAR CAVITY (TYMPANIC CAVITY)

It contains:
Three bones (auditory ossicles)

Two nerves

Two muscles
 Walls of middle ear cavity
The middle ear is a six wall cavity
 B-THE EUSTACHIAN TUBE (THE AUDITORY
TUBE)
1- communicates the middle ear cavity with the nasopharynx
2-The tube is shorter, wider, and more
horizontal in children than in adults
3-. It opens during swallowing and yawing to ventilate the middle ear.

C -THE MASTOID AIR CELLS

-they are located within the mastoid process of the temporal bone
-The largest air cell is the mastoid antrum, which lies behind the attic

Functions of the middle Ear

1- Middle ear collects the sound waves from the outer ear in the form of
pressure waves. The middle ear is involved in transmitting sound
from the outer ear to the inner ear.
2- The Eustachian tube functions to equalize air pressure of the eardrum
 Otitis media
What is otitis media?
Otitis media is an inflammation of the mucoperiosteal
lining of the middle ear cleft
( eustichian tube,tympanic cavity,mastoid antrum and air
cell)
Incidence:
they are most common in infants and young children. For
the following causes:
A- a child's eustachian tubes are narrower and shorter
than an adults', and it's easier for fluid to get trapped in
the middle ear.
 B- Blockage of the eustachian tubes may be
caused by:
• Respiratory infection (cold)
• Allergies
• Exposure to cigarette smoke
• Infected or overgrown adenoids (tonsils)
• For infants, being fed lying down (drinking a bottle while lying on the back)

Microbiology
The infection is initially commonly viral in origin
Later the middle ear mucosa becomes secondarily infected by pathogenic
bacteria. The bacteria commonly implicated in this disorder is :
A-Streptococcus pneumoniae
B-Haemophilus influenzae.
C-Moraxella catarrhalis.
 Pathogenesis:
Functions of Eustachian tube:
a-Equalize pressure between the middle ear and
atmosphere-middle ear pressure slightly negative
normally
b-protect the middle ear from nasopharyngeal
Eustachian tube obstruction leads to negative pressure within
secretions and sounds
:the middle ear ...Obstruction may be due to
C-drainage of secretions from the middle ear into the nasopharynx
a-intrinsic narrowing

b- functional obstruction

C- Extrinsic obstruction
Flask model explaining the role of eustachean tube in
middle ear infections

The mouth of the flask represents the-1

nasopharyngeal end
the narrow neck, the isthmus of the-2
,Eustachian tube
the bulbous portion, the middle ear and-3
. mastoid air chamber

The fluid flow through the neck of the

flask would be
dependent on the pressure at either end,
the radius and length of the neck, and the
viscosity of the liquid
Reflux of liquid into.
the body of the flask
occurs if
the neck of the flask is
excessively wide, or
the length of the neck
of the flask is
too short
Because infants have.
a shorter eustachean
tube than adults, reflux
is more likely to occur
.in the baby
 Clincial features:

Acute suppurative otitis media passes through

4 stages:
1-Stage of hyperemia.
2. Stage of exudation.
3. Stage of suppuration.
4. Stage
Stage of resolution.
of hyperemia

a-otalgia

b-fever

c- fullness in the affected ear

Stage of exudation
symptoms
. a-Pain is the most prominent feature of this stage
.b- The patients may have fever and fullness in the ear

Signs

This stage is characterised by

a-oedema of the mucoperiosteum due to vascular engorgement.
b-Otoscopy show dilated vessels along the handle of malleus
 Stage of suppuration
The exudate present in the middle ear cavity is a
very good culture medium and hence there is
secondary bacrterial infection leading On
suppuration
Stage of resolution
is preceded by rupture of the ear drum leading
to a serous / serosanguinous / purulent
disharge from the ear. When the middle ear is
free from the exudate / pus the stage of
resolution sets in.
 complications:
1- chronicity
2-cranial and intra cranial complications

Diagnosis of Otitis Media

1-can only be detected by examining the ear with an
otoscope.
2-two tests may be performed .One of these tests is an
audiogram,
The second test, called a tympanogram, measures the
air pressure in the middle ear

3-In recurrent cases or when an acute case does not

respond to treatment, it may be necessary to obtain a
culture from the middle ear,
 Treatment:
-Acute suppurative otitis media is a self limiting condition.
. If appropriate antibiotics is started early then it resolves-
. Amoxycillin is the drug of choice-
. Cephalosporins may also be started in refractive cases-
Patients who are refractory to medical management may under-
go myringotomy in order to decompress the middle ear cavity
 Presented by :
Asmaa Beltagy.
 Introduction
Definition:
• persistent inflammation of mucosa of the
middle ear cleft
• recurrent or persistent ear discharge
(otorrhoea) over 6-12 weeks through a
perforation of the tympanic membrane.
• Pathology is usually irreversible and doesn't
resolve spontenously.
Predisposing factors of CSOM:
1. Acute necrotizing otitis media:
• occur in ill children with low immunity &
suffering from measles or mumps.
• Virulent organism.
• Large ear drum perforation.
• Lead to atticoantra CSOM
• with secondary cholesteatoma
Predisposing factors of CSOM:
2. Eustachian tube
dysfunction and
obstruction:
increased negative
pressure induces a chronic
engorgement

a contributing factor towards

lessened resistance in the
event of infection occurring.
 Predisposing factors of CSOM:
3. Improper treatment of ASOM.
4. Mixed infection with multiple organisms.
5. Large perforation of tympanic membrane
6. Retraction of tympanic membrane and
formation of cholesteatoma.
7. General low resistance of the patient
8. Infection of mastoid process predisposes to
osteitis.
• Microbiology of CSOM:

• gram negative bacilli i.e. Ps. aeruginosa,

E. coli, and B. proteus.
Types of chronic suppurative otitis media:

1. Tubotympanic 2. Atticoantral
disease (safe disease (unsafe
type). type).

Another classification:
Inactive: with only perforation.
Active: with cholesteatoma.
 Tubo-tympanic CSOM
• also known as safe disease
• serious complications less commonly
occur.
• infection is limited to the mucosa and the
anteroinferior part of the middle ear cleft
• The infective activity of it is related to the
frequency of URT infections, the
discharge tending to increase with
increasing frequency of URI infections.
Etiology:
• inadequately treated acute otitis
media.
• Acute suppurative otitis media
causing persistent perforation which is
infected from bacteria in the external
auditory canal.
 Clinical features of tubotympanic
disease:
Symptoms:
1. The discharge (otorrhea)
• Profuse,
• Mucopurulent,
• odourless,
• intermittent between dry and discharging
stages
Symptoms:
2. Conductive deafness due to
• perforation of tympanic membrane
• accentuated by thickening of round
window membrane due to the presence
of secretions.
• Hearing loss is usually about 30 - 40 dB.
• Signs (otoscopic finding):

1.Discharge:
2.Central perforation.
3.Mucosa.
4.Poylpi
Tuning fork tests show:
• Rinne - Negative on the affected side
• Weber - Lateralized to the good ear
 Pathology of tubotympanic disease:
Active stage:
• ear is actively discharging.
• The mucosa of the middle ear cavity
is hypertrophied, and congested.
Inactive stage:
• dry perforation of ear drum, in its
antero inferior part,
• The middle ear mucosa is normal.
Quiescent stage:
• Perforation of ear drum is present,
• the middle ear is dry and mucosa may be
normal or hypertrophied.
Healed stage:
• perforation of ear drum has healed by
formation of thin scar.
• There may even be tympanosclerotic
patches / chalky deposits on the ear drum.
• The ossicular chain is invariably intact.
 Investigations:
1. Pure Tone audiometry
• Show conductive hearing loss.
• The hearing loss is invariably
under 40 dB
2. Mastoid X-ray
• Hazy mastoid
3.Culture and sensitivity
Radiogram showing
well-pneumatized mastoid
air cells.

Radiogram showing sclerotic

(poorly pneumatized) mastoid
 Prognosis:
• Less liable to form
complication
• Main problems of the patient
are otorrhea and hearing loss.
 Management of tubotympanic disease:
1.Conservative management:
• Aural toileting
• Suction method
• Syringing the affected ear with warm
saline mixed with acetic acid (1.5%).

• antihistamines and nasal

1.Conservative management:
Role of antibiotics in the management of
tubotympanic disease:
• depending on the culture report.
• The best route of administration is topical
• Ototoxic drugs are to be avoided
• Ciprofloxacillin can be administered topically
• Oral amoxicillin or penicillins in adequate doses
may be beneficial.
1.Conservative management:
• Precautions:
1. The ear must be kept dry.
2. Avoid blowing of the nose
during URT infection

3. Pre existing sinus infections

if any must be treated
aggressively.
4. Presence of focal sepsis in
the throat (tonsils commonly)
must be ruled out.
 2. Surgical management:
• Adenotonsillectomy

• myringoplasty
 2. Surgical management:
• Tympanoplasty (myringoplast + ossiculoplasty)
•Cortical Mastoidectomy
 Attico-antral CSOM
• This is termed as unsafe
• This condition mainly affects the attic
region of the middle ear.

• Pathology of attico-antral CSOM

1. cholesteatoma;
2.Osteitis , bone erosions and
granulation tissue
 1. Cholesteatoma:
• Cholesteatoma is defined as a cystic bag
like structure lined by stratified squamous
epithelium on a fibrous matrix
 Types of cholesteatoma:
• 1. Congenital cholesteatoma
• 2. Primary acquired
cholesteatoma
• 3. Secondary acquired
cholesteatoma
 Congenital cholesteatoma:
• arise from embryonic cell rests
present in the middle ear cavity.
• Infact congenital cholesteatoma is
seen as a whitish mass behind an
intact tympanic membrane.
Criteria to diagnose congenital cholesteatoma:

• The patient should not have previous

episodes of middle ear disease
• Ear drum must be intact and normal
• It is purely an incidental finding
• If discharge and ear drum perforation is
present then it should be considered that
congenital cholesteatoma has managed to
erode the tympanic membrane.
 Acquired Cholesteatoma
Primary acquired cholesteatoma:
• no history of previous episodes of otitis
media or perforation.
• arise from the attic region of the middle ear.
Secondary acquired cholesteatoma:
• follows active middle ear infection which
destroy the ear drum along with the annulus
through marginal perforation.
• It follow acute necrotizing otitis media
following exanthematous fevers like measles
 Theories to explain pathogenesis of
cholesteatoma:

• Cawthrone theory
• Theory of immigration (invasion
theory)
• Theory of invagination
• Metaplastic theory
• Implantation theory:
 Cawthrone theory
• cholesteatoma always originated
from congenital embryonic cell
rests present in various areas of
the temporal bone.
 Theory of immigration (invasion theory)
• cholesteatoma was derived by immigration of
squamous epithelium from the deep portion of
the EAC. into the middle ear cleft through a
marginal or a total perforation of the ear drum
• as seen in acute necrotizing otitis media.
• It explains secondary cholesteatoma
 Theory of invagination
• states that persistent negative
pressure in the attic region
• invagination of pars flaccida causing a
retraction pocket.
• This retraction pocket becomes later
filled with desquamated epithelial
debris
• which forms a nidus for the infection
to occur later.
• This theory is the best explaining
primary acquired cholesteatoma
attic retraction pockets is classified into 4
grades:
• Grade I: The retracted pars flaccida is not in contact
with the neck of the malleus.
• Grade II: The retracted pars flaccida is in contact
with the neck of the malleus
• Grade III: Here in addition to the retracted pars
flaccida being in contact with the neck of the malleus
there is also a limited erosion of the outer attic wall
or scutum.
• Grade IV: In this grade in addition to all the above
said changes there is severe erosion of the outer
attic wall or scutum.
Metaplastic theory:
• The attic area of the middle ear cavity is
lined by epithelium.
• This epithelium undergoes metaplastic
changes in response to sub-clinical
infections.
• This metaplastic mucosa is squamous in
nature thereby forming a nidus for
cholesteatoma formation in the attic
region.
Implantation theory:
implantation of squamous epithelium from
external ear into the middle ear following
surgery or trauma to the tympanic
2. Osteitis, bone erosions and granulation tissue:
• There is sequestration of bone and the
sequestrated bone is surrounded by
granulation tissue.
• Bone lesions are explained by:
• Pressure theory :

• Enzymatic theory:

• Pyogenic osteitis:
 Clinical features of attico-antral CSOM:
Symptoms:
• Ear discharge:
• Hearing loss and tinnitus:
Sensory hearing loss
CHL
• Vertigo
• Facial palsy
 Signs:
oDischarge:
oPerforation:
Attic or in the postero-superior quadrant
Marginal
oCholesteatomatous flakes and
granulation tissue may be seen through
the perforation like cotton wooly
oThere is associated sagging of the
posterior superior meatal wall.
o Polypi are common and hyperemic
Tunning fork tests:
• Usually conductive hearing loss
• Rinne`s negative in the diseased ear
• Weber`s is lateralized to the
diseased ear
• TFT can show mixed hearing loss
 Investigation:
• PTA:
Early stages: conductive hearing loss with AB
gap.
Late stages : mixed hearing loss
• X-Ray mastoid: may show
sclerosis.
presence of cavity.
• CT scan: show extent of bone complications
by cholesteatoma.
• MRI: to show intra cranial complications.
 Prognosis:
• More liable to form complications

• The patient is disturbed by continous

discharge and hearing loss
 Treatment:
• It is only surgical. No medical treatment
• The aims of the surgical procedure are as
follows:
1. To exteriorise the disease
2. To create adequate ventilation to the
middle ear cavity
3. To give the patient a safe dry ear.
4. To keep ear functioning if possible.
 Surgical procedures are:
• Atticotomy: removal of lat attic wall to get access to attic
cholesteatoma

• Canal up mastoidectomy.

• Tympanomastoidectomy
• Canal down mastoidectomy.