KEY LEARNING POINTS 

- Chronic Otitis Media (COM) is defined as a chronic disease of the middle ear cleft with a persistent perforation of the pars tensa.

- There is no universally accepted definition for COM, and terms like Chronic Suppurative Otitis Media (CSOM) are used interchangeably.

- The prevalence of COM varies globally, with rates reported in studies from Nepal, the UK, and other regions.

- Risk factors for COM include high rates of cross-infection, crowded living conditions, poor nutrition, reduced access to medical services, and genetic predisposition.

- Infections play a crucial role in COM, with various microorganisms like Pseudomonas aeruginosa, Staphylococcus aureus, and Streptococci contributing to chronic ear infections.

- Ventilation tube insertion and upper respiratory tract infections (URTIs) are also linked to the development of COM.

- Pathologically, COM involves chronic inflammation, tissue destruction, mucosal metaplasia, and immune responses in the middle ear cleft.

- The natural history of COM can progress from inactive mucosal disease to active inflammation, leading to complications like ossicle damage and acquired cholesteatoma.

- Clinical features of COM include symptoms like hearing loss, recurrent ear discharge, and signs like tympanic membrane perforation, polyps, and oedematous middle ear mucosa.

- Treatment for active COM stages involves cleaning the ear, administering topical/oral antibiotics, managing URTIs and allergies, and keeping the ears dry to prevent recurrent ear discharge.

- Surgical treatments for COM include polypectomy, chemical cautery, aural toilet, closure of tympanic membrane perforations, and myringoplasty.

- Myringoplasty is a surgical procedure aimed at closing perforations in the tympanic membrane to improve hearing and prevent complications.

- Graft materials like temporalis fascia, cartilage, and other tissues are used in myringoplasty procedures, with different surgical approaches and techniques based on the perforation size and surgeon's preference.- Hidden cholesteatoma can be a disadvantage in myringoplasty surgery.

- Post operative ventilation tube insertion (VTI) may be difficult in certain cases.

- Murbe et al. (2007) highlighted hearing results that could be criticized post surgery.

- Various techniques, such as the Palisade technique and Perichondrium/cartilage island graft, can be employed in myringoplasty.

- Neumann et al. (2003) introduced the cartilage shield technique as another option for myringoplasty.

- Other techniques include using cartilage rings and islands, as well as a double island cartilage approach.

- Simple underlay myringoplasty is another technique that can be used in certain cases.

- Eversion edges can be used for splinting perforations, especially in traumatic cases.

- Closure promotion healing techniques like using FGF, Gel foam, and fibrin glue have shown a high success rate in promoting healing post surgery.

- Regenerative treatments involving 53 patients showed a 98% success rate in treating TM perforations (Roosli et al., 2010).

- Endoscopic myringoplasty can be beneficial but may have challenges in visualizing the anterior margin of perforations in narrow canals.

- LASER-assisted myringoplasty welds collagen grafts onto the TM for sealing perforations.

- Hyaluronic acid ester myringoplasty has shown comparable results to the underlay technique in treating TM perforations.

- Three-dimensional porous chitosan scaffolds have been used effectively for TM regeneration, especially in cases of recurrent perforations (Kim et al., 2011).

- Additional techniques and treatments include using fibrin glue, EGF, mesenchymal stem cells for postoperative management.

- Postoperative instructions should be followed to ensure proper healing, including avoiding blowing the nose, exposing the ear to water, flying, heavy weight lifting, and straining.

- Return of hearing may take 4-8 weeks post surgery, with PTA assessment recommended at 3-4 months.

- Complications of myringoplasty can include chorda tympani injury, SNHL, vertigo, VII injury, and others like postoperative wound infection and perichondritis.

- Late complications can include drum cholesteatoma, graft failure, and EAC stenosis.

- Literature mentions different follow-up times for assessing success rates post myringoplasty surgery.

- Adjuvant procedures like cortical mastoidectomy may be needed if reservoir infection persists, and hearing aids like bone conduction or BAHA can be considered in certain cases.


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SLIDES PPT OUTLINE


Chronic Otitis Media - Mucosal
Definition
No universally accepted definition

 Chronic disease of middle ear cleft

Persistent perforation of pars tensa
Definition

Chronic suppurative otitis media (Tubotympanic)
Chronic infection of the middle ear cleft 
Non-intact tympanic  membrane and discharge  
Otorrhoea  for two weeks or longer

Chronic otitis media
Chronic  suppurative  otitis media 
Chronic  perforation  of  tympanic membrane

                                                                            (WHO Foundation Workshop ,1999)
Definition
Chronic otitis media 
Confusing and potentially misleading   
Should  not be used
Some  mean chronic otitis media with effusion
Others mean chronic suppurative otitis  media
Others include cholesteatoma under this term


The panel prefers the term 'chronic suppurative otitis media' and define 
     this to mean 'a chronic perforation of tympanic membrane with chronic 
     otitis media'. 

                           (International  Symposium on Recent Advances in Otitis Media, 1 999)
Prevalence

WHO Criteria






                                                                   
                                                                                   (WHOFoundation Workshop ,1999)
 
                             
Prevalence


7.4 %
                                           ( Little et al.,1993)
 UK 
 12% (Healed COM)
1.5% (Active)
 2.6% (Inactive)

                                                                           ( UK national study of hearing , 2004)
Classification

    a. Healed chronic otitis media (COM)

     b. Inactive Mucosal COM

     c. Active Mucosal COM

     d. Inactive Squamous COM

    e. Active Squamous COM

                                                                         (Browning, 1997)
Classification
Active COM
 Inflammation and production of pus

 Inactive COM
 Potential for  ear to become active at some time

Healed COM 
Permanent abnormalities of pars tensa
No propensity to become active 
Intact pars tensa 
 No significant retractions of  pars tensa or flaccida.
End result of successful surgery
Risk Factors
High rates of cross-infection

Crowded  accommodation

Age at first episode of acute otitis media

Poor nutritional status

Reduced exposure to medical services 

Immune genes
Aetiology

   A. AOM & OME 
         Histology: Degenerated LP
                             Reduce elastic property
                            Chronic perforation & retraction
                                                                                             ( speculation but controversial)

B. Genetic & Race
Common in genetic group
 High incidence in low socio-economic group 
                                           (Confounding variable)
 Mastoid air cells size.
                                                                                                (Controversial)

Aetiology
C. Environment
General health
Diet 
Over crowding.
D. Infection
 Microorganisms –  6x106-6x109  in  symptomatic ear
 Pseudomonas aeruginosa                                        Staphylococcus aureus    
                                                               
 Streptococci                                                               Gram-negative bacilli  
                                               
 Anaerobes ( Bacteroides and Fusobacterium species)

Synergism between anaerobes and aerobes

Increased incidence of  intracranial complications 

Aetiology

D. Infection





                                                                                                                      (Picozzi et al.,2003)



Aetiology

D. Infection
Helicobacter pylori
100% cases of tympanosclerosis
Chronic perforation
14 patients
                                                                                                      (Iriz et al.,2011)
Morexela catarrhalis
Cold shock response
Acute inflammatory exacerbation

                                                                                 (Aebi,2011)



Aetiology
E. Ventilation tube insertion
 T – tube : 16.6%
 Short term tubes : 2.2%
 Average : 10 %
                                                        (da Costa et al., 2003)

 F. URTI
Transient eustachian tube dysfunction

Viral infection – secondary bacterial infection

Speculation:-Bacteria secondary invaders
Aetiology
G. ET dysfunction
Still not known (primary or secondary factor)
Weak innate immunity-homeostatic defence  of  eustachian tube
                                                                                                     (Park et al.,2011)
 H. Trauma
Secondary infection.
 I. Craniofacial Anomaly, Allergy, Autoimmune Diseases

J .Clinical Syndromes
Little evidence in the literature
     Cleft palate : Tympanic membrane perforation in 11 percent cases
     Down syndrome : 1% cases

                                                                                         (da Costa et al., 2003)
 Route of infection
I. Eustachian tube 
URTI
Nose blow
Regurgitate milk or vomitus

II. Tympanic Membrane perforation  
Bathing
Oil instillation

III. Blood borne 
Influenza, Exanthematous fever.
 Prevention of  Resolution of  Otitis Media

Repeated infection from  nasophaynx

Repeated infection from external ear canal

Persistent colonisation by bacterial biofilms

Small colony variants of biofilms- More dangerous
                                                                                                    (Park et al.,2011)

         Virtuous circle & vicious circle
Discharge & healing

Incomplete healing (Chronic)

Follow route of infection. 
Pathology
 
General Pathological Picture

 Submucosal mononuclear cell infiltration 

Mucosal metaplasia:  
     development of glandular structures, 
     mucus producing cells and ciliated cells 

Tissue destruction and attempts at healing

Submucosal fibrosis


Pathology
Mucosal reaction to chronic infection

Columnar metaplasia

MALT  proliferation in subepithelial layer

90 sections of temporal bone
                                                                                                        (Paul AM,2011)
Incrased MUC5AC expression- protective

                                                                                                          (Kerschner,2010)
Pathology
Formation of highly vascular  granulation tissue

Osteitis

 Cholesterol  granuloma  

Tympanosclerosis

Healing 
 Hyperplasia and migration of  squamous epithelium 
 Advances ahead of connective tissue rich in fibroblasts
 Failure of this process  attributed to persistent infection
 Endoepithelial junction at the perforation edge


Pathology
 
     B. COM Mucosal Inactive

Permanent perforation  of pars tensa

Middle ear & mastoid  air cells mucosa not inflammed

Lamina Propria thickened

Mucocutaneous junction

Squamous epithelium migration.
Pathology
C. COM Mucosal Active

Chronic inflammation

Granulation tissues

Mucopurulent discharge

Polyp formation

Involve mastoid antrum 

Treatment failure
Pathology
Resorptive osteitis : Ossicles destruction 

Cytokines, Prostaglandins, Growth Factors, Neurotransmitters  and 
     Nitric oxide 

Osteoclasts activation.

 Bone resorption.
Natural History 
  A. COM Mucosal Inactive

         I. Progression towards healing
 Endarteritis – Incomplete healing

          II. Progression towards activity
 More common 
 Increase mucus production
 Bacterial growth
 Sino-nasal disease – Controversial role
Natural History 
B.  COM Mucosal Active
              I. Progression with continued activity
Complication.
Ossicles damage
Secondary acquired choloesteatoma

II. Progression towards Healing
Clinical Features











                                                                                    

                                                                                           n=438
                                                                                                                   (Piccozi et al,2003)
Clinical Features
 A.  COM Mucosal Inactive
       Symptoms:
Hearing loss (varying degree)
    
       Signs:
Pars tensa – perforation.
Ossicles – intact or damaged
Clinical Features
B.  COM Mucosal Active
        Symptoms:
Recurrent ear discharge.
Hearing loss 

        Signs:
Ear discharge
Perforation of pars tensa.
Middle Ear Mucosa – Oedematous.
Ossicles.
 Polyps.
Clinical Features
 Clinical Test of Hearing 
    A. Whisper tests:
         
    B. Tunning Fork Tests:
         512Hz.




Clinical  Test of Balance
Judge effect of disease, suction or packing
Investigations
A. PTA:
        4 frequencies (500,1000,2000,3000Hz)
        
(Committee on hearing & equilibrium of  AAO-HNS,2006)

 B. Speech audiogram
        
 C. Pus C/S
Different speculations. 
D. CT Scan: 
TM not visualized (narrow or stenosed canal)
 
Treatment
Active stage

Cleaning the ear

Mopping or suction of discharge

Topical/Oral  Antibiotics

URTI  and Nasal Allergy

Keeping the ears scrupulously dry as the fundamental step in the
    prevention of chronic ear discharge in the presence of a perforated
    tympanic Membrane

Australian salt water study
Treatment

Topical antibiotics with aural toilet :  most effective method of  
    treatment 

Quinolones : more effective than other types of antibiotics in 
      resolving otorrhoea

Antiseptics : just as effective as antibiotics

                                                                                                                (Acuin et al ,2003)
Treatment
Combined ciprofloxacin and hydrocortisone preparation :

Approved by Food and Drug Administration in 1998
Minimum side effects and systemic uptake on local application

Aminoglycosides

As effective as quinolones
The advisory group recommendations 

Should only be in the presence of obvious infection
No longer than two weeks
Justification  explained to the patient
Baseline audiometry  performed

Treatment
No SNHL with aminoglycosides

Round window niche relatively deep & protected by pseudomembrane

Precaution to prevent recurrent ear discharge
Surgical Treatment
Aural polyp

Polypectomy or chemical cautry
Polyp attached with stapes superstructure or facial nerve

B. Closure of TM perforation

If perforation <=2mm,
Chemical cautery
Fat graft
M’Plasty if fails
Preoperative 

 1) Age                                                                 2) ET function  
 
3) Previous surgery                                          4) Extent of perforation 

5) Size of  external auditory canal                   6) Patch Test 

7) Consent                                                         8) Post op issues- counselling
Myringoplasty
Definition
Closure of TM without interfering ME

Aims
Stop discharge
Hearing improvement
Occupation
Recreation
Prevent complication
Hearing aid
Myringoplasty: History

1640 – Banzer
First attempt at repair of a TM perforation
 Pigs bladder as a lateral graft.

1853 – Toynbee
Placed a rubber disk attached to a silver wire over the TM.
 
1863 – Yearsley.
Placed a cotton ball over a perforation 

1877 – Blake  
Paper patch
Myringoplasty: History
1876  –  Roosa
Treated TM perforation with chemical cautery.

1878  –  Berthold
Coined the term myringoplasty.
Placed cork plaster against TM to remove epithelium.
Applied a FTSG .
Myringoplasty: History
1950s – Wullstein and Zollner

STSG over de-epithelialized TM.
 
1957 – Shea

First medial  vein graft.

1961 – Storrs 

Introduced  temporalis fascia grafting.
Medial grafting.

1961 and 1967– House, Glasscock  and  Sheehy 

Developed and refined techniques for lateral grafting 
Myringoplasty:Prerequisites
 Dry ear: preferred
Controversial
No influence of condition of ear at time of surgery in graft uptake rate.                                                                                                             
                                                                            (Kotecha et al ,1995)
 Age >=7 years
Reason
Controversy

Graft Materials
Temporalis fascia 




2. Cartilage (Tragal, Conchal)
Low metabolic rate  ( Yung M, 2008 )
Bradytrophic properties 
Increased stability and resistance to negative pressure
Nourished largely by diffusion 
Well incorporated in TM 
High resistance to infection 
Long lasting vitality even years after surgery 
             




    (Beutner et al., 2009)
Graft Materials
Loose areolar tissue/Fat  
          
4.   Vein.

5.   Canal skin.

6.   Split Thickness Skin Graft  
                                    
 7.   Composite cartilage/perichondrium

8.   Pericardium, Dura, Amniotic Membrane materials
Approaches

Postaural Approach.
Transcanal Approach.
Endaural Approach.
Extended Endaural Approach
Circumferential Approach
       Depends on 
Perforation Size
Anatomy of  External Auditory Canal
Surgeon's Preference
 
Approaches
Permeatal  
Small posterior perforations

Medium-size perforations with favourable ear canal anatomy 

Visible anterior tympanic membrane rim 

Less discomfort 

Better  healing 

Poor exposure to anterior mesotympanum

Obscured visualization by flap

Avoided by  less experienced surgeons






Approaches
Postaural
 
Both hands free

Excellent exposure 

More postoperative  discomfort

Delayed healing

 Useful  if  limited atticotomy anticipated along with 
    tympanoplasty



Approaches
Endaural
 
Anterior bony overhang

Head on access to mesotympanum

Preference of Surgeon

 Canal  stenosis,  Perichondritis, Scar





Techniques
Underlay Technique

Overlay technique

Over underlay Technique
Underlay Technique
Underlay Technique
Advantages
Technically less demanding & less time consuming
 Assessment of Middle Ear
 Higher success rate
Ideal for small, easily visualized perforations 
 Avoids lateralization and blunting
Disadvantages
Less visualize anterior meatal recess.
Reduce middle ear space.
Less suitable (Large anterior perforation)
Difficulty with small EAC.
Overlay Technique
Overlay Technique
Advantages 

Excellent exposure 

High success rate. (TM pretty much left intact)

 Middle ear space maintained

 Reliable

Anterior and pantympanic defects


Overlay  Technique
Disadvantages 
Requires precision, Technically demanding

 Graft lateralization

 Blunting

Delayed healing

 Longer operative time

 Epithelial cyst formation or iatrogenic cholesteatoma

Surgical Steps

Post-auricular incision



Temporalis fascia graft





T-shaped incision

Surgical Steps
Elevation of periosteum towards canal





Canal incision (12 to 6 o’clock) 2-5 mm lateral to annulus








Freshening of perforation margin

Surgical Steps

Elevation of TM flap (anteriorly)




ME inspection, palpation of ossicles



Packing of middle ear with Gelfoam.

Surgical Steps
Placement of graft and tucked anteriorly







Repositioning of annulus



Surgical Steps

Packing of EAC








Closure
Other Techniques
1. Cartilage Myringoplasty
Indications
Subtotal or bilateral perforations 
Revision tympanoplasty 
Anterior  Perforation     
                                                                         (Celil et al., 2010) 
Disadvantages 
Hidden cholesteatoma 
Difficult for post operative VTI 
Criticized for hearing result
                                                                          (Murbe et al., 2007)



Other Techniques

Various techniques
 
Palisade technique

Perichondrium/cartilage island graft

Butterfly graft

Cartilage/perichondrium ring graft

Cartilage shield technique 
                                                            (Neumann et al., 2003)

Other Techniques


Other Techniques
Cartilage Ring





 Cartilage Island
Other Techniques
B. Cartilage Double Island
Other Techniques
2. Simple Underlay Myringoplasty
Other Techniques
3. Splinting of perforation

Eversion of edges
Used for traumatic perforations

4. Closure by promotion of healing

FGF, Gel foam and fibrin glue
53 patients
98% success rate at 3 weeks
Regenerative treatment of TM perforation
                                                                         
                                                                                 (Roosli et al.,2010)


Other Techniques

 Endoscopic  Myringoplasty

Narrow canal
Difficult y in visualisation of anterior margin of perforation

6.  LASER assisted M’plasty

Welds collagen from graft to TM

 7. Hyaluronic acid ester in M’plasty 
131 patients
Hyaluronic acid fat graft myringoplasty
Results comparable with underlay technique

                                                                                                               (saliba et al.,2011)
       
Other Techniques
8. Three dimensional porus  chitosan  scafolds

More effective TM regeneration
Growth through pores
All three layers
Optimal healing method in recurrent  perforations
                                              
                                                                                                           (Kim et al.,2011)
 9. Others

Fibrin glue.
EGF
Mesenchymal stem cells.
Postoperative Instructions
To insure proper healing, avoid the following: 

Blowing  nose 
Sneezing 
Exposing  ear to water
Flying 
Heavy weight lifting and straining 
Return of hearing may take up to 4 - 8 weeks.
     PTA after 3-4 months

 
COMPLICATIONS
Early Complications
Chorda tympani injury: sensory disturbance ,metallic taste.

SNHL.

Vertigo.

VII injury.

Injury to sigmoid sinus, jugular bulb, dura

CSF leakage

Tinnitus: usually clears up

Postoperative wound infection

Perichondritis

COMPLICATIONS

LATE COMPLICATIONS

 Drum cholesteatoma

 Graft failure

 Blunting of anterior  tympanomeatal angle

 EAC stenosis


Success Rate of Myringoplasty

 In TUTH 
      >95% at 2 months F/U

 In Literature
  

. 
Prognostic Factors
. 

ADJUVANT CORTICAL MASTOIDECTOMY
If reservoir of infection persists.


HEARING AID
      a. Bone conduction hearing aid:
For otorrhoea treatment

      b. BAHA:
If B/L COM (active) not controlled.