CHRONIC SUPURATIVE OTITIS MEDIA, Essays (university) of Medicine

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CHRONIC SUPURATIVE OTITIS MEDIA

Middle Ear Anatomy The middle ear is an air-filled chamber imagined as a six-sided box, with the posterior wall wider than the anterior wall to form a wedge-like box. Figure 1 Anatomy of the boundaries of the middle ear Its lateral border, the tympanic membrane, separates it from the outer ear. The medial boundaries from top to bottom are the horizontal cermiscircular canal, the facial canal, the oval window, the round window, and the promontory. The anterior border is connected with the eustachian tube. Posterior boundary with aditus ad antrum and facial canal pars verticalis. The superior border or roof of the middle ear cavity is formed by the tegmen tympani, and the inferior border or floor of the middle ear cavity is adjacent to the jugular foramen. There are several buildings that also make up the middle ear:

1. Tympanic membrane The main and largest part of the tympanic membrane is the pars tensa, while the upper part of the tympanic membrane is the pars flaccida (Shrapnell's membrane) which is attached directly to the processus lateralis malleus area between the two end areas of the tympanic notch of Rivinus, to the annular area.

Figure 3 Bones of Hearing

3. Tympanic cavity Is a room in the middle ear that is located in the temporal bone, irregularly shaped and filled with air, which originates from the nasopharyngeal space through the Eustachian tube to then go to the nasopharynx and in its posterior part will be connected with the air cell system of the mastoid cavity and the petrous part of the temporal bone. On the lateral side it will abut the tympanic membrane. Figure 4 Kavum Tympani The tympanic cavity based on its topography is divided into 3 chambers: 5

1. Epitympanum (atici): at the upper boundary of the tympanic membrane
2. Mesotympanum: between the tympanic membrane and promontory
3. Hypotympanum: below the lower border of the tympanic membrane. B. Definition of CSOM Chronic suppurative otitis media (CSOM) is defined as a perforated tympanic membrane with persistent drainage from the middle ear for more than 2-6 weeks. Chronic suppuration may occur with or without cholesteatoma, and the clinical history of the two conditions can be very similar. CSOM differs from chronic serous otitis media because chronic serous otitis media can be defined as a middle ear effusion without perforation that is reported to last for more than 1-3 months.

as granulation tissue, which can develop into polyps in the middle ear cavity. (A study by Wang et al demonstrated that in CSOM, T-cell-mediated cellular immunity plays a role in granulation tissue formation.)8 Cycles of inflammation, ulceration, infection, and granulation tissue formation can continue, eventually destroying the surrounding bony margin and ultimately causing various complications of CSOM F. Classification Tympanic membrane perforations can be found in the central, marginal and atic areas. In a central perforation, the perforation is in the pars tensa, whereas all around the edges of the perforation there are remnants of the tympanic membrane. In marginal perforation, some of the edges of the perforation are directly connected to the annulus or tympanic sulcus. Attic perforation is a perforation located in the pars flaccida. 9 Based on the location of the tympanic membrane perforation and the presence or absence of cholesteatoma, CSOM can be classified into 2 types, namely the safe type (mucous type) and the dangerous type (malignant type or bone type):

1. CSOM Safe type The inflammatory process is limited to the mucosa, and usually does not affect the bone. The perforation is centrally located. Generally do not cause dangerous complications. In this type of CSOM, there is no cholesteatoma. 9
2. Malignant type of CSOM CSOM accompanied by cholesteatoma. The perforation in CSOM of this type is marginal or atic, sometimes there is also a cholesteatoma in CSOM with subtotal perforation. Most of the fatal complications arise in the malignant type of CSOM. 9 G. Diagnosis The diagnosis of CSOM can be established based on the results of history taking, physical examination, ENT examination, especially otoscopy and supporting examinations if needed.

Anamnesis The main symptoms are foul-smelling otorrhea and hearing loss. Meanwhile, symptoms such as otalgia are rarely found, except in acute exacerbations. Persistent otalgia, especially those frequently associated with headaches, usually has a process that has spread to the central nervous system. Vertigo, rare. If this complaint appears, then the possibility of involvement of labyrinthitis or labyrinth fistula is suspected, vertigo appears especially when we are going to do cleaning of secretions, aspiration of secretions. Meanwhile, spontaneous nystagmus that appears at that time is also suspected of possibly having a labyrinth fistula Physical Examination and Otolaryngology 5,  512-Hz tuning fork examination: evaluation to determine whether hearing loss is present and whether it is conductive or sensorineural.  Examination of the external acoustic canal will reveal an inflammatory process, and sometimes crusting.  Otoscopy, odorous otorrhea, perforated tympanic membrane, granulation tissue, polyps, or cholesteatoma will be found.  Examination may also reveal a retroauricular abscess or fistula Supporting investigation In CSOM, audiometric examinations, mastoid X-rays, CT scans, cultures and germ resistance tests from ear secretions can be carried out. 9 On audiometric examination, the results will be found in the form of conductive or mixed deafness, where the degree of disturbance depends on the severity of the CSOM. Examination by conducting a tuning fork test, pure tone audiometry, speech reception test (SRT), Word Discrimination Score (WDS). Radiological examination is needed if there is excessive otorrhea, and there are possible complications, such as nerve dysfunction, labyrinthine disorders and central nervous system.

or widespread cholesteatoma. In this operation the mastoid cavity and

the tympanic cavity is cleaned of all pathological tissue. The boundary wall between the external ear canal and the middle ear canal with the mastoid is torn down, so that the three anatomical areas become one room.

3. Radical mastoidectomy with modification This operation is performed on CSOM with cholesteatoma in the attic area, but has not damaged the tympanic cavity. The entire cavity is cleaned and the posterior wall of the ear canal is lowered. The goal of surgery is to remove all pathological tissue from the mastoid cavity, and preserve hearing that still exists
4. Myringoplasty This operation is also known as Tympanoplasty type 1, reconstruction is only performed on the tympanic membrane. The aim of this operation is to prevent recurrence of middle ear infections in the safe type CSOM with persistent perforations.
5. Tympanoplasty This operation is performed on a safe type of CSOM with more severe damage or a safe type of CSOM that cannot be calmed down by medical treatment. The goal of surgery is to cure the disease and improve hearing
6. Tympanoplasty with a dual approach (Combined Approach Tympanoplasty) This operation is a tympanoplasty surgical technique that is carried out in cases of dangerous type of CSOM or safe type of CSOM with extensive granulation tissue. The goal of surgery is to heal hearing without undergoing a radical mastoidectomy technique. Cleaning the cholesteatoma and granulation tissue in the tympanic cavity is carried out in two ways, namely through the ear canal and the mastoid cavity by performing a posterior tympanotomy.