Chronic Suppurative Otitis Media| causes, symptoms, diagnosis and treatment

Definition: C.S.O.M is a chronic inflammation of mucosal lining of middle ear cleft, characterized by irreversible pathological changes, intermittent or persistent discharge, with permanent abnormality of the pars tensa or flaccida.

Types of C.S.O.M:
1. Tubo – tympanic disease:
  • It is also called "mucosal”, because it starts in the middle ear & Eustachian tube mucous membrane.
  • It is called “safe CSOM”, because it is much less liable to cause complications, as the infection is mucosal.
2. Attico-antral disease:

  • It is called “attico – antral disease”, because it starts in the attic (epitympanum) & mastoid antrum.
  • It is called “unsafe CSOM”, because it is much more liable to cause complications, as it causes bone erosion.
  • Cholesteatoma is usually present.

Tubotympanic (mucosal) CSOM

It occurs usually secondary to A.S.O.M due to:
  1. Inadequate treatment: inadequate antibiotic therapy, or inadequate drainage of discharge (small or high perforation).
  2. Repeated middle ear infection through the Eustachian tube or through a persistent T.M. perforation.
  3. High virulence of the organism.
  4. Low resistance of the patient.
  5. Persistent predisposing factor e.g. E.T. dysfunction.

Symptoms of Tubotympanic (mucosal) CSOM:

  • Aural discharge: it is mucopurulent or mucoid, usually odourless, and profuse in amount.
  • T.M. perforation: the perforation is usually central in the pars tensa. It may attain any size or shape.
  • Middle ear mucosa: if visible through the perforation may look:
a. Oedematous, congested and velvety pink during active infection.
b. Thin pale during the inactive phase.


  1. Audiogram (PTA): conductive hearing loss.
  2. Plain X-ray of mastoid: usually well pneumatised.
  3. Culture and sensitivity of the discharge.

Treatment of Tubotympanic (mucosal) CSOM

A. Conservative treatment:
The aim of conservative treatment is to obtain a safe dry ear, to allow spontaneous healing of the perforation, or before surgery.

1. systemic antibiotics:
  • Best according to culture and sensitivity, avoid ototoxic drugs.
  • They may not be effective as fibrosis doesn’t allow antibiotics to reach tissues in a proper concentration.
2- Topical application of antibiotic ear drops, but avoid ototoxic ones.
3- Aural toilet: repeated local cleaning and removal of discharge by suction or mopping.
4- Avoidance of reinfection:
  • Avoid forcible blowing of the nose during rhinitis.
  • Avoid wetting the ear.
  • Control upper respiratory tract infection e.g :sinusitis.
  • Adenotonsillectomy, in children to avoid reinfection.
B. Surgical treatment:
Tympanoplasty , with or without cortical mastoidectomy, with the aim of:
  • Eradication of irreversible changes in the middle ear mucosa and to clear it from infection.
  • Reconstruction of the conductive hearing mechanism (ossicular reconstruction).
- Cortical mastoidectomy is combined with tympanic membrane grafting, if there is persistent aural discharge (mastoid reservoir) to eradicate the mastoid pathology.

- The grafting material commonly used to repair the defect in the T.M. is temporalis fascia, or tragal perichondrium.

Squamous (atticoantral) C.S.O.M

The presence of a squamous epithelium within the middle ear (i.e. skin in an abnormal site). Cholesteatoma is a misnomer because it is neither a tumor, nor it necessarily contains cholesterol crystals.

A- Congenital cholesteatoma.
-Develops from persistent embryonic squamous epithelial cells,may be at different sites related to petrous bone.
-It is sterile so long as it is not connected with the external canal (i.e. an intact T.M.)
Presents usually in adult life, with deafness or facial palsy.

B- Acquired cholesteatoma
1-Primary acquired cholesteatoma (no previous history of O.M)
Retraction pocket theory (Attic retraction): most accepted. Prolonged intratympanic negative pressure causes invagination of part of T.M. into the middle ear with formation of retraction pocket which becomes filled with keratin.

2-Secondary acquired cholesteatoma (previous history of O.M.)
a- Migration therapy: direct migration of stratified squamous epithelium from surface of T.M. into the middle ear through a marginal perforation.
b- Metaplasia theory: due to chronic irritation of the middle ear mucosa by chronic infection.


A cholesteatoma is a sac lined by keratinizing stratified squamous epithelium (matrix) and is filled with concentric sheets of white-yellow keratin flakes, in which the cholesterol crystals may be embedded. It has an onion like appearance on cut section.

Bone erosion is due to:
1- Osteolytic enzymes and collagenases
2- Secondary bacterial infection, so, the cholesteatoma becomes activated to secrete deminiralizing and osteolytic enzymes.
3- Increase osteoclastic activity.
4- Pressure necrosis by the cholesteatoma sac (doubtful).

Signs of Squamous (atticoantral) C.S.O.M

1- Aural discharge: occurs due to secondary infection of the cholesteatoma. It is purulent (never mucoid or mucopurulent), and may be bloody due to formed granulations and polypi.
It is scanty and has a foul odour (characteristic) which is due to bone necrosis (osteitis) and anaerobic infection.
It may contain cheesy white epithelial flakes (debris).

2- Tympanic membrane perforation: it is a marginal perforation (destruction of the bony annulus), in the posterosuperior quadrant of pars tensa or attic perforation.

3- A retraction pocket may be seen posterosuperiorly without perforation in the T.M (inactive).
4- Cholesteatoma itself may be seen as pearly white sheets or cheesy white masses of keratin (active).
5- Granulations are frequent and appear as sessile, fleshy red projections that bleed easily on touch, or polyp
6- Signs of complications when they arise.
7- Tuning fork tests:
  • Variable degrees of conductive hearing loss, but may be mixed.
  • Sometimes, there is normal or mild conductive hearing loss, and this occurs with early retraction pocket or when the cholesteatoma itself “bridges” the gap in the ossicular chain.
  1. Audiogram (PTA): Variable degrees of conductive or mixed hearing loss.
  2. Plain X-ray mastoid: The cholesteatoma appears as an irregular area surrounded by sclerosed bone, bone erosion.
  3. CT scan of petrous bone: to detect the cholesteatoma mass, bone erosion and condition of the ossicular chain. It should always be done if complication is suspected, in children, and in revision cases.
  4. Culture and sensitivity of discharge.

Treatment of  Squamous (atticoantral) C.S.O.M (surgical)

- The main line of treatment is surgery, aiming at safe & dry ear.
- Two techniques are used to eradicate the cholesteatoma:

A. Open (canal wall down) technique

This entails removal of all or a part of the posterosuperior bony meatal wall and includes:
1-Radical mastoidectomy; this is the most common procedure performed, where all mastoid cell are exenterated, ossicles are removed except footplate of stapes, with the posterior and superior meatal wall; aiming at dry and safe ear regardless of hearing.
2-Modified radical mastoidectomy: in limited cholesteatoma with good hearing.

NB: Atticotomy; in limited attic cholesteatoma.

B. Closed (Canal wall up) technique

-  An opening is done in the posterior meatal wall (posterior tympanotomy), in a site called facial recess, via which small cholesteatoma could be removed.
- A second look operation is mandatory after 6 months for detection of residual or recurrent cholesteatoma.

Reconstruction of the radial cavity: 

may be needed including reconstruction of hearing after being sure of complete eradication of the cholesteatoma for a year or later on.
Uses of endoscopy in cholesteatoma (recently introduced)
- It is used to detect residual or recurrence after performing the closed technique.
- It may also be used to clean difficult sites as the sinus tympani
Chronic Suppurative Otitis Media| causes, symptoms, diagnosis and treatment
Dr.Tamer Mobarak


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