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Department of Otorhinolaryngology

Department of Otorhinolaryngology. CHOLESTEATOMA. Chronic Suppurative Otitis Media Attico-Antral Type. Cholesteatoma. Is epidermal cyst of the middle ear and/or Temporal bone with a squamous epithelial lining. Contain keratin and desquamated epithelium. Can be congenital or acquired

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Department of Otorhinolaryngology

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  1. Department of Otorhinolaryngology

  2. CHOLESTEATOMA Chronic SuppurativeOtitis Media Attico-Antral Type

  3. Cholesteatoma • Is epidermalcystof the middle ear and/or Temporal bone with a squamous epithelial lining. • Contain keratinand desquamated epithelium. • Can be congenital or acquired • Natural history is progressive growth with erosion of surrounding bone due to pressure effects and osteoclast activation. It is skin in wrong place

  4. Cholesteatoma It erodes bone by: 1.Enzymatic activity. 2.Pressure necrosis (expansion of the sac). This may open pathways for spread of infection (Bony or Unsafe type o CSOM)

  5. Pathogenesis of Cholesteatoma Congenital Cholesteatoma: Arises from embryonic epithelial tissue in the temporal bone ( may be in ME cavity or temporal bone especially the petrous apex). Epidermal cysts usually present in the anterior superior quadrant of the middle ear near the Eustachian tube orifice.

  6. Congenital Cholesteatoma: Diagnosed as a pearly white mass behind an intact tympanic membrane in a child with no history of chronic ear disease.

  7. Acquired Cholesteatoma Pathogenesis Squamous epithelium may be found in the middle ear as a result of: • Invagination • Migration (through a perforation) • Squamous metaplasia

  8. Acquired CholesteatomaPathogenesis

  9. Acquired Cholesteatoma 1) Invagination Theory ( primary acquired ) Prolonged ET obstruction creates negative ME pressure leading to retraction of pars flaccida (or the superior part of the membrana tensa) which becomes aninvaginated into the ME (retraction pocket) and gradually distend with accumulated keratin and later on separate from the drum membrane.

  10. Primary acquired cholesteatoma Normal TM Primary acquired (M Flaccida)

  11. Primary acquired cholesteatoma Normal TM Mesotympanic Type (primary)

  12. Primary acquired cholesteatoma

  13. Pathogenesis Of Cholesteatoma(cont.) 2) Migration Theory (Secondry acquired) The stratified squamous epithelium of the deep external auditory meatus grows through a marginal perforation into the middle ear cavity. 3) Metaplasia Theory Long standing suppuration can stimulate metaplasia of the simple squamous epithelium of the middle ear to stratified squamous epithelium.

  14. Secondary Acquired Cholesteatoma • Migration Theory – most accepted • Originates from a tympanic membrane perforation • As the edges of the TM try to heal, the squamous epithelium migrates into the middle ear

  15. Clinical Picture symptoms 1) Hearing loss (marked) and tinnitus. Sometimes HL is minimal as the sac may bridges the gap between the necrosedossicles. 2) Foul smelling ear discharge. Signs 1- Fetid scanty purulent ear discharge 2- Perforated DM with cholesteatoma debris 3- Conductive or mixed HL

  16. Clinical Picture • Mass behind intact tympanic membrane in cases of congenital cholesteatoma • Sometimes the first presentation is with one of complications e.g. facial nerve paralysis or lateral sinus thrombophlebitis • Granulation tissue or aural polyp may fill the ear canal with bloody ear discharge

  17. Investigations 1- Culture and Sensitivity: of the ear discharge. 2- Audiological assessment - CHL, mixed HL or dead ear 3- Imaging of the temporal bone: Only in cases with - Suspected or presence of complications, - Congenital cholesteatoma or - History of previous ear surgery

  18. Imaging of Temporal Axial Section Coronal Section

  19. Cholesteatoma Imaging

  20. Treatment of Cholesteatoma Is Surgical, No role for medical treatment except for active ear infection (ototopical drops) Tympanoplasty with Mastoidectomy is the standard surgical procedure In cases with total HL radical mastoidectomy is indicated

  21. Mastoidectomy • Intact (bony ear) canal wall mastoidectomy • Canal wall down mastoidectomy • Radical Mastoidectomy ( dead ear) • Modified Radical Mastoidectomy

  22. Cholesterol Granuloma CGs, first reported in the mastoid and middle ear in 1894, may occur anywhere in the air cell system of temporal bone when eustachian tube obstruction, mucosal edema, temporal bone fracture, cholesteatoma, chronic otitis media or any another process blocks the air cell tracts.

  23. Cholesterol Granuloma • Cholesterol granuloma is a histological term used for the description of a tissue response to a foreign body such as cholesterol crystals released by the breakdown of blood and local tissue. • It may arise any portion of the pneumatized temporal bone but most frequently involves the petrous apex

  24. Cholesterol Granuloma CG can be a perfectly localized and isolated mass in any pneumatized area in the temporal bone, the middle ear cavity, mastoid antrum, external auditory canal and the petrous apex.

  25. Cholesterol Granuloma Cholesterol granuloma (CG) of the middle ear typically presents with a conductive hearing loss and a blue eardrum; those at the petrous apex either manifest with side-effects from bony erosion (with sensorineural hearing loss, tinnitus, vertigo or cranial nerve impairment), or are identified as incidental findings.

  26. OTORRHOEA Definition: Discharge of abnormal material through the external ear canal Ear Wax is considered as normal external ear secretion not discharge

  27. OTORRHOEA Description Amount: Scanty or profuse Nature: Watery, mucoid (& muco-purulent), purulent or bloody (sanginous) Smell: Cholesteatoma & external otitis

  28. OTORRHOEA The source of ear discharge: 1- External ear 2- Middle ear 3- Intracranial (CSF)

  29. WATERY OTORRHOEA CSF Otorrhoea: Mostly traumatic • Skull base fracture (commonly the longitudinal type) • Iatrogenic (post-operative) • Rarely, malignant neoplasm eroding the skull base

  30. Bloody Otorrhoea • Traumatic: Trauma of the external, middle ear and skull base • Inflammatory: Bullous myringitis, acute and chronic otitis media • Neoplastic: glomus , carcinoma of external or middle ear

  31. Mucopurulent Otorrhoea Always from middle ear; Acute and chronic otitis media Pulsating ear discharge: Acute or acute on top of chronic suppurative otitis media with small perforation of drum membrane Intra-cranial complications of suppurative otitis media ( extra-dural abscess)

  32. Muc-opurulent Otorrhoea Reservoir Sign: Rapid recollection of discharge in the external ear canal which indicates coalescent mastoiditis

  33. PURULENT OTORRHOEA External otitis and cholesteatoma Usually smelly (fetid) Management of cases of ear discharge is according to the cause N.B.No packing of external ear in suspected cases of CSF otorrhoea.

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