Atticoantral Type CSOM ENT

CSOM: Atticoantral Type

AKA: Unsafe or Dangerous Type.

Site: Posterosuperior part of middle ear cleft (Attic, Antrum, Posterior Tympanum, Mastoid).

⚠ Why Dangerous?
Associated with Cholesteatoma which has bone-eroding properties, leading to serious intracranial and extracranial complications.

Pathology

  1. Cholesteatoma: The hallmark of the disease.
  2. Osteitis & Granulation: Involves outer attic wall/posterosuperior margin. Fleshy red polyp may fill meatus.
  3. Ossicular Necrosis: Common.
    • Long process of Incus > Stapes superstructure > Handle of Malleus.
    • Cholesteatoma Hearer: When the cholesteatoma mass bridges the gap between destroyed ossicles, preserving hearing temporarily.
  4. Cholesterol Granuloma: Reaction to old hemorrhage/secretions. Causes a "Blue Drum" if behind intact membrane.

Clinical Features

Symptoms

  • Discharge: Scanty, but foul-smelling (due to bone destruction).
  • Hearing Loss: Conductive or Mixed. Usually greater than Tubotympanic type.
  • Bleeding: On cleaning ear (from granulations/polyp).

Signs

  • Perforation: Attic or Posterosuperior Marginal.
  • Retraction Pocket: Invagination of Pars Tensa/Attic.
  • Cholesteatoma: Pearly-white flakes visible in pockets.
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Stages of Retraction Pockets

Stage I: Mild retraction. No contact with incus.
Stage II: Deep retraction. Contacts incus.
Stage III (Atelectasis): TM lies on promontory/ossicles. No middle ear space. TM can be lifted with suction.
Stage IV (Adhesive Otitis Media): TM adherent to promontory. Mucosal lining absent. Cannot be lifted.

Diagnosis & Assessment

  • Microscopy: Essential. To assess extent of cholesteatoma/bone destruction.
  • Tuning Fork/Audiometry: Determine hearing loss level.
  • CT Temporal Bone: Preferred over X-ray. Shows extent of destruction (Attic/Antrum), low-lying dura, or sigmoid sinus position.

Complications: "Red Flags"

A patient with CSOM presenting with these requires URGENT attention:

  • Pain: Suggests extradural/brain abscess.
  • Vertigo: Erosion of lateral semicircular canal.
  • Facial Weakness: Facial canal erosion.
  • Persistent Headache: Intracranial complication.
  • Fever + Neck Rigidity: Meningitis.
  • Diplopia: Petrositis (Gradenigo syndrome).
  • Ataxia: Cerebellar abscess.
  • Listless Child: Extradural abscess.

Treatment

Mainstay: SURGERY.
Goal 1: Make ear safe (remove disease). Goal 2: Preserve hearing.

1. Canal Wall Down (CWD) Procedures

  • Examples: Modified Radical Mastoidectomy, Atticotomy.
  • Concept: Mastoid cavity left OPEN into external canal. Disease fully exteriorized.
  • Pros: Safe, low recurrence.
  • Cons: Open cavity needs cleaning; water precautions needed.

2. Canal Wall Up (CWU) Procedures

  • Examples: Combined approach tympanoplasty (CAT).
  • Concept: Disease removed via posterior tympanotomy. Posterior meatal wall preserved.
  • Pros: Normal anatomy maintained, no water restrictions.
  • Cons: High risk of residual/recurrent cholesteatoma. Requires "Second Look" surgery after 6 months.

Comparison: CWU vs CWD

Feature Canal Wall Up (CWU) Canal Wall Down (CWD)
Meatus Normal appearance Widely open (meatoplasty)
Maintenance Self-cleaning Dependent on doctor (cleaning 1-2x/year)
Safety High recurrence risk Safe (Low recurrence)
Lifestyle No limitations (Swimming OK) Water precautions (No swimming)
Hearing Aid Easy to fit Difficult (large meatus)
📚 Source: ENT Dhingra

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