TUBOTYMPANIC TYPE CSOM ENT

Tubotympanic CSOM (Safe Type)

Definition: A chronic infection of the middle ear cleft localized to the mucosa, mostly in the anteroinferior part. It is a mucosal disease with no evidence of squamous epithelium invasion.

Aetiology

Starts in childhood; common in that age group.

Sequela of Acute Otitis Media: Usually following exanthematous fever, leaving a large central perforation.
Ascending Infections: Via Eustachian tube from infected tonsils, adenoids, or sinuses.
Allergy: Persistent mucoid otorrhoea due to ingestants (milk, eggs, fish).

Pathology

Characterized by co-existing healing (fibrosis) and destruction.

Perforation: ALWAYS CENTRAL. Variable size/position in Pars Tensa.
Mucosa: Normal (quiescent) or Oedematous/Velvety (active).
Polyp: Smooth, pale mass of oedematous mucosa. (Contrast: Pink, fleshy polyp in atticoantral disease).
Ossicular Chain: Usually intact/mobile. Necrosis may occur (Long process of incus).
Tympanosclerosis: Hyalinization/calcification (chalky white deposits). May cause fixation and conductive deafness.
Fibrosis/Adhesions: May impair ossicular mobility or block ET.

Bacteriology

Culture: Usually multiple organisms.

Aerobes: Pseudomonas aeruginosa, Proteus, E. coli, Staph. aureus.
Anaerobes: Bacteroides fragilis, Anaerobic Streptococci.

Classification of Disease

1. Tubotympanic (Mucosal)

State	Features
Active	Perforation + Inflammation + Mucopurulent discharge.
Inactive	Permanent perforation + No inflammation + Dry ear.
Healed	TM healed (often 2 layers, atrophic/retracted) + Tympanosclerosis.

2. Atticoantral (Squamosal)

(Provided for contrast)

Inactive: Retraction pockets (Pars flaccida/Posterosuperior tensa).
Active: Cholesteatoma present. Bone erosion + Granulation + Offensive discharge.

Clinical Features

Ear Discharge: Non-offensive, mucoid/mucopurulent. Constant or intermittent (triggered by URI or water entry).
Hearing Loss: Conductive, rarely > 50 dB.
Paradoxical Effect: Patient hears better when ear is wet. Mechanism: Discharge produces "Round Window Shielding", maintaining phase differential. In dry ear with perforation, sound cancels out at oval/round windows.
Perforation: Central (Anterior/Posterior/Inferior to malleus handle) or Subtotal.
Mucosa: Red/swollen if inflamed; Pale pink/moist if normal.

Assessment

Microscope Examination: Essential. Checks for granulations, epithelial ingrowth, ossicular status, and hidden cholesteatoma.
Audiogram: Assess degree/type of loss (usually Conductive).
Culture & Sensitivity: For antibiotic selection.
Imaging (X-ray/CT): Sclerotic mastoid or clouding. No bone destruction (unlike atticoantral).

Treatment

Aim: Control infection → Eliminate discharge → Restore hearing.

1. Medical Management

A. Aural Toilet:

Remove discharge/debris (Suction, Dry mopping, or Irrigation).
Note: Ear must be dried after irrigation.

B. Ear Drops (Mainstay of Treatment):

Contents: Antibiotics (Neomycin, Polymyxin, Chloromycetin, Gentamicin) + Steroids (for local anti-inflammatory effect).
Method of Use:
1. Patient lies down with diseased ear up.
2. Antibiotic drops are instilled.
3. Intermittent pressure applied on Tragus. (Essential for solution to reach middle ear).
4. Frequency: 3–4 times a day.
Acid pH: Irrigations with 1.5% Acetic Acid are useful to eliminate Pseudomonas.

⚠ Care & Complications:

May cause maceration of canal skin, local allergy, or fungal growth.
Risk of organism resistance.
Ototoxicity: Some drops are potentially ototoxic (e.g., aminoglycosides).

C. Systemic Antibiotics: Useful only in acute exacerbations.

D. Precautions: Keep water out (bathing/swimming) and avoid hard nose blowing.

E. Treat Contributory Causes: Adenoids, Tonsils, Sinuses, Allergy.

2. Surgical Management

Aural Polypectomy:
⚠ WARNING: Never avulse a polyp! It may arise from Stapes, Facial Nerve, or Horizontal Canal. Avulsion → Facial Paralysis or Labyrinthitis.
Reconstructive Surgery: Myringoplasty (with/without ossicular reconstruction) once ear is dry (quiescent).

📚 Source: Dhingra ENT | Chapter 11

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