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DEFINITION
CSOM is chronic inflammation of the middle ear cavum, mastoid and tympanic membrane is intact (perforated) also found an intermittent purulent secretions (othorea). Secretions may be watery or thick, clear or in the form of pus and lasted more than 2 months.
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CLASSIFICATION
CSOM can be divided into two types :
1. Tubotympany = benign type = rhinogen safe.
Tubotympany characterized by the presence of a central perforation or pars Tens and clinical symptoms that vary depends on wide and severity of disease. Clinically divided into:
a. active
In this type, there are secretions of the ear and deafness. Usually preceded by the expansion of the upper respiratory tract infections through the eustachius tube or after swimming where germs enter through the outer ear canal. Secretions varied from mucoid to mucopurulent.
b. not active
From examination the ear found total dry perforation with middle ear mucosa is pale. Symptoms encountered a mild conductive deafness. Other symptoms are encountered, such as vertigo, tinnitus, or a feeling of fullness in the ear.
2. Type aticoantral = wild type = danger = bone type
In this type were found Cholesteatoma and dangerous. Aticoantral type is more often about flaccida pars and the trademark is the formation of retraction pockets, which is where the accumulation of keratin to produce Cholesteatoma.
Cholesteatoma can be divided
above two types, namely:
a. Congenital
b. Obtained.
In general, there Cholesteatoma in chronic otitis media with perforation marginal, but some are located in the pars flaccida (Attic retraction cholesteatom).
ETIOLOGY
CSOM occurs almost always starts with recurrent otitis media in children, rarely in the adult. Infection factor usually comes from the nasopharynx (adenoiditis, tonsillitis, rhinitis, sinusitis), reaching the middle ear through the tube of Eustachius. Eustachius tube abnormal function are predisposing factors which found in children with cleft palate and Down's syndrome. Presence of tubal pathology, causing reflux of contents nasopharynx which is a factor of the high incidence of CSOM in the United States. Humoral abnormalities (such as hipogammaglobulinemia) and cell-mediated (such as HIV infection) can manifest as chronic ear secretion.
Causes of CSOM among others:
1. Environment
2. Genetic
3. history of otitis media.
4. Infection
5. Upper respiratory tract infection
6. Autoimmune
7. Allergy
8. Eustachius tube disfunction.
Some of the factors that cause persistent tympanic membrane perforation in CSOM:
• Infections that persist in the middle ear mastoid resulting in the production of purulent ear discharge persists.
• The continued obstruction Eustachius tube which reduces the spontaneous closure of the perforation.
• Several large perforations suffered through the mechanism of spontaneous closure of epithelial migration.
• At the edge of the perforation of squamous epithelium can experience rapid growth over the medial side of the tympanic membrane. This process also prevents the spontaneous closure of the perforation.
Factors that cause middle ear infections become chronic suppurative compound, among others:
1. Eustachius tube dysfunctions chronic or recurrent.
a. Nose and throat infections are chronic or recurrent.
b. Partial or total anatomic obstruction tube Eustachius
2. Persistent tympanic membrane perforation.
3. The occurrence of squamous metaplasia or other permanent pathological changes in the middle ear.
4. Persistent obstruction of the aeration of the ear or mastoid cavity.
5. There are areas with sekuester or persistent osteomyelitis in the mastoid.
6. Basic constitutional factors such as allergies, general weakness or changes in the body's defense mechanisms.
Pathogenesis
CSOM Patogensis not yet fully known, but in this case is the chronic stage of acute otitis media (OMA) with a perforation that has been formed, followed by the release of secretions that keep menerus1. OMA perforation can occur secondary to chronic uneventful middle ear infection in eg dry perforations. Some authors claim this as an inactive state of chronic otitis media.
PATHOLOGY
CSOM is more often a recurrent disease. This chronic condition is more time-based rather than pathology, and staging. In general, the picture found is:
1. There is a perforated tympanic membrane in the central part.
2. Mucosa varies according to disease stage
3. The bones of hearing can be damaged or not, depending on the severity of infection
previously.
4. Mastoid pneumatization
CSOM most often in childhood. Most recent mastoid pneumatization occurs between 5-10 years. When chronic infection persists, the mastoid had sclerotic process, thereby shrinking the size of the mastoid processes.
CLINICAL MANIFESTASIONS
1. Discharge Ear (Otorrhoe)
Purulent or mucoid secretions is dependent stage of inflammation. In CSOM benign type, the liquid that comes out muco pus that do not stink, often as a reaction to irritation of the mucosa of the middle ear by the tympanic membrane perforation and infection.
The exit discharge is usually intermittent. In the inactive stage CSOM not found adannya ear secretions. In CSOM wild type, element and mucoid middle ear secretions reduced or lost due to widespread destruction of the mucosal lining. Secretions are mixed with blood-related presence of granulation tissue and ear polyps and a sign of Cholesteatoma. If secretions are watery watery without the possibility of tuberculosis leads to pain.
2. Hearing Loss
Conductive deafness is usually encountered but can also be mixed. Severity of deafness depends on the magnitude and location of tympanic membrane perforation and mobility sound delivery system into the middle ear. In CSOM malignant type, usually obtained severe conductive deafness.
3. Otalgia (Ear Pain)
In CSOM, complaints of pain caused dammed pus drainage. Pain may mean the threat of complications due to drainage constraints secretions, exposure durameter or lateral sinus wall, or the threat of brain abscess formation. Pain is a sign of developing complications such as Petrositis CSOM, subperiosteal abscess or lateral sinus thrombosis.
4. Vertigo
vertigo often appears, is a sign of labyrinthine fistula caused by the occurrence of erosion of the walls of the maze by Cholesteatoma. Vertigo that arises usually due to a sudden change in air pressure or the sensitive patient. vertigo can occur simply because a large perforation of tympanic membrane, causing a maze more easily aroused by the temperature difference. The spread of infection into the labyrinth will also be led to complaints of vertigo. Vertigo can also occur from complications of the cerebellum.
CLINICAL SIGNS
Clinical signs of malignant type CSOM
1. Presence of abscess or fistula retroauricular
2. Granulation tissue or polyps in the ear canal from the tympanic cavity.
3. Pus is always active or foul smelling (smell Cholesteatoma)
4. X-ray mastoid Cholesteatoma the picture.
CLINICAL EXAMINATION
To complete the examination, clinical examination can be performed as
follows:
Audiometric examination
In patients with CSOM audiometric examination is usually found to conductive deafness. But it can also be found there sensorineural deaf, deafness severity depending on the size and location of the tympanic membrane perforation as well as the integrity and mobility
The degree of hearing loss threshold of hearing
Normal: -10 dB to 26 dB
Mild : 27 dB to 40 dB
Moderate: 41 dB to 55 dB
Moderat to Severe: 56 dB to 70 dB
Severe: 71 dB to 90 dB
Total deafness: more than 90 dB.
To evaluate, the following observations :
1. Perforation usually cause deafness conductive generally no more than 15-20 dB
2. Damage to the bones of the circuit causing deafness conductive hearing loss 30-50 dB when accompanied by perforation.
3. Discontinuity of bone behind of intact tympanic membrane causing conductive deafness 55-65 dB.
4. Weaknesses and low discrimination speech, no matter what the conductive of bone, showed severe damage cochlea.
Radiological examination.
1. Projection Schuller
Shows the extent of mastoid pneumatization of the lateral direction and over. This photo is useful for surgery because it shows the position of the lateral sinus and the tegmen.
2. Projection Mayer or Owen,
Taken from the middle ear and anterior direction. Will look picture the bones of hearing and tweaking so it can be known whether the bone damage has on structures.
3. Projection Stenver
Shows a picture along the petrosal pyramid and more clearly shows the internal auditory canal, vestibule and semicircular canals. These projections put the antrum in cross section so as to show the existence of enlargement.
4. Projection Chause III
Give an especial longitudinally so that it can show early damage to the lateral wall of tweaking. Politomografi and or CT scans can depict bone damage because Cholesteatoma.
Bacteriology
Bacteria are often found in CSOM are Pseudomonas aeruginosa, Staphylococcal aureus and Proteus. While the OMSA streptococcus bacteria pneumonie, H. influenza, and Morexella kataralis. Other bacteria found in CSOM E. Coli, Difteroid, Klebsiella, and anaerobes are Bacteriodes sp.
1. Specific bacteria
Eg Tuberculosis. Otitis tuberculosis is very rare (less than 1%). In adults is usually caused by advanced lung infection. These infections enter the middle ear through the tube. Tuberculous otitis media can occur in children who are relatively healthy as a result of drinking milk that is not pasteurized
2. Non-specific bacteria both aerobic and anaerobic.
Aerobic bacteria are often met by Pseudomonas aeruginosa, Staphylococcus aureus and Proteus sp. Antibiotics are sensitive to ceftazidime and Pseudomonas aeruginosa is ciproflokxacin, and is resistant to penicillins, cephalosporins and macrolides. While Proteus mirabilis sensitive to antibiotics except for macrolides. Staphylococcus aureus resistant to sulphonamides and trimethoprim and sensitive to cephalosporin generations I and gentamicin
MANAGEMENT
The principle of treatment depends on the type and extent of infectious diseases, where treatment can be divided into:
1. Conservative
2. Surgery
CSOM benign INACTIVE
This situation does not require treatment, and advised not to scrape the ears, the water should not enter the ear during bathing, swimming is prohibited and immediately seek treatment when suffering from upper respiratory tract infection. If the facility allows reconstruction surgery should be performed (miringoplasty, tympanoplasty) to prevent recurrent infections and hearing loss.
CSOM benign ACTIVE
The principle of treatment of CSOM is:
1. Clean ear canal and tympanic cavity.
2. antibiotics:
- Topical antibiotics (antimicrobial)
- Systemic.
Topical antibiotics
Antibiotics topically in the ear and a lot of secretions without cleaning first, is not effective. If the discharge is reduced / no longer progressive but given
drops containing antibiotics and topical drug delivery kortikosteroid.4 Given meant to go to the middle ear, it is not recommended that antibiotics such as neomycin and duration ototoxic not more than 1 week. How to best selection of antibiotics based on culture, and resistency test.
Ear powder used as:
a. Acidum boricum with or without iodine
b. Terramycin.
c. Asidum borikum chloromicetin 2.5 grams mixed with 250 mg
Topical antibiotic treatment can be widely used for active CSOM combined with ear cleaning. Topical antibiotics that can be used in chronic otitis media is:
1. Polymyxin B or polymyxin E
These drugs are bacterisid against gram-negative bacteria, Pseudomonas, E.
Koli Klebeilla, Enterobakter, but the resistant gram-positive, Proteus, B. fragilis Toxic to kidneys and nervous system.
2. Neomycin
bactericid drugs on gram-positive and negative, for example: Staphylococcal aureus, Proteus sp. Resistant to all anaerobes and Pseudomonas. Toxic to the kidneys and ears.
3. Chloramphenicol
These drugs are bactericid
Systemic antibiotics
Antibiotics are not more than 1 week and must be accompanied cleaning profus secretions. In the event of treatment failure, keep in mind that there are reasons of failure in these patients. Antimicrobials can be divided into 2 groups. The first class of power killed him dependent measure. The higher levels of the drug, the more germs were killed, for example with the quinolone class of aminoglycosides.
The second category is a particular concentration of antimicrobial that killed her best resources. Elevation does not increase the dose of killing power of this class of antimicrobials, such as beta-lactam class.
Systemic antibiotic therapy is recommended in chronic otitis media is.
Pseudomonas: Aminoglycosides ± carbenicillin
P. mirabilis: Ampicillin or cephalosporin
P. morganii, P. vulgaris: Aminoglycosides ± carbenicillin
Klebsiella: Cephalosporin or aminoglycosides
E. coli: Ampicillin or cephalosporin
S. Anti-stafilikokus aureus: penicillin, cephalosporin, erythromycin, aminoglycosides
Streptococci: Penicillin, cephalosporin, erythromycin, aminoglycosides
B. fragilis: clindamycin
Class of quinolone antibiotics (ciprofloxacin and ofloxacin) are able to nalidixic acid derivate that has anti-pseudomonal activity and can be administered orally. But it is not recommended for children under the age of 16 years. Cephalosporin Group III generation (cefotaxime, and ceftriaxone seftazidinm) are also active against Pseudomonas, but must be administered parenterally. This therapy is very good for the OMA, while for CSOM is uncertain enough, although it can cope with CSOM. Have the effect of metronidazole for anaerobic bactericid. According to Browsing et al metronidazole can be given with and without antibiotics (cephalexin and cotrimoxazol) on active CSOM, a dose of 400 mg per 8 hours for 2 weeks or 200 mg per 8 hours for 2-4 weeks.
Malignant CSOM
Treatment for Malignant CSOM is surgery. Conservative medical treatment is only a temporary treatment before surgery. If there is a subperiosteal abscess, the abscess incision should be done separately before then performed mastoidektomy.
There are several types of surgery or surgery techniques that can be done in CSOM with chronic mastoiditis, either benign or malignant type, among others:
1.Mastoidektomy simple (simple mastoidectomy)
2. radical Matoidectomy
3.radical with modifications mastoidectomy
4.Miringoplasty
5.Timpanoplasty
6. Combined approach tympanoplasty)
The goal is to stop operating permanently infection, tympanic membrane perforation repair, prevent complications or more severe hearing damage, and improve hearing.
COMPLICATIONS
Tendency of complications of otitis media gets depends on the pathological abnormalities that cause otorrhoea. Nevertheless resistant organisms and lack of effective treatment, would lead to complications. usually obtained in patients with CSOM complications malignant type, but an acute otitis media or an acute exacerbation by a virulent bacteria in CSOM benign type can cause complications.
Serious intra-cranial complications more often seen in acute exacerbation of CSOM associated with Cholesteatoma.
A. Complications of middle ear:
1. Persistent tympanic membrane perforation
2. Erosion of bone loss
3. Facial nerve paralysis
B. Ear complications in
1. Labyrinth fistula
2. Labyrinitis suppurative
3. Nerve deafness (sensorineural)
C. Complications of Extradural
1. Extradural abscess
2. Lateral sinus thrombosis
3. Petrositis
D. Complications to the central nervous system
1. Meningitis
2. Brain abscess
3. Hindrocephalus otitis
Complication of middle ear infections trip to the intra-cranial must pass through three kinds of trajectories:
1. From the middle ear cavity to the brain membrane
2. Penetrate the lining of the brain.
3. brain expansion.
