Clinical Case Discussion: Chronic Suppurative Otitis Media (CSOM) - Atticoantral type

🩺 Clinical Case Discussion: Atticoantral type of Chronic Suppurative Otitis Media (CSOM)

Today, we'll have a clinical case discussion on a very common and important ENT case: Atticoantral type of Chronic Suppurative Otitis Media (CSOM).

This case discussion format will be helpful for both undergraduates and postgraduates.

We'll go through the patient's history, discuss how history guides us to a provisional diagnosis, cover the clinical examination findings and their significance, summarize the case, arrive at a provisional diagnosis, and outline the management plan.

Let's begin!

Patient Details

• Age/Sex: 40-year-old male
• Residence: Bangalore
• Religion: Hindu
• Occupation: Software Engineer
• Chief Complaints:
  1. Discharge from the right ear for 2 years
  2. Decreased hearing in the right ear for 1 year

📜 History of Present Illness

1- Ear Discharge

• Onset: Insidious → Suggestive of CSOM (Sudden onset suggests ASOM)

• Nature: Continuous → Favors atticoantral type (intermittent discharge favors tubotympanic type)

• Amount: Scanty → Seen in atticoantral type due to low cuboidal epithelium without goblet cells

• Consistency: Purulent

What are causes of purulent ear discharge?

What are the different types of ear discharge?

• Colour: Yellowish → Suggests staphylococcal or streptococcal infection

What are the different colors of ear discharge seen? Name some conditions for each of them.

• Odour: Foul smelling (fishy) → Seen in atticoantral type

What are the causes of foul smelling discharge in Atticoantral CSOM?

Name some other causes of foul smelling ear discharge.

• Blood Staining: Occasionally seen in atticoantral CSOM.

Name some causes of Blood stained ear discharge.

What are the differentiating points in ear discharge between Atticoantral CSOM and Tubotympanic CSOM?

2. Hearing Loss

• Onset: Insidious

What are the causes of sudden onset hearing loss?

• Laterality: Unilateral → Common in CSOM, Herpes zoster oticus, acoustic neuroma

• Ability to Hear Whispers: Absent → Suggestive of moderate CHL

How do you assess degree of hearing loss through just history taking?

• Fluctuation: Absent

What are the causes of Fluctuating hearing loss?

• Change During Discharge: No change

Why can you sometimes hear better in presence of discharge?

What is Round window baffling effect?

• Speech Understanding: Preserved → Indicates conductive hearing loss

How would you differentiate between conductive and sensorineural hearing loss based on history?

What is the cause of Sensorineural hearing loss in a cholesteatoma case?

3. Negative History (Importance)

What is the most common site of labyrinthine fistula?

What is the triad seen in Gradenigo’s Syndrome?

🩺 Past History Significance

• Similar complaints: Indicates chronicity

• Diabetes mellitus: Risk for malignant otitis externa, otomycosis; control sugars preoperatively

• Hypertension: Preoperative BP control needed

• Tuberculosis:

What are the features of Tuberculosis in ear?

• Thyroid disorder: Hypothyroidism & antithyroid drugs may cause giddiness

• Exanthematous fever:

  • Indicates poor immunity → recurrent URTI → CSOM
  • Early scarlet fever → acute necrotizing otitis media

• Bronchial asthma: Risk of intraoperative bronchospasm under General Anaesthesia

• Addictions

What is the importance of knowing smoking history in a case of CSOM?

🩺 Clinical Examination of the Ear

• Left Ear: Normal.

• Right Ear (Diseased Ear):

  • External Appearance: Pinna, pre-auricular, and post-auricular areas are normal.

  • External Auditory Canal (EAC): Contains purulent discharge.

  • Tympanic Membrane (TM):

    • An attic perforation is noted in the pars flaccida.
    • Purulent discharge with cholesteatoma flakes and granulation tissue are seen protruding through the perforation.
    • The pars tensa shows a grade 2 retraction.
    • The TM is pearly white, and the cone of light is absent.
    • Partial erosion of the scutum is observed.

  • Tragal tenderness, three-point tenderness, and fistula test are all negative.

• Rinne's Test (Right Ear): Negative for 256 Hz and 512 Hz; positive for 1024 Hz.

Rinne's Test (Left Ear): Positive for all frequencies.

• Weber's Test: Lateralized to the right ear.

• Absolute Bone Conduction (ABC) Test: Same as the examiner in both ears.

• Balancing Tests: Romberg's test is negative, gait is normal, and there is no nystagmus, past-pointing, or dysdiadochokinesia.

• Facial Nerve Examination: Normal.

Which ear should you examine first? Why?

Other Systemic Examination:

• Oral Cavity, Oropharynx, Laryngoscopy, Nose Examination, Neck Examination: Within normal limits.

🗣️ Discussion of Clinical Examination Points

1- Preauricular Area

Here, we look for:

• Sinuses or fistulas
• Enlarged lymph nodes
• Scars
• Skin tags
• Congenital deformities

2- Pinna

• Pathologies: Look for signs of cauliflower ear, keloids, or perichondritis.

How would you know if pinna is of normal size in a person?

What is Frank's Sign? What is it's importance?

3. Post-auricular Area

Check for:

• Scars: Especially from previous surgeries like tympanoplasty or mastoidectomy (post-aural approach).

• Lymph Nodes: Note any enlargement.

• Retro-auricular Groove: Is it normal, obliterated, or accentuated?

• Sinuses or Fistulas

Which disease is Retroauricular groove obliterated in?

What are the differences between Acute Mastoiditis and Furunculosis?

What is Ironed-Out Appearance of mastoid? Where do you see it?

What is Battle's Sign? Where do you see it?

What is Griesinger's Sign? Where do you see it?

4- Findings of the Tympanic Membrane (TM)

Our case showed a Grade 2 retraction of the pars tensa.

What are the Features of a Retracted Tympanic Membrane?

What is Sade's Classification of Pars Tensa Retraction?

What is Tos's Classification of Pars Flaccida Retraction?

Where does Retraction pocket start?

What are the Boundaries of Prussakʼs Space?

🧪 Clinical Tests & What They Tell Us

1- Three-Point Tenderness Test - This test helps localize the source of pain.

What is 3 point tenderness test? How do you perform it?

What are the boundaries of McEwen's Triangle?

2- Fistula Test - This test detects a fistula (an abnormal opening) in the bony labyrinth.

How do you perform Fistula test? What does positive fistula test mean?

What is Hennebert's Sign? Name some diseases where you see it.

What is False Negative Fistula Test? Name some conditions.

What are the uses of Siegel's Pneumatic Speculum?

3- Functional Hearing Tests

How can you grade hearing loss using Tuning fork tests?

If you do not have all the 3 tuning forks, which would be the most preferred tuning fork to be used? Why?

What is False Negative Rinne? Where do you see it?

If you had to choose and perform only one test in between Rinne and Weber, which one would you choose? Why?

📝 Case Summary

A 35-year-old male presents with a 2 year history of foul-smelling, purulent, blood-stained discharge and a 1 year history of progressive hearing loss in the right ear. Examination reveals an attic perforation with cholesteatoma flakes, granulation tissue, and partial scutum erosion. Tuning fork tests are consistent with moderate conductive hearing loss in the right ear.

🩺 Provisional Diagnosis

Based on the history and examination findings:

Right sided active squamous type of chronic otitis media with moderate conductive hearing loss, without complications.

Elements of a Complete Diagnosis:

1. Side: Right or Left.

2. Stage: Refers to the stage of discharge. Active (discharge) or Inactive.

3. Type: Squamous (unsafe/atticoantral) or Mucosal (safe/tubotympanic). This is the current preferred term for Atticoantral CSOM.

4. Hearing Status: Type (conductive, sensorineural, mixed) and degree (mild, moderate, severe).

5. Complications: Presence or absence.

Justification for Diagnosis:

• History: The features of the discharge (scanty, foul-smelling, purulent, blood-stained) are classic for a squamous (atticoantral) type of disease.

• Examination: Findings of an attic perforation, cholesteatoma flakes, granulation tissue, and scutum erosion are definitive signs of squamous disease.

• Hearing Loss: Tuning fork results confirm a moderate conductive hearing loss.

• No Complications: The absence of fever, vertigo, neck rigidity, and other systemic signs rules out active complications.

What is granulation tissue?

Define CSOM. What are the different types of CSOM?

What is Cholesteatoma?

What are the Theories of Formation of Cholesteatoma?

How does Cholesteatoma erode bone?

Which is the first bone to get eroded in Cholesteatoma? Why?

Describe the Spread of Cholesteatoma.

What is Cholesteatoma hearer?

What is the Minimum Hearing Loss to Suspect Ossicular Discontinuity?

What is the Microorganism isolated in Cholesteatoma?

🏥 Management Plan

Management involves two key aspects: Investigations and Treatment.

1. Investigations:

• Examination Under Microscope (EUM): To confirm findings and assess ossicular status.

• Pus for Culture & Sensitivity: To guide antibiotic therapy.

• Pure Tone Audiometry (PTA): To quantify the type and degree of hearing loss and for medico-legal documentation.

• HRCT of the Temporal Bone: Essential to see the extent of the disease, check for bone erosion, assess for anatomical variations (low-lying dura, anteriorly placed sigmoid sinus), and look for impending complications.

2. Treatment: The definitive treatment is surgical.

Surgical Plan: Modified Radical Mastoidectomy (MRM) of the right ear under general anesthesia.

What is Modified Radical Mastoidectomy?

What are the indications and contraindications of Modified Radical Mastoidectomy?

What are the steps of Modified Radical Mastoidectomy? How to perform Reconstruction after MRM?

What are the different incisions in ear surgery?

What are the advantages and disadvantages of Modified Radical Mastoidectomy?

What are the complications of Modified Radical Mastoidectomy?

What is Facial Bridge?

What is Facial Ridge?

What is Anterior buttress and Posterior Buttress?

What is Cog?

What is Korner's Septum? What is it's clinical importance?

What is the Differential Diagnosis for large mastoid cavity?

How to differentiate whether cavity is due to Cholesteatoma or post Mastoidectomy?

What are the advantages of canal wall up procedures?

What is Combined Approach Tympanoplasty?

What are the Indications for medical management in Cholesteatoma?

What is Recidivism?

What are the Hidden areas in ear?

What are the boundaries of Facial Recess?

What are the boundaries of Sinus Tympani? What are the types of Sinus Tympani?