atticoantral disease

1. CHRONIC SUPPURATIVE OTITIS
MEDIA-2
(atticoantral TYPE)
Dr Chandra Bhan
Assistant professor ENT

2. ATTICO ANTRALDISEASE
• Chronic inflammatory condition confined to postero
superior part of the middle ear cleft i.e. posterosuperior
mesotympanum , attic, antrum and mastoid air cell
system.
• Aassociated with bone eroding disease or cholesteatoma
• Risk of complications is higher
• Characterized by thick, purulent, scanty, foul smelling,
blood stained, persistent discharge and may be
associated with perforation in pars flaccida

4. PATHOLOGY
Cholesteatoma
Osteitis and granulation tissue
 Osteitis involves outer attic wall, posterosuperior
margin of tympanic ring
Granulation tissue surrounds it may even fill the attic,
antrum, posterior tympanum, mastoid
Fleshy red polypus

5. Ossicular necrosis
Destruction may be limited to the long process of incus.
may involves stapes supera-stucture, handle of malleus/
entire ossicular chain
Greater hearing loss
• Cholesteatoma hearer Occasionally, the cholesteatoma
bridges the gap caused by the destroyed ossicles and hearing
loss is not apparent.
Cholesterol granuloma
Mass of granulation tissue with foreign body giant cells
surrounding the cholesterol crystals.

6. CHOLESTEATOMA
• It is a cystic bag like structure lined by stratified
squamous epithelium containing desquamated
epithelial debris lying on a fibrous tissue stroma
of variable thickness
• "Skin in the wrong place"
• Synonym: keratoma, epidermosis

8. THEORIES OF CHOLESTEATOMA
1. Congenital cell rests
2. Invagination theory:
(Wittmack)
-Invagination of TM from
attic or posterosuperior
part of pars tensa in the
form of retraction pocket.

9. RETRACTION POCKETS
Retraction pocket is an invagination of the tympanic
membrane.
The negative middle ear pressure is the cause of
retraction pocket
Toss classified attic retraction pockets into 4 grades:

10. Grade I: The pars flaccida is not in contact with the
neck of the malleus.
Grade II: The retracted pars flaccida is in contact
with the neck of the malleus and wrap around it.
Grade III: Addition to grade II features there is
minimal erosion of the outer attic wall
Grade IV: in addition to all the above changes there
is severe erosion of the outer attic wall or scutum.

11. SADE classified pars tensa retraction as
Stage I. Tympanic membrane is retracted but does not contact the
incus.
Stage II. Tympanic membrane is retracted deep and contacts the
incus; middle ear mucosa is not affected.
Stage III. Also called middle ear atelectasis. Tympanic membrane
comes to lie on the promontory and ossicles. Middle ear space is
totally or partially obliterated but middle ear mucosa is intact.
Stage IV. Also called adhesive otitis media. Tympanic membrane is
very thin and wraps the promontory and ossicles. There is no
middle ear space, mucosal lining of the middle ear is absent.
Stage V. Adhesion with perforation

12. 3. Epithelial invasion
(Habermann theory)
-Squamous epithelium from
outer surface of TM or
meatus migrates to middle
ear via pre-existing TM
perforation (specially in
marginal type)

13. 4. Basal cell hyperplasia theory(ruedi
theory)
Due to repeated Infection or inflammation
Basal cell of germinal layer of skin proliferate
And form keratinizing squamous epithelium
Squamous epithelium invade into sub epithelial
tissue in pars flaccida and form cholesteatom.
This enlarges and perforates through the TM

14. 5. Squamous metaplasia theory: (sade’s
theory)
• The epithelium in the attic area of the middle ear
undergoes metaplastic changes in response to
subclinical infection.
• This metaplastic mucosa is squamous in nature there
by forming a nidus for cholesteatoma formation in the
attic region.

15. TYPES OF CHOLESTEATOMA
• Congenital- due to embryonic epidermal
cell rests in the middle ear cleft
• Acquired
- primary- without TM perforation
- Secondary- after TM perforation

16. CONGENITAL CHOLESTEATOMA
Embryonic epidermal cell rests in the middle ear cleft/
temporal bone, petrous apex, cerebellopontine angle
Middle ear: white mass behind an intact tympanic
membrane
conductive hearing loss
Discovered: during routine exam/myringotomy
May spontaneously rupture- TM-discharging ear

17. Congenital cholesteatoma

18. PRIMARYACQUIRED CHOLESTEATOMA
 No h/o previous infection/ pre-existing perforation
 Invagination of pars flaccida
Persistent negative pressure in the attic retraction
pocket which accumulates keratin debris expand
middle ear
 Basal cell hyperplasia
Proliferation of the basal layers of pars flaccida
induced by subclinical infection
 Squamous metaplasia
Normal pavement epithelium of attic undergoes
metaplasia, keratinizing squamous epithelium
formation

19. SECONDARYACQUIRED CHOLESTEATOMA
 Already a pre-existing perforation in pars tensa
 Associated with posterosuperior marginal
perforation
 Migration of squamous epithelium
from EAC/ outer surface of TM migrates through the
perforation into the middle ear
Metaplasia: repeated infections of middle ear- pre-
existing perforation

21. Causes of bone destruction
Hyperaemic decalcification
Osteoclastic bone resorption due to:
Pressure necrosis
Acid phosphatase
Collagenase Acid proteases
Proteolytic enzymes
Leukotrienes
Cytokines

22. SYMPTOMS
• Ear Discharge- scanty, fowl smelling, continuous
• Hearing Loss- conductive or mixed type
• Bleeding- due to granulation
• Ear Ache- due to osteitis and OE
• Dizziness
• Tinnitus
• Symptoms Of Complications

23. SIGNS
PERFORATION
• Either attic or posterosuperior marginal type
• can be missed due to crust
RETRACTION
POCKET
• Invagination of TM is seen in the
attic/posterosuperior part of PT
• Early: shallow,self cleansing
• Later: deep,acumulation of keratin mass,infected
CHOLESTEATOMA
• Pearly white flakes can be sucked from the
retraction pocket

25. PARS TENSA CHOLESTEATOMASIGNS
• Retraction Pockets
• Cholesteatoma Flakes
• Granulation Tissue
• Polyp
• Hearing Loss

26. CONCLUSION
TUBOTYMPANIC/SAFE ATTICOANTRAL/UNSAFE
DISCHARGE Profuse, mucoid odourless Scanty, purulent, foul smelling
PERFORATION Central Attic/marginal
GRANULATION
S
Uncommon Common
POLYPS Pale Red and fleshy
CHOLESTEATO
MA
Absent Present
COMPLICATIO
NS
Rare Common
AUDIOGRAM Mild to moderate
conductive deafness
Conductive/mixed deafness

27. INVESTIGATIONS
 Examination under microscope. May reveal
presence of cholesteatoma, evidence of bone
destruction etc
 Tuning fork test & audiogram
 X-ray/CT mastoids. Attic and antrum destruction
caused by cholesteatoma.
 Culture and sensitivity of discharge

28. CONSERVATIVE TREATMENT
 If Cholesteatoma is small, easily accesible to suction
clearance under microscope
 Elderly >65 years old
 Unfit for SURGERY/ refused
Polyps,granulation tissue: cup forceps removal/
cauterized by chemical agents (silver nitrate/
trichloroacetic acid)
Aural toilet, dry ear precautions

29. SURGERY
•Surgery is the definitive treatment
•Primary aim- To remove the disease and let the ear safe
prevent from complication
•Secondary aim- preserve and reconstruct the hearing
mechanism
•But never at the cost of primary

31. CANAL WALL UP CANAL WALL DOWN
MEATUS Normal appearance Widely open meatus
communicating with mastoid
DEPENDENCE Does not require routine
cleaning
Dependence on for
cleaning mastoid cavity
once/twice a year
RECURRENCE/
RESIDUAL SX
High rate- cholesteatoma Low rate
2ND LOOK
SURGERY
Require: after 6months of
surgery/rule out
cholesteatoma
Not required
PATIENTS
LIMITATIONS
No. can swim Swimming infection of
mastoid cavity
AUDITORY
REHABILITATION
Easy to wear a hearing
aid if needed
Problems in fitting d/t large
meatus & infected mastoid
cavity

33. Thank you