The initial evaluation of patients with chronic otitis media should include a thorough otologic and general medical history. The otologic history must include careful documentation of symptoms and previous treatment, both medical and surgical. The general medical history should include documentation of potential predisposing factors including upper respiratory allergy, smoking, diabetes mellitus, and possible immunologic compromise.
Examination should include a thorough otologic and complete head and neck examination. Audiometry is essential. Bac-teriologic cultures, including anaerobes in cases of chronic otitis media with otorrhea may be helpful. Computed tomography
(CT) of the temporal bones, in both the axial and coronal planes, will provide valuable information concerning pneuma-tization of the mastoid, extent of cholesteatoma and granulation tissue, potential complications such as dehiscence of a semicircular canal or the facial nerve, or unexpected findings such as extension of disease to the petrous apex. In chronic otitis media with impending complications, CT is particularly useful.
As part of the initial evaluation of the patient with chronic otitis media, an attempt should be made to assign the disease process to one of the categories shown in Table 38-1. In the author's hands, such subcategorization of disease will suggest a management strategy selected from a medical and/or surgical algorithm. Failure to control chronic otitis media can be attributed to the improper selection of a medical or surgical strategy at least as often as inadequate execution of that procedure.
REVIEW OF ALGORITHM FOR MANAGEMENT OF PRIMARY CHRONIC OTITIS MEDIA
After initial evaluation, including ancillary studies and assignment to a subcategory of disease (Table 38-1), possible contributory disease processes such as allergic rhinosinusitis, smoking, obesity and/or diabetes mellitus, immunocompro-mise, should be assessed and controlled if possible (Fig. 38-1).
Chronic otitis media with cholesteatoma almost always requires surgical intervention. In those cases without otorrhea,
Chronic active otitis media With cholesteatoma With otorrhea Without otorrhea Without cholesteatoma With otorrhea Chronic inactive otitis media With frequent reactivation Without frequent reactivation
History (Otologic and General) Examination (Otologic and Head and Neck) Audiometry Other
Computerized Tomography of Temporal Bones
Assignment to Subcategory and Management of Contributory Disease -Allergic rhinosinusitis
Chronic Active Otitis Media
Chronic Inactive Otitis Media
Without otorrhea With otorrhea
Trial of Medical Management
Surgery limited to removal of cholesteatoma and reconstruction
Tympanomastoidectomy (CWU or CWD)
Elective tympano-plasty (after 6 mos.)
Chronic Otorrhea i
Intermittent With Frequent Without Frequent Otorrhea Reactivation Reactivation i i
(usually CWU) Tympanoplasty
Figure 38-1 Algorithm for management of primary chronic otitis media. CWU, canal wall-up; CWD, canal wall-down.
surgery may be limited to the removal of cholesteatoma and reconstruction of the ossicular chain and tympanic membrane. However, in those with otorrhea, even with limited cholesteatoma, a complete tympanomastoidectomy, either canal wall-up or canal wall-down, should be performed. For example, chronic active otitis media with cholesteatoma limited to the attic with no history of otorrhea may be managed successfully with atticotomy and reconstruction without mastoidectomy, whereas chronic active otitis media with cholesteatoma, limited to the attic, but with a history of recurrent or chronic infection, mandates mastoidectomy as well as atticotomy. Similarly, chronic inactive otitis media without frequent reactivation represents an elective surgical candidacy for reconstruction of the tympanic membrane and ossicles and does not require mas-toidectomy. By contrast, chronic inactive otitis media with frequent reactivation, that is spontaneous recurrent otorrhea after adequate medical management, generally requires rnastoidec-tomy. In many of these cases, the recurrent otorrhea may be explained by obstruction of the aditus ad antrum and sequestration of the mastoid air space by "aditus block."17
In those cases with chronic active otitis media without cholesteatoma, a trial of medical management should be undertaken. This includes management of potential contributing diseases, and knowledge of the bacteriology of the suppuration. In most patients in whom otorrhea has stopped for at least 6 months, elective tympanoplasty and ossiculoplasty may be considered. For those who fail medical management, those with persistent chronic suppuration should undergo tympanomastoidectomy. Cases in which the suppuration temporarily clears only to recur promptly after cessation of medical management should be reassigned to the category "chronic inactive otitis media with frequent reactivation."
FACTORS AFFECTING CHOICE OF CANAL WALL-UP OR CANAL WALL-DOWN APPROACH
The selection of the canal wall-up versus the canal wall-down approach should be individualized based on the experience of the surgeon and details of the clinical variables of the case in question. Examples of preoperative clinical variables that frequently have an influence on this decision are shown in Table 38-2. For example, a very poorly pneumatized mastoid as determined by preoperative physical examination and imaging is a relatively negative indicator for the canal wall-up approach. Similarly, a unilateral nonhearing ear (dead ear) with chronic otitis media, is a good candidate for canal wall-down surgery and tympanomastoid obliteration. In patients who have had multiple previous procedures, particularly those in whom the canal has been partially or totally removed, I prefer the canal wall-down technique with mastoid obliteration. Individuals with bilateral longstanding chronic otitis media are generally managed by canal wall-down technique.
Intraoperative findings that will suggest selection of the canal wall-down technique include inadequate surgical access with preservation of the canal wall, extensive cholesteatoma, and the presence of complications such as facial paresis or labyrinthine fistula.
Factors Affecting Choice of CWU or CWD Approach
Preoperative Bilateral disease Multiple previous procedures Only hearing ear
Pneumatization of mastoid and temporal bone Nonhearing ear ("dead ear") Intraoperative
Inadequate surgical access Extensive cholesteatoma Presence of complication Facial paresis Labyrinthine fistula
CWU, canal wall-up; CWD, canal wall-down.
TREATMENT ALGORITHM FOR MANAGEMENT OF RECURRENT CHRONIC OTITIS MEDIA (SURGICAL FAILURE)
Although there is obvious similarity in the management of recurrent chronic otitis media with that of primary chronic otitis media, nevertheless there are some differences (Fig. 38-2). I find it useful to categorize these patients into those who have had previous canal wall-up versus those who have had previous canal wall-down surgery. In general, in previous surgical failures, CT imaging in axial and coronal planes is a valuable tool. Recurrent cholesteatoma with or without otorrhea almost always requires revision surgery. However, management of chronic or recurrent otorrhea without cholesteatoma differs significantly between canal wall-up and canal wall-down groups. Thus, those who have had previous canal wall-up surgery are treated in a similar manner as those with primary chronic otitis media without cholesteatoma, but with otorrhea. Depending on the bacteriology of the otorrhea, medical management with topical and oral antibiotics may prove successful. Those with continued or recurrent drainage undergo CT scanning and a revision tympanomastoidectomy, either canal wall-up or canal wall-down. In patients who have undergone previous canal wall-down technique, but who have persistent or recurrent otorrhea (the problematic mastoid bowl), bacteriology is essential. The prevalence of anerobes as pathogens in persistent chronic otitis media after canal wall-down surgery has been estimated to be in the range of 50%.18-21 The use of antibiotics with good anero-bic coverage may result in a dry ear. Mastoid bowls with persistent or recurrent otorrhea, despite otic drops, may become candidates for a diagnostic/therapeutic trial of split-thickness skin grafting, which can be done in the office with minimal morbidity, and may well result in a dry ear. Those with persistent or recurrent otorrhea should undergo CT imaging and revision canal wall-down tympanomastoidectomy with thorough exenteration of residual contaminated air cells, both in the mastoid and in the hypotympanum, with a mastoid obliteration to facilitate postoperative long-term management of the mastoid bowl.
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