chronic otitis media in a child

Submitted by ugofisch on Mon, 04/16/2018 - 17:51

A 10 yrs. old boy came to us because of recurring spells of otitis media involving the left ear with chronic discharge which did not stop despite antibiotics over 7 years. Otoscopy did show a very narrow left external auditory canal with total atelectasis of the tympanic membrane and retention of keratin in the epitympanum. Audiometry revealed a surprising minimal  conductive deafness of the left ear Fig.1a) with a very reduced compliance on Tympanometry (Fig. 1b). Radiology (HRCT) showed a reduced pneumatization with sclerotic mastoid of the left temporal bone. The left mastoid cells, middle ear and attic were filled with scar and fluid. The scutum was eroded with a sharp cut destruction of the lateral attic wall. The malleus head and incus body were unclearly delineated (Figs. 2a, 2b). The diagnosis was: Left chronic otitis media with secondary acquired cholesteatoma. There was no abnormality of the right temporal bone.

My questions are:
1. Does the left ear needs surgery?
2. If surgery: open or closed cavity?
3. If open cavity: obliteration of the mastoid cavity and if yes how?
4. Myringoplasty: how?
5. Ossiculoplasty: how (one stage two stages)?
6. What result would you predict in regard to: 1. Dry ear  2. Hearing  3. Recurrence of cholesteatoma?

Thank you for your help

 The Figures are enclosed as PDF

Fig. 1a  PTA - Fig. 1b  Tympanometry

Fig. 1aFig. 1b

Figs. 2a  HRCT  axial

Fig. 2aFig.2b

Fig.2cFig. 2a

Fig 2aFig.2a

Fig. 2b  HRCT coronal

Fig 2bFig.2b

Fig. 2b Fig. 2b

Fig. 2bFig. 2b

 

ZaniniOtavio

Wed, 04/18/2018 - 00:12

Dear Prof. Fisch,

I assume that this patient has a chronic dysfunction of the eustachian tube. The evolution to atelectasis and the poor pneumatization support this hypothesis. There are some peculiar findings in the CT, that my be taken in count to decide which is the best approach to deal with the problem:

- The ossicular chain doesn't seem to be medialized (Prussak space is not enlarged), but there is hypodensity in the anterior epitympanum

-Thin/eroded Tegmen tympani, low but flat Tegmen mastoideum

- Possible dehiscence of geniculate ganglion/tympanic segment of the facial nerve

- Sinus tympani with pathologic hypodensity

The good hearing must be caused by columelar effect or myringostapedopexy

I think that two pathologic pathways may be occurring in this case in parallel : Atelectasis (with possible underlaying osteitis) and possible Anterior Epitympanic Cholesteatoma

My opinion about this questions:

1. Yes, for solving the chronic otorrhea;

2. Open MastoidoEpitympanectomy, for better access (including supratubal recess) and management of this extensive and agressive disease;

3. Yes, removing the tip and making a miosubcutaneous occipital flap;

4. Type III tympanoplasty if stapes suprastructure is present. Second stage ossiculoplasty (Titanium Total) if suprastructure is absent, and if the tympanic membrane is stable. An option in this case would be discussing a bone conduction hearing system;

5. If necessary, in two stages, as above mentioned;

6. 1. Feasible dry ear; 6.2 Probably a little bit worse (30dB GAP possible); 6.3 Not expected.

Thank you for sharing this interesting case. I am anxious to see also your opinions about that.