The following CBME core competencies are covered in this chapter. EN4.6: Elicit, document and present a correct history, demonstrate and describe the clinical features, choose the correct investigations and describe the principles of management of a discharging ear. EN4.7: Elicit document and present a correct history demonstrate and describe the clinical features, choose the correct investigations and describe the principles of management of mucosal type of CSOM. EN4.8: Elicit document and present a correct history demonstrate and describe the clinical features, choose the correct investigations and describe the principles of management of squamosal type of CSOM.

How to Present a CSOM Long Case in University Exams

A Step-by-Step Guide for MBBS and ENT PG Students

You have already studied CSOM from the textbook. However, presenting a long case in an exam is completely different from knowing the disease. Therefore, this chapter does not repeat everything you already know. Instead, it gives you a word-for-word presentation script, the exact questions examiners ask, and the common traps you must avoid. Consequently, after studying this chapter, you will walk into your viva with confidence and present any CSOM long case flawlessly.

Section 1: Understanding Chronic Suppurative Otitis Media (CSOM) – The Essentials

Before you learn the presentation, you must understand what CSOM actually is. Chronic Suppurative Otitis Media (CSOM), also referred to as Chronic Otitis Media (COM), is a persistent infection affecting a part or whole of the middle ear cleft. It is characterised by ear discharge lasting at least two weeks and a permanent tympanic membrane (TM) perforation. This condition is a significant cause of hearing impairment and can lead to serious intracranial and intratemporal complications if not managed appropriately. Therefore, understanding CSOM comprehensively is paramount for all medical students and aspiring ENT specialists.

Types of CSOM

Memorise this table. Examiners will ask you to differentiate these two types repeatedly.

Feature	Safe (Tubotympanic) CSOM	Unsafe (Atticoantral) CSOM
Pathology	Mucosal disease, inflammation of the mucoperiosteum	Cholesteatoma (epidermal cyst), bone erosion, presence of granulations
Perforation	Central	Marginal or attic (pars flaccida)
Discharge	Mucoid or mucopurulent, non-foul-smelling, profuse, non-blood-tinged, intermittent	Purulent, foul-smelling (fetid), scanty, blood-tinged, often continuous
Hearing loss	Conductive (mild to moderate)	Conductive (moderate to severe); mixed or SNHL if labyrinth is involved
Ossicular chain	Intact or partially eroded	Often eroded, especially the long process of incus and stapes suprastructure
Granulations or polyps	Less common; they usually indicate secondary infection	Common; they often indicate cholesteatoma
Complications	Less common (mainly hearing loss, acute mastoiditis, occasional facial palsy)	Very common; high risk of intracranial and intratemporal complications
Treatment	Primarily medical; surgery (tympanoplasty) for chronic cases or hearing improvement	Primarily surgical (mastoidectomy) to eradicate the disease and prevent complications. Generally, no role of medications,

Understanding the distinctions between these two types is crucial for accurate diagnosis and effective management, both of which are essential for achieving optimal patient outcomes.

Section 2: What Examiners Expect in a CSOM Long Case

Before you learn the presentation, understand what the examiner is judging.

What Examiners Look For	Why It Matters
Chronological order of complaints	Shows you understand disease progression
Systematic history taking	Shows you did not miss important details
Differentiation of safe vs unsafe CSOM	Shows you can identify complications
Negative history (ruling out complications)	Shows you are thinking beyond the obvious
Correct examination technique	Shows you can perform and interpret findings
Clear diagnosis statement	Shows you can synthesise information
Confident, fluent presentation	Shows you have practised

Therefore, structure your presentation exactly as the examiner expects. Do not deviate.

Section 3: Basic Scheme of History Taking for CSOM Long Case

Before you present, remember the sequence. Follow these steps in order.

1. Personal particulars
2. Chief complaints with duration
3. History of present illness
4. Past history
5. Drug history
6. Personal history
7. Family history
8. Examination
9. Provisional Diagnosis
10. Management

Section 4: The Complete CSOM Long Case Presentation Script

Use this script word-for-word in your exam. Fill in the blanks based on your patient. Practise it until you can say it without looking at your notes.

Step 1: Opening Statement and Personal Particulars

“Good morning, sir. I am presenting the case of [patient’s name], a [age]-year-old [male/female], [occupation] by occupation, resident of [place].”

Background knowledge for personal particulars (know this, but do not say all in viva):

• Name: Essential for patient identification, record-keeping, and rapport-building with the patient.
• Age: Certain diseases are more common in specific age groups; therefore, age helps you make a differential diagnosis. For example, younger age groups commonly present with acute otitis media, foreign bodies, or epistaxis due to nose picking. Adolescent males may present with juvenile nasopharyngeal angiofibroma. Older age groups commonly present with presbycusis or carcinomas.
• Sex: Some conditions have a gender predilection; therefore, sex helps narrow your differential diagnosis. For example, otosclerosis is more common in females, whereas juvenile nasopharyngeal angiofibroma primarily affects males.
• Religion: This may be relevant for understanding dietary habits or cultural practices that influence health or treatment choices. For instance, consanguineous marriages increase the risk of congenital sensorineural hearing loss.
• Occupation: Certain diseases are more common in particular occupations. Noise-induced hearing loss occurs more frequently in construction workers and those in workplaces with loud noises. Vocal nodules due to voice abuse are more common in professions such as teaching, singing, and hawking.
• Address: Geographic location can sometimes correlate with certain endemic diseases. For example, rhinosporidiosis is more common in Jharkhand, Chhattisgarh, Madhya Pradesh, and West Bengal.

Step 2: Chief Complaints (Chronological Order)

“Presented with the chief complaints of:”

1. “[Right/Left] ear discharge for the last [duration] years.”
2. “Decreased hearing in the [right/left] ear for the last [duration] years.”

In your viva, say: “The complaint that appeared first is ear discharge, followed by hearing loss. Therefore, I have written them in chronological order.”

Step 3: History of Present Illness (HOPI) – Ear Discharge

“In the history of present illness, the patient was apparently well [duration] years back when he developed [right/left/bilateral] ear discharge, which was”

Now describe the essential features of the discharge. This is the most critical part of history. Therefore, elicit precise characteristics of each symptom to differentiate between the types of CSOM and to identify potential complications.

In your viva, say the following (choose the correct option based on your patient):

• For safe CSOM: “The discharge was gradual in onset, mucoid in nature, profuse in amount, non-blood-tinged, white/clear/grey in colour and non-foul-smelling. The discharge increases during upper respiratory tract infections and relieves with medication.”
• For unsafe CSOM: “The discharge was gradual in onset, purulent in nature, scanty in amount, blood-tinged, creamy yellow/dark yellow/green in colour and foul-smelling. The discharge increases during upper respiratory tract infections and does not relieve with medication.”

Background knowledge (know these details for viva questions):

Feature	What to Assess	Clinical Significance
Onset	Gradual vs Sudden	Gradual suggests CSOM; sudden suggests AOM or traumatic TM rupture
Duration	Acute (<3 weeks), subacute (3 weeks to 3 months), chronic (>3 months)	Chronic (>3 months) is seen with COM and malignancy
Progression	Progressive refers to chronic, long-term drainage (>6 weeks), or worsening; Non-progressive refers to acute, short-term drainage (<6 weeks), stable or improving.	Progressive in CSOM; Non-progressive in ASOM
Nature	Watery (CSF otorrhoea, otitis externa); Mucoid/sticky white (safe CSOM); Mucopurulent/sticky yellowish (AOM or safe CSOM with secondary infection); Purulent/yellow non-sticky (unsafe CSOM, malignant otitis externa); Cheesy/foul-smelling (cholesteatoma); Serous (otitis media with effusion); Blood-stained (unsafe COM, AOM, malignancy, malignant otitis externa, granulations, polyps, trauma)	Tells you the type of CSOM
Colour	White (fungal); Yellow (bacterial); Green (Pseudomonas); Transparent (CSF); Black (otomycosis); Brown (wax)	Helps identify the organism
Amount	Profuse (discharge that comes out of the ear, wets the pillow at night – safe CSOM); Scanty (seen only when patient cleans ear – unsafe CSOM)	Profuse suggests inflammation of the middle ear mucosa (mucus-secreting glands & goblet cells). Scanty suggests bone erosion, obstruction by cholesteatoma or granulations
Smell	Non-foul (safe CSOM); Foul/fetid/putrid (unsafe CSOM with cholesteatoma, malignancy); Musty smell (otomycosis)	Smell is your most significant differentiating factor
Continuous or intermittent	Continuous (ear is never dry – squamous COM); Intermittent (periods of no discharge in between – mucosal COM)	Helps differentiate the type of CSOM
Aggravating factors	URTI aggravates discharge (safe CSOM); URTI does not aggravate discharge (unsafe CSOM)	Infection spreads from nasopharynx via eustachian tube
Relieving factors	Relieves with medication (safe CSOM); Does not relieve (unsafe CSOM)	Helps differentiate type of CSOM
Bleeding from the ear	Frank bleeding from the ear	Trauma, glomus tumour, vascular anomalies of middle ear and EAC
Associated symptoms	Preceding events, trauma, treatment taken	Provides context

Step 4: History of Present Illness – Hearing Loss

“Along with the discharge, the patient also noticed decreased hearing in the same ear.”

In your viva, say: “The hearing loss was gradual in onset, progressive in nature, and unilateral. The hearing loss increases with discharge. There is no history of Paracusis Willisii.”

Background knowledge (know these details for viva questions):

Feature	What to Assess	Clinical Significance
Onset	Gradual vs sudden	Gradual: CSOM, presbycusis, otosclerosis; Sudden: viral infection, ototoxic drugs, temporal bone fracture
Duration	How long	Establishes chronicity
Progression	Progressive vs Non-progressive	Progressive in CSOM, presbycusis, Meniere’s disease
Unilateral/bilateral	One ear or both	Unilateral: CSOM, acoustic neuroma, herpes zoster oticus; Bilateral: presbycusis, Meniere’s, otosclerosis
Severity of Hearing Loss	Mild/moderate/severe and problems due to loss, e.g. inability to hear the doorbell, difficulty in telephonic conversation and difficulty in normal conversation.	Establishes severity
Paracusis Willisii	All patients with conductive hearing loss have better hearing in noisy surroundings. This is because the person in noisy surroundings speaks louder enough to overcome the conductive deafness of the patient.	Helps differentiate between CHL and SNHL
Fluctuating Hearing Loss	Meniere’s disease – Hearing loss increases during vertigo episodes.	Provides clinical clues
Aggravating/relieving factors	What worsens or improves hearing

Step 5: Negative History (Ruling Out Complications)

This is a high-yield section. Examiners always ask this.

In your viva, say: “There is no history of earache, pain behind the ear, vertigo, nausea, vomiting, blurred vision, diplopia, fever, headache, facial asymmetry, neck rigidity, delirium, convulsions, or projectile vomiting. Therefore, there are no clinical features of any complications.”

Background knowledge (know these for viva questions):

Symptom	Rules Out
Earache or pain behind the ear	Mastoiditis
Vertigo or dizziness	Labyrinthine fistula or labyrinthitis
Nausea or vomiting	Labyrinthitis or intracranial complications
Blurred vision or diplopia	Petrositis (Gradenigo’s syndrome)
Fever	Meningitis, brain abscess, mastoiditis, lateral sinus thrombophlebitis
Headache	Meningitis, brain abscess, lateral sinus thrombophlebitis
Facial asymmetry or weakness	Facial palsy
Neck rigidity	Meningitis
Delirium, convulsions, projectile vomiting	Brain abscess

Mnemonics for negative history (complications):

• “FEMALE” for common complications: Facial palsy, Extradural abscess, Mastoiditis, Abscess (brain), Labyrinthitis, Excellent (meaning no complications).
• “HEADACHE” for intracranial complications: Headache, Emesis (vomiting), Altered sensorium, Diplopia, Abscess (brain), Convulsions, Hydrocephalus, Extradural or subdural abscess.

Step 6: Past History (Keep It Brief)

In your viva, say: “Past history: No history of similar complaints, no previous ear surgeries, no trauma. No history of diabetes, hypertension, or tuberculosis.”

Background knowledge (know what to ask, but keep the viva brief):

A thorough past medical history provides context for the current presentation.

• Similar complaints in the past: Recurrent ear infections or discharge.
• Treatment taken for past complaints: Efficacy and nature of previous interventions.
• History of surgeries, accidents, or radiations: Any previous ear surgeries (e.g., tympanoplasty, mastoidectomy) or head trauma.
• Complications from previous illnesses: Any long-term issues.
• Systemic diseases: Inquire about tuberculosis, hypertension, diabetes mellitus, thyroid disease, coronary artery disease, liver or kidney disease, HIV/AIDS, any known allergies, or bleeding disorders. These conditions can impact healing, immune response, and suitability for surgery.

Step 7: Drug History (Keep It Brief)

In your viva, say: “Drug history: No significant drug history. No history of ototoxic drug intake.”

Background knowledge (know this for viva questions):

Document all medications the patient is currently taking or has recently taken.

• Steroids: Can mask infection symptoms.
• Chemotherapy: May cause immunosuppression.
• Insulin or antihypertensives: Important for managing systemic conditions.
• Ototoxic drugs: Aminoglycosides (e.g., gentamicin), loop diuretics, high-dose aspirin, and some chemotherapeutic agents can cause hearing loss.
• Allergy to medications: Crucial for safe prescribing.

Step 8: Personal History (Keep It Brief)

In your viva, say: “Personal history: No smoking, no alcohol intake. [For women: Mention menstrual history if relevant].”

Background knowledge (know this for viva questions):

• Diet: Vegetarian or non-vegetarian.
• Bowel and bladder habits: General health indicator.
• Personal habits: Smoking, tobacco chewing, alcohol intake, and chewing of paan or supari. These can influence general health and healing.
• Lifestyle: Sedentary or active.
• Marital status: As relevant.
• Menstrual and obstetric history (for women): Includes menarche, cycle regularity, number of pregnancies, and miscarriages.

Step 9: Family History (Keep It Brief)

In your viva, say: “Family history: No history of hearing loss in the family. No consanguinity.”

Background knowledge (know this for viva questions):

• Hearing loss in the family: Suggests genetic conditions like otosclerosis or certain types of sensorineural hearing loss.
• Consanguinity: Increases the risk of congenital sensorineural hearing loss.
• Malignancies or autoimmune disorders: Some have familial tendencies.
• Infectious diseases: Tuberculosis, mumps, diphtheria, and STDs can affect multiple family members.

Step 10: General Physical Examination

In your viva, say: “On general physical examination, the patient is comfortable, well-oriented to time, place, and person. Vitals are stable. There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy, or oedema.”

Background knowledge: Note whether the patient is comfortable and well-oriented to time, place, and person. Check the vital signs: pulse, blood pressure, and respiratory rate. Look for pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, and oedema.

Step 11: Facial Nerve Examination

In your viva, say: “Facial nerve examination: The patient can raise eyebrows, close eyes tightly, blow out cheeks, and show teeth symmetrically. Therefore, facial nerve function is intact bilaterally.”

Background knowledge: Assess the integrity of the facial nerve (cranial nerve VII) because it is susceptible to damage in CSOM, especially with cholesteatoma. Test both sides symmetrically.

Ask the patient to:

• Raise the eyebrows (tests the frontalis muscle)
• Close the eyes tightly (tests the orbicularis oculi)
• Blow out the cheeks (tests the orbicularis oris and buccinator)
• Blow a whistle (tests the orbicularis oris)
• Show the teeth or grimace (tests the zygomaticus major and minor and the levator labii superioris)

Step 12: Local Examination of the Ear

In your viva, say: “I examined the better ear first to gain the patient’s cooperation.”

Background knowledge: Always offer to examine the better ear first. This approach gains the patient’s cooperation and establishes a baseline.

In your viva, describe each area:

Area	What to Say	What to Look For
Preauricular area	“No scar, no sinus, no accessory tragus.”	Scars (post-endomeatal tympanoplasty), sinuses (preauricular sinus), accessory tragus (improper fusion of hillocks of His)
Pinna	“Normal in size and shape.”	Microtia (small), macrotia (large), anotia (absent), bat ear (absence of antihelix), Darwin’s tubercle
Postauricular area	“No scar, no swelling, no fistula, no erythema.”	Mastoidectomy scar, mastoiditis, postauricular abscess, fistula
External auditory canal (without speculum)	“[Describe discharge: thick/thin, profuse/scanty, colour]”	Obvious discharge, foreign bodies
External auditory canal (with speculum)	“[Confirm discharge character]”	Detailed view of canal contents

Step 13: Otoscopy (The Most Critical Step)

In your viva, say: “After suction cleaning the discharge, I visualised the tympanic membrane.”

Draw a diagram of both tympanic membranes in your answer sheet.

• For safe CSOM, say: “On the right side, there is a moderate central perforation involving the anterosuperior and anteroinferior quadrants. The margins are smooth and regular. The middle ear mucosa is pale and healthy. There is no cholesteatoma or granulation. The left ear is normal with a visible cone of light and normal mobility.”
• For unsafe CSOM, say: “On the right side, there is a marginal perforation in the attic or posterosuperior quadrant. I see pearly white flakes and keratin debris, which is characteristic of cholesteatoma. Granulation tissue is present. The left ear is normal.”

Background knowledge (examine the tympanic membrane for the following):

Feature	What to Assess	Clinical Significance
Perforation site	Central (safe), marginal or attic (unsafe)	Differentiates safe vs unsafe
Perforation size	Small, moderate, large, subtotal	Guides surgical planning
Perforation shape	Irregular, kidney-shaped	May indicate a cause
Perforation margins	Smooth, regular, inverted, everted	Regular in COM, irregular in trauma
Quadrants involved	Anterosuperior, anteroinferior, posterosuperior, posteroinferior	Precise documentation
Middle ear mucosa	Pale, inflamed, granulations, polyps	Indicates disease activity
Ossicles	Visible or eroded	Guides surgical approach
Cholesteatoma	Pearly white flakes, keratin debris, retraction pocket	Definitive sign of unsafe CSOM
Contralateral ear	Note its TM appearance, including the cone of light, normal mobility, and shadow of the incudostapedial joint.	Baseline comparison

Step 14: Palpation and Special Tests

In your viva, say:

Test	What to Say
Tragal sign	“Tragal sign is absent.”
Mastoid tenderness	“Mastoid tenderness is absent. I performed the three-finger test.”
Fistula test	“Fistula test is negative.”

Background knowledge:

1. Tragal sign: Press the tragus. Pain upon pressing the tragus is positive in otitis externa but is usually absent in CSOM.
2. Mastoid tenderness: Press over the mastoid process. Tenderness suggests mastoiditis. Perform the three‑finger test: press over the mastoid tip, the suprameatal triangle (Macewen’s triangle), and along the posterior wall of the external auditory canal.
3. Fistula test: Press the tragus or use a Siegle’s speculum to create pressure changes in the EAC. A positive test induces vertigo, nystagmus, or a sense of falling. This indicates a labyrinthine fistula, often due to bone erosion by cholesteatoma. This is a very significant sign of a complicated, unsafe CSOM. A negative test occurs in normal ears or “dead ears” where the labyrinth is non‑functional.

In your viva, say: “The three-finger test includes pressure over the mastoid tip, the suprameatal triangle, and the posterior wall of the external auditory canal.”

Step 15: Tuning Fork Tests

In your viva, say: “I performed tuning fork tests using a 512 Hz fork.”

For conductive hearing loss (safe CSOM), say: “Rinne test is negative on the right ear and positive on the left ear. The Weber test lateralises to the right ear. Absolute bone conduction is normal. Therefore, this indicates a right-sided conductive hearing loss of moderate degree.”

Viva: Why is a 512 Hz tuning fork preferred? Because lower frequencies (128 Hz, 256 Hz) produce tactile vibration, and higher frequencies (1024 Hz) decay too quickly. 512 Hz produces minimum overtones and has an optimum decay time, ideal for bone conduction testing.

Background knowledge:

Test	Safe CSOM (Conductive Loss)	Normal Ear
Rinne test	Negative on affected ear (BC > AC)	Positive on both ears (AC > BC)
Weber test	Lateralises to affected ear	Central
Absolute bone conduction	Normal	Normal

Use a 512 Hz tuning fork to assess the type and approximate degree of hearing loss quickly. Document your findings clearly.

Step 16: Vestibular Function Tests

In your viva, say (if relevant): “Vestibular function tests are normal.”

Background knowledge: These tests help rule out vestibular complications, especially in unsafe CSOM. However, they are not always indicative of labyrinthine involvement in all CSOM cases.

Step 17: Writing the Diagnosis

Use this exact formula:

“[Right/Left] ear Chronic Suppurative Otitis Media, [Safe/Unsafe] type, [Active/Inactive], with [mild/moderate/severe] conductive hearing loss, without any complications.”

Examples:

• “Right ear Chronic Suppurative Otitis Media, Safe type, Active, with moderate conductive hearing loss, without any complications.”
• “Left ear Chronic Suppurative Otitis Media, Unsafe type, Active, with severe conductive hearing loss, without any complications.”
• “Right ear Chronic Suppurative Otitis Media, Unsafe type, Active, with mixed hearing loss, with facial palsy.”

Key elements of the diagnosis:

Element	Specification
Ear involved	Right or left ear
Type of CSOM	Safe (tubotympanic) or unsafe (atticoantral)
Activity	Active (current discharge) or inactive/quiescent (no discharge for 6 months)
Hearing loss	Type (conductive, sensorineural, mixed) and degree (mild, moderate, severe, profound)
Complications	Present or absent (specify if present, e.g., “with facial palsy”)

Step 18: Investigations (What to Mention Briefly)

In your viva, say: “I would order the following investigations:”

1. “Pure tone audiometry – to confirm the type and degree of hearing loss.”
2. “Ear discharge culture and sensitivity – to guide antibiotic therapy.”
3. “HRCT temporal bone – for unsafe CSOM to assess ossicular erosion and cholesteatoma extent.”
4. “Examination under microscope – to confirm otoscopy findings.”

“For pre-operative fitness, I would order CBC, blood sugar, renal and liver function tests, viral markers, and ECG.”

Background knowledge (detailed investigations):

Ear-specific investigations:

1. Examination under operating microscope (EUM): This provides a magnified view of the external ear canal and tympanic membrane. It allows you to confirm the otoscopic findings by precisely assessing the perforation, middle ear mucosa, ossicular chain, and detecting subtle cholesteatoma or granulations. It is also useful for performing aural toilet (suction clearance) and taking samples for culture.
2. Ear discharge pus culture and sensitivity (C/S): This identifies the causative bacteria (common organisms include Pseudomonas aeruginosa, Staphylococcus aureus, and Proteus species) and determines their sensitivity to various antibiotics. Therefore, it helps guide appropriate antimicrobial therapy and prevents antibiotic resistance.
3. Pure tone audiometry (PTA): This is the gold standard for assessing hearing loss. It objectively measures the patient’s hearing thresholds for air conduction and bone conduction across different frequencies. It tells you the type of hearing loss (conductive, sensorineural, or mixed), the degree of hearing loss (mild, moderate, moderately severe, severe, or profound), and the configuration of hearing loss (specific pattern across frequencies). PTA guides management, especially surgical planning for hearing improvement.
4. Impedance audiometry (tympanometry and acoustic reflexes):This evaluates middle ear function, tympanic membrane mobility, and eustachian tube function. In CSOM with a perforation, you expect a flat tympanogram (Type B) with a large ear canal volume. Acoustic reflexes are absent in conductive hearing loss.
5. X‑ray mastoid (Schuller’s and Towne’s views): Perform this primarily in unsafe CSOM or long‑standing safe CSOM to assess mastoid pneumatisation. Schuller’s view shows the mastoid air cell system, tegmen mastoideum (roof of the mastoid), sigmoid sinus plate, and temporomandibular joint. It is useful for assessing pneumatisation of air cells, the extent of disease, a low‑lying dura, and an anteposed sigmoid sinus. Towne’s view is best for visualising the petrous apex and internal auditory canal. Findings in CSOM may show a sclerotic mastoid (poor pneumatisation) or haziness due to inflammation or pus.
6. High‑resolution computed tomography (HRCT) of the temporal bone:This is the imaging modality of choice for CSOM, particularly in unsafe CSOM or suspected complications. It provides excellent bony detail. HRCT shows the detailed anatomy of the middle ear and mastoid, evidence of ossicular erosion or bony dehiscence (e.g., facial canal or lateral semicircular canal), the presence and extent of cholesteatoma, granulations, or fluid, and the integrity of the tegmen tympani and mastoideum (to rule out intracranial extension).
7. Magnetic resonance imaging (MRI): Use MRI in specific situations, such as diagnosing soft tissue pathology (e.g., differentiating cholesteatoma from granulation tissue, especially in recurrent cases), detecting intracranial complications (e.g., brain abscess, meningitis, or lateral sinus thrombophlebitis), and evaluating the extent of intralabyrinthine spread. The diffusion‑weighted imaging (DWI) sequence is highly sensitive for detecting residual or recurrent cholesteatoma because cholesteatoma shows restricted diffusion.

Basic Routine Investigations (Pre‑Operative)

Perform these investigations before any surgical intervention. They include a complete blood count (CBC) to check for anaemia and leukocytosis (infection), blood grouping and cross‑matching, renal function tests (urea and creatinine), liver function tests (bilirubin, AST, ALT, ALP), blood sugar (fasting and post‑prandial or random) to rule out or manage diabetes, viral markers (HIV, HBsAg, HCV), an electrocardiogram (ECG) for cardiac assessment, a chest X‑ray for pulmonary status, and urine analysis for infection or other abnormalities.

Step 19: Management (One Line for Viva)

Important Viva Question: How will you manage this case?

• For safe CSOM, say: “I will start with medical management: aural toilet, topical antibiotic ear drops, and ear protection from water. If the ear becomes dry and remains dry for 6 weeks, I will consider tympanoplasty for hearing improvement.”
• For unsafe CSOM, say: “This requires surgical management. I will perform a canal wall down mastoidectomy to completely eradicate the cholesteatoma and prevent complications. Medical management is only temporary to control acute infection.”

Background knowledge (detailed management): The management of CSOM depends primarily on its type (safe vs unsafe), activity, and the presence of complications. The goal is to achieve a safe, dry ear and, secondarily, to improve hearing.

Management of Tubotympanic (Safe) CSOM

We usually manage this type medically first. We consider surgery for persistent discharge or for hearing improvement.

Conservative or medical management:

1. Aural toilet: Regularly clean the ear canal and middle ear of discharge and debris using suction, cotton swabs, or dry mopping. This is fundamental for the efficacy of topical medication.
2. Systemic antibiotics: Prescribe these based on culture and sensitivity reports, especially during acute exacerbations or for persistent discharge. Common choices include quinolones (e.g., ciprofloxacin) because of their good penetration into middle ear fluid and activity against common pathogens like Pseudomonas.
3. Local (topical) antibiotics: Ear drops (e.g., ciprofloxacin or ofloxacin) are highly effective because they reach the site of infection directly. We often combine them with steroids (e.g., dexamethasone) to reduce inflammation.
4. Systemic antihistamines: Use these if there is associated allergic rhinitis or eustachian tube dysfunction.
5. Local decongestant nasal drops (e.g., xylometazoline) can help improve eustachian tube function, especially if there is associated rhinitis or sinusitis.
6. Protection of the ear from water: This is crucial advice for all CSOM patients. Advise patients to keep the ear dry and to avoid water entering the ear during bathing, swimming, or hair washing. They can use earplugs or cotton wool with petroleum jelly. Water introduces bacteria and can trigger acute exacerbations.

Surgical management: We consider surgery when medical management fails, for recurrent disease, or to improve hearing.

1. Tympanoplasty: The goal is to achieve a safe, dry, and stable ear by repairing the tympanic membrane perforation (myringoplasty) and, if necessary, reconstructing the ossicular chain (ossiculoplasty). The secondary aim is to improve hearing.
2. Types of tympanoplasty: Myringoplasty is the repair of the TM perforation using a graft (e.g., temporalis fascia or tragal perichondrium). Tympanoplasty type I is myringoplasty alone. Tympanoplasty types II to V involve ossicular chain reconstruction along with myringoplasty, depending on the extent of ossicular damage.
3. Timing: We usually perform surgery when the ear has been dry for at least 2 weeks.

Management of Atticoantral (Unsafe) CSOM

Unsafe CSOM, because of the presence of cholesteatoma and the high risk of complications, primarily requires surgical management. Medical treatment is only a temporary measure to control acute infection.

Conservative treatment: This is similar to safe CSOM. We use medical management with aural toilet and antibiotics to control acute exacerbations, but it is not curative for cholesteatoma.

Surgical management: Mastoid exploration under general anaesthesia.

Goal: To completely eradicate the disease (cholesteatoma and associated pathology) and to create a safe, dry ear, thereby preventing complications. Hearing improvement is a secondary goal.

Types of mastoidectomy:

1. Cortical mastoidectomy (Schwartze’s operation): This involves the removal of mastoid air cells while preserving the posterior and superior canal walls. We typically perform this in early cholesteatoma without extensive bone erosion, or for a mastoid abscess.
2. Canal wall up (CWU) mastoidectomy (intact canal wall mastoidectomy): This preserves the posterior and superior bony external auditory canal wall. It offers better hearing potential and avoids the creation of a mastoid cavity. However, it requires a “second‑look” surgery to check for residual cholesteatoma.
3. Canal wall down (CWD) mastoidectomy (radical or modified radical mastoidectomy): This involves removal of the posterior and superior bony external auditory canal wall, thereby exteriorising the mastoid cavity and middle ear space into a single common cavity with the external auditory canal. This creates a larger, self‑cleaning cavity, allowing for complete eradication of cholesteatoma and easier follow‑up. We typically perform this for extensive cholesteatoma or for complications. It often results in a larger mastoid cavity that may require lifelong maintenance.

—— End of the chapter ——

Common Viva Questions and How to Answer Them

• Q1: How do you differentiate between safe and unsafe CSOM on history alone? Answer: “On history alone, safe CSOM presents with profuse, mucoid, non-foul, intermittent discharge that relieves with medication. Unsafe CSOM presents with scanty, purulent, foul-smelling (fetid), continuous discharge that does not relieve with medication. Therefore, the smell and amount of discharge are the most differentiating features.”
• Q2: What is the significance of a positive fistula test? Answer: “A positive fistula test (vertigo or nystagmus on pressing the tragus) indicates a labyrinthine fistula, most commonly of the lateral semicircular canal. This occurs when cholesteatoma erodes the bony covering of the canal. It is a serious complication of unsafe CSOM and requires urgent surgical intervention.”
• Q3: Why does unsafe CSOM produce a foul smell? Answer: “In unsafe CSOM, cholesteatoma causes bone erosion. The eroded bone, along with accumulated keratin debris, becomes secondarily infected by anaerobic bacteria. These bacteria cause putrefaction of the bone and debris, which produces the characteristic foul or fetid odour.”
• Q4: What is paracusis Willisii? Is it seen in CSOM? Answer: “Paracusis Willisii is the phenomenon of hearing better in noisy surroundings. It is characteristic of conductive hearing loss in otosclerosis. However, it is NOT typically seen in CSOM. Therefore, if a patient with CSOM reports this symptom, I would reconsider my diagnosis.”
• Q5: How do you perform the three-finger test? Answer: “I stand behind the patient. I place my first finger on the mastoid tip, my second finger on the suprameatal triangle (Macewen’s triangle), and my third finger on the posterior wall of the external auditory canal. I then press gently. If the patient winces in pain, the test is positive for mastoiditis.”
• Q6: When do you order HRCT temporal bone in CSOM? Answer: “I order HRCT temporal bone in all cases of unsafe CSOM to assess the extent of cholesteatoma, ossicular erosion, and bony dehiscence of the facial canal or semicircular canals. I also order it in long-standing safe CSOM if I suspect complications, or before any major ear surgery to plan the approach.”
• Q7: What is the difference between canal wall up and canal wall down mastoidectomy? Answer: “Canal wall up mastoidectomy preserves the posterior bony canal wall. It offers better hearing potential but requires a second-look surgery for residual cholesteatoma. Canal wall down mastoidectomy removes the posterior canal wall, creating a common cavity. It allows complete disease removal but creates a larger cavity that requires lifelong maintenance.”
• Q8: What is the most important advice you give to a CSOM patient? Answer: “I advise the patient to keep the ear dry at all times. Water entry introduces bacteria from the environment into the middle ear, which triggers acute exacerbations. I advise using earplugs or cotton wool with petroleum jelly during bathing, swimming, or hair washing.”
• Q9: What is the most common organism in CSOM? Answer: “Pseudomonas aeruginosa is the most common organism isolated in CSOM, followed by Staphylococcus aureus and Proteus species.”
• Q10: What are the indications for tympanoplasty? Answer: “Indications for tympanoplasty include a persistent dry perforation for at least 6 weeks, failure of medical management, recurrent discharge, and the patient’s desire for hearing improvement.”

One-Minute Revision Summary

Read this 5 minutes before your exam.

• Safe CSOM: Central perforation, mucoid, profuse, non-foul, intermittent discharge → Medical → Tympanoplasty
• Unsafe CSOM: Marginal/attic perforation, purulent, scanty, foul (fetid), continuous discharge → Surgical → Mastoidectomy
• FEMALE mnemonic: Facial palsy, Extradural abscess, Mastoiditis, Abscess, Labyrinthitis, Excellent
• Three-finger test: Mastoid tip, suprameatal triangle, posterior EAC wall
• Paracusis willisii: Seen in otosclerosis, NOT in CSOM
• Positive fistula test: Labyrinthine fistula (lateral semicircular canal)
• Most common organism: Pseudomonas aeruginosa
• Diagnosis formula:Ear + type + activity + hearing loss + complications

High-Yield Points for Quick Revision

1. CSOM requires ear discharge for at least 2 weeks with a permanent TM perforation.
2. Safe CSOM has a central perforation and non‑foul mucoid discharge.
3. Unsafe CSOM has a marginal or attic perforation and foul‑smelling (fetid) discharge.
4. Cholesteatoma is the hallmark of unsafe CSOM and appears as pearly white flakes or a retraction pocket.
5. A positive fistula test (vertigo on pressure change) indicates a labyrinthine fistula, usually from unsafe CSOM.
6. Paracusis Willisii (better hearing in noise) is characteristic of otosclerosis, not CSOM.
7. The three‑finger test for mastoid tenderness presses over the mastoid tip, suprameatal triangle, and posterior EAC wall.
8. HRCT of the temporal bone is the imaging modality of choice for unsafe CSOM.
9. Cholesteatoma shows restricted diffusion on diffusion‑weighted MRI.
10. Tympanoplasty repairs the TM perforation and reconstructs the ossicular chain.
11. Canal wall down mastoidectomy creates a larger cavity but allows complete disease removal.
12. Always examine the better ear first in any ENT examination.
13. Aural toilet is fundamental to the medical management of all CSOM types.

Clinical-Based Questions (Practical Exam & Viva Scenarios)

Case Scenario 1: A 26‑year‑old Male with Right Ear Discharge and Hearing Loss

Patient details: A 26‑year‑old male, Mr Sanju Kumar, resident of Dwarka, New Delhi, Hindu by religion, and labourer by occupation, presents to the ENT OPD.

How to Present Your Case

Good morning, sir or madam. I am presenting the case of Mr. Sanju Kumar, a 26‑year‑old male, resident of Dwarka, New Delhi, Hindu by religion, and labourer by occupation. He presented to the ENT OPD with the following chief complaints.

Chief complaints (in chronological order):

• Right ear discharge for the last 5 years
• Decreased hearing in the right ear for the last 1 year

History of presenting illness (HOPI):

My patient was apparently well 5 years back when he developed discharge from the right ear, which was gradual in onset (D/D: sudden in onset: AOM, gradual in onset: CSOM), discharge was aggravated during URTI (Write any preceding events causing onset and treatment taken), relieved with medication. (D/D: safe CSOM usually gets relieved with medication, while Unsafe CSOM is usually not relieved with medication), the discharge is progressive in nature (D/D: progressive in CSOM, non-progressive in ASOM), discharge is intermittent (D/D: continuous/intermittent), discharge is mucopurulent type (D/D: watery in CSF otorrhoea, otitis externa; mucoid in CSOM safe type; mucopurulent in ASOM, CSOM with secondary infection; purulent in unsafe CSOM, malignant otitis externa), discharge is yellow in colour (D/D: white in mucoid/fungal infection; yellow in bacterial infection; green in pseudomonas infection), discharge is profuse in amount (D/D: profuse in safe type, scanty in unsafe type), discharge is non-foul smelling (D/D: non foul smelling in safe type, foul smelling in unsafe type) and discharge is not blood stained (D/D: non blood stained in CSOM safe type, blood stained in unsafe type usually because of the granulations present in the middle ear). Write aggravating/relieving factors, other accompanying complaints, and the treatment taken.

Note:

• Continuous/Intermittent discharge – Continuous is when discharge does not stop. Intermittent is when discharge stops, then recurs.
• Mucoid discharge is described by the patient as a sticky white type of discharge, Mucopurulent is described as a sticky yellowish type of discharge, and purulent is described as yellow, non-sticky, frank discharge.
• Profuse discharge is when it is coming out of the ear, and Scanty when it is not coming out of the ear and is seen only when the patient is cleaning the ear.
• Foul-smelling discharge is seen in unsafe CSOM (cholesteatoma), and it is due to the bone erosion and later on putrefaction of the bone.

Along with the discharge, patient also have complaints of decreased hearing from last 1 year which was gradual in onset (D/D: sudden in viral infections, ototoxic drugs, temporal bone fracture), more from right ear (D/D: unilateral in CSOM, Acoustic neuroma, herpes zoster oticus; bilateral in presbycusis, meniere’s disease, otosclerosis), progressive in nature (D/D: presbycusis, CSOM, meniere’s disease), first noticed while talking on the phone, not associated with discharge (imp : increase in hearing loss with discharge in active stage or flaring up of disease, decrease in hearing loss with discharge suggests ossicular disruption), no change in hearing in noisy environment (imp: otosclerosis patient hears better in noisy environment k/a paracusis willisi). Write aggravating/relieving factors, other accompanying complaints, and the treatment taken.

Negative History: There is no history of earache (Otitis externa, ASOM, mastoiditis), pain behind the ear (mastoiditis), vertigo (labyrinthitis), nausea (labyrinthitis), blurred vision, diplopia (petrositis), Fever (meningitis, mastoiditis, brain abscess, lateral sinus thrombophlebitis), headache (meningitis, brain abscess, lateral sinus thrombophlebitis), facial asymmetry (facial palsy).

(Negative history is taken to rule out any complications):

• Earache, swelling behind the ear, fever: To rule out Mastoiditis.
• Nausea, vomiting, vertigo: To rule out Labyrinthitis.
• Blurred vision, diplopia, retro-orbital pain, headache: To rule out Petrositis.
• Facial asymmetry: To rule out Facial palsy.
• Headache, Fever. To rule out an extradural abscess.
• Headache, Fever. To rule out a subdural abscess.
• Headache, high-grade fever, neck rigidity: To rule out Meningitis.
• Headache, fever, delirium, convulsions, projectile vomiting: To rule out a brain abscess.
• Headache, fever, neck rigidity, projectile vomiting: To rule out Lateral sinus thrombophlebitis.

Past history: There is no past history of tuberculosis, hypertension, thyroid disease, diabetes mellitus, coronary artery disease, liver or kidney disease, HIV/AIDS, any allergies, or bleeding disorders. He has no similar complaints in the past, no history of surgeries, accidents, radiations, or complications.

Drug history: There is no significant drug history. He is not taking any steroids, chemotherapy, insulin, antihypertensives, diuretics, MAO inhibitors, contraceptives, or hormone replacement therapy.

Personal history: The patient is a vegetarian by diet, with normal bladder and bowel habits. He has no history of smoking, tobacco chewing, or alcohol intake. He is a labourer by occupation, has a sedentary lifestyle, and is married.

Family history: There is no history of hearing loss in the family, which rules out otosclerosis. There is no history of consanguinity, which rules out congenital sensorineural hearing loss.

General physical examination:

The patient is sitting comfortably on a chair and is well oriented to time, place, and person. There is no pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, or oedema. Pulse is 88 beats per minute, with normal rhythm, normal volume, and symmetrical. There is no radio‑radial or radio‑femoral delay. Blood pressure is 110/70 mm Hg, taken in the left hand in a sitting position. Respiratory rate is 18 per minute.

Facial nerve examination (motor function):

The patient can raise his eyebrows, blow a whistle, close his eyes tightly, and blow out his cheeks symmetrically. Therefore, the facial nerve function is intact bilaterally.

Local examination of the ear (better ear first):

1. Preauricular area: No scar, no sinus, and no accessory tragus. Therefore, there is no evidence of a preauricular sinus, previous endomeatal tympanoplasty, or preauricular appendage.
2. Pinna: Normal in size and shape, with no anomalies. There is no microtia (small ear), macrotia (large ear), anotia (absent ear), bat ear (absence of antihelix), or prominent Darwin’s tubercle.
3. Postauricular area: No scar, no swelling, no fistula, and no erythema. Therefore, there is no evidence of a previous ear surgery scar, mastoiditis, or mastoid fistula.
4. External auditory canal (using bull’s eye lamp and head mirror): Without a speculum, I saw thick, profuse discharge. With a speculum, I see thick, profuse, purulent discharge.
5. Tympanic membrane (visualised after suction clearing the discharge): On the right side, a moderate central perforation is present, involving the anterosuperior and anteroinferior quadrants. The margins are smooth and regular. I see discharge in the middle ear. On the left side, a normal tympanic membrane is seen. The cone of light is present in the anteroinferior quadrant. Normal mobility is present. The shadow of the incudostapedial joint is seen in the posterosuperior quadrant.
6. Tragal sign: A positive tragal sign would suggest otitis externa.
7. Mastoid tenderness: Tenderness would suggest mastoiditis. I checked this using the three‑finger test over the mastoid tip, suprameatal triangle, and posterior wall of the external auditory canal.
8. Fistula test: A positive test would suggest a labyrinthine fistula or Hennebert’s sign. A negative test occurs in a normal ear or a “dead ear.”
9. Tuning fork tests (using 512 Hz tuning fork): The Rinne test is negative on the right ear and positive on the left ear. The Weber test lateralises to the right ear. Therefore, this indicates a right‑sided conductive hearing loss of moderate degree.

Diagnosis:

Right ear chronic suppurative otitis media, active safe (tubotympanic) type, with moderate conductive hearing loss, without any complications.

Investigations planned:

1. Examination under the microscope – to confirm the diagnosis and to assess ossicular chain mobility. I can also take a sample for culture sensitivity.
2. Ear discharge pus culture and sensitivity – to avoid antibiotic resistance.
3. Pure tone audiometry – to know the type and degree of hearing loss objectively.
4. X‑ray mastoid (Schuller’s and Towne’s views) – usually done in unsafe CSOM, but I can do it in long‑standing safe CSOM to assess mastoid pneumatisation, sigmoid sinus position, jugular bulb position, and tegmen position.
5. HRCT temporal bone – usually done in unsafe CSOM or in cases of complications. It provides good bony anatomy and demonstrates evidence of ossicular or bone erosion.
6. Basic routine investigations (blood, urine, viral markers, ECG) for pre‑anaesthetic check‑up fitness if I plan for surgery.

Management plan:

For tubotympanic (safe) type CSOM, I will start with conservative or medical management first.

Conservative management:

• Aural toilet – regular cleaning of the ear canal and middle ear.
• Systemic and local antibiotics – based on culture sensitivity.
• Systemic antihistamines – if there is an associated allergy.
• Local decongestant nasal drops – to improve eustachian tube function.
• Protection of the ear from water – strict advice to keep the ear dry.

Surgical management: If medical management fails or if the patient desires hearing improvement, I will consider tympanoplasty. The goal is to achieve a safe, dry ear, with a secondary aim of hearing improvement.

Thank you. 

NEET PG Style MCQs

1. Which of the following is the most characteristic feature distinguishing unsafe CSOM from safe CSOM? A) Profuse mucoid discharge B) Central tympanic membrane perforation C) Foul-smelling ear discharge D) Gradual onset of hearing loss
2. A 40-year-old male presents with recurrent ear discharge and progressive hearing loss. On examination, a posterosuperior retraction pocket with pearly white flakes is seen. Which investigation is most crucial for further evaluation of this patient? A) X-ray Mastoid (Schuller’s view) B) Pure Tone Audiometry C) High-Resolution CT Temporal Bone D) Ear Discharge Pus Culture & Sensitivity
3. The definitive management for Chronic Suppurative Otitis Media (CSOM) with cholesteatoma is: A) Long-term oral antibiotics B) Regular aural toilet and topical ear drops C) Mastoidectomy D) Tympanoplasty alone
4. A positive Rinne’s test indicates: A) Conductive hearing loss B) Sensorineural hearing loss or normal hearing C) Mixed hearing loss D) Tympanic membrane perforation
5. Which of the following symptoms, if present in a patient with CSOM, would raise immediate concern for an intracranial complication? A) Intermittent ear discharge B) Mild conductive hearing loss C) Persistent headache and projectile vomiting D) Non-foul-smelling discharge
6. The primary goal of tympanoplasty in safe CSOM is: A) To eradicate cholesteatoma B) To achieve a safe, dry ear with secondary hearing improvement C) To manage acute exacerbations of discharge D) To perform a radical mastoidectomy
7. Which tuning fork test finding is typically associated with a right-sided conductive hearing loss? A) Rinne’s negative on the right, Weber lateralizes to the left B) Rinne’s positive on the right, Weber lateralizes to the right C) Rinne’s negative on the right, Weber lateralizes to the right D) Rinne’s positive on the right, Weber lateralizes to the left
8. Which of the following describes a “scanty” ear discharge in CSOM? A) Discharge coming out of the ear freely B) Discharge seen only when the patient cleans the ear C) Mucoid, sticky discharge D) Profuse, watery discharge
9. Which anatomical structure is commonly eroded by cholesteatoma, leading to a positive fistula test? A) Tegmen tympani B) Posterior semicircular canal C) Lateral semicircular canal D) Facial nerve canal
10. In a patient with CSOM, what is the significance of the complaint “increased hearing loss with discharge”? A) Suggests ossicular discontinuity. B) Indicates active inflammation or flaring up of the disease. C) Points towards otosclerosis. D) Implies a resolving infection.

Answers to MCQs:

1. C) Foul-smelling ear discharge. Explanation: Foul-smelling discharge is a classic indicator of bone erosion and bacterial putrefaction associated with cholesteatoma, which is the hallmark of unsafe CSOM.
2. C) High-Resolution CT Temporal Bone. Explanation: The presence of a retraction pocket with pearly white flakes strongly suggests cholesteatoma. HRCT temporal bone is the imaging modality of choice for delineating bony erosion, assessing the extent of cholesteatoma, and identifying any complications.
3. C) Mastoidectomy. Explanation: Cholesteatoma has the potential for significant bone erosion and serious complications. Therefore, surgical removal of the cholesteatoma via mastoidectomy is the definitive treatment.
4. B) Sensorineural hearing loss or normal hearing. Explanation: A positive Rinne’s test means air conduction is better than bone conduction (AC > BC), which is normal. If there is sensorineural hearing loss, both AC and BC are reduced proportionally, maintaining AC > BC.
5. C) Persistent headache and projectile vomiting. Explanation: These are classical symptoms of increased intracranial pressure and meningeal irritation, highly suggestive of intracranial complications like brain abscess or meningitis, which are serious and require immediate intervention.
6. B) To achieve a safe, dry ear with secondary hearing improvement. Explanation: Tympanoplasty in safe CSOM aims primarily to close the perforation, thereby making the ear safe from recurrent infections and dry. Hearing improvement is an important secondary goal once the ear is stable.
7. C) Rinne’s negative on the right, Weber lateralizes to the right. Explanation: A negative Rinne’s test (BC > AC) on a specific side indicates conductive hearing loss on that side. Weber’s test lateralizes to the ear with conductive hearing loss (the “affected” ear), further confirming the conductive nature of the loss.
8. B) Discharge is seen only when the patient cleans the ear. Explanation: Scanty discharge means it’s not profusely draining out. It’s often found only upon active cleaning of the ear canal.
9. C) Lateral semicircular canal. Explanation: The lateral semicircular canal is the most common site for cholesteatoma erosion due to its anatomical proximity and thin bony wall, leading to the development of a labyrinthine fistula and a positive fistula test.
10. B) Indicates active inflammation or flaring up of the disease. Explanation: When CSOM is active and flaring up, the increased inflammation and discharge can temporarily worsen hearing due to more efficient obstruction of sound conduction through the middle ear. Conversely, a decrease in hearing loss with discharge might suggest ossicular discontinuity.

Frequently Asked Questions in Viva

1. What is the most important differentiating feature between safe and unsafe CSOM? The most important differentiating feature is the smell of the discharge. Safe CSOM produces non-foul discharge; unsafe CSOM produces foul-smelling (fetid) discharge due to bone erosion and putrefaction.
2. What does a positive fistula test indicate? A positive fistula test indicates a labyrinthine fistula, most commonly of the lateral semicircular canal, due to cholesteatoma erosion in unsafe CSOM.
3. Why do you examine the better ear first? Examining the better ear first gains the patient’s cooperation, reduces anxiety, and establishes a baseline for comparison.
4. What is the definitive treatment for unsafe CSOM with cholesteatoma? The definitive treatment is surgical mastoidectomy (canal wall up or canal wall down) to completely eradicate the cholesteatoma and prevent complications.
5. When do you perform tympanoplasty in safe CSOM? Perform tympanoplasty when the ear has been dry for at least 2 to 6 weeks, when medical management fails, for recurrent discharge, or to improve hearing.
6. What is the most common organism in CSOM? Pseudomonas aeruginosa is the most common organism isolated in CSOM.
7. What is paracusis Willisii? Paracusis Willisii is the phenomenon of hearing better in noisy surroundings. It is characteristic of otosclerosis and is NOT seen in CSOM.
8. What are the indications for HRCT temporal bone in CSOM? HRCT temporal bone is indicated in all cases of unsafe CSOM to assess cholesteatoma extent, ossicular erosion, and bony dehiscence. It is also indicated in long-standing safe CSOM with suspected complications.

—-End—-

Download the full PDF Link:

Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology Head and Neck Surgery.
• Glasscock-Shambaugh, Textbook of  Surgery of the Ear.
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck surgery.

Author:

Dr. Rahul Bagla MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi) Fellow Rhinoplasty & Facial Plastic Surgery. Renowned Teaching Faculty Mail: msrahulbagla@gmail.com India

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• Please read. Anatomy of External Ear. https://www.entlecture.com/anatomy-of-ear/
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