CSOM Long Case

Understanding Chronic Suppurative Otitis Media (CSOM) – An Overview.

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, 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 extracranial complications if not managed appropriately. Therefore, understanding CSOM comprehensively is paramount for all medical students and aspiring ENT specialists. This chapter provides a detailed, exam-focused approach to CSOM, covering history taking, examination, diagnosis, and management, along with high-yield points and practice questions.

Types of CSOM: (Read more link)

1. Tubotympanic (Safe) CSOM: This type remains localised to the mucosa of the anteroinferior part of the middle ear cleft, involving the eustachian tube and mesotympanum, and is associated with a central perforation. It is considered “safe” because it generally does not involve bone erosion and thus has a lower risk of serious complications. However, it can still cause significant hearing loss.
2. Atticoantral (Unsafe) CSOM: This more aggressive form involves the posterosuperior part of the middle ear cleft (attic, antrum, posterior tympanum, and mastoid). It involves the pars flaccida or posterior-superior quadrant of the pars tensa, often leading to a marginal or attic perforation. Atticoantral disease (AAD) is characterised by bone erosion caused by cholesteatoma, granulations, or osteitis. AAD type is often termed “unsafe” or “dangerous” due to its high risk of complications, including hearing loss, vestibular dysfunction, facial paralysis, and intracranial infections.

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.

Table: Differentiation between Safe and Unsafe CSOM

Feature	Tubotympanic (Safe) CSOM	Atticoantral (Unsafe) CSOM
Pathology	Mucosal disease, inflammation of mucoperiosteum	Cholesteatoma (epidermal cyst), bone erosion, granulations
Perforation	Central	Marginal, attic (pars flaccida)
Discharge	Mucoid/mucopurulent, non-foul smelling, profuse, intermittent	Purulent, foul smelling (fetid), scanty, often continuous
Hearing Loss	Conductive (often mild to moderate)	Conductive (often moderate to severe), mixed if labyrinth involved
Ossicular Chain	Intact or partially eroded	Often eroded, especially long process of incus and stapes suprastructure
Granulations/Polyps	Less common, usually indicate secondary infection	Common, often indicative of cholesteatoma
Complications	Less common, mainly hearing loss, occasional facial palsy	Very common, high risk of intracranial and extracranial complications
Treatment	Primarily medical, surgery (tympanoplasty) for chronic cases/hearing improvement	Primarily surgical (mastoidectomy) to eradicate disease and prevent complications

Basic Scheme of History Taking of CSOM Long Case

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

 1. Personal Particulars

• Significance of Name: Essential for patient identification, maintaining records, and forming a rapport with the patient.
• Significance of Age: Certain diseases are more commonly found in certain age groups; therefore, it is useful to make a differential diagnosis. For instance, Younger age: AOM, Foreign Bodies, Epistaxis due to nose picking. Adolescent age: JNA; Older age: Presbycusis, carcinomas.
• Significance of Sex: Some conditions have a gender predilection; therefore useful to make a differential diagnosis. For example, otosclerosis is more common in females, whereas juvenile nasopharyngeal angiofibroma (JNA) primarily affects males.
• Significance of Religion: Relevant for understanding dietary habits or cultural practices that might influence health or treatment choices (e.g., consanguineous marriages increasing the risk of congenital sensorineural hearing loss).
• Significance of Occupation: Certain diseases are more commonly found in certain occupations. Noise-induced hearing loss is found more commonly in construction workers and workplaces with loud noises. Vocal nodules due to voice abuse are more commonly found in professions such as teaching, singing, and hawking.
• Significance of Address: Geographic location can sometimes correlate with certain endemic diseases, such as rhinosporidiosis is more common in Jharkhand, Chhattisgarh, Madhya Pradesh and West Bengal.

2. Chief Complaints with Duration: Chief complaints should be in chronological order, i.e. the complaints that came first will be written first. This approach helps in understanding the progression of the disease.

Example:

• Right ear discharge for 5 years
• Decreased hearing for 1 year

3. History of Present Illness (HPI): This is the most critical part of the history, detailing the evolution of each chief complaint. Elicit precise characteristics of each symptom to differentiate between types of CSOM and potential complications.

A. Ear Discharge (Otorrhea): Inquire about the following characteristics:

• Onset: Gradual: CSOM; Sudden: AOM or a ruptured tympanic membrane from trauma.
• Duration: Acute – <3 weeks; Subacute – >3 weeks to <3 months; Chronic >3 months.
• Progression: Progressive in CSOM; Non-progressive in ASOM
• Nature/Consistency: Watery: CSF otorrhoea or otitis externa; Mucoid/Sticky white: Safe CSOM; Mucopurulent/Sticky yellowish: AOM or safe CSOM with secondary infection; Purulent/Yellow, non-sticky frank discharge: Unsafe CSOM or malignant otitis externa; Cheesy/Foul-smelling: Highly suggestive of cholesteatoma (unsafe CSOM).
• Colour: White: Fungal infection; Yellow: Bacterial infection; Green: Pseudomonas infection; Blood-stained: Granulation tissue or polyps, often seen in unsafe CSOM, or trauma.
• Amount: Profuse: Safe CSOM, when it is coming out of the ear; Scanty: Unsafe CSOM, where drainage might be obstructed by cholesteatoma or granulations, or when discharge is seen only upon cleaning the ear.
• Smell: Non-foul smelling: Safe CSOM; Foul-smelling (fetid/putrid): A hallmark of unsafe CSOM (cholesteatoma) due to bone erosion and later on putrifaction of the bone. This is a very significant differentiating factor.
• Aggravating/Relieving Factors: Aggravated by URTI: Common in CSOM, as infection can spread from the nasopharynx via the Eustachian tube; Relieved with medication: Safe CSOM usually gets relieved with medication, while Unsafe CSOM is usually not relieved with medication
• Associated Symptoms: Any preceding events, trauma, or treatment taken for the discharge.

B. Decreased Hearing (Hearing Loss): A detailed inquiry into hearing loss is crucial for assessing its type, degree, and impact on the patient’s life.

• Onset: Gradual: Common in CSOM, presbycusis, or otosclerosis; Sudden: May indicate viral infection, ototoxic drug exposure, or temporal bone fracture.
• Duration: How long has the patient noticed a hearing impairment?
• Progression: Is the hearing loss progressive (e.g., CSOM, presbycusis, Meniere’s disease)?
• Unilateral/Bilateral: Unilateral: Suggests CSOM, acoustic neuroma, or herpes zoster oticus; Bilateral: Points towards presbycusis, Meniere’s disease, or otosclerosis.
• Effect of Discharge: Increased hearing loss with discharge: Indicates active inflammation or flaring up of the disease; Decreased hearing loss with discharge: Suggests ossicular discontinuity, where the discharge might act as a conductive medium, improving sound transmission. This is an important historical clue.
• Paracusis Willisii: Does the patient hear better in noisy environments? This is a classic symptom of otosclerosis, where competing background noise makes the speaker raise their voice, effectively improving the patient’s hearing. This is not typically seen in CSOM.
• Aggravating/Relieving Factors: Any factors that seem to worsen or improve hearing.
• Impact on Daily Life: How does the hearing loss affect communication, work, and social interactions

4. Negative History: This section is vital for ruling out potential complications of CSOM. Always ask specifically about symptoms that might indicate intracranial or extracranial spread of infection. This is a high-yield area for viva questions.

• Earache/Otalgia: To rule out acute otitis externa, AOM, or mastoiditis.
• Pain behind the ear/Postauricular pain: To rule out mastoiditis.
• Vertigo/Dizziness: To rule out labyrinthitis
• Nausea/Vomiting: Can be associated with labyrinthitis or more severe intracranial complications.
• Blurred vision/Diplopia/Retro-orbital pain: To rule out Petrositis (Gradenigo’s syndrome).
• Fever: Indicates active infection, potentially suggesting mastoiditis, meningitis, brain abscess, or lateral sinus thrombophlebitis.
• Headache: To rule out meningitis, brain abscess, or lateral sinus thrombophlebitis.
• Facial asymmetry/Weakness: To rule out Facial palsy.
• Neck rigidity: Rules out meningitis.
• Delirium, convulsions, projectile vomiting: Highly concerning for brain abscess.

Mnemonics for Negative History (Complications):

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

5. Past History: 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/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/Kidney disease, HIV/AIDS, any known allergies, or bleeding disorders. These conditions can impact healing, immune response, and suitability for surgery.

6. Drug History: Document all medications the patient is currently taking or has recently taken. This includes:

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

7. Personal History: Provides insight into lifestyle and social factors impacting health.

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

8. Family History: Genetic predispositions or infectious diseases within the family can be relevant.

• 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/Autoimmune disorders: Some have familial tendencies.
• Infectious diseases: Tuberculosis, mumps, diphtheria, and STDs can affect multiple family members.

 

Clinical Examination in CSOM

 1. General Physical Examination: Note if the patient is comfortable, well-oriented to time, place, and person. Check vitals (Pulse, BP, Respiratory Rate). Look for pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, and oedema.

Facial Nerve Examination (Motor Function): Assess the integrity of the facial nerve (Cranial Nerve VII) as it is susceptible to damage in CSOM, especially with cholesteatoma. Test both sides symmetrically:

• Raising eyebrows: Frontalis muscle.
• Closing eyes tightly: Orbicularis oculi.
• Blowing out cheeks: Orbicularis oris and buccinator.
• Blowing whistle: Orbicularis oris.
• Showing teeth/Grimacing: Zygomaticus major/minor, levator labii superioris.

2. Local Examination of the Ear: Always offer to examine the better ear first to gain the patient’s cooperation and establish a baseline.

 Inspection:

• Preauricular Area: Look for scars (e.g., post-endomeatal tympanoplasty), sinuses (preauricular sinus), or accessory tragus (due to improper fusion of Hillocks of His).
• Pinna (Auricle) Size and Shape: Normal, or anomalies like microtia (small), macrotia (large), anotia (absent), or prominent Darwin’s tubercle. Bat ear due to the absence of the antihelix.
• Postauricular Area: Inspect for scars (e.g., mastoidectomy scar), swelling (mastoiditis, postauricular abscess), erythema, or fistula.
• External Auditory Canal (EAC):
  • Without speculum (using Bull’s eye lamp/head mirror): Observe any obvious discharge, its character (thick, profuse, purulent), or foreign bodies.
  • With speculum: Note the discharge character more precisely.

 3. Otoscopy (Visualisation of Tympanic Membrane – TM): This is a crucial step. Always suction clear any discharge to visualise the TM properly. Always draw a diagram of both TM.

Tympanic Membrane (TM):

• Perforation:
  • Site: Central (safe CSOM), marginal (unsafe), attic (unsafe).
  • Size: Small, moderate, large, subtotal.
  • Shape: Irregular, kidney-shaped.
  • Margins: Smooth, regular, inverted, everted.
  • Involving Quadrants: Note which quadrants are involved (e.g., anterosuperior, anteroinferior).
• Middle Ear Mucosa: Observe if it is inflamed, pale, or shows granulations or polyps.
• Ossicles: Can the ossicular chain (malleus, incus, stapes) be visualised? Is there any evidence of ossicular erosion?
• Discharge: Note its presence and character within the middle ear.
• Cholesteatoma: Look for pearly white flakes, keratin debris, or a retraction pocket in the attic or posterosuperior quadrant. This is a definitive sign of unsafe CSOM.

Contralateral Ear: Always examine the opposite ear for comparison, noting its TM appearance (e.g., cone of light, normal mobility, shadow of the incudostapedial joint).

 4. Palpation and Special Tests:

• Tragal Sign: Pain upon pressing the tragus. Positive in otitis externa, usually absent in CSOM.
• Mastoid Tenderness: Tenderness over the mastoid process. Positive for mastoiditis. Perform the three-finger test: press over the mastoid tip, suprameatal triangle (Macewen’s triangle), and along the posterior wall of the external auditory canal.
• Fistula Test: Pressing the tragus or using a Siegle’s speculum to create pressure changes in the EAC.
  • Positive: Induces vertigo, nystagmus, or a sense of falling, indicating a labyrinthine fistula (often due to bone erosion by cholesteatoma). This is a very significant sign of a complicated, unsafe CSOM.
  • Negative: Normal ears or “dead ears” (where the labyrinth is non-functional) will show no response.

5. Tuning Fork Tests: (Read more link). Tuning fork tests (using a 512 Hz tuning fork) are essential for quickly assessing the type and approximate degree of hearing loss.

6. Vestibular Function Tests:  While not always indicative of labyrinthine involvement in all CSOM cases, these tests help rule out vestibular complications, especially in unsafe CSOM. 

Diagnosis of CSOM

Based on the comprehensive history and examination findings, a precise diagnosis can be formulated.

Example of Diagnosis: Right ear Chronic Suppurative Otitis Media, Active Safe Type, with moderate conductive hearing loss, without any complications.

Key Elements of Diagnosis:

• Ear Involved: Specify right or left ear.
• Type of CSOM:
  • Safe (Tubotympanic): Indicated by central perforation, mucoid/mucopurulent non-foul-smelling discharge, and absence of bone erosion signs.
  • Unsafe (Atticoantral): Indicated by marginal/attic perforation, foul-smelling discharge, presence of cholesteatoma (pearly white flakes/retraction pocket), granulation tissue, or polyps.
• Activity:
  • Active: Presence of current ear discharge.
  • Inactive/Quiescent: No discharge for at least 6 months, but a perforation is present.
• Hearing Loss: Specify type (conductive, sensorineural, mixed) and degree (mild, moderate, severe, profound) based on tuning fork tests and later confirmed by audiometry.
• Complications: Explicitly state if any intracranial or extracranial complications are present or ruled out. For example, “with facial palsy” or “without any complications.”

 

Investigations for CSOM

Investigations are crucial for confirming the diagnosis, assessing the extent of the disease, and planning management, especially surgical interventions.

Ear-Specific Investigations:

1. Examination Under Operating Microscope (EUM): Provides a magnified view of the external ear canal and tympanic membrane. It allows confirmation of the otoscopic findings by precise assessment of the perforation, middle ear mucosa, ossicular chain, and detection of 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): Identifies the causative bacteria (common organisms: Pseudomonas aeruginosa, Staphylococcus aureus, Proteus species) and determines their sensitivity to various antibiotics. This helps in guiding appropriate antimicrobial therapy and preventing 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.
   • Type of hearing loss: Conductive, sensorineural, or mixed.
   • Degree of hearing loss: Mild, moderate, moderately severe, severe, profound.
   • Configuration of hearing loss: Specific pattern across frequencies.
   • Importance: Guides management, especially surgical planning for hearing improvement.

4. Impedance Audiometry (Tympanometry and Acoustic Reflexes): Evaluates the middle ear function, tympanic membrane mobility, and Eustachian tube function.
   • Tympanometry: In CSOM with perforation, a flat tympanogram (Type B) with large ear canal volume is expected.
   • Acoustic Reflexes: Absent in conductive hearing loss.
5. X-ray Mastoid (Schuller’s and Towne’s Views): Primarily done in unsafe CSOM or long-standing safe CSOM to assess mastoid pneumatization.
   • Schuller’s View: Shows the mastoid air cell system, tegmen mastoideum (roof of mastoid), sigmoid sinus plate, and temporomandibular joint. Useful for assessing pneumatization of air cells, extent of disease, low lying dura and anteposed sigmoid sinus.
   • Towne’s View: Best for visualising the petrous apex and internal auditory canal.
   • Findings in CSOM: May show sclerotic mastoid (poor pneumatization) or haziness due to inflammation/pus.
6. High-Resolution Computed Tomography (HRCT) Temporal Bone: The imaging modality of choice for CSOM, particularly in unsafe CSOM or suspected complications. It provides excellent bony detail.

• • Detailed anatomy of the middle ear and mastoid.
  • Evidence of ossicular erosion, bony dehiscence (e.g., facial canal, lateral semicircular canal).
  • Presence and extent of cholesteatoma, granulations, or fluid.
  • Evaluation of the integrity of the tegmen tympani and mastoideum (to rule out intracranial extension).

7. Magnetic Resonance Imaging (MRI): Useful 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, lateral sinus thrombophlebitis).
   • Evaluating the extent of intralabyrinthine spread.
   • Diffusion-weighted imaging (DWI) sequence: Highly sensitive for detecting residual or recurrent cholesteatoma, as cholesteatoma shows restricted diffusion.

2. Basic Routine Investigations (Pre-Operative):

• Complete Blood Count (CBC): Check for anaemia, leukocytosis (infection).
• Blood Grouping and Cross-matching.
• Renal Function Tests (RFTs): Urea, Creatinine.
• Liver Function Tests (LFTs): Bilirubin, AST, ALT, ALP.
• Blood Sugar (Fasting and Post-prandial/Random): To rule out or manage diabetes.
• Viral Markers: HIV, HBsAg, HCV.
• Electrocardiogram (ECG): For cardiac assessment.
• Chest X-ray: For pulmonary status.
• Urine Analysis: For infection or other abnormalities.

 

Management of CSOM

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

Management of Tubotympanic (Safe) CSOM:

This type is usually managed medically first, with surgery considered for persistent discharge or hearing improvement.

1. Conservative / Medical Management:

• Aural Toilet: Regular cleaning of the ear canal and middle ear of discharge and debris using suction, cotton swabs, or dry mopping. This is fundamental for topical medication efficacy.
• Systemic Antibiotics: Prescribed based on culture and sensitivity reports, especially during acute exacerbations or persistent discharge. Common choices include quinolones (e.g., ciprofloxacin) due to their good penetration into middle ear fluid and activity against common pathogens like Pseudomonas.
• Local (Topical) Antibiotics: Ear drops (e.g., ciprofloxacin, ofloxacin) are highly effective in reaching the site of infection directly. They are often combined with steroids (e.g., dexamethasone) to reduce inflammation.
• Systemic Antihistamines: May be used if there’s associated allergic rhinitis or Eustachian tube dysfunction.
• Local Decongestant Nasal Drops: (e.g., xylometazoline) Can help improve Eustachian tube function, especially if there’s associated rhinitis or sinusitis.
• Protection of the Ear from Water: Crucial advice for all CSOM patients. Patients should keep the ear dry and avoid water entering the ear during bathing, swimming, or hair washing (e.g., by using earplugs or cotton wool with petroleum jelly). Water introduces bacteria and can trigger acute exacerbations.

2. Surgical Management. Surgery is considered when medical management fails, for recurrent disease, or to improve hearing.

Tympanoplasty:

• Goal: 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.

Types:

• Myringoplasty: Repair of the TM perforation using a graft (e.g., temporalis fascia, tragal perichondrium).
• Tympanoplasty Type I: Myringoplasty alone.
• Tympanoplasty Type II-V: Involve ossicular chain reconstruction along with myringoplasty, depending on the extent of ossicular damage.

• Timing: Usually performed when the ear has been dry for at least 2 weeks.

2. Management of Atticoantral (Unsafe) CSOM:

Unsafe CSOM, due to 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: Similar to safe CSOM, medical management with aural toilet and antibiotics can be used 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 create a safe, dry ear, and prevent complications. Hearing improvement is a secondary goal.

Types of Mastoidectomy:

• Cortical Mastoidectomy (Schwartze’s Operation): Removal of mastoid air cells but preserving the posterior and superior canal walls. Typically performed in early cholesteatoma without extensive bone erosion, or for mastoid abscess.
• Canal Wall Up (CWU) Mastoidectomy (Intact Canal Wall Mastoidectomy): Preserves the posterior and superior bony external auditory canal wall. Offers better hearing potential and avoids the creation of a mastoid cavity. However, it requires a “second look” surgery to check for residual cholesteatoma.
• Canal Wall Down (CWD) Mastoidectomy (Radical Mastoidectomy, Modified Radical Mastoidectomy): 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. It is typically performed for extensive cholesteatoma or complications. It often results in a larger mastoid cavity that may require lifelong maintenance.

—— End of the chapter ——

High-Yield Points for Quick Revision

These points are frequently tested in NEET PG MCQs and university exams.

• The most common cause of foul-smelling ear discharge in CSOM: Cholesteatoma (due to bone erosion and bacterial putrefaction).
• Hallmark of unsafe CSOM:
• The most common complication of CSOM: Hearing loss (conductive).
• Gold standard for assessing hearing loss: Pure Tone Audiometry (PTA).
• Investigation of choice for bony anatomy and cholesteatoma: HRCT Temporal Bone.
• Investigation of choice for intracranial complications or recurrent cholesteatoma: MRI with Diffusion-Weighted Imaging (DWI).
• Fistula test positive in: Labyrinthine fistula (often due to cholesteatoma eroding the lateral semicircular canal).
• Management of safe CSOM: Medical (aural toilet, antibiotics), then Tympanoplasty.
• Management of unsafe CSOM: Primarily surgical (Mastoidectomy).
• Purpose of mastoidectomy: To create a safe, dry ear by eradicating disease and preventing complications.
• Most common bacteria in CSOM: Pseudomonas aeruginosa and Staphylococcus aureus.
• Paracusis Willisii: Better hearing in noisy environments, seen in Otosclerosis, NOT typically in CSOM.
• Negative Rinne’s and Weber lateralizing to affected ear: Classic for conductive hearing loss.
• “Second look” surgery is often required in: Canal Wall Up (CWU) Mastoidectomy to check for residual cholesteatoma.
• Signs of complications requiring immediate attention: Facial asymmetry, severe headache, vertigo, fever, neck rigidity.

 

Clinical-Based Questions (Practical Exam & Viva Scenarios)

These scenarios simulate questions you might encounter in your practical exams and viva sessions.

Case Scenario 1: A 26-year-old male, Name – Sanju Kumar, presented to the ENT OPD with complaints of right ear discharge for the last 5 years and Rt side decreased hearing for the last 1 year.

HOW TO PRESENT YOUR CASE

Good Morning, sir/ Madam. I am presenting the case of Mr. Sanju Kumar, 26 year old male resident of Dwarka, New Delhi, Hindu by religion and labourer by occupation. Presented to the ENT OPD with the

Chief complaints of :

• Right ear discharge for 5 years
• Decreased hearing for 1 year

Chief complaints should be in chronological order, i.e. the complaints that came first will be written first.

History of presenting illness:

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 Extradural abscess.
• Headache, Fever. To rule out Subdural abscess.
• Headache, high grade fever, neck rigidity: To rule out Meningitis.
• Headache, fever, delirium, convulsions, projectile vomiting: To rule out Brain abscess.
• Headache, fever, neck rigidity, projectile vomiting: To rule out Lateral sinus thrombophlebitis.

Past History: There is no past history of TB, Hypertension, thyroid disease, diabetes mellitus, coronary artery disease, liver or kidney disease, tuberculosis, HIV/AIDS any allergies or bleeding disorder.

Note: Past history includes similar complaints in the past and the treatment taken and history of surgeries accidents, radiations and complications. All the diseases suffered by the patient in past whether seemingly relevant/ irrelevant should be recorded in a chronological order.

Drug History: No significant drug history.

Note: Drug history includes all the drugs that the patient was/is taking such as steroids, chemotherapy, insulin, antihypertensive, diuretics, monoamine oxidase (MAO) inhibitors, contraceptives and hormone replacement therapy.

Personal history: Patient is a vegetarian by diet, with normal bladder and bowel habits. No history of smoking, tobacco chewing or alcohol intake.

Note: Personal history includes the patient’s occupation, personal habits (smoking, alcohol and chewing of Paan, Supari and tobacco), food habits (vegetarian/non-vegetarian, regular/irregular, spicy food), lifestyle (exercise or sedentary), and marital status. In women’s menstrual history and number of pregnancies and miscarriages should be recorded.

Family history: There is no history of hearing loss in the family (otosclerosis), no history of consanguinity (congenital SNHL).

Note: It is important as many ENT diseases run in families and have genetic basis such as otospongiosis, certain types of sensorineural hearing loss, malignancies and autoimmune disorders. Infectious diseases such as STD, tuberculosis, mumps, pediculosis, scabies and diphtheria can affect other family members.

Examination:

General physical examination: Patient is sitting comfortably on a chair and well oriented to time place, and person. There is no pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy and oedema. Pulse: 88 beats per min, normal rhythm, volume, symmetrical, no radio radial or radio femoral delay. BP: 110/70 mm Hg taken in left hand sitting position. Respiratory Rate: 18/min.

Facial Nerve Examination (motor function): Raising the eyebrows, blowing a whistle, closing the eyes, and blowing cheeks.

Local examination: Unless instructed otherwise, offer to examine the better ear first.

Ear: Right/Left

• Preauricular area: no scar, no sinus, no accessory tragus. (D/D: Preauricular sinus, endomeatal tympanoplasty, preauricular appendage/extra tragus due to improper fusion of Hillocks of His)
• Pinna: normal in size and shape, no anomalies. (D/D: small: microtia, large: macrotia, absent: anotia, congenital anomalies: bat ear d/t absence of antihelix, prominent Darwin tubercle)
• Post auricular area: No scar, no swelling, no fistula, no erythema. (D/D: previous ear surgery scar, mastoiditis, mastoid fistula)
• External auditory canal: Using Bull’s eye lamp and Head mirror. (Without speculum): Thick, profuse discharge (with speculum): Thick, profuse, purulent discharge.
• Tympanic Membrane: Visualised after suction clearing the discharge (D/D: draw a diagram of both TM). (Right) moderate central perforation present involving anterosuperior and anteroinferior quadrants, smooth and regular margins, discharge seen in the middle ear. (Left) Normal tympanic membrane seen, cone of light present in the anteroinferior compartment, normal mobility, shadow of the IS joint seen in the posterior superior quadrant
• Tragal sign:Absent (D/D: Positive in otitis externa)
• Mastoid tenderness: Absent  (D/D: Positive in mastoiditis, checked by three finger test)
• Fistula test: Absent (D/D: Positive in laby fistula, Hennebert’s sign, Negative in normal ear or dead ear)
• Examination of Facial Nerve: Facial nerve function is intact bilaterally

Tuning Fork Test: (D/D: Done to know the type and degree of hearing loss) done with 512 Hz tuning fork.

Vestibular function tests.

Diagnosis:

Right ear chronic suppurative otitis media active safe type with mild/ moderate/ Severe conductive hearing loss without any complications. (Write the complication if it is there).

Investigations:

1. Examination under the microscope. To confirm the diagnosis and to assess the ossicular chain mobility. We can also take a sample for culture sensitivity.
2. Ear discharge, pus culture and sensitivity. To avoid resistance to antibiotics
3. Pure tone audiogram. (To know the type and degree of hearing loss)
4. X-ray mastoid. – Schuller’s and Towne’s view (Note: Usually done in Unsafe CSOM. But it can be done in safe also if the disease is long-standing). It is done to see the degree of mastoid pneumatisation, Sigmoid sinus position, Jugular bulb position, and Tegmen position.
5. HRCT temporal bone. Usually done in cases of unsafe CSOM, or in cases of any complication. It provides good bony anatomy and demonstrates evidence of ossicular or bone erosion.
6. (Note: It can be done in unsafe CSOM having recurrent cholesteatoma, recidivism)
7. Basic routine investigations(Blood, Urine, Viral markers, ECG) for Pre Anaesthetic Check-up fitness if the patient is planned for surgery.

 Management :

Tubotympanic (safe) type :

• Conservative / Medical: Aural toilet, Systemic and local antibiotics, Systemic antihistamines, Local decongestant nasal drops, Protection of ear from water.
• Surgical: Tympanoplasty (Goal is to achieve a safe, dry ear, with a secondary aim of hearing improvement)

Note: Management of Atticoantral (unsafe) type: Conservative treatment as the safe type, but the main treatment of the unsafe type remains to be surgery.

• Mastoidectomy
• Canal wall up mastoidectomy
• Canal wall down mastoidectomy

 

Scenario 2: A 35-year-old male presents with a 7-year history of left ear discharge that is scanty, foul-smelling, and associated with gradually progressive hearing loss. He occasionally experiences dizziness, especially when cleaning his ear vigorously. On examination, a posterosuperior perforation with pearly white flakes is noted.

Q1: What is your most probable diagnosis based on the history and examination findings? Justify your answer.

A1: The most probable diagnosis is Left ear Chronic Suppurative Otitis Media, Atticoantral (Unsafe) Type, with cholesteatoma and possible labyrinthine fistula.

Justification:

1. Chronic discharge and progressive hearing loss: Point towards CSOM.
2. Scanty, foul-smelling discharge, posterosuperior perforation, pearly white flakes: Classic features of cholesteatoma, indicating unsafe CSOM.
3. Dizziness when cleaning the ear (pressure changes): Highly suggestive of a positive fistula test, indicating labyrinthine involvement, most likely a fistula in the lateral semicircular canal due to cholesteatoma erosion.

Q2: What specific investigations would you order for this patient, and what do you expect to find?

A2:

1. High-Resolution CT Temporal Bone: This is crucial to delineate the extent of cholesteatoma, assess ossicular erosion, and look for any dehiscence (e.g., labyrinthine fistula). I would expect to see soft tissue density in the middle ear and mastoid, ossicular erosion, and possibly a defect in the bony labyrinth.
2. Pure Tone Audiometry: To quantify the degree and type of hearing loss (likely mixed or conductive, but inner ear involvement from fistula can lead to sensorineural component).
3. Ear Discharge Pus Culture & Sensitivity: To identify the causative organism for targeted antibiotic therapy, though surgery is primary.

Q3: What is the definitive management for this patient?

A3: The definitive management for this patient is surgical intervention, specifically a mastoidectomy, given the clear signs of cholesteatoma and suspected labyrinthine fistula. The choice between Canal Wall Up (CWU) or Canal Wall Down (CWD) mastoidectomy would depend on the extent of the disease and the surgeon’s preference, but a CWD approach might be favoured due to the extensive nature and suspected complications. The primary goal is to eradicate the cholesteatoma and secure a safe, dry ear.

Scenario 3: A 10-year-old boy presents with intermittent, mucoid, non-foul-smelling discharge from his right ear for 3 years, exacerbated by common colds. His mother also notes mild hearing difficulty. On examination, a central perforation is seen in the right tympanic membrane, and the rest of the ENT examination is unremarkable.

Q1: What is your provisional diagnosis?

A1: The provisional diagnosis is Right ear Chronic Suppurative Otitis Media, Active Tubotympanic (Safe) Type, with mild conductive hearing loss.

Q2: Outline your initial management plan for this patient.

A2: My initial management would be conservative/medical:

1. Aural Toilet: Thorough cleaning of the ear canal and middle ear.
2. Topical Antibiotic-Steroid Ear Drops: Such as Ciprofloxacin-Dexamethasone ear drops, for 1-2 weeks.
3. Systemic Antibiotics: If there are signs of acute infection or systemic symptoms, based on sensitivity, if culture is done.
4. Protection of Ear from Water: Strict instructions to avoid water entry into the ear (e.g., using cotton wool with Vaseline during bathing).
5. Referral for Pure Tone Audiometry: To objectively assess the degree of hearing loss.
6. Eustachian Tube Function Assessment/Management: Address any underlying nasal allergy or adenoid hypertrophy if present.
7. Follow-up: Re-evaluate after a course of medical management. If the ear becomes dry and remains dry for 3-6 months, surgical intervention (Tympanoplasty/Myringoplasty) can be considered to close the perforation and improve hearing.

NEET PG Style MCQs

These multiple-choice questions are designed to test your understanding of high-yield concepts for NEET PG 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

• Q: What is Chronic Suppurative Otitis Media (CSOM)? A: CSOM is a persistent infection of the middle ear and mastoid characterised by recurrent ear discharge through a perforated eardrum.
• Q: What are the two main types of CSOM? A: The two main types are Tubotympanic (Safe), typically with a central perforation, and Atticoantral (Unsafe), often with a marginal or attic perforation and associated cholesteatoma.
• Q: What is cholesteatoma, and why is it dangerous? A: Cholesteatoma is a skin-like cyst that grows in the middle ear and mastoid; it is dangerous because it can erode bone, leading to hearing loss, dizziness, facial palsy, and serious intracranial complications.
• Q: How is CSOM diagnosed? A: Diagnosis involves a detailed patient history, thorough ear examination (otoscopy), tuning fork tests, andis  often confirmed by Pure Tone Audiometry and High-Resolution CT Temporal Bone imaging.
• Q: What is the primary treatment for unsafe CSOM? A: The primary treatment for unsafe CSOM, especially with cholesteatoma, is surgical intervention, typically a mastoidectomy, to remove the disease and prevent complications.

—-End—-

Download the full PDF Link:

How to present CSOM Long Case Best Lecture Notes Dr Rahul Bagla ENT Textbook

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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