Chronic suppurative otitis media (CSOM) is the commonest form of chronic otitis media. Clinically it is characterized by otorrhoea and conduction hearing loss of variable severity. Otoscopy reveals a perforated eardrum. The condition is classified into the safe (tubotympanic) and unsafe (atti-coantral) variety depending on the likelihood of coexisting cholesteatoma.
The safe variety is CSOM without cholesteatoma. It can be further classified into active or inactive depending on whether there is infection or not. Safe inactive CSOM can be managed
either conservatively or surgically. Safe active CSOM should be treated initially conservatively to control the infection. A tympanoplasty procedure should then be performed to prevent recurrent infection.
The unsafe variety is CSOM with cholesteatoma (Fig. 20.4). The presence of cholesteatoma is usually obvious on otoscopy. Occasionally, cholesteatoma may be more difficult to diagnose. If otoscopy reveals granulation tissue, aural polyps or middle ear infection that is resistant to conservative treatment, cholesteatoma should be excluded. Traditionally, in the presence of a marginal perforation or a deep retraction pocket, CSOM is considered potentially unsafe. However with modern endoscopic equipment and CT, assessment of the middle ear becomes much more accurate than before. Diagnostic uncertainty occurs only rarely. The treatment of unsafe simple chronic otitis media (SCOM) is surgical as cholesteatoma can cause serious complications that may be fatal. The type of surgical procedure to employ is controversial. The classical radical mastoidectomy, modified radical mastoidectomy or the 'combined approach tympanoplasty' may be chosen depending on the extent of cholesteatoma and more importantly on the experience of the surgeon. Whatever the procedure chosen, the aim of the surgery is to remove all the disease and to give the patient a safe, dry and functioning ear.
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