ISSN: 2320-5407 Int. J. Adv. Res.

11(04), 1082-1086

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/16763

DOI URL: http://dx.doi.org/10.21474/IJAR01/16763

RESEARCH ARTICLE
ENDOSCOPIC TYMPANOMASTOIDECTOMY IN ATTICO-ANTRAL CHRONIC SUPPURATIVE
OTITIS MEDIA - AN OBSERVATIONAL STUDY

Dr. Grace Budhiraja1 , Dr. Danish Guram2, Dr. Navjot Kaur3, Dr. Harsimrat Singh4, Dr. Harpreet5, Dr.
Prabhjot6, Dr. Harpreet Singh Khullar7, Dr. Anu8 and Dr. Nischai Goyal9
1. Professor, Department Of ENT, Adesh Institute Of Medical Sciences And Research, BATHINDA, PUNJAB.
2. Resident, Department Of ENT, Adesh Institute Of Medical Sciences And Research, BATHINDA, PUNJAB.
3. Asisstant Professor, Department Of ENT, Adesh Institute Of Medical Sciences And Research, BATHINDA,
PUNJAB.
4. Asisstant Professor, Department Of ENT, Adesh Institute Of Medical Sciences And Research, BATHINDA,
PUNJAB.
5. Resident, Department Of ENT, Adesh Institute Of Medical Sciences And Research, BATHINDA, PUNJAB.
6. Resident, Department Of ENT, Adesh Institute Of Medical Sciences And Research, BATHINDA, PUNJAB.
7. Resident, Department Of ENT, Adesh Institute Of Medical Sciences And Research, BATHINDA, PUNJAB.
8. Resident, Department Of ENT, Adesh Institute Of Medical Sciences And Research, BATHINDA, PUNJAB.
9. Resident, Department Of ENT, Adesh Institute Of Medical Sciences And Research, BATHINDA, PUNJAB.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History An Observational Study was undertaken at Department of
Received: 28 February 2023 Otorhinolaryngology
Final Accepted: 31 March 2023 and Head and Neck Surgery, AIMSR from Jan 2019 - August 2020.
Published: April 2023 The aim of
this study was to observe the outcome of endoscopic
Key words:-
Tympanoplasty, Temporalis Fascia, tympanomastoidectomy for
Endoscopic Tympanomastoidectomy, attico-antral type of CSOM. All the patients attending ENT OPD at
Pure Tone Audiometery, Impedence AIMSR within
Audiometry
the age group of 11-60 yrs, irrespective of sex with Attico-Antral
CSOM either
unilateral or bilateral were included in this study. However, revision
mastoidectomies, patients with intracranial complications of CSOM or
actively
discharging ear, or patients with external and middle ear abnormalities
either
congenital or acquired, medically and surgically unfit patients and
Patient‘s
unwilling to take part in study were not included. In our study of 50
patients, 40
patients had graft uptake after disease clearance and 8 had failure of
graft uptake
without chronic otorrhoea and 2 had failure with chronic otorrhoea.
Through this
study we concluded that Endoscopic Tympano-mastoidectomy for
attico-antral
type of CSOM is an excellent technique for complete removal of

Corresponding Author:- Dr. Grace Budhiraja 1082

Address:- Professor, Department Of ENT, Adesh Institute Of Medical Sciences
And Research, BATHINDA, PUNJAB.
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 1082-1086

cholesteatoma
especially from inaccessible areas of middle ear cleft.

Copy Right, IJAR, 2023,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
Chronic Supportive Otitis Media (CSOM) is a long standing bacterial
contamination of the middle ear that has been well recognized since ancient
times.1 In this illness one encounters an irregular or constant mucoid,
mucopurulent or purulent ear discharge through a chronic and permanently
perforated TM. The Attico-antral chronic otitis media is characterized by the
formation of granulation tissue and cholesteatoma. This cholesteatoma has been
frequently observed to run a threatening course subsequently weakening the
patient's hearing and spreading to adjacent structures like middle cranial fossa,
accordingly accentuating the morbidity and mortality of individuals involved.
Despite the fact that, the introduction and popularization of antibiotics like sulpha
based medications by Domegk in 1935 and penicillins group by Alexander Fleming in 1942 diminished the
mortality if there should arise an occurrence of
tubotympanic type of CSOM, but they couldn't permanently fix atico-antral CSOM.1

Medical procedure was backbone of therapy for atico-antral CSOM till the
eighteenth century. Before the advent of working magnifying instrument the point
of a medical procedure was to change over the hazardous ear into safe ear. On
those occasions the focal point of consideration was getting rid of the illness from
the mastoid cavity and permitting any leftover infection to deplete remotely by
means of meatoplasty. Treatment along these lines left exceptionally high rate of
tiny remaining sickness in the ear and mastoid.

Material and Methods:-

Study design : Prospective Study
Study place : Department of ENT Adesh Institute of Medical
Sciences and Research.
Study period : Jan 2019 - August 2020(9 months of data
collection and 6 months of follow up)
Sample size : 50 patients
Inclusion criteria
Patients attending ENT OPD at Adesh Institute of Medical sciences and research
with
 Age 11-60 yrs
 Sex: both Male and Female.
 Attico-Antral Chronic Suppurative Otitis Media.
 Unilateral or Bilateral disease.

Exclusion criteria
 Revision Mastoid surgeries.
 Patients with intracranial complications of CSOM.
 Patients with actively discharging ear.
 Patients with external and middle ear abnormalities (congenital or
acquired).
 Medically and surgically unfit patients.
 Patients unwilling to take part in study.

1083
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 1082-1086

Results:-
The study consist of 50 patients with attico-antral chronic suppurative otitis media
who were analysed taking into consideration a number of parameters. The
following are the observations made during our study.

In our study patient age varied from 11 yrs to 40 yrs. The maximum incidence was 43 percent in the third decade
than 31 percent in second decade and followed by 26 percent in the fourth decade. The mean age in this
study was 24 years.

The most common symptom encountered was otorrhoea in 88.5%

patients, followed by impaired hearing in 80%. Otalgia and tinnitus were seen in 17 and 11.5 % patients
respectively. Vertigo was seen in 11.5% patients.

48.5% patients had CSOM in the active stage with persistent ear
discharge. 40% patients presented with occasional discharge and 11.5%
presented with no discharge.

44/50 patients presented with complaints of discharge. Out of these 44 patients ,

39 presented with some degree of hearing impairment. Longer duration of otorrhoea more is the severity of the
disease and morethe hearing
impairment. Also the degree of the hearing loss is more in sinus cholesteatoma
than attic cholesteatoma. This is due to involvement of the ossicular chain
frequently by the sinus cholesteatoma.

Visualization of the tympanic membrane without any manipulation was possible in 51.5% of the cases and
visualization after manipulation was possible in 31.5% of the cases. However partial visualization even after
manipulation was seen in 17% cases.

Among the 50 cases,66% of showed postero superior quadrant retraction pocket

(PSQRP) with cholesteatoma, 17 patients showedfindings in the attic region and
out of these 10 patients (20%) showed attic perforation while 7 patients (14%)
showed attic granulation .

In 55% of the cases the diseased ear showed retracted pars tensa with the TM
directly resting over the head of stapes. 14% patients showed same side central
perforation and 31% showed normal TM. On the contralateral side retraction was
noticed in 40% of the cases, perforation in 9% and about 51% had normal TM.

Out of 50 cases B/L sclerosis was noted in about 31% and U/L sclerosis on the
affected side in 37% . B/Lly Pneumatised mastoid was noted in 26%. The cavitary mastoid diagnosed in only 6%.

Sinus cholesteatoma showed more amount of hearing loss.

Pure CHL implies > 25db air conduction loss and A-B gap > 20db and in the mixed variety the bone conduction loss
> 25db and A-B gap > 20db. In our study 66% showed Pure conductive hearing loss and 33% showed mixed
hearing loss.

Incus was most common ossicle necrosed because of the nature of its blood of
supply and its location seen in 50% of the patients , next was suprastructure of
stapes (26%),followed by partial necrosis of malleus head noted in 14%. Absent
ossicles were seen in 11% of the cases. This incus erosion was more frequently encountered in Sinus type of
cholesteatoma (66 %) than Attic cholesteatoma (34%).

The cholesteatoma was seen extending to the attic in 11% of the cases, involving
further the aditus as well in 11% of the cases, spreading further to mastoid antrum in 11% of the cases.
Cholesteatoma limited to the posterior mesotympanum was seen in 17% of the cases. Cholesteatoma involving both

1084
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 1082-1086

the posterior mesotympanum and aditus ad antrum was seen in 20% of the cases. Extension into mastoid tip cells
was seen in 28.5% patients.

On the basis of extent of the disease different surgical procedures were used ,
65% underwent CWD procedure with augumented tympanoplasty with autologous incus and cartilage graft placed
over head of stapes in 31% and over footplate of stapes in 34%.17% with limited cholesteatoma disease confined to
posterior mesotympanum underwent marginectomy with tympanoplasty and about 11% had atticotomy with
tympanoplasty.

While assessing the post-operative graft uptake it was observed that successful
graft uptake was seen in 96% cases while graft uptake was unsuccessful in 4%
cases after 6 months of followup. At routine follow ups of 1, 3 and 6 months it was observed that the chances of
graft uptake decreased as the post op time period increased (p<0.05).

While assessment of post op chronically discharging ear it was observed that only 2% of the cases had chronic
discharge at 6 month follow up period. Chronically discharging ear is negatively associated with post
operative time period(p<0.005). As time progresses the rate of chronically
discharging ear decrease.

Degree of hearing improvement is from 10-14dB in 36% of

cases and 15-19 dB in 34% of the cases and 20-25 dB in 2% of the cases and 25-30 dB in 1% of the cases at the end
of the study period. When the degree of
hearing improvement was compared at 1, 3 and 6 months follow up it was
observed that endoscopic tympanomastoidectomy had a positive effect on post
operative degree of hearing improvement (p value< 0.05).

Immediate postoperative complication including canal stenosis and postoperative

infection was seen in 11% and 21% respectively.

Discussion:-
The management of cholesteatoma is one of the most challenging tasks in
otologic surgery as the chances of residual disease and the morbidity of the
conventional procedures involved in the cholesteatoma treatment are high. With
incorporation of endoscopes in the otologic field much of the recidivism and
morbidity of the procedures has been reduced.

Endoscopic Tympano-mastoidectomy for attico-antral type of CSOM is an

excellent technique for complete removal of cholesteatoma especially from
inaccessible areas of middle ear cleft including facial recess and
sinustympani. Transmeatal removal of disease from mastoid antrum and even tip cells is possible with
endoscopes.Preservation of as much of normal mucosa of the middle ear cleft is possible with this technique, which
promotes early reaeration of the mastoid cavity leading to better hearing outcome.
Like Functional Endoscopic sinus surgery (FESS) for nose, Endoscopes
have changed the treatment concept of atticoantral disease, with complete
removal of the disease and preservation of normal mucosa, that restores
the normal physiology of middle ear cleft. This has led to the development
of new concept of Functional Endoscopic Ear Surgery (FEES) for
atticoantral type of CSOM.

Conclusion:-
Endoscopic Tympano-mastoidectomy for attico-antral type of CSOM is an
excellent technique for complete removal of cholesteatoma especially from
inaccessible areas of middle ear cleft including facial recess and
sinustympani.

1085
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 1082-1086

Informed Consent:
written informed consent was taken from patients .

Ethical Approval:
Ethical committee approval was taken from the AIMSR institutional committee of ethics.

Source Of Funding-
Funding source was self

Conflict Of Interest –
There was no conflict of interest

References:-
Takahashi H. The middle ear: the role of ventilation in disease and surgery.
Springer Science and Business Media; 2012 Dec 6.
2. Takahashi H, Hasebe S, Sudo M, Tanabe M, Funabiki K. Soft-wall
reconstruction for cholesteatoma surgery: reappraisal. Otology and
Neurotology. 2000 Jan 1;21(1):28-31.
3. Tarabichi M. Endoscopic management of cholesteatoma: long-term results.
Otolaryngology—Head and Neck Surgery. 2000 Jun;122(6):874-81.
4. Tarabichi M. Endoscopic middle ear surgery. Annals of Otology, Rhinology
and Laryngology. 1999 Jan;108(1):39-46.
5. Marchioni D, Mattioli F, Alicandri-Ciufelli M, Presutti L. Endoscopic approach
to tensor fold in patients with attic cholesteatoma. Acta oto-laryngologica.
2009 Jan 1;129(9):946-54.
6. Marchioni D, Mattioli F, Alicandri-Ciufelli M, Molteni G, Masoni F, Presutti L.
Endoscopic evaluation of middle ear ventilation route blockage. American
journal of otolaryngology. 2010 Nov 1;31(6):453-66.
7. Sade J. The correlation of middle ear aeration with mastoid pneumatization.
European archives of oto-rhino-laryngology. 1992 Oct 1;249(6):301-4.
8. Sadé J, Fuchs C. Secretory otitis media in adults: II. The role of mastoid
pneumatization as a prognostic factor. Annals of Otology, Rhinology and
Laryngology. 1997 Jan;106(1):37-40.
9. Haginomori SI, Takamaki A, Nonaka R, Mineharu A, Kanazawa A,
Takenaka H. Postoperative aeration in the middle ear and hearing outcome
after canal wall down tympanoplasty with soft-wall reconstruction for
cholesteatoma. Otology and Neurotology. 2009 Jun 1;30(4):478-83.
10. Wackym PA, King WA, Barker FG, Poe DS. Endoscope‐assisted vestibular
neurectomy. The Laryngoscope. 1998 Dec;108(12):1787-93.
56
11. Karhuketo TS, Puhakka HJ, Laippala PJ. Tympanoscopy to increase the
accuracy of diagnosis in conductive hearing loss. The Journal of
Laryngology and Otology. 1998 Feb;112(2):154-7.
12. Rosenberg SI, Silverstein H, Willcox TO, Gordon MA. Endoscopy in otology
and neurotology. The American journal of otology. 1994 Mar;15(2):168-72.
13. Poe DS, Bottrill ID. Comparison of endoscopic and surgical explorations for
perilymphatic fistulas. The American journal of otology. 1994 Nov
1;15(6):735-8.
14. Nomura Y. Endoscopic photography of the middle ear. Otolaryngology--
Head and Neck Surgery. 1982 Jul;90(4):395-8.
15. Thomassin JM, Korchia D, Doris JM. Endoscopic‐guided otosurgery in the
prevention of residual cholesteatomas. The Laryngoscope. 1993
Aug;103(8):939-43.

1086