Unsafe eardrum perforation is
Ans. b (Marginal) (Ref. Diseases of ENT PL Dhingra 3rd/pg, 91-99).Attic and posterosuperior marginal perforations are seen in dangerous type of CSOM and are often associated with cholesteatoma while central perforation is considered safe, as cholesteatoma is usually not asso with it.OTITIS MEDIA# Tubotympanic disease (central perforation) remains localized to mucosa and that too mostly to anteroinferior part of middle ear cavity.# While atticoantral type or marginal or unsafe otitis media involves posterosuperior part of middle ear cleft (attic, antrum, posterior tympanum and mastoid) and is associated with cholesteatoma, which due to its bone-eroding property causes risk of serious complications and hence called unsafe or dangerous type.Chronic suppurative otitis mediaChronic suppurative otitis media (CSOM) is classified into two types: tubotympanic disease, in which there is a perforation of the pars tensa; and atticoantral disease, in which a retraction pocket develops from the pars flaccida.CSOM of the tubotympanic type. CSOM of the tubotympanic type can result from trauma or infection. When perforated the tympanic membrane usually repairs itself, but occasionally the outer layer of the tympanic membrane fuses with inner mucosa and a chronic perforation results. With this type of disease the patient's main symptoms are of an intermittent or chronic mucoid discharge associated with a mild conductive hearing loss. It is rare for this type of disease to be associated with intracranial complications. A diagnosis is made on otoscopy and the tuning forks usually suggest a conductive hearing impairment. The first-line treatment is topical antibiotic and steroid drops, and on occasion microsuction. If medical treatment fails, the patient may request an operation to graft the tympanic membrane in order to give a dry ear. This operation is termed a myringoplasty (type I tympanoplasty). The edges of the perforation are freshened and a small piece of temporalis fascia is inserted under the tympanic membrane to graft the drum.CSOM of the atticotympanic type. CSOM of the atticoantral type is important because of the complications associated with it. Cholesteatoma is the alternative name and means a cyst or sac of squamous epithelium that is present in the attic part of the middle ear. The exact aetiology of cholesteatoma is not known, although poor eustachian tube function is implicated. A retraction pocket develops in the pars flaccida and, if the squamous epithelium cannot migrate out of this pocket, a cholesteatoma results. The expanding ball of skin causes a low-grade osteomyelitis which results in the release of fatty acids from the bone. This gives the discharge its characteristic faecal smell. Invariably the discharge is accompanied by hearing loss and mild discomfort. The infection spreads to the dura via emissary veins which connect the middle ear mucosa to the dura or by direct extension of the disease through the bone. Meningitis, extradural, subdural or intracerebral abscess, or a combination of these may occur. Diagnosis should be suspected on otoscopy. Pus, crusts, granulations or a whitish debris in the attic are hallmarks of the disease. Examination under the microscope, audiometry and, sometimes, HRCT are indicated. The treatment is surgical and follows the principle of exposing the disease, excising the disease and then exteriorising the affected area. Two commonly applied operations for this disease are an atticotomy and a modified radical mastoidectomy.
Central
Marginal
Paracentral
Multiple central
CSOM and its Complications