EN4.{6,10} | Mucosal CSOM with Myringotomy and Tympanoplasty — Summary & Reflection

KEY TAKEAWAYS

Mucosal (tubotympanic) CSOM — the 'safe' type — is characterised by a central perforation in the pars tensa of the tympanic membrane, mucosal middle ear disease, absence of cholesteatoma, and a low risk of intracranial complications. It is the commonest form of CSOM (~80% of cases) and arises as the end result of recurrent or inadequately treated childhood ASOM. The cardinal presentation is chronic recurrent odourless mucoid/mucopurulent discharge and conductive hearing loss without pain — the absence of pain in uncomplicated disease is diagnostically important, and its onset is a red flag for complication. The critical examination finding is a central perforation in the pars tensa with an intact pars flaccida and no whitish pearly debris — distinguishing it from the unsafe squamosal type (attic/marginal perforation + cholesteatoma). Investigations include PTA (showing conductive air-bone gap), ET function testing (mandatory before surgery), and HRCT only if complications or ossicular erosion is suspected. Management follows a two-phase approach: conservative (aural toilet, safe topical ciprofloxacin drops, ET treatment) to achieve a dry ear for ≥6 weeks; then surgical (tympanoplasty) to repair the TM and restore hearing. Wullstein Type I (myringoplasty, most common) repairs the TM alone when ossicles are intact; higher types address progressive ossicular erosion. The graft of choice is temporalis fascia, placed in the underlay position — deep to the TM remnant — supported by Gelfoam packing in the middle ear.

REFLECT

You are reviewing a 35-year-old woman with a 20-year history of left ear discharge who has been told by a previous doctor to 'keep taking ear drops.' On examination she has a large central perforation in the pars tensa. The pars flaccida appears intact. The middle ear looks moist but there is no active discharge today. PTA confirms a 40 dB conductive hearing loss on the left. She asks you: 'Can my ear be fixed? I have been managing this for 20 years.' Reflect on the following: What is the immediate management priority before you can offer surgery? What specifically are you assessing about her Eustachian tube function, and how? What type of tympanoplasty does she need based on the available information, and what graft material would you choose? If she asks about the risk that this operation might fail, what factors predict success or failure of myringoplasty?