Ossicular erosion in mucosal type of chronic suppurative otitis media in our experience.
CSOM is the most common cause of hearing loss in children and adults in our country. Incidence of chronic suppurative otitis media is high in children, it causes considerable morbidity with destruction of ossicles which leads to conductive hearing loss. When it is bilateral it causes speech and learning disabilities in children. In adults, chronic suppurative otitis media is a common cause of conductive hearing loss. Chronic suppurative otitis media with or without cholesteatoma can cause ossicular erosion/destruction which leads to conductive hearing loss.
The proposed mechanism for erosion is chronic middle ear inflammation as a result of overproduction of cytokines-TNF Alpha, Interleukin-2, Fibroblast Growth Factor, and Platelet Derived Growth Factor, which promote hypervascularisation, osteoclast activation and bone resorption causing ossicular damage. [1,2]
Austin in 1971 classified ossicular defects into group A having malleus and stapes intact and erosion of long process of incus being the most common defect,  group B with only malleus and absent stapes, group C with only stapes and absent malleus, group D with absent malleus and stapes suprastructure. Kartush added three more classes to Austin classifications for intact ossicular chain but with ossicular fixation, E for ossicular head fixation with intact ossicles, F for stapes fixation with presence of all ossicles. [3,4]
MATERIALS AND METHODS
The patients attending the OPD of Department of ENT and also patients referred from other departments of Sri Manakula Vinayagar Medical College and Hospital formed the subjects for our study. Study was conducted for a period of one and half years from December 2014 to May 2016.
The objective of this study was to determine the incidence of ossicular chain erosions in patients suffering from chronic otitis media, mucosal type.
Patients with chronic ear discharge, diagnosed to be having COM, mucosal type belonging to all the age groups were included in the study. Patients with squamosal type of COM, otosclerosis with stapes fixation, sensorineural hearing loss, malignancy, previous ear surgeries, ear trauma were excluded from the study. A written informed consent was taken from all the patients. A detailed history taking, thorough clinical examination was done for these patients.
Investigations including pure tone audiometry, X-ray of bilateral mastoids, routine blood investigations like complete haemogram, renal function tests, HIV, HBsAg screening were done. Intraoperatively, tympanic membrane perforation, continuity of ossicular chain, condition of middle ear mucosa, condition of mastoid air cells and antrum, patency of aditus were noted using otomicroscope and endoscopes where needed. Tympanoplasty and mastoidectomy was performed accordingly.
Our study included 60 patients with mucosal type of chronic suppurative otitis media, out of which 33 were male, 27 were female.
Patients were in the range of 10 years to 58 years of age, majority of which belonged to 11-20 years age group i.e. 35 (58.33%). Out of 60 patients, 38 patients had unilateral disease, 22 patients had bilateral disease.
Intraoperatively, 37 patients had intact ossicular chain and 23 patients had ossicular erosion.
Among 22 patients with bilateral disease, 16 patients (26.67%) had ossicular erosions in the operated ear, suggesting that patients with bilateral disease are at more risk for ossicular erosion.
Among 60 patients included in the study, 35 patients had central perforation of tympanic membrane and 25 patients had subtotal perforation. Out of 23 patients with ossicular erosion, 19 patients had subtotal perforation, whereas 4 patients had smaller central perforations.
Incus was the most common ossicle to undergo erosion in our study i.e. 20 (33.33%) cases, followed by head of the stapes in 3 cases (5%). Malleus was not eroded in any patients in our study.
Granulation tissue was found in the middle ear in 16 patients.
Among 16 patients with granulation tissue in the middle ear, 15 patients had ossicular erosions.
We performed myringostapediopexy in 20 patients using autologous incus, myringoplatinopexy in 3 cases using autologous malleus and type 1 tympanoplasty in rest of the patients using autologous temporalis fascia.
Based on X-ray of mastoids and intraoperative findings, 46 patients had sclerotic mastoid, whereas 14 patients had pneumatised mastoid.
Intraoperatively, 12 cases had granulation tissue in the mastoid. Cortical mastoidectomy was performed for 50 cases and aditus patency was achieved. In 10 cases, aditus block was present due to granulation tissue and patency was achieved by intact canal wall technique.
In this study, 60 patients with chronic otitis media, mucosal type were evaluated for ossicular chain erosions, along with other factors like tympanic membrane perforation, presence of granulation tissue, pneumatisation of mastoid, etc. Patients were of the age ranging from 10 years to 58 years, majority being in the age group of 11-20 years. Among the patients, males were affected more than females. This is in accordance with majority of studies.
Chronic otitis media causes various changes in the middle ear. These changes are seen more commonly in unsafe type, but safe type can also present with many of these changes. Among the ossicles, the long process of incus, stapes crura, body of incus and manubrium are involved in that order of frequency. The reason that the long process of incus and stapes superstructure is most frequently affected is likely to be due to their delicate structure and location, rather than their tenuous blood supply. 
Continuous mechanical pressure effect of the retraction pocket, granulation or cholesteatoma on the ossicles, osteoclastic enzymes released by disease activity and bacterial activity in case of associated infections may play minor roles.  Malleus and stapes are more resistant to necrosis. 
In this study, intraoperatively, condition of the ossicular chain was assessed using otomicroscope and endoscopes. Long process of incus was found to be most commonly involved ossicle, followed by stapes suprastructure. Malleus was not found to be involved in this study. Mathur et al  in 1991 observed erosion of incus in 22% of cases in unsafe chronic suppurative otitis media.
In a study by Rout et al,  involvement of incus was 25 (17%) with ossicular involvement. Saboo et al  noticed ossicular chain pathology in 26.6% of safe type of CSOM, incus being eroded in 17% cases. Ossicular involvement was found more commonly in patients with subtotal perforation in comparison to central perforation  which is in accordance with our study. In our study, among 13 patients with ossicular erosion, 19 patients (%) had subtotal perforations, whereas 4 patients (%) had smaller central perforations. G. S. N. Murthy et al found ossicular necrosis only in 8% cases of CSOM. In a study by Kashyap et al, ossicular pathology was found in 24% cases of tubotympanic type of CSOM.
In a study by Varshney et al  in safe CSOM, the incus was found intact in 92.23%, eroded in 5.55%, and absent in 2.22% cases. Lenticular process was the most commonly necrosed part of the incus and was found eroded in 5.55% cases.
In a study by Jeng FC et al  in the non-cholesteatoma group, perforation edges adhering to the promontory revealed a higher incidence of ossicular discontinuity.
C. Srinivas et al  studied various factors influencing ossicular status in mucosal chronic otitis media. Of the parameters studied, three were reliable to predict ossicular discontinuity in tubotympanic disease viz. duration of the disease, adherence of the margins of perforation to the promontory, PTA, and the ABG. The other otomicroscopic findings like myringosclerosis, polypoid middle ear mucosa, and granulation tissue on the tympanic membrane/middle ear mucosa did not have a significant correlation with ossicular discontinuity. But in our study, 16 patients (%) had granulation tissue in the middle ear and 15 of them were associated with ossicular erosion.
According to R Albera et al,  ossicular chain damages in patients with non-cholesteatomatous middle ear pathologies are not frequent and are present in no more than 10% of the patients, but lesions found were similar to those reported in patients with cholesteatoma.
Ossicular chain erosions in patients with chronic otitis media, mucosal type are frequent and are present in 38.33% of the patients as per this study. Incus is the most common ossicle to get eroded (33.33%). Subtotal perforation, bilateral disease and granulation tissue in the middle ear can be considered as good indicators of ossicular chain involvement.
 Slattery WH. Pathology and clinical course of inflammatory diseases of the middle ear. 5th edn. In: Glasscock ME, Gulya AJ. (eds). Glasscock-Shambaugh surgery of the ear. New Delhi, Reed Elsevier India Pvt. Ltd, 2003:428-9.
 Sade J, Berco E, Buyanover D, et al. Ossicular damage in chronic middle ear inflammation. Acta Otolaryngol 1981;92(3-4):273-83.
 Aristides Sismanis "Tympanoplasty" In: Glasscock-Shambaugh surgery of the ear. 5th edn. pp 463-85.
 Frootko NJ. Reconstruction of the middle ear. Vol 3. In: Brooth JB, Butterworth. (eds). Scott-Brown's otolaryngology. Bath Press, London 1997:11/111/30.
 Browning GG. Chronic otitis media in Michael Gleeson. Scott-Brown's Otorhinolaryngology. 7th edn. Head and Neck Surgery. Hodder Arnold Ltd. 2008:3397-9.
 Mansour S, Magnan J, Haidar H, et al. Comprehensive and clinical anatomy of the middle ear. 1st edn. New York, Springer 2013.
 Mathur NN, Kakar P, Sing T, et al. Ossicular pathology in unsafe chronic suppurative otitis media. Indian J Otolaryngo 1991;43(1):9-12.
 Rout MR, Das P, Mohanty D, et al. Ossicular chain defects in safe type of chronic suppurative otitis media. Indian J Otol 2014;20(3):102-5.
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 Murthy GSN, Bhimeshwar R, Veera Kumar M, et al. Mastoid, middle ear and ossicular pathology in CSOM with central perforation and role of cortical mastoidectomy in the management. 4(1):/ORL28181314/Pg1-9.
 Kashyap SK, Singh B, Purohit JP, et al. Incidence of ossicular chain pathology tubotympanic type of C.S.O.M. Journal of Evolution of Medical and Dental Sciences 2015;4(67):11701-7.
 Varshney S, Nangia A, Bist SS, et al. Ossicular chain status in chronic suppurative otitis media in adults. Indian J Otolaryngol Head Neck Surg 2010;62(4):4216.
 Jeng FC, Tsai MH, Brown CJ. Relationship of preoperative findings and ossicular discontinuity in chronic otitis media. Otology Neurotol 2003;24(1):2932.
 Srinivas C, Kulkarni NH, Bhardwaj NS, et al. Factors influencing ossicular status in mucosal chronic otitis media-an observational study. Indian J Otol 2014;20(1):16-9.
 Albera R, Dagna F, Filippini C, et al. Ossicular chain lesions in tympanic perforations and chronic otitis media without cholesteatoma. J Int Adv Otol 2015;11(2):143-6.
Santhanakrishnan Kaliavaradan (1), Poornima Shankar Bhat (2), Muraleedharan Radha Harish (3), Akshaya A. C (4)
(1) Assistant Professor, Department of Otorhinolaryngology, Sri Manakula Vinayagar Medical College, Kalitheerthalkuppam.
(2) Assistant Professor, Department of Otorhinolaryngology, Sri Manakula Vinayagar Medical College, Kalitheerthalkuppam.
(3) Postgraduate Student, Department of Otorhinolaryngology, Sri Manakula Vinayagar Medical College, Kalitheerthalkuppam.
(4) Postgraduate Student, Department of Otorhinolaryngology, Sri Manakula Vinayagar Medical College, Kalitheerthalkuppam.
Financial or Other, Competing Interest: None.
Submission 23-01-2017, Peer Review 14-02-2017, Acceptance 21-02-2017, Published 27-02-2017.
Corresponding Author: Dr. Santhanakrishnan Kaliavaradan, Assistant Professor, Department of ENT, Sri Manakula Vinayagar Medical College and Hospital, Kalitheerthalkuppam, Madagadipet, Pondicherry-605107. E-mail: firstname.lastname@example.org
Caption: Figure 1. Showing Long Process of Incus Erosion
Caption: Figure 2. Showing Subtotal Perforation
Caption: Figure 3. Showing Eroded Long Process of Incus
Caption: Figure 4 & 5. Shows Ossicular Reconstruction
Table 1. Showing Sex Distribution among the Patients Sex Distribution Number of of Patients Patients (%) Males 33 (55%) Females 27(45%) Table 2. Showing Laterality of Chronic Otitis Media Laterality of CSOM Number of Patients (%) Unilateral 38 (63.33%) Bilateral 22 (36.67%) Table 3. Showing Ossicular Status Ossicular Status Number of Patients (%) Intact 37 (61.67%) Eroded 23 (38.33%) Table 4. Showing Number of Patients with Bilateral Disease and Ossicular Erosions Bilateral COM with Ossicular No. of Erosion in the Operated Ear Patients (%) Present 16 (26.67%) Absent 6 (10%) Table 5. Showing type of TM Perforation in Patients with Ossicular Erosion Type of TM Perforation in Number of Patients with ossicular Erosion Patients (%) Small/medium/large central 4 (6%) Subtotal 19 (31.67%) Table 6. Showing the Type of Ossicular Erosion Type of Ossicular Erosion Number of Patients (%) Incus (Long process/lenticular 20 (33.33%) process) Stapes suprastructure 3 (5%) Table 7. Showing Number of Patients with Granulation Tissue in the Middle Ear Presence of Granulation Number of Tissue in the Middle Ear Patients (%) Present 16 (26.67%) Absent 44 (73.33%) Table 8. Showing Number of Patients with Ossicular Erosion along with Granulation Tissue in the Middle Ear Ossicular Erosion along with No. of Granulation Tissue in the Middle Ear Patients (%) Present 15 (25%) Absent 1 (1.67%) Table 9. Showing Mastoid Pneumatisation Mastoid Status Number of Patients (%) Sclerotic 46 (76.67%) Pneumatised 14 (23.33%) Table 10. Showing Type of Mastoidectomy done Type of Mastoidectomy Number of Patients (%) Cortical mastoidectomy 50 (83.33%) Intact canal wall technique 10 (16.67%)
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|Title Annotation:||Original Research Article|
|Author:||Kaliavaradan, Santhanakrishnan; Bhat, Poornima Shankar; Harish, Muraleedharan Radha; Akshaya, A.C.|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Feb 27, 2017|
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