Chronic otitis media (COM) is characterized chronic inflammatory changes of the mucoperiosteal lining of the middle ear cleft. It can be categorized into COM with and without cholesteatoma. Both types of chronic otitis media can cause erosion of ossicles.1

Otitis media is the most common bacterial disease in children and happens in 80% of children between the ages of one and six years, and it is the disease most frequently managed with antibiotics. But later in life, in some of these patients may result in serious morbidity and complication, such as, Cholesteatoma and ossicular erosion (1).

Cholesteatoma is an expanding destructive disease of the temporal bone that is composed of stratified squamous epithelium. This disease is often developed in the mastoid and middle ear but it can form in every part of the temporal bone (2). Despite a decrease in the incidence of chronic otitis media, it is still a major cause of considerable morbidity (3).

The incus is most frequently affected by bony erosion followed by stapes and malleus.8 Multiple ossicles involvement is more common than single ossicular erosion. Destruction of ossicular chain leads to failure of middle ear mechanics and results in substantial conductive hearing loss.(4) The status of ossicular chain helps us to select the type of intervention and to determine the prognosis.(5) In this study, we aim evaluate the state of the ossicular bones in patients who require surgery for cholesteatoma, so that the findings can be used to predict the need for bone reconstruction and determine the choice of prosthesis preoperatively.

A total of 30 patients suffering with cholesteatoma operated on during a 1-year period are included in study.

All patients underwent a canal wall down mastoidectomy. During the operation all the ossicles were analyzed in terms of health, erosion, and total loss.

The results were analyzed in a retrospective manner. The details of incomplete erosions are also discussed. The statistical significance of differences between paired groups (such as sex) was tested using the chi-squared test and significance was defined as P< 0.05.

A total of 30 patients 47% of the patients were female and 53% were male.

Figure-1: Distribution of patients with gender

Table-1: Age and side distribution in present study

Mean age of 27.9 years (range: 7–50 years), all of whom had chronic otitis media with cholesteatoma were the subjects of this study. The majority of the patients were within an age range of 10 to 20 years old, and overall most patients were younger than 40.

Most of the people in study are with right sided ear effected.

Table-2: Clinical manifestations in chronic otitis media with cholesteatoma

Most common symptom in present study for which they approached is hearing loss

Figure-2: Degree of hearing loss in patients

Moderate degree of hearing loss is seen in most of the patients with 14 cases, mid in 10 cases and 6 cases it is severe.

5 patients in present study have complications as facial nerve palsy in 3 cases, weekness in 1 case and only giddiness in 1 case

Table-3: State of the middle ear bones in patients with chronic otitis media with cholesteatoma as determined during surgery.

Out of the 30 patients, 28 (93%) were affected by erosion of the ossicles. Involvement of the incus was most common (86.7%), followed by involvement of the stapes (66.7%), and then the malleus (43.3%).Overall, the most common pattern of damage was observed in the incus bone, which included total loss in 56.7% of cases and partial damage in 30%.

The most widely damaged part of the incus was its long process (25%) and the second most common site of damage to the incus was its body (5%). Damage to the stapes was the second most common type of damage observed, and mostly involved its superstructure. Erosion of the stapes superstructure was more common than total loss of the bone (27%, respectively). Even though damage to the malleus was least common, the number of cases where the stapes superstructure was intact was greater than the number of cases of an intact malleus (60% vs. 56.7%).

Ossicular chain erosion is the frequent finding in cholesteoma. Destruction of ossicular chain leads to impairment in sound conduction mechanism and hearing loss. So it is important to identify ossicular lesion during surgery for reconstruction of sound conductive mechanism.

In our study, 93 % of patients were suffering from ossicular damage. The majority of these patients had extension of cholesteatoma into the tympanic and mastoid cavities. It seems that the presence of cholesteatoma is a chronic phenomenon and that patients are only referred for treatment in the later stages of the disease, which suggests a lack of information, education, training, and shortage of health care. (6,7)

The percentage of cases with involvement of each of the osiccles in our study is  incus 86.7%, stapes 66.7%, and malleus 43.3% which is very much similar to Ghodrat Mohammadi et al(3) study with  percentage involvement of each of the osiccles was as follows incus 86.1%, stapes 66.9%, and malleus 43.9%.  In a study by Kurien and colleagues(8) these figures were: incus 100% and malleus 67%, with stapes involvement occurring more in children than in adults (95% vs. 67%) . There are some differences between these figures and in our study involvement of the stapes was more prevalent in patients aged below 30 (90% vs. 57%). In another study by Garap and Dubey(9), involvement of the ossicles was reported as follows: incus 89%, stapes 41%, and malleus 32 % . However, a study by Brakeman(10) had different results again and showed that in children all the ossicles were intact in 9% of cases, the malleus and stapes were intact in 11% of cases, and only the stapes was intact in 46% of cases.

Albera et al(11) also showed incus erosion in 49% and absent in 31% while long process was eroded in 45% cases. Mohammadi et al(12) also found incus eroded in 30.7% while absent in 55.4%. Varshney et al(13) in a prospective study with 150 patients in which 60 patients had unsafe chronic otitis media, found incus partially eroded in 45% and absent in 40% cases . Long and lenticular process were necrosed in 35% cases. Albera et al(11) reported stapes intact in 71 % and erosion of crura in 29% cases. Thakur et al reported stapes intact in 51.92% and suprastructure erosion in 48.08%. Mohammadi et al (12)found stapes intact in 59% and suprastructure eroded in 41% cases.

However, our patients were almost all the ossicles were damaged. Another study also mentioned that most patients had the moderate pattern of cholesteatoma expansion hearing loss(7)). Thus it seems that most patients that were referred to our clinic were in the advanced stages of the disease. According to the high rate of cholesteatoma extension into the mastoid and tympanic cavity in patients with erosion of multiple ossicles, it seems that these patients were experiencing severe cholesteatoma. Once in this severe state they will need wider and more aggressive surgeries to stop the remaining cholesteatoma.

Thus, due to the extensive damage to the ossicles, the difficulty of restoring the bone during a single procedure, and the probable need for several surgeries, the outcome of attempts to restore hearing can be limited in these patients. Patients must therefore be fully informed about the potential issues before surgery.

In this study, we found that ossicular erosion is a frequent finding in chronic otitis media with cholesteatoma. Incus is the most commonly involved ossicle while malleus is most resistant to erosion.

Despite a decrease in the number of cases of chronic otitis media, there are still cases of extensive cholesteatoma that can cause greater ossicular erosion and poor hearing outcomes. To decrease this ossicular damage, physicians need to be alert and informed about chronic otitis media and the extensive cholesteatoma that causes erosion of the ossicles.a

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