CHRONIC SUPPURATIVE OTITIS MEDIA INTRODUCTION
This complex subject covers the whole field of chronic middle-ear infection and chronic perforation of the tympanic membrane. Conventionally, otologists subdivide chronic suppurative otitis media into two kinds, namely tubotympanic disease and atticoantral disease. Tubotympanic disease is characterised by a simple (central) perforation of the tympanic membrane. Central perforations occur within the pars tensa (see the middle ear, Chapter 2) and typically have a rim of tympanic-membrane remnant around them on all sides (Figure 19). Central perforations are not usually associated with invasive skin scale in the middle ear (cholesteatoma). The simplest situation in tubotympanic disease is the presence of a chronic perforation of central type which is dry, or only becomes infected periodically with head colds or when the ear is wetted. A more difficult situation exists where a central perforation of the pars tensa is associated with chronic discharge arising typically from granulations (inflamed tissue) in the middle ear cleft. This is still referred to as tubotympanic disease, which may also be associated with destruction of parts of the ossicular chain (the chain of bones within the middle ear, see Chapter 2).