A child presents with left ear hearing loss of three month duration. On examination, foul smelling purulent discharge is seen with perforation in pars flaccida. What is the most appropriate management?

Foul smelling discharge and perforation in the Pars flaccida suggest CSOM of the unsafe type (Atticoantral type) This type of CSOM is often associated with a bone eroding process such as cholesteatoma, granulations or osteitis. Risk of complications is high Surgery is the mainstay of treatment. The primary aim is to remove the disease process by tympano-mastoid exploration and render the ear safe. Tympano-mastiod exploration can be done through various procedures. 1. Canal wall down procedures - Atticotomy, modified radical mastoidectomy and rarely radical mastoidectomy. 2. Canal wall up procedures Tympanoplasty is a surgical procedure that repairs or reconstructs the hearing mechanism. 'Type I Defect is perforation of tympanic membrane which is repaired with a graft. It is also called myringoplasty. -Type II Defect is perforation of tympanic membrane with erosion of malleus. Graft is placed on the incus or remnant of malleus. 'Type III Malleus and incus are absent. Graft is placed directly on the stapes head. It is also myringostapediopexy or columella tympanoplasty. -Type IV Only the footplate of stapes is present. It is exposed to the external ear, and graft is placed between the oval and round windows. A narrow middle ear (cavum minor) is thus created, to have an air pocket around the round window. A mucosa-lined space extends from the eustachian tube to the round window. Sound waves in this case act directly on the footplate while the round window has been shielded. *Type V Stapes footplate is fixed but round window is functioning. In such cases, another window is created on horizontal semicircular canal and covered with a graft. Also called fenestration operation.