Chronic Suppurative Otitis Media

Definition

An inflammatory disease of the middle ear cleft evidenced by persistent perforation of the tympanic membrane with or without ear discharge of at least 2-3 months duration.

The Tympanic Membrane Structure

Outer layer (stratum epidermicum): This layer is continuous with the skin lining the external auditory canal and is made up of stratified squamous epithelium. It provides protection against dust, debris, and foreign objects entering the middle ear.

Middle layer (stratum fibrosum): This fibrous layer is the thickest and most important layer of the tympanic membrane. It consists of collagen fibers arranged in a radial and circular pattern, giving the membrane its elasticity and strength. These fibers are responsible for transmitting sound vibrations to the ossicles, the tiny bones of the middle ear.

Inner layer (stratum mucosum): This thin layer of mucosal epithelium is continuous with the lining of the middle ear cavity. It secretes a sticky fluid that lubricates the ossicles and protects the middle ear from infections.

Europe:

• Healed: 12%
• Inactive: 2.6%
• Active: 1.5%

Nigeria: 1%-7.3%

• General:
• Environmental: low socioeconomic status
• Poor general health
• Poor diet
• Overcrowding
• Genetic: Inconclusive
• Previous otitis media
• Sequelae of acute otitis media or otitis media with effusion
• URTI (Upper Respiratory Tract Infection)
• Viral infections allowing bacterial overgrowth
• Via eustachian tube
• Autoimmunity: autoimmune disease increases the incidence of CSOM (Chronic Suppurative Otitis Media)
• Eustachian tube malfunction
• Stagnation, stasis, infection

Routes of Infection

1. Eustachian tube
2. Traumatic perforation
3. Hematological

• Tubotympanic Disease: Perforation in the pars tensa.
• Also known as safe ear.
• It does not cause any serious complications.
• Infection is limited to the antero-inferior part of the middle ear cleft.
• Associated with central perforation.

Tubotympanic Disease
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Tubotympanic Disease
• Attico-antral Disease: Perforation in the pars flaccida.
• This type primarily affects the attic and antrum, air spaces above the middle ear cavity. Cholesteatoma formation is a frequent complication, and otorrhea tends to be foul-smelling and purulent. The tympanic membrane may show superior perforations or be retracted.

Cholesteatoma

Cholesteatoma is characterized by the presence of skin in the wrong place - a sac in the middle ear which is lined by keratinizing squamous epithelium containing desquamated epithelium as keratin debris.

• Congenital
• Acquired

Tubotympanic CSOM vs Atticoantral CSOM

Feature	Tubotympanic CSOM	Atticoantral CSOM
Area of involvement	Eustachian tube and tympanic cavity	Attic and antrum (air spaces above middle ear)
Otorrhea (ear discharge)	Profuse, mucoid, odorless	Scanty, foul-smelling and purulent
Tympanic membrane perforation	Central	Attic or marginal
Cholesteatoma	Uncommon	Frequent
Ossicular involvement	Uncommon	More common
Granulation tissue	Less common	Common
Hearing loss	Conductive	Conductive or mixed
Complications	Rare	More common

Active Otitis Media

Presence of pathogens, ongoing symptoms, and abnormal otoscopic/tympanometric findings.

Inactive Otitis Media

No active pathogens, resolved symptoms, but residual eardrum damage and possible Eustachian tube dysfunction.

• There is TM perforation but no current evidence of inflammation either of the middle ear mucosa or TM.
• The natural history of such an ear is to become active or remain inactive.

Healed Otitis Media

The tympanic membrane is intact.

Complete resolution of all signs and symptoms, normal eardrum and middle ear function.

History

• Ear discharge
• Tubotympanic: Profuse, mucoid, intermittent, seldom malodorous.
• Atticoantral: Scanty, foul-smelling.
• Hearing loss.
• Otalgia occasionally.

Examination

• Pinna: Scar of previous ear surgery.
• Otoscopy: Ear discharge, TM (Tympanic Membrane) perforation, polyp.

Bacteriology

• Aerobes
• Proteus spp
• Pseudomonas aeruginosa
• Staph aureus
• E. coli
• Anaerobes
• Bacteroides spp

Audiological Assessment

• PTA: Conductive hearing loss; 45-60dB or less.
• Speech audiogram.

Radiology

• Conventional X-ray mastoids: Sclerosis

X-ray mastoids
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X-ray mastoids

X-ray mastoids
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X-ray mastoids
• CT Scan Mastoids: Cholesteatoma, intracranial complications.
• MRI Mastoids: Role being evaluated.

MRI Mastoids
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MRI Mastoids

Medical Management

Topical Antimicrobials

• Many are ototoxic
• Gentamycin, Neomycin, Polymixin B
• Steroid combination: Gentisone
• New ones are not
• Ciprofloxacin, Ofloxacin

TOPICAL ANTIMICROBIAL PREPARATIONS
Cipro HC Otic	Ciprofloxacin + hydrocortisone (suspension)
Ciprodex	Ciprofloxacin + dexamethasone
Cortisporin Otic	Polymyxin + neomycin + hydrocortisone (suspension or solution)
Cortisporin TC Otic	Neomycin + thonzonium + colistin + hydrocortisone (suspension)
Pediotic	Polymyxin + neomycin + hydrocortisone
Floxin Otic	Ofloxacin (solution)
Zoto HC	Chloroxylenol + pramoxine + hydrocortisone
Cortane B	(chloroxylenol = antimicrobial | pramoxine = topical anesthetic)
TOPICAL PREPARATIONS WITHOUT ANTIMICROBIALS
Domeboro Otic	Acetic acid + aluminum acetate (solution)
Swim Ear	Isopropyl alcohol + anhydrous glycerins (solution)

Aural Toilet

Done only for the active stage.

Dry mopping with cotton swab.

Suction clearance: best method.

Gentle irrigation (wet mopping).

1.5% acetic acid solution used T.I.D.

Removes accumulated debris.

Acidic pH discourages bacterial growth.

Antihistamines

• Sinufed
• Piriton
• Loratidine
• Desloratidine
• Cetirizine
• Levocetirizine, etc.

Surgical Management

• Removal of polyps
• Cauterization of granulation (silver nitrate)
• Myringoplasty
• Tympanoplasty

EXTRACRANIAL COMPLICATIONS

• Labyrinthitis
• Facial nerve paralysis
• Subperiosteal abscesses
• Preauricular
• Postauricular/Mastoid
• Infraauricular
• Digastric

Abscesses in Relation to Mastoid Infection

• Postauricular Abscess: This type of abscess occurs behind the ear.
• Meatal Abscess (Luc Abscess): This abscess occurs in the ear canal.
• Zygomatic Abscess: This abscess occurs in the cheekbone.
• Behind the Mastoid (Citelli's Abscess): This abscess occurs behind the mastoid bone.
• Bezold Abscess: This abscess occurs in the neck, behind the sternocleidomastoid muscle.
• Para/Retropharyngeal Abscess: This abscess occurs in the deep spaces behind the throat.

Mastoid Abscess

If a subperiosteal abscess develops, fluctuation can be elicited.

Confirmation and assessment are done by Radiological C.T. scan.

Extent of the opacification of the mastoid air cells and development of any subperiosteal abscess is confirmed.

Postauricular Abscess: Commonest abscess - forms over mastoid.

• Pinna displaced - outward & forward.
• Infection may spread from mastoid to subperiosteal space.
• Treatment includes incision and drainage along with mastoidectomy.

INTRACRANIAL COMPLICATIONS

• Extradural Abscess
• Subdural Abscess
• Sigmoid Sinus Thrombophlebitis
• Leptomeninigitis
• Pachymeningitis
• Brain Abscess
• Otitic Hydrocephalus