Chronic suppurative otitis media is a persistent, chronically draining (> 6 weeks), suppurative perforation of the tympanic membrane. Symptoms include painless otorrhea with conductive hearing loss. Complications include development of aural polyps, cholesteatoma, and other infections. Treatment requires complete cleaning of the ear canal, careful removal of granulation tissue, and application of topical corticosteroids and antibiotics. Systemic antibiotics and surgery are reserved for severe cases.
Chronic suppurative otitis media can result from acute otitis media, eustachian tube obstruction, mechanical trauma, thermal or chemical burns, blast injuries, or iatrogenic causes (eg, after tympanostomy tube placement). Risk is increased in patients with craniofacial abnormalities (eg, Down syndrome, cri du chat syndrome, cleft lip and/or cleft palate, 22q11.2 deletion [also called velocardiofacial syndrome, Shprintzen syndrome, Shprintzen-Goldberg syndrome, and DiGeorge syndrome]).
Chronic suppurative otitis media may be exacerbated after an upper respiratory infection or by water entering the middle ear through a tympanic membrane perforation during bathing or swimming. Chronic exposure to air pollution and poor hygiene related to living in a low-resource community can also exacerbate symptoms.
Infections often are caused by gram-negative bacilli or Staphylococcus aureus, resulting in painless, purulent, sometimes foul-smelling otorrhea. Persistent chronic suppurative otitis media may result in destructive changes in the middle ear (such as necrosis of the long process of the incus) or aural polyps (granulation tissue prolapsing into the ear canal through the tympanic membrane perforation). Aural polyps are a serious sign, almost invariably suggesting cholesteatoma. In immunocompromised patients (eg. patients with diabetes), Pseudomonas infections are common.
A cholesteatoma is an epithelial cell growth that forms in the middle ear, mastoid, or epitympanum. Lytic enzymes, such as collagenases, produced by the cholesteatoma can destroy adjacent bone and soft tissue (including the tympanic membrane). The cholesteatoma is also a nidus for infection; purulent labyrinthitis, facial paralysis, or intracranial abscess may develop.
Symptoms and Signs of Chronic Suppurative Otitis Media
Chronic suppurative otitis media usually manifests with conductive hearing loss and otorrhea. Pain is uncommon unless an associated osteitis of the temporal bone occurs. The tympanic membrane is perforated and draining, and the auditory canal is macerated and littered with granulation tissue.
A patient with cholesteatoma may have fever, vertigo, and/or otalgia. There is white debris in the middle ear, a draining polypoid mass protruding through the tympanic membrane perforation, and an ear canal that appears clogged with mucopurulent granulation tissue. Even without continuous drainage for > 6 weeks, cholesteatoma may manifest with hearing loss and intermittent episodes of drainage that temporarily subside after courses of topical fluoroquinolones.
PROFESSOR TONY WRIGHT, INSTITUTE OF LARYNGOLOGY & OTOLOGY/SCIENCE PHOTO LIBRARY
Diagnosis of Chronic Suppurative Otitis Media
Clinical evaluation
Diagnosis of chronic suppurative otitis media is usually clinical. Samples of the discharge are cultured.
When cholesteatoma or other complications are suspected (as in a febrile patient or one with vertigo or otalgia), CT or MRI is done. These tests may show intratemporal or intracranial processes (eg, labyrinthitis, ossicular or temporal erosion, abscesses). If patients have persistent or recurrent granulation tissue, biopsies should be done to exclude a neoplasm.
Treatment of Chronic Suppurative Otitis Media
Topical antibiotic drops
Removal of granulation tissue
Surgery for cholesteatomas
Dry ear precautions are required unless patients are being treated with antibiotic ear crops. Dry ear precautions include occluding the external canal (eg, using a cotton ball lathered with petroleum jelly) while bathing and showering and avoiding swimming.
Four to 5 drops of topical ciprofloxacin (or ofloxacin) solution are instilled in the affected ear 2 times a day for 10 to 14 days. Ear drops that contain aminoglycosides (eg, neomycin, tobramycin) or polymyxin should not be prescribed for patients with a perforated tympanic membrane or a tympanostomy tube because of potential ototoxicity.
When granulation tissue is present, it may be removed with microinstruments or cauterization with silver nitrate sticks. Ciprofloxacin and dexamethasone is then instilled into the ear canal for 7 to 10 days. Sometimes ciprofloxacin and dexamethasone are given for 10 to 14 days without debridement. When granulation tissue persists or continues to recur in spite of adequate local treatment, a biopsy to rule out a neoplasm should be done.
Severe exacerbations require systemic antibiotic therapy with amoxicillin 250 to 500 mg orally every 8 hours for 10 days or a third-generation cephalosporin; if needed, antibiotics are subsequently modified based on culture results and response to therapy.
Tympanoplasty is indicated for patients with marginal or attic perforations and chronic central tympanic membrane perforations. A disrupted ossicular chain may be repaired during tympanoplasty as well.
Cholesteatomas must be removed surgically, and the middle ear must be reconstructed. Because recurrence is common, reconstruction of the middle ear is usually deferred until a 2nd-look operation (using an open surgical approach or a small-diameter otoscope) is done 6 to 12 months later.
Ключові моменти
Chronic suppurative otitis media is a persistent perforation of the tympanic membrane with chronic suppurative drainage.
The middle ear structures are often damaged; less commonly, intratemporal or intracranial structures are affected.
Initially, treat with topical antibiotics.
If patients have severe exacerbations, treat with systemic antibiotics.
Surgery is needed for certain types of perforation and damaged ossicles and to remove any cholesteatomas.
