CHRONIC SUPPURATIVE OTITIS MEDIA

Introduction

• CSOM is a long-standing infection of a part or whole of the middle ear cleft characterized by ear discharge and a permanent perforation.

Epidemiology

• Higher in developing countries because of poor socioeconomic standards, poor nutrition and lack of health education.

• Both sexes and all age groups.

TYPES

Tubotympanic or safe

• Profuse, mucoid, odourless discharge

• Central perforation• Granulations uncommon• Pale polyp• Cholesteatoma absent• Complications rare• Mild to moderate conductive

deafness

Atticoantral or unsafe

• Scanty, purulent, foul-smelling discharge

• Attic or marginal perforation• Granulations common• Red and fleshy polyp• Cholesteatoma present• Complications common• Conductive or mixed deafness

Tubotympanic type

Aetiology

• It is the sequelae of acute otitis media usually following exanthematous fever and leaving behind a large central perforation.

• Ascending infections via the eustachian tube.• Persistent mucoid otorrhea is sometimes the result of

allergy to ingestants such as milk, eggs, fish, etc.

Central perforation

Pathology

• Perforation of pars tensa• Middle ear mucosa- normal when disease is quiscent or

inactive. Oedematous and velvety when disease is active.• Polyp• Ossicular chain• Tympanosclerosis• Fibrosis and adhesions

Bacteriology

• Pus culture in both types of aerobic and anaerobic CSOM may show multiple organisms.

• Common aerobic organisms are Ps. Aeruginosa, Proteus, E. coli and Staph. Aureus, while anaerobes include Bacteroides fragilis and anaerobic Streptococci.

Alternative classification

Tubotympanic

• Active- perforation of pars tensa, inflammation of mucosa and mucopurulent discharge.

• Inactive- permanent perforation of pars tensa but middle ear mucosa is not inflamed and there is no discharge.

Atticoantral

• Active- presence of cholesteatoma of posterosuperior region of pars tensa or in pars flaccida.

• Inactive- retraction pockets in pars tensa or pars flaccida.

Clinical features

• Ear discharge- non-offensive, mucoid or mucopurulent, constant or intermittent.

• Hearing loss- conductive type

Round window phenomenon• Perforation• Middle ear mucosa- normally, it is pale pink and moist;

when inflamed it looks red, oedematous and swollen.

Investigations

• Examination under microscope• Audiogram• Culture and sensitivity of ear discharge• Mastoid X- rays/ CT scan temporal bone

Treatment

• Aural toilet• Ear drops• Systemic antibiotics• Precautions• Treatment of contributory causes- tonsils, adenoids,

maxillary antra and nasal allergy• Surgical treatment• Reconstructive surgery

Atticoantral type

• Aetiology- cholesteatoma• Patology

1. Cholesteatoma

2. Osteitis and granulation tissue

3. Ossicular necrosis

4. Cholesterol granuloma

Cholesteatoma

Symptoms and signs

Symptoms

• Ear discharge- usually scanty, but always foul smelling due to bone destruction

• Hearing loss• Bleeding

Signs

• Perforation• Retraction pocket• Cholesteatoma

Investigations

• Examination under microscope• Tuning fork tests and audiogram• X- ray mastoids/ CT scan temporal bone• Culture and sensitivity of ear discharge

Features indicating complications of CSOM

• Pain• Vertigo• Persistent headache• Facial weakness• A listless child refusing to take feeds and easily going to

sleep• Fever, nausea and vomiting• Irritability and neck rigidity• Diplopia• Ataxia• Abscess around ear

Treatment

• Surgical treatment

1. Canal wall down procedure

2. Canal wall up procedure• Reconstructive surgery• Conservative treatment

Comparison of procedures

Canal wall up procedure Canal wall down procedure

Meatus Normal appearance Widely open meatus communicating with mastoid

Dependence Does not require routine cleaning Dependence on doctor for cleaning mastoid cavity once or twice a year

Recurrence or residual disease High rate of recurrent or residual cholesteatoma

Low rate of recurrence or residual disease and thus a safe procedure

Second look surgery Requires second look surgery after 6 months or so to rule out cholesteatoma

Not required

Patients limitations No limitation. Patient allowed swimming.

Swimming can lead to infection of mastoid cavity and it is thus curtailed

Auditory rehabilitation Easy to wear a hearing aid if needed

Problems in fitting a hearing aid due to large meatus and mastoid cavity which sometimes gets infected