Otitis Media (Chronic Suppurative)
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). Further, patients with craniofacial abnormalities (eg, Down syndrome, cri du chat syndrome, cleft lip and/or cleft palate, 22111.2 deletion [also called velocardiofacial syndrome, Shrpintzen syndrome, Shprintzen-Goldberg syndrome, and DiGeorge syndrome]) have an increased risk.
Chronic suppurative otitis media may become exacerbated after an upper respiratory infection or when water enters the middle ear through a tympanic membrane (TM) perforation during bathing or swimming. 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 TM perforation). Aural polyps are a serious sign, almost invariably suggesting cholesteatoma.
A cholesteatoma is an epithelial cell growth that forms in the middle ear, mastoid, or epitympanum after chronic suppurative otitis media. Lytic enzymes, such as collagenases, produced by the cholesteatoma can destroy adjacent bone and soft tissue. The cholesteatoma is also a nidus for infection; purulent labyrinthitis, facial paralysis, or intracranial abscess may develop.
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 has 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.
Diagnosis of chronic suppurative otitis media is usually clinical. Drainage is 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 reveal 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 recurrent neoplasm.
Ten drops of topical ciprofloxacin solution are instilled in the affected ear 2 times/day for 14 days.
When granulation tissue is present, it is removed with microinstruments or cauterization with silver nitrate sticks. Ciprofloxacin 0.3% and dexamethasone 0.1% is then instilled into the ear canal for 7 to 10 days. When granulation tissue persists or continues to recur in spite of adequate local treatment, a biopsy to rule out 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 3rd-generation cephalosporin, subsequently modified by 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. 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 8 months later.
Chronic suppurative otitis media is a persistent perforation of the tympanic membrane with chronic suppurative drainage.
Damage to middle ear structures often develops; less commonly, intratemporal or intracranial structures are affected.
Initial treatment is with topical antibiotics.
Severe exacerbations require systemic antibiotics.
Surgery is needed for certain types of perforation and damaged ossicles and to remove any cholesteatomas.