Chronic Otitis Media

If an attack of acute otitis media fails to heal, the perforation and discharge may in some cases persist.This leads to mixed infection and further damage to the middle-ear structures, with worsening conductive deafness.The predisposing factors in the development of chronic suppurative otitis media (CSOM) are listed in Box 9.1. 39 CAUSES OF CHRONIC OTITIS MEDIA: 1 Late treatment of acute otitis media. 2 Inadequate or inappropriate antibiotic therapy. 3 Upper airway sepsis. 4 Lowered resistance, e.g. malnutrition, anaemia,immunological impairment. 5 Particularly virulent infection, e.g. measles. There are two major types of CSOM. 1 Mucosal disease with tympanic membrane perforation (tubo-tympanic disease, relatively safe). 2 Bony: (a) osteitis; (b) cholesteatoma—dangerous (attico-antral disease). Box 9.1 Causes of chronic otitis media. Mucosal infection In these cases there may be underlying nasal or pharyngeal sepsis that will require attention if the ear is to heal. The ear will discharge, usually copiously, and the discharge is mucoid. Remember—mucoid discharge from an ear must mean that there is a perforation present, even if you cannot identify it. The perforation is in the pars tensa, and may be large or very small and difficult to see (Fig. 9.1). Serious complications are very rare but if left untreated the condition may result in permanent deafness. The ear may become quiescent from time to time, a feature less likely to happen with bony CSOM, and the perforation may heal. If healing does not occur, surgical repair may be necessary. TREATMENT OF MUCOSAL-TYPE CSOM Ear discharge When the ear is discharging, a swab should be sent for bacteriological analysis. The mainstay of treatment is thorough and regular aural toilet. Appropriate (as determined by the culture report) antibiotic therapy is instituted and in most cases the ear will rapidly become dry.The perforation may heal, especially if it is small. If the ear does not rapidly become dry, admission to hospital for regular aural toilet is often effective. If infection persists, look for chronic nasal or pharyngeal infection. Dry perforation When there is a dry perforation, surgery may be considered but is not mandatory.Myringoplasty is the repair of a tympanic membrane perforation; the tympanic membrane is exposed by an external incision, the rim of the perforation is stripped of epithelium and a graft is applied, usually on the medial aspect of the membrane.Various tissues have been used for graft material but that in most common use is autologous temporalis fascia, which is readily available at the operation site. Success rates for this procedure are very high; repair of the tympanic membrane may be combined with ossicular reconstruction, if necessary, in order to restore hearing—the operation is then referred to as a tympanoplasty. BONY OR ATTICO-ANTRAL TYPE OF CSOM The bone affected by this type of CSOM comprises the tympanic ring, the ossicles, the mastoid air cells and the bony walls of the attic, aditus and antrum.The perforation is postero-superior (Fig. 9.2) or in the pars flaccida (Schrapnell’s membrane) (Fig. 9.3) and involves the bony annulus. The discharge is often scanty but usually persistent, and is often foul smelling. There are other features of this type of CSOM. 1 Granulations as a result of osteitis—bright red and bleed on touch. 2 Aural polyps—formed of granulation tissue, which may fill the meatus and present at its outer end. 3 Cholesteatoma.This is formed by squamous epithelium within the middle- ear cleft, starting as a retraction pocket in the tympanic membrane. It results in accumulation of keratotic debris. This will be visible through the perforation as keratin flakes, which are white and smelly. The cholesteatoma expands and damages vital structures, such as dura, lateral sinus, facial nerve and lateral semicircular canal. Cholesteatoma is potentially lethal if untreated. TREATMENT OF BONY-TYPE CSOM 1 Regular aural toilet in early cases of annular osteitis may be adequate to prevent progression, but such a case should be watched closely. 2 Suction toilet under the microscope may evacuate a small pocket of cholesteatoma, and a dry ear may result. 3 Mastoidectomy is nearly always necessary in established cholesteatoma and takes several forms, depending on the extent of the disease

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