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Otitis Media (Chronic)
Chronic otitis media is a persistent, chronically draining (> 6 wk), 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 several times daily, careful removal of granulation tissue, and application of topical corticosteroids and antibiotics. Systemic antibiotics and surgery are reserved for severe cases.
Chronic 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, velocardiofacial syndrome [Shprintzen syndrome]) have an increased risk.
Chronic otitis media may become exacerbated after a URI 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 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 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 otitis media usually manifests with conductive hearing loss and otorrhea. Pain is uncommon unless an associated osteitis of the temporal bone occurs. The TM 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 TM perforation, and an ear canal that appears clogged with mucopurulent granulation tissue.
Diagnosis 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).
The ear canal is irrigated with a bulb syringe 3 times/day with a slightly warmed solution of half vinegar and half sterile water. After the ear drains, 10 drops topical ofloxacin 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.
Severe exacerbations require systemic antibiotic therapy with amoxicillin 250 to 500 mg po q 8 h 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 TM 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 is done 6 to 8 mo later.
Chronic otitis media is a persistent perforation of the TM with chronic suppurative drainage.
Damage to middle ear structures often develops; less commonly, intratemporal or intracranial structures are affected.
Initial treatment is with irrigation and topical antibiotics.
Severe exacerbations require systemic antibiotics.
Surgery is needed for certain types of perforation and damaged ossicles and to remove any cholesteatomas.
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