Chronic otitis media (COM) is a condition characterized by persistent, and recurrent aural symptoms lasting for more than six to twelve weeks [1] [2]. Based on the middle ear mucosal pathology it has been classified as simple chronic otitis media, chronic cholesteatoma otitis media, chronic granulomatous otitis media (e.g. tuberculosis), and chronic otitis media associated with specific diseases (e.g. eosinophilic granuloma, eosinophilic otitis media, Wegener granulomatosis) [3] [4] [5] [6] [7].

Risk factors associated with COM include acute otitis media, eustachian tube dysfunction, thermal /mechanical or chemical trauma, blast injuries, iatrogenic factors such as tympanostomy tube placement, and craniofacial anomalies like cri du chat syndrome, Down syndrome, cleft lip and/or cleft palate, and velocardiofacial syndrome.

Patients present with purulent, serous, mucoid or blood stained, occasionally foul smelling, painless otorrhea which may increase during episodes of upper respiratory tract infections. This is accompanied by either conductive or mixed or sensorineural hearing loss in the affected ear. There may be tympanic membrane perforation with granulations or even polyps in the middle ear. In granulomatous COM, the middle ear mucosa appears very pale with thin, serous otorrhea. Foul smelling and blood stained otorrhea are noticed in cholesteatomatous COM due to secondary gram-negative bacterial infection. Rarely patients can present with complications of COM like mastoiditis, facial palsy, labyrinthitis, vertigo, lateral sinus thrombophlebitis, petrositis, and even life-threatening intracranial abscess or meningitis [8]. COM with cholesteatoma has a higher incidence of intra-temporal and intracranial complications as cholesteatoma causes osteitis and bone destruction [9] [10] [11].

• Surgical Procedure

  The most common surgical procedure in children is the placement of myringotomy tubes. [entforkidsalabama.com]

  Several potential prognostic factors were evaluated: cholesteatoma present vs absent; type of surgical procedure, state of the middle ear mucosa, state of the ossicular chain, type of prosthesis. [ncbi.nlm.nih.gov]

  procedures include: Tympanoplasty: Surgery to reconstruct the eardrum and small bones of the middle ear Mastoidectomy: Surgery to remove the mastoid air cells Typanomastoidectomy: A surgical procedure to clear the infection both in the middle ear and [dovemed.com]

• Recurrent Otitis Media

  […] of tympanic membrane due to otitis media Persistent acute otitis media Recurrent acute otitis media Recurrent otitis media Recurrent right otitis media Right acute otitis media Right acute persistent otitis media Right chronic otitis media Right chronic [icd9data.com]

  A 10-year-old boy was referred to Tokyo Metropolitan Children's Medical Center with a 7-year history of recurrent otitis media despite treatment with antibiotics and ventilation tubes. [ncbi.nlm.nih.gov]

  […] related to abnormal middle ear pressure prolonged serious hearing loss which may compromise speech and IQ development recurrent otitis media •Impending rupture of the TM Otitis media can result in excessive positive or negative pressure within the middle [rnceus.com]

  media (COM) and recurrent otitis media (ROM) have been investigated in previous studies. [journals.plos.org]

• Soft Tissue Mass

  Ceruminous carcinomas should be considered in the differentialdiagnosis of middle and external ear pathologies in cases of soft tissue mass in the EAC. [ncbi.nlm.nih.gov]

  CT signs of cholesteatoma are: Soft tissue mass in the middle ear Especially if located in Prussaks space In advanced cholesteatoma the presence of aerated parts of the middle ear denote a mass and not an effusion Non-dependent soft tissue particularly [radiologyassistant.nl]

• Fracture

  Longitudinal fractures generally spare the inner ear, which is more often breached by transverse fractures. [radiologyassistant.nl]

  Although pneumocephalus is quite common following trauma, especially with a fracture involving paranasal sinuses it is a rare manifestation of chronic otitis media. [ncbi.nlm.nih.gov]

  […] cholesteatoma causes disruption and erosion of the auditory ossicles mass-like appearance rather than dependent fluid can be difficult to exclude if the middle ear cavity is diffusely opacified hemotympanum following trauma associated with skull base fracture [radiopaedia.org]

  Cholesteatoma - a special form of chronic otitis media - can in rare cases be congenital ("genuine" cholesteatoma) or else acquired, for example after a longitudinal temporal bone fracture ("post-traumatic" cholesteatoma). [ims.uniklinik-freiburg.de]

  Trauma, such as a basilar skull fracture, can also lead to discharge from the ear due to cerebral spinal drainage from the brain and its covering (meninges). [en.wikipedia.org]

• Ear Discharge

  We report a case of carcinoma originating from the ceruminous glands of the external ear canal (EAC), operated based on a diagnosis of chronic otitis media with polyp. A 48-year-old man presented with left ear discharge and hearing loss. [ncbi.nlm.nih.gov]

  […] infection can cause persistent foul-smelling ear discharge and hearing loss. [singhealth.com.sg]

  We defined patients with chronic ear discharge as those with at least two weeks of ear discharge, where the cause of the discharge was unknown. [cochranelibrary.com]

  The benefits of ear cleansing are unknown, although this treatment is usually recommended for children with ear discharge. [aafp.org]

• Hearing Impairment

  impairment (adjusted OR, 1.95; 95% CI, 1.34-2.85), moderate hearing impairment (adjusted OR, 4.00; 95% CI, 2.21-7.22), tinnitus (adjusted OR, 1.82; 95% CI, 1.34-2.49), increased hearing thresholds in pure tone audiometry in the right ear (adjusted OR [ncbi.nlm.nih.gov]

  A total of 364 million people have mild hearing impairment, while 624 million are estimated to have some level of hearing impairment and 80% of these live in low and middle-income countries [ 10 ]. [panafrican-med-journal.com]

  Although the hearing loss caused by otitis media is usually temporary, untreated otitis media may lead to permanent hearing impairment. [phagetherapycenter.com]

  The perforation may close spontaneously in an unknown portion of cases, but it persists in others, leading to mild to moderate hearing impairment (about a 26- to 60-dB increase in hearing thresholds), based on surveys among children in Africa, Brazil, [aafp.org]

• Tinnitus

  INTRODUCTION: Previous reports indicated that middle ear surgery might partially improve tinnitus after surgery. However, until now, no influencing factor has been determined for tinnitus outcome after middle ear surgery. [ncbi.nlm.nih.gov]

  Learn More About Topic Tinnitus Over 50 million Americans have experienced tinnitus, or ringing in ears, which is the perception of sound without an external source being present. [entnet.org]

• Hearing Problem

  Chronic otitis media can seriously affect quality of life progressively and in long-term, and it remains the major source of hearing problems in the developing world. [ncbi.nlm.nih.gov]

  Surgery Your doctor may recommend surgery for chronic ear infections that aren’t responding to treatment or are causing hearing problems. Hearing problems can be especially problematic in children. [healthline.com]

  However, long-term OME can cause hearing problems and other difficulties, particularly in children. [medicalnewstoday.com]

  A chronic ear infection can cause severe hearing problems. Such a hearing deficit in young children can lead to speech and language problems early in their development. [research.sklarcorp.com]

  Can Ear Infections Affect Hearing? Fluid buildup in the middle ear also blocks sound, which can lead to temporary hearing problems. [kidshealth.org]

• Progressive Hearing Loss

  Progressive hearing loss on the left ear. Patient Data Age: 40 Gender: Female Loading images... Axial bone window transverse The left middle ear is filled by soft tissue completely encasing the auditory ossicles. [radiopaedia.org]

  This tympano fibrosis or tympano sclerosis causes a progressive loss of hearing in the middle ear. [ims.uniklinik-freiburg.de]

  Persistent hearing loss during the first two years of life may increase learning disabilities and poor scholastic performance. Progressive hearing loss may occur among those in whom infection persists and discharge recurs. [aafp.org]

  A large vestibular aqueduct is associated with progressive sensorineural hearing loss. This progression is reportedly associated with minor head trauma, which exposes the inner ear to pressure waves via the large vestibular aqueduct. [radiologyassistant.nl]

• Dizziness

  OBJECTIVES: This study aims to evaluate whether chronic otitis media (COM) may cause inner ear damages or middle ear surgery may improve this damage with regard to sensorineural hearing loss (SNHL) and tinnitus and dizziness-related disability. [ncbi.nlm.nih.gov]

  Hain, MD of Chicago Dizziness and Balance Page last modified: January 1, 2018 Normal ear structures Definition of Chronic Otitis Media (COM) The term otitis media means that there is inflammation of the middle ear. [dizziness-and-balance.com]

  ENT specialists treat conditions such as ear infection, hearing loss, dizziness, ringing in the ears (called tinnitus), ear, face, or neck pain, and more. [entnet.org]

• Vertigo

  The most common symptoms are conductive hearing loss, tinnitus and vertigo. The treatment of choice is complete surgical removal of the tumour with no adjuvant radiotherapy being required. [ncbi.nlm.nih.gov]

  Benign Paroxysmal Positional Vertigo (BPPV) Benign paroxysmal positional vertigo, or BPPV, is the most common inner ear problem and cause of vertigo, or false sense of spinning. [entnet.org]

• Confusion

  As the infection spreads, the patient develops more severe restlessness, delirium and confusion. Treatment is high-dose IV antibiotics for 7 to 21 days. Acute mastoiditis: This is an infection that affects the mastoid bone located behind the ear. [sciencedaily.com]

  Also, seek emergency care for fever, swelling, tenderness or redness behind the ear, persistent or severe ear pain, dizziness, headache, confusion, or facial weakness. [drugs.com]

  Nonetheless, the other case of confusion between tastes happened between bitter and sour, which have different activation pathways and there is no explanation for it so far. [scielo.br]

  […] cholesteatoma, which is an abnormal skin growth Persistence of fluid behind the eardrum Persistent blockage in the ear, fullness of the ear Other signs and symptoms may include: Problems with balance Facial weakness Persistent ear pain and headache Fever Confusion [dovemed.com]

• Giddiness

  Symptoms  Ear discharge – foul smelling scanty predominantly purulent occasionally blood stained  Deafness  Itching and pain in the ear – with otitis externa  Tinnitus & giddiness – early symptoms of complication 15. [slideshare.net]

  If labyrinthine fistula is present the patient will feel giddy and will have nystagmus. Facial palsy may indicate erosion of facial nerve canal with involvement of facial nerve. [drtbalu.com]

The diagnosis of COM is based on a history of chronic otorrhea, recurrent ear infections, and hearing loss [12]. A thorough examination of the ear under a microscope or with an oto-endoscope along with suctioning of the discharge is essential to detect the pathology and the extent of the disease as well as to obtain the discharge for gram stain, microbiological culture, and antibiotic sensitivity. Routine laboratory tests like complete blood count, erythrocyte sedimentation rate are obtained prior to surgical intervention. Cerebrospinal fluid testing may have to be ordered in patients presenting with clinical features of meningitis. Audiological evaluation with a tuning fork and audiogram are performed in all cases of COM, as a routine, except in those presenting with life-threatening complications.

High resolution computed tomogram (HRCT) and magnetic resonance imaging (MRI) are indicated to detect complications like labyrinthitis, ossicular chain or temporal bone erosion, intracranial abscesses. HRCT of the temporal bone provides reliable information about mastoid, middle ear, and labyrinthine anatomy as well as pathology [13] [14] [15]. Spiral CT scan is superior to conventional CT scan in the diagnosis of cholesteatoma and other lesions associated with COM [16] [17].

An effective treatment of COM depends on the stage of the diagnosed infection. Early stage COM can be tackled with a combination of topical antibiotics and steroids. In case of systemic and large-scale infections, oral or parenteral administration of antibiotics is an advisable approach to fight the infection. During the treatment it is imperative to guarantee a dry middle ear cavity [18].

Medication options in the treatment of COM involve the prescription of ciprofloxacin, which offers a broad spectrum of antimicrobial activity; another possibility is to combine ciprofloxacin with dexamethasone to offer an additional anti-inflammatory treatment. The most widely used antibiotic in the context of COM is tobramycin because of its long and successful treatment history. However, there is a significant risk of vestibular and cochlear toxicity in case of its prolonged use, if the patient does not present with inflammation symptoms. Piperacillin can be taken into consideration for prescription, if the patient has been diagnosed with a pseudomonal infection. Ceftadizime is an excellent option for a systemic antibiotic treatment of COM, because it does not feature long-term side effects [19].

If medication measures fail to ease the symptoms of COM, a surgical intervention is necessary. The objectives of these procedures are the eradication of the source of inflammation, i.e. the removal of middle-ear mucosa, the preservation of the mastoid bone and a surgical remodeling of the middle ear in order to preserve and recover hearing. Recommended surgery options are a myringoplasty, a tympanoplasty and a mastoidectomy [11].

Patients usually respond well to antimicrobial agents. Children may have to prolong the antibiotic treatment to experience the desired effect. Chronic ear infections can be recurrent, so regular medical check-ups are advisable in any case.

Untreated COM offers a plethora of complications ranging from mastoiditis, cholesteastoma, tympanosclerosis, paralysis of the facial nerve, generic damage to the middle ear, epidural abscess in or around the brain to balance perturbations and speech issues. In rare cases, patients can develop complete deafness [8].

Surgical treatments also comes with possible side effects. The most dangerous possibility is a large-scale post-operative infection, which is why the use of perioperative antibiotics may be advisable. Taste disturbance may occur as a consequence of a damage to the tympani nerve. Further hearing loss can be found in case of a scarring of the tympanic membrane. Vertigo and temporary facial paralysis has often been reported in the immediate aftermath of the procedure [2].

However, a tympanoplastic procedure usually provides excellent healing chances in the vast majority of cases. Patients will soon be free of symptoms but regular post-operative checks are necessary to maintain a healthy middle ear.

The main cause of COM is an acute infection (acute otitis media, AOM) in the middle ear involving severe inflammation symptoms and the traumatic perforation of the tympanic membrane. COM usually develops as a consequence of a translocation of bacteria from the external auditory canal into the middle ear after the above-mentioned perforation of the tympanic membrane. The middle ear is usually dry and well-ventilated by constant air flow from the eustachian tube. Impaired air flow through the middle ear sets the stage for a possible infection of the middle ear. Clogging of the eustachian tube may thus be another cause of COM, which can occur as a consequence of allergies, post nasal drainage, sinus infections, an immature eustachian tube in children or viral infections of the upper respiratory tract [1] [2].

COM has an average rate of incidence of 39 in 100 000 in children and adolescents younger than 15. There is no conclusive statistics suggesting a gender preference for COM [20].

The probability of occurence is higher in children than in adults, as shown in a study reporting an almost two-fold higher chance of COM in children (0.9% in children vs. 0.5% in adults). In countries with a warmer climate, COM prevalence can be significantly smaller (e.g. 0.039% of Israeli children). Some ethnicities are more prone to develop COM for unknown reasons. Native Americans and Inuit people have a statistical chance of eight and twelve percent to develop COM, respectively. It has been speculated that a wider eustachian tube may play a role in increasing the odds of a chronic middle ear infection in these cases. People from Guam, Hong Kong, South Africa and the Solomon Islands may suffer from a similar predisposition [21].

COM typically results from an acute infection of the middle ear. The immune system attempts to resolve this infection with an inflammatory response. This response creates mucosal edema which may ulcerate in long-lasting inflammation scenarios and create a granulation tissue. Recurring episodes of infections, inflammations, ulcerations and granulation tissue formations can gradually deteriorate the middle ear bones and lead to severe complications of COM [14].

The infection is most frequently caused by the following bacteria in descending order of likelihood: Pseudomonas aeruginosa, Staphylococcus aureus, Proteusspecies and Klebsiella pneumoniae [22]. Multicultural infections are possible, but rare. Anaerobes (Bacteroides, Peptostreptococcus, Peptococcus) and fungi (Aspergillus, Candida) have also been reported as possible infection causes [23].

There is no recipe to reliably prevent COM. Some lifestyle changes may, however, reduce the risk of infection. Snoring and mouth breathing are an early symptom for possibly enlarged adenoids which may increase the odds of a middle ear infection. High standards in everyday hygiene and a smoke-free home may reduce infection risks, too. After COM treatment it is imperative for the patients to keep their ears dry, in particular after daily showers and after swimming. Professional allergy controls in children may also reduce the risk.

Chronic otitis media is a major complication of an acute infection episode of the middle ear. Inflammation is usually caused by the migration of bacteria into the middle ear space. Clogging of this space creates a warm and damp micro-climate and leads to recurrent episodes of inflammation conducive to more serious symptoms that can result into a complete loss of hearing. Diagnosis must prove a perforated tympanic membrane and a mucosal infection of the inner ear based on culture extraction and/or imaging techniques. Topical and systemic antimicrobial treatments typically offer best healing chances. In severe cases, surgery must be considered in order to preserve middle ear structure. Patients are advised to regularly check back with their medical professionals to ascertain a dry and well-ventilated middle ear.

Chronic otitis media is a serious infection of the middle ear which requires immediate attention of a doctor. If left untreated, chronic otitis media can lead to severe and irreversible damage of the middle ear. After professional treatment, you will be required to keep your ear dry at all times and regularly consult a professional to ascertain the desired healing process. A smoke-free environment and high standards in everyday hygiene will likely help you keep future infections at bay.

1. Matsuda Y, Kurita T, Ueda Y, Ito S, Nakashima T. Effect of tympanic membrane perforation on middle-ear sound transmission. J Laryngol Otol. 2009; 31:81-89.
2. Wright D, Safranek S. Treatment of otitis media with perforated tympanic membrane. Am Fam Physician. 2009; 79(8):650-654.
3. Wiatr M, Wiater A, Skladzien J, et al. Determinants of change in air-bone gap and bone conduction in patients operated on for chronic otitis media. Med Sci Monit. 2015; 21:2345 -2351.
4. Chung WJ, Lee JH, Lim HK, et al. Eosinophilic otitis media: CT and MRI findings and literature review. Korean J Radiol. 2012; 13(3):363-367.
5. Ma KH, Tang PS, Chan KW. Aural tuberculosis. Am J Otol. 1990; 11(3):174-177.
6. Abdel-Aziz M, Rashed M, Khalifa B, et al. Eosinophilic granuloma of the temporal bone in children. J Craniofac Surg. 2014; 25(3):1076-1078.
7. Brihaye P, Halama AR. Fluctuating hearing loss in sarcoidosis. Acta Otorhinolaryngol Belg. 1993; 47(1):23-26.
8. Smith JA, Danner CJ. Complications of chronic otitis media and cholesteatoma. Otolaryngol Clin North Am. 2006; 39(6):1237-1255.
9. Sudhoff H, Hildmann H. Current theories on the origin of cholesteatoma. HNO. 2003; 51(1):71–82.
10. Koike T, Murakoshi M, Hamanishi S, et al. An apparatus for diagnosis of ossicular chain mobility in humans. Int J Audiol. 2006; 45(2):121–128.
11. Fisch U. Tympanoplastyka, mastoidektomia i chirurgia strzemiączka. Wrocław: Urban & Partner; 2004.
12. Berman S. Management of acute and chronic otitis media in pediatric practice. Curr Opin Pediatr. 1995; 7(5):513–522.
13. Blevins NH, Carter BL. Routine preoperative imaging in chronic ear surgery. Am J Otol. 1998; 19(4):527–535.
14. Chole R, Sudhoff H. Chronic otitis media, Mastoiditis and Petrositis. In: Cummimngs C, Fint PW, Harker LA, Haughey BH, Richardson MA, Robbins KT, et al., editors. Otolaryngology Head and Neck Surgery. 4th ed. Philadelphia, PA: Elsevier; 2005.
15. Boyraz E, Erdogan N, Boyraz I, et al. The importance of computed tomography examination of temporal bone in detecting tympanosclerosis. Kulak Burun Bogaz Ihtis Derg. 2009; 19(6):294–298.
16. Kong Q, Deng X, Wang X, Zhang Y. The application of spiral CT in diagnosing the otitis media with cholesteatoma. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2007; 21(1):22–24.
17. Naghibi S, Seifirad S, Dehkordi MA, et al. Comparison of conventional versus spiral computed tomography with three-dimensional reconstruction in chronic otitis media with ossicular chain destruction. Iran J Radiol. 2016; 13(1):e9018.
18. Hannley MT, Denneny JC 3rd, Holzer SS. Use of Ototopical Antibiotics in Treating 3 Common Ear Diseases. Otol Head Neck Surg. 2000; 122(6):934-940.
19. Roland PS, Dohar JE, Lanier BJ, et al. Topical ciprofloxacin/dexamethasone otic suspension is superior to ofloxacin otic solution in the treatment of granulation tissue in children with acute otitis media with otorrhea through tympanostomy tubes. Otolaryngol Head Neck Surg. 2004; 130(6):736-741.
20. van der Veen EL, Schilder AG, van Heerbeek N, Verhoeff M, Zielhuis GA, Rovers MM. Predictors of chronic suppurative otitis media in children. Arch Otolaryngol Head Neck Surg. 2006; 132(10):1115-1118.
21. Vikram BK, Khaja N, Udayashankar SG, Venkatesha BK, Manjunath D. Clinico-epidemiological study of complicated and uncomplicated chronic suppurative otitis media. J Laryngol Otol. 2008; 122(5):442-446.
22. Mansoor T, Musani MA, Khalid G, Kamal M. Pseudomonas aeruginosa in chronic suppurative otitis media: sensitivity spectrum against various antibiotics in Karachi. J Ayub Med Coll Abbottabad. 2009; 21(2):120-123.
23. Talwar P, Chakrabarti A, Kaur P, Pahwa RK, Mittal A, Mehra YN. Fungal infections of ear with special reference to chronic suppurative otitis media. Mycopathologia. 1988; 104(1):47-50.