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Chronic Otitis Media

Chronic otitis media is an otological condition with symptoms like painless otorrhea and hearing loss persisting for more than six weeks. It can occur with or without cholesteatoma and is associated with the formation of aural polyps, granulations, destruction of the ossicles and occasional complications like facial palsy, labyrinthitis and even intracranial abscess.


Presentation

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].

Recurrent Otitis Media
  • 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]
  • Otitis media is a continuum of conditions that includes acute otitis media, otitis media with residual or persistent effusion, unresponsive otitis media, recurrent otitis media, otitis media with complications, and chronic suppurative otitis media.[journals.lww.com]
  • ) Both sides otitis media with eardrum ruptures Both sides persistent acute otitis media Both sides recurrent otitis media Chronic otitis media Chronic otitis media after insertion of tympanic ventilation tube Chronic otitis media status post pe tubes[icd9data.com]
  • otitis media Otitis media is most common in the younger age groups.[meddean.luc.edu]
  • The prophylactic use of antibiotics to prevent recurrent otitis media is controversial. Current AAP Practice Guidelines don't recommend prophylactic antibiotics to reduce the frequency of episodes of AOM.[emedexpert.com]
Wound Infection
  • These devices have several complications including skin reaction, wound infection, growth of skin over the abutment, and implant extrusion.[ncbi.nlm.nih.gov]
  • In one patient, wound infection had occurred, and implant was removed along with implantation at contralateral ear. Other subjects showed no evidence of recurrence.[ncbi.nlm.nih.gov]
  • The duration (days) of postsurgical local wound treatment was measured as an outcome, because this duration was assumed to be prolonged by the existence of wound infection.[ncbi.nlm.nih.gov]
  • Surgical complications included transient vertigo (n 2), wound infection (n 2), and temporary facial nerve palsy (n 1).[ncbi.nlm.nih.gov]
Mucosal Edema
  • This response creates mucosal edema which may ulcerate in long-lasting inflammation scenarios and create a granulation tissue.[symptoma.com]
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]
Plethora
  • 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[symptoma.com]
Malocclusion
  • We report a case of chronic otitis media with spread of the infection into the temporomandibular joint (TMJ), causing displacement of the joint and malocclusion.[ncbi.nlm.nih.gov]
Mouth Breathing
  • 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.[symptoma.com]
Fracture
  • 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]
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]
  • IMPORTANCE: Several sources have suggested an association between chronic sensory hearing impairment and chronic otitis media (COM).[ncbi.nlm.nih.gov]
  • All patients had COME and AH diagnosed by an otolaryngologist and had moderate to severe hearing impairment. COM treatment was based on close observation over time, nasal decongestants and surgical intervention.[ncbi.nlm.nih.gov]
  • Hearing impairment and ear pathology in Nepal. J Laryngol Otol. 1993;107(5):395-400. Upadhyay MP. Sunsari health examination survey, B P Koirala Institute of Health Sciences. 1996. Maharjan M, Bhandari S ,Singh I ,Mishra SC.[ijorl.com]
  • ., placement of tympanostomy tubes) is only indicated if hearing impairment occurs or if the effusion persists. Acute OME in adults should raise suspicion of a nasopharyngeal malignancy and prompt swift evaluation.[amboss.com]
Ear Discharge
  • A 48-year-old man presented with left ear discharge and hearing loss. Clinical examination showed a well-circumscribed polypoid mass limited to the EAC.[ncbi.nlm.nih.gov]
  • We report a 40-year-old woman who presented with complaints of ear discharge, deep-seated ear pain and loss of hearing in her right ear. Early diagnosis demands heightened suspicion in a patient with otological symptoms and facial paralysis.[ncbi.nlm.nih.gov]
  • Symptoms Recurrent ear discharge, pain and hearing loss are the most common symptoms. The ear discharge and pain are due to infection and hearing loss due to perforation of the eardrum and occasionally, erosion of the ossicles in the middle ear.[singhealth.com.sg]
  • INTRODUCTION: Chronic otitis media (COM), affecting all over the world and in a wide range of age groups in Turkey, is an important cause of ear discharge and hearing loss.[ncbi.nlm.nih.gov]
  • Granulation tissue and ear discharge are often associated with secondary infection of the desquamating epithelium.[aafp.org]
Tinnitus
  • Abstract The purpose of this study is to investigate what characteristics of tinnitus in patients with chronic otitis media was reduced after tympanoplasty and to assess the relationship between post-operative tinnitus reduction and pre-operative tinnitus[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • 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]
  • […] adjusted OR, 1.78; 95% confidence interval [CI], 1.06-3.01), chronic rhinosinusitis (adjusted OR, 1.87; 95% CI, 1.17-2.98), mild hearing 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[ncbi.nlm.nih.gov]
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]
  • 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]
  • 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]
  • Fluid buildup in the middle ear also blocks sound, which can lead to temporary hearing problems.[kidshealth.org]
  • In otitis media with effusion antibiotics may help if the fluid is still present after a few months and is causing hearing problems in both ears.[emedexpert.com]
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]
  • There was a statistically significant difference in the mean preoperative and postoperative THI and DHI scores between the groups (p CONCLUSION: Our study results suggest that a successful surgery results in improved tinnitus and vertigo symptoms in patients[ncbi.nlm.nih.gov]
  • Surgical complications included transient vertigo (n 2), wound infection (n 2), and temporary facial nerve palsy (n 1).[ncbi.nlm.nih.gov]
  • If untreated, cholesteatoma will eventually erode the middle ear structures (little bones of hearing), the labyrinth (the inner ear) to cause loss of hearing, dizziness or vertigo and facial paralysis.[newyorkear.com]
  • 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.[symptoma.com]

Workup

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].

Treatment

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].

Prognosis

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.

Etiology

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].

Epidemiology

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].

Sex distribution
Age distribution

Pathophysiology

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].

Prevention

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.

Summary

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.

Patient Information

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.

References

Article

  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.

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Last updated: 2019-07-11 21:05