Chronic Otitis Media


Chronic Otitis Media-various aspects- 

A persistent, persistently draining (more than six weeks), suppurative perforation of the tympanic membrane is referred to as chronic otitis media. Otorrhea without pain and hearing loss due to conductivity are symptoms. The emergence of auditory polyps, cholesteatoma, and various infections are complications. The ear canal must be thoroughly cleaned many times each day, the granulation tissue must be carefully removed, and topical corticosteroids and antibiotics must be applied. Surgery and systemic antibiotics are only used in severe situations.

Chronic Otitis Media
Chronic Otitis Media

Acute otitis media, eustachian tube obstruction, mechanical trauma, thermal or chemical burns, blast injuries, or iatrogenic causes can all lead to chronic otitis media . Chronic Otitis(eg, after tympanostomy tube placement). Patients who have craniofacial anomalies, such as velocardiofacial syndrome, Shprintzen syndrome, Shprintzen-Goldberg syndrome, or DiGeorge syndrome, are also at a higher risk. Examples include Down syndrome, cri du chat syndrome, cleft lip and/or palate, and 22q11.2 deletion.

Etiology of  chronic otitis media
Although viruses are the most frequent cause of otitis media, children who have chronic suppurative otitis media are frequently impacted by bacteria. A polymicrobial aetiology is typical. Staphylococcus aureus is the most frequent bacterium detected in this disorder (MRSA). Additional pathogens that can cause the disease include Pseudomonas aeruginosa, Proteus species, Klebsiella species, Bacteroides species, and Fusobacterium species. Aspergillus spp. and Candida spp. are less frequent but are more frequently discovered in immunocompromised people. [4] In places with a high incidence of tuberculosis, it is more common to develop chronic otitis media as a result of tuberculosis.

Epidemiology of chronic otitis media-
Early childhood is when chronic suppurative otitis media typically occurs, most frequently around age two. Children from low-income families are those most at risk. [5] Children with craniofacial deformities, such as cleft palates and those born with Down syndrome, are also more likely to develop this disease. Although extremely uncommon, Gradenigo syndrome includes otitis media along with orbito-facial discomfort and sixth cranial nerve palsy. A persistent suppurative otitis media problem that might result in this syndrome is otitis media. [6] The Eustachian tube dysfunction that characterises these congenital defects predisposes the affected youngsters to middle ear disorders. The most common acute otitis media episodes, upper respiratory tract infections, injuries to the tympanic membrane, poor nutrition, and living conditions are the main risk factors for developing chronic suppurative otitis media.

During an upper respiratory infection or when water enters the middle ear through a rupture in the tympanic membrane (TM) while bathing or swimming, chronic suppurative otitis media may worsen. Prolonged exposure to air pollution and poor hygiene brought on by living in a neighborhood with limited resources can also make symptoms worse. Gram-negative bacteria or Staphylococcus aureus frequently cause infections that result in painless, purulent, and occasionally foul-smelling otorrhea. Chronic otitis media with suppuration that lasts for a long time might damage the middle ear and cause aural polyps or necrosis of the long process of the incus (granulation tissue prolapsing into the ear canal through the TM perforation). Aural polyps are a significant symptom that nearly always denotes cholesteatoma.

With persistent chronic otitis media , an epithelial cell growth known as a cholesteatoma develops in the middle ear, mastoid, or epitympanum. The cholesteatoma produces lytic enzymes like collagenases that can obliterate nearby soft tissue and bone. Moreover, the cholesteatoma can become infected, leading to the development of facial paralysis, purulent labyrinthitis, or cerebral abscess.

Physical examination and and history in  chronic otitis media
The most common symptom of chronic suppurative otitis media is otorrhea, though dry ears can sometimes occur. Hearing loss, tinnitus, and auditory fullness are symptoms that may be present but are not necessary for diagnosis. [8] It’s vital to remember that kids might frequently present asymptomatically or extremely dangerously unwell with intracranial problems. It is critical to look into the patient’s history of vertigo and how it relates to any ear symptoms. All patients should be questioned on their recent antibiotic use, surgery, and ear infection history. Together with cigarette exposure, any additional medical conditions including allergic rhinitis and gastric reflux should be noted.

Chronic otitis media symptoms and signs
Conductive hearing loss and otorrhea are frequently associated with chronic suppurative otitis media symptoms. Unless the temporal bone develops an accompanying osteitis, pain is rare. The auditory canal is macerated and covered in granulation tissue, and the tympanic membrane is punctured and draining.

A cholesteatoma patient may experience fever, vertigo, and/or otalgia. A draining polypoid mass is protruding through the tympanic membrane perforation, there is white debris in the middle ear, and the ear canal looks to be blocked with mucopurulent granulation tissue

Evaluation of chronic otitis media-
The ears can be examined using either a surgical or operating otoscope head or a diagnostic or pneumatic otoscope head. It is possible to detect fluid in the middle ear, a sign of otitis media, by looking at how mobile the tympanic membrane is in response to negative or positive pressure. The tympanic membrane may also exhibit erythema, bulging or fullness, or severe retraction. A microbiologic examination must be used as the basis for the therapy of chronic suppurative otitis media, with the microorganism being targeted in accordance with the findings.

One of the organisms that is most common and pervasive in our physical world is pseudomonas, which prefers damp regions. It is believed that it first infects tissues by adhering to epithelial cells via pili or fimbriae.

Visit: Management / Therapy of chronic otitis media-
For chronic suppurative otitis media, topical quinolones are preferred because they are as efficacious as or even more so than aminoglycosides while posing no ototoxicity risk. Quinolones work well at treating otorrhoea and getting rid of the bacteria. [9] Parenteral antibiotic therapy together with diligent auditory cleansing is likely to be effective in eliminating the infection in chronic otitis media   if there is no concomitant cholesteatoma, but in recalcitrant situations, tympanomastoidectomy may be necessary. Ceftazidime and other beta-lactam antipseudomonal medications are utilised when a parental regimen is required. The alternative medication ticarcillin-clavulanate is efficient against S. aureus and Pseudomonas sp.

The pathophysiology of the infection and antibiotic resistance have both been linked to biofilm development.

Surgery may be able to prevent some consequences of  chronic otitis media if this is addressed, but patients may still experience postoperative ear discharge.

Referring the patient to otolaryngology is essential if the patient does not react to the initial course of treatment and/or develops a cholesteatoma or any other mass. Mastoidectomy with tympanoplasty requires assistance from the otolaryngology team when cholesteatoma is present.

Also, it is crucial to always evaluate hearing function and offer the proper follow-up to any patients who arrive with chronic otitis media.

Differential Diagnosis of chronic otitis media
It is crucial to take into account different illnesses that could exhibit a chronic suppurative otitis media-like clinical picture. The presence of a foreign body in the ear canal needs to be checked out because otorrhea is one of the most frequent indications seen in this entity and the most frequent age at presentation is often less than 5 years. A foul odour coming from the ear can help distinguish between chronic supportive otitis media and otorrhea brought on by a foreign body. Myringitis and otitis externa are two more illnesses that might be confused for chronic otitis media because they both exhibit otorrhea-like symptoms, but a physical examination can clarify the diagnosis in these cases as well. The more severe disorders of mastoiditis, abscess, and meningitis must also be ruled out. Some situations manifest more seriously and have systemic signs.

Differential Diagnosis of chronic otitis media

Histiocytosis of Langerhans cells
foreign object
thrombus in the sigmoid sinus
Hydrocephalus otitis
Additional abscess
brain infection
Granulomatosis Wegener
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Treatment of Toxicities and Adverse Effects
Aminoglycosides are one of the options available, although not being regarded as the first-line treatment for chronic suppurative otitis media. The possible ototoxicity that aminoglycosides may produce must be taken into account. [5]

Access: Prognosis of chronic otitis media-
Overall, if therapy is given and complications are avoided, the prognosis for chronic suppurative otitis media is favourable. There are certain refractory cases that can be detected, and these need more thorough analysis and care. As acute otitis media frequently follows chronic suppurative otitis media, it is crucial to identify and treat the bacterial etiology of acute otitis media in order to prevent chronic suppurative otitis media. The Pneumococcus vaccine’s introduction has had a beneficial impact on lowering the prevalence of acute otitis media, which in turn lowers the number of cases presenting with chronic suppurative otitis media. [5]

Complications of chronic otitis media-
Chronic suppurative otitis media can lead to a variety of problems, including labyrinthitis, tympanosclerosis, polyps, osteitis, sclerosis, and epidural, subdural, or brain abscesses. Hearing loss, whether conductive or sensorineural, is the most frequent consequence of chronic otitis media .  Language deficits and behavioural issues are related to hearing loss. [10]

Visit: Patient Education and Deterrence
Parents should get information on the value of routine well-child visits and be advised to seek immediate medical attention when their children complain of ear pain or discomfort. Also, it’s critical to evaluate instructor complaints, particularly if hearing loss is thought to be present. To lessen the likelihood of long-term problems, it is essential to treat and monitor children with chronic otitis media.

Visit: Improving Healthcare Team Results
The ear condition known as chronic suppurative otitis media-chronic otitis media  which mainly affects children under the age of two, is characterised by a persistent chronic infection of the middle ear without an intact tympanic membrane. This syndrome frequently precedes an episode of acute otitis media, and when this is suspected, urgent isolation of the causative agent is required. Chronic suppurative otitis media without treatment can result in serious side effects such polyps, sclerosis, tympanosclerosis, labyrinthitis, epidural, subdural, or brain abscesses, as well as conductive or sensorineural hearing loss that affects the child’s academic ability. For better results and to avoid problems, early diagnosis and treatment are essential.

The ENT specialist doctor can correctly identify and treat chronic suppurative otitis media by using the procedures described above. Engaging otolaryngology is beneficial, particularly in situations where more extensive treatment than antibiotics may be necessary.

Chronic Suppurative Otitis Media –chronic otitis media – Diagnosis-
clinical assessment
Chronic suppurative otitis media is typically diagnosed clinically. It is cultivated drainage. A CT or MRI is performed when cholesteatoma or associated problems are suspected (such as in a feverish patient or one who has vertigo or otalgia). These examinations could demonstrate intratemporal or cerebral processes (eg, labyrinthitis, ossicular or temporal erosion, abscesses). Biopsies should be performed to rule out recurrent neoplasia in patients with chronic or recurrent granulation tissue.

Therapy for Chronic Otitis Media with Pus
antibiotic drops for the skin
surgery-Mastoid surgery to remove granulation tissue and treat cholesteatomas
Two times daily for 14 days, ten drops of topical ciprofloxacin solution are injected into the afflicted ear.

Granulation tissue is eliminated when it is present by cauterising with silver nitrate sticks or using microinstruments. Thereafter, for seven to ten days, dexamethasone and ciprofloxacin are injected into the ear canal. Granulation tissue should be tested for neoplasms using a biopsy if it persists or keeps coming back despite receiving sufficient local treatment.

Severe exacerbations call for systemic antibiotic therapy with amoxicillin 250 to 500 mg taken orally every eight hours for 10 days or a third-generation cephalosporin, which is then adjusted based on culture findings and treatment response.

Patients with persistent central tympanic membrane perforations as well as marginal or attic perforations should consider tympanoplasty. During tympanoplasty, an ossicular chain that has become disorganised may also be repaired.

Cholesteatomas require surgical removal-Mastoid surgery is done. Reconstruction of the middle ear is typically delayed until a second-look procedure (using an open surgical technique or a small-diameter otoscope) is performed 6 to 8 months later due to the prevalence of recurrence.

Major Points for chronic otitis media
A persistent perforation of the tympanic membrane with ongoing suppurative discharge is referred to as chronic suppurative otitis media.
Injury to intratemporal or intracranial structures occurs less frequently than damage to middle ear structures.
Topical antibiotics are used as the initial treatment.
Systemic antibiotics are necessary for severe exacerbations.
For some perforations, broken ossicles, and to remove any cholesteatomas, surgery is required.
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My child is having ear discharge since last few months ,whenever we take treatment from our regular doctor ,there is temporary relief ,but after that ear discharge starts again, what should we do now ?
You need to consult a qualified and experienced ENT specialist doctor.
He will first clean the ear under ear microscope and with the help of in built camera system you will be able to view the tympanic membrane on the monitor.
Findings may be of myringitis ,bulging tympanic membrane ,granular myringitis,central perforation of tympanic membrane or cholesteotoma. Cholesteotoma is complication of chronic otitis media ,
Detailed history is taken by the ENT specialist doctor as to whether the child has frequent cold ,nocturnal mouth breathing ,drooling of saliva from the mouth-if yes then a CT -SCAN -PNS(Paranasal sinuses) is done- if it shows enlarged adenoids and the child is symptomatic then tonsillectomy with adenoidectomy is necessary-without this the symptoms do not subside as infection from throat due to adenoids and tonsills travels to middle ear through eustachian tube .
It should be remembered that adenoidectomy is not done below the age if 3 yrs and tonsillectomy is not advised below the age of 5 yrs.
In most of the cases ear discharge subsides after tosillectomy and adenoidectomy ,but in some cases ear surgery is required -tympanoplasty or mastoid surgery-but this expanation is not just enough ,for detailed understanding of the subject ,pl  go through this article on chronic otitis media above

Any patient requiring surgery or opd consultation/online appointment from ENT specialist doctor -Dr Sagar Rajkuwar may contact him at the following address-

Prabha ENT clinic, plot no 345,Saigram colony, opposite Indoline furniture Ambad link road ,Ambad ,1 km from Pathardi phata Nashik ,422010 ,Maharashtra ,India -Dr Sagar Rajkuwar (MS-ENT), Cel no- 7387590194,  9892596635

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