Chronic Suppurative Otitis Media

Chronic Suppurative Otitis Media (CSOM), also referred to as Chronic Otitis Media (COM), is a persistent infection affecting a part or whole of the middle ear cleft characterized by ear discharge lasting at least two weeks and a permanent tympanic membrane (TM) perforation. The perforation becomes permanent when the outer squamous epithelial layer of the tympanic membrane merges with the inner mucosal layer of the tympanic membrane at the perforation margins, preventing spontaneous healing. If a perforation persists beyond 12 weeks, it is considered as permanent and lead to CSOM.

Epidemiology

CSOM is more common in developing countries due to poor socioeconomic conditions, inadequate nutrition, and a lack of health education. In India, prevalence is higher in rural areas (46/1000) than urban (16/1000).

Types of CSOM

1. Tubotympanic (Safe, Benign Type or Mucosal CSOM).
2. Atticoantral (Unsafe, Dangerous Type Or Squamosal CSOM).

Tubotympanic type of CSOM

This type remains localized to the mucosa of the anteroinferior part of the middle ear cleft, involving the eustachian tube and mesotympanum, and is associated with a central perforation. The central means that the perforation anywhere in the pars tensa is which not marginal. Complications are rare in TTD but the cochlea may sustain damage due to the absorption of the toxins (ear discharge) from the oval and round windows, potentially resulting in mixed hearing loss.

Aetiology.

1. It often begins in childhood, following acute otitis media, negative middle ear pressure, or otitis media with effusion (OME) and lead to a large central perforation.
2. Permanent perforation allows repeated infections through the external ear canal, causing otorrhea. The exposed middle ear mucosa also becomes sensitized to environmental allergens such as dust and pollen.
3. Ascending infections from the eustachian tube, often originating from infected tonsils, adenoids, or sinuses, can be responsible for persistent or recurring otorrhoea.
4. Persistent mucoid otorrhea may sometimes result from allergies to certain foods such as milk, eggs, or fish.

Pathology. The pathological changes observed include:

1. Central perforation of Pars Tensa, varying in size and position.
2. Middle Ear Mucosa: Appears normal when inactive, but is oedematous and velvety during active disease.
3. Polyp Formation: A polyp is a smooth, swollen mass of inflamed mucous membrane that has protruded through a perforation and appears in the external canal. Typically, it is pale in colour, distinguishing it from the pink, fleshy polyps commonly seen in atticoantral disease.
4. Ossicular Chain Integrity: Generally intact and mobile, but may exhibit necrosis, particularly in the long process of the incus.
5. Tympanosclerosis: It is the hyalinization and calcification of subepithelial connective tissue in the middle ear, often resulting from long-standing, silent chronic otitis media. It presents as white, chalky deposits on structures like the tympanic membrane, ossicles, joints, tendons, promontory and, oval & round windows, impairing mobility and causing conductive hearing loss.
6. Fibrosis and Adhesions: Resulting from the healing process, further impeding ossicular chain mobility or eustachian tube function.

Causative Organisms.

CSOM involves multiple aerobic and anaerobic organisms:

• Aerobic: Pseudomonas aeruginosa, Proteus species, Escherichia coli, Staphylococcus aureus.
• Anaerobic: Bacteroides fragilis, anaerobic Streptococci.

Clinical Features.

1. Ear Discharge: Ear discharge is typically non-offensive, painless, and odourless and can be either mucoid or mucopurulent. The amount of discharge may vary from profuse to scanty and can be constant or intermittent. This discharge often occurs during upper respiratory tract infections or when water accidentally enters the ear.
2. Hearing Loss: The hearing loss is primarily conductive, usually not exceeding 50 dB. Interestingly, some patients experience improved hearing in the presence of ear discharge due to the “round window shielding effect,” which helps maintain phase differential. In chronic cases, toxin absorption through the oval and round windows can damage the cochlea, resulting in mixed hearing loss. In dry perforations, sound waves simultaneously strike both the oval and round windows, cancelling each other’s effects and further worsening hearing loss. Additionally, prolonged disease can lead to ossicular necrosis, particularly affecting the long process of the incus due to its poor blood supply, further contributing to increased hearing loss.
3. Perforation: The perforation is always central and may be located anterior, posterior, or inferior to the handle of the malleus. The size of the perforation can vary, being small, medium, large, or extending up to the annulus, known as subtotal.
4. Otoscopy/Microscopy/Endoscopy: During examination, a central perforation of the pars tensa is noted, with attention to the following points:

• • Size: The perforation can be small, medium, large, or subtotal.
  • Position: It can be located anterior, posterior, or inferior to the handle of the malleus.
  • Middle Ear Mucosa: When the perforation is large, the middle ear mucosa can be observed. Normally, it appears pale pink and moist. When inflamed, it looks red, edematous, and swollen.

5. No erosion of bony walls: There is no erosion of bony walls of the middle ear in safe CSOM/mucosal COM. Erosion of bony walls is seen in unsafe CSOM characterised by cholesteatoma

Assessment.

1. Examination under microscope (EUM): It allows thorough cleaning of the discharge and confirmation of the diagnosis. Assesses ossicular chain status, identifies granulations, epithelial ingrowth, hidden discharge or cholesteatoma, tympanosclerosis, and adhesions. Facilitates pus collection for Culture and Sensitivity testing. All patients with chronic middle ear disease should be examined under the microscope.
2. Audiometry and Tuning Fork Tests: Determines the degree and type of hearing loss (conductive, sensorineural, or mixed).
3. Culture and Sensitivity: Identifies causative microorganisms and guides appropriate antibiotic therapy to avoid resistance.
4. Mastoid X-ray: Reveals sclerotic or pneumatized mastoid with clouded air cells. The absence of bone destruction helps differentiate it from atticoantral disease.

Treatment.

1. Aural Toilet: Essential for removing discharge and debris, achieved through dry mopping, suction cleaning under a microscope, or irrigation with sterile saline. Thorough drying post-irrigation is crucial.
2. Ear Drops: Antibiotic drops (e.g., neomycin, polymyxin, gentamicin) combined with steroids are used for their antimicrobial and anti-inflammatory effects. The proper application involves lying with the affected ear upward, instilling drops, and applying tragus pressure to facilitate middle ear entry. Acidic solutions (e.g., 1.5% acetic acid) help combat Pseudomonas. Caution is needed to avoid side effects like maceration, allergies, fungal growth, or ototoxicity.
3. Systemic Antibiotics: Useful during acute on chronic ear disease but have limited efficacy in chronic cases.
4. Precautions: Patients should avoid water entry into the ear during bathing or swimming, use protective inserts, and refrain from hard nose blowing or self-cleaning.
5. Treatment of Contributory Causes: Address concurrent infections (e.g., tonsils, adenoids, maxillary antra) and nasal allergies to prevent recurrent ear infections.
6. Surgical Treatment: Remove aural polyps or granulations before local antibiotic treatment to enhance efficacy. However, an aural polyp should never be avulsed as it may arise from structures such as the stapes, facial nerve, or horizontal canal, leading to potential complications like facial paralysis or labyrinthitis.
7. Reconstructive Surgery: Myringoplasty, with or without ossicular reconstruction, can restore hearing and prevent reinfection. Cortical mastoidectomy combined with myringoplasty can be performed even in active cases, though a dry ear is preferable.

 

Atticoantral type of CSOM

Unlike the tubotympanic type, which affects the anteroinferior part, the atticoantral type of CSOM involves the posterosuperior part of the middle ear cleft (attic, antrum, posterior tympanum, and mastoid) and is associated with an attic or marginal perforation. Atticoantral disease (AAD) is characterized by bone erosion caused by cholesteatoma, granulations, or osteitis. AAD type is often termed “unsafe” or “dangerous” due to its high risk of complications, including hearing loss, vestibular dysfunction, facial paralysis, and intracranial infections.

Aetiology.

Cholesteatoma, a benign cystic structure with a keratinizing epithelial lining, is a hallmark of AAD. It typically originates from a retraction pocket in the pars flaccida or posterosuperior pars tensa due to Eustachian tube dysfunction and negative middle ear pressure. Due to their greater blood supply compared with the rest of the tympanic membrane, the pars flaccida and the posterosuperior quadrant of the pars tensa are more susceptible to inflammatory cell infiltration in acute otitis media (AOM) and otitis media with effusion (OME). This susceptibility may result in a thinner fibrous layer in these areas compared to the rest of the tympanic membrane. Cholesteatomas can also arise from epithelial metaplasia or migration through a pre-existing tympanic membrane perforation. Cholesteatoma causes local destruction by releasing enzymes like collagenase and proteolytic enzymes, leading to bone erosion and complications.

Pathology.

Atticoantral diseases are associated with the following pathological processes:

1. Cholesteatoma. Cholesteatomas invade surrounding structures, initially following the path of least resistance and later through enzymatic bone destruction. They can extend backwards into the aditus, antrum, and mastoid, and downwards into the mesotympanum, surrounding ossicles like the incus and malleus. Bone destruction is mediated by enzymes released by osteoclasts and inflammatory cells, rather than pressure necrosis.
2. Osteitis and Granulation Tissue. Cholesteatoma induces osteitis and granulation tissue which leads to bone erosion and spread of infection. Granulation tissue may fill the attic, antrum, and mastoid, sometimes presenting as a fleshy red polypus in the meatus.
3. Ossicular Necrosis. Ossicular necrosis, particularly of the long process of the incus (but can extend to the superstructure of the stapes, the handle of the malleus, or the entire ossicular chain), is common in AAD, resulting in severe hearing loss. However, in some cases, cholesteatoma bridges the gap left by necrosed ossicles, preserving hearing (“cholesteatoma hearer”).
4. Cholesterol Granuloma.Cholesterol granuloma is a pathological entity characterized by a mass of granulation tissue containing foreign body giant cells that encircle cholesterol crystals. This condition arises as a reaction to the prolonged retention of secretions or haemorrhage and may or may not coexist with cholesteatoma. When cholesterol granuloma is present in the mesotympanum, behind an intact tympanic membrane, the latter may appear blue.

Causative Organisms.

• Common aerobic organisms are Pseudomonas aeruginosa, Proteus, Escherichia coli and Staphylococcus aureus.
• Anaerobes include Bacteroides fragilis and anaerobic Streptococci.

Symptoms.

1. Ear Discharge: The discharge is typically scanty but foul-smelling due to osteitis, bone erosion by cholesteatoma, and anaerobic bacterial infection. It may be minimal, often unnoticed by the patient. Sudden cessation of discharge, especially after prolonged activity, is a serious sign, indicating possible obstruction by crusted discharge, inflammatory mucosa, or a polyp, leading to pus accumulation and complications.
2. Hearing Loss: Hearing loss may not be apparent if the ossicular chain is intact or if cholesteatoma bridges gaps left by necrosed ossicles (“cholesteatoma hearer”). While hearing loss is predominantly conductive, there may also be a sensorineural component. Eroding cholesteatoma causes ossicular necrosis, leading to conductive deafness, and inner ear involvement, resulting in sensorineural deafness.
3. Bleeding: Bleeding may occur from granulations or polyps during the cleaning of the ear.

Signs.

1. Perforation: Perforations in the attic or posterosuperior marginal region are hallmarks of atticoantral disease. In attic perforation, there is perforation in the pars flaccida which may be missed due to crusted discharge or obscured by granulomas, while in marginal perforations there is loss of annulus, exposing the attic, the antrum, and the mastoid cell system, often associated with cholesteatoma.

•  

2. Retraction Pockets: A retraction pocket is a localized area of indrawing (or invagination) of the tympanic membrane into the middle ear or attic. The initial cause of retraction pockets is recurrent or chronic negative pressure in the middle ear, due to dysfunction of the eustachian tube. Collagenase and elastase enzymes secreted by inflammatory cells during acute otitis media or serous otitis media can destroy the middle fibrous layer of the tympanic membrane making it atrophic and more prone to retraction. Retraction pockets can resolve automatically or they can stay safe & stable for a long period of time or can become unstable leading to invasion of middle ear cleft and formation of cholesteatoma in later stages. Read more on retraction pockets: https://www.entlecture.com/tympanic-membrane-retraction-pockets/
3. Cholesteatoma: Pearly-white flakes of cholesteatoma can be extracted from retraction pockets. Suction clearance and examination under an operating microscope are crucial components of the clinical examination and assessment of any type of chronic suppurative otitis media (CSOM).

Assessment and Imaging

1. Microscopic Examination under microscope (EUM). It allows thorough cleaning of the discharge and confirmation of the diagnosis. Assesses ossicular chain status, identifies granulations, epithelial ingrowth, hidden discharge or cholesteatoma, tympanosclerosis, and adhesions. Facilitates pus collection for Culture and Sensitivity testing. All patients with chronic middle ear disease should be examined under the microscope.

• • Classify the retraction according to Tos. Can I see the fundus of the retraction pocket or not? Is this thought to be self-cleansing or not? Whether a retraction pocket is self-cleansing or not is a qualitative judgement based on size and appearance. A small, clean retraction pocket in the pars flaccida or pars tensa is likely to be self-cleansing, but such judgements can only be confirmed over time by clinical review.
  • Examination of cholesteatoma, its site and extent, evidence of bone destruction, granuloma, condition of ossicles and pockets of discharge.

2. Audiometry and Tuning Fork Tests: Determines the degree and type of hearing loss (conductive, sensorineural, or mixed).
3. Culture and Sensitivity: Identifies causative microorganisms and guides appropriate antibiotic therapy avoiding resistance.
4. X-ray mastoids. They indicate the extent of bone destruction and the degree of mastoid pneumatization. They are useful to indicate a low-lying dura or an anteposed sigmoid sinus when the operation is being contemplated on a sclerotic mastoid. Cholesteatoma causes destruction in the area of the attic and antrum (key area), better seen in lateral view.
5. HRCT Temporal Bone Scan: Preferred over mastoid X-rays, provides detailed anatomical landmarks and extent of bone destruction.
6. DW-MRI: Differentiates cholesteatoma from inflammatory tissue and brain, useful for detecting residual cholesteatoma post-surgery.
7. Otoendoscopy: Useful for outpatient assessment, especially in patients with narrow ear canals.

Features Indicating Complications in CSOM

1. Pain: Pain is uncommon in uncomplicated chronic suppurative otitis media (CSOM). Its presence is considered serious as it may indicate extradural, perisinus, or brain abscess. Sometimes, it is due to otitis externa associated with a discharging ear.
2. Vertigo: Vertigo indicates erosion of the lateral semicircular canal, which may progress to labyrinthitis or meningitis. A fistula test should be performed in all cases.
3. Persistent Headache: Persistent headache is suggestive of an intracranial complication.
4. Facial Weakness: Facial weakness indicates erosion of the facial canal.
5. Listless Child: A listless child refusing to take feeds and easily falling asleep may indicate an extradural abscess.
6. Fever, Nausea, and Vomiting: These symptoms are indicative of an intracranial infection.
7. Irritability and Neck Rigidity: These symptoms are suggestive of meningitis.
8. Diplopia: Diplopia may indicate Gradenigo syndrome or petrositis.
9. Ataxia: Ataxia may indicate labyrinthitis or cerebellar abscess.
10. Abscess Around the Ear: This indicates mastoiditis.

Treatment

The primary management of unsafe CSOM is surgical which involves mastoid exploration (mastoidectomy) to remove disease from the mastoid and middle ear. Discharge in unsafe CSOM is primarily due to bony erosion, so medical management with local or systemic antibiotics is reserved for superimposed acute infections or complications like intracranial infections caused by cholesteatoma.

Surgery is the cornerstone of treatment, with the primary goal being the eradication of disease to achieve a safe, dry, and self-cleaning ear. The secondary goal is to preserve or reconstruct hearing, but never at the expense of disease eradication. Hearing can be restored by myringoplasty or tympanoplasty, performed either at the time of primary surgery or as a second-stage procedure. In cases of intracranial complications, these are addressed first.

There are two main mastoid exploration procedures:

1. Canal Wall Down Mastoidectomy: The posterior wall of the middle ear is removed entirely to provide better access and visualization of the disease.
2. Intact Canal Wall Mastoidectomy: A small opening is made in the posterior wall of the middle ear (common wall between the middle ear and mastoid) while preserving the canal wall.

The initial steps of mastoid exploration (mastoidectomy) for both above mastoidectomy are identical until reaching the mastoid antrum. The steps are:

1. A post-auricular incision (Wilde’s incision) is made, and Macewen’s triangle is exposed.
2. Mastoid exploration begins at Macewen’s triangle using a cutting drill burrs to remove mastoid air cells.
3. Adequate irrigation is maintained during drilling to wash away bone dust, improve visualization, and reduce heat-related injury risks.
4. Near critical structures like the facial nerve, diamond burrs are used for precision.
5. Haemostasis is achieved using bipolar cautery, bone wax, or diamond burrs, which produce bone dust to seal bleeding vessels.

1. Canal Wall Down Procedures (Open Cavity): These procedures leave the mastoid cavity open into the external auditory canal, fully exteriorizing the diseased area. Commonly performed operations include:

• Atticotomy: Limited to the attic region; the defect in the attic wall is closed with tragal or conchal cartilage.
• Atticoantrostomy: An anterior-to-posterior approach where cholesteatoma is identified in the epitympanum or posterior mesotympanum and followed backward.
• Modified Radical Mastoidectomy: A posterior-to-anterior approach where the mastoid is opened behind the external auditory canal, the cholesteatoma is identified, and the posterior bony wall of the canal is removed.
• Radical Mastoidectomy: Extensive removal of diseased tissue.

Common causes of ear discharge following canal wall down procedures include:

• a high facial ridge
• a sump in the cavity below the floor of the external auditory canal
• perforation in the tympanic membrane
• small external auditory meatus.

2. Canal Wall-Up Procedures (Closed Cavity or Combined Approach Tympanoplasty):

In this, the disease is removed both per-meatally and through a cortical mastoidectomy & posterior tympanotomy approach, creating a window between the mastoid and middle ear through the facial recess to reach the sinus tympani, retaining an intact external auditory canal without creating a mastoid cavity. Hearing reconstruction if required is done through the EAC side. This approach is technically more challenging and time-consuming, but it results in a dry ear and facilitates the reconstruction of the hearing mechanism.

Steps of surgery:

1. Post-Auricular Incision: A Wilde’s incision exposes Macewen’s triangle, the surgical landmark for mastoid exploration.
2. Mastoid Exenteration: Mastoid air cells are meticulously drilled to access the mastoid antrum (~1.5 cm deep to Macewen’s triangle).
3. Antral Disease Removal: Cholesteatoma or granulations within the antrum are excised.
4. Posterior Tympanotomy: A small opening is made in the facial recess (lateral to the vertical fallopian canal) to access the middle ear.
5. Sinus Tympani Clearance: The sinus tympani—medial to the fallopian canal and a common site for residual disease—is visualized and cleared through the tympanotomy window. 

Advantages:

• Preserves natural ear anatomy, reducing postoperative cavity maintenance.
• Facilitates hearing reconstruction (ossiculoplasty) via the EAC.
• Achieves a dry, functional ear with minimal cosmetic impact.

Challenges:

• Residual Disease Risk: there is a risk of leaving residual cholesteatoma behind, leading to a high incidence (20-50%) of recurrent disease.
• Second-Look Surgery: Often required after 12–18 months to detect residual disease. Second look can often be avoided with the use of diffusion-weighted MRI (DW-MRI).

 

Conservative Treatment: Conservative treatment has a limited role in managing cholesteatoma but can be attempted in selected cases where the cholesteatoma is small and easily accessible to suction clearance under an operating microscope. Repeated suction clearance and periodic check-ups are essential. Conservative treatment is also considered for elderly patients above 65, those unfit for general anesthesia, or those refusing surgery. Polyps and granulations can be surgically removed by cup forceps or cauterized with chemical agents like silver nitrate or trichloroacetic acid. Additional measures such as aural toilet and dry ear precautions are also necessary. Hearing aids should always be considered in cases of hearing disability.

 

 

Alternative Classification of Chronic Otitis Media

Another commonly used classification system for chronic otitis media is gaining prevalence in contemporary medical practice. This system provides a detailed framework for understanding and diagnosing the condition, allowing for more precise treatment plans and better patient outcomes. This classification categorises the disease based on specific clinical features, anatomical involvement, and complications.

1. Mucosal disease, is characterized by the absence of squamous epithelial invasion and primarily involves the mucosal lining of the middle ear.

i. Inactive Mucosal Chronic Otitis Media (COM) (Dry Perforation)
– This condition is marked by a permanent perforation of the pars tensa, with the middle ear and mastoid remaining non-inflamed. Inactive mucosal COM indicates that the middle ear structure and hearing may be compromised due to the tympanic membrane perforation, but there is no active infection or mucoid discharge. Such an ear can remain inactive, become active, or occasionally heal spontaneously.

ii. Active Mucosal Chronic Otitis Media (COM) (Perforation with Ear Discharge)
– This form of COM presents with a perforation of the pars tensa, accompanied by mucopurulent discharge and inflammation of the middle ear and mastoid mucosa. The condition may persist, become inactive, or lead to complications.

iii. Healed Chronic Otitis Media (COM)
– In this condition, the tympanic membrane has healed, usually forming a two-layer structure that is atrophic and prone to retraction under negative middle ear pressure. Healed otitis media may also feature tympanosclerosis patches on the tympanic membrane or within the middle ear, affecting the promontory, ossicles, and tendons of the stapedius and tensor tympani muscles. 

2. Squamosal Disease

i. Inactive Squamous Epithelial Chronic Otitis Media (COM) (Retraction, Atelectasis, and Epidermization)
– This condition is characterized by retraction pockets in the pars tensa (typically the posterosuperior region) or pars flaccida. While there is no discharge, the retraction pockets may harbor squamous debris (cholesteatoma) that can become infected and start discharging. Some retraction pockets are shallow and self-cleansing. Negative static middle ear pressure can cause the tympanic membrane to retract (atelectasis). ‘Epidermization’ refers to a more advanced stage where the middle ear mucosa is replaced by keratinizing squamous epithelium without the retention of keratin debris.

ii. Active Squamous Epithelial Chronic Otitis Media (COM) (Acquired Cholesteatoma)
– This condition is characterized by the presence of cholesteatoma in the posterosuperior region of the pars tensa or in the pars flaccida. The cholesteatoma erodes bone, forms granulation tissue, and produces a purulent, offensive discharge.

———— End of the chapter ————

Download the full PDF Link:
Chronic Suppurative Otitis Media Best Lecture Notes Dr Rahul Bagla ENT Textbook

Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Glasscock-Shambaugh, Textbook of Surgery of the Ear.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Salah Mansour, Middle Ear Diseases – Advances in Diagnosis and Management.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Rob and smith, Textbook of Operative surgery.
• Anirban Biswas, Textbook of Clinical Audio-vestibulometry.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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