Chronic Suppurative Otitis Media

Introduction

Otitis media is inflammation process in the middle ear, it can be acute or

chronic. Chronic Suppurative Otitis Media (CSOM) is a chronic infection in the
middle ear, with continuous or intermittent otorrhea through a perforated tympanic
membrane. Chronic suppuration can occur with or without cholesteatoma and the
clinical history of both conditions can be very similar. Chronic otitis media develops
after long-standing inflammation in the middle ear and mastoid. It is commonly
associated with the perforation of the tympanic membrane and, often, cholesteatoma.
The actual cause of chronic otitis media maybe difficult to ascertain; however, it
seems to be associated with a history of Eustachian tube dysfunction, regardless of the
cause. Poor socioeconomic status, overcrowding, poor nutrition, poor hygiene, and
infectious diseases (eg: meashles) have been found to contribute to the development
of CSOM. Adenoid hypertrophy and chronic sinusitis also contribute to the
development of CSOM. CSOM can be more simply divided into mucosal disease and
cholesteatoma. Mucosal disease is typified by a bacterial infection of the middle ear
cleft with the presence of pus, associated with discharge through a pars tensa
perforation, for longer than 3 months. Acquired cholesteatoma, usually arising form
the pars flaccid skin, typically involves the epitympanum and the mastoid antrum and,
as stated above can be erosive, causing serious complications. The ciliated, much of
the morbidity of CSOM comes from the associated conductive hearing loss and the
social stigma of an often fetid fluid draining from the affected ear. The mortality of
CSOM arises from associated intracranial complications. CSOM itself is not a fatal
disease. Although some studies report sensorineural hearing loss as a morbid
complication of CSOM, other evidence conflicts with this claim. Certain population
subsets are at increased risk for developing CSOM. The American Indian and Eskimo
demonstrate an increased risk of infection. 8% of American Indians and up to 12% of
Eskimos are affected by CSOM. The anatomy and function of the Eustachian tube
play a significant role in this increased risk. The Eustachian tube is wider and more
open in these populations than in others, thus placing them at increased risk for nasal

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reflux of bacteria. Other populations at increased risk include children from Guam,
Hong Kong, South Africa, and the Solomon Islands.

Anatomy of the Ear

The ear can be divided into 3 sections: external,middle and inner. The external
ear is formed by the auricle and the external auditory canal (from the bottom of the
concha to the tympanic membrane). It is subdivided into :-
a) A cartilaginous portion, in its outer 1/3

b) A bony portion, in its inner 2/3. The posterosuperior portion is formed by the
squama, the remainder by the tympanic plate.

The middle ear is an air-containing space that houses the 3 hearing bones. It
can be thought of as a 6-sided cube. Its lateral boundary, the tympanic membrane,
separates it from the outer ear. Its medial boundary is formed by the promontory,
which denoted the basal turn of cochlea. Anteriorly, it is related to the tendon of
tensor tympani superiorly and the opening of the Eustachian tube inferiorly.
Posteriorly, it is related superiorly to the aditus, which connects the middle ear cavity
with the mastoid antrum, and inferiorly to the facial ridge. The roof of the middle ear
cavity is formed by the tegmen tympani, and the floor of the middle ear cavity lies in
close relation to the jugular foramen. The whole cleft is lined by a continuous layer of
epithelium. The Eustachian tube and antero-inferior part of tympanic cavity is lined
by respiratory type membrane (columnar, ciliated in parts);elsewhere the epithelium is
flattened (cuboidal).
The cleft consists of
1) Eustachian tube – 1.5 inches long. Upper 1/3 is bony, the lower 2/3 is
cartilaginous. It is directed upwards, backwards, and outwards from its lower
opening in the lateral wall of the nasopharynx to its upper opening in the
anterior wall of the tympanic cavity. The orifice lies behind and on level with
the posterior end of the inferior turbinate. The tube is normally closed at rest,
but is opened on yawning or swallowing by the combined actions of the
sphincter of the nasopharyngeal isthmus and the tensor palati muscle, which is
attached to the cartilaginous medial wall of tube. The tube is more horizontal
and relatively wider and shorter in the infant than the adult.

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 2) Tympanic cavity- lies between external and inner ear, is the shape of the
biconcave disc. The tympanic membrane has 3 layers:

a. Outer epithelial layer, continuous with the epithelium of the external

auditory canal

b. Middle fibrous later, containing circular and radial fibres and the
handle of the malleus.

c. Inner ‘mucosal’ layer, where the fibrous layer is absent at the portion
of membrane which occupies the notch of Rivinus, and thus the
membrana flaccida (Shrapnell’s membrane) is formed.

It has 2 distinct zones. The larger of the 2 zones is the pars tensa. This zone
consists of tough resilient fibrous layer with a diaphanous mucosal layer inside and
squamous epithelium outside. The smaller zone is the pars flaccid, which lies superior
to the suspensory ligaments of the malleus and lacks a fibrous layer. Perforations of
this area often are described as more frequently associated with complications. The
surface of the TM is approximately 25 times larger than that of the stapes footplate,
with the resulting amplification of sound to 45 dB. At the same time, the TM forms a
safe shield with the round window of the labyrinth against direct sound waves.
3)ossicular chain (malleus,incus and stapes). The ossicular chain connects the
tympanic membrane, in which the handle of the malleus is embedded, to the oval
window, on which sits the footplate of the stapes. The manubrium is attached to the
tensor tympanic muscle. The incus has a body and a short process; also a long process
which descends behind the handle of the malleus and parallel to it. The stapes has a
head, a neck, anterior and posterior crura, and a footplate which is held in the oval
window by the annular ligament.
Vascular supply:- is derived from numerous branches of both external and
internal carotid arteries. the tympanic membrane is supplied by the auricular branch of
the internal maxillary artery, the stylomastoid branch of the posterior auricular artery
and the timpanic branch of the maxillary artery. The superficial veins drain into the
external jugular vein whereas the deeper veins drain into the transverse sinus, part of
which drains into the duramater veins and the rest, into the Eustachian tube’s plexus.
The anterior part of the tympanic cavity, which includes the mucosal layer, is supplied
by the anterior tympanic membrane, a branch of the maxillary artery whereas the

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outer surface of the tympanic membrane is supplied by the profundal auricular artery,
a branch of the internal maxillary artery which penetrates the cartilage or bony wall of
the ear canal.
The bleeding of the tympanic cavity originates from the branch of external
carotid artery. The anterior tympanic artery from the maxillary artery supplies the
anterior tympanic cavity, whereas the posterior tympanic cavity is supplied by the
posterior tympanic artery which is a branch of the stylomastoid artery. The inferior
tympanic artery which is a branch of the external carotid supplies the inferior part of
the tympanic cavity. The superior part is supplied by the superficial petrosus artery
and the superior tympanic artery, a branch from the medial meningeal artery. The
veins run together with the arteries to drain into the superior petrosus sinus and
pterygoideal plexus.
Innervation:- the outer part of the tympanic membrane’s sensoric innervations
is a continuation of the ear canal’s skin sensoric innervations. The auricular temporal
nerve innervates the posterior and inferior tympanic membrane, whereas the anterior
and superior part is innervated by the auricular branch of the vagus nerve (Arnold
nerve). The sensory innervations of the tympanic membrane’s surface is innervated by
the Jacobson nerve, which is a branch of the glossopharyngeal nerve.
The tympanic cavity’s sensory innervations is served by tympanic plexus,
branch of glossopharyngeal, whereas the sympathetic innervations originates from the
internal carotid nerve plexus, especially the vascularization and vasoconstrictive
effect. The stapedius muscle is innervated by the facial nerve and will contract when
exposed to high dB. The tensor tympani muscle is innervated by N VII, and when
contracts, will pull the maleus medially until the tympanic membrane is tense.
The inner-ear is completely encased in bone and consists of the cochlear
vestibular apparatus and its associated nerves. The cochlear vestibular apparatus is
housed in a series of winding tunnels and interconnecting spaces named the labyrinth
and the bony labyrinth encases the membranous labyrinth. The cochlear portion is a
snail-shaped organ that houses the organ of Corti. The vestibular system consists of a
large chamber (ie, vestibule), from which 3 semicircular canals protrude. Within the
vestibule, 2 sensors, ie, the utricle and the saccule, detect linear acceleration, while the
semicircular canals detect rotational movements in the 3 planes of rotation. The
vestibular apparatus gives off 2 nerves: the superior and inferior vestibular nerves.

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Together with the cochlear and facial nerves, the vestibular nerves travel through the
internal auditory canal to the cerebellopontine angle.

Chronic Suppurative Otitis Media

Chronic otittis media, is a chronic infection of middle ear that can be divided
by 3 groups: chronic suppurative otitits media which characterized by the continuous
or intermittent discharge , chonic non suppurative otitis media which do not produce
the discharge, and specific chronic otitis media (bhargava, 2002). There are some
reference about the definition of chronic onset in otitis media. In ballenger’s
otorhinolaryngology head and neck surgery, 1996, the chronicity is defined by
persistent otitis media for more than 3 month, in buku ajar ilmu penyakit telinga
hidung tenggorok, 2001, it defined as persistent otitis media for more than 2 month.
Rolland, 2002, said that persistent otitis media that last longer than 6 weeks has been
defined as chronic otitis media.

Definition
Chronic suppurative otitis media can be divided into 2 types, the safe one
(benign or mucosal type), and the unsafe one (malignant or bony type). The unsafe
one, usually consist of cholesteatome, that can cause many dangerous complications.
We can assume whether it is the safe or unsafe chronic suppurative otitis media from
the type of tympanic membrane perforation. Usually, the unsafe one has the
perforation in the border of tympanic membrane (marginal type) or in the flaccid part
of the tympanic membrane (attic type). And the tympanic membrane perforation of
the benign one usually located centrally, or sometimes subtotal without the existence
of cholesteatome.

Etiology

P aeruginosa is the most commonly recovered organism from the chronically

draining ear. Various researchers over the past few decades have recovered
pseudomonads from 48-98% of patients with CSOM.
S aureus is the second most common organism isolated from chronically
diseased middle ears. Reported data estimate infection rates from 15-30% of culture
positive draining ears. The remainder of infections is caused by a large variety of

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gram-negative organisms. Klebsiella (10-21%) and Proteus (10-15%) species are
slightly more common than other gram-negative organisms.
Five to 10% of infections are polymicrobial in etiology, often demonstrating a
combination of gram-negative organisms and S aureus. The anaerobes (Bacteroides,
Peptostreptococcus, Peptococcus) and fungi (Aspergillus, Candida) complete the
spectrum of colonizing organisms in this disease. The anaerobes make up 20-50% of
the isolates in CSOM and tend to be associated with cholesteatoma. Fungi have been
reported in up to 25% of cases, but their pathogenic contribution to this disease is
unclear.

Clinical Manifestation

Patients with CSOM present with a draining ear of some duration traumatic
perforation, or placement of ventilation tubes. Typically, they deny pain or
discomfort. A common presenting symptom is hearing loss in the affected ear, fever,
vertigo, tinnitus, and swelling.
In the physical examination we can find the discharge fetid, purulent, and
cheeselike to clear and serous. There is tympanic membrane perforation in central.
Granulation tissue is sometimes can be seen in the medial canal or middle ear space.
The middle ear mucosa visualized through the perforation may be edematous or even
polypoid, pale, or erythematous.

Differential Diagnosis

The differential diagnosis could be otitis externa, acute otitis media,

Additional Examination
Investigation can be done from the most simplest such as plain x-ray, until CT
Scan or MRI. CT scanning is a necessary adjunct to treatment if the clinician suspects
a neoplasm or if the clinician anticipates intratemporal or intracranial complications.
A fine-cut CT scan can reveal bone erosion from cholesteatoma, ossicular erosion,
involvement of petrous apex, coalescent mastoiditis, erosion of the fallopian canal,
and subperiosteal abscess.MRI is for intratemporal or intracranial complications are

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suspected (Dural inflammation, sigmoid sinus thrombosis, labyrinthitis, and
extradural and intracranial abscesses).

Management

Patients with CSOM respond more frequently to topical than to systemic therapy.
Successful topical therapy consists of 3 important components: selection of an
appropriate antibiotic drop, regular aggressive aural toilet, and control of granulation
tissue:
1. An appropriate antibiotic, usually given topically.
The antibiotic should have an appropriate spectrum of activity that includes
gram-negative organisms, especially pseudomonas, and gram-positive organisms,
especially S. aureus. The antibiotics that meet this initial criterion are the
fluoroquinolones (e.g. ofloxacine or ciprofloxacine).

2. Regular intensive aural toilet to remove debris.

Aural toilet is a critical process in the treatment of CSOM. The external
auditory canal and tissues lateral to the infected middle ear are often covered with
mucoid exudate or desquamated epithelium. Topically applied preparations cannot
penetrate affected tissues until these interposing materials are removed.
Aural irrigation is an effective alternative that is often less burdensome for
patients and physicians. A solution of 50% peroxide and 50% sterile water is
generally painless and effective. Thirty to 40 mL of this solution can be irrigated
through the external auditory canal, using a small syringe or bulb-type aspirator.
The irrigant solution can be allowed to drain out for 5-10 minutes prior to
instilling the ototopical antimicrobial. For best results, aural toilet should be
performed 2-3 times per day just before the administration of topical antimicrobial
agents.

3. Control of granulation tissue

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 Granulation tissue often fills the middle ear and medial portions of the external
auditory canal. Granulation tissue can prevent topically applied antimicrobial
agents from penetrating to the site of infection. The use of topical antimicrobial
drops is the first step in controlling granulation. These drops help reduce
granulation tissue by eliminating infection and by removing the inciting irritating
inflammation.

Case Report

I. Identity
Name : Mr. R
Sex : Male
Age : 44 years
Address : Kalibagor, Banyumas
MR number : 00560395

II. Anamnesis
Chief complaint:
Sticky liquid coming out from his right ear

History of Recent Illness:

Patient come to the clinic because of sticky liquid that coming out from his
right ear since ten days ago. The liquid is yellow (+), thick (+), smelly (-). There is
hearing complaint in his right ear. No pain in his right ear but it felt itchy. He often
cleans his ear with cotton bud. There is no complaint in his left ear.
Buzzing in ear (-), common cold (-), fever (-), dizziness (-), nasal congestion
(-), pain on swallowing (-). no complaint of the nose and throat.

History of Post Illness:

The patient had experienced similar complaints since 2 years ago. The
discharge intermittenly coming out from his ear He felt pain in his right ear and there
is liquid coming out from his right ear. The doctor gave him an eardrop.
History of allergy (-), diabetes mellitus(-), hypertension (-).

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Family History:
Families with similar complaints (-).

Resume:
Fullness (+) in his right ear.
Itchy (+)
Discharge (+)
Decrease on hearing (+)

III. Physical examination

• General status:
General Condition : good, compos mentis
Vital signs : BP = 110/80 HR = 80
RR = 20 T = afebris
• Local status:
1. ear status
Inspection. :
lump on aurikula -/-
meatus externus laceration -/-
otorrhea +/-
hiperemis +/-
edema +/-
cerumen -/-
tympanic membrane central perforation/intact
Palpation :
tragus pain -/-
lnn retroauricular -/-
lnn preauricular -/-
Otoscopy :
light reflex -/+
2. Nose
Inspection :
Deformity -/-

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 septum nasi deviation -/-
edema -/-
hiperemis -/-
cicatrix -/-
discharge -/-
Palpation :
tenderness -/-
crepitaion -/-
Anterior rhinoscopy :
nasal mucosa hiperemis -/-
nasal mucosa edema -/-
choncha edema -/-
choncha surface slippery/slippery
discharge -/-
mass -/-
Posterior rhinoscopy :
not done
3. Throat
Inspection :
tongue mucosa : no abnormality
pharynx mucosa : hiperemis (-), granular (-),
edema (-)
uvula : hiperemis (-)
tonsil : swelling (-), T1-T1,
hiperemis (-)
Palpation :
lnn.mandibula (-)
tenderness (-)

Working Diagnosis
right ear : save chronic suppurative otitis media

Management

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  Ofloxacin eardrop 3x 5 drops
 Pseudoephedrine + terfenadin 2 x 1 tab
 Na diclofenac 3 x 1tab
 Ambroxol 3 x 1 tab

Problem
 Recurrency

Planning
 Culture
 Education

Discussion
Otitis media is inflammation process in the middle ear, it can be acute or
chronic. Chronic Suppurative Otitis Media (CSOM) is a chronic infection in the
middle ear, with continuous or intermittent otorrhea through a perforated tympanic
membrane.
Patients with CSOM present with a draining ear of some duration traumatic
perforation, or placement of ventilation tubes. Typically, they deny pain or
discomfort. A common presenting symptom is hearing loss in the affected ear, fever,
vertigo, tinnitus, and swelling.
In the physical examination we can find the discharge fetid, purulent, and
cheeselike to clear and serous. There is tympanic membrane perforation in central.
Granulation tissue is sometimes can be seen in the medial canal or middle ear space.
The middle ear mucosa visualized through the perforation may be edematous or even
polypoid, pale, or erythematous.
In this patient, we found sticky liquid that coming out from his right ear since
ten days ago. The liquid is yellow (+), thick (+), smelly (-). There is hearing
complaint in his right ear. No pain in his right ear but it felt itchy.
So, we diagnose this patient as right ear safe active CSOM.

Conclusion

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 We have reported patient, male, 44 years old, diagnosed as safe active CSOM
of right ear. Our plan is to treat the patient with medical therapy using ofloxacine ear
drops, natrium diclofenac, pseudoephedrine+terphenadine, and ambroxol, despite
routine aural toiletc. While waiting for the culture sensitivity test result.

Reference

1. Buchmann C.A., Levine J.D., Balkany T.J. Infections of The Ear in Essential
Otolaryngology Head and Neck Surgery. 8th ed. McGraw Hill, 2003.
2. Djaafar Z A. Kelainan Telinga Tengah. Dalam: Buku Ajar Ilmu Penyakit
Telinga Hidung Tenggorokan. FK UI. Jakarta 1998: 49-61
3. Lee K J. Infection of The Ear. In: Essential Otolaryngology Head and Neck
Surgery. McGraw-Hill Companies. USA. 2003:462-511.
4. Paparella M M, Adams G L, Levine S C. Penyakit Telinga Tengah dan
Mastoid. Dalam Boeis Buku Ajar Ilmu THT edisi 6. Penerbit Buku
Kedokteran EGC, Jakarta 1997: 88-118.
5. Parry D. Middle Ear, Chronic Supurative Otitis, Medical Treatment.
www.emedicine.com. 2009
6. Roland P S. Middle Ear, Cholesteatoma. www.emedicine.com. 2009
7. Snown J B, Ballenger J J. Otitis Media and Middle Ear Effusions. In:
Ballenger”s Otorhinolaryngology Head and Neck Surgery. B.C Decker Inc.
Spanyol. 2003:249-260

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