FACULTY OF MEDICINE AND HEALTH SCIENCES

SPK 3933
OTORHINOLARYGOLOGY POSTING

CASE REPORT OF
CHRONIC SUPPURATIVE OTTITIS MEDIA COMPLICATED
WITH MARGINAL PERFORATION

NAME: NURNADHIRAH BT HJ ZULKIFLI

MATRIC NO: 190386
YEAR: THIRD YEAR
GROUP: B1
SUPERVISOR: MISS NURFARISSA BT HUSSIN
 Chronic suppurative otitis media (CSOM)
A CASE REPORT
Nurnadhirah Zulkifli1
1
Third Year Medical Student, Faculty of Medicine and
Health Sciences, Universiti Putra Malaysia.

INTRODUCTION
HISTORY TAKING

Chronic suppurative otitis media (CSOM) is a perforated tympanic membrane with persistent

drainage from the middle ear (lasting >6-12 weeks) (Wright & Safranek, 2009). Chronic

suppuration can occur with or without cholesteatoma, and the clinical history of both

conditions can be very similar. The treatment plan for cholesteatoma always includes

tympanomastoid surgery with medical treatment as an adjunct. CSOM is initiated by an

episode of acute infection. The pathophysiology of CSOM begins with irritation and

subsequent inflammation of the middle ear mucosa. The inflammatory response creates

mucosal edema. Ongoing inflammation eventually leads to mucosal ulceration and

consequent breakdown of the epithelial lining (Buttha et al., 2017). Jensen (2013) stated that

patients with CSOM have a good prognosis with respect to control of infection. The recovery

of associated hearing loss varies depending on the cause. Conductive hearing loss can often

be partially corrected with surgery. The goal of treatment is to provide the patient a safe ear.

Chief complaint

Mr Syahmi, a 19 years old Malay gentleman with not known medical illness and had

underlying history of left middle ear infection 6 years ago presented with left otalgia

associated with discharge for 3 weeks in duration since March 2019.

History of presenting illness

It initially started since March 2013 in which his left ear presented with earache and

discharge for 2 weeks in duration. Initially patient did not bother about it until he felt intense

pain and went to private clinic. The doctor only treated him with chlromphenicol otic drop

and refer him to Hospital Serdang for further management. However patient defaulted as he

believe it will healed if he kept his ear dry and clean. However, after 6 years, the similar

symptoms presenting in which there was painful discharge and this current episode was the

worse by far requiring him to seek medical attention quickly. The discharge was insidious

onset and gradually progressive. He only noticed the discharge after he went to swimming

although he did wear the earplug. It was scanty, yellowish and foul smelling. The amount of

discharge was increased during episode of upper respiratory tract infection and during entry

of water to his left ear. He required about 2 pieces of tissue to stop the discharge. The

discharge was associated with ear pain. On further questioning, the pain was sudden onset

and he claimed that he heard a pop sound from his left ear. He believe that it was the cause of

his ear pain. The pain was aggravated with sneezing and blowing of nose. It was relieved by

rest. The pain score was 5/10 and it occasionally disturb his sleep at night. Otherwise there

was no hearing loss, itchiness, tinnitus, vertigo, dizziness and denied any trauma on his ear.

There were no fever, malaise, fatigue and no constitutional symptoms. His right eaar was

normal. There was no nasal and throat symptoms. Currently studying in Sport Sciences

course at UITM. He always went to swimming during his free time. Otherwise, he is a non

smoker and non alcoholic and had active lifestyle. No family history of malignancy.

Systemic reviews

Cardiovascular system No chest pain, no palpitation, no orthopnoea

Respiratory system No shortness of breath, no cough, no
haemoptysis
Central nervous system No neurological symptoms
Genitourinary system No dysuria, no haematuria
Abdominal system No abdominal pain, no jaundice
PHYSICAL EXAMINATION (day 2 of admission)

On general inspection, patient was sitting comfortably on bed. He was alert, conscious and

not in respiratory distress. His hydration and nutritional status is adequate. His vital signs:

 Temperature: 37.0 C

 Pulse rate: 68 beats/min with regular rhythm and normal

volume

 Respiratory rate: 20 breath/min

 Blood pressure: 129/75 mmHg

 SpO2: 99%

EAR EXAMINATION

On inspection, both of ears are present. There is no deformity, no swelling, no surgical scar,

no ulceration and no underlying skin changes. Both of external auditory canal were present.

There were no erythematous over the mastoid bilaterally. No active discharge. On palpation,

there was no area of tenderness over the pinna and mastoid area.

Otoscope examination :

Left ear : examination revealed that there is was and mucopous inside the EAC. Otherwise no

vesicles, granulations or polyp seen. The tympanic membrane was red and there is loss of

anatomical landmarks. It was retracted and there is marginal perforation seen. Otherwise no

vessicles or bullae over the TM surface.

Right ear : Normal findings.

Functional examinations : Rinne test was positive bilaterally. Weber test was centrally

equalize.
NOSE EXAMINATION

The nose appeared normal bilaterally. No scars, swelling or any deformities seen. On anterior

rhinoscopy, the septum was notdeviated. Both of inferior turbinates was normal. Otherwise

mucosa appeared pink, not pale and non edematous bilaterally. No polyp or foreign body

seen.

MOUTH EXAMINATION

Lip and buccal mucosa was well hydrated. No trismus. Dentition was good, no missing teeth

and bleeding gums. No tongue atrophy or deviation. Hard palate was normal. No mass or

ulcer seen in oral cavity. Tonsils was normal and non edematous or congested. Uvula

centrally located.

NECK EXAMINATION

There was no noticeable swelling, prominent vein or no underlying skin changes. On

palpation, no area of tenderness, mass or cervical lymphadenopathy. Trachea was not

deviated.

OTHER EXAMINATION

Cranial nerve examination : All cranial nerves was intact. No facial asymmetry. Other

systems were unremarkable.

SUMMARY

Mr Syahmi, a 19 years old Malay gentleman with not known medical illness and had

underlying history of left ear infection 6 years ago presented with left otorrhoea associated
with otalgia for 3 weeks in duration since March 2019. Otoscope of left ear revealed that

tympanic membrane was retracted and marginal perforation was seen.

DIAGNOSIS

Provisional diagnosis Points for Points against

- Atticoantral chronic - Otalgia - No hearing loss
suppurative otitis - Ottorhoea with foul - No polyp, granulations or
media complicated smelling cholesteatoma seen on
with marginal - Previous history of otoscope
perforation middle ear infection
Differential diagnosis
1) Recurrent otitis media - Otalgia - No fever
- Otorrhoea - No hearing loss
- No recurrent URTI
2) Otitis media with - Unresolved otitis - No hearing loss
effusion media - No itchiness
- Otalgia - No facial pain
- No fluid level/air bubble
seen on otoscope
3) Secondary acquired - Had previous history - No pearly white keratin
cholesteatoma of otitis media flakes seen from attic area
- Tympanic membrane
was perforated

INVESTIGATIONS

1. Urea and electrolyte

Component Result Interpretation
Urea 3.3 mmol/L Normal
Sodium 136 mmol/L Normal
Potassium 3.7 mmol/L Normal
Chloride 99 mmol/L Normal
 2. Coagulation profile
Component Result Interpretation
Prothrombin time 13.1 sec Normal
International normalised 0.98 Normal
ratio (INR)
Activated partial 35.6 sec Normal
thromboplastin time
APTT ratio 1.2

3. Full blood count

Component Result Interpretation
Red blood cell 4.53 x 10^12/L Normal
Haemoglobin 12.9 g/ dL Normal
Haematocrit 38.8% Normal
Mean cell volume 85.7 fl Normal
Mean cell haemoglobin 28.5 pg Normal
Red cell distribution width 13%
Platelet 335 x 10^9/L Normal
Mean platelet volume 9.5 fL
White blood cell 6.2 x 10^9/L Normal
Absolute neutrophil 2.3 x 10^9/L Normal
Absolute lymphocyte 2.48 x 10^9/L Normal
Absolute monocyte 0.540 x 10^9/L Normal
Absolute eosinophil 0.810 x 10^9/L High
Absolute basophil 0.070x 10^9/L Normal

4. Culture and sensitivity

Culture of the pus collected show that there is presence of pseudomonas aeruginosa
organism.

MANAGEMENT
Plan of management carried out including:

To start the analgesic medication (IV Tramal 50mg tds) to relieve his pain, monitor the vital

signs, planned for a myringoplasty.

DISCUSSION

Chronic suppurative otitis media (CSOM) is a long standing infection of a part or whole of

the middle ear cleft characterized by ear discharge and a permanent perforation. A perforation

becomes permanent when its edge are covered by squamous epithelium and it does not heal

spontaneously. A permanent perforation can be likened to an epithelium-lined fistulous track.

Incidence of CSOM is higher in developing countries because of poor socioeconomic

standards, poor nutrition and lack of health education. It affects both sexes and all age groups

(Smith & Danner, 2006). Clinically it is divided into Tubotympanic type and Atticoantral

type (Dhingra, 2018). In studies carried out with the aim of revealing CSOM factors, the

aerobic microorganisms most frequently isolated are Pseudomonas aeruginosa,

Staphylococcus aureus, and gram-negative organisms, such as Proteus spp., Klebsiella spp.,

Escherichia spp., and Haemophilus influenzae (Verhoeff et al., 2006). In this presentation, the

Proteus aeruginosa was identified from the ear discharge of a case with chronic otitis media

using culture and sensitivity test. There were features indicating complications in CSOM that

should be obtained through history from the patients. Pain is uncommon in uncomplicated

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. Next any

vertigo experienced by patient may indicates erosion of lateral semicircular canal which may
progress to labryinthitis. Mastoiditis is not uncommon for a patient of CSOM. It then

demands urgent attention and emergency medical or surgical treatment.

Medical and surgical options are limited, with side effects and risks, and sometimes are not

successful in eliminating disease. Topical antibiotics, which are the first-line therapy of

choice, are limited only to those that are not potentially ototoxic. Additionally, surgery carries

the risks of worsening hearing, as well as the potential for damage to the facial nerve and

resulting facial nerve paresis (Samson et al., 2013).

CONCLUSION

After being diagnosed as left chronic suppurative otitis media, proper treatment should be

given to this patient promptly to prevent progression of the disease.

DISCLOSURE

The author declares that the project is an original work except for quotations and citations

which have been duly acknowledge. The consent of patient for full disclosure of the

information were obtained and to be used only for study purpose.

REFERENCES

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Understanding the aetiology and resolution of chronic otitis media from animal and

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2. Diseases of Ear, Nose and Throat & Head and Neck Surgery, 7th Edition, PL

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