EAR DISCHARGE

PART 1: CHRONIC SUPPURATIVE OTITIS MEDIA

DEFINITION:
Chronic Suppurative Otitis Media (CSOM)

-persistent inflammation of the middle ear or mastoid cavity

-presents with persistent or recurrent ear discharge (otorrhea) over 3 months through a
perforation of the tympanic membrane.

Synonyms:

“chronic otitis media (without effusion)”

“chronic mastoiditis”

“chronic tympanomastoiditis

CONDITIONS ASSOCIATED/EXACERBATING CSOM:

allergic rhinitis

chronic sinusitis

adenoid hyperplasia

cleft palate

 note that these affect the Eustachian tube

ORGANISMS CULTURED FROM CSOM EAR DISCHARGE

A. Aerobes

Staphylococcus aureus

Pseudomonas aeruginosa

Klebsiella spp.

Proteus spp.

Entero/acinetobacter

B. Anaerobes

Bacteroides

Peptostreptococcus
 Proprionibacterium

PATHWAYS FOR SPREAD OF INFECTION BEYOND THE MIDDLE EAR:

a. bone erosion- mainly by _____________

b. thrombophlebitis

c. preformed opening- e.g.,dehiscences

d. surgical opening

e. hematogenous

COMPLICATIONS

A. Extracranial

subperiosteal abscess

labyrinthitis/labyrinthine fistula

facial weakness

petrositis (Gradenigo’s Syndrome- otorrhea, retroorbital pain, lateral rectus

palsy)

B. Intracranial

meningitis

subdural, epidural, perisinus, or brain abscess

lateral sinus thrombosis – remittent, picket fence-type fever

CHOLESTEATOMA- keratin debris lined by metabolically-active matrix with osteoclasts, resulting

in bone erosion

Theories of Cholesteatoma Formation

1. Metaplasia theory - transformation of respiratory epithelium into keratinizing squamous

epithelium

2. Loss of contact inhibition theory – because of the perforation there is extension of the
keratinizing squamous mucosa within the middle ear
 3. Formation of retraction pouch theory - a sac filled with keratin debris slowly expands as the
keratin debris accumulates

cholesteatoma

SAFE VS. UNSAFE/DANGEROUS EAR

Safe Ear Unsafe Ear

tubotympanic Atticoantral
Mucoid, non-foul smelling discharge Purulent, fetid discharge
Conductive hearing loss
No cholesteatoma Prone to cholesteatoma, complications
Medical treatment Will likely need surgery

TREATMENT

Otic Drops:

Ofloxacin, Ciprofloxacin, Polymyxin/neomycin, Chloramphenicol, Gentamicin

+/- steroids (to control inflammation, granulation tissue)

Aural Toilet: to clear discharge at home, enable drops to reach middle ear mucosa

Systemic antibiotics: for concomitant bacterial URTI(oral) or complications (IV)

Surgery: for persistent otorrhea despite adequate medical therapy; complications; unsafe ears-
Mastoidectomy is done to eradicate infection, by exenterating mastoid air cells and removing
diseased mucosa. Tympanoplasty , or reconstruction of the middle ear conducting mechanism,
is done when possible. It can also be done in inactive cases, to improve hearing.

PART TWO: ACUTE OTITIS MEDIA

PATHOGENS

Viral Bacterial
respiratory syncytial virus Streptococcus pneumoniae
rhinovirus Hemophilus influenzae
Coronavirus Moraxella catarrhalis
Parainfluenza
Adenovirus
Enterovirus
 NATURAL HISTORY

a. Stage of hyperemia/ retraction

• Generalized hyperemia of the mucoperiosteum

• Mild earache, ear fullness, fever

• Otoscopy: erythematous & markedly retracted eardrum

b. Stage of exudation

Outpouring of fluid from dilated permeable capillaries

Aggravated symptoms especially pain & fever

Otoscopy: erythematous & bulging eardrum

c. Stage of suppuration/ perforation

Eardrum ruptures  middle ear discharge

Relief of pain & fever

Worsening of hearing loss

d. Stage of coalescence and mastoiditis

Recurrence of pain, mastoid tenderness & fever (milder degree)

(+) mastoid tenderness & sagging of posterosuperior wall

e. Stage of resolution

May occur at any stage of the disease

DIAGNOSIS

Clinical history is poorly predictive of AOM especially in younger children

• Abrupt onset of otalgia/ ear tugging

• irritability in an infant/ toddler

• otorrhea and fever  non-specific and are also found in patients with URTI
 Mild Moderate to severe
Pain Mild VAS Moderate to severe
Duration <48 hours >48 hours
Tmax <39˚ C >39˚ C

TREATMENT

A. Medical: Antibiotics vs observation: moderate to severe disease- use antibacterials; for

mild- see guidelines depending on age and bilaterality

Mild AOM: Amoxicillin (high-dose)

Severe/Failure: Co-amoxiclav

Macrolides, Cephalosporins, Clindamycin for Penicillin-allergic individuals

IV antibiotics for acute complications

Pain relief with paracetamol or ibuprofen

B. Surgical: For failure of medical therapy
Myringotomy with ventilation tube insertion
Mastoidectomy

COMPLICATIONS

chronic otitis media

mastoiditis

labyrinthitis/labyrinthine fistula

facial weakness

Intracranial complications

RISK FACTORS

1. Host factors- allergy, immunology, gender, race, age, genetics

2. Anatomic/physiologic factors- Eustachian tube, cleft palate

3. Environmental factors- Day care, tobacco smoke exposure, seasonality, breast/bottle feeding,
pacifier use, obesity
 PART THREE: CHRONIC NON-SUPPURATIVE OTITIS MEDIA

TYPES OF OTITIS MEDIA

Suppurative Non-suppurative
Acute suppurative Aerotitis (Barotrauma)
Acute necrotizing Serous otitis media with effusion/ Otitis
media with effusion
Chronic suppurative
Tuberculous

ADULT vs INFANT EUSTACHIAN TUBE: shorter, floppier, more horizontal

PATHOPHYSIOLOGY

ET obstruction or barotrauma negative middle ear pressuremiddle ear

transudate OME

ET obstruction + microbial invasion of middle ear AOM

Impaired ventilation of the middle ear

Stenosis due to inflammatory mucosal swelling (eg. upper respiratory tract infection)

Negative pressure due to rapid rise of ambient air pressure (aircraft landing)

Extrinsic obstruction (tumor)

Deficient active opening of the tube by the tensor veli palatini muscle

Congenital or acquired bony stenosis of stricture during scarring

ET DYSFUNCTION IN OTITIS MEDIA

A. FUNCTIONAL OBSTRUCTION: from collapse of tube/inability to open

1) Cleft palate, other craniofacial abnormalities (deficient tensor veli palatini
function)
2) Negative middle ear pressure from rapid rise of ambient air pressure during
aircraft landing
B. MECHANICAL OBSTRUCTION:
1) Inflammation: infection, allergy
2) Masses: adenoids, nasopharyngeal tumors
C. ABNORMAL PATENCY: usually with sudden or severe weight loss; may lead to reflux
OM
DIAGNOSIS

Otoscopic findings: non-hyperemic TM, bubbles/fluid level, severe retraction in adhesive

OM

Pneumatic Otoscopy- no TM movement on (+) /(-) pressure

Audiometry & Tympanometry-Conductive hearing loss, type __ tympanogram

TREATMENT

Treat underlying cause

Majority: spontaneous resolution in 12 weeks

Myringotomy with ventilation tube insertion

PART FOUR: EXTERNAL EAR CONDITIONS

PATHOGENESIS

Canal skin irritation/ trauma- Bacterial Infection & Inflammation- Diffuse (transudate) or
Circumscribed (pus )

COMMON PATHOGENS

Bacteria Fungus
Pseudomonas Aspergillus
Staphylococcus epidermidis Candida
Staph. aureus

TYPES

1) Acute Diffuse Otitis Externa (a.k.a. swimmer’s ear) – from traumatic cleaning

Treatment:

Gentle cleaning

Analgesics/antipyretics

Ear wick + topical antibiotic drops

2) Necrotizing Otitis Externa- in elderly diabetics, immunocompromised; from minor trauma,

sometimes from vigorous aural irrigation for impacted cerumen

Treatment: Debridement, IV antibiotics

 3) Acute Circumscribed Otitis Externa (Furunculosis) – arises around hair follicle; purulent
discharge - if ruptured

Etiologic Org:

Staph aureus

Treatment:

Gentle cleaning

Analgesics/antipyretics

Oral Antibiotics

Incision & drainage

4)Chronic Otitis Externa- more of a dermatologic condition; flaking with itchiness, made
intractable by constant scratching/cotton bud use

5) Otomycosis- Common in tropics , heat and humidity ideal for growth of fungus

Causes:

use of contaminated ear cleaning devices

In diabetics and the immunocompromised

Overuse of topical antibiotics/steroids

Treatment:

cleaning

Topical antifungal for at least 2 weeks

keep dry!

OTITIS EXTERNA vs OTITIS MEDIA

Externa Media
Pain More severe Less severe, unless with
complication
Tenderness Tragal tenderness None, unless with
subperiosteal abscess
Fever None, usually Usually present
URTI None Usual
Hearing Loss None, unless canal totally Present
closed
 Mastoid Radiograph/CT Normal May have evidence of
mastoiditis

CERUMEN- made up of exfoliated stratum corneum cells and secretions of the ceruminous glands of the
outer 2/3 (or cartilaginous) part of the external ear canal

-needs to be removed when it causes conductive hearing loss, hinders evaluation of the ear
(which includes assessment of the tympanic membrane and audiometry), or results in otitis externa
from attempts to clean it.

- methods of removal (any or a combination of the following):

1) cerumenolytics (oil- or water-based)

2) aural irrigation (contraindicated in swollen ear canals and perforated eardrums)

3) manual removal