Introduction
Otitis media (OM) is a prevalent condition in pediatrics, frequently manifesting as fever. Chronic suppurative otitis media (CSOM), also known as chronic otitis media, represents a persistent infection of the middle ear characterized by a non-intact tympanic membrane. This condition involves chronic inflammation of the middle ear and mastoid cavity, typically presenting with persistent otorrhea lasting from 2 to 6 weeks through a perforated tympanic membrane.[1] Eustachian tube dysfunction is a significant factor, observed in approximately 70% of patients undergoing middle ear surgery for CSOM. Impaired pressure regulation and aeration in the middle ear due to Eustachian tube dysfunction are hallmark features of CSOM.[2] Acquired hearing loss is commonly associated with CSOM, and without appropriate intervention, it can lead to significant morbidity and potential mortality.[3]
Etiology
While viral infections are the predominant cause of acute otitis media, bacterial pathogens are frequently implicated in chronic suppurative otitis media. CSOM is often polymicrobial in etiology. Staphylococcus aureus, including methicillin-resistant strains (MRSA), is a frequently identified microorganism. Other bacteria such as Pseudomonas aeruginosa, Proteus spp, Klebsiella spp, Bacteroides spp., and Fusobacterium spp. can also contribute to the disease. Less common fungal agents like Aspergillus spp. and Candida spp. are more often seen in immunocompromised individuals.[4] Mycobacterium tuberculosis should also be considered as a cause of CSOM, particularly in regions with a high prevalence of tuberculosis.
Epidemiology
CSOM typically emerges in early childhood, with the highest incidence around two years of age. Children from low-income backgrounds are disproportionately affected.[5] Furthermore, children with craniofacial anomalies, such as cleft palate, and those with Down syndrome have an elevated risk. Although rare, CSOM can be a component of Gradenigo syndrome, characterized by orbito-facial pain and sixth cranial nerve palsy, arising as a complication of CSOM.[6] A commonality among these congenital conditions is Eustachian tube dysfunction, which predisposes children to middle ear disease. Key risk factors associated with CSOM include: a) recurrent episodes of acute otitis media, b) upper respiratory tract infections, c) tympanic membrane trauma, and d) poor nutrition and living conditions.[5]
Pathophysiology
In CSOM, bacterial pathogens invade the middle ear mucosa, often through the external auditory canal.[7] This invasion triggers an inflammatory response in the middle ear, leading to edema and fibrosis. Spontaneous tympanic membrane perforation and persistent infection are characteristic features of the pathophysiology. CSOM can also develop as a sequela of tympanostomy tube placement, which is commonly performed to manage otitis media with effusion.
Histopathology
Routine microscopic examination of middle ear tissue is not typically performed in children with CSOM and is not necessary for diagnosis or treatment. However, if ear microscopy is conducted, it will reveal the tympanic membrane perforation.[7]
History and Physical Examination
Otorrhea is the most common presenting symptom of CSOM, although some patients may present with “dry ears.” Additional symptoms that may be present but are not essential for diagnosis include hearing impairment, tinnitus, and aural fullness.[8] It is crucial to recognize that children with CSOM can be asymptomatic or, conversely, present with severe illness including intracranial complications. A thorough history should include inquiries about vertigo and its relation to ear symptoms. Clinicians should also gather information on prior ear infections, recent antibiotic use, and any history of ear surgery. Co-existing medical conditions such as allergic rhinitis and gastroesophageal reflux, as well as exposure to tobacco smoke, should be documented.[2]
Evaluation
Otoscopic examination is fundamental in evaluating CSOM. Two types of otoscope heads are available: surgical (operating) and diagnostic (pneumatic). Pneumatic otoscopy allows for assessment of tympanic membrane mobility in response to positive and negative pressure, which can indicate the presence of middle ear effusion, a key sign of otitis media. Other tympanic membrane abnormalities that may be observed include erythema, bulging or fullness, and marked retraction. Microbiological evaluation of the otorrhea is essential to guide targeted treatment of CSOM. Pseudomonas aeruginosa is frequently isolated and is ubiquitous in moist environments. This organism often initiates infection by adhering to epithelial cells via pili or fimbriae.
Treatment and Management
Topical quinolone antibiotics are considered the first-line treatment for CSOM due to their efficacy in resolving otorrhea and eradicating causative microorganisms. Quinolones are as effective, if not more effective, than aminoglycosides and crucially, lack the potential for ototoxicity.[9] In cases without cholesteatoma, parenteral antimicrobial therapy combined with meticulous aural cleaning can effectively clear the infection. However, refractory cases may necessitate tympanomastoidectomy. For parenteral regimens, beta-lactam antipseudomonal antibiotics, such as ceftazidime, are utilized. Ticarcillin-clavulanate represents an alternative agent with activity against both Pseudomonas species and S. aureus. Biofilm formation is implicated in the pathogenesis of CSOM and can contribute to antibiotic treatment resistance.[5] Surgical intervention may mitigate complications, but postoperative ear discharge can still occur. Referral to otolaryngology is essential for patients who do not respond to initial treatment or when cholesteatoma or other masses are suspected. In the presence of cholesteatoma, surgical management by an otolaryngologist, involving mastoidectomy with tympanoplasty, is typically required. Audiological assessment is critical in all patients with CSOM to evaluate hearing function and ensure appropriate follow-up.
Differential Diagnosis of Chronic Suppurative Otitis Media
When evaluating a patient presenting with symptoms suggestive of chronic suppurative otitis media, it is crucial to consider a range of other conditions that may mimic CSOM. The differential diagnosis is broad and encompasses conditions affecting the external auditory canal, middle ear, and even intracranial structures. Given that otorrhea is a primary symptom and CSOM is most common in children under 5 years, the differential diagnosis must be carefully considered.
Foreign Body in the Ear Canal
Especially in young children, a foreign body in the ear canal is a common cause of otorrhea. This is a critical differential consideration as the management is straightforward removal of the foreign object. A foul-smelling discharge may be more suggestive of a foreign body compared to typical CSOM otorrhea, but careful otoscopic examination is essential to visualize and rule out a foreign body.
Otitis Externa
Otitis externa, or infection of the external auditory canal, is another frequent cause of otorrhea and ear discomfort. Distinguishing features of otitis externa include pain on manipulation of the pinna and tragus, which is typically absent in CSOM unless there is associated external canal involvement. Otoscopic examination in otitis externa reveals inflammation and edema of the external canal skin, often with purulent discharge originating from the canal itself, not through a tympanic membrane perforation.
Myringitis
Myringitis, an inflammation of the tympanic membrane, can also present with otorrhea and ear pain. However, in myringitis, the inflammation is localized to the tympanic membrane without the chronic middle ear involvement characteristic of CSOM. Otoscopic examination will show a diffusely inflamed tympanic membrane, but typically without a perforation in the early stages. Bullous myringitis, a variant, presents with vesicles on the tympanic membrane.
Cholesteatoma
While cholesteatoma can be a complication of CSOM, it also represents a distinct entity in the differential diagnosis. Cholesteatoma is an abnormal skin growth in the middle ear and mastoid. It can present with chronic otorrhea, hearing loss, and potentially vertigo or facial nerve weakness. Differentiating cholesteatoma from uncomplicated CSOM often requires otolaryngologic expertise and may involve imaging studies like CT scans to assess for the extent of the disease and involvement of bony structures. Cholesteatoma typically requires surgical management.
Mastoiditis
Mastoiditis is a serious complication of otitis media, representing infection of the mastoid air cells. It presents with post-auricular pain, swelling, erythema, and often protrusion of the auricle. Patients with mastoiditis are typically systemically ill with fever and malaise. While CSOM can be a precursor, mastoiditis is a more acute and severe condition requiring prompt and aggressive management, often including intravenous antibiotics and potentially surgical drainage.
Petrositis and Gradenigo Syndrome
Petrositis is an infection of the petrous apex of the temporal bone, a rare but serious condition that can arise from middle ear infections. Gradenigo syndrome is a classic presentation of petrositis, characterized by the triad of retro-orbital pain, diplopia (due to abducens nerve palsy – sixth cranial nerve), and otorrhea. The presence of cranial nerve deficits in the context of chronic otitis media should raise suspicion for petrositis.
Langerhans Cell Histiocytosis (LCH) and Neoplasia
Rarely, chronic ear discharge can be caused by more unusual conditions such as Langerhans cell histiocytosis (LCH) or neoplasia of the middle ear or mastoid. LCH is a rare disorder that can affect the temporal bone and present with chronic otitis media-like symptoms. Neoplasms, while uncommon in the middle ear, should be considered in cases of persistent, unusual otorrhea, particularly in adults or when accompanied by atypical features like facial nerve paralysis or rapidly progressive hearing loss.
Intracranial Complications
Serious intracranial complications of otitis media, such as extradural abscess, subdural empyema, brain abscess, sigmoid sinus thrombosis, otitic hydrocephalus, and meningitis, must be considered in the differential diagnosis, particularly in patients presenting with severe symptoms. These conditions typically present with systemic symptoms, neurological deficits, and signs of increased intracranial pressure. While less likely to be mistaken for uncomplicated CSOM, they represent the severe end of the spectrum of complications and must be ruled out in cases with atypical or worsening symptoms.
Systemic Granulomatous Diseases
Conditions like tuberculosis and Wegener granulomatosis (now known as granulomatosis with polyangiitis) can, in rare instances, manifest with ear involvement and chronic otorrhea. Tuberculosis otitis media should be considered in patients from high-risk populations or with a history of tuberculosis exposure. Wegener granulomatosis, a systemic vasculitis, can affect the upper respiratory tract, including the ears, and may present with chronic ear disease.
Labyrinthitis
Labyrinthitis, an inflammation of the inner ear, can occur as a complication of otitis media and may present with vertigo, hearing loss, and tinnitus. While not typically presenting with otorrhea as a primary symptom, it can be part of the clinical picture in complicated CSOM and should be considered when patients report significant vestibular symptoms.
Differentiating CSOM from these conditions relies on a thorough history, detailed physical examination including pneumatic otoscopy, and often, microbiological studies of the otorrhea. In complex or atypical cases, imaging studies (CT or MRI) and referral to specialists like otolaryngologists and neurologists may be necessary for definitive diagnosis and management.
Toxicity and Adverse Effect Management
While topical quinolones are the preferred treatment for CSOM due to their safety profile, aminoglycosides remain an alternative option. However, it is critical to acknowledge the potential for ototoxicity associated with aminoglycosides.[5] When aminoglycosides are used, monitoring for signs of ototoxicity, such as new-onset or worsening tinnitus, vertigo, or hearing loss, is essential.
Prognosis
The overall prognosis for CSOM is generally favorable with timely and appropriate treatment, aimed at preventing complications. However, some cases of CSOM can be refractory to initial treatments and require more extensive evaluation and management. Given that CSOM frequently follows acute otitis media, effective diagnosis and treatment of acute otitis media are crucial in preventing the development of CSOM. The introduction of the pneumococcal vaccine has demonstrated a positive impact on reducing the incidence of acute otitis media, consequently leading to a decrease in CSOM cases.[5]
Complications
Untreated or poorly managed CSOM can lead to a range of complications, including the formation of aural polyps, osteitis, sclerosis, tympanosclerosis, labyrinthitis, and serious intracranial suppurative complications such as epidural, subdural, or brain abscesses. The most common complication is hearing loss, which can be conductive, sensorineural, or mixed. Hearing loss associated with CSOM can have significant consequences for children, including language delays and behavioral problems.[10]
Deterrence and Patient Education
Educating parents and caregivers about the importance of routine well-child visits and seeking prompt medical attention when children experience ear pain or discomfort is crucial for deterrence. Furthermore, it is important to consider reports from teachers and educators, particularly if hearing loss is suspected. Vigilant management and follow-up of CSOM are essential to minimize the risk of long-term complications that can impact a child’s development and well-being.
Enhancing Healthcare Team Outcomes
Chronic suppurative otitis media remains a significant health concern, particularly in early childhood. Prompt identification of the causative agent and initiation of appropriate treatment are essential to prevent severe complications. Effective management of CSOM requires a collaborative, interprofessional healthcare team approach, including pediatricians, otolaryngologists, audiologists, and nurses. Early diagnosis and treatment are paramount for achieving optimal outcomes and preventing complications. In cases requiring interventions beyond initial antibiotic therapy, timely engagement of otolaryngology specialists is vital. Routine audiological assessment and follow-up are integral to ensure comprehensive care and address potential hearing deficits.
References
1.Head K, Chong LY, Bhutta MF, Morris PS, Vijayasekaran S, Burton MJ, Schilder AG, Brennan-Jones CG. Topical antiseptics for chronic suppurative otitis media. Cochrane Database Syst Rev. 2020 Jan 06;1(1):CD013055. [PMC free article: PMC6956662] [PubMed: 31902140]
2.Emmett SD, Kokesh J, Kaylie D. Chronic Ear Disease. Med Clin North Am. 2018 Nov;102(6):1063-1079. [PubMed: 30342609]
3.Master A, Wilkinson E, Wagner R. Management of Chronic Suppurative Otitis Media and Otosclerosis in Developing Countries. Otolaryngol Clin North Am. 2018 Jun;51(3):593-605. [PubMed: 29525390]
4.Özcan N, Saat N, Yildirim Baylan M, Akpolat N, Atmaca S, Gül K. Three cases of Chronic Suppurative Otitis Media (CSOM) caused by Kerstersia gyiorum and a review of the literature. Infez Med. 2018 Dec 01;26(4):364-368. [PubMed: 30555142]
5.Uddén F, Filipe M, Reimer Å, Paul M, Matuschek E, Thegerström J, Hammerschmidt S, Pelkonen T, Riesbeck K. Aerobic bacteria associated with chronic suppurative otitis media in Angola. Infect Dis Poverty. 2018 May 03;7(1):42. [PMC free article: PMC5932871] [PubMed: 29720274]
6.Bozan N, Düzenli U, Yalinkilic A, Ayral A, Parlak M, Turan M, Kiroglu AF. Gradenigo Syndrome Induced by Suppurative Otitis Media. J Craniofac Surg. 2018 Oct;29(7):e645-e646. [PubMed: 29894453]
7.Jensen RG, Johansen HK, Bjarnsholt T, Eickhardt-Sørensen SR, Homøe P. Recurrent otorrhea in chronic suppurative otitis media: is biofilm the missing link? Eur Arch Otorhinolaryngol. 2017 Jul;274(7):2741-2747. [PubMed: 28466356]
8.Reiss M, Reiss G. [Suppurative chronic otitis media: etiology, diagnosis and therapy]. Med Monatsschr Pharm. 2010 Jan;33(1):11-6; quiz 17-8. [PubMed: 20131670]
9.Harris AS, Elhassan HA, Flook EP. Why are ototopical aminoglycosides still first-line therapy for chronic suppurative otitis media? A systematic review and discussion of aminoglycosides versus quinolones. J Laryngol Otol. 2016 Jan;130(1):2-7. [PubMed: 26584651]
10.Rosa-Olivares J, Porro A, Rodriguez-Varela M, Riefkohl G, Niroomand-Rad I. Otitis Media: To Treat, To Refer, To Do Nothing: A Review for the Practitioner. Pediatr Rev. 2015 Nov;36(11):480-6; quiz 487-8. [PubMed: 26527627]
