Chronic Suppurative Otitis Media

Chronic otitis media is a persistent, chronically draining (> 6 wk), suppurative tympanic membrane perforation. Symptoms include painless otorrhea with conductive hearing loss. Treatment requires completely cleaning the ear canal several times daily, carefully removing granulation tissue, and applying topical corticosteroids and antibiotics. Systemic antibiotics and surgery are reserved for severe cases.

Geriatric Essentials

• Chronic suppurative otitis media may develop in elderly people who have had an asymptomatic chronic ear infection after a URI or after bathing or swimming.
• In elderly patients with otorrhea, squamous and basal cell carcinomas should be considered.

Chronic suppurative otitis media may be a complication of a retracted or perforated tympanic membrane. It may develop in elderly people who have had a quiescent chronic ear infection that has become exacerbated after a URI or when water enters the middle ear during bathing or swimming.

Tympanic membrane perforation may be permanent, and the middle ear mucosa may become hypertrophic. In some patients, the inflamed, polypoid hypertrophic mucosa protrudes through the perforation into the external auditory canal as an aural polyp. A cholesteatoma may be present. Some cases are complicated by abscess formation or erosion into bone.

Symptoms and Signs

Patients usually report painless, purulent, sometimes foul-smelling ear drainage and hearing loss. Fever and otalgia may indicate abscess formation. Vertigo and facial nerve paralysis are ominous signs suggesting erosion of the labyrinthine bone.

Diagnosis

Culture and sensitivity testing of the discharge are done; usually, Pseudomonas aeruginosa or Staphylococcus aureus is detected. Among elderly patients with ear drainage, squamous and basal cell carcinomas should be considered; patients need close follow-up. When complications of chronic suppurative otitis media are suspected (eg, suggested by fever, vertigo, otalgia), CT or MRI is done. These tests may confirm an underlying cholesteatoma, labyrinthitis, ossicular or temporal bone erosion, or abscess.

Treatment

Treatment begins with irrigation to remove purulent debris. The ear canal is irrigated once daily by using a bulb syringe and a slightly warmed solution of ½ distilled white vinegar and ½ sterile water. Irrigations are continued until the canal is clear of debris. Twice daily, an antibiotic preparation is instilled. First-line ototopical antibiotics are ciprofloxacin (with or without a corticosteroid) or ofloxacin; antibiotic therapy should continue for 7 to 10 days. When irrigation has cleared much of the debris, granulation tissue can be removed with a microinstrument or cauterized with silver nitrate sticks. Removal with a microinstrument or cautery with silver nitrate should be done only by ENT specialists trained in microsurgery of the ear. A solution of 2% acetic acid with 1% hydrocortisone is then instilled into the ear. As aural toilet improves and granulation tissue resolves, penetration of topical antibiotics improves.

Patients who do not respond to this therapy may require systemic antibiotic therapy with amoxicillin 250 to 500 mg po q 8 h for 10 days or a 3rd-generation cephalosporin; antibiotic choice can be subsequently modified by culture results and response to therapy. Tympanoplasty is indicated for patients with marginal or attic perforations and chronic central tympanic membrane perforations. A disrupted ossicular chain may be repaired during tympanoplasty as well. Cholesteatomas must be removed surgically; because recurrence is common, reconstruction of the middle ear is usually deferred until a 2nd-look operation is done 6 to 8 mo later.

This topic was last updated June 2006.