Chronic otitis media

Chronic otitis media (OM) refers to a group of chronic inflammatory diseases of the middle ear, which often affects children. Chronic suppurative otitis media (CSOM) is characterized by a persistent drainage from the middle ear through a perforated tympanic membrane (TM). The condition is often seen in patients with a history of acute otitis media with TM rupture and presents with painless otorrhea and conductive hearing loss. The diagnosis is confirmed by detection of a TM defect during otoscopy. Treatment consists of conservative measures (e.g., antibiotic drops) and tympanoplasty if conservative management fails. Chronic otitis media with effusion (OME) is most likely caused by eustachian tube dysfunction (ETD) and is characterized by a buildup of effusion behind the intact TM. Clinically, OME presents with a sensation of fullness or pressure in the ear, as well as conductive hearing loss. The effusion often resolves spontaneously and treatment (e.g., placement of tympanostomy tubes) is only indicated if hearing impairment occurs or if the effusion persists. Acute OME in adults should raise suspicion of a nasopharyngeal malignancy and prompt swift evaluation.

• Definition: persistent drainage from the middle ear through a perforated tympanic membrane lasting > 6–12 weeks
• Epidemiology: most common in children and adolescents > 15 years old
• Etiology: bacterial infection following perforation of the tympanic membrane due to
  • (Recurrent) acute otitis media
  • Placement of ventilation tube
  • Trauma
• Pathophysiology: infection secondary to translocation of bacteria of the external ear canal into the middle ear through the perforated tympanic membrane
• Clinical features
  • Painless, recurrent otorrhea (usually odorless; mucoid or serous )
  • Conductive hearing loss → Weber test lateralizes to the affected ear
  • Possibly development of concurrent cholesteatoma
  • Fever is not typical and indicative of complications if it occurs.
• Diagnostics
  • Clinical diagnosis
  • Otoscopy: visible defect of the tympanic membrane → confirmation of diagnosis
  • Cranial CT or MRI: if complications are suspected (see below)
• Treatment
  • Goal: restore integrity of the tympanic membrane , prevent permanent hearing loss
  • Conservative treatment: : rinsing of the ear; topical antibiotic (e.g., ciprofloxacin) and steroid drops (e.g., dexamethasone)
  • Surgical treatment: tympanoplasty with insertion of a graft
• Complications
  • Possibly life-threatening spread of infection (e.g., meningitis, intracranial abscess, facial paralysis); rarely occurs with adequate treatment
  • Tympanosclerosis
    • Scarring of the tympanic membrane due to recurrent ear infections or otitis media with effusion
    • May be asymptomatic or lead to conductive hearing loss
    • White calcified plaques in the tympanic membrane seen on otoscopy
• Prognosis: usually good with adequate treatment; conductive hearing loss can often be improved, but may not be fully recovered

References:^[1][2][3]

Chronic OME in children

• Definition: chronic mucoid or serous effusion in the tympanic cavity in the absence of infection lasting for > 3 months
• Epidemiology: : observed particularly in toddlers after an episode of acute OM
• Etiology: incompletely understood, but primarily thought to be due to eustachian tube dysfunction
• Pathophysiology: : ETD causes negative middle ear pressure → triggers formation of transudate → dysfunctional eustachian tube prevents adequate drainage → accumulation of fluid
• Clinical features
  • May be asymptomatic
  • Typically painless sensation of pressure in the affected ear
  • Conductive hearing loss
  • Speech and language impairment
• Diagnostics
  • Best initial test: pneumatic otoscopy to assess the tympanic membrane
    • Intact TM
    • TM is opaque, yellow-colored, may be retracted
    • Air-fluid level behind the TM
    • Impaired mobility of the TM
  • If pneumatic otoscopy is inconclusive: impedance tympanometry
  • Persistent OME for > 3 months or speech impairment: audiometry
    • Conductive hearing loss of 20–40 dB
• Differential diagnosis: : presence of pain or fever indicates acute otitis media
• Treatment
  • Patients without speech impairement at the time of diagnosis: monitor for 3 months
  • Patients with speech impairement or persistent OME at follow-up
    • Age < 4 years: placement of tympanostomy tubes
    • Age ≥ 4 years; : placement of tympanostomy tubes and/or adenoidectomy

In children, reduced hearing ability due to OME may result in speech and language impairment. Therefore, early initiation of treatment is important!

Pharmacologic therapy (e.g., oral steroids, antihistamines, nasal decongestants, antibiotics) shows little effect and is not generally recommended!

Acute OME in adults

• Etiology
  • Obstruction secondary to nasopharyngeal carcinoma (rare)
  • Rhinitis, sinusitis, pharyngitis
  • Recurrent otitis media
• Clinical features
  • Sensation of pressure in the affected ear
  • Conductive hearing loss
• Diagnostics
  • Otoscopy for assessment of TM (see findings in “Diagnostics” section above)
  • If unilateral OME recurs or persists, perform endoscopy of the nasopharynx to rule out carcinoma
• Treatment
  • Effusion often resolves spontaneously → monitor
  • Treatment of the underlying disease
  • Valsalva maneuver/autoinflation to enable drainage
  • Consider myringotomy with aspiration of the effusion

References:^[4][5][6][7]