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For further information, see CMDT Part 8-05: Diseases of the Middle Ear

Key Features

Essentials of Diagnosis

  • Chronic otorrhea with or without otalgia

  • Tympanic membrane perforation with conductive hearing loss

  • Often amenable to surgical correction

General Considerations

  • Generally develops as a consequence of recurrent acute otitis media, although it may follow other diseases and trauma

  • The bacteriology of chronic otitis media differs from that of acute otitis media; common organisms include

    • Pseudomonas aeruginosa

    • Proteus species

    • Staphylococcus aureus

    • Mixed anaerobic infections

Clinical Findings

  • Purulent aural discharge

  • Drainage may be continuous or intermittent, with increased severity during upper respiratory tract infection or following water exposure

  • Pain is uncommon except during acute exacerbations

Diagnosis

  • Conductive hearing loss results from destruction of the tympanic membrane or ossicular chain, or both

  • Perforation of the tympanic membrane is usually present; may be accompanied by

    • Mucosal changes, such as polypoid degeneration

    • Granulation tissue and osseous changes, such as osteitis and sclerosis

Treatment

Medication

  • Regular removal of infected debris

  • Use of earplugs to protect against water exposure

  • Topical antibiotic drops (eg, ofoxacin 0.3% or ciprofloxacin with dexamethasone) for exacerbations

  • Ciprofloxacin, 500 mg orally twice a day for 1–6 weeks, may help dry a chronically discharging ear

Surgery

  • Tympanic membrane repair may be accomplished with temporalis muscle fascia

  • Successful reconstruction of the tympanic membrane may be achieved in about 90% of cases, often with elimination of infection and significant improvement in hearing

  • When the mastoid air cells are involved by irreversible infection, they should be exenterated at the same time through a mastoidectomy

Outcome

Complications

  • Cholesteatoma

    • A special variety of chronic otitis media

    • Most common cause is prolonged eustachian tube dysfunction, with inward migration of the upper flaccid portion of the tympanic membrane

    • Typically erode bone, with early penetration of the mastoid and destruction of the ossicular chain

    • Over time they may erode into the inner ear, involve the facial nerve, and on rare occasions spread intracranially

    • Otoscopic examination may reveal an epitympanic retraction pocket or a marginal tympanic membrane perforation that exudes keratin debris, or granulation tissue

    • Treatment involves surgical marsupialization of the sac or its complete removal

  • Petrous apicitis

    • The medial portion of the petrous bone between the inner ear and clivus may become a site of persistent infection when the drainage of its pneumatic cell tracts becomes blocked

    • Foul discharge, deep ear and retro-orbital pain, and sixth nerve palsy (Gradenigo syndrome) may result

    • Meningitis may be a complication

    • Treatment is with prolonged antibiotic therapy (based on culture results) and surgical drainage via petrous apicectomy

  • Facial paralysis

    • Usually evolves slowly due to chronic pressure on the seventh nerve in the middle ear or ...

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