ESSENTIALS OF DIAGNOSIS
Chronic otorrhea with or without otalgia.
Tympanic membrane perforation with conductive hearing loss.
Often amenable to surgical correction.
Chronic infection of the middle ear and mastoid generally develops as a consequence of recurrent acute otitis media, although it may follow other diseases and trauma. Perforation of the tympanic membrane is usually present. This may be accompanied by mucosal changes such as polypoid degeneration and granulation tissue and osseous changes such as osteitis and sclerosis. The bacteriology of chronic otitis media differs from that of acute otitis media. Common organisms include P aeruginosa, Proteus species, Staphylococcus aureus, and mixed anaerobic infections.
The clinical hallmark of chronic otitis media is 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. Conductive hearing loss results from destruction of the tympanic membrane or ossicular chain, or both.
The medical treatment of chronic otitis media includes regular removal of infected debris, use of earplugs to protect against water exposure, and topical antibiotic drops (ofloxacin 0.3% or ciprofloxacin with dexamethasone) for exacerbations. Oral ciprofloxacin, active against Pseudomonas, 500 mg twice a day for 1–6 weeks, may help dry a chronically discharging ear.
Definitive management is surgical in most cases. 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.
et al. Chronic ear disease. Med Clin North Am. 2018 Nov;102(6):1063–79.
et al. Management of chronic suppurative otitis media and otosclerosis in developing countries. Otolaryngol Clin North Am. 2018 Jun;51(3):593–605.
Complications Of Otitis Media
Cholesteatoma is a special variety of chronic otitis media (Figure 8–3). The most common cause is prolonged eustachian tube dysfunction, with inward migration of the upper flaccid portion of the tympanic membrane. This creates a squamous epithelium-lined sac, which—when its neck becomes obstructed—may fill with desquamated keratin and become chronically infected. Cholesteatomas 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. The treatment of cholesteatoma is surgical marsupialization of the sac or its complete removal. This may require the creation of a “mastoid bowl” in which the ear canal and mastoid are joined into a large common cavity that must be periodically cleaned.
Cholesteatoma. (Used, with permission, from Vladimir Zlinsky, MD, in Roy F. Sullivan, PhD: Audiology Forum: Video Otoscopy, www.RCSullivan.com; from Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley H, Tysinger J. The Color Atlas of Family Medicine. McGraw-Hill, 2009.)
et al. Updates in pediatric cholesteatoma: minimizing intervention while maximizing outcomes. Otolaryngol Clin North Am. 2019 Oct;52(5):813–23.
et al. Cholesteatoma definition and classification: a literature review. J Int Adv Otol. 2017 Aug;13(2):266–71.
Acute suppurative mastoiditis usually evolves following several weeks of inadequately treated acute otitis media. It is characterized by postauricular pain and erythema accompanied by a spiking fever. CT scan reveals coalescence of the mastoid air cells due to destruction of their bony septa. Initial treatment consists of intravenous antibiotics (eg, cefazolin 0.5–1.5 g every 6–8 hours) directed against the most common offending organisms (S pneumoniae, H influenzae, and S pyogenes), and myringotomy for culture and drainage. Failure of medical therapy indicates the need for surgical drainage (mastoidectomy).
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. This may cause foul discharge, deep ear and retro-orbital pain, and sixth nerve palsy (Gradenigo syndrome); meningitis may be a complication. Treatment is with prolonged antibiotic therapy (based on culture results) and surgical drainage via petrous apicectomy.
et al. The changing face of petrous apicitis—a 40-year experience. Laryngoscope. 2018 Jan;128(1):195–201.
et al. Acute otitis media and associated complications in United States emergency departments. Otol Neurotol. 2018 Sep;39(8):1005–11.
Facial palsy may be associated with either acute or chronic otitis media. In the acute setting, it results from inflammation of the seventh nerve in its middle ear segment, perhaps mediated through bacterially secreted neurotoxins. Treatment consists of myringotomy for drainage and culture, followed by intravenous antibiotics (based on culture results). The use of corticosteroids is controversial. The prognosis is excellent, with complete recovery in most cases.
Facial palsy associated with chronic otitis media usually evolves slowly due to chronic pressure on the seventh nerve in the middle ear or mastoid by cholesteatoma. Treatment requires surgical correction of the underlying disease. The prognosis is less favorable than for facial palsy associated with acute otitis media.
et al. Facial nerve paralysis. Med Clin North Am. 2018 Nov;102(6):1135–43.
et al. Facial nerve paralysis in acute suppurative otitis media—management. Indian J Otolaryngol Head Neck Surg. 2017 Mar;69(1):58–61.
et al. The etiology of Bell’s palsy: a review. J Neurol. 2019 Mar 28. [Epub ahead of print]
E. Sigmoid Sinus Thrombosis
Trapped infection within the mastoid air cells adjacent to the sigmoid sinus may cause septic thrombophlebitis. This is heralded by signs of systemic sepsis (spiking fevers, chills), at times accompanied by signs of increased intracranial pressure (headache, lethargy, nausea and vomiting, papilledema). Diagnosis can be made noninvasively by magnetic resonance venography (MRV). Primary treatment is with intravenous antibiotics (based on culture results). Surgical drainage with ligation of the internal jugular vein may be indicated when embolization is suspected.
F. Central Nervous System Infection
Otogenic meningitis is by far the most common intracranial complication of ear infection. In the setting of acute suppurative otitis media, it arises from hematogenous spread of bacteria, most commonly H influenzae and S pneumoniae. In chronic otitis media, it results either from passage of infection along preformed pathways, such as the petrosquamous suture line, or from direct extension of disease through the dural plates of the petrous pyramid.
Epidural abscesses arise from direct extension of disease in the setting of chronic infection. They are usually asymptomatic but may present with deep local pain, headache, and low-grade fever. They are often discovered as an incidental finding at surgery. Brain abscess may arise in the temporal lobe or cerebellum as a result of septic thrombophlebitis adjacent to an epidural abscess. The predominant causative organisms are S aureus, S pyogenes, and S pneumoniae. Rupture into the subarachnoid space results in meningitis and often death. (See Chapter 30.)
et al. Neurological complications of acute and chronic otitis media. Curr Neurol Neurosci Rep. 2018 Feb 14;18(3):11.
et al. Is anticoagulation beneficial in acute mastoiditis complicated by sigmoid sinus thrombosis? Laryngoscope. 2018 Nov;128(11):2435–6.