[13] Chronic Suppurative Otitis Media Flashcards
What is chronic suppurative otitis media?
Inflammation of the middle ear and mastoid cavity for at least 6 weeks
What is chronic otitis media characterised by?
Discharge from the middle ear through a perforated TM
What can chronic suppurative otitis media be divided into?
‘Safe’ and ‘Unsafe’
What is the division of chronic suppurative otitis media into ‘safe’ and ‘unsafe’ based on?
The risk of developing cholesteatoma
What constitutes a low risk of cholesteatoma development in chronic suppurative otitis media?
Perforation in the tubotympanic (anterio-inferior) part of the TM
What constitutes a high risk of cholesteatoma development in chronic suppurative otitis media?
Perforation in the atticoantral (postero-superior) aspect of the TM
What cycle underlies the pathology of chronic suppurative otitis media?
Inflammation -> Ulceration -> Infection -> Granulation
How does inflammation in chronic suppurative otitis media first occur?
Due to acute infection of the middle ear causing irritation
What does inflammation in the middle ear lead to in chronic suppurative otitis media?
Mucosal ulceration and breakdown of the epithelial lining
What happens as a result of the ulceration and epithelial breakdown in chronic suppurative otitis media?
Granuloma formation developing into polyps in the middle ear
What can happen due to the inflammation, ulceration and granulation in chronic suppurative otitis media?
Destruction of surrounding structures and complications
What may cause the perforation in chronic suppurative otitis media?
- Trauma
- Iatrogenic
- Acute otitis media
How can perforation of TM occur iatrogenically?
Grommet placement
How does the bacteria enter the middle ear in chronic suppurative otitis media?
From the external auditory canal via the perforation
What are the most common causative organisms in chronic suppurative otitis media?
- Pseudomonas aeruginosa
- Staph. aureus
- Proteus species
- Klebsiella pneumoniae
What are the risk factors for developing chronic suppurative otitis media?
- Multiple episodes of acute otitis media
- Living in crowded conditions
- Being a member of a large family
- Attending daycare
- Craniofacial abnormalities
What craniofacial abnormalities can increase the risk of chronic suppurative otitis media?
- Cleft lip or palate
- Down’s syndrome
- Choanal atresia
- Microcephaly
How doe chronic suppurative otitis media present?
- Chronic (>2 weeks) ear discharge
- Absence of otalgia and fever
- Conductive* hearing loss
- History of perforation mechanism
- What does mixed hearing loss suggest?
Extensive disease
What test should be performed in a patient with suspected chronic suppurative otitis media?
- Audiogram
- Tympanometry
What can make audiometry and tympanometry difficult?
Heavy discharge
How is chronic suppurative otitis media usually diagnosed?
Clinically
What additional test should be performed if there is suspicion of cholesteatoma development?
CT of petrous temporal bone
What are the differentials of chronic suppurative otitis media?
- Otitis externa
- Foreign body
- Impacted earwax
- Cholesteatoma
- Wegener’s granulomatosis
- Neoplasm
What are the initial mainstays of therapy for chronic suppurative otitis media?
- Aural toileting
- Topical antibiotics and steroids
When should aural toileting and topical therapies for chronic suppurative otitis media stop?
When symptoms are reduced or resovled
What should the antibiotics used in chronic suppurative otitis media have activity against?
- Gram -ve (especially pseudomonas)
- Gram +ve (especially S. aureus)
What are the topical steroids used for in chronic suppurative otitis media?
Reduce granuloma formation
What is systemic therapy reserved for in chronic suppurative otitis media?
Failure to respond to topical therapy
What other treatment options are available in chronic suppurative otitis media?
Surgery
What is the success of surgery in chronic suppurative otitis media dependent on ?
- Size of perforation
- Site of perforation
What is the aim of closing the perforation in chronic suppurative otitis media?
- Relieve symptoms
- Prevent recurrent infection
- Potentially improve hearing
What is the improvement in hearing post-surgery for chronic suppurative otitis media dependent upon?
Pre-operative state of the auditory apparatus
What are the surgical options for chronic suppurative otitis media?
- Myringoplasty
- Tympanoplasty
What is a myringoplasty?
Closure of the perforation in the pars tense
How is closure of the pars tense achieved inchronic suppurative otitis media?
Autologous graft harvested from the tragal cartilage or temporalis fascia
What is tympanoplsty?
- Myringoplasty combined with reconstruction of the ossicular chain
What are the potential complications of chronic suppurative otitis media?
- Sequelae of the condition
- Intra-temporal complications
- Intra-cranial complications
What are the sequelae of chronic suppurative otitis media?
- Hearing loss
- Tympanosclerosis
What are the intra-temporal complications of chronic suppurative otitis media?
- Petrositis
- Facial paralysis
- Labyrinthitis
What are the intra-cranial complications of chronic suppurative otitis media?
- Lateral sinus thrombophlebitis
- Meningitis
- Intracranial abscess
