Chronic Suppurative Otitis Media Clinical Presentation

Patients with chronic suppurative otitis media (CSOM) present with a draining ear of some duration and a premorbid history of recurrent acute otitis media, traumatic perforation, or the placement of ventilation tubes. Typically, they deny pain or discomfort. A common presenting symptom is hearing loss in the affected ear. Reports of fever, vertigo, and pain should raise concern about intratemporal or intracranial complications. A history of persistent CSOM after appropriate medical treatment should alert the physician to consider cholesteatoma.

The external auditory canal may or may not be edematous and is not typically tender. The discharge varies from fetid, purulent, and cheeselike to clear and serous. Granulation tissue is often seen in the medial canal or middle ear space. The middle ear mucosa visualized through the perforation may be edematous or even polypoid, pale, or erythematous.

In the present era of antibiotics, complications from CSOM are rarely seen because of early antibiotic intervention. However, surgery does play an important role in managing CSOM with or without cholesteatoma.

CSOM without prompt, proper treatment can progress to a variety of mild to life-threatening complications that can be separated into 2 subgroups: intratemporal and intracranial.^[14] Intratemporal complications include petrositis, facial paralysis, and labyrinthitis. Intracranial complications include lateral sinus thrombophlebitis, meningitis, and intracranial abscess. Sequelae include hearing loss, acquired cholesteatoma, and tympanosclerosis.

Petrositis

Petrositis occurs when the infection extends beyond the confines of the middle ear and mastoid into the petrous apex. Patients may present with Gradenigo syndrome (ie, retro-orbital pain, aural discharge, and abducens palsy). A CT scan of the head and temporal bone helps define the extent of the disease, diagnose any intracranial spread, and plan a surgical approach. Treatment includes systemic antibiotics with petrosectomy.

Facial paralysis

Facial paralysis can be observed in CSOM with or without cholesteatoma. Surgical exploration with removal of diseased mucosa, granulation tissue, and inspissated pus (usually by mastoidectomy) should be undertaken promptly.

Labyrinthitis

Labyrinthitis occurs when the infection spreads to the inner ear. This may happen emergently or over an extended period. The infection gains access to the inner ear through the round and oval windows or through one of the semicircular canals exposed by bony erosion. The 4 categories of labyrinthitis have been recognized as acute serous, acute suppurative, chronic, and labyrinthine sclerosis.

The symptoms of acute serous labyrinthitis are acute onset of vertigo and hearing loss. Early surgical exploration to remove the infection mitigates damage to the labyrinth.

Patients with acute suppurative labyrinthitis present with profound hearing loss, tinnitus, and vertigo with associated nausea and vomiting. Patients initially demonstrate nystagmus with the rapid component directed toward the affected ear; they later demonstrate nystagmus away from the affected ear after destruction of the membranous labyrinth. Treatment includes aggressive surgical debridement (including labyrinthectomy) to prevent the possibly lethal intracranial complications of meningitis or encephalitis. Administration of broad-spectrum antibiotics with cerebrospinal fluid penetration is also necessary. Culture and sensitivities should direct any changes in the antibiotic regimen.

Chronic labyrinthitis is characterized by the gradual onset of vertigo, tinnitus, and hearing loss. Most commonly, the infection reaches the labyrinth through the lateral canal. Treatment involves mastoidectomy, culture, and appropriate medical therapy.

Labyrinthine sclerosis occurs as the inflammation in the labyrinth causes the body to replace it with fibrous tissue and new bone.

Lateral sinus thrombophlebitis

Lateral sinus thrombophlebitis occurs as the infection extends through the mastoid bone into the sigmoid or lateral sinus. The infected thrombus may release septic embolic causing distal infarcts. Patients present with altered mental status, possible seizures, and fever. Mastoidectomy with surgical excision of the thrombus and culture-directed antimicrobial treatment are the first steps in the management of sinus thrombophlebitis.

Meningitis

Meningitis develops as a consequence of direct or hematogenous spread of the infection. If meningitis is suspected, a lumbar puncture should be performed to recover the causative organism for culture and sensitivity prior to the initiation of empiric broad-spectrum antibiotic therapy. When stable, patients are taken to the operating room for surgical removal of the cholesteatoma or middle ear infection. Patients with CSOM may develop intracranial abscesses, but it is rare.

Intracranial abscesses

The various intracranial abscesses that may occur can be extradural, subdural, or parenchymal.

A patient with an extradural abscess may present with meningitic signs and symptoms or may be asymptomatic. Regardless of the presentation, imaging to define the abscess should be acquired, and the abscess should be drained with the assistance of neurosurgeons as needed.

Patients with subdural abscesses are very ill and exhibit meningeal signs, possible seizures, and hemiplegia. Prompt neurosurgical consultation, adequate imaging, drainage, and antibiotics are the appropriate treatment. Otologic surgery to remove the nidus of infection is necessary once the patient has stabilized.

Parenchymal abscesses occur as the infection spreads through the tegmen tympani or tegmen mastoideum to the temporal lobe or the cerebellum. Their presentation may be indolent, as this disease initially grows in "silent" areas of the brain. However, if the clinician suspects intracranial involvement, the previous plan of imaging, neurosurgical drainage, and antibiotic therapy is the standard of care.

Conductive hearing loss as a consequence of CSOM may result from the perforated tympanic membrane, a disruption in the ossicular chain, or both. Surgical removal of the infection and cholesteatoma with ossicular chain reconstruction mitigates morbidity associated with decreased hearing.