eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Middle Ear & Mastoid

Middle Ear, Chronic Suppurative Otitis, Medical Treatment: Follow-up

Author: David Parry, MD, Staff Physician, Department of Otolaryngology-Head and Neck Surgery, ENT Associates of Children's Hospital, Boston
Coauthor(s): Peter S Roland, MD, Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director of Clinical Center for Auditory, Vestibular and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Adjunct Professor of Communicative Disorders, University of Texas School of Human Development
Contributor Information and Disclosures

Updated: Jul 7, 2009

Follow-up

Further Inpatient Care

Inpatient care is rarely necessary for the patient with CSOM. In patients for whom the otolaryngologist chooses systemic parenteral antibiotics, inpatient hospitalization may be required. Otherwise, excluding complications, this disease can be treated effectively in the outpatient setting.

Inpatient & Outpatient Medications

  • Ototopical fluoroquinolone with or without steroid (eg, Floxin, Cipro HC, Ciprodex)
    • This should be considered as an initial choice for topical antibiotic because of its broad spectrum and low adverse effect profile with minimal toxicity.
    • Fluoroquinolones are not ototoxic and are very effective in the eradication of CSOM.
  • Ototopical aminoglycoside with steroid (eg, Cortisporin, Otobiotic)
    • These antibiotic preparations also have excellent broad-spectrum coverage with minimal adverse reactions.
    • Prolonged use carries no known risk of ototoxicity. These preparations have demonstrated ototoxicity in animal studies of normal middle ears.
  • Ototopical acetic acid or alcohol preparations (eg, Domeboro, Swim-Ear, VoSoL Otic)

Transfer

  • Patients who present with suspected intracranial complications to hospitals that function without CT scanning capabilities or neurosurgical care should be transferred as soon as possible to an institution with such capabilities. Antibiotic therapy should be started prior to transfer.

Deterrence/Prevention

  • The following measures help prevent recurrence and allow for early intervention in patients with recurrent infections:
    • Patients should be advised to keep their ears dry to prevent future complications, even after medical treatment results in a safe and dry ear. Swimming is not contraindicated if patients dry their ears afterward.
    • Tympanoplasty, a surgery that seals the perforation, prevents the translocation of bacteria from the external ear canal into the middle ear. The uninflamed, protected middle ear mucosa deters future development of chronic suppurative otitis media.
    • Early symptoms of aural fullness, otalgia with or without fever, and headache warrant evaluation by an otolaryngologist in patients with a recent history of CSOM.

Complications

  • CSOM without prompt proper treatment can progress into a variety of mild to life-threatening complications that can be separated into 2 subgroups: intratemporal and intracranial.5 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 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 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 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 (1) acute serous, (2) acute suppurative, (3) chronic, and (4) labyrinthine sclerosis.
      • 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 after destruction of the membranous labyrinth, away from the affected ear. Treatment includes aggressive surgical debridement of the disease (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 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 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 represent the first steps in its management.
    • Meningitis develops as a consequence of direct or hematogenous spread of the infection. If suspected, perform lumbar puncture 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. Rarely, patients with CSOM develop intracranial abscesses.
    • The various intracranial abscesses may be extradural, subdural, or parenchymal.
      • A patient with an extradural abscess may present with meningitic signs and symptoms or may be asymptomatic. Regardless of 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 with meningeal signs, possible seizures, and hemiplegia. Prompt neurosurgical consultation, adequate imaging, drainage, and antibiotics are 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 TM, 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.

Prognosis

Patients with CSOM have a good prognosis with respect to control of infection. The recovery of associated hearing loss varies, depending on the cause. Conductive hearing loss can often be partially corrected with surgery. The goal of treatment is to provide the patient a safe ear.

Miscellaneous

Medicolegal Pitfalls

  • Possible medicolegal pitfalls occur with hearing loss and CSOM.
    • Although studies suggest only a slight risk of sensorineural hearing loss in humans from short courses of topical aminoglycosides, the risk of vestibular toxicity appears to be much higher.
    • The introduction of fluoroquinolones, which have no potential for ototoxicity, relegates aminoglycosides to a secondary treatment alternative in most areas. Patients who receive aminoglycoside drops when fluoroquinolone drops are available and subsequently develop sensorineural hearing loss or balance disturbance may blame their physician.
 


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Follow-up: Middle Ear, Chronic Suppurative Otitis, Medical Treatment
Multimedia: Middle Ear, Chronic Suppurative Otitis, Medical Treatment
References
Further Reading
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References

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Further Reading

Clinical guidelines

Evidence based clinical practice guideline for medical management of acute otitis media in children 2 months to 13 years of age.
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center.  1999 (revised 2004 Oct 29; reviewed 2006 Aug).  16 pages.  NGC:003958

Otitis media.
University of Michigan Health System - Academic Institution.  1997 Nov (revised 2007 Jul).  12 pages.  NGC:006032

Adapting your practice: treatment and recommendations for homeless children with otitis media.
Health Care for the Homeless (HCH) Clinician's Network - Medical Specialty Society
National Health Care for the Homeless Council, Inc. - Private Nonprofit Organization.  2003 (revised 2008).  29 pages.  NGC:006943

Clinical trials

Magnetic Resonance (MR) Imaging in the Post Operative Follow-up of Cholesteatoma in Children

Study of Different Kinds of Ear Tubes


Related eMedicine topics

 Otitis Media

Middle Ear, Acute Otitis Media, Surgical Treatment

Middle Ear, Otitis Media With Effusion

Middle Ear, Chronic Suppurative Otitis, Surgical Treatment

Middle Ear, Acute Otitis Media, Medical Treatment

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Keywords

chronic otitis media, chronic perforated tympanic membrane, perforated tympanic membrane, chronically draining ear, chronic suppurative otitis media, CSOM, ear infection, chronic otorrhea, cholesteatoma, acute otitis media, AOM, middle ear drainage

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Contributor Information and Disclosures

Author

David Parry, MD, Staff Physician, Department of Otolaryngology-Head and Neck Surgery, ENT Associates of Children's Hospital, Boston
Disclosure: Nothing to disclose.

Coauthor(s)

Peter S Roland, MD, Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director of Clinical Center for Auditory, Vestibular and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Adjunct Professor of Communicative Disorders, University of Texas School of Human Development
Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Laryngological Rhinological and Otological Society, American Neurotology Society, American Otological Society, North American Skull Base Society, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Alcon labs Honoraria Speaking and teaching; GSK Honoraria Speaking and teaching; Advanced Bionics Honoraria Board membership; Cochlear corp Honoraria Board membership; Med El corp travel grants Consulting

Medical Editor

John C Li, MD, Private Practice in Otology and Neurotology; Medical Director, Balance Center
John C Li, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Tinnitus Association, Florida Medical Association, and North American Skull Base Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gregory C Allen, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Gregory C Allen, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Christian Medical & Dental Society, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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