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

Middle Ear, Chronic Suppurative Otitis, Surgical Treatment

Author: Peter A Weisskopf, MD, Neurotologist, Arizona Otolaryngology Consultants; Head, Section of Neurotology, Barrow Neurological Institute
Coauthor(s): Anurag Jain, MBBS, FRCS(Ire), MS, FRCS(Oto), MS(Oto), DLO(RCSEngland), Specialist Registrar, Department of Otolaryngology, Pinderfields General Hospital, Wakefield, UK; Jeffrey Robert Knight, MBChB, FRCS, Consulting Surgeon, Department of Otolaryngology, Mayday University Hospital, London
Contributor Information and Disclosures

Updated: Oct 22, 2009

Introduction

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

History of the Procedure

McKenzie and Brothwell (1967) demonstrated evidence of chronic suppurative otitis in a skull found in Norfolk, United Kingdom, which is thought to be from the Anglo-Saxon period.¹ Radiologic changes in the mastoid caused by previous infection have been seen in a number of specimens, including 417 temporal bones from South Dakota Indian burials and 15 prehistoric Iranian temporal bones.^2,3

Zollner and Wullstein popularized the modern surgery for chronic otitis media in the 1950s. Prior to their work, ear surgery was primarily successful at draining active infection and less concerned with long-term functional outcomes. Current goals for surgery for chronic ear disease include a dry safe ear and the preservation of normal structure and function to the extent possible.

Problem

Chronic suppurative otitis media is typically a persistent disease, insidious in its onset. This disease often causes severe destruction and irreversible sequelae. It manifests clinically as discharge and deafness.

Frequency

The incidence of chronic suppurative otitis media appears to depend on race and socioeconomic factors. Chronic suppurative otitis media is found more frequently in Eskimos, American Indians,⁴ Alaskan indigenous population,⁵ Australian aboriginal children,⁶ and South African blacks.⁷

Etiology

Chronic otitis media develops after long-standing inflammation in the middle ear and mastoid. It is commonly associated with perforation of the tympanic membrane and, often, cholesteatoma. The actual cause of chronic otitis media maybe difficult to ascertain; however, it seems to be associated with a history of eustachian tube dysfunction, regardless of the cause. Poor socioeconomic status, overcrowding, poor nutrition, poor hygiene, and infectious diseases (eg, measles) have been found to contribute to the development of chronic suppurative otitis media. The disorder is more prevalent in some specific populations, such as Eskimos and American Indians, as well as in people with cleft palates. Adenoid hypertrophy and chronic sinusitis also contribute to the development of chronic suppurative otitis media.

Pathophysiology

Chronic otitis media develops after longstanding inflammation of the middle ear cleft. There are likely a number of a reasons for the inflammation, including acute otitis media, perforation of the tympanic membrane and eustachian tube dysfunction. The exposure to chronic inflammatory mediators leads to weakening of the tympanic membrane while causing mucosal edema. Eventually eustachian tube dysfunction leads to negative middle ear pressure that causes tympanic membrane retraction and perforation. Longstanding negative pressure can damage surrounding bone and ossicles, leading to cholesteatoma or loss of ossicular continuity.

Chronic negative pressure can lead to an atticoantral type of chronic suppurative otitis media is characterized by the formation of cholesteatoma. Cholesteatoma is simply skin that has migrated medially to the tympanic membrane. The cholesteatoma sac tends to slowly expand along the path of least resistance, collecting keratin debris within that tends to become infected. Clinical symptoms of discharge and hearing loss develop because of chronic inflammation and interruption of the ossicular chain. If left untreated, cholesteatoma can cause life-threatening complications such as permanent hearing loss, facial nerve dysfunction, and brain abscess.

Various theories, as outlined below, have been put forward regarding the formation of cholesteatoma.

• Metaplasia theory: This theory states that the formation of cholesteatoma occurs as a result of the transformation of respiratory epithelium into keratinizing squamous epithelium.
• Loss of contact inhibition theory: Normally, the keratinizing squamous epithelium of the external canal is inhibited by coming into contact with the tympanic membrane or its remnants; however, in the case of total perforation, this contact inhibition is lost, leading to extension of the keratinizing squamous mucosa within the middle ear.
• Formation of retraction pouch theory: As the most widely accepted theory, it states that cholesteatoma initially develops from the formation of retraction pouches in the tympanic membrane, especially in the attic region. The retraction pouch prevents adequate drainage of the keratin of the external canal, thereby forming a sac filled with keratin debris, which slowly expands as the keratin is progressively shed. A crisis arises when the relatively small pouch opening is unable to allow drainage of the keratin debris. This bottleneck obstruction leads to expansion of the cholesteatoma and destruction of the middle ear structures.

Presentation

Ear discharge and hearing loss are the typical symptoms of a patient with chronic suppurative otitis media. The examination of the ear may reveal a central perforation in the eardrum, which is typically painless, with some mucopurulent ear discharge.

In patients with chronic suppurative otitis media with cholesteatoma, serosanguineous and foul-smelling ear discharge (usually unresponsive to eardrops) is observed. Hearing loss may occur. The examination of the ear reveals an attic perforation or a retraction pouch filled with either keratin debris or foul-smelling ear discharge. Occasionally, the superior quadrant of the tympanic membrane is obscured by a polyp. It remains the physician's responsibility to clear the polyp and to confirm that no cholesteatoma is present. Attic polyps almost always represent hidden cholesteatoma.

Indications

In patients with chronic suppurative otitis media without cholesteatoma, surgery is considered if the perforation is persistent and long-standing and causes clinical symptoms, such as recurrent ear discharge and hearing loss. The age, general physical condition, and any other coexisting diseases (fitness for general anesthesia) of the patient also play an important role in considering surgery.

For patients with early or mild chronic suppurative otitis media cholesteatoma, aural toilet and repeated suction clearance of the ear with watchful expectancy may be performed; for patients with advanced disease, exploration of the mastoid and tympanoplasty is recommended.

The principal aim of surgery for chronic suppurative otitis media is first to clear out the disease and only then, if possible, to reconstruct the patient's hearing. Hearing reconstruction is often completed in a planned second-stage operation in patients with cholesteatoma. Staging the ear allows for the development of a healthy, air-containing middle ear space. Further inspection of the middle ear and mastoid cavity can confirm that the cholesteatoma has been eradicated. Silastic or other material is often placed in the middle ear and mastoid cavity to prevent postoperative scarring. This material is then removed during the second-stage procedure.

General indications for surgery are as follows:

• Perforation that persists beyond 6 weeks
• Otorrhea that persists for longer than 6 weeks despite antibiotic use
• Cholesteatoma formation
• Radiographic evidence of chronic mastoiditis, such as coalescent mastoiditis
• Conductive hearing loss

Relevant Anatomy

The middle ear cleft can be thought of as a 6-sided cube. Its lateral boundary, the tympanic membrane, separates it from the outer ear. Its medial boundary is formed by the promontory, which denotes the basal turn of cochlea. Anteriorly, it is related to the tendon of tensor tympani superiorly and the opening of the eustachian tube inferiorly. Posteriorly, it is related superiorly to the aditus, which connects the middle ear cavity with the mastoid antrum, and inferiorly to the facial ridge. The roof of the middle ear cavity is formed by the tegmen tympani, and the floor of the middle ear cavity lies in close relation to the jugular foramen.

The anterior and posterior malleolar folds, which radiate from the short process of the malleus, form the boundary between the pars flaccida and the pars tensa, which lie above and below it, respectively. Atticoantral disease predominantly affects the pars flaccida, and tubotympanic disease affects the pars tensa.

The middle ear cavity also consists of the ossicular chain (malleus, incus, and stapes). The ossicular chain connects the tympanic membrane, in which the handle of the malleus is embedded, to the oval window, on which sits the footplate of the stapes. In atticoantral disease, the ossicular chain is frequently affected by cholesteatoma, thereby causing hearing loss. The malleus and or incus may be sacrificed if they are extensively involved by cholesteatoma. In these cases, a planned second-stage reconstruction is often appropriate.

Contraindications

Contraindications (relative and absolute) to surgery for tubotympanic disease are as follows:

• Surgery on the only hearing ear
• Poor general physical condition, old age, or debility that makes general anesthesia risky
• Patients unwilling to undergo surgery
• Surgery on patients with unilateral vestibular ablation

Contraindications to surgery for atticoantral disease are as follows:

• Early or mild cholesteatoma amenable to aural toilet
• Patients who are severely ill and those with complications secondary to cholesteatoma, such as a brain abscess (Drainage of the brain abscess and intravenous administration of antibiotics should be considered first.)

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