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

Middle Ear, Chronic Suppurative Otitis, Surgical Treatment

Peter A Weisskopf, MD, Neurotologist, Arizona Otolaryngology Consultants; Head, Section of Neurotology, Barrow Neurological Institute
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

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.

Anatomy of the external and middle ear.

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.)

Workup

Laboratory Studies

• If an unusual organism such as Tuberculosis is suspected, a culture and sensitivity is appropriate.
• Other routine studies should be performed as are required for general anesthesia at the treating hospital.

Imaging Studies

• CT scans can be obtained in selected cases, such as when the patient reports vertigo and before revision surgery. Although not necessary, the CT scan can alert the surgeon to dehiscents of the semi-circular canals or facial nerve.
  • MRI might be appropriate upon suspicion of dural herniation or extensive cholesteatoma extending into the petrous apex.

Other Tests

Preoperative complete audiograms should be obtained, ideally within 3 months of surgery.

Treatment

Medical Therapy

Surgical Therapy

Chronic otitis media without cholesteatoma

Myringoplasty is the operation specifically designed to close tympanic membrane defects.

The approach to the ear can be transcanal, endaural, or retroauricular. The transcanal approach requires less surgical exposure and leads to a faster healing. The downside is the potential limitation of exposure. The endaural approach can improve exposure in ears with a lateral soft tissue or cartilage overgrowth but, again, tends to limit the surgical view. The retroauricular approach allows for maximal exposure but requires an external skin incision.

Two main surgical techniques of tympanoplasty are commonly used, the underlay and the overlay. The underlay technique involves placing the graft material underneath (or medial to) the eardrum.

The overlay technique involves grafting lateral to the eardrum. Various graft materials may be used. The most common materials are temporalis fascia, tragal perichondrium, and vein graft. An additional technique is the "stuff through." This may be useful for small perforations in otherwise healthy ears. This procedure essentially freshens the edges of the perforation and then fills it with a plug of tissue, usually fat.

The underlay technique requires dissection and elevation of a tympanomeatal flap. The margins of the perforation are freshened by removing the epithelium from the edges of the hole. The graft material is tucked underneath the eardrum and is sometimes supported with Gelfoam. Then, the reconstituted eardrum is flipped back to its normal resting position, and the ear canal is filled with packing material. The lateral graft technique requires removal of the ear canal and tympanic membrane epithelium, as well as a canaloplasty. This technique is particularly well suited to revision tympanoplasty or ears with narrow canals. It is somewhat more technically demanding but has a very high success rate, particularly in scarred tympanic membranes.

Chronic otitis media with cholesteatoma

A range of surgical procedures are available for the management of chronic suppurative otitis media with cholesteatoma, and the choice of procedure depends on the extent and the severity of the disease and the hearing of the individual. The ultimate aim of the procedure is to provide the patient with a safe dry ear. Hearing improvement is a secondary consideration and, if attempted, is usually performed during a second-stage surgery. Hearing reconstruction should not be performed at the cost of or by compromising the clearance of the disease in the patient.

The following definitions are used for middle ear surgery and mastoid surgery:

• Tympanoplasty is performed to eradicate disease from the middle ear and to reconstruct the hearing mechanism, with or without grafting of the tympanic membrane. As described by Wullestein, 5 different types of tympanoplasties have been defined. These are primarily of historical interest.
  • Type 1 is simple closure of the tympanic membrane perforation without reconstructing the ossicular chain.
  • Type 2 is any kind of ossicular reconstruction involving the malleus, the incus, or both. The stapes head is intact.
  • Type 3 involves putting the tympanic membrane graft over the head of the stapes.
  • Type 4 occurs when the stapes head is absent but the footplate is present. The stapes footplate is exteriorized to the mastoid cavity, and the graft is placed over the rest of the middle ear cavity, including the round window; hence, the phase difference is maintained.
  • Type 5 is also called the fenestration operation. It involves making a fenestra in the lateral semicircular canal and then putting a graft over it. This is not often performed today.
• Today, tympanoplasty is broken down into 2 primary types: lateral grafting or medial grafting. In the lateral graft technique, the graft material is laid laterally to the annulus after the remnant of squamous tissue is denuded. In medial grafting, the annulus is raised and the graft slipped medially.
• Mastoidectomy
  • Cortical mastoidectomy is also known as the Schwartze operation. It consists of the removal of the outer wall of the mastoid cortex and the exteriorization of all the mastoid air cells. This may be performed immediately in coalescent mastoiditis, in which case a drain may be left postoperatively.
  • Canal wall-up mastoidectomy refers to the removal of mastoid air cells while retaining the posterior canal wall. Using this approach with a facial recess (drilling the bone of the posterior mesotympanum or facial recess between the incus, the chorda tympani nerve, and the facial nerve), the middle ear structures can be accessed for careful dissection of the cholesteatoma. This approach leaves the normal ear canal anatomy intact, preventing the potential problems seen with a mastoid cavity. This is also the common approach for cochlear implantation.
  • Modified radical mastoidectomy differs from radical mastoidectomy in that the ossicles and the tympanic membrane remnants are preserved for possible hearing reconstruction at a later stage.
  • Radical mastoidectomy involves eradication of all disease from the middle ear and the mastoid and exteriorization of these structures into a single cavity. It also includes removing the entire tympanic membrane and the ossicles (except the stapes footplate) and closing the eustachian tube opening. Currently, this procedure is performed only in very unusual situations.

Postoperative Details

Follow-up

See Postoperative details.

Complications

Complications of tympanoplasty may include the following:

• Graft failure: The failure rate ranges from 10-20% depending on the technique used and the experience of the surgeon
• Infection: A potential complication with any surgical procedure, it is rare in tympanoplasty. Some surgeons recommend perioperative antibiotics, though little data to support their use.
• Bleeding: Hematomas can develop with postauricular approaches.
• Taste disturbance: This occurs secondary to damage to the chorda tympani nerve. It tends to be self-limiting but can be disturbing to patients.
• Ear numbness: The postauricular incision can sever peripheral sensory nerves, leading to some numbness of the pinna and lobule. This can be particularly disturbing to people with pierced ears who depend on the feeling in the lobule to place earrings.
• Hearing loss: Both conductive and sensorineural hearing loss can occur. Conductive loss can occur secondary to ossicular disruption or sclerosis. Scarring of the neo-tympanic membrane that leads to lateralization can also cause a conductive loss. Sensorineural hearing loss is a rare but serious complication.
• Vertigo: This can occur during any middle ear procedure and is usually self-limiting; however, if it is severe or persistent, further workup may be in order.
• Facial paralysis: This is also a very rare occurrence. Facial paralysis is sometimes seen secondary to local anesthetic infiltration, though anesthetic-related paralysis usually resolves soon after surgery.

Complications of mastoidectomy or tympanomastoidectomy include those listed above and the following:

• CSF leak: If the dura is encountered and violated during the dissection, CSF may leak. If recognized during surgery this can often be repaired.
• Intracranial complications: These can include brain abscess, meningitis, or physical damage to the brain itself.

Outcome and Prognosis

Tympanoplasty provides most patients with a healed dry ear. In patients with cholesteatoma, staged procedures are often necessary, and residual cholesteatoma is evaluated during ossicular reconstruction. Keep in mind that chronic ear disease is just that—chronic. These patients often suffer recurrence over time, and regular lifetime surveillance is normal.

The general and most desirable outcome for a patient who has undergone a tympanomastoidectomy is a dry, nondischarging, healthy ear. Long-term follow-up care of these patients is essential to detect the recurrence of cholesteatoma at its earliest onset. In such cases, a second procedure may be necessary. The likelihood of hearing preservation depends on the extent of the disease and the involvement of the ossicles, and it varies widely.

Multimedia

Media file 1: Anatomy of the external and middle ear.

References

1. McKenzie W, Brothwell D. Disease in the Ear. Disease in Antiquity. 1967;464-73.

2. Gregg JB, Steele JP, Holzhueter A. Roentgenographic evaluation of temporal bones from South Dakota Indian burials. American Journal of Physical Anthropology. 1965;23:51-62.

3. Rathbun TA, Mallin R. Middle ear disease in a prehistoric Iranian population. Bull N Y Acad Med. Dec 1977;53(10):901-5. [Medline].

4. Fairbanks DN. Antimicrobial therapy for chronic suppurative otitis media. Ann Otol Rhinol Laryngol Suppl. May-Jun 1981;90(3 Pt 3):58-62. [Medline].

5. Maynard JE, Fleshman JK, Tschopp CF. Otitis media in Alaskan Eskimo children. Prospective evaluation of chemoprophylaxis. JAMA. Jan 31 1972;219(5):597-9. [Medline].

6. McCafferty CJ, Coman WB, Shaw E. Cholesteatoma in Australian aboriginal children. Cholesteatoma: First International Congress. 1977.

7. Meyrick PS. The incidence of diseases of the ear, nose and throat; a survey of a remote native reserve. S Afr Med J. Sep 29 1951;25(39):701-4. [Medline].

8. Booth JB, Kerr AJ. Scott-Brown's Otolaryngology (Otology). 1987.

9. Brackmann, et al. Otologic Surgery. Second Edition. 2001.

10. Kim HH, Battista RA, Kumar A, Wiet RJ. Should ossicular reconstruction be staged following tympanomastoidectomy. Laryngoscope. Jan 2006;116(1):47-51. [Medline].

11. Leskinen K, Jero J. Acute complications of otitis media in adults. Clin Otolaryngol. Dec 2005;30(6):511-6. [Medline].

12. Ludman H, Wright T. Diseases of the Ear. 1998.

13. McMurphy AB, Oghalai JS. Repair of iatrogenic temporal lobe encephalocele after canal wall down mastoidectomy in the presence of active cholesteatoma. Otol Neurotol. Jul 2005;26(4):587-94. [Medline].

Keywords

chronic suppurative otitis, chronic suppurative otitis media, otitis media, myringoplasty, tympanoplasty, mastoidectomy, ossicular reconstruction, ossiculoplasty, ossicular chain, tympanic membrane, malleus, incus, stapes, fenestration operation, semicircular canal

Contributor Information and Disclosures

Author

Peter A Weisskopf, MD, Neurotologist, Arizona Otolaryngology Consultants; Head, Section of Neurotology, Barrow Neurological Institute
Peter A Weisskopf, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and American College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Anurag Jain, MBBS, FRCS(Ire), MS, FRCS(Oto), MS(Oto), DLO(RCSEngland), Specialist Registrar, Department of Otolaryngology, Pinderfields General Hospital, Wakefield, UK
Anurag Jain, MBBS, FRCS(Ire), MS, FRCS(Oto), MS(Oto), DLO(RCSEngland) is a member of the following medical societies: Association of Otolaryngologists of India, British Association of Otorhinolaryngologists, Head and Neck Surgeons, British Medical Association, Royal College of Surgeons in Ireland, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Jeffrey Robert Knight, MBChB, FRCS, Consulting Surgeon, Department of Otolaryngology, Mayday University Hospital, London
Disclosure: Nothing to disclose.

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
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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
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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
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