Chronic Suppurative Otitis Media PETER MORRIS, Menzies School of Health Research, Casuarina, Northern Territory, Australia

Clinical Evidence Handbook A Publication of BMJ Publishing Group

This is one in a series of Chronic suppurative otitis media causes We do not know whether tympanoplasty chapters excerpted from recurrent or persistent discharge (otorrhea) with or without mastoidectomy improves the Clinical Evidence Handbook, published by through a perforation in the tympanic mem- symptoms compared with no surgery or the BMJ Publishing Group, brane, and can lead to thickening of the other treatments in adults or children with London, U.K. The medical middle ear mucosa and mucosal polyps. It chronic suppurative otitis media. information contained herein is the most accurate usually occurs as a complication of persistent Cholesteatoma is an abnormal accumula- available at the date of acute otitis media (AOM) with perforation tion of squamous epithelium usually found publication. More updated in childhood. in the middle ear cavity and mastoid process and comprehensive infor- Chronic suppurative otitis media is a of the temporal bone. Granulation tissue mation on this topic may • be available in future print common cause of hearing impairment, dis- and ear discharge are often associated with editions of the Clinical Evi- ability, and poor scholastic performance. secondary infection of the desquamating dence Handbook, as well Occasionally it can lead to fatal intracranial epithelium. as online at http://www. infections and acute mastoiditis, especially Cholesteatoma can be congenital (behind clinicalevidence.bmj.com (subscription required). in developing countries. an intact tympanic membrane) or acquired. In children with chronic suppurative oti- If untreated, it may progressively enlarge and A collection of Clinical tis media, topical antibiotics may improve erode the surrounding structures. Evidence Handbook published in AFP is available symptoms compared with antiseptics. The • We do not know the beneficial effects at http://www.aafp.org/ benefits of ear cleansing are unknown, of surgery, whether surgery can be delayed, afp/bmj. although this treatment is usually recom- or which surgical techniques are associated CME This clinical content mended for children with ear discharge. with the best outcomes in children or adults conforms to AAFP criteria • We do not know whether topical anti- with cholesteatoma. for continuing medical septics, topical or systemic antibiotics, or education (CME). See CME Quiz on page 643. topical corticosteroids (alone or in combi- Definition nation with antibiotics) improve symptoms Chronic suppurative otitis media is persistent Author disclosure: Peter Morris declares that in children with chronic suppurative oti- inflammation of the middle ear or mas- he has no competing tis media compared with placebo or other toid cavity. Synonyms include chronic otitis interests. treatments. media, chronic mastoiditis, and chronic tym- In adults with chronic suppurative otitis panomastoiditis. Chronic suppurative otitis media, topical antibiotics (alone or in com- media is characterized by recurrent or persis- bination with topical corticosteroids) may tent ear discharge (otorrhea) over two to six improve symptoms compared with placebo weeks through a perforation of the tympanic or topical corticosteroids alone, although membrane. Chronic suppurative otitis media we found few adequate studies. There is usually begins as a complication of persistent consensus that topical antibiotics should be AOM with perforation in childhood. Typical combined with ear cleansing so the antibiot- findings may also include thickened granu- ics are able to reach the middle ear space. lar middle ear mucosa and mucosal pol- • We do not know whether topical antisep- yps. Occasionally, chronic suppurative otitis tics, topical corticosteroids, or systemic anti- media will be associated with a cholesteatoma biotics are beneficial in reducing symptoms. within the middle ear. Chronic suppurative • It is possible that antibiotics effective otitis media is differentiated from chronic against gram-negative bacteria may reduce otitis media with effusion, in which there is an ear discharge more than other classes of intact tympanic membrane with fluid in the antibiotics or placebo. middle ear but no active infection. Chronic

Downloaded694 American from the Family American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2013 American AcademyVolume of Family 88, Number Physicians. 10 For ◆ Novemberthe private, non15,- 2013 commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Clinical Evidence Handbook suppurative otitis media does not include The most commonly isolated microorgan- chronic perforations of the eardrum that are isms associated with chronic suppurative dry, or that only occasionally produce dis- otitis media are Pseudomonas aeruginosa and charge, and have no signs of active infection. Staphylococcus aureus; P. aeruginosa has been Cholesteatoma is an abnormal accumula- particularly implicated in the causation of tion of squamous epithelium usually found bony necrosis and mucosal disease. One in the middle ear cavity and mastoid process systematic review found a lack of studies of the temporal bone. Granulation tissue assessing the role of prophylactic antibiotics and ear discharge are often associated with in preventing the progression of disease to secondary infection of the desquamating chronic suppurative otitis media. Most cho- epithelium. Cholesteatoma is most often lesteatomas are thought to occur as a compli- detected by careful otoscopic examination cation of a retraction pocket in the tympanic in children or adults with persistent dis- membrane. They are associated with recur- charge that does not respond to treatment. rent or persistent middle ear disease, family history, and craniofacial abnormalities. Incidence and Prevalence If untreated, a cholesteatoma may progres- The worldwide prevalence of chronic sup- sively enlarge and erode the surrounding purative otitis media is 65 to 330 million structures. persons, and 39 to 200 million (60%) of those individuals have clinically significant Prognosis hearing impairment. Cholesteatoma can be The natural history of chronic suppura- either congenital (behind an intact tympanic tive otitis media is poorly understood. The membrane) or acquired. The overall inci- perforation may close spontaneously in an dence is estimated to be around nine per 100,000 persons. At least 95% of cholesteato- mas are acquired. The incidence is similar in Clinical Questions children and adults. What are the effects of treatments for chronic suppurative otitis Etiology and Risk Factors media in adults? Chronic suppurative otitis media is usually a Likely to be beneficial Antibiotics (topical) complication of persistent AOM, but the risk Antibiotics (topical) plus corticosteroids (topical) factors for the condition vary in different set- Unknown effectiveness Antibiotics (systemic; unclear if as effective as topical) tings. Frequent upper respiratory tract infec- Antibiotics (topical plus systemic; unclear if tions and poor socioeconomic conditions more effective than topical alone) (e.g., overcrowded housing, poor hygiene and Antiseptics (topical) nutrition) are often associated with the devel- Corticosteroids (topical) opment of chronic suppurative otitis media. Ear cleansing In developed countries and advantaged pop- Tympanoplasty (with or without mastoidectomy) ulations, previous insertion of tympanostomy tubes is now probably the single most What are the effects of treatments for chronic suppurative otitis media in children? important etiologic factor. Of those children Unknown effectiveness Antibiotics (systemic) who have tympanostomy tubes in place, a Antibiotics (topical) history of recurrent AOM, older siblings, Antibiotics (topical) plus corticosteroids (topical) and attendance at a child care center increase Antiseptics (topical) the risk of developing chronic suppurative Corticosteroids (topical) otitis media. In developing countries and Ear cleansing disadvantaged populations, poverty, over- Tympanoplasty (with or without mastoidectomy) crowding, family history, exposure to smoke, and being indigenous to the area are impor- What are the effects of treatments for cholesteatoma in adults? tant. Improvements in housing, hygiene, and Unknown effectiveness Surgery nutrition decreased the prevalence of chronic What are the effects of treatments for cholesteatoma in children? suppurative otitis media by one-half in Maori Unknown effectiveness Surgery children between 1978 and 1987.

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unknown portion of cases, but it persists in The frequency of serious complications fell others, leading to mild to moderate hearing from 20% in 1938 to 2.5% in 1948 world- impairment (about a 26- to 60-dB increase in wide, and is currently estimated to be about hearing thresholds), based on surveys among 0.7% to 3.2% worldwide. This is believed to children in Africa, Brazil, India, and Sierra be associated with increased use of antibiotic Leone, and among the general population treatment, tympanoplasty, and mastoidec- in Thailand. In many developing countries, tomy. Otitis media was estimated to have chronic suppurative otitis media represents caused 3,599 deaths and a loss of almost 1.5 the most common cause of moderate hear- disability-adjusted life-years in 2002, 90% of ing loss (40 to 60 dB). Persistent hearing loss which were in developing countries. Most of during the first two years of life may increase these deaths were probably owing to chronic learning disabilities and poor scholastic per- suppurative otitis media, because AOM is a formance. Progressive hearing loss may occur self-limited infection.

among those in whom infection persists and SEARCH DATE: May 2010. discharge recurs. Less often, spread of infection may lead to Adapted with permission from Morris P. Chronic suppurative otitis media. Clin Evid Handbook. December life-threatening complications such as intra- 2012:149-150. Please visit http://www.clinicalevidence. cranial infections and acute mastoiditis. bmj.com for full text and references. ■

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