EAR DISCHARGE
PART 1: CHRONIC SUPPURATIVE OTITIS MEDIA
DEFINITION:
Chronic Suppurative Otitis Media (CSOM)
-persistent inflammation of the middle ear or mastoid cavity
-presents with persistent or recurrent ear discharge (otorrhea) over 3 months through a
perforation of the tympanic membrane.
Synonyms:
“chronic otitis media (without effusion)”
“chronic mastoiditis”
“chronic tympanomastoiditis
CONDITIONS ASSOCIATED/EXACERBATING CSOM:
allergic rhinitis
chronic sinusitis
adenoid hyperplasia
cleft palate
note that these affect the Eustachian tube
ORGANISMS CULTURED FROM CSOM EAR DISCHARGE
A. Aerobes
Staphylococcus aureus
Pseudomonas aeruginosa
Klebsiella spp.
Proteus spp.
Entero/acinetobacter
B. Anaerobes
Bacteroides
Peptostreptococcus
Proprionibacterium
PATHWAYS FOR SPREAD OF INFECTION BEYOND THE MIDDLE EAR:
a. bone erosion- mainly by _____________
b. thrombophlebitis
c. preformed opening- e.g.,dehiscences
d. surgical opening
e. hematogenous
COMPLICATIONS
A. Extracranial
subperiosteal abscess
labyrinthitis/labyrinthine fistula
facial weakness
petrositis (Gradenigo’s Syndrome- otorrhea, retroorbital pain, lateral rectus
palsy)
B. Intracranial
meningitis
subdural, epidural, perisinus, or brain abscess
lateral sinus thrombosis – remittent, picket fence-type fever
CHOLESTEATOMA- keratin debris lined by metabolically-active matrix with osteoclasts, resulting
in bone erosion
Theories of Cholesteatoma Formation
1. Metaplasia theory - transformation of respiratory epithelium into keratinizing squamous
epithelium
2. Loss of contact inhibition theory – because of the perforation there is extension of the
keratinizing squamous mucosa within the middle ear
3. Formation of retraction pouch theory - a sac filled with keratin debris slowly expands as the
keratin debris accumulates
cholesteatoma
SAFE VS. UNSAFE/DANGEROUS EAR
Safe Ear Unsafe Ear
tubotympanic Atticoantral
Mucoid, non-foul smelling discharge Purulent, fetid discharge
Conductive hearing loss
No cholesteatoma Prone to cholesteatoma, complications
Medical treatment Will likely need surgery
TREATMENT
Otic Drops:
Ofloxacin, Ciprofloxacin, Polymyxin/neomycin, Chloramphenicol, Gentamicin
+/- steroids (to control inflammation, granulation tissue)
Aural Toilet: to clear discharge at home, enable drops to reach middle ear mucosa
Systemic antibiotics: for concomitant bacterial URTI(oral) or complications (IV)
Surgery: for persistent otorrhea despite adequate medical therapy; complications; unsafe ears-
Mastoidectomy is done to eradicate infection, by exenterating mastoid air cells and removing
diseased mucosa. Tympanoplasty , or reconstruction of the middle ear conducting mechanism,
is done when possible. It can also be done in inactive cases, to improve hearing.
PART TWO: ACUTE OTITIS MEDIA
PATHOGENS
Viral Bacterial
respiratory syncytial virus Streptococcus pneumoniae
rhinovirus Hemophilus influenzae
Coronavirus Moraxella catarrhalis
Parainfluenza
Adenovirus
Enterovirus
NATURAL HISTORY
a. Stage of hyperemia/ retraction
• Generalized hyperemia of the mucoperiosteum
• Mild earache, ear fullness, fever
• Otoscopy: erythematous & markedly retracted eardrum
b. Stage of exudation
Outpouring of fluid from dilated permeable capillaries
Aggravated symptoms especially pain & fever
Otoscopy: erythematous & bulging eardrum
c. Stage of suppuration/ perforation
Eardrum ruptures middle ear discharge
Relief of pain & fever
Worsening of hearing loss
d. Stage of coalescence and mastoiditis
Recurrence of pain, mastoid tenderness & fever (milder degree)
(+) mastoid tenderness & sagging of posterosuperior wall
e. Stage of resolution
May occur at any stage of the disease
DIAGNOSIS
Clinical history is poorly predictive of AOM especially in younger children
• Abrupt onset of otalgia/ ear tugging
• irritability in an infant/ toddler
• otorrhea and fever non-specific and are also found in patients with URTI
Mild Moderate to severe
Pain Mild VAS Moderate to severe
Duration <48 hours >48 hours
Tmax <39˚ C >39˚ C
TREATMENT
A. Medical: Antibiotics vs observation: moderate to severe disease- use antibacterials; for
mild- see guidelines depending on age and bilaterality
Mild AOM: Amoxicillin (high-dose)
Severe/Failure: Co-amoxiclav
Macrolides, Cephalosporins, Clindamycin for Penicillin-allergic individuals
IV antibiotics for acute complications
Pain relief with paracetamol or ibuprofen
B. Surgical: For failure of medical therapy
Myringotomy with ventilation tube insertion
Mastoidectomy
COMPLICATIONS
chronic otitis media
mastoiditis
labyrinthitis/labyrinthine fistula
facial weakness
Intracranial complications
RISK FACTORS
1. Host factors- allergy, immunology, gender, race, age, genetics
2. Anatomic/physiologic factors- Eustachian tube, cleft palate
3. Environmental factors- Day care, tobacco smoke exposure, seasonality, breast/bottle feeding,
pacifier use, obesity
PART THREE: CHRONIC NON-SUPPURATIVE OTITIS MEDIA
TYPES OF OTITIS MEDIA
Suppurative Non-suppurative
Acute suppurative Aerotitis (Barotrauma)
Acute necrotizing Serous otitis media with effusion/ Otitis
media with effusion
Chronic suppurative
Tuberculous
ADULT vs INFANT EUSTACHIAN TUBE: shorter, floppier, more horizontal
PATHOPHYSIOLOGY
ET obstruction or barotrauma negative middle ear pressuremiddle ear
transudate OME
ET obstruction + microbial invasion of middle ear AOM
Impaired ventilation of the middle ear
Stenosis due to inflammatory mucosal swelling (eg. upper respiratory tract infection)
Negative pressure due to rapid rise of ambient air pressure (aircraft landing)
Extrinsic obstruction (tumor)
Deficient active opening of the tube by the tensor veli palatini muscle
Congenital or acquired bony stenosis of stricture during scarring
ET DYSFUNCTION IN OTITIS MEDIA
A. FUNCTIONAL OBSTRUCTION: from collapse of tube/inability to open
1) Cleft palate, other craniofacial abnormalities (deficient tensor veli palatini
function)
2) Negative middle ear pressure from rapid rise of ambient air pressure during
aircraft landing
B. MECHANICAL OBSTRUCTION:
1) Inflammation: infection, allergy
2) Masses: adenoids, nasopharyngeal tumors
C. ABNORMAL PATENCY: usually with sudden or severe weight loss; may lead to reflux
OM
DIAGNOSIS
Otoscopic findings: non-hyperemic TM, bubbles/fluid level, severe retraction in adhesive
OM
Pneumatic Otoscopy- no TM movement on (+) /(-) pressure
Audiometry & Tympanometry-Conductive hearing loss, type __ tympanogram
TREATMENT
Treat underlying cause
Majority: spontaneous resolution in 12 weeks
Myringotomy with ventilation tube insertion
PART FOUR: EXTERNAL EAR CONDITIONS
PATHOGENESIS
Canal skin irritation/ trauma- Bacterial Infection & Inflammation- Diffuse (transudate) or
Circumscribed (pus )
COMMON PATHOGENS
Bacteria Fungus
Pseudomonas Aspergillus
Staphylococcus epidermidis Candida
Staph. aureus
TYPES
1) Acute Diffuse Otitis Externa (a.k.a. swimmer’s ear) – from traumatic cleaning
Treatment:
Gentle cleaning
Analgesics/antipyretics
Ear wick + topical antibiotic drops
2) Necrotizing Otitis Externa- in elderly diabetics, immunocompromised; from minor trauma,
sometimes from vigorous aural irrigation for impacted cerumen
Treatment: Debridement, IV antibiotics
3) Acute Circumscribed Otitis Externa (Furunculosis) – arises around hair follicle; purulent
discharge - if ruptured
Etiologic Org:
Staph aureus
Treatment:
Gentle cleaning
Analgesics/antipyretics
Oral Antibiotics
Incision & drainage
4)Chronic Otitis Externa- more of a dermatologic condition; flaking with itchiness, made
intractable by constant scratching/cotton bud use
5) Otomycosis- Common in tropics , heat and humidity ideal for growth of fungus
Causes:
use of contaminated ear cleaning devices
In diabetics and the immunocompromised
Overuse of topical antibiotics/steroids
Treatment:
cleaning
Topical antifungal for at least 2 weeks
keep dry!
OTITIS EXTERNA vs OTITIS MEDIA
Externa Media
Pain More severe Less severe, unless with
complication
Tenderness Tragal tenderness None, unless with
subperiosteal abscess
Fever None, usually Usually present
URTI None Usual
Hearing Loss None, unless canal totally Present
closed
Mastoid Radiograph/CT Normal May have evidence of
mastoiditis
CERUMEN- made up of exfoliated stratum corneum cells and secretions of the ceruminous glands of the
outer 2/3 (or cartilaginous) part of the external ear canal
-needs to be removed when it causes conductive hearing loss, hinders evaluation of the ear
(which includes assessment of the tympanic membrane and audiometry), or results in otitis externa
from attempts to clean it.
- methods of removal (any or a combination of the following):
1) cerumenolytics (oil- or water-based)
2) aural irrigation (contraindicated in swollen ear canals and perforated eardrums)
3) manual removal
