1

Case Report Session

CHRONIC SUPPURATIVE OTITIS MEDIA

By:

Shofi Faiza (1010312069)
Mohd. Luthfi B (1010312024)


Preceptor :
dr. Jacky Munilson, Sp.THT-KL



ENT HN DEPARTMENT
DR. M. DJAMIL HOSPITAL PADANG
FACULTY OF MEDICINE, UNIVERSITAS ANDALAS
2014
2

PREFACE
Alhamdulillah, we extend our gratitude to Allah SWT, thanks to His grace
and guidance so that we can finish this paper with the title "Chronic Suppurative
Otiti Media". We say also successive greetings to Prophet Muhammad and his
family, companions and followers.
This paper is one of the requirements for their clinical follow ENT health
sciences at the Faculty of Medicine, University of Andalas. We would like to
thank our precept dr.Jacky Munilson, Sp.THT-KL as mentors who have provided
input and guidance in the preparation of this paper,
We are fully aware that this paper is still far from perfection, therefore we
expect criticism and suggestions to improve this paper. Hopefully, this paper can
be useful for us all to understand the importance of chronic suppurative otitis
media.

Padang, June 2014
Penulis

3

TABLE OF CONTENT
PREFACE
CHAPTER 1 FOREWORD
1.1.Introduction..................................................................................................... 4
1.2.Point of discussion............................................................................................5
1.3.Goals..............................................................................................................5
1.4.Method...........................................................................................................5
BAB II LITERATURE REVIEW
2.1.Anatomy ...6
2.2.Physiology....12
2.3.Definition.........................................................................................................12
2.4.Classification...13
2.5.Epidemiology..................................................................................................13
2.6.Etiology and Pathogenesis......................................................................... 14
2.7.Clinical Manifestation.....................................................................................15
2.8.Diagnosis..........................................................................................................15
2.9.Complication....................................................................................................16
2.10. Treatment .........................................................................................21
2.11. Differential diagnosis.......................................................................... 27
2.12. Prognosis....................................................................................................27
CHAPTER III CASE ILUSTRATION.............................................................29
CHAPTER IV DISCUSSION ... 33
REFERENCES ...34

4

CHAPTER 1
FOREWORD

1. 1. Introduction
Chronic suppurative otitis media (CSOM) is the result of an initial episode
of acute otitis media and is characterized by a persistent discharge from the
middle ear through a tympanic perforation. The chronic otitis media is defined as
a permanent perforation of the drum membrane, which does not close by itself,
and an inflammatory reaction in the mucosa (mucositis) of the middle ear. It is an
important cause of preventable hearing loss, particularly in the developing world.
The larger the tympanic membrane perforation, the more likely the patient is to
develop CSOM. Some studies estimate the yearly incidence of CSOM to be 39
cases per 100,000 persons in children and adolescents aged 15 years and younger.
In Britain, 0.9% of children and 0.5% of adults have CSOM. In Israel, only
0.039% of children are affected.
1,2
Microbial, immunological, and genetically determined factors, as well as
Eustachian tube characteristics, are supposed to be involved in the pathogenesis of
CSOM, many aspects of the pathogenesis of CSOM still need to be clarified.
Optimal treatment strategy has not been established yet. The objective of this
review is to present and evaluate the current state of knowledge of CSOM.
3
Two main forms of the chronic otitis media are distinct: the suppurative
otitis media and the cholesteatoma. The suppurative otitis media is often
accompanied by secretion into the external ear canal (otorrhoe), but "dry ears" are
also common. Other frequent, but not obligatory symptoms are hearing
impairment, tinnitus, and aural pain or pressure. Although genetically determined
microbial and immunological factors, as well as Eustachian tube characteristics,
are supposed to be involved in the pathogenesis of chronic suppurative otitis
media, many aspects of the pathogenesis still need to be clarified. Ear microscopy
will show the perforation in the drum membrane. Further diagnostic tools are
audiometry, vestibular testing, radiological examination (high-resolution
5

computed tomography) and microbiological investigation. The curative treatment
for chronic suppurative otitis media is surgery (tympanoplasty, i.e. closure of the
perforation in the drum membrane and also--if necessary--the reconstruction of
the ossicular chain), not conservative antimicrobial therapy.
3
To help identify the disease at an early stage without unduly increasing the
number of unnecessary referrals to specialists, the questions that health workers
should ask and the procedures for visualizing the eardrum must be refined,
standardized, and validated. Before the management of any patient with CSOM
one should take into account the fact that patients with intracranial or extracranial
infections are more appropriately treated with surgery.Mastoidectomy with or
without tympanoplasty eradicates mastoid infection in about 80% of patients and
may be combined with surgical drainage of otogenic abscesses elsewhere.
However, such treatment is costly and does not always lead to satisfactory hearing
improvement, and is inaccessible in many developing countries.
1

1.2 Point of discussion
This working paper dicusses about definition, epidemiology, etiology,
pathogenesis, clinical manifestation, diagnoses, complication, treatment, and
prognoses of chronic suppurative otitis media.

1.3 Goal
This working paper has goal to improve knowledge about Chronic
Suppurative Otitis Media
1.4 Method
Method of this working paper by using literature review and clinical study.


6

CHAPTER 2
LITERATURE REVIEW
2.1 Anatomy
External Ear

Figure 2.1
The external or outer ear is that portion of the ear that is lateral to the
tympanic membrane. It consists of the external auditory canal as well as the
auricle and cartilaginous portion of the ear. The auricle is a semicircular plate of
elastic cartilage characterized by a number of ridges or grooves. The major ridges
of the auricle are the helix and antihelix, the tragus and antitragus, which
surround the concha, (figure 1.1) which is the scaphoid depression posterior to the
external auditory meatus.
9
7


Figure 2.2
The cartilage of the external auditory meatus is continuous with that of the
outer portion of the ear canal and auricle. The external auditory canal is made up
of a cartilaginous extension of the auricle in its outer half and the mastoid and
tympanic portion of the TB in its medial half. Tympanic membrane circular and
concave when viewed from the direction of the ear canal and seen obliquely to the
axis of the ear canal. The upper part is called the pars flaccida (shrapnell
membrane), while the lower part is called the pars Tensa (membrane propria).
Pars flaccida consists of two layers, namely the outer ear canal is skin epithelium
and the inside is lined with ciliated cube cells, such as airway mucosal epithelium.
Pars Tensa has one more layer is the middle layer consisting of collagen fibers
and elastin fibers that little run radier on the outside and circular on the inside.


Figure 2.3
8

Shadow protrusion malleus on the bottom of the tympanic membrane
called the umbo. From the umbo there will be light reflex (cone of light) toward
the bottom is at 7 o'clock for the left ear and right ear at 5 oclock.
10

Medial ear

Figure 2.4
The middle ear is an air-filled cavity called the tympanic cavity
(tympanum). The walls of the cavity are formed from the temporal bone and the
cavity is lined with mucous membrane tissue. The overall volume of the middle
ear is approximately 2 cm
3
(0.12 in
3
).
3
The lateral wall of the middle ear contains
the tympanic membrane (previously described), and the medial wall is formed by
a bony wall that separates the middle ear from the inner ear. This wall contains
two membranous windows, called the oval and round windows, which act to
anatomically and physiologically connect the middle ear with the inner ear. The
air in the middle ear cavity remains just below atmospheric pressure due to the
connection between the tympanic cavity and the upper part of throat
(nasopharynx) by a narrow duct called the Eustachian tube (auditory tube).
9

Within the middle ear cavity are three small bones called the malleus (hammer),
incus (anvil), and stapes (stirrup). These bones are collectively called the ossicles
and form a chain called ossicular chain that connects the tympanic membrane with
the oval window. The chain is suspended inside the cavity by middle ear
ligaments and two middle ear muscles: the tensor tympani and the stapedius.
13


Figure 2.5
Inner Ear
The inner ear is the final and the most complex part of the ear. It occupies a
small bony cavity called the bony labyrinth (osseous labyrinth) that is located
directly behind the medial wall of the middle ear. The inner ear consists of three
main anatomical elements: the semicircular canals, the vestibule, and the cochlea.
The structure and main elements of the inner ear are shown in Figure 8-10. The
bony labyrinth of the inner ear has a volume of approximately 2 cm and is lined
by the membranous labyrinth that closely follows the shape of the bony
labyrinth.
5
The blood supply to the membranous labyrinth is provided by various
small blood vessels extending from the labyrinthine artery. The space between the
bony labyrinth and the membranous labyrinth is filled with incompressible body
10

fluid called perilymph. The perilymph is high in sodium but low in potassium
resembling in its chemical composition in the blood and the cerebrospinal fluid
surrounding the brain. The space inside the membranous labyrinth is filled with
another incompressible body fluid called endolymph. Endolymph is low in
sodium but high in potassium and chemically resembles the intercellular fluid
found inside cells in the body. The differences in the chemical composition of the
perilymph and endolymph create an electric potential difference that like a
battery, sustains the physiological activities of the sensory organs located in the
inner ear.
12

Figure 2.6
Cochlea
The cochlea is a coiled structure that resembles the snail and extends
anteriolaterally from the vestibule. Its structural base is the bony spiral lamina,
which makes 2 to 2 turns around the bony core of the cochlea called the
modiolus. The external diameter of the cochlea varies from approximately 9 mm
(0.35 in) at its base to approximately 5 mm (0.20 in) at its apex (top) and its
uncoiled length is 32 to 35 mm (1.25 to 1.38 in). The cochlea is divided along its
11

length into three parallel channels: the scala vestibuli, scala media, and scala
tympani. The scala vestibuli and scala tympani are parts of the bony labyrinth
whereas the scala media is a part of the membranous labyrinth. The scala
vestibuli and scala tympani are connected at the apex (top) of the cochlea through
a small opening called the helicotrema. At the base of the cochlea, the scala
vestibuli joins the vestibule. The scala vestibule is terminated at its base by the
oval window, the fenestra ovalis, while scala media terminates at the round
window, the fenestra rotunda. The membrane of the oval window has a surface
area of 3.2 to 3.5 mm2, is completely covered by the footplate of the stapes, and is
sealed in the bony opening by the annular ligament. The round window has a
surface area of approximately 2 mm
2
and is located inferior and anterior to the
oval window in the wall between the middle ear and inner ear and serves as a
pressure valve between the two scalae. When an acoustic stimulus causes
mechanical vibration of the stapes footplate this movement is translated to the
membrane of the oval window. The membrane pushes back and forth on the
perilymph of the scala vestibuli and through the helicotrema, the perilymph of the
scala tympani. This motion results in alternating outward and inward movement
of the membrane of the round window. The membrane bulges outward as the fluid
moves from the scala vestibuli to the scala tympani and bulges inward as the fluid
moves from the scala tympani to the scala vestibule.
12
Organ Corti
Organ of Corti lies in the width of the basilar membrane in the basal part
of 0:12 mm and up to 0.5 mm wide at the apex, shaped like a spiral. Some of the
important components of the organ of Corti is the hair cells inside, the outer hair
cells, supporting Deiters cells, Hensen's, Claudiu's, tektoria membrane and
reticular lamina. Hair cells are arranged in four rows, which consists of 3 lines of
the outer hair cells are located lateral to the tunnel formed by the pillars of Corti,
and a line of hair cells located in the medial to the tunnel. Hair cells in the
amounts to about 3500 and the number of outer hair cells play a role in changing
12

the 12000 sound conduction in the form of mechanical energy into electrical
energy.
9

Figure 2.7
2.2 Physiology
Scheme of the hearing process begins with the arrest of sound energy by the
outer ear and vibrate the tympanic membrane into the middle ear and passed
through a series of bone loss that would amplify the vibrations through the
ossicular leverage and multiplication ratio of the tympanic membrane and the oval
aperture. Vibrating energy that has been amplified is passed to the inner ear and
are projected on the basilar membrane, so that will cause relative motion between
the basilar membrane and membrane tektoria. This process is mechanical stimuli
that cause deflection stereosilia hair cells, so that the ion channels open and the
release of electrically charged ions from the cell body. This situation raises the
hair cell depolarization, thus releasing neurotransmitters into the synapse that
would give rise to an action potential in the auditory nerve, and then proceed to
the auditory nucleus to the auditory cortex.
9
2.3 Definition
A unifying definition of the term chronic otitis media is any structural
change in the middle ear system associated with a permanent defect in the
13

tympanic membrane (TM).
1
Chronic supurative otitis media (CSOM) is chronic
infection in middle ear with tymphanic membrane perforation and with secretions
that come out continuously or intermittent.
2
The condition is considered chronic
if the TM defect is present for a period greater than 3 months.
1
Generally, patients
with tympanic perforations which continue to discharge mucoid material for
periods of from 6 weeks to 3 months, despite medical treatment, are recognized as
CSOM cases. The WHO definition requires only 2 weeks of otorrhoea, but
otolaryngologists tend to adopt a longer duration, e.g. more than 3 months of
active disease.
1


2.5 Classification
CSOM can be divided into 2 type in general :
10
a. Safety type CSOM (benigna)
The process of inflammation is confined to the mucosa only and usually
not on the bone. Perforations located in the central part. Generally safety
type CSOM rarely cause dangerous complications and no cholesteatoma.
b. Danger type CSOM (maligna)
In this danger type is usually accompanied by cholesteatoma. This CSOM
is also known by bone type. Perforation of this type located in marginal or
in attic. Most of these danger type are accompanied with danger and fatal
complications.

Based on the known activity of secretions known active and inactive type
CSOM. Active type CSOM is secretions out of the tympanic cavity is actively
while inactive type is a state when tympanic membrane looks wet or dry and the
secretions not active.
10

Other classification devided into 2 groups : CSOM with cholesteatoma or
CSOM without cholesteatoma.
2.6 Epidemiology
14

Prevalence survey by WHO show that global burden oh illness from CSOM
involves 65-330 million indviduals with draining ears, 60% oh whom (36-200
million) suffer from significant hearing impairment. CSOM accounts for 28.000
deaths and a disease burden over 2 million DALYs. Over 90% of the burden is
borne by countries in the South-east Asia and Western Pacific regions, Africa and
several ethnic minorities in the Pacific rim.
6
Some studies estimate the yearly
incidence of CSOM to be 39 cases per 100,000 persons in children and
adolescents aged 15 years and younger. In Britain, 0.9% of children and 0.5% of
adults have CSOM. In Israel, only 0.039% of children are affected.
7
Other
populations at increased risk include children from Guam, Hong Kong, South
Africa, and the Solomon Islands. The prevalence of CSOM appears to be
distributed equally between males and females.Exact prevalence in different age
groups is unknown; however, some studies estimate the yearly incidence of
CSOM to be 39 cases per 100,000 in children and adolescents aged 15 years and
younger.
14
2.7 Etiology and Pathogenesis
The diagnosis of CSOM requires a perforated tympanic membrane. These
perforations may arise traumatically, iatrogenically with tube placement, or after
an episode of acute otitis media, which decompresses through a tympanic
perforation. Most of the CSOM develop from acute otitis media (AOM), with
condition : late therapy, non-adequate therapy, high virulence bacterial, lack of
immunity or bad hygiene.
10
In CSOM the bacteria may be aerobic (Pseudomonas aeruginosa, Escheria
coli, S.aureus, streptococcus pyogenes, proteus mirabilis, Klabsiela species) or
anaerobic (Bacteroides, Peptostreptococcus, Proprionibacterium). These bacteria
are infrequently found in the skin of the external canal, but may proliferate in the
presence of trauma, inflammation, lacerations or high humidity.
1
There are several risk factor which cause CSOM :
a. Chronis inflammation due to persisten Eustachian tube dysfunction.
15

b. Genetic and constitutional factor that affect healing capacity and resistance
of the mucosa
c. Special anatomic characteristic s oh the middle ear spaces such as
pneumatization and relative size.
d. The nature, pathogenicity, virulence, and resistance oh the infecting organ.
The presence of perforation tympanic membrane cause infection from the ear
canal.
1
And also cause cholesteatoma. Cholesteatoma is epiterial cyst containing
epithelial desquamation (cheratine). It formed by the entry of the ear canal skin
from the side of a perforated tympanic membrane or ear canal into the middle or
occur as a result of the tympanic cavity mucous metaplasia due to infection that
lasts a long time. Cholesteatoma is a good medium for the growth of germs
(infection). The most frequent is proteus and pseudomonas aeruginosa. And these
infections can lead to local immune response resulting in the production of
various inflammatory mediators and cytokines. These inflammatory mediators
stimulate cells cholesteatoma keratinocytes are hyperproliferative, destructive and
stimulate angiogenesis. This will suppress the cholesteatoma mass and
surrounding organs and urgent cause necrosis of the bone. The process was
intensified by necrosis of the bone due to the formation of acid reaction by
bacterial decay. This facilitates the process of bone necrosis onset of
complications such as labyrinthitis, meningitis and brain abscess.
1,6,9
2.8 Clinical manifestation
CSOM safety type usually present initially with chronic otorrhea, generally a
mucopurulent discharge. After the secret clear the patient few or no ther
symptoms other than a variable degree oh hearing loss. For acute exacerbations
inflammation usually present pain in several patient.
1
CSOM danger type present abses or retroauriculer fistel, polyp, or granulation
tissue in outer ear canal. And also present mucopurulent secret and characteristic
odor.
1
2.9. Diagnosis
16

1. Anamnesis
History-taking should be carried out to elicit the symptoms of ear pain, ear
discharge, ear tugging or crying when the ear is touched, all of which suggest an
ear problem.
1
A history of previous ear discharge, especially when accompanied
by episodes of colds, sore throat, cough or some other symptom of upper
respiratory infection, should raise the suspicion of CSOM. A history of vigorous
ear cleaning, itching or swimming that could traumatize the external ear canal
suggests acute otitis externa (AOE), and not usually CSOM. A history of ear pain
suggests AOE or AOM, not usually CSOM
4
.
In the case of AOM, the ear is only painful until the eardrum perforates, relieving
the pressure. Thus, if the main symptom is painless otorrhoea, the duration of
otorrhoea will help distinguish AOM from CSOM.
Reliable history-taking depends on good recall on the part of the patient or
carer, an infrequent trait since neither parents nor teachers of children with otitis
media have been shown to reliably estimate the number of otitis media episodes,
the degree of hearing loss, or the possible impact of the condition
5
.
The exact duration of otorrhoea that distinguishes CSOM from AOM is
controversial, but this is only crucial in the absence of actual visualization of the
eardrum. The size of the perforation, character of discharge, and the appearance of
the middle ear mucosa on otoscopy can confirm the presence of CSOM more than
patient anamnesis.

2. Physical Examination
1

Otoscopy
The diagnosis of CSOM rests on the verification of a discharging
tympanic perforation. This is only possible by removing any obstructing wax, ear
discharge, debris or masses in the external auditory canal and visualizing the
whole expanse of the eardrum and, if possible, the middle ear through the
perforation. Such an examination requires adequate illumination through a head
mirror, head light, otoscope or otomicroscope, suction apparatus and small
instruments.
17

Not all draining ears are CSOM. Acute otitis externa and acute otitis
media can produce both ear pain and ear discharge. However, tragal pain is found
in otitis externa, mastoid pain in otitis media. The discharge in otitis externa is
less profuse and foul-smelling and there is no mucus, as can be tested with a
cotton mop by the tendency to form mucus threads. Fever is also higher in otitis
media than in otitis externa.
4
CSOM produces painless mucoid otorrhoea without
fever, unless accompanied by otitis externa or complicated by an extracranial or
intracranial infection.

Figure 2.8 central perforation

The diagnostic value of bacterial cultures
In places where bacterial cultures are available, can they be used to aid in
diagnosing CSOM ? . Bacterial cultures may not be needed to establish the
diagnosis of CSOM since exhaustive studies have established that 90100% of
chronic draining ears yield two or more isolates consisting of both aerobic and
anaerobic bacteria. Also, treatment may eradicate middle ear bacteria but this does
not guarantee non-recurrence of otorrhoea or complete resolution of the CSOM.
Leiberman et al. reported recovering Pseudomonas aeruginosa from
draining ears in the pre-treatment and in the recurrent stage. Some would argue
that perforated drums might develop discharge from time to time even without the
presence of bacteria and that this does not constitute CSOM which must be
treated. In practice, however, patients with draining ears do expect some treatment
regardless of culture results. Since topical treatment is often effective and seldom
18

harmful, most experts would start with a wide-spectrum antibiotic on an empiric
basis and make a request for cultures if drug resistance is suspected.

2.10. Complication
In the present era of antibiotics, complications from CSOM are rarely seen
because of early antibiotic intervention. However, surgery does play an important
role in managing CSOM with or without cholesteatoma. CSOM without prompt,
proper treatment can progress to a variety of mild to life-threatening
complications that can be separated into 2 subgroups: intratemporal and
intracranial.

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.
4

Petrositis
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 culture-directed antibiotics with petrous apicectomy in cases that do not
respond to medical therapy.
Facial paralysis
Facial paralysis may occur in the setting of CSOM with or without
cholesteatoma. Surgical exploration with removal of diseased mucosa, granulation
tissue, and inspissated pus (usually by mastoidectomy) should be undertaken
promptly in the setting of cholesteatoma or chronic otitis media.
Labyrinthitis
19

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 acute serous, acute suppurative, chronic, and labyrinthine sclerosis.
The symptoms of acute serous labyrinthitis are acute onset of vertigo and hearing
loss. Early surgical exploration to remove the infection may reduce 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 away from the affected ear after destruction
of the membranous labyrinth. Treatment includes aggressive surgical debridement
(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 the 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
Lateral sinus thrombophlebitis occurs as the infection extends through the
mastoid bone into the sigmoid sinus. The infected thrombus may release septic
emboli, causing distal infarcts. Patients may present with altered mental status,
headaches, retroauricular pain, postauricular edema, and fever. Mastoidectomy
with incision and drainage of perisinus purulence is indicated in patients who do
not respond to systemic antibiotics. Removal of the entire thrombus until bleeding
20

is visualized is not necessary and may result in additional complications,
including intracranial hemorrhage. Ligation of the internal jugular vein is rarely
required for patients with progressive septic emboli who do not respond to
systemic therapy. Culture-directed antimicrobial treatment is the first step in the
management of sinus thrombophlebitis. Debate still exists on the necessity of
anticoagulation and its efficacy in establishing recanalization of the sinus.
5

Meningitis
Meningitis develops as a consequence of direct or hematogenous spread of
the infection. If meningitis is suspected, a lumbar puncture should be performed 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.
Intracranial abscesses
The various intracranial abscesses that may occur can be extradural,
subdural, or parenchymal. A patient with an extradural abscess may present with
meningitic signs and symptoms or may be asymptomatic. Regardless of the
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 and exhibit meningeal signs,
possible seizures, and hemiplegia. Prompt neurosurgical consultation, adequate
imaging, drainage, and antibiotics are the 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.
6

21

Middle ear complications
Conductive hearing loss as a consequence of CSOM may result from the
perforated tympanic membrane, 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.
2.11. Treatment
2.11.1 Medical management
9
The treatment of CSOM generally begins with local care of the ear and outpatient
medical management. For medical management to be successful, aural toilet is
imperative. This intervention requires repeat microscopic examination of thebear
and diligent suctioning. The main goal is to remove debris from the external
auditory canal (EAC) overlying the TM and middle ear cleft so that topical
antimicrobial agents can successfullybpenetrate to the middle ear mucosa.
9
Topical medications may include antibiotics, antifungals, antiseptics, and
corticosteroid preparations alone or in combination with other medications. The
use of neomycin in ototopical preparations continues to be extremely widespread
owing to long-standing prescribing habits and low cost, despite the fact that
almost no strains of Pseudomonas remain sensitive to this medication. In addition,
there is a fairly high incidence of localized and diffuse allergic reactions to the
topical use of neomycin. For these reasons, preparations containing neomycin
should eventually fade from the ototopical armamentarium. More recently,
fluoroquinolone antibiotic drops such as ciprofloxacin and ofloxacin have gained
popularity because of their antipseudomonal properties, minimal bacterial
resistance, and lack of ototoxicity. If otorrhea is profuse, it may be helpful to have
the patient irrigate the ear daily with a body temperature half-strength solution of
acetic acid (50% white vinegar diluted with warm water) prior to the application
of otic drops.
9
The use of systemic antibiotics in COM is limited by several factors.
Antibiotic penetration into the middle ear may be hampered by mucosal edema.
22

Systemic aminoglycosides carry a risk of ototoxicity and require parenteral
administration with monitoring of serum levels. Oral ciprofloxacin has proven to
be a safe and effective treatment for adults with COM; however, safety in patients
under 18 years of age has not been established.
9
For patients with otorrhea secondary to cholesteatoma, the hope is to
minimize granulation tissue and perhaps achieve a dry ear prior to surgical
intervention. Before addressing the granulation tissue with topical cautery, one
must be reasonably convinced that the critical landmarks are properly identified
and that there is no dural defect with an encephalocele present.
9
Medical management of COM may be difficult for both the patient and the
physician. Multiple office visits are often required for adequate aural toilet.
Patients are asked to comply with a regimen that may include not only daily
irrigation but also multiple administrations of otic drops throughout the day.
Medical treatment usually requires 14 to 21 days. Most often, it is appropriate to
proceed to operation if the ear does not respond to microscopic dbridement and
ototopical management.
9

2.11.2 Surgical Management
9
The primary goal of surgery for COM is to eradicate disease and obtain a
dry, safe ear. Restoration of hearing is by necessity a secondary consideration
because any attempt at middle ear reconstruction will fail in the setting of
persistent inflammation and otorrhea. Absolute indications for surgical
intervention include impending or established intratemporal or intracranial
complications. Various pathologic conditions within the middle ear, such as
cholesteatoma and chronic fibrotic granulation tissue, are irreversible and require
elective surgical attention. In addition, patients with otorrhea failing to respond to
medical treatment are surgical candidates, as well as those who respond but are
left with a correctable conductive hearing loss or a TM perforation.
9

Tympanoplasty
The goal of tympanoplasty is to repair the TM with a connective tissue
graft in the hope that squamous cell epithelium will proliferate over the graft and
23

seal the perforation. Various grafting materials are available. Autogenous
temporalis fascia is used most often because it is readily available through a
postauricular incision and is extremely effective. Other alternatives include tragal
perichondrium, periosteum, and vein.
9

Preserved homograft materials such as cadaveric TM, dura, and heart
valve have limited application because of concern for disease transmission. The
two most common approaches are the transcanal tympanomeatal flap and the
postauricular approach with creation of a vascular strip. The two classic types of
tympanoplasty are the lateral and the medial technique, which define the final
relationship of the graft to the fibrous layer of the TM remnant and the anulus
tympanicus.
9

In both techniques, the graft is placed medial to the handle of the malleus.
The lateral technique is more technically demanding but provides more reliable
results when repairing large anterior or pantympanic perforations. It is useful
when ear canal anatomy is unfavorable and extensive removal of bone from the
anterior canal wall (canalplasty) is necessary. The canalplasty improves access to
the anterior half of the TM. The lateral technique may be complicated by
displacement of the graft laterally during healing and formation of cholesteatoma
between the graft and the remnant of the TM.
9

If, in the canalplasty, the soft tissue of the temporomandibular joint is
violated, the posterior aspect of the joint can be eroded, allowing the condyle of
the mandible to prolapse into the ear canal. This feared complication is difficult to
correct and should be assiduously avoided. The medial technique is easier and less
time consuming, and postoperative care is less compared with the lateral
technique. Ultimately, the technique chosen will depend on the location of the
perforation, the bony anatomy of the EAC, and the surgeons experience.
9

Myringoplasty , which the lightest kind of tympanoplasty type.
Reconstruction is only performed on the tympanic membrane , performed on
CSOM benign type and quite phase, with only mild hearing loss caused by
perforation of the tympanic membrane .

24

Ossicular Chain Reconstruction
9

The numerous techniques and middle ear prostheses available to the
otologic surgeon lend credence to the claim that ossicular chain reconstruction
remains to be perfected. Reconstruction should achieve closure of the airbone
gap to within 20 dB in two-thirds of patients with an intact stapes arch and one
half of patients missing the stapes superstructure. Autograft ossicles are removed
from the patient and sculpted to serve as inter-position grafts. The incus is used
most often. Immediate availability, obvious biocompatibility, and a low extrusion
rate have made autograft ossiculoplasty very popular. However, extensive bone
erosion caused by middle ear disease may limit availability.

Cortical Mastoidectomy
9

Tympanoplasty failures occur in eustachian tube dysfunction and
persistent inflammatory disease. For this reason, a cortical mastoidectomy is often
recommended as an adjuvant to tympanoplasty. The goal is to eliminate all
irreversible mucosal disease, improve mastoid ventilation, and increase the
buffering action of the mastoid cavity by enlarging its volume.
Intact Canal Wall Tympanoplasty with Mastoidectomy
9

In an attempt to expose and eradicate middle ear disease better while
preserving normal anatomic relationships for improved sound conduction, the
posterior tympanotomy approach was introduced. This technique allows access
from a cortical mastoidectomy defect into the posterior mesotympanum by
removal of the bony wall bound by the fossa incudis, the second genu of the facial
nerve, and the chorda tympani. Since the access point into the middle ear is the
facial recess of the posterior part of the tympanum, this operation is often referred
to as a facial recess approach.
The major advantage of the intact canal wall (ICW) tympanoplasty with
mastoidectomy is the avoidance of a mastoid bowl that requires lifelong cleaning.
However, this advantage comes with a higher risk of residual and recurrent
disease because preservation of the posterior canal wall limits visualization and
access to the middle ear. Because an ICW tympanoplasty with mastoidectomy
25

does not address the problem of negative pressure within the middle ear, ideal
candidates are individuals with large pneumatized mastoids and wellaerated
middle ear clefts. As a result of the high rate of recidivism, most surgeons
advocate a second-stage procedure when treating cholesteatoma in this manner.

Modified Radical Mastoidectomy
9

Today, the classic Bondy modified radical mastoidectomy is used
infrequently since it only addresses the rare instance when one is treating isolated
atticoantral cholesteatoma with disease lateral and posterior to the ossicles.
Modifications have been made to the original approach to explore the middle ear
and correct the conductive hearing loss that often results in the setting of
cholesteatoma. This combination of the open mastoidectomy and tympanoplasty
with or without ossicular chain reconstruction is what most surgeons mean today
when they use the term modified radical mastoidectomy. An alternate, less
ambiguous term for this operation is tympanoplasty with canal wall down
(CWD) mastoidectomy. A small, sclerotic mastoid, a low-lying middle cranial
fossa dura, and an anteriorly positioned sigmoid sinus will limit surgical exposure
and often necessitate the removal of the canal wall. Other indications include
operating on extensive cholesteatoma in the only hearing ear, presence of a large
labyrinthine fistula, recurrent retraction cholesteatoma in the epitympanum, and
significant destruction of the scutum or posterior canal wall.
The major disadvantage of this approach is the need for periodic mastoid
bowl cleaning. Success of a CWD mastoidectomy and long-term care of the
mastoid cavity depend on key operative techniques, including opening air cells at
the sinodural angle, along the tegmen and in the perilabyrinthine region; lowering
the facial ridge to leave a thin layer of bone over the facial nerve; exenterating the
mastoid tip cells and amputating the tip; saucerizing, by wide beveling, the cavity
to form smooth walls; and creating a meatoplasty by resecting a crescent of
conchal cartilage.
Open cavities take 6 to 10 weeks to heal. During this period, the patient is
seen every 2 to 3 weeks for dbridement of the cavity and management of
26

granulation tissue. Early granulation tissue is suctioned away, and the base is
cauterized. Early neomembrane formation is disrupted. Ototopical drops with an
antibiotic and corticosteroid should be continued until there is no granulation
tissue and the cavity is lined with skin.

Radical Mastoidectomy
9

Radical mastoidectomy entails exteriorization of the entire middle ear and
mastoid by combining a CWD mastoidectomy with removal of the TM and the
ossicles (with the exception of the stapes if present). In doing so, the mastoid,
middle ear, and EAC become one common cavity. There is no attempt at middle
ear reconstruction, and patients are left with a substantial conductive hearing loss.
Given this significant functional deficit, radical mastoidectomy is considered a
last resort, usually after previous surgical attempts have failed or when it is not
possible to remove mesotympanic cholesteatoma. Radical mastoidectomy is also
indicated if middle ear ventilation is impossible owing to complete inadequacy of
eustachian tube function.

Mastoid Cavity Obliteration
9

The mastoid cavity created by a radical or modified radical mastoidectomy
is at risk for chronic infection and persistent drainage. In the setting of a
potentially large cavity, some surgeons elect to perform a mastoid obliteration
procedure using materials such as bone pate, cartilage, acrylic, and HA cement.
Alternatives include free abdominal fat grafts and regional soft tissue flaps. The
major disadvantage associated with obliteration of the mastoid is that recurrent
disease can remain hidden within the cavity. A CT scan may be required to
evaluate patients for recurrent disease.

2. 12 Differential Diagnosis
1
Difference between CSOM and other forms of chronic otitis media
27

Several systems of nomenclature have been developed to distinguish
between different types of otitis media, reflecting the lack of complete
understanding of the processes responsible for the inflammation and healing of
the middle ear. For the purpose of this report, the presence of a persistent
tympanic perforation and middle ear discharge differentiates CSOM from other
chronic forms of otitis media. CSOM is also called chronic active mucosal otitis
media, chronic oto-mastoiditis, and chronic tympanomastoiditis. A subset of
CSOM may have cholesteatomas or other suppurative complications. The non-
CSOM group includes such entities as chronic non-suppurative otitis media,
chronic otitis media with effusion (COME), chronic secretory otitis media,
chronic seromucous otitis media, chronic middle ear catarrh, chronic serous otitis
media, chronic mucoid otitis media, otitis media with persistent effusions, and
glue ear. All these are recurrent or persistent effusions in the middle ear behind an
intact tympanic membrane in which the principal symptom, if present at all, is
deafness and not ear discharge.
1

2.13. Prognosis
Patients with chronic suppurative otitis media (CSOM) respond more
frequently to topical therapy than to systemic therapy. Successful topical therapy
consists of 3 important components: selection of an appropriate antibiotic drop,
regular aggressive aural toilet, and control of granulation tissue.
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. 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.
28

Failures of topical antimicrobial therapy are almost always failures of
delivery. Specifically, failure of delivery describes the inability of an appropriate
topical antibiotic to reach the specific site of infection within the middle ear.
Various elements may obstruct the delivery of the medication, including
infectious debris, granulation tissue, cholesteatoma, neoplasia, cerumen, and
others. When topical therapy fails, the patient needs a thorough evaluation for
anatomic obstruction, including microscopic examination and radiologic studies
as needed. Additionally, a clear understanding of the very high concentration of
the antibiotic within topical preparations must be kept in mind.
Surgical Prognosis
Tympanoplasty provides most patients with a healed, dry ear. In patients
with cholesteatoma, a staged procedure may be beneficial to ensure complete
eradication of cholesteatoma. The ossicular chain can be reconstructed with
autologous tissue (cartilage, bone) or with prosthetic implants at the second
surgery. These patients require diligent surveillance as recurrence of the original
disease process is not uncommon.
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, another procedure may be necessary. The
likelihood of hearing preservation depends on the extent of the disease and the
involvement of the ossicles, which varies widely.


29

CHAPTER 3
CASE ILUSTRATION
PATIENT IDENTITY
Name : Mr. M
Age : 37 y.o
Sex : Male

Anamnesis :
Man, 37 y.o, came to ENT-HN Department of Dr. M.Djamil Hospital on June 2
nd
,
2014 with
Chief complaint :
Discharge flew from right ear in a month ago.
Clinical course :
Patient got discharge in right ear for a month ago
Discharge in right ear was looked like clear then yellowish and no smell
Symptom increased when cough and cold,
History discharge in left ear is negative
Patient has right nasal obstruction
Patient ever happened pain at the right fore ear
history lump behind the left ear negative,
negative wry face, dizziness negative spin,
nausea vomiting (-) history of loss of consciousness (-) ringing in the ears
(+)
Past medical history :
history sneezing more than 5 ti mes if exposed to dust and cold (-)
long history of cough (-) fever (-)
Patient clean the ears by his self
Smoking (+) , drinking alcohol (-)
30

Patient ever went to see doctor since 6 months ago, then getting cured at
that time, but now symptom re-appear and was suggested for operation
History of familial disease
Atopi (-)
history of the same disease
Physical examination
Vital Sign
General state : Good Pulse rate : 84x/ minutes
Awareness : CMC Respiratory rate : 20x/minutes
Cyanosis : negative Temperature : 36,5 C
Edema : negative Icterus : negative

Skin : warm
Head : normocephal
Eyes : conjunctiva anemis (-), sclera icterus (-) , pupil isocorhea, pupil reflex
+/+
Thorax
Pulmo : Inspection : symmetrical , retraction (-)
Palpation : fremitus : left = right
Percussion : sonor
Auscultation : vesicular, ronchi -/- , wheezing -/-
Cor : inspection : ictus cant be seen
Palpation : ictus palpated 1 finger medial SMCL ICS V
Percussion : normo
Auscultation : heart sound : pure, ritmic regular, noise (-)
Abdomen : inspection : distended ()
Palpation : hepar and lien ( non-palpated) )
Percussion : timpanic
Auscultation : intestinal noise (-)
Back : normo
Extremity : warm and good perfusion
31

ENT Local Status
Examination Abnormality Dextra Sinistra
Auricular Congenital
abnormality
Trauma
Metabolic
abnormality
Retraction pain
Tragus pain
-
-
-
-
-
-
-
-
-
-
Wall and Canal
Ear
wide enough (N)
Narrow
Hyperemic
Edema
Mass
+
-
-
-
-
+
-
-
-
-
Secrete and cerumen - -
Timpani
membrane
Intact Central perforated
Mastoid - -
Tuning fork Test Rinne
Swabach
Weber
+
Same with
examiner
No lateralitation
-
Prolong
No lateralitation
Paranasal sinus and nasal Congenital abnormalities (-)
Outer part No deformity
Inner part Vestibulum
Nasal cavity
Medial concha
Inferior concha
Septal
Secret
Mass
Vibrae (+)
Wide
hypertrophy
hypertrophy
Deviasi (+)
-
-
Vibrae (+)
Wide
Eutrophy
Eutrophy
Deviasi(-)
-
-






Nasopharynx Choana
Mucose
Tube orifice
Open
Pink
Open
Open
Pink
Open
Adenoid -
Post nasal drip +
Mass -
Oropharynx and
mouth
Pharyngeal arch
Palatum
Pharyngeal wall
Symmetrical
Still and uvula in the middle
Posterior still
Palatine tonsil Size T1 T1
Color Pink Pink
Crypt Normo Normo
Detritus - -
32

Peritonsil Normal Normal
Mass -
Teeth Caries + +
Tongue Normal
Larynx and
hypopharynx
Epiglotis
Aritenoid
Pseudo plica
vocalis
Plica vocalis
Subglotis
Trachea
Mass
Still
Still
Moving symmetrically
Moving symmetrically
Open
Still
-
Lymphadenopathy -

Laboratory findings :
Hb : 15 /dL
Leukosit : 9200 /mm
3
Ht : 45 %
Trombosit : 286.000 /mm
3

Imaging findings :
Impression: right mastoiditis, no bone destruction, thickening sphenoidalis sinus
mucosal and bilateral maxillary sinus, especially at left side.
Diagnosis : Chronic Suppurative Otitis Media Auricula Dextra Susp. Benign
type, quite Phase
Treatment :
- Local myringoplasty

33

CHAPTER 4
DISCUSSION
A male patient , aged 37 years , present with watery right ear at 1 month ago . The
fluid that came out initially and then colored clear turned yellowish and odorless .
Patients also experienced right ear buzzing with diminished hearing . Complaints
increased when patients cough and cold , with a runny nose until thick yellowish
translucent color . While the history of the left ear has not discharge and hearing
loss. The patient also had experienced pain in the front of the ear . Patients also
experience nasal congestion in the nasal cavity of the right. Patients have a habit
of picking his own ears and smoking . At 6 months ago the patient had
experienced similar complaints , then went to the ENT specialist and experienced
recovery, but the complaint re-appeared and advised patients for surgery . In
localist ENT status , obtained the right ear canal is quite roomy , central tympanic
membrane perforation right , on the right ear, we found Rinne test - , Weber test
lateralized to the right , extending swabach test . Results for anterior rinoscopy,
nasal cavum quite large, medial concha hypertrophy , inferior concha
hypertrophy , septal deviation + ( crest ) , secretions - . Based on history and
physical examination , the diagnosis can be established that chronic suppurative
otitis media type safe quiet phase . For the definitive management of these
patients is myringoplasty , which the lightest kind of tympanoplasty type.
Reconstruction is only performed on the tympanic membrane , performed on
CSOM benign type and quite phase, with only mild hearing loss caused by
perforation of the tympanic membrane .
34

REFERENCES
1. WHO, 2004. Chronic Suppurative Otitis Media : Burden of illness and
Management Options. Geneva, Switzerland : WHO
2. Vikram BK, Khaja N, Udayashankar SG, Venkatesha BK, Manjunath D.
Clinico-epidemiological study of complicated and uncomplicated chronic
suppurative otitis media. J Laryngol Otol. May 2008;122(5):442-6.
3. Verhoeff M, van der Veen EL, Rovers MM, Sanders EA, Schilder AG, 2006.
Chronic Suppurative otitis media : a review. Accesed from
http://www.ncbi.nlm.nih.gov/pubmed/16198004 on June, 1st 2014
4. Brobby GW. The discharging ear in the tropics: a guide to diagnosis and management
in the district hospital. Tropical Doctor, 1992, 22 (1): 10-13.
5. Alho OP. The validity of questionnaire reports of history of acute otitis media. Am J
Epid., 1990, 132 (6): 1164-1169.
6. Smith JA, Danner CJ. Complications of chronic otitis media and cholesteatoma.
Otolaryngol Clin North Am. Dec 2006;39(6):1237-55. [Medline].
7. Neilan RE, Isaacson B, Kutz JW Jr, Lee KH, Roland PS. Pediatric otogenic lateral
sinus thrombosis recanalization. Int J Pediatr Otorhinolaryngol. Jun 2011;75(6):850-3.
[Medline].
8. Isaacson B, Mirabal C, Kutz JW Jr, Lee KH, Roland PS. Pediatric otogenic intracranial
abscesses. Otolaryngol Head Neck Surg. Mar 2010;142(3):434-7. [Medline].
9. Steven A. Telian, Cecelia E. Schmalbach,, 2003. Chronic Otitis Media. In
Ballenger's Otorhinolaryngology Head & Neck Surgery. Ontario: BC Decker,
16th edition, pp.49-53.
10. Soetirto, Indro dkk. 2012. Gangguan Pendengaran. Dalam: Buku Ajar Ilmu
Kesehatan Telinga Hidung Tenggorokan Kepala Leher. Edisi ke-7. Jakarta: Badan
Penerbit FK UI.
11. Yost, W., and Nielsen, D. 1977. Fundamentals of Hearing: An Introduction.
New York: Holt, Rinehart, and Winston.
12. Meroonroge S, Diana C, Tomasz R. 2010. Basic Anatomy of The Hearing
System. Available from URL http://www.usaarl.army.mil/pu
blications/HMD_Book09 /files.pdf. Accessed 1 Juni, 2014.
35

13. Buckingham, R., and Valvassordi, G. Inner fluid volumes and resolving power
of magnetic resonance imaging: Can it differentiate endolymphatic structures?.
Annals of Otology, Rhinology, and Laryngology. 2001: 110, 113-117.
14. van der Veen EL, Schilder AG, van Heerbeek N, et al. Predictors of chronic
suppurative otitis media in children. Arch Otolaryngol Head Neck Surg. Oct
2006;132(10):1115-8