AIMS AND OBJECTIVES

1)To find out the organisms responsible for CSOM in both

safe and unsafe type by
taking the earswab for culture and sensitivity
2)To study the antibiotic sensitivity pattern of the
organism isolated

METHODOLOGY
The present study A BACTERIOLOGICAL STUDY OF CSOM
is conducted in the department of Otorhinolaryngology ,
Academy of medical sciences , Pariyaram, Kannur, from
April 2011 to October 2012.It is a descriptive cross
sectional study of 100 patients of CSOM of all age groups
and both sexes attending the Out Patient Department and
those admitted in Otorhinolaryngology wards.patients
were selected randomly for the study.
Inclusion criteria
All cases of middle ear discharge for more than 3 months
Exclusion criteria
Conditions which mimic CSOM like
Otitis externa
Acute suppurative otitis media
History taking

A profoma is used for documenting age, sex, address,

clinical information including chief complaints , duration
of symptoms ,predisposing factors and any previous
history of treatment .

Collection of sample
Ear discharge is collected under aseptic precautions in
clinically diagnosed cases of CSOM.Excess ear discharge
was mopped out from external auditory canal.Then with
sterile swab , specimen was collected and sent
immediately to Department of Microbiology with a
requisition for culture and sensitivity.

OBSERVATIONS
Direct smear examination
In Microbiology Department ,a thin smear is made on a
clean glass slide and is fixed with 95% methanol ,by
pouring one or two drops on smear and allowed to act for
a minimum of 2 minutes or until the methanol dries on
the smear.
Gram staining is done for the smears so made and
is examined under oil immersion objective to note the
various morphological types of bacteria ,their
number,Gram reaction ,presence or absence of

inflammatory cells and also to note the number of

squamous epithelial cells in the sample
Aerobic culture
The discharge is used for inoculation on blood sugar
,nutrient agar and MacConkey agar plates .All plates were
incubated aerobically at 37 deg c
and evaluated at 24 hours,48 hours and 72 hours and the
plates were discarded if there is no growth.The specific
identification of bacterial pathogens was done based on
microscopic morphology ,staining characteristics,cultural
and biochemical properties using standard laboratory
procedures.
Antibacterial susceptibility of the bacterial isolates to
the commonly used antibiotics is done by Kirby-Bauer
disc effusion method.
Statistical analysis :Proportions and frequencies are
used to find the organisms in the ear discharge and
antibiotic sensitivity

OBSERVATIONS
In the present study A BACTERIOLOGICAL STUDY OF
CSOM is conducted for a period of one and a half
years ,from April 2011 to October 2012 ,100 pateints
were randomly selected and analysed ,from those
coming to ENT OPD and admitted in ENT wards ,in

the Academy of Medical Sciences , Pariyaram,

Kannur.
Out of 100 patients observed and analysed , CSOM is
found to be more predominant in males (68%) than
females (32%).
Out of 100 patients observed and analysed ,CSOM is
found to be more common among student population
(65%)
Out of 100 patients examined and analyzed, CSOM is
found common in the age group 6-20 years (62%)
and least number of patients were found in the age
group 31-40 years (10%).A total of (22%) were found
in the age groups 21-30 years and (6%) in 0-5
years .The most number of patients according to the
age group (62%) goes in accordance with the student
population(65%).
Out of 100 patients examined and analyzed , CSOM
is found common in lower socioeconomic status
(62%) and very less number of patients was found in
higher socioeconomic status (14%).
Out of 100 patients examined and analyzed, majority
of patients with CSOM presented with both ear
discharge and loss of hearing (51%).(33%) of them
presented with ear discharge and (16%) presented
with only loss of hearing.
Out of 100 patients examined and analyzed,majority
patients with CSOM presented with 1 to 3 years of
ear discharge (45%) followed by ear discharge since
childhood (10.5%)

 Out of 100 patients examined and analyzed ,majority

of patients with CSOM were normal (64%) without
any significant history of previous illness.
Out of 100 patients examined and analyzed ,majority
of patients with of patients with CSOM did not have
any family history of same disease (88%).
Out of 100 patients examined and analyzed Out of
100 patients examined and analyzed ,few of our
patients in the study group has the personal history
of swimming, putting foreign materials in the ear,
smoking, alcoholism, but in majority of them, there
was no significant personal history (54%).
Out of 100 patients examined and analyzed ,
majority of CSOM patients were undernourished
(53%). This goes in accordance with low
socioeconomic status of (62%).
Out of 100 patients examined and analyzed , none of
our patients with CSOM showed anaemia, jaundice,
cyanosis, koilonychia, temperature,
lymphadenopathy. The general examination of
patients were found normal.
Out of 100 patients examined and analyzed , major
population in patients with CSOM was with
respiratory tract infection (63%). Among them URTI is
more prone to cause CSOM (53%).( 37%) of them
were normal without any infection.
Out of 100 patients examined and analyzed , the
pinna, pre and post auricular region, EAC appeared
normal in patients with CSOM.

 Out of 100 patients examined and analyzed , there is

no tragal or mastoid tenderness in patients with
CSOM.
Out of 100 patients examined and analyzed ,
majority of patients with CSOM showed profuse ear
discharge (57%), compared to scanty (43%).
Out of 100 patients examined and analyzed ,
majority of patients with CSOM showed
mucopurulent ear discharge (54%) followed by
mucoid (33%) and purulent (13%).
Out of 100 patients examined and analyzed ,majority
of the discharge is yellow in colour (64%), (33%)
were colourless and (3%) were yellow and blood
tinged suggestive of AAD.
Out of 100 patients examined and analyzed ,
majority of patients with CSOM has odourless ear
discharge (88%) and only (12%) of the ear discharge
were foul smelling.
Out of 100 patients examined and analyzed , all
patients are with active ear discharge.
Out of 100 patients examined and analyzed , most of
the patients with CSOM showed central perforation.
Out of 100 patients examined and analyzed ,
majority of patients with CSOM has moderate size
perforation (68%) followed by large perforation
(15%).
Out of 100 patients examined and analyzed majority
of patients with CSOM has Rinne negative on the
affected ear (93%), Weber is lateralized to the
affected ear (93%) and Absoluted Bone Conduction is

normal in (81%), in (7%) we couldnt asses TFT as

they were children in lower age group. ABC is
reduced in older age group (12%).
Out of 100 patients examined and analyzed ,(56%) of
patients with CSOM has mild hearing loss (26-40dB)
and (29%) has moderate hearing loss (41-55dB). In
(7%) we couldnt access PTA as they were children of
lower age group.
Out of 100 patients examined and analyzed ,external
appearance of the nose is normal (73%)in majority of
patients with CSOM and in (27%) it is abnormal.
Out of 100 patients examined and analyzed 70% of
patients with CSOM are with deviated nasal septum.
Out of 100 patients examined and analyzed ,(26%) of
patients with CSOM showed adenoid hypertrophy.
(66%) were normal and in (8%) the procedure was
not done.
Out of 100 patients examined and analyzed ,
majority of patients with CSOM are with
Tubotympanic disease (88%) and (12%) were with
Atticoantral disease.
Out of 100 patients examined and analyzed , only in
(11%) X-Ray was taken. (5%) of the patients were
with bony erosion. (3%) were sclerotic. (2%) showed
both cavity and bony lesion and in (1%) there was
only cavity lesion. In (89%) X-Ray was not taken.
Out of 100 patients examined and analyzed , only in
11% CT scan was adviced. (5%) were with
cholesteatoma and bony erosion followed by (3%)
with cavity lesion in addition to the above.

DISSCUSION
Hundreds of patients with CSOM of all groups and
both sexes attending the out patient department and
those admitted in otolaryngology wards was selected
randomly for the study in the department of
Otolaryngology, academy of medical sciences ,
pariyaram.
Due to changing pattern of bacteriological profile of
otitis media and sensitivity of micro organisms
towards antibiotics, it has become very important to
find out the organism causing the disease.
The gender distribution of csom in the present
studies (68%) males and (32%) females . the male
and female ratio is 2:1 suggestive of male
preponderance .
The present study shows that , csom is found to be
more common among student population (65%)
Our study showed that csom is found common in the
age group 6-20 years (62%) followed by 21 to 30
years . the cause for the increased incidence in this
age group could be due to recurrent respiratory tract
infection.
In the present study , the disease is more prevalent
in the poor socio economic group(62%) as compared
to other groups in the society
In our study , majority of the patients presented with
ear discharge and loss of hearing(51%)
Majority of patients in our present study presented
with ear discharge of 1-3 years of duration (45%)

 Present study shows that majority of patients with

csom were normal(64%) without any significant
history of previous illness and there is no evidence
suggestive of genetic susceptibility in csom. Few of
our patients in our study group has personal history
of swimming , putting foreign material in the ear,
smoking , alcoholism , but in majority of them , there
is no significant personal history
Major population in our study group were under
nourished (53%)
None of the patients in our study group has anemia ,
jaundice , cyanosis, koilonychia, temperature, lymph
adenopathy .the general examination of the patient
was found normal.
Major population in patients in the present study ,
with csom had/has RTI (63%)
Among them URTI is more prone to cause CSOM
(53%)
The pinna , pre and post auricular region , EAC
appeared normal and there is no tragal or mastoid
tenderness.
Majority of patients with CSOM showed profuse ear
discharge (57%) compared to scanty (43%)
Majority of patients with CSOM in the present study
showed mucopurulent ear discharge (54%)
For most of the people in the present study ,
discharge is yellow in colour (64%), (33%) were
colourlessand (3%) were yellow and blood tinched
suggestive of AAD

 All patients in the present study , has active ear

discharge .most of the patients with csom showed
central perforation.
majority of patients with CSOM has moderate size
perforation (68%) followed by large perforation
(15%).
majority of patients with CSOM has Rinne negative
on the affected ear (93%), Weber is lateralized to the
affected ear (93%) and Absoluted Bone Conduction is
normal in (81%),
Pure tone audiometry was done in the present study
(56%) of patients with csom has mild hearing loss
(26-40db) and (29%) has moderate hearing loss (4155db)
Nasal examination of patients with csom showed
normal external appearance (73%) and abnormal in
27%. Anterior rhinoscopy showed deviated nasal
septum in 70%. There was adenoid hypertrophy in
(26%) on post rhinoscopic examination and in (8%) it
is not done as they were children in lower age
group.none of them hadparanasal sinus tenderness.
In the present study , examination of oral cavity ,
oropharynx and throat were within normal limits
Majority of patients with csom in the present study
are with TTD (88%) and (12%) were with AAD
The mastoid x-ray of the patient with csom in our
study showed that 5% were with bony erosion ,
3%were sclerotic , 2% showed both cavity and bony
erosion and in 1% there was only cavity lesion .

 CT was not taken in majority of cases . it was advised

mainly for AAD. Out of these , 11% showed
cholesteatoma sac with bony erosion, cavity lesion
and sclerosis of the mastoid .
According to our study , the gram staining of the
organism isolated showed gram negative organisms
in majority of the cases (60%) and gram positive
organisms in (30%).P.aeruginosa is the predominant
organism followed by Klebsiella.
In the present study of 100 patients with csom , the
commonest organism found in the culture is
P.aeruginosa (42%) followed by S.aureus (21%). The
next comes klebsiella (9%), proteus and CNSA(5%)
each and Acinobacter and Ecoli(4%) each.there is no
growth in (8%) and (2%) are commensals .
In our present study , the organisms isolated in csom
shows maximum sensitivity to gentamicin followed
by ciprofloxacin , amikacin , cefotaxime
In the present study P aeroginosa is higly sensitive to
gentamicin followed by ciprofloxacin , ceftriaxone ,
cefotaxime , amikacin ,cefuroxime
In the present study S.aureus showed maximum
sensitivity to amikacin followed by ciprofloxacin ,
cefotaxim , gentamicin , cotrimoxazole , cephalexin .
In the present study , klebsiella showed maximum
sensitivity to ciprofloxacin followed by gentamicin ,
cotrimoxazole , cefotaxime , amikacin .
In the present study , Ecoli showed maximum
sensitivity to ciprofloxacin followed by gentamicin ,
amikacin , cephalexin , cefotaxime .

 In the present study CNSA shows maximum

sensitivity to amikacin followed by gentamicin ,
erythromycin , cefoxitin
In the present study , acinectobacter showed
maximum sensitivity to ciprofloxacin , gentamicin ,
amikacin , ampicillin/amoxicillin
Eventhough , gentamicin is the most effective drug in
the management of CSOM , ciprofloxacin should be
also considered as the most effective drug in the
management of CSOM , because it can be
administered both orally and intravenously.it is
cheapest , less toxic compared to gentamicin ,
amikacin , erythromycin , ampicillin . gentamicin can
be only given intravenously and is systemically toxic
especially ototoxicity and nephrotoxicity .

SUMMARY
The study on A Bacteriology of CSOM was done
from April 2011 to October 2012 in the department
of Otolaryngology, Academy Of Medical Sciences,
Pariyaram, Kannur. Patients were selected randomly
from the outpatient department and ENT wards. Each
case of CSOM was examined clinically as per
proforma and ear swab were taken by aseptic
precaution and sent to Department of Microbiology
for culture and sensitivity.
In the present study of A Bacteriological Study of
CSOM out of hundred cases 68% were males and

32% were females. This shows the incidence of

CSOM has got preponderance in male patients.
CSOM is found to be more common among student
population (65%). The cause of increased incidence
in this group could be due to recurrent RTI.
The minimum age of the patient is 1 year 3 months
and maximum age is 48 years. The maximum
number of patients were in the age group 16-20
years (28%). Next between 6 to 10 (22%) years and
11-15 (12%) years. The cause for increased
incidence in this age group could be due to recurrent
RTI.
62% of patients were of low socioeconomic group
and 24% were in middle SES group and only 14%
were in high SES group.
Majority of patients with CSOM presented with both
ear discharge and LOH (51%).
The presenting complaints were of 1 to 3 year
duration.
Most of our patients were normal (64%) without any
significant history of previous illness.
CSOM didnt show any familial predisposition or
significant personal history.
Majority of patients with CSOM were undernourished
(53%). This goes in accordance with low SES of
(62%).
Major population in patients with CSOM was with RTI
(63%). Among them URTI is more prone to cause
CSOM (53%).

 Majority of patients with CSOM had profuse ear

discharge (57%) which was mucopurulent (54%),
yellow in colour (64%), and odourless (88%).
Majority of patients with CSOM showed moderate CP
(68%) followed by large CP.
Majority of patients with CSOM has Rinn negative on
the affected ear (93%). Weber is lateralized to the
affected ear (93%) and ABC is normal ib (81%). In
(7%) we couldnt access TFT as they were children in
lower age group. ABC is reduced in older age group
(12%).
PTA showed, (56%) of patients with CSOM has mild
hearing loss (26-40dB) and (29%) has moderate
hearing loss (41-55dB). In 7% we couldnt access PTA
as they are children of lower age group.
External appearance of the nose is normal (73%) in
majority of patients with CSOM and in (27%) it is
abnormal.
70% of patients with CSOM were with DNS.
26% of patients with CSOM showed adenoid
hypertrophy. 66% were normal and in 8% the
procedure was not done.
None of the patients had / has PNS tenderness.
The oral cavity, oropharynx and indirect
laryngoscopy were with normal limits.
Majority of patients with CSOM are wit TTD (88%)
and (12%) were with AAD.
Only in (11%) X-ray was taken. 5% of patients were
with bony erosion. 3% sclerotic. 2% showed both
cavity and bony lesion and in 1% there was only
cavity lesion. In 89% X-ray was not taken.

 Only in 11% CT scan was advised. 5% were with

cholesteatoma and bony erosion followed by 3% with
cavity lesion in addition to the above.
Gram negative organisms were found in majority
(60%) and gram positive in (30%). Gram staining was
not done in 10% as they were commensals and no
growth.
The commonest organism found in the culture was
P.Aeruginosa (42%) followed by S.Aureus (21%). Next
comes Klabsiella (9%), Proteus CNSA (5% each) and
Acinetobacter and E.coli 4% each. There is no growth
in 8% and 2% are commensals.
The organisms isolated in CSOM shows maximum
sensitivity to Gentamycin followed by Ciprofloxacin,
Amikacin, Cefotaxime. It is less sensitive to
Doxycycline, Norfloxacin, Tobramicin, Roxithromicin,
Cefazolin, Chloramphenicol.
P.Aeuruginosa showed maximum sensitivity to
Gentamycin followed by Ciprofloxacin, followed by
Ceftriaxone, Cefotaxime, Amikacine, Cefuroxime.
S.Aureus showed maximum sensitivity to Amikacine,
Ciprofloxacine, Cefotaxime, Gentamycin, Cotrimoxazole, Cephelexin.
Klabsiella showed maximum sensitivity to
Ciprofloxacin followed by Gentamycin, Amikacin.
Proteus showed maximum sensitivity to Ciprofloxacin
followed by Gentamycin, Co-trimoxazol, Cefotaxime,
Amikacin.

 E.coli showed maximum sensitivity to Ciprofloxacin

followed by Gentamycin, Amikacin, Cephalexin,
Amikacine.
CNSA showed maximum sensitivity to Amikacine
followed by Gentamycin followed by Erythromycin,
Cefoxitin.
Acinetobacter showed maximum sensitivity to
Ciprofloxacin, Gentamycin, Amikacin, Ampicillin/
Amoxicillin.

CONCLUSIONS
Out of 100 patients examined and analyzed , The
commonest organism found in the culture is
Pseudomonas Aeruginosa (42%) followed by
Staphylococcus Aureus (21%). The next comes
Klabsiella (9%) Proteus and Coagulase negative
Staphylococcus Aureus (5%) each and Acinetobacter
and Eschersia Coli (4%) each. There is no growth in
(8%) and (2%) are commensals.
Pseudomonas Aeruginosa showed maximum
sensitivity to Gentamycin, followed by Ciprofloxacin,
Ceftriaxone, Cefotaxime, Amikacin, Cefuroxime.

 Staphylococcus Aureus showed maximum sensitivity

to Amikacin followed by Ciprofloxacin, Cefotaxime,
Gentamycine, Co-trimoxazole, Cephelexin.
Gentamycin is the most effective antibiotic followed
by Ciprofloxacin, Amikacin, Cefotaxime.
Majority of patients with CSOM has/had respiratory
tract infection.
Majority of patients with CSOM were from poor
socioeconomic status and under nourished.
It is found to be more common among student age
group ie 6 to 20 years with male predominance.
Ciprofloxacin should be considered as the most
effective drug in the management of CSOM because
it can be given both orally and intravenously, it is
cheap, less toxic compared to Gentamicin.