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Chronic suppurative otitis media of Chronic suppurative

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Chronic suppurative otitis media
  Updated 2008 Sep 23 02:55 PM: contralateral ear may have increased risk of disease in patients with
  chronic otitis media (Arch Otolaryngol Head Neck Surg 2008 Mar)
  Links added to drug topics
  University of Michigan Health System guideline on otitis media (National Guideline Clearinghouse 2008
  Feb 25)

  General Information (including ICD-9/-10 Codes)
     Description:
             recurrent or persistent otorrhea (ear discharge) for at least 6 weeks through
             central or marginal perforation of tympanic membrane

     Also called:
             otomastoiditis, active chronic otitis media, suppurative chronic otitis media,
             chronic otitis media without effusion, chronic mastoiditis, chronic
             tympanomastoiditis

     ICD-9 Codes:
             382.1 chronic tubotympanic suppurative otitis media
             382.2 chronic atticoantral suppurative otitis media
             382.3 unspecified chronic suppurative otitis media
             382.4 unspecified suppurative otitis media
             382.9 unspecified otitis media

     ICD-10 Codes:
             H66 suppurative and unspecified otitis media [use additional code (H72), if
             desired, to identify presence of perforated tympanic membrane]
                    H66.1 chronic tubotympanic suppurative otitis media
                    H66.2 chronic atticoantral suppurative otitis media
                    H66.3 other chronic suppurative otitis media
                    H66.4 suppurative otitis media, unspecified
                    H66.9 otitis media, unspecified

     Organs Involved:
             eustachian tube-middle ear-mastoid cell system

     Who is most affected:
             childhood
                    mastoid pneumatization is most active at age 5-10 (may be halted or
                    reversed)
                    however intermittent aural discharge in children most likely due to
                    recurrent acute otitis media

             most common in developing countries, certain high risk populations in
             developed countries, and children with tympanostomy tubes (Int J Pediatr
             Otorhinolaryngol 1998 Jan;42(3):207)

     Incidence/Prevalence:
       15% prevalence reported in high-risk Australian Aboriginal
       communities; clinical evaluation of 709 children aged 6-30 months living
       in remote Aboriginal communities in Australia with social deprivation and
       large extended families with multiple children living together, 107 (15%)
       had chronic suppurative otitis media (95% confidence interval 11% to 19%)
       defined as middle ear discharge observed and tympanic perforation for > 6
       weeks and covering at least 2% of pars tensa of tympanic membrane (BMC
       Pediatrics 2005 Jul 20;5:27)

Causes and Risk Factors
  Causes:
       32% P. aeruginosa (greenish discharge), 55% anaerobes (55% cocci, 33%
       Bacteroides species), E. coli (coliform odor), Proteus (foul odor), Staph,
       Strep, gram-negative rods, Pneumoccus, diphtheroids, Mycobacterium
       tuberculosis

  Pathogenesis:
       unknown, #1 theory is neglected (serous) necrotizing otitis media resulting
       in large tympanic membrane perforation

  Likely risk factors:
       poor eustachian tube function (chronic or recurrent nose and throat
       infection, anatomic obstruction, scarring, thickened mucosa, polyps,
       granulation tissue, tympanosclerosis)
       ear disease in early childhood, persistent tympanic membrane perforation,
       squamous metaplasia of middle ear, virulent otitis media (scarlet fever,
       measles), areas of sequestration or persistent osteomyelitis in mastoid
       allergy, debility, immunosuppression

  Possible risk factors:
       incidence of otitis media is higher in formula-fed infants than in breast-fed
       infants, in a study of 85 infants the incidence of prolonged ear infections
       was 5x higher among formula-fed infants (J Pediatr 1995 May;126(5 Pt
       1):696)
       risk factors in children
             previous tympanostomy tube insertion (odds ratio [OR] 121.4, 95%
             CI 38.9-379.3)
             > 3 upper respiratory tract infections in past 6 months (OR 12.2,
             95% CI, 3.5-42.3)
             parents with a low education level (OR 14.1, 95% CI, 2.9-68.6)
             having older siblings (OR 4.4, 95% CI, 1.6-12.6)
             Reference - case-control study of 100 children with chronic
             suppurative otitis media and 161 controls aged 1-12 years (Arch
             Otolaryngol Head Neck Surg 2006 Oct;132(10):1115)

       risk factors in children with tympanostomy tube
             > 3 episodes of otitis media in past year (OR 4.9, 95% CI, 2.2-11)
             attending day care (OR 3.6, 95% CI, 1.7-7.8)
             having older siblings (OR 2.6, 95% CI, 1.2-5.5)
             Reference - case-control study with 83 cases and 136 controls in
             children with tympanostomy tubes (Arch Otolaryngol Head Neck Surg
             2006 Oct;132(10):1115)

Complications and Associated Conditions
  Complications:
           cholesteatoma more likely with marginal perforation, always with attic
           perforation
           meningitis, epidural abscess, brain abscess
           sigmoid sinus thrombosis
           paralysis of cranial nerve VII
           cholesterol granuloma, tympanosclerosis

  Associated conditions:
           contralateral ear may have increased risk of disease in patients with
           chronic otitis media
                 based on cross-sectional study
                 500 consecutive patients (mean age 26.3 years) with chronic otitis
                 media in 1 ear with or without cholesteatoma and with or without
                 otorrhea had digital otoendoscopy on both ears
                 chronic otitis media defined as chronic inflammation of middle ear
                 and/or mastoid associated with permanent perforation or retraction of
                 tympanic membrane; definition did not distinguish chronic serous
                 otitis media from chronic suppurative otitis media
                 abnormality in contralateral ear found in 75.2% patients overall
                       of 302 patients without cholesteatoma in affected ear, 69.9%
                       had abnormality in contralateral ear
                       of 198 patients with cholesteatoma in affected ear, 83.3% had
                       abnormality in contralateral ear

                 abnormalities in contralateral ear included
                       retraction of tympanic membrane in 38.2%
                       perforation of tympanic membrane in 26.2%
                       cholesteatoma in 5.2%
                       tympanosclerosis in 3.6%
                       fluid in middle ear in 2%

                 Reference - Arch Otolaryngol Head Neck Surg 2008 Mar;134(3):290
                 full-text

History
  Chief Concern (CC):
           painless aural discharge
           hearing impairment

  History of Present Illness (HPI):
           usually recurrent, especially with upper respiratory infection
           usually poor hearing with central perforation (annulus intact), usually good
           hearing with attic perforation, hearing may be poor with marginal
           perforation

Physical
  HEENT:
           otologic exam may reveal
                 tympanic perforations - central, marginal (usually posterior-superior),
                 or attic (pars flaccida)
                 thickened granular middle ear mucosa
                 mucosal polyps
              cholesteatoma
              atrophic 2-layer membrane lacking fibrous elements
              necrosis of long process of incus (thrombosis of mucosal vessels)

       intact tympanic membrane suggests chronic otitis media with effusion

Diagnosis
  Imaging studies:
       x-ray usually shows dense, small, sclerotic, undeveloped acellular mastoids

  Other diagnostic testing:
       culture and sensitivity (C+S), repeat C+S if treatment inadequate

Prognosis
  Prognosis:
       poorer with marginal perforation

Treatment
  Treatment overview:
       drainage of pus (aural toilet) hastens resolution and allows better exam to
       rule out cholesteatoma
       aural irrigation with sterile saline twice daily
       topical antibiotics (especially fluoroquinolones) or topical povidone-iodine
       5% eardrops
       hearing aid or surgery may alleviate hearing impairment

  Activity:
       simple ear cleansing did not reduce persistent otorrhea or tympanic
       perforations in children based on 1 systematic review, no randomized trials
       of ear cleansing (aural toilet) vs. no treatment identified in adults

  Medications:
       antibiotic eardrops
              topical quinolone antibiotics clear aural discharge better than
              no drug treatment or topical antiseptics (level 2 [mid-level]
              evidence)
                    based on Cochrane review with limited trial quality
                    systematic review of 14 randomized trials of any topical
                    antibiotic without steroids in patients with chronic suppurative
                    otitis media (CSOM)
                    1,724 patients or ears were analyzed
                    CSOM sometimes defined as chronically discharging ears with
                    underlying tympanic membrane perforations, but some studies
                    included otitis externa, mastoid cavity infections and other
                    diagnoses
                    trial quality varied and often poorly reported, follow-up usually
                    short
                    topical quinolone antibiotics
                          better at clearing discharge at 1 week than no drug
                          treatment in 2 trials with 197 patients
                          better than antiseptics at 1 week (3 trials with 263
                          patients) and 2-4 weeks (4 trials with 519 patients
      non-quinolone antibiotics
            mixed results over time compared to antiseptics in 4
            trials with 254 patients
            not significantly different than quinolone antibiotics at 1
            week (3 trials with 402 patient) or 3 weeks (2 trials with
            77 patients), but possibly less effective at 2 weeks (4
            trials with 276 patients, but only significant due to effects
            of 1 heterogeneous trial)

      Reference - systematic review last updated 2005 Aug 24
      (Cochrane Library 2005 Issue 4:CD004618)
      editorial commentary on earlier Cochrane review can be found
      in BMJ 2000 Jul 15;321(7254):126

topical quinolone antibiotics may clear aural discharge better
than systemic antibiotics (level 2 [mid-level] evidence)
      based on Cochrane review with limited trial quality
      systematic review of 9 randomized trials comparing any
      systemic versus topical treatment (excluding steroids) for
      chronic suppurative otitis media
            833 patients randomized, 842 patients or ears analyzed
            inclusion criteria, disease severity and methodological
            quality varied
            trials generally short-term and poorly reported

      topical quinolone antibiotics better than systemic antibiotics at
      clearing discharge at 1-2 weeks in each of the following
      comparisons
            topical quinolone vs. systemic non-quinolone antibiotics
            in 2 trials with 116 patients
            topical quinolone vs. systemic quinolone in 3 trials with
            175 patients
            systemic plus topical quinolone vs. systemic quinolone
            alone in 2 trials with 90 patients

      no statistically significant benefit at 2-4 weeks, but numbers
      were small
      no benefit for adding systemic to topical treatment at 1-2
      weeks in 3 trials with 204 patients
      hearing worsened by ototoxicity (damaging auditory hair cells)
      seen with chloramphenicol drops
      Reference - systematic review last updated 2005 Nov 15
      (Cochrane Library 2006 Issue 1:CD005608), commentary can
      be found in ACP J Club 2006 Sep-Oct;145(2):48
        EBSCOhost Full Text

topical fluoroquinolones
      topical ciprofloxacin improves resolution rates of otorrhea; 147
      Aboriginal children < 15 years old in Australia with chronic
      suppurative otitis media were treated with povidone-iodine
      0.5% ear cleaning twice daily and randomized to ciprofloxacin
      0.3% vs. framycetin 0.5%/gramicidin/dexamethasone (FGD)
      eardrops as 5 drops twice daily for 9 days, 111 children ages 1-
      14 years (76%) completed treatment; cure rates (defined as
      resolution of otorrhea) were 76.4% with ciprofloxacin vs.
      51.8% with FGD eardrops (p = 0.009, NNT 4); no differences in
           tympanic membrane perforation size or hearing impairment;
           most common bacterial pathogen (48%) was Pseudomonas
           aeruginosa (Med J Aust 2003 Aug 18;179(4):185 full-text)
           topical quinolone antibiotics improved otoscopic appearances
           compared to placebo in adults in randomized trials; no
           randomized placebo-controlled trials identified in children; no
           clear evidence of significant differences in efficacy in trials
           comparing topical antibiotics (Clinical Evidence)
           ofloxacin 0.3% (Floxin Otic Solution) approved for chronic
           suppurative otitis media in patients > 12 (Monthly Prescribing
           Reference 1998 Mar:A-24)

     topical povidone-iodine 5% eardrops as effective as ciprofloxacin with
     less expense; 40 patients > 10 years old with actively discharging
     chronic suppurative otitis media and moderate to large central
     perforation were randomized to povidone-iodine 5% vs. ciprofloxacin
     0.3% ear drops as 3 drops 3 times daily for 10 days, patients
     followed weekly for 4 weeks and aural toilet done if active discharge
     at weekly visit; no differences in clinical improvement rates which
     were 68% vs. 71% at 1 week and 88-89% vs. 90-91% at 2-4 weeks,
     bacterial isolates from 7 patients had in vitro resistance to
     ciprofloxacin but all bacterial isolates were sensitive to povidone-
     iodine (Arch Otolaryngol Head Neck Surg 2003 Oct;129(10):1098)

insufficient evidence regarding oral or IV antibiotics
     oral antibiotics less effective in improving otoscopic appearances than
     topical antibiotics based on 1 systematic review in adults
     insufficient evidence in children
     oral trimethoprim/sulfamethoxazole may reduce otorrhea in
     children with chronic active otitis media (level 2 [mid-level]
     evidence)
           based on randomized trial without intention-to-treat analysis
           accounting for dropouts
           101 children aged 1-12 years with continuous otorrhea through
           perforated tympanic membrane or tympanostomy tube for at
           least 3 months were randomized to
           trimethoprim/sulfamethoxazole 18 mg/kg vs. placebo orally
           twice daily for 6-12 weeks
                 children had failed conventional management with topical
                 medications and/or short-course systemic antibiotics
                 children with cholesteatoma or immunodeficiency were
                 excluded
                 study medication given for 6 weeks, then continued for
                 additional 6 weeks if persistent otorrhea, restarted if
                 otorrhea recurred after 6 weeks
                 all children given topical hydrocortisone/bacitracin/colistin
                 for 7-10 days, switched to
                 hydrocortisone/neomycin/polymyxin B eardrops during
                 study based on product availability in the Netherlands

           follow-up (and analysis) done for 98 children at 6 weeks, 96
           children at 12 weeks and 90 children at 1 year
           comparing trimethoprim/sulfamethoxazole vs. placebo
                 28% vs. 53% had otorrhea at 6 weeks (NNT 4)
                 32% vs. 47% had otorrhea at 12 weeks (not significant)
                 25% vs. 20% had otorrhea at 1 year (not significant)
                          9% vs. 2% had vomiting or diarrhea in first 6 weeks
                          (NNH 14)
                          1 vs. 1 child had mastoiditis in first 12 weeks

                   pure-tone hearing levels improved similarly in both groups
                   health-related quality of life improved similarly in both groups
                   Reference - Pediatrics 2007 May;119(5):897

       no randomized trials of topical steroids identified

  Surgery:
       tympanoplasty
             reconstruction of tympanic membrane and ossicular chain
             no randomized trials of tympanoplasty with or without mastoidectomy
             identified in patients without cholesteatoma

       (modified) radical mastoidectomy if cholesteatoma - remove disease,
       reconstruct hearing

Prevention and Screening
  Prevention:
       treatment of acute otitis media believed to prevent development of chronic
       suppurative otitis media, but not demonstrated by clinical trials
       repair of chronic tympanic membrane perforations might prevent recurrence
       no randomized trials found regarding use of antibiotics to prevent chronic
       suppurative otitis media in children; systematic review last updated 2006
       Jul 10 (Cochrane Library 2006 Issue 4:CD004401)

References including Reviews and Guidelines
  General references used:
       Clinical Evidence search date 2001 Nov (BMJ 2002 Nov 16;325(7373):1159)

  Reviews:
       clinical symposium on chronic ear disease 2002 Jan 18-20 published in ENT
       Journal 2002 Aug;81(8) supplement

  Guidelines:
       clinical management guidelines for otitis media from Office for Aboriginal
       and Torres Strait Islander Health, algorithm 5 covers chronic suppurative
       otitis media
       University of Michigan Health System guideline on otitis media can be found
       at National Guideline Clearinghouse 2008 Feb 25:11685

Patient Information
  Patient information:
       no patient information handout found after extensive Web searching

Acknowledgements
     DynaMed topics are created and maintained by the DynaMed Editorial Team.
     Over 500 journals and evidence-based sources (DynaMed Content Sources) are
     monitored directly or indirectly using a 7-step evidence-based method for
     systematic literature surveillance. DynaMed topics are updated daily as newly
     discovered best available evidence is identified.
      Special acknowledgements:
             Arindam Basu MB BS, MPH (Consultant Otolaryngologist, Guru Tegh
             Bahadur Medical Center, Kolkata, India) provided peer review from 2003
             Mar 9 to 2006 Apr 5.

      Competing interests:
             Each participating member of the DynaMed Editorial Team has declared no
             competing interests (financial or otherwise) related to this topic.


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