Introduction
Earlier, the imaging used to evaluate otitis media could have been better. With advancements in radiological tools, the visualization and management of otitis media have become effective. To plan surgical intervention, chronic otitis media is examined with high-resolution computed tomography (HRCT). Radiological imaging can identify the presence and distribution of soft tissues in the middle ear cleft (consisting of the middle ear cavity or tympanic cavity) and mastoid (bone located at the base of the skull). In addition, the extent of the disease and asymptomatic complications can be visualized.
What Is Otitis Media?
Otitis media is also known as middle ear inflammation (redness and swelling). Otitis media can be acute, associated with effusion, or chronic. All the forms of otitis media have similarities and overlapping features. Otitis media is a common disorder occurring in young children. Chronic suppurative otitis media is a significant cause of hearing loss in developing countries.
What Is Acute Otitis Media?
It is a middle ear infection occurring in children. Middle ear disease can be due to viral or bacterial infection. The infection of the ear occurs after an upper respiratory tract infection. The main goal of treating acute otitis media is to control infections and pain.
What Is Otitis Media With Effusion?
The disease is a collection of non-infected fluid in the middle ear space. The disease may develop from a cold, sore throat, or upper respiratory tract infection. Most patients with otitis media with effusion recover without any long-term complications.
What Is Chronic Suppurative Otitis Media?
It is a condition with chronic middle ear inflammation and mastoid cavity inflammation. The infection in chronic otitis media is caused by Staphylococcus aureus (bacterial disease-causing organism). The most distinctive feature of this disorder is persistent or recurrent ear discharge through tympanic membrane perforation (perforated eardrum) or ventilation tubes (ear tubes that restore ventilation). It can result in conductive hearing loss (sounds cannot get through the outer and middle ear) and damage to the middle ear ossicles (three tiny bones in the middle ear). In addition, there is a risk of permanently developing sensorineural hearing loss (hearing loss caused by damage to the inner ear) and intracranial complications.
-
Causes for Chronic Suppurative Otitis Media
It can result from acute otitis media, eustachian tube obstruction, mechanical trauma, thermal or chemical burns, or blast injuries. The iatrogenic cause for developing chronic suppurative otitis media is tympanostomy tube (small tube placed in the eardrum) placement. Patients with Down syndrome (a genetic disorder caused by abnormal cell division), cri du chat syndrome (a genetic disorder caused by missing part in chromosome), and cleft lip or palate syndrome have an increased risk of developing the disease.
-
Factors Responsible for the Exacerbation of Chronic Suppurative Otitis Media
Upper respiratory tract infections or water entering the middle ear through the tympanic membrane perforation while swimming or bathing can exacerbate the disease. In addition, prolonged exposure to air pollution and poor hygiene can also increase disease severity. Persistent chronic otitis media for an extended period can cause necrosis of a long process of incus (middle ear ossicles) or aural polyps (growth in the external ear canal or middle ear).
What Are the Sign and Symptoms of Chronic Suppurative Otitis Media?
-
Conductive hearing loss.
-
Otorrhea (ear discharge).
-
Pain occurs if osteitis (inflammation of the bone) of the temporal bone is present.
-
The tympanic membrane is perforated and draining. The discharge may be fetid (unpleasant smell), purulent (discharge of pus), cheese-like (discharge caused by yeast infection ), precise, or serous (body fluids resembling serum).
-
The auditory canal is filled with granulation tissue.
-
Fever.
-
Vertigo (feeling of dizziness or unbalance).
What Is the Diagnostic Evaluation of Chronic Otitis Media?
The diagnosis for chronic otitis media is clinical evaluation. The symptoms of ear pain and ear discharge suggest chronic otitis media. In addition, few patients can experience cold, sore throat, cough, or upper respiratory tract infection symptoms.
-
The pus or liquid draining from the ear is cultured to identify the disease-causing agent.
-
If there is the development of cholesteatoma (cyst-like growth behind the ear drum), CT (computed tomography) or MRI (magnetic resonance imaging) evaluation is required. The CT imaging can reveal labyrinthitis (inflammation in the inner ear), ossicular or temporal erosion (erosive change in middle ear ossicles or temporal bone), and abscesses. The imaging is recommended if intracranial complications or neoplasm (cancer) is suspected. MRI imaging can show the fluid collection in the middle ear. The ability of MRI to visualize soft tissues facilitates visualization of Dural inflammation (inflammation in an outer protective layer of the brain or spinal cord), sigmoid sinus thrombosis (blood clots in the sinus), and extradural and intracranial abscesses. CT is followed by MRI imaging to obtain further details. High-resolution computed tomography (HRCT) is essential for diagnosis in a few patients.
-
If the granulation tissue persists, a biopsy is advised to rule out a neoplasm.
What Is the Role of HRCT in the Diagnosis of Chronic Otitis Media?
It is a gold standard technique used in chronic otitis media diagnosis. HRCT has a significant role in diagnosing and managing middle ear disorders. The imaging facilitates the confirmation of otoscopic findings, clinical doubt resolution, and effectiveness of surgery. HRCT temporal bone is very effective in diagnosing diseases occurring in the middle ear cleft and adjacent structures unresponsive to treatment. In addition, the scan may reveal osseous erosion of the scutum (bony projection in external auditory canal), ossicles, ear canal, mastoid, the fallopian canal (canal through which facial nerve passes), or tegmen (bony plate that forms roof in the tympanic cavity) which is suggestive of cholesteatoma. The imaging can also reveal intracranial or subperiosteal abscesses and lateral sinus thrombosis.
What Is the Treatment Provided for Chronic Suppurative Otitis Media?
-
Topical antibiotic drops are used to treat the disease. Ten drops of topical Ciprofloxacin are administered in the affected ear twice daily for 14 days. The commonly used drops contain aminoglycosides (antibiotics containing various agents) and fluoroquinolones antibacterial agent).
-
A severe form of chronic suppurative otitis media requires systemic antibiotic therapy with amoxicillin or cephalosporins (beta-lactam antimicrobials).
-
The aural toilet is a process in which a microscope and micro instruments are used to remove mucous secretion, the desquamated epithelium (skin peeling), and other materials blocking the canal. It is performed 2 to 3 times daily before topical antibiotic drops are administered.
-
The granulation tissue is removed with micro instruments or cauterization (tissue destruction with chemicals, hot or cold instruments) with silver nitrate sticks. Followed by, Ciprofloxacin (antibiotics) and Dexamethasone (steroid) administration into the middle ear canal for 7 to 10 days.
-
Tympanoplasty is recommended for patients with marginal or central tympanic membrane perforations.
-
Myringoplasty is a procedure that surgically closes tympanic membrane defects.
-
Cholesteatomas, if present, are removed surgically.
What Is the Prognosis for Chronic Otitis Media?
The disease has a good prognosis when the cause of the infection is treated. However, the recovery from hearing loss depends on the cause. Conductive hearing loss can be corrected partially with surgery. Long-standing cases of otitis media are irreversible. Hence, early diagnosis is key to improved prognosis.
Conclusion
Chronic otitis media is an inflammatory disease affecting the middle ear cavity in children. Most patients recover with treatment without major complications. However, patients unresponsive to medical treatment or with a protracted disease course may experience hearing loss or fatal complications. Early detection with high-resolution computed tomography can improve outcomes.
