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Chronic Otitis media- sign and symptoms, management

CHRONIC OTITIS MEDIA

Chronic otitis media is the result of repeated episodes of acute otitis media causing irreversible tissue pathology and persistent perforation of the tympanic membrane. Chronic infections of the middle ear damage the tympanic membrane, destroy the ossicles, and involve the mastoid. Before the discovery of antibiotics, infections of the mastoid were life-threatening. The use of medications in acute otitis media has made acute mastoiditis a rare condition in developed countries.

Clinical Manifestations

Symptoms may be minimal.

  • Varying degrees of hearing loss
  • Persistent or intermittent foul-smelling otorrhea
  • Pain is not usually experienced, except in cases of acute mastoiditis, when the postauricular area is tender to the touch and may be erythematous and edematous
  • Otoscopic evaluation of the tympanic membrane may show a perforation, and cholesteatoma can be identified as a white mass behind the tympanic membrane or coming through to the external canal from a perforation.

Cholesteatoma is an in-growth of the skin of the external layer of the eardrum into the middle ear. It is generally caused by a chronic retraction pocket of the tympanic membrane, creating a persistently high negative pressure of the middle ear. The skin forms a sac that fills with degenerated skin and sebaceous materials. The sac can attach to the structures of the middle ear or mastoid, or both. Cholesteatoma alone usually does not cause pain; however, if treatment or surgery is delayed, the cholesteatoma may destroy structures of the temporal bone. In cases of cholesteatoma, audiometric tests often show a conductive or mixed hearing loss.

Medical Management

  • Careful suctioning of the ear under microscopic guidance
  • Instillation of antibiotic drops or application of antibiotic powder is used to treat a purulent discharge
  • Systemic antibiotics are usually not prescribed except in cases of acute infection

Surgical Management

Surgical procedures are used after medical treatments are determined to be ineffective. Chronic otitis media can cause chronic mastoiditis and lead to the formation of cholesteatoma. It can occur in the middle ear, mastoid cavity, or both, often dictating the type of surgery to be performed. If untreated, cholesteatoma will continue to enlarge, possibly causing damage to the facial nerve and horizontal canal and destruction of other surrounding structures.

Tympanoplasty

It is the surgical reconstruction of the tympanic membrane. Reconstruction of the ossicles may also be required. The purposes of a tympanoplasty are to reestablish middle ear function, close the perforation, prevent recurrent infection, and improve hearing. There are five types of tympanoplasties:

  • Type I (myringoplasty), is designed to close a perforation in the tympanic membrane.
  • Types II through V, involve more extensive repair of middle ear structures. The structures and the degree of involvement can differ, but all tympanoplasty procedures include restoring the continuity of the sound conduction mechanism.

Tympanoplasty is performed through the external auditory canal with a transcanal approach or through a post-auricular incision. The contents of the middle ear are carefully inspected, and the ossicular chain is evaluated. Ossicular interruption is most frequent in chronic otitis media, but problems of reconstruction can also occur with malformations of the middle ear and ossicular dislocations due to head injuries. Dramatic improvement in hearing can result from closure of a perforation and reestablishment of the ossicles. Surgery is usually performed in an outpatient environment under moderate sedation or general anesthesia.

Ossiculoplasty

Many people use the term tympanoplasty to include ossiculoplasty, or surgical reconstruction of the middle ear bones to restore hearing. Prostheses made of materials such as Teflon, stainless steel, and hydroxyapatite are used to reconnect the ossicles, thereby reestablishing the sound conduction mechanism. However, the greater the damage, the lower the success rate for restoring normal hearing.

Mastoidectomy

The objectives of mastoid surgery are to remove the cholesteatoma, gain access to diseased structures, and create a dry and healthy ear. If possible, the ossicles are reconstructed during the initial surgical procedure. Occasionally, extensive disease dictates that this be performed as part of a planned second-stage operation. A mastoidectomy is usually performed through a postauricular incision. Infection is eliminated by removing the mastoid air cells. Although infrequently injured, the facial nerve, which runs through the middle ear and mastoid, is at some risk for injury during mastoid surgery. As the patient awakens from anesthesia, any evidence of facial paresis should be reported to the physician. A second mastoidectomy may be necessary to check for recurrent or residual cholesteatoma. The hearing mechanism may be reconstructed at this time. The success rate for correcting this conductive hearing loss is approximately 75%. Surgery is usually performed in an outpatient setting. The patient has a mastoid pressure dressing, which can be removed 24 to 48 hours after surgery.