Chronic Suppurative Otitis Media

Charles D. Bluestone, MD* Jerome O. Klein, MD

*

Eberly Professor of Pediatric Otalaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA.

Professor of Pediatrics, Boston Univerisity School of Medicine, Boston MA. Dr Klein is a consultant to Eli Lily Company; is a consultant to and lecturer for Bristol Myers Squibb and SmithKline Beecham; is a consultan to and has grant support from Abott Laboratories abd Pfizer Pharmaceuticals; and is a consultant to a, lecturer for, and has grant support from Roche Laboratories.

Introduction
Chronic suppurative otitis media (CSOM) is a chronic infection of the middle ear cleft (including eustachian tube, middle ear, and mastoid) that is defined by three elements: 1) perforation of the tympanic membrane due to acute infection or tympanotomy tube, 2) discharge from the middle ear (otorrhea), and 3) prolonged duration (;gt;2 wk). The initial therapy of most cases is use of appropriate topical and systemic antibiotics, which can be managed by the pediatrician. Otolaryngologic referral is necessary in four circumstances: 1) if otomicroscopy is required for initial or subsequent examination, 2) if the patient fails to respond to initial therapy, 3) if a cholesteatoma or other mass is present, and 4) if a suppurative complication occurs.

Epidemiology
CSOM affects diverse racial and cultural groups living not only in temperate climates but in climate extremes ranging from the Arctic Circle to the equator. Among the groups affected most are the Inuits of Alaska (30% to 46%), Australian aborigines (12% to 25%), and certain Native Americans (eg, Apache and Navajo tribes) (4% to 8%). Studies from industrialized nations have reported low rates of CSOM due to acute infection with perforation, but many cases of CSOM are associated with use of tympanotomy tubes. No population-based data are available regarding the incidence of CSOM associated with tympanotomy tubes. Risk factors attributed to high rates of CSOM are similar to factors associated with recurrent acute otitis media (AOM): lack of breastfeeding, overcrowding, poor hygiene, poor nutrition, passive smoking, high rates of nasopharyngeal colonization with potentially pathogenic bacteria, and inadequate and unavailable health care. Data from Thailand and Kenya indicate that public health measures and appropriate medical care are

effective in decreasing the rate of CSOM.

Hearing and CSOM

When hearing is assessed in children who have otitis media with effusion (OME), the median level is 25 dB (equivalent to putting plugs in the ear canals). The average hearing loss in ears that have perforation of the tympanic membrane or CSOM usually is worse than that reported when OME is present. One study from Sierra Leone evaluated hearing in children who had perforation with and without suppuration. Of 37 ears that had dry perforations, 33 (89%) had a pure tone average of 26 dB or greater; of the 100 ears that had CSOM, 96 (96%) had this degree of hearing loss.

Pathogenesis
Persistent perforation with otorrhea is a complication of AOM (particularly in untreated patients) and may occur following placement of a tympanostomy tube. In either circumstance, reinfection of the middle ear may occur in one of two ways: 1. AOM and otorrhea are not treated or treated inadequately. The perforation makes the middle ear vulnerable to invasion from organisms in the external ear canal, including Pseudomonas aeruginosa and Staphylococcus aureus. The secondary infection results in persistent otorrhea and the disease CSOM. 2. Infection by organisms (eg, P aeruginosa) that are present in water and enter during bathing and swimming.

Microbiology
The bacteria that cause AOM and perforation with otorrhea or acute otorrhea through a tympanotomy tube usually are the pathogens of AOM: Streptococcus pneumoniae and Haemophilus influenzae (Table) . The most common organism isolated from the ear discharge of patients who have CSOM is P aeruginosa; S aureus also is found. Anaerobic bacteria are isolated infrequently.

Diagnosis
The evaluation of the patient should include a complete examination of the ear with an otoscope; an otomicroscope may be required if a satisfactory assessment cannot be performed with the standard otoscope or if the child has failed appropriate initial treatment. The occasional child who cannot be assessed successfully when awake should be examined under general anesthesia. A polyp seen emerging through the perforation may indicate the presence of a cholesteatoma. Cholesteatoma appears as a white mass or epithelial tissue within the drum defect. If the child has ear pain, tenderness to touch in the mastoid area or pinna, vertigo, or fever, mastoiditis or another suppurative complication should be considered. Purulent material and debris should be cleaned from the ear canal with a cotton-tipped wire loop; after cleaning the canal, a new loop should be used to obtain drainage from the middle ear. If an otolaryngologist is consulted, material may be obtained for culture from the middle ear through the perforation or tube with the aid of otomicroscopy. Gram stain of a smear often will reveal the dominant bacterial pathogen. Underlying causes of CSOM include eustachian tube dysfunction, adenoid hypertrophy, sinusitis, or upper respiratory tract allergy. Unusual causes include neoplasm, eosinophilic granuloma, and infections with organisms such as Mycobacterium tuberculosis. Computed tomography (CT) of the temporal bones is indicated when: 1) intensive medical treatment (including intravenous antimicrobial therapy) fails, 2) the child has an early recurrence, or 3) cholesteatoma or tumor is suspected.

Management
Initial treatment of CSOM is ototopical antibiotics with or without oral antimicrobial agents. The drugs should be effective against P aeruginosa and S aureus. Although ototopical drugs have been used for CSOM for more than 30 years, appear to be effective, and are considered the standard for therapy, there are limitations and ambiguities to their use. Some of the preparations used in the ear canal are approved only for ophthalmic use (eg, gentamicin and tobramycin suspensions). Ototoxicity is a possible adverse event associated with ototopical use of polymyxins and aminoglycosides, although there are no data documenting the incidence of such events and few reports despite extensive usage. At present, there are no oral antimicrobial agents approved by the United States Food and Drug Administration (FDA) for children that are effective against P aeruginosa, although many physicians believe that oral antibiotics approved for treatment of AOM are effective despite their lack of pseudomonal activity.

OTOTOPICAL MEDICATIONS
Currently available antibiotic suspensions that are used extensively as ototopical drugs include: 1) colistin sulfate-neomycin sulfate-thonzonium bromide-hydrocortisone acetate otic suspension (Cortisporin-TC Otic Suspension); 2) neomycin and polymyxin B sulfates and hydrocortisone otic suspension (Pediotic Suspension Sterile); 3) ciprofloxacin hydrochloride and hydrocortisone otic suspension (Cipro HC Otic Suspension); and 4) ofloxacin otic solution 0.3% (Floxin Otic). Ciprofloxacin and ofloxacin have been used as ear drops in investigational studies of adults and children who have CSOM and are reported to be safe and effective, but only the latter is approved for use in children by the FDA (June 1999). The addition of a corticosteroid to the antimicrobial agent may hasten resolution of the inflammation, but no data have documented the efficacy of the steroid component. Antiseptic ototopical drops or aluminum acetate (eg, acetic acid) commonly are used in underdeveloped countries and are reported to be effective, but data about adverse events are lacking. Ototopical regimens involve use of a topical antibiotic medication for 7 days (3 to 4 drops administered 3 to 4 times/day) plus daily visits to the office or outpatient facility to have the discharge thoroughly aspirated or swabbed (ie, "aural toilet") and to have the ototopical medication instilled into the middle ear through the perforation or tympanotomy tube using a surgical head otoscope (or otomicroscope). In most cases, the discharge improves with ototopical treatment within 1 week, after which the ear drops may be administered at home until the discharge resolves. When daily administration by the physician is not feasible, the parent/caregiver can administer the drops, but the child should be re-examined approximately 1 week later. If the otorrhea persists for more than 2 weeks, other treatment options, including parenteral therapy and otolaryngologic consultation, should be considered.

ORAL ANTIMICROBIAL AGENTS

Many clinicians include an oral antimicrobial agent effective for AOM in the regimen for CSOM (despite the lack of efficacy of oral drugs against P aeruginosa) based on the belief that treating the initial infecting organisms may be beneficial. Orally administered ciprofloxacin has been shown to be effective in adults who have CSOM, but it is not approved for patients younger than age 18 years (June 1999).

PARENTERAL ANTIMICROBIAL AGENTS

If the child fails to improve following administration of ototopical agents, with or without an oral antimicrobial agent, parenteral therapy is indicated with a beta-lactam antipseudomonal drug such as ceftazidime. Ticarcillin-clavulanate is an alternative agent that is effective against Pseudomonas sp and S aureus (not approved for children <12 y). The results of culture and susceptibility studies dictate the antimicrobial agent used subsequently. Hospitalization is warranted for initial parenteral antibiotic therapy and daily aural toilet using otomicroscopy. The duration of parenteral therapy is 10 to 14 days and may be completed at home if a home-care program is available. The patient should be followed at periodic intervals to watch for closure of the perforation, which should occur after appropriate treatment of the infection in the middle ear and mastoid.

SURGERY
If the discharge fails to respond to intensive medical therapy (including intravenous antibiotics, daily aural toilet, and ototopical medications) within several days, surgery on the middle ear and mastoid (ie, tympanomastoidectomy) usually is indicated. A CT scan should be obtained. Failures usually occur when there is: 1) an underlying blockage of the communication between the middle ear and mastoid (ie, aditus ad antrum), 2) chronic irreversible osteitis, 3) cholesteatoma (or tumor), or 4) an early recurrence with the same causative organism. If the CSOM is associated with a perforation that is too small to permit adequate drainage or the perforation closes frequently and reopens with episodic drainage, insertion of a tympanotomy tube can be helpful. On the other hand, if the CSOM is related to a tympanotomy tube, some clinicians advocate removal of the tube. However, recurrent AOM or persistent OME for which the tube was inserted originally is common.

Prevention
Because CSOM is preceded in most cases by AOM, the most effective method of prevention is prompt and appropriate treatment of AOM. If acute otorrhea occurs in a child who has a tympanotomy tube in place, early treatment of the acute otorrhea as AOM should be effective. Treatment with an oral antimicrobial agent may be enhanced by the addition of an ototopical agent. Antimicrobial prophylaxis using amoxicillin should be considered for the child who has persistent perforation or a tympanotomy tube in whom AOM recurs. If a tympanotomy tube is present and the middle ear becomes disease-free, removal of the tube may restore middle ear-eustachian tube physiology (ie, prevent reflux or self-insufflation of nasopharyngeal secretions). However, removal of tympanotomy tubes may not be desirable, especially in infants and young children, and in these cases, antimicrobial prophylaxis should be considered until the tubes extrude spontaneously. If the child has a chronic perforation that is now dry, tympanoplastic surgery should be considered.

Complications and Sequelae

The most common sequelae of CSOM are chronic hearing loss and the potential deficits related to this disability. The chronic infection may result in permanent conductive hearing loss due to damage to the ossicles; sensorineural loss also may occur. CSOM also can progress to intratemporal (extracranial) suppurative complications, such as acute mastoiditis, acute labyrinthitis, facial paralysis, or an intracranial suppurative complication, which requires immediate surgical intervention.

Summary and Conclusions

Most children who have CSOM can be managed effectively with ototopical antibiotic medications, with or without oral antimicrobial agents. When these measures fail, children require: 1) re-examination of the external canal and tympanic membrane with otoscope or otomicroscope (under general anesthesia, if necessary); 2) reaspiration of middle-ear drainage for Gram stain, culture, and susceptibility studies; 3) aspiration/swabbing of the ear canal and, if possible, the middle ear (ie, aural toilet); 4) direct instillation of the appropriate ototopical medication daily; and 5) parenteral administration of an appropriate antimicrobial agent. Consultation with an otolaryngologist should be considered if otomicroscopic examination is necessary, when medical therapy fails, and when a cholesteatoma or other mass is present. Prevention of subsequent episodes of CSOM requires: 1) early and appropriate antimicrobial therapy for AOM, 2) antimicrobial prophylaxis, 3) removal of the tympanotomy tube, or 4) surgical repair of the tympanic membrane defect.

Suggested Reading
Bluestone CD. Epidemiology and pathogenesis of chronic suppurative otitis media: implications for prevention and treatment. Int J Pediatr Otorhinolaryngol. 1998;42:207223[Medline] Bluestone CD. Otologic surgical procedures. In: Bluestone CD, Stool SE, eds. Atlas of Pediatric Otolaryngology. 1994:27-128 WB Saunders Co Philadelphia, Penn Bluestone CD, Klein JO. Intratemporal complications and sequelae of otitis media. In: Bluestone CD, Stool SE, Kenna MA, eds. Pediatric Otolaryngology. 3rd 1996:583-647 WB Saunders Philadelphia, Penn Browning GG. The unsafeness of ldquo;safe" ears. J Laryngol Otol. 1984;98:23[Medline] Mandel EM, Casselbrant ML, Kurs-Lasky M. Acute otorrhea: bacteriology of a common complication of tympanotomy tubes. Ann Otol Rhinol Laryngol. 1994;103:713718[Medline]