CASE REPORT

CHRONIC SUPPURATIVE OTITIS MEDIA

Moderator : dr.H. KRT Bambang Purwoatmodjo .Sp THT-KL,MM

Adre Dwi Wiratama

(10/296883/KU/13696)
Khavidz Faza G
(10/296941/KU/13709)

Introduction
Chronic suppurative otitis media (CSOM) defined as a
chronic inflammation of the middle ear and mastoid
cavity which presents with recurrent ear discharge or
otorrhea through a tympanic perforation. (WHO,2004)
A study in Jakarta shows that the prevalence of CSOM in
2012 is 3,4%. It is considered as high CSOM prevalence
by WHO (2-4%). (Pasra, 2012)
CSOM typically occur in children. (Lasisi, 2007)

Anatomy of Middle Ear

Tortora, 2009

Tympanic Membrane

Divided into 4
quadrants:
1. Anterosuperior
2. Anteroinferior
3. Posterosuperior
4. Posteroinferior

Dhingra, 2006

Histology of Middle Ear

Antero-inferior compartment of the middle ear were

composed by cilliated pseudostratified epithel with
goblet cell and have a thick connective tissue.
Postero-superior compartment were layered with
monocellular epithel which do not have cillia and
produce mucous.
Helmi, 2005

Vascularization of Middle Ear

Vascularization of middle ear provided by the branches
external carotid arteries.
Superficial petrose arteries + Superior tympanic arteries
superior part of middle ear
Tympanic posterior arteries posterior part of middle
ear
Tympanic inferior arteries inferior part of middle ear
Helmi, 2005

Definition
A chronic inflammation of the middle ear and mastoid
cavity which presents with:
recurrent ear discharge or otorrhea through a
tympanic perforation.
Patients with tympanic perforations which continu to
discharge mucoid material for periods of from 6 weeks
to 3 months, despite medical treatment, are
recognized as CSOM.
WHO, 2004

Classification

Benign

Mucosal/safe/non
cholesteatum/tubotympanic

Malign

Bone/dangerous/cholesteatum/atticoant
ral
Helmi, 2005

Pathogenesis
Most of benign CSOM was started from the dysfunction
of eustachian tube
Pathophysiology of CSOM occurred in 2 ways:
1. Some patient develop CSOM as the result of acute
otitis media that are unresolved completely. It
could happened because the inadequate and
incomplete treatment. The presence of CSOM was
mostly caused by recurrent acute otitis media
2. Some patient develop CSOM as the result from preexisting tympanic membrane perforation which
eliminates the middle ear cushion and allowing
the air to escape from middle part of the ear and
the nasopharyngeal secretes could flow retrograde
into the middle cavity.
Roland, 2002 & Helmi, 2005

Pathogenesis
Unresolved acute otitis media could happened because:
Does not diagnosed promptly
Delayed treatment
Does not treated with adequate treatment
High virulence
Patient with immuno-depressed
Malnutrition condition.

Recurrences of perforation can lead into CSOM and a larger

perforation size.
Wiertsema & Leach, 2009

CSOM PATHWAY
Extrinsic
Intrinsic

Tubal
dysfunction

Obstruction

Air
absorption
Negative
pressure

Inadequate therapy,
immunodepressed, high
virulence, and delayed
treatment

Retracted
eardrum
Transudation
Infection
Exudation

AOM

CSOM
6-12
weeks

Perforation

Soepardi, 2012

Bacteria

Number of Findings

Percentage

Aerobic

11

22,46

aeruginosa
Staphylococcus aureus

16,33

A. anitratus

14,29

Proteus nirabilis

8,16

Difteroid

6,12

Streptococcus

4,08

epidermidis
Klebsiella pneumonia

2,04

2,04

hemolyticus
P. alkalifacies

2,04

Streptococcus

2,04

anhemolyticus
Anaerobic

Bacreiodes fragilis

8,16

Clostridium sporogens

6,12

Clostridium perforogens

4,08

Clostridium novyi

2,04

Pseudomonas

Streptococcus

ETI
OLO
GY

Helmi,

Risk Factor
Intrinsic Factor:
1.Race
2.Young age
3.Upper respiratory
tract infection
4.Educational level of
parent

Extrinsic Factor:
1.Parental smoking
2.Daycare attendance
3.Breastfeeding vs
bottlefeeding

Morris 2013 & Van der veen 2006

Signs and Symptoms

Otorrhea with purulent and mucoid consistency which
can be occured continuously or intermitten,
decreasing the hearing ability (conductive hearing
loss), and tympanic membrane perforation

Helmi, 2005

Diagnosis

Perforated eardrum with a history of persistent or

recurrent otorrhea for more than 2 months
Helmi, 2005

History-taking - Physical Examination - Supportive

Examination
WHO, 2004

Management
1st management: ( Primary care )
1. Rule out complication
2. Aural toilet to start antiseptic and antibiotic
treatment
3. Topical antibiotic treatment as a first line or
monotherapy
WHO, 2004

Helmi, 2005

CASE REPORT

CASE REPORT
History taking
Name

:S

Age
Sex

: 62 years old

No.RM

: 362733

: Male

MAIN COMPLAINT
Discharge in left ear

Present Illness History

Patient complained about discharge in his left ear in 2 weeks
continuously.
The discharge, according to the patient, was
mucopurulen consistency without foul smelling.

yellowish

Patient also mentioned slight loss of hearing and pain in the left
ear.
Patient experience itching in the left ear and didnt experience
any dizziness. Those symptoms didnt appear in the right ear.
Patient at that time was not experiencing cough, flu or fever,
but did so in the previous week.

Patient Illness History

Patient has been experiencing the same
symptoms with discharge since two years ago
intermittent.
The symptoms were relieved after using eardrops.
History of allergy: denied
History of Diabetes Mellitus + Hypertension:
denied

Family Illness History

History of the same disease: (-)
History of Diabetes Mellitus and Hypertension:
(-)

PHYSICAL EXAMINATION
General appearance :
Compos Mentis, good nutritional status
Vital sign
Heart rate
: 72 bpm
Respiratory rate
: 16 x/menit
Temperature
: -C
Blood pressure
: 110/70 mmHg

PHYSICAL EXAMINATION
Right ear

: within normal limit

Left ear

: discharge (+) occluding CAE

Left ear post-suction

mass (-)

: hyperemic (-), edema (-),

Right ear otoscopy : within normal limit

Left ear otoscopy
: cone of light (-), discharge
in tympanic membrane, central perforation.

PHYSICAL EXAMINATION
Rhinoscopy anterior

: within normal limit

Rhinoscopy posterior

: within normal limit

Oropharyng

: within normal limit

Laryngoscopy indirect

: within normal limit

Ear
Test
Rinne
Webber
Schwabach

Right Auricle

Left Auricle

Left lateralization
Same as
prolonged
examiner

Suspect : AS CHL
Tuning Fork Test : Conductive Hearing Loss Auris
Sinistra

Diagnosis
Chronic Suppurative Otitis Media, Benign
Type Active phase Auris Sinistra

Management

Aural Toilet: Hydrogen Peroxide 3% AS, 2x1

Ciprofloxacin 2x 500 mg
Ambroxol 30mg Tab 3x1
Tremenza Tab 2x1

Education for Patient

Keep ear dry: close ear holes while showering,
avoid swimming, avoid water entering the ear
canal
Avoid cough and flu.

Problem
Recurrence

Planning
Come back in a week to assess the effectivity of
therapy.
Microbiological culture if no improvement

Conclusion

Patient diagnosed with chronic suppurative otitis

media benign type active phase of left ear. The
patient was treated with aural toilet with 3% of
Hydrogen Peroxide twice a day, Ciprofloxacin
antibiotic , ambroxol tablet thrice a day, and
Triprolidine hcl + Pseudoephedrine hcl tablet twice a
day.

Thankyou