Which Product Is Ideal for You?

Summary

Definition: chronic suppurative otitis media is a common cause of chronic otorrhea and is defined as discharge through a non-intact tympanic membrane (TM) for >6 wk; may occur in the setting of perforation, cholesteatoma, or tympanostomy tubes

Pathophysiology: initial acute infection results in inflammation and subsequent mucosal edema and ulceration; host immune response leads to formation of granulation tissue and polyps, and progression of inflammation results in osteitis and bony destruction; osteitis increases susceptibility for infection; common pathogenic agents — Pseudomonas is implicated in 50% to 98% of cases; Staphylococcus aureus is the second most common; other causes include gram negative bacteria, anaerobic bacteria, and fungal species

Evaluation: patients may have a history of recurrent acute otitis media, traumatic TM perforation, prior tympanostomy tubes, or prior ear surgery

Management: drainage is controlled using topical antibiotics, aural toilet, and strict water precautions; systemic antibiotics are administered in resistant cases; surgery may be considered as a final resort

Eosinophilic otitis media: often intractable and characterized by accumulation of eosinophils in the effusion and mucosa of the middle ear; patients often present with thick inspissated fluid; strongly associated with asthma and chronic sinusitis with nasal polyposis

Diagnostic criteria: otitis media with effusion or chronic otitis media with eosinophil-dominant effusion are major diagnostic criteria and must be accompanied by ≥2 minor criteria, which include highly viscous effusion of the middle ear, resistance to conventional treatment for otitis media, or association with bronchial asthma or nasal polyps

Histopathology: shows an abundance of eosinophils, eosinophilic mucin, and Charcot-Leyden crystals; severe cases may present with polypoid changes in the middle ear or frank polyps that are often pale and fibrous

Outcomes: sensorineural hearing loss may occur if untreated; may result from an overly patent Eustachian tube and is an extension of sinonasal disease into the middle ear space; secondary infections caused by pathogens in the middle ear can contribute to eosinophilic otitis media; effusions are resistant to conventional treatment

Management: usually nonsurgical, although debridement of polyps from the middle ear may be beneficial in cases of heavy polyp burden; often requires frequent suctioning; topical steroid drops or triamcinolone injections into the middle ear or oral steroids are often beneficial; leukotriene receptor inhibitors and monoclonal antibody therapy with omalizumab (eg, Xolair) can be administered; patients should be on the recalcitrant nature and need for frequent suctioning and hearing aids

Chronic draining mastoid cavity: often caused by inadequate ventilation, poor oral hygiene or cleaning, and increased moisture (particularly if the meatus is small or the patient uses a hearing aid); infection, inflammation, granulation tissue, and mucosalization are often present in the mastoid, which results in chronic discharge

Workup: otomicroscopy examination is recommended to identify the size of the meatus and presence of deep air cell tracks in the sinodural angle, high facial ridge, or a dependent mastoid tip; important to rule out cholesteatoma, assess the integrity of the TM, distinguish between fungal and bacterial infection, and assess the burden of granulation tissue

Initial management: topical antibiotics are considered standard and are generally most effective because their potency is 100 to 1000 times greater compared with systemic therapy; infections are often caused by gram negative species; topical powders include chloramphenicol sulfa and amphotericin B (eg, CSF Otic Powder) or CCDB (ciprofloxacin, clotrimazole, dexamethasone, and boric acid); tobramycin-dexamethasone ear drops (eg, Tobradex) can be used after ruling out perforation (vestibular loss has been reported with a perforated TM); antifungal agents include nystatin and triamcinolone acetonide (eg, Mycolog), natamycin, and clotrimazole (eg, Alevazol, Lotrimin, Mycelex); patients should be educated on aural toilet and strict water precautions; hearing aids should be removed and cleaned of exudate or desquamated epithelium; silver nitrate is used to control granulation tissue; removal of moisture is important

Management of persistent infection: collect sample for culture and sensitivity, and administer systemic antibiotics for 3 to 4 wk; surgery is considered a last resort; surgical approaches include revision of the mastoid or mastoid obliteration; closure of the external auditory canal and fitting a bone conduction hearing device may be considered and leads to satisfactory outcomes for many patients

Wegener granulomatosis: immune-mediated vasculitis that affects small and medium blood vessels; characterized by infiltration of immune cells around capillaries and blood vessels; primarily affects the lung, kidneys, and upper airway tract; otologic manifestations occur in ≈40% of cases and may include chronic suppurative otitis media or sensorineural hearing loss accompanied by facial nerve symptoms in rare cases; necrotizing granulomas are hallmark pathologic findings; should be considered if the patient does not respond to conventional treatment and lacks bony destruction; antineutrophil cytoplasmic antibody (c-ANCA) test is diagnostic; initial treatment includes prednisone; long-term treatment may include immunotherapy or chemotherapy with cyclophosphamide or methotrexate; remission rate is ≈75%

Spontaneous cerebrospinal fluid (CSF) leak: characterized by persistent drainage after placement of a tube or topical treatment for serous otitis media; discharge is often thin and watery; women account for ≈72% of cases; associated with body mass index >30 kg/m²; elevated intracranial pressure may be present; patients may be at risk for meningitis, although recent studies challenge the validity of this association; beta-2 transferrin is diagnostic if a fluid sample can be obtained (must be refrigerated if collected by the patient); computed tomography of the temporal bone can also be used for diagnosis; surgery is recommended for most patients