http://informahealthcare.com/pgm ISSN: 0032-5481 (print), 1941-9260 (electronic) Postgrad Med, 2015; 127(4): 391–395 DOI: 10.1080/00325481.2015.1027133
CLINICAL FEATURE REVIEW
Chronic otitis media Sebastian Wallis, Helen Atkinson and Andrew P. Coatesworth
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
Department of Otolaryngology, Head and Neck Surgery, York Teaching Hospitals NHS Foundations Trust, York, UK
Abstract
Keywords
Chronic otitis media (COM) is a common problem facing general practitioners, pediatricians and otolaryngologists. This article reviews the aetiopathogenesis, epidemiology, presentation, natural history, complications and management of COM. The literature was reviewed by using the PubMed search engine and entering a combination of terms including “COM”, “diagnosis”, “incidence”, “complications” and “management”. Relevant articles were identified and examined for content. What is the “take-home” message for the clinician? COM is a common problem with various sub-categories according to the disease state. It most commonly presents with painless otorrhoea and hearing loss. Treatment options vary according to the activity and type of disease encountered. COM carries significant patient morbidity.
Chronic, cholesteatoma, otitis media, otology History Received 8 December 2014 Revised 17 February 2015 Accepted 5 March 2015
Introduction
Aetiopathogenesis
This is the third of three papers reviewing otitis media. The first paper dealt with otitis media with effusion, and the second reviewed acute otitis media. This article focuses on chronic otitis media (COM). Each review outlines the theories of aetiopathogenesis, modes of presentation, diagnosis and management options. Various terms have been used previously to describe chronic middle ear disease. Chronic supporative otitis media, atticoantral, tubotympanic, safe and unsafe are old terms, which have been replaced with a simpler classification – see Table 1. An ear can be referred to as having squamous or mucosal disease, which is either active or inactive. The term healed COM is applied to ears where one of the above processes has been present in the past but the middle ear has now healed leaving an abnormal tympanic membrane.
Mucosal COM
Epidemiology COM is a common problem; the prevalence in adults in the UK is 1.5% and 2.6% for active and inactive disease respectively [1]. COM is more common in certain indigenous populations such as Native Americans and Australian aborigines and in Alaska [2,3], which suggests that genetics may play a role. A prior history of acute otitis media, parental history of COM, larger families, higher crowding index and care in large day-care centers have been identified as risk factors for children developing COM [4].
Mucosal COM – in mucosal COM the underlying problem is that of a permanent perforation of the pars tensa portion of the tympanic membrane (see Figure 1 and 2). This is most likely due to chronic Eustachian tube dysfunction alone or in conjunction with recurrent acute otitis media. A permanent perforation is also a recognized complication of grommet insertion, occurring after 2.2% of short-term ventilation tubes and 16.6% of long-term ventilation tubes [5]. .
.
Inactive mucosal COM – here there is no active inflammation and no suppuration from the middle ear. As no pus is being produced by the mucosa the perforation is termed “dry”. Active mucosal COM – in this case there is inflammation of the middle ear mucosa resulting in a mucopurulent discharge through the perforation. Inflammation may lead to ulceration, granulation tissue formation and polyps. This can also be described as a “wet” perforation.
Squamous COM Squamous COM – when negative middle ear pressure is long standing, the tympanic retracts either in its entirety or in one particular area. The most common place for this is the pars flaccida portion of the tympanic membrane or “attic”. This area is thinner and lacks the fibrous element of the pars tensa. A retracted segment of the tympanic membrane is often referred to as a retraction “pocket”.
Coresspondence: Sebastian Wallis, ENT Department, York Hospitals NHS Foundations Trust, Wigginton Road, York, YO31 8HE, UK. E-mail: [email protected] 2015 Informa UK, Ltd.
392
S. Wallis et al.
Postgrad Med, 2015; 127(4):391–395
Table 1. Classification of chronic otitis media.
Active Inactive
Squamous
Mucosal
Cholesteatoma Retraction pocket
Wet perforation Dry perforation
Incudostapedial joint
Malleus
Dry perforation Tympanosclerosis
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
Figure 2. Diagram to illustrate features of a tympanic membrane perforation.
Figure 1. A dry perforation of the posterior pars tensa, right ear.
.
.
Inactive squamous COM – here there is retraction of the drum but no keratin build up within the pocket. The retracted area may be involving the pars tensa or the pars flaccida or both. Keratin formed on the squamous surface of the tympanic membrane normally migrates out of the ear along the ear canal. If, despite the retraction, this migration continues, the retraction is said to be “selfcleaning”. Chronic retraction may lead to breakdown of the fibrous layer of the drum, atelectasis and progressively adherence of the drum onto the ossicles. The bony shield over the attic area of the middle ear becomes eroded, similarly the ossicles, over time. Active squamous COM – here the retraction does not allow keratinous debris to migrate outwards, leading to increasing keratin build-up within the retraction pocket. This is referred to as a cholesteatoma, which is a misnomer, as it has nothing to do with cholesterol. Cholesteatoma can be simply dry keratin, or more commonly becomes secondarily infected developing into a wet offensive smelling discharge. Cholesteatomas produce an inflammatory reaction, which causes a local osteitis and bony erosion (see Figure 3 and 4).
Presentation and diagnosis For patients with inactive disease symptoms are few. There may be symptoms of Eustachian tube dysfunction with a blocked sensation, and the need to “pop” the ear. There is often associated hearing loss of a conductive nature. For those with active disease patients commonly present with ear discharge also termed otorrhoea. This is often offensive
Figure 3. An attic cholesteatoma. Note the bony erosion and associated inflammatory granulation tissue.
Eroded attic Keratin
Granulation tissue seen above & behind eardrun Malleus
Figure 4. Diagram to illustrate features of an attic cholesteatoma.
smelling with cholesteatoma. Discharge is usually mucoid in nature as opposed to a watery discharge in otitis externa. Inflamed middle ear mucosa can bleed easily and may result in bloody discharge. When disease is active patients may notice a drop in their hearing. In some cases, the patient may not present until complications have developed. Diagnosis is based on history and clinical examination of the ear. If there is active disease with discharge, microsuction
Chronic otitis media
DOI: 10.1080/00325481.2015.1027133
may be required to clean the ear and allow identification of the underlying abnormality. Pure tone audiogram will establish the level of hearing. A conductive hearing loss is common in COM: a perforation of the eardrum may result in an air-bone-gap of up to 30 decibel, whereas a conductive loss of >30 decibel would suggest erosion and discontinuity of the ossicular chain. Very occasionally, a patient may present with a “dead ear” where there is no functional hearing at all. This is most likely due to erosion of the bony labyrinth by a cholesteatoma. Tympanometry may be beneficial to assess the intact nature of the drum. A flat trace (type B) with high ear canal volume is typically seen with a perforated eardrum.
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
Natural history Inactive disease, of both mucosal and squamous type, is unlikely to progress to healing unless the underlying causative factors, such as Eustachian tube dysfunction or recurrent acute otitis media, resolves. Inactive mucosal COM may revert back to active disease following upper respiratory tract infections or the introduction of unclean water through the perforation into the middle ear. Active mucosal COM may be treated medically, as described below, and revert to the inactive state. Common causative bacteria found in active COM are pseudomonas species, proteus species and staphylococcus aureus [6,7]. Complex bacterial communities, known as biofilms, have also been identified in the middle ear mucosa of COM patients [8]. Mucosal COM may remain active despite topic treatment if the organisms involved have antibiotic resistance or there is a suppressed immune response. Continued activity may result in erosion of the ossicular chain leading to worsening hearing loss. Active squamous COM, cholesteatoma, generally progresses if left untreated. Whereas the rate and manner of disease progression is variable, paediatric cholesteatomas are usually considered more aggressive than the adult form [9]. As the cholesteatoma sac enlarges it typically spreads into the attic and then into the mastoid bone via the antrum, although other patterns of spread are possible. Cholesteatomas commonly erode the ossicular chain, the incus being the most vulnerable ossicle [10]. Other local structures are at risk, (e.g.) the bony labyrinth, and these are discussed in the complications section.
Management Inactive mucosal disease A dry perforation of the tympanic membrane is unlikely to cause symptoms other than a hearing loss. This may be addressed by the use of a digital hearing aid. If the perforation is becoming intermittently active or restricting the patient’s lifestyle (e.g.) preventing from swimming, then surgery can be offered. Tympanoplasty is an operation, which involves repairing the tympanic membrane ± the ossicular chain. Common methods involve using either temporalis fascia or cartilage (either tragal or conchal) as graft material to close the perforation. The success rate for closure is ~80%
393
[11] and if the ossicular chain is intact there may be a slight improvement in the hearing post-operatively [12]. If there is erosion of the ossicular chain, this can be corrected by an ossiculoplasty either at the time of tympanoplasty or at a planned later date. Various prostheses can be used to reconstruct the ossicular chain according to the defect encountered. The most successful ossiculoplasties are those where the stapes suprastructure is intact [13]. Active mucosal disease The initial management of active mucosal COM is cleaning the ear canal and tympanic membrane by use of microsuction and administering topical antibiotics. Topical antibiotic drops provide a higher concentration of antibiotic to the site of infection without unwanted systemic side effects of the oral equivalents. Topical preparations are also more effective than oral antibiotics [14]. Quinolone and aminoglycoside preparations are commonly used and have similar effectiveness [15]. Aminoglycosides should only be prescribed in short courses and when there is obvious activity in mucosal COM to reduce the theoretical risk ototoxicity [16]. Quinolone preparations do not carry a risk of ototoxicity. Combined antibiotic and steroid preparations are also useful, especially where there is significant edema of the middle ear mucosa or polyp formation. In cases where there is continued activity despite medical therapy, swabs can be taken to see if there is any bacterial resistance to guide further treatment. Occasionally, some perforations will not dry up with the above measures and in these cases it would be reasonable to proceed directly to tympanoplasty. Inactive squamous disease Stable, self-cleaning retraction pockets of the tympanic membrane can, on the whole, be managed conservatively. If there is an associated otitis media with effusion, then this should be managed accordingly. Retraction pockets in the pediatric population should, however, be monitored more closely, as there is a greater risk of them developing into cholesteatoma. At present, there is no convincing evidence that surgery has a role in inactive COM [17]. Active squamous disease/cholesteatoma Cholesteatomas cause persistent otorrhoea and can lead to complications. Surgery is the definitive treatment for cholesteatoma. In some cases, for example when a patient is not medically fit enough for general anaesthetic, regular outpatient microsuction and topical preparations may keep the symptoms under control. A number of different surgical techniques are described to tackle cholesteatoma, but they all share the same principles. Surgery should aim to: remove all of the cholesteatoma; preserve the hearing as much as possible and result in a healthy, self-cleaning ear. Canal wall down (CWD) mastoidectomy involves opening the mastoid from behind, removing the cholesteatoma and leaving the mastoid and ear canal combined in a single large cavity. Canal wall up (CWU) mastoidectomy involves
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
394
S. Wallis et al.
Postgrad Med, 2015; 127(4):391–395
opening the mastoid but keeping the posterior ear canal wall intact whilst removing the cholesteatoma, thereby at the end of the procedure the ear canal retains its normal, pre-operative, anatomy. The advantage of the CWU technique is that the patient avoids a large mastoid cavity, which may require long-term follow-up for cleaning. However, CWU surgery requires a “second-look” procedure after 1 year to check for recurrent cholesteatoma, which is not be visible due to the intact ear canal wall. Disease surveillance is easier with the CWD technique as the whole mastoid cavity is opened for inspection. The CWU technique is often reported to achieve better postoperative hearing but long-term results between the two techniques are comparable [18]. Large mastoid cavities can be reconstructed or obliterated with either bone or soft tissue such as cartilage or muscle, at the time of surgery, or at a later date, to reduce the size of the cavity and enable a self-cleaning ear [19,20]. There is no single best surgical technique for all cholesteatomas. Surgical planning should be directed by the pattern of disease encountered and the preference of the surgeon for a particular technique. Complications Active COM may lead to complications, which can be classified as being either extra- or intracranial dependent upon their location. The complications are summarized in Table 2. Infection arising in the middle ear may spread into the mastoid portion of the temporal bone causing mastoiditis, which in turn may lead to subperiosteal abscess formation. Rarely, pus in the mastoid cavity may escape out of the mastoid tip infero-medially and track down to form an abscess in the neck musculature known as Bezold’s abscess [21]. The facial nerve courses through the temporal bone and there may be a natural dehiscence in the middle ear. Cholesteatoma may also erode the bony covering of the facial nerve and facial palsy may result from local inflammation and infection. Dehiscent facial nerves are found in nearly 20% of patients operated on for cholesteatoma [22]. The bony labyrinth is also at risk from cholesteatoma. The most common site of erosion is the lateral semi-circular canal, which may manifest as symptoms of imbalance or vertigo. Passage of infective organisms through a fistula into the inner ear may cause labyrinthitis, manifesting as acute vertigo, and potentially complete sensorineural hearing loss, termed a “dead ear”. Infection at the apex of the temporal bone has the potential to affect the fifth and sixth cranial nerves. Gradenigo’s Table 2. Summary of COM complications. Extracranial Intracranial Mastoiditis ± subperiosteal abscess Facial nerve palsy Labyrinthine fistula Chronic otitis externa Bezold’s abscess Gradenigo’s syndrome
Meningitis Extradural abscess Subdural abscess Brain abscess (temporal lobe or cerebellum) Sigmoid sinus thrombosis Otitic hydrocephalus
syndrome comprises ipsilateral retro-orbital pain, abducens nerve palsy (unable to abduct the eyeball) and otorrhoea [23]. A chronically discharging middle ear can, in turn, cause inflammation of the ear canal skin termed otitis externa. If left untreated this can lead to edema and narrowing of the ear canal, which may be itchy and painful. Intracranial complications may occur secondary to COM due to transmission of infection by a number of possible routes. Cholesteatoma may erode the skull base directly and lead to extradural or subdural abscess formation. Meningitis occurs by hematogenous spread to the meninges and infection can pass through emissary veins into the brain causing intracerebral (temporal lobe) or cerebellar abscesses. Infection may spread to the sigmoid sinus via local venous channels and result in sigmoid sinus thrombosis. Septic emboli may propagate from the sinus resulting in distant spread of infection and sepsis. Inflammation of the ventricles is a rare but important intracranial complication of COM. Cerebrospinal fluid outflow may be impeded leading to raised intracranial pressure and this is known as otitic hydrocephalus. On the whole complications of COM are relatively uncommon. One study looked at 2890 patients with COM over a 9-year period and found that 3.2% developed either extra- or intra-cranial complications [24]. The annual risk of an adult developing an intracranial abscess has been calculated to be about 1 in 10000 [25]. All intracranial complications are very serious and have an associated mortality of up to 16%, although this has reduced as antibiotic treatments have improved [24-27]. A high index of suspicion is necessary when seeing patients with COM who present with symptoms of headache, fevers or any new neurological signs. Diagnosis is made either by CT or MRI and the patient should be commenced on broadspectrum IV antibiotics immediately. A full neurological assessment should be made and a neurosurgical opinion sought. Extradural abscesses can be drained via a mastoidectomy approach but subdural and brain abscesses are managed by neurosurgeons. Addressing the underlying cause of the COM (e.g. cholesteatoma) can usually be deferred until after the patient’s neurological condition has stabilized. Thankfully, since the introduction of more effective antibiotics and advances in surgical techniques, the associated morbidity and mortality from COM complications has improved. It is important to remember that surgery for COM, in particular cholesteatoma surgery, carries a small but significant risk of complications too. Facial nerve palsy and dead ear are recognized complications of mastoid surgery with an incidence of ~ 1% and 2%, respectively [28].
Summary COM is a common disease process that can be classified into squamous or mucosal type and can be active or inactive. There is a significant morbidity attached to COM and complications, whilst thankfully rare, can be disabling and potentially fatal. A variety of medical and surgical treatments exist and each patient should be considered individually and managed according their needs.
DOI: 10.1080/00325481.2015.1027133
Declaration of interest The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
References [1] Browning G, Gatehouse S. The prevalence of middle ear disease in the adult British population. Clin Otolaryngol Allied Sci 1992;17: 317–21. [2] Wiet RJ. Patterns of ear disease in the southwestern American Indian. Arch Otolaryngol 1979;105:381–5. [3] Miller ML. Epidemiology of otitis media: problem and research focus for geographers. Soc Sci Med 1979;13D:233–6. [4] Fliss DM, Shoham I, Leiberman A, Dagan R. Chronic suppurative otitis media without cholesteatoma in children in southern Israel: incidence and risk factors. Pediatr Infect Dis J 1991;10:895–9. [5] Kay DJ, Nelson M, Rosenfeld RM. Meta-analysis of tympanostomy tube sequelae. Otolaryngol Head Neck Surg 2001;124:374–80. [6] Ricciardiello F, Cavaliere M, Mesolella M, Iengo M. Notes on microbiology of cholesteatoma: clinical findings and treatment. Acta Otorhinolaryngol Ital 2009;29:197–202. [7] Prakash R, Juyal D, Negi V, Pal S, Adekhandi S, Sharma M, Sharma N. Microbiology of chronic supporative otitis media in a tertiary care setup of Uttarakhand State, India. N Am J Med Sci 2013;5:282–7. [8] Kaya E, Dag I, Incesulu A, Gurbuz MK, Acar M, Birdane L. Investigation of the presence of biofilms in chronic supporative otitis media, nonsupporative otitis media, and chronic otitis media with cholesteatoma by scanning electron microscopy. ScientificWorldJournal 2013;2013:638715. [9] Glasscock ME, Dickins JR, Wiet R. Cholesteatoma in children. Laryngoscope 1981;91:1743–53. [10] Mohammadi G, Naderpour M, Mousaviagdas M. Ossicular erosion in patients requiring surgery for cholesteatoma. Iran J Otorhinolaryngol 2012;24:125–8. [11] Kotecha B, Fowler S, Topham J. Mryingoplasty: a prospective audit study. Clin Otolaryngol Allied Sci 1999;24:126–9. [12] Lee P, Kelly G, Mills RP. Myringoplasty: does the size of the perforation matter? Clin Otolaryngol Allied Sci 2002;27:331–4.
Chronic otitis media
395
[13] Mills RP. The influence of pathological and technical variables on hearing results in ossiculoplasty. Clin Otolaryngol Allied Sci 1993;18:202–5. [14] Macfadyen CA, Acuin JM, Gamble CL. Systemic antibiotics versus topical treatments for chronically discharging ears with eardrum perforations. Cochrane Database Syst Rev 2006:CD005608. [15] Miro N. Controlled multicentre study on chronic supporative otitis media treated with topical applications of ciprofloxacin 0.2% solution in single-dose containers or combination of polymyxin B, neomycin, and hydrocortisone suspension. Otolaryngol Head Neck Surg 2000;123:617–23. [16] Phillips JS, Yung MW, Burton MJ, Swan IR. Evidence review and ENT-UK consensus report for the use of aminoglycosidecontaining ear drops in the presence of an open middle ear. Clin Otolaryngol Allied Sci 2007;32:330–6. [17] Nankivell PC, Pothier DD. Surgery for tympanic membrane retraction pockets. Cochrane Database Syst Rev 2010:CD007943. [18] Karmarkar S, Bhatia S, Saleh E, DeDonato G, Taibah A, Russo A, Sanna M. Cholesteatoma surgery: the individualized technique. Ann Otol Rhinol Laryngol 1995;104:591–5. [19] Kurien G, Greeff K, Gomaa N, Ho A. Mastoid obliteration with autologous bone graft a quality of life study. J Otolaryngol Head Neck Surg 2013;42:49. [20] Birzgalis AR, Farrington WT, O’Keefe L. Reconstruction of discharging mastoid cavities using the temporalis myofascial flap. Clin Otolaryngol Allied Sci 1994;19:70–2. [21] Gaffney RJ, O’Dwyer TP, Maguire AJ. Bezold’s abscess. J Laryngol Otol 1991;105:765–6. [22] Moody MW, Lambert PR. Incidence of dehiscence of the facial nerve in 416 cases of cholesteatoma. Otol Neurotol 2007;28:400–4. [23] Motamed M, Kalan A. Gradenigo’s syndrome. Postgrad Med J 2000;76:559–60. [24] Osma U, Cureoglu S, Hosoglu S. The complications of chronic otitis media: report of 93 cases. J Laryngol Otol 2000;114:97–100. [25] Nunez DA, Browning GG. Risks of developing an otogenic intracranial abscess. J Laryngol Otol 1990;104:468–72. [26] Kangsanarak J, Fooanant S, Ruckphaopunt K, Navacharoen N, Teotrakul S. Extracranial complications of supporative otitis media. Report of 102 cases. J Laryngol Otol 1993;107:999–1004. [27] Yorgancilar E, Yildirim M, Gun R, Bakir S, Tekin R, Gocmez C, Meric F, et al. Complications of chronic supporative otitis media: a retrospective review. Eur Arch Otorhinolaryngol 2013;270:69–76. [28] Harkness P, Brown P, Fowler S, Grant H, Ryan R, Topham J. Mastoidectomy audit: results of the Royal College of surgeons of England comparative audit of ENT surgery. Clin Otolaryngol Allied Sci 1995;20:89–94.
CLINICAL FEATURE REVIEW
Chronic otitis media Sebastian Wallis, Helen Atkinson and Andrew P. Coatesworth
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
Department of Otolaryngology, Head and Neck Surgery, York Teaching Hospitals NHS Foundations Trust, York, UK
Abstract
Keywords
Chronic otitis media (COM) is a common problem facing general practitioners, pediatricians and otolaryngologists. This article reviews the aetiopathogenesis, epidemiology, presentation, natural history, complications and management of COM. The literature was reviewed by using the PubMed search engine and entering a combination of terms including “COM”, “diagnosis”, “incidence”, “complications” and “management”. Relevant articles were identified and examined for content. What is the “take-home” message for the clinician? COM is a common problem with various sub-categories according to the disease state. It most commonly presents with painless otorrhoea and hearing loss. Treatment options vary according to the activity and type of disease encountered. COM carries significant patient morbidity.
Chronic, cholesteatoma, otitis media, otology History Received 8 December 2014 Revised 17 February 2015 Accepted 5 March 2015
Introduction
Aetiopathogenesis
This is the third of three papers reviewing otitis media. The first paper dealt with otitis media with effusion, and the second reviewed acute otitis media. This article focuses on chronic otitis media (COM). Each review outlines the theories of aetiopathogenesis, modes of presentation, diagnosis and management options. Various terms have been used previously to describe chronic middle ear disease. Chronic supporative otitis media, atticoantral, tubotympanic, safe and unsafe are old terms, which have been replaced with a simpler classification – see Table 1. An ear can be referred to as having squamous or mucosal disease, which is either active or inactive. The term healed COM is applied to ears where one of the above processes has been present in the past but the middle ear has now healed leaving an abnormal tympanic membrane.
Mucosal COM
Epidemiology COM is a common problem; the prevalence in adults in the UK is 1.5% and 2.6% for active and inactive disease respectively [1]. COM is more common in certain indigenous populations such as Native Americans and Australian aborigines and in Alaska [2,3], which suggests that genetics may play a role. A prior history of acute otitis media, parental history of COM, larger families, higher crowding index and care in large day-care centers have been identified as risk factors for children developing COM [4].
Mucosal COM – in mucosal COM the underlying problem is that of a permanent perforation of the pars tensa portion of the tympanic membrane (see Figure 1 and 2). This is most likely due to chronic Eustachian tube dysfunction alone or in conjunction with recurrent acute otitis media. A permanent perforation is also a recognized complication of grommet insertion, occurring after 2.2% of short-term ventilation tubes and 16.6% of long-term ventilation tubes [5]. .
.
Inactive mucosal COM – here there is no active inflammation and no suppuration from the middle ear. As no pus is being produced by the mucosa the perforation is termed “dry”. Active mucosal COM – in this case there is inflammation of the middle ear mucosa resulting in a mucopurulent discharge through the perforation. Inflammation may lead to ulceration, granulation tissue formation and polyps. This can also be described as a “wet” perforation.
Squamous COM Squamous COM – when negative middle ear pressure is long standing, the tympanic retracts either in its entirety or in one particular area. The most common place for this is the pars flaccida portion of the tympanic membrane or “attic”. This area is thinner and lacks the fibrous element of the pars tensa. A retracted segment of the tympanic membrane is often referred to as a retraction “pocket”.
Coresspondence: Sebastian Wallis, ENT Department, York Hospitals NHS Foundations Trust, Wigginton Road, York, YO31 8HE, UK. E-mail: [email protected] 2015 Informa UK, Ltd.
392
S. Wallis et al.
Postgrad Med, 2015; 127(4):391–395
Table 1. Classification of chronic otitis media.
Active Inactive
Squamous
Mucosal
Cholesteatoma Retraction pocket
Wet perforation Dry perforation
Incudostapedial joint
Malleus
Dry perforation Tympanosclerosis
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
Figure 2. Diagram to illustrate features of a tympanic membrane perforation.
Figure 1. A dry perforation of the posterior pars tensa, right ear.
.
.
Inactive squamous COM – here there is retraction of the drum but no keratin build up within the pocket. The retracted area may be involving the pars tensa or the pars flaccida or both. Keratin formed on the squamous surface of the tympanic membrane normally migrates out of the ear along the ear canal. If, despite the retraction, this migration continues, the retraction is said to be “selfcleaning”. Chronic retraction may lead to breakdown of the fibrous layer of the drum, atelectasis and progressively adherence of the drum onto the ossicles. The bony shield over the attic area of the middle ear becomes eroded, similarly the ossicles, over time. Active squamous COM – here the retraction does not allow keratinous debris to migrate outwards, leading to increasing keratin build-up within the retraction pocket. This is referred to as a cholesteatoma, which is a misnomer, as it has nothing to do with cholesterol. Cholesteatoma can be simply dry keratin, or more commonly becomes secondarily infected developing into a wet offensive smelling discharge. Cholesteatomas produce an inflammatory reaction, which causes a local osteitis and bony erosion (see Figure 3 and 4).
Presentation and diagnosis For patients with inactive disease symptoms are few. There may be symptoms of Eustachian tube dysfunction with a blocked sensation, and the need to “pop” the ear. There is often associated hearing loss of a conductive nature. For those with active disease patients commonly present with ear discharge also termed otorrhoea. This is often offensive
Figure 3. An attic cholesteatoma. Note the bony erosion and associated inflammatory granulation tissue.
Eroded attic Keratin
Granulation tissue seen above & behind eardrun Malleus
Figure 4. Diagram to illustrate features of an attic cholesteatoma.
smelling with cholesteatoma. Discharge is usually mucoid in nature as opposed to a watery discharge in otitis externa. Inflamed middle ear mucosa can bleed easily and may result in bloody discharge. When disease is active patients may notice a drop in their hearing. In some cases, the patient may not present until complications have developed. Diagnosis is based on history and clinical examination of the ear. If there is active disease with discharge, microsuction
Chronic otitis media
DOI: 10.1080/00325481.2015.1027133
may be required to clean the ear and allow identification of the underlying abnormality. Pure tone audiogram will establish the level of hearing. A conductive hearing loss is common in COM: a perforation of the eardrum may result in an air-bone-gap of up to 30 decibel, whereas a conductive loss of >30 decibel would suggest erosion and discontinuity of the ossicular chain. Very occasionally, a patient may present with a “dead ear” where there is no functional hearing at all. This is most likely due to erosion of the bony labyrinth by a cholesteatoma. Tympanometry may be beneficial to assess the intact nature of the drum. A flat trace (type B) with high ear canal volume is typically seen with a perforated eardrum.
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
Natural history Inactive disease, of both mucosal and squamous type, is unlikely to progress to healing unless the underlying causative factors, such as Eustachian tube dysfunction or recurrent acute otitis media, resolves. Inactive mucosal COM may revert back to active disease following upper respiratory tract infections or the introduction of unclean water through the perforation into the middle ear. Active mucosal COM may be treated medically, as described below, and revert to the inactive state. Common causative bacteria found in active COM are pseudomonas species, proteus species and staphylococcus aureus [6,7]. Complex bacterial communities, known as biofilms, have also been identified in the middle ear mucosa of COM patients [8]. Mucosal COM may remain active despite topic treatment if the organisms involved have antibiotic resistance or there is a suppressed immune response. Continued activity may result in erosion of the ossicular chain leading to worsening hearing loss. Active squamous COM, cholesteatoma, generally progresses if left untreated. Whereas the rate and manner of disease progression is variable, paediatric cholesteatomas are usually considered more aggressive than the adult form [9]. As the cholesteatoma sac enlarges it typically spreads into the attic and then into the mastoid bone via the antrum, although other patterns of spread are possible. Cholesteatomas commonly erode the ossicular chain, the incus being the most vulnerable ossicle [10]. Other local structures are at risk, (e.g.) the bony labyrinth, and these are discussed in the complications section.
Management Inactive mucosal disease A dry perforation of the tympanic membrane is unlikely to cause symptoms other than a hearing loss. This may be addressed by the use of a digital hearing aid. If the perforation is becoming intermittently active or restricting the patient’s lifestyle (e.g.) preventing from swimming, then surgery can be offered. Tympanoplasty is an operation, which involves repairing the tympanic membrane ± the ossicular chain. Common methods involve using either temporalis fascia or cartilage (either tragal or conchal) as graft material to close the perforation. The success rate for closure is ~80%
393
[11] and if the ossicular chain is intact there may be a slight improvement in the hearing post-operatively [12]. If there is erosion of the ossicular chain, this can be corrected by an ossiculoplasty either at the time of tympanoplasty or at a planned later date. Various prostheses can be used to reconstruct the ossicular chain according to the defect encountered. The most successful ossiculoplasties are those where the stapes suprastructure is intact [13]. Active mucosal disease The initial management of active mucosal COM is cleaning the ear canal and tympanic membrane by use of microsuction and administering topical antibiotics. Topical antibiotic drops provide a higher concentration of antibiotic to the site of infection without unwanted systemic side effects of the oral equivalents. Topical preparations are also more effective than oral antibiotics [14]. Quinolone and aminoglycoside preparations are commonly used and have similar effectiveness [15]. Aminoglycosides should only be prescribed in short courses and when there is obvious activity in mucosal COM to reduce the theoretical risk ototoxicity [16]. Quinolone preparations do not carry a risk of ototoxicity. Combined antibiotic and steroid preparations are also useful, especially where there is significant edema of the middle ear mucosa or polyp formation. In cases where there is continued activity despite medical therapy, swabs can be taken to see if there is any bacterial resistance to guide further treatment. Occasionally, some perforations will not dry up with the above measures and in these cases it would be reasonable to proceed directly to tympanoplasty. Inactive squamous disease Stable, self-cleaning retraction pockets of the tympanic membrane can, on the whole, be managed conservatively. If there is an associated otitis media with effusion, then this should be managed accordingly. Retraction pockets in the pediatric population should, however, be monitored more closely, as there is a greater risk of them developing into cholesteatoma. At present, there is no convincing evidence that surgery has a role in inactive COM [17]. Active squamous disease/cholesteatoma Cholesteatomas cause persistent otorrhoea and can lead to complications. Surgery is the definitive treatment for cholesteatoma. In some cases, for example when a patient is not medically fit enough for general anaesthetic, regular outpatient microsuction and topical preparations may keep the symptoms under control. A number of different surgical techniques are described to tackle cholesteatoma, but they all share the same principles. Surgery should aim to: remove all of the cholesteatoma; preserve the hearing as much as possible and result in a healthy, self-cleaning ear. Canal wall down (CWD) mastoidectomy involves opening the mastoid from behind, removing the cholesteatoma and leaving the mastoid and ear canal combined in a single large cavity. Canal wall up (CWU) mastoidectomy involves
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
394
S. Wallis et al.
Postgrad Med, 2015; 127(4):391–395
opening the mastoid but keeping the posterior ear canal wall intact whilst removing the cholesteatoma, thereby at the end of the procedure the ear canal retains its normal, pre-operative, anatomy. The advantage of the CWU technique is that the patient avoids a large mastoid cavity, which may require long-term follow-up for cleaning. However, CWU surgery requires a “second-look” procedure after 1 year to check for recurrent cholesteatoma, which is not be visible due to the intact ear canal wall. Disease surveillance is easier with the CWD technique as the whole mastoid cavity is opened for inspection. The CWU technique is often reported to achieve better postoperative hearing but long-term results between the two techniques are comparable [18]. Large mastoid cavities can be reconstructed or obliterated with either bone or soft tissue such as cartilage or muscle, at the time of surgery, or at a later date, to reduce the size of the cavity and enable a self-cleaning ear [19,20]. There is no single best surgical technique for all cholesteatomas. Surgical planning should be directed by the pattern of disease encountered and the preference of the surgeon for a particular technique. Complications Active COM may lead to complications, which can be classified as being either extra- or intracranial dependent upon their location. The complications are summarized in Table 2. Infection arising in the middle ear may spread into the mastoid portion of the temporal bone causing mastoiditis, which in turn may lead to subperiosteal abscess formation. Rarely, pus in the mastoid cavity may escape out of the mastoid tip infero-medially and track down to form an abscess in the neck musculature known as Bezold’s abscess [21]. The facial nerve courses through the temporal bone and there may be a natural dehiscence in the middle ear. Cholesteatoma may also erode the bony covering of the facial nerve and facial palsy may result from local inflammation and infection. Dehiscent facial nerves are found in nearly 20% of patients operated on for cholesteatoma [22]. The bony labyrinth is also at risk from cholesteatoma. The most common site of erosion is the lateral semi-circular canal, which may manifest as symptoms of imbalance or vertigo. Passage of infective organisms through a fistula into the inner ear may cause labyrinthitis, manifesting as acute vertigo, and potentially complete sensorineural hearing loss, termed a “dead ear”. Infection at the apex of the temporal bone has the potential to affect the fifth and sixth cranial nerves. Gradenigo’s Table 2. Summary of COM complications. Extracranial Intracranial Mastoiditis ± subperiosteal abscess Facial nerve palsy Labyrinthine fistula Chronic otitis externa Bezold’s abscess Gradenigo’s syndrome
Meningitis Extradural abscess Subdural abscess Brain abscess (temporal lobe or cerebellum) Sigmoid sinus thrombosis Otitic hydrocephalus
syndrome comprises ipsilateral retro-orbital pain, abducens nerve palsy (unable to abduct the eyeball) and otorrhoea [23]. A chronically discharging middle ear can, in turn, cause inflammation of the ear canal skin termed otitis externa. If left untreated this can lead to edema and narrowing of the ear canal, which may be itchy and painful. Intracranial complications may occur secondary to COM due to transmission of infection by a number of possible routes. Cholesteatoma may erode the skull base directly and lead to extradural or subdural abscess formation. Meningitis occurs by hematogenous spread to the meninges and infection can pass through emissary veins into the brain causing intracerebral (temporal lobe) or cerebellar abscesses. Infection may spread to the sigmoid sinus via local venous channels and result in sigmoid sinus thrombosis. Septic emboli may propagate from the sinus resulting in distant spread of infection and sepsis. Inflammation of the ventricles is a rare but important intracranial complication of COM. Cerebrospinal fluid outflow may be impeded leading to raised intracranial pressure and this is known as otitic hydrocephalus. On the whole complications of COM are relatively uncommon. One study looked at 2890 patients with COM over a 9-year period and found that 3.2% developed either extra- or intra-cranial complications [24]. The annual risk of an adult developing an intracranial abscess has been calculated to be about 1 in 10000 [25]. All intracranial complications are very serious and have an associated mortality of up to 16%, although this has reduced as antibiotic treatments have improved [24-27]. A high index of suspicion is necessary when seeing patients with COM who present with symptoms of headache, fevers or any new neurological signs. Diagnosis is made either by CT or MRI and the patient should be commenced on broadspectrum IV antibiotics immediately. A full neurological assessment should be made and a neurosurgical opinion sought. Extradural abscesses can be drained via a mastoidectomy approach but subdural and brain abscesses are managed by neurosurgeons. Addressing the underlying cause of the COM (e.g. cholesteatoma) can usually be deferred until after the patient’s neurological condition has stabilized. Thankfully, since the introduction of more effective antibiotics and advances in surgical techniques, the associated morbidity and mortality from COM complications has improved. It is important to remember that surgery for COM, in particular cholesteatoma surgery, carries a small but significant risk of complications too. Facial nerve palsy and dead ear are recognized complications of mastoid surgery with an incidence of ~ 1% and 2%, respectively [28].
Summary COM is a common disease process that can be classified into squamous or mucosal type and can be active or inactive. There is a significant morbidity attached to COM and complications, whilst thankfully rare, can be disabling and potentially fatal. A variety of medical and surgical treatments exist and each patient should be considered individually and managed according their needs.
DOI: 10.1080/00325481.2015.1027133
Declaration of interest The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
References [1] Browning G, Gatehouse S. The prevalence of middle ear disease in the adult British population. Clin Otolaryngol Allied Sci 1992;17: 317–21. [2] Wiet RJ. Patterns of ear disease in the southwestern American Indian. Arch Otolaryngol 1979;105:381–5. [3] Miller ML. Epidemiology of otitis media: problem and research focus for geographers. Soc Sci Med 1979;13D:233–6. [4] Fliss DM, Shoham I, Leiberman A, Dagan R. Chronic suppurative otitis media without cholesteatoma in children in southern Israel: incidence and risk factors. Pediatr Infect Dis J 1991;10:895–9. [5] Kay DJ, Nelson M, Rosenfeld RM. Meta-analysis of tympanostomy tube sequelae. Otolaryngol Head Neck Surg 2001;124:374–80. [6] Ricciardiello F, Cavaliere M, Mesolella M, Iengo M. Notes on microbiology of cholesteatoma: clinical findings and treatment. Acta Otorhinolaryngol Ital 2009;29:197–202. [7] Prakash R, Juyal D, Negi V, Pal S, Adekhandi S, Sharma M, Sharma N. Microbiology of chronic supporative otitis media in a tertiary care setup of Uttarakhand State, India. N Am J Med Sci 2013;5:282–7. [8] Kaya E, Dag I, Incesulu A, Gurbuz MK, Acar M, Birdane L. Investigation of the presence of biofilms in chronic supporative otitis media, nonsupporative otitis media, and chronic otitis media with cholesteatoma by scanning electron microscopy. ScientificWorldJournal 2013;2013:638715. [9] Glasscock ME, Dickins JR, Wiet R. Cholesteatoma in children. Laryngoscope 1981;91:1743–53. [10] Mohammadi G, Naderpour M, Mousaviagdas M. Ossicular erosion in patients requiring surgery for cholesteatoma. Iran J Otorhinolaryngol 2012;24:125–8. [11] Kotecha B, Fowler S, Topham J. Mryingoplasty: a prospective audit study. Clin Otolaryngol Allied Sci 1999;24:126–9. [12] Lee P, Kelly G, Mills RP. Myringoplasty: does the size of the perforation matter? Clin Otolaryngol Allied Sci 2002;27:331–4.
Chronic otitis media
395
[13] Mills RP. The influence of pathological and technical variables on hearing results in ossiculoplasty. Clin Otolaryngol Allied Sci 1993;18:202–5. [14] Macfadyen CA, Acuin JM, Gamble CL. Systemic antibiotics versus topical treatments for chronically discharging ears with eardrum perforations. Cochrane Database Syst Rev 2006:CD005608. [15] Miro N. Controlled multicentre study on chronic supporative otitis media treated with topical applications of ciprofloxacin 0.2% solution in single-dose containers or combination of polymyxin B, neomycin, and hydrocortisone suspension. Otolaryngol Head Neck Surg 2000;123:617–23. [16] Phillips JS, Yung MW, Burton MJ, Swan IR. Evidence review and ENT-UK consensus report for the use of aminoglycosidecontaining ear drops in the presence of an open middle ear. Clin Otolaryngol Allied Sci 2007;32:330–6. [17] Nankivell PC, Pothier DD. Surgery for tympanic membrane retraction pockets. Cochrane Database Syst Rev 2010:CD007943. [18] Karmarkar S, Bhatia S, Saleh E, DeDonato G, Taibah A, Russo A, Sanna M. Cholesteatoma surgery: the individualized technique. Ann Otol Rhinol Laryngol 1995;104:591–5. [19] Kurien G, Greeff K, Gomaa N, Ho A. Mastoid obliteration with autologous bone graft a quality of life study. J Otolaryngol Head Neck Surg 2013;42:49. [20] Birzgalis AR, Farrington WT, O’Keefe L. Reconstruction of discharging mastoid cavities using the temporalis myofascial flap. Clin Otolaryngol Allied Sci 1994;19:70–2. [21] Gaffney RJ, O’Dwyer TP, Maguire AJ. Bezold’s abscess. J Laryngol Otol 1991;105:765–6. [22] Moody MW, Lambert PR. Incidence of dehiscence of the facial nerve in 416 cases of cholesteatoma. Otol Neurotol 2007;28:400–4. [23] Motamed M, Kalan A. Gradenigo’s syndrome. Postgrad Med J 2000;76:559–60. [24] Osma U, Cureoglu S, Hosoglu S. The complications of chronic otitis media: report of 93 cases. J Laryngol Otol 2000;114:97–100. [25] Nunez DA, Browning GG. Risks of developing an otogenic intracranial abscess. J Laryngol Otol 1990;104:468–72. [26] Kangsanarak J, Fooanant S, Ruckphaopunt K, Navacharoen N, Teotrakul S. Extracranial complications of supporative otitis media. Report of 102 cases. J Laryngol Otol 1993;107:999–1004. [27] Yorgancilar E, Yildirim M, Gun R, Bakir S, Tekin R, Gocmez C, Meric F, et al. Complications of chronic supporative otitis media: a retrospective review. Eur Arch Otorhinolaryngol 2013;270:69–76. [28] Harkness P, Brown P, Fowler S, Grant H, Ryan R, Topham J. Mastoidectomy audit: results of the Royal College of surgeons of England comparative audit of ENT surgery. Clin Otolaryngol Allied Sci 1995;20:89–94.
