6/12/2016

ChronicSuppurativeOtitisMedia:Background,Anatomy,Pathophysiology

ChronicSuppurativeOtitisMedia
Author:PeterSRoland,MDChiefEditor:ArlenDMeyers,MD,MBAmore...
Updated:Mar27,2015

Background
Chronicsuppurativeotitismedia(CSOM)isaperforatedtympanicmembranewith
persistentdrainagefromthemiddleear(ie,lasting>612wk). [1,2]Chronic
suppurationcanoccurwithorwithoutcholesteatoma,andtheclinicalhistoryofboth
conditionscanbeverysimilar.Thetreatmentplanforcholesteatomaalways
includestympanomastoidsurgerywithmedicaltreatmentasanadjunct.
CSOMdiffersfromchronicserousotitismediainthatchronicserousotitismedia
maybedefinedasamiddleeareffusionwithoutperforationthatisreportedto
persistformorethan13months.ThechronicallydrainingearinCSOMcanbe
difficulttotreat. [3]McKenzieandBrothwelldemonstratedevidenceofchronic
suppurativeotitisinaskullfoundinNorfolk,UnitedKingdom,whichisthoughttobe
fromtheAngloSaxonperiod. [4]Radiologicchangesinthemastoidcausedby
previousinfectionhavebeenseeninanumberofspecimens,including417
temporalbonesfromSouthDakotaIndianburialsand15prehistoricIranian
temporalbones. [5,6]

Anatomy
Themiddleearcleftcanbethoughtofasa6sidedcube.Itslateralboundary,the
tympanicmembrane,separatesitfromtheouterear.Itsmedialboundaryisformed
bythepromontory,whichdenotesthebasalturnofthecochlea.Anteriorly,itis
relatedtothetendonoftensortympanisuperiorlyandtheopeningoftheeustachian
tubeinferiorly.Posteriorly,itisrelatedsuperiorlytotheaditus,whichconnectsthe
middleearcavitywiththemastoidantrum,andinferiorlytothefacialridge.Theroof
ofthemiddleearcavityisformedbythetegmentympani,andthefloorofthe
middleearcavityliesincloserelationtothejugularforamen.(Seetheimagebelow
displayinganatomyoftheear).

Anatomyoftheexternalandmiddleear.

Theanteriorandposteriormalleolarfolds,whichoriginateatthelevelofthelateral
processofthemalleus,formtheboundarybetweentheepitympanumand
mesotympanum,whichlieaboveandbelowit,respectively.Atticoantraldisease
predominantlyaffectstheparsflaccida,andtubotympanicdiseaseaffectsthepars
tensa.
Themiddleearcavityalsoconsistsoftheossicularchain(malleus,incus,and
stapes).Theossicularchainconnectsthetympanicmembrane,inwhichthehandle
ofthemalleusisembedded,totheovalwindow,onwhichsitsthefootplateofthe
stapes.Inatticoantraldisease,theossicularchainisfrequentlyaffectedby
cholesteatoma,therebycausinghearingloss.Removalofthemalleusandorincus
maybenecessaryiftheyareextensivelyinvolvedbycholesteatoma.Inthesecases,
aplannedsecondstagereconstructionisoftenappropriate.

Pathophysiology
CSOMisinitiatedbyanepisodeofacuteinfection.ThepathophysiologyofCSOM
beginswithirritationandsubsequentinflammationofthemiddleearmucosa.The
inflammatoryresponsecreatesmucosaledema.Ongoinginflammationeventually
leadstomucosalulcerationandconsequentbreakdownoftheepitheliallining.The
host'sattemptatresolvingtheinfectionorinflammatoryinsultmanifestsas
granulationtissue,whichcandevelopintopolypswithinthemiddleearspace.The
cycleofinflammation,ulceration,infection,andgranulationtissueformationmay
continue,eventuallydestroyingthesurroundingbonymarginsandultimatelyleading
tothevariouscomplicationsofCSOM. [7,8]

Commonbacteria
Pseudomonasaeruginosa,Staphylococcusaureus,Proteusspecies,Klebsiella

http://emedicine.medscape.com/article/859501overview

1/4

6/12/2016

ChronicSuppurativeOtitisMedia:Background,Anatomy,Pathophysiology

pneumoniae,anddiphtheroidsarethemostcommonbacteriaculturedfrom
chronicallydrainingears.Anaerobesandfungimaygrowconcurrentlywiththe
aerobesinasymbioticrelationship.Theclinicalsignificanceofthisrelationship,
althoughunproven,istheorizedtobeanincreasedvirulenceoftheinfection.
Understandingthemicrobiologyofthisdiseaseenablesthecliniciantocreatea
treatmentplanwiththegreatestefficacyandleastmorbidity.
Paeruginosaisthemostcommonlyrecoveredorganismfromthechronically
drainingear.Variousresearchersoverthepastfewdecadeshaverecovered
pseudomonadsfrom4898%ofpatientswithCSOM.
Paeruginosausespilitoattachtonecroticordiseasedepitheliumofthemiddle
ear.Onceattached,theorganismproducesproteases,lipopolysaccharide,andother
enzymestopreventnormalimmunologicdefensemechanismsfromfightingthe
infection.Theensuingdamagefrombacterialandinflammatoryenzymescreates
furtherdamage,necrosis,and,eventually,boneerosionleadingtosomeofthe
complicationsofCSOM.Fortunately,intheimmunocompetentindividual,the
infectionrarelycausesseriouscomplicationsordisseminateddisease.Pseudomonal
infectionscommonlyresistmacrolides,extendedspectrumpenicillins,andfirstand
secondgenerationcephalosporins.Thiscancomplicatetreatmentplans,especially
inchildren.
Saureusisthesecondmostcommonorganismisolatedfromchronicallydiseased
middleears.Reporteddataestimateinfectionratesfrom1530%ofculturepositive
drainingears.Theremainderofinfectionsarecausedbyalargevarietyofgram
negativeorganisms.Klebsiella(1021%)andProteus(1015%)speciesareslightly
morecommonthanothergramnegativeorganisms.
Polymicrobialinfectionsareseenin510%ofcases,oftendemonstratinga
combinationofgramnegativeorganismsandSaureus.Theanaerobes
(Bacteroides,Peptostreptococcus,Peptococcus)andfungi(Aspergillus,Candida)
completethespectrumofcolonizingorganismsresponsibleforthisdisease.The
anaerobesmakeup2050%oftheisolatesinCSOMandtendtobeassociatedwith
cholesteatoma.Fungihavebeenreportedinupto25%ofcases,buttheir
pathogeniccontributiontothisdiseaseisunclear.

Etiology
ThediagnosisofCSOMrequiresaperforatedtympanicmembrane.These
perforationsmayarisetraumatically,iatrogenicallywithtubeplacement,orafteran
episodeofacuteotitismedia,whichdecompressesthroughatympanicperforation.
[3,9,10,11]

Themechanismofinfectionofthemiddleearcleftispostulatedtobetranslocation
ofbacteriafromtheexternalauditorycanalthroughaperforationintothemiddle
ear.Someauthorssuggestthatthepathogenicorganismsmayenterthroughreflux
oftheeustachiantube.Thedatasupportingthistheoryareinconclusive.Mostof
thepathogenicbacteriaarethosecommontotheexternalauditorycanal.
Theriskofdevelopingotorrhea(butnotnecessarilyCSOM)throughaventilation
tubeisreportedly2150%.Annually,morethanamilliontubesareplacedinthe
UnitedStatesforrecurrentotitismediaandotitismediawitheffusion.Studieshave
reportedthat13%ofpatientswithventilationtubesdevelopthisdisease.
TheriskofdevelopingCSOMincreaseswiththefollowingcircumstances[12]:
Ahistoryofmultipleepisodesofacuteotitismedia
Livingincrowdedconditions
Daycarefacilityattendance
Beingamemberofalargefamily
Studiestryingtocorrelatethefrequencyofthediseasewithparentaleducation,
passivesmoke,breastfeeding,socioeconomicstatus,andtheannualnumberof
upperrespiratorytractinfectionsareinconclusive.
PatientswithcraniofacialanomaliesarespecialpopulationsatriskforCSOM.Cleft
palate,Downsyndrome,criduchatsyndrome,choanalatresia,DiGeorge
syndrome,cleftlip,andmicrocephalyareotherdiagnosesthatincreasetheriskof
CSOM,presumablyfromalteredeustachiantubeanatomyandfunction.

Epidemiology
Thelargerthetympanicmembraneperforation,themorelikelythepatientisto
developCSOM.SomestudiesestimatetheyearlyincidenceofCSOMtobe39
casesper100,000personsinchildrenandadolescentsaged15yearsandyounger.
InBritain,0.9%ofchildrenand0.5%ofadultshaveCSOM.InIsrael,only0.039%
ofchildrenareaffected. [13]
CertainpopulationsubsetsareatincreasedriskfordevelopingCSOM.TheNative
AmericanandEskimopopulationsdemonstrateanincreasedriskofinfection.Eight
percentofNativeAmericansandupto12%ofEskimosareaffectedbyCSOM.The
anatomyandfunctionoftheeustachiantubeplayasignificantroleinthisincreased
risk.Theeustachiantubeiswiderandmoreopeninthesepopulationsthanin
others,thusplacingthematincreasedriskfornasalrefluxofbacteriacommonto
acuteotitismediaandrecurrentacuteotitismediaandleadingtomorefrequent
developmentofCSOM.
OtherpopulationsatincreasedriskincludechildrenfromGuam,HongKong,South
Africa,andtheSolomonIslands.TheprevalenceofCSOMappearstobe
distributedequallybetweenmalesandfemales.Exactprevalenceindifferentage
groupsisunknownhowever,somestudiesestimatetheyearlyincidenceofCSOM
tobe39casesper100,000inchildrenandadolescentsaged15yearsandyounger.
[12]

Prognosis
http://emedicine.medscape.com/article/859501overview

2/4

6/12/2016

ChronicSuppurativeOtitisMedia:Background,Anatomy,Pathophysiology

PatientswithCSOMhaveagoodprognosiswithrespecttocontrolofinfection.The
recoveryofassociatedhearinglossvariesdependingonthecause.Conductive
hearinglosscanoftenbepartiallycorrectedwithsurgery.Thegoaloftreatmentisto
providethepatientasafeear.
MuchofthemorbidityofCSOMcomesfromtheassociatedconductivehearingloss
andthesocialstigmaofanoftenfetidfluiddrainingfromtheaffectedear.The
mortalityofCSOMarisesfromassociatedintracranialcomplications.CSOMitselfis
notafataldisease.Althoughsomestudiesreportsensorineuralhearinglossasa
morbidcomplicationofCSOM,otherevidenceconflictswiththisclaim.
AstudybyJensenetaloftwogroupsofchildreninGreenlandfoundthatamong
thosechildrenwithCSOM,91%sufferedpermanenthearinglossofgreaterthan15
dBHL(decibelhearinglevel).Thegroupswerefollowedupfor10and15years. [14]
AstudybyAarhusetalofhearinglossinvarioustypesofotitismediafoundthat
childhoodhearinglossfromCSOMisassociatedwithadulthearingloss,withthe
effectonhearingthresholdsbeinggreaterinmiddleage(age4056years)thanin
youngadulthood(age2040years).Thesameheldtrueforrecurrentacuteotitis
media. [15]
ClinicalPresentation

ContributorInformationandDisclosures
Author
PeterSRoland,MDProfessor,DepartmentofNeurologicalSurgery,ProfessorandChairman,Departmentof
OtolaryngologyHeadandNeckSurgery,Director,ClinicalCenterforAuditory,Vestibular,andFacialNerve
Disorders,ChiefofPediatricOtology,UniversityofTexasSouthwesternMedicalCenterChiefofPediatric
Otology,ChildrensMedicalCenterofDallasPresidentofMedicalStaff,ParklandMemorialHospitalAdjunct
ProfessorofCommunicativeDisorders,SchoolofBehavioralandBrainSciences,ChiefofMedicalService,
CallierCenterforCommunicativeDisorders,UniversityofTexasSchoolofHumanDevelopment
PeterSRoland,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanAuditory
Society,TheTriologicalSociety,NorthAmericanSkullBaseSociety,SocietyofUniversityOtolaryngologists
HeadandNeckSurgeons,AmericanNeurotologySociety,AmericanAcademyofOtolaryngicAllergy,American
AcademyofOtolaryngologyHeadandNeckSurgery,AmericanOtologicalSociety
Disclosure:ReceivedhonorariafromAlconLabsforconsultingReceivedhonorariafromAdvancedBionicsfor
boardmembershipReceivedhonorariafromCochlearCorpforboardmembershipReceivedtravelgrantsfrom
MedElCorpforconsulting.
Coauthor(s)
BrandonIsaacson,MD,FACSAssociateProfessor,DepartmentofOtolaryngologyHeadandNeckSurgery,
UniversityofTexasSouthwesternMedicalCenter
BrandonIsaacson,MD,FACSisamemberofthefollowingmedicalsocieties:AmericanAcademyof
OtolaryngologyHeadandNeckSurgery,AmericanCollegeofSurgeons,NorthAmericanSkullBaseSociety,
TexasMedicalAssociation,TriologicalSociety,AmericanNeurotologySociety
Disclosure:ReceivedconsultingfeefromMedtronicMidasRexInsituteforconsultingReceivedmedicaladvisory
boardfromAdvancedBionicsforboardmembershipReceivedconsultingfeefromStrykerforspeakingand
teaching.
ChiefEditor
ArlenDMeyers,MD,MBAProfessorofOtolaryngology,Dentistry,andEngineering,UniversityofColorado
SchoolofMedicine
ArlenDMeyers,MD,MBAisamemberofthefollowingmedicalsocieties:AmericanAcademyofFacialPlastic
andReconstructiveSurgery,AmericanAcademyofOtolaryngologyHeadandNeckSurgery,AmericanHeadand
NeckSociety
Disclosure:Serve(d)asadirector,officer,partner,employee,advisor,consultantortrusteefor:
MedvoyTestappropriateCerescanEmpiricanRxRevu<br/>ReceivednonefromAllergySolutions,Incforboard
membershipReceivedhonorariafromRxRevuforchiefmedicaleditorReceivedsalaryfromMedvoyforfounder
andpresidentReceivedconsultingfeefromCorvectraforseniormedicaladvisorReceivedownershipinterest
fromCerescanforconsultingReceivedconsultingfeefromEssiahealthforadvisorReceivedconsultingfeefrom
CarespanforadvisorReceivedconsultingfeefromCovidienforconsulting.
Acknowledgements
AnuragJain,MBBS,FRCS(Ire),MS,FRCS(Oto),MS(Oto),DLO(RCSEngland)SpecialistRegistrar,
DepartmentofOtolaryngology,PinderfieldsGeneralHospital,Wakefield,UK
AnuragJain,MBBS,FRCS(Ire),MS,FRCS(Oto),MS(Oto),DLO(RCSEngland)isamemberofthefollowing
medicalsocieties:AssociationofOtolaryngologistsofIndia,BritishAssociationofOtorhinolaryngologists,Head
andNeckSurgeons,BritishMedicalAssociation,RoyalCollegeofSurgeonsinIreland,andRoyalCollegeof
SurgeonsofEngland
Disclosure:Nothingtodisclose.
JeffreyRobertKnight,MBChB,FRCSConsultingSurgeon,DepartmentofOtolaryngology,MaydayUniversity
Hospital,London
Disclosure:Nothingtodisclose.
JohnCLi,MDPrivatePracticeinOtologyandNeurotologyMedicalDirector,BalanceCenter
JohnCLi,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOtolaryngologyHeadand
NeckSurgery,AmericanCollegeofSurgeons,AmericanMedicalAssociation,AmericanNeurotologySociety,
AmericanTinnitusAssociation,FloridaMedicalAssociation,andNorthAmericanSkullBaseSociety
Disclosure:Nothingtodisclose.
DavidParry,MDStaffPhysician,DepartmentofOtolaryngologyHeadandNeckSurgery,ENTAssociatesof
Children'sHospital,Boston
Disclosure:Nothingtodisclose.

http://emedicine.medscape.com/article/859501overview

3/4

6/12/2016

ChronicSuppurativeOtitisMedia:Background,Anatomy,Pathophysiology

FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeReferenceSalaryEmployment
PeterAWeisskopf,MDNeurotologist,ArizonaOtolaryngologyConsultantsHead,SectionofNeurotology,
BarrowNeurologicalInstitute
PeterAWeisskopf,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOtolaryngology
HeadandNeckSurgeryandAmericanCollegeofSurgeons
Disclosure:Nothingtodisclose.

References
1.MatsudaY,KuritaT,UedaY,ItoS,NakashimaT.Effectoftympanicmembraneperforationonmiddleear
soundtransmission.JLaryngolOtol.2009May.123Suppl31:819.[Medline].
2.WrightD,SafranekS.Treatmentofotitismediawithperforatedtympanicmembrane.AmFamPhysician.
2009Apr15.79(8):650,654.[Medline].
3.VikramBK,KhajaN,UdayashankarSG,VenkateshaBK,ManjunathD.Clinicoepidemiologicalstudyof
complicatedanduncomplicatedchronicsuppurativeotitismedia.JLaryngolOtol.2008May.122(5):4426.
[Medline].
4.McKenzieW,BrothwellD.DiseaseintheEar.DiseaseinAntiquity.1967.46473.
5.GreggJB,SteeleJP,HolzhueterA.RoentgenographicevaluationoftemporalbonesfromSouthDakota
Indianburials.AmericanJournalofPhysicalAnthropology.1965.23:5162.
6.RathbunTA,MallinR.MiddleeardiseaseinaprehistoricIranianpopulation.BullNYAcadMed.1977
Dec.53(10):9015.[Medline].[FullText].
7.MeyerhoffWL,KimCS,PaparellaMM.Pathologyofchronicotitismedia.AnnOtolRhinolLaryngol.1978
NovDec.87(6Pt1):74960.[Medline].
8.KennaMA.MicrobiologyofChronicSuppurativeOtitisMedia.AnnOtolRhinolLaryngol.1988.97(suppl
131):910.
9.KennaMA.EtiologyandPathogenesisofChronicSuppurativeOtitisMedia.AnnOtolRhinolLaryngol.
1988.97(Suppl131):1617.
10.MatsudaY,KuritaT,UedaY,ItoS,NakashimaT.Effectoftympanicmembraneperforationonmiddleear
soundtransmission.JLaryngolOtol.2009May.123Suppl31:819.[Medline].
11.WrightD,SafranekS.Treatmentofotitismediawithperforatedtympanicmembrane.AmFamPhysician.
2009Apr15.79(8):650,654.[Medline].
12.vanderVeenEL,SchilderAG,vanHeerbeekN,etal.Predictorsofchronicsuppurativeotitismediain
children.ArchOtolaryngolHeadNeckSurg.2006Oct.132(10):11158.[Medline].
13.VikramBK,KhajaN,UdayashankarSG,VenkateshaBK,ManjunathD.Clinicoepidemiologicalstudyof
complicatedanduncomplicatedchronicsuppurativeotitismedia.JLaryngolOtol.2008May.122(5):4426.
[Medline].
14.JensenRG,KochA,HomoeP.Theriskofhearinglossinapopulationwithahighprevalenceofchronic
suppurativeotitismedia.IntJPediatrOtorhinolaryngol.2013Sep.77(9):15305.[Medline].
15.AarhusL,TambsK,KvestadE,etal.ChildhoodOtitisMedia:ACohortStudyWith30YearFollowUpof
Hearing(TheHUNTStudy).EarHear.2014Nov14.[Medline].
16.SmithJA,DannerCJ.Complicationsofchronicotitismediaandcholesteatoma.OtolaryngolClinNorth
Am.2006Dec.39(6):123755.[Medline].
17.NeilanRE,IsaacsonB,KutzJWJr,LeeKH,RolandPS.Pediatricotogeniclateralsinusthrombosis
recanalization.IntJPediatrOtorhinolaryngol.2011Jun.75(6):8503.[Medline].
18.IsaacsonB,MirabalC,KutzJWJr,LeeKH,RolandPS.Pediatricotogenicintracranialabscesses.
OtolaryngolHeadNeckSurg.2010Mar.142(3):4347.[Medline].
19.DoharJE.OldandNewOtotopicalAgentsfortheAcuteandChronicDrainingEar.SeminarsinOtitis
MediaManagement.1.1998.114.
20.DoharJE,AlperCM,RoseEA,DoyleWJ,CasselbrantML,KennaMA.Treatmentofchronicsuppurative
otitismediawithtopicalciprofloxacin.AnnOtolRhinolLaryngol.1998Oct.107(10Pt1):86571.[Medline].
21.DoharJE,KennaMA,WadowskyRM.TherapeuticimplicationsinthetreatmentofauralPseudomonas
infectionsbasedoninvitrosusceptibilitypatterns.ArchOtolaryngolHeadNeckSurg.1995Sep.
121(9):10225.[Medline].
22.RolandPS,DoharJE,LanierBJ,HekkenburgR,LaneEM,ConroyPJ.Topical
ciprofloxacin/dexamethasoneoticsuspensionissuperiortoofloxacinoticsolutioninthetreatmentof
granulationtissueinchildrenwithacuteotitismediawithotorrheathroughtympanostomytubes.
OtolaryngolHeadNeckSurg.2004Jun.130(6):73641.[Medline].
23.ConsensusPanel,HannleyMT,DennennyIIIJC.UseofOtotopicalAntibioticsinTreating3CommonEar
Diseases.OtolHeadNeckSurg.2000.93440.
24.SomekhE,CordovaZ.Ceftazidimeversusaztreonaminthetreatmentofpseudomonalchronicsuppurative
otitismediainchildren.ScandJInfectDis.2000.32(2):1979.[Medline].
25.BegueP,GarabedianEN,BertrandC,AubertB,ChicheD.Penetrationofceftazidimeintomiddleearfluid
inchildrenwithotitismediawitheffusion.Laryngoscope.1998May.108(5):6624.
MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/859501overview

4/4