Chronic otitis media

• Otitis media with effusion (glue ear) - OME

• Chronic suppurative otitis media

chronic mucoid or serous effusion in the tympanic cavity in the absence of infection lasting for > 3 months

• Epidemiology: observed particularly in toddlers after an episode of acute OM

• Etiology: incompletely understood, but primarily thought to be due to eustachian tube dysfunction

• Pathophysiology: ETD causes negative middle ear pressure → triggers formation of transudate → dysfunctional eustachian tube prevents adequate drainage → accumulation of fluid

• May be asymptomatic

• Typically painless sensation of pressure in the affected ear

• Conductive hearing loss

• Speech and language impairment

• Best initial test: pneumatic otoscopy to assess the tympanic membrane

  • Intact TM

  • TM is opaque, yellow-colored, may be retracted

  • Air-fluid level behind the TM

  • Impaired mobility of the TM

• If pneumatic otoscopy is inconclusive: impedance tympanometry

• Persistent OME for > 3 months or speech impairment: audiometry

  • Conductive hearing loss of 20–40 d

• Patients without speech impairment at the time of diagnosis: monitor for 3 months

• Patients with speech impairment or persistent OME at follow-up

  • Age < 4 years: placement of tympanostomy tubes

  • Age ≥ 4 years: placement of tympanostomy tubes and/or adenoidectomy

-> Pharmacologic therapy (e.g., oral steroids, antihistamines, nasal decongestants, antibiotics) shows little effect and is not generally recommended!

• Etiology

  • Obstruction secondary to nasopharyngeal carcinoma (rare)

  • Rhinitis, sinusitis, pharyngitis

  • Recurrent otitis media

• Clinical features

  • Sensation of pressure in the affected ear

  • Conductive hearing loss

• Diagnostics

  • Otoscopy for assessment of TM

  • If unilateral OME recurs or persists, perform endoscopy of the nasopharynx to rule out carcinoma

• Treatment

  • Effusion often resolves spontaneously → monitor

  • Treatment of the underlying disease

  • Valsalva maneuver/autoinflation to enable drainage

  • Consider myringotomy with aspiration of the effusion

persistent drainage from the middle ear through a perforated tympanic membrane lasting > 6–12 weeks

• Epidemiology: most common in children and adolescents < 15 years old

• Etiology: bacterial infection following perforation of the tympanic membrane due to

  • (Recurrent) acute otitis media

  • Placement of ventilation tube

  • Trauma

• Pathophysiology: infection secondary to translocation of bacteria of the external ear canal into the middle ear through the perforated tympanic membrane

• Painless, recurrent otorrhea (usually odorless; mucoid or serous )

• Conductive hearing loss → Weber test lateralizes to the affected ear

• Possibly development of concurrent cholesteatoma

• Fever is not typical and indicative of complications if it occurs.

• Diagnostics

  • Clinical diagnosis

  • Otoscopy: visible defect of the tympanic membrane → confirmation of diagnosis

  • Cranial CT or MRI: if complications are suspected (see below)

• Treatment

  • Goal: restore integrity of the tympanic membrane , prevent permanent hearing loss

  • Conservative treatment: aural toilet; topical fluoroquinolone (e.g., ciprofloxacin)

  • Surgical treatment: tympanoplasty with insertion of an autologous graft

• Complications

  • Possibly life-threatening spread of infection (e.g., meningitis, intracranial abscess, facial paralysis); rarely occurs with adequate treatment

  • Tympanosclerosis

    • Scarring of the tympanic membrane due to recurrent ear infections or otitis media with effusion

    • May be asymptomatic or lead to conductive hearing loss

    • White calcified plaques in the tympanic membrane seen on otoscopy

• Prognosis: usually good with adequate treatment; conductive hearing loss can often be improved, but may not be fully recovered