This document discusses the natural history, management, and outcomes of chronic otitis media (COM). It describes inactive mucosal COM, where a permanent tympanic membrane defect exists without active infection or discharge. It can remain inactive, become active, or occasionally heal. Active mucosal COM may remain active, become inactive, or progress to complications with continuing damage to the ossicular chain and inner ear. Management includes aural toilet, topical antibiotics, and surgery such as myringoplasty to repair perforations or ossiculoplasty to reconstruct the ossicular chain. Outcomes of surgery depend on factors like size of perforation and extent of ossicular involvement, but aim to improve hearing while preventing recurrence of

1. Natural history, Management
&outcomes of COM
Inactive mucosal COM
Inactive mucosal COM is the condition of the ear where the structure & often the hearing is
impaired by presence of a permanent TM defect ,but in which there is no active infection or mucus
discharge. Such an ear may remain inactive ,become active or even occasionally heal.
Progression towards healing
The pregression towards healing is presumable impaired by the disease that resulted in COM in the
first place.This is usually recurrent episodes of acute infection with perforation of the Drum,which
initially heals successfully within a few days , but after a variable attacks the TM fails to heal.This is
regarded as a result of failure of the blood supply to the perforation edges due to endarteritis.
Progression towards activity
Progrssion towards activity is more common, provoked by factors such as an URTI or ingress of
water,particularly if contaminated by bacteria or irritants.
Presentation
Inactive COM presents with a hearing impairment. Many patients have more recent episodes of
discharge& this does influence management.
Investigations
PTA :assesses the magnitude of the hearing impairment.The degree of air –bone gap depend on
Size of the perforation,erosion of the ossicular chain& significant granulation tissue.
Management
Management option are surgery,a hearing aid or no treatment.
Objective of surgery;
Dry perforation that are symptom free, do not usually require closure.
If the only option is a hearing impairment, the chances of improving hearing with surgery should be
considered carefully.Not just the hearing in the operated ear but the overall hearing ability of the
patient .
Myringoplasty: Tympanoplasty refers to any operation involving reconstruction of the TM and /or
ossicular chain. Myringoplasty is a tympanoplasty without ossicular reconstraction.

2. The most widely used & accepted method is under lay graft of temporalis fascia or sometimes
perichondium. The basic procedure is to excise the rim of the perforation so that there is a raw
surface from which new tissue will grow.The mucosa on the under surface of the remaining TM
near to the perforation is removed or scraped with a sickle knife. The mucosa over the promontory
should be carefully preserve to reduce the likelihood of postoperative adhsions between the graft &
promontory.
The closer rate is higher in small perforation 74% than large perforation56%. Failure rate in anterior
perforation is higher & can be reduced by anchoring the anterior margin of the graft beneath the
annulus.
Out come of hearing: successful closure of the TM usually gives only a small improvement in
hearing.(8 -10db).
In those patients in whom the air –bone gap is35 db or more , there will be either erosion or fixation
of the ossicular chain. Here surgery would required myringoplasty & ossiculoplasty.
Ossiculoplasty: the most common pathology in the middle ear is ersion of the long process of the
incus, the preferred option is to place a prosthesis between handle of malleus & head of the stapes.
When the stapes superstructure are missing, the malleus handle has to be connected to the stapes
footplate.
Hearing improvement from ossiculoplasty when the malleus & stapes are present is only 14db,
hearing aids should always be considered in management.
Tympanosclerosis & surgery
Tympanosclerosis is found in the middle ear ,the mobility of the ossicular chain is reduced by
Tympanosclerois in the attic or the oval window.
If the ossicular chain is intact & only the incus & the head of the malleus are fixed, this can be
corrected by removing the incus and head of the malleus And reconstructing the ossicular chain
between handle of malleus or TM and stapes.
When stapes is involved, surgery involves mobilization of the stapes or stapectomy. Result of the
stapes surgery in tympanosclerosis are not as good as in otosclerosis.

3. ACTIVE MUCOSAL COM
Active mucosal COM may remain active ,become inactive or progress to complications.Continuing
activity may be the result of infection with a virulent or persistent organism ,commonly
pseudomonas. Nutrition, environment, hygiene play a part in predisposing to COM.
Progression with continuing activity
Continuing activity of COM increasing damage to the ossicular chain& potential to inner ear. The
inflammatory reaction in the middle ear is associated with granulation tissue formation to be most
likely factor for ossicular damage.
Incus long process & stapes super structure where there is abundant osteoclastic activity
&osteoblastic inflenences appear weak.( the same process may play a part in the development of a
sclerotic mastoid in COM where osteoblastic activity predominate).
Hearing in Active mucosal COM
One of the cardinal symptoms of COM is hearing loss & conductive in type although SNHL may
occur.
Loss 30 -40 db HL are common.
If ossiular chain loses continuity loss increasing to 50 to60dbHL.
Presentation
Otorrhoea & Hearing impairment.
The discharge may be continuous or intermittent, mucoid, purulent.
Intermittent otorrhoea , an increase in discharge may follow an URTI or entry of contaminated
water into middle ear.
Unaware of otorrhoea > quantity is insufficient to appear to external auditory canal.>dry up at deep
meatus >crusts > mistake for wax.
Examination; PTA
Bacteriology If complication
Management
Aural toilet : suction also allows accurate assessment of the extent of disease.
Dry mopping before topical medication.
Topical medication:Topical antibiotic more effective than oral or intramuscular.
Surgery: In those cases that do not become inactive on medical treatment ,surgery is required to
heal the ear.

4. Those cases become inactive, should have closure of the perforation to prevent recurrence.
Myringoplasty: though it is preferable to make active ears inactive before surgery, this is not always
possible and surgery should not be postponed
The success of surgery is not influenced by prophylactic antibiotic therapy.
Use of preoperative antibiotic has no influence on graft take or complications rate.
Role of adjuvant cortical mastiodectomy; Many authers suggest cortical mastiodectomy should
carried out at the same time as myringoplasty in active ear. There is no evidence that mastoidectomy
increases the success rate of surgery in these ears.
Aural polyps;
Can be removed by suction.It should be remembered that polyps can be attached to the stapes
superstructure or to the facial nerve, and that damage to these structure can occur.
Cauterization of the polyps with silver nitrate on a stick is also helpful.> care to avoid damage to
the facial nerve.
Removal of the polyps usually causes bleeding in the ear that interferes with surgical access but
this can be reduced by the use of a laser.
Key points ;
1) In many patients with active mucosal COM ,the only symptom is hearing impairment.
2) Initial management is aural toilet with topical antibiotic with steroid.
3) Quinolone are preferable antibiotic to aminoglycosides because of ototoxicity.
4) Definitive management is surgery, at least to close the perforation.
5) There is no evidence that the out come o f surgery is poor in active ears.