Chronic Suppurative Otitis Media (CSOM) by Devi Nadilah

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Chronic Suppurative Otitis
Media
DEVI NADILAH
R. YUSA HERWANTO

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Background
Otitis media is any inflammation of part or all of the mucosa of the middle ear, eustachian tube, mastoid
antrum, and mastoid cells. Otitis media is divided into acute otitis media (AOM), otitis media with effusion
(OME: glue ear) and chronic suppurative otitis media (CSOM)
One type of otitis media that causes hearing loss and chronic is chronic suppurative otitis media
• Hearing loss. Hearing loss in children  impaired language development, cognitive function, psychosocial,
and education. Based on Riskesdas (2013), it was found that 2.6% experienced hearing loss for more than
5 years due to CSOM
• CSOM can cause intratemporal and intracranial complications
• Decreased quality of life
Based on WHO, the prevalence of CSOM in the world is around 65-330 million suffer from this disease and
60% of whom (39-200 million) suffer from significant hearing loss. CSOM accounts for 28,000 deaths and
over 2 million sufferers became disabled. The CSOM prevalence at all ages was 5,4% in Indonesia

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DEFINITION
Chronic suppurative otitis media
supuratif kronis is known as
perforated otitis media. Chronic
suppurative otitis media (CSOM) is
inflammation of the middle ear with
permanent perforation of the
tympanic membrane with
intermittent/persistent discharge
(otorrhoea) watery/thick/clear/pus
for more than 12 weeks.

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EPIDEMIOLOGY
• The prevalence of CSOM in the world is around 65-330 million
suffer from this disease
• More than 90% occur in countries in the Southeast Asia and West
Pacific region, Africa, and some ethnic minorities in the Pacific Rim.
CSOM is rare in the Middle East, America, Europe,and Australia.
• The CSOM prevalence at all ages was 5,4% in Indonesia.
• CSOM often occurs in children, especially young children.
• Based on research conducted at Sanglah Hospital Denpasar in
2019, Dr. Hospital. Hasan Sadikin Bandung in 2011 and research in
Yemen in 2015, it was found that the incidence of CSOM tends to
occur in men.

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ETIOLOGY
Aerobic bacteria in CSOM :
- Pseudomonas aeruginosa
- Staphylococcus aureus
- Proteus spp.
- Klebsiella spp.
- Escherichia spp.
- Haemophilus influenza.
Anaerobic bacteria in CSOM:
-Bacteroides spp.
-Fusobacterium spp.
Fungi also play a role in CSOM, especially Aspergilluss
spp., and Candida spp.

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RISK Factors
• AOM  CSOM due to delay in therapy, inadequate therapy, high
bacterial virulence, immunocompromise, poor hygiene, and
malnutrition.
•Chronic otitis media with effusion The occurrence of
degeneration of fibrous tissue on the tympanic membrane and
softening of the tympanic membrane occurs.  susceptible to
membrane perforation
•Unsafe sanitation
•Recurrent upper tract infection
•Allergy/ Atopy
•Passive smoker
•Inadequate health care facilities
•Low social income
•Trauma

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PATHOGENESIS
Pathogenic bacteria invade the middle ear mucosa. These bacteria
can enter the middle ear through the ear canal. The inflammatory
reaction results from edema and fibrosis with spontaneous
tympanic membrane perforation and the infection
Bacterial enzyme and inflammation causes
further damage, necrosis, and eventually, bone erosion can cause
some complication of CSOM

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Pathogenesis (Cont.)
Biofilm: colonies of bacteria that grow slowly and are covered by a layer of glycopolysaccharide
called the glycocalyx. Bacterial binding to the host surface forms a biofilm. Biofilms are resistant to
antibiotics and adhere tightly to damaged tissue, are difficult to treat, and recurrent
Cytokines are also involved in the pathogenesis of otitis media. Research showing the role of
cytokines in the pathogenesis of CSOM is very limited. The levels of pro-inflammatory
cytokines such as IL-8, TNF-a, IL-6, IL-1b, and IFN-c were found in the middle ear mucosa of
CSOM patients. This imbalance of proinflammatory cytokine regulation can lead to tissue
damage as well as the transition from AOM to CSOM
The cycle of occurrence is inflammation, ulceration, infection, and continous
formation of granulation  destruction of around the edge of the bone
CSOM complications

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Classification
Benign type of CSOM Malignant type of CSOM
•Benign type of
CSOM=mucosa type/
cholesteatoma type/
tumbotympanic type
• In the benign type of
CSOM, it can find central
perforation and without
cholesteatoma
•Malignant type of CSOM
was known as bone
type/cholesteatoma type/
atticoantral type
•In the early stages of this
type of disease: marginal
and perforation attic
perforation.
•An advanced stage:
abscess / retroauricular
fistula, polyps / granulation
tissue in the ear canal, and
cholesteatoma.

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Cholesteatoma is the abnormal accumulation of
skin, squamous epithelium, within the middle ear
cleft and mastoid air cells. It has the appearance of
a ‘‘sac’’ that communicates with the ear canal.
Cholesteatoma
Cholesteatoma is divided into 2 types :
• Congenital cholesteatoma: formed during embryo,
the tympanic membrane appears intact without
signs of infection. The cholesteatoma is in the form
of a milky white mass without discoloration in the
tympanic cavity/petrosal mastoid
area/cerebellopontine angle.
• Acquired cholesteatoma is divided into primary
acquired cholesteatoma and secondary acquired
cholesteatoma. Primary acquired cholesteatoma
occurs due to tubal dysfunction. Secondary acquired
cholesteatoma occurs due to tympanic membrane
perforation and chronic infection.

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CLASSIFICATION CSOM BASED ON DISCHARGE ACTIVITY
• Active : ear discharge occurs from the perforation hole.
• Inactive : tympanic cavity looks dry

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Clinical
manifestation
Clinical manifestation of benign type of CSOM:
• Otorrhoea with mucoid and intermittent discharge
• Less distinctive smell
• Central type tympanic membrane perforation
• Inflammation found only in the mucosa
Clinical manifestation of malignant type of CSOM:
• Retroauricular abscess or fistula retroauricular
• Presence of polyps or granulation tissue
• Cholesteatoma in the middle ear.
• Otorrhoea with purulent and persistent discharge,
cholesteatoma scent, accompanied by blood spots.
Conductive/ sensorineural hearing loss
Otalgia if the process has been invasive

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Diagnosis
History Taking
● Ask the onset, history of ear infections, current antibiotic
treatment, and surgery
● CSOM mostly comes with complaints of ear producing
secretions (otorrhoea), although dry ears can also be found.
● Other symptoms : Hearing loss, tinnitus, and clogged ears.
However, it is not a symptom that is mandatory for diagnosis.
● In patients who experience vertigo and its association with ear
complaints, further investigation is needed.

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Diagnosis (Cont.)
Physical examination
● Inspection  Pinna and postauricular area. Look for
scars (from surgery or trauma), inflammation of the
skin, swelling, pits, or sinuses around the pinna.
● Palpation  with palpation of the mastoid, pinna,
as well as the parotid and temporomandibular joints.
● Otoscopy Assess the ear canal and tympanic
membrane. Note the presence of polyps/granulation
tissue, the size and location of the tympanic
membrane perforation, edema, inflammation of the
middle ear mucosa, and ear discharge.

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Diagnosis (Cont.)
Workup
● Culture of ear discharge and sensitivity test.
● Assess hearing loss : tuning fork test and audiology (audiometry
and speech discrimination)
● Radiography
Plain radiograph of the mastoid to determine the presence of a
cholesteatoma. Computed tomography (CT) scan is performed if
the intracranial invasion is suspected and to assess the condition
of the mastoid bone and middle ear.

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Conservative treatment
• Aural Toilet
the aural toilet is useful for cleaning discharge by washing the ear using
H2O2 3% for 3-5 days.
• Topical Antibiotics
Topical antibiotics are more effective than oral antibiotics. Topical drugs of
the aminoglycoside group are the first choice, but the quinolones are more
effective than the aminoglycosides and do not have ototoxic side effects.
• Systemic Antibiotics
Systemic antibiotic therapy is required in CSOM patients to reach the
infected tissue. Oral antibiotics that can be given such as ampicillin,
erythromycin, or ampicillin-clavulanic acid, cephalosporins, ciprofloxacin,
and ofloxacin. Amoxicillin/clavulanate is the drug of the first choice in
CSOM patients, while quinolones are the second drug of choice.
Intravenous antibiotics should be used as a last resort in the management
of CSOM patients

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Conservative treatment (cont.)
• Patient education to keep ears dry.
•The source of infection is important to eradicate. For example by
performing adenoidectomy and tonsillectomy.
•In the benign type of CSOM, observations were made for 2
months. If the discharge has dried, but the perforation is still
there, then ideally myringoplasty or tympanoplasty is performed.
This surgery aims to stop the infection permanently, repair the
perforated tympanic membrane, prevent complications or more
severe hearing damage, and improve hearing. Conservative
therapy is only temporary therapy before surgery

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Definitive Treatment
Simple Mastoidectomy
•Indication : Benign type of who do not
improve with conservative therapy.
•Method: clean the pathological tissue in the
mastoid space. In this type of surgery, the
hearing function is not corrected
Radical Mastoidectomy with modification
• Indication: Cholesteatoma type in the attic
area but has not damaged the entire
tympanic cavity.
• Method: clean the entire mastoid cavity and
leave the posterior ear wall
Radical Mastoidectomy
• Indication: malignant type of CSOM with
infection/ extensive cholesteatoma
• Aim : remove pathological tissue and
prevent intracranial complication.
• Method: cleaning the pathological tissue in
the mastoid space and tympanic cavity. The
boundary wall of the middle ear canal-
mastoid cavity is broken down and it
becomes one room. The tympanic
membrane, incus, and malleus are removed
and leave only the stapes. The eustachian
tube is left open or plugged using a graft.
•The disadvantages of this technique are the
patients are prohibited from swimming for
their entire life, must be regularly monitored to
prevent infection, and their hearing is greatly
reduced.

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Definitive
treatment (CONT.)
Myringoplasty (tympanoplasty type I)
• Indication: benign type of CSOM that is quiet with mild
deafness only due to tympanic membrane perforation and
infection has been treated previously.
• Aim: to prevent recurrence of middle ear infection.
• Method: reconstructing the tympanic membrane without
repairing the middle ear. if the bones of the middle ear are
damaged by disease, ossiculoplasty can be performed to
improve hearing.
Tympanoplasty (type II,III,IV,V)
• Indication: benign type of CSOM with more severe damage or
failure with medical therapy.
•This procedure was carried out in 2 stages: the first stage was
the exploration of the tympanic cavity with/without
mastoidectomy to clean the pathological tissue. The second
stage was the reconstruction of the tympanic membrane and
ossicles. This operation is carried out in 2 stages with a distance
of 6 to 12 months.

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Defivinite treatment (CONT.)
Combined Approach Tympanoplasty
• Indication: Benign type of CSOM with
extensive granulation tissue or malignant type
CSOM.
•Aim: to cure and improve hearing without
radical mastoidectomy.
•The technique of action is to clean the
cholesteatoma and granulation tissue in the
tympanic cavity in two ways, namely the ear
canal and the mastoid cavity (posterior
tympanotomy). Maintaining the posterior ear
wall aims to avoid an open cavity. This
surgery is usually performed in two or more
stages, with the second stage primarily to
check for residual or recurrent cholesteatoma.
Aticotomy and aticoantrostomy are surgeries
in which part of the ossicular chain and
tympanic membrane may be preserved or
reconstructed. The drawback of
aticoantrostomy is that the operating field is
narrow, so the risk of facial nerve injury is
higher

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Prognosis
● The prognosis for CSOM is generally good if it is managed adequately and complications
are avoided. Several recurrent cases may be found and require more extensive evaluation
and management
●Recovery from CSOM related hearing loss varies depending on the cause. Conductive
hearing loss can often be partially corrected with surgery.
●Chronic suppurative otitis media is most often followed by acute otitis media. It is
important to diagnose and treat acute otitis media to prevent chronic suppurative otitis
media. Prevention with pneumococcal vaccine also reduces the incidence of AOM which
leads to a reduction in cases with CSOM.
● CSOM mortality occurs as a result intracranial complications.
●Sensorineural hearing loss as a complication of CSOM is still controversial. Several
predisposing factors are associated with sensorineural hearing loss in CSOM such as
diabetes mellitus, duration of illness, frequent discharge, and an increase in the size of the
tympanic membrane perforation.

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Complication
Hearing loss
Intratemporal Intrakranial
Mastoiditis
Petrositis
Subperiosteal abscess
Facialis paralysis
Persistent membrane perforation
Labirinitis
Epidural abscess
Subdural abscess
Meningitis
Brain abscess
Lateralis sinus thrombophlebitis
Otitic Hydrocephalus
Decrease quality of
life

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Conclusion
Chronic suppurative otitis media (CSOM) is inflammation of the middle ear
with permanent tympanic membrane perforation accompanied by
intermittent/persistent discharge (otorrhoea) for more than 12 weeks. The
prevalence of CSOM in the world is around 65-330 million. The prevalence
of CSOM patients at all ages was 5.4% in Indonesia. CSOM often occurs in
children, especially young children. The most common microorganisms that
cause CSOM are Pseudomonas aeruginosa and Staphylococcus aureus.
The occurrence of CSOM is multifactorial. The diagnosis of CSOM is based
on history, physical examination, and workup. Management includes
conservative therapy and surgery. Adequate therapy is useful in preventing
intratemporal and intracranial complications. The prognosis for CSOM is
generally good if managed adequately and complications are avoided.

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