CHRONIC SUPURATIVE OTITIS MEDIA

Middle Ear Anatomy

The middle ear is an air-filled chamber imagined as a six-sided box, with the posterior
wall wider than the anterior wall to form a wedge-like box.

Figure 1 Anatomy of the boundaries of the middle ear

Its lateral border, the tympanic membrane, separates it from the outer
ear. The medial boundaries from top to bottom are the horizontal
cermiscircular canal, the facial canal, the oval window, the round window,
and the promontory. The anterior border is connected with the eustachian
tube. Posterior boundary with aditus ad antrum and facial canal pars
verticalis. The superior border or roof of the middle ear cavity is formed by
the tegmen tympani, and the inferior border or floor of the middle ear cavity
is adjacent to the jugular foramen.

There are several buildings that also make up the middle ear:

1. Tympanic membrane
The main and largest part of the tympanic membrane is the pars
tensa, while the upper part of the tympanic membrane is the pars flaccida
(Shrapnell's membrane) which is attached directly to the processus
lateralis malleus area between the two end areas of the tympanic notch of
Rivinus, to the annular area.
 rim so as to form a small triangle which is covered by a thin and loose
membrane.

Figure 2 Tympanic membrane

The medial part of the pars flaccida to the medial part of the neck
malleus is called the Prussak space, where this room is the main place for
cholesteatoma extension.
2. Hearing bones
In the middle ear area there are 3 ossicles which function as
conductors for the transmission of sound energy by means of a
vibrational process and amplify the sound energy during the process in
the middle ear before continuing to the inner ear through the foramen
ovale.

The ossicles are: 5

1. Malleus
2. Incus
3. Stapes
Figure 3 Bones of Hearing
 3. Tympanic cavity
Is a room in the middle ear that is located in the temporal bone,
irregularly shaped and filled with air, which originates from the
nasopharyngeal space through the Eustachian tube to then go to the
nasopharynx and in its posterior part will be connected with the air cell
system of the mastoid cavity and the petrous part of the temporal bone .
On the lateral side it will abut the tympanic membrane.

Figure 4 Kavum Tympani

The tympanic cavity based on its topography is divided into 3 chambers: 5
1) Epitympanum (atici): at the upper boundary of the tympanic
membrane
2) Mesotympanum: between the tympanic membrane and promontory
3) Hypotympanum: below the lower border of the tympanic membrane.

B. Definition of CSOM

Chronic suppurative otitis media (CSOM) is defined as a perforated

tympanic membrane with persistent drainage from the middle ear for more
than 2-6 weeks. Chronic suppuration may occur with or without
cholesteatoma, and the clinical history of the two conditions can be very
similar. CSOM differs from chronic serous otitis media because chronic
serous otitis media can be defined as a middle ear effusion without
perforation that is reported to last for more than 1-3 months.
C. Epidemiology
Globally, the average CSOM incidence is estimated at 4.76% and
22% occurs in children under 5 years. The prevalence of CSOM varies
between countries but is higher in low to middle income countries. 2 In
Indonesia the prevalence of CSOM is 5.4%. In addition, research on school-
age children in Indonesia shows that 2.7% of children experience CSOM in
rural areas, while in urban areas 0.7% experience CSOM. This prevalence is
relatively high with most cases in rural areas

D. Etiology
The type of bacteria that is active in CSOM disease, most studies
show Pseudomonas aeruginosa bacteria, with a prevalence rate of 40% -65%,
then Staphylococcus aerius, with a prevalence rate of 10% - 20%. Other
microorganisms such as Proteus spp, Klebsiella spp, Bacteroides spp. and
Fusobacterium spp can also cause CSOM. Rarer are Aspergillus spp and
Candida spp which are more frequently found in immunocompromised
patients. Tuberculosis may also cause CSOM which is more common in
areas with a high incidence of tuberculosis. 7

The etiology of CSOM is usually polymicrobial. Polymicrobial

infection is seen in 5-10% of cases, often representing a combination of
gram-negative organisms and S aureus. Anaerobes (Bacteroides,
Peptostreptococcus, Peptococcus) and fungi (Aspergillus, Candida) complete
the spectrum of colonial organisms responsible for these diseases. Anaerobes
make up 20-50% of isolates in CSOM and tend to be associated with
cholesteatoma.5

E. Pathophysiology
The pathophysiology of CSOM is complex and multifactorial.
Current theory suggests that CSOM is initiated by an episode of acute
infection. The pathophysiology of CSOM begins with irritation and
inflammation of the middle ear mucosa. The inflammatory response creates
mucosal edema. The ongoing inflammation eventually leads to mucosal
ulceration and consequent destruction of the epithelial lining. Host attempts
to overcome infection or inflammatory disturbances manifest
 as granulation tissue, which can develop into polyps in the middle ear cavity.
(A study by Wang et al demonstrated that in CSOM, T-cell-mediated cellular
immunity plays a role in granulation tissue formation.)8 Cycles of
inflammation, ulceration, infection, and granulation tissue formation can
continue, eventually destroying the surrounding bony margin and ultimately
causing various complications of CSOM

F. Classification
Tympanic membrane perforations can be found in the central,
marginal and atic areas. In a central perforation, the perforation is in the pars
tensa, whereas all around the edges of the perforation there are remnants of
the tympanic membrane. In marginal perforation, some of the edges of the
perforation are directly connected to the annulus or tympanic sulcus. Attic
perforation is a perforation located in the pars flaccida. 9

Based on the location of the tympanic membrane perforation and the

presence or absence of cholesteatoma, CSOM can be classified into 2 types,
namely the safe type (mucous type) and the dangerous type (malignant type
or bone type):

1) CSOM Safe type

The inflammatory process is limited to the mucosa, and usually does not
affect the bone. The perforation is centrally located. Generally do not
cause dangerous complications. In this type of CSOM, there is no
cholesteatoma. 9
2) Malignant type of CSOM
CSOM accompanied by cholesteatoma. The perforation in CSOM of this
type is marginal or atic, sometimes there is also a cholesteatoma in
CSOM with subtotal perforation. Most of the fatal complications arise in
the malignant type of CSOM. 9

G. Diagnosis
The diagnosis of CSOM can be established based on the results of
history taking, physical examination, ENT examination, especially otoscopy
and supporting examinations if needed.
Anamnesis

The main symptoms are foul-smelling otorrhea and hearing loss.

Meanwhile, symptoms such as otalgia are rarely found, except in acute
exacerbations. Persistent otalgia, especially those frequently associated with
headaches, usually has a process that has spread to the central nervous
system. Vertigo, rare. If this complaint appears, then the possibility of
involvement of labyrinthitis or labyrinth fistula is suspected, vertigo appears
especially when we are going to do cleaning of secretions, aspiration of
secretions. Meanwhile, spontaneous nystagmus that appears at that time is
also suspected of possibly having a labyrinth fistula

Physical Examination and Otolaryngology 5,9

 512-Hz tuning fork examination: evaluation to determine whether

hearing loss is present and whether it is conductive or sensorineural.
 Examination of the external acoustic canal will reveal an inflammatory
process, and sometimes crusting.
 Otoscopy, odorous otorrhea, perforated tympanic membrane,
granulation tissue, polyps, or cholesteatoma will be found.
 Examination may also reveal a retroauricular abscess or fistula

Supporting investigation

In CSOM, audiometric examinations, mastoid X-rays, CT scans,

cultures and germ resistance tests from ear secretions can be carried out. 9

On audiometric examination, the results will be found in the form of

conductive or mixed deafness, where the degree of disturbance depends on
the severity of the CSOM. Examination by conducting a tuning fork test,
pure tone audiometry, speech reception test (SRT), Word Discrimination
Score (WDS).

Radiological examination is needed if there is excessive otorrhea, and

there are possible complications, such as nerve dysfunction, labyrinthine
disorders and central nervous system.
 CT Scan is mainly used to assess the extent of the expansion of the
disease and its effect on the surrounding tissue. In circumstances to assess
complications of CSOM to the intracranial area, such as a brain abscess, this
examination has very important value. 5

H. Management
The management of CSOM differs depending on the type of CSOM.
The principle of safe type CSOM therapy is conservative or medical. If the
secretions come out continuously, then earwash is given, in the form of a 3%
H2O2 solution for 3-5 days. After the secretions are reduced, the therapy is
continued by giving ear drops containing antibiotics and cortisteoid. Orally
given antibiotics from the class of ampicillin, or erythromycin (if the patient
is allergic to penicillin), before the resistance test results are received. If the
cause is suspected to be resistant, or resistance tests prove to be resistant,
second-line antibiotics are given: Amoxicillin-Clavulanic Acid,
Ciprofloxacin, Levofloxacin, Cefixime, Clindamycin, Cefadroxyl. Focal
therapy of infection is a decongestant, mucolytic. When the secretions have
dried, but the perforation is still there after 2 months of observation, so
ideally a mirioplasty or tympanoplasty is performed. 9
The principle of dangerous type of CSOM therapy is surgery, namely
mastoidectomy. So if there is a dangerous type of CSOM, then the right
therapy is to do a mastoidectomy with or without tympanoplasty.
Conservative therapy with medication is only a temporary therapy before
surgery

Type of surgery in CSOM9

1) Simple mastoidectomy
This operation is carried out on safe types of CSOM that do not
heal with conservative treatment. Cleaning of the mastoid space from
pathological tissue was carried out. The goal is that the infection calms
down and the ear doesn't runny anymore. In this operation hearing
function is not repaired.
2) Radical mastoidectomy
This operation is performed on dangerous CSOM with infection
or widespread cholesteatoma. In this operation the mastoid cavity and
 the tympanic cavity is cleaned of all pathological tissue. The boundary
wall between the external ear canal and the middle ear canal with the
mastoid is torn down, so that the three anatomical areas become one
room.
3) Radical mastoidectomy with modification
This operation is performed on CSOM with cholesteatoma in the
attic area, but has not damaged the tympanic cavity. The entire cavity is
cleaned and the posterior wall of the ear canal is lowered. The goal of
surgery is to remove all pathological tissue from the mastoid cavity, and
preserve hearing that still exists
4) Myringoplasty
This operation is also known as Tympanoplasty type 1,
reconstruction is only performed on the tympanic membrane. The aim of
this operation is to prevent recurrence of middle ear infections in the
safe type CSOM with persistent perforations.
5) Tympanoplasty
This operation is performed on a safe type of CSOM with more
severe damage or a safe type of CSOM that cannot be calmed down by
medical treatment. The goal of surgery is to cure the disease and
improve hearing
6) Tympanoplasty with a dual approach (Combined Approach
Tympanoplasty)
This operation is a tympanoplasty surgical technique that is
carried out in cases of dangerous type of CSOM or safe type of CSOM
with extensive granulation tissue. The goal of surgery is to heal hearing
without undergoing a radical mastoidectomy technique. Cleaning the
cholesteatoma and granulation tissue in the tympanic cavity is carried
out in two ways, namely through the ear canal and the mastoid cavity by
performing a posterior tympanotomy.
I. Complications5,10
a. Intratemporal Complications
 Complications in the middle ear: facial nerve paresis, damage to the
ossicles, perforation of the tympanic membrane
 Complications to the mastoid cavity: petrositis, coalescent mastoiditis
 Complications to the inner ear: labyrinthitis, nerve/sensorineural
deafness
b. Extratemporal complications
 Intracranial complications: extradural abscess, subdural abscess, brain
abscess, meningitis, lateral sinus thrombophlebitis, otic hydrocephalus
 Extracranial complications: retroauricular abscess, Bezold's abscess.
zygomatic abscess

J. Prognosis
Patients with CSOM have a good prognosis with respect to infection
control. Hearing loss recovery varies depending on the cause. Conductive
hearing loss can often be corrected with surgery. 5,7

Most of the morbidity of CSOM stems from the associated conductive

hearing loss and the social stigma of the often foul-smelling discharge from
the affected ear. CSOM death is caused by intracranial complications. CSOM
itself is not a fatal disease. Although several studies have reported
sensorineural hearing loss as a complication of CSOM