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Case Report Chronic Suppurative Otitis Media

Presented by: Siti Nashria Rusdhy Arjanto Ramadhian Anindya Khairunnisa Zahra Lee Eng Siang Moderator : dr. Adhi

Otorhinolaryngology and Head Neck Surgery Department Medical Faculty of GadjahMada University / Dr. Sardjito Hospital Yogyakarta 2011

CHAPTER I INTRODUCTION

Chronic suppurative otitis media (CSOM) is a major cause of acquired hearing impairment in children. It is also an important cause of preventable hearing loss, particularly in developing countries. Chronic suppurative otitis media (CSOM) is the result of an initial episode of acute otitis media and is characterized by a persistent discharge from the middle ear through a tympanic perforation. Prevalence surveys, which vary widely in disease definition, sampling methods, and methodologic quality, show that the global burden of illness from CSOM involves 65330 million individuals with draining ears, 60% of whom (39200 million) suffer from significant hearing impairment. CSOM accounts for 28 000 deaths and a disease burden of over 2 million DALYs. Over 90% of the burden is borne by countries in the South-east Asia and Western Pacific regions, Africa, and several ethnic minorities in the Pacific rim. CSOM is uncommon in the Americas, Europe, the Middle East, and Australia.

CHAPTER II LITERATURE REVIEW

ANATOMY OF THE MIDDLE EAR The middle ear together with the Eustachian tube, aditus, antrum and mastoid air cells is called the middle earcleft. It is lined by mucous membrane and filled with air. The middle ear extends much beyond the limits of tympanic membrane which forms its lateral boundary and is sometimes divided into (i) mesotympanum (lyingopposite the pars tensa) , (ii) epitympanum or the attic (lying above the pars tensa but medial to Shrapnell'smembrane and the bony lateral attic wall), (iii) hypotympanum (lying below the level of pars tensa).The portion of middle ear around the tympanic orifice of the eustachian tube is sometimes called the protympanum. Middle ear can be likened to a six-sided box with aroof, a floor, medial, lateral, anterior and posterior walls. The roof is formed by a thin plate of bone called tegmen tympani. It also extends posteriorly to form the roof of the aditus and antrum. It separates tympanic cavity from the middle cranial fossa. The floor is also a thin plate of bone which separates tympanic cavity from the jugular bulb. Sometimes, it is congenitally deficient and the jugular bulb may then project into the middle ear; separated from the cavity only by the mucosa. The anterior wall has a thin plate of bone which separates the cavity from internal carotid artery. It also has two openings; the lower one for the eustachian tube and the upper one for the canal of tensor tympani muscle. The posterior wall lies close to the mastoid air cells. It presents a bony projection called the pyramid throughthe summit of which appears the tendon of the stapedius muscle to get attachment to the neck of stapes. Aditus, an opening through which attic communicates with the antrum, lies above the pyramid. Facial nerve runs in the posterior wall just behind the pyramid. Facial recess or the posterior sinus is a depression in the posterior wall lateralto the pyramid. It is bounded medially by the vertical part of the VIIth cranial nerve, laterally by the chorda tympani and above, by the fossa incudis. Surgically, facial recess is important, as direct access can be made through this into the middle ear without disturbing the posterior canal wall.

The medial wall is formed by the labyrinth. It presents a bulge called promontory which is due to the basal coil of cochlea; oval window into which is fixed the footplate of stapes; round window or the fenestra cochleae which is covered by the secondary tympanic membrane. Above the oval window is the canal for facial nerve. Its bony covering may sometimes be congenitally dehiscent and the nerve may lie exposed making it very vulnerable to injuries or infection. Above the canal for facial nerve is the prominence of lateral semicircular canal. Just anterior to the oval window, the medial wall presents a hook-like projection called the processus cochleariformis. The tendon of tensor tympani takes a turn here to get attachment to the neck of malleus. The cochleariform process also marks the level of the genu of the facial nerve which is an important landmark for surgery of the facial nerve. Medial to the pyramid is a deep recess called sinus tympaniwhich is bounded by the subiculum below and the ponticulus above. The lateral wall is formed largely by the tympanicmembrane and to a lesser extent by the bony outer attic wall called the scutum. The tympanic membrane is semi-transparent and forms a 'window' into the middle ear. It is possible to see some structures of the middle ear throughthe normal tympanic membrane, e.g. the long process of incus, incudostapedial joint and the round window. There are three ossicles in the middle ear- the malleus,incus and stapes. The malleus has head, neck, handle (manubrium), alateral and an anterior process. Head and neck of malleuslie in the attic. Manubrium is embedded in the fibrouslayer of the tympanic membrane. The lateral process forms a knob-like projection on the outer surface of the tympanic membrane and gives attachment to the anterior and posterior malleal (malleolar) folds. The incus has a body and a short process, both of which lie in the attic, and a long process which hangsvertically and attaches to the head of stapes.The stapes has a head, neck, anterior and posterior crura and a footplate. The footplate is held in the oval window by annular ligament. The ossicles conduct sound energy from the tympanicmembrane to the oval window and then to the inner ear fluid. There are two muscles- tensor tympani and the stapedius; the former attaches to the neck of malleus and tenses thetympanic membrane while the latter attaches to the neck of stapes and helps to dampen very loud sounds thus preventing noise trauma to the inner ear. Stapedius is a 2nd arch muscle and is supplied by a branch of CN VII while tensor tympani develops from the 1st arch and is suppliedby a branch of mandibular nerve (V3).

Tympanic plexus lies on the promontory and is formed by (i) tympanicbranch of glossopharyngeal and (ii) sympathetic fibres from the plexus round the internal carotid artery. Tympanicplexus supplies innervation co the medial surface of thetympanic membrane, tympanic cavity, mastoid air cells and the bony eustachian tube. It also carries secretomotor fibres for the parotid gland. Section of tympanicbranch of glossopharyngeal nerve can be carried out inthe middle ear in cases of Frey's syndrome. Course of secretomotor fibres to the parotid: Inferior salivary nucleus CN IX Tympanic branch Tympanic plexus Lesser petrosal nerve Otic ganglion Auriculotemporal nerve Parotid gland. Chorda tympani nerve is a branch of the facial nerve which enters the middle ear through posterior canaliculus, and runs on the medial surface of the tympanic membrane between the handle of malleus and long process of incus, above the attachment of tendon of tensor tympani. It carries taste from the anterior two-thirds of the tongue and supplies secretomotor fibres to the submaxillary and sublingual salivary glands. Mucous membrane of the nasopharynx is continuous with that of the middle ear, aditus, antrum and the mastoidair cells. It wraps the middle ear structures-the ossicles, muscles, ligaments, and nerves-like peritoneum wrapsvarious viscera in the abdomen-raising several folds anddividing the middle ear into various compartments. Middleear contains nothing but the air; all the structures lie outside the mucous membrane. Histologically, the eustachian tube is lined by ciliated epithelium which is pseudostratified columnar in the cartilaginous part, columnar in the bony part with several mucous glands in the submucosa. Tympanic cavity is lined by ciliated columnar epithelium in its anterior and inferior part which changes to cuboidal type in the posterior part. Epitympanum and mastoid air cells are lined by flat, nonciliated epithelium. Middle ear is supplied by six arteries, out of which two are the main, i.e.(i) Anterior tympanic branch of maxillary artery whichsupplies tympanic membrane.(ii) Stylomastoid branch of posterior auricular artery which supplies middle ear and mastoid air cells. Four minor vessels are: (i) Petrosal branch of middle meningeal artery (runs along greater petrosal nerve).(ii) Superior tympanic branch of middle meningeal artery traversing along the canal for tensor tympanimuscle. (iii) Branch of artery of pterygoid canal (runs along eustachian tube).(iv)

Tympanic branch of internal carotid. Veins drain into pterygoid venous plexus and superior petrosal sinus. Lymphatics from the middle ear drain into retropharyngealand parotid nodes while those of the eustachian tube drain into retropharyngeal group.

B. Chronic suppurative otitis media 1. Definition Chronic suppurative otitis media is defined as chronic infection of the middle ear accompanied by tympanic membrane perforation and continuous or intermittent middle ear discharge of more than two months. An infection process of less than 2 months is called subacute suppurative otitis media. The discharge may be serous, mucous or purulent. 2. Etiology Organisms found include: Proteus sp. S. aureus P. aeruginosa E. coli Bacteroides sp.

Predisposing factors include: Acute otitis media Chronic necrotic otitis media Traumatic perforation Congenital cholesteatoma

3. Clinical Features The typical signs of CSOM are long-standing otorrhea through a nonintact tympanic membrane. The ear is usually painless except when eczematoid otitis interna intervenes,

significant intratemporal or intracranial complications occur, or when malignancy is present. Patients usually report hearing loss as well. Examination frequently reveals a tympanic membrane perforation with moderately edematous middle ear mucosa. There may be associated granulation tissue in and around the perforation. When cholesteatoma is present, a retraction pocket or squamous debris may present. In these cases, there may also be evidence of bony external auditory canal erosion. Tuning fork exam will confirm an associated conductive hearing loss in most cases unless a complication is present. Long standing cholesteatoma may result in erosion into the otic capsule with resulting vertigo and sensorineural hearing loss. Erosion of the fallopian canal may also result in facial paralysis. Rarely, cholesteatoma can involve the central nervous system (Bailey)

4. Diagnosis Diagnosis of CSOM is made based on clinical features and otolaryngologic exam, especially the otoscopic exam. History-taking should be carried out to elicit the symptoms of long-standing otorrhea, the ear is usually painless, except when eczematoid otitis interna intervenes, significant intratemporal or intracranial complications occur, or when malignancy is present. Vertigo, sensorineural hearing loss, facial paralysis may be present in erosion caused by long standing cholesteatoma. A history of previous ear discharge, especially when accompanied by episodes of colds, sore throat, cough or some other symptoms of upper respiratory infection, should raise the suspicion of CSOM. Patients usually report hearing loss as well. Examination frequently reveals a tympanic membrane perforation with moderately edematous middle ear mucosa and there may be associated granulation tissue in and around the perforation. When cholesteatoma is present, a retraction pocket or squamous debris may present. In these cases, there may be also evidence of bony external auditory canal erosion. Tuning forks exam will confirm an associated conductive hearing loss in most cases unless a complication is present. (Bailey) 5. Management

The two principal aims of management are the eradication of infection and the closure of the tympanic perforation. Eradication of the infection decreases the mortality and morbidity associated with severe CSOM and the closure of the tympanic perforation aims to relieve hearing loss and to prevent microbial infection. Patients with safe type CSOM can be managed by conservative medical treatment. Among such patients, medical treatment can be aimed at control of infection and elimination of ear discharge as short-term goals and eventual healing of the tympanic perforation and improvement of hearing as ultimate goals.

Aural toilet Aural toilet must be part of the standard medical treatment for CSOM. Cleaning the ear of mucoid discharge could reduce, even if temporarily, the quantity of infected material from the middle ear and could facilitate middle ear penetration of topical antimicrobials (105). 2 Aural toilet is best performed in the clinics by means of small suction tips, forceps and curettes (95) to remove small mucosal granulations from the middle ear.

Topical antiseptics Topical antiseptics tended to be more effective than aural toilet alone in resolving otorrhoea in the trial by Eason et al. (50) (OR= 0.67,95%CL= 0.2,2.25). Topical antiseptics, as reported in the literature include Zinc peroxide powder (47), Dilute acetic acid drops, such as Domeboro solution or Vosol (85) , Alum acetate or Burow's solution (38,107) and Spirit eardrops BPC containing industrial methylated spirit and water (24,110)

Antibiotics 1) Antibiotics with aural toilet A Cochrane review found that aural toilet combined with antimicrobial treatment is more effective than aural toilet alone (OR= 0.31, 95%CL = 0.23, 0.43)

(26,49,57,138,147,153). Most otolaryngologists recommend topical antibiotic therapy and point out the poor penetration by most antibiotics into a devascularized middle ear mucosa marked with subepithelial scarring and thickening (85).

2) Topical versus systemic antibiotics The Cochrane review found that topical antibiotics were more effective than systemic antibiotics in resolving otorrhoea and eradicating middle ear bacteria (OR= 0.46,95%CL= 0.30,0.68). One additional RCT(43) found that topical ciprofloxacin was better than oral ciprofloxacin (86% versus 60% in terms of clinical and bacteriological cure, respectively). 3) Topical quinolones are better than topical non-quinolones The Cochrane review showed that among topical antibiotics, topical fluoroquinolones are more effective than other types of topical antibiotics. Five studies (55,61,103,165,171) found that topical ofloxacin or ciprofloxacin was more effective than intramuscular gentamicin, topical gentamicin, tobramycin or neomycin-polmyxin in resolving otorrhoea (OR= 0.36,95%CL= 0.22,0.59) and in eradicating bacteria (OR= 0.34,95%CL= 0.20,0.57). Supiyaphun et al.(160) found that topical ofloxacin was more effective than topical chloramphenicol (with oral amoxycillin) in terms of resolution of ear discharge (76.9% and 37%,respectively),ear pain (79.2% and 53.3%,respectively),and middle ear inflammation (63.2% and 54.8%, respectively). Ciprofloxacin otic drops and ophthalmic drops and ofloxacin (Floxin) otic drops carry no risk of ototoxicity when they pass through a tympanic perforation into the middle ear.5 The safety and effectiveness of topical quinolones in children have been well documented (48).Adverse reactions have been minor and as frequent as with other topical antibiotics. The concentrations of these drugs are highest in otorrhoea, the main route of exit from the ear, and lowest in the serum (130).
4) Combined oral-systemic therapy

The Cochrane review showed that combined oral-topical antibiotics were no more effective than topical antibiotics alone; the rates of resolution of otorrhoea were 50% and 53%, respectively. The other (43) showed the cure rates with topical ciprofloxacin and with combination oral and topical ciprofloxacin to be the same (88%).

Surgery Polypectomy and granulomectomy may be performed to remove polyps and granuloma. Tympanic perforations may be closed by placement of a gradt on the inner surface of the ear drum. Unsafe ears should undergo mastoidectomy which involves removing the mastoid air cells, granulations and debris using bone drills and microsurgical instruments. Tympanoplasty involves closure of the tympanic perforation by a soft tissue graft with or without reconstruction of the ossicular chain.

Patient Education Patients must be educated to prevent the entry of water or soap into the ear, particularly during bathing. This can be done by plugging the ear with rubber or cotton wool covered with vaseline (97).This also prevents soiling and irritating the skin surrounding the ear canal with infected discharge.

CHAPTER III CHAPTER III CASE REPORT

Patient Identity Name Age Address Occupation Medical record number : Mrs. W L : 32 years old : Delanggu Klaten : Housewife : 654763

A. Anamnesis Chief complaint : Decrease in hearing in both ears. History of present illness : Patient complains that there is a decrease in hearing in both ears since around two months ago and yellowish, thick, odorless discharge issuing from both ears. The patient also complains of tinnitus and occasional pain in the left ear. The patient denies any cough or cold before the ear discharge. Becuase of the tinnitus, the patient frequently cleans the ears using cotton buds. History of previous illness : Previous history of ear ache and discharge. History of hypertension, diabetes mellitus, heart disease, asthma and allergies were denied. Family history of illness : A family history of hypertension, diabetes mellitus, heart disease, asthma and allergies were denied. B. Physical Examination General status Vital sign: Blood pressure Pulse Respiratory Rate Temp : compos mentis, good nutritional status : 110/80 mmHg : 84 x/min : 20 x/min : 37 C

ENT Examination: Ear : mucopurulent discharge from AD/AS, tympanic membranes hyperemic AD/AS, cone of light AD/AS, central perforations in both AD/AS Nose : within normal limits Throat : within normal limits Neck : within normal limits C. Diagnosis The diagnosis of this patient is chronic suppurative otitis media AD/AS D. Management Ciprofloxacin 500 mg 2 x 1 Efedrin 2x1 Ambroxol 3x1 E. Problem Complications F. Planning Patient education. Follow up visit at the clinic in 5 days.

CHAPTER IV DISCUSSION

Based on the findings of the anamnesis and the physical examination the diagnosis of this case is correct. The management of this patient is correct