Patients with suspected or diagnosed cholesteatoma or permanent perforation of the eardrum in a dry ear should be referred to an ENT specialist without performing any therapeutic interventions.
If the patient has an ear with discharge, adequate local treatment should be provided before referring to an ENT specialist.
Definition
The patient is considered to have chronic otitis media if the infection has lasted for more than 2 months. The activity of the infection may vary and the infection may even subside, but a permanent injury or functional impairment may result.
Active chronic otitis media
A permanent perforation in the tympanic membrane remains, through which there is discharge into the ear canal.
The middle ear may at times only look wet and glistening, or the purulent discharge is visible through the perforation. Sometimes there is profuse discharge requiring several daily changes of cotton wool tampons at the opening of the ear canal.
Cholesteatoma
The keratinized epithelium of the ear canal or tympanic membrane grows into the middle ear and the mastoid bone resulting in an osteolytic, tumour-like mass.
Causative agents
The bacteria are different than in acute otitis media, and several species can be isolated simultaneously.
The prevailing bacteria are Pseudomonas aeruginosa and Staphylococcus aureus. Proteus species, Klebsiella, E. coli and many other aerobic bacteria are also common. In one third of cases anaerobic bacteria are also detected.
Symptoms and signs
Continuous or occasional discharge from the ear, either purulent or clear and glue-like
There is a perforation in the eardrum and the mucosa of the middle ear is swollen and secretory.
A perforation in the upper part of the eardrum (pars flaccida) is almost invariably a sign of a cholesteatoma.
A perforation along the margin of the central eardrum (pars tensa) predisposes to cholesteatoma, and a keratinized mass can often be seen in the middle ear.
Conservative treatment of chronic otitis media
In the beginning, it is important to gain proper understanding of the disease process: this can be assessed on the basis of changes in the eardrum.
If the ear is dry and a central perforation in the pars tensa is present, no immediate treatment is indicated. The patient is referred to an ENT specialist for assessment.
If a perforation is seen in the upper part of the eardrum (pars flaccida) the patient most probably has a cholesteatoma and an operation is indicated.
Treatment of an ear with discharge
First consultation
Take a bacterial culture of the middle ear discharge. If antibiotics have already been administered also take a fungal specimen (for both microscopy and culture), because yeasts, Candida, Penicillium, or Aspergillus may be present, and continuous antibiotic treatment only makes the symptoms worse.
Rinse the ear thoroughly with sterile, 37°C sodium chloride solution, dry the ear canal (cotton swab or suction), and record carefully the status.
Rinsing and drying is essential before administration of ear drops. If suction is used remember the possibility of a caloric reaction caused by flowing cold air, and discontinue the suction immediately if the patient gets vertigo.
Before the antibiotic resistance assay has been performed, preferably use antibiotic-free eardrops. If the process is in the upper part of the eardrum, 3% borate spirit solution is recommended. If the middle ear mucosa is widely exposed do not use surgical spirit stronger than 50%, due to its stinging effect. Alternatively, non-ototoxic drops can be used (flumethasone-clioquinol, ciprofloxacin-hydrocortisone) 4-5 drops 2 times a day. The bottle should be warmed by keeping it in the palm before administration of the drops to avoid vertigo caused by the caloric reaction. During the administration the patient should lie for 5 minutes with the affected ear upwards.
Systemic antimicrobials are indicated in patients whose ear has earlier been dry or moist or there has been just minor discharge, but during an upper respiratory infection the discharge has become more profuse. In such a case, the same bacterial aetiologies and antimicrobial choices as in acute otitis media are to be considered.
Second and third consultation
The second consultation after about 7 days may show that the ear is already dry.
Repeat clinical examination, as the disappearance of the swelling may result in altered findings.
If there is still discharge, rinse the ear with sodium chloride solution.
At this stage antibiotic drops (not systemic antibiotics) can be prescribed according to the result of the antibiotic resistance test Treatment of Chronic Suppurative Otitis Media.
Ototoxicity of the eardrops need not be considered in the treatment of a profusely discharging ear because the swollen mucous membrane near the round window prevents contact of the drug with the membrane and possible absorption through it.
If fungal culture is positive, fungicides can be administered in the ear, e.g. 3% borate spirit and miconazole powder. Combined glucocorticoid-antibiotic drops should be avoided in fungal otitis. The ear canal and the tympanic membrane can be wiped through an ear speculum with a cotton swab moistened with 0.5-1% methyl rose solution.
If the ear remains discharging in spite of good local treatment and repeated rinsing, the patient should be referred to an ENT unit for assessment.
Referral
Indications for specialist consultation:
deterioration of the general condition, intensive ear pain or headache
facial paralysis
rotatory vertigo
cholesteatoma
continuous discharge for more than 4 weeks
tympanic perforation that is not closed within 3 months.