Chronic Otitis Media

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.

First consultation

1. 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.
2. Rinse the ear thoroughly with sterile, 37°C sodium chloride solution, dry the ear canal (cotton swab or suction), and record carefully the status.
3. 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.
4. 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.
5. 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.

1. Repeat clinical examination, as the disappearance of the swelling may result in altered findings.
2. If there is still discharge, rinse the ear with sodium chloride solution.
3. 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.
4. 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.
5. 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.