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Chronic suppurative otitis media continues to be an important disease in the pediatric population and a significant cause of hearing problems leading to language development disorders and school difficulties in children. This article covers the etiology, epidemiology, and pathophysiology of chronic suppurative otitis media and the treatment and long term complications that may impact school-age children. This is an important area of study, and our role is to highlight the appropriate care for patients afflicted with this condition. This article reviews and describes the evaluation and management of chronic suppurative otitis media and explains the healthcare team's role in evaluating, treating, and improving care for patients with this condition. Objectives: Review the etiology of chronic suppurative otitis media. Describe the appropriate evaluation of chronic suppurative otitis media. Outline the management options available for chronic suppurative otitis media. Summarize interprofessional team strategies for improving care coordination and communication to advance chronic suppurative otitis media and improve outcomes. Access free multiple choice questions on this topic.

Otitis media is a common cause of fever in the pediatric population. Chronic suppurative otitis media, also known as chronic otitis media, is a stage of ear disease characterized by an ongoing infection of the middle ear without an intact tympanic membrane. This disease is a chronic inflammation of the middle ear and mastoid cavity. The characteristic presentation is chronic or persistent otorrhoea over 2 to 6 weeks through a perforated tympanic membrane.[1] The Eustachian tube plays an important role in this disease, and dysfunction of this tube is found in 70% of patients undergoing middle ear surgery. When the Eustachian tube is dysfunctional, pressure equilibration in the middle ear is impaired, leading to disturbed middle ear aeration and the classic symptoms of chronic suppurative otitis media.[2] Acquired hearing loss is also characteristically found in patients with this condition and, if left untreated, can lead to further morbidity and mortality.[3]

Although viruses are the most common cause of otitis media, bacteria often cause chronic suppurative otitis media in children. The etiology is usually polymicrobial. The most common microorganisms found in this pathology are Staphylococcus aureus (MRSA). Others, like Pseudomonas aeruginosa, Proteus spp., Klebsiella spp., Bacteroides spp., and Fusobacterium spp., can cause the disease. Less common are Aspergillus spp and Candida spp., which are more frequently found in immunocompromised patients.[4] Tuberculosis can also cause chronic suppurative otitis media; it is a more common cause in areas with a high incidence of tuberculosis.

Chronic suppurative otitis media usually develops in early childhood, most commonly around age 2. The children at most significant risk are those of low-income status.[5] This disease is also most common in children with craniofacial anomalies, such as cleft palate, and those born with Down syndrome. Although rare, otitis media may occur in Gradenigo syndrome, characterized by orbitofacial pain and 6th cranial nerve palsy. This syndrome can occur as a complication of chronic suppurative otitis media.[6] The common feature of these congenital anomalies is a deficiency in Eustachian tube function, which predisposes these children to middle-ear disease. The main risk factors for chronic suppurative otitis media include frequent episodes of acute otitis media, upper respiratory tract infections, tympanic membrane trauma, and poor nutrition and living conditions.[5]

In chronic suppurative otitis media, bacterial pathogens invade the middle ear mucosa through the external canal.[7] An inflammatory reaction occurs in the middle ear, accompanied by edema and fibrosis with spontaneous perforation of the tympanic membrane and ongoing infection. Also, chronic suppurative otitis media can occur as a complication of tympanostomy tubes inserted to treat otitis media with effusion.

Microscopic examination is not routinely performed in children with chronic suppurative otitis media, and it's not necessary for the diagnosis and treatment. If ear microscopy is performed, however, it demonstrates the perforation in the drum membrane.[7]

Chronic suppurative otitis media presents with otorrhea in most cases, although dry ears can also be found. Symptoms that may be present but are not obligatory for diagnosis include hearing impairment, tinnitus, and aural fullness.[8] It is important to consider that children can often be asymptomatic or have a very critical presentation with intracranial complications. It is crucial to investigate whether the patient has had vertigo and whether this is related to any ear complaints. All patients should be asked about their history of ear infections, recent antibiotic treatment, and surgery. Any other medical problems, such as allergic rhinitis and gastroesophageal reflux, should be noted, as well as smoke exposure.[2]

Two types of otoscope heads are used to evaluate the ears: surgical (operating) and diagnostic (pneumatic). By inspecting the ears, the degree of tympanic membrane mobility in response to negative or positive pressure can be evaluated to assess for middle ear fluid, a hallmark of otitis media. Other abnormalities of the tympanic membrane include erythema, bulging or fullness, or extreme retraction. The treatment of chronic suppurative otitis media should be guided by microbiologic investigation, with targeted therapy based on the results. Pseudomonas is among the organisms most frequently found in the physical environment and is ubiquitous, with a predilection for moist areas. It is thought to first infect tissues by adhering to epithelial cells via pili or fimbriae.

Topical quinolones are the treatment of choice for chronic suppurative otitis media; they are equally or more effective than aminoglycosides and lack the risk of ototoxicity. Quinolones are effective in resolving otorrhoea and eliminating the microorganism.[9] If there is no associated cholesteatoma, parenteral antimicrobial treatment combined with assiduous aural cleansing is likely to be successful in clearing the infection, but in refractory cases, tympanomastoidectomy can be required. Beta-lactam antipseudomonal drugs such as ceftazidime are used in cases that need a parenteral regimen. Ticarcillin-clavulanate is an alternative agent that is effective against Pseudomonas sp. and S. aureus. The formation of biofilm has been linked to the pathogenesis of infection and to antibiotic resistance.[5] If treated with surgery, this might help prevent complications, but patients may still have postoperative ear discharge. If the patient does not respond to the initial treatment regimen and/or a cholesteatoma or any other mass develops, it is imperative to refer the patient to otolaryngology. When cholesteatoma is present, intervention from the otolaryngology team is required for mastoidectomy with tympanoplasty. It is also very important to always assess hearing function and provide appropriate follow-up in all patients presenting with chronic otitis media.

It is important to consider other pathologies that may present with a clinical picture similar to that of chronic suppurative otitis media. Because otorrhea is among the most common signs encountered in this entity, and the most frequent age at presentation is usually less than 5 years, the presence of a foreign body in the ear canal needs to be ruled out. The presence of a foul-smelling odor emanating from the ear can help differentiate an otorrhea caused by a foreign body or chronic supportive otitis media. Other conditions that can be mistaken for chronic otitis media are myringitis and otitis externa (both share the signs of otorrhea). Still, a physical examination can elucidate the diagnosis. More serious conditions that must also be ruled out are mastoiditis, abscess, and meningitis. In these cases, the presentation is more severe, with systemic symptoms. Cholesteatoma Petrositis Langerhans cell histiocytosis Neoplasia Foreign body Sigmoid sinus thrombosis Otitic hydrocephalus Extradural abscess Meningitis Brain abscess Tuberculosis Labyrinthitis Wegener granulomatosis

Overall, the prognosis for chronic suppurative otitis media is good if treatment is provided and complications are avoided. Some refractory cases can be found, and these require more extensive evaluation and treatment. Because chronic suppurative otitis media often follows acute otitis media, it's important to diagnose and treat the bacterial cause of acute otitis media to prevent chronic suppurative otitis media. The introduction of the Pneumococcus vaccine has reduced the incidence of acute otitis media, leading to fewer cases of chronic suppurative otitis media.[5]

Multiple complications can result from chronic suppurative otitis media, such as polyps, osteitis, sclerosis, tympanosclerosis, labyrinthitis, and intracranial suppurative complications, such as epidural, subdural, or brain abscesses. The most common complication is hearing loss, either conductive or sensorineural. Hearing loss is associated with language delays and behavioral problems.[10]

Parents should be educated and counseled on the importance of regular well-child care visits and to seek prompt care when children complain of ear pain or discomfort. It is also important to consider teachers' complaints, especially if hearing loss is suspected. It is imperative to treat and follow chronic suppurative otitis media to decrease the chances of further complications that might affect the child long-term.

Chronic suppurative otitis media is a type of ear disease characterized by an ongoing infection of the middle ear without an intact tympanic membrane; it usually occurs in early childhood, typically around 2 years of age. An episode of acute otitis media often precedes this condition, and when suspected, prompt isolation of the etiologic agent is necessary. If left untreated, chronic suppurative otitis media can lead to severe complications, including polyps, sclerosis, tympanosclerosis, labyrinthitis, epidural, subdural, or brain abscesses, and conductive or sensorineural hearing loss affecting the child's performance in school. Early detection and prompt treatment are crucial for better outcomes and preventing complications. By following the steps outlined above, the pediatrician can properly diagnose and treat chronic suppurative otitis media. It is worthwhile to engage otolaryngology, especially in cases that may require further interventions beyond antibiotics.