Definition

Chronic suppurative otitis media (CSOM) is characterized by a perforated tympanic membrane and persistent fluid discharge from the middle ear. It typically lasts longer than six weeks and can manifest with or without cholesteatoma, an abnormal growth of skin cells in the middle ear.

CSOM is generally categorized into two types: benign and malignant. The benign type, also known as CSOM without cholesteatoma, typically involves perforation in the central part of the eardrum and tends to have fewer severe complications.

The malignant type, or CSOM with cholesteatoma, involves eardrum perforation that can affect the bones forming the walls of the outer ear canal. This condition is accompanied by the excessive growth of skin cells in the middle ear, which is destructive and likely to cause severe complications.

Based on the type of fluid discharge, CSOM is also classified into active and inactive types. In active CSOM, a thick, purulent fluid, often with foul smells, continuously flows from the perforated eardrum. In inactive CSOM, the ear canal tends to remain dry.

Causes

While viral infections are the most common cause of otitis media in children, bacterial infections predominantly cause chronic suppurative otitis media. The bacteria frequently implicated in CSOM include Staphylococcus aureus or MRSA (Methicillin-resistant Staphylococcus aureus), Pseudomonas aeruginosa, Proteus spp., Klebsiella spp., Bacteroides spp., and Fusobacterium spp. In immunocompromised individuals, fungi such as Aspergillus spp. and Candida spp. can also cause CSOM. In regions with high tuberculosis prevalence, CSOM cases often result from tuberculosis infection.

Pathogens causing CSOM enter the surface of the middle ear from the external environment, either through a perforation in the eardrum or in people with ventilation tubes. These pathogens could trigger a prolonged inflammatory response in the middle ear, lasting more than six weeks.

Risk factor

Several factors can increase the likelihood of developing chronic suppurative otitis media (CSOM). These include:

• Acute otitis media (AOM) that is not managed correctly or treated too late can progress to CSOM, particularly in individuals with poor hygiene or compromised immune systems.
• Injured eardrum to extensive tympanic membrane perforation can also lead to CSOM.

Symptoms

Symptoms of CSOM may include:

• Hearing loss in the affected ear
• Ear pain
• Discharge from the ear, which can range from thick, cheese-like fluid to clear fluid
• If accompanied by fever and vertigo, immediate medical attention is necessary as it may indicate the spread of the infection to the intracranial area.

Diagnosis

To diagnose CSOM, a doctor will inquire about symptoms and related diseases, such as a history of fluid discharge from the ear over a certain period, recurrent ear infections, or ventilation tube placement in the ear.

If the patient has a persistent history of CSOM despite appropriate treatment, the doctor will consider the occurrence of cholesteatoma.

Physical Examination

The doctor will inspect the earlobe and areas behind the ear. A procedure called otoscopy could be done by using an otoscope to examine the ear canal for abnormalities. 

Diagnostic Tests

To confirm the diagnosis, the doctor may recommend several diagnostic tests, including:

• Ear fluid discharge sample analysis. A sample of the ear discharge is taken to the laboratory to identify the pathogens that cause CSOM.
• Audiometry test. This test could help determine the type of hearing loss, typically conductive in CSOM, though mixed or sensorineural hearing loss can also occur.
• CT scan or MRI. In cases where CSOM does not respond to medical treatment, these imaging tests can help reveal abnormalities and complications within the ear.

Management

If your doctor diagnoses you with chronic suppurative otitis media (CSOM), they will provide treatments based on the type of CSOM you have. CSOM typically responds better to topical treatments, which are medicines applied directly to the ear, compared to oral treatments that circulate systematically throughout the body.

Topical treatment involves three key components: choosing the appropriate antibiotic ear drops, softening ear wax with a 3% hydrogen peroxide solution to facilitate its removal, and managing excessive tissue growth in the ear. Systemic treatment is only considered if the disease does not respond adequately to topical treatment.

If topical or systemic treatments are ineffective, your doctor may consider surgical intervention to prevent complications and preserve existing hearing function.

Complications

Chronic suppurative otitis media can spread intracranially. If you experience symptoms such as fever and vertigo, report them to your doctor immediately, which could indicate that the ear infection has spread to the cranial cavity. Intracranial infection can lead to serious conditions such as epidural, subdural, or brain abscesses, which are accumulations of pus caused by bacterial infection.

Besides increasing the risk of intracranial infections, CSOM can also result in complications such as hearing loss, which can be conductive, sensorineural, or mixed. This hearing loss may be temporary, but in some cases, it can be permanent. In children, hearing loss can lead to speech and language development delays and behavioral disorders.

Prevention

To prevent CSOM, seeking regular medical care for ear infections and completing the prescribed treatment is crucial. Adhering to proper treatment can prevent the development of chronic suppurative otitis media.

When to see a doctor?

Consult a doctor immediately if you experience any symptoms of an ear infection, such as ear pain, hearing loss, or ear discharge. Early and appropriate treatment is essential to prevent complications and manage the disease effectively.

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