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ChronicSuppurativeOtitisMediaTreatment&
Management
Author:PeterSRoland,MDChiefEditor:ArlenDMeyers,MD,MBAmore...
Updated:Mar27,2015

ApproachConsiderations
Patientswithchronicsuppurativeotitismedia(CSOM)respondmorefrequentlyto
topicaltherapythantosystemictherapy.Successfultopicaltherapyconsistsof3
importantcomponents:selectionofanappropriateantibioticdrop,regular
aggressiveauraltoilet,andcontrolofgranulationtissue.
InpatientcareisrarelynecessaryforthepatientwithCSOM.Inpatientsforwhom
theotolaryngologistchoosessystemicparenteralantibiotics,inpatienthospitalization
mayberequired.Otherwise,excludingcomplications,thisdiseasecanbetreated
effectivelyintheoutpatientsetting.Patientswhopresentwithsuspectedintracranial
complicationstohospitalsthatfunctionwithoutCTscanningcapabilitiesor
neurosurgicalcareshouldbetransferredassoonaspossibletoaninstitutionwith
suchcapabilities.Antibiotictherapyshouldbestartedpriortotransfer.

AntibioticDrops
Theantibioticshouldhaveanappropriatespectrumofactivitythatincludesgram
negativeorganisms(especiallypseudomonads)andgrampositiveorganisms
(especiallySaureus).Aminoglycosidesandthefluoroquinolonesareantibioticsthat
meetthisinitialcriterion.Topicalantibioticdropscontainingaminoglycosideshave
beenmarketedandusedformorethan20years.

NeomycinandpolymyxinB
Mostdropsmarketedspecificallyforotologicusecontainneomycincombinedwitha
cationicdetergent(polymyxinB).Neomycinhasremainedfairlyeffectiveoverthe
last2decadesforgrampositiveorganisms,butithaslostalmostallofits
effectivenessforcombatinggramnegativeorganisms.Doharsstudiesindicatethat
fewerthan20%ofgramnegativeorganismsremainsensitivetoneomycin
however,polymyxinBhasremainedeffectiveforgramnegativebacteria.The
combinationconsequentlyremainsreasonablyeffectivefromanantimicrobialpoint
ofview. [19,20,21]

Gentamicin,dexamethasone,andtobramycin
Gentamicinandtobramycincontainingophthalmicdropshavebeenwidelyused
offlabelforthetreatmentofotologicinfections.Afixedratiocombinationof
tobramycinanddexamethasone(TobraDex)hasbeenespeciallypopularinthe
UnitedStates,whilegentamicincontainingdropshavebeenmorepopularin
CanadaandEurope.

Aminoglycosides
Allaminoglycosideshavesignificantpotentialtoxicity.Somearemorevestibular
toxicthancochleartoxicand,therefore,aremorelikelytoproducevestibular
dysfunctionthanhearingloss.Forotheraminoglycosides,theoppositeistrue.
Studiesdesignedtodetecthearinglossfromtheuseofototopicalaminoglycosides
demonstratethattheincidenceofaminoglycosiderelatedhearinglossis,atworst,
low.Recentinformation,however,suggeststhatthepotentialforvestibulartoxicity
maybemuchhigher,especiallyifpreparationscontaininggentamicinareused.

pHlevelofdrops
OticdropsdifferinpH.Dropsdesignedforoticuseareoftenbufferedslightlytoan
acidicpHbecausethenormalenvironmentoftheexternalauditorycanalisacidic.
Thesedropscanbeextremelypainfuliftheypenetrateintothemiddleear,
especiallyifthemiddleearmucosaisnormal.WhilelowpHisanadvantagewhen
treatinginfectionsintheexternalauditorycanal,theadvantageislostinthemiddle
earbecausethenormalpHofthemiddleearisneutral.Withinthemiddleear
space,thepotentialforlowpHsolutionstocausepainortoirritatemucosacan
renderthemdisadvantageous.
Mostototopicantibioticsteroidcombinationsareatleastsomewhatacidicbecause
itisalmostimpossibletokeepeitherquinolonesoraminoglycosidesinsolutionata
neutralorbasicpH.Theacidityofpolymyxin,neomycin,andhydrocortisonevaries
fromaslowas3.5to4.5.CiprofloxacinandhydrocortisonecombinationshaveapH
of4.55.0,asdotobramycinanddexamethasonecombinations.

Viscosityofdrops
Ototopicalpreparationsvaryinviscosity.Preparationscontaininganantibioticare
usuallysolutionsandhaverelativelylowviscositiesapproachingthatofwater(1.0
cP).Preparationscontainingasteroidareoftenofconsiderablyhigherviscosity,
rangingfrom28cP.Polyviscoussolutionsmayeffectivelycoatandremainin
contactwithtissuesforlongerperiods,althoughtheyarelesslikelytomovethrough
oraroundsmallspaces(eg,tympanostomytubes,granulationtissue,polyps)than
arepreparationsoflowerviscosity.

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Bacterialresistance
Somecontroversysurroundsthedevelopmentofbacterialresistancedueto
ototopicaltreatment.Recentstudieshavenotidentifiedanyincreaseinbacterial
resistancethroughototopicalantibioticadministration.Specifically,the
concentrationinquinoloneototopicaldropsoverwhelmsthemostresistant
pseudomonalandstaphylococcalstrains.Failureoftopicalantibioticdeliverytothe
pathogenicorganismsshouldbeconsideredacauseofpersistentinfections.

Steroidcontainingdrops
Rolandetaldemonstratedthattheantiinflammatoryeffectofsteroidsisan
importantadvantagewhensignificantamountsofgranulationtissuearepresent. [22]
Ototopicalswithsteroidsweresuperiortosteroidfreeototopicalsinreducing
granulationtissueatdays11and18oftreatment.Thesteroidcontainingdrops
shouldbeconsideredinCSOMwithgranulationtissue.

AuralToilet
AuraltoiletisacriticalprocessinthetreatmentofCSOM.Theexternalauditory
canalandtissueslateraltotheinfectedmiddleearareoftencoveredwithmucoid
exudateordesquamatedepithelium.Topicallyappliedpreparationscannot
penetrateaffectedtissuesuntiltheseinterposingmaterialsareremoved.
Traditionally,inotolaryngology,auraltoilethasbeenachievedusingthemicroscope
andmicroinstrumentstomechanicallyremovemucoidexudates,desquamated
epithelium,andotherinterposingmaterials.Forbestresults,auraltoiletshouldbe
performed23timesperdayjustbeforetheadministrationoftopicalantimicrobial
agents.
Auralirrigationisaneffectivealternativethatisoftenlessburdensomeforpatients
andphysicians.Asolutionof50%aceticacidand50%sterilewaterisgenerally
painlessandeffective.Thirtyto40mLofthissolutioncanbeirrigatedthroughthe
externalauditorycanal,usingasmallsyringeorbulbtypeaspirator.Theirrigant
solutioncanbeallowedtodrainoutfor510minutespriortoinstillingtheototopical
antimicrobial.

GranulationTissueControl
Granulationtissueoftenfillsthemiddleearandmedialportionsoftheexternal
auditorycanal.Granulationtissuecanpreventtopicallyappliedantimicrobialagents
frompenetratingthesiteofinfection.Theuseoftopicalantimicrobialdropsisthe
firststepincontrollinggranulation.Thesedropshelpreducegranulationtissueby
eliminatinginfectionandbyremovingtheincitingirritatinginflammation.As
previouslydiscussed,mostphysiciansbelievethattopicalsteroidsareimportantand
hastentheresolutionofmiddleeargranulation,thusimprovingpenetrationof
topicallydeliveredantimicrobialagents.
Cauteryisoftenusedtoreducetheamountofgranulationtissueandtocontrolits
formation.Microbipolarcauterycanbeusedintheoffice,butchemicalcauteryis
usedmorecommonly.Silvernitratecanconvenientlybeappliedintheformofsilver
nitratesticks.Cautionmustbeexercised,asthedepthofthechemicalburninduced
bytheapplicationofchemicalagents,includingsilvernitrate,isuncontrolled.
Excisionofgranulationtissuecanbeaccomplishedintheofficewiththeuseofa
microscopeandmicroinstruments.Silvernitrateisoftenusedtocontrolbleeding
andtoenhancetheefficacyofgranulationtissueremoval.
Animportantpart(perhapsthemostimportantpart)oftympanomastoidectomyfor
thetreatmentofCSOMconsistsofremovingandcontrollinggranulationtissue
withinthemiddleear,mastoid,andmastoidantrum.

FailureofTopicalTreatment
Failuresoftopicalantimicrobialtherapyarealmostalwaysfailuresofdelivery.
Specifically,failureofdeliverydescribestheinabilityofanappropriatetopical
antibiotictoreachthespecificsiteofinfectionwithinthemiddleear.Various
elementsmayobstructthedeliveryofthemedication,includinginfectiousdebris,
granulationtissue,cholesteatoma,neoplasia,cerumen,andothers.Whentopical
therapyfails,thepatientneedsathoroughevaluationforanatomicobstruction,
includingmicroscopicexaminationandradiologicstudiesasneeded.Additionally,a
clearunderstandingoftheveryhighconcentrationoftheantibioticwithintopical
preparationsmustbekeptinmind.
Theminimalinhibitoryconcentrations(MICs)forSaureus,Spneumoniae,andthe
otherorganismsthatcommonlycauseCSOMaregenerally12mcg/mL.Generally,
intravenouslyadministeredaminoglycosidesandanypseudomonalcephalosporins
canslightlyexceedtheselevels.
OrallyadministeredfluoroquinolonesalsoslightlyexceedtheMICsofmostofthe
relevantorganisms(oraladministrationachievesbloodlevelsashighasthose
achievedwithparenteraladministration).Concentrationsofmedicinesinthemiddle
earfluidrarelyexceed46mcg/mL.Incontrast,a0.3%topicalantibioticsolution
contains3000mcg/mL,aconcentration1001000timesthatwhichcanbeachieved
usingsystemicadministration.Moreover,thisconcentrationgreatlyexceedstheMIC
foranyrelevantorganism.
Becauseofthehighconcentrationsofantimicrobialagents,topicaltherapyismore
likelytobeeffectivethansystemictherapy.Studiescomparingsystemic
administrationtotopicaladministrationshowthattopicalcureratesnearlydouble
systemicrates.Topicaltherapydoesnotfailbecausetheorganismisresistanteven
supposedlyresistantorganismssuccumbtotheseveryhighconcentrations.For
instance,evenanextraordinarilyresistantstrainofSaureuswithanMICof256
mcg/mLcannotsurviveinanenvironmentinwhichtheconcentrationofantibioticis
3000mcg/mL.Theemergenceofresistancetotopicaltherapyisextremely

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uncommon.Therapidkillratesandhighconcentrationsoftopicallyadministrated
dropsdonotpermitevenmutantstrainswithhigherMICstosurvive.
Consequently,whentopicaltherapyforCSOMfails,itisalmostneverbecauseof
antimicrobialresistancetherefore,cultureandsensitivityareoflittlebenefitaslong
astherapyistopical.Sensitivityreportsfromtheclinicallaboratoryareirrelevant.
Sensitivitytestingintheclinicallaboratoryisdesignedforthetissueconcentrations
achievablebysystemicadministration.Consequently,apseudomonadwithanMIC
of48mcg/mLislikelytobereportedasresistantbytheclinicallaboratory.

SystemicTherapy
SystemictherapyshouldbereservedforcasesofCSOMthatfailtorespondto
topicaltherapy.Topicaltherapypresumablyfailsbecausetheantibioticscannot
reachinfectedtissues.Systemictherapyisexpectedtosucceedinthepenetration
ofthetissues.
Ifafocusofinfectioninthemastoidcannotbereachedbytopicaldrops,thereisa
reasonablechancethatsystemicallyadministeredantibioticscanpenetratethese
areasinsufficientconcentrationstocontroloreliminateinfection,althoughthe
concentrationsarelower.Ototopicaltherapyisgenerallycontinuedoncesystemic
therapyisbegun.Indeed,sincesystemictherapyfrequentlyinvolveshospitalization
fortheintravenousadministrationofdrugs,auraltoiletcanfrequentlybeintensified.
Theabilitytoperformreliableauraltoiletmaybeasimportantasthesystemic
antimicrobialtherapyineliminatingthediseaseforsomepatients.
Priortoinstitutingsystemictherapy,acultureshouldbeobtainedforsensitivity.
Sensitivitytestingisimportantwhensystemictherapyisbeingconsidered.The
antibioticsshouldbeselectedonthebasisoftheresultingsensitivityprofile.The
narrowestspectrumantibioticwiththefewestadverseeffectsandcomplications
shouldbeused.
Alloftheaminoglycosidesarepotentiallyuseful,althoughtobramycinhasbeen
showntobemoreeffectiveagainstpseudomonadsthangentamicin.Doharetal
haveshownthatpiperacillinisprobablythemosteffectiveantibiotic.Ceftazidime
remainsausefulchoiceformanypatients.Systemictherapyshouldbecontinued
for34weeks.Mostindividualsexperiencethecessationofotorrheainshorter
periods.Antimicrobialtherapyshouldprobablybecontinuedatleast34daysafter
thecessationofotorrhea.
Ciprofloxacinremainsthemosteffectiveofthequinolonesforpseudomonads.
Someofthelategeneration"respiratoryquinolones"appeartobemoreefficacious
forSaureus.Fluoroquinolonesarenotapprovedforuseinchildrenbecauseanimal
studiesusingjuvenilesubjectshaveshownthattheyelicitjointinjury.Nevertheless,
alargedatabaseofchildrenwithcysticfibrosiswhohavebeentreatedwithsystemic
fluoroquinolonesatrelativelyhighdosesforprolongedperiodsdemonstratesthat
theriskofjointinjuryappearstobeabsentorverylow.Nocasesofpermanentjoint
injuryhavebeenreported.
Afewchildrenofthemanythousandstreatedhavedevelopedpainthatremitted
withthecessationoftherapy.Giventherealpotentialtoxicityofintravenously
administeredantibiotics(especiallytheaminoglycosides),seriousconsideration
shouldbegiventotheuseoforalfluoroquinoloneswhentreatingchildrenwith
CSOMunresponsivetotopicaltherapy.Potentially,thefluoroquinolonesarethe
mostusefulclassoforalantibioticsfortreatingCSOM.Oraltherapyachievesserum
concentrationsashighasparenteraltherapy,obviatingtheneedforintravenous
delivery.
Theriskofinjury,adversereaction,orsignificantadverseeffectsappearstobe
loweroverallwithsystemicquinolonesthanwithmanyoftheotherantibiotics
normallyusedtotreatgramnegativeinfections.Mostparentsareamenabletothe
offlabeluseoforalfluoroquinolonesiftheyunderstandtherelativerisksand
potentialbenefitsofferedbythisclassofdrugsincomparisontothevariable
alternatives.
SurgeryshouldbeconsideredifCSOMfailstorespondtoacombinationoftopical
andsystemictherapy.Atympanomastoidectomycaneliminateinfectionandstop
otorrheain80%ofpatients.

SurgeryforChronicEarDisease
PatientswithCSOMthatisunresponsivetotopicaland/orsystemicmedicaltherapy
withappropriateauraltoiletandcontrolofgranulationtissuerequiresurgery.The
modernsurgeryforchronicotitismediawaspopularizedinthe1950s.Priortothis,
earsurgerywasprimarilysuccessfulatdrainingactiveinfection,andtherewasless
concernaboutlongtermfunctionaloutcomes.Currentgoalsforsurgeryforchronic
eardiseaseincludeadry,safeearandthepreservationofthenormalstructureand
functioningtothegreatestextentpossible.
InpatientswithCSOMwithoutcholesteatoma,surgeryisconsideredifthe
perforationispersistentandlongstandingandcausesclinicalsymptoms,suchas
recurrenteardischargeandhearingloss.Theage,generalphysicalcondition,
fitnessforgeneralanesthesia,andcoexistingdiseasesofthepatientalsoplayan
importantroleinconsideringsurgery.
Generalindicationsforsurgeryareasfollows:
Perforationthatpersistsbeyond6weeks
Otorrheathatpersistsforlongerthan6weeksdespiteantibioticuse
Cholesteatomaformation
Radiographicevidenceofchronicmastoiditis,suchascoalescentmastoiditis
Conductivehearingloss
ForpatientswithearlyormildCSOMcholesteatoma,auraltoiletandrepeated
suctionclearanceoftheearwithwatchfulexpectancymaybeperformedfor
patientswithadvanceddisease,explorationofthemastoidandtympanoplastyis

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recommended.
TheprincipalaimofsurgeryforCSOMisfirsttoclearoutthediseaseandonly
then,ifpossible,toreconstructthepatient'shearing.Hearingreconstructionisoften
completedinaplannedsecondstageoperationinpatientswithcholesteatoma.
Stagingtheearallowsforthedevelopmentofahealthy,aircontainingmiddleear
space.Furtherinspectionofthemiddleearandmastoidcavitycanconfirmthatthe
cholesteatomahasbeeneradicated.Silasticorothermaterialisoftenplacedinthe
middleearandmastoidcavitytopreventpostoperativescarring.Thismaterialis
thenremovedduringthesecondstageprocedure.
Contraindications(relativeandabsolute)tosurgeryfortubotympanicdiseaseareas
follows:
Surgeryontheonlyhearingear
Poorgeneralphysicalcondition,oldage,ordebilitythatmakesgeneral
anesthesiarisky
Patientsunwillingtoundergosurgery
Surgeryonpatientswithunilateralvestibularablation
Contraindicationstosurgeryforatticoantraldiseaseareasfollows:
Earlyormildcholesteatomaamenabletoauraltoilet
Patientswhoareseverelyillandthosewithcomplicationssecondaryto
cholesteatoma,suchasabrainabscess(drainageofthebrainabscessand
intravenousadministrationofantibioticsshouldbeconsideredfirst)

MyringoplastyandTympanoplasty
Myringoplastyistheoperationspecificallydesignedtoclosetympanicmembrane
defects.Theapproachtotheearcanbetranscanal,endaural,orretroauricular.The
transcanalapproachrequireslesssurgicalexposureandleadstofasterhealing.The
downsideisthepotentiallimitationofexposure.Theendauralapproachcan
improveexposureinearswithalateralsofttissueorcartilageovergrowth,but
again,ittendstolimitthesurgicalview.Theretroauricularapproachallowsfor
maximalexposurebutrequiresanexternalskinincision.
Twomainsurgicaltechniquesoftympanoplastyarecommonlyused:theunderlay
andtheoverlay.Theunderlaytechniqueinvolvesplacingthegraftmaterial
underneath(ormedialto)theeardrum.Theunderlaytechniquerequiresdissection
andelevationofatympanomeatalflap.Themarginsoftheperforationare
freshenedbyremovingtheepitheliumfromtheedgesofthehole.Thegraft
materialistuckedunderneaththeeardrumandissometimessupportedwith
Gelfoam.Then,thereconstitutedeardrumisflippedbacktoitsnormalresting
position,andtheearcanalisfilledwithpackingmaterial.Thelateralgrafttechnique
requiresremovaloftheearcanalandtympanicmembraneepithelium,aswellasa
canaloplasty.Thistechniqueisparticularlywellsuitedtorevisiontympanoplastyor
earswithnarrowcanals.Itissomewhatmoretechnicallydemandingbuthasavery
highsuccessrate,particularlyinscarredtympanicmembranes.
Theoverlaytechniqueinvolvesgraftinglateraltotheeardrum.Variousgraft
materialsmaybeused.Themostcommonmaterialsaretemporalisfascia,tragal
perichondrium,andveingraft.Anadditionaltechniqueisthe"stuffthrough."This
maybeusefulforsmallperforationsinotherwisehealthyears.Thisprocedure
essentiallyfreshenstheedgesoftheperforationandthenfillsitwithaplugof
tissue,usuallyfat.

Chronicotitismediawithcholesteatoma
ArangeofsurgicalproceduresareavailableforthemanagementofCSOMwith
cholesteatoma,andthechoiceofproceduredependsontheextentandtheseverity
ofthediseaseandthehearingoftheindividual.Theultimateaimoftheprocedure
istoprovidethepatientwithasafe,dryear.Hearingimprovementisasecondary
considerationand,ifattempted,isusuallyperformedduringasecondstagesurgery.
Hearingreconstructionshouldnotbeperformedatthecostoforbycompromising
theclearanceofthediseaseinthepatient.
Tympanoplastyisperformedtoeradicatediseasefromthemiddleearandto
reconstructthehearingmechanism,withorwithoutgraftingofthetympanic
membrane.The5differenttypesoftympanoplastieshavebeendefined.Theseare
primarilyofhistoricalinterest.Thefollowingdefinitionsdescribingthe5typesof
tympanoplastiesareusedformiddleearsurgeryandmastoidsurgery:
Type1issimpleclosureofthetympanicmembraneperforationwithout
reconstructingtheossicularchain
Type2isanykindofossicularreconstructioninvolvingthemalleus,the
incus,orboththestapesheadisintact
Type3involvesputtingthetympanicmembranegraftovertheheadofthe
stapes
Type4occurswhenthestapesheadisabsentbutthefootplateispresent
thestapesfootplateisexteriorizedtothemastoidcavity,andthegraftis
placedovertherestofthemiddleearcavity,includingtheroundwindow
hence,thephasedifferenceismaintained.
Type5isalsocalledthefenestrationoperationitinvolvesmakingafenestra
inthelateralsemicircularcanalandthenputtingagraftoveritthisisnot
oftenperformedtoday
Tympanoplastyisbrokendowninto2primarytypes:lateralgraftingandmedial
grafting.Inthelateralgrafttechnique,thegraftmaterialislaidlaterallytothe
annulusaftertheremnantofsquamoustissueisdenuded.Inmedialgrafting,the
annulusisraisedandthegraftslippedmedially.

Mastoidectomy
CorticalmastoidectomyisalsoknownastheSchwartzeoperation.Itconsistsofthe

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removaloftheouterwallofthemastoidcortexandtheexteriorizationofallthe
mastoidaircells.Thismaybeperformedimmediatelyincoalescentmastoiditis,in
whichcaseadrainmaybeleftpostoperatively.
Canalwallupmastoidectomyreferstotheremovalofmastoidaircellswhile
retainingtheposteriorcanalwall.Usingthisapproachwithafacialrecess(drilling
theboneoftheposteriormesotympanumorfacialrecessbetweentheincus,the
chordatympaninerve,andthefacialnerve),themiddleearstructurescanbe
accessedforcarefuldissectionofthecholesteatoma.Thisapproachleavesthe
normalearcanalanatomyintact,therebypreventingthepotentialproblemsseen
withamastoidcavity.Thisisalsothecommonapproachforcochlearimplantation.
Modifiedradicalmastoidectomydiffersfromradicalmastoidectomyinthatthe
ossiclesandthetympanicmembraneremnantsarepreservedforpossiblehearing
reconstructionatalaterstage.Radicalmastoidectomyinvolveseradicationofall
diseasefromthemiddleearandthemastoidandexteriorizationofthesestructures
intoasinglecavity.Italsoincludesremovingtheentiretympanicmembraneandthe
ossicles(exceptthestapesfootplate)andclosingtheeustachiantubeopening.
Currently,thisprocedureisperformedonlyinveryunusualsituations.

PostoperativeDetails
Withmastoidectomy/tympanoplasty,earpackingcanberemovedafter3weeks
(earlierifinfected).Often,eardropsareprescribedtobestarted3weeksafter
surgery.Thepackingisthenremovedat56weekspostoperatively,particularlyin
thelateralgrafttympanoplasty,whichrequiresadditionalhealingtime.
Thepatientreceivesfollowupcareregularlyuntilthecanalorcavityiswell
epithelialized.Ateachfollowupvisit,anysignsofrecurrentcholesteatomaare
noted.Ifanyhearingreconstruction/ossiculoplastyhasbeenperformed,an
audiogramisindicatedat3months.Oncethecanalishealed,waterprecautions
canbestopped.Ifacanalwalldownmastoidectomyisperformed,waterentrance
maystillbediscouraged.Themastoidcavitycanbeirrigatedwithasolutionof
alcoholandvinegarasneeded.Routinecleaningofthemastoidcavitymayalsobe
indicatedifcanalwalldownproceduresareperformed.

SurgicalComplications
Complicationsoftympanoplastymayincludethefollowing:
Graftfailureratesrangefrom1020%dependingonthetechniqueusedand
theexperienceofthesurgeon
Infectionisapotentialcomplicationwithanysurgicalprocedurebutisrarely
seenintympanoplastysomesurgeonsrecommendperioperativeantibiotics,
buttherearelittledatatosupporttheiruse
Hematomascandevelopwithpostauricularapproaches
Tastedisturbanceoccurssecondarytodamagetothechordatympaninerve
ittendstobeselflimitingbutcanbedisturbingtopatients
Earnumbnesscanresultifthepostauricularincisionseversperipheral
sensorynerves,leadingtosomenumbnessofthepinnaandlobulethisis
particularlydisturbingtopatientswithpiercedearswhodependonthe
feelinginthelobuletoplaceearrings
Conductivehearinglosscanoccursecondarytoossiculardisruptionor
sclerosisscarringoftheneotympanicmembranethatleadstolateralization
canalsocauseaconductiveloss
Sensorineuralhearinglossisrarelyseenbutisconsideredaserious
complication
Vertigocanoccurduringanymiddleearprocedureandisusuallyself
limitinghowever,ifitissevereorpersistent,furtherworkupmaybeinorder
Facialparalysisisrarebutissometimesseensecondarytolocalanesthetic
infiltration,althoughanestheticrelatedparalysisusuallyresolvessoonafter
surgery
Complicationsofmastoidectomyortympanomastoidectomyincludethoselisted
aboveandthefollowing:
CSFleakmayoccuriftheduraisencounteredandviolatedduringthe
dissectionthiscanoftenberepairedifrecognizedduringsurgery
Intracranialcomplicationscanincludebrainabscess,meningitis,orphysical
damagetothebrainitself

SurgicalPrognosis
Tympanoplastyprovidesmostpatientswithahealed,dryear.Inpatientswith
cholesteatoma,astagedproceduremaybebeneficialtoensurecomplete
eradicationofcholesteatoma.Theossicularchaincanbereconstructedwith
autologoustissue(cartilage,bone)orwithprostheticimplantsatthesecondsurgery.
Thesepatientsrequirediligentsurveillanceasrecurrenceoftheoriginaldisease
processisnotuncommon.
Thegeneralandmostdesirableoutcomeforapatientwhohasundergonea
tympanomastoidectomyisadry,nondischarging,healthyear.Longtermfollowup
careofthesepatientsisessentialtodetecttherecurrenceofcholesteatomaatits
earliestonset.Insuchcases,anotherproceduremaybenecessary.Thelikelihood
ofhearingpreservationdependsontheextentofthediseaseandtheinvolvement
oftheossicles,whichvarieswidely.

Prevention
Thefollowingmeasureshelppreventrecurrenceandallowforearlyinterventionin
patientswithrecurrentinfections:
Patientsshouldbeadvisedtokeeptheirearsdrytopreventfuture
complications,evenaftermedicaltreatmentresultsinasafeanddryear

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swimmingisnotcontraindicatedifpatientsdrytheirearsafterward
Tympanoplasty,asurgerythatsealstheperforation,preventsthe
translocationofbacteriafromtheexternalearcanalintothemiddleearthe
uninflamed,protectedmiddleearmucosadetersfuturedevelopmentof
CSOM
Earlysymptomsofauralfullness,otalgiawithorwithoutfever,andheadache
warrantevaluationbyanotolaryngologistinpatientswitharecenthistoryof
CSOM
Medication

ContributorInformationandDisclosures
Author
PeterSRoland,MDProfessor,DepartmentofNeurologicalSurgery,ProfessorandChairman,Departmentof
OtolaryngologyHeadandNeckSurgery,Director,ClinicalCenterforAuditory,Vestibular,andFacialNerve
Disorders,ChiefofPediatricOtology,UniversityofTexasSouthwesternMedicalCenterChiefofPediatric
Otology,ChildrensMedicalCenterofDallasPresidentofMedicalStaff,ParklandMemorialHospitalAdjunct
ProfessorofCommunicativeDisorders,SchoolofBehavioralandBrainSciences,ChiefofMedicalService,
CallierCenterforCommunicativeDisorders,UniversityofTexasSchoolofHumanDevelopment
PeterSRoland,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanAuditory
Society,TheTriologicalSociety,NorthAmericanSkullBaseSociety,SocietyofUniversityOtolaryngologists
HeadandNeckSurgeons,AmericanNeurotologySociety,AmericanAcademyofOtolaryngicAllergy,American
AcademyofOtolaryngologyHeadandNeckSurgery,AmericanOtologicalSociety
Disclosure:ReceivedhonorariafromAlconLabsforconsultingReceivedhonorariafromAdvancedBionicsfor
boardmembershipReceivedhonorariafromCochlearCorpforboardmembershipReceivedtravelgrantsfrom
MedElCorpforconsulting.
Coauthor(s)
BrandonIsaacson,MD,FACSAssociateProfessor,DepartmentofOtolaryngologyHeadandNeckSurgery,
UniversityofTexasSouthwesternMedicalCenter
BrandonIsaacson,MD,FACSisamemberofthefollowingmedicalsocieties:AmericanAcademyof
OtolaryngologyHeadandNeckSurgery,AmericanCollegeofSurgeons,NorthAmericanSkullBaseSociety,
TexasMedicalAssociation,TriologicalSociety,AmericanNeurotologySociety
Disclosure:ReceivedconsultingfeefromMedtronicMidasRexInsituteforconsultingReceivedmedicaladvisory
boardfromAdvancedBionicsforboardmembershipReceivedconsultingfeefromStrykerforspeakingand
teaching.
ChiefEditor
ArlenDMeyers,MD,MBAProfessorofOtolaryngology,Dentistry,andEngineering,UniversityofColorado
SchoolofMedicine
ArlenDMeyers,MD,MBAisamemberofthefollowingmedicalsocieties:AmericanAcademyofFacialPlastic
andReconstructiveSurgery,AmericanAcademyofOtolaryngologyHeadandNeckSurgery,AmericanHeadand
NeckSociety
Disclosure:Serve(d)asadirector,officer,partner,employee,advisor,consultantortrusteefor:
MedvoyTestappropriateCerescanEmpiricanRxRevu<br/>ReceivednonefromAllergySolutions,Incforboard
membershipReceivedhonorariafromRxRevuforchiefmedicaleditorReceivedsalaryfromMedvoyforfounder
andpresidentReceivedconsultingfeefromCorvectraforseniormedicaladvisorReceivedownershipinterest
fromCerescanforconsultingReceivedconsultingfeefromEssiahealthforadvisorReceivedconsultingfeefrom
CarespanforadvisorReceivedconsultingfeefromCovidienforconsulting.
Acknowledgements
AnuragJain,MBBS,FRCS(Ire),MS,FRCS(Oto),MS(Oto),DLO(RCSEngland)SpecialistRegistrar,
DepartmentofOtolaryngology,PinderfieldsGeneralHospital,Wakefield,UK
AnuragJain,MBBS,FRCS(Ire),MS,FRCS(Oto),MS(Oto),DLO(RCSEngland)isamemberofthefollowing
medicalsocieties:AssociationofOtolaryngologistsofIndia,BritishAssociationofOtorhinolaryngologists,Head
andNeckSurgeons,BritishMedicalAssociation,RoyalCollegeofSurgeonsinIreland,andRoyalCollegeof
SurgeonsofEngland
Disclosure:Nothingtodisclose.
JeffreyRobertKnight,MBChB,FRCSConsultingSurgeon,DepartmentofOtolaryngology,MaydayUniversity
Hospital,London
Disclosure:Nothingtodisclose.
JohnCLi,MDPrivatePracticeinOtologyandNeurotologyMedicalDirector,BalanceCenter
JohnCLi,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOtolaryngologyHeadand
NeckSurgery,AmericanCollegeofSurgeons,AmericanMedicalAssociation,AmericanNeurotologySociety,
AmericanTinnitusAssociation,FloridaMedicalAssociation,andNorthAmericanSkullBaseSociety
Disclosure:Nothingtodisclose.
DavidParry,MDStaffPhysician,DepartmentofOtolaryngologyHeadandNeckSurgery,ENTAssociatesof
Children'sHospital,Boston
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeReferenceSalaryEmployment
PeterAWeisskopf,MDNeurotologist,ArizonaOtolaryngologyConsultantsHead,SectionofNeurotology,
BarrowNeurologicalInstitute
PeterAWeisskopf,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOtolaryngology
HeadandNeckSurgeryandAmericanCollegeofSurgeons
Disclosure:Nothingtodisclose.

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ChronicSuppurativeOtitisMediaTreatment&Management:ApproachConsiderations,AntibioticDrops,AuralToilet

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