Chronic suppurative otitis media (CSOM)

1 Chronic suppurative otitis media

1. Definition

Chronic suppurative otitis media (CSOM) is a stage of the disease chronic infection which is being in progress on the ear middle without presence of membrane intact tympani. This condition is a chronic inflammation that occurs in the middle ear and mastoid cavity. This condition can cause continuous discharge accompanied by hearing loss. The discharge can be in the form of clear, thin or thick secretions and accompanied by pus, which lasts for a period of 6-12 weeks. Chronic suppurative otitis media is usually a complication of acute otitis media that occurs in children. ^8,9

Figure 1 Chronic suppurative otitis media (CSOM)

2 Epidemiology

Based on WHO data in 2013, it shows that around 360 million people worldwide experience hearing loss. Basic Health Research (Riskesdas) data in 2013 shows that around 2.6% experience hearing loss. The prevalence of CSOM in Indonesia is generally reported to be around 3.9%. According to a survey conducted in 7 provinces in Indonesia in 1996, the highest morbidity in the middle ear is CSOM, especially for benign CSOM (around 3%). In some populations, especially in humid and hot places where fungi can thrive, 50% of cases are found with CSOM. The incidence of CSOM cases is estimated at more than 20 million people worldwide. The prevalence of CSOM worldwide is around 65-330 million people with complaints of runny ears, 60% of whom (39-200 million) suffer from hearing loss. significant. Otitis incident chronic media with cholesteatoma is 3 in 100,000 in children and 9.2 in 100,000 adults. ^10,11

Chronic suppurative otitis media usually occurs in childhood, which most often occurs at the age of two years. The most common risk factor for CSOM in children is those who come from families with low socioeconomic status. This condition is also most common in children with craniofacial abnormalities, such as cleft palate and Down syndrome. Although very rarely reported, complications of CSOM can also occur in Gradenigo syndrome. This condition is accompanied by orbito-facial pain accompanied by paralysis of the sixth cranial nerve. Common characteristics that occurs in this congenital anomaly is a deficiency of Eustachian tube function, which is a predisposing factor for this disease. The main risk factors associated with CSOM are frequent episodes of acute otitis media, untreated upper respiratory tract infections, a history of trauma affecting the tympanic membrane, and poor nutritional conditions. ^8,9,123

3 Etiology

CSOM condition begins with acute otitis media (AOM) that does not improve or occurs repeatedly. Failure to heal tympanic membrane perforation that occurs in AOM is the basis for the development of CSOM. Several factors can cause this failure including: ^8,12,13

1. Persistent infection in the middle ear cavity with purulent otorrhea. Viral infection is the most common etiology of otitis media, but bacterial infection is also a common etiology of CSOM in children. The etiology of this condition is usually polymicrobial. In CSOM, both aerobic and anaerobic bacteria can be involved. The most common microorganism found in this condition is Staphylococcus aureus (MRSA). Other bacteria such as Pseudomonas aeruginosa, Proteus spp, Klebsiella spp, Bacteroides spp. and Fusobacterium spp can also cause this condition. Some bacteria, especially Pseudomonas aeruginosa and Staphylococcus aureus, can form biofilms with other pathogens. The bacterial biofilm that forms can protect the bacteria from antibiotics and the body's immune response. Less common causes are Aspergillus spp and Candida spp., where these organisms are found more frequently on patient Which experience disturbance system immunity. Tuberculosis can also cause CSOM and is the most common cause in areas with high incidence of tuberculosis.

2. Obstruction of the eustachian tube causing low pressure in the tympanic cavity and leading to inflammation. Obstruction of the eustachian tube can happen in a way functional (for example on condition cleft palate And paradoxical constriction) or in a way mechanical (for example, secretion mucoid, edema, neoplasm, nasogastric tube, adenoid hypertrophy).

3. Size perforation Which big.

4. The formation of network granulation And polyp in in cavity timpani. This network is formed in response to infection or inflammation.

    

   4 Pathophysiology

Pathophysiology from CSOM nature multifactorial, However mainly involves disturbance function of the tube eustachian. On basically The Eustachian tube has three main functions, namely preventing reflux of nasopharyngeal secretions into the middle ear, and regulating the pressure between the middle ear and the external environment to remain the same. Thus, obstruction of the Eustachian tube, whether functional or mechanical, will cause disruption of these functions, in this case in the form of increased negative pressure in the middle ear. This will cause transudation of serous fluid into the middle ear which can facilitate bacteria or other pathogens to replicate. Infections that occur will cause the formation of purulent exudate in the tympanic cavity which if the pressure is not reduced can lead to rupture of the tympanic membrane. In a perforated tympanic membrane, pathogens can still enter through the nasopharynx retrogradely as a result of the loss of the gas cushion. In addition, the tympanic membrane that fails to close can cause secondary infections in the form of pathogens entering the middle ear through the external acoustic canal through the perforated tympanic membrane. The ongoing inflammatory process as the body's immune response to ongoing infections can cause mucosal edema, mucosal ulceration, the formation of granulation tissue that can develop into polyps, and metaplasia of the middle ear epithelium that changes the cuboidal epithelium into a pseudostratified columnar epithelium so that capable increase secretion mucoid. Overall process Which happen if Keep going to be continued can destroy margin bone in surrounding area and causes various complications of CSOM. ^14-16

5 Diagnosis

The clinical manifestations of CSOM patients have several similarities with other disorders. other in the ear, so it requires further examination. carry on. In principle, the diagnosis of CSOM is based on the results of clinical examination in the form of anamnesis, physical examination and can be assisted by supporting examinations consisting of audiometry, bacterial culture and radiological examination. From the results of the anamnesis, complaints of ear pain (otalgia), discharge from the ear (otorrhea) that is continuous or intermittent for more than 2 months and hearing loss were obtained. A history of previous ear discharge was also obtained, especially accompanied by with episode have a cold, Sick throat, cough or some other symptoms of upper respiratory tract infection that can increase the suspicion of CSOM. Another sign of CSOM comes from a physical examination using an otoscope which aims to see the overall condition of the ear canal and tympanic membrane. In CSOM patients, it will provide a picture of tympanic membrane perforation which usually occurs in the central part. ^8,9,14 The examination can be supplemented with supporting examinations in the form of audiometry tests, bacterial cultures and radiological examinations. The audiometry test aims to determine the type and degree of hearing loss using pure tone audiometry, speech audiometry and BERA ( Brainstem Evoked Response Audiometry ) examination for patients or children who are uncooperative with pure tone audiometry examinations. Bacterial culture examination may not be necessary to establish a diagnosis of CSOM because the results of anamnesis and examination using an otoscope can already establish a diagnosis of CSOM. Bacterial culture is performed to identify pathogenic bacteria that cause CSOM, so that bacterial culture can determine antibiotics Which appropriate And increase process healing from CSOM. Bacterial culture is usually performed in cases of CSOM that do not improve with therapy due to antibiotic resistance. While the examination Plain radiography of mastoid Schuller position aimed at viewing cholesteatoma to differentiate between safe and dangerous types of CSOM. Results Plain mastoid radiographs in dangerous type CSOM will show a cloudy image of the mastoid and the disappearance of mastoid cell water. ^8,9,16,17

There are two types of procedures to evaluate the ear, namely: 1) surgical or operative and 2) diagnostic or pneumatic. By examining the ear, the degree of mobility of the tympanic membrane in response to negative or positive pressure can be evaluated to assess the presence of fluid in the middle ear, which is a characteristic of otitis media. Other abnormalities in the tympanic membrane found are erythema, protruding or full, or extreme retraction. Treatment CSOM need guided by inspection microbiology with targeting microorganisms according to the results. Pseudomonas is one of the most frequently found organisms in the physical environment and tends to live in humid areas. It is thought that this organism first infects tissue by attaching to epithelial cells through pili or fimbriae. ⁹

6 Treatment

The principle of treatment for safe type CSOM is conservative or medication. If the discharge continues to come out, then give ear wash medicine, namely with 3% H2O2 solution for 3-5 days. After the discharge decreases, then therapy is continued by administering ear drops containing antibiotics and corticosteroids. Antibiotic ear drops should not be given for more than 1 or 2 weeks because they are ototoxic. Topical quinolones are the treatment of choice for chronic suppurative otitis media. Quinolones are the same drugs or more effective than aminoglycosides and do not have the risk of ototoxicity. Quinolones effective in overcome otorrhea And eradicate microorganisms. Drug Ofloxacin ear drops have been reported to be safe and non-toxic to the labyrinth. Orally, patients can be given antibiotics of the ampicillin or erythromycin class (if the patient is allergic to penicillin). In infections suspected because the cause is resistant to ampicillin, ampicillin-clavulanic acid can be given. ^2,12 If there is no associated cholesteatoma, then parenteral antimicrobial therapy combined with thorough ear cleaning is likely to clear the infection, but in difficult-to-cure cases, tympanomastoidectomy surgery is required. Beta-lactam antipseudomonal drugs such as ceftazidime are used in cases requiring a parental regimen. Ticarcillin-clavulanate is an alternative agent that is effective against Pseudomonas sp. and S. aureus. ⁹

If the secretion has dried, but the perforation is still there after being observed for 2 months, then myringoplasty or tympanoplasty is performed. This operation aims to to permanently stop the infection, repair the perforated tympanic membrane, prevent complications or more severe hearing damage, and improve hearing. Meanwhile, the principle of treatment for dangerous type CSOM is with surgery, namely mastoidectomy with or without tympanoplasty. Conservative therapy with medication is a therapy while before surgery. If there is a retroauricular sub-periosteal abscess, then the abscess incision should be done separately before mastoidectomy. ¹⁸

Biofilm formation has been linked to the pathogenesis of infections and resistance to antibiotic treatment. If treated surgically, this may have some effect in preventing complications, but patients may still experience postoperative ear discharge. If the patient does not respond to the initial treatment regimen and/or develops a cholesteatoma or other mass, then the patient should be referred to an ENT. If a cholesteatoma is present, intervention from team ENT required For do mastoidectomy with tympanoplasty. It is also very important to always assess hearing function and provide appropriate follow-up to all patients who experiencing chronic otitis media. ^10.19

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