Definition and Frequency
When an inflammatory process in the middle ear lasts beyond three months and becomes established, it is defined as chronic middle ear inflammation (chronic otitis media). In this condition there is usually a hole in the eardrum that does not close, and the lining (mucosa) of the middle ear becomes prone to recurrent infections. Chronic otitis media can arise when some acute middle ear infections in childhood fail to heal completely and become chronic, but it can also develop in adulthood. Although its frequency in the population varies by region, it is regarded as a condition commonly encountered among patients attending ENT outpatient clinics. Rates are higher in communities where lower respiratory tract infections are frequent, access to healthcare is limited or Eustachian tube function is poor.
The disease can take two main forms: the mucosal type (simple chronic suppurative otitis media) and the cholesteatoma type. In the mucosal type, discharge comes from the permanent hole in the eardrum from time to time, and as long as there is no serious damage to the ossicular chain (the chain of hearing bones), hearing loss may remain limited. In the cholesteatoma type, tissue resembling the skin of the outer ear canal grows into the middle ear, forming an advancing mass that erodes the surrounding bony structures; this form follows a more aggressive course and carries a risk of complications.
Symptoms
The most typical sign of chronic otitis media is intermittent or continuous discharge from the ear. The discharge may be odourless, slightly smelly or, when cholesteatoma is present, quite foul-smelling. The amount of discharge increases during an upper respiratory tract infection, when water gets into the ear or when nasal congestion worsens. Most patients also have reduced hearing; this results from impaired sound conduction caused by the hole in the eardrum and possible damage to the hearing bones. A feeling of fullness in the ear, mild itching and occasional ringing may also be reported.
Pain is usually not prominent in chronic otitis media; signs such as marked pain, fever, dizziness, facial weakness or severe headache suggest that a complication may have developed and require urgent evaluation. When cholesteatoma is present, patients sometimes describe a feeling of pressure in the ear, progressive hearing loss and recurrent discharge that resists treatment. In children, chronic discharge should be monitored particularly carefully, as it can lead to hearing loss that may adversely affect speech development and school performance.
Causes and Risk Factors
Chronic otitis media is most often rooted in acute middle ear infections that did not heal completely, middle ear fluid left untreated for a long time (otitis media with effusion) and Eustachian tube dysfunction. The Eustachian tube ventilates the middle ear and balances its pressure; when this tube cannot perform its function adequately, negative pressure builds up in the middle ear, the eardrum is drawn inwards and, over time, an environment prone to infection develops.
Frequent upper respiratory tract infections, enlarged adenoids, exposure to cigarette smoke, growing up in crowded settings, anatomical differences such as cleft palate, and conditions such as allergic rhinitis increase the risk by impairing Eustachian tube function. Permanent holes in the eardrum left after trauma or surgery can also become a basis for chronic infection. In the development of cholesteatoma, long-standing retraction (inward collapse) of the eardrum or migration of skin tissue into the middle ear from the edge of a permanent perforation usually plays a role.
Diagnostic Process
Diagnosis begins with the patient’s history and an ear examination. During otoscopic examination with the help of a microscope or endoscope, the hole in the eardrum, the nature of the discharge, the condition of the middle ear lining and any skin debris belonging to a cholesteatoma are assessed. If discharge is present, the ear is cleaned first; this both makes the examination easier and allows a culture to be taken from the discharge when necessary.
Audiometry (pure-tone hearing test) and tympanometry are performed to determine the degree and type of hearing loss. Tympanometry provides information about middle ear pressure and the mobility of the ossicular chain; in the presence of a large eardrum perforation a flat curve may be obtained. When cholesteatoma is suspected, or when bone erosion or involvement of the inner ear or the facial nerve canal needs to be assessed, a CT scan of the temporal bone is requested. This imaging also provides important information for surgical planning. Rarely, when inner ear involvement is suspected, additional vestibular (balance) tests may be needed.
Treatment Options
Conservative Approach
During a period of active discharge, the first goal is to bring the infection under control. Regular, gentle cleaning of the ear, topical antibiotic ear drops and, when necessary, oral antibiotic treatment help reduce the discharge. Avoiding contact with water, using earplugs while swimming and treating conditions that cause nasal obstruction (such as allergic rhinitis or enlarged adenoids) can reduce recurrences. However, conservative treatment does not close a permanent hole in the eardrum; it temporarily stops the discharge and suppresses the infection.
Surgical Treatment
The standard treatment for repairing a permanent perforation and protecting the middle ear is tympanoplasty surgery. In this procedure the hole in the eardrum is closed using the patient’s own tissue (usually cartilage from around the outer ear or muscle membrane/fascia). In suitable cases the procedure can also be performed entirely endoscopically, without an incision behind the ear. If damage to the ossicular chain is found, repair of the ossicular chain (ossiculoplasty) can be planned in the same session or in a second session. When cholesteatoma is present, the aim is not only to improve hearing but, first and foremost, to clear the disease completely in order to prevent serious complications involving the inner ear, the facial nerve and the membranes of the brain; for this reason, surgery in cholesteatoma cases is usually planned more extensively, and a second-look operation is sometimes needed.
Recovery and Follow-up
After surgery the ear must be kept dry for several weeks, and contact with water and actions that can cause pressure changes, such as blowing the nose forcefully, should be avoided. Air travel and strenuous exercise may also be restricted for the period recommended by the doctor. The graft tissue usually takes several weeks to take hold; during this period the healing process is monitored with regular check-up examinations. Hearing is assessed once the swelling has subsided and the graft has fully settled; many patients experience a marked gain in hearing, but the result can vary depending on the inner ear reserve and the condition of the ossicular chain.
In patients operated on for cholesteatoma, long-term regular follow-up is important because of the possibility of the disease recurring. In some cases, periodic checks with imaging methods (such as magnetic resonance imaging) may be recommended. If ear discharge returns, or signs such as a sudden drop in hearing, dizziness or facial weakness develop, a physician should be consulted without delay.
Expectations and Quality of Life After Surgery
After tympanoplasty, the problem of recurrent ear discharge disappears in most patients, and they no longer face as many restrictions regarding contact with water as before. This markedly improves day-to-day quality of life, especially for patients who swim, holiday by the sea or play sport regularly. The improvement in hearing can differ from person to person depending on the condition of the ossicular chain before surgery, the health of the middle ear lining and the inner ear reserve; for this reason it is important to share realistic expectations with the patient before surgery. In some patients the intended result may not be achieved in a single session, and additional procedures such as ossicular chain repair may be planned in a second session.
Rarely after surgery, the graft may not take fully, a new hole may form or the infection may recur; in such cases re-evaluation and, if necessary, a second surgical procedure may be considered. For this reason, keeping to the recommended post-operative check-up schedule is of great importance for healing to be completed properly.
Frequently Asked Questions
Does chronic otitis media go away on its own? An eardrum hole that has become permanent does not tend to close on its own; infection episodes can be controlled with medication; when permanent closure of the hole is desired and it is clinically suitable, surgical repair is considered.
Can it be treated with drops alone, without surgery? Drops are effective in reducing active discharge and infection, but they do not close the hole in the eardrum; when permanent closure of the hole is desired, tympanoplasty is considered in clinically suitable patients.
Does cholesteatoma always require surgery? Yes. Because cholesteatoma is a progressive disease and can lead to serious complications, surgical treatment is recommended.
Does hearing return completely to normal after surgery? Many patients gain a marked improvement in hearing, but the result varies from person to person depending on the condition of the ossicular chain and inner ear function.
Does chronic otitis media affect hearing development in children? Because untreated chronic hearing loss can adversely affect speech and language development, early evaluation and treatment are important in children.
For the summary:
Back to the short articleThis article is for general information purposes only; please consult your physician for diagnosis and treatment.