OMCr+Review

REVIEW ARTICLE

Chronic suppurative otitis media: A review

Monique Verhoeff a, Erwin L. van der Veen a, Maroeska M. Rovers a,b,c,Elisabeth A.M. Sanders c, Anne G.M. Schilder a,*

aDepartment of Otorhinolaryngology (KE04.140.5), Wilhelmina Children’s Hospital,University Medical Centre Utrecht, P.O. Box 85090, 3508 AB Utrecht, The Netherlandsb Julius Centre for Health Sciences and Primary Care (STR 6.131), University Medical Centre Utrecht,P.O. Box 85090, 3508 AB Utrecht, The NetherlandscDepartment of Pediatric Immunology (KC03.063.0), Wilhelmina Children’s Hospital Utrecht,University Medical Centre Utrecht, P.O. Box 85090, 3508 AB Utrecht, The Netherlands

Received 10 April 2005; accepted 26 August 2005

International Journal of Pediatric Otorhinolaryngology (2006) 70, 1—12

www.elsevier.com/locate/ijporl

KEYWORDSChronic suppurativeotitis media (CSOM);Pathogenesis;Risk factors;Clinical management

Summary

Objectives: Chronic suppurative otitis media (CSOM) remains one of the most com-mon childhood chronic infectious diseases worldwide. Although microbial, immuno-logical, and genetically determined factors, as well as Eustachian tubecharacteristics, are supposed to be involved in the pathogenesis of CSOM, manyaspects of the pathogenesis of CSOM still need to be clarified. Optimal treatmentstrategy has not been established yet. The objective of this review is to present andevaluate the current state of knowledge of CSOM.Design: Systematic narrative review.Methods: A PubMed search (1966—January 2005) was performed for studies onepidemiology, pathogenesis, clinical management, and complications of CSOM. Allincluded articles were categorized according to level of evidence.Results: Five hundred and fifty papers were identified, of which 79 were found to berelevant for this review. The definition of CSOM was found to vary. CSOM is amultifactorial disease. Regarding management of CSOM, there is no consensus asto what the optimal management strategy should entail. No convincing evidence isavailable for most medical and surgical therapies. Topical quinolones have proveneffective, but need further monitoring regarding adverse effects.Conclusions and recommendations: Important goals in research of CSOM should beachieving consensus about the definition of CSOM and gaining more in-depth knowl-edge of the pathogenesis of CSOM, especially the role of innate and adaptiveimmunity. There is also a need for further well-designed studies on the effectivenessof various management strategies for CSOM.# 2005 Elsevier Ireland Ltd. All rights reserved.

* Corresponding author. Tel.: +31 302504004; fax: +31 302505348.E-mail address: [email protected] (Anne G.M. Schilder).

0165-5876/$ — see front matter # 2005 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.ijporl.2005.08.021

2 M. Verhoeff et al.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22. Search strategy and selection criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24. Definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25. Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36. Risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37. Pathogenesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38. Eustachian tube function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49. Microbiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

10. Immunology and genetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511. CSOM in systemic conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512. Complications and sequelae of CSOM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513. Clinical management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

13.1. Topical treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613.2. Systemic treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613.3. Surgical treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

14. Hearing revalidation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 815. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1. Introduction

Chronic suppurative otitis media (CSOM) remainsoneof themost commonchildhood chronic infectiousdiseases worldwide, affecting diverse racial and cul-tural groups both in developing and industrializedcountries. It involves considerable morbidity andcan cause extra- and intracranial complications[1—5].

There are still many questions about the patho-genesis of CSOM and consequently about what theoptimal management — medical and/or surgical —should entail.

In this article, the current state of knowledge inepidemiology, pathogenesis, complications, andmanagement of CSOM is reviewed systematicallyfrom a clinical perspective, the ultimate aim beingto provide the clinician a tool in the management ofthis condition. In this connection, future researchgoals will be identified.

2. Search strategy and selectioncriteria

A PubMed search was done for articles dating from1966 to January 2005 with the MESH heading ‘‘Otitismedia, Suppurative’’ in combination with text- andkeywords complications, drug therapy, epidemiol-ogy, etiology, genetics, history, immunology, micro-biology, pathology, physiopathology, surgery, andtherapy. All studies in English on chronic suppurativeotitis media in children and adults, containing thesetext- and keywords were considered for inclusion.

After critical assessment of the abstracts identifiedby the initial search, the full content of all poten-tially relevant papers was reviewed for final selec-tion and data extraction.

The following articles were excluded: those deal-ing with topics other than CSOM, e.g. cholestea-toma; those focussing on technical aspects ofsurgery in CSOM; those with information includedin more recent updates on CSOM.

Subsequently, a review of identified report bib-liographies and a manual search of standard text-books on ENT surgery was undertaken.

3. Results

The search resulted in 550 citations, which afterapplying the criteria for in- and exclusion left 79articles for inclusion; 42 additional references werealso used. The articles were independently categor-ized by two authors (M.V. and M.M.R.) in levels ofevidence (Table 1) [6].

4. Definition

The textbook definition of CSOM is chronic inflam-mation of the middle ear and mastoid mucosa inwhich the tympanic membrane is not intact (per-foration or tympanostomy tube) and discharge(otorrhea) is present [7—9]. There is, however, noconsensus about the duration of the symptoms. TheWorld Health Organisation (WHO) [10] defines CSOMas ‘‘otorrhea through a perforated tympanic mem-

Chronic suppurative otitis media: A review 3

brane present for at least 2 weeks’’, while othersdefine ‘‘chronic’’ as symptoms persisting for morethan 6 weeks [1,11—14]. Since it is accepted thatCSOM is preceded by acute otitis media (AOM) trea-ted either incomplete or unsuccessfully [11,15,16],these variations in definition of duration of symp-toms suggest that the transition from otorrhea as asign of AOM to that of CSOM is not clearly estab-lished.

CSOM should be distinguished from tympanostomytube otorrhea (TTO), which is the most commoncomplication of tympanostomy tube placement[17,18], but as with AOM and CSOM, the transitionfrom TTO to CSOM is not well defined. At the sametime,CSOM shouldbedistinguished fromchronicOME(otitis media with effusion), in which no perforationor active infection is present, as well as from achronic perforation of the tympanic membrane(TM), in the absence of middle-ear infection [19].If a cholesteatoma is present, the term chronic sup-purative otitis media with cholesteatoma is used.

5. Epidemiology

The divergent definitions of CSOM and the inclusionof patients with cholesteatoma in reported preva-lences of CSOM, preclude an accurate estimate ofthe true prevalence and incidence of CSOM. CSOMmost often occurs in the first 5 years of life [20], andit is most common in developing countries, in specialpopulations such as children with craniofacialanomalies [21], and in certain racial groups [19].Highest prevalences of CSOM in children arereported among the Inuits of Alaska, Canada and

Table 1 References categorized in level of evidence

Level of evidence Study design

1a Systematic review of RCTsa

1b Individual RCTa (good quality)2a Systematic review of cohort studie2b Individual cohort study, incl. cohor

of cases; RCTa of low quality,e.g. <80% follow-up, allocation bia

3a Systematic review of case-control3b Individual case-control study3c Surveys4 Case-series, poor-quality cohort, a

case-control studies5 Expert opinionsOther e.g. in vitro studies, animal model

book chapters, etc.

Totala RCT: randomised controlled trial.

Greenland, American Indians, and Australian Abor-igines, and range from 7% to 46% [19,22—25]. Inter-mediate prevalences are reported in the SouthPacific Islands, Africa, Korea, India, and Saudi Ara-bia, ranging from 1% to 6% [19,26—28]. The lowestprevalences are found in highly developed industrialcountries such as the UK and the US: <1% [19,29].

6. Risk factors

Fliss et al. [30] have identified a history of acute andrecurrent otitis media, parental history of chronicotitis media, and crowded conditions (i.e. largefamilies with several siblings, large day care cen-tres) as significant risk factors for CSOM. They couldnot establish an association between CSOM andallergy, recurrent upper respiratory infections,breastfeeding, sex, parental age, or passive smok-ing. From a clinical perspective, however, some ofthese risk factors for AOM are likely to play a role inCSOM [31—33]. No quantitative data on risk factorsfor CSOM, such as odds ratios or prognostic modelsthat can predict which children will develop CSOM,are available.

7. Pathogenesis

The pathogenesis of CSOM is multifactorial: envir-onmental versus genetically determined factors aswell as anatomical and functional characteristics ofthe Eustachian tube are involved. The followingparagraphs describe the main causative factorsfor CSOM in greater detail.

References(PubMed search)

References(additional)

2 —— —

s — —t

s, low power

18 8

studies — —3 3

15 1nd 22 9

18 12s, 1 9

79 42


8. Eustachian tube function

The Eustachian tube has three important functionswith respect to the middle ear: ventilation, protec-tion, and clearance. Both endogenous and exogen-ous factors can impair these functions andtherefore cause OM (otitis media) [5,19,34,35].When a perforation of the tympanic membrane ispresent, either spontaneously or due to a tympa-nostomy tube, the middle ear ‘‘gas cushion’’ is lost,resulting in reflux of nasopharyngeal secretionsthrough the Eustachian tube and consequent con-tamination of themiddle earwith potential respira-tory pathogens [11,19,35]. Infants and youngchildren are especially at risk for such refluxbecause their Eustachian tubes are short, horizon-tal, and ‘‘floppy’’ [19,35]. Similarly, Down syn-drome and craniofacial anomalies such as cleftpalate affect both the anatomy and function ofthe Eustachian tube and so predispose to CSOM[21]. Yuceturk et al. [34] studied Eustachian tubefunction (automatic Toynbee test, tympanometry,Valsalva’s manouvre) in 60 ears with CSOM and 146control ears, finding Eustachian tube dysfunction in72% (95% CI, 61—83) versus 35% (95% CI, 27—43),respectively, ( p < 0.05).

Reduced ciliary function of the middle ear andEustachian tube mucosa has been associated withimpairment of clearance of middle-ear secretionsand may, therefore, facilitate the progression fromAOM/OME into CSOM [36,37].

Table 2 Most frequently isolated aerobic and anaerobic(percentage per ear)a

Author [ref.] Aerobic micro-organisms

Pseudomonasaeruginosa

Staphylococcusaureus

Grro

Kenna et al. [15] 67 20Fliss et al. [48] 62 14 7Arguedas et al. [13] 26 14 14Indudharan et al. [40] 36 31 10Brook and Yocum [46] 20 22 20Brook [44] 22 15 15Miro [41] 18 25 5Jonsson et al. [42] 30 30Erkan et al. [43] f 37 23 21Papastavros et al. [45] 55 29de Uzeda and Rocha [47] 18 33 31Ibekwe et al. [49] 25 23a Minimum and maximum (min—max) data are given when moreb Escherichia spp., Klebsiella spp., Proteus spp.c Data on Klebsiella species not provided.d Only total number of Haemophilus spp. is provided.e Data on Klebsiella spp. and Escherichia spp. not provided.f Percentage per case.g Data on Escherichia spp. not provided.

Gastroesophageal reflux may also contribute toEustachian tube dysfunction and subsequent mid-dle-ear infection [38,39].

9. Microbiology

In CSOM, bacteria can reach the middle ear eitherfrom the nasopharynx through the Eustachian tubeor from the external ear canal through a non-intacttympanic membrane [11,19,35]. The aerobic micro-organisms most frequently isolated in CSOM arePseudomonas aeruginosa (in 18—67% of ears), Sta-phylococcus aureus (14—33%), Gram-negativeorganisms, such as Proteus spp., Klebsiella spp.,and Escherichia spp. (4—43%), and Haemophilusinfluenzae (1—11%) [13,15,40—49]. The most fre-quently isolated anaerobic organisms are Bacter-oides spp. (1—91%) and Fusobacterium spp. (4—15%) (Table 2) [42—47]. In CSOM, the middle-earenvironment is thought to be more tolerant tounusual organisms like P. aeruginosa, S. aureus,and anaerobes; therefore, it is still uncertainwhether these bacteria are true pathogens in CSOMor might reflect secondary invaders or contamina-tion from the external auditory canal [2,7]. Thelarge variability in recovery rates of aerobic andanaerobic bacteria may be related to differences intiming of sampling during the course of the disease,prior use of antibiotics, and differences in sampling-and processing techniques, e.g. sterilizing the audi-

micro-organisms in chronic suppurative otitis media

Anaerobic micro-organisms

am-negativedsb

Haemophilusinfluenzae

Bacteroidesspp.

Fusobacteriumspp.

4—8c 4—6 n/a n/a—15 10—11 n/a n/a—22 1 n/a n/a—15 8 n/a n/a—43 9 24—61 15—35 9 17—71 8—11—10 2d n/a n/a21e 2 23 4

—40 n/a 11—34 56—9 n/a 5—10 n/a—42g 9 24—91 7—114—7g 7 1 n/a

than one Gram-negative rod or species was identified.


tory canal before sampling, transport media, ordelays in inoculation [2,7,11]. Fungi are alsothought to play a role in CSOM, especially Aspergil-lus spp. and Candida spp. [50,51]. In some popula-tions, especially those inhabiting hot, humid regionswhere fungi may well flourish, fungi are isolated in50% of cases with CSOM [50,51].

Recently, concern has risen about secondary fun-gal overgrowth as a complication of treatment withquinolone eardrops [52].

Recently, bacterial biofilms have gained atten-tion as a source of chronic infections. A biofilm is apopulation of bacterial cells growing on a surface,enclosed in an exopolysaccharide matrix; being dif-ficult to eradicate, they could be the source ofpersistent infections [53,54]. Biofilms may attachto damaged tissue, such as exposed osteitic boneand ulcerated middle-ear mucosa, or to otologicimplants such as tympanostomy tubes, and aretherefore thought to cause persistent infection inCSOM [11,54—56].

10. Immunology and genetics

In general, immunoglobulins IgG and IgA are mostimportant in the defence againstmucosal infectionslike CSOM. Secretory IgA (SIgA) is synthesizedlocally by plasma cells in the mucosa of the mid-dle-ear cavity and may be important in preventingbacteria from attaching to and colonizing the mid-dle-ear mucosa. Children with CSOM may lack SIgA[57]. IgG-class immunoglobulins facilitate phago-cytosis directly or via complement activation. IgGand IgG-subclass concentrations depend on age[58]. Children with recurrent upper respiratoryinfections may have low specific IgG-subclass(mostly IgG2) antibody levels (10—20% of cases)[59,60]. For CSOM no such data are available. Anessential condition for immunoglobulins to act istheir adherence to the bacterial wall, i.e. coating[58]. In CSOM, intense SIgA and IgG coating ofbacteria is common, but when P. aeruginosa isthe causative agent of the infection, no bacterialcoating is seen. This may well explain why infec-tions caused by P. aeruginosa are so difficult toeradicate [57,61].

Although many have reported on inflammatorymediators in AOM and OME, evidence about thespecific role of such factors in CSOM, like localcytokine production, is not yet available.

Genetic determinants of CSOM are still unknown.Against the background of twin studies in OM, show-ing a higher concordance rate in OM for monozygotictwins than for dizygotic twins, a genetic componentis also likely for CSOM [62,63].

Low serum levels of mannose-binding lectin (MBL)and polymorphisms of Fc gamma receptor have beenassociated with recurrent upper respiratory infec-tions and otitis media in childhood [64—66]. Furtherresearch into these and other modifier genes isnecessary to confirm their role in CSOM.

11. CSOM in systemic conditions

CSOM may occur as a part of a systemic condition,e.g. M. Wegener, tuberculosis, and Histiocytosis X[21,67,68], where the mastoid and middle ear maybe the localization of this specific inflammation.

12. Complications and sequelae ofCSOM

The most common sequela of CSOM is hearing loss,either conductive or sensorineural; this may affect ayoung child’s language development and school pro-gress. Chronic infection of the middle ear, causingoedema of the middle-ear lining and discharge,tympanic membrane perforation, and possibly ossi-cular chain disruption, results in a conductive hear-ing loss ranging from 20 to 60 dB [7,69,70].

There is some evidence that CSOM causes sensor-ineural hearing loss. Animal studies have shown thatinflammatory mediators, penetrating into the innerear through the round windowmembrane, can causethe loss of hair cells in the cochlea [71,72]. A recentstudy in humans has shown loss of outer and innerhair cells in the basal turn of the cochlea in patientswith CSOM [73].

Four studies have been identified reporting onsensorineural hearing loss in CSOM.

In one retrospective study of 218 patients (aver-age age 35 years) with unilateral CSOM the boneconduction threshold was 9—14 dB lower in diseasedears than in healthy ears [74]. In another retro-spective study of 121 patients (average age 37years) with unilateral CSOM, the bone conductionthreshold was 10—12 dB in the diseased ear com-pared to 3—4 dB in the healthy ear [75].

On the other hand, in two prospective studies, oneof 286 patients with unilateral CSOM (average age 50years) and the other of 87 children with bilateralCSOM (average age 5.5 years), no effect of the infec-tion on bone conduction thresholds was found[69,76]. No evidence was found suggesting that chil-dren are more susceptible to develop sensorineuralhearing loss in CSOM than adults [69,74—76].

CSOM can result in serious extracranial and intra-cranial complications. The reported overall extra-


and intracranial complication rate in CSOM variesfrom 0.7% to 3.2%; extracranial complications alonefrom 0.5% to 1.4% and intracranial complicationsfrom 0.3% to 2.0% [3,79]. The incidence of compli-cations appeared higher in pediatric patients than inadults with CSOM. With CSOM being more frequentin children, however, no adequate comparisonbetween complication rates in children and adultscan be made.

Themost frequent extracranial complications arefacial paralysis, subperiosteal abscess, mastoiditis,and labyrinthitis, with reported incidences of 13—58%, 40—68%, 14—74%, 7—34% of all extracranialcomplications, respectively [3,4,77—80].

The most common intracranial complications ofCSOM are meningitis, cerebral abscess, lateral sinusthrombosis, extradural abscess, otic hydrocephalus,and encephalitis, with reported incidences of 21—72%, 18—42%, 2—26%, 7—16%, 5—11%, and 2% of allintracranialcomplications,respectively[3,4,77—80].

13. Clinical management

13.1. Topical treatment

In developing countries, antiseptic drops, e.g. alu-minium acetate, boric acid, iodine powder, andpovidone-iodine are commonly used for CSOMbecause of their low cost and availability [81—83]. Eardrops containing antimicrobial agents eitherwith or without an anti-inflammatory componenthave been promoted as an effective therapy forCSOM since the 1950s [84—86]. Since the 1990s,fluoroquinolone drops have become available[33,41,87—92].

The effectiveness of ototopical drops was eval-uated in a Cochrane Review [82]. CSOM was definedaccording to WHO criteria, i.e. otorrhea through aperforated tympanic membrane present for at least2 weeks. Overall success percentages (dry ear) ofototopical drops varied from 40% to 100%. It wasconcluded that treatment with antibiotic or anti-septic eardrops accompanied by aural toilet wasmore effective in resolving otorrhea than no treat-ment (OR 0.37, 95% CI, 0.24—0.57) or aural toiletalone (OR 0.31, 95% CI, 0.23—0.43). Topical anti-biotics were not more effective than topical anti-septics (OR 1.34, 95% CI, 0.64—2.81), and topicaltreatment with antibiotic or antiseptic eardrops wasmore effective than systemic antibiotics (OR 0.46,95% CI, 0.30—0.69). The benefit of combinations oftopical antibiotics and steroids as compared totopical antibiotics alone has not been evaluatedformally. Combined treatment with topical and sys-temic antibiotics was not more effective than treat-

ment with topical antibiotics alone in terms ofotorrhea resolution (OR 1.71, 95% CI, 0.88—3.34).Topical quinolones appeared to be more effectivethan non-quinolone eardrops (OR 0.26, 95% CI,0.16—0.41).

Another systematic review by Abes et al. [93] alsoshowed that quinolone eardrops were more effec-tive than non-quinolones. They found a 2.67 timeshigher cure rate with topical 0.3% ofloxacin oticsolution, than with other topical or systemic anti-biotics (95% CI, 2.04—3.50). In a third non-systema-tic review, however, the authors stated that topicalquinolones were not superior to topical aminoglyco-sides [94].

The overall quality of the studies included inthese three reviews [82,89,93—97], was generallyconsidered low. The definition of CSOM, duration ofdischarge (3 weeks—40 years), age range of thepatients (21 months—79 years) and follow-up variedconsiderably. No consistent relation between dura-tion of CSOM or age of the patients and outcome wasfound. In all studies, outcome was defined as reso-lution of otorrhea; no data regarding the quality ofthe tympanic membrane or hearing were given.

The risk of ototoxicity by ototopical preparationshas been the subject of discussion for many years[84,98]. Potential ototoxicity of antibiotics, sol-vents, and antiseptics has been demonstrated inanimal studies, but information regarding theseadverse effects in humans is scarce [85]. In thestudies reviewed by Acuin et al. [82] negligible ratesof ototoxicity were found.

Secondary fungal overgrowth causing otitisexterna has been reported as a side effect of treat-ment with topical quinolones. With the growingenthusiasm for the use of these eardrops, the inci-dence of this complication is found to increase [52].

13.2. Systemic treatment

Systemic antibiotics are advised both as initial ther-apy for CSOM [21,51,96] and as secondary whentopical therapy fails [1,7,11,15,99—102]. InTable 3, the results of the available studies onsystemic treatment of CSOM are summarized; thesuccess rate of systemic antibiotics appears to bequite high, approximately 70%. Overall, the meth-odological quality of these studies was low. Becauseof heterogeneity of study populations and studydesign the data could not be pooled, nor couldsubgroups of patients with better or poorer outcomebe identified.

An expert panel called together by the AmericanAcademy of Otolaryngology–—Head and Neck Sur-gery concluded recently that systemic therapyshould only be considered in patients with CSOM


Table

3Systemic

treatmentforch

ronic

suppurative

otitismedia

(CSO

M)

Author[ref.]

NAve

rage

age

(ran

ge)

Typeofstudy

Antibiotictype

Durationof

treatment

Initial/seco

ndary

treatment

Route

of

administration

(oral,IV,IM)

Follow-up

Success

rate

(%)

Khan

naetal.[51]

110

n/a

RCTa

Culture

directedAB

vs.co

-trimoxa

zole

14Day

smax

imum

Initial

Oral

2Weeks

85vs.75

Flissetal.[1]

484Ye

ars

(1—12

years)

RCTa

Mezclocillin

vs.

ceftazidim

e10

—14

Day

sSe

condary

IV12

Day

s10

0Both

Kennaetal.[15]

36(1—17

Years)

Casereport

VarioustypesofAB

3—35

Day

sSe

condary

IV4—

20Months

89Dag

anetal.[101

]37

(6Months—

16ye

ars)

Cohort

of

cases

Ceftazidim

e21

Day

smax

imum

Seco

ndary

IV/IM

12Months

76

Esposito

etal.[100

]52

8.4Ye

ars

(6—12

years)

Casereport

Ceftazidim

e7—

10Day

sSe

condary

IM40

Day

smax

imum

67

Somekh

etal.[99]

304.2Ye

ars

(1—12

years)

RCTa

Ceftazidim

evs.

aztreonam

14Day

smax

imum

Seco

ndary

IV90

Day

s73

vs.53

Lege

ntetal.[96]

7542

.6Years

RCTa

Ciprofloxa

cinvs.

amoxycillin/clavu

lanic

acid

9Day

sInitial

Oral

10Day

s58

vs.37

aRCT:

randomisedco

ntrolledtrial.

showing signs of complicated or invasive infectionsor signs of systemic disease [84]. Consensus is lack-ing as to which antibiotic to use systemically as wellas about the duration of treatment in CSOM[11,103,104]; both broad-spectrum antibiotics, aswell as culture-directed therapy, have been advo-cated as initial oral therapy for CSOM [11,103].

13.3. Surgical treatment

Tympanomastoidectomy has been advocated as thesurgical treatment of choice in CSOM since the 1970s[7,16,105]. However, no prospective, randomised,controlled trials justifying this guidance have beenpublished [82]. Only three retrospective studies onsurgical treatment for CSOM are available. Vartia-nen et al. [105] reported the outcome of 221 earswith CSOM in children and adults managed witheither a one-stage tympanomastoidectomy (84%)or a mastoidectomy, with planned second-stagetympanoplasty (15%). The overall success rate,defined as dry ear plus an intact, mobile eardrum,was 73% (95% CI, 67—79). No differences were foundbetween results in children and adults. Anotherreport by the same authors, limited to children withCSOM, showed an equally successful outcome of(tympano)mastoidectomy, namely 74% (95% CI,59—89) [16]. Balyan et al. [106] analyzed the surgi-cal outcome in 323 patients (age range 4—68 years)with CSOM managed by: (I) tympanoplasty and mas-toidectomy (discharging ears); (II) tympanoplastyalone (discharging ears); or (III) tympanoplastyalone (dry ears). Graft success rates in groups I—III were 91% (95% CI, 83—98), 86% (95% CI, 73—99),and 90% (95% CI, 85—93), respectively. Mean resi-dual air-bone gaps were 17, 20, and 19 dB, respec-tively. The success percentage of surgery appearedto be higher in children below 16 years of age. Theeffect of duration of symptoms on outcome was notstudied. The authors concluded that results of tym-panoplasty combined with mastoidectomy are nobetter than tympanoplasty alone in patients withCSOM.

Studies comparing surgical versus medical thera-pies for CSOM are not available.

Regarding the timing of mastoid surgery andtympanoplasty for CSOM in children, opinions vary.Procter [9] recommends that mastoid surgery shouldbe delayed until puberty when possible, while Blue-stone et al. [7] and Vartiainen [16,105] considermastoid surgery indicated in all cases of CSOM thatdo not respond to conservative treatment, regard-less of age.

Regarding tympanoplasty alone in children withCSOM, some authors recommend this operation onlyin children older than 10—12 years of age because of


a higher incidence of surgical failures in youngerchildren [107,108]. Other authors state that agedoes not affect the outcome of tympanoplasty inchildren with CSOM [16,109,110].

In cases of therapy-resistant CSOM radical mas-toidectomy may be considered, with or withoutmastoid obliteration [111—114]. In one retrospec-tive case study of 16 patients (average age 44 years)who had undergone a radical revision mastoidect-omy, 80% obtained a dry ear (95% CI, 60—99) [111].In another case-control study of 30 patients withCSOM who had been managed by revision mastoi-dectomy with mastoid obliteration using a tempor-oparietal fascial flap, 96% (95% CI, 89—100) had adry ear at 12 months follow-up versus 10% (95% CI,1—21) of 30 conservatively treated patients withCSOM [114].

14. Hearing revalidation

Bone-anchored hearing aids (BAHA) became avail-able in the 1980s. They are considered a goodalternative to conventional bone-conduction hear-ing aids in patients with chronic draining ears [115—118]. A retrospective study of 69 patients with CSOMpreviously using a conventional hearing aid showed areduction of discharge in 84% of patients followingfitting with a BAHA; 58% of patients were moresatisfied with their BAHA than with their previousaid [116]. Audiologically, patients with CSOM do notperform better with BAHAs than with air conductingaids [115,118].

Up till the 1980s CSOM was considered a contra-indication for cochlear implantation because of therisk of spread of the infection to the intracranialspace [119]. However, two recent studies whichincluded 19 patients with CSOM, one with an aver-age follow-up period of 18 months and the other 4years, showed that cochlear implantation could besafely achieved in these patients [120,121].

15. Discussion

A large number of studies have been published aboutCSOM, but the great variability of these studiesprecluded pooling of the results in a meta-analysisor a systematic review. Therefore, this review isnarrative. As such, it might be prone to bias in theselection of articles, interpretation of results, andrecommendations.

To minimize such bias, we performed an elabo-rate PubMed search using a MESH heading, whichensured us of finding all articles about suppurativeotitis media. We included all articles that provided

us actual and relevant information about CSOM; allother subjects than CSOM were excluded. This studyshows that most articles on CSOM are expert opi-nions or case-series, using very variable definitionsof CSOM, small study populations, and short follow-up duration, hence overall yielding poor evidence.

We, therefore, believe that future research inCSOM should be directed to:

1. A
chieving consensus regarding the definition ofthe disease, including its duration. The WHOdefinition of CSOM as ‘‘otorrhea present for atleast 2 weeks’’, is not of much help to theclinician who is generally faced with patientswith a much longer duration of symptoms. Thevarious stages of this disease, especially thetransitional phase from AOM to CSOM, need tobe defined more clearly.
2. Id
entifying the risk factors and pathogenesis ofCSOM. It is assumed that factors involved in AOMalso have an important role in CSOM, but goodevidence for this assumption is lacking. Optimalmanagement of the disease and advice to theparents should be based on the knowledge of therisk factors and pathogenesis of CSOM. In parti-cular, the role of innate and adaptive immunity,e.g. modifier genes, as well as the role of bac-terial biofilms needs further study, as these canbe targets for new therapies.
3. D
eveloping prognostic models including factorsthat can predict which children will developCSOM.
4. S
ince so few well-designed studies of currentmedical and surgical therapies are available,management of CSOM is still controversial. Topi-cal quinolones are a promising option in themanagement of CSOM. Prospective and well-con-trolled studies are needed to establish the role ofboth medical and surgical therapies, includingthe optimal duration of treatment, for variousstages of CSOM.
Acknowledgment

The study was funded by a grant from the HealthCare Insurance Council, The Netherlands.

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