Open Access Review

Article DOI: 10.7759/cureus.43729

Chronic Suppurative Otitis Media: A

Comprehensive Review of Epidemiology,
Received 07/19/2023
Pathogenesis, Microbiology, and Complications
Review began 08/03/2023
Review ended 08/10/2023 Mihika Khairkar 1 , Prasad Deshmukh 1 , Hindol Maity 2, 3 , Vijayshri Deotale 2
Published 08/18/2023

© Copyright 2023 1. Department of Otolaryngology, Head and Neck Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of
Khairkar et al. This is an open access Higher Education and Research, Wardha, IND 2. Department of Microbiology, Mahatma Gandhi Institute of Medical
article distributed under the terms of the Sciences, Sevagram, Wardha, IND 3. Department of Pathology, Jawaharlal Nehru Medical College, Datta Meghe
Creative Commons Attribution License CC- Institute of Higher Education and Research, Wardha, IND
BY 4.0., which permits unrestricted use,
distribution, and reproduction in any
medium, provided the original author and Corresponding author: Vijayshri Deotale, [email protected]
source are credited.

Abstract
Otitis media is a significant contributor to healthcare visits and the prescription of drugs. Its associated
complications and consequences pose the primary factors for preventable hearing impairment, especially in
developing nations. Chronic suppurative otitis media (CSOM) is prevalent among children globally as one of
the commonest chronic infectious diseases during childhood. The subsequent complications and sequelae
play a central role in causing avoidable hearing loss, particularly within developing countries. In addition to
impaired hearing, this condition can lead to severe health complications, such as issues involving the
intracranial region. Despite the involvement of microbial, immunological, and genetic factors as well as
Eustachian tube characteristics, in the development of CSOM, there remains a need for further elucidation
regarding its pathogenesis. Based on its microorganisms, the treatment of choice will be affected to prevent
further complications in the child. The primary approach to treating acute otitis media (AOM) involves
effectively addressing ear pain and fever symptoms, while antibiotics are only administered in cases where
children experience severe, long-lasting, or frequent infections.

Despite the extensive investigation on AOM pathogenesis, research is scarce regarding CSOM. Given that
antibiotic resistance and drug-induced ear damage are growing problems and surgery-related complications,
it is imperative to devise effective therapeutic interventions against CSOM arises. Therefore,
comprehending the host's immune function concerning CSOM and identifying how bacteria sidestep these
potent responses becomes crucial. Acquiring insight into molecular mechanisms associated with CSOM will
enable scientists to formulate innovative treatment approaches to combat this disease, thereby averting
hearing loss consequences. The management consists of watchful waiting, primarily for children with
chronic effusions and hearing loss.

Categories: Family/General Practice, Otolaryngology, Infectious Disease

Keywords: tympanoplasty, cholesteatoma, biofilm infections, aom, csom

Introduction And Background

Chronic suppurative otitis media (CSOM) is one of the most common infectious diseases encountered in the
practice of otolaryngology, affecting children globally, regardless of geographical or socioeconomic status.
The incidence of CSOM is estimated at more than 20 million people worldwide. Research conducted in
industrialized nations reveals that roughly 80% of preschoolers might have gone through at least a single
episode of acute otitis media (AOM) before they turn three, and nearly 40% will experience six or more
recurrences by the time they reach the age of seven. Comparable to other communicable ailments, AOM's
impact varies significantly among different countries based on factors such as suppurative complications
prevalence like mastoiditis, meningitis incidence rate, and sequelae development likelihood associated with
CSOM resulting in hearing loss [1-3]. CSOM is a condition where there is a prolonged inflammation of the
mucosa in the middle ear and mastoid space. It persists for more than two months, which causes a hole to
form in the eardrum and results in ongoing discharge from the ear canal. This persistent ailment can cause
profound health implications, such as complications within the intracranial area and significant morbidity
among those affected. These adverse outcomes make CSOM a major public health issue that requires
immediate attention to curb its prevalence worldwide [4-7]. The occurrence of this condition exhibits
considerable variation across different nations; however, it is particularly prevalent in countries with low-
and middle-income levels. By definition, chronic suppurative otitis media is a chronic infectious disease
associated with inflammation of the middle ear and mastoid mucosa, which can lead to perforation or
formation of a tympanostomy tube and discharge (otorrhea) [8,9]. There is no common consensus regarding
symptom duration, although some classifications define it as "otorrhea through a perforated tympanic
membrane lasting for at least two weeks," whereas others describe 'chronic' symptoms persisting beyond six
weeks [10-13].

The definition of CSOM varies depending on the duration and severity of symptoms, but it is generally

How to cite this article

Khairkar M, Deshmukh P, Maity H, et al. (August 18, 2023) Chronic Suppurative Otitis Media: A Comprehensive Review of Epidemiology,
Pathogenesis, Microbiology, and Complications. Cureus 15(8): e43729. DOI 10.7759/cureus.43729
 acknowledged that CSOM follows unsuccessfully or partially treated acute otitis media [14,15]. However,
there is no clear distinction between otorrhea as a sign of AOM and CSOM. It should be noted that
tympanostomy tube otorrhea, which results from complications with placing ear tubes, should not be
confused with CSOM. Chronic otitis media with effusion (OME) without active infection or perforation in
the eardrum must also be differentiated from CSOM and chronic perforations without middle-ear infections.
When dealing with cases involving cholesteatoma deposition around the inflamed tissues inside the ears, it
is referred to as CSOM with cholesteatoma. However, CSOM primarily affects children in the first five years
of life, particularly in developing countries and among populations with craniofacial anomalies [16].

CSOM has two distinct types: the first is the benign or tubotympanic type, which primarily affects the
inferior anterior region of the middle ear cleft and results in permanent central perforation. Despite this
symptom, individuals with this type of CSOM are not prone to severe complications. On the other hand, the
second classification is known as the malignant or atticoantral type-also called the "danger" type since it
involves both the attic and posterosuperior regions of the middle ear-posing severe health risks for those
affected by it [17]. The misuse and excessive use of antibiotics in recent times have led to changes in
important bacterial strains as well as their responses to antibiotics. As a result, addressing this situation has
become more complex. There have been reports on the changing prevalence and antibiogram (antibiotic
sensitivity patterns) of micro-organisms causing chronic otitis media over time and across different regions.
This is likely due to the indiscriminate usage of antibiotics. Therefore, regularly updating information on the
prevalence and antibiogram of these microorganisms for chronic otitis media would aid in patient
treatment. Currently, early identification through microbiological diagnosis ensures timely and effective
treatment while also helping prevent complications.

Review
Risk factors
Several risk factors can contribute to the development of CSOM. It is more commonly observed in children,
especially those in lower socioeconomic groups. The immature immune system and higher susceptibility to
infections in children increase their risk. Other risk factors include frequent or untreated acute otitis media,
inappropriate treatment for ear infections, poor hygiene, and environmental factors such as living in an
unclean or overcrowded environment, low socioeconomic status, limited access to healthcare facilities,
inadequate healthcare resources, genetic predisposition, malnutrition, and structural abnormalities like
cleft palate [18]. Other unique factors that increase the likelihood of CSOM include frequent AOM and
parents who have had CSOM in the past [3]. Further, allergies can be considered another risk factor, given
that certain research studies have indicated the existence of allergens causing hindrance to both the
Eustachian tube and nasal passages [19].

Methodology
Literature Search

To gather extensive information on the topic, we performed a thorough literature search with 47 PDF-
accessible articles after removing the duplicates published after 2015 (Appendix, Table 1). Additional articles
were referred to, which were cited by these articles. We utilized various databases such as PubMed, Cochrane
Library, and Google Scholar. Our search included specific keywords relevant to our study, including "chronic
suppurative otitis media", "CSOM", "microbiology", "treatment", "prevalence", and "burden of disease". We
also manually searched the reference lists of relevant articles to identify additional studies.

Inclusion and Exclusion Criteria

Incorporated in our research were studies that explored the various aspects of CSOM, such as microbiology,
epidemiology, diagnosis, treatment, and prevention. However, we opted to exclude non-English studies and
those that did not undergo the peer-review process.

Data Extraction and Synthesis

In order to conduct our analysis, we obtained information from each study that was included in the research.
To evaluate this collected information effectively, we employed a narrative approach, which allowed us to
provide an overview while highlighting important and current details.

Data Analysis

In our analysis, we employed a qualitative method to examine the data. We focused on identifying recurring
themes and patterns that emerged from the studies included in our research. Furthermore, we utilized
descriptive statistics as a means of succinctly summarizing the findings obtained.

Epidemiology

2023 Khairkar et al. Cureus 15(8): e43729. DOI 10.7759/cureus.43729 2 of 11

 CSOM is frequent, especially prevalent in underprivileged communities and developing nations. Its
predominance varies between 1 and 46% according to the demographic region and population [20]. Although
CSOM affects adults too, it primarily strikes children, mainly from two- to five-year-olds. It has also been
documented among elders more frequently [21]. A shared characteristic of these congenital abnormalities
pertains to insufficient Eustachian tube functionality, a condition that elevates the vulnerability of affected
children towards middle-ear ailments [22]. Risk determinants primarily related to CSOM consist of (A)
frequent occurrences of acute otitis media, (B) infections within the upper respiratory tracts, (C) any injury
affecting the tympanic membrane, and (D) inadequate nutrition and poor living arrangements.

Globally, the illness impacts many individuals, ranging from 65 to 330 million. The majority who are affected
reside in less developed nations. It has been approximated that there is an annual incidence of 31 million
new cases of CSOM, out of which approximately one-fifth account for children below five years old [23].

Mechanisms/Pathophysiology

Despite the substantial disease burden, OM cases in developed countries are typically uncomplicated and
self-limiting, with little incidence of persistent hearing impairment or developmental delay [24]. However,
high-risk populations residing in developing and well-developed regions often experience significant
lifelong hearing loss due to complex exposure to multiple genetic, environmental, and social risk factors.
The progression of OM pathology is an intricate amalgamation that begins with early colonization by
bacteria within the nasopharynx, followed by premature onset acute otitis media (AOM). Over time, this
leads to acute inflammation cycles within the middle ear due to ongoing exposure to infective agents such as
bacterial persistence through biofilm formation; viral infection ultimately results in severe chronic
conditions involving the ears (Figure 1) [25].

FIGURE 1: Pathways and factors affecting otitis media.

Image adapted with permission from Reference [25].

Eustachian Tube Anatomy

A functional Eustachian tube plays a vital role in safeguarding the middle ear by preventing the invasion of
bacterial otopathogens and respiratory viruses, facilitating the drainage of secretions from this area, and
ensuring pressure equalization. In infants, immature Eustachian tube anatomy significantly contributes to
susceptibility to infections in the middle ear. The main line of defense against entry and colonization by
otopathogens is located within the epithelium lining this structure, consisting primarily of ciliated
respiratory epithelial cells that synthesize antimicrobial proteins (e.g., lysozyme). Additionally, goblet cells
interspersed among these produce both serous and mucoid mucus. The action controls the proper direction

2023 Khairkar et al. Cureus 15(8): e43729. DOI 10.7759/cureus.43729 3 of 11

 through which mucociliary flow occurs, moving from the nasopharynx toward the middle ear, while
antimicrobial protein secretion protects against inflammatory reactions caused by bacteria residing there
[26].

In neonates and young children less than one year of age, the Eustachian tube is characterized by a shorter
length, a wider diameter, and a greater horizontal inclination. This structure permits easier transmission of
pathogens to the middle ear, leading to a higher susceptibility to otitis media. Placing infants in a supine
position also aggravates their vulnerability to infections. As kids grow older, a shift downward in skull base
elevation results in a gradual increase at an angle from 10° (at birth) up to about 45° (in adults), while
concomitantly increasing in length from approximately 13 mm at birth until it reaches ∼35 mm when fully
grown-up. Adjustments occurring due to these alterations, along with maturation in immune function, can
contribute towards a decreased risk profile about OM even among those classified as high-risk candidates for
otitis media infection [27].

Bacterial Infections and Biofilms

The pathogenesis of CSOM involves a fusion of various factors that contribute to the continued existence of
middle ear infections and inflammation. The onset of this condition generally starts with acute otitis media,
characterized by an infection in the intermediate ear. Inadequate treatment or inherent risk elements may
result in the development of CSOM, an advanced stage of AOM. Impaired Eustachian tube function plays a
significant role in leading to CSOM. When a rupture in the tympanic membrane occurs spontaneously or due
to the insertion of tubes into the eardrum, it leads to the loss of the middle ear's "gas cushion." This results
in backflow or reflux of secretions from the nasopharynx through the Eustachian tube [28].

As a consequence, contamination with respiratory pathogens takes place. Pressure equilibrium between the
middle ears and the outer atmosphere can lead to insufficient drainage and ventilation, causing bacteria or
fungus overgrowth. Reduced ciliary functions of the middle ear and Eustachian tubes; persistence or
frequent recurrence is another significant factor leading to chronic irritation among individuals with CSOM;
it could be due to incomplete eradication methods against bacterial pathogens or restrained immune
response mechanisms inadequately combating infections. Biofilms in CSOM, comprising structured bacterial
communities enclosed within a protective matrix, can be attributed to the persistence of the infection
[29,30]. The presence of biofilms enhances antibiotic resistance and the immune evasion ability of bacteria,
thereby hindering effective treatment measures [31].

Microbiology

The microbiology of CSOM entails the existence of diverse microorganisms, occasionally including fungi,
within the middle ear. Among these bacteria, Pseudomonas aeruginosa prevails and is deemed clinically
consequential due to its adeptness in developing biofilms and capacity for antibiotic resistance. Alongside it,
Staphylococcus aureus usually cohabits with a similar inflammatory impact, as this bacterium can generate
harmful toxins that trigger tissue damage. Moreover, Streptococcus pneumoniae is another common cause of
acute otitis media that may also lead to CSOM cases.

Other bacteria include Haemophilus influenzae, Moraxella catarrhalis, Proteus spp., and anaerobic
microorganisms such as Peptostreptococcus spp. and Prevotella spp. Furthermore, in areas with specific
geographic conditions or among individuals who have a weakened immune system, fungal infections like
Aspergillus spp. and Candida spp. can also contribute to the condition's progression. To find out the
anaerobic etiological agent, the otolaryngologist needs to remember the probability that anaerobic
organisms are also causative agents. Based on the gram staining picture, the microbiologist can report the
probable causative agent. Depending on factors like geographical location, personal immunity status, history
of antibiotic use, and other host elements involved, CSOM microbiology varies greatly. Henceforth,
appropriately identifying pathogens through microbiological testing is crucial for formulating effective
treatment strategies to manage them effectively.

Immunology and Genetics

The body's immune system and genetic makeup are critical in managing CSOM. Immunoglobulins IgG, IgA,
and secretory IgA are most effective in guarding against mucosal infections like CSOM. Locally synthesized
by plasma cells within the middle-ear cavity mucosa, SIgA helps prevent bacterial attachment to and
colonization of this area. However, children with CSOM may have deficient levels of SIgA [32]. The IgG-class
immunoglobulin concentration primarily acts to facilitate phagocytosis either directly or indirectly via
complement activation, which depends on the age factor. Children experiencing recurring upper respiratory
tract illnesses portray reduced levels of specific subclasses, such as mostly low-targeting antibody activity
from subclass-IgG2 in 10-20% of cases [33,34]. For antibodies to be action-ready for infection prevention,
coating on bacteria walls stands prerequisite. While intense SIgA and IgG coatings prevail commonly during
a case involving bacterial causation other than Pseudomonas aeruginosa responsible, there has been no
sighted coverage when that particular pathogen causes an infection, indicating its resistance towards these
two responses.

2023 Khairkar et al. Cureus 15(8): e43729. DOI 10.7759/cureus.43729 4 of 11

 Despite conflicting data regarding inadequate antibody responses to otopathogens in children at risk of
developing OM, there is increasing clarity on the possible involvement of cell-mediated impairment. The
impact of genetics on these findings remains uncertain, and it is plausible that interactions between
pathogens, hosts, and surroundings could play a part. Additional investigation is required for a
comprehensive comprehension of how genetic factors contribute to the development of OM.

Complications and sequelae

CSOM can result in various complications, including conductive or sensorineural hearing loss, extracranial
complications (e.g., facial paralysis, subperiosteal abscess, mastoiditis), and intracranial complications (e.g.,
meningitis, cerebral abscess). Prompt diagnosis and management are crucial to prevent long-term
consequences, particularly in pediatric patients. Meningitis and brain abscesses are the primary causes of
death resulting from OM and CSOM. WHO estimates show that a significant number, ranging from 65
million to 330 million individuals, display symptoms associated with CSOM [23], out of which half suffer
from hearing impairment. In developed nations, after hypertension and arthropathy, hearing loss (including
conductive and sensorineural) is considered the third chronic ailment prevailing among older adults
affecting their physical and mental well-being in considerable ways. Conversely, data on less industrialized
countries' adult populations remains sparse regarding such conditions. Therefore, a thorough understanding
of AOM's incidence rate across demographics must be established to reduce health issues alongside social-
economic adversity by intervening at the right time (Figure 2).

FIGURE 2: Sequalae of otitis media.

Image adapted from Reference [10], which was originally published and distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are credited.

Prognosis

In general, CSOM’s outlook is favorable, provided it receives proper treatment and no complications are
involved. A few cases may be refractory, which entails a more comprehensive assessment and management.
It is vital to identify and treat the bacterial origin of acute otitis media, as this can lead to CSOM in most
instances. The use of the Pneumococcus vaccine has resulted in a positive reduction in the incidence of
acute otitis media, thereby decreasing the occurrence rate of patients presenting with CSOM.

Prevention

Due to the complex nature of OM, there are several preventive measures that can be employed. These
measures primarily center around minimizing modifiable factors that contribute to risk, such as infectious
agents and environmental hazards.

2023 Khairkar et al. Cureus 15(8): e43729. DOI 10.7759/cureus.43729 5 of 11

 Vaccines directed against bacterial otopathogens: The vaccines aim to reduce or eliminate nasopharyngeal
colonization by S. pneumoniae and H. influenzae. The vaccine has been added to the primary series of
universal vaccination schedules with a 20% reduction in the CSOM by using ventilation tubes.

Deterrence and patient education

Parents need to be informed and guided about the significance of consistent visits for their child's overall
health check-ups, as well as being encouraged to promptly seek medical attention when their children report
ear pain or discomfort. Additionally, it is crucial to take into account any concerns raised by teachers
regarding potential hearing loss in a child. Addressing and managing CSOM in a timely manner is critical in
reducing the risk of long-term complications that may impact the child's well-being.

Enhancing Healthcare Team Outcomes

CSOM is a medical condition characterized by a persistent infection in the middle ear that damages the
eardrum. This disease usually manifests during early childhood, typically around two years old, and may
follow an episode of acute otitis media. It is vital to isolate the causative agent upon suspicion of this
ailment promptly. If left unchecked, CSOM can result in severe complications such as polyps, sclerosis, or
hardening of tissues within the ear cavity walls; tympanosclerosis or thickening and scarring on hearing-
related components within our ears causing conductive hearing loss; labyrinthitis, which triggers
inflammation affecting areas close to inner-ear nerves leading to balance issues with dizziness spinning
sensations and nausea over time these symptoms lead up cognitive impedances like disorientation seizures,
etc.; epidural abscesses culminating in excruciating headaches swelling nervousness convulsion depression
(psychiatric disorders), subdural abscesses making it difficult for one's coordination, tongue movement
awareness, memory processing, communication problem solving skills, mental flexibility, adaptation
capability, along with development requiring surgery intervention if necessary, alongside brain abscesses
compromising one's ability, even more debilitating auditory effects are so familiar that children are unable
to attend school regularly because of decreased academic performance impacting scholastic ability.

Limitations
There are a number of limitations in our review that need to be acknowledged. Firstly, it is important to note
that non-English studies were excluded from the analysis, which may lead to some bias and restrict the
generalizability of our findings. Additionally, we should consider potential publication bias as another
limitation since there is always a possibility that studies with significant results are more likely to be
published compared to those with null or non-significant findings. Lastly, it's worth mentioning that the
quality of the included studies varied across different sources, which could have an impact on the overall
validity and reliability of our conclusions.

Conclusions
CSOM remains a significant childhood chronic infectious disease with global implications. A child with
persistent upper respiratory tract infection with pain in the ear has the highest chance of developing otitis
media. If failed to treat timely can lead to severe complications. Understanding its epidemiology,
pathogenesis, microbiology, and associated complications is essential for effectively managing and
preventing long-term sequelae. The complications of CSOM do affect the cognitive and educational
development of the child as well as long-term effects on the child's communication. Further research is
needed to enhance our knowledge of CSOM and develop targeted interventions.

Appendices
Paper title Abstract summary Authors DOI Year

Two hundred fifty patients of all

age having complications due to
chronic suppurative otitis media
Complications of chronic Hasan SZ, Gul I,
enrolled from admitted patients 10.37762/jgmds.3-01.46 2016
suppurative otitis media Ahmad A
in ENT department Khyber
Teaching Hospital Peshawar
were included in the study.

The comparative analysis of The surgical intervention on the

the clinical and morphological dry ear of the patients with the
picture of the various forms of tubotympanic form of chronic Baike EV 10.17116/otorino201681230-33 2016
chronic suppurative otitis suppurative otitis media was
media 91.4%.

Management of acute otitis A bulging tympanic membrane Le Saux N,

media in children six months is a major diagnostic criterion for 10.1093/PCH/21.1.39 2016

2023 Khairkar et al. Cureus 15(8): e43729. DOI 10.7759/cureus.43729 6 of 11

 of age and older acute otitis media. Robinson JL

Adjuvant adenoidectomy at the

time of initial grommet insertion
Otitis media with effusion:
decreased the risks of Karuna N,
comparative effectiveness of 10.9790/0853-150722934 2016
reinsertion and re-admission for Sreekanth G
treatments
conditions related chronic otitis
media with effusion.

The intraoperative
pathological findings in cases
of chronic suppurative otitis Cholesteatoma can be found in Thakur S, Ghimire N,
media with central perforation tubotympanic type of chronic Acharya R, Singh S, 10.3126/AJMS.V8I1.15944 2017
of tympanic membrane at a suppurative otitis media. Afaque A
tertiary care center in Eastern
Nepal

The irrational use of broad

Mycological profile of chronic
spectrum antibiotics, use of
suppurative otitis media in a Haneefa S, Bhama S,
steroids and immunodeficiency 10.20546/IJCMAS.2017.602.018 2017
tertiary care hospital in South Rajahamsan J
disorders favors the secondary
India
infection by fungi.

Bacteriological profile of Treating active discharge of Sowmya TR, Dudda R,

chronic suppurative otitis chronic suppurative otitis media Prasad M, Balaji NK, 10.18203/ISSN.2454-
2017
media in a tertiary care reduces the bacterial load in the Sumangala B, 5929.IJOHNS20173031
hospital middle ear. Gudikote M

Chronic suppurative otitis media

Aetiological factor for chronic
is an important cause of 10.18203/ISSN.2454-
suppurative otitis media: a Hardik D, Sinha M 2017
morbidity in very large group of 5929.IJOHNS20170931
retrospective study
Indian population.

Surgical intervention consisting Guillermo LM, Pande

Noninvasive in vivo optical
of myringotomy and P, Nolan RM, Shelton
coherence tomography
tympanostomy tube placement RL, Porter RG, Novak
tracking of chronic otitis media 10.1117/1.JBO.22.12.121614 2017
provides a means to clear the M, Spillman D, Chaney
in pediatric subjects after
middle ear of infection-related E, McCormick D,
surgical intervention
components. Boppart S

Schilder AG, Marom T,

Bhutta MF,
Casselbrant ML,
Watchful waiting is optional in
Panel 7: Otitis media: Coates H, Gisselsson-
mild to moderate acute otitis 10.1177/0194599816633697 2017
treatment and complications Solén M, Hall AJ,
media.
Marchisio P, Ruohola
A, Venekamp RP,
Mandel EM

Acute otitis media can be Shawabka MA, Haidar

Acute otitis media-an update defined as a rapid onset of fever H, Larem A, Aboul- 10.15406/JOENTR.2017.08.00252 2017
and otalgia. Mahmood Z, Alsaadi A

Spectrum and antibiogram of

Samples of pus were collected
bacteria in chronic Asima B, Samhitha V,
from the deeper aspect of 10.15406/JSRT.2017.02.00069 2017
suppurative otitis media and Karthik S
external auditory meatus.
biofilm formation

Ghogare H, Vitore V,
Microbiological profile of Chronic suppurative otitis media
Hatkar S, Bhalchandra
chronic suppurative otitis is a major problem in developing 10.20546/ijcmas.2018.710.128 2018
MH, Wyawhare AS,
media countries like India.
Bansal VP

Comment to empirical therapy Culture and sensitivity is

Bareeqa SB, Ahmed
for chronic suppurative otitis essential in eradicating the 10.1177/1179550618810226 2018
SI
media causative organism.

The medical assistance The most frequently practiced Garov EV,

seeking behaviour of the form of the surgical treatment Khamzalieva RB,
patients presenting with employed for the management Zelenkova VN, Garova 10.17116/otorino20188305126 2018

2023 Khairkar et al. Cureus 15(8): e43729. DOI 10.7759/cureus.43729 7 of 11

 suppurative chronic otitis of suppurative chronic otitis EE, Meparishvili AS,
media and their treatment in media is tympanoplasty. Lapenko EG
Moscow

Antimicrobial susceptibility
The most common organism
pattern of bacterial isolates in Mahajan RK, Agarwal
isolated in patients suffering
patients of chronic suppurative S, Jeram H, 10.18203/2320-6012.IJRMS20184434 2018
from chronic suppurative otitis
otitis media in a tertiary care Vashishtha RC
media was Pseudomonas spp.
hospital in India

A study of aerobic
Smitha NR,
bacteriological profile of Staphylococcus isolates were
Jnaneshwara KB, Patil
chronic suppurative otitis highly sensitive to vancomycin 10.18231/2394-5478.2018.0096 2018
AB, Harshika YK,
media in a tertiary care and linezolid.
Medegar S
hospital, South India

Surgical treatment of chronic Tympanoplasty for subtotal wet

ear disease in remote or perforations is frequently Smith MC, Huins C,
10.1017/S0022215118002165 2018
resource-constrained encountered in resource-poor Bhutta M
environments. conditions.

CT scans are used to diagnose

Role of computed tomography
complications in chronic Abdulsattar OA,
in diagnosis of complications
suppurative otitis media among Alturaihy SH, Hussein 10.36295/asro.2019.22052 2019
in chronic suppurative otitis
40 patients between June 2018 AA
media
and June 2019.

A dental abscess was found on

A rare case of odontogenic computed tomography to be the Schartz DA, Polacco
chronic suppurative otitis source of concurrent ipsilateral MA, Holmgren EP, 10.7759/cureus.4284 2019
media maxillary sinusitis and McCool RR
mastoiditis.

Complications of chronic The complications of chronic

suppurative otitis media and suppurative otitis media are a Mohite AA, Mane RS, 10.18203/ISSN.2454-
2019
their management: five year great challenge in developing Patil BC, Mohanty RM 5929.IJOHNS20192593
study at tertiary care centre countries.

The most acceptable definition

Aerobic bacteriological profile of chronic suppurative otitis
of chronic suppurative otitis media is an infection of the
Hundekar JR, Surekha
media and special reference middle ear that lasts more than 10.20546/IJCMAS.2019.807.257 2019
YA, Krishna S
to methicillin resistant three months and is
Staphylococcus aureus accompanied by tympanic
membrane perforation.

Abraham ZS,
Prevalence and etiological
Ntunaguzi D, Kahinga
agents for chronic suppurative The most common isolates were
AA, Mapondella KB, 10.1186/s13104-019-4483-x 2019
otitis media in a tertiary facultative anaerobes.
Massawe ER, Nkuwi
hospital in Tanzania
EJ, Nkya A

The concept of a relationship

Sinonasal and
between sinonasal and
nasopharyngeal pathology in
nasopharyngeal pathologies and Kayedjohar KR 10.17511/jooo.2019.i07.02 2019
chronic otitis media patients: a
chronic otitis media has been
prospective study
supported by the present study.

Pseudomonas aeruginosa was Ayaz Z, Taj B, Yaseen

Causality of chronic
the most common causative MS, Ishaq U, Laique T,
suppurative otitis media: an 10.7759/cureus.9832 2020
agent of chronic suppurative Malik J, Baig A,
observational study
otitis media at our institute. Sakhawat K

Evaluation of single stage

The development and
tympanomastoid surgery in
appropriate use of antibiotics
unsafe chronic suppurative Mir P, Makhdoomi O, 10.18203/issn.2454-
have led to decrease in 2020
otitis media in Kashmiri Syed WA 5929.ijohns20201691
potentially devastating
population: a cross sectional
complications.
study

2023 Khairkar et al. Cureus 15(8): e43729. DOI 10.7759/cureus.43729 8 of 11

 Chronic suppurative otitis media
Relation between the duration is defined as a chronic
of disease and audiogram inflammation of the middle ear
10.18203/issn.2454-
findings in tubotympanic type and mastoid cavity which Rajamohan G, Saai RT 2020
5929.ijohns20205061
of chronic suppurative otitis presents with recurrent ear
media after myringoplasty discharges through a tympanic
perforation.

A study on chronic Chronic suppurative otitis media

suppurative otitis media in a is a very common disease in all Satyajit M 10.20546/IJCMAS.2020.912.220 2020
Tribal Area Medical College age group and both sexes.

A study of complications of Different complications can Parmar BD, Jha S,

10.18203/issn.2454-
chronic suppurative otitis develop in spite of availability of Sinha V, Chaudhury N, 2020
5929.ijohns20200146
media at tertiary care hospital higher antibiotics. Dave G

Study of bacterial pathogens

causing chronic suppurative Chronic suppurative otitis media
otitis media and the antibiotic is a highly prevalent disease Geetha MN, Tanya 10.18203/issn.2454-
2020
susceptibility pattern of the and commonly encountered in TM, Bindhu V, Lancy J 5929.ijohns20201288
isolates at a tertiary care ENT OPD.
center in Kochi

Detection of bio-film
production among the most
The bacteria may gain entry to
frequent bacterial isolates in Bhat P, Peer S,
the middle ear through a chronic 10.20546/ijcmas.2020.906.167 2020
cases of chronic suppurative Yoganand R
perforation.
otitis media: a cross-sectional
study

Pseudomonas aeruginosa are

Bacteriological study of
the most common isolated Hadi AA, Khammas
chronic suppurative otitis 10.26505/djm.19015680920 2020
bacteria in chronic suppurative AH, Alsaeed WM
media
otitis media.

Patients with otorrhoa in Angola Filipe M, Karppinen M,

Suppurative otitis media in
were characterized by Kuatoko P, Reimer Å,
Angola: clinical and 10.1111/tmi.13466 2020
demographic and clinical Riesbeck K, Pelkonen
demographic features
findings. T

Clinico-microbial profile of Acute suppurative otitis media is

Otomycosis in discharging a major otolarynological
Wagh K, Ghule S 10.18231/2394-5478.2018.0046 2020
otitis media in tertiary care problem in India commonly seen
hospital in children and adults.

Microbiology and antibiotic

The active form of chronic
sensitivity of uncomplicated
suppurative otitis media persists
chronic suppurative otitis 10.18203/ISSN.2454-
into adulthood in a very small Kotu M, Olwoch IP 2021
media at Dr. George Mukhari 5929.IJOHNS20211177
percentage of the affected
Academic Hospital, South
population.
Africa

Nasal septal deviation is

Unilateral chronic suppurative
commonly found in patients with
otitis media: effect of nasal Ali AA, Majeed N 10.21474/IJAR01/12564 2021
unilateral chronic suppurative
septal deviation
otitis media.

Staphylococcus aureus and

Microorganisms and culture
Pseudomonas aeruginosa were
and sensitivity pattern in Shrestha KS, Madhup
the most common organisms
chronic suppurative otitis SK, Shrestha BL, 10.3126/jcmsn.v17i3.39719 2021
responsible for chronic
media in a tertiary care Pokharel M, Dhakal A
suppurative otitis media in our
hospital
study.

The study of bacteriological

agents of chronic suppurative
otitis media aerobic culture Antimicrobials like imipenem,
and antibiotic sensitivity piperacillin, and quinolones are Shyamala R, Reddy
10.17511/jopm.2021.i04.09 2021
testing pattern at a tertiary effective against most cases of PS

2023 Khairkar et al. Cureus 15(8): e43729. DOI 10.7759/cureus.43729 9 of 11

 care hospital in and around chronic suppurative otitis media.
Rajamundry: A cross-sectional
study
Role of 1.5% acetic acid
Ear, nose, and throat infections
irrigation and medical
are common clinical problems Bhavya K, Sowmya L, 10.18203/ISSN.2454-
management in chronic 2021
occurring in the general Teja 5929.IJOHNS20212124
persistent suppurative otitis
population.
media

Bacterial agents causing S. aureus has been identified as

chronic suppurative otitis the leading pathogen in chronic Jhajharia R 10.32553/ijmbs.v6i5.2539 2022
media otitis media.

Chronic suppurative otitis media

Case report: management of
with complications of cerebral
chronic supurative otitis media
abscess is treated with abscess
cholesteatoma type with Ikhlas KA, Edward Y 10.19184/ams.v8i1.25338 2022
drainage if the abscess size is
recurrent brain abscess
>2 cm and followed by canal
complication
wall down mastoidectomy.

Complications of suppurative The most aggressive Othman M, Hamza

otitis media still occur in the complication of suppurative otitis alshafae, Emaad 10.37375/sjms.v1i1.288 2022
21st century media is the malignant type. alfasse

The predominant aetiologies of

Antimicrobial sensitivity profile
otitis media were Pseudomonas
of bacterial agents in chronic
aeruginosa, Klebsiella Habeeb AH 10.53730/ijhs.v6ns4.10448 2022
suppurative otitis media
pneumoniae, Proteus mirabilis,
patients in Samawa city
and Staphylococcus aureus.

Abubakar A, Isa A,
Methicillin-resistant
The prevalence of MRSA Baba A, Yahaya M,
Staphylococcus aureus
otorrhoea in this study was Zailani A, Abdulmajid 10.56167/jjms.2022.0301.05 2022
(MRSA) infection in chronic
relatively high. IY, Amina MA, Kodiya
suppurative otitis media.
A

Evaluation of complications Mehwish H, Alina A,

Patients should be given higher
and management of chronic Arunandan K, Sheikh
doses of intravenous antibiotics 10.53350/pjmhs22165461 2022
suppurative otitis media: a SA, Deepak R,
followed by mastoid surgery.
retrospective study Naveed A

Case report: suppurative

Suppurative labyrinthitis must Qianwen X, Yuzhong
labyrinthitis induced by
not be overlooked and Z, Jingrong L, Jun Y, 10.3389/fneur.2022.892045 2022
chronic suppurative otitis
neglected. Qing Z
media

Bone tissue in patients with

Clinical-morphological,
chronic suppurative otitis media
intraoperative study of bone Bashrullaevich MU,
is important for physicians, 10.31435/rsglobal_ws/30062022/7823 2022
tissue in patients with chronic Abdullaevna KL
especially pediatricians,
purulent otitis media
therapists.

TABLE 1: Literature reviewed.

Additional Information
Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.

References

2023 Khairkar et al. Cureus 15(8): e43729. DOI 10.7759/cureus.43729 10 of 11

 1. Teele DW, Klein JO, Rosner B: Epidemiology of otitis media during the first seven years of life in children in
greater Boston: a prospective, cohort study. J Infect Dis. 1989, 160:83-94. 10.1093/infdis/160.1.83
2. Vergison A, Dagan R, Arguedas A, et al.: Otitis media and its consequences: beyond the earache . Lancet
Infect Dis. 2010, 10:195-203. 10.1016/S1473-3099(10)70012-8
3. Fliss DM, Dagan R, Houri Z, Leiberman A: Medical management of chronic suppurative otitis media without
cholesteatoma in children. J Pediatr. 1990, 116:991-6. 10.1016/s0022-3476(05)80666-3
4. Brook I: Role of anaerobic bacteria in chronic otitis media and cholesteatoma . Int J Pediatr
Otorhinolaryngol. 1995, 31:153-7. 10.1016/0165-5876(94)01080-h
5. Osma U, Cureoglu S, Hosoglu S: The complications of chronic otitis media: report of 93 cases . J Laryngol
Otol. 2000, 114:97-100. 10.1258/0022215001905012
6. Trimis G, Mostrou G, Lourida A, Prodromou F, Syriopoulou V, Theodoridou M: Petrositis and cerebellar
abscess complicating chronic otitis media. J Paediatr Child Health. 2003, 39:635-6. 10.1046/j.1440-
1754.2003.00251.x
7. Bluestone CD: Studies in otitis media: Children's Hospital of Pittsburgh-University of Pittsburgh progress
report-2004. Laryngoscope. 2004, 114:1-26. 10.1097/01.mlg.0000148223.45374.ec
8. Roland PS: Chronic suppurative otitis media: a clinical overview . Ear Nose Throat J. 2002, 81:8-10.
9. Kenna MA, Rosane BA, Bluestone CD: Medical management of chronic suppurative otitis media without
cholesteatoma in children-update 1992. Am J Otol. 1993, 14:469-73. 10.1097/00129492-199309000-00010
10. Monasta L, Ronfani L, Marchetti F, et al.: Burden of disease caused by otitis media: systematic review and
global estimates. PLoS One. 2012, 7:e36226. 10.1371/journal.pone.0036226
11. Arguedas A, Loaiza C, Herrera JF, Mohs E: Antimicrobial therapy for children with chronic suppurative otitis
media without cholesteatoma. Pediatr Infect Dis J. 1994, 13:878-82. 10.1097/00006454-199410000-00006
12. Morris PS: Management of otitis media in a high risk population . Aust Fam Physician. 1998, 27:1021-9.
13. Kenna MA, Bluestone CD, Reilly JS, Lusk RP: Medical management of chronic suppurative otitis media
without cholesteatoma in children. Laryngoscope. 1986, 96:146-51. 10.1288/00005537-198602000-00004
14. Vartiainen E: Results of surgical treatment for chronic noncholesteatomatous otitis media in the pediatric
population. Int J Pediatr Otorhinolaryngol. 1992, 24:209-16. 10.1016/0165-5876(92)90018-k
15. Bluestone CD: Epidemiology and pathogenesis of chronic suppurative otitis media: implications for
prevention and treatment. Int J Pediatr Otorhinolaryngol. 1998, 42:207-23. 10.1016/s0165-5876(97)00147-x
16. Wintermeyer SM, Nahata MC: Chronic suppurative otitis media . Ann Pharmacother. 1994, 28:1089-99.
10.1177/106002809402800915
17. Kong K, Coates HL: Natural history, definitions, risk factors and burden of otitis media . Med J Aust. 2009,
191:39-43. 10.5694/j.1326-5377.2009.tb02925.x
18. van Hasselt P, van Kregten E: Treatment of chronic suppurative otitis media with ofloxacin in
hydroxypropyl methylcellulose ear drops: a clinical/bacteriological study in a rural area of Malawi. Int J
Pediatr Otorhinolaryngol. 2002, 63:49-56. 10.1016/s0165-5876(01)00648-6
19. Hurst DS, Denne CM: The relation of allergy to eustachian tube dysfunction and the subsequent need for
insertion of pressure equalization tubes. Ear Nose Throat J. 2020, 99:39S-47S. 10.1177/0145561320918805
20. WHO/CIBA Foundation Workshop: London UK, Impairment WHOP for the P of D and H, Foundation C:
Prevention of hearing impairment from chronic otitis media : report of a WHO/CIBA Foundation Workshop,
London, U.K., 19-21 November 1996. (1998). Accessed: August 10, 2023:
https://apps.who.int/iris/handle/10665/63870.
21. Lewis K: Riddle of biofilm resistance. Antimicrob Agents Chemother. 2001, 45:999-1007.
10.1128/AAC.45.4.999-1007.2001
22. Uddén F, Filipe M, Reimer Å, et al.: Aerobic bacteria associated with chronic suppurative otitis media in
Angola. Infect Dis Poverty. 2018, 7:42. 10.1186/s40249-018-0422-7
23. World Health Organization. Chronic suppurative otitis media: burden of illness and management options .
(2004). Accessed: July 2023: https://apps.who.int/iris/handle/10665/42941.
24. Stewart PS, Costerton JW: Antibiotic resistance of bacteria in biofilms . Lancet. 2001, 358:135-8.
10.1016/s0140-6736(01)05321-1
25. Schilder AG, Chonmaitree T, Cripps AW, Rosenfeld RM, Casselbrant ML, Haggard MP, Venekamp RP: Otitis
media. Nat Rev Dis Primers. 2016, 2:16063. 10.1038/nrdp.2016.63
26. Berry JA, Biedlingmaier JF, Whelan PJ: In vitro resistance to bacterial biofilm formation on coated
fluoroplastic tympanostomy tubes. Otolaryngol Head Neck Surg. 2000, 123:246-51.
10.1067/mhn.2000.107458
27. Post JC, Stoodley P, Hall-Stoodley L, Ehrlich GD: The role of biofilms in otolaryngologic infections . Curr
Opin Otolaryngol Head Neck Surg. 2004, 12:185-90. 10.1097/01.moo.0000124936.46948.6a
28. Verhoeff M, van der Veen EL, Rovers MM, Sanders EA, Schilder AG: Chronic suppurative otitis media: a
review. Int J Pediatr Otorhinolaryngol. 2006, 70:1-12. 10.1016/j.ijporl.2005.08.021
29. Stenfors LE, Räisänen S: Immunoglobulin-coated bacteria in effusions from secretory and chronic
suppurative otitis media. Am J Otolaryngol. 1991, 12:161-4. 10.1016/0196-0709(91)90147-8
30. Rosenfeld RM, Kay D: Natural history of untreated otitis media . Laryngoscope. 2003, 113:1645-57.
10.1097/00005537-200310000-00004
31. Veenhoven R, Rijkers G, Schilder A, Adelmeijer J, Uiterwaal C, Kuis W, Sanders E: Immunoglobulins in
otitis-prone children. Pediatr Res. 2004, 55:159-62. 10.1203/01.PDR.0000099776.66136.39
32. Gross S, Blaiss MS, Herrod HG: Role of immunoglobulin subclasses and specific antibody determinations in
the evaluation of recurrent infection in children. J Pediatr. 1992, 121:516-22. 10.1016/s0022-3476(05)81137-
0
33. Massa HM, Cripps AW, Lehmann D: Otitis media: viruses, bacteria, biofilms and vaccines . Med J Aust. 2009,
191:44-9. 10.5694/j.1326-5377.2009.tb02926.x
34. Berman S: Otitis media in developing countries . Pediatrics. 1995, 96:126-31.

2023 Khairkar et al. Cureus 15(8): e43729. DOI 10.7759/cureus.43729 11 of 11