Evaluation and Management of Persistent Otorrhea

Educational Objectives

The goal of this program is to improve diagnosis and management of persistent otorrhea. After hearing and assimilating this program, the clinicians will be better able to:

1. Review the characteristics, diagnosis, and management of chronic otorrhea.
2. Diagnose atypical causes of chronic otorrhea.

Summary

Definition: chronic suppurative otitis media is a common cause of chronic otorrhea and is defined as discharge through a non-intact tympanic membrane (TM) for >6 wk; may occur in the setting of perforation, cholesteatoma, or tympanostomy tubes

Pathophysiology: initial acute infection results in inflammation and subsequent mucosal edema and ulceration; host immune response leads to formation of granulation tissue and polyps, and progression of inflammation results in osteitis and bony destruction; osteitis increases susceptibility for infection; common pathogenic agents — Pseudomonas is implicated in 50% to 98% of cases; Staphylococcus aureus is the second most common; other causes include gram negative bacteria, anaerobic bacteria, and fungal species

Evaluation: patients may have a history of recurrent acute otitis media, traumatic TM perforation, prior tympanostomy tubes, or prior ear surgery

Management: drainage is controlled using topical antibiotics, aural toilet, and strict water precautions; systemic antibiotics are administered in resistant cases; surgery may be considered as a final resort

Eosinophilic otitis media: often intractable and characterized by accumulation of eosinophils in the effusion and mucosa of the middle ear; patients often present with thick inspissated fluid; strongly associated with asthma and chronic sinusitis with nasal polyposis

Diagnostic criteria: otitis media with effusion or chronic otitis media with eosinophil-dominant effusion are major diagnostic criteria and must be accompanied by ≥2 minor criteria, which include highly viscous effusion of the middle ear, resistance to conventional treatment for otitis media, or association with bronchial asthma or nasal polyps

Histopathology: shows an abundance of eosinophils, eosinophilic mucin, and Charcot-Leyden crystals; severe cases may present with polypoid changes in the middle ear or frank polyps that are often pale and fibrous

Outcomes: sensorineural hearing loss may occur if untreated; may result from an overly patent Eustachian tube and is an extension of sinonasal disease into the middle ear space; secondary infections caused by pathogens in the middle ear can contribute to eosinophilic otitis media; effusions are resistant to conventional treatment

Management: usually nonsurgical, although debridement of polyps from the middle ear may be beneficial in cases of heavy polyp burden; often requires frequent suctioning; topical steroid drops or triamcinolone injections into the middle ear or oral steroids are often beneficial; leukotriene receptor inhibitors and monoclonal antibody therapy with omalizumab (eg, Xolair) can be administered; patients should be on the recalcitrant nature and need for frequent suctioning and hearing aids

Chronic draining mastoid cavity: often caused by inadequate ventilation, poor oral hygiene or cleaning, and increased moisture (particularly if the meatus is small or the patient uses a hearing aid); infection, inflammation, granulation tissue, and mucosalization are often present in the mastoid, which results in chronic discharge

Workup: otomicroscopy examination is recommended to identify the size of the meatus and presence of deep air cell tracks in the sinodural angle, high facial ridge, or a dependent mastoid tip; important to rule out cholesteatoma, assess the integrity of the TM, distinguish between fungal and bacterial infection, and assess the burden of granulation tissue

Initial management: topical antibiotics are considered standard and are generally most effective because their potency is 100 to 1000 times greater compared with systemic therapy; infections are often caused by gram negative species; topical powders include chloramphenicol sulfa and amphotericin B (eg, CSF Otic Powder) or CCDB (ciprofloxacin, clotrimazole, dexamethasone, and boric acid); tobramycin-dexamethasone ear drops (eg, Tobradex) can be used after ruling out perforation (vestibular loss has been reported with a perforated TM); antifungal agents include nystatin and triamcinolone acetonide (eg, Mycolog), natamycin, and clotrimazole (eg, Alevazol, Lotrimin, Mycelex); patients should be educated on aural toilet and strict water precautions; hearing aids should be removed and cleaned of exudate or desquamated epithelium; silver nitrate is used to control granulation tissue; removal of moisture is important

Management of persistent infection: collect sample for culture and sensitivity, and administer systemic antibiotics for 3 to 4 wk; surgery is considered a last resort; surgical approaches include revision of the mastoid or mastoid obliteration; closure of the external auditory canal and fitting a bone conduction hearing device may be considered and leads to satisfactory outcomes for many patients

Wegener granulomatosis: immune-mediated vasculitis that affects small and medium blood vessels; characterized by infiltration of immune cells around capillaries and blood vessels; primarily affects the lung, kidneys, and upper airway tract; otologic manifestations occur in ≈40% of cases and may include chronic suppurative otitis media or sensorineural hearing loss accompanied by facial nerve symptoms in rare cases; necrotizing granulomas are hallmark pathologic findings; should be considered if the patient does not respond to conventional treatment and lacks bony destruction; antineutrophil cytoplasmic antibody (c-ANCA) test is diagnostic; initial treatment includes prednisone; long-term treatment may include immunotherapy or chemotherapy with cyclophosphamide or methotrexate; remission rate is ≈75%

Spontaneous cerebrospinal fluid (CSF) leak: characterized by persistent drainage after placement of a tube or topical treatment for serous otitis media; discharge is often thin and watery; women account for ≈72% of cases; associated with body mass index >30 kg/m²; elevated intracranial pressure may be present; patients may be at risk for meningitis, although recent studies challenge the validity of this association; beta-2 transferrin is diagnostic if a fluid sample can be obtained (must be refrigerated if collected by the patient); computed tomography of the temporal bone can also be used for diagnosis; surgery is recommended for most patients

Readings

Ashman PE et al. Otologic manifestations of eosinophilic granulomatosis with polyangiitis: a systematic review. Otol Neurotol. 2021;42:e380-e387; doi: 10.1097/MAO.0000000000003024; Bhutta MF et al. Aural toilet (ear cleaning) for chronic suppurative otitis media. Cochrane Database Syst Rev. 2020;9:CD013057; doi: 10.1002/14651858.CD013057.pub2; Chen T et al. Diagnosis and management of eosinophilic otitis media: a systematic review. Acta Otolaryngol. 2021;141:579-587; doi: 10.1080/00016489.2021.1901985; Kutz JW Jr et al. Management of spontaneous cerebrospinal fluid otorrhea. Laryngoscope. 2008;118(12):2195-2199. doi:10.1097/MLG.0b013e318182f833; Ratmeyer PR et al. Granulomatosis with polyangiitis as a cause of sudden-onset bilateral sensorineural hearing loss: case report and recommendations for initial assessment. Case Rep Otolaryngol. 2021;2021:6632344; doi: 10.1155/2021/6632344.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Cunningham was recorded virtually at the 45th Midwinter Symposium of Practical Challenges in Otolaryngology, held February 22, 2021, and presented by the University of Illinois College of Medicine, Chicago, Department of Otolaryngology-Head and Neck Surgery. For information about future CME activities from this sponsor, please visit https://www.uicentskimeeting.org/. Audio Digest thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT541801

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.