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Chronic purulent otitis media — Clinical Guidelines

Overview

Chronic purulent otitis media involves persistent infection and inflammation of the middle ear, often leading to complications such as mastoiditis, cholesteatoma, and hearing loss. Effective management requires surgical intervention, particularly in cases refractory to medical treatment.

Diagnosis

Clinical Presentation: Persistent otorrhea, hearing loss, and ear pain 1 2 19.

Imaging: Pre-operative CT scans to assess extent of disease, middle ear involvement, and mastoid pneumatization 9 10.

Grading: Utilization of classifications like EAONO/JOS for cholesteatoma to define severity and guide treatment 7.

Management

Surgical Interventions:

- Cortical Mastoidectomy: Indicated for extensive disease, with varying difficulty levels noted among novice and intermediate surgeons 1. - Tympanoplasty: For tympanic membrane repair, often performed by trainees with supervision 4 13. - Ossiculoplasty: Utilized to reconstruct ossicular chain, predominantly using artificial prostheses 15.

Anesthesia and Hemodynamics:

- Controlled Hypotension: Dexmedetomidine or remifentanil for improved surgical field exposure 14.

Monitoring:

- Facial Nerve Monitoring: Essential during chronic ear surgeries to prevent nerve damage 20.

Special Populations

Pediatrics: Pediatric cholesteatoma may exhibit more aggressive behavior, necessitating vigilant monitoring and early intervention 7.

Training and Competency:

- Learning Curves: Significant improvement in outcomes with increasing experience, particularly noted in tympanoplasty and mastoidectomy 1 12 13. - Supervision: Trainees require close supervision, especially in complex cases, to achieve comparable outcomes to senior surgeons 19 23.

Key Recommendations

Surgical Training and Competency Assessment: Develop and apply standardized assessment tools for evaluating surgical competency in mastoidectomy across institutions (Evidence: Moderate) 3 8 12.

Use of Advanced Techniques: Implement advanced surgical techniques such as endoscopic approaches and microclip applications to enhance graft stability and surgical outcomes (Evidence: Moderate) 22 26.

Intraoperative Monitoring: Employ intraoperative facial nerve monitoring during chronic ear surgeries to minimize complications (Evidence: Moderate) 20.

Pre-operative Imaging Accuracy: Ensure accurate pre-operative CT interpretations by both radiologists and otologists to guide surgical planning (Evidence: Weak) 9 10.

Supervision of Trainees: Trainees should operate under close supervision, especially in complex cases, to ensure patient safety and optimal outcomes (Evidence: Expert opinion) 19 23.

References

1 Lamtara JC, Wijewickrema S, O'Leary S, Gerard JM. How difficult is it to learn different steps of a cortical mastoidectomy?. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2025. link 2 Hickson C, Gao C, Parsons N, Neumann C. Inter and Intraobserver Agreement of the IOOG SAMEO ATO Classification for Tympanomastoid Surgery. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 2022. link 3 Kerwin T, Wiet G, Hittle B, Stredney D, De Boeck P, Moberly A et al.. Standard Setting of Competency in Mastoidectomy for the Cross-Institutional Mastoidectomy Assessment Tool. The Annals of otology, rhinology, and laryngology 2020. link 4 Alzhrani F, Aldueb R, Alosaimi K, Islam T, Almuhawas F, Alsanosi A. Safety of tympanoplasty and ossiculoplasty performed by otorhinolaryngology trainees. The Journal of laryngology and otology 2020. link 5 Das A, Mitra S, Kumar S, Sengupta A. Two-drape closed pocket technique: minimizing aerosolization in mastoid exploration during COVID-19 pandemic. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2020. link 6 Baruah P, Lee JDE, Pickering C, de Wolf MJF, Coulson C. The learning curve for endoscopic tympanoplasties: a single-institution experience, in Birmingham, UK. The Journal of laryngology and otology 2020. link 7 Fontes Lima A, Carvalho Moreira F, Sousa Menezes A, Esteves Costa I, Azevedo C, Sá Breda M et al.. Is pediatric cholesteatoma more aggressive in children than in adults? A comparative study using the EAONO/JOS classification. International journal of pediatric otorhinolaryngology 2020. link 8 Kerwin T, Hittle B, Stredney D, De Boeck P, Wiet G. Multi-Institutional Development of a Mastoidectomy Performance Evaluation Instrument. Journal of surgical education 2017. link 9 Badran K, Ansari S, Al Sam R, Al Husami Y, Iyer A. Interpreting pre-operative mastoid computed tomography images: comparison between operating surgeon, radiologist and operative findings. The Journal of laryngology and otology 2016. link 10 Vlastarakos PV, Kiprouli C, Papacharalampous G, Maragoudakis P, Xenelis J, Nikolopoulos TP. Variation among pre-surgical CT assessments of chronic otitis media. B-ENT 2013. link 11 Youngs R, Weir N, Tharu P, Bohara RB, Bahadur D. Diagnostic otoscopy skills of community ear assistants in Western Nepal. The Journal of laryngology and otology 2011. link 12 Francis HW, Masood H, Laeeq K, Bhatti NI. Defining milestones toward competency in mastoidectomy using a skills assessment paradigm. The Laryngoscope 2010. link 13 Liu CY, Yu EC, Shiao AS, Wang MC. Learning curve of tympanoplasty type I. Auris, nasus, larynx 2009. link 14 Richa F, Yazigi A, Sleilaty G, Yazbeck P. Comparison between dexmedetomidine and remifentanil for controlled hypotension during tympanoplasty. European journal of anaesthesiology 2008. link 15 Dhanasekar G, Khan HK, Malik N, Wilson F, Raut VV. Ossiculoplasty: a UK survey. The Journal of laryngology and otology 2006. link 16 Motonaga A, Akazawa K, Takahashi S, Yamamoto Y, Tsukada H, Inagawa K et al.. A method for displaying two images on a screen in distance medical education. Computer methods and programs in biomedicine 2004. link00024-5) 17 Yung MW, Rajendra T. Delayed hypersensitivity reaction to topical aminoglycosides in patients undergoing middle ear surgery. Clinical otolaryngology and allied sciences 2002. link 18 Murray N, Fitzpatrick P, Guarisco JL. Powered partial adenoidectomy. Archives of otolaryngology--head & neck surgery 2002. link 19 Vartiainen E. The results of chronic ear surgery in a training programme. Clinical otolaryngology and allied sciences 1998. link 20 Pensak ML, Willging JP, Keith RW. Intraoperative facial nerve monitoring in chronic ear surgery: a resident training experience. The American journal of otology 1994. link 21 Tsuruta Y, Hata F, Yane K, Kashiwagi N, Fujita N, Kitaoku Y et al.. Tissue transmigration of CZON (Cosmosin) to middle ear mucosa, maxillary sinus mucosa, and palatine tonsils. Auris, nasus, larynx 1994. link80086-1) 22 el-Guindy A. Endoscopic transcanal myringoplasty. The Journal of laryngology and otology 1992. link 23 Vartiainen E, Nuutinen J, Härmä R. Training of ear surgeons. The American journal of otology 1986. link 24 Smyth GD. Microsurgery in otology and laryngology: a review of developments during the past thirty years. Journal of microsurgery 1979. link 25 Cheesman AD. Changes in otological teaching following analysis of failures in surgical technique. Clinical otolaryngology and allied sciences 1978. link 26 Williams JD. Microclip application in tympanoplasty. The Annals of otology, rhinology, and laryngology 1977. link

Chronic purulent otitis media