Otitis media refers to inflammatory conditions affecting the middle ear, the air-filled space behind the eardrum. These conditions are common, especially in children, and are categorized by their duration. Chronic otitis media is defined by inflammation or fluid that persists in the middle ear for an extended period, typically three months or longer. Unlike acute infections, which have sudden onset and severe pain, chronic forms involve a prolonged course that can silently affect hearing and the delicate structures within the ear.
Defining Chronic Otitis Media
Chronic otitis media is not a single condition but encompasses two main forms. Chronic Otitis Media with Effusion (COME), also known as “glue ear,” is characterized by the presence of non-infectious fluid in the middle ear space behind an intact eardrum. The fluid in COME can persist for weeks or months, often after an episode of acute infection has resolved.
The second major form is Chronic Suppurative Otitis Media (CSOM), which involves persistent or recurrent drainage, known as otorrhea, through a hole in the eardrum. CSOM is a chronic infection of the middle ear and mastoid cavity, distinct from COME because it involves an active infection and a perforation. In complex cases of chronic inflammation, a cholesteatoma may develop, which is an abnormal, non-cancerous growth of skin cells in the middle ear. This skin accumulation can grow, causing erosion and damage to the tiny bones of hearing.
Underlying Causes and Risk Factors
The primary cause for the development of chronic otitis media is mechanical failure in the middle ear’s ventilation system. The Eustachian tube connects the middle ear to the back of the throat, equalizing pressure and draining secretions. When this tube becomes dysfunctional or blocked, air pressure cannot be properly regulated, leading to a vacuum effect and fluid accumulation in the middle ear space. This Eustachian tube dysfunction is an underlying issue in many chronic ear problems.
Chronic disease often results from recurrent or poorly treated acute infections. An acute episode can cause a persistent eardrum perforation that fails to heal, allowing bacteria to continually enter the middle ear. Bacteria may form protective structures called biofilms, dense layers that shield microorganisms from antibiotics and the immune system. Anatomical differences, particularly in children whose Eustachian tubes are shorter and more horizontal, make them more prone to this dysfunction. Other risk factors include seasonal allergies and exposure to environmental smoke, which contribute to middle ear inflammation.
Recognizable Symptoms and Potential Consequences
The most common defining symptom of chronic otitis media is conductive hearing loss. This occurs because fluid or chronic inflammation prevents sound vibrations from efficiently traveling through the middle ear structures. Patients with COME may experience a feeling of fullness or pressure in the ear, or a ringing sound known as tinnitus. Pain is often minimal or absent in chronic forms, which can lead to the condition being overlooked.
For CSOM, the primary symptom is persistent or intermittent ear discharge (otorrhea), which can sometimes be foul-smelling. This drainage occurs through the eardrum perforation. If the underlying inflammation is left unmanaged, the consequences can be serious, extending beyond hearing loss. Prolonged inflammation can damage the ossicles, the small bones that transmit sound, leading to permanent hearing impairment. Though rare, chronic infection can spread to the nearby mastoid bone, causing mastoiditis, or, in very severe instances, lead to intracranial complications like abscesses.
Treatment and Management Strategies
Management of chronic otitis media depends on the specific type and severity. For Chronic Otitis Media with Effusion (COME), “watchful waiting” is often employed, especially in young children, as the fluid frequently resolves on its own within three months. Non-surgical care also involves addressing contributing factors, such as managing allergies or avoiding smoke exposure. For active infections like CSOM, topical antibiotic ear drops, often containing quinolones, are the treatment of choice to resolve persistent drainage.
When medical management fails or the condition affects hearing and speech development, surgical intervention is considered. Ventilation tubes, also called tympanostomy tubes, are inserted into the eardrum to provide an artificial pathway for pressure equalization and fluid drainage, which is a common approach for persistent COME. For CSOM with a persistent eardrum perforation, a procedure called tympanoplasty may be performed to repair the hole and restore the integrity of the middle ear. Cases involving a cholesteatoma or significant involvement of the bone often require a mastoidectomy, a surgical procedure to clean the infected tissue and remove the abnormal skin growth from the mastoid bone.