|Year : 2015 | Volume
| Issue : 3 | Page : 170-173
Demographic influences on complicated chronic suppurative otitis media
Sameer Raisuddin Qureshi, Uneeba Rehman Rehman
Department of ENT, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
|Date of Web Publication||17-Jul-2015|
Sameer Raisuddin Qureshi
Department of ENT, Jinnah Postgraduate Medical Centre, Karachi
Source of Support: None, Conflict of Interest: None
Objective: Chronic suppurative otitis media (CSOM) can lead to dreadful and fatal complications. Objective of my study is an assessment of factors leading to the development of CSOM complications in different age groups and which age group is more prone to the development of complications. And to find out most frequent complication occurring in the target population. Introduction: CSOM is a long standing infection of a part or whole of the middle ear cleft characterized by ear discharge and a permanent perforation. It affects both sexes and all age groups. Pathways of spread of infection: Direct bone erosion, venous thrombophlebitis, preformed pathways. Classification of complications: Intracranial - Mastoiditis, facial paralysis, labrynthitis, petrositis. Extracranial - Meningitis, extradural abscess, subdural abscess, brain abscess, lateral sinus thrombophlebitis, otitic hydrocephalus. Development of complications depends upon; organism's virulence, poor resistance of the patient, systemic disease, resistance to antibiotics, poor socioeconomic status, lack of awareness about healthcare, lack of availability of trained specialist. Materials and Methods: A descriptive cross-sectional study was carried out from 2008 to 2013 in ENT Head and Neck Surgery Department, Jinnah Postgraduate Medical Centre, Karachi. Record of 65 patients was selected through nonprobability convenient sampling; sample was divided into two groups according to age Group A 10-18 years and Group B 18-45 years. Data were analyzed on SPSS software; Chi-square test was used and P < 0.05 was considered significant with confidence interval taken as 95%. Results: Population means age was found to be 18.28. Population sex dominant was male 63.1%. Mean duration of complaints is 1.69. There are strong associations between duration of complaints and family income (P = 0.05), and also between age of patient and diagnosed complication (P = 0.00). Conclusions: Most of the patients were of poor socioeconomic background with disease negligence, delayed treatment, poor access to health facilities and improper use of antibiotics. Mostly low age group patients develop complications.
Keywords: Chronic suppurative otitis media, Extracranial complications, Intracranial complications
|How to cite this article:|
Qureshi SR, Rehman UR. Demographic influences on complicated chronic suppurative otitis media. Indian J Otol 2015;21:170-3
| Introduction|| |
Chronic suppurative otitis media (CSOM) is CSOM with perforated tympanic membrane with persistent drainage from the middle ear lasting for >6-12 weeks. CSOM, a phenomenon virtually nonexistent in the developed world, still constitutes a major public health problem in children and adults in Africa, Asia and Latin America.  It is an infection characterized by recurrent middle ear discharge through a persistent tympanic membrane perforation, which can be managed at the primary health care level thereby preventing the development of deafness and even fatal complications.  Commonly a disease of the developing world with malnutrition, over-crowding, substandard hygiene, frequent upper respiratory tract infections and under-resourced health care (all linked to low socioeconomic status) listed as risk factors. , The poorer rural communities have the highest prevalence.  It is the most common childhood infectious disease worldwide  starting early in life but in our environment, presentation may be in adult life.  Individuals in our environment tend to live with the disease, tolerate its discomfort with resultant fatal consequences not only because of insufficient work force and health care facilities but also due to inaccessibility to health care. , When established, it is very difficult to treat. Medical management needs to be continued for many weeks and even when the perforation is dry; patients are at risk of further episodes of discharge until the tympanic membrane has healed.  The infection can spread from the middle ear to involve the mastoid, facial nerve, labyrinth, lateral sinus, meninges and brain leading to mastoid abscesses, facial nerve paralysis, deafness, lateral sinus thrombosis, meningitis and intracranial abscesses.  Of all these complications, hearing loss associated with the chronic discharging ear is nearly always significant, reported in 50% of cases and tending to be more severe than those associated with other types of otitis media.  Which means affected individuals will need additional audiological and educational support. , CSOM can occur with or without cholesteatoma. CSOM is initiated by an episode of infection. The cycle of inflammation, ulceration, infection and granulation formation continue, eventually, destroying the surrounding bony margins and ultimately leading to various complications of CSOM. , Common pathogens involved are bacteria including pseudomonas aeruginosa, Staphylococcus aureus and anaerobes, and certain fungi.  Risks of developing CSOM increases with following:  History of multiple episodes of ASOM. Living in crowded conditions. Day care facility attendance. Being member of a large family. CSOM without prompt treatment can progress to a variety of mild to life threatening complications.  Complications of CSOM: Extracranial - Mastoiditis, facial nerve paralysis, labrynthitis, petrositis. Presentations of complicated CSOM: Extracranial - Facial weakness, vertigo, tinnitus, mastoid tenderness n swelling, diplopia. Intracranial - Neck stiffness and other signs of meningitis, altered sensorium contributing factors in the progression of CSOM to complicated CSOM; Age, socioeconomic status, organism's virulence, cholesteatoma, immune status.
Extracranial complications occur most commonly and include cholesteatoma and otitis media with perforation. Intracranial complications are less common and include meningitis, brain abscess and lateral sinus thrombosis. In Australia, approximately 60% of extracranial and intracranial complications of otitis media occur in children.  Intracranial complications of otitis media are uncommon, but are potentially life-threatening and are more likely to occur among Indigenous than nonindigenous children.  Reduced access to medical care, lower socioeconomic status and remote living conditions mean that levels of early childhood hearing loss among Indigenous children are likely to be underestimated.  This has implications for early childhood speech and language development and education. Although global complication rates from otitis media have reduced substantially since the advent of the antibiotic era, morbidity and mortality remains a problem, particularly in developing countries  In Pakistan according to studies otogenic intracranial complications like meningitis and brain abscesses are still common in spite of advances in the medical sciences. 
| Materials and Methods|| |
A descriptive cross-sectional study was carried out in a tertiary care hospital Jinnah Postgraduate Medical Centre Karachi in Department of ENT Head and Neck Surgery from 2008 to 2013. Total record of 65 patients was selected through nonprobability convenient sampling.
- Inclusion criteria: (1) Age 10-45, (2) CSOM with intra or extracranial complications
- Exclusion criteria: (1) Comorbid as diabetes mellitus and hypertension, (2) Uncomplicated CSOM with dry perforation.
There were 42 males and 23 females in our study.
Patient sample was subdivided in; Group A = 10-18 years, Group B = 18-45 years.
With total mean age of 18.28.
Data were analyzed on SPSS version 19; Chi-square test was used and P < 0.05 was considered significant with confidence interval taken as 95%.
| Results|| |
Patients were assessed, and common factors contributing to complication were analyzed. Most of our patients present with complication were of Group A in comparison to Group B.
Population mean age is 18.28. And mean duration of complain is 1.69 [Table 1].
Percentage of population sex is male 63.1% and female 36.9% reflecting male predominance. Majority of patients had a history of ear discharge and hearing loss.
Significant associations were found between;
- Duration of complain and family income P = 0.05
- Age of patient and diagnosis P = 0.00 [Table 2].
| Discussion|| |
Chronic suppurative otitis media is an infection commonly associated with poor socioeconomic status or poverty-related conditions such as malnutrition, over-crowding, substandard hygiene, frequent upper respiratory tract infections and under-resourced health care. 
Like in other studies, our study shows that children are the most affected by this disease, especially the under-fives, , accounting for 31.1% of all otologic presentations and 15.2% of all new cases in our study. These are astonishing figures considering the fact that this disease is preventable. Experts declare that when the prevalence of CSOM is 3% or greater, it must be targeted as a high priority disease.  In many developing countries prioritizing health care needs is a difficult task in the face of limited and diminishing resources. 
Complication leads to disability especially if not treated. This disability was the reason for the loss of jobs recorded in few patients, as most were laborers [Table 3].
Chronic suppurative otitis media and its complications like any chronic disease can limit an individual's employability and quality of life. They are particularly disadvantaged because of scarcity of work, poor living conditions and limited health care.  As long as health care delivery fails to target high-risk groups in developing countries, infections like CSOM will persist. Therefore, improving equal access to good health care and ensuring health care programs respond appropriately to individual health needs is a critical factor to ultimately ridding the world of this disease.
| Conclusions|| |
Most common complication of CSOM according to our study is an extracranial complication mastoiditis occurring more in Group A, with male predominance. Important factor was low socioeconomic background of the patient with low monthly income leading to negligence to seek medical assistance on time and delayed treatment. We also noticed that patients from far flung areas with are more prone to develop full-fledged complication as they have no medical facilities available and disease progresses to morbidity and complication. Irrational and excessive use of antibiotics by local doctors without prior bacteriology creates even more disease burden.
With proper education and adequate precautions, this frequency can be reduced significantly thus decreasing the unnecessary financial burden on the state and loss of human resources.
| References|| |
Dhingra PL, Shruti Dhingra. Diseases of Ear, Nose and Throat and head nd Neck Surgery, 6 th
ed. Elseiver Health sciences 2014
van Hasset P. Chronic suppurative otitis media. Comm Ear Hearing H 2007;4:19-21.
Lasisi AO, Sulaiman OA, Afolabi OA.Socio-economic status and hearing loss in chronic suppurative otitis media in Nigeria. Ann Trop Paediatr 2007; 27:291-6.
Ologe FE, Nwawolo CC. Chronic suppurative otitis media in school pupils in Nigeria. East Afr Med J 2003;80:130-4.
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.
Okafor BC. The chronic discharging ear in Nigeria. J Laryngol Otol 1984;98:113-9.
Morris PS, Leach AJ. Prevention and management of chronic suppurative otitis media in aboriginal children: A practical approach. Comm Ear Hearing H 2007;4:22-25.
Matsuda Y, Kurita T, Ueda Y, Ito S, Nakashima T. Effect of tympanic membrane perforation on middle-ear sound transmission. J Laryngology Otol 2009;123 Suppl 31:81-9.
Wright D, Safranek S. Treatment of otitis media with perforated tympanic membrane. Am FAM Physician 2009;79:650, 654.
Meyerhoff WL, Kim CS, Paparella MM. Pathology of chronic otitis media. Ann Otol Rhino Laryngology. 1978;87 (6 Pt 1):749-60.
Kenna MA. Microbiology of Chronic Suppurative Otitis Media. Ann Otol Rhino Laryngology 1988;97 (Suppl 131):9-10.
van der Veen EL, Schilder AG, van Heerbeek N, Verhoeff M, Zielhuis GA, Rovers MM. Predictors of chronic suppurative otitis media in children. Arch Otolaryngol Head Neck Surg 2006;132:1115-8.
Smith JA, Danner CJ. Complications of chronic otitis media and cholesteatoma. Otolaryngology Clin North Am 2006; 39:1237-55.
O′corner TE, Perry CF, Lannigam FJ. Complications of Otitis media in Indigenous and non indigenous children. Med J Aust 2009,191:S60-4.
Hidayat Ullah Khan, Muhammad Saleem, Isteraj Shahabi, Muhammad Ismail Intracaranial Complications of Chronic Suppurative Otitis media Journal of Post Graduate Medical Institute 2011;22:216-8.
Acuin JM. Chronic suppurative otitis media: A disease waiting for solutions.Comm Ear Hearing H 2007;4:17-19.
Olusanya BO, Newton VE. Promoting a global health agenda for permanent childhood hearing impairment. Comm Ear Hearing H 2007;4:25-7.
Ologe FE, Nwawolo CC. Prevalence of chronic suppurative otitis media (CSOM) among school children in a rural community in Nigeria. Niger Postgrad Med J 2002;9:63-6.
World Health Organization.Prevention of hearing impairment from chronic otitis media. Report of a WHO/CIBA foundation workshop.Geneva, 1998
[Table 1], [Table 2], [Table 3]