Acute and Chronic Mastoiditis and Chronic

Suppurative Otitis Media

Charles D. Bluestone, MD
The objectives of this article are to enhance the clinician's ability to (1) diagnose mastoiditis
and chronic suppurative oUtis media, (2) effectively treat these infections, and (3) appropriately refer patients to an otolaryngologist for possible surgical intervention. When inflammation of the mastoid is diagnosed by computed tomography or magnetic resonance imaging
as an incidental finding in which there is no evidence of mastoid osteitis or signs or
symptoms of acute mastoiditis, the disease is most likely a natural extension of otitis media
(ie, acute mastoiditis-otitis media) and should be managed as any other episode of otitis
media. When there are clinical signs of acute mastoiditis (eg, protrusion of the pinna and
postauricular erythema) but no radiographic evidence of mastoid osteitis (ie, acute
mastoiditis with periostitis), the child should have a tympanocentesis and myringotomy
and receive parenteral antimicrobial therapy; referral for possible mastoidectomy is
indicated if the child does not rapidly improve with this management. Presence of a
subperiosteal abscess or radiographic evidence of mastoid osteitis, or both (ie, acute
mastoid osteitis), also calls for mastoid surgery. Likewise, referral is indicated whenever
acute mastoiditis is associated with another suppurative complication of otitis mediamastoiditis and when acute mastoiditis develops in a child who has chronic suppurative
otitis media (CSOM) or cholesteatoma, or both. Treatment of CSOM with appropriate
ototopical antimicrobial medications or oral antibiotics, or both, is frequently effective. If the
child does not respond to these measures, he or she requires parenteral administration of
an antimicrobial agent. Referral to an otolaryngologist may be necessary.
Copyright 9 1998 by W.B. Saunders Company

n the preantibiotic era, acute mastoiditis was the most

common infection for which infants and children were
hospitalized. Since the widespread use of antimicrobial agents,
the incidence has been reduced dramatically, but the clinician
should be aware that acute mastoiditis remains the most
common suppurative complication of acute otitis media (AOM).J
In addition, there is some evidence that the incidence of acute
mastoiditis recently has increased in geographic areas where
antimicrobial agents are withheld from children who have
AOM. 2 Chronic mastoiditis that develops after an episode of
acute mastoiditis also has decreased during the past 50 years for
similar reasons, but it is still a major problem when chronic
suppurative otitis media (CSOM) is present. Because CSOM is
one of the most common chronic infectious diseases in children
in underdeveloped countries and in certain populations of
developed nations, chronic infection of the mastoid is a public
health problem now being addressed by the World Health
Organization. Also, with the popularity of the use of tympanostomy tubes to prevent recurrent AOM and chronic otitis media

Fromthe Children"sHospitalofPittsburgh,Pittfburgh,PA.
Addresscorrespondenceto CharlesD. Bluestone,MD, Deparln~ntofPediatric
Otola~yngology,Children'sHospitalofPittsburgh,3705Fifth Ave, Pittsburgh,PA
15213.
Copyright9 1998by W.B. SaundersCompany
1045-1870/98/0901-000558.00/0
12

with effusion in highly industrialized nations, CSOM is a

world-wide concern.

Acute

Mastoiditis

Acute M a s t o i d i t i s - O t i t i s M e d i a
Acute mastoiditis can be a natural extension and part of the
pathological process of acute middle-ear infection. Most likely,
the mastoid air cells are involved in many children who have
acute otitis media (AOM). No specific signs or symptoms of
mastoid infection (eg, protrusion of the pinna, postauricular
swelling, tenderness, pain, and e~ythema) are present in this
most common stage of mastoiditis. Computed tomographic
(CT) scans are not indicated when the process is self-limited,
but when they are obtained, usually for other reasons (ie,
incidental finding), the mastoid area frequently is read as
"cloudy mastoids." In reality, this finding is indicates of inflammation; no mastoid osteitis (ie, bony erosion of the mastoid air
cells) is evident. The process usually is reversible as the middle
ear-mastoid infection resolves either as a natural process or as a
result of medical management (eg, antimicrobial therapy with
or without myringotomy). Thus, in the absence of osteitis of the
mastoid, periosteal involvement of the postauricular region, and
subperiosteaI abscess, this first stage of acute mastoiditis is not a
suppurative complication ofotitis media.

Seminars in PediatricInfectiousDiseases, Vol 9, No I (January), 1998:pp 12-26

13

Mastoiditis and Otitis Media

Because this initial stage of acute mastoiditis is a natural

extension of otitis media, management is appropriately provided by the primary care physician, but if a tympanocentesis/
myringotomy is required and the clinician is not an expert in
performing this procedure, an otolaryngologist should be consulted. Indications for tympanocentesis (diagnostic aspiration of
the middle ear) are the same as when AOM is diagnosed and
the status of the mastoid is undetermined, such as when the
patient (1) is severely ill or toxic, (2) fails to improve rapidly
while on appropriate and adequate antibiotic treatment, (3)
develops otitis media while receiving antimicrobial agents, (4)
develops otitis media in the newborn period, (5) is immunologically deficient, or (6) has a suppurative complication? Myringotomy is indicated when drainage of the middle ear is desirable, such as when the child has severe otalgia or when a
suppurative complication is suspected or is present.
Tympanocentesis is performed through the inferior portion
of the tympanic membrane by using an 18-gauge spinal needle
attached to a tuberculin syringe or collection trap. If an unusual
pathogen is suspected, taking a culture of the ear canal and
cleansing the canal with alcohol should precede the procedure;
the canal culture is helpful in determining whether the cultured
organisms are contaminants from the exterior canal or pathogens from the middle ear. When therapeutic drainage is
required, a myringotomy knife should be used and the incision
should be large enough to allow for adequate drainage and
aeration of the middle ear.
If a perforation of the tympanic membrane is present, the
canal initially must be cleaned with the aid of suction or
cotton-tipped applicators in an attempt to avoid contaminants
from the ear canal. At the point of exit from the tympanic
membrane, the discharge is cultured with a cotton-tipped wire
culture swab or, preferably, a needle and syringe under direct
vision. If the defect in the eardrum is too small to allow adequate
drainage, a myringotomy should be performed. A Gram'sstained smear of the pus provides rapid information about the
responsible organisms.
When acute infection in the mastoid (and usually the middle
ear as well) does not resolve at this stage, the disease can rapidly
progress to acute mastoiditis with periosteitis, followed by acute
mastoid osteitis, which can occur with or without the presence of
a subperiosteal abscess; referral to an otolaryngologist may be
necessary, as will be described.

mortality rate during that period. In some studies, the mortality

rate dropped to almost zero.46 At the Children's Hospital of
Pittsburgh, only 18 mastoidectomies were performed between
1980 and 1995 for acute mastoiditis.' Today's increasing enthusiasm in some countries for withholding antimicrobial therapy
most likely will result in an increase in this suppurative complication. Indeed, Hoppe et al 2 reported that in their children's
hospital in Germany, the rate of acute mastoiditis has statistically increased recently, which they attribute in some cases to
withholding antimicrobial agents.
Pathogenes/s, Infection in the mastoid air cells, which is
frequently part of an episode of AOM, usually resolves spontaneously or after effective antimicrobial treatment. The effusion
within the mastoid air cells drains into the middle ear and, in
turn, into the eustachian tube. The communication between the
middle ear and the mastoid air cells is narrow and is called the
aditus-ad-antrum (Fig 1A). Physiologically, the mastoid air cell
system is most likely a reservoir of gas for the middle ear, and
this narrow passage makes it more difficult for middle-ear
infection to enter the mastoid. When infection is in the mastoid,
the aditus-ad-antrum can become obstructed because of edema
and granulation tissue (Fig 1B). This obstruction has been
called the "bottleneck" and has been implicated in the pathogen-

Aditus-ad-antrum
Mastoid antrum

~ /

Attic

VI ~ O rw~c..^

~")-

tube

membrane I

Aditus-ad-antrum

"Block"

Acute
Mastoiditis

oq
Zr176
/ .~

/
,.'V_r

/I..3
f > 77 r /

~ /

Acute Mastoiditis With Periosteitis

When infection within the mastoid spreads to the periosteum
covering the mastoid process, periosteitis can develop. The route
of infection from the mastoid cells to the periosteum is by
venous channels, usually the mastoid emissary vein. The condition should not be confused with the presence ofa subperiosteal
abscess because management of the latter condition usually
requires a mastoidectomy, whereas the former frequently responds to medical treatment and tympanocentesis/myringotomy.
Ep/dembo/ogy. Before the era of antibiotic use, the frequency of mastoidectomy performed for acute mastoiditis as a
complication of AOM was high. In 1938, the rate was 20%; 10
years later, it was 2.8%, an almost 90% reduction in the

Figure 1, Schematic depiction of right eustachian tube, middle

ear, and mastoid air cell anatomy. The middle ear is normally
connected to the mastoid air cells through the narrow aditus-adantrum (A). When the middle ear and mastoid are infected, the
aditus-ad-antrum can become obstructed by mucosal edema
and granulation tissue, which has been termed aditus block or the
bottleneck (B).

14

Charles D. Bluestone

esis of acute mastoiditis, ff the obstruction persists, acute

mastoiditis with periosteitis can develop, progress into acute
mastoid osteitis (with and without subperiosteal abscess), and
further develop into another suppurative complication in the
temporal bone or the intracranial cavity.
Clinical Presentation. Clinically, the child has the classic
signs and symptoms of AOM, such as fever and otalgia, but also
postauricular erythema. Mild tenderness and some edema also
may be present in the postauricular area. The pinna may or may
not be displaced inferiorly and anteriorly, with loss of the
postanricular crease. Subperiosteal abscess is absent. Examination of the eardrum typically reveals evidence of AOM. However, the middle ear may be effusion-free in the presence of
acute mastoiditis if there is an obstruction of the aditus-adantrum; the middle-ear effusion drains into the eustachian tube,
but the infection in the mastoid cannot drain into the middle
ear. Table 1 shows the frequency of the presenting signs and
symptoms in 72 infants and children who had acute mastoiditis
diagnosed at the Children's Hospital of Pittsburgh from 1980 to
1995. (Some of these patients had acute mastoid osteitis with
and without subperiosteal abscess.) l
For this stage of acute mastoiditis, a CT scan of the temporal
bones (and intracranial cavity) may be obtained to determine if
Table 1. Age, Presenting Symptoms, and Signs of 72 Infants
and Children with Acute Mastoiditis

Patients (%)

Age (years)
0-3
4-6
7-12
13-18

36 (50.0)
12 (16.7)
17 (23.6)
7 (9.7)

Symptoms
Otalgia
Postauricular pain
Fever
Otorrhea
Upper respiratory infection
Irritability
Hearing loss
Signs
Postanricular tenderness
Pinna protrusion
Postauricular erythema
Middle-ear effusion
Tympanic membrane erythema
Contralateral middle-ear abnormalities
Middle-ear effusion
Tympanic membrane bulging
Tympanic membrane erythema
Tympanic membrane perforation
Tympanic membrane bulging
Otorrhea
Fever -->38.3~
Tympanic membrane perforation
Postauricular mass
Cervical adenopathy
Postauricular abscess
Sagging of posterior auditory canal wall
Reprinted with permission)

62 (86.1)
58 (80.6)
51 (70.8)
29 (40.3)
17 (23.6)
16 (22.2)
6 (8.3)
58 (80.6)
51 (70.8)
51 (70.8)
48 (66.7)
42 (58.3)
35 (48.6)
20 (27.8)
8 (11.1)
6 (8.3)
1 (1.4)
34 (47.2)
24 (33.3)
24 (33.3)
13 (18.1)
13 (18.1)
12 (16.7)
9 (12.5)
2 (2.8)

Table 2. Bacteriology of Effusions, Otorrhea, and Mastoids in

65 Infants and Children with Acute Mastoiditis

Organism

Number Isolates (%)

Streptococcuspneumoniae
Pseudomonas aeruginosa
Streptococcuspyogenes
Diphtheroids
Anaerobes
Others*
No growth
Totalt

21 (32.3)
19 (29.2)
12 (18.5)
9 (13.9)
7 (10.8)
39 (60.0)
6 (9.2)
113

*Staphylococcuscoagulase negative,23ct-Hemolyticstreptococcus,4Haemophilus influenzae,3Micrococcusspecies,2Moraxdla catarrhalis,1Staphylococcus aureus,l Staphylococcus species,1 Enterobacter cloacae,l Neisseria species,l Enterococcus species,1Citrobacterdiversus,l
tTotal isolates greater than 100%because some cultures were polymicrobial.
Reprinted with permission.1
osteitis of the mastoid is present. However, a CT scan is not
mandatory if the infection is limited to the middle ear and
mastoid and the child is not severely ill or toxic and rapidly
improves after tympanocentesis/myringotomy and antimicrobial therapy.
M/crob/o/ogy. Middle-ear aspirates show bacterial pathogens similar to those isolated from the ears of children who have
uncomplicated acute middle-ear infection, such as Streptococcus
pneumoniae, Streptococcus pyogenes, or Haemophilus influenzae. In
addition, there may be unusual organisms, such as Pseudomonas
aeruginosa, if there has been otorrhea (Table 2). l~
Managongnt. The patient may be managed on an ambulatory basis if the infection is not severe. However, hospitalization
usually is necessary because parenteral antimicrobial therapy
frequently is needed; most patients require an immediate
tympanocentesis (for aspiration and microbiological assessment
of the middle ear-mastoid effusion) and myringotomy for
drainage of the middle ear, which in the absence of an obstruction of the aditus-ad-antrum, should also drain the mastoid. If
the child has had recurrent attacks of AOM, or has the current
episode of AOM superimposed on chronic otitis media with
effusion (OME), insertion of a tympanostomy tube is indicated.
Placement of a tympanostomy tube is desirable and will enhance drainage over a longer period of time than will myringotomy alone. Despite reports that antibiotic treatment without
the benefit of tympanocentesis or myringotomy was successful
in curing some children, aspiration of the middle ear is an
important diagnostic (and therapeutic) procedure today because an antibiotic-resistant bacterial pathogen may be the
causative organism. 7-1~
Cultures for bacteria from the middle ear are required to
identify the causative organism(s). Antimicrobial susceptibility
studies are important for selecting the most effective antibiotic
agent. For empiric parenteral antimicrobial therapy, cefuroxime sodium, ticarcillin disodium with clavulanate potassium, or
ampicillin-sulbactumcan be initiated until the Gram's stain, the
culture, and the susceptibility studies of the middle-ear aspirates are available. If a penicillin-resistant S pneumoniae is the
possible pathogen, today some clinicians also would add vancomycin while awaiting the culture and susceptibly reports.

Mastoiditis and Otitis Media

The periostea] involvement should resolve within 24 to 48
hours after the tympanic membrane has been opened for
drainage and adequate and appropriate antimicrobial therapy
has begun. A mastoidectomy should be performed if (1) the
symptoms of the acute infection, such as fever and otalgia,
persist; (2) the postauricular involvement does not progressively
improve; or (3) a subperiosteal abscess develops. A C T scan can
be helpful in the decision regarding surgical intervention. A
mastoidectomy also is indicated if another intratemporal (extracranial) suppurative complication of otitis media, such as facial
paralysis, labyrinthitis, petrous apicitis, or an intracranial complication (eg, meningitis, lateral sinus thrombosis, or abscess of
the epidural or subdural space or brain), is present.
Outcome. In the review by Goldstein and colleagues, 1 54 of
the 72 infants and children (75%) with acute mastoiditis at the
Children's Hospital of Pittsburgh were managed conservatively
with broad spectrum intravenous antibiotics and myringotomy,
with and without tympanostomy tube insertion. The remaining
18 (25%) required mastoidectomy; 14 of these 18 children (78%)
had one or more of the following: mastoid osteitis, subperiosteal
abscess, cholesteatoma, or another suppurative complication
(eg, facial paralysis). 1A recent review from Australia by Harley
and associates3 reported an experience similar to what occurred
in Pittsburgh. Between 1982 and 1993, 58 infants and children
were admitted to the Royal Children's Hospital of Melbourne.
Forty-five (78%) were treated conservatively with intravenous
antimicrobial therapy, with and without tympanostomy tube
insertion; the remaining 13 patients required mastoidectomy.
Other investigators also have reported that the majority of
children with acute mastoiditis can be managed conservatively,
whereas yet other centers have reported that most of their
patients required a mastoidectomy. 7,u-16 Most likely, the reasons for these conflicting reports are the lack of uniform
definitions of the disease, dissimilarity in presentation of the
cases, and variations in management. My opinion is that most
patients with acute mastoiditis with only periosteitis recover
without the need for mastoidectomy.
Immediate treatment at this stage of acute mastoiditis is
mandatory because failure to do so may result in the development of acute mastoid osteitis (with or without a subperiosteal
abscess) or, potentially more life-threatening to the child, a
suppurative complication such as meningitis or brain abscess.
In the absence of mastoid osteitis (with or without subperiosteal abscess), the primary care physician or pediatric infectious
disease specialist can provide the initial medical care for
patients with acute mastoiditis with periosteitis. However,
because tympanocentesis/myringotomyis required, an otolaryngologist will be needed if the medical specialists are untrained in
this procedure. Referral to an otolaryngologist is appropriate if a
mastoidectomy is indicated. Also, immediate referral for surgical evaluation and management is appropriate when acute
mastoid infection develops in a child with CSOM or cholesteatoma, or both.

Acute Mastoid Osteitis

Acute mastoid osteitis also has been called acute "coalescent"
mastoiditis or acute surgical mastoiditis, but in reality, the

15

pathologic process is osteitis. A subperiosteal abscess may or

may not be present. When infection within the mastoid
progresses, rarefying osteitis can cause destruction of the bony
trabeculae that separate the mastoid cells such that there is a
"coalescence" of the cells. At this stage, a mastoid empyema is
present. The pus may spread in one or more of the following
directions:
1. Anterior to the middle ear through the aditus-ad-antrum, in
which case spontaneous resolution usually occurs.
2. Lateral to the surface of the mastoid process, resulting in a
postauricular subperiosteal abscess.
3. Anterior into the zTgomatic cells to develop into an abscess in
the anterior and superior portions of the pinna and the
preauricular area.
4. Inferior through the tip of the mastoid to burrow beneath the
skin to form a soft tissue abscess below the pinna or behind
the attachment of the sternocleidomastoid muscle in the
neck, which is known as a Bezold abscess.17,m
5. Medial to the petrous air cells, resulting in petrositis.
6. Posterior to the occipital bone, which can result in osteomyelitis of the calvarium or a Citelli abscess. Infection also may
spread medial to the lab)rinth, involve the facial nerve, or
extend into the intracranial cavity, causing one or more
suppurative complications.
Clinical Presentation. The child with acute mastoid osteitis
usually has the same signs and symptoms as those associated
with AOM, such as fever and otalgia, although the fever may be
low-grade with occasional temperature spikes. Some patients
may seem "toxic." The signs and s~,rnptoms referrable to the
mastoid infection are (1) swelling, er,ythema, and tenderness to
touch over the mastoid bone; (2) displacement of the pinna
outward and do~aaward; and (3) swelling or sagging of the
posterosuperior external auditor,:" canal wall (Table 1). A fluctuant subperiosteal abscess or even a draining fistula from the
mastoid to the postauricular area may be present. The subperiosteal abscess can be in any of the anatomic sites described
previously.
Examination of the tympanic membrane may show purulent
discharge and a perforation. Conversely, the tympanic membrane and middle ear may seem almost healthy when mastoiditis with periosteitis occurs. Acute mastoid osteitis (without
otitis media) also may be the focus of infection when a child has
a fever of unknown origin.
D / a g n o ~ . The diagnosis should be suspected on the basis of
clinical signs and s}a'nptoms. CT scans of the mastoid area
usually show one or more of the following: (1) haziness,
distortion, or destruction of the mastoid outline; (2) loss of
sharpness of the shadows of cellular walls caused by demineralization, atrophy, and ischemia of the bony septa; (3) decrease in
density and cloudiness of the areas of pneumatization caused by
inflammatory swelling of the air cells; or (4) in longstanding
cases, a chronic osteoblastic inflammatory reaction that may
obliterate the cellular structure. Small abscess cavities in sclerotic bone may be confused with pneumatic cells.
Management. An otolar}aagologist should be consulted if a
child has a diagnosis of acute mastoid osteitis. Parenteral
antimicrobial therapy should be instituted as described previ-

16

CharlesD. Bluestone

ously for acute mastoiditis with periosteitis, To ensure that

drainage of the middle ear and mastoid is adequate, in the
absence of a large perforation and otorrhea, a wide-field large
myringotomy should be performed immediately. Insertion of a
tympanostomy tube, in addition to a large myringotomy incision, can provide more prolonged drainage from the middle
ear-mastoid than can myringotomy alone. Also, the tympanostomy tube placement will help prevent recurrence of AOM (and
mastoiditis).
A complete, simple ("cortical") mastoidectomy usually is
required when there is evidence of acute mastoid osteitis,
especially when the mastoid empyema extends outside the
mastoid bone and a subperiosteal abscess is present. The
procedure should be considered an emergency, but the timing of
the surgery must depend on the status of the child. Ideally,
sepsis should be under control, and the patient must be able to
tolerate a general anesthetic. The principle is to clean out the
mastoid infection, drain the mastoid air cell ~ystem into the
middle ear by eIiminating any obstruction that is caused by
edema or granulation tissue in the aditus-ad-antrum, and
provide external drainage (Figure 2).mffa suppurative intratemporal or intracranial complication also is present, surgical
interventionfor these conditions also may be required,

obstruction

Acute
Mastoiditis..,-.

~t

~"

Simple ("cortical")

/ ~Oo~o-e~.~,/}
O'~O u ~
~"

IF

I /..~

''

/ /.-"- /

Mastoidectomy

Aditus-ad-antrum

M a s t o ' d ca " y

Figure 2. Schematic depiction ofaditus-ad-antrum "block" (A)

and the principals of a cortical ("simple") mastoidectomy (B) in
a right ear. The infected mastoid air cel}walls are removed with
a surgical drill to form one large mastoid cavity, and the
granulation tissue in the aditus-ad-antrum is excised to promote
drainage from the mastoid to the middle ear.

Role o f the Otolaryngologist

Table 3 shows the clinical features on presentation to the
physician and findings on a CT scan of acute mastoiditis related
to my recommended management. I recommend consultation
with an otolaryngologist for possible tympanocentesis and myringotomy (and tympanostomy tube insertion) whenever the
primary physician lacks the expertise (or qualifications for
tympanostomy tube placement) to perform these procedures.
Also, consultation with the otolaryngotogist is indicated for
possible mastoidectomy whenever (1) a child has the diagnosis
of acute mastoiditis with subperiosteal abscess, irrespective of
the results of CT scan and (2) the CT scan shows osteitis,
irrespective of the other clinical features.
An otolaryngologist should be consulted immediately whenever acute mastoiditis is associated with another possible suppurative complication of otitis media and mastoiditis and when
acute mastoiditis develops in a child who has CSOM or cholesteatoma, or both.

Subacute Mastoiditis ("Masked

Mastoiditis")
Although relatively uncommon, if the acute middle-ear and
mastoid infection does not totally resolve within the usual 10 to
14 days, subacute mastoiditis (also termed "masked mastoiditis") may develop.2~At this stage, the infection in the mastoid
can even develop into an intratemporal or intracranial complication. Typically, the patient lacks the classic signs and symptoms
of AOM and mastoiditis but can have recurrent low-grade or no
fever and mild otalgia. Also, the child may have persistent or
recurrent mild-to-moderate postauricular pain. Examination of
the tympanic membrane may show a middle-ear effusion,
although it can seem to be disease-free if the middle-ear
infection has resolved but there is persistent mastoid infection
caused by an obstruction of the aditus-ad-antrum (Fig I).
The diagnosis usually is made by a CT scan of the temporal
bones or by a bone scan71 For children who have an intratemporaI or intracranial suppurative infection, which could possibly be
caused by mastoid infection, a CT scan of the temporal bones
should be included in the workup, even though there is no
evidence of middle-ear disease on otoscopy. Although unusual, a
child who has a fever of unknown origin may have subacute
mastoiditis.
Management of this stage of mastoiditis is the same as that
described previously for acute mastoiditis with periosteitis,
which is encountered much more commonly. Although some
clinicians have recommended mastoidectomy for this condition,
less aggressive management, such as tympanocentesis (and
possible myringotomy) to identify the causative organism and
culture-directed antimicrobial therapy, usually is successful. In
my experience, these children usually have persistent middle
ear-mastoidinfection (ie, subacute odtis media that is unresponsive to commonly prescribed antibiotics) and, therefore, the
offending bacterium should be identified and the appropriate
antibiotic administered.22 Indications for consultation with the
otolaryngologist and for possible mastoidectomy are similar to
those described when acute mastoiditis is present.

Mastoiditis and Otitis Media

17

Table 3. Features of Acute Mastoiditis Related to Recommended Management

Management
Features
Pinna
Protrusion
No
No
Yes
Yes
Yes
Yes
Yes

Postauricular
Periosteitis
No
No
Yes
Yes
No
Yes
Yes

Subperiosteal
Abscess
No
No
No
No
No
Yes
Yes

Antibiotics
Osteitis(on computed
tomography scan)

Oral

No
Yes
No
Yes
Yes
No
Yes

Yes
No
No
No
No
No
No

Parenteral
No
Yes
Yes
Yes
Yes
Yes
Yes

Tympanocentesis
with or without
Myringotomy
Opt *
Yes
Yes
Yes
Yes
Yes
Yes

Mastoidectomy
No
Yes
Not"
Yes
Yes
Yes
Yes

*Optional;indicationssame as for acute otitis media.

"j'Yes,if treatment failureafter myringotomyand parenteral antibiotics.

Chronic Mastoiditis
Today, chronic mastoiditis most commonly is associated with
CSOM (discussed later). However, an occasional child will
develop acute mastoiditis, which is unrecognized, untreated, or
inappropriately treated, and the infection will progress into a
chronic stage. These children may present with a fever of
unknown origin or chronic otalgia and tenderness over the
mastoid process.
Examination of the tympanic membrane shows evidence of
middle-ear effusion, but the eardrum may appear normal if the
chronic infection is localized only to the mastoid. A CT scan
should be obtained. The mastoid may be poorly pneumatized,
sclerotic, or have bone destruction with opacification of the
mastoid.
The chronic infection at this stage may be brought under
control by medical treatment with antimicrobial agents (similar
to those recommended previously for acute mastoiditis). A
tympanocentesis (for Gram's stain, culture, and susceptibility
studies) and myringotomy (for drainage) should be performed.
However, when there are extensive amounts of granulation
tissue and osteitis in the mastoid, or if the child does not respond
to medical therapy, referral to an otolaryngologist is needed
because a tympanomastoidectomy is required to eliminate the
chronic mastoid osteitis.
Chronic mastoiditis also can be caused by a cholesteatoma,
which usually manifests by chronic otorrhea through a defect in
the tympanic membrane and requires definitive surgical treatment.

Chronic Suppurative Otitis Media

Throughout the world, CSOM is one of the most common
chronic diseases of childhood in many underdeveloped countries, especially among the poor, and in certain populations of
developed nations. With the popularity of tympanostomy tubes
for management of recurrent acute AOM and chronic OME,
CSOM also can become a potential problem for any child who
has them inserted. Because this infection is associated with
chronic hearing loss, which may affect development of speech,
language, cognition, and school performance, effective treatment and prevention are imperative.

Def'mitions
CSOM is a stage of ear disease in which there is chronic
infection of the middle ear-cleft (ie, eustachian tube, middle
ear, and mastoid) and in which a nonintact tympanic membrane
(eg, perforation or tympanostomy tube) and discharge (otorrhea) are present. This stage of ear infection has been called
simply chronic otitis media, but this term can be confused with
chronic OME, in which no perforation is present. When chronic
otorrhea is eradicated, a chronic perforation may persist, which
also has been inappropriately termed CSOM; a more precise
term is chronic perforationfl 3
Despite this strict definition, a review of the literature shows
that many reports that describe the epidemiology of CSOM
include entity chronic perforation, with and without otorrhea.
Also, some clinicians consider a chronic perforation that is
associated with infection to be "active," and when infection is
absent, "inactive. ''24 Chronic otomastoiditis is another term
used by clinicians, but this term is synonymous with CSOM.
Cholesteatoma also can be associated with CSOM, which is
important to diagnose because cholesteatoma invariably demands surgical intervention,whereas most children with CSOM
require only medical treatment. In this section, I will discuss
only CSOM without cholesteatoma; the presence of cholesteatoma requires prompt referral to an otolaryngologist.

Epidemiology
CSOM is a major health problem in many populations around
the world, affecting diverse racial and cultural groups living not
only in temperate climates but also in climate extremes ranging
from the Arctic Circle to the equator. From a review of
approximately 50 reports published during the past 30 years,
four groups of populations based on the prevalence of the
disease, seem to emerge (Table 4). The populations in which the
prevalence of CSOM (defined here as chronic perforation with
and without suppuration, but not cholesteatoma) has been
reported to be the highest are the (1) Inuits of Alaska (30% to
46~ 2~-~7 Canada (7% to 31%),z8-34 and Greenland (7% to
12%)3~37; (2) Australian Aborigines (12% to 33%)3847; and (3)
certain Native Americans (eg, Apache and Navajo tribes) (4% to
8%).~53 Apparently, these North American Indian tribes have

18

CharlesD. Bluestone

Table 4. Prevalence of Chronic Otitis Media

Highest

Population

Prevalence(%)

INUITS
Alaska 25-27
Canada 28-34
Greenland 35-~7
AUSTRALIAN ABORIGINES 38"47

30-46
7-31
7-12
12-33

N A T I V E A M E R I C A N S 4a'53

High

Low

I~west

Apache, Navajo
S O U T H PACIFIC
Solomon Islands 55
New Zealand Maori 56,57
Malaysia 58
Micronesia 5961
AFRICA
Sierra Leone 63
Gambia 64
Kenya 65
Tanzania 66-68
KOREA 72
INDIA 73
SAUDI ARABIA74
UNITED STATES 75-77
UNITED KINGDOM~~
DENMARKa~
FINLAND TM

4-8
4-6
4
4
4
6
4
4
2-3
2
2
1.4
< l
< 1
<1
< 1

higher rates than do others. 54 One study from the Eastern

Canadian Arctic compared the rates in Cree Indian school

children with Inuit children living in the same area and found
the rate in the Innit to be 22%, in contrast to only 1% in the
Cree. 33
The following are populations with moderately high rates:
1. Certain natives of the South Pacific islands, such as the
Solomon Islands (4% to 6%), 55 New Zealand Maori (4%), 56,57
Malaysia (4%), 58 and Micronesia (4%). 59-61 In contrast to
these high rates in some islands of the South Pacific, natives
of Melanesia have an extremely low rate, less than 1%.62
2. Some African populations, such as Sierra Leone (6%), 63
Gambia (4%), 64 Kenya (4%), 65 and Tanzania (2% to 3%). 66-68
However, not all reports from Africa have documented these
relatively high rates. One study from Nigeria reported less
than 1% with the disease69; another study found a 4% rate. 7~
One study of South African rural blacks also found a rate of
less than 1%. 71
Countries with relatively low rates of CSOM are Korea
(2%), 72 India (2%), 7~ and Saudi Arabia (1.4%). 74 Studies from
highly-industrialized nations have reported the lowest rates
(none or less than 1%); these include the United States, 75-77
Finland, TMthe United Kingdom 2~where in one adult population,
the rate has been reported to be 3.1%, 24 and Denmark. g~With
the widespread use of tympanostomy tubes in these countries,
however, CSOM occurs as a common complication in infants
and children. 81
Risk factors that have been attributed to the high rates of
CSOM in these populations are lack of breast-feeding, overcrowding, poor hygiene, poor nutrition, passive smoking, high rates of

nasopharyngeal colonization with potentially pathogenic bacteria, and inadequate and unavailable health care. 29,3a,46,82

Hearing and Chronic Suppurative Otitis Media

Many studies have assessed hearing in children with OME. In a
study of Pittsburgh infants and children who had documented
OME, the average speech awareness threshold in 222 infants, 7
to 24 months of age, was 25 dB hearing level. In 540 older
children, aged 2 to 12 years, the average air-conduction threshold was 27 dB. 83 Although, only a few studies report hearing in
populations that have a high rate of CSOM, the average hearing
loss is usually worse than that reported when OME is present.
One recent excellent study from Sierra Leone evaluated the
hearing in children who had perforation with and without
suppuration. O f the 3 7 ears with dry perforations, 33 (89%) had
a pure tone average of 26 dB or greater, and of the 100 ears with
CSOM, 96 (96%) also had this degree of hearing loss. 63

Pathogenesis
The cause and pathogenesis of CSOM is mnltifactorial; one or
more of the risk factors noted previously are involved. CSOM
usually begins with an episode of AOM. Thus, the factors that
have been associated with AOM and may be initially involved
include upper respiratory tract infection (URI); anatomic factors, such as eustachian tube dysfunction; host factors, such as
young age, immature or impaired immunologic status, presence
of upper respiratory allergy; familial predisposition; presence of
older siblings in the household; male sex; race; method of
feeding (bottle v breast); and environmental (eg, smoking in the
household) and social factors. ~ Probably the most important
factors related to the onset of AOM in infants and young
children are immaturity of the structure and function of the
eustachian tube and immaturity of the immune system. 85
Chronic perforation of the tympanic membrane develops
after an acute perforation occurs. Tympanic membrane perforations that are acute (and not caused by trauma) usually are
secondary to AOM, but they also may occur during the course of
chronic OME in certain populations, such as Australian Aborigines. 47 Because a spontaneous perforation commonly accompanies an episode of A O M that is untreated with an antimicrobial
agent and is less commonly observed after adequate treatment,
it may be part of the natural history of the disease process rather
than a complication.
CSOM occurs when acute drainage through a nonintact
tympanic membrane (ie, perforation or tympanostomy tube)
persists for 3 weeks to 3 months or longer. (There is no
consensus on the duration of otorrhea that is necessary for the
process to be termed chronic; some clinicians consider the
presence of Pseudomonas species as indicative of CSOM because
the management is the same irrespective of the duration.)
Factors most likely related to the progression of acute otorrhea
into the chronic stage have been noted previously, but most
likely the process, if longstanding, results in a chronic osteitis of
the middle-ear cleft. 86 Figure 3 shows the sequence of events
after an attack of AOM that can lead to a chronic perforation or
CSOM.
When a chronic perforation of the tympanic membrane is

Mastoiditis and Otitis Media

Tympanic
membrane
Middle ear
Mastoid / - % ~
/Eustachian tube
Ear

Negative middle ear

pressure
Aspiration,

~-/) X~ ~
A t - J ~ ~
insufflation,
canal~ / d , ~ ~ - - N a s o p h a r y n x
~. / ~ t ~ ~
reflux of
XV" ~
~i
V /~
" ~ \ ~ nasopharyngeal
/~ / r A ' q ~ \
u m ----~/ / ~ B
,~,~\\\ secre!ionsl
" " " ""
""~"
o ~
I~
N~\'~\orgamsms into
/~%.)"
"~\\\\
/
~
m,w ~\\" middle ear
Acute Otitis Media

Tympanic ~
membrane

~ - perforation~ ~
~

19

k.~'~r~-,
-- ~.Lk~ ~

Otorrhea
~
A
c

_u

Resolution & healing

membrane

of tympanic

Secondary
bacterial

aeruginoSaureu.~~

~...."'S~:~'~
infection " ~ " ~ / ~ "
"~k~ll~
t

P.

Resolution but chronic

perforation of
tympanic membrane

s.

Chronic Suppurative
Otitis Media

Figure 3. One possible sequence of events following an episode of acute otitis media that can result in a chronic perforation of the
tympanic membrane or chronic suppurative otitis media in a right ear (A). During an episode of an upper respiratory tract infection,
nasopharyngeal secretions with viruses and bacteria can gain entrance into the middle ear (B), causing acute otitis media, perforation
of the tympanic membrane, and otorrhea (C), after which bacteria from the ear canal can enter the middle ear (D), resulting in
chronic suppurative otitis media (E). Alternatively, the infection resolves but the perforation persists and becomes chronic (El), or
there is both resolution of the otorrhea and healing of the perforation (E2).

present but dry, reinfection of the middle ear cleft probably

occurs in one of two ways:
I. Bacteria from the nasopharynx gain access to the middle ear
by reflux or insuffiation (caused by crying in the infant, nose
blowing, or swallowing when there is nasal obstruction
present, ie, "Toynbee phenomenon ''87) of nasopharyngeal
secretions, through the eustachian tube, because the middleear "air cushion" is lost; an episode usually occurs with an
URI. In most instances, these bacteria initially are the same
as those usually isolated from episodes of AOM that occur
behind an intact tympanic membrane (eg, Spneumonia a n d H
inJ/uenzae). Following the onset of acute otorrhea, P aerug/nosa,
Staphylococcus aureus, and other organisms from the external
ear canal enter the middle ear through the nonintact tympanic membrane, resulting in secondary infection and acute
otorrhea and CSOM (Fig 4).
2. The middle-ear cleft is contaminated by organisms (eg, P
aerug/nosa) that are present in water and enter through the
nonintact eardrum during bathing and swimming (Fig 5). 23
Likely eustachian tube dysfunction is involved in the process.
In a study of eustachian tube function in the ears ofJapanese
children and adults who had chronic perforations, Iwano and
associates found impaired active opening function of the
tube. 88 They concluded that the tube was functionally obstructed; however, "organic" (ie, mechanical or anatomic)
obstruction also was considered to be involved in the pathogenesis of CSOM in adults.

Populations at High Risk. As described previously, certain

populations are at high risk of developing chronic perforation of
the tympanic membrane, with and without CSOM. What other

host factors contribute to their high rate of disease? One

important possible explanation is that these groups have eustachian tubes that make them more prone than others to
middle-ear infection. One study identified anatomical differences in the bony segment of the eustachian tube in the
craniofacial structures of Eskimo, Native American, white, and
African-American crania. 89 Also, in a clinical study, White
Mountain Apache Indians were found to have eustachian tubes
that were semipatulous (of low resistance) in comparison with
those of a group of whites. 9~Similar results have been reported
in Canadian Inuits. Ramesar calibrated the eustachian tube
with ureteric catheters in Canadian Inuits and white individuals
and found the tubes to be larger in the former than in the
latter, m
One study reported that environment plays a role in one
high-risk population, but that genetic differences are probably
more important in those who are at high risk. Adopted Apache
children had more episodes of AOM than did their non-Apache
siblings and had an illness rate similar to that of Apache
children who remained on the reservation. 92

Microbiology
The bacteria that cause the initial episode of AOM and
perforation, or acute otorrhea through a tympanostomy tube,
are usually not those that are isolated from patients with
CSOM. The most common organism isolated from around the
world isPaeruginosa. S aureus is found less commonly93-97Table 5
shows the frequency of bacteria isolated from children with
CSOM at the Children's Hospital of Pittsburgh. 98
Anaerobic bacteria also have been isolated from ears with
CSOM, but whether or not they are true pathogens remains to

Charles D. Bluestone

20

Reflux/insufflation
of nasopharyngeal
secretions/organisms
l---~into middle ear

Middle ear

~"~:~4PNasopharynx

V
/

/ W o n - i n t a c t ' , ~ '~, ) ]
)tympanic
.3membrane

t ~
")PO\[ t.

g
Acute Otorrhea

"

/~)r)

\\\\\\

\ \ \ \ \\

"~"~

P. a e r u g i n o s a
S. aureus

Chronic Suppurative Otitis Media

Figure 4. One of two proposed sequences of events in the pathogenesis of recurrence of otorrhea when the tympanic membrane is
not intact and active infection is absent in a right ear (A). After an upper respiratory tract infection, nasopharyngeal organisms are
refluxed or insuffiated into the middle ear (B), which results in an acute otitis media and otorrhea (C). Organisms from the external
canal then can enter the middle ear (D), which can result in chronic suppurative otitis media (E). (Tensor veli palatini muscle).
be shown. Brook isolated Bacteroides melaninogenicus in 40% and
Peptococcus species in 35% of middle-ear exudates. 99 There have
also been reports of the isolation of uncommon organisms, such
as Mycobacterium tuberculosis, actinomycosis, Alcaligenes piechaudii,
Mycobacterium chelonae, andBlast0myc0sis dermatitidis. 100"104

Differential Diagnosis
Examination includes assessment of the child, as well as the ear.
The evaluation should include a complete examination of the
ear with an otoscope. An otomicroscope may be required if a
satisfactory assessment cannot be performed with the standard
otoscope or if the child has not responded to appropriate and
adequate initial treatment. An occasional child who cannot be
successfully assessed when awake should undergo the examination under general anesthesia. A polyp may be observed coming
through the perforation, which may indicate the child has a
cholesteatoma, which appears as a white mass or a remnant of
epithelial tissue within the tympanic membrane. Prompt referral to an otolaryngologist is indicated for management. The
child will have no otalgia, tenderness to touch in the mastoid
area or pinna, vertigo, or fever. If any of these signs or symptoms
is present, the examiner should look for a possible suppurative
complication.

Diagnostic assessment should include a Gram's-stained smear

and culture of the discharge. Purulent material and debris
should be cleaned from the ear canal and, ideally, the culture
should be obtained from the middle ear (ie, through the
perforation or tube with a swab or by needle aspiration). An
underlying cause of the chronic infection, such as adenoid
hypertrophy, paranasal sinusitis, upper respiratory tract allergy,
immunologic disorder, or, on rare occasion, a tumor of the head
and neck, should be considered.
A C T scan of the temporal bones is indicated when (1) a
suppurative complication of otitis media-mastoiditis, cholesteatoma, or tumor is present or suspected; (2) intensive medical
treatment (including intravenous antimicrobial therapy) fails;
or (3) the child has an early recurrence.
One should always be alert to the possible presence of
unusual causes of a chronic draining ear such as neoplasm,
eosinophilic granuloma, or an unusual organism as the cause of
the infection. These must be considered in the differential
diagnosis of CSOM.

Management
Treatment of CSOM initially is medical and directed toward
eliminating the infection from the middle ear and mastoid.

Mastoiditis and Otitis Media

A

Middle ear
/"
f
I

Eustachian
"
"~.~
tube
~,
~
L A
~ ~ - -

21

Br Water
j
contamination(
fl'om ear--,~'-{,

~
~

# ~
~
~..,,~.
~
~

/M~asto~~~ ear~/~
(

/-~<.-/

\\\,~v

T.

canal to

~ /:,'

middle

P. aeruginosa
S. auraus

Ear canal

& Otorrhea

Chronic Suppurative Otitis Media

Figure 5. One of two proposed sequences of events in the pathogenesis of recurrence of otorrhea when the tympanic membrane is
not intact and active infection is absent in a right ear (A). The middle ear is contaminated by organisms in water that enter the middle
ear through the perforation (B), which can result in acute otitis media and otorrhea (C), and, if persistent, chronic suppurative otitis
media (D). (Tensor veli palatini muscle
Because gram-negative bacteria are isolated most often, the
antimicrobial agent that is selected should be effective against
these organisms.
Ototopical Medications. Although a suspension containing
polymyxin B, neomycin, hydrocortisone (Cortisporin, Glaxo
Wellcome Inc, Research Park, NC), and one that has neomycin,
polymyxin E, and hydrocortisone (Coly-Mycin, Parke-Davis,
Morris Plains, NJ) have been advocated, caution is advised
because of the concern over the potential ototoxicity of these
agents? ~176 In addition, a recent in vitro susceptibility study
showed that only 18% of middle-ear isolates were sensitive to
topical neomycin.81Some clinicians use topical tobramycin (with
dexamethasone) (Tobradex Alcon Laboratories, Fort Worth,
TX) or gentamicin (Garamycin Schering Corporation, Kenilworth, NJ) ophthalmic drops instilled into the ear when Pseudomonas is isolated; however, these agents are aminoglycosides
and, therefore, may be ototoxic, l~N3 Nevertheless, ototopical
agents are popular and seem to be effective. (Currently, there
are no ototopical medications approved for use when the
tympanic membrane is not intact.) Furthermore, if the infection
is not eliminated, it too may cause damage to the inner ear. 114
The bacteria, or their byproducts, may enter the inner ear
through the round window during a middle-ear infection? ]5,1t6

Ciprofloxacin and ofloxacin, as topical agents, have been

used for investigational purposes in adults and children with
CSOM and are reported to be safe and effective, but they are
not available for commercial use at this time; both agents are
approved for ophthalmic u s e . 117-119 One study showed that
topical ciprofloxacin was more effective than topical gentamicin
for treating CSOM? 2~Topical ofloxacin has been shown to be
more effective than the combination of neomycin-polymyxin
B-hydrocortisone otic drops. 12j There is still no consensus about
the potential efficacy of the addition of a corticosteroid component to the antimicrobial agent, but steroids may hasten
resolution of the inflammation.122
As an alternative to a topical antibiotic agent, some clinicians
recommend antiseptic drops. An antiseptic ototopical agent
(aluminum acetate) was found to be as effective as topical
gentamicin sulfate for otorrhea in a randomized clinical trial
reported from the United Kingdom. 123 Antiseptic drops (eg,
acetic acid) commonly are used in underdeveloped countries
and are reputed to be effective; because of cost and availability,
ototopical antibiotic agents are used when antiseptic drops are
ineffective.
If topical antibiotic medication is elected, ideally the child
should return to the outpatient facility daily to have the

Charles 1). Bluestone

22

Table 5. Bacteriology of Otorrhea in 51 Children (80 Ears)

with Chronic Suppurative Otitis Media 98

Bacteria Isolated

Number of Isolates*
(n = 118)

Pseudomonas aeruginosa
Staphylococcus aureus
Diphtheroids
Streptococcuspneumoniae
Haemophilus inj'luenzae (nontypable)
Bacteroides species
Candida albicans
Candida parapsilosis
Enterococcus
Acinetobacter
Staphylococcus epidermidis
MorganeUa morgagni
Providentia stuartii
KlebsieUa species
Proteus species
Serratia marcescens
Moraxella
Pseudornonas cepacia
Providentia rettgeri
Pseudomonas maltophilia
Achromobacter xyloso:~dans
Eikendla

56
18
8
7
6
3
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1

*Number exceeds 80 because more than one organism isolated in 38

ears.
discharge thoroughly aspirated or swabbed (ie, "aural toilet,"
"ear mopping") and to have the ototopical medication directly
instilled into the middle ear through the perforation or tympanostomy tube by the otoscope (or otomicroscope). Frequently,
the discharge will improve with this type of treatment within a
week, after which the eardrops may be administered at home
until there is complete resolution of the middle ear-mastoid
inflammation. When daily administration by the physician is not
feasible, the parent/caregiver can administer the drops.
Oral Antimicrobial Agents. Oral antibiotics that are approved for treatment of AOM may be effective if the bacterium
is susceptible, but because the organism is usually P aeruginosa,
agents that currently are approved for children usually will not
be effective; approximately 40% of Pseudomonas is susceptible in
vitro to trimethoprim-sulfamethoxazole.124 Despite these potential drawbacks, many clinicians administer a broad-spectrum
oral antibiotic in hope that the underlying infection is caused by
the usual bacteria that are isolated from ears with AOM. In a
recent report of a randomized clinical trial conducted in Kenya,
Smith and colleagues compared (1) oral amoxicillin-clavulanate, "dry mopping" of the ear, and ototopical antibioticcortisone drops; (2) "dry mopping" alone; and (3) no treatment.
They found the combination of oral antibiotic and topical agents
was statistically most effective. 125 However, one randomized
clinical trial found that topical ofloxacin was more effective than
systemic amoxicillin-clavulanate (without ear drops) in adults
with CSOM) 26
Orally-administered ciprofloxacin has been shown to be
effective in adults and Israeli children who had CSOM, but this
agent currently is not approved for patients below the age of 17
years in the United States. 94,127-129

When ototopical agents or oral antimicrobial agents, or both,

are used, the child should be reexamined in about 1 week, when
adjustments can be made in the medications if the results of the
microbiologic studies so indicate. After approximately 1 week,
there should be cessation of the discharge or marked improvement. If the otorrhea is improving, the child is reexamined
periodically thereafter until complete resolution occurs. If after
1 to 2 weeks there is no improvement, other treatment options,
such as parenteral antimicrobial therapy, should be considered.
Parenteral Antimicrobial Agents. If the otorrhea has not
been resolved after the administration ofototopical agents, with
or without an oral antimicrobial agent, the patient should
receive a parenteral beta-lactam antipseudomonal drug, such as
ticarcillin, piperacillin, or ceftazidime; empirically, ticarcillinclavulanate usually is selected because Pseudomonas, with and
without S aureus, is frequently isolated; the results of the culture
and susceptibility studies dictate the antimicrobial agent ultimately chosen. 93,98,130,131Also, the purulent material and debris
in the external canal (and middle ear, if possible) are aspirated
and the ototopical medication instilled daily. This method of
treatment usually is performed with the child hospitalized, but,
can be performed on an ambulatory basis.lS2
In about 90% of children, the middle ear will be free of
discharge and the signs of CSOM will be greatly improved or
absent within 5 to 7 days. If resolution occurs during hospitalization, the child can be discharged and receive the parenteral
antibiotic and eardrops (by the parent/caregiver) for a period of
10 to 14 days at home. The patient should be followed at periodic
intervals to watch for signs of spontaneous closure of the
perforation, which happens frequently after the middle ear and
mastoid are no longer infected.
Surgery. If the discharge does not respond to intensive
medical therapy (ie, intravenous antibiotics, aural toilet, and
ototopical medications) within several days, or if there is an
early recurrence with the same organism, surgery on the middle
ear and mastoid (ie, t3,mpanomastoidectomy) may be required
to eradicate the infection. A C T scan should be obtained.
Failures usually occur when there is (1) an underlying blockage
of the communication between the middle ear and mastoid (ie,
at the aditus-ad-antrum, (2) irreversible chronic osteitis, or (3)
cholesteatoma (or tumor).98 Insertion of a tympanostomy tube
can be helpful if the CSOM is associated with a perforation that
is too small to permit adequate drainage or the perforation
frequently closes, only to reopen with episodic drainage. On the
other hand, if the CSOM is related to a tympanostomy tube (ie,
the middle-ear "air cushion" is absent), some clinicians advocate
removal of the tube in hope that the infection subsequently will
subside. However, the recurrent/chronic ear infections for which
the tube was inserted originally frequently recur. There may be
some merit in attempting this approach in a child who has had a
longstanding retained tube.
Prevention of Recurrence. With an understanding of the
pathogenesis of CSOM (ie, chronic otorrhea is preceded by
acute otorrhea), the most effective way to prevent a recurrence
of otorrhea when the tympanic membrane is intact and an
episode of AOM occurs is to promptly, appropriately, and
adequately treat the infection with the usual oral antimicrobial
agents that are recommended for AOM. If the tympanic
membrane is not intact (ie, perforation or a tympanostomy tube

Mastoiditis and Otitis Media

is present without evidence of infection), early treatment of
acute otorrhea (ie, AOM) should be effective; treatment with an
oral antimicrobial agent may be enhanced by the addition of an
ototopical agent(s) in an effort to prevent a secondary infection
with organisms found in the external ear canal, such as

Pseudomonas.
W h e n a perforation (or tympanostomy tube) is present in
the absence of middle ear-mastoid infection and it is desirable to
maintain middle-ear ventilation through a nonintact eardrum,
recurrent episodes of otorrhea usually can be prevented with
antimicrobial prophylaxis (eg, amoxicillin). 133 If a tyalapanostomy tube is present and the middle ear is now disease-free, its
removal may restore middle ear-eustachian tube physiology (ie,
prevent reflux or insuffiation of nasopharyngeal secretions).
Yet, removal of tyrnpanostomy tubes may not be desirable,
especially in infants and young children. In these cases, antimicrobial prophylaxis also should be considered until the tubes
extrude spontaneously. Tympanoplastic surgery should be considered if the child has a chronic perforation that is now dry.. The
same factors should be entertained when deciding to repair an
eardrum perforation in children, as described previously in
regard to removal of a tympanostomy tube.134

Complications and Sequelae

The most common sequela of CSOM is chronic hearing loss and
the potential deficits related to this disability. The chronic
infection may result in p e r m a n e n t conductive hearing loss
caused by damage to the ossicles, and sensorineural loss also
may occur. CSOM also can progress into one or more of the
intratemporal suppurative complications, such as acute mastoiditis, acute labyrinthitis, facial paralysis, or an intracranial suppurative complication, which will require immediate surgical
intervention. Intracranial complications caused by CSOM occur
with equal or greater frequency than those caused by cholesteatoma. This finding is not only important in underdeveloped
countries, where CSOM is common, but has been reported from
industrialized nations. 135

Referral to an O t o l a r y n g o l o g i s t
Many children who have CSOM can be effectively managed by
the primary health care provider with ototopical antimicrobial
medications or oral antibiotic agents, or both. When the child
does not respond to these measures, the child requires parenteral administration of an antimicrobial agent. Referral to an
otolaryngologist is advisable when:
1. A suppurative complication, eholesteatoma, or tumor is
present or suspected.
2. An otomicroscope is necessary to completely examine the
ear.
3. An examination under general anesthesia is required to
completely evaluate the ear and child (eg, nose and pharynx).
4. A child does not respond to intensive medical therapy,
because tympanomastoidectomy is usually required.
5. Prevention of recurrence involves possible adenoidectomy,
surgery for chronic/recurrent paranasal sinusitis, surgical
repair of a tympanic m e m b r a n e perforation (ie, tympanoplasty), or removal of a tympanostomy tube.

23

References
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September, 1996, Otola~"ngol Head Neck Surg (in press) (abstr)
2. Hoppe JE, Koster S, Bootz F: Acute mastoiditis-relevant once
again. Infection (Medizin Verlag GmbH Munchen, Munchen)
22:180-182, 1994
3. Bluestone CD, Klein JO (eds): Otitis Media in Infants and
Children (ed 2). Philadelphia, PA, Saunders, 1995
4. Sorensen H: Antibiotics in suppurative otitis media. Otolaryngol
Clin NorthAm 10:45-50, 1977
5. Herberts G, Jeppson PH, N}4en O, et al: Acute otitis media:
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