Clinical Case Discussion: Chronic Suppurative Otitis Media (CSOM)

Clinical Case Discussion: Chronic Suppurative Otitis Media (CSOM)

Today, we'll have a clinical case discussion on a very common and important ENT case: Chronic Suppurative Otitis Media (CSOM).

This case discussion format will be helpful for both undergraduates and postgraduates.

We'll go through the patient's history, discuss how history guides us to a provisional diagnosis, cover the clinical examination findings and their significance, summarize the case, arrive at a provisional diagnosis, and outline the management plan.

Let's begin!

📋 Patient History

Here's the history of our patient:

• Patient Name: Vinod
• Age: 35 years
• Sex: Male
• Location: Kolkata
• Religion: Hindu
• Occupation: Clerk

History of Present Illness (HPI):

Patient was apparently asymptomatic 6 months back when he started complaining of:

1. Discharge from the Right Ear:

   • Onset: Insidious
   • Duration: 6 months
   • Progress: Gradually progressive
   • Character: Mucopurulent
   • Continuity: Intermittent
   • Color: Yellowish
   • Smell: Non-foul smelling
   • Blood: Non-blood stained
   • Quantity: Profuse
   • Aggravated by: Upper respiratory tract infections (URTIs)
   • Relieved on: Using medications

2. Diminished Hearing in the Right Ear:

   • Onset: Insidious
   • Duration: 4 months
   • Progress: Gradually progressive
   • Degree: Initially only to whispers, but now to normal conversation as well.
   • Fluctuation: No fluctuation in hearing loss.
   • Prefers using the left ear for telecommunication.

Negative History (Rule-outs):

(Though not a formal heading, these points are crucial to ask and document within the History of present illness)

• No history of trauma
• No history of ear pain
• No history of giddiness or vertigo
• No history of ringing sensation (tinnitus) in the ear
• No history of fever
• No history of headache
• No history of neck stiffness
• No history of nausea or vomiting
• No history of doubling of vision or blurring of vision
• No history of irritability or facial asymmetry
• No history of nose or throat complaints

Past History:

• No history of Diabetes Mellitus
• No history of Hypertension
• No history of TB
• No history of Thyroid disorders
• No history of Exanthematous fevers in childhood
• No history of surgeries in the past

Family History:

• Nothing significant

Treatment History:

• History of usage of ear drops, with which the discharge subsided. (Patient unable to name the drops).

Personal History:

• Sleep and appetite: Normal
• Diet: Non-vegetarian
• Bladder and Bowel habits: Normal
• Addiction: Chronic smoker for 10 years.

🗣️ Discussion of History Points

1. Discharge from Right Ear:

• Insidious Onset:

More indicative of CSOM (develops over time) vs. Sudden onset (more typical of ASOM flare-up, often post-URTI, with sudden pain).

• Mucopurulent Character:

Mucopurulent discharge suggests infected tubotympanic CSOM or Tuberculous Otitis Media.

• Intermittent Continuity:

Discharge aggravated by URTIs and relieved by medication. This pattern is characteristic of tubotympanic CSOM, where Eustachian tube dysfunction during URTIs leads to middle ear ventilation issues and flare-ups.

• Yellowish Color:

Points towards purulent or mucopurulent nature.

• Non-foul Smelling:

Absence of foul smell points away from atticoantral disease and towards tubotympanic CSOM.

• Non-blood Stained:

Absence of blood stain suggests no significant granulation tissue, polyp, or vascular tumor.

• Profuse Quantity:

Seen in tubotympanic CSOM. The middle ear mucosa has goblet cells secreting mucin, leading to copious discharge.

• Aggravated by URTIs / Relieved by Medication:

Confirms Eustachian tube involvement and suggests tubotympanic CSOM. URTIs cause ET dysfunction, preventing ventilation and promoting infection flare-ups. Medication resolves the URTI and aids ET function, reducing discharge.

Viva Question: What is Reservoir Sign?

Viva Question: What is Lighthouse Sign?

2. Diminished Hearing:

• Insidious Onset (4 months):

Consistent with a chronic condition like CSOM, Presbycusis, Acoustic Neuroma, Otosclerosis, or insidious Noise-Induced Hearing Loss.

Rules out sudden causes like viral labyrinthitis, acoustic trauma, trauma.

• Gradually Progressive:

Hearing loss worsening over time.

• Degree (Whispers to Normal Conversation):

Suggests a worsening hearing loss. Need tuning forks/PTA for precise grading.

• No Fluctuation:

Points away from conditions like Secretory Otitis Media (hearing better when supine), Meniere's Disease.

• Side (Unilateral):

While CSOM can be bilateral, unilateral hearing loss is common.

Points away from bilateral causes like Presbycusis or bilateral Otosclerosis without a clear history of unilateral onset.

Viva Question: How to differentiate Conductive Hearing Loss (CHL) vs. Sensorineural Hearing Loss (SNHL) from history without tuning forks/PTA?

• Viva Terms:

  • Autophony: Hearing one's voice loudly (Secretory Otitis Media, Patulous ET).
  • Diplacusis: Same tone heard at different pitches in each ear (Meniere's Disease).
  • Paracusis Willisii: Hearing better in noisy environments (Otosclerosis).
  • Recruitment: Small increase in sound intensity causes discomfort (Cochlear SNHL).

Negative History Significance:

• No Trauma:

Rules out traumatic TM perforation, temporal bone fracture, hemotympanum.

• No Ear Pain:

Absence of pain, especially retroauricular pain, rules out Acute Mastoiditis.

Absence of severe, constant pain rules out Malignant Otitis Externa.

• No Giddiness/Vertigo:

Rules out labyrinthine involvement (Labyrinthitis - intratemporal complication), Cerebellar Abscess (intracranial complication).

• No Ringing (Tinnitus):

While tinnitus can occur in CSOM, its absence is noted.

• No Fever, Headache, Neck Stiffness, Nausea, Vomiting, Visual Disturbances, Irritability:

Crucial for ruling out Intracranial Complications of CSOM (Meningitis - neck stiffness, Kernig's/Brudzinski's signs; Brain Abscess - headache, fever, vomiting, irritability; Lateral Sinus Thrombophlebitis - headache, fever, nausea, vomiting).

Viva Question: What syndrome involves 6th nerve palsy in petrositis?

Viva Question: What type of fever is seen in Lateral Sinus Thrombophlebitis?

• No Facial Asymmetry:

Rules out Facial Nerve Palsy (intratemporal or intracranial complication), which can occur due to granulation tissue, cholesteatoma, or inflammation affecting the nerve in CSOM.

• No Nose or Throat Complaints:

Rules out an active primary nose/throat infection or anatomical issue directly causing or aggravating the ear issue (e.g., large adenoids, severe rhinitis).

Past History Significance:

• Diabetes Mellitus:

Predisposes to SNHL, Malignant Otitis Externa (especially uncontrolled), Otomycosis. Important to control pre-operatively.

• Hypertension:

Associated with SNHL, can worsen epistaxis.

• TB:

Can cause Tuberculous Otitis Media (painless otorrhea, multiple TM perforations that coalesce, pale middle ear mucosa, profound/disproportionate SNHL). Anti-TB drugs can be ototoxic.

• Thyroid Disorders:

Can cause vertigo/giddiness.

• Exanthematous Fevers (Childhood):

Can cause Sensorineural Hearing Loss (e.g., Measles, Mumps, Rubella - historically causes deaf-mutism).

• No Surgeries in the Past:

Rules out a post-operative cavity as the source of discharge.

Treatment History Significance:

• Usage of ear drops where discharge subsided suggests the discharge was responsive to local treatment, consistent with inflammation/infection.

• Need to know if any ototoxic drops (Gentamicin) or excessive steroids were used (risk of otomycosis).

• Oral ototoxic drugs (Aminoglycosides) should also be asked about.

Personal History Significance:

• Chronic Smoker (10 years):

Smoking can impair mucosal clearance, potentially affecting CSOM. Advise smoking cessation pre-operatively for better graft uptake in tympanoplasty.

✨ Clinical Examination Findings

Right Ear:

• Pre-auricular area, Pinna, Post-auricular area: Normal.
• Tragal Sign: Negative.
• EAC: Normal.
• Tympanic Membrane (TM):
  • Small central perforation in the antero-inferior quadrant, surrounded by remnant TM on all sides.
  • Rest of the pars tensa looks congested.
  • Cone of light is absent.
  • Pars flaccida is normal.
• Middle Ear: Mucosa looks normal (seen through perforation).
• Mastoid: Tenderness negative.
• Facial Nerve: Normal function (grossly).

Left Ear:

• General Examination: Normal.
• TM: Normal, pearly white in color. Cone of light present in antero-inferior quadrant. Pars flaccida normal.

Tuning Fork Tests (Right Ear):

• Rinne's Test: Negative for 256 Hz and 512 Hz. Positive for 1024 Hz.
• Weber's Test: Lateralized to the Right ear.
• Absolute Bone Conduction (ABC) Test: Same as examiner.

Tuning Fork Tests (Left Ear):

• Rinne's Test: Positive for all three frequencies (256, 512, 1024 Hz).
• ABC Test: Same as examiner.

Other Systemic Examination:

• Oral Cavity, Oropharynx, Laryngoscopy, Nose Examination, Neck Examination: Within normal limits.

🗣️ Discussion of Clinical Examination Points

General Ear Examination:

• Pinna:

  • Normal extent from supraorbital margin to ala of nose.
  • Check for deformities like Cauliflower ear, keloids, perichondritis).

• Post-auricular Area:

  • Look for scars (previous surgery), lymph nodes.
  • Check retroauricular groove (obliterated in mastoid abscess - pinna pushed down/up/out).

What is Battle sign?

What is Griesinger sign?

• Tragal Sign:

Pain on pressing tragus/pulling pinna (Circumduction sign). Indicates Otitis Externa or furunculosis.

Negative here rules this out.

• EAC:

Check for wax, furuncles, fungal spores (Wet Newspaper appearance in Otomycosis), congestion (Otitis Externa), stenosis, foreign body.

Normal here rules out primary EAC issues.

Tympanic Membrane:

• Color: Our patient's TM is congested in pars tensa.

Which disease do we see Flamingo pink color in Tympanic membrane?

• Perforation:

  • Central Perforation: In pars tensa, surrounded by remnant TM. (Seen in our patient). Suggests tubotympanic CSOM.

  • Marginal Perforation: In pars tensa, involves annulus. Reaches sulcus. Suggests atticoantral CSOM (squamosal type). Posterior superior marginal is common.

  • Attic Perforation: In pars flaccida (attic). Suggests atticoantral CSOM (squamosal type), associated with cholesteatoma.

  • Our patient has a small central perforation in the antero-inferior quadrant.

• Cone of Light: Reflection of light from otoscope beam. Normally seen in antero-inferior quadrant (due to shape of TM). Absent in our patient's right ear (due to pathology).

Middle Ear Mucosa:

• Seen through perforation.
• Appears normal and pink in our patient.
• If pale/edematous/polypoidal/granulation tissue is seen, it suggests more active disease or atticoantral involvement.

Mastoid Tenderness:

• Check with Three Finger Test (Middle finger on cymba concha - antrum; Index finger on posterior mastoid - mastoiditis; Thumb on mastoid tip - emissary vein). Apply pressure alternatively. Negative tenderness here rules out active mastoiditis.

Tuning Fork Tests:

• Right Ear:

  • Rinne's Negative (256, 512 Hz) & Positive (1024 Hz):

  Indicates Conductive Hearing Loss (CHL).

  Bone conduction (BC) is heard better or equal to air conduction (AC) at lower frequencies, but AC becomes better at higher frequencies.

  • Weber's Lateralized to Right (Poorer Ear):

  Confirms CHL in the right ear. Sound is perceived louder in the poorer ear in CHL because the pathology masks background noise heard by air conduction, making bone conduction relatively louder.

  • ABC Same as Examiner:

  Confirms CHL. Bone conduction threshold is similar to the examiner's, indicating no significant SNHL component.

• Left Ear:

  • Rinne's Positive (all frequencies):

  Normal hearing or SNHL.

  • Weber's No Lateralization (or Lateralized Away from Right):

  Normal hearing or SNHL in left ear.

  • ABC Same as Examiner:

  Confirms no significant SNHL in the left ear.

• Grading CHL from Rinne's Test (Approximate):

  • Rinne's Negative 256 Hz only: Mild CHL (15-30 dB).
  • Rinne's Negative 256, 512 Hz, Positive 1024 Hz: Moderate CHL (30-40 dB). (Seen in our patient).
  • Rinne's Negative for all three: Severe CHL (>45 dB).

Viva Question: Most preferred tuning fork frequency and why?

Viva Question: What is False Negative Rinne and where do you see it?

Viva Question: If you could choose only one tuning fork test, which one would you choose?

📝 Case Summary

A 35-year-old male presented with a 6-month history of intermittent, profuse, mucopurulent, non-foul smelling, non-blood stained discharge from the right ear, aggravated by URTIs and relieved by medication. He also has a 4-month history of gradually progressive diminished hearing in the right ear, now affecting normal conversation, without fluctuation. He denies pain, vertigo, tinnitus, facial asymmetry, or symptoms of intracranial complications. Examination shows a small central perforation in the antero-inferior quadrant of the right TM. Tuning fork tests reveal moderate conductive hearing loss in the right ear. Left ear and systemic exam are normal.

🩺 Provisional Diagnosis

Based on the history and examination findings:

Right-sided Inactive Mucosal Type of Chronic Suppurative Otitis Media with Moderate Conductive Hearing Loss, without any complication.

• Right-sided: Specifies the affected ear.

• Inactive: Refers to the stage of discharge. Discharge-free for more than 6 months.

Viva Question: What are the different stages of discharge?

• Mucosal Type:

This is the current preferred term for Tubotympanic CSOM.

The history (intermittent, profuse, mucopurulent, non-foul smell, URTI aggravated) strongly supports the mucosal (tubotympanic) type, which involves the middle ear cavity and Eustachian tube function, and is associated with central perforations.

• Chronic Suppurative Otitis Media: The duration (>3 months) and presence of discharge are criteria for chronicity.

• Moderate Conductive Hearing Loss: Confirmed by tuning fork tests and likely due to the Tympanic membrane perforation and potential ossicular chain involvement or fluid.

• Without any complication: Ruled out by negative history points (no pain, vertigo, fever, neuro symptoms, facial palsy).

🏥 Management Plan

Management involves two key aspects: Investigations and Treatment.

Investigations:

1. Examination Under Microscope (EUM):

2. Pus for Culture & Sensitivity (C&S): Only if ear discharge is active at the time of presentation. Guides antibiotic choice if empirical treatment is needed.

3. Pure Tone Audiometry (PTA): Should be performed when the ear is dry (no active discharge).

4. X-ray Mastoid (Schuller's View): Provides a basic view of the mastoid pneumatization and certain anatomical landmarks.

Treatment:

Since our patient's ear is currently inactive (or at least has periods of dryness based on history), the focus shifts towards definitive management.

1. Pre-operative Management (Making the Ear Dry): If there is any active discharge, this must be controlled first.

   • Aural Toileting (cleaning the ear canal and middle ear).

   • Topical Antibiotic Ear Drops (e.g., quinolones are often preferred for efficacy and low ototoxicity risk, though systemic absorption from middle ear exposure is a theoretical concern).

   • Oral Antibiotics (if infection is more widespread or not controlled by drops).

   • Nasal Decongestants/Antihistamines (if associated nose/throat issues or ET dysfunction contributing to flare-ups).

2. Surgical Management: Once the ear is dry and systemically optimized (e.g., blood sugar controlled if diabetic), surgical intervention is considered.

   • Tympanoplasty of the Right Ear: The surgical procedure to repair the TM perforation and potentially reconstruct the ossicular chain if damaged, and eradicate disease in the middle ear.

Viva Question: Difference between Myringoplasty and Tympanoplasty?

Viva Question: Most common graft used in Tympanoplasty and why?

This concludes our clinical case discussion on Chronic Suppurative Otitis Media, Mucosal Type. We've walked through the history, examination, provisional diagnosis, and management principles.