Chronic Otitis Media (COM)

InCheat Sheets / Otolaryngology

Chronic otitis media is a long-standing infection of the middle ear (> 6 weeks) characterized by ear discharge and permanent perforation.

The incidence of COM is high in developing countries. It affects both sexes equally and all age groups. It is the single most important cause of hearing impairment in the rural population.

Types of COM

	Tubotympanic (safe)	Atticoantral (unsafe)
Location	Anteroinferior middle ear	Posterosuperior middle ear
Description	Central perforation with involvement of the eustachian tube and mesotympanum	Marginal perforation with involvement of the attic, antrum, and mastoid
Discharge	Profuse, mucoid, odourless	Scanty, purulent
Granulations	Uncommon	Common
Polyp	Pale	Red and fleshy
Cholesteatoma	Absent	Present
Risk of complication	Low	High
Audiometry	Conductive hearing loss	Conductive or mixed hearing loss

Risk factors
- Abnormal Eustachian tube (cleft palate, Down syndrome)
- Cholesteatoma
- Immune deficiency
- Ciliary dysfunction
- Radiation
Causative organisms
- Mixed infection
- Gram-negative bacilli
- Staphylococcus
- Anaerobes
Pathophysiology
- Chronic inflammation of the middle ear space/mastoid due to chronic Eustachian Tube Dysfunction
- Chronic Perforation or Presence of a cholesteatoma
Signs and symptoms
- Ear discharge (mucopurulent, odorous)
- Hearing loss (CHL or MHL)
- Bleeding (from granulations, polyp or trauma during cleaning)
- Low-grade otalgia
Signs and symptoms indicating complications
- Pain (extradural, perisinus, or brain abscess, or otitis externa)
- Vertigo (erosion of lateral semicircular canal → labyrinthitis or meningitis)
- Persistent headache (intracranial complication)
- Facial weakness (erosion of the facial canal)
- Neck rigidity, photophobia (meningitis)
- Diplopia (Petrositis – Gradenigo syndrome)
- Ataxia (labyrynthitis, cerebellar abscess)
- Swelling around the ear (mastoiditis)
Otoscopic findings
- Perforation of the tympanic membrane
- Ear discharge
- Retraction pockets (invaginations of the tympanic membrane)
Investigations
- Examination under microscope
  - Cholesteatoma
  - Bone destruction
  - Granuloma
  - Pockets of discharge
- X-ray of mastoids or CT-scan temporal bone: inability to visualize the tympanic membrane, facial weakness, suspected labyrinthine fistula or intracranial complication
  - Extent of bone destruction
  - Degree of mastoid pnuematization
  - Cholesteatoma
  - Labyrinthine fistula
- Culture and sensitivity of ear discharge
Treatment
- Surgery to remove the disease and render the ear safe e.g. Mastoidectomy, Adenoidectomy,
- Reconstructive surgery to restore hearing e.g. Myringoplasty, Tympanoplasty, Ossiculoplasty
Complications of Chronic Otitis Media
- Intratemporal complications
  - Mastoiditis
  - Petrositis
  - Facial paralysis
  - Labyrinthitis
- Intracranial complications
  - Extradural abscess
  - Subdural abscess
  - Meningitis
  - Brain abscess
  - Lateral sinus thrombophlebitis
  - Otitic hydrocephalus

Dr. Jeffrey Kalei

Author and illustrator for Hyperexcision. Interested in emergency room medicine. I have a passion for medical education and drawing.

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Biochemistry

Adrenocorticotrophic hormone	P: <80 ng/L
Alanine aminotransferase (ALT)	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alkaline phosphatase	P: 30–130 U/L (adults)
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
Antidiuretic hormone (ADH)	P: 0.9–4.6 pmol/L
Aspartate transaminase	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
C-reactive protein	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol	P: AM 450–700 nmol/L, Midnight 80–280 nmol/L
Creatine kinase (CK)	P: ♂ 25–195 U/L, ♀ 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P/S: 2–8 U/L ♂ (luteal); >25 U/L menopause
Gamma-glutamyl transpeptidase	P: ♂ 11–51 U/L, ♀ 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron	S: ♂ 14–31 μmol/L, ♀ 11–30 μmol/L
Lactate	P: Venous 0.6–2.4 mmol/L, Arterial 0.6–1.8 mmol/L
Lactate dehydrogenase (LDH)	P: 70–250 U/L
Lead	B: <1.8 mmol/L
LH	P: 3–16 U/L (luteal)
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
Parathyroid hormone (PTH)	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin	P: ♂ <450 U/L, ♀ <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin	P: Erect 2.8–4.5, Recumbent 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
Thyroxine (T4)	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
Total iron-binding capacity	S: 54–75 μmol/L
Triglycerides (fasting)	P: 0.50–2.3 mmol/L
Triiodothyronine (T3)	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate	P: ♂ 210–480 μmol/L, ♀ 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol creatinine
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids	♂ 28–30 μmol/24h, ♀ 21–66 μmol/24h
17-Oxosteroids (neutral)	♂ 17–76 μmol/24h, ♀ 14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
Red cell count	♂ 4.5–6.5 ×10¹²/L, ♀ 3.9–5.6 ×10¹²/L
Haemoglobin	♂ 130–180 g/L, ♀ 115–160 g/L
PCV / Haematocrit	♂ 0.4–0.54 L/L, ♀ 0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelet count	150–400 ×10⁹/L
Reticulocyte count	0.8–2.0% / 25–100 ×10⁹/L
ESR	Depends on age
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (beats per minute)
Neonate (<1 month)	140–160
Infant (<1 year)	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Temperature
Normal range	36.6–37.2 °C
38.0 °C	Fever (infant)
38.5 °C	Fever (>3 months)
Respiratory Rate (tachypnoea)
Neonate (0–2 months)	≥60 breaths/min
2–12 months	≥50 breaths/min
1–5 years	≥40 breaths/min
>5 years	≥30 breaths/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Head Circumference
Term	35 cm ± 2
1 year	+1 cm/month
2–3 years	+2 cm/year
4–5 years	+1 cm/year
5 years	~53 cm
10 years	56–57 cm
Height
Term	52–55 cm
1 year	75 cm
2–12 years	6a + 77 cm
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Blood Transfusion
Whole blood	20 mL/kg
pRBC	10 mL/kg
Formula	6 × (weight in kg) × Hb deficit
Normal Paediatric Lab Values
Haemoglobin (g/dL)	Hematocrit (%)
Term newborn: 13–20	40–58
1 month: 11–18	32–54
2 months: 10–15	28–44
1–2 years: 10–13	32–40
>2 years: 11–14	33–42
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

Dr. Jeffrey Kalei

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