OVERVIEW

What is suppurative otitis media?

• Suppurative otitis media is a common disease in otolaryngology, characterized by acute or chronic purulent inflammation of the tympanic membrane, middle ear mucosa, and even bone tissue.

• It not only affects hearing but may also be life-threatening. Its features include varying degrees of hearing loss, tympanic membrane perforation, and recurrent ear discharge.

• It can be classified into two types: acute suppurative otitis media and chronic suppurative otitis media.

• If ear discharge persists for 6–8 weeks after acute inflammation subsides, the condition is considered to have progressed to chronic suppurative otitis media.

SYMPTOMS

Is Purulent Otitis Media Serious?

Purulent otitis media primarily causes local symptoms, with systemic symptoms generally being mild. However, if the inflammation spreads to surrounding areas, or if the pathogen is highly virulent and the patient has low resistance (e.g., infants, children, or the elderly), serious complications can occur.

• One of the main symptoms of purulent otitis media is ear discharge. During acute purulent otitis media or acute episodes of chronic purulent otitis media, pus continuously drains from the ear canal.

• If the amount of discharge suddenly decreases or stops, accompanied by chills, fever, severe headache, ear pain, dizziness, nausea, vomiting, or altered consciousness, it may indicate intracranial complications.

• Due to incomplete physical development, children have thin cranial bones and unfused sutures, making it easier for inflammation to spread into the skull during acute otitis media, leading to severe complications such as otogenic meningitis, brain abscess, or sigmoid sinus thrombophlebitis.

• Elderly individuals often suffer from chronic purulent otitis media. If accompanied by cholesteatoma, bone destruction may occur, and inflammatory substances can irritate the intracranial space, causing severe complications.

Can Purulent Otitis Media Cause Facial Paralysis?

The facial nerve controls facial expression muscles. Any lesion or damage to it can result in facial nerve paralysis (facial palsy), leading to symptoms like a crooked mouth.

The main trunk of the facial nerve runs through a narrow and curved canal surrounding the middle ear, making it susceptible to otitis media. Therefore, facial paralysis is a relatively common complication of otitis media.

Facial palsy can occur at any stage of otitis media due to facial nerve damage.

In the early stages of acute otitis media, vascular irritation may reduce blood supply to the facial nerve, or bacterial toxins may directly cause facial nerve edema, leading to paralysis. In chronic otitis media, cholesteatoma or osteitis can compress or even necrotize the facial nerve, resulting in paralysis.

Can Purulent Otitis Media Cause Tinnitus?

Purulent otitis media can cause varying degrees of tinnitus.

Inflammatory substances, including cholesteatoma, can directly or indirectly irritate and compress the local auditory nerve, generating abnormal neural signals that lead to tinnitus.

Can Purulent Otitis Media Cause Dizziness?

Inflammatory substances from purulent otitis media can damage adjacent inner ear structures.

The inner ear not only generates auditory signals but also regulates balance. Therefore, purulent otitis media can cause symptoms like dizziness.

Can Purulent Otitis Media Turn into Middle Ear Cancer?

Acute purulent otitis media does not lead to middle ear cancer, but chronic purulent otitis media may.

Long-term recurrent inflammatory stimulation causes squamous epithelial cells in the middle ear cavity to continuously repair and proliferate, potentially leading to malignant transformation and eventually middle ear cancer. Symptoms may include bloody, foul-smelling ear discharge and facial paralysis.

Patients should seek timely diagnosis and treatment, including CT, MRI, and pathological examinations for early confirmation.

What Are the Symptoms of Purulent Otitis Media?

Acute Purulent Otitis Media

• Ear pain: Most patients experience severe pain before eardrum perforation, affecting sleep; pain lessens after perforation and pus drainage. A few may have no obvious pain.
• Hearing loss and tinnitus: Early symptoms often include ear fullness, low-pitched tinnitus (e.g., a dull buzzing rather than a sharp whistle), and hearing impairment. Hearing may improve after perforation. Some may experience dizziness.
• Pus discharge: After perforation, fluid drains from the ear, initially bloody, later turning purulent.
• Systemic symptoms: Vary in severity, including chills, fever, fatigue, and poor appetite. Children may show irritability, crying, ear grabbing, vomiting, or diarrhea. Symptoms usually improve after perforation. If symptoms persist or worsen, complications should be suspected.

Chronic Purulent Otitis Media

• Ear discharge: Intermittent or continuous, worsening during acute infections, possibly with pain. Discharge may be mucoid or purulent, foul-smelling if long-standing. Bloody discharge may occur during acute episodes or with polyps/granulation tissue. Otoscopy may reveal perforations or cholesteatoma debris.
• Hearing loss: Varies in degree and type, depending on perforation size/location, ossicular chain integrity, and inner ear damage.
• Tinnitus: Some patients experience tinnitus, often related to inner ear damage or perforation (may resolve after repair).
• Dizziness: Rare in chronic cases but may occur during acute episodes or labyrinth damage.
• Systemic symptoms: Uncommon unless intracranial complications arise (e.g., headache, fever), which can be life-threatening.

Temporal bone high-resolution CT is effective for evaluating chronic purulent otitis media, assessing mastoid pneumatization, ossicle condition, and disease extent.

Is Ear Discharge Always Purulent Otitis Media?

Both acute and chronic purulent otitis media involve ear discharge, but not all ear discharge indicates purulent otitis media.

Other conditions, like otitis externa, can also cause discharge. In otitis externa, severe bacterial skin infection in the ear canal produces pus without significant hearing loss (unlike otitis media), helping differentiate the two.

CAUSES

What are the causes of suppurative otitis media?

• Acute suppurative otitis media: More common in children, pathogens are mostly various bacteria, fungal infections are rare, and generally invade through the following three pathways:
  • Eustachian tube pathway, the most common. During upper respiratory tract infections, poor hygiene while swimming, or incorrect feeding positions in infants can trigger acute suppurative otitis media.
  • External auditory canal-tympanic membrane pathway. Trauma or other causes leading to tympanic membrane perforation, or unsterilized tympanocentesis or incision, can also result in middle ear inflammation.
  • Hematogenous infection pathway. Bacteria from infections elsewhere in the body enter the bloodstream and infect the middle ear through the blood, though this is rare.
• Chronic suppurative otitis media
  • Acute suppurative otitis media that is not treated promptly or effectively, lasting over 8 weeks; or acute necrotizing otitis media with deeper lesions affecting the bone.
  • Presence of adenoid hypertrophy, chronic tonsillitis, chronic sinusitis, or other conditions in the nose or throat, which can lead to recurrent and persistent otitis media.
  • Systemic factors. Primarily conditions that weaken immunity, such as malnutrition, chronic anemia, or diabetes.

Is suppurative otitis media closely related to colds?

A cold, or acute upper respiratory tract infection, can directly cause acute suppurative otitis media via the Eustachian tube pathway or trigger acute episodes of chronic suppurative otitis media.

Therefore, preventing colds is essential. After catching a cold, timely treatment and rest are necessary to recover quickly and avoid otitis media or other complications.

Why are children more prone to suppurative otitis media?

Acute suppurative otitis media is one of the most common ear diseases in children, closely related to their ear anatomy, physiology, and pathology.

• In infants, the Eustachian tube is shorter, wider, lower, and more horizontal, making it easier for nasal bacteria to enter the middle ear and cause infection.
• Infants have underdeveloped immune systems and weaker resistance, making them susceptible to upper respiratory infections. Pathogens can easily invade the middle ear through the Eustachian tube, leading to acute inflammation.
• Improper feeding, such as lying flat while feeding or giving water, may cause choking or vomiting, allowing milk or water to enter the middle ear and trigger otitis media.
• Children often have chronic conditions near the Eustachian tube, such as chronic nasopharyngitis, sinusitis, tonsillitis, or adenoid hypertrophy, allowing pathogens to enter the middle ear and cause suppurative otitis media.
• During a cold, nasal congestion and excessive mucus may be forced into the Eustachian tube when blowing the nose too hard, leading to middle ear infection. Thus, avoid blowing the nose forcefully.

Can ear cleaning cause suppurative otitis media?

Improper ear cleaning can damage the skin of the external auditory canal, causing external otitis with pain or even pus discharge, which resembles suppurative otitis media.

However, if cleaning is too deep, it may perforate the eardrum, allowing external pathogens to enter the middle ear and cause otitis media. Therefore, ear cleaning should be done cautiously.

DIAGNOSIS

What are the classifications of suppurative otitis media?

Suppurative otitis media is generally divided into acute and chronic types.

• Characteristics of acute suppurative otitis media: Sudden onset, rapid progression, severe pain, significant hearing loss, and obvious tympanic membrane lesions. During the suppurative phase, severe systemic reactions such as fever, headache, nausea, and vomiting may occur.
• Chronic suppurative otitis media has three characteristics: Ear discharge, tympanic membrane perforation, and hearing loss. Chronic suppurative otitis media was previously classified into three types: simple type, necrotic type (osteitis type), and cholesteatoma type, but the terminology has now changed. Cholesteatoma otitis media is also called dangerous otitis media, meaning that once diagnosed, surgical intervention should be performed as soon as possible. Otherwise, it may lead to intracranial or extracranial complications, especially intracranial complications such as otogenic meningitis or brain abscess, which can be life-threatening.

What tests are required for surgery for chronic suppurative otitis media?

Surgery for chronic suppurative otitis media is relatively lengthy and usually requires general anesthesia, so comprehensive and careful preoperative examinations are necessary. These include:

• General examinations: Including blood pressure, blood sugar, liver and kidney function, routine urine and stool tests, chest X-rays, pulmonary function tests, electrocardiograms, etc., to fully assess overall health and identify potential risks.
• Specialized examinations: Such as ear appearance, otoscopy, audiology, and eustachian tube function tests to evaluate middle ear function and ensure a clear understanding.
• Imaging examinations: High-resolution CT is the first choice to clarify the condition of the middle ear, inner ear, and adjacent bone structures, providing accurate evidence for surgical planning. If intracranial complications or malignancy are suspected, MRI may be added.

Is cholesteatoma in otitis media a tumor?

Cholesteatoma is not actually a true "tumor" because it does not contain tumor cells or cancer cells.

Long-term inflammation and pus discharge in the middle ear cause perforation of the tympanic membrane, allowing small amounts of epidermal cells from the external ear canal to repeatedly enter the middle ear and accumulate, damaging the bone.

The main process is as follows:

Epidermal debris from the external ear canal easily enters the middle ear cavity and mastoid cavity through the perforation.

The epithelial layer of the epidermis repeatedly sheds, accumulating over time and growing in size, compressing the surrounding bone and causing it to resorb, forming a cavity. This results in a "tumor" composed of accumulated shed epithelial cells internally and surrounded by epithelial tissue externally. Its appearance resembles tofu dregs. Under microscopic examination, large amounts of cholesterol crystals can be seen, hence the name cholesteatoma.

TREATMENT

How to Treat Suppurative Otitis Media?

Acute suppurative otitis media is treated based on the following principles: control infection, ensure drainage, and eliminate the cause.

• Systemic Treatment

Administer sufficient antibiotics early to control the infection and ensure complete recovery. Commonly used antibiotics include penicillin and cephalosporins. Timely and appropriate treatment can prevent tympanic membrane perforation.

After perforation, collect pus for bacterial culture and sensitivity testing, then switch to sensitive antibiotics based on the results. Antibiotics are typically required for about 10 days. Rest and maintaining normal bowel movements are important during treatment. Severe systemic symptoms may require supportive therapies like fluid infusion.

• Local Treatment

Before tympanic membrane perforation: Use 2% phenol glycerin ear drops to reduce inflammation and pain. If systemic or local symptoms are severe, the tympanic membrane is significantly bulging, or perforation is too small for proper drainage, a tympanotomy should be performed under sterile conditions to facilitate drainage.

After perforation: First, thoroughly clean the external ear canal with hydrogen peroxide or use suction to remove pus (avoid excessive suction pressure). Then apply antibiotic ear drops (e.g., ofloxacin or rifampicin compound solution). Avoid powders, as they may clump with pus and obstruct drainage. Perforations often heal spontaneously after infection and inflammation subside. Persistent perforations may require tympanoplasty.

• Surgical Treatment

Acute mastoiditis or postauricular abscess may require mastoidectomy.

• Etiological Treatment

Address chronic nasal and pharyngeal conditions, such as adenoid hypertrophy, chronic sinusitis, or chronic tonsillitis.

Chronic suppurative otitis media treatment principles:

• Control infection, ensure drainage, remove lesions, restore hearing, and eliminate causes.

• Treat upper respiratory conditions contributing to otitis media.

• Perform bacterial culture and sensitivity testing on pus to select appropriate antibiotics. Mild cases may use topical ear drops after cleaning with hydrogen peroxide or boric acid solution. Systemic antibiotics are needed for systemic symptoms.

• Surgical goals: 1) Thoroughly remove lesions to reduce recurrence. 2) Ensure drainage by assessing the Eustachian tube, anterior/posterior tympanic isthmus, and tympanic antrum. 3) Functional reconstruction, including hearing restoration and posterior ear canal wall repair.

Common procedures include mastoidectomy, tympanoplasty, ossiculoplasty, myringoplasty, and conchoplasty, tailored to individual cases for optimal hearing recovery.

How to Administer Ear Drops Correctly for Suppurative Otitis Media?

Ear drops are crucial for treating external and middle ear diseases, as they act directly on the affected area. Patients or caregivers should learn proper administration.

• Before each application, clean the affected ear canal or use hydrogen peroxide. Tilt the head or lie on the unaffected side, apply 3–4 drops, gently pull the auricle, and press the tragus to distribute the medication evenly.

• Choose ear drops based on the condition. Water-based solutions are preferable for small perforations; oil-based solutions are used for larger perforations or mucosal edema. For large perforations with minimal pus, apply chloramphenicol powder sparingly after cleaning. Avoid excessive powder to prevent blockage.

• Perform pus sensitivity testing to select effective antibiotics. Avoid powders for small perforations.

• Ensure the solution is at body temperature to prevent nausea or vomiting. Avoid contaminating the dropper by touching the ear canal.

Are There Any Home Remedies for Suppurative Otitis Media?

Home remedies typically involve topical treatments like drops, oils, or powders. However, these lack scientific validation and should not be relied upon.

When Is Surgery Needed for Chronic Suppurative Otitis Media?

Surgery depends on the type and stage of the disease. It is required if conservative treatment fails or complications arise, such as:

• Cholesteatoma (chronic cholesteatomatous otitis media).

• Recurrent infections unresponsive to medication.

• Persistent tympanic membrane perforation with dry ear for over a month, requiring hearing improvement.

• Soft tissue density in the mastoid on CT scan, unresponsive to antibiotics.

• Intracranial/extracranial complications (e.g., postauricular abscess, labyrinthitis, meningitis, brain abscess).

What Are the Risks of Surgery for Chronic Suppurative Otitis Media?

Surgery, usually under general anesthesia, carries risks such as:

• Infection, scar-related ear canal narrowing, or auricular infection.
• Facial nerve damage causing paralysis (temporary or permanent).
• Vertigo or tinnitus due to inner ear or brain stimulation.
• Further hearing loss, possibly requiring hearing aids or reconstruction.
• Mild headaches, manageable with medication.

Will Hearing Improve After Surgery for Chronic Suppurative Otitis Media?

Not always. The primary goal is lesion removal. Hearing restoration may require additional procedures or aids.

Is Follow-Up Needed After Surgery for Chronic Suppurative Otitis Media?

Yes. Post-discharge, ear canal packing is removed after about a week, followed by inflammation management and regular check-ups.

Why Is Early Surgery Needed for Cholesteatoma?

• Cholesteatoma erodes bone, spreading infection to nearby structures like the brain, major vessels, or nerves.
• Untreated, it can lead to life-threatening complications (e.g., abscesses, meningitis).
• Early surgery is critical to prevent such risks.

Can Hearing Aids Be Used for Suppurative Otitis Media?

Yes, if hearing loss is severe, but only after infection control to avoid obstructing drainage or damaging the device.

DIET & LIFESTYLE

What issues should be paid attention to after surgery for chronic suppurative otitis media?

After successful surgery for chronic suppurative otitis media, close observation is necessary to avoid delays that may lead to irreversible consequences. The specific precautions are as follows:

• Monitor for signs of facial paralysis. This is a critical aspect after surgery for suppurative otitis media. If symptoms such as crooked mouth, air leakage when puffing cheeks, weak or incomplete eye closure, or shallow/disappearing forehead wrinkles occur, inform the doctor immediately.
• Watch for symptoms of intracranial complications. If severe headaches, dizziness, nausea, or vomiting occur, do not rely solely on medication—rule out intracranial complications.
• Observe overall conditions such as fever and fatigue. A low-grade fever (below 38.5°C) may occur within the first three days after surgery. However, prolonged fever or temperatures exceeding 38.5°C should raise concern.
• After surgery, rest is essential. Maintain a nutritious diet, ensure smooth bowel movements, and prevent colds.

What dietary precautions should be taken for suppurative otitis media?

Traditional beliefs suggest avoiding "trigger foods" for otitis media, but modern medicine does not support this claim.

However, modern medicine acknowledges that certain foods high in specific absorbable components may negatively affect the condition.

For otitis media, so-called "trigger foods" like fish and shrimp can still be consumed, while spicy foods such as chili peppers may increase secretions and should be avoided.

PREVENTION

How to Prevent Acute Suppurative Otitis Media?

• Engage in regular physical exercise to strengthen your immune system as the foundation.

• Prevent colds. Since most cases of suppurative otitis media are caused by infections of the Eustachian tube, which often occur after a cold, preventing colds significantly reduces the risk of developing suppurative otitis media.

• Learn the correct method of blowing your nose.

• Practice proper breastfeeding. Mothers should breastfeed infants in a sitting position to prevent milk from entering the baby's middle ear through the Eustachian tube.

• When children suffer from infectious diseases such as colds, measles, or whooping cough, closely monitor them for potential otitis media complications and seek timely treatment.

• Avoid inhaling water into the nasopharynx while swimming to prevent it from entering the middle ear.

• Properly manage eardrum injuries to prevent otitis media. Those with existing eardrum perforations should prevent water from entering the ear during hair washing or bathing and must avoid swimming.

How to Prevent Recurrence of Chronic Suppurative Otitis Media?

Chronic suppurative otitis media is prone to recurrence, so in addition to active treatment, preventive measures against relapse are essential.

The key to prevention lies in identifying the causes of recurrence, such as chronic rhinitis, allergic rhinitis, chronic sinusitis, nasopharyngitis, adenoid hypertrophy, or chronic tonsillitis. Treating these conditions alongside otitis media not only speeds up recovery but also significantly reduces the likelihood of recurrence. Beyond addressing these underlying causes, the following precautions should be taken:

• Maintain regular physical exercise to improve overall health and immunity. Avoid colds, excessive fatigue, and ensure a balance between work and rest. Excessive smoking and alcohol consumption are also contributing factors to recurrence.
• Since suppurative otitis media involves eardrum perforation, prevent contaminated water from entering the ear canal during face washing, hair washing, or bathing. Patients with otitis media should not swim.
• Blow your nose correctly—avoid excessive force. Instead of forcefully blowing through the nostrils, gently inhale mucus and expel it through the mouth.