Surgical Outcomes of Chronic Suppurative Otitis Media

Objectives: The purpose of this study is to observe the surgical outcomes of chronic suppurative otitis media. 1. To assess the result of surgical procedure to obtain dry and safe ears. 2. To assess the hearing levels after surgery. 3. To observe the complications that occur during the operation and in the immediate postoperative period Methods: A total 60 patients with CSOM (active squamous variety) who underwent tympanomastoid surgery studied in a period of 1 year from July 2013 to June 2014 at CMH Dhaka. Results: The maximum patients were from15-24 years (35%) age group, male to female ratio was 1.2:1. Highest number of patients (39%) was from middle class family. All the 60 patients presented with discharge from ear and hearing impairment. Maximum (40%) were with attic and postero-superior marginal perforation along with granulation tissue. In 1post op month,53 (88.33%) manifested dry ear and in 3 month after operation 52 (90%) patients manifested dry ear. 7 (11.66%) patients showed discharge from the ear after 1 month which decreased to the 0% after 3 month. Graft was taken successfully in 56 (93.33%) patients after the first month of operation which reduced to 51 (85%) after third month of operation. Hearing status of the patients before operation proclaimed that 48% patients suffered from moderate hearing loss, 22% and 17% patients suffered from mild and moderately severe loss respectively. 13% patients suffered from severe hearing loss After surgery 86% patients’ condition was improved, 4% patients’ condition deteriorated and 10% patients’ condition remain unchanged . The mean preoperative air-bone gap was 32.10 dB and mean postoperative air-bone gap was 19.10 dB . Key Word: COM, Active squamous, Attico-antral, Cholesteatoma, CWDT 1. Classified Specialist in OtolaryngologyHead & Neck Surgery, BGB Hospital, Peelkhana, Dhaka. 2. Classified Specialist in OtolaryngologyHead & Neck Surgery, CMH Dhaka. 3. Classified Specialist in OtolaryngologyHead & Neck Surgery, CMH Rangpur. 4. Classified Specialist in Psychiatry, BGB Hospital, Peelkhana, Dhaka. 5. Professor, Department of Otolaryngology-Head & Neck Surgery, BSMMU, Dhaka. Address of Correspondence: Dr.(Lt Col) Mohammed Sirazul Islam, Department of ENT and HeadSurgery, BGB Hospital, Peelkhana, Dhaka. Mobile No:01711730201 Original Article Bangladesh J Otorhinolaryngol 2017; 23(2): 187-194 ENT 23 (2), 2017 188 Introduction Chronic suppurativeotitis media has been an important cause of middle ear disease since prehistorical time. It is a worldwide health problem and is still prevalent in the modern antibiotic era. It is one of the most common ear disease in developing countries. Chronic otitis media (COM) is an inflammatory process in the middle ear space that results in long-term, or more often, permanent changes in the tympanic membrane including atelectasis, dimmer (formerly “monomer”) formation, perforation, tympanosclerosis, retraction pocket development, or cholesteatoma. In Bangladesh, chronic otitis media (COM) is a common disease in clinical practice. Poor hygiene, malnutrition, lack of health education and inadequate health care all have been suggestive as a basis for the widespread prevalence of chronic otitis media in our country.5 CSOM & its complication are a major health problem in Bangladesh. Prevalence of CSOM on developing countries represents a wide range0.4% to 33.3%. In Bangladesh it’s prevalence is 12.44, 7.39. Hearing loss arising from COM is a matter of serious concern because of its long-term effects on communication, language development and educational process. An estimated 2/3 of the world’s hearing impaired population are believed to be distributed among developing countries. In Bangladesh 16.95% of mild to moderate conductive hearing loss in children and young adult was due to CSOM. The degree of hearing loss varies with size and position of tympanic membrane defect, impairment of ossicular chain and presence of middle ear pathology. There are many different surgical techniques for managing active squamous COM, which can be categorized as open cavity (canal wall down) and closed cavity (intact canal wall) mastoidectomy. The principle aim of surgery for active squamous COM (cholesteatoma) is to completely remove disease and minimize the risk of recurrence, but, in addition, the ear should be returned to as near normal as possible. The ear should be selfcleansing and should not require regular aural toilet and the hearing should be restored.Now, canal wall down tympanoplasty (CWDT) are widely performed, recurrences are reduced in CWDT and hearing outcome is not sacrificed. Tympanomastoid surgery is a new method of surgery which is one stage mastoidectomy with tympanoplasty. It has been in a state of constant evolution from the early 1980’s. The original technique has gradually been moulded and improved as newer methods of ear surgery. The outcome of the surgery depends on diagnosis category of CSOM (with cholesteatoma and without cholesteatoma), pathogenic organisms, extent of mastoid pneumatization, regional factors such as associated mucosal disease of the nose &paranasal sinuses and systemic factors such as diabetes Hearing gain after tympanomastoid surgery is 10-25 dB & recurrent rate is 5-71%. When indicated mastoidectomy might improve tympanoplasty results and prevent graft failure. Relative indications for mastoidectomy during tympanoplasty are a history of profuse otorrhoea especially purulent otorrhoea, a previous tympanoplasty failure, secondary acquired cholesteatoma and severe tympanic membrane that is not respectable without further exposure provided by mastoidectomy.The extent of disease often will determine the aggressiveness of surgery approach. Aims & Objectives General Objective To observe the outcome of surgical management of chronic suppurative otitis media (active squamous variety) 188 Bangladesh J Otorhinolaryngol Vol. 23, No. 2, October 2017 ENT 23 (2), 2017 189 Specific Objectives: 4. To assess the result of surgical procedure to obtain dry and safe ears. 5. To assess the hearing levels after surgery. 6. To observe the complications that occur during the operation and in the immediate postoperative period Materials & Methods Type of study : Prospective clinical study Sampling method : Simple random sampling.


Introduction
Chronic suppurativeotitis media has been an important cause of middle ear disease since prehistorical time. 1 It is a worldwide health problem and is still prevalent in the modern antibiotic era. 2 It is one of the most common ear disease in developing countries. 3 Chronic otitis media (COM) is an inflammatory process in the middle ear space that results in long-term, or more often, permanent changes in the tympanic membrane including atelectasis, dimmer (formerly "monomer") formation, perforation, tympanosclerosis, retraction pocket development, or cholesteatoma. 4 In Bangladesh, chronic otitis media (COM) is a common disease in clinical practice. Poor hygiene, malnutrition, lack of health education and inadequate health care all have been suggestive as a basis for the widespread prevalence of chronic otitis media in our country. 5 CSOM & its complication are a major health problem in Bangladesh. 2 Prevalence of CSOM on developing countries represents a wide range-0.4% to 33.3%. In Bangladesh it's prevalence is 12.44, 7.39. 6 Hearing loss arising from COM is a matter of serious concern because of its long-term effects on communication, language development and educational process. 5 An estimated 2/3 rd of the world's hearing impaired population are believed to be distributed among developing countries. 6 In Bangladesh 16.95% of mild to moderate conductive hearing loss in children and young adult was due to CSOM. 2 The degree of hearing loss varies with size and position of tympanic membrane defect, impairment of ossicular chain and presence of middle ear pathology. 5 There are many different surgical techniques for managing active squamous COM, which can be categorized as open cavity (canal wall down) and closed cavity (intact canal wall) mastoidectomy. The principle aim of surgery for active squamous COM (cholesteatoma) is to completely remove disease and minimize the risk of recurrence, but, in addition, the ear should be returned to as near normal as possible. The ear should be self-cleansing and should not require regular aural toilet and the hearing should be restored. 7 Now, canal wall down tympanoplasty (CWDT) are widely performed, recurrences are reduced in CWDT and hearing outcome is not sacrificed. 2 Tympanomastoid surgery is a new method of surgery which is one stage mastoidectomy with tympanoplasty. It has been in a state of constant evolution from the early 1980's. The original technique has gradually been moulded and improved as newer methods of ear surgery. 2 The outcome of the surgery depends on diagnosis category of CSOM (with cholesteatoma and without cholesteatoma), pathogenic organisms, extent of mastoid pneumatization, regional factors such as associated mucosal disease of the nose &paranasal sinuses and systemic factors such as diabetes . 8 Hearing gain after tympanomastoid surgery is 10-25 dB & recurrent rate is 5-71%. 9 When indicated mastoidectomy might improve tympanoplasty results and prevent graft failure. Relative indications for mastoidectomy during tympanoplasty are a history of profuse otorrhoea especially purulent otorrhoea, a previous tympanoplasty failure, secondary acquired cholesteatoma and severe tympanic membrane that is not respectable without further exposure provided by mastoidectomy. 10 The extent of disease often will determine the aggressiveness of surgery approach.

Aims & Objectives General Objective
To observe the outcome of surgical management of chronic suppurative otitis media (active squamous variety) 2) Patients more than 5 years & below 50 years of age .
3) Patients dropped out from follow up. 4) Patient unfit for general anesthesia due to other medical causes.

Data collection:
The data were collected by the active participation of the patients' interview by the preformed proforma of data collection sheet and then data were gathered, decorated & tabulated after data cleaning and edition. Then the results were found and presented in graphical and tabular form. Detail history, physical examination and relevant investigations were done pre-operatively and post-operatively. Post operative follow up after 1month, 2 months and 3 months were done.

Data analysis:
Data were compiled, analyzed by manual calculator, computer software.

Results
The present study was conducted among the indoor patients of Otolaryngology ward Combined Military Hospital, Dhaka from 1 st July 2013 to 30 th June 2014 with an ultimate view to observe the outcome of surgical management of active squamous variety of chronic suppurative otitis media (CSOM). Besides, this study also was aimed at to assess the results of surgical procedure to obtain dry and safe ears. The study also tried to assess the hearing levels after surgery as well as the peroperative and immediate postoperative complications.
In this study, 60 patients were selected using the purposive sampling method. Then according to age, sex, educational status , socioeconomic status, area of residence, presenting symptoms, signs, postoperative follow up and surgical outcomes -data were gathered, tabulated, analysed.

Discussion
In this study 60 cases of CSOM with active squamous disease underwent modified radical mastoidectomy with type-III tympanoplasty and results were assessed in post op followup period.
The principle aim of surgery for active squamous COM (cholesteatoma) is to complete removal of disease and minimize the risk of recurrence, but, in addition, the ear should be self-cleansing and should not require regular aural toilet and the hearing should be restored. 7 Now a days, canal wall down tympanoplasty (CWDT) are widely performed, recurrence are reduced and hearing outcomes not sacrificed. 2 CSOM with cholesteatoma is more common among younger age group (11-20 years). The younger age group suffers more as because of cellular mastoid, horizontal position of Eustachian tube and enlarged adenoid 2 . In our study, the highest number of cases belong to the 15-24 years age group (35%) which correlate with other study. The age groups in close proximity to this peak were 25-34 years (25%) and 25-34 years (20%). This may be In different studies, it was shown that CSOM affected more in male than female 2,4,5,6,12,13 . This might be due to increase prevalence of CSOM among the male or it might be simple reflection of overall high male attendance in hospital. Female are also reluctance to come forward for treatment on our country. 22 Here, this study showed male (55%) and female (45%) with male & female ratio 1.2:1 which might reflect the overall improved health cautiousness and easy access to the specialist doctor by the patient entitled in CombinedMilitaryHospital Majority of cases of CSOM with cholesteatoma is more in low socio-economic class worldwide due to overcrowding, poor hygiene, poor sanitation, malnutrition 2,4,5,6,13 .
In my study majority of the patients came from middle class family (65%) and significant number came from poor class family (30%).
Illiterate, day labourer, rural people, who used to take bath in river and ponds are affected more in CSOM 2,4,5,6 .This reflects that lack of knowledge and awareness about the consequence of the diseases, inadequate health care facilities, improper practice of hygiene 2 . In my study, only entitled patients to get treatment facilities from CombinedMilitaryHospital were taken. Among these, rural people, primary & secondary high school level educated people, service & house wives and who taking bath in tube well and shower were affected more by CSOM with active squamous disease (cholesteatoma) which differ a little bit with above mentioned studies.
The common clinical symptoms in CSOM with active squamouse disease (cholesteatoma) are malodorous scanty aural discharge and impairment of hearing 14. In our study, malodorous scanty aural discharge and impairment of hearing were found in all the cases which correlated with above study. Other variable symptoms were otalgia, fever, headache, facial weakness & vertigo 2, 14 . In our study the above symptoms were variable in frequency and intensity which consisted with above studies.
The common clinical signs in CSOM with active squamous disease (cholesteatoma) are foul smelling scanty discharge may be with blood stained with attic or marginal perforation in almost all cases 2,14 . In our study the foul smelling scanty aural discharge was found in almost all cases, attic perforation in 66.66% cases and marginal perforation in 33.33% cases which also correlated with above studies. Other signs include cholesteatoma pearl, facial palsy, granulation tissue, aural polyp in variable extent. 14 A canal wall down mastoidectomy with Wullstein type-III tympanoplasty was done in 21 cases of CSOM with ossicular erosion resulting the mean hearing gain was 5 dB. 9 In our study, results of 60 cases of modified radical mastoidectomy with type -III tympanoplasty in CSOM with cholesteatoma was almost similar result of above study.
Lee et al. Palva and Ramsay 15 studied on 261&281 cases and meanhearing improvement were 8.1dB & 8.0dB respectively. In our study, meanhearing improvement was 13 dB which was significant clinically and overall success rate was 86% (52 out of 60). The surgical failure in eightcases (14%) was characterized byevidence of a graft failure at the last followupvisit. Four patients condition deteriorated in later follow up period and total failure was observed in 8 (14%) patients. Graft failure occurred during the first 4 weeks in 2 of the 8 cases.
The pre-operative mean Air conduction threshold was 48.45 dB and bone conduction was 18.35dB. The pre-operative mean air bone gap was 24.29 dB 9 . In our study, pre-operative mean air conduction was 52.45 dB and bone conduction was 18.35, air bone gap 32.10dB. This result is almost similar to above mentioned study.
Post-operative air conduction was 25-55 dB, mean 39.29 dB, the bone conduction was 15-35 dB, mean 20.23 dB, post-operative air bone gap 10-35 dB, mean 19.29 dB 9 . In our study, air conduction was 37.35 dB, bone conduction was 19.10 dB, and air bone gap was 19.10 dB, which is also correlate with above mentioned study. The mean hearing gain was 5 dB 9 . In our study, mean hearing gain was 13 dB which is significantly higher than the other study.
Ajalloueyar Met al showed hearing improvement better than 40 dB in 42% patients, between 40-60 dB in 39% and 4% patients with poor hearing 16 . In another study was shown hearing improved in 30%, remained unchanged in 55% and worsened in 15%. The mean hearing gain was only 5 dB 17 . In our study, hearing threshold remained unchanged in 33.33% cases, hearing was improved by 10-19 dB in 86% cases, 20-29 dB in 10% cases and more than 29 dB in 4% cases. Thus hearing threshold was improved in 86% cases and hearing deterioration occurred in 4% cases.
In post-operative follow-up of patients with CSOM with cholesteatoma, 20-25% patients were discharging ear. 18 In our study, postmastoidectomy discharging ear was 0% after 3 rd month which showedsignificant better results.
In open cavity mastoidectomy,recurrence of cholesteatoma was 12.8% 19 . In our study,recurrence of cholesteatomawas 5% which also showed significantly better results.

Conclusion
Chronic supportive otitis media is a common health hazard in ENT practice all over the world. Cholesteatoma erodes ossicular chain and result in loss of hearing.Hearing loss arising from COM is a matter of serious concern because of its long-term effects on communication, language development and educational process. Early diagnosis and intervention by skilled Otologist is recommended to regain hearing as well as to prevent disability and complications.