Treatment of Chronic Otitis Media with Tympanic Membrane Perforation and Cholesteatoma
Surgical intervention is the definitive treatment for cholesteatoma with tympanic membrane perforation and chronic otitis media, as medical management alone is insufficient for disease eradication and prevention of serious complications.
Initial Medical Management
- Before surgical intervention, topical antibiotic therapy should be initiated for active infection control 1, 2
- For chronic suppurative otitis media with perforated tympanic membranes, ofloxacin otic solution 0.3% is indicated - ten drops (0.5 mL, 1.5 mg ofloxacin) instilled into the affected ear twice daily for fourteen days 2
- Systemic antibiotics should be reserved for cases with signs of invasive infection, mastoiditis with systemic symptoms, or extensive disease 1
- Appropriate pain management should be implemented as needed 1
Diagnostic Evaluation
- Accurate diagnosis requires careful otoscopic examination to visualize the tympanic membrane perforation and cholesteatoma, which typically appears as abnormal whitish material in the middle ear 1
- CT imaging should be performed to assess disease extent, particularly to evaluate mastoid involvement and potential intracranial complications 1
- Audiometric testing should be conducted to establish baseline hearing status and guide surgical approach 1
Surgical Management
Indications for Surgery
- Cholesteatoma is a clear indication for surgical treatment; conservative approaches are not appropriate due to risk of serious complications 3
- Surgery aims to:
Surgical Approaches
The surgical approach depends on:
Common surgical approaches include:
Specific Surgical Procedures
Tympanoplasty for repair of perforated tympanic membrane 1, 5
Mastoidectomy options:
- Canal wall up (closed technique) - preserves posterior canal wall
- Canal wall down (open technique) - removes posterior canal wall
- Selection depends on disease extent and surgeon preference 3
Management of Complications
- Complications of chronic otitis media and cholesteatoma have decreased with antibiotic use but still occur and can be lethal if not properly identified and treated 6
- For serious complications such as sigmoid sinus thrombosis, anticoagulation may be considered in the absence of contraindications 1
- Surgical intervention for source control is essential for managing complications 1, 6
Follow-up Care
- Regular follow-up is essential due to high recurrence rates, particularly with cholesteatoma 3
- Post-surgical monitoring should continue lifelong in cases of cholesteatoma 3
- Audiometric testing should be performed to assess hearing outcomes 1
- Evaluation at 6 months post-treatment shows significant improvement in symptoms 7
Special Considerations
- Patients with diabetes or immunocompromised states require special attention due to increased risk of complications 1
- Early surgical intervention during the carious process in patients with cholesteatoma in the remission phase can significantly reduce disease extension and allow middle ear reconstruction in approximately 70% of patients 4
Common Pitfalls and Caveats
- Delaying surgical intervention for cholesteatoma can lead to serious complications including intracranial extension 6
- Conservative "wait-and-see" approaches are inappropriate for cholesteatoma management 3
- Mechanical factors and unresolved problems such as continuing tubal dysfunction and chronic inflammation can affect successful restoration of normal hearing 3
- Postoperative complications such as inner ear trauma and facial nerve injury are rare but require early diagnosis and treatment 3