What is the role of surgical management in an elderly patient with chronic suppurative otitis media, bilateral complete hearing loss, diabetes, and cardiovascular disease?

Surgical Management of Chronic Suppurative Otitis Media in Elderly Patients with Multiple Comorbidities

Surgery is indicated for this patient to eradicate cholesteatoma if present, control chronic infection, and repair the tympanic membrane perforation, despite the bilateral complete hearing loss, diabetes, and cardiovascular disease. 1

Primary Surgical Indications

The presence of chronic suppurative otitis media (CSOM) with tympanic membrane perforation requires surgical intervention when:

• Cholesteatoma is suspected or confirmed – Any patient with suspected cholesteatoma requires referral to an otolaryngologist for definitive surgical management, as this represents a potentially life-threatening condition that can progress to skull base osteomyelitis, particularly in elderly diabetic patients. 2, 1

• Medical management has failed – Topical fluoroquinolones, while having the strongest evidence for CSOM treatment, frequently fail long-term due to biofilm formation and antibiotic-tolerant persister cells. 3 Surgical intervention should be considered earlier in refractory disease to minimize antibiotic resistance and allow biofilm debridement. 3

• Complete disease eradication is needed – Surgical removal of cholesteatoma with mastoidectomy achieves only 3.6% recurrence rates, making it the definitive treatment. 4

Critical Pre-operative Assessment

Before proceeding with surgery in this high-risk patient, perform:

• Otoscopic examination to visualize the perforation and identify whitish material suggesting cholesteatoma. 1, 4

• CT imaging to assess mastoid involvement and evaluate for intracranial complications, which is essential given the patient's immunocompromised state from diabetes. 1

• Cardiovascular risk stratification given the patient's cardiovascular disease – coordinate with cardiology for perioperative optimization. 2

Special Considerations for Diabetes and Cardiovascular Disease

Patients with diabetes require heightened vigilance and modified surgical planning:

• Never irrigate the ear canal in diabetic patients, as this predisposes to necrotizing otitis externa, a potentially fatal skull base osteomyelitis. 2

• Assess for necrotizing otitis externa before surgery – look for granulation tissue at the bony-cartilaginous junction, facial nerve paralysis, or severe otalgia disproportionate to findings. 2 If present, this requires aggressive systemic antibiotics covering Pseudomonas and MRSA plus surgical debridement before definitive ear surgery. 2

• More aggressive pre-operative infection control is needed due to increased complication risk in immunocompromised states. 4

• Systemic antibiotics should be added to topical therapy in diabetic patients with active infection, rather than topical therapy alone. 2

Surgical Approach Selection

The surgical technique depends on disease extent:

For CSOM with perforation alone:

• Tympanoplasty using cartilage reconstruction (not temporalis fascia) achieves superior outcomes with 92.4% graft integration versus 84.3% for fascia. 1, 4

For CSOM with cholesteatoma:

• Complete cholesteatoma removal with mastoidectomy as needed, with the extent determined by CT findings and intraoperative disease. 1
• Canal wall down mastoidectomy with cavity obliteration may be preferred in resource-limited follow-up scenarios or extensive disease. 5

For CSOM with mastoiditis:

• Mastoidectomy is required for source control and prevention of intracranial complications. 1

Hearing Considerations

The bilateral complete hearing loss does NOT contraindicate surgery – the goals shift from hearing preservation to:

• Infection eradication to prevent life-threatening complications (meningitis, brain abscess, sigmoid sinus thrombosis). 1
• Prevention of progressive disease. 1
• Improved quality of life through elimination of chronic otorrhea. 6

The patient is not a candidate for hearing reconstruction given bilateral complete loss, but this should not delay necessary surgery for disease control. 1

Perioperative Medical Management

Pre-operative infection control:

• Topical ofloxacin 0.3% (non-ototoxic fluoroquinolone) for active infection – never use ototoxic preparations with non-intact tympanic membrane. 4
• Systemic antibiotics covering Pseudomonas and Staphylococcus aureus if signs of invasive infection. 1, 7
• Strict ear dryness – no water exposure or irrigation. 4

Glycemic control optimization before surgery to minimize infection risk. 2

Post-operative Surveillance

Lifelong follow-up is mandatory for cholesteatoma cases:

• Monitor for recurrence (3.6% rate with complete excision). 4
• Assess for late complications including myringosclerosis, atrophy, or persistent perforation. 4
• Serial otoscopic examinations at 3-6 month intervals initially. 2

Risk-Benefit Analysis

Benefits of surgery outweigh risks in this scenario:

• Prevention of potentially fatal complications (necrotizing otitis externa, intracranial extension) that are more likely in elderly diabetic patients. 2
• Definitive disease control with low recurrence rates. 4
• Improved quality of life through elimination of chronic drainage. 6

Surgical risks are manageable with appropriate precautions:

• Cardiovascular complications can be minimized with proper perioperative optimization. 2
• Wound healing concerns in diabetes are addressed through meticulous technique and glycemic control. 2
• The patient's complete hearing loss means no risk of iatrogenic hearing deterioration. 1