What are the recommended guidelines for managing inactive mucosal chronic otitis media?

Management of Inactive Mucosal Chronic Otitis Media

For inactive mucosal chronic otitis media, watchful waiting with regular surveillance every 3-6 months is the cornerstone of management, reserving surgery (myringoplasty/tympanoplasty) for patients with persistent hearing loss, recurrent infections, or when the patient desires definitive repair of the tympanic membrane perforation. 1, 2

Initial Assessment and Documentation

At each visit, document the following specific findings: 1, 2

• Laterality (unilateral vs bilateral perforation)
• Duration of the perforation and any associated otorrhea
• Size and location of the tympanic membrane perforation (anterosuperior, anteroinferior, posterosuperior, or posteroinferior quadrant)
• Presence and severity of hearing loss and other symptoms affecting quality of life

Confirm the diagnosis using pneumatic otoscopy as the primary method, supplemented by tympanometry if findings are uncertain. 2

Obtain formal audiometric testing with pure tone audiometry to quantify the degree of conductive hearing loss. 1, 2

Conservative Management Strategy

Observation Protocol

Implement surveillance at 3-6 month intervals until one of the following occurs: 3, 1

• The perforation heals spontaneously
• Significant hearing loss develops or worsens
• Structural abnormalities of the tympanic membrane or middle ear are identified
• Recurrent otorrhea develops despite preventive measures

Communication and Environmental Strategies

During the observation period, counsel patients on the following measures to optimize hearing: 1, 2

• Speak within 3 feet of the patient, face-to-face
• Eliminate background noise during conversations
• Use visual cues and speak clearly
• For children, arrange preferential classroom seating near the teacher
• Avoid water ingress into the ear canal (no swimming, use ear protection during bathing) 4

Medications to Avoid

Do NOT prescribe the following medications, as they are completely ineffective for inactive mucosal chronic otitis media: 1, 2

• Antihistamines and decongestants (no benefit whatsoever)
• Oral or intranasal corticosteroids (any short-term benefit becomes nonsignificant within 2 weeks)
• Prophylactic oral antibiotics (no long-term efficacy, unnecessary risks)

Exception: If the patient has coexisting allergic rhinitis, aggressively treat the rhinitis with intranasal corticosteroids and second-generation antihistamines, as this may theoretically reduce Eustachian tube inflammation. 1

Surgical Intervention Criteria

Clear Indications for Surgery

Refer to otolaryngology for myringoplasty/tympanoplasty when any of the following are present: 3, 1, 4, 5

• Persistent perforation ≥3-4 months with documented conductive hearing loss (air-bone gap ≥20 dB)
• Recurrent otorrhea despite conservative measures and water precautions
• Patient desire for definitive repair to allow water activities or improve hearing
• Structural damage to the tympanic membrane (progressive retraction pockets, atelectasis)
• Occupational or quality of life concerns related to the perforation

Surgical Technique Selection

Myringoplasty (tympanoplasty Type I) is the procedure of choice for inactive mucosal chronic otitis media without ossicular chain involvement. 4, 5

• Cartilage grafts provide better structural outcomes (fewer postoperative perforations) compared to temporalis fascia, though hearing outcomes are similar. 3
• Post-auricular approach is most commonly used and provides excellent exposure. 5
• Success rates for graft uptake range from 84-93%, with higher success for posterior and medium-sized perforations compared to anterior or subtotal perforations. 5

Procedures NOT Recommended

Do NOT perform the following procedures for inactive mucosal chronic otitis media: 3, 1

• Adenoidectomy (unless a distinct indication exists such as nasal obstruction or chronic adenoiditis)
• Tonsillectomy (ineffective for chronic otitis media)
• Myringotomy alone without grafting (incision closes within days, providing no benefit)

Expected Outcomes

Hearing Improvement

Following successful myringoplasty, expect: 5

• Mean hearing gain of 11-12 dB in air conduction thresholds
• 67-68% of patients achieve clinically significant hearing improvement
• Postoperative air conduction thresholds typically improve to 16-30 dB HL range

Graft Success Rates

Graft uptake rates of 84-93% can be expected with modern techniques, with failure rates of 7-16%. 5 Success is higher with:

• Posterior perforations (93% success) vs anterior perforations
• Medium-sized perforations (87% success) vs subtotal perforations
• Small perforations (100% success in some series)

Common Pitfalls to Avoid

Do not operate on actively draining ears without first achieving a dry ear for at least 3 months, as inflamed, wet middle ear mucosa is a major risk factor for graft failure. 4

Do not delay audiometric testing beyond 3 months of observation, as quantifying hearing loss is essential for surgical decision-making. 1, 2

Do not screen asymptomatic patients without risk factors or symptoms attributable to the perforation. 1, 2

Counsel patients about lifelong water precautions if they decline surgery, as water ingress can trigger recurrent infections. 4