¹Senior Resident, ²Associate Professor, Department Of E.N.T, A.N.M.C.H Gaya, Bihar, INDIA.

Email: drskr2004@gmail.com  

RESULTS

After applying inclusion and exclusion criteria, total 216 patients were considered for study. Most common age group in present study was 11-20 years (37%) followed by 21-30 years (24%), 31-40 years (13%). Mean age was 25.5± 13.8 years.

Table 1: Age distribution

Tubotympanic type (84%) was far more common type of CSOM than atticoantral type (16%). CSOM was common in female sex (56%) as compared to male (44%). Male to female ratio was 0.78:1.

Table 2: Sex distribution in various types of CSOM

Complicated CSOM (7 %) was less common than uncomplicated CSOM (93%). Complicated CSOM was common in patients with duration of disease more than 3 years.

Table 3: Sex distribution in complicated and uncomplicated CSOM

Ear discharge was sent for microbiological assay. Pure growth was noted in 73% samples while mixed growth in 17% and no growth in 10% samples.

Table 3: Type of growth obtained from ear discharge

Pseudomonas aeruginosa (45%) was most common organism isolated in ear discharge samples followed by Staphylococcus aureus species (36%). Staphylococcus aureus species were further distributed as Methicillin‑sensitive Staphylococcus aureus (MSSA) (24%), Coagulase‑negative Staphylococcus aureus (CONS) (7%) and Methicillin‑resistant Staphylococcus aureus (MRSA) (5%). Other organism were proteus species (6%), escherichia coli (6%), klebsiella species (5%), enterobacter species (1%) and citrobacter species (1%).

Table 5: Organisms isolated in pure growth culture samples

Antibiotic sensitive for pseudomonas aeruginosa was meropenem (89%) followed by piperacillin and tazobactam (83%) and ciprofloxacin (77%). Sensitivity to other antibiotics was amikacin (72%), ceftazidime (68%), gentamycin (61%), amoxycillin + clavulanic acid (44%).

Table 6: Antibiotic sensitivity pattern for pseudomonas aeruginosa.

DISCUSSION

Chronic suppurative otitis media is persistent infection and resultant perfora­tion of the tympanic membrane. Chronic suppurative otitis media (CSOM) is a disease associated with the structural change in middle ear and permanent abnormality of pars tensa or parse flaccida mostly as a sequelae of long standing middle ear effusion, inadequately treated acute otitis media or eustachian tube dysfunction and negative middle ear pressure. Chronic suppurative otitis media pres­ents with persistent or recurrent otorrhea through a perforated tympanic membrane (active), or with a dry but permanent per­foration of the tympanic membrane (inac­tive). Other features include thickened granular mucosa, polyps, and choles­teatoma in the middle ear.⁴ According to a report by WHO, India belongs to the highest (>4%) CSOM prevalent countries.⁵ CSOM is more common in low socio-economic status groups, communities with overcrowding, inadequate housing, poor hygiene, lack of breast feeding, poor nutrition, impaired immunologic status, passive smoking, frequent upper respiratory tract infection, high rates of nasopharyngeal colonization with potentially pathogenic bacteria and inadequate or unavailable health care. While the incidence of complications is low, untreated cases of CSOM can lead to a wide range of problems such as persistent otorrhea, labyrinthitis, mastoiditis, and paralysis of the facial nerve to more serious complications, Hearing impairment is one of the most common sequelae of CSOM. The resultant hearing loss can have a negative impact on a child’s speech development, education and behaviour. Mortality due to complications of CSOM is typically higher than other types of otitis media. Intracranial complications like brain abscess and meningitis are the most common causes of death in CSOM patients.^6,7 Most common age group in present study was 11-20 years (37%) followed by 21-30 years (24%), this indirectly signals acute exposure during the childhood. Similar age pattern has been reported by Raakhee T et al.⁸ and Panchal et al..⁹ The high prevalence of otitis media in early age group may be attributed to the fact that they are usually more prone to develop upper respiratory tract infections (URTIs).¹⁰

Pseudomonas spp. (45%) was the most common isolate followed by Staphylococcus aureus (36%) which is similar to findings as observed by other investigators.^11,12 Pseudomonas aeruginosa in known to cause deep seated and progressive destruction of middle ear and mastoid structures through its toxins and enzymes.⁴ The ability of P. aeruginosa to survive in competition with other organisms may be due to minimum nutrition requirement. Ability of pseudomonas to use pile to attach to the necrotic or diseased epithelium of the middle ear. After attachment pseudomonas produces enzymes like proteases, lipopolysaccharides to elude from normal defence mechanism of body required for fighting infections.¹³ The indiscriminate, haphazard use of antibiotics and poor follow up of the patients have resulted in persistent low grade infectional changes in the microbiology of the disease, the advent of new antimicrobials, anti-inflammatory and anti-histamine agents make an evaluation of bacterial flora of CSOM important. Topical antibiotics are the mainstay of therapy while systemic antibiotics are given in acute exacerbations and in complications due to CSOM.¹⁴ Antibiotic sensitive for pseudomonas aeruginosa was meropenem (89%) followed by piperacillin and tazobactam (83%) and ciprofloxacin (77%). Study by Prakash et al. showed ciprofloxacin and gentamicin as an effective first line topical antibiotic in the treatment of otorrhea in CSOM.³ The declining sensitivity trend of organisms with commonly used antimicrobial agents may be explained by number of factors including injudicious use, inappropriate doses of antimicrobials and development of enzymatic resistance in microorganisms.

CONCLUSION

The study of microorganisms associated CSOM and their antibiotic sensitivity pattern is most important for clinician to plan general outline of treatment of chronically discharging ear. Early and effective treatment based on the knowledge of causing microorganisms and their sensitivity results in good clinical recovery and prevents damage and complications caused by CSOM. Although the best modality of treatment for COM with or without cholesteatoma is surgery, that is modified radical mastedectomy, but the role of antibiotics and knowledge about the bacterial isolates responsible for development of COM will help the treating otololaryngologists for choosing rationale antibiotic prior to, during and immediately after surgery for complete eradication of infection and cure from disease, in the coming future.

REFERENCES

1. Srivastava A, Singh R, Varshney S, Gupta P, Bist S, Bhagat S, et al.. Microbiological evaluation of an active tubotympanic type of chronic suppurative otitis media. Nepalese Nepalese J ENT Head Neck Surg. 2010;1(2):14-6.
2. Sharma K, Manjari M, Salaria N. Middle ear cleft in chronic otitis media: a [3]clinicohistopathological study. Indian Journal of Otolaryngology and Head and Neck Surgery. 2013;65(Suppl 3):493-97.
3. Prakash R, Juyal D, Negi V, Pal S, Adekhandi S, Sharma M, et al.. Microbiology of chronic suppurative otitis media in a tertiary care setup of Uttarakhand state, India. North Am J Med Sci. 2013 Apr;5(4):282.
4. Acuin J, for the World Health Organization. Chronic Suppurative Oti­tis Media. Burden of Illness and Management Options. Geneva: World Health Organization, 2004.
5. Shyamala R, Reddy PS. The study of bacteriological agents of chronic suppurative otitis media-Aerobic culture and evaluation. J Microbiol Biotechnol Res. 2017;2:152e162.
6. Aarhus, L., Tambs, K., Kvestad, E. and Engdahl, B. (2015). Childhood otitis media: a cohort study with 30-year follow-up of hearing (The HUNT Study). Ear Hear 36, 302–308.
7. Qureishi, A., Lee, Y., Belfield, K., Birchall, J. P. and Daniel, M. (2014). Update on otitis media – prevention and treatment. Infect Drug Resist 7, 15–24.
8. Raakhee T, Unguturu SR. Bacteriological study of discharging ear in patients attending a tertiary care hospital. Int J Res Med Sci. 2014 May;2(2):602-6.
9. Panchal PD, Patel BV. Evaluation of bacteriological profile and antibiotic susceptibility pattern of patients with otorrhea in a tertiary care teaching hospital. Inter J Res Med Sci. 2017 Jan 16;3(11):3167-70.
10. Nazir A, Kadri SM. Aerobic bacteriology of chronic suppurative otitis media: A hospital based study. Int J Res Med Sci 2017;2:15215
11. Chavan A, Nagarkar R, Chavan GN, Deshmukh PT. A study of microbiological spectrum with its antibiotic susceptibility in patients of chronic suppurrative otitis media at RIMS, Adilabad. Int J Healthcare Biomed Res. 2014;03(1):152-7.
12. Arif D, Mukhia RK, Goud SK, Nissar J, Shah RP, Singh S, et al.. Bacteriological profile of ear infections and its antibiotic susceptibility pattern in tertiary care hospital Navi Mumbai. IOSR J Dent Med Sci. 2014;13(5):58-62.
13. Hirapure PV, Pote MK. Microbial Profile and Antibiograms of Active Patients of Chronic Suppurative Otitis Media in Latur, Maharashtra, India. International Research Journal of Medical Sciences. 2014;2(5):6-9.
14. Prajna L, Vijayakumar A. Atlas of Fungal Corneal Ulcers Clinical Features and Laboratory Identification Methods. New Delhi: Jaypee Broth Med Publishers; 2008:24e28.