Chronic Otitis Media (Chronic Middle Ear Infection)

Types of chronic otitis media

Chronic suppurative otitis media (CSOM)

A persistent hole (perforation) in the eardrum with recurrent or ongoing discharge. It often follows repeated acute ear infections, especially in childhood, or a perforation that never healed. Water or germs enter through the hole and cause flare-ups. It is a major cause of hearing loss worldwide, particularly in children in low-resource settings and some Indigenous communities.

Cholesteatoma

A cholesteatoma is a growth of skin cells trapped in the middle ear, usually arising from a retracted part of the eardrum. It causes foul-smelling discharge and hearing loss, and slowly erodes the small hearing bones and surrounding bone. It can lead to serious complications and almost always needs surgery.

Chronic otitis media with effusion

Glue ear is fluid behind an intact eardrum lasting 3 months or longer, without acute infection. It is common in young children and causes muffled hearing. It is sometimes grouped with chronic otitis media.

Causes and risk factors

• repeated acute otitis media in childhood
• Eustachian tube dysfunction, where the tube connecting the ear to the back of the nose does not ventilate the middle ear
• eardrum perforation from infection, injury or after ear tubes
• cleft palate, Down syndrome and other craniofacial differences
• allergies and chronic sinusitis
• exposure to tobacco smoke
• crowded living conditions, malnutrition and limited access to health care

Common bacteria include Pseudomonas aeruginosa and Staphylococcus aureus.

Symptoms

• discharge from the ear, often painless, watery, thick or yellow, that comes and goes, especially after colds or water exposure
• foul-smelling discharge (more typical of cholesteatoma)
• hearing loss in the affected ear
• a feeling of fullness
• tinnitus
• pain is usually mild or absent unless there is a flare-up or complication

Complications

Chronic otitis media can spread beyond the middle ear. Complications are more common with cholesteatoma:

• permanent hearing loss, conductive from damage to the eardrum and hearing bones, or sensorineural if the inner ear is affected
• mastoiditis: infection of the bone behind the ear
• facial nerve palsy: weakness of one side of the face
• labyrinthitis: inner ear infection with vertigo
• meningitis and brain abscess: rare but life-threatening

Diagnosis

• Otoscopy or microscope examination: shows the perforation, discharge, retraction pocket or cholesteatoma. The ear is often cleaned by suction first.
• Swab of discharge to identify bacteria and antibiotic sensitivity.
• Audiogram: measures the type and degree of hearing loss.
• CT scan of the temporal bone: shows the extent of cholesteatoma or bone erosion, and is used for surgical planning.
• MRI: for suspected complications or recurrent cholesteatoma.

Treatment

Medical treatment for CSOM

• Aural toilet: careful cleaning of discharge by suction or dry mopping, which helps drops reach the infection.
• Antibiotic or antibiotic-steroid ear drops, typically quinolone drops such as ciprofloxacin or ofloxacin, which are safe with a perforated eardrum. Avoid aminoglycoside drops, which can damage hearing when the eardrum is open.
• Oral or IV antibiotics only for spreading infection or complications.
• Keep the ear dry: use a cotton ball coated with petroleum jelly or a custom earplug when bathing, and avoid swimming unless protected.

Surgery

• Tympanoplasty (myringoplasty): repairs the eardrum with a graft, usually once the ear is dry. It reduces infections and often improves hearing.
• Ossiculoplasty: reconstructs damaged hearing bones.
• Mastoidectomy: removes infected mastoid bone and cholesteatoma. Follow-up imaging or second-look surgery is often needed because cholesteatoma can recur.

Hearing support

Hearing aids, including bone-conduction devices for draining ears, help when hearing loss remains.

Outlook

With treatment, most people's ears become dry and stable, and many have improved hearing after surgery. Untreated cholesteatoma continues to grow. Regular follow-up with an ENT specialist is important, especially for children, as hearing loss can affect speech, language and school.

Frequently asked questions

What is chronic otitis media?

Chronic otitis media is middle ear inflammation lasting more than 3 months. The most common type involves a hole in the eardrum with recurring, often painless discharge and hearing loss. Cholesteatoma, a skin growth in the middle ear, is a more destructive type.

What causes chronic ear discharge?

The most common cause is chronic suppurative otitis media, in which a perforated eardrum lets infections recur. Other causes include cholesteatoma, chronic outer ear canal infection, and ear tubes. Discharge lasting more than 2 weeks should be checked by a doctor.

Can chronic otitis media cause permanent hearing loss?

Yes. Ongoing infection can damage the eardrum and the tiny hearing bones, and, less often, the inner ear. Early treatment and surgery to repair the eardrum and hearing bones can preserve or improve hearing. Hearing aids help when loss remains.

How is chronic otitis media treated?

Treatment includes regular ear cleaning, antibiotic ear drops that are safe for perforated eardrums, and keeping water out of the ear. Many people need surgery to repair the eardrum (tympanoplasty), and cholesteatoma requires surgical removal.

Is chronic otitis media dangerous?

Usually it causes discharge and hearing loss rather than danger. However, especially with cholesteatoma, infection can spread to the mastoid bone, facial nerve, inner ear or brain. Seek urgent care for severe headache, fever, facial weakness, swelling behind the ear or vertigo.