Chronic suppurative otitis media:

Case sheet lay out:

Name: Age: Sex: Occupation:

The name of the patient, age and sex should be clearly written. A detailed occupation history should also be taken because of the propensity for certain occupation to cause disorders in hearing (i.e. like working in noisy environment which could cause noise induced sensorineural hearing loss).

Chief complaints:

Under this heading the following questions must be put and the answers given by the patient diligently noted in their own language. (No medical terminology should be used here).

1. Ear discharge : Presence / absence, ? ear is affected, duration
2. Ear pain: Which ear is affected ? Duration ?
3. Hard of hearing: Which ear? Duration? ? Assocaited with tinnitus


History of presenting illness:
Under this heading the patients complaints should be described in the chronological order as presented by the patient.
Ear discharge: ? ear / duration
Onset / progressive ?
Quantity of discharge: scanty / profuse ( Discharge from unsafe ears are usually scanty, while discharge from safe ears are profuse. Profuse discharge sometimes may also be due to subdural abscess )
Characteristics of discharge: This includes color of the discharge and smell emitted by it.
If the discharge is yellowish - it could be only pus
If the discharge is white - the discharge is termed mucoid (common in acute otitis media)
If the discharge is blood stained it is termed serosanguinous in nature. This type of discharge is commonly seen in acute suppurative otitis media, presence of granulation tissue, myringitis granulosa etc.
Aggravating / relieving factors if any should be noted.

Hard of hearing:
? Duration
Onset: Progressive / stationary
The patient's ability to hear well in noisy environment "whispering Pectoriloquy " if any should be noted. This is a classic feature seen in otosclerosis.
Aggravating / relieving factors if any should be documented.
If hard of hearing is associated with tinnitus it indicates sensorineural deafness.
Ear ache:
Ear ache if any should be documented.
Aggravating / relieving factors if any should be noted.
In otitis externa ear ache is more when the patient is chewing food.
Past History:
History of head ache: This is positive in cases with CSOM associated with intracranial complications.
History of nasal block / URI: This is one indirect way of ruling out focal sepsis to be the cause for CSOM.
History of throat pain: Infection / inflammation of waldayer's ring may cause CSOM.
History of diplopia (double vision), retroorbital pain: This is positive in patients with petrositis. (These constitute features of Gradenigo's syndrome).
History of vertigo / giddiness - to rule out labyrinthitis
History of itching in the ear - Itching could indicate unresolved eustachean catarrh, impacted cerumen, fungal infections of external auditory canal, discharge due to chronic suppurative otitis media.
History of nasal block / discharge: Nasal block in children could commonly be caused due to adenoid hypertrophy. In adults this could indicate nasal allergy which could predispose to chronic ear infections.
History of throat pain / sorethroat: to rule out focal sepsis
History of fever: Indicates active infection. If the fever is of picket fence pattern it could indicate lateral sinus thrombophlebitis due to CSOM. Fever associated with neck stiffness could indicate meningitis.
History of headache. nausea, vomiting: could indicate intracranial complications due to CSOM. Vomiting is usually projectile in nature in these individuals.
History of exanthematous fevers like measles: This should be sought for. These fevers could cause acute necortising otitis media leading on to secondary acquired cholesteatoma formation.
History of diabetes mellitus, Epilepsy, thyroid disease, tuberculosis and asthma should be elicited.
History of previous surgery / History of trauma / History of chronic drug intake / hostpitalisation.
Personal history:
Smoking / alcohol / drug abuse
History of diet
History of allergy
Family history: Any relevant details should be noted. Otosclerosis is considered to be familial.
History of bleeding disorders / History of consanguineous marriage.

Examination of Ear:
1. Preauricular region: Presence of preauricular sinus, preauricular lymphadenitis, scar due to previous surgery if any should be noted. Preauricular sinus is usually bilateral.
2. Post auricular region: Should be examined for the presence of scar of previous mastoid surgery (Wild's incision), post auricular lymphadenitis, cystic swelling in the post aural region. Mastoid tenderness if any should be noted.
3. External auditory canal: should be examined by straightening it. In adults the pinna will have to be pulled downwards, outwards and laterally to straighten the external canal. Presence of wax should be noted.
(* presence of wax is normal *). Look for evidence of fungal infections (otomycosis). Whitish wet plaques are seen in candida infections, Blackish plaques indicate aspergillus niger infections. Look for evidence of furuncle in the external auditory canal. Pressure is applied over tragus to elicit tragal tenderness sign. This is an important sign for otitis externa.
Examiantion of ear drum:

Color of the drum is noted. Normally it is pearly white in color.
A red drum is seen in:
Acute otitis media
Perforation if any is noted. A small pin hole perforation with a pulsatile ear discharge is seen in Acute suppurative otitis media (Light house sign).
The quadrants involved in the perforation should be illustrated.
Discharge if any is cleaned by dry mopping. If it is foul smelling it could indicate unsafe ear. The color of the discharge and quantity is also noted.
If perforation / cholesteatoma flakes are seen in the attic region then it indicates unsafe ear.



Right ear drum.

Look for the cone of light arising from the umbo and pointing towards the anteroinferior quadrant. The cone of light may be distorted in retracted ear drum.

Features of retracted ear drum are:
1. Distorted cone of light
2. Prominence of lateral process of malleus
3. Apparent foreshortening of handle of malleus
4. Mobility of ear drum appears to be restricted


Diagram of left ear drum

If there is perforation the middle ear seen through the perforation is studied and the mucosal changes if any are noted.

Tests for hearing:
Tuning fork tests are performed. Frequencies used include 256 Hz, 512 Hz and 1024 Hz. Among these three frequencies 512 Hz is preferred because it closely matches the human speech frequency.
Tuning fork tests performed include:
Rinne's test
Weber's test
ABC test

Examination of nose and throat are also performed with special emphasis to rule out evidence of focal sepsis.
General examination should also be performed.

Final diagnosis should include:
Side of the disease.
Whether the disease is in active / inactive stage.
Whether the disease is tubotympanic / atticoantral type.
Type of perforation.
Type & degree of deafness.