a-clinicopathological-and-microbiological-study-of-chronic-otitis-media.pdf

Otolaryngology Open Access Journal
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A Clinicopathological and Microbiological Study of Chronic Otitis Media Otolaryngol Open Access J
A Clinicopathological and Microbiological Study of Chronic Otitis
Media
Prashanth N1
*, Rathi A2
, Jain R1
, Ahmed R3
, Gauri HA4
and Bhardwaj V3
1
Assistant Professor, Department of Otolaryngology, Head and Neck Surgery, Jaipur National
University, India
2
Associate Professor, Department of Otolaryngology, Head and Neck Surgery, Jaipur National
University, India
3
Senior Resident, Department of Otolaryngology, Head and Neck Surgery, Jaipur National
University, India
4
Junior Resident, Department of Otolaryngology, Head and Neck Surgery, Jaipur National University, India
*Corresponding author: Prashanth N, Assistant Professor, Department of Otolaryngology, Head and Neck Surgery, Jaipur
National University, Jaipur, Rajasthan, India, Tel: 8056292642; Email: prasi39@gmail.com
Research Article
Volume 9 Issue 1
Received Date: March 22, 2024
Published Date: May 31, 2024
DOI: 10.23880/ooaj-16000292
Abstract
Objective: To determine both tubotympanic and atticoantral disease in active chronic otitis media. To identify the
microbiological species that cause these two categories, as well as their sensitive medications, by culture and sensitivity
testing.
Methods: This was a prospective observational cross-sectional study conducted on Fifty Chronic otitis media patients from
the Department of Otorhinolaryngology at Jaipur National University during November 2021 to October 2023. An assessment
of the clinical presentation and course of Chronic otitis media and analysis of the microbiological etiology of the disease was
done. Clinical assessment included history taking, physical examination, and audiometric testing. Microbiological analysis
included culture and susceptibility testing and molecular testing.
Results: Fifty Chronic otitis media patients were included in the study and studied over the course of two years. There were
22 males and 28 females. The most common bacterial etiologies of Chronic otitis media were Streptococcus pneumoniae,
Pseudomonas aeruginosa, and Staphylococcus aureus. A mucopurulent type of discharge was seen in most pseudomonas
infections (50%). Acinetobacter (100%) and Staphylococcus (75%) both mostly discharged mucopurulent material.
Conclusion: These results provide insight into the management of Chronic otitis media and highlight the importance of proper
diagnosis and treatment of the condition.
Keywords: Clinicopathological; Microbiological; Chronic Otitis Media; Otolog
Abbreviation: COM: Chronic Otitis Media. Introduction
Chronic otitis media (COM) is a common condition that
affects the middle ear and is characterized by a chronic

2
Prashanth N, et al. A Clinicopathological and Microbiological Study of Chronic Otitis Media.
Otolaryngol Open Access J 2024, 9(1): 000292.
Copyright© Prashanth N, et al.
inflammation and accumulation of fluid in the middle ear,
accompanied by frequent ear infections [1]. COM is a chronic
and progressive condition, and is one of the most common
causes of hearing impairment and deafness in children. It
is also one of the most frequent causes of hospitalization
in childhood, and can lead to long-term complications if
left untreated [2]. The middle ear is a small space located
between the outer ear and the inner ear, and is responsible
for transmitting sound waves from the outer ear to the
inner ear. In COM, the infection and inflammation of the
middle ear causes a build-up of fluid and pus in the middle
ear, resulting in hearing loss [3]. Otitis Media is caused by
bacteria, viruses, or fungi and can be classified into two
types: acute and chronic. Acute otitis media is caused by a
single episode of infection that may last for a short period
of time, while chronic otitis media is caused by recurrent
episodes of infection that can lead to complications if left
untreated [4]. The symptoms of COM vary depending on the
severity of the condition, but may include earache, a feeling
of fullness in the ear, drainage from the ear, hearing loss, and
dizziness [5]. Treatment for COM may include antibiotics to
fight the infection, cleaning of the ear canal, and surgery
to repair any damage caused by the infection. In addition,
hearing aids may be prescribed to help with sensorineural
hearing loss caused by COM [6].
COM is a common condition that affects the middle
ear and can be a source of hearing loss and deafness in
children [7]. It is important for parents to be aware of the
signs and symptoms of COM and to seek prompt medical
attention if they suspect their child may be suffering from
it [8]. Early diagnosis and treatment can help to reduce
the risk of complications and long-term hearing loss [9]. In
underdeveloped nations SM Sc & Gupat H [10,11], COM is
more prevalent. In our country, the disease impact is too high
due to the huge population. The prevalence of COM ranges
from 65 to 330 million per year worldwide [12]. Southeast
Asia, Western Pacific, and African nations are said to bear the
majority of the global COM impact [13].
India is among the nations with the highest prevalence
rates (prevalence > 4%) [14]. Communities with high
rates of overcrowding, poor personal hygiene, and low
socioeconomic level are more likely to have COM [15,16].
Due to better housing conditions and the extensive use
of antibiotic medication, the incidence of COM has been
dropping [17]. Some authors conducted studies on COM
Chandrashekharayya SH, et al. [18]. According to one of the
authors, histological studies of the mucosa of the middle ear
were performed on 100 people diagnosed with COM [19].
The findings were consistent with chronic inflammation,
with lymphoplasmacytic infiltrations accounting for the
majority of the abnormalities [20].
Granulation tissue was associated with mucopurulent
discharge in a small number of cases [13]. Granulation tissue
patients are more susceptible to ossicular necrosis [21].
By obtaining an ear swab for culture, sensitivity testing
and treating the patient in accordance with the culture report
[22], the current research seeks to identify the organisms
that are the cause of COM. Analyses and studies are done on
the treatment’s reaction.
Materials and Methods
This was a prospective observational cross-sectional
study conducted on Fifty COM patients of various genders
and ages in the Department of Otorhinolaryngology at
Jaipur National University from November 2021 to October
2023. The study was conducted after getting prior approval
from institutional ethics committee. Informed consent was
obtained from the all patients and were randomly recruited
for the research. Demographic data pertaining to age, sex,
diagnosis was noted.
Inclusion Criteria
All instances of middle ear discharge lasting longer than
three months.
Exclusion Criteria
Conditions that resemble COM includes Otitis externa and
Acute otitis media.
History Taking and Examination Criteria
Each patient’s age, sex, residence, and clinical data,
including major complaints, duration of symptoms,
predisposing factors, and any prior therapy, were recorded on
a case record form. The patient’s medical history also included
diabetes, hypertension, and Tuberculosis, among others.
Sample Collection
In clinically identified instances of CSOM, ear discharge
was collected using aseptic care. The external auditory
canal was wiped free of excess discharge. The specimen
was then obtained using a sterile swab and forwarded to
the Microbiology Department with a request for culture and
sensitivity.
Assessment through Direct Smear
A thin smear was prepared on a clean glass slide at the
Microbiology Department, and the smear was fixed with 95%

3
methanol by pouring one or two drops into the smear and
letting it sit for at least 2 minutes or until the methanol dried.
The prepared smears were Gram stained and studied
using an oil immersion objective to identify the kinds of
bacteria present, the number of bacteria, the Gram response,
the presence or absence of inflammatory cells, and the
percentage of squamous epithelial cells in the sample.
Aerobic Culture
To inoculate blood agar, nutritional agar, and MacConkey
agar plates, the discharge was utilized. All the plates were
placed in an aerobic environment and heated to 37 degrees
Celsius. After 24 hours, 48 hours, and 72 hours, the plates
were inspected for signs of development and discarded if no
growth was found.
Standard laboratory approaches were applied to identify
bacterial pathogens based on their microscopic appearance,
staining features, cultural and biochemical properties.
Figure 1: Antibiotic Susceptility Test.
Figure 2: Showing the Distribution of Patients According
to Age and Sex.
Using the Kirby-Bauer disc effusion technique, the
sensitivity of bacterial isolates to frequently used antibiotics
was determined. The concentrations of antibiotics used
were: A-10 mg, Ak – 30 mg, Cb – 100 mg, Ci – 30mg.
Figure 3: Showing the Distribution of Patients According
to Age and Type of CSOM.
Figure 4: Showing Types of Organisms Found in Ear
Discharge.
Figure 5: Showing type of Organisms Vs Type of COM.

4
Figure 6: Showing Types of Organisms Vs Types of
Discharge.
Results
Fifty CSOM patients of various genders and ages were
included in the study. There were 22 males and 28 females.
50 cases were chosen at random and studied over the course
of two years. Demographic details of patients were illustrated
in Table 1.
Age in year Male % Female %
0 – 5 0 0 2 7.14
6 – 10 1 4.55 0 0
11 – 20 4 18.2 6 21.4
21 – 30 7 31.8 6 21.4
31 – 40 3 13.6 7 25
41 – 50 3 13.6 4 14.3
51-60 3 13.6 2 7.14
61-70 1 4.55 1 3.57
Total 22 100 28 100
Table 1: Showing the Distribution of Patients According to
Age and Sex.
Age in year Tubo-tympanic % Atticoantral %
0 – 10 3 8.11 0 0
11 – 20 6 16.2 4 30.8
21 – 30 9 24.3 4 30.8
31 – 40 9 24.3 1 7.69
41 – 50 4 10.8 3 23.1
51 – 60 4 10.8 1 7.69
61 – 70 2 5.41 0 0
Total 37 100 13 100
Table 2: Showing the Distribution of Patients According to
Age and Type of COM.
A mucopurulent type of discharge was seen in the
majority of pseudomonas infections (50%).
Acinetobacter (100%) and Staphylococcus (75%) both
mostly discharged mucopurulent material.
Infection with Klebsiella (66.67%) and E. coli (50%)
often resulted in mucoid discharge. It is fascinating to learn
thatmucoiddischargewaspresentineverycaseofnogrowth.
The link between bacteria and discharge was evaluated using
chi square, and it was shown to be statistically nonsignificant.
Pseudomonas has a high sensitivity to A (84.6), Cb
(69.2%), and Ak (65.4%), with a maximum sensitivity to
Ci (92.3%). S. aureus has high sensitivity for Ak (75%).
Klebsiella has high sensitivity to Ci and A. (both being 83.3%).
Acinetobacter has 50% sensitivity to A, Ak, Ci, and Cb.
Coagulase negative staphylococcus had 100% sensitivity to
Ak and high sensitivity to A. Proteus shown great sensitivity
to Ak, Cb (66.7%), as well as 100% sensitivity to Cf and A. Ak,
Cf, A caused 100% sensitivity in E. coli.
Total number of ears examined – 59 (Table 3)
Organisms Number of discharges Percentage
P. aeruginosa 26 44.06
S. aureus 15 25.4
Klebsiella 5 8.4
E. Coli 3 5.08
Proteus 3 5.08
Acinetobacter 1 1.69
No growth 5 8.4
Commensal 1 1.69
Total 59 100
Table3:ShowingTypesofOrganismsFoundinEarDischarge.
Some patients had more than one ear discharge, and
each one was tested for bacteria separately. P. aeruginosa
was found to be the most common bacterial infection
(44.06%) among the patients. The least number of bacteria
was Acinetobacter (1.69%). It is interesting to know that
about 8% of the discharges didn’t have any bacteria.
Majority of the infection among the study patients had
tubo-tympanic disease (74%). Majority of the organisms
were Gram negative organisms (68%) and Gram positive
were (27%). 13% of the infection did not have any growth
(Table 4).

5
Bacteria Tubo-tympanic disease Percentage Attico-antral disease Percentage
P. aeruginosa 17 42.5 6 42.86
S. aureus 11 27.5 4 28.57
Klebsiella 3 7.5 2 14.29
Acinetobacter 0 0 1 7.14
Proteus 3 7.5 0 0
E. coli 1 2.5 0 0
Commensal 1 2.5 0 0
No growth 4 10 1 7.14
Total 40 100 14 100
Table 4: Showing Type of Organism’s Vs Type of COM.
Discussion
A clinical, pathological and microbiological study of
active chronic otitis media was conducted to gain insights
into the etiology, pathogenesis, and clinical outcomes of
this inflammatory ear condition. Results showed that the
most common bacteria isolated from the middle ear fluid
were Streptococcus pneumonia, P. aeruginosa, S. aureus, and
Klebsiella. In addition, a high prevalence of fungal species
was also observed. Moreover, the study identified several
risk factors, including age, immunosuppression, and chronic
illness, that may increase a person’s risk of developing
COM. The findings of this study can be used to improve the
diagnosis, management, and prevention of COM. Moreover,
the results can be used to support the development of new
therapies to reduce the burden of this disease (Table 5).
Gram positive organisms No. Percentage Gram Negative organisms No. Percentage
S.aureus 15 93.75 P.aeruginosa 23 67.65
Acinetobacter 1 6.25 Klebsiella 5 14.71
- - 0 E. Coli 3 8.82
- - 0 Proteus 3 8.82
Total 16 100 Total 34 100
Table 5: Showing Distribution of Gram Positive and Gram-Negative Organisms.
In the developing world, chronic otitis media is
regarded as a significant public health issue, and India is one
of the countries with a high prevalence where immediate
attention is required. It is a chronic condition that carries
the potential of developing permanent consequences and
is a significant contributor to avoidable hearing loss in both
adults and children. Early microbiological identification
promotes efficient therapy since chronic otitis media is a
condition that has severe morbidity. Therefore, identifying
infections and their pattern of antibiotic sensitivity will
aid treating doctors in choosing the proper medications,
therefore reducing complications and the emergence of
resistance strains (Table 6).
Organisms Muco-purulent discharge % Purulent discharge % Mucoid discharge %
Pseudomonas 15 50 3 38 5 27.8
S. aureus 10 33.3 3 38 2 11.1
Klebsiella 2 6.67 0 0 3 16.7
E. coli 1 3.33 1 13 1 5.56
Proteus 1 3.33 1 13 1 5.56
Acinetobacter 0 0 0 0 1 5.56
No growth 0 0 0 0 5 27.8
Commensal 1 3.33 0 0 0 0
Total 30 100 8 100 18 100
Table 6: Showing Types of Organisms Vs Types of Discharge.

6
Because the bacteria that cause middle ear infections are
becoming less sensitive to antibiotics and their patterns are
changing, it has become very important to find the organism
that is causing the disease. In this study, the number of
people with COM was highest among those aged 11 to 20
(42%), then among those aged 0 to 10 (28%). Poorey V.K.
and Iyer A.2’s (2002) study found that the most common age
groups were the first and second decades of life, with the
1–10year age group being the most common (46%), which
is different from our study [23]. In this study, 68% of the
CSOM participants were men and 32% were women. This
shows that COM happens in both sexes. The number of men
to women was 2.1 to 1, which suggests that men were more
common. In the current study, the disease was found to be
more common in the low-income group (62%) than in any
other group in society. Our study has some limitations, such
as a limited sample size.
Conclusion
59 ears were examined out of 50 cases. In the present
collection, only aerobic bacteria were isolated. The most
prevalent organism isolated was P. aeruginosa, which
was found in 26 (44.06%) samples, followed by S. aureus
15 (25.4%), Klebsiella in 5, E. coli in 3, Proteus in 3, and
Acinetobacter in 1. Five (8.4%) of the discharge samples
exhibited no growth, while one (1.69%) contained
commensal. In the modern time of antibiotics, antibiotic
resistance is becoming more prevalent. Human ignorance
is the most major contributor to the evolution of antibiotic
resistance. As soon as symptoms lessen, people cease taking
antibiotics prior to the conclusion of treatment, allowing
partly resistant microorganisms to thrive. Such conduct
should be discouraged, and patients should be instructed to
avoid it.
Therefore, it is crucial that each case of COM should be
investigated bacteriologically to avoid the use of unnecessary
antibiotics. This will undoubtedly aid in getting a dry ear and
avoiding difficulties.
Sources of Financial Support
None
Conflict of Interest Statement
The authors declare no conflict of interest.
Ethical Standards
The authors assert that all procedures contributing
to this work comply with the ethical standards of the
relevant national and institutional guidelines on human
experimentation (Indian- GCP, ICH-GCP, ICMR guidelines)
and with the Helsinki Declaration of 1975, as revised in 2008.
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