Chronic otitis media is recurrent or persistent infection of the middle ears.  The middle ear space is the area between the eardrum and the inner ear.  It is normally an air containing space, which houses the ossicles (small bones of hearing).  This space is connected to the nasopharynx (back of the nose) through the eustachian tube.  It extends posteriorly into the mastoid cavity.  When there is a dysfunction of, the eustachian tube, air cannot fill the middle ear.  This creates a negative pressure, which can lead to fluid build-up in the middle ear, infection of the middle ear, retraction of the eardrum, and/or a perforation of the eardrum.  Major causes of  eustachian tube dysfunction include:  immature eustachian tube development in the child, the common cold, allergic rhinitis, non-allergic rhinitis, acute or chronic sinusitis, adenoid hypertrophy, and nasopharyngeal tumors.  If the function the eustachian tube does not improve, chronic otitis media will develop in one of three forms; recurrent acute otitis media, chronic secretory otitis media or chronic otitis media with a perforation, retraction pocket or cholesteatoma.

Acute otitis media is characterized by ear pain, fever, conductive hearing loss, and sometimes ear drainage.  It is extremely common in childhood, but may affect adults as well.  Acute otitis media should be treated with an antibiotic and a decongestant.  Amoxicillin is the first choice in non-allergic individuals, with Bactrim reserved for Penicillin allergic individuals.  Sudafed is a good decongestant.  The hallmark of recurrent acute infections is that the symptoms improve with antibiotics and decongestants, only to recur again shortly after stopping the medications.  Subsequent infections should be treated with progressively broader spectrum antibiotics, such as Cedax or Suprax, Augmentin or Zithromax.  Myringotomy tubes should be considered when one of the following occurs:  seven infection in one year, five infections per year for two years, three infections per year for three or more years.

Chronic secretory otitis media is the condition of persistent fluid in the middle ears.  This generally leads to discomfort in the ears, a mild conductive hearing loss, balance disorders, and eventually speech delay, if untreated.  Again this should be treated with an antibiotic and a decongestant.  Amoxicillin is the first choice in non-allergic individuals, with Bactrim reserved for Penicillin allergic individuals.  Sudafed is a good decongestant.  Persistent fluid should be treated with progressively broader spectrum antibiotics such as Cedax, Suprax, Augmentin or Zithromax.  Myringotomy tubes should be considered when at least three antiobiotics, including a broad spectrum choice, have been tried for at least two weeks in each, and middle ear fluid persists.

If eustachian tube dysfunction persists, a perforation of the eardrum, a retraction of the eardrum, or cholesteatoma (skin trapped in the middle ear or mastoid) may develop.  These may lead to serious problems such as erosion of the ossicles, severe conductive hearing loss, ear drainage, ear pain, facial weakness, vertigo, sensorineural hearing loss, meningitis, and brain abscess.  Small retraction pockets may be treated with myringotomy tubes.  Perforations, large retraction pockets and cholesteatoma require an outpatient operation called tympanoplasty.  If the cholesteatoma involves a mastoid cavity, a mastoidectomy will also be necessary.  It is imperative that the cause of the eustachian tube dysfunction be treated (ie allergic rhinitis with allergy shots), or the risk of recurrent middle ear disease requiring revision surgery is high.