European Journal of Cardiovascular Medicine

Chronic suppurative otitis media (CSOM) is defined as a chronic inflammation of the middle ear and mastoid cavity, characterised by recurrent or persistent ear discharge through a non-intact tympanic membrane, typically of more than 2 to 6 weeks' duration.1 It is one of the oldest and most prevalent diseases described in otology and remains a major public health problem in developing countries, including India, owing to poor nutrition, overcrowding, low socioeconomic status, and inadequate access to healthcare.2

The World Health Organisation has recognised CSOM as a significant cause of preventable hearing impairment, especially in children, and has emphasised the need for community-based ear care programmes in high-burden countries.3 Indian community-based surveys conducted prior to 2017 have reported a prevalence of CSOM ranging from 4.6% to 8.3% in the general population, with a higher burden noted among school-going children and those residing in rural and peri-urban areas.4 Gupta and Mittal, in a hospital-based study on the clinical and epidemiological profile of CSOM at a tertiary care centre, observed that the disease was most common in the second and third decades of life, with the tubotympanic variety accounting for the majority of cases.5

CSOM is broadly classified into two types – tubotympanic (safe) type, which involves the pars tensa and is generally associated with a central perforation and mucosal disease, and atticoantral (unsafe) type, which involves the pars flaccida, is often associated with cholesteatoma, and carries a higher risk of complications such as ossicular erosion, labyrinthine fistula, facial nerve palsy, and intracranial spread.6 Aerobic bacteriological studies from various parts of India conducted before 2017, including from Uttarakhand, Rajasthan, and other tertiary centres, have consistently identified Pseudomonas aeruginosa and Staphylococcus aureus as the predominant organisms isolated from ears with active discharge, with a variable degree of antibiotic resistance being reported.7

Despite being largely preventable and treatable, CSOM continues to contribute significantly to the burden of hearing loss in India, and untreated or inadequately treated disease can progress to serious, occasionally life-threatening, intracranial and extracranial complications.8 There is a paucity of updated hospital-based data from many regions of the country describing the current clinical and demographic profile of patients with this condition. The present retrospective study was therefore undertaken to analyse the clinical profile, otoscopic findings, and pattern of presentation of patients with CSOM attending the outpatient department of a tertiary care hospital, with the aim of generating locally relevant data that may help guide screening, treatment protocols, and preventive strategies.

Study design and setting: This was a hospital-based retrospective observational study conducted in the Department of Otorhinolaryngology (ENT) at Venkateshwara Institute of Medical Sciences, Gajraula over a period of  January 2019 to December 2019.

Study population: The case records of all patients clinically diagnosed with chronic suppurative otitis media, presenting to the outpatient department during the study period, were retrieved and reviewed. A total of 200 cases satisfying the inclusion and exclusion criteria were included in the final analysis.

Inclusion criteria:

• Patients of either sex and any age group with a clinical and otoscopic diagnosis of CSOM (persistent or recurrent ear discharge for more than 6 weeks through a non-intact tympanic membrane).
• Complete and legible case records with adequate demographic and clinical data.

Exclusion criteria:

• Patients with acute otitis media or otitis externa.
• Incomplete or illegible case records.
• Patients who had undergone prior ear surgery at another centre with unavailable operative details.

Data collection: Relevant data were extracted using a pre-designed proforma from case sheets, outpatient records, and audiometric charts, including age, sex, residence (urban/rural), laterality (unilateral/bilateral), duration of symptoms, character of ear discharge (mucoid/mucopurulent/ purulent, foul-smelling or odourless), type of CSOM (tubotympanic or atticoantral), tympanic membrane perforation site and size, associated symptoms (otalgia, tinnitus, vertigo), degree and type of hearing loss on pure tone audiometry, and presence of any complications.

Statistical analysis: Data were entered into Microsoft Excel and analysed using appropriate statistical software (e.g., SPSS version 26). Descriptive statistics were used to express categorical data as frequencies and percentages, and continuous data as mean ± standard deviation. The Chi-square test was used to assess association between categorical variables, with a p-value of <0.05 considered statistically significant.

Ethical considerations: The study was conducted after obtaining approval from the Institutional Ethics Committee. As this was a retrospective record-based study, the requirement for individual informed consent was waived by the committee, and patient confidentiality was maintained throughout.

A total of 200 patients diagnosed with chronic suppurative otitis media were included in this study.

Table 1: Age and sex distribution of study population (n = 200)

Table 2: Laterality and residence of patients

Table 3: Type of CSOM and character of ear discharge

Table 4: Site of tympanic membrane perforation (tubotympanic group, n = 152)

Table 5: Type and degree of hearing loss on pure tone audiometry

Table 6: Associated complications (n = 200)

The most common age group affected was 21–30 years, with an overall male preponderance. Unilateral involvement was more common than bilateral disease, and a majority of patients belonged to rural areas. The tubotympanic type was seen in the majority of patients, with mucoid, non-foul-smelling discharge being the predominant presentation. Conductive hearing loss of moderate degree was the most frequently observed audiometric finding. Complications, though seen in a minority of patients, were more frequent among those with the atticoantral variety of disease.

The present hospital-based retrospective study found that CSOM predominantly affected patients in the second and third decades of life, a finding that is consistent with earlier Indian hospital-based studies. Gupta and Mittal, in their study on the clinical and epidemiological profile of CSOM at a tertiary care centre, similarly reported a peak incidence in the younger age groups, attributing this to greater exposure to upper respiratory tract infections and poor ear hygiene practices in this population.5 The slight male preponderance observed in the present study is comparable to observations from other Indian series, which have been attributed to greater outdoor exposure and delayed health-seeking behaviour among male patients in certain community settings.

The predominance of the tubotympanic (safe) type of CSOM over the atticoantral (unsafe) type in the present study is in agreement with earlier Indian hospital-based and community-based studies, which have consistently reported the tubotympanic variety to be more common, generally accounting for two-thirds to three-fourths of cases.4 Saini et al., in their bacteriological study of paediatric and adult CSOM, similarly noted that mucosal (tubotympanic) disease with mucoid or mucopurulent discharge was more frequently encountered than squamosal (atticoantral) disease in Indian patients presenting to tertiary care centres.9 This distribution has important clinical implications, as the tubotympanic type generally responds well to conservative medical management, whereas the atticoantral type more often requires surgical intervention due to its association with cholesteatoma and higher complication rates.

With regard to microbiological correlation, although the present study was primarily clinical in nature, earlier Indian studies conducted on the bacteriological profile of CSOM – including from tertiary care centres in Uttarakhand and other regions – have consistently identified Pseudomonas aeruginosa and Staphylococcus aureus as the predominant aerobic organisms isolated from discharging ears, underscoring the importance of a rational, locally-validated antibiotic policy for empirical treatment of CSOM.7 The predominance of conductive hearing loss in the present study is expected, given that the disease primarily affects the sound-conducting mechanism of the middle ear through tympanic membrane perforation and/or ossicular involvement; the smaller proportion of patients with sensorineural or mixed hearing loss likely reflects cochlear involvement secondary to long-standing infection or ototoxicity.

The relatively low overall complication rate observed in this study is reassuring and may reflect reasonably timely presentation of patients to the hospital; however, the fact that complications such as mastoiditis, facial nerve palsy, and intracranial spread were still encountered, albeit infrequently, reaffirms the importance of early diagnosis and treatment of CSOM, particularly in patients with the atticoantral variety.8 The higher proportion of patients from rural backgrounds in this study is consistent with the higher disease burden reported from rural and peri-urban Indian populations in earlier community-based surveys, and highlights the continuing need for community-level ear health education, hearing screening programmes, and improved access to ENT care in underserved areas.3

Limitations

This study has certain limitations inherent to its retrospective design, including reliance on the completeness and accuracy of existing case records, absence of long-term follow-up data, and the single-centre hospital-based setting, which may not be fully representative of the general population. Prospective, multicentric studies with longer follow-up, along with microbiological and radiological correlation, would help to further characterise the disease burden and outcomes of CSOM in the Indian population.

Chronic suppurative otitis media continues to affect a predominantly young population in the productive age group, with a slight male preponderance and a higher burden among patients from rural areas. The tubotympanic (safe) type remains more common than the atticoantral (unsafe) type, and conductive hearing loss is the most frequent audiometric abnormality. Although the overall complication rate was low, the occurrence of serious complications in a small proportion of patients underscores the need for early diagnosis, prompt and appropriate treatment, and sustained public health efforts towards ear health education and screening, particularly in high-risk rural and paediatric populations, in order to reduce the preventable burden of hearing loss due to CSOM in India.

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