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Pre and intraoperative findings of chronic otitis media

Chronic otitis media (COM) is still highly prevalent in developing countries and often become main cause of deafness and morbid complication. Appropriate management may decrease the morbidity and mortality rate. The aim of the study are to evaluate preoperative and intraoperative finding among COM patients. A descriptive study was conducted at Mohammad Hoesin Hospital Palembang from April 2015 to April 2018. A secondary data was taken from medical records. A total of 252 patients were included in this study with the highest incidence was at 21-30 years old group (29,36 %) with male predominance. The most frequent preoperative assessment were total perforation of tympanic membrane in 104 patients (41.26 %), moderately severe mixed hearing loss in 61 patients (24,2%), and mastoiditis with cholesteatoma in computed tomography (CT) finding in 158 patients (62,69 %). In intraoperative finding, there were 202 patients (80,15%) with cholesteatoma whereas 103 patients (40,87 %) with granulation tissue. Ossicular chain destruction were found in 141 patients (55,95 %). Canal Wall Down Mastoidectomy (CWD) were performed in 190 patients (75,39 %). The prevalence of COM with cholesteatoma at Mohammad Hoesin hospital is still high. Operative management using CWD technique is preferred in cases of COM with cholesteatoma.


Introduction
Otitis media is an infection and inflammation of the middle ear. Otitis media is a common disease and generally occurs in developing countries. A study showed that approximately 80% had children already suffered otitis media at least one time in their first 3 years of age. Otitis media are divided into two types, acute and chronic. Acute otitis media is characterized by an acute inflammatory process, with symptoms of otalgia, fever, and ear discharge, whereas, chronic otitis media (COM) is characterized by persistent discharge from middle ear with perforated tympanic membrane for more than 3 months. COM involves 65-350 million individuals worldwide especially in developing countries. It is estimated that there are 31 million of new cases of COM each year. Mahdevan et al reported COM prevalence in Indonesia was 5.4% and in Thailand, Philippines, Malaysia and Vietnam ranged from 2 to 4% compared to 0.01-0.03/1000 cases in America. Anggraeni R et al reported 3.4% out of 7005 children had COM in Indonesia [1-3].
COM is diagnosed by anamneses and physical examination. From anamneses, complaints of ear discharge accompanied by hearing loss, otalgia, tinnitus, and vertigo are obtained. Perforated tympanic membrane is shown on otoscopy examination and pocket retraction with granulation tissue could also be found. Radiology imaging with high resolution CT of temporal bone can provide information of ossicular chain, facial nerve, semicircular canal, and pathological tissue in the middle ear [4]. Management of COM is done conservatively with antibiotic ear drops and aural toilet. Operative management in COM is the final treatment when COM failed to respond to the conservative management, in cases of complication, such as facial nerve paresis, subperiosteal abscess, petrositis, sinus venosus thrombosis, and other complications. There are two common surgical approaches in managing COM with or without cholesteatoma. These approaches are Canal Wall Up Mastoidectomy (CWU) and Canal Wall Down Mastoidectomy (CWD) [4,5].
Preoperative general characteristics, audiometry, imaging, and intraoperative findings in COM patients are varied. This study aimed to describe the preoperative and intraoperative finding in COM patients at Mohammad Hoesin Hospital Palembang.

Methods
This is a descriptive study using a secondary data of medical records of patients who underwent COM surgery in ENT department Mohammad Hoesin Hospital Palembang from April 2015 to April 2018. Data on age, sex, operated ear, otorrhea duration, perforation type, hearing loss type, computed tomography features, surgery type, intraoperative findings, cholesteatoma stage, ossicular condition, and duramater condition.
The inclusion criteria were all COM patients underwent surgery at the ENT Department of Mohammad Hoesin Hospital Palembang from April 2015 to April 2018. Exclusion criteria were COM patient who did not have a complete medical records data. All data were collected and presented in descriptive form of tables and diagrams.

Results
This study involved 252 patients consisting of 141 men and 111 women. The youngest age in this study was 5 years old, while the oldest age was 95 years old. The highest age group was 21-30 years old (29,36%) while the least was > 60 years old (1,59%) (see table 1).
A total of 114 patients (45,23%) underwent surgery on the right ear and 138 patients (54,76%) had surgery on the left ear. Based on the duration of otorrhea, it was found that most of the patients had been complaining of otorrhea for >5 years 100 patient (39,68%) and fewer patients had otorrhea over a period of >1 year to < 3 years 39 patients (15,47%). From the otoscopy, 104 patients (41,26 %) with total perforation of tympanic membrane were the most frequent while only 1 patient (0,39%), with marginal type was the least.
Intraoperatively, there were 141 patients (55.95%) with ossicular destruction and 111 patients (44.05%) with intact ossicular chain. Most of the patients presented with Austin Kartush D type (48.8%) while the least was B type (3.51%) (see figure 4). In this study, more surgeries were performed on the left ear (54.76%) with the otorrhea duration >5 years (39.68%). The most common type of perforated tympanic membrane was total perforation (41.26%). Kolo et al found that the right ear operations are more common than the left ear with an average duration of 6 years otorrhea. Thakur et al found that from 172 COM cases, the most common were total perforation (50%), followed by subtotal perforation (43.6%) and small center perforation (6.39 %). Aquino et al conducted a study on 1146 patient of COM and found that the perforation is most likely to occur were attic perforation (59.9%), followed by marginal perforation (13.7%), total perforation (13.2%) and central perforation (13.3%) [1,6,8].   Additional examinations used to evaluate COM, were plain X-ray, computed tomography (CT) and magnetic resonance imaging (MRI). However, CT is the gold standard imaging examination to diagnose COM. High resolution CT can provide information on the range of ossicular chain, facial nerve, semicircular canal, and pathological tissue in the middle ear. However, CT has not been able to  12,13].

Discussions
The aim of surgical treatment of COM with cholesteatoma is to eradicate the disease, to maintain the existing hearing function, and normal ear structure preservation. There are two types of surgical techniques used in COM with cholesteatoma, such as Canal Wall Down (CWD) and Canal Wall Up (CWU). CWD is a mastoidectomy procedure that is still preferred in COM in developing countries due to cholestheatoma. The advantages of CWD are superior access to middle ear, especially with broad cholesteatoma, rarely requires a second surgery, and the reccurence rate is considerably low.  Cholesteatoma is a cyst lesion formed by abnormal accumulation of keratinized squamous epithelium in the middle ear, epitympanum, mastoid cavity, petrous apex, or temporal bone. Invasive cholesteatoma growth may cause destruction of the middle ear. Theories of the main pathogenesis of cholesteatoma included 1) Invagination (retraction pocket); 2) Invasion or epithelial migration; 3) Squamous metaplasia; 4) Papillary ingrowth of the hyperplasia. Bluestone classification furtherly classify choleasteatoma based on the location and the invasion. The classification consists of stage 1: Cholesteatoma is confined to the middle ear (hypoepitympanum and mesoepitympanum), without erosion of ossicular chain; Stage 2: Stage 1 but with erosion of one or more ossicles, stage 3: middle ear and mastoid gas cell system are involved without erosion of ossicles, stage 4: same as stage 3 but with erosion of one or more ossicles, stage 5: extensive cholesteatoma of the middle ear, mastoid, and other portions of the temporal bone, the extent of which in not totally accessible to surgical removal 14 6 (e.g., medial to labyrinth), with one or more ossicles involved. fistula of labyrinth may or may not be present. and stage 6: same as stage 5, but cholestheatoma extends beyond the temporal bone. Abdullah et al reported that 57% of the study population were found with cholesteatoma, 21% with cholesteatoma and granulation tissue, and 22% without both. In our study, there were 103 patients

Conclusions
The prevalence of COM with cholesteatoma ini our center is still high, especially in adolescent and adults. Operative management using CWD technique is preferred in cases of COM with cholesteatoma. Increasing public awareness about the dangers of COM by actively educating and counseling can prevent further complications.