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Year : 2021  |  Volume : 27  |  Issue : 1  |  Page : 22-25

Chronic suppurative otitis media and microbial flora: Adult versus pediatric population

1 Department of ENT, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Microbiology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission11-Jun-2020
Date of Acceptance04-Aug-2020
Date of Web Publication26-Oct-2021

Correspondence Address:
Dr. Anitya Srivastava
Department of ENT, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.INDIANJOTOL_128_20

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Context: Chronic suppurative otitis media (CSOM) is an inflammatory condition of the middle ear which manifests as recurrent episodes of ear discharge. Due to the inappropriate use of antibiotics, the microbiological profile and the drug sensitivity pattern is changing, leading to either inadequate treatment or recurrence. Hence, there is a need to study the microbial profile and its sensitivity pattern in order to initiate the appropriate treatment. Aim: The study has been done to evaluate the microbiological profile of ear discharge in patients of CSOM and also to assess any difference in the microbiology in the adult and pediatric population. Setting and Design: A cross-sectional record-based study was conducted in a tertiary care hospital in North India on patients diagnosed to have tubotympanic type of CSOM. Materials and Methods: The study duration was 12 months. Sterile swabs were collected from the study individuals. The organisms were isolated using the standard microbiological methods and antimicrobial susceptibility test was performed using diffusion method. Statistical Analysis: Descriptive statistics were used. Appropriate parametric and nonparametric tests were applied to assess the association between various variables. Results: Amongst children, the most common isolate was Staphylococcus aureus and this was followed by Proteus mirabilis and Pseudomonas aeruginosa. Among adults, the most common organism was P. aeruginosa and this was followed by S. aureus. Conclusion: Age, environmental, and geographical conditions of an individual affect the microbiological profile. Antibiotic therapy administered in accordance to the sensitivity pattern achieves best result.

Keywords: Antibiotic sensitivity, chronic suppurative otitis media, microbiological profile

How to cite this article:
Agarwal AC, Srivastava A, Sen M. Chronic suppurative otitis media and microbial flora: Adult versus pediatric population. Indian J Otol 2021;27:22-5

How to cite this URL:
Agarwal AC, Srivastava A, Sen M. Chronic suppurative otitis media and microbial flora: Adult versus pediatric population. Indian J Otol [serial online] 2021 [cited 2021 Dec 2];27:22-5. Available from: https://www.indianjotol.org/text.asp?2021/27/1/22/329094

  Introduction Top

Chronic suppurative otitis media (CSOM) is a frequently encountered middle ear infection which manifests as ear discharge through a tympanic membrane perforation.[1] As per the World Health Organization (WHO), 65–330 million people worldwide are affected by CSOM.[2] The disease is common in developing countries due to malnutrition, overcrowding, poor hygiene, inadequate health care, and recurrent upper respiratory tract infections.[3] It is a condition which can even lead to extradural and intradural complications if left untreated.[4]

CSOM is classified into two types: tubotympanic (safe type) and atticoantral (unsafe type). Atticoantral disease is notoriously famous for causing complications. Infection spreads from the middle ear to the nearby vital structures namely facial nerve, labyrinth, lateral sinus, meninges, and the brain.[5]

Various forms of bacteria are the usual incriminating organism and there can be a super added fungal infection. The prevalence of these organisms varies according to the geography and economic status of the area. Antibiogram of the organisms is variable due to the rampant and haphazard use of antibiotics. Hence, it is important that a periodic update of the causative organism and its antibiotic sensitivity be done to avoid improper antibiotic treatment, as this leads to increased morbidity.[5]

Some studies on CSOM have shown that there is an inclination toward the younger age group.[6] A prospective population-based longitudinal cohort study among the children aged 0–4 years demonstrated a cumulative incidence rate of CSOM to be 14%.[7] The microbiological profile of children can be different from the adults and hence research is required to assess the prevalent organism and the future course of medical management. Due to increasing drug resistance, a periodic monitoring of the microbiological profile and its clinical correlation will help in reducing the disease burden.

  Materials and Methods Top

A cross-sectional record-based study was conducted in the department of ENT and the department of microbiology of the tertiary care center of Northern India. The study duration was 12 months (January 2018–December 2019). Patients who were diagnosed with actively discharging tubotympanic type of CSOM and not on any antibiotics for the past 15 days were taken into consideration. Patients having atticoantral type of CSOM, history of ear surgery, having malignancy of the ear, having a history of radiation to the head and neck region, diagnosed cases of tuberculosis, or having a history of taking antitubercular therapy were excluded from the study. Based on the inclusion criteria, the number of samples which could be included during the study period of twenty four months was 54. The ear discharge of the patient were collected under sterile conditions and inoculated onto the culture medium (Robert Cooks Meat Media and McKonkey Agar) and then growth was studied along with the antibiotic sensitivity. Antimicrobial susceptibility tests were performed by diffusion method. The patient's data were recorded using retrospective charts review data collection method based on the articulated aims of the study. The data were analyzed using Microsoft Excel and SPSS version 20 statistical software (IBM SPSS version 22 licenced to Dr Ram Manohar Lohia Institute Of Medical Sciences, Lucknow). Descriptive statistics were used. Appropriate parametric and nonparametric tests were applied to assess the association between various variables and were expressed in percentage.

Ethical clearance was taken from the institute's ethical board [IEC No: 60/20]

  Results and Observation Top

Based on the inclusion criteria, the number of samples which could be included during the study period was 54. Among these, 23 (42.5%) were in the pediatric age group (≤15 years age) and 31 (57.5%) were adults. The mean age of the children was 7.8 years and adults 38 years.

In terms of gender distribution, there were 28 (51.86%) males and 26 (48.14%) females. The male to female ratio was 1.07:1. On distributing the cases on the basis of age and gender, 15 cases were male and 8 were female in the pediatric age group, whereas, 13 males and 18 females in the adult age group [Table 1].
Table 1: Gender distribution of the subjects

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Of the 54 ear swabs, microbial growth was seen in 50 swabs (92.5%) and 4 swabs were sterile (7.5%). Of the 50 swabs having a microbial growth, 5 (10%) had polymicrobial growth and 45 (90%) showed monomicrobial growth. [Table 2] shows the distribution of the microbes in the pediatric and adult age groups. From the data of table 2, it can be deduced that the fungal growth was more common in the adult population.
Table 2: Distribution of the isolated organism in the two age groups

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Aeruginosa was the predominant organism among the adults (growth was seen in 15 swabs), whereas Staphylococcus aureus Scientific Name Search  was the predominant organism in the pediatric age group (growth was seen in 9 swabs) [Table 3].
Table 3: Profile of the various bacteria which were isolated

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Although fungal growth was observed in both the age groups, it was more common in adults. Three swabs from the adult population showed the growth of Aspergillus [Table 4].
Table 4: Profile of the various fungi which were isolated

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Antimicrobial sensitivity was carried out for all the microorganisms and it was observed that P. aeruginosa was susceptible to cefoperazone + sulbactam and piperacillin + tazobactam. S. aureus was most susceptible to amikacin followed by cefoperazone and ciprofloxacin. Coagulase-negative staphylococcus was most sensitive to amikacin. Proteus mirabilis and  Escherichia More Details coli were isolated from the pediatric group and were susceptible to gentamycin.

  Discussion Top

CSOM is one of the common health problems in India affecting pediatric and adult population. It is a chronic disease with serious complications which might even be fatal. It is a major concern in children as the hearing impairment can hamper communication and language development. It is characterized by intermittent ear discharge through a perforation of the tympanic membrane. Microorganisms gain access to the middle ear either through the perforation or from the nasopharynx through the  Eustachian tube More Details.[8]

The results of our study showed that majority of the ear swabs had a monomicrobial growth. A similar result was shown the studies conducted by Loy et al.,[1] Prakash et al.,[5] Vishwanath et al.[9]

It has been observed that CSOM commonly affects the children as they are prone to recurrent upper respiratory tract infections and poor personal hygiene in the underdeveloped societies. In our study, 42.5% cases were children and 57.5% were adults, which were similar to result of certain studies.[5],[10],[11] The male to female ratio was 1.07:1. A similar finding has also been reported in a few studies[3],[12] done before. A slight predominance of males can be an incidental finding as there is no knowledge of any anatomical difference in the structure of ear between males and females.

In our study, S. aureus was the most common organism followed by coagulase negative staphylococcus and P. aeruginosa affecting the pediatric age group. A similar finding was reported in the study by Ahmad.[13] In this study, it was observed that the children are equally predisposed to both Aspergillus and Candida infection and this was similar to a finding in a study by Ibekwe et al.[14] The isolated fungus depends on the geographical area and environment affecting the cases of CSOM.

Among the adult population of our study, it was observed that P. aeruginosa was the most common isolated bacteria and this was followed by S. aureus. Similar findings have also been reported previously.[1],[5],[9],[13],[15] Pseudomonas does not usually inhabit the upper respiratory tract and hence its presence in the middle ear should be considered as an invasion through an ear drum perforation.[5],[9] Among fungi; Aspergillus was the most common isolate in our study.

On comparing the adult and pediatric population of our study, the most common isolated organism was different in the two groups. In children, S. aureus can be a commensal present in the nasal cavity and nasopharynx. In adults, P. aeruginosa was the most common isolate and this is usually present in the ear canal. Hence, it can be said that the causative organism in the two age groups come from different sources. According to a report[16] of the WHO, children are more susceptible to S. aureus where as adults are susceptible to Gram-negative organism such as P. aeruginosa.

The isolation of various aerobic, anaerobic, and fungal organisms in different studies showed that environmental and geographical conditions affect the microbiological profile and hence periodic studies are necessary to assess the current microbial profile affecting CSOM patients to administer appropriate antimicrobial therapy.

On comparing the results of our study with other studies,[1],[3],[4],[5],[9] it can be understood that the choice of an antimicrobial agent is affected by the sensitivity of the organism which in turn keeps changing due to rampant and haphazard use of antibiotics. The growth pattern of microorganisms is affected by the geography, economic status, education standard, hygiene, and health facilities available in the area. In our study, we found that the most susceptible antimicrobial was amikacin, cefoperazone + sulbactam, piperacillin + tazobactam, and gentamycin. In countries like India where the health facilities are restricted, periodic update of the prevalence of the organism and its antibiotic sensitivity will help in designing a better protocol for the treatment of CSOM and also reduce the disease burden.

  Conclusion Top

Microbiological profile of the patients in CSOM is influenced by the age, health awareness, sanitization, environmental and geographical conditions. Culture and sensitivity is important in administration of the appropriate antibioti cs.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Loy AH, Tan AL, Lu PK. Microbiology of chronic suppurative otitis media in Singapore. Singapore Med J 2002;43:296-9.  Back to cited text no. 1
WHO. Chronic Suppurative Otitis Media: Burden of Illness and Management Options. Vol. 4. Geneva: WHO Library Cataloguing; 2005. p. 89-115.  Back to cited text no. 2
Kumar H, Seth S. Bacterial and Fungal study of 100 cases of chronic suppurative otitis media. J Clin Diagn Res 2011;5:1224-7.  Back to cited text no. 3
Sharma S, Rehan HS, Goyal A, Jha AK, Upadhyaya S, Mishra SC. Bacteriological profile in chronic suppurative otitis media in Eastern Nepal. Trop Doct 2004;34:102-4.  Back to cited text no. 4
Prakash R, Juyal D, Negi V, Pal S, Adekhandi S, Sharma M, et al. Microbiology of chronic suppurative otitis media in a tertiary care setup of uttarakhand state, India. N Am J Med Sci 2013;5:282-7.  Back to cited text no. 5
Patil AC, Khairnar PS. Assessment of demographic factors and clinical presentation of chronic suppurative otitis media cases in tertiary health care center catering tribal population in Maharashtra. WJPMR 2017;3:174-5.  Back to cited text no. 6
Sade J, Berco E, Buyanover D, Brown M. Ossicular damage in chronic middle ear inflammation. Acta Otolaryngol 1981;92:273-83.  Back to cited text no. 7
Verhoeff M, van der Veen EL, Rovers MM, Sanders EA, Schilder AG. Chronic suppurative otitis media: A review. Int J Pediatr Otorhinolaryngol 2006;70:1-2.  Back to cited text no. 8
Vishwanath S, Mukhopadhyay C, Prakash R, Pillai S, Pujary K, Pujary P. Chronic suppurative otitis media: Optimizing initial antibiotic therapy in a tertiary care setup. Indian J Otolaryngol Head Neck Surg 2012;64:285-9.  Back to cited text no. 9
Gordon MA, Grunstein E, Burton WB. The effect of the season on otitis media with effusion resolution rates in the New York Metropolitan area. Int J Pediatr Otorhinolaryngol 2004;68:191-5.  Back to cited text no. 10
Rovers MM, Straatman H, Zielhuis GA, Ingels K, van der Wilt GJ. Seasonal variation in the prevalence of persistent otitis media with effusion in one-year-old infants. Paediatr Perinat Epidemiol 2000;14:268-74.  Back to cited text no. 11
Poorey VK, Thakur P. Clinico-microbiological evaluation and antibiotic susceptibility in cases of chronic suppurative otitis media. Indian J Otol 2015;21:107-10.  Back to cited text no. 12
  [Full text]  
Ahmad S. Antibiotics in chronic suppurative otitis media: A bacteriological study. Egyptian J Ear, Nose, Throat Allied Sci 2013;14:191-4.  Back to cited text no. 13
Ibekwe AO, al Shareef Z, Benayam A. Anaerobes and fungi in chronic suppurative otitis media. Ann Otol Rhinol Laryngol 1997;106:649-52.  Back to cited text no. 14
Mittal R, Lisi CV, Gerring R, Mittal J, Mathee K, Narasimhan G, et al. Current concepts in the pathogenesis and treatment of chronic suppurative otitis media. J Med Microbiol 2015;64:1103-16.  Back to cited text no. 15
World Health Organization. Chronic Suppurative Otitis Media Burden of Illness and Management Options: Child and Adolescent Health and Development Prevention of Blindness and Deafness. Geneva: World Health Organization; 2004. p. 9-13.  Back to cited text no. 16


  [Table 1], [Table 2], [Table 3], [Table 4]


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