What is the treatment for acute suppurative otitis media (ASOM) with spontaneous rupture of the tympanic membrane (eardrum)?

From the Guidelines

The treatment for acute suppurative otitis media with spontaneous rupture of the ear drum includes oral antibiotics, pain management, and proper ear care, with first-line antibiotic therapy being amoxicillin 80-90 mg/kg/day divided twice daily for children or 500-875 mg three times daily for adults for 10 days, as recommended by recent guidelines 1. The goal of treatment is to reduce morbidity, mortality, and improve quality of life by preventing complications such as mastoiditis or hearing loss.

• Key components of treatment include:
  • Oral antibiotics to treat the underlying bacterial infection
  • Pain management with acetaminophen or ibuprofen as needed
  • Proper ear care to keep the ear dry during healing and prevent further infection
• For penicillin-allergic patients, alternative antibiotics such as azithromycin or trimethoprim-sulfamethoxazole may be used 1.
• It is essential to keep the ear dry during healing, avoiding swimming and protecting the ear during showering with cotton balls coated with petroleum jelly.
• Any drainage should be cleaned by gently wiping the outer ear with a clean cloth.
• Most perforations heal spontaneously within 1-2 weeks, but follow-up care is necessary if symptoms worsen, fever persists beyond 48 hours of treatment, or drainage continues beyond 7-10 days.
• The use of topical antibiotic is the treatment of choice in acute tube otorrhea, and symptomatic hearing loss due to persistent otitis media with effusion is best treated with tympanostomy tubes, as suggested by recent literature and guidelines 1.

From the FDA Drug Label

The recommended dosage regimen for the treatment of chronic suppurative otitis media with perforated tympanic membranes in patients 12 years and older is: Ten drops (0.5 mL, 1. 5 mg ofloxacin) instilled into the affected ear twice daily for fourteen days.

The treatment for acute suppurative otitis media with spontaneous rupture of ear drum is not directly addressed in the provided drug label. However, the label does provide information on the treatment of chronic suppurative otitis media with perforated tympanic membranes, which may be relevant.

• For patients 12 years and older, the recommended dosage is ten drops (0.5 mL, 1.5 mg ofloxacin) instilled into the affected ear twice daily for fourteen days 2. However, this may not be directly applicable to acute cases. Key points to consider when treating acute suppurative otitis media with spontaneous rupture of ear drum are:
• The provided label does not directly address this specific condition.
• Treatment should be guided by clinical judgment and may involve ofloxacin (OTIC), but the exact dosage and duration are unclear based on the provided information.

From the Research

Treatment of Acute Suppurative Otitis Media with Spontaneous Rupture of Ear Drum

• The treatment of acute suppurative otitis media (ASOM) with spontaneous rupture of the ear drum, also known as spontaneous tympanic membrane perforation (STMP), is primarily focused on managing the underlying infection and promoting healing of the perforation.
• According to a study published in 2017 3, the principal aim is to present the current knowledge regarding ASOM with STMP and to address the question of whether ASOM with STMP is a disease with specific characteristics or a severe case of ASOM.
• The study found that early Streptococcus pneumoniae infection due to invasive pneumococcal strains, in addition to coinfections and biofilm production due mainly to non-typeable Haemophilus influenzae, seem to be precursors of STMP.

Antibiotic Treatment

• A study published in 2006 4 compared the efficacy of amoxicillin-clavulanate and azithromycin in the treatment of acute otitis media (AOM) and found that although clinical response rates were better in patients treated with amoxicillin-clavulanate, this was not statistically significant.
• Another study published in 1990 5 compared the efficacy of trimethoprim-sulfamethoxazole and amoxicillin-clavulanate in the treatment of AOM and found that the combined rate of cure and improvement was significantly higher with trimethoprim-sulfamethoxazole (93%) than with amoxicillin-clavulanate (82%).
• A review published in 2003 6 found that amoxicillin/clavulanic acid is a well-established broad-spectrum antibacterial treatment that is effective and well-tolerated in the treatment of AOM in pediatric patients.

Current Trends in Antibiotic Use

• A study published in 2023 7 found that nonguideline concordant antibiotic use is common when treating AOM in children, including use of broad-spectrum agents and longer-than-recommended antibiotic durations.
• The study also found that patterns of antibiotic use were similar for medicaid-insured children and that more children under the age of 2 received three or more antibiotics over the following year compared to children over the age of 6.

Specific Characteristics of ASOM with STMP

• The study published in 2017 3 found that it is unclear why some children have several STMP episodes during the first years of life that resolve without complications in adulthood, whereas other children develop chronic suppurative otitis media.
• The study also found that although specific aetiological agents appear to be associated with an increased risk of AOM with STMP, further studies are needed to determine whether AOM with STMP is a distinct disease with specific aetiological, clinical and prognostic characteristics or a more severe case of AOM than the cases that occur without STMP.