What is the best treatment for chronic suppurative otitis media (CSOM) with profuse discharge?

Treatment of Chronic Suppurative Otitis Media (CSOM) with Profuse Discharge

Topical quinolone antibiotics (ofloxacin 0.3%) are the first-line treatment for chronic suppurative otitis media with profuse discharge, administered as 10 drops twice daily for 14 days.

Understanding CSOM

Chronic suppurative otitis media (CSOM) is defined as chronic inflammation of the middle ear and mastoid mucosa with a non-intact tympanic membrane (perforation) and persistent ear discharge 1. This condition differs from acute otitis media and requires specific management approaches due to its chronic nature.

First-Line Treatment

Topical Antibiotic Therapy

• Primary treatment: Topical ofloxacin 0.3% ear drops
  • Dosage: 10 drops twice daily for 14 days 2
  • Application technique:
    • Warm the solution by holding the bottle in hand for 1-2 minutes to prevent dizziness
    • Position patient with affected ear upward
    • After instilling drops, pump the tragus 4 times to facilitate penetration into the middle ear
    • Maintain position for 5 minutes 2

Rationale for Topical Antibiotics

• Topical antibiotics provide higher local concentrations directly at the infection site
• Cochrane evidence suggests topical antibiotics may be more effective than systemic antibiotics in achieving resolution of ear discharge 3
• Quinolones (like ofloxacin) are effective against common CSOM pathogens including Pseudomonas aeruginosa, Staphylococcus aureus, and Proteus mirabilis 2
• Quinolones have not shown ototoxicity, making them safer than aminoglycosides for perforated eardrums 1

Adjunctive Measures

Aural Toileting

• Gentle cleaning and removal of discharge before applying ear drops
• Improves penetration of topical antibiotics
• Can be performed by suctioning or dry mopping 4

Systemic Antibiotics

• Consider adding oral antibiotics in cases of:
  • Severe or extensive disease
  • Signs of spreading infection
  • Immunocompromised patients
  • Treatment failure with topical therapy alone 5
• Options include amoxicillin-clavulanate or ciprofloxacin 5

Treatment Failure Management

If no improvement after 72 hours of initial therapy:

1. Reassess diagnosis and compliance
2. Consider culture and sensitivity testing of ear discharge
3. Switch therapy options:
   • If started on quinolones, consider combination therapy with oral antibiotics
   • Consider referral to otolaryngology for possible tympanocentesis and culture 1
   • For resistant cases, consider topical antibiotics with different mechanisms of action 4

Special Considerations

Potential Complications

• Without appropriate treatment, CSOM can lead to:
  • Persistent middle ear effusion
  • Conductive hearing loss
  • Mastoiditis
  • Spread of infection to surrounding structures 5

Referral Indications

• Discharge persisting despite appropriate therapy for >4 weeks
• Significant hearing loss
• Vertigo
• Facial nerve paralysis
• Intracranial complications 5

Follow-up

• Reassess after 14 days of treatment
• If discharge persists, consider culture-directed therapy
• Long-term follow-up may be needed to monitor for recurrence and hearing status

Emerging Approaches

For persistent perforations that don't heal with standard therapy:

• Tissue-engineered myringoplasty with basic fibroblast growth factor
• Bioengineered scaffolds to enhance tympanic membrane repair 5

For cases resistant to medical management, surgical options like tympanomastoidectomy may be necessary 6.