What is the recommended treatment for chronic suppurative otitis media?

Treatment of Chronic Suppurative Otitis Media

Topical antibiotics, specifically quinolones such as ofloxacin, are the first-line treatment for chronic suppurative otitis media (CSOM), combined with regular aural toileting. 1, 2

Definition and Clinical Features

Chronic suppurative otitis media (CSOM) is defined as:

• Chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity
• Characterized by persistent ear discharge (otorrhea) through a perforated tympanic membrane
• Discharge continuing for more than 2 weeks
• Primary symptoms include ear discharge and hearing loss

First-Line Treatment Approach

Topical Antibiotic Therapy

• Ofloxacin otic solution 0.3% is FDA-approved for CSOM with perforated tympanic membranes 1
  • Dosage: 10 drops (0.5 mL) instilled into affected ear twice daily for 14 days
  • Warm solution before instillation to prevent dizziness
  • Patient should lie with affected ear upward during instillation
  • Tragus should be pumped 4 times to facilitate penetration into middle ear
  • Maintain position for 5 minutes after instillation

Aural Toileting

• Regular cleaning and debridement of the ear canal is essential
• Should be performed before antibiotic administration to improve penetration
• Can be done by suction or gentle dry mopping 2, 3

Evidence Supporting Topical Antibiotics

Topical quinolones are more effective than:

• Placebo (resolution rate 84% vs 12%) 2
• Topical antiseptics like boric acid (RR 1.86,95% CI 1.48 to 2.35) 4

Advantages of topical over systemic antibiotics:

• Higher local concentration of antibiotics at the infection site
• Fewer systemic side effects
• May increase resolution of ear discharge (RR 1.48,95% CI 1.24 to 1.76) 5

Second-Line Treatment Options

If first-line treatment fails:

1. Combination therapy: Consider adding systemic antibiotics to topical treatment 3

   • Particularly for extensive or severe infections
   • Ceftazidime (50 mg/kg/dose twice daily) has shown efficacy in children 3

2. Alternative topical antibiotics: Consider aminoglycosides if quinolones fail

   • Note: Aminoglycosides carry a higher risk of ototoxicity compared to quinolones 2

3. Surgical intervention: For persistent cases unresponsive to medical therapy

   • Tympanoplasty (closure of tympanic membrane perforation)
   • Reconstruction of ossicular chain if needed 6

Special Considerations

Duration of Treatment

• Standard course is 14 days for topical antibiotics 1
• Extended treatment may be necessary for persistent infections

Monitoring and Follow-up

• Reassess after completion of treatment course
• Check for:
  • Resolution of discharge
  • Healing of perforation
  • Improvement in hearing
  • Signs of complications

Common Pitfalls to Avoid

1. Inadequate aural toileting: Failure to clean the ear canal properly before antibiotic administration reduces treatment efficacy
2. Insufficient duration of therapy: Premature discontinuation can lead to treatment failure
3. Ignoring underlying factors: Eustachian tube dysfunction or systemic conditions may contribute to persistence
4. Delayed surgical referral: Persistent cases despite adequate medical therapy should be considered for surgical intervention
5. Using ototoxic antibiotics without caution: Aminoglycosides should be used with care in patients with perforated tympanic membranes

Long-Term Outcomes

• Spontaneous healing of tympanic membrane occurs in approximately 39% of cases 7
• Without appropriate treatment, complications may include:
  • Persistent hearing loss
  • Spread of infection to surrounding structures
  • Potential for intracranial complications in severe cases

In summary, CSOM requires prompt and appropriate treatment with topical antibiotics (preferably quinolones) combined with regular aural toileting. Surgical intervention should be considered for cases that fail to respond to medical management.