What is the treatment for chronic suppurative otitis media?

Treatment of Chronic Suppurative Otitis Media

Topical antibiotic therapy, particularly fluoroquinolones, is the first-line treatment for chronic suppurative otitis media (CSOM), with ofloxacin otic solution administered as 10 drops twice daily for 14 days being the recommended regimen for patients with perforated tympanic membranes. 1

Initial Medical Management

Topical Antibiotics

• Topical antibiotics are more effective than systemic antibiotics for treating CSOM 2
• Fluoroquinolone drops (such as ofloxacin or ciprofloxacin) are the preferred agents:
  • For patients 12 years and older: 10 drops (0.5 mL) instilled into the affected ear twice daily for fourteen days 1
  • Solution should be warmed by holding the bottle in hand for 1-2 minutes to prevent dizziness
  • Patient should lie with affected ear upward during administration
  • The tragus should be pumped 4 times to facilitate penetration into the middle ear
  • Position should be maintained for five minutes after instillation 1

Aural Toilet (Ear Cleaning)

• Aural toilet combined with topical antibiotics is more effective than no treatment or aural toilet alone 3
• Should be performed before administering topical medications to improve drug delivery to the middle ear

Duration of Treatment

• Standard treatment duration for CSOM is 14 days 1, 4
• Clinical response rates increase from 39.1% at 2 weeks to 57.8% at 4 weeks for CSOM patients 4
• Bacterial eradication rates reach 91.0% at 2 weeks and 94.6% at 4 weeks 4
• Patients with insufficient improvement after 2 weeks may benefit from extending treatment to 3-4 weeks 4

Comparative Effectiveness of Treatments

Topical vs. Systemic Antibiotics

• Topical antibiotics are more effective than systemic antibiotics in resolving ear discharge (odds ratio 0.46,95% CI 0.30 to 0.69) 3
• Combining topical and systemic antibiotics does not provide additional benefit over topical antibiotics alone 3
• Topical administration may slightly increase resolution of ear discharge compared to systemic administration of the same antibiotic (RR 1.48,95% CI 1.24 to 1.76) 2

Antibiotic Classes

• Topical quinolones are more effective than non-quinolone antibiotics (odds ratio 0.26,95% CI 0.16 to 0.41) 3
• Quinolones are likely more effective than boric acid in resolving ear discharge at 1-2 weeks (RR 1.86,95% CI 1.48 to 2.35) 5
• For MRSA-positive cases, topical fluoroquinolones and sulfacetamide have been associated with successful resolution 6

Surgical Management

• The curative treatment for CSOM is surgery (tympanoplasty) 7
• Surgical intervention includes:
  • Closure of the tympanic membrane perforation
  • Reconstruction of the ossicular chain if necessary 7
• Tympanostomy tube insertion is recommended for patients with large perforations and recurrent otitis media 8
• Adenoidectomy may be considered as an adjunctive procedure for patients with recurrent infections that do not resolve with tympanostomy tubes and antibiotic management 8

Follow-up and Monitoring

• Follow-up in 2-3 weeks to ensure resolution of middle ear effusion 8
• If otitis media persists beyond 3 months, hearing testing is recommended 8
• Regular monitoring for complications such as persistent pain, vertigo, or facial weakness 8
• Ongoing audiological monitoring to ensure hearing is maintained at appropriate levels for language and educational development 8

Prevention of Recurrence

• Reduce risk factors:
  • Limit daycare attendance
  • Eliminate tobacco smoke exposure
  • Ensure pneumococcal and influenza vaccinations are up-to-date
  • Promote breastfeeding in infants 8

Common Pitfalls and Caveats

1. Misdiagnosis: Ensure accurate diagnosis with pneumatic otoscopy to assess tympanic membrane color, opacity, position, and integrity 8

2. Inadequate Ear Cleaning: Failure to perform proper aural toilet before administering topical medications can reduce treatment efficacy

3. Inappropriate Antibiotic Selection: Using non-quinolone antibiotics as first-line therapy may result in lower cure rates 3

4. Premature Discontinuation: Stopping treatment too early may lead to incomplete resolution and recurrence; the full 14-day course should be completed 1, 4

5. Overlooking Surgical Options: Relying solely on medical management for cases that require surgical intervention can lead to persistent disease 7

6. Ignoring Hearing Assessment: Failure to evaluate hearing in persistent cases may miss conductive hearing loss requiring intervention 8

The evidence strongly supports topical fluoroquinolones as the most effective medical treatment for CSOM, with surgical intervention being the definitive curative approach for cases that do not respond to medical management.