What is the treatment for Chronic Suppurative Otitis Media (CSOM)?

Treatment for Chronic Suppurative Otitis Media (CSOM)

Topical antibiotics are the first-line treatment for chronic suppurative otitis media, with quinolone ear drops being more effective than other options for resolving ear discharge. 1, 2

First-Line Treatment

• Topical antibiotics: Quinolone antibiotics (such as ofloxacin or ciprofloxacin) are the most effective first-line treatment for CSOM 1, 2

  • Dosage for ofloxacin: Ten drops (0.5 mL, 1.5 mg ofloxacin) instilled into the affected ear twice daily for fourteen days 3
  • Topical antibiotics are more effective than systemic antibiotics for resolving ear discharge 4
  • Quinolones are likely more effective than boric acid antiseptic solutions (1 additional person will have resolution for every 4 people treated with quinolones vs. boric acid) 2

• Aural toileting: Ear cleaning should be performed before applying topical medications to improve medication penetration 5

  • Proper technique: Patient should lie with affected ear upward, then the drops should be instilled
  • The tragus should be pumped 4 times by pushing inward to facilitate penetration into the middle ear
  • This position should be maintained for five minutes 3

Second-Line Options

• Topical antibiotics with steroids: May be considered when topical antibiotics alone are ineffective, though evidence suggests limited additional benefit 6

  • Low-certainty evidence indicates that some types of topical antibiotics without steroids may be better than topical antibiotic-steroid combinations for improving resolution of discharge 6

• Systemic antibiotics: Should be reserved for cases with systemic involvement or when topical treatment fails 4, 7

  • When used alone, it is very uncertain if systemic antibiotics are more effective than placebo 7
  • When added to topical antibiotics, there seems to be little additional benefit in resolution of ear discharge 7

Surgical Management

• Tympanoplasty: Consider for persistent tympanic membrane perforation that fails to heal spontaneously 5
  • Cartilage reconstruction (CR) shows better morphologic success compared to temporalis muscle fascia (TMF) with mean graft integration rates of 92.4% vs 84.3% 5
  • Novel adjuvant treatments to enhance tympanic membrane repair include biomolecules (platelet-derived growth factor, hyaluronic acid) and bioengineered scaffolds 5

Special Considerations

• Swimming: No significant changes in nasopharyngeal or middle ear microbiology were found between CSOM patients who swam versus those who did not 5

• Spontaneous healing: About 39% of tympanic membrane perforations in CSOM may heal spontaneously over long-term follow-up (10-12 years) 5

• Complications to monitor: Common complications include myringosclerosis (17-38%), tympanic membrane atrophy (1-28%), and persistent perforation (0.6-2.4%) 5

Treatment Algorithm

1. Initial assessment:

   • Confirm diagnosis of CSOM (ear discharge >2 weeks through perforated tympanic membrane)
   • Identify causative organisms if possible (common: Pseudomonas aeruginosa, Staphylococcus aureus, Proteus mirabilis) 3

2. First-line treatment:

   • Aural toileting to remove discharge
   • Topical quinolone antibiotics for 14 days (ofloxacin 0.3%, 10 drops twice daily) 3
   • Reassess after 2 weeks

3. If persistent discharge after 2 weeks:

   • Consider culture-directed therapy
   • Consider topical antibiotic-steroid combination
   • Evaluate for complications or underlying conditions

4. For refractory cases:

   • Consider short course of systemic antibiotics
   • Evaluate for surgical intervention (tympanoplasty)

Pitfalls and Caveats

• Ototoxicity risk: Monitor for signs of ototoxicity with aminoglycoside antibiotics; quinolones generally have lower ototoxicity risk 1, 2

• Treatment adherence: Emphasize the importance of completing the full course of treatment even if symptoms improve earlier 5

• Recurrence prevention: Address underlying factors such as upper respiratory infections, allergies, or anatomical abnormalities that may contribute to recurrence 5

• At-risk populations: Children with Down syndrome and craniofacial malformations such as cleft palate are more prone to CSOM and its complications but are often excluded from clinical trials 5