What are the diagnosis and treatment options for ENT conditions?

Diagnosis and Management of Chronic Suppurative Otitis Media (CSOM)

Topical antibiotics are the most effective first-line treatment for chronic suppurative otitis media, with quinolone ear drops (such as ciprofloxacin) showing superior outcomes compared to other treatments. 1

Diagnosis of CSOM

• CSOM is characterized by chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity, with ear discharge (otorrhea) through a perforated tympanic membrane 2
• Primary symptoms include persistent ear discharge and hearing loss 2
• Diagnostic criteria include:
  • Otoscopic findings: perforated tympanic membrane with discharge, tympanic membrane retraction, or limitations of membrane motion 2
  • Duration of symptoms: ear discharge continuing for more than 2 weeks 1

Diagnostic Methods

• Pneumatic otoscopy is the primary diagnostic method with 94% sensitivity and 80% specificity when performed by experienced clinicians 2
• Tympanometry can confirm the diagnosis with sensitivity of 91% and specificity of 76% when type B tympanogram is considered positive 2
• Audiometry is essential to assess the degree of hearing loss, which can be conductive, sensorineural, or mixed 2

Complications and Impact

• CSOM is associated with significant hearing loss - up to 91% absolute risk of permanent hearing loss when occurring in childhood 2
• Long-term CSOM (>10 years) is associated with significantly higher rates of sensorineural hearing loss compared to shorter duration disease 3
• Cognitive and developmental impacts include:
  • Impaired auditory skills at ages 8-12 years in children with previous otitis media 2
  • Lower IQ test scores later in life associated with cumulative exposure to otitis media with effusion and hearing loss 2
• Serious complications (rare but potentially fatal) include:
  • Mastoiditis, meningitis, and brain abscesses 2
  • Globally, approximately 21,000 people die from complications of otitis media annually 2

Treatment Algorithm for CSOM

First-Line Treatment

• Topical antibiotics (without steroids) are the mainstay of treatment 1
  • Quinolone ear drops (e.g., ciprofloxacin 0.2%) are preferred due to:
    • Higher resolution rates compared to aminoglycosides 1
    • Lower risk of ototoxicity compared to aminoglycosides 1
    • Twice daily administration for 7 days is effective 4

Adjunctive Treatments

• Aural toilet (ear cleaning) should be performed before applying topical medications 2, 4

  • Use dry mopping or gentle suction to remove debris 4
  • Avoid irrigation if tympanic membrane perforation is suspected 4

• Topical antiseptics may be considered when antibiotics are unavailable:

  • Boric acid in alcohol with dry mopping may help resolution of ear discharge 5
  • Povidone-iodine with systemic antibiotics may increase resolution rates 5

For Refractory Cases

• Systemic antibiotics in addition to topical antibiotics may increase resolution rates (88% vs 60% with systemic antibiotics alone) 1
• Surgical options for persistent cases include:
  • Tympanoplasty with cartilage reconstruction shows better structural outcomes (92.4% graft integration rate) compared to temporalis muscle fascia (84.3%) 2
  • Tissue-engineered myringoplasty with fibroblast growth factor has shown 98.1% tympanic membrane closure rate 2

Special Considerations

• Children with CSOM may benefit from parenteral antimicrobial therapy with daily aural toilet (89% resolution rate) before considering surgery 6
• Swimming does not appear to significantly change the nasopharyngeal or middle ear microbiology in children with CSOM 2

Monitoring and Follow-up

• Reassess within 48-72 hours if symptoms do not improve or worsen 4
• Consider alternative diagnosis or treatment if no improvement is seen 4
• Monitor for fungal infection if patient fails to respond to initial topical therapy within 48-72 hours 4

Common Pitfalls to Avoid

• Misdiagnosis: Failure to differentiate between otitis externa (affecting ear canal skin) and otitis media (affecting middle ear space) 4
• Overuse of systemic antibiotics: Topical therapy alone is usually sufficient for uncomplicated cases 4
• Inadequate pain control: CSOM can cause significant discomfort requiring appropriate analgesia 4
• Delayed treatment: Prolonged duration of CSOM (>10 years) significantly increases risk of sensorineural hearing loss 3

Patient Education

• Keep ears dry during treatment 4
• Avoid swimming or submerging head in water 4
• Use ear protection if water exposure is unavoidable 4
• Emphasize importance of completing full course of treatment even if symptoms improve 4