What is the treatment for chronic suppurative otitis media (CSOM)?

Treatment of Chronic Suppurative Otitis Media (CSOM)

The first-line treatment for CSOM is aural toileting followed by topical antibiotic therapy, specifically ofloxacin otic solution 10 drops (0.5 mL, 1.5 mg) instilled into the affected ear twice daily for fourteen days. 1, 2

Initial Management

• Aural toileting (ear cleaning) should be performed before applying topical medications to improve medication penetration 1
• Topical antibiotics are more effective than systemic antibiotics for resolution of ear discharge 3
• For patients 12 years and older with perforated tympanic membranes, ofloxacin otic solution should be administered as 10 drops (0.5 mL, 1.5 mg) instilled into the affected ear twice daily for fourteen days 2
• The solution should be warmed by holding the bottle in the hand for 1-2 minutes to avoid dizziness 2
• Patient should lie with the affected ear upward before instilling drops 2
• The tragus should be pumped 4 times by pushing inward to facilitate penetration into the middle ear 2
• This position should be maintained for five minutes 2

Antibiotic Selection

• Quinolone antibiotics (ofloxacin, ciprofloxacin) are indicated for CSOM due to their effectiveness against common pathogens including Pseudomonas aeruginosa, Staphylococcus aureus, and Proteus mirabilis 2, 4
• Topical quinolones are likely more effective than boric acid for resolution of ear discharge at 1-2 weeks 5
• Topical antibiotics may be more effective than placebo or when used in addition to systemic antibiotics 4

Management of Persistent Discharge

• If discharge persists after 2 weeks of initial treatment, consider culture-directed therapy 1
• For refractory cases, consider a short course of systemic antibiotics 1, 3
• Topical antibiotics with steroids may be considered, though evidence does not clearly show they are superior to topical antibiotics alone 6

Surgical Management

• For persistent tympanic membrane perforation that fails to heal spontaneously, tympanoplasty may be considered 1
• Cartilage reconstruction for tympanoplasty shows better morphologic success compared to temporalis muscle fascia 1, 7
• Novel adjuvant treatments to enhance tympanic membrane repair include biomolecules and bioengineered scaffolds 1

Special Considerations

• Approximately 39% of tympanic membrane perforations in CSOM may heal spontaneously over long-term follow-up 1
• Common complications include myringosclerosis, tympanic membrane atrophy, and persistent perforation 1
• Children with Down syndrome and craniofacial malformations are more prone to CSOM and its complications 1
• Patients should complete the full course of treatment even if symptoms improve earlier to prevent recurrence and complications 1
• Address underlying factors such as upper respiratory infections, allergies, or anatomical abnormalities that may contribute to recurrence 1

Important Pitfalls to Avoid

• Failure to perform adequate aural toileting before administering topical medications can reduce treatment efficacy 1, 4
• Using ototoxic topical antibiotics (such as aminoglycosides) when safer alternatives (quinolones) are available 4, 5
• Discontinuing treatment prematurely when symptoms improve, which can lead to recurrence 1
• Neglecting to evaluate for cholesteatoma, which requires surgical management 7
• Failing to address underlying factors contributing to recurrence, such as upper respiratory infections or allergies 1