How do you manage Chronic Suppurative Otitis Media (CSOM) as a family physician?

Management of Chronic Suppurative Otitis Media (CSOM) as a Family Physician

As a family physician, you should initiate treatment with topical fluoroquinolone antibiotics (ciprofloxacin or ofloxacin) combined with aural toilet (ear cleaning), and refer to ENT for surgical evaluation if discharge persists beyond 2-4 weeks of appropriate medical therapy. 1, 2, 3

Initial Assessment and Diagnosis

• Confirm the diagnosis by documenting a perforated tympanic membrane with persistent ear discharge (>2 weeks duration) using pneumatic otoscopy 1
• Assess hearing loss as CSOM is a leading cause of hearing loss globally, with conductive hearing loss being the predominant symptom 1
• Rule out complications including mastoiditis, meningitis, or brain abscess, which cause an estimated 21,000 deaths annually worldwide 1

First-Line Medical Management

Topical Antibiotic Therapy (Preferred)

Topical fluoroquinolones are the treatment of choice for CSOM based on the strongest available evidence 1, 3:

• Ofloxacin otic solution for patients ≥12 years: 10 drops (0.5 mL) into affected ear twice daily for 14 days 2
• Ciprofloxacin otic solution is an alternative topical fluoroquinolone 1, 3
• Warm the bottle in your hand for 1-2 minutes before instillation to prevent dizziness 2
• Instillation technique: Patient lies with affected ear upward, instill drops, pump tragus 4 times inward to facilitate middle ear penetration, maintain position for 5 minutes 2

Aural Toilet (Ear Cleaning)

• Perform aural toilet at the initial visit to remove debris and discharge, which enhances antibiotic penetration 1, 3
• This can be done via suction or gentle irrigation with saline 1

Why Topical Over Systemic Antibiotics

• Topical antibiotics may be more effective than systemic antibiotics for achieving dry ear (RR 1.48,95% CI 1.24 to 1.76) 4
• Systemic antibiotics alone show little to no benefit when added to topical therapy (RR 1.02,95% CI 0.93 to 1.12) 5
• Avoid systemic antibiotics as monotherapy unless topical therapy is not feasible 3, 4, 5

Common Pitfalls and Why Treatment Fails

Biofilm Formation

• Bacterial biofilms are present in chronic and recurrent infections, protecting bacteria against antibiotics and immune responses 6, 7
• Persister cells within biofilms are antibiotic-tolerant and can proliferate, leading to treatment failure even with appropriate antibiotics 7
• This explains why long-term treatment failure is common despite initial response to fluoroquinolones 7

Microbiology Considerations

• Pseudomonas aeruginosa and Staphylococcus aureus are the most common pathogens in CSOM 8, 7
• Other organisms include E. coli, Klebsiella pneumoniae, and anaerobic bacteria 8
• This polymicrobial nature differs from acute otitis media, which is primarily caused by S. pneumoniae, H. influenzae, and M. catarrhalis 6, 8

When to Refer to ENT

Refer to otolaryngology if:

• Discharge persists after 2-4 weeks of appropriate topical antibiotic therapy 1, 3
• Suspected cholesteatoma or structural abnormalities of the middle ear 1
• Significant hearing loss that impacts quality of life 1
• Recurrent episodes despite medical management 1

Surgical Options

• Tympanoplasty to repair the tympanic membrane perforation 1
• Tympanomastoidectomy for refractory cases or cholesteatoma 1, 7
• Consider surgery earlier in refractory cases to debride biofilm and minimize antibiotic resistance development 7
• Cartilage reconstruction shows better graft integration rates (92.4%) compared to temporalis muscle fascia (84.3%) 1

Monitoring and Follow-Up

• Reassess at 2 weeks to evaluate response to topical therapy 3
• Document resolution of ear discharge, improved hearing, or improved quality of life 1
• Obtain audiometry if hearing loss persists after resolution of discharge 1
• Reevaluate every 3-6 months if discharge becomes chronic until resolution or surgical intervention 1

Treatments to Avoid

• Do NOT use aminoglycosides (gentamicin, neomycin, tobramycin) as first-line due to ototoxicity risk and uncertain superiority over quinolones 1, 3
• Do NOT use topical antiseptics (boric acid, acetic acid) as primary therapy, as topical antibiotics show superior outcomes 1, 3
• Do NOT use systemic antibiotics alone without topical therapy, as evidence shows minimal benefit 4, 5
• Do NOT use corticosteroids, antihistamines, or decongestants, as these are ineffective for CSOM 1

Special Populations

• Children with Down syndrome or cleft palate have 60-85% prevalence of middle ear disease and require more aggressive monitoring 9
• Immunocompromised patients may require culture-directed therapy and earlier surgical intervention 8
• Patients with treatment failure should have middle ear cultures obtained to guide therapy, particularly to identify resistant organisms or anaerobes 8