What is the best course of treatment for an elderly patient with 10-12 years of bilateral complete hearing loss, recurrent chronic suppurative otitis media, and on oral hypoglycemic agents, antiplatelets, anticoagulants, and antihypertensives, presenting with left ear discharge and perforation of the tympanic membrane?

Management of Chronic Suppurative Otitis Media with Tympanic Membrane Perforation in an Elderly Patient

The best treatment is topical fluoroquinolone ear drops (ofloxacin 10 drops twice daily for 14 days) combined with aural toileting, avoiding all systemic antibiotics and ototoxic preparations given the permanent bilateral sensorineural hearing loss. 1

Immediate Treatment Priorities

Topical Antibiotic Therapy

• Ofloxacin otic solution is the FDA-approved first-line treatment for chronic suppurative otitis media with perforated tympanic membrane in patients 12 years and older: 10 drops (0.5 mL, 1.5 mg) instilled into the affected ear twice daily for 14 days 1
• The solution should be warmed by holding the bottle in hand for 1-2 minutes to avoid dizziness from cold solution instillation 1
• Patient should lie with affected ear upward, then pump the tragus 4 times by pushing inward to facilitate penetration into the middle ear, maintaining this position for 5 minutes 1
• Topical fluoroquinolone antibiotics are superior to systemic antibiotics for CSOM, with topical administration likely increasing resolution of ear discharge (RR 1.48,95% CI 1.24 to 1.76) 2
• Topical quinolones are likely to increase resolution of ear discharge at 1-2 weeks compared with boric acid ear drops (RR 1.86,95% CI 1.48 to 2.35), meaning one additional person achieves resolution for every four people treated 3

Critical Safety Considerations

• Never use aminoglycoside ear drops (gentamicin, tobramycin, neomycin) in this patient—they cause permanent sensorineural hearing loss when applied to perforated tympanic membranes, and this patient already has permanent bilateral neural hearing loss 4, 5
• The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends avoiding ototoxic preparations when the tympanic membrane is not intact 4
• Keep the ear dry to prevent infection and avoid irrigation, as this can introduce infection and worsen complications 4

Systemic Antibiotics: Not Indicated

Why Systemic Antibiotics Should Be Avoided

• Do not prescribe systemic antibiotics—there is no evidence they provide benefit when added to topical antibiotics for CSOM 5, 6
• When oral ciprofloxacin was added to topical ciprofloxacin ear drops, there was little or no difference in resolution of ear discharge (RR 1.05,95% CI 0.94 to 1.17) 6
• The evidence is very uncertain whether systemic antibiotics alone are more effective than placebo for CSOM 6
• Given this patient's complex medication regimen (oral hypoglycemics, antiplatelets, anticoagulants, antihypertensives), avoiding unnecessary systemic antibiotics reduces drug-drug interaction risks and adverse effects 6

Aural Toileting (Ear Cleaning)

Recommended Technique

• Aural toileting with suction clearance under microscopic guidance should be performed, especially given the patient's diabetes and immunocompromised considerations 4
• Suction clearance is more effective than dry mopping for removing epithelial debris and thick pus in CSOM 7
• The American Academy of Otolaryngology-Head and Neck Surgery recommends keeping the ear dry and using non-ototoxic topical preparations when treating associated infections 4
• Avoid ear irrigation completely in this patient with confirmed tympanic membrane perforation, as it introduces infection risk 4

Monitoring and Follow-Up

Assessment Parameters

• Reassess at 2 weeks to evaluate resolution of ear discharge 1
• If discharge persists after completing the 14-day course of topical ofloxacin, consider ENT referral for further evaluation rather than adding systemic antibiotics 5
• Monitor for any signs of serious complications including mastoiditis, meningitis, or intracranial extension, though these are rare 8

Hearing Considerations

• This patient has permanent bilateral neural hearing loss confirmed by audiometry—the sensorineural component will not improve with treatment of the CSOM 8
• The current active infection with tympanic membrane perforation may add a conductive component to the hearing loss 8
• After resolution of the active infection and perforation healing, consider cochlear implant evaluation given 10-12 years of bilateral complete hearing loss 8

Surgical Considerations for Tympanic Membrane Repair

When to Consider Tympanoplasty

• After achieving complete resolution of active infection and dry ear for at least 3 months, consider referral for tympanoplasty 4
• Cartilage reconstruction provides superior structural outcomes compared to temporalis muscle fascia, with better graft integration rates (92.4% vs 84.3%) 4, 5
• Basic fibroblast growth factor (b-FGF) with gelatin sponge scaffold achieves 98.1% closure rates versus 10% with saline control 4, 5
• However, given the permanent bilateral sensorineural hearing loss, the primary goal of tympanoplasty would be to prevent recurrent infections rather than hearing restoration 8

Common Pitfalls to Avoid

• Never prescribe aminoglycoside ear drops—this is the single most important safety consideration given the existing permanent bilateral neural hearing loss 4, 5
• Do not add systemic antibiotics to topical therapy, as they provide no additional benefit and only increase adverse effects and drug interactions 5, 6
• Do not use ear irrigation for cleaning—use only suction clearance or dry mopping 4, 7
• Do not assume the hearing loss is reversible—the audiometry confirms permanent bilateral neural hearing loss that predates the current infection by 10-12 years 8
• Avoid cold ear drops, as they can cause dizziness; always warm the bottle in hand before instillation 1

Special Considerations for This Elderly Patient

Medication Management

• Given the patient is on anticoagulants and antiplatelets, be cautious with any procedures that might cause bleeding 4
• Oral hypoglycemic use suggests diabetes, which may impair healing and increase infection risk—ensure good glycemic control 4
• The combination of antihypertensives, antiplatelets, and anticoagulants suggests significant cardiovascular disease, making avoidance of systemic antibiotics (and their potential adverse effects) even more important 6

Prognosis

• With appropriate topical fluoroquinolone therapy and aural toileting, resolution of ear discharge should occur within 2-4 weeks 1, 2
• The recurrent nature of the CSOM (10-12 years of history) suggests this patient may benefit from tympanoplasty after infection resolution to prevent future episodes 4, 5
• The permanent bilateral neural hearing loss will not improve with treatment of the CSOM, and cochlear implant evaluation should be considered for hearing rehabilitation 8