What is the recommended treatment for a patient with chronic suppurative otitis media?

Treatment of Chronic Suppurative Otitis Media

Topical fluoroquinolone antibiotics are the first-line treatment for chronic suppurative otitis media (CSOM), not systemic antibiotics. 1, 2

Initial Assessment and Confirmation

Before initiating treatment, confirm the diagnosis by documenting:

• A perforated tympanic membrane with persistent ear discharge lasting more than 2 weeks using pneumatic otoscopy 2
• Assess for hearing loss, as CSOM is a leading global cause of conductive hearing loss 2
• Rule out life-threatening complications including mastoiditis, meningitis, or brain abscess, which cause approximately 21,000 deaths annually worldwide 2

First-Line Medical Management

Perform aural toilet (ear cleaning) at the initial visit to remove debris and discharge, which enhances antibiotic penetration into the middle ear 2

Prescribe topical fluoroquinolone ear drops as the primary treatment:

• Ofloxacin 0.3% otic solution: 10 drops (0.5 mL) twice daily for 14 days in patients 12 years and older 3
• Warm the bottle in hand for 1-2 minutes before instillation to avoid dizziness 3
• Patient should lie with affected ear upward, then pump the tragus 4 times after instillation to facilitate middle ear penetration 3
• Maintain position for 5 minutes 3

Critical: Never use aminoglycoside ear drops (gentamicin, tobramycin) when the tympanic membrane is perforated, as they cause permanent sensorineural hearing loss through ototoxicity 1, 2

Evidence Supporting Topical Over Systemic Antibiotics

The evidence strongly favors topical over systemic antibiotics:

• Topical fluoroquinolones achieve 77-96% clinical cure rates compared to only 30-67% with oral antibiotics 4
• Topical ciprofloxacin may slightly increase resolution of ear discharge at 1-2 weeks (RR 1.48,95% CI 1.24-1.76) compared to oral ciprofloxacin 5
• Adding systemic antibiotics to topical antibiotics provides little or no additional benefit (RR 1.05,95% CI 0.94-1.17) 6

When Systemic Antibiotics Are NOT Recommended

Do not prescribe systemic antibiotics for CSOM, as they provide no benefit and only increase adverse effects 1, 6. The evidence is very uncertain whether systemic antibiotics alone are more effective than placebo 6.

Monitoring and Follow-Up

Reassess after 2-4 weeks of topical fluoroquinolone therapy 2:

• Document resolution of ear discharge, improved hearing, or improved quality of life 2
• If discharge persists beyond 2-4 weeks of appropriate topical therapy, refer to otolaryngology 2

Obtain audiometry if hearing loss persists after discharge resolution 2

Re-evaluate every 3-6 months if discharge becomes chronic until resolution or surgical intervention 2

Indications for ENT Referral

Refer to otolaryngology when:

• Ear discharge persists after 2-4 weeks of topical fluoroquinolone therapy 2
• Suspected cholesteatoma or structural middle ear abnormalities 2
• Significant hearing loss impacting quality of life 2
• Recurrent episodes requiring multiple treatment courses 3

Surgical Considerations

The definitive curative treatment for CSOM is surgery (tympanoplasty), not conservative antimicrobial therapy 7. Surgery involves:

• Closure of the tympanic membrane perforation 7
• Reconstruction of the ossicular chain if necessary 7
• Tympanomastoidectomy may be required for refractory cases 8

Critical Pitfalls to Avoid

• Never use ototoxic ear drops (aminoglycosides) with tympanic membrane perforation, as they cause permanent sensorineural hearing loss 1, 2
• Avoid ear irrigation in patients with perforation, as this introduces infection risk 1
• Do not prescribe systemic antibiotics as monotherapy or added to topical therapy, as evidence shows no benefit 1, 6
• Limit topical fluoroquinolone drops to no more than 10-14 days to prevent otomycosis 4, 3
• If prolonged use results in overgrowth of non-susceptible organisms, obtain cultures to guide further treatment 3

Special Considerations

If two or more episodes occur within 6 months, further evaluation is recommended to exclude underlying conditions such as cholesteatoma, foreign body, or tumor 3

Keep the ear dry during treatment and avoid water exposure 1