What is the treatment for a patient with chronic suppurative otitis media (CSOM) and ear discharge?

Medical Treatment for CSOM Ear Discharge

For chronic suppurative otitis media (CSOM) with ear discharge, use topical ofloxacin ear drops (10 drops twice daily for 14 days in patients ≥12 years) combined with aural toileting (ear cleaning), while strictly avoiding aminoglycoside drops due to ototoxicity risk through the perforated tympanic membrane. 1, 2

Immediate Treatment Protocol

First-Line Topical Antibiotic Therapy

• Topical ofloxacin (quinolone) is the treatment of choice for CSOM with tympanic membrane perforation, dosed as 10 drops (0.5 mL, 1.5 mg) instilled into the affected ear twice daily for 14 days in patients 12 years and older 2

• The patient should lie with the affected ear upward, instill the drops, then pump the tragus 4 times by pushing inward to facilitate penetration into the middle ear, maintaining this position for 5 minutes 2

• Warm the bottle in your hand for 1-2 minutes before instillation to avoid dizziness from cold solution 2

• Topical quinolones are likely superior to boric acid antiseptic drops, increasing resolution of ear discharge (one additional person achieves dry ear for every 4-5 people treated at two weeks) 3, 4

Essential Aural Toileting (Ear Cleaning)

• Perform aural toileting with suction clearance under microscopic guidance as a critical component of treatment, especially in patients with diabetes or immunocompromised status 1

• Aural toileting is mandatory before adequate otoscopic examination, as failure to visualize the tympanic membrane leads to missed middle ear pathology 5

• Keep the ear completely dry and avoid irrigation entirely in patients with confirmed tympanic membrane perforation, as this introduces infection risk 1

Critical Safety Warnings

Ototoxic Medications to Avoid

• Never use aminoglycoside ear drops (gentamicin, tobramycin, neomycin) in patients with perforated tympanic membranes, as they cause permanent sensorineural hearing loss 1

• The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends avoiding all ototoxic preparations when the tympanic membrane is not intact 1

Role of Systemic Antibiotics

When Systemic Antibiotics Are NOT Indicated

• Adding oral antibiotics to topical quinolone therapy provides little or no additional benefit for CSOM resolution at 1-2 weeks (RR 1.05,95% CI 0.94 to 1.17) 6

• Systemic antibiotics alone (without topical therapy) show very uncertain effectiveness compared to placebo for CSOM 6

• Topical antibiotics are superior to systemic antibiotics when comparing the same antibiotic class (topical ciprofloxacin may slightly increase resolution compared to oral ciprofloxacin, RR 1.48,95% CI 1.24 to 1.76) 7

When to Consider Systemic Antibiotics

• Consider systemic antibiotics only if the patient develops NEW acute symptoms (fever, severe otalgia, bulging tympanic membrane), which represents new-onset acute otitis media requiring treatment targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 8

Alternative Topical Antiseptics

Acetic Acid

• Acetic acid may increase resolution of ear discharge when compared to aminoglycosides at 1-2 weeks, though evidence is of low certainty 3

• One study showed acetic acid with aural toileting (suction every 2 days) was more effective than combined topical and oral quinolones at one month (RR 0.69,95% CI 0.53 to 0.90) 4

Boric Acid

• Topical quinolones are likely more effective than boric acid for resolution of ear discharge at 1-2 weeks (RR 1.86,95% CI 1.48 to 2.35), with moderate-certainty evidence 3

• Boric acid may cause more ear pain, discomfort, or irritation compared with quinolones (RR 0.56,95% CI 0.32 to 0.98) 3

Follow-Up and Monitoring

Short-Term Assessment

• 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 1

• If infection is not improved after one week, obtain cultures to guide further treatment 2

• If two or more episodes of otorrhea occur within six months, further evaluation is recommended to exclude cholesteatoma, foreign body, or tumor 2

Long-Term Surgical Considerations

• After achieving complete resolution of active infection and dry ear for at least 3 months, consider referral for tympanoplasty (surgical repair of the tympanic membrane) 1

• Cartilage reconstruction provides superior structural outcomes compared to temporalis muscle fascia, with better graft integration rates (92.4% vs 84.3%) 1

• The recurrent nature of CSOM suggests the patient may benefit from tympanoplasty after infection resolution to prevent future episodes 1

Common Pitfalls to Avoid

• Do not use systemic or intranasal corticosteroids for treating CSOM, as they are ineffective and may cause adverse effects 8

• Avoid antihistamines or decongestants, as Cochrane meta-analysis shows no significant benefit (RR 0.99,95% CI 0.92-1.05) 8

• Do not fail to adequately visualize the tympanic membrane due to canal debris or discharge, which can lead to missed middle ear pathology 5

• Avoid contaminating the applicator tip with material from fingers or other sources to preserve sterility of the drops 2

• Discontinue use immediately and contact physician at the first sign of rash or allergic reaction, as systemic quinolones have been associated with hypersensitivity reactions 2

Special Population Considerations

• In patients with diabetes, ensure good glycemic control as it may impair healing and increase infection risk 1

• Monitor for signs of serious complications including mastoiditis, meningitis, or intracranial extension, though these are rare 1

• Be cautious with any procedures that might cause bleeding in patients on anticoagulants and antiplatelets 1

• Permanent bilateral neural hearing loss will not improve with treatment of CSOM; cochlear implant evaluation should be considered for hearing rehabilitation 1