Treatment for Chronic Suppurative Otitis Media in Patients ≥12 Years
Topical quinolone antibiotics (ofloxacin or ciprofloxacin) are the most frequently used and recommended first-line treatment for patients 12 years or older with CSOM and ear discharge. 1, 2, 3
First-Line Treatment Approach
Topical Quinolone Antibiotics
Ofloxacin 0.3% otic solution is FDA-approved specifically for CSOM in patients 12 years and older, administered as 10 drops (0.5 mL, 1.5 mg) into the affected ear twice daily for 14 days 4
Topical quinolones are superior to topical antiseptics (boric acid) for achieving dry ear, with one additional person achieving resolution of ear discharge for every 4-5 people treated compared to boric acid at two weeks (RR 1.56-1.86) 1, 5, 6
Quinolones have the critical advantage of being non-ototoxic, making them safe for use with tympanic membrane perforations, unlike aminoglycosides which should be avoided 1, 2
Essential Adjunctive Measure
Aural toileting (ear cleaning) must be performed before applying topical medications to remove debris and discharge, ensuring medication penetration to the middle ear space 2, 3
The tragus should be pumped 4 times after instillation to facilitate medication entry into the middle ear 4
Treatment Algorithm
Initial Management (First 2 Weeks)
Clean the ear canal thoroughly of all debris and discharge 2, 3
Prescribe topical quinolone (ofloxacin 10 drops twice daily for 14 days) 4
Implement water precautions during active otorrhea until discharge resolves 2
Limit topical therapy to a single 10-14 day course to avoid fungal external otitis 2, 4
When to Add Systemic Antibiotics
Systemic antibiotics should be added to topical therapy only in specific circumstances: 2
- Cellulitis of the pinna or adjacent skin
- Signs of severe infection (fever, systemic symptoms)
- Persistent or worsening otorrhea despite 2 weeks of topical therapy
- Immunocompromised patients
- Concurrent bacterial infections requiring antibiotics
Evidence shows that combining systemic and topical antibiotics is NOT more effective than topical antibiotics alone in uncomplicated CSOM 1
Follow-Up and Refractory Cases
Schedule follow-up within 1-2 weeks to assess healing and resolution 2
If discharge persists after 2 weeks, obtain culture-directed therapy 3
For refractory cases after 4 weeks, consider:
Evidence Strength and Nuances
The recommendation for topical quinolones is based on moderate-certainty evidence from guideline sources 1 and FDA approval 4, making this the strongest available evidence. The 2016 Nature Reviews Disease Primers guideline specifically states that topical quinolones are more effective than topical antiseptics, systemic antibiotics, and no treatment for clearing CSOM-related discharge in the short term (<4 weeks) 1.
Topical quinolones are likely superior to systemic antibiotics alone when both are compared directly, with low-certainty evidence suggesting topical administration may increase resolution rates (RR 1.48) 7. However, the evidence comparing topical versus systemic routes is older (>15 years) and limited 7.
Critical Pitfalls to Avoid
Never use aminoglycoside-containing ear drops (gentamicin, neomycin, tobramycin) due to ototoxicity risk with tympanic membrane perforation 2
Do not prescribe Ciprodex (ciprofloxacin-dexamethasone) as the steroid component may delay tympanic membrane healing, though the quinolone component itself is safe 2
Ensure completion of the full 14-day course even if symptoms improve earlier to prevent recurrence 3
Address underlying factors such as upper respiratory infections, allergies, or anatomical abnormalities that contribute to recurrence 3
Recognize high-risk populations: Children with Down syndrome and craniofacial malformations are more prone to CSOM and complications 3