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

Treatment of Chronic Suppurative Otitis Media

Topical antibiotics are the first-line treatment for chronic suppurative otitis media (CSOM), with topical quinolones (specifically ofloxacin or ciprofloxacin) being the preferred agents, administered after aural toileting. 1, 2

Initial Management Approach

Aural Toileting (Ear Cleaning)

• Perform aural toileting before applying topical medications to improve medication penetration and effectiveness 1
• This should be done at the initial visit and may need to be repeated during treatment 1

First-Line Topical Antibiotic Treatment

For patients ≥12 years with CSOM and perforated tympanic membrane:

• Ofloxacin 0.3% otic solution: 10 drops (0.5 mL, 1.5 mg) instilled into the affected ear twice daily for 14 days 2
• Warm the solution by holding the bottle in hand for 1-2 minutes to avoid dizziness 2
• Patient should lie with affected ear upward, then pump the tragus 4 times by pushing inward to facilitate penetration into the middle ear 2
• Maintain this position for 5 minutes 2

Alternative topical quinolone:

• Ciprofloxacin otic drops can be used with similar efficacy 3, 4
• Duration should be at least 14 days for optimal results 4

Evidence Supporting Topical Antibiotics

Topical Antibiotics vs. Antiseptics

• Topical quinolones are likely superior to boric acid, with one additional person achieving resolution of ear discharge for every 4-5 people treated (compared to boric acid) at two weeks 3, 5
• Topical antibiotics appear more effective than topical antiseptics in resolving otorrhea, though benefits versus placebo in children remain unclear 6

Topical Antibiotics vs. Systemic Antibiotics

• Adding topical antibiotics to systemic antibiotics may increase resolution of ear discharge at 1-2 weeks (88% with topical plus systemic vs 60% with systemic alone) 6
• However, when topical antibiotics are already being used, adding systemic antibiotics may provide little or no additional benefit 7

Treatment Algorithm

Week 1-2:

• Perform aural toileting 1
• Initiate topical quinolone (ofloxacin or ciprofloxacin) as described above 2, 4
• Reassess at 2 weeks 1

If Persistent Discharge After 2 Weeks:

• Consider culture-directed therapy to identify resistant organisms 1
• Continue topical antibiotics for full 14-day course if not yet completed 2, 4

If Refractory After 14 Days:

• Consider short course of systemic antibiotics (though evidence is limited) 1
• Evaluate for surgical intervention (tympanoplasty) 1
• Rule out underlying conditions such as cholesteatoma, foreign body, or tumor 2

Natural History and Surgical Considerations

• Approximately 39% of tympanic membrane perforations in CSOM may heal spontaneously over long-term follow-up 1
• Tympanoplasty should be considered for persistent perforations that fail to heal spontaneously 1
• Cartilage reconstruction shows better morphologic success compared to temporalis muscle fascia 1

Critical Pitfalls to Avoid

Ototoxicity Concerns

• Avoid aminoglycosides when possible due to ototoxicity risk, especially with perforated tympanic membrane 3
• Quinolones have a better safety profile for ototopical use 3, 5

Treatment Duration

• Do not stop treatment prematurely - emphasize completing the full 14-day course even if symptoms improve earlier to prevent recurrence 1, 2
• If discharge persists after one week, obtain cultures rather than immediately switching antibiotics 2

Underlying Conditions

• If otorrhea persists after full course of therapy, or if ≥2 episodes occur within 6 months, further evaluation is mandatory to exclude cholesteatoma, foreign body, or tumor 2

Systemic Antibiotics

• Systemic antibiotics alone (without topical therapy) have very uncertain efficacy for CSOM 7
• Reserve systemic antibiotics for refractory cases or when there are signs of invasive infection 1

Special Populations

Children

• Ofloxacin is FDA-approved for CSOM in patients ≥12 years 2
• For younger children, consider alternative quinolones with appropriate pediatric dosing 3

High-Risk Patients

• Patients with diabetes or immunocompromised states require closer monitoring due to increased risk of complications 8
• Children with Down syndrome and craniofacial malformations are more prone to CSOM and its complications 1

Monitoring and Follow-Up

• Reassess at 2 weeks to evaluate response to treatment 1
• If discharge resolves, monitor for recurrence 1
• Audiometric testing should be performed to assess hearing outcomes after treatment resolution 8
• Address underlying factors such as upper respiratory infections, allergies, or anatomical abnormalities that may contribute to recurrence 1