What are the treatment options for a patient with chronic suppurative otitis media?

Treatment of Chronic Suppurative Otitis Media (CSOM)

The first-line treatment for chronic suppurative otitis media is aural toileting followed by topical antibiotics, specifically topical quinolones (such as ofloxacin 10 drops twice daily for 14 days in patients ≥12 years), which are more effective than topical antiseptics and likely superior to systemic antibiotics alone. 1, 2, 3

Initial Management Algorithm

Step 1: Aural Toileting

• Perform aural toileting (ear cleaning/suction) 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 1

Step 2: First-Line Topical Antibiotic Therapy

For patients ≥12 years with tympanic membrane perforation:

• Ofloxacin otic solution: 10 drops (0.5 mL, 1.5 mg) instilled into the affected ear twice daily for 14 days 2
• Warm the bottle in hand for 1-2 minutes before instillation 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 quinolones:

• Ciprofloxacin drops are also effective and likely increase resolution of ear discharge compared to boric acid (moderate-certainty evidence showing one additional person achieves resolution for every 4-5 people treated) 3, 4

Why Topical Quinolones Are Preferred

• Topical quinolones are likely more effective than topical antiseptics (boric acid) at achieving resolution of ear discharge at 1-2 weeks (RR 1.86,95% CI 1.48 to 2.35) 3
• Topical antibiotics may be more effective than systemic antibiotics alone 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) 5
• Adding topical antibiotics to systemic antibiotics increases resolution rates from 60% to 88% at 1-2 weeks 1

Step 3: Management of Persistent Discharge

If discharge persists after 2 weeks of topical therapy:

• Consider culture-directed therapy to identify resistant organisms 1
• Obtain culture and sensitivity testing to guide antibiotic selection 1

For refractory cases:

• Consider a short course of systemic antibiotics in addition to topical therapy 1
• Oral amoxicillin-clavulanate (covering beta-lactamase-producing organisms) can be added to topical therapy 6
• Reassess within 48-72 hours to confirm improvement 6

Step 4: Surgical Evaluation

Consider ENT referral for tympanoplasty if:

• Tympanic membrane perforation persists beyond 3 months and fails to heal spontaneously 1, 6
• Discharge persists beyond 2-3 weeks despite appropriate antibiotic therapy 6
• Note that approximately 39% of tympanic membrane perforations may heal spontaneously over long-term follow-up 1

Surgical considerations:

• Cartilage reconstruction shows better morphologic success compared to temporalis muscle fascia for tympanoplasty 1
• Novel adjuvant treatments include biomolecules and bioengineered scaffolds 1

Comparison of Treatment Options

Topical Antibiotics vs. Topical Antiseptics

Topical quinolones vs. acetic acid:

• The evidence is very uncertain whether acetic acid differs from topical quinolones at 1-2 weeks 3
• Acetic acid may increase resolution compared to aminoglycosides at 1-2 weeks (low-certainty evidence) 3

Topical quinolones vs. boric acid:

• Topical quinolones likely result in greater hearing improvement (mean difference 2.79 dB) compared to boric acid, though this may not be clinically significant 3
• There may be less ear pain, discomfort, or irritation with quinolones compared to boric acid (RR 0.56,95% CI 0.32 to 0.98) 3

Systemic Antibiotics

• Systemic antibiotics alone (without topical therapy) have very uncertain effectiveness compared to placebo for CSOM 7
• When topical antibiotics are used in both groups, adding oral antibiotics may provide little or no additional benefit (RR 1.05,95% CI 0.94 to 1.17 at 1-2 weeks) 7
• The evidence supporting systemic antibiotics is limited and of very low certainty 7

Critical Pitfalls to Avoid

• Do not use ototoxic preparations (such as aminoglycosides) when tympanic membrane integrity is uncertain, as these can cause permanent hearing damage 6
• Do not continue topical therapy alone beyond 72 hours without improvement, as this delays appropriate systemic treatment and risks complications 6
• Complete the full 14-day course of treatment even if symptoms improve earlier to prevent recurrence and complications 1
• Do not misdiagnose as acute otitis media - CSOM is defined as chronic discharge through a perforated tympanic membrane, distinct from acute suppurative otitis media 8
• Address underlying factors such as upper respiratory infections, allergies, or anatomical abnormalities that may contribute to recurrence 1

Special Populations at Higher Risk

• Children with Down syndrome are more prone to CSOM and its complications 1
• Patients with craniofacial malformations have increased susceptibility 1
• These populations require closer monitoring and may need earlier surgical intervention 1

Common Complications to Monitor

• Myringosclerosis (scarring of the tympanic membrane) 1
• Tympanic membrane atrophy 1
• Persistent perforation requiring surgical repair 1