What is the diagnosis and treatment for chronic otitis media?

From the Guidelines

Chronic otitis media should be treated with a combination of medical and possibly surgical approaches, prioritizing topical antibiotic ear drops such as ciprofloxacin/dexamethasone or ofloxacin as first-line therapy, to reduce the risk of complications and improve quality of life. The treatment of chronic otitis media involves a comprehensive approach to manage the underlying infection and inflammation, as well as to address any associated complications. According to the most recent guidelines 1, the use of topical antibiotic ear drops is recommended as first-line therapy for uncomplicated cases of chronic otitis media.

Key Considerations

• The ear canal should be carefully cleaned by a healthcare provider before administering topical antibiotic ear drops, such as ciprofloxacin/dexamethasone (4 drops twice daily for 7-10 days) or ofloxacin (5 drops twice daily for 10 days) 1.
• Oral antibiotics like amoxicillin-clavulanate (875/125 mg twice daily for 10-14 days) may be necessary for more extensive infections, as noted in previous studies 1.
• Patients should keep their ears dry during treatment by avoiding swimming and using earplugs during showers to prevent further complications.
• For cases with persistent perforation, tympanic membrane repair (tympanoplasty) may be necessary, as highlighted in the guidelines 1.
• Cholesteatoma, a growth of skin cells in the middle ear, requires surgical removal to prevent further complications.

Complications and Risks

• Without proper treatment, complications can include hearing loss, mastoiditis, facial nerve paralysis, or intracranial infections, making timely and appropriate management essential, as emphasized in the guidelines 1.
• The risks of tube insertion, such as tympanostomy tubes, must be balanced against the risks of chronic otitis media, recurrent otitis media, or both, which include suppurative complications, damage to the tympanic membrane, adverse effects of antibiotics, and potential developmental sequelae of mild to moderate hearing loss that is often associated with middle ear effusion 1.

Quality of Life

• Tympanostomy tubes can improve quality of life (QOL) for children with chronic otitis media, recurrent acute otitis media, or both, by reducing the risk of complications and improving hearing outcomes, as noted in the guidelines 1.

From the FDA Drug Label

14.2 Acute Bacterial Otitis Media and Diarrhea in Pediatric Patients One U.S./Canadian clinical trial was conducted which compared 45/6. 4 mg/kg/day (divided every 12 hours) of amoxicillin and clavulanate potassium for 10 days versus 40/10 mg/kg/day (divided every 8 hours) of amoxicillin and clavulanate potassium for 10 days in the treatment of acute otitis media. The clinical efficacy rates at the end of therapy visit (defined as 2 to 4 days after the completion of therapy) and at the follow-up visit (defined as 22 to 28 days post-completion of therapy) were comparable for the 2 treatment groups, with the following cure rates obtained for the evaluable patients:

• At end of therapy, 87% (n = 265) and 82% (n = 260) for 45 mg/kg/day every 12 hours and 40 mg/kg/day every 8 hours, respectively.
• At follow-up, 67% (n = 249) and 69% (n = 243) for 45 mg/kg/day every 12 hours and 40 mg/kg/day every 8 hours, respectively. Chronic otitis media is not directly addressed in the provided drug label, as the label only discusses acute bacterial otitis media. Therefore, no conclusion can be drawn regarding the treatment of chronic otitis media with amoxicillin-clavulanate 2.

From the Research

Definition and Symptoms of Chronic Otitis Media

• Chronic otitis media (COM) is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity, characterized by ear discharge (otorrhoea) through a perforated tympanic membrane 3.
• The predominant symptoms of COM are ear discharge and hearing loss 3, 4.

Treatment Options for Chronic Otitis Media

• Antibiotics are the most common treatment for COM, which act to kill or inhibit the growth of micro-organisms that may be responsible for the infection 3, 5.
• Topical antibiotics may be more effective than systemic administration of antibiotics in achieving resolution of ear discharge (dry ear) 3.
• Systemic antibiotics may be used alone or in addition to other treatments for COM, such as ear cleaning (aural toileting) 5.
• Antibiogram guided optimized medical treatment may be a useful interventional strategy before surgery 6.

Comparison of Topical and Systemic Antibiotics

• Topical administration of antibiotics may slightly increase resolution of ear discharge compared to systemic administration 3.
• There is limited evidence available regarding different types of antibiotics, and it is unclear if one class of antibiotic is more effective than another 3, 5.
• Systemic antibiotics may have adverse effects, but these were poorly reported in the studies included 5.

Management and Outcome of Chronic Otitis Media

• Medical treatment is appropriate either as a curative measure, or for preoperative preparation of the ear 7.
• Surgical outcome may be improved with antibiogram guided optimized medical treatment 6.
• COM carries significant patient morbidity, and treatment options vary according to the activity and type of disease encountered 4.