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‫ ﻣﻮرد‬1 : ‫ﺗﻌﺪاد اﯾﺘﻢ ﻗﺎﺑﻞ ﻣﺸﺎﻫﺪه ﺑﺎﻗﯿﻤﺎﻧﺪه‬

Version May 2021

  

‫ﺟﺴﺘﺠﻮ‬ ‫ﻋﻨﻮاﻥ‬

Chronic suppurative otitis media (CSOM): Treatment,

complications, and prevention
Authors:
Jessica Levi, MD

Robert C O'Reilly, MD

Section Editor:
Glenn C Isaacson, MD, FAAP

Deputy Editor:
Carrie Armsby, MD, MPH

Literature review current through: Apr 2021. | This topic last updated: Dec 03, 2018.

INTRODUCTION — Chronic suppurative otitis media (CSOM) is one of the most common childhood infectious
diseases worldwide and is a common cause of hearing impairment in resource-limited settings, although it is less frequently seen in resource-
rich settings [1]. It is characterized by chronic drainage from the middle ear associated with tympanic membrane perforation (picture 1) [2,3].
CSOM is usually preceded by an episode of acute otitis media (AOM).

The treatment, complications, and prevention of CSOM are reviewed here. The clinical features and diagnosis of CSOM are discussed in detail
separately. CSOM in the setting of tympanostomy tubes is also reviewed separately. (See "Chronic suppurative otitis media (CSOM): Clinical
features and diagnosis" and "Tympanostomy tube otorrhea in children: Causes, prevention, and management".)

AOM, otitis media with effusion, and cholesteatoma in children and acute and chronic otitis media in adults are reviewed separately:

● (See "Acute otitis media in children: Epidemiology, microbiology, and complications".)

● (See "Acute otitis media in children: Treatment".)

● (See "Otitis media with effusion (serous otitis media) in children: Management".)

● (See "Cholesteatoma in children".)

● (See "Acute otitis media in adults".)

● (See "Chronic otitis media, cholesteatoma, and mastoiditis in adults".)

INITIAL THERAPY — We suggest aural toilet plus empiric topical antibiotics for initial therapy. The primary goal
of treatment is eradicating infection and preventing complications, which is achieved by producing a dry ear. Longer term goals include
healing/repair of the tympanic membrane (TM) and improvement in hearing [4].

Educating caregivers on the proper administration of topical antibiotics and other measures that reduce recurrence is an important aspect of
initial management. One study found that families randomized to an educational program regarding the placement of ear drops as well as
decreasing risk factors had a higher cure rate than those given antibiotics alone at one, three, and six months [5].

Aural toilet — We suggest aural toilet in combination with a topical quinolone for initial therapy. (See 'Ototopical antibiotics' below.)
Aural toilet is a key component of treatment, since it allows the topical antibiotic or antiseptic to truly penetrate to the source of the disease.
However, its efficacy is debated, particularly when used as the sole therapy.
Aural toilet is performed until the ear is consistently dry and free of debris [6]. Techniques include:

● Dry mopping (the otorrhea is absorbed by a wisp of cotton wool that is wrapped around a probe used for ear wax removal and inserted into
the ear canal under direct visualization with a head lamp, otoscope, or microscope)

● Ear wicking

● Gentle syringing

● Suctioning

Careful suctioning of the ear canal to remove gross amounts of debris can be accomplished in the office. The preferred method is suctioning
under the microscope (typically performed by an otolaryngologist), because it also allows for a better examination to help rule out cholesteatoma.
Wick placement, if there is sufficient canal edema to hold the wick in place, can also be performed by a clinician and then removed at a later date
by either the patient/caregiver or the clinician.

There are no standards regarding how often aural toilet should be performed. The frequency of suctioning depends upon how fast the debris
accumulates and how easy it is for the patient to return to the office. Some otolaryngologists advise performing aural toilet at least two to three
times per week [7], but this frequency may not be necessary in less severe cases. Daily aural toilet may be beneficial in patients who have failed
previous therapy [8].

Limited data suggest that aural toilet alone is not as effective as topical or systemic antibiotic therapy alone or in combination with aural toilet.
Observational studies suggested that otorrhea may resolve with aural toilet in as many as 60 to 80 percent of cases [9,10]; however, results of
randomized trials contradict these findings [4,11]. In a randomized trial of 524 children with CSOM assigned to combination therapy (consisting of
aural toilet plus topical and systemic antibiotics plus topical steroids), aural toilet alone, or no specific treatment, 51 percent of patients in the
combination therapy group had resolved otorrhea by 16 weeks compared with only 22 percent in the other two treatment groups [4]. In a similar
small randomized trial, all 21 children with CSOM treated with aural toilet and intravenous (IV) antibiotic improved, whereas only 1 of 12 patients
who received aural toilet alone had resolution of otorrhea [11].

Ototopical antibiotics — We suggest ofloxacin otic solution (five drops three times a day) or ciprofloxacin otic
solution (0.25 mL single dose container twice daily) for two weeks in addition to aural toilet. (See 'Aural toilet' above.)

Treatment with topical antibiotic therapy is preferred over systemic antibiotic therapy for the following reasons:

● Oral antibiotics may have limited efficacy in some patients with CSOM because of tissue damage, inflammation, scarring, and limited
vascularization of the middle ear mucosa. (See 'Oral antibiotics' below.)

● Systemic side effects are minimized with topical antibiotic therapy, particularly in children [12].

● In most cases, systemic antibiotics alone or in combination with topical preparations do not improve treatment outcomes over topical
antibiotics alone [13,14].

Cost-effectiveness studies have shown that aural toilet plus drops are more cost effective than other treatments [15].

Fluoroquinolones (eg, ciprofloxacin, ofloxacin) are effective against many of the gram-positive and gram-negative organisms that cause CSOM
and are the most commonly used topical medication for CSOM in the United States. (See "Chronic suppurative otitis media (CSOM): Clinical
features and diagnosis", section on 'Microbiology'.)

Fluoroquinolones are highly effective in treating CSOM, with reported cure rates ranging from 75 to 100 percent [16-19]. Data from randomized
clinical trials suggest topical quinolones are more effective than other alternatives, including oral amoxicillin-clavulanic acid, oral ciprofloxacin,
and topical aminoglycosides [13,16-18]. Additional considerations that favor topical fluoroquinolones over topical aminoglycosides include their
greater effectiveness against Pseudomonas and lower risk of ototoxicity [20]. However, some Pseudomonas and many methicillin-resistant
Staphylococcus aureus (MRSA) isolates are resistant to fluoroquinolones and require culture-directed treatment. (See 'Treatment failure' below.)

With the exception of ototopical ofloxacin and ciprofloxacin, there are no US Food and Drug Administration (FDA)-approved topical antibiotics for
use in the presence of a non-intact TM or patent tympanostomy tube. Although non-FDA-approved agents are widely used, including topical
aminoglycoside drops, antifungals, and other agents (eg, neomycin/polymyxin B), the potential for ototoxicity should be kept in mind and
discussed with the patients, especially if long-term or frequent use is planned [21-23].

Ototopical corticosteroids — Topical corticosteroid use (usually in combination with an ototopical antibiotic) is
controversial and not well studied. We typically only use a combination drop (antibiotic plus corticosteroid) if granulation tissue (picture 2) is
present [24,25]. A randomized controlled trial in 110 patients with CSOM found no difference in disease resolution among patients treated with
combination ofloxacin plus dexamethasone compared with those treated with ofloxacin alone [26]. The use of combination fluoroquinolone plus
corticosteroid ototopical therapy in the management of tympanostomy tube otorrhea is discussed separately. (See "Tympanostomy tube otorrhea
in children: Causes, prevention, and management", section on 'Uncomplicated acute tympanostomy tube otorrhea'.)

Antiseptic agents — Use of topical antiseptic agents to clean the ear canal and middle ear of debris is generally limited to
settings where suction is unavailable or for patients who cannot easily get to a clinician's office for the initial or subsequent cleanings. Examples
of antiseptic agents used in this setting include hydrogen peroxide, zinc, boric acid, acetic acid (vinegar), and povidone-iodine (PVP-I). Although
these agents are widely used, the potential for ototoxicity should be kept in mind and discussed with patients, especially if long-term or frequent
use is planned. The potential for ototoxicity with these agents is uncertain; however, data from animal studies suggest ototoxicity may occur with
PVP-I [27]. (See 'Alternatives in resource-limited settings' below.)

In our practice, when an alternative to aural toilet is needed, we typically use a 50 percent peroxide solution in sterile water for clearing the ear
canal prior to placement of topical therapies. However, there are no published data on this approach. We typically instill approximately five drops
of the solution into the affected ear, let it sit in the ear canal for at least 30 seconds if possible, and then have the patient tip their head to let the
solution and debris drain out.

Alternatives in resource-limited settings — Antibiotics (topical, oral, and IV) are often not
available to patients in resource-limited settings. Alternative irrigation solutions are frequently used to treat CSOM in these situations. Commonly
used agents include Burrow's solution (13 percent aluminum acetate) and other topical antiseptics as previously described (see 'Antiseptic
agents' above). Most antiseptic agents have ototoxic potential [7].

Treatment with acetic acid (vinegar) achieves resolution of otorrhea in approximately 60 to 80 percent of patients [28,29]. Unfortunately, acidic
solutions can irritate the middle ear, so compliance is a potential issue. In an in vitro study, Burrow's solution had greater activity against several
of the organisms commonly found in the draining ear than acetic acid [30]. Burrow's solution was also as effective as topical gentamicin (67 and
68 percent, respectively) in another series [31]. However, there are no studies that have compared these solutions with topical quinolones. (See
'Ototopical antibiotics' above.)

Another topical antiseptic option is PVP-I, which is effective against gram-positive and gram-negative bacteria, anaerobes, spores, mycobacteria,
fungi, viruses, and protozoans. In one randomized trial of 40 patients with CSOM, PVP-I was equivalent to topical ciprofloxacin when
administered three times daily for 10 days (88 percent versus 90 percent cure, respectively) [32]. In addition, 17 percent of the organisms were
resistant to topical ciprofloxacin, but no organisms were resistant to PVP-I. Based on animal studies, PVP-I has a potential risk of ototoxicity [27].

TREATMENT FAILURE
Causes — Treatment is considered to have failed if otorrhea continues after approximately three weeks of medical therapy. Causes of
failure include resistant organisms, poor adherence to the medical regimen, presence of a cholesteatoma, or underlying immunodeficiency (eg,
HIV) [33-36].

Failure rates of medical treatment vary widely in the literature (from 20 to 80 percent), often depending upon the therapy used [34]. The actual
failure rate of medical therapy for CSOM may be lower than reported, however, since some patients may have an unrecognized underlying
cholesteatoma, a surgical disease that will not resolve with medical treatment. (See "Cholesteatoma in children".)

Evaluation — Cultures should be obtained in patients who fail initial therapy. Cultures should be obtained under the microscope
directly through the tympanic membrane (TM) perforation, since cultures taken from the external auditory canal may be unreliable or misleading
[37].

In addition, evaluation for alternative or additional diagnoses should be considered in cases of treatment failure, particularly in patients with good
adherence to the medical regimen. (See "Chronic suppurative otitis media (CSOM): Clinical features and diagnosis", section on 'Differential
diagnosis'.)

If cholesteatoma is suspected, high resolution computed tomography (CT) may be warranted. (See "Cholesteatoma in children", section on
'Diagnosis'.)

Treatment — Patients with treatment failure are treated with culture-directed topical antibiotics in addition to aural toilet. If there is no
therapeutic topical option based on the susceptibility patterns of the isolated pathogen, we use oral antibiotics. If the patient fails culture-directed
topical or oral therapy, we treat with intravenous (IV) antibiotics. However, some centers advocate surgery rather than IV antibiotics for patients
who fail ototopical or oral antibiotic courses. Other experts (including the authors of this topic) believe that middle ear and mastoid surgery should
be reserved for children who fail maximal medical therapy (including IV antibiotics) [38] or have recurrent disease over a relatively short period of
time (approximately six to eight weeks) [39]. Recurrent disease is discussed below. (See 'Recurrent disease' below.)

Topical antibiotics — Ofloxacin and ciprofloxacin otic solutions are the only topical preparations approved by the US
Food and Drug Administration (FDA) for use in ears with perforated tympanic membranes (TMs); thus, use of all other topical antibiotics is off
label for CSOM. As an example, in cases of methicillin-resistant Staphylococcus aureus (MRSA) that are not sensitive to quinolones, we use
vancomycin ophthalmic solution (25 mg/mL), three drops in affected ear(s) three times a day for up to two weeks, with audiologic monitoring and
ear examination at least weekly to make sure hearing is stable and to determine length of therapy [40].

Oral antibiotics — We use oral antibiotics in patients who fail initial topical therapy and whose culture results indicate that
there is no therapeutic topical antibiotic available. The choice of antibiotic is based on culture results. Oral quinolones (eg, ciprofloxacin) are
reserved for cases in which there is no other safe and effective alternative. We typically treat for 14 to 21 days.

Oral antibiotics may have limited efficacy in CSOM because of tissue damage, inflammation, and scarring, as well as limited vascularization of
the middle ear mucosa, that make it difficult for systemic therapy to reach the source of the infection [7,41]. In addition, they have greater
potential side effects than do topical antibiotics. However, the available data suggest that oral quinolones may be effective agents in patients who
have failed topical therapy and have bacteria resistant to other antibiotics [42,43]. Oral linezolid is effective in treating refractory CSOM caused
by MRSA and multiple drug-resistant S. pneumoniae [44].

Intravenous antibiotics — In patients who fail culture-directed topical or oral therapy (for a minimum of 14 to 21
days), we treat with IV antibiotics. If the patient is in an inpatient setting, or lives close by, frequent aural toilet in the office in conjunction with IV
therapy may facilitate clearing of the infection (see 'Aural toilet' above). We advise consultation with an infectious disease specialist to help
determine the best antibiotic choice in patients who require IV therapy. High resistance rates are seen with IV penicillin G and ampicillin, and
poor response rates are also seen with erythromycin [45,46]. Better response rates are seen with more broad-spectrum antibiotics, such as
mezlocillin and ceftazidime [11,46].
Pseudomonas aeruginosa and methicillin-resistant MRSA are the most commonly identified resistant organisms in CSOM [10,45,47]. P.
aeruginosa was most susceptible to ciprofloxacin and imipenem in one series [45], and aztreonam was as effective against P. aeruginosa as
ceftazidime in a small randomized trial (10 of 15 and 13 of 15 patients cured, respectively) [48]. However, ciprofloxacin-resistant P. aeruginosa
was identified in all 88 patients (including adults) with CSOM unresponsive to treatment with topical ciprofloxacin in a subsequent study [49]. In
vitro testing of these bacterial isolates revealed that nearly all (96 percent) were susceptible to imipenem; whereas <60 percent were susceptible
to other antibiotics (including amikacin, piperacillin-tazobactam, and ceftazidime).

In a series of patients with community-acquired MRSA, all organisms were susceptible to trimethoprim-sulfamethoxazole and 90 percent were
susceptible to rifampin [50]. In a retrospective study, drainage resolved in 17 of 22 patients treated with teicoplanin and 12 of 15 patients treated
with vancomycin for CSOM with MRSA, which was similar to the rate of improvement seen with aural toilet and irrigation with acetic acid or
Burrow's solution [10].

Surgery — We prefer to exhaust all medical options before proceeding with surgical therapy. Surgical options include
tympanoplasty or tympanomastoidectomy. When possible, we obtain a CT scan in patients who fail medical therapy to evaluate for
cholesteatoma prior to surgery, since this finding affects the surgical approach (usually mastoidectomy with tympanoplasty is performed rather
than tympanoplasty alone). Surgical therapy was the mainstay of treatment for CSOM until the mid-1980s [51]. However, its precise role in
uncomplicated CSOM without cholesteatoma and exactly which procedure should be performed are controversial. Management of
cholesteatoma is discussed in greater detail separately. (See 'Management of recurrent disease' below and "Cholesteatoma in children".)

The available data suggest that there is no role for mastoidectomy in treating children with uncomplicated CSOM [52]. One retrospective study
compared three groups of patients with CSOM; those with dry ears undergoing tympanoplasty only (n = 242), those with wet ears undergoing
tympanoplasty only (n = 53), and those with wet ears undergoing canal wall up tympanomastoidectomy (n = 28) [53]. There were no differences
among the three groups with respect to hearing outcomes or graft success rates [54]. Another retrospective study similarly compared patients
with CSOM undergoing tympanoplasty with (n = 147) and without (n = 104) mastoidectomy and also found no difference in graft success rate,
regardless of preoperative otorrhea or CT scan findings. Performing a mastoidectomy in addition to tympanoplasty adds cost, time, and potential
for complications. In addition, in resource-limited regions where rates of CSOM are highest, access to surgical care can be limited.

Patients with bilateral disease can be treated at the same time with bilateral tympanoplasties [55].

RECURRENT DISEASE — CSOM is generally a remitting and relapsing disease. In a small number of
patients, it is truly chronic without cessation of symptoms despite therapy.

Frequency and risk factors — Recurrence is most common during the first several months after initial therapy.
The rates of relapse do not appear to be affected by age, duration of ear drainage, specific antibiotic used, or presence of granulation tissue.
Recurrence rates are variable, ranging from 15 to 65 percent, probably due in part to the lack of consistency in treatment approaches
[10,29,39,43,56-59]. In one study, early recurrence was associated with poorer response to subsequent therapy including antimicrobials and
surgery [57].

One of the main determining factors for recurrence is the status of the tympanic membrane (TM). Even when the perforation is dry and the acute
infection has been treated adequately, the patient is at risk for further episodes of suppuration until the TM has healed.

In a report of 51 children with CSOM who were followed for a median of 4.3 years after initial treatment, two patients failed initial medical therapy
and underwent tympanomastoidectomy (one of whom had recurrent CSOM and was discovered to have a cholesteatoma on repeat surgery)
[39]. Of the 49 patients who responded to initial medical therapy, 22 patients (45 percent) had recurrent disease, most of whom cleared with
outpatient medical management. Four patients required intravenous antibiotic therapy and nine required surgery due to recurrent disease that
did not clear with medical management. Four of these patients required revision surgery, at which time three were found to have a
cholesteatoma.

Prevention of recurrences — Measures to prevent recurrences of CSOM after successful treatment depend in
part on the function of the Eustachian tube, which tends to improve with age. Preventive measures include teaching the patient to keep the ears
dry (ie, aural toilet and strict water precautions) and surgical repair of the perforated TM if needed [38]. We prefer these approaches rather than
long courses of prophylactic antibiotics, which can make subsequent treatment more difficult if antibiotic resistance develops. (See 'Management
of recurrent disease' below and 'Aural toilet' above.)

Management of recurrent disease — We advise strict water precautions for patients with recurrent
disease. In addition, the patient should undergo a computed tomography (CT) scan to evaluate for cholesteatoma if this has not already been
performed, since cholesteatoma can present as recurrent otorrhea. We perform tympanoplasty in patients without cholesteatoma who continue
to have recurrent disease despite water precautions. (See "Chronic suppurative otitis media (CSOM): Clinical features and diagnosis", section on
'Differential diagnosis'.)

Surgery for persistent tympanic membrane perforation — TM perforations often

heal with effective treatment of CSOM and surgery is not required in these cases. As an example, approximately 14 percent of 524 children had
healing of the TM by 16 weeks [4], and in another series 24 of 32 patients (75 percent) diagnosed with CSOM between the ages of 0 and 4
healed spontaneously by ages 11 to 15 [60]. Tympanoplasty is advised in patients who have persistent perforation for >6 to 12 months after
resolution of CSOM to prevent recurrence, but we do not advise routine mastoidectomy in this setting. (See 'Surgery' above.)

COMPLICATIONS — Complications include extra- and intracranial spread of infection, persistent hearing loss,
and rarely, death.
Risk factors — Complicated CSOM occurs most commonly in adolescents and young adults [61-63]. Several studies have
reported that males are at greater risk for complicated CSOM [61,63]. Other risk factors include:

● Low socioeconomic status [63,64]

● Prolonged symptom duration before seeking medical attention [35]

● Atticoantral type of CSOM [61,65] (see "Chronic suppurative otitis media (CSOM): Clinical features and diagnosis", section on 'Anatomic
classification of CSOM')

● Cholesteatoma [61,63,65,66] (see "Cholesteatoma in children")

● Infection caused by multidrug resistant bacteria [35]

● Underlying HIV infection [35]

Infectious extra- and intracranial complications — Extra- and intracranial

complications occur when the infection spreads through natural or pathologic bony dehiscences and vascular channels to involve the mastoid,
facial nerve, labyrinth, lateral sinus, cerebrospinal fluid, and brain (figure 1).

A change in clinical picture should alert the clinician to an infectious complication [64]:

● Extracranial complications – Extracranial complications may include [63,66-70]:

• Mastoiditis (picture 3A-B), which is the most common (see "Acute mastoiditis in children: Clinical features and diagnosis", section on
'Complications')

• Subperiosteal abscess (see "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Complications')

• Facial paralysis (see "Facial nerve palsy in children")

• Labyrinthitis (see "Vestibular neuritis and labyrinthitis")

Dizziness suggests a labyrinthine fistula, and facial nerve palsy suggests inflammation of the facial nerve. Subperiosteal mastoid abscesses
are often associated with cholesteatoma [70]. (See "Cholesteatoma in children".)

● Intracranial complications – Patients with intracranial complications often present with fever, headache, earache, vestibular symptoms,
meningeal signs, and alteration in mental status [66]. Reported intracranial complications of CSOM include [62,64,66-69,71]:

• Meningitis (see "Bacterial meningitis in children older than one month: Clinical features and diagnosis")

• Subdural, epidural, perisinus, or brain abscess (see "Pathogenesis, clinical manifestations, and diagnosis of brain abscess" and
"Intracranial epidural abscess")

• Lateral sinus thrombosis (see "Septic dural sinus thrombosis", section on 'Septic lateral sinus thrombosis')

Brain abscess and meningitis are the most commonly reported intracranial complications [67,71]. Multiple intracranial complications can
occur together. Reported mortality rates range from 3 to 19 percent [66,71].

Extracranial and intracranial complications often necessitate surgery in addition to broad spectrum intravenous antibiotics, although the exact
procedure differs depending upon the complication. Consultation with a neurosurgeon may be warranted for children with clinical or radiologic
evidence of an intracranial complication.

The rate of intra- and extracranial complications varies depending on risk factors in the population studied, particularly poverty. In most series,
the complication rate is <1 percent [66,67,72]. Extracranial complications are more common than intracranial complications, and approximately
one-third of patients have two or more complications [61,64,66].

The bacteriology in complicated CSOM differs somewhat from that of uncomplicated cases, with Proteus being the most common isolate
followed by anaerobes, and most specimens comprised of mixed flora [62,65,67,69].

The mortality in complicated CSOM ranges from 0 to 20 percent depending on the population studied [61,62,66,68].

Persistent hearing loss — CSOM is one of the most common causes of preventable hearing loss [1,35]. In one
series, 90 percent of children with CSOM had permanent hearing loss of >15 decibels (dB) [73]. (See "Chronic suppurative otitis media (CSOM):
Clinical features and diagnosis", section on 'Hearing loss'.)

Conductive hearing loss is more common than sensorineural hearing loss (SNHL), but both may occur. The type of hearing loss is important
because while conductive hearing loss may improve with therapy and/or surgery; SNHL generally does not. Conductive hearing loss results from
fluid in the middle ear and eventually from erosion of the ossicles, preventing conduction of the sound to the cochlea. In contrast, SNHL is
thought to be due to chemical mediators and toxins that are produced by the disease process and enter the cochlea. Exposure to ototoxic
medications (eg, aminoglycosides) may also play a role. Reported risk factors for developing SNHL include older age, longer disease duration,
larger perforations, smoking, and diabetes [74-76].

There have been few reports of cochlear implantation in patients with a history of CSOM, since cochlear implants can only be placed after the
disease is completely eradicated and it is not often an option in resource limited settings [77-80]. In the reported case series, patients underwent
a single procedure or a staged procedure depending on whether there was additional pathology (eg, cholesteatoma, unstable mastoid cavity)
and complication rates were low with good audiometric outcomes [77-80]. If CSOM develops in a patient with a pre-existing cochlear implant, it is
possible to treat the infection without removing the implant, as long as there is no cholesteatoma [81].
Treatment of hearing impairment, including the use of cochlear implants, is discussed in greater detail separately. (See "Hearing loss in children:
Treatment", section on 'Cochlear implants' and "Hearing amplification in adults", section on 'Cochlear implants'.)

PREVENTION — The cornerstone of disease management for CSOM is prevention, because the availability of different
treatment modalities may be limited in many settings, failure rates are often high, and hearing loss can occur even when adequate treatment is
provided. (See 'Persistent hearing loss' above.)

One of the first steps in primary disease prevention is education and knowledge about the disease process, which is lacking in much of the at-
risk population [82]. CSOM frequently begins with acute otitis media (AOM). Thus, preventing and promptly and appropriately treating AOM
should decrease the incidence of CSOM [3]. In theory, public health interventions that address risk factors, such as passive smoke exposure,
contaminated water, and malnutrition, may also decrease rates of CSOM, although definitive proof that these measures are effective is lacking
[83]. (See "Chronic suppurative otitis media (CSOM): Clinical features and diagnosis", section on 'Risk factors' and "Acute otitis media in
children: Epidemiology, microbiology, and complications" and "Acute otitis media in children: Treatment" and "Acute otitis media in children:
Prevention of recurrence" and "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Complications of AOM'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from

selected countries and regions around the world are provided separately. (See "Society guideline links: Acute otitis media, otitis media with
effusion, and external otitis".)

SUMMARY AND RECOMMENDATIONS

● Chronic suppurative otitis media (CSOM) is one of the most common childhood infectious diseases worldwide and is a common cause of
hearing impairment in resource-limited settings, although it is less frequently seen in resource-rich settings. It is characterized by chronic
drainage from the middle ear associated with tympanic membrane (TM) perforation (picture 1). CSOM is usually preceded by an episode of
acute otitis media (AOM). (See 'Introduction' above.)

● For patients with uncomplicated CSOM without cholesteatoma, we suggest aural toilet plus an ototopical fluoroquinolone (eg, ciprofloxacin,
ofloxacin) for initial therapy rather than other topical antibiotics or either therapy alone (Grade 2C). Acceptable regimens include ofloxacin
otic solution (five drops three times a day) or ciprofloxacin otic solution (0.25 mL single dose container twice daily) for two weeks. Aural toilet
is performed until the ear is consistently dry and free of debris. (See 'Initial therapy' above.)

● For patients who fail initial therapy (defined as persistent otorrhea after approximately three weeks of initial topical treatment), we suggest
culture-directed antibiotic therapy rather than surgery (Grade 2C). Cultures should be obtained from the middle ear (ie, through the TM
perforation), not from the external auditory canal. We typically use a topical antibiotic, unless there is no suitable option based upon the
susceptibility pattern of the isolated pathogen, in which case we use an oral antibiotic. We generally reserve intravenous antibiotic therapy
for patients who fail culture-directed topical or oral therapy. (See 'Treatment failure' above.)

● CSOM is a remitting and relapsing disease, with recurrence most common during the first several months after initial therapy. While
recurrence is common, most patients are successfully treated with medical therapy alone. We advise strict water precautions for prevention
and management of recurrent disease. We also obtain a computed tomography scan to evaluate for cholesteatoma if this has not already
been performed. Tympanoplasty is an appropriate treatment option for patients without cholesteatoma who have recurrent disease despite
water precautions, or a persistent TM perforation >6 to 12 months after resolution of CSOM. (See 'Recurrent disease' above.)

● Complications of CSOM include extra- and intracranial spread of infection, persistent hearing loss, and rarely, death. (See 'Complications'
above.)

● The cornerstone of disease management for CSOM is prevention, because the availability of different treatment modalities may be limited in
many settings, failure rates are often high, and hearing loss can occur even when adequate treatment is provided. Primary prevention is
focused on promptly and appropriately treating AOM, which usually precedes CSOM. In addition, public health interventions that address
risk factors may also decrease rates of CSOM. (See 'Prevention' above.)

REFERENCES
Verhoeff M, van der Veen EL, Rovers MM, et al. Chronic suppurative otitis media: a review. Int J Pediatr Otorhinolaryngol 2006; 70:1.
WHO. Child and adolescent health and development. Prevention of blindness and deafness. Chronic suppurative otitis media. Burden of illness a
nd management options. Geneva, Switzerland: WHO; 2004. http://www.who.int/pbd/deafness/activities/hearing_care/otitis_media.pdf (Accessed
on September 17, 2012).
Bluestone CD. Epidemiology and pathogenesis of chronic suppurative otitis media: implications for prevention and treatment. Int J Pediatr
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Topic 91002 Version 15.0

References

1 : Chronic suppurative otitis media: a review.

2 : Chronic suppurative otitis media: a review.

3 : Epidemiology and pathogenesis of chronic suppurative otitis media: implications for prevention and treatment.

4 : Randomised controlled trial of treatment of chronic suppurative otitis media in Kenyan schoolchildren.

5 : Impact of Educational Program on the Management of Chronic Suppurative Otitis Media among Children.

6 : Impact of Educational Program on the Management of Chronic Suppurative Otitis Media among Children.

7 : Topical treatment of chronic suppurative otitis media.

8 : Outpatient management of chronic suppurative otitis media without cholesteatoma in children.

9 : Chronic suppurative otitis media in a children's hospital in Addis Ababa, Ethiopia.

10 : The appropriate medical management of methicillin-resistant Staphylococcus aureus in chronic suppurative otitis media.

11 : Medical management of chronic suppurative otitis media without cholesteatoma in children.

12 : Ofloxacin otic solution in patients with otitis media: an analysis of drug concentrations.

13 : Efficacy of Empirical Therapy With Combined Ciprofloxacin Versus Topical Drops Alone in Patients With Tubotympanic Chronic
Suppurative Otitis Media: A Randomized Double-Blind Controlled Trial.

14 : Topical vs Combination Ciprofloxacin in the Management of Discharging Chronic Suppurative Otitis Media.

15 : Cost-effectiveness of selected interventions for hearing impairment in Africa and Asia: a mathematical modelling approach.

16 : Ofloxacin eardrop treatment for active chronic suppurative otitis media: prospective randomized study.

17 : Effectiveness of ototopical antibiotics for chronic suppurative otitis media in Aboriginal children: a community-based, multicentre, double-
blind randomised controlled trial.

18 : Why are ototopical aminoglycosides still first-line therapy for chronic suppurative otitis media? A systematic review and discussion of
aminoglycosides versus quinolones.

19 : Topical antibiotics without steroids for chronically discharging ears with underlying eardrum perforations.

20 : In vitro susceptibility of aural isolates of Pseudomonas aeruginosa to commonly used ototopical antibiotics.

21 : Steroids in aminoglycoside-containing ear drops: do they reduce cochlear toxicity?

22 : Is there an ototoxicity risk from Cortisporin and comparable otic suspensions? Distortion-product otoacoustic emission findings.
23 : Ototoxicity caused by topical administration of gentamicin versus tobramycin in rabbits.

24 : Use of ototopical antibiotics in treating 3 common ear diseases.

25 : Chronic suppurative otitis media

26 : Efficacy and safety of ofloxacin and its combination with dexamethasone in chronic suppurative otitis media. A randomised, double blind,
parallel group, comparative study.

27 : Ototoxicity of Povidone-Iodine applied to the middle ear cavity of guinea pigs.

28 : Role of Acetic Acid Irrigation in Medical Management of Chronic Suppurative Otitis Media: A Comparative Study.

29 : The management of chronic suppurative otitis media with acid media solution.

30 : The antibacterial activity of acetic acid and Burow's solution as topical otological preparations.

31 : A double-blind, randomized, prospective trial of a topical antiseptic versus a topical antibiotic in the treatment of otorrhoea.

32 : Evaluation of topical povidone-iodine in chronic suppurative otitis media.

33 : Preoperative treatment of children with chronic suppurative otitis media.

34 : The role of anaerobic bacteria in chronic suppurative otitis media in children: implications for medical therapy.

35 : Predictors of disease complications and treatment outcome among patients with chronic suppurative otitis media attending a tertiary
hospital, Mwanza Tanzania.

36 : Changes in antibiotic resistance in recurrent Pseudomonas aeruginosa infections of chronic suppurative otitis media.

37 : Reliability of the microbiology of spontaneously draining acute otitis media in children.

38 : Current management of chronic suppurative otitis media in infants and children.

39 : Medical management of chronic suppurative otitis media without cholesteatoma in children--update 1992.

40 : Topical vancomycin for chronic suppurative otitis media with methicillin-resistant Staphylococcus aureus otorrhoea.

41 : Systemic antibiotics versus topical treatments for chronically discharging ears with underlying eardrum perforations.

42 : Microbiology of the chronic suppurative otitis media.

43 : Oral ciprofloxacin in the management of chronic suppurative otitis media without cholesteatoma in children: preliminary experience in 21
children.

44 : Linezolid for tympanostomy tube otorrhea caused by methicillin-resistant Staphylococcus aureus and multiple drug-resistant
Streptococcus pneumoniae.

45 : Etiology and therapy of chronic suppurative otitis.

46 : Management of chronic suppurative otitis media: superiority of therapy effective against anaerobic bacteria.

47 : Antimicrobial resistance of Staphylococcus from otorrhea in chronic suppurative otitis media and comparison with results of all isolated
Staphylococci.

48 : Ceftazidime versus aztreonam in the treatment of pseudomonal chronic suppurative otitis media in children.

49 : Emergence of ciprofloxacin-resistant pseudomonas in chronic suppurative otitis media.

 9 e ge ce o c p o o ac es sta t pseudo o as c o c suppu at e ot t s ed a

50 : The changes of MRSA infections in chronic suppurative otitis media.

51 : Medical management of chronic suppurative otitis media without cholesteatoma in children.

52 : Role of aerating mastoidectomy in noncholesteatomatous chronic otitis media.

53 : Mastoidectomy in noncholesteatomatous chronic suppurative otitis media: is it necessary?

54 : Tympanoplasty with and without mastoidectomy for non-cholesteatomatous chronic otitis media.

55 : Evaluation of simultaneous bilateral same day tympanoplasty type I in chronic suppurative otitis media.

56 : Antimicrobial therapy for children with chronic suppurative otitis media without cholesteatoma.

57 : Medical treatment of chronic suppurative otitis media without cholesteatoma in children--a two-year follow-up.

58 : Long-term follow-up evaluation of mastoidectomy in children with non-cholesteatomatous chronic suppurative otitis media.

59 : A pre- and postoperative bacteriological study of chronic suppurative otitis media.

60 : Long-term follow-up of chronic suppurative otitis media in a high-risk children cohort.

61 : Complications of chronic suppurative otitis media and their management.

62 : Intracranial complications of chronic suppurative otitis media.

63 : Extracranial complications of chronic suppurative otitis media.

64 : Complications of suppurative otitis media: still a problem in the 21st century.

65 : Intracranial abscesses associated with chronic suppurative otitis media.

66 : Extracranial and intracranial complications of suppurative otitis media. Report of 102 cases.

67 : Complications of Chronic Suppurative Otitis Media and Their Management: A Single Institution 12 Years Experience.

68 : Complications of chronic suppurative otitis media: a retrospective review.

69 : Chronic suppurative otitis media: complicated versus uncomplicated disease.

70 : Subperiosteal mastoid abscesses in chronic suppurative otitis media.

71 : Intracranial complications of CSOM in pediatric patients: A persisting problem in developing countries.

72 : Chronic suppurative otitis media and related complications at the University Clinic of Kinshasa.

73 : The risk of hearing loss in a population with a high prevalence of chronic suppurative otitis media.

74 : Frequency of Sensorineural hearing loss in chronic suppurative otitis media.

75 : Sensorineural hearing loss in patients with chronic suppurative otitis media: Is there a significant correlation?

76 : Risk factors of sensorineural hearing loss in patients with unilateral safe chronic suppurative otitis media.

77 : Cochlear implantation in chronic suppurative otitis media.

78 : Cochlear implantation in the presence of chronic suppurative otitis media.

79 : The role of subtotal petrosectomy in cochlear implant surgery--a report of 32 cases and review on indications.

80 : Cochlear implantation in patients with chronic suppurative otitis media.

81 : Impact of Chronic Suppurative Otitis Media in Pediatric Cochlear Implant Recipients-Insight into the Challenges from a Tertiary Referral
Center in UK.

82 : Clinico-epidemiological profile of chronic suppurative otitis media patients attending a tertiary care hospital.

83 : Chronic suppurative otitis media in a birth cohort of children in Greenland: population-based study of incidence and risk factors.

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