Otitis media - chronic suppurative
Exam Tips
- In UK primary care OSCEs: suspected CSOM + no red flags = do not start empirical ear-drop treatment; refer to ENT for confirmation and specialist cleaning.
- Classic stem: chronic painless otorrhoea through a perforated drum with hearing loss.
- Always screen for red flags (vertigo, facial weakness, post-auricular swelling, severe headache, fever) because they change urgency to same-day ENT/hospital assessment.
- Differentiate from otitis externa: OE usually has marked canal pain/itch and an inflamed ear canal without middle-ear perforation.
- Mention water precautions and hearing/language impact in children for holistic marks.
- If discussing drugs, explicitly state aminoglycoside ototoxicity risk with perforated tympanic membrane and need for specialist oversight.
Definition
Chronic suppurative otitis media (CSOM) is persistent inflammation and infection of the middle ear/mastoid associated with a non-healing tympanic membrane perforation and recurrent or continuous otorrhoea. In practice, discharge lasting more than 2 weeks raises suspicion (some specialists use >6 weeks), particularly when there is hearing loss and little systemic upset.
Pathophysiology
CSOM usually follows acute otitis media in which the tympanic membrane perforation fails to close. A persistent perforation permits repeated contamination of the middle ear, leading to chronic mucosal inflammation, granulation tissue, and recurrent polymicrobial infection (classically Pseudomonas aeruginosa, also Staphylococcus aureus, Proteus spp, Aspergillus spp, Candida). Ongoing inflammation can damage ossicles (conductive loss) and, less commonly, spread toxins/infection to the inner ear (sensorineural component). Chronic disease may extend to mastoid or intracranial structures if untreated.
Risk Factors
- Age under 5 years
- Recurrent or previous acute otitis media
- Persistent tympanic membrane perforation after infection/trauma/grommets
- Upper respiratory tract infection
- Allergy or atopy
- Exposure to second-hand smoke
- Social deprivation
- Snoring
- Risk factors for worse hearing outcome: diabetes, smoking, active otorrhoea, larger perforation, longer disease duration
Clinical Features
Symptoms
- Persistent or recurrent ear discharge (typically >2 weeks)
- Reduced hearing in the affected ear
- Tinnitus
- Aural fullness/pressure
- Often minimal pain and no fever in uncomplicated disease
Signs
- Tympanic membrane perforation on otoscopy
- Middle ear mucosal inflammation and discharge
- Possible conductive hearing deficit on bedside assessment
- Red flags suggesting complications: post-auricular swelling/tenderness, fever, vertigo, nystagmus, severe headache, facial weakness/paralysis, signs of labyrinthitis
- See Figure: otoscopic appearance of a central tympanic membrane perforation with mucopurulent discharge
Investigations
Management
Lifestyle Modifications
- Refer all suspected CSOM cases to ENT; urgent same-day assessment/admission if red flags for mastoiditis, facial palsy, labyrinthitis, or intracranial spread
- Keep the ear dry (no water entry when swimming/showering; use ear protection)
- Dry mopping of external discharge with clean cotton wool/tissue
- Assess impact of hearing loss on school/work, language development, and mental health
Pharmacological Treatment
Topical quinolone antibiotic (specialist-led, often off-label in CSOM)
- Ciprofloxacin 0.3% ear drops: 4 drops into affected ear twice daily for 7 days (may be extended to 14 days by specialist)
Usually started after microsuction/aural toilet in secondary care; avoid routine initiation in primary care when CSOM is only suspected.
Topical quinolone + steroid combination (specialist use)
- Ciprofloxacin 0.3% with dexamethasone 0.1% ear drops: 4 drops twice daily for 7 days
May reduce inflammation and discharge; choice depends on local ENT protocol and otoscopic findings.
Topical aminoglycoside-containing drops (alternative under strict specialist supervision)
- Neomycin-containing otic drops, typical short course up to 7 days (dose per product-specific BNF/SPC)
Safety warning: potential ototoxicity with tympanic membrane perforation; use only if benefits outweigh risks and specialist follow-up is available.
Analgesia if symptomatic
- Paracetamol: 1 month-2 years 60-120 mg every 4-6 hours (max 4 doses/24 h); 2-3 months 60 mg up to 4 times daily
- Ibuprofen: 3 months-5 months 50 mg three times daily; 6 months-11 years 5-10 mg/kg 3-4 times daily (max 30 mg/kg/day)
Useful for pain/fever but do not treat underlying chronic ear sepsis.
Surgical / Interventional
- Microsuction/debridement (aural toilet) as part of specialist care
- Tympanoplasty (myringoplasty) to close persistent perforation
- Ossiculoplasty if ossicular erosion contributes to hearing loss
- Mastoidectomy for persistent disease, complications, or cholesteatoma
Complications
- Persistent conductive hearing loss (and possible sensorineural component)
- Speech/language and educational impact in children
- Facial nerve palsy
- Mastoiditis and petrositis
- Labyrinthitis/vertigo
- Meningitis
- Intracranial abscess
- Psychological morbidity related to hearing impairment (anxiety/depression/stress)
- Rare mortality in severe intracranial spread
Prognosis
With timely ENT-led treatment, discharge can often be controlled and hearing may improve, especially after closure of the perforation. However, recurrent disease is common, and longstanding childhood CSOM is associated with a high lifetime risk of at least mild hearing loss; prognosis worsens with prolonged active otorrhoea, larger perforations, smoking, and diabetes.
Sources & References
✅NICE Guidelines(1)
- Otitis media - chronic suppurative[overview]
📖Textbook References(5)
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 96, 97)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 97)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 684, 685)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 685)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 684, 685)[context]