Version May 2024
INTRODUCTION — Chronic suppurative otitis media (CSOM) is one of the most common childhood infectious diseases worldwide and is a leading cause of hearing impairment in resource-limited settings. It is less frequently seen in resource-abundant 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).
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: Clinical manifestations and diagnosis".)
●(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 and cholesteatoma 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 [1].
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 [2].
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 [3]. 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 on 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 [4], but this frequency may not be necessary in less severe cases. Daily aural toilet may be beneficial in patients who have failed previous therapy [5].
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 [6,7]; however, results of randomized trials contradict these findings [1,8,9]. 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 [1]. 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 [8].
Alternatives to aural toilet in resource-limited settings (antiseptics) — In resource-limited settings, suction and other equipment required for aural toilet are often unavailable. In addition, it may be challenging for patients to travel back and forth from the clinician's office for the initial or subsequent cleanings. Alternative irrigation solutions are frequently used to treat CSOM in these settings.
In our practice, when an alternative to aural toilet is needed, we typically use a 50% 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.
Other commonly used agents include:
●Burrow's solution (13% aluminum acetate)
●Zinc
●Boric acid
●Acetic acid (vinegar)
●Povidone-iodine
Limited evidence suggests that these agents may be more effective than no treatment, but it is uncertain if one agent is superior to others [10-15]. 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 povidone-iodine [16]. In addition, some of these agents (eg, boric acid and acetic acid) can irritate the middle ear, which may limit compliance.
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 [17].
●In most cases, systemic antibiotics alone or in combination with topical preparations do not improve treatment outcomes over topical antibiotics alone [18,19].
Cost-effectiveness studies have shown that aural toilet plus drops are more cost effective than other treatments [20].
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 [21-24]. Data from randomized clinical trials suggest topical quinolones are more effective than other alternatives, including oral amoxicillin-clavulanic acid, oral ciprofloxacin, and topical aminoglycosides [18,21-23,25,26]. Additional considerations that favor topical fluoroquinolones over topical aminoglycosides include their greater effectiveness against Pseudomonas and lower risk of ototoxicity [27]. 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 [28-30].
Ototopical corticosteroids — Use of topical corticosteroids (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 is present (picture 2) [31,32]. 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 [33]. 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'.)
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) [34-37].
Failure rates of medical treatment vary widely in the literature (from 20 to 80 percent), often depending on the therapy used [35]. 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, under the microscope directly through the tympanic membrane (TM) perforation since cultures taken from the external auditory canal may be unreliable or misleading [38].
In addition, treatment failure in patients with good adherence to the medical regimen should prompt evaluation for alternative or additional diagnoses, particularly cholesteatoma. (See "Chronic suppurative otitis media (CSOM): Clinical features and diagnosis", section on 'Differential diagnosis'.)
If cholesteatoma is suspected, high-resolution computed tomography (CT) of the temporal bone should be obtained. (See "Cholesteatoma in children", section on 'Diagnosis'.)
Management
Our approach — 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) [39] or have recurrent disease over a relatively short period of time (approximately six to eight weeks) [40]. 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 TMs; thus, use of all other topical antibiotics is off-label for CSOM. As an example, in cases of methicillin-resistant S. 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 ensure hearing is stable and to determine length of therapy [41].
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, which make it difficult for systemic therapy to reach the source of the infection [4,42]. 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 [43,44]. Oral linezolid is effective in treating refractory CSOM caused by MRSA and multiple drug-resistant Streptococcus pneumoniae [45].
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 [46,47]. Better response rates are seen with more broad-spectrum antibiotics, such as mezlocillin and ceftazidime [8,47].
Pseudomonas aeruginosa and MRSA are the most commonly identified resistant organisms in CSOM [7,46,48]. P. aeruginosa was most susceptible to ciprofloxacin and imipenem in one series [46], 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) [49]. 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 [50]. 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 [51]. 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 [7].
Surgery — Surgical options for refractory CSOM include tympanoplasty or tympanomastoidectomy. Patients with bilateral disease can be treated at the same time with bilateral tympanoplasties [52]. We prefer to exhaust all medical options before proceeding with surgical therapy. 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 [53]. However, its precise role in uncomplicated CSOM without cholesteatoma and exactly which procedure should be performed are controversial. Surgical management of cholesteatoma is discussed in greater detail separately. (See "Cholesteatoma in children", section on 'Surgical treatment'.)
The available data suggest that there is no role for routinely performing mastoidectomy in children with uncomplicated CSOM (ie, without cholesteatoma) [54-56]. 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.
In a retrospective study that included patients with CSOM and dry ears who underwent tympanoplasty only (n = 242), patients with wet ears who underwent tympanoplasty only (n = 53), and patients with wet ears who underwent canal wall up tympanomastoidectomy (n = 28), hearing outcomes and graft success rates were similar in all three groups [55]. 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 [56].
The presence or absence of active disease at the time of surgery (ie, wet versus dry ears) and the type of microorganisms isolated in culture do not appear to impact the success rates of tympanoplasty [57-59].
The role for balloon eustachian tuboplasty at the time of tympanoplasty is uncertain [60,61].
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 [7,11,40,44,62-65]. In one study, early recurrence was associated with poorer response to subsequent therapy including antimicrobials and surgery [63].
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, >95 percent of patients responded to initial medical therapy; however, nearly one-half had recurrent disease, most of whom cleared with outpatient medical management [40]. Four patients required intravenous (IV) antibiotic therapy and nine required surgery due to either failed initial medical therapy or 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 their ears dry (ie, aural toilet and strict water precautions) and surgical repair of the perforated TM if needed [39]. 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 [1] and, in another series, 24 of 32 patients (75 percent) diagnosed with CSOM between the ages of zero and four healed spontaneously by ages 11 to 15 [66].
We suggest tympanoplasty for patients who have persistent perforation for >6 to 12 months after resolution of CSOM to prevent recurrence. We do not advise routine mastoidectomy in this setting, as discussed above. (See 'Surgery' above.)
For patients with persistent perforation and frequent recurrences of CSOM, surgery reduces the likelihood of subsequent recurrences compared with continued medical management. In one study, the mean time to recurrence in patients treated medically was four months, while for those treated surgically, it was five to seven years [67].
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 [68-70]. Several studies have reported that males are at greater risk for complicated CSOM [68,70]. Other risk factors include:
●Low socioeconomic status [70,71]
●Prolonged symptom duration before seeking medical attention [36]
●Atticoantral type of CSOM [68,72] (see "Chronic suppurative otitis media (CSOM): Clinical features and diagnosis", section on 'Anatomic classification of CSOM')
●Cholesteatoma [68,70,72,73] (see "Cholesteatoma in children")
●Infection caused by multidrug-resistant bacteria [36]
●Underlying HIV infection [36]
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 the clinical picture should alert the clinician to an infectious complication [71]:
●Extracranial complications – Extracranial complications may include [70,73-77]:
•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 [77]. (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 [73]. Reported intracranial complications of CSOM include [69,71,73-76,78]:
•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")
Brain abscess and meningitis are the most commonly reported intracranial complications [74,78]. Multiple intracranial complications can occur together. Reported mortality rates range from 3 to 19 percent [73,78].
Extracranial and intracranial complications often necessitate surgery in addition to broad-spectrum intravenous (IV) antibiotics, although the exact procedure differs depending on 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 [73,74,79]. Extracranial complications are more common than intracranial complications, and approximately one-third of patients have two or more complications [68,71,73].
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 [69,72,74,76].
The mortality in complicated CSOM ranges from 0 to 20 percent, depending on the population studied [68,69,73,75].
Persistent hearing loss — CSOM is one of the most common causes of preventable hearing loss [36,80]. In one series, 90 percent of children with CSOM had permanent hearing loss of >15 decibels [81]. (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. In one study, the prevalence of SNHL among patients with CSOM was approximately 40 percent [67]. Reported risk factors for developing SNHL include older age, longer disease duration, larger perforations, smoking, and diabetes [82-84]. Tinnitus may be a harbinger of SNHL, and patients reporting tinnitus should be monitored closely for development of SNHL [85].
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 [86-89]. 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 [86-89]. If CSOM develops in a patient with a preexisting cochlear implant, it is possible to treat the infection without removing the implant, as long as there is no cholesteatoma [90].
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 [91]. CSOM frequently begins with acute otitis media (AOM). Thus, preventing and promptly and appropriately treating AOM should decrease the incidence of CSOM [92]. 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 [93]. (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
●Importance – Chronic suppurative otitis media (CSOM), which is characterized by chronic drainage from the middle ear associated with tympanic membrane (TM) perforation (picture 1), is one of the most common childhood infectious diseases worldwide. It is a leading cause of hearing impairment in resource-limited settings. (See 'Introduction' above and "Chronic suppurative otitis media (CSOM): Clinical features and diagnosis".)
●Initial therapy – For patients with uncomplicated CSOM without cholesteatoma, we suggest aural toilet plus an ototopical fluoroquinolone (eg, ciprofloxacin, ofloxacin) for initial therapy rather than either intervention alone, other topical therapies, or oral antibiotics (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.)
●Treatment failure – 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 other interventions, including surgery (Grade 2C). Cultures should be obtained from the middle ear (ie, through the TM perforation), not from the external auditory canal. Culture-directed antibiotic therapy typically consists of a topical antibiotic, unless there is no suitable option based upon the susceptibility pattern of the isolated pathogen, in which case, an oral antibiotic is used. We generally reserve intravenous (IV) antibiotic therapy for patients who fail culture-directed topical or oral therapy. (See 'Treatment failure' above.)
●Recurrences – 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. Evaluation and management of patients with recurrent disease includes (see 'Recurrent disease' above):
•Counsel patients to follow strict water precautions. (See 'Prevention of recurrences' above.)
•Obtain temporal bone computed tomography (CT) to evaluate for cholesteatoma, if this has not already been performed. (See "Cholesteatoma in children", section on 'Diagnosis'.)
•For patients without cholesteatoma who have recurrent disease despite water precautions, we suggest tympanoplasty (Grade 2C). We also suggest tympanoplasty as a preventative measure for patients with persistent TM perforation >6 to 12 months after resolution of CSOM (Grade 2C). (See 'Surgery' above and 'Surgery for persistent tympanic membrane perforation' above.)
●Complications – Complications of CSOM include extra- and intracranial spread of infection and persistent hearing loss. (See 'Complications' above.)
●Prevention – Prevention is the cornerstone of disease management for CSOM 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 acute otitis media (AOM), which usually precedes CSOM. In addition, public health interventions that address risk factors may also decrease rates of CSOM. (See 'Prevention' above.)
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