Treatment for Chronic Suppurative Otitis Media (CSOM)

First-Line Treatment

Aural toileting should be performed before applying topical medications to improve medication penetration, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1, 2

Tympanoplasty may be considered for persistent tympanic membrane perforation that fails to heal spontaneously, with cartilage reconstruction showing better morphologic success compared to temporalis muscle fascia, according to the American Academy of Otolaryngology-Head and Neck Surgery 1
Novel adjuvant treatments to enhance tympanic membrane repair include biomolecules and bioengineered scaffolds, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery and reviewed in Nature Reviews Disease Primers 1, 3

About 39% of tympanic membrane perforations in CSOM may heal spontaneously over long-term follow-up, as observed by the American Academy of Otolaryngology-Head and Neck Surgery 1
Common complications include myringosclerosis, tympanic membrane atrophy, and persistent perforation, with incidence rates reported by the American Academy of Otolaryngology-Head and Neck Surgery 2, 4

If persistent discharge after 2 weeks, consider culture-directed therapy, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1
For refractory cases, consider short course of systemic antibiotics and evaluate for surgical intervention, such as tympanoplasty, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 1

Emphasize the importance of completing the full course of treatment even if symptoms improve earlier, to prevent recurrence and complications, as advised by the American Academy of Otolaryngology-Head and Neck Surgery 2
Address underlying factors such as upper respiratory infections, allergies, or anatomical abnormalities that may contribute to recurrence, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2, 5
Children with Down syndrome and craniofacial malformations are more prone to CSOM and its complications, as reviewed in Nature Reviews Disease Primers 3

The American Academy of Otolaryngology-Head and Neck Surgery suggests that topical antibiotics appear more effective than topical antiseptics in resolving otorrhea, though benefits versus placebo in children remain unclear 6, 7
Adding topical antibiotics to systemic antibiotics may increase resolution of ear discharge at 1-2 weeks, with 88% resolution rate compared to 60% with systemic antibiotics alone 6

The American Academy of Otolaryngology-Head and Neck Surgery recommends considering culture-directed therapy to identify resistant organisms if discharge persists after 2 weeks 6

Topical antibiotic therapy (e.g., ciprofloxacin) resolves cholesteatoma‑related otorrhea more effectively than topical antiseptic agents in patients with cholesteatoma, as demonstrated in a 2017 study published by the American Academy of Otolaryngology‑Head and Neck Surgery. This finding applies to the general (mixed‑age) population undergoing pre‑operative management. 8

The quality of evidence supporting the superiority of topical antibiotics over antiseptics in children is limited, indicating that while the trend favors antibiotics, further high‑quality pediatric studies are needed to confirm the benefit. 8