Chronic suppurative otitis media

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Chronic suppurative otitis media (CSOM) is characterized by at least 2 weeks–3 months of inflammation and infection of the middle ear in patients with a nonintact tympanic membrane (TM). CSOM is one of the most common causes of hearing loss in low-income countries where it typically affects children under 5 years of age. Infections in CSOM are usually polymicrobial. Risk factors include recurrent acute otitis media, frequent upper respiratory tract infections, and poor nutritional status. Patients typically report painless, recurrent discharge from the ear and hearing loss. CSOM is a clinical diagnosis supported by a thorough history and otoscopic findings of otorrhea and a perforated TM. Hearing loss should be evaluated with diagnostic hearing tests. For uncomplicated infections, conservative treatment with topical medications (i.e., antibiotics +/- steroids) is preferred. Neuroimaging, laboratory studies, systemic antimicrobials, and/or surgery may be indicated for patients with persistent CSOM that does not respond to conservative measures. If left untreated, the infection may spread and result in extracranial and intracranial CNS complications. Primary prevention and timely management of acute otitis media are essential to preventing CSOM.

See also “Acute otitis media” and “Otitis media with effusion.”

• North America: < 1% prevalence across all ages (adults and children) ^[2]
• Globally
  • 4–10% prevalence in some regions
  • Most common in children ≤ 5 years of age (peak at ∼ 2 years) ^[2]

In many low-income countries, CSOM is the most common cause of hearing loss. ^[3][4]

Epidemiological data refers to the US, unless otherwise specified.

Common pathogens ^[2][3][4]

CSOM is typically a polymicrobial infection that may include any of the following pathogens:

• Gram-positive
  • Aerobic: S. aureus (common), S. pyogenes
  • Anaerobic: Propionibacterium, Peptostreptococcus
• Gram-negative
  • Aerobic: P. aeruginosa (common)
  • Anaerobic (including facultative anaerobes): Bacteroides, E. coli, P. mirabilis, K. pneumoniae
• Fungal: Aspergillus

When a single pathogen is isolated, S. aureus and P. aeruginosa are the most common species isolated. ^[3][4]

Risk factors ^[2][4][5]

• Prior tympanostomy tube placement, especially if:
  • ≥ 3 episodes of acute otitis media (AOM) in the preceding 12 months
  • Exposure to other children (e.g., in daycare, older siblings)
• Recurrent AOM; see also “Risk factors for AOM.”
• Frequent upper respiratory tract infections ^[5]
• Socioeconomic factors

• Painless, recurrent otorrhea for at least ≥ 2 weeks ^[2][4]
• Nonintact tympanic membrane (i.e., a perforation or tympanostomy tube is present) ^[4]
• Additional features may include: ^[2][4]
  • Hearing loss (in up to 50% of patients) ^[2][6]
  • Acquired cholesteatoma ^[4][6]
  • Mucosal changes of the ear canal ^[4]
  • Otomycosis (if fungal etiology)

Patients with CSOM are usually clinically well; signs of systemic illness (e.g., fever) should raise concerns for complications. ^[7][8][9]

Red flags for complications of CSOM ^[7][8][9]

• Otalgia
• Signs of systemic illness, e.g., fever
• Focal neurologic signs
• Altered mental status
• Headache
• Clinical features of mastoiditis
• Immunocompromised state ^[10]

Tubotympanic CSOM ^[2][9]

• TM perforation is centrally located and only involves the pars tensa.
• Otorrhea may or may not be foul-smelling. ^[2]
• Complications are unlikely.
• No cholesteatoma

Atticoantral CSOM ^[2][9]

• TM perforation affecting any of the following locations:
  • Peripheral edge of the TM (i.e., marginal perforation)
  • Superoposterior quadrant of the TM
  • Pars flaccida (i.e., attic perforation)
• Otorrhea is typically foul-smelling. ^[2]
• Acquired cholesteatoma
• Granulations
• Increased risk for complications of CSOM

Post-tympanostomy tube CSOM ^[9]

• In North America and Europe, this is the most common cause of CSOM. ^[9]
• Is one cause of persistent tympanostomy tube otorrhea ^[11]

General principles ^[2][3]

• CSOM is a clinical diagnosis; based on characteristic symptoms and otoscopy confirming perforation of the TM.
• An audiogram should be performed to evaluate for hearing loss and to monitor hearing in response to treatment. ^[9]
• Further studies are usually only required for persistent symptoms or suspected complications.

Further studies ^[2][3][7]

• Bacterial, and possibly fungal, cultures of middle ear aspirate ^[2][9][12]
• Neuroimaging
  • Symptoms determine the imaging modality and location.
  • For potential findings, see “Diagnostics of mastoiditis” and “Otogenic abscess.” ^[7][13][14]
• Biopsy of persistent granulation tissue to exclude neoplasia or granulomatous disorders. ^[9]

Other causes of chronic otorrhea, e.g.: ^[15]

• AOM with perforated TM
• Tympanostomy tube otorrhea (TTO)
• Otitis externa
• Ear foreign body
• Isolated cholesteatoma
• Tumors of the temporal bone
• Immunodeficiency ^[10][12]

The differential diagnoses listed here are not exhaustive.

Approach ^[2][4][6]

• Evaluate for red flags for complications of CSOM and if present:
  • Urgently consult otolaryngology.
  • Obtain relevant diagnostic studies (e.g., neuroimaging, cultures).
  • Initiate urgent antimicrobial therapy in consultation with infectious disease (ID).
• For all other patients, determine subtype of CSOM. ^[2][6][12]
  • Tubotympanic CSOM or posttympanostomy tube CSOM: Initiate conservative management for CSOM.
  • Atticoantral CSOM, recurrent CSOM, or persistent symptoms ^[2]
    • Refer to otolaryngology.
    • Surgical management for CSOM may be required.
• All patients: Initiate ongoing management of CSOM.

The goals of treatment are to eradicate the infection and ensure healing of the TM (either spontaneously or through surgical repair). ^[2]

Conservative management for CSOM ^[2][4][9]

• Indications
  • Tubotympanic CSOM
  • Posttympanostomy tube CSOM
• Preferred: usually determined in consultation with otolaryngology
  • Topical antibiotic (usually a fluoroquinolone) with/without a topical steroid, e.g.: ; ^[2][9][16]
    • Ofloxacin
    • Ciprofloxacin (off-label) ^[17][18]
    • Ciprofloxacin/dexamethasone (off-label) ^[19][20]
  • Aural toilet (unclear benefit) ^[9][21]
  • Suspected fungal infection: Add a topical antifungal in consultation with ID. ^[22]
• Alternative
  • Oral antibiotics ^[2]
  • Topical antiseptics ^[2][9]

Topical aminoglycoside drops, which are ototoxic to the middle ear, are contraindicated when the tympanic membrane is perforated. ^[23][24][25]

Surgical management for CSOM ^[2][4]

• Indications
  • Atticoantral CSOM
  • Recurrent or persistent CSOM
  • Any associated urgent complications of CSOM
• Procedures
  • Tympanoplasty with or without mastoidectomy
  • In individuals with complications, additional surgeries may be indicated. ^[8][26]

Ongoing management of CSOM ^[26][27]

• Recommend dry ear precautions until the TM has healed. ^[26][27]
• Advise patients to seek prompt treatment for AOM if symptoms develop.
• For patients with recurrent CSOM ^[26]
  • Prophylactic antibiotics are not recommended because of the risk of antibiotic resistance.
  • Obtain CT of the mastoid to evaluate for potential causes of recurrent disease (e.g., cholesteatoma, mastoid abscess formation).
  • Consider surgical management (e.g., tympanoplasty). ^[26]

Urgent complications of CSOM ^[2][7]

Similar to urgent complications of acute otitis media, e.g.:

• Local spread (extracranial): mastoiditis, labyrinthitis, facial nerve palsy
• CNS spread (intracranial): lateral sinus thrombosis, meningitis, otogenic abscess

Nonurgent complications ^[2][7]

• Tympanosclerosis
  • May be asymptomatic or lead to conductive hearing loss
  • White calcified plaques in the tympanic membrane seen on otoscopy
• Persistent hearing loss

We list the most important complications. The selection is not exhaustive.

Prevention of CSOM is predominantly prevention of AOM and the early recognition and treatment of AOM. ^[2][27]