Current Infectious Disease Reports

, Volume 14, Issue 2, pp 121–127 | Cite as

Topical Treatment of Chronic Suppurative Otitis Media

Upper Respiratory, Head, and Neck Infections (I Brook, Section Editor)


Chronic suppurative otitis media (CSOM) is a chronic inflammation of the middle ear and mastoid cavity presenting with ear discharge or otorrhea through a non-intact tympanic membrane. CSOM is the most common cause of childhood hearing impairment in developing countries. Accurate diagnosis depends on a high index of suspicion, micro-otoscopic examination, and judicious use of imaging as required. CSOM can be classified into 3 types: tubotympanic, atticoantral, and post-tympanostomy tube insertion. Aerobes, anaerobes and fungi are all potential pathogens in CSOM. This review summarizes the results of recent studies on the bacteriology of CSOM, biofilms, and the role of the nasopharynx pathogens that may have important implications for the treatment of this important pathology; that is often associated with misdiagnosis or delayed diagnosis. Particular emphasis will be placed on topical treatment options including choices of antibiotic, antifungal, and antiseptic agents, delivery technique, spectrum of activity, and risk of ototoxicity.


Chronic suppurative otitis media Chronic mastoiditis Cholesteatoma Eardrops Topical treatment Bacteriology Ototoxicity Otorrhea Draining ear Biofilms Aerobes Anaerobes Fungi 



Dr. S. J. Daniel has received grant support from Alcon, Honoraria from Abbott, and payment for development of educational presentations from Merck and Alcon.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Daniel SJ, Kozak FK, Fabian MC, et al. Guidelines for the treatment of tympanostomy tube otorrhea. J Otolaryngol. 2005;34 Suppl 2:S60–3.PubMedGoogle Scholar
  2. 2.
    Roland PS. Chronic suppurative otitis media: a clinical overview. Ear Nose Throat J. 2002;81(8 Suppl 1):8–10.PubMedGoogle Scholar
  3. 3.
    Goycoolea MV, Hueb MM, Ruah C. Otitis media: the pathogenesis approach. Definitions and terminology. Otolaryngol Clin North Am. 1991;24(4):757–61.PubMedGoogle Scholar
  4. 4.
    •• Madana J, Yolmo D, Kalaiarasi R, et al. Microbiological profile with antibiotic sensitivity pattern of cholesteatomatous chronic suppurative otitis media among children. Int J Pediatr Otorhinolaryngol. 2011;75(9):1104–8. This study showed that in attico-antral CSOM with cholesteatoma, the most common organisms was P. aeruginosa, P. mirabilis and S. aureus; all were susceptibie to ceftazidime and vancomycin.PubMedCrossRefGoogle Scholar
  5. 5.
    Bowd AD. Otitis media: health and social consequences for aboriginal youth in Canada’s north. Int J Circumpolar Health. 2005;64(1):5–15.PubMedGoogle Scholar
  6. 6.
    Daly KA, Hunter LL, Giebink GS. Chronic otitis media with effusion. Pediatrics in review/American Academy of Pediatrics. 1999;20(3):85–93. quiz 94.PubMedCrossRefGoogle Scholar
  7. 7.
    •• Mathew R, Asimacopoulos E, Valentine P. Toward safer practice in otology: A report on 15 years of clinical negligence claims. Laryngoscope. 2011;121(10):2214–9. This is the first study to report outcomes of negligence claims in otology. Claims in otology are associated with a high success rate. A significant proportion of claims are not related to surgery.PubMedCrossRefGoogle Scholar
  8. 8.
    Kaplan GJ, Fleshman JK, Bender TR, et al. Long-term effects of otitis media: a ten-year cohort study of Alaskan Eskimo children. Pediatrics. 1973;52(4):577–85.PubMedGoogle Scholar
  9. 9.
    Adoga AA, Bakari A, Afolabi OA, et al. Bacterial isolates in chronic suppurative otitis media: a changing pattern? Nigerian journal of medicine: journal of the National Association of Resident Doctors of Nigeria. 2011;20(1):96–8.Google Scholar
  10. 10.
    Lee SK, Lee MS, Jung SY, et al. Antimicrobial resistance of Pseudomonas aeruginosa from otorrhea of chronic suppurative otitis media patients. Otolaryngol Head Neck Surg. 2010;143(4):500–5.PubMedCrossRefGoogle Scholar
  11. 11.
    •• Brook I. The role of anaerobic bacteria in chronic suppurative otitis media in children: implications for medical therapy. Anaerobe. 2008;14(6):297–300. This article describes the microbiology, diagnosis and medical management of chronic suppurative otitis media (CSOM) in children highlighting the role of anaerobic bacteria.PubMedCrossRefGoogle Scholar
  12. 12.
    Brook I. The role of anaerobic bacteria in otitis media: microbiology, pathogenesis, and implications on therapy. Am J Otolaryngol. 1987;8(2):109–17.PubMedCrossRefGoogle Scholar
  13. 13.
    Brook I, Burke P. The management of acute, serous and chronic otitis media: the role of anaerobic bacteria. J Hosp Infect. 1992;22(Suppl A):75–87.PubMedCrossRefGoogle Scholar
  14. 14.
    •• Brook I, Yocum P, Shah K. Aerobic and Anaerobic Bacteriology of Otorrhea Associated with Tympanostomy Tubes in Children. Acta Otolaryngol (Stockh). 1998;118:206–10. This article reveals that specimens collected from the external auditory canals can be misleading. Reliable information can be obtained from the ear exudates when collected through the tympanostomy tubes or through the open perforation after their removal.CrossRefGoogle Scholar
  15. 15.
    •• Saunders J, Murray M, Alleman A. Biofilms in chronic suppurative otitis media and cholesteatoma: scanning electron microscopy findings. Am J Otolaryngol. 2011;32(1):32–7. Using scanning electron microscopy, this study showed that bacterial biofilms are common in chronic infections associated with cholesteatoma and are present in some cases of chronic suppurative otitis media without cholesteatoma.PubMedCrossRefGoogle Scholar
  16. 16.
    • Chang J, Lee SH, Choi J, et al. Nasopharynx as a microbiologic reservoir in chronic suppurative otitis media: preliminary study. Clinical and experimental otorhinolaryngology. 2011;4(3):122–5. This study suggests that it is necessary to perform nasopharynx cultures together with conventional middle ear culture to orient antibiotherapy pre-operatively.PubMedCrossRefGoogle Scholar
  17. 17.
    Browning GG, Gatehouse S, Calder IT. Medical management of active chronic otitis media: a controlled study. J Laryngol Otol. 1988;102(6):491–5.PubMedCrossRefGoogle Scholar
  18. 18.
    Saunders MW, Robinson PJ. How easily do topical antibiotics pass through tympanostomy tubes?–an in vitro study. Int J Pediatr Otorhinolaryngol. 1999;50(1):45–50.PubMedCrossRefGoogle Scholar
  19. 19.
    Boyd NH, Gottschall JA. Assessing the efficacy of tragal pumping: a randomized controlled trial. Otolaryngol Head Neck Surg. 2011;144(6):891–3. Epub 2011 Feb 18.PubMedCrossRefGoogle Scholar
  20. 20.
    Hannley MT, Denneny 3rd JC, Holzer SS. Use of ototopical antibiotics in treating 3 common ear diseases. Otolaryngol Head Neck Surg. 2000;122(6):934–40.PubMedCrossRefGoogle Scholar
  21. 21.
    ••Macfadyen CA, Acuin JM, Gamble C: Systemic antibiotics versus topical treatments for chronically discharging ears with underlying eardrum perforations. Cochrane database of systematic reviews 2006(1):CD005608 (online 2009). This study shows that short courses of topical quinolone antibiotics are more effective than systemic antibiotics alone for the short-term resolution of otorrhea from uncomplicated CSOM. Google Scholar
  22. 22.
    ••Macfadyen CA, Acuin JM, Gamble C: Topical antibiotics without steroids for chronically discharging ears with underlying eardrum perforations. Cochrane database of systematic reviews 2005(4):CD004618 (online 2009). In this review, short courses of topical quinolone antibiotics were shown to be more effective than no drug treatment or topical antiseptics for the short-term resolution of otorrhea from uncomplicated CSOM. Google Scholar
  23. 23.
    Klein JO. Strategies for decreasing multidrug antibiotic resistance: role of ototopical agents for treatment of middle ear infections. Am J Manag Care. 2002;8(14 Suppl):S345–52.PubMedGoogle Scholar
  24. 24.
    Weber PC, Roland PS, Hannley M, et al. The development of antibiotic resistant organisms with the use of ototopical medications. Otolaryngol Head Neck Surg. 2004;130(3 Suppl):S89–94.PubMedCrossRefGoogle Scholar
  25. 25.
    Agro AS, Garner ET, Wright 3rd JW, et al. Clinical trial of ototopical ofloxacin for treatment of chronic suppurative otitis media. Clin Ther. 1998;20(4):744–59.PubMedCrossRefGoogle Scholar
  26. 26.
    Manolidis S, Friedman R, Hannley M, et al. Comparative efficacy of aminoglycoside versus fluoroquinolone topical antibiotic drops. Otolaryngol Head Neck Surg. 2004;130(3 Suppl):S83–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Macfadyen C, Gamble C, Garner P, et al. Topical quinolone vs. antiseptic for treating chronic suppurative otitis media: a randomized controlled trial. Trop Med Int Health. 2005;10(2):190–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Leach AJ, Morris PS: Antibiotics for the prevention of acute and chronic suppurative otitis media in children. Cochrane database of systematic reviews (Online) 2006(4):CD004401.Google Scholar
  29. 29.
    Daniel SJ, Munguia R. Ototoxicity of topical ciprofloxacin/dexamethasone otic suspension in a chinchilla animal model. Otolaryngol Head Neck Surg. 2008;139(6):840–5.PubMedCrossRefGoogle Scholar
  30. 30.
    Roland PS, Stewart MG, Hannley M, et al. Consensus panel on role of potentially ototoxic antibiotics for topical middle ear use: Introduction, methodology, and recommendations. Otolaryngol Head Neck Surg. 2004;130(3 Suppl):S51–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Matz G, Rybak L, Roland PS, et al. Ototoxicity of ototopical antibiotic drops in humans. Otolaryngol Head Neck Surg. 2004;130(3 Suppl):S79–82.PubMedCrossRefGoogle Scholar
  32. 32.
    Ichibangase T, Yamano T, Miyagi M, et al. Ototoxicity of Povidone-Iodine applied to the middle ear cavity of guinea pigs. Int J Pediatr Otorhinolaryngol. 2011;75(9):1078–81.PubMedCrossRefGoogle Scholar
  33. 33.
    Boudewyns A, Claes J. Acute cochleovestibular toxicity due to topical application of potassium iodide. Eur Arch Otorhinolaryngol. 2001;258(3):109–11.PubMedCrossRefGoogle Scholar
  34. 34.
    Oishi N, Inoue Y, Saito H, et al. Burow’s solution-induced acute sensorineural hearing loss: report of two cases. Auris Nasus Larynx. 2010;37(3):369–72.PubMedCrossRefGoogle Scholar
  35. 35.
    Haynes DS, Rutka J, Hawke M, et al. Ototoxicity of ototopical drops–an update. Otolaryngol Clin North Am. 2007;40(3):669–83. xi. Review.PubMedCrossRefGoogle Scholar
  36. 36.
    Daniel SJ, Akinpelu OV, Sahmkow S, et al. Oxymetazoline ototoxicity in a chinchilla animal model. Otolaryngol Head Neck Surg. 2012;146(1):114–8.PubMedCrossRefGoogle Scholar
  37. 37.
    Isaacson G, Buttaro BA, Mazeffa V, et al. Oxymetazoline solutions inhibit middle ear pathogens and are not ototoxic. Ann Otol Rhinol Laryngol. 2005;114(8):645–51.PubMedGoogle Scholar
  38. 38.
    •• Munguia R, Daniel SJ. Ototopical antifungals and otomycosis: a review. Int J Pediatr Otorhinolaryngol. 2008;72(4):453–9. This review discusses the topical antifungals most commonly used in otomycosis and their ototoxic potential. Candida albicans and Aspergillus are the most commonly identified organisms. Antifungals from the Azole class seem to be the most effective, followed by Nystatin and Tolnaftate.PubMedCrossRefGoogle Scholar
  39. 39.
    • Daniel SJ, Sahmkow S, Akinpelu OV. Is Ototopical Nystatin Ototoxic?: A Chinchilla Model. Otolaryngol Head Neck Surg. 2011;145(6):1022–4. This study demonstrates the safety of topical nystatin in an animal model.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.The Montreal Children’s HospitalMontrealCanada

Personalised recommendations