Clinical Practice Guidelines: Chronic Suppurative Otitis Media in Adults

CLINICAL PRACTICE
GUIDELINES
Chronic Suppurative Otitis Media in Adults
Dr. Lawrence Y. Maliwat

1st year Resident
QMMC ORL-HNS
INTRODUCTION
Scope
Objectives
Definition
Prevalence
SCOPE
For use of Philippine
Society of
Otolaryngologists
Covers diagnosis
and management
of CSOM in adults
(> 18 yo)
OBJECTIVES
1.) To emphasize
the requisites
of diagnosis
2.) To evaluate
current
diagnostic
techniques
3.) To describe
DEFINITION
CHRONIC SUPPURATIVE
OTITIS MEDIA (CSOM)
Persistent inflammation of the
middle ear or mastoid cavity
Persistent or recurrent otorrhea
over 3 months
Perforation of the tympanic
membrane
PREVALENCE
Worldwide prevalence
65-330 million people
Philippines
2.5-29.5%
RECOMMENDATIONS ON
THE
DIAGNOSIS
OF CHRONIC SUPPURATIVE
OTITIS MEDIA
1.The diagnosis of CSOM is made

by thorough history and
otoscopic examination (grade A)
Typical findings may

include thickened
granular middle ear
mucosa, mucosal
polyps and
cholesteatoma within
the middle ear
2. Pure tone audiometry and

speech testing may be
performed as part of the
evaluation (grade C)
gives baseline data regarding the preoperative hearing status for evaluating the
effectivity of tympanoplasty and
ossiculoplasty
done ONLY AFTER cleaning and absence of
acute suppurative symptoms
3.Radiographic imaging in
the form of computerized
tomographic imaging or
plain mastoid
radiography are
considered ancillary
diagnostic tools (grade C)
CT scan - imaging study of choice

May have value in the following
situations:
1. Medically unresponsive
2. Presence of Cholesteatoma
3. Uncooperative
4. Patients with an atypical course
5. High risk patients
6. Tympanic membrane cannot be adequately
visualized
7. Patients who have had previous mastoid

surgery
4.
Culture and
Sensitivity of ear
discharge is NOT
part of the
routine initial
diagnostic
Bacteria most commonly seen in

CSOM:
Aerobic: Pseudomonas aeruginosa, E.
coli, S. aureus, Streptococcus
pyogenes, Proteus mirabilis, Klebsiella
species
Anaerobic: Bacteroides,
Peptostreptococcus, Proprionbacerium
CULTURE SENSITIVITY
- patients who do not respond or has
persistent infection despite maximal
medical therapy
RECOMMENDATIONS ON THE DIAGNOSIS

OF CHRONIC SUPPURATIVE OTITIS MEDIA
1.Thorough History and Otoscopic

Examination (Grade A)
2.PTA and ST may be part of the
evaluation (Grade C)
3.Radiographic imaging are
ancillary tools (Grade C)
4.Culture and Sensitivity is not
part of routine (Grade C)
RECOMMENDATIONS ON
THE
TREATMEN
T
1. Aural toilet is an essential part of the

treatment of CSOM in ALL patients (Gr. A)
AURAL TOILET
Ear cleansing
Mechanical removal of
ear discharge and other
debris by mopping with
cotton swabs, wicking
with gauze, flushing with
sterile solution, or
suctioning.
AURAL TOILET
GOALS
Clean the ear canal and middle ear

cavity
Adequately visualize and assess
middle ear
Allow topical antibiotic to reach middle ear

cavity
Provide symptomatic relief for the

patient
2. Topical antibiotics are

recommended for the initial
management of CSOM for a
period of 10-14 days.
Topical combinations of
antibiotics and steroids are not
recommended over topical
antibiotics alone (Gr. A)
topical ofloxacin given for 10-14 days is

highly recommended
2.1 For persistent otorrhea, the

patient must be re-evaluated.
Continuing medical therapy for an
additional TWO WEEKS may be
considered (Gr. C)
Duration and time frame of medical

treatment for these patients still remain
unclear
This is an area of future research
2.2 Topical antiseptics may

be used if topical antibiotics
are not immediately
available (Gr. C)
No significant difference between topical
antiseptic and topical antibiotics in persistent
activity on otoscopy
Antiseptics are pharmacologically active agents
and can exert beneficial effects on weeping
ears.
Cost-effective
TOPICAL ANTISEPTICS
Boric acid
Zinc peroxide powder
Iodine powder
Dilute acetic acid drops
Aluminum acetate
3. Systemic antibiotic
should not be routinely
given to patients with
CSOM either alone or in
combination with
topical antimicrobials
better resolution of otorrhea with topical

antibiotics than with systemic antibiotics
(5 RCTs)
Topical antibiotics used: (ofloxacin, ciprofloxacin,

gentamycin and chloramphenicol)
Systemic antibiotics used: (cefalexin, cloxacillin,
amoxicillin, ofloxacin, ciprofloxacin, co-amoxiclav
and IM gentamycin)
There is no clear benefit with adding a

systemic to a topical antibiotic (economic
implication)
4. Surgery must be performed on

all cases of CSOM with
suppurative complications (Gr. A)
GOAL OF SURGERY
- eradication of infection
- permanent resolution of otorrhea
ABSOLUTE INDICATION
- any Intracranial or Extracranial complications
5. Surgery may be performed in

most cases of CSOM with
cholesteatoma (Gr. C)
Some cases may not be treated
surgically such as in elderly with poor
GMC
Manage the cholesteatoma in the
orifice
Aggressive aural toilet
prevent extension, infections, complications
6. Surgery may be performed for

those who fail to respond to
adequate medical treatment based
on recommendations 1 and 2 (Aural
toilet, Topical antibiotics) (Gr.C)
Indications for abandoning
medical therapy are
currently unclear
Duration and time frame
of medical treatment still
remain unclear
Area of future research
RECOMMENDATIONS ON THE TREATMENT

OF CHRONIC SUPPURATIVE OTITIS MEDIA
1.Aural Toilet (Grade A)

2.Topical Antibiotic Usage (Grade
A)
2.1. Persistent Otorrhea - 2 weeks
extension (Grade C)
2.2. Topical Antiseptic Usage (Grade C)
3. Refrain usage of Systemic

Antibiotics (Grade A)
4.Surgery performed in all cases

with complications(Grade A)
THANK YOU FOR LISTENING
Dr. Lawrence Y. Maliwat

1st year Resident
QMMC ORL-HNS

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CLINICAL PRACTICE

Dr. Lawrence Y. Maliwat

1.The diagnosis of CSOM is made

Typical findings may

2. Pure tone audiometry and

CT scan - imaging study of choice

7. Patients who have had previous mastoid

Bacteria most commonly seen in

RECOMMENDATIONS ON THE DIAGNOSIS

1.Thorough History and Otoscopic

1. Aural toilet is an essential part of the

Clean the ear canal and middle ear

Allow topical antibiotic to reach middle ear

Provide symptomatic relief for the

2. Topical antibiotics are

topical ofloxacin given for 10-14 days is

2.1 For persistent otorrhea, the

Duration and time frame of medical

This is an area of future research

2.2 Topical antiseptics may

better resolution of otorrhea with topical

Topical antibiotics used: (ofloxacin, ciprofloxacin,

There is no clear benefit with adding a

4. Surgery must be performed on

5. Surgery may be performed in

6. Surgery may be performed for

RECOMMENDATIONS ON THE TREATMENT

1.Aural Toilet (Grade A)

3. Refrain usage of Systemic

4.Surgery performed in all cases

THANK YOU FOR LISTENING

Dr. Lawrence Y. Maliwat

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