Chronic suppurative otitis media

Last updated: November 20, 2023

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Summarytoggle arrow icon

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.”

Epidemiologytoggle arrow icon

  • 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.

Etiologytoggle arrow icon

Common pathogens [2][3][4]

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

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

Risk factors [2][4][5]

Clinical featurestoggle arrow icon

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]

Subtypes and variantstoggle arrow icon

Tubotympanic CSOM [2][9]

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]

Diagnosticstoggle arrow icon

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]

Differential diagnosestoggle arrow icon

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

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Approach [2][4][6]

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]

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]

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]

Complicationstoggle arrow icon

Urgent complications of CSOM [2][7]

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

Nonurgent complications [2][7]

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

Preventiontoggle arrow icon

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

Referencestoggle arrow icon

  1. Kliegman RM, Geme JS. Nelson Textbook of Pediatrics, 2-Volume Set. Elsevier ; 2019: p. 3623-3633
  2. Sabella C. Management of otorrhea in infants and children. Pediatr Infect Dis J. 2000; 19 (10): p.1007-1008.doi: 10.1097/00006454-200010000-00014 . | Open in Read by QxMD
  3. Mushi MF, Mwalutende AE, Gilyoma JM, et al. Predictors of disease complications and treatment outcome among patients with chronic suppurative otitis media attending a tertiary hospital, Mwanza Tanzania. BMC Ear Nose Throat Disord. 2016; 16 (1).doi: 10.1186/s12901-015-0021-1 . | Open in Read by QxMD
  4. $Chronic suppurative otitis media : burden of illness and management options.
  5. Daniel SJ. Topical Treatment of Chronic Suppurative Otitis Media. Curr Infect Dis Rep. 2012; 14 (2): p.121-127.doi: 10.1007/s11908-012-0246-8 . | Open in Read by QxMD
  6. Rosenfeld RM. Tympanostomy Tube Controversies and Issues: State-of-the-Art Review. Ear Nose Throat J. 2020; 99 (1_suppl): p.15S-21S.doi: 10.1177/0145561320919656 . | Open in Read by QxMD
  7. $Contributor Disclosures - Chronic suppurative otitis media. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  8. Li MG, Hotez PJ, Vrabec JT, Donovan DT. Is Chronic Suppurative Otitis Media a Neglected Tropical Disease?. PLoS Negl Trop Dis. 2015; 9 (3): p.e0003485.doi: 10.1371/journal.pntd.0003485 . | Open in Read by QxMD
  9. Schilder AGM, Chonmaitree T, Cripps AW, et al. Otitis media. Nat Rev Dis Primers. 2016; 2 (1).doi: 10.1038/nrdp.2016.63 . | Open in Read by QxMD
  10. Morris P. Chronic suppurative otitis media. BMJ Clin Evid. 2012; 2012.
  11. van der Veen EL, Schilder AGM, van Heerbeek N, et al. Predictors of Chronic Suppurative Otitis Media in Children. Arch Otolaryngol Head Neck Surg. 2006; 132 (10): p.1115.doi: 10.1001/archotol.132.10.1115 . | Open in Read by QxMD
  12. Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2). McGraw-Hill Education / Medical ; 2018
  13. Yorgancılar E, Yıldırım M, Gun R, et al. Complications of chronic suppurative otitis media: a retrospective review. Eur Arch Otorhinolaryngol. 2012; 270 (1): p.69-76.doi: 10.1007/s00405-012-1924-8 . | Open in Read by QxMD
  14. Dubey SP, Larawin V. Complications of Chronic Suppurative Otitis Media and Their Management. Laryngoscope. 2007; 117 (2): p.264-267.doi: 10.1097/01.mlg.0000249728.48588.22 . | Open in Read by QxMD
  15. Sharma A, Kirsch CFE, Aulino JM, et al. ACR Appropriateness Criteria® Hearing Loss and/or Vertigo. J Am Coll Radiol. 2018; 15 (11): p.S321-S331.doi: 10.1016/j.jacr.2018.09.020 . | Open in Read by QxMD
  16. Trojanowska A, Drop A, Trojanowski P, Rosińska-Bogusiewicz K, Klatka J, Bobek-Billewicz B. External and middle ear diseases: radiological diagnosis based on clinical signs and symptoms. Insights Imaging. 2011; 3 (1): p.33-48.doi: 10.1007/s13244-011-0126-z . | Open in Read by QxMD
  17. Chong LY, Head K, Webster KE, et al. Topical versus systemic antibiotics for chronic suppurative otitis media. Cochrane Database Syst Rev. 2021; 2021 (2).doi: 10.1002/14651858.cd013053.pub2 . | Open in Read by QxMD
  18. Médecins Sans Frontières Clinical guidelines: Diagnosis and treatment manual. Updated: March 1, 2023. Accessed: May 4, 2023.
  19. Valentini C, Lin J, Golub JS, Lustig L. Price Differences Between Otic and Ophthalmic Drops. Otol Neurotol. 2020; 42 (2): p.274-277.doi: 10.1097/mao.0000000000002930 . | Open in Read by QxMD
  20. Kutz JW, Roland PS, H Lee K. Ciprofloxacin 0.3% + dexamethasone 0.1% for the treatment for otitis media. Expert Opin Pharmacother. 2013; 14 (17): p.2399-2405.doi: 10.1517/14656566.2013.844789 . | Open in Read by QxMD
  21. de Souza C. Otorhinolaryngology- Head & Neck Surgery. Jaypee Brothers Medical Publishers ; 2017
  22. Bhutta MF, Head K, Chong LY, et al. Aural toilet (ear cleaning) for chronic suppurative otitis media. Cochrane Database Syst Rev. 2020.doi: 10.1002/14651858.cd013057.pub2 . | Open in Read by QxMD
  23. England RJA, Shamil E. Scott-Brown's Essential Otorhinolaryngology, Head & Neck Surgery. CRC Press ; 2022
  24. Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical Practice Guideline: Acute Otitis Externa. Otolaryngol Head Neck Surg. 2014; 150 (1_suppl): p.S1-S24.doi: 10.1177/0194599813517083 . | Open in Read by QxMD
  25. Matz G, Rybak L, Roland PS, et al. Ototoxicity of Ototopical Antibiotic Drops in Humans. Otolaryngol Head Neck Surg. 2004; 130 (S3).doi: 10.1016/j.otohns.2003.12.007 . | Open in Read by QxMD
  26. 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 (S3).doi: 10.1016/j.otohns.2003.12.010 . | Open in Read by QxMD
  27. Mittal R, Lisi CV, Gerring R, et al. Current concepts in the pathogenesis and treatment of chronic suppurative otitis media. J Med Microbiol. 2015; 64 (10): p.1103-1116.doi: 10.1099/jmm.0.000155 . | Open in Read by QxMD

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