Chronic suppurative otitis media

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Chronic middle-ear discharge is both an infection problem and an anatomical problem. A perforation provides a route through which fluid from inflamed mucosa can reach the canal, and water can enter the middle ear. Some people describe painless episodes after swimming or hair washing, while others have almost continuous drainage. The duration defining chronic suppuration varies between settings; the practical distinction is persistence or recurrence through a chronic defect rather than a single acute perforation that is healing.

A useful consultation separates three aims: controlling current inflammation, establishing that the ear is safe, and improving hearing or day-to-day function. These aims may require different interventions. Drops can suppress susceptible local infection but cannot reconstruct a perforated membrane or remove a cholesteatoma. Equally, a dry perforation that causes little difficulty may be managed with advice and follow-up rather than urgent surgery. The patient’s work, swimming, hearing needs and willingness to undergo an operation belong in the decision.

Key points

Chronic suppurative otitis media involves persistent or recurrent drainage through a longstanding tympanic membrane perforation.
A perforation can also be dry and inactive; it does not require antibiotics merely because a hole remains.
Establish whether discharge comes from middle-ear mucosa, the external canal or a cholesteatoma.
Localized active disease usually needs suitable topical treatment and cleaning rather than routine oral antibiotics.
Culture is useful when discharge is persistent, recurrent or failing correctly delivered treatment.
A non-intact drum changes which ear preparations can be used safely.
Assess hearing and discuss rehabilitation or reconstructive surgery according to symptoms, anatomy and preference.
A temporarily dry ear is an encouraging response but does not prove that a hidden destructive lesion has been excluded.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

A persistent membrane defect

Previous infection, trauma or ear surgery can leave a perforation through which discharge recurs. Ask about the original event, previous repair attempts and whether the ear has ever remained reliably dry.

Local microbial persistence

Repeated wetting, debris and chronically inflamed mucosa favour recurrent microbial growth. Prior antibiotic exposure changes susceptibility, making a carefully collected specimen useful when empirical treatment has failed.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Open middle-ear communication
The normal barrier between the ear canal and middle ear is interrupted. External contamination and inflamed middle-ear secretions can therefore perpetuate episodes, especially when the opening is repeatedly exposed to water.
2
Impaired mechanical transmission
A perforation reduces the effective vibrating membrane area, while inflammation or ossicular damage can further disrupt conduction. The amount of hearing impairment depends on more than the visible size of the hole.
3
Persistent structural disease
A course of drops may settle active drainage while the anatomical defect remains. Continuing follow-up decisions should therefore consider hearing, recurrence and examination of the entire drum rather than discharge alone.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Characterise the discharge

Ask whether drainage is continuous or intermittent, painful or painless, and related to water exposure. Record smell, bleeding, recent medicines and the response to each correctly completed course.

Understand the operated ear

Previous grommets, mastoid surgery or tympanoplasty can alter appearances and treatment choices. Obtain the surgical history and avoid assuming that every large canal space or membrane defect has the same significance.

Examine the whole membrane

Debris may need removal by a trained clinician using an appropriate method. Identify the perforation, inspect the remaining drum and attic, and note granulation, retraction or keratin that needs specialist assessment.

Assess hearing and complication symptoms

Ask about communication difficulty, tinnitus, balance, facial movement and sudden change from baseline. Examine the mastoid and cranial nerves if pain or the wider history suggests deeper disease.

Red flags requiring action

New facial asymmetry, severe vertigo or rapidly worsening hearing can indicate damage beyond the chronically inflamed middle-ear lining.
Mastoid swelling, meningism, severe headache or altered consciousness requires emergency assessment for extension of infection.
A keratin-containing retraction pocket, an unexplained polyp or recurrent foul discharge raises concern for cholesteatoma.
Persistent bloody discharge or tissue that obscures the drum needs specialist examination and sometimes biopsy, rather than repeated empirical drops.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Ear swab from active dischargeFirst step
Why
Guide treatment when infection persists or repeatedly returns.
Interpretation and limitations
Take a useful specimen from fresh discharge, ideally before changing antimicrobial treatment. Interpret growth with the clinical picture, acknowledging that a surface sample can contain colonising organisms.
02
Otomicroscopy and aural toilet
Why
Expose the underlying anatomy and improve local treatment delivery.
Interpretation and limitations
Removal of obstructing debris can reveal a previously hidden pocket or polyp and allows drops to reach the affected area. Routine water irrigation is inappropriate when an infected perforation is present.
03
Audiometry
Why
Measure hearing impairment and guide rehabilitation or reconstructive discussion.
Interpretation and limitations
Record air and bone conduction where feasible and compare both ears. A conductive gap may be amenable to treatment, but a mixed deficit requires counselling about the limits of surgery.
04
Imaging or biopsy for selected findings
Why
Investigate suspected destructive disease, complications or an abnormal tissue lesion.
Interpretation and limitations
CT and specialist MRI are not routine tests for every simple dry perforation. ENT selects imaging when cholesteatoma, erosion or complications are suspected, and requests histology for tissue that needs diagnosis.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Cholesteatoma

Keratin accumulation in a pocket or middle-ear space can cause foul discharge and erosion. Suspicious debris, a hidden pocket or a polyp requires ENT assessment even when an antibiotic temporarily improves symptoms.

External canal infection

Canal tenderness and diffuse skin inflammation suggest otitis externa, which may coexist with middle-ear drainage. Establishing both the origin and membrane integrity prevents selection of an unsuitable preparation.

Recent acute perforation

A newly painful febrile illness followed by discharge may represent acute otitis media with spontaneous rupture. Its expected course and antimicrobial decision differ from established recurrent mucosal disease.

Tumour or retained foreign material

Persistent unilateral bleeding or abnormal tissue should not be treated indefinitely as infection. Specialist examination, removal of obstructing material and tissue diagnosis may be needed to resolve the cause.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Active localized dischargeClean and treat safelyFirst stepDischarge is consistent with uncomplicated mucosal infection through a chronic perforation.

1Inspect adequately, obtain culture where appropriate and arrange trained aural cleaning when debris prevents assessment or drug delivery.
2Use a topical preparation selected for the open middle ear under the local ENT or prescribing pathway, explaining any off-label use.
3Keep water out with a suitable barrier at the canal entrance during washing and avoid inserting cotton buds or unprescribed liquids.
4Arrange review of response and membrane findings; simple localized disease does not routinely need an oral antibiotic.

02Persistent or recurrent diseaseRecheck the diagnosis and treatment routeDischarge continues despite appropriate local care or returns repeatedly.

1Check the actual preparation, duration, administration technique and whether canal obstruction prevented delivery before labelling bacterial resistance.
2Use culture results and ENT advice to revise treatment, considering fungal overgrowth, contact allergy or a different anatomical source.
3Refer for specialist assessment when two appropriate local courses fail in the GGC pathway, or sooner when findings suggest cholesteatoma or another important cause.
4EscalationEscalate immediately for new neurological, mastoid or systemic features rather than awaiting a routine appointment.

03Inactive or settled earAddress the lasting perforation and hearingThe acute discharge has resolved but the defect or hearing difficulty remains.

1Explain that a dry perforation alone does not need continuing antibiotic drops and discuss practical protection from water.
2Arrange audiology and consider suitable hearing rehabilitation in collaboration with ENT when the ear’s condition limits device choice.
3Discuss myringoplasty or tympanoplasty when recurrent infection, the anatomical problem or patient priorities make repair appropriate.
4Agree follow-up and return advice, including the possibility that hearing benefit depends on ossicular and inner-ear status.

Key medicines and prescribing safety1 treatment · regimens, roles and cautions

A topical antibiotic and steroid option named in the GGC chronic mucosal otitis media pathway, alongside assessment, swabbing and ear care. Treatment through a chronic perforation falls outside this generic product’s licensed AOE indication.

Ciprofloxacin with dexamethasone for selected active CSOM

Use an ENT-directed off-label CSOM prescription that specifies the exact preparation, number of drops, frequency and review or stop date. GGC recommends this combination for discharging chronic mucosal disease but does not publish a fixed CSOM course. For formulation reference only, the 3 mg/mL plus 1 mg/mL generic SmPC specifies four drops twice daily for seven days for acute otitis externa; this is not GGC-endorsed CSOM dosing.

Avoid quinolone, dexamethasone or excipient allergy and fungal or relevant viral otic infection. Shake this suspension and warm it in the hands. Reassess persistent discharge after a course rather than repeating it indefinitely. Stop for hypersensitivity or tendon inflammation. Pregnancy use requires clear necessity and benefit outweighing risk; use breastfeeding caution. Do not substitute another concentration or steroid combination using the same drop count.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Persistent hearing impairment

Conductive loss can affect work, communication and safety, even when discharge is minimal. Audiology can also identify an additional sensorineural component that a membrane repair alone will not correct.

Recurrent inflammation and treatment harm

Repeated courses without examination may promote resistance, fungal overgrowth or contact sensitisation. An unsuitable ototoxic preparation can add vestibular or cochlear injury when the middle ear is open.

Local or intracranial spread

Destructive disease or an acute complication can threaten the labyrinth, facial nerve, mastoid or intracranial structures. New pain or neurological symptoms require escalation rather than continuation of routine chronic care.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Confirm that drainage settles and that the remaining drum can be assessed adequately after treatment.
Review new dizziness, tinnitus or a hearing change promptly, especially after a new topical preparation.
Check whether water precautions are practical and whether work or hearing-device use is perpetuating problems.
Revisit hearing and surgical goals after inflammation settles rather than judging hearing outcome during active discharge.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Off-label does not mean interchangeable

An ear preparation may be used outside its licensed indication within an established local pathway, but its formulation and dose still matter. Record the exact product rather than simply cipro drops.

Aminoglycoside exceptions need specialist judgement

Some specialists use an aminoglycoside briefly when resistant infection leaves no suitable alternative. That exception does not override the contraindication to routine use of neomycin-containing spray in a perforated ear or justify prolonged repeat courses.

Repair and hearing are separate outcomes

Closing the membrane can reduce recurrent contamination. Hearing improvement varies with the ossicular chain and cochlear reserve, so consent should distinguish a dry ear, successful closure and better hearing.

Do not confuse suppression with diagnosis

A hidden keratin pocket can continue to grow while surrounding infection becomes quieter. Persistent abnormal anatomy deserves assessment even when the patient is pleased that the discharge stopped.

11Common pitfallsFrequent interpretation and management errors.

01
Repeated oral antibiotics are a poor substitute for examination and appropriate topical delivery in localized chronic disease.
02
Do not prescribe an ototoxic ear spray without checking for perforation, grommets or previous surgery.
03
A painless discharging ear can still contain a cholesteatoma requiring specialist treatment.
04
Do not promise that membrane repair will restore normal hearing in every patient.