Curr Infect Dis Rep (2012) 14:121127
DOI 10.1007/s11908-012-0246-8
UPPER RESPIRATORY, HEAD, AND NECK INFECTIONS (I BROOK, SECTION EDITOR)
Topical Treatment of Chronic Suppurative Otitis Media
Sam J. Daniel
Published online: 5 February 2012
# Springer Science+Business Media, LLC 2012
Abstract 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. Accu-
rate diagnosis depends on a high index of suspicion, micro-
otoscopic examination, and judicious use of imaging as re-
quired. 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 nasophar-
ynx 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 tech-
nique, spectrum of activity, and risk of ototoxicity.
Keywords Chronic suppurative otitis media . Chronic
mastoiditis . Cholesteatoma . Eardrops . Topical treatment .
Bacteriology . Ototoxicity . Otorrhea . Draining ear .
Biofilms . Aerobes . Anaerobes . Fungi
Introduction
Chronic suppurative otitis media (CSOM) is a chronic inflam-
mation of the middle ear and mastoid cavity presenting with ear
discharge or otorrhea through a non-intact tympanic mem-
brane. This includes eardrum perforations and tympanostomy
S. J. Daniel (*)
The Montreal Childrens Hospital,
2300 Rue Tupper, Rm. B-240,
Montreal, QC H3H 1P3, Canada
e-mail: sam.daniel@mcgill.ca
tubes [1]. Its pathogenesis is multifactorial including environ-
mental and genetic factors as well as anatomical and functional
characteristics of the Eustachian tube. There is currently no
consensus on the duration of symptoms. While the World
Health Organizations definition requires that otorrhea be pres-
ent for a minimum of two weeks, most clinicians consider the
diagnosis of CSOM when discharge persists, despite treatment,
for periods varying from 6 weeks [2] to up to over 3 months [3].
CSOM is the most common cause of childhood hearing
impairment in developing countries [4]. This can have
serious deleterious effects on the childs language, and fu-
ture school performance [4, 5, 6]. In a review of 15 years
of otology negligence claims in the UK, CSOM was the
condition that was the most frequently associated with mis-
diagnosis or delayed diagnosis [7]. Accurate diagnosis
depends on a high index of suspicion, micro-otoscopic
examination, and judicious use of imaging as required. A
normal eardrum anatomy is shown in Fig. 1.
CSOM can be classified into 3 types:
1) Tubotympanic type where the disease is confined to the
pars tensa with central perforation [4];
2) Atticoantral type in which the disease involves the pars
flaccida or posterosuperior marginal quadrant, with or
without cholesteatoma and/or granulations [8]. This
type accounts for the majority of otogenic complica-
tions such as intracranial abscess, facial nerve palsy, and
meningitis;
3) post-tympanostomy tube insertion CSOM which is the
most common type in North America and Europe.
Isolated Pathogens
While aerobes, anaerobes and fungi are all potential patho-
gens in CSOM, the majority of patients have a mixed
122
Fig. 1 Normal anatomy of the eardrum
infection with both aerobic and anaerobic organisms. The
most frequently isolated organism in CSOM from different
parts of the world is Pseudomonas aeruginosa [9]. Antibiotic
susceptibility to Pseudomonas can vary widely, making it
important to perform susceptibility testing to guide therapy
when patients fail to respond to an initial empiric course of
therapy [10]. In a thorough review by Brook, the predomi-
nant aerobic isolates were Pseudomonas aeruginosa and
Staphylococcus aureus and the most frequently isolated
anaerobic organisms were Peptostreptococcus, Fusobacte-
rium spp, pigmented Prevotella, and Porphyromonas spp
[11]. The differences in the rate of recovery of anaerobic
bacteria in various reports may be due to inherent differ-
ences in geographic locations and laboratory techniques. A
recent study shows a different trend in a West African
country with Klebsiella species, Escherichia coli, and Strep-
tococcus species as the leading pathogenic organisms [9].
Knowledge of the true frequency of polymicrobial infection
and the extent of anaerobe involvement is dictated by differ-
ences in collection and culture techniques [12, 13]. Brook
showed that in children with chronic, previously untreated
otorrhea associated with tympanostomy tubes; about half of
the bacteria recovered from the middle ear were also present in
the external ear canal [14]. Furthermore, canal cultures in
many cases yielded bacteria that were not present in the middle
ear. This demonstrates that cultures of tympanostomy tube
otorrhea collected from the external auditory canal can be
misleading. This is particularly important in the case of P.
aeruginosa, which is more frequently a colonizer of the ear
canal and not a true pathogen. Direct middle ear aspirations are
therefore more reliable in establishing the bacteriology of
chronic otorrhea, and can assist in the selection of proper
antimicrobial therapy. Other sources of variability in recovery
Curr Infect Dis Rep (2012) 14:121127
rates of aerobic and anaerobic bacteria may be related to differ-
ences in the timing of pathogen sampling during the course of
the disease, as well as prior use of antibiotics, transport media
and delays in inoculation.
The 3 different types of CSOM are likely to harbor differ-
ent bacterial profiles. In a recent study of organisms found in
atticoantral CSOM associated with cholesteatoma the most
common organisms found were P. Aeruginosa, P. mirabilis,
and S. Aureus [4]. Other organisms found included Methi-
cillin resistant S. aureus, Candida albicans, Enterococcus spe-
cies, E. coli, and Streptococcus species [4]. Furthermore, a
current study has revealed that bacterial biofilms are quite
common in chronic infections associated with cholesteatoma
and can also be present in some cases of chronic suppurative
otitis media without cholesteatoma [15].
Finally, the nasopharynx has been shown to be a micro-
biologic reservoir in CSOM and some studies suggest the
necessity to perform nasopharyngeal cultures together with
conventional middle ear cultures pre-operatively [16].
Diagnosis
The most common symptom of CSOM is recurrent or per-
sistent ear drainage. Patients may also report the sensation of
aural fullness or clogged ears as well as hearing loss. The
degree and nature of the hearing loss is related to the
location and size of the eardrum perforation, the status of
the middle ear (adhesions, retractions, scarring, granula-
tion), and prior usage of ototoxic medication. Patients usu-
ally do not complain of otalgia, fever, or other systemic
signs of infection.
Physical examination reveals a discharge in the presence
of a non-intact tympanic membrane. Careful otoscopy
should be done to exclude a retraction pocket or cholestea-
toma. Otomicroscopy with suctioning, is frequently re-
quired, necessitating referral to an otolaryngologist. Gram
stains and cultures can be useful in guiding therapy and
should be obtained from the middle ear rather than the
external ear canal to prevent contaminants. Direct middle
ear and mastoid cavity cultures are best obtained by an
otolaryngologist using a microscope. After cleaning the
external ear canal, sterile suction traps can be used to obtain
secretions directly from the middle ear or mastoid cavity
under microscopic guidance.
Hearing testing should be performed to determine the
degree of hearing loss and the need for hearing aid use. In
cases with chronic otitis media and constant otorrhea pre-
venting the patient from wearing hearing aids, a bone an-
chored hearing aid such as a BAHA can be extremely
useful. Imaging with a CT scan or MRI should be performed
if one suspects extracranial or intracranial complications; for
example cholesteatomas, mastoiditis, or abscesses.
Curr Infect Dis Rep (2012) 14:121127
Additionally, if there is no response to medical therapy,
persistent granulation tissue should be biopsied to exclude
granulomatous or neoplastic pathology.
Differential Diagnosis
The differential diagnosis of CSOM comprises chronic ex-
ternal otitis including dermatological conditions such as
eczema. Other conditions to be ruled out include granulo-
matous disease, mycobacterial and fungal infections, and
malignancies such as nasopharyngeal carcinoma or
lymphoma.
Treatment Philosophy
The goals of CSOM treatment are to eradicate the infection
and inflammation, stop the otorrhea, heal the tympanic
membrane, prevent complications and avoid recurrence.
Treatment strategies include aural hygiene, appropriate top-
ical and occasional systemic antibiotic therapy, surgery of
the tympanic membrane, middle ear, and/or mastoid.
Aural Toilet
Aural toilet is extremely important as it cleans the ear of the
discharge and debris, and allows the topical antibiotics to
penetrate into the middle ear [17]. If canal debris is not
removed, topical antibiotics will not reach the area of infec-
tion, and will not be effective despite the high local concen-
trations that are reached. It is therefore important to try to clear
as much discharge from the external auditory canal as possi-
ble. Ideally, the external auditory canal should be suctioned
under the microscope. Suctioning under microscopy allows
the otolaryngologist to perform a good aural cleaning, inspect
the middle ear for cholesteatoma, and obtain proper cultures.
This should be initiated at the beginning of the therapy and
performed thereafter 2 to 3 times a week until the infection is
clear. Unfortunately, suctioning requires equipment generally
available only at an otolaryngologists office. Alternatively, in
less severe cases or until an appointment is obtained with a
specialist, physicians and parents can gently clean the outer
ear and then use a dry rolled tissue (eg, Kleenex) to gently
remove the mucopurulent discharge from the canal. Cotton
swabs should not be used in the canal.
Delivery Technique
Proper delivery of local therapy is vital because it probably
constitutes the most common cause of ototopical failure [1].
123
An important step to propel the drops into the middle ear is
to pull the auricle slightly upwards and backwards to
straighten the canal and pump on the tragus at least 5 times
[1]. This pumping action ensures that the antibiotic drops
enter the middle ear space through the tympanostomy tube.
While some controversy has been raised in the past as to
whether topical agents can get into the middle ear in a reliable
fashion, this has been partly addressed in an artificial middle
ear model [18]. It was found that pressures required for leak-
age of solutions into the middle ear through a tympanostomy
tube differed significantly between solutions and tube sizes,
smaller lumen tubes requiring higher trans-tympanic pressure
for leakage to occur. The presence of middle ear secretions
reduced the pressure required for leakage of solution. Of
interest, tragal massage generated pressures of 21.35 cm of
H20 which would be enough to force solution into the middle
ear in all tube/solution combinations [18]. In fact, a recent
randomized controlled trial has revealed that tragal pumping
improves the middle ear penetration of ototopical medications
via a patent pressure equalization tube [19].
Reasons for Failure of Ototopical Antibiotics
Pus and debris in the ear canal are impediments to success-
ful topical therapy. It is imperative that debris are cleaned,
often repetitively, to facilitate penetration of the ear drops to
the site of the infection. Reasons for ototopical therapy
failure include canal obstruction by debris or cerumen,
improper administration technique, poor compliance, re-
infection, resistant organisms, fungal infection, nasopharyn-
geal reflux, immunodeficiency, and physical factors such as:
granulation tissue, sequestered nidus of infection, large vol-
ume of otorrhea blocking access of the tube lumen, and
mucosal edema. Biofilms coating some types of tympanos-
tomy tubes have also been theorized to cause chronic tympa-
nostomy tube otorrhea, with planktonic organisms being
periodically released from the biofilm, leading to repeat acute
infections [1]. The extent to which these biofilms are the cause
of, and not the result of, persistent infection is unclear.
Topical Therapy
Topical therapies can be classified as antibacterial, antifun-
gal, and antiseptic. Many agents are combined with steroids
to decrease inflammation. Also many otic preparations con-
tain some type of acid, such as boric or acetic acid, to lower
the pH as most pathogenic organisms of the ear canal (e.g.,
pseudomonas and fungi) grow best in an alkaline environ-
ment. Non-antibiotic remedies usually contain not only the
acid but also nonspecific antiseptic agents which are effec-
tive against both fungi and bacteria. A wide variety of
124 Curr Infect Dis Rep (2012) 14:121127

antiseptic drops are available and many have been used for
hundreds of years, including alcohols, phenols, and iodine.
Most of these chemical agents demonstrate broad-spectrum
antimicrobial and antifungal activity.
Common topical agents used in CSOM can be found in
Tables 1, 2, and 3.
In the absence of systemic infection or serious underlying
disease, topical antibiotics constitute first-line treatment for
most patients with CSOM [20]. In treating ear infections with
antibiotics, topical delivery allows a much higher concentra-
tion of antibiotic delivered to the site of infection, and permits
alteration of the local microenvironment. For example a 0.3%
antibiotic solution of ciprofloxacin contains 3000 mcg/mL of
antibiotic as opposed the middle ear concentration of 610
mcg/mL after oral administration of Amoxicillin at 90 mg/kg.
These high concentrations are pharmacodynamically im-
portant for antibiotics known to have a concentration-
dependent mechanism of action such as aminoglycosides
and quinolones. Consequently, the concentration of deliv-
ered topical antibiotics is always well above the MIC of the
relevant organism, making the emergence of bacterial resis-
tance extremely unlikely.
In a recent Cochrane review, Topical quinolone antibiotics
were found to clear aural discharge better than systemic anti-
biotics [21, 22]. This could be explained by the difficulty
of systemic drug penetration through poorly vascularized
mucosa, as opposed to the very high concentrations that could
be reached with topical delivery. Furthermore, with topical
therapy there is minimal systemic absorption and therefore
much less systemic side-effects [20, 23, 24]. MacFadyens
systematic review of nine trials (833 randomized participants)
found topical quinolones better than systemic antibiotics at
clearing discharge at two weeks [21]. While CSOM defini-
tions and severity varied, topical quinolone antibiotics were
better than systemic antibiotics at clearing discharge at 1
2 weeks [21]. The relative risks (RR) were, 3.21 using
systemic non-quinolone antibiotics (2 trials, N0116), and
3.18 using systemic quinolone (3 trials, N0175); and 2.75 in
favor of systemic plus topical quinolone over systemic quino-
lone alone (2 trials, N090). No statistically significant benefit
was seen at 2 to 4 weeks for topical non-quinolone antibiotic
(without steroids) or topical antiseptic over systemic antibi-
otics (mostly non-quinolones), but numbers were small. No
benefit of adding systemic to topical treatment at 1 to 2 weeks
was detected either, although evidence was limited (three
trials, N0204). Evidence regarding safety and risk of ototox-
icity was generally weak. Several studies hint that fluoroqui-
nolone drops may be superior to topical aminoglycoside
agents, but data are limited by small sample sizes [21, 25,
26]. There is equally lack of evidence for the benefit of the
addition of a topical corticosteroid to topical antibiotic therapy
but an American Academy of OtolaryngologyHead and
Neck Surgery (AAO-HNS) consensus panel supported its
consideration, if granulation tissue is present [20].
With regards to antiseptics, Macfadyen found that short
courses of topical quinolone antibiotics are more effective
than boric acid for the short-term resolution of otorrhea from
uncomplicated CSOM [27]. In another Cochrane review by
the same author on Fourteen trials (1724 subjects), topical
quinolone antibiotics (without steroids) were better than no
drug treatment at clearing discharge at one week: relative
risk (RR) was 0.45 [22]. Topical quinolones were

Table 1 Examples of topical antibiotics used for CSOM along with their spectrum of efficacy

ANTIBIOTIC- BASED topical agents Spectrum of Activity Adverse Effects

Gram-Positive Organisms Gram-Negative Organisms

Ofloxacin ++ +++ Pseudomonas aeruginosa Safe
Ciprofloxacin No ototoxicity
Ciprofloxacin Hydrocortisone Overuse can lead to fungal infection
Ciprofloxacin dexamethasone

Gentamicin + +++ Ototoxicity potential

Tobramycin + +++ Ototoxicity potential
Neomycin + ++ Contact dermatitis
Solution of Neomycin, Ototoxicity
Polymyxin B, Hydrocortisone Pseudomonas sp. resistance
Framycetin-gramicidin-dexamethasone + +++ Ototoxicity
Polymyxin B +++ Renal toxicity if absorbed
Chloramphenicol ++ ++ Ototoxicity
(some staph resistance) Rare cases of aplastic anemia reported
after use in the eye

+++, excellent activity and spectrum; ++, good activity and spectrum; +, fair activity and spectrum; , no activity
Curr Infect Dis Rep (2012) 14:121127
Table 2 Examples of topical
antiseptic agents used for CSOM ANTISEPTIC agents
Povidone-iodine (Betadine)
Iodine powder
Boric acid
Aluminum acetate
Water, aluminum acetate, and sodium acetate
2% acetic acid solution
(otic Domeboro, VSol, VoSl HC Acetasol)
Acetic acid
3% boric acid in 70% alcohol, aqueous merthiolate, and 25% M-cresyl acetate
Gentian violet
Oxymetazoline
significantly better at curing CSOM than antiseptics: RR
0.52 (95% CI 0.41 to 0.67) at one week (three trials, N0
263), and 0.58 (0.47 to 0.72) at two to four weeks (four
trials, N0519). Meanwhile, non-quinolone antibiotics com-
pared to antiseptics were more mixed [22]. Studies were
also inconclusive as to differences between quinolone and
non-quinolone antibiotics, although indirect comparisons
suggesting a benefit of topical quinolones could not be ruled
out. Adverse events data were also weak.
While the literature on CSOM has shortcomings in terms of
length of follow-up, sample size, and methodological quality,
compiling the current body of knowledge, there is reasonable
evidence for the efficacy of topical fluoroquinolones, which
are preferred to alternative agents due to their safety profile
[20, 27, 28]. The concern for ototoxicity with the use of
aminoglycoside agents has prompted a consensus panel of
the American Academy of Otolaryngology-Head and Neck
Surgery (AAO-HNS) to recommend that When possible,
topical antibiotic preparations free of potential ototoxicity
are preferred over ototopical agents that have the potential
for injury if the middle ear and mastoid are open [2931].
Spectrum of Activity of Topical Agents
The spectrum of activity of antibiotic drops is listed in Table 1.
Ofloxacin and ciprofloxacin are fluoroquinolones with
Table 3 Examples of common
topical antifungal agents classi- Antifungal agents with ototoxicity potential
fied according to their ototoxic in human or animal studies
potential
Acetic acid otic
Boric Acid (?)
Cresylate otic
Locacorten-vioform
Gentian Violet
125
Ototoxic potential
Yes [32, 33]
Unknown
Yes [34]
Yes [35]
Yes [35]
Yes [35]
No [36, 37]
activity against most Gram-negative and Gram-positive
microorganisms found in CSOM. Fluoroquinolones act by
inhibiting the DNA gyrase enzyme that is essential for DNA
replication, repair, deactivation, and transcription. To date, the
majority of isolates of Pseudomonas aeruginosa are still sen-
sitive to ciprofloxacin. However overuse of topical antibiotic
eardrops is leading in some instances to otomycosis. The
aminoglycosides gentamicin and tobramycin are also highly
effective against most pathogens in CSOM, with tobramycin
being slightly more effective against Pseudomonas. The oldest
aminoglycoside neomycin which remains reasonably effec-
tive against Gram-positive organisms has seen a decline in its
effectiveness against Gram-negative organisms in recent
years. Polymyxin B increases the permeability of bacterial
cell membranes and is bactericidal against almost all Gram-
negative bacilli except the Proteus group.
Antiseptics are also useful because of wide-spectrum
antibacterial and antifungal effects. Antiseptics are less like-
ly to select for resistant organisms; however, little is known
about their mode of action in comparison to antibiotics.
Topical Treatment of Otomycosis
Chronic suppurative otitis media can occasionally be caused
or accompanied with fungal infection. The most prominent
symptoms present at the time of diagnosis include otalgia,
Antifungal agents shown non-ototoxic
in human or animal studies
Aluminium acetate otic
Clotrimazole
Fluconazole
Ketoconazole
Miconazole
Nystatin
126
otorrhea, hearing loss, aural fullness, pruritus, and tinnitus
[38]. Predisposing factors include extensive use of antibi-
otic eardrops, humid climate, weak immune function, dia-
betes, open mastoid cavities, hearing aids with occlusive
molds, and autoinoculation of the ear canal by patients
suffering of dermatomycoses [38].
Treatment of fungal otitis is challenging, and requires a
close follow-up. 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 [38, 39]. To date there is no
FDA approved antifungal otic preparation for the treatment
of otomycosis. Many agents with various antimycotic prop-
erties have been used, and clinicians have struggled to
identify the most effective agent to treat this condition. In
addition to topical therapy, aural hygiene is of paramount
importance in the treatment of otomycosis, as ototopical
medications work best following cleaning of secretions
and debris. While several topical antifungal agents have
ototoxic potential and should be used with caution, many
have been shown safe in human studies or animal models
[38, 39]. Table 3 lists common antifungal agents used for
otomycosis.
Systemic Antibiotics
Systemic antibiotics should be considered in patients at risk
for aggressive ear infections, local or distal complications as
well as those who have received several courses of empiric
topical therapy and are at higher risk for resistant organisms.
Culture results should be used to guide the treatment.
Surgery
Surgery is indicated for patients who develop complications,
to ablate infected tissue in the middle ear and mastoid, and
to repair the conductive hearing loss. The priority is to
eradicate irreversible disease such as cholesteatoma, polyp-
oid disease, and infected bone in order to create a dry, safe
ear that is free of infection.
Conclusions
The 3 types of CSOM: tubotympanic, atticoantral, and post-
tympanostomy tube insertion could harbor a mixture of aero-
bes, anaerobes and fungi. Exclusion of conditions such as
cholesteatoma and immune dysfunction is of paramount im-
portance. In the absence of systemic disease or complicated
local disease, topical agents play an important role in the
treatment. Short courses of topical quinolone antibiotics are
Curr Infect Dis Rep (2012) 14:121127
more effective than no drug treatment or topical antiseptics for
the short-term resolution of otorrhea from uncomplicated
CSOM. More research is needed as to comparing the long
term efficacy of quinolone versus non-quinolone antibiotics
and antiseptics. Attention should be placed in the choice of an
agent without a risk of ototoxicity whenever there is a breach
of tympanic membrane. Treatment should also be accompa-
nied by regular follow-ups to monitor for adverse effects of
treatment (particularly ototoxicity), and for complications of
the disease. Physicians should also advise patients on appro-
priate ear care, with aural toilet and effective instillation of the
drops, to ensure that the drops reach the site of infection and
work effectively.
Disclosure 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
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127
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