Download Chronic suppurative otitis media (CSOM)

Chronic suppurative otitis media (CSOM)
(Painless discharging ear)
Recommend
 Use antibiotic ear drops with tissue spears (dry mopping) to reduce the production
of pus [1]
 Document the duration of ear discharge and size and position of perforation [1]
 Consult MO if perforation found in attic region (unsafe perforation) of the
ear drum
 Treat discharging ears actively especially in young children < 5 years of age as this
is the age when long term problems can be prevented
Background
 CSOM is diagnosed in children who have discharging ears for more than
6 weeks despite appropriate treatment for AOM with perforation [1]
Related topics:
 Acute otitis media with perforation, page 550
Cholesteatoma, page 553
Cleaning techniques for ears with chronic discharge, page 558
1. May present with:

Intermittent and continuous ear discharge which is worse with URTI (child) symptoms, past
history of AOM but not always



Often poor hearing leading to learning difficulties
Mucopurulent ear discharge, a chronic perforation of the drum may be seen
Perforations in the upper drum (attic) maybe seen
2. Immediate management:

Consult MO if perforation found in attic region (unsafe perforation) of the ear drum
3. Clinical assessment:

Obtain a complete patient history
 social history, surgical history, medical history
 of particular importance are problems with hearing and speech and/or problems with
school (if school age patient)
 how long has the discharge been present?
 is this the first episode? Note the number of past episodes
 is there a history of AOM with perforation?
 is there a history of URTI? How many?

Perform standard clinical observations

Perform physical examination
 inspect the external ear - is there any sign of inflammation?
 palpate the ear – is it warm to touch?
 palpate behind the ear? Is the mastoid bone swollen? hot?
 palpate the occiput, around the ears, both sides of the neck for lymph glands
 is there auricular pain? tenderness on palpation of mastoid?
 do not put otoscope into discharging ear. Treat and then inspect.
 examine the nose and throat is there any discharge from nose? describe
 auscultate the chest for air entry and any sounds (crackles or wheezes)
4. Management:

Recommended treatment to affected ear/s with dry mopping
1. Ciprofloxacin ear drops
2. Sofradex ear drops
3. Vinegar (acetic acid solution) or diluted (1:20) betadine (not currently recommended as
sole treatment [1])

Consult MO for Ciprofloxacin order

See cleaning techniques for ears with chronic discharge for removal of pus and debris from ear canal

In young children it is difficult for family members to adequately clean the ears and instil the drops –
clinic staff are advised to do this daily for 7 days

Encourage personal hygiene in children - washing hands and face and keeping face clear of
nasal discharge

Advise regular nose blowing

Avoid swimming or immersing head under water
Schedule
4
Ciprofloxacin hydrochloride
ear drops
DTP IHW
Ciprofloxacin hydrochloride ear drops must be ordered by Medical Officer
Authorised Indigenous Health Workers can only administer on MO order
Route of
Form
Strength
Recommended Dosage
Administration
Ear drops
2mg / mL
Topical
Instil 3 drops in affected ear twice daily
Duration
7 days
The patient should be sitting or lying down with the affected ear upwards. Once the drops have been instilled maintain position
for 30-60 secs
Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops have been instilled to
assist the drops through the perforation
Ciprofloxcin drops are restricted to Aboriginal and Torres Strait Islander patients over 1 month of age, whether they are located
in an S100 community or otherwise.
Medical Officers prescribing Ciprofloxacin for Non- Aboriginal and Torres Strait Islander patients are required to obtain an
authority script.
Provide Consumer Medicine Information if available:
Management of Associated Emergency: As for severe allergic reactions see Anaphylaxis
Or
Sofradex ® ear drops
DTP
Schedule
4
(Dexamethasone 0.5 mg/ Framycetin Sulphate 5 mg/Gramicidin 0.05
IHW
/
IPAP
/ RIN / NP
mg/mL)
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO
Rural and Isolated Practice Endorsed Registered Nurses may proceed
Nurse Practitioners may proceed
Form
Strength
Route of Administration
Recommended Dosage
Ear drops
See above
Topical
3 drops 3-4 times a day
Duration
7 days
The patient should lie with their head on a pillow for several minutes after administration to allow the drops to gravitate to the
bottom of the ear canal.
Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops have been instilled to
assist the drops through the perforation
Provide Consumer Medicine Information if available: evidence of ototoxicity – limit treatment to no longer than 10 days
Management of Associated Emergency: Consult MO
5. Follow up:

Review children under 5 years of age daily for treatment for 7 days

If not improving Consult MO

Teach patient / carer cleaning technique and instillation of drops

See next MO clinic

Review weekly thereafter until ear is dry

If the ear is still discharging, Consult MO

When the ear dries review at 3 months

To prevent recurrent otitis media encourage personal hygiene in children - washing hands
and face and keeping face clear of nasal discharge

BBC program is targeted at school aged kids
6. Referral / Consultation:

Consult MO as above including a presentation with perforation in the upper drum (attic)

For hearing assessment – audiometry and tympanometry when ear dry

With education staff

MO may consider referring for surgical repair (tympanoplasty). This should be considered if there is
bilateral hearing loss and/or a perforation is large, has been dry for 3 months and the patient and
parents are well motivated. Surgery is rarely undertaken in children under 10 years