Clinical guide - CSOM
This is a guide to the management of CSOM. As with all guidance it simplifies the problem and should always be supplemented by other reading on anatomy and pathophysiology. Its purpose is to give you guidance only – it is not a set of unchangeable rules.
CSOM may be either mucosal (perforations) or squamous (cholesteatoma). It is important that these diseases are diagnosed and treated because they cause hearing impairment and discharge and may give rise to life threatening complications.
Your responsibility to patients is to diagnose the problem, treat infections, educate the patient, offer hearing assistance and refer for possible surgery if required.
The principles of CSOM management are to take a good history and examination and:
Clean the ear of all pus and debris
Diagnose the nature of the disease
Document the degree and type of hearing loss
Use medication to clear infection
Review the patient and repeat the steps above until the ear is dry
Refer for surgery if the patient is suitable
The medications that you use will depend upon local availability and the advice below is based upon drugs available at the time of writing.
These are available as either an eye or an eye/ear preparation. Both are acceptable in the ear. The drug has good efficacy against the common pathogens found in the discharging middle ear. It is not ototoxic and is, therefore, safer than aminoglycoside drops.
If ciproxin drops fail change to an alternative e.g. polydexa.
This is a combination of neomycin and a steroid. Neomycin is an aminoglycoside and should only be used in the presence of active CSOM and for only seven days. It also has a wide effect against common ear pathogens and also contains steroid. This gives additional benefit when you are treating polyps or disease resistant to ciproxin drops. It is safe in the unperforated ear.
Remember that neomycin occasionally gives rise to a type of allergic type reaction in the skin and, if the ear appears to be getting worse on treatment, you should stop it.
Ears that are perforated but dry are suitable for myringoplasty or tympanoplasty so you can refer these if the patient has suffered greatly. Ears with cholesteatomas should all be referred when possible.
NB. Some ears will not settle down until nasal conditions have been treated. Always consider the nose and treat it with antibiotics or nasal sprays if required.