2. Workup Laboratory Studies Prior to instituting systemic therapy, a culture should be obtained for sensitivity.

3. Imaging Studies CT scanning – Unresponsive to medical treatment, to look for occult cholesteatoma or foreign body – suspects a neoplasm – intratemporal or intracranial complications.

4. Imaging Studies MRI – intratemporal or intracranial complications are suspected – to reveal dural inflammation, sigmoid sinus thrombosis, labyrinthitis, and extradural and intracranial abscesses.

5. Updates on Management of CSOM Aural toilet part of standard medical treatment reduce quantity of infected material from middle ear could facilitate middle ear penetration of topical antimicrobials

6. Aural toilet From the Cochrane review, aural toilet alone was not significantly better in resolving otorrhoea and in healing perforations than no treatment.

7. Aural toilet This was based on two field trials among children in the Solomon Islands (50) and Kenya (155). Antimicrobial Treatment, aural toilet must be combined with antibiotics or antiseptics to be effective.

8. Oral antibiotics Oral antibiotics are better than aural toilet alone A trial comparing various oral antibiotics with aural toilet alone reported a higher otorrhoea resolution rate in the antibiotic treated group.

9. Oral antibiotics Another trial comparing oral clindamycin with aural toilet alone found otorrhoea resolution rates of 93% and 29%, respectively

10. Topical antibiotics Topical antibiotics are better than aural toilet alone The addition of topical antibiotics to aural toilet was associated with a 57% rate of otorrhoea resolution, compared to 27% with aural toilet alone

11. Topical antibiotics topical antibiotics: framycetin, gramicidin, ciprofloxacin, tobramycin, gentamicin and chloramphenicol. Podoshin et al. also showed that topical ciprofloxacin or tobramycin was more effective than placebo (clinical response rates were 78.9%, 72.2% and 41.2%, respectively)

12. Topical antibiotics are better than systemic antibiotics The Cochrane review found that topical antibiotics were more effective than systemic antibiotics in resolving otorrhoea and eradicating middle ear bacteria.

13. topical antibiotics: gentamicin, chloramphenicol, ofloxacin, and ciprofloxacin topical antiseptics: hydrogen peroxide and boric acid with iodine powder as systemic antibiotics: cephalexin, flucloxacillin, cloxacillin, amoxycillin, coamoxiclav, erythromycin, metronidazole, piperacillin, ciprofloxacin, azactam, trimethoprim-sulfa, ofloxacin, and intramuscular gentamicin

14. Combined topical and systemic antibiotics are no better than topical antibiotics alone The Cochrane review showed that combined oral-topical antibiotics were no more effective than topical antibiotics alone; the rates of resolution of otorrhoea were 50% and 53%, respectively.

15. Thus, although combination antibiotics are effective in resolving otorrhoea, adding oral antibiotics to topical antibiotics and aural toilet increases the cost without increasing the success rate.

16. This confirms the difficulty of systemic drug penetration through the devascularized, fibrotic mucosa of the middle ear and mastoid. It also emphasizes the critical role of local treatment.

17. Parenteral antibiotics Parenteral antibiotics are better than aural toilet alone One trial found that intravenous mezlocillin and ceftazidime were more effective than aural toilet alone in resolving otorrhoea and eradicating middle ear bacteria (100% and 8%, respectively).

18. Surgery Mastoidectomy and/or tympanoplasty are fre- quently necessary to permanently cure CSOM. Mastoidectomy - removing the mastoid air cells, granulations and debris using bone drills and microsurgical instruments. Tympanoplasty - closure of the tympanic perforation by a soft tissue graft with or without reconstruction of the ossicular chain.

19. References: Chronic suppurative otitis media, Burden of Illness and Management Options, Child and Adolescent Health and Development, Prevention of Blindness and Deafness, World Health Organization, Geneva, Switzerland, 2004