Treatment first aims to control infection and eliminate ear discharge, followed later by surgical correction of hearing loss.
Aural toilet
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Remove all discharge and debris using dry mopping with absorbent cotton buds, suction under a microscope or irrigation with sterile normal saline.
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Irrigation should not involve forceful syringing. The ear must be dried afterward.
Topical treatment and administration
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Antibiotic ear drops may contain neomycin, polymyxin, chloromycetin or gentamicin. Steroids are combined with them for a local anti-inflammatory effect.
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The patient lies with the diseased ear upward. After instillation, intermittent pressure on the tragus helps the antibiotic solution reach the middle ear; this is done three or four times daily.
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An acidic pH helps eliminate pseudomonas infection, and irrigation with 1.5% acetic acid is useful.
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Ear drops may cause canal skin maceration, local allergy, fungal growth or organism resistance. Some drops are potentially ototoxic.
Systemic treatment and contributing factors
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Systemic antibiotics are useful in acute exacerbations of a chronically infected ear; their role in CSOM is otherwise limited.
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Concomitantly infected tonsils, adenoids and maxillary antra, as well as nasal allergy, should be treated.
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Water should be kept out of the ear during bathing, swimming and hair washing; rubber inserts may be used.
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Hard nose blowing should be avoided because it can push infection from the nasopharynx into the middle ear.
Polyp management and reconstruction
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Aural polyps or granulations should be removed before local antibiotic treatment to facilitate ear toilet and effective delivery of ear drops.
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An aural polyp must never be avulsed: it may arise from the stapes, facial nerve or horizontal canal, and avulsion may cause facial paralysis or labyrinthitis.
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Once the ear is dry, myringoplasty with or without ossicular reconstruction can restore hearing.
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Closure of the perforation also checks repeated infection from the external canal.