A 41-year-old man presents to the clinic with persistent drainage from his right ear for the past 4 months. He reports intermittent hearing loss but denies fever, vertigo, or acute ear pain. His history is notable for recurrent ear infections as a child. Vital signs are within normal limits. Otoscopic examination reveals a perforated tympanic membrane with mucopurulent discharge in the middle ear. There is no postauricular swelling or tenderness. Audiometry demonstrates conductive hearing loss in the affected ear.
Which of the following is the most appropriate initial management?
The correct answer is:
D: Topical antibiotic ear drops.
This patient has chronic suppurative otitis media (CSOM), defined as persistent inflammation of the middle ear with otorrhea through a tympanic membrane perforation for longer than 6 weeks. Patients typically present with chronic ear drainage and conductive hearing loss, often without systemic signs of infection. First-line treatment for uncomplicated CSOM is topical antibiotic therapy, usually fluoroquinolone ear drops, which provide high local antibiotic concentrations directly to the site of infection and effectively target common organisms such as Pseudomonas aeruginosa and Staphylococcus aureus. Topical therapy is preferred over systemic antibiotics due to better efficacy and fewer systemic adverse effects.
Answer choice A: High-dose oral amoxicillin-clavulanate, is incorrect. Although oral antibiotics are commonly used for acute otitis media, they are less effective for CSOM because systemic drug levels in the middle ear may be inadequate, particularly in the presence of chronic infection and biofilm formation. Oral therapy may be considered only if topical treatment fails or if there are systemic symptoms.
Answer choice B: Intravenous broad-spectrum antibiotics, is incorrect. IV antibiotics are reserved for patients with severe complications of CSOM, such as mastoiditis, intracranial abscess, or systemic toxicity. This patient is clinically stable and lacks signs of invasive disease.
Answer choice C: Surgical mastoidectomy, is incorrect. Surgical intervention is not first-line therapy for uncomplicated CSOM. Mastoidectomy may be indicated for refractory infection, cholesteatoma, or complications but should follow appropriate medical management.
Answer choice E: Watchful waiting without treatment, is incorrect. Untreated CSOM can lead to progressive conductive hearing loss, ossicular erosion, cholesteatoma formation, and intracranial complications. Active treatment is necessary even in the absence of systemic symptoms.
Key Learning Point
Chronic suppurative otitis media presents with persistent otorrhea through a perforated tympanic membrane and is initially managed with topical antibiotic ear drops rather than systemic therapy.
