Medication Summary

An expert panel of the American Academy of Otolaryngology-Head and Neck Surgery has provided guidelines for the use of antibiotics in chronic suppurative otitis media (CSOM).^[42]The panel concluded that topical antibiotics alone constitute first-line treatment for most patients, barring systemic infection. If systemic infection is present, oral or, if necessary, parenteral antibiotics are warranted.

Although studies suggest only a slight risk of sensorineural hearing loss in humans from short courses of topical aminoglycosides, the risk of vestibular toxicity appears to be much higher.

The introduction of fluoroquinolones, which have no potential for ototoxicity, relegates aminoglycosides to a secondary treatment alternative in most areas. Patients who receive aminoglycoside drops when fluoroquinolone drops are available and subsequently develop sensorineural hearing loss or balance disturbance may blame their physician.

A retrospective Korean study, by Park et al, found that in patients with CSOM or chronic cholesteatomatous otitis media, methicillin-resistant Staphylococcus aureus (MRSA) infections demonstrated greater resistance to the antibiotics ciprofloxacin, clindamycin, erythromycin, gentamicin, levofloxacin, and tetracycline than they did in patients with otitis media with effusion or acute otitis media.^[43]

Class Summary

Topical and systemic antibiotics are used in the treatment of CSOM. Fluoroquinolone otic preparations, with or without a corticosteroid, are excellent options for topical treatment. Aminoglycoside otics may also be used, but monitoring of vestibular or cochlear toxicity is necessary. Representative examples of each class are listed below.

Ciprofloxacin (Cetraxal)

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Ciprofloxacin is an ototopical fluoroquinolone containing hydrocortisone. This class of antimicrobial has a broad spectrum of activity. Additionally, fluoroquinolones do not cause vestibular or cochlear toxicity recognized with aminoglycosides.

Ciprofloxacin/dexamethasone combination (Ciprodex)

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This combination of drugs treats bacterial infection and decreases the inflammation associated with bacterial infections.

Tobramycin (Tobrex)

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Tobramycin is an ototopical aminoglycoside that may be combined with a corticosteroid. It has a long, successful history in the treatment of CSOM and is widely used today. The risk of vestibular or cochlear toxicity with prolonged use or use on the noninflamed middle ear exists; consider this when choosing to treat CSOM with this class of medication.

Tobramycin and dexamethasone (TobraDex)

This combination of drugs treats bacterial infection and decreases the inflammation associated with bacterial infections.

Piperacillin

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Piperacillin inhibits the biosynthesis of cell wall mucopeptides and the stage of active multiplication; additionally, piperacillin shows antipseudomonal activity.

Ceftazidime (Fortaz, Tazicef)

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Studies show ceftazidime to be an effective IV antibiotic for the systemic treatment of CSOM.^{[24, 25]}It penetrates the middle ear mucosa effectively and does not cause vestibular or cochlear toxicity.

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Media Gallery

Anatomy of the external and middle ear.

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Author

Denny Varughese, MD Resident Physician, Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Coauthor(s)

Yu-lan Mary Ying, MD Assistant Professor of Otology-Neurotology, Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School; Attending Otolaryngologist, Hackensack UMC Mountainside Hospital, St Barnabas Hospital, and University Hospital

Yu-lan Mary Ying, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Neurotology Society, North American Skull Base Society, Otosclerosis Study Group

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Emeritus Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Neosoma; MI10;<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10 advisor.

Additional Contributors

Peter S Roland, MD Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for Communicative Disorders, University of Texas School of Human Development

Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Neurotology Society, American Otological Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, The Triological Society

Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.

Brandon Isaacson, MD, FACS Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center

Brandon Isaacson, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, North American Skull Base Society, Texas Medical Association, Triological Society, American Neurotology Society

Disclosure: Received consulting fee from Medtronic Midas Rex Insitute for consulting; Received medical advisory board from Advanced Bionics for board membership; Received consulting fee from Stryker for speaking and teaching.

Acknowledgements

Anurag Jain, MBBS, FRCS(Ire), MS, FRCS(Oto), MS(Oto), DLO(RCSEngland) Specialist Registrar, Department of Otolaryngology, Pinderfields General Hospital, Wakefield, UK

Anurag Jain, MBBS, FRCS(Ire), MS, FRCS(Oto), MS(Oto), DLO(RCSEngland) is a member of the following medical societies: Association of Otolaryngologists of India, British Association of Otorhinolaryngologists, Head and Neck Surgeons, British Medical Association, Royal College of Surgeons in Ireland, and Royal College of Surgeons of England