Management Strategies for Chronic Suppurative Otitis Media and Why They Fail

Chronic suppurative otitis media (CSOM) affects up to 330 million people globally and is one of the leading causes of pediatric hearing loss. Defined by a state of chronic infection in the middle ear in the setting of a tympanic membrane perforation, CSOM is traditionally most frequently associated with infection with Pseudomonas and Staphylococcus aureus species. The current therapeutic options for CSOM include medical therapy in the form of topical antibiotics or antiseptics (i.e., boric acid, acetic acid, povo-iodine), as well as surgical intervention with tympanoplasty or tympanomastoidectomy in refractory cases. While topical fluoroquinolones have the strongest level of evidence supporting their use for CSOM treatment, they are frequently associated with long-term treatment failure. Treatment failure is secondary to the presence of persister cells in CSOM, which are antibiotic tolerant and have the potential to proliferate and gain additional antibiotic resistance. As biofilms and persister cells are not routinely tested for in clinical medicine, there is limited data on therapeutic options that may eradicate biofilms and persister cells while limiting ototoxic effects. While future research should aim to identify such ototopical treatment options, clinicians may also consider surgical intervention earlier in patients with disease refractory to topical treatment to both minimize the risk of encouraging antibiotic resistance and to maximize the ability to debride the biofilm.