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Evidence summaries

Treatment of Chronic Suppurative Otitis Media

The effectiveness and safety profile of topical antiseptics and antibiotics in the treatment of chronic suppurative otitis media is insufficient. However, topical antibiotics might possibly result in an increase in resolution of ear discharge compared with topical antiseptic at up to two weeks, although the evidence is insufficient. Level of evidence: "D"

Comment: The quality of evidence is downgraded by study quality (inadequate or unclear allocation concealment), imprecise results (few studies in most of the comparisons) and indirectness (short follow-up time).

A Cochrane review [Abstract] 1 included 5 studies. It was not possible to calculate the total number of participants as two studies only provided the number of ears included in the study.

  • Topical antiseptic (boric acid) vs. placebo or no treatment (one study): It is uncertain whether treatment with an antiseptic leads to an increase in resolution of ear discharge at both 4 weeks (RR 1.94, 95% CI 1.20 to 3.16; n=174) and at 3 to 4 months (RR 1.73, 95% CI 1.21 to 2.47; n=180).
  • Topical antiseptic vs. topical antiseptic (one study, n=93): It is uncertain whether more patients had resolution of ear discharge with boric acid powder vs. acetic acid at 4 weeks (RR 2.61, 95% CI 1.51 to 4.53), or whether there was a difference between the arms with respect to ear discomfort due to the low number of reported events (RR 0.10, 95% CI 0.01 to 1.81).

Another Cochrane review [Abstract]2 included 17 studies with a total of 2198 patients.

  • Topical antibiotics vs. placebo or no treatment:Ciprofloxacin was better than saline in terms of resolution of discharge at one to two weeks: 84% vs. 12% (RR 6.74, 95%CI 1.82 to 24.99; one study, n=35).
  • Topical antibiotics vs. placebo or no treatment (with use of oral antibiotics in both arms): Ciprofloxacin was better than no treatment, resolution of discharge occurring in 88.2% vs. 60% at one to two weeks (RR 1.47, 95% CI 1.20 to 1.80; 2 studies, n=150). The studies did not report ear pain or discomfort/local irritation.
  • Comparisons of different topical antibiotics:
    • Quinolones vs. aminoglycosides: Seven studies compared an aminoglycoside (gentamicin, neomycin or tobramycin) with ciprofloxacin (n=734) or ofloxacin (n=214). Resolution of discharge at one to two weeks was higher in the quinolones group (RR 1.95, 95% CI 0.88 to 4.29; 6 studies, n=694). One study measured ear pain and reported no difference between the groups.
    • Quinolones vs. aminoglycosides/polymyxin B combination ±gramicidin: Ciprofloxacin was better (RR 1.12, 95% CI 1.03 to 1.22; n=186).
  • Others:Other studies examined topical gentamicin vs. a trimethoprim/sulphacetamide/polymixin B combination (n=91) and rifampicin versus chloramphenicol (n=160). Limited data were available and the findings were very uncertain.

The third Cochrane review [Abstract]3 included 7 studies with a total of 935 patients.

  • Topical antiseptic (acetic acid) vs. topical antibiotics (quinolones or aminoglycosides): It is uncertain if there is a difference in resolution of ear discharge with acetic acid vs. aminoglycosides at one to two weeks (RR 0.88, 95% CI 0.72 to 1.08; 1 study, n=100). No study reported results for ear discharge after 4 weeks. It was very uncertain if there was more ear pain, discomfort or local irritation with acetic acid or topical antibiotics due to the low numbers of events (RR 0.16, 95% CI 0.02 to 1.34; 2 RCTs, n=189).
  • Topical antiseptic (boric acid) vs. topical antibiotics (quinolones): There were more patients with resolution of ear discharge when using topical antibiotics (quinolones) vs. boric acid ear drops at between one to two weeks (RR 1.56, 95% CI 1.27 to 1.92; 1 study, n=409). No study reported results for ear discharge after 4 weeks. There was a bigger improvement in hearing in the topical antibiotic group vs. the topical antiseptic group (MD 2.79 dB, 95% CI 0.48 to 5.10; 1 study, n=390) but this difference may not be clinically significant. There may be more ear pain, discomfort or irritation with boric acid compared with quinolones (RR 0.56, 95% CI 0.32 to 0.98; 2 studies, n=510).
  • Topical antiseptic (povidone-iodine) versus topical antibiotics (quinolones): It is uncertain if there is a difference between quinolones and povidone-iodine with respect to resolution of ear discharge at one to two weeks (RR 1.02, 95% CI 0.82 to 1.26; 1 RCT, n=39). There were no differences between the groups for hearing and no patients developed ototoxic effects. No results beyond 4 weeks were reported.
  • Topical antiseptic (acetic acid) + aural toileting vs. topical + systemic antibiotics (quinolones): Participants with topical and oral antibiotics had less resolution of ear discharge vs. acetic acid ear drops and aural toileting (suction clearance every two days) at one month (RR 0.69, 95% CI 0.53 to 0.90; n=100). The study did not report results for resolution of ear discharge at between one to two weeks, ear pain, discomfort or irritation, hearing or suspected ototoxicity.

    References

    • Head K, Chong LY, Bhutta MF et al. Topical antiseptics for chronic suppurative otitis media. Cochrane Database Syst Rev 2020;1():CD013055. [PubMed]
    • Brennan-Jones CG, Head K, Chong LY et al. Topical antibiotics for chronic suppurative otitis media. Cochrane Database Syst Rev 2020;1():CD013051. [PubMed]
    • Head K, Chong LY, Bhutta MF et al. Antibiotics versus topical antiseptics for chronic suppurative otitis media. Cochrane Database Syst Rev 2020;1():CD013056. [PubMed]

Primary/Secondary Keywords