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Child health Ear, nose and throat

Otitis media - chronic suppurative

Last revised in July 2022

Chronic suppurative otitis media (CSOM) is a chronic inflammation of the middle ear and mastoid cavity

Otitis media - chronic suppurative: Summary

  • Chronic suppurative otitis media (CSOM) is defined as chronic inflammation of the middle ear and mastoid cavity, which presents with recurrent ear discharges (otorrhoea) through a tympanic perforation for at least 2 weeks.
  • CSOM is assumed to be a complication of acute otitis media (AOM).
    • The World Health Organization definition states that AOM is considered to be CSOM after at least 2 weeks of discharge, whereas some experts suggest that more than 6 weeks of discharge is the cut-off point.
  • The true prevalence of CSOM is unknown, but in the UK it is estimated to be less than 1%.
  • Hearing loss that can be a feature of CSOM may cause problems with language development in children.
  • If left untreated, infection may spread extracranially (causing facial paralysis or mastoiditis) or intracranially (causing meningitis or a cerebral abscess), although this is rare.
  • Symptoms that support a diagnosis of CSOM include:
    • Ear discharge (for at least 2 weeks) without pain or fever.
    • A history of AOM (ear pain, fever, and irritability), a history of ear trauma, or a previous glue ear and grommet insertion.
    • A painless ear examination (unlike AOM or acute otitis externa), with evidence of tympanic membrane perforation.
    • Possible hearing loss.
  • Assessment should include:
    • Checking for postauricular swelling (tenderness), facial paralysis, vertigo, and signs or symptoms of intracranial infection (requiring admission).
    • Asking about hearing loss and, if appropriate, the effect of CSOM on daily activities (such as school or work) and language development.
    • Excluding alternative causes for persistent ear discharge such as otitis externa (suggested by an inflamed, eczematous canal without a perforation), a foreign body (particularly in children), impacted ear wax, and neoplasm (ear canal swelling that bleeds on contact).
  • Admission should be arranged for people with signs of infection beyond the ear, such as postauricular swelling or tenderness, headache, facial paralysis, or vertigo.
  • If CSOM is suspected, referral to an ear, nose, and throat specialist (for diagnosis, treatment, and follow up) should be made:
    • The ears should not be swabbed.
    • Treatment should not be initiated.
    • Reassurance should be given that any hearing loss will usually return when the perforation heals, but that a hearing test may be carried out in secondary care.

Have I got the right topic?

From age 1 month onwards.

This CKS topic covers the assessment and management of suspected chronic suppurative otitis media (CSOM) in primary care.

This CKS topic does not cover advice on treatments used for CSOM in secondary care, such as antibiotics, aural cleansing, or surgery.

There are separate CKS topics on Cholesteatoma, Otitis media - acute, Otitis media with effusion, and Otitis externa.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

July 2022 — reviewed. A literature search was conducted in July 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. Supporting references have been added to the existing guidance, with no major changes made to the recommendations.

Previous changes

July to September 2017 — reviewed. A literature search was conducted in July 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone restructuring. No major changes to the recommendations have been made.

June 2017 — Minor update. Information added on differential diagnosis of osteonecrosis of the external auditory canal. 

April 2014 — minor update. Text updated to include a cholesteatoma as a differential diagnosis of chronic suppurative otitis media.

December 2012 — reviewed. A literature search was conducted in December 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. No changes to clinical recommendations have been made.

July to October 2008 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 July 2022.

HTAs (Health Technology Assessments)

No new HTAs since 1 July 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 July 2022.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 July 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 July 2022.

New policies

No new policies or guidelines since 1 July 2022.

New safety alerts

No new safety alerts since 1 July 2022.

Changes in product availability

No changes in product availability since 1 July 2022.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a diagnosis of chronic suppurative otitis media.
  • Arrange urgent ear, nose, and throat (ENT) assessment or admission where serious complications are suspected.
  • Refer all people with uncomplicated chronic suppurative otitis media for routine ENT assessment.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • The World Health Organization (WHO) defines chronic suppurative otitis media (CSOM) as 'a chronic inflammation of the middle ear and mastoid cavity, which presents with recurrent ear discharges (otorrhoea) through a tympanic perforation' [WHO, 2004].
  • CSOM is assumed to be a complication of acute otitis media (AOM).
  • The WHO states that otorrhoea for a period of 2 weeks or more may be indicative of CSOM [WHO, 2004], whereas some experts suggest that duration of more than 6 weeks of discharge should be used to make the diagnosis [Verhoeff, 2006].
    • These variations in clinical definitions demonstrate that the transition from otorrhoea as a sign of AOM to that of CSOM is not clearly established [Verhoeff, 2006].

What causes it?

  • Chronic suppurative otitis media (CSOM) occurs when a persistent tympanic membrane perforation leads to recurrent middle ear infection and chronic inflammation.
    • Persistent tympanic membrane perforation can occur following a previous perforation if the outer squamous layer heals with the inner mucosal layer.
  • CSOM usually first presents in childhood, often as a spontaneous tympanic perforation following an acute infection of the middle ear.
  • CSOM can be caused by bacterial and/or fungal infection (often polymicrobial), including:
    • Pseudomonas aeruginosa (most common).
    • Staphylococcus aureus.
    • Proteus species.
    • Aspergillus species.
    • Candida albicans.

[WHO, 2004; Tsilis, 2013; Mohite, 2019; Wan Draman, 2021]

How common is it?

The true prevalence of chronic suppurative otitis media (CSOM) is unknown.

  • In 2004, the World Health Organization estimated the prevalence in the UK to be less than 1% [WHO, 2004].
  • A more recent systematic review stated that the incidence of CSOM in 2005 in Western Europe was 3.57% [Monasta, 2012].
  • A population-based observational study demonstrated a high lifetime risk of hearing loss following CSOM in childhood, with up to 91% experiencing at least mild hearing loss [Homøe, 2017].

What are the risk factors?

Risk factors for chronic suppurative otitis media (CSOM) include:

  • Younger age — children under 5 years old are most commonly affected.
  • Allergy/atopy. 
  • Upper respiratory tract infection.
  • Acute or recurrent otitis media.
  • Exposure to second-hand smoke.
  • Social deprivation.
  • Snoring.

Risk factors for hearing loss in people with CSOM include:

  • Diabetes.
  • Smoking.
  • Longer duration of disease.
  • Presence of otorrhoea (active discharge).
  • Size of the tympanic perforation.

[Monasta, 2012; Zhang, 2014; Singer, 2018]

What are the complications?

Complications of chronic suppurative otitis media (CSOM) can include:

  • Hearing loss and (in children) problems with language development.
    • A single study has demonstrated an increased prevalence of depression, anxiety, and stress among people with hearing loss as a consequence of CSOM [Mehboob, 2019].
  • Facial paralysis, mastoiditis, petrositis — caused if infection spreads extracranially.
  • Meningitis, cerebral abscess — caused if infection spreads intracranially.
  • Death (rare in developed countries).

[WHO, 1996; Verhoeff, 2006; Monasta, 2012; Yorgancilar, 2013; Schilder, 2017; Mohite, 2019]

Diagnosis of chronic suppurative otitis media

When should I suspect chronic suppurative otitis media?

  • Suspect chronic suppurative otitis media (CSOM) in a person with:
    • Ear discharge persisting for more than 2 weeks, without ear pain or fever.
    • Hearing loss in the affected ear.
    • A history of acute otitis media (AOM), ear trauma, or glue ear and grommet insertion. See the CKS topics on Otitis media - acute and Otitis media with effusion for more information.
    • A history of allergy, atopy, and/or upper respiratory tract infection.
    • Tinnitus and/or a sensation of pressure in the ear may also be present.
  • Examination of the ear may reveal tympanic membrane perforation and/or middle ear inflammation.
  • Note: Red flag symptoms which can indicate serious complications (such as mastoiditis and/or intracranial infection) in a person with CSOM include:
    • Headache.
    • Nystagmus.
    • Vertigo.
    • Fever.
    • Labyrinthitis.
    • Facial paralysis.
    • Swelling/tenderness behind the ear.

Basis for recommendation

CKS did not identify any national guidelines on the diagnosis of chronic suppurative otitis media (CSOM). These recommendations are therefore based on expert opinion within the World Health Organization guideline Chronic suppurative otitis media: burden of illness and management options [WHO, 2004], in narrative review articles [Verhoeff, 2006; Tsilis, 2013; Qureishi, 2015], and NHS Scotland patient pathway guidance ENT Aural Discharge [NHS Scotland, 2022].

  • In primary care, only a provisional diagnosis of CSOM can be made, as specialist equipment (for example an otomicroscope) and expertise to assess the middle ear mucosa are not usually available.
  • Conductive hearing loss can occur in more than 50% of people with CSOM. Sensorineural hearing loss may occur by inflammation reaching the inner ear [WHO, 1996].

What else might it be?

The differential diagnoses of chronic suppurative otitis media (CSOM) include:

  • Otitis externa — suggested by ear pain, itching, discharge, and reduced hearing. Examination may reveal an inflamed, eczematous canal without a perforation. Can also be concurrent with CSOM. See the CKS topic on Otitis externa for more information.
  • Acute suppurative otitis media (ASOM) — suggested by ear pain, fever, vomiting in children, reduced hearing, and discharge if the eardrum perforates (or examination may reveal pus in the middle ear). Most cases resolve spontaneously within a few days. See the CKS topic on Otitis media - acute for more information.
  • Otitis media with effusion (OME) — suggested by fluid in the middle ear without acute signs or symptoms. See the CKS topic on Otitis media with effusion for more information.
  • A foreign body.
  • Impacted ear wax.
  • A cholesteatoma — suggested by chronic smelly ear discharge, and the presence of squamous epithelium and keratin in the middle ear. See the CKS topic on Cholesteatoma for more information.
  • Neoplasm — suggested by an ear canal swelling that bleeds on contact.
  • Osteonecrosis of the external auditory canal — consider in people receiving denosumab and/or bisphosphonates who present with chronic ear infection or suspected cholesteatoma.

Basis for recommendation

The information on differential diagnoses of chronic suppurative otitis media is based on expert opinion in the World Health Organization guideline on Chronic suppurative otitis media: burden of illness and management options [WHO, 2004] and in narrative review articles [Verhoeff, 2006; Qureishi, 2015].

Management

Scenario: Management of chronic suppurative otitis media

From age 1 month onwards.

How should I manage a person with suspected chronic suppurative otitis media?

  • If the person's signs and symptoms suggest a serious complication, arrange urgent admission or assessment by an ear, nose, and throat (ENT) specialist using clinical judgement.
  • For all other people with suspected chronic suppurative otitis media (CSOM):
    • Do not swab the ear or initiate treatment.
    • Refer for ENT assessment.
      • Explain that secondary care treatment is likely to involve antibiotics and steroids (usually topical), and intensive cleaning of the affected ear.
    • Ask about hearing loss and, if appropriate, the effect of CSOM on daily activities (for example school or work), language development, and mental health. 
      • Explain that any hearing loss will usually return when the perforation heals, but a hearing test may be carried out in secondary care.
    • Advise the person to keep the affected ear dry.
    • Dry mopping the affected ear using cotton wool or tissue paper will help to clean discharge from the ear.
      • Explain that it is not known whether this will improve symptoms of ear discharge or hearing loss.

Basis for recommendation

CKS did not identify any national guidelines on management of people with chronic suppurative otitis media (CSOM) in primary care. These recommendations are therefore largely derived or extrapolated from information contained within the World Health Organization guideline Chronic suppurative otitis media: burden of illness and management options [WHO, 2004], in narrative review articles [Verhoeff, 2006; Tsilis, 2013; Qureishi, 2015], and NHS Scotland patient pathway guidance ENT Aural Discharge [NHS Scotland, 2022].

Urgent referral
  • The advice to urgently refer people with suspected serious complications is pragmatic, based on what CKS considers to be good medical practice.
Routine referral for all people with suspected CSOM
  • A specialist referral is necessary to:
    • Confirm CSOM.
      • Microsuctioning or debridement are likely to be required to clearly view the tympanic membrane perforation and also to detect possible ossicular lesions, polyps, cholesteatoma, granulation tissue, or mucosal oedema. 
      • High-resolution CT imaging of the temporal bone may also be required to assess the status of the middle ear and surrounding structures, the ossicles, and the presence of cholesteatoma or granulation.
    • Assess the risk of complications — the size and position of the perforation and appearance of the middle ear will influence prognosis and management (a perforation in the upper ear drum [compared with the centre] is more likely to lead to mastoiditis requiring surgery).
    • Initiate treatment.
      • Very few non-specialists have the equipment or training to carry out aural cleaning.
      • Topical quinolones are used off-licence. Aminoglycosides are a potential alternative but can cause ototoxicity. Specialist supervision is therefore required for both of these treatment options.
  • The role of ear swabs in CSOM is controversial. Some experts believe that treatment failure is rarely due to resistant organisms (topical antibiotic concentrations are so high that they kill even resistant organisms) and is mainly due to poor administration.
  • Surgical intervention may eventually be required to repair the tympanic membrane and restore hearing.
Discussing the impact of CSOM on daily activities, language development, and mental health
  • CSOM associated with hearing loss in childhood can impact language development, school, and social performance.
  • A single study has demonstrated an increased prevalence of depression, anxiety, and stress among people with hearing loss as a consequence of CSOM [Mehboob, 2019].
Communication
  • The recommendations on explaining secondary care treatment and the likely duration of any hearing loss are pragmatic, based on what CKS considers to be good medical practice.
Keeping the affected ear dry
  • People with tympanic membrane perforation are routinely advised to avoid getting the affected ear wet by avoiding swimming and taking care when showering or washing their hair [NHS, 2020].
    • The recommendation to avoid getting the affected ear wet is made in the absence of high quality clinical evidence, but is based on what CKS considers to be good medical practice.
Dry mopping the affected ear to remove discharge
  • A 2020 Cochrane systematic review assessed the evidence relating to aural toileting (ear cleaning) for people with CSOM [Bhutta, 2020].
    • Aural toileting is a term used to describe several manual ear cleaning techniques.
    • These include dry mopping (with cotton wool or tissue paper), suction clearance (typically under a microscope), or irrigation (using manual or automated syringing).
    • Dry mopping may be effective in removing mucopurulent discharge, but irrigation or microsuction techniques are more effective in removing epithelial debris or thick pus.
    • Irrigation or microsuction cannot be performed by people with CSOM at home.
  • The review only identified three small to moderately sized studies, and two of these compared daily dry mopping with no treatment.
    • These studies do not provide any high quality evidence that daily dry mopping improves symptoms of ear discharge or hearing loss.
    • No results were available to determine the risk of adverse events with daily dry mopping.

Supporting evidence

This CKS topic is largely based on information contained within the World Health Organization guideline Chronic suppurative otitis media: burden of illness and management options [WHO, 2004], in narrative review articles [Verhoeff, 2006; Tsilis, 2013; Qureishi, 2015], and NHS Scotland patient pathway guidance ENT Aural Discharge [NHS Scotland, 2022]. The recommendations relevant to primary care were developed from the expert opinions of the guideline development group or from the review authors. The evidence for specialist management strategies is not discussed as they are beyond the scope of this CKS topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of chronic suppurative otitis media.

Search dates

June 2017 - June 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp otitis media, suppurative/, Exp tympanic membrane perforation/, CSOM.ti,ab., Chronic otitis media.ti,ab., Chronic suppurative otitis media.ti,ab., Discharging ears

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Bhutta, M.F., Head, K., Chong, L-Y., et al. (2020) Cochrane Review: Aural toilet (ear cleaning) for chronic suppurative otitis media. Issue 9. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Homøe, P., Kværner, K., Casey, J.R., et al. (2017) Research Conference Report from the 18th International Conference on Recent Advances in Otitis Media, Start of the Art Review, Panel 1: Epidemiology and Diagnosis. Otolaryngology – Head and Neck Surgery 156(4_suppl), S1-S21. [Abstract] [Free Full-text]
  • Mehboob, S., Tariq Rafi, S.M., Ahmed, N. and Mehjabeen (2019) Association of hearing loss with depression, anxiety and stress in patients suffering from chronic suppurative otitis media. Pakistan Journal of Medical Sciences 35(2), 510-514. [Abstract] [Free Full-text]
  • Mohite, A.A., Mane, R.S., Patil, B.C. and Mohanty, R.M. (2019) Complications of chronic suppurative otitis media and their management: five year study at tertiary care centre. International Journal of Otorhinolaryngology and Head and Neck Surgery 5(4), 900-905. [Free Full-text]
  • Monasta, L., Ronfani, L., Marchetti, F., et al. (2012) Burden of disease caused by otitis media: systematic review and global estimates. PLoS One 7(4), e36226. [Abstract]
  • NHS Scotland (2022) ENT Aural Discharge Patient Pathway (Adults). NHS Greater Glasgow and Clyde. https://www.nhsggc.scot [Free Full-text]
  • NHS (2020) Health A to Z; Perforated eardrum. National Health Service (NHS). https://www.nhs.uk [Free Full-text]
  • Qureishi, A., Lee, Y., Belfield, K., et al. (2015) Update on otitis media - prevention and treatment. Infection and Drug Resistance 7, 15-24. [Abstract]
  • Schilder, A.G.M., Marom, T., Bhutta, M.F., et al. (2017) Research Conference Report from the 18th International Conference on Recent Advances in Otitis Media, Start of the Art Review, Panel 7: Otitis Media: Treatment and Complications. Otolaryngology – Head and Neck Surgery 156(4_suppl), S88-S105. [Abstract] [Free Full-text]
  • Singer, A.E.A., Abdel-Naby Awad, O.G., El-Kader, R.M.A. and Mohamed, A.R. (2018) Risk factors of sensorineural hearing loss in patients with unilateral safe chronic suppurative otitis media. American Journal of Otolaryngology 39(2), 88-93. [Abstract]
  • Tsilis, N.S., Vlastarakos, P.V., Chalkiadakis, V.F., et al. (2013) Chronic otitis media in children: an evidence-based guide for diagnosis and management. Clinical Pediatrics (Philadelphia) 52(9), 795-802. [Abstract]
  • Verhoeff, M., van der Veen, E.L., Rovers, M.M., et al. (2006) Chronic suppurative otitis media: a review. International Journal of Pediatric Otorhinolaryngology 70(1), 1-12. [Abstract]
  • Wan Draman, W.N.A., Daud, M.K.M, Mohamed, H., Hassan, S.A. and Rahman, N.A. (2021) Evaluation of the current bacteriological profile and antibiotic sensitivity pattern in chronic suppurative otitis media. Laryngoscope Investigative Otolaryngology 6(6), 1300-1306. [Abstract] [Free Full-text]
  • WHO (1996) Prevention of hearing impairment from chronic otitis media. World Health Organization. http://www.who.int [Free Full-text]
  • WHO (2004) Chronic suppurative otitis media: burden of illness and management options. World Health Organization. http://www.who.int [Free Full-text]
  • Yorgancılar, E., Yildirim, M., Gun, R., et al. (2013) Complications of chronic suppurative otitis media: a retrospective review. European Archives of Oto-Rhino-Laryngology 270(1), 69-76. [Abstract]
  • Zhang, Y., Xu, M., Zhang, J., et al. (2014) Risk factors for chronic and recurrent otitis media-a meta-analysis. PLoS One 9(1), e86397. [Abstract]
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