This article is on chronic suppurative otitis media, a common condition of the ears seen by General Practitioners, Otolaryngologists, and Audiologists. This resource is open to everyone. Patients, medical students and health professionals may find this useful. Adjacent boxes provide additional information for Medical Professionals


What is Suppurative otitis media?

Chronic suppurative otitis media (CSOM) means the middle ear is infected or inflamed for a long time. This is shown by ongoing discharge or fluid from the ear and a hole in the eardrum (a perforation). There is usually hearing loss.


Who gets Suppurative otitis media?

Both children and adults can get CSOM. In children, CSOM is seen most in those who have had many middle ear infections with a hole in the eardrum.

It is estimated that around the word, there are 65-330 million people with CSOM. Most are living in developing countries.


What are the causes?

Things that put you at higher risk of middle ear infections are:

  • Exposure to cigarettes / tobacco
  • Going to daycare / kindergarten
  • Crowded, damp housing
  • Family history
  • Allergic history (e.g. eczema, asthma, hayfever, etc.)
  • Sick often (e.g. colds, infections)
  • Underlying medical conditions (e.g. cleft palate, Downs Syndrome)

Breastfeeding seems to protect against middle ear infections. The effect of this is greatest up to six months old, and until the age of two.


What are the symptoms?

CSOM usually has fluid coming out of the ear for at least two weeks. This is usually painless. There are usually no signs of infection (e.g. fever), but there may be a past history of ear infections.

The doctor can look inside the ear using a scope (called an otoscope). The ear canal may have extra tissue growth, which can be a sign of repeat infection or fluid. Fluid may be seen. In almost all cases, there may be a hole in the eardrum itself.

Some doctors may use a special tool called a tympanometer. After having a look inside the ear, the doctor will use this tool. It sits snug inside the ear and measures how well your eardrum moves in response to a noise. It makes a graph, which the doctor can read. This may suggest fluid behind the ear, or a hole in the eardrum.

As there are repeat ear infections, fluid coming out and a hole in the eardrum, CSOM can affect hearing. In children, this could affect language and speech development. This could affect how they do at school.

Signs of more severe CSOM can be pain and fever. Pain may be in the ear, or just behind the ear.  Some people also get dizzy, like the room is spinning around them. Some also have trouble with balance. In severe cases, there may be problems with the face muscles.


How is it diagnosed?

CSOM is diagnosed when there is a hole in the eardrum and ongoing fluid coming from the ears for at least two weeks. This is usually based on an exam. If it is severe, the doctor may order special head scans.


What are the potential complications?

CSOM can affect hearing. There is fluid in the middle ear, but also the repeat infections and fluid can slowly wear down the small ear bones of hearing. This can result in hearing problems as the small bones are important for hearing. If there is spreading infection, it may affect inner ear organs which makes it harder for the ear to send hearing signals to the brain. This can also affect balance.

In some cases, a cholesteatoma may form. This is an abnormal growth of the inner lining of the ear that slowly gets bigger over time. This can destroy the small bones inside the ear and lead to hearing loss. Signs of a cholesteatoma include ongoing discharge despite treatment, new hearing loss or your doctor may be able to see features in the eardrum. This requires surgery to fix.

In rare cases, the infection can spread from the ear to other places within the head. One place is the mastoid antrum, a space of air-filled cells behind the ear, called ‘mastoiditis’. Untreated mastoiditis can lead to its own issues, include hearing loss, abscesses (a collection of pus), deeper infections and damage to nerves of the face. Another place is the meninges, a lining just covering the outside part of the brain. This leads to meningitis which can be life-threatening.


What are the treatment options?

CSOM usually needs specialist treatment by an ENT surgeon. This includes regular cleaning of the ears and special eardrops.

Regular cleaning helps keep the ear dry. This is to prevent extra tissue growth caused by inflammation.

You should NOT use cotton buds at home. Cotton buds can make things worse as it could make a hole in the eardrum. Cotton buds can also break and get stuck inside the ear.

Eardrops usually combine an antibiotic and steroids. The drops work by clearing bacteria and reducing tissue growth due to the fluid. Eardrops do not always work however and CSOM may persist despite treatment.

Surgery is another option. It is used in treating the complications of CSOM or if non-surgical management has failed. Surgery may be needed to fix the hole in the eardrum or the eardrum entirely. In some cases, the eardrum hole can heal by itself. As CSOM results in damage to the bones in the ear, a surgery may be needed to try fix the small bones to improve hearing. Surgery has many risks itself, which includes general anaesthetic

Patients with signs of severe CSOM may need treatment in hospital.


Can you prevent Suppurative otitis media ?

Preventing AOM can be tricky, as some risk factors can be hard to control (e.g. if there is an underlying medical condition).

Some things that you can do are:

  • Keeping the home dry or warm where possible
  • Being smoke-free
  • Keeping up-to-date with vaccinations


What is the prognosis?

CSOM takes time to get better and needs regular treatment. In severe cases, hearing may not return to its normal level. There may be some level of hearing loss despite treatment.


Impact on DALY

Repeat ear infections can have an impact on a child’s development. Build-up of fluid or pus behind the eardrum means the ear bones do not move as well, which means you do not hear well. Children with hearing problems can have trouble developing speech and language skills.

The regular cleaning needed for CSOM will mean repeat visits to the doctor. This could impact on work schedules. If surgery is needed, this may also need time off work.


Further reading:




Author + Affiliation:
Brian Yeom, MBChB BMedSc(Hons). Counties Manukau Health

Date of Publication +/- Review:

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