A 32-year-old woman from rural Maharashtra presents with a 6-month history of foul-smelling ear discharge from the left ear. She reports conductive hearing loss and occasional ear pain. On otoscopy, there is a central perforation with purulent discharge. Audiometry shows air-bone gap of 35 dB. She denies fever, vertigo, or facial weakness. What is the most appropriate next step in management?

Explanation

## Chronic Suppurative Otitis Media (CSOM): Management Approach ### Clinical Diagnosis This patient has **tubotympanic (safe) CSOM** with: - Central perforation (safe type) - Conductive hearing loss (air-bone gap 35 dB) - No complications (no fever, vertigo, or facial nerve involvement) - Duration >6 weeks (chronic) ### Management Algorithm ```mermaid flowchart TD A[CSOM diagnosed]:::outcome --> B{Complications present?}:::decision B -->|Yes: fever, vertigo, facial palsy| C[Imaging + Urgent surgery]:::urgent B -->|No| D[Aural toilet + Topical ABx]:::action D --> E[Wait 6 weeks]:::action E --> F{Discharge persists?}:::decision F -->|Yes| G[Tympanoplasty]:::action F -->|No| H[Continue conservative care]:::action ``` ### Rationale for Tympanoplasty **Key Point:** The standard protocol for uncomplicated CSOM is: 1. **Aural toilet** (cleaning, removal of debris) 2. **Topical antibiotics** (ciprofloxacin or ofloxacin drops) for 6 weeks 3. **Tympanoplasty** if discharge persists after conservative management **High-Yield:** Tympanoplasty should NOT be performed while active discharge is present — the graft will fail. The ear must be dry for at least 6 weeks before surgery. ### Why This Patient Needs Tympanoplasty - 6-month history suggests chronic infection unlikely to resolve spontaneously - Conductive hearing loss (air-bone gap 35 dB) will improve with successful graft - No contraindications (no complications, no systemic disease) - Success rate of tympanoplasty in CSOM: 85–95% ### Timing **Clinical Pearl:** The phrase "after 6 weeks of aural toilet and topical antibiotics" is key — this allows: - Clearance of active infection - Epithelialization of perforation margins - Assessment of whether perforation will heal spontaneously (rare in CSOM) [cite:Hazarika ENT 5e Ch 12]