A 28-year-old woman with bilateral CSOM (mucosal type) is being counseled about medical and surgical management options. Regarding the management of CSOM, all of the following statements are correct EXCEPT:

Explanation

## CSOM Management: Medical and Surgical Principles **Key Point:** Mastoidectomy is NOT indicated in all cases of CSOM. The decision to perform mastoidectomy depends on disease extent, ossicular status, hearing levels, and patient factors. Many cases of uncomplicated mucosal CSOM can be managed with canal wall-up (CWU) techniques or even medical management alone. ### Management Algorithm for CSOM ```mermaid flowchart TD A[CSOM Diagnosis]:::outcome --> B{Active Discharge?}:::decision B -->|Yes| C[Aural Toilet + Topical Quinolones]:::action B -->|No| D[Observe or Plan Surgery]:::action C --> E{Discharge Controlled?}:::decision E -->|Yes| F[Hearing Assessment]:::outcome E -->|No| G[Consider Mastoidectomy]:::action F --> H{Ossicular Erosion + CHL?}:::decision H -->|Yes| I[Ossiculoplasty After Infection Resolved]:::action H -->|No| J[Conservative Management]:::action G --> K[Canal Wall Up vs Down]:::decision K -->|CWU| L[Endoscopic-Assisted if Revision]:::action K -->|CWD| M[Meatoplasty if Needed]:::action ``` ### Comparison of Management Strategies | Intervention | Indication | Evidence | |--------------|-----------|----------| | **Aural toilet + topical quinolones** | Acute exacerbation, active discharge | First-line; aminoglycosides contraindicated if perforation present | | **Mastoidectomy** | Recurrent discharge, ossicular erosion, complications, CWD desired | NOT routine in all CSOM; depends on disease pattern | | **Ossiculoplasty** | Conductive hearing loss + ossicular erosion after infection control | Performed after 4–6 weeks of dry ear; improves hearing | | **Endoscopic-assisted surgery** | Revision cases, difficult anatomy, sinus tympani disease | Improves visualization; reduces revision rates | **High-Yield:** The statement "mastoidectomy is indicated in ALL cases" is FALSE because: 1. Many patients with mucosal CSOM have limited disease confined to the middle ear 2. Ossicular status varies—some have intact ossicles and good hearing 3. Surgical decision depends on: disease activity, ossicular erosion, hearing levels, patient age, and compliance 4. Some cases resolve with medical management alone **Clinical Pearl:** A patient with inactive CSOM (no discharge for months), intact ossicles, and normal hearing may not require mastoidectomy—observation or canal wall-up tympanoplasty alone may suffice. **Warning:** Performing mastoidectomy in every CSOM patient leads to unnecessary surgery, morbidity (facial nerve injury, CSF leak, hearing loss), and complications. Individualize surgical approach based on disease severity and patient factors.