A 32-year-old man from rural India presents with a 6-month history of foul-smelling purulent otorrhea from the left ear, conductive hearing loss, and a central perforation on otoscopy. Audiometry shows air-bone gap of 25 dB. He has no fever, facial nerve involvement, or vertigo. What is the most appropriate next step in management?

Explanation

## Clinical Assessment **Key Point:** This patient has **active** (wet) uncomplicated chronic suppurative otitis media (CSOM) — tubotympanic (safe) type — with foul-smelling purulent otorrhea, central perforation, and a 25 dB air-bone gap. The **most appropriate next step** is medical management to achieve a dry ear before any surgical intervention. ## Management Algorithm for Active CSOM ``` Active CSOM (wet ear, central perforation) ↓ Medical therapy: aural toilet + topical fluoroquinolone ± systemic antibiotics ↓ Dry ear achieved (6–8 weeks)? Yes → Audiometry + CT temporal bone → Myringoplasty ± Ossiculoplasty No → Re-evaluate, consider resistant organisms, rule out cholesteatoma ``` ## Rationale for Medical Management First **High-Yield:** The standard of care for **active CSOM** (discharging ear) is to first control infection before planning any reconstructive surgery. Surgery on an actively infected ear carries significantly higher risks of: - Graft failure (myringoplasty failure rate increases 3–4× in wet ears) - Spread of infection to mastoid or intracranial compartment - Poor wound healing and persistent perforation **Clinical Pearl (Scott-Brown's Otorhinolaryngology / Dhingra ENT):** The first-line treatment for active tubotympanic CSOM is: 1. **Aural toilet** (dry mopping / syringing to remove discharge) 2. **Topical fluoroquinolone drops** (ciprofloxacin) — most effective against *Pseudomonas aeruginosa* and *Staphylococcus aureus*, the commonest organisms 3. **Systemic antibiotics** (amoxicillin-clavulanate) for 2–4 weeks when systemic signs or resistant organisms are suspected ## Why Other Options Are Incorrect - **Option A (CT + ossiculoplasty):** Ossiculoplasty is an elective procedure performed only after the ear is dry. Imaging and reconstruction planning come *after* infection control, not as the immediate next step. Jumping to ossiculoplasty in an actively discharging ear is inappropriate. - **Option C (Immediate myringoplasty):** Myringoplasty is contraindicated in an actively discharging ear. Surgery is deferred until the ear has been dry for at least 6–8 weeks. - **Option D (Mastoid exploration + cortical mastoidectomy):** Reserved for unsafe CSOM (cholesteatoma), complications (facial palsy, vertigo, meningitis), or failure of medical management. This patient has no such features. ## Summary **High-Yield:** In active tubotympanic CSOM without complications → **medical management first** (topical ciprofloxacin + systemic amoxicillin-clavulanate + aural toilet). Surgical reconstruction (myringoplasty ± ossiculoplasty) is planned only after achieving a dry ear for at least 6–8 weeks. [cite: Dhingra PL, Diseases of Ear Nose and Throat, 7th ed., Ch. 9; Scott-Brown's Otorhinolaryngology Head and Neck Surgery, 8th ed., Vol. 3]