A 32-year-old man presents with a 10-year history of chronic suppurative otitis media with active drainage from the ear canal. Otoscopy reveals a central perforation with mucopurulent discharge. He has no fever and no complications. What is the drug of choice for topical management of the active infection?

Explanation

## Topical Antibiotic Selection in CSOM **Key Point:** Ciprofloxacin is the preferred topical antibiotic in chronic suppurative otitis media because it is a fluoroquinolone with excellent activity against Pseudomonas aeruginosa and Staphylococcus aureus — the most common pathogens in CSOM drainage. **High-Yield:** Ciprofloxacin is non-ototoxic, making it safe for use in perforated eardrums, whereas aminoglycosides (gentamicin, tobramycin) carry a significant risk of permanent sensorineural hearing loss if they penetrate the middle ear through a perforation. **Clinical Pearl:** In CSOM with active drainage, the goal is to control infection and promote drainage. Fluoroquinolone otic drops achieve high concentrations in the middle ear and external auditory canal while avoiding systemic absorption. ### Why Ciprofloxacin is Superior | Feature | Ciprofloxacin | Gentamicin | Chloramphenicol | Acetic Acid | |---------|---------------|-----------|-----------------|-------------| | **Ototoxicity** | None | High (aminoglycoside) | Low | None | | **Pseudomonas coverage** | Excellent | Good | Moderate | No | | **Penetration to middle ear** | Excellent | Good | Moderate | Poor | | **Use in perforation** | Safe | Contraindicated | Relative contraindication | Safe but weak | | **Gram-positive coverage** | Good | Excellent | Excellent | No | **Mnemonic:** **FQ-SAFE** — Fluoroquinolones are Safe for Active Fluid drainage in Ears (perforated tympanum). **Warning:** Gentamicin and other aminoglycosides must be avoided in CSOM with perforation because they are ototoxic and can cause permanent hearing loss if they reach the inner ear. This is a common NEET PG trap.