GPAtlas🧭 When to suspect
Suspect chronic suppurative otitis media (CSOM) in a patient with:
• Persistent or recurrent ear discharge (otorrhoea) through a perforated tympanic membrane, lasting more than 2 weeks and usually accompanied by conductive hearing loss
• Typically painless and afebrile – the hallmark, which is precisely what distinguishes it from acute otitis media (painful, febrile, intact or bulging drum) and from otitis externa (canal inflammation with an intact drum)
The clinically decisive step is to separate the two phenotypes:
• Mucosal (tubotympanic) CSOM has a central perforation and is the so-called “safe” ear
• Cholesteatomatous (atticoantral) CSOM has an attic or marginal perforation and is the “unsafe” ear, because keratinising squamous epithelium erodes bone and drives the serious complications – mastoiditis, facial nerve palsy and intracranial spread
So in primary care: recognise CSOM and refer it, and never miss a cholesteatoma or a complication. New pain, vertigo, facial weakness or post-auricular swelling are red flags, not features of uncomplicated disease.
| Feature | Mucosal – tubotympanic (“safe”) | Cholesteatomatous – atticoantral (“unsafe”) |
|---|---|---|
| Perforation site | Central (pars tensa) | Attic or marginal (pars flaccida or posterosuperior) |
| Discharge | Mucoid or mucopurulent, usually non-offensive, often profuse | Often scanty, foul-smelling, may be blood-stained |
| Key otoscopic clue | • Perforation with otorrhoea • Conductive hearing loss |
White keratin debris, crust or retraction pocket in the attic |
| Complication risk | Lower | Higher – bone erosion, mastoiditis, facial palsy, intracranial spread |
|
🧠 Clinical pearl • Almost all of the danger in CSOM comes from cholesteatoma and its capacity to erode bone. • A chronically discharging ear is never “just an infection” to be treated and forgotten. • In primary care the priority is not which drop to use but ENT review to exclude cholesteatoma. • There is no safe way to watch-and-wait a foul, attic-based discharge in the community. |
Source: NICE · Cochrane ENT
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