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. The hallmark is that it is typically painless and afebrile – 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.
The two skills in primary care are therefore to recognise CSOM and refer it, and to 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 / 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 – so a chronically discharging ear is never “just an infection” to be treated and forgotten. The single most important decision in primary care is not which drop to use, but ensuring 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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