Chronic otitis media (chronic suppurative otitis media): symptoms and management

The middle ear is the air-filled space behind the eardrum, linked to the back of the nose by the eustachian tube. The NHS explains that middle ear infections (otitis media) usually affect children and are caused by viruses like colds and flu. Most ear infections clear within 3 days, although sometimes symptoms last up to a week.

Chronic suppurative otitis media is different: it is long-standing. NICE CKS defines it as chronic inflammation of the middle ear and mastoid cavity with recurrent discharge through a hole (perforation) in the eardrum lasting at least 2 weeks. It is assumed to be a complication of acute otitis media. NICE CKS notes that the World Health Organization definition treats acute otitis media as chronic after at least 2 weeks of discharge, while some experts suggest more than 6 weeks as the cut-off.

The key feature is a discharge from the ear that persists or keeps returning. NICE CKS says supportive features are discharge for at least 2 weeks without pain or fever, a history of acute otitis media, ear trauma or previous glue ear and grommet insertion, and a painless ear examination with evidence of a perforated eardrum. There may be hearing loss.

This pattern contrasts with acute ear infection, where the NHS lists pain, a high temperature, difficulty hearing, discharge, a feeling of pressure and, in young children, rubbing or pulling the ear and irritability.

• Ear discharge lasting at least 2 weeks, often without pain or fever.

• A hole in the eardrum, seen at examination.

• Possible hearing loss in the affected ear.

• A history of earlier ear infections, trauma or glue ear and grommets.

NICE CKS highlights that other causes of persistent ear discharge need excluding. Examples are otitis externa (suggested by an inflamed, eczematous canal without a perforation), a foreign body, particularly in children, impacted wax and, rarely, a growth in the ear canal that bleeds on contact. This is why examination matters, and why a GP or specialist looks at the ear rather than relying on symptoms alone. A cholesteatoma, a build-up of skin cells in the middle ear, can also cause discharge and needs separate assessment.

NICE CKS says admission should be arranged for people with signs of infection beyond the ear, such as swelling or tenderness behind the ear, headache, facial paralysis or vertigo. The NHS says to ask for an urgent GP appointment or call NHS 111 if you have symptoms of an ear infection and feel generally unwell, have a very high temperature, swelling around the ear, a change in hearing or new hearing loss, feel sick or dizzy, or have a weakened immune system or other long-term conditions.

Anyone with a stiff neck, severe headache, confusion or a drooping face should be treated as an emergency: call 999.

NICE CKS advises GPs that if chronic suppurative otitis media is suspected, the ear should not be swabbed and treatment should not be started in primary care before referral; the patient should be referred to an ear, nose and throat specialist for diagnosis, treatment and follow-up. The specialist will decide on further assessment and treatment, which may include a hearing test; the sources used here do not set out the specialist treatment in detail.

NICE CKS says people can be reassured that hearing loss will usually return when the perforation heals, though a hearing test may be done in secondary care. Meanwhile the NHS advises keeping water and shampoo out of an infected ear, not putting anything into the ear, and not swimming while there is an ear infection.

NICE CKS says hearing loss associated with chronic suppurative otitis media may cause problems with language development in children, which is why it asks clinicians to enquire about the effect on school, work and language. Parents who notice that a child with a discharging ear is not responding to sounds, or whose speech is delayed, should raise this with their GP or health visitor so that hearing can be tested.

Assessment on the NHS usually starts with a GP or an ear care service, then referral to ENT and audiology. Private ENT consultations and microscopic ear examinations are available and can be quicker to arrange, though a surgical repair of the eardrum, if needed, would be a considered decision with the surgeon. Any signs of infection spreading beyond the ear need urgent NHS assessment rather than a scheduled private appointment.