Key messages
– We do not know how effective ear cleaning is for people with inflammation and infection of the middle ear (called chronic suppurative otitis media), and whether it causes unwanted effects.
– We are very uncertain about the evidence within the very few studies on this topic. Unwanted effects were not well reported in the studies we found. We need researchers to conduct studies that compare ear cleaning to no cleaning, and compare different cleaning techniques and frequency, so that we can assess the benefits and harms of ear cleaning for people with chronic suppurative otitis media.
What is chronic suppurative otitis media?
Chronic suppurative otitis media, which is also known as chronic otitis media, is an inflammation and infection of the middle ear that lasts for two weeks or more. People with chronic suppurative otitis media usually have recurrent or persistent ear discharge (pus that leaks out from a hole in the eardrum) and hearing loss.
How can chronic suppurative otitis media be treated?
There are a few approaches to clean the affected ears and remove discharge. These include:
– using cotton wool or tissue paper (called dry mopping);
– sucking out pus and fluid that is blocking the ear with a small device (usually done under a microscope); or
– washing out the ear (called irrigation).
What is the aim of this review?
We wanted to know how effective ear cleaning is in treating people with chronic suppurative otitis media, and whether it causes unwanted effects. In particular, we wanted to know whether ear cleaning stopped ear discharge, and whether it affected people's quality of life or hearing. We also wanted to know if it caused pain, discomfort, or irritation in the ear; unwanted effects such as dizziness or ear bleeding; or any serious complications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and consistency of results.
What are the main results of the review?
This is the first update of a review published in 2020, which did not find any new studies. Overall, we found three studies that involved 431 people with chronic suppurative otitis media. Two studies included only children, while the third included both children and adults. One study recruited people from the Solomon Islands, who were considered to be a high-risk Indigenous group. People were followed for between six weeks and six months after treatment.
Daily dry mopping compared to no treatment
Two studies (351 people) assessed this comparison. We are very uncertain if dry mopping stops ear discharge after four weeks, and no studies looked at the presence of discharge earlier. One study reported serious complications, but it was unclear whether the people who reported complications had their ears cleaned with dry mopping or not, or whether the complications occurred before or after treatment. Therefore, we do not know if dry mopping caused serious complications, or how often these occurred. One study looked at hearing, but did not report the results in a way that could tell us whether or not dry mopping affected hearing. The studies did not report quality of life, ear pain, or harms such as dizziness or balance problems.
Daily suction compared to one instance of suction only, both in addition to antibiotic ear drops
One study (80 people) assessed this comparison. We do not know whether daily suction stops ear discharge between one and two weeks compared with one instance of suction plus antibiotics. The results for discharge after four weeks could not be interpreted. The authors only reported that there was no difference between the two groups in hearing results. One study mentioned one person had dizziness in the one suction plus antibiotics group, which the authors attributed to the use of cold antibiotics. The studies did not report quality of life or ear pain.
What are the limitations of the evidence?
Limitations of the review included lack of good-quality evidence, and limited information on the population groups or treatments.
How up to date is this review?
The evidence is current to June 2022.
We are very uncertain whether treatment with aural toileting is effective in resolving ear discharge in people with CSOM when compared to no treatment, due to a lack of data and the poor quality of the available evidence. The evidence was considered very low-certainty as there were concerns over risk of bias, indirectness, imprecision, and suspected publication bias. We also remain uncertain about other outcomes, including adverse events, as these were not well reported. Similarly, we are very uncertain whether daily suction clearance, followed by antibiotic ear drops administered at a clinic, is better than a single episode of suction clearance followed by self-administration of topical antibiotic ear drops. Limitations of the review include lack of recency in data, and limited information on certain population groups or interventions.
Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media, is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss.
Aural toileting describes processes for manually cleaning the ear, including dry mopping (with cotton wool or tissue paper), suction clearance (typically under a microscope), or irrigation (using manual or automated syringing). Aural toileting can be used alone or in addition to other treatments for CSOM, such as antibiotics or topical antiseptics.
This is one of a suite of seven Cochrane reviews evaluating the effects of non-surgical interventions for CSOM. This is the first update of a Cochrane review published in 2020.
To assess the benefits and harms of aural toilet procedures for people with chronic suppurative otitis media.
We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP). The searches were run on 15 June 2022.
We included randomised controlled trials with at least a one-week follow-up involving adults or children who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks.
We included any aural toileting method as the intervention, at any frequency, and for any duration. The main comparisons were aural toileting versus placebo or no intervention, and one aural toileting method versus another aural toileting method. Within each comparison, we separated studies into those in which both groups received other concomitant treatments (e.g. antiseptics or antibiotics) and those without concomitant treatments.
We used standard Cochrane methodology. Our primary outcomes were resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at one week to up to two weeks, two weeks to up to four weeks, and after four weeks; health-related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and adverse events (dizziness/vertigo/balance problems, ear bleeding). We used GRADE to assess the certainty of the evidence for each outcome.
This update did not find any new studies. We included three studies with 431 participants (465 ears) reporting on two comparisons. Two studies included only children with CSOM in the community (351 participants) and the other study (80 participants) included children and adults with chronic ear discharge for at least six weeks. One study recruited participants from the Solomon Islands, who were considered a 'high-risk' Indigenous group. None of the included studies reported health-related quality of life, ear pain, or ear bleeding.
1. Daily aural toileting versus no treatment
Two studies (351 children; 370 ears) compared daily dry mopping with no treatment. For resolution of ear discharge after four weeks, only one study reported the results per person. We are very uncertain whether there is a difference at 16 weeks (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.60 to 1.72; 1 study, 217 participants; very low-certainty evidence).
There were no results reported for the adverse events of dizziness, vertigo, or balance problems. Only one study reported serious complications, but it was not clear which group these participants were from, or whether the complications occurred pre- or post-treatment, and therefore the certainty of evidence was very low. One study reported hearing, but the results were presented by treatment outcome rather than by treatment group, so it was not possible to determine whether there was a difference between the two groups.
2. Daily aural toileting versus single aural toileting episode (both in addition to topical ciprofloxacin)
One study (80 participants; 95 ears) compared daily aural toileting (suction) with administration of topical antibiotic (ciprofloxacin) ear drops in a clinic, to a single aural toileting (suction) episode followed by daily self-administered topical antibiotic drops, in participants of all ages. We are very uncertain if there is a difference in resolution of ear discharge at between one and up to two weeks (RR 1.09, 95% CI 0.91 to 1.30; 1 study, 80 participants; very low-certainty evidence).
The results for resolution of ear discharge after four weeks were presented by ear, not person, and could not be adjusted to by person. The authors only reported qualitatively that there was no difference between the two groups in hearing results (very low-certainty evidence). One participant in the group with single aural toileting and self-administration of topical antibiotic ear drops reported the adverse event of dizziness, which the authors attributed to the use of cold topical ciprofloxacin. It is very uncertain whether there is a difference between the groups (RR 0.33, 95% CI 0.01 to 7.95; 1 study, 80 participants; very low-certainty evidence). There were no results reported for the other adverse events of vertigo or balance problems, or for serious complications.