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Process for sifting search results and selecting studies for inclusion.

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Figure 1

Process for sifting search results and selecting studies for inclusion.

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'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1: Aural toileting versus no aural toileting, Outcome 1: Resolution of ear discharge (4 weeks +)

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Analysis 1.1

Comparison 1: Aural toileting versus no aural toileting, Outcome 1: Resolution of ear discharge (4 weeks +)

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Comparison 2: Daily aural toileting versus single aural toileting, Outcome 1: Resolution of ear discharge (1 to 2 weeks)

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Analysis 2.1

Comparison 2: Daily aural toileting versus single aural toileting, Outcome 1: Resolution of ear discharge (1 to 2 weeks)

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Comparison 2: Daily aural toileting versus single aural toileting, Outcome 2: Vertigo/dizziness/tinnitus

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Analysis 2.2

Comparison 2: Daily aural toileting versus single aural toileting, Outcome 2: Vertigo/dizziness/tinnitus

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Summary of findings 1. Aural toileting compared to no aural toileting for chronic suppurative otitis media

Aural toileting compared to no aural toileting for chronic suppurative otitis media

Patient or population: children with chronic suppurative otitis media
Setting: community setting
Intervention: aural toileting (dry mopping)
Comparison: no aural toileting (no specific treatment)

Outcomes

Relative effect
(95% CI)

Number of participants (studies)

Anticipated absolute effects* (95% CI)

Certainty of the evidence
(GRADE)

What happens

Without aural toileting

With aural toileting

Difference

Resolution of ear discharge ‐ 1 to 2 weeks

No study reported this outcome at this time point.

Resolution of ear discharge ‐ 4 weeks or more

Assessed by: otoscopically confirmed

Follow‐up: 16 weeks

RR 1.01 (0.60 to 1.72)

217
(1 RCT)

Study population

⊕⊝⊝⊝
very low1

We are uncertain about the effect of aural toileting on resolution of ear discharge (at 4 weeks or more) compared with no treatment.

22.2%

22.4%
(13.3 to 38.2)

0.2% more
(8.9 fewer to 16.0 more)

Health‐related quality of life

No study reported this outcome.

Ear pain (otalgia) or discomfort or local irritation

No study reported this outcome.

Hearing

Hearing was measured in one study but the results were presented by treatment outcome rather than by treatment group, so it is not possible to determine whether there is a difference between the two groups.

Serious complications

—

48

(1 RCT)

One study reported one case of mastoiditis and one case of meningitis with focal encephalitis. It is not clear which group these patients were from (the study was a five‐arm trial of which only two arms are presented here), or whether the complications occurred pre‐ or post‐treatment.

⊕⊝⊝⊝
very low2

We are very uncertain about the effect of aural toileting on serious complications compared with no treatment.

Adverse events: dizziness/vertigo/balance problems

No study reported this outcome.

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; RCT: randomised control trial; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

1Downgraded to very low certainty: downgraded by one level due to study limitations (risk of bias) because there was unclear allocation concealment, attrition bias and selective reporting bias. Downgraded by one level for indirectness (only children were included in the study). Downgraded by two levels for imprecision (as the results are based on one small study with wide confidence intervals). Downgraded by one level for suspected publication bias (this area has a known issue with trials not being published in peer‐reviewed journals).

2Downgraded to very low certainty: downgraded by one level due to study limitations (risk of bias) because it was at high risk of bias for randomisation and was at unclear risk of bias for allocation concealment, attrition bias and selective reporting bias. The study was unblinded. Downgraded by one level for indirectness (only children were included in the study). Downgraded by two levels for imprecision as it was not clear to which group the events could be attributed. Downgraded by one level for suspected publication bias (this area has a known issue with trials not being published in peer‐reviewed journals).

Figuras y tablas -
Summary of findings 1. Aural toileting compared to no aural toileting for chronic suppurative otitis media
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Summary of findings 2. Daily aural toileting compared to single aural toileting episode for chronic suppurative otitis media

Daily aural toileting compared to single aural toileting episode for chronic suppurative otitis media

Patient or population: people (of any age) with otorrhoea for a duration of at least 6 weeks
Setting: ENT clinic (Turkey)
Intervention: daily external ear channel aspiration and topical antibiotics
Comparison: single episode of external ear channel aspiration at first visit and topical antibiotics

Outcomes

Relative effect
(95% CI)

Number of participants (studies)

Anticipated absolute effects* (95% CI)

Certainty of the evidence
(GRADE)

What happens

Single aural toileting

Daily aural toileting

Difference

Resolution of ear discharge ‐ 1 to 2 weeks

Assessed by: unknown ‐ unclear if otoscopically confirmed

RR 1.09, (0.91 to 1.30)

80

(1 RCT)

Study population

⊕⊝⊝⊝
very low1

We are uncertain about the effect of daily aural toileting on resolution of ear discharge (at 1 to 2 weeks) compared with single episode of aural toileting.

82.5%

89.9%

(75.1 to 100)

7.4% more

(7.4% fewer to 17.5% more)

Resolution of ear discharge ‐ 4 weeks or more

Assessed by: unknown ‐ unclear if otoscopically confirmed

Follow‐up: 3 months

Kiris 1998 provided results for this outcome by ear, but the results could not be adjusted to provide results per person.

Health‐related quality of life

No study reported this outcome.

Ear pain (otalgia) or discomfort or local irritation

No study reported this outcome.

Hearing

—

80

(1 RCT)

Results were only reported qualitatively, the report stating that "there were no differences in pre‐ and post audiographic results or bone conduction in either group ..."

⊕⊝⊝⊝
very low2

We are uncertain about the effect of daily aural toileting on hearing compared with a single episode of aural toileting.

Serious complications

The study did not report that any participant died or had any intracranial or extracranial complications.

Adverse events: dizziness

Assessed by: self reported

Follow‐up: 15 days

RR 0.33, (0.01 to 7.95)

80

(1 RCT)

Study population

⊕⊝⊝⊝
very low3

We are uncertain about the effect of daily aural toileting on dizziness compared with a single episode of aural toileting.

2.5%

0.8%

(0% to 19.9%)

1.7% less

(2.5% fewer to 17.4% more)

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; RCT: randomised control trial; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

1Downgraded to very low certainty: downgraded by two levels due to risk of bias (unclear randomisation, allocation concealment, unblinded trial and possible selective reporting). Downgraded by one level due to indirectness: the population is people with otorrhoea for more than six weeks so it is unclear if all included patients had CSOM. Downgraded by one level due to imprecision: the results are from one small study so the confidence intervals are wide.

2Downgraded to very low certainty: downgraded by two levels due to risk of bias (unclear randomisation, allocation concealment, unblinded trial and possible selective reporting). Downgraded by one level due to indirectness: the population is those with otorrhoea so it is unclear if all included patients had CSOM. Downgraded by two levels due to imprecision: the results are from one small study and only reported qualitatively.

3Downgraded to very low certainty: downgraded by two levels due to risk of bias (unclear randomisation, allocation concealment, unblinded trial and possible selective reporting). Downgraded by one level due to indirectness: the population is those with otorrhoea so it is unclear if all included patients had CSOM. Downgraded by two levels due to imprecision: the results are from one small study and only one event was reported resulting in very wide confidence intervals.

Figuras y tablas -
Summary of findings 2. Daily aural toileting compared to single aural toileting episode for chronic suppurative otitis media
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Table 1. Table of Cochrane Reviews

Topical antibiotics with steroids

Topical antibiotics

Systemic antibiotics

Topical antiseptics

Aural toileting (ear cleaning)

Topical antibiotics with steroids

Review CSOM‐4

Topical antibiotics

Review CSOM‐4

Review CSOM‐1

Systemic antibiotics

Review CSOM‐4

Review CSOM‐3

Review CSOM‐2

Topical antiseptics

Review CSOM‐4

Review CSOM‐6

Review CSOM‐6

Review CSOM‐5

Aural toileting

Review CSOM‐4

Not reviewed

Not reviewed

Not reviewed

Review CSOM‐7

Placebo (or no intervention)

Review CSOM‐4

Review CSOM‐1

Review CSOM‐2

Review CSOM‐5

Review CSOM‐7

CSOM‐1: Topical antibiotics for chronic suppurative otitis media (Brennan‐Jones 2020).

CSOM‐2: Systemic antibiotics for chronic suppurative otitis media (Chong 2018a).

CSOM‐3: Topical versus systemic antibiotics for chronic suppurative otitis media (Chong 2018b).

CSOM‐4: Topical antibiotics with steroids for chronic suppurative otitis media (Brennan‐Jones 2018b).

CSOM‐5: Topical antiseptics for chronic suppurative otitis media (Head 2020a).

CSOM‐6: Antibiotics versus topical antiseptics for chronic suppurative otitis media (Head 2020b).

CSOM‐7: Aural toilet (ear cleaning) for chronic suppurative otitis media (Bhutta 2018).

Figuras y tablas -
Table 1. Table of Cochrane Reviews
Ir a la tabla de la revisión
Table 2. Summary of study characteristics

Ref ID

(no. of participants)

Setting

Population

Intervention

Comparison

Treatment

Follow‐up

Background treatment

Notes

Daily dry mopping versus no specific treatment

Eason 1986

(n = 48 people, 67 ears)

Solomon Islands, villages (community)

Children with CSOM for more than 3 months

Mean age 5.4 years

4 times daily aural toilet (dry mopping)

No treatment

3 to 6 weeks

6 weeks

None

Part of a 5‐arm trial

Smith 1996

(n = 303 people)

Kenya (school)

Children with CSOM for more than 2 weeks

Mean age not given.

80% of children were between 5 and 14 years.

Twice daily dry mopping (except weekends)

No specific treatment

Up to 16 weeks

Up to 16 weeks

None

Part of a 3‐arm trial

Daily suction cleaning PLUS topical antibiotics versus single suction cleaning PLUS topical antibiotics

Kiris 1998

(n = 80 people, 95 ears)

Turkey (ENT clinic)

Otorrhoea with at least 6 weeks duration

Mean: 26.5 years (range 21 months to 70 years)

Daily external ear channel aspiration

Single external ear channel aspiration at first visit

15 days

3 to 6 months

Topical ciprofloxacin

—

CSOM: chronic suppurative otitis media
Figuras y tablas -
Table 2. Summary of study characteristics
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Table 3. Resolution of ear discharge outcome

Reference

Unit of randomisation

Reported

Definition

Otoscopically confirmed?

Time points

Notes

Eason 1986

Person

Ear

"dry" or "not discharging"

Unclear

2 to 4 weeks (3 weeks)

4+ weeks (6 weeks)

Although the results were presented by ear, sensitivity analysis based on converting the results to people did not affect the outcome so we used the results in this review.

Kiris 1998

Person

Ear, person could be determined

Resolution of otorrhoea

Unclear

1 to 2 weeks (between 3 to 12 days of treatment)

The results are presented by ear but sufficient data existed to provide the data by person. The base case assumption is that most of the cases were unilateral disease, which provides the most conservative estimate of effect size.

Smith 1996

School

Person

"resolution": absence of otorrhoea at 2 successive visits

"healed": complete repair of the
tympanic membrane perforation at any visit

Otoscopically confirmed

4+ weeks (16 weeks)

—
Figuras y tablas -
Table 3. Resolution of ear discharge outcome
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Comparison 1. Aural toileting versus no aural toileting

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1.1 Resolution of ear discharge (4 weeks +) Show forest plot

1

217

Risk Ratio (M‐H, Fixed, 95% CI)

1.01 [0.60, 1.72]
Figuras y tablas -
Comparison 1. Aural toileting versus no aural toileting
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Comparison 2. Daily aural toileting versus single aural toileting

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

2.1 Resolution of ear discharge (1 to 2 weeks) Show forest plot

1

80

Risk Ratio (M‐H, Random, 95% CI)

1.09 [0.91, 1.30]

2.2 Vertigo/dizziness/tinnitus Show forest plot

1

80

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.01, 7.95]
Figuras y tablas -
Comparison 2. Daily aural toileting versus single aural toileting
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