Treatment of chronic suppurative otitis media with topical tobramycin and dexamethasone

Microbial Etiologies of Otitis Media with Resistance Pattern in a Tertiary Care Hospital in North India

Aim

The study aimed to evaluate the bacterial and fungal profiles in Otitis Media (OM), Acute Otitis Media (AOM), and Chronic Otitis Media (COM) and the sensitivity patterns to antibiotics available in our hospital settings.

Materials and Methods

A total of 150 clinically diagnosed cases of OM (AOM or COM) with ear discharge were enrolled. Swabs were cultured for microbial flora. Drug susceptibility testing was conducted using the Kirby-Bauer disc diffusion method.

Results

The most common bacteria isolated in AOM was Streptococcus spp., and in COM it was Staphylococcus aureus. Among fungal isolates, Candida albicans dominate. The antimicrobial profile of the organisms revealed maximum sensitivity to Fluoroquinolones.

Conclusions

Correct diagnosis and precise antibiotic prescription reduce the load of antibiotic resistance.

Antibiogram guided optimized medical treatment in chronic otitis media: A useful interventional strategy before surgery?

BACKGROUND

Chronic otitis media is a middle ear cleft disease presenting with tympanic membrane perforation and discharge. Wet ear after tympanoplasty and discharging mastoid cavity are problematic in clinical practice.

MATERIAL AND METHODS

1050 patients of age 10 to 50 years presenting with active ear discharge and clinically diagnosed with unilateral chronic suppurative otitis media were included in the study. The patients were equally divided into two equal groups, Group ET, and AT. All patients were prescribed topical ciprofloxacin, oral levocetirizine 5 mg and n-acetyl cysteine 600 mg BD for one week. Swabs of ear discharge were collected in ET groups for antibiogram. Both groups were evaluated on next visit and treatment changed in AT groups and result observed in next visit. Surgical outcome was evaluated at end of 2 yrs.

RESULT

A total of 1158 organisms were isolated in culture out of which, 69.94 % were aerobes, 13.47 % anaerobes and 16.58 % were fungi. On the second visit in group AT, treatment of 85.14 % patients was changed in accordance with culture sensitivity report. In patients with mucosal disease, only 46.87 % patients of group ET had a favorable outcome in comparison to 90.28 % patients of group AT while in patients with squamosal disease, 17.56 % patients of group ET and 28.99 % patients in group AT had a dry ear. Surgeries in AT group were found to have statistically significant higher success rate as compared to ET group.

The effect of N-acetyl cysteine on biofilm layers in an experimental model of chronic otitis media

Objectıve

The aim of this study was to investigate the efficacy of N-acetylcysteine (NAC) on biofilm layers and on the course of disease in chronic otitis media.

Methods

Twenty-five rats that were induced with chronic otitis media (COM) were separated into three groups. In Group 1 (N = 18), 0.2% ciprofloxacin + 0.1% dexamethasone sodium phosphate + 0.5 mg/ml NAC solution was locally injected to the right ear of the rats; in Group 2, (N=18) 0.2% ciprofloxacin + 0.1% dexamethasone sodium phosphate was locally injected to the left ear of the rats. No treatment was applied to either ear of rats in Group 3 (N = 5). Histopathological and scanning electron microscope (SEM) evaluations were performed in all groups.

Results

SEM revealed biofilm formation in all COM induced groups. No significant difference was seen between groups 1 and 2 in terms of suppuration levels, fibrosis, inner ear involvement, infection staging and biofilm formation (p > 0.05).

Conclusıons

In this study, while histopathological and SEM evaluation revealed no effect of 0.5 mg/ml NAC on the biofilm layer in COM-induced rats, further studies with NAC at different concentrations are still needed on different types of experimental animals.

An extended release ciprofloxacin/dexamethasone hydrogel for otitis media

OBJECTIVE

Otitis media and associated otorrhea are frequent complications following tympanostomy tube insertion; the most common otologic procedure performed in children in the United States. Current treatments include the administration of antibiotic or antibiotic/anti-inflammatory combination drops to the affected ear. Several studies have demonstrated that using an antibiotic/anti-inflammatory combination product is more effective than the use of antibiotics alone. However, administration of any drops through the tympanostomy tube is very difficult in children, and patient compliance can be an issue. Our group has developed a novel combination drug/hydrogel formulation for the treatment of otitis media/otorrhea that releases both ciprofloxacin and dexamethasone over a 2-3 week period. This has the potential to offer significant advantages over current treatments in use in the clinic.

METHODS

The release of drugs from the combination hydrogel was validated in vitro over the desired time frame and the activity of the released drugs was monitored via assays to confirm retention of full activity throughout the dissolution period. The safety of the ciprofloxacin/dexamethasone hydrogel and its inactive excipients was evaluated through in vivo otic toxicity studies in guinea pigs, including hearing tests, gross microscopy, and cytocochleogram analysis.

RESULTS

Extended release of both drugs was demonstrated in vitro and antibiotic/anti-inflammatory activities were retained. The hydrogel components and its excipients did not cause adverse reactions in animals, demonstrating safety of the hydrogel combination in vivo.

CONCLUSION

The studies presented lay the groundwork for extended release middle ear hydrogel formulations that are capable of safely releasing combinations of active pharmaceutical agents over a desired period of time. This would be more advantageous than therapeutics that are currently used in the clinic for the treatment of otitis media/otorrhea associated with tympanostomy tube insertion.

Potential Ototopical Antiseptics for the Treatment of Active Chronic Otitis Media: An In Vitro Evaluation

OBJECTIVES

Primary: to compare, in vitro, the antimicrobial activity of different antiseptic agents versus quinolone drops, against the common organisms of chronic otitis media.Secondary: to examine the possible role of pH on the antimicrobial activity of the antiseptic solutions.

METHODS

Three antiseptic powders (boric acid; iodine; and a 1:1 combination of these two) and four solutions (2% boric acid; 2% acetic acid; 3.25% aluminum acetate; and 5% povidone iodine) were tested against five bacteria and two fungi common in chronic otitis media, using both agar plates and the modified broth dilution method. These results were compared with the antimicrobial activity of quinolone drops.The potential role of pH of solutions was tested by reducing the acidity of the agents and repeating the broth dilution.

RESULTS

Of the powders, iodine, and iodine/boric acid combined, are very effective against all organisms. Boric acid powder showed moderate effectiveness against all organisms. All solutions performed poorly on the agar plates. 5% povidone iodine has good effectivity when tested with the broth dilution method. 3.25% aluminum acetate had the best activity against Pseudomonas aeruginosa.

CONCLUSION

Boric acid powder and 5% povidone iodine solution show promise for clinical use. Boric acid powder has proven clinical effectiveness. 5% povidone iodine requires further clinical research. Although very effective in vitro, iodine powder is toxic to tissues and cannot be recommended for clinical use. The pH of solutions does not seem to play a significant role in their antimicrobial activity in vitro.

Topical antibiotics for chronic suppurative otitis media

BACKGROUND

Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and often polymicrobial infection (involving more than one micro-organism) 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. Topical antibiotics, the most common treatment for CSOM, act to kill or inhibit the growth of micro-organisms that may be responsible for the infection. Antibiotics can be used alone or in addition to other treatments for CSOM, such as antiseptics or ear cleaning (aural toileting).

OBJECTIVES

To assess the effects of topical antibiotics (without steroids) for people with CSOM.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 April 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least a one-week follow-up involving participants (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antibiotic agent(s) of any class, applied directly into the ear canal as ear drops, powders or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antibiotic compared to a) placebo or no intervention and b) another topical antibiotic (e.g. topical antibiotic A versus topical antibiotic B). Within each comparison we separated studies where both groups of participants had received topical antibiotic a) alone or with aural toileting and b) on top of background treatment (such as systemic antibiotics).

DATA COLLECTION AND ANALYSIS

We used the standard Cochrane methodological procedures. We used GRADE to assess the certainty of the evidence for each outcome. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks and after four weeks; health-related quality of life using a validated instrument; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes included hearing, serious complications and ototoxicity measured in several ways.

MAIN RESULTS

We included 17 studies with a total of 2198 participants. Twelve studies reported the sample size in terms of participants (not ears); these had a total of 1797 participants. The remaining five studies reported both the number of participants and ears, representing 401 participants, or 510 ears. A: Topical antibiotics versus placebo or no treatment (with aural toilet in both arms and no other background treatment) One small study compared a topical antibiotic (ciprofloxacin) with placebo (saline). All participants received aural toilet. Although ciprofloxacin was better than saline in terms of resolution of discharge at one to two weeks: 84% versus 12% (risk ratio (RR) 6.74, 95% confidence interval (CI) 1.82 to 24.99; 35 participants, very low-certainty evidence), the very low certainty of the evidence means that it is very uncertain whether or not one intervention is better or worse than the other. The study authors reported that "no medical side-effects and worsening of audiological measurements related to this topical medication were detected" (very low-certainty evidence). B: Topical antibiotics versus placebo or no treatment (with use of oral antibiotics in both arms) Four studies compared topical ciprofloxacin to no treatment (three studies; 190 participants) or topical ceftizoxime to no treatment (one study; 248 participants). In each study all participants received the same antibiotic systemically (oral ciprofloxacin, injected ceftizoxime). In at least one study all participants received aural toilet. Useable data were only available from the first three studies; ciprofloxacin was better than no treatment, resolution of discharge occurring in 88.2% versus 60% at one to two weeks (RR 1.47, 95% CI 1.20 to 1.80; 2 studies, 150 participants; low-certainty evidence). None of the studies reported ear pain or discomfort/local irritation. C: Comparisons of different topical antibiotics The certainty of evidence for all outcomes in these comparisons is very low. Quinolones versus aminoglycosides Seven studies compared an aminoglycoside (gentamicin, neomycin or tobramycin) with ciprofloxacin (734 participants) or ofloxacin (214 participants). Whilst resolution of discharge at one to two weeks was higher in the quinolones group the very low certainty of the evidence means that it is very uncertain whether or not one intervention is better or worse than the other (RR 1.95, 95% CI 0.88 to 4.29; 6 studies, 694 participants). One study measured ear pain and reported no difference between the groups. Quinolones versus aminoglycosides/polymyxin B combination ±gramicidin We identified three studies but data on our primary outcome were only available in one study. Comparing ciprofloxacin to a neomycin/polymyxin B/gramicidin combination, for an unknown treatment duration (likely four weeks), ciprofloxacin was better (RR 1.12, 95% CI 1.03 to 1.22, 186 participants). A "few" patients experienced local irritation upon the first instillation of topical treatment (numbers/groups not stated). Others Other studies examined topical gentamicin versus a trimethoprim/sulphacetamide/polymixin B combination (91 participants) and rifampicin versus chloramphenicol (160 participants). Limited data were available and the findings were very uncertain.

AUTHORS' CONCLUSIONS

We are uncertain about the effectiveness of topical antibiotics in improving resolution of ear discharge in patients with CSOM because of the limited amount of low-quality evidence available. However, amongst this uncertainty there is some evidence to suggest that the use of topical antibiotics may be effective when compared to placebo, or when used in addition to a systemic antibiotic. There is also uncertainty about the relative effectiveness of different types of antibiotics; it is not possible to determine with any certainty whether or not quinolones are better or worse than aminoglycosides. These two groups of compounds have different adverse effect profiles, but there is insufficient evidence from the included studies to make any comment about these. In general, adverse effects were poorly reported.

Topical Ciprofloxacin/Dexamethasone Otic Suspension is Superior to Ofloxacin Otic Solution in the Treatment of Granulation Tissue in Children with Acute Otitis Media With Otorrhea Through Tympanostomy Tubes

OBJECTIVE: Comparison of topical ciprofloxacin/dexamethasone otic suspension (CIP/DEX) to ofloxacin otic solution (OFL) for treatment of granulation tissue in children with AOMT.

STUDY DESIGN: 599 children aged ≥6 months to 12 years with AOMT of up to 3 weeks' duration were enrolled. Patients received either CIP/DEX 4 drops twice daily for 7 days or OFL 5 drops twice daily for 10 days. Granulation tissue severity was graded at clinic visits on days 1, 3, 11, and 18.

RESULTS: Granulation tissue was present in 90 of 599 AOMT patients (15.0%) at baseline. CIP/DEX treatment was superior to OFL for reduction of granulation tissue at the day 11 visit (81.3% compared with 56.1%, P = 0.0067) and the day 18 visit (91.7% compared with 73.2%, P = 0.0223). Both topical otic preparations are safe and well tolerated in pediatric patients.

CONCLUSION: CIP/DEX was superior to OFL in the treatment of granulation tissue in children with AOMT. (Otolaryngol Head Neck Surg 2004;130: 736-41.)

Topical versus oral antibiotics, with or without corticosteroids, in the treatment of tympanostomy tube otorrhea

OBJECTIVE

Antibiotic treatment is the standard of care for tympanostomy tube otorrhea. This meta-analysis aims to evaluate the efficacy of topical antibiotics with or without corticosteroids versus oral antibiotics in the treatment of tube otorrhea in children.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and ProQuest.

REVIEW METHODS

The above databases were searched using a search strategy for randomized controlled trials for optimal treatment of tube otorrhea in the pediatric population. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed. Primary outcome was cure (i.e. clearance of otorrhea) at 2-3 weeks. Secondary outcomes were microbiological eradication and complications such as dermatitis and diarrhea. The incidence of these events was defined as dichotomous variables and expressed as a risk ratio (RR) and number needed to benefit (NNTB) in a random-effects model.

RESULTS

We identified 1491 articles and selected 4 randomized controlled trials which met our inclusion criteria. Topical treatment had better cure (NNTB = 4.7, pooled RR = 1.35, p < 0.001) and microbiological eradication (NNTB = 3.5, pooled RR = 1.47, p < 0.001 among 3 of the studies) than oral antibiotics. Oral antibiotics had higher risk of diarrhea (pooled RR = 21.5, 95% CI 8.00-58.0, p < 0.001, Number needed to harm (NNTH) = 5.4) and dermatitis (pooled RR = 3.14, 95% CI 1.20-8.20, p = 0.019, NNTH = 32). The use of topical steroids in addition to topical antibiotics was associated with a higher cure rate (pooled RR = 1.59, p < 0.001 vs pooled RR = 1.57, p = 0.293).

CONCLUSION

Topical antibiotics should be the recommended treatment for management of tympanostomy tube otorrhea in view of its significantly improved clinical and microbiological efficacy with lower risk of systemic toxicity as compared to oral antibiotics. Further research is necessary to confirm the benefits of topical corticosteroids as an adjunct to topical antibiotics.

Tuberculous Otitis Media: Clinical Aspects of 12 Cases

The clinical features of tuberculous otitis media (TOM) have changed. This study was performed to evaluate changing trends in the clinical manifestations of TOM. We reviewed a series of 12 cases of TOM (13 ears) recently treated at Osaka Prefectural Habikino Hospital. The results showed a mean age of 41 years and a male predominance of 1.4 to 1. Central or total perforations of the tympanic membrane were observed in most cases, but none of the patients had multiple perforations. Nine patients (75%) had active pulmonary tuberculosis. Normal lung status or inactive pulmonary tuberculosis was significantly more frequent in the older age group. Diagnosis of primary TOM required more time than that of secondary TOM. Most cases of primary TOM had high infectiousness of the primary lesion. We summarize the clinical features of patients who should be evaluated for TOM.

Formulation of Thermosensitive in situ Otic Gel for Topical Management of Otitis Media

Antibiotics and antiinflammatory agents are the primary and main therapeutic categories in the treatment of otitis media. One of the simpler and feasible approaches of minimizing the problem of repeated use and subsequent resistance is development of sustained release formulation. Therefore, the present investigation aimed to develop a sustained release in situ gel formulation containing combination of broad spectrum antibiotic and antiinflammatory agents for the management of otits media. The prolonged release is achieved by phase transition of Poloxamer 407 (in situ) from sol to gel at a physiological temperature in combination with viscosity imparting agent Natrasol 250 and Klucel HF. The formulation P3N3 (19% w/v Poloxamer 407, 1.5% w/v Natrasol 250) and P3K3 (19% w/v Poloxamer 407, 1.5% w/v Klucel HF) showed mucoadhesive strength 37.17±0.32×10³ and 38.12±0.13×10³ dyne/cm², respectively, and gel strength 2.1 and 2 cm, respectively. Both these formulations indicated good drug content and viscosity besides a good gelling ability. The in vitro diffusion has demonstrated prolongation of release of both the drugs over a period of 8 h.

Molecular diagnostics and personalised medicine in wound care: assessment of outcomes

OBJECTIVE

This large, level A, retrospective cohort study set out to compare healing outcomes in three large cohorts of wound patients managed universally for bioburden: standard of care group, who were prescribed systemic antibiotics on the basis of empiric and traditional culture-based methodologies; treatment group 1, who were prescribed an improved selection of systemic antibiotics based on the results of molecular diagnostics; treatment group 2 who received personalised topical therapeutics (including antibiotics) based on the results of molecular diagnostics.

METHOD

Apart from the differences in diagnostic methods and antibiotic treatments described above, all three cohorts were subjected to the same biofilm-based wound care protocol, which included evaluation of the host and bioburden, frequent sharp debridement, use of wound dressings and comprehensive standard care (reperfusion therapy, nutritional support, offloading, compression and management of comorbidities).

RESULTS

In all, 1378 patients were recruited into the study. In the standard of care group 48.5% of patients (244/503) healed completely during the 7-month study period. This increased to 62.4% (298/479) in treatment group 1 and 90.4% (358/396) in treatment group 2. Cox proportional hazards analysis revealed the time to complete closure decreased by 26% in treatment group 1 (p<0.001) and 45.9% in treatment group 2 (p<0.001) compared with the standard of care group. Patients in treatment group 2 had >200% better odds of healing at any given time point compared with the other cohorts.

CONCLUSION

Implementation of personalised topical therapeutics guided by molecular diagnosis resulted in statistically and clinically significant improvements in outcome. The integration of molecular diagnostics and personalised medicine provides a directed and targeted approach to wound care.

CONFLICT OF INTEREST

SED and RDW are owners of PathoGenius Laboratories, a clinical diagnostic laboratory. SED and RDW are owners of Research and Testing Laboratory, which develops molecular diagnostics. CJ and JK are clinical advisors for PathoGenius. CJ and JK are owners of Southeastern Medical Compounding, Savannah, GA and Southeastern Medical Technologies, Savannah, GA.

Protease inhibitors α1-antitrypsin and ilomastat are not ototoxic in the chinchilla

OBJECTIVES

Proteases of both the serine and the metalloprotease families have been shown to play a role in the pathogenesis of otitis media. Inhibitors of proteases from each of these families have been shown to beneficially impact disease progression in a number of related chronic inflammatory conditions. The purpose of this study was to assess the safety of protease inhibitors when instilled into the middle ear, with a view to their potential use in the treatment of human otitis media.

STUDY DESIGN

Prospective, randomized, controlled trial in the chinchilla model.

METHODS

After completing baseline auditory testing and bilateral transpalatal obstruction of the Eustachian tube, chinchillas received weekly transbullar injections of protease inhibitor (alpha1-antitrypsin, ilomastat, or both), vehicle, or saline. After 1 month, hearing was tested and the animals were sacrificed. Temporal bone histopathologic examination was performed.

RESULTS

All treatment groups demonstrated a statistically insignificant average loss in long-term hearing (0 dB) for all measures using clicks and tones (P >.15 for all conditions). All treatment groups were statistically insignificantly different from one another (P =.5625). Histopathologic examination revealed no significant inner ear changes.

CONCLUSIONS

Protease inhibitors that are currently under study in animal models and humans for the treatment of inflammatory diseases that are related to imbalances between protease and protease inhibitor have no significant toxic effect on the inner ear of chinchillas. These findings support the safety of further clinical trials using these inhibitors to treat middle ear inflammation.

Control of chronic otitis media and sensorineural hearing loss in C3H/HeJ mice: glucocorticoids vs mineralocorticoids

OBJECTIVE

The impact of glucocorticoids and mineralocorticoids on chronic otitis media (COM) in toll-like receptor 4-deficient C3H/HeJ mice was investigated.

STUDY DESIGN

To evaluate control of COM by steroids with differences in their anti-inflammatory (prednisolone, dexamethasone), and fluid absorption functions (fludrocortisone, aldosterone). A minimum sample size of five animals for each group was required based on power analysis calculations. Sample sizes ranged from 7 to 17 mice per treatment group.

SUBJECTS AND METHODS

Auditory brain stem response (ABR) thresholds were performed at baseline, 2 weeks and 4 weeks. Histopathologic test results were evaluated on all mice ears at the end of the study.

RESULTS

Analysis of variance (ANOVA) of ABR threshold change showed significant treatment effects (P < 0.05) by both steroid types at all time intervals and ABR frequencies except 4 weeks/8 kHz. Histologic assessment showed prednisolone-treated mice (62%) had a higher rate of clearance of middle and inner ear inflammation than control mice (4%).

CONCLUSION

It was concluded that steroid treatments can improve the physiology of chronic middle and inner ear disease seen with COM.

A double-blind randomised clinical trial of the treatment of otitis externa using topical steroid alone versus topical steroid-antibiotic therapy

The objective of the study was to determine if the addition of topical antibiotic increases the efficacy of topical steroid in controlling otitis externa. A double-blind randomised controlled trial was performed from February 2003 to April 2005 in an otolaryngology emergency clinic (acute urban teaching hospital) in the United Kingdom. Patients were followed up for 2 weeks. Forty-five adults with otitis externa based on the presence of oedema, discharge or debris in the outer ear canal were recruited. The patients were randomised to one of the two treatment groups, namely using betamethasone sodium phosphate 0.1% (Vista-Methasone) or betamethasone sodium phosphate 0.1% with neomycin sulphate 0.5% (Vista-Methasone N), and were instructed to use the trial medication at three drops three times a day for 2 weeks. Subjects' visual analogue symptom scores (blockage, pain, discharge, and itching) for otitis externa pre-treatment (day 0) and post-treatment (day 15), percentage changes in visual analogue symptom scores as a result of treatment, proportion of patients whose symptom scores failed to improve or deteriorated on treatment were analysed. The two experimental arms demonstrated statistically similar presenting symptom scores at recruitment (mean symptom scores of 19.2 for betamethasone group and 28.7 for betamethasone-neomycin group). The mean symptom score change in response to treatment was 82.8 and 47.8% in the betamethasone-neomycin and betamethasone-alone groups, respectively. There was no statistically significant difference between the groups in median percentage symptom score change in response to treatment. All patients in the betamethasone-neomycin group showed symptom improvement but in the betamethasone alone group, five patients got worse (Fishers exact, P = 0.05). Topical antibiotic-steroid combination therapy is superior to steroid-alone treatment for symptomatic control of otitis externa.

Effects of Ciprofloxacin-Dexamethasone on Myringotomy Wound Healing

OBJECTIVE

To evaluate the effects of the ciprofloxacin-dexamethasone (CDX) combination ototopical treatment after myringotomy on tympanic membrane (TM) healing in ears with eustachian tube obstruction (ETO) and unobstructed ears.

STUDY DESIGN

Prospective, randomized, masked, controlled.

METHODS

ETO was created in the left ear of 30 rats to induce a model of otitis media with effusion (OME). After 3 weeks, bilateral myringotomy was performed (day 0). Animals were randomized into three groups to receive no treatment or bilateral once daily ototopical treatment with balanced salt solution (BSS, vehicle) or CDX for 13 days. Bilateral otomicroscopy was performed on days 7, 14, and 28. On day 14, five randomly selected animals per group were humanely euthanized and the TM harvested for histology. Three additional rats provided normal negative control ears for histologic comparisons.

RESULTS

On day 14, TM perforation healing rates were 100% in all ears of untreated and BSS-treated animals, 89% (8/9) in CDX-treated obstructed ears, and 30% (3/10) in CDX-treated unobstructed ears (P < .05 vs. BSS). On day 28, 100% (5/5) of the CDX-treated unobstructed ears and 80% (4/5) of the CDX-treated obstructed ears were healed. Histology showed initial TM thickening postmyringotomy in all ears but no significant qualitative differences between groups on day 28.

CONCLUSION

Myringotomy healing was transiently modulated by treatment with CDX but proceeded normally after CDX discontinuation. This early modulation might enhance middle ear drainage and middle ear concentrations of CDX when tympanostomy tube surgery is performed in patients with active OME and ETO, thus potentially reducing otorrhea and preventing or treating infection. It would not be expected to increase the risk of premature tube extrusion or adversely affect normal healing of the TM after usual spontaneous extrusion.

Mitigation of hearing loss from semi-circular canal transection in pseudomonas otitis media with ciprofloxacin-dexamethasone irrigation

HYPOTHESIS

Irrigation of the mastoid with a quinolone antibiotic-steroid solution may mitigate hearing loss caused by iatrogenic semicircular canal injury in the presence of Pseudomonas aeruginosa (PA) otitis media (OM).

BACKGROUND

Studies have shown the cochlea to be more vulnerable to semicircular canal transection (SCT)-related hearing loss in the presence of PA OM. Prophylactic systemic antibiotics and steroids may decrease this hearing loss, but SCT is usually not planned. The aim of this study was to determine if irrigation with ciprofloxacin-dexamethasone (cipro-dex) could improve hearing outcomes following SCT in PA OM.

METHODS

PA OM was induced in 28 animals. After three to five days, unilateral SCT was performed in each animal, with sham SCT on the contralateral ear. At surgery, half of the animals (n = 14) underwent irrigation of the both mastoid bullae with cipro-dex; the second group of animals (n = 14) underwent irrigation of the bullae with sterile saline. Auditory thresholds were obtained immediately prior to SCT and 7-10 days after SCT.

RESULTS

SCT ears treated with cipro-dex showed a mean click threshold improvement of 4.6 dB from pre-transection to 7-10 days post-transection, whereas thresholds in the SCT ears treated with saline worsened by 7.5 dB (p = 0.15).

CONCLUSION

Irrigation of the guinea pig bulla with cipro-dex following SCT in the setting of PA OM appears safe and may yield beneficial effects on hearing.

Topical ciprofloxacin/dexamethasone superior to oral amoxicillin/clavulanic acid in acute otitis media with otorrhea through tympanostomy tubes

OBJECTIVE

This study was a comparison of topical ciprofloxacin/dexamethasone otic suspension to oral amoxicillin/clavulanic acid suspension in children with acute otitis media with otorrhea through tympanostomy tubes.

METHODS

This was a randomized, observer-masked, parallel-group, multicenter trial of topical ciprofloxacin/dexamethasone otic suspension versus amoxicillin/clavulanic acid suspension in 80 children aged 6 months to 12 years with acute otitis media with otorrhea through tympanostomy tubes of < or = 3 weeks' duration and visible otorrhea. Patients were randomly assigned to receive either 4 drops of topical ciprofloxacin 0.3%/dexamethasone 0.1% (Ciprodex Sterile Otic Suspension) into the affected ear(s) twice daily for 7 days or 600 mg of amoxicillin/42.9 mg of clavulanic acid oral suspension (Augmentin ES-600 Oral Suspension) every 12 hours for 10 days. Clinical signs and symptoms of acute otitis media with otorrhea through tympanostomy tubes were evaluated on days 1 (baseline), 3, 11 (end-of-therapy), and 18 (test-of-cure), and twice-daily assessments of otorrhea were recorded in patient diaries.

RESULTS

The median time to cessation of otorrhea was significantly shorter with ciprofloxacin/dexamethasone otic suspension than with amoxicillin/clavulanic acid suspension (4.0 vs 7.0 days; n = 79). This resulted in significantly more clinical cures at the test-of-cure visit (85% vs 59%, respectively). Frequent adverse events (> 3%) related to ciprofloxacin/dexamethasone otic suspension included ear pain (5.1%) and related to amoxicillin/clavulanic acid suspension included diarrhea (19.5%), dermatitis (7.3%), and gastroenteritis (4.9%).

CONCLUSIONS

Topical otic treatment with ciprofloxacin/dexamethasone otic suspension is superior to treatment with oral amoxicillin/clavulanic acid suspension and results in more clinical cures and earlier cessation of otorrhea with fewer adverse effects in children with acute otitis media with otorrhea through tympanostomy tubes.

Alpha1-antitrypsin single dose adjuvant therapy for acute otitis media

OBJECTIVES

Proteases have been shown to play a role in the pathogenesis of otitis media. Inhibition of these proteases can improve treatment outcomes in certain conditions. The goal of this study was to determine if intratympanic administration of a single dose of the protease inhibitor, recombinant alpha 1-antitrypsin (rAAT), can facilitate resolution of acute otitis media (AOM) in the chinchilla.

METHODS AND MEASURES

Pneumococcus was injected into both middle ears of 12 chinchillas. After 3 to 4 days, middle ears were cultured, systemic antibiotics were initiated, and rAAT or its vehicle was administered into the middle ears of all animals. Serial tympanic membrane (TM) scoring, tympanometry, and auditory-evoked brain stem response testing were performed. Animals were sacrificed at varying timepoints and temporal bones studied for objective measures of OM.

RESULTS

Although not reaching statistical significance, there was a trend to more rapid resolution of AOM in rAAT-treated ears. Tympanometry, auditory thresholds, and quantitative histologic parameters did not differ between rAAT and vehicle treated ears.

CONCLUSIONS

A single dose of intratympanic rAAT likely does not facilitate the resolution of antibiotic-treated pneumococcal AOM in the chinchilla model. Serial administration of this protease inhibitor may be necessary to see a significant treatment effect.

Long-term follow-up evaluation of mastoidectomy in children with non-cholesteatomatous chronic suppurative otitis media

OBJECTIVE

In spite of declining prevalence chronic suppurative otitis media without cholesteatoma (CSOM) still poses a significant health problem. Randomized clinical trials comparing medical and surgical intervention are not available. Hence, the treatment of CSOM is almost exclusively based on empirical experience. The purpose of the present study was to evaluate the long-term effects of mastoidectomy combined with myringotomy and exploration of the middle ear in children with CSOM.

METHODS

47 children with CSOM underwent surgery including mastoidectomy. Ear status was investigated peri-operatively and at a long-term follow-up (5-21 years post-operatively).

MAIN OUTCOME MEASURES

Final success rate, FS (dry ears for several years) and the optimal final success rate, OFS (dry ears for several years without re-operations and without retractions/perforations) were estimated.

RESULTS

No serious surgical complications occurred. Post-operatively re-mastoidectomy was performed in 13% and re-myringoplasty/tympanoplasty in 21%. At the long-term follow-up the FS rate was 94% and the OFS rate was 61%.

CONCLUSIONS

Surgery alone did not entirely cure CSOM which may justify randomized studies comparing conservative treatment and myringoplasty with/without mastoidectomy. Finally, mastoidectomy in these patients must be considered as a last resort when intense conservative treatment fails.

In vitro efficacy of the successive or staggered use of eardrops

Chronic suppurative otitis media is still a significant health problem. Several topical agents such as antibacterials, steroids and acid media eardrops are widely used alone or in combination to control active otorrhea and obtain a dry ear. Patients frequently ask if there is any benefit or loss in the effect of these due to their use in a successive or staggered manner. This question led us to design this in vitro study to investigate the effect of the acetic acid solution and dexamethasone sodium phosphate on the antimicrobial effects of some ototopical antibiotics during their successive or staggered usage. Staphylococcus aureus, Pseudomonas aeruginosa, Proteus mirabilis and Escherichia coli were used for testing the antimicrobial activities of the selected antibiotic drops. Six microliters of acetic acid solution and dexamethasone sodium phosphate were used alone or together with 6 microl each of ciprofloxacin HCl, tobramycin and ofloxacin solution. Drops were placed on Whatman no. 1 paper disks with a diameter of 6 mm, and the disks were placed onto Mueller-Hinton agar plates on which bacteria had been swabbed over the entire surface. After overnight incubation of the plates at 35 degrees C, the diameters of the inhibition zones were recorded. There was no antibacterial effect in response to either acid solution or dexamethasone used alone. The inhibition zones of the antibiotics did not change with either steroid or acid media solution added onto the antibiotic disks alone or together. Acid solution or steroids should be preferred to use in combination with antibacterial otic drugs in in-vivo settings; no negative or positive effects were seen in in-vitro conditions. Therefore, prescribed eardrops can be used in a successive or staggered manner without any influence on the treatment results.

Mucosal Biofilm Formation on Middle-Ear Mucosa in a Nonhuman Primate Model of Chronic Suppurative Otitis Media

BACKGROUND

An increased awareness of bacterial biofilms and their formation has led to a better understanding of bacterial infections that occur in the middle ear. Perhaps the best studied pathogen for its propensity toward biofilm formation is Pseudomonas aeruginosa, also the primary pathogen in chronic suppurative otitis media (CSOM).

OBJECTIVE

The aim of this study was to determine whether P. aeruginosa forms a biofilm in the middle ear in the setting of CSOM in a nonhuman primate model.

METHODS

Cynomolgus monkeys underwent perforation of the tympanic membrane and inoculation of the middle ear with a known biofilm-forming strain of P. aeruginosa. The contralateral ear was used as an internal control and was neither perforated nor infected. At the end of the study period, both ears were irrigated to remove planktonic bacteria, and the middle ear mucosa was removed and examined ultrastructurally using scanning electron microscopy (SEM) for determination of the presence or absence of biofilm formation.

MAIN OUTCOME MEASURE

The identification of middle ear biofilm containing rod-shaped bacteria.

RESULTS

SEM revealed that P. aeruginosa formed bacterial biofilm in vivo on the middle ear mucosal surface, seen only in the infected ear. Interestingly, biofilm formation caused by cocci was also seen in both the experimental as well as the control ear.

CONCLUSION

P. aeruginosa forms biofilms in the middle ear in CSOM in primates. To our knowledge, this is the first report of disease-associated bacterial biofilm in a nonhuman primate model of CSOM. Such a model lays a foundation for much needed study into the role of biofilms in the pathophysiology of CSOM. Should CSOM be caused by biofilms, which is uncertain at this time, development of novel strategies for treatment and prevention may be possible. The finding of both rods and cocci forming biofilms also warrants further investigation.

Ototoxic eardrops and tympanic membrane perforations: time for a change?

Until recently the only available antibiotic eardrops for treatment of the discharging middle ear and mastoid cavity have been potentially ototoxic. With the advent of non-ototoxic fluoroquinolone eardrops, consensus panels in the USA, Canada and the UK have advocated the preferential use of these agents in the open middle ear. However, in Australia, no fluoroquinolone topical agent is approved for use with tympanic membrane perforations, and when used as an 'off label' eardrop, none is on the Pharmaceutical Benefits Scheme. This creates an ethical dilemma, particularly with best practice management of chronic suppurative otitis media in indigenous children. Despite concerns regarding resistance issues with ototopical use of systemic antibiotics, bacterial resistance has not been documented in major studies. For equity and ethical reasons, Australian regulatory authorities should consider approving a sterile non-ototoxic eardrop for use in the open middle ear.

Role of glucocorticoids in ototopical antibiotic-steroid preparations in the treatment of chronic suppurative otitis media

BACKGROUND

It is conventional to use antibiotic-steroid combination eardrops, although the advantage of steroid combination has not been substantiated. The present prospective randomized comparative study is designed to assess the role of glucocorticoids in ototopical antibiotic-steroid preparations in the treatment of chronic suppurative otitis media (CSOM).

METHODS

Pre-treatment clinical assessment, bacteriology of the middle ear discharge and pure tone audiogram were done. CSOM with organisms sensitive to gentamicin were treated either with plain gentamycin (GM) or gentamycin steroid combination (GM-S) eardrops for a period of 3 weeks. Post-treatment clinical, bacteriological and audiogram response was recorded 1 week after discontinuing the eardrops. The post-treatment clinical improvement, bacteriologic improvement and changes in hearing threshold at speech frequencies were analyzed by using unpaired Student's t test and chi(2) tests.

RESULTS

The most common organism associated with CSOM was Pseudomonas aeruginosa (33.92%). Clinical improvement was seen in 87.7 and 86.5% cases but bacteriological improvement in only 82.5 and 75% of cases treated with GM and GM-S (p >0.05), respectively. On comparing the pre- and post-treatment pure tone audiograms in 95 patients, 28.9% treated with GM and 30% with GM-S showed deterioration in bone conduction threshold above 5 dB (p >0.05) at speech frequencies. The mean increase in bone conduction in the two groups was 7.7 and 8.57 dB (p >0.05), respectively.

CONCLUSIONS

Our results indicate that there is no difference in the clinical and bacteriological improvement or ototoxicity either with topical GM or GM-S. Hence, we conclude that it is unnecessary to combine steroids with topical antibiotic preparations for the management of CSOM.

Effect of Corticosteroid-Antibiotic Agents on Granulation Tissue in a Murine Model

OBJECTIVE

To compare the effects of 3 commonly used ototopical corticosteroid-antibiotic agents, currently available for use in the treatment of inflammatory conditions of the external and middle ear, on granulation tissue in an established murine model of wound healing.

SUBJECTS

Twelve C57/BL6J mice.

DESIGN

Eight-millimeter wounds, created bilaterally on the dorsum of the mice, were treated with combinations of 0.3% ciprofloxacin and 0.1% dexamethasone (CiproDex), 0.3% tobramycin and 0.1% dexamethasone (TobraDex), 0.2% ciprofloxacin hydrochloride and 1% hydrocortisone (Cipro HC), or phosphate-buffered saline (n = 6 each) for 3 days (days 4-6) and then harvested on day 7. Wound sections were stained with hematoxylin-eosin, Gomori trichrome, and CD31. Extracellular matrix deposition was graded from 1-4, and neovascularization was assessed by counting the number of endothelial-lined vessel lumens per high-power field (HPF).

RESULTS

The mean +/- SEM grade of extracellular matrix deposition was lower in CiproDex- (1.7 +/- 0.2) and TobraDex- (2.0 +/- 0.2) but not Cipro HC-(2.9 +/- 0.3) treated wounds compared with control wounds (2.9 +/- 0.2) (P<.01). The mean +/- SEM number of vessel lumens per HPF was lower in CiproDex- (0.9 +/- 0.2 lumens/HPF), TobraDex- (1.5 +/- 0.3 lumens/HPF) and Cipro HC-(0.9 +/- 0.3 lumens/HPF) treated wounds compared with controls (3.3 +/- 0.5 lumens/HPF) (P<.01).

CONCLUSIONS

All 3 ototopical corticosteroid-antibiotic agents studied were equally effective at reducing neovascularization, although dexamethasone-based products were more effective at reducing extracellular matrix deposition. The results of this study suggest that ototopical agents containing dexamethasone may be more effective for the treatment of granulation tissue resulting from external and middle ear inflammatory conditions.

Studies in otitis media: Children's Hospital of Pittsburgh-University of Pittsburgh progress report--2004

OBJECTIVES/HYPOTHESIS

The present Progress Report has summarized the key otitis media clinical trials and laboratory studies conducted since 1969 by investigators at the Children's Hospital of Pittsburgh-University of Pittsburgh (Pittsburgh, PA).

STUDY DESIGN

Review.

METHODS

Included in the discussion are the following: 1) studies of the epidemiology and risk factors; 2) anatomy and pathology of the eustachian tube-middle ear from human temporal bone histopathological specimens; 3) physiology and pathophysiology of the eustachian tube-middle ear in humans and animal models; 4) pathogenesis; 5) otitis media in special populations (e.g., patients with cleft palate, Native Americans, patients with Down syndrome); 6) microbiology; 7) diagnosis; 8) outcomes of randomized clinical trials that evaluated efficacy of nonsurgical and surgical methods of treatment and prevention; 9) studies of certain complications and sequelae (e.g., effect of middle-ear effusion on hearing, early child development, and the vestibular system; chronic suppurative otitis media). Also included are relevant summary tables and 256 references.

A cost threshold analysis of ciprofloxacin-dexamethasone versus ofloxacin for acute otitis media in pediatric patients with tympanostomy tubes

OBJECTIVE

The aim of this study was to determine the cost-effectiveness hreshold of a ciprofloxacin 0.3% and dexamethasone 0.1% (CD) otic suspension relative to olfloxacin otic solution (OFX) for the treatment of acute otitis media in pediatric patients with tympanostomy tubes (AOMT).

METHODS

This study used a decision-analytic model to simulate the costs and consequences of the ototopical treatment of AOMT. The AOMT model consisted of 3 tiers of antimicrobial therapy. Each successive tier represented the repeat treatment of clinical failures from the preceding tier. Patients were modeled for treatment until cured or until third-tier therapy was complete, at which time patients were considered cured. First-tier therapy modeled a comparison of CD and OFX using efficacy rates taken from a randomized clinical trial with a population of 599 patients. Second-tier therapy modeled the use of amoxicillin and clavulanic acid using an efficacy rate taken from the medical literature. Third-tier therapy was modeled as being pathogen specific and could follow 1 of 3 possible clinical pathways: (1) PO fluconazole, (2) IM ceftriaxone, or (3) IV antibiotics administered in a hospital setting. Third-tier therapeutic pathway probabilities were based on the microbiologic spectrum of the treatment failures from the clinical trial. Cost information (in year-2003 US dollars) was taken from accepted cost reference sources and presented from the perspective of a third-party payer. The economic outcome of interest was the cost-effectiveness threshold of CD relative to OFX.

RESULTS

Given the model parameters, CD had a cost-effectiveness threshold value of 4.5 times the wholesale acquisition cost of OFX. Based on actual cost, first-tier CD therapy was more cost-effective than OFX up to a threshold price of US 152.64 dollars.

CONCLUSION

In this decision-analytic model, CD was more cost-effective than OFX for AOMT therapy in pediatric patients up to a threshold price of 4.5 times the price of OFX.

Emergence of ciprofloxacin-resistant pseudomonas in chronic suppurative otitis media

The most frequently isolated organism in chronic suppurative otitis media (CSOM) is Pseudomonas aeruginosa. Ototopical ciprofloxacin has proven effectiveness against P. aeruginosa. The purpose of this study is to evaluate the patients with recurrent otorrhoea caused by CSOM that was unresponsive to topical ciprofloxacin. Eighty-eight patients (18-77 years of age) with otorrhoea due to CSOM were reviewed retrospectively. All of them were initially treated with ciprofloxacin eardrops but the otorrhoea failed to resolve. Bacteriological specimens were processed and identified with standard cultures. In vitro antimicrobial susceptibility of these bacterial isolates was assessed by an agar disc diffusion method. Isolates were tested against 16 antibiotics. Ciprofloxacin-resistant P. aeruginosa were isolated in all cases. Imipenem was the most sensitive antibiotic agent with an overall susceptibility rate of 96.5%, followed by amikacin (55.6%), piperacillin/tazobactam (37.5%) and ceftazidime (31.8%). In our series, ciprofloxacin-resistant P. aeruginosa is increasing recently. Continuous surveillance is necessary to monitor antimicrobial resistance and to guide antibacterial therapy.

Topical ciprofloxacin/dexamethasone is superior to ciprofloxacin alone in pediatric patients with acute otitis media and otorrhea through tympanostomy tubes

OBJECTIVE

To determine whether topical administration of a corticosteroid improves resolution of acute tympanostomy tube otorrhea when combined with topical antibiotic drops.

STUDY DESIGN

Randomized, patient-masked, parallel-group, multicenter trial of topical otic ciprofloxacin/dexamethasone versus topical ciprofloxacin alone in 201 children aged 6 months to 12 years with acute otitis media with tympanostomy tubes (AOMT) of less than or equal to 3 weeks' duration and visible otorrhea.

METHODS

Eligible patients were randomized to receive three drops of either ciprofloxacin 0.3%/dexamethasone 0.1% or ciprofloxacin 0.3% into the affected ear or ears twice daily for 7 days. Clinical signs and symptoms of AOMT were evaluated on days 1 (baseline), 3, 8 (end-of-therapy), and 14 (test-of-cure), and twice-daily assessments of otorrhea were recorded in patient diaries.

RESULTS

The mean time to cessation of otorrhea in the microbiologically culture-positive patient population (n = 167) was significantly shorter with topical ciprofloxacin/dexamethasone than with ciprofloxacin alone (4.22 vs. 5.31 days; P =.004). This resulted in significantly better clinical responses on days 3 and 8 (P <.0001 and P =.0499, respectively). However, there were no significant differences between the two treatment groups in either the clinical response or the microbial eradication rate by day 14.

CONCLUSIONS

Topical otic treatment with ciprofloxacin/dexamethasone is superior to treatment with ciprofloxacin alone and results in a faster clinical resolution in children with AOMT. The contribution of the corticosteroid in achieving a 20% reduction (1.1 day) in time to cessation of otorrhea is clinically meaningful and represents an important advance over single-agent antibiotic therapy.

Topical ciprofloxacin/dexamethasone otic suspension is superior to ofloxacin otic solution in the treatment of children with acute otitis media with otorrhea through tympanostomy tubes

OBJECTIVE

To determine the efficacy and safety of topical ciprofloxacin/dexamethasone otic suspension compared with ofloxacin otic solution in the treatment of acute otitis media with otorrhea through tympanostomy tubes (AOMT) in pediatric patients.

METHODS

This multicenter, prospective, randomized, observer-masked, parallel-group study was conducted at 39 sites in 599 children aged >or=6 months to 12 years with an AOMT episode of <or=3 weeks' duration. The mean age of patients was 2.5 years (standard deviation: 2.37 years). Patients received either ciprofloxacin 0.3%/dexamethasone 0.1% otic suspension 4 drops twice daily for 7 days or ofloxacin 0.3% otic solution 5 drops twice daily for 10 days. Clinical signs and symptoms of AOMT were evaluated at clinic visits on days 1 (baseline), 3 (on therapy), 11 (end of therapy), and 18 (test of cure). A patient diary was used to measure time to cessation of otorrhea. Principal pretherapy pathogens included Streptococcus pneumoniae (16.8%), Staphylococcus aureus (13.0%), Pseudomonas aeruginosa (12.7%), Haemophilus influenzae (12.4%), S epidermidis (10.2%), and Moraxella catarrhalis (4.1%).

RESULTS

Ciprofloxacin/dexamethasone is superior to ofloxacin for clinical cure (90% vs 78%) and microbiologic success (92% vs 81.8%) at the test-of-cure visit, produces fewer treatment failures (4.4% vs 14.1%), and results in a shorter median time to cessation of otorrhea (4 days vs 6 days). Ciprofloxacin/dexamethasone treatment is also superior to improvement in clinical response by visit, absence of otorrhea by visit, and reduction of otorrhea volume by visit. Both topical otic preparations are safe and well tolerated in pediatric patients. No change in speech recognition threshold or decrease in hearing from baseline, based on audiometric testing, was noted with either regimen.

CONCLUSION

Topical ciprofloxacin/dexamethasone treatment is superior to topical ofloxacin in the treatment of AOMT.