Prophylactic antibiotic drops after tympanostomy tube placement

The necessity and effect of prophylactic quinolone ear drops after ventilation tube insertion for otitis media with effusion

BACKGROUND

Otitis media with effusion (OME) is a condition where non-infective fluid builds up in the middle ear. Long-term OME can cause damage to the middle ear and hearing impairment. Ventilation tube insertion (VTI) is an efficient procedure to drain persistent OME. However, the effect of prophylactic ear drops after VTI remains controversial because no infection is present. This study investigated the need for and effect of quinolone ear drops in patients with OME after VTI.

METHODS

Between July 2018 and July 2021, 272 patients (436 ears with OME) who underwent VTI were enrolled. Prophylactic quinolone ear drops (ofloxacin) were used in 271 OME ears and not used in 165. The clinical findings and effect of the ear drops were assessed.

RESULTS

The group with postoperative ofloxacin had less postoperative otorrhea (p < 0.001). In univariate analysis, age ≥ 13 years (odds ratio [OR] = 1.499, 95% confidence interval [CI]: 1.003-2.238, p = 0.046) was significantly associated with recovery to normal middle ear functioning (type A on postoperative tympanometry). No adenoid hypertrophy (OR = 1.692, 95% CI: 1.108-2.585, p = 0.014) and no postoperative otorrhea (OR = 2.816, 95% CI: 1.869-4.237, p < 0.001) were significant independent factors associated with middle ear recovery in both univariate and multivariate analysis. After VTI, 65% of tympanic membranes in the group with postoperative ofloxacin recovered to normal, while in 67% of tympanic membranes in the group without ofloxacin scarring remained.

CONCLUSIONS

Patients who received prophylactic postoperative ofloxacin had less postoperative otorrhea. No adenoid hypertrophy and no postoperative otorrhea were significant independent predictors of middle ear recovery to normal function in both univariate analysis and multivariate analysis. However, prophylactic ofloxacin was not an independent predictor of normal middle ear functioning after VTI. After VTI, most OME patients who had used ofloxacin postoperatively had eardrums that were in better condition than those of patients who had not used ofloxacin. In this study, we confirmed the advantages and limitations of OME after VTI with prophylactic ofloxacin, thus providing clinicians with some guidance regarding the decision to administer prophylactic ofloxacin.

Otitis media prone children with cystic fibrosis: A new normal

OBJECTIVES

To determine if children with cystic fibrosis (CF) who are otitis media prone and treated with tympanostomy tube placement (TTP) follow the natural course of non-CF children regarding the incidence of tympanostomy tube otorrhea (TTO) (21-34%).

METHODS

All CF patients seen at a large tertiary pediatric hospital were retrospectively reviewed from 2010 to 2019. A total of 483 patients were identified and seventeen met the inclusion criteria and were included in the analysis. Data collected included demographics, CF diagnosis history including date of diagnosis and genotype, TTP notes, and otorrhea found in otolaryngology clinic and pediatrician clinic notes for up to 18 months post-TTP.

RESULTS

CF was diagnosed at a median age of 13 days (0 days to 6 years). In terms of surgical frequency, 14/17 (82.4%) patients had one TTP, 2/17 (11.8%) had two TTPs, and 1/17 (5.9%) had five TTPs. The median (range) age at first TTP was 2 years (3 months to 13 years). After the first TTP, TTO occurred in 5 (29.4%) patients at 3 months, 6 (35.3%) at 6 and 9 months, and 7 (41.2%) at 12 and 18 months at median (range) = 1 (0-5) otolaryngology appointments and median (range) = 0 (0-8) pediatrician appointments.

CONCLUSION

To our knowledge this is the first study to report that CF children are more likely to be severely affected with recurrent acute otitis media (RAOM), to require TTP, and to exhibit a natural history of TTO commensurate with the non-CF population.

Steroid Versus Antibiotic Drops in the Prevention of Postoperative Myringotomy Tube Complications

Objectives:

To determine the incidence of early postoperative tympanostomy tube insertion otorrhea and obstruction in pediatric patients receiving antibiotic ear drops with or without steroid perioperatively.

Methods:

A retrospective chart review was performed on patients who underwent outpatient myringotomy and tube placement. Patients from June 2013 to February 2014 received ciprofloxacin/dexamethasone perioperatively while patients from May 2014 to April 2015 received ofloxacin. Statistical analysis was performed to compare outcomes between the cohorts.

Results:

One hundred thirty-four patients received topical ciprofloxacin/dexamethasone, and 116 patients received topical ofloxacin. The rate of postoperative otorrhea was 5.2% for the ciprofloxacin/dexamethasone group and 8.2% for the ofloxacin group. Tube obstruction was seen in 6.0% of the ciprofloxacin/dexamethasone group and 5.2% in the ofloxacin group. Neither outcome had a statistically significant difference ( P = .21 and .85, respectively). There was no difference in the rate of effusion at the time of tube placement between the 2 cohorts ( P = .16), and this included subgroup analysis based on effusion type (mucoid, purulent, serous). Patients with a mucoid effusion at the time of surgery were more likely to experience otorrhea/obstruction than patients with dry ears (odds ratio = 2.23, P = .02).

Conclusion:

No significant difference in the incidence of immediate postoperative tympanostomy tube otorrhea or obstruction was seen between the antibiotic-steroid and antibiotic alone cohorts, regardless of effusion type. Overall, patients with mucoid effusions are more likely to develop tube otorrhea or obstruction at follow-up. Cost-effective drops should be used when prescribing topical therapy to prevent complications after ear tubes.

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.)

Randomized Clinical Trial of a Sustained-Exposure Ciprofloxacin for Intratympanic Injection During Tympanostomy Tube Surgery

Objective:

This exploratory clinical trial evaluated the safety and clinical activity of a novel, sustained-exposure formulation of ciprofloxacin microparticulates in poloxamer (OTO-201) administered during tympanostomy tube placement in children.

Methods:

Double-blind, randomized, prospective, placebo- and sham-controlled, multicenter Phase 1b trial in children (6 months to 12 years) with bilateral middle ear effusion requiring tympanostomy tube placement. Patients were randomized to intraoperative OTO-201 (4 mg or 12 mg), placebo, or sham (2:1:1 ratio).

Results:

Eighty-three patients (52 male/31 female; mean age, 2.80 years) were followed for safety (otoscopic exams, cultures, audiometry, and tympanometry) and clinical activity, defined as treatment failure (physician-documented otorrhea and/or otic or systemic antibiotic use ≥3 days post surgery). At baseline, 14.3% to 36.8% of children showed positive cultures of middle ear effusion samples in at least 1 ear. Through day 15, treatment failures accounted for 14.3%, 15.8%, 45.5%, and 42.9% of patients (OTO-201 4 mg, OTO-201 12 mg, placebo, and sham, respectively); treatment failure reductions for OTO-201 doses were significant compared to pooled control (P values = .023 and .043, respectively). Observed OTO-201 safety profile was indistinguishable from placebo or sham.

Conclusions:

Results of this first clinical trial suggest that OTO-201 was well tolerated and shows preliminary clinical activity in treating tympanostomy tube otorrhea.

Interventions for the prevention of postoperative ear discharge after insertion of ventilation tubes (grommets) in children

BACKGROUND

Grommets are frequently inserted in children's ears for acute otitis media and otitis media with effusion. A common complication is postoperative ear discharge (otorrhoea). A wide range of treatments are used to prevent the discharge, but there is no consensus on whether or not intervention is necessary nor which is the most effective intervention.

OBJECTIVES

To assess the effectiveness of prophylactic interventions, both topical and systemic, in reducing the incidence of otorrhoea following the surgical insertion of grommets in children.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 3 July 2012.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared the efficacy of prophylactic interventions against placebo/control and/or with other prophylactic interventions for postoperative otorrhoea in children.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and risk of bias, and extracted data. The outcome data were dichotomous for all the included trials. We calculated individual and pooled risk ratios (RR) using the Mantel-Haenszel fixed-effect method. We also calculated the numbers needed to treat to benefit (NNTB).

MAIN RESULTS

We found 15 eligible RCTs (2476 children, aged from four months to 17 years). We graded seven RCTs as being at a low risk of bias (n = 926 children) and for an eighth RCT we also graded two of the arms as being at a low risk of bias. We graded the other seven trials as being at a high risk of bias.For a single application at surgery, there was evidence from two low risk of bias trials that at two weeks postoperatively the risk of otorrhoea was reduced by multiple saline washouts (from 30% to 16%; RR 0.52, 95% confidence interval (CI) 0.27 to 1.00; NNTB 7; one RCT; 140 children) and antibiotic/steroid ear drops (from 9% to 1%; RR 0.13, 95% CI 0.03 to 0.57; NNTB 13; one RCT; 322 ears). A meta-analysis of two low risk of bias trials (222 ears) failed to find an effect of a single application of antibiotic/steroid ear drops at four to six weeks postoperatively.For a prolonged application of an intervention, there was evidence from four low risk of bias trials that the risk of otorrhoea was reduced two weeks postoperatively by antibiotic ear drops (from 15% to 8%; RR 0.54, 95% CI 0.30 to 0.97; NNTB 15; one RCT; 372 children), antibiotic/steroid ear drops (from 39% to 5%; RR 0.13, 95% CI 0.05 to 0.31; NNTB 3; one RCT; 200 children), aminoglycoside/steroid ear drops (from 15% to 5%; RR 0.37, 95% CI 0.18 to 0.74; NNTB 11; one RCT; 356 children) or oral antibacterial agents/steroids (from 39% to 5%; RR 0.13, 95% CI 0.03 to 0.51; NNTB 3; one RCT; 77 children).Only one trial assessed the secondary outcome of ototoxicity, but no effect was found. There were no trials that assessed quality of life.

AUTHORS' CONCLUSIONS

Our review found that each of the following were effective at reducing the rate of otorrhoea up to two weeks following surgery: (1) multiple saline washouts at surgery, (2) a single application of topical antibiotic/steroid drops at surgery, (3) a prolonged application of topical drops (namely antibiotic ear drops, antibiotic/steroid eardrops or aminoglycoside/steroid ear drops) and (4) a prolonged application of oral antibacterial agents/steroids. However, the rate of otorrhoea between RCTs varied greatly and the higher the rates of otorrhoea within a RCT, the smaller the NNTB for therapy.We conclude that if a surgeon has a high rate of postoperative otorrhoea in children then either saline irrigation or antibiotic ear drops at the time of surgery would significantly reduce that rate. If topical drops are chosen, it is suggested that to reduce the cost and potential for ototoxic damage this be a single application at the time of surgery and not prolonged thereafter.

Vascular endothelial cells mediate mechanical stimulation-induced enhancement of endothelin hyperalgesia via activation of P2X2/3 receptors on nociceptors

Endothelin-1 (ET-1) is unique among a broad range of hyperalgesic agents in that it induces hyperalgesia in rats that is markedly enhanced by repeated mechanical stimulation at the site of administration. Antagonists to the ET-1 receptors, ET(A) and ET(B), attenuated both initial as well as stimulation-induced enhancement of hyperalgesia (SIEH) by endothelin. However, administering antisense oligodeoxynucleotide to attenuate ET(A) receptor expression on nociceptors attenuated ET-1 hyperalgesia but had no effect on SIEH, suggesting that this is mediated via a non-neuronal cell. Because vascular endothelial cells are both stretch sensitive and express ET(A) and ET(B) receptors, we tested the hypothesis that SIEH is dependent on endothelial cells by impairing vascular endothelial function with octoxynol-9 administration; this procedure eliminated SIEH without attenuating ET-1 hyperalgesia. A role for protein kinase Cε (PKCε), a second messenger implicated in the induction and maintenance of chronic pain, was explored. Intrathecal antisense for PKCε did not inhibit either ET-1 hyperalgesia or SIEH, suggesting no role for neuronal PKCε; however, administration of a PKCε inhibitor at the site of testing selectively attenuated SIEH. Compatible with endothelial cells releasing ATP in response to mechanical stimulation, P2X(2/3) receptor antagonists eliminated SIEH. The endothelium also appears to contribute to hyperalgesia in two ergonomic pain models (eccentric exercise and hindlimb vibration) and in a model of endometriosis. We propose that SIEH is produced by an effect of ET-1 on vascular endothelial cells, sensitizing its release of ATP in response to mechanical stimulation; ATP in turn acts at the nociceptor P2X(2/3) receptor.

Pseudomonas biofilm formation after Haemophilus infection

OBJECTIVES

Tympanostomy tube (TT) biofilm formation may lead to refractory otorrhea and occlusion. Biofilms are commonly composed of multiple microbial species. One species may promote or inhibit biofilm formation by other species.The aim of this study was to determine if Haemophilus influenzae(HI) promotes the development of Pseudomonas aeruginosa(PA) biofilm on TTs.

STUDY DESIGN

Controlled, in vitro.

SETTING

Academic research laboratory.

SUBJECTS AND METHODS

Fluoroplastic TTs (20 per group) were exposed to plasma, allowed to dry, and cultured with HI for 7 days. TTs were either gas sterilized or treated for 24 hours with 10 or 3000 μg/mL ciprofloxacin. Half of the TTs from each treatment group underwent bacterial counts or scanning electron microscopy. The remainder, as well as TTs not exposed to HI, were cultured with PA for 4 days and treated with gentamicin to kill planktonic PA. Biofilm formation was quantified with bacterial counts.

RESULTS

TTs treated with ciprofloxacin 3000 μg/mL had lower HI counts than TTs treated with 10 μg/mL (P = .0001), but viable HI persisted. PA biofilm formation on TTs with prior HI biofilm and treated with ciprofloxacin 10 μg/mL or gas sterilization was not different than TTs without HI. Less PA biofilm formed on TTs with HI treated with 3 mg/mL ciprofloxacin(P = .002).

CONCLUSIONS

HI biofilm does not promote PA biofilm formation on TTs. Use of high-dose ototopical therapy to clear HI may reduce subsequent PA biofilm formation.

Contemporary indications for ventilation tube placement

PURPOSE OF REVIEW

To discuss the current indications for ventilation tube placement

RECENT FINDINGS

In the past year, several studies have challenged the current guidelines for ventilation tube placement and antibiotic use for otitis media in children. Critics argue that some of these studies have poor scientific validity, yet these studies are being referenced, and sometimes misinterpreted, by the media. Fueled by these media reports, many concerned parents are now questioning otolaryngologists as to the efficacy and safety of ventilation tube placement. Whereas the indications for tube placement in children may be in a state of flux, the indications for tube placement in adults has (and is) fairly static. I will discuss the current published guidelines and the potential for changing trends in tube placement rates. I will also review the literature for the past year regarding postoperative management and adjuvant therapies.

SUMMARY

Although there have been no radical changes in the indications for ventilation tube placement, recent studies have challenged the current clinical indicators and the ramifications of these studies may be more evident in the years to come.

A single topical agent is clinically equivalent to the combination of topical and oral antibiotic treatment for otitis externa

OBJECTIVE

To demonstrate clinical equivalence (statistical noninferiority) of topical ciprofloxacin and hydrocortisone (CHC, Cipro HC) and topical neomycin/polymyxin b/hydrocortisone (NPH, Cortisporin) with systemic amoxicillin (AMX, Amoxil), for treatment of acute otitis externa (AOE).

DESIGN

Randomized, active-control, observer-blind, multicenter trial.

PATIENTS

Altogether, 206 patients were enrolled (CHC, 106; NPH + AMX, 100). Patients were > or =1 year of age, had AOE >2 days with at least mild symptoms, and gave informed consent. All were evaluable for safety, and 151 were evaluable for efficacy.

INTERVENTIONS

Ciprofloxacin and hydrocortisone 3 drops twice daily for 7 days (adults and children) or NPH 4 drops (adults) or 2 drops (children) with AMX 250 mg (adults and children) 3 times daily for 10 days, as directed in approved product labeling.

MAIN OUTCOME MEASURES

The primary efficacy variable was response to therapy 7 days after treatment ended (test of cure). Secondary variables included time to end of pain, symptom scores (otalgia and tenderness) and microbiological eradication. Noninferiority was declared if the lower confidence limit around the measurement difference was above -10 (nearer zero).

RESULTS

Response to therapy was higher for CHC (95.71% vs 89.83%) but was statistically noninferior (lower confidence limit, -4.98) to NPH + AMX. Median time to end of pain was 6 days for both groups. Noninferiority was declared for symptom scores at all measurement periods and for microbiological eradication. No serious adverse events related to treatment were reported.

CONCLUSIONS

Ciprofloxacin and hydrocortisone is clinically equivalent to NPH + AMX for the treatment of AOE in adults and children. However, low systemic exposure, absence of ototoxicity, and less frequent dosing clearly favor Cipro HC.

Ciprofloxacin/dexamethasone drops decrease the incidence of physician and patient outcomes of otorrhea after tube placement

OBJECTIVE

To evaluate ciprofloxacin 0.3%/dexamethasone 0.1% (CIPRODEX, Alcon, Ft. Worth, TX) for the prevention of early post-operative otorrhea following TT placement.

METHODS

This was a single-center, randomized, evaluator-blinded, parallel-group study. Two hundred children undergoing bilateral TT placement were categorized as having unilateral ("wet/dry"), bilateral ("wet/wet"), or no ("dry/dry") effusion at the time of surgery. All patients received Ciprodex or no treatment for 5 days post-operatively and returned at 2 weeks.

RESULTS

Physician-observed otorrhea was reported in 5 (4.95%) patients receiving Ciprodex and 39 (39.39%) patients receiving no treatment (p<0.0001). Treatment decreased otorrhea in all groups, while the greatest benefit was observed in patients with bilateral effusion (93% reduction). Ciprodex treatment also decreased the rate of clinically diagnosed otitis media (OM) and effusion following TT placement (p< or =0.0006).

CONCLUSION

Ciprodex reduced early post-operative otorrhea, clinically diagnosed OM and effusion following TT insertion. The greatest reduction in otorrhea was observed in patients with bilateral effusion at the time of surgery.

Post-tympanostomy tube otorrhea: a meta-analysis

INTRODUCTION

Post-tympanostomy tube otorrhea is the most common complication of tympanostomy tube placement. The incidence of this problem varies from 3.4% to 74%. Trials that study post-tympanostomy tube otorrhea may involve valid randomization "by patient" or "by ear." In an attempt to define "best practice," we conduct a meta-analysis to quantify the benefit of using topical prophylactic antibiotic drops in the postoperative period. We then compare our findings with previous results found in the literature.

METHODS

We selected randomized studies for which antibiotic drops had been used for at least 48 hours after tympanostomy tube insertion. Nine studies, 3 "by ear" and 6 "by patient," met our inclusion criteria. The odds ratio and 95% confidence intervals were calculated for each to conduct the meta-analysis.

RESULTS

Overall, prophylaxis appears to be effective at reducing the incidence of post-tympanostomy tube otorrhea. The odds ratios for all studies were less than 1.0. However, none of the 3 "by ear" studies and only 3 of the 6 "by patient" studies were statistically significant. The mean odds ratio was 52%, suggesting that prophylaxis may reduce the incidence of post-tympanostomy tube otorrhea by half.

CONCLUSION

This meta-analysis suggests that routine post-tympanostomy tube prophylaxis is beneficial, but this finding is dependent on selection criteria used.

EBM RATING

A-1a.

Oxymetazoline solutions inhibit middle ear pathogens and are not ototoxic

OBJECTIVES

This study was performed to explore the antimicrobial activity of two commercially available oxymetazoline hydrochloride preparations against the common pathogens of otitis media and to demonstrate the lack of ototoxicity of these agents and of United States Pharmacopeia (USP) oxymetazoline in a standard animal model.

METHODS

Disc diffusion assays and minimum inhibitory concentration studies against American Type Culture Collection reference strains of common middle ear pathogens were used to evaluate the antimicrobial activity of oxymetazoline solutions and fluoroquinolone drops, and outer hair cell counts were performed on scanning electron micrographs of guinea pig basal cochlear segments after chronic exposure to oxymetazoline solutions and positive and negative controls.

RESULTS

Oxymetazoline nasal spray and eyedrops had activity against all species tested except Haemophilus influenzae and Pseudomonas aeruginosa. The USP oxymetazoline had limited antimicrobial activity. Oxymetazoline nasal spray, oxymetazoline eyedrops, and USP oxymetazoline had ototoxicity profiles indistinguishable from that of the saline solution control.

CONCLUSIONS

Commercially available oxymetazoline solutions are active against several of the common pathogens of otitis media. This antimicrobial activity is not due to oxymetazoline, and is more likely due to preservatives present in the solutions. The solutions tested are not ototoxic to guinea pig outer hair cells. Oxymetazoline solutions are potential substitutes for broad-spectrum antibiotic drops after tympanostomy tube placement.

Oxymetazoline is Equivalent to Ciprofloxacin in Preventing Postoperative Otorrhea or Tympanostomy Tube Obstruction

OBJECTIVE

To compare the effectiveness of ciprofloxacin and oxymetazoline solutions instilled after tympanostomy tube placement in the prevention of postoperative otorrhea and tube occlusion.

STUDY DESIGN

Prospective cross-sectional series.

METHODS

We reviewed all bilateral myringotomy and tube placement operations performed by two full-time attending pediatric otolaryngologists during a 9 month period. Data from 488 patients who underwent surgery for otitis media were collected. Demographic and clinical variables including age, sex, number of tube insertions in the past, previous adenoidectomy, type of effusion present at surgery, and type of drop prescribed postoperatively were recorded. All patients were evaluated in the office 2 to 4 weeks postoperatively. Multivariate logistic regression analysis was used to estimate the relationship of these variables with the occurrence of otorrhea and tube patency. Odds ratios were calculated.

RESULTS

No significant differences in postoperative otorrhea or tube patency were found between ciprofloxacin (Ciloxan) and oxymetazoline solutions (Afrin, Visine LR).

CONCLUSION

Oxymetazoline and ciprofloxacin solutions are equivalent in the prevention of postoperative otorrhea and tube occlusion after tympanostomy tube placement. The implications for medication cost and potential adverse reactions are discussed.

Otic drops used to clear a blocked grommet: an in vitro prospective randomized controlled study with blinded assessment

Clinicians often prescribe otic drops anecdotally to try and clear grommets blocked with blood. We carried out an in vitro double-blind randomized controlled study comparing the efficacy of sodium bicarbonate, Locorten Vioform and olive oil drops in clearing Shah grommets placed in 'artificial ears' and blocked with blood in a standardized fashion. There were 33 grommets in each group, and drops were inserted three times a day for 7 days. Olive oil drops cleared 17 of 33 (51.51%), Locorten Vioform cleared one of 33 (3%) and sodium bicarbonate cleared zero of 33 (0%) blocked grommets. Statistical comparison between pairs indicates that olive oil was significantly better than both Locorten Vioform (P < 0.001) and sodium bicarbonate drops (P < 0.001) at clearing grommets blocked with blood.

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.

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.

Follow-up of 366 Ears after Tympanostomy Tube Insertion: Why is it Draining?

OBJECTIVE: Tympanostomy tube insertion is one of the most frequently performed procedures in otolaryngology. Complications, such as otorrhea, tympanosclerosis, and cholesteatoma, have been reported in the literature after its application.

STUDY DESIGN: This study reports the complications encountered with 239 children (439 ears) with a follow-up of 7 to 73 months (median, 29 months) after tympanostomy tube insertion. Hearing results and middle ear pressures were compared and complications were noted in 366 ears that were available for the study.

RESULTS: Otorrhea developed in 3 (0.8%) cases. Tympanosclerosis was seen in 74 (20.2%) cases. Tympanic membrane perforation, retraction pocket, granulation tissue, and atelectasis were seen in 4.6%, 5.2%, 1.1%, and 6%, respectively. No patients developed cholesteatoma after tube insertion. Hearing results were improved postoperatively in 93.4% of patients (median, 14.2 dB) and worse in 6.6% of patients (median, 8.3 dB). The average extrusion time was 7.3 months for grommet and 16.3 months for T-tubes.

CONCLUSION: Multifactor etiologies show some unsolved or misunderstood underlying pathology, or unmentioned environmental factor such as atopy due to rich flora and humidity might exist to consider in the pathophysiology of the otorrhea.

Otorrhea in young children after tympanostomy-tube placement for persistent middle-ear effusion: prevalence, incidence, and duration

OBJECTIVE

To characterize the occurrence of tube otorrhea after tympanostomy-tube placement (TTP) for persistent middle-ear effusion (MEE) in a group of otherwise healthy infants and young children.

METHODS

In a long-term, prospective study of child development in relation to early-life otitis media, we enrolled by 2 months of age healthy infants who presented for primary care at 1 of 2 urban hospitals or 1 of 2 small-town/rural and 4 suburban private pediatric group practices. We monitored their middle-ear status closely. Children who developed persistent MEE of specified durations within the first 3 years of life became eligible for random assignment to undergo TTP either promptly or after an extended period if MEE persisted. The present report concerns 173 randomly assigned children who underwent bilateral TTP between ages 6 and 36 months and were followed for at least 6 months thereafter. Episodes of tube otorrhea were treated with oral antimicrobial drugs and, if persistent, with ototopical medication.

RESULTS

Socioeconomic status, as estimated from maternal education and type of health insurance, was lowest at the urban sites and highest at the suburban sites. The tenure of the 230 tubes that were extruded during the observation period ranged from 19 days to 38.5 months (mean = 13.8 months; median = 13.5 months). During the first 18 months after TTP, the proportion of children who had tubes in place and who developed 1 or more episodes of otorrhea increased progressively, reaching 74.8% after 12 months and 83.0% after 18 months. The mean number of episodes per child was 0.79 in the first 6 months, 1.50 in the first 12 months, 2.17 in the first 18 months, and 2.82 in the first 24 months. Overall, otorrhea occurred earliest and was most prevalent among urban children and occurred latest and was least prevalent among suburban children. The mean estimated duration of episodes of tube otorrhea was 16.0 days (standard deviation = 16.9 days), the median was 10 days, and the range was 3 to 131 days. The duration was >30 days in 13.2% of the episodes. Six of the 173 children (3.5%) developed on 1 or more occasions tube otorrhea that failed to improve satisfactorily with conventional outpatient management. Five of these children were hospitalized to receive parenteral antibiotic treatment, 1 child twice and 1 three times, and 1 also underwent tube removal. The sixth child underwent tube removal as an outpatient.

CONCLUSIONS

Tube otorrhea is a common and often recurrent and/or stubborn problem in young children who have undergone tube placement for persistent MEE. The extent of the problem seems to be related inversely to socioeconomic status. Tube otorrhea does not always respond satisfactorily to outpatient management and for resolution may require parenteral antimicrobial treatment and/or tube removal.

Protection against aminoglycoside otic drop-induced ototoxicity by a spin trap: I. Acute effects

Topical administration of aminoglycoside antibiotic drops containing neomycin and polymyxin B disrupts cochlear structure and function in rodents, possibly as a result of reactive oxygen species generation. This study investigated the ability of a spin trap, alpha-phenyl-tert-butyl-nitrone (PBN), to prevent acute aminoglycoside antibiotic drop-induced cochlear dysfunction. Guinea pigs were monitored for compound action potential thresholds and 1.0 microV root-mean-square cochlear microphonic isopotential curve values, then injected intraperitoneally with PBN (60 mg/kg) or saline solution. After 10 minutes, 50 microl of PBN (100 mmol/L) or artificial perilymph was applied to the round window membrane, followed after 10 minutes with artificial perilymph or aminoglycoside antibiotic drops (50 microl). From 10 to 60 minutes after exposure, mean compound action potential thresholds progressively increased in the artificial perilymph-aminoglycoside antibiotic drop group, beginning with high frequencies and later including ever-lower frequencies. These threshold shifts in compound action potentials were significantly greater (p<0.05) than those seen in the artificial perilymph-artificial perilymph or PBN-aminoglycoside antibiotic drop groups. This finding indicates that PBN provided protection against acute aminoglycoside antibiotic drop-induced compound action potential threshold sensitivity loss. Mean cochlear microphonic shift values at 60 minutes in the artificial perilymph-aminoglycoside antibiotic drop group significantly exceeded those of the other groups only at the highest frequencies. These data suggest that acute aminoglycoside antibiotic drop-induced cochlear disruption primarily affects high frequency compound action potential function and may be partially reactive oxygen species-mediated and preventable.

Prophylactic treatment after ventilation tube insertion: comparison of various methods

Otitis media is recognized as one of the most common diseases of childhood. Insertion of tympanostomy tubes for the treatment of otitis media is the most frequently performed otologic operation, and postoperative otorrhea is its most common complication. Many authors have suggested various reasons for posttympanostomy otorrhea, and many different prophylactic treatments were proposed in recent years to prevent this bothersome and frustrating complication. This retrospective study was designed to investigate and compare the efficacy of various prophylactic treatments and to define the most effective method of reducing the rate of postoperative otorrhea.

Resistance to biofilm formation on otologic implant materials

New materials and coatings are now being developed to resist permanent bacterial contamination of implanted medical devices. This study exposed several styles of middle ear ventilation tube materials and coatings to high concentrations of Pseudomonas and Staphylococcus. Electron microscopy was then used to evaluate these tubes' resistance to bacterial biofilm formations. Ionized, processed silicone tubes were the only tubes resistant to Pseudomonas adhesion. Tubes that were made of fluoroplastic or that were ionized processed were very resistant to Staphylococcus contamination when compared with untreated silicone or silver oxide-treated silicone. This study suggests that ionized, coated fluoroplastic would be a highly effective tube material in preventing bacterial biofilm contamination of implanted ventilation tubes.

Early Postoperative Otorrhea after Tympanostomy Tube Placement: A Comparison of Topical Ophthalmic and Otic Drops

In a retrospective review of the incidence of early postoperative otorrhea, we compared cortisporin otic suspension with sulfacetamide/prednisolone ophthalmic drops and found them to be approximately equally effective.

The beneficial effect of topical otic and ophthalmic antibiotic drops after tympanoplasty tube placement has already been well documented. It is therefore suggested that the potentially more comfortable and theoretically less ototoxic ophthalmic drop be used to decrease the incidence of early postoperative otorrhea.