Efficacy and Safety of Ciprofloxacin Plus Fluocinolone Acetonide Among Patients With Acute Otitis Externa: A Randomized Clinical Trial

Importance

Ciprofloxacin, 0.3%, plus fluocinolone acetonide, 0.025%, otic solution seems to be efficacious and safe in treating acute otitis externa (AOE) compared with ciprofloxacin, 0.3%, or fluocinolone acetonide, 0.025%, otic solution alone.

Objective

To evaluate the superiority of ciprofloxacin, 0.3%, plus fluocinolone acetonide, 0.025%, otic solution compared with ciprofloxacin, 0.3%, or fluocinolone acetonide, 0.025%, otic solution alone in treating AOE.

Design, Setting, and Participants

A phase 3 randomized, double-blind, active-controlled clinical trial was conducted between August 1, 2017, and September 14, 2018, at 36 centers in the US. The study population comprised 493 patients aged 6 months or older with AOE of less than 21 days' duration with otorrhea, moderate or severe otalgia, and edema, as well as a Brighton grading of II or III (tympanic membrane obscure but without systemic illness). Statistical analysis was performed from November 14, 2018, to February 14, 2019.

Interventions

Participants were randomly assigned to receive ciprofloxacin plus fluocinolone, ciprofloxacin, or fluocinolone twice daily for 7 days and were evaluated on day 1 (visit 1; baseline), days 3 to 4 (visit 2; conducted via telephone), days 8 to 10 (visit 3; end of treatment), and days 15 to 17 (visit 4; test of cure).

Main Outcomes and Measures

The primary outcome was therapeutic cure (clinical and microbiological) at the end of the treatment period. The principal secondary end point was the time to end of ear pain. Efficacy analyses were conducted in the microbiological intent-to-treat population, clinical intent-to-treat population, and microbiological intent-to-treat population with Pseudomonas aeruginosa and Staphylococcus aureus.

Results

A total of 493 patients (254 female patients [51.5%]; mean [SD] age, 38.2 [23.1] years) were randomized (197 to receive ciprofloxacin plus fluocinolone, 196 to receive ciprofloxacin, and 100 to receive fluocinolone). Therapeutic cure in the modified intent-to-treat population with ciprofloxacin plus fluocinolone (63 of 103 [61.2%]) was statistically comparable to that of ciprofloxacin (49 of 91 [53.8%]; difference in response rate, 7.3%; 95% CI, -6.6% to 21.2%; P = .30) and fluocinolone (20 of 45 [44.4%]; difference in response rate, 16.7%; 95% CI, -0.6% to 34.0%; P = .06) at visit 3 and significantly superior to ciprofloxacin at visit 4 (90 of 103 [87.4%] vs 69 of 91 [75.8%]; difference in response rate, 11.6%; 95% CI, 0.7%-22.4%; P = .04). A statistically faster resolution of otalgia was achieved among patients treated with ciprofloxacin plus fluocinolone (median, 5.0 days [range, 4.2-6.3 days]) vs ciprofloxacin (median, 5.9 days [range, 4.3-7.3 days]; 95% CI, 4.3-7.3 days; P = .002) or fluocinolone (median, 7.7 days [range, 6.7-9.0 days]; 95% CI, 6.7-9.0 days; P < .001). Ciprofloxacin plus fluocinolone demonstrated statistical superiority in sustained microbiological response vs ciprofloxacin (94 of 103 [91.3%] vs 74 of 91 [81.3%]; difference in response rate, 9.9%; 95% CI, 0.3%-19.6%; P = .04) and fluocinolone (34 of 45 [75.6%]; difference in response rate, 15.7%; 95% CI, 2.0%-29.4%; P = .01) and in the microbiological outcome vs fluocinolone by visit 3 (99 of 103 [96.1%] vs 37 of 45 [82.2%]; difference in response rate, 13.9%; 95% CI, 2.1%-25.7%; P = .01) and ciprofloxacin by visit 4 (97 of 103 [94.2%] vs 77 of 91 [84.6%]; difference in response rate, 9.6%; 95% CI, 0.9%-18.2%; P = .02). Fifteen adverse events related to study medications were registered, all of which were mild or moderate.

Conclusions and Relevance

Ciprofloxacin, 0.3%, plus fluocinolone acetonide, 0.025%, otic solution was efficacious and safe in treating AOE but did not demonstrate superiority vs ciprofloxacin, 0.3%, or fluocinolone acetonide, 0.025%, otic solutions alone in the main study end point of therapeutic cure.

Trial Registration

ClinicalTrials.gov Identifier: NCT03196973.

IL-36 signaling in keratinocytes controls early IL-23 production in psoriasis-like dermatitis

IL-36R signaling plays an important role in the pathogenesis of psoriasis. We ought to assess the specific function of IL-36R in keratinocytes for the pathology of Aldara-induced psoriasis-like dermatitis. Il36r ΔK mice presenting deletion of IL-36R in keratinocytes were similarly resistant to Aldara-induced ear inflammation as Il36r -/- mice, but acanthosis was only prevented in Il36r -/- mice. FACS analysis revealed that IL-36R signaling in keratinocytes is mandatory for early neutrophil infiltration in Aldara-treated ears. RNASeq and qRT-PCR experiments demonstrated the crucial role of IL-36R signaling in keratinocytes for induction of IL-23, IL-17, and IL-22 at early time points. Taken together, our results demonstrate that IL-36R signaling in keratinocytes plays a major role in the induction of Aldara-induced psoriasis-like dermatitis by triggering early production of IL-23/IL-17/IL-22 cytokines and neutrophil infiltration.

In vivo efficacy study of the anti-inflammatory properties of Surolan

This study evaluated the anti-inflammatory properties of Surolan with the use of a pinna model of inflammation in 80 mice and a randomized complete block design. Within each of 8 blocks, 10 treatments, consisting of different combinations of the constituents of Surolan with and without the prednisolone acetate component, were randomly assigned to the 9-wk-old CD-1 mice. The treatments were administered as a single dose 30 min after pinna inflammation was induced with tetradecanoylphorbol acetate. Ear-skin edema and erythema were assessed and measured 4 and 6 h thereafter. Treatment effects were evaluated with repeated-measures analysis of variance. Inclusion of prednisolone acetate with the Surolan vehicle, either alone or in combination with the nonsteroidal constituents of the suspension, resulted in a significant reduction in mean ear-skin thickness and erythema. The inflammation-reducing properties of prednisolone were not significantly affected by the other components of Surolan.

Topical anti-inflammatory activity of 2alpha-hydroxy pentacyclic triterpene acids from the leaves of Ugni molinae

Leaf extracts of Ugni molinae Turcz. are used in the Chilean cosmetic industry on the assumption that they have decongestant, regenerative, and anti-aging properties. A bioassay-guided fractionation of this plant material showed that some extracts have potent anti-inflammatory activities. Further fractionation led to the isolation and identification of betulinic acid, a mixture of ursolic and oleanolic acids, and the 2alpha-hydroxy derivatives alphitolic, asiatic, and corosolic acids. The latter three were evaluated in vivo in the mouse ear assay for their topical anti-inflammatory activity, inducing inflammation with either arachidonic acid (AA) or 12-O-tetradecanoylphorbol-13 acetate (TPA). Only corosolic acid was active in the AA assay, with similar potency to nimesulide, but all three triterpene acids inhibited TPA-induced inflammation with potencies comparable to that of indomethacin.

Potential of atelocollagen-mediated systemic antisense therapeutics for inflammatory disease

To study the possibility of using atelocollagen as an oligonucleotide (ODN) delivery carrier in vivo, the activity of formulated antisense ODN targeted against the intercellular adhesion molecule-1 (ICAM-1) mRNA was investigated in an allergic dermatitis model in mice. The allergic dermatitis was elicited in one ear of animals sensitized by treatment with 2,4-dinitrofluorobenzene. Antisense ODN was given to the animals as a single intravenous injection of formulation containing atelocollagen. Antisense activity was determined by measurement of ear thickness, histopathology, and immunohistochemistry 24 hr after the initiation of the dermatitis. Antisense activity was found to increase according to the concentration of atelocollagen in the formulation. The effect mediated by the ODN formulated with 0.05% atelocollagen was more than 50 times greater than that provided by ODN infusion, although the levels of ODN formulated with atelocollagen dropped below that of the 24-hr infusion group within 30 min. The formulated ODN could suppress inflammatory progression by treatment at 8 hr after the ear challenge when inflammation had already commenced at the challenged site. Moreover, antisense activity was noted even when the formulated ODN was injected 3 days before the initiation of inflammation. These data demonstrate that atelocollagen can enhance antisense activity remarkably and that the sustainable antisense activity mediated by the formulation of ODN with atelocollagen could completely change the strategy of antisense therapeutics.

[Sarcoidal allergic contact dermatitis due to palladium following ear piercing]

Granulomatous tissue reactions due to jewelry made of gold, silver, nickel and palladium are rare but nevertheless have been known for a long time. A female patient developed nodular infiltrates after having been pierced with ear stickers containing palladium. A contact allergic reaction could be demonstrated as the underlying cause by inducing similar histological changes following patch testing with palladium.

Prostaglandin synthase 2 gene disruption causes severe renal pathology in the mouse

The prostaglandin endoperoxide H synthase isoform 2, cyclooxygenase 2 (COX-2), is induced at high levels in migratory and other responding cells by pro-inflammatory stimuli. COX-2 is generally considered to be a mediator of inflammation. Its isoform, COX-1, is constitutively expressed in most tissues and is thought to mediate "housekeeping" functions. These two enzymes are therapeutic targets of the widely used nonsteroidal anti-inflammatory drugs (NSAIDs). To investigate further the different physiologic roles of these isoforms, we have used homologous recombination to disrupt the mouse gene encoding COX-2 (Ptgs2). Mice lacking COX-2 have normal inflammatory responses to treatments with tetradecanoyl phorbol acetate or with arachidonic acid. However, they develop severe nephropathy and are susceptible to peritonitis.

Prostaglandin synthase 1 gene disruption in mice reduces arachidonic acid-induced inflammation and indomethacin-induced gastric ulceration

Cyclooxygenases 1 and 2 (COX-1 and COX-2) are key enzymes in prostaglandin biosynthesis and the target enzymes for the widely used nonsteroidal anti-inflammatory drugs. To study the physiological roles of the individual isoforms, we have disrupted the mouse Ptgs1 gene encoding COX-1. Homozygous Ptgs1 mutant mice survive well, have no gastric pathology, and show less indomethacin-induced gastric ulceration than wild-type mice, even though their gastric prostaglandin E2 levels are about 1% of wild type. The homozygous mutant mice have reduced platelet aggregation and a decreased inflammatory response to arachidonic acid, but not to tetradecanoyl phorbol acetate. Ptgs1 homozygous mutant females mated to homozygous mutant males produce few live offspring. COX-1-deficient mice provide a useful model to distinguish the physiological roles of COX-1 and COX-2.

Suppressive effects of central opioids on delayed type hypersensitivity to trinitrochlorobenzene: comparative study with morphine and electroacupuncture

We reported previously that electroacupuncture (Acu) applied to the acu-point equivalent to GV4 in the mouse just before the 2,4,6-trinitrochlorobenzene (TNCB) challenge suppressed the delayed type hypersensitivity (DTH) through endogenous opioidergic systems in the brain, and the pituitary was pivotal in this immunosuppression. The purpose of the present study was to compare the suppressive effects of Acu with those of single, acute doses of morphine on TNCB-DTH in intact and hypophysectomized (HPX) mice. Subcutaneous morphine 10 mg/kg in ddY mice, 30 mg/kg in BALB/c mice or intracisternal morphine 40 micrograms/mouse in BALB/c mice given just before TNCB challenge suppressed (40-53%) the maximal extent of ear swelling at 24 hrs after challenge in intact mice. In HPX mice, the suppressive effects of intracisternal morphine 10 and 100 micrograms/mouse were less pronounced than those observed in intact mice and there was no significant difference between intact and HPX groups. In addition, suppressive effects observed with Acu or subcutaneous morphine (30 mg/kg) were effectively antagonized by pretreatment with intracisternal naloxone at a dose of as low as 2 micrograms/mouse. Naloxone alone had no effect of its own. These results suggest that 1) the activation of opioid receptor-mediated pathways in the brain, which occurs when opioids are endogenously released (Acu) or exogenously given (morphine), is important in the suppression of TNCB-induced DTH, a cell-mediated immune response, and 2) the pituitary is less pivotal in the suppressive effects of acute morphine than in those of Acu.

A new assay for antiphlogistic activity: zymosan-induced mouse ear inflammation

A new model of local inflammation has been developed: intradermal zymosan-induced mouse ear edema. The symptoms of inflammation induced by injecting zymosan into one of the ears were followed up for 72 h. The ear edema and the local accumulation of polymorphonuclear leukocytes' (PMN) marker enzyme, myeloperoxidase (MPO), were determined. Edema peaked at 4-6 h, while MPO activity peaked at 24 h after zymosan application. The correlation between inflammatory response and concentration of zymosan was also tested. Of the various concentrations tested, 1% suspension has been found optimal. Anti-inflammatory drugs and mediator antagonists were examined in order to establish the selectivity and sensitivity of the assay. A glucocorticoid (dexamethasone), two cyclooxygenase inhibitors (indomethacin, piroxicam) and an interleukin-1 (IL-1) release inhibitor (IX 207-887, Sandoz) all reduced edema and MPO activity as well. However, a lipoxygenase inhibitor (phenidone), a serotonin receptor antagonist (methysergide) and H1 and H2 receptor antagonists (clemastine and cimetidine, respectively) all failed to inhibit the reaction.

Study on the suppressive effect of iodine-enriched egg on LT-C4 production in arachidonic acid-induced ear inflammation

The anti-inflammatory mechanism of iodine-enriched egg was investigated in mice by means of arachidonic acid-induced ear inflammation. The lipid fraction of iodine-enriched egg was capable of suppressing the increase in ear weight induced by arachidonic acid in a dose-dependent manner. The lipid fraction was further separated into neutral and polar lipid fractions. Of these two fractions, only the neutral lipid fraction was capable of suppressing LT-C4 production in arachidonic acid inflammation. Neither the neutral nor polar lipid fractions of ordinary egg, however, showed any anti-inflammatory effect. These results suggest that the anti-inflammatory activity of iodine-enriched egg is present in the neutral lipid fraction, and its mechanism is assumed to be inhibition of LT-C4 production.

Allergic contact dermatitis from the earmolds of hearing aids

Hearing aid users with longstanding and severe dermatitis in the ear canal were examined by a dermatologist and patch tested. In 6 of 22 (27%) patients, contact allergy to the earmold material was found. Four of the six had a positive test reaction to methyl methacrylate and two also to triethyleneglycol dimethacrylate and urethane dimethacrylate. Positive patch test reactions to substances used for topical treatment were found as well. Routines including liberal patch testing for this group of patients are suggested.

Severe hypertrichosis of the external ear canal during minoxidil therapy

Minoxidil is a potent peripheral vasodilator used to treat patients with severe hypertension that is unresponsive to other medications. Hypertrichosis of the forehead, face, neck, shoulders, upper part of the arms, and legs is a frequent side effect that occurs in the majority of patients that use this drug. This phenomenon appears to be due to increased blood flow to hair follicles, with resultant excessive hair growth. We describe a patient with severe hypertrichosis of the external ear canal resulting in chronic otitis externa and hearing loss.

Allergies to ear moulds. A study of reactions encountered by hearing aid users to some ear mould materials

In recent years, a number of people have encountered some form of otitis externa due, it was suspected, to the use of acrylic ear moulds. The intention of this study was to discover whether the reaction was purely allergic or if it was due to various other causes. Having eliminated reactions due to ill-fitting ear moulds, friction sores or lack of hygiene, a study of 25 people with ear mould problems was carried out. These consisted of three groups; those who had no other ear or skin trouble, those who had existing otitis externa and/or other skin trouble, and those who suffered with ear infections or were prone to ear infections. A sample of the population who did not wear hearing aids was taken as a control.

Reversible, retinoid-induced secretion of canine ceruminous glands

The long-term (12 months) oral administration of the aromatic retinoid Ro 10-1670 (etretin) to dogs in relatively high doses of 5.0, 15.0 and 50.0/30.0 mg/kg/day was followed by acanthotic hyperplasia of the epidermis in the external auditory meatus and dose-dependent hypertrophy and/or hyperplasia of the canine ceruminous glands. These morphological changes were accompanied by a secretory stimulation on the ceruminous glands which was slight in the low-dose dogs but in the majority of the high-dose dogs reached a degree that was followed by secondary acute infectious inflammation. The alterations in the external auditory canal ceased almost immediately when treatment of dogs with the aromatic retinoid was stopped but recommenced when it was restarted.

Late effects of local anesthetics on tympanic membrane structure

With the rat tympanic membrane used as a model, various topical anesthetics in current clinical use (phenol, Bonain's liquid, and Xylocaine spray) were tested. Structural changes were observed for up to five months from the time of anesthetic application. The most protracted changes affect the lamina propria, which exhibits a pronounced thickening. The extent of the changes, however, differs according to the agent used; for example, phenol applied to discrete areas exhibited the least widespread changes. In the tympanic portion of the lamina propria, the connective tissue was loosely packed with less regularly arranged collagen fibers, while a tightly packed fiber bundle existed on the meatal side. It is inferred that the submucosal connective tissue layer is the portion of the connective tissue layer where the remodeling and reconstruction of the fibrous layer occur.

Modulation of mouse ear edema by cyclooxygenase and lipoxygenase inhibitors and other pharmacologic agents

Inhibitors of arachidonic acid (AA) metabolism and other pharmacologic agents were evaluated against ear edema produced in mice by tetradecanoylphorbol acetate (TPA) or AA. Drugs were administered orally and topically either 30 min prior to AA or 30 min after TPA, except for steroids which were administered 2.5-3 hr prior to AA. Several cyclooxygenase (CO) inhibitors including indomethacin, aspirin, piroxicam and timegadine were without effect when administered orally against either irritant; the same drugs inhibited TPA edema when they were administered topically. Mixed CO/lipoxygenase (LO) inhibitors, phenidone and BW755C, were active orally against AA edema (ED50S of 84 and 65 mg/kg, respectively) and against TPA edema (ED50S of 235 and 88 mg/kg, respectively). Phenidone was more active topically against AA edema (ED50, 0.1 mg/ear) than BW755C (ED50, 2.8 mg/ear); however, BW755C was more active topically against TPA edema (ED50, 0.2 mg/ear) than phenidone (ED50, 0.6 mg/ear). Methylprednisolone was very effective in the AA (oral ED50, 17 mg/kg; topical ED50, greater than 1 mg/ear) and TPA models (oral ED50, 4.3 mg/kg; topical ED50, 0.03 mg/ear. MK-447 was topically and orally effective only in the TPA model. Not surprisingly, drugs were more effective topically than orally in both mouse ear edema assays. The models were somewhat selective for CO and CO/LO inhibitors; however, dapsone was orally effective in the ear models, and a number of mediator antagonists and CNS drugs, especially anti-psychotics, were topically active primarily against TPA edema. These models may be useful for the detection of in vivo activity of CO/LO or 5-LO inhibitors.

Ear piercing--a cause of nickel allergy in schoolgirls?

960 schoolgirls of ages 8, 11 and 15 years were investigated regarding the frequency of ear piercing and the prevalence of nickel and cobalt allergy. 72% had had their ears pierced. The prevalence of nickel allergy in the whole material was 9%, among girls with pierced ears 13% and among those without pierced ears 1%. The results show that the prevalence of nickel allergy is just as high among schoolgirls as among adult women. There is a clear relationship between ear piercing and induction of nickel allergy. Prophylactic measures to reduce the prevalence of nickel allergy should be directed against this risk factor.

Toxic and drug-induced disorders in otolaryngology

Toxic and drug-induced disorders can be identified with alarming frequency. Otolaryngologists in the past were acutely aware of the ototoxic properties of certain medications but, with today's increasing armamentarium, new problems arise that may have an iatrogenic cause.

Pharmacological study of cantharidin-induced ear inflammation in mice

Cantharidin applied to the Swiss mouse ear induced a clearly observable inflammatory reaction after 6 hr, maximal after 24 hr, and persisting several days. Desonide and hydrocortisone strongly inhibited the acute (6 hr) and delayed (24 hr) phases after their local application, while, after oral treatment, a reduction in the acute edema was obtained only when using high doses. The cutaneous application of high doses of mepyramine, disodium cromoglycate, methysergide, and (at a quite lower level) cimetidine reduced the 6-hr inflammation. Phenylbutazone and acetylsalicylic acid showed little activity on the same phase after their cutaneous administration. All the nonsteroid compounds produced little or no effect on the 24-hr inflammation after their cutaneous application and were quite inactive on both phases after their systemic treatment. The cantharidin-induced inflammatory reaction in Swiss mouse seems thus to be characterized by two phases. The chronic delayed phase is an example of chronic inflammation without the involvement of immunological processes. Histamine and serotonin might be involved in the acute inflammation.

Lymphadenoid structure induced by gold hypersensitivity

An allergic sensitivity to gold earrings produced a lymphadenoid reaction with germinal centers in the dermis of the pierced earlobes of a 21-year-old woman, However, a patch test for 1% gold sodium thiomalate gave a long-lasting, clinically and histologically eczematous response. Electron microscopic and cytochemical observations showed that non-T lymphocytes and plasma cells were dominant in the dermal infiltrate of the lesions, whereas lymphocytes with convoluted nuclei (which were probably T cells) and monocytes invaded the epidermis in the patch test site. These findings suggest that continuous exposure of the dermis to gold in a sensitized person may induce a lymphadenoid cellular reaction different from the histologic findings seen after contact with the epidermis.

Experimentally induced otitis and audiogenic seizure in the mouse

Audiogenic seizures can be induced in genetically non-susceptible 17-day-old mice (Rb/3 strain) with various results. Priming only induces 9% of seizures, auditory insulation 3,8%, while experimental otitis leads to 79%. The hypothesis concerning disuse supersensitivity subsequent to acoustic deprivation was not confirmed by the experiment. However, modification of acoustic transmission at middle ear level induced by otitis or ear physical damage during the maturation period, exposes the upper nervous centers to intense stimulation to which the reaction is a recruiting response.

Physician and patient-induced diseases in otolaryngology office practice

"Theragenic" diseases produce common ENT complaints. They are frequently and predictably induced by self or physician treatment. Fifteen percent of first office visits in various practice situations stem from therapeutically-induced disease. Self treatment by cotton tip applicator ear cleaning, nasal decongestants, mouth washes, and lozenges produce symptoms which mimic other etiologies. Prescription medications produce diseases with ENT symptoms which are based on pharmacologic toxicity, multiple drug therapy, drug intolerance, and occasional idiopathic hypersensitivity. The treatment of these diseases is simple and effective once their etiology is discovered.