Ears To You Costa Rica

1
Ears To You Costa Rica!

• Renee A. Walker, D.O.
• Pediatric Otolaryngologist
• Joplin, Missouri

2
Educational Objectives

• Identify the clinically important characteristics
  of the different forms of external otitis.
• Discuss the current bacterial resistance
  patterns.
• Methods of treatment.

3
Otitis Externa

• Acute diffuse bacterial otitis externa (AOE)
• Furunculosis
• Viral otitis externa (Ramsey-Hunt Syndrome)
• Eczematous otitis externa
• Fungal otitis externa
• Chronic otitis externa
• Foreign body

4
External Auditory Canal (EAC) Anatomy

• EAC is a skin-lined tube with
• Cartilaginous portion (outer one third)
• Skin is thick and adherent
• Cerumen production
• Bony portion (inner two thirds)
• Skin is thin, sensitive to palpation, and
  susceptible to trauma
• EAC can be straightened by pulling pinna backward
  and upward

Photo courtesy of Michael Hawke, MD.
5
External Auditory Canal Function

• Primary role - Protective Curved shape prevents
  direct entry from exterior (bugs, debris, trauma)
• Secondary role -sound amplification
• Self-cleanses via epithelial migration

Photos courtesy of Michael Hawke, MD.
6
Cerumen Protective Effects in the EAC

• Produced in outer third of external
  auditorycanal (EAC)
• Contains lysozymes, immunoglobulins, and
  polyunsaturated fatty acids
• Is slightly acidic (pH 6.1)
• Controls the growth of some bacteria, especially
  Pseudomonas aeruginosa
• Has a waterproofing effect
• Reduces maceration of the EAC

7
Microbiology of the Healthy External Auditory
Canal
Distribution of All Recovered Microorganisms
288/310 (93)
Gram-positive organisms
286/314 (92)
14/310 (4.5)
Gram-negative organisms
3/314 (1)
8/310 (2.5)
Fungal isolates
23/314 (7)
Candida, Curvularia, or Penicillium sp. Stroman
DW, et al. Laryngoscope. 20011112054-2059.
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Microbiology of the Healthy External Auditory
Canal
288 Gram-Positive Organisms

• Staphylococcus sp
• S auricularis
• S capitis
• S epidermidis

66
13
Turicella otitidis
7
14
Alloiococcus otitis
Other
Stroman DW, et al. Laryngoscope.
20011112054-2059.
9
Microbiology of the Healthy External Auditory
Canal
14 Gram-Negative Organisms

• Pseudomonads
• P aeruginosa
• P stutzeri

28.6

• Moraxella sp
• M osloensis
• M catarrhalis

Proteus mirabilis
7.1
35.7
28.6
Other
Stroman DW, et al. Laryngoscope.
20011112054-2059.
10
Diagnosis of Bacterial Acute Otitis Externa

• History
• Pain
• Tenderness
• Itching
• Hearing loss
• Physical examination
• Swollen external auditory canal
• Erythema (variable)
• Watery, scant exudate
• Pronounced tenderness

Photo courtesy of Michael Hawke, MD.
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Ouchie!
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Acute Otitis Externa Risk Factors and
Pathogenesis

• Usually diffuse and bacterial
• Summer season (year-round in tropical and
  subtropical regions)
• High temperature
• High humidity
• Prolonged water exposure (ie, swimming)
• Alkalinization of the external auditory canal
• Canal trauma

Photo courtesy of Michael Hawke, MD.
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Simply Sydney
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Otomycosis
Photo courtesy of Michael Hawke, MD.
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Viral Acute Otitis Externa Herpes Zoster
Photo courtesy of Michael Hawke, MD.
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Bacterial Acute Otitis Externa (AOE) Types

• Furunculosis
• Abscess in lateral portion of external auditory
  canal
• May require systemic antibiotic therapy
• Think comm. Acquired MRSA!

Photo courtesy of Michael Hawke, MD.
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Bacterial Acute Otitis Externa (AOE) Types

• Necrotizing
• Occurs in diabeticand other immunocompromised
  patients
• IV,PO, Topical Quinolones
• Can be fatal
• Requires urgent referral to a specialist

Photo courtesy of Michael Hawke, MD.
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Microbiology of Acute Otitis Externa
Organisms () Recovered During a Series of
Clinical Trials
Gram-positives Staphylococcus sp 27.4 Coryneform
s 12.1 Streptococcus Enterococcus 3.9 Bacillu
s Paenibacillus 1.5 Micrococcus 0.24 Actinomy
cetes 0.14
Gram-negatives Pseudomonas aeruginosa 37.7 Ente
robacteriaceae Vibrionaceae 8.5 Nonfermentativ
e Gram-negatives 3.9 Other Pseudomonads 2.3 Oth
er Gram-negatives 0.45
Gram-positives 45.3
Gram-negatives 52.9
Fungi and Yeast 1.7
Roland P, Stroman D. Laryngoscope.
20021121166-1177.
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Happy Easter
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Principles of Treating Bacterial AcuteOtitis
Externa

• Clean the canal
• Deliver the antibiotic - wick
• Topical therapy
• Suitable pain management

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Aural Toilet

• Suction and microscopic removal of debris
• Irrigation
• Dry mopping

22
Topical Therapy

• Topical antibiotic therapy to cover Gram and ,
  especially pseudomonads
• Aminoglycosides
• Fluoroquinolones
• Systemic antibiotics generally not required for
  uncomplicated cases

23
Prophylaxis of Acute Otitis Externa

• Aural hygiene
• Dry ear after swimming
• Appropriate for individuals with recurrent
  infections
• Several commercial products available
• Solution of ½ alcohol (if tympanic membrane
  intact) or H2O and ½ vinegar
• OUCH!

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Potential Advantages of Ototopical Antibiotics

• Deliver a high concentration of the antibiotic to
  the infection site, which
• Increases the likelihood of successful pathogen
  eradication
• Shortens duration of therapy
• Reduces the potential for antibiotic resistance
  and treatment failure
• Minimal systemic effects
• Lower cost

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Potential Advantages of Antibiotic-Steroid
Combination Products

• Reduce duration of drainage
• Enhance treatment adherence
• Have potential for improved efficacy
• Provide cost savings
• Reduce duration of pain1

1. Pistorius B, et al. Infect Dis Clin Pract.
19998387-395.
26
Potential Disadvantages ofOtotopical Agents

• Local discomfort
• pH
• Alcohol
• Temperature
• Some antibiotics (eg, gentamicin) may be ototoxic
  when tympanic membrane is perforated
• Otorrhea or canal edema may prevent direct
  contact
• Topical sensitization (especially neomycin)
• Unfavorable alteration of external auditory canal
  microenvironment (increased alkalinity)

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Ototopical Therapeutic Options

• Without an antibiotic
• With an antibiotic
• Aminoglycoside
• Fluoroquinolone
• With an antibiotic a steroid
• With Antibacterial antifungal analgesic
• Other considerations
• Low pH
• Low viscosity

28
Ototopical Agents Without Antibiotics

• Acetic acid hydrocortisone
• VoSol Otic and VoSol propylene glycol
• 1 hydrocortisone
• pH 3.0
• Acetic acid
• Domeboro Otic Solution
• 2 acetic acid in modified Burows
  solution(aluminum acetate)
• pH 4.5 to 6.0
• HC Otic
• 2 acetic acid in

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Glamour Girl
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Aminoglycoside Agents

• Neomycin, gentamicin, tobramycin
• Active against many common otic pathogens
• Pseudomonas aeruginosa
• Staphylococcus aureus
• Other Gram-negative aerobic bacteria
• Both otologic and ophthalmic preparations are
  available and widely used

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Aminoglycosides Ototoxicity

• Polymyxin B neomycin hydrocortisone
• Inner ear toxicity documented following middle
  ear application in guinea pigs,1 chinchillas,2
  and primates3

1. Barlow DW, et al. Acta Otolaryngol (Stockh).
1995115231-235. 2. Wright CG, Meyerhoff WL. Am
J Otolarygnol. 19845166-176. 3. Wright CG, et
al. Am J Otol. 1987856-60.
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Aminoglycosides Neomycin Sensitization

• Incidence increasing due to widespread,
  long-standing use1-4
• Cross-reactivity with other aminoglycosides4
• Routine use not recommended because of high risk
  for sensitization4

1. Rasmussen PA. Acta Otolaryngol (Stockh).
197477344-347. 2. Fraki JE, et al. Acta
Otolaryngol (Stockh). 1985100414-418.
3. Smith IM, et al. Clin Otolaryngol.
199015155-158. 4. Van Ginkel CJW, et al. Clin
Otolaryngol. 199520326-328.
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Aminoglycosides Vestibular Toxicity

• Commonly recognized with systemic
  aminoglycosides1
• Damage is irreversible with confirmed
  histopathologic changes in the vestibular end
  organs2
• Acute symptoms may include disequilibrium or
  imbalance and may be unrecognized3

1. Govaerts PJ, et al. Toxicol Lett.
199052227-251. 2. Nakashima T, et al. Acta
Otolaryngol. 2000120904-911.3. Halmagyi GM, et
al. Otolaryngol Head Neck Surg. 1994111571-574.
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Aminoglycosides Vestibular Toxicity (Contd)

• Vestibular toxicity with the use of commercial
  ototopical aminoglycosides in humans has
  increasingly been documented through1-3
• Perforated tympanic membranes
• Tympanostomy tubes

1. Marais J, Rutka JA. Clin Otolaryngol.
199823360-367. 2. Bath AP, et al. Laryngoscope.
19991091088-1093.3. Kaplan DM, et
al. Laryngoscope. 2002112689-695.
35
Aminoglycosides Cochlear Toxicity

• High-frequency hearing is most affected1 and
  hearing loss is permanent2
• Susceptibility is linked to a genetic mutation3
• 3.4 of practicing otolaryngologists have
  reported cases of irreversible hearing loss
  linked to aminoglycoside ear drops4
• Of increasing medicolegal concern, especially
  with use in patients with tympanic membrane
  perforations or tympanostomy tubes5,6

1. Fausti SA, et al. J Infect Dis.
19921651026-1032. 2. Barlow DW, et al. Acta
Otolaryngol (Stockh). 1994115231-235.3.
Fischel-Ghodsian N, et al. Am J Otolaryngol.
199718173-178. 4. Lundy LB, Graham MD. Am J
Otol. 199314141-146. 5. Rutka J. ENT J Suppl.
20038215. 6. Haynes DS. ENT J Suppl. 20038213.
36
Fluoroquinolone Ototopical Agents No
Ototoxicity

• Lack of ototoxicity is well documented in
  published in vivo andin vitro studies
• 0.1 mL of 0.75 ciprofloxacin BID for 7 days into
  guinea pigmiddle ear1
• 100 mg/kg/day ciprofloxacin orally in rats for 2
  weeks2
• Ciprofloxacin hydrocortisone is least toxic
  otic drop in cultured outer hair cells3
• Appropriate spectrum of antimicrobial activity,
  including pathogenic organisms found in AOE1,4

1. Brownlee RE, et al. Arch Otolaryngol Head Neck
Surg. 1992118392-396. 2. Nomura M, et al. Drug
Res. 199242398-403. 3. Russell PT, et al. Acta
Otolaryngol. 2001121135-139. 4. Roland PS,
Stroman DW. Laryngoscope. 20021121166-1177.
37
Ototopical SteroidsNo Ototoxicity

• Lack of ototoxicity is well documented in
  published in vivo and in vitro studies
• Ciprofloxacin hydrocortisone is least toxic
  otic drop in cultured outer hair cells1
• Trans-tympanic injection of 500 ?L of 0.4
  dexamethasone phosphate into guinea pig middle
  ear weekly for 4 weeks2
• Trans-tympanic injection of 100 ?L of 1
  suspension of dexamethasone base or phosphate
  daily for 5 days3
• Safety and potent anti-inflammatory activity make
  ototopical steroids ideal agents for treating
  acute otitis externa, salicylate-induced
  ototoxicity, and sudden sensorineuronal hearing
  loss

1. Russell PT, et al. Acta Otolaryngol.
2001121135-139. 2. Shirwany NA, et al. Am J
Otol. 199819230-235. 3. Parker FL, James GWL. J
Pharm Pharmacol. 197830236-239.
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The Next GenerationCiprofloxacin Dexamethasone

• Ciprofloxacin HCl 0.3 dexamethasone 0.1
  (Ciprodex Otic Suspension)
• Proposed indications AOE and AOMT with otorrhea
• pH 4.5 (range, 4.0-5.5)
• Viscosity 1-10 cps

Investigational agent. AOE acute otitis
externa AOMT acute otitis media with
tympanostomy tubes cps centipoise.
39
Ciprofloxacin Dexamethasone vs PNHin AOE
Clinical Cure Rate
90.9
ofPatients With Clinical Cure
83.9
(n199)
(n197)
PNH polymyxin B 10,000 IU/mL, neomycin 0.35,
hydrocortisone 1.0 AOE acute otitis
externa. P .0375.
Data on file Alcon Laboratories, Inc.
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Ciprofloxacin 0.3 Dexamethasone 0.1 Dosing
and Administration for AOE

• Shake well and warm solution to body temperature
  before instilling
• For patients 6 months old, place 4 drops in
  affected ear BID x 7 days
• Tragal pump

AOE acute otitis externa. Data on file Alcon
Laboratories, Inc.
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Snack Time
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Overview of Chronic Otitis Media (Chronic
Draining Ear)

• Chronic nonsuppurative otitis media
• Cholesteatoma
• Dry perforation
• Chronic suppurative otitis media
• Without cholesteatoma
• With cholesteatoma

43
Acute Otitis Media With Tympanostomy Tubes Risk
Factors and Pathogenesis

• Predisposing factors include
• Upper respiratory infection
• Water exposure?

Photo courtesy of Michael Hawke, MD.
44
Diagnosis of AOMT Signs and Symptoms
Acute Otitis MediaWith Tympanostomy Tubes
Acute OtitisMedia
?

• Acute purulent otorrhea
• Ear pain
• Fever
• Other systemic signs

?
?
?
Dohar JE, et al. Arch Otolaryngol Head Neck
Surg. 1999125537-545
45
AOMT Bacteriology
30
25
20
of Episodes
15
10
5
0
?- hemolytic
S pneumoniae
H influenzae
M catarrhalis
S aureus
P aeruginosa
Streptococcus
Pathogenic Organisms
AOMT acute otitis media with tympanostomy
tubes. Includes mixed infections blue bars
middle ear pathogens white bars external
auditory canal pathogens.
Dohar JE, et al. Arch Otolaryngol Head Neck
Surg. 1999125537-545.
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Are We Sure about the Pathogens?
47
Distribution of AOMT Pathogens by Age
of Pathogens
?
Age, Years
AOMT acute otitis media with tympanostomy
tubes. Dohar JE, et al. Arch Otolaryngol Head
Neck Surg. 1999125537-545.
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Resistant Vermin
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Resistance Patterns

• S. pneumoniae 30 up to 60 in daycare setting
• 45 resistance to sulfa
• H. influenza -- 40 beta-lactamase producers
• 25 resistance to sulfa
• M. catarrhalis -- 98 beta-lactamase producers
• 90 resistance to sulfa

50
Treating AOMT Antibiotics

• Ototopical antibiotics alone are appropriate
  therapy in uncomplicated cases
• Fluoroquinolones
• Adjunctive systemic antibiotics may be used
• Ototopicals have failed after 7 days
• Snotty nose
• When infection has spread beyond middle ear or
  external ear canal
• Non- compliance with ototopical therapy
• Special populations (eg, immunocompromised
  patients) require additional consideration

.
AOMT acute otitis media with tympanostomy
tubes. Goldblatt EL. Pediatr Infect Dis J.
200120116-119.
51
Treating AOMT Other Procedures

• Exudate removal, aural toilet
• Dry mopping
• Suctioning
• Irrigation
• Stenting swollen external auditory canal with a
  wick for 48 to 72 hours may improve delivery of
  topical medication

AOMT acute otitis media with tympanostomy
tubes.
Photo courtesy of Seth Pransky, MD.
52
Why Ototopicals Fail

• Failure of delivery
• Administration
• Compliance
• Technique
• Lack of tragal pump
• Anatomic
• Otorrhea
• Granulation tissue
• Mucosal edema
• Sequestered nidus

53
Why Ototopicals Fail

• Reinfection
• From external auditory canal
• Eustachian tube reflux
• Lack of middle ear pillow
• Diseases of nasopharynx, sinuses, adenoids
• Immunological defects
• Biofilms
• Lack of antibiotic efficacy

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Fungal otitis externa Otomycosis

• Opportunistic infections
• FOE Candida gets out of hand
• Otomycosis sapprophytic overgrowth on a cerumen
  media

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Feeding time
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Fungal otitis externa treatment

• Zinotic
• antibiotic, antifungal (choloroxylenol 0.1),
• analgesic (pramoxine Hcl 0.5)
• zinc acetate 0.1

57
Tympanostomy Tube Granulation Diagnosis

• Presents as bloody or recurrent otorrhea
• Tube frequently cannot be seen on physical
  examination
• Suspect this when short-term tx fails

Photo courtesy of Michael Hawke, MD.
58
Chronic eczemoid otitis externa

• Old standby treat acute infection
• Maintain with triamcinalone cream and prednisone
  ophthalmic drops
• New treatment
• DermOtic oil
• Fluocinolone acetonide 0.01 in peanut oil
  suspension

59
Tympanostomy Tube Granulation Treatment

• Topical antibiotics with steroids are most
  effective
• Systemic antibiotics are rarely needed

Photo courtesy of Seth Pransky, MD.
60
Potential Etiology of TympanostomyTube
Granulation

• Foreign body reaction
• Granulation within lumen of tube
• Extruding tube
• Tube on tympanic membrane or in external
  auditory canal
• Entrapped debris under flange of tube
• Infectious
• Bacteriology Staphylococcus, Pseudomonas

61
Ciprofloxacin Dexamethasone vs Ofloxacin in
AOMT Shorter Time to Cessation of Otorrhea

• Median No. of Days to Cessation of Otorrhea

6
Days
4
(n171)
(n180)
AOMT acute otitis media with tympanostomy
tubes. P .0187.
Data on file Alcon Laboratories, Inc.
62
Summary

• External Otitis is a big family
• Know which type you are treating
• PO think resistance
• Topicals think pseudomonas, usual cast of
  characters
• Combo therapy

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