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

Antibiotics versus non-antibiotic treatments for acute otitis externa: A systematic review and meta-analysis

BACKGROUND

Otitis externa is a condition causing inflammation of the outer ear canal, which presents with itching, discharge and pain. Most cases of acute otitis externa are caused by bacterial infection and are thus treated with antibiotics. This systematic review and meta-analysis of randomised controlled trials aims to assess the effectiveness of topical non-antibiotic treatments compared to topical antibiotic treatment for the treatment of acute otitis externa.

METHODS

Systematic review and meta-analysis databases searched: Cochrane Library including ClinicalTrials.gov; MEDLINE; World Health Organisation International Clinical Trials Registry Platform and Web of Science to identify randomised clinical trials evaluating topical antibiotics and topical non-antibiotic agents in adults and children with acute otitis externa. Non-antibiotic therapeutics for comparison with topical antibiotics included antiseptics, steroids, non-pharmaceuticals and astringents.

RESULTS

Seventeen trials were eligible for inclusion, with 10 combined in meta-analysis. Data could be pooled comparing antiseptic and steroid monotherapies with topical antibiotic agents. There were no significant differences in cure rates in any pairwise comparisons. Individually, the majority of studies favoured topical antiseptics or steroids over antibiotics, however these differences were not significant when pooled in meta-analysis.

CONCLUSION

Antiseptic, steroid and antibiotic monotherapies are all effective for the management of acute otitis externa. There is insufficient evidence to suggest that topical antiseptic or steroid agents are superior or inferior to topical antibiotics.

Classical versus chemometrics tools for spectrophotometric determination of fluocinolone acetonide, ciprofloxacin HCl and ciprofloxacin impurity-A in their ternary mixture

Green, simple, accurate and robust univariate and chemometrics assisted UV spectrophotometric approaches have been adopted and validated for concurrent quantification of fluocinolone acetonide (FLU), ciprofloxacin HCl (CIP) together with ciprofloxacin impurity-A (CIP imp-A) in their ternary mixture. Double-divisor ratio spectra derivative (DDRD) method has been used for determination of FLU. On the other hand, the first (D¹) and second (D²) derivative approaches have been applied for the quantification of CIP and CIP imp-A, respectively. For the ratio difference (RD), derivative ratio (DR), and mean centering of ratio spectra (MC) methods, CIP and its impurity A have been simultaneously determined. The acquired calibration plots were linear over the concentration range of 0.6-20.0 μg/mL, 1.0-40.0 μg/mL and 1.0-40.0 μg/mL for fluocinolone acetonide, ciprofloxacin HCl, and ciprofloxacin impurity-A, respectively. The chemometrics methods namely; partial least squares (PLS) and artificial neural networks (ANN) were used for the concurrent determination of the three adopted components via using twenty-five mixtures as calibration set and fifteen mixtures as validation one. The investigated approaches were validated in accordance with International Council for Harmonisation (ICH) guidelines, and statistically compared with the official ones. The proposed methods were acceptably applied to the examination of FLU and CIP in their pure powders and pharmaceutical ear drops.

Two Validated Chromatographic Methods for Determination of Ciprofloxacin HCl, One of its Specified Impurities and Fluocinolone Acetonide in Newly Approved Otic Solution

Two sensitive, selective and precise chromatographic methods have been established for concomitant quantification of ciprofloxacin HCl (CIP), fluocinolone acetonide (FLU) along with ciprofloxacin impurity A (CIP-imp A). The first method was thin-layer chromatography (TLC-densitometry) where separation was accomplished using TLC silica plates 60 G.F254 as a stationary phase and chloroform-methanol-33%ammonia (4.6:4.4:1, by volume) as a developing system. The obtained plates were scanned at 260 nm over concentration ranges of 1.0-40.0, 0.6-20.0 and 1.0-40.0 μg band-1 for CIP, FLU and CIP-imp A, respectively. The second method was based on high-performance liquid chromatography using a Zorbax ODS column (5 μm, 150 × 4.6 mm i.d.) where adequate separation was achieved through a mobile phase composed of phosphate buffer pH 3.6-acetonitrile (45:55, v/v) at flow rate 1.0 mL min-1 with ultraviolet detection at 254 nm. Linear regressions were obtained in the range of 1.0-40.0 μg mL-1 for CIP, 0.6-20.0 μg mL-1 for FLU and 1.0-40.0 μg mL-1 for CIP-imp A. The suggested methods were validated in compliance with the International Conference on Harmonization guidelines and were successfully applied for determination of CIP and FLU in bulk powder and newly marketed otic solution.

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.

Effect of Physician Consultation on Satisfaction With Hearing Aid Use: A Randomized Clinical Trial

Importance

Hearing loss is one of the most common chronic disabilities in older adults, yet reported rates of users' satisfaction with hearing aids are low. Some believe that physicians can provide patients who are pursuing a hearing aid fitting an impartial opinion that will improve hearing aid satisfaction.

Objective

To determine whether a physician consultation increased or decreased patients' satisfaction with hearing aids compared with patients undergoing hearing aid fitting with a dispensing audiologist alone.

Design, Setting, and Participants

This multicenter, parallel-group, standard regimen-controlled, randomized clinical trial was conducted in offices of audiologists, family physicians, and a hospital-based neurotologist in Vancouver, British Columbia, Canada, and recruited participants from July 2016 to December 2020 with a 3-month postintervention follow-up. The final data analysis was conducted on March 25, 2022. Adult first-time hearing aid users with averaged sensorineural hearing losses of more than 25 dB were prospectively allocated by random number generation to control and intervention groups. Participants were excluded from analysis if they did not attend follow-up or complete the study questionnaire.

Interventions

Control participants were followed up solely by their dispensing audiologist. The intervention group attended a single structured visit with a physician in addition to their audiologist's determined follow-up.

Main Outcomes and Measures

Primary outcome: hearing aid satisfaction 3 months postfitting as measured by the Satisfaction with Amplification in Daily Life (SADL) questionnaire. Secondary outcome: number of returned hearing aids. Prerecruitment null hypothesis: no intergroup difference in postfitting hearing aid satisfaction. Intergroup difference in mean SADL questionnaire scores analyzed by effect size and the Student t test and proportion of returned hearing aids by the Fischer exact test.

Results

A total of 133 participants (mean [SD] age, 70.9 [8.5] years; 64 women [48.1%]) were recruited. Of these, 51 randomized to the control group (mean [SD] age, 71.7 [8.3] years; 28 women [54.9%]) and 42 to the physician intervention (mean [SD] age, 69.9 [7.6] years; 17 women [40.5%]) had results that were analyzed. There was no clinically meaningful intergroup difference in participants' SADL scores (control: mean [SD] score, 5.33 [0.72]; physician consultation: mean [SD] score, 5.35 [0.61]), the mean difference of 0.02 (95% CI, -0.25 to 0.29), or returned hearing aids (control, 1; physician consultation, 0).

Conclusions and Relevance

The results of this randomized clinical trial suggest that a physician consultation that is focused on hearing change does not alter a patient's satisfaction with hearing aids 3 months postfitting.

Trial Registration

ClinicalTrials.gov Identifier: NCT02842905.

Fingerprint Spectrophotometric Methods for the Determination of Co-Formulated Otic Solution of Ciprofloxacin and Fluocinolone Acetonide in Their Challengeable Ratio

Six spectrophotometric methods were developed to determine a new single-dose otic solution known as "Otovel®," which consists of two components: the major one is ciprofloxacin (CIP) and the minor is fluocinolone acetonide (FLU). The ratio of (CIP) and (FLU) in Otovel® is 12 : 1, which is considered a challengeable ratio for UV determination. Thus, spectrum addition as a sample enrichment technique was required for the analysis of (FLU) low concentration. All these methods were capable of resolving the spectra for each component in D 0 belonging to the fingerprint resolution technique. The former absorptivity centering (a-centering) method was recently developed in 2018; it was effectively applied for its solution of both binary components in Otovel®, while another method, ratio subtraction (RS), is considered as an original resolution method that could be applied to determine only one component in mixtures. However, the other four methods that are related to their original method (RS) were extended ratio subtraction (EXRS), constant multiplication (CM), unified constant subtraction (UCS), and spectrum subtraction (SS). They were also easily applied for completing the quantification of binary mixture drugs present in Otovel®. The linearity ranges were found to be 3.0-15.0 μg/mL for (CIP) and (FLU), respectively. All results acquired from the proposed methods were successfully estimated according to ICH criteria and were statistically compared with official ones where no differences were noticed.

A pilot randomized controlled trial comparing bismuth iodine paraffin paste external ear pack and no ear pack after middle ear surgery

To pilot a substantive randomized control trial comparing post-operative external ear canal pack with no ear pack after middle ear surgery, 32 adults undergoing primary posterior bony canal wall preserving middle ear surgery were randomized to have either a bismuth iodoform paraffin paste pack or no ear pack post-operatively. Outcome measures included clinician- and patient-recorded visual analogue scale scores for ear signs and symptoms at 3 weeks and 3 months and audiometric findings at 3 months post-operatively. There was no statistically significant inter-group difference in 3-week clinician and patient cumulative scores for ear signs and symptoms. There was also no significant difference in graft take rate, appearance of ear canals and audiometric results in either group at 3 months. No difference in ear symptoms, clinician findings or hearing was demonstrated between patients with a post-operative pack compared to those without a pack following middle ear surgery in this pilot study.

Betamethasone augments the antifungal effect of menadione--towards a novel anti-Candida albicans combination therapy

The fluorinated glucocorticoid betamethasone stimulated both the extracellular phospholipase production and hypha formation of the opportunistic human pathogen Candida albicans and also decreased the efficiency of the polyene antimycotics amphotericin B and nystatin against C. albicans in a dose-dependent manner. Importantly, betamethasone increased synergistically the anti-Candida activity of the oxidative stress generating agent menadione, which may be exploited in future combination therapies to prevent or cure C. albicans infections, in the field of dermatology.

A meta-analysis of the efficacy of quinolone containing otics in comparison to antibiotic-steroid combination drugs in the local treatment of otitis externa

BACKGROUND

The term otitis externa denotes the inflammation of the external auditory canal and can be treated locally in the form of monotherapy or a combination drug.

OBJECTIVE

The aim of the present meta-analysis was to compare the efficacy of an antibiotic-steroid combination drug with that of monotherapy. According to current data, a comparable investigation based on network analysis does not exist.

METHODS

After systematically searching the PubMed, Medline, Medpilot, Web of Science and Embase electronic databases, 12 relevant randomized, controlled, clinical studies were identified involving 2682 evaluable patients with regard to the cure rate and seven publications with 1251 microbiologically assessable patients. The collected data were compared directly and indirectly by means of network analysis.

RESULTS

The direct comparison showed a trend towards the superiority of the monotherapy containing quinolone. The network analysis verified this tendency and demonstrated that pure quinolone drugs can achieve a significantly higher cure rate (OR: 1.29; 95% CI: 1.06-1.57; p = 0.01) and a significantly superior eradication rate (OR: 1.44; 95% CI: 1.03-2.02; p = 0.03) compared to combination drugs not containing quinolone. We found substantial heterogeneity (with I(2) up to 88.7%) between studies, presumably due to treatments applied in varying frequency, thus bearing on compliance and outcome.

CONCLUSION

With a level Ia evidence, this investigation validates the clinical benefit of quinolones as compared to classic combination drugs in the local treatment of acute otitis externa.

Otitis externa: a clinical review

This article provides a clinical overview of otitis externa, focusing on clinical aspects of the aetiology, diagnosis and management of this important and debilitating condition.

The management of otitis externa in UK general practice

Acute otitis externa is common and provides a heavy workload for general practitioners. We aim to determine the first-line treatment used by general practitioners in the management of otitis externa and subsequent second-line treatment in a hospital ENT clinic. In addition, this study aims to ascertain whether local and national guidelines are being followed appropriately. A prospective observational study on the management of otitis externa in consecutive patients referred to an ENT emergency clinic was undertaken. Data were collected and analysed on symptoms, initial management by general practitioners, findings and treatment in the ENT clinic. A total of 106 patients were studied. The mean duration of symptoms before presentation to clinic was 13 days; 42% of patients received no treatment by their GP prior to referral to the ENT emergency clinic. Only 14% of patients received topical antibiotics alone, whilst 44% received oral antibiotics, either alone or in conjunction with topical antibiotics by their GP. Of the 106 patients, 86% received topical antibiotics in the ENT emergency clinic and oral antibiotics were reserved for those presenting with complicated acute otitis externa. Topical antibiotics are associated with a decrease in disease persistence, whilst oral antibiotics are associated with an increase. However, general practitioners are prescribing oral antibiotics more often than required. There are few regional guidelines and no explicit national guidelines on the management of acute otitis externa for GPs to refer to. We suggest the implementation of national guidelines to aid clinical practice.

Comparison of steroid antibiotic pack and 10% ichthammol glycerine pack in relieving pain of acute otitis externa in children

OBJECTIVE

This study was carried out with the objective of comparing clinical efficacy of 10% ichthammol glycerine (IG) pack with steroid-antibiotic pack for relieving pain in cases of acute otitis externa.

MATERIALS AND METHODS

A prospective quasi-randomized clinical trial was completely carried out in 65 patients at Department of ENT and Head and Neck Surgery, TU Teaching Hospital, Kathmandu. Patients of less or equal to 12 years of age and both gender presenting in our outpatient department from October 2008 to December 2009 and diagnosed to have acute otitis externa was evaluated. Six patients were excluded from the study because of not meeting the inclusion criteria. Alternately IG and steroid antibiotic packing were done. For steroid antibiotic group, we use betnovate-N, a combination of betnovate sodium phosphate 0.1% and neomycin sulphate 0.5%. Before packing was carried out, pain was assessed using Wong Baker Scale. Statistical analysis was done using "Z" test of mean to compare average number of pain score and visits in two different groups.

RESULTS

There were 33 patients in IG pack group and 32 patients in steroid antibiotic group. In less than 4 years, there were 30 children and in more than 4 years children, there were 35 children. There was male predominance in both the treatment groups and disease was most common in age group less than 4 years. There was statistical significant decrease in number of visits in steroid group in both children less than and more than 4 years. There was also significantly less pain in children with steroid antibiotic group.

CONCLUSION

Use of steroid antibiotic pack in children presenting with acute otitis externa causes earlier relief of pain as well as significantly lesser number of visits. Thus, steroid antibiotic pack is better than 10% ichthammol glycerine packs in relieving pain in acute otitis externa in children.

Interventions for acute otitis externa

BACKGROUND

Acute otitis externa is an inflammatory condition of the ear canal, with or without infection. Symptoms include ear discomfort, itchiness, discharge and impaired hearing. It is also known as 'swimmer's ear' and can usually be treated successfully with a course of ear drops.

OBJECTIVES

To assess the effectiveness of interventions for acute otitis externa.

SEARCH STRATEGY

Our search for published and unpublished trials included the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources. The date of the most recent search was 6 January 2009.

SELECTION CRITERIA

Randomised controlled trials evaluating ear cleaning, topical medication or systemic therapy in the treatment of acute otitis externa were eligible.We excluded complicated acute otitis externa; otitis externa secondary to otitis media or chronic suppurative otitis media; chronic otitis externa; fungal otitis externa (otomycosis); eczematous otitis externa; viral otitis externa and furunculosis.

DATA COLLECTION AND ANALYSIS

Two authors assessed eligibility and quality.

MAIN RESULTS

Nineteen randomised controlled trials with a total of 3382 participants were included. Three meta-analyses were possible. The overall quality of studies was low.Topical antimicrobials containing steroids were significantly more effective than placebo drops: OR 11 (95% CI 2.00 to 60.57; one trial).In general, no clinically meaningful differences were noted in clinical cure rates between the various topical interventions reviewed. One notable exception involved a trial of high quality which showed that acetic acid was significantly less effective when compared with antibiotic/steroid drops in terms of cure rate at two and three weeks (OR 0.29 (95% CI 0.13 to 0.62) and OR 0.25 (95% CI 0.11 to 0.58) respectively).One trial of low quality comparing quinolone with non-quinolone antibiotics did not find any difference in clinical cure rate.No trials evaluated the effectiveness of ear cleaning.Only two trials evaluated steroid-only drops. One trial of low quality suggested no significant difference between steroid and antibiotic/steroid but did not report the magnitude or precision of the result. Another trial of moderate quality comparing an oral antihistamine with topical steroid against topical steroid alone found that cure rates in both groups were high and comparable (100% (15/15) and 94% (14/15) respectively at three weeks).

AUTHORS' CONCLUSIONS

There is a paucity of high quality trials evaluating interventions for acute otitis externa. The results of this systematic review are largely based on odds ratios calculated from single trials, most of which have very broad 95% confidence intervals because of small to modest sample sizes. The findings may not be wholly generalisable to primary care for a variety of reasons; only two of the 19 trials included in the review were conducted in a primary care population setting, and in 11 of the 19 trials ear cleaning formed part of the treatment (an intervention unlikely to be available in primary care). Despite these reservations, some meaningful conclusions can be drawn from the evidence available:Topical treatments alone, as distinct from systemic ones, are effective for uncomplicated acute otitis externa. In most cases the choice of topical intervention does not appear to influence the therapeutic outcome significantly. Any observed differences in efficacy were usually minor and not consistently present at each follow-up visit. Acetic acid was effective and comparable to antibiotic/steroid at week 1. However, when treatment needed to be extended beyond this point it was less effective. In addition, patient symptoms lasted two days longer in the acetic acid group compared to antibiotic/steroid.The evidence for steroid-only drops is very limited and as yet not robust enough to allow us to reach a conclusion or provide recommendations. Further investigation is needed.Given that most topical treatments are equally effective, it would appear that in most cases the preferred choice of topical treatment may be determined by other factors, such as risk of ototoxicity, risk of contact sensitivity, risk of developing resistance, availability, cost and dosing schedule. Factors such as speed of healing and pain relief are yet to be determined for many topical treatments and may also influence this decision.Patients prescribed antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun. Although patients are usually treated with topical medication for seven to 10 days it is apparent that this will undertreat some patients and overtreat others. It may be more useful when prescribing ear drops to instruct patients to use them for at least a week. If they have symptoms beyond the first week they should continue the drops until their symptoms resolve (and possibly for a few days after), for a maximum of a further seven days. Patients with persisting symptoms beyond two weeks should be considered treatment failures and alternative management initiated.