External auditory canal pH in chronic otitis externa

Impact of Reduced Acidic Earwax pH and Earwax-Determinant Genotypes in Acquired Middle Ear Cholesteatoma

OBJECTIVE

The development of acquired middle ear cholesteatoma is associated with a single nucleotide polymorphism, 538G>A, in the human adenosine triphosphate-binding cassette transporter C11 (ABCC11) gene, which is a determinant of the earwax morphotype, such as wet- and dry-type earwax; however, the mechanism underlying this association is unclear. We focused on the earwax pH and aimed to elucidate the mechanism between ABCC11 genotypes and acquired middle ear cholesteatoma.

STUDY DESIGN

Prospective observational study.

SETTING

Single-center, academic hospital.

METHODS

We recruited 40 patients with acquired middle ear cholesteatoma who underwent surgery and 115 controls with no history of middle ear cholesteatoma. We assessed the earwax pH and ABCC11 genotypes in all participants. Clinical information was collected from the patients with cholesteatoma.

RESULTS

The earwax pH was significantly less acidic in patients with cholesteatoma and those carrying wet earwax genotypes (ABCC11 538G/G or 538G/A) than in the controls and those carrying the dry earwax genotype (ABCC11 538A/A), respectively. Furthermore, earwax pH was significantly positively correlated with high preoperative cholesteatoma stages in the patients with cholesteatoma.

CONCLUSION

Our results show that the less acidic earwax pH was significantly related to the development and progression of acquired middle ear cholesteatoma. The less acidic earwax pH may play an important role in the mechanism underlying the association between acquired middle ear cholesteatoma and the ABCC11 gene at site 538.

To Determine the PH of External Auditory Canal in Otitis Externa: A Prospective Observational Study in a Tertiary Health Care Centre

Otitis externa is an inflammatory condition of the external auditory canal which occurs due to any trauma, changes in the PH of the skin of external auditory canal. The normal PH of the external auditory canal skin should be in the acidic medium. This inhibits the growth of certain infectious microorganisms. Once the external canal skin PH becomes alkaline, the chances of inflammation of the skin increases. To assess the pH of the external auditory canal in cases of otitis externa with secretion and compare the treatment efficacy of treating it with topical anti-inflammatory like ichthammol glycerine, topical steroid cream and oral antibiotics. A prospective observational study involved a total of 120 patients who came with symptoms and signs of external otitis. pH of external canal was measured during first visit and at 42 days. The patients were divided into three groups. First group was treated with Ichthammol glycerine, second group was treated with Ichthammol glycerine with topical steroid cream and third group was treated with oral antibiotics with topical steroid cream. Patients were analyzed based on severity score during first visit, at 7 days, at 21 days and 42 days. This study involved 64(53.3%) patients were male and 56(46.7%) were females. The mean age group involved in the study was 42.50 years. The mean PH value in the external auditory canal during the first visit was alkaline (6.09) and the mean PH value at 42 days was changed to acidic (4.95) which was statistically significant (p = 0.00). There was significant reduction in the severity score in the oral antibiotic with topical steroid cream, followed by IG with topical steroid cream followed by Ichthammol glycerine (p = 0.001). In this study we have analyzed the pH level favorable in causing otitis externa and the best available treatment for the same. It has been observed that the alkaline Ph is more favorable in causing otitis externa. Efficacy of Topical corticosteroid with antibiotics is maximum in the management of otitis externa.

Effect of an ear cleaner instillation containing lipacids in a model of re-acidification of the external auditory canal in dogs

Background

In humans, the acidic pH of the ear canal plays a protective role against infection and a change towards alkalinity of the external auditory canal (EAC) is a local factor in the progression of acute to chronic otitis externa (OE). The use of acidic preparations alone for treatment of OE without concurrent antibiotic use is well‐documented in humans. In dogs, only one study has investigated the EAC pH in healthy dogs and in dogs with OE, and investigations to understand the role of EAC pH in the pathogenesis of canine OE are lacking.

Hypothesis/objectives

To obtain physiological EAC pH values in beagle dogs. To develop a model of re‐acidification of the EAC in dogs and to investigate how an acidic solution may accelerate the return to a physiological pH.

Animals

Ten healthy beagle dogs in a laboratory setting.

Materials and Methods

A model of re‐acidification of the EAC was developed by instillation of a pH 10.1 phosphate‐buffered saline (PBS) solution and the subsequent acidic effect of an ear cleaner containing lipacids was evaluated in this model.

Results

Mean physiological EAC pH was 6.12 (± 0.36). EAC re‐acidification took up to 9 h in this model. Mean pH values dropped immediately to 6.38 (± 0.27) on ears treated with an acidic ear cleaner. No abrupt drop was observed of the mean pH values for the control ears.

Conclusion and clinical importance

This study confirms that physiological EAC pH in dogs is acidic. This model of re‐acidification of the EAC pH allows investigations on acidic properties of topical ear products in healthy ears.

Background – In humans, the acidic pH of the ear canal plays a protective role against infection and a change towards alkalinity of the auditory canal (EAC) is a local factor in the progression of acute to chronic otitis externa (OE). The use of acidic preparations alone for treatment of OE without concurrent antibiotic use is well‐documented in humans. In dogs, only one study has investigated the EAC pH in healthy dogs and in dogs with OE, and investigations to understand the role of EAC pH in the pathogenesis of canine OE are lacking.

Hypothesis/objectives –To obtain physiological EAC pH values in beagle dogs. To develop a model of re‐acidification of the EAC in dogs and to investigate how an acidic solution may accelerate the return to a physiological pH.

Conclusion and clinical importance – This study confirms that physiological EAC pH in dogs is acidic. This model of re‐acidification of the EAC pH allows investigations on acidic properties of topical ear products in healthy ears.

Cerumen Management: An Updated Clinical Review and Evidence-Based Approach for Primary Care Physicians

Objective: To provide family physicians with a practical, evidence-based approach to managing patients with cerumen impaction. Methods: MEDLINE, The Cochrane Library, and the Turning Research Into Practice (TRIP) database were searched for English-language cerumen impaction guidelines and reviews. All such articles published between 1992 and 2018 were reviewed, with most providing level II and III evidence. Results: Cerumen impaction is a common presentation seen in primary care and cerumen removal is one of the most common otolaryngologic procedures performed in general practice. Cerumen impaction is often harmless but can be accompanied by more serious symptoms. Cerumenolytics and irrigation of the ear canal are reasonable first-line therapies and can be used in conjunction or isolation. If irrigation and cerumenolytics are contraindicated, manual removal is appropriate, but the tools necessary are not commonplace in primary care clinics and specialized training may be required to prevent adverse outcomes. Conclusion: Family physicians play a key role in the assessment and management of cerumen impaction and are well equipped to do so. Knowledge of the available techniques for cerumen removal as well as their contraindications ensures that cerumen is removed safely and effectively. When cerumen removal cannot be removed safely in a primary care setting, referral to Otolaryngology-Head and Neck Surgery is appropriate.

Otitis Externa

BACKGROUND

Otitis externa has a lifetime prevalence of 10% and can arise in acute, chronic, and necrotizing forms.

METHODS

This review is based on publications retrieved by a selective search of the pertinent literature.

RESULTS

The treatment of acute otitis media consists of anal- gesia, cleansing of the external auditory canal, and the appli- cation of antiseptic and antimicrobial agents. Local antibiotic and corticosteroid preparations have been found useful, but there have been no large-scale randomized controlled trials of their use. Topical antimicrobial treatments lead to a higher cure rate than placebo, and corticosteroid preparations lessen swelling, erythema, and secretions. Oral antibiotics are indi- cated if the infection has spread beyond the ear canal or in patients with poorly controlled diabetes mellitus or immuno- suppression. Chronic otitis externa is often due to an under- lying skin disease. Malignant otitis externa, a destructive infection of the external auditory canal in which there is also osteomyelitis of the petrous bone, arises mainly in elderly diabetic or immunosuppressed patients and can be life- threatening.

CONCLUSION

With correct assessment of the different types of otitis externa, rapidly effective targeted treatment can be initi- ated, so that complications will be avoided and fewer cases will progress to chronic disease.

Otic drug delivery systems: formulation principles and recent developments

Disorders of the ear severely impact the quality of life of millions of people, but the treatment of these disorders is an ongoing, but often overlooked challenge particularly in terms of formulation design and product development. The prevalence of ear disorders has spurred significant efforts to develop new therapeutic agents, but perhaps less innovation has been applied to new drug delivery systems to improve the efficacy of ear disease treatments. This review provides a brief overview of physiology, major diseases, and current therapies used via the otic route of administration. The primary focuses are on the various administration routes and their formulation principles. The article also presents recent advances in otic drug deliveries as well as potential limitations. Otic drug delivery technology will likely evolve in the next decade and more efficient or specific treatments for ear disease will arise from the development of less invasive drug delivery methods, safe and highly controlled drug delivery systems, and biotechnology targeting therapies.

Change of External Auditory Canal pH in Acute Otitis Externa

Objectives

We investigated 1) the correlation between the degree of acute otitis externa (AOE) and a change of pH and 2) the recovery of pH after acidification compared to an antibiotic otic solution in AOE. A change of pH in the external auditory canal (EAC) is very important for the pathogenesis of otitis externa. Therefore, not only an antibiotic otic solution, but also acidification, is known to be a good treatment for AOE. However, pH has only been investigated in chronic otitis externa, and not in AOE.

Methods

This was a prospective randomized control study. Forty adult patients (56 ears) with AOE and 40 normal control subjects (80 ears) participated in this study. The severity of disease was graded as mild, moderate, or severe. The pH of each EAC was then measured. The patients were randomly assigned into 2 groups: one for vinegar irrigation and the other for topical antibiotics. The pH of the diseased ears was measured at 1 and 2 weeks after the treatment.

Results

The mean (±SD) pH for the normal control subjects was 5.4 ± 0.48, and the EAC lost its acidity proportionately to the degree of disease (p < 0.05). For both the vinegar irrigation and topical antibiotic groups, the acidity was restored dramatically (p < 0.05) at 1 and 2 weeks for the moderate and severe grades of otitis, but not for the mild grade. There was no difference in recovery between the 2 groups.

Conclusions

The EAC lost its acidity proportionately to the degree of disease in AOE. Vinegar irrigation and topical antibiotics were equally effective for restoration of pH.

The shape of the osseous external auditory canal and its relationship to chronic external otitis

BACKGROUND

In literature and based on clinical observations, the shape of the osseous external auditory canal (OEAC) has often been suggested to be an etiologic factor in chronic otitis externa (COE). However, to date, no evidence has been presented to confirm this correlation. The aim of this study was to see whether evidence of such a correlation exists, and if so, what shape of the OEAC is related to COE.

METHODS

Using CT scans of 2 groups of patients (with and without COE), a novel and easy to use method was introduced to measure 2 dimensions of the OEAC: the pretympanic recess (the depth (DPTR) and anterior curvature (ACPTR)). In addition, a descriptive classification of the entire OAEC was introduced.

RESULTS

The proposed method was demonstrated to be useful as excellent interobserver agreements were found (r = 0.89). No significant differences in the descriptive classifications of the OEAC were observed between COE and the non-COE patients. The DPTR was significantly deeper in COE patients. For the ACPTR, no significant differences were observed.

CONCLUSION

Based on a new method of determining the DPTR, we demonstrate that the DPTR is significantly deeper in COE patients and that the shape of the OEAC is thus of importance in the pathogenesis of COE.

Clinical Practice Guideline

Objective

This clinical practice guideline is an update and replacement for an earlier guideline published in 2006 by the American Academy of Otolaryngology—Head and Neck Surgery Foundation. This update provides evidence-based recommendations to manage acute otitis externa (AOE), defined as diffuse inflammation of the external ear canal, which may also involve the pinna or tympanic membrane. The variations in management of AOE and the importance of accurate diagnosis suggest a need for updating the clinical practice guideline. The primary outcome considered in this guideline is clinical resolution of AOE.

Purpose

The primary purpose of the original guideline was to promote appropriate use of oral and topical antimicrobials for AOE and to highlight the need for adequate pain relief. An updated guideline is needed because of new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group. The target patient is aged 2 years or older with diffuse AOE. Differential diagnosis will be discussed, but recommendations for management will be limited to diffuse AOE, which is almost exclusively a bacterial infection. This guideline is intended for primary care and specialist clinicians, including otolaryngologists–head and neck surgeons, pediatricians, family physicians, emergency physicians, internists, nurse practitioners, and physician assistants. This guideline is applicable in any setting in which patients with diffuse AOE would be identified, monitored, or managed.

Action Statements

The development group made strong recommendations that (1) clinicians should assess patients with AOE for pain and recommend analgesic treatment based on the severity of pain and (2) clinicians should not prescribe systemic antimicrobials as initial therapy for diffuse, uncomplicated AOE unless there is extension outside the ear canal or the presence of specific host factors that would indicate a need for systemic therapy. The development group made recommendations that (1) clinicians should distinguish diffuse AOE from other causes of otalgia, otorrhea, and inflammation of the external ear canal; (2) clinicians should assess the patient with diffuse AOE for factors that modify management (nonintact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state, prior radiotherapy); (3) clinicians should prescribe topical preparations for initial therapy of diffuse, uncomplicated AOE; (4) clinicians should enhance the delivery of topical drops by informing the patient how to administer topical drops and by performing aural toilet, placing a wick, or both, when the ear canal is obstructed; (5) clinicians should prescribe a non-ototoxic preparation when the patient has a known or suspected perforation of the tympanic membrane, including a tympanostomy tube; and (6) clinicians should reassess the patient who fails to respond to the initial therapeutic option within 48 to 72 hours to confirm the diagnosis of diffuse AOE and to exclude other causes of illness.

Role of pH of External Auditory Canal in Acute Otitis Externa

Prospective and interventional. We studied the pH of external auditory canal (EAC) in normal individuals and patients with acute otitis externa (AOE), its variation with change of temperature and humidity, different symptoms and number of symptoms at presentation (Day 0) and various stages of treatment in 100 normal ears and forearms and 50 ears having AOE. The mean pH of normal EAC was 3.950 ± 1.199 while that of forearm was 4.775 ± 0.910. There was increase in the number of patients with increase in relative humidity, however, the change in the pH of EAC was statistically not significant (p > 0.05). Significant fall in pH was observed at 1 and 2 weeks of treatment. The normal EAC pH is relatively more acidic as compared to that of forearm skin and it became more alkaline in cases of AOE with reversion back to acidic pH after treatment. Acidification of the EAC is the only treatment required in most cases. No significant change in pH of ears was observed with changes of temperatures and humidity.

Earache

Earache, a common emergency department presentation, may be caused by a variety of conditions, some distant from the ear. This article discusses the diagnosis and treatment of acute otitis media, otitis media with effusion, otitis externa, otitis media with ruptured tympanic membrane or tympanostomy tubes, malignant otitis externa, mastoiditis and petrositis, traumatic ruptured tympanic membrane, cerumen impactions, and foreign bodies in the ears.

Assessment and management of chronic otitis externa

PURPOSE OF REVIEW

Chronic otitis externa (COE) remains a frustrating problem for both patient and physician. The end stage of disease, medial fibrosing otitis externa, is very challenging to repair. New and old therapies and promising approaches to the treatment of this often recalcitrant problem are presented in this review.

RECENT FINDINGS

Tacrolimus, a nonsteroidal immunosuppressant, and fluocinolone acetonide oil 0.01%, a medium-high potency steroid preparation, may offer additional therapeutic options in the struggle against this inflammatory ear canal/skin condition of often unknown cause. Relative potencies of many steroid preparations will be presented along with several treatment strategies for controlling COE. Underlying autoimmune problems such as Sjögren's disease, sarcoidosis, and amyloidosis must be searched and, if present, addressed and treated for resolution of symptoms. Cutting edge therapies, including use of bacteriophages and inflammatory proteases, will also be reviewed.

SUMMARY

No single therapy will be successful for every patient with COE. The search for an underlying cause, the removal of all possible irritants to the ear canal skin (e.g. Q-tips, water), debridement, and both topical and occasionally, systemic therapy will control (not cure …) the disease process in the vast majority of patients.

The pH of commonly used topical ear drops in the treatment of otitis externa

Healthy ear canal skin has an acidic pH. Evidence suggests that reacidification of the ear canal may lead to resolution of otitis externa. The pH of 15 commonly prescribed topical ear drop preparations used in the treatment of otitis externa was measured using a Jenway 3020 pH meter with temperature compensation at 37.5 °C. The pH values ranged from 2.89 to 7.83. Two-thirds of preparations tested were of acidic pH. The remaining one-third were alkaline. Reacidification of the ear canal may help in the treatment of otitis externa.

Arytenoid Abduction: Indications and Limitations

Objectives

I report further experience with arytenoid abduction (AAb), a procedure that enlarges the glottis by external rotation of the arytenoid cartilage and thus moves the vocal process laterally and rostrally, but does not preclude adduction for phonation. Therefore, AAb has the potential to preserve voice in patients with bilateral abductor laryngeal paralysis.

Methods

I performed a retrospective review of AAb in 11 patients with bilateral laryngeal paralysis and 3 patients with other neurologic causes of glottal airway compromise, ie, adductor breathing dystonia, frequent laryngospasm, and progressive laryngeal breathing dysfunction.

Results

Seven of the 11 patients with bilateral paralysis had dramatic airway improvement. One patient required a tracheotomy after AAb, and 3 patients with an existing tracheotomy could not be decannulated. Arytenoid abduction relieved airway obstruction in the patient with recurrent laryngospasm and in the child with progressive laryngeal breathing dysfunction, but the patient with adductor breathing dystonia has persistent stridor. The factors associated with a poor airway outcome included prolonged tracheotomy, electromyographic evidence of inspiratory activity of adductor muscles, chronic obstructive pulmonary disease, sleep apnea, and prior cordotomy or arytenoidectomy.

Conclusions

Arytenoid abduction is most effective in patients with bilateral laryngeal paralysis of less than 1 year's duration who do not have unfavorable laryngeal adductor activity.

The use of trichloroacetic acid in the treatment of acute external otitis

The purpose of this study was to evaluate the effectiveness of 5% trichloroacetic acid (TCA) in the treatment of acute external otitis (AEO) in comparison with a standard clinical treatment. All patients who consecutively presented in our emergencies with AEO during the summer months of the previous year were included in the study. They were randomly divided into two groups: the study group included 117 patients treated with TCA and the control group included 98 patients treated with ear drops containing antibiotic and corticosteroid. Occasionally, an antibiotic was administered orally for 7 days, in severe cases of AEO. All patients were evaluated on days 1, 3, 5, 7 and 10, whereas another review appointment was given 20 days later. Outcome measures included evaluation of efficacy using a six-step infection score and tolerability by visual analogue scale. Additionally, adverse reactions, complications and recurrencies were recorded. Treatment was successful for all patients of the study group, whereas 8 failures were found in the control group. The infection score improved faster in the study group than in the control group, resulting in an earlier clinical cure (mean 4.1 and 8.6 days, respectively). Tolerability was significantly better in the study group, on all points of evaluation. Complications and adverse reactions were minimal on both groups. Our results show that TCA is a very effective and nontoxic agent for the treatment of AEO. Rapid pain relief and prevention of recurrencies are its main advantages.

Clinical practice guideline: acute otitis externa

OBJECTIVE

This guideline provides evidence-based recommendations to manage diffuse acute otitis externa (AOE), defined as generalized inflammation of the external ear canal, which may also involve the pinna or tympanic membrane. The primary purpose is to promote appropriate use of oral and topical antimicrobials and to highlight the need for adequate pain relief.

STUDY DESIGN

In creating this guideline, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) selected a development group representing the fields of otolaryngology-head and neck surgery, pediatrics, family medicine, infectious disease, internal medicine, emergency medicine, and medical informatics. The guideline was created with the use of an explicit, a priori, evidence-based protocol.

RESULTS

The group made a strong recommendation that management of AOE should include an assessment of pain, and the clinician should recommend analgesic treatment based on the severity of pain. The group made recommendations that clinicians should: 1) distinguish diffuse AOE from other causes of otalgia, otorrhea, and inflammation of the ear canal; 2) assess the patient with diffuse AOE for factors that modify management (nonintact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state, prior radiotherapy); and 3) use topical preparations for initial therapy of diffuse, uncomplicated AOE; systemic antimicrobial therapy should not be used unless there is extension outside of the ear canal or the presence of specific host factors that would indicate a need for systemic therapy. The group made additional recommendations that: 4) the choice of topical antimicrobial therapy of diffuse AOE should be based on efficacy, low incidence of adverse events, likelihood of adherence to therapy, and cost; 5) clinicians should inform patients how to administer topical drops, and when the ear canal is obstructed, delivery of topical preparations should be enhanced by aural toilet, placing a wick, or both; 6) when the patient has a tympanostomy tube or known perforation of the tympanic membrane, the clinician should prescribe a nonototoxic topical preparation; and 7) if the patient fails to respond to the initial therapeutic option within 48 to 72 hours, the clinician should reassess the patient to confirm the diagnosis of diffuse AOE and to exclude other causes of illness. And finally, the panel compiled a list of research needs based on limitations of the evidence reviewed.

CONCLUSION

This clinical practice guideline is not intended as a sole source of guidance in evaluating patients with AOE. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all individuals with this condition and may not provide the only appropriate approach to the diagnosis and management of this problem.

SIGNIFICANCE

This is the first, explicit, evidence-based clinical practice guideline on acute otitis externa, and the first clinical practice guideline produced independently by the AAO-HNSF.

Relative humidity of the external auditory canal in normal and abnormal ears, and its pathogenic effect

OBJECTIVE

To find the relative humidity of the normal external ear canal and to demonstrate that the relative humidity of the external auditory canal was higher in abnormal ears, i.e. ears commonly associated with chronic discharge.

SETTING

Secondary health care within the ENT departments of Addenbrooke's and Hinchingbrooke hospitals.

DESIGN

A clinical observational study.

PARTICIPANTS

Volunteers seen in ENT outpatients. Inclusion criteria for the normal ear group, was a normal ear with no history of infection or previous ear disease. Inclusion criteria for abnormal ear group commonly associated with chronic discharge. Exclusion criteria were the presence of pus or infection within the ear canal.

METHOD

The relative humidity of the external ear canal was measured in normal and abnormal ears. Abnormal ears were grouped as those commonly associated with chronic discharge, mastoid cavities, tympanic perforations, recurrent otitis externa and hearing-aided ears.

RESULTS

The range of relative humidity of normal ears is 40-70%. The humidity in abnormal ears was found to be significantly higher than the humidity in normal ears (P < 0.0001).

CONCLUSION

The raised relative humidity in the external canal may explain the predisposition of certain abnormal ears to chronic discharge and infection. If the humidity of the canal could be brought down to a normal level, this could offer a new therapeutic treatment.