Clinical efficacy of three common treatments in acute otitis externa in primary care: randomised controlled trial

Exploring the OTITIS Research Landscape Through a Scientometric Approach

Otitis media is a common health problem affecting people of all ages and significantly impacting public health and healthcare costs. Otitis media, a type of middle ear disease, is one of the most common types. This scientometric study aimed to provide an overview of the knowledge domain in otitis media research. Documents were retrieved from the Web of Science database. A scientometric study was then performed on a sample of 27,213 documents. This study found that research on otitis media has increased significantly in recent years, with an annual growth rate of 4.58%. The average age of the documents analyzed was 18 years, with an average of 21.88 citations and an average of 4.58 authors. The United States, the United Kingdom, and Japan ranked first to third in terms of number of publications. Still, the United States, China, and Sweden were in a better position in terms of impact on the research network. Co-occurrence word analysis showed that significant attention was given to topics such as chronic inflammation in autism, acute inflammation in otitis media, and increased fluid in the middle ear. This study highlights the need to prioritize and focus attention on otitis, particularly otitis media, due to its prevalence and impact on public health. The use of scientometric software, such as Biblioshiny and CiteSpace, provides a valuable means of assessing research trends and identifying important areas for future study in the field of knowledge.

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.

Development of Microchip Isotachophoresis Coupled with Ion Mobility Spectrometry and Evaluation of Its Potential for the Analysis of Food, Biological and Pharmaceutical Samples

An online coupling of microchip isotachophoresis (µITP) with ion mobility spectrometry (IMS) using thermal evaporation interface is reported for the first time. This combination integrates preconcentration power of the µITP followed by unambiguous identification of trace compounds in complex samples by IMS. Short-chain carboxylic acids, chosen as model analytes, were first separated by the µITP in a discontinuous electrolyte system at pH 5–6, and subsequently evaporated at 130 °C during their transfer to the IMS analyzer. Various parameters, affecting the transfer of the separated sample components through the evaporation system, were optimized to minimize dispersion and loss of the analytes as well as to improve sensitivity. The following analytical attributes were obtained for carboxylic acids in the standard solutions: 0.1–0.3 mg L⁻¹ detection limits, 0.4–0.9 mg L⁻¹ quantitation limits, linear calibration range from the quantitation limit to 75 mg L⁻¹, 0.2–0.3% RSD of the IMS response and 98–102% accuracy. The analytical potential of the developed µITP-IMS combination was demonstrated on the analysis of various food, pharmaceutical and biological samples, in which the studied acids are naturally present. These include: apple vinegar, wine, fish sauce, saliva and ear drops. In the real samples, 0.3–0.6% RSD of the IMS response and 93–109% accuracy were obtained.

Acetic acid and the skin: a review of vinegar in dermatology

Vinegar is commonly used as a home remedy for many skin problems. It is important for dermatologists to understand the evidence supporting its use in skin disease, as well as potential adverse effects, so they can properly counsel patients on the safe use of this widely available treatment. Vinegar possesses antimicrobial and antioxidant properties that provide utility in wound care as well as bacterial and fungal infections. There is also evidence to support its use in pruritus, head lice removal, and treatment of striae gravidarum. While generally safe, inappropriate use can result in damage to the skin. In this review, we discuss the evidence supporting vinegar as a treatment for skin disease, as well as adverse events reported from misuse, to provide dermatologists the knowledge to counsel patients on the safe and appropriate use of vinegar.

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.

Evaluation of the Efficacy and Tolerability of Oral Ciprofloxacin used in the Comprehensive Treatment of External Bacterial Otitis: An Observational Prospective Study

Introduction  Otitis Externa is common ear infection with a prevalence of 1%.

Objective  The objective of this study is to evaluate the clinical and microbiological efficacy and safety profile with oral ciprofloxacin in the external bacterial otitis (EBO) management.

Methods  This is a prospective observational study conducted with EBO outpatients referred to the otorhinolaryngology center in Moscow between March and August 2013. Our study included patients from two cohorts, acute external bacterial otitis (AEBO) - Group 1 - and exacerbation of chronic otitis externa (CEBO) - Group 2. We administered Ciprofloxacin 500 mg twice daily with standard topical EBO treatment for up to 10 days. Patients underwent evaluation on study visit days 1, 3, 5, and 10 for the severity. Bacteriological examination of ear canal cultures took place on Day 1 and Day 10.

Results  We collected data from 60 EBO outpatients (AEBO: N  = 30 and CEBO: N  = 30). Swimming was the major risk factor associated with the disease in addition to the most common pathogenic organisms - Staphylococcus aureus and Pseudomonas aeruginosa . was We attained complete resolution of the inflammatory process in 28 (93%) and 27 (90%) patients in the AEBO and CEBO group, respectively. We confirmed this by microbiological test with almost complete eradication of the causative organisms. Overall, we observed good positive dynamics of ear canal with no major side effects.

Conclusion  We found that Ciprofloxacin 500 mg, when administered orally twice daily for 7 to 10 days in otitis externa patients is clinically and microbiologically effective and comparatively safer than other antimicrobials.

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.

Expansile properties of otowicks: an in vitro study

Objective:

To determine the expansile and absorptive properties of the expandable ear wick when tested with commonly prescribed ear drop preparations.

Design:

This in vitro study assessed wick expansion and absorption of drops when different ear drop preparations were applied. Nine commonly used ear drop preparations were tested (Gentisone HC, Sofradex, Otomize, Betnesol, Exocin, Canesten, Locorten-Vioform, EarCalm and ichthammol glycerin) with a standard expandable ear wick.

Main outcome measures:

Weight, length and width of otowick following exposure to ear drops.

Results:

There was a marked difference in the absorption and expansion of the otowick when different drops were used. This corresponded to the aqueous or oil base of each preparation. All aqueous ear drop preparations (i.e. Gentisone HC, Sofradex, Otomize, Betnesol, Exocin and EarCalm) produced similar rates of absorption into, and expansion of, the otowick. The oil-based ear drop preparations (i.e. Canesten, Locorten-Vioform and ichthammol glycerin) failed to expand the wick and showed poor rates of absorption into the wick.

Conclusion:

Expandable ear wicks should only be used in conjunction with aqueous ear drops. When using expandable otowicks as an adjunct to treating fungal otitis externa, acetic acid ear drops should be prescribed, as all other anti-fungal drops are oil-based.

Systematic review of topical antimicrobial therapy for acute otitis externa

OBJECTIVE: To determine the efficacy of topical antimicrobials for acute otitis externa.

STUDY DESIGN: Systematic review and random effects metaanalysis of randomized, controlled trials with parallel groups permitting one or more of the following comparisons: antimicrobial vs placebo, antiseptic vs antimicrobial, quinolone antibiotic vs nonquinolone antibiotic, steroid-antimicrobial vs antimicrobial, or antimicrobial-steroid vs steroid.

RESULTS: Twenty trials met inclusion criteria and 18 had data suitable for pooling. Topical antimicrobials increased absolute clinical cure rates over placebo by 46% (95% confidence interval [CI], 29% to 63%) and bacteriologic cure rates by 61% (95% CI, 46% to 76%). No significant differences were noted in clinical cure rates for other comparisons, except that steroid alone increased cure rates by 20% compared with steroid plus antibiotic (95% CI, 3% to 38%). Quinolone drops increased bacteriologic cure rates by 8% compared with nonquinolone antibiotics (95% CI, 1% to 16%), but had statistically equivalent rates of clinical cure and adverse events

CONCLUSION: Topical antimicrobial is highly effective for acute otitis externa with clinical cure rates of 65% to 80% within 10 days of therapy. Minor differences were noted in comparative efficacy, but broad confidence limits containing small effect sizes make these of questionable clinical significance.

SIGNIFICANCE: Summary estimates from the 13 meta-analyses can be used to facilitate evidence-based management recommendations and clinical practice guideline development. © 2006 American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc. All rights reserved.

Topical ear treatment - options, indications and limitations of current therapy

Topical otic products form an integral part of the overall management of otitis externa. With an ever increasing array of ear drops and cleaners to choose from, appropriate selection of therapy can be difficult. The investigation of all cases of otitis externa should consider primary and secondary causes and predisposing and perpetuating factors. This article considers topical therapy under these same broad headings and discusses, through literature review, the various properties of the components of the ear cleaning solutions and drops.

Comparison of Boric Acid and Combination Drug of Polymyxin, Neomycin and Hydrocortisone (polymyxin NH) in the Treatment of Acute Otitis Externa

INTRODUCTION

Acute otitis externa is an inflammation of the external auditory canal known as "swimmer's ear". Direct costs including medical treatment, painkillers, antibiotics, steroids or both and indirect costs are also remarkable.

AIM

The aim of this study was to compare the effect of boric acid and polymyxin, neomycin and hydrocortisone composition in the treatment of acute otitis externa.

MATERIALS AND METHODS

This randomized clinical trial was carried out on 80 patients aged more than 17-year-old who were referred to Kashani hospital clinic with a diagnosis of acute otitis externa by otolaryngologist. The patients were randomly allocated to two groups (A: Boric acid and B: polymyxin NH ear drops) and Painkiller was prescribed and administered orally for all patients and in the presence of fever, cellulitis around the ears and neck adenopathy, broad-spectrum systemic antibiotics were used besides topical treatment. Symptoms of patients who were evaluated by a physician includes pain, discharge from the ear, swelling of the ear canal, auricle swelling, tenderness, and ear itching. In addition, pain was evaluated in patients and was recorded by Macgill Pain Questionnaire, in the first, third, seventh and tenth days.

RESULTS

Results showed that itching on third day (p=0.007) and swelling of the ear canal in the examination of the third day (p=0.006) and the seventh day (p=0.001) in the polymyxin NH group was more than those of boric acid group. Overall mean pain based on McGill questionnaire was 11.10±1.49 in boric acid group in the examination on the first day and was 4.05±0.22 in the examination on the tenth day and in the polymyxin NH group, it was 10.9±0.99 on the first day and 4.20±0.40 on the tenth day. In both groups, pain relief was the same and there was no significant difference between two groups (p=0.075).

CONCLUSION

The findings of this study showed slight differences in the effectiveness of the boric acid drug and combination of polymyxin, neomycin and hydrocortisone in the treatment of patients with acute otitis externa that is of clinical significance.

Investigation of the effectiveness of Syzygium aromaticum, Lavandula angustifolia and Geranium robertianum essential oils in the treatment of acute external otitis: a comparative trial with ciprofloxacin

BACKGROUND

Antibiotics and anti-inflammatory agents are the mainstay of acute external otitis (AEO) treatment. The present study investigated the effectiveness of a combination herbal drop (Lamigex) composed of essential oils from Syzygium aromaticum, Lavandula angustifolia, and Geranium robertianum in the alleviation of AEO symptoms and compared its effects to those of ciprofloxacin 0.3% drop.

METHODS

Seventy patients were randomly assigned to receive ciprofloxacin 0.3% (n = 35) or Lamigex (n = 35) drop. Each group was administered with three drops every 12 hours for a week. Patients were examined for AEO symptoms and ear discharge cultures at baseline as well as at the end of trial. Pain severity was also recorded using a visual analogue scale at baseline, the 3(rd) day, and the 7(th) day of the trial.

RESULTS

All assessed symptoms (tenderness, itching, erythema, edema and discharge) were equally improved in the ciprofloxacin and Lamigex groups by the end of trial (p > 0.05). There were remarkable reductions in the visual analogue scale score by the end of trial in both groups (p < 0.001). However, the rate of pain improvement was not found to be significantly different between the groups, either at the 3(rd) or 7(th) day of trial (p > 0.05). The numbers of positive cultures for all tested microorganisms were clearly reduced by the end of the trial in both groups but were not significantly different between the groups (p > 0.05).

CONCLUSION

The herbal combination drop that was investigated in the present study exhibited good efficacy in reducing the burden of infection as well as AEO symptoms.

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.

Acute otitis externa

Acute otitis externa, also known as 'swimmer's ear', is a common disease of children, adolescents and adults. While chronic suppurative otitis media or acute otitis media with tympanostomy tubes or a perforation can cause acute otitis externa, both the infecting organisms and management protocol are different. This practice point focuses solely on managing acute otitis externa, without acute otitis media, tympanostomy tubes or a perforation being present.

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.

Minimal inhibitory concentration of natural vinegar and of aluminium acetate-tartrate solution

HYPOTHESIS

Vinegar and aluminium acetate preparations are used for treatment of ear infections. It is instrumental to know the minimal inhibitory concentration to get effective remedies. This study was performed to assess the lowest dilution of vinegar (specified content, 6% acetic acid) and aluminium acetate-tartrate solution (specified content, 1.4% aluminium and 6% acetic acid) to determine the minimum inhibitory concentration against bacteria commonly found in chronic ear infections.

BACKGROUND

Laboratory study on 2 samples of aluminium acetate-tartrate and on 1 sample of natural white wine vinegar on antibacterial effects against Staphylococcus aureus, Staphylococcus epidermidis, Proteus vulgaris, Pseudomonas aeruginosa, and Escherichia coli.

METHODS

Performing of a susceptibility testing-determination of the minimum inhibitory concentration (MIC) with the method of microbouillon dilution (DIN 58940 part 7).

RESULTS

Acetic acid was found to be effective in vitro in concentrations of 0.1% to 0.2% against the tested bacteria; aluminium acetate-tartrate solution was found to be effective in vitro in concentrations of 1.25% to 2.5% against the tested bacteria.

CONCLUSION

Vinegar respectively acetic acid diluted with water and aqueous aluminium acetate-tartrate solution could be effective ototopic preparations caused by one of the tested bacteria. For its effectiveness, an acid pH not higher than 4.5 is essential. Experiments with aluminium acetate-tartrate preparations on animals and clinical trials are required to obtain information about the response rates in ear infections and about any adverse effects.

Acute otitis externa in children

QUESTION

In the summer months I see many children with uncomplicated acute otitis externa (AOE). I am aware of the multiple ototopical preparations. Which is the best first-line agent to treat AOE, and is there a role for an oral antibiotic?

ANSWER

There are no specific Canadian guidelines for the management of AOE. However, current American guidelines promote initial ototopical therapy without systemic antibiotics for uncomplicated AOE; suggest there is little difference between the various ototopical preparations; and recommend the choice of treatment be based on the specific clinical situation. In practice, this often results in prescribing an antibiotic-steroid formulation for 7 to 10 days. This ototopical treatment option is supported by a recent Cochrane review that has documented the superiority of an antibiotic-steroid combination when compared with placebo or acetic acid in providing clinical resolution of AOE.

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.

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.

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.

Acute bacterial otitis externa: efficacy and safety of topical treatment with an antibiotic ear drop formulation in comparison to glycerol treatment

OBJECTIVES

To demonstrate the efficacy and safety of an antibiotic ear drop formulation combining polymyxin B sulfate, neomycin sulfate and gramicidin (PS) in patients with acute bacterial otitis externa (AOE). The combination was compared to glycerol ear drops, a non-pharmacologic treatment of AOE.

METHODS

An active controlled, double-blind, randomized, parallel group, multicenter clinical trial study design was performed in ear, nose and throat (ENT) practices with a planned interim analysis for sample size adaptation. In total, 244 patients aged 19-84 with no previous episode of otitis externa within the last year were randomized to receive either PS or glycerol ear drops thrice daily for 10 ± 2 days.

OUTCOME MEASURES

Absolute change in the clinical symptom score (CSS) (with subscores redness, swelling, pain, and secretion) from Day 1 to 4 was measured. As second endpoints, absolute change in CSS, individual subscores, pain perception measured on a visual analog scale (VAS) and intake of paracetamol 500 mg tablets were noted. Moreover, patient's assessment of efficacy at Day 10 and the frequency and type of adverse events were noted.

RESULTS

On Day 4, the CSS showed a clear advantage for the PS group over the glycerol group, being lower by 0.6 (p < 0.03); the clinical outcome was even more pronounced after 10 days (p = 0.006). The swelling subscore showed a statistically significant difference favoring the PS treatment group in Days 1-4 (p = 0.01) and Days 1-10 (p = 0.003). More PS- than glycerol-receiving patients rated the efficacy as good (glycerol: 32%; PS: 36%) or very good (glycerol: 38%; PS: 48%). Males, patients with AOE for >2 days and those with positive microbiologic findings profited most from PS therapy.

CONCLUSION

This study proves that PS is an effective and well-tolerated drug, showing results superior to glycerol, especially in patients with a longer pre-existing condition before therapy. The absence of a group treated with another established antibiotic is a limitation of this trial.

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.

Otitis externa

INTRODUCTION

Otitis externa is thought to affect 10% of people at some stage, and can present in acute, chronic, or necrotising forms. Otitis externa may be associated with eczema of the ear canal, and is more common in swimmers, humid environments, people with absence of ear wax or with narrow ear canals, hearing-aid users, and after mechanical trauma.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of empirical and prophylactic treatments for otitis externa? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2007 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found nine systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review, we present information relating to the effectiveness and safety of the following interventions: oral antibiotics, specialist aural toilet, topical acetic acid drops or spray, topical aluminium acetate drops, topical antibacterials, topical antifungals, topical anti-infective agents, topical corticosteroids, and water exclusion.

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.

Dexamethasone phosphate in antibiotic ear drops for the treatment of acute bacterial otitis externa

OBJECTIVES

To compare the efficacy and safety of polymyxin sulfate 7500 IU/neomycin sulfate 3500 IU/dexamethasone phosphate 0.1% (PN+Dx) otic solution with polymyxin sulfate 7500 IU/neomycin sulfate 3500 IU (PN-Dx) in patients with acute bacterial otitis externa (AOE), in order to determine the possible benefit of the addition of dexamethasone.

RESEARCH DESIGN AND METHODS

Active controlled, double-blind, randomized, parallel group, multi-center clinical trial in ear, nose, and throat (ENT) specialist practices with a planned interim analysis for sample size adaptation. In total, 338 patients aged 18-76 who had a previous episode of otitis externa within the last year were randomized to receive 10 +/- 2 days of treatment with two drops, three times daily, of either PN+Dx or PN-Dx.

MAIN OUTCOME MEASURES

Change in the clinical symptom score (consisting of the subscores redness, swelling, pain, and secretion) and of the visual analogue scale (VAS) rating for pain from Visit 1 (Day 1) to Visit 2 (Day 4 +/- 1), patient's assessment of efficacy at Visit 3 (Day 10 +/- 2), and the frequency and type of adverse events.

RESULTS

There was a significantly greater reduction of swelling from Visit 1 to Visit 2 with PN+Dx, and more patients rated the efficacy of PN+Dx as 'very good' or 'good' at Visit 3 (p = 0.03). There was also a significantly greater decrease in the clinical symptom score from Visit 1 to Visit 2 in the PN+Dx group in patients who had at least a moderately severe symptom score with more than seven points at Visit 1 (p = 0.01) and in patients suffering from their current episode of otitis externa for more than 2 days (p = 0.02). In total, 14 adverse events were reported during the study period with no related adverse drug reactions for PN+Dx.

CONCLUSIONS

The addition of dexamethasone phosphate to polymyxin B/neomycin significantly reduces swelling in patients with AOE and leads to significantly higher patient's ratings of treatment efficacy. It especially leads to an overall reduction of symptoms in cases of moderately or more severe otitis externa and cases lasting for more than 2 days.

Otitis externa

INTRODUCTION

Otitis externa is thought to affect 10% of people at some stage, and can present in acute, chronic, or necrotising forms. Otitis externa may be associated with eczema of the ear canal, and is more common in swimmers, humid environments, people with absence of ear wax or with narrow ear canals, hearing-aid users, and after mechanical trauma.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of empirical and prophylactic treatments for otitis externa? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found nine systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: oral antibiotics, specialist aural toilet, topical acetic acid drops or spray, topical aluminium acetate drops, topical antibacterials, topical antifungals, topical anti-infective agents, topical corticosteroids, and water exclusion.

Topical treatment of acute otitis externa: clinical comparison of an antibiotics ointment alone or in combination with hydrocortisone acetate

The study was designed to investigate the potential contribution of hydrocortisone acetate to the efficacy and safety of an antibiotics ointment in the treatment of acute otitis externa (AOE). In a double-blind study 151 patients with a unilateral acute bacterial otitis externa were randomized either to receive an ointment with polymyxin-B sulfate (7,500 I.E./g) + bacitracin (300 I.E./g) alone (AB) or the same antibiotic ointment with 10 mg hydrocortisone acetate/g ointment (AB + HC). Primary efficacy endpoint was the change of an aggregate clinical symptom score (CSS) (subscores: redness, swelling, pain and secretion) found at Visit 2 versus baseline (Visit 1). Secondary outcome parameters were the change of the CSS from Visit 1 to the study termination, and the changes in the subscores and of a visual analog scale for pain. In the group treated with AB + HC, significantly more patients with severe redness [14 (56%) vs. 7 (28%), P = 0.045] or severe secretion [23 (70%) vs. 10 (40%), P = 0.024] at inclusion were symptom-free at the last visit. Fewer pain-relieving tablets (1.1 +/- 2.2 vs. 2.3 +/- 4.6 paracetamol tablets) were used in the AB + HC-group. In the steroid group there was a slightly larger though not significant reduction in CSS at Visit 2 and Visit 3 versus baseline. Similar results were documented for redness, pain and secretion. No serious adverse events occurred. Both ointments are effective and safe in the topical treatment of AOE. Hydrocortisone acetate combined with the antibiotics improved individual symptoms better as did the steroid-free ointment.

[Clinical and therapeutic management of respiratory tract infections. Consensus document of the Andalusian infectious diseases society and the Andalusian family and comunitary medicine society]

Respiratory tract infections are frequent and they are one of the commonest causes of antibiotic prescription. However, there are few clinical guidelines that consider this group of infections. This document has been written by the Andalusian Infectious Diseases Society and the Andalusian Family and Community Medicine Society. The primary objective has been to define the recommendations for the diagnosis and antibiotic treatment of respiratory tract infections apart from pneumonia. The clinical syndromes evaluated have been: a) pharyngitis; b) sinusitis; c) acute otitis media and otitis externa; d) acute bronchitis, laryngitis, epiglottitis; e) acute exacerbation of chronic bronchitis; and f) respiratory infectious in patients with bronchiectasis. This document has focused on immunocompetent patients.

[Clinical and therapeutic management of respiratory tract infections. Consensus document of the Andalusian Infectious Diseases Society and the Andalusian Family and Community Medicine Society]

Respiratory tract infections are frequent and they are one of the commonest causes of antibiotic prescription. However, there are few clinical guidelines that consider this group of infections. This document has been written by the Andalusian Infectious Diseases Society and the Andalusian Family and Community Medicine Society. The primary objective has been to define the recommendations for the diagnosis and antibiotic treatment of respiratory tract infections apart from pneumonia. The clinical syndromes evaluated have been: a) pharyngitis; b) sinusitis; c) acute otitis media and otitis externa; d) acute bronchitis, laryngitis, epiglottitis; e) acute exacerbation of chronic bronchitis; and f) respiratory infectious in patients with bronchiectasis. This document has focused on immunocompetent patients.

Common ENT disorders

OBJECTIVE

To provide a succinct and updated discussion on common ear, nose, and throat (ENT) disorders encountered by primary care physicians.

METHODS

Review of recent and pertinent literature.

RESULTS

Recent data was identified via a PubMed search as well as commonly utilized texts in otolaryngology.

DISCUSSION

While it is impossible to discuss all of the ENT disorders encountered by primary care physicians, it is helpful to have a succinct resource to highlight the common disorders and their presenting signs, symptoms and initial treatments.

CONCLUSION

Recognizing specific signs and symptoms can help primary care physicians diagnose common ENT disorders. This review discusses these presentations and provides the initial management steps, as well as when to refer patients for further evaluation.

Prospective randomised single-blind controlled trial of glacial acetic acid versus glacial acetic acid, neomycin sulphate and dexamethasone spray in otitis externa and infected mastoid cavities

OBJECTIVES

The literature reports the merits of antibacterial, antibiotic and steroid agents in treating otological infections but no controlled clinical trial has directly compared 2% glacial acetic acid (EarCalm; Stafford-Miller Ltd, Brentford, UK) against 2% glacial acetic acid, 0.1% dexamethasone and 3250 U/ml of neomycin sulphate (Otomize; Stafford-Miller Ltd) in the treatment of otitis externa and infected mastoid cavities.

DESIGN

Prospective, single-blind randomised controlled trial.

SETTING

Outpatients, Derby Royal Infirmary, Derby, UK.

PATIENTS

Emergency and GP referrals with acute otitis externa (n = 53) and infected mastoid cavities (n = 56).

MAIN OUTCOME MEASURES

Otoscopy was performed at initial randomisation and then at 2 and 4 weeks, the ear assessed for active and inactive disease.

RESULTS

Patients with active otitis externa, 71% (15/21) resolved with glacial acetic acid, dexamethasone and of neomycin sulphate after 2 weeks, increasing to 86% (18/21) after 4 weeks treatment. Patients on glacial acetic acid had only 38% (12/32) resolution after 4 weeks (P < 0.0005). Two per cent glacial acetic acid, dexamethasone and neomycin sulphate resolved only 30% (8/27) of infected mastoid cavities compared to only 10% (3/29) on glacial acetic acid (P < 0.07). A further 2 weeks treatment this increased to 67%, (18/27) with glacial acetic acid, dexamethasone and neomycin sulphate and 48% (14/29) with glacial acetic acid. These results are not statistically significant.

CONCLUSION

Glacial acetic acid, dexamethasone and neomycin sulphate is significantly more effective in treating otitis externa when compared with glacial acetic acid. This effect failed to be significant in the infected mastoid cavities group. We therefore recommend that in conjunction with aural toilet, antibiotic/steroid combination is more effective than an antibacterial agent for otitis externa. Larger numbers of infected mastoid cavities are required to be studied.

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.

Therapy of other bacterial infections

Cutaneous bacterial disease continues to account for a significant proportion of clinical visits. The continuing emergence of strains that are resistant to available antibacterial agents creates a challenge for dermatologists, who need to keep abreast of current treatment strategies. In this article, antibacterial regimens are presented for skin infections caused by organisms such as Staphylococcus, Streptococcus, Pseudomonas, Neisseria, Haemophilus ducreyi, Treponema pallidum, Bacillus anthracis, Yersinia pestis, Pasteurella multocida, Vibrio vulnificus, Actinomyces, and Nocardia.