Efficacy of Boric Acid as a Treatment of Choice for Chronic Suppurative Otitis Media and Its Ototoxicity

Potential Toxicity of Boric Acid Powder Otic Insufflation

OBJECTIVE

Boric acid (BA) powder is commonly used to treat otologic conditions, such as mastoid bowl inflammation and chronic otitis externa. Exposure to 50 mg per day is thought to cause systemic toxicity in humans. Inflamed skin and mucosal surfaces readily absorb BA. The aim of this study was to measure the doses of BA commonly used in clinical otology and alert the otolaryngology community to BA's underappreciated potential source of systemic toxicity.

STUDY DESIGN

Prospective, controlled.

SETTING

Laboratory.

METHODS

BA dose administration was measured by weighing the BA generated by common insufflators: accordion bellows, House-Sheehy insufflator, DeVilbiss insufflator, and pneumatic powder blower. Manual insufflation was performed with 3 compressions of the bulb. The pneumatic blower was sprayed for 1 second. Measurements were repeated 10 times.

RESULTS

The DeVilbiss insufflator delivered the lowest mean BA dose, 6.1 mg (SD 3.4, range 2.1-13.7), followed by the House-Sheehy 8.9 mg (SD 8.4, range 1.6-27.8), the pneumatic blower 192.8 mg (SD 38.3, range 150.0-261.7), and the accordion, 284.1 mg (SD 215.0, range 37.8-730.8).

CONCLUSION

BA dose delivery is highly variable by insufflator type, and doses thought to cause systemic toxicity are commonly generated. Awareness of and further investigation into the potential toxicity of otic administration of BA seems warranted.

In silico and biological activity evaluation of quercetin-boron hybrid compounds, anti-quorum sensing effect as alternative potential against microbial resistance

Boronic acid compounds and the natural flavonoid compound quercetin were handled to synthesize two novel ligands encoded as B1(2,2'-(1,4-phenylenebis (benzo [1,3,2] dioxaborole-2,5-diyl)) bis (3,5,7-trihydroxy-4H- chromen-4-one) and B2(3.3.6. 3,5,7-trihydroxy-2-(2-(6-methoxypyridin-3-yl)benzo[d][1,3,2]dioxaborol-5-yl)- 4 H-chromene-4). Antioxidant activities of ligands were investigated by DPPH, ABTS and CUPRAC methods. Cholinesterase inhibition effects of ligands were determined by acetylcholinesterase and butyrylcholinesterase enzyme inhibition methods, cytotoxic effects of ligands were applied to healthy breast and colon cancer cell lines by MTT method, and urease and tyrosinase enzyme activities were determined. Antimicrobial properties of the compounds were analyzed by detecting their anti-QS potentials on Chromobacterium violaceum biosensor strain. Both compounds were found to have significant antioxidant effects compared to controls. It was determined that the compound B1 at 1-10 µg/mL was more active than the reference compounds (α-TOC and BHT). Moreover, the enzyme activity studies on ligands demonstrated that acetylchoinesterase and butyrylcholinesterase enzyme inhibitions were higher than the reference compounds. As expected, boron derivatives exhibited respectable activity against the biofilms of Escherichia coli (E. coli) and P. aeruginosa (P. aeruginosa). These results demonstrate the potential applicability of boron derivatives in the treatment of biofilm-associated infections and provide a practical strategy for the design of new boron-based antimicrobial materials. In silico molecular docking studies were performed on ligands to identify newly synthesized compounds. The binding parameter values and binding sites of the compounds were also determined. In conclusion, our studies showed that newly synthesized hybrid compounds could be solutions for antimicrobial resistance and enzyme-related disorders.

Mapping of audiometric analysis with microbiological findings in patients with chronic suppurative otitis media (CSOM): a neglected clinical manifestation

Otitis media (OM) is an umbrella term for a number of conditions associated with middle ear inflammation. Chronic suppurative otitis media (CSOM), a type of OM, is characterized by long-term middle ear infection with perforated ear drum and otorrhea. The most common outcome associated with it is acquired hearing impairment in infected individuals which ultimately affects their cognitive and scholastic developments. Clinically, CSOM is thought to be a sequel of re-occurring episodes of Acute otitis media (AOM). Pseudomonas aeruginosa and Staphylococcus aureus are found to be the predominant pathogenic isolates in these patients. However, with the emergence of antibiotic resistance amongst these pathogens, the adequate evaluation and treatment of this condition has become more problematic. The disease has also been recognized as one of the neglected tropical clinical manifestations with high prevalence in school-age children, especially in poor or underprivileged countries. Moreover, untreated cases have further worsened the situation by contributing to various life-threatening complications. Thus, effective treatment and surgical strategies, as well as strengthening of hearing care algorithms along with the discovery of novel animal models for advanced clinical research, can jointly help to fight this disease. In this regard, mapping of the audiological analysis with microbiological findings in CSOM patients may help elucidate the frequency that favors growth of specific pathogens. Knowledge about this potential correlation can then support timely detection of the infection, which is perceived as one of the emerging approaches for its management. In addition to these strategies, creating a true sense of awareness among people can also help mitigate this pathological condition by facilitating early identification, prevention, and treatment. This review discusses the incidence, pathogenesis, investigations, complications, and available treatment modalities associated with CSOM.

Boron- and Boric Acid-Treated Titanium Implant Surfaces in Sheep Tibia: A Histologic, Histomorphometric and Mechanical Study

The aim of this study was to compare the topographical, chemical and osseointegration characteristics of sandblasting and acid-etching (SLA) surfaces and dental implants treated by boron compounds. Titanium (Ti) disks (n = 20) were modified using boron (B) and boric acid (H3BO3) and then compared with the conventional SLA surface via surface topographic characterizations. Dental implants (3.5 mm in diameter and 8 mm in length) with the experimental surfaces (n = 96) were inserted into the tibias of six sheep, which were left to heal for 3 and 7 weeks. Histologic, histomorphometric (bone−implant contact (BIC%)) and mechanical tests (removal torque value (RTV)) were performed. The boron-coated surface (BC group) was smoother (Rz: 4.51 μm ± 0.13) than the SLA (5.86 μm ± 0.80) and the SLA-B (5.75 μm ± 0.64) groups (p = 0.033). After 3 weeks, the highest mean RTV was found in the SLA group (37 N/cm ± 2.87), and the difference compared with the BC group (30 N/cm ± 2.60) was statistically significant (p = 0.004). After 7 weeks, the mean RTV was >80 N/cm in all groups; the highest was measured in the H3BO3-treated (BS) group (89 N/cm ± 1.53) (p < 0.0001). No statistically significant differences were found in the BIC%s during both healing periods between the groups. H3BO3 seems to be a promising medium for dental implant osseointegration.

Sıçanlarda pseudomonas aeruginosa ile indüklenen kronik otitis media modelinde borik asit tedavisinin etkinliği

Amaç: Kronik otitis media (KOM), bakteriyel veya viral patojenlerin neden olduğu orta kulağın sık görülen enfeksiyöz hastalıklarından biridir. Bu çalışmanın amacı, sıçanlarda Pseudomonas aeruginosa (P. aeruginosa) ile indüklenen KOM modelinde topikal %4’lük ve %8’lik borik asit (BA) uygulamasını sistemik siprofloksasin ile karşılaştırarak KOM tedavisinde borik asidin etkinliğini araştırmaktır. Gereç ve Yöntem: 42 Sprague Dawley cinsi sıçan 7 eşit gruba ayrıldı. P. aeruginosa ile KOM modeli oluşturuldu. Kontrol grubu, KOM grubu, topikal %4’lük ve %8’lik BA tedavi grubu, sistemik siprofloksasin tedavi grubu ve topikal %4’lük ve %8’lik BA temas grubu arasında klinik, histopatolojik ve immünohistokimyasal karşılaştırmalar yapıldı. Bulgular: KOM modelinde %4’lük BA uygulaması ile orta derecede ödem, enflamasyon, dejenerasyon ve orta derecede tümör nekroz faktör-alfa (TNF-α) ekspresyonu tespit edildi. %8’lik BA uygulaması ile hafif ödem, inflamasyon, dejenerasyon ve hafif TNF-α ekspresyonu tespit edildi. Sonuç: %4’lük ve %8’lik BA tedavisinin önemli klinik, histopatolojik ve immünohistokimyasal iyileşme sağladığı görüldü. %8’lik BA uygulamasının daha yüksek tedavi etkinliğine sahip olduğu ve orta kulak mukozasına zararlı bir etkisinin olmadığı gösterildi.

A contemporary overview on the enigma of managing recalcitrant or intractable post-operative otorrhoea following middle-ear surgery: perspectives, principles and practices

Background

A common problem in otological surgeries is the persistence of ear discharge in a patient who has undergone middle-ear reconstructive surgery, despite an intact graft. There is a dearth of knowledge in the literature on treatment strategies in such post-operative cases of recalcitrant otorrhoea.

Method

This was a retrospective observational descriptive study conducted on 45 patients who fitted the criteria for recalcitrant post-operative otorrhoea. All 45 patients showed no response to conservative treatment for 14 days from onset of discharge. Therefore, these patients were then given antiseptic ear drops.

Results

Thirty patients out of 45 showed a good response to antiseptic ear drops and achieved a dry ear at the end of the treatment.

Conclusion

In patients with recalcitrant otorrhoea with or without granulations after middle-ear reconstruction surgery, this study found that topical antiseptic ear drops, particularly those using boric acid powder, are more effective than topical antibiotic drops.

Topical antiseptics for chronic suppurative otitis media

BACKGROUND

Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Topical antiseptics, one of the possible treatments for CSOM, inhibit the micro-organisms that may be responsible for the infection. Antiseptics can be used alone or in addition to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). Antiseptics or their application can cause irritation of the skin of the outer ear, manifesting as discomfort, pain or itching. Some antiseptics (such as alcohol) may have the potential to be toxic to the inner ear (ototoxicity), with a possible increased risk of causing sensorineural hearing loss, dizziness or tinnitus.

OBJECTIVES

To assess the effects of topical antiseptics for people with chronic suppurative otitis media.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL; 2019, Issue 4, via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 April 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least a one-week follow-up involving patients (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antiseptic agent of any class, applied directly into the ear canal as ear drops, powders or irrigations, or as part of an aural toileting procedure. Two main comparisons were topical antiseptics compared to: a) placebo or no intervention; and b) another topical antiseptic (e.g. topical antiseptic A versus topical antiseptic B). Within each comparison we separated studies where both groups of patients had received topical antiseptics a) alone or with aural toileting and b) on top of antibiotic treatment.

DATA COLLECTION AND ANALYSIS

We used the standard Cochrane methodological procedures. We used GRADE to assess the certainty of the evidence for each outcome. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health-related quality of life using a validated instrument; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes included hearing, serious complications and ototoxicity measured in several ways.

MAIN RESULTS

Five studies were included. It was not possible to calculate the total number of participants as two studies only provided the number of ears included in the study. A. Topical antiseptic (boric acid) versus placebo or no treatment (all patients had aural toileting) Three studies compared topical antiseptics with no treatment, with one study reporting results we could use (254 children; cluster-RCT). This compared the instillation of boric acid in alcohol drops versus no ear drops for one month (both arms used daily dry mopping). We made adjustments to the data to account for the intra-cluster correlation. The very low certainty of the evidence means it is uncertain whether or not treatment with an antiseptic leads to an increase in resolution of ear discharge at both four weeks (risk ratio (RR) 1.94, 95% confidence interval (CI) 1.20 to 3.16; 174 participants) and at three to four months (RR 1.73, 95% CI 1.21 to 2.47; 180 participants). This study narratively described no differences in suspected ototoxicity or hearing outcomes between the arms (very low-certainty evidence). None of the studies reported results for health-related quality of life, adverse effects or serious complications. B. Topical antiseptic A versus topical antiseptic B Two studies compared different antiseptics but only one (93 participants), comparing a single instillation of boric acid powder with daily acetic acid ear drops, provided any information for this comparison. The very low certainty of the evidence means that it is uncertain whether more patients had resolution of ear discharge with boric acid powder compared to acetic acid at four weeks (RR 2.61, 95% CI 1.51 to 4.53; 93 participants), or whether there was a difference between the arms with respect to ear discomfort due to the low number of reported events (RR 0.10, 95% CI 0.01 to 1.81; 93 participants). Narratively, the study reported no difference in hearing outcomes between the groups. None of the included studies reported any of the other primary or secondary outcomes.

AUTHORS' CONCLUSIONS

Due to paucity of the evidence and the very low certainty of that which is available the effectiveness and safety profile of antiseptics in the treatment of CSOM is uncertain.