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2122.e2PART VII | OTOLOGY, NEUROTOLOGY, AND SKULL BASE SURGERY
60. Aviel A, Marshak G: Ramsay Hunt syndrome: a cranial polyneu ropathy. Am J
Otolaryngol 3:61–66, 1982.
61. Adour KK: Otological complications of herpes zoster. Ann Neurol
(35 Suppl):S62–S64, 1994.
62. Furuta Y, Takasu T, Fukuda S, et al: Detection of varicella-zoster virus DNA in
human geniculate ganglia by polymerase chain reac tion. J Infect Dis 166:1157–
1159, 1992.
63. Kinishi M, Amatsu M, Mohri M, et al: Acyclovir improves recovery rate of facial
nerve palsy in Ramsay Hunt syndrome. Auris Nasus Larynx 28:223–226, 2001.
64. Ko JY, Sheen TS, Hsu MM: Herpes zoster oticus treated with acy clovir and
prednisolone: clinical manifestations and analysis of prognostic factors. Clin
Otolaryngol Allied Sci 25:139–142, 2000.
65. Uscategui T, Dorée C, Chamberlain IJ, et al: Antiviral therapy for Ramsay Hunt
syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database
Syst Rev CD006851, 2008.doi:10.1002/
14651858.CD006851.pub2
66. Uscategui T, Dorée C, Chamberlain IJ, et al: Corticosteroids as adjuvant to
antiviral treatment in Ramsay Hunt syndrome (herpes zoster oticus with facial
palsy) in adults. Cochrane Database Syst Rev
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67. Robillard RB, Hilsinger RL, Adour KK: Ramsay Hunt facial paraly sis: clinical
analyses of 185 patients. Otolaryngol Head Neck Surg 95:
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68. Lee D-H, Chae S-Y, Park Y-S, et al: Prognostic value of electroneu rography in
Bell’s palsy and Ramsay-Hunt’s syndrome. Clin Otolar yngol 31:144–148, 2006.
69. Pavan-Langston D: Herpes zoster ophthalmicus. Neurology 45:S50–
S51, 1995.
70. Choo PW, Galil K, Donahue JG, et al: Risk factors for postherpetic neuralgia.
Arch. Intern. Med 157:1217–1224, 1997.
71. Sang CN, Sathyanarayana R, Sweeney M: DM-1796 Study Investiga tors
Gastroretentive Gabapentin (G-GR) Formulation Reduces Intensity of Pain
Associated With Postherpetic Neuralgia (PHN).
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72. Marais J, Dale BA: Bullous myringitis: a review. Clin Otolaryngol Allied Sci 22:497–
499, 1997.
73. Roberts DB: The etiology of bullous myringitis and the role of mycoplasmas in ear
disease: a review. Pediatrics 65:761–766, 1980.
74. Drendel M, Yakirevitch A, Kerimis P, et al: Hearing loss in bullous myringitis. Auris
Nasus Larynx 39:28–30, 2012.
75. Wetmore SJ, Abramson M: Bullous myringitis with sensorineural hearing loss.
Otolaryngol Head Neck Surg 87:66–70, 1979.
76. Hariri MA: Sensorineural hearing loss in bullous myringitis. A prospective study of
eighteen patients. Clin Otolaryngol Allied Sci 15:
351–353, 1990.
77. Hoffman RA, Shepsman DA: Bullous myringitis and sensorineural hearing loss.
Laryngoscope 93:1544–1545, 1983.
78. Keene WE, Markum AC, Samadpour M: Outbreak of Pseudomonas aeruginosa
infections caused by commercial piercing of upper ear cartilage. JAMA 291:981–
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79. McAdam LP, O’Hanlan MA, Bluestone R, et al: Relapsing poly chondritis:
prospective study of 23 patients and a review of the literature. Medicine
(Baltimore) 55:193–215, 1976.
80. Damiani JM, Levine HL: Relapsing polychondritis–report of ten
cases. Laryngoscope 89:929–946, 1979.
81. Mathew SD, Battafarano DF, Morris MJ: Relapsing polychondritis in the
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82. Piepergerdes MC, Kramer BM, Behnke EE: Keratosis obturans and external
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83. Saunders NC, Malhotra R, Biggs N, et al: Complications of keratosis
obturans. J Laryngol Otol 120:740–744, 2006.
84. Corbridge RJ, Michaels L, Wright T: Epithelial migration in kera tosis obturans.
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85. Persaud RAP, Hajioff D, Thevasagayam MS, et al: Keratosis obturans and
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Topical Therapies for 138ÿ

External Ear Disorders
Daniel J. Lee | Daniel Roberts

Key Points
ÿ An understanding of the efficacy and side-effect profile of prescription and nonprescription topical
therapies is important for the successful management of the patient with a nonneoplastic condition
of the external ear.
ÿ Debridement under binocular microscopy in the otolaryngologist’s office is both diagnostic and
therapeutic for common conditions that involve the external ear.
ÿ Most ototopical therapies are safe for the management of uncomplicated infections of the outer
ear, provided that the tympanic membrane is intact.
ÿ Aminoglycosides and acidifying agents should be avoided when a tympanic membrane perforation is
present because of the possible risk of ototoxicity.
ÿ An emphasis on meticulous ear hygiene and avoidance of self-manipulation is crucial to avoid
recurrent or chronic infections.
ÿ Systemic therapy should be considered in severe or chronic infections and in patients who are
immunocompromised. ÿ Persistent infections should be cultured, and suspicious or diseased
tissue should be biopsied to
exclude the possibility of a malignancy.
ÿ Dermatologic and rheumatologic evaluations should be considered in refractory or bilateral cases
of eczematoid otitis externa.

Topicalÿ therapiesÿ forÿ externalÿ earÿ disordersÿ areÿ amongÿ theÿ
mostÿcommonlyÿprescribedÿmedicationsÿforÿpediatricÿandÿadultÿ
patientsÿwhoÿcomeÿtoÿanÿotolaryngologyÿoffice.ÿTheÿlocalÿdeliv eryÿ
ofÿantibioticÿandÿantiinflammatoryÿmedicationsÿtoÿtheÿexter nalÿ earÿ
hasÿ severalÿ advantagesÿ overÿ systemicÿ therapiesÿ andÿ includeÿ
1)ÿ easeÿ ofÿ patientÿ use,ÿ 2)ÿincreasedÿ concentrationÿ ofÿ drugÿ
levelsÿinÿ theÿaffectedÿ region,ÿ 3)ÿ decreasedÿ systemicÿ sideÿ
effects,ÿandÿ4)ÿlowerÿcost.ÿTheÿuseÿofÿototopicalÿantibioticsÿinÿ
particularÿ avoidsÿ theÿ selectionÿ ofÿ resistantÿ organismsÿ inÿ theÿ
gastrointestinalÿ andÿ respiratoryÿ tractsÿ thatÿ canÿ beÿ seenÿ withÿ
systemicÿ therapy.ÿDisadvantagesÿincludeÿ theÿdifficultyÿofÿusingÿ
topicalÿmedicationsÿinÿanÿedematousÿorÿoccludedÿexternalÿaudi toryÿ
canal,ÿhypersensitivityÿorÿallergicÿreactions,ÿandÿaÿtheoreticÿ riskÿofÿ
injuryÿtoÿtheÿinnerÿearÿwhenÿtheÿtympanicÿmembraneÿisÿ perforated.ÿ
Thisÿchapterÿprovidesÿanÿevidence-basedÿdiscussionÿ ofÿtopicalÿ
therapiesÿforÿexternalÿearÿdisordersÿbasedÿonÿdiseaseÿ categories.ÿ
Theseÿ categoriesÿ includeÿ bacterialÿ otitisÿ externa,ÿ fungalÿotitisÿ
externa,ÿmyringitis,ÿeczematoidÿotitisÿexterna,ÿviralÿ infectionsÿ ofÿ
theÿ externalÿ ear,ÿ cerumenÿ impaction,ÿ andÿ theÿ chronicallyÿ
drainingÿear.
datesÿ backÿ overÿ 1000ÿ yearsÿ andÿ wasÿ originallyÿ adoptedÿ asÿ
aÿ methodÿofÿremovingÿcerumenÿfromÿtheÿcanal.ÿInÿthisÿprocess,ÿ
aÿhollowÿcandleÿisÿlitÿonÿoneÿendÿthatÿcreatesÿaÿvacuumÿatÿtheÿ
otherÿ end;ÿ whenÿ insertedÿ intoÿ theÿ ear,ÿ theÿ candleÿ drawsÿ
outÿ debrisÿfromÿtheÿcanal.ÿContemporaryÿstudiesÿhaveÿshownÿ
thatÿ earÿcandlingÿisÿlargelyÿineffective.ÿInÿsomeÿcases,ÿthisÿ
techniqueÿ depositsÿhotÿcandleÿwaxÿintoÿtheÿcanalÿandÿresultsÿinÿ
burns.3 ÿInÿ theÿ 1800s,ÿ “rattlesnakeÿ oil”—turpentine,ÿ camphor,ÿ
menthol,ÿ andÿsassafras—wasÿmarketedÿasÿaÿcureÿforÿotorrhea.ÿ
Byÿtheÿearlyÿ 1900s,ÿ astringentsÿ andÿ alcoholsÿ wereÿ introduced.ÿ
Theÿ acidityÿ andÿhighÿalcoholÿconcentrationÿmadeÿtheseÿ
preparationsÿsome whatÿ effectiveÿ ifÿ givenÿ earlyÿ inÿ theÿ courseÿ
ofÿ anÿ infection;ÿ however,ÿ theyÿ hadÿ noÿ targetedÿ antimicrobialÿ
activity.ÿ Onlyÿ duringÿtheÿmid-twentieth centuryÿwereÿ topicalÿ
antibioticsÿandÿ antifungalsÿ developedÿ toÿ treatÿ theÿ mostÿ
commonÿ pathogensÿ associatedÿwithÿotitisÿexternaÿ(OE) andÿotitisÿ
mediaÿ(OM).1,2ÿInÿ particular,ÿototopicalÿaminoglycosidesÿhaveÿ
beenÿavailableÿ forÿ overÿ 20ÿ yearsÿ andÿ areÿ stillÿ prescribedÿ
frequently.ÿ However,ÿ newerÿfluoroquinoloneÿagentsÿareÿgainingÿinÿ
popularity,ÿsinceÿ studiesÿhaveÿshownÿlessÿototoxicityÿassociatedÿwithÿtheirÿuse

TOPICAL THERAPY MECHANISM OF ACTION

HISTORY
Topicalÿ therapiesÿhaveÿbeenÿusedÿ toÿmanageÿexternalÿearÿdis
ordersÿforÿthousandsÿofÿyears.ÿAccordingÿtoÿMyer,1,2ÿmixturesÿofÿ
redÿlead,ÿtreeÿresin,ÿandÿoliveÿoilÿasÿwellÿasÿfrankincense,ÿgooseÿ
grease,ÿcreamÿfromÿcow’sÿmilk,ÿcrushedÿsoda,ÿvermilion,ÿcumin,ÿ
assÿ ear,ÿ andÿ hatetÿ oilÿ wereÿ usedÿ toÿ treatÿ chronicallyÿ drainingÿ
earsÿasÿlongÿasÿ3500ÿyearsÿago.ÿAÿprocessÿknownÿasÿear candling
Theÿexternalÿauditoryÿcanalÿ(EAC)ÿisÿlinedÿwithÿepitheliumÿthatÿ
providesÿ aÿ naturalÿ barrierÿ againstÿ theÿ environment.ÿ Theÿ suc
cessfulÿ deliveryÿ ofÿ topicalÿ medicationsÿ requiresÿ penetrationÿ
acrossÿthisÿbarrier,ÿandÿtheÿstratumÿcorneum,ÿtheÿmostÿsuperfi cialÿ
layerÿofÿ theÿepidermis,ÿprovidesÿ theÿgreatestÿresistanceÿ toÿ theÿ
permeationÿofÿdrugs.5 ÿPassiveÿdiffusionÿallowsÿ forÿmostÿofÿ theÿ
transportÿacrossÿ theÿ stratumÿcorneum,ÿandÿ theÿdegreeÿ ofÿ

2123
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2124 PARTÿVII | OTOLOGY, NEUROTOLOGY, AND SKULL BASE SURGERY
absorptionÿisÿrelatedÿtoÿtheÿpropertiesÿofÿtheÿagentÿbeingÿused.5
Twoÿ routesÿ ofÿ passiveÿ diffusionÿ acrossÿ theÿ stratumÿ corneumÿ
have beenÿ proposed,ÿ transappendagealÿ andÿepidermal. ÿ Becauseÿ
6
onlyÿ0.1%ÿofÿskinÿareaÿisÿcomposedÿofÿappendagesÿsuchÿasÿhairÿ
follicles,ÿ sebaceousÿ glands,ÿ andÿ soÿ on,ÿ theÿ epidermalÿ routeÿ
isÿ feltÿ toÿ beÿ theÿ moreÿ importantÿ routeÿ ofÿ drugÿ permeation.5,6
Topicalÿmedicationsÿ canÿdiffuseÿ throughÿ theÿ epidermisÿ trans
cellularlyÿorÿintercellularly.6 ÿTranscellularÿ transportÿisÿusedÿbyÿ
hydrophilicÿdrugs,ÿwhereasÿintercellularÿdiffusionÿoccursÿwithÿ
lipophilicÿcompounds.5,6ÿClearly,ÿtheÿagentÿorÿvehicleÿusedÿinÿaÿ
particularÿototopicalÿagentÿwillÿaffectÿitsÿabsorptionÿandÿdiffu sionÿ
acrossÿtheÿepidermis.
TOPICAL ANTIBIOTICS
Extremelyÿhighÿlocalÿconcentrationsÿ(3000ÿµg/mLÿ forÿaÿ0.3%ÿ oticÿ
solution)ÿofÿototopicalÿantibioticsÿcanÿbeÿachievedÿinÿ theÿ externalÿ
canal.ÿTheÿminimumÿinhibitoryÿconcentrationsÿ(MICs)ÿ forÿ
antibioticsÿ againstÿ commonÿ pathogensÿ associatedÿ withÿ externalÿ
earÿinfectionsÿareÿtypicallyÿlessÿthanÿ100,ÿbutÿtheyÿcanÿ beÿinÿtheÿ
mid-200sÿforÿresistantÿPseudomonas. trationsÿassociatedÿwithÿ
ÿTheÿlocalÿconcen
8
ototopicalsÿareÿsignificantlyÿhigherÿthanÿ theÿMICsÿforÿallÿpathogensÿ
thatÿhaveÿbeenÿisolatedÿfromÿexter nalÿearÿinfections,ÿwhichÿ
includesÿresistantÿorganisms.8 ÿInÿcon trast,ÿ theÿlocalÿ concentrationÿ
ofÿ antibioticsÿinÿ theÿmiddleÿ earÿ followingÿ oralÿ administrationÿ
ofÿ amoxicillin,ÿ erythromycin,ÿ azithromycin,ÿ orÿ cefiximeÿ (givenÿ
inÿ standardÿ adultÿ doses)ÿ rangesÿ fromÿ 1ÿ toÿ 15ÿµg/mL,ÿ
althoughÿ itÿ canÿ beÿ asÿ highÿ asÿ 35ÿµg/mLÿwithÿintravenousÿ(IV)ÿ
ceftriaxone,ÿandÿitÿmayÿnotÿbeÿ overÿtheÿMICsÿforÿtheÿoffendingÿ
organisms.9-11ÿTheseÿlevelsÿwereÿ observedÿasÿearlyÿasÿ4ÿhoursÿ
afterÿoralÿadministrationÿinÿhumanÿ subjectsÿ andÿ wereÿ measuredÿ
inÿ middleÿ earÿ fluidÿ samplesÿ obtainedÿusingÿtympanocentesis.ÿ
Noÿstudiesÿhaveÿbeenÿdoneÿtoÿ examineÿtheÿconcentrationsÿofÿ
antibioticsÿgivenÿsystemicallyÿinÿ theÿ externalÿ ear;ÿ however,ÿitÿisÿ
unlikelyÿ thatÿ thoseÿ concentra tionsÿ wouldÿ beÿ vastlyÿ differentÿ
fromÿ thoseÿ observedÿ inÿ theÿ middleÿear.
TOPICAL ANTIINFLAMMATORY
MEDICATIONS
Theÿmostÿcommonlyÿusedÿprescriptionÿantiinflammatoryÿmedi
cationsÿforÿexternalÿearÿconditionsÿalsoÿincludeÿanÿantibioticÿorÿ
antifungalÿagent,ÿalthoughÿoccasionallyÿanÿotolaryngologistÿwillÿ
prescribeÿaÿtopicalÿsteroidÿaloneÿforÿchronicÿpruritusÿorÿeczema.ÿ
FIGURE 138-1. Acute otitis externa. Erythema, edema, and copious purulent debris are seen (left), and in some cases, an edematous canal with granulation
tissue (right) necessitates placement of an ear wick to facilitate topical drug delivery in the acute setting. (Courtesy John House, MD.)
Mostÿofÿtheÿcurrentÿunderstandingÿofÿhowÿtheÿsteroidÿcompo
nentÿ ofÿ theseÿ preparationsÿ isÿ absorbedÿ regionallyÿ throughÿ
topicalÿapplicationÿcanÿbeÿfoundÿinÿtheÿdermatologicÿliterature.ÿ
Theÿ efficacyÿ ofÿ aÿ particularÿ steroidÿ preparationÿ isÿ associatedÿ
withÿ theÿinherentÿpotencyÿofÿ theÿcompoundÿandÿitsÿabilityÿ toÿ
penetrateÿtheÿepidermis.12ÿLipophilicÿ(nonpolar)ÿpreparationsÿ areÿ
transportedÿ acrossÿ theÿ stratumÿ corneumÿ moreÿ effectivelyÿ than
areÿhydrophilicÿ(polar)ÿmolecules.12ÿTheÿstratumÿcorneumÿ canÿ
alsoÿ actÿ asÿ aÿ reservoirÿ forÿ topicalÿ steroids,ÿ allowingÿ forÿ aÿ
prolongedÿregionalÿeffectÿafterÿtherapyÿisÿstopped.5,12ÿVehiclesÿ
such asÿethanolÿorÿpropyleneÿglycolÿincreaseÿtheÿsolubilityÿofÿaÿ
topicalÿagentÿ toÿenhanceÿpermeability.12ÿTheÿhydrationÿofÿ theÿ
stratumÿcorneumÿcanÿalsoÿbeÿenhancedÿbyÿusingÿocclusiveÿvehi
clesÿsuchÿasÿointments,ÿwhichÿalsoÿimproveÿdrugÿpenetration.12
EXTERNAL EAR DISORDERS
ACUTE BACTERIAL OTITIS EXTERNA
Acuteÿotitisÿexternaÿ(AOE),ÿorÿswimmer’s ear,ÿisÿaÿcommonÿdis
orderÿ thatÿ affectsÿ allÿ ageÿ groupsÿ andÿisÿ aÿ causeÿ ofÿ
significantÿ painÿandÿmorbidity.ÿTheÿdiseaseÿburdenÿofÿAOEÿisÿ
significantÿ andÿ accountsÿ forÿ 2.4ÿ millionÿ U.S.ÿ healthÿ visitsÿ
(8.1ÿ visitsÿ perÿ 1000ÿpopulation)ÿandÿ$0.5ÿbillionÿinÿspendingÿperÿyear.13ÿAOEÿ
isÿanÿinfectionÿofÿtheÿsensitiveÿEACÿskinÿthatÿoftenÿarisesÿfromÿ
prolongedÿmoistureÿsecondaryÿtoÿswimmingÿorÿbathing.ÿWhenÿ theÿ
skinÿbecomesÿmaceratedÿfromÿwaterÿexposure,ÿitÿisÿsuscep tibleÿ
toÿbacterialÿinvasion,ÿwhichÿcausesÿedemaÿandÿinflamma tion.ÿ
Copiousÿ purulentÿ debrisÿ developsÿ thatÿ canÿ becomeÿ trappedÿ
inÿ theÿ canalÿ ifÿ theÿ edemaÿ isÿ significantÿ (Fig.ÿ 138-1).ÿ
Additionally,ÿ traumaÿ toÿ theÿ canalÿ skin—forÿ example,ÿ fromÿ
instrumentationÿ withÿ cotton-tippedÿ swabs—alsoÿ increasesÿ theÿ
riskÿofÿAOE.14ÿApproximatelyÿ90%ÿofÿAOEÿcasesÿareÿbacterial,ÿ
whereasÿ onlyÿ 10%ÿ areÿ fungal.15ÿ Theÿ mostÿ commonÿ bacterialÿ
pathogenÿisÿPseudomonas aeruginosa,ÿ followedÿ byÿ Staphylococcus
aureus,ÿgram-negativeÿbacteria,ÿandÿanaerobes.15-17 Signs and
Symptoms AÿpatientÿwithÿAOEÿwillÿoftenÿcomplainÿofÿotalgia,ÿ
malodorousÿ otorrhea,ÿ andÿ hearingÿ lossÿ inÿ theÿ affectedÿ ear.ÿ
Theÿ physicalÿ examinationÿwillÿrevealÿpainÿtoÿpalpationÿofÿtheÿ
tragusÿorÿpinna,ÿ edematousÿandÿerythematousÿcanalÿ skin,ÿandÿ
purulentÿdebrisÿ (seeÿFig.ÿ138-1).ÿTheÿtympanicÿmembraneÿ(TM)ÿ
isÿoftenÿdiffi cultÿ toÿvisualizeÿinÿAOE;ÿ thusÿaÿ secondaryÿ
perforationÿcannotÿ beÿexcludedÿuntilÿafterÿdebridementÿorÿ
improvementÿofÿedema.ÿ Tuningÿforksÿwillÿusuallyÿlateralizeÿtoÿtheÿ
affectedÿear,ÿevenÿinÿ
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veryÿmildÿinfections,ÿandÿanÿaudiogram,ÿifÿperformedÿduringÿ
theÿacuteÿinfection,ÿwillÿconfirmÿaÿmildÿconductiveÿhearingÿloss.ÿ
Inÿsevereÿinfections,ÿtheÿpatientÿmayÿhaveÿcellulitisÿthatÿextendsÿ
toÿ theÿ faceÿ andÿ neckÿ inÿ additionÿ toÿ cervicalÿ lymphadenopa thyÿ
onÿ theÿ affectedÿ side.ÿ Inÿ chronicÿ OE,ÿ patientsÿ willÿ haveÿ
minimalÿotalgiaÿandÿwillÿoftenÿcomplainÿofÿpersistentÿotorrhea,ÿ
pruritus,ÿandÿmuffledÿhearing.ÿPhysicalÿexaminationÿmayÿrevealÿ
canalÿ thickening,ÿmoisture,ÿdebris,ÿand,ÿoccasionally,ÿgranula tionÿ
tissue.
Topical Therapy Options
Treatmentÿ ofÿ AOEÿ oftenÿ involvesÿ topicalÿ antibioticÿ prepara tions,ÿ
withÿorÿwithoutÿsteroids.ÿInÿmildÿacuteÿorÿchronicÿOE,ÿorÿ
asÿ aÿ preventiveÿ measure,ÿ acidifyingÿ agentsÿ mayÿ beÿ used.ÿ Sys
temicÿantibioticsÿareÿindicatedÿinÿsevereÿorÿrefractoryÿcasesÿorÿ
inÿpatientsÿwhoÿareÿimmunocompromised,ÿasÿdiscussedÿbelow.ÿ
Irrespectiveÿ ofÿ theÿ therapyÿ chosenÿ toÿ treatÿ AOE,ÿ removalÿ ofÿ
debrisÿ fromÿ theÿexternalÿcanalÿandÿevaluationÿofÿ theÿstatusÿofÿ
theÿTMÿareÿcrucialÿpriorÿtoÿusingÿanyÿototopicalÿtherapies,15,18-20
andÿ oralÿ analgesicsÿ areÿ oftenÿ neededÿ inÿ moderateÿ orÿ severeÿ
cases.ÿRepeatÿdebridementÿofÿtheÿcanalÿunderÿbinocularÿmicros copyÿ
isÿessentialÿtoÿimproveÿanÿinfectionÿthatÿremainsÿrefractoryÿ
to ototopicalÿ therapies.ÿ Inÿcasesÿwhereÿ theÿcanalÿisÿ extremelyÿ
edematous, itÿ mayÿ beÿ impossibleÿ toÿ visualizeÿ theÿ TM.ÿ Inÿ thisÿ
instance,ÿcareÿshouldÿbeÿ takenÿ toÿavoidÿ theÿuseÿofÿototopicalsÿ
withÿ potentialÿ ototoxicÿ sideÿ effects.18ÿ Significantÿ swellingÿ andÿ
edemaÿalsoÿrequireÿwickÿplacementÿ toÿensureÿproperÿdeliveryÿ
ofÿototopicalÿantibioticsÿmediallyÿinÿtheÿcanalÿ(seeÿFig.ÿ138-1).ÿ
Theÿwickÿshouldÿbeÿchangedÿorÿremovedÿwithinÿ3ÿtoÿ5ÿdaysÿofÿ
itsÿ insertion.ÿ Ifÿ theÿ canalÿ isÿ patent,ÿ tragalÿ massageÿ willÿ helpÿ
deliverÿ theÿ medicationÿ toÿ theÿ medialÿ EAC,ÿ andÿ holdingÿ theÿ
headÿinÿaÿdependentÿpositionÿforÿseveralÿminutesÿwillÿallowÿforÿ
sufficientÿfillingÿofÿtheÿinfectedÿcavity.
Ototopical Antibiotics. Ototopicalÿantibioticÿpreparations,ÿwithÿ
orÿwithoutÿsteroids,ÿareÿtheÿmostÿcommonÿagentsÿusedÿtoÿtreatÿ
AOEÿinÿtheÿotolaryngologyÿoffice.ÿTheseÿpreparationsÿachieveÿ
localÿtissueÿconcentrationsÿaboutÿaÿthousandÿtimesÿthatÿofÿsys temicÿ
antibiotics,ÿtheyÿhaveÿaÿfavorableÿsideÿeffectÿprofile,ÿandÿ
theyÿalsoÿdemonstrateÿaÿlowerÿincidenceÿofÿbacterialÿresistanceÿ
whenÿ comparedÿ withÿ systemicÿ antibiotics.7,15ÿ Theÿ Americanÿ
AcademyÿofÿOtolaryngology–HeadÿandÿNeckÿSurgeryÿFounda tionÿ
(AAO-HNSF)ÿ developedÿaÿClinicalÿ PracticeÿGuidelineÿinÿ
2006ÿforÿtheÿtreatmentÿofÿOE.ÿThisÿevidence-basedÿreportÿwasÿ
developedÿ byÿ representatives fromÿ otolaryngology–headÿ andÿ
neckÿ surgery,ÿ pediatrics,ÿ familyÿ medicine,ÿ infectiousÿ disease,ÿ
internalÿ medicine,ÿ emergencyÿ medicine,ÿ andÿ medicalÿ infor matics.ÿ
Theÿgroupÿmadeÿfirmÿrecommendationsÿtoÿuseÿ“topicalÿ
preparationsÿforÿinitialÿtherapyÿofÿdiffuse,ÿuncomplicatedÿAOE;ÿ
(systemic)ÿ antimicrobialÿ therapyÿ shouldÿ notÿ beÿ usedÿ unlessÿ
thereÿ isÿ extensionÿ outsideÿ ofÿ theÿ earÿ canalÿ orÿ unlessÿ specificÿ
hostÿfactorsÿareÿpresentÿthatÿwouldÿindicateÿaÿneedÿforÿsystemicÿ
therapy,ÿ suchÿ asÿ diabetes,ÿ priorÿ radiotherapy,ÿ orÿ immuno
compromise.18ÿDespiteÿ theseÿ recommendations,ÿ systemicÿanti
microbialsÿareÿstillÿutilizedÿinÿapproximatelyÿoneÿthirdÿofÿpatientÿ
visitsÿ asÿ ofÿ 2010ÿ afterÿ theÿ exclusionÿ ofÿ complicatingÿ factors,ÿ
andÿprescribingÿpatternsÿhaveÿnotÿchanged inÿresponseÿtoÿtheÿ
Clinicalÿ Practiceÿ Guidelineÿ inÿ 2006;ÿ thisÿ highlightsÿ theÿ needÿ
toÿ embraceÿ evidence-basedÿ guidelinesÿmovingÿ forward.21,22
Manyÿototopicalÿantibioticÿoptionsÿareÿavailableÿforÿtheÿman
agementÿ ofÿ AOE.ÿ Onlyÿ aÿ fewÿ clinicalÿ studiesÿ haveÿ carefullyÿ
examinedÿ theÿ relativeÿ efficacy,ÿ safety,ÿ andÿ cost-effectivenessÿ
amongÿtheseÿcommonlyÿprescribedÿtopicalÿagents.ÿHowever,ÿaÿ
recentÿ Cochraneÿ reviewÿ suggestedÿ thatÿ topicalÿ antimicrobialsÿ
thatÿcontainÿsteroidsÿareÿmoreÿeffectiveÿthanÿplacebo,ÿwithÿnoÿ
majorÿdifferencesÿinÿefficacyÿamongÿdifferentÿtopicalÿformula tions.23ÿ
Someÿcommonlyÿusedÿpreparationsÿforÿtheÿtopicalÿman agementÿofÿ
AOEÿareÿdiscussedÿhere.
138 | TOPICAL THERAPIES FOR EXTERNAL EAR DISORDERS 2125
Cortisporin.ÿ Cortisporinÿoticÿsuspensionÿandÿsolutionÿ(neo mycin,ÿ
polymyxin,ÿandÿhydrocortisoneÿ1%)ÿhaveÿbothÿantibac terialÿ andÿ
antiinflammatoryÿ properties.ÿ Theÿ suspensionÿ isÿ aÿ
milkyÿwhiteÿagentÿandÿhasÿbeenÿaÿpopularÿchoiceÿ forÿuncom
plicatedÿ bacterialÿ AOEÿ forÿ manyÿ yearsÿ owingÿ toÿ itsÿ efficacy,ÿ
patientÿ tolerance,ÿ andÿlowÿ cost.ÿTheÿ suspensionÿ andÿ solutionÿ
eachÿcontainÿaÿ3.5-mgÿneomycinÿbase,ÿ10,000ÿunitsÿpolymyxinÿ
B,ÿandÿ10ÿmgÿofÿhydrocortisoneÿ1%ÿperÿmilliliter.ÿTheÿsuspen sionÿ
vehicleÿingredientsÿincludeÿcetylÿalcohol,ÿpropyleneÿglycol,ÿ
polysorbate,ÿandÿwater,ÿwhereasÿtheÿsolutionÿusesÿcupricÿsulfate,ÿ
glycerin,ÿhydrochloricÿacid,ÿpropyleneÿglycol,ÿandÿwater.24,25ÿTheÿ
suspensionÿhasÿaÿlessÿacidicÿpHÿ(3.0ÿcomparedÿwithÿ2.0ÿforÿtheÿ
solution)ÿandÿisÿthereforeÿbetterÿtolerated.ÿNeomycinÿhasÿbeenÿ
inÿuseÿforÿoverÿ40ÿyearsÿandÿisÿoneÿofÿtheÿoldestÿaminoglycosides.ÿ
However,ÿPseudomonasÿhasÿdevelopedÿresistanceÿtoÿneomycin,8,26
andÿlessÿ thanÿ20%ÿ ofÿPseudomonasÿpathogensÿ retainÿ sensitivity.8
Polymyxinsÿareÿ cationicÿ detergentÿantibioticsÿ thatÿ disruptÿ theÿ
bacterialÿcellÿmembrane.ÿTheyÿworkÿwellÿagainstÿgram-negativeÿ
rods,ÿ especiallyÿ Pseudomonas.ÿ Althoughÿ neomycinÿ andÿ poly
myxinÿ haveÿ ototoxicÿ potentialÿinÿ animalÿ studies,ÿ humanÿ dataÿ
areÿ equivocal.15,27-30ÿ Weÿ haveÿ usedÿ thisÿ preparationÿ forÿ manyÿ
yearsÿinÿtheÿmiddleÿearÿtoÿsoakÿGelfoamÿpacking, withoutÿcon
sequence.ÿ Theÿ manufacturerÿ recommendsÿ thatÿ Cortisporinÿ
OticÿshouldÿnotÿbeÿusedÿinÿpatientsÿwithÿTMÿperforations.24,25
Ofloxacin.ÿ Ofloxacinÿ (ofloxacinÿ 0.3%ÿ withÿ benzalkoniumÿ
chlorideÿ0.0025%,ÿsodiumÿchlorideÿ0.9%,ÿandÿwaterÿ[pHÿ6.5])ÿ
isÿaÿtopicalÿfluoroquinoloneÿcommonlyÿusedÿinÿAOE.ÿItÿcanÿbeÿ
usedÿwithÿTMÿperforationsÿandÿventilationÿtubes,ÿbecauseÿitÿhasÿ
noÿknownÿriskÿofÿototoxicity,4,31,32ÿwhichÿmakesÿofloxacinÿaÿrea
sonableÿchoiceÿ forÿearÿ surgeryÿprophylaxis.ÿ Indeed,ÿofloxacinÿ
oticÿ isÿ approvedÿ byÿ theÿ U.S.ÿ Foodÿ andÿ Drugÿ Administrationÿ
(FDA)ÿforÿuseÿinÿpatientsÿwithÿsuppurativeÿOMÿandÿperforatedÿ
TMs.33ÿ Likeÿ allÿ fluoroquinolones,ÿ ofloxacinÿ actsÿ byÿinhibitingÿ
DNAÿsynthesisÿandÿbacterialÿgrowthÿbyÿbindingÿtoÿDNAÿgyraseÿ
andÿ topoisomerases.ÿCommonlyÿ reportedÿ sideÿ effectsÿincludeÿ
pruritusÿandÿaÿbitterÿtasteÿifÿusedÿwithÿaÿperforatedÿTM.ÿClinicalÿ
cureÿ ratesÿ forÿ AOEÿ afterÿ treatmentÿ withÿ ofloxacinÿ haveÿ beenÿ
shownÿtoÿbeÿgreaterÿthanÿ80%ÿinÿadultsÿandÿgreaterÿthanÿ95%ÿ
inÿchildren.31
Ciprofloxacinÿ andÿ Hydrocortisone.ÿ Ciprofloxacinÿ withÿ hydro
cortisoneÿ(CiproÿHCÿOtic;ÿciprofloxacinÿ0.2%,ÿhydrocortisoneÿ
1%,ÿandÿbenzylÿalcoholÿasÿpreservative)ÿisÿaÿtopicalÿfluoroquino loneÿ
thatÿalsoÿcontainsÿaÿ steroidÿagent.ÿ Itÿhasÿbroad-spectrumÿ
coverage,ÿwhichÿincludesÿPseudomonas,ÿ althoughÿ itÿhasÿnoÿactivity
againstÿ anaerobes.ÿ Ototoxicityÿ hasÿ notÿ beenÿ shownÿ toÿ beÿ aÿ
concernÿwithÿtopicalÿciprofloxacin;ÿthusÿitÿisÿfeltÿtoÿbeÿsafeÿforÿuseÿ
withÿTMÿperforations.34,35ÿAlthoughÿmanyÿphysiciansÿuseÿCiproÿ
HCÿOticÿinÿtheÿpresenceÿofÿTMÿperforations,ÿtheÿmanufacturerÿ
recommendsÿagainstÿthis,ÿbecauseÿtheÿbottleÿisÿnotÿsterile.36
Ciprofloxacinÿ andÿ Dexamethasone.ÿ Ciprofloxacinÿ withÿ dexa
methasoneÿ (Ciprodexÿ Otic;ÿ ciprofloxacinÿ 0.3%,ÿ dexametha soneÿ
0.1%)ÿ alsoÿ combinesÿ ciprofloxacinÿ withÿ aÿ steroidÿ forÿ
antiinflammatoryÿproperties.ÿItÿisÿsafeÿforÿuseÿwithÿTMÿperfora tionsÿ
andÿ isÿ FDAÿ approvedÿ forÿ useÿ inÿ patientsÿ withÿ patentÿ
tympanostomyÿ tubes.37ÿCiprodexÿ hasÿ beenÿ shownÿinÿ random izedÿ
clinicalÿ trialsÿ toÿbeÿmoreÿ effectiveÿatÿ resolvingÿAOEÿ thanÿ
wasÿneomycin/polymyxin/hydrocortisone38ÿandÿhasÿalsoÿbeenÿ
shownÿinÿaÿlarge,ÿrandomizedÿblindedÿstudyÿtoÿbeÿsuperiorÿtoÿ
ofloxacinÿinÿ treatingÿacuteÿOMÿwithÿotorrheaÿ throughÿ tympa
nostomyÿ tubes.39ÿ Noÿ studyÿ directlyÿ comparesÿ Ciprodexÿ withÿ
CiproÿHCÿOticÿsuspensionÿinÿhumans,ÿalthoughÿSobolÿandÿcol
leagues40ÿdemonstratedÿinÿanÿanimalÿmodelÿthatÿCiprodexÿwasÿ
superiorÿtoÿCiproÿHCÿatÿtreatingÿgranulationÿtissueÿinÿtheÿexter nalÿ
andÿmiddleÿear.
TobramycinÿandÿDexamethasone.ÿ Tobramycin plusÿdexameth
asoneÿ(Tobradex;ÿtobramycinÿ0.3%,ÿdexamethasoneÿ0.1%,ÿandÿ
benzalkoniumÿchlorideÿ0.01%ÿasÿaÿpreservative)ÿisÿanÿophthal micÿ
preparationÿwithÿbothÿantibacterialÿandÿantiinflammatoryÿ
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2126 PARTÿVII | OTOLOGY, NEUROTOLOGY, AND SKULL BASE SURGERY
activity.ÿ Tobramycinÿ isÿ anÿ aminoglycosideÿ thatÿ bindsÿ toÿ theÿ
30Sÿ andÿ 50Sÿ ribosomalÿ subunitsÿ andÿ leadsÿ toÿ inhibitionÿ ofÿ
bacterialÿ proteinÿ synthesisÿ andÿ resultsÿinÿ aÿ defectiveÿ bacterialÿ
cellÿmembrane.ÿTobramycinÿshouldÿbeÿavoidedÿinÿpatientsÿwithÿ
TMÿ perforationsÿ orÿ tympanostomyÿ tubesÿ becauseÿ ofÿ possibleÿ
ototoxicity.41-43
Topicalÿ Gentamicin.ÿ Topicalÿ gentamicinÿ (Garamycinÿ Oph
thalmic;ÿgentamicinÿ0.3%ÿ[pHÿ7])ÿisÿanotherÿophthalmicÿprep arationÿ
thatÿ canÿ beÿ usedÿ inÿ AOE,ÿ especiallyÿ whenÿ additionalÿ
gram-negativeÿcoverageÿisÿneeded.ÿAgain,ÿitÿshouldÿbeÿavoidedÿ
withÿTMÿperforationsÿbecauseÿofÿconcernsÿforÿototoxicity.41-43
Evidence-Based Data on Ototopical Antibiotics in Acute Otitis
Externa. Rolandÿ andÿ colleagues38,44ÿ performedÿ twoÿ random izedÿ
multicenterÿ studiesÿ thatÿcomparedÿototopicalÿantibiotics.ÿ
Theÿclinicalÿefficacyÿofÿ1ÿweekÿofÿciprofloxacinÿplusÿdexametha soneÿ
(Ciprodex)ÿorÿneomycinÿandÿpolymyxinÿBÿplusÿhydrocor tisoneÿ
(Cortisporin)ÿwasÿstudiedÿinÿ468ÿadultsÿandÿchildrenÿwithÿ
AOEÿ andÿ intactÿ TMs.ÿ Ciprofloxacinÿ plusÿ dexamethasoneÿ
showedÿ higherÿ bacterialÿ eradicationÿ ratesÿ andÿ moreÿ rapidÿ
symptomÿ improvementÿ comparedÿ withÿ neomycinÿ andÿ poly myxinÿ
Bÿplusÿhydrocortisone.ÿThisÿwasÿfollowedÿbyÿaÿstudyÿthatÿ
investigatedÿtheÿefficacyÿofÿciprofloxacinÿhydrocortisoneÿ(Ciproÿ
HC)ÿcomparedÿwithÿthatÿofÿCortisporinÿandÿsystemicÿamoxicil lin.ÿ
Ciproÿ HCÿ wasÿ foundÿ toÿ beÿ clinicallyÿ equivalentÿ forÿ theÿ
treatmentÿofÿadultsÿandÿchildrenÿwithÿOE.44ÿVanÿBalenÿandÿcol
leagues45ÿ performedÿ aÿ randomizedÿ clinicalÿ trialÿ ofÿ ototopicalÿ
therapiesÿ thatÿ comparedÿ aceticÿ acidÿ alone,ÿ aceticÿ acidÿ plusÿ
corticosteroid,ÿ andÿ antibioticÿ plusÿ corticosteroidÿ forÿ AOE.ÿ Inÿ
213ÿadultsÿwithÿAOE,ÿpatientsÿwhoÿreceivedÿpreparationsÿ thatÿ
includedÿsteroids,ÿeitherÿaceticÿacidÿorÿantibiotics,ÿhadÿsignifi cantlyÿ
higherÿ cureÿ ratesÿ comparedÿ withÿ thoseÿ whoÿ receivedÿ
aceticÿacidÿalone.45ÿTheÿaceticÿacid–aloneÿgroupÿalsoÿhadÿhigherÿ
recurrenceÿratesÿofÿOE.45ÿSchwartz46ÿperformedÿaÿrandomizedÿ
multicenterÿblindedÿstudyÿinÿwhichÿpatientsÿwithÿAOEÿreceivedÿ
eitherÿ ototopicalÿ ofloxacinÿ administeredÿ onceÿ dailyÿ orÿ
neomycin/polymyxin/hydrocortisoneÿadministeredÿfourÿtimesÿ
daily.ÿ Inÿ 278ÿ pediatricÿ patientsÿ withÿ pseudomonalÿ OE,ÿ bothÿ
agentsÿwereÿfoundÿtoÿbeÿequallyÿeffectiveÿatÿeradicatingÿdiseaseÿ
andÿ hadÿ similarÿ safetyÿ profiles.ÿ Givenÿ theÿ decreasedÿ ototoxicÿ
potentialÿ ofÿ ofloxacinÿ andÿ theÿ easierÿ dosingÿ schedule,ÿ theÿ
authorÿ concludedÿ thatÿ ofloxacinÿ mightÿ beÿ aÿ betterÿ first lineÿ
agent.ÿTheÿsameÿconclusionÿwasÿreachedÿbyÿSimpsonÿandÿ
Markham31ÿ inÿ aÿ meta-analysisÿ ofÿ theÿ literatureÿ concerningÿ
ofloxacinÿuseÿforÿAOE.ÿMyer1 ÿfoundÿthatÿwhenÿcomparedÿwithÿ
aminoglycosides,ÿototopicalÿfluoroquinolonesÿhaveÿanÿimprovedÿ
safetyÿprofile,ÿaÿbroadÿantimicrobialÿspectrum,ÿandÿaÿlowerÿcost,ÿ
andÿ theÿconvenientÿdosingÿ scheduleÿisÿ toleratedÿwellÿbyÿmostÿ
patients.ÿRosenfeldÿandÿcolleagues47ÿfoundÿ18ÿstudiesÿthatÿcon
cernedÿototopicalÿtherapyÿforÿAOEÿandÿcomparedÿtheÿfollowingÿ
groups:ÿantimicrobialÿversusÿplacebo;ÿantisepticÿversusÿantimi crobial;ÿ
fluoroquinoloneÿ antibioticÿ versusÿ antibiotic;ÿ steroidÿ
plusÿ antimicrobialÿ versusÿ antimicrobial;ÿ orÿ antimicrobialÿ plusÿ
steroid versusÿ steroid.ÿ Clinicalÿ cureÿ ratesÿ wereÿ betweenÿ 65%ÿ
andÿ80%ÿwithinÿ10ÿdaysÿofÿtherapyÿwithÿallÿofÿtheÿaboveÿototopi calÿ
antibiotics,ÿandÿnoÿstatisticalÿdifferenceÿinÿclinicalÿcureÿratesÿ
wasÿ notedÿ amongÿ anyÿ ofÿ theÿ treatmentÿ groups.ÿ Fluoroquino
lonesÿ didÿ haveÿ anÿ 8%ÿ higherÿ bacteriologicÿ cureÿ rateÿ comparedÿ
withÿnonquinoloneÿototopicals;ÿhowever,ÿtheÿclinicalÿcureÿrateÿ
andÿ ratesÿ ofÿ adverseÿ sideÿ effectsÿwereÿ theÿ sameÿ asÿ thoseÿ seenÿ
withÿtheÿotherÿpreparations.47ÿTheÿadditionÿofÿaÿsteroidÿtoÿfluo
roquinoloneÿ agentsÿ decreasesÿ theÿ symptomaticÿ periodÿ byÿ
approximatelyÿ0.8ÿdays.1,3ÿHowever,ÿasÿdiscussedÿbelow,ÿsteroidsÿ
doÿhaveÿaÿsmallÿriskÿofÿcausingÿaÿhypersensitivityÿreaction.
Althoughÿ lessÿ commonlyÿ recommendedÿ byÿ otolaryngolo gists,ÿ
someÿ studiesÿ advocateÿ usingÿ onlyÿ steroidÿ preparationsÿ
withoutÿ antibiotics.ÿ Tsikoudasÿ andÿ colleagues48ÿ performedÿ aÿ
randomizedÿdouble-blindedÿstudyÿofÿ39ÿpatientsÿwithÿAOEÿwhoÿ
wereÿtreatedÿwithÿeitherÿaÿsteroidÿandÿanÿaminoglycosideÿorÿtheÿ
sameÿ steroidÿ alone.ÿ Theyÿ foundÿ noÿ additionalÿ benefitÿ ofÿ theÿ
addedÿ aminoglycoside.ÿ Similarly,ÿ Emgårdÿ andÿ associates49
studiedÿ51ÿpatientsÿwithÿAOEÿinÿanÿopen,ÿrandomizedÿparallel groupÿ
trialÿthatÿcomparedÿsteroidÿdropsÿaloneÿ(0.05%ÿsolutionÿ
ofÿbetamethasoneÿdipropionate)ÿwithÿearÿdropsÿthatÿcontainedÿ
aÿ steroidÿ withÿ anÿ antibioticÿ (hydrocortisoneÿ withÿ oxytetracy clineÿ
hydrochlorideÿ andÿ polymyxinÿ B).ÿ Theyÿ foundÿ thatÿ theÿ
steroid aloneÿhadÿaÿhigherÿclinicalÿcureÿrateÿthanÿtheÿantibioticÿ
andÿ steroidÿ together.ÿ Theseÿ dataÿ areÿ inÿ contrastÿ toÿ aÿ moreÿ
recentÿstudy,ÿwhichÿshowedÿsuperiorityÿofÿtheÿantibiotic-steroidÿ
combinationÿbetamethasoneÿsodiumÿphosphateÿ0.1%ÿwithÿneo mycinÿ
sulfateÿ 0.5%ÿ (Vista-Methasoneÿ N)ÿ whenÿ comparedÿ toÿ
betamethasoneÿsodiumÿphosphateÿ0.1%ÿ(Vista-Methasone).50
Resistance Associated with Ototopical Antibiotic Therapy.
Grade B evidenceÿisÿdefinedÿbyÿtheÿU.S.ÿPreventativeÿServicesÿTaskÿ
Forceÿasÿevidenceÿthatÿsuggestsÿbenefitsÿoutweighÿtheÿpotentialÿ
risks,ÿandÿ thisÿisÿwhatÿWeberÿandÿcolleagues51ÿ foundÿoverall—
thatÿnoÿsignificantÿantibioticÿresistanceÿdevelopsÿ fromÿ theÿuseÿ
ofÿototopicalÿantibioticÿtherapy,ÿwhichÿdoesÿofferÿsomeÿbenefit.ÿ
Cantrellÿandÿcolleagues26ÿexaminedÿtheÿsusceptibilityÿofÿisolatesÿ
fromÿAOEÿtoÿneomycin/polymyxinÿandÿofloxacin.ÿTheÿMICsÿofÿ
eachÿantimicrobialÿdrugÿforÿtheÿmajorÿpathogens,ÿPseudomonas
andÿ Staphylococcus aureus,ÿ wereÿ studied,ÿ alongÿ withÿ bacterialÿ
eradicationÿandÿclinicalÿefficacy,ÿfromÿ1995ÿthroughÿ1996ÿandÿ
fromÿ1999ÿ throughÿ2000.26ÿTheÿdataÿ fromÿ1999ÿ throughÿ2000ÿ
showedÿ thatÿ theÿ MICsÿ forÿ allÿ pathogensÿ increasedÿ aboveÿ theÿ
breakpointÿforÿpolymyxinÿB.ÿInÿcontrast,ÿtheÿMICsÿofÿallÿisolatesÿ
forÿofloxacinÿremainedÿsimilarÿbetweenÿ theÿ twoÿ timeÿperiods,ÿ
indicatingÿ thatÿ resistanceÿ developedÿ toÿ neomycin/polymyxinÿ
butÿnotÿtoÿofloxacin.26ÿWaiÿandÿTong32ÿnoteÿthatÿminimalÿresis
tanceÿhasÿ beenÿ documentedÿagainstÿ ofloxacinÿ sinceÿitsÿinitialÿ
useÿinÿtheÿ1980s,ÿbecauseÿonlyÿtwoÿstrainsÿofÿPseudomonasÿhaveÿ
beenÿ shownÿ toÿhaveÿ slightÿ resistanceÿ toÿofloxacin.ÿBecauseÿofÿ
extremelyÿhighÿlocalÿconcentrationsÿachievedÿwithÿtopicalÿther apiesÿ
thatÿfarÿexceedÿevenÿtheÿhighestÿMICsÿforÿresistantÿPseu domonas,ÿ
itÿisÿunlikelyÿthatÿresistanceÿwillÿbeÿaÿlargeÿfactorÿinÿtheÿ
choiceÿofÿototopicalÿantibiotics.
Acidifying Agents in Acute Bacterial Otitis Externa
Acidifyingÿagentsÿmayÿbeÿusedÿinÿmildÿacuteÿorÿchronicÿcasesÿ
whereÿthereÿisÿminimalÿotalgia,ÿbutÿtheirÿmainÿutilityÿisÿinÿtheÿ
preventiveÿcareÿofÿpatientsÿwhoÿareÿproneÿtoÿdevelopingÿrecur rentÿ
acuteÿorÿchronicÿOEÿ(swimmers,ÿhearingÿaidÿusers,ÿandÿsoÿ
on).ÿ Alkalineÿ pHÿ hasÿ beenÿ shownÿ toÿ beÿ aÿ riskÿ factorÿ forÿ theÿ
developmentÿofÿacuteÿandÿchronicÿOE,52,53ÿwithÿlossÿofÿacidityÿ
proportionalÿ toÿ theÿ degreeÿ ofÿ OE,54ÿ andÿ thusÿ restoringÿ theÿ
naturalÿ acidityÿ ofÿ theÿ EACÿ canÿ inhibitÿ theÿ growthÿ ofÿ patho
genicÿ bacteria.ÿUnfortunately,ÿtheÿacidicÿpHÿofÿtheseÿprepara tionsÿ
mayÿlimitÿpatientÿcomplianceÿbecauseÿofÿpainÿandÿlocalÿ
irritation.20ÿTheseÿagentsÿareÿcontraindicatedÿifÿaÿTMÿperfora tionÿ
orÿ tympanostomyÿ tubeÿ isÿ presentÿ becauseÿ ofÿ possibleÿ
ototoxicity.3,55
Theÿ followingÿ areÿ commonlyÿ usedÿ acidifyingÿ solutionsÿ for
mild OE,ÿchronicÿOE,ÿorÿpreventiveÿcareÿofÿtheÿexternalÿcanal.
1.ÿ Alcohol-vinegarÿsolutionÿthatÿisÿ50%ÿalcohol,ÿ25%ÿwhiteÿ
vinegar,ÿandÿ25%ÿdistilledÿwater.ÿThisÿisÿinexpensive,ÿeasyÿ
toÿprepareÿatÿhome,ÿandÿcanÿbeÿasÿeffectiveÿasÿprescrip tionÿ
agentsÿinÿthisÿcategory.ÿTypically,ÿseveralÿdropsÿ(4ÿtoÿ
5),ÿwhichÿcanÿeasilyÿbeÿdeliveredÿwithÿaÿsyringe,ÿareÿused
inÿtheÿaffectedÿearÿtwoÿtoÿfourÿtimesÿdailyÿuntilÿsymptoms
resolve.ÿItÿisÿcontraindicatedÿinÿpatientsÿwithÿTMÿperfora tionsÿ
orÿ ventilationÿ tubes,ÿ orÿifÿ theÿpatientÿhasÿaÿhyper sensitivityÿ
toÿ anyÿ ofÿ theÿ components.ÿ Thisÿ preparationÿ
canÿ beÿ usedÿ safelyÿ asÿ anÿ irrigationÿ solutionÿ ifÿ copiousÿ
debrisÿisÿpresentÿinÿ theÿcanalÿandÿnoÿTMÿperforationÿisÿ
present.
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138 | TOPICAL THERAPIES FOR EXTERNAL EAR DISORDERS 2127
2.ÿ Aceticÿacidÿinÿaluminumÿacetateÿdropsÿ(Domeboro)ÿmayÿ
beÿusedÿinÿmildÿcasesÿofÿOEÿ toÿhelpÿacidifyÿandÿdryÿ theÿ
canal.ÿ Fiveÿdropsÿareÿappliedÿ toÿ theÿaffectedÿ earÿ twoÿ to
fourÿtimesÿdaily.ÿThisÿshouldÿnotÿbeÿusedÿifÿaÿTMÿperfora
tionÿorÿventilationÿtubeÿisÿpresent.55,56 3.ÿ Propyleneÿ glycolÿ
andÿ aceticÿ acidÿ oticÿ solutionÿ (VoSol)ÿ andÿhydrocortisoneÿ
1%ÿplusÿpropyleneÿglycolÿandÿaceticÿ acidÿoticÿsolutionÿ
(VoSolÿHC) alsoÿworkÿwellÿinÿsuperficial infections.ÿ Theÿ
aceticÿ acidÿ hasÿ antibacterialÿ properties,ÿ whereasÿ theÿ
hydrocortisoneÿ helpsÿ reduceÿinflammation andÿpruritus.ÿBothÿ
ofÿtheseÿpreparationsÿareÿquiteÿviscous andÿhaveÿaÿpHÿofÿ
approximatelyÿ3.ÿTwoÿtoÿfourÿdropsÿareÿ appliedÿtwoÿtoÿfourÿ
timesÿdaily.ÿThisÿsolutionÿshouldÿnotÿ beÿusedÿinÿtheÿsettingÿ
ofÿaÿTMÿperforationÿorÿventilationÿ tubeÿbecauseÿofÿaÿ
concernÿforÿototoxicity.57,58 Withÿsoÿfewÿtrialsÿtoÿexamineÿ
andÿcompareÿtheÿmanyÿdiffer entÿototopicalÿformulations,ÿtheÿ
decisionÿregardingÿwhichÿoneÿ toÿchooseÿforÿAOEÿisÿoftenÿleftÿupÿ
toÿtheÿpersonalÿclinicalÿexpe rienceÿ andÿ opinionÿ ofÿ theÿ treatingÿ
physician.ÿ Inÿ additionÿ toÿ efficacy,ÿ theÿconcernÿofÿototoxicityÿ
whenÿaÿTMÿperforationÿorÿ ventilationÿtubeÿisÿpresent,ÿpatientÿ
toleranceÿandÿdosageÿsched ule,ÿandÿhypersensitivityÿ concernsÿ
mayÿhelpÿ guideÿ theÿ choiceÿ ofÿtopicalÿantibioticÿtherapyÿforÿAOE.
WhenÿinitialÿtherapyÿfailsÿtoÿtreatÿAOE,ÿtheÿphysicianÿshould
considerÿnotÿonlyÿ theÿpossibilitiesÿofÿimproperÿadministrationÿ orÿ
ineffectivenessÿofÿtheÿototopicalÿbutÿalsoÿotherÿpossibleÿdiag
noses,ÿ suchÿ asÿ contactÿ dermatitis,ÿ malignantÿ otitisÿ externaÿ
(MOE),ÿorÿotherÿmalignancyÿ(Boxÿ138-1).15 Systemic Therapy for
Acute Bacterial Otitis Externa
TheÿAAO-HNSFÿrecommendsÿthatÿaddingÿaÿsystemicÿantibioticÿ
mayÿ beÿ beneficialÿ inÿ patientsÿ withÿ OEÿ andÿ aÿ historyÿ ofÿ
priorÿ radiationÿ therapy,ÿ diabetes,ÿ orÿ immunocompromisedÿ
state.18 Additionally,ÿ patientsÿ withÿ concomitantÿ parotitisÿ orÿ
cellulitisÿ thatÿ extendsÿ toÿ theÿ auricle,ÿ face,ÿ orÿ neckÿ andÿ
patientsÿ withÿ concurrentÿOMÿwithoutÿTMÿperforationÿorÿ
tympanostomyÿtubeÿ shouldÿ receiveÿ oralÿ antibiotics.ÿ Finally,ÿ
patientsÿ whoÿ failÿ toÿ respondÿ toÿaÿ fullÿcourseÿ ofÿ ototopicalsÿ
mayÿ benefitÿ fromÿ oralÿ antibiotics.7,17,18,20ÿ Itÿmayÿ beÿprudentÿ
toÿ obtainÿaÿcultureÿpriorÿ toÿstartingÿantibioticsÿinÿpatientsÿwithÿ
refractoryÿOEÿorÿpriorÿtoÿ startingÿ topicalÿ therapyÿ inÿ patientsÿ
withÿ underlyingÿ immuneÿ compromise.
Special Considerations in Chronic
Bacterial Otitis Externa
Symptomsÿ suchÿasÿpersistentÿotorrhea,ÿauralÿ fullness,ÿmuffledÿ
hearing,ÿandÿpruritusÿlastingÿlongerÿ thanÿ 3ÿmonthsÿmayÿindi cateÿ
chronicÿOE.ÿThisÿcanÿbeÿtheÿresultÿofÿinadequatelyÿtreatedÿ
infectiousÿOE,ÿbutÿnoninfectiousÿcausesÿshouldÿalsoÿbeÿconsid
eredÿ andÿ areÿ discussedÿ inÿ theÿ section onÿ eczematoidÿ OEÿ
below.15,59ÿ InÿchronicÿOE,ÿ topicalÿantibioticÿ therapiesÿmayÿnotÿ
Box 138-1. DIFFERENTIAL DIAGNOSIS IF ACUTE
OTITIS EXTERNA FAILS TO RESPOND TO INITIAL
OTOTOPICAL THERAPY
Self-instrumentation trauma
Malignant external otitis
Contact dermatitis
Failure to adhere to preventive measures such as avoiding water in
the ear
Improper administration of ototopical
Immunosuppression (diabetes, prior radiotherapy)
Inadequate penetration of ototopical because of debris or thickened
canal skin
Misdiagnosis (psoriasis, cancer, tuberculosis)
Resistance of involved organism to ototopical choice
beÿasÿeffectiveÿinÿresolvingÿlong-standingÿinflammation.ÿRecentÿ
evidenceÿ suggestsÿ aÿ roleÿ forÿ biofilmsÿ inÿ theÿ pathogenesisÿ ofÿ
chronicÿbacterialÿOE,ÿandÿbiofilmsÿareÿpresentÿinÿoverÿ90%ÿofÿ
cases,ÿ whichÿ mayÿ contributeÿ toÿ theÿ difficultÿ natureÿ ofÿ theseÿ
cases.60ÿInÿmanyÿcases,ÿinadequateÿearÿhygieneÿorÿmanipulationÿ
withÿ cotton-tippedÿ swabsÿ mayÿ contributeÿ toÿ chronicÿ bacterialÿ
infectionÿ andÿ shouldÿ beÿ addressedÿ byÿ theÿ otolaryngologist.ÿ
Dailyÿirrigationÿwithÿanÿacidifyingÿorÿdehydratingÿagentÿandÿuseÿ
ofÿaÿhairÿdryerÿonÿaÿlow,ÿcoolÿsettingÿafterÿwaterÿexposureÿwillÿ
helpÿtoÿoptimizeÿdailyÿearÿhygiene.ÿDryÿpowderÿpreparationsÿasÿ
discussedÿ belowÿareÿaÿ reasonableÿalternativeÿ toÿ topicalÿdrops,ÿ
becauseÿcontinuedÿmoistureÿfromÿlong-termÿototopicalÿuseÿcanÿ
contributeÿ toÿ macerationÿ ofÿ theÿ externalÿ canalÿ skinÿ andÿ canÿ
leadÿ toÿ chronicÿ infection.ÿ Culturesÿ ofÿ theÿ canalÿ shouldÿ beÿ
obtainedÿ toÿ ensureÿ sensitivityÿ ofÿ theÿ organismsÿ toÿ theÿ
chosenÿ ototopicalÿantibiotic.
Steroidÿcreamsÿandÿlocalÿsteroidÿinjectionsÿhaveÿbeenÿusedÿ
withÿtopicalÿantibioticsÿtoÿimproveÿtheÿefficacyÿofÿtreatmentÿinÿ
chronicÿOE.ÿStuckÿandÿcolleagues61ÿexaminedÿ13ÿpatientsÿwithÿ
refractoryÿOEÿdespiteÿtreatmentÿwithÿtopicalÿsteroidsÿandÿanti
biotics,ÿandÿtheyÿinjectedÿtheÿearÿcanalÿskinÿwithÿtriamcinoloneÿ
acetonide;ÿ theÿmajorityÿofÿ theseÿpatientsÿreportedÿaÿcompleteÿ
resolutionÿofÿsymptoms.ÿInÿsuchÿcases,ÿchronicÿOEÿmayÿnotÿbeÿ
theÿresultÿofÿpersistentÿbacterialÿinfection,ÿandÿitÿisÿimportantÿtoÿ
considerÿotherÿetiologies,ÿsuchÿasÿcontactÿdermatitisÿandÿeczemaÿ
orÿ anÿ underlyingÿ canalÿ cholesteatoma,ÿ keratosisÿ obturans,ÿ orÿ
malignancy.ÿ Inÿ addition,ÿ itÿ mayÿ beÿ difficultÿ toÿ distinguishÿ aÿ
failureÿofÿinitialÿ therapyÿ fromÿhypersensitivityÿreactionsÿ toÿ theÿ
ototopicalÿ agent,ÿ becauseÿ theÿ signsÿ andÿ symptomsÿ areÿ oftenÿ
similar.ÿItÿisÿthereforeÿimportantÿtoÿhaveÿaÿhighÿindexÿofÿsuspi cionÿ
forÿpossibleÿdrugÿreactions,ÿespeciallyÿwhenÿusingÿprepara tionsÿ
withÿhigherÿratesÿofÿsensitization.
Otherÿ lessÿ commonÿ approachesÿ includeÿ silverÿ nitrateÿ gel,ÿ
whichÿhasÿ shownÿ someÿefficacyÿinÿpatientsÿwithÿrefractoryÿOEÿ
orÿ otomycosis.62ÿ Inÿ rareÿ cases,ÿ persistentÿ fociÿ ofÿ granulationÿ
tissueÿhaveÿbeenÿ treatedÿwithÿ smallÿ fragmentsÿofÿ silverÿnitrateÿ
placedÿ inÿ theÿ externalÿ canalÿ withÿ theÿ binocularÿ microscope.ÿ
Thisÿapproachÿ shouldÿbeÿavoidedÿinÿpreviouslyÿoperatedÿ earsÿ
andÿ specificallyÿinÿ patientsÿwhoÿ haveÿ undergoneÿ aÿ canal-wall
downÿmastoidectomy,ÿinÿtheÿeventÿthatÿanÿunrecognizedÿdehis
centÿfacialÿnerveÿisÿfoundÿinÿtheÿregionÿofÿgranulationÿtissue.
PoorlyÿmanagedÿorÿrefractoryÿchronicÿOEÿcanÿleadÿtoÿcanalÿ
skinÿ thickening,ÿ scarring,ÿ canalÿ stenosis,ÿ andÿ bluntingÿ ofÿ theÿ
externalÿ canal/TMÿ withÿ associatedÿ conductiveÿ hearingÿ loss.ÿ
Someÿphysiciansÿ referÿ toÿ thisÿprocessÿasÿstenosing otitis externa,
inÿwhichÿtheÿexternalÿcanalÿcontinuesÿtoÿbeÿmoistÿdespiteÿexten
siveÿmedicalÿtherapy.ÿTheÿcanalÿgraduallyÿnarrowsÿfromÿmedialÿ
toÿ lateral,ÿ andÿinÿ theÿ endÿ stage,ÿitÿisÿ dryÿ withÿminimalÿ toÿ noÿ
drainageÿorÿirritation.ÿTacrolimus,ÿaÿnonsteroidalÿimmunosup
pressant,ÿmayÿ beÿ consideredÿinÿ recalcitrantÿ casesÿwhenÿ otherÿ
therapiesÿ areÿ unsuccessful.63ÿ Inÿ theseÿ cases,ÿ canalplastyÿ
andÿ tympanoplastyÿ canÿ beÿ helpfulÿ toÿ removeÿ scarredÿ orÿ
diseasedÿ tissueÿ onceÿ theÿ diseaseÿ hasÿ reachedÿitsÿ
noninflammatoryÿ endÿ point.
Indications for Biopsy Inÿ
patientsÿwithÿOEÿ thatÿisÿ unresponsiveÿ toÿmaximalÿmedicalÿ
therapy,ÿ havingÿ failedÿ topicalÿ andÿ systemicÿ antibiotics,ÿ repeatÿ
culturesÿandÿaÿbiopsyÿofÿtheÿdiseasedÿearÿcanalÿshouldÿbeÿcon
sidered,ÿ andÿ anÿ autoimmuneÿ workupÿ shouldÿ beÿ initiated.ÿ Aÿ
biopsyÿshouldÿbeÿperformedÿifÿpersistentÿgranulationÿtissueÿorÿ
ulcerativeÿlesionsÿinÿtheÿEACÿareÿvisualized,ÿespeciallyÿifÿpainÿisÿ
present,ÿandÿinÿpatientsÿwhoÿareÿimmunocompromised.ÿHigh
resolutionÿ temporalÿ boneÿ computedÿ tomographyÿ (CT)ÿ scansÿ
areÿhelpfulÿtoÿdetermineÿbonyÿinvolvement.ÿAggressiveÿfungalÿ
infections,ÿ malignancy,ÿ andÿ tuberculosisÿ canÿ masqueradeÿ asÿ
recurrentÿ acuteÿ orÿ chronicÿ OEÿ byÿ presentingÿ asÿ anÿinflamedÿ
andÿdrainingÿear.
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2128 PARTÿVII | OTOLOGY, NEUROTOLOGY, AND SKULL BASE SURGERY
They malign the outer ear
MalignantÿOEÿ(MOE)ÿisÿanÿosteomyelitisÿthatÿoriginatesÿinÿtheÿ
earÿcanalÿandÿextendsÿtoÿtheÿsurroundingÿbone.ÿThisÿaggressiveÿ
bacterialÿ infection,ÿ typicallyÿ causedÿ byÿ Pseudomonas,ÿ spreadsÿ
throughÿ theÿ fissuresÿ ofÿ Santoriniÿ andÿ theÿ bony-cartilaginousÿ
junctionÿ toÿ involveÿ theÿ temporalÿ bone,ÿ skullÿ base,ÿ andÿ sur
roundingÿcranialÿnerves.
Signs and Symptoms
Patientsÿ withÿ MOEÿ mayÿ complainÿ ofÿ progressiveÿ nocturnalÿ
pain,ÿauralÿfullness,ÿfever,ÿandÿotorrhea.66ÿTheÿexaminationÿcanÿ
revealÿproptosisÿofÿtheÿauricle,ÿcanalÿskinÿnecrosis,ÿgranulationÿ
atÿ theÿosseocartilaginousÿjunction,ÿcranialÿnerveÿinvolvement,ÿ
vertigo,ÿorÿmeningealÿsigns.66ÿTheÿfacialÿnerveÿisÿtheÿmostÿcom
monlyÿaffectedÿcranialÿnerveÿinÿMOE,ÿbutÿcranialÿnervesÿIX,ÿX,ÿ
XI,ÿandÿXIIÿcanÿbeÿaffectedÿifÿtheÿdiseaseÿprogressesÿalongÿtheÿ
skullÿ base.67ÿ Cranialÿ nervesÿ Vÿ andÿ VIÿ canÿ beÿ affectedÿ ifÿ
theÿ diseaseÿ extendsÿ toÿ theÿ petrousÿ apex.ÿ Aÿ technetiumÿ
scanÿ canÿ determineÿ theÿ presenceÿ ofÿ bonyÿinvolvementÿwithÿ
MOE,ÿandÿ high-resolutionÿtemporalÿboneÿCTÿscansÿareÿbeingÿ
usedÿincreas inglyÿtoÿassessÿbonyÿerosion.68,69ÿAÿhighÿindexÿofÿ
clinicalÿsuspi cionÿmustÿbeÿmaintained,ÿhowever,ÿbecauseÿaÿdelayÿ
inÿdiagnosisÿ commonlyÿ occursÿ inÿ casesÿ ofÿ MOE,ÿ particularlyÿ
whenÿ risk factorsÿsuchÿasÿdiabetesÿareÿpresent.70 Management
Options Theÿhistoricallyÿhighÿmortalityÿ rateÿ fromÿMOEÿhasÿ
decreasedÿ withÿ theÿ useÿ ofÿ systemicÿantibiotics.71ÿExtensionÿ
toÿ skullÿ base,ÿ cranialÿ nerveÿ involvement,ÿ andÿ intracranialÿ
extensionÿ identi fiedÿ onÿ theÿ initialÿ Tc-99mÿ scanÿ areÿ correlatedÿ
withÿ mortal
ity.72,73ÿ Currently,ÿ studiesÿ haveÿ shownÿ thatÿ inÿ patientsÿ
withoutÿ intracranialÿcomplicationsÿorÿcranialÿneuropathies,ÿ
prolongedÿ outpatientÿ therapyÿwithÿoralÿciprofloxacinÿisÿeffectiveÿ
atÿ treat ingÿMOE.74-76ÿ Severalÿ reports,ÿ however,ÿ haveÿ shownÿ
thatÿPseu domonasÿ isÿ developingÿ resistanceÿ toÿ oralÿ
fluoroquinolones,ÿ andÿ oneÿ studyÿ reportsÿ failureÿ ofÿ outpatientÿ
therapyÿ inÿ upÿ toÿ 33%ÿ ofÿ patients.68,77ÿ Forÿ thoseÿ whoÿ failÿ
outpatientÿ therapyÿ withÿ oralÿ antibiotics,ÿ hospitalÿ admissionÿ
forÿ placementÿ ofÿ aÿ peripherallyÿinsertedÿ centralÿ catheterÿlineÿ
andÿ IVÿ antibiotics,ÿ typicallyÿaÿfluoroquinolone,ÿisÿrequired.ÿ
Patientsÿwhoÿareÿoth erwiseÿ stableÿ canÿ beÿ dischargedÿ home,ÿ
withÿ frequentÿ visitsÿ toÿ theÿ otolaryngologist’sÿ officeÿ forÿ
debridementÿ ofÿ theÿ externalÿ canal.ÿ Patientsÿ withÿ ciprofloxacin-
resistantÿ Pseudomonasÿ mayÿ requireÿ aÿ third-ÿ orÿ fourth-
generationÿ cephalosporinÿ withÿ orÿ withoutÿ anÿ aminoglycoside.65ÿ
Galliumÿ scansÿ canÿ beÿ usedÿ toÿ determineÿ theÿ responseÿ ofÿ
MOEÿ toÿ systemicÿ antibioticÿ therapy.69
Ototoxicity Associated with Topical Antibiotics. Theÿ possibleÿ
riskÿofÿototoxicityÿwithÿtheÿuseÿofÿtopicalÿantibiotics,ÿparticularlyÿ
aminoglycosidesÿ (gentamicin,ÿ neomycin, streptomycin),ÿ con tinuesÿ
toÿbeÿaÿconcern.ÿFreeÿradicalsÿthatÿcanÿinjureÿvestibularÿ andÿ
cochlearÿ hairÿ cellsÿ areÿ generatedÿ byÿ aminoglycosidesÿ inÿ theÿ
innerÿ ear.ÿ Twoÿ mutationsÿ inÿ theÿ mitochondrialÿ 12Sÿ ribo
somalÿRNAÿgeneÿhaveÿbeenÿreportedÿtoÿpredisposeÿcarriersÿtoÿ
aminoglycoside-inducedÿ ototoxicity.41ÿ Theÿ vestibulotoxicÿ andÿ
cochleotoxicÿ sideÿ effectsÿ wereÿ initiallyÿ recognizedÿ afterÿ sys
temicÿ useÿ ofÿ aminoglycosides,ÿ andÿ subsequentÿ researchÿ hasÿ
examinedÿ theirÿ toxicityÿ whenÿ usedÿ inÿ topicalÿ form.ÿ Animalÿ
studiesÿperformedÿsinceÿtheÿ1950sÿhaveÿconsistentlyÿconfirmedÿ
theÿototoxicÿpotentialÿofÿ topicalÿaminoglycosides.ÿWrightÿandÿ
Meyerhoff27ÿshowedÿnearlyÿtotalÿdestructionÿofÿallÿtheÿhairÿcellsÿ
inÿtheÿinnerÿearÿofÿtheÿchinchillaÿwithÿonlyÿaÿsingleÿapplicationÿ
ofÿ neomycin,ÿ polymyxin,ÿ orÿ chloramphenicol.ÿ Unfortunately,ÿ noÿ
large,ÿrandomizedÿcontrolledÿtrialsÿhaveÿexaminedÿtheÿissueÿ ofÿ
ototoxicityÿ fromÿ topicalÿantibioticÿ therapyÿinÿhumans.ÿTheÿ dataÿ
thatÿdoÿexistÿ fromÿhumanÿ studiesÿareÿequivocal,ÿandÿ theÿ
incidenceÿofÿtopicalÿaminoglycoside–associatedÿototoxicityÿmayÿ
beÿaboutÿ1ÿperÿ10,000ÿpatients.4,78ÿPossibleÿexplanationsÿforÿ
thisÿ differenceÿinÿototoxicityÿbetweenÿhumansÿandÿanimalsÿareÿ
thatÿ humansÿ haveÿ thickerÿ roundÿ windowÿ membranes;ÿ aÿ
deeperÿ roundÿ windowÿ niche,ÿ whichÿ providesÿ greaterÿ
protection;ÿ andÿ oftenÿ aÿ pseudomembraneÿ (mucousÿ membrane)ÿ
thatÿ overliesÿ theÿroundÿwindowÿandÿmayÿminimizeÿtopicalÿ
absorption.7 ÿPoly myxin,ÿ aÿ componentÿ ofÿ Cortisporinÿ oticÿ
drops,ÿ hasÿ ototoxicÿ propertiesÿinÿanimalÿ studies—evenÿmoreÿ
soÿ thanÿneomycin— andÿisÿthoughtÿtoÿhaveÿototoxicÿpotentialÿinÿ
humansÿasÿwell,27,79 butÿ theseÿdataÿareÿconflicting.ÿ Inÿcontrastÿ
toÿaminoglycosidesÿ andÿpolymyxin,ÿototoxicityÿfromÿfluoroquinolonesÿ
hasÿnotÿbeenÿ reportedÿinÿanimalÿorÿhumanÿdata.32 Inÿ2007,ÿtheÿ
ClinicalÿAuditÿandÿPracticeÿAdvisoryÿGroupÿofÿ theÿ Britishÿ
Associationÿ ofÿ Otolaryngologists–Headÿ andÿ Neckÿ Surgeonsÿ
(ENT-UK)ÿ reviewedÿ theÿ literatureÿ withÿ theÿ goalÿ ofÿ establishingÿ
aÿclinicalÿguidelineÿforÿtheÿuseÿofÿaminoglycosidesÿ inÿAOEÿinÿ
humans.ÿTheyÿfoundÿnoÿconvincingÿdataÿregardingÿ theÿ ototoxicityÿ
ofÿ aminoglycosidesÿ butÿ recommendedÿ thatÿ aÿ topicalÿ
aminoglycosideÿshouldÿonlyÿbeÿusedÿinÿtheÿpresenceÿofÿ obviousÿ
infectionÿ andÿ forÿ noÿ longerÿ thanÿ 2ÿ weeks.ÿ Baselineÿ
audiometry wasÿ recommendedÿ ifÿ possibleÿ beforeÿ treatmentÿ
withÿtopicalÿaminoglycosides.80
Linderÿandÿcolleagues81ÿexaminedÿ134ÿpatientsÿforÿpossibleÿ
ototopicalÿ antibiotic–relatedÿ ototoxicityÿ andÿ foundÿ onlyÿ twoÿ
patientsÿwithÿsignificantÿsensorineuralÿhearingÿlossÿattributableÿ
toÿ excessiveÿ administrationÿ ofÿ framycetin-ÿ andÿ polymyxin
containingÿearÿdropsÿinÿtheÿpresenceÿofÿTMÿperforation.ÿMatzÿ
andÿcolleagues82ÿperformedÿaÿreviewÿofÿtheÿliteratureÿandÿfoundÿ
14ÿ articlesÿ thatÿ dealtÿ directlyÿ withÿ theÿ evaluationÿ ofÿ eitherÿ
hearingÿlossÿorÿchangesÿinÿvestibularÿfunctionÿafterÿtheÿuseÿofÿ
ototopicalÿantibioticÿdrops.ÿAlthoughÿmostÿarticlesÿwereÿinÿtheÿ
levelÿIIIÿtoÿIIIbÿevidenceÿcategory—opinionsÿofÿrespectedÿauthor
itiesÿbasedÿonÿclinicalÿexperience,ÿdescriptiveÿstudies,ÿorÿreportsÿ
ofÿ expertÿ committees—twoÿ wereÿinÿ theÿ Ibÿ category,ÿ evidenceÿ
obtainedÿfromÿatÿleastÿoneÿproperlyÿdesignedÿrandomizedÿcon
trolledÿtrial.ÿAÿtotalÿofÿ54ÿcasesÿofÿgentamicin-inducedÿvestibularÿ
toxicityÿwereÿdocumented,ÿandÿcochlearÿ toxicityÿwasÿnotedÿinÿ
24ÿofÿtheseÿpatients.ÿInÿthisÿreview,ÿ11ÿcasesÿofÿcochlearÿandÿ2ÿ
casesÿofÿvestibularÿtoxicityÿassociatedÿwithÿneomycin-basedÿoto
topicalsÿ wereÿ alsoÿ observed.82ÿ Berenholzÿ andÿ associates83ÿ
per formedÿ aÿ retrospectiveÿ reviewÿ ofÿ 500ÿ patientsÿ whoÿ
receivedÿ Cortisporinÿdropsÿafterÿventilationÿtubeÿplacement.ÿTheyÿ
foundÿ noÿcasesÿofÿnew-onsetÿsensorineuralÿhearingÿlossÿandÿ
notedÿthatÿ Cortisporinÿ dropsÿ wereÿ lessÿ thanÿ halfÿ asÿ
expensiveÿ asÿ topicalÿ fluoroquinolones.
Aÿ consensusÿpanelÿ ofÿ theÿAAO-HNSFÿmadeÿ recommenda
tionsÿ inÿ 2004ÿ onÿ theÿ useÿ ofÿ topicalÿ aminoglycosidesÿ inÿ theÿ
middleÿearÿorÿinÿ theÿpresenceÿofÿTMÿperforation.4 ÿTheÿpanelÿ
determinedÿ that,ÿwheneverÿpossible,ÿ“topicalÿantibioticÿprepa
rations freeÿ ofÿ potentialÿ ototoxicityÿ shouldÿ beÿ usedÿinÿ prefer
enceÿ toÿ ototopicalÿ preparationsÿ thatÿ haveÿ theÿ potentialÿ forÿ
otologicÿinjuryÿifÿ theÿmiddleÿ earÿ orÿmastoidÿ areÿ open.”ÿTheyÿ
pointedÿ outÿ thatÿ aminoglycosideÿ topicalÿ agentsÿ areÿ notÿ FDAÿ
approvedÿ forÿ useÿinÿ theÿmiddleÿ ear,ÿ andÿwarningÿlabelsÿ fromÿ
theÿmanufacturerÿstateÿthatÿtheyÿshouldÿnotÿbeÿusedÿifÿtheÿTMÿ
isÿperforated.ÿTheÿpanelÿdidÿagreeÿ thatÿ theÿpotentialÿototoxicÿ
sideÿ effectsÿ ofÿ aminoglycosidesÿ areÿ quiteÿinfrequentÿ andÿ thatÿ
theÿdataÿfromÿhumanÿtrialsÿareÿequivocal,ÿbutÿtheyÿdeterminedÿ
thatÿbecauseÿantibioticsÿwithoutÿanyÿknownÿototoxicÿpotentialÿ
areÿ availableÿ andÿ efficaciousÿ (fluoroquinolones),ÿ theyÿ shouldÿ
beÿusedÿasÿaÿfirst-lineÿtreatment.ÿTheÿcommitteeÿrecommendedÿ
thatÿ patientsÿ shouldÿ beÿwarnedÿ ofÿ theÿ potentialÿ ototoxicÿ
sideÿ effectsÿ andÿ thatÿ aminoglycosidesÿ shouldÿ onlyÿ beÿ usedÿ
inÿ anÿ acutelyÿ infected ear.ÿ Prophylacticÿ useÿ hasÿ notÿ beenÿ
shownÿ toÿ beÿbeneficial,ÿandÿthereforeÿtheÿrisksÿinÿnonacuteÿ
casesÿwouldÿ definitelyÿ outweighÿ anyÿ potentialÿ benefits.4 ÿ Theÿ
panelÿ alsoÿ concludedÿthatÿaminoglycosidesÿcouldÿbeÿusedÿifÿ theÿbenefitsÿ
Machine Translated by Google
outweighedÿ theÿ risksÿ ofÿ possibleÿ ototoxicity,ÿ suchÿ asÿ inÿ treat
mentÿ failuresÿ withÿ fluoroquinolones,ÿ priorÿ adverseÿ reactions,ÿ
patientÿ allergyÿ toÿ fluoroquinolones,ÿ orÿ cultureÿ resultsÿ thatÿ
suggestÿ thatÿ fluoroquinolonesÿ wouldÿ notÿ beÿ effective.ÿ Theseÿ
recommendationsÿareÿalsoÿsupportedÿbyÿtheÿAustralianÿSocietyÿ ofÿ
OtolaryngologyÿHeadÿandÿNeckÿSurgery,ÿwhichÿhasÿreleasedÿ
similarÿ guidelinesÿ forÿ theÿ useÿ ofÿ potentiallyÿ ototoxicÿ topicalÿ
antibiotics.84 Althoughÿmostÿreportsÿfocusÿonÿpotentialÿcochleotoxicÿ
sideÿ effects,ÿ Maraisÿ andÿ Rutkaÿ showedÿ thatÿ vestibulotoxicityÿ
isÿ moreÿcommonÿthanÿcochleotoxicityÿfromÿaminoglycosideÿoticÿ
drops.42,43ÿIndeed,ÿgentamicinÿisÿfrequentlyÿusedÿforÿtheÿpurposeÿ
ofÿachievingÿvestibulotoxicityÿinÿpatientsÿwithÿMeniereÿdiseaseÿ andÿ
intractableÿvertigo.41 Finally,ÿevidenceÿexistsÿthatÿcombiningÿ
aminoglycosideÿoto topicalsÿwithÿsteroids,ÿasÿwithÿTobradex,ÿresultsÿ
inÿsignificantlyÿ lessÿ ototoxicityÿ thanÿ usingÿ theÿ aminoglycosideÿ
alone,85ÿ whichÿ indicatesÿthatÿtheÿcombinationÿdropsÿmayÿbeÿaÿ
betterÿoptionÿifÿ anÿaminoglycosideÿisÿdesired.
Hypersensitivity Associated with Ototopical Antibiotics. Inÿ
additionÿtoÿtheÿpotentialÿforÿototoxicity,ÿtheÿpossibilityÿofÿdrugÿ
hypersensitivityÿ reactionsÿ mayÿ helpÿ toÿ guideÿ theÿ selectionÿ ofÿ
antibioticÿpreparationsÿforÿtreatmentÿofÿOE.ÿPatientsÿwhoÿcomeÿ toÿ
medicalÿattentionÿwithÿaÿhypersensitivityÿreactionÿwillÿcom plainÿofÿ
pruritusÿandÿtendernessÿofÿtheÿearÿassociatedÿwithÿclearÿ otorrhea.ÿ
Examinationÿoftenÿrevealsÿanÿerythematous,ÿmaculo papularÿ rashÿ
associatedÿ withÿ edemaÿ andÿ thickeningÿ ofÿ theÿ externalÿauditoryÿ
meatusÿandÿconchalÿbowl,ÿwhereÿpoolingÿofÿ theÿ topicalÿpreparationÿ
hasÿoccurredÿduringÿapplication.ÿSpe cifically,ÿ neomycinÿ seemsÿ
toÿ beÿ theÿ mostÿ commonÿ sensitizer,ÿ followedÿ byÿ gentamicin.86ÿ
Smithÿ andÿ colleagues87ÿ showedÿ anÿ incidenceÿofÿ32%ÿofÿ
neomycinÿhypersensitivityÿinÿpatientsÿwithÿ chronicÿOE.ÿOtherÿ
studiesÿ reportÿ aÿlowerÿincidence,ÿ rangingÿ fromÿ 5%ÿ toÿ
18%.15,88ÿ Millardÿ andÿ Orton29ÿ foundÿ thatÿ inÿ 45ÿ patientsÿ
withÿ documentedÿ drug-inducedÿhypersensitivityÿ reac tions,ÿ 76%ÿ
ofÿ thoseÿ wereÿ fromÿ neomycin,ÿ followedÿ byÿ framy cetinÿ andÿ
gentamicin.ÿ Holmesÿ andÿ colleagues89ÿ performedÿ patchÿ testingÿ
onÿ 40ÿpatientsÿwithÿchronicÿOEÿandÿ foundÿ thatÿ 35%ÿ hadÿ aÿ
medication-inducedÿ allergicÿ contactÿ dermatitis.ÿ Neomycin,ÿ
framycetin,ÿclioquinol,ÿandÿgentamicinÿwereÿfoundÿ toÿbeÿtheÿmajorÿ
sensitizers.ÿFinally,ÿaminoglycosidesÿareÿcapableÿ ofÿ cross-
sensitization,ÿ andÿ soÿ carefulÿ selectionÿ ofÿ alternativeÿ therapiesÿ
shouldÿbeÿmadeÿonceÿaÿpatientÿdevelopsÿaÿ reactionÿ toÿoneÿ
memberÿofÿthisÿclass.
Hypersensitivityÿtoÿsteroidÿpreparationsÿhasÿalsoÿbeenÿdocu
mentedÿbutÿisÿsignificantlyÿlessÿcommonÿ(<0.1%ÿforÿhydrocorti
sone).ÿLauerma90ÿperformedÿpatchÿtestingÿusingÿthreeÿdifferentÿ
corticosteroidsÿ onÿ 727ÿ patientsÿ andÿ foundÿ thatÿ 3.9%ÿ reactedÿ
toÿtixocortolÿpivalate,ÿ1.4%ÿtoÿhydrocortisone-17-butyrate,ÿandÿ
0.4%ÿ toÿ hydrocortisone.ÿ Preservativesÿ suchÿ asÿ benzalkoniumÿ
chloride,ÿthimerosal,ÿandÿpropyleneÿglycolÿcanÿalsoÿinciteÿlocalÿ
sensitizationÿ andÿ shouldÿ beÿ consideredÿ asÿ possibleÿ culpritsÿ ifÿ
topicalÿtherapyÿdoesÿnotÿresolveÿotorrhea;ÿinÿaddition,ÿpropyleneÿ
glycolÿincreasesÿtheÿsolubilityÿofÿtheÿdrugÿinÿtheÿepidermis.15,20,88
Fungal infection of the external ear
Approximatelyÿ10%ÿofÿinfectiousÿOEÿisÿ theÿresultÿofÿaÿ fungal,ÿ
ratherÿthanÿaÿbacterial,ÿinfection.15-17ÿWhereasÿfungiÿmayÿbeÿtheÿ
initialÿorganismsÿresponsibleÿforÿacuteÿOE,ÿitÿisÿalsoÿpossibleÿforÿ
aÿfungalÿsuperinfectionÿtoÿdevelopÿinÿcasesÿofÿbacterialÿOEÿthatÿ
wereÿinadequatelyÿ treatedÿwithÿ topicalÿantibacterialÿdrops.91-94
AraizaÿandÿBonifaz92ÿfoundÿthatÿtheÿmainÿpredisposingÿfactorsÿ
forÿ fungalÿ OEÿ wereÿ traumaÿ toÿ theÿ earÿ canalÿ (scratchingÿ orÿ
itching)ÿandÿtheÿuseÿofÿototopicalÿantibioticÿpreparations.ÿAsper
gillusÿisÿtheÿmostÿcommonÿcauseÿofÿotomycosisÿ(~80%ÿtoÿ90%),ÿ
especiallyÿA. fumigatus,ÿ A. niger,ÿandÿA. flavus,92,95,96ÿfollowedÿbyÿ
138 | TOPICAL THERAPIES FOR EXTERNAL EAR DISORDERS 2129
Candidaÿand,ÿrarely,ÿMucorÿspecies. 97,98ÿChronicÿmoistureÿofÿ
theÿ canalÿisÿalsoÿassociatedÿwithÿtheÿdevelopmentÿofÿfungalÿOE.
Signs and Symptoms
Patientsÿwillÿcomplainÿofÿotalgiaÿ(butÿnotÿalwaysÿasÿsevereÿasÿ
withÿ bacterialÿ AOE),ÿ pruritus,ÿ muffledÿ hearing,ÿ andÿ malodorousÿ
otorrhea.99ÿOnÿphysicalÿexamination,ÿwhiteÿand/orÿblackÿfungalÿ
hyphaeÿareÿtypicallyÿseenÿassociatedÿwithÿedemaÿandÿpurulentÿ
debris.
Management Options for Fungal Otitis Externa Topical
Therapy. Theÿ treatmentÿofÿchoiceÿincludesÿ thoroughÿ debridementÿ
followedÿ byÿ topicalÿ applicationÿ ofÿ antifungalÿ agents.98-100ÿAsÿ
withÿ bacterialÿOE,ÿacidificationÿ ofÿ theÿ externalÿ canalÿwithÿ
ototopicalÿpreparationsÿisÿeffectiveÿatÿclearingÿmildÿ casesÿofÿ
otomycosis.ÿTheÿacidificationÿhelpsÿinhibitÿbothÿbacte rialÿandÿ
fungalÿgrowth.ÿReestablishingÿaÿdryÿEACÿwithÿroutineÿ hygiene,ÿ
waterÿ precautions,ÿandÿmaintenanceÿirrigationsÿwithÿ aceticÿacidÿ
orÿmildÿalcoholÿsolutionsÿ(inÿtheÿsettingÿofÿanÿintactÿ TM)ÿisÿanÿ
importantÿ stepÿinÿpreventingÿrecurrentÿ fungalÿOE.ÿ Refractoryÿ
fungalÿ OEÿ mayÿ requireÿ moreÿ specificÿ antifungalÿ preparations.ÿ
AsÿwithÿtreatmentÿoptionsÿforÿacuteÿbacterialÿOE,ÿ veryÿfewÿstudiesÿ
haveÿcomparedÿtheÿefficacyÿandÿsafetyÿprofilesÿ forÿ theÿvariousÿ
antifungalÿagents.ÿAsÿsuch,ÿnoÿclearÿconsensusÿ hasÿ beenÿ
reachedÿ amongÿ otolaryngologistsÿ aboutÿ theÿ relativeÿ treatmentÿ
efficacyÿofÿtheseÿpreparations.
Acidifying Agents. Aluminumÿacetateÿoticÿdropsÿ(Burow’sÿsolu
tion),ÿaceticÿacid/propyleneÿglycol/hydrocortisoneÿ1%ÿ(VoSolÿ HC),ÿ
aceticÿacidÿ(DomeboroÿOtic),ÿandÿboricÿacidÿsolutionÿareÿ allÿ
acidifyingÿagentsÿcommonlyÿusedÿinÿtheÿtreatmentÿofÿuncom
plicatedÿotomycosis.ÿHoÿandÿcolleagues99ÿfoundÿthatÿaluminumÿ
acetateÿ dropsÿ wereÿmoreÿ thanÿ 80%ÿ effectiveÿinÿmildÿ casesÿ
ofÿ fungalÿOE.ÿInÿaddition,ÿdelÿPalacioÿandÿassociates101ÿ
confirmedÿ thatÿboricÿacidÿsolutionÿwasÿasÿeffectiveÿasÿ theÿ
antifungalÿ11%ÿ ciclopiroxÿolamineÿcreamÿ(orÿ1%ÿsolution)ÿinÿ
treatingÿpatientsÿ withÿotomycosisÿbutÿthatÿtheÿboricÿacidÿgroupÿ
hadÿsignificantlyÿ moreÿ discomfort.ÿ Sternÿ andÿ colleagues100ÿ
foundÿ thatÿ VoSol,ÿ Burow’sÿsolution,ÿandÿ95%ÿethanolÿdidÿnotÿ
resultÿinÿanyÿzoneÿ ofÿinhibitionÿforÿfungiÿculturedÿfromÿpatientsÿ
withÿotomycosisÿ inÿvitro.ÿKiakojuriÿandÿothers102ÿshowedÿinÿaÿ
prospectiveÿstudyÿ thatÿ acidificationÿ ofÿ theÿ canalÿ inÿ combinationÿ
withÿ aÿ topicalÿ antifungalÿ (miconazole)ÿ didÿ notÿimproveÿ efficacyÿ
whenÿ com paredÿ withÿ miconazoleÿ alone.ÿ Acidifyingÿ agentsÿ
haveÿ beenÿ shownÿtoÿsuccessfullyÿtreatÿmostÿmildÿcasesÿofÿfungalÿ
OE,ÿespe ciallyÿwhenÿcombinedÿwithÿthoroughÿdebridementÿofÿtheÿ
exter nalÿcanal.ÿDataÿthatÿcompareÿtheirÿsafetyÿandÿefficacyÿ
profiles,ÿ however,ÿ haveÿ notÿ beenÿ carefullyÿ studied,ÿ andÿ theÿ
choiceÿ isÿ againÿleftÿlargelyÿtoÿtheÿclinician.
Topical Antiseptics. Cresylateÿoticÿdropsÿ25%ÿwereÿdeterminedÿ
byÿHoÿandÿcolleagues99ÿ toÿbeÿmoreÿ thanÿ 80%ÿ effectiveÿinÿ theÿ
treatmentÿofÿfungalÿOE.ÿInÿaddition,ÿgentianÿvioletÿhasÿprovedÿ
usefulÿinÿ refractoryÿ cases,ÿ butÿitÿ shouldÿ beÿ avoidedÿ whenÿ
theÿ TMÿisÿperforated.ÿAlso,ÿmercurochromeÿwasÿfoundÿbyÿ
Chanderÿ andÿ colleagues95ÿ toÿ beÿ moreÿ effectiveÿ thanÿ
clotrimazoleÿ orÿ miconazole,ÿandÿaÿsingleÿapplicationÿofÿsilverÿ
nitrateÿgelÿ1%ÿwasÿ foundÿbyÿvanÿHasseltÿandÿassociates62ÿinÿaÿ
prospectiveÿrandom izedÿtrialÿtoÿcureÿ92%ÿofÿearsÿwithÿrefractoryÿotomycosisÿw
1ÿweek.
Topical Antifungals for Fungal Otitis Externa
Clotrimazoleÿ Cream.ÿ Ologeÿ andÿ Nwabuisi98ÿ demonstratedÿ
aÿ 96%ÿsymptom-freeÿrateÿafterÿaÿsingleÿapplicationÿofÿclotrimazoleÿ
creamÿfollowingÿdebridementÿofÿtheÿcanal.ÿComplicationsÿwereÿ
rareÿ andÿ includedÿ aÿ lessÿ thanÿ 3%ÿ recurrenceÿ rate,ÿ andÿ theÿ
requiredÿone-timeÿapplicationÿisÿtoleratedÿwellÿbyÿmostÿpatientsÿ
andÿ isÿ costÿ effective.ÿ Sternÿ andÿ colleagues100ÿ showedÿ thatÿ
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2130 PARTÿVII | OTOLOGY, NEUROTOLOGY, AND SKULL BASE SURGERY

clotrimazoleÿ1%ÿcreamÿwasÿeffectiveÿagainstÿallÿcommonÿfungalÿ diseaseÿ ofÿ theÿ TM,ÿ butÿ itÿ mayÿ alsoÿ resultÿ fromÿ theÿ spreadÿ
pathogensÿ inÿ vitroÿ whenÿ measuringÿ zonesÿ ofÿ inhibitionÿ ofÿ ofÿ fungalÿOE.ÿSimilarly,ÿeczematousÿmyringitisÿcanÿbeÿisolatedÿ
variousÿantifungals.ÿSimilarly,ÿMaherÿandÿothers103ÿalsoÿdemon toÿ theÿTM,ÿbutÿitÿcanÿalsoÿoccurÿinÿpatientsÿwithÿchronicÿeczema
stratedÿthatÿclotrimazoleÿwasÿeffectiveÿagainstÿtheÿlargeÿvarietyÿ tousÿ OE.ÿ Myringitisÿ granulosa,ÿ orÿ granularÿ myringitis,ÿ occursÿ
ofÿ fungi isolatedÿfromÿclinicalÿotomycosisÿspecimens.ÿOverÿ94%ÿ whenÿtheÿTMÿisÿcoveredÿwithÿgranulationÿtissue.
ofÿ theÿ59ÿfungusÿspeciesÿhadÿanÿMICÿlessÿthanÿ0.1ÿµg/mL,ÿandÿ
forÿ theÿremainingÿ6%,ÿitÿwasÿbetweenÿ0.4ÿandÿ1ÿµg/mL.103 Topical Therapy Options for Myringitis Treatmentÿ
Miconazoleÿ (2%).ÿ Kiakojuriÿ andÿ colleagues102ÿ showedÿ inÿ ofÿ myringitisÿ dependsÿ onÿ theÿ etiology.ÿ Forÿ acuteÿ primaryÿ
aÿ prospectiveÿ trialÿ thatÿmiconazoleÿwasÿ effectiveÿatÿ treatingÿoto bacterialÿmyringitisÿorÿmyringitisÿassociatedÿwithÿacuteÿ OM,ÿoralÿ
mycosisÿandÿ thatÿ theÿadditionÿofÿacidifyingÿdropsÿ(aceticÿacidÿ antibioticsÿareÿtheÿprimaryÿtherapy.ÿSystemicÿantibiot icsÿ shouldÿ
3%ÿplusÿalcoholÿ97%)ÿdidÿnotÿsignificantlyÿimproveÿoutcome. beÿ directedÿ againstÿ theÿ mostÿ commonÿ pathogensÿ associatedÿ
Ketoconazole.ÿ Hoÿandÿassociates99ÿshowedÿthatÿketoconazoleÿ withÿOM:ÿS. pneumoniaeÿandÿHaemophilus influenzae.
hadÿaÿbetterÿefficacyÿandÿlowerÿrecurrenceÿofÿotomycosisÿwhenÿ ForÿindividualsÿwithÿacuteÿOE,ÿstandardÿtherapyÿincludesÿtopicalÿ
comparedÿwithÿcresylateÿoticÿandÿaluminumÿacetate. antibioticÿandÿsteroidÿearÿdrops.ÿTheÿtopicalÿpreparationsÿmen
Tolnaftate.ÿ Maherÿ andÿ colleagues103ÿ demonstratedÿ theÿ tionedÿearlierÿinÿthisÿchapterÿareÿeffectiveÿinÿtreatingÿexternalÿ
effi cacyÿofÿtolnaftateÿandÿclotrimazoleÿinÿanÿinÿvitroÿstudy.ÿTheÿ canalÿdisordersÿwithÿassociatedÿmyringitis.ÿKagaÿandÿIchimura108
MICÿ forÿeachÿofÿtheÿdrugsÿwasÿlessÿthanÿ1ÿµg/mLÿforÿallÿ59ÿ performedÿaÿsmallÿpilotÿstudyÿtoÿexamineÿtheÿefficacyÿofÿofloxa
speciesÿ ofÿfungiÿtestedÿfromÿpatientsÿwithÿotomycosis. cinÿ onÿ infantileÿ myringitisÿ andÿ chronicÿ OM.ÿ Treatmentÿ withÿ
Nystatin.ÿ Nystatinÿisÿaÿpolyeneÿantifungalÿagentÿthatÿdamagesÿ twice-dailyÿofloxacinÿeradicatedÿ theÿcausativeÿpathogenÿinÿ theÿ
fungalÿmembranesÿbyÿalteringÿpermeability.ÿItÿcanÿbeÿusedÿasÿaÿ majorityÿofÿtheÿ21ÿpatientsÿexaminedÿinÿtheirÿcohort.ÿForÿfungalÿ
topicalÿ suspension,ÿcream,ÿor powder.ÿSternÿandÿcolleagues100 infectionsÿ thatÿinvolveÿ theÿTM,ÿ topicalÿantifungalsÿmentionedÿ
foundÿ thatÿ nystatinÿ hadÿ theÿ widestÿ rangeÿ ofÿ activityÿ againstÿ earlierÿareÿtheÿmainstayÿofÿtreatment.ÿInÿmoreÿsevereÿcasesÿwithÿ
aÿ varietyÿofÿpathogensÿwhenÿmeasuringÿtheÿzonesÿofÿinhibitionÿ externalÿcanalÿinvolvement,ÿanalgesicsÿandÿbroad-spectrumÿoralÿ
ofÿ variousÿantifungals. antibioticsÿ mayÿ beÿ useful.ÿ Chronicÿ myringitisÿ treatmentÿ may
Ciclopiroxolamineÿ 0.77%ÿ Antifungalÿ Creamÿ orÿ Solution.ÿ includeÿantibioticÿearÿdropsÿorÿaceticÿacidÿearÿcanalÿirrigationsÿ
CiclopiroxolamineÿwasÿshownÿbyÿdelÿPalacioÿandÿcolleagues101 followedÿbyÿapplicationÿofÿsteroidÿcream.
inÿaÿrandomizedÿprospectiveÿ trialÿ toÿhaveÿequalÿefficacyÿwhenÿ Granular myringitisÿ isÿ aÿ chronicÿ inflammatoryÿ conditionÿ ofÿ
comparedÿ withÿ boricÿ acid,ÿ butÿ itÿ wasÿ betterÿ toleratedÿ byÿ theÿepidermalÿlayerÿofÿtheÿTMÿandÿmayÿbeÿtreatedÿwithÿsurgicalÿ
patients. removal,ÿchemicalÿcauterization,ÿorÿvinegarÿirrigations.ÿInÿ2007,ÿ
NeilsonÿandÿHussain109ÿperformedÿaÿliteratureÿreviewÿofÿgranu larÿ
Ototoxicity Associated with Topical Antifungal Therapy. Oto myringitisÿmanagementÿ andÿ foundÿ thatÿ noÿlargeÿ random izedÿ
toxicityÿ ofÿ topicalÿ antifungalÿ therapiesÿ hasÿ notÿ beenÿ wellÿ controlledÿ studiesÿ addressÿ thisÿ question.ÿ Jungÿ andÿ
studied.ÿTom30ÿshowedÿthatÿclotrimazole,ÿmiconazole,ÿandÿtol colleagues110ÿ foundÿ aÿ 96%ÿ reductionÿ inÿ granularÿ myringitisÿ
naftateÿhadÿnoÿototoxicÿeffectsÿwhenÿappliedÿtoÿtheÿmiddleÿearÿ recurrenceÿwithÿdailyÿdiluteÿ vinegarÿirrigationsÿinÿaÿcohortÿofÿ 15ÿ
ofÿguineaÿpigsÿcomparedÿwithÿnormalÿcontrolsÿandÿanimalsÿwhoÿ patients.ÿAllÿpatientsÿtreatedÿwithÿdiluteÿvinegarÿsolutionÿhadÿ
receivedÿtopicalÿneomycinÿ(anÿagentÿknownÿtoÿcauseÿototoxic ity)ÿ resolutionÿ ofÿ theirÿ originalÿ otorrheaÿ withinÿ 3ÿ weeks,ÿ whereasÿ
appliedÿtoÿtheÿmiddleÿear.ÿNystatinÿalsoÿhadÿnoÿototoxicity,ÿ butÿitÿ onlyÿtwoÿthirdsÿofÿpatientsÿtreatedÿwithÿtopicalÿantibioticÿdropsÿ
didÿleaveÿaÿpersistentÿresidueÿatÿtheÿroundÿwindowÿniche,ÿ andÿ hadÿrecovered.ÿEl-SeifiÿandÿFouad111ÿperformedÿaÿretrospectiveÿ
gentianÿvioletÿwasÿ foundÿ toÿbeÿextremelyÿototoxic.ÿMarshÿ andÿ studyÿ ofÿ 94ÿ patientsÿ withÿ granularÿ myringitisÿ andÿ notedÿ thatÿ
Tom104ÿobservedÿthatÿpreparationsÿthatÿcontainÿaceticÿacidÿ orÿ surgicalÿ excisionÿ ofÿ granulationÿ tissueÿ resultedÿ inÿ anÿ 80%ÿ
propyleneÿ glycolÿ causeÿ elevationÿ ofÿ brainstemÿ responseÿ reductionÿinÿdiseaseÿrecurrenceÿwhenÿcomparedÿwithÿantibioticÿ
thresholdsÿ whenÿ appliedÿ toÿ theÿ middleÿ earÿ ofÿ guineaÿ pigs,ÿ therapy.ÿHoshinoÿ andÿ associates112ÿ publishedÿ aÿ caseÿ reportÿ
whereasÿclotrimazoleÿandÿtolnaftateÿhadÿnoÿototoxicÿeffects. ofÿ fiveÿ patientsÿwithÿ granulomatousÿmyringitis.ÿAllÿ patientsÿwereÿ
treatedÿ byÿ removingÿ theÿ areaÿ ofÿ granulomaÿ withÿ cupÿ forcepsÿ
Myringitis followedÿ byÿ cauterizationÿ withÿ 20%ÿ trichloroaceticÿ acid.ÿ Twoÿ
toÿ threeÿ treatmentsÿ resultedÿ inÿ completeÿ resolutionÿ inÿ allÿ
MyringitisÿisÿanÿinflammatoryÿconditionÿofÿtheÿTMÿandÿcanÿbeÿ patients, withÿ noÿ recurrences.112ÿ Inÿ aÿ systematicÿ reviewÿ ofÿ
acuteÿorÿchronic.ÿAcuteÿbullousÿor hemorrhagicÿmyringitisÿcanÿ beÿ theÿ managementÿofÿgranularÿmyringitis,ÿtheÿconclusionsÿwereÿ
theÿconsequenceÿofÿaÿbacterialÿinfection,ÿsuchÿasÿwithÿStrep thatÿ managementÿwithÿeitherÿsurgicalÿexcisionÿofÿgranulationÿ
tococcus pneumoniaeÿorÿStaphylococcusÿspecies,ÿorÿaÿviralÿ tissueÿ orÿ applicationÿ ofÿ diluteÿ vinegarÿ solutionÿ appearsÿ toÿ
infection,ÿ such asÿ withÿ influenzaÿ orÿ herpesÿ zoster.ÿ Theÿ beÿ moreÿ efficaciousÿ thanÿ conventionalÿ topicalÿ antibioticÿ andÿ
pathogenÿ mayÿ infectÿtheÿTMÿaloneÿ(primary myringitis),ÿorÿitÿmayÿ steroidÿ drops.109
causeÿacute OMÿorÿ OEÿ withÿ secondaryÿ involvementÿ ofÿ theÿ
TMÿ (secondary myringitis).ÿApproximatelyÿ8%ÿofÿchildrenÿagedÿ6ÿ ECZEMATOID OTITIS EXTERNA
monthsÿtoÿ12ÿ yearsÿ withÿ AOMÿ haveÿ hadÿ acuteÿ bullousÿ
myringitis.105,106ÿ Theÿ viralÿandÿbacterialÿpathogensÿresponsibleÿ EczematoidÿOEÿisÿanÿimportantÿnoninfectiousÿcauseÿofÿchronicÿ
forÿacuteÿOMÿandÿOEÿ areÿtheÿsameÿorganismsÿresponsibleÿforÿ OEÿ andÿ isÿ aÿ chronicÿ inflammatoryÿ conditionÿ ofÿ theÿ externalÿ
acuteÿviralÿandÿbacterialÿ myringitis,ÿexceptÿforÿaÿslightÿincreaseÿ canalÿskin.15,59ÿAllergicÿcontactÿdermatitisÿtoÿlotions,ÿshampoos,ÿ
inÿproportionÿofÿS. pneu moniaeÿ pathogensÿ inÿ bullousÿ cosmetics,ÿ hearingÿ aidÿmolds,ÿ andÿjewelryÿmayÿ causeÿ chronicÿ
myringitis.106ÿ Palmuÿ andÿ col leagues107ÿperformedÿaÿlongitudinalÿ irritationÿ ofÿ theÿ externalÿ ear.86,88,113ÿ Smithÿ andÿ colleagues87
cohortÿstudyÿtoÿexploreÿtheÿ relationshipÿ betweenÿ acuteÿ foundÿthatÿ58%ÿofÿpatientsÿwithÿchronicÿOEÿhadÿcontactÿhyper
myringitisÿ andÿ theÿ presenceÿ ofÿ middleÿearÿdiseaseÿinÿchildren.ÿ sensitivityÿonÿpatchÿtesting.ÿHypersensitivityÿtoÿototopicalÿanti bioticÿ
Ofÿ82ÿpatientsÿwithÿacuteÿbullousÿ myringitis,ÿ97%ÿhadÿconcomitantÿ preparations,ÿespeciallyÿneomycin-basedÿ solutions,ÿusedÿ toÿ treatÿ
middleÿearÿfluid,ÿandÿ82%ÿofÿ patientsÿ withÿ acuteÿ hemorrhagicÿ acuteÿOEÿmayÿalsoÿ resultÿinÿchronicÿOE.87,89-91ÿFinally,ÿ
myringitisÿ hadÿ concurrentÿ middleÿearÿdisease.ÿTheyÿalsoÿnotedÿ noninfectiousÿchronicÿOEÿmayÿbeÿtheÿresultÿofÿaÿfoodÿsensitiv ity,ÿ
thatÿtheÿpathogensÿrespon sibleÿforÿacuteÿbacterialÿmyringitisÿareÿ andÿpatchÿ testingÿ forÿ foodÿhypersensitivityÿ shouldÿbeÿcon
theÿsameÿasÿthoseÿrespon sibleÿforÿacuteÿOMÿinÿchildren,ÿbutÿ sideredÿinÿpatientsÿwithÿeczematoidÿOEÿthatÿcannotÿbeÿexplainedÿ
thatÿS. pneumoniaeÿ wasÿ theÿ mostÿprevalentÿorganism.ÿFungalÿmyringitisÿmayÿbeÿaÿprimaryÿ
byÿotherÿetiologies.114
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Signs and Symptoms
Patientsÿ withÿ eczematoidÿ OEÿ canÿ comeÿ toÿ medicalÿ attentionÿ
withÿchronicÿpruritus,ÿirritation,ÿandÿdrainageÿofÿ theÿaffectedÿ ear.ÿ
Otalgia isÿusuallyÿnotÿpresentÿunlessÿaÿsuperimposedÿbacte rialÿ
infectionÿresultsÿ fromÿskinÿmacerationÿasÿaÿresultÿofÿaccu mulatedÿ
debris.ÿTheÿskinÿofÿtheÿexternalÿmeatusÿandÿcanalÿcanÿ
beÿ dry,ÿ scaling,ÿ erythematous,ÿ weeping,ÿ andÿ excoriatedÿ fromÿ
manipulationÿandÿscratching.ÿGeneralizedÿskinÿconditionsÿsuchÿ asÿ
eczemaÿandÿpsoriasisÿmayÿalsoÿaffectÿtheÿexternalÿearÿcanal,ÿ
andÿ thisÿcanÿleadÿ toÿinflammation,ÿaccumulationÿofÿdebrisÿinÿ theÿ
canal,ÿandÿresultingÿpruritus.
Management Options in Eczematoid Otitis Externa Onceÿ
identified,ÿ offendingÿ agents—suchÿ asÿ lotions,ÿ jewelry, foods,ÿ
ototopicals—shouldÿbeÿavoided,ÿbutÿdelaysÿinÿdiagnosisÿ areÿoftenÿ
significantÿbecauseÿofÿtheÿsimilaritiesÿinÿpresentationÿ betweenÿ
infectiousÿ andÿ noninfectiousÿ causesÿ ofÿ OE.ÿ Carefulÿ
debridementÿ ofÿ theÿ affectedÿ earÿ underÿmicroscopyÿisÿ crucial,ÿ
asÿisÿuseÿofÿappropriateÿototopicalÿantibioticsÿwhenÿaÿsuperim
posedÿbacterialÿinfectionÿisÿpresent,ÿonceÿtheÿpossibilityÿofÿsen
sitivityÿtoÿaÿpreviouslyÿusedÿototopicalÿhasÿbeenÿeliminated.
Ifÿtheÿeliminationÿofÿpossibleÿsensitizingÿagentsÿandÿdiligentÿ
earÿ hygieneÿ areÿ notÿ successfulÿ inÿ managingÿ eczematoidÿ OE,ÿ
antiinflammatoryÿmedicalÿtherapyÿisÿwarranted.ÿTopicalÿgluco
corticoidsÿareÿtheÿgoldÿstandardÿforÿmanagementÿofÿeczematousÿ
OE.ÿManyÿsteroidÿpreparationsÿareÿavailableÿandÿareÿprescribedÿ
frequentlyÿtoÿhelpÿreduceÿinflammation,ÿskinÿflaking,ÿandÿpru ritus.ÿ
Refractoryÿcasesÿmayÿwarrantÿsystemicÿsteroidsÿandÿreferralÿ toÿaÿ
dermatologistÿorÿrheumatologist.
Steroids for Eczematoid Otitis Externa. Jacobssonÿ andÿ col
leagues115ÿ performedÿ aÿ double-blindedÿ studyÿ ofÿ 60ÿ patientsÿ
withÿeczematoidÿOEÿwhoÿwereÿrandomizedÿtoÿaÿplaceboÿgroupÿ
orÿ aÿ treatmentÿ groupÿ inÿ whichÿ theyÿ receivedÿ therapyÿ withÿ
budesonide,ÿaÿglucocorticoid.ÿTheÿtreatmentÿgroupÿhadÿsignifi cantÿ
improvementÿ ofÿ erythema,ÿ edema,ÿ andÿ drainageÿ whenÿ
comparedÿ withÿ theÿ placeboÿ group.ÿ Stuckÿ andÿ colleagues61
injectedÿ triamcinoloneÿ acetonideÿ intoÿ theÿ earÿ canalsÿ ofÿ 13ÿ
patientsÿwithÿchronicÿOEÿandÿ foundÿ substantialÿimprovementÿ ofÿ
symptomsÿinÿallÿpatients.ÿInjectionÿofÿ theÿexternalÿcanalÿinÿ anÿ
awakeÿ patient,ÿ however,ÿ canÿ beÿ quiteÿ painful.ÿ Hoareÿ andÿ
colleagues116ÿperformedÿaÿmeta-analysisÿofÿ272ÿrandomizedÿcon
trolledÿtrialsÿofÿatopicÿeczemaÿthatÿcoveredÿatÿleastÿ47ÿdifferentÿ
interventionsÿandÿconcludedÿthatÿ“ThereÿwasÿreasonableÿRCTÿ
[randomizedÿ controlledÿ trial]ÿ evidenceÿ toÿ supportÿ theÿ useÿ ofÿ
oralÿcyclosporin,ÿtopical corticosteroids,ÿpsychologicalÿapproachesÿ
andÿultravioletÿlightÿtherapy.”
Noÿclinicalÿtrialsÿhaveÿexploredÿtheÿefficacyÿofÿtheÿdifferentÿ
steroid preparationsÿ inÿ theÿ treatmentÿ ofÿ eczematoidÿ OE;ÿ
however,ÿ itÿ mayÿ beÿ possibleÿ toÿ extrapolateÿ findingsÿ fromÿ theÿ
dermatologyÿ literature.ÿ Juhlin117ÿ performedÿ aÿ randomized,ÿ
double-blind,ÿparallel-groupÿ studyÿofÿ 120ÿpatientsÿ toÿ examineÿ
theÿ efficacyÿ ofÿ fluticasoneÿ propionateÿ creamÿ 0.05%ÿ andÿ
hydrocortisone-17-butyrateÿ creamÿ 0.1%ÿ inÿ theÿ treatmentÿ ofÿ
eczema.ÿ Bothÿ preparationsÿ hadÿ minimalÿ sideÿ effects,ÿ andÿ noÿ
statisticallyÿ significantÿ differenceÿ inÿ efficacyÿ at reducingÿ theÿ
severityÿofÿeczemaÿwasÿreported.ÿJames118ÿperformedÿaÿrandom
ized,ÿ double-blindÿ trialÿ ofÿ 125ÿ patientsÿ toÿ compareÿ theÿ sameÿ
twoÿ preparationsÿ (fluticasoneÿ propionateÿ creamÿ 0.05%ÿ andÿ
hydrocortisone-17-butyrateÿ creamÿ 0.1%)ÿ inÿ theÿ treatmentÿ ofÿ
psoriasis.ÿInÿthisÿstudy,ÿfluticasoneÿpropionateÿcreamÿwasÿsupe riorÿ
toÿhydrocortisone-17-butyrateÿcream.ÿCleared,ÿexcellent,ÿorÿ goodÿ
end-of-treatmentÿresponseÿratesÿwereÿ79%ÿforÿfluticasoneÿ
propionateÿ comparedÿ withÿ 68%ÿ forÿ hydrocortisone-17-butyr ate.ÿ
Callen119ÿ comparedÿ theÿ safetyÿ andÿ efficacyÿ ofÿ fluticasoneÿ
propionateÿ creamÿ 0.05%ÿ andÿ betamethasoneÿ valerateÿ creamÿ
0.1%ÿ inÿ theÿ treatmentÿ ofÿ moderate-to-severeÿ psoriasis.ÿ Thisÿ
138 | TOPICAL THERAPIES FOR EXTERNAL EAR DISORDERS 2131
randomized,ÿ double-blind,ÿ parallel-groupÿ studyÿ foundÿ thatÿ
fluticasoneÿpropionateÿcreamÿ0.05%ÿhadÿaÿsimilarÿefficacyÿandÿ
side-effectÿ profileÿ asÿ betamethasoneÿ valerateÿ creamÿ 0.1%.ÿ
Ashtonÿ andÿ associates120ÿ comparedÿ 0.25%ÿ andÿ 0.05%ÿ desoxy
methasone,ÿ0.1%ÿbetamethasoneÿvalerate,ÿandÿ1%ÿhydrocorti
soneÿ creamsÿ inÿ theÿ treatmentÿ ofÿ eczemaÿ inÿ aÿ randomizedÿ
controlledÿtrialÿofÿ96ÿpatients.ÿTheÿ0.25%ÿdesoxymethasoneÿwasÿ
theÿmostÿeffectiveÿtreatment,ÿhydrocortisoneÿwasÿtheÿleastÿeffec
tive,ÿ andÿ 0.05%ÿ desoxymethasoneÿ andÿ 0.1%ÿ betamethasoneÿ
wereÿ ofÿ intermediateÿ effectiveness.ÿ Noÿ significantÿ adverseÿ
effectsÿwereÿreportedÿduringÿtheÿstudy.ÿFluocinoloneÿacetonideÿ oilÿ
0.01%ÿ(DermOticÿOil;ÿHillÿDermaceuticals,ÿSanford,ÿFL)ÿisÿ
currentlyÿ theÿonlyÿFDA-approvedÿ treatmentÿ forÿchronicÿpruri tusÿ
ofÿtheÿexternalÿear.ÿTheÿmanufacturerÿstatesÿthatÿtheÿpeanutÿ oilÿ
vehicleÿmoistensÿ theÿ earÿ canalÿ andÿloosensÿ cerumen,ÿ andÿ
theÿ corticosteroidÿ reducesÿ irritationÿ andÿ inflammation.ÿ Itÿ isÿ
approvedÿ forÿpatientsÿ overÿ 2ÿ yearsÿ ofÿage,ÿandÿ twice-dailyÿ
useÿ forÿ 2ÿ weeksÿ isÿ recommended.ÿ Aÿ placebo-controlledÿ studyÿ
forÿ theÿtreatmentÿofÿchronicÿeczematousÿexternalÿotitisÿclaimsÿDer
mOticÿoilÿ toÿbeÿ superiorÿ toÿplaceboÿinÿclearingÿ theÿ signsÿandÿ
symptomsÿofÿeczematousÿexternalÿotitis.121 Inÿgeneral,ÿitÿisÿ
reasonableÿ toÿ startÿwithÿaÿreadilyÿavailable, over-the-counter,ÿ
mildÿtopicalÿglucocorticoidÿsuchÿasÿhydrocor tisoneÿ 1%ÿ whenÿ
faced withÿ aÿ patientÿ withÿ eczematousÿOE.ÿ Ifÿ theÿinitialÿtreatmentÿ
regimenÿfails,ÿchangingÿtoÿaÿmoreÿpotentÿ glucocorticoidÿ isÿ aÿ
reasonableÿ option.ÿ Patientsÿ withÿ aÿ docu mentedÿpeanutÿallergyÿ
shouldÿavoidÿthisÿtherapy.
ClassesÿofÿTopicalÿSteroids.ÿ Theÿstrengthÿofÿaÿsteroidÿisÿ
deter minedÿbyÿaÿstandardizedÿtestÿthatÿmeasuresÿtheÿextentÿtoÿ
whichÿ itÿ canÿ causeÿ bloodÿ vesselsÿ toÿ constrictÿ inÿ theÿ upperÿ
dermis.ÿ Someÿofÿ theÿmoreÿpopularÿ steroidsÿinÿ eachÿclassÿareÿ
listedÿinÿ Boxÿ138-2ÿinÿorderÿofÿdecreasingÿpotency.
Ototoxicity Associated with Ototopical Steroids. Ototoxicityÿ hasÿ
notÿbeenÿdocumentedÿ fromÿ theÿ topicalÿuseÿofÿglucocorti coids.ÿ
Inÿfact,ÿmultipleÿstudiesÿhaveÿshownÿthatÿtheyÿmayÿhaveÿ aÿ
protectiveÿ effectÿ onÿ innerÿ earÿ function.ÿ Kieferÿ andÿ associ
ates122ÿ andÿ Yeÿ andÿ colleagues123ÿ showedÿ thatÿ roundÿ
windowÿ applicationÿofÿtriamcinoloneÿhasÿnoÿototoxicÿeffectÿinÿaÿ
gerbilÿ modelÿ andÿ thatÿ intracochlearÿ applicationÿ viaÿ aÿ
cochleostomyÿ resultedÿ inÿ anÿ increasedÿ recoveryÿ ofÿ cochlearÿ
functionÿ afterÿ surgicalÿtrauma.ÿIntratympanicÿinjectionsÿofÿhigh-
doseÿsteroidsÿ such asÿdexamethasoneÿorÿmethylprednisoloneÿareÿ
usedÿforÿtheÿ treatmentÿ ofÿ idiopathicÿ suddenÿ sensorineuralÿ
hearingÿ lossÿ (SSNHL).124-126ÿKiliçÿandÿcolleagues127ÿshowedÿ
inÿaÿprospectiveÿ randomizedÿcontrolledÿ trialÿ ofÿ 37ÿpatientsÿ thatÿ
intratympanicÿ injectionÿ ofÿ methylprednisoloneÿ improved hearingÿ
resultsÿ inÿ patientsÿ whoÿ failedÿ aÿ trialÿ ofÿ oralÿ steroidsÿ forÿ
SSNHL.ÿ Theseÿ resultsÿ wereÿ alsoÿ confirmedÿ byÿ Xenellisÿ andÿ
colleagues128ÿ inÿ theirÿ randomizedÿ controlledÿ prospectiveÿ trialÿ ofÿ 37ÿ patie
withÿ SSNHLÿ whoÿ alsoÿ failedÿ oralÿ steroidÿ treatment.ÿ Theseÿ
studiesÿ areÿ small,ÿ butÿ manyÿ inÿ vitroÿ andÿ inÿ vivoÿ studiesÿ
haveÿ supportedÿanÿotoprotectantÿroleÿofÿtopicalÿsteroids.
Antiinflammatory and Immunosuppressive Agents
Tacrolimus.ÿ Tacrolimusÿ isÿ aÿ macrolideÿ immunosuppressiveÿ
drugÿthatÿinhibitsÿcalcineurinÿandÿtherebyÿinhibitsÿT-lymphocyteÿ
signalÿtransductionÿandÿinterleukinÿ2ÿtranscription.ÿItÿhasÿbeenÿ
shownÿtoÿbeÿasÿeffectiveÿasÿsomeÿmoderate-strengthÿsteroidsÿbutÿ
canÿbeÿusedÿforÿlongÿperiods,ÿbecauseÿitÿdoesÿnotÿhaveÿtheÿ
sameÿ side-effectÿ profileÿ asÿ topicalÿ steroids,ÿ whichÿ includesÿ
skinÿ atrophy.ÿ Itÿ canÿ alsoÿ beÿ usedÿ inÿ regionsÿ ofÿ fragileÿ orÿ
sensitiveÿ skin.ÿSideÿeffectsÿincludeÿburning,ÿpruritus,ÿflulikeÿ
symptoms,ÿ andÿ headache.129,130ÿReitamoÿ andÿ colleagues131,132ÿ
showedÿinÿ aÿ randomizedÿ controlledÿ prospectiveÿ trialÿ ofÿ 485ÿ
patientsÿ thatÿ topicalÿ0.03%ÿandÿ0.1%ÿtacrolimusÿointmentsÿwereÿ
moreÿeffec tiveÿthanÿ1%ÿhydrocortisoneÿacetateÿinÿadultsÿandÿ
childrenÿwithÿ moderateÿtoÿsevereÿatopicÿdermatitis,ÿandÿtheÿ0.1%ÿtacrolimusÿ
Machine Translated by Google
2132 PARTÿVII | OTOLOGY, NEUROTOLOGY, AND SKULL BASE SURGERY
Box 138-2. POTENCIES OF TOPICAL STEROIDS
Group I (Most Potent)
Clobetasol propionate 0.05% (Temovate)
Betamethasone dipropionate 0.25% (Diprolene)
Halobetasol propionate 0.05% (Ultravate)
Diflorasone diacetate 0.05% (Psorcon)
Group II
Fluocinonide 0.05% (Lidex)
Halcinonide 0.05% (Halog)
Amcinonide 0.05% (Cyclocort)
Desoximetasone 0.25% (Topicort)
Group III
Triamcinolone acetonide 0.5% (Kenalog, Aristocort cream)
Mometasone furoate 0.1% (Elocon ointment)
Fluticasone propionate 0.05% (Cutivate)
Betamethasone dipropionate 0.05% (Diprosone)
Group IV
Fluocinolone acetonide 0.01% to 0.2% (Synalar, Synemol, Fluonid)
Hydrocortisone valerate 0.2% (Westcort)
Hydrocortisone butyrate 0.1% (Locoid)
Flurandrenolide 0.05% (Cordran)
Triamcinolone acetonide 0.1% (Kenalog, Aristocort A ointment)
Mometasone furoate 0.1% (Elocon cream, lotion)
Group V
Triamcinolone acetonide 0.1% (Kenalog, Aristocort cream, lotion)
Fluticasone propionate 0.05% (Cutivate cream)
Desonide 0.05% (Tridesilon, DesOwen ointment)
Fluocinolone acetonide 0.025% (Synalar, Synemol cream)
Hydrocortisone valerate 0.2% (Westcort cream)
Group VI
Prednicarbate 0.05% (Aclovate Dermatop, cream and ointment)
Triamcinolone acetonide 0.025% (Aristocort A cream, Kenalog lotion)
Fluocinolone acetonide 0.01% (Capex shampoo, Derma-Smoothe)
Desonide 0.05% (DesOwen cream, lotion)
Group VII (Least Potent)
Hydrocortisone 2.5% (Hytone cream, lotion, ointment)
Hydrocortisone 1% (many over-the-counter brands)
preparationÿ wasÿ moreÿ effectiveÿ thanÿ 0.03%ÿ ointment.ÿ Theseÿ
researchersÿ alsoÿ demonstratedÿ thatÿ 0.1%ÿ tacrolimusÿ hadÿ effi
cacyÿsimilarÿtoÿthatÿofÿ0.1%ÿhydrocortisoneÿbutyrateÿointment.133
Bieberÿ andÿ colleagues134ÿ comparedÿ theÿ efficacyÿ andÿ safetyÿ
ofÿ 0.1%ÿ methylprednisoloneÿ aceponateÿ ointmentÿ withÿ 0.03%ÿ
tacrolimusÿointmentÿinÿchildrenÿwithÿanÿacuteÿflareÿofÿatopicÿ
dermatitis.ÿTheyÿfoundÿthatÿtheÿtwoÿointmentsÿhadÿsimilarÿeffi cacyÿ
inÿ resolvingÿ theÿ flareÿ butÿ thatÿ theÿ methylprednisoloneÿ ointmentÿ
wasÿbetterÿatÿreducingÿitchÿandÿimprovingÿsleepÿandÿ wasÿ
significantlyÿ lessÿ expensive.ÿ Theyÿ suggestedÿ thatÿ steroidÿ creamsÿ
shouldÿstillÿbeÿtheÿinitialÿtreatmentÿofÿchoiceÿforÿatopicÿ dermatitisÿ
flares.
CaffierÿandÿHarthÿandÿtheirÿcolleagues129,130ÿstudiedÿtheÿeffi
cacyÿofÿtacrolimusÿointmentÿforÿchronicÿnoninfectiousÿOEÿinÿaÿ
prospectiveÿtrialÿofÿ53ÿpatientsÿwhoseÿdiseaseÿwasÿrefractoryÿtoÿ
standardÿmanagement.ÿOtowicksÿinfusedÿwithÿtacrolimusÿoint mentÿ
wereÿ placedÿ everyÿ 2ÿ toÿ 3ÿ daysÿ forÿaÿ totalÿ ofÿ threeÿ treat
ments;ÿ 85%ÿ ofÿ theÿ patientsÿ hadÿ significantÿ improvementÿ inÿ
otalgia,ÿ edema,ÿ otorrhea,ÿ erythema,ÿ pruritus,ÿ andÿ desquama tionÿ
inÿtheÿshortÿterm;ÿitÿwasÿreportedÿthatÿ46%ÿofÿpatientsÿdidÿ notÿ
haveÿrelapsingÿsymptomsÿinÿtheÿ10-ÿtoÿ22-monthÿfollow-up,ÿ andÿ
theÿ 54%ÿ ofÿ patientsÿ thatÿ didÿ haveÿ relapsesÿ hadÿ longerÿ
symptom-freeÿperiods.ÿ Onlyÿmildÿ sideÿ effectsÿ thatÿ includedÿ aÿ
localÿfeelingÿofÿheat,ÿoccasionalÿskinÿburning,ÿandÿitchingÿwereÿ
reported.
Pimecrolimus.ÿ Pimecrolimusÿ creamÿ 1%ÿ isÿ alsoÿ aÿ calci
neurinÿ inhibitorÿ andÿ isÿ usedÿ inÿ milderÿ casesÿ ofÿ dermatitis.ÿ
Pimecrolimus isÿmoreÿ skin-selectiveÿ thanÿ tacrolimus,ÿwhichÿisÿ
alsoÿ usedÿ asÿ aÿ generalÿ immunosuppressantÿ forÿ transplantÿ
patients.ÿ Djalilianÿ andÿ Memar135ÿ performedÿ aÿ retrospectiveÿ
chartÿreviewÿofÿ36ÿpatientsÿwithÿpruriticÿexternalÿearsÿwhoÿwereÿ
treatedÿwithÿtopicalÿpimecrolimusÿointmentÿforÿ3ÿmonths.ÿTheyÿ
foundÿ thatÿ 34ÿ outÿ ofÿ 36ÿ patientsÿ experiencedÿ significantÿ
improvementÿinÿ pruritusÿwhenÿ comparedÿwithÿ aÿ groupÿ ofÿ 19ÿ
controlÿ patientsÿwhoÿ receivedÿ onlyÿauralÿhygiene.ÿRecentÿ evi
denceÿ suggestsÿ aÿ roleÿ forÿ topicalÿ 1%ÿ pimecrolimusÿ followingÿ
treatmentÿwithÿbetamethasoneÿ forÿmaintenanceÿofÿremissionsÿ
ofÿatopicÿdermatitis.ÿSteroidÿresponsivenessÿwasÿmaintainedÿinÿ
73.5%ÿ ofÿ patientsÿ afterÿ 3ÿ weeksÿ ofÿ double-blindÿ treatmentÿ
versusÿ39.4%ÿtreatedÿwithÿvehicle,ÿsuggestingÿaÿroleÿasÿaÿpossibleÿ
adjunctiveÿtherapy.136ÿSimilarÿresultsÿwereÿalsoÿdemonstratedÿinÿ
pediatricÿpatientsÿwithÿfacialÿeczema.137ÿWeinberg138ÿperformedÿ
aÿreviewÿofÿsecondaryÿ sourcesÿ toÿ evaluateÿ theÿ keyÿ characteris
ticsÿ thatÿ differentiateÿpimecrolimusÿ fromÿsteroidsÿandÿ tacroli musÿ
inÿ theÿ treatmentÿ ofÿatopicÿdermatitis,ÿandÿheÿ concludedÿ thatÿ
pimecrolimusÿ isÿ anÿ effectiveÿ steroid-sparingÿ therapyÿ forÿ mild toÿ
moderateÿatopicÿdermatitisÿandÿthatÿitÿisÿsafeÿandÿappro priateÿ forÿ
intermittentÿ long-termÿ therapy.ÿ Pimecrolimusÿ hasÿ fewerÿ sideÿ
effectsÿ thanÿ topicalÿ steroidsÿ andÿ aÿ hasÿ betterÿ side effectÿprofileÿ
thanÿtacrolimus.ÿTheÿdirectÿdrugÿcostÿofÿpimecro limusÿcomparesÿ
favorablyÿwithÿtacrolimus,ÿbutÿitÿisÿsignificantlyÿ moreÿ expensiveÿ
thanÿ genericÿ topicalÿ steroidÿ creams.124,138 Hebert139ÿ andÿ alsoÿ
Wellingtonÿ andÿ Jarvis140ÿ alsoÿ substantiatedÿ theseÿfindingsÿinÿ
meta-analysesÿofÿtheÿliteratureÿonÿtheÿefficacyÿ andÿsafetyÿofÿ
pimecrolimus.ÿSideÿeffectsÿwereÿmildÿandÿincludedÿ application-siteÿ
reactions,ÿ nasopharyngitis,ÿ headache,ÿ cough,ÿ pyrexia,ÿinfluenza,ÿ
andÿbronchitis,ÿwhichÿoverallÿwereÿnotÿsig nificantlyÿ differentÿ fromÿ
patientsÿ treatedÿ withÿ vehicleÿ cream.ÿ Paulÿandÿcolleagues141ÿ
determinedÿinÿaÿreviewÿofÿ1133ÿpatientsÿ agedÿ 3ÿ toÿ 22ÿ monthsÿ
thatÿ topicalÿ pimecrolimusÿ wasÿ safeÿ inÿ infants.ÿAshcroftÿandÿ
colleagues142ÿperformedÿaÿCochraneÿData baseÿ reviewÿ ofÿ theÿ
literatureÿ andÿ determinedÿ thatÿ topicalÿ pimecrolimus 1%ÿwasÿlessÿ
effectiveÿ thanÿ 0.1%ÿ tacrolimusÿ butÿ workedÿasÿwellÿasÿmoderateÿ
andÿpotentÿcorticosteroids.ÿStudiesÿ toÿcompareÿpimecrolimusÿwithÿ
mildÿcorticosteroidsÿareÿlacking.
ForÿtheÿtreatmentÿofÿeczematousÿOEÿandÿpruriticÿears,ÿsomeÿ
cliniciansÿ stillÿ dependÿ onÿ anÿ oldÿ remedy,ÿ coalÿ tar,ÿ whichÿ hasÿ
beenÿusedÿforÿoverÿ100ÿyearsÿandÿwasÿtheÿmainstayÿforÿtreatingÿ
inflammatoryÿ skinÿ conditionsÿ priorÿ toÿ theÿ developmentÿ ofÿ
topicalÿ steroids.143ÿ Althoughÿ noÿ randomizedÿ controlledÿ trialsÿ
existÿtoÿproveÿitsÿefficacyÿinÿtreatingÿthisÿdisorder,ÿtheÿdermatol ogyÿ
literatureÿ doesÿ commentÿ onÿ coalÿ tarÿinÿ theÿ treatmentÿ ofÿ
truncalÿ andÿ extremityÿ eczema.ÿ Roelofzenÿ andÿ associates144
describeÿcoalÿtarÿasÿhavingÿantiinflammatory,ÿantibacterial,ÿanti
pruritic,ÿandÿantimitoticÿeffects,ÿalongÿwithÿtheÿcommonÿshort termÿ
sideÿ effectsÿ ofÿ folliculitis,ÿ irritation,ÿ andÿ contactÿ allergy.ÿ Theÿ
carcinogenicityÿofÿcoalÿtarÿhasÿbeenÿshownÿbothÿinÿanimalsÿ andÿinÿ
humansÿexposedÿtoÿthisÿcompoundÿinÿoccupationalÿset tings,ÿ
althoughÿnoÿclearÿevidenceÿsupportsÿanÿincreasedÿriskÿofÿ skinÿ
tumorsÿ orÿ internalÿ tumorsÿ inÿ randomizedÿ clinicalÿ trialsÿ
usingÿ coalÿ tarÿ forÿ eczema.ÿ Hoareÿ andÿ others116ÿ performedÿ
aÿ meta-analysisÿ onÿ theÿ treatmentsÿ forÿ atopicÿ eczemaÿ andÿ
deter minedÿ thatÿ evidenceÿ wasÿ insufficientÿ toÿ makeÿ recommenda
tionsÿ onÿ theÿ useÿ ofÿ coalÿ tarÿ inÿ theÿ treatmentÿ ofÿ theÿ disease.ÿ
Schmidÿ andÿ Korting145ÿ reviewedÿ theÿ literatureÿ andÿ foundÿ atÿ
leastÿ limitedÿ evidenceÿ ofÿ theÿ efficacyÿ ofÿ coalÿ tarÿ inÿ treatingÿ
inflammatoryÿskinÿconditions,ÿalthoughÿtheyÿcautionedÿthatÿtheÿ
possibleÿriskÿofÿcarcinogenicityÿneedsÿtoÿbeÿfurtherÿexplored.
VIRAL INFECTIONS
Viralÿ lesionsÿ ofÿ theÿ externalÿ earÿ areÿ uncommonÿ andÿ includeÿ
RamsayÿHuntÿsyndromeÿandÿauralÿpapillomatosis.ÿRamsayÿHuntÿ
syndromeÿ isÿ dueÿ toÿ reactivationÿ ofÿ varicellaÿ zosterÿ virusÿ andÿ
resultsÿ inÿ auricularÿ vesicles,ÿ unilateralÿ facialÿ nerveÿ paralysis,ÿ
severeÿotalgia,ÿandÿotherÿsymptomsÿandÿsignsÿsuchÿasÿtinnitus,ÿ
Machine Translated by Google
FIGURE 138-2. Human papillomavirus (HPV) infection of the right external
auditory canal. The previous biopsy site is seen in the posterior-superior
quadrant. This otherwise healthy woman with no previous history of HPV
infection came to medical attention with chronic pruritus bilaterally and
muffled hearing. Examination revealed numerous, circumferential papillo
mata of the lateral external auditory canal bilaterally. She was referred to
a dermatologist for treatment with topical immune-response modifiers.
The arrow points to a papilloma.
hearingÿloss,ÿnausea,ÿvomiting,ÿvertigo,ÿandÿnystagmus.146ÿAuralÿ
papillomatosisÿisÿanÿextremelyÿrareÿconditionÿthatÿinvolvesÿpap illomasÿ
fillingÿ theÿ EACÿ (Fig.ÿ 138-2).ÿ Humanÿ papillomavirusÿ
typeÿ6ÿ(HPV-6)ÿhasÿbeenÿshownÿtoÿbeÿtheÿcauseÿofÿauralÿpapil
lomatosis.147ÿ Middleÿ earÿ invertingÿ papillomasÿ areÿ rarelyÿ
describedÿinÿtheÿliterature andÿmayÿextendÿthroughÿaÿTMÿper forationÿ
intoÿtheÿexternalÿcanal.
Management Options
Noÿ topicalÿ therapiesÿareÿ knownÿ toÿaddressÿRamsayÿHuntÿ syn drome;ÿ
thusÿ treatmentÿinvolvesÿ antiviralsÿ andÿ oralÿ steroids.146
Onlyÿ aÿ fewÿ casesÿ ofÿ auralÿ papillomatosisÿ haveÿ beenÿ reported,ÿ
withÿ malignantÿ transformationÿ toÿ squamousÿ cellÿ carcinomaÿ
reportedÿinÿaÿ singleÿcase.147ÿSuccessfulÿ treatmentÿhasÿinvolvedÿ
primaryÿresection.147,148ÿBlairÿandÿassociates149ÿmanagedÿaÿpatientÿ
withÿ auralÿ papillomatosisÿ withÿ carbonÿ dioxideÿ laserÿ removal.ÿ
Yadavÿandÿassociates150ÿtreatedÿaÿ3-year-oldÿpatientÿwithÿsurgicalÿ
excisionÿ ofÿ theÿ externalÿ canalÿ auralÿ papillomatosis.ÿ Noÿ trialsÿ
existÿtoÿdocumentÿtheÿuseÿofÿtopicalÿtherapiesÿfor auralÿpapil lomatosis;ÿ
however,ÿ theÿ immune-responseÿ modulatorÿ 5%ÿ
imiquimodÿhasÿbeenÿusedÿtopicallyÿwithÿgoodÿsuccessÿinÿtreatingÿ
HPV-6–associatedÿ papillomatosisÿ ofÿ theÿ externalÿ genitals.151
Topicalÿ treatmentÿwithÿ 5%ÿimiquimodÿ threeÿ timesÿweeklyÿ forÿ
16ÿweeksÿresultedÿinÿupÿtoÿ50%ÿcompleteÿresolutionÿofÿdiseaseÿ
andÿ upÿ toÿ 74%ÿ partialÿ resolutionÿ ofÿ diseaseÿ inÿ randomizedÿ
controlledÿ trials.151ÿ Inÿ aÿ meta-analysisÿ ofÿ theÿ literature,ÿ mildÿ
localizedÿ sideÿ effectsÿ ofÿ imiquimod—erythema,ÿ itching,ÿ andÿ
burning—areÿtheÿmostÿcommonlyÿreportedÿadverseÿeventsÿandÿ
occurÿinÿupÿtoÿ67%ÿofÿpatientsÿwhoÿapplyÿimiquimodÿ5%ÿcreamÿ
3ÿ timesÿ aÿ week.152ÿ Basedÿ onÿ theseÿ data,ÿ topicalÿ imiquimodÿ
therapyÿmayÿbeÿaÿreasonableÿnonsurgicalÿoptionÿforÿauralÿpapil
lomatosis.ÿ Interestingly,ÿimiquimodÿisÿcurrentlyÿbeingÿused byÿ
someÿpractitionersÿtoÿminimizeÿkeloidÿrecurrenceÿafterÿexcisionÿ
fromÿtheÿauricle.153,154ÿTheseÿstudiesÿareÿsmallÿandÿuncontrolledÿ
138 | TOPICAL THERAPIES FOR EXTERNAL EAR DISORDERS 2133
butÿhaveÿshownÿnoÿsignificantÿsideÿeffectsÿotherÿthanÿmildÿlocal izedÿ
skinÿirritationÿ withÿ theÿ useÿ ofÿ topicalÿ 5%ÿimiquimodÿ onÿ
theÿexternalÿear.153,154
CERUMEN IMPACTION
Cerumenÿ impactionÿ isÿ anÿ extremelyÿ commonÿ problemÿ forÿ
whichÿ patientsÿ seekÿ otolaryngologicÿ adviceÿ andÿ treatment,ÿ
becauseÿ itÿ canÿ causeÿ discomfort,ÿ hearingÿ loss,ÿ tinnitus,ÿ dizzi ness,ÿ
andÿ chronicÿ cough.155ÿCerumenÿimpactionÿisÿpresentÿinÿ
approximatelyÿ10%ÿofÿchildren,ÿ5%ÿofÿhealthyÿadults,ÿ57%ÿofÿ
olderÿ patientsÿ inÿ nursingÿ homes,ÿ andÿ 36%ÿ ofÿ patients withÿ
mentalÿretardation.156ÿChronicÿmanipulationÿwithÿcotton-tippedÿ
applicators,ÿ narrowÿ externalÿ canals,ÿ hairÿ inÿ theÿ lateralÿ canal,ÿ
hearingÿ aids,ÿ andÿ earplugÿ useÿ haveÿ beenÿ associatedÿ withÿ anÿ
increasedÿincidenceÿofÿcerumenÿimpaction.ÿCerumenÿremovalÿ
isÿtheÿmostÿcommonÿotolaryngologicÿprocedureÿperformedÿinÿ
theÿprimaryÿcareÿsetting.155,157
Therapy Options
Manyÿ approachesÿ forÿ removingÿ cerumen—includingÿ manualÿ
debridement,ÿirrigation,ÿandÿceruminolytics—haveÿbeenÿde scribedÿ inÿ
theÿ literature.ÿ However,ÿ noÿ dataÿ fromÿ largeÿ ran domizedÿ prospectiveÿ
trialsÿ haveÿ comparedÿ theÿ efficacyÿ ofÿ theÿ
differentÿmethodsÿ ofÿ cerumenÿ removal.ÿManualÿ removalÿ andÿ
irrigationÿareÿcertainlyÿeffective,ÿbutÿ theseÿmayÿriskÿ traumaÿ toÿ
theÿcanalÿ skinÿalongÿwithÿinfectionÿorÿTMÿperforation.ÿ Irriga tionÿshouldÿ
notÿbeÿdoneÿifÿaÿTMÿperforationÿorÿmyringotomyÿ
tubeÿisÿpresent.158
Initialÿtreatmentÿofÿcerumenÿimpactionÿwithÿceruminolyticsÿ
isÿreasonableÿinÿmostÿcases,ÿandÿaÿplethoraÿofÿover-the-counterÿ
andÿprescriptionÿ optionsÿareÿavailable.ÿCochraneÿ reviewsÿ sug gestÿaÿ
benefitÿforÿcerumen-softeningÿpreparations,ÿalthoughÿnoÿ
particularÿagentÿappearsÿtoÿhaveÿsuperiorÿefficacy.159ÿThreeÿtypesÿ
ofÿ cerumen-softeningÿ preparationsÿ areÿ water-based,ÿ oil-based,ÿ
andÿnon–water-based/non–oil-basedÿpreparations.ÿRepresenta tivesÿfromÿ
eachÿcategoryÿareÿlistedÿinÿTableÿ138-1.ÿWater-basedÿ
andÿnon–water-based/non–oil-basedÿagentsÿincreaseÿcerumenÿ
miscibility,ÿwhereasÿoil-basedÿpreparationsÿlubricateÿtheÿwax.ÿAllÿ
ceruminolyticsÿ shouldÿ beÿ avoidedÿ inÿ patientsÿ withÿ tympanos tomyÿ
tubesÿorÿTMÿperforation,ÿandÿmanualÿremovalÿofÿcerumen,ÿ
ideallyÿusingÿaÿbinocularÿmicroscope,ÿmayÿbeÿ theÿbestÿoptionÿ
forÿ thisÿpopulation.ÿUtilizationÿ ofÿdocusateÿ sodiumÿasÿaÿ ceru minolyticÿ
isÿalsoÿcontraindicatedÿinÿcasesÿofÿTMÿperforationÿorÿ
myringotomyÿ tube,ÿ becauseÿ animalÿ modelsÿ suggestÿ thatÿ thisÿ
agentÿmayÿhaveÿototoxicÿproperties.160
Ceruminolyticsÿcanÿbeÿusedÿaloneÿasÿaÿprimaryÿtreatmentÿforÿ
cerumenÿimpactionÿorÿinÿpreparationÿforÿirrigationÿorÿmanualÿ
debridement.ÿ Whenÿ usingÿ ceruminolyticsÿ alone,ÿ Handÿ andÿ
Harvey161ÿ concludedÿ inÿ theirÿ reviewÿ ofÿ theÿ literatureÿ thatÿ tri
ethanolamineÿwasÿbetterÿthanÿsalineÿandÿthatÿlongerÿtreatmentÿ
durationÿwithÿsofteningÿagentsÿwasÿbetterÿthanÿaÿshorterÿdura tion inÿ
overallÿ efficacyÿ ofÿ treatingÿ cerumenÿ impaction.ÿ Theyÿ
alsoÿnotedÿthatÿdocusateÿsodiumÿwasÿnotÿstatisticallyÿbetterÿthanÿ
triethanolamineÿorÿsaline.161ÿRolandÿandÿcolleagues162ÿfoundÿnoÿ
statisticalÿdifferenceÿinÿresolutionÿofÿcerumenÿimpactionÿinÿ74ÿ
patientsÿrandomizedÿtoÿsaline,ÿCerumenex,ÿorÿMurineÿearÿwaxÿ
removalÿproducts,ÿandÿWhatleyÿandÿassociates163ÿfoundÿnoÿdif ferenceÿ
amongÿsaline,ÿColace,ÿandÿtriethanolamine.
Theÿuseÿofÿceruminolyticsÿbeforeÿirrigationÿmayÿincreaseÿtheÿ
successÿ ofÿ irrigationÿ byÿ upÿ toÿ 97%.161ÿ Useÿ ofÿ aÿ ceruminolyticÿ
agentÿ 15ÿ toÿ 30ÿ minutesÿ beforeÿ irrigationÿ wasÿ foundÿ toÿ beÿ asÿ
effectiveÿasÿseveralÿdaysÿofÿtreatment,164ÿandÿaÿwater-basedÿagentÿ
(eitherÿwater,ÿsaline,ÿorÿtriethanolamine)ÿwasÿfoundÿtoÿbeÿsupe riorÿtoÿ
carbamideÿperoxideÿ(aÿnon–water-based/non–oil-basedÿ
preparation)ÿpriorÿtoÿirrigation.161ÿOverall,ÿwhenÿusedÿimmedi atelyÿpriorÿ
toÿirrigation,ÿnoÿceruminolyticsÿappearedÿtoÿbeÿsupe riorÿtoÿsaline,ÿmakingÿ
salineÿanÿinexpensiveÿfirst-lineÿagent.ÿInÿ
Machine Translated by Google

2134 PARTÿVII | OTOLOGY, NEUROTOLOGY, AND SKULL BASE SURGERY

TABLE 138-1. Cerumen-Softening Agents for Cerumen Removal

Agent Use Dosing
Water-BasedÿSolutions

10%ÿTriethanolamineÿpolypeptideÿoleateÿ Softenÿcerumenÿbeforeÿirrigation Fillÿaffectedÿearÿcanalÿ15ÿtoÿ30ÿminutesÿ

condensateÿ(Cerumenex) beforeÿirrigation
Docusate sodiumÿ(Colace) Softenÿcerumenÿbeforeÿirrigation Fillÿaffectedÿearÿcanalÿwithÿ1ÿmLÿ15ÿtoÿ30ÿ
minutes beforeÿirrigation
3%ÿHydrogenÿperoxide Softenÿcerumenÿbeforeÿirrigation Fillÿaffectedÿearÿcanalÿ15ÿtoÿ30ÿminutesÿ
beforeÿirrigation
2.5%ÿAceticÿacid Homeÿtreatmentÿofÿimpactedÿ Fillÿaffectedÿearÿwithÿ2ÿtoÿ3ÿmLÿtwiceÿdailyÿ forÿ
earwax upÿtoÿ14ÿdays
10%ÿSodiumÿbicarbonate Softenÿcerumenÿbeforeÿirrigationÿorÿ useÿ Fillÿaffectedÿearÿwithÿ2ÿtoÿ3ÿmLÿ15ÿtoÿ30ÿ
asÿanÿalternativeÿtoÿirrigation minutes beforeÿirrigationÿorÿ alternativelyÿforÿ
3ÿtoÿ14ÿdaysÿatÿhomeÿ withÿorÿwithoutÿ
irrigation
Waterÿorÿsaline Softenÿcerumenÿbeforeÿirrigation Ifÿirrigationÿisÿattemptedÿwithoutÿ
softeningÿandÿisÿineffectiveÿwithÿtheÿfirstÿ
irrigationÿattempt,ÿinstillÿwaterÿandÿwaitÿ 15ÿ
minutesÿbeforeÿrepeatingÿirrigation
Non–Water-Based/ Non–Oil-BasedÿSolutions

Carbamideÿperoxideÿ(Debrox,ÿMurineÿremovalÿ Softenÿcerumenÿbeforeÿirrigationÿorÿ useÿ Putÿ5ÿtoÿ10ÿdropsÿintoÿtheÿaffectedÿearÿ

kit)
50%ÿCholineÿsalicylateÿandÿglycerolÿ(EarexÿPlus,ÿ
Audax);ÿethyleneÿoxideÿpolyoxypropyleneÿglycolÿ (Addax);ÿ
propyleneÿglycol;ÿ0.5%ÿchlorbutol
Oil-BasedÿSolutions
asÿanÿalternativeÿtoÿirrigation twiceÿdailyÿforÿupÿtoÿ7ÿdays
Softenÿcerumenÿbeforeÿirrigationÿorÿ useÿ Putÿ3ÿdropsÿintoÿtheÿaffectedÿearÿtwiceÿ
asÿanÿalternativeÿtoÿirrigation dailyÿforÿ4ÿdays

57.3%ÿArachisÿoil,ÿ5%ÿchlorbutol,ÿ2%ÿ Softenÿcerumenÿbeforeÿirrigationÿorÿ useÿ Fillÿaffectedÿearÿwithÿ5ÿmLÿtwiceÿdailyÿforÿ 2ÿtoÿ

paradichlorobenzene,ÿ10%ÿoilÿofÿturpentineÿ asÿanÿalternativeÿtoÿirrigation 3ÿdays
(Cerumol)

Arachisÿoil,ÿalmondÿoil,ÿrectifiedÿcamphor oilÿ Softenÿcerumenÿbeforeÿirrigationÿorÿ useÿ Putÿ4ÿdropsÿintoÿtheÿaffectedÿearÿtwiceÿ

(Otocerol,ÿEarex) asÿanÿalternativeÿtoÿirrigation dailyÿforÿupÿtoÿ4ÿdays
Oliveÿoil,ÿalmondÿoil,ÿorÿmineralÿoil Softenÿcerumenÿbeforeÿirrigation Putÿ3ÿdropsÿintoÿtheÿaffectedÿearÿatÿ
bedtimeÿforÿ3ÿorÿ4ÿdays
FromÿMcCarterÿD,ÿCourtneyÿA,ÿPollartÿS.ÿCerumenÿimpaction.ÿAm Fam Physicianÿ2007;75:1523-1528.

theirÿ reviewÿ ofÿ theÿ literature,ÿ McCarterÿ andÿ colleagues155,165
stateÿthat:ÿ“Basedÿonÿcurrentÿevidence,ÿifÿtreatmentÿwithÿaÿceru
minolyticÿ agentÿ followedÿ byÿ irrigationÿ isÿ chosen,ÿ anÿ initialÿ
attemptÿatÿirrigationÿwithÿwaterÿshouldÿbeÿmade.ÿIfÿirrigationÿisÿ
unsuccessful,ÿtheÿwaterÿshouldÿbeÿinstilledÿandÿleftÿinÿtheÿEACÿ
forÿ15ÿtoÿ30ÿminutes,ÿafterÿwhichÿanotherÿattemptÿatÿirrigationÿ
shouldÿbeÿmade.ÿIfÿthisÿsecondÿattemptÿisÿalsoÿunsuccessful,ÿitÿ
wouldÿ beÿ reasonableÿ toÿ useÿ aÿ ceruminolyticÿ forÿ twoÿ toÿ
threeÿ days,ÿfollowedÿbyÿanotherÿtrialÿofÿirrigation.”
Noÿlargeÿbodyÿofÿrandomizedÿcontrolledÿevidenceÿsupportsÿ theÿ
useÿofÿoneÿceruminolyticÿoverÿanother,ÿasÿdeterminedÿbyÿaÿ 2009ÿ
CochraneÿDatabaseÿreview.159ÿItÿisÿthereforeÿleftÿlargelyÿtoÿ
physicianÿ experienceÿandÿpreferenceÿwhenÿchoosingÿ theÿbestÿ
methodÿforÿcerumenÿremoval.
EAR HYGIENE AND THE
CHRONICALLY DRAINING EAR
Inÿ patientsÿ withÿ chronicÿ otorrheaÿ orÿ moistÿ ears,ÿ aÿ thoroughÿ
historyÿ andÿ physicalÿ examinationÿ areÿ requiredÿ toÿ ruleÿ outÿ aÿ
hypersensitivityÿ toÿ previousÿ ototopicalÿ therapy,ÿ autoimmuneÿ
condition,ÿcholesteatoma,ÿgranuloma,ÿorÿmalignancy.ÿChronicÿ
inflammationÿ and/orÿ low-gradeÿ chronicÿ infectionÿ withÿ theÿ sameÿ
bacteriaÿresponsibleÿforÿchronicÿOEÿmayÿresultÿinÿpersis tentÿ
otorrhea.ÿAsÿmentionedÿ earlier,ÿ earÿ hygieneÿ andÿ dryÿ earÿ
precautionsÿareÿofÿutmostÿimportance.
Theÿ AAO-HNSFÿ statesÿ “Aÿ dryÿ earÿ isÿ unlikelyÿ toÿ becomeÿ
infected,ÿ soÿitÿisÿimportantÿ toÿ keepÿ theÿ earsÿ freeÿ ofÿmoistureÿ
afterÿ swimmingÿ orÿ bathing.ÿ Removableÿ earplugs,ÿ sometimesÿ
wornÿforÿhearingÿprotection,ÿcanÿbeÿusedÿtoÿkeepÿmoistureÿoutÿ
ofÿ theÿ earÿ canal.ÿ Q-tipsÿ shouldÿ notÿ beÿ usedÿ forÿ thisÿ
purpose,ÿ becauseÿ theyÿ mayÿ packÿ materialÿ deeperÿ intoÿ theÿ
earÿ canal,ÿ removeÿprotectiveÿearwax,ÿandÿirritateÿtheÿthinÿskinÿofÿ
theÿearÿ canal,ÿ creatingÿ theÿ perfectÿ environmentÿ forÿ infection.ÿ
Theÿ safestÿwayÿtoÿdryÿyourÿearsÿisÿwithÿaÿhairÿdryer,ÿsetÿonÿtheÿ
coolÿ setting.ÿ Ifÿ youÿ doÿ notÿ haveÿ aÿ perforatedÿ eardrum,ÿ
isopropylÿ rubbingÿ alcoholÿ (68.5%ÿ toÿ 71.5%ÿ vol./vol.ÿ ofÿ
absoluteÿ ethylÿ alcohol)ÿ orÿ aÿ 50ÿ:ÿ50ÿ mixtureÿ ofÿ alcoholÿ andÿ
vinegarÿ usedÿ asÿ eardropsÿwillÿevaporateÿexcessÿwaterÿandÿkeepÿ
yourÿearsÿdry.”166 Usingÿearÿplugsÿorÿcottonÿballsÿwithÿpetroleumÿ
jellyÿwhileÿshow eringÿ orÿ swimmingÿ canÿ helpÿinÿ thisÿ regard.ÿ
Mack’sÿEarÿ Plugsÿ makesÿ anÿ earÿ dryerÿ withÿmoldedÿ earÿ
piecesÿ designedÿ forÿ theÿ purposeÿofÿdryingÿmoistÿcanals.
Acidifyingÿ orÿ alcoholÿ dropsÿ canÿ beÿ usedÿ asÿ aÿ preventiveÿ
measureÿ duringÿ theÿ at-riskÿ periodÿ (e.g.,ÿ swimÿ season,ÿ scubaÿ
divingÿtrip)ÿandÿcanÿalsoÿbeÿusedÿasÿaÿtreatmentÿinÿpatientsÿwithÿ
chronicallyÿdrainingÿears.ÿMildÿchronicÿinfectionÿorÿinflamma tionÿ
canÿbeÿtreatedÿwithÿanÿaceticÿacidÿsolution,ÿsuchÿasÿDome boroÿ
orÿ trichloroaceticÿ acidÿ solutions,ÿ and/orÿ aÿ 90%ÿ toÿ 95%ÿ
alcoholÿ solution.15,19,168ÿTheÿ dropsÿhelpÿ evaporateÿmoistureÿ
inÿ theÿcanal,ÿandÿ theÿacidifyingÿagentsÿhelpÿ toÿpreventÿ bacterialÿ
overgrowth.ÿThereÿareÿalsoÿreportsÿofÿusingÿiodineÿorÿhydrogenÿ
peroxideÿforÿroutineÿearÿhygiene,ÿalthoughÿnoÿrandomizedÿorÿ
controlledÿstudiesÿexistÿ toÿexploreÿ theÿefficacyÿofÿanyÿofÿ theseÿ
formsÿofÿearÿhygiene.
Fewÿ studiesÿ existÿ toÿ exploreÿ theÿ possibilityÿ ofÿ ototoxicity
fromÿ theÿacidifyingÿagents,ÿandÿnoÿ studiesÿinvolveÿhumans.ÿAÿ
Machine Translated by Google
138 | TOPICAL THERAPIES FOR EXTERNAL EAR DISORDERS 2135
A B
FIGURE 138-3. Powder insufflator. A, Assembled insufflator and #3 capsules filled with compounded antibacterial and steroidal components. B, An individual
capsule is opened, and the open end containing the medicated powder is inserted and left in the insufflator before reassembly. Care should be taken to avoid
overapplication.
reviewÿofÿtheÿexistingÿliterature,ÿhowever,ÿindicatesÿthatÿhydro genÿ
peroxide,ÿaceticÿacidÿ(VoSol,ÿDomeboro),ÿandÿalcoholÿsolu tionsÿ
mayÿbeÿototoxicÿandÿ thusÿ shouldÿbeÿavoidedÿinÿpatientsÿ withÿ TMÿ
perforations.55,169,170ÿ Iodineÿ andÿ Burow’sÿ solutionÿ doÿ notÿ
appearÿtoÿhaveÿototoxicÿorÿvestibulotoxicÿpotential.170,171ÿItÿ isÿ
largelyÿ theÿ practitioner’sÿ preferenceÿ thatÿ dictatesÿ whichÿ ofÿ theÿ
aboveÿ optionsÿ toÿ useÿ forÿ initialÿ treatmentÿ ofÿ theÿ chroni cally
drainingÿorÿmoistÿear.
Aÿ varietyÿ ofÿ powdersÿ designedÿ forÿ useÿ inÿ theÿ externalÿ ear
canalÿhaveÿbeenÿdevelopedÿasÿtreatmentsÿforÿchronicallyÿmoistÿ
canalsÿ andÿ mastoidÿ bowls.ÿ Manyÿ differentÿ compoundsÿ haveÿ
beenÿ used.ÿ Mostÿ preparationsÿ areÿ aÿ mixtureÿ ofÿ antibacterialÿ
antibiotics,ÿ antifungalÿ agents,ÿ andÿ steroids.ÿ Twoÿ preparationsÿ
areÿ usedÿ atÿ theÿ Universityÿ ofÿ Texasÿ Southwesternÿ Medicalÿ
Center.ÿGold dust powderÿisÿcomprisedÿofÿchloramphenicol,ÿsul
fanilamide,ÿ andÿ hydrocortisone.ÿTheÿ chloramphenicolÿinÿ theÿ
powderÿ hasÿ ototoxicÿ potentialÿ andÿ shouldÿ notÿ beÿ usedÿ withÿ
perforatedÿTMs.172-174 Mastoid powderÿisÿcomprisedÿofÿciprofloxa
cin,ÿclotrimazole,ÿdexamethasone,ÿandÿboricÿacid.ÿTheÿmastoidÿ
powderÿappearsÿmoreÿeffectiveÿandÿisÿeasierÿtoÿapplyÿthanÿtheÿ goldÿ
dust.ÿMastoidÿpowderÿhasÿaÿreducedÿtendencyÿtoÿclump,ÿisÿ muchÿ
easierÿtoÿdisperseÿbyÿblowing,ÿandÿseemsÿtoÿdistributeÿasÿaÿ finerÿ
powderÿthanÿgoldÿdust.7 ÿAdditionally,ÿtheÿmastoidÿpowderÿ ingredientsÿ
areÿsafeÿtoÿuseÿinÿaÿpatientÿwithÿaÿTMÿperforation,ÿ becauseÿ noneÿ
ofÿ theÿ ingredientsÿ hasÿ beenÿ shownÿ inÿ animalÿ experimentsÿorÿinÿ
vitroÿstudies toÿcauseÿdamageÿtoÿtheÿvestibularÿ orÿcochlearÿ sensoryÿ
organs.4,30-32,124-126ÿTheÿHouseÿEarÿ Instituteÿ developedÿaÿ
mastoidÿpowderÿthatÿconsistsÿofÿchloramphenicolÿ 50ÿmg,ÿsulfanilamideÿ
50ÿmg,ÿandÿAmphotericinÿBÿ5ÿmg,ÿcalledÿ CSF powder.ÿHydrocortisoneÿ
(HC)ÿpowderÿmayÿalsoÿbeÿaddedÿtoÿ makeÿCSF-HC powder.ÿAtÿ
JohnsÿHopkins,ÿaÿpreparationÿconsist ingÿofÿhydrocortisoneÿpowderÿ
4%ÿandÿboricÿacidÿ96%ÿisÿused.ÿ Theseÿpowdersÿareÿnotÿalwaysÿ
readilyÿavailable,ÿbecauseÿaÿphar macyÿcapableÿofÿcompoundingÿisÿ
requiredÿtoÿprepareÿthem.
Inÿ 1983,ÿ JohnÿHouseÿ andÿ Jamesÿ Sheehyÿ atÿ theÿHouseÿ Ear
Clinicÿdevelopedÿaÿbulbÿinsufflatorÿforÿtheÿtopicalÿapplicationÿ
ofÿtheseÿpowdersÿtoÿtheÿEACÿorÿmastoidÿbowl.ÿThisÿbulbÿisÿcom
monlyÿ usedÿ todayÿ andÿ acceptsÿ #3ÿ medicationÿ capsulesÿ (Fig.
138-3).ÿ Mostÿ otolaryngologyÿ clinicsÿ willÿ stockÿ theÿ insufflator,ÿ
whichÿcanÿbeÿbilledÿtoÿtheÿinsuranceÿcompanyÿorÿsoldÿdirectlyÿ toÿ
theÿ patient.ÿ Severalÿimportantÿ pointsÿ aboutÿ theÿ useÿ ofÿ theÿ
insufflatorÿshouldÿbeÿemphasized.ÿFirst,ÿaÿcapsuleÿthatÿcontainsÿ theÿ
medicatedÿ powderÿisÿ carefullyÿ openedÿ byÿ theÿ userÿ andÿisÿ thenÿ
placedÿwithÿtheÿopenÿendÿintoÿtheÿdisassembledÿinsuffla tor,ÿ asÿ
illustratedÿ inÿ Figureÿ 138-3.ÿ Oneÿ capsuleÿ shouldÿ lastÿ atÿ leastÿ 1ÿ
weekÿ ifÿ usedÿ sparinglyÿ andÿ ifÿ dailyÿ applicationsÿ areÿ
recommended.ÿ Second,ÿ carefulÿ patientÿ counselingÿ shouldÿ beÿ
providedÿ toÿavoidÿoveruse,ÿbecauseÿexcessiveÿaccumulationÿofÿ
powderÿ inÿ aÿ smallÿ mastoidÿ bowlÿ orÿ EACÿ canÿ occur.ÿ Inÿ rareÿ
cases,ÿ theÿ powderÿ canÿ consolidateÿ inÿ anÿ earÿ cavity,ÿ makingÿ
debridementÿdifficultÿorÿpainful.
Finally,ÿ theÿ underlyingÿ causeÿ ofÿ chronicÿ otorrheaÿinÿmanyÿ
casesÿmayÿbeÿtheÿpresenceÿofÿgranulationÿtissue,ÿtoÿwhichÿsilverÿ
nitriteÿcanÿbeÿappliedÿtopically.175-176ÿInÿpatientsÿwhoÿhaveÿhadÿ aÿ
canal-wall-downÿmastoidectomy,ÿitÿisÿessentialÿtoÿnoteÿwhetherÿ theÿ
facialÿ nerveÿisÿ dehiscentÿ priorÿ toÿ usingÿ silverÿ nitriteÿ soÿ as notÿ
toÿaccidentallyÿchemicallyÿcauterizeÿtheÿnerve.ÿBecauseÿtheÿ silverÿ
nitriteÿ sticksÿ areÿ frequentlyÿ tooÿ largeÿ andÿ impreciseÿ toÿ placeÿ
directlyÿ onÿ granulationÿ tissueÿinÿ theÿ externalÿ ear,ÿ smallÿ sliversÿ
canÿbeÿobtainedÿandÿalligatorÿforceps,ÿguidedÿbyÿaÿbin ocularÿ
microscope,ÿcanÿbeÿusedÿtoÿpreciselyÿapplyÿtheÿchemicalÿ cautery.ÿ
Careÿshouldÿbeÿtakenÿtoÿuseÿasÿlittleÿasÿpossible,ÿbecauseÿ theÿ
depthÿofÿburnÿcannotÿbeÿeasilyÿcontrolled.
SUMMARY
Manyÿtopicalÿtherapiesÿareÿavailableÿtoÿtheÿotolaryngologistÿforÿ theÿ
treatmentÿofÿexternalÿearÿdisorders.ÿTheseÿcomeÿinÿsuspen sion,ÿ
solution,ÿlotion,ÿointment,ÿorÿpowderÿformsÿandÿareÿsum marizedÿinÿ
Tableÿ138-2.ÿAlthoughÿmostÿototopicalsÿcanÿbeÿusedÿ safelyÿ forÿ
theÿ managementÿ ofÿ commonÿ bacterialÿ andÿ fungalÿ infectionsÿ ofÿ
theÿ externalÿ ear,ÿ concernsÿ forÿ ototoxicityÿ andÿ
 Neomycin,ÿ Antibiotics Aceticÿ
acidÿ
inÿ Alcohol-
vinegar Acidifyingÿ
Agents TABLE
138-2.
Summary
of
Available
Ototopical
Agents
Ciprofloxacinÿ
+ Ciprofloxacinÿ
+ Ofloxacin Hydrocortisoneÿ Propyleneÿ
glycolÿ Generic
Name
hydrocortisone polymyxinÿ
B,ÿ dexamethasone hydrocortisone acidÿ
oticÿ
solution glycol,ÿ
andÿ
aceticÿ oticÿ
solution andÿ
aceticÿ
acidÿ acetate aluminumÿ mix
1%,ÿ
propyleneÿ
Cortisporin Floxinÿ
(0.3%ÿ
solution) VoSolÿ
HC VoSol Domeboro/
modifiedÿ 50%ÿ
alcohol,ÿ
25%ÿ Brand
Name
Ciprodexÿ
(0.3%/
0.1%ÿ Ciproÿ
HCÿ
(0.2%/
1%ÿ
(solution,ÿ
suspension)
susp.) suspension) Burow’sÿ
solution 25%ÿ
distilledÿ
water whiteÿ
vinegar,ÿ
andÿ
Bacterialÿ
OE Bacterialÿ
OE,ÿ Bacterialÿ
OE OM
w/
tube Bacterialÿ
OE,ÿ Mildÿ
fungal/ Mildÿ
fungal/ Mildÿ
fungal/ Preventionÿ
ofÿ Indication
OM
w
tubes
/ earÿ
surgery otorrheaÿ
afterÿ preventionÿ
ofÿ bacterialÿ
OE bacterialÿ
OE bacterialÿ
OE bacterialÿ
OE ofÿ
acuteÿ forÿ
mildÿ
casesÿ OE,ÿ
treatmentÿ
Children: 4-5ÿ
drops Adult: Adults:ÿ
10ÿ
drops 4-5ÿ
drops Dose
3ÿ
drops 4ÿ
drops 3ÿ
drops Children: 2-4ÿ
drops 2-4ÿ
drops 5ÿ
drops
(<13ÿ
y):ÿ
5ÿ
drops
3-4ÿ
timesÿ
daily
Maximumÿ BID BID QDÿ
orÿ
BID 2-4ÿ
timesÿ
daily
10ÿ
days 2-4ÿ
timesÿ
daily
10ÿ
days 2-4ÿ
timesÿ
daily
10ÿ
days 2-4ÿ
timesÿ
perÿ Frequency
day
7ÿ
days 7ÿ
days 7-10ÿ
days Duration
Contraindications
10ÿ
days
Hypersensitivity,ÿ
TMÿ Hypersensitivity,ÿ
viral Hypersensitivity,ÿ
viralÿ Hypersensitivity TMÿ
perforation,ÿ
tubes,ÿ TMÿ
perforation,ÿ
tubes,ÿ TMÿ
perforation,ÿ
tubes,ÿ TMÿ
perforation,ÿ
tubes,ÿ
viralÿ
earÿ
infection perforation,ÿ
tubes,ÿ infection external
earÿ perforation infection,ÿ
TMÿ hypersensitivityÿ hypersensitivityÿ hypersensitivityÿ reaction hypersensitivityÿ
externalÿ
earÿ reaction reaction reaction
Categoryÿ
C
Unknown Categoryÿ
C
Probablyÿ
safe
Safe Categoryÿ
C
Probablyÿ
safe
Safe Categoryÿ
C
Unknown Categoryÿ
C
Unknown Unknown Unknown Safe Pregnancy
Lactation
Safe
Safe Safe Safeÿ
>3ÿ
years Safeÿ
>3ÿ
years Safe Safe Children
Suspensionÿ Safeÿ
inÿ
middleÿ
ear Safeÿ
inÿ
middleÿ
ear Mayÿ
beÿ
usedÿ
moreÿ Mayÿ
beÿ
usedÿ
moreÿ Notes
solutionÿ
burns recommended;ÿ isÿ
present copiousÿ
debrisÿ irrigationÿ
ifÿ copiouslyÿ
forÿ isÿ
present copiousÿ
debrisÿ irrigationÿ
ifÿ copiouslyÿ
forÿ
Machine Translated by Google
 Pregnancy
Category
C:ÿ
Animalÿ
reproductionÿ
studiesÿ
haveÿ
shownÿ
anÿ
adverseÿ
effectÿ
onÿ
theÿ
fetus,ÿ
andÿ
noÿ
adequateÿ
andÿ
well-
controlledÿ
studiesÿ
haveÿ
beenÿ
doneÿ
inÿ
humans,ÿ
butÿ
potentialÿ
benefitsÿ
mayÿ
warrantÿ
useÿ
ofÿ Pregnancy
Category
B:ÿ
Animalÿ
reproductionÿ
studiesÿ
haveÿ
failedÿ
toÿ
demonstrateÿ
aÿ
riskÿ
toÿ
theÿ
fetus,ÿ
andÿ
noÿ
adequateÿ
andÿ
well-
controlledÿ
studiesÿ
haveÿ
beenÿ
doneÿ
inÿ
pregnantÿ
women,ÿ
andÿ
noÿ
animalÿ
studiesÿ
haveÿ Hypersensitivity
BID,
twiceÿ
aÿ
day;ÿ
OE,ÿ
otitisÿ
externa;ÿ
OM,ÿ
otitisÿ
media;ÿ
QD,ÿ
everyÿ
day;ÿ
TID,ÿ
threeÿ
timesÿ
aÿ
day;ÿ
TM,ÿ
tympanicÿ
membrane.
Cresylateÿ
Oticÿ
25% Gentianÿ
violetÿ
1%ÿÿ
Antiseptics Ciclopiroxÿ Nystatin
(100,000 Tolnaftate
(1% Ketoconazoleÿÿ Miconazole Clotrimazoleÿ
(1%ÿ
Antifungals Gentamicin Tobramycinÿ
+ Generic
Name
theÿ
drugÿ
inÿ
pregnantÿ
womenÿ
despiteÿ
potentialÿ
risks. shownÿ
anÿ
adverseÿ
effect,ÿ
butÿ
adequateÿ
andÿ
well-
controlledÿ
studiesÿ
inÿ
pregnantÿ
womenÿ
haveÿ
failedÿ
toÿ
demonstrateÿ
aÿ
riskÿ
toÿ
theÿ
fetusÿ
inÿ
anyÿ
trimester.
orÿ
2% cream,ÿ
susp. Olamine
0.77% ointment) units/
gÿ
cream,ÿ cream) cream,ÿ
solution) dexamethasone
(2%ÿ
cream) (2%ÿ
cream)
Loprox Mycostatin Tinactin Nizoral,ÿ
Xolegel Micatin,
Monistat Lotrimin
AF,
Mycelex Gentamicinÿ
ophthalmicÿ Tobradexÿ
ophthalmicÿ Brand
Name
(0.3%ÿ
drops) (0.1%/
0.3%ÿ
susp.)
Mildÿ
fungalÿ
OE Mildÿ
fungalÿ
OE
1ÿ
application Fungal
OE Fungal
OE Fungal
OE Fungal
OE Fungal
OE Fungal
OE Bacterialÿ
OE Bacterialÿ
OE Indication
1ÿ
applicationÿ
toÿ 1ÿ
applicationÿ
toÿ 1ÿ
applicationÿ
toÿ 1ÿ
applicationÿ
toÿ 1ÿ
applicationÿ
toÿ Solution:ÿ
3-4ÿ Cream:ÿ
1ÿ 3-4ÿ
drops 3-4ÿ
drops Dose
externalÿ
canal externalÿ
canal externalÿ
canal externalÿ
canal externalÿ
canal drops application
Adults:ÿ
2ÿ
toÿ
3ÿ Frequency
Children:ÿ
1ÿ
toÿ BID TIME TIME
2ÿ
timesÿ
daily timesÿ
daily
3ÿ
days 7ÿ
days 7ÿ
days 7ÿ
days Duration
Contraindications
TMÿ
perforation Hypersensitivity Hypersensitivity Hypersensitivity,ÿ
TMÿ Hypersensitivity Hypersensitivity Hypersensitivity Hypersensitivity Hypersensitivity,ÿ
TMÿ Hypersensitivity,ÿ
TMÿ
perforation perforation,ÿ
tubes perforation,ÿ
tubes
Unknown Categoryÿ
C
Safe Categoryÿ
B
Safe Categoryÿ
C
Safe Categoryÿ
C
Safetyÿ Categoryÿ
C
Safetyÿ Categoryÿ
C
Probablyÿ
safe
Safe Categoryÿ
B
Probablyÿ
safe
Safe Categoryÿ
C
Unknown Categoryÿ
C
Unknown Pregnancy
Lactation
unknown unknown
Safe >10ÿ
years Safe Safe Safe Unknown Safe Children
Causesÿ
staining Notes
Machine Translated by Google
Machine Translated by Google
2138 PARTÿVII | OTOLOGY, NEUROTOLOGY, AND SKULL BASE SURGERY
hypersensitivityÿ mustÿ beÿ considered,ÿ especiallyÿ inÿ refractoryÿ
casesÿ orÿ inÿ thoseÿ patientsÿ withÿ aÿ perforatedÿ TM.ÿ Systemicÿ
therapyÿshouldÿbeÿincludedÿinÿpatientsÿwhoÿareÿimmunocom
promised.ÿSevereÿorÿchronicÿinfectionsÿthatÿdoÿnotÿrespondÿtoÿ
aggressiveÿototopicalÿ treatment,ÿsystemicÿ therapy,ÿandÿmanualÿ
debridementÿ mustÿ be carefullyÿ reevaluatedÿ toÿ excludeÿ theÿ
possibilityÿ ofÿ malignancy,ÿ cholesteatoma,ÿ keratosisÿ obturans,ÿ
autoimmuneÿdisorder, hypersensitivity,ÿorÿMOE.ÿInÿmostÿcases,ÿ
however,ÿ meticulousÿ earÿ hygieneÿ andÿ avoidanceÿ ofÿ self
manipulationÿ willÿ contributeÿ toÿ betterÿ outcomesÿ forÿ patientsÿ
withÿinfectiousÿandÿinflammatoryÿconditionsÿofÿtheÿexternalÿear.
For a complete list of references, see expertconsult.com.
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Machine Translated by Google
138 | TOPICAL THERAPIES FOR EXTERNAL EAR DISORDERS2138.e1
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