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Management Otitis Externa • Acidification of ear canal with drops – Reduced pH retards antibiotic growth – Acetic acid • +/- topical antibiotics – Treats bacterial infection and reduces edema – Polymyxin B, neomycin and hydrocortisone; ciprofloxacin; ofloxacin (bacterial growth) – Nystatin powder (fungal infections) Otitis Externa • Acetic acid with and without hydrocortisone (EarSol HC, VoSoL HC, Acetasol HC) – Treats superficial bacterial infections of the EAC – 5-10 gtt in affected ear tid • Neomycin, polymyxin B, and hydrocortisone (Cortisporin Otic) – Used for steroid-responsive inflammatory condition for which a corticosteroid is indicated and where bacterial infection or a risk of bacterial infection exists. – 5 gtt in affected ear tid Otitis Externa • Ciprofloxacin / Ofloxacin – Inhibits bacterial growth by inhibiting DNA gyrase. – 5-10 gtt in affected ear bid or (ofloxacin) 10 drops in affected ear qd • Nystatin powder (Mycostatin, Nilstat) – Fungicidal and fungistatic antibiotic obtained from Streptomyces noursei Administer until 48h after disappearance of symptoms. Topical application reduces fungal growth. – 1-2 puffs from handheld nebulizer q1wk administered by treating physician Otitis Externa • Further Outpatient Care The patient requires suctioning of the external auditory canal on a weekly basis until debris has been removed. • Inpatient & Outpatient Medications Topical eardrops are the mainstay of both inpatient and outpatient treatment. Oral antibiotics or antifungal agents are usually reserved for refractory cases. Otitis Externa • Deterrence/Prevention Otitis externa can be prevented by avoiding use of cotton-tipped swabs or objects such as bobby pins to clean ears. Use of cotton-tipped swabs or bobby pins can cause excoriation of the canal skin that can lead to otitis externa. CSOM • Medical Treatment – In uncomplicated cases, the aim is to eliminate infection and to control otorrhea – topical liquid agents used in the treatment of chronic middle ear disease include a combination of antibiotics, antifungals, antiseptics, solvents, and steroids. The most commonly used topical antibiotics for CSOM include quinolone derivatives, such as ciprofloxacin and ofloxacin, and aminoglycosides – Oral antibiotics should be prescribed to patients with severe infections and to those who are systemically ill – Medical treatment should be accompanied by aural toilet. CSOM • Principal aim of surgery for chronic suppurative otitis media – to clear out the disease – if possible, to reconstruct the patient's hearing • General indications for surgery are as follows: – Perforation that persists beyond 6 weeks – Otorrhea that persists for longer than 6 weeks despite antibiotic use – Cholesteatoma formation – Radiographic evidence of chronic mastoiditis, such as coalescent mastoiditis – Conductive hearing loss CSOM • Tympanoplasty – Goal: to eradicate disease from the middle ear and to reconstruct the hearing mechanism, with or without grafting of the tympanic membrane – 2 primary types: • lateral graft technique, the graft material is laid laterally to the annulus after the remnant of squamous tissue is denuded. • medial grafting, the annulus is raised and the graft slipped medially CSOM w/o Cholesteatoma • Myringoplasty - operation specifically designed to close tympanic membrane defects. • Two main surgical techniques of tympanoplasty are commonly used, the underlay and the overlay. – underlay technique involves placing the graft material underneath (or medial to) the eardrum. – overlay technique involves grafting lateral to the eardrum – most common graft materials are temporalis fascia, tragal perichondrium, and vein graft – "stuff through” - may be useful for small perforations in otherwise healthy ears. This procedure essentially freshens the edges of the perforation and then fills it with a plug of tissue, usually fat. CSOM w/ Cholesteatoma • Tympanoplasty • Mastoidectomy – removal of the outer wall of the mastoid cortex and the exteriorization of all the mastoid air cells. This may be performed immediately in coalescent mastoiditis, in which case a drain may be left postoperatively. – Canal wall-up mastoidectomy - removal of mastoid air cells while retaining the posterior canal wall. This is also the common approach for cochlear implantation. – Modified radical mastoidectomy - the ossicles and the tympanic membrane remnants are preserved for possible hearing reconstruction – Radical mastoidectomy - eradication of all disease from the middle ear and the mastoid and exteriorization of these structures into a single cavity; includes removing the entire tympanic membrane and the ossicles (except the stapes footplate) and closing the eustachian tube opening. AOM • Medical Management – Mostly viral in origin, especially those that accompany coryza. Most common: RSV, influenza viruses, adenovirus, and parainfluenza – Treatment is purely symptomatic and supportive – High doses of amoxicillin (Pedia - 90 mg/kg; Adult 250 mg PO q8h) - result in middle ear fluid levels that exceed the minimum inhibitory concentration of all S pneumoniae – 10 days for children younger than 6 years and for children with severe symptoms; children older than 6 years can be treated for 5-7 days. AOM • Erythromycin (E-Mycin, Ery-Tab) – Has an antibacterial spectrum similar but not identical to that of penicillin; alternative for patients who are allergic to penicillin. – Adult - 250-500 mg PO q6h or 0.5-1 g PO q12h; in severe infections, not to exceed 4 g/d – Pediatric - <2 years: 125 mg PO q6h; 2-8 years: 250 mg PO q6h; double dose for severe infections; >8 years: Administer as in adults • Penicillin G benzathine (Bicillin L-A) – Remains a useful antibiotic but is inactivated by bacterial beta-lactamases. Parenteral therapy with benzylpenicillin is used initially in severe infections, followed by 3-7 days of oral phenoxymethylpenicillin (penicillin V). – Adult - 2.4-4.8 mg/d IV/IM divided qid; increase prn in more serious infections – Pediatric - Premature infants and neonates: 50 mg/kg/d IV/IM divided bid; Infants, 1-4 weeks: 75 mg/kg/d IV/IM divided tid 1 month to 12 years: 100 mg/kg/d IV/IM divided qid (may require higher doses); >12 years: Administer as in adults AOM • Gentamicin with hydrocortisone (Jenamicin, Garamycin) – Aminoglycosides although commonly used topical antibiotics, controversy surrounds topical therapy because of its potential for ototoxicity. Literature contains sporadic reports of sensorineural hearing loss associated with their use. Medication must be compounded at pharmacy. – Adult - 2-3 gtt tid/qid – Pediatric - 1 gtt qid • Ciprofloxacin (Ciloxan) – Quinolone derivatives, such as ciprofloxacin and ofloxacin, have excellent antipseudomonal activity. Inhibits bacterial DNA synthesis and, consequently, growth. Also available as ototopical preparations, with little demonstrable systemic effects. Approved for ophthalmic use but used ototopically off-label. – Adult - 5 gtt bid for 10 d AOM • Medical Management – Pain control is essential to treatment, especially in the first 24 hours after diagnosis, since pediatric population is often undertreated for pain. In addition to ibuprofen and acetaminophen, topical benzocaine can also be given for pain control. Guidelines also include the use of narcotic analgesia with codeine for severe pain. AOM • Surgical Management – Myringotomy - an incision is made in the tympanic membrane to adequately drain the middle ear; reserved for AOM associated with severe otalgia or high fever in patients who have had a poor response to antibiotics. – Recurrent AOM in children may be due to chronic sinus infections, nasopharyngeal obstruction, or cleft palate. Surgically treating these conditions may decrease the number of ear infections.