Treatment Of Chronic Suppurative Otitis Media Research Articles

A Comparative Study of Tympanoplasty with or without Mastoidectomy in Tubotympanic Type of Chronic Suppurative Otitis Media

Background: One of the most frequent ear illnesses in underdeveloped countries is chronic suppurative otitis media (CSOM). In the treatment of CSOM, otolaryngologists debate whether to perform tympanoplasty with or without cortical mastoidectomy. Objective: To compare the outcome of tympanoplasty with or without cortical mastoidectomy in the treatment of tubotympanic type chronic suppurative otitis media. Methods: This comparative study was carried out in the Department of Otolaryngology - Head and Neck Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka from July 2017 to June 2019 over a period of 02 years. A total number of 60 patients who underwent type 1 tympanoplasty with or without cortical mastoidectomy were enrolled in this study. After enrollment the condition of the pinna, preauricular region, postauricular region and external auditory cannal were examined. On otoscopy, site and size of perforation of tympanic membrane, condition of the rest of the tympanic membrane, condition of the middle car mucosa and the ossicles were also examined. Tuning fork tests, test for facial nerve integrity and fistula test were performed. Hearing level was assessed by pure tone audiometry with masking. Enrolled patients were grouped into two groups. Patients who underwent type- 1 tympanoplasty alone kept in group A and who underwent type 1 tympanoplasty with cortical mastoidectomy kept in group B. Complete blood count, blood urea, serum creatinine, random sugar, ECG and X-ray chest P/A view were done routinely. Results: Females were 76.7% in group-A and 53.3% in group-B. All patients were of age between 16 to 60 years and most of them were in the age group of 21-30 years. Majority of the patients were from rural area and maximum patients were from middle class family. In most of the patients unilateral ear involvement was observed. Perforation site was central malleolar in maximum cases followed by anterior central and posterior central. Perforation size was ........

P329 A tele of fungal burden in chronic suppurative otitis media (CSOM) patients of a tertiary care center of Nepal

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PM ObjectivesThe study was designed to find out the fungal etiological agents in chronic suppurative otitis media (CSOM) patients attending the tertiary care center of Nepal.MethodsThe laboratory-rooted study was performed at the Department of Clinical Microbiology. Specimen was collected in the ENT and Head and Neck Surgery Department of Tribhuvan University Teaching Hospital (TUTH), Nepal from February 2016 to July 2016. All clinical specimens were collected from hospitalized as well as outdoor patients having CSOM. Specimens were processed according to standard methodology. A total of 117 patients having CSOM were confirmed cases by the otolaryngologists and their 123 specimens were included in the study. Ear discharge was collected using sterile swab sticks which were labeled and sent to the laboratory for potassium hydroxide (KOH) mount and fungal culture studies.ResultsA total of 123 specimens were collected and processed. Distribution of patients according to the site among the total patients (n = 117), 69 (59.0%) were specimens from the left ear, 42 (35.9%) right ear, and 6 (5.1%) from both ears (bilateral) (Table 1). The 19-30 years age group was highest (34.1%) and followed by 31-50 years having 23.6%. Occupationally students were higher in number (29.9%) and it was followed by housewives (27.4%). A total of 47.8% of cases are from Kathmandu and remain from different regions of Nepal. Out of 123 specimens, 23 (18.7%) were found KOH mount positive (Table 2). The distribution of fungal isolates is as follows—among total isolates Aspergillus flavus 7, A. fumigatus 6, Acremonium 3, Candida albicans 2, Penicillium 2 A. niger 1, C. krusei 1, C. tropicalis 1, Curvularia 1, Fusarium 1, Mucor 1, and Syncephalastrum racemosum 1 (Table 3).ConclusionThe prevalence of fungi in CSOM patients was quite high (21.9%). This observation was different from the study of India conducted by Kumar et al. (15%) and in contrast with another researcher in Singapore, Loy et al. (8.8%). Aslam et al. from Pakistan study revealed only 2.1% and Khwakhali et al. study from Nepal estimated about 1.94% of the Nepalese population suffer from a serious fungal infection annually (commonly in HIV/AIDS and immunocompromised hosts) which are diluted by our findings. The possible reason may be due to location, temperature, negligence on mycological complications, and their treatment in Nepal. Treatment of CSOM should be based on the result of fungal culture. CSOM cases are found in all age groups (2-80 years) with various health statuses, different occupations, and in dispersed regions of Nepal. Phenotyping identification is cumbersome and have risk of infections which increases the chance of applying genotyping technique will be beneficial. Antifungal susceptibility testing should be mandatory since it helps in improving clinical outcomes by optimization of antifungal practices. Many CSOM patients complained that they were not cured even long time of use of antibacterial drugs. It clears that fungal etiological agents can't be neglected. If I am not wrong, Nepal has no separate designated mycology laboratory. There is also a lack of funding for clinical fungal studies and their awareness regarding fungal pathogens.

Review of patients with chronic suppurative otitis media in the National Ear care centre, Kaduna Nigeria.

Background: Chronic suppurative otitis media (CSOM) is the most common condition presenting to Otolaryngological clinics, often patients present late with consequent complications that require surgical intervention. This study aimed to review the mode of clinical presentation, modality and outcome of treatment of CSOM seen at NECC Kaduna. Methodology: This was a retrospective study carried out in the National Ear Care Centre, Kaduna for a period of 3 years; from January 2016 - December 2018. Results: Two hundred and thirty-four patients with CSOM were studied. There were 127 males and 107 females making M: F =1.2:1. The age range was from 8-60years with a mean age of 26.5±12.6years. The age group 11-20 (31.2%) had the highest number. Majority presented with hearing loss and ear discharge 228(97.4%) and 182(77.8%) respectively. Other symptoms were otalgia, tinnitus, vertigo and nasal symptoms. Eleven (4.7%) had complications at presentation. Ninety-two (39.3%) had surgery, 64 had only aural toileting and dressing with topical antibiotic with recorded success as majority achieved dry ear, while 38 patients were lost to follow up. Postoperative complications include; loss of taste sensation, facial nerve palsy, recurrent/persistent ear discharge, persistent dizziness, and infection of the donor site and no mortality was recorded. Conclusion: One-third of the patients who benefitted from surgery had a good outcome and for those with conservative treatment, the majority achieved dry ear. Early presentation is advised to avoid complications.

Aural toilet (ear cleaning) for chronic suppurative otitis media.

Aural toilet (ear cleaning) for chronic suppurative otitis media.

Topical antibiotics with steroids for chronic suppurative otitis media.

Topical antibiotics with steroids for chronic suppurative otitis media.

Tympanoplasty With or Without Balloon Eustachian Tuboplasty for Chronic Suppurative Otitis Media With Obstructive Eustachian Tube Dysfunction.

To further elucidate the role of balloon Eustachian tuboplasty (BET) in tympanoplasty, we conducted a study to compare the outcomes of tympanoplasty with and without BET for the treatment of chronic suppurative otitis media (CSOM) with obstructive Eustachian tube dysfunction (OETD). Case control study. Tertiary referral center. A total of 70 ears diagnosed with CSOM (tubotympanic type) and OETD were included in this study. Thirty-five patients were prospectively enrolled for BET and tympanomastoidectomy between February 2018 and June 2019. Thirty-five control subjects were matched by sex and age and retrospectively enrolled for tympanomastoidectomy between July 2016 and January 2018. BET, tympanomastoidectomy. The graft take rate, hearing levels, and Eustachian tube function test results. The graft take success rate was higher in the BET group (80.0%; 28/35) than in the control group (68.6%; 24/35). However, the difference was not statistically significant. The average air-bone gap (ABG) improvement was 10.93 ± 7.70 dB in the BET group and 7.11 ± 8.08 dB in the control group, with a statistically significant between-group difference (p = 0.033). Our findings suggest that BET can objectively and subjectively improve the Eustachian tube function, with a slight but significant improvement in ABG despite the lack of a clinically significant improvement overall. However, it does not affect the graft take rate. In summary, BET could be used as an adjunctive procedure in the treatment of CSOM with OETD.

Topical antiseptics for chronic suppurative otitis media.

Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Topical antiseptics, one of the possible treatments for CSOM, inhibit the micro-organisms that may be responsible for the infection. Antiseptics can be used alone or in addition to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). Antiseptics or their application can cause irritation of the skin of the outer ear, manifesting as discomfort, pain or itching. Some antiseptics (such as alcohol) may have the potential to be toxic to the inner ear (ototoxicity), with a possible increased risk of causing sensorineural hearing loss, dizziness or tinnitus. To assess the effects of topical antiseptics for people with chronic suppurative otitis media. The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL; 2019, Issue 4, via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 April 2019. We included randomised controlled trials (RCTs) with at least a one-week follow-up involving patients (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antiseptic agent of any class, applied directly into the ear canal as ear drops, powders or irrigations, or as part of an aural toileting procedure. Two main comparisons were topical antiseptics compared to: a) placebo or no intervention; and b) another topical antiseptic (e.g. topical antiseptic A versus topical antiseptic B). Within each comparison we separated studies where both groups of patients had received topical antiseptics a) alone or with aural toileting and b) on top of antibiotic treatment. We used the standard Cochrane methodological procedures. We used GRADE to assess the certainty of the evidence for each outcome. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health-related quality of life using a validated instrument; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes included hearing, serious complications and ototoxicity measured in several ways. Five studies were included. It was not possible to calculate the total number of participants as two studies only provided the number of ears included in the study. A. Topical antiseptic (boric acid) versus placebo or no treatment (all patients had aural toileting) Three studies compared topical antiseptics with no treatment, with one study reporting results we could use (254 children; cluster-RCT). This compared the instillation of boric acid in alcohol drops versus no ear drops for one month (both arms used daily dry mopping). We made adjustments to the data to account for the intra-cluster correlation. The very low certainty of the evidence means it is uncertain whether or not treatment with an antiseptic leads to an increase in resolution of ear discharge at both four weeks (risk ratio (RR) 1.94, 95% confidence interval (CI) 1.20 to 3.16; 174 participants) and at three to four months (RR 1.73, 95% CI 1.21 to 2.47; 180 participants). This study narratively described no differences in suspected ototoxicity or hearing outcomes between the arms (very low-certainty evidence). None of the studies reported results for health-related quality of life, adverse effects or serious complications. B. Topical antiseptic A versus topical antiseptic B Two studies compared different antiseptics but only one (93 participants), comparing a single instillation of boric acid powder with daily acetic acid ear drops, provided any information for this comparison. The very low certainty of the evidence means that it is uncertain whether more patients had resolution of ear discharge with boric acid powder compared to acetic acid at four weeks (RR 2.61, 95% CI 1.51 to 4.53; 93 participants), or whether there was a difference between the arms with respect to ear discomfort due to the low number of reported events (RR 0.10, 95% CI 0.01 to 1.81; 93 participants). Narratively, the study reported no difference in hearing outcomes between the groups. None of the included studies reported any of the other primary or secondary outcomes. Due to paucity of the evidence and the very low certainty of that which is available the effectiveness and safety profile of antiseptics in the treatment of CSOM is uncertain.

Chronic suppurative otitis media: A microbiological review of 20 years

Chronic infection of the middle ear cleft for at least 2 weeks or more is known as chronic suppurative otitis media (CSOM). It usually manifests as a complication of acute otitis media. It is more prevalent in developing countries due to various predisposing factors such as malnutrition, overcrowding, poor hygiene, inadequate health care, and recurrent upper respiratory tract infection. Due to advancement in medical facility, India still falls under high prevalence zone. In India, the average prevalence of CSOM is 5.2%. Pseudomonas aeruginosa and Staphylococcus aureus were the predominant isolates in most of the studies. Other common aerobic isolates were Klebsiella spp., Proteus spp., Escherichia coli, Bacteroides fragilis, Prevotella spp., Candida spp., and Aspergillus spp. However, there was no significant geographical variation of pathogens in India. In recent years, there is increased preponderance of multidrug-resistant organisms due to the irrational use of antibiotics, making treatment of CSOM more difficult. Colistin and polymyxin-B were the most effective antibiotics which showed sensitivity against P. aeruginosa by up to 100%. Carbapenems were showing good sensitivity against P. aeruginosa in most of the studies, but there was decreased tendency of sensitivity for piperacillin-tazobactam, amikacin, gentamicin, ceftazidime, and ciprofloxacin. Nine studies isolated methicillin-sensitive S. aureus significantly higher in number than methicillin-resistant S. aureus. For S. aureus, vancomycin and linezolid showed ≥90% sensitivity in most of the studies. Amikacin, gentamicin, erythromycin, and ciprofloxacin were other active drugs against S. aureus, which were showing resistant pattern significantly.

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

Chronic suppurative otitis media (CSOM) is one of the most common chronic infectious diseases worldwide, especially affecting children. The patients or the parents of the affected children are often worried about the cost of medical visits, prescription medicines, or inconsistently effective medication. The complications of CSOM have been greatly reduced because of the development of antibiotics; however, the irrational use of antibiotics has led to the emergence of organisms resistant to the commonly used drugs. Owing to the increase in antibiotic resistance, the development of new treatments that will efficiently eradicate infectious microorganisms has become imperative. Boric acid solutions are effective in the treatment of CSOM because of their acidic effect. Various databases, such as the PubMed, The Cochrane Library, and SciELO, were searched for references related to the efficacy of boric acid in the treatment of mucosal CSOM, as well as its ototoxicity. The search revealed that boric acid is relatively effective in treating CSOM, especially at a high concentration. Boric acid in distilled water was found safe in animal studies. However, the ototoxicity of boric acid concentrations higher than 4% needs further evaluation, considering the effectivity of boric acid at high concentrations.

Present scenario of microbiological pattern in chronic suppurative otitis media and its management guidelines

AIMS: Chronic suppurative otitis media (CSOM) is a common infectious chronic ear disease in India resulting in serious complications, especially hearing impairment. Irrational use of antibiotics for its management has led to the emergence of multidrug-resistant bacterial strains. Considering this, this study was conducted to know the pattern of causative organisms associated with CSOM and their antimicrobial sensitivity. Materials and Methods: Ear discharge from 200 clinically diagnosed cases of CSOM was collected by suction using sterile techniques in a sterilised test tube on wash bottle principle consisting of a glass tube made air tight with the help of a cork with an inlet and outlet facility. All samples were processed in the department of microbiology for the identification of bacterial and fungal isolates and their antimicrobial sensitivity testing. Results: Among the 200 samples of ear discharge, 127 were from ear having tubotympanic (mucosal or safe) type of CSOM while 73 were from ear with attico-antral (squamosal or unsafe) CSOM. Among aerobic isolates, Pseudomonas aeruginosa (35%) was most common followed by Staphylococcus aureus. Other aerobes isolated were Klebsiella spp., coagulase-negative Staphylococcus, Proteus spp. and Escherichia coli. Fungus was isolated in tubotympanic (9.45%) CSOM only. Among anaerobic isolates, Peptostreptococcus (1%) was most common. Conclusion: Monomicrobial isolates, especially P. aeruginosa and Staphylococcus species, were found to be most common in our study. Therefore, evaluation of microbiological pattern and their antibiotic sensitivity pattern in local area becomes helpful in prescribing empirical antibiotics for successful treatment of CSOM.

Treatment of Chronic Suppurative Otitis Media: A Comparison between Topical, Systemic and Combined Topical-Systemic antibiotics

Background and Objectives: The present study was undertaken to determine which of the three treatment modalities (topical, systemic and topical systemic combined) is the best in treating chronic suppurative otitis media (CSOM) in children.
 Patients & Methods: This comparative clinical trial was conducted prospectively in Dhaka Shisu Hospital, Sher-e-Bangla Nagar, Dhaka over a period of 6 months. We enrolled 92 children with chronic CSOM, aged 5- 12 years, from patients attending at pediatric ENT OPD. The children were randomly assigned to three treatment groups. All parents were advised dry mopping of their children two times daily. The first group (n = 51) received topical ciprofloxacin 4 times daily, the second group received systemic ciprofloxacin only10 mg/kg body weight/day twice daily for 14 days and the third group received both systemic and topical ciprofloxacin. The primary outcome measures were resolution of otorrhoea by 2 - 3 weeks of intervention and healing of tympanic membranes on otoscopy by 8-12weeks of intervention. Hearing levels were assessed by audiometry.
 Results: Of the three groups of children enrolled in the study, the topical-systemic group was significantly older than the topical and systemic groups (p = 0.003). However, the groups were not different in terms of sex and duration of illness (p = 0.125 and p = 0.191 respectively). The cardinal presentation was otorrhoea. Over half of the children in each group had marginal perforation (p=0.062). Most of the children in each group had mild hearing impairment (p = 0.212). Poor attention and poor academic performance were rarely found. After 2 weeks of treatment, majority of patients in Topical, Systemic and Topical Systemic Combined Group had a successful resolution (92.1%, 95.4% and 94.7%) with no significant difference among the groups (p = 0.641). Time taken for resolution was almost similar among the groups with mean resolution time being 2 weeks (p = 0.313). Difference among the groups regarding hearing impairment was evident with highest impairment being in the Topical and the lowest in the combined group (p = 0.048). Among groups, topical and systemic group had higher improvement of hearing threshold than topical, systemic combined group (p=0.024). The groups were no different with respect to treatment failure (p = 0.595)
 Conclusions: The study concluded that there was no significant difference in outcome in three modalities of treatment - topical, systemic and topical-systemic combined. So only topical antibiotics will do suffice in the treatment of CSOM, unless there is no sign of complications (like fever and/or pain).
 Ibrahim Cardiac Med J 2014; 4(1): 27-32

In vitro efficacy of N-acetylcysteine on bacteria associated with chronic suppurative otitis media.

BackgroundThe safety and efficacy of Ciprodex® has been demonstrated for treatment of chronic suppurative otitis media (CSOM). However, symptoms fail to resolve in 9-15% of patients. The objective of this study is to evaluate the efficacy of N-acetylcysteine (NAC) on S. aureus, and planktonic and sessile (biofilm forming) P. aeruginosa in vitro using clinical isolates from patients with CSOM.Methods1) Stability was assessed using liquid chromatography-mass spectrometry for each component in a prepared mixture of Ciprodex® and NAC over 15 days. Sterility was assessed by measuring bacterial growth on a blood agar plate. Efficacy was assessed using a disc diffusion method by inoculating plates with S. aureus ATCC 29513 and P. aeruginosa ATCC 27853, and measuring the clearance zone.2) Fifteen P. aeruginosa strains were isolated from patients with CSOM and tested in vitro using the bioFILM PA™ antimicrobial susceptibility assay. Treatment solutions included Ciprodex® & ciprofloxacin +/- NAC, and NAC alone (0.25%, 0.5% & 1.25%).Results1) NAC combined with Ciprodex® demonstrated stability, sterility, and efficacy over a two-week period2) P. aeruginosa strains in the sessile (33%-40%) and planktonic (13%) state demonstrated resistance to Ciprodex® and ciprofloxacin. When NAC ≥0.5% was used in isolation or as an adjunct to either of these medications, no resistance was found in the sessile or planktonic state among all 15 strains.Conclusion1) Ciprodex® combined with NAC has a shelf life of at least two weeks given the documented preservation of stability, sterility, and clinical efficacy of the mixed compounds.2) P. aeruginosa strains demonstrated resistance to both Ciprodex® and ciprofloxacin. NAC ≥0.5% overcomes issues with resistance and shows promise in the treatment of CSOM.

Efficacy of a topical suspension of bacterial antigens for the management of chronic suppurative otitis media

The aim of this study was to compare the efficacy and safety of a topical suspension of bacterial antigens for the management of chronic suppurative otitis media (CSOM). Two-hundred ten patients with CSOM were enrolled in this study. The patients were divided into two numerically equal groups and randomized to receive a topical suspension of bacterial antigens, Lantigen B (group A), or placebo (group B), according to the following protocol: 5 drops thrice a day for 12 consecutive weeks in the external acoustic duct. The topical suspension of bacterial antigens and placebo were administered by identical, anonymous dispensers in order to maintain double-blind conditions. Before, at the end and 3 months, and after the end of the treatment, all patients who entered in the study underwent pure tone audiometry, microscopic examination of ears, microbiological examination of the ear swab, aural suctioning and subjective assessment of symptoms by visual analog scale. In group A, we saw a statistically significant improvement in the different items measured. A topical suspension of bacterial antigens was significantly more effective than placebo in the treatment of CSOM.

Chronic suppurative otitis media in children of Luanda, Angola

Evaluation of clinical characteristics, bacteriology and hearing in paediatric patients with and without chronic suppurative otitis media (CSOM) in Luanda, Angola. Interview, clinical examination, ear-discharge culture, open air pure-tone audiometry and brainstem auditory-evoked potentials of 23 outpatients with CSOM and 23 controls in a paediatric hospital. Of the CSOM vs. control children, 35% vs. 26% had running water, 70% vs. 70% electricity, 64% vs. 0% HIV (p<0.0001) and 36% vs. 0% tuberculosis in history (p=0.002). Ten (43%) children had bilateral CSOM. The major ear-discharge pathogens were Proteus spp. (44%) and Pseudomonas (22%). Hearing impairment of >25 dB was present in 52% of CSOM-affected ears and bilateral hearing loss in 7 (30%) CSOM children vs. zero control child (p=0.009). Only one hearing-impaired child's family had previously detected the handicap. CSOM occurred in children with high co-morbidity. Persistent otorrhoea was usually caused by Proteus spp. or Pseudomonas, and often suggestive of either HIV or hearing impairment. In the developing countries, prompt diagnosis and treatment of CSOM would enhance the children's linguistic and academic development.

The role of anaerobic bacteria in chronic suppurative otitis media in children: Implications for medical therapy

This review describes the microbiology, diagnosis and medical management of chronic suppurative otitis media (CSOM) in children highlighting the role of anaerobic bacteria. In studies that employed adequate method for recovery of anaerobic bacteria polymicrobial aerobic and anaerobic flora was isolated from over half of the children with CSOM. The predominant aerobic isolates were Staphylococcus aureus and Pseudomonas aeruginosa and the most frequently isolated anaerobic organisms were Peptostreptococcus, Fusobacterium spp. and pigmented Prevotella and Porphyromonas spp. Several studies illustrated the efficacy of anti-infective agents effective against anaerobic bacteria in the treatment of CSOM. The medical therapy of CSOM should be directed at the eradication of the pathogenic aerobic and anaerobic organisms.

&lt;p&gt;Effectiveness of ototopical antibiotics for chronic suppurative otitis media in Aboriginal children: a community-based, multicentre, double-blind randomised controlled trial&lt;/p&gt;

Objectives: To compare the effectiveness of ototopical ciprofloxacin (0.3%; CIP) with framycctin (0.5%), gramicidin, dexamethasone (FGD) eardrops (5 drops twice daily for 9 days), together with povidone-iodine (0.5%) ear cleaning, as treatments for chronic suppurative otitis media (CSOM) in Aboriginal children.&#x0D; Design and Participants: Aboriginal community-controlled, community-based, multicentre, double-blind, randomised controlled trial in eight Aboriginal Community Controlled Health Services across northern Australia, involving 147 Aboriginal children with CSOM.&#x0D; Main Outcome Measures: Resolution of otorrhoea (clinical cure), proportion of children with healed perforated tympanic membrane (TM) and improved hearing, 10-21 days after starting treatment.&#x0D; Results: 111 children aged 1-14 years (CIP, 55; FGD, 56) completed treatment. CSOM cures occurred in 64% (CIP, 76.4%; FGD, 51.8%), with a significantly higher rate in the ciprofloxacin group (P = 0.009, absolute difference of 24.6% [95% CI, 15.8%-33.4%]). TM perforation size and the level of hearing impairment did not change. Pseudomonas aeruginosa was the most common bacterial pathogen (in 47.6%), while respiratory pathogens were rare (in 5.7%).&#x0D; Conclusions: Twice-daily ear cleaning and topical ciprofloxacin are effective at community-level in achieving cure for CSOM. Healthcare providers to Aboriginal children with CSOM should be given special access to provide ototopical ciprofloxacin as first-line treatment.&#x0D; Published courtesy of:Med J Aust. 2003; 179(4):185-190

CLINICAL NEED FOR OTOTOPICAL FLUOROQUINOLONES OUTWEIGHS MINISCULE RISK OF ANTIBIOTIC RESISTANCE

5 January 2006 Dear Editor The National Aboriginal Community Controlled Health Organisation (NACCHO), in a double-blind randomized controlled trial, showed that the use of topical ciprofloxacin to treat chronic suppurative otitis media (CSOM) among 111 Aboriginal children improved the odds of clinical cure three fold compared with the current standard of topical aminoglycoside. Treatment did not lead to resistant isolates when followed up for 21 days, even among those with persistent discharge.1 Given the demonstrated efficacy and concerns about ototoxicity of aminoglycosides, it was recommended that ototopical ciprofloxacin be used as first-line treatment (in conjunction with ear toilet) for CSOM. Dr Coates correctly concludes in his review article that the theoretical concerns of resistance emerging from ototopical fluoroquinolones in this setting were considerably outweighed by the risk of bacterial resistance emerging from oral use.2 In a recent hospital case series, Jang and Park speculated that ciprofloxacin resistance in Pseudomonas aeruginosa arose from ototopical use in CSOM.3 As there were no controls, no information on prior use of ciprofloxacin, no pretreatment antibiotic sensitivity testing nor information on patient adherence and with potential selection bias and confounders, this report neither confirms nor refutes the hypothesis that ototopical use of ciprofloxacin for CSOM was the cause of the bacterial resistance. The international evidence suggests that if there is a risk at all of antibiotic resistance from ototopical fluoroquinolone use in CSOM, it must be very small. The consistent view is that resistance arising from ototopical fluoroquinolones use for CSOM is negligible when compared with its use for systemic disease. We argue that favouring ototopical fluoroquinolone use for CSOM can lead to less oral and systemic use, by reducing the need for preoperative intravenous therapy, and avoiding complications from poorly treated CSOM.4 The response to the antibiotic resistance debate thus hinges on a risk to benefit analysis. Among Aboriginal children, CSOM is a major public health problem, with substantial otologic complications if untreated.4 Providing ‘no treatment’ should be considered unethical. The provision of ‘tissue spears’ or other forms of dry mopping without other treatment is the ‘same as doing nothing’.4 The alternative (to continue using ototopical aminoglycosides in a population of children for whom little or no monitoring of adverse events occurs and who are less likely to initiate medicolegal action because of disadvantage) is no longer acceptable to either the medical profession5 or Aboriginal representatives now that safer and more effective alternatives are available. For some, the fear of antibiotic resistance in Australia is magnified because the problem of CSOM mostly affects Aboriginal children. It has been declared to us that ototopical fluoroquinolone use may be tantamount to ‘throwing around fluoroquinolone drops in the bush’ because the infection is so prevalent. If such views influence social institutions (e.g. in decisions on the registration of therapeutic goods or subsidy schemes) the outcome can be discrimination against a disadvantaged population group and, in effect, institutionalized racism.6 Health policy based on spurious notions of the ‘greater good’ that has the effect of restricting access to best practice by vulnerable sub-populations are reminiscent of the white Australia policy, when decisions of public health were made not for the benefit of Aboriginal peoples, but to prevent the spread of disease to Europeans on the frontier.7 Proponents arguing that Aboriginal children should be denied access to this medication should also be aware that ototopical fluoroquinolones are widely used ‘off-label’ in Australia by those who can afford it.2 Thus, current supply arrangements ‘ration’ ototopical fluoroquinolones on the basis of who can afford to pay – which is obviously unacceptable. Fluoroquinolones have replaced ototoxic aminoglycosides as treatment for CSOM in the USA, Japan, Spain and other countries,8 and it is high time that Australia did the same.

TIME FOR A CHANGE? YES, BUT NOT TO CIPROFLOXACIN

5 January 2006 Dear Editor, We read with interest the opinion of Coates1 about ear drops and tympanic membrane perforations. While we strongly agree that it is ‘time for a change’ away from topical aminoglycosides, we do not agree that the change should be to fluoroquinolones. Fluoroquinolones have established themselves as extremely valuable agents for the treatment of serious bacterial infections in humans, including those caused by bacteria resistant to other classes of drugs. Their value lies not only in these properties, but in our ability to use them orally and allow outpatient treatment for such infections, either as follow on from initial hospital treatment, or from the outset. Reflecting this perspective, the Pharmaceutical Benefits Scheme allows access to fluoroquinolones that is limited to ‘Authority required’ (except for ciprofloxacin and gonorrhoea which is a ‘Restricted benefit’). This is true for both oral and eye drop formulations, and for all fluoroquinolones. In addition, Australia has been one of the few countries to successfully prevent the introduction of fluoroquinolones into food animal production, thereby reducing resistance coming through the food chain to humans. Although arguments are sometimes made to the contrary, resistance can be selected with topical therapy despite locally high concentrations. If the opposite were true, then we would not be observing mupirocin resistance, because this agent is only used topically in ‘high concentration’. Unfortunately mupirocin resistance is now well documented, especially in areas of intensive use such as remote aboriginal communities – the same population where treatment of chronic suppurative otitis media (CSOM) is common.2 Of specific relevance to the use of ciprofloxacin ear drops, and counter to that stated by Coates, resistance has been selected during the treatment of CSOM. Jang and Park3 reported on failed ciprofloxacin therapy of CSOM in 88 patients. All patients were shown to have ciprofloxacin resistant Pseudomonas aeruginosa when recultured. Furthermore, topical use can provide the opportunity for local colonization with resistant organisms. Clinical trials of ciprofloxacin ear drops have not given rise to resistance selection in commensals in the short term. However, we cannot assume that it will not emerge in the long term, and indeed microbiological experience shows that eventually it does, with only rare exceptions. Evidence for resistance selection at sites distant to application of topical antibiotics has been demonstrated for tetracycline when used for acne4 and for he treatment of trachoma.5 We are therefore concerned that fluoroquinolones are now gaining currency as topical agents. While this can be justified for such sight-threatening conditions as bacterial keratitis, it is less than prudent to use them for minor conditions. Although CSOM is not a trivial infection, evidence has yet to emerge that topical antibiotics of any kind preserve hearing in the long term or prevent serious complications.6,7 Instead, the benefits are short-term and re-treatment is frequently required, leading to repeated antibiotic exposure and greater selection pressure for resistance. Hence, selecting for resistance with topical fluoroquinolone therapy for non-serious infections or for ‘prophylaxis’ puts the value of this class for truly serious infections under threat. To make our position clear, we are not strong supporters either of the use of topical aminoglycosides on resistance grounds. Aminoglycosides are also valuable antibiotics for serious infections. However, we know that neomycin, which is not used systemically, does not necessarily select for resistance to the standard systemic aminoglycosides such as gentamicin, and therefore not all topical aminoglycosides are alike. Unfortunately, using one fluoroquinolone topically will necessarily select for resistance to a range of valuable fluoroquinolones. The clinical problem addressed by Coates is a troublesome one, but rather than following his suggestions to lobby a wide range of groups to get ready access to ciprofloxacin ear drops, we believe that prescribers should urgently lobby the pharmaceutical industry to produce a safe and effective antimicrobial ear drop that does not have resistance implications for valuable reserve systemic antimicrobials. Australia has been very effective at controlling resistance to fluoroquinolones. We would like to keep it that way.

Intracranial abscesses associated with chronic suppurative otitis media

Intracranial abscesses are serious complications of chronic suppurative otitis media (COM). This study included 32 patients presenting with intracranial abscesses from 780 patients hospitalized for treatment of COM. The 32 patients had 59 intracranial complications. Perisinus abscess (13 of 32) was the most common intracranial abscess, followed by temporal lobe abscess (8 of 32), epidural abscess (7 of 32), cerebellar abscess (6 of 32) and subdural empyema (2 of 32). Headache (93%), fever (87%) and altered mental status (62%) were the most common presenting symptoms and signs, along with symptoms of COM. All patients were treated with intravenous antibiotics and canal wall down mastoidectomy. Cholesteatoma with granulation tissue and bony defects at the sinus plate and/or dural plate were seen in most of the patients. Gram negative bacilli and anaerobes were the most common organisms cultured from the abscesses. Three patients had neurological sequels. One patient died. The early diagnosis of these complications requires a high index of suspicion and imaging studies. A multidisciplinary and coordinated approach is important for the management of these patients.

Chronic suppurative otitis media in Gombe, Nigeria

Background: Chronic suppurative otitis media is a common problem in developing countries and it is necessary to determine the local epidemiology for adequate treatment. Method: A retrospective study of 206 patients with chronic suppurative otitis media (COSM). Results: All the patients presented with ear discharge and tympanic membrane perforations while 57 (27.7%) had associated nasal symptoms. The most common tympanic membrane perforation was the central type seen in 125 (60.7%) of the patients. Of the 206 patients studied, using standard microbiological methods, 87.4% of patients had positive bacterial culture. These were staphylococcus aureaus 37.8%, pseudomonas aeruginosa 28.9% and proteus species 18.3%. Children within the age group of 0 – 10 years were the most affected. Antibiotic sensitivity result showed that gentamicin (88.5%), cefuroxime (63.7%) and cephalexin (61.7%) were active against majority of the isolates. Conclusion: Gentamicin, cefuroxime and cephalexin are recommended as first line antibiotics in the treatment of COSM. Other modalities of treatment are further highlighted. Key Words: Chronic otitis media, tympanic membrane perforation, Gombe Nigerian Journal of Surgical Research Vol.5(1&2) 2003: 120-123