Otic Products(2)

Treatment of Ear disorders

General Guidelines:• Infection of the auricle or external ear canal

is a skin infection and should be treated as such

• Surgical interventions maybe necessary for deep cuts, bruises or abrasions of the ear

• Severe infections usually require both systemic & local antibiotics

Treatment of Ear disorders• In 1995, the FDA issued a statement that said

that insufficient data exist to prove the safety & effectiveness of acetic acid, isopropyl alcohol, anhydrous glycerin or any other OTC otic product in prevention of swimmer’s ear or to dry water-clogged ears

• Because most bacteria, fungi do not thrive in acidic environment, an important feature of any otic solution acidic pH

Why necessary to treat otitis externa?

Otitis externa should always be treated promptly, • to prevent spread to mastoid bone or middle ear

cavity• Severe cases may result in permanent hearing

loss

• In mild cases of otitis externa topical treatment is all that is necessary

Treatment of otitis externa1. Topical antibiotics & hydrocortisone

drops/cream applied to ear canal2. If cellulitis & lymphadenopathy are

present use oral antibiotics3. 5% Aluminum acetate solution (Burow’s

solution)4. Soaking ear with saline, or Burow’s solution

is useful in treatment of crusting & edema in auricle & surrounding tissue

Treatment of otitis externa5. Irrigation with soft rubber bulb ear syringe

maybe uncomfortable but should never be painful (if pain occurs stop, if pain is severe & knife-like, there may be tympanic membrane perforation & vertigo may occur)

• The use of forced water spray should be reserved for health professional trained in aural hygiene

Ear bulb syringe

Water-Pik spray

Contact dermatitisOtitis externa

.

Otitis Externa

• An aminoglycoside combined with a second antibiotic and a topical steroid such as neomycin-polymyxin B-hydrocortisone used to be the most commonly prescribed topical antibiotic.

• Neomycin-dexamethsone-acetic acid• Caution must be used to recognize a

hypersensitivity reaction and ototoxicity to the neomycin component.

• One literature review concluded that the use of ciprofloxacin 0.3%/dexamethasone 0.1% otic suspension for otitis externa is safe and effective and that dexamethasone improves treatment success

• Mild fungal infections can usually be treated with an acetic acid solution, whereas more severe cases may require a topical antifungal such as 1% clotrimazole.

Acetic Acid• Used in the form of household vinegar (5%)• Has been used successfully for many years to

treat mild forms of otitis externa & recommended for swimmer’s ear

• Advantages: 1. Has bactericidal & fungicidal properties (Candida, Aspergillus & Pseudomonas); 2.Well tolerated & nonsensitizing and does not induce resistant organisms

Acetic Acid• Four drops of dilute acetic acid (2-3%) placed

into the ear canal four times daily will lower the pH < 3. (NB. The optimal pH for bacterial growth 7.2-7.6)

• Solutions of <1% lack bactericidal properties

• Disadvantages: has an unpleasant vinegar-like odor, and can be very painful if applied to the middle ear

Application Technique:• Tilt head downward, affected ear up• If there is no possibility that there is a hole in the

eardrum, carefully squeeze a medicine dropper full of the solution into the ear canal

• With one hand, move the ear back & forth to move the solution all the way into the ear

• Tilt the head to the other affected side, to let the solution out, gently tapping the unaffected side

• Repeat the procedure in the opposite ear

Aluminum Acetate solution (Burow’s Solution)

• Given as anti-inflammatory, antipruritic, astringent & limited antibacterial

• Widely used to treat external otitis or local itching of external ear caused by dermatitis or otomycosis, edema & crusting associated with acute moist ear canals

• A wet compress is used with a gauze dressing on the auricle. Drops may be instilled into the canal, 4-6 drops every 4-6 hrs until symptoms subsides

Aluminum Acetate solution (Burow’s Solution)

1. Has astringent properties: 1. dry the affected area by reducing the secretory function of the skin glands and, 2. toughen skin, help prevent re-infection

2. Its major value: acidity which restores the normal antibacterial pH of the ear canal

• Well tolerated, nonsensitizing. Rare adverse effects

Cerumen-Softening agents• Cerumen-softening & cerumenolytic agents

only soften & loosen the cerumen.

• These agents do not readily remove cerumen

• Patients then can remove minor amounts of excessive ear wax by rinsing the ear canal with an ear syringe

• Hardened or impacted earwax removed by doctor, or if pain is present refer to doctor

Carbamide Peroxide (urea hydrogen peroxide, 6.5% in glycerine)

• The effervescence caused by oxygen release mechanically assists in disintegrating wax accumulations in the ear

• Carbamide (urea) helps to increase penetration of solution into the plug

• Removal of the softened cerumen may be assisted by warm water irrigation using a soft rubber ear syringe

• Recognized by FDA as safe & effective for occasional OTC use

Carbamide Peroxide (urea hydrogen peroxide)

• FDA recommends use twice daily for up to 4 days if needed

• 5 drops of the solution should be instilled into the affected ear & allowed to remain at least 15 minutes, either by tilting the head up or by inserting small amount of cotton into the canal opening then irrigate with warm water using a soft rubber ear syringe

Carbamide Peroxide (urea hydrogen peroxide)

• If condition not improved after 4 days consult a doctor

1. Procedure not recommended for children under 12 years of age

2. Should not be used if there is ear drainage, pain or dizziness or injury or perforation of the eardrum

Carbamide Peroxide (urea hydrogen peroxide)

3. Should not be used if surgery has been performed in the past 6 weeks

4. Carbamide peroxide should be discontinued whenever irritation or rash appears

5. Not recommended for treating pain of inflamed tissue, swimmer’s ear or itching of the ear canal

Other cerumen-softening products

• Occasional instillation of olive oil, turpentine oil, glycerin, diluted hydrogen peroxide (1:1 of 3% solution) or propylene glycol, sodium bicarbonate or docusate sodium may soften the cerumen and promote the normal process of removal

• These products should be used only under medical supervision if the tympanic membrane is perforated or is not known to be intact;

Other cerumen-softening products

• To prevent cerumen build-up: rinse ear canal every few days with a mixture of 20-30% alcohol & water or aluminum acetate solution;

• Over-irrigation of the ear is not recommended as maceration of the skin may happen and may lead to infection

Glycerin• Used as a solvent, emollient or humeactant

• It is safe & nonsensitizing when applied to open wounds or abraded skin

Olive oil (Sweet Oil)• Used as an emollient & topical lubricant

• Alleviates itching & burning, softens earwax and smothers insects

Propylene Glycol• A solvent that has preservative and

humeactant properties• Because it is viscous, increases contact with

the skin• Adding acetic-acid to it increases solution’s

acidity, enhancing its anti-infective properties• If used for a long period of time, may cause

allergic dermatitis in susceptible individuals

Choline Salicylate• Local analgesic, has a counterirritant effect• Used for earache• Hydrolysed by cutaneous esterases to salicylic

acid that has anti-inflammatory effect• Softens ear wax as it is usually in combination

with glycerol

Ear Drop Administration

• Pharmacist must make sure that patient understands the proper techniques of drug administration & use:

• Eardrops maybe applied as often as 4 times daily

Patient Counseling• The involved ear should be tilted up for at

least 2 minutes following placement of 2-4 eardrops to permit effective contact

• Apply a piece of cotton or gauze to the area

• A cotton wick may be inserted gently into ear canal to help medication maintain contact with the affected area in ear canal

Patient Counseling• Patients should also fully understand the

proper use of medicine dropper for administering ear drops & of ear syringes for irrigating the ear

• Eardrops should be warmed to body temperature by: (1) or (2) but not the microwave! WHY NOT?

Patient Counseling• Cotton wicks, however, usually require

insertion using appropriate instruments & should be used only by trained personnel

• Gently pulling the auricle backward may allow medication to reach a greater depth into ear canal

• Patients should be advised that symptoms should subside 1-2 days following self-treatment. If symptoms persist or worsen, consult doctor

Water Clogged Ears

• Some patients are prone to this due to the shape of their ear canal, or excessive cerumen

• Excessive moisture in the ear, due to hot humid climate, swimming, bathing, etc.

• Isopropyl alcohol 95% in anhydrous glycerine.

• Acetic acid in in isopropyl alcohol (50:50)