Do not use aminoglycoside antibiotic eardrops in the presence of a perforation or ventilation tube, because they may be ototoxic if they enter the middle ear

Do not use aminoglycoside antibiotic eardrops in the presence of a perforation or ventilation tube, because they may be ototoxic if they enter the middle ear: Excerpt from Avoiding Common Pediatric Errors

Author: William Giasi, Jr., MD

What to Do - Make a Decision

Acute otitis externa (AOE) is the acute onset of inflammation of the external auditory canal, which may involve the pinna and tympanic membrane. AOE classically has a rapid onset, symptoms of ear canal inflammation, and findings of ear canal inflammation. Symptoms of otitis externa include otalgia, itching, fullness, or ear canal pain with chewing. The hallmark physical finding of AOE is intense tenderness and pain of the tragus and/or pinna with movement. Otitis externa is common with an incidence of 1:100 to 250 in the general population and peaks between 7 and 12 years of age. Otitis externa is a cellulitis of the external ear with acute inflammation and edema, and bacterial organisms account for 98% of cases. The most common pathogens are Pseudomonas aeruginosa, Staphylococcus aureus, and polymicrobial infections. Gram-negativeorganisms(excludingPseudomonas)accountfornomorethan 2% to 3% of cases and fungal infections are a rare cause of primary AOE.

The treatment objective in otitis externa is to eradicate the pathogens responsible for the infection and reduce ear pain. Topical antibiotics are the most beneficial and efficacious for the treatment of AOE. Topical antibiotics are recommended for the initial treatment of diffuse uncomplicated AOE. Oral antibiotics are often prescribed in addition to topical antibiotics but have limited efficacy against P. aeruginosa and S. aureus. Topical therapy allows for a high concentration of antimicrobial that exceeds the minimal inhibitory concentration needed for pathogen eradication and has little systemic absorption, thus limiting systemic side effects. Furthermore, there are lower persistence and recurrence rates with topical antimicrobials.

There are many different types of antimicrobial treatments that are efficacious and available for treatmentofotitisexterna. Specialconsideration mustbegiventothe patientwithanonintact tympanicmembrane,whetherit is perforated or has tympanostomy tubes. Visual assessment of the tympanic membrane may be difficult and impeded by pain, edema, drainage, or debris. If the tympanic membrane is not intact, topical medications may enter the middle, and ultimately, the inner ear. Topical drops that contain alcohol, have a low pH, or both should be avoided with nonintact membranes because they cause pain and have an ototoxic potential. Ototoxic medications, such as aminoglycosides,haveinexperimentalanimalscausedseverehearinglossand injury to the inner ear. Clinical experience has shown that ototoxicity does resultincasesof excessiveadministrationor prolonged courses.Medications that are ototoxic or potentially ototoxic should not be used with a perforated tympanic membrane because the risk of ototoxicity outweighs the benefits of nonototoxic antimicrobials that are equally efficacious. The only U.S. Food and Drug Administration-approved topical antimicrobials approved for middle ear use are otic ofloxacin and ciprofloxacin/dexamethasone.

Suggested Readings

Beers SL, Abramo TJ. Otitis externa review. Pediatr Emerg Care. 2004;20(4):250–256. Dohar JE. Evolution of management approaches for otitis externa. Pediatr Infect Dis J. 2003;22:299–308.
McCoy SIZell ER, Besser RE. Antimicrobial prescribing for otitis externa in children. Pediatr Infect Dis J. 2004;23(2):181–183.
Rosenfeld RM, Brown L, Cannon CR, et al. American Academy of Otolaryngology–Head and Neck Surgery Foundation. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2006;134(4 Suppl):S4–S23.
RosenfeldRM,SingerM,WassermanJM,etal.Systemicreviewoftopicalantimicrobialtherapy for acute otitis externa. Otolaryngol Head Neck Surg. 2006;134(4 Suppl):S24–S48.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

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