Refractory External Otitis

External Otitis caused by bacterial strains that were resistant to floxin, ciprodex, cortisporin, tobradex. On each of these 3 occasions, I’ve only had success with serial debridement and the application of boric acid powder and gentian violet. I have yet to have a failure with this regimen and I’m not looking forward to the day I do. BTW, ASL pharmacy in CA will compound otic irrigations at a reasonable price and allow higher volume flushes of the ear than you can get with just drops. I have had success with overwhelming the bacteria with abx in some cases, particularly with MRSA. I get my gentian violet from Medical Chemical Corp out of Torrance, CA. After debriding the desquamatous debris from the EAC, I make a miniature ball of cotton, hold it with an alligator, dip it in the GV, and play Pablo Picasso in the ear. Caution: if you are not careful, the GV will play permanent Jackson Pollack on your everything. 2 thoughts: You could try having the patient insufflate several times a week with CSF powder (chloramphenicol, sulfa, and fungizone, aka, Amphoterecin B)–contact the House Clinic in LA for the specifics. The other thought is having 100 mg of Nizoral added to a relatively inexpensive, eg, Cipro HC otic generic, ear drop and have the patient use it several times daily for at least a month. The possibility of fungi is pretty high in this case from what I’ve encountered over the past 26 plus years of treating patients with varying forms of chronic otitis externa. I see a fair numbers of kids with MRSA growing from purulent ear discharge. I usually put them on Garamycin ophthalmic drops and sometimes oral Clinda as well. Agree with boric acid powder and/or gentian violet. I’ve also had success with blephamide drops when the organism is sensitive to sulfa. Every once in a while I resort to gentamycin gtts You haven’t mentioned the culture results with respect to the specific bacteria. Are you seeing more cipro resistant gram negative infections (i.e. cipro resistant pseudomonas) or perhaps MRSA resistant to fluoroquinolones? It makes a difference in terms of options. I’ve recently seen several patients that needed to be admitted for IV antibiotics in similar settings. Don’t do any more cultures – they are a waste. Thoroughly clean out the ear and fill up the ear with gentian violet, wait a few seconds and then suction out any excess. Don’t put anything else in the ear and instruct the patient to keep it dry. See them back in a week and repeat. You very seldom have to do it more than two times. The reason cultures are a waste: 1.) Otitis exterma is almost always mixed flora. 2.) The sensitivities are based on the anitibiotic levels (MIC’s) one would see in serum – nowhere near the concentration you’d get with antibiotic drops in an ear canal. The reason the otitis externa persists in a case like this is not because of the bacterial etiology, but because of local physical characteristics – i.e. persistent debris, persistent moisture, dermatologic problems, (all good sources for biofilms) and rarely fungal infection. The good news is that most fungal OE will respond to the above regimen as well as bacterial OE. Consider fungal component and adding lotrimin. Also serial debridment , keeping the ear as dry as possible and gentian violet help. I paint the ear with gentian violet after office debridment. I also have the pt blow dry their EAC with a blow dryer afer swimming, showers and hair washing. 1. With kids, the whole “filling up the canal and letting it sit before you suction it out,” using isopropyl alcohol straight or, heaven forbid, hoping that you won’t make a huge mess with an ear canal full of Gentian violet (even for a couple of seconds) is a pipedream. Do the best debridement you can, and do it often, and get the parents doing gentle flushes early in the process. The alcohol almost always stings the kids, so start with half water, half white vinegar and decrease the proportion of vinegar until they’re actually compliant. 2. Don’t worry so much about aminoglycosides with an open TM–we used them a ton before the topical quinolones came along. The reports of significant inner ear toxicity with TOPICAL aminoglycosides used as drops were pretty extreme cases. There also is evidence that inflamed middle ear mucosa (which you would undoubtedly have in a case like this with an open middle ear) is protective. 3. As to what fredanddoris said, plain Floxin is great for a number of reasons: (a) it’s cheap, especially compared to Ciprodex; (b) it’s not a goopy suspension, so you don’t have to shake it and it tends to get in little crevices well; and (c) you can always have the parents do dexamethasone eye drops if you also want a steroid. The two bottles together will cost about ten times less than Ciprodex. 4. I pulled the ancient papers from the House and Glasscock groups on powders in ear canals and mastoid bowls, and found a couple of compounding pharmacies that can make them up for me. I wrote a pre-printed script that includes a request that they supply the patient with a House-Sheehy insufflator and the name and number of one of the medical supply houses that carries it. I use cresylate instead of gention violet Cresylate is available from Recsei Labs in Goleta, California. yes doctrbob, cresylate is still available and I use it a lot. Its good for cleaning out the squamous debris. Works on bacteria and fungus. Mostly use in the office, but will prescribe for some patients to use at home- t.i.d., either for repeated cases or the more resistant cases. 1/2 vinegar irrigations with medicine dropper bid, hair dryer to ear (not too close!), csf powder or can get compounded cipro/lotrimin/boric acid/salicylic acid powder to insufflate after cleansings. Acetic acid should usually work because there are no resistance concerns, and has worked well for me. Just trying to add another option to all the other great suggestions, if you have some prepared Dakin’s solution around, you can start the patient off quickly. If you are concerned about chlorine in the ear, it is in many swimming pools and not known for causing harm. Strengths of Dakins solution: Well studied in root canals: “They looked at concentrations of Dakins(.25%, .025%, and .0125%) for toxicity and bactericidal effect. Concentrations of .25% killed both healthy cells and bacteria, but only bacteria at .025%. Dakins at .0125% was ineffective for killing bacteria. They concluded that modified Dakins (.025%) was the better choice.” How to make at home: The original Dakin’s solution, which included boric acid, from Wikipedia was: “This solution is a highly diluted antiseptic, consisting of sodium hypochlorite (0.4% to 0.5%) and boric acid (4%)” which should be diluted to the bacteriocidal but not tissue injuring concentration Like several other posters, curing OE has not been a problem in 35 years of practice. Office toilet under the scope combined with Cortisporin, Ciprodex or Lotrimin solution, as appropriate, routinely results in cures. I have had to use Cresylate on occasional cases of resistant fungus. I would hasten to add that abstinence from Q tip use is essential to both treatment success and prevention of recurrence. Ever notice how many more cases of OE you see in the right ear versus the left ear? In my office it’s about 3 or 4 to 1, I surmise because most people are right-handed, it’s awkward to reach around the head to the left ear, but they can really give the right ear a workout with comfort and confidence that they are doing great things for their ear. And it feels so-o-o-o-o good! As long as Q tips are sold, we will have work. Ear cultures go for $135 to $300 in my area. I don’t order them. Referring docs often have already ordered them and refer after culture-based treatment fails. I attended a lecture by Dr. Brackman of House group a couple of years ago, and he says he doesn’t order them either. Putting ointment or cream in the ear blocks the hearing. It is unnecessary, since there are many effective solutions from which to choose. Gential violet is messy and unnecessary. I have never used it. Has anyone tried Betadine drops for OE? There was an article in one of the throwaway journals (ENT Monthly, I believe) a few years ago that showed efficacy in chronic OM that was equal to Cipro HC Otic. That must have given Alcon Labs a scare!

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