Pharmacotherapy/Treatment Of Otitis Media And Otitis External

The ear is the organ of hearing and, in mammals, balance. The ear  has three parts—the outer ear, the middle ear and the inner ear. The outer ear consists of the pinna and the ear canal. Since the outer ear is the only visible portion of the ear in most animals, the word "ear" often refers to the external part alone. The middle ear includes the tympanic cavity and the three ossicles. The inner ear sits in the bony labyrinth, and contains structures which are key to several senses: the semicircular canals, which enable balance and eye tracking when moving; the utricle and saccule, which enable balance when stationary; and the cochlea, which enables hearing.

Ear infection

Ear Disease

The ear may be affected by disease, including infection and traumatic damage. Diseases of the ear may lead to hearing loss, tinnitus and balance disorders such as vertigo, although many of these conditions may also be affected by damage to the brain or neural pathways leading from the ear.

There are two types of ear infections. They are otitis media and otitis externa.

Otitis Media

Otitis media is a group of painful types of ear infection. It affects the middle ear which is behind the eardrum. It is caused by infection and results in inflammation. Otitis media with effusion (OME) present with pain. Chronic suppurative otitis media (CSOM) is a middle ear inflammation that is present with discharge from the ear for more than three months. Pain is hardly present and it is developed from acute otitis media (AOM). Burging of the tympanic membrane suggest AOM and not OME. OME follow AOM and it is related to upper respiratory viral infection, irritants and allergies.

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Adhesive otitis media (AOM) occurs when a thin retracted eardrum becomes stuck into the middle ear space, vesicles and other bones in the middle ear. This can lead to lack of movement of tympanic membrane.

Acute OM incidence rate is 10.85 percent i.e. 709 million cases each year with 51 percent of these occurring in under-fives. Chronic suppurative OM incidence rate is 4.76 percent i.e. 31 million cases, with 22.6 percent of cases occurring annually in under-fives. OM-related hearing impairment has a prevalence of 30.82 per ten-thousand. Each year 21 thousand people die due to complications of OM. The number of deaths from OM is dropping each year. This is attributed to more knowledge and advanced therapy. 

OM is more common in children than adults. Children experience more otitis media because the eustachian tube is short and horizontal giving microorganisms more structure to survive and thrive. It is more common among males than females. AOM can cause discharge from the ear with perforation of eardrum.

It affects those who have cleft lip and palate or down syndrome

Symptoms

Children often present with;

1. Crying

2. Pulling ear

3. Sleeplessness

4. Fever

5. Loss of appetite

6. Cough and nasal congestion/discharge

Adults often present with;

1. Ear pain

2. Headache

3. Neck pain

4. Irritability

5. Sleeplessness

6. Feeling fullness in the ear

7. Fluid drainage

8. Vomiting and diarrhea

9. Lack of balance

10. Hearing loss

Causes

1. Allergies

2. Cold

3. Flu

4. Skin infection

5. Infected or enlarged adenoids

6. Drinking while lying down

These causes are not directly involved in otitis media. They cause the eustachian tube to block leading to swollen or blocked out trap fluids in the middle of the ear. The ear is then exposed to infection.

Bacteria responsible for otitis media are streptococcus pneumoniae followed by nontypeable haemophilus influenzae (NTHI) and moraxella catarrhalis. Others are respiratory syncytial virus, corona viruses, influenza virus, adenovirus and picornaviruses.

Complications

1. Enlarged adenoids and tonsils

2. Ruptured eardrum

3. Cholesteatoma

4. Speech delay

5. Infection of the mastoid bone in the skull (mastoiditis)

6. Infection of the mening in the brain (meningitis)

Risk Factors

1. Children between 6-36 months

2. Using a pacifier

3. Children in daycare

4. Children still been bottle-fed

5. Air pollution

6. Change in altitude

7. Change in climate

8. Genetic

9. Recent infection or cold, flu, sinus and allergy

Diagnosis

1. Pneumatic otoscope to look for redness, swelling, blood, pus, air bubbles, perforation of the eardrum, and mobility in the tympanic membrane.

2. Tympanometry is the measurement of the air pressure in the child's ear to determine if the eardrum is ruptured using tympanogram.

3. Reflectometry determines the fluid in the ear from the reflection of a sound wave.

4. Hearing test/audiometry

5. CT scan and MRI

Pharmacotherapy/Treatment

Some home remedies include the use of warm, moist washcloth to clean the external ear. Drugs for reducing pain both oral and/or topical such as diclofenac can be used. Antibiotics is recommended for only children below 2 years of age or when it is severe. The first line of antibiotics is oral amoxicillin. Others are second generation cephalosporins such as cefuroxime (30mg/kg) daily in two divided doses, cefdinir (14mg/kg) daily in 1 or 2 doses, cefpodoxime (10mg/kg) daily suitable for penicillin allergic patient. Azithromycin 10mg/kg single dose of clarithromycin 15mg/kg daily in two divided doses are also recommended.

More advanced drugs are amoxicillin/clavulanic acid (90mg/kg of amoxicillin or 64mg/kg of clavulanic acid) daily in two divided doses. Parenteral administration of ceftriaxone (50mg/kg) daily for 3 days if the person is vomiting or cannot swallow. Ear drop is not recommended.

Adenoidectomy is a surgery adjuvant to other options. It is a process whereby the enlarged adenoid is removed, then added tubes to drain out the air and fluid.

Prevention is the use of vaccines and personal hygiene. Vaccination against most infections reduces the chance of getting it.

Otitis Externa

This is an infection of the outer ear also called swimmer's ear. The name swimmers ear was curled from the fact that it is common in swimmers. Acute otitis externa is when the infection occurs within a space of 6 weeks but chronic is when the infection lasts for more than 3 months.

Necrotizing external otitis (malignant) is uncommon that affects poorly controlled diabetes or those with compromised immunity. The infection affects the bony ear canal. It can also affect skull base, osteomyelitis which can lead to death.

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It affects about 1-3 percent of people each year. 95 percent of those are in acute phase. About 10 percent of people will experience an episode before they die. It is common in children below the age of seven and the elderly. The condition is common in warm climate environments.

Symptoms

Mild

1. Itchy in the canal

2. Slight redness inside the ear

3. Some drainage of clear, colourless fluid

Moderate progression

1. More intense itching

2. Increase pain

3. More redness

4. Excess fluid drainage

5. Feeling of fullness inside the ear and partial blocking by swelling, debris or fluid

6. Decrease or muffled hearing

Advance progressive

1. Pain that may radiate to the face, neck or side of the head

2. Complete blockage of the ear canal

3. Redness or swelling of the outer ear

4. Swelling of the lymph nodes in the neck

5. Fever

Cause

Introduction of injury and infection from the use of fingers, cotton swabs (Q-tips ™) and other objects when the thin layer of the ear canal is damaged. Water makes it easy to damage the ear canal and create a suitable environment for infection to thrive.

Others are allergies and autoimmune disorders. Acute is associated with psoriasis and dermatitis were malignant OE is associated with diabetes.

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The names of infection species are pseudomonas aeruginosa, staphylococcus aureus, candida albican, aspergillus app and the fungi, mucor. It is more common in people with narrow ears.

Diagnosis

Use of otoscope to check for red, swollen and scaly ear canal

Complications

1. Temporary hearing loss

2. Deep tissue infection

3. Bone and cartilage damage

4. More widespread infection

Pharmacotherapy/Treatment

Treatment always begins with cleaning the ear using a suction device or ear curettage to remove discharge, clumps of earwax, flaky skin and other debris. Acidic solutions of acetic acid drop can be used to disinfect the ear. Burrow solutions of aluminium sulphate and acetic acid is another solution. Homemade cleaning solutions like vinegar and absorbing alcohol one part each can be used.

Pain and inflammation can be managed with Ibuprofen and naproxen sodium oral or ear drop. Oral paracetamol and steroids can also be used for pain and inflammation. Steroid ear drop should be used with caution.

Antibiotics and antifungal drops may be used to manage infection. Fluoroquinolones like ciprofloxacin and ofloxacin ear drops are recommended. Others are aminoglycoside and polymyxin. When the ear drop is not staying in the ear when applied, an ear wick can be used to plug the ear to prevent the drop from escaping. The wick is soaked with the drop and left there. Oral antibiotics and antifungal agents are needed when the infection affects the skin. Treatment of otomycosis, a fungal infection is for 3 days.