Chapter 105

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.

Chapter 105Chapter 105

Drugs for the EarDrugs for the Ear

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. 2

Anatomy of the EarAnatomy of the Ear The external earThe external ear

Auricle or pinnaAuricle or pinna External auditory canal (EAC)External auditory canal (EAC)

The middle earThe middle ear Malleus, incus, and stapesMalleus, incus, and stapes

The inner earThe inner ear Semicircular canals and the cochleaSemicircular canals and the cochlea


Fig. 105-1. Anatomy of the ear.The purple arrows indicate flow of the mucociliary system, which can transport bacteria out of the middle ear.


Otitis MediaOtitis Media Inflammation of and fluid in the middle earInflammation of and fluid in the middle ear Otalgia – ear painOtalgia – ear pain Children may tug or hold affected earChildren may tug or hold affected ear May be bacterial, viral, or bothMay be bacterial, viral, or both Usually starts as viral infection of the Usually starts as viral infection of the

nasopharynxnasopharynx Diagnosis (must have all three of following)Diagnosis (must have all three of following)

Acute onset of signs and symptomsAcute onset of signs and symptoms Middle ear effusionMiddle ear effusion Middle ear inflammationMiddle ear inflammation


Standard Treatment of Otitis MediaStandard Treatment of Otitis Media

Required pain medicationRequired pain medication Acetaminophen, ibuprofen, codeineAcetaminophen, ibuprofen, codeine

Some should receive antibiotics when clearly Some should receive antibiotics when clearly indicatedindicated

80% of cases resolve spontaneously without 80% of cases resolve spontaneously without antibioticsantibiotics


Treatment of Otitis MediaTreatment of Otitis Media Acute otitis media (AOM)Acute otitis media (AOM)

AmoxicillinAmoxicillin Antibiotic-resistant otitis mediaAntibiotic-resistant otitis media

High-dose amoxicillin-clavulanateHigh-dose amoxicillin-clavulanate PreventionPrevention

Breast-feeding for at least 6 monthsBreast-feeding for at least 6 months Avoiding child care centers when respiratory Avoiding child care centers when respiratory

infections are prevalentinfections are prevalent Treatment of influenzaTreatment of influenza Vaccination against Vaccination against Streptococcus pneumoniaeStreptococcus pneumoniae


Recurrent Otitis MediaRecurrent Otitis Media Acute otitis media that occurs three or more Acute otitis media that occurs three or more

times within 6 months or four or more times times within 6 months or four or more times within 12 monthswithin 12 months Short-term antibacterial therapyShort-term antibacterial therapy Prophylactic antibacterial therapyProphylactic antibacterial therapy Prevention and treatment of influenzaPrevention and treatment of influenza Tympanostomy tubesTympanostomy tubes


Otitis Media With EffusionOtitis Media With Effusion Often seen following AOM episodeOften seen following AOM episode Fluid in middle ear without local or systemic Fluid in middle ear without local or systemic

illnessillness May cause mild hearing loss but no painMay cause mild hearing loss but no pain Antibiotics have minimal effect – do not useAntibiotics have minimal effect – do not use


Otitis ExternaOtitis Externa Acute otitis externa (OE) – “swimmer’s ear”Acute otitis externa (OE) – “swimmer’s ear”

Bacterial infection of the EACBacterial infection of the EAC• Abrasion and excessive moistureAbrasion and excessive moisture

Topical treatmentTopical treatment• 2% solution of acetic acid + alcohol as ear drops2% solution of acetic acid + alcohol as ear drops

Oral treatmentOral treatment• Adults Adults –– ciprofloxacin ciprofloxacin• Children – cephalexin (Keflex) fluoroquinolonesChildren – cephalexin (Keflex) fluoroquinolones

PreventionPrevention


Otitis Externa PreventionOtitis Externa Prevention Don’t put anything in the ear, including Don’t put anything in the ear, including

swabs.swabs. Dry the EAC after swimming and showering Dry the EAC after swimming and showering

(with towel and tipping of head).(with towel and tipping of head). Don’t remove earwax.Don’t remove earwax. Don’t use earplugs, except when swimming.Don’t use earplugs, except when swimming.


Necrotizing Otitis ExternaNecrotizing Otitis Externa Rare but potentially fatal complication of acute OE Rare but potentially fatal complication of acute OE High-risk groups – elderly patients with diabetes and High-risk groups – elderly patients with diabetes and

immunocompromised patientsimmunocompromised patients Bacteria in EAC invade mastoid or temporal boneBacteria in EAC invade mastoid or temporal bone

Infection can spread to skull base, cranial nerves, and dura Infection can spread to skull base, cranial nerves, and dura mater, causing meningitis and lateral sinus thrombosismater, causing meningitis and lateral sinus thrombosis

Treatment antipseudomonal Treatment antipseudomonal Ear drops and/or IVEar drops and/or IV Oral ciprofloxacin Oral ciprofloxacin


Fungal Otitis Externa (Otomycosis)Fungal Otitis Externa (Otomycosis)

10% of OE caused by fungi, not bacteria10% of OE caused by fungi, not bacteria Two most common pathogensTwo most common pathogens

80%-90% caused by 80%-90% caused by AspergillusAspergillus CandidaCandida

Intense pruritus and erythema with/without Intense pruritus and erythema with/without pain or hearing losspain or hearing loss

Managed with thorough cleansing and Managed with thorough cleansing and acidifying dropsacidifying drops

1% clotrimazole used if acidifying drops are 1% clotrimazole used if acidifying drops are not effectivenot effective

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