1. Otic Products (2)

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

3. 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

4. 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

5. Treatment of otitis externa
Topical antibiotics & hydrocortisone drops/cream applied to ear canal
If cellulitis & lymphadenopathy are present use oral antibiotics
5% Aluminum acetate solution (Burow’s solution)
Soaking ear with saline, or Burow’s solution is useful in treatment of crusting & edema in auricle & surrounding tissue

6. Treatment of otitis externa
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

7. Ear bulb syringe
Water-Pik spray
Otitis externa
Contact dermatitis

8. .

9. 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.

10. One literature review concluded that the use of ciprofloxacin 0
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.

11. 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

12. 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 )
Solutions of <1% lack bactericidal properties
Disadvantages: has an unpleasant vinegar-like odor, and can be very painful if applied to the middle ear

13. 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

14. 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

15. Aluminum Acetate solution (Burow’s Solution)
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
Its major value: acidity which restores the normal antibacterial pH of the ear canal
Well tolerated, nonsensitizing. Rare adverse effects

16. 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

17. 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

18. 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

19. Carbamide Peroxide (urea hydrogen peroxide)
If condition not improved after 4 days consult a doctor
Procedure not recommended for children under 12 years of age
Should not be used if there is ear drainage, pain or dizziness or injury or perforation of the eardrum

20. Carbamide Peroxide (urea hydrogen peroxide)
Should not be used if surgery has been performed in the past 6 weeks
Carbamide peroxide should be discontinued whenever irritation or rash appears
Not recommended for treating pain of inflamed tissue, swimmer’s ear or itching of the ear canal

21. 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;
In Jordan:
Waxol ear drops: Na docusate
Dewax ear drops: Na docusate

22. 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

23. Not proven to be safe and effective by FDA
Benzocaine
Antipyrine
Camphor
Chloroform
Menthol
Ichthammol

24. Glycerin Olive oil (Sweet Oil)
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

25. 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

26. 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

27. 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

28. 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

29. 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?
Water used for irrigation should be sterile to prevent contamination
Eardrops should be warmed to body temperature by: holding the medication container in the balm of the hand or placing it into a vessel of warm water for few minutes before administration
Heated eardrops should never be applied to ear canal because they are likely to damage the ear or the ingredients in the eardrop

31. 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

32. 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)