A Comparative Study of Antibiotic-steroid Pack with Glycerine Pack in Treatment of Acute Otitis Externa

Abstract

Objective

To compare the clinical efficacy of Antibiotic-Steroid pack with Glycerine pack for relieving pain and oedema in cases of acute otitis externa.

Study Design

A COMPARATIVE STUDY.

Setting

Tertiary care center ( S.N.Medical college, Bagalkot).

Subjects

20 patients clinically diagnosed with acute otitis externa.

Results

There were 10 patients in antibiotic-steroid pack group and 10 patients in glycerine group. There was female predominance in both the treatment groups and disease was most common in age group 12–20 years. There was no statistical significant decrease in pain and oedema in both the groups. But early reduction in sign and symptoms was noted in antibiotic-steroid group than glycerine group.

Conclusions

Since the control of pain and edema is more and hence the number of visits is less in steroid–antibiotic packing group, so it is worthwhile to use steroid–antibiotic than glycerine pack.

Introduction

Otitis externa is a generalized condition of the skin of the external auditory canal. It is characterized by oedema and erythema associated with itch, pain and discharge [1].It can present as diffuse or localized form of inflammation of external ear canal. It is the very common condition which is encountered in day to day outpatient services. Any condition that disturbs the lipid/acid balance of the ear will predispose an individual to Otitis externa [2]. Edema occurring due to inflammation distracts the lining of external auditory canal causing extreme amount of pain [3].

Common pathogens implicated in acute otitis externa include Pseudomonas aeruginosa(50%),Staphylococcus aureus(23%),anaerobes and gram-negative organisms(12.5%)[4].

Diagnosis of acute otitis externa is made on clinical features alone, although microbial evidence is sought in refractory cases in order to direct anti-microbial therapy [5]. So treatment includes not only antibiotics and analgesics systemically but also aural packing. It acts by its chemical ingredients and also mechanically by splinting action pressing the soft tissues towards the non-distended position[6]. Antibiotic-steroid pack has antiseptic and anti-staphylococcal action while Glycerine has hygroscopic action and exerts its effects mainly due to dehydration action. Steroid reduces edema by its action over capillary wall tone and antibiotic controls overall infection. This study was carried out with the objective of comparing clinical efficacy of antibiotic-steroid pack with glycerine pack for relieving pain in cases of acute otitis externa.

Materials and methods

A COMPARATIVE STUDY was carried out in patients at ENT OPD tertiary care center S.N.Medical college, Bagalkot from November 2020 to April 2021 and diagnosed to have acute otitis externa were evaluated. Diagnosis was made by history and examination of the patients. Patients > 12yrs to 70yrs coming with complaint of ear pain,itching,ear discharge were included in the study. Patients with recurrent episodes of chronic otitis externa,co-existing middle ear pathology, immunocompromised were excluded from the study. Ethical clearance from the institution taken was obtained from all patients included in the study. Physical examination included careful assessment of the external auditory canal for tenderness, swelling, erythema and discharge. At initial presentation ,gentle aural toilet was performed on affected ear of each patient ,following this they were randomized to one of the two treatment modalities using computer randomized generator. Group 1 had Antibiotic-Steroid pack and Group 2 received Glycerine pack. Dressings were left in ear canal for 48 h in both groups and patients reviewed after 2 days.

Comparison of treatment modalities was made by measuring patients pain and signs improvement on follow up at 3rd ,7th and 10th day. Pain was assessed using -Visual analogue scale(range 0 to 10,0 being no pain and 10 indicating the most severe pain). Sign scale for assessing the ear canal swelling, tenderness and erythema as an indicator for measuring improvement of clinical signs was evaluated by the same examiner.

Results

The total number of patients included in the study was 20. Among them 15 (75%) were female and 5 (25%) were female (Table 1). The age group ranged from 12 to 70 years (mean age of 33 years) as shown in Table 2. In 10 (50%) patients antibiotic-steroid packing was performed whereas in another 10 (50%) patients glycerine pack was kept. The average duration of pain among included patient was 2 days (1–10 days) on presentation. Regarding the OPD follow up, in antibiotic-steroid pack, maximum number of patients had complete pain relief by 2nd visit, that is 5(50%) patients, whereas in glycerine group complete pain relief was seen in all the patients on 3rd visit ,but it was not statistically significant( p = 0.3705).Regarding subsidence of oedema ,in steroid-antibiotic group all patients 10(100%) had complete oedema improvement by 2nd visit, whereas in glycerine group all patients had oedema subsidence by 3rd visit, but both was not statistically significant( p = 0.0793).

Table 1.

Sex distribution(n = 20)

Male	Female
5	15

In our study, females were 15(75%) more than males who were 5(25%) in number

Table 2.

Age distribution (n = 20)

12–20 years	7
21–30 years	2
31–40 years	5
41–50 years	3
51–60 years	2
61–70 years	1

In the above table, it shows that age 12-20years were more commonly affected, least affected was 61-70years

Discussion

Acute otitis externa is a common condition involving inflammation of the ear canal. The acute form is caused primarily by bacterial infection, with Pseudomonas aeruginosa and Staphylococcus aureus the most common pathogens. Acute otitis externa presents with the rapid onset of ear canal inflammation, resulting in otalgia, itching, canal edema, canal erythema, and otorrhea, and often occurs following swimming or minor trauma from inappropriate cleaning. Tenderness with movement of the tragus or pinna is a classic finding[7].

Several factors may predispose patients to the development of acute otitis externa. One of the most common predisposing factors is swimming, especially in fresh water. Other factors include skin conditions such as eczema and seborrhea, trauma from cerumen removal, use of external devices such as hearing aids, and cerumen buildup[7]. In the present study, it was observed that self inflicted injury using ear buds as the most common cause .These factors appear to work primarily through loss of the protective cerumen barrier, disruption of the epithelium (including maceration from water retention), inoculation with bacteria, and increase in the pH of the ear canal[8–13].

Meticulous cleaning of the external auditory canal by a traumatic micro suctioning is regarded as an important first step in the initial treatment of otitis externa[11]. Further management divers among various practices, but essentially is addressed at removing the causative micro organisms, controlling pain and reducing the oedema of the external auditory canal. In most instances, topical antibiotics, with or without steroids, are used. Oral therapy mainly includes analgesics to control the severe pain. This is caused by the underlying oedema stretching the epidermal and dermal layers of external auditory canal. The topical medication is delivered into the external auditory canal either directly in the form of ear drops or through the placement of an ear canal dressing. This facilitates the passage of antibiotic medication and also helps in control of the pH[12].

Ear canal dressings are essential in cases of edematous external auditory canal to the extent of obscuring or obliterating the tympanic membrane view. The added benefit of inserting an ear canal dressing is that it prevents further self-inflicted trauma, which can often potentate the disease process. The ear dressing stays in for 24–48 h and hence patient compliance to treatment is also not an issue. A study by Hornigold et al. [13] shows a statistically significant increase in the proportion of patients with symptoms of otitis externa responding to betamethasone–neomycin compared to IG pack. This suggests that there is benefit from adding steroid antibiotic pack to improve pain control of children with otitis externa. The use of an ointment instead of drops in the treatment of otitis externa can be seen from two points of view. On the one hand, the occlusive effect of an ointment may raise the humidity in the affected ear.[13] On the other hand, fewer hypersensitivity reactions are to be expected because no preservatives are required for water-free ointments, whereas eardrops are often preserved. We performed the studies using antibiotics (amoxicillin-clavulanate) and analgesics (paracetamol) in all included patients to avoid bias. Amoxiclav was used because it is one of the choices of drug in cases of acute otitis externa and was the part of protocol of our hospital.

Masood et al.[5] in their randomized control trial used steroid pack and found statistically significant improvement in pain parameters when compared with 10% IG pack. Similarly, prospective study performed by Hornigold et al. using topical steroid ear drops failed to show any difference.[13] Study performed by Bhatta et al. showed statistically significant decrease in pain and number of visits in steroid-antibiotic group as compared to 10% ichthammol glycerine pack[2].

So in our study, there was no statistically significant reduction in pain and reduction in number of visits in steroid-antibiotic group as compared to 10% glycerol pack group which is contrasting to study performed by Masood et al. [5]

Table 3.

Pain relief in both groups.(n = 20)

	3rd day	7th day	10th day
Antibiotic –steroid pack	3	5	2
Glycerine pack	2	3	5

Table 4.

Signs improvement .(n = 20)

	3rd day	7th day	10th day
Antibiotic –steroid pack	4	6	0
Glycerine pack	2	4	4

Limitations

As the sample size is less, significant differences could not be made out, so large sample size is required and further follow ups required to look for any recurrence of sign and symptoms.

Conclusions

In acute otitis externa suspected nonspecific bacterial origin, the control of pain and edema is earlier with less number of visits in steroid–antibiotic packing group. So it is worthwhile to use steroid–antibiotic pack than glycerine pack.