|Year : 2019 | Volume
| Issue : 1 | Page : 29-32
Role of Betadine irrigation in chronic suppurative otitis media: Our experiences in a tertiary care teaching hospital of East India
Santosh Kumar Swain1, Ishwar Chandra Behera2, Mahesh Chandra Sahu3
1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan (Deemed to be University), Bhubaneswar, Odisha, India
2 Department of Community Medicine, IMS and SUM Hospital, Siksha “O” Anusandhan (Deemed to be University), Bhubaneswar, Odisha, India
3 Department of Medical Research Laboratory, IMS and SUM Hospital, Siksha “O” Anusandhan (Deemed to be University), Bhubaneswar, Odisha, India
|Date of Web Publication||18-Feb-2019|
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
BACKGROUND: Chronic suppurative otitis media (CSOM) is persistent and insidious disease of the middle ear cleft characterized by otorrhea, permanent perforation of the tympanic membrane, and hearing loss. It is one of the most common bacterial infections in otolaryngology.
OBJECTIVE: The objective is to find out an appropriate medical treatment for CSOM patients. The effect of diluted Betadine irrigation along with systemic antibiotic in CSOM and consider the most appropriate medical treatment..
MATERIALS AND METHODS: This study was a prospective study and done from 2015 to 2017 in patients with tubotympanic type of CSOM where 600 such patients were participated in this study and randomly divided into two groups. One group was treated with diluted povidone Betadine aural toileting whereas another group only with topical and systemic antibiotics.
RESULTS: In Group A, otorrhea resolution was seen in 86%, and healing of the perforation was noted in 28% cases in the group treated with regular aural Betadine toileting. In Group B, those were treated with only topical and systemic antibiotic, 65% of the patients show otorrhea resolution, and 15% achieved healing of the perforation.
CONCLUSION: Aural toileting and irrigation with diluted Betadine are a desirable and well accepted compared to topical and oral antibiotics.
Keywords: Biofilm, chronic suppurative otitis media, diluted Betadine, middle ear
|How to cite this article:|
Swain SK, Behera IC, Sahu MC. Role of Betadine irrigation in chronic suppurative otitis media: Our experiences in a tertiary care teaching hospital of East India. Int J Health Allied Sci 2019;8:29-32
|How to cite this URL:|
Swain SK, Behera IC, Sahu MC. Role of Betadine irrigation in chronic suppurative otitis media: Our experiences in a tertiary care teaching hospital of East India. Int J Health Allied Sci [serial online] 2019 [cited 2022 Aug 12];8:29-32. Available from: https://www.ijhas.in/text.asp?2019/8/1/29/252447
| Introduction|| |
Chronic suppurative otitis media (CSOM) is defined as a chronic inflammatory condition of the middle ear cleft which is characterized by recurrent otorrhea, perforation in tympanic membrane, and hearing loss. CSOM is an insidious and persistent disease. It is a common bacterial infection in day-to-day clinical practice in the field of otolaryngology. Medical treatment of CSOM is essential before surgery. Biofilms are the most common microbial form in a biological environment and play a major role in chronic infection. CSOM is leveled as a biofilm disease, and it explains the resistance to antibiotics. At present, there is no specific reliable alternative option for eradicating or preventing biofilms in patients. There are a number of treatment options are under consideration and proposed for treatment in the patients. There are no established standard guidelines for treating chronic otitis media. The drawback for longstanding use of antibiotics both parentally and orally is toxic reactions, cost, adverse effect, and inconvenience for patients to use regularly. There is also no consensus among otolaryngologists and physicians regarding medical treatment of CSOM. However, aural toileting is a part of the medical treatment in CSOM. There is no much study for evaluating the role of diluted povidone-iodine irrigation in CSOM. It is known that iodine is a known antiseptic solution used in surgical procedure since long. Povidone-iodine solution is often used to reduce the infections at extrinsic part of the body. It has been well documented to decrease the wound infection., Betadine or povidone-iodine solution is inexpensive and easily available. The aim of this study is to consider appropriate medical treatment modality for CSOM by comparing efficacy of aural toileting with diluted Betadine with topical and systemic antibiotics.
| Materials and Methods|| |
This is a prospective study conducted at the department of otorhinolaryngology of a tertiary care teaching hospital at the eastern part of India and study period from July 2012 to December 2017. The study was approved by the Institutional Ethics Committee. Inclusion criteria of the patients were active disease of tubotympanic type of CSOM with mucopurulent discharge for >1 month. Six hundred patients were included in this study and randomly divided into two groups. In this study, the exclusion criteria were CSOM with dry ear, CSOM with atticoantral disease, CSOM with otomycosis, CSOM with vertigo, serous otitis media and patients already taken systemic antibiotics or topical antibiotics applications. All patients had undergone pure-tone audiometry before and after the treatment and also X-ray mastoid in all patients participating in the study. Out of the two groups, one group (Group A) patients were treated with aural toileting and irrigation with Betadine, and in another group (Group B), patients were treated with systemic and topical antibiotics. In Group A, patients were advised to visit the clinic every week. At each visit, the ear canal and middle ear were irrigated with diluted povidone Betadine (5%) using 5-ml syringe and suction cleaning. The criteria to stop treatment were no otorrhea, dry and clean external auditory canal, and middle ear and dry and nonedematous middle ear mucosa. In Group B, the external ear and middle ear were properly suctioned out and applications of topical antibiotics (ciprofloxacin eardrop for 3 months). The topical antibiotics were combined with oral ciprofloxacin 500 mg twice daily for 2 weeks. Follow-up was done for 3 months, and the signs such as absence of otorrhea, healing of perforation, and status of middle ear mucosa were documented.
| Results|| |
A total of 600 patients were included in this study with age range of 6–82 years (mean age: 28.7 years), in which 376 were male and 224 were female. Otorrhea and hearing loss were presenting complaints in all patients. Tinnitus was present in 25% of patients and no one presented with vertigo and any other complications. In Group A (those treated with Betadine), dry ear was seen in 258 patients (86%) in the mean 23 days. One hundred and sixteen patients (38.66%) had dry ear in 17 days, 112 patients (37.33%) in 1 month, 27 patients (9%) in 1½ months, and 12 patients (4%) in 3 months [Figure 1]. Perforation of the tympanic membrane healed in 99 patients (33%) during 1–3 months. In Group B (those treated with systemic and topical antibiotic), dry ear was seen in 195 patients (65%) in the mean 38 days. One hundred and seven patients (35.66%) had dry ear in 16 days, 97 patients (32.33%) in 1 month, 55 patients (18.33%) in 1½ months, and 34 patients (11.33%) in 2 months [Figure 2]. Eleven patients (3.66%) achieved dry ear after 3 months. Perforation of the tympanic membrane healed in 45 patients (15%). The minimum time for healing was 1 month and the maximum time was 3 months.
|Figure 1: Results obtained in Group A (patients treated with Betadine irrigation)|
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|Figure 2: Results obtained in Group B (patients treated with topical and systemic antibiotics)|
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| Discussion|| |
CSOM is defined as a chronic inflammatory condition of the middle ear and mastoid cavity which presents with recurrent otorrhea through perforated tympanic membrane. CSOM is a commonly seen infection of the middle ear cleft all over the world. The disabilities and mortality due to otitis media are often related to the complications of CSOM. CSOM is the most common cause of hearing impairment in the community, particularly in low socioeconomic group where accessibility of primary health care is poor. Untreated cases of CSOM may lead to broad range of complications which are due to spread of infections to the adjacent structures of the ear. The complications of the CSOM range from mastoiditis, labyrinthitis, and facial nerve palsy to intracranial abscess. The prevalence of CSOM in underdeveloped countries like Africa is between 2% and 6% whereas in developed country like the USA and Europe is below 1%. CSOM and its complications are common clinical conditions seen by general practitioners and otologists. CSOM is a persistent infective condition of the middle ear cleft affecting all age group and is characterized by persistent or recurrent otorrhea through permanent perforation of the tympanic membrane leading to hearing loss and different extracranial and intracranial complications which need urgent attention. Bacteria can enter middle ear through the perforated tympanic membrane through external auditory canal. Chronic infection of the middle ear mucosa results in recurrent ear discharge. CSOM is a common and dangerous clinical entity that is difficult to treat as common bacteria are often resistant to several antibiotics. These may cause spread of bacteria into adjacent structures of the middle ear leading to complications such as mastoiditis, labyrinthitis, and facial nerve paralysis to more serious situations such as brain abscess or lateral sinus thrombosis. The mechanisms of aural cleaning with Betadine are removal of inflammatory debris, prevent destructive effect on biofilm, and lead to alteration of the pH in the ear canal interrupts the growth of the bacteria by affecting amino acids so that change the three dimensional structure of bacterial enzymes and prevent from infections. Extreme alterations in pH lead to protein denaturation. The main treatment of uncomplicated CSOM is meticulous aural toileting with suction or mopping up of ear discharge and application of topical and systemic antibiotic. The use of antibiotic is often started empirically before the result of microbiological culture. The selection of the antibiotic is often decided by its efficacy, resistance of bacteria, risk of toxicity, safety, and cost. The antibiotic sensitivity of local microorganisms is important for effective and cost-saving treatment. The CSOM is often due to bacterial infections such as Staphylococcus aureus and Pseudomonas aeruginosa followed by Proteus mirabilis and Escherichia More Details coli. The conservative management in CSOM usually includes topical, with suction cleaning along with instillation of broad-spectrum antibiotic eardrops. The preferred antibiotic topical eardrop is quinolone such as ciprofloxacin and ofloxacin which are effective in 69%–95% of the patients and often lack ototoxicity. The topical eardrops are usually instilled twice daily for period of 1–2 weeks with aural cleaning and follow-up regularly. We selected povidone-iodine in chronic otitis media as it is easily available in hospital and has been proven to be effective against microorganisms in CSOM. Povidone-iodine is chemically stable, cheap, and resistance for fungi and bacteria which are yet to be reported. No studies are showing resistance of povidone-iodine to any microorganism. Excess use of topical antibiotic and antimicrobials may lead to emergence of resistance to micro-organisms. Povidone-iodine overcomes this type of problems. In developing and third world countries like India, the cheaper, effective and without any complications of medication like ototoxicity is a need and it forms a better choice. Therefore, the appropriate treatment for CSOM is need always. It seems that still larger sample size and comprehensive study needed to clarify sensitivity of recalcitrant otomycosis to gelfoam soaked povidone-iodine in the clinical setting. The health parameters such as personal hygiene, sanitation, and low nutrition in developing country like India play important role in aggravating the clinical presentations of CSOM. Most of our patients are from low socioeconomic status, so aural toileting with diluted Betadine improves the healing process of chronic otitis media and decreases the cost and toxic reactions of drugs. Local treatment with Betadine toileting is more helpful as systemic drug penetration through the devascularized and fibrotic mucosa of the middle ear and mastoid. Hence, it provides emphasis of major role for local treatment. There is risk for ototoxicity for prolonged use of topical antibiotics which is a stumbling block in the widespread of topical antibiotic. There is also a chance of sensorineural hearing loss in patients using prolonged topical antibiotic eardrop and so clinician is trying to avoid topical antibiotics., Topical quinolone antibiotics often clear otorrhea than systemic antibiotics while topical Betadine irrigation of the ear is not studied much in medical literature. Further studies for Betadine irrigation in the ear is needed for antiseptic effectiveness, long-term outcome in terms of resolution, healing, and hearing improvement.
| Conclusion|| |
Medical treatment of CSOM without cholesteatoma by frequent aural irrigation and cleaning using Betadine can be more desirable option as compared to the oral and topical antibiotics. It is safe and economical without causing any side effects. Removal of deep-seated debris from poorly vascularized sites such as bone, mechanical disruption of biofilm, and alteration of pH of the ear canal are important contributing factors of the Betadine for healing process in the CSOM.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Macassey E, Dawes P. Biofilms and their role in otorhinolaryngological disease. J Laryngol Otol 2008;122:1273-8.
Roland PS. Chronic suppurative otitis media: A clinical overview. Ear Nose Throat J 2002;81:8-10.
Ludman H. Discharge from the ear: Otitis externa and acute otitis media. Br Med J 1980;281:1616-7.
Knight CD Jr., Farnell MB, Hollier LH. Treatment of aortic graft infection with providone-iodine irrigation. Mayo Clin Proc 1983;58:472-5.
Kwaan JH, Connolly JE. Successful management of prosthetic graft infection with continuous povidone-iodine irrigation. Arch Surg 1981;116:716-20.
Ahmad S. Antibiotics in chronic suppurative otitis media: A bacteriologic study. Egypt J Ear Nose Throat Allied Sci 2013;14:191-4.
Healy GB, Rosbe KW. Otitis media and middle ear effusion in snow. In: Ballenger JJ, editor. Ballenger's Otorhinolaryngology Head Neck Surgery. Canada: BC Decker Inc.; 2003.
van Hasselt P, van Kregten E. Treatment of chronic suppurative otitis media with ofloxacin in hydroxypropyl methylcellulose ear drops: A clinical/bacteriological study in a rural area of Malawi. Int J Pediatr Otorhinolaryngol 2002;63:49-56.
Acuin J. Extracts from "Concise clinical evidence" Chronic suppurative otitis media. BMJ 2002;325:1159.
Gehanno P. Multicenter study of the efficacy and safety of oral ciprofloxacin in the treatment of chronic suppurative otitis media in adults. The French Study Group. Otolaryngol Head Neck Surg 1997;117:83-90.
Jones CE, Kennedy JP. Treatment options to manage wound biofilm. Adv Wound Care (New Rochelle) 2012;1:120-6.
Agarwal A, Kumar D, Goyal A, Goyal S, Singh N, Khandelwal G. Microbiological profile and their antimicrobial sensitivity pattern in patients of otitis media with ear discharge. Indian J Otol 2013;19:5-8.
Simpson KL, Markham A. Ofloxacin otic solution: A review of its use in the management of ear infections. Drugs 1999;58:509-31.
Jaya C, Job A, Mathai E, Antonisamy B. Evaluation of topical povidone-iodine in chronic suppurative otitis media. Arch Otolaryngol Head Neck Surg 2003;129:1098-100.
Gupta C, Agrawal A, Gargav ND. Role of acetic acid irrigation in medical management of chronic suppurative otitis media: A comparative study. Indian J Otolaryngol Head Neck Surg 2015;67:314-8.
Swain SK, Behera IC, Sahu MC, Das A. Povidone iodine soaked gelfoam for the treatment of recalcitrant otomycosis – Our experiences at a tertiary care teaching hospital of Eastern India. J Mycol Med 2018;28:122-7.
[Figure 1], [Figure 2]