9/7/2013. Ciprodex Webinar Leader. Off label Uses

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1 Alcon labs Ciprodex Webinar Leader Off label Uses Deena B Hollingsworth MSN, FNP-BC, CORLN ENT Specialists of Northern Virginia Falls Church, Virginia Examine common physiologic changes of aging Discuss common causes of hearing loss in the elderly Discuss the diagnosis and management of acute and chronic otitis externa. Participate in an interactive discussion on the care of the geriatric patient with hearing loss. Aging is not a disease Individuals age at different rates Characteristics of aging: -cellular and physiologic deterioration -increased mortality with age following maturation -increased vulnerability to disease -decreased ability to adapt to stress Tympanic membrane flexibility decreases with age High frequency sound perception declines much faster than low frequency sound perception Ossicle articulation becomes more rigid Presbycusis or hearing loss with aging is this sensorineural hearing loss Cerumen becomes drier and more tenacious, prone to impaction Presbycusis is worse with background noise but amplification often helps 1

2 Cardiovascular disease Cochlea has a rich but tenuous vascular supply and is susceptible to ischemia. Patients with CVD are more likely to have impaired cochlear function Smoking Diabetes Smokers are 70% more likely to have a hearing loss ( Cruikshanks et al, JAMA, 1998) Among U.S. residents aged 65 years and older, 10.9 million, or 26.9% had diabetes in Known cause of vascular damage Known cause of nerve damage Blood flow and oxygen are both extremely important to maintaining healthy hair cells in your inner ear and nicotine and carbon monoxide from smoking deplete oxygen levels and constrict blood vessels all over your body. Nicotine is considered to be ototoxic, meaning it can damage hearing. In addition to hearing loss, nicotine can cause tinnitus (or ringing in the ears), dizziness and vertigo. Smoking may also make you more sensitive to loud noises and therefore more susceptible to developing noise-induced hearing loss. ( Healthy Hearing, Jan. 2013) CDC, 2011 Exocrine sweat glands and sebaceous glands decrease Loss of subcutaneous tissue AAO-HNS Evidence-based guideline 2008 Definition: An accumulation of cerumen that causes symptoms and/or prevents assessment of the ear. Impaired blood flow to skin Does not require complete obstruction of EAC Symptoms include: hearing loss fullness otalgia odor tinnitus itching otorrhea cough 2

3 More common in elderly and persons with cognitive impairment Associated with hearing loss and diminished cognitive function Estimated 57% of people in nursing homes and 36% of those with mental retardation Prevents accurate auditory or vestibular testing ( AAO-HNS,2008) 3

4 Non intact tympanic membrane Ear canal stenosis Exostoses/ osteoma Acetic acid Cerumenex Colace Hydrogen peroxide ( Debrox) Sodium bicarbonate Sterile saline Methods Manual removal with instruments and/or suction Irrigation with warm water Ear candling Diabetes Immunocompromised state Anticoagulent therapy Almond oil Arachis oil Earex Olive oil Mineral oil 4

5 Advantages: Often quicker Allows direct visualization of EAC Does not expose the ear to water Requirements: Adequate training/ experience Proper equipment Complications: Trauma to EAC TM perforation Infection Vertigo No Q-Tips Schedule maintainance Routine prophylactic preparations Hydrogen peroxide Olive oil Most is bacterial Pseudomonas auriginosa Staphylococcus aureus Strep pneumoniae Proteus mirabilis Fungal more common in chronic AOE Also known as swimmer s ear or tropical ear AAO-HNS Clinical Practice Guideline 2006 Definition: diffuse inflammation of the EAC which may also involve the pinna or TM. Rapid onset ( generally within 48 hours) Otalgia, fullness, or itching with or without hearing loss or jaw pain Tenderness of the tragus, pinna or both Diffuse EAC edema and /or erythema W or W/O otorrhea, regional lymphadenopathy,tm erythema, or peripheral cellulitis Diagnose Debride Dry Drops Preciado,

6 Over cleaning Debris from dermatologic conditions Local trauma from self cleaning Wearing hearing aids Sweating Allergy Stress Poor water quality Furunculosis ( localized OE) Infected hair follicle ( found in outer 1/3 of canal) Clinical findings: Otalgia otorrhea, localized pain Treatment Local heat I&D Systemic antibiotics ( cover staph aureus) Inflammatory dermatoses Eczema Seborrhea Contact dermatitis Allergic reaction to allergen Metals, chemicals, plastics, leather, drugs Viral infections Herpes zoster With or without rash Pain Facial paresis Lose of taste anterior 2/3 of tongue Decreased lacrimation on the involved side Progressive, necrotizing OE More common in elderly, diabetics, and immunocompromised patients Psuedomonas aeruginosa (90%) Develops into skull based osteomyelitis Facial nerve paralysis early sign Granulation tissue classically seen on floor of canal Elevated ESR and abnormal CT or MRI Treat with IV antibiotics Definition: external otitis lasting longer tan 4 weeks Four or more episodes in a 12 month period Bacterial or fungal Common in the elderly Skin changes Dermatoses Co-morbidities 6

7 Fungal infection common in the tropics, immunocompromised patients, diabetics and HIV. Aspergillus and Candida most common Symptoms Treatment Itching Thick otorrhea hyphae Debridment Topical antifungal Remove obstructing cerumen to limit water accumulation Use acidifying drops before and after swimming Use of an ear dryer Ear plugs for water exposure Avoidance of trauma ( Qtips, fingernails, hairpins) 7

8 Aural toilet Acidifying drops Steroid drops Topical antibiotics Oral antibiotics Pain management Acetic acid, aluminum acetate Acetic acid, hydrocortisone Ciprofloxin, hydrocortisone Ciprofloxin, dexamethasone Neomycin,polymyxin B hydrocortisone Ofloxacin Clotrimazole solution* Ketoconazole cream* Nystatin cream* Gentian violet * *off label Otic Domeboro VoSol HC Cipro HC Ciprodex Cortisporin Otic Floxin otic Lotrimin Arch Otolaryngol Head Neck Surg. 2011;137(7): doi: /archoto Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Cigarette Smoking and Hearing Loss: The Epidemiology of Hearing Loss Study FREE Cruickshanks Karen et.al. JAMA. 1998;279(21): doi: /jama Healthy Hearing, January 10,2013. Roland Peter, et al. Clinical Practice Guideline: Cerumen Impaction. Otolaryngology-Head and Neck Surgery(2008) 139. S1-S21 Rosenfeld Richard, et.al. Clinucal Practice Guideline: Acute otitis externa. Otolaryngology- Head and Neck Surgery(2006) 134, S4-S23. 8