OTITIS EXTERNA

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional Application Serial No. 60/915,813, filed May 3, 2007. The entire disclosure of the earlier application is incorporated herein by reference.

BACKGROUND

1. Technical Field

This document relates to methods and materials involved in treating otitis externa. For example, this document relates to methods and materials involved in using a steroid (e.g., dexamethasone) and an antiseptic (e.g., iodine) to treat otitis externa.

2. Background Information

Otitis externa is an inflammation, irritation, or infection of the outer ear and ear canal that can affect mammals in all age groups, particularly older pediatric and young adult populations. A bacterial infection is typically responsible for causing otitis externa, but the disease may also be associated with a fungal infection or a variety of noninfectious systemic or local dermato logic processes. For example, otitis externa can be caused by moisture trapped in the ear canal after swimming or bathing that results in maceration of the skin and provides a breeding ground for microbes such as

Pseudomonas aeruginosa, Staphylococcus aureus or, less commonly, fungi such as Candida or Aspergillus species. For this reason, otitis externa is sometimes referred to as "swimmer's ear." Otitis externa also can be caused by trauma to the ear canal that allows invasion of bacteria into the damaged skin. Such trauma can occur during attempts at cleaning the ear with a cotton swab or paper clip.

Once infection is established, an inflammatory response can occur with erythema and swelling of the canal. The two most characteristic presenting symptoms of otitis externa are otalgia (ear discomfort) and otorrhea (discharge in or coming from the external auditory canal). The ear discomfort can range from pruritus to severe pain that is exacerbated by motion of the ear, including chewing. If inflammation causes sufficient

swelling to occlude the external auditory canal, loss of hearing can occur. If severe, the infection may spread and cause lymphadenitis or cellulitis of the face or neck. Complications of bacterial otitis externa include necrotizing or malignant otitis externa, which is a life-threatening extension of external otitis into the mastoid or temporal bone. Most commonly caused by Pseudomonas aeruginosa, necrotizing otitis externa is an osteomyelitis that occurs most often in elderly patients with diabetes mellitus. However, all immunocompromised mammals, especially those infected with an immunodeficiency virus, are at risk.

SUMMARY

This document provides methods and materials related to treating otitis externa. For example, this document provides methods and materials for using a steroid (e.g., dexamethasone) and an antiseptic (e.g., povidone-iodine) to treat otitis externa. The methods and materials provided herein can be used to reduce the severity of a symptom of otitis externa and/or to reduce progression of otitis externa. Reducing the severity of a symptom or the progression of otitis externa can decrease morbidity associated with otitis externa and inhibit the spread of infectious otitis externa.

As described herein, this document is based in part on the discovery that a combination of the antiseptic povidone-iodine and the steroid dexamethasone (Betadex) can be used to treat otitis externa. Such a combination can destroy or inhibit the growth of a broad spectrum of bacteria as well as fungi and viruses. In addition, since the mechanism of action of an antiseptic can differ from that of an antibiotic, use of an antiseptic and a steroid to treat otitis externa can be associated with a low level of bacterial resistance. Additional advantages of using an antiseptic such as povidone - iodine and a steroid such as dexamethasone to treat otitis externa can include improved efficacy, low cost, and anti-inflammatory properties.

In some cases, the methods and materials provided herein (e.g., a composition containing an antiseptic and a steroid) can be administered to a mammal (e.g., an ear and/or sinonasal cavity of the mammal) to treat otitis externa, otitis media, a sinus infection, and/or a nasal infection.

In general, one aspect of this document features a method for treating a mammal having otitis externa. The method comprises, or consists essentially of, administering to the mammal an antiseptic and a steroid under conditions wherein a symptom of otitis externa is reduced. The mammal can be a human. The otitis externa can be caused by bacteria. The otitis externa can be caused by fungi. A composition comprising, or consisting essentially of, the antiseptic and the steroid can be administered to the mammal. The antiseptic can be iodine. The iodine can be a povidone-iodine. The steroid can be dexamethasone. The antiseptic and the steroid can be administered as ear drops. The symptom can be reduced by 25 percent. The symptom can be reduced by 50 percent. The symptom can be reduced by 75 percent. The symptom can be reduced by 100 percent.

Another aspect of this document features a method for treating a mammal having otitis externa, otitis media, a nasal infection, a sinus infection, or a combination thereof. The method comprises, or consists essentially of, administering to the mammal an antiseptic and a steroid under conditions wherein a symptom of otitis externa, otitis media, a nasal infection, or a sinus infection is reduced. The mammal can be a human. The otitis externa, otitis media, nasal infection, or sinus infection can be caused by bacteria. The otitis externa, otitis media, nasal infection, or sinus infection can be caused by fungi. A composition comprising, or consisting essentially of, the antiseptic and the steroid can be administered to the mammal. The antiseptic can be iodine. The iodine can be a povidone-iodine. The steroid can be dexamethasone. The antiseptic and the steroid can be administered as ear drops. The symptom can be reduced by 25 percent. The symptom can be reduced by 50 percent. The symptom can be reduced by 75 percent. The symptom can be reduced by 100 percent. Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention pertains. Although methods and materials similar or equivalent to those described herein can be used to practice the invention, suitable methods and materials are described below. All publications, patent applications, patents, and other references mentioned herein are incorporated by reference in their entirety. In case of conflict, the present specification, including definitions, will control. In addition, the materials,

methods, and examples are illustrative only and not intended to be limiting.

The details of one or more embodiments of the invention are set forth in the accompanying drawings and the description below. Other features, objects, and advantages of the invention will be apparent from the description and drawings, and from the claims.

DETAILED DESCRIPTION

This document provides methods and materials related to treating otitis externa in mammals. For example, this document provides methods and materials related to the use of an antiseptic (e.g., povidone -iodine) and a steroid (e.g., dexamethasone) to treat otitis externa in a mammal. The methods and materials provided herein can be used to treat otitis externa in any type of mammal including, without limitation, mice, rats, dogs, cats, horses, cows, pigs, monkeys, and humans. Any type of otitis externa can be treated. For example, otitis externa caused by one or more bacteria, viruses, fungi, or combinations thereof can be treated. In some cases, non- infectious otitis externa can be treated.

In general, otitis externa can be treated by administering an antiseptic and a steroid to a mammal having otitis externa. It will be appreciated that an antiseptic and a steroid can be used to treat otitis externa upon administration either individually or in combination. For example, a mammal having otitis externa can be treated by administering an antiseptic and a steroid individually. In some cases, otitis externa can be treated by administering a composition containing an antiseptic and a steroid to a mammal.

Any antiseptic can be used in combination with any steroid to treat otitis externa including, without limitation iodine or povidone-iodine. Non-limiting examples of steroids include dexamethasone, clobetasol, betamethasone, halbetasol, diflorasone, fluocinonide, halcinonide, amcinonide, desoximetasone, triamcinolone, mometasone, fluticasone, fluocinolone, hydrocortisone, flurandrenolide, triamcinalone, desonide, and prednicarbate. An antiseptic and a steroid can be obtained or produced by any appropriate method. For example, an antiseptic and a steroid can be chemically synthesized and purified using standard organic synthetic chemistry methods. An antiseptic and a steroid can also be obtained from a commercial source. For example,

dexamethasone sodium phosphate powder can be obtained from Gallipot, located at 2400 Pilot Knob Road, St. Paul, MN, 55120. A 10% solution of povidone-iodine can be obtained from Humco, located at 7400 Alumax Drive, Texarkana, TX, 75501.

An antiseptic and a steroid can be combined to produce a composition useful for treating otitis externa. For example, a composition can be prepared that contains 10% povidone-iodine and 0.1% dexamethasone. A composition containing an antiseptic and a steroid can be in any appropriate form. For example, a composition provided herein can be in the form of a gel or solution for topical administration or administration in the ear (e.g., ear drops). In some cases, a composition can contain additional ingredients including, without limitation, pharmaceutically acceptable excipients. A pharmaceutically acceptable excipient can be, for example, water, sodium hydroxide, or a surfactant.

Any appropriate method can be used to administer an antiseptic and a steroid to a mammal. For example, an antiseptic and a steroid can be administered topically or in the form of ear drops. In some cases, an antiseptic and a steroid can be administered by different routes. For example, an antiseptic can be administered as topical ear drops and a steroid can be administered orally. In some cases, an antiseptic and a steroid can be administered to an ear or sinonasal cavity either individually or as a combination.

Before administering an antiseptic and a steroid to a mammal, the mammal can be assessed to determine whether or not the mammal has otitis externa. Any appropriate method can be used to determine whether or not a mammal has otitis externa. For example, a mammal (e.g., human) can be identified as having otitis externa when the ear canal of the mammal appears red and swollen or has an eczema- like appearance with scaly shedding of skin. In some cases, increased pain upon touching or moving the outer ear can indicate that a mammal has otitis externa. Difficulty visualizing the eardrum with an otoscope due to narrowing of the ear canal from inflammation and the presence of drainage and debris also can indicate that a mammal has otitis externa. In some cases, exudate from the ear of a mammal can be cultured to identify bacteria or fungi causing otitis externa in the mammal. After identifying a mammal as having otitis externa, the mammal can be administered an antiseptic and a steroid. An antiseptic and a steroid can be administered

to a mammal in any amount, at any frequency, and for any duration effective to achieve a desired outcome (e.g., to reduce the severity of a symptom of otitis externa or to reduce spreading of infectious otitis externa). In some cases, an antiseptic and a steroid can be administered to a mammal having otitis media to reduce the severity of a symptom or to reduce the progression rate of otitis externa by 5, 10, 25, 50, 75, 100, or more percent. For example, the severity of a symptom can be reduced in a mammal such that the symptom is no longer detected by the mammal. In some cases, the progression of infectious otitis externa can be reduced such that no additional progression is detected. Any method can be used to determine whether or not the severity of a symptom or the progression rate of otitis externa is reduced. For example, a mammal having otitis externa can be questioned about pain or discomfort before and after treatment to determine whether a symptom of otitis externa (e.g., ear pain or ear itching) is reduced. In some cases, a mammal can be observed or tested for the severity of a symptom of otitis externa (e.g., ear discharge, sensitivity of the ear to pressure, sensitivity of the earlobe to touch, or reduced hearing) before and after treatment with an antiseptic and a steroid to determine whether or not the severity of a symptom is reduced. In some cases, an otolaryngologist can assess the severity of otitis externa (e.g., by performing a physical examination and assigning a Grade 1 to 4 score) before and after treatment to determine whether the severity of a symptom is reduced. To determine whether or not progression of otitis externa is reduced, a physical examination can be performed at different time points to determine the amount of erythema and/or edema in and around the ear canal. The amount of erythema and edema observed at different time points can be compared to assess the progression rate. After treatment as described herein, the progression rate can be determined again over another time interval to determine whether or not the progression rate has decreased.

An effective amount of an antiseptic and a steroid can be any amount that reduces the severity of a symptom or the progression of otitis externa without producing significant toxicity to the mammal. For example, an effective amount of an antiseptic such as povidone -iodine can be from about 5% to about 20% (e.g., about 10%) povidone- iodine in an otic drop formulation. An effective amount of a steroid such as dexamethasone can be from about 0.05% to about 0.20% (e.g., about 0.10%)

dexamethasone in an otic drop formulation. In addition, an effective amount of an antiseptic such as povidone-iodine and a steroid such as dexamethasone can be from about 2 drops to about 8 drops of an otic drop formulation containing about 10% povidone-iodine and about 0.10% dexamethasone applied to the ear. If a particular mammal fails to respond to a particular amount, then the amount of one or more of the antiseptic and the steroid can be increased by, for example, two fold. After receiving this higher concentration, the mammal can be monitored for both responsiveness to the treatment and toxicity symptoms, and adjustments made accordingly. The effective amount can remain constant or can be adjusted as a sliding scale or variable dose depending on the mammal's response to treatment. Various factors can influence the actual effective amount used for a particular application. For example, the frequency of administration, duration of treatment, use of multiple treatment agents, route of administration, immunocompetency of the mammal, and severity of the otitis externa may require an increase or decrease in the actual effective amount administered. The frequency of administration can be any frequency that reduces the severity of a symptom or progression rate of otitis externa without producing significant toxicity to the mammal. For example, the frequency of administration can be from about once daily to about four times daily (e.g., about twice daily). The frequency of administration can remain constant or can be variable during the duration of treatment. In addition, the frequency of administration of an antiseptic and a steroid can be the same or can differ. For example, an antiseptic can be administered three times daily, while a steroid can be administered once daily. A course of treatment with an antiseptic and a steroid can include rest periods. For example, an antiseptic and a steroid can be administered over a two week period followed by a two week rest period, and such a regimen can be repeated multiple times. As with the effective amount, various factors can influence the actual frequency of administration used for a particular application. For example, the effective amount, duration of treatment, use of multiple treatment agents, route of administration, immunocompetency of the mammal, and severity of the otitis externa may require an increase or decrease in administration frequency. An effective duration for administering a composition provided herein can be any duration that reduces the severity of a symptom or the progression rate of otitis externa

without producing significant toxicity to the mammal. Thus, the effective duration can vary from several days to several weeks, months, or years. In general, the effective duration for the treatment of otitis externa can range in duration from several days to several weeks. In some cases, an effective duration can be for as long as an individual mammal is alive. Multiple factors can influence the actual effective duration used for a particular treatment. For example, an effective duration can vary with the frequency of administration, effective amount, use of multiple treatment agents, route of administration, immunocompetency of the mammal, and severity of the otitis externa.

After administering an antiseptic and a steroid (e.g., a composition containing an antiseptic and a steroid) provided herein to a mammal, the mammal can be monitored to determine whether or not the otitis externa was treated. For example, a mammal can be assessed after treatment to determine whether or not a symptom of otitis externa was reduced (e.g., stopped). As described herein, any method can be used to assess symptoms and progression of otitis externa. A composition disclosed herein such as a composition containing iodine and a steroid such as dexamethasone can be provided together with a cleaning material (e.g., a wipe, tissue, or cloth) and/or a cleaning agent that can be used to remove any excess iodine from skin or clothing. Examples of cleaning agents include, without limitation, solutions containing alcohol, ascorbic acid, and/or salicylic acid (see, for example, U.S. Patent No. 6,309,471). A cleaning material and a cleaning agent can be combined together in one container in a ready to use form. For example, a cleaning material such as a wipe can be impregnated in a cleaning agent such as an organic (e.g., ethanol) or aqueous solution containing salicylic acid. In addition, a cleaning material, a cleaning agent, and a composition containing an antiseptic and a steroid can be provided in a kit. The kit can include informational material that can be descriptive, instructional, marketing, or other material that relates to use of the kit components.

The invention will be further described in the following examples, which do not limit the scope of the invention described in the claims.

EXAMPLES

Example 1 - Treating otitis externa with povidone-iodine and dexamethasone

A solution containing 0.1% dexamethasone and 10% povidone-iodine was prepared as follows. Dexamethasone sodium phosphate powder was obtained from Gallipot (St. Paul, MN), and 1.3 grams of the powder, corresponding to 1 gram of dexamethasone, were weighed out using an analytical balance. A 10% solution of povidone-iodine was obtained from Humco (Texarkana, TX). The dexamethasone sodium phosphate powder (1.3 grams) was mixed into one liter of the 10% povidone- iodine solution on a stir plate at a low spin rate for about five minutes. The mixture was allowed to stand until the foam subsided. The solution was then filtered in a laminar flow hood using aseptic technique. A Baxa pump and a Millex-GP 50 mm, 0.22 micron filter (Millipore, Billerica, MA) were used to filter the solution into 30 mL sterile amber plastic dropper bottles (Healthcare Logistics, Circleville, OH). The filter was changed after every fourth bottle was filled. Each bottle was capped immediately after being filled and labeled.

Sterility testing was performed using the Millipore system. Filters were wetted using 100 mL of a 0.9% sodium chloride solution. A dropper bottle to be tested was wiped with alcohol and allowed to dry. A needle was inserted into the bottle, and the solution was filtered. The filter was rinsed three times with 200 mL of 0.9% sodium chloride (100 mL per canister). The caps were placed on the outlets of the canisters. One of the tubing lines was clamped off. Growth media (100 mL) was added to a canister. The clamp was switched to the other tubing line, and 100 mL of the second growth media was placed into the other canister. Each canister was prepared for incubation. A "Quality Assurance for Sterile Formulations" form was completed, and each canister was marked with identifying information. The canisters were incubated and monitored for microbial growth. No microbial growth was observed after 90 days of incubation.

A study is performed to determine the effectiveness and adverse side effects of Betadine / Dexamethasone combination otic drops at a concentration of 10% Povidone- Iodine/0.15% Dexamethasone applied as otic drops (four drops) in an effected ear twice daily for seven days. The otic drops are applied for the treatment of uncomplicated AOE.

The study population consists of 45 individuals eighteen years or older presenting with AOE, manifested by pain, inflammation, and tenderness of less than two weeks duration in one or both ears and who desire to participate in a clinical research study of this type. All patients are evaluated by an Otolaryngology resident, board certified Otolaryngologist, or experienced Otolaryngology Physician Assistant. All members of the study population have intact tympanic membranes (no middle ear exposure). Exclusion criteria include previous treatment, in the past two weeks, with systemic antibiotics, or ototopical preparations of any kind; a history of diabetes mellitus with or without signs of malignant otitis externa; pregnancy (female patients of child bearing age undergo a urine pregnancy test); known tympanic membrane perforation, inability to assess for tympanic membrane perforation, or current presence of a ventilating tube; presence of concomitant acute otitis media, mastoiditis, perichondritis of the pinna or other infectious complication in addition to the acute otitis externa; known immunodeficiency or other systemic disease involving the ears; allergy or sensitivity to betadine, sulfonamide antibiotics, dexamethasone, other topical steroid intolerance, or any other ingredient in the preparation; known viral infections of the external auditory canal; and congenital abnormalities of the external auditory canal, or exostoses.

Data are collected for a minimum of 21 days for each of the patients enrolled in the study. Patients undergo three required evaluations in the otolaryngology clinic days after initial diagnosis (on days 1, 7-10, and 21).

Table 1. Schedule of Study Events

Patient are assessed for efficacy using photodocumentation. Patients undergo photodocumentation with the use of a digital camera on day 1 and day 7-10. If patients

experience persistent infection, documentation is also obtained on day 21. The degree of inflammation of the external canal is also assessed using a Grading system as follows:

1. Normal.

2. Mild: otorrhea with out external canal swelling. 3. Moderate: otorrhea with external canal swelling leading to partial visual obstruction of the tympanic membrane. 4. Severe: otorrhea with complete external auditory canal obstruction.

Investigator unable to see the tympanic membrane without dilation of the ear canal. The degree of inflammation is documented on day 1, 7-10, and day 21 as needed for persistent infections. Evidence of purulence and discharge is documented as part of the evaluation. In addition, a questionnaire is filled out on day 1 of presentation to assess whether the patient meets study inclusion criteria. Another questionnaire is administered on day 7-10 and possibly on day 21 if the patient has persistent symptoms. Two board certified otolaryngologists assess the severity of infection by reviewing the documented pictures and assigning a Grade 1 to 4 score. The reviewer is blinded to the point in the treatment cycle the pictures were taken. Referred patients are seen by a dedicated Otolaryngology professional, either a board certified otolaryngologist, Otolaryngology resident, or experienced Otolaryngology Physician Assistant. Pre-treatment and post- treatment gram stains, cultures, and bacterial sensitivities are obtained.

A prospective randomized study is performed to compare Betadine / Dexamethasone with a Ciprodex® preparation. A randomized comparison group of 15 patients are assigned treatment with Ciprodex®, four drops in the affected ear twice daily for seven days. Randomization is preformed with pre-assigned envelopes. Statistical methods are used to analyze the data. Nominal and categorical variables are summarized by calculating frequencies and percentages, and continuously scaled variables are summarized by calculating mean, median, standard deviation and range. The demographic characteristics of the patients are summarized as well as the results of the examinations and questionnaire responses at baseline, day 7-10, and day 21. In addition, the frequency of side effects is tabulated.

OTHER EMBODIMENTS

It is to be understood that while the invention has been described in conjunction with the detailed description thereof, the foregoing description is intended to illustrate and not limit the scope of the invention, which is defined by the scope of the appended claims. Other aspects, advantages, and modifications are within the scope of the following claims.