Aminoglycoside or Quinolone Ear Drops in the Postoperative Management of Tympanoplasty: What Choice Do We Have?

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To the Editor: In the recent study from Alrwisan et al. (1), authors compared the rates of tympanic membrane (TM) perforation after use of the two available ear drop classes, quinolones, and neomycin, following ear tube surgery. Authors found an increased risk of perforation in children which used quinolone ear drops, with an adjusted hazard ratio of 1.49 (95% confidence interval [CI], 1.05–2.09) for ofloxacin, 1.94 (95% CI, 1.32–2.85) for ciprofloxacin plus hydrocortisone, and 2.00 (95% CI, 1.18–3.41) for ciprofloxacin. Furthermore, a recent cell culture study showed that treatment of mouse TM fibroblasts with ciprofloxacin led to marked cytotoxicity and depression in collagen synthesis (2). These findings, together with the well-known detrimental effect of systemic quinolones on human collagenous tissue (3), point to the possibility that quinolones could contribute to the development of persistent TM perforations. Clinicians face a difficult dilemma as alternative ear drops with aminoglycosides have been known to cause hearing loss in the presence of TM perforation (4), and risks against potential benefits must be carefully weighted before suggesting either ear drops.
Ear drops are frequently prescribed in the postoperative management of tympanoplasty, especially for episodes of acute otitis externa (5). In tympanoplasty, ear surgeons use different surgical techniques and different graft materials to repair the perforated TM (6). A large number of autologous tissues, homografts, and synthetic materials were described as graft options (7). Traditionally, temporalis muscle fascia and tragus cartilage have been widely used (8). According to the recent findings regarding quinolone ear drops (1,2), they could rationally increase the risk of recurrent TM perforations after tympanoplasty, especially when collagenous tissues (i.e., fascia and cartilage) have been grafted for reparation of the TM.
Until we will not have a deeper understanding regarding the safety of quinolone topical applications on the ear, it is our opinion that, in the presence of an intact repair TM after tympanoplasty, ear surgeons should consider to prescribe aminoglycoside over quinolone ear drops to reduce the risk of a recurrent TM perforation.

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