amoxicillin-potassium-clavulanate-combination and Otitis-Media--Suppurative

Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and often polymicrobial infection (involving more than one micro-organism) of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Antibiotics are the most common treatment for CSOM, which act to kill or inhibit the growth of micro-organisms that may be responsible for the infection. Antibiotics can be administered both topically and systemically, and can be used alone or in addition to other treatments for CSOM such as ear cleaning (aural toileting).. To assess the effects of topical versus systemic antibiotics for people with CSOM.. The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 16 March 2020.. We included randomised controlled trials (RCTs) with at least a one-week follow-up involving patients (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The studies compared topical antibiotics against systemic (oral, injection) antibiotics. We separated studies according to whether they compared the same type of antibiotic in both treatment groups, or different types of antibiotics. For each comparison we considered whether there was background treatment for both treatment groups, for example aural toileting (ear cleaning).. We used the standard Cochrane methodological procedures. We used GRADE to assess the certainty of the evidence for each outcome. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not, measured at between one week and up to two weeks, two weeks up to four weeks, and after four weeks), health-related quality of life using a validated instrument, ear pain (otalgia) or discomfort or local irritation. Secondary outcomes included hearing, serious complications and ototoxicity measured in several ways.. Six studies (445 participants), all with high risk of bias, were included. All but two studies included patients with confirmed CSOM, where perforation of the ear drum was clearly documented. None of the studies reported results for resolution of ear discharge after four weeks or health-related quality of life. 1. Topical versus systemic administration of the same type of antibiotics (quinolones) Four studies (325 participants) compared topical versus systemic (oral) administration of ciprofloxacin. Three studies reported resolution of ear discharge at one to two weeks and found that the topical administration may slightly increase resolution (risk ratio (RR) 1.48, 95% confidence interval (CI) 1.24 to 1.76; 285 participants; 3 studies; I. There was a limited amount of low-quality evidence available, from studies completed over 15 years ago, to examine whether topical or systemic antibiotics are more effective in achieving resolution of ear discharge for people with CSOM. However, amongst this uncertainty there is some evidence to suggest that the topical administration of antibiotics may be more effective than systemic administration of antibiotics in achieving resolution of ear discharge (dry ear). There is limited evidence available regarding different types of antibiotics. It is not possible to determine with any certainty whether or not topical quinolones are better or worse than systemic aminoglycosides. These two groups of compounds have different adverse effect profiles, but there is insufficient evidence from the included studies to make any comment about these. In general, adverse effects were poorly reported.

Topics: Administration, Topical; Adult; Aminoglycosides; Amoxicillin-Potassium Clavulanate Combination; Anti-Bacterial Agents; Bias; Child; Chronic Disease; Humans; Ofloxacin; Otitis Media, Suppurative; Quinolones; Randomized Controlled Trials as Topic; Time Factors

The insertion of grommets (also known as ventilation or tympanostomy tubes) is one of the most common surgical procedures performed on children. Postoperative otorrhoea (discharge) is the most common complication with a reported incidence ranging from 10% to 50%. In the UK, many ENT surgeons treat with topical antibiotics/steroid combinations, but general practitioners, mainly through fears of ototoxicity, are unlikely to prescribe these and choose systemic broad-spectrum antibiotics.. 1. To identify the most effective non-surgical management of discharge from ears with grommets in place.2. To identify the risks of non-surgical management for this condition (e.g. ototoxicity), and to set benefits of treatment against these risks.. We searched the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2005), MEDLINE (1966 to 2005) and EMBASE (1974 to 2005). We also searched the CINAHL, AMED, LILACS, ISI WEB OF KNOWLEDGE, ISI PROCEEDINGS, mRCT, NNR, ZETOC, KOREAMED, CSA, MEDCARIB, INDMED and SAMED databases. The date of the last search was February 2005.. Randomised controlled trials of adults or children, with any type of grommet and an ear with discharge were included. The trials compared treatment with placebo or one treatment with another. The primary outcome measure was the duration of the discharge.. The trials were selected independently according to the above criteria by the four reviewers. Differences in opinion over the inclusion of studies were resolved by discussion. The studies were graded using the CASP critical appraisal tool. Analyses were based on the presence of discharge seven days from the onset of treatment.. There was very little good quality evidence. Four studies were included, all of them investigating different interventions and therefore a meta-analysis was not possible.Only one study demonstrated a significant difference. Oral amoxicillin clavulanate was compared to placebo in 79 patients. The odds of having a discharge persisting eight days after starting treatment was 0.19 (95% CI 0.07 to 0.49) . The number needed to treat to achieve that benefit is 2.5. Participants in both arms of this study also received daily aural toilet. The results will therefore not be applicable to most settings including primary care. No significant benefit was shown in the two studies investigating steroids (oral prednisolone with oral amoxicillin clavulanate and topical dexamethasone with topical ciprofloxacin ear drops), or the one study comparing an antibiotic-steroid combination (Otosporin®) drops versus spray (Otomize®) (although more patients preferred the spray form).. The authors of this review have been unable to identify the most effective intervention or to assess the associated risks. Research is urgently needed into the effectiveness of oral versus topical antibiotics in this group of patients. Clinicians considering antibiotic treatment need to balance any potential benefit against the risks of side effects and antibiotic resistance.

Topics: Adult; Amoxicillin-Potassium Clavulanate Combination; Anti-Bacterial Agents; Cerebrospinal Fluid Otorrhea; Child; Ciprofloxacin; Dexamethasone; Drug Combinations; Humans; Hydrocortisone; Middle Ear Ventilation; Neomycin; Otitis Media, Suppurative; Polymyxin B; Randomized Controlled Trials as Topic; Tympanic Membrane Perforation

The insertion of grommets (also known as ventilation or tympanostomy tubes) is one of the most common surgical procedures performed on children. Postoperative otorrhoea (discharge) is the most common complication with a reported incidence ranging from 10% to 50%. In the UK, many ENT surgeons treat with topical antibiotics/steroid combinations, but general practitioners, mainly through fears of ototoxicity, are unlikely to prescribe these and choose systemic broad-spectrum antibiotics.. 1. To identify the most effective non-surgical management of discharge from ears with grommets in place.2. To identify the risks of non-surgical management for this condition (e.g. ototoxicity), and to set benefits of treatment against these risks.. We searched the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2005), MEDLINE (1966 to 2005) and EMBASE (1974 to 2005). We also searched the CINAHL, AMED, LILACS, ISI WEB OF KNOWLEDGE, ISI PROCEEDINGS, mRCT, NNR, ZETOC, KOREAMED, CSA, MEDCARIB, INDMED and SAMED databases. The date of the last search was February 2005.. Randomised controlled trials of adults or children, with any type of grommet and an ear with discharge were included. The trials compared treatment with placebo or one treatment with another. The primary outcome measure was the duration of the discharge.. The trials were selected independently according to the above criteria by the four reviewers. Differences in opinion over the inclusion of studies were resolved by discussion. The studies were graded using the CASP critical appraisal tool. Analyses were based on the presence of discharge seven days from the onset of treatment.. There was very little good quality evidence. Four studies were included, all of them investigating different interventions and therefore a meta-analysis was not possible. Only one study demonstrated a significant difference. Oral amoxicillin clavulanate was compared to placebo in 79 patients. The odds of having a discharge persisting eight days after starting treatment was 0.19 (95% CI 0.07 to 0.49) . The number needed to treat to achieve that benefit is 2.5. Participants in both arms of this study also received daily aural toilet. The results will therefore not be applicable to most settings including primary care. No significant benefit was shown in the two studies investigating steroids (oral prednisolone with oral amoxicillin clavulanate and topical dexamethasone with topical ciprofloxacin ear drops), or the one study comparing an antibiotic-steroid combination (Otosporin(R)) drops versus spray (Otomize(R)) (although more patients preferred the spray form).. The authors of this review have been unable to identify the most effective intervention or to assess the associated risks. Research is urgently needed into the effectiveness of oral versus topical antibiotics in this group of patients. Clinicians considering antibiotic treatment need to balance any potential benefit against the risks of side effects and antibiotic resistance.

Topics: Adult; Amoxicillin-Potassium Clavulanate Combination; Anti-Bacterial Agents; Cerebrospinal Fluid Otorrhea; Child; Ciprofloxacin; Dexamethasone; Drug Combinations; Humans; Hydrocortisone; Middle Ear Ventilation; Neomycin; Otitis Media, Suppurative; Polymyxin B; Randomized Controlled Trials as Topic; Tympanic Membrane Perforation

The role of routine antimicrobial treatment of acute middle-ear infections is under debate, because the efficacy of antimicrobials in the resolution of middle-ear fluid has not been unambiguously proven. Acute tube otorrhea is regarded as evidence of acute otitis media, and for methodologic reasons it was chosen to provide objectivity for diagnostics and outcome assessment. The objective of this study was to assess whether amoxicillin-clavulanate accelerates the resolution of acute tube otorrhea.. Randomized, double-blind, placebo-controlled study in outpatient setting.. Volunteer sample of basically healthy 6- to 72-month-old children with a tympanostomy tube. Eligibility required having acute tube otorrhea of <48 hours' of duration and no prior treatment within the last 2 weeks. The mean age of the participants was 25 months; they had a history of 3 episodes of acute otitis media (median), and 99% had manifestations of a concomitant respiratory infection. Of 79 randomized patients, 7 were withdrawn because of adverse events; 66 patients completed the study.. Amoxicillin-clavulanate (N = 34; 45 mg/kg/d) or matching placebo (N = 32) for 7 days and daily suction of middle-ear fluid through tympanostomy tube.. Duration of acute tube otorrhea and duration of bacterial growth in middle-ear fluid.. The median duration of tube otorrhea was significantly shorter in amoxicillin-clavulanate than in the placebo group (3 vs 8 days). At the end of the 7-day medication period, tube otorrhea was resolved in 28 of 34 children receiving amoxicillin-clavulanate compared with 13 of 32 children on placebo (treatment-control difference 41%; 95% confidence interval, 20%-63%; number needed to treat, 2.4). The median duration of bacterial growth in middle-ear fluid was shorter in amoxicillin-clavulanate than in the placebo group (1 vs 8 days).. Oral antibiotic treatment significantly accelerates the resolution of acute tube otorrhea by reducing bacterial growth in middle-ear fluid.

Topics: Acute Disease; Amoxicillin-Potassium Clavulanate Combination; Child; Child, Preschool; Double-Blind Method; Drug Administration Schedule; Drug Therapy, Combination; Female; Gram-Negative Bacterial Infections; Haemophilus Infections; Haemophilus influenzae; Humans; Infant; Male; Middle Ear Ventilation; Moraxella catarrhalis; Otitis Media, Suppurative; Pneumococcal Infections; Streptococcus pneumoniae

Otorrhea occurs in 21 to 50% of all children with tympanostomy tubes in the United States. More than 1 million children annually undergo tubomyringotomy, constituting placement of more than 2 million tympanostomy tubes each year. The organisms typically responsible for otorrhea are the same as those that cause otitis media in very young children, including Streptococcus pneumonia, Haemophilus influenzae and Moraxella catarrhalis. Drainage from tympanostomy tubes in older children involves organisms that colonize the external auditory canal, the most common being Pseudomonas aeruginosa and Staphylococcus aureus. Ofloxacin (Floxin otic), a newer fluoroquinalone antibiotic, has several advantages over other agents available for the treatment of otorrhea caused by acute otitis media in patients with tympanostomy tubes. The twice daily dosing regimen encourages better patient adherence to therapy, which is likely to improve treatment efficacy. Ofloxacin has not been associated with ototoxicity in animal models or in children participating in the clinical trials. It provides coverages for a wide range of pathogens, including Pseudomonas sp., and is indicated for use in children > or =1 year old and currently approved for patients > or =12 years with chronic suppurative otitis media. Ofloxacin applied topically in children with tympanostomy tubes in place and purulent otorrhea is as efficacious as oral amoxicillin/clavulanate (Augmentin) therapy. Other currently available therapeutic options are discussed.

Topics: Acute Disease; Amoxicillin-Potassium Clavulanate Combination; Anti-Infective Agents; Child; Child, Preschool; Drug Administration Schedule; Drug Therapy, Combination; Female; Humans; Infant; Male; Middle Ear Ventilation; Ofloxacin; Otitis Media, Suppurative; Pseudomonas; Treatment Outcome; United States

Two dosage regimens of cefdinir were compared with amoxicillin/clavulanate for the treatment of suppurative acute otitis media (AOM) in children.. This was an investigator-blinded, randomized, comparative, multicenter trial, in which tympanocentesis was performed in 384 patients, ages 6 months to 12 years, who had nonrefractory AOM. Patients were randomized to receive one of three 10-day treatment regimens: cefdinir 14 mg/kg daily (QD; n = 128); cefdinir 7 mg/kg twice a day (BID; n = 128); or amoxicillin/clavulanate 40/10 mg/kg/day divided for use three times a day (TID; n = 128).. Of the 384 enrolled patients 303 were evaluable for clinical efficacy. Clinical success rates were statistically equivalent for the 3 treatment groups at the end of therapy: 85 of 102 (83.3%) for cefdinir QD; 81 of 101 (80.2%) for cefdinir BID; 86 of 100 (86%) for amoxicillin/clavulanate. Of the 197 evaluable patients from whom a susceptible pathogen was recovered, presumptive eradication rates at end of therapy were equivalent: 55 of 65 (84.6%), 54 of 66 (81.8%) and 55 of 66 (83.3%) for cefdinir QD-, cefdinir BID- and amoxicillin/clavulanate-treated patients, respectively. However, presumptive eradication rates for Streptococcus pneumoniae were significantly lower for cefdinir BID (55.2%) than for amoxicillin/clavulanate (89.5%; P = 0.0019) and marginally lower than for cefdinir QD (80%; P = 0.054). Diarrhea was the most common treatment-associated adverse reaction in all groups but was significantly more common in amoxicillin/clavulanate-treated patients (35%) than in patients who had been treated with cefdinir QD (10%, P<0.001) or cefdinir BID (13%, P<0.001).. A 10-day regimen of cefdinir 14 mg/kg QD or 7 mg/kg BID was as clinically effective overall as a 10-day regimen of amoxicillin/ clavulanate 40/10 mg/kg/day divided TID in the treatment of tympanocentesis-confirmed, nonrefractory AOM in children. These data suggest that cefdinir QD may be a better alternative than cefdinir BID for refractory AOM. Both dosing regimens of cefdinir were associated with significantly fewer gastrointestinal adverse reactions than was amoxicillin/clavulanate.

Topics: Acute Disease; Amoxicillin-Potassium Clavulanate Combination; Cefdinir; Cephalosporins; Child; Child, Preschool; Drug Therapy, Combination; Female; Humans; Infant; Male; Otitis Media, Suppurative; Treatment Outcome

An investigator-blinded, randomized, multicenter study was conducted to compare the efficacy and safety of cefdinir and amoxicillin/ clavulanate (amoxicillin/CA) in the treatment of pediatric patients with acute suppurative otitis media. Patients 6 months to 12 years of age were randomized in a 1:1:1 ratio to receive cefdinir 14 mg/kg once-daily, cefdinir 7 mg/kg b.i.d., or amoxicillin/CA 13.3 mg/kg t.i.d. Test-of-cure was determined 11 to 16 days posttherapy. Of the 752 patients who entered the study, 665 (88%) completed treatment and 595 (79%) were evaluable. Response rates in the three treatment groups were similar. Overall rates of adverse events were statistically lower in the cefdinir once-daily group than in the amoxicillin/CA group. Diarrhea was the most common adverse event in all treatment groups. Cefdinir given either once-daily or twice-daily is a safe and effective treatment for pediatric patients with acute suppurative otitis media.

Topics: Acute Disease; Amoxicillin-Potassium Clavulanate Combination; Cefdinir; Cephalosporins; Child; Child, Preschool; Drug Therapy, Combination; Female; Humans; Infant; Male; Otitis Media, Suppurative; Treatment Outcome

Acute otitis media (AOM) in children with tympanostomy tubes in place typically presents with otorrhea (draining ear). Because therapy is not standardized, various topical and systemic antibiotics of unproven efficacy and safety have been used in this indication. This study compared the safety and efficacy of ofloxacin otic solution, 0.3% (OFLX) with that of Augmentin oral suspension (AUG) in pediatric subjects 1-12 years of age with tympanostomy tubes and acute purulent otorrhea. Subjects were randomized to receive 10d of OFLX, 0.25 ml topically bid, or of AUG, 40 mg/kg per day. Audiometry was performed in subjects > or =4 years of age. Overall cure rate for clinically evaluable subjects was 76% with OFLX (n = 140) and 69% with AUG (n = 146; P = 0.169). Overall eradication rates for OFLX and AUG were similar for Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis and were superior with OFLX for Staphylococcus aureus and Pseudomonas aeruginosa (P<0.05 for both). OFLX had a greater overall pathogen eradication rate (96% vs. 67%; P<0.001). Treatment-related adverse event rates were 31% for AUG and 6% for OFLX (P<0.001). Neither treatment significantly altered hearing acuity. Topical ofloxacin 0.3% otic solution 0.25 ml bid was as effective and better tolerated than systemic therapy with Augmentin oral suspension 40 mg/kg per day in treating AOM in children with tympanostomy tubes.

Topics: Acute Disease; Administration, Oral; Administration, Topical; Amoxicillin-Potassium Clavulanate Combination; Anti-Infective Agents; Audiometry; Bacterial Infections; Child, Preschool; Drug Therapy, Combination; Female; Humans; Male; Middle Ear Ventilation; Ofloxacin; Otitis Media, Suppurative

Topics: Amoxicillin; Amoxicillin-Potassium Clavulanate Combination; Child; Child, Preschool; Combined Modality Therapy; Double-Blind Method; Drug Therapy, Combination; Female; Humans; Infant; Male; Otitis Media with Effusion; Otitis Media, Suppurative; Penicillins; Treatment Outcome

The efficacy and tolerability of ciprofloxacin (500 mg twice daily) was compared with that of amoxycillin/clavulanic acid (500 mg three times daily) in 76 patients with acute exacerbations of chronic non-cholesteatomatous suppurative otitis media enrolled in this open randomized multicentre trial. A total of 40 ciprofloxacin-treated patients and 35 amoxycillin/clavulanic acid-treated patients were evaluable for clinical efficacy following the 9-day treatment period. Pseudomonas aeruginosa was the main pathogen isolated prior to treatment. At the end of treatment, otorrhoea had disappeared in 57.5% of the ciprofloxacin group and 37.1% of the amoxycillin/clavulanic acid group (p = 0.04). Bacterial eradication rate was also significantly greater with ciprofloxacin (69.7%) than with amoxycillin/clavulanic acid (27.3%). Both treatments were well tolerated. Ciprofloxacin appears to be an effective treatment of chronic otitis media, and superior to amoxycillin/clavulanic acid.

Topics: Adult; Amoxicillin; Amoxicillin-Potassium Clavulanate Combination; Bacterial Infections; Chronic Disease; Ciprofloxacin; Clavulanic Acids; Drug Therapy, Combination; Female; Humans; Male; Middle Aged; Otitis Media, Suppurative; Pseudomonas Infections; Time Factors

This report presents a prospective randomized study of 0.3 percent ofloxacin eardrops for the treatment of active chronic suppurative otitis media. Twenty-nine patients were treated with ofloxacin eardrops for 1 week, and another 27 patients were treated with Augmentin for 1 week. One week after completion of treatment, 22 (76%) patients of the group treated with ofloxacin had dry ears, and only seven (26%) patients treated with Augmentin had dry ears. Ofloxacin eardrops were effective in the initial treatment of active chronic suppurative otitis media.

Topics: Administration, Oral; Adolescent; Adult; Aged; Amoxicillin; Amoxicillin-Potassium Clavulanate Combination; Anti-Infective Agents; Chronic Disease; Clavulanic Acids; Drug Therapy, Combination; Female; Humans; Instillation, Drug; Male; Middle Aged; Ofloxacin; Otitis Media, Suppurative; Prospective Studies; Severity of Illness Index

Otitis media is a more frequent occurrence in children, and the disease may progress from an acute to chronic state if appropriate and timely intervention is not initiated.. A total of 212 children aged 6 months to 10 years were examined and treated for otitis media, in a 13-month hospital-based study.. Acute otitis media was diagnosed in 130 (61.3 per cent) of the patients. There were 82 (38.7 per cent) chronic suppurative otitis media cases. The incidence of acute otitis media and chronic suppurative otitis media in the first year of life was 54.6 per cent and 45.1 per cent respectively. Chronic suppurative otitis media patients were assigned to one of three treatment groups. Recovery occurred in 70.4 per cent of amoxicillin-treated patients, in 88.9 per cent of amoxicillin-clavulanic acid treated patients and in 96.4 per cent of culture and antibiotic sensitivity test patients. Relapses were seen only in the amoxicillin (five cases) and amoxicillin-clavulanic acid (two cases) groups.. The success rate in patients treated with antibiotics makes this option mandatory for an established diagnosis.

Topics: Acute Disease; Amoxicillin; Amoxicillin-Potassium Clavulanate Combination; Child; Child, Preschool; Chronic Disease; Female; Humans; Infant; Male; Microbial Sensitivity Tests; Nigeria; Otitis Media; Otitis Media, Suppurative

Topics: Amoxicillin; Amoxicillin-Potassium Clavulanate Combination; Female; Humans; Male; Microbial Sensitivity Tests; Otitis Media; Otitis Media, Suppurative

Topics: Amoxicillin; Amoxicillin-Potassium Clavulanate Combination; Female; Humans; Male; Microbial Sensitivity Tests; Otitis Media; Otitis Media, Suppurative

Topics: Administration, Oral; Administration, Topical; Adrenal Cortex Hormones; Amoxicillin-Potassium Clavulanate Combination; Bacitracin; Bacterial Infections; Child, Preschool; Colistin; Germany; Humans; Hydrocortisone; Middle Ear Ventilation; Otitis Media, Suppurative; Postoperative Complications; Randomized Controlled Trials as Topic

The objective of this paper is to present and discuss the common features of temporal petrositis and the different approaches to its management. Petrositis used to be common before the antibiotic era. It can be associated with life-threatening complications. The management of this problem used to be by an aggressive surgical approach. However, recent reports are describing good results with more conservative medical treatment and minimal surgical intervention, with the reservation of more aggressive surgical interventions for chronic or refractory cases.

Topics: Amoxicillin-Potassium Clavulanate Combination; Anti-Bacterial Agents; Cefaclor; Cephalosporins; Child; Humans; Male; Middle Ear Ventilation; Ocular Motility Disorders; Otitis Media, Suppurative; Petrous Bone; Recurrence; Tomography, X-Ray Computed

To compare advice given by specialist otolaryngologists to patients following ventilation tube insertion and the management of purulent otorrhoea in these patients.. A postal questionnaire was sent to all 59 specialists currently listed in the New Zealand Otolaryngology Specialist Register.. 96.5% of specialist otolaryngologists replied, 88% in sufficient detail for analysis in this study. The vast majority (96%) allowed patients to swim with tubes in situ, and all allowed hair washing. Advice for ear protection varied. If otorrhoea develops with ventilation tubes in situ, 90% of specialists advise patients to stop swimming, but allow hair washing to continue with ear protection. Ninety percent of specialists' initial treatment of otorrhoea involves a combination of suction toilet and topical steroid/antibiotic drops.. In general, specialist otolaryngologists in New Zealand give similar advice to patients with ventilation tubes. However, the specific methods of ear protection advised when swimming and hair washing varies markedly.

Topics: Amoxicillin; Amoxicillin-Potassium Clavulanate Combination; Anti-Inflammatory Agents; Attitude of Health Personnel; Betamethasone; Clavulanic Acids; Dexamethasone; Drug Combinations; Drug Therapy, Combination; Ear Protective Devices; Framycetin; Gramicidin; Hair Preparations; Humans; Middle Ear Ventilation; Neomycin; New Zealand; Otitis Media, Suppurative; Otolaryngology; Recurrence; Swimming