Patient Presentation
A 14-year-old male came to clinic with a history of mild ear pain and drainage for a couple of days. He noticed that there was an increasing strong odor to the drainage which was increasing in amount. He had had some otitis media as a young child and one instance of otitis externa after swimming in a lake; none of which caused any complications. He denied any recent swimming but had noticed that he would have some intermittent “plugging” of his ear over the last several months.
The pertinent physical exam showed a healthy male with normal vital signs. He had yellow thinnish fluid from his right ear. There was some pain with pushing on the tragus. There was also a fair amount of cerumen.
The diagnosis of probable otitis media was made. His ear was irrigated with warm hydrogen peroxide in water and re-examination showed a normal tympanic membrane but a very irritated ear canal. He was started on quinolone ear drops.
The patient’s clinical course showed that he returned at the end of 5 days stating that the ear drops had improved the drainage and pain initially, but for the past day the drainage had recurred. The physical examination showed a similar ear canal with debris. The otolaryngologist in the same building was able to see him that day. His ear canal was debrided and boric acid powder applied. He was to restart another course of topical antibiotics in 24-48 hours. A few weeks later, he said that the drainage resolved after the otolaryngologist’s treatment.
Discussion
Boron is possibly an essential trace element for humans and is found in water and plants. Common sources are apples, beans (cooked and dried), coffee, fruits, milk, and potatoes. Borates are used as cleaning agents, fertilizers, greasing agents, food preservatives, in fiberglass production, as an insecticide, and even to help prevent wet and dry rot in wood. They can be used to acidify or thicken fluids.
Toxic borate exposure can occur through inhalation, or oral and dermal routes with non-intact skin being a bigger problem. Borate toxicity can cause abdominal pain, diarrhea, emesis, fever, irritability, seizures, and death. Borates can cause skin irritation and there can be some reproductive changes as well.
Learning Point
Boric acid is used as an antiseptic on the skin, and in mucous membranes including very dilute solutions for eyes, mouth and for bacterial vaginosis. It is also used in ear infections often in addition to antibiotics to help change the pH and also act as a local drying agent in addition to its antiseptic qualities. The most recent (2020) Cochrane Collaboration review states, “[t]reatment of [chronic suppurative otitis media] with topical antibiotics (quinolones) probably results in an increase in resolution of ear discharge compared with boric acid at up to two weeks.” They also reviewed other topical antiseptics such as acetic acid, povidone-iodine and aluminum acetate (Burow’s solution) but it was “…not possible to know whether there is a difference between the groups for any other outcome.” Another study from 2016 which looked at in vitro antimicrobial activity of common antiseptic eardrops against Staphylococcus aureus and quinolone-resistant Pseudomonas aeruginosa found that Burow’s solution had the highest antimicrobial activity “…followed by 2% acetic acid, vinegar with water (1:1) and 4% boric acid.””
Questions for Further Discussion
1. What topical antiseptics do you use in your clinical practice?
2. How do you treat otitis externa?
Related Cases
- Disease: Ear Infections
- Symptom/Presentation: Ear Pain
- Specialty: Otolaryngology | Infectious Diseases
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Minerals.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Office of Dietary Supplements – Boron. Accessed April 11, 2023. https://ods.od.nih.gov/factsheets/Boron-HealthProfessional/
Youn CK, Jang SJ, Jo ER, Choi JA, Sim JH, Cho SI. Comparative antibacterial activity of topical antiseptic eardrops against methicillin-resistant Staphylococcus aureus and quinolone-resistant Pseudomonas aeruginosa. Int J Pediatr Otorhinolaryngol. 2016;85:80-83. doi:10.1016/j.ijporl.2016.03.031
Powell A, Ghanem KG, Rogers L, et al. Clinicians’ use of Intravaginal Boric Acid Maintenance Therapy for Recurrent Vulvovaginal Candidiasis and Bacterial Vaginosis. Sex Transm Dis. 2019;46(12):810-812. doi:10.1097/OLQ.0000000000001063
Antibiotics versus topical antiseptics for chronic suppurative otitis media – PMC. Accessed April 11, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6956626/
Hadrup N, Frederiksen M, Sharma AK. Toxicity of boric acid, borax and other boron containing compounds: A review. Regul Toxicol Pharmacol. 2021;121:104873. doi:10.1016/j.yrtph.2021.104873
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa