Can vinegar be used in treating Pseudomonas ear infections in a patient with a perforated eardrum?

6/29/17, 5:42 PM

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Can vinegar be used in treating Pseudomonas ear

infections in a patient with a perforated eardrum?
By Muhamed Aslam Khan, MS, MRCSEd; Nazneen Khan, MBBS, DGO, DRCOG

Introduction
Chronic Pseudomonas infection of the ear in humans is difficult to treat, especially in immunodeficient patients. This
infection has remained resistant to many modalities of treatment, leading to frustration for patients and physicians
alike. Pseudomonas organisms can be killed in an acidic environment, which can be created with substances such as
vinegar.1-5

Vinegar has been used by veterinarians in the successful treatment of Pseudomonas ear infections in canines.
Similarly, it is well known that sterile vinegar can be used in the treatment of human infections.1-5 However, its
benefits are limited by the reluctance of some clinicians to use it in patients who have a perforated eardrum.
Moreover, the use of vinegar is discouraged because it can cause a burning sensation in the ear.

In this article, we report the successful use of vinegar in treating a case of a chronic Pseudomonas ear infection in an
immunocompromised patient who had a perforation of the tympanic membrane.

Case report
A 32-year-old man presented with intermittent high-grade fever, weight loss, joint pains, complex partial seizures, and
a perforation of the right eardrum, which was associated with a loss of hearing and a serosanguineous discharge.
Findings on audiometry were consistent with a right-sided hearing loss secondary to a tympanic membrane
perforation (figure 1). The right ear discharge revealed tuberculous bacilli on acid-fast bacilli staining. Aspirate
obtained from the affected joints was also positive for tuberculosis. Magnetic resonance imaging of the brain detected
lesions suggestive of multiple tuberculomas, with a collection in the right mastoid cavity and middle ear. A chest x-ray
demonstrated miliary mottling in both lungs.

Figure 1. At presentation, audiometry shows the hearing

loss in the right ear.

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Can vinegar be used in treating Pseudomonas ear infections in a patient with a perforated eardrum? 6/29/17, 5:42 PM

On the basis of all these findings, we diagnosed the patient with disseminated tuberculosis. He was started on
antituberculosis therapy along with a corticosteroid and an antiepileptic. He underwent an urgent right modified radical
mastoidectomy to evacuate the collection in the mastoid cavity, as well as to clear the granulation debris in the right
middle ear. The damaged ossicles had to be removed. A tympanoplasty was performed with temporal fascia.

At 1 month postoperatively, the patient developed a perforation in the tympanic membrane graft and a persistent
serosanguineous discharge. Microscopic examination of the fluid identified many gram-negative bacilli and pus cells.
No fungal hyphae or yeast cells were found. Culture and sensitivity testing revealed that the patient had an acquired
Pseudomonas infection that was resistant to most of the cephalosporins, but sensitive to most of the quinolones and
aminoglycosides. Regular aural toilet and various combinations of antibiotics were undertaken in addition to other
supportive measures, but since the patient was immunocompromised, the infection persisted.

For the next 3 years, a corticosteroid had to be given on an intermittent basis to control flare-ups of the paradoxical
immune granuloma at the brain tuberculoma sites. The patient remained on the antiepileptic agent. In view of the
severity of his presenting illness and the prolonged treatment with the corticosteroid, there appeared to be no way to
control the Pseudomonas ear infection. Eventually, the patient lost the last remnant of hearing in his right ear, and
audiometry showed profound deafness (figure 2).

Figure 2. Five years after presentation, audiometry shows

the loss of the last remnant of hearing in the right ear.

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Can vinegar be used in treating Pseudomonas ear infections in a patient with a perforated eardrum? 6/29/17, 5:42 PM

At that point, we tried treating the ear with a 2% vinegar solution. By then, the severity and chronicity of the ear
infection had led to exposure of the chorda tympani and allowed the perforation of the tympanoplasty to persist. The
patient was made aware of the side effects of vinegar therapy, and he provided informed consent prior to treatment.

The volume of the application was based on the size of the mastoid cavity, which for our patient was approximately
0.25 ml; this volume was just sufficient to smear the mastoid cavity and fill the inner one-third of the ear canal. The
vinegar was instilled into the right ear canal twice daily only under strict observation, since this was not a conventional
treatment and because the patient had gross immunosuppression. The drops were left in situ for 15 minutes and then
drained completely (dependent drainage). Then the pinna was wiped with sterile cotton.

Therapy was continued for 3 weeks, and the ear infection cleared. Examination of ear swabs confirmed eradication of
the Pseudomonas organisms. At that point, the patient developed an infection with Candida albicans and
Staphylococcus aureus, but it completely cleared in 5 days with appropriate antibiotics.

Discussion
Chronic Pseudomonas ear infections remain a common clinical challenge to practitioners in treating immunodeficient
patients such as those with diabetes, severe disseminated illness, malignancies, etc. Vinegar therapy is a time-tested
measure for the treatment of these infections.1-5 It is inexpensive, simple, easy to administer, and very effective. Its
side effects are negligible; a burning sensation is the most common, but it is generally well tolerated by patients. The
benefits of vinegar therapy far outweigh the side effects, and clinicians should not be hesitant to use it in very severe
or chronic infections, especially in immunocompromised patients.

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Can vinegar be used in treating Pseudomonas ear infections in a patient with a perforated eardrum? 6/29/17, 5:42 PM

Our patient had an exposed chorda tympani and a perforation of the eardrum, yet he did not develop any neurologic
symptoms subsequent to the vinegar treatment. Our patient did experience a profound hearing loss before we
instituted the vinegar treatment; perhaps this might have been prevented if we had instituted vinegar therapy earlier.

In conclusion, we suggest that vinegar in the recommended clinical concentration can be used with caution in patients
with a perforated eardrum and intact hearing.

References
1. Lang U. Minimal inhibitory concentration of natural vinegar and of aluminium acetate-tartrate solution. Otol Neurol
2013; 34 (5): 795-7.
2. Washington E A. Instillation of 3% hydrogen peroxide or distilled vinegar in urethral catheter drainage bag to
decrease catheter-associated bacteriuria. Biol Res Nurs 2001; 3 (2): 78-87.
3. Jung H H, Cho S D, Yoo C K ,et al. Vinegar treatment in the management of granular myringitis. J Laryngol Otol
2002; 116 (3): 176-80.
4. Madhusudhan V L. Efficacy of 1% acetic acid in the treatment of chronic wounds infected with Pseudomonas
aeruginosa: Prospective randomised controlled clinical trial. Int Wound J 2015 Apr. 8 [Epub ahead of print].
5. Clayton M I, Osborne J E, Rutherford D, Rivron R P. A double-blind, randomized, prospective trial of a topical
antiseptic versus a topical antibiotic in the treatment of otorrhoea. Clin Otolaryngol Allied Sci 1990; 15 (1): 7-10.

From the Department of General Practice, Al Ameen Hospital, Trichy, Tamil Nadu, India.
Corresponding author: Dr. Muhamed Aslam Khan, Department of General Practice, Al Ameen Hospital, 16/31
Anaikatti Maidan, Beema Nagar, Trichy, Tamil Nadu, India 620001. Email: aslamneenu@gmail.com
(mailto:aslamneenu@gmail.com)
Ear Nose Throat J. 2015 August;94(8):E52

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