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Evaluation of otoscope cone cleaning and disinfection

procedures commonly used in veterinary medical


practices: a pilot study
Blackwell Publishing Ltd

Heide M. Newton, Wayne S. Rosenkrantz,


Russell Muse and Craig E. Griffin
Animal Dermatology Clinic, Tustin, CA, USA
Correspondence: Heide M. Newton, Animal Dermatology Clinic, 2695
Edinger Avenue, Tustin, CA, USA.
E-mail: heidemarie@mindspring.com
Presented in ACVD Residents Session at April 2005
North American Veterinary Dermatology Forum Meeting.

Abstract
The objective of this study was to evaluate the relative
efficacy of otoscope cone cleaning and disinfection
methods commonly used in veterinary practices.
Using sterile technique, 60 new gas-sterilized 4-mm
otoscope cones were inoculated with a broth culture
of 1.5 billion Pseudomonas aeruginosa bacteria per mL
then allowed to dry for 10 min. Six study groups of
10 cones each were created. Group 1 served as positive control and received no cleaning or disinfection.
Group 2 cones were wiped with sterile cotton-tipped
applicators and gauze then rinsed with water. Group
3 cones were wiped with 70% isopropyl alcohol.
Group 4 cones were scrubbed in a speculum cleaner
with Cetylcide II solution (Cetylite Industries, Inc.,
Pennsauken, NJ). Groups 5 and 6 cones were soaked
for 20 min in Cetylcide II and chlorhexidine gluconate
2% solutions, respectively. Using sterile technique and
after 10 15 min drying time, the cones were swabbed
in a consistent pattern, and samples were submitted
for quantitative culture. Culture results showed no
growth from cones soaked in Cetylcide II or chlorhexidine solutions. Two of the 10 cones wiped with alcohol,
3/10 cones wiped then rinsed with water, and 3/10
cones scrubbed with the speculum cleaner showed
growth of P. aeruginosa. All (10/10) cones in the control group showed heavy growth of P. aeruginosa.
These results show that P. aeruginosa can survive on
otoscope cones cleaned and disinfected by several
commonly used methods. Further study is needed to
determine practical and optimal cleaning and disinfection methods for otoscope cones.
Received 25 September 2005; accepted 12 December 2005

cones often touch the ear canal and may become contaminated with microorganisms. Bacterial infection with
Pseudomonas aeruginosa, an aerobic, gram-negative
rod-shaped bacteria, is often associated with chronic otitis
externa and media in dogs.13 Pseudomonas organisms
are commonly isolated from the ear canals of dogs with
chronic otitis and are often highly resistant to antimicrobials.4,5 There is a concern that otoscope cones could
serve as a vector for the spread of infection, particularly
resistant infections, if the cones are inadequately cleaned
and disinfected.
Few would disagree that otoscope cones should be
free of pathogenic organisms when used. Although there
are no discovered studies in the veterinary literature
documenting nosocomial infection spread by otoscope
cones, human medical literature supports the concern for
potential iatrogenic inoculation of bacteria into a susceptible
ear canal. In one paper, external otitis caused by a methicillinresistant Staphylococcus aureus was reported in a nurse
after extensive use of a stethoscope.6 When the otitis recurred
after treatment, culture of the stethoscopes earpieces
revealed a similar organism. That study concluded that
bacterial colonization of the stethoscopes earpieces possessed the potential for causing nosocomial infections.6
Studies in human medical clinical settings showed that
some otoscopes, stethoscopes and other nondisposable
instruments were contaminated with potentially pathogenic
microorganisms, including P. aeruginosa and methicillinresistant S. aureus.69 One study examined the efficacy of
the cleaning techniques of nondisposable otolaryngology
equipment and found bacterial contamination of some
instruments after cleaning.7 Consequently, regular disinfection of these instruments is recommended to minimize
the risk of spreading infections to patients through contaminated equipment.69
A variety of methods are used to clean and disinfect
otoscope cones in veterinary practices. No studies were
discovered in veterinary literature that examined how to
clean and disinfect otoscope cones effectively. The purpose of this pilot study was to determine whether bacteria
could be cultured from otoscope cones cleaned and disinfected by several methods commonly used in Southern
California veterinary practices and to evaluate the relative
efficacy of those techniques.

Materials and methods


Introduction
Otoscopes are used everyday in veterinary medical
practices to examine healthy and infected ears. Otoscope

Preliminary survey
An informal telephone survey of 12 local veterinary medical practices
was conducted to determine commonly used methods of cleaning
and disinfecting otoscope cones. Over the phone, a veterinary

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H M Newton et al.

technician was asked to describe how that practice cleaned and


disinfected otoscope cones. The survey identified five predominant
methods, and those five methods were evaluated in this study.

Overview of study design


Six study groups were created: one positive control group and one
group for each of the five cleaning and disinfection methods identified
in the telephone survey. Ten cones were assigned to each group.
Using consistent and sterile technique, each cone was inoculated
with a bacterial broth and then treated according to its group assignment. Quantitative cultures of each cone were performed to assess
the relative efficacy of each cleaning and disinfection method.
Sixty new, individually wrapped, gas-sterilized 4-mm otoscope
cones were used. A broth culture of a strain of P. aeruginosa containing 1.5 billion bacteria per millilitre was obtained from the California
Microbiological Reference Laboratory. The same broth culture was
used to inoculate all 60 cones.
Sterile technique was employed throughout the study. Sterile surgical gloves and a surgical mask were worn, and a sterile drape was
used for the working field. All cones were handled with a sterile haemostat and placed into separate sterile containers.

1/50 mL (0.02 mL) loop of each saline sample, and each plate was
incubated for 24 h. The colonies were counted and multiplied by 50
to calculate the number of colonies per millilitre of saline. When more
than 100 colonies were present, a 1 : 100 dilution of the sample was
created. A 1/50 mL loop of the 1 : 100 dilution was then inoculated and
incubated again, and the number of colonies per millilitre was calculated
by multiplication by factors of 50 and 100 to account for the dilution.

Results
The culture results, shown in Table 1, were reported as
the numbers of colonies of P. aeruginosa per millilitre of
saline. All 10 of the group 1 positive control cones showed
growth of large numbers of colonies. In group 2 (dry wipe
and water rinse), 3 of the 10 cones showed growth of P.
aeruginosa. Two of the 10 cones in group 3 (alcohol wipe)
showed growth. Two of the 10 cones scrubbed in group 4
(speculum cleaner) showed growth. None of the cones in
groups 5 (Cetylcide soak) or 6 (chlorhexidine soak)
showed growth.

Inoculation technique
Each cone was inoculated with bacteria using the same technique.
Each cone was grasped at the otoscope attachment site with the sterile haemostat. Each cone was then vertically dipped into the centre of
a container filled with the bacterial broth until the narrow tip of the
cone touched the bottom of the container. Each cone was immediately removed from the broth and placed into a separate sterile container for 10 min to dry. After the 10 min of drying, each cone was
cleaned and disinfected according to its group assignment.

Study groups
Group 1 served as a positive control. These cones received no cleaning
or disinfection. Cones in group 1 were sampled for quantitative culture immediately after the 10 min of drying time.
Cones in group 2 (dry wipe and water rinse) were wiped down in a
single consistent motion with dry sterile gauze on the outer surface
and a dry sterile cotton-tipped applicator on the inner surface. The
cones were then rinsed with tap water.
Cones in group 3 (alcohol wipe) were wiped in the same pattern as
group 2 using sterile gauze and cotton-tipped applicators soaked in
70% isopropyl alcohol.
Cones in group 4 (speculum cleaner) were scrubbed five times by
being passed in and out of a S.Q.R.U.B. Speculum Cleaner (S.J.
Eganhouse Inc., Madison, WI) filled with freshly prepared, diluted
(15.6 mL L1) Cetylcide II solution (Cetylite Industries, Inc., Pennsauken, NJ).
Cones in group 5 (Cetylcide soak) were soaked for 20 min in a separate sterile containers filled with freshly prepared, diluted
(15.6 mL L1) Cetylcide II solution.
Cones in group 6 (chlorhexidine soak) were soaked for 20 min in a
separate sterile container filled with chlorhexidine gluconate 2%
solution.
Cones in groups 2 through 6 were placed into separate new sterile
containers for 1015 min of drying time following their group treatment.

The results of this study demonstrate that P. aeruginosa


can survive on otoscope cones cleaned and disinfected by
several commonly used methods. Specifically, cones in
groups 2 (dry wipe and water rinse), 3 (alcohol wipe), and
4 (speculum cleaner) showed growth. These results suggest that otoscope cones cleaned by these methods could
serve as vectors for the spread of infection. No growth
was seen in groups 5 (Cetylcide soak) or 6 (chlorhexidine
soak), suggesting that these methods were the most effective
of the five, given the conditions evaluated in this study.
The fact that all 10 cones in the positive control group
showed growth of large numbers of bacteria has important clinical significance. Those cones were allowed to
dry but were not cleaned or disinfected. After drying,
the cones appeared clean by routine visual inspection.
Despite the 10 min of drying, large numbers of viable
Pseudomonas organisms survived on these cones. These
results suggest that these positive control cones could
also have served as potential vectors of infection. Similarly, in the clinical practice setting, it may not always be
apparent whether an otoscope cone has been disinfected,
and unintentional use of a contaminated otoscope cone
that appears clean could serve to spread infection.
Several variables limit the interpretation of the results of
this pilot study. First, only five of the many possible cleaning and disinfection methods were employed. Also, there
Table 1. Number of viable colonies Pseudomonas aeruginosa per
millilitre of saline

Sampling for quantitative culture


Each cone was sampled for quantitative culture using the same technique. A sterile swab was moistened with sterile saline. Each cone was
swabbed in the same pattern on the inner and outer surfaces with the
moistened swab. The swab was passed along the inner surface in a spiral pattern, and the outer surface was swabbed with six longitudinal
passes followed by a swabbing of the narrow tip of the cone. The
swab was manually spun in a 5-mL sterile saline tube and then
pressed against the inside of the tube to express the saline, and this
process was performed twice. The saline was submitted to the laboratory for quantitative culture.
Quantitative cultures were performed using a calibrated loop
technique.10,11 Mueller-Hinton agar was inoculated with a calibrated

148

Discussion

Group 1

Group 2

Group 3

Group 4

Group 5

Group 6

250 000
190 000
155 000
120 000
120 000
115 000
110 000
110 000
100 000
45 000

2400
800
500

2500
150

3000
250

2006 The Authors. Journal compilation 2006 European Society of Veterinary Dermatology.

Otoscope cone cleaning and disinfection procedures

were only a small number of cones in each study group,


and only a single bacterial strain was used to inoculate the
cones. Moreover, in the opinion of a consulting statistician,
meaningful statistical analysis of the data was not possible
because of the small number of samples with a large
number of cones yielding no growth.
The controlled conditions of this study limit the conclusions that can be drawn for application to clinical veterinary practice. Ears are often infected by more than one
organism and may harbour highly resistant bacteria.
Also, infected ears usually contain excessive amounts of
organic material. The amount of organic material present
has major impact on the efficacy of most disinfectants.12
Consequently, soaking a cone coated with debris from an
infected ear canal for 20 min in disinfectant solution would
not be expected to prevent bacterial growth as reliably
as seen in this study. Additionally, in this study, only new
otoscope cones were used. In contrast, otoscope cones in
clinical practice are used multiple times and often acquire
surface scratches and other defects that may enhance
bacterial adherence and survival. It is likely that an optimal
method for the clinical setting will require thorough physical
cleaning to remove any organic debris prior to disinfection.12
The goal of this pilot study was to determine whether
bacteria could be cultured from otoscope cones cleaned
and disinfected by several commonly used techniques.
This study was not attempting to promote any particular
method but instead aimed to evaluate some of the methods that are currently being used. This study clearly shows
that Pseudomonas can survive on otoscope cones, and
consequently, inadequately cleaned or disinfected cones
could serve as a source of unintentional inoculation of bacteria into ear canals. More study is needed to determine
practical and optimal cleaning and disinfection methods
for otoscope cones used in veterinary practices.

Acknowledgements
The authors would like to thank Glenn Hutcheson of the
California Microbiological Reference Laboratory; Thereza

Escobedo, Veterinary Technician, Joel Griffies DVM,


DipACVD, Colleen Mendelsohn DVM, DipACVD and Mike
Canfield DVM of the Animal Dermatology Clinic, Tustin,
CA; Mona Boord DVM, DipACVD, Ann Trimmer DVM and
Brett Wildermuth DVM of the Animal Dermatology Clinic,
San Diego, CA.

References
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2. Scott DW, Miller WH, Griffin CE. Diseases of eyelids, claws, anal
sacs, and ears. In: Muller and Kirks Small Animal Dermatology,
6th edn. Philadelphia: W.B. Saunders, 2001: 12134.
3. Foster AP, DeBoer DJ. The role of Pseudomonas in canine ear
disease. Compendium 1998; 20: 90917.
4. Graham-Mize CA, Rosser Jr EJ. Comparison of microbial isolates
and susceptibility patterns from the external ear canal of dogs
with otitis externa. Journal of the American Animal Hospital Association 2004; 40: 1028.
5. Cole LK, Kwochka KW, Kowalski JJ et al. Microbial flora and antimicrobial susceptibility patterns of isolated pathogens from the
horizontal ear canal and middle ear in dogs with otitis media. Journal of the American Veterinary Medical Association 1998; 212:
5348.
6. Brook I. Bacterial flora of stethoscopes earpieces and otitis
externa. Annals of Otology, Rhinology, and Laryngology 1997;
106: 7512.
7. Powell S, Perry J, Meikle D. Microbial contamination of nondisposable instruments in otolaryngology out-patients. Journal of
Laryngology and Otology 2003; 117: 1225.
8. Cohen HA, Liora H, Paret G et al. Aurioscope earpieces a potential
vector of infection? International Journal of Pediatric Otorhinolaryngology 1998; 45: 4750.
9. Cohen HA, Amir J, Matalon A et al. Stethoscopes and otoscopes
a potential vector of infection? Family Practice 1997; 14: 446
9.
10. Vandepitte J, Verhaegen J, Engbaek K et al. Basic Laboratory Procedures in Clinical Bacteriology, 2nd edn. Geneva: World Health
Organization, 2003: 3233.
11. Forbes BA, Sahm DF, Weissfeld AS. Bailey and Scotts Diagnostic
Microbiology, 11th edn. St. Louis: Mosby, 2002: 9334.
12. Boothe HW. Antiseptics and disinfectants. Veterinary Clinics of
North America: Small Animal Practice 1998; 28: 23348.

Rsum Le but de cette tude tait dvaluer lefficacit compare des techniques de nettoyage et de
strilisation des cnes dotoscope en pratique vtrinaire. En utilisant une technique strile, 60 cnes
striles dotoscope de quatre millimtres ont t inoculs avec une culture de 1.5 billion Pseudomonas
aeruginosa/ml et laisss au sec pendant 10 minutes. Six groupes de 10 cnes ont t tudis. Le premier
groupe a servi de contrle positif et na pas t lav ni dsinfect. Les cnes du groupe 2 ont t nettoys
avec des cotons tiges striles et rincs leau. Les cnes du groupe 3 ont t nettoys avec de lalcool
70%. Les cnes du groupe 4 ont t nettoys avec un nettoyant pour speculum, le Cetylcide II (Cetylite
Industries, Inc., Pennsauken, NJ). Les cnes des groupes 5 et 6 ont t plongs pendant 20 minutes dans
le Cetylcide II et une solution 2% de gluconate de chlorhexidine respectivement. Strilement, et aprs
10/15 minutes de schage, les cnes ont t prlevs avec un couvillon qui ont t envoys au laboratoire
pour culture bactriologique. Les rsultats de la culture nont pas montr de pousse pour les cnes lavs
avec le Cetylcide II ou la chlorhexidine. 2/10 cnes nettoys lalcool, 3/10 cnes rincs leau et 3/10 cnes
nettoys avec le nettoyant pour spculum ont montr une pousse de P. aeruginosa. Tous (10/10) les cnes
du groupe contrle ont montr une pousse importante de P. aeruginosa. Ces rsultats montrent que
P. aeruginosa peut survivre sur les cnes dotoscope nettoys et dsinfects par des techniques classiques.
Des tudes supplmentaires sont indiques pour dterminer une technique pratique de nettoyage et de
dsinfection des cnes dotoscope.
Resumen El objetivo de este estudio fue evaluar la relativa eficacia de la limpieza y desinfeccin de conos
del otoscopio con los mtodos normalmente utilizados en las clnicas veterinarias. Utilizando tcnicas
estriles, 60 conos de otoscopio de 4 mm esterilizados con gas fueron inoculados con un caldo de cultivo
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H M Newton et al.

que contena 1.5 billones de bacterias Pseudomona aeruginosa/ml, y despus secados durante 10 minutos.
Se crearon seis grupos de estudio con diez conos cada uno. El primer grupo fue el control positivo y no fue
desinfectado. En el grupo numero 2 los conos se limpiaron con gasas y bastoncillos de algodn estriles,
y despus se aclararon con agua. En el grupo numero 3 los conos se limpiaron con 70% alcohol isoproplico.
En el grupo numero 4 los conos se fregaron con un limpiador de espculos conteniendo solucin Cetylcide
II (Industrias Cetylite, Inc., Pennsauken, NJ). Los grupos 5 y 6 fueron sumergidos durante 20 minutos en
Cetylcide II y en solucin de gluconato de clohexidina al 2%, respectivamente. Manteniendo tcnicas de
esterilidad, y tras 10 15 minutos de tiempo de secado, los conos fueron muestreados para bacteriologa
de manera uniforme y las muestras se remitieron para un cultivo cuantitativo. Los resultados del cultivo mostraron la ausencia de crecimiento en los conos sumergidos en Cetylcide II o en clorhexidina. 2/10 conos
limpiados con alcohol, 3/10 conos limpiados con agua y 3/10 conos frotados con el limpiador de espculos
mostraron crecimiento de P. aeruginosa. Todos los conos del grupo control tuvieron crecimiento en gran
numero de P. aeruginosa. Estos resultados demuestran P. aeruginosa puede sobrevivir en conos de
otoscopio limpiados con algunas de las tcnicas.
Zusammenfassung Das Ziel dieser Studie war eine Evaluierung der relativen Wirksamkeit der Reinigung
des Otoskoptrichters und von Desinfektionsmethoden, die hufig in Veterinrpraxen verwendet werden.
Mittels steriler Technik wurden 60 neue, mit Gas sterilisierte vier mm Otoskoptrichter mit einer Brhkultur
von 1.5 Milliarden Pseudomonas aeruginosa Bakterien/ml inokuliert und 10 Minuten trocknen gelassen.
Sechs Untersuchungsgruppen von je zehn Trichtern wurden geschaffen. Trichter in Gruppe 1 dienten als
Positivkontrolle und wurden weder gereinigt noch desinfiziert. Trichter in Gruppe 2 wurden mit sterilen
Wattestbchen und Gaze abgewischt und danach mit Wasser abgesplt. Trichter in Gruppe 3 wurden mit
70% Isopropyl-Alkohol abgewischt. Trichter in Gruppe 4 wurden in einem Spekulumreiniger mit Cetylcide
II Lsung (Cetylite Industries, Inc., Pennsauken, NJ) gebrstet. Trichter in Gruppe 5 und 6 wurden 20
Minuten lang in Cetylcide II Lsung bzw. in Chlorhexidinglukonat 2% Lsung eingeweicht. Von den Trichtern
wurden nach einer Trocknungsdauer von 10 bis 15 Minuten mittels einer sterilen Methode in gleichbleibender Weise Tupfer entnommen und die Proben fr quantitative Analyse eingeschickt. Die Ergebnisse
der Bakterienkulturen zeigten kein Wachstum der Proben von Trichtern, die in Cetylcide II oder Chlorhexidin
Lsungen eingeweicht worden waren. Zwei von 10 Trichtern, die mit Alkohol abgewischt wurden, 3/10
Trichtern, die abgewischt und dann mit Wasser abgesplt wurden und 3/10 Trichtern, die im Spekulumreiniger gereinigt wurden, zeigten Wachstum von P. aeruginosa. Alle (10/10) Trichter der Kontrollgruppe
zeigten starkes Wachstum von P. aeruginosa. Diese Ergebnisse zeigen, dass P. aeruginosa an Otoskoptrichtern
berleben kann, die mit verschiedenen hufig verwendeten Methoden gereinigt und desinfiziert worden
waren. Weitere Studien sind notwendig, um praktische und optimale Reinigungs- und Desinfektionsmethoden
fr Otoskoptrichter zu bestimmen.

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2006 The Authors. Journal compilation 2006 European Society of Veterinary Dermatology.