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A. Schuyler, NP
A. Schuyler, NP, Nurse Practitioner
Category: Health
Satisfied Customers: 14936
Experience:  Board Certified NP, MS, RN. Private practice & hospitalist
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Camille,How are you? Its been some time since we last

Customer Question

Camille,

How are you? It's been some time since we last chatted and I thought I'd run something by you as you've assisted me admirably in the past.

I have had Psoriasis for 14 years now and recently added to my resume Seborrheic Dermatitis - which in turn resulted in Blephoritus and Meimitous in my eyes - per a recent consult with an Opthamologist.

My last post to you was regarding a drug I took for a couple of days called Amitriptyline which resulted in tinnitus that persists to this day but has lessened in intensity until recently.

My question:

Opthamologist perscribed Tobramex ointment to be used once each evening for 6 weeks. He also perscribed Minocycline at 50mg a day, once a day each morning with food.

I started with the cream the first night and a couple of days later with the Minocycline. Was on Minocycline for only 2 days as my tinnitus increased to a more noticeable level. I continued the ointment for 4 more days - so a total of 6 for the ointment. In addition I have been doing hot compresses and lid scrubs with Ocusoft pads 2x daily.

1. Ototoxicity - I'm getting a hearing test tomorrow as a result of the uptick in tinnitus and a general feeling of uneasiness.
- From your 30 years of experience has Tobramex ointment applied topically to the eyelid (while eyes are closed mind you) caused Otoxicity and if so was it reversible? I stopped taking this because I realized that Tobrimycn is an Aminoglycoside and well these are terrible for your ears - that said I seemed to find a consensus online that only system injection is what really can do you in while topical isn't absorbed well and is generally considered safe; alas I'm not a doctor and would hope that I was prescribed safe meds at a safe dosage for a safe amount of time.

2. Ditto (all above) for Minocycline?

The couple of doctors I have talked to did their best to reassure me they thought I was fine and had done no harm. They understand my anxiety around taking drugs like this given past experience.

3. Any additional thoughts as to which (or possibly the combination of the two drugs) may have caused an uptick in my tinnitus - that has quieted a little but still seems on edge (maybe that's the anxiety doing what it does best eh?) - Do you think this recent flair will die down to "normal tinnitus levels" and perhaps when? I have been off Minocycline for 6 days now and Tobradex for 4 days.

Thank you in advance and I do hope things are well with you.

Kindest Regards,

Jeff
Submitted: 1 year ago.
Category: Health
Expert:  Gina-Moderator replied 1 year ago.
My name is XXXXX XXXXX I am the Moderator.

I noticed you have requested Camille, however, she has not been online in a very long while..I have opened your question to other Professionals so that your question can be answered.

If I can help further, please let me know:)
Expert:  A. Schuyler, NP replied 1 year ago.

Hello, Jeff,

Thanks for using Just Answer. My name is XXXXX XXXXX I will do whatever I can to try to help you.

 

TobraDex is a combination of an antibiotic (tobramycin) and an anti-inflammatory. I have never ehard of its having ototoxicity, and cannot imagine a mechanism by which this could happen.

 

Minocycline 50 mg is a low-dose tetracycline antibiotic typicaly prescribed for skin infections such as your eyes, and for acne. Teens take it for months at a time for acne control. It has no record of ototoxicity.

 

I expect the increase in tinnitus is related to your anxiety about taking medications rather than the medications themselves. A hearing test is a great idea. If you haven't seen an otolarygologist (an ear/nose/throat physician specialist) that would also be a good plan to find a reason for the tinnitus.

 

Please let me know if you have questions.

 

Best regards,

 

Schuyler

 

 

A. Schuyler, NP, Nurse Practitioner
Category: Health
Satisfied Customers: 14936
Experience: Board Certified NP, MS, RN. Private practice & hospitalist
A. Schuyler, NP and 3 other Health Specialists are ready to help you
Customer: replied 1 year ago.

Schuyler,


 


Appreciate your answer. There is this book floating around online that is called Ototoxicity - Ototoxic drugs exposed. While the book appears to be grounded in fact there are (as it seems with the web) horror stories associated to a variety of prescription drugs, including topicals. Two such stories are called out in excerpts available online regarding Tobradex drops and ointment.


 


Aren't Aminoglycosides ototoxic or is it just just when they are given via IV form? When. I say ototoxic I'm including vestibiotoxicity as well. The other thing I've heard / read with these drugs is that one has to be monitored closely after succession and can't go into noise environments for 6 mo.because this class of drug doesn't leave the ear quickly - again this may only pertain to IV administration.


 


Any additional thoughts? I mean maybe this guy is just trying to sell books but he teaches seminars etc. Obviously I'm trying to do the best I can in taking care of myself and protecting myself. I know medicine will be required at different points in my life but I'd like to take the closest thing to water so to speak whenever possible.


 


Thank you for reading. If other experts you know are able to weigh in on my story I'd be grateful.


 


Had a hearing test 5 days after succession of both drugs in question and it was fine. Again only tested up to 8khz which is normal. Not sure if there is any cause for concern if either of these affect ultra high frequency hearing as some (at least IV administered drugs in this class claim they can).


 


Kindest Regards,


 


Jeff

Expert:  A. Schuyler, NP replied 1 year ago.

Hi, Jeff,

 

"Aren't Aminoglycosides ototoxic or is it just just when they are given via IV form? When. I say ototoxic I'm including vestibiotoxicity as well. The other thing I've heard / read with these drugs is that one has to be monitored closely after succession and can't go into noise environments for 6 mo.because this class of drug doesn't leave the ear quickly - again this may only pertain to IV administration."

 

That's like asking "Aren't all Irishmen drunkards?"

 

Aminoglycosides include a lot of useful drugs (among them deriviatives of the Micromomospora genus including the antibiotics amikacin, arbekacin, gentamicin. kanamicin, neomycin, netilmicin, paromomicin; and those derived from Streptomyces fenus such as streptomycin, tobramycin and apramycin).

 

The ototoxicity is one possible side effect and it is dosage related. Higher doses of these drugs are reserved for serious, life-threatening illnesses such as septicemia and other truly serious infections. They are given IV or IM because they aren't well absorbed from the GI tract.

 

Mild, low dilutions of tobramycin are used for a number of milder infections. There is little to no chance of ototoxicity, and none with topical application. I've been around for a while and I've never heard of ototxicity from topical tobramycin.

 

I haven't seen the book you refer to online. By the time I keep up with patients, medical journals and taking coursework on new medical material to keep current, I don't have time to read the sensationalist junk people put online to make a buck.

 

Glad that your hearing tests were fine. Obviously, your concern wasn't grounded,a nd you are fine.

 

When one expert answers a question, others do not "chime in, since only one may be paid for their time.

 

 

 

Kind regards,

 

Schuyler

 

Customer: replied 1 year ago.

Schuyler,


 


Thank you for your response and for being patient with me. Believe me when I say I don't like thinking about this stuff; its not the most fun thing in the world. One other question to add on to what you said before:


 


Are there any transient effects you've seen from either of the medications I talked about - hearing (i.e. tinnitus) or otherwise (given my duration of treatment, dosage etc.)?


 


Any other follow up tests or appointments you'd recommend or is it simply carry on as you have previously?


 


I'm also going to give you some additional coin as your responses have been both detailed and insightful.


 


Thank you again for helping provide some piece of mind and overall good advice.


 


Jeff


 


 

Expert:  A. Schuyler, NP replied 1 year ago.

Hi, Jeff,

 

I've never seen tinnitus from such a short usage and never from topical usage.

 

Occasioally someone will be allergic to a drug or to one of the fillers used in it. We just take them off it and prescribe an antihistamine for the allergy symptoms. It doesn't sound like you had an allergy.

 

There is really no test to recommend. You are fine, other than the anxiety.

 

Thanks for the excellent rating.

 

 

Kind regards,

 

Schuyler

Customer: replied 1 year ago.

Schuyler,


 


I sent a little something your way for your additional in depth response. I really appreciate it. I want we what we all want "a worry free lifestyle" or at least a minimized one. Thank you for giving me some piece of mind; I'll take all I can get Laughing.


 


Have a wonderful week ahead.


 


-Jeff

Expert:  A. Schuyler, NP replied 1 year ago.

Hi, Jeff,

Thanks so much for the bonus and excellent rating. I really appreciate them both. I'm always happy to help people with answers to their questions.

Have a great week!

Schuyler

Customer: replied 1 year ago.

Schuyler,


 


After being off the above for ~3 weeks I took a natural supplement to attempt to combat the increase in tinnitus - and this is when I noticed some new symptoms...not sure if the previous prescriptions have to do with this at all; from your synopsis it sounds categorically unlikely.


 


If I turn my head to the side while walking (either direction) or look down for a prolonged period I start feeling woozy and ever so slightly nauseous. My balance also feels somewhat off - by off I mean there are times where I just feel a little wobbly. Also feeling that sense of head bobbing (maybe Oscillopsia..err? when I walk) On this last point - does everyone have some degree of this that is normal meaning when I am standing still things don't appear to move vertically up and down but when I walk and a little more so when I run there appears to be some up and down vertical movement...if this is normal maybe I am being hypervigilant and noticing it now...


 


Supplement Info: The Hearing Loss Pill supplement | http://thehearingfix.com/blog/wp-content/uploads/2013/03/hearing-fix-ingredients.png - the standard dosage which isn't shown on the label is 1 pill TWICE daily with no more than 6 pills taken in a day.


 


I took 2 pills - 1 in the morning 1 in the evening for 14 days.



After stopping this supplement - I stopped all supplements for about 4 weeks and felt really bad so I then started taking a multi-vitamin again, calcium and magnesium supplement, vitamin D supplement, ubiquinol (coq10) and Nordic Naturals Ultimate Omega Fish Oil - all of which I had previously taken but stopped. I have a vitamin D deficiency normally so maybe going off my Vit D supplement which was 4-6k i.u.'s daily made things worse...


 


Sorry for the long post - hope it is concise enough. Please let me know if you have questions. I was recently unemployed a couple of weeks ago so I lost my medical; was planning on seeing someone about these recent feelings. I just hope I'm okay :)...I really have felt anything but.


 


Thank you for being so helpful as always (once upon a time I used to be a lot more chilled out guy I promise you).


 


-Jeff

Expert:  A. Schuyler, NP replied 1 year ago.

Hi, Jeff,

 

Sorry to hear you've been having problems. I'm glad you're back on your normal supplements. None of them are harmful and with a vitamin D deficiency you need that supplement particularly. The hearing supplement is laughable. I'm sorry you were duped into spending a fortune for this stuff that really cannot deliver what it promises. The ingredients are just vitamins and minerals. Nothing to write home about, and nothing to harm you, but nothing to help either.

 

As for seeing objects move up and down either while still or walking, neither is normal. The problem may be hypervigilence due to your anxiety, or you may have an inner ear problem. Your ENT (ear, nose, throat specialist) would be the one to evaluate that. If nothing is found, you can rack it up to one more symptom of anxiety. The fact that you were out of work surely added to the stress and anxiety.

 

 

Warm regards,

 

Schuyler

 

Customer: replied 1 year ago.

Schuyler,


 


Thank you as always for your prompt response. Thankfully I don't have any noticeable issues when still its just when walking; when walking I realize that things shouldn't be moving so to speak but is there anything normal about the fact there is a bit of an up an down motion to a person's walk and that this motion can change the perspective of what is seen? I agree I'd like to see an ENT - unfortunately being out of work recently and losing health benefits that complicates that option some; primarily because of cost.


 


Can anxiety cause an issue like this? I suppose anxiety and stress can cause a lot. I feel kind of stupid posing these questions but health wise (outside of worrying less) this is really my only definitive approach at the moment given my current situation - which is a bummer.


 


I really appreciate you being so thorough in your answers. I'm glad to know that what I have taken (Tobradex, Minocycline and this supplement) appears to be much ado about nothing - just wish I could explain my symptoms - it "feels" like more than anxiety in the way that seasonal allergies can feel more like a cold at times than just allergies.


 


I will include another bonus for you as well. I do appreciate your time and efforts. Sigh, ...I just want to feel better.


 


Two last notes - that vitamin supplement thankfully can be returned for a full refund which I'm in the process of doing and can an Audiologist evaluate these symptoms at all or is an ENT the main person? Neurologist? I want to go the right route - when I go there, but if I can be cost effective given my circumstances I'd like to do that as well.


 


Thank you again.


 


Jeff

Expert:  A. Schuyler, NP replied 1 year ago.

Hi, Jeff,

 

Let's tackle the questions one by one:

 

"...when walking I realize that things shouldn't be moving so to speak but is there anything normal about the fact there is a bit of an up an down motion to a person's walk and that this motion can change the perspective of what is seen?"

It isn't the "things" that are moving, it is your body. Somehow your brain may be processing this (probably due to the hypervigilence of anxiety) as the things being moving instead of your body.

 

"...Can anxiety cause an issue like this?..." Absolutely it can. We treat far more anxiety attacks in the ER than heart attacks. Anxiety can also cause digestive issues, insomnia, pains with physical reason to exist, and dozens of other symptoms.

 

"...

Two last notes - that vitamin supplement thankfully can be returned for a full refund which I'm in the process of doing..."

Great news that you can get a refund on the supplement.

 

"...and can an Audiologist evaluate these symptoms at all or is an ENT the main person? Neurologist? I want to go the right route - when I go there, but if I can be cost effective given my circumstances I'd like to do that as well...."

An audiologist evaluates hearing acuity (how well you hear sound) and suggests hearing aids as required. An ENT diagnoses and treats disorders of the ear, nose, and throat. A neurologist treats nerve problems all over the body. It seems that the first specialist to see (if you aren't already seeing one) is a psychiatrist to get the anxiety under control.

 

Until it is under control, there is no way to tell if the problem is a physical one based in your ears or an imbalance of brain chemicals causing the anxiety which is the basis for all the symptoms. As with everything else in medicine, you have to know what it is you are treating before you begin a treatment plan. In this case we know there is anxiety, and that needs to be under control before going fishing for other disorders.

 

Warm regards,

 

Schuyler

 

 

Customer: replied 1 year ago.
Schuyler,

Greatly appreciate all your time and efforts. I agree that the anxiety is problematic to say the least - being recently out of work and having to deal with that as well only complicates things. I have seen someone in the past and will circle back with them.

The thing that has been the most troubling is I feel like I keep getting things - explainable or not and they seem to follow something I take (in this case Minocycline, Tobradex and Vitamins combo). When something like this happens in the past with other prescriptions or natural remedies it's hard not to shake the feeling nothing will ever help and that things won't get better - or at the very least things gotten will go away (and be transient in nature) as opposed to hanging onto to me.

Again, I appreciate your confirmation that I haven't "hurt" myself or that doctors haven't tried to "screw me up" with the treatments taken. It's comforting to know that what I have done shouldn't / almost certainly couldn't do anything and that would be easy as water to swallow if I was symptom free and just curious if I had done anything...alas I'm sure if I had no symptoms I probably wouldn't be concerned or alarmed either.

Thank you for reading and for answering my additional questions. It means a great deal. I hope that the people you work with value your contributions, advice and insight as much as I do.

Warm Regards,

Jeff
Expert:  A. Schuyler, NP replied 1 year ago.

Hi, Jeff,

 

Thanks so much for the kind words. It means a lot to me to be appreciated.

 

Sometimes just getting the anxiety "fixed" will eliminate the other symptoms so I hope you will be able to see your previous provider soon. For symptoms that crop up while you are without insurance there are the free clinics you could try. There are a couple of lists below, but there may be more in your local telephone directory since not all local clinics make the national lists. The clinic where I volunteer, for instance, sees thousands of patients a year, but we aren't on the national lists. We don't just see the homeless and transients, but professional people who have been laid off and are temporarily without health insurance. Most clinics work on a sliding scale according to income since most people do really want to pay something toward their care.

http://bphc.hrsa.gov/

 

http://www.freeclinics.us/freeclinic.php

 

Customer: replied 1 year ago.

Schuyler,

 

Happy Thursday. I hope your week has been treating you well. I had one quick follow up question regarding the Tobradex - topical treatment that I took.

 

Based on current knowledge, do Topical Aminoglycosides (Tobradex in this case - applied to the eyelid) enter the inner ear at the same rate as IV or pill form? Or does this not happen at all? Are they absorbed into the bloodstream or just absorbed locally (skin)? Finally, do topical Aminoglycosides (Tobradex in this case) stay in your system (or in your inner ear cells etc.) long after application or does this only happen with IV / pill varients? I mention all this as I have read that Aminoclycosides "can" continue to cause damage to your ear long after cessation - 6 months and upwards of a year.

 

Thank you for entertaining this question and for helping me further beat this proverbial dead horse.

 

On a positive note I have been in a regular exercise program to vent off steam and keep a positive mindset . I have found this to be most helpful.

 

Cheers (and I greatly appreciate all the help you have provided),

 

Jeff

Expert:  A. Schuyler, NP replied 1 year ago.

Hi, Jeff,

 

Happy Thursday back at you.

 

Repeated use of aminoglycosides can result in delayed hypersensitivity reaction. However, you used ophthalmic Tobradex for two days. That isn't repeated use. Repeated us is using it for 2-3 weeks at a time, one episode after another, such as might happen with someone with recurrent ear infections. And hypersensitivity reaction also isn't ototoxicity. That is an extreme case usually encountered when someone has had to take IV aminoglycosides for very serious bacterial infections. I expect that most people, given a choice of some hearing loss versus death, would choose to live.

 

Some ophthalmic Tobradex would be absorned into the bloodstream but it would be a very little. Ophthalmic Tobradex is already a very low concentration drug since it is being used around the eye. They leave the bloodstream fairly quickly. The plasma half-life is about 2 hours (half the dose is eliminated in 2 hours; half the remaining half in the next two hours, etc.). That is even faster than orally administered acetaminophen (Tylenol). I can't imagine it being around months later.

 

Glad to hear about the exercise program. It really can help with both depression and anxiety as well as just being a healthy lifestyle.

 

 

All the best,

 

Schuyler

ξ

Customer: replied 1 year ago.

f

Expert:  A. Schuyler, NP replied 1 year ago.

Pardon?

 

Customer: replied 1 year ago.

Schuyler,

 

For some reason just answer is not letting me post a very long response. Thus I have to edit after I post. Sorry for the confusion on that last one. That letter was a placeholder.

 

Schuyler,

 

Thank you for your in depth response as always Laughing. Slight correction (although I don't think it changes anything you said in the slightest) but I took Tobradex ointment once a night for 6 nights in a row instead of 2 before I called it quits.

 

If I can interject a couple of other quick q's on this before I close this out for good:

 

1. I have read that Aminoglycosides when taken head straight for your inner ear fluids - the endolymph and perilymph and that they get there quickly and easily...true for Topical or ...only oral or IV?

 

2. I have read that Aminoclycosides "can" continue to cause damage to your ear long after cessation of the drug because they stay in the ear fluids... for 6 months and upwards of a year...true for Topical or ...only oral or IV?

 

3. Finally - Smile I took Minocycline for 2 days after being on Tobradex ointment for 2 days. I stopped because I felt "my tinnitus was affected - not sure how common this occurrence is). My dosage was 50 mg once per day. Are there any known interactions or propensity (when taking these in combo, even for a short bout of time) for ototoxicity or vestibular toxicity?

 

If any of those questions / my reply changes something feel free to add anything additional.

 

Again, thank you for being so awesome. The exercise program is indeed positive on all accounts. That and the fun side note that yesterday I became an Uncle - :)

 

Cheers,

 

Jeff

 

Expert:  A. Schuyler, NP replied 1 year ago.

Hi,

 

The site has been kind of kinky today. Don't know what's going on.

 

1. I have read that Aminoglycosides when taken head straight for your inner ear fluids - the endolymph and perilymph and that they get there quickly and easily...true for Topical or ...only oral or IV?

Neither. It's bogus. The drug is in your bloodstream and goes all over your body, except past the blood-brain barrier.

 

2. I have read that Aminoclycosides "can" continue to cause damage to your ear long after cessation of the drug because they stay in the ear fluids... for 6 months and upwards of a year...true for Topical or ...only oral or IV?

 

Again, all bogus. The half-life is about 2 hours.

 

3. Finally -

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I took Minocycline for 2 days after being on Tobradex ointment for 2 days. I stopped because I felt "my tinnitus was affected - not sure how common this occurrence is). My dosage was 50 mg once per day. Are there any known interactions or propensity (when taking these in combo, even for a short bout of time) for ototoxicity or vestibular toxicity?

 

No interactions and no combo problems for oto- or vestibular toxicity.

 

Congratulations on becoming an uncle

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Schuyler

 

 

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A. Schuyler, NP
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