AU2014200457B2 - Controlled release antimicrobial compositions and methods for the treatment of otic disorders - Google Patents

Abstract

CONTROLLED RELEASE ANTIMICROBIAL COMPOSITIONS AND METHODS FOR THE TREATMENT OF OTIC DISORDERS Abstract Disclosed herein are compositions and methods for the treatment of otic diseases or conditions with antimicrobial agent compositions and formulations administered locally to an individual afflicted with an otic disease or condition, through direct application of these compositions and formulations onto or via perfusion into the targeted auris structure(s).

Description

CONTROLLED RELEASE ANTIMICROBIAL COMPOSITIONS AND METHODS FOR THE TREATMENT Of OTIC DISORDERS

CROSS-REFERENCE f8®0ll This paten! application claims .the benefit ofU.S. Proviskmal Application Ser. No. 61/0152,450 filed My 21., 200$; ILS. FrovMoiml Application Sear.'No. 61/083,871 filed July 25,20010 0.S. Provisional Application See Mb, 60094,384 filed September 04,2008; U.S. Provisional. Applkaifoo Sex. No. 61/1,01,112 filed September Z9r '2008; U,S, Froviskmal Application Ser, Mo. 61 /140,033 .filed December 22,2008; U.S, Application Sep No, 12/427*663 filed .Apfil 2 L 2000; and U.S. Application Sen Mo. 12/466310 filed May 14, 2009; all of which are iacorporaled by reference herein in their entirety,

RACK-GROUND OF THE INVENTION

[00021 Vertebrates have a pair of ears, placed symmetrically on opposite sides of the Mead The ear serves as both the sense orpsa· that detects sound and the organ that, nminmins balance and body position. The ear is generally divided into three portions: the outer ear, auris media (or middle.ear) and the amte tesm (or inner ear).

SUMMARY OF THE INVENTION

[0ΜΛ| Described hem in are compositions, formulations, 'mtmufacimsjg methods, therapeutic methods, uses, kits, and delivery devices for the controlled release of desired agents to at least one'structure or region of the 'ear. |0Q04| Disclosed herein are controlled release- footiulatkms for delivering at least one antimicrobial agent to foe w, or a targitopoillon thereof, far foe .treatment of-an otic disorder. In some embodiments, the anfinticrobM agent, is an amihacterial agent, an antiteigal agent, ait antiviral agent· an antiprotozoal «genty and/or an aatiparaskic agent, In certain embodiments, the &fomkmbial agent is a pfotein, an antibody, DMA, a Cttrix%dri¥tei tminorganic compound, art organic compoond, or combinations thereof. in certain embodiments, foe aihinriembial agent is a small organic molecule, [0004a] In one aspect there is presented an intratympanic composition when used in the treatment of an otic disease or condition comprising an auris acceptable hydrogel and a multiparticulate antimicrobial agent; wherein the multiparticulate antimicrobial agent is essentially in the form of micronized particles that are non-microencapsulated. ΡΚΚΒ] In some emtedimoiits, the target portion o f the ear is the middle ear or aeris media. In otter embodiments, the target portion of the ear is the m»er ear, or sum interna or a speciile sifctructure therein, In other atdxxikaeths, the target portton of the ear is the middle ear, or amis media, to still other emhodimenfe, the target portion of the ear is both the marts media and the aims interna. In some embodiments, the controlled release ibrtmtlaliom further comprise a rapid or immediate release component Ibr delivering an antimicrobial agent to 'the auris media and/or the auris interna. All formulations comprise excipients that, are auris-media and/or auris-intema acceptable.

[0006] In certain embodiments, the controlled release composition further comprises an additional therapeutic agent, including an additional antimicrobial agent, an antiinflammatory agent, a corticosteroid, a cytotoxic agent, an anti-TNF agent, a collagen, a gamma-globulin, an interferon, a platelet activator factor antagonist, a nitric oxide synthase inhibitor, or combinations thereof. In another aspect, the additional therapeutic agent is an immediate release or a controlled release agent.

[0007] Disclosed herein 'are controlled release formulations for delivering an antimicrobial agent to the ear. In some embodiments, the composition is administered so that the composition is m contact with the crista fenestrae cochleae, the round window or the tympanic cavity.

[0008] The auris formulations and therapeutic methods described herein have numerous advantages that overcome the praviously-unrecognized limitations of formulations and therapeutic methods described in prior art.

Sterility [0009] The en vironment of the inner ear is an isolated environment. The endolymph and the perilymph are static fluids and are not in contiguous contact with the circulatory system.

The blood - labyrinth - barrier (BLB), which includes a blood-endolymph barrier and a blood-perilymph barrier, consists of tight junctions between specialized epithelial cells in the labyrinth spaces (i.e., the vestibular and cochlear spaces). The presence of the BLB limits delivery of active agents (e.g., antimicrobial agents) to the isolated microenvironment of the inner ear. Auris hair cells are bathed in endolymphatic or perilymphatic fluids and cochlear recycling of potassium ions is important for hair cell function. When the inner ear is infected, there is an influx of leukocytes and/or immunoglobins (e.g. in response to a microbial infection) into the endolymph and/or the perilymph and the delicate ionic composition of inner ear fluids is upset by the influx of leukocytes and/or immunoglobins. In. certain instances, a change in the ionic composition of inner ear fluids results in hearing loss, loss of balance and/or ossification of auditory structures. In certain instances, even trace amounts Of pyrogens and/or microbes can trigger infections and related physiological changes in the isolated microenvironment of the inner ear.

[0010] Due to the susceptibiily of the inner ear to infections, auris formulations require a level of sterility that has not been recognized hitherto in prior art. Provided herein are auris formulations that are manufactured with low bioburden or sterilized with stringent sterilty requirements and are suitable for administration to the middle and/or inner ear. In some embodiments, the auris.'compatible compositions described herein are substantially tree of pyrogens and/or microbes.

Compatibility with inner Ear Environment (0011) Described herein are otic formulations with an ionic balance that is compatible with the perilymph and/or the endolymph and does not cause any change in cochlear potential. In specific embodiments, osmolarity/osmolality of the present formulations is adjusted, for example, by the use of appropriate salt concentrations (e.g., concentration of sodium salts) or the use of tonicity agents which renders the formulations endolymph-compatible and/or perilymph-compatible (i.e. isotonic with the endolymph and/or perilymph), in some instances, the endolymph-compatible and/or perilymph-compatible formulations described herein cause minimal disturbance to the environment of the inner car and cause minimum discomfort (e.g, vertigo) to a mammal (e.g., a human) upon adminstration. Further, the formulations comprise polymers that are biodegradable andfor dispensable, and/or otherwise non-foxic to the inner ear environment. In some embodiments, the formulations described herein are free of preservati ves and cause minimal disturbance (e.g., change in pH or osmolarity, irritation) in auditory structures, In some embodiments, the formulations described herein comprise antioxidants that are non-irritating and/or non-toxic to otic structures.

Dosing Frequency |0012] The current standard of care for auris formulations requires multiple administrations of drops or injections (e.g. intratympanic injections) over several days (e.g., up to two weeks), including schedules of receiving multiple injections per day. In some embodiments, auris formulations described herein are controlled release formulations, and are administered at reduced dosing frequency compared to foe current standard of care. In certain .instances, when an auris formulation is administered via intratympanic injection, a reduced frequency of administration alleviates discomfort caused by multiple intratympanic injections in individuals undergoing treatment, for a middle and/or inner ear disease, disorder or condition. In certain instances, a reduced frequency of administration of intratympanic injections reduces the risk of permanent damage (e.g,, perforation) to the ear drum. The formulations described herein provide a constant, sustained, extended, delayed or pulsatile rate of release of an active agent into the inner ear envkonment and thus avoid any variability in drag exposure in treatment of otic disorders. In some embodiments, the compositions or devices described herein avoid variability in contact with the round windo w (a major site of inner ear drug absorption) . In some embodiments, the compositions or devices described herein avoid a short residence time in the middle ear.

Therapeutic Index |!>0l3f Anris formulations described herein are administered into the ear canal, or in the vestibule of the ear. Access to, for example, the vestibular and cochlear apparatus will occur through the auris media including the round window membrane, the oval window/'stapes footplate, the annular li gament and through the otic capsule/temporal bone. Otic administration of the formulations described herein avoids toxicity associated with systemic administration (e.g., hepatotoxieity, cardiotoxicity, gastrointestinal side effects, renal toxicity) of the active agents, In some instances, localized administration in the ear allows an active agent to reach a target organ (e.g., inner ear) in the absence of systemic accumulation of the active agent. In some instances, local administration to the ear provides a higher therapeutic Index for an active agent that would otherwise have dose-limiting systemic toxicity.

Prevention of Drainage into Eustachian Tube (0014( In some instances, a disadvantage of liquid formulations is their propensity to drip into the eustaehian tube and cause rapid clearance of the formulation from the inner ear. Provided herein, in certain embodiments, are auris formulations comprising polymers that gel at body temperature and remain in contact with the target auditory surfaces (e.g., the round window) for extended periods of time. In some embodiments, the formulations further comprise mucoadhesives that allow the formulations to adhere to otic mucosal surfaces. In some instances, the auris formulations described herein avoid attenuation of therapeutic benefit due to drainage or leakage of active agents via the eustaehian tube.

Description of certain embodiments (0015( Described herein are controlled release compositions and devices for treating otic disorders comprising a therapeuttealiy-effective amount of an antimicrobial agent, a controlled release auris-acceptable excipient and an auris-acceptable vehicle. In one aspect, the controlled release auris-acceptable excipient is an auris-acceptable polymer, an auris-aeceptable viscosity enhancing agent, an auris-aeceptable gel, an auris-acceptable paint, an anris-aeecptable mierosphere, microcapsule or mieroparticle, an auris-acceptable in situ forming spongy material, an auris-aceeptable hydrogel, an auris-aeceptable liposome, an auris-aeceptable nanocapsule, nanoparticle, or nanosphere, an auris-acceptabie foermoreversible gel, an auris-aeceptable foam, an auris-acceptabie xerogel, or combinations thereof. In certain specific embodiments, the auris-acceptabie viscosity enhancing agent is a carbomer, a cellulose, a cellulose ether, alginate, polyvinylpyrrolidone, a gum, a cellulosic polymer or combinations thereof. In yet another embodiment, the auris-acceptabie viscosity enhancing agent is present in an amount sufficient to provide a viscosity of between about 1.000 to about 1,000,000 eentipoise. In still another aspect, the auris-acceptabie viscosity enhancing agent is present in an amount sufficient to provide a v iscosity of between about 50,000 to about 1,000,000 eentipoise. In some embodiments, the antimicrobial agent formulations or compositions are optimal for osmolality or osmolarity of the target auris structure to ensure homeostasis is maintained, [0016J In some embodiments, the compositions are formulated for pH, and a practical osmolality or osmolaritv to ensure that homeostasis of the target auris structure is maintained. Λ perilymph-suitable osmolarity/osmolality is a praetieal/deliverable osmolarity/osmolality that maintains the homeostasis of the target auris structure during administration of the pharmaceutical formulations described herein.

[0017] For example, the osmolarity of the perilymph is between about 270-300 m(>sm/L, add the compositions described herein are optionally formulated to provide a practical osmolaritv of about 150 to about 1000 mOsm/L. In certain embodiments, the formulations described herein provide a practical and/or deliverable osmolarity within about 150 to about 500 mOsm/L at. the target site of action (e.g,, the inner ear and/or the perilymph and/or the endolymph), In certain embodiments, the formulations described herein provide a practical osmolarity within about 200 to about 400 mOsm/L at the target site of action (e.g. , the inner ear and/or the perilymph and/or the endolymph). In certain embodiments, the Formulations described herein provide a practical osmolarity within about 250 to about 320 mOsm/L at the target site of action (e.g,, the inner ear and/or the perilymph and/or the endolymph). In certain embodiments, the formulations described herein provide a perilymph-suitable osmolarity within about 150 to about 500 mOsm/L, about 200 to about 400 mOsm/L or about 250 to about 320 mOsrn/L at foe target site of action (e.g. , the inner ear and/or the perilymph and/or the endolymph). In certain embodiments, the formulations described herein provide a perilymph-suitable osmolality within about 150 to about 500 mOsm/kg, about 200 to about 400 mOsm/kg or about 250 to about 320 mOsm/kg at the target site of action (e.g., the inner ear and/or foe perilymph and/or the endolymph). Similarly, foe pH of the perilymph is about 7.2-7 A and die pH of the present formulations is formulated (e.g., with the use of buffers) to provide a perilymph-suitable pH of about 5.5 to about 9.0, about 6.0 to about 8.0 or about 7.0 to about 7.6, In certain embodiments, the pH of the formulations is within about 6.0 to about 7,6. In certain instances, the pH of the endolymph is about 7.2-7.9, and the pH of the present formulations is formulated (e.g., with the use of buffers) to be within about 5.5 to about 9.0,: within about 6.5 to about 8.0 or within about 7.0 to about 7.6. (0018) In some aspects, the controlled-release auris-acceptable excipient is biodegradable.

In some aspects the controlled release auris-acceptable excipient is bioeliminated (e.g,, degraded and/or eliminated through urine, feces or other routes of elimination). In another aspect, the controlled release composition further comprises an auris-acceptable mucoadhesive, an auris-acceptable penetration enhancer or an auris-acceptable bioadhesive, )0019] In one aspect, the controlled release antimicrobial agent composition is delivered using a drug delivery device, which is a needle and syringe, a pump, a microinjection device or combinations thereof. In some embodiments, the antimicrobial agent of the controlled release composition has limited or no systemic release, is toxic when administered systetnically, has poor pK characteristics or combinations thereof. In some aspects, the antimicrobial agent is a small molecule. {¢020) Also disclosed herein are methods for the treatment of otic disorders comprising local administration of an antimicrobial agent controlled release formulation to the ear. Otic disorders treatable with the formulations disclosed herein include otitis externa, otitis media, Ramsay Hunt syndrome, otosyphilis, autoimmune inner ear disease (All*!)), Meniere's disease, and vestibular neuronitis. In certain embodiments, a method for treating an otic disorder comprises administering any of the compositions disclosed herein at least once every 3,4,5, 6, 7, 8,9, 10,11,12, 13, 14 or 15 days; or at least once a week, once every two weeks, once every three weeks, once every· four weeks, once even' five weeks, or once every six weeks; or once a month, once every two months, once every three months, once every four months, once every five months, once every' six months, once every' seven months, once every eight months, once every nine months, once every ten months, once every eleven months, or once every twelve months. )0021 ] In particular embodiments, the controlled release formulations described herein provide a sustained dose of anfimierobial agent to the inner ear between subsequent doses of the controlled .release formulation- That is, taking one example only, if new doses of the antimicrobial agent controlled release formulation are adminstered via intratympanie injection to the round window membrane every· 10 days, then the controlled release formulation provides an effective dose of antimicrobial agent to the inner ear (e.g,. across the round window membrane) during that 10-day period. {0022} In one aspect, the composition is administered so that the composition is in contact with tire crista fenestrae cochleae, the round window membrane or the tympanic cavity. In one aspect the composition is administered by intratympanie injection. (0023} Provided herein is a pharmaceutical composition or device comprising an amount of an antimicrobial agent that is therapeutically effecti ve for treating an otic disease or condition associated with a microbial infection, the pharmaceutical composition or device comprising substantially low degradation products of the antimicrobial agent, the pharmaceutical composition or device further comprising two or more characteristics selected from: (i) between about 0.1% to about 10% by weight of the antimicrobial agent, or pharmaceutically acceptable prodmg or salt thereof; (ii) between about 14% to about 21% by weight of a poiyoxyethylene-polyoxy propylene triblock copolymer of general formula El 06 P70 El 06; (til) sterile water, q.s,, buffered to provide a pH between about 5,5 and about 8.0; (iv) multiparticulate antimicrobial agent; (v) a gelation temperature between about 19 eC to about 42 °C| (vi) less than about 50 colony forming units (efu) of microbiological agents per gram of formulation; (vii) less than about 5 endotoxin units (Ell) per kg of body weight of a subject; (viii) a mean dissolution time of about 30 hours for the antimicrobial agent; and (ix) an apparent viscosity of about 100,000 cP to about 500,000 cP, 10024( In some embodiments, the pharmaceutical composition comprises at least three of the aforementioned characteristics, in some embodiments, the pharmaceutical composition comprises at least four of the aforementioned characteristics, in some embodiments, the pharmaceutical composition comprises at least five of the aforementioned characteristics. In some embodiments, the pharmaceutical composition comprises at least six of the aforementioned characteristics, In some embodiments, the pharmaceutical composition comprises at least seven of the aforementioned characteristics. In some embodiments, the pharmaceutical composition comprises all of the aforementioned characteristics. ]0925j In some embodiments, a pharmaceutical composition 'or-device described herein comprises: (I) between about 0,1% to about 10% by weight of the antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof; (ii) between about 14% to about 21% by weight of a polyoxyethylene- polvoxypropylene triblock copolymer of general formula E106 P70 El 06; and (Hi) multiparticulate antimicrobial agent; and (iv) an apparent viscosity of about 100,000 e P to about 500,000 cP.

[0026] In some embodiments, a pharmaceutical composition or device described herein comprises: (i) between about 0.1% to about '10% by weight of the antimicrobial agent, or pharmaceutically acceptable prodrag or salt thereof: (ii) between about 14% to about 21% by weight of a polyoxyethylene-polyoxypropylene triblock copolymer of general formula E l 06 P70 E l 06; (iif) multiparticulate antimicrobial agent: (iv) a gelation temperature between about 19 °C to about 42 °C; and (v) a mean dissolution time of about 30 horns for the antimicrobial agent. {0027] In some embodiments, a pharmaceutical composition or device described herein comprises: (i) multiparticulate antimicrobial agent: (ii) a gelation temperature between about 19 °C to about 42 °C; and (Hi) a mean dissolution time of about 30 hours for the antimicrobial agent; and (vis) an apparent viscosity of about 100,000 cP to about 500,000 eP, [0028] In some embodiments, a pharmaceutical composition or device described herein comprises: (i) multiparticulate: antimicrobial agent; and (ii) a mean dissolution lime of about 30 hours for the antimicrobial agent, {0029] In some embodiments a pharmaceutical composition or device described above provides a practical osmolarity between about 150 and 500 mOsm/L, In some embodiments a pharmaceutical composition or-device described above provides a practical osmolarity between about. 200 and 400 mOsm/L, In some embodiments a pharmaceutical composition or device described above provides a practical osmolarity between about 250 and 3.20 mOsm/L, l(H)30j In some embodiments, the antimicrobial agent is released from the pharmaceutical composition or device described above for a period of at least 3 days, in some embodiments, the antimicrobial agent is released from the .pharmaceutical composition or device described above for a period of at least 5 days. In some embodiments, the antimicrobial agent is released from the pharmaceutical composition or device described above for a period of at least 10 days. In some embodiments, the antimicrobial agent is released from the pharmaceutical composition or device described above for a period of at least 14 days. In some embodiments, the antimicrobial agent is released from the pharmaceutical .'composition or device described above for a period of at least one month.

[0031] In some embodiments, a pharmaceutical composition or device described above comprises antimicrobial agent as a neutral compound, a free acid, a free base, a salt or a prodrug. In some embodiments, a pharmaceutical composition or device described above comprises antimicrobial agent as a neutral compound, a free acid, a free base, a salt or a prodrug, or a combination thereof. In some embodiments of the pharmaceutical compositions or devices described herein, the antimicrobial agent is administered in the form of a ester prodrug or a phosphate prodrug. In some embodiments pharmaceutical compositions or devices described herein comprise one or more antimicrobial agent, or pharmaceutically acceptable salt thereof, prodrug or combination thereof as. an immediate release agent.

[0032] in some embodiments, a pharmaceutical ..composition or device described above is an auris-acceptable thennoreversible gel. In some embodiments of the pharmaceutical composition or device, the polyoxyethylene-polyoxypropylene tribloek copolymer is bioeliminated. f00331 In some embodiments the pharmaceutical'composition or device further comprises a penetration enhancer, in some embodiments., the pharmaceutical composition or device further comprises a dye, [0034] In some embodiments, the pharmaceutical composition or device further comprises the antimicrobial agent, or pharmaceutically acceptable salt thereof prodrug or combination, thereof as an immediate release agent.

[0035] In some embodiments the pharmaceutical composition or device comprises the antimicrobial agent as multiparticulates. In some embodiments of the pharmaceutical composition or device, the antimicrobial agent .is essentially in the form ofmicronized particles. In some embodiments of the pharmaceutical composition or device, the antimicrobial agent is in the form of micron ized antimicrobial agent powder.

[0036] In some embodiments, a pharmaceutical composition or device described above comprises about 10% of apolyoxyethylenerpolyoxypropylene triblock copolymer of general formula El 06 P70 El 06 by weight of the composition. In some embodiments, a pharmaceutical composition or device described above comprises about 15% of a polyoxyethylene-polyoxypropylene triblock copolymer of general formula El 06 P70 E106 by weight of the composition, in some embodiments, a pharmaceutical composition or device described above comprises about 20% of a polyoxyethylene-polyoxypropvlene triblockcopolymer of general formula El 06 P70 E106 by weight of the composition. In some embodiments, a pharmaceutical composition or device described above comprises about 25% of apolyoxyelhylene-polyoxypropylene triblock copolymer of general formula E106 P70 El 06 by weight of the composition.

[0037] In some embodiments, a pharmaceutical composition or device described above comprises about 0.01% of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof, by weight of the composition. In some embodiments, a pharmaceutical composition or device described above comprises about 0,05% of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof, by weight of the composition. In some embodiments, a pharmaceutical composition or device described above comprises about 0.1% of an antimicrobial agent, or pharmaceutically acceptable prodrag or salt thereof, by weight of the composition. In some embodiments, a pharmaceutical· composition or device described above comprises about 1% of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof, by weight of the composition. In some embodiments, a pharmaceutical composition or device described above comprises about 2,5% of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof by weight of the composition. In some embodiments, a pharmaceutical composition or device described above comprises about 5% of an antimicrobial agent, or pharmaceutically acceptable prodrag or salt thereof by weight of the composition. In some embodiments, a pharmaceutical composition or device described above comprises about 1()% of an antimicrobial agent, or pharmaceutically acceptable prodmg or salt thereof by weight of the composition. In some embodiments, a pharmaceutical composition or device described above comprises, about 2,0% of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof by weight of the composition. In some embodiments, a pharmaceutical composition or device described above comprises aboitt'30% of an antimicrobial agent, or phannaceutieally acceptable prodrug or salt thereof, by wei ght of the composition, in some embodiments, a pharmaceutical composition or device described above comprises about 40% of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof, by weight of the composition. In some embodiments, a pharmaceutical composition or device described above comprises about 50% of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof, by wei ght of the composition.

[0038( In some embodiments, a pharmaceutical composition or device described above has a pH between about 5.5 to about 8.0. in some embodiments, a pharmaceutical composition or device described above has a pH between about 6,0 to about 8,0. In some embodiments, a pharmaceutical composition or device described above has a pH between about 6,0 to about 7,6, In some embodiments, a pharmaceutical composition or device described above has a pH between about 7.0 to about 7.6. (8039] In some embodiments, a pharmaceutical composition or device described above contains less than '100 colony forming units (efu) of microbiological agents per gram of formulation. In some embodiments, a pharmaceutical composition or device described above contains less than 50 colony forming units (efu) of microbiological agents per gram of formulation. In some embodiments, a pharmaceutical composition or device described above contains less than 10 colony forming units (efu) of microbiological agents per gram of formulation.

[0:048( In some embodiments, a pharmaceutical composition or device described above contains less than 5 endotoxin units (EU) per kg of body weight of a subject. In some embodiments, a pharmaceutical composition or device described above contains less than 4 endotoxin units (EU) per kg of body weight of a subject.

[0041] In some embodiments a pharmaceutical composition or device described above provides a gelation temperature between about between about 19 °C to about 42 <5C. In some embodiments a pharmaceutical composition or device described above provides a gelation temperature between about between about 19 ®C to about 37 °C. In some embodiments a pharmaceutical composition or device described above provides a gelation temperature between about between about 191>C to about 30 °€.

[0042( In some embodiments, a pharmaceutical composition or device described above further comprises an ami-inflammatory agent lit some embodiments, a pharmaceutical composition or device described above further comprises an anti-inflairanatory agent that is essentially in the form of micronized particles.

[0043] In some embodiments, the pharnraceuticai composition or device is an auris-acceptable thermoreversible gel. In some embodiments, the polyoxyethylene-polyoxypropylene triblock copolymer is biodegradable and/or bioeliminated (e.g., the copolymer is eliminated From the body by a biodegradation: process, e.g., elimination in the urine, the feces or the like). In some embodiments, a pharmaceutical composition or device described herein further comprises a mucoadhesive. In some embodiments, a pharmaceutical composition or device described herein'further comprises a penetration enhancer. In some embodiments, a pharmaceutical composition or device described herein further comprises a thickening agent. In some embodiments, a pharmaceutical composition or device described herein further comprises a dye.

[0044] In some embodiments, a pharmaceutical composition or device described herein further comprises a drag delivery device selected from a needle and syringe, a pump, a microinjection device, a wick, an in situ forming spongy material or combinations thereof, [0045] In some embodiments, a pharmaceutical composition or device described herein is a pharmaceutical composition or device wherein the antimicrobial agent, or pharmaceutically acceptable salt thereof, has limited or no systemic release, systemic toxicity, poor PK. characteristics, or combinations thereof.

[0046] In some embodiments, pharmaceutical compositions or devices described herein are pharmaceutical compositions or devices wherein the pH of the pharmaceutical composition or device is between about 6.0 to about 7.6.

[0047] In some embodiments of the pharmaceutical compositions or devices described herein, the ratio of a polyoxyethylene-polyoxypropyiene tilblock copolymer of general formula El 06 P70 El06 to a thickening agent is from about 40:1 to about 5:1. In some embodiments, tire thickening agent is carboxyraethyl cellulose, hydroxypropyl cellulose or hydroxypropyl methylcellulose.

[0048] In some embodiments, the otic disease or condition is otitis externa, otitis media, Ramsay Hunt syndrome, otosyphilis, AIED, Meniere’s disease, or vestibular neuronitis.

[0049] Also provided herein is a method of alleviating infection or inflammation associated with an otic intervention comprising administering to an individual in need thereof at intratympanie composition or device comprising a therapeutically effective amount of an antimicrobial agent, the composition or device comprising substantially low degradation products of the antimicrobial agent, the composition or device further comprising two or more characteristics selected from: (i) between about 0.1% to about 1: 0% by weight of the antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof; (ii) between about 14% to about 21% by weight of a polyoxyethylene-polyoxypropylene triblock copolymer of general formula El06 P70 El 06; (iii) sterile water, q,s„ buffered to provide a pH between about 5.5 and about 8.0; (iv) multiparticulate antimicrobial agent; (v) a gelation temperature between about 19 °C to about 42 °C: (vi) less than about 50 colony forming units (cfii) of microbiological agents per gram of formulation;; (vii) less than about 5 endotoxin units (EU) per kg of body weight of a subject; (viii) a mean dissolution time of about 30 hours; and (ix) an apparent viscosity of abo ut 100,000 cP to about 500,000 cP.

[0050] in some embodiments, die pharmaceutical composition compri ses at least three of the aforementioned characteristics. In some embodiments, the pharmaceutical composition comprises at least four of the aforementioned characteristics. In some embodiments, the pharmaceutical composition comprises at least five of the aforementioned characteristics, in some embodiments, the pharmaceutical composition comprises at least six of the aforementioned characteristics. In some embodiments, tire pharmaceutical composition comprises at least seven of the aforementioned characteristics. In some em bodiments, the pharmaceutical composition comprises all of the aforementioned characteristics, [00511 Also provided herein is a method of treating an otic disease or condition associated with a microbial infection comprising administering to an individual in need thereof an intratympanic composition or device comprising a therapeutically effective amount of an antimicrobial agent, the composition or device comprising substantially low degradation products o f the antimicrobial agent, the composition or device further comprising two or more characteristics selected from: (i ) between about 0.1% to about 10% by weight of the antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof: (ii) between about 14% to about 21% by weight of a polyoxyethylene-polyoxypropylene triblock copolymer of general formula E106 P70 E106; (iii) sterile water, q.s., buffered to provide a pH between about 5.5 and about 8.0; (i v) multiparticulate antimicrobial agent; (v) a gelation temperature between about!?) °C to about 42 °C; (vi) less than about 50 colony forming units (efu) .of microbiological agents per gram; of formulation; (vii) less than, about 5 endotoxin units (EU ) per kg of body wei ght of a subject; (viii) a mean dissolution time of about 30 hours for the antimicrobial agent; and (ix) an apparent viscosity of about 100.000 eP to about 500,000 cP.

[0052 j In some embodiments, the pharmaceutical composition comprises at least three of the aforementioned characteristics. In some embodiments, the pharmaceutical composition comprises at least four of the aforementioned characteristics. In some embodiments, the pharmaceutical composition comprises at least five of the aforementioned characteristics. In some embodiments, the pharmaceutical composition comprises at least six of the aforementioned characteristics. In some embodiments, the pharmaceutical composition comprises at least seven of the aforementioned characteristics. In some embodiments, the pharmaceutical composition comprises all of the aforementioned characteristics, {6053] In some embodimen ts of the methods described above, the antimicrobial agent is released from the composition or device for a period of at least 3 days. In some embodiments of the methods described above, the antimicrobial agentis released from the composition or device for a period of at least 5 days. In some embodiments of the methods described above, the antimicrobial agent is released from the composition or device for a period of at least 10 days. In some embodiments of the method described above, the antimicrobial agent is essentially in the form of mieronized particles.

[6054] In some embodiments of the methods, a pharmaceutical composition or device described above further comprises an anti-inflammatory agent. In some embodiments of the methods, a pharmaceutical composition or device described above further comprises an anti-inflammatory agent that is essentially m the form of mieronized particles'. In some embodiments of the methods, a pharmaceutical composition or device described above is administered in combination with an otic intervention. In some embodiments of the methods, a pharmaceutical composition or device described above is administered before an otic intervention. In some embodiments of the methods, a pharmaceutical composition or device described above is administered during an otic intervention. In some embodiments of the methods, a pharmaceutical composition or device described above is administered after an otic intervention.

[0055] In some embodiments, the otic and/or vestibular disorder is otitis externa, otitis media, Ramsay Hunt syndrome, otosyphilis. AIED, Meniere’s disease, or vestibular neuronitis. In some embodiments, administration of any antimicrobial composition or device described above reduces the risk of development of antibiotic resistance.

BRIEF DESCRIPTION OF FIGURES

[0056] Figure 1. illustrates a comparison of non-sustained release and sustained release formulations, [0057] Figure 2 illustrates the effect of concentration on the viscosity of aqueous solutions of Bianose refined CMC.

[0058] Figure 3 illustrates the effect of concentration on the viscosity of aqueous solutions of Methocel, [0059} Figure 4 illustrates the anatomy of the ear [0060] Figure 5 shows predicted tunable release of an active agent from four compositions.

DETAILED DESCRIPTION OF THE INVENTION

[0061] Provided herein are controlled release antimicrobial agent compositions and formulations for the treatment of otic disorders, including otitis externa, otitis media, Ramsay Hunt syndrome, otosyphilis, AIED, Meniere's disease, and vestibular neuronitis. In some embodimenF^Ihe/smtunicrobial agent is an antibacterial agent, an antifungal agent, an antiviral agent, an antiprotozoal agent, and/or an antiparasitic agent. In certain embodiments, the antimicrobial agent is a protein, an antibody, DNA, a carbohydrate, an inorganic compound, an organic compound, or combinations thereof. In certain particular embodiments, the antimicrobial agent is a-small organic molecule. Compositions comprising combinations of therapeutic agents useful for the treatment of otic disorders, including combinations of di fferent antimicrobial agents, as well as combinations of antimicrobial agents with other therapeutic agents, are also encompassed in certain embodiments disclosed herein.

[0062] Otitis externa (OE), also referred to as swimmer’s, ear, is an inflammation of the external ear and/or ear canal. OE is primarily caused by bacteria (e.g., Pseudomonas aeruginosa and Staphylococcus aureus) or fungi (e.g., Candida albicans and Aspergillus) in the outer ear, which establish infection following damage to the skin of the ear canal. Symptoms of OE include otalgia, swelling, and otorrhea, if the condition progresses significantly, OB may cause temporary conductive hearing loss as a result of the swelling and discharge. Treatment of OE involves eliminating the aggravating pathogen from the ear canal and reducing inflammation, which is usually accomplished by administering combinations of antimicrobial agents, e.g., antibacterial and antifungal agents, with antiinflammatory agents, e.g,, steroids.

[0063] Otitis media (OM) is an inflammation of the middle ear. Bacterial infection accounts for a large percentage of OM cases , with more than 40% of cases attributed to.

Sitepiococcus pneumoniae infection, However, viruses, as well as other microbes, may account for OM conditions. Because OM can be caused by a virus, bacteria or both, various antimicrobial agents are used to eliminate the underhung pathogen.

[0064] Syphilis is a venereal disease, caused by the spirochete Treponemapallidunh which may result in otic disorders, particularly cochleovestibular disorders, due to membranous labyrinthitis, and secondarily meningitis. Both acquired and congenital syphilis can cause otic disorders. Symptoms of cochleovestibular disorders resulting from syphilis are often sim ilar to those of other otic di sorders, such as ATED and Meniere's disease, and include tinnitus, deafness, vertigo, malaise, sore throat, headaches, and skin rashes.

[0065] Treatment of otosyphllis (syphilis- presenting otic symptoms) typically includes a combination of steroids and antibacterial agents. Such treatments may be effecti ve in eradicating the spirochete organism while reducing inflammation. However, Treponemas may remain in the cochlear and vestibular endolymph even after eradication from other sites in the body. Accordingly, long term treatment with penicillins may be required to achieve complete eradication of the spirochete organism from the endolymph fluid.

[0066] Systemic· antimicrobial administration for the treatment of otic disorders, e.g., 01¾ OM and otosyphilis, may create a potential inequality' in drug concentration with higher circulating levels in the serum, and lower levels in the target auris interna organ structures. As a result, fairly large amounts of drug are required to overcome this inequality in order to deliver sufficient, therapeutically effective quantities to the inner ear. Further, bioavailability is often decreased due to metabolism of the drug by the liver. In addition, systemic drug administration may increase the likelihood of systemic toxicides and adverse side effects as a result of the high serum amounts required to effectuate sufficient focal delivery to the target site. Systemic ixtxicities may also occur as a result of liver breakdown and processing of the therapeutic agents,, forming toxic· metabolites that effectively erase any benefit attained from the administered therapeutic.

[0067] To overcome the toxic and attendant undesired side effects of systemic delivery of antimicrobial agents (which are generally understood to be toxic to cells), disclosed herein are methods and compositions for local delivery of antimicrobial agents to auris media and/or auris interna structures. Access to, for example, the vestibular and cochlear apparatus will occur through the auris media or auris interna, including the round window membrane, the oval window/stapes footplate, the annular ligament and through the otic eapsule/teinporal bone. In further or alternative embodiments, the auris controlled-release formulations are capable of being administered on or near the round window membrane via intraiympanic injection. In other embodiments, the auris controlled release formulations are administered on or near the round window or the crista fenestra© cochleae through entry via a post-auricular incision and surgical manipulation into or near the round window or the crista fenestrae cochleae area. Alternatively, the auris controlled release formulation is applied via syringe and needle, wherein the needle is inserted through the tympanic membrane and gui ded to the area of the round window or crista fenestrae cochleae, [0068] In addition, localized treatmen t of the auris interna also affords the use of previously undesired therapeutic agents, including agents with poor pK profiles, poor uptake, kw systemic release, and/or toxicity issues.

[0069] Because of the localized targeting of the antimicrobial agent formulations and compositions, as well as the biological blood barrier present in the auris interna, the risk of adverse effects will be reduced as a result of treatment with previously characterized toxic or ineffective antimicrobial agent. Localized administration of antimirobial agent compositions reduces the risk of development of resistance to antibiotics compared to the risk for development of antibiotic resistance when an antibiotic is administered systemically. The compositions described herein are effective for recurring otic diseases or eonditions including, for example, recurring ear infections in children without the need for changing treatment regimens (e.g., in response to development of antibiotic resistance). Accordingly, also contemplated within the scope of the embodiments herein is the use of antimicrobial agents in the treatment of otic diseases or conditions including otitis externa, otitis media, Ramsay Hunt syndrome, oto,syphilis, AIIiD, Meniere's disease, and vestibular neuronitis, including therapeutic agents that have been previously rejected by practitioners because of adverse effects or ineffectiveness of the antimicrobial agent(s).

[0070( Also included within the embodiments disclosed herein is the use of additional auris media and/or auris interna-acceptable agents in combination with the antimicrobial agent formulations and compositions disclosed herein. When used, such agents assist in the treatment of hearing or equilibrium loss or dysfunction resulting from an autoimmune disorder, i ncluding vertigo, tinnitus, hearing loss, balance disorders, infections, inflammatory response or combinations thereof. Accordingly, agents that ameliorate or reduce the effects of vertigo, tinnitus, hearing loss, balance disorders, infections, inflammatory response or combinations thereof are also contemplated to be used in combination with the antimicrobial agent(s) described herein. (0071( In some embodiments, the composition further comprises an antimicrobial agent as an immediate release agent wherein the immediate release antimicrobial agent is die same agent as the eontrolled-release agent, a different antimicrobial agent, an additional therapeutic agent, or a combination thereof. In some embodiments, the composition further comprises an additional therapeutic agent, including an additional antimicrobial agent an anti-inflammatory agent a corticosteroid, a cytotoxic agent, an anti-TNF agent, a collagen, a gamma-globulin, an interferon, a platelet activator factor antagonist, a nitric oxide synthase inhibitor, or combinations thereof In another aspect the additional therapeutic agent is an immediate release or a controlled release agent (0072] In some embodiments, the additional therapeutic agent is an immediate release agent. In some embodiments, the additional therapeutic agent is a controlled release agent. (0073] Accordingly, provided herein are controlled release antimicrobial agent formulations and compositions to locally treat auris media and/or auris interna structures, thereby avoiding side effects as a result of systemic administration of the antimicrobial agents. The locally applied antimicrobial agent formulations and compositions are compatible with auris media and/or auris interna structures, and are administered either directly to the desired auris media and/or auris interna structure, e g, the cochlear region or the tympanic cavity, or administered to a structure in direct communication with areas of the auris interna, including but not limited to the round window membrane, the crista fenestrae cochleae or the oval window membrane. By specifically targeting the auris media or auris interna structures, adverse side effects as a result of systemic treatment are avoided. Moreover, by providing a controlled release antimicrobial agent formulation or composition to treat otic disorders, a constant and/or extended source of antimicrobial agent is provided to the individual or patient suffering from an otic di sorder, reducing or eliminating the variability of treatment. (0074] Intratym panic injection of therapeutic agents i s the technique of injecting a therapeutic agent behind the tympanic membrane, into the auris media and/or auris interna. Despite early success with this technique (Sehuknecht, Laryngoscope (1956) 66, 859-870) some challenges do remain. For example, access to the round window membrane, the site of drug absorption into the auris interna, can be challenging.

[0075] However, intra-tympanic injections create several unrecognized probi ems not addressed by currently available treatment regimens, such as changing the osmolality and pH of the perilymph and endolymph, and i ntroducing pathogens and endotoxins that directly or indirectly damage inner ear structures. One of the reasons the art may not have recognized these problems is that there are no approved intra-tympanic compositions: the inner ear provides sui generis formulation challenges. Thus, compositions developed for other parte of the body have little to no relevance for an intra-tympanic composition. jft076J There is no guidance in the prior art regarding requirements (e.g., level of sterility, pH, osmolarity) for otic formulations that are suitable for administration to humans. There is wide anatomied disparity between the ears of animals across species. A consequence of the inter-species differences in auditory structures is that animal models of inner ear disease are often unreliable as a tool for testing therapeutics that are being developed for clinical approval. 100771 Provided herein are otic formulations that meet stringent criteria for pi 1. osmolarity, ionic balance, sterility, endotoxin and/or pyrogen levels. The auris compositions described herein are compatible with the microenvironment of the inner ear (e.g., the perilymph) and are suitable for administration to humans. In some embodiments, the formulations described herein comprise dyes and aid visualization of the administered compositions obviating the need for invasive procedures (e.g. , removal of perilymph) during preclinica! and/or clinical development of intratympanie therapeutics. {0078} Provided herein are controlled release antimicrobial agent formulations and compositions to locally treat targeted auris structures, thereby avoiding side effects as a result of sy stemic administration of the antimicrobial agent formulations and compositions. The locally applied antimicrobial agent formulations and compositions and devices are compatible with the targeted auris structures, and administered either directly to the desired targeted auris structure, e.g, the cochlear region, the tympanic cavity or the external ear, or administered to a structure in direc t communication with areas of the auris interna, including but not limited to the round window membrane, the crista fenestrae cochleae or the oval window^ membrane. By specifically targeting an auris structure, adverse side effects as a result of systemic treatment are avoided. Moreover, clinical studies have shown the benefit of having long term exposure of drug to the perilymph of the cochlea, for example with improved clinical efficacy of sudden hearing loss when the therapeutic agent is given on multiple occasions. Thus,, by providing a controlled release antimicrobial agent formulation or composition to treat otic disorders, a constant, and/or extended source of antimicrobial agent is provided to the .individual or patient suffering from an otic disorder, reducing or eliminating variabilities in treatment. Accordingly, one embodiment disclosed herein is to. provide a composition that enables at least one antimicrobial agent to be released in therapeutically effective doses either at variable or constant rates such as to ensure a continuous release of the at least one agent.. In some embodiments, the antimicrobial agents disclosed herein are administered as an immediate release formulation or composition, hr other embodiments, the antimicrobial agents are administered as a sustained release fonnulation, released either continuously, variably or in a pulsatile manner, or variants thereof. In still other embodiments, antimicrobial agent formulation is administered as both an immediate release and sustained release formulation, released either continuously, variably or in a pulsatile manner, or variants thereof. The release is optionally dependent on environmental or physiological conditions, for example, the external ionic environment (see, e.g. Oros® release system, Johnson &amp; Johnson). 100791 In addition, the auris-acceptable controlled-release antimicrobial agent formulations and treatments described herein are provided to the target ear region of the individual in need, including the inner ear, and the individual in need is additionally administered an oral dose of antimicrobial agent, in some embodiments, the ora! dose of antimicrobial agent is administered prior to administration of the auris-acceptable controlled-release antimicrobial agent formulation, and then the oral dose is tapered off over the period of time that the auris-acceptable controlled-release antimicrobial agent formulation is provided. Alternatively, the oral dose of antimicrobial agent is administered during administration of the auris-acceptable controlled-release antimicrobial agent formulation, and then the oral dose is tapered off over the period of time that the auris-acceptable controlled-release antimicrobial agent formulation is provided. Alternatively, the oral dose of antimicrobial agent is administered after administration of the auris-acceptable controlled-release antimicrobial agent formulation has been initialed, and then the oral dose is tapered off over the period of time that tire auris-acceptable controlled-release antimicrobial agent formulation is provided.

[0080'j In addition, the antimicrobial agent pharmaceutical compositions or formulations or devices included herein also include carriers, adjuvants, such as preserving, stabilizing. 'wetting or emulsifying agents, solution promoters, salts for regulating the osmotic pressure, and/or buffets. Such earners, adjuvants, and other excipients will be compatible with the environment in the targeted auris structure!'s). Accordingly, specifically contemplated for the compositions and devices described herein are carriers, adjuvants and excipients that lack ototoxicity or are minimally ototoxic in order to allow effective treatment of the otic disorders contemplated herein with minimal side effects in the targeted, regions or areas. [0081j Intratyinpauic injection of compositions or devices creates several additional problems that must also be addressed before the composition or device can be administered. For example, there are many excipients that are ototoxic. While these excipients can be used when formulating an active agent for delivery by another method (e.g., topical;), their use should be limited, reduced or eliminated when formulating a delivery device to be administered to the ear due to their ototoxic effects.

[0082| By way of non-limiting example, the use of the following commonly used solvents should be limited, reduced or eliminated when formulating agents for administration to the ear: alcohols, propylene glycol, and cyclohexane. Thus, in some embodiments, a device disclosed herein is free or substantially free of alcohols, propylene glycol, and cyclohexane. In some embodiments, a device disclosed herein comprises less than about 50 ppm of each of alcohols, propylene glycol, and cyclohexane. In some embodiments, a device disclosed herein comprises less than about 25 ppm of each of alcohols, propylene glycol, and cyclohexane. In some embodiments, a device disclosed herein comprises less than about 2() pptft of each of alcohols, propylene glycol, and cyclohexane. In some embodiments, a device disclosed herein comprises less than about 10 ppm of each of alcohols, propylene glycol, and cyclohexane, in some embodiments, a device disclosed herein comprises less than about 5 ppm of each of alcohols, propylene glycol, and cyclohexane. In some embodiments, a device disclosed herein comprises less than about 1 ppm. of each bf alcohols, propylene glycol, and cyclohexane. (0Q$3j Further, by way of non-limiting example, the use of the following commonly utilized preservatives should be limited, reduced or eliminated when formulating agents tor administration to the ear: Benzethonium chloride, Benzalkonium chloride, and ThiomersaL Thus, in some embodiments, a device disclosed herein is free or substantially free of benzethonium chloride, benzalkonium chloride, and thiomersal. In some embodiments, a device di sclosed herein comprises less than about 50 ppm of each of benzethonium chloride, benzalkonium chloride, and thiomersal. In some embodiments, a .device disclosed herein comprises less than- about 25 ppm of each of benzethonium chloride, benzalkonium chloride, and thiomersaL In some embodiments, a device disclosed herein comprises less than about 20 ppm of each of benzethonium chloride, benzalkonium chloride, and thiomersal. In some embodiments, a device disclosed herein comprises less than about10 ppm of each of henzethonium chloride, benzalkonium chloride, and thiomersal. In some embodiments, a device disclosed herein comprises less than about 5 ppm of each of benzethonium chloride, benzalkonium chloride, and thiomersal. In some embodiments, a device disclosed herein comprises less than about 1 ppm of each of benzethonium chloride, benzalkonium chloride, and thiomersal.

[0084] Certain antiseptics used to disinfect components of therapeutic preparations (or the devices utilized to administer the preparations) should be limited, reduced, or eliminated in otic preparations. For example, acetic acid, iodine, and merbromin are all known to lie ototoxic. Additionally, ehlorhexidene, a commonly used antiseptic, should be limited, reduced or el iminated to disinfect any component of an otic preparation (including devices used to administer the preparation) as it is highly ototoxic in minute concentrations (e.g., 0,05%), Thus, in some embodiments, a device disclosed herein is free or substantially free of acetic acid, iodine, merbromin, and ehlorhexidene. In some embodiments, a device disclosed herein comprises less than about 50 ppm of each of acetic acid, iodine, merbromin, and ehlorhexidene. In some embodiments, a device disclosed herein comprises less than about 25 ppm of each of acetic acid, iodine, merbromin, and ehlorhexidene. In some embodiments, a device disclosed herein comprises less than about 20 ppm of each of acetic acid, iodine, merbromin, and ehlorhexidene. in some embodiments, a device disclosed herein comprises less than about 10 ppm of each of acetic acid, iodine, merbromin, and ehlorhexidene. In some embodiments, a device disclosed herein comprises less than about 5 ppm of each of acetic acid, iodine, merbromin, and ehlorhexidene. In some embodiments, a device disclosed herein comprises less than about 1 ppm of each of acetic acid, iodine, merbromin, and ehlorhexidene.

[00851 Further, otic preparations require particularly tow concentrations of several potentially-common contaminants that are known to be ototoxic. Other dosage forms, while seeking to limit the contamination attributable to these compounds, do not require the stringent precautions that otic preparations require. For example, the following contaminants should be absent or nearly absent horn otic preparations: arsenic, lead, mercury, and tin. Thus, in some embodiments, a device disclosed herein is free or substantially free of arsenic, lead, mercury, and tin. In some embodiments, a device disclosed herein comprises less than about 50 ppm of each of arsenie, lead* mercury, and tin. In some embodiments, a device disclosed herein comprises less than about 25 ppm of each of arsenic, lead, mercury, and tin. In some embodiments, a device disclosed herein comprises less than about 20 ppm of each of arsenic, lead, mercury, and tin. In some embodiments, a device disclosed herein comprises less than about 10 ppm of each of arsenic, lead, mercury', and tin. In some embodiments, a device disclosed herein comprises less than about 5 ppm of each of arsenic, lead, mercury, and tin. In some embodiments, a device disclosed herein comprises less than about 1 ppm of each of arsenic, lead, mercury , and tin. 10086} To prevent ototoxicity, antimicrobial agent pharmaceutical compositions or formulations or devices disclosed herein are optionally targeted to distinct regions of the targeted turns structures,including but not limited to the tympanic cavity,-vestibular bony and membranous labyrinths, cochlear bony and membranous labyrinths and other anatomical or physiological structures located within the auris interna.

Certain Definitions [0087| The term “auris-aeeeptable” with respect to a formulation, composition or ingredient, as used herein, includes having no persistent detrimental effect on the auris interna (or inner ear) of the subj ect being treated . By "auris-pharmac eutically acceptable,” as used herein, refers to a material, such as a carrier or diluent, which does not abrogate the bi ological activity or properties of the compound in reference to the auris interna (or i nner ear), and is relatively or is reduced in toxicity to the auris interna (or inner ear), Le,s the material is administered to an individual without: causing undesirable biological effects or interacting in a deleterious manner with any of the components of the composition in which it is contained. {00.88} As used herein, amel ioration or lessening of the symptoms of a particular: oti c disease, disorder or condition by administration of a particular compound or pharmaceutical composition refers to any decrease of severity, delay in onset, slowing of progression, or shortening of duration, whether permanent or temporary'', lasting or transient that is attributed to or associated with administration of the compound or composition, (0089] “Antioxidants” are auris-pharmaceutically acceptable antioxidants, and include, for example, butylated hydroxytoluene (BHT), sodium; ascorbate, ascorbic acid, sodium metabisulfite and tocopherol. In certain embodiments, antioxidants enhance chemical stability where required. Antioxidants are also used to counteract the ototoxic effects of certain therapeutic agents, including agents that are used in combination with the antimicrobial agents disclosed herein.

[0090] “Anris interna” refers to the inner ear, including the cochlea and the vestibular labyrinth, and the round window that connects the cochlea with the middle ear.

[0091] “Auris-interna bioavailability” refers to the percentage of the administered dose of compounds disclosed herein that becomes available in the inner ear of the animal or human being studied.

[0092] “Anris media” refers to the middle ear, including the tympanic cavity, auditory ossicles and oval window, which connects the middle ear with the inner ear.

[0093] “Balance disorder” refers to a disorder, illness, or condition which causes a subject to feel unsteady, or to have a sensation of movement. Included in this definition are dizziness, vertigo, disequilibrium, and pre-syncope. Diseases which are classified as balance disorders include, but are not limited to, Ramsay Hunt’s Syndrome, Meniere’s Disease, mal de debate] uement, benign paroxysmal positional vertigo, and labyrinthitis.

[0094] “Blood plasma concentration” refers to the concentration of compounds provided herein in the p lasm a com ponent of blood of a subject.

[0095] “Carrier materials" are excipients that are compatible with the antimicrobial agent, the auris interna and the relea.se profile properties of the auris-acceptabie pharmaceutical formulations. 'Such'carrier materials include, e.g., binders, suspending agents, disintegration agents, filling agents, surfactants, solubilizers, stabilizers, lubricants, wetting agents, diluents, and the like. “Auris-pharmaeeutieally compatible carrier materials” include, but are not limited to, acacia, gelatin, colloidal silicon dioxide, calcium glycerophosphate, calcium lactate, maltodextrin, glycerine, magnesium silicate, polyvinylpyrrolidone (PVP), cholesterol, cholesterol esters, sodium caseinate, soy lecithin, tauroeholic acid, phosphatidylcholine, sodium chloride, tricalcium phosphate, dipotassium phosphate, cellulose and cellulose conjugates, sugars sodium stearoyi lactylate, carrageenan, monoglyceride, diglyceride, pregelatiniz.ed starch, and the like.

[0096] The term “diluent” refers to chemical compounds that are used to dilute the antimicrobial agent prior to delivery and which are compatible with die auris interna.

[0097] “Dispersing agents,” and/or “viscosity modulating agents” are materials that control the diffusion and homogeneity of the antimicrobial agent through liquid media. Examples of diffusion facilitators/dispersing agents include but are not limited to hydrophilic polymers, electrolytes, Tween® 60 or 80, PEG, -polyvinylpyrrolidone (PVP; commercially known as. Plasdone'*'), and the carbohydrate-based dispersing agents such as, for example, hydroxypropyl celluloses (e.g., HPC, FIPC-SL, and PIPC-L), hydroxypropyl methykelluloses (e.g., HPMC KIOO, HPMC R4M, HPMC K15M, and HPMC RlOOM), carboxymethylcelluiose-sodium,methylceliulose, hycboxyethyicelluiose, hydroxypropylcellulose, hydroxypropylmetbylcellulose phthalate, hydroxypropylmethylcelluiose acetate stearate (HPMCAS), noncrystalline cellulose, magnesium aluminum silicate, triethanolamine, polyvinyl alcohol (PVA), vinyl pyrrolidone/viny 1 acetate copolymer ($630), 4-(1,1,3,3-tetramethvlbuty 1 (-phenol polymer with ethylene oxide and formaldehyde (also known as tyloxapol), poloxamers (e.g., Plutonics F68 "( F88®, and F108 % which are block copolymers of ethylene oxide and propylene oxide}:; and poloxaniines (e.g., Tetronic 908®, also known as Poloxamine 908®, which is a tetrafunctional block copolymer derived from sequential addition of propylene oxide and ethylene oxide to ethylenediamme (BASF Corporation, Parsippany.N.J.)), polyvinylpyrrolidone K12, polyvinylpyrrolidone K17, polyvinylpyrrolidone K25, or polyvinylpyrrolidone K30, polyvinylpyrrolidone/Vinyl acetate copolymer (S-630), polyethylene glycol, e.g., the polyethylene glycol has a molecular' weight of about 300 to about 6000, or about 3350 to about 4000, or about 7000 to about 5400, sodium carboxymethylcellulose, methylceliulose, polysorbate-80, sodium alginate, gums, such as, e.g., gum tragacanth and gum acacia, guar gum, xanthans, including xanthan gum, sugars, cellulosics, such as, sodium carboxymethyleelluiose, methylceliulose, sodium carboxymethylcellulose. polysorbate-80, sodium alginate, polyethoxyiated sorbitan monolaurate. polyetlioxylated sorbitan monolaurate, povidone, carbomers, polyvinyl alcohol (PVA), alginates, chitosans and combinations thereof. Plasticizers such as cellulose or triethyl cellulose are also be used as dispersing agents. Dispersing agents useful in liposomal dispersions and self-emulsifying dispersions of the antimicrobial agents disclosed herein are dimyristeyl phosphatidyl choline, natural phosphatidyl choline from eggs, natural phosphatidyl glycerol from eggs, cholesterol and isopropyl myri state. £00981 “Drug absorption’' or '‘absorption'’ refers to the process of movement of the antimicrobial agents from tire localized site of administration, byway of example only, the round window membrane of the inner ear, and across a barrier (the round window membranes, as descri bed below) into the auris interna or inner ear structures. The terms “co-administration.” or the like, as used herein, are meant to encompass administration of the antimicrobial agents to a single patient, and are intended to include treatment regimens in which the ..antimicrobial agen ts are admi nistered by the same or different route of administration or at the same or different time.

[6099] The terms "effective amount” or "therapeutically effective -amount»” :as used herein, refer to a sufficient .amount of the active agent or otic agent (e.g.. air antimicrobial agent, an anti-inflammatory agent) being administered .that-would be expected to relieve to Some extent one or more of the symptoms of the disease or condition being treated. For example, the result of administration of an antimicrobial agent disclosed herein is reduction and/or alleviation of tire signs, symptoms, or causes of tinnitus or balance disorders. For example, an “effective amount” for therapeutic uses is the amount of antimicrobial agent, including a .formulation as disclosed herein, required to provide a decrease or amelioration in disease symptoms without undue adverse side effects. The term ‘‘therapeutically effective amount” includes, for example, a piophylactically effective amount. An “effective amount” of an antimicrobial agent disclosed herein is an amount effective to achieve a desired pharmacologic effect or therapeutic improvement without undue adverse side effects. It is understood that “an effective amount” or “a therapeutically effective amount” varies, in some embodiments, from subject to subject, due to variation in metaboli sm of the compound administered, age, weight, general condition of the subject, the condition being treated, the severity of the condition being treated, and the judgment of the prescribing physician. It is also understood that “an effective amount” in an extended-release dosing format may diff er from “an effecti ve amount” in an immediate release design format based upon pharmacokinetic and pharmacodynamic considerations.

[601.00] The terms “enh ance'' or “enhancing” refers to an increase or prolongation of either the potency or duration of a desired effect of antimicrobial agent, or a diminution of any adverse symptomatology that is consequent upon the administration of the therapeutic agent. Thus, in regard to enhancing the effect, of the antimicrobial agents disclosed herein, tire term “enhancing” refers to the ability to increase or prolong, either in-potency or duration, the effect of other therapeutic agents that are used in combination with the antimicrobial agent disclosed herein. An “enhancing-effective amount,” as used herein, refers to an amount of antimicrobial agent or other therapeutic agent which is adequate to enhance the effect of another therapeutic agent or antimicrobial agent of the target auris structure in a desired system. When used in a patient, amounts effective for this itse will depend on the severity and course of the disease, disorder or condition, previous therapy, the patient’s health status and response to the drugs, and the judgment of the treating physician. |<W1(U] The term “inhibiting” includes preventing, slowing, or reversing the development of a condition, for example, or advancement of a condition in a patient necessitating treatment. |00i02] The terms “kit” and “article, of manufacture” are used as synonyms, [00103} “Pharmacodynamics” refers to the 'factors· which determine the biologic response observed relative to the concentration of drug at the desired site wi thin the auris media and/or auris interna. ]00104| “Pharmacokinetics” refers to the factors: which determine the attainment and maintenance of the appropriate concentration of drug at the desired site within the amis media and/or auris interna, [00105] As used herein, the term “antimicrobial agent" refers to compounds that inhibit the growth, proliferation, or multiplication of microbes, or that kill microbes. Suitable “antimicrobial agents” may be antibacterial agents (effective against bacteria), antiviral agents (effective against viruses), antifungal agents (effective against fungi), antiprotozoal (effective against protozoa), and/or antiparasitic to any class of microbial parasites. “Antimicrobial agents”' may work by any suitable mechanism against the microbes, including by being toxic or cytostatic.

[00106] The phrase “antimicrobial small molecule" refers to antimicrobial compounds that are of relatively low molecular weight, e.g., less than 1,000 molecular weight, that are effective for the treatment of otic disorders, particularly otic disorders caused by pathogenic microbes, and are suitable for use in the formulations disclosed herein. Suitable “antimicrobial small molecules” include antibacterial, antiviral, antifungal, antiprotozoal, and antiparasitic small molecules.

[00107] The term “otic intervention" means an external insult or trauma to one or more auris structures and includes implants, otic surgery, injections, cannulations, or die like. Implants include auris-intema or auris-media medical devices, examples of which include cochlear implants, hearing sparing devices, hearing-improvement devices, tympanostomy tubes, short electrodes, micro-prostheses or piston-like prostheses; needles; stem cell transplants; drug delivery devices; any cell-based therapeutic; or the like. Otic surgery includes middle ear surgery, inner ear surgery; typanostomy, cochleostomy, labyrinthotomy, mastoidectomy, stapedectomy, stapedotomy, endolymphatic sacculotomy or the like, injections include intratympanic injections, intracochleaf injections, injections across the round window membrane or the like, Cannulations include intratympanic, intracoehlear, endolymphatic, perilymphatic or vestibular cannulations or the like.

[00108] In prophylactic applications, compositions comprising the antimicrobial agents described herein are administered to a patient susceptible to or otherwise at risk of a particular disease, disorder or condition. For example, such conditions include and are not limited to otitis externa, otitis media, Ramsay Hunt syndrome, otosyphilis, A1ED, Meniere’s disease, and vestibular neuronitis. Such an amount is defined to be a “prophylacticatty effective amount or dose.'” In this use. the precise amounts also depend on the patient's state of health, weight, and the like.

[00109] As used herein, a “pharmaceutical device” includes any composition described herein that, upon adminstration to an ear, provides a reservoir for extended release of an active agent described herein.

[001.10] The term “substantially low degradation products” means less than 5% by weight of the active agent are degradation products of the active agent. In further embodiments, the term means less than 3% by weight of the active agent are degradation products of the active agent, In yet further embodiments, the term means less than 2% by weight of the active agent are degradation products of the active agent. In further embodiments, the term means less than 1 % by weight of the active agent are degradation products of the active agent. In some embodiments, any individual impurity (e.g,, metal impurity, degradation products of acti ve agent and/or excipients, or the like) present in a formulation described herein is less than 5%, less than 2%, or less than 1% by weight of the active agent. In some embodiments the formulation does not contain precipitate during storage or change in color after manufacturing and storage.

[β®111] As used herein "essentially in the form of micronized powder" includes, by way of example only, greater than 70% by weight of the active agent is in the form of micronized particles of the active agent. In further embodiments, the term means greater than 80% by weight of the active agent is in the form of micronized particles of the acti ve agent In yet further embodiments, the term means greater than 90% by weight of the active agent is in the form of micronized particles of the active agent. 100112| The mean residence time (M.RT) is the average time that molecules of an active agent (e.g., a microbial agent) reside in an otic structure after a dose. {00113] A “prodrug” refers to an antimicrobial agent that is converted into the parent drug in vivo. In certain embodiments, a prodrug is enzymatically metabolized by one or more steps or processes to the biologically, pharmaceutically or therapeutically active form of the compound. To produce a. prodrug, a pharmaceutically active compound is modified such that the active compound will be regenerated upon in vivo administration. In one embodiment, the prodrug is designed to alter the metabolic stability or the transport characteristics of a drug, to mask side effects or toxicity, or to alter other characteristics or properties of a drug. Compounds provided herein, in some embodiments, are derivatized into suitable prodmgs.

[00114] “Solubilizers*" refer to auris-acceptable compounds such as triacetin, triethyl citrate, ethyl oleate, ethyl eaprylate, sodium lauryl sulfate, sodium doccusate, vitamin E TPGS, dimetliylacetamide, 'N-methyipyrrolidone, N-hydroxyethylpyrroiidone, polyvinylpyriolidone, hydroxypropylmethyl cellulose, hydroxypropyl cyelodextrins, ethanol, n-butanol, isopropyl alcohol, cholesterol, bile salts, polyethylene glycol 2()0-60(), glyeofurol, transeutol, propylene glycol, and dimethyl isosorbide and the like that assist or increase the solubi lity of the antimicrobial agents disclosed herein. 1061151 “Stabilizers’' refers to compounds such as any antioxidation agents, buffers, acids, preservatives and the like that are compatible with the environment of the auris interna. Stabilizers include but are not limited to agents that will do any of {1) improve the compatibility of excipients with a container, or a delivery system, including a syringe or a glass bottle, (2) improve the stability' of a component of the composition, or (3 ) improve formulation stability.

[001161 “Stead iy state,” as used herein, is when the amount of drug administered to the auris interna is equal to the amount of drug eliminated within one dosing, interval resulting in a plateau or constant levels of drug exposure within the targeted structure.

[001171 As Used herein, the term “subject” is used to mean an animal, preferably a mammal, including a human or non-human. The terms patient and subject may be used interchangeably.

[00118J “Surfactants” refer to compounds that are auris-aeeeptable, such as sodium lauryl sulfate, sodium docusate, Tween 60 or 80. triacetin, vitamin E TPGS, sorbitan monooleate, polyoxyethylene sorbitan monooleate, polysorbates, polaxomers, bile salts, glyceryl monostearate, copolymers of ethylene oxide and propylene oxide, e.g., Pluronic*' (BASF), and the like. Some other -surfactants include, polyoxyethylene tatty acid glycerides and vegetable oils, e.g., polyoxyethylene (60) hydrogenated castor oil; and polyoxyethylene. alkylethers and alkylphenyl ethers, e,g., octoxynol 10,. octoxynol 40. In some embodiments, surfactants are included to enhance physical stability or for other purposes. (00119] The terms ‘treat,” “treating” or “treatment,” as used herein, include alleviating, abating or ameliorating a disease or condition, for example tinnitus, symptoms, preventing additional symptoms, ameliorating or preventing the underlying metabolic causes of symptoms, inhibiting the disease or condition, e.g., arresting tire development of the disease or condition, relieving the disease or condition, causing regression of the disease or condition, relieving a condition caused by the disease or condition, or stopping the symptoms of the disease or condition either prophylactieally and/or therapeutically.

[00120( Other objects, features, and advantages of the methods and compositions described herein will become apparent from the following detailed description. It should be understood, however, that tire detailed description and the specific examples, while indicating specific embodiments, are given by way of illustration only.

Anatomy of the Ear (00121] As shown in Figure 4, the outer ear is the external portion of the organ and is composed of the pinna (auricle), the auditory canal (external auditory meatus) and the outward facing portion of the tympanic membrane, also known as the ear drum. The pinna, which is the fleshy part of the external ear that is visible on the side of the head, collects sound waves and directs them toward the auditory canal. Thus, the function of the outer ear. in part, is to collect and direct sound waves towards the tympanic membrane and the middle ear.

[00l22|The middle ear is an air-filled cavity, called the tympanic cavity, behind the tympanic membrane. Πιε tympanic membrane, also known as the ear drum, is a thin membrane that separates the external ear from the middle ear. The middle ear lies within the temporal bone, and includes·'within this space the three ear bones (auditory ossicles): the malleus, the incus and the stapes. The auditory ossicles are linked together via tiny ligaments, which form a bridge across the space of the tympanic cavity. The malleus, which is attached to the tympanic membrane at one end, is linked to the incus at its anterior end, which in turn is linked to the stapes. The stapes is attached to the oval window, one of two windows located within the tympanic cavity . A fibrous tissue layer, known as the annular ligament connects the stapes to the oval window. Sound waves from the outer ear first cause the tympanic membrane to vibrate. The vibration is transmitted across to the cochlea through the auditory ossicles and oval window, which transfers the motion to the fluids in the auris interna. Thus, the auditory ossicles are arranged to provide a mechanical linkage between the tympanic membrane and the oval windo w of the fluid-filled auris interna, where sound is transformed and transduced to the auris interna for further processing. Stiffness, rigidity or loss of movement of the auditor}· ossicles, tympanic membrane or oval window leads to hearing loss, e.g. otosclerosis, or rigidity of the stapes bone.

[0D123]The tympanic cavity also connects to the throat via the eusiachian tube. The eustachian tube provides the ability to equalize the pressure between the outside air and the middle ear cavity. The round window, a component of the auris interna but which is also acce ssible within the ty mpanic ca vity , opens into the cochlea of the auri s interna. The round window is covered by round window membrane, which consists of three layers: an external or mucous layer, an intermediate or fibrous layer, and an internal membrane, which communicates directly with the cochlear fluid. The round window", therefore, has direct communication with the auris interna via the internal membrane.

[00124] Movements in the oval and round window are interconnected, i.e. as the stapes bone transmits movement from the tympanic membrane to the oval window to move inward against the.auris interna fluid, the round window·' (round window membrane) is correspondingly pushed out and away from the cochlear fluid. This movement of the round windo w allows movement of fluid within the cochlea, which leads in him to movement of the cochlear inner hair cells, allowing hearing signals to be transduced.-.Stiffness and rigidity in round window membrane leads to hearing loss because of the lack of ability of movement in the cochlear fluid. Recent studies have focused on implanting mechanical transducers onto the round window, which bypasses the normal conductive pathway through the oval window and provides amplified input into the cochlear chamber.

[00125] Auditor}" signal transduction takes place in the auris' interna. The fluid-filled auris interna, or inner ear. consists of two major components: the cochlear and the vestibular apparatus. The auris interna is located in part within the osseous or bony labyrinth, an intricate series of passages in the temporal bone of the skull. The vestibular apparatus is the organ of balance and consists of the three semi-circular canals and the vestibule. The three semi-circular canals are arranged relative to each other such that movement of the head along the three orthogonal planes in space can be detected by the movement of the fluid and subsequent signal processing by the sensory organs of the semi-circular canals, called the crista ampullaris. The crista ampullaris contains hair cells and supporting cells, and is covered by a dome-shaped gelatinous mass called the cupula. The hairs of the hair cells are embedded in the cupula. The semi-circular canals detect dynamic equilibrium, the equilibrium of rotational or angular movements, (.60126] When the head turns rapidly, the semicircular canals move with the head, but endolymph fluid'located in the membranous semi-circular canals tends to remain stationary,. The endolymph fluid pushes against the cupula, which tilts to one side. As the cupula tilts, it. bends some of the hairs on the hair cells of the crista ampullaris, which triggers a sensory impulse. Because each semicircular canal is located in a different plane, the corresponding crista ampullaris of each semi-circular canal responds differently to the same movement of the head. This creates a mosaic of impulses that, are transmitted to the central nervous system on the vestibular branch of the vestibulocochlear nerve. The central nervous system interprets this information and initiates the appropriate responses to maintain balance. Of importance in the central nervous system is the cerebellum, which mediates the sense of balance and equilibrium. (60127] The vestibule is the central portion of the auris interna and contains mechanoreceptors bearing hair cells that ascertain static equilibrium, or the position of the head relative to gravity. Static equilibrium plays a role when the head is motionless or moving in a. straight line. The membranous labyrinth in the vestibule is divided into two sac-like structures, the utricle and the saccule. Each structure in turn contains a small structure called a macula, which is responsible for maintenance of static equilibrium. The macula consists of sensory hair cells, which are embedded in a gelatinous mass (similar to the cupula) that covers the macula. Grains of calcium carbonate, called otoliths, are embedded on the surface of the gelatinous layer.

[00128( When the head is in an upright position, the hairs are straight along the macula.

When the head tilts, the gelatinous mass and otoliths tilts correspondingly, bending some of the hairs on the hair cells of the macula. T his bending action initiates a signal impulse to the central nervous system, which travels via the vestibular branch of the vestibulocochlear nerve, which in turn relays motor impulses to the appropriate muscles to maintain balance. [00129( The cochlea is the portion of the auris interna related to hearing. The cochlea is a: tapered tube-like structure which is coiled into a shape resembling a snail. The inside of the cochlea is divided into three regions, which is further defined by the-position of the vestibular membrane and the basilar membrane. The portion above the vestibular membrane is the seal a vestibuli, which, extends from the oval window to the apex of the cochlea and contains perilymph..fluid, an aqueous liquid low in potassium and high in sodium content.

The basilar membrane defines the scala tympani region, which extends from the apex of the cochlea to the round window and also contains perilymph. The basilar membrane contains thousands of stiff fibers, which gradually increase in length from the round window to the apex of the cochlea. The fibers of the basement membrane vibrate when activated by sound. In between the scala vestibuli and the scala tympani is the cochlear duet, which ends as a closed sac at tire apex of the cochlea. The cochlear duet contains endolymph fluid, which is similar to cerebrospinal fluid and is high in potassium, [60130] The organ of Corti, the sensory organ for hearing, is located on the basilar membrane and extends upward into the cochlear duct. The organ of Corti contains hair cells, which have.hairlike projections that extend from their tree surface, and contacts a gelatinous surface called the tectorial membrane. Although hair cells have no axons, they are surrounded by sensory nerve fibers that form the cochlear branch of the vestibulocochlear nerve (cranial nerve VII l), [00131] As discussed, the oval window, also known as the elliptical window communicates with the stapes to relay sound waves that vibrate from the tympanic membrane. Vibrations transferred to the oval window1 increases pressure inside the fluid-filled cochlea via the perilymph and scala vestibuli/scala tympani, which in turn causes the round window membrane to expand in response, The concerted inward pressing of the oval window/outward expansion of the round window allows for the movement of fl uid within the cochlea without a change of intra-cochlear pressure. However, as vibrations travel through the perilymph in the scala vestibuli, they create corresponding oscillations in the vestibular membrane. These corresponding oscillations travel through the endolymph of the cochlear duct, and transfer to the basilar membrane. When the basilar membrane oscillates, or moves up and down, the organ of Corti moves along with it. The hair cell receptors in the Organ of Corti then move against the tectorial membrane, causing a mechanical deformation in the tectorial membrane. This mechanical deformation initiates the nerve impulse which travels via the vestibulocochlear nerve to the central nervous system, mechanically transmitting the sound wave received into signals that are subsequently processed by die central nervous system.

Diseases [06132] Otic disorders, ineluding amis interna, auris media, and auris externa disorders, produce symptoms which include but are not limited to healing loss, nystagmus, vertigo, tinnitus, inflammation, swelling, infection and congestion. These disorders may have many causes,; such as infection, injury, -inflammation, tumors and adverse response to drugs or other chemical agents.

Inflammatory Disorders of the Ear (00133] Otitis externa (OE), also referred to as swimmer's ear. is an inflammation and/or infection of the external ear. OE is often caused by bacteria in the outer ear, which establish infection following damage to the skin of the ear canal. Primary bacterial pathogens that cause OE are Pseudomonas aeruginosa and Staphylococcus aureus, but the condition is. associated with the presence of many other strains of gram positive and negative bacteria. OE is also sometimes caused by fungal infection in the outer ear, including Candida albicans and Aspergillus. Symptoms of OE include otalgia, swelling, and otorrhea. If the condition progresses significantly, OE may cause temporary conductive hearing loss as a result of the swelling and discharge.

[00134] Treatment of OE in volves eliminating the aggravating pathogen from the ear canal and reducing inflammation, which is usually accomplished by administering combinations of antimicrobial agents, e.g., antibacterial and antifungal agents, with antiinflammatory agents, e.g., steroids. Typical antibacterial agents for the treatment of OE include aminoglycosides' (e.g., neomycin, gentamycin, and tobramycin), polymyxins (e.g., polymyxin B)s fluoroquinolone (e.g.. ofloxacin, ciprofloxacin, levofloxaein, trovafloxacin), cephalosporins (e.g., eefuroxime, cefiaeor, cefproziL loraearbefi cefindir, eeflxime, cefpodoxime proxetiL cefibuten, and ceftriaxone), penicillins (e.g., amoxicillin, amoxicillin-clavulanate, and penicillinase-resistant penicillins), and combinations thereof. Typical antifungal agents for the treatment of OE include clotrimazole, thimerasol, M-cresyl acetate, tolnaftate, itraconazole, and combinations thereof. Acetic acid is also administered to the ear, alone and in combination with other agents, to treat bacterial and fungal infections. Ear drops are often used as the vehicle for administration of foe active agents. In the case that ear swelling has progressed substantially and ear drops do not penetrate significantly into the ear canal, a wick can be inserted into the ear-canal to facilitate penetration of the treatment solutions. Oral antibiotics are also administered in the case of extensive soft tissue swelling that extends to foe face and neck. When the pain of OE is extremely severe such that it interferes with normal activity, e.g., sleeping, pain relievers such as topical analgesics or oral narcotics may be given until the underlying inflammation and infection are alleviated. {e0135{Notabl>\ some types of topical ear drops, such as ear drops containing neomycin, are safe and effective for use in the ear canal, but can be irritating and even ototoxic to the auris media, prompting concern that such topical preparations should not be used unless the tympanic membrane is known to be intact. Utilization of'the formulations disclosed herein for the treatment of OE allows for use of active agents that are potenti ally damaging to the auris media, even when the tympanic membrane is not intact Specifically, the controlled release formulations disclosed herein can be applied locally in the external ear with improved retention time, thus eliminating concern that the active agents will leak out of the ear canal into the auris media, Furthermore, otoprotectants can be added when ototoxic agents, such as neomycin, are used. |00I36}Treatment of severe QE with the antimicrobial compositions disclosed herein, particularly highly viscous and/or mueoadhesive formulations, also obviates the need for extended use of an ear wick. Specifically, the compositions disclosed herein have increased retention time in the ear canal as a result of tire formulation technology, thus eliminating the need for a device to maintain their presence in the outer ear. The formulations can be applied in the outer ear with a needle or an ear dropper, and the active agents can be maintained at the site of inflammation without the aid of an ear wick. In some embodiments, antimicrobial agent compositions described herein further comprise anti-inflammatory agents and are useful in the treatment of otitis externa. 100137] In some embodiments, the treatment of OE with antimicrobial formulations disclosed herein encompasses the treatment of granular myringitis, a specific form of OB characterized by chronic inflammation of the pars tensa of the tympanic membrane. The outer epithelial and underlying fibrous layers of the tympanic membrane are replaced by a proliferating granulation tissue. I he predominant symptom is foul-smelling otorrhea. A variety of bacteria and fungi cause the condition, including Proteus and Psuedomonm species. Accordingly, antimicrobial agent formulations disclosed herein comprising antibacterial or antifungal agents are useful for the treatment of granular myringitis. 100138] In some embodiments, the treatment of OE with antimicrobial formulations disclosed herein encompasses the treatment of chronic, stenosing otitis externa. Chronic stenosing otitis externa is characterized by repeated infections, typically caused by bacteria or fungi. The primary symptornsare pruritus in the ear canal, otorrhea, and chronic swelling. Antimicrobial agent formulations disclosed herein comprising antibacterial or antifungal agents are useful for the treatment of .chronic stenosing otitis externa. 1001391¾ In some embodiments, the treatment of OE with antimicrobial formulations disclosed herein encompasses the treatment of malignant or necrotizing external otitis, an infection involving the temporal and adjacent bones. Malignant external otitis is typically a complication of external otitis. It occurs primarily in persons with compromised immunity, especially in older persons with diabetes mellitus, Malignant external otitis is often caused by the bacteria Pseudomonas aeruginosa. Treatment typically involves correction of immunosuppression when possible, in conjunction with antibacterial therapy and pain relievers. According, antimicrobial agent formulations disclosed herein are useful for the treament of malignant or necrotizing external otitis. {00140] Otitis -.media (OM), which includes acute otitis media (AOM), chronic otitis media, otitis media with effusion (OME), recurrent acute otitis media (RAOM), chronic otitis media with effusion (COME), secretory otitis media, and chronic secretory otitis media as examples, is a condition affecting both adults and children. QM susceptibility is multifactorial and complex, including environmental, microbial and host factors. Bacterial infection accoun ts for a large percentage of OSV! cases, with more than 40% of cases attributed to Streptococcus pneumoniae infection. However, viruses, as well as other microbes, may also account for OM conditions. In some instances, otitis media is associated with eustachian tube dysfunction that is caused by, for example, anatomic blockage to inflammation, secondary to allergies, upper respiratory tract infection (liRTf), trauma or the like. {00141] Otitis media with effusion (OME) is characterized by a nonpurulent effusion of the middle ear that may be either mucoid or serous. Symptoms usually involve hearing loss or aural fullness. In children, hearing loss is generally mild and is often detected only with an audiogram. Serous otitis media is a specific type of OME caused by transudate formation as a result of a rapid decrease in middle car pressure relative to the atmospheric pressure. {00142] Because OM can be caused by a virus, bacteria or both, it is often difficult to identify' the exact cause and thus the most appropriate treatment. Treatment.-options· for OM include antibiotics, such as penicillins (e.g., amoxicillin and amoxicillin-clavulanaie), clavulanate acid, trimethoprim-suliamethoxazole, fluoroquinolone (e.g,. ofloxacin, ciprofloxacin, levofloxaein, travafloxacin), cephalosporins (e.g., cefuroxime, ceflaeor, ceiprozil. loracarbef, eefindir, cefixime, cefpodoxime proxetiL cefibuten, and ceftriaxone), macrolides and-azatid.es (e.g., erythromycin, clarithromycin, and azithromycin), sulfonamides, and combinations thereof. Surgical intervention is also available, including myringotomy, an operation to insert a tympanostomy tube through the tympanic membrane and into the patient’s middle ear to drain the fluid and balance the pressure between the outer and middle ear. Antipyretics and analgesics, including benzoeaine, ibuprofen and acetaminophen, may also be prescribed to treat accompanying fever or pain effects. Antimicrobial agent compositions disclosed herein comprising antibacterial or antifungal agents are useful for the treatment of Otitis media (DM), which includes acute otitis media (AOM), chronic otitis media, otitis media with effusion (OME), recurrent acute otitis media (RAOM), chronic otitis media with effusion (COME), secretory otitis media, and chronic-secretory otitis media or the like. In some embodiments, antimicrobial agent compositions described herein further comprise anti-inflammatory agents and are useful in the treatment of Otiti s media (DM), which includes acute otitis media (AOM), chronic otitis media, otitis media with effusion (OME), -recurrent.acute otitis media (RAOM), chronic otitis media with effusion (COME), secretory' otitis media, and chronic secretory otitis media or the like, [00143j Regardless of the causative agent, increases in cytokine production, including interleukins and TNF, have been observed in the effluent media of individuals afflicted with OM. 11.,-1β, 1L-6 and TNF-ce are acute-phase cytokines that promote acute inflammatory response after infection with viruses and bacteria. Moreover, higher TNF-α levels have been associated with a history of multiple tympanostomy tube placements, indicating a role lor TNF-α. in chronic OM cases. Finally, direct injection of TNF-α and interleukins has been shown to induce middle ear inflammation in a guinea pig model. These studies support the role that cytokines may play in the origin and maintenance of OM in the auris media. Thus, treatment of OM includes the use of antimicrobial agents in conjunction with an tiinflammatory agents to eliminate the pathogen and treat the symptoms of inflammation. Such treatments include use of steroids, TNF-α inhibitors, platelet activating factor antagonists, nitric oxide synthase inhibitors, histamine antagonists, and combinations thereof in conjunction with the antimicrobial formulations disclosed herein.

[00144) Mastoiditis is an infection of the mastoid process, which is the portion of the temporal bone behind the car. It is typically caused by untreated acute otitis media. Mastoiditis may be acute or chronic. Symptoms include pain, swelling, and tenderness in the mastoid region, as well as otalgia, erythematous, and otorrhea. Mastoiditis typically occurs as bacteria spread from the middle ear to the mastoid air cells, where the -inflammation causes damage to the bony .structures. The most common bacterial pathogens are Streptococcus pneumoniae, Streptococcus pyogenes. Staphylococcus aurem, and gramnegative bacilli. Accordingly, antimicrobial agent formulations disclosed herein comprising antibacterial agents effective against the bacteria are useful for the treatment of mastoiditis, including acute mastoiditis and chronic mastoiditis.

[001,45] Bullous myringitis is an infection of the tympanic membrane, caused by a variety of bacteria and viruses, including Mycoplasma bacteria. The infection leads to inflammation of the tympanic membrane and nearby canal , and causes the formation of blisters on the ear drum. The primary symptom of Bullous myringitis is pain, which may be relieved through the administration of analgesics. Antimicrobial formulations disclosed herein comprising antibacterial and antiviral agents are useful for the treatment of Bullous myringitis, [00146] Eustachian tubal catarrh, or Eustachian salpingitis, is caused from inflammation and swelling of the Eustachian tubes, resulting in a build-up of catarrh. Accordingly, antimicrobial formulations di sclosed herein are useful for the treatment of Eustachian salpingitis, [()0147] Labyrinthitis, e.g,, serous labyrinthitis» is an inflammation of the inner ear that involves one or more labyrinths housing the vestibular system. The primary symptom is vertigo, but the condition is also characterized by hearing loss, tinnitus, and nystagmus. Labrynthitis maybe acute, lasting for one to six weeks and being accompanied by severe vertigo and vomiting, or chronic, with Symptoms lasting for months or even years, labyrinthitis is typically caused by viral or bacterial infection. Accordingly, antimicrobial formulations disclosed herein comprising antibacterial and antiviral agents are useful for the treatment of labyrinthitis.

[00148] Faci al nerve neuritis is a form of neuritis, an inflammation of the peripheral nervous system, afflicting the facial nerve. The primary symptoms of the condition are a tingling and burning sensation, and stabbing pains in the affected nerves. In severe cases, there may be numbness, loss of sensation, and paralysis of the nearby muscles. The condition is typically caused by herpes zoster or herpes simplex viral infection, but has also been associated with bacterial infection, e.g., leprosy. Accordingly, antimicrobial fominlations disclosed herein comprising antibacterial and antiviral agents are useful for the treatment of facial nerve neuritis.

[00149] In some embodiments, antimicrobial formulations disclosed herein are also useful for the treatment of temporal bone osteoradioneeiOsis.

Ramsay Hunt Syndrome (Herpes Zoster (Mens) (00150] Ramsay Hunt syndrome is caused by a herpes zoster infection of the auditory nerve. The infection may cause severe ear pain, hearing loss, vertigo, blisters on the outer ear, in. the ear canal, as well as on the skin of the face or neck supplied by the nerves. Facial muscles may also become paralyzed if the faci al nerves are compressed by the swelling. Hearing loss may be temporary or permanent, with vertigo symptoms usually lasting from several days to weeks* 100151} Treatment of Ramsay Hunt’s syndrome includes administration of antiviral agents, such as ganciclovir, acyclovir, famciclovir and valacyclovir. Antiviral agents may he given in combination with agents that treat symptoms of the infection, such as corticosteroids, analgesics and narcotics to relieve the pain, and scopolamine, diazempam, or other central nervous system agents to suppress vertigo. Capsaicin, lidocainc patches and nerve blocks may also be used. Surgery may fee performed on compressed facial nerves to relieve facial paralysis,

Ofosyphilis [00152} Syphilis is a venerea! disease, caused by the spirochete Treponema pallidum, which in its secondary and tertiary stages may result in otic disorders, particularly cochleovestibular disorders, due to membranous labyrinthitis, and secondarily meningitis. Both acquired and congenital syphilis can cause otic disorders. Symptoms of cochleovestibular disorders resulting from syphilis are often similar to those of other otic disorders, such as AIED and Meniere's disease, and include tinnitus, deafness, vertigo, malaise, sore throat headaches, and skin rashes. Syphilis infection may lead to congenital prenatal hearing loss, affecting approximately 11.2 per 100,000 live births in the United States, as well as sudden hearing loss in adults.

[00153]Treatment of otosyphilis (syphilis presenting otic symptoms) typically includes a combination of steroids (e.g.. prednisilone) and antibacterial agents (e.g., benzathine penicillin G (BICILLIN LA®), penicillin G procaine, doxycycline, tetracycline, ceftriaxone, azithromycin). Such treatments may be effective in eradicating the spirochete organism. However, Treponemas may remain in the cochlear and vestibular endolymph even after eradication from other sites in the body. Accordingly, long terra treatment with penicillins may be required to achieve complete eradication of the spirochete organism from the endolymph fluid. Also, in the case of a severe or advanced case of syphilis, a uricosuric drug, such as probenecid, may be administered in conjunction with the antibacterial agent to increase its efficacy.

Other Microbial Infections Causing Coekleovestibidar Disorders (001541 Other microbial infections are known to cause cochleovestibular disorders, including hearing loss. Such infections include rubella, cytomegalovirus, mononucleosis, varicella zoster -(chicken pox)* pneumonia, Borrelia species of bacteria (Lyme disease), and certain fungal infections. Accordingly, controlled release antimicrobial agent formulations disclosed herein are also used for localized treatmentof these infections in fee ear.

Autoimmune Inner Ear Disease [00155] Autoimmune inner ear disease (AIED) is one of fee few reversible causes of sensorineural hearing loss, it is a disorder appearing in both adults and children that often involves a bilateral disturbance of the audio and vestibular functions of the auris interna. In many cases, AIED occurs without systemic autoimmune sy mptoms, but up to one-third of patients also suffer from a systemic autoimmune illness, such as Inflammatory bowel disease, rheumatoid .arthritis, Ankylosing spondylitis. Systemic Lupus Erythematosus (SLE), Sjdgren’s Syndrome, Cogan’s disease, ulcerative colitis, Wegener’s granulomatosis and scleroderma. Belfeefs disease, a multisystem disease, also commonly has audiovestihular problems. A classification scheme tor AIED has been developed (Harris and Keithley Otorhinolaryngology. Mead'ami Neck Surgery .(2002) 91,18-3 2).

[00156] The Immune system normal ly performs a crucial role in protecting the inner ear from invasive pathogens such as bacteria and viruses. However, in AIED the immune System i tself begins to damage fee delicate inner ear tissues. The inner ear is fully capable of mounting a localized immune response to foreign antigens. When a foreign antigen enters the inner ear, it is first processed by immunocompetent cells'which reside in and around the endolymphatic sac. Once the foreign antigen has been processed by these immunocompetent cells, these cells secrete various cytokines which modulate the immune response of the inner ear. One result of this cytokine release is to facilitate the influx of inflammatory cells, which are recruited from the systemic circulation. These systemic inflammatory cells enter the cochlea via diapedesis through the spiral modiolar vein and its tributaries, and begin to participate in antigen uptake and deregulation just as it occurs in other parts of the body. Interleukin 1 (IL-1) plays an important role in modulating the innate (nonspecific) immune response and is a known activator of resting I helper cells and B~ cells, T helper cells, once activated by IL-1, produce 1L-2.IL-2 secretion results in differentiation of pluri potent T~eells into helper, cytotoxic and suppressor T-cell subtypes. II .-2 also assists T helper cells in the acti vation of B lymphocytes and probably plays a pivotal role in the inmrunoregulation of the immune response of the vestibular and cochlear regions. IL-2 is within the perilymph of the auris interna as early as 6 h after antigen challenge with peak, levels at 18 h after antigen challenge. The perilymphatic levels of IL-2 then dissipate, and it is no longer present -within.the.perilymph at 120 hours post antigen challenge, !OOI57].Bolh IL-Ιβ and tumor necrosis faetor-α (TNF-α) may play a key role in the initiation and amplification of the immune response, IL-Ιβ is expressed by the fibrocytes of the spiral ligament in the presence of trauma such as surgical trauma or acoustic trauma in a nonspecific response. TNF-α is expressed either by infiltrating systemic cells or by resident cells contained wi thin the endolymphatic sac in tire presence of antigen. TNF-α is released as part of the adaptive (specific) immune response in animal model s. When antigen is injected into the auris intema of mice, IL-1 β and TNF-α are both expressed and a vigorous immune response occurs. However, when antigen is introduced to the auris intema via the cerebral spi nal flui d in the absence of trauma, only TNF-α is expressed and the immune response in minimal. Importantly, cochlear trauma in isolation also results in a minimal immune response. These results suggestthat both the nonspecific and specific components of the immune response act in concert in the auris intema to achieve a maximal response, [(M)158] Thus, if the cochlea is traumatized and an antigen is injected for in the case of autoimmune disease, the patient has immune cells directed against inner ear antigens), both the nonspecific and the specific immune responses can be activated simultaneously. This results in the concurrent production of IL-Ιβ as well as TNF-α which causes a greatly amplified level of inflammation leading to substantial damage to the auris intema.

[00159) Certain evidence suggests that viral infection is a factor in the initiation of the inflammatory response that results in AIED. Various autoimmune conditions are induced or enhanced by a variety of DN A and RNA virus infections. Acute or persistent viral infections induce or enhance autoimmune diseases in animal models as well. Similar antigenic determinants have also been observed on viruses and host components. Oldsione, M.B.A.J. Autoimmun. (1989) 2(suppl): 187-194. Further, serological tests have identified viral infection in at least one patient diagnosed with a systemic autoimmune disorder that is often associated with AIED (Cogan’s syndrome). Garcia-Berroeal, et al. O.R.L (2008) 70: 16-20. )00160} Accordingly, in some embodiments, controlled release antimicrobial agent compositions and form illations disclosed herein are administered for the treatment of AIED.

Particularly,-in certain embodiments, formulations disclosed herein, comprising antiviral agents are administered for treatment of AIED. In other embodiments, the antimicrobial agent form ulations discl osed herein are administered, for the treatment of AIE D in conjunction with other pharmaceutical agents useful for treating the same conditions or symptoms of the same conditions, including steroids, cytotoxic agents, collagen, gamma globulin infusion, or other immune modulating drugs. Steroids include, .e.g., prednisone or decadron. Cytotoxic agents for the treatment of AIED include, e,g., methotrexate, cyclophosphamide, and thalidomide. Plasmapheresis procedures are optionally used. Treatment with oral col lagen, gamma globulin infusions, or other immune modulating drugs (e.g. beta-interferon, alpha-interferon or copaxone) is also optionally used, in combination with the antimicrobial agent formulations disclosed herein. The additional pharmaceutical agents are· optionally administered together with the controlled release formulations disclosed herein, or through other modes of administration, e.g., orally, by injection, topically, nasally or through any other suitable means. The additional pharmaceutical agents are optionally co-adminisiered, or administered at different time periods,

Meniere's -.Disease {ftOliillMeniere’s disease is characterized by sudden attacks of vertigo, nausea and vomiting that may last for 3 to 24 hours, and may subside gradually. Progressive heating loss, tinnitus and a sensation of pressure in the ears accompanies the disease through time. The cause of symptoms associated with Meniere's disease is likely an imbalance of inner ear fluid homeostasis, including an increase in production or a decrease in reabsorption of inner ear fluid. {00162J A l though the cause of Meniere’s disease is unknown, certain evidence suggests a viral etiology for the disease. Specifically, histopathologic analysis of temporal bones in patients with Meniere’s disease revealed viral ganglionitis. Also, viral DNA has been observed in the ganglia of patients with Meniere’s disease at a higher rate than in healthy patients. Oliveira et al. 0j?i(2008). 70:42-51. Based on these studies, a pilot study of intratympanic injection of the antiviral agent ganciclovir was conducted, resulting in an improvement of patients suffering from Meniere’s disease. Guyot et al. ORL (2008 ) 70: 21 -27, Accordingly, controlled release formulations disclosed herein comprising antiviral agents, e.g., ganoid vir, acyclovir, famovir, and valgancyclovir. can be administered to the ear for localized treatment of Meniere’s disease. (00163| Other treatments of Meniere5 s disease axe aimed at dealing with the immediate symptoms and prevention of recurrence. Low-sodium diets, avoidance of caffeine, alcohol, and tobacco have been ad vocated. Medications that temporarily relieve vertigo attacks include antihistamines (e.g., meclizine), and central nervous system agents, including barbiturates and/or benzodiazepines (e.g., lorazepam or diazepam). Other examples of drugs that may be useful in relieving symptoms include muscarinic antagonists, including scopolamine. Nausea and vomiting may be relieved by suppositories containing antipsychotic agents, including the phenothiazine agent prochlorperazine (Compazine*, Buecastem, Stemetil and Phenotil). Thus* other treatments of Meniere’s disease are optionally used in Combination with the controlled release fomrrdations disclosed herein for the treatment of Meniere’s disease. {©0:164J Surgical procedures have also been used to relieve symptoms of Meniere’s disease, including destruction of vestibular function to relieve vertigo symptoms. These procedures aim to either reduce fluid pressure in the inner ear and/or to destroy inner ear balance function. An endolymphatic shunt procedure, which relieves fluid pressure, may be placed in the inner ear to relieve symptoms of vestibular dysfunction. Severing of the vestibular nerve may also be employed, -which may control vertigo while preserving hearing, {001651 Another approach to destruction of vestibular function for the treatment of severe Meniere’s disease is intratympanic application of an agent that destroys sensory hair cell function in the vestibular system, thereby eradicating inner ear balance function. Various antimicrobial agents are used in the procedure, .including aminoglycosides such as gentamicin and streptomycin, The agents are injected through the tympanic membrane using a small needle, a tympanostomy tube with or Without a wick, or surgical catheters. Various dosing regimens are used to administer the antimicrobial agents, including a low dose...method in which less of the agents are administered over longer periods of time (e.g,, one month between injections), and high dose methods in which more of the agents are administered over a shorter time frame (e.g., every week). Although the high dose method is typically more effective, it is more risky, as it may result in hearing, loss.

[00166] Accordingly, formulations disclosed herein are also useful for administration of antimicrobial agents, e.g., gentamicin and streptomycin, for disabling the vestibular apparatus to treat Meniere’s disease. The formulations disclosed herein can be used to maintain a steady release of the active agents inside the tympanic membrane, thereby avoiding the need for multiple injections or the insertion of a tympanostomy tube. Further, by keeping the active agents localized in the vestibular system, the formulations disclosed herein can also be used to administer higher doses of the antimicrobial agents with a decreased risk of hearing loss,

Meniere ’$ Syndrome [00167] Meniere’s syndrome, which displays similar symptoms as Meniere’s disease, is attributed as a secondary’ affliction to another disease process, e.g. thyroid disease or inner ear inflammation due to syphilis infection. Meniere’s syndrome is thus a collection of secondary effects to various processes that interfere with normal production or resorption of endolymph, including microbial infection. Treatment of patients afflicted with Meniere’s syndrome is similar to Meniere’s disease,

Vestibular Neuronitis [00168] Vestibular neuronitis is characterized by sudden vertigo attacks, which may present as a single attack of vertigo, a series of attacks, or a persistent: condition which diminishes over a matter of weeks. Symptoms typically include nausea, vomiting, and previous upper respiratory tract infections, although there are generally no auditory symptoms. Vestibular neuronitis may also he associated with eye nystagmus, a condition characterized by flickering of the eyes involuntarily toward the affected side. It is caused by inflammation of the vestibular nerve, the nerve that connects the inner ear to the brain, and is likely caused by viral infection. Diagnosis of vestibular neuronitis usually involves tests for nystagmus using eiectronystamography, a method of electronically recording eye movements.

Magnetic resonance imaging may also be performed to determine if other causes may play a role in the vertigo symptoms.

[00169] Treatment of vestibular neuronitis typically involves alleviating the symptoms of the condition, primarily vertigo, until the condition clears on its o wn. Treatment of vertigo is often identical to Meniere’s disease, and may include meclizine, lorazepam, prochlorperazine, or scopolamine. Fluids and electrolytes may also be intravenously administered if the vomiting is severe. Corticosteroids, such as prednisilone, are also given if the condition is detected early enough.

[00170] Compositions disclosed herein comprising an antiviral agent can be administered for the treatment of vestibular neuronitis. Further, the compositions maybe administered with other agents that are typically used to treat symptoms of the condition, including anticholinergics, antihistamines, benzodiazepines, or steroids.

Postural Vertigo [00171 [Postural vertigo, otherwise known as positional vertigo, is characterized by sudden violent vertigo that is triggered by certain head positions. This condition may be caused by damaged semicircular canals caused by physical injury to the inner ear, otitis media, ear surgery or blockage of the artery to the inner ear.

[0® 172] Vertigo onset in patients with postural vertigo usually develops when a person lies on one ear or tilts the head back to look up. Vertigo may be accompanied by nystagmus. Treatment of postural vertigo often involves the same treatment as in Meniere’s disease. In severe cases of postural vertigo, the vestibular nerve is severed to the affected semicircular canal. Treatment of vertigo is often identical to Meniere’s disease, and may include meclizine, lorazepatn. prochlorperazine or scopolamine. Fluids and electrolytes may also be intravenously administered if the vomiting is severe. &amp;mo?meiF(rfMearfng Loss [00173] Sensorineural hearing loss occurs when the components of the inner ear or accompanying neural components are affected, and may contain a neural (i.e., the auditory nerve or auditory nerve pathways in the brain are affected) or sensory component. Sensory' hearing loss may be hereditary, or it may be caused by acoustic trauma (i.e, very' loud noises), a viral infection, drug-induced or Meniere’s disease. In some instances, noise induced hearing loss is caused by loud noises, for example, gun fire, loud music or other human-based noise. Neural hearing loss may occur as a result of brain tumors, infections, or various brain and nerve disorders, such as stroke. Some hereditary diseases, such as Refsum’s disease (defective accumulation of branched fatty acids), may also cause neural disorders affecting hearing loss. Auditory nerve pathways may be damaged by demyelinating diseases, e.g. idiopathic inflammatory demyelinating disease (Including multiple sclerosis), transverse myelitis, Devic’s disease, progressive multifocal leukoeneephalopathy, GiuIIam-Barre syndrome, chronic inflammatory demyelinating polyneuropathy and anti-MAG perpheral neuropathy.

[00174] The incidence of sudden deafness, or sensorineural hearing loss, occurs in about 1 in 5,000 individuals, and maybe caused by viral or bacterial infections, e.g. mumps, measles, influenza, chickenpox, cytomegalovirus, syphilis or infectious mononucleosis, or physical injury-to the inner ear organ, in some eases, no cause can be identified. Tinnitus and vertigo may accompany sudden deafness, which subsides gradually. Oral corticosteroids are frequently prescribed to treat sensorineural hearing loss. In some cases, surgical intervention may be necessary .

Hereditary Disorders [00175] Hereditary disorders, including Seheibe, Mondini-Miehelie, Waardenburg’s, Michel, Alexander’s car deformity, hypertelorism, Jcrvcll-Langc Nielson, Rcfsum’s and Usher’s syndromes, are found in approximately 20% of patients wi th sensorineural hearing loss. Congenital ear malformations may result from defects in the development of the membranous labyrinthine, the osseous labyrinthine, or both. Along with profound hearing loss and vestibular function abnormalities, hereditary1 deformities may also he associated with other dy sfunctions, including development of recurring meningitis, cerebral spinal fluid (CSF) leaks, as well as perilymphatic fistulas, Treatment of chronic.-infections may be necessitated in hereditary disorder patients.

Pharmaceutical Agents {00176} Provided herein are antimicrobial agent compositions and formulations that treat otic disorders and/or their attendant symptoms, including but not limited to infection, hearing loss, nystagmus, vertigo, tinnitus, inflammation, swelling, and congestion. Otic disorders, including A1ED, otitis media, otitis externa, Meniere’s disease, Ramsay Hunt syndrome, otosyphilis, hereditary disorders and vestibular neuronitis, have causes and symptoms that are responsive to the pharmaceutical agents disclosed herein, or other pharmaceutical, agents. Antimicrobial agents that are not disclosed herein but which are useful for the amelioration or eradication of otic disorders are expressly included and intended within the seope of the embodiments presented. In some embodiments, pharmaceutically active metabolites, salts, polymorphs, prodrugs, analogues, and derivatives of the antimicrobial agents disclosed herein that retain the ability of the parent, antimicrobial agents to treat otic disorders are useful in the formulations.

[60177} Moreover, pharmaceutical agents which have been previously shown to he excessively toxic, harmful or non-effective during systemic or localized application in other organ, systems, for example through toxic metabolites formed after hepatic processing, toxicity of the drug in particular organs, tissues or systems, through high levels needed to achieve efficacy, through the inability to be released through systemic pathways, or through poor PK characteristics, are useful in some embodiments. Accordingly, pharmaceutical agents which have limited or no systemic release, systemic toxicity', poor PK characteristics or combinations thereof are contemplated within the scope of the embodiments disclosed herein. 1001781 The antimicrobial agent formulations disclosed herein are optionally targeted directly to otic structures where treatment is needed, For example, one embodiment contemplated is the direct application of the antimicrobial agent formulations disclosed herein onto the round window membrane or the crista fenestrae cochlea of the auris interna, allowing direct access and treatment of the auris interna, or inner ear components, in other embodiments, the antimicrobial agent '.formulations disclosed herein are applied directly to the oval window. In yet other embodiments, direct access is obtained through mieroinjection directly into the auris interna, for example, through cochlear microperfusion. Such embodiments also optionally comprise using a drug delivery device, wherein the drug delivery device delivers the antimicrobial agent formulations through a needle and syringe, a pump, a mieroinjection device or any combination thereof! to the target. In still other embodiments, application of the antimicrobial agent: formulation is targeted to the auris media through piercing of the intratympanic membrane and applying the antimicrobial agent formulation directly to the auris media structures affected, including the walls of the tympanic cavity or auditory ossicles. By doing so, the antimicrobial agent formulations disclosed herein are confined to the targeted auris media structure, and will not be lost, for example, through diffusion or leakage through the eustaehian tube or pierced tympanic membrane. In some embodiments, antimicrobial agent formulations disclosed herein are delivered to the auris externa in any suitable manner, including by cotton swab, injection dr ear drops. Also, in other embodiments, the antimicrobial agent formulations are targeted to specific regions of the auri s externa by application with a needle and syringe, a pump, a mieroinjection device, an in situ forming spongy material or any combination thereof. For example, in the case of treatment .of otitis externa* -antimicrobial agent formulations disclosed herein are delivered directly to the ear canal, where they are retained, thereby reducing loss of the active agents from the target ear structure by drainage or leakage. {00179! Some pharmaceutical agents, either alone or in combination, are ototoxic. For example, some antibiotics, including erythromycin, gentamicin, streptomycin, dihydrostreptomycin, tobramycin, netilmicin, amikacin, neomycin, kanamycin, eiiomycin, vancomycin, metronidizole, capreomycin, are mildly to very ototoxic, and affect tire vestibular and cochlear structures differentially. However, in some instances, the combination of an ototoxic drug with an otoprotectatt! lessens the ototoxic effects of the drug. Moreover, localized application of the potentially ototoxic drug lessens the toxic effects that otherwise occur during systemic administration through the use of lower amounts with maintained efficacy, and/or the use of targeted amounts fora shorter period of time. {00180( In formulating a controlled release .-antimicrobial agent formulation, it is advised to avoid or combine the appropriate excipients, diluents or earners to lessen or eliminate potential ototoxic components from the formulation, or to decrease the amount of such excipients, diluents or carriers. The ototoxicity of the pharmaceutical agents, excipients, diluents, carriers, or formulations and compositions disclosed herein can be ascertained using an accepted animal model. See, e.g., Maritini. A., et al. Ann. N.Y. Acad Set {1999} 884:85-98. In some embodiments, a controlled release antimicrobial agent formulation disclosed herein optionally includes otoproteclive agents, such as antioxidants, alpha lipoic acid, calcium, fosfomycin or iron chelators, or other otoprotectant agents, to counteract potential ototoxic effects that may arise from the use of speci fic therapeutic agents or excipients, diluents or carriers.

Antimicrobial Agents [00.181( Any antimicrobial agent useful for the treatment of otic disorders, e.g., inflammatory diseases or infections of the ear, is suitable for use in the formulations and methods disclosed herein, in some embodiments, the antimicrobial agent is an antibacterial agent, an antifungal agent, an antiviral agent, ait antiprotozoal agent, and/or an ontiparasifie agent. Antimicrobial agents include agents that act to inhibit or eradicate microbes, including bacteria, fungi, viruses» protozoa, and/or parasites. Specific antimicrobial agents may be used to combat specific microbes. Accordingly, a skilled practitioner would know which antimicrobial agent would be relevant or useful depending on the microbe identified, or the symptoms displayed. (00182( In some embodiments, the antimicrobial agent is a protein, a peptide, an antibody, DNA, a carbohydrate, an inorganic molecule, or an organic molecule. In certain embodiments, the -antimicrobial-agents are antimicrobial small molecules. Typically, antimicrobial small molecules are of relatively low molecular weight, e.g., less than 1,000, or less than 600-700, or between 300-700 molecular weight.

[00183} In some embodiments, the antimicrobial agent is an antibacterial agent. In some embodiments, the antibacterial agent treats infections caused by gram positive bacteria. In some embodiments, the antibacterial, agent treats infections caused by gram negative bacteria. In some embodiments, the antibacterial agent treats infections caused by mycobacteria. In .some embodiments, the antibacterial agent treats infections caused by giardia.

[80Ϊ84]In some embodiments, the antibacterial agent treats infections by inhibiting bacterial protein synthesis. In some embodiments, the antibacterial agent treats infections by disrupting synthesis of bacteria! cell wall. In some embodiments, the antibacterial agent treats infections by changing permeability of bacterial cell membranes. In some embodiments, the antibacterial agent treats infections by disrupting DNA replication in bacteria.

[0ΟΪ85{Ιη some embodiments, the antibacterial agent is an antibiotic. In some embodiments, the antibiotic is an aminoglycoside. Examples of aminoglycoside antibiotics include and are not limited to amikacin, gentamicin, kanamycin, neomycin, netilmicin, streptomycin, tobramycin, paromycin or the like. In some embodiments, the antibiotic is an ansamycin. Examples of ansamycins include and are not limited to geldanamycin, berbimycin or the like. In some embodiments, the antibiotic is a earhacephem. Examples of carbecephems include and are not limited to loracarbef or the like. In some embodiments, the antibiotic is a earfaapenem . Examples of carbapenems include and are not limited to eriapenem, doripenem, imipenem (cilostatin), meropenem or the like. In some embodiments, the antibiotic is a cephalosporin (including, for example, first, second, third, fourth or fifth generation cephalosporins). Examples of cephalosporins include and are not limited to cefaclor, cefamandole, cefotoxin, ceiprozil, cefuraxime, cefixime, cefdinir, cefditoren, cetpodoxlme, ceftazidime, ceftibuten, ceftizoxime, ceftriaxone, cefepime, ceftobirprole or the like. In some embodiments, the antibiotic is a glycopeptide. Examples of glycopeptides include and are not limited to vancomycin or the like. In some embodiments, the antibiotic is a macrolide antibiotie, Examples of macrolides include and are not limited to azithromycin, clarithromycin, dirithiOmycin, erythromycin, roxithromycin, troleandomycin, telithromycin, spectinomycin, or the like. In some embodiments, the antibiotic is a monobactarn. Examples of monobactams include and are not limited to a/Jreonam or the like. In some embodiments, the antibiotic is a penicillin. Examples of pcncillins include and are not limited to amoxicillin, ampicillin, azociling, carbenicillin. eloxacillin, dicloxacillin, flucloxacillin, mezlocillin, meticillin, naicillin, oxacillin, peperaeillin, ticarcillin or the like. In some embodiments, tire antibiotic is a polypeptide. Examples of polypeptide antibiotics include and are not limited to bacitracin, eolistm, polymyxin B or the like. In some embodiments, the antibiotic is a quinolone. Examples of qurnolones include and are not limited to ciprofloxacin, enoxacin, gatifloxacin, levofloxacim lomeflqxacin, moxifloxacin, nonfioxacin, ofloxacin, trovafloxacin, grepafloxacin, sparfloxacin, AL-15469A, AL-3S905 or the like. In some embodiments, the antibiotic is a sulfonamide. Examples of suflonamides include and me not limited to afenidc, prontosii, sui facetamide, sidfamethiazole, sulfanilimide, sulfasalazine, sulflsoxazole, trimethoprim, coirimoxazole or the like. In some embodiments, the antibiotic is a tetracycline antibiotic. Examples of tetracyclines include and are not limited to demeelocyclme, doxycycline, minocycline, oxytetracyelme, tetraydine or the like. In some embodiments, the antibiotic is an oxazolidinone antibiotic. Examples of oxazoiidinone antibiotics include and are not limited to linezolid or the like. In some embodiments, the antibiotic is arsogebanubem chloramphenicol, clindamycin, lincomycin, ethambutol, fosfomycin, fusidic acid, furazolidone, isoniarid, lipezolid, metronidazole, mupirocin, nitrofurantoin, platensimycin, pyrazinaniide, quinupristm, dalfopristin, rifampicin, thamphenicol, Imidazole or the like.

[00186] Antibacterial agents include amikacin, gentamicin, kanamyciii, neomycin, netilmicin, streptomycin, tobramycin, paromomycin, geldamnycin. herbimycin, loracarbef, ertapenem, doripenem, imipenem, cilastatih, raeropenem, cefadroxii, eeiazolin, cefaiotln, cefalexin, cefaclor, cefamandole, cefoxitin, defprozil, cefuroxime, cefixime, cefdinir, eefditoren, cefoperazone, cefotaxime, cefpodoxkne, ceflazidime, ceftibuten, ceftizoxime, ceftriaxone, cefepime, ceftobiprole, teicoplanin, vancomycin, azithromycin, clarithromycin, dirithromycin, erythromycin, roxithromycin, troleandomyein, telithromycin, speclinomycin, aztreonam. amoxicillin, ampiciilin, azlociilin, carbenicillin, cloxaciilm, dicioxadllin, flucloxacillin, mezlocillin, metici bin, nafciliin, oxacillin, penicillin, piperacillin, ticarciflan, 'bacitracin, colistin, polymyxin B, ciprofloxacin, enoxacin, gatifloxacin, levofloxacin, lomefloxacin, moxifloxacin, norfloxacin, ofloxacin, trovfloxacin, mafenide, prontosii, sulfacetamide, sulfamethizole, sulfanimilimde, sulfsalazine, stilfsioxazole, trimethoprim, demeclocycline, doxycycline, minocycline, oxtetracyclitte, tetracycline, arsphenamine, chloramphenicol, clindamycin, lincomycin, ethambutol, tosfomycin, fusidic acid, furazolidone, isoniazid, linezolid, metronidazole, mupirocin, nitrofurantoin, platensimycin, pyrazinamide, qumuspristin/dd'fopristin, rifampin, tinidazole, and combinations thereof [00187] In some embodiments, an antibiotic compatible with the compositions described herein is a broad spectrum antibiotic. In some embodiments, an antibiotic compatible with the compositions described herein is effective in treating infections that are resistant to other classes of antibiotics. For example, hi some instances, vancomycin is effective in treating infections caused by methieillm resistant staphyloccocus aureus bacteria, in some embodiments, intratympanic admnistration of an antibiotic composition described herein reduces the risk of development of anti biotic resistance that is seen with systemic treatments.

[OGlSSjln specific embodiments., an antibiotic used in compositions or devices described herein is ciprofloxacin (Cipro). In specific embodiments, an antibiotic used in compositions or devices described herein is gentamicin, tn specific embodiments, an antibiotic used in compositions or devices described herein is a penicillin. In specific .embodiments* an antibiotic used in compositions or devices described herein is streptomycin.

[0=01891¾ some embodiments, an antimicrobial agent is a peptide or a lantibiofic ffieluding, by way of example. Maximin H5, Dermcidin, Cecropins, andropin, moricin, ceratotoxin and mellttin, Magainin, dermascptin, bombinin, brevinin-1 ,esculentins and buforin II, CAP 18, LL37 , abaecin, apidaecins, prophenin, indoHcidin, brevinins, protegrin, lachyplesins, defcnsiris, drosomyein, alamethicin, pexiganan or MSI-78, and other MSI peptides like MSI-843 and MS1-594, polyphemusin, Class 1II and III bacterocins like: colicin. pyocin, klebiein, subtilin, epidennin. herbicolacin, breviein, halocin, agroein, alveicin, carnoein, curvatiem, dlvercin ,e»terocin, enterolysm, erwintoein, glycinecin, laetococin, laefidn, leucocein. mesentericin, pediocin, plantariein, sakacin, sulfolobicin, vibriocm, warnerinand, nisin or the like. 100190) Antiviral agents include acyclovir, famciclovir and vaiacyclovir. Other antiviral agents include abacavir, aciciovir, adfovir, amantadine, amprenavir, arbidol, aiazanavir, artipla. brivudine, cidofovir, combivir, edoxudine, efavirenz, emtricitabme, enfuvirtide, entecavir, fomvirsen, fosamprenavir, foscamet, fpsfimet, ganciclovir, gardasil, ibacitabine, imunovir, idoxuridine, imiquimod, indinavir, inosine, integrate inhibitors, interferons, including interferon type III, interferon type II, interferon type I, lamivudine, lopinavir, loviride, MK.-0518. maraviroc, mofoxydme, nelfinavir, nevirapine, nexavir, nucleoside analogues, oseltamivir, penctclovir. peramivir, pleconaril, podophytlotoxin, protease inhibitors, reverse transcriptase inhibitors, ribavirin, rimantadine, ritonavir, saquinavir, stavudine. tenofovir, tenofovir disoproxil, tipranavir, trifluridine, tri/.ivir, tromantadine, truvada, valganciciovir, vicriviroc, yidarabine, viramidine, zalcitabine, zanamivir, zidovudine, and combinations thereof. )00191] Antifungal agents include amrolfine, utenafme, naftifine, terbinafrne, flucytosine, fluconazole, itraconazole, ketoeonazoie. posaconazole, ravuconazole, voriconazole. clotrimazole, econazole, miconazole, oxiponazcde, sulconazole, terconazole, tioeonazole. nlkkomycin Z, caspofungin, mieaiungin, anidulafungln, amphotericin B, liposomal nystastin, pimaricin, griseofulvin, ciclopirox olamine, haloprogin, tolnaftate, undecylenate, clioquinoL and combinations thereof.

[00192] Antiparasitic agents, include amitraz, amoseanate, avermectin, carbadox, diethylcarbamizme, dimetridazole, diminazene, ivermectin, macrofilarieide, malathion, mitaban, oxamniquine, permethrm, praziquantel, prantel pamoate, selameetia. sodium Stibogluconate, thiabendazole, and combinations thereof.

[00193] Antimicrobial agents that axe not disclosed herein but which are "useful for the amelioration or eradication of otic disorders are expressly included and intended within the scope of the embodiments presented,

Antiinflammatory Agents [00194] Glucocorticoids or other anti-inflammatory steroids may be used with the formulations disclosed herein. Systemic glucocorticoid administration is the current therapy in use for autoimmune hearing loss. Typical treatment duration lasts for months and die side effects item systemic therapy can be substantial. In some of the early studies on AIED, prednisone combined with cyclophosphamide was an effective therapy. However, the risks associated with cyclophosphamide rendered it a drug of last resort especially In young individuals of child-hearing age. One advantage of the use of a formulation described herein is the greatly reduced systemic exposure to anti-inflammatory glucocorticoid steroids. [0019511η one embodiment is the active pharmaceutical ingredient of the formulation described herein is prednisolone. In another embodiment, the active pharmaceutical ingredient of the formulation described herein is dexamethasone. In an additional embodiment, the active pharmaceutical ingredient of (he formulation described herein is beclomethasone. In a further embodiment, the active pharmaceutical ingredient of the formulation described herein is selected from 21 -acetoxypregnenolone, alelometasone, algestone, ameinomde. beclomethasone, betamethasone, budesonide, chloroprednisone, clobetasol, clobeiasone, elocortolone, eloprednol, corticosterone, cortisone, cortivazol, deflazacort, dcsonide, desoximetasone, dexamethasone, difiorasone, diflucortolone, difluprednate, enoxolone, fluazaeort, flue 1 oronide. flumethasone. flunisolide, iluocinolone aeetonide, fluoeinomde, fluocortin butyl, fluocorfokme, fluorometholone, fluperolone acetate, fluprednidene acetate, jfluprednisolone, flurandrenolide, fluticasone propionate, formocortal, halcinonide, halobetasol propionate, halometasone, halopredone acetate, hydrocortamate, hydrocortisone, loteprednol etabonate, mazipredone, medrysone, meprednisone, melhyiprednisolone, mometasone furoate, paramethasonc, predniearbatc, prednisolone, prednisolone 25-diethyiammo-acetaie, prednisolone sodium phosphate, prednisone, prednival, predny lidene, rimexolone, tixocortol, triamcinolone, triamcinolone acetonide, triamcinolone benctonide, triamcinolone hexacetonide, or combinations thereof. J00196J Corticosteroids are thought to act by the induction of phospholipase A a inhibitory proteins, collectively called lipocortins. It is postulated that these proteins control the biosynthesis of potent mediators of inflammation such as prostaglandins and leukotrienes by inhibiting the release of their common precursor aracliidonic acid. Arachidonic acid is released from membrane phospholipids by phospholipase .¾.

Prednisolone {00197| Prednisolone is a corticosteroid drug with predominantly glucocorticoid and low mineralocortieoid activity. It has about 4-5 times the potency of endogenous cortisol, it is useful for the treatment of a wide range of inflammatory and auto-immune conditions such as asthma, rheumatoid arthritis, Ulcerative Colitis and Crohn's disease, multiple sclerosis, cluster headaches and Systemic Lupus Erythematosus. It can also be used as an immunosuppressive drug For organ transplants and in cases of adrenal insufficiency (Addison's).

Dexamethasone 100198] Pexametbasone is a corticosteroid drug with glucocorticoid activity. It has about 25-30 times the potency of endogenous cortisol. It is used to treat many inflammatory and autoimmune conditions such as rheumatoid arthritis. In some embodiments, a composition or device described herein comprises dexamethasone. In some embodiments, a composition or device comprising dexamethasone is used

Beciomethmone [00199] Beolomeihasone diprppionate, also referred to as beelometasone, is a very potent glucocorticoid steroid drug, In tire form of an inhaler, it is. used for the prophylaxis of asthma. As a nasal spray, it is used for the· treatment of rhinitis (e.g. hayfever) and sinusitis. In some instances it is used by oral pathologists in the treatment of unusually severe canker sores. As a cream or ointment it: is used to treat severe inflammatory skin disorders (e.g. eczema.) unresponsive to less potent steroids, but is generally avoided in the treatment of psoriasis due to the risk of rebound on withdraw al.

Budesonide [ΘΟ2Θ0)'Budesonide is a potent glucocorticoid steroid 60-fold more potent than cortisol. It is indicated for the treatment of asthma (via oral inhaler), non-infectious rhinitis, including hay fever and other allergies (via nasal inhaler). Additionally, it is used for inflammatory bowel disease.

Cioheimol [00201] Clobetasol. is a very potent corticosteroid used in topical formulations. It has antiinflammatory, ahtipruritic, vasoconstrictive, and immune-modulating properties. It is currently used in the treatment of a variety of hyperproliferative and/or inflammatory dermatoses, including psoriasis and atopic dermatitis.

[00202] Dexamethasone, beeloroethasone and prednisolone have long-term efficacy with biological hali-lifes of 36-72 hours. 100203]In some embodiments, anti-inflammatory agents are antt-TNF agents, TNF-α con verting enzyme inhibitors, IKK inhibitors, caleineurin inhibitors, toll-like receptor inhibitors, interleukin inhibitors, or the like. Anti-inflammatory agents that, are not disclosed herein but which are useful for the amelioration or eradication of otic disorders arc expressly included and intended within the scope of the embodiments presen ted. RNAi [00204] In some embodiments, where inhibition or down-regulation of a target is desired RNA interference may be utilized. In some embodiments, the agent that inhibits or down-re gulates the target is an siRNA molecule. In certain embodiments, the siRNA molecule inhibits or down-regulates genes encoding one or more mediator of inflammation (e.g,, cytokines, IKKs, TACEs, ealcineurins. TLRs or the like). In certain instances, the siRNA molecule inhibits the transcription of a target by RN A interference (RNAi). In some embodiments, a double stranded RNA (dsRNA) molecule with sequences complementary to a target is generated (e.g. by PCR). In some embodiments, a 20-25 bp siRNA molecule with sequences complementary to a target is generated. In some embodiments, the 20-25 bp siRNA molecule has 2.-5 bp overhangs on the 3’ end of each strand, and a 5’ phosphate terminus and a 3’ hydroxyl terminus. In some embodiments, the 20-25 bp siRNA molecule has blunt ends. For techniques for generating RNA sequences see Molecular Cloning: A Laboratory Manual, second edition (Sambrook et al., 1089) and Molecular Cloning: A Laboratory Manual, third edition (Sambrook and Russel, 2001), jointly referred to herein as ‘'Sambrook”); Current Protocols in Molecular Biology (F, M. Ausuhel et aL eds.. 1987, including supplements through 2001); Current Protocol's in Nucleic Acid Chemistry’ John

Wiley &amp; Sons, Inc., New York, 2000) which are hereby incorporated by reference for such disclosure. 100205] In some embodiments, the dsRNA or siRNA molecule is incorporated into a eontrolled-release auris-acceptable microsphere or microparticle, hydrogel, liposome, actinic radiation curable gel, solvent-release gel, xerogel, paint, foam, in situ forming spongy material, or thermoreversible gel. In some embodiments, the auris-acceptable microsphere, hydrogel, liposome, paint, foam, in situ forming spongy material, nanocapsule· or nanosphere or thermoreversible gel is injected into the inner ear. In some embodiments, the auris-acceptable microsphere or microparticle, actinic radiation curable gel, solvent-release gel, hydrogel, liposome, or thermoreversible gel i s injected through the round window membrane. In some embodiments, foe auris-acceptable microsphere, hydrogel, liposome, paint, foam, in situ forming spongy material, actinic radiation curable-gel, solvent-release gel, nanocapsule or nanosphere or thermoreversible gel is injected into the cochlea, the organ of Corti, the vestibular labyrinth, or a combination thereof, [00206] In certain instances, after administration of the dsRNA or siRNA molecule, cells at the site of administration (e,g. the cells of cochlea, organ of Corti, and/or the vestibular labyrinth) are transformed with the dsRNA or siRNA molecule. In certain instances following transformation, the dsRNA molecule is cleaved into multiple fragments of about 20-25 bp to yield siRNA molecules. In certain instances, foe fragments have about 2bp overhangs on foe 3 ' end of each strand. ]00207|ln certain instances, an siRNA molecule is divided into two strands (the guide strand and foe anti-guide strand) by an RNA-induced Silencing Complex (RISC), In certain instances, the guide strand is incorporated into the catalytic component of the RISC (he. argonaute). In certain instances, the guide strand binds to a complementary target mRNA sequence. In certain instances, the RISC cleaves the target mRN A. In certain instances, the expression of the target gene is down-regulated.

[00208] In some embodiments, a sequence complementary to a target is ligated into a vector. In some embodiments, the sequence is placed between two promoters. In some embodiments, the promoters are orientated in opposite directions. In some embodiments, the vector is contacted with a cell. In certain instances, a cel! is transformed with the vector. In certain instances following transformation, sense and anti-sense strands of the sequence me generated. In certain instances, the sense and anti-sense strands hybridize to form a dsRNA molecule which is cleaved into siRNA molecules. In certain instances, the strands hybridize to form an siRNA molecule. In some embodiments, the vector is a plasmid (e.g pSUPER: pSUPER.neo; pSUPER.neo+gfp).

[00209] In some embodiments* the vector is incorporated into a controlied-release auris-acceptable microsphere or microparticle, hydrogel, liposome, or thermoreversible gel. In some embodiments, the auris-aeceptable mierosphere. hydrogel, liposome, paint, foam, in situ forming spongy material, nanocapsule or nanosphere or thermoreversible gel is injected into the inner ear. In some embodiments, the auris-acceptahle microsphere or microparticle, hydrogel, liposome, or thermoreversible gel. In some embodiments, the auris-aceeptable mierosphere, hydrogel, liposome, paint, foam, in situ forming spongy material, nanocapsule or nanosphere or thermoreversible gel is injected into the cochlea, the organ of Corti, the vestibular labyrinth, or a combination thereof.

Antimicrobial agents and Anti-inflammatory agents (00210] Contemplated within the scope of the embodiments presented herein are compositions and devices that comprise an antimicrobial agent in combination with an antiinflammatory agent. In specific embodiments, a composition or device described herein comprises an antibiotic (e.g., any antibiotic described herein) in combination with an antiinflammatory agent (e,g., any anti-inflammatory agent described herein). In certain embodiments, a composition or device described herein comprises an antibiotic (e.g., any antibiotic described herein) in combination with a corticosteroid. (0021 IJIn some embodiments, a composition comprising an antimicrobial agent and an antiinflammatory agent has different release profiles for each of the active agents. For example, in some embodiments, a composition comprising an antibiotic and a corticosteroid provides a sustained release of the antibiotc and an intermediate 'release of the corticosteroid. In some embodiments, a composition comprising an antibiotic and a corticosteroid provides a sustained release of the antibiotic and an immediate release of the corticosteroid. In some embodiments, a composition comprising an antibiotic and a corticosteroid provides an immediate release of the antibiotic and a sustained release of the corticosteroid. In some embodiments, a composition comprising an antibiotic and a corticosteroid provides an immediate release of the antibiotic and an intermediate release of the corticosteroid.

[00212{ In other embodiments, a composition comprising an antimicrobial agent and an-antiinflammatory agent has similar release profiles for each of the active agents. For example, in some embodiments, a composition comprising an antibiotic and a corticosteroid provides immediate release of the antibiotic and corticosteroid. In some embodiments, a composition comprising an antibiotic and a corticosteroid provides intermediate release of the ant ibiotic and corticosteroid. In some embodiments, a composition comprising an antibiotic and a corticosteroid provides a sustained release of the antibiotic and corticosteroid.

[00213] In certain embodiments, a composition or device described herein comprises an antibiotic in combination with dexamethasone. In certain embodiments, a composition or device described herein comprises an antibiotic in combination with methylprednisolone or prednisolone. In certain .embodiments, a, composition or device described herein comprises ciprofloxacin in combination with dexamethasone. In certain embodiments, a composition or device described herein comprises ciprofloxacin in combination with methylprednisolone or prednisolone/In certain embodiments, a composition or device described herein comprises gentamicin in combination with dexamethasone. In certain embodiments, a composition or device described herein comprises gentamicin in combination with methylprednisolone or prednisolone.

[60214] In some embodiments, a composition comprising an antibiotic and a corticosteroid contains one or both active agents as micronized active agents. By way of example, in some embodiments, a composition comprising micronized dexamethasone and micronized ciprofloxacin provides extended release of dexamethasone over 3 day s and extended release of ciprofloxacin over 10 days. By wav of example, in some embodiments, a composition comprising micronized dexamethasone and micronized ciprofloxacin provides extended release of ciprofloxacin over 3 days and extended release of dexamethasone over 10 days. [00215) In some embodiments, pharmaceutically active metabolites, salts, polymorphs, prodrugs, analogues, and derivatives of the antimicrobial agents or anti-inflammatory agents discussed above that retain the ability of the parent agents to treat otic disorders of the ear are also useful and compatible with the formulations disclosed herein.

Combination Therapy [00216} In some embodiments, any composition or device described herein comprises one or more active agents and/or a second therapeutic agent including biH not limited to anti-emetic agents, cytotoxic agents, anti-TNF agents, otoprotectants or the like.

Cytotoxic Agents [002171 Any cytotoxic agent useful for the treatment of otic disorders is suitable for use in the; formulations and methods disclosed herein. In certain embodiments, the cytotoxic agent is an antimetabolite, ait antifolate, an alkylating agent and/or a DNA intercolator. In some embodiments, the cytotoxic agent is a protein, a peptide, an antibody, DNA, a carbohydrate, an inorganic molecule, or an organic molecule. In certain, embodiments, the cytotoxic agents are cytotoxic small molecules. Typically, cytotoxic small molecules are of relatively low molecular weight, e.g., less than 1,000, or less than 600-700, or between 300-700 molecular weight. In some embodiments, the cytotoxic small molecules will also have antiinflammatory' properties.

[00218] In certain embodiments, the cytotoxic agent is methotrexate (RHEUMATREX*. Amethopterm), cyclophosphamide (CYTOXAN®), or thalidomide (THAUDOMID” ). All of the compounds have anti-inflammatory 'properties-and. can be used in the formulations and compositions disclosed herein for the treatment of inflammatory disorders of the ear, including AIED, In some embodiments, cytotoxic agents used in the compositions, formulations, and methods disclosed herein are metabolites, salts, polymorphs, prodrugs, analogues, and derivatives of cytotoxic agents, including methotrexate, cyclophosphamide, and thalidomide. Particularly preferred are metabolites, salts, polymorphs, prodrugs, analogues, and derivatives of cytotoxic agents, e.g., methotrexate, eyelopliosphamide, and thalidomide, that retain at least partially the cytotoxicity and anti-inflammatory properties of the parent compounds. In certain embodiments, analogues of thalidomide used in the formulations and compositions disclosed herein are lenalidomide (REVL1M1D*) and CC-4047 (ACTIMHA

[00219} Cyclophosphamide is a prodrug that undergoes in vivo metabolism when administered systemicaliy. The oxidized metabolite 4-hydroxyeyclophosphamide exists in equilibrium with aldophospharnide, and the two compounds serve as the transport forms of the active agent phosphoramide mustard and the degradation byproduct acrolein. Thus, in some embodiments, preferred cyclophosphamide metabolites for incorporation into the formulations and compositions disclosed herein are d-liydroxycyclophosphamide, aldophospharnide, phosphoramide mustard, and combinations thereof,

Anti-TNF Agents [00220] Contemplated for use in conjunction with the antimicrobial .agent formulations disclosed herein are agents that reduce or ameliorate symptoms or effects resulting from an autoimmune disease and/or inflammatory disorder, including AIED or QM. Accordingly, some embodiments incorporate the use of agents which block the effects ofTNF-ct, including anti-XMF agents. By way of example only, anti-TNF agents include etanercept (ENBREL*), infliximab (REMICADE®), adalimumab (HUMIRA^), and golimumab (ONTO 148) or combinations thereof.

[00221] Infliximab and adalimumab are anti-TNF monoclonal antibodies, and etanereept is a fusion protein designed to bind specifically to the 'TNF protein. All are currently approved for use in the treatment of rheumatoid arthritis. Gcdimumab, which is currently in Phase 3 clinical trials for rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis, is a fully-hunlmized anii-TNF-a IgGl monoclonal antibody that targets and neutralizes both the soluble and the membrane-bound form of TNF-a.

[00222] Other antagonists of INF, by way of example only, include INF receptors (pegylated soluble TNF receptor type 1; Amgen); INF binding factors (Onercept; Serono); IMF antibodies (US Patent App. Mo. 2005/0123341; US Patent App. No. 2004/0185047); single domain antibodies against the p55 TNF receptor (US Patent App, No. 2008/00088713); soluble TNF receptors (US Patent App. No. 2007/()249538): fusion polypeptides binding to TNF (US Patent App. No. 2007/0128177); TNF-α converting enzyme inhibitors (Skotnicki et at, Annual Reports in Medicinal Chemistry ¢2003), 38, 153-162); IKpC. inhibitors (Karin e/ al,Nature Reviews Drug Discovery (2004), 3, 17-26) and flavone derivatives (US Patent App. No. 2006/0105967), all of which are incorporated by reference for such disclosure.

[00223] The use of Onercept, a soluble TNF p55 receptor, was discontinued in 2005.Three phase-ill clinical trials reported patients diagnosed with fata! sepsis. A risk to benefit analysis was subsequently performed, resulting in the discontinuation of the clinical trials. As discussed above, the embodiments herein specifically encompass the use of anti-TNF agents that have been previously shown to have limited or no systemic release, systemic toxicity, poor PK characteristics of combinations thereof.

Anti-Emetic Agents/Central Nervous System Agents {00224] Anti-emetic agents are optionally used in combination with the antimicrobial agent formulations disclosed herein. Anti-emetic agents include antihistamines and central nervous agents, including anti-psychotic agents, barbiturates, benzodiazepines and phenothiazines. Other anti-emetic agents include the serotonin receptor antagonists, which include doiasetron, granisetron, ondansetron, tropisetron, palonosetran, and combinations thereof; dopamine antagonists, including domperidone, properidol, haioperidol, chforpromazine, promethazine, prochlorperazine and combinations thereof; cannabinoids, including dronabinol, nabilone, sativex, and combinations thereof; anticholinergics, including seopolarnine; and steroids, including dexamethasone; trimethobenzamine, emetroi, propofol, muscimol, and combinations thereof [00225) Optionally, central, nervous system agents and barbiturates are useful in the treatment of nausea and vomiting, symptoms that often accompany otic disorders. When used, an appropriate barbiturate and/or central nervous system agent is selected to relieve or ameliorate specific symptoms without.possible side effects, including ototoxicity.

Moreover, as discussed above, targeting of the drugs to. the round window membrane of the auris interna reduces possible side effects and toxicity caused by systemic administration of these drugs. Barbiturates, which act as a central nervous system depressant, include ailobarbital. alphenal, amobarbital, aprobarbital, barnexaclone, barbital, brallobarbitai, butabarbital, buialbital, butallyional, butobarbital, corvalol, crotylbarbital, cyclobarbital, eyelopal, ethallobarbital, iebarbamate, heptabarbital, hexethai, hexobarbital, metharbital, methohexital, methylphenobarbital, nareobarbitai, nealbarbital, pentobarbital, phenobarbital, primidone, probarbitai, propallylonah proxibarbital, reposal, secobarbital, sigmodal, sodium thiopental, talbutal, thialbarbital, tbiamvlal, thiobarbital, thiobutabarbital, tuinal, valofane, vinbarbital, vinylbital, and combinations thereof. {0=0226)()11161 central ..nervoussystem agents which are optionally used in conjunction with the antimicrobial agent formulations disclosed herein include benzodiazepines of phenothiazines. Useful benzodiazepines include, but are not limited to diazepam, lorazepam, oxazepam, prazepam, alprazolam, bromazepam, chlordiazepoxide, clonazepam, clorazepate, brotizolara, estazolam, flunitrazepam, flurazepam, loprazolam, lormetazepam, midazolam, nimetazepam, nitrazepam, temazepam, triazolam, and combinations thereof. Examples-of phenothiazines include prochlorperazine, clilOrpromazine, promazine, triflupromazine, levopromazine, methotrimepranwine, mesoridazirie, thiroridazine, fluphenazine, perphenazine, llupcntixol, trifluoperazine, and combinations thereof.

[00227) Antihistamines, or histamine antagonists, act to inhibit the release or action of histamine. Antihistamines that target the HI receptor are useful in the alleviation or reduction of nausea and vomiting symptoms that are associated with AIED, other autoimmune disorders, as well as anti-inflammatory' disorders. Such antihistamines include, but are not limited to, meclizine, diphenhydramine, loratadine and quetiapine. Other antihistamines include mepyramine, piperoxan, antazoline, caibinoxamine, doxydamine, clemastine, dimenhydrinate, pheniramine, chlorphenamine, chloipheniramine, dexchlorpheniramine, brompheniramine, triproltdine, cyclizine, cblorcyelizine, hydroxyzine, promethazine, alimemazinc, trimeprazine, cyproheptadine, azatadine, kctotifen, oxatomide and combinations thereof

Platelet Activating Factor Antagonists [0O228|Piate]et activating factor antagonists are also contemplated for use in combination with the antimicrobial agent formulations disclosed herein, Platelet activating factor antagonists include, by way of example only, kadsurenone, phomactiu G, giBsenosid.es, apafant (4-(2-ehlorophenyI)-9-methyl-2P(4-mGjpholinyl)~3-propmidl-1- yl[(>H-thienol3.2-tj[ 1.2.4]triazolo]4,3-l ]] 1 Ajdiazepine), A-85783, BN-52063, BN-52021, BN-50730 (tetrahedra-4,7,8,10 .methyl-1 (ehloro-l phenyl)-6 (methoxy-4 phenyl-carbamoyl)-9 pyrido [4',3 -4,5] thieno [3,2-f] iriazoIo-1,2,4 [4,3-a] diazepine-1,4), BN 50739. SM-12502, RP-55778, Ro 24-4736, SR27417A, CV-6209, WEB 2086, 'WEB 2170, 14-deoxyandrographolide, CL 184005, CV-3988, TCV-309, PMS-601, TCV-309 and combinations thereof.

Nitric Oxide Synthase Inhibitors (00229] Nitric oxide synthase (NOS) inhibitors are also contemplated for use in combination with the antimicrobial agent formulations disclosed herein. NQS inhibitors include, by wav of example only, aminoguamdine, l-Amino-2-hydroxyguanidine p-Toluensuliate, guaiudinoethyldi sulfide (GED), Bromocriptine Mesylate, Dexamethasone, Ν°,Ν°-

Di rti ethyl - I, -arginine, I) i hyd rochioride, Dipheny 1 eneiodoni urn Chloride, 2-Efhyl-2-thiopseudourea, haloperidol, L-N5-(1 -hninuethyl)ornithine, MEG, S-Methylisothiourea Sulfide (SMT), S-Methyl-L-thiocitmlline, NG-Monoethyl~L~argmine, N°-Monomethyl-D-arginine, NG-Nitro-L-arginine Methyl Ester, L-NIL, NG-Mtro-L-argMne (L-NNA), 7-Nitromdazole, nNOS inhibitor Ϊ, 1,3-PBITU, L-Thiocitnilline, N°-Propyl-L-argmine, SKF-523A, TRIM, NG-mtro-L-atgmine methyl ester (L-NAME), MTR-105, L-NMM A, BBS-2, GNO-1714 and combinations thereof.

Other Additional Active Agents [00230] Other pharmaceutical agents that are optionally used in combination with the antimicrobial agent formulations disclosed herein for the treatment of otic disorders, include other agents that have been used to treat the same condi tions, including corticosteroids; cytotoxic agents, treatment with eollagen, gamma globulin, interferons, and/or eopaxone: and combinations thereof. In addition, other pharmaceutical agents are optionally used to treat attendant symptoms of otic disorders disclosed herein, including A1ED, otitis media, otitis externa, Meniere’s disease, Ramsay Hunt syndrome, otosyphilis, and vestibular neuronitis, such as. vomiting, dizziness and general malaise. The additional active agents can be formulated with the antimicrobial agents in the compositions and formulations" disclosed herein, or they can be administered separately through alternative modes of deli very . Concentration of active agent [002313111 some embodiments, the compositions described herein have a concentration of active pharmaceutical ingredient between about 0.01% to about 90%, between about 0.01% to about 50%, between about 0.1% to about 70%, between about 0,1% to about 50%, between about 0.1 % to about 40%, between about 0.1 % to about 30%, 'between about 0.1 % to about 20%. between about 0,1% to about 10%, or between about 0.1% to about 5%, of the active ingredient, or 'pharmaceutically acceptable prodrug or salt thereof, by weight of the composition. In some embodiments:, the compositions described herein have a concentration of active pharmaceutical agent, or pharmaceuticaOy acceptable prodrug or salt thereof between about 1% to about 50%, between about 5% to about 50%, between about 10% io about 40%, or between about 30% to about 30%, of the active ingredient, or pharmaceutically acceptable prod-rug or salt thereof, by weight of the composition, in some embodiments, formulations described herein comprise about 70% by weight of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof by weight of the formulation. In some embodiments,; formulations described herein comprise about 60% by weight of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof by-weight, of the formulation, In some embodiments, formulations described herein comprise about 50% by weight of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof by weight of the formulation. In some embodiments, formula tions described herein comprise about 40% by weight of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof by weight of the formulation. In some embodiments, formulations described herein comprise about 30% by weight, or pharmaceutically acceptable prodrug or salt thereof of an antimicrobial agent by weight of the formulation, in some embodiments, formulations described herein comprise about 20% by weight of an antimicrobial agent, or pbarmaceutically acceptable prodrug or salt thereof by weight of the formulation, In some embodiments, formulations described herein comprise about 15% by weight of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof by weight of the formulation, In some embodiments, formulations described herein comprise about 10% by weight of an antimicrobial agent by weight of the formulation, In some embodiments, formulations described herein comprise about 5% by weight of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof, by weight of the formulation. In some embodiments:, formulations described herein comprise about 2.5% by weight of an antimicrobial agent, of pharmaceutically -acceptable prodrug or salt thereof, by weight of the formulation, M some embodiments, formulations described herein comprise about 1% bv weight of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof by wei ght of the formulation . In some embodiments, formulations described herein comprise about 0. 5% by weight of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof by weight of the formulation. In some embodiments, formulations deseribed herein comprise about 0.1% by weight of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof by weight of the formulation. In some embodiments, formulations described herein comprise about 0.01 % by weight of an antimicrobial agent, or pharmaceutically acceptable prodrug or salt thereof by weight of the formulation. In some embodiments, the formulations described herein have a concentration of active pharmaceutical ingredient, or pharmaceutically acceptable prodrug or salt thereof between about 0,1 to about 70 mg/nlL, between about 0.5 mg/mL to about 70 ing/mL. between about 0,5 mg/mL to about 50 mg/mL, between about 0,5 mg/mL to about 20 mg/mL, between about 1 mg to about 70 mg/mL, between about I mg to about 50 mg/mL, between about 1 mg/mL and about 20 mg/mL, between about i mg/mL to about 10 mg'inL, or between about l mg/mL to about 5 mg/mL, of the active agent, or pharmaceutically acceptable prodrug or salt therof by volume of the formulation.

Otic Surgery and Implants (00232( In some embodiments, the pharmaceutical formulations, compositions or devices described herein are used in combination with (e.g., implantation, short-term use. long-term use, or removal of) implants (e.g., cochlear implants).-As used herein, implants include auris-interoa or auris-media medical devices, examples·, of which include cochlear implants, hearing sparing devices, hearing-improvement devices, short electrodes, tympanostomy tubes, micro-prostheses or piston-like prostheses; needles; stem cell transplants ; drug delivery devices; any cell-based therapeutic; or the like. In some instances, the implants are used in conjunction with a patient experiencing hearing loss. In some instances, the hearing loss is present at birth. In some instances, the hearing loss is associated with,conditions such as AI£D, bacterial meningitis or the like that lead to osteoneogenesis and/or nerve damage with rapid obliteration of cochlear structures and profound hearing loss. (0Q233J It» some instances, an implant is an immune cell or a stem cell transplant in the ear.

In some instances, an implant is a small electronic device that has an external portion placed behind the ear, and a second portion that is surgically placed under the skin that helps provide a sense of sound to a person who is profoundly deaf or severely hard-of-hearing. By way of example, such cochlear medical device implants bypass damaged portions of the ear and directly stimulate the auditory nerve, in some instances cochlear implants are used in single sided deafness, in some instances cochlear implants are used for deafness in both ears. {00234] In some embodiments, administration of an antimicrobial composition or device described herein in combination with an otic intervention (e.g., an intratympanic infection, a stapedectomy, a tympanostomy, a medical device implant or a cell-based transplant) delays or prevents collateral damage to auris structures, e.g., irritation, inflammation and/or infection, caused by the external otic intervention (e.g,, installation of an external device and/or cells In the ear). In some embodiments, administration of an antimicrobial composition or device described herein in combination with an implant allows for a more effective restoration of hearing loss compared to an implant alone.

[00235] In some embodiments, administration of an mitimicrobial composition or device described herein reduces damage to cochlear structures caused by underlying conditions (e.g., bacterial meningitis, autoimmune ear disease (AIED)) allowing for successful cochlear device implantation. In some embodiments, administration of a composition or device described herein, in conjunction with otic surgery, medical device implantation and/or cell transplantation, reduces or prevents cell damage and/or inflammation associated with otic surgery , medical device implantation and/or cell transplantation, [00236] In some embodiments, administration of an antimicrobial composition or device described herein (e.g., a composition or device comprising a corticosteriod) in conjunction with a-cochlear-implant or stem ceil transplant has a trophic effect (e.g., promotes healthy growth of cells and/or healing of tissue in the area of an implant or transplant). In some embodiments, a trophic effect is desirable during otic surgery or during intratympanic injection procedures. In some embodiments, a trophic effect is desirable after installation of a medical de vice or after a ceil transplant. In some of such embodiments, the antimicrobial, compositions or devices described herein are administered via direct cochlear injection, through a choehleostomy or via deposition on the round window. In some embodiments, a medical device is coated with a composition described herein prior to implantation in the ear.

[00237] In some embodiments, administration of an anti-inflammatory or immunosuppressant composition (e.g., a composition comprising an imnlimosuppresant such as a corticosteroid) reduces inflammation and/or infections associated with otic surgery, implantation of a medical device or a cell transplant, in some instances, perfusion of a surgical area with an antimicrobial formulation described herein and/or an antiinflammatory’ formulation described herein reduces or eliminates post-surgical and/or post-implantation .complications'inflammation, cell damage, infection, osteoneogenesis or the like). In some instances, perfusion of a surgical area with a formulation described herein reduces post-surgery or post-implantation recuperation time.

[00238] In one aspect, the formulations described herein, and modes of administration thereof, are applicable to methods of direct perfusion of the inner ear compartments. Thus, the formulations described herein arc useful in combination with otic interventions. In some embodiments, an otic intervention is an implantation procedure (e.g,, implantation of a hearing device in the cochlea). In some embodiments, an otic intervention is a surgical procedure including, by way of non-limiting examples, eochleostomy, labyrinthotomy, mastoidectomy, stapedectomy, stapedoiomy, tympanostomy, endolymphatic sacculotomy or the like. In some embodiments, the inner ear compartments are perfused with a formulation described herein prior to otic intervention, dining otic intervention, or after otic intervention, or a combination thereof.

[00239] In some embodiments, when perfusion is carried out in combination with otic intervention, the antimicrobial compositions are immediate release compositions (e.g., a composition comprising ciprofloxacin). In some of such embodiments, the immediate release formulations described herein are non-thiekened compositions and are substantially free of extended release components (e.g., gelling components such as polyoxyethylene-polyoxypropylene copolymers). In some of such embodiments, the compositions contain less than 5% of the extended release components (e.g., gelling components such as polyoxyethylene-polyoxypropylene tribiock copolymers) by weight of the formulation. In some of such embodiments, the composi tions contain l ess than 2% of the extended release components (e.g., gelling components such as polyoxyethylcne-polyoxypropylene triblock copolymers) by weight of the formulation. In some of such embodiments, the compositions contain less than 1% of the extended release components (e.g., gelling components such as polyoxyethylene-poiyoxy'propylene triblock copolymers) by weight of the formul ation. In some of such embodiments, a composition described herein that is used for perfusion of a surgical area contains substantially no gelling component and is an immediate release composition. 109240] In certain embodiments, a composition described herein is administered before an otic intervention (e.g., before implantation of a medical device or a cell-based therapeutic). In certain embodiments, a composition described herein is administered during an otic intervention (e.g., during implantation of a medical device or a cell-based therapeutic). In other embodiments, a composition described herein is administered after an otic intervention (e.g., after implantation of a medical device or a cell-based therapeutic). In some of such embodiments, a composition described herein that is administered after the otic intervention is an intermediate release or extended release composition (e.g., a composition comprising an antibiotic, a composition comprising an anti-inflammatory agent, a composition comprising a an antibiotic and an anti-inflammatory agent or the like) and contains gelling components as described herein. In some embodiments, an implant (e.g., a tympanostomy tube) is coated with a composition or device described herein prior to insertion in the ear. {00241] Presented below (Table 1) are examples of active agents contemplated for use with the formulations and devices disclosed herein. One or more active agents are used in any of the formulations or devices described herein.

[0924:2] Active Agents (including pharmaceutically acceptable salts, prodrugs of these acti ve agents) for use with the Formulations Disclosed Herein (TABLE 1)

General Methods of Sterilization [00243] Provided herein are otic compositions that ameliorate or lessen otic disorders described herein, Further provided herein are methods comprising the administration of said otic compositions. In some embodiments, the compositions or devices are sterilized. Included within the embodiments disclosed herein are means and processes for sterilization of a pharmaceutical composition or device disclosed herein for use in humans. The goal is to provide a safe pharmaceutical product, relatively tree of infection causing microorganisms. The U. S. Food and Drug Administration has provided regulatory guidance in the publication “Guidance .for Industry: Sterile Drug Products Produced by Aseptic Processing” available at: http://www.fda.gOv/cder/giddanc.e/S882M.htm, which is incorporated herein by reference in its entirety.

[09244] As used herein, sterilization means a process used to destroy or remove microorganisms that are present in a product or packaging. Any suitable method available for sterilization of objects and compositions is used. Available methods for the inactivation of microorganisms .include, but are not limited to, the application of extreme heat, lethal chemicals, or gamma radiation. In some embodiments is a process for the preparation of an otic therapeutic formulation comprising subjecting the formulation to a sterilization method selected from heat sterilization, chemical sterilization, radiation sterilization or filtration sterilization. The method used depends largely? upon the nature of the device or composition to be sterilized. Detailed descriptions of many methods of sterilization are given in Chapter 40 of Remington: T he Science and Practice of Pharmacy published by Lippincott, Williams &amp; Wilkins, and is incorporated by reference with respect to this subject matter.

Sterilization by Heat [09245] Many methods are available for sterilization by the application of extreme heat. One method is through the use of a saturated steam autoclave. In this method, saturated steam at a temperature of at least 121. °C is allowed to contact the object to be sterilized. The transfer of heat is either directly to the microorganism, in the case of an object to be sterilized, or indirectly to the microorganism by heating the bulk of an aqueous solution to be sterilized. This method is widely practiced as it allows flexibility, safety and economy in the sterilization process.

[00246] Dry heat sterilization is a method which is used to kill microorganisms and perform depyrogenation at elevated temperatures. This process takes place in an apparatus suitable for heating HEP A-filtered nricroorganisni-free air to temperatures of at least 130-180 GC for the sterilization process and to temperatures of at least 230-250 °C for the depyrogenation process. Water to reconstitute concentrated or powdered formulations is also sterilized by autoclave. In some embodiments, the formulations described herein comprise micronized antimicrobial agents (e.g., micronized ciprofloxacin powder) that are sterilized by dry heating, e.g., heating: for about 7 - 11 hours at internal powder temperatures of 130-140 °C, or for 1-2 hours atintermal fempearatures of 150-180 °C,

Chemical Sterilization [fW)247] Chemical sterilization methods are an alternative for products that do not withstand the extremes of heat sterilization. I n this method, a variety of gases and vapors with germicidal properties, such as ethylene oxide, chlorine dioxide, formaldehyde or ozone are used as the anti-apoptotic agents. The germicidal activity of ethylene oxide, for example, arises from its ability to serve as a reactive alkylating agent. Thus, the sterilization process requires the ethylene oxide vapors to make direct contact with the product to be sterilized.

Radiation Sterilization 100248] One advantage of radiati on sterilization is the ability to sterilize many types of products without heat degradation or other damage. The radiation commonly employed is beta radiation or alternatively, gamma radiation from a 60Co source. The penetrating ability of gamma radiation allows its use in the sterilization of many product types, including solutions, compositions and heterogeneous mixtures. The germicidal effects of irradiation arise from the interaction of gamma radiation with biological macromoleeules. This interaction generates charged species and free radicals, Subsequent chemical reactions, such as rearrangements and cross-linking processes, result in the loss of normal function for these biological macromolecules. The fomutlations described herein are also optionally sterilized using beta irradiation.

Filtration J00249] Filtration sterilization is a method used to remove but not destroy microorganisms from solutions. Membrane filters are used to filter heat-sensitive solutions. Such filters are thin, strong, homogenous polymers of mixed ceflulosic esters (MCE), polyvinylidene fluoride (PVF; also known as PVDF), or pohuetrafluGroetliylene (PTFE) and have pore sizes ranging from 0.1 to 0.22 pm. Solutions of various characteristics are optionally filtered using different filter membranes. For example, PVF and PTFE membranes are well suited to filtering organic solvents while aqueous solutions are filtered through PVF or MCE membranes. Filter apparatus are available for use on many scales ranging from the single point-of-use disposable filter attached to a syringe up to commercial scale filters for use in manufacturing plants. The membrane filters are sterilized by autoclave or chemical steri lization. Validation of membrane filtration systems is performed following standardized protocols (Microbiological Evaluation of Filters for Sterilizing Liquids, Vol 4, No. 3, Washington, D.C: Health Industry Manufacturers Association, 1981) and involve challenging the membrane filter with a known quantity (ca. 10,;cm2) of unusually small microorganism s, such as Brevundimonas diminuta (ATC.C 19146).

[00250]Pharmaceutical compositions are optionally sterilized by passing through membrane filters: Formulations -comprising nanoparticles (U.S. Pat No. 6,.139,870) or multi lamellar vesicles (Richard et al., International Journal of Pharmaceutics {2006), 312(1-2):144-50) are amenable to .sterilization by fi ltration, through 0..22 μΐή filters without destroying their organized structure.

[902511 In some embodiments, the methods disclosed herein comprise sterilizing the formulation (or components thereof) by means of filtration sterilization. In another embodiment the auris-aceeptable otic therapeutic agent formulation comprises a particle wherein the particle formulation is suitable for filtration sterilization. In a further embodiment said particle formulation comprises particles of less than 300 nm in size, of less than 200 tun in size, of less than 100 nrn in size. In another embodiment the auris-aeeeptable formulation .comprises a particle formulation wherein the sterility of the particle is ensured by sterile filtration of the precursor component, solutions, in another embodiment the auns-acceptable formulation comprises a particle formulation wherein the sterility of the particle formulation is ensured by low temperature sterile filtration. In a further embodiment, low temperature sterile filtration is carried out at a temperature between 0 and 30 °C, between 0 and 20 °C, between 0 and 10 °C, between 10 and 20 °C, or between 20 and 3 0' C.

[00252] In. another embodiment is a process for the preparation of an auris-acceptable particle formulation comprising· filtering the aqueous solution containing the particle formulation at low temperature through a sterilization tiller; lyophillzing the sterile solution; and reconstituting the particle formulation with sterile water prior to administration. In some embodiments, a formulation described herein is .manufactured as a suspension in a single vial formulation containing the micronized acti ve pharmaceutical ingredient A single vial formulation is prepared by aseptically mixing a sterile poloxamer solution with sterile micronized active ingredient (e.g., ciprofloxacin) and transferring the formulation to sterile pharmaceutieal containers. In some embodiments, a single vial containing a formulation described herein as a suspension is resuspended before dispensing and/or administration. [©0253] In specific embodiments, filtration and/or filling procedures are carried out at about 5°C below the gel temperature ( ! gel) of a formulation described herein and with viscosi ty below a theoretical, value of 1 OOcP to allow for filtration in a reasonable time using a peristaltic pump.

[00254] In another embodiment the auris-aeeeptable otic therapeutic agent formulation comprises a nanoparticle formulation wherein the nanoparticle formulation is suitable for filtration sterilization. In a further embodiment the nanoparticle formulation comprises nanoparticles of less than 3()0 nm in size, of less than. 200 nm in size, or of less than 100 nm in size. In another embodiment the auris-acceptable formulation comprises a microsphere formulation wherein tire sterility of the microsphere is ensured by sterile filtration of the precursor organic solution and aqueous solutions. In another embodiment the auris-aeeeptable formulation comprises a thermoreversible gel formulation wherein the sterility of the gel formulation is ensured by low temperature sterile filtration. In a further embodiment,, the low temperature sterile filtration occurs at a temperature between 0 and 30 °C, or between 0 and 20 °C, or between 0 and 10 °C, or between 10 and 20 °C, or between 20 and 30 °C. In another embodiment is a process for the preparation of an auris-aeeeptable thermoreversible gel formulation comprising: filtering the aqueous solution containing the thermoreversible gel components at low temperature through a sterilization./filter;, lyophilizing the sterile solution; and reconstituting the thermoreversible gel formulation with sterile water prior to administration.

[00255] In certain embodiments, the active ingredients are dissolved in a suitable vehicle (e.g. a butter) and sterilized separately (e.g. by heat treatment, filtration, gamma radiation). In some instances, the active ingredients are sterilized separately in a dry stale, hi some instances, the active ingredients are sterilized as a suspension or as a colloidal suspension. The remaming excipients (e.g,, fluid gel components present in auris formulations) are sterilized in a separate step hv a suitable method (e.g. filtration and/or irradiation of a cooled mixture of excipients); the two solutions that are separately sterilized are then mixed aseptically to provide a final auris formulation. In some instances, the final aseptic mixing is performed just prior to administration of a fonnulation described herein.

[00256] In some instances, conventionally used methods of sterilization (e,g., heat treatment (e.g., in an autoclave), gamma irradiation, filtration) lead to irreversible degradation of polymeric components (e.g., thermosetting, gelling or mucoadhesive polymer components) and/or the active agent in the formulation. In some instances, sterilization of an auris formulation by filtration through membranes (e.g., 0.2 μΜ membranes) is not possible if the formulation comprises thixotropic polymers that gel during the process of filtration. {00257] Accordingly, provided herein are methods for sterilization of auris formulations that prevent degradation of polymeric components (e.g., thermosetting and/or gelling and/or mucoadhesive polymer components) and/or the active agent during the process of sterilization. In some embodiments; degradation of the active agent (e.g., any therapeutic otic agent described herein) is reduced or eliminated through the use of speci fic pH ranges for buffer components and specific proportions of gelling agents in the formulations. In some embodiments, the choice of an appropriate gellling agent and/or thermosetting polymer al lows for sterilization of formulations described herein by filtration. in some embodiments, the use of an appropriate thermosetting polymer and an appropriate copolymer (e,g,s a gellling agent) in combination with a specific pH range for the formulation allows for high temperature sterilization of formulations described with substantially no degradation of the therapeutic agent or the polymeric excipients. An advantage of the methods of sterilization provided herein is that, in certain instances, the formulations are subjected to terminal sterilization via autoclaving without any loss of the active agent and/or excipients and/or polymeric components during tire sterilization step and are rendered substantially free of microbes and/or pyrogens.

Microorganisms [00258] Provided herein are auris-acceptable compositions or devices that ameliorate or lessen Otic disorders described herein. Further provided herein are methods comprising the administration of said otic compositions, in some embodiments, the compositions or devices are substantially free of microorganisms. Acceptable bioburden or sterility levels are based on applicable standards that define therapeutically acceptable compositions, including but not limited to United States Pharmacopeia Chapters <1111> et seq. For example, acceptable sterility (e.g., bioburden) levels include about 10 colony forming units (efu) per gram of formulation, about 50 efu per gram of formulation, about 100 cfu per gram of formulation, about 500 cfu per gram of formulation or about 1000 cfu per gram of formulation. In some embodiments, acceptable bioburden levels or sterility for formulations include less than 10 ciii/raL, less that 50 cfu/mL, less than 500 efu/ml, or less than 1000 cfu/'mL microbial agents. In addition, acceptable bioburden levels or sterility include the exclusion of specified objectionable microbiological agents. By way of example, specified objectionable microbiological agents include: but are not limited to Escherichia coli (E. eoii). Salmonel la sp. , Pseudomonas aeruginosa (P. aeruginosa) and/or other specific microbial agents.

[00259] Sterility of the auris-acceptable otic therapeutic agent formulation is confirmed through a sterility assurance program in accordance with United States Pharmacopeia

Chapters <61>, <62> and <7l>. A key component of the sterility assurance quality control, quality assurance and validation process is the method of sterility testing. Sterility testing, by way of example only, is performed by two methods. The first is direct inoculation wherein a sample of the composition to be tested is added to growth medium and incubated for a period of time up to 21 days. Turbidity of the growth medium indicates contamination. Drawbacks to this method include the small sampling size of bulk materials which reduces sensitivity , and detection of microorganism growth based on a visual observation. An alternative method is membrane filtration sterility testing. In this method, a volume of product is passed through a small membrane filter paper. The filter paper is then placed into media to promote the growth of microorganisms. This method has the advantage of greater sensitivity as the entire bulk, product is sampled. The commercially available Millipore Steritest sterility testing system is optionally used for determinations by membrane filtration sterility testing. For the filtration testing of creams or ointments Steritest filter system No. TLHVSL21Q are used. For the filtration testing of emulsions or viscous products Steritest filter system No. TLAREM210 or TDAREM210 are used. For the filtration testing of prefilled swinges Steritest filter system No. ITHASV2:10 are used. For the filtration testing of material dispensed as an aerosol or foam Steritest filter system No. TTHVA210 are used. For the filtration testing of soluble powders in ampoules or vials Steritest filter system No. TTHADA210 or TTHADV210 are used. (00260] Testing for E. coli and Salmonella includes the- use of lactose broths incubated at 30 - 35 °C for 24-72 hours, incubation in MaeConkey and/or EMB agars for 18-24 hours, and/or the use of Rappaport medium. Testing for the detection of P. aeruginosa includes the use of NAC agar. United States Pharmacopeia Chapter <62> further enumerates testing procedures for specified objectionable microorganisms.

[§0261|In certain embodiments, any controlled release formulation described herein has less than about 60 colony forming units (CPU), less than about 50 colony forming units, less than about 40 colony forming units, or less than about 30 colony forming units of microbial agents per gram of formulation. In certain embodiments, the otic formulations described herein are formulated to be isotonic with the endolymph and/or the perilymph.

Endotoxins [00262] Provided herein are otic compositions that ameliorate or lessen otic disorders described herein. Further provided herein arc methods comprising the administration of said otic compositions. In some embodiments, the compositions or devices are substantially tree of endotoxins. An additional aspect of the sterilization process is the removal of by-products from the killing of microorganisms: (hereinafter, “Product”). The process of depyrogenation removes pyrogens from the sample. Pyrogens are endotoxins or exotoxins which induce an immune response. An example of an endotoxin is the lipopolysaccharide (I,PS) molecule found in the cell wall of gram-negative bacteria. While sterilization procedures such as autoclaving or treatment with ethylene oxide kill the bacteria, the LPS residue induces a promflammatory immune response, such as septic shock. Because the molecular size of endotoxins can vary widely, the presence of endotoxins is expressed in “endotoxin units” (EU), One EU is equivalent to 100 picograms of E. eoli LPS. Humans can develop a response to as little as 5 EU/kg of body weight. The bioburden (e.g., microbial limit) and/or sterility (e.g., endotoxin level) is expressed in any units as recognized in the art. In certain embodiments, otic compositions described herein contain lower endotoxin levels (e ,g.<4 EU/kg of body weight of a subject) when compared to 'conventionally acceptable endotoxin levels (e.g., 5 EU/kg of body weight of a subject). In some embodiments, the auris-acceptable otic therapeutic agent formulation has less than about 5 ELEkg of body weight of a subject. In other embodiments, the auris-acceptable otic therapeutic agent formulation has less than about 4 EU/kg; of body wei ght of a subject, in additional embodiments, the auris-acceptable otic therapeutic agent formulation has less than about 3 EU/kg of body weight of a subject. In additional embodiments, the auris-acceptabie otic therapeutic agent formulation has less than about 2 EU/kg of body weight of a subject, 1002631 In some embodiments, the auris-acceptable otic therapeutic agent formulation or device has less than about 5 EU/kg of formulation. In oilier embodiments, the auris-acceptable otic therapeutic agent formulation has less than about 4 EU/kg of formulation. In additional embodiments, the auris-acceptable otic therapeutic agent formulation has less than about 3 EU/kg of formulation. In some embodiments, the auris-acceptabie otic therapeutic agent formulation has less than about 5 EU/kg Product. In other embodiments, the auris-acceptable otic therapeutic agent formulation has less than about 1 EU/kg Product. In additional embodiments, the auris-acceptable otic therapeutic agent formulation has less than about 0.2 EU/kg Product. In some embodiments, the auris-acceptable otic therapeutic agent formulation has less than about 5 EU/g of unit or Product. In other embodiments, the auris-acceptable otic therapeutic agent formulation has less than about 4 EU/ g of unit or Product. In additional embodiments, the auris-acceptable otic therapeutic agent formulation has less than about 3 EU/g of unit or Product, in some embodiments, the auris-acceptable otic therapeutic agent formulation has less than about 5 EU/mg of unit or Product. In other embodiments, the auris-acceptable otic therapeutic agent-formulation has less than about4. ELI/ mg of unit'or Product. In additional embodiments, the auris-acceptable otic therapeutic agent formulation has less than, about 3 EU/mg of unit or Product. In certain embodiments, otic compositions described herein contain from about I to about 5 EU/mL of formulation. In certain embodiments, otic compositions described herein contain from about 2 to about 5 EU/mL of formulation, from about 3 to about 5 EU/mL of formulation, or from about 4 to about 5 EU/mL of formulation.

[00264] In certain embodiments, otic compositions or devices described herein contain lower endotoxin levels (e.g. < 0.5 EU/mL of formulation) when compared to conventionally acceptable endotoxin levels (e.g., 0.5 EU/niL of formulation). In some embodiments, the auris-acceptable otic therapeutic agent formulation or device has less than about 0.5 EU/mL of formulation. In other embodiments, the auris-acceptable otic therapeutic agent formulation has less than about 0.4 EU/mL· of formulation. In additional embodiments, the auris-acceptable otic therapeutic agent formulation has less than about 0.2 EU/mL of formulation, [00265] Pyrogen detection, by way of example only, is performed by several methods. Suitable tests for sterility include tests described in United States Pharmacopoeia (USP) <71> Sterility Tests (23rd edition, 1995). The rabbit pyrogen test, and the Limulus amebocyte lysate test are both specified in the United States Pharmacopeia Chapters <85> and <151> (IJSP23/NF 18, Biological Tests, The United States Pharmacopeial Convention, Rockville, MD, 1995). Alternative pyrogen assays have been developed based upon the monocyte activation-cytokine assay, Uniform ceil lines suitable for quality control applications have been developed and have demonstrated the ability to detect pyrogenicity in samples that have passed the rabbit pyrogen test and the Limulus amebocyte lysate test (Taktaket al, J, Pharm. Pharmacol. (1990), 43:578-82). in an additional embodiment, the auris-acceptable otic therapeutic agent formulation is subject to depyrogenation. In a further embodiment, the process for the manufacture of the amis-acceptable otic therapeutic agent formulation comprises testing the formulation, for pyrogenicity. In certain embodiments, the formulations described here in are substantially free of pyrogens . pH and Practical Osnaolarity [00266] In some embodiments, an otic composition or device disclosed herein is formulated to provide an ionic balance that is compatible with inner ear fluids (e.g., endolymph and/or perilymph).

[00267] In certain instances, the ionic composition of the endolymph and perilymph regulate the electrochemical impulses of hair cells and thus hearing. In certain instances, changes in the conduction of electrochemical impulses along otic hair cells results in hearing loss. In certain instances, changes in the ionic balance of the endolymph or perilymph results in complete hearing loss. In certain instances, changes in the ionic balance o f the endol ymph or perilymph results in partial hearing loss. In certain instances, changes in the ionic balance of the endolymph or perilymph results in permanent hearing loss. In certain instances, changes in the ionic balance of the endolymph or perilymph results in temporary hearing loss.

[00268] In some embodiments, a composition or device disclosed herein is formulated in order to not disrupt the ionic balance of the endolymph. In some embodiments, a composition or device disclosed herein has an ionic balance that is the same as or substantially the same as the endolymph. In some embodiments, a composition or device disclosed herein does not does not disrupt the ionic balance of the endolymph so as to result in partial or complete hearing loss. In some embodiments, a composition or device disclosed herein does not does not disrupt the ionic balance of the endolymph so as to result in temporary or permanent hearing loss, [00269] In some embodiments, a composition or device disclosed herein does not substantially disrupt the ionic balance of the perilymph. In some embodiments, a composition or device disclosed herein has an ionic balance that is the same as or substantially the same as the perilymph. In some embodiments, a composition or device disclosed herein does not result in parital or complete hearing loss as the composition or device does not disrupt the ionic balance of the perilymph. In some embodiments, a composition or device disclosed herein does not result in temporary or permanent hearing loss as the composition or device does not disrupt die ionic balance of the perilymph. |fl0270| As used herein, 'practical osmolarity/osmolality” or ‘'deliverable osnM>latity/osmolal%w means the osmolarity/osmolality of a composition or device as determined by measuring the osmolarity/osmolality of the active agent and all excipients except the gelling and/or the thickening agent (e.g., polyoxyethylene-polyooxypropyiene copolymers, earhoxymethy lcelliilose or the like). The practical osmolarity of a composition or device disclosed herein is measured by a suitable method, e.g., a freezing point depression method as described in Viegas et. aL, Ini. J Pharm., 1998,160,157-162. In some instances, the practical osmolarity of a composition or device disclosed herein is measured by vapor pressure osmometry (e.g., vapor pressure depression method) that allows for determination of the osmolality of a composition or device at higher temperatures. In some instances, vapor pressure depression method allows for determination of the osmolarity of a composition or device comprising a gelling agent (e.g., a thermoreversible polymer) at a higher temperature wherein the gelling agent is in the form of a gel.

[002711 In some embodiments, the osmolality at a target site of action (e.g., the perilymph) is about the same as the delivered osmolarity (i.e., osmolarity of materials that cross or penetrate the round window membrane) of a composition, or device described herein. In some embodiments, a composition or device described herein has a deliverable osmolarity of about 150 mOsrn/L to about 500 mOsm/L, about 250 mOsm/'L to about 500 mOsnv'L, about 250 mOsm/L to about 350 mQsm/L, about 280 mOsm/'L to about 370 mOsm/L or about 250 raOsm/L to about 320 mOsm/L. {00272} The practical osmolality of an otic composition or device disclosed herein is from about 100 mOsm/kg to about 1000 m()sm/kg, from about 200 mOsm/kg to about 800 mOsm/kg, from about 250 mOsm/kg to about 500 mOsm/kg, or from about 250 mOsm/kg to about 320 mOsm/kg, or from about 250 mOsm/kg to about 350 mOsm/kg or from about 280 mQsm/kg to about 320 mOsm/kg. In some embodiments, a composition or device described herein has a practical osmolarity of about 3 00 mOsm/L to about 1000 mOsm/L, about 200 raOsm/L to about 800 mOsm/L, about 250 mOsm/L to about 500 mOsm/L, about 250 mOsm/L to about 350 mOsm/L, about 250 mOsm/L to about 320 mOsm/L, or about 280 mOsm/L to about 320 mOsm/L. (00273} The main cation present in the endolymph is potassium. In addition the endolymph has a high concentration of positively charged amino acids. The main cation present in the perilymph is sodium. In certain instances, the ionic composition of the endolymph and perilymph regulate the electrochemical impulses of hair cells. In certain instances, any change in the ionic balance of the endolymph or perilymph results in a loss of hearing due to changes in the conduction of electrochemical impul ses along otic hair cells. In: some embodiments, a composition disclosed herein does not disrupt the ionic balance of the perilymph. In some embodiments, a composition disclosed herein has an ionic balance that is the same as or substantially the same as the perilymph. In some embodiments, a composition disclosed herein does not disrupt the ionic balance of the endolymph, In some embodiments* a composition disclosed herein has an ionic balance that is the same as or substantially the same as the endolymph. In some embodiments, an otic formulation described herein is formulated to provide an ionic balance that is compatible with inner ear fluids (e.g., endolymph and/or perilymph). {00274)The endolymph and the perilymph have a pH that is close to the physiological pH of blood. The endolymph has a pH range of about 7.2-7.9; the perilymph has a pH range of about 7.2 ™ 7,4. The in situ pH of the proximal endolymph is about 7.4 while the pH of distal endolymph is about 7.9.

[0027511η some embodiments, the pH of a composition described herein is adjusted (e.g., by use of a buffer) to an en do lymph-compatible pH range of about 5.5 to 9.0. in specific embodiments, the pH of a composition described, herein is adjusted to a perilymph-suitable pH range of about 5,5 to about 9.0. In some embodiments, the pH of a composition described herein is adjusted to a perilymph-suitable range of about 5.5 to about 8.0, about 6 to about 8,0 or about 6.6 to about 8.0, In some embodiments, the pH of a composition described herein is adjusted to a perilymph-suitable pH range of about 7.0 - 7.6.

[00276] In some embodiments, useful formulations also include one or more pH adjusting agents or buffering agents. Suitable pH adjusting agents or buffers include, but are not limited to acetate, bicarbonate, ammonium chloride, citrate, phosphate, pharmaceutically acceptable salts thereof and combinations or mixtures thereof.

[00277J In one embodiment, when one or more buffers are utilized in the formulations of the present disclosure, they are combined, e.g., with a pharmaceutically acceptable vehicle and are present in the final formulation, e.g., in an amount ranging from about 0.1% to about 20%, from about 0.5% to about 10%. In certain embodiments of the present disclosure, the amount of buffer included in the gel formulations are an amount such that the pH of the gel formulation does not interfere with the body's natural buffering system.

[00278] In one embodiment, diluents are also used to stabilize compounds because they can provide a more stable environment. Salts dissolved in buffered solutions (which also can provide pH control or maintenance) are utilized as diluents in the art, including, but not limited to a phosphate buffered saline solution.

[00279) In some embodiments, any gel formulation described herein has a pH that allows for sterilization (e.g, by filtration or aseptic mixing or heat treatment and/or autoclaving (e.g.. terminal sterilization) of a gel formulation without degradation of the pharmaceutical agent (e g., antimicrobial agent) or the polymers comprising the gel. In order to reduce hydrolysis and/or degradation of the otic agent, and/or the gel polymer during sterilization, the buffer pH is designed to maintain pH of the formulation in foe 7-8 range during the process of sterilization (e.g,, high temperature autoclaving). {0028011η specific embodiments, any gel formulation described herein has a pH that allows for terminal sterilization (e.g, by heat treatment and/or autoclaving) of a gel formulation without degradation of the pharmaceutical agent (e.g., antimicrobial agent) or the polymers comprising the gel. For example, in order to reduce hydrolysis and/or degradation of the otic agent and/or foe gel polymer during autoclaving, the buffer pFI is designed to maintain pH of the formulation in the 7-B range at elevated temperatures. Any appropriate buffer is used depending on the otic agent used in the formulation, in some instances, since pKa of TRIS decreases as temperature increases at approximately -0.03/°Ο and pKa of PBS increases as temperature increases at approximately 0.003/¾ autoclaving at 250°? (121 °C) results in a significant downward pH shift (i.e. more acidic) in the TRIS buffer whereas a relatively much less upward pH shift in the PBS buffer and therefore much increased hydrolysis and/or degradation of an otic agent in TRIS than in PBS. Degradation of an otic agent is reduced by the use Of an appropriate combination of a buffer and polymeric additives (e.g. CMC) as described herein, [002811 In some embodiments, a formulation pH of between about 5,0 and about 9.0, between about 5.5 and about 8.5, between about 6.0 and about 7.6, between about 7 and about 7.8, between about 7.0 and about 7.6, between about 7,2 and 7,6, or between about 7,2 and about 7,4 is suitable for sterilization (e.g, by filtration or aseptic mixing or heat treatment and/or autoclaving (e.g.. terminal sterilization)) of auris formulations described herein. In specific embodiments a formulation pH of about 6.0, about 6.5, about 7.0, about 7,1, about 7.2, about 7.3, about 7.4, about 7,5, or.about 7.6 is suitable for sterilization (e.g, by filtration or aseptic mixing or heat treatment and/or autoclaving (e.g., terminal sterilization)) of any composition descibed herein. {(M>282JIn some embodiments, the formulations have a pH as described herein, and include a thickening agent (e.g, a vicosity enhancing agent) such as, by way of non-limiting example, a cellulose based thickening agent described herein. In some instances, foe addition of a secondary polymer (e.g,:, a thickening agent) and a pH of formulation as described herein, allows for sterilization of a formulation described herein without any substantial degradation of the otic agent and/or the polymer components in the otic .formulation. In some embodiments, the ratio of a thermoreversible poloxamer to a thickening agent in a formulation that has a pH as described herein, is about 40:1, about 35:1, about 30:1, about 25:.1, about 20:1, about 15:1 about 5.0:Lor about 5:1, For example, in certain embodiments, a sustained and/or extended release formulation described herein comprises a combination of poloxamer 407 (piuronic F127) and carboxymethylcellulose (CMC) in a ratio of about 40:1, about;35:1, about 30:1, about 25:1, about 20:1, about 15:1, about 10:1 or about 5:1, [002S31 In some embodiments, the amount of theratoreversible polymer in any formulation described herein is about 10%, about 15%, about 20%, about 25%, about 30%, about 35% or about 40% of the total weight of the formulation. In some embodiments, the amount of thermoreversible polymer in any formulation described herein is about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 175¾. about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24% or about 25% of the total weight of the formulation. In some embodiments, the amount of thermoreversible polymer (e.g., piuronic FI 27) in any formulation described herein is about 7.5% of tire total weight of the formulation , in some embodiments, the amount of thermoreversible polymer (e.g., piuronic FI 27) in any formulation described herein is about 10% of the total weight of the formulation. In some embodiments, the amount of thermoreversible polymer (e.g., piuronic FI 27) in any formulation described herein is about 11% of the total· weight of the formulation, in some embodiments, the amount of thermoreversible· polymer (e.g,, piuronic FI 27) in any formulation described herein is about 12% of the total weight of the formulation. In some embodiments, the amount of thermoreversible polymer (e.g., piuronic 1127} in any formulation described herein is about 13% of the total weight of the formulation, fo some embodiments, the amount of thermoreversible polymer (e.g., piuronic F127) many fomiulation described herein is about 1.4% of the total weight of the formulation. In some embodiments, the amount of thermoreversible polymer (e.g., piuronic FI 27) in any formulation described herein is about 15% of the total weight of the formulation. In some embodiments, the amount of thermoreversible polymer (e.g,, piuronic F127) in any formulation described herein is about 16% of the total weight of the formulation. In some embodiments, the amount of thermoreversible polymer (e.g., piuronic-F127) in airy formulation described herein is about 17%. of the total weight of the formulation, in some embodiments, the amount of thermoreversible polymer (e.g., piuronic FI 27) in any formulation described herein is about 18% of the total weight of tire formulation. In some embodiments, the amount of thermoreversible polymer (e.g., pluronic P I 27) in any formulation described herein is about 19% of the total weight of the formulation. In some embodiments, the amount of thermoreversible polymer (e.g,, pluronic FI 27) in any formulation described herein is about 20% of the total weight of the formulation. In some embodiments, the amount of thermoreversible polymer (e.g., pluronic F127) in any formulation described herein is about 21% of the total weight of the formulation, in some embodiments, the amount of thermoreversible polymer (e.g., pluronic F127) in any formulation described herein is about 23% of the total weight of the formulation, in some embodiments, the amount of thennoreversible polymer (e.g., pluronic F127) in any formulation described herein is about 25% ofthe total weight of the formulation. In some embodiments, the amount ofthickening agent (e.g., a gelling agent) in any formulation described herein is about 1 %, about 5%, about 10%, or about T5% ofthe total weight of the formulation. In some embodiments, the amount of thickening agent (e.g., a gelling agent) in any formulation described herein is about 0.5%, about 1%, about l.S%, about 2%. about 2.5%, about 3%, about 3.5%, about 4%, about 4.5%, or about 5% ofthe total weight of the formulation.

[00284] In some embodiments, the pharmaceutical formulations described herein are stable with respect to pH over a period of any of at least about 1 day, at least about 2 days, at least about 3 days, at least about 4 days, at least about 5 days, at least about 6 days, at least about 1 week, at least about 2 weeks, at least about 3 weeks, at least about 4 weeks, at least about 5: weeks, at least about 6 weeks, at least about 7 weeks, at least about 8 weeks, at least about 1 month, at least about 2 months, at least about 3 months, at least about 4 months, at least about 5 months, or at least about 6 months. In other embodiments, the formulations described herein are stable with respect to pH over a period of at least about 1 week. Also described herein are formulations that are stable with respect to pH over a period of at least about 1 month.

Tonicity Agents }00285|In general, the endolymph has a higher osmolality than the perilymph. For example, the endolymph has an osmolality of about 304 mOsm/kg H^O while the perilymph has an osmolality of about 294 mOsm/kg H >0, In certain embodiments, tonicity agents are added to the formulationsdescribed herein in an amount as to provide a practical osmolality of an otic formulation of about 100 mOsm/kg to about 1000 mOsm/kg, from about 200 mOsm/kg to about H00 mOsm/kg, from about 250 mOsm/kg to about 500 mOsm/kg, or from about 250 mGsm/kg to about 350 mOsm/kg or from about 280 mOsm/kg to about 320 mOsm/kg. In some embodiments, the formulations described herein have a practical osmolarity of about 100 mOsm/L to about 1000 mOsm/L, about 200 mOsm/L to about 800 mQsm/L, about 250 mOsm/L· to about 500 mOsm/L·,: about 250 mOsm/L to about 350 mQsm/L, about 280 mOstn/L to about 320 tnOsm/L or about 250 mQs.m/L to about 320 mOsm/L.

[00286] In some embodiments, the deliverable osmolarity of any formulation described herein is designed to be isotonic with the targeted otic structure (e.g., endolymph, perilymph or the like), fn specific embodiments, auris compositions described herein are formulated to provide a delivered perilymph-s'uitable osmolarity at the target site of action of about 250 to about 320 mOsttil; and preferably about 270 to about 320 mOsm/'L. In specific embodiments, auris compositions described herein are formulated to provide a delivered perilymph-suitable osmolality at the target site of action of about about 250 to about 320 mOsm/kg HjO; or an osmolality of about 270 to about 320 mOsm/kg HaO. In specific embodiments, the deliverable osmolarity/osmolality of the formulations (i.e., the osmolarity/osmolality of the formulation in the absence of gelling or thickening agents (e.g., thermoreversible gel. polymers) is adjusted, for example, by the use of appropriate salt concentrations (e.g.. concentration of potassium or sodium salts) or the use of tonicity agents which renders the formulations endoiymph-eoinpauble and/or perilymph-compatible (i.e. isotonic with the endolymph and/or perilymph) upon delivery at the target site . The osmolarity of a .formulation comprising a thermoreversible gel polymer is an unreliable measure due to the association of varying amounts of water with the monomeric units of the polymer. The practical osmolarity of a formulation (i.e., osmolarity in the absence of a gelling or thickening agent (e.g. a thermoreversible gel polymer) is a reliable measure and is measured by any suitable method (e.g., freezing point depression method, vapor depression method). In some instances, the formulations described herein provide a deliverable osmolarity (e.g,, at a target site (e.g., perilymph) that causes minimal disturbance to the environment of the inner ear and causes minimum discomfort (e.g., vertigo and/or nausea) to a mammal upon administration.

[00287] In some embodiments, any formulation described herein is isotonic with the perilymph and/or endolymph. Isotonic formulations are provided by the addition of a tonicity agent. Suitable tonicity agents include, but arc not limited to any pharmaceutically acceptable sugar, salt or any combinations or mixtures thereof, such as, but not limited to dextrose, glycerin, mannitol, sorbitol, sodium chloride, and other electrolytes. In some embodiments, tonicity agents are noR-ototoxic, [00288j Useful auris compositions include one or more salts in an amount required to bring osmolality of the composition into an acceptable range. Such salts include those having sodium, potassium or ammonium, cations and chloride, citrate, ascorbate, borate, phosphate, bicarbonate, sulfate, thiosulfate or bisulfite anions; suitable salts include sodium chloride, potassium chloride, sodium thiosulfate, sodium bisulfite and ammonium sulfate.

[802891 In some embodiments, the formulations described herein have a pH and/or practical osmolarity as described herein, andhave a concentration of active pharmaceutical ingredient between about 1 μΜ and about 10 pM, between about 1 mM and about 100 mM, between about 0.1 mM and about 100 mM, betwen about 0.1 mM and about 100 nM. In some embodiments, the formulations described herein have a pH and/or practical osmolarity as described herein, and have a concentration of active pharmaceutical ingredient between about 0.01% -- about 20%, between about 0.01% - about 10%., between about 0.01% -about 7.5%, between about 0.01% — 6%, between about 0.01 - 5%, between about 0.1 -about 10%, or between about 0.1 -about 6% of the active ingeredient by weight of the formulation. In some embodiments, the formulations described herein have a pH and/or practical Qsmoiarity as described herein, and have a concentration of active pharmaceutical ingredient between about 0,1 and about 70 mg, between about 1 mg and about 70 mg/mL, between about 1 mg and about 50 mg/mL, between about I mg/mL and about 20 mg/mL, between about 1 mg/mL to about 10 mg/mL,. between about 1 mg/mL to about 5 mg/ml.., or between about 0.5 mg/mL to about 5 mg/mL of the active agent by volume of the formulation. In some embodiments, the formulations described herein have a pH and/or practical osmolarity as described herein, and have a concentration of active pharmaceutical ingredient between about 1 pg/mL and about 500 pg/mL, between about 1 pg/mL and about 250 pg/mL. between about 1 pg and about 100 ug/'raL, between about 1 pg/mL and about 50 pg/mL, or between about 1 pg/mL and about 20 pg/mL of the active agent by volume of the formulation,

Particle Size [00290] Size reduction is used to increase surface area and/or modulate formulation dissolution properties. It is also used to maintain a consistent average particle size distribution (PSD) (e.g.„ micrometer-sized particles, nanometer-sized particles or the like)' for any formulation described herein. In some embodiments, any formulation described herein comprises multiparticulates, i.e., a plurality of particle sizes (e.g., micronized particles, nano-sized particles, non-sized particles, colloidal particles); i.e, theformulationis a multiparticulate formulation; In some embodiments, any formulation described herein comprises one or more multiparticulate (e.g., micronized) therapeutic agents, Micronization is a process of reducing the average diameter of particles of a solid material. Micronized particles are from about micrometer-sized in diameter to about nanometer -sized in diameter. In some embodiments, the average diameter of particles in a micronized solid is from about 0,5 pm to about 500 pm. In some embodiments, the average diameter of particles in a micronized solid is from about 1 pm to about 200 pm. In some embodiments, the average diameter of particles in a micronized solid is from about 2 pm to about 100 pm. In some embodiments, the average diameter of particles in a micronized solid is front about 3pm to about 50 pm. In some embodiments, a particulate micronized solid comprises particle sizes of less than about 5 microns, less than abou t 20 microns and/or less than about 100 microns. In some embodiments, the use of particulates (e.g,, micronized particles) of antimicrobial agent allows for extended and/or sustained release of the antimicrobial agent from any formulation described herein compared to a formulation comprising non-multiparticulate (e.g, non-micromzed) antimicrobial agent. In some instances, formulations containing multiparticulate (e.g. micronized) antimicrobial agent are ejected from a lmL syringe adapted with a 27G needle without any plugging or clogging. f0029l]In some instances, any particle in any formulation described herein is a coated particle (e.g., a coated micronized particle, nano-particle) and/or a microsphere and/or a liposomal particle. Particle size reduction techniques include, by way of example, grinding, milling (e.g., air-attrition milling (jet milling), ball milling), coacervation, complex conservation, high pressure homogenization, spray drying and/or supercritical fluid crystallization, In some instances, particles are sized by mechanical impact (e.g., by hammer mills, ball mill and/or pin mills). In some instances, particles are sized via fluid energy (e.g., by spiral jet mills, loop jet mills, and/or fluidized bed jet mills). In some embodiments formulations described herein comprise crystalline particles and/or isotropic particles. In some embodiments, formulations described herein comprise amorphous particles and/or anisotropic particles. In some embodiments, formulations described herein comprise therapeutic agent particles wherein the therapeutic agent is a Free base, or a salt, or a prodrug of a therapeutic agent, or any combination thereof.

[00292} in some embodiments, a formulation described herein comprises one or more antimicrobial agents wherein the antimicrobial agent comprises nanoparticulates, In some embodiments, a formulation described herein comprises antimicrobial agent beads (e.g., vancomycin beads) that are optionally coated with controlled release excipients. In some embodiments, a formulation described herein comprises an antimicrobial agentthat is granulated and/or reduced in size and coated with controlled release excipients;, the granulated, coated antimicrobial agent particulates are then optionally micronized and/or formulated in any of the compositions described herein. {00293} In some instances, a combination of an antimicrobial agent as a neutral molecule, free acid or free base and/or a salt of the antimicrobial agent is used to prepare pulsed release otic agent formulations using the procedures described herein. In some formulations, a combination of a micronized antimicrobial agent (and/or salt or prodrug thereof) and coated particles (e.g., nanoparticles, liposomes, microspheres) is used to prepare pulsed release otic agent formulations using any procedure described herein. Alternatively, a pulsed release profile is achieved by so lubilizing Up to 20% of the delivered dose of the antimicrobial agent(e.g., micronized antimicrobial agent, free base, free acid or salt or prodrug thereof; multiparticulate -antimicrobial, agent, free base, free acid or salt, or prodrug thereof) with the aid of eye lodextrins, surfactants (e.g., poioxamers (407, 338,188), tween (80, 60, 20,81), PEG-hydrogenated castor oil. cosolvents like N-methyh2-Pyrrolidone or the like and preparing pulsed release formulations using any procedure described herein. [60294]In specific embodiments, any auris-compatihle formulation described herein comprises one or more micronized pharmaceutical agents {e.g., antimicrobial agents). In some of such embodiments, a micronized pharmaceutical agent comprises micronized particles, coated (e.g., with an extended release coat) micronized particles, ora combination 'thereof. In some of such embodiments, a micronized pharmaceutical agent comprising micronized particles, coaled micronized particles, or a combination thereof, comprises air antimicrobial agent as a neutral molecule, a free acid, a free base, a salt, a prodrug or any combination thereof. In certain embodiments, a pharmaceutical composition described herein comprises an antimicrobial agent as a micronized powder. In certain embodiments, a pharmaceutical composition described herein comprises an antimicrobial agent in the form of a micronized antimicrobial agent powder.

[00295} The multiparticulates and/or micronized antimicrobial agents described herein are delivered to an auris structure (e.g., inner ear) by means of any type of matrix including solid, liquid or gel matrices. In some embodiments, the multiparticulates and/or micronized antimicrobial agents described herein are delivered to an auris structure (e.g., inner ear) by means of any type of matrix including solid, liquid or gel matrices via iniratympanie injection.

Tunable Release Characteristics 1002961 The release of acti ve agent from any formulation*, composition or device described herein is optionally tunable to the desired release characteristics. In some embodiments, a composition described herein is a solution that is substantially free of gelling components.

In such instances, the composition provides essentially immediate release of an active agent. In some of such embodiments, the composition is useful in perfusion of otic structures, e.g., during surgery, [00297} In some embodiments, a composition described herein is a solution that is substantially free of gelling components and comprises micronized otic agent (e.g., a corticosteroid, an antimicrobial agent or the like). In some of such embodiments, the composition pro vides release of an active agent from about 2 days to about 4 days.

In some embodiments, a composition described herein comprises a gelling agent (e.g., poloxamer 407) and provides release of an active agent over a period of from about 1 day to about 3 days. In some embodiments, a composition described herein comprises a gelling agent (e.g., poloxamer 407) and provides release of an active agent over a period of from about 1 day to about 5 days. In some embodiments, a composition described herein comprises a gelling agent (e.g., poloxamer 407) and provides release of an active agent over a period of from about 2 days to about 7 days.

[00298]lh some embodiments, a composition described herein comprises a gelling agent (e.g., poloxamer 407) in combination with micronized otic agent and provides extended sustained release over a longer period of time. In some embodiments, a composition described herein comprises about 14-17% of a gelling agent (e.g., poloxamer 407) and micronized otic agent, and provides extended sustained release over a period of from about 1 week to about 3 weeks. In some embodiments, a composition described herein comprises about 18-21% of a gelling agent (e.g., poloxamer 407) and micronized otic agent, and provides extended sustained release over a period of from about 3 weeks to about 6 weeks. [00299} Accordingly, the amount of gelling agent in a composition, and the particle size of an otic agent are tunable to the desired release profile of an otic agent front the composition, [00300} As described herein, compositions comprising micronized otic agents provide extended release over a longer period of time compared to compositions comprising non-micronized otic agents. In some instances, the micronized otic agent provides a steady supply (e.g., +/- 20%) of active agent via slow degradation and serves as a depot for the active agent; such a depot effect increases residence time of the otic agent in the ear. In specific embodiments, selection of an appropriate particle size of the active agent (e.g., micronized active agent) in combination with the amount of gelling agent in the composition provides tunable extended release characteristics that allow for release of an active agent o ver a period of hours, days, weeks or months, [0030.1] In some embodiments, the viscosity of any formulation described herein is designed to provide a suitable rate of release from an auris compatible gel . in some embodiments, the concentration of a thickening agent (e.g., gelling components such as poiyoxyethylene-polyoxypropylene copolymers) allows for a tunable mean dissolution time (MDT). lire MDT is inversely proportional to the release rate of an active agent from a composition or device described herein. Experimentally, the released otic agent is optionally fitted to the Korsmeyer-Peppas equation

[00302] where Q is the amount of otic agent released at time 1, Qa is the overall released amount of otic agent, k is a release constant of the nth order, n is a dimensionless number related to the dissolution mechanism and b is the axis intercept, characterizing tire initial burst release mechanism wherein n=l characterizes an erosion controlled mechanism. The mean dissolution time (MDT) is the sum of different periods of time the drug molecules stay in the matrix before release, divided by the total number of molecules and is optionally calculated by:

f 00303} For ex ample, a linear relationship between the mean disso lution time (MDT) of a composition or device and the concentration of the gelling agent (e.g., poloxamer) indicates that the otic agent is released due to the erosion of the polymer gel (e.g., poloxamer) and not via diffusion, In another example, a non-linear relationship indicates release ol'otie agent via a combination of diffusion and/or polymer gel degradation. In another example, a faster gel elimination time course of a composition or device (a faster release of active agent) indicates lower mean dissolution time (MDT). The concentration of gelling components and/or active agent in a composition are tested to determine suitable parameters for MDT',

In some embodiments, injection volumes are also tested to determine suitable parameters for preclinieal and clinical studies. The gel strength and concentration, of the active agent affects release kinetics of an otic agent from the composition. At low poloxamer concentration, elimination rate is accelerated (MDT is lower). An increase in otic agent concentration in the composition or device prolongs residence time and/or MDT of the otic agent in the ear. {©0304} In some embodiments, the MDT for poloxamer from a composition or device described herein is at least 6 hours. In some embodiments, the MDT for poloxamer from a composition or device described herein is at least 10 hours.

[00305] In sortie embodiments, the MDT for an active agent from a composition or device described herein is from about 30 hours to about 48 hours. In some embodiments, the MDT for an active agent from a composition or device described herein is from about 30 hours to about 96 hours. In some embodiments, the MDT for an active agent from a composition or device described herein is front about 30 hours to about 1 week. In some embodiments, the MDT for a composition or device described herein is from about 1 week to about 6 weeks.

[00506] In some embodiments, the mean residence time (MRT) for an active agent in a composition or device described herein is from about 20 hours to about 48 hours. In some embodiments, the MRT for an active agentfrom a composition or device described herein is front about 20 hours to about 96 hours. In some embodiments, the MRT for an active agent from a composition or device described herein is from about 20 hours to about 1 week, [00307] In some embodiments, the MRT for an active agent is about 20 hours. In some embodiments, the MR T for an active agent is about 30 hours. In some embodiments, the MRT for an active agent is about 40 hours. In some embodiments, the MRT for an active agent is about 50 hours. In some embodiments, the MRT for an active agent is about 60 hours. In some embodiments, the MR T for an active agent Is about 70 hours. In some embodiments, the MRT for an active agent is about 80 hours. In some embodiments, the MRT for an active agent is about 90 hours. In some embodiments, the MR T for an active agent is about 1 week. In some embodiments, the MRT for an active agent is about 90 hours. In some embodiments, the MRT tor a composition, or device described herein is from about 1 week to about 6 weeks, In some embodiments, the MRT for an active agent is about 1 week, in some embodiments, the MRT for an active agent is about 2 weeks. In some embodiments, the MRT for an active agent is about 3 weeks. In some embodiments, the MRT for an active agent is about 4 weeks. In some embodiments, the MRT for an active agent is about 5 weeks. The half life of an otic agent and mean residence time of the otic agent are determined for each formulation by measurement of concentration of the otic-agent in the perilymph using procedures described herein. 10030811η certain embodiments, any -controlled- release otic formulation described herein increases the exposure of an otic agent and increases the Area Under the Curve (AUG) in otic fluids (e.g., endolymph and/or perilymph) by about 30%, about 40%. about 50%, about 60%. about 70%, about 80% or about 90% compared to a formulation that is not a controlled release otic formulation. In certain embodiments, any controlled release otic formulation described herein increases the exposure time of an otic agent and decreases the Gmax in otic fluids (e.g,, endolymph and/or perilymph) by about 40%, about 30%, about 20%, or about 10%, compared to a.formulation that is not a controlled release otic formulation, in certain embodiments, any controlled release otic formulation described herein alters (e.g. reduces) the ratio of Gmax to Gorin.compared to a formulation that is not a controlled release otic formulation. In certain embodiments, any controlled release otic formulation described herein increases the exposure of an otic agent and increases the length of time that the concentration of an otic agent is above Gmin by about 30%, about 40%, about 50%, about 60%, about 70%, about 80% or about 90% compared to a forraulation that is not a controlled release otic formulation. In certain instances, controlled release formulations described herein delay the time to Gmax, In certain instances, the controlled steady release of a drug prolongs the time the concentration of the drug will stay above the Gmin. In some embodiments, auris 'compositions.described herein prolong the residence time of a drug in the inner ear and provide a stable drug exposure profile. In some instances, an increase in concentration of an active agent in the composition saturates the clearance process and allows for a more rapid and stable steady state to be reached. {00309] In certain instances, once drug exposure (e.g.. concentration in the endolymph or perilymph) of a drug reaches steady state, the concentration of the drug in the endolymph or perilymph stays at or about the therapeutic dose for an extended period of time (e.g., one day, 2 days, 3 days, 4 days, 5 days, 6 days, or 1 week, 3 weeks. 6 weeks, 2 months). In some embodiments, the steady stole .concentration of active agent released from a controlled release formulation described herein is about 5 to about 20 times the steady state concentration of an active agent released from a formulation that is not a controlled release formulation. In some embodiments, the steady state-concentration of active agent released from a controlled release formulation described herein is about 20 to about 50 times the steady state concentration of an active agent released from a formulation that is not a controlled release formulation. Figure 5 stows predicted tunable release of an active agent from four compositions.

Pharmaceutical Formulations [00310] Provided herein are pharmaceutical compositions or devices that include at least one antimicrobial agent and a pharmaceutically- acceptable dilueni(s), excipient(s), or carriers). In some embodiments, the pharmaceutical compositions include other medicinal or pharmaceutical agents, carriers, adjuvants, such as preserving, stabilizing, wetting or emulsifying agents, solution promoters, stilts for regulating the osmotic pressure, and/or buffers. In other embodiments, the pharmaceutical compositions also contain other therapeutic substances.

[003111 In some embodiments, the compositions or devices described herein include a dvc to help enhance the visualization of the gel when applied. In some embodiments, dyes that are compatible with the auris-acceptable compositions or devices described herein include Evans blue (e.g., 0.5% of the total weight of an otic formulation), Methylene blue (e.g., 1% of the total weight of an otic formulation), Isosulfan blue (e.g., 1% of the total weight of an otic formulation), Trypan blue (e .g., 0,15% of the total weight of an otic formulation), and/or indocyanine green (e.g,, 25mg/vjal). Other common dyes, e.g, FD&amp;C red 40, FD&amp;C red 3, FD&amp;C yellow' 5, FD&amp;C yellow 6, FD&amp;C blue 1, FD&amp;C blue2, FD&amp;C green 3, fluorescence dyes (e.g,, Fluorescein isothiocyanate, rhodamine, Alexa Fluors, DyLight -Fluor») and/or dyes that are visualizable in conjunction with non-invasive imaging techniques such as MRI, CAT scans, PET scans or the like. Gadolinium-based MR! dyes, iodine-base dyes, barium-based dyes or the like are also contemplated for use with any otic formulation described herein. Other dyes that are compatible with any formulation or composition described herein are listed in the Sigma-Aldfich catalog under dyes (which'is included herein by reference for such disclosure).

[00312]In some embodiments, mechanical or imaging devices are used to monitor or survey the hearing, balance or other auris disorder. For example, magnetic resonance imaging (MRI) devices are specifically contemplated within the scope of the embodiments, wherein the MRI devices (for example, 3 Tesla MRI devices) arc capable of evaluating Meniere Disease progression, and subsequent treatment with the pharmaceutical, formulations disclosed herein. Gadolinium-based dyes, iodine-base dyes, barium-based dyes or the like are also contemplated for use with any auris-cornpatible composition or device described herein and/or with any mechanical or imaging devices described herein. In certain embodiments, gadolinium hydrate is used in combination with MR] and/or any pharmaceutical composition or device described herein to evaluate disease severity (e,g., size of endolymphatic hydrops), formulation penetration into the inner ear, and/or therapeutic effectiveness of the pharmaceutical formuiations/devices in the otic diseases described herein (e.g,, Meniere's disease), [003131 Any phaimacentical composition or device described herein is administered by locating the composition or device in contact with the crista fenesfcrae cochlea, the round window, the tympanic cavity, the tympanic membrane, the auris media or the auris externa.

[00314] In one specific embodiment of the auris-acceptabie controlled release antimicrobial agent pharmaceutical formulations described herein, the antimicrobial agent is provided in a gel matrix, also referred to herein as “auris acceptable gel formidations,’* “auris inierna-acceptable gel formulations,” “auris media-acceptable gel formulations/' “auris externa-acceptable gel formulations", “auris gel formulations" or variations thereof. All of the components of the gel formulation must be compatible with the targeted auris structure. Further, the gel formulations provide controlled release of the antimicrobial agent to the desired site within the targeted auris structure; in some embodiments, the gel formulation also has an immediate or rapid release component for delivery of the antimicrobial agent to the desired target site. In other embodiments, the gel formulation has a sustained release component for delivery of the antimicrobial agent. In some embodiments, the gel formulation comprises a multiparticulate (e.g., micronized) antimicrobial agent. In some embodiments, the auris gel formulations are biodegradeabie. In other embodiments, the amis gel formulations include a mucoadhesive excipient to allow adhesion to the external mucous layer of the round window membrane. In y et other .embodiments, the auris gel formulations include a penetration enhancer excipient.

[00315] In further embodiments, the auris gel formulation contains a viscosity enhancing agent sufficient to provide a viscosity of between about 500 and 1,000,000 centipoise, between about 750 and 1,000,000 centipoise; between about 1000 and 1,000,000 centipoise; between about 1000 and 400,000 centipoise; between about 2000 and 100,000 centipoise: between about 3000 and 50,000 centipoise; between about 4000 and 25,000 centipoise; between about 5000 and 20,000 centipoise; or between about 6000 and 15,000 centipoise. (n some embodiments, the auris gel formulation contains a viscosity enhancing agent sufficient to provide a viscosity of between about 50,0000 and 1,000,000 ccntipoise.

[00316} In some embodiments, the compositions or devices described herein are low viscosity compositions or devices at body temperature. In some embodiments, low viscosity compositions or devices contain from about 1% to about 10% of a viscosity enhancing agent (e.g., gelling components such as polyoxyediylene-polyoxypropylene copolymers). In some embodiments, low viscosity’ compositions or devices contain from about 2% to about 10% of a viscosity enhancing agent (e.g., gelling components such as polyoxyethylene-polyoxypropylene copolymers). In some embodiments, low viscosity compositions or devices contain from about 5% to about 10% of a viscosity7 enhancing agent (e.g., gelling components such as polyoxyethylcne-polyoxypropylene copolymers). In some embodiments, low viscosity compositions or devices are substantially free of a viscosity enhancing agent (e.g,, gelling components such as polyTixyethylene-poIyoxypropylene copolymers). In some embodiments, a low viscosity’ antimicrobial composition or device described herein provides an apparent viscosity of from about 100 eP to about 10,000 cP. In some embodiments, a low viscosity’ antimicrobial composition or device described herein provides an apparent viscosity of from about 500 cP to about 10,000 cP, In some embodiments, a low viscosity antimicrobial composition or device described herein provides an apparent viscosity of from about 1000 cP to about 10,000 cP, In some of such embodiments, a low viscosity antimicrobial composition or device is administered in combination with an external otic intervention, e.g., a surgical procedure Including but not limited to middle ear surgery, inner ear surgery, typanostomy, eochleostorny, labyrinthotomy, mastoidectomy, stapedectomy, stapedotomy, endolymphatic sacculotomy or the like. In some of such embodiments, a low viscosity antimicrobial composition or device is .administered during an otic intervention, br other such embodiments, a low viscosity antimicrobial composition or device is administered before .the Otic intervention, [60317] In some embodiments, the compositions or devices described herein arc high viscosity compositions or devices at body temperature. In some embodiments, high viscosity compositions or devices contain from about 10% to about 25% of a viscosity enhancing agent (e.g., gelling components such as polyoxyethylene-polyoxypropylene copolymers). In some embodiments, high viscosity' compositions or devices contain from about ;14% to about 22% of a viscosity enhancing agent (e.g,, gelling componen ts such as polyoxyethyiene-polyoxypropylene copolymers). In some embodiments, high viscosity' compositions or devices contain from about 15% to about 21% of a viscosity enhancing agent (e.g., gelling components such as polyoxyethylene-polyoxypropylene copolymers), in some embodiments, a high viscosity antimicrobial composition or device described herein provides an apparent viscosity of from about 100,000 cP to about 1,000.000 cP, In some embodiments, a high viscosity antimicrobial composition or device described herein provides an apparent viscosi ty of from about 150,000 cP to about. 500.000 cP. In. some embodiments, a high viscosity antimicrobial composition or device described herein provides an apparent viscosity of from about 250,000 cP to about 500,000 cP. in some of such embodiments, a high viscosity Composition or device is a liquid at room temperature and gels at about between room temperature and body temperature .(including an Individual with a serious fever, e.g., up to about 42 aC). In some embodiments, an antimicrobial high viscosity composition or device is administered as monotherapy for treatment, of an otic disease or condition described herein. In some embodiments, an antimicrobial high viscosity composition or device is administeredin combination with an external otic intervention, e.g., a surgical procedure including but not limited to middle ear surgery, inner ear surgery, typanostomy, cochleostomy, labyrinthotomy, mastoidectomy, stapedectomy, stapedotomy, endolymphatic sacculotomy or the like. In some of such embodiments, a high viscosity' antimicrobial composition or device is administered after the otic intervention, in other such embodiments, a high viscosity antimicrobial composition or device is administered before the otic intervention.

[00318] In other embodiments, the aims interna pharmaceutical formulations described herein further provide an auris-aeceptable hydrogel; in yet other embodiments, the auris pharmaceutical formulations provide an auris-accepiable microsphere or microparticle· in still other embodiments, the auris pharmaceutical formulations provide an auris-aeceptable liposome. In some embodiments, the auris pharmaceutical formulations provide an auris-aceeptable foam; in yet other embodiments, the auris pharmaceutical formulations provide an auris-aeceptable paint; in still further embodiments, the auris pharmaceutical formulations provide an auris-accepiable in situ forming spongy material. In some embodiments, the auris pharmaceutical formulations provide an auris-aceeptabie solvent release gel. In some embodiments, the auris pharmaceutical formulations provide tm actinic radiation curable gel. Further embodiments include a thermoreversible gel in the auris pharmaceutical formulation, such that upon preparation of the gel at room temperature or below, the formulation is a fluid, but upon application of the gel into or near the auris interna and/or auris media target site, including the tympanic cavity, round window membrane or the crista fenestrae cochleae, the auris-pharmaceutieal formulation stiffens or hardens into a gel-like substance. (00319] In further or alternative embodiments, the auris gel formulations are capable of being administered on. or near the round window membrane via intratympanic injection. In other embodiments, the auris gel formulations are administered on or near the round window or the crista fenestrae cochleae through entry via a post-auricular incision and surgical manipulation into or near the round window or the crista fenestrae cochleae area. Alternatively, the auris gel formulation is applied via syringe and needle, wherein the needle is inserted through the tympanic membrane anti guided to the area of the round window or crista fenestrae cochleae. The auris gel formulations are then deposited on or near the round window or crista fenestrae cochleae for localized -treatment of autoimmune otic disorders. In other embodiments, the auris gel formulations are applied via microcathethers implanted into the patient, and in yet further embodiments the formulations arc administered via a pump device onto or near the round window membrane. In still further embodiments, the auris gel formulations are applied at or near the round window membrane via a microinjection device, in yet other embodiments, the auris gel formulations are applied in the tympanic cavity. In. some embodiments, the auris gel formulations are applied on the tympanic membrane, in still other embodiments, the auris gel formulations are applied onto or in the auditory canal. (00320} In further specific embodiments, any pharmaceutical composition or device described herein comprises a multiparticulate antimicrobial agent in a liquid matrix (e.g., a liquid composition for intratympanic injection, or otic drops]. In certain embodiments, any pharmaceutical composition described herein comprises a multiparticulate antimicrobial agent in a solid matrix.

Controlled Release Formulations (00321)1¾ general, controlled release drug formulations impart control over the release of drug with respect, to site of release and time of release within the body. As discussed herein, controlled release refers to immediate release, delayed release, sustained release, extended release, variable release, pulsatile release and bi-modai release. Many advantages are offered by controlled release. First, controlled release of a pharmaceutical agent allows less frequent dosing and thus minimizes repeated treatment. Second, controlled release treatment results in more efficient drug utilization and (ess of the compound remains as. a residue.

Third* controlled release offers the possibility of localized drug delivery by placement of a delivery device or .formulation at the site of disease. Still further, controlled release offers the opportunity to administer and release two or more different drags, each having a unique release profile, or to release the same drag at different rates or for different durations, by means of a single dosage unit. {60322] Accordingly, one aspect of the embodiments disclosed herein is to provide a controlled release antimicrobial agent auris-acceptable composition or device for the treatment of autoimmune disorders, infections and/or inflammatory disorders. The controlled release aspect of the compositions and/or formulations and/or devices disclosed herein is imparted through a variety of agents, including but not limited to excipients, agents or materials that are acceptable for use in the auris interna or other otic structure. By way of example only, such excipients, agents or materials include an auris-acceptable polymer, an auris-acceptable viscosity enhancing agent, an auris-acceptable gel, an auris-acceptable paint, an auris-acceptable foam, an auris-acccptable xerogel, an auris-acceptable microsphere or microparticle, an auris-acceptable hydrogel, an auris-acceptable in situ forming spongy material, an auris-acceptable actinic radiation curable gel, an auris-acceptable solvent release gel, an auris-acceptable liposome, an auris-acceptable nanocapsule or nanosphere, an auris-acceptabie foermoreverslble gel, or combinations thereof.

Auris-Aeccptable Gels (00323] Gels, sometimes referred to as jellies, have been defined in various ways. For example, the United States Pharmacopoeia defines gels as semisoiid systems consisting of either suspensions made up of small inorganic particles or large organic molecules interpenetrated by a liquid. Gels include a single-phase or a two-phase system. A singlephase gel consists of'organic macromolecules, distributed uniformly throughout a liquid in such a maimer that no apparent boundaries exist between the dispersed macromolecules and the liquid. Some single-phase gels are prepared from synthetic macromolecules (e.g„ carbomer) or from natural gums, (e.g., tragacanth). in some embodiments, single-phase gels are generally aqueous, but will also be made using alcohols and oils. I wo-phase gels consist of a network of small discrete particles. f00324]Gels can also be classified as being hydrophobic or hydrophilic. In certain embodiments, the base of a hydrophobic gel consists of a liquid paraffin with polyethylene or fatty oils gelled with colloidal silica, or aluminum or zinc soaps. In contrast, the base of hydrophobic gels usually consists of water, glycerol, or propylene glycol gelled with a suitable gelling agent (e.g,, tragacanth, starch, cellulose derivatives, carboxwinylpolymers, and magnesium-ahiminuni silicates). In certain embodiments, the rheology of the compositions or devices disclosed herein is pseudo plastic, plastic, thixotropic, or dilatant. [00325} In one embodiment the enhanced viscosity auris-acceptable formulation described herein is not a liquid at room temperature. In certain embodiments, the enhanced viscosity formulation is characterized by a phase transition between room temperture and body temperature (including an individual with a serious fever, e.g., up to about 42 C'C). In some embodiments, the phase transition occurs at I °G below body temperature, at 2 °C below body temperature, at 3 °C below body temperture, at 4 °C below body temperature, at 6 °C below body temperature, at 8 °C below body temperature, or at 10 °C below' body temperature. In some embodiments, the phase transition occurs at about 15 °C below body temperature, at about 20 °C below body temperature or at about 25 °C below body temperature. In specific embodiments, the gelation temperature (Tgei) of a formulation described herein is about 20 °C, about 25 °C, or about 30 °C. In certain embodiments, the gelation temperature (Tgel) of a formulation described herein is about 35 °€, or about 40 °C. In one embodiment, administration of any formulation described herein at about body temperature reduces or inhibits vertigo associated with intratympanic administration of otic formulations. Included within the definition of body temperature is the body temperature of a healthy individual, or an unhealthy individual, including an individual with a fever (up to -42 °C). In some embodiments, the pharmaceutical compositions or devices described herein are liquids at about room temperature and are administered at or about room temperature, reducing or ameliorating Side effects such as, for example, vertigo.

[003261 Polymers composed of polyoxypropylene and polyoxyethylene form thermoreyersible gels when incorporated into aqueous solutions. These polymers have the ability to change from the liquid state to the gel state at tempertures close to body temperture, therefore allowing useful formulations that are applied to the targeted auris struciure(s). The liquid state-to-gcl state phase transition is dependent on the polymer concentration and the ingredients in. the solution.

[00327} Poloxamer 407 (PF-127) is a nonionic surfactant composed of polyoxyethylene-polyoxypropylene copolymers. Other poioxamers include 188 (F-68 grade), 237 (F~87 grade), 338 (F-108 grade). Aqueous solutions of poioxamers are stable in the presence of acids, alkalis, and metal ions. PF-127 is a commercially available polyoxyethylene-polyoxypropylene triblock copolymer of general, formula E106 P70 E106, with an. average molar mass of 13.000. The polymer can be further purified by suitable methods that will enhance gelation properties of the polymer. Ii contains approximately 70% ethylene oxide, which accounts tor its hydrophilicity. It is one of the series of poloxamer ABA block copolymers, whose members share the chemical formula shown below. hydrophilic hydrophilic H~|o --CHz-CH2^0'“CH--CH2j{o---CHg~CH2^0H a CH3 b a hydrophobic {00328) PF-127 is of particular interest since concentrated solutions (>20% w/vv) of the copolymer are transformed from low viscosity transparent solutions to: solid gels on. heating to body temperature. This phenomenon, therefore, suggests that when placed in contact with the body, the gel preparation will form a semi-solid structure and a sustained release depot. Furthermore, PF-127 has good solubilizing capacity, low toxicity and is, therefore, considered a good medium for drug delivery systems. (00329) In an alternative embodiment, the thermogel is a PEG-PLGA-PEG triblock copolymer (Jeong, etai*Mature (1997), 388:860-2; Jeong etai, J. Control. Release (2000), 63:155-63: Jeong etai, Adv. Drug Delivery Rev. (2002), 54:37-51). The polymer exhibits sol-gel behavior over a concentration of about 5% w/w to about 40% w/w. Depending on the properties desired, the laetide/glyeolMe molar ratio in the PLGA copolymer ranges from about 1:1 to about 20:1. The resulting coploymers are soluble in water and form a free-flowing liquid at room temperature, but form a hydrogel at body temperature. A commercially available PEG-PLGA-PEG triblock copolymer is RESOMER RGP150106 manufactured by Boehringer Ingelheim. This material is composed of a PGLA copolymer of 50:50 poly(DL-lacticie-co-giycoUde) and is 10% w/w of PEG and has a molecular weight of about:..6000. )00330] RsGel® is a tradename of MacroMed Incorporated for a class of low molecular weight, biodegradable block copolymers having reverse thermal gelation properties as described in U.S, Pat Nos. 6,004,573, 6,117949, 6,201,072, and 6,287,588. It also includes biodegradable polymeric drug carriers disclosed in pending U.S. patent application Ser.

Nos. 09/906,041,09/559*799 and 10/919,603. The biodegradable drug carrier comprises ABA-type or BAB-type triblock copolymers or mixtures thereof, wherein the A-blocks are relatively hydrophobic and comprise biodegradable polyesters or poly(orthoester)s; and the B-blocks are relatively hydrophilic and comprise polyethylene glycol (PEG), said copolymers having a hydrophobic content of between 50,1 to 83% by weight and a hydrophilic content of between 17 to 49.9% by weight, and an overall block copolymer molecular weight of between 2000 and 8000 Daltons. The drug carriers exhibit water solubility at temperatures below normal mammalian body temperatures and undergo reversible thermal gelation to then exist as a gel at temperatures equal to physiological mammalian body temperatures. The biodegradable, hydrophobic A polymer block comprises a polyester or poly(ortho ester), in which the polyester is synthesized from monomers selected .trom the group consisting of DX-laetide, D-lactide, L-laetide, D.L-lactic acid, D-lactie acid, L-lactic acid, glycoltde, glycolic acid, ε-caprolactone, «-hydroxyhexanoic- acid, γ-butyrolactone, y-hydroxybutyrie acid, δ-valerolactone, δ-hydroxy valeric acid, hydroxybutyric acids, malic acid, and copolymers thereof and having an average molecular weight of between about 600 and 3000 Daltons. The hydrophilic B-block segment is preferably polyethylene glycol (PEG) having an average molecular weight of between about 500 and 2200 Daltons.

[00331 j Additional biodegradable thermoplastic polyesters include AtriGel® (provided by Atrix Laboratories, Inc.) and/or those disclosed, e.g,, in ITS. Patent Nos. 5,324,519; 4,938,763; 5,702,716; 5.744,153; and 5,990,194; wherein .the suitable biodegradable thermoplastic polyester is disclosed as a tliermopiastie polymer. Examples of suitable biodegradable thermoplastic polyesters include polylactides, polyglycolides, polycaprolactones, copolymers thereof, terpoiymers thereof, and any combinations thereof, in some such embodiments, the suitable biodegradable tliermopiastie polyester is a polylactide, a polyglycolide, a copolymer thereof, a terpplymer thereof) or a combination thereof, in one embcKliment, the biodegradable thermoplastic polyester is 50/50 poly(DL-lactide-co-glycolide) having a carboxy terminal group; is present in about 30 wt. % to about 40 wt, % of the composition; and has an a verage molecular Weight of about 23,000 to about 45,000. Alternatively, in another embodiment, the biodegradable thermoplastic polyester is 75/25 poly (DL-lactide-co-glycolide) without a carboxy terminal- group; is present in about 40 wt, % to about 50 wt, % of the composition; and has an average molecular weight of about 15.000 to about 24,000. In further or alternative embodiments, the terminal groups of the poly(DL-iactide-co-glycoiide) are either hydroxyl, carboxyl, or ester depending upon the method of polymerizat ion. Polyeondensation of lactic or glycolic acid provides a polymer with terminal hydroxyl and carboxyl groups. Ring-opening polymerization of the cyclic lac-tide or glycolide monomers with water, lactic acid, or glycolic acid provides polymers with the same terminal groups. However, ring-opening of the cyclic monomers with, a monofunctional alcohol such as methanol, ethanol, or 1-dodecanol provides a polymer with one hydroxyl group and one ester terminal groups. Ring-opening polymerization of the cyclic monomers with a diol such as 1,6-hexanediol or polyethylene glycol provides a polymer with only hydroxyl terminal groups.

[00332] Since the polymer systems of thermoreversibie gels dissolve more completely at reduced temperatures, methods of solubilization include adding the required amount of polymer to the amount of water to be used at reduced tempertures. Generally after wetting the polymer by shaking, the mixture is capped and placed in a cold chamber or in a thermostatic container at about 0-10 °C in order to dissolve the polymer. The mixture is Stirred Or shaken to bring about a more rapid dissolution of the tliermoreversible gel polymer. The antimicrobial agent and various additives such as buffers, salts, and preservatives are subsequently added and dissolved. In some instances the antimicrobial agent and/or other pharmaceutically active agent is suspended if it is insoluble in water. The pH is modulated by the addition of appropriate buffering agents, round window membrane mucoadhesive characteristics are optionally imparted to a thermoreversibie gel by incorporation of round window' membrane mucoadhesive carbomers, such as Carbopol® 934P, to the composition (Majithiya etal, AAPS PharmSciTeeh (2006), 7(3), p. El; EP0551626, both of which is incorporated herein by reference for such disclosure). j00333Sln one embodiment are auris-acceptable pharmaceutical gel formulations which do not require the use of an added viscosity' enhancing agent. Such gel formulations incorporate at least one pharmaceutieally acceptable buffer. In one aspect is a gel formulation comprising an antimicrobial agent and a pharmaceutically acceptable buffer. In another embodiment , the pharmaceutieally acceptable excipient or-carrier is a gelling agent. [00334] I n other embodiments, useful antimicrobial agent auris-acceptable pharmaceutical formulations also include one or more pH adjusting agents or buffering agents to provide an endoivmph or perilymph suitable pH, Suitable pH adjusting agents or buffers include, but are not limited to acetate, bicarbonate, ammonium chloride, citrate, phosphate, pharmaceutically acceptable salts thereof and combinations or mixtures thereof. Such pH adjusting agents and buffers are included in an amount required to maintain pi! of the composition between a pH of about 5 and about 9, in one embodiment a pH between about 6,5 to about 7,5, and in yet another embodiment at a pH of about 6.5, 6.6, 6.7,6.8, .6,¾ 7.0, 7.1, 7.2, 7.3, 7.4. 7.5. In one embodiment, when one or more buffers are utilized in the .formulations of the present di sclosure, they are combined, e g., with a pharmaceutically acceptable vehicle and are present in the final formulation, e.g., in an amount ranging from about 0.1% to about 20%, from about 0.5% to about 10%. In certain embodiments of the present disclosure, the amount of buffer included in the gel formulations are an amount such that the pH of the gel formulation does not interfere with the auris media or amis infema’s natural, buffering sy stem, or does not i nterfere with the natural pH of the endoiymph or perilymph : depending on where in the cochlea the antimicrobial agent formulation is targeted. In some embodiments, from about 10 μΜ to about 200 mM concentration of a buffer is present in the gel fbnnulation. In certain embodiments, from about a 5 mM to about a 200 mM concentration of a buffer is present. In certain embodiments, from about a 20 mM to about a 100 mM concentration of a buffer is present. In one embodiment is a buffer such as acetate or citrate at slightly acidic pH. In one embodiment the buffer is a sodium acetate buffer haying a pH of about 4-5 to about 6.5. In one embodiment the buffer is a sodium citrate buffer haying a pH of about 5.0 to about 8.0, or about 5.5 to about 7.0. [0033511η an alternative embodiment, the buffer used is tris(hydroxymelhyl)aminomethane, bicarbonate, carbonate or phosphate at slightly basic pH. In one embodiment, the buffer is a sodium bicarbonate buffer having a pH of about 6.5 to about 8,5, or about 7,0 to about 8.0, In another embodiment the buffer is a sodium phosphate dibasic buffer having a pH of about 6.0 to about 9.0.

[003361 Also described herein are controlled release formulations or devices comprising an antimicrobial agent and a viscosity enhancing agent. Suitable viscosity-enhancing agents include by way of example only, gelling agents and suspending agents. In one embodiment, the enhanced viscosity formulation does not include a buffer. In other embodiments, tire enhanced viscosity formulation includes a pharmaceutically acceptable buffer. Sodium chloride or other tonicity agents are optionally used to adjust tonicity, if necessary.

[003371 By way of example only, the aum-acceptable viscosity agent include hydroxypropyl methylcellulose, hydroxyethyl cellulose, polyvinylpyrrolidone, carboxvmethyl cellulose, polyvinyl alcohol, sodium ehondroi tin sulfate, sodium hyaluronate. Other viscosity enhancing agents compatible with the targeted auris structure include, but are not limited to, acacia (gum arabie), agar, aluminum magnesium silicate, sodium alginate, sodium stearate, bladderwraek, bentonite, earbomer, carrageenan, Carbopol, xanthan, cellulose, microcrystalline cellulose (MCC), ceratonia, chitin, carboxyraethyiated ehitosan, chondrus, dextrose, fureellaran, gelatin, Cihatti gum, guar gum, hectorite, lactose, sucrose, maitodextrin, mannitol, sorbitol, honey, maize starch, wheat starch, rice starch, potato starch, gelatin, sterculia gum, xanthum gum, gum tragacanth, ethyl cellulose, ethyihydroxyethy! cellulose, ethylmethyl cellulose, methyl cellulose, hydroxyethyl cellulose, hydroxyethylmethyl cellulose, hydroxypropyl cellulose, polythydroxyethyl methacrylate), oxypdygelatin, pectin, polygeline, povidone, propylene carbonate, methyl vinyl ether/maleic anhydride copolymer (P VM/MA), po!y(methoxyethyl methacrylate), pplyimethoxyethoxyethyl methacrylate), hydroxypropyl cellulose, hydroxypropylmethyl-cellulose (HPMC), sodium carboxymethyi-eellulose (CMC), silicon dioxide, polyvinylpyrrolidone (PVP: povidone), Splenda® (dextrose, maitodextrin and sucralose) or combinations thereof. In specific embodiments, the viscosity-enhancing excipient is a combination of MCC and CMC, In another embodiment, the viscosity-enhancing agent is a combination of carboxymethylated ehitosan, or chitin, and alginate. The combination of chitin and alginate With the antimicrobial agents disclosed herein acts as a controlled release formulation, restricting the diffusion of tire antimicrobial agents ironi the formulation. Moreover, the combination of carboxymethylated ehitosan and alginate is optionally used to assist in increasing the permeability of the antimicrobial agents through the round window membrane, (00338| In some embodiments is an enhanced viscosity formulation, comprising from about 0.1 niM arid about 100 mM of an antimicrobial agent, a pharmaceutically acceptable viscosity agent, and water for injection, the concentration of the viscosity· agent in the water being sufficient to provide a enhanced viscosity formulation with a final viscosity from about 100 to about 100,000 cP. In certain embodiments, the viscosity of the gel is in the range from about 100 to about 50.000 cP, about 100 eP to about 1,000 cP, about 500 cP to about 1500 cP, about 1000 cP to about 3000 cP, about 2000 cP to about 8,000 cP, about 4,000 cP to about 50,000 cP, about 10,000 cP to about 500,000 cP, about 15,000 cP io about 1,000,000 cP. In other embodiments, when an even more viscous medium is desired, the biocompatible gel comprises at least about 35%, at least about 45%, at least about 55%, at least about 65%. at least about 70%, at least about 75%, or even at least about 80% or so by weight of the antimicrobial agent. In highly concentrated samples, the biocompatible enhanced viscosity formulation comprises at least about 25%, at least about 35%, at least about 45%, at least about 55%, at least about 65%, at least about 75%, at least about 85%, at least about 90% or at least about 95% or more by weight of the antimicrobi al agent. 1003391 In some embodiments, the viscosity of the gel formulations presented herein are measured by any means described. For example, in some embodiments, an LVBV-II-NCP Cone Plate Viscometer and a Cone Spindle CPE-40 is used to calculate the viscosity of the gel formulation described herein. In other embodiments, a Brookfield (spindle and cup) viscometer is used to calculate the viscosity of the gel formulation described herein. In some embodiments, the viscosity ranges referred to herein are measured at room temperature, in other embodiments, the viscosity ranges referred to herein are measured at body tem perature (e.g., at the average body temperature of a healthy human), {00340] In one embodiment, the pharmaceutically acceptable enhanced viscosity auris-acceptable formulation comprises at least one antimicrobial agent and at least one gelling agent. Suitable gelling agents for use in preparation of the gel formulation include, but are not limited to, celluloses, cellulose derivatives, cellulose ethers (e.g., carboxymethylcellulose, ethyleeliulose, hydroxyethylcellulose, hydroxymethylceliulose, hydroxypropyim'ethylcellnlose, hydroxypropylcellulose, methyicellulose), guar gum, xanthan gum, locust bean gum, alginates (e.g., alginic acid), silicates, starch, tragaeanth, carboxyvinyl polymers, carrageenan, paraffin, petrolatum and any combinations or mixtures thereof. In some other embodiments, hydroxypropylmethyicellulose (Methocel©) is utilized as the gelling agent. In certain embodiments, the viscosity enhancing agents described herein are also utilized as the gelling agent for the gel formulations presented herein. 1903411 Jn some embodiments, the otic therapeutic agents disclosed herein are dispensed as an auris-aceeptabfe paint. As used herein, paints (also known as film formers) are solutions comprised of a solvent, a monomer or polymer, an active agent, and optionally one or more pharmaceu deal ly-acceptable excipients. After application to a tissue, the sol vent e vaporates leaving behind a thin coating comprised of the monomers or polymers, and the active agent. The coating protects active agents and maintains them in an immobilized state at the site of application. This decreases the amount of active agent which may be lost and correspondingly increases the amount delivered to the subject. By way of non-limiting example, paints include collodions (e.g. Flexible Collodion, US:P), and solutions comprising saccharide siloxane copolymers and a cross-linking- agent. Collodions are ethyl ether/ethanoi solutions containing pyroxylin (a nitrocellulose). After application, the ethyl etheriethanoi solution evaporates leaving behind a thin Him of pyroxylin. In solutions comprising saccharide siloxane copolymers, the saccharide siloxane copolymers form the coating after evaporation of the solvent initiates the cross-linking of the saccharide siloxane copolymers. For additional disclosures regarding paints, see Remington: The Science and Practice of Pharmacy which is hereby incorporated with respect to this subject matter. The paints contemplated for use herein, are flexible such that they do not interfere with the propagation of pressure waves through the ear. Further, the paints may be applied as a liquid (i.e, solution, suspension, or emulsion), a semisolid five; a gel, foam, paste, or jelly) or an aerosol.

[00342] In some embodiments, the otic therapeutic agents disclosed herein are dispensed as a eontrolled-release foam. Examples of suitable foamable carriers for use in the compositions disclosed herein include, but are not limited to, alginate and derivatives thereof, carboxyTaethylceiluiose and derivatives thereof, collagen, polysaccharides, including, for example, dextran, dextran deri vatives, pectin, starch, modified starches such as starches having additional carboxyl and/or carboxamide groups and/or having hydrophilic side-chains, cellulose and derivatives thereof, agar and derivatives thereof, such as agar stabilised with polyacrylamide, polyethylene oxides, glycol methacrylates, gelatin, gums such as xanthum, guar, karaya, gellan, arabic, tragacanth and locust bean gum, or combinations thereof. Also sui table are the salts of the aforementioned carriers, for example, sodium alginate, The formulation optionally further comprises a foaming agent, which promotes the .formation of the foam, including a surfactant or external propellant. Examples of suitable foaming agents include cetrimide, lecithin, soaps, silicones and the like. Commercially available surfactants such, as Tween® are also suitable.

[00343] In some embodiments, other gel formulations are useful depending upon the particular antimicrobial agent, other pharmaceutical agent or excipients/additives used, and as such are considered to tall within the scope of the present disclosure. For example, other cornmeicially-available glycerin-based gels, glycerin-derived compounds, conjugated, or erosslinked gels, matrices, hydrogels, and polymers, as well as gelatins and their derivatives, alginates, and alginate-based gels, and even various native and synthetic hydrogel and hydrogel-derived compounds are all expected to be useful in the antimicrobial agent formulations described herein, in some embodiments, auris-acceptable gels include, but are not limited to, alginate hydrogels SAFiP-Gcl (ConvaTee, Princeton, N.J.), Duoderm® 1 iydroactive Gel (ConvaTee), Nu-gel ^(Johnson &amp; Johnson Medical,

Arlington, Tex.); Carrasyn®(V) Acemannan Hydrogel (Carrington Laboratories, Inc.,

Irving, Tex.); glycerin.gels Etta® Hydrogel (Swiss-Ameriean Products, Inc., Dallas, Tex.) and K-Y® Sterile (Johnson &amp; Johnson). In farther embodiments, biodegradable biocompatible gels also represent compounds present in auris-acceptable formulations disclosed and described herein.

[00344] in some formulations developed for administration to a mammal, and for compositions formulated for human administration, the auris-acceptable gel comprises substantially all of the weight of the composition. In other embodiments, the auris-acceptable gel comprises as much as about 98% or about 99% of the composition by weight. This is desirous when a substantially non-fluid, or substantially viscous formulation is needed. In a further embodiment, when slightly less viscous, or slightly more fluid auris-acceptable pharmaceutical gel formulations are desired, the biocompatible gel portion of the formulation comprises at least about 50% by weight, at least about 60% by weight, at least about 70% by weight, or even at least about 80% or 90% by weight of the compound. All intermediate' integers within these ranges are contemplated to fall within the scope of this disclosure, and in some alternative embodiments, even more fluid (and consequently less viscous) auris-acceptable gel compositions are formulated, such as for example, those In 'Which the gel or matrix component of the mixture comprises not more than about 50% by weight, not more than about 40% by weight, not more than about 30% by weight, or even those than comprise not more than about 15% or about 20% by weight of the composition.

Au ris-Accepta ble Suspending Agents [00345] In one embodiment, at least one antimicrobial agent is included in a pharmaceutically acceptable enhanced viscosity formulation wherein the formulation Further comprises at least one suspending agent, wherein the suspending agent assists in imparting controlled release characteristics to the formulation. In some embodiments, suspending agents also serve to increase the viscosity of the auris-acceptable antimicrobial agent formulations and compositions, {00346] Suspending agents include, by way of example only, compounds such as polyvinylpyrrolidone, e.g., polyvinylpyrrolidone K12, polyvinylpyrrolidone K17, polyvinylpyrrolidone K25, or polyvinylpyrrolidone K30, vinyl pyrrolidone/vinyl acetate copolymer ($630), sodium earboxymethylceilulose, methyleellulose, hydroxypropylmethylceilulose (hypromellose), hydroxymethylcellulose acetate stearate, poiysorbate-80, hydroxyethylcellulose, sodium alginate, gums, such as. e.g.. gum tragaeanth and gum acacia, guar gum. xanthans, including xanthan gum, sugars, cellulosics, such as. e.g., sodium, carboxymethyleellulose, methylceilulose, sodium carboxymethyleellulose, hydrpxvpropylmethyl cellulose, hydroxyethyleellulose, polysorbate-80, sodium alginate, polyethoxylated sorbitmvmonolaurate, polyethoxylated sorbitan monolaurate, povidone and the like, hi some embodiments, useful aqueous suspensions also contain one or more polymers as suspending agents. Useful polymers include water-soluble polymers such as eellulosie polymers, e.g.f hydroxypropyl methylceilulose, and water-insoluble polymers such as cross-linked carboxyl-containing polymers. J00347}hi one embodiment, the present disclosure provides auris-acceptable gel compositions comprising a therapeutically effective amount of an antimicrobial agent in a hydroxvethyl. cellulose gel. Hydroxyethyl cellulose (HEC) is obtained as a dry powder which is reconstituted in water or an aqueous buffer solution to give the desired, viscosity (generally about 200 cps to about 30,000 cps, corresponding to about 0,2 to about 10% HEC). In one embodiment the concentration of HEC is between about 1% and about 15%, about 1% and about 2%, or about 1.5% to about 2%, (00348] Ip other embodiments, the auris-acceptable formulations, including gel formulations and viscosity-enhanced formulations, further include excipients, other medicinal or pharmaceutical agents, .carriers, adjuvants, such as preserving, stabilizing, wetting or emulsifying agents, solution promoters, salts, solubilizers, an antifoaming agent, an antioxidant, a dispersing agent, a wetting agent, a surfactant, and combinations thereof.

Auris-Acceptable Actinic Radiation Curable Gel (00349] In other embodiments, the gel is an actinic radiation curable gel, such that following administration to or near the targeted auris structure, use of actinic radiation (or light, including LfV light, visible light, or infrared light) the desired gel properties are formed. By wav of example only, fiber optics are used to provide the actinic radiation so as to form the desired gel properties. In some embodiments, the fiber optics and the gel administration device form a single unit. In other embodiments, the fiber optics and the gel administration device are provided separately,

Auris-Aceeptable Solvent Release Gel (00350] In some embodiments, the gel is a solvent release gel such that the desired gel properties are formed after administration to or near the targeted auris structure* that is, as the solvent in the injected gel formulation diffuses out the gel, a gel having the desired gel properties is formed. For example, a formulation that comprises sucrose acetate isobutyrate, a pharmaceutically acceptable solvent, one or more additives, and the antimicrobial agent is administered at or near the round window membrane: diffusion of the solvent out of the injected formulation provides a depot having the desired gel properties. For example» use of a water soluble solvent provides a high viscosity depot when the solvent diffuses rapidly out of tile injected formulation. On the other hand, use of a hydrophobic solvent (e.g., benzyl benzoate) provides a less viscous depot. One example of an auris-acceptable solvent release gel formulation is the SABER™'Delivery System marketed by D1JRECT Corporation.

Anns-Acceptable In Situ Forming Spongy Material (00351} Also contemplated within the scope of the embodiments is the use of a spongy material , formed in situ in the auris interna or auris media. In some embodiments, the Spongy material is formed from hyaluronic acid or its derivatives. The spongy material is impregnated with a desired antimicrobial agent and placed within the aids media so as to provide controlled release of the antimicrobial agent within the auris media, or in contact with the round window membrane so as to provide controlled release of the antimicrobial agent into the auris interna. In some embodiments, the spongy material is biodegradable.

Round window membrane Mucoadhesives [00352} Also contemplated within the scope of the embodiments is the addition o f a round window membrane mucoadhesive with the antimicrobial agent formulations and compositions and devices disclosed herein. The term ‘mucoadhesion5 is used for materials that bind to the mucin layer of a biological membrane, such as the external membrane of die 3 -layered, round window' membrane. To .serve as round window' membrane m ucoadhesive polymers, the polymers possess some general physiochemical features such as predominantly anionic hydrophilieity with numerous hydrogen bond forming groups, suitable surface property for wetting mueus/mueosal tissue surfaces or sufficient flexibility to penetrate the mucus network. {00353} Round window membrane mucoadhesive agents that are used with the auris-acceptable formulations include, but are not limited to, at least one soluble polyvinylpyrrolidone polymer (FVP); a wmer-swellable, but water-insoluble, .fibrous, cross-linked earhoxy-lunctional polymer; a erosslinked poly(acrylie acid) (e.g. Carbopol® 947P); a carbomer homopolymer; a earbomer copolymer; a hydrophilic polysaccharide gum, maitodextrin, a cross-linked aiignate gum gel, a water-dispersible polycarboxylated vinyl polymer, at least two particulate components selected from the group consisting of titanium dioxide, silicon dioxide, and clay, or a mixture thereof. The round window' membrane mucoadhesive agent is optionally used in combination with an auris-acceptable viscosity increasing excipient, or used alone to increase the interaction of the composition with the mucosal layer target otic component. In one non-limiting example, the mucoadhesive agent is maltodextrin. In some embodiments, the mucoadhesive agent is an alginate gum. When used, the round window membrane mucoadhesi ve character imparted to the composition is at a level that is sufficient to deliver an effective amount of the antimicrobial agent composition to, for example, the mucosal layer of round window membrane or the crista fenestrae cochleae in an amount that eoats the mucosal membrane, and thereafter deliver the composition to the affected areas, including by way of example only, the vestibular and/or cochlear structures of the auris interna. When used, the mucoadhesive characteristics of the compositions provided herein are determined, and using this information (along with the other teachings provided herein), the appropriate amounts are determined. One method for determining sufficient mueoadhesiveness includes monitoring changes in the interaction of the composition with a mucosal layer, including but not limited to measuring changes in residence or retention time of the composition in the absence and presence of the mucoadhesive excipient, [00354] Mucoadhesive agents have been described, for example, in U.S. Patent Nos, 6,638,521, 6,562,363, 6,509,028,6,348,502,6,319,513,6,306,789, 5,814.330, and 4,900,552, each of which is hereby incorporated byreference for such disclosure.

[00355] In another non-limiting example, a mucoadhesive agent is, for example, at least two particulate components selected from titanium dioxide, silicon dioxide, and clay, wherein the composition is not further diluted with any liquid prior to administration and the level of silicon dioxide, if present, is from about 3% to about 15%, by weight of the composition. Silicon dioxide, if present, includes filmed silicon dioxide, precipitated silicon dioxide, coacervated silicon dioxide, gel silicon dioxide, and mixtures thereof. Clay, if present, includes kaolin minerals, serpentine minerals, smectites, illite or a mixture thereof. For example, clay includes laponite, bentonite, hectorite, saponite, montmorillonites or a mixture thereof.

[00356] In one non-limiting example, the round window membrane mucoadhesive agent is maltodextrin. Maltodextrin is a carbohydrate produced by the hydrolysis of starch that is optionally derived from com, potato, wheat or other plant products. Maltodextrin is optionally used either alone or in combination with other round window membrane mucoadhesive agents to impart mucoadhesive characteristics on the compositions disclosed herein. In one embodiment, a combination of mal todextrin and a carbopol polymer are used to increase the round window membrane mueoadhesive characteristics of the compositions or devices disclosed herein.

[00357] In another embodiment, the round window membrane mueoadhesive agent is an alkyl-glycoside and/or a saccharide alkyl ester. As used herein, art “alkyl-glycoside” means a compound comprising any hydrophilic saccharide (e.g. sucrose, maltose, or glucose) linked to a hydrophobic alkyl. In some embodiments, the round window' membrane mueoadhesive agent is an alkyl-glycoside wherein the alkyl-glycoside comprises a sugar linked to a hydrophobic alkyl (e.g., an alkyl comprising about 6 to about 25 carbon atoms) by an. amide linkage, an amine linkage, a carbamate linkage, an ether linkage, a thioether linkage, an ester linkage, a thloester linkage, a glycosidic linkage, a thioglycosidic linkage, and/or a ureide linkage. In some embodiments, the round window membrane mueoadhesive agent is a hexyl-, heptyl.-, octyl·, nonyl-,deeyl·, undecyl-, dodecyl-, trideeyl· , tetradeeyl, pentadecyl·, hexadecyl·, heptadeeyl-, and ociadecyl a- or β-D-maltoside; hexyl·, heptyl-, octyl-, nonyl-, decyl·, nndecyl-, dodecyl-, trideeyl-, tetradecyh pentadecyl-, hexadecyl-» heptadeeyl·, and oetadecyl a- or β-D-glucoside; hexyl-, heptyl-, octyl-, nonyl·, decyl-, undecyl-, dodecyl-, trideeyl-, tetradeeyl, pentadecyl·, hexadecyl-, heptadeeyl-, and oetadecyl a- or β-D-sueroside; hexyl-, heptyl-, octyl·, dodecyl·, trideeyl·, and tetradecyl-β-D-thiomaltoside; dodecyl maltoside;. heptyl- or octyl-1 -thio-α- or β-D- giucopyranoside; alkyl thibsucroSes; alkyl maltotrio sides; long chain aliphatic carbonic acid amides of sucrose β-amino-alkyl ethers; derivatives of palatinose or isomaltamine linked by an amide linkage to an alkyl chain and derivatives of isomaltamine linked by urea to an alkyl chain-long chain aliphatic carbonic acid ureides of sucrose β-amino- alkyl ethers and long chain aliphatic carbonic acid amides of sucrose β- amino-alkyl ethers. In some embodiments, the round window membrane mueoadhesive agent is an. alkyl-glycoside wherein the alkyl glycoside is maltose, sucrose, glucose, pr a combination thereof linked by a glycosidic linkage to an alkyl chain of 9-16 carbon atoms (e.g,, nonyl-, decyl-, dodecyl- and tetradeeyl sucroside; nonyl-, decyl-, dodecyl- and tetradeeyl glucoside; and nonyl-, decyl·, dodecyl-and tetradeeyl maltoside). In some embodiments, the round window membrane mueoadhesive agent is an alkyl-glycoside wherein the alkyl glycoside is dodecylmaltoside, tridecylmaltoside, and tetradecylmaltoside. |00358|In some embodiments, the round window membrane mueoadhesive agent is an alkyl-glycoside wherein the alkyl-glycoside is a disaccharide with at least one glucose, in some embodiments, the auris acceptable penetration .enhancer is a surfactant comprising a- D-glucopyranosyl-p-glycopyranoside, n-Dodecyl-4-O-ot- D-glucopyranosyl-p-glycopyranoside, and/or n-tctradecyi-4-Ο-α- D-glucopyrimosyl-p-glycopyrtmoside. In some embodiments, the round window membrane mucoadhesive agent is an alkyl-glycoside wherein, the 'alkyl-glycoside has a critical miseelle concentration (CMC) of less than about lmM in pure water or in aqueous solutions. In some embodiments, the round window membrane mucoadhesive agent is an alkyl-glycoside wherein an oxygen atom within the alkyl-glycoside is substituted with a sulfur atom. In some embodiments, the round window' membrane mucoadhesive agent is an alkyl-glycoside wherein the aikylglycoside is the β anomer. in some embodiments, the round window membrane mucoadhesive agent is an alkyl-glycoside wherein the alkylglyeoside comprises 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 9S%, 99%, 99,1%, 99.5%, or 99.9% of the β anomer.

Auris-Accep table Controlled Release Particles [0(1359] Antimicrobial agents and/or other pharmaceutical agents disclosed herein are optionally incorporated within controlled release particles, lipid complexes, liposomes, nanopafiicl.es, microparticles, .microspheres, coacervates, nanocapsules or other agents which enhance or facilitate the localized delivery of the antimicrobial agent. In some embodiments, a single enhanced viscosity formulation is used, in which at least one antimicrobial agent is present, while in other embodiments, a pharmaceutical formulation that comprises a mixture of two or more distinct enhanced viscosity formulations is used , in which at least one antimicrobial agent is present. In some embodiments, combinations of sols, gels and/or biocompatible matrices is also employed to provide desirable characteristics of the controlled release antimicrobial agent compositions or fonnulations. in certain embodiments, the controlled release antimierobial agent formulations or compositions are cross-linked by one or more agents to alter or improve the properties of the composition.

[90360] Examples of microspheres relevant to the pharmaceutical formulations disclosed herein include: Luzzi, L. A., J. Pharm. Psy. 59:1367 (1970); US. Pat. No. 4,530.840; Lewis, D. H„ "Controlled Release of Bioaetive Agents from Lactides/Cjlycolide Polymers" in Biodegradable Polymers as Drug Delivery Systems, Chasm,. M. and Langer, R., eds.,

Marcel Decker (1990); U.S. Pat. No. 4,675,189; Beck el al., "Polyflactie acid) and Poly(lactic aeid-eo-glycolie acid) (Contraceptive Delivery Systems," in Long Acting Steroid Contraception, Mishell, D. R., ed.. Raven Press (1983); U.S. Pat. No. 4,758,435; U.S, Pat, No. 3,773,919; U.S. Pat. No. 4,474,572. Examples of protein therapeutics formulated as mierospheres include: IJ.S. Pat, No. 6,458,387; U.S. Pat. No. 6,268,053; U.S. Pat. No, 6,090,925; U.S. Pat. No. 5,981,719; and U.S. Pat. No. 5,578,709, and are herein incorporated by reference for such disclosure.

[00361] Mierospheres usually have a spherical shape, although irregularly-shaped microparticles are possible. Mierospheres may vary in size, ranging from submicron to 1000 micron diameters. Microspheres suitable for use with the auris-acceptable formulations disclosed herein are submicron to 250 micron diameter microspheres, allowing administration by injection with a standard gauge needle. The auris-acceptable microspheres are prepared by any method which produces mierospheres in. a size range acceptable for use in an injectable composition. Injection is optionallyaecompli shed with standard gauge needles used for administering liquid compositions.

[003621 Sui table examples of polymeric- matrix materials for use in the auris-acceptable controlled release particles herein include polyfglvcolic acid), poly-d,l-lactie acid, poly-l-lactic acid, copolymers of the foregoing, poly(aliphatic carboxylic acids), copolyoxalates, polycaprolaetone, polydioxonene, poly(orthocarbonates), poiy(aeetals), polyflaetic acid-caprolactone), polyorthoesters, poly(glyeoIie acid-caprolactone), polydioxonene, polyanhydrides, polyphosphazines, and natural polymers including albumin, casein, and some waxes, such as, glycerol mono* and distearate, and the like. Various commercially available poly (lactide-co-glycolide) materials (PLQA) are optionally used in the method disclosed herein. For example, poly (d, ITac tic- co- glycolic acid) is commercially available from Boehringer-Ingelheim as RESOMER RG 503 H. 'Ibis product has a mole percent composition of 50% lactide and 50% glycolide. These copolymers are available in.a wide range of molecular weights and ratios of lactic acid to glycolic acid. One embodiment includes the use of the polymer poiy(d,Mactide-co-glycoiide). Hie molar ratio oflactide to glycolide in such a copolymer includes the range of from about 95:5 to about 50:50. [0O.363jThe molecular weight of the polymeric matrix material is of some importance. The molecular weight should be high enough so that it forms satisfactory .polymer .coatings, i.e., the polymer should be a good film former. Usually, a satisfactory molecular weight is in the range of 5,000 to 500,000 daltons. The molecular weight of a polymer is also important from the point of view that molecular weight influences the biodegradation rate of the polymer. For a diffusions! mechanism of drug release, the polymer should remain intact until all of the drug is released from the microparticles and then degrade. The drug is also released from the microparticles as the polymeric excipient bioerodes. By an appropriate selection of polymeric materials a microsphere formulation is made such that the resulting microspheres exhibit both diffusional release and biodegradation release properties. This is useftil in affording, multiphasie release patterns.

[00364] A variety of methods are known by which compounds are encapsulated in microspheres, in. these methods, the antimicrobial agent is generally dispersed or emulsified, using stirrers, agitators, or other dynamic mixing techniques, in a solvent, containing a wall-forming material. Solvent is then removed from the microspheres, and thereafter the' micro-sphere product is obtained, [00365] In one embodiment, controlled release antimicrobial agent formulations are made through the incorporation of the antimicrobial agents and/or other pharmaceutical agents into ethylene-vinyl acetate copolymer matrices. (See U.S, Patent No, 6,083,534, incorporated herein tor such disclosure). In another embodiment, antimicrobial agents are ..incorporated:into poly (laciic-glycolic acid) or poly-L-lactic acid microsplieres. Id. in yet another embodiment, the antimicrobial agents are encapsulated into alginate microspheres. (.See U.S, Patent No, 6,036.978, incorporated herein for such disclosure), Biocompatible methacrylate-based polymers to encapsulate the antimicrobial agent compounds or compositions are optionally used in the formulations and methods disclosed herein. A wide range of methacrylate-based polymer systems are commercially available, such as the EUDRAGIT polymers marketed by Evonik, One useful aspect of methacrylate polymers is that the properties of the formulation are varied by incorporating various co-polymers. For example, poly(aciylic acid-co-methylmethacrylate) microparticles exhibit enhanced mucoadhesion properties as the carboxylic acid groups in the poly(acrylie acid) form hydrogen bonds with mucin (Park etal, Phartn, Res. (19:87) 4(6):457-464). Variation of the ratio between acrylic acid and methylmethacrylate monomers serves to modulate the properties of the co-polymer, Methacrylate-based microparticles have also been used in protein therapeutic formulations (Naha et al, Journal of Microencapsulation 04 February, 2008 (online publication)). In one embodiment, the enhanced viscosity auris-acceptable formulations described herein comprises antimicrobial agent microspheres wherein the microspheres are formed from a methacrylate polymer or copolymer. In an additional embodiment, the enhanced viscosity formulation described herein comprises antinuerobial agent microspheres wherein the microspheres are mueoadhesi ve. Other controlled release systems, including incorporation or deposit of polymeric materials or matrices onto solid or hollow-spheres containing antimicrobial agents, are also explicitly contemplated within the embodiments disclosed herein. The. types of controlled release systems available ’without significantly losing activity of the antimicrobial agent are determined using the teachings, examples, and principles disclosed herein [00366} Art example of a conventional microencapsulation process for pharmaceutical preparations is shown in U.S. Pat. No. 3,737,337, incorporated herein by reference for: such disclosure. The antimicrobial agent substances to be encapsulated or embedded are dissolved or dispersed in the organic solution of the polymer (phase A), using conventional mixers, including (in the preparation of dispersion) vibrators and high-speed stirrers, etc. The dispersion of phase (A), containing the core material in solution or in suspension, is carried out in the aqueous phase (B), again using conventional mixers, such as high-speed mixers, vibration mixers, or even spray nozzles, in which case the particle., size of the micrbspheres will be determined not only by the concentration of phase (A), but also by the emulsate or microsphere size. With conventional techniques for the microencapsulation of antimicrobial agents, the mierospheres form when the solvent containing, an active agent and a polymer is emulsified or dispersed in an immiscible solution by stirring, agitating, vibrating, or some other dynamic mixing technique, often for a relatively long period of time.

[60367} Methods for the construction of mierospheres are also described in U.S. Pat. No. 4,389,330, and. U.S. Pat. No, 4,530,840, incorporated herein by reference for such disclosure. The desired antimicrobial agent is dissolved or dispersed in an appropriate solvent. To the agent-containing medium is added the polymeric matrix material in an amount relative to the active ingredient which gives a product of the desired loading of active agent. Optionally, all of the ingredients of the antimicrobial agent microsphere product can be blended in the solvent medium together. Suitable solvents for the agent and the polymeric matrix material include organic solvents such as acetone, halogenated hydrocarbons such as chloroform, methylene chloride and the like, aromatic hydrocarbon compounds, halogenated aromatic hydrocarbon compounds, cyclic ethers, alcohols, ethyl acetate and the like. {00368} The mixture of ingredients in the sol vent is emulsified in a continuous-phase processing medium; the continuous-phase medium being such that a dispersion of microdroplets containing the indicated ingredients is formed in the continuous-phase medium. Naturally, the continuous-phase processing medium and the organic solvent must be immiscible, and includes water although nonaqueous media such as xylene and toluene and synthetic oils and natural oils are optionally used. Optionally, a surfactant is added to the continuous-phase processing medium to prevent the-microparticles from agglomerating and to control the size of the solvent microdroplets in the emulsion. A preferred surfactant-dispersing medium combination is a 1 to 10 wt. % poly (vinyl alcohol) in water mixture.

The dispersion is formed by mechanical agitation of the mixed materials. An emulsion is optionally formed by adding small drops of the active agent-wall fobbing material solution to the c ontinuous phase processing medium. The temperature during the formation of the emulsion is not especially critical but influences the size and quality of the microspheres and the solubility of the drug in the continuous phase. It is desirable to have as little of the agent in the continuous phase as possible. Moreover, depending on the solvent and continuous-phase processing, medium employed, the temperature must not be too low or the solvent and processing medium will solidify or the processing medium will become too viscous for practical purposes, or too high that the processing medium will evaporate, or that the liquid processing medium will not be maintained. Moreover, the temperature of the medium cannot be so high that the stability of the particular agent being incorporated in the microspheres is adversely affected. Accordingly, the dispersion process is conducted at any temperature which maintains stable operating conditions, which preferred temperature being about 15 °C to 60 °C, depending upon the drag and excipient selected.

[00369] The dispersion which is formed is a stable emulsion and from this dispersion the organic solvent immiscible fluid is optionally partially removed in the first step of the solvent removal process, The solvent is removed by techniques such as heating, the application of a reduced pressure or a combination of both. The temperature employed to evaporate solvent from the microdroplets is not critical, but should not be that high that it degrades the antimicrobial agent employed in the preparation of a given microparticle, nor should it be so high as to evaporate solvent, at such a rapid rate to cause defects in the wall forming: material. Generally, from 5 to 75%, of the solvent is removed in the first solvent removal step. {003701 After the first stage, tire dispersed -microparticles in the solvent immiscible fluid medium are isolated from the fluid medium by any convenient means of separation. Thus, for example, the fluid is decanted from the :mierosphere or the microsphere suspension is filtered, Still other, various combinations of separation techniques are used if desired, [Θ0371 [Following the isolation of the microspheres from the continuous-phase processing medium, the remainder of the solvent in the micro-spheres is removed by extraction. In this step, the microspheres arc suspended in the same continuous-phase processing medium used in step one, with or without surfactant or in another liquid. The extraction medium removes the solvent from the microspheres and yet does not dissolve the microspheres. During the extraction, the extraction medium with dissolved solvent is optionally removed and replaced with fresh extraction medium. This is best done on a continual basis. The rate of extraction medium replenishment of a given process is a variable which is determined at the time the process is performed and, therefore, no precise limits for the rate must be predetermined. After the majority of the solvent has been removed from the microspheves, the mkrospheres are dried by exposure to air or by other conventional drying techniques such as vacuum drying, diving over a desiccant, or the like. This process is very efficient in encapsulating the antimicrobial agent since core loadings of up to SO wl. %, preferably up to 60 wt. % are obtained, {00372] Alternatively, controlled release microspheres containing an antimicrobial agent is prepared through the use of static mixers. Static or motionless mixers consist of a conduit or tube in which is received a number of static mixing agents. Static mixers provide homogeneous mixing in a relatively short length of conduit, and in a relatively short period of time. Wi th static m ixers, the fluid moves through the mixer, rather than some part of the mixer, such as a blade, moving through the fluid.

[00373| A static mixer is optionally used to create an emulsion. When using a static mixer to form an emulsion, several factors determine emulsion particle size, including the density and viscosity of the vari ous solutions or phases to be mixed, volume ratio of the phases, interfacial tension between the phases, static mixer parameters (conduit diameter; length of mixing element; number of mixing elements), and linear velocity through the static mixer. Temperature is a variable because it affects density, viscosity, and interfacial tension. Die controlling variables are linear velocity, sheer rate, and pressure drop per unit length of static mixer, [00374] In order to create microspheres containing an antimicrobial agent using a static mixer process, an organic phase and an aqueous phase are combined. The organic and aqueous phases are· largely or substantially immiscible, with the aqueous phase constituting the continuous phase of the emulsion. The organic phase includes an antimicrobial agent as well as a wall-forming polymer or polymeric matrix material. The organic phase is prepared by dissolving an antimicrobial agent in an organic or other suitable solvent, or by forming a dispersion or an emulsion containing the antimicrobial agent, The organic phase and the aqueous phase are pumped so that the two phases flow simultaneously through' a static mixer, thereby forming an emulsion which comprises microspheres containing the antimicrobial agent encapsulated in the polymeric matrix material. The organic and aqueous phases are pumped through the static mixer into a large volume of quench liquid to extract or remove the organic solvent. Organic solvent is optionally removed from the microspheres while they are washing or being stirred in the quench liquid. After the microspheres are washed in a quench liquid, they are isolated, as through a sieve, and dried.

[00375] in one embodiment, microspheres are prepared using a static mixer. The process is not limited to the sol vent extraction technique discussed above, but is used with other encapsulation techniques. For example, the process is optionally used with a phase separation encapsulation technique. To do so, an organic phase is prepared that comprises an antimicrobial agent suspended or dispersed in a polymer solution. The non-solvent second phase is free from solvents for the polymer and active agent. A preferred non-solvent second phase is silicone oil. The organic phase and the non-solvent phase are pumped through a Static mixer into a non-solvent quench liquid, such as heptane. The semi-solid particles are quenched for complete hardening and washing. The process of microencapsulation includes spray drying, solvent evaporation, a combination of evaporation and extraction, and melt extrusion.

[00376] in another embodiment, the microencapsulation process involves the use of a static mixer with a single solvent. This process is described in detail in U.S. application Seri No. 08/338,805, herein incorporated by reference for such disclosure. An alternative process involves the use of a static mixer with co-solvents. In this process, biodegradable microspheres comprising a biodegradable polymeric binder and an antimicrobial agent are prepared, which comprises a blend of at least two substantially non-toxic solvents, tree of halogenated hydrocarbons to dissolve both the agent and the polymer. The solvent blend containing the dissolved agent and polymer is dispersed in an aqueous solution to form droplets. The resulting emulsion is then added to an aqueous extraction medium preferably containing at least one of the solvents of the blend, whereby the rate of extraction of each solvent is controlled, whereupon the biodegradable microspheres containing the pharmaceutically active agent are formed. This process has the advantage that less extraction medium is required because the solubility of one solvent in water is substantially independent of the other and solvent selection is increased, especially with sol vents that are particularly difficult, to extract.

[P377J Nanopartieles are also contemplated for use with the antimicrobial agents disclosed herein. Nanoparticles are material structures of about 100 am or less in size. One use of nanopartieles in pharmaceutical formulations is the formation of suspensions as the interaction of the particle surface with solvent is strong enough to overcome differences in density. Nanoparticle suspensions are sterilized as the nanopaitieles axe small enough to be subjected to sterilizing filtration (see, e.g., U.S. Patent No. 6,139,870, herein incorporated, by reference for such disclosure). Nanopartieles comprise at least one hydrophobic, water-insoluble and water-indispersible polymer or copolymer emulsified in a solution or aqueous dispersion of surfactants, phospholipids or fatty acids. The antimicrobial agent is optionally introduced with the polymer or the copolymer into the nanopartieles.

[00378jLipid nanocapsules as controlled release structures, as well for penetrating the round window membrane and reaching auris interna and/or auris media targets, is also Contemplated herein. Lipid nanocapsules are optionally formed by emulsifying capric and caprylie acid triglycerides (Labrafac WL 1349; avg. niw 512), soybean lecithin (LIPOID® S75-3; 69% phosphatidylcholine and other phospholipids), surfactant (ibr example, Solutol HS15). a mixture of polyethylene glycol 660 hydroxystearate and free polyethylene glycol 660; NaCl and water. The mixture is stirred at room temperature to obtain an oil emulsion in water. After progressive heating at a rate of 4 "C/raiit under magnetic stirring, a short interval of transparency should occur close to 70 °C\ and the inverted phase (water droplets in oil) obtained at 85 °C. Three cycles of cooling and heating is then applied between 85 °C and 60 i!C at the rate of 4 c’C/min, and a fast dilution in cold water at a temperature close to 0 °C to produce a suspension of nanocapsules. To encapsulate the antimicrobial agents, the agent is optionally added just prior to the dilution with cold water.

[00379) Antimicrobial agents are also inserted into the lipid nanocapsules by incubation for 90 minutes with an aqueous micellar solution of the auris active agent. The suspension is then vortexed every 15 minutes, and then quenched in an ice bath lor 1 minute, |©0380| Suitable auris-acceptable surfactants are, by way of example, cholic acid or taurocholic acid salts, TaurochoMc acid, tire conjugate formed from cholic acid and taurine, is a fully metabolizable sulfonic acid surfactant. An analog of taurocholic acid, tauroursodeo.xycholie acid (TUDCAj, is a naturally occurring bite acid and is a conjugate of taurine and ursodeoxycholic acid (L'DCA), Other naturally occurring anionic (e.g., galactocerebroside sulfate), neutral (e.g., lactosylceramide) or zwltteriomc surfactants (e.g., sphingomyelin, phosphatidyl choline, palmitoyi carnitine) are optionally used to prepare nanoparticles. {00381} The auris-acceptable phospholipids are chosen, by way of example, from-natural., synthetic or semi-synthetic phospholipids; lecithins (phosphatidylcholine) such as, for example, purified egg or soya lecithins (lecithin E l 00, lecithin E80 and phospholipous, for example phospholipon 90), phosphatidyiethanolamine, phosphatidylserine, phosphatidyiinositoi, phosphatidylglycerol. dipalmitoylphosphatidyicholme, dipalmitoylglycerophosphatidylcholine, dimyristoylphosphatidyleholine, distearoylphosphatidyleholine and phosphatidic acid or mixtures thereof are used more particularly. {00382} Fatty acids for use with the auris-acceptable formulations are chosen from, by way of example, lauric acid, naysristie acid, palmitie aeid, stearic acid, isostearic acid, arachidic aeid, behenic acid, oleic acid, myristoleic aeid, palmitoleic aeid, linoleic acid, alpha-linoleic acid, arachidonic acid, eicosapentaenoic acid, enietc acid, doeosaliexaenoie acid, and the like, {00383) Suitable auris-acceptable suriactants are selected from known organic and inorganic pharmaceutical excipients. Such excipients include various polymers, low molecular weight oligomers, natural products, and surfactants. Preferred surface modifiers include nonionic and ionic surfactants. Two or more surface modifiers are used in combination. {00384] Representative examples of auris-acceptable surfactants include cetyl pyridinium chloride, gelatin, casein, lecithin (phosphatides), dextran, glycerol, gum acacia, cholesterol, tragacanth, stearic acid, calcium stearate, glycerol monostearate, cetostearyl alcohol, eetomacrogo! emulsifying wax, sorbitan esters, polyoxyethylene alkyl ethers, polyoxyethylene castor oil deri vatives, polyoxyethylene sorbitan fatty acid esters; dodecyl trimethyl ammonium bromide, poIyoxyethylenestearates, colloidal silicon dioxide, phosphates, sodium dodecylsulfate, carboxymethylcellulose calcium, hydroxypropyl cellulose (HPC, HPC-SL, and HPC-L), hydroxypropyl methyicellulose (HPMC), carboxyraethyleell ulose sodium, methylceliulose, hydroxyethyicdkdose, hydiOxypropylcellulose, hydroxypropyimethyl-celiulose phthalate, nonerystalline cellulose, magnesium aluminum silicate, triethanolamine, polyvinyl alcohol (PVA), polyvinylpyrrolidone.(PVP), 4-(1,1,3 J-tetaameth.ylbutyi)-phenol polymer with ethylene oxide and formaldehyde (also known as tyloxapol, superione, and triton), poioxarners, poloxamnines, a charged phospholipid such as dimyristoyl phophatidyl glycerol, dioctylsulfosuecinate (DOSS); Tetronic® 1508, dialkylesters of sodium sulfosuccime acid, Duponol. P, Tritons X-200, Cfodestas F-l 10, p-isononylphenoxypoly-Qdycidol), Crodestas SL-40 (Croda, Inc.); and SA90HC0, which is C«.Hj? m2 (CONCCHsVCHj (CHOH)4 (CHj OH)2 (Eastman Kodak Co,); deeanoyl-N-metftylglueamMe; n-deeyl β-Ι)-glucopyranoside' n-decyl β-D-maltopyranoside; n-dodeeyl β-D-glucopyranoside; n-dodecyl p-B-maltoside; heplanoyi-N-mefhyigiucamide; n-hepiyi-p-D-ghjeopyranoside; n-heptyl β-D-tMoglucoside; n-hexyl β-D-ghicopyranoside; nonanoyd-N-methylglueamide; n-noyi β-D-glucopyranoside; Octanoyl-N-metbylglucarmide; n-octyl-p-D-glucopyranoside: octyl β-D-thioglucopyranoside; and the like. Most of these surfactants are known pharmaceutical excipients and are described in detail in the Handbook of Pharmaceutical Excipients, published jointly by the American Pharmaceutical Association and The Pharmaceutical Society of Great Britain (The Pharmaceutical Press, 1986), specifically incorporated by reference for such disclosure. |ft0385]Th.e hydrophobic, water-insoluble and water-indispersible polymer or copolymer may be chosen from biocompatible and biodegradable polymers, for example lactic or glycolic acid polymers and copolymers thereof, or polylactic/polyethylene (or polypropylene) oxide copolymers, preferably with molecular weights of between 1000 and 2 06,000, poh hydroxy butyric acid polymers, polylactones of fatty acids containing at least 12 carbon atoms, or poly anhydrides, {003861 The nanoparticles may be obtained by coaeervation, or by the technique of evaporation of solvent, from an aqueous dispersion or solution of phospholipids and of an oleic acid salt into which is added an immiscible organic phase comprising the active principle and the hydrophobic, water-insoluble and watei'-indispersible polymer or copolymer. The mixture is pre-emulsified and theft subjected to homogenization and evaporation Of the organic solvent to obtain an aqueous suspension of very small-sized nanoparticles.

[00387] A variety of methods are optionally employed to fabricate the antimicrobial agent nanoparticles that are within the scope of the embodiments. These methods include vaporization methods, such as free jet expansion, laser vaporization, spark erosion, electro explosion and chemical vapor deposition; physical methods involving mechanical attrition (e.g., "pearlmilling" technology. Elan Nanosystems), super critical €02 and interfacial deposition following solvent displacement In one embodiment, the solvent displacement method is used. The size of nanoparticles produced by this method is sensitive to the concentration of polymer in the organic solvent; the rate of mixing; and to the surfactant employed in the process. Continuous flow mixers provide the necessary turbulence to ensure small particle size. One type of continuous flow mixing device that is optionally used to prepare nanoparticles has been described (Hansen et al ) Phys Chem 92* 2189-96.1988). In other embodiments, ultrasonic devices, flow through homogenizes or supercritical CO;2 devices may be used to prepare nanoparticles. 100388] If suitable nanoparticle homogeneity is not obtained on direct synthesis, then size-exclusion chromatography is used to produce highly uniform drug-containing particles that are freed of other components involved in their fabrication. Size-exclusion chromatography (SEC) techniques, such as gel- filtration chromatography, is used to separate particle-bound antimicrobial agent or other pharmaceutical compound from free antimicrobial agent or other pharmaceutical compound, or to select a suitable size range of antimicrobial agent -containing nanoparticles. Various SEC media, such as Superdex 200, Superose 6, Scphacrvl 1000 are commercially available and are employed for the size-based fractionation of such mixtures. Additionally, nanoparticles are optionally purified by centrifugation, membrane filtration and by use of other molecular sieving devices, crosslinked gels/materials and membranes.

Auris-Aeceptablc Cydodextrin and Other Stabilizing Formulations (OT389]In a specific embodiment, the aiiris-acceptable formulations alternatively comprises a cyclodextrin. Cyclodextrins are cyclic oligosaccharides containing 6, 7, or 8 glucopyranose units, referred to as fi-eyclodextrin, β-cyclodextrm, or y-cyclodextrin respectively. Cyclodextrins have a hydrophilic exterior, which enhances water-soluble, and a hydrophobic interior which forms a cavity. In an aqueous environment, hydrophobic portions of other molecules often enter the hydrophobic cavity of cyclodextrin to form inclusion compounds. Additionally, cyclodextrins are also capable of other types of' nonbonding interactions with molecules that are not inside the hydrophobic cavity, Cyclodextrins have three free hydroxyl groups for each glucopyranose unit, or 18 hydroxyl groups on ά-cyclodextrin, 21 hydroxyl groups on β-cyciodextrin, and 24 hydroxyl groups on y-c vclodextrin. One or more of these hydroxyl groups can be reacted with any of a number of reagents to form a large variety of cyclodextrin derivatives, including hydroxypropyl ethers, sulfonates, and sulfoalkylethers. Shown below is the structure of β-cyciodextrin and the hydroxypropyl-p-eyclodextrin (HPpCD),

|(M)390|In some embodiments, the use of cyclodextrins in the pharmaceutical compositions described herein improves the solubility of the drug. Inclusion compounds are involved in many cases of enhanced solubility'; however other interactions between cyclodesirins and insoluble compounds also improves solubility'. Hydroxypropy]-p~cyclodextrin (HPpCD) is commercially available as a pyrogen free product, ft is a nonhygroscopic white powder that readily dissolves in water. HPpCD is theimally stable and does not degrade at neutral pH. Thus, cyclodextrins impro ve the solubility of a therapeutic agent in a composition or formulation. Accordingly, in some embodiments, cyclodextrins are included to increase the solubility of the auris-acceptable antimicrobial agents within the formulations described: herein, in other embodiments, cyclodextrins in addition serve as controlled release excipents within the formulations described herein.

[00391] By way of example only, cyclodextrin derivatives for use include α-cyclodextrin. p-cyelodextrin, γ-cyclodextrin, hydroxyethyl β-cyciodextrih, hydroxy-propyl γ-cyclodextrin, suSMed β-cyclodextrin. sulfated α-cyclodextrin, sulfobutyl ether p-cyclodextrin, 1003921 The concentration of the cyclodextrin used in the compositions' and methods disclosed herein varies according to the physiochemicai properties, pharmacokinetic properties, side effect or adverse events, formulation considerations, or other factors associated with the therapeutically active agent, or a salt or prodrug thereof, or with the properties of other excipients in the composition. Thus, in certain circumstances, the concentration or amount of cyclodextrin used in accordance with the compositions and methods disclosed herein will vary, depending on the need. When used, the amount of cyclodextrins needed to increase solubility of the antimicrobial agent and/or function as a controlled release excipient in any of the formulations described herein is selected using the principles, examples, and teachings described herein, f00393] Other stabilizers that are useful in the auris-aeceptable formulations disclosed herein include, for example, tatty acids, fatty alcohols, alcohols, long chain fatty acid esters, long chain ethers, hydrophilic derivatives of fatty acids, polyvinyl pyrrolidones, polyvinyl ethers, ;polyvinyI alcohols, hydrocarbons, hydrophobic polymers, moisture-absorbing polymers, and combinations thereof. In some embodiments, amide analogues of stabilizers are al so used . In further embodiments, the chosen stabi lizer changes the hydrophobicity of the formulation (e,g„ oleic acid, waxes), or improves the mixing of various components in the formulation (e.g,, ethanol), controls the moisture lew! in the formula (e.g., PVP or polyviny l pyrrolidone), controls the mobility of the phase (substances with melting points higher than room temperature such as long chain fatty acids, alcohols, esters, ethers, amides etc, or mixtures thereof; waxes), and/or improves the compatibility of the formula with encapsulating materials (e.g., oleic acid or wax), in another embodiment some of these stabilizers are used as solvents/co-solvents (e.g.. ethanol). In other embodiments, stabilizers are present in sufficient amounts to inhibit the degradation of the antimicrobial agent. Examples of such, stabilizing agents, include, but are not limited to: (a) about 0.5% to about 2% w/v glycerol, (b) about 0.1% to about 1% w/v methionine, (c) about 0.1% to about 2% w/v monothioglycerol, (d) about 1 mM to about 10 mM EDI A, (e) about 0.01 % to about 2% w/v ascorbic acid, (f) 0,003% to about 0,02% w/v polysorbate 80, (g) 0.001% to about 0.05% w/v, polysorbate 20, (h) arginine, (ij heparin, (j) dextran sulfate, (k) cyclodextrins, (1) pentosan polySulfate and other heparinoids, (m) divalent cations such as magnesium and zinc: or (n) combinations thereof. (00394] Additional useful antimicrobial agent auris-acceptable formulations include one or more anti-aggregation additives to enhance stability of antimicrobial agent formulations by reducing the rate of protein aggregation. The anti-aggregation additi ve selected depends upon the nature of the conditions to which the antimicrobial agents, for example antimicrobial agent antibodies are exposed. For example, certain formulations undergoing agitation and thermal stress: require a different anti-aggregation additive than a formulation undergoing lyophilization and reconstitution. Useful ami-aggregation additives include, by way of example only, urea, guanidinium chloride, simple amino acids such as glycine or arginine, sugars, polyaleohols, polysorbates, polymers such as polyethylene glycol and dextrans, alkyl saccharides, such as alkyl glycoside, and surfactants.

[90395]Other useful formulations optionally include one or more auris-aeeeptable antioxidants to enhance chemical stability where required. Suitable antioxidants include, by way of example only, ascorbic acid, methionine, sodium thiosulfate and sodium Hietabisuifite. In one embodiment, antioxidants are selected from metal chelating agents, thiol containing compounds and other general stabilizing agents. 100396] Still other useful compositions include one or more auris-acceptable surfactants to enhance physical stability or for other purposes. Suitable nonionic surfactants include, but are not limited to. polyoxyethylene tatty acid glycerides and vegetable oils, e.g., polyoxyethylene (60) hydrogenated castor oil; and polyoxyethylene alkylethers and alkylphenyl ethers, e.g., octoxynol 10, octoxynol 40.

[0039711η some embodiments, the auris-acceptable pharmaceutical formulations described herein are stable with respect to compound degradation over a period of any of at least about 1 day, at least about 2 days, at least about 3 days, at least about 4 days, at least about 5 days, at least about 6 days, at least about 1 week, at least about 2 weeks·, at least about 3 weeks, at least about 4 weeks, at least about 5 weeks, at least about 6 weeks, at least about 7 weeks, at least about 8 weeks, at least about 3 months, at least about 4 months, at least about 5. months, or at least about 6' months. In other embodiments, the formulations described herein are stable with respect to compound degradation over a period of at least about 1 week. Also described herein are formulations that are stable with respect to compound degradation over a period of at least about 1 month. 100398) In other embodiments, art additional surfactant (co-surfactant) and/or buffering agent is combined with one or more of the pharmaceutically acceptable vehicles previously described herein so that the suriactant and/or buffering agent maintains the product at an optimal pH for stability. Suitable co-surfactants include, but are not limited to: a) natural and synthetic lipophilic agents, e.g., phospholipids, cholesterol, and cholesterol fatty acid esters and derivatives thereof; b) nomonic surfactants, which include for example, polyoxyethylene fatty alcohol esters, sorbitan fatty acid esters (Spans), polyoxyethylene sorbitan fatty acid esters (e.g., polyoxyethylene (20) sorbitan roonooleate (Tween 80), polyoxyethylene: (20) sorbitan monostearate (Tween 60), polyoxyethylene (20) sorbitan monolaurate.(Tween 20) and other Tweens, sorbitan esters, glycerol esters, e.g., Myrj and glycerol triacetate (triacetin), polyethylene glycols, cetyl alcohol, cetostcaryl alcohol, stcaryl alcohol, polysofbate 80. poloxamers, poloxamines, polyoxyethylene castor oil derivatives (e.g.., Cremophor® RH40, Cremphor A25, Crempbor A20. Cremophor"1 EL) and other

Cremophors, sulfosuccinates, alky! sulphates (SLS); PEG glyceryl fatty add esters such as PEG-8 glyceryl caprylate/caprate (Labrasol), PEG-4 glyceryl caprylate/caprate (Lahrafac Hydro WL 1219), PEG-32 glyceryl laurate (Gelueire 444/14), PEG-6 glyceryl mono oleate (Labratll M 1944 CS), PEG-0 glyceryl iinoleate (Labrafil M 2125 CS); propylene glycol mono- and di-fatty acid esters, such as propylene glycol laurate, propylene glycol caprylate/caprate; Brrj® 700, aseorby!-6-pairnitate, stearylamine, sodium lauryl sulfate, polyoxethylenegiyeerol triiriciaoleate, and any combinations or mixtures thereof; e) anionic surfactants include, but are not limited to, calcium carboxymethvice! 1 uiose. sodium carboxymethylcellulose, sodium sulfosuccinate, dioctyl, sodium alginate, alkyl polyoxyethylene sulfates, sodium lauryl sulfate, triethanolamine stearate, potassium laurate, bile salts, and any combinations or mixtures thereof: and d) cationic surfactants such as eetyltrimethylammoniurn bromide, and lauryldimethylbenzyl-anunoniuin chloride.

[00399] In a further embodiment, when one or more co-surfactants are utilized in the auris-acceptable formulations of the present disclosure, they are combined, e.g., with a pharmaceutically acceptable vehicle and is present in the final formulation, e.g., in an amount ranging from about 0.1% to about 20%, from about 0.5% to about 10%.

[00400] In one embodiment, the surfactant has an HER value of 0 to 20. In additional embodiments, the surfactant has an HLB value of 0 to 3, of 4 to 6, of 7 to 9, of 8 to 18, of 13 to 15, of 10 to 18.

[00401] In one embodiment, diluents are also used to stabilize the antimicrobial agent or other pharmaceutical compounds because they provide a more stable environment. Salts dissolved in buffered solutions (which also can provide pH control or maintenance) are Utilized as diluents, including, but not limited to a phosphate buffered saline solution. In Other embodiments, the gel formulation is isotonic with the endolymph or the perilymph: depending on tire portion of the cochlea that the antimicrobial agent formulation is targeted. Isotonic formulations are provided by the addition of a tonicity agent. Suitable tonicity agents include, but are not limited to any pharmaceutically acceptable sugar, salt or any combinations or mixtures thereof, such as, but not limited to dextrose and sodium chloride. In further embodiments, the tonicity agents are present in an amount from about 100 mOsm/kg to about 500 mQsm/kg. In some embodiments, the tonicity agent is present in an amount from about 200 mOsm/kg to about 400 mOsm/kg, from about 280 mOsm/kg to about 320 mOsm/kg. The amount of tonicity agents will depend on the target structure of the pharmaceutical formulation, as described herein.

[00402{Useful tonicity compositions also include one or more salts in an amount required to bring osmolality of the composition into an acceptable range for the perilymph or the endolymph. Such salts include those having sodium, potassium or ammonium cations and chloride, citrate, ascorbate, borate, phosphate, bicarbonate, sulfate, thiosulfate or bisulfite anions; suitable salts include sodium chloride, potassium chloride, sodium thiosulfate, sodium bisulfite and ammonium sulfate.

[00403] In some embodiments, the auris-acceptable gel formulations disclosed herein alternatively or additionally contains preservatives to prevent microbial growth. Suitable auris-acceptable preservatives for use in the enhanced viscosity formulations described herein include, but are not limited to benzoic acid, boric acid, p-hydroxybenzoates, alcohols, quarternary compounds, stabilized chlorine dioxide» mercuriaLs, such as merfen and thiomersal, mixtures of the foregoing and the like.

[00404] In a further embodiment, the preservati ve is, by way of example only, an antimicrobial agent, within the auris-acceptable formulations presented herein. In one embodiment, the formulation includes a preservative such as bv way of example only, methyl paraben, sodium bisulfite, sodium thiosulfate, ascorbate, 'chore butanol, thimerosai, parabens» benzyl alcohol, phenylethanol and others. In another embodiment, the methyl paraben is at a concentration of about 0.05% to about 1.0%, about 0.1 % to about 0.2%. In a further embodiment, the gel is prepared by mixing water, methylparaben, hydroxyethylceilufose and sodium citrate, in a further embodiment, the gel is prepared by mixing water, methylparaben, hydroxyethylcellulose and sodium acetate. In a further embodiment, the mixture is sterilized by autoclaving at 120 °C for about 20 minutes, and tested for pH, methylparaben concentration and viscosity before mixing with the appropriate amount of the antimicrobial agent disclosed herein.

[00405] Suitable auris-acceptable water soluble preservatives which are employed in the drug delivery vehicle incl ude sodium bisulfite, sodium thiosulfate, ascorbate, chorobutanol, thimerosai, parabens, benzyl alcohol, Butylated hydroxy-toluene (BHT), phenylethanol and others. These agents are present, generally, in amounts of about 0.001% to about 5% by weight or, in the amount of about 0.01 to about 2% by weight. In some embodiments, auris-compatible formulations described herein are free of preservatives.

Round window membrane Penetration Enhancers [00406] in another embodiment, the formulation further comprises one or more round window membrane penetration enhancers, Penetration across the round window membrane is enhanced by the presence of round window membrane penetration enhancers. Round window membrane penetration enhancers are chemical entities that facilitate transport of coadministered substances across the round window membrane. Round window membrane penetration enhancers are grouped according to chemical structure. Surfactants, both ionic and non-ionic, such as sodium laiiryl sulfate, sodium laurate, polyQxyethyiene-20-cetvi ether, laureth-9, sodium dodecylsulfate, dioctyl sodium sulfosucelnate, polyoxyethylene-9-laury t ether (PLE), Tween® 80, tioftylphenoxypo-iyethylene tNP-POE), polysorbates and the like, function as round window membrane penetration enhancers. Bile salts (such as sodium glycocholate, sodium deoxycholate, sodium taurocholate;, sodium taurodihydrofusidate, sodium: glycodihydrofusidate and the like), fatty acids and derivatives (such as oleic acid, eaprylie acid, mono- and di-glycerides, lauric acids, acyicholines, caprylic acids, acylcamitines, sodium caprates and the like), chelating agents (such as EDTA, citric acid, salicylates and the like), sulfoxides (such as dimethyl sulfoxide (DMSO), decylmethyl sulfoxide and the like), and alcohols (such as ethanol, isopropanol, glycerol, propanediol and the like) also function as round window membrane penetration enhancers, (OQ407|In some embodiments, the auris acceptable penetration enhancer is a surfactant comprising an alkyl-glycoside wherein the alkyl glycoside is tetradecyl- β-D-maltoside. In some embodiments, the auris acceptable penetration enhancer is a surfactant comprising an alkyl-glycoside wherein the alkyl glycoside is dodecyl-maltoside. In certain instances, the penetration enhancing agent is a hyaluronidase. In certain instances, a hyaluronidase is a human or bovine hyaluronidase. in some instances, a hyaluronidase is a human hyaluronidase (e.g., hyaluronidase found in human sperm, PH20 (Halozyme). Hyelenex® (Baxter International, Inc.)). In some instances, a hyaluronidase is a bovine hyaluronidase (e.g., bovine testicular hyaluronidase, Amphadase® (Amphastar Pharmaceuticals),

Hvdase® (PrimaPharm, Inc). In some instances, a hyluronidase is an ovine hyaluronidase, Vitrase® (ISTA Pharmaceuticals), In certain Instances, a hyaluronidase described herein is a recombinant hyaluronidase. In some instances, a hyaluronidase described herein is a humanized recombinant hyaluronidase. In some instances, a hyaluronidase described herein is a pegylated hyaluronidase (e.g., PEGPH2Q (Halozyme)), In addition, the peptide-like penetration enhancers described in U.S. Patent Nos. 7,151.191, 6,221,367 and 5,714,167, herein incorporated by references for such disclosure, are contemplated as an additional embodiment. These penetration enhancers are amino-acid and peptide derviativ.es and enable drug absorption by passive transeeihilar drffiision without affeeting the integrity of .membranes or intercellular tight junctions.

Round window membrane Permeable Liposomes [00408] Liposomes or lipid particles may also be employed to encapsulate the antimicrobial agent formulations or compositions. Phospholipids that are gently dispersed in an aqueous medium form multilayer vesicles with areas of entrapped aqueous media separating the lipid layers. Sonicatlon. or turbulent agitation, of these multilayer veisbles results in the formation of single layer vesicles, commonly refered to as liposomes, with sizes of about 10-1000 nm. These liposomes have many advantages as antimicrobial agents or other pharmaceutical agent carriers. They are biologically inert; biodegradable, non-toxic and non-antigenic. Liposomes are formed in various sizes and with varying compositions and surface: properties. Additionally, they arc able to entrap a wide variety of agents and release the agent at the site of liposome collapse.

[00409] Suitable phospholipids for use in auris-aceeptable liposomes here are, for example, phosphatidyl cholines, ethanol amines and serines, sphingomyelins, eardiolipins, plasmalogens, phosphalidic acids and eerebrosides, in particular those which are soluble together with the antimicrobial agents herein in non-toxic, pharmaceutically acceptable organic solvents. Preferred phospholipids are, for example, phosphatidyl choline, phosphatidyl ethanoimine, phosphatidyl serine, phosphatidyl inositol, lysophosphatidyl choline, phosphatidyl glycerol and the like, and mixtures thereof especially lecithin, e.g. soya lecithin. The amount of phospholipid used in the present formulation range from about 10 to about 30%, preferably from about 15 to about 25% and in particular is about 20%.

[00410] lipophilic additives may he employed advantageously to modify selectively the characteristics of the- liposomes. Examples of such additives include bv way of example only, stearylaniine, phosphatidic acid, tocopherol, cholesterol, cholesterol hemisuccinate and lanolin extracts. The amount of lipophilic additive used range from 0.5 to 8%, preferably from 1.5 to 4% and in particular is about 2%. Generally, the ratio of the amount of .lipophilic.· additive to the amount of phospholipid ranges from about 1:8 to about 1:12 and in particular is about 1:10. Said phospholipid, lipophilic additive and the antimicrobial agent and other pharmaceutical compounds are employed in conjunction with a non-toxic, pharmaceutical!)· acceptable organic sol vent system which dissolve said ingredients. Said solvent system not only must dissolve the antimicrobial agent completely, but it also has to allow the formulation of stable single hilayered liposomes. The solvent system comprises dimethylisosorbide and tetraglycol {glyeofurol tetrahydrofurfuryl alcohol polyethylene glycol ether) in an amount of about 8 to about 30%. In said solvent system, the ratio of the amount of dimethylisosorbide to the amount of tetraglycol range from about 2:1 to about 1:3, in particular from about 1:1 to about 1:2.5 and preferably is about 1:2. The amount of tetraglycol in the final composition thus vary from 5 to 20%, in particular from 5 to 1S% and preferably is approximately 10%. Tire amount of dimethylisosorbide in the final composition tlius range from 3 to 10%, in particular from 3 to 7% and preferably is approximately 5%.

[00411]The term, "organic component" as used hereinafter refers to mixtures comprising said phospholipid, lipophilic additives and organic solvents. The antimicrobial agent may be dissolved in the organic component, or other means to maintain full activity of the agent. The amount of antimicrobial agent in the final formulation may range from 0.1 to 5.0%. in addition, other ingredients such as anti-oxidants may be added to the organic component. Examples include tocopherol, butylated hydroxyanisole, butyiated hydroxytoiuene, aseorbyl pahnitate, aseorbyl oleate and the tike.

[0()412] Liposomal formulations are alternatively prepared, for antimicrobial agents or other pharmaceutical agents that are moderately heat-resistant, by (a) heating the phospholipid and the organic solvent system to about 60-80 °C in a vessel, dissolving the active ingredient, then adding arty additional formulating agents, and stirring the mixture until complete dissolution is obtained; (b) heating the aqueous solution to 90-95 °€ in a second vessel and dissolving the preservatives therein, allowing the mixture to cool and then adding the remainder of the auxiliary formulating agents and the remainder of the water, and stirring the mixture until complete dissolution is obtained; thus preparing the aqueous component; (e) transferring the organic phase directly into the aqueous component, while homogenizing the combination with a high performance mixing apparatus, for example, a high-shear mixer; and (d) adding a viscosity enhancing agent to the resulting mixture while further homogenizing. The aqueous component is optionally placed in a suitable vessel which is equipped with:».'homogenizer and homogenization is effected by creating turbulence during the inj ection of the organic component. Any mixing means or homogenizer which exerts high shear forces on the mixture may be employed. Generally, a mixer capable of speeds from about 1,500 to 20,000 rpm, in particular from about 3,000 to about 6.000 rpm may be employed. Suitable viscosity enhancing agents for use in process step (d) are for example, xanthan gum, hydroxypropyl cellulose,,hydroxypropyh methylcellulose Dr mixtures thereof. The amount of viscosity enhancing agent depends on the nature and the concentration of the other ingredients and in genera! ranges from about 0,5 to 2,0%, or approximately 1.5%, In order to prevent degradation of the materials used during the preparation ofthe liposomal formulation, it is advantageous to purge all solutions with an inert gas such as nitrogen or argon, and to conduct all steps under an inert atmosphere. Liposomes prepared by the above described method usually contain most of the active ingredient bound in the lipid bi layer and separation ofthe liposomes from nneneapsulated material is not required, {00413] In other embodiments, the auris-acceptable formulations, including gel formulations and viscosity-enhanced formulations, further include excipients, other medicinal or pharmaceutical agents, carriers, adjuvants, such as preserving, stabilizing, wetting or emulsifying agents, solution promoters, salts, solubilizers, an antifoaming agent, an antioxidant, a dispersing agent, a welting agent, a surfactant, and combinations thereof. [00414] Suitable carriers for use in an auris-acceptable formulation described herein include, but are not limited to, any pharmaceutically acceptable solvent compatible with the targeted auris structure’s physiological environment. In other embodiments, the base is a combination of a pharmaceutically acceptable surfactant and solvent .

[004151 In some embodiments, other excipients include, sodium stearyl fumarate, diethanolamine cetyl sulfate, isostearate, polyethoxylated castor oil, nonoxyl 10, octoxynol 9, sodium Jauryl sulfate, sorbitan esters (sorbitan monolaurate, sorbitan monooleatc. sorbitan monopalmitate, sorbitan monostearate, sorbitan sesquioleate, sorbitan trioleate, sorbitan tristearate, sorbitan laurate, sorbitan oleate, sorbitan palrmtate, sorbitan stearate, sorbitan dioieate, sorbitan sesqui-isostearate, sorbitan sesquistearate, sorbitan tri-isostearate), lecithin pharmaceutical acceptable salts thereof and combinations or mixtures thereof [0041611η other embodiments, the carrier is a polysorbate. Polysorbates are nonionie surfactants of sorbitan esters. Polysorbates useful in the present disclosure inc lude, but are not limited to polysorbate 20, polysorbate 40, polysorbate 60, polysorbate 80 (Tween 80) and any combinations or mixfores thereof. In further embodiments, polysorbate 80 is utilized as the pharmaceutically acceptable carrier.

[0041711η one embodiment, water-soluble glycerin-based auris-acceptable enhanced viscosity formulations utilized in the preparation of pharmaceutical deli very vehicles comprise at least one aniimierobiai agent containing at least about 0,1% of the water-soluble glycerin compound or more* In some embodiments, the percentage of antimicrobial agent is varied between about 1 % and about 95%, between about 5% and about 80%, between about 10% and about §0% or more of the weight or volume of the total, pharmaceutical formulation. In some embodiments, the amount of the compound(s) in each therapeutically useful antimicrobial agent formulation is prepared in such a way that a suitable dosage will be obtained in any given unit dose of the compound. Factors such as solubility, bioavailability, biological half-life, route of administration, product shelf life, as well as other pharmacological considerations are contemplated herein.

[00418) If desired, the auris-aceepiable pharmaceutical gels also contain co-solvents, preservati ves, cosolvenIs, ionic strength and osmolality adjustors and other excipeints in addition to buffering agents. Suitable auris-acceptable water soluble buffering agents are alkali or alkaline earth metal carbonates, phosphates, hicarbonates, citrates, borates, acetates, succinates and the like, such as sodium phosphate, citrate, borate, acetate, bicarbonate, carbonate and tromethamine (TRIS). These agents are present in amounts sufficient to maintain the pH of the system at 7.4±0.2 and preferably, 7.4. As such, the buffering agent is as much as 5% on a weight basis of the tota l composition.

[0041Cosolvents are used to enhance antimicrobial agent solubility, however, some antimicrobial agents or other pharmaceutical compounds are insoluble. These are often suspend ed in the polymer vehicle with the aid of suitable suspending or viscosity enhancing agents.

[09420] Examples of therapeutically acceptable otic formulations:

[00421] The .formulations disclosed herein alternatively encompass an otoprotectant agent in addition to the at least one active agent and/or excipients, including but not limited to such agents as antioxidants, alpha lipoic acid, calcium, fosfomycin or iron chelators, to counteract potential ototoxic effects that may arise from the use of specific therapeutic agents or excipients, diluents or carriers.

Modes of Treatment

Dosing Methods and Schedules [00422}Drugs delivered to the inner ear have been administered systemically via oral, intravenous or intramuscular routes. However, systemic administration for pathologies local to the inner ear increases the likelihood of systemic toxicities and adverse side effects and creates a non-producti ve distribution of drug in which high levels of drug are found in die serum and correspondingly lower levels arc found at the inner ear.

[00423] Intratympanic injection of therapeutic agents is the technique of injecting a therapeutic agent behind the tympanic membrane into the middle and/or inner ear . In one embodiment, the formulations described herein are administered directly onto the round windo w membrane via translympanie injection. In another embodiment the antimicrobial agent auris-aeceptable formulations described herein are administered onto the round window membrane via a non-transtympanic approach to the inner ear. In additional embodiments, the formulation described herein is administered onto the round window membrane via a surgical approach to the round window membrane comprising modification of the crista fenestrae cochleae.

[00424] In one embodiment the delivery system is a syringe and needle apparatus that is capable of piercing the tympanic membrane and directly accessing the round window membrane or. crista fenestrae cochleae of the auris interna. In some embodiments, the needle on the syringe is 'wider than a 18 gauge needle. In another embodiment, the needle gauge is from 18 gauge to 31 gauge. In a forther'-embodiment, the needle gauge is from 25 gauge to 30 gauge. Depending upon the thickness or viscosity of the antimicrobial agent compositions or formulations, die gauge level of the syringe or hypodermic needle may be varied accordingly, in another embodiment, the internal diameter of the needle can be increased by reducing the wall thickness of the needle (commonl y refered as thi n wall or extra thin wall needles) to reduce the possiblily of needle clogging while maintaining an adequate needle gauge.

[00425] In. another embodiment, the needle is a hypodermic needle used for instant delivery of the gel formulation, The hypodermic needle may be a single use needle or a disposable needle. In some embodiments, a syringe may be used for delivery of the phannaceutlcally acceptable gel-based antimicrobial agent-containing compositions as disclosed herein wherein the syringe has a press-fit (Luer) or twist-on (Luer-lock) fitting. In one embodiment, the syringe is a hypodermic syringe. In another embodiment, the syringe is made of plastic or glass. In yet another embodiment, the hypodermic syringe is a single use syringe. In a further embodiment, the glass swinge is capable of being sterilized. In yet a further embodiment, the sterilization occurs through an autoclave, In another embodiment, the syringe comprises a cylindrical syringe body wherein the gel formulation is stored before use. In other embodiments,; the syringe comprises a cylindrical syringe body' wherein the antimicrobial agent pharmaceutically acceptable gel-based compositions as disclosed herein is stored before use which conveniently allows for mixing-with a suitable pharmaceutically acceptable buffer, in other embodiments, the syringe may contain other excipients, stabilizers, suspending agents, diluents or a combination thereof to stabilize or otherwise stably store the antimicrobial agent or other pharmaceutical compounds contained therein.

[00426] In some embodiments, the syringe comprises a cylindrical syringe body wherein the body is compartmentalized in that each compartment is able to store at least one component of the auris-aeceptable antimicrobial agent gel formulation. In a further embodiment, the syringe having a compartmentalized body allows for mixing of the components prior to injection into the amis media or auris interna. In other embodiments, the delivery system comprises multiple syringes, each syringe of the multiple syringes contains at least one component of the gel formulation such that each component is pre-mixed prior to injection or is mixed subsequent to injection. In a further embodiment, the syringes disclosed herein comprise at least one reservoir wherein the at least one reservoir comprises an antimicrobial agent, or a pharmaceutically acceptable buffer, -or 'a viscosity enhancing agent, such as a gelling agent or a combination thereof. Commercially avai lable injection devices are optionally employed in their simplest form as ready-io-use plastic syringes with a syringe barrel, needle assembly with a needle, plunger with a plunger rod, and holding flange, to perform an intratympanic injection.

[00427] In some embodiments, the delivery device is an apparatus designed for administration of therapeutic agents to the middle and/or inner ear. By way of example only: GYRUS .Medical GmbJi offers micro-otoscopes for visualization of and drug delivery" to the round window niche; Arenberg has described a medical treatment device to deliver fluids to inner ear structures in U.S. Patent Nos. 5,421,818; 5,474,529; and 5,476,446, each of which is incorporated by reference herein for such disclosure. U.S. Patent Application No. 08/874,208, which is incorporated herein hv reference for such disclosure, describes a surgical method for implanting a fluid transfer conduit to deliver therapeutic agents to the inner ear, U.S. Patent Application Publication 2007/0167918, which is incorporated herein by reference for such disclosure, further describes a combined otic aspirator and medication dispenser for intratympanic fluid sampling and medicament application, [©0428] The auris-aeeeptable compositions or formulations containing the antimicrobial agent eompound(s) described herein are administered for prophylactic and/or therapeutic treatments. In therapeutic applications, the antimicrobial agent compositions are administered to a patient already suffering from an autoimmune disease, condition or disorder, in an amount sufficient to cure or at least partially arrest the symptoms of the disease, disorder or condition. Amounts effective for this use will depend on the severity and course of the disease, disorder or condition, previous therapy, the patient's health status and response to the drugs, and the judgment of foe treating physician,

Frequency" of Administration [00429] in some embodiments, a compositon disclosed herein is administered to an individual in need thereof once. In some embodiments, a compositon disclosed herein is administered to an indi vidual in need thereof more than once. In some embodiments, a first administration of a composition disclosed herein is followed by a second administration of a composition di sclosed herein. In some embodiments, a first administration of a composition disclosed herein is followed by a second and third administration of a.composition disclosed herein,. In some embodiments, a first admini stration of a composition disclosed herein is followed by a second, third, and fourth administration of a composition disclosed herein , in some embodiments, a First administration of a composition disclosed herein is followed by a second, third, fourth, and fifth administration of a composition disclosed herein. In some embodiments, a first administration of a composition discl osed 'herein is followed by a drug holiday, [00430} The number of times a composition is administered to an individual in need thereof depends on the discretion of a medical professional, the disorder, the severity of the disorder, and the individuals's response to the formulation, in some embodiments, a composition disclosed herein is administered once to an individual in need thereof with a mild acute condition. In some embodiements, a composition disclosed herein is administered more than once to an individual in need thereof with a moderate or severe acute condition. In the case wherein the patient’s condition does not improve, upon the doctor’s discretion the administration of an antimicrobial may be administered chronically, that is, for an extended period of time, including throughout the duration of the patient’s life in order to ameliorate or otherwise control or limit the symptoms of the patient’s disease or condition, [00431 jin the case wherein the patient’s condition does not improve, upon the doctor’s discretion the administration of the antimicrobial agent compounds may be administered chronically, that is, for an extended period of time, including throughout the duration of the patient’s life in order to ameliorate or otherwise control or limit the symptoms of the patient’s disease or condition, |00432JIn the case wherein the patient’s status does improve, upon the doctors discretion the administration of the antimicrobial agent compounds may be given continuously; alternatively, the dose of drug being administered may be temporarily reduced or temporarily suspended for a certain length of time (i.e., a “drug holiday”). The length of the drug holiday varies between 2 days and 1 year, including by way of example only, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 10 days, 12 days, 15 days, 20 days, 28 days, 35 days, 50 days, 70 days, 100 days, 120 days, 150 days, 180 days, 200 days, 250 days, 280 days, 300 days, 320 days, 350 days, and 365 days. The dose reduction during a drug holiday maybe from 10%-100%, including by way of example only 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, and 100%, [00433} Once improvement of the patient's otic conditions has occurred, a maintenance antimicrobial agent dose is administered if necessary. Subsequently, the dosage or the frequency of administration, or both, is optionally reduced, as a function of the symptoms, to a level at which the improved disease, disorder or condition is retained. In certain embodiments, patients require intermittent treatment-on-a-long-term basis upon any recurrence of symptoms. (00434] lire amount of antimicrobial agent that will correspond to such an amount will vary depending upon factors such as the particular compound, disease condition and its severity, according to the particular circumstances surrounding the case, including, e.g., the specific antimicrobial agent being administered, the route of administration, the autoimmune condition being treated, the target area being treated, and tire subject or host being treated.

In general, however, doses employed for adult human treatment will typically be in the range of 0.02-50 mg per administration, preferably 1-15 mg per administration. The desired dose is presented in a single dose or as divided doses administered 'simultaneously (or over a short period of time) or at appropri ate interval s. (004351 In some embodiments, the initial administration is a particular antimicrobial agent and the subsequent administration a different formulation or antimicrobial agent. Pharmacokinetics of Controlled Release Formulations (00436] in one embodiment, the .formulations disclosed herein additionally provides an immediate release of an antimicrobial agent from the composition, or within 1 minute, or within 5 minutes, or within 10 minutes, or within 15 minutes, or within 30 minutes, or within 60 minutes or within 90 minutes. In other embodiments, a therapeutically effective amount of at least one antimicrobial agent is released from the composition immediately, or within 1 minute, or within 5 minutes:, or within 10 minutes, or wi thin 15 minutes, or within. 30 minutes, or within 60 minutes or within 90 minutes. In certain embodiments the composition comprises an auris-pharmaceutically acceptable gel formulation providing immediate release of at least one antimicrobial agent, Additional embodiments of the formulation may also include an agent that enhances the viscosity of the formulations included herein. (00437( In other or further embodiments, the formulation provides an extended release formulation of at least one antimicrobial agent. In certain embodiments, diffusion of at least one antimicrobial agent from the formulation occurs for a time period exceeding 5 minutes, or 15 minutes, or 30 minutes, or 1 hour, or 4 hours, or 6 hours, or 12 hours, or 18 hours, or 1 day, or 2 days, or 3 days, or 4 days, or 5 days, or 6 days, or 7 days, or 10 days, or 12 days, or 14 days, or 18 days, or 21 days, or 25 days, or 30 days, or 45 days, or 2 months or 3 months or 4 months or 5 months or 6 months or 9 months or 1 year. In other embodiments, a therapeutically effective amount of at least one antimicrobial agent is released from the formulation for a time period exceeding 5 minutes, or 15 minutes, or 30 minutes, or 1 hour, or 4 hours, or 6 hours, or 12 hours, or 18 hours, or 1 day, or 2 days, or 3 days, or 4 days, or 5 days, or 6 days, or 7 days, or 10 days, or 12 days, or 14 days, or 18 days, or 21 days, or 25 days, or 30 days, or 45 days, or2 months or 3 months or 4 months or 5 months or 6 months or 9 months or 1 year, [00438'j ln other embodiments, the formulation provides both an immediate release and an extended release formulation of an antimicrobial agent. In yet other embodiments, the formulation contains a 0.25:1 ratio, or a 0,5:1 ratio, or a 1:1 ratio, or a 1:2 ratio, ora 1:3, or a 1:4 ratio, or a 1:5 ratio, or a 1:7 ratio, or a 1:10 ratio, or a 1: 15 ratio, or a 1:20 ratio of immediate release and extended release formulations. In a further embodiment: the formulation provides an immediate release of a first antimicrobial agent and .an extended release of a second antimicrobial agent or other therapeutic agent. In yet other embodiments, the formulation provides an immediate release and extended release formulation of at least one antimicrobial agent, and at least one therapeutic agent. In some embodiments, the formulation provides a 0.25:1 ratio, or a 0.5:1 ratio, or a 1:1 ratio, or a 1:2 ratio, or a 1:3, or a 1:4 ratio, or a 1:5 ratio, or a 1:7 ratio, or a 1:10 ratio, or a 1: 15 ratio, or a 1:20 ratio of immediate release and extended release formulations of a first antimicrobial agent and second therapeutic agent, respectively, {0O439|In a specific embodiment the formulation provides-a therapeutically effective amount of at least one antimicrobial agent at the site of disease with essentially no systemic exposure. In an additional embodiment the formulation provides a therapeutical1y effeciive amount of at least one .antimicrobial agent at the site of disease with essentially no detectable systemic exposure, in other embodiments, the formulation provides a therapeutically effective amount of at least one antimicrobial agent at the site of disease with little or no detectable detectable systemic exposure. f0044ftj The combination of immediate release, delayed release and/or extended release antimicrobial agent compositions or formulations may be combined with other pharmaceutical agents, as well as the excipients» diluents, stabilizers, tonicity agents and other components disclosed herein. As such, depending upon the antimicrobial agent used, the thickness or viscosity desired, or the mode of delivery chosen, alternati ve aspects of the embodiments disclosed herein are combined with the immediate release, delayed release and/or extended release embodiments accordingly.

[00441] In certain embodiments, the pharmacokinetics of the antimicrobial agent formulations described herein are determined by injecting the formulation on or near the round window membrane of a test animal (including by way of example, a guinea pig or a chinchilla), At a determined period of time (e.g„ 6 hours, 12 hours, 1 day, 2 days, 3 days, 4 days, 5 days,, 6 days, and 7 days for testing the pharmacokinetics of a Formulation over a 1 week period), the test animal is euthanized and a 5 mL sample of the perilymph fluid is tested. The inner'par removed and tested for the presence of the antimicrobial agent. As needed, the level of antimicrobial agent is measured in other organs. In addition, the systemic level of the antimicrobial agent is measured by withdrawing a blood sample from the test animal. In order to determine whether the formulation impedes hearing, the hearing of the test animal is optionally tested, ]00442] Alternatively , an inner ear is provided (as removed from a test animal) and the migration of the antimicrobial agent is measured. As yet another alternative», an in vitro model of a round window membrane is provided and the migration of the antimicrobial agent is measured.

Kits/Articles of Manufacture [00443] The disclosure also provides kits for preventing, treating or ameliorating the symptoms of a disease or disorder in a mammal. Such kits generally will comprise one or more of the antimicrobial agent eontrolled-release compositions or devices disclosed herein, and instructions for Using the kit. The disclosure also contemplates the use of one or more of the antimicrobial agent controlfed-release compositions, in the manufacture of medicaments for treating, abating, reducing, or ameliorating the symptoms of a disease, dysfunction, or disorder in a mammal, such as a human that has, is suspected of having, or at risk for developing an inner ear disorder, [00444] In some embodiments, kits include a carrier, package, or container that is compartmentalized to receive one or more containers such as vials, tubes, and the like, each of the containers) including one of the separate elements to be used in a method described herein. Suitable containers include, for example, bottles, vials, syringes, and test tubes. In other embodiments, the containers are formed from a variety of materials such as glass or plastic.

[00445} The articles of manufacture provided herein contain packaging materials. Packaging materials for use in packaging pharmaceutical products are al so presented herein. See, e,g.s U.S, Patent Nos, 5.323,907, 5,052,558 and 5,033,252. Examples of pharmaceutical packaging materials include, but are not limited to, blister packs, bottles, tubes, inhalers, pumps, bags, vials, containers, syringes, bottles, and any packaging material suitable for a selected formulation and intended mode of administration and treatment. A wide array of antimicrobial agent formulations compositions provided herein are contemplated as are a variety of treatments for any disease, disorder, or condition that would benefit-by "controlled release administration of an antimicrobial agent to the inner ear, [00446} In some embodiments, a kit includes one or more additional containers, each with one or more of various materials (such as reagents, optionally in concentrated form, and/or devices) desirable from a commercial and user standpoint for use of a formulation described herein. Non-limiting examples of such materials include, but not limited to, buffers, diluents, filters, needles, syringes; carrier, package, container, vial and/or tube labels listing contents and/or instructions for use and package inserts with instructions for use. A set of instructions is optionally Included. In a further embodiment, a label is on or associated with the container. In yet a further embodiment, a label is on a container when letters, numbers or other characters forming the label are attached, molded or etched into the container itself; a label is associated with a container when it is present within a receptacle or carrier that also holds the container, e.g., as a package insert. In other embodiments a label is used to indicate that the contents are to be used for a specific therapeutic application. In vet another embodiment, a label also indicates directions tor use of the contents, such as in the methods described herein.

[00447} In certain embodiments, the pharmaceutical compositions are presented in a pack or dispenser device which contains one or more unit dosage forms .containing a compound provided herein. In another embodiment, the pack for example contains metal or plastic foil, such as a blister pack. In a further embodiment, the pack or dispenser device is accompanied by instructions for administration. In yet a further embodiment, the pack or dispenser is also accompanied with a notice associated with the container in form prescribed by a governmental agency regulating the manufacture, use, or sale of pharmaceuticals, which notice is reflective of approval by the agency of the form of the drug for human or veterinary administration. In another embodiment, such notice, for example, is the labeling approved by the U.S. Food and Drug -Administration for prescription drugs, or the approved product insert. In yet another embodiment, compositions containing a compound provided herein formulated in a compatible pharmaceutical carrier are also prepared, placed in an appropriate container, and labeled for treatment of an indicated condition,

EXAMPLES

Example 1 — Preparation of an Amoxicillin Thermoreversible Gel Formulation

JO0448] A 10-g batch of gel formulation containing 05% of the antimicrobial agent amoxicillin is prepared by suspending 1.75 g of Poloxamer 407 (BASF Corp.) in 5.00 g of TRIS 11(. I buffer (0.1 M) and the components are mixed under agitation overnight at 4 °C to ensure complete dissolution. The hydroxypropyl methylcellulose (150.0 mg), methylparaben (10 nag) and additional TRIS HCl buffer (0,1 M) (3.04 g) are added and further stirring allowed until complete dissolution is observed. Amoxicillin (50 mg) is added and mixed in order to solubilize. The mixture is maintained below room temperature until use.

Example 2 - Preparation of a Neomycin Mucoadhesive, Thermoreverstble Gel Formulation Containing an Otoprotectant

[00449] A 10-g batch of a mueoadhesive, gel formulation containing 0.6% of the antimicrobial agent neomycin is prepared by suspending 20.0 mg of Carbopol 934P and 1.80 g of Poloxamer 407 {BASF Corp.) in 5,00 g of TR1S HC1 buffer ¢0.1 M) and the components are mixed under agitation overnight at 4 °C to ensure complete dissolution. The hydroxypropyl methylcellulose (150.0 mg), methylpaiahen (10 mg) and additional TRIS HO buffer (0,1 M) (2,91 g) are added and further stirring allowed until complete dissolution is observed, The neomycin (60 mg) and deferoxamine (50 mg) are added and mixed in order to solubilize. The mixture is maintained below room temperature until use. Example 3 — Preparation of a Benzathine penicillin G Mucoadhesive-hased Formulation

[00450] The cream-type formulation is first prepared by gently mixing benzathine penicillin G with an organic solvent, A second system is prepared by mixing paraffin oil, trihydroxystearate and cetyl dimethicon copolyol with warming to 60 °C. Upon cooling to room temperature, the lipid system is mixed with the aqueous phase for 30 minutes. Example 4 --Preparation ofaGiMicMoyk

Formulation

{00451 ] The Carbopol 934P and Poloxamer 407 (BASF Corp.) are first suspended in the TRIS HC1 buffer (0.1 M) and the. components are mixed under agitation overnight at 4 °G to ensure complete dissolution. The methylparaben is added and further stirring .allowed until complete dissolution is observed. Ganciclovir sodium is mixed in while maintaining stirring to produce a 2.0% ganciclovir mucoadhesive. thermoreversibie gel formulation. The mixture is maintained below room temperat ure until use.

Example 5 - Preparation of a Gentamicin Gel Formulation

[00452.] A 5 ml solution of acetic acid is titrated to a pH of about 4.0, T'hechitosan is added to achieve a pH of about 5,5 The gentamicin is then dissolved in the chitosan solution. This solution is sterilized by filtration. A 5 ml aqueous solution of glycerophosphate disodium is also prepared and sterilized. Hie two solutions arc mixed and within 2 h at 37° C, the desired gel is formed. (004531 Viscosity determinations of the pharmaceutical compositions described herein are performed at room temperature and 37 °C and are made using a Brookfield (spindle and cup) viscometer at' 20 rpm.

Example 6 -- Controlled/lmmediate Release Antimicrobial Formulation

1

I

I 100454] PL A (poiy(L-laetlde)) mierospheres comprising benzathine penicil Lin G are prepared by adding sufficient PLA to 100 mL dichloromethane to produce a 3%-wf/vol. solution. 1.29 g benzathine penicillin G is added to the solution with mixing. The solution is then added dropwise to 2 L distilled water containing 0.5% wt/vol polytyinyi alcohol) with stirring to produce an oil/water emulsion. Stirring is continued tor a sufficient period to allow eva poration of the dichloromethane and the formation of solid microspheres. Microspheres are filtered, washed with distilled water, and dried until no weight' loss is observed. (00455] line immediate release portion of the formulation is prepared by generating a 2% methylcellulose solution in a water/propylene glyeoi/glycerin solvent system under stirring. Benzathine penicillin G is added to the solution while stirring is continued to yield a 1% benzathine penicillin G low-viscosity gel. The appropriate amount of microspheres comprising benzaihine penicillin G is then mixed with the low-viscosity gel to yield a combination controlied/immediate release benzathine penicillin G otic formulation.

Example 7 - Preparation of a Thermoreversible Gel Ciprofloxacin Composition comprising micronized ciprofloxacin powder

[60456] A 30-g batch of gel formulation containing 2.0% micronized ciprofloxacin Is prepared. Micronized ciprofloxacin, 13.8 mg of sodium phosphate dibasic dihydrate USP (Fisher Scientific.) + 3.1 mg of sodium phosphate monobasic monohydrate USP (Fisher Scientific.) + 74 mg of sodium chloride USP (Fisher Scientific.) is dissolved with 8.2g of steri le filtered DI water and the pH is adjusted to 7.4 with 1 M NaOH. The buffer solution is chilled down and 1.6 g of potoxamer 407 (BASF Corp., containing approximately 100 ppm of BHT) is sprinkled into the chilled PBS solution while mixing, solution is mixed until all the poloxamer Is dissolved. The poloxamer is sterile filtered using a 33mm PVDF 0,22pm sterile syringe filter (Millipore Corp.) and delivered to 2 mL sterile glass vials (Wheaton) in an aseptic environment, the vials are closed with sterile butyl rubber stoppers (Kimble) and crimped sealed with 13 mm Al seals (Kimble), 20 mg of micronized ciprofloxacin is placed in separate clean depyrogenated. vials, the vials are closed with sterile butyl rubber stoppers (Kimble) and crimped scaled with 13 mm Al seals (Kimble), vials are dry heat sterilized (Fisher Scientific isotemp oven) for 7 hours at J'4.0°€. Before administration for the experiments described herein, 1 rnL of the cold poloxamer solution is delivered to a vial containing 20 mg of sterile micronized ciprofloxacin using a 21G needle (Bectors Dickinson) attached to a 1 m,L sterile syringe (Becton Dickinson), suspension mixed well by shaking to ensure homogeneity of the suspension. The suspension is then withdrawn with the 21G syinge and the needle is switched to a 27 G needle for administration. 100457] Formulations comprising gentamicin, azithromycin and micronized dexamethasone are prepared using the-above procedure.

Example 8 ~ Preparation of a Themtoreversible Gel Composition comprising micronized ciprofloxacin powder and micronized dexamethasone powder

j ............... ‘-------——— j i ! i i

]0®458{A 10-g batch of gel formulation containing 2.0% (micronized ciprofloxacin and micronized dexamethasone) is prepared. Micronized ciprofloxacin, micronized dexamethasone, 13,8 mg of sodium phosphate dibasic dihydrate USP (Fisher Scientific.) T

3,1 mg of sodium phosphate monobasic monohydrate IJSP (fisher Scientific.) + 74 mg of sodium chloride USP (Fisher Scientific.) is dissolved with 8.2 g of sterile filtered DI water and the pH is adjusted to 7.4 with 1 M NaOI L The buffer solution is chilled down and 1.6 g of poloxamer 407 (BASF Corp., containing approximately 100 ppm of BHT) is sprinkled into the chilled PBS solution while mixing, solution is mixed until all the poloxamer is dissolved. The poloxamer is sterile filtered using a 33mm PVDF 0.22μηι sterile syringe filter (Millipore Corp.) and delivered to 2 ml. sterile glass vials (Wheaton) in an aseptic environment, the vials are closed with sterile butyl rubber stoppers (Kimble) and. crimped sealed with 13'nun Al seals (Kimble). 20 mg of micronized ciprofloxacin and micronized dexamethasone powders is placed in separate clean depyrogenated vials, the vials are closed with sterile butyl rubber stoppers (Kimble) and crimped sealed with 13 mm Al Seals (Kimble), vials are dry heat sterilized (Fisher Scientific Isotemp oven) For 7 hours at :140°C·.. Before administration for the experiments described herein, 1 mL of the cold poloxamer solution is delivered to a vial containing 20 mg of sterile micronized ciprofloxacin and micronized dexamethasone using a 21G needle (Becton Dickinson) attached to a 1 mL sterile syringe (Becton Di ckinson), suspension mixed well by shaking to ensure homogeneity of the suspension. The suspension is then withdrawn with the 21G syinge and the needle is switched to a 27 G needle for administration, I

Example 9 Effect of pH on degradation products for autoclaved 17% poloxamer 407NF/ 2¾ otic agent in PBS buffer {00459} A stock solution of a 17% poloxamer 407/ 2% otic agent is prepared by dissolving 351.4 mg of sodium chloride (Fisher Scientific), 302.1 mg of sodium phosphate dibasic anhydrous (Fisher Scientific), 122.1 mg of sodium phosphate monobasic anhydrous (Fisher Scientific) and an appropriate amount of an otic agent with 79.3 g of sterile filtered Dl water. The solution is cooled down in a ice chilled water bath and then 17.05 g of poloxamer 4Q7NF (SPECTRUM CHEMICALS) is sprinkled into the cold solution while mixing. Ί/he mixture is fiirther mixed until the poloxamer is completely dissolved. The pH for this solution is measured. (00460} 17% poloxamer 407/ 2% otic agent in PBS pH of 5.3. Take an aliquot (approximately 30mL) of the above solution and adjust the pH to 5.3 by the addition of 1 M HC1. (00461} 17% poloxamer 407/ 2% otic agent in PBS pH of 8.0. Take an aliquot (approximately 30mL) of the above stock solution and adjust the pH to 8.0 by the addition of 1 MNaOH.

[00462} A PBS buffer (pH 7.3) is prepared by dissolving 805.5 mg of sodium chloride (Fisher Scientific), 606 mg of sodium phosphate dibasic anhydrous (Fisher Scientific), 247 mg of sodium, phosphate monobasic anhydrous (Fisher Scientific), then QS to 200g with sterile filtered DI water.

[00463] A 2% solution of an otic agent in PBS pH 7.3 is prepared by dissolving an appropriate amount of the otic agent in the PBS buffer and QS to 10 g with PBS buffer.

[00464] One ml samples are individually placed in 3 ml. screw cap glass vials (with rubber lining) and closed tightly. The vials are placed in a Market Forge-sterihriatie autoclave (settings, slow liquids) and sterilized at 250QF for 15 minutes. After die autoclave the samples are left to cool down to room temperature and then placed in refrigerator. The samples are homogenized by mixing the vials while cold.

[0Q465] Appearance (e.g., discoloration .and/or precipitation) is observed and recorded. HPLC analysis is performed using an Agilent 1200 equipped with a Luna Cl8(2) 3pm. lOOA, 250x4.6 ttiiti column) using a 30-80 acetonitrile gradient (l-10min) of (water -acetonitrile mixture containing 0.05%TFA), for a total run of 15 minutes. Samples are diluted by taking 3DpL of sample and dissolved with 1.5mL of a 1:1 acetonitrile water mixture. Purity of the o tic agent in the autoclaved samples is recorded.

[00466] .Formulations comprising gentamicin, ciprofloxacih and mieronized dexamethasone, prepared according to the procedure above, are tested using the above procedure to determine the effect of pH on degradation during the autoclaving step.

Example 10 Effect of autocl aving on the release profile and viscosity of a 17% poloxamer 407N F/ 2% otic agent In PBS.

[00467] An aliquot of a sample (autoclaved and not autoclaved) is evaluated For release profile and viscosity measurement to evaluate the impact of heat sterilization on the properties of the gel, [00468] Dissolution is performed at 37°C in snapwells (6,5 mm diameter polycarbonate membrane with a pore size of 0,4 pm). 0.2 mL of gel is placed into snapwell and left to harden, then 0.5 mL is placed into reservoir and shaken using a Labline orbit shaker at 70 rpm. Samples are taken every hour (0.1 mL withdrawn and replace with warm buffer). Samples are analyzed for poloxamer concentration, by UV at 624 nm using the cobalt thiocyanate method, against an external calibration standard curve. In brief, 20p.L of the sample is mixed with 1980pL of a I5mM cobalt thiocyanate solution and absorbance measured at 625 nm, using a Evolution 160 UV/Vis spectrophotometer (Thermo Scientific).

[00469] The. released otic agent is fitted to the Korsmeyer-Peppas equation

where Q is the amount of otic agent released at time /, Q„ is the overall released amount of otic agent, k is a release constant of the nth order, n is a dimensionless number related to the dissolution mechanism and b is the axis intercept, characterizing the initial burst release mechanism wherein η·~1 characterizes an erosion controlled meehanism. Tire mean dissolution time (MDT) is the sum of different periods of time the drug molecules stay in the matrix before release, divided by the total number of molecules and is calculated by:

(004701 Viscosity measurements are performed using a Brookfield viscometer RVDV-II+P with a CPE-51 spindle rotated at 0.08 rpm (shear rate of 0.31 s'1), equipped with a water jacketed temperature control unit (temperature ramped from 15-34°C at 1.6 °C/min). Tgel is defined as the inflection point of the curve where the increase in viscosity occurs due to the sol-gel transition.

[00471} Formulations comprising gentamicin, ciprofloxacin and micronized dcxamethasone. prepared according to tine procedures described above, are tested using the procedure described above to determine Tgel.

Example 11 Effect of addition of a secondary polymer on the degradation products and viscosity of a formulation containing 2% otic agent and 17% poloxamer 407NP after heat sterilization (autoclaving). (001721 Solution A. A solution of pH 7.0 comprising sodium carboxymethyleellulose (CMC) in PBS buffer is prepared by dissolving 178.35 mg of sodium chloride (Fisher Scientific), 300.5 mg of sodium phosphate dibasic anhydrous (Fisher Scientific), 126.6 mg of sodium phosphate monobasic anhydrous (Fisher Scientific) dissolved with 78.4 of sterile filtered DI water, then 1 g of Blanose 7M65 CMC (Hercules, viscosity of 5450cP (1¾ 2%) is sprinkled into the buffer solution and heated to aid dissolution, and the solution is then cooled down. (00473( A solution of pH 7.0 comprising 1:7% poloxamer 407NF/1% CMC/2% otic agent in PBS buffer is made by cooling down 8.1-g of solution A in a ice chilled water bath and then adding an appropriate amount of an otic agent followed by mixing. 1,74g of poloxamer 407NF (Spectrum Chemicals ) is sprinkled into the cold solution while mixing. The mixture is further mixed until all the poloxamer is completely dissolved. (O0474| Two mL of the above sample is placed in a 3mL. screw cap glass vial (with rubber lining) and closed tightly. The vial is placed in a Market Forge-sterilmatie autoclave (sellings, slow liquids) and sterilized at 250°F for 25 minutes. After autoclaving the sample is left to cool down to room temperature and then placed in refrigerator. The sample is homogenized by mixing while the vials are cold.

[0047$]Precipitation or discoloration are observed after autoclaving. HPI.C analysis is performed using an Agilent 1200 equipped with a Luna €18(2) 3pm. 100A. 250x4.6 mm column) using a 30-80 acetonitrile gradient (1 -1.0mm) of (water -acetonitri le mixture containing 0.05%TFA), for a total run of 15 minutes. Samples are diluted by taking 30pL of sample and dissolving with 1,5mL of a 1:1 acetonitrile water mixture. Purity of the otic agent in the autoclaved samples is recorded.

[00476] Viscosity measurements are performed using a Brookfield viscometer ilVDV-ll+P with a CPE-51 spindle totaled at 0.08 rpm (shear rate of 0.31 s"1), equipped with a water jacketed temperature control unit (temperature ramped from 15-34¾ at 1.6 0C/min). Tgel is defined as the inflection; point of the curve where the increase in vi scosity occurs due to the sol-gel transition.

[00477] Dissolution is performed at 3TC for the non-autoclaved sample in snapweiis (6.5 mm di ameter polycarbonate membrane with a pore size of 0.4 pm), 0.2 mL of gel is placed into snapwelt and left to harden, then 0.5 mL is placed into reservoir and shaken using a Labline orbit shaker at 70 rpm. Samples are taken every hour (0.1 mL withdrawn and replaced with warm buffer). Samples are analyzed tor otic agent concentration by UV at 245 nm, against an external calibration, standard curve.

[00478] Formulations comprising gentamicin, ciprofloxacin and micronized dexamethasone, are tested using the above procedure to determine the effect addition of a secondary polymer on the degradation products and viscosity of a formulation containing 2% otic agent and 17% poloxamer 407NP after heat sterilization (autoclaving), [00479| Example 12 Effect of buffer type on the degradation products for formulations containing poloxamer 407NF after heat sterilization (autoclaving).

[00480] A IRIS buffer is made by dissolving 377.8 mg of sodium chloride (Fisher Scientific), and 602.9' mg of Tromethamine (Sigma Chemical Co.) then QS to lOQg with sterile filtered D! water, pH is adjusted to 7.4 with LM HC1.

Stock solution containing 25% Poloxamer 407 solution in TRIS buffer: [00481] Weigh. 45 g of IRIS buffer, chill in an ice chilled bath then sprinkle into the buffer, while mixing, 15 g of poloxamer 407 NF (Spectrum Chemicals). The mixture is further mixed until all the poloxamer is completely dissolved.

[00482] A series of formulations is prepared with the above stock solution, An appropriate amount of Otic agent (or salt or prodrug thereof) and/or otic agent as micronized/coated/liposomal particles (or salt or prodrug thereof) is used for all experiments.

Stock solution (pH 7.3) containing 25% Poloxamer 407 solution in PBS buffer: [00483] PBS buffer described above is used. Dissolve 704mg of sodium chloride (Fisher Scientific), 601 ,.2 mg of sodium phosphate dibasic anhydrous (Fisher Scientific), 242.7 mg of sodium phosphate monobasic anhydrous (Fisher Scientific) with 140.4 g of sterile filtered DI water. The solution is cooled down in an ice chillexi water bath and then 50g of poloxamer 407NF (SPECTRUM CHEMICALS) is sprinkled into the cold solution while mixing. The mixture is further mixed until the poloxamer is completely dissolved. [O0484jA.seri.es of formulations is prepared with the above stock solution. An appropriate amount of otic agent (or salt or prodr tig thereof) and/or otic agent as micronized/coated/liposomal particles (or salt or prodrug thereof) is used for all experiments.

[00485] Tables 2 and 1 list samples prepared using the procedures described above. An appropriate amount of otic agent is added to each sample to provide a final concentration of 2% otic agent in the sample.

Table 2. Preparation of samples containing THIS buffer

Table 3. Preparation of samples containing PBS buffer (pH of 7.3)

|00486j One mL samples are individually placed in 3mL screw cap glass vials (with rubber lining) and closed tightly. The vials are placed in a Market Forge-steriltnaiic autoclave (setting* slow' liquids) and sterilized at 250°F for 2$ minutes. Alter the autoclaving the samples are left to cool down to room temperature. 1'he vials are placed in the refrigerator and mixed while cold to homogenize the samples.

[00487] HPLC analysis is performed using an Agilent 1200 equipped with a Luna G18(2) 3μηρ lOOA, 250x4.6 mm column) using a 30-80 acetonitrile gradient (1-l.Omin) of (water -acetonitrile mixture containing 0.05%TFA), for a total run of 15 minutes. Samples are diluted by taking 30pL of sample and dissolving with 1.5mL of a 1:1 acetonitrile water mixture. Purity of the otic agent in the autoclaved samples is recorded. The stability of formulations in I RIS and PBS buffers is compared. )88488) Viscosity measurements are performed using a Brookfield viscometer RVDV-H+P with a CPE-51 spindle rotated at 0.08 rpm (shear rate of 0.31 s'1), equipped with a water jacketed temperature control unit (temperature ramped from 15-34°C at 1.6 °G/min). Tgel is defined as the inflection point of the curve where the increase in viscosity occurs due to the sol-gel transition. Only formulations that show no change after autoclaving are analyzed. (80489)Formulations comprising gentamicin, ciprofloxacin aid micronized dexamethasone, are tested using the above procedure to determine file effect addition of a secondary polymer on the degradation products and viscosity of a formulation containing 2% otic agent and 17% poloxamer 407NF after heat sterilization (autoclaving). Stability of formulations containing micronized otic agent is compared to non-micronized otic agent formulation counterparts.

Example .13: Pulsed release otic formulations {00490} A combination of ciprofloxacin and ciprofloxacin hydrochloride (ratio of 1*1) is used to prepare a pulsed release otic agent formulation using the procedures described herein. 20% of the delivered dose of ciprofloxacin is solubilized in a 17% poloxamer solution of example 9 with the aid of beta-cyclodextrins. The remaining 80% of the otic agent is then added to the mixture and the final formulation is prepared using any procedure described herein. (004911 Pulsed release formulations comprising gentamicin, azithromycin arid micronized dexamethasone, prepared according to the procedures and examples described herein, are tested using procedures described herein to determine pulse release profiles.

Example 14: Preparation of a 17% poloxamer 407/2% otic agent/78 pnm Evans blue in PBS [00492J A Stock solution of Evans Blue (5.9mg/mL) in PBS buffer is prepared by dissolving 5.9 mg of Evans Blue (Sigma Chemical Co) with 1 mL of PBS buffer (from example 9). [00493} A Stock solution containing 25% Poloxamer 407 solution in PBS buffer is used in this study. An appropriate amount of an otic agent is added to the stock solution to prepare formulations comprising 2% of an otic agent (Table 4).

Table 4. Preparation of poloxamer 407 samples containing Evans Blue

[00494} Formulations comprising gentamicin, ciprofloxacin and micronized dexamethasone, are prepared according to the procedures described above and ate sterile filtered through 0.22 pm PVDF syringe filters (Millipore corporation), and autoclaved.

[00495] The above formulations are dosed to guinea pigs in the middle ear by procedures described herein and the ability of formulati ons to gel upon contact and the location of the gel is identified after dosing and at 24 hours after dosing.

Example 15: Terminal sterilization of poloxamer 407 formulations with and without a visualization dye.

[00496117% i>oloxamcr407/ 2% otic agent/ in phosphate buffer, pH 7.3: Dissolve 709mg of sodium chloride (Fisher Scientific). 742 mg of sodium phosphate dibasic dehydrate USP (Fisher Scientific), 251.1 mg of sodium: phosphate monobasic monohydrate DSP (Fisher Scientificfand an appropriate amount of an otic agent witlx 158.1 g of sterile filtered D1 water. The solutionis cooled down in an ice chilled water bath and then 34.13g of poloxamer 407NF (Spectrum chemicals) is sprinkled into the cold solution whi le mixing. 1'he mixture is further mixed until tlie poloxamer is completely dissolved, [00497] 17% noloxamer407/ 2% otic agent/ 59pmn Evans blue in phosphate buffer: Take two ml, of the 17% poloxamer407/ 2% otic agent/ in phosphate buffer solution and add 2 mL of a 5.9 mg/mL Evans blue (Sigma-Aldrich chemical Co) solu tion in PBS buffer. 109498125% ooloxaincr407/ 2% otic agent/ in phosphate buffer: Dissolve 330.5mg of sodium chloride (Fisher Scientific). 334.5 mg of sodium phosphate dibasic dehydrate USP (Fisher Scientific). 125.9 mg of sodium phosphate monobasic monohydrate USP (Fisher $cientific)and an appropriate amount of an otic agent with 70.5 g of sterile filtered D1 water. [00499}The solution is cooled down in an ice chilled water bath and then 25.1 g of poloxamer 407NF (Spectrum chemicals) is sprinkled into the cold solution .while mixing. The mixture is further mixed until the poloxamer is completely dissolved.

[00500] 25% poioxamer407/ 2% .otic agent/ 59i>pm Evans bine in phosphate buffer: Take two mL of the 25% poioxamcr407/ 2% otic agent/in phosphate buffer solution and add 2 mL of a 5.9 mg/mL Evans blue (Sigma-Aldrich chemical Co) solution in PBS buffer.

[00501] Place 2 mL of formulation into a 2 mL glass vial (Wheaton serum glass vial) and seal with 13 mm butyl str (kinible stoppers) and crimp with a 13 mm aluminum seal. The vials are placed in a Market Forge-sterilmatic autoclave (settings, slow liquids) and sterilized at 250°F for 25 minutes. After the autoclaving the samples are left to cool down to room temperature and then: placed in refrigeration. The vials are placed in the refrigerator and mixed while cold to homogenize the samples. Sample discoloration or precipitation after autoclaving is recorded.

[00502] HPLC analysis is performed using an Agilent 1200 equipped with a Luna Cl 8(2) 3pm, :100A, 250x4.6 mm column) using a 30-95 methanol:acetate buffer pH 4 gradient (1-6min),. then isocratk- for 11 minutes, for a total run of 22 minutes. Samples are diluted by taking 30ftL of sample and dissolved with 0.97.mL of water. The main peaks are recorded. Purity before autoclaving is greater than 99% using this method.

[60503] Viscosity measurements are performed using a Brookfield viscometer RVDV-IH P with a CPE-51 spindle rotated at 0.08 rpm (shear-rate of 0.31 s'1), equipped with a water jacketed temperature control unit (temperature ramped from 15-34°C at 1.6 "C/min). Tgel is defined as the inflection point of the -curve··where- the increase in viscosity1 occurs due to the sol-gel transition, [00564) Formulations comprising gentamicin, ciprofloxacin and micronized dexamethasone, prepared according to the procedures described herein, are tested using the above procedures to determine stability of the formulations.

Example 16: hi vitro comparison of relase profile.

[00505] Dissolution is performed at 37°C in snapwells (6.5 mm diameter polycarbonate membrane with a pore size of 0.4 pm), 0.2 mL of a gel formulation described herein is placed into snapwell and left to harden, then 0.5 mL buffer is placed into reservoir and shaken using a Labline orbit shaker at 70 rpm. Samples are taken every hour (0.1 mL withdrawn and replace with warm buffer). Samples are analyzed for otic agent concentration by UY at 245nm against an. external calibration standard curve. Piuronic concentration is analyzed at 624 nm using the cobalt thiocyanate method. Relative rank-order of mean dissolution time (MDT) as a function of %P407 is determined. A linear relationship between the formulations mean dissolution time (MDT) and the P407 concentration indicates that the otic agent is released due to the erosion of the polymer gel (poloxamer) and not via diffusion. A non-linear relationship indicates release of otic agent via a combination of diffusion and/or polymer gel degradation.

[00506] Alternatively, samples are analyzed using the method described by Li Xin-Yu paper [Acta Pharmaceutics Simca 2008,43(2):208-203] and Rank-order of mean dissolution time (MDT) as a function of %P407 is determined.

[00507] Formulations comprising gentamicin, ciprofloxacin and micronized dexamethasone, prepared according to the procedures described herein, are tested using the above procedure to determine the release profile of the otic agents.

Example 17: In vitro comparison of gelation temperature [00508] The effect of Poloxamer 188 and an otic agent on the gelation temperature and viscosity:of Poloxamer 407:formulations is evaluated with the purpose of manipulating the the gelation temperature.

[00500] A 25% Poloxamer 407 stock solution in PBS buffer and the PBS solution described above are used. Poloxamer 188NF from BAS E is used. Art appropriate amount of otic agent is added to the solutions described in Table 5 to provide a 2% formulation of the otic agent. Table 5 Preparation of samples containing poloxamer 407/poloxamer 188

[00510] Mean dissolution time, viscosity and gel temperature of the above formulations are measured using procedures described herein.

[00511] An equation is fitted to the data obtained and can be utilized to estimate the gelation temperature of F127/F68 mixtures (for 17-20% FI27 and 0-10% F68).

Tgef* -1.8 (%F127) + 1.3 (%F68)+53 [00512} An equation is fitted to the data obtained and can be utilized to estimate the Mean: Dissolution Time (hr) based on the gelation temperature of F127/F68 mixtures (tor 17-25% FI.'27' and 0-10% F68), using results obtained in examples above. MDT == -0,2.¾) + 8 100513] .Formulations comprising gentainiein, ciprofloxacin and microaized dexamethasone, are prepared by addition of an appropriate amount of otic agents to the solutions described in Table 5 , The gel temeparature of the formulatioiis i s determined using the procedure described above.

Example 18: Determination of temperature ranee-for sterile filtration [00514} Hie viscosity at low temperatures is measured to help guide the temperature range at which the sterile filtration needs to occur to reduce the possibility of clogging.

[00515} Viscosity measurements are performed using a Brookfield viscometer R VDV-IB P with a CPE-40 spindle rotated at 1, 5 and 10 rpm (shear rate of 7.5, '37.5 and 75 s'1), equipped with a water jacketed temperature control unit (temperature ramped from 10-25liC at 1.6 uC/min).

[00516] The Tgel of a 17% Pluronic P407 is determined as a function of increasing concentration of otic agent. The increase in Tgel for a 17% pluronic formulation is estimated by: ATger- 0.93{% otic agent] [OOSlTjFormulations comprising gentamicin, ciprofloxacin and micronized dexamethasone, prepared according to procedures described herein, are tested using the above procedure to determine the temperature range for sterile filtration. The effect of addition of increased amounts of otic agent on the Tgel, and the apparent viscosity of the formulations is recorded.

Example 19; Determination of manufacturma conditions

Table 6, Viscosity of potential formulations at manufacturing / filtration conditions. j ' &amp; Viscosity measured at a shear rate of 37.5 s'"1

[hOSI 8] An 8 liter batch of a 17% P407 placebo is manufactured to evaluate the manufacturing/filtration conditions. The placebo is manufactured by placing 6.4 liters of Dt water in a 3 gallon SS pressure vessel, and left to cool down in the refrigerator overnight..

The following morning the tank is taken out (water temperature 5°€, RT 18°€) and 48g of sodium chloride, 29,6 g of sodium phosphate dibasic dehydrate and 10 g of sodium phosphate monobasic monohydrate is added and dissolved with an overhead mixer (IK.A RW2.0 @ 1720 rpm). Half hour later, once the buffer is dissolved (solution temperature 8°Cti RT 18°C), 1.36kg of poloxamer 407 NF (spectrum chemicals) is slowly sprinkled into the buffer solution in a 15 minute interval (solution, temperature 12°<D, RT 18:°C)5 then speed is increased to 2430 rpm. After an additional one hour mixing, mixing speed is reduced to 1062 rpm (complete dissolution).

[M519|The temperature of the room is maintained below 25°C to retain the temperature of the solu tion at below 19°C. The temperature of the sol ution is maintained at below 19°C up to 3 hours of the initiation of the manufacturi ng, without tire need to chill/cool the container.

[00520] Three different Sartoscale (Sartorius Stedim) filters with a surface area of 173 cm2 are evaluated at 20 psi and,I4°C of solution 1) Sartopore 2,0,2pm 5445307HS-FF (PES), flow rate of 16mL/min 2) Sartobran P, 0.2μηΐ 5235.307HS-FF (cellulose ester), flow rate of 12mL/min 3) Sartopore 2 XLI, 0.2pm 5445307IS-FF (PES), flow rate of ISmL/min [00521] Sartopore 2 filter 5441307H4-SS is used, filtration is carried out at the solution temperature using a 0.45,0.2μιη Sartopore 2 150 sterile capsule (Sartorius Stedim) with a surface area of 0.015nf at a pressure of 16psi, Flow rate is measured at approximately 100 mL/min at 16psi, with no change in flow rate wfiile the temperature is maintained in the 6,5-14°C range. Decreasing pressure and increasing temperature of the solution causes a decrease in flow rate due to an increase in the viscosity of the solution. Discoloration of the solution is monitored during the process.

Table 7. Predicted filtration time for a 17%poloxamer 407 placebo at a solution temperature range of 6.5-14°C using Sartopore 2, 0.2μιη filters at a pressure of 16 psi of pressure.

[00522} Viscosity, Tgel and UV/Vis absorption is checked before filtration evaluation. Plutonic UV/Vis spectra are obtained hv a Evolution 160 UV/Vis (Thermo Scientific), A peak in the range of 250-300am is attributed to BHT stabilizer present in the raw material (poloxamer). Table 8 lists physicochemical properties of the above solutions before and after nitration.

Tabic 8. Physicochemical properties of 17% poloxamer 407 placebo solution before and after filtration

3 Viscosity measured at a shear rate of 37,5 s"T

[00523] The above process is applicable for manufacture of 17% P407 formulations, and includes temperatm-e analysis of the room conditions. Preferably, a maximum temperat ure of ! 9r'C reduces cost of cooling the container during manufacturing. In some instances, a jacketed container is used to further control the temperature of the solution to ease manufacturing concerns.

Example 20 In vitro Release of otic agent from an autoclaved micronized sample [00524] 17% poloxamef 407/1.5% otic agent in 'I RIS buffer: 250.8 mg of sodium chloride (Fisher Scientific), and 302.4mg of Tromethamine (Sigma Chemical Co.) is dissolved in 39.3g of sterile filtered DI water, pH is adjusted to 7,4 with 1M H€l. 4.9 g of the above solution is used and an appropriate amount of micronized otic agent is suspended and dispersed well 2 mL of the formulation is transferred into a 2 mL glass vial (Wheaton serum glass vial.) and seald with 13 mm butyl styrene (kimble stoppers) and crimped with a 13 mm aluminum seal. The vial is placed in a Market Forge-sterilmatic autoclave (settings, slow liquids) and sterilized at 250°F for 25 minutes. After the autoclaving the sample is left to cool down to room temperature. The vial is placed in the refrigerator and mixed while cold to homogenize the sample. Sample discoloration or precipitation after autoclaving is recorded.

[00525] Dissolution is performed at 37°G in snapwells (6.5 mm diameter polycarbonate membrane with a pore size of 0.4 pm), 0.2mLof gel is placed into snapwell and left to harden, then 0.5 mL FBS buffer is placed into reservoir and shaken using a Labline orbit shaker at 70 rpm. Samples are taken every hour [0.1 mL withdrawn and replaced with warm PBS buffer containing 2% PEG-40 hydrogenated castor oil (BASF) to enhance otic agent solubility]. Samples are analyzed for otic agent concentration by UV at 245nm against an external calibration standard curve. The release rate is compared to other formulations disclosed herein. MDT time is calculated for each sample, {00526] Solubilization of otic agent, in the 17% poloxamer system is evaluated by measuring the concentration of the otic agent, in the supernatant, after centrifuging samples at 15.000 rpm for 10 minutes using an eppendorf centrifuge 5424. Otic agent concentration in the supernatant is measured by UV at 245nm against an external calibration standard curve.

[00527] Formulations comprising gentamicin, ciprofloxacin and micronized dexamethasone, prepared according to the procedures described herein, are tested using die above procedures to determine release rate of the otic agent from each formulation,

Example 21: Release rate or MDT and viscosity of formulation containing sodium carboxvmethvl cellulose.

[00528] 17% poloxamer 407/2% Otic agent/1 % CMC (Hercules Bianose 7.VI): A sodium carboxymethylcelluiose (CMC) solution (pH 7.0) in PBS buffer is prepared by dissolving 205.6 mg of sodium chloride (Fisher Scientific), 372,1 mg of sodium phosphate dibasic dihydrate (Fisher Scientific), 106.2 mg of sodium phosphate monobasic monohydrate (Fisher Scientific) in 78,1 g of sterile filtered DI water. 1 g of Bianose 7M CMC (Hercules, viscosity of 533cP @ 2%) is sprinkled into the buffer solution and heated to ease solution, solution is then cooled down and 17.08 g poloxamer 407NF (Spectrum Chemicals ) is sprinkled into the cold solution while mixing. A formulation comprising 17% poloxamer 407NF/1% CMC/2% otic agent in PBS buffer is made adding/dissolving an appropriate amount of otic agent to 9.8 g of the above solution, and mixing until all the otic agent is completely disso 1 ved.

[00529] 17% poloxamer 407/2% otic agent/0.5% CMC (Bianose 7M65): A sodium carboxyraethy (cellulose (CMC) solution (pH 7.2) in PBS buffer is prepared by dissolving 257 rag of sodium chloride (Fisher Scientific), 375 mg of sodium phosphate dibasic dihydrate (Fisher Scientific), 108 mg of sodium phosphate monobasic monohydrate (Fisher Scientific) in 78.7g of sterile filtered DI water. 0,502 g of Bianose 7M65 CMC (Hercules, viscosity of 5450cP @ 2%) is sprinkled into the buffer solution and heated to ease solution, solution is then cooled down and 17,(16 g poloxamer 407NF (Spectrum Chemicals) is sprinkled into the cold solution while mixing. A 17% poloxamer 407NF/i% CMC/2% otic agent solution in PBS buffer is made adding/dissolving an appropriate amount of otic agent to 9.8 g of the above solution, and mixing until the otic agent is completely dissolved.

[©0530117% poloxamer 407/2% otic agent/0.5% CMC (Blanose 7H9): A sodium carboxymethylceOulose (CMC) solution (pH 7.3) in PBS buffer is prepared by dissolving 256.5 mg of sodium chloride (Fisher Scientific), 374 mg of sodium phosphate dibasic dihydrate (Fisher Scientific), 307 mg of sodium phosphate monobasic monohydrate(Fisher Scientific) in 78.6g of sterile filtered DI water, then 0.502 g of Blanose 7H9 CMC (Hercules, viscosity of 5600cP @ 1%) is sprinkled to the buffer solution and heated to ease solution, solution is then cooled down and 17.03 g poloxamer 407NF (Spectrum Chemicals ) is sprinkled into the cold solution while mixing. A17% poloxamer 407NF/i% CMC/2% otic agent solution in PBS buffer is made adding/dissoiving an appropriate amount of otic agent to 9.8 of the above solution, and mixing until the otic agent Is completely dissolved. [0653.1] Viscosity measurements are performed using a Brookfield viscometer RVDV-II+P with a CPE-40 spindle rotated at O.OSfpm (shear rate of 0.6s~!), equipped with a water jacketed temperature control unit (temperature ramped from 10-34°C at 1.6 °C/min). Tgei is defined as the inflection point of the Curve where the increase in viscosity occurs due to the sol-gel transition. 1605321 Dissolution is performed at 37°C in snap wells (6.5 mm diameter polycarbonate membrane with a pore size of 0.4 pm). 0.2 mL of gel is placed into snap\vell and left, to harden, then 0.5 mL PBS buffer is placed into reservoir and shaken using a Labline orbit shaker at 70 rpm. Samples are taken every hour, 0.1 mL withdra wn and replaced with warm PBS buffer, Samples are analyzed for otic agent concentration by UV at 245nm against an external calibration standard'curve; lire release rate is compared to the formulations disclosed in above examples, and Ml)T time is calculated, tor each of the above formulations. JO0533J Formulations comprising gentamicin, ciprofloxacin and microntzed dexamethasone, prepared according to procedures described above, are tested using the above procedures to determine relationship between release rate and/or mean dissolution time and viscosity of formulation containing sodium carboxymethyl cellulose. Any con-elation between themean dissolution time (MDT) and the apparent viscosity (measured at 2°C below the gelation temperature) is recorded.

Example 22 Effect of poloxamer concentration and otic agent concentration on release kinetics [60534] A series of compositions comprising varying concentrations of a gelling agent and microntzed dexamethasone was prepared using procedures described above. The mean dissolution lime (MDT) for each composition in Table 9 was determined using procedures described above.

Table ? Preparation of poloxamer/otic agent compositions

[00535! The effect of gel strength and otic agent concentration on release kinetics of an otic agent from the composition or device was determined bv measurement of the MDT for poloxamer. and measurement of MDT for otic agent. The half life of the otic agent and mean residence time (MRT) of the otic agent was also determined for each formulation by measurement of concentration, of the otic agent in the perilymph using procedures described herein. {00536! The apparent viscosity of each composition was measured as described above. A thermoreversible polymer gel concentration of about 15.5% in a composition or device described above provided an apparent viscosity of about 270.000 cP. A fhcrmorcversiblc polymer gel concentration of about 16% in a composition or device described above provided an apparent viscosity of about 360,000 cP. A thermoreversible polymer gel concentration of about 17% in a composition or device described above provided an apparent viscosity of about 480.000 cP. {O0537J Compositions comprising gentamicin, ciprofloxacin and amoxicillin, prepared according to the procedures described above are tested using the above procedure to determine release rate of the otie agent from each composition.

Example 23 - Application of an Enhanced Viscosity Anti microbial Agent Formulation onto the Round Window Membrane {00538J A formulation according to Example 7 is prepared and loaded into 5 ml siliconized glass syringes attached to a 15-gauge lucr lock disposable needle. Lidocaine is topically applied to the tympanic membrane, and a small incision made to allow visualization into the middle ear cavity. The needle tip is guided into place over the round window membrane, and the antimicrobial agent formulation applied directly onto the round-window membrane.

Example 24 - In vivo testing of Intratvm panic injection of antimicrobial agent formulation in a guinea pig.

[005391A cohort of 21 guinea pigs (Charles River, females weighing 200-300g) is. intratympanicall'y injected with 50 pL of different P4G7-otie agent formulations described herein, containing 0 to 50% otic agent The gel elimination time course for each formulation is determined. A faster gel elimination time course of a formulation indicates lower mean dissolution time (MDT). Thus the injection volume and the concentration of an antimicrobial agent in a formulation, are tested to determine optimal parameters for preclinieal and clinical studies.

Example 23 - In vivo extended release kinetics [1)0540] A cohort of 2.1 guinea pigs (Charles River, females weighing 200-300g) is intratympanieally injected with 50 pL 17% Plutonic I·'-127 form elation buffered at 280 mOsm/kg and containing 1.5% to 35% antimicrobial agent by weight of the formulation. Animals are dosed on day 1. The release profile for the formulations is determined based on analysis of the perilymph.

Example 26 - Evaluation of Antimicrobid Agent Formulations in an A1ED Animal Model Methods and Materials

Induction of Immune Response [00541J Female albino National Institutes of Health-Swiss mice (Harlan Sprague-Dawley, Inc., Indianapolis, Inc.) weighing 20 to 24 g are used. Keyhole limpet hemocyanin {KLH; Pacific Riomarine Supply Co., Venice. CA) is suspended in phosphate-buffered saline (PBS) IpH 6,4), dialyzed aseptieally against PBS and centrifuged twice. The precipitate (associated KLH) is dissolved in PBS and injected subcutaneously in the back of the animal (0.2 mg emulsified in 'Freund’s complete, adjuvant), The animals are given a booster (0.2 mg KLH in Freund’s incomplete adjuvant, and then injected ten weeks later with 0.1 mg KLH in 5 pi PBS (pH 6.4) through a microhole drilled through 'the cochlear capsule. The cochlea is approached using an operating microscope and sterile technique. A postauricular incision is made, and a hole is drilled into the bullae to allow good visualization of the promontory of the cochlear basal turn, stapedial artery, and round window niche. The stapedial -artery is cauterized and removed, and a 25 pm hole is drilled through the cochlear capsule into the seala tymparii of the lateral basal turn. KLH or PBS control, is slowly injected using a Hamilton syringe coupled with a plastic tube to a glass micropipette filled with the antigen or control. The hole is sealed with bone wax alter injection, and excess fluid is removed. Only one cochlea per animal is treated with KLH.

Treatment: [00542] KLH and control mice are sorted into two groups(n = 10 in each group). The antimicrobial agent formulation of Example 4 is applied to the round window membrane of one group of animals, Control formulation containing no ganciclovir is applied to the second group. The antimicrobial agent and control formulations are reapplied three days after the initial application. The animals are sacrificed after the seventh day of treatment.

Analysis of Results

Electrophysiologic Testing [00543] The hearing threshold tor the auditory brainstem response threshold (ABR) to click stimuli for each ear of each animal is initially measured and 1 week after the experimental procedure, I'he animals are placed hi a single-walled acoustic booth (Industrial Acoustics Co, Bronx, NY, USA) on a heating pad, Subdermal electrodes (Astro-Med, Inc. Grass Instrument Division, West Warwick, Rl, USA) were inserted at the'vertex, (active electrode), the mastoid (reference), and the hind teg (ground). Click stimuli (0,1 millisecond) are computer generated and delivered to a Beyer DT 48, 200 Ohm speaker fitted wi th an ear speculum for placement in the external auditory meatus'. The recorded ABR is amplified and digitized by a battery-operated preamplifier and input to a Tucker-Davis Technologies ABR recording system that provides computer control of the stimulus, recording, and averaging functions (Tucker Davis Technology, Gainesville, FL, USA). Successively decreasing amplitude stimuli are presented in 5-dB steps to the animal, and the recorded -stimulus-locked activity is averaged <n-512) and displayed. Threshold is defined as the stimulus level between the record with no visibly detectable response and a clearly identifiable response. llistoehemical analysis [00544] Animals are anesthsized and sacrificed via intracardiac perfusion of heparinized warm saline followed by approximately 40 ml periodate-Iysme-paraformaidehyde (4% paraformaldehyde final concentration) fixative. Right-side temproal bones are immediately removed and decalcified with buffered 5% ethyienediamine tetra-acetate (pH 7.2) for 14 days (40C), After decakifteation, temporal bones are immersed sequentially in increasing concentrations (50%, "75%, .100%).of optimal cutting temperature (OCT) compound (Tissue-Teli, Miles Inc., Elkhart, IN), snap-frozen (-70°C), and cryostat-sectioned (4 pm) parallel to the modiolus. Sections are collected for hematoxylin and eosin (H&amp;E) staining and immunohistochemical analysis.

[00545] The severity of inflammation is assessed according to the amount of cellular infiltration of the scala tympani, and an unbiased score is gi ven to each cochlea. A score of 0 indicates no inflammation, and a score of 5 indicates that all cochlear turns had severe infiltration of inflammatory cells.

Example 27 - Evaluation of Antimicrobial Agent Formulations in an Otitis Media Animal Model [00546] Healthy adult chinchillas weight 400 to 600 g with normal middle ears, ascertained by otoscopy and tympanometry are used for these studies. Eustachian tube obstruction is performed 24 hours before inoculation to prevent the inoculum from flowing out of the eustaehian tube. One milliliter of type 3 S.pneumoniae strain at 4-h-log phase (containing approximately 40 colony forming units (CPU)) is placed directly into both middle ear hypotympanic bullae of the chinhiHas. Control mice are inoculated with one millil iter sterile PBS.

Treatment [00547] S. pneumoniae inoculated and control mice are sorted into two groups (n ~ 10 in each group). The antimicrobial agent formulation of Example 1 containing amoxicillin is applied to the walls of the tympanic cavity of one group of animals. Control..'formulation containing no amoxicillin is applied to the second group, fhe amoxicillin and control formulations are reapplied thiee days after the initial application. The animals are sacrificed after the seventh day of treatment.

Analysis of Results [00548] Auris media ear fluid (MEF) is sampled at 1,2, 6, 12, 24,48 and 72 hours after pneumoecai inocualdon. Quantitative MEF cultures are performed on sheep blood agar, with the quantitation threshold set at 50 CFU/ml. Inflammatory cells are quantitated with a hemacytometer, and differential cell enumeration performed with Wright’s staining.

Example 28 - Evaluation of Antimicrobial Agent Formulations in an Otitis Externa Animal Model {00549} Otitis externa ls induced in 20 Sprague-Dawley rats using a plastic pipette to aggravate the tissue of the ear canal. All of the rats develop QE within one day. The an dm t crobtal form ulati on of Example 2 containing neomycin is administered to the ears of half of the rats using: a needle and syringe, while the remaining rats receive the same formulation without, the neomycin. The ear canal tissue is observed for redness and swelling that characterizes the condition. Light microscopy is used to. analyze biopsy samples from the rats.

Example 29 - Clinical Trial of Antimicrobial Agent Formulations for the T reatment of

Qtosvohilis [09559] Patients selected for the study present symptoms of cochieovestibular dysfunction and positive syphilis serology. Patients are divided into two groups, a test group receiving intratympanic administrati on of the formulation of Example 6 in conjunction with an intramuscular (IM) injection of 2.4 million units of benzathine penicillin G (the recommended treatment for syphilis), and a control group receiving only the carrier and microspheres of the otic formulation of Example 6 In conjunction with an IM injection of 2.4 million units of benzathine penicillin G, Patients are monitored for improvement of hearing, tinnitus, vertigo, and nystagmus following administration of the active agents. The primary outcome of the trial is improvement of cochieovestibular function at the 6 month post-treatment visit. The outcome for patients receiving foe formulation of Example b and the recommended therapy is compared to the outcome for patients receiving only the carrier for the otic formulation and the recommended therapy in order to determine foe efficacy of localized delivery of an antimicrobial agent formulation for the treatment of otic symptoms of syphilis.

Example 30 - Clinic al Trial of Antimicrobial Agent Formulati ons in c ombination with Tympanostomy for Treatment of Otitis Media with Effusion [60551] The purpose of this study is to determine if a composition comprising a combination of Ciprofloxacin and Dexamethasone administered in combination with a tympanostomy is safe and effective in preventing and/or treating middle ear infections in patients with ear tubes. (00552) Study Type: Interventional ί00553) Study Design: This wilTbe. a non-inferiority open label study to compare the current standard of care versus the use of extended release intratympamc compositions in combinati on with tympanostomy . The current standard of care requires the use of otic drops for 5-7 days post-surgery; The study is designed to test whether administration of a sustained release composition at the time of surgery obviates the need for out-patient treatment. The test hypothesis is that administration of a single injection of an extended release composition at the time of surgery is not inferior to administration of otic drops after surgery.

[00554] Inclusion Criteria: 6 months to 12 years old. Acute Otitis Media with effusion in one or both ears

Patient may not have had otic surgery other than tube placement in the last year

Patient may not have any disease or condition that would negatively affect the conduct of the study

Patient may not require any other systemic antimicrobial therapy during the study.

Analgesic use (other than- acetaminophen) is not allowed Patient may not be pre-disposed to neurosensory hearing loss [00555] Exclusion Criteria; Age [00550] Study Protocol: Twenty patients will be divided into two groups, lire first group of patients will receive an injection of an extended release composition comprising micronfzed ciprofloxacin and mieronized dexamethasone during the surgical procedure. Each patient will undergo a tympanostomy for placement of a tube. During the surgical procedure, the surgeon will clean the ear of all effusion and while the myngotomoy incision is open, the surgeon injects a test composition into tire middle ear space. The tube is inserted after in jection of the extended release composition into the middle ear space. The test composition is either prepared in the operating room by suspending dry micronized powder of ciprofloxacin and dexamethasone with other excipients, or the test composition is a prepared suspension ready for injection.

[00557] The second group of patients will, be given car drops comprising non-microftized ciprofloxacin and non-micronized dexamethasone as immediate release components to be administered for 5-7 days after the surgery. {00558] Patients are monitored with weekly follow up visits for one month. Any differences in treatment outcomes between the two groups are recorded. (00559] Pri mary Outcome Measures: Time to cessation of otorrhea as recorded by the parent or guardian via a patient, (005601 Secondary Outcome Measures: Clinical cure rate; Microbiological outcome; Treatment failures; Recurrence of disease. ]0056t{ The treatment outcome for each group of patients is compared to determine whether administration of the extended release composition comprising ciprofloxacin and dexamethasone in combination with tympanostomy is no worse than administration of ear drops comprising ciprofloxacin and dexamethasone after surgery' for reduction of otorrhea, infections, or inflammation associated with tympanostomy. (00562] While preferred embodiments of the present invention have been shown and described herein, such embodiments are provided by way of example only. Various alternatives to the embodiments described herein are optionally employed in practicing the inventions. It is intended that the following claims define the scope of the invention and that methods and structures within the scope of these claims and their equivalents be covered thereby.

Claims (18)

1. CLAIMS:

   1. An intratympanic composition when used in the treatment of an otic disease or condition comprising an auris acceptable hydrogel and a multiparticulate antimicrobial agent; wherein the multiparticulate antimicrobial agent is essentially in the form of micronized particles that are non-microencapsulated.
2. 2. The composition of claim 1, wherein the composition has a pH of 7.0-8.0.
3. 3. The composition of claim 1 or 2, wherein the composition has an osmolarity of from 250 to 320 mOsm/kg.
4. 4. The composition of any one of claims 1 to 3, wherein the composition is a liquid that is suitable for administration by a narrow gauge needle or cannula.
5. 5. The composition of any one of claims 1 to 4, wherein the antimicrobial agent is an antibiotic.
6. 6. The composition of claim 5, wherein the antibiotic is selected from a sulfonamide, a penicillin, a quinolone, a cephalosporin or a macrolide antibiotic.
7. 7. The composition of claim 5, wherein the antibiotic is a sulfonamide selected from afenide, prontosil, sulfacetamide, sulfamethiazole, sulfanilimide, sulfasalazine, sulfisoxazole, trimethoprim, and cotrimoxazole.
8. 8. The composition of claim 5, wherein the antibiotic is a penicillin selected from amoxicillin, ampicillin, azociling, carbenicillin, cloxacillin, dicloxacillin, flucloxacillin, mezlocillin, meticillin, nafcillin, oxacillin, peperacillin, and ticarcillin.
9. 9. The composition of claim 5, wherein the antibiotic is a quinolone selected from ciprofloxacin, enoxacin, gatifloxacin, levofloxacin, lomefloxacin, moxifloxacin, nonfloxacin, ofloxacin, trovafloxacin, grepafloxacin, sparfloxacin, AL-15469A, and AL-38905.
10. 10. The composition of claim 5, wherein the antibiotic is a cephalosporin selected from cefaclor, cefamandole, cefotoxin, cefprozil, cefuroxime, cefixime, cefdinir, cefditoren, cefpodoxime, ceftazidime, ceftibuten, ceftizoxime, ceftriaxone, cefepime, and ceftobirprole.
11. 11. The composition of claim 5, wherein the antibiotic is a macrolide antibiotic selected from azithromycin, clarithromycin, dirithromycin, erythromycin, roxithromycin, troleandomycin, telithromycin, and spectinomycin.
12. 12. The composition of claim 5, wherein the antibiotic is ciprofloxacin.
13. 13. The composition of any one of claims 1 to 12, wherein the antimicrobial agent is an antifungal agent
14. 14. The composition of claim 13, wherein the antifungal agent is selected from amrolfine, utenafine, naftifine, terbinafine, flucytosine, fluconazole, itraconazole, ketoconazole, posaconazole, ravuconazole, voriconazole, clotrimazole, econazole, miconazole, oxiconazole, sulconazole, terconazole, tioconazole, nikkomycin Z, caspofungin, micafungin, anidulafungin, amphotericin B, liposomal nystastin, pimaricin, griseofulvin, ciclopirox olamine, haloprogin, tolnaftate, undecylenate, and clioquinol.
15. 15. The composition of any one of claims 1 to 14, wherein the otic disease or condition is otitis media.
16. 16. The composition of any one of claims 1 to 14, wherein the composition is administered in combination with tympanostomy.
17. 17. A method of treating an otic disease or condition comprising administering a therapeutically effective amount of the composition of any one of claims 1 to 14 to a subject in need thereof.
18. 18. The use of the composition of any one of claims 1 to 14 for the manufacture of a medicament for the treatment of an otic disease or condition.