Otomycosis with Tympanic Membrane Perforation: Treatment Using Clotrimazole Soaked Gelfoam

We are very uncertain whether or not treatment with aural toileting is effective in resolving ear discharge in people with CSOM, due to a lack of data and the poor quality of the available evidence. We also remain uncertain about other outcomes, including adverse events, as these were not well reported. Similarly, we are very uncertain whether daily suction clearance, followed by antibiotic ear drops administered at a clinic, is better than a single episode of suction clearance followed by self-administration of topical antibiotic ear drops.

PurposeInjury or inflammation of the middle ear often results in the persistent tympanic membrane (TM) perforations, leading to conductive hearing loss (HL). However, in some cases the magnitude of HL exceeds that attributable by the TM perforation alone. The aim of the study is to better understand the effects of location and size of TM perforations on the sound transmission properties of the middle ear.MethodsThe middle ear transfer functions (METF) of six human temporal bones (TB) were compared before and after perforating the TM at different locations (anterior or posterior lower quadrant) and to different degrees (1 mm, ¼ of the TM, ½ of the TM, and full ablation). The sound-induced velocity of the stapes footplate was measured using single-point laser-Doppler-vibrometry (LDV). The METF were correlated with a Finite Element (FE) model of the middle ear, in which similar alterations were simulated.ResultsThe measured and calculated METF showed frequency and perforation size dependent losses at all perforation locations. Starting at low frequencies, the loss expanded to higher frequencies with increased perforation size. In direct comparison, posterior TM perforations affected the transmission properties to a larger degree than anterior perforations. The asymmetry of the TM causes the malleus-incus complex to rotate and results in larger deflections in the posterior TM quadrants than in the anterior TM quadrants. Simulations in the FE model with a sealed cavity show that small perforations lead to a decrease in TM rigidity and thus to an increase in oscillation amplitude of the TM mainly above 1 kHz.ConclusionSize and location of TM perforations have a characteristic influence on the METF. The correlation of the experimental LDV measurements with an FE model contributes to a better understanding of the pathologic mechanisms of middle-ear diseases. If small perforations with significant HL are observed in daily clinical practice, additional middle ear pathologies should be considered. Further investigations on the loss of TM pretension due to perforations may be informative.

Distortion product otoacoustic emissions: Sensitive measures of tympanic -membrane perforation and healing processes in a gerbil model

1. Charles D. Bluestone, MD* 2. Jerome O. Klein, MD† 1. 2. *Eberly Professor of Pediatric Otalaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA. 3. 4. †Professor of Pediatrics, Boston Univerisity School of Medicine, Boston MA. Dr Klein is a consultant to Eli Lily Company; is a consultant to and lecturer for Bristol Myers Squibb and SmithKline Beecham; is a consultan to and has grant support from Abott Laboratories abd Pfizer Pharmaceuticals; and is a consultant to a, lecturer for, and has grant support from Roche Laboratories. Chronic suppurative otitis media (CSOM) is a chronic infection of the middle ear cleft (including eustachian tube, middle ear, and mastoid) that is defined by three elements: 1) perforation of the tympanic membrane due to acute infection or tympanotomy tube, 2) discharge from the middle ear (otorrhea), and 3) prolonged duration (;gt;2 wk). The initial therapy of most cases is use of appropriate topical and systemic antibiotics, which can be managed by the pediatrician. Otolaryngologic referral is necessary in four circumstances: 1) if otomicroscopy is required for initial or subsequent examination, 2) if the patient fails to respond to initial therapy, 3) if a cholesteatoma or other mass is present, and 4) if a suppurative complication occurs. CSOM affects diverse racial and cultural groups living not only in temperate climates but in climate extremes ranging from the Arctic Circle to the equator. Among the groups affected most are the Inuits of Alaska (30% to 46%), Australian aborigines (12% to 25%), and certain Native Americans (eg, Apache and Navajo tribes) (4% to 8%). Studies from industrialized nations have reported low rates of CSOM due to acute infection with perforation, but many cases of CSOM are associated with use of tympanotomy tubes. No population-based data are available regarding the incidence of CSOM associated with tympanotomy tubes. Risk factors attributed to high rates of CSOM are similar to factors associated with recurrent acute otitis media (AOM): lack of breastfeeding, overcrowding, poor hygiene, poor nutrition, passive smoking, high rates of nasopharyngeal colonization with potentially pathogenic bacteria, and inadequate and unavailable health care. Data from Thailand and Kenya indicate that public health measures and appropriate medical care are effective in decreasing the rate of CSOM. When hearing is assessed in children who have otitis media with effusion (OME), the median level is 25 dB (equivalent …

To evaluate the utility of fluorescence to assess penetration of quinolone ear drops (EDs) through tympanostomy tubes (TTs), the middle ear, eustachian tube, and into the oropharynx. Before-and-after trial. Academic, tertiary care hospital. Young children undergoing TT placement for otitis media and adolescents or adults undergoing repair of tympanic membrane (TM) perforations were included. Fluorescence of ofloxacin otic solution and serial dilutions was assessed with a Wood's lamp in vitro. Passage of ototopically administered ofloxacin into the pharynx was assessed in patients at the time of TT placement or TM repair. The oropharynx was visualized for fluorescence with a UV light for up to 2 hours after otic instillation. Oropharyngeal fluorescence. Ofloxacin otic fluorescence was visible at up to a 1:4 dilution. Fluorescence was confirmed in vivo by placing 1 drop of ofloxacin into the posterior pharynx and visualizing it transorally. Fluorescence was not identified in any of 20 patients after TT placement and in any of 6 patients prior to tympanoplasty. Two patients undergoing tympanoplasty reported tasting the EDs. Fluorescence is not a satisfactory method of assessing quinolone ED penetration through TTs and TM perforations, the middle ear, and into the nasopharynx.

Chronic Candida albicans otitis media in children with immunodeficiency.

Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Topical antiseptics, one of the possible treatments for CSOM, inhibit the micro-organisms that may be responsible for the infection. Antiseptics can be used alone or in addition to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). Antiseptics or their application can cause irritation of the skin of the outer ear, manifesting as discomfort, pain or itching. Some antiseptics (such as alcohol) may have the potential to be toxic to the inner ear (ototoxicity), with a possible increased risk of causing sensorineural hearing loss, dizziness or tinnitus. To assess the effects of topical antiseptics for people with chronic suppurative otitis media. The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL; 2019, Issue 4, via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 April 2019. We included randomised controlled trials (RCTs) with at least a one-week follow-up involving patients (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antiseptic agent of any class, applied directly into the ear canal as ear drops, powders or irrigations, or as part of an aural toileting procedure. Two main comparisons were topical antiseptics compared to: a) placebo or no intervention; and b) another topical antiseptic (e.g. topical antiseptic A versus topical antiseptic B). Within each comparison we separated studies where both groups of patients had received topical antiseptics a) alone or with aural toileting and b) on top of antibiotic treatment. We used the standard Cochrane methodological procedures. We used GRADE to assess the certainty of the evidence for each outcome. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health-related quality of life using a validated instrument; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes included hearing, serious complications and ototoxicity measured in several ways. Five studies were included. It was not possible to calculate the total number of participants as two studies only provided the number of ears included in the study. A. Topical antiseptic (boric acid) versus placebo or no treatment (all patients had aural toileting) Three studies compared topical antiseptics with no treatment, with one study reporting results we could use (254 children; cluster-RCT). This compared the instillation of boric acid in alcohol drops versus no ear drops for one month (both arms used daily dry mopping). We made adjustments to the data to account for the intra-cluster correlation. The very low certainty of the evidence means it is uncertain whether or not treatment with an antiseptic leads to an increase in resolution of ear discharge at both four weeks (risk ratio (RR) 1.94, 95% confidence interval (CI) 1.20 to 3.16; 174 participants) and at three to four months (RR 1.73, 95% CI 1.21 to 2.47; 180 participants). This study narratively described no differences in suspected ototoxicity or hearing outcomes between the arms (very low-certainty evidence). None of the studies reported results for health-related quality of life, adverse effects or serious complications. B. Topical antiseptic A versus topical antiseptic B Two studies compared different antiseptics but only one (93 participants), comparing a single instillation of boric acid powder with daily acetic acid ear drops, provided any information for this comparison. The very low certainty of the evidence means that it is uncertain whether more patients had resolution of ear discharge with boric acid powder compared to acetic acid at four weeks (RR 2.61, 95% CI 1.51 to 4.53; 93 participants), or whether there was a difference between the arms with respect to ear discomfort due to the low number of reported events (RR 0.10, 95% CI 0.01 to 1.81; 93 participants). Narratively, the study reported no difference in hearing outcomes between the groups. None of the included studies reported any of the other primary or secondary outcomes. Due to paucity of the evidence and the very low certainty of that which is available the effectiveness and safety profile of antiseptics in the treatment of CSOM is uncertain.

BackgroundMost tympanic membrane (TM) perforations heal spontaneously, but approximately 10-20% remain open as chronic TM perforations. Chronic perforations can lead to an impaired hearing ability and recurrent middle ear infections. Traditionally, these perforations must be surgically closed, which is costly and time consuming. Therefore, there is a need for simpler therapeutic strategies. Previous studies by us have shown that plasminogen (plg) is a potent pro-inflammatory regulator that accelerates cutaneous wound healing in mice. We have also shown that the healing of TM perforations is completely arrested in plg-deficient (plg-/-) mice and that these mice develop chronic TM perforations. In the present study, we investigated the therapeutic potential of local plg injection in acute and chronic TM perforation mice models.MethodsPlg-/- mice and wild-type mice were subjected to standardized TM perforations followed by local injection of plg into the soft tissue surrounding the TM. TM perforations with chronic characteristics were induced by leaving TM perforations in plg-/- mice untreated for 9 days before treatment. The healing process was observed through otomicroscope and finally confirmed by immunostaining. The quality of TM healing was evaluated based on the morphology of the TM.ResultDaily local injections of plg into the soft tissue surrounding the TM restored the ability to heal TM perforations in plg-/- mice in a dose-dependent manner, and potentiated the healing rate and quality in wild-type mice. A single local injection of plg initiated the healing of the chronic-like TM perforations in these mice, resulting in a closed TM with a continuous but rather thick outer keratinocyte layer. However, three plg injections led to a completely healed TM with a thin keratinizing squamous epithelium covering a connective tissue layer.ConclusionOur data suggests that plg is a promising drug candidate for the treatment of chronic TM perforations in humans.

Tympanic membrane (TM) perforation is one of the most common causes of hearing impairment. Apart from conduction of sound waves across the middle ear, the tympanic membrane, also sub-serves a protective function to the middle ear cleft and round window niche. It has been established that the larger the perforation on the tympanic membrane, the greater the decibel loss. The aim of this study is to determine the effect of the size of the tympanic membrane perforation on hearing. The study was conducted at Al-Jumhoori teaching hospital during march 2011 to march 2012. Seventy-eight patients with perforated tympanic membranes were included in the study.They all have TM perforation due to recurrent or chronic otitis media. Patients with traumatic TM perforation were excluded from the study. There were 47 males (46.5%) and 54 females (53.5%). Twenty patients had left ear perforation, 35 patients had right ear perforation, and 23 patients had bilateral perforations. Each ear was taken as a case, so the total number of the perforated ear drums were 101. The age ranged from 13- 56 with the mean of (31.64 ± 13.249) years. The TM perforation was examined and photo image was taken with the aid of the endoscope, and the percentage of the perforation was measured from the whole area by using a special Microsoft (infomap). Controls were 55 patients with a mean age 30.73 ±12.09( range 14-53) years. Male controls were 34 (61.8%), and 21 female controls(38.2%). There was a highly significant correlation between size of TM perforation with the hearing level, air bone gap, high frequency hearing loss and low frequency hearing loss. As a conclusion, there is strong relationship between the size of TM perforation and the hearing level, air-bone gap and both the low frequency and the high frequency hearing level and air-bone gaps.

We are uncertain about the effectiveness of topical antibiotics in improving resolution of ear discharge in patients with CSOM because of the limited amount of low-quality evidence available. However, amongst this uncertainty there is some evidence to suggest that the use of topical antibiotics may be effective when compared to placebo, or when used in addition to a systemic antibiotic. There is also uncertainty about the relative effectiveness of different types of antibiotics; it is not possible to determine with any certainty whether or not quinolones are better or worse than aminoglycosides. These two groups of compounds have different adverse effect profiles, but there is insufficient evidence from the included studies to make any comment about these. In general, adverse effects were poorly reported.

This study aimed to determine how tympanic membrane (TM) perforations and their closure, using a paper-patch technique, affect middle-ear mechanics and, thus, conductive hearing for different sizes of the TM perforation. Temporal bone (TB) study and prospective clinical trial. Tertiary referral center. Nine patients with chronic otitis media for more than 3 months. The TM perforations were closed with a paper patch in all 9 patients. In 5 of 9 patients, myringoplasty was performed. Matching TM perforations were created in a TB model (n = 8) and closed using the paper patch. Air-bone gap was measured in all 9 patients of the patient cohort with TM perforations before and after closure and in 5 patients after myringoplasty. Stapes velocity and sound pressure difference between the ear canal and middle-ear cavity were measured in TBs with intact TM, with TM perforations, and with the perforations closed by the paper patch. All measurements in the patient cohort and TBs were performed for different sizes of TM perforations to determine if the effects varied as a function of size. Degree of the air-bone gap differed as a function of size of the TM perforations and its recovery after closure, and myringoplasty was independent of the size of the TM perforation in the frequency range of 0.25 to 4 kHz. In the TB measurements, although pressure difference across the TM was almost fully recovered by closing the perforation with a paper patch, recovery of the stapes motion was limited at frequencies above 4.5 kHz for larger sizes of TM perforations. Hearing loss caused by TM perforations depends on the size of the perforation. Hearing returns almost completely across the frequency range after closure except above 4 kHz for larger perforations. This is because the structural damage caused by large TM perforations cannot be completely restored by application of a paper patch.

Tympanic membrane(TM) perforation is one of the most common causes of hearing impairment. Apart from conduction of sound waves across the middle ear, the tympanic membrane, also sub-serves a protective function to the middle ear cleft and round window niche. The aim of the study is to determine the effect of the site of the tympanic membrane perforation on hearing. Seventy-eight patients with perforated tympanic membranes were included in the study.They all have TM perforation due to recurrent or chronic otitis media. Patients with traumatic TM perforation were excluded from the study. There were 47 males (46.5%) and 54 females (53.5%). Twenty patients had left ear perforation, 35 patients had right ear perforation, and 23 patients had bilateral perforations. Each ear was taken as a case, so the total number of the perforated ear drums was 101. The age ranged from 13- 56 with the mean of age was (31.64 ± 13.249) years. The TM perforation was examined and photo image was taken with the aid of the endoscope. Controls were 55 patients with a mean age 30.73 ±12.09 (range 14-53) years. Male controls were 34 (61.8%), and 21 female controls (38.2%). There is a positive correlation between site of TM perforation and hearing level, air bone gap, low frequency hearing level and high frequency hearing level. As a conclusion, there is a positive relationship between the site of TM perforation and hearing level being more in the posterior-superior and inferior parts.

Retrospective study of risk factors for tympanic membrane perforation in the early period after intratympanic steroid injection

Treatment of CSOM with topical antibiotics (quinolones) probably results in an increase in resolution of ear discharge compared with boric acid at up to two weeks. There was limited evidence for the efficacy of other topical antibiotics or topical antiseptics and so we are unable to draw conclusions. Adverse events were not well reported.

Background: Tympanic membrane (TM) perforation is a recognised cause of hearing loss in our environment. The integrity of the TM can be compromised by varying aetiological factors which are often preventable. TM perforation occurs in different dimensions which tend to influence the degree of hearing loss. Aim: The aim of this study is to determine the aetiological factors and dimensions of TM perforation among adolescents and adults in Benin City. Methods: This was a 1-year prospective study carried out from 1st July 2014 to 30th June 2015 at the Ear, Nose and Throat Clinic of University of Benin Teaching Hospital. Consecutive patients with TM perforation were examined using a hand-held otoscope as well as Firefly video otoscope and subsequently had an interviewer administered questionnaire. Data were analysed using Statistical Package for Social Sciences (SPSS) version 20 and ImageJ software. Results: One hundred and forty-eight patients with TM perforation in either or both ears were studied. There were 67 (45.3%) males and 81 (54.7%) females; ratio of 1:1.2. Ages ranged from 10 to 64 years, with a mean age of 34.5 ± 15.7 years. Chronic suppurative otitis media (CSOM) was the major cause of TM perforation in this study, 148 (74.0%). The small perforation was predominant, 54 (55.1%) and 48 (47%) in the right and left ears, respectively while the central anterior perforation, 93 (46.5%) occurred commonly. Conclusion: Central and small perforations were the predominant TM perforation while CSOM was the major cause of TM perforation.