Otitis Media Research Articles

Two cases of MPO-ANCA-positive hypertrophic pachymeningitis mimicking as intracranial infection

Hypertrophic pachymeningitis (HP) is a rare disorder marked by thickening of the dura mater due to diverse etiologies. MPO-ANCA-positive HP represents a variant of AAV confined to the central nervous system, distinguished by the presence of serum MPO antibodies. Distinguishing HP triggered by MPO-ANCA from other causes can be challenging.In this study, we present two cases of MPO-ANCA-positive HP initially misdiagnosed as intracranial infections. Case 1 underwent surgery for chronic suppurative otitis media, with histopathological findings revealing inflammatory changes without definitive suppuration. He was presumed to have a secondary intracranial infection resulting from the surgery. However, his condition deteriorated despite two weeks of antibiotic and antiviral treatment. Case 2 presented with headache and was initially suspected of having intracranial Brucellosis given his serum Brucella positivity. Despite treatment for brucellosis, his symptoms persisted, and he developed visual and hearing impairments. Both patients were ultimately diagnosed with MPO-ANCA-positive HP, exhibiting serum MPO antibody positivity. Their symptoms showed improvement with glucocorticoid and immunosuppressive therapy.Based on these observations, we propose that MPO-ANCA-positive HP may initially present as intracranial infection. For HP patients presenting with headache, mastoiditis, otitis media, and visual loss, it is imperative to conduct ANCA antibody-related tests to enhance diagnostic precision.

The therapeutic use of exosomes in children with adenoid hypertrophy accompanied by otitis media with effusion (AHOME): a protocol study

BackgroundThe adenoids act as a reservoir of bacterial pathogens and immune molecules, and they are significantly involved in children with otitis media with effusion (OME). As an essential carrier of intercellular substance transfer and signal transduction, exosomes with different biological functions can be secreted by various types of cells. There remains significant uncertainty regarding the clinical relevance of exosomes to OME, especially in its pathophysiologic development. In this study, we will seek to determine the biological functions of exosomes in children with adenoid hypertrophy accompanied by OME (AHOME).MethodsThe diagnostic criteria for OME in children aged 4–10 years include a disease duration of at least 3 months, type B or C acoustic immittance, and varying degrees of conductive hearing loss. Adenoidal hypertrophy is diagnosed when nasal endoscopy shows at least 60% adenoidal occlusion in the nostrils or when nasopharyngeal lateral X-ray shows A/N > 0.6. Children who meet the indications for adenoidectomy surgery undergo adenoidectomy. Peripheral blood, nasopharyngeal swab, and adenoid tissue will be collected from patients, and the exosomes will be isolated from the samples. Following the initial collection, patients will undergo adenoidectomy and peripheral blood and nasopharyngeal swabs will be collected again after 3 months.Expected resultsThis study aims to identify differences in exosomes from preoperative adenoid tissue and peripheral blood samples between children with AHOME and those with adenoid hypertrophy alone. Additionally, it seeks to determine changes in microbial diversity in adenoid tissue between these groups.ConclusionsThe findings are expected to provide new insights into the diagnosis and treatment of OME, to identify novel biomarkers, and to enhance our understanding of the pathophysiology of OME, potentially leading to the development of innovative diagnostic and therapeutic approaches.

Efficacy of biologics for eosinophilic otitis media

Background Eosinophilic otitis media (EOM) is an intractable condition primarily treated with steroids. Recently, biologics targeting IgE or IL-5 have been introduced. Objectives This study aimed to evaluate the efficacy of biologics for EOM. Materials and Methods We retrospectively collected data on EOM patients treated from January 2008 to December 2020 from electronic medical records. Patients were classified into the steroid group, treated with systemic or local steroids, and the biologics group, treated with biologics with or without steroids. Results The otorrhea remission rate was 63.33% in the steroid group, comparable to 58.82% in the biologics group (p = 0.760). Before treatment, the steroid group showed better bone-conduction (BC) thresholds at 0.5 kHz and 1 kHz than the biologics group. Post-treatment, the steroid group improved in air-conduction (AC) threshold and air-bone gap (ABG) at 1 kHz and 2 kHz. The biologics group exhibited stable audiological results. No significant differences were observed post-treatment between the groups, except for the BC threshold at 0.5 kHz, which remained as pre-treatment. Conclusions and Significance Biologics demonstrated similar efficacy in otorrhea remission as steroids and might help maintain hearing levels. Biologics can be considered for controlling EOM with active otorrhea and reducing systemic steroid use.

Clinical Patterns and Factors Contributing to Ophthalmic and Otologic Events Associated With Immune Checkpoint Inhibitors: A Narrative Review.

Immune checkpoint inhibitors, which are a type of cancer immunotherapy, have been associated with the development of adverse events related to an overactive immune system caused by the effect of this type of therapy. It affects a wide range of organs, including the ear and eye. Ophthalmic toxicity related to immune checkpoint inhibitors usually occurs bilaterally. Corneal toxicity (mainly dry eye disease) and uveitis are the most commonly reported patterns of toxicity. Other patterns of involvement include optic neuritis, serous retinal detachment, keratitis, ophthalmoplegia, and ocular myasthenia, but are not limited to them. Potential factors contributing to the development of toxicity are age, previous history of ocular immune disease, type, doses, and duration of treatment, and race. Ototoxicity is also reported in the literature, usually manifesting as bilateral, symmetrical/asymmetrical hearing loss. Ear toxicity presenting as ear fullness, tinnitus, and vertigo has also been mentioned in the literature. Hearing loss is often associated with word/speech recognition. An audiogram usually shows a pattern of sensorineural hearing loss. Otitis media has also been reported to be a potential cause of ear toxicity. Immune checkpoint inhibitor toxicity was present more commonly when used along with other anti-neoplastic agents. Ear toxicity, which presumably results from damage to the melanocytes in the ear, often presents with other melanocytotic manifestations, like uveitis and vitiligo. According to the literature, some agents (ipilimumab, nivolumab, atezolizumab, and pembrolizumab) were more commonly associated with toxic effects on the eye and ear and more when combined with each other.

Endoscopic ear surgery in the treatment of chronic otitis media with atelectasis.

Atelectasis otitis media (AtOM) is a chronic condition where the tympanic membrane (TM) becomes retracted towards the middle ear and the ossicular chain. Surgical treatment for this condition could be indicated based on stage of atelectasis, patient's clinical condition and hearing loss. Over the years, AtOM has been treated with various types of tympanoplasty under microscopic view. The aim of this study is to present the results of endoscopic ear surgery in AtOM. Forty-five patients who underwent endoscopic trans-canal tympanoplasty were included in the study. Preoperative features, intraoperative findings and postoperative outcomes were collected. Preoperatively, none of the study's patients were classified with a Sadè Grade I, whereas grades II, III and IV were 3 (6.6%), 23 (32.1%) and 19 (67.8%) respectively. The 3 patients with Sadè grade II showed a conductive hearing loss higher than 20dB and a continuous ear fullness, therefore they were surgically treated. The postoperative graft success rate was estimated at 95.5%. During follow-up, 2 patients showed a TM perforation (at 6 and 12months after surgery) whereas 1 patient experienced a recurrence of atelectasis in the TM (16months after surgery). The overall success rate at the final follow-up was calculated at 88.8%. The average preoperative air-conduction threshold was 51.1 ± 21.5, which reduced to 34.6 ± 22.1 (p = 0.04) at follow-up. The preoperative air-bone gap decreased from 28 ± 7.2 to 11.8 ± 10 (p = 0.002) after surgery. Atelectasis otitis media might be suitable for exclusive endoscopic surgical treatment, as it appears to exhibit a low recurrence rate and promising audiological outcomes.

Association between Helicobacter pylori antibodies and otolaryngological diseases

ObjectiveObservational studies have shown that Helicobacter pylori is related to some otolaryngological diseases. However, it is unclear if H. pylori infection causally affects these diseases. To elucidate H. pylori role in 12 common otolaryngological diseases, we conducted two-sample Mendelian randomization analysis. MethodsSingle-nucleotide polymorphisms associated with 7 H. pylori antibodies (IgG, CagA, Catalase, GroEL, OMP, UREA and Vac A) served as instrumental variables. We primarily employed random-effects inverse variance weighting for causal estimation, supplemented by MR Egger, weighted median, simple mode, and weighted mode. Sensitivity analyses, including heterogeneity, pleiotropy, and leave-one-out tests, validated robustness. ResultsMR analysis using inverse variance weighting (random effects) revealed genetically predicted H. pylori CagA antibodies correlated with increased risk of nonsuppurative otitis media (OR = 1.0778, 95% CI 1.0114–1.1487, p-value = 0.021). No causal relationship was observed between H. pylori antibodies and other common otolaryngological diseases. Sensitivity analyses found no pleiotropy or heterogeneity, affirming result reliability. ConclusionThis study suggests that the levels of H. pylori CagA antibodies may contribute to the development of nonsuppurative otitis media. Further studies are needed in the future to elucidate the specific mechanism of H. pylori in this disease. Level of evidenceLevel III.

A Phase 1/2a Study Evaluating Safety and Immunogenicity of Ad26.RSV.preF in RSV-seronegative Toddlers Aged 12-24 Months.

Respiratory syncytial virus (RSV) causes serious illness in children. The Ad26.RSV.preF vaccine candidate was immunogenic with acceptable safety in a phase 1/2a study of RSV-seropositive children. Here, we assessed its safety and immunogenicity in RSV-seronegative children. In this randomized, observer-blinded, placebo-controlled, phase 1/2a study (NCT03606512; https://www.clinicaltrials.gov/ct2/show/NCT03606512), RSV-seronegative toddlers aged 12-24 months received Ad26.RSV.preF (2.5 × 1010 viral particles) or placebo on days 1, 29, and 57 (a meningococcal vaccine [Nimenrix] could substitute for day 57 placebo). Primary endpoints were solicited local and systemic adverse events (AEs; 7 days after each vaccination), unsolicited AEs (28 days postvaccination), and serious AEs (first vaccination until study end). Participants were monitored for RSV-respiratory tract infection to assess infection rates and for severe RSV-lower respiratory tract infection as an indication of enhanced disease. RSV-A2 neutralizing, RSV (A and B) preF binding, and RSV postF immunoglobulin G-binding antibodies were evaluated on days 1 (predose), 8, and 85, and after RSV season 1. Thirty-eight participants were enrolled and vaccinated (Ad26.RSV.preF, n = 20; placebo, placebo/Nimenrix, n = 18). Solicited AEs were more common following Ad26.RSV.preF than placebo; most were mild/moderate. No vaccine-related serious AEs were reported. Five of 19 participants receiving Ad26.RSV.preF and 2/18 receiving placebo or placebo/Nimenrix had confirmed RSV-respiratory tract infection or RSV-associated otitis media; none were considered severe. At the final season 1 study visit, most Ad26.RSV.preF recipients had ≥2-fold increases from baseline in RSV-A2 neutralizing, RSV A and B preF binding, and RSV postF antibodies. Ad26.RSV.preF was well tolerated and immunogenic in RSV-seronegative toddlers.

Genome-wide association study indicates novel associations of annexin A13 to secretory and GAS2L2 with mucous otitis media

To evaluate the genetics of chronic nonsuppurative otitis media (OM). We performed a genome-wide association study of 429,599 individuals included in the FinnGen study using three different case definitions: combined chronic nonsuppurative OM (7034 cases) (included serous and mucous chronic OM), mucous chronic OM (5953 cases), and secretory chronic OM (1689 cases). Individuals without otitis media were used as controls (417,745 controls). We used immunohistochemistry (IHC) of the murine middle ear to evaluate the expression of annexin A13. Four loci were significantly associated (p < 1.7 × 10−8) with nonsuppurative OM. Three out of the four association signals included missense variants in genes that may play a role in otitis media pathobiology. According to our subtype-specific analyses, one novel locus, located near ANXA13, was associated with secretory OM. Three loci (near TNFRSF13B, GAS2L2, and TBX1) were associated with mucous OM. Immunohistochemistry of murine middle ear samples revealed annexin A13 expression at the apical pole of the Eustachian tube epithelium as well as variable intensity of the secretory cells of the glandular structure in proximity to the Eustachian tube. We demonstrated that secretory and mucous OM have distinct and shared genetic associations. The association of GAS2L2 with ciliary epithelium function and the pathogenesis of dysfunctional mucosa in mucous OM is suggested. The abundant expression of annexin A13 in the Eustachian tube epithelium, along with its role in apical transport for the binding and transfer of phospholipids, indicates the role of annexin A13 and phospholipids in Eustachian tube dysfunction.

Otitis in paediatric practice: clinic presentation, diagnosis, role of topical therapy

The article considers the main pathological processes in the outer and middle ear, which are detected at the primary paediatric visit. A particular focus has been placed on the importance of otoscopy and the need for sustainable routing of a child with ear pain. The basic principles for the treatment of acute external and otitis media in children are outlined, and indications for additional examinations and systemic antimicrobial therapy are determined. The benefits of topical combination ear drops in the treatment of acute external and otitis media are presented. The benefits of combination ear drops in the treatment of ear pathology in children from 6 years of age are demonstrated by examples of clinical studies and retrospective analysis of clinical efficacy. Clinical cases from our own observations are presented: a 7-year-old patient with acute non-perforative otitis media and a 12-year-old patient with acute exacerbation of chronic external otitis, myringitis. The combination ear drops containing chloramphenicol, beclomethasone dipropionate (anhydrous), clotrimazole and lidocaine hydrochloride monohydrate demonstrated high clinical efficacy. The combination drug with a beneficial and clinically proven effect can help solve the issue of otitis in children from 6 years of age. The authors have developed a treatment and prevention reminder for ear pathologies in children, which will help the paediatrician explain the main principles of treatment and prevention of otitis media to parents in an easily accessible form. It was concluded that ear pathology is a current and multi-etiological challenge that requires attention and expert knowledge of a paediatrician. The active parental involvement in ear pathology prevention in their child will help their children to grow physically healthy.

Texture-based speciation of otitis media-related bacterial biofilms from optical coherence tomography images using supervised classification.

Otitis media (OM), a highly prevalent inflammatory middle-ear disease in children worldwide, is commonly caused by an infection, and can lead to antibiotic-resistant bacterial biofilms in recurrent/chronic OM cases. A biofilm related to OM typically contains one or multiple bacterial species. OCT has been used clinically to visualize the presence of bacterial biofilms in the middle ear. This study used OCT to compare microstructural image texture features from bacterial biofilms. The proposed method applied supervised machine-learning-based frameworks (SVM, random forest, and XGBoost) to classify multiple species bacterial biofilms from in vitro cultures and clinically-obtained in vivo images from human subjects. Our findings show that optimized SVM-RBF and XGBoost classifiers achieved more than 95% of AUC, detecting each biofilm class. These results demonstrate the potential for differentiating OM-causing bacterial biofilms through texture analysis of OCT images and a machine-learning framework, offering valuable insights for real-time in vivo characterization of ear infections.

Variability in Antimicrobial Prescribing Across Five Ambulatory Settings Within a Large Integrated Health System.

Background: Lack of access to timely, detailed antibiotic use data has limited ambulatory antibiotic stewardship efforts. Antibiotic utilization is tracked across ambulatory care sites and emergency departments (ED) within a large integrated health system. Methods: This is a retrospective cohort analysis from June 1, 2019 to May 31, 2020 comparing antibiotic prescribing for all patients with ICD-10 diagnosis codes for cystitis, otitis media, pharyngitis, sinusitis, and upper respiratory tract infections (URTIs) among five ambulatory care departments across northeast Ohio and southeast Florida locations: ED, Urgent Care (UC), On-Demand Telehealth (TEL), Pediatrics (PED), and Primary Care (PC). Results: A total of 261,947 encounters were included (ED:56,766, UC:92,749, TEL:8,783, PED:29,151, PC:74,498) for the treatment of cystitis (30,932), otitis media (22,094), pharyngitis (59,964), sinusitis (53,693), or URTI (95,264). The population was 63% female with a median age of 34.2 years [12.8-56.3]. A total of 17% of patients had documented penicillin allergies and 18% of patients with pharyngitis received Group A Streptococcus (GAS) testing. Antibiotics were prescribed in 44% of encounters (ED:21,746 [38%], UC:45,652 [49%], TEL:4,622 [53%], PED:10,909 [37%], PC:33,547 [45%]; P < 0.001). Guideline concordant antibiotics were prescribed in 65% of encounters (ED:14,338 [66%], UC:31,532 [69%], TEL:3,869 [84%], PED:8,212 [75%], PC:17,263 [51%]; P < 0.001). Conclusions: Observed rates of antibiotic and guideline concordant antibiotic prescribing were similar to national published rates of antibiotic prescribing in the ambulatory setting. The variability in antibiotic prescribing demonstrates opportunities for targeted outpatient stewardship efforts. Timely antibiotic tracking tools can facilitate ambulatory antimicrobial stewardship activities.

Comparison of endoscopic tympanoplasty, cartilage vs. temporalis fascia in chronic suppurative otitis media with inactive mucosal disease: A prospective randomised study.

The introduction of endoscopy into middle ear has open up new opportunities for minimal invasive temporal bone surgery. The present study was planned to compare anatomical and functional outcome in patients who underwent endoscope assisted tympanoplasty using cartilage and temporalis fascia graft. The present prospective observational randomized study was carried out in the Department of Otorhinolaryngology of a tertiary care teaching hospital of Rajasthan, India from September 2020 to July 2021. Fifty patients of age group 18-60 years, with diagnosis of chronic otitis media having inactive mucosal disease were enrolled in the study and divided into two groups viz. cartilage (group I) and temporalis fascia group (group II). Each patient postoperatively underwent otoscopic examination of ear and pure tone audiometery at 8 weeks and 3rd month. Local wound condition, graft uptake and healing and hearing were assessed and compared. Graft uptake was 92% in cartilage group and 84% in temporalis fascia group. Air conduction and air-bone gap of patients in both the groups showed significant improvement after 3 months of surgery. (p˂0.05) Regarding bone conduction, both groups had shown non-significant changes. (p > 0.05) Hearing gain was comparable on both groups which was 6.71dB in cartilage group vs. 5.9 dB in other group. The present study showed that graft placement time for temporalis fascia graft was less than cartilage graft, but the difference was insignificant. Hearing improvement, graft uptake and clinical improvement were found to be statistically insignificant between both groups.

Applicability of ChOLE staging to preoperative HRCT temporal bone in chronic otitis media with cholesteatoma.

Chronic otitis media with cholesteatoma is a frequent disease entity in otology, requiring surgery in overwhelming majority of cases. Despite the huge burden there is no established grading system available to assess the severity and extent of disease preoperatively until date. Aim of our study is to assess the applicability of ChOLE staging to preoperative HRCT temporal bone in Chronic otitis media with cholesteatoma. Patients clinically diagnosed as COM with cholesteatoma, who underwent preoperative HRCT temporal bone imaging and mastoid exploration at our tertiary care centre were included. Preoperative radiology was assessed and a radiological ChOLE (r-ChOLE) was given by radiologist. This was then compared with the postop ChOLE. 21 patients were included in the study. Data was linear and normally distributed (Shapiro wilk test). Pearson's product-moment correlation used to see relationship between radiological and postop Total score showed strong statistically significant positive correlation with correlation coefficient (r) of 0.977. Paired t test showed p value was 0.329(p > 0.05) suggesting no significant difference between radiological and postop Total scores. Cohen kappa test of agreement was applied. It revealed an overall strong agreement (p < 0.001). ChOLE staging may be extended to preoperative HRCT of temporal bone in COM with cholesteatoma (rCHOLE). A preoperative radiological staging will help in better prioritizing, planning and execution of tympanomastoid surgeries.

Subdural empyema—a rare complication of chronic otitis media: a case report

BackgroundSubdural empyema is an extremely rare and fatal intracranial complication of chronic otitis media. Due to its rarity and vague symptoms, it is often diagnosed late if not completely missed; specially in developing countries where the diagnostic modalities are hardly available or accessible. To the best knowledge of the authors, this is a preliminary reported case of subdural empyema as a complication of chronic otitis media in Eritrea. It aims to provide vital information on the clinical presentation, preferred diagnostic modalities, and the proper management of such cases.Case reportAn 8 years old female patient from the Rashaida ethnic group presented with fever, right ear purulent discharge, right post-auricular swelling, and altered mental status. Prior to her admission, she had history of recurrent purulent discharge from her right ear for almost 2 years, and had been diagnosed with chronic otitis media. Upon admission her GCS was 13/15 which later on deteriorated to be 3/15 on day 3. MRI was done and showed a right fronto-tempo-parietal subdural empyema with mass effect, shifting the midline to the left. She was immediately started on empirical broad-spectrum antibiotics. After the diagnosis was made, craniotomy was done, and 30 ml of pus was removed from the subdural space. Culture and sensitivity of the pus obtained intraoperatively was done but produced no yield. Hence, she was continued on the empirically started antibiotics. The patient’s condition was well improved by post-operative day 4.ConclusionIt is important to have a high index of suspicion of intracranial complications in patients with history of chronic otitis media or other otologic complaints, who present with neurologic manifestations. Subdural empyema still being uncommon even among the intracranial complications of COM, it is often missed. Hence, timely diagnosis with MRI, immediate surgical evacuation of the empyema along with the prolonged administration of broad-spectrum antibiotics is highly recommended.

Bezold Abscess in a Case of Eosinophilic Otitis Media.

A 57-year-old man with a history of bronchial asthma and eosinophilic sinusitis presented to the emergency department with an exacerbation of otitis media. His primary complaints were otopyorrhea, headache, and neck pain with redness. Contrast-enhanced computed tomography revealed a posterior neck abscess contiguous with the mastoid process. The patient underwent mastoidectomy and received antimicrobial therapy. Eosinophilic granulation tissue in the middle ear obstructed the middle ear aditus and directed the inflammatory process toward the mastoid tip. Bezold abscess is a rare extracranial complication of acute mastoiditis. Therefore, clinicians should consider neck pain with redness as an important physical sign that suggests Bezold abscess in patients with otitis media.

Endoscopic cartilage underlay myringoplasty with or without balloon Eustachian tuboplasty for chronic perforation with Eustachian tube dysfunction

ObjectiveThe objective of this study was to compare the outcomes of endoscopic cartilage underlay myringoplasty(CNM) with or without balloon Eustachian tuboplasty (BET) for the treatment of chronic perforation with Eustachian tube dysfunction (ETD). Materials and methodsA total of 50 ears diagnosed with chronic perforation and ETD were randomly divided into receiving alone CNM and CNM + BET. During the 12 months follow-up, the Eustachian tube score (ETS), Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7), ET inflammation scale, hearing results and graft success rate of the patients were recorded and analyzed. ResultsThe improvement in the ETDQ-7 score was 6.23 ± 2.51 in the CNM + BET group, which was significantly higher than that in the CNM group (4.22 ± 3.85, P < 0.01) at postoperative 3 months, however, no significant between-group difference was found at post-12 months.The graft success rate was 88.0 % in the CNM group and 92.0 % in the CNM + BET group at postoperative 3 months (P > 0.05). Also, no significant difference was found among two groups (84.0 % vs 88.0 %, P > 0.05).The ABG improvement was 13.16 ± 3.19 dB in the CNM + BET group and 9.74 ± 2.56 dB in the CNM group, with a statistically significant between-group difference (P < 0.01)at postoperative 3 months. However, no significant between-group difference was found at postoperative 12 months. During followup process, neither complications nor patulous symptoms were noted. No patients developted atelectasis or otitis media with effusion. However, myringitis was seen in 8 % patients in the CNM group and 12 % patients in the CNM + BET group. ConclusionsAlthough BET combined with endoscopic cartilage myringoplasty had better short-term improvement of hearing and ETDQ-7 scores compared with endoscopic cartilage myringoplasty for the treatment of chronic large perforation with ETD, the long-term outcomes was not satisfactory. Also, BET did not improve the 3-and 12 months graft success rate.

Adam Politzer (1835-1920): The Founder of Clinical Otology.

Adam Politzer was a Hungarian surgeon and medical scientist, credited with describing the cochlear nucleus and otitis media, revolutionizing its treatment through his invention of "Politzerization." After receiving training from notable medical figures in Vienna and London, where he studied and trained as a surgeon respectively, he became Vienna's first professor of otology. In 1873, he established the first dedicated otology clinic in the world. His five-volume textbook, "Lehrbuch der Ohrenheilkunde," unified otologic knowledge in his time and remains a resource to this day. Politzer's contributions continue to influence modern otology, solidifying his legacy as a pioneering leader in medicine.

Comparative Study of Endoscopic Transcanal Tympanoplasty and Tympanoplasty by Conventional Postaural Approach in a Tertiary Care Hospital in Central India.

Background Chronic otitis media (COM) often necessitates tympanoplasty to repair the tympanic membrane. While conventional postaural tympanoplasty (PA) is well-established, endoscopic transcanal tympanoplasty (ET) is gaining traction for its minimally invasive benefits. This study aims to compare these two surgical techniques regarding their anatomical and functional outcomes and assess the role of platelet-rich plasma (PRP) in improving these outcomes. Material and methods This prospective comparative study was conducted at Acharya Vinoba Bhave Rural Hospital, involving 60 patients with COM. Participants were randomly assigned to receive either ET or PA, with each group further subdivided based on PRP use. Preoperative evaluations included auditory function tests and diagnostic endoscopy. Postoperative assessments were performed at seven days, one month, and three months to evaluate graft acceptance and hearing improvement using pure tone audiometry (PTA). Statistical analyses included the chi-square test, t-test, ANOVA, and paired t-test. Results The study included patients with a mean age of 38.1 years, predominantly female (71.67%). ET demonstrated superior anatomical outcomes compared to PA, with higher graft acceptance rates and better hearing improvements. The average hearing gain was 10.4 dB in the ET group versus 8.1 dB in the PA group. PRP uses enhanced graft acceptance and hearing restoration across both surgical approaches, contributing to better overall outcomes. Conclusion ET offers significant advantages over conventional postaural tympanoplasty in terms of anatomical and functional results. PRP further improves surgical outcomes, making ET a preferable option for tympanoplasty in COM patients. These findings support the broader adoption of ET and PRP to enhance patient outcomes in tympanoplasty procedures.

Challenges in Managing Newly Diagnosed Granulomatosis With Polyangiitis and Concurrent Respiratory Infections: A Retrospective Case Series.

Granulomatosis with polyangiitis (GPA), formerly termed Wegener's granulomatosis, is an autoimmune disease marked by necrotizing granulomatous inflammation and vasculitis affecting small-sized vessels. It commonly impacts the renal and respiratory systems. This retrospective case series sampling conductedin a tertiary care hospital between May 2023 and April 2024 examined six newly diagnosed GPA patients who wereproteinase 3 cytoplasmic-antinuclear cytoplasmic antibody (PR3 c-ANCA) positive and had concurrent respiratory infections. None of them had any prior immunosuppressive conditions.The age range was 18-47 years with a mean of 35.0 (standard deviation: 11.83). All the patients had pneumonia (N=6, 100%). Out of all, five hadbacterial pneumonia (N=5, 83.3%) and one had tuberculous pneumonia (N=1, 16.7%). A high levelof PR3 c-ANCA (>150 RU/mL) was noted in four patients (N=4, 66.7%).Common symptoms included dry cough (N=5, 83.3%), loss of weight and appetite(N=2, 33.3%), and fever (N=2, 33.3%). Three patients had otitis mediaand/or nasal polyposis (N=3, 50%). Two patients (N=2, 33.3%) with life-threatening organ dysfunction were given concurrent antibiotics and steroids; the antibiotics were later modified based on culture and sensitivity results. One of these patients received antituberculosis therapy as Mycobacterium tuberculosis (MTB) was detected after 27 days of incubation in mycobacterial growth indicator tube broth. The remaining four patients (N=4, 66.7%)receivedantibiotics initially for 5-7 days until clinical resolution of pneumonia. Ultimately, they all showed clinical and radiological resolution (N=6, 100%) within 3-6 months of treatment. The patients exhibited constitutional symptoms such as fever and weight loss; lower airway disease symptoms including dry cough and hemoptysis; nasal and ear disease symptoms like epistaxis, ear pain, and ear discharge; and a renal disease symptom, hematuria.Computed tomography of the thorax revealed bilateral consolidations, most of which were cavitating. Bronchoalveolar lavagecultures grew Escherichia coli, Burkholderia cepacia, Pseudomonas aeruginosa, Klebsiella pneumoniae, and MTB, whereas pus swab cultures from otitis media grew Pseudomonas aeruginosa, Staphylococcus aureus,and coagulase-negative staphylococci. This study highlights the therapeutic challenges of GPA complicated by concurrent infections. Patients exhibited typical GPA signs, confirmed by PR3 c-ANCA levels. Concurrent infections require cautious antibiotic treatment before starting immunosuppressive therapy, except in life-threatening organ dysfunction. A unique case presented with both tuberculosis and GPA. Tailored treatment regimens combining antibiotics and immunosuppressives, including corticosteroids, methotrexate, and rituximab, resulted in clinical and radiological improvement in all the patients within 3-6 months. The addition of co-trimoxazole reduced the incidence of non-severe GPA relapses. Tailored treatment plans addressing both infectious and autoimmune aspects are essential for optimal care in GPA complicated by concurrent infections. This study highlights the need for a multidisciplinary approachinvolving pulmonologist, rheumatologist, microbiologist, and pathologistin the diagnosis and treatment of GPA, emphasizing the importance of individualized treatment plans tailored to the specific clinical scenario.

Otitis media sequelae and hearing in adolescence after administration of an 11-valent conjugate pneumococcal vaccine in infancy: a prospective cohort study with long-term follow-up of the ARIVAC trial

Pneumococcal conjugate vaccines (PCVs) have been shown in randomised controlled trials and epidemiological studies to prevent acute otitis media caused by vaccine serotype pneumococci, although their role in preventing complications of acute otitis media is less clear. We hypothesised that the 11-valent PCV would reduce the long-term sequelae of acute otitis media, including moderate-to-severe ear disease and hearing loss. This prospective cohort study, referred to as 11PCV study, included follow-up after 16-20 years of children previously enrolled in 2000-04, at age 6 weeks to 6 months, in the randomised, placebo-controlled, ARIVAC trial of 11-valent PCV for the prevention of radiographical pneumonia. The ARIVAC trial and this 11PCV study were conducted at six study centres in Bohol, Philippines. Ear disease was classified using video-otoscopy review and observations derived from the ear exam. The final classification of the worst ear disease was mild (ie, acute otitis media, otitis media with effusion, healed perforation, or tympanosclerosis), moderate (ie, dry perforation or adhesive otitis media), or severe (chronic suppurative otitis media). Hearing loss was assessed following a standard schema and classified according to the worst ear as mild (>15 to 30 dB puretone average) or moderate-to-profound (>30 dB pure tone average). We calculated the relative and absolute risk reduction in the primary outcome of moderate-to-severe ear disease and the secondary outcomes of mild or moderate-to-profound hearing loss in adolescents who previously received the 11-valent PCV compared with those who received placebo during infancy in ARIVAC. Of the 15 593 children assessed for eligibility in ARIVAC, 12 194 were randomly assigned and 8926 were alive and could be located for enrolment in this 11PCV study between Sept 19, 2016, and Dec 13, 2019. 8321 (4188 in the vaccine group and 4133 in the placebo group) completed follow-up of the 11PCV study by March 30, 2020, and had sufficient data to classify ear disease and be included in the primary outcome analysis. The primary outcome of the absolute risk reduction in moderate-to-severe ear disease in the vaccine group (310 [7·4%] of 4188) versus those in the placebo group (356 [8·6%] of 4133) was 1·2% (95% CI 0·0-2·4; p=0·046) and the relative risk reduction was 14·1% (0·0 to 26·0). There were no differences in secondary outcomes of mild hearing loss or moderate-to-profound hearing loss between the vaccine and placebo groups. The absolute risk reduction for moderate-to-severe ear disease in adolescence of 1·2% (12 per 1000 children) was almost three times higher than the 0·45% reduction (4·5 per 1000 children) in radiographical pneumonia in the first 2 years of life shown in ARIVAC. Administration of 11-valent PCV in infancy was associated with absolute and relative risk reductions in the sequelae of acute otitis media 16-20 years after the original ARIVAC trial. Bill & Melinda Gates Foundation.