Middle Ear Aspirates Research Articles

Should we aspirate middle-ear effusions prior to insertion of ventilation tubes?

Routine aspiration of middle-ear effusions prior to ventilation tube (grommet) insertion is practised by many surgeons. It has been suggested that removing the fluid from the middle ear improves immediate post-operative hearing levels and reduces the chance of the ventilation tube becoming obstructed. The potential adverse effects of applying suction to the middle ear include acoustic trauma and an increased risk of tympanosclerosis and otorrhoea. We undertook a review of the literature in order to determine the benefits or side effects associated with middle-ear aspiration prior to ventilation tube insertion. To compare clinical outcomes associated with aspirating versus not aspirating the middle ear prior to ventilation tube insertion. The Cochrane ENT group trials register, DARE, the Cochrane central register of controlled trials (CENTRAL), MEDLINE (1960-2005) and EMBASE (1960-2005) were searched using relevant terms. Reference lists of selected studies were scanned for additional research material. Seven studies were identified, of which three fitted the inclusion criteria of our review. Current evidence suggests that aspiration of middle-ear effusions prior to insertion of ventilation tubes is not associated with any improvement in clinical outcome, in terms of post-operative hearing levels, otorrhoea or rates of blockage of ventilation tubes. Significantly increased rates of tympanosclerosis were observed in one study and the development of acoustic trauma was observed; however, no significant association was confirmed. Although more research is needed, there is no evidence that aspiration of middle-ear effusion prior to grommet insertion confers any advantage.

Characterization of genetic and phenotypic diversity of invasive nontypeable Haemophilus influenzae.

The ability of unencapsulated (nontypeable) Haemophilus influenzae (NTHi) to cause systemic disease in healthy children has been recognized only in the past decade. To determine the extent of similarity among invasive nontypeable isolates, we compared strain R2866 with 16 additional NTHi isolates from blood and spinal fluid, 17 nasopharyngeal or throat isolates from healthy children, and 19 isolates from middle ear aspirates. The strains were evaluated for the presence of several genetic loci that affect bacterial surface structures and for biochemical reactions that are known to differ among H. influenzae strains. Eight strains, including four blood isolates, shared several properties with R2866: they were biotype V (indole and ornithine decarboxylase positive, urease negative), contained sequence from the adhesin gene hia, and lacked a genetic island flanked by the infA and ksgA genes. Multilocus sequence typing showed that most biotype V isolates belonged to the same phylogenetic cluster as strain R2866. When present, the infA-ksgA island contains lipopolysaccharide biosynthetic genes, either lic2B and lic2C or homologs of the losA and losB genes described for Haemophilus ducreyi. The island was found in most nasopharyngeal and otitis isolates but was absent from 40% of invasive isolates. Overall, the 33 hmw-negative isolates were much more likely than hmw-containing isolates to have tryptophanase, ornithine decarboxylase, or lysine decarboxylase activity or to contain the hif genes. We conclude (i) that invasive isolates are genetically and phenotypically diverse and (ii) that certain genetic loci of NTHi are frequently found in association among NTHi strains.

The microbiology of glue ear in Australian Aboriginal children.

To study the bacterial cultures of middle ear aspirates from 27 Aboriginal children with otitis media with effusion. Standard bacteriological techniques were used to analyse the middle-ear aspirates collected during surgery to insert grommets in 27 Aboriginal children. Swabs of the tympanic membrane were taken for comparison. Forty-five aspirates were collected from 59 myringotomies. Positive cultures were obtained from 19 of these (13 children) with potentially pathogenic organisms identified in 11 children including Staphylococcus, Pseudomonas, Haemophilus influenzae, Moraxella, Achromobacter, Enterobacter and Corynebacterium. This is only the second study to look at the bacteria in middle ear effusions in Aboriginal children. Streptococcus pneumoniae was notable in its absence as was found in a previous study.

Detection of LMP-1 gene in middle ear effusion of NPC

Nasopharyngeal carcinoma (NPC) is closely related with Epstein–Barr virus (EBV). Almost every NPC tumor cells carries clonal EBV genomes. Detection of EBV derived latent membrane protein-1 gene (LMP-1) indicate the presence of NPC. Middle ear effusion (MEE) is a frequent sign of NPC. There have been no reports on LMP-1 in MEE. Tympanocentesis of 88 ears with MEE of 66 patients were done in three groups of patients, group (I) NPC, 31 patients, 50 ears, (II) other head and neck cancers, five patients, six ears and (III) no cancer history, 30 patients, 32 ears. The middle ear aspirate and nasopharyngeal swab specimen were collected to detect LMP-1 with a PCR-based method. Sixty aspirates (68%) out of 88 ears with MEE had enough DNA for PCR amplification. LMP-1 was detected in six middle ear aspirate specimen from three patients in group I who had petrous apex invasion. LMP-1 was detected in 30 swab specimen (93.8%) out of 32 nasopharyngeal swabs in group I. LMP-1 was not detected in middle ear aspirates or nasopharyngeal swab in group II and III patients. LMP-1 was not detected in MEE in patients without NPC. In NPC patients, the detection of LMP-1 may indicate petrous apex invasion.

Stimulation of adenoidal lymphocytes by Alloiococcus otitidis.

Otitis media with effusion (OME) is characterized by persistent effusion in the middle ear cavity and by chronic inflammation in the middle ear mucosa. Alloiococcus otitidis, a gram-positive aerobic bacterium, has been isolated in middle ear effusion, and by means of sensitive polymerase chain reaction detection assays it has been detected in as many as 20% of middle ear aspirates of patients with OME. Because A otitidis may freely interact with leukocytes in the middle ear effusion, it may potentially modulate the inflammatory reaction in OME. To study the nature of these interactions, we applied an in vitro assay in which killed A otitidis bacteria were incubated with peripheral blood and adenoidal mononuclear cells. The expression of the proliferation-associated surface marker CD69 was then measured in B lymphocytes and in CD4+ helper and CD8+ cytotoxic-suppressor T lymphocytes by means of multicolor flow cytometry. Alloiococcus otitidis induced the expression of CD69 in both peripheral blood and adenoidal T and B cells. Among the T cells, the cytotoxic-suppressor T lymphocytes were preferentially activated. It was also tested whether A otitidis would have an effect in another cytotoxic and immunoregulatory system, namely, the induction of natural killer cell activity in peripheral blood mononuclear cells. However, the effect was minimal compared with that of Salmonella minnesota or Staphylococcus aureus. The results show that A otitidis has a unique immunostimulatory capacity in vitro that is mainly confined to CD8+ T lymphocytes.

Documentation of the prevalence of penicillin-resistant Streptococcus pneumoniae isolated from the middle ear and sinus fluid of children undergoing tympanocentesis or sinus lavage.

With increasing pneumococcal resistance to penicillin and other antibiotics, use of antibiotic therapy for children with upper respiratory tract infections such as otitis media and sinusitis has become difficult. Selecting an appropriate treatment regimen has become more challenging due to frequent concomitant microbial resistance to multiple antibiotics. In a prospective, nonrandomized study, we obtained middle ear and sinus aspirate specimens from all children undergoing outpatient tympanocentesis or sinus lavage for any indication at our institution over two 4-week periods. One hundred fifty-four specimens were obtained. Of these, 12 grew Streptococcus pneumoniae, 7 of which were resistant to penicillin. A 6-month retrospective review of these patients' medical histories evaluated their antibiotic use prior to surgical intervention. An association between penicillin resistance and recent use of 2 or more antibiotics in children with positive S pneumoniae cultures was confirmed, as has been documented in prior reports. Those with penicillin-resistant S pneumoniae also demonstrated a higher incidence of multidrug-resistant organisms.

Resistance to antimicrobials used for therapy of otitis media and sinusitis: effect of previous antimicrobial therapy and smoking.

We undertook to identify the antimicrobial susceptibility of the pathogens isolated from patients with otitis media or maxillary sinusitis who failed to respond to antimicrobial therapy, and correlate it with previous antimicrobial therapy and smoking. We analyzed isolates recovered from 2 consecutive cultures obtained from middle ear aspirate obtained through an open perforation in 22 children with otitis, and maxillary sinus aspirate collected by endoscopy from 20 patients. Forty-seven isolates were repeatedly recovered from 42 culture-positive individuals. The organisms isolated were Streptococcus pneumoniae (15 isolates), Haemophilus influenzae (14), Staphylococcus aureus (7), Moraxella catarrhalis (6), and Streptococcus pyogenes (5). Resistance of at least 2 tube dilutions to the antimicrobial agents used was found in 23 of the 47 (49%) isolates that were found in 20 (48%) of the patients. These included 10 of 15 (67%) isolates of S pneumoniae, 4 of 14 (29%) H influenzae (all were beta-lactamase producers), 4 of 7 (57%) S aureus (all beta-lactamase producers), 5 of 6 (83%) M catarrhalis (all beta-lactamase producers), and none of 5 S pyogenes. In the 21 patients who failed to respond to amoxicillin, H influenzae and S pneumoniae predominated. Streptococcus pneumoniae was recovered from 4 of the 11 (36%) after trimethoprim-sulfamethoxazole, 4 of 21 (19%) after amoxicillin, 2 of 3 (67%) after azithromycin dihydrate, and 1 of 4 (25%) after cefixime. A statistically significant higher recovery of resistant organisms was noted in those treated 2 to 6 months previously, and in those with sinusitis who smoked. The data illustrate the relationship between resistance to antimicrobials and failure of patients with otitis media and sinusitis to improve.

Acute otitis media in children with bronchiolitis.

We investigated the prevalence and the etiology of acute otitis media (AOM) in children with bronchiolitis to determine whether AOM in such children is due entirely or mainly to respiratory syncytial virus (RSV), in which case routine antimicrobial treatment would not be appropriate. The study group consisted of children aged 2 to 24 months with bronchiolitis. In patients with AOM at entry, nasal washings for RSV enzyme-linked immunosorbent assay were obtained, and Gram-stained smear, bacterial culture, and reverse transcriptase polymerase chain reaction to detect the presence of RSV were performed on middle-ear aspirates. Patients without AOM were reevaluated at 48 to 72 hours, 8 to 10 days, and 18 to 22 days. Forty-two children with bronchiolitis were enrolled. Sixty-two percent had AOM at entry or developed AOM within 10 days. An additional 24% had or eventually developed otitis media with effusion. Only 14% remained free of both AOM and otitis media with effusion throughout the 3-week observation period. All patients with AOM had 1 or more bacterial pathogens isolated from one or both middle-ear aspirates. Of 33 middle-ear aspirates, Streptococcus pneumoniae was isolated in 15, Haemophilus influenzae in 8, Moraxella catarrhalis in 8, and Staphylococcus aureus in 2. Two middle-ear aspirates yielded 2 pathogens each; 2 aspirates had no growth. RSV was identified in 17 (71%) of 24 patients with AOM. Bacterial AOM is a complication in most children with bronchiolitis. Accordingly, in patients with bronchiolitis and associated AOM, antimicrobial treatment is indicated.

Aerobic and Anaerobic Bacteriology of Otorrhea Associated with Tympanostomy Tubes in Children

The microbiology of in 55 ear aspirates obtained from 34 children with chronic otorrhea was studied. Aspiration of the middle ear exudate was done immediately following removal of tympanostomy tube (TT). The middle ear aspirates and swab specimens of the external auditory canals were cultured for aerobic and anaerobic bacteria. Sixty-five isolates were recovered only from the middle ears, 73 only from the external ear canals, and 73 were present at both sites. Analysis of the 138 middle ear isolates demonstrated the recovery of aerobic bacteria only in 28 patients (50%), anaerobes only in seven (13%), and both aerobes and anaerobes in 20 (36%). There were 77 aerobic and 61 anaerobic isolates. Commonly recovered aerobes were Pseudomonas aeruginosa (17 isolates), Staphylococcus aureus (11), Proteus sp. (7), Moraxella catarrhalis (6), Klebsiella pneumoniae (5) and non-typable Haemophilus influenzae (5). Commonly isolated anaerobes were Peptostreptococcus sp. (25 isolates), Prevotella sp. (25), Bacteroides sp. (10) and Fusobacterium sp. (6). Pseudomonas aeruginosa and S. aureus were more often isolated in children older then 6 years. These findings demonstrate the polymicrobial bacteriology of TT-related otorrhea in children. Specimens collected from the external auditory canals can be misleading. Reliable information can be obtained from the ear exudes when collected through the TT or through the open perforation after their removal.

Chlamydia pneumoniaein Children with Otitis Media

In this study the polymerase chain reaction was used to test for the presence of Chlamydia pneumoniae DNA in 118 middle-ear aspirates from 20 children with acute otitis media (AOM) and 53 children with otitis media with effusion (OME). C. pneumoniae was detected in 8 samples obtained from 5 children with OME and, together with Streptococcus pneumoniae, in a sample from 1 child with AOM. The mean age of these five children (6.6 +/- 1.4 years) was significantly higher than that of the 48 children with OME in whom C. pneumoniae could not be detected (4.3 +/- 1.9 years). The presence of C. pneumoniae in 9.4% of the examined children with OME suggests that C. pneumoniae might be a significant supplementary factor in the etiology of this common children's disease.

Étude bactériologique au cours de l'otite moyenne aiguë

Aim. — A prospective study on bacteriological epidemiology in acute otits media was conducted in a pediatric hospital emergency service from January 1993 to October 1995. Patients. — One hundred and fifty-eight children, aged 6 months to 6 years, with an acute otitis media were included. Culturing and cleansing of the ear canal and tympanocentesis for aspiration and culture of the secretions were performed in 118 children (46 of whom had received antibiotics before for 48 hours). Main results. — Middle ear aspirates were sterile in 35% of the children who had not received antibiotics and in 64% of those already treated. Bacteria in middle ear were predominantly Haemophilus influenzae and Streptococcus pneumoniae. Fifty-nine percent of S pneumoniae strains were penicillin-resistant; however, they were responsible for clinical failure in only 8% of cases. No Staphylococcus strains, commensal of the ear canal, could be considered as pathogenic for the middle ear. Conclusion. — The preciseness with which secretions of middle ear are aspirated reduces the risk of contamination and comparison of ear canal and middle ear cultures allows to identify them. The high ratio of sterile middle ear aspirates after antibiotic treatment raises the question if other factors are responsible for persistent symptoms. The existence of penicillin-resistant S pneumoniae must be known to adjust treatment.

Chlamydia in Pediatric Otitis

The bacteria most commonly isolated from middle ear aspirates are pneumococcus, Hemophilus influenzae, Moraxella catarrhalis, and group A strep. Chlamydia pneumoniae (Cp) has been isolated from the nasopharynx in 14% of children 3 to 12 years old with community-acquired pneumonia, and is a common …

Experimental Otitis Media withMoraxella (Branhamella) Catarrhalis

Two hundred fifty gerbils and 7 chinchillas were utilized in 11 experiments to determine the effect of inoculating viable and heat-killed suspensions of Moraxella (Branhamella) catarrhalis into the middle ear cavity. Development of otitis media was observed by otoscopy and histopathology. Gerbils were found to be susceptible to 2 x 10(4) viable M catarrhalis cells. Depending on the number of cells inoculated, the resulting untreated inflammation was a very mild to moderately severe, self-limiting disease with no permanent sequelae except in animals inoculated with high [10(6) to 10(7)] numbers of bacteria. Viable bacteria could not be isolated from the middle ears 24 hours after inflammation was induced. Heat-killed cells produced less severe acute inflammation with no permanent sequelae. We conclude 1) gerbils and chinchillas are susceptible to a self-limited inflammation caused by M catarrhalis, 2) no infection occurs, since viable bacteria cannot be recovered from middle ear aspirates, and 3) viable cells produce more severe inflammation than heat-killed cells.

Capsular types and antibiotic susceptibility of pneumococci isolated from patients in Belgium with serious infections, 1980-1993.

During the 13-year period from 1 November 1980 to 31 January 1993, we received and serotyped a total of 5,619 clinically significant strains of Streptococcus pneumoniae isolated in more than 75 laboratories in Belgium (4,079 [72.6%] were from blood or pleural fluid, 462 [8.2%] were from cerebrospinal fluid, 691 [12.3%] were from middle ear aspirates, and 387 [6.8%] were from various other body fluids). The isolates belonged to 64 of the 84 currently recognized serotypes. Among the 4,722 isolates tested for susceptibility since 1983, 22% were resistant to at least one antimicrobial agent. Resistance to penicillin has slowly increased since 1985 but remained stable at a level of 2%-4% between 1986 and 1993. Of the 119 isolates with reduced penicillin susceptibility, only 23 were fully resistant (MIC, > or = 2 micrograms/mL) and none of these proved to be resistant to cephalosporins. Resistance to erythromycin increased significantly from 5.2% in 1986 to 21.5% in 1993. Resistance to penicillin and erythromycin was also more frequently recognized in a smaller number of capsular types of S. pneumoniae.

Persistent acute otitis media

In this three-year prospective study, 137 children with acute otitis media (AOM) that had not responded after one or two empiric antimicrobial treatment courses (termed persistent AOM) underwent tympanocentesis to determine additional antimicrobial therapy based on in vitro susceptibility testing of the bacterial isolate(s). One hundred eleven children with AOM not previously treated are described for comparison. In the persistent AOM group middle ear aspirates grew Streptococcus pneumoniae (24%), Haemophilus influenzae (7%), Brahamella catarrhalis (7%), Streptococcus pyogenes (6%), Staphylococcus aureus (5%), two pathogens (3%) or no bacterial growth (49%); pathogens in previously untreated AOM were similar but fewer patients (30%) had no bacterial growth. After tympanocentesis additional antimicrobial therapy for persistent AOM patients utilizing drugs shown to be effective in vitro against the isolated pathogen failed to produce clinical resolution of infection in 27 (28%) of ears. Differing clinical efficacy was observed with various antimicrobials: amoxicillin (57% failure); trimethoprim/sulfamethoxazole (75% failure); cefaclor (37% failure); cefixime (23% failure); amoxicillin/clavulanate (12% failure); and cefuroxime axetil (13% failure). Presumptive clinical cure for previously untreated AOM patients was similar to that for untreated AOM except for fewer amoxicillin failures (30%). We conclude that clinical failure in persistent AOM occurs (1) even when no pathogen is isolated from tympanocentesis (50% of patients) and (2) despite demonstrated in vitro activity against culture-proved pathogens.

Persistent acute otitis media

In this prospective study tympanocentesis was performed to determine the pathogens isolated from middle ear fluid of 200 ears in 137 children with acute otitis media (AOM) which had not responded after one or two empiric antimicrobial treatment courses (termed persistent AOM). For comparison tympanocentesis from 154 ears in 111 children with AOM not previously treated are described. Patients were enrolled from October, 1989, until September, 1992. In the persistent AOM group amoxicillin and trimethoprim/sulfamethoxazole were the most frequently used antimicrobials before tympanocentesis. Middle ear aspirates produced no pathogenic bacterial growth in 49% of persistent AOM patients, Streptococcus pneumoniae in 24%, Haemophilus influenzae in 7%, Branhamella catarrhalis in 7%, Streptococcus pyogenes in 6%, Staphylococcus aureus in 5% and two pathogens in 3%. Two (18%) of 11 S. pneumoniae isolates tested were penicillin-resistant; 1 was intermediate and 1 was highly resistant. Ten (83%) of 12 H. influenzae and all of 11 B. catarrhalis AOM isolates produced beta-lactamase. In comparison previously untreated AOM patients produced no bacterial growth from tympanocentesis in 30%, S. pneumoniae in 36% (8% penicillin-resistant), H. influenaze in 13% (44% beta-lactamase-producing) and B. catarrhalis in 11% (85% beta-lactamase producing). AOM which is persistent after initial empiric antimicrobial therapy may be caused by middle ear inflammation after bacteria are killed or involve penicillin-resistant S. pneumoniae, beta-lactamase-producing H. influenzae or B. catarrhalis more commonly than occurs in AOM which has not been recently treated.

Factors influencing outcome in children treated with antibiotics for acute otitis media

Factors affecting outcome were analyzed from 3 antibiotic clinical trials that had identical case definition and outcome criteria. Overall 102 subjects with acute otitis media had an initial tympanocentesis, were enrolled in one of the clinical trials, were randomized to receive 10 days of oral treatment and had a posttherapy visit. The antibiotics used were cefixime (38), cefaclor (25), loracarbef (14), amoxicillin plus clavulanate (16) or amoxicillin (9). Fifty-five of the 102 (54%) study subjects were classified as cured or improved at the 21- to 28-day posttherapy visit. Factors analyzed in relation to outcome included antibiotic administered, isolation of a pathogen from the middle ear aspirate, study subject age and sex, history of recurrent otitis media, unilateral vs. bilateral involvement, season of enrollment and history of antibiotic administration in the month before enrollment. Univariate analysis identified the following four factors associated with higher posttherapy visit failure rates: a history of recurrent otitis media; enrollment during winter respiratory season (December through March); a history of being treated with an antibiotic during the month before enrollment; and administration of cefaclor compared with other antibiotics. However, only a history of recurrent otitis media and enrollment during the winter respiratory season met the 0.05 significance level for entry into a model derived from logistic regression to assess interactions among factors. Clinical guidelines for the management of otitis media should take into consideration that children with a prior history or recurrent otitis media and infection during the winter season more often fail to respond to antibiotic treatment and have a higher risk of developing a persistent middle ear effusion.

ASSOCIATION OF CHLAMYDIA PNEUMONIAE INFECTION WITH OTITIS MEDIA WITH EFFUSION

Chlamydia pneumoniae has recently been recognized to cause various human respiratory tract diseases, including pharyngitis, bronchitis and pneumonia. The most common pathogens of respiratory tract infections such as Streptococcus pneumoniae and Haemophilus influenzae are frequently present in middle ear effusions. Therefore, it is possible that C. pneumoniae play a role in otitis media with effusion (OME). Isolation of C. pneumoniae from middle ear aspirates of OME was performed by the culture method using the HeLa 229 or HL cell line. Identification as C. pneumoniae was based on positive staining for inclusions by a species-specific fluorescein-conjugated monoclonal antibody. C. pneumoniae was recovered from 17.8% (13 of 73) of the patients with acute OME, and 7.1% (3 of 42) of those with chronic OME, Moreover, antibodies to C. pneumoniae were measured by the microimmunofluorescence method in 14 patients who yielded the agent, and all of them had detectable antibodies to C. pneumoniae. Evidence of recent or current infection by the organism was found in nine patients on the basis of either on IgM antibody titer of 1:16 or higher, or a four-fold rise in the titer of IgG antibody. The study findings indicate that C. pneumoniae can cause OME and that the organism is a new candidate as an etiological agent of middle ear diseases.

An ad hoc tympanocentesis apparatus.

Myringotomy is one of the commonest procedures carried out by ENT surgeons. Analysis of middle ear aspirate is sometimes helpful in the management of ear disease. A simple method of constructing an apparatus for collection of middle ear aspirate is described.

Bacteriology of Acute Otitis Media in Adults

--The objective of this study was to determine the bacteriology of acute otitis media in adults. Although this has frequently been studied in children, no data have recently been reported from adults in the United States. Additionally, information on the prevalence of Haemophilus influenzae as a causative organism in acute otitis media in adults has not been available. --Middle-ear aspirates for cultures were obtained by myringotomy from adults meeting entry criteria. --Emergency department, Eye and Ear Hospital of Pittsburgh, Pa. --Thirty-four patients (volunteer sample) met the eligibility requirements. Exclusion criteria included history of chronic otitis media, recent antibiotic therapy, immunosuppressive illnesses, or prior otologic surgery. --Ten days of oral cefuroxime axetil (250 mg) was prescribed. --Patients were followed closely for at least 6 weeks. Aerobic and anaerobic cultures were incubated and evaluated per the scheduled protocol. --Haemophilus influenzae and Streptococcus pneumoniae were grown on culture of specimens from nine and seven patients (26% and 21%), respectively. Twenty-two percent (2/9) of the H influenzae isolates and the single isolate of Moraxella catarrhalis produced beta-lactamase (9% overall). --The present results suggest that, as in children, amoxicillin would be an appropriate first-line agent for empiric therapy of acute otitis media in adults. Antimicrobials inactive against H influenzae (eg, penicillin V, cephalexin, erythromycin, or tetracyclines) are not appropriate for initial therapy. Antimicrobials with efficacy against organisms producing beta-lactamase, such as cefuroxime axetil, which was used to treat the study patients, do not appear to be required for routine initial therapy in adults. However, they would be appropriate when an organism producing beta-lactamase is isolated from the middle ear or when a patient fails to improve rapidly on amoxicillin therapy.