Persistent Middle Ear Effusion Research Articles

Mechanical ventilation and middle ear effusions among tracheostomy-dependent children

ObjectiveTo determine the cumulative 24-month incidence of middle ear effusion (MEE) among tracheostomy-dependent children requiring ventilatory support. MethodsA prospective longitudinal cohort study included all children under 2 years of age with a tracheostomy placed at a tertiary care children's hospital between 2015 and 2020 that obtained at least one tympanometry exam. The development of MEE, defined as a flat tympanogram with normal external canal volume, and mechanical ventilation requirement at examination were recorded. ResultsNinety-four children with a mean age at tracheostomy of 5.4 months (SD: 3.7) were included. During a mean follow-up of 18.3 months (SD: 14.6) (median: 14.1 months, interquartile range: 6.6–27.8), 192 tympanometry examinations were obtained with 59% (114/192) while requiring mechanical ventilation. Within 24 months after tracheostomy, 56.5% (95% CI: 48.9–64.4%) of children developed at least one MEE. Among those on mechanical ventilation, 74.0% (95% CI: 65.6–82.5%) developed MEE compared to 31.2% (95% CI: 21.4–44.0%) not on mechanical ventilation (HR: 2.97, 95% CI: 1.46–6.05, P = .003). A persistent MEE on two consecutive exams was not statistically more common for children on a ventilator (OR: 0.64, 95% CI: 0.01–6.95, P = .70). When controlling for age at exam, craniofacial syndrome, and newborn hearing test results on logistic regression, ventilator-dependence significantly predicted the presence of MEE (OR: 2.34, 95% CI: 1.18–4.68, P = .02). ConclusionChildren with a tracheostomy were more likely to develop MEE when requiring mechanical ventilation. Clinicians should recognize this risk factor and appropriately assess for development of MEE to mitigate adverse speech and language development outcomes in this vulnerable population.

Antibiotics for otitis media with effusion in children.

Otitis media with effusion (OME), one of the most common diseases in early childhood, is a self-limited illness1 with an estimated recurrence rate of 50% within 24 months2 . OME is characterized by an accumulation of fluid in the middle ear without symptoms or signs of acute infection.3 In most cases OME causes mild hearing impairment for a short period. OME in the pediatric population can lead to diminished hearing which in theory could hinder early learning. Some studies have shown an association with adult hearing loss as well.4 In one study, for instance, OME and recurrent otitis media before the age of 3 were weakly associated with worse classroom concentration, mathematical skills, oral performance and reading skills5 .

Outcome of Gastroesophageal Reflux Therapy in Children with Persistent Otitis Media with Effusion.

Introduction Otitis media with effusion (OME) is considered one of the most common disorders that affect children during the first years of life. There are many risk factors of persistent middle ear effusion; one of these risk factors is gastroesophageal reflux. Association between persistent OME and gastroesophageal reflux diseases (GERDs) could be explained by respiratory tract infections, insufficient ciliary clearance, and poor drainage of the Eustachian tube. Objective To investigate whether the control of gastroesophageal reflux plays a role in the management of persistent OME and decreases tympanostomy tube insertion Method A cross-sectional study was conducted on 50 children complaining of persistent OME. Their ages ranged between 5 and 12 years old. All children were subjected to full history taking, audiological assessment and 24-hour esophageal pH monitoring. The study group was divided according to pH results into two groups: GERD positives and GERD negatives. Result The prevalence of GERD in persistent OME was 58%. There were statistically significant differences in the hearing levels and middle ear condition before and after the treatment ( p < 0.05). The percentage of improvement of children complaining of persistent OME after antireflux treatment was 52%. Conclusion Gastroesophageal reflux disease should be considered in patients with persistent OME. The administration of proton pump inhibitor (PPI) can set aside superfluous surgical treatment (such as tympanostomy).

Tympanostomy Tube Controversies and Issues: State-of-the-Art Review.

To review current pragmatic issues and controversies related to tympanostomy tubes in children, in the context of current best research evidence plus expert opinion to provide nuance, address uncertainties, and fill evidence gaps. Each issue or controversy is followed by the relevant current best evidence, expert insight and opinion, and recommendations for action. The role of expert opinion and experience in forming conclusions is inversely related to the quality, consistency, and adequacy of published evidence. Conclusions are combined with opportunities for shared decision-making with caregivers to recommend pragmatic actions for clinicians in everyday settings. The issues and controversies discussed include (1) appropriate tube indications, (2) rationale for not recommending tubes for recurrent acute otitis media without persistent middle ear effusion, (3) role of tubes in at-risk children with otitis media with effusion, (4) role of new, automated tube insertion devices, (5) appropriateness and feasibility of in-office tube insertion in awake children, (6) managing methicillin-resistant Staphylococcus aureus acute tube otorrhea, and (7) managing recurrent or persistent tube otorrhea. Despite a substantial, and constantly growing, volume of high-level evidence on managing children with tympanostomy tubes, there will always be gaps, uncertainties, and controversies that benefit from clinician experience and expert opinion. In that regard, the issues discussed in this review article will hopefully aid clinicians in everyday, pragmatic management decisions.

Hearing status and behavioural patterns among school aged children with cleft lip and/or palate

ObjectiveThere is a dearth of studies on long term hearing status and behavioural patterns among cleft lip and/or palate children after their primary lip and palate closure in Malaysia. This study describes the audiology status and behavioural patterns in a group of school aged children with cleft lip and/or palate. MethodA cross sectional study was carried out where caretakers of cleft lip and/or palate were asked to complete the translated Malay language version of Strength Difficulties Questionnaire. The hearing status of the children was analyzed based on recent pure tone audiometric and tympanogram results. The patients’ age, gender, type of cleft pathology, age of palatal surgery and behavioural patterns were examined for their potential relationship with hearing status. ResultsA total of 74 children (148 ears) aged between 7 and 17 years with cleft lip and/or palate were recruited. The result showed 37 ears (25.0%) had hearing loss with majority suffered from mild conductive hearing loss. There were 16 ears (10.8%) that had persistent middle ear effusion. Hearing improvement occurred when palatal repair was performed at the age of less than 1 year old. (p = 0.015) There was no significant relationship between patients' gender, age, type of cleft and history of myringotomy with their hearing status. In terms of behavioural patterns, 16.3% were abnormal for total behavioural score, 39.2% for peer problem and 17.6% for conduct problem. For prosocial behaviour, 16.3% were rated low and very low. There was fair correlation between age and hyperactivity problems (r = 0.44). Patients’ gender, type of cleft pathology, had been teased apart and hearing status was found not related to behavioural problems. ConclusionCleft lip and/or palate patients have a good longterm hearing outcome. Majority had normal hearing and if there is hearing impairment, it is only a mild loss. Early palatal repair surgery before the age of 1 year can significantly reduce the risk of hearing loss. Cleft lip and/or palate patients experienced peer problems. There was no significant correlation between behavioural difficulty and hearing status among school-aged children with cleft lip and palate.

PREVIOUSLY HEALTHY 15-MONTH OLD FEMALE WITH RAPIDLY PROGRESSIVE ATAXIA AND MILESTONE REGRESSION

Introduction Primary immunodeficiencies can present with physical findings that may not be readily apparent to members of the healthcare team. Early recognition of PI improves quality of life and reduces comorbidities. Here we describe a challenging case where physical findings led to a rare diagnosis. Case Description Our previously healthy patient was initially evaluated at the age of 15 months for recurrent “dizziness” and poor balance. Between the ages of 15 and 22 months, her neurologic symptoms worsened. Extensive imaging revealed no abnormalities. An ENT evaluation was undertaken secondary to persistent middle ear effusions. Around the age of 22 months a Pediatric Neurologist finally determined that her symptoms represented ataxia and not developmental delay. Evaluation at that point included measurement of alfa fetoprotein levels which were markedly abnormal. After referral to our tertiary academic center, an immunologic evaluation revealed abnormal quantitative immunoglobulins, marked lymphopenia and absent response to polysaccharide antigens when challenged with the pneumococcal polysaccharide vaccine. Genetic testing confirmed the suspected diagnosis of Ataxia Telangiectasia and revealed the presence of two novel mutations in the ATM gene that had not been previously reported. Discussion Ataxia Telangiectasia typically presents in an older child with a history of recurrent infections, ataxia, and telangiectasias of the eyes. Our patient's early onset ataxia was striking, and even trained neurologists struggled with the diagnosis. We propose that the two novel mutations, being premature stop codons, may explain her very early onset ataxia and rapid neurologic decline compared to the natural history of other patients with Ataxia Telangiectasia.

Characterization of mucoid and serous middle ear effusions from patients with chronic otitis media: implication of different biological mechanisms?

BackgroundChronic Otitis Media with effusion (COME) is characterized by persistent middle ear effusions that are in most cases highly viscous, but some patients present with serous fluid. This study aimed at comprehensively characterizing the macromolecular composition of mucoid vs. serous MEEs.MethodsMEEs from patients with COME were analyzed for proteins by Mass Spectrometry (MS) and western blot techniques, total DNA quantity, bacterial DNA (16S sequencing) and cytokine content. Proteomics datasets were studied in Ingenuity pathway analysis (IPA).ResultsMucoid samples showed a global tendency of increased pro- inflammatory mediators. IL1-β and IL-10 were significantly more abundant in serous samples (p<0.01). Mucoid samples had higher DNA quantity (p=0.04), more likely to be positive in MUC5B protein (p=0.008) and higher peptide counts (12786 vs 2225), as well as an overall larger number of identified proteins (331 vs 177), compared to serous. IPA found the mucoid sample dataset to be related to immune cell function and epithelial remodeling whereas the serous sample dataset showed acute responses and blood related proteins. Interestingly, serous samples showed more bacterial DNA than mucoid ones, with less bacterial genera variability.ConclusionThis study demonstrates divergent immune responses in children with COME by effusion quality.

Antibiotics for otitis media with effusion in children.

Otitis media with effusion (OME) is characterised by an accumulation of fluid in the middle ear behind an intact tympanic membrane, without the symptoms or signs of acute infection. Since most cases of OME will resolve spontaneously, only children with persistent middle ear effusion and associated hearing loss potentially require treatment. Previous Cochrane reviews have focused on the effectiveness of ventilation tube insertion, adenoidectomy, nasal autoinflation, antihistamines, decongestants and corticosteroids in OME. This review, focusing on the effectiveness of antibiotics in children with OME, is an update of a Cochrane review published in 2012. To assess the benefits and harms of oral antibiotics in children up to 18 years with OME. The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2016, Issue 3); PubMed; Ovid EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 April 2016. Randomised controlled trials comparing oral antibiotics with placebo, no treatment or therapy of unproven effectiveness in children with OME. We used the standard methodological procedures expected by Cochrane. Twenty-five trials (3663 children) were eligible for inclusion. Two trials did not report on any of the outcomes of interest, leaving 23 trials (3258 children) covering a range of antibiotics, participants, outcome measures and time points for evaluation. Overall, we assessed most studies as being at low to moderate risk of bias.We found moderate quality evidence (six trials including 484 children) that children treated with oral antibiotics are more likely to have complete resolution at two to three months post-randomisation (primary outcome) than those allocated to the control treatment (risk ratio (RR) 2.00, 95% confidence interval (CI) 1.58 to 2.53; number needed to treat to benefit (NNTB) 5). However, there is evidence (albeit of low quality; five trials, 742 children) indicating that children treated with oral antibiotics are more likely to experience diarrhoea, vomiting or skin rash (primary outcome) than those allocated to control treatment (RR 2.15, 95% CI 1.29 to 3.60; number needed to treat to harm (NNTH) 20).In respect of the secondary outcome of complete resolution at any time point, we found low to moderate quality evidence from five meta-analyses, including between two and 14 trials, of a beneficial effect of antibiotics, with a NNTB ranging from 3 to 7. Time periods ranged from 10 to 14 days to six months.In terms of other secondary outcomes, only two trials (849 children) reported on hearing levels at two to four weeks and found conflicting results. None of the trials reported data on speech, language and cognitive development or quality of life. Low quality evidence did not show that oral antibiotics were associated with a decrease in the rate of ventilation tube insertion (two trials, 121 children) or in tympanic membrane sequelae (one trial, 103 children), while low quality evidence indicated that children treated with antibiotics were less likely to have acute otitis media episodes within four to eight weeks (five trials, 1086 children; NNTB 18) and within six months post-randomisation (two trials, 199 children; NNTB 5). It should, however, be noted that the beneficial effect of oral antibiotics on acute otitis media episodes within four to eight weeks was no longer significant when we excluded studies with high risk of bias. This review presents evidence of both benefits and harms associated with the use of oral antibiotics to treat children up to 16 years with OME. Although evidence indicates that oral antibiotics are associated with an increased chance of complete resolution of OME at various time points, we also found evidence that these children are more likely to experience diarrhoea, vomiting or skin rash. The impact of antibiotics on short-term hearing is uncertain and low quality evidence did not show that oral antibiotics were associated with fewer ventilation tube insertions. Furthermore, we found no data on the impact of antibiotics on other important outcomes such as speech, language and cognitive development or quality of life.Even in situations where clear and relevant benefits of oral antibiotics have been demonstrated, these must always be carefully balanced against adverse effects and the emergence of bacterial resistance. This has specifically been linked to the widespread use of antibiotics for common conditions such as otitis media.

Tympanostomy Tube Selection: A Review of the Evidence

ABSTRACT Tympanostomy tube (TT) insertion for ventilation of the middle ear is one of most commonly performed procedures in the United States. Indications for tube insertion include otitis media with effusion, recurrent acute otitis media, hearing loss caused by middle ear effusion and persistent acute otitis media. In general, TTs are divided into two categories, short-term tubes and long-term tubes. Depending on the indications for tube placement and surgeon experience with the TT, different tubes can be used. A myriad of tubes have been created since their first documented use in 1845 in attempts to provide better middle ear ventilation, improve ease of placement and prevent complications, such as post-tube otorrhea, persistent perforation and tube occlusion. In order for a tube to be effective, it should be biocompatible with the middle ear to minimize a foreign body reaction. Teflon and silicone remain two of the most commonly used materials in TTs. In addition, the tube design also plays a role for insertion and retention times of TTs. Lastly, TTs can also be coated with various substances, such as silver-oxide, phosphorylcholine and more recently, antibiotics and albumin, in order to prevent biofilm formation and decrease the rate of post-TT otorrhea. Persistent middle ear effusion affects many children each year and can impact their quality of life as well as hearing and language development. With nearly 1 out of every 15 children by the age of 3 years receiving TTs, it is imperative that the right tube be chosen to facilitate optimal ventilation of the middle ear while minimizing complications. How to cite this article Ho S, Kay DJ. Tympanostomy Tube Selection: A Review of the Evidence. Int J Head Neck Surg 2016;7(1):17-22.

Newborn hearing screening may predict Eustachian tube dysfunction

IntroductionThere is evidence for temporary hearing loss in neonates immediately after birth because of residual liquid derived from amniotic fluid in the ME cavity.This study examines whether a referred newborn hearing screen (NBHS) with subsequent testing confirming normal hearing can be attributed to persistence of middle ear effusion and predict poor Eustachian tube function manifested as recurrent otitis media or otitis media with effusion in the first year of life. The aims of the present study are to investigate the following: (1) whether infants who fail a neonatal hearing screen and subsequently pass are more likely to experience recurrent otitis media or otitis media with effusion, (2) whether these infants are more likely to obtain tympanostomy tubes. MethodsThis retrospective cohort study examined newborns who referred their NBHS and were subsequently noted to have normal hearing and a control group comprised of newborns who passed their NBHS. Univariate and multivariate analysis was performed on the data collected as well as generation mean cumulative function plots. ResultsThe baseline characteristics of the case and control groups are not statistically significant with regards to gender, number of otitis media (OM), delivery mode, or the need for tubes in the follow up period. Within the refer group, those with bilateral refers were twice as likely to have otitis media than those with a unilateral refer (p=0.012). The logistic regression model for odds of subsequent otitis media was not statistically significant for bilateral or unilateral refer though the logistic regression model for odds of tubes demonstrated a statistically significant increased risk in bilateral refer patients. With time to event analysis, it was seen that bilateral refer patients are more likely to have OM than control and unilateral refer patients. ConclusionThere is no difference in the incidence of subsequent OM between those infants who passed the NBHS versus those who initially referred and then passed subsequent audiology examination. However there was a difference in the number of otitis media between those infants who referred bilaterally versus those who referred unilaterally.

Antibiotic treatment in otitis media reduces middle ear effusion duration

Tapiainen T, Kujala T, Renko M, Koivunen P, Kontiokari T, Kristo A, et al. Effect of Antimicrobial Treatment of Acute Otitis Media on the Daily Disappearance of Middle Ear Effusion: A Placebo-Controlled Trial. JAMA Pediatr. 2014;165:635-41. Among children with otitis media (OM), what is the therapeutic efficacy of antibiotics, compared with placebo, in resolution of middle ear effusion (MEE)? Randomized controlled trial. Outpatient clinics, Oulu, Finland. Children, 6 months to 15 years old. Time to disappearance of MEE. On day 14, 69% of children in the antimicrobial group and 38% in the placebo group had normal tympanometry findings (number needed to treat [NNT] 4; 95% CI, 2-11). On day 60, 2 children (5%) in the antimicrobial group and 10 children (24%) in the placebo group had persistent MEE (NNT 6; 95% CI, 3-22). Antimicrobial treatment effectively reduced the duration of MEE in children with AOM, and the risk for persistent MEE.

Effect of antimicrobial treatment of acute otitis media on the daily disappearance of middle ear effusion: a placebo-controlled trial.

Antimicrobial treatment reduces the symptoms of acute otitis media (AOM). The effect of antimicrobial treatment on the duration of middle ear effusion (MEE) and concomitant hearing impairment is not known. To determine whether the antimicrobial treatment of AOM reduces the duration of MEE. This randomized, double-blind, placebo-controlled trial involved a total of 84 children with AOM between 6 months and 15 years of age. Participants were recruited from September 14, 1999, to January 4, 2000; October 10, 2005, to December 16, 2005; and September 22, 2009, to June 4, 2012, from among children attending an AOM prevention trial and children visiting local outpatient clinics in Oulu, Finland. Children were randomly allocated to receive either 40 mg/kg of amoxicillin-clavulanate or a placebo mixture per day for 7 days. The primary outcome measure was the time to the disappearance of MEE as defined by a normal tympanogram finding (A curve) from both ears on 2 consecutive measurement days. Parents performed daily tympanometry at home. The study physician performed tympanometry and otoscopy at study entry, after 3 and 7 days, and then weekly until both ears were healthy. The main secondary outcome measures were the time to normal otoscopy findings and the proportion of children without persistent MEE at 14 days and 2 months. Middle ear effusion disappeared 2.0 weeks (13.7 days) earlier (P = .02) in the antimicrobial group (mean time, 2.7 weeks; 95% CI, 1.7-3.7) than in the placebo group (4.7 weeks; 95% CI, 3.6-5.7). Normal otoscopy findings were observed 1.4 weeks sooner in the antimicrobial group than in the placebo group (P = .02). On day 14, 69% of children in the antimicrobial group and 38% in the placebo group had normal tympanometry findings (number needed to treat, 3.2; 95% CI, 2.0-10.5). On day 60, 2 children (5%) in the antimicrobial group and 10 children (24%) in the placebo group had persistent MEE (P = .01). Antimicrobial treatment effectively reduced the duration of MEE and possible concomitant hearing impairment in children with AOM. Antimicrobial treatment also reduced the risk for persistent MEE. clinicaltrials.gov Identifier: NCT01244581.

Parental role in the diagnostics of otitis media: Can parents be taught to use tympanometry reliably?

ObjectiveTympanometry can be used to detect middle ear effusion (MEE). As the need for rearrangement of clinical resources at the primary care level increases, it is important to determine whether layman parents could be taught to use the tympanometer reliably, aiming to reduce unnecessary physician visits during respiratory tract infections. MethodsFrom our AOM treatment trial we enrolled 78 children (age 6–35 months) who had persistent MEE, parents were voluntary and willing to use a tympanometer at home, the child was sufficiently co-operative, and parents learned technically the use of the tympanometer. At home, parents were asked to perform daily bilateral tympanometry on their child. We included those parental tympanometric examinations, to which the corresponding tympanometric examination, within one day by a study physician was available. Parental tympanometric examinations were compared to the pneumatic otoscopy by a study physician which served as the diagnostic standard. ResultsThis study involved 78 children and a total of 432 parental tympanometric examinations. From these 432 examinations, parents obtained an interpretable tympanogram in 83% (359/432) and physicians in 91% (393/432) (absolute rate difference 8%, 95% CI 3–12%). Both obtained an interpretable tympanogram from the same ear in 75% (326/432) of the tympanometric examinations. Of these 326 interpretable examinations, parents and physicians were in accordance with either a peaked or a flat tympanogram in 88% of examinations (288/326) (kappa-value 0.77). When the tympanogram was peaked, pneumatic otoscopy indicated healthy middle ear in 72% (122/169) of parental and in 69% (149/217) of study physicians’ tympanometric examinations (absolute rate difference 4%, 95% CI −6% to 13%). When the tympanogram was flat, pneumatic otoscopy indicated any MEE in 92% of parental (174/190) and in 96% (169/176) of study physicians’ tympanometric examinations (absolute rate difference 4%, 95% CI −9% to 1%). ConclusionThis study showed that layman parents are able to use tympanometry technically successfully, and that the parental tympanometric examinations are as reliable as those obtained by study physicians.

Diode laser myringotomy for short-term middle-ear ventilation: a pilot study on children

EnAbstract Objective The aim of the study was to evaluate diode laser myringotomy (DLM) in children for the management of Eustachian tube and middle-ear disorders that require myringotomy for short-term treatment. Study design This is a prospective clinical study. Patients and methods The study comprised 20 children selected to undergo DLM for middle-ear ventilation as a mode of treatment for recurrent acute serous otitis media; these children suffered from persistent middle-ear effusion and had experienced failure of medical treatment for at least 8 weeks. Postoperative weekly visits to evaluate the myringotomy opening (MO) were carried out until healing was recorded. The Eustachian tube and hearing ability were evaluated preoperatively and postoperatively 4 weeks after healing of the tympanic membrane. Cases were deemed to be failed when the MO closed early within the second week postoperatively without improvement in hearing, or the myringotomy persisted until the end of the third month postoperatively. Outcome measures were the state of the MO and of the ear drum, the patency time of the myringotomy, improvement in hearing and Eustachian tube function and incidence of operative and postoperative complications. Results The mean operative time was 5 min. No operative complications occurred. Procedural success was achieved in 16/20 ears (80%). Two ears showed postoperative persistent perforations, and two recorded early closure of the MO. The mean improvement in the air/bone gap was 12 dB for the successful cases. Twelve ears with healed MOs showed type A curve (75%). Four ears showed type C curve (25%) and needed further management. Conclusion DLM is useful in children for the management of Eustachian tube and middle-ear disorders needing myringotomy for short-term treatment.

Sustained bilateral middle ear effusions post orthognathic surgery successfully treated with grommet insertion

We present the case of a patient who developed persistent bilateral middle ear effusions post Le Fort I maxillary osteotomy.

A Study of Persistent Unilateral Middle Ear Effusion Caused by Occult Skull Base Lesions

The goal of this article is to review a series of patients with persistent unilateral middle ear effusion (MEE) and to suggest a more contemporary diagnostic algorithm. The author conducted a retrospective chart review of adults with persistent unilateral MEE and normal findings on physical and nasopharyngoscopic examinations whose MEE was eventually found to be caused by a variety of occult skull base lesions. The study population was made up of 79 patients—52 women and 27 men, aged 21 to 83 (mean: 54.8) at presentation—who had been referred to an academic tertiary care medical center between July 1, 1988, and June 30, 2008. Follow-up ranged from 9 months to 19.5 years (mean: 8.7 yr). Of this group, 50 patients (63.3%) had a malignant tumor, 26 (32.9%) had a benign tumor, and 3 (3.8%) had an internal carotid artery aneurysm. Eustachian tube occlusion had been caused by diffuse invasion in 33 patients (41.8%), by intracranial pathology in 24 (30.4%), and by extracranial-infratemporal lesions in 22 (27.8%). Nasopharyngoscopy cannot identify a variety of rare skull base lesions that cause eustachian tube compression or tissue invasion that ultimately leads to MEE. Therefore, patients with unexplained persistent unilateral MEE should undergo coronal magnetic resonance imaging or computed tomography to look for any intra- or extracranial lesions before undergoing ventilation tube placement.

A Study of Persistent Unilateral Middle Ear Effusion Caused by Occult Skull Base Lesions

The goal of this article is to review a series of patients with persistent unilateral middle ear effusion (MEE) and to suggest a more contemporary diagnostic algorithm. The author conducted a retrospective chart review of adults with persistent unilateral MEE and normal findings on physical and nasopharyngoscopic examinations whose MEE was eventually found to be caused by a variety of occult skull base lesions. The study population was made up of 79 patients-52 women and 27 men, aged 21 to 83 (mean: 54.8) at presentation-who had been referred to an academic tertiary care medical center between July 1, 1988, and June 30, 2008. Follow-up ranged from 9 months to 19.5 years (mean: 8.7 yr). Of this group, 50 patients (63.3%) had a malignant tumor, 26 (32.9%) had a benign tumor, and 3 (3.8%) had an internal carotid artery aneurysm. Eustachian tube occlusion had been caused by diffuse invasion in 33 patients (41.8%), by intracranial pathology in 24 (30.4%), and by extracranial-infratemporal lesions in 22 (27.8%). Nasopharyngoscopy cannot identify a variety of rare skull base lesions that cause eustachian tube compression or tissue invasion that ultimately leads to MEE. Therefore, patients with unexplained persistent unilateral MEE should undergo coronal magnetic resonance imaging or computed tomography to look for any intra- or extracranial lesions before undergoing ventilation tube placement.

Refractory otitis media: An unusual presentation of childhood granulomatosis with polyangiitis

Childhood granulomatosis with polyangiitis (cGPA), previously known as Wegener's granulomatosis, is a rare, potentially fatal necrotizing vasculitis, the symptoms of which overlap with infection. We present a 16-year-old girl who, following 6 months of treatment for persistent middle ear effusion with progressive sensorineural hearing loss, developed rapidly progressing pneumonia, with pleural effusion, and multiple cavitatory lung lesions. Investigations demonstrated high titer c-ANCA and nasal septal biopsy confirmed the diagnosis of cGPA. This case highlights the difficulty in diagnosing cGPA and the potentially life-threatening consequences of failing to do so.

Development of an Algorithm for the Diagnosis of Otitis Media

Looking back 100 years from now, how will you judge the professional integrity of medicine in the second decade of the 21st century, more than 8 decades after Fleming discovered penicillin? Among young children, acute otitis media (AOM) has been the most frequent diagnosis for which antibiotics are prescribed.1,2 The diagnosis and management of AOM should provide a telling case study. You assume medicine had long ago mastered the treatment of AOM and persistent middle ear effusion, two of the most common acute and chronic conditions encountered in primary care settings.

Persistent middle ear effusion presumably biofilm-related in a paediatric patient with common variable immunodeficiency

Bacterial biofilms play a role in upper respiratory tract diseases, including acute and chronic middle ear diseases, and are involved in chronic infections and resistance to antibiotic treatment. In particular, the nasopharynx and the surrounding tissues act as important reservoirs of resistant bacterial biofilms, which have been detected in biopsies taken from adenoid and/or middle ear mucosa of children with chronic middle ear effusion. Here we describe the management of a child with congenital immunodeficiency and a chronic middle ear effusion, resistant to traditional medical treatment and presumably due to nasopharyngeal colonization by bacterial biofilms, which has been successfully treated by means of medicated nasal douches delivering antibiotic and a biofilm-destroying compound.