Purulent Otitis Media Research Articles

Late results and complications of tympanostomy tube insertion for prophylaxis of recurrent purulent otitis media in pediatric age.

We have evaluated from a clinical and functional point of view a total of 61 children (37 boys and 24 girls with a median age of 3 years, range 4 months to 6 years) who had been submitted before 1978 to insertion of tympanostomy tubes (in a total of 131 ears) for prophylaxis of recurrent purulent otitis media. Of these, 67.6% remained free from recurrencies after removal or extrusion of grommets, whereas in the remaining group discharge could be cured with local and/or general antibiotic treatment. Sixteen cases had tympanic calcifications, 6 an atrophic drum, and 10 a severe tympanic retraction, but only 8 out of these 32 cases had signs of conductive hearing loss (average loss 20 dB on frequencies from 500 to 2000 Hz). Further complications observed in this follow-up have been perforations (6 cases) and one case of migration of the tube into the tympanic cavity. No cholesteatoma has been observed in our series. A few considerations can be drawn from these observations: insertion of grommets, correctly performed in the anterior-inferior part of the drum appears to prevent a large percentage of recurrencies, and should therefore be considered, even in the long-term, an adequate prophylaxis for the otitis-prone child; complications as seen during a long follow-up period are relatively few, can be cured, and have a modest functional impact.

Sensorineural hearing loss in otitis media.

Additional evidence is presented to support the hypothesis that both acute purulent otitis media (POM) and chronic suppurative otitis media (COM) can cause high frequency sensorineural hearing loss. In selected patients and in animals (chinchillas) in a pilot study using electrophysiological methods, both temporary threshold shifts and permanent threshold shifts of basal cochlear turn involvement were demonstrated in POM. Data of cochlear involvement in 475 ears with bilateral COM, 607 ears with unilateral COM, and 607 ears serving as controls were obtained from six centers in five countries. In group 1 (15 dB or greater), 43% of ears with unilateral COM and 42% of ears with bilateral COM showed losses, for a combined odds ratio eight times that in controls. In group 2 (30 dB or greater), 16% of ears with unilateral COM and 17% of ears with bilateral COM demonstrated, respectively, seven and ten times that in controls. These statistically significant findings influence clinical considerations.

Experimental background for the use of tympanostomy tubes.

Already within 24 h, splitting of the soft palate in rats caused production of effusion in the attic space. During the next couple of days the effusion material filled the meso- and hypotympanon. The production of a serous fluid in the attic space appeared concomitant with an elevated histamine content in the middle ear cavity, irrespective of whether the ears were ventilated or not. In the artificially ventilated middle ears no effusion appeared in the meso- and hypotympanon and the hypotympanal mucosal lining remained normal. The serous effusion filling the middle ear cavities with the intact tympanic membranes was replaced at about 7 days by a purulent effusion material containing mainly Gram-negative enteric rods. Thus it seems that a serous otitis media and a purulent otitis media occur in a continuum. The change to a purulent infection could be prevented by artificial ventilation, but as soon as the myringotomies were healed or the tympanostomy tubes got clogged a flocculent, pus-like effusion also appeared in these middle ear cavities.

New Sign of Middle Ear Disease?

To the Editor.— For years I have observed children pulling on their ears "in sickness and in health." Now, my 11-month-old daughter has introduced me to a new symptom of middle ear disease that was not described during my medical school or residency training. In addition, I have never observed it in my patients. She developed a right purulent otitis media and was treated with antibiotics. Following ten days of antibiotic therapy, she developed a persistent middle ear effusion for about 2 months.

Otitis media in early infancy

Acute purulent otitis media (APOM) occurs frequently during childhood, particularly in the first two years of life.le5 However, this infection seems to develop less often in infants less than three months of age. Additionally, APOM in the child during the first three months is difficult to diagnose and may lead to serious complications. It is often necessary to attempt to isolate a specific etiologic agent and to begin treatment with intravenous antibiotics. Because APOM affects young infants less often than older children, the emergency physician may not be fully aware of its manifestations during the first few months of life; yet, an accurate diagnosis assumes even greater importance because of the potential for life-threatening complications. We describe a neonate seen in our emergency department with bacteriologically confirmed APOM and discuss the clinical manifestations, diagnostic modalities, bacteriology, complications, and treatment regimens in the young infant.

Pneumococcal antibodies and complement during and after periods of recurrent otitis.

Streptococcus pneumoniae frequently accounts for acute purulent otitis media (AOM) episodes. Recurrences are common and are most often caused by pneumococci of groups 6, 19 and 23. In 15 two-year-old children with recurrent AOM ( rAOM ) complement (C) components and antibodies against various pneumococcal capsular polysaccharides were analyzed during the acute phase of an AOM episode and 6 years later. Comparison was made with findings in non-otitis-prone children of comparable age. In contrast to non-otitis-prone children, 60% of children with rAOM had no detectable IgG antibodies against the pneumococcal capsular polysaccharides 6A or 19F. Analysis of C1 subcomponent complexes together with the finding of relatively low C1q concentrations gave evidence of disturbed C1 function in the acute phase of rAOM . At the 6-year follow-up antibodies against all the investigated pneumococcal capsular polysaccharides had increased in most of the children, but low IgG antibodies to type 6A polysaccharide were still more frequently found in the former rAOM children than in non-otitis-prone children. The C profiles had normalized at follow-up. These findings indicate a reduced ability in rAOM children to respond adequately with IgG antibodies to pneumococcal types encountered in rAOM . The combination of low antibody concentrations and the interference with the complement system and efficient opsonization through classical pathway activation could possibly contribute to the development of rAOM .

Impairment in cochlear function produced by chloramphenicol and noise

Ototoxic interaction between chloramphenicol and noise was studied in two separate investigations. In the first study, permanent ototoxicity was demonstrated in a group of rats which were subjected to short-duration, high-intensity noise and were then given chloramphenicol orally. The anatomical damage in this group was consistent with observed changes in cochlear round window recordings of cochlear microphonics at 4 kHz and of the N1 component of the eighth nerve action potential. In the second study, a temporary depression in the function of the cochlea was observed in rats subjected to the noise-chloramphenicol regimen used in the first study. Depressions in recordings of the round window similar to those in the first study were seen only during the first five days of recordings. After the fifth day, the recordings of the round window were normal, indicating recovery from a temporary shift in threshold produced by chloramphenicol and noise. Incidence of purulent otitis media was found in 57 and 0% of the animals in the first and second studies, respectively. The combination of chloramphenicol and noise appears to be responsible for the production of temporary cochlear deficits. The addition of the third variable, otitis media, appears to result in permanent impairment of the cochlea.

Ｃｅｆｍｅｎｏｘｉｍｅ（ＣＭＸ）耳用液の臨床的研究

A clinical evaluation was made of the efficacy of a new cephalosporin antibiotic, Cefmenoxime (CMX) Otic Solution for acute purulent otitis media, chronic purulent otitis media, chronic purulent otitis media with sudden exacerbation and acute diffuse otitis externa. Of the 31 patients treated, 24 showed definite improvement.The main microorganisms detected were Staphylococcus aureus, Pseudomonas aeruginosa and Pseudomonas cepacia, against all of which CMX was effective in terms of MIC tests. It was further observed that CMX has gained better MIC figures and had a broader spectrum than other antibiotic agents such as CP, CEZ, or FRM.No side effects were observed, and it may be concluded that CMX Otic Solution is clinically useful.

Housing standards, social group, and respiratory infections in children of Upernavik, Greenland.

During one year, contacts with the health service due to respiratory infections--including diseases of ear, nose, and throat--were studied in the 310 children of Upernavik town. 166 contacts were recorded. Children from low socio-economic groups had been expected to have a higher overall contact rate than other children, but this did not prove to be so. The disease pattern of these children was characterized by a low level of contacts due to certain acute respiratory infections and a high level of contacts due to chronic purulent otitis media, compared with children from higher socio-economic groups. The differences did not reach statistical significance, however.

Prediction of serous versus purulent otitis media by otoscopy and tympanometry in an animal model

Non-invasive methods for distinguishing different types of otitis media would have clinical value in predicting otologic morbidity. Two such methods, otoscopy and tympanometry, were used in two experimental models of otitis media to determine whether there are unique otoscopic and tympanometric characteristics of serous and purulent otitis media. A flat (type B or B+) tympanogram and yellow tympanic membrane each had a high likelihood of predicting middle ear effusion in these models, and the best prediction was obtained using both parameters simultaneously. A yellow tympanic membrane color predicted purulent otitis media in one model but did not distinguish purulent from serous ears in the other model. In one model, serous otitis media was frequently associated with a type C (negative pressure) tympanogram. Tympanometry provided a valuable adjunct to otoscopy in detecting effusion and in distinguishing serous and purulent disease. These observations may apply to otitis media in humans, although the variable etiologies of otitis media in humans may confound the ability of otoscopy and tympanometry to distinguish middle ear effusion types.

Primary and secondary ciliary dyskinesia.

It has recently been shown that patients with Kartagener's triad and also some subjects with similar symptoms, but without situs inversus, have a congenital abnormality of cilia as an explanation for their chronic airway symptoms; this disease has been named "the immotile-cilia syndrome" or more correctly "primary ciliary dyskinesia". Studying 27 such patients, we have found daily nose blowings since birth, chronic-recurrent sinusitis, and chronic secretory otitis media highly characteristic features. The frequency of common colds was not increased, and most patients did not suffer from repeated episodes of acute purulent otitis media. The number of ciliated cells with immotile cilia was increased, but only a single patient had completely immotile cilia; also the degree of asynchrony within the single ciliated cell was increased. Electron microscopy showed a decreased number of dynein arms in some patients, and abnormal arrangement of microtubules in others. Some patients, however, had normal ultrastructure, and this appeared to be associated with a hyperfrequent beating pattern. At least three subgroups of patients with primary ciliary dyskinesia can be delineated based on the motility-ultrastructure studies. Bacterial infection tends to reduce the number of ciliated cells with motile cilia, and viral infection (common cold) gives a very marked and long-lasting reduction in the number of ciliated cells. This may account for some otherwise unexplainable subchronic symptoms from nose and throat.

Clinical Evaluation of Bacampicillin in Acute Purulent Otitis Media in Children

Clinical Evaluation of Bacampicillin in Acute Purulent Otitis Media in Children

Rhinitis, sinusitis and otitis media in Kartagener's syndrome (primary ciliary dyskinesia).

Ear, nose and throat symptoms and signs were studied in 15 patients with Kartagener's syndrome: a triad consisting of chronic rhinosinusitis, chronic bronchitis with bronchiectasis, and situs inversus. The triad is caused by primary ciliary dyskinesia and characterized by absent or considerably reduced mucociliary transport. Daily accumulation of secretions in the nose, chronic recurrent secretory otitis media and sinusitis occurred in all subjects. Characteristically, nasal discharge started at birth or was first detected in early childhood. Apparently, the frequency of common colds and of acute purulent otitis media was not increased. As primary ciliary dyskinesia can occur without situs inversus, knowledge of the typical ENT symptoms is essential for making an early diagnosis, which is important for the correct management of the disease. While a conservative surgical approach to treatment of the ENT symptoms is recommended, early and active treatment of the bronchial symptoms is probably important for prevention of further lung damage and development of bronchiectasis.

Rheoencephalography and echoencephalography in the diagnosis of the initial forms of otogenic intracranial complications

With the help of rheoencephalography, echoencephalography, and rheoaurography, 216 patients with chronic purulent otitis media were examined. In patients with chronic purulent epitympanitis and epimesotympanitis, hemodynamic disturbances were revealed during rheoaurography. Hydrocephalic-hyperhydration syndrome was noted rheoencephalographically in local leads in 73% of patients in this group. Echoencephalography showed signs of hydrocephalus in 56% of patients. The complex application of rheoencephalography and echoencephalography made it possible to establish signs characteristic of the initial, clinical forms of otogenic intracranial complications.

Epidemiology of otitis media with effusion in children.

The recently accepted international classification for otitis media was applied to a study population of 898 children less than 12 years of age having otitis media with effusion persisting at least three months. Mucoid effusion was aspirated from 48% of ears, was found more often in younger than older patients, was more often bilateral, and was a more stable state during longitudinal observation than was serous otitis media or purulent otitis media (POM). Serous otitis media occurred in only 10% of ears, but was found more often than in younger patients; POM was found in only 7% of ears. Otoscopy did not distinguish among the three effusion types. Known middle-ear pathogens were cultured more often behind red and bulging tympanic membranes from these cases of chronic effusion than behind membranes lacking these characteristics. These observations provide an epidemiologic and clinical base for further investigations of these otitis media types.

Otological manifestations of Wegener's granulomatosis.

The otological manifestations of Wegener's granulomatosis were studied in 13 patients; diagnosis was confirmed histologically in 10, and in 1 patient periarteritis nodosa presented similar appearances. One patient had destruction of the external ear, and several had refractory otitis externa, usually associated with otitis media: 3 patients had serous otitis media, 4 had purulent otitis media of a fairly mild course, while 6 had otitis media of a fulminant and long-lasting course, accompanied in 5 cases by cranial nerve palsy and in 2 by widespread destruction. Most patients had major sensory hearing loss. Two had short-lasting anacusis during exacerbation of the pulmonary lesions. Often, otological manifestations were the initial signs of the disease. It is important to bear this diagnosis in mind in cases of long-lasting and atypical inflammations and in the presence of peculiar constellations of symptoms from several different organ systems.

Effect of tympanostomy tubes on the pathogenesis of acute otitis media

Intubation of the tympanic membrane as a treatment for acute otitis media is extremely controversial. This study was designed to determine the effect of tympanic membrane intubation in an experimental model for acute purulent otitis media. The right tympanic membrane of the chinchilla was intubated with Paparella Type I tympanostomy tubes. This procedure was followed in seven days by nasopharyngeal inoculation of Streptococcus pneumoniae and in an additional three days by nasopharyngeal inoculation of influenza A virus. Nasopharyngeal inoculation with these microorganisms results in acute purulent otitis media in 70 per cent of animals. The presence of the tympanostomy tubes did not reduce the incidence of clinical otitis media, nor did it reduce the pathologic changes within the middle ear space. The tympanostomy tubes did, however, significantly reduce the incidence and severity of pathologic changes in the subepithelial space of the middle ear mucosa.

Influenza A virus-induced polymorphonuclear leukocyte dysfunction in the pathogenesis of experimental pneumococcal otitis media.

The role of influenza A virus-induced polymorphonuclear leukocyte and eustachian tube dysfunction in the pathogenesis of acute purulent otitis media was studied in chinchillas. Polymorphonuclear leukocyte function, middle ear pressure, and the incidence of pneumococcal otitis media were observed after intranasal inoculation with influenza A virus, Streptococcus pneumoniae, or both. Results showed that depressed negative middle ear pressure and polymorphonuclear leukocyte chemiluminescence and chemotactic activity occurred after influenza inoculation, but not after inoculation with pneumococcus alone. The greatest incidence of pneumococcal otitis media occurred when the pneumococcus was inoculated just before the time of influenza-induced polymorphonuclear leukocyte dysfunction and negative middle ear pressure. Animals that had unilateral tympanostomy tubes placed before inoculation of influenza with pneumococcus showed no difference in the occurrence of pneumococcal otitis media in ventilated and nonventilated ears, suggesting that polymorphonuclear leukocyte dysfunction contributes more to the pathogenesis of pneumococcal otitis media than does negative middle ear pressure in this animal model.

Panel discussion: pathogenesis of otitis media. Pathology and microbiology of otitis media.

Otitis media (OM) can be subdivided into purulent, serous, mucoid, and chronic forms. It may occur in the absence of tympanic membrane changes and involve the inner ear. Purulent otitis media is characterized early by edema, hyperemia, and polymorphonuclear leukocyte infiltration in the subepithelial space (SES) and later by mucosal metaplasia, granulation tissue, and osteitis. S. pneumoniae and H. influenza are most commonly identified. Serous and mucoid OM frequently develop from eustachian tube dysfunction. Serous transudate from vessels in the SES passes to the middle ear (serous otitis media). Basal cells differentiate into goblet cells and subepithelial glandular formation occurs. This secretory activity, coupled with fluid reabsorption, results in a mucoid effusion. Bacteria can be cultured from about 30% of these effusions. Chronic otitis media denotes irreversible tissue pathology. It may be sterile although S. aureus and coliform bacteria are frequently isolated.

Identification of prostaglandins and other arachidonic acid metabolites in experimental otitis media

Although prostaglandins (PGs) have been detected in the middle ear fluids, the exact identification of PGs, and other arachidonic acid (AA) metabolites has not been made. The AA metabolites were identified in experimentally induced serous otitis media and purulent otitis media in chinchillas using a radiochromatography method. The relative abundance of each metabolite synthesized was also determined. Two major AA metabolites, 6-Keto-PGF 1α and 15-hydroxy-5,8,11,13-eicosatetraenoic acid (15-HETE), were positively identified by gas chromatography-mass spectrometry. The AA metabolites in Eustachian tube obstructed middle ear mucosa (MEM) were predominantly 6-keto-PGF 1α, followed by PGD 2, 15-HETE, hydroxyheptadecatrienoic acid (HHT), PGF 2α and PGE 2. In infected MEM, the predominant product was 15-HETE followed by 6-keto-PGF 1α, PGD 2, HHT, PGF 2α, and PGE 2. The possible role of PGs and other AA metabolites in the pathogenesis of otitis media will be discussed.