Purulent Otitis Media Research Articles

Notable names in the history of surgery: 2. William Arbuthnot Lane (1856–1943)

Surgery today owes much to the services of early practitioners who made their advances as a result of wide clinical experience and compassion. This two‐part series explores the careers of Percivall Pott and William Arbuthnot Lane. Sir William Arbuthnot Lane was the most brilliant technical surgeon in Britain during the first half of the 20th century. He was one of the many famous physicians and surgeons to train at Guy's Hospital in London since its founding in 1724. Although some of his ideas may be controversial, he had made many original contributions and innovations in a variety of surgical techniques. He introduced mastoid drainage in purulent otitis media with specially designed chisels and gouges; resection of the cervical oesophagus for cancer and reconstruction by skin graft; and the repair of cleft lip and palate in neonates. His greatest contribution must be the introduction of the ‘no‐touch technique’ in open reduction and plating of long bone fractures by Lane's steel plates. In later life, Lane became obsessed with the role of regular bowel motion in health. To combat various real or imagined ailments, he first short‐circuited and later resected the whole large intestine. When surgery failed to resolve the problem, Lane advised regularly taking paraffin oil for the relief of constipation. He was a firm believer as well as a pioneer in alternative or homeopathic medicine. Lane's concept of chronic intestinal stasis is a classic case of a flawless surgical technique subservient to a faulty hypothesis.

Acute otitis media in the era of effective pneumococcal conjugate vaccine: will new pathogens emerge?

The immunogenicity of pneumococcal conjugate vaccine (PCV) in young infants and its serotype-specific efficacy in otitis media (OM) results in a modest reduction in total episodes of OM and a more substantial reduction in disease due to the most frequent pneumococcal serotypes. Since PCV will only prevent disease due to the most common serotypes, concerns about potential changes in the microbiology of OM have emerged. Insight into potential changes can be obtained from reviewing middle ear and nasopharyngeal isolates from studies of antimicrobial prophylaxis and bacterial polysaccharide immune globulin for prevention of OM and PCV for prevention of invasive pneumococcal disease, respectively. In children receiving PCV, a shift in serotypes of SP colonizing the nasopharynx has been observed. Since non-vaccine serotypes are already present in the community as the etiology of acute purulent OM, it is predictable that these non-vaccine serotypes will become more common especially in children less than two years of age.

Soluble l-selectin and interleukin-8 in otitis media with effusion

Objective: adhesion of leukocytes to vascular endothelium and their invasion into local tissues are important steps in inflammation. l-selectin plays a crucial role in leukocyte rolling and adhesion on endothelial cell surface. Interleukin-8 (IL-8) is a potent chemotactic substance toward neutrophils and lymphocytes-T and mediate their migration to local inflammation. The levels of soluble l-selectin (s l-selectin) and IL-8 were measured in middle ear effusions (MEE) from children with otitis media (OM) to estimate their role in pathogenesis of inflammation in middle ear. Methods: MEE were collected from 113 ears of 62 children during routine myringotomy. The entire specimen was diluted with phosphate-buffered saline (PBS) to 2 ml and centrifugated at 1500 rpm for 15 min to separate cellular components. Supernatants of MEE were stored frozen at −20°C for s l-selectin and at −80°C for IL-8 assessment. The concentration of s l-selectin and IL-8 were estimated with ELISA and compared with total protein concentration measured by Bradford assay. Results: MEEs from children with chronic mucous otitis media contained significantly higher mean concentrations of IL-8 559.4 pg/mg total protein (TP) (±535.6) in comparison with normal serum 17.79 pg/mg TP (±10.9), serous OM 40.3 pg/mg TP (±28.1) and purulent OM 104.4 pg/mg TP (±128.6). High concentration of IL-8 was found in MEE from the children with early recurrence of OMS. The levels of s l-selectin were higher in purulent effusions 77.2 ng/mg TP (±67.4) than those of chronic mucoid 27.6 ng/mg TP (±36.7) and serous OM 26.3 ng/mg TP (±27.1). Conclusion: the results support a hypothesis that IL-8 can be responsible for prolongation of inflammatory process in middle ear, therefore long-term treatment and observation of children with the high levels of IL-8 in MEE may be necessary. Elevated level of s l-selectin in acute OM suggests the involvement of l-selectin in the acute phase of OM.

Labeling of the glucocorticoid receptor and Na,K-ATPase in a rat otitis media model

Glucocorticoid hormones exert an influence on the inflammatory response of the middle ear during acute otitis media. Rats with experimentally induced purulent otitis media were given either glucocorticoid hormones in excess or a glucocorticoid hormone blocker that deprived the animals of the hormone.Acute otitis media is a common inflammatory disease among children. Streptococcus pneumoniae is the most usual causative agent. The standard treatment today is phenoxymethylpenicillin. The role of glucocorticoid hormones in inflammatory reactions in the middle ear has been widely debated.In an otitis media model, a suspension of pneumococci was inoculated into the bulla of the rat, after the animals were pretreated with either a dose of corticosteroid hormones or the glucocorticoid receptor blocking agent RU 486. Rats with induction of otitis media only, but no pretreatment, were used as control subjects, as were the left control-operated ears of all rats. The inflammatory response in the inner ear and in the middle ear was evaluated. The presence of glucocorticoid receptors and the enzyme Na,K-ATPase was investigated with immunohistochemistry.The inflammatory response in the animals with untreated otitis media and in the group with otitis media in rats pretreated with the receptor blocker was much more extensive than in the group of animals pretreated with corticosteroids. In the corticosteroid-treated group, the tympanic membrane and the mucous membrane of the middle ear were less edematous, but the middle ear cavity contained more pus. Only a few lymphocytes were found in the inner ears of these rats. When the inner ear was labeled with antibodies against glucocorticoid receptors, there seemed to be no difference between the labeling patterns in the three groups. This was also the case for antibody labeling against Na,K-ATPase.The present results indicate that the reaction in the middle ear mucous membrane is more pronounced in rats that had been pretreated with the hormone receptor blocking drug. An increase of corticosteroid hormone levels during the inflammatory process seem to diminish the reaction in the tympanic membrane and the middle ear mucosa. Neither the hormone receptor blocking drug nor the steroid hormones change the content of glucocorticoid receptors and Na,K-ATPase in the inner ear in the otitis media rat model.

Effects of Active Immunization with a Pneumococcal Surface Protein (PspA) and of Locally Applied Antibodies in Experimental Otitis media

An experimental rat model for Streptococcus pneumoniae otitis media was used to investigate passive protection by anti-type 3 capsular antibodies and effects of immunization with pneumococcal surface protein A (PspA). Anti-type 3 antibodies instilled into the middle ear reduced purulent otitis media as compared to control animals (p = 0.015). Secondly, after immunization with PspA, the right middle ear was inoculated with S. pneumoniae type 6A in a dose calibrated to induce purulent otitis media. There was an anti-PspA antibody response in all rats immunized and a reduction in signs of purulent otitis media as compared to control animals (p = 0.026). Thus, purulent (acute) otitis media can be reduced by local application of antibodies in the middle ear and also by immunization with a non-type-specific pneumococcal protein, PspA.

Ventilation Tubes and Persisting Tympanic Membrane Perforations

Surgical management of otitis media with effusion and recurrent acute otitis media includes myringotomy and the use of ventilation tubes. Since this procedure was reintroduced by Armstrong in 1954, it has become one of the most commonly performed operations in otolaryngology. In most series perforation of the tympanic membrane in some patients has been reported after spontaneous extrusion or removal of the tympanostomy tubes. We present a retrospective review designed to examine the incidence of persisting perforations of the tympanic membrane in our series of 2604 operated ears. The study also identifies and analyzes the variables and the contributing risk factors. Perforations occurred in 3.06% of the ears: with a greater incidence in children younger than 5 years, when the indication was recurrent purulent otitis media, with the use of long-term Goode T tubes, in cases with repeated insertions of ventilation tubes, and in cases in which postoperative otorrhea was frequent.

Moraxella catarrhalis‐induced purulent otitis media in the rat middle earL

To study the effects of viable and heat-killed Moraxella catarrhalis bacteria on the middle ear mucosa and to evaluate the protection after whole-cell immunizations, Sprague-Dawley rats were challenged and rechallenged with four different M. catarrhalis strains. The animals were monitored by clinical observations, bacterial and histological samples from middle ears, and serum IgG levels. Only viable bacteria at a high concentration induced purulent otitis media, which was culture positive in 58% of the cases on day 4. The infection was characterized by a mild acute reaction lasting otomicroscopically about 8 days, together with quantitative and qualitative changes of the goblet cells. Structurally the mucosal effects of the heat-killed bacteria were less pronounced in the early phase compared to the viable bacteria, but similar at the end of the experiment at 6 months. The intrabullar and subcutaneous immunizations evoked an IgG antibody response in all animals, and the protection rate after immunization was 50% or more. The induced protection was not strain-specific. The study showed the rat to be a possible alternative for the study of different aspects of M. catarrhalis otitis media, an infection that is clinically and structurally different from that elicited by Streptococcus pneumoniae and Haemophilus influenzae in the rat.

中耳コレステリン肉芽腫の成因

Cholesterol of cholesterol granulomas is found in pooled fluid in the mastoid antrum and in the granulation tissue. The cholesterol may be related to erythocytic membranes rich in freecholesterol. The reasons why erythrocytes exude and why cholesterol precipitates remain unknown.In surgical cases of cholesterol granuloma (35 ears), we investigated the history of otitis media and the incidence of complications involving the upper respiratory tract.The lipid peroxide concentration in the pooled fluid in the mastoid antrum was measured by a free radical reaction.The temporal bone pathologic anatomy in two ears affected by cholesterol granuloma was evaluated during autopsy.The history of otitis media included acute repetitive purulent otitis media in 76% and acute purulent otitis media in 18% inflammation of the upper respiratory tract was a complication in 73%. The lipid peroxide level was 17nmol/ml, which was 1.8 times higher than that in cases of otitis media with effusion.Since acute purulent otitis media is present in many cases of cholesterol granuloma, inflammation often remains in the mastoid antrum which is blocked.Recurrence of concealed otitis media may follow eustachitis resulting from infection of the upper respiratory tract. The mastoid air cells become narrow due to edematous mucosa resulting in negative pressure. Since the blood vessels within neogranulomas are weak, erythrocytes may exude.As the disease advances the effusion lacks ventilation and leukocytes engulf intiltrated inflammatory cells, releasing active oxygen. This destroys the erythrocytic membranes by hyperoxidation, resulting in lipids from the broken membrane and tissue fragments and cholesterol precipitation through clasmatosis.The proliferative mucosa in the effusion is replaced with granulation tissue and cholesterol granuloma slowly forms.

Myringotomy: A Prerequisite for the Development of Myringosclerosis?

Streptococcus pneumoniae was inoculated into the left middle-ear cavity in two groups of rats, resulting in purulent otitis media. After 3 days, one group of infected animals and a third group of noninfected animals were subjected to left-sided myringotomy. The tympanic membranes were examined both otomicroscopically and histologically 1 and 3 months later. On otomicroscopic examination the noninfected myringotomized animals had developed extensive myringosclerotic lesions, whereas only minimal sclerotic deposits were noted in the myringotomized animals with acute otitis media (AOM). On histologic examination both the noninfected myringotomized animals and the myringotomized animals with AOM were similar in the frequency and extension of sclerotic lesions in the tympanic membrane. The nonmyringotomized rats with AOM were free of sclerotic lesions, except for minor changes found in one animal.

Inhibitory effect of macrolide antibiotics on biofilm formation by Pseudomonas aeruginosa

In recent years, various medical indwelling devices have been developed and used. Bacteria adhering to these devices often cause refractory infection. In the field of otolaryngology, refractory infection accompanying these medical indwelling devices such as middle ear ventilation tubes and artificial auditory ossicles has been reported. The concept of bacterial biofilm infection has been suggested as an explanation for the refractory infection. Furthermore it has been reported that a bacterial biofilm is involved in refractory infection unrelated to medical indwelling devices. Topical biofilm formation was detected in patients with chronic sinusitis, chronic purulent otitis media or habitual tonsillitis. In this study, we morphologically and quantitatively examined the biofilm-forming capacity of a clinically isolated strain of mucoid type Psecudomonas aeruginosa on Teflon to investigate the effects of macrolide antibiotics on bacterial biofilm formation. In the morphological examination, P.aeruginosa was cultured together with a Teflon sheet in minimal medium containing various concentrations of the macrolide antibiotics clarithromycin (CAM), erythromycin (EM) and midecamycin (MDM), at 37 degrees C for 7 days. The surfaces of the Teflon sheets were examined by electron microscopy. The adherent bacteria and biofilm formation on Teflon sheets soaked in minimal medium containing CAM or EM were found to be decreased in a dose-dependent manner. However, in the Teflon sheets soaked in minimal medium containing MDM, there was no decrease in biofilm formation regardless of the MDM concentration. In the quantitative examination, P. aeruginosa was cultured in minimal medium containing various concentrations of the macrolide antibiotics at 37 degrees C for 7 days together with Teflon beads. The levels of hexose, protein and alginate adhering to the Telfon beads were quantified as an estimation of biofilm formation. On Teflon beads treated with CAM or EM, there were dose-dependent decreases in hexose, protein and alginate levels. In particular, marked decreases were noted when CAM and EM concentrations were 10 micrograms/ml or more. Furthermore, there was no significant difference between CAM and EM. However, in the presence of MDM, there was no decrease in hexose, protein or alginate levels regardless of the MDM concentration. The minimal inhibitory concentration (MIC100) of each macrolide against P. aeruginosa used in this experiment was 100 micrograms/ml or more. There may be no bactericidal effect on this strain at the macrolide concentrations used in this experiment. However, this experiment used 7-day treatment. The long-term bactericidal activity of macrolides was examined. In the presence of CAM or MDM, bacterial levels after culture were similar to preculture levels or slightly lower than the preculture levels. In the presence of EM, bacterial levels were similar to the preculture levels. These results demonstrated that CAM and EM, which are 14-membered macrolides inhibited biofilm formation, while MDM which is 16-membered macrolide, did not. These inhibitory effects of CAM and EM may be related to actions other than bactericidal activity. In our experiment, CAM and EM inhibited biofilm formation at 10 micrograms/ml or more. This concentration corresponded to 1/20 x MIC. This concentration can be achieved in tissues, nasal discharge and sputum with actual clinical doses. Therefore, these agents may be effective against biofilm disease caused by P. aeruginosa in the field of otolaryngology.

Tympanic membrane changes in experimental purulent otitis media

The stiffness properties of the gerbil tympanic membrane (TM) were investigated during the early course of experimental purulent otitis media produced by middle ear inoculation (n=49) with type 3 Streptococcus pneumoniae. In a first approach the acoustic admittance and susceptance were measured in vitro with tympanometry and in a second approach the tympanic membrane displacement in response to static pressure was measured with moire interferometry. A histological assessment of the tympanic membrane was made concurrently. The acoustic admittance and susceptance reduced during the initial days post-inoculation. These reductions seem to correlate with an oedema simultaneously developing in the pars tensa. The pressure-induced displacement increased with time of disease, i.e. the mechanical stiffness of the TM reduced. Local deformation zones, or `weak spots' appeared in the inferior half of the pars tensa in three out of eight cases measured at 3 or 4 days post-inoculation. The loss of stiffness in the pars tensa may affect the further course of otitis media, and the `weak spots' are possible precursors of retraction pockets and/or perforations. The stiffness reductions may be caused by changes on a sub-microscopical, molecular level. ©1997 Elsevier Science B.V. All rights reserved

Levels of Eosinophil Cationic Protein and Myeloperoxidase from Chronic Middle Ear Effusion in Patients with Allergy and/or Acute Infection.

Allergy may play a role in the middle ear inflammation that leads to otitis media with effusion. The purpose of this study was to determine whether an elevated mediator correlated with the patient's disease and thus could be used to differentiate allergy vs. infection as the cause of the middle ear inflammation. WE evaluated 57 individuals with otitis media with effusion, 32 with persistent effusion but no recent acute infection, 14 with recent infection and purulent otitis media with effusion, and II healthy subjects. The mediator activity of eosinophils and neutrophils in effusion was studied in patients characterized as having allergy by positive intradermal skin test results and positive radioallergosorbent test results. Eosinophils were characterized by measurement of eosinophil cationic protein in the effusion. Neutrophils were characterized by measurement of myeloperoxidase in the effusion. The levels of eosinophil cationic protein and myeloperoxidase in patients with and without allergy were correlated to patient history. Significantly elevated levels of both eosinophil cationic protein and myeloperoxidase indicated that inflammation in the ear of patients with otitis media with effusion was characterized by a pronounced involvement of both eosinophils and neutrophils. Eighty-nine percent of all patients with disease had allergy. A higher ratio of myeloperoxidase to eosinophil cationic protein in patients with purulent otitis media with effusion indicated that in patients with a superimposed acute infection, neutrophil activity was increased even further. The level of eosinophil cationic protein was elevated only during the effusion of patients with allergies as compared with controls (p < 0.01). Among 29 cases of nonpurulent otitis media with effusion, 96.5% had allergic immune-mediated disease proved by skin testing, which was related clinically to their ear disease. Eighty-nine percent (89.6%) of these patients had eosinophil cationic protein levels greater than 10 microgram/L. Middle ear eosinophil cationic protein may be used as a marker of related allergy.

Levels of eosinophil cationic protein and myeloperoxidase from chronic middle ear effusion in patients with allergy and/or acute infection

BACKGROUND AND OBJECTIVE: Allergy may play a role in the middle ear inflammation that leads to otitis media with effusion. The purpose of this study was to determine whether an elevated mediator correlated with the patient's disease and thus could be used to differentiate allergy vs. infection as the cause of the middle ear inflammation. METHODS: We evaluated 57 individuals with otitis media with effusion, 32 with persistent effusion but no recent acute infection, 14 with recent infection and purulent otitis media with effusion, and 11 healthy subjects. The mediator activity of eosinophils and neutrophils in effusion was studied in patients characterized as having allergy by positive intradermal skin test results and positive radioallergosorbent test results. Eosinophils were characterized by measurement of eosinophil cationic protein in the effusion. Neutrophils were characterized by measurement of myeloperoxidase in the effusion. The levels of eosinophil cationic protein and myeloperoxidase in patients with and without allergy were correlated to patient history. RESULTS: Significantly elevated levels of both eosinophil cationic protein and myeloperoxidase indicated that inflammation in the ear of patients with otitis media with effusion was characterized by a pronounced involvement of both eosinophils and neutrophils. Eighty-nine percent of all patients with disease had allergy. A higher ratio of myeloperoxidase to eosinophil cationic protein in patients with purulent otitis media with effusion indicated that in patients with a superimposed acute infection, neutrophil activity was increased even further. The level of eosinophil cationic protein was elevated only during the effusion of patients with allergies as compared with controls (p < 0.01). Among 29 cases of nonpurulent otitis media with effusion, 96.5% had allergic immune-mediated disease proved by skin testing, which was related clinically to their ear disease. Eighty-nine percent (89.6%) of these patients had eosinophil cationic protein levels greater than 10 μg/L. CONCLUSION: Middle ear eosinophil cationic protein may be used as a marker of related allergy. (Otolaryngol Head Neck Surg 1996;114:531-44.)

Microbial dynamics of persistent purulent otitis media in children

Repeated aspirations (for a period of 36 to 55 days) of the exudate through an open perforation were performed in seven children with acute otitis media that did not respond to antimicrobial therapy. Penicillin-resistant organisms were present in all but one of the first two aspirates. Failure to respond to antimicrobial therapy was associated with the emergence of resistant anaerobic and aerobic bacteria in the third and fourth cultures. The infection was cured in all instances after administration of antimicrobial agents effective against these bacteria. (J P EDIATR 1996;128:237-40)

Suppurative petrous apicitis: Osteitis or osteomyelitis? An imaging case report

(Editorial Comment: Modern imaging techniques suggest that petrous apicitis develops from direct extension of acute purulent otitis media into a pneumatized petrous apex.) Although recognition and treatment of suppurative petrous apicitis was discussed in the otologic literature early in the century, it was the decade of the 1930s that saw the great controversies concerning the pathophysiology and operative treatment of this once frequently fatal disease process. Vigorous discussions began in 1931 with the publication of Eagleton’s Unlocking of the Petrous Pyramid for Localized Bulbar (Pontile) Meningitis Secondary to Suppuration of the Petrous Apex.l In this landmark manuscript, Eagleton proposed that unlike mastoiditis, suppuration in the petrous apex was caused by a true osteomyelitis. Although many agreed with Eagleton, others argued that acute petrous apicitis was a result of coalescent osteitis within the pneumatized spaces of the petrous apex. Perhaps the most vocal advocate of osteitis of the petrous air cells as the underlying disease process in petrous apicitis was Julius Lempert.2 With the development of antibiotics, the great controversies concerning petrous apicitis quietly disappeared. The pathogenesis argument of osteomyelitis versus osteitis was never resolved. A recent patient with suppurative petrous apici

Influenza A Virus-Induced Acute Otitis Media

To better understand the significance of viral upper respiratory tract infections in the pathogenesis of acute otitis media (OM), 27 adults underwent intranasal inoculation with influenza A virus. Monitoring consisted of antibody titer determination, tympanometry, and otoscopy. Microbiologic analysis consisted of cultures and polymerase chain reaction (PCR)-based detection for influenza A virus, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. All subjects became infected with the challenge virus. By day 4, 16 (59%) developed middle ear pressures of -100 mm H2O or below and 4 (25%) of them developed OM. One subject (4%) developed purulent OM requiring myringotomy for pain relief. Middle ear effusion cultures were negative. PCR analysis of that subject's middle ear effusion and nasal washes were positive for influenza A virus and S. pneumoniae. These findings support a causal role for viral upper respiratory tract infections in the pathogenesis of OM, possibly mediated by middle ear underpressures and viral and bacterial middle ear infection.

Meningitis in the Child With a Smile-Reply

I agree with Dr Baptist's critique that a smile may not be a 100% accurate test to rule out meningitis in a febrile infant, but I hope no one thought I was failing to obtain a full history and results of a physical examination before deciding whether or not to initiate laboratory studies. My only contention is that in 45 years as a solo suburban pediatrician, I have never yet seen a febrile infant with meningitis who smiled. However, what test ever is 100% accurate? Even results of an initial lumbar puncture that show CSF free of cells and normal results of chemistry studies do not rule out meningitis. I have examined a 3-month-old infant with purulent otitis media and suspicious meningeal signs whose initial CSF findings were normal, only to be told 12 hours later that the CSF culture was growing pneumococci. I think Dr McCarthy's reply

Surgical considerations in treating sensorineural hearing loss with acute and chronic otitis media

Sensorineural hearing loss, especially of high frequencies, can be an important sequela of both acute and chronic otitis media. Recent studies of this phenomenon by various associates of our laboratory and clinic are briefly reviewed. Two illustrative case studies are presented. The first, involving acute purulent otitis media, showed both temporary threshold shift (TTS) and permanent threshold shift (PTS). The second case was a teenager with intractable chronic otitis media and mastoiditis and severe labyrinthine symptoms that were ameliorated with a flexible surgical approach. Surgical tips used to deal with this problem are presented.

Exacerbation of the chronic inflammatory process of the ear and maxillary sinus against the background of viral meningoencephalitis

In recent years, cases of serous meningitis with influenza have become more frequent. Here is our observation. Sh., 12 years old, was admitted to the clinic on November 22, 1993 with purulent discharge from the right ear for a long time and discharge with an unpleasant odor and itching in the left ear. The child has a history of frequent pneumonia, acute respiratory viral infections, goimoritis and purulent otitis media. In 98 he underwent adenotomy. In February 1990, a radical operation was performed on the right ear for otogenic meningitis.

Current methods of treatment infectious inflammatory diseases of ear and upper respiratory tracts

The experience of the treatment of acute and chronic purulent otitis media by the meatotympanal injection of medicinal agents, the use of laser energy and ozone is given. The method of the functional diagnosis of chronic tonsillitis rheoteonsillography, as well as the stages of intensive therapy of acute laryngotracheitis in children are described. The data of the use of laser irradiation in combined treatment of mycoses of the ear and upper respiratory tracts are given.