Purulent Otitis Media Research Articles

The temporal bone in multiple myeloma

Multiple myeloma is a malignant disease of the skeleton. Anatomically, any bone may ultimately come to be involved in a given case. In a literature review, no published series of temporal bone findings have been reported. In this study, oto-histopathologic changes associated with multiple myeloma are analyzed and reported in 15 temporal bones from 8 patients. The bone marrow of 13 temporal bones was involved by the tumor. Osteolysis was evident in 11 temporal bones. Serous otitis media (SOM) or purulent otitis media (POM) was seen in 13 ears with 12 showing mastoid effusions. Eight ears exhibited pathological changes in inner ears, including degeneration of the organ of Corti, atrophy of stria vascularis, decreased ganglion cells, and labyrinthine hydrops. The inner ear changes were most severe in 2 patients who had otologic symptoms. Infiltration of myeloma cells was not apparent in the middle ear mucosa or the inner ears.

Determining otitis media severity from middle ear fluid analysis.

Otitis media has a complex multifactorial pathogenesis, and the middle ear inflammatory response is typified by the accumulation of cellular and chemical mediators in middle ear effusion. However, specific biochemical and immunochemical factors that may be responsible for the severity or chronicity of otitis media have not been identified. Identification of factors involved in chronicity appears to be an essential step in the treatment and ultimate prevention of chronic otitis media. We analyzed 70 effusion samples from patients 1 to 10 years of age who had chronic otitis media with effusion for two cytokines (interleukin-1 beta and tumor necrosis factor alpha) and total collagenase. The highest concentrations of all three inflammatory mediators were found in purulent otitis media, and concentrations were higher in younger than in older patients. Mediator concentrations were similar in samples obtained from patients having their first myringotomy for otitis media with effusion and in those who had had multiple previous myringotomies. The multiresponse star, which incorporates several biochemical parameters in one graphic illustration, may best characterize the complex nature of middle ear inflammation.

Surgical Advances in Treating Otitis Media

Surgical methods of treating otitis media and its sequelae are discussed, according to the classification of otitis media presented in an earlier report. Surgical management of otitis media with effusion and recurrent purulent otitis media includes myringotomy and use of ventilation tubes. Occasionally, otitis media with effusion will lead to structural and other pathologic changes in the middle ear, and conservative treatments such as use of medication or tubes will not suffice. Indications and methods for exploratory tympanotomy and reconstruction of the middle ear are discussed. In such instances, tympanoplasty can be used to the patient's benefit. Chronic otitis media with mastoiditis, defined by the presence of intractable pathologic tissue, generally requires surgical correction. Classic methods include simple mastoidectomy, modified radical (Bondy) mastoidectomy, and radical mastoidectomy. Current classifications of procedures would also include closed-cavity tympanomastoidectomy, open-cavity tympanomastoidectomy, and intact-bridge tympanomastoidectomy (a combined approach). The diagnostic and surgical approach to silent or subclinical otitis media is discussed. Diagnosis and treatment of sequelae of otitis media, including sequelae in the middle ear and, less commonly, in the inner ear, are discussed.

Quantitative Analysis of Soluble Cell Adhesion Molecules in Otitis Media with Effusion

The levels of the soluble intercellular adhesion molecule 1 (sICAM-1) and soluble granule membrane protein-140 (sGMP-140) were measured in middle ear effusions (MEEs) of otitis media (OM) with ELISA. MEEs of chronic serous and mucoid OM in children contained significantly higher levels of sICAM-1 and sGMP-140 compared with normal serum. sGMP-140 in acute and chronic OM in children was higher than in adult chronic serous OM, and in acute purulent OM higher chronic serous OM in children. Cytologic analysis showed that the mean level of sGMP-140 was significantly higher in the neutrophil dominant group than in other groups except the few cells type. sICAM-1 showed no differences among the cytologic classifications. Copious amounts of sICAM-1 and sGMP-140 in MEEs were observed in this study, and were probably the result of shedding from the cells expressed cell adhesion molecules. These cell adhesion molecules in MEEs were thought to modify the inflammatory response in OM.

Arachidonic Acid Metabolites in Experimental Otitis Media and Effects of Anti-Inflammatory Drugs

Previous studies have shown that arachidonic acid (AA) metabolites are important in the pathogenesis of otitis media with effusion. The AA metabolites in 4 different experimental models for otitis media were analyzed, and the effect of anti-inflammatory drugs was studied. Purulent otitis media was induced in rats by inoculation of Streptococcus pneumoniae in the tympanic bulla, serous otitis media by blocking the tympanal orifice of the eustachian tube, and mucoid otitis media by combining the two procedures. Middle ear effusion was also induced by stimulating the external auditory canal with cold air. Indomethacin and hydrocortisone were used to inhibit AA metabolism in the latter model. Lipoxygenase products dominated in the purulent and cold air otitis media models. Cyclooxygenase products dominated in the mucoid and serous models. Indomethacin inhibited accumulation of middle ear effusion in the cold air otitis media model, whereas hydrocortisone did not. Apart from AA metabolites, other mechanisms and mediators appear to be responsible for the increased vessel permeability observed in the cold air otitis media model, such as interactions between mast cells and nerves in the middle ear mucosa.

Otitis Media

Definitions When the diagnosis of otitis media has been made on the basis of skilled clinical observation and the tympanic membrane is intact, it is practical to assume that an effusion is present. However, this can be confirmed only by recovery of fluid from the middle ear on tympanocentesis or myringotomy. Several methods will confirm the diagnosis of effusion with the indicated accuracy, as generally reported in the literature (Table 1). Acute Otitis Media A common error in the diagnosis of otitis media with effusion (OME) is equating an "injected" or "red" eardrum with OME. Acute otitis media may present with an injected drum, but the critical factor is not drum color but the presence of fluid in the middle ear cavity. The drum frequently is suffused and red when an infant or toddler is crying from either fear or pain during the otoscopic examination. A bulging eardrum, on the other hand, usually is regarded as defining acute otitis media (also called suppurative or purulent otitis media) with or without symptoms (pain, sleeplessness, fever, irritability) of systemic illness. Experienced clinicians try to avoid the "red ear" error with either tympanometry or acoustic reflectivity (Table 1) or by careful removal of all external ear contents to visualize fully the landmarks (eg, both ends of the malleolus) and their mobility with the pneumatic otoscope.

Opsonization and phagocytosis of bacteria during various middle ear infections

Samples of middle ear effusions (MEE) obtained from 50 children suffering from acute purulent otitis media (AOM; 23 ears), otitis media with effusion (OME; 15 ears) or chronic suppurative otitis media (COM; 23 ears) were subjected to cytological (cellular differentiation, degree of phagocytosis) and bacteriological (species quantification and identification, degree of opsonization) analyses. Methods used were direct microscopy of acridine orange stained material, immunofluorescence assay using fluorescein-labelled antibodies to immunoglobulin G (IgG) and complement cleavage product C3b, and standard bacterial culturing on agar plates. The most intense opsonization and phagocytosis was evident in COM effusions culture-positive for Staphylococcus aureus. AOM and OME effusions showed rather poor opsonization and roughly 1% of the phagocytes harboured intracellular bacteria. COM effusions, culture-positive for Pseudomonas aeruginosa, showed no bacterial opsonization or phagocytosis whatsoever. Opsonization and phagocytosis of bacteria in the middle ear cleft is highly species-specific.

Round Window Membrane in Serous and Purulent Otitis Media: Structural Study in the Rat

The rat was used as an animal model to reveal structural alterations in the round window membrane (RWM) during serous otitis media (SOM) and purulent otitis media (POM) over a 6-week period. Comparison of POM animals and control animals showed that the RWM in the former became almost six times as thick as that in controls, whereas that of SOM animals was twice as thick. The structural changes in the RWM in POM animals were confined mainly to the epithelium facing the middle ear cavity and the subepithelial space, which was invaded by inflammatory cells and exhibited dilated vessels. The normal flat epithelium was transformed via cuboidal cells to a cylindric epithelium containing both ciliated and goblet cells. In SOM animals, light microscopy revealed only minor changes in the RWM structure. Ultrastructurally, however, the connective tissue layer exhibited dense aggregations of collagen, increased numbers of fibroblasts, and, in one case, elastic fibers. This last phenomenon was not observed in either POM ears or normal ears. The study showed that various inflammatory conditions of the middle ear, both noninfectious (SOM) and infectious (POM), can cause different structural alterations of the RWM. These structural changes may influence passage through the RWM differently.

The Determination of Phospholipids in Middle Ear Effusion from Experimental Otitis Media in the Chinchilla

Phospholipid types were clarified both in eustachian tube secretion (ETS) and middle ear effusions (MEEs) from chinchilla middle ear. ETS was obtained from normal healthy animals and from animals with experimentally induced purulent otitis media (POM). MEE was obtained from experimentally induced serous and purulent otitis media (SOM and POM). In normal ETS, phosphatidylcholine (36.4%) was predominant followed by phosphatidylethanolamine (30.6%), sphingomyelin (18.0%), phosphatidylinositol (7.2%), phosphatidylglycerol (8.8%) and phosphatidylserine (2.5%). A significant loss of phosphatidylcholine was observed in ETS and MEE from experimentally induced otitis media. These findings suggest that both POM and SOM might be caused by a relative decrease of phospholipids, which is a major component of surfactants. Furthermore, the analysis of phospholipids in MEE may yield baseline information necessary to specify the factors responsible for chronicity or the tendency of recurrence of otitis media.

Phenol anesthesia of the tympanic membrane in purulent otitis media: a structural analysis in the rat.

In the present study, local anesthetics were applied to the tympanic membrane (TM) of rats following experimentally evoked purulent otitis media (POM). The structure of the TM was evaluated 24 h, 2 weeks and 3 months after application of phenol to a discrete are of the right TM. The left ear was used as a control. POM induced swelling of all tissue layers of the pears tensa. The tissues were invaded by inflammatory cells and disintegrated. The fibrous layer also dissolved, leaving spontaneous perforations. However, phenol on inflamed TMs did not further alter the TM structure. These findings infer that the injurious effect of topical anesthesia on the intact TM is more or less negligible when applied to diseased TMs.

Abnormalities of the neonatal ear: otoscopic observations, histologic observations, and a model for contamination of the middle ear by cellular contents of amniotic fluid.

It is unknown whether childhood ear disease could be present long before symptoms provoke an initial otoscopic examination. A newborn middle ear might or might not start in a pristine, privileged state. The clinician evaluating later infant and childhood ear disease is often unaware of the status of a patient's ear from the neonatal period, the earliest time at which the tympanic membrane can be evaluated. Adding to the physician's handicap, normative otoscopic and histologic data on the neonatal ear are incomplete. In order to test the hypothesis that disease in the neonatal middle ear may be more common than is generally appreciated, the population of critically ill neonates was selected for study since this group can provide both clinical as well as histologic data. This manuscript is divided into three parts. Clinically, otoscopic observations were analyzed on infants in an intensive care unit. Histologically, neonatal temporal bones were studied for normal anatomy and pathology of the middle ear and antrum. Experimentally, an animal study was performed to evaluate the potential effect of amniotic fluid cellular contents aspirated into the middle ear. I. Clinical Otoscopic Observations. Daily otoscopic examination was conducted on 44 neonates in an intensive care unit. Specific parameters of the otoscopic examination were evaluated to compare with the normal, translucent tympanic membrane of the older child. The otoscopic appearance was found to be abnormal in 97.7% of neonatal ears. Of the otoscopic parameters evaluated, right ears averaged 2.6 abnormalities and left ears averaged 2.5 otoscopic abnormalities. The otoscopic appearance of the neonate in the neonatal intensive care unit is nearly universally abnormal. II. Temporal Bone Histologic Observations. One hundred eleven temporal bones from 56 neonates were collected for histologic study by light microscopy. Mesenchyme filling more than 60% of the middle ear space was found in 13 bones. Amniotic fluid cellular content was detected in 90 bones. Purulent otitis media was detected in 24 bones. Varying amounts of blood were found in the middle ear space of 34 bones. Only 7 of the bones had no significant middle ear abnormality. It is concluded that in the critically ill neonate, the middle ear and antrum usually contain cellular or fluid material, often in significant volume, that would not be considered normal in the older patient. III. An Animal Model Simulating Contamination of the Middle Ear by Cellular Contents of Amniotic Fluid.(ABSTRACT TRUNCATED AT 400 WORDS)

Mechanisms of retraction pocket formation in the pediatric tympanic membrane.

The epidemiological nature of acquired cholesteatoma in children has shown that it occurs more often in the posterosuperior quadrant of the pars tensa and in the pars flaccida. This type of cholesteatoma is rarely seen before the age of 3 years, and serous otitis media is the most important risk factor for its occurrence. In an attempt to present a pathological rationale for these clinical findings, tympanic membranes from 11 temporal bones with purulent otitis media and 13 with serous otitis media were evaluated light microscopically and compared with 14 temporal bones without disease. Ages ranged from newborn to 3 years 6 months. The persistence of mesenchyme and greater inflammatory reaction observed in the pars flaccida and the posterosuperior quadrant of the pars tensa and changes in collagen and elastin observed in purulent otitis media and serous otitis media may represent a pathological rationale for the epidemiological nature of cholesteatoma in children.

Tympanogenic labyrinthitis and meningitis

Otitis media can result in pathological changes not only in the middle ear but also the inner ear and meninges. Paparella et all have described silent otitis media as pathological conditions behind an intact tympanic membrane that may be “undetected” or “undetectable” especially in chronic cases. Evidence also indicates that insidious labyrinthine’ and meningitic changes3 can be associated with or result from silent otitis media. Cochlear dysfunction has been associated with chronic otitis media (COM), purulent otitis media (POM), and even otitis media with effusion by Paparella et a1,‘s4 English et a1,5 Munker,’ Arnold et a1,7 and Harada et al.’ It was shown by Paparella et al” that otitis media led to gross invasion through the round window and consequently resulted in complete cochlear deafness. Meningitis is the most common intracranial complication of otitis media.“*” It follows either an acute or chronic episode of otitis media. Inflammation of the meninges can occur by direct infection from the middle ear or by direct bony erosion. Hematogenous dissemination also plays an important role in bacterial meningitis.

Purulent Otitis Media in Adults

While the bacterial origin of otitis media has been studied extensively in children, there are few data regarding adults with this disease. We undertook this study to identify the incidence, prevalence, and bacteriologic origin of purulent otitis media in adults. This was accomplished through a review of the English-language literature on adult otitis media and a retrospective review of adult patients with this disease who were hospitalized at our institution. Results of literature review indicate that Streptococcus pneumoniae and Haemophilus influenzae are the most common causes of otitis media in ambulatory adults, but this illness is uncommon, with an incidence of only 0.25%. Hospitalized patients in whom this diagnosis was established suffered a variety of serious suppurative complications such as mastoiditis, meningitis, or brain abscess. Otalgia and fever were the most common symptoms noted in this patient population. Further studies of adult otitis media need to be performed to determine bacteriologic, symptomatic, and high-risk patient groups.

ＯＦＬＸ耳用液の炎症性耳疾患への有用性

The clinical efficacy of ofloxacin otic solution was evaluated in acute purulent otitis media, exacerbation of chronic purulent otitis media, chronic purulent otitis media, otitis externa and myringitis. Two to ten drops of 0.3% ofloxacin otic solution were administrated once or twice a day for 7 days.1) The rate of clinical efficacy (excellent and good responses) judged by the doctor in charge was 75.9% (44/58), and judged by the peer review committee it was 61.5% (16/26).2) The rate of bacteriological elimination was 93.1% (27/29).3) The efficacy rate was higher in patients with chronic purulent otitis media treated twice a day (84.4% (27/32)) than in those treated once a day (65.4% (17/26)) (P<0.1), but no siginificant difference was observed between the two administration methods in patients with other diseases.4) In the patients with a history of operation, the rate of clinical efficacy was 83.3% (10/12), similar to that in those without a history of operation (73.8% (31/42)).5) None of the 71 patients examined had any side effects.6) It was concluded that ofloxacin otic solution is useful.

Immunoglobulin- and complement-coated bacteria in middle ear effusions during the early course of acute otitis media.

We used an immunofluorescence assay to investigate the content of secretory IgA- (SIgA), IgG-, IgM- and C3b-coated bacteria in middle ear effusions obtained within 12-72 h after the onset of acute symptoms of purulent otitis in 28 patients (37 ears). Simultaneously we analyzed the bacteria, both qualitatively and quantitatively, using standard culturing methods and fluorescein conjugated (FITC) antibodies to Haemophilus influenzae and Streptococcus pneumoniae. The ages of the patients were in the range of 5 months to 17 years; 18 were males and 10 females. 73% of the samples harboured no antibody- or C3b-coated bacteria, and particularly those of young patients (< 20 months). 92% of the samples were culture-positive, while 8% showed dormant bacteria. The predominant species were S. pneumoniae and H. influenzae. In 8% of the samples there was heavy and in 11% slight peripheral SIgA-coating of the 5% showed heavy and 19% slight peripheral IgG-coating. Only 3 samples were intensely opsonized, i.e. the bacteria were coated with IgG and C3b simultaneously. In most cases of acute purulent otitis media, the middle ear cavity of young individuals is not able to coat pathogens with SIgA, IgG, IgM and C3b during the early course of infection.

Otologic sequelae after pneumococcal meningitis: A survey of 164 consecutive cases with a follow‐up of 94 survivors

As part of a comprehensive study on sequelae after pneumococcal meningitis, 94 of 111 consecutive survivors were re-examined 4 to 16 years after discharge. Twenty-three patients had otological sequelae after pneumococcal meningitis. In these patients, 17 had hearing losses, 7 had tinnitus, 9 had vertigo, 13 had vestibular areflexia, 4 had loss of smell, and 3 had loss of taste. Among the patients with hearing loss, 4 were bilaterally deaf, 6 were unilaterally deaf, and 2 had mild and 5 had slight hearing losses. From correlations with extensive data from the medical records, preadmission antibiotic treatment appeared to protect from acousticovestibular damage. Purulent otitis media and otosurgical intervention did not correlate to the fatality rate or the development of sequelae. Acute purulent otitis media appeared as a concomitant manifestation, rather than the focus of pneumococcal meningitis.

Phase III study results of Lomefloxaciin (NY-198) otic solution for the treatment of chronic purulent otitis media and its acute exacerbations

Phase III study results of Lomefloxaciin (NY-198) otic solution for the treatment of chronic purulent otitis media and its acute exacerbations

Histopathology of the tensor tympani muscle in otitis media

Involvement of the tensor tympani muscle (TTM) and tendon in otitis media have been suggested both clinically and experimentally. Extensive postmortem histopathological studies of the human TTM in cases with known otitis media have not been done. One-hundred-five human temporal bones with and without otitis media were evaluated using light microscopy to determine the pathological changes of the TTM and tendon. Fatty cell infiltration and degenerative changes of the muscle fibers were observed in non-otitis and otitis media groups, but were greater in those cases with otitis media. Inflammatory cell infiltration and fibroblastic reactions occurred more often in chronic and purulent otitis media, and hypercontracted fibers were more frequent in serous and chronic otitis media. This study indicates that the human TTM and tendon are pathologically involved in the inflammatory process of otitis media.

Uptake of horseradish peroxidase by the middle ear mucosa in experimentally induced otitis media

Electron microscopy was used to study the characteristics of uptake of the protein tracer, horseradish peroxidase (HRP), by the middle ear mucosa of chinchillas. Two types of experimental otitis media were used: serous otitis media (SOM) produced by eustachian tube obstruction and purulent otitis media (POM) produced by inoculation of Streptococcus pneumoniae type 7F. HRP was placed in each tympanic bulla for either 1 min or 10 min. In the 1-min installation of HRP, the degree of HRP uptake was higher in SOM and POM animals than in control animals. Following the 10-min installation of HRP, the degree of HRP uptake was higher in SOM and POM animals than in control animals. Following the 10-min installation of HRP, the degree of tracer uptake was almost the same as among the control, SOM and POM animals. The mechanism of uptake was pinocytosis. In another experiment, 5-hydroxydopamine (mol. wt. 256) was used as a small tracer placed into the bulla to examine the permeability of epithelial tight junctions. No labelling of reaction product was observed in the tight junctions of the control, SOM or POM animals. These findings suggest that otitis media increases the uptake of HRP by pinocytosis and that epithelial tight junctions remain intact in inflammation of the middle ear cavity.