Tympanostomy Tube Otorrhea Research Articles

Topical ciprofloxacin is superior to topical saline and systemic antibiotics in the treatment of tympanostomy tube otorrhea in children: The results of a randomized clinical trial

To compare the clinical failure rates among children with otorrhea through tympanostomy tubes treated with topical or systemic antibiotics versus topical saline. Randomized, double-blind, controlled patient study. A three-armed randomized clinical trial using topical ciprofloxacin or oral amoxicillin or topical saline. The primary outcome was treatment failure defined as presence of otorrhea in at least one ear after 7 days of treatment. The treatment failure rates were 23% and 70% in the group treated with topical ciprofloxacin and oral amoxicillin, respectively. Treatment failures were seen in 58% of children treated with topical saline. Thus, topical ciprofloxacin significantly reduced treatment failures compared to both oral amoxicillin and topical saline. The most frequent bacteria isolated from treatment failures in general were streptococci and Moraxella catarrhalis. The significant effect of topical ciprofloxacin is probably related to a higher local concentration of antibiotics in the middle ear rather than the result of mechanical rinsing and dissolution of the bacterial load.

Linezolid for tympanostomy tube otorrhea caused by methicillin-resistant Staphylococcus aureus and multiple drug-resistant Streptococcus pneumoniae

To describe a consecutive series of children with refractory tympanostomy tube otorrhea treated with linezolid and document its clinical effectiveness and adverse effects. Retrospective, single institution case series. The records of children treated with linezolid for refractory gram-positive otorrhea from 2003 to 2007 were analyzed for causative organisms, antimicrobial sensitivities, history of prior medical treatments, time to cessation of otorrhea, adverse effects of linezolid and recurrence of infection. Ten episodes of refractory gram-positive otorrhea treated with linezolid were documented among eight children during the study period. Seven were caused by methicillin-resistant Staphylococcus aureus and three by multiple-drug resistant Streptococcus pneumoniae. Prior treatment regimes included clindamycin, trimethoprim-sulfamethoxazole/rifampin, amoxicillin-clavulanate, and/or a third-generation cephalosporin. Seven of eight children had failed extended courses of fluoroquinolone ear drops. All children were free of otorrhea by the 14th day of twice-daily treatment with oral linezolid at 20mg/kg/day. One child developed two additional episodes of S. aureus otorrhea three and 10 months after initial treatment. Each was successfully controlled with linezolid. There were no adverse effects from linezolid treatment. Oral linezolid is highly effective in the treatment of refractory otorrhea caused by methicillin-resistant S. aureus and multiple drug-resistant S. pneumoniae. It has a low risk of serious side effects. It is one of only a few oral agents with activity against these organisms and is very expensive. Linezolid should be used only when otorrhea cannot be treated with conventional agents or when complications of otitis media pose a risk to life or function.

The Dynamics of Bacteria in the Middle Ear During the Course of Acute Otitis Media With Tympanostomy Tube Otorrhea

Dynamics of bacteria during acute otitis media (AOM) has not been thoroughly studied because it requires repeated tympanocentesis. AOM with tympanostomy tube otorrhea provides a unique opportunity to study the appearance and disappearance of pathogens during the course of the disease without stressing the child. Middle ear fluid (MEF) samples were taken before treatment (amoxicillin clavulanate or placebo) and then daily during follow-up from 75 children having AOM with otorrhea through a tympanostomy tube. Bacteria were identified by culture, and typical AOM pathogens also by polymerase chain reaction. Bacteria were initially shown in 67 (89%) children. New bacteria appeared in MEF more often in placebo than in amoxicillin clavulanate recipients [9 of 38 (24%) versus 2 of 37 (5%); P = 0.032]. During the follow-up, new occurrences of Moraxella catarrhalis were detected in MEF more frequently than those of Streptococcus pneumoniae or Haemophilus influenzae. Of the 28 patients with bilateral otorrhea, 11 (39%) had disparate bacteria at study entry and/or during the follow-up. Changes in bacterial findings during the course of AOM are common in patients not receiving treatment, and even possible despite adequate treatment. In bilateral otorrhea, disparate bacterial findings are common.

Choosing the Best Practice: Evidence to Support Fluoroquinolone Drops for Acute Otitis Media Through Tympanostomy Tubes

To the Editor .— In his commentary, “Why Don't Those Ear Drops Work for My Patients?”1 Isaacson presented his argument against the use of ototopical fluoroquinolones alone or in combination with a steroid as the first line of defense for the treatment of acute tube otorrhea in infants. He made several points to discount the use of these agents in pediatric patients with acute otitis media with tympanostomy tubes. However, rooted in the first sentence of the commentary was the fact that seems to lie at the epicenter of his concerns: “‘Topical Ciprofloxacin/Dexamethasone Is Superior to Oral Amoxicillin/Clavulanic Acid in Acute Otitis Media With Otorrhea Through Tympanostomy Tubes,’ [is] the latest in a series of pharmaceutical industry–funded articles… .” Isaacson's first critique of this article2 pertains to the study population. He stated that “[i]f one were trying to design a study to demonstrate the superiority of ototopical drops over oral antibiotics, the ideal population would be older children.” This statement directly contradicted his other criticism that “more than half of their subjects were >22 months of age.” In fact, 58% of the subjects in the study were <23 months of age, and the remaining patients were 2 to 11 years of age. These age distributions reflect …

Structural features of tympanostomy tube biofilm formation in ciprofloxacin-resistant Pseudomonas otorrhea

Bacterial biofilm formation has been implicated in the high rate of persistent otorrhea after tympanostomy tube insertion. In this study, we evaluated Pseudomonal biofilm formation from intractable post tympanostomy tube otorrhea in children. Twelve patients (seven males, five females) with unilateral post tympanostomy tube P. aeruginosa otorrhea were evaluated prospectively. All patients were treated with ciprofloxacin otic drops but the otorrhea failed to resolve. Ear discharge for culture was collected from the external auditory canal using a swab. The tympanostomy tubes were removed and collected for evaluation of biofilm formation using a scanning electron microscopy. In all cases, ciprofloxacin-resistant P. aeruginosa was the only organism grown. The surface of the silicone tube contained undulations or microfissures throughout. The thick biofilms present on most tube surfaces were densities with no intervening spaces, consistent with biofilms. Biofilms can be directly observed by scanning electron microscopy. Therefore, our results demonstrate that bacterial aggregates called biofilms, that are resistant to treatment by antibiotics, can be detected by standard culture techniques, and may play a major etiologic role in posttympanostomy otorrhea.

Ofloxacin Otic Drops vs Neomycin–Polymyxin B Otic Drops as Prophylaxis Against Early Postoperative Tympanostomy Tube Otorrhea

To evaluate the incidence of tympanostomy tube (TT) sequelae, tube otorrhea, and tube obstruction immediately postoperatively in patients receiving TT for otitis media and to compare patients receiving postoperative otic drops with controls. Blinded randomized control trial. A tertiary pediatric otolaryngology practice. The study population comprised 306 patients undergoing TT placement. The 306 patients were enrolled into the following 3 groups: (1) those receiving no postoperative otic drop prophylaxis (control group), (2) those receiving ofloxacin otic drops (FLOX group), and (3) those receiving neomycin sulfate-polymyxin B sulfate-hydrocortisone otic drops (COS group). Overall otorrhea rates postoperatively were 14.9% for the control group, 8.1% for the FLOX group, and 5.5% for the COS group. When controlling for disease severity, the rate of otorrhea was significantly higher for the control group than for both the FLOX (P = .04) and COS (P = .01) groups. Nonpatent, plugged, tube rates were added to otorrhea rates for a TT failure analysis postoperatively. The control group demonstrated a significantly greater failure rate (29.9%) than both the FLOX (12.1%) and COS (7.7%) groups. The only differences between the patients in the 2 groups receiving drops were that ofloxacin was more well liked by patients (P = .04) and caused less pain (P = .004). Nonpatency and otorrhea are the most frequent sequelae immediately following TT placement. Few studies have compared different treatment regimens in a randomized controlled trial. These results demonstrate that otic drops clearly provide benefit postoperatively in preventing TT plugging and otorrhea but primarily in patients who have middle ear fluid at the time of TT placement. In addition, consideration of drop choice should be based on patient tolerance and medication safety profiles.

Fungal causes of otitis externa and tympanostomy tube otorrhea

To describe the occurrence of fungal organisms in the setting of otitis externa and tympanostomy tube otorrhea, review the treatment course, timing of diagnosis, organism identified and time to resolution with fungal infections. Retrospective review. Pediatric otolaryngology clinic within a tertiary care hospital. One hundred and sixty-six patients (ages 16 days to 18 years) with fungal organisms on ear culture. Number of prior therapies, number of office visits, time to resolution and anti-fungal therapy. Ear cultures positive for fungal organisms were found in 166 patients seen between 1 January 1996 and 30 September 2003 from a total of 1242 patients undergoing ear culture. Comparing the 3-year period (1996-1998) prior to the availability of fluoroquinolone ototopical drops to the 3-year period after (1999-2001), there is a statistically significant increase in the incidence of positive fungal culture (p<0.001). Otitis media was diagnosed in 72% of these children, with otitis externa comprising 25%. Approximately 3% carried a diagnosis of both otitis externa and otitis media. Candida albicans was identified in 43% of fungal organism-positive cultures. Candida parapsilosis was found in 24% of and Aspergillus fumigatus in 13%. The remainder of the cultures yielded three other Candida and three other Aspergillus species, each at less than 5%. Time to resolution ranged from 1 week to 9 months, with a median of 3.8 weeks for symptom resolution. Patients were treated with an average of 1.7 oral antibiotics and 1.1 ototopical agent before a culture was taken. Otorrhea due to fungal organisms occurs in the setting of refractory infection and is often discovered after multiple oral and ototopical antibacterial medications. Due to the extended treatment period required to clear fungal organism, timely diagnosis with culture for bacteria and fungus is required in patients with persistent otorrhea. An increase in incidence of fungal infections of the ear was found in the period after widespread use of ofloxacin began.

Chronic rhinosinusitis and biofilms

Biofilms have been implicated in several head and neck infectious processes such as the following: dental and periodontal disease, otitis media, tympanostomy tube otorrhea, and chronic tonsillitis. We believe that biofilms also are associated with chronic rhinosinusitis. No information is known regarding the presence of biofilms in chronic rhinosinusitis. With institutional review board approval, tissue was obtained from consenting chronic rhinosinusitis patients who were undergoing functional endoscopic sinus surgery. Specimens were taken bilaterally from the ethmoid and maxillary sinuses. Inclusion criteria consisted of a positive diagnosis with pathologic tissue confirmation of chronic inflammation. Diagnosis was based on patient history, physical exam, and coronal sinus CT findings. Once collected, the specimens were labeled and fixed in formalin. The specimens were subsequently dehydrated, with successive immersions in increasing concentrations of diluted ethanol. The specimens were allowed to air dry and then were affixed to aluminum stubs with colloidal carbon. The sample surface was coated with a gold and palladium layer. The specimens were examined under an electron microscope. Areas of interest were photographed. Specimens from 5 patients were examined. All revealed bacterial biofilms. Invariably, biofilms were seen in the ethmoid, as well as in other samples. Denudation of ciliated and goblet cells was noted in all specimens. Biofilms resembled that of Staphylococcus species. Unidentified biofilms were also seen. This is the first documentation of biofilms in association with chronic rhinosinusitis. Further investigation is warranted, especially with control research subjects.

Chronic rhinosinusitis and biofilms

Objectives: Biofilms have been implicated in several head and neck infectious processes such as dental and periodontal disease, otitis media, tympanostomy tube otorrhea, and chronic tonsillitis. We believe that biofilms are also associated with chronic rhinosinusitis. No information is known regarding the presence of biofilms in chronic rhinosinusitis. Methods: With IRB approval, tissue from consented, chronic rhinosinusitis patients undergoing FESS because of failure of medical therapy were obtained. Specimens were taken bilaterally from the ethmoid and maxillary sinuses. Inclusion criteria consisted of a positive diagnosis and pathological tissue confirmation of chronic inflammation. Diagnosis was based on patient’s history, physical exam, and coronal sinus CT findings. Once collected, the specimens were labeled and fixed in formalin. The specimens were subsequently dehydrated with successive immersions in increasing concentration dilutions of ethanol. The specimens were allowed to air dry and then affixed to aluminum stubs using colloidal carbon. The sample surface was coated with a gold/palladium layer. The specimens were examined under a JEOL (Model: JSM-6400) Scanning Electron Microscope. Areas of interest were photographed. Results: Specimens from 4 patients were examined. All revealed bacterial biofilms. Invariably, biofilms were seen in the ethmoid, as well as in other samples. Denudation of ciliated and goblet cells was noted in all specimens. Biofilms resembled that of Staphylococcus species. Unidentified biofilms were also seen. Conclusions: This is the first documentation of biofilms in association to chronic rhinosinustis. Further investigation is warranted, especially with control research subjects.

The development of antibiotic resistant organisms with the use of ototopical medications

Objective There is growing concern over the use of systemic antibiotics and the development of bacterial resistance. The question remains as to whether ototopical medications may also promote antibiotic-resistant organisms, either on a local level (in the ear) or in other areas of the aerodigestive tract. We performed an evidence-based review to answer the following clinical question, “Do antibiotic ototopical medications induce antibiotic resistant organisms?” Study design We performed a MEDLINE search of the published literature from 1966 to the present. We used appropriate search terms such as “ototopical antibiotics,” “ototopical drops,” “antibiotic resistance,” “topical antibiotics and otitis externa,” “otitis externa and treatment,” “otitis externa and antibiotic drops,” “otitis externa and ototopical drops,” “otitis media,” “otitis media and treatment,” “otitis media and antibiotic drops,” “chronic suppurative otitis media,” “chronic suppurative otitis media and treatment,” “chronic suppurative otitis media and antibiotic drops,” “ otitis externa and resistant organisms,” “otitis media and resistant organisms,” “chronic suppurative otitis media and resistant organisms,” “ophthalmic antibiotic drops,” “draining ear,” “P.E. tube otorrhea,” “pressure equalizing tube otorrhea,” “pressure equalizing tube otorrhea and treatment,” and “pressure equalizing tube otorrhea and ototopical therapy” to identify pertinent articles. These articles were reviewed and graded according to the evidence quality. Results After an initial screening of over 2,500 articles, 38 articles were analyzed further; of these, 11 were determined to warrant extensive review. Eight articles evaluated chronic suppurative otitis media; 2, otitis externa; and 1, post–tympanostomy tube otorrhea, whereas 3 others studied systemic absorption. Of the 8 chronic suppurative otitis media studies, there were thought to be 5 grade 2B studies, 1 grade 1B study, and 1 grade 2C study. These studies did not demonstrate a propensity for the development of resistant organisms. No study answered the question as to whether resistance to systemic antibiotics might occur in otitis externa. Conclusions Overall grade B evidence seems to indicate that no significant antibiotic resistance develops from the use of ototopical antibiotic treatment.

Posttympanostomy tube otorrhea

This article will focus on some theories and recent advances to explain chronic post tympanostomy tube otorrhea, a step-wise approach to treatment and future research areas of interest.

Use of ototopical antibiotics in treating 3 common ear diseases

Prompted by rising rates of antibiotic resistance, lack of standardized treatment regimens, and new treatment alternatives, the American Academy of Otolaryngology–Head and Neck Surgery convened an expert consensus panel to consider recommendations for the responsible use of antibiotics in chronic suppurative otitis media, tympanostomy tube otorrhea, and otitis externa. The Panel concluded that in the absence of systemic infection or serious underlying disease, topical antibiotics alone constitute first-line treatment for most patients with these conditions, finding no evidence that systemic antibiotics alone or in combination with topical preparations improve treatment outcomes compared with topical antibiotics alone. Topical preparations should be selected on the basis of expected bacteriology and informed knowledge of the risk-benefit of each available preparation. The use of nonototoxic preparations in treating acute otitis externa (when the tympanic membrane is perforated or its status is unknown), chronic suppurative otitis media, and tympanostomy tube otorrhea should be considered. (Otolaryngol Head Neck Surg 2000;122:934-40.)

Middle Ear Irrigation During Insertion of Ventilation Tubes

Tympanostomy and insertion of ventilation tubes has become one of the most commonly performed operations in the United States. Most authors reporting complications of this procedure describe a postoperative rate of otorrhea in the range of 10-20% with some reports much higher. This rate of presumed suppuration would generally be considered high by surgeons operating in other areas of the body. It is a commonly accepted surgical practice to follow incision and drainage of a relatively closed space infection with irrigation of that space. This is true in the surgery for the paranasal sinuses, deep space infections of the neck, joint spaces and abscesses in general. However, this practice is not routinely performed when incising and draining the middle ear. We have completed a prospective controlled double blind study on post tympanostomy tube otorrhea utilizing irrigation of the middle ear. In 220 consecutive cases, the use of middle ear irrigation reduced postoperative infections in the first 6 months from 16 to 4%. Irrigation was also found to be useful in removing very thick effusions from the middle ear by displacement, including those effusions localized in the hypo or epitympanum which were not initially identified at the time of incision and suction. A soft plastic, angled irrigation catheter with radial ports was developed for this purpose.