Otoscopic and tympanometric findings in acute otitis media yielding dry tap at tympanocentesis

BACKGROUND

The value of tympanometry in detection of middle ear effusion (MEE) has been widely studied in otitis media with effusion. There has been no direct comparison of tympanometric and tympanocentesis (TAP) findings in acute otitis media (AOM). We compared otoscopic, tympanometric and TAP findings in AOM including cases of AOM without effusion.

METHODS

In a study of AOM treatment of 90 children, a tympanogram was obtained, and TAP was performed before and after 5 days of treatment. Subjects were followed with otoscopy and tympanometry every 2 weeks for 3 months or until the MEE cleared.

RESULTS

In 130 AOM ears, otoscopic, tympanometric and TAP findings were available; MEE was obtained from 110 ears. Of 20 ears with a dry tap, 18 had abnormal tympanogram and otoscopic findings. With TAP findings as the standard, sensitivity and positive predictive value of type B tympanogram were 97 and 87%, respectively. Of 18 AOM ears yielding dry tap, 2 yielded MEE 5 days later, and 8 continued with evidence of MEE 5 days-12 weeks later. Five subjects with 8 AOM ears yielding dry tap were lost to follow-up; all had short duration of clinical symptoms.

CONCLUSIONS

Although otoscopic and tympanometric findings suggested the presence of MEE in AOM, MEE was unobtainable by TAP in 14% of cases. Dry tap cases likely represent early AOM before accumulation of detectable MEE. However, technical difficulty in obtaining small amounts of or highly viscous MEE could not be excluded. Sensitivity and positive predictive value of abnormal tympanograms in detection of MEE in AOM cases are comparable with those in otitis media with effusion.

Antibiotics for otitis media with effusion

Otitis media with effusion (OME) is defined as asymptomatic middle-ear effusion, that is, without the signs and symptoms of acute otitis media (AOM), such as fever, otalgia, or otorrhea. OME can occur after an episode of AOM or may occur without any prior or concurrent symptoms and is often noted on a routine physical examination or screening. Because children with OME are usually not ill, there is a question of whether treatment is warranted for this condition. Also adding to the complexity of this problem is the high spontaneous cure rate of OME. This paper will review the many clinical trials of the efficacy of antimicrobial therapy for OME. We have grouped the studies into 4 major categories: antibiotic vs no treatment, antibiotic vs placebo, antibiotic vs antibiotic, and antibiotic prophylaxis. While study designs, definitions, and quality vary widely, these studies show a trend toward short-term efficacy of antimicrobial treatment, but long-term efficacy is doubtful. In this age of antimicrobial resistance, coupled with the high natural cure rate, routine antimicrobial treatment of OME is not warranted. It may be useful in selected patients, particularly those with chronic OME (3 months or longer of bilateral effusion or 6 months or longer of unilateral effusion) for whom surgery is being considered: a 1-time short course of antibiotic may allow cancellation or at least postponement of a surgical procedure, particularly in spring/summer when one would like to avoid placing tubes in the ears and placing the child at risk for otorrhea due to water exposure. Also, antimicrobial therapy may provide at least short-term relief for symptomatic children (hearing loss, developmental delay, etc.) for whom surgery must be postponed or is contraindicated.

The role of free oxygen radicals on the development of otitis media with effusion

OBJECTIVE

The purpose of this study was to determine if free oxygen radicals (FORs) and antioxidant enzyme activities have some role in pathogenesis of otitis media with effusion (OME) in children with adenoid hyperplasia.

METHODS

Seventy-four patients were enrolled in three groups of this study. The study group (Group I) included 26 patients who had adenoidectomy with ventilation tube placement due to chronic OME. The control adenoid group (Group II) consisted of 28 age-matched patients who had adenoidectomy without ventilation tube insertion. Twenty children were included in the healthy control group (Group III). Erythrocyte malondialdehyde (MDA) levels, superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GSH-Px) enzyme activities were investigated in the venous blood sample.

RESULTS

Erythrocyte MDA level and GSH-Px enzyme activity in the blood samples of study group (Group I) were significantly higher than those of Group II and Group III (P < 0.05). SOD enzyme activity in the blood samples of Group I was significantly lower than Group II (P < 0.05), and were significantly higher than Group III (P < 0.05). CAT enzyme activity of Group I was significantly lower than that of Group III (P < 0.05). However, there was no statistically significant difference between Group I and Group II regarding CAT antioxidant enzyme activity (P < 0.05).

CONCLUSIONS

The inflammation of the middle ear increases the level of FORs in erythrocyte. FOR level is normally maintained at a steady state by antioxidant enzymes. When the antioxidant defense system is weakened, the increased FORs may contribute to OME formation. We supposed that, antioxidant vitamins C and E, and scavenger enzymes such as CAT, SOD and GSH-Px may be added in the management of OME.

The effect of montelukast sodium on the duration of effusion of otitis media

This study tests the hypothesis that montelukast sodium, a selective leukotriene receptor antagonist, will decrease the duration of the effusion of otitis media. Tympanometry and spectral gradient acoustic reflectometry were used to confirm the effusion of otitis media in patients between 2 and 12 years of age. Patients were treated with amoxicillin for 10 days and montelukast sodium or placebo for 30 days in a random, double-blind manner. Sixty patients completed the study: 31 received placebo and 29 received montelukast sodium. At a 4-week follow-up visit, 5 ears (16%) were free of effusion in the placebo group and 17 (58%) in the montelukast sodium group. The difference was significant. The efficacy of montelukast sodium in clearing the effusion was 49%.

[Adjuvant treatment of anisodamine to acute serous otitis media]

OBJECTIVE

To evaluate the adjuvant treatment of anisodamine to acute serous otitis media.

METHOD

Sixty-one acute otitis media patients were divided randomly into two groups. Group A with 30 patients were treated with 1% ephedrine nosedrop, antibiotic and antihistamine. Group B with 30 patients were treated with 1% ephedrine nose drops, antibiotic, antihistamine and anisodamine. They took anisodamine 10 mg twice a day. Then the treating efficiency of group A was compared with that of group B in 5 days and 10 days respectively.

RESULT

The symptoms including hearing loss, tinnitus, hydrotympanum and eustachian tube function of group B recover more guickly than that of group A.

CONCLUSION

Anisodamine adjuvant treatment of acute serous otitis media by improving the function of eustachian tube and microcirculation.

Otitis caused by Scedosporium apiospermum in an immunocompetent child

Scedosporium apiospermum (Pseudallescheria boydii) is a ubiquitous saprophytic mold. It is considered an infrequent but important and emerging human pathogen, mostly in immunocompromised hosts. Otomycosis secondary to S. apiospermum is extremely rare. We report an 8-year-old immunocompetent male who developed otitis media and otitis externa from S. apiospermum, which was successful treated with combination of surgical debridement and topical clotrimazole therapy. A brief literature review of infections caused by S. apiospermum follows the case presentation.

Otitis Media: Treatment With Intranasal Aerosolized Surfactant

OBJECTIVES/HYPOTHESIS

The objective was to determine the effect of intranasal surfactant alone and with other medications administered by metered dose inhaler aerosol on the function of the eustachian tube and on the resolution of experimentally induced otitis media with effusion (OME) and acute otitis media (AOM).

STUDY DESIGN

Randomized, experimental, controlled animal studies.

METHODS

Previously unreported (experiment 4) as well as published (experiments 1-3) data were detailed so that the reader could understand the continuum of information leading to the conclusions. In experiment 1, after a live-animal technique of measuring eustachian tube passive opening pressure was developed and validated, eustachian tube passive opening pressure was determined in 61 adult gerbils and 34 mice at baseline and 5 and 10 minutes after delivery of aerosolized intranasal metered dose inhaler surfactant. In experiments 2 and 3 (Klebsiella pneumoniae), lipopolysaccharide-induced OME was developed in gerbils. Thirty-five animals were randomly assigned to control, placebo, surfactant, surfactant with betamethasone, and surfactant with phenylephrine groups. Seventy animals were randomly assigned to control, placebo once daily (QD) and twice daily (BID), surfactant QD and BID, surfactant with betamethasone QD and BID, and surfactant with phenylephrine QD and BID groups. Intranasal aerosolized MDI medications were administered from postinfection day 2 until the effusion resolved. Otomicroscopy and tympanometry were performed on alternate days for 30 days. In experiment 4, AOM was developed in 39 chinchillas via transbullar injection of nontypeable Haemophilus influenzae on day 1. Thirteen animals each received placebo BID or surfactant BID, beginning on day 1. Thirteen animals received surfactant BID beginning on day 3. All administrations were continued for 10 days. Examinations were performed on seven occasions until day 27. Appropriate statistical measurements were employed, including one- and two-way ANOVA, strength-of-association measure (omega) calculation, chi, and Newman-Keuls post hoc multiple comparison tests. Significance was set as P value of less than.05.

RESULTS

In experiment 1, a significant reduction in passive opening pressure was seen in both 5- and 10-minute postsurfactant measurements. Propellant alone was not effective. In experiments 2 and 3, OME resolved after an average period of 16 to 16.5 days in control, placebo QD and BID, and surfactant with phenylephrine QD groups. A significant decrease in OME days was seen in the surfactant QD (10.57 d) and BID (8.57 d), and surfactant with betamethasone QD (8.57 d) and BID (6.3 d) groups. A significant increase was seen in the phenylephrine BID group (18.67 d). In experiment 4, tympanometry was normal or near-normal in 62% and 48% of treated ears and in only 24% of placebo ears on day 12. Sixty-seven percent of placebo ears were culture positive at day 27, compared with 10% and 16% in surfactant groups 1 and 2. Seventy-five percent of untreated animals developed severe labyrinthitis, compared with 15% in groups 1 and 2. On day 27, 58% of placebo group middle ears had fluid, whereas 61% and 62% of ears in groups 1 and 2, respectively, were dry. These findings were significant.

CONCLUSION

Intranasal application of aerosolized metered dose inhaler surfactant alone or with steroid reduced eustachian tube passive opening pressure in normal animals and duration of effusion in animals with experimental OME. Intranasal surfactant reduced the severity and duration of middle ear infection in AOM in this animal model.

Otitis media

Otitis media (OM) continues to be one of the most common childhood infections and is a major cause of morbidity in children. The pathogenesis of OM is multifactorial, involving the adaptive and native immune system, Eustachian-tube dysfunction, viral and bacterial load, and genetic and environmental factors. Initial observation seems to be suitable for many children with OM, but only if appropriate follow-up can be assured. In children younger than 2 years with a certain diagnosis of acute OM, antibiotics are advised. Surgical candidacy depends on associated symptoms, the child's developmental risk, and the anticipated chance of timely spontaneous resolution of the effusion. The recommended approach for surgery is to start with tympanostomy tube placement, eventually followed by adenoidectomy. The ideal intervention for OM, however, does not yet exist, and an urgent need remains to explore new and creative options based on modern insights into the pathophysiology of OM.

Single dose azithromycin for the treatment of uncomplicated otitis media

Three clinical trials have examined the efficacy and safety of single dose azithromycin (30 mg/kg) in children with uncomplicated acute otitis media (AOM). In the first trial, a small pilot study, the clinical and microbiologic efficacy of single dose azithromycin was comparable with that of 3-day azithromycin or single dose ceftriaxone. A second, non-comparative trial confirmed the clinical and microbiologic efficacy of the single dose regimen. The third study, a large double blind, double dummy trial, demonstrated comparable clinical success rates between single dose azithromycin and 10-day standard amoxicillin/clavulanate. The incidence of drug-related adverse events in patients treated with single dose azithromycin was low in all three trials and similar to rates that have been reported for other antimicrobial agents used for the treatment of patients with AOM. In the amoxicillin/clavulanate trial, compliance with single dose azithromycin was significantly better than with the amoxicillin/clavulanate regimen (P < 0.001). We conclude that a single dose of azithromycin (30 mg/kg) is safe and effective for the treatment of uncomplicated AOM in children.

The evolution of ototopical therapy: from cumin to quinolones

A radical change has occurred in the management of otorrhea over the past decade. Multiple studies have supported the efficacy of topical quinolones in the management of acute otitis media, acute otitis externa, and CSOM. For the first time, otolaryngologists have a scientific foundation on which to base our treatment protocols for these conditions. We no longer must rely solely on our clinical experience and prejudices. The quinolone drops have a superior safety profile and a broad antimicrobial spectrum, their overall cost is lower than the alternatives, and their convenient dosing schedule is tolerated well by most patients. When one takes all these factors into consideration, it becomes clear that topical quinolone therapy, with or without a steroid additive, is the treatment of choice for otorrhea in patients with a tympanic membrane perforation or ventilating tube. The development of ototopical medications has followed along the lines of Darwinian evolution, and the quinolone drops have clearly demonstrated the concept of "survival of the fittest."

Topical ciprofloxacin/dexamethasone otic suspension is superior to ofloxacin otic solution in the treatment of children with acute otitis media with otorrhea through tympanostomy tubes

OBJECTIVE

To determine the efficacy and safety of topical ciprofloxacin/dexamethasone otic suspension compared with ofloxacin otic solution in the treatment of acute otitis media with otorrhea through tympanostomy tubes (AOMT) in pediatric patients.

METHODS

This multicenter, prospective, randomized, observer-masked, parallel-group study was conducted at 39 sites in 599 children aged >or=6 months to 12 years with an AOMT episode of <or=3 weeks' duration. The mean age of patients was 2.5 years (standard deviation: 2.37 years). Patients received either ciprofloxacin 0.3%/dexamethasone 0.1% otic suspension 4 drops twice daily for 7 days or ofloxacin 0.3% otic solution 5 drops twice daily for 10 days. Clinical signs and symptoms of AOMT were evaluated at clinic visits on days 1 (baseline), 3 (on therapy), 11 (end of therapy), and 18 (test of cure). A patient diary was used to measure time to cessation of otorrhea. Principal pretherapy pathogens included Streptococcus pneumoniae (16.8%), Staphylococcus aureus (13.0%), Pseudomonas aeruginosa (12.7%), Haemophilus influenzae (12.4%), S epidermidis (10.2%), and Moraxella catarrhalis (4.1%).

RESULTS

Ciprofloxacin/dexamethasone is superior to ofloxacin for clinical cure (90% vs 78%) and microbiologic success (92% vs 81.8%) at the test-of-cure visit, produces fewer treatment failures (4.4% vs 14.1%), and results in a shorter median time to cessation of otorrhea (4 days vs 6 days). Ciprofloxacin/dexamethasone treatment is also superior to improvement in clinical response by visit, absence of otorrhea by visit, and reduction of otorrhea volume by visit. Both topical otic preparations are safe and well tolerated in pediatric patients. No change in speech recognition threshold or decrease in hearing from baseline, based on audiometric testing, was noted with either regimen.

CONCLUSION

Topical ciprofloxacin/dexamethasone treatment is superior to topical ofloxacin in the treatment of AOMT.

Microbiology of otitis media in Costa Rican children, 1999 through 2001

BACKGROUND

Because of the increasing number of resistant middle ear pathogens and the impact of the new conjugate Streptococcus pneumoniae vaccine, an active surveillance of the microbiology and susceptibility pattern of middle ear pathogens is required.

OBJECTIVE

To study the microbiology and susceptibility pattern of middle ear pathogens obtained from Costa Rican children with acute otitis media (AOM), recurrent otitis media (ROM) and therapeutic failure otitis media (FOM).

METHODS

Between 1999 and 2001 middle ear fluid (MEF) was collected from 276 Costa Rican patients. S. pneumoniae serotyping and pulsed field gel electrophoresis analysis was done on available strains.

RESULTS

Among the total study population, 102 were AOM patients, 98 were ROM patients and 76 were FOM patients. Overall S. pneumoniae (88 strains) was the most common pathogen isolated followed by Haemophilus influenzae (41 strains) and Streptococcus pyogenes (10 strains). H. influenzae was the most common agent in FOM patients (P = 0.015). Beta-lactamase production was observed in 3 of 41 (7%) H. influenzae strains and 3 of 3 (100%) Moraxella catarrhalis strains. Penicillin-nonsusceptible S. pneumoniae strains were more common in FOM (64%) and ROM (63%) patients than in AOM (42%) patients (P = 0.05). S. pneumoniae serotype 19F was the most prevalent serotype, mainly within one distinct clone.

CONCLUSIONS

Overall S. pneumoniae serotype 19F was the most common isolate from the middle ear fluid of Costa Rican children. Beta-lactamase-negative H. influenzae was the most prevalent in the subpopulation of patients with FOM. S. pyogenes was the third most common isolate and M. catarrhalis was uncommon.

Microbiology of otorrhea in children with tympanostomy tubes: implications for therapy

OBJECTIVE

Based on the prevalence of children with tympanostomy tubes who develop otorrhea, an analysis was performed to identify specific prognostic indicators in this population to enable clinicians to determine the likelihood of specific pathogens and select the best empiric therapy.

METHODS

Data from two multicenter clinical trials of ofloxacin otic solution 0.3% (OFLX) trials in pediatric patients 1-12 years of age were used to develop a statistical model to predict the likelihood of external auditory canal (EAC) or nasopharyngeal (NPG) pathogens. Data were available for 283 microbiologically evaluable patients. Potential indicators included subject age, season of enrollment, ear aspiration, cleaning, otorrhea, and granulation tissue. The model used a stepwise logistic regression analysis relating the occurrence of NPG or EAC pathogens to the potential prognostic indicators.

RESULTS

Among the total study population, 42.8 and 61.5% had NPG and EAC pathogens, respectively; 10.6% had both. The most frequently isolated valid pathogens were Streptococcus pneumoniae and Haemophilus influenzae. Significant prognostic indicators for NPG pathogens were subject age, season of enrollment, and presence of ear odor. Although these indicators were similar for EAC and NPG pathogens, the correlation was reversed, i.e. older subjects had EAC pathogens, and younger ones (< 2 years) had NPG pathogens; EAC pathogens were associated with presence of ear odor and NPG pathogens, with absence of ear odor.

CONCLUSIONS

A statistically and clinically valid model has been developed that has prognostic value for the clinician treating children with otorrhea and tympanostomy tubes and serves as an aid in the appropriate choice of empiric therapy.

Is it possible to achieve bacterial eradication in otitis media with effusion by empirical antibiotic high doses and concomitant administration of acetaminophen? A microbiological and pharmacological study in the gerbil model

The efficacy of amoxycillin-clavulanic acid (10 and 15 mg/kg amoxycillin) and erythromycin (20 and 50 mg/kg) was assessed in a gerbil model of otitis media with effusion induced by beta-lactamase-producing Haemophilus influenzae. Animals were divided into groups receiving acetaminophen concomitantly or not receiving it. Treatment started 2 h post-middle ear inoculation and continued t.i.d. for up to three doses. Middle ear samples were obtained on day 2 post-inoculation. Amoxycillin-clavulanic acid showed significantly higher efficacy than erythromycin, regardless of acetaminophen administration (P<0.05). Amoxycillin-clavulanic acid middle ear concentrations exceeded the amoxycillin MIC (1/0.5 microg/ml) by 1.88-fold, whereas erythromycin concentrations were below MIC level of 4 microg/ml. Animals receiving acetaminophen showed significantly fewer polymorphonuclear cells and more Haemophilus organisms in the middle ear exudate.

Effect of macrolide antibiotics on nitric oxide synthase and xanthine oxidase activities, and malondialdehyde level in erythrocyte of the guinea pigs with experimental otitis media with effusion

Although the long-term administrations of macrolide antibiotics are effective for diffuse panbronchiolitis, otitis media with effusion (OME), and some other diseases, their mechanism of action has not been fully understood. In order to elucidate the mechanisms of possible effects of macrolide antibiotics on activities of erythrocyte nitric oxide synthase (NOS), xanthine oxidase (XO), and malondialdehyde (MDA) levels in experimental OME, we aimed to evaluate the effect of macrolide antibiotics (erythromycin, azithromycin, roxithromycin, and clarithromycin) using an experimental guinea pig otitis media model. Erythrocyte NOS, XO activities, and MDA level were measured in all groups. Erythrocyte NOS activities were significantly higher in erythromycin-, azithromycin-, roxithromycin-, and clarithromycin-treated groups than in the experimental group. Erythrocyte XO activities were significantly lower in erythromycin-, azithromycin-, roxithromycin-, and clarithromycin-treated groups than in the control group. However, erythrocyte XO activities in experimental group were significantly higher than those of control group. Erythrocyte MDA levels were significantly lower in erythromycin-, azithromycin-, roxithromycin-, and clarithromycin-treated groups than those of the experimental group. The MDA levels in erythromycin- and roxithromycin-treated groups were significantly higher than those of azithromycin-treated group. The MDA levels in azithromycin-treated group were significantly lower than those of roxithromycin-treated group. In conclusion, the present study shows that the macrolide antibiotics (erythromycin, azithromycin, roxithromycin, and clarithromycin) increase NOS activity, decrease XO activity and MDA level, which is an important indicator of oxidative stress.

Persistent otorrhoea after ventilation tube insertion: a treatment protocol

Otorrhoea is the commonest complication of ventilation tube (grommet) insertion. In some cases it may be unresponsive to short courses of topical antibiotic/steroid drops and/or systemic antibiotics. This study investigated whether a five-day course of inpatient treatment with intravenous antibiotics, topical medication and daily microsuction was effective in treating persistent otorrhoea. Eleven subjects were included, of whom nine responded to the proposed treatment regimen. We recommend that patients with persistent otorrhoea after ventilation tube insertion should be managed according to these guidelines before considering an examination under anaesthetic or a ventilation tube removal.

Bullous myringitis: a case-control study

Prior studies have shown that bullous myringitis (BM) accounts for <10% of acute otitis media (AOM) cases, and that the distribution of viral and bacterial pathogens in BM is similar to that in AOM without BM, except for a relative increase in the proportion of Streptococcus pneumoniae in BM. We studied 518 cases of AOM in children aged 6 months to 12 years. Using tele-otoscopy to assist the diagnosis, we identified 41 cases (7.9%) with BM. Children who had AOM with BM were older than AOM patients without BM (median age: 4.3 years vs 18 months). We compared 41 cases of AOM with BM to 41 control cases of age-, race-, and gender-matched AOM patients without BM. When compared with this matched control group, children with BM had more severe symptoms at the time of diagnosis and were more likely to have bulging of the tympanic membrane in the quadrants that were not obscured by the bulla. Children with AOM and BM may require aggressive pain management. Although parents and clinicians may agree that a watchful waiting approach is appropriate for older children with mild AOM, children experiencing painful AOM with BM may not be successful candidates for a watchful-waiting approach, because parents may resist postponement of antibiotic therapy in children who are more symptomatic.

Acute otitis media disease management

A first step in management decisions regarding otitis media must focus on accurate diagnosis to distinguish normal from acute otitis media (AOM) from otitis media with effusion (OME) or a retracted tympanic membrane without middle ear effusion. There are several classification schemes for AOM that may impact management decisions: patients with acute, persistent, recurrent, or chronic AOM may have a different distribution of bacterial pathogens and a different likelihood of success from antimicrobial therapy. Patient age, prior treatment history and daycare attendance are other important variables. The natural history of AOM without antibiotic treatment is generally favorable; however, from the few studies available, this is difficult to quantitate because the diagnosis was infrequently confirmed by tympanocentesis leaving the possibility that many patients entered into these trials may not have had bacterial AOM. Antibiotic choices should reflect pharmacokinetic/pharmacodynamic data and clinical trial results demonstrating effectiveness in eradication of the most likely pathogens based on tympanocentesis sampling and antibiotic sensitivity testing. Thereafter, compliance factors such as formulation, dosing schedule and duration of treatment and accessibility factors such as availability and cost should be taken into account. The increasing prevalence of antibiotic resistance among AOM pathogens and the changing susceptibility profiles of these bacteria should be considered in antibiotic selection. Current best practice recommends amoxicillin for uncomplicated AOM; continuing or switching to an alternative antibiotic based on clinical response after 48 hours of therapy; and selection of second line antibiotics as first line choices when the patient has already been on an antibiotic within the previous month or is otitis prone. Preferred second-line agents frequently noted in various guidelines include amoxicillin/clavulanate, cefdinir, cefpodoxime, cefprozil, and cefuroxime. Three injections of ceftriaxone or gatifloxacin (when approved) or diagnostic/therapeutic tympanocentisis (when approved) become a third-line treatment option. No single antibiotic or management strategy is ideal for all patients.

Otitis media. A scholarly review of the evidence

Antibiotic therapy remains the treatment of choice for otitis media in most countries despite persuasive evidence that antibiotic therapy provides limited clinical benefit and promotes bacterial resistance. Meta-analysis of randomized, placebo-controlled trials demonstrated that antibiotics increased resolution at 1 week by only 13%. Amoxicillin remains as effective as any other antibiotic, despite increasing resistance to amoxicillin among the major bacterial pathogens. Immediate antibiotic treatment has been shown to reduce the duration of symptoms by 1 day but not until after the first 24 hours when symptoms were already improving. A delayed prescribing strategy is currently utilized in most children for management of acute otitis media in the Netherlands; this method is now being evaluated elsewhere. Antibiotic therapy is delayed for 48-72 hours after diagnosis; thereafter, antibiotics are initiated only if symptoms persist or worsen. In 2 studies utilizing this strategy (England and the United States), only 24-30% of the patients in the delayed treatment group initiated antibiotic therapy; a majority of parents of children in the delayed group were satisfied with their child's treatment. Treatment of bacterial otitis media ("pus drum") with high dose amoxicillin (80-100 mg/kg/kd) is recommmended; for acute otitis media without bulging, watchful waiting with a delayed prescribing strategy and treatment of pain is preferred. Yearly administration of the influenza vaccine and/or treatment of influenza with an antiviral (oseltamivir) can significantly decrease the incidence of acute otitis media during influenza season. Although pneumococcal vaccination effectively reduces the incidence of acute otitis media due to vaccine-related serotypes, there is a significant increase in the number of episodes of acute otitis media due to other serotypes of S. pneumoniae such that the overall incidence of acute otitis media is reduced only minimally by pneumoccocal vaccine. The careful use of strict diagnostic criteria coupled with judicious use of antibiotic therapy will direct antibiotic treatment to only those patients likely to benefit.

Diagnostic accuracy of otitis media and tympanocentesis skills assessment among pediatricians

The comparative study presented here evaluated pediatricians from Italy, Greece, South Africa, and a reference group in the USA to determine (i) their ability to accurately diagnose acute otitis media (AOM) and otitis media with effusion (OME) using otoscopy, (ii) their knowledge of antibiotics, and (iii) their technical competence in performing tympanocentesis. The participants included 66 pediatricians from Italy, 115 from Greece, 36 from South Africa and 2,190 from the USA (reference group). Each pediatrician viewed nine video-recorded otoscopic examinations of tympanic membranes, after which their ability to differentiate AOM, OME and normal was ascertained. Questions were posed regarding appropriate, pathogen-directed antibiotic selection for AOM. A mannequin model was used to assess the technical proficiency of each pediatrician in performing tympanocentesis. Results were recorded for each group as the mean percentage +/- standard deviation. The correct diagnosis was made by each group of pediatricians in the following frequencies: Italy, 54+/-27% (range, 18-94%); Greece, 36+/-12% (range, 23-56%); South Africa, 53+/-21% (range, 22-88%); and the USA, 51+/-11% (range, 29-72%). The difference between results from Greece and the US reference group was statistically significant ( P=0.002). Pediatricians from each group over-diagnosed AOM with the following frequencies: Italy, 18+/-19% (range, 2-49%); Greece, 34+/-13% (8-50%); South Africa, 23+/-14% (7-44%); and the US reference group, 26+/-19% (7-51%). Pediatricians correctly selected an antibiotic recommended for treatment of AOM caused by drug-resistant Streptococcus pneumoniae as follows: Italy, 89%; Greece, 77%; South Africa, 82%; and the USA, 80%. For treatment of beta-lactamase-producing Haemophilus influenzae, the results were: Italy, 90%; Greece, 70%; South Africa, 81%; and the USA, 77%. Tympanocentesis was optimally performed by >/=86% of all pediatricians. The results indicate that pediatricians may often misdiagnose OME as AOM, but they select appropriate antibiotics about 80% of the time and can be trained to accurately perform tympanocentesis.

Penetration of cefprozil to middle ear effusion in children with chronic otitis media with effusion

BACKGROUND

Because of chronic otitis media with effusion (COME) demonstrates pathogenic bacteria, treatment with appropriate antibiotic is reasonable.

OBJECTIVE

We determined the penetration of cefprozil into the middle ear effusion (MEE) in children with COME.

MATERIALS AND METHODS

25 patients 2-13 years of age with COME were eligible for study. After the single dose of 15 mg/kg patients were assigned to have MEE, and serum samples were obtained during ventilation tube insertion at 0.5, 2, 3, 5, or 6 h after administration of the dose. The concentration of cefprozil was measured using validated high performance liquid chromatography method.

RESULTS

The mean concentrations of cefprozil in the MEE ranged from 0.4 to 4.4 microg/ml. The penetration into MEE was rapid and effective. Cefprozil in the MEE was maintained at a greater level than MIC 90 in S. pneumoniae for at least 6 h after administration of 15 mg/kg.

CONCLUSION

Cefprozil penetrated well into the MEE in children with COME.

Systemic inflammatory responses in children with acute otitis media due to Streptococcus pneumoniae and the impact of treatment with clarithromycin

This pilot study was designed to determine the serum cytokine profile of acute otitis media (AOM) due to Streptococcus pneumoniae and the impact of clarithromycin (Abbott Laboratories, Inc). Serum levels of interleukin-1 beta (IL-1 beta), tumor necrosis factor alpha (TNF-alpha), IL-6, and IL-8 were measured at diagnosis and 3 to 5 days after start of antibiotic treatment in 10 patients (mean age, 18.3 +/- 13.9 months) who had middle ear fluid culture positive for S. pneumoniae. The mean concentrations of all cytokines were elevated at diagnosis of AOM compared to levels in healthy controls, yet only IL-6 reached statistical significance (P = 0.05). IL-6 showed a statistically significant decrease in mean serum concentration at visit 2 (P = 0.03). IL-8 displayed a similar pattern to IL-6, but the difference between samples from day 1 and day 2 did not reach statistical significance. The cytokines IL-1 beta and TNF-alpha appear to be elevated in the serum of patients with S. pneumoniae AOM, but there was no significant change between mean serum levels obtained pre- and postinitiation of antibiotic treatment in the time frame studied. The results suggest a systemic inflammatory response as evidenced by increased IL-6. A significant decrease of IL-6 and improvement of clinical symptoms were observed. Determining cytokine levels, especially IL-6, in AOM could offer a powerful tool for objective assessment of response to treatment, minimizing unnecessary treatment of asymptomatic children who may still have some otoscopic findings suggestive of AOM at follow-up visits.

Increased antimicrobial resistance in organisms recovered from otitis media with effusion

Previous studies concerning the microbiology of otitis media with effusion (OME) did not correlate the past use of antimicrobial agents with the recovered organism's antimicrobial susceptibility. A retrospective analysis of cultures obtained from aspirates of 129 children with OME was performed. The study identified the isolated organisms and determined their susceptibility to the most recently administered antimicrobials. Bacterial growth was noted in 58 (45 per cent) patients. Aerobic organisms only were recovered in 37 aspirates (63 per cent of the culture-positive aspirates); anaerobic bacteria in seven (12 per cent); and mixed aerobic and anaerobic bacteria in 14 (24 per cent). A total of 92 bacterial isolates were recovered, accounting for 1.6 isolates per specimen (1.1 aerobes and 0.5 anaerobes). There were a total of 66 aerobic isolates, including Haemophilus influenzae non type-b (20 isolates), Streptococcus pneumoniae (17), and Staphylococcus spp. (seven). Twenty-six anaerobes were recovered, including Peptostreptococcus spp. and Prevotella spp. (eight each) and Propionibacterium acnes (four). Resistance to the antimicrobial used was found in 60 (65 per cent) isolates, recovered from 41 (71 per cent) of the patients. Of the 41 patients in whom resistance was detected, 37 (90 per cent) had been treated within three months of culture and four (10 per cent) had completed treatment more than three months before the cultures were taken (p < 0.01). The highest rate of recovery of resistant organisms was following trimethoprim-sulfamethoxazole (96 per cent), amoxycillin (71 per cent), and azithromycin (56 per cent). Of the patients treated with amoxycillin, H influenzae predominated. S pneumoniae was recovered from four of the seven (57 per cent) after trimethoprim-sulfamethoxazole, four of 14 (29 per cent) following amoxycillin, and three of 11 (27 per cent) after azithromycin. The data illustrate the relationship between resistance to the antimicrobials given to children and their recovery from the middle ear of patients with OME.

Naturopathic treatment for ear pain in children

OBJECTIVE

Otitis media is 1 of the most frequent diseases of early infancy and childhood and 1 of the most common reasons for children to visit a physician. In the past 2 decades, there has been a substantial increase in the diagnosis of otitis media worldwide. In the United States, 93% of all children have had at least 1 episode of acute otitis media (AOM) by 7 years of age. Otalgia is the hallmark of AOM. Most affected children either complain of earache or manifest behavior that the parents interpret as indicating ear pain. Treatment of the ear pain early in the course of AOM decreases both parental anxiety and the child's discomfort and accelerates the healing process. The objective of this study was to determine the efficacy and tolerability of naturopathic versus traditional treatment for the management of otalgia commonly associated with AOM in children.

METHODS

The study was designed as a double-blind trial in an outpatient community clinic. A total of 171 children who were aged 5 to 18 years and had otalgia and clinical findings associated with middle-ear infection were studied. The children were randomly assigned to receive treatment with Naturopathic Herbal Extract Ear Drops (NHED) or anesthetic ear drops, with or without amoxicillin. On enrollment, the children were assigned by computer-numbered randomization to receive NHED (contents: allium sativum, verbascum thapsus, calendula flores, hypericum perfoliatum, lavender, and vitamin E in olive oil) 5 drops 3 times daily, alone (group A) or together with a topical anesthetic (amethocaine and phenazone in glycerin) 5 drops 3 times daily (group B), or oral amoxicillin 80 mg/kg/d (maximum 500 mg/dose) divided into 3 doses with either NHED 5 drops 3 times daily (group C) or topical anesthetic 5 drops 3 times daily (group D). A double-blind design was used, and all ear drops were placed in identical bottles. Treatment was initiated by the nurse in all cases. A single physician (M.S.) evaluated and treated all of the patients included in the study and recorded all of the data. The presence or absence of ear pain was assessed over 3 days with a visual analog scale. Ear pain was assessed by a specially devised observational instrument based on previous reports. One side of the instrument consisted of a linear numbered scale, from 1 (no pain) to 10 (worst possible pain), and a corresponding color scale, ranging from blue to dark red. The reverse side contained a scale of 5 facial expressions, ranging from broad smile (no pain) to a sad and crying face (worst possible pain), and a corresponding color scale, ranging from blue to dark red.

RESULTS

There were no significant between-group differences in patient age or gender, degree of fever, main symptoms, associated symptoms, and severity or laterality of acute otitis media. Each group had a statistically significant improvement in ear pain over the course of the 3 days. Patients who were given ear drops alone had a better response than patients who were given ear drops together with amoxicillin. Results were better in the NHED group than in the controls. Nevertheless, the findings indicated that the pain was mostly (80%) self-limited and could be explained simply by the time elapsed. The American Academy of Otolaryngology-Head and Neck Surgery guidelines recommend topical medications as the first line of treatment for ear pain in the absence of systemic infection or serious underlying disease. Because no evidence was found that systemic antibiotics alone improved treatment outcome, if antibiotics do not change the natural course of otitis media, then the main goal of treatment, as in the present study, should be to alleviate the ear pain. The alternative, naturopathic herbal extract medications, may offer many new possibilities in the management of ear pain associated with AOM. Primary care physicians should be aware that at least 10% of their patients may have tried 1 or more forms of alternative/complementary medicine before presenting for consultation. As it was widely reported in the medical literature, these herb, these herbal extracts have the potential to meet all of the requirements of appropriate medication that could be routinely used in the pediatric patient, namely in vitro bacteriostatic and bacteriocidal activity against common pathogens, immunostimulation ability, antioxidant activity, and anti-inflammatory effects. They are also well-absorbed with good penetration into the tissue surrounding the tympanic membrane. They have been found to enhance local immunologic activity. Finally, herbal extracts are well-tolerated (owing to their long elimination time), easy to administer, and less expensive than the new antibiotics. There are no documented side effects. On the basis of our findings that the group with the most significant treatment effects (NHED with topical anesthetic) explained only 7.3% of the total pain reduction, we propose that sometimes the general practitioner or pediatrician needs to give the human body a chance to repair itself. Nevertheless, if the physician believes that there is an indication for some treatment, especially if the parents are anxious, then a local treatment such as one used in our study might be adequate.

CONCLUSIONS

This study suggests that in cases of ear pain caused by AOM in children in which active treatment, besides a simple 2- to 3-day waiting period, is needed, an herbal extract solution may be beneficial. Concomitant antibiotic treatment is apparently not contributory.

Hyper immunoglobulin-E syndrome: a case with chronic ear draining mimicking polypoid otitis media

The hyper-IgE syndrome is a rare, complex immunoregulatory disorder characterized by pruritic dermatitis, recurrent staphylococcus skin abscesses and extremely elevated levels of IgE in serum. In this report, an 8-year-old girl with hyper-IgE syndrome is presented. She had pruritic dermatitis and skin abscesses on her extremities and scalp. Discharge and granulation tissue in right external ear canal were recognized in otorhinolaryngologic examination. Cultures of the suppuration of the external ear canal yielded S. aureus. Biopsy of the lesion was reported as granulation tissue. Local treatment of the ear canal was performed with ear wick soaked with steroid and antibiotic solutions two times per day.

Middle ear fluid histamine and leukotriene B4 in acute otitis media: effect of antihistamine or corticosteroid treatment

OBJECTIVE

Two potent mediators of acute inflammation, histamine and leukotriene B4 (LTB4), have been shown to play important roles in the pathogenesis and clinical course of acute otitis media (AOM) in children. The purpose of this study was to evaluate the ability of adjuvant drugs, antihistamine and corticosteroid, in reduction of the levels of histamine and LTB4 in the middle ear and their ability to improve outcomes of AOM.

METHODS

Eighty children with AOM (aged 3 months to 6 years) were enrolled in a prospective, randomized, double-blind, placebo controlled study. All children received one dose of intramuscular ceftriaxone and were randomly assigned to receive either chlorpheniramine maleate (0.35 mg/kg per day) and/or prednisolone (2 mg/kg per day) or placebos three times a day for 5 days. Tympanocentesis was performed at enrollment and after 5 days of adjuvant drug treatment. MEFs were collected for bacterial and viral studies and histamine and LTB4 levels. The subjects were followed for the duration of middle ear effusion or up to 3 months.

RESULTS

Histamine or LTB4 levels in the MEF after 5 days of treatment were not significantly reduced by adjuvant drug treatment. However, subjects receiving corticosteroid had a lower rate of treatment failure during the first 2 weeks and shorter duration of middle ear effusion.

CONCLUSIONS

Five day of antihistamine or corticosteroid treatment does not reduce the levels of histamine or leukotriene B4 in the MEF of children with AOM. Positive clinical outcomes of AOM cases associated with corticosteroid treatment needs to be confirmed in a larger clinical trial of children with intact tympanic membranes, who do not receive tympanocentesis.

Recurrent acute otitis media occurring within one month from completion of antibiotic therapy: relationship to the original pathogen

OBJECTIVES

(1) To determine the relationship between acute otitis media (AOM) pathogens isolated in cases of early clinical recurrence of AOM (occurring within 1 month from completion of therapy) to the original pathogens causing the initial AOM episode; and (2) To determine whether shorter time intervals between completion of antibiotic therapy and clinical recurrences of AOM are associated with higher rates of true bacteriologic relapse.

PATIENTS AND METHODS

From 1995 through 2000, 1077 infants and young children ages 3 to 36 months with AOM were enrolled in double tympanocentesis (performed on Day 1 in all patients and Days 4 to 6 in those initially culture-positive) studies. Of these, 834 (77%) completed successfully the antibiotic treatment [pathogen eradication on Days 4 to 6 of therapy or no pathogen on middle ear fluid (MEF) culture on Day 1 and clinical improvement at end of therapy]. Patients were followed for 3 to 4 weeks after completion of therapy, and additional MEF cultures were obtained if clinical recurrence occurred. True bacteriologic relapse was defined as the presence of a pathogen identical with that isolated before therapy by serotype and pulsed field gel electrophoresis for and by pulsed field gel electrophoresis for Streptococcus pneumoniae and beta-lactamase production for Haemophilus influenzae.

RESULTS

MEF cultures were performed in 108 consecutive patients with early recurrent AOM. One hundred pathogens were isolated at recurrence in 88 of 108 (81%) patients: 54 H. influenzae; 45 S. pneumoniae; and 1 Moraxella catarrhalis. Most recurrent AOM episodes developed during the first 2 weeks of follow-up; 39 (36%), 38 (35%), 21 (19%) and 10 (9%) recurrent AOM episodes occurred on Days 1 to 7, 8 to 14, 15 to 21 and 22 to 28 after completion of therapy, respectively. In most patients these episodes were caused by a new pathogen. True bacteriologic relapses were found in 30 (28%) of 108 patients whose MEF cultures were positive for 35 pathogens: 13 of 108 (12%) S. pneumoniae; 12 of 108 (11%) H. influenzae; and 5 of 108 (5%) both. When timing of recurrent AOM after completion of therapy was analyzed, true bacteriologic relapses were found in 16 of 39 (41%), 10 of 38 (26%), 3 of 21 (14%) and 1 of 10 (10%) of all episodes on Days 1 to 7, 8 to 14, 15 to 21 and 22 to 28 after completion of therapy, respectively (P = 0.01). The respective rates for were 11 of 17 (65%), 3 of 10 (30%), 3 of 13 (23%) and 1 of 5 (20%) (P = 0.02). For H. influenzae the respective rates were 8 of 19 (42%), 9 of 23 (39%), 0 of 8 (0%) and 0 of 4 (0%) (P = 0.02).

CONCLUSIONS

Most recurrent AOM episodes occurring within 1 month from completion of antibiotic therapy are in fact new infections. Most of the true bacteriologic AOM relapses occur within 14 days after completion of therapy, but even during this time interval most of the recurrences are caused by new pathogens. H. influenzae is very unlikely to cause true bacteriologic AOM relapses 14 days or later after completion of therapy.

Differences in nasopharyngeal bacterial flora in children with nonsevere recurrent acute otitis media and chronic otitis media with effusion: implications for management

BACKGROUND

The interactions between nasopharyngeal flora and the individual entities covered by the broad term otitis media have not been completely elucidated. We investigated in infants and children ages 6 months to 7 years with nonsevere recurrent acute otitis media (rAOM) or with chronic otitis media with effusion (cOME): (1) the nasopharyngeal carriage rate and bacterial density of respiratory pathogens and alpha-hemolytic streptococci in comparison with healthy children; (2) the resistance pattern of respiratory pathogens; and (3) the relationship between the type of nasopharyngeal colonization and long term outcome.

METHODS

Nasopharyngeal cultures were obtained from 85 children with rAOM,113 children with cOME and 55 controls. A semiquantitative analysis was used in the reading of cultures. A 12-week follow-up without treatment was planned.

RESULTS

The carrier rate of respiratory pathogens was significantly greater in cOME (70%) than in rAOM (45%) (P = 0.0006) or controls (31%) (P < 0.0001). Similarly colonization density was significantly greater in cOME than in rAOM. The carriage rate and the colonization density of alpha-hemolytic streptococci were significantly lower in rAOM than in cOME or controls. The incidence of resistant (R) strains was greater in rAOM (Streptococcus pneumoniae penicillin-R, 24%; macrolide-R, 64%; Haemophilus influenzae amoxicillin-R, 24%) compared with cOME (S. pneumoniae penicillin-R,18%; macrolide-R, 44%; H. influenzae amoxicillin-R, 5%) or controls (S. pneumoniae penicillin-R, 8%; macrolide-R, 23%; H. influenzae amoxicillin-R, 10%). During the follow-up period persistence of OME and occurrence of AOM were greater among carriers of respiratory pathogens at baseline.

CONCLUSIONS

There are substantial differences in nasopharyngeal flora between children with nonsevere rAOM and children with cOME. The results of nasopharyngeal cultures should be taken into account to avoid treatment with drugs that are ineffective and likely to select resistant organisms.

Bordetella pertussis causing otitis media: a case report

OBJECTIVE/HYPOTHESIS

is an unusual cause of otitis media with effusion. We report a case in a neonate.

STUDY DESIGN

Case report.

METHODS

A case is presented.

RESULTS

A 1-month-old infant girl was admitted because of respiratory distress and subsequently was found to have pertussis. On examination she was noted to have a middle ear effusion. Myringotomy was performed for culture. Culture confirmed. We were unable to find a previous report of otitis media.

CONCLUSION

has been identified in the middle ear effusion of an infant with the pertussis syndrome.

[Erespal effectiveness in exudative otitis media]

Standard conservative treatment of exudative otitis media (EOM) was performed in 82 patients, but 44 of them received adjuvant fenspiride (erespal) in a dose 80 mg per os 3 times a day for 10 days. Dynamic pure tone audiometry, tympanometry and subjective response demonstrated higher treatment efficiency in the erespal group. Therefore, it is recommended to include erespal in combined conventional therapy of EOM.

Systemic steroid for chronic otitis media with effusion in children

OBJECTIVE

To determine the efficacy of a short course of an adrenocorticosteroid agent (prednisolone) given with amoxicillin as compared with that of amoxicillin alone for the treatment of chronic middle ear effusion (MEE). The efficacy of 2 weeks versus 4 weeks of amoxicillin with and without steroid was also assessed.

METHODS

In a double-blind, randomized trial, children who were 1 to 9 years of age and had MEE of at least 2 months' duration were assigned to 1 of 4 treatment arms: 1) steroid + amoxicillin for 14 days, then amoxicillin for 14 more days; 2) steroid + amoxicillin for 14 days, then placebo for amoxicillin for 14 more days; 3) placebo (for steroid) + amoxicillin for 14 days, then amoxicillin for 14 more days; or 4) placebo (for steroid) + amoxicillin for 14 days, then placebo for amoxicillin for 14 more days. Children were examined by otoscopy, tympanometry, and audiometry at entry and 2 and 4 weeks after entry; those without MEE at the 4-week visit returned monthly for up to 3 more visits or until recurrence of effusion. Serum immunoglobulin (Ig) G, IgM, IgA, and varicella titers were obtained at entry, and allergy skin testing was performed at the 4-week visit.

RESULTS

A total of 144 children was entered; 135 children (94%) returned for the 2-week visit, and 132 (92%) were seen for the 4-week visit. At the 2-week visit, 33.3% of children in the steroid + amoxicillin group had no MEE compared with 16.7% in the placebo + amoxicillin group (95% confidence interval for the difference in proportions: 2.4%-31.0%). At the 4-week visit, the percentage of children with no MEE in the steroid-treated group was 32.8%, whereas that in the placebo group was 20.0% (95% confidence interval for the difference in proportions in the 2 groups: -2.0%-27.7%). Comparing change in middle ear status from the 2- to the 4-week visit, there were no significant differences in recurrence of MEE or additional clearance of MEE between those who were treated with amoxicillin for 2 weeks and those who were treated for 4 weeks. By the 4-month visit, 68.4% of children who were in the steroid group and had no MEE at the 4-week visit had recurrence of MEE as did 69.2% of such children in the placebo group. A total of 126 (87.5%) children underwent allergy skin testing. Of the 122 children who had a positive reaction to histamine, 51 (41.8%) had 1 or more positive reactions to the test allergens. There was no difference in response to treatment between those with positive allergy tests and those without.

CONCLUSIONS

There was a significant difference in the proportion of children who were effusion-free immediately after 14 days of treatment with steroid and amoxicillin compared with those who were treated only with amoxicillin for 14 days. Within 2 weeks of finishing treatment, there was no longer any significant difference between the 2 groups regardless of whether amoxicillin was continued or not. Therefore, we conclude that treatment with the dose and type of steroid used in this study should not be universally recommended for treatment of chronic otitis media with effusion, and treatment with amoxicillin, if used, should not continue beyond 14 days.

[The influence of medicine to the expression of cell adhesion molecule in experimental otitis media with effusion]

OBJECTIVE

To study the influence of Cefaclor and Prednisonum to the expression of cell adhesion molecule in experimental otitis media with effusion (OME).

METHOD

SD rats models of OME were made using formalin killed nontypeable Hemophilus influenzae and the expression of adhesion molecules Mac-1 and L-Selectin was analysed by flow cytometry using white blood cell obtained by cardiac puncture in control, bacterial and medicine groups. The pathology of middle ear mucosa was investigated to understand the relationship between the expression of adhesion molecules and the pathology.

RESULT

It was found that the expression of adhesion molecules Mac-1 and L-Selection in bacteria group increased obviously with pathological change of the middle ear mucosa. Cefaclor and Prednisonum could decrease the expression of adhesion molecules and inhibited the leukocyte accumulation in the middle ear cavity though there was no significant differences except for the L-Selectin in the Cefaclor group between the bacteria group and the medicine group.

CONCLUSION

Dead bacteria in the middle ear may act as an antigen to induce the inflammatory response and effusion of the middle ear. The expression of adhesion molecules Mac-1 and L-Selectin is highly related to the inflammatory response. Cefaclor and Prednisonum may improve otitis media with effusion, which may related to the decreasing expression of Mac-1 and L-Selectin.

Bias in a placebo-controlled study due to mismeasurement of disease status and the regression effect

We raise the concern of whether the use of a placebo group in a randomized clinical trial is sufficient to eliminate bias in the assessment of the effectiveness of a drug when enrollment into the trial prior to intervention requires diagnosis of a dichotomous disease, and the diagnostic test is subject to uncertainty. Due to misclassification and the regression effect, the observed difference in the proportions of diseased individuals between the treatment and placebo groups at follow-up will be equal to the true difference multiplied by the positive predictive value at screening and the difference between the sensitivity and the false-positive value at follow-up. Thus, measurement error of disease status before and after administering the intervention attenuates the intervention effect. Validation data corresponding to both the screening and follow-up conditions are necessary to provide additional information on the validity of the diagnostic test. Proper statistical analysis should include such data for an accurate portrayal of the effectiveness of the treatment.

[Tuberculosis of ear and cutis]

We describe a 26 year old woman treated for near a year because of deafness, purulent otitis, cough and purulent skin lesions. She was treated by otolaryngologist. Sputum examination for acid fast bacilli and chest x-ray were not done a that time. In hospital chest x-ray revealed a cava in left lung and tuberculous bacilli were found in sputum and in content from ear. Tuberculin test was positive. Tuberculosis of lung, skin and cor was recognized. After 4 months of initial treatment patient was referred to outpatient department for further therapy.

Changes in bacteriology of discharging ears

A bacteriological study on 161 consecutive out-patients presenting with otorrhoea was performed prospectively at a local teaching hospital in Taiwan between August 2000 and June 2001. A total of 177 isolates were recovered. Staphylococcus aureus was found in 77 (43.5 per cent) isolates, and non-Staphylococcus aureus in 100 (56.5 per cent) isolates. Pseudomas sp was found to be the most common pathogen (28.8 per cent) in the non-Staphylococcus aureus group. Staphylococcus aureus had become more common than Pseudomonas aeruginosa in acute otitis externa, granular myringitis, and chronic otitis media in Taiwan. Methicillin-resistant Staphylococcus aureus (MRSA) was also an increasing problem in all three disease entities. The prevalence of community-acquired MRSA infections in discharging ears was found to be 13.7 per cent (22/161). MRSAs were highly susceptible to vancomycin, teicoplanin, fusidic acid, and minocycline. More studies should be done to determine the susceptibility of MRSA to ofloxacin in the future.

Cytokine profiles in a rat model of otitis media with effusion caused by eustachian tube obstruction with and without Streptococcus pneumoniae infection

OBJECTIVE

Cytokine expression was studied in a rat model of otitis media with effusion.

METHODS

The left eustachian tube was obstructed (eustachian tube obstruction [ETO]) in 84 rats. Forty-two ears were challenged with, and those rats were treated from day 2 to day 7 with ampicillin. Twelve rats (6 per group) were killed on days 1, 2, 7, 21, 35, 56, and 112; mucosa was harvested and assayed for interleukin-1beta (IL-1beta), tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), interleukin-10 (IL-10), interferon-gamma (IFN-gamma), transforming growth factor-beta (TGF-beta), monocyte chemoattractant protein-1 (MCP-1), and interleukin-8 (IL-8) gene expression, and effusion was assayed for IL-1beta, TNF-alpha, IL-6, IL-10, and macrophage inflammatory protein-2 (MIP-2) protein.

RESULTS

Most cytokines were detectable in the effusion from infected ears with ETO on days 1 and 2 only. MIP-2 exhibited a biphasic response. Only effusion MIP-2 was consistently detected in uninfected ears with ETO. Three patterns of mucosal cytokine messenger RNA (mRNA) upregulation were observed: isolated early (IL-1beta, IL-8), isolated late (TNF-alpha, IFN-gamma), and biphasic (MCP-1, IL-6, TGF-beta) responses. Early cytokine mRNA upregulations were observed only in the infected ears with ETO, whereas late upregulations were observed in both groups.

CONCLUSIONS

Early expression of the assayed cytokines occurred only in ears with active infection. For both groups, a late upregulation of cytokine message but not protein was documented. The profile of cytokine expression during otitis media episodes may be useful in defining etiology, disease stage, and prognosis.

Medical and surgical management of otitis media in children

OM, though frequent and seemingly simple to evaluate and manage, remains a treatment challenge. Increasingly sophisticated clinical trials assessing OM medical treatment efficacy and outcome have demonstrated that many treatment regimens that were commonly used a decade ago are no longer recommended. Surgical therapy for OM, though remaining the same, has come under intense scrutiny from several angles but still plays a central role for this disease. Given the multiple facets of OM, its frequency, and its potential to cause short- and long-term morbidity in children, the next decade is sure to bring further treatment innovations.

Dynamics of pneumococcal nasopharyngeal carriage in children with nonresponsive acute otitis media treated with two regimens of intramuscular ceftriaxone

BACKGROUND

A 3-day intramuscular ceftriaxone regimen was superior to a 1-day regimen in the treatment of nonresponsive acute otitis media caused by resistant Streptococcus pneumoniae. However, the effect of various regimens of intramuscular cefriaxone on the nasopharyngeal carriage of S. pneumoniae and especially that of resistant strains during and after therapy has not been thoughtfully studied.

OBJECTIVES

To compare the effect of one dose and three dose intramuscular ceftriaxone regimens on the nasopharyngeal carriage of S. pneumoniae in patients with nonresponsive acute otitis media treated with these two regimens and to document the dynamics of nasopharyngeal colonization with S. pneumoniae during and after completion of these two therapeutic regimens.

PATIENTS AND METHODS

In a prospective study performed during January, 1998, through September, 1999, 170 evaluable patients ages 3 to 36 months with nonresponsive acute otitis media were randomized to receive the 1 (n = 83)- or 3 (n = 87)-day intramuscular ceftriaxone regimen (50 mg/kg/day), respectively. Nasopharyngeal cultures for S. pneumoniae were obtained on Days 1, 4 to 5, 11 to 14 and 28 to 30. Susceptibility of S. pneumoniae to penicillin and ceftriaxone was determined by E-test.

RESULTS

On Day 1 nasopharyngeal S. pneumoniae carriage was found in 108 (64%) patients, 54 in each treatment group. Forty-seven of 54 (87%) and 9 of 54 (17%) S. pneumoniae isolates from the one dose group were nonsusceptible to penicillin and ceftriaxone, respectively; the respective values in the three dose group were 49 of 54 (91%) and 8 of 54 (15%). On Days 4 and 5 negative nasopharyngeal cultures were achieved in 43 of 83 (52%) and 70 of 87 (80%) cases from the one dose and three dose group, respectively (P < 0.001). Eradication of penicillin-nonsusceptible S. pneumoniae was achieved on Day 4 to 5 in 18 of 49 (37%) and 39 of 49 (80%) organisms isolated from the one dose and three dose groups, respectively (P < 0.001). Nasopharyngeal S. pneumoniae carriage among evaluable patients on Days 11 to 14 and Days 28 to 30 was 43 of 69 (62%) and 31 of 45 (69%) for the one dose group and 42 of 73 (58%) and 31 of 50 (62%) for the three dose group, respectively (P not significant). A decrease was observed during the study period in the proportion of highly penicillin-resistant S. pneumoniae isolated in the three dose group compared with the one dose group (30, 24, 17 and 13% vs. 30, 27, 19 and 26% at Days 1, 4 to 5, 11 to 14 and 28 to 30, respectively; P = 0.05).

CONCLUSIONS

A marked reduction in the carriage of penicillin-nonsusceptible S. pneumoniae (including highly penicillin-resistant organisms) was achieved on Days 4 to 5 of therapy with both ceftriaxone regimens. The 3-day intramuscular ceftriaxone regimen was significantly superior to the 1-day regimen in the reduction of carriage during the treatment period. The reduction of overall S. pneumoniae nasopharyngeal carriage by both ceftriaxone regimens was a short-lived phenomenon followed by rapid recolonization of the nasopharynx.

[The efficacy of combining antibiotic treatment with topical intranasal steroid administration in the treatment of chronic otitis media with effusion]

OBJECTIVES

We evaluated the efficacy of antibiotic treatment with or without topical administration of intranasal budesonide in chronic otitis media with effusion (OME).

PATIENTS AND METHODS

The study included 62 patients (age range 2 to 12 years) with chronic OME. The patients were randomly assigned to three groups, namely, antibiotic treatment (20 patients, ampicillin/sulbactam, 25 mg/kg/daily), antibiotic treatment combined with intranasal budesonide (20 patients, 200 mg/daily), and no treatment (22 patients). All patients and families were questioned regarding the presence of allergy, frequent upper respiratory tract infections, passive smoking, low birth weight, and pre-school nursery attendance. Otoscopic examination findings and the results of tympanograms obtained at the time of diagnosis, and at the end of four and eight weeks of treatment were evaluated.

RESULTS

At the end of eight weeks, significant improvement in tympanograms and otoscopic findings was obtained in both groups when compared with the control group (p<0.05). Resolution rates were 24% (9/37 ears), 39% (14/36), and 5% (2/40) with antibiotic, budesonide, and no treatment groups, respectively. Although budesonide treatment was associated with a higher rate of resolution of effusion compared to that of antibiotic alone, this did not reach significance (p>0.05).

CONCLUSION

Further studies with larger patient series are required to better evaluate the efficacy of antibiotic treatment and topical intranasal steroid administration in chronic OME.