Allergy and Otitis Media in Clinical Practice

Panel 1: Epidemiology and global health, including child development, sequelae and complications

OBJECTIVE

To summarise the published research evidence on the epidemiology of otitis media, including the risk factors and sequelae associated with this condition.

DATA SOURCES

Medline (PubMed), Embase, and the Cochrane Library covering the period from 2019 to June 1st, 2023.

REVIEW METHODS

We conducted a broad search strategy using otitis [Medical Subject Heading] combined with text words to identify relevant articles on the prevalence, incidence, risk factors, complications, and sequelae for acute otitis media, otitis media with effusion, and chronic suppurative otitis media. At least one review author independently screened titles and abstracts of the retrieved records for each condition to determine whether the research study was eligible for inclusion. Any discrepancies were resolved by reviewing the full text followed by discussion with a second review author. Studies with more than 100 participants were prioritised.

RESULTS

Over 2,000 papers on otitis media (OM) have been published since 2019. Our review has highlighted around 100 of these publications. While the amount of otitis media research on the Medline database published each year has not increased, there has been an increase in epidemiological studies using routinely collected data and systematic review methodology. Most of the large incidence studies have addressed acute otitis media (AOM) in children. Several studies have described a decrease in incidence of AOM after the introduction of conjugate PCV vaccines. Similarly, a decrease was noted when rates of coronavirus disease of 2019 (COVID-19) were high and there were major public health efforts to reduce the spread of infection. There have been new studies on OM in adults and OM prevalence in a broader range of countries and population subgroups.

CONCLUSION

Overall, the rates of severe and/or suppurative OM appeared to be decreasing. However, there is substantial heterogeneity between populations. While better use of available data is informative, it can be difficult to predict rates of severe disease without accurate examination findings. Most memorably, the COVID-19 pandemic had an enormous impact on the research and clinical services for otitis media for most of the period under review.

IMPLICATIONS FOR PRACTICE

The use of routinely collected data for epidemiological studies will lead to greater variability in the definitions and diagnostic criteria used. The impact of new vaccines will continue to be important. Some of the lessons learned during the COVID-19 pandemic concerning behaviours that reduce spread of respiratory viruses can hopefully be used to decrease the burden of otitis media in the future. There are still many countries in the world where the burden of otitis media is not well described. In countries where otitis media has been studied over many years, new potential risk factors continue to be identified. In addition, a better understanding of the disease in specific subgroups has been achieved.

Chronic Otitis Media in Patients with Chronic Rhinosinusitis: A Systematic Review

Introduction: Chronic otitis media (COM) and chronic rhinosinusitis (CRS) are two of the most common otolaryngological disorders. CRS and COM share pathophysiological mechanisms such as bacterial infection, biofilm, and the persistence of the obstruction state of ventilation routes. The purpose of this systematic review was to evaluate all available information on the association between COM and CRS. Methods: The protocol of this investigation was registered on PROSPERO in November 2022. Pubmed, Scopus, Web of Science, and Cochrane databases were systematically searched according to the PRISMA statement. Results: After the application of inclusion-exclusion criteria, four manuscripts with adequate relevance to this topic were included in the review. The study population consisted of 20,867 patients with a diagnosis of CRS, of whom 991 were also diagnosed with COM (4.75%). Conclusions: The included studies have shown that CRS has become significantly associated with COMas: a global inflammatory process that involves the epithelium in both the middle ear and upper airway. The identification of a relationship between CRS and COM may contribute to preventing chronic inflammatory conditions through the early management of the associated disease. Further, carefully designed studies are necessary to demonstrate the relationship between COM and CRS.

Otitis media in severe asthma associated with chronic rhinosinusitis with nasal polyps: a new therapeutic target for biologics

Background: Chronic rhinosinusitis with nasal polyps (CRSwNPs) is associated with otitis media with effusion (OME) in about 25% of cases. The objective of this study was to assess the clinical efficacy of the 4 biologic agents currently available in France for severe asthma (omalizumab, mepolizumab, benralizumab and dupilumab) in 17 patients followed for both asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) and presenting otitis media with effusion (OME) on otoscopy. Methods: It was a multicenter retrospective study performed in 4 academic ENT and respiratory departments in Paris, France, with assessment of the clinical evolution of 17 patients with severe eosinophilic asthma and with chronic refractory OME and CRSwNPs treated by biologic agents. Global evaluation of treatment effectiveness (GETE) on asthma, CRSwNP and OME was classified on a 5-point scale as 1, excellent; 2, good; 3, moderate; 4, poor; or 5, symptoms worsening. Response was defined as an excellent/good score (1 or 2). Results: 17 patients were prescribed a total of 30 biologics. The evolution of OME did not follow that of asthma and CRSwNPs in 15 (88%) and 12 (70%) cases, respectively. Concerning OME, 19/30 (63%) patients were non-responders. Among the 10 patients who successively received ≥ 2 biologic agents, the OME response differed, depending on the considered agent Dupilumab had the highest response rate. Conclusions: Resistant OME, associated with asthma and chronic rhinosinusitis with nasal polyps, can present a disconnected evolution under biologics. CRSwNP-associated OME requires a specific evaluation to define the best treatment.

Predictive Value of Adenoid-Nasopharyngeal Ratio in the Diagnosis of Secretory Otitis Media

OBJECTIVES

To explore the associated factors of otitis media with effusion (OME) and analyze the diagnostic value of the adenoid-nasopharyngeal (A/N) ratio to OME.

METHODS

Patients with adenoid hypertrophy (AH) recently in 2 years were collected, including sex, age, duration, with/without rhinosinusitis, and examination results, including Cone Beam Computerized Tomography (CBCT) sinus imaging, tympanometry, pure tone audiometry (PTA), blood test, and allergen detection. According to Liden/Jerger's classification, the patients were divided into two groups: Type B and type C, which were defined as the tympanometry abnormal group (TAG), and the rest were classified as the tympanometry normal group (TNG).

RESULTS

A total of 316 children were included in this study. Age and duration were significantly younger and shorter in TAG (6.0(4.0-9.0) vs.5.0(4.0-7.0)); 12.0(4.0-24.0) vs.6.0(2.0-12.0)). Compared to TNG, the allergen test results of fx5 (protein, milk, cod, wheat, peanut, and soybean) in TAG were higher (0.09(0.04-0.25) vs.0.14(0.05-0.45)), but eosinophilia in blood was lower (count: 0.21(0.13-0.35) vs. 0.18(0.12-0.27); ratio: 3.10 (1.90-4.70) vs. 2.50 (1.65-3.80)). A/N ratio and Visual obstruction ratio had a statistical difference (Z = -3.770, P < .01) but the two ratios didn't have too much disparity (0.82(0.74-0.88) VS 0.80(0.75-0.80)), and they had a positive correlation (r = 0.345, P < .01). A/N ratio of TAG was higher than TNG (0.78(0.70-0.85) vs. 0.86(0.82-0.90)) and had a positive correlation with increasing negative middle ear pressure (r = -3.777, P < .01). A/N ratio was an associated factor of OME (OR:1355.611, P = .006), the cut-off value of A/N ratio was 0.815(sensitivity: 75.3%, specificity: 64.3%, area under the curve (AUC): 0.747).

CONCLUSIONS

A/N ratio indirectly reflected the abnormality of tympanometry in this study. When A/N ratio reaches 0.815, patients are at a higher risk of having OME so it could be a predictor of OME in patients with adenoid hypertrophy.

Cell division cycle 42 positively correlates with T helper 2 cytokine, effusion viscosity, and hearing loss degree in otitis media with effusion patients

OBJECTIVE

Cell division cycle 42 (CDC42) participates in the pathogenesis of some T-cell-mediated inflammatory diseases via regulating CD4⁺ T-cell differentiation and inflammation response. This study aimed to evaluate the correlation of CDC42 and T helper (Th)1/Th2 cytokines with disease risk, effusion viscosity, and hearing loss degree of otitis media with effusion (OME).

METHODS

CDC42, interleukin (IL)-4, and interferon-gamma (IFN-γ) in effusion and serum of 78 OME patients were determined by enzyme-linked immunosorbent assay. Besides, the effusion (irrigating fluid) and serum samples of 30 controls (adenoid hypertrophy patients without OME) were also obtained for CDC42, IL-4, and IFN-γ determination.

RESULTS

Effusion CDC42 and IL-4 were elevated in OME patients compared with controls (both p < 0.001). Effusion CDC42 was positively correlated with effusion IL-4 in OME patients (p = 0.004) and controls (p = 0.012) but was not related to effusion IFN-γ (both p > 0.050). Additionally, effusion CDC42 (p = 0.025) and IL-4 (p = 0.023) were increased in OME patients with mucoid effusion compared to patients with serous effusion, while effusion IFN-γ was of no difference between those patients (p = 0.215). Meanwhile, elevated effusion CDC42 (p = 0.012) and IL-4 (p = 0.033) were linked with increased hearing loss degrees, whereas effusion IFN-γ was not related to hearing loss degrees (p = 0.057). Moreover, the findings of serum CDC42, IL-4, and IFN-γ showed similar trends as effusion ones; nonetheless, their correlation with disease features was generally weaker.

CONCLUSION

OME patients present with elevated CDC42 and IL-4 levels; the latter factors are intercorrelated and positively associate with effusion viscosity and hearing loss degree.

The Role of Allergen-Specific Immunotherapy in ENT Diseases: A Systematic Review

Previous studies have demonstrated that both subcutaneous (SCIT) and sublingual specific immunotherapy (SLIT) are effective in treating allergic rhinitis (AR). Further studies have evaluated the efficacy of allergen-specific immunotherapy (AIT) on different ear, nose, and throat (ENT) manifestations, in which allergy might have an etiopathogenetic role, such as local allergic rhinitis (LAR), rhinosinusitis (RS), otitis media (OM), and adenotonsillar (AT) disease. Nevertheless, the management of allergy in ENT diseases is still debated. To the best of our knowledge, this is the first systematic review assessing the efficacy of AIT in ENT diseases aside from AR. Literature data confirmed that AIT might be an effective therapeutic option in LAR, although its effect is restricted to studies with short-term follow-up. Furthermore, previous research demonstrated that AIT may improve symptoms and surgical outcomes of chronic rhinosinusitis when used as an adjunctive treatment. Few studies supported the hypothesis that AIT may exert positive therapeutic effects on recurrent upper airway infections as adenotonsillar disease. Finally, some clinical observations suggested that AIT may add some benefits in the management of otitis media with effusion (OME). The results of this systematic review allow us to conclude that the efficacy of AIT in ENT disorders has been only slightly investigated and additional studies are needed.

Turbinate Hypertrophy, Allergic Rhinitis, and Otitis Media

PURPOSE OF REVIEW

Otitis media (OM) is a disease with high prevalence in infancy; it has a substantial burden on healthcare resources, and a relevant impact on the quality of life of families. The link between OM and allergic rhinitis (AR) is still debated. However, there is agreement about the relevance of type 2 inflammation on turbinate hypertrophy (TH) generation. There is also evidence that TH is associated with middle ear dysventilation: a pathogenic factor promoting OM. Therefore, a vicious circle among AR, TH, and OM may occur.

RECENT FINDINGS

There are some recent studies exploring this issue through different approaches, such as epidemiological, mechanistic, and therapeutic. Identifying allergy as a pathogenic factor for OM could improve the management of OM patients. Vice versa, suspecting AR in OM patients, could be reasonable in selected patients. The current narrative review provides an overview of the evidence concerning the potential role of AR, and associated TH, in OM patients.

Turbinate Hypertrophy, Allergic Rhinitis, and Otitis Media

PURPOSE OF REVIEW

Otitis media (OM) is a disease with high prevalence in infancy; it has a substantial burden on healthcare resources and a relevant impact on the quality of life of families. The link between OM and allergic rhinitis (AR) is still debated. However, there is agreement about the relevance of type 2 inflammation on turbinate hypertrophy (TH) generation. There is also evidence that TH is associated with middle ear dysventilation: a pathogenic factor promoting OM. Therefore, a vicious circle among AR, TH, and OM may occur.

RECENT FINDINGS

There are some recent studies exploring this issue through different approaches, such as epidemiological, mechanistic, and therapeutic. Identifying allergy as a pathogenic factor for OM could improve the management of OM patients. Vice versa, suspecting AR in OM patients could be reasonable in selected patients. The current narrative review provides an overview of the evidence concerning the potential role of AR, and associated TH, in OM patients.

Bone-conduction threshold and air-bone gap may predict frequency-specific air-conduction threshold after tympanoplasty

Postoperative hearing improvement is one of the main expectations for patients receiving tympanoplasty. The capacity to predict postoperative hearing may help to counsel a patient properly and avoid untoward expectations. It is difficult to predict postoperative hearing without knowing the disease process in the middle ear, which can only be assessed intraoperatively. However, the duration and extent of the underlying pathologies may represent in bone-conduction threshold and air-bone gap. Here in patients undergoing tympanoplasty without ossiculoplasty, we sorted and separated the surgery dates into the first group to build the predicting models and the second group to test the predictions. There were 87 and 30 ears, respectively. No specific enrollment or exclusion criteria were based on underlying pathologies such as the perforation size of the tympanic membrane or the middle ear conditions. The results show that bone-conduction threshold and air-bone gap together predicted air-conduction threshold after the surgery, including each frequency of 0.5k, 1k, 2k, and 4k Hz. The discrepancies between the predictions and recordings did not differ among these four frequencies. Of the variance in mean postoperative air-conduction threshold, 56.7% was linearly accounted for by these two preoperative predictors in this sample. The results suggest a trend that, the higher the frequency, the larger the part was accounted for by these two preoperative predictors. These together may help a surgeon to estimate frequency-specific hearing outcome after the surgery, answer patients' questions with quantitative statistics, and counsel patients with proper expectations.