Classification of otitis media and surgical principles

Our Experience of Comparison of Hearing Outcomes in Patients Undergoing Type-1 Tympanoplasty with Different Graft Materials

The present study was undertaken to compare the results of various autogenous tissues: temporalis fascia, sliced tragal cartilage and fascia lata as graft materials for type I tympanoplasty in terms of hearing improvement in safe type of chronic suppurative otitis media. A total of 75 cases with central perforation were considered in the study. Of the 75 cases, temporalis fascia graft was used in 25 cases (Group-A), fascia lata graft in 25 cases (Group-B), and sliced tragal cartilage graft in 25 cases (Group-C). The results were evaluated in the form of hearing improvement with respect to the graft materials. A significant association was observed between the groups, that is, temporalis fascia (Group-A), fascia lata (Group-B), and sliced tragal cartilage (Group-C) in terms of improvement in AB gap (P = 0.047). Improvement in AB gap was statistically significant between groups B and A, but not between the other groups. In the present study, fascia lata showed better graft uptake as compared to temporalis fascia and sliced tragal cartilage. The hearing assessment at post-operative 3rd month showed statistically significant hearing improvement with fascia lata when compared to temporalis fascia.

Comparative Study on Temporalis Fascia Graft Versus Tragal Cartilage in Type-1 Tympanoplasty in Paediatric Patients

The aim of the study was to compare anatomical and functional outcomes of temporalis fascia graft versus tragal cartilage graft in type 1 tympanoplasty in paediatric patients. A prospective, comparative and randomised study. A detailed history was taken from all the patients visiting the ENT OP dept after fulfilling the inclusion and exclusion criterion patients were enrolled for the study. Written and informed consent was taken for all the patients from legally acceptable guardians. Preoperative assessment was done and the patients were subjected to type1 tympanoplasty with Temporalis fascia graft or tragal cartilage graft. All the patients were followed up on the third, sixth postoperative months to assess hearing improvement. All the patients were followed up on the first and third,sixth postoperative months for graft status with otoscopic examination. In the present study out of 80 patients, 40 patients underwent type 1 tympanoplasty with temporalis fascia and the remaining 40 patients with tragal cartilage. Both groups were assessed postoperatively for anatomical and functional success with maximum follow up of six months. There was no statistical significance between the outcome and the age or site and size of tympanic membrane perforation. Both groups had comparable graft success rate and hearing improvement. The cartilage group had a higher anatomical success rate. The functional outcome was similar. However, there was no statistically significant difference found in the outcome of two groups. Tympanoplasty can be performed in a paediatric age group with a good success rate in suitable patients. It can be done at an early age,safely with good anatomical and functional outcomes. The age group, site or size of perforation, the type of graft used for tympanoplasty does not alter the anatomical or functional outcome significantly.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03490-1.

Which is Better for Management of Tympanic Membrane Perforation Temporalis Fascia or Fascia Lata Graft?

A good graft material is the one which is easily available and harvestable, tough and is easy to be handling and survival is good. Both temporalis fascia and fascia lata graft satisfy all these criteria. Keeping all these factors in mind, the comparative study of temporalis fascia and fascia lata graft in tympanoplasty is undertaken. All the patient reporting to ENT OPD with tympanic membrane perforation who are fit for surgery were advised tympanoplasty or tympanoplasty with mastoidectomy were included in the study. Our observation and data analysis have shown that fascia lata is definitely better than temporalis fascia in terms of intactness of graft (95.1% in fascia lata and 90.24% in temporalis fascia) and PTA average improvement is higher in fascia lata graft (11.56 ± 5.005) as compared to temporalis fascia graft (10.32 ± 4.634) and ABG improvement is higher in fascia lata graft (2.7317 ± 1.118) as compared to temporalis fascia graft (2.634 ± 1.089). Fascia lata has better dimensional stability, easy handling and thickness of the graft and it provides more resistant to negative middle ear pressure. Hence, fascia lata is one of the good choices in otologist's armentorium for tympanoplasty graft material.

Construction of an MRI-based decision tree to differentiate autoimmune and autoinflammatory inner ear disease from chronic otitis media with sensorineural hearing loss

Autoimmune and autoinflammatory inner ear diseases (AIED/AID) are characterized by the symptom of sensorineural hearing loss (SNHL). To date, standardized diagnostic tools for AIED/AID are lacking, and clinically differentiating AIED/AID from chronic otitis media (COM) with SNHL is challenging. This retrospective study aimed to construct a magnetic resonance imaging (MRI)-based decision tree using classification and regression tree (CART) analysis to distinguish AIED/AID from COM. In total, 67 patients were enrolled between January 2004 and October 2019, comprising AIED/AID (n = 18), COM (n = 24), and control groups (n = 25). All patients underwent 3 T temporal bone MRI, including post-contrast T1-weighted images (postT1WI) and post-contrast FLAIR images (postFLAIR). Two radiologists evaluated the presence of otomastoid effusion and inner ear contrast-enhancement on MRI. A CART decision tree model was constructed using MRI features to differentiate AIED/AID from COM and control groups, and diagnostic performance was analyzed. High-intensity bilateral effusion (61.1%) and inner ear enhancement (postFLAIR, 93.8%; postT1WI, 61.1%) were the most common findings in the AIED/AID group. We constructed two CART decision tree models; the first used effusion amount as the first partitioning node and postT1WI-inner ear enhancement as the second node, whereas the second comprised two partitioning nodes with the degree of postFLAIR-enhancement of the inner ear. The first and second models enabled distinction of AIED/AID from COM with high specificity (100% and 94.3%, respectively). The amount of effusion and the degree of inner ear enhancement on MRI may facilitate the distinction between AIED/AID and COM with SNHL using decision tree models, thereby contributing to early diagnosis and intervention.

Complications of tympanostomy tubes in head and neck cancer patients

PURPOSE

To assess myringotomy plus tympanostomy tube (MTT) complication rates in head and neck cancer (HNC) patients with otitis media (OM).

MATERIALS AND METHODS

We performed a retrospective review of 182 HNC patients with OM treated between January 2000 and October 2007 for demographic data and data about MTT-related complications, tumor type and outcomes following MTT.

RESULTS

We identified OM in 35 nasopharyngeal (NP), 34 paranasal sinus (PNS), and 24 larynx cancer patient ears; of these, 29 (83%), 31 (91%), and 22 (92%), respectively, were treated with MTT. Of the 29 NP cancer patient ears treated with MTT, 13 (45%) received MTT before radiotherapy; complications included otorrhea in 11 ears (38%), otorrhea with perforation in 3 ears (10%), and cholesteatoma in 1 ear (3%). Of the 31 PNS cancer patient ears treated with MTT, 17 (55%) received MTT before radiotherapy; complications included otorrhea in 10 ears (32%) and otorrhea with perforation in 3 ears (10%). All 22 laryngeal cancer patient ears were treated with MTT before radiotherapy; 5 ears (23%) developed chronic otorrhea. Patients with pre-existing eustachian tube dysfunction had significantly higher rates of tympanostomy tube otorrhea (p=.009).

CONCLUSIONS

The complication rates of OM in the setting of NP or PNS cancer were not significantly different regardless of intervention timing in relation to radiotherapy. Laryngectomy patients had a high rate of tympanostomy sequelae after radiotherapy. MTT for OM has high complication rates in HNC patients.

The Role of Oxidants and Antioxidants in Otitis Media with Effusion in Children

OBJECTIVE: Determine the possible role of oxidants and antioxidants in the pathogenesis of otitis media with effusion in children.

STUDY DESIGN AND SETTING: Randomized controlled trial, tertiary referral center. The study group was made up of children with otitis media with effusion who were to undergo bilateral ventilation tube insertion and adenoidectomy. The control group was comprised of otherwise healthy children. The blood levels of antioxidants (retinol, β-carotene, (α-tocopherol, laycopene, ascorbic acid, superoxide dismutase, glutathione peroxidase, GSH) and oxidation products (malondialdehyde) were determined before and 1 month after the operation in the study group and once only in the control group. These substances were also measured in the adenoid tissue and middle ear fluids.

RESULTS: In the study group, the blood levels of antioxidants and oxidants before and after the operation were significantly different when compared with the control group ( P < 0.05). In the study group, the blood antioxidant levels increased and oxidant levels decreased significantly after the operation ( P < 0.05). The levels after the operation never reached those of the control group.

CONCLUSIONS AND SIGNIFICANCE: Oxidants and antioxidants played a significant role in the pathogenesis of otitis media with effusion in children. These children are under significant oxidative stress. Insertion of a ventilation tube and adenoidectomy significantly decreased the oxidative stress in these patients, but could not normalize it completely. Additional studies are necessary in the clinical use of antioxidants in otitis media with effusion.

Otitis Media with Effusion in Primary Schools in Princes' Islands, Istanbul: Prevalence and Risk Factors

The prevalence of otitis media with effusion (OME) and environmental risk factors were investigated in 423 children aged 7 – 12 years at three primary schools in Princes' Islands, Istanbul, Turkey. An ear, nose and throat examination, including tympanometry, was performed in April (end of the school year) and the families completed a questionnaire about potential risk factors. Type B or C2 tympanograms were taken as indicating OME. The overall prevalence of OME was 16%. OME was significantly associated with numbers of episodes of upper respiratory tract infections (URTI) and acute otitis media (AOM) during the previous year, class size and snoring, but not with allergic symptoms, kindergarten years, breast-feeding duration, parental smoking, domestic animals at home, numbers of siblings and family members, type of home heating, parents' educational level or monthly income. Four or more URTIs and two or more AOM episodes in a year, snoring and class size larger than 20 were risk factors for OME.

Comparative study of underlay tympanoplasty with temporalis fascia and tragal perichondrium

The perforations of the tympanic membrane maybe of traumatic origin or due to chronic suppurative otitis media. If the perforations fail to heal conservatively, they require surgical closure. Autologous graft materials have stood the test of time in repairing tympanic membrane perforations. In our tertiary care institution we conducted a prospective randomized control trial on 50 subjects to evaluate the comparative efficacy of temporalis fascia and tragal perichondrium as grafting material in underlay tympanoplasty. In this study surgical success was evaluated in terms of intact drum membrane during the follow up period and closure of A-B gap within 10 dB. Temporalis fascia achieved a graft uptake of 84% and a satisfactory hearing improvement in 76% of the patients. Tragal perichondrium achieved a success rate of 80% graft uptake and 75% hearing gain. The rates are comparable with no statistical significance of the difference between them.

Nitric oxide synthase activity and nitric oxide level in erythrocytes of guinea pigs with experimental otitis media with effusion

Free radicals have been implicated in the pathogenesis of an increasing number of disease and inflammatory states. They may cause cell and tissue damage by chemical modification of proteins, carbohydrates, nucleotides and lipids. Under physiological conditions free radicals are parts of normal regulatory circuits and are neutralized by antioxidants. Infections are one cause of increased free radicals production. The aim of our study was to assess whether increased oxidative stress is reflected by erythrocyte nitric oxide synthase activity and nitric oxide levels in guinea pigs with experimental otitis media with effusion (n = 6) and in a control group (n = 6). Erythrocyte nitric oxide synthase activity and nitric oxide levels were measured in both groups. The nitric oxide synthase activity and nitric oxide level in the experimental otitis media with effusion were significantly higher than those of the control group. There was a significant positive correlation between the nitric oxide synthase activity and nitric oxide in the experimental otitis media with effusion group. Thus, increased nitric oxide levels may play an important role in cell and tissue damage due to experimental otitis media with effusion.

Effect of dantrolene on lipid peroxidation, lutathione and glutathione-dependent enzyme activities in experimental otitis media with effusion in guinea pigs

The aims of our study were to assess whether the increased oxidative stress in experimental otitis media with effusion (OME) induced by histamine was reflected erythrocytes and middle ear effusion fluid by lipid peroxidation; to survey the alterations in antioxidant enzyme activities in experimental OME; and to determine the effect of dantrolene on this oxidative stress. Erythrocyte and middle ear effusion malondialdehyde (MDA) level, erythrocyte glutathione (GSH) and glutathione peroxidase (GSH-Px), glutathione reductase (GRD) and glutathione-S-transferase (GST) activities were measured in three groups of seven guinea pigs, 3 hours after injection of 0.1 mL of histamine (or saline) into the middle ear in guinea pigs with OME (experimental group), in a dantrolene sodium group and in a control group. Erythrocyte and effusion MDA levels in the dantrolene group were significantly lower than those of the experimental group. Erythrocyte GSH-Px, GST, GRD activities, and GSH levels were significantly higher in the dantrolene group than in the experimental group. Dantrolene sodium decreased the erythrocyte and effusion MDA levels, on the other hand, it increased the GSH and GSH-dependent enzymes. These findings suggest that reactive oxygen species (ROS) play a role in histamine-induced OME. Pre-treatment with dantrolene sodium increases antioxidant enzymes activities and decreases formation of MDA, the indicator of lipid peroxidation, in histamine-induced OME.

Effect of melatonin on lipid peroxidation, glutathione and glutathione-dependent enzyme activities in experimental otitis media with effusion in guinea pigs

Melatonin plays a role in the prevention of oxidative damage. In the present study, we investigated whether the increased oxidative stress in experimental otitis media with effusion (OME) induced by histamine is reflected in erythrocytes and middle ear effusion fluid. Lipid peroxidation in effusion fluid was measured to determine the effects of melatonin on oxidative stress. Erythrocyte and middle ear effusion malondialdehyde (MDA) levels, erythrocyte glutathione (GSH) levels and glutathione peroxidase (GPx), glutathione reductase (GRd) and glutathione-S-transferase (GST) activities were measured in three groups of six guinea pigs each at 3 hr after the injection of 0.1 mL of histamine (or saline) into the middle ear. In erythrocyte and middle ear effusion samples, MDA levels showed a significant increase in guinea pigs with experimental OME group when compared with the control animals. Erythrocyte GPx, GST, GRd activities and GSH levels significantly reduced in experimental OME guinea pigs when compared with the control and melatonin-treated animals. Erythrocyte GPx activity also significantly increased after melatonin treatment when compared with the control group. These findings suggest that reactive oxygen species play a role in histamine-induced OME. Pretreatment with melatonin increases antioxidant enzyme activities and reduced formation of MDA, an indicator of lipid peroxidation, in histamine-induced OME.

Laser office ventilation of ears with insertion of tubes

OBJECTIVE

Myringotomy with insertion of pressure equalization tubes has proven to be extremely effective in treating persistent serous otitis media (SOM). This study compares the advantages and disadvantages of this procedure when performed in the operating room or with a laser in an office setting.

PATIENTS AND METHODS

Patients selected either traditional myringotomy and tube (M & T; n = 29) done in an operating room under general anesthesia or Laser Office Ventilation of Ears with Insertion of Tubes (LOVE IT; n = 35) done in an office setting with only topical anesthesia. The reasons for selecting either M&T or LOVE IT and satisfaction with the procedure chosen were evaluated by survey, the results of which were compared statistically. Chart review was performed to determine the time and cost of the procedures, time interval from diagnosis to treatment, tube longevity, and complications.

RESULTS

Overall satisfaction was similar with both procedures. Patients and families were more likely to choose LOVE IT based on the anesthetic technique involved (P < 0.001, chi(2)). M&T required less time to perform, whereas the cost of LOVE IT was less. Tube longevity and complication rates were similar between the two procedures, and all complications were minor.

CONCLUSIONS

LOVE IT is a potential alternative to traditional M&T in the treatment of SOM. LOVE IT is most likely to be selected by patients/parents who wish to avoid a general anesthetic and provides a level of satisfaction similar to that of traditional M&T.

Computed tomography and magnetic resonance imaging of pathologic conditions of the middle ear

Computed tomography (CT) is an excellent technique for demonstrating even small abnormalities of the thin and complex bony structures of the middle ear. For this reason, it is the modality of choice in the study of conductive hearing loss (CHL). However, not every patient complaining of CHL requires a CT study. In fact, established indications encompass complex conditions, such as the complications of acute and chronic otomastoiditis, the postoperative ear in chronic otomastoiditis or in the localization of prosthetic devices, and the assessment of congenital or vascular anomalies. Particularly, the precise extent of bone erosion associated with cholesteatoma is correctly demonstrated by high resolution CT. Conversely, although fistulization through the tegmen tympani or the posterior wall of temporal bone is usually detectable by CT, the actual involvement of meninges and veins are better assessed by magnetic resonance (MR). MR is also indicated when complicated inflammatory lesions are suspected to extend into the inner ear or towards the sigmoid sinus or jugular vein. Neoplasms arising from or extending into the middle ear require the use of both techniques as their combined data provide essential information. Most important data for surgical planning concern the destruction of thin bony structures and the relationships of the lesion with the dura and surrounding vessels. DSA and interventional vascular techniques maintain an essential role in the presurgical work-up and embolization of paragangliomas extended into the middle ear.

Negative pressure tympanograms in children less than 2 years of age--different bacterial findings in otitis media by tympanometric results

OBJECTIVE

The interpretation of negative pressure tympanograms as indicators of the presence of middle ear fluid has been ambiguous. Our purpose was to assess the occurrence and implications of negative pressure tympanograms and to study their association with bacterial pathogens in otitis media.

METHODS

Altogether 329 infants were enrolled at a well-baby clinic for the Finnish Otitis Media Cohort Study, a longitudinal prospective cohort study. The children were closely followed in a special study clinic from 2 to 24 months of age for respiratory diseases, especially acute otitis media. Children were examined at the study clinic with tympanometry and pneumatic otoscopy whenever visiting the study clinic for respiratory disease. Myringotomy with aspiration was performed if middle ear fluid was suspected in otoscopy. Occurrence of middle ear fluid in ears with negative pressure tympanograms (less than -100 daPa) was assessed. Nested case control design matched by visit type (acute or follow-up visit) and month of visit was used for analysis of association of bacterial pathogens and tympanometric results.

RESULTS

Middle ear fluid was encountered in 15% of ears with negative tympanometric peak pressure, a lower proportion than described previously. In otitis media with a negative tympanometric peak pressure, 71% of bacterial cultures remained negative for the main pathogens, compared to 36% in matched controls (P<0.001). Especially Streptococcus pneumoniae but also Haemophilus influenzae were rarely found in samples from negative pressure ears. Moraxella catarrhalis was equally often found.

CONCLUSIONS

Negative pressure tympanogram is a poor indicator for the presence of middle ear fluid. Furthermore, if otitis media is diagnosed with negative tympanometric peak pressure negative middle ear bacterial culture for the main pathogens is highly probable. Expectant follow-up might be more appropriate than routine antibiotic treatment.

Treatment of Chronic Suppurative Otitis Media with Broncasma Berna

Broncasma Berna, an inactivated bacterial vaccine, has been safely used throughout the world for 30 years for the prevention or treatment of various infectious processes. Until now, there has been no published report regarding its use as a treatment for chronic suppurative otitis media. In this small study, five such patients (median age: 57 years) underwent a series of seven 0.05-ml injections of Broncasma Berna. In all cases, their otorrhea diminished markedly and their tympanic membranes were almost completely dry. The cost of treatment was extremely low.

Concentration of nitric oxide metabolites in middle ear effusion

Free radicals such as nitric oxide (NO) seem to be important in the pathogenesis of otitis media with effusion (OME). NO can be quantitated by measuring its metabolites, nitrate (NO(3)(-)) and nitrite (NO(2)(-)). The purpose of this study is to determine the concentrations of NO in human middle ear effusion (MEE). Samples of human MEE were collected at the time of myringotomy and tympanostomy tube insertions. The type of MEE was classified as serous (SOM), mucoid (MOM) or purulent (POM) at the time of surgery. Samples of MEE were assayed for NO metabolites (nitrate and nitrite) with colorimetric assay (Griess method). Concentrations of NO metabolites were highest in MOM followed by SOM and POM. This study suggests that NO is present in human MEE and may play an important role in the pathogenesis of OME.

Inhibition of OM pathogens by alpha-hemolytic streptococci from healthy children, children with SOM and children with rAOM

The present study was undertaken to elucidate the inhibitory activity of the normal nasopharyngeal flora against the three most common otitis media (OM) pathogens in healthy children, children with secretory otitis media (SOM) and children with recurrent otitis media (rAOM). Isolates of alpha-hemolytic streptococci (AHS) and OM pathogens were recovered from the tubal orifice in each child. The samples were taken from 20 healthy children under general anesthesia, from 19 children with SOM and 20 children with rAOM. The method used to test the bacterial interference in vitro was a modified agar overlay method. The AHS sampled from the tubal orifice of the healthy children were able to inhibit 92% of the S. peumoniae isolates, 74% of the non-typable H. influenzae isolates and 89% of the M. catarrhalis isolates. The corresponding figures for children with SOM and children with rAOM were: 73% of the S. pneumoniae isolates, 58 and 54% of the non-typable H. influenzae isolates and 86 and 89% of the M. catarrhalis isolates. The AHS from children with SOM and children with rAOM were significantly less capable of inhibiting the S. peumoniae and the H. influenzae isolates (P<0.001). There was no significant difference between the three groups of children regarding inhibitory activity against M. catarrhalis. The results suggest that the inhibitory activity of the normal bacterial flora at the tubal orifice against pneumococci and H. influenzae may be reduced in children with SOM and rAOM.