Treatment of Chronic Suppurative Otitis Media

Povidone-iodine ear wash and oral cotrimoxazole for chronic suppurative otitis media in Australian aboriginal children: study protocol for factorial design randomised controlled trial

Background

Chronic suppurative otitis media (CSOM) is a significant health issue affecting Aboriginal Australians. Long-term hearing loss can cause communication problems, educational disadvantage, and social isolation. Current standard treatment for CSOM in our region is twice daily dry mopping of the pus from the ear canal followed by instillation of ciprofloxacin antibiotic ear drops for up to 16 weeks, or until the discharge resolves for a period of 3 days. The treatment is long, laborious and fails to resolve ear discharge in 70% of cases in remote communities. Bacterial pathogens also persist. Povidone-iodine ear wash is the preferred method of clearing ear discharge in Western Australia. However, evidence of its effectiveness is lacking. In systematic reviews, topical antibiotics (ciprofloxacin) have been shown to be more effective than oral antibiotics or topical antiseptics. Currently, it is unclear whether there are any benefits of combining these treatments.

Methods

This protocol describes a 2 × 2 factorial randomised controlled trial of two different interventions (povidone-iodine ear wash and oral cotrimoxazole), given as adjunctive therapy to standard treatment for CSOM. 280 children, between 2 months and 17 years of age, Indigenous or non-Indigenous, living in participating Northern Territory (NT) communities are randomised to standard treatment (dry mopping and ciprofloxacin drops) plus one of two topical treatments (dilute povidone-iodine ear wash or no wash) and one of two oral medication treatments (16 weeks of cotrimoxazole or placebo).

Discussion

Current treatment of CSOM in our region shows that eradication of bacterial pathogens from the middle ear space and dry ears is often not achieved. This trial will evaluate the efficacy of adjunctive treatments of antiseptic ear washes and oral antibiotics. Clinical, microbiological and hearing outcomes will be reported.

Trial registration

This trial (ACTRN12614000234617) was registered with ANZCTR on 05 April 2014.

Risk factors of sensorineural hearing loss in patients with unilateral safe chronic suppurative otitis media

PURPOSE

Chronic suppurative otitis media (CSOM) is the major cause of hearing impairment, especially conductive hearing loss. Few patients also had sensorineural component, the sensorineural hearing loss (SNHL) in CSOM is controversial, especially for safe mucosal type. This study aims to assess the relationship between the frequency of SNHL development in patients with safe mucosal CSOM and its relation to patient's age, sex, duration of disease, size of perforation and different audiological findings.

MATERIAL AND METHODS

This is a prospective study conducted from June 2016 to June 2017 in a tertiary referral hospital. 200 patients with unilateral mucosal type of CSOM with normal contralateral ear were included in the study. The diseased ears were taken as study ears and normal ears as control ears in all patients. Detailed otologic history, clinical and audiometric findings were recorded and analyzed. Results were statistically compared in all patients for both study and control ears using different parameters.

RESULTS

Twenty patients had an average bone conduction threshold of all frequencies above 25dB, which implies SNHL (10%). The incidence of SNHL was statistically significant at higher speech frequencies. The incidence increased with the presence of Diabetes Mellitus, smoking, duration of disease, presence of active discharge and the increase in size of perforation. However, it is not age dependent and there was no difference between males and females.

CONCLUSION

Safe mucosal CSOM can cause SNHL with multiple predisposing factors.

Tympanostomy tubes and otic suspensions: Do they reach the middle ear space?

The treatment of patients with tympanostomy tubes (TTs) and otorrhea with medicated otic suspensions is well known, but confirmation of penetration into the middle ear is difficult. To address this question, we created an in vitro model of the human head and ear and then tested it with 5 different types of liquid exposure: tap water, soapy water, polymyxin B sulfate (Cortisporin), tobramycin and dexamethasone (TobraDex), and ciprofloxacin (Cipro) suspensions. A positive test result corresponded to liquids entering the middle ear through the TT. No positive test result was elicited with tap water (0/20), but soapy water did enter the middle ear (10/40) and was statistically significant ( P = 0.0112). Without the use of slight tragal pressure, Cortisporin, TobraDex, and Cipro drops did not consistently pass through the TT (0/20, 1/25, 1/25). By placing the drops with the addition of tragal pressure, a statistically significant difference was obtained for each solution (20/20, 20/20, and 20/20, respectively [ P < 0.0001]). We conclude that with a clean external auditory canal, patent TT, and no middle ear fluid, medicated otic suspensions enter the middle ear only when combined with slight tragal pressure.

Predictors of disease complications and treatment outcome among patients with chronic suppurative otitis media attending a tertiary hospital, Mwanza Tanzania

Background

Chronic suppurative otitis media (CSOM) is a major health problem in developing countries causing hearing loss and life threatening complications. Early and effective treatment based on the knowledge of causative micro-organisms and predictors of outcome are crucial in preventing these associated complications. This study was conducted to determine the predictors of CSOM complications, treatment outcome and antimicrobial susceptibility of pathogens, thus providing essential evidence to formulate a policy for management of CSOM.

Methods

This was a prospective hospital based cross sectional study involving 301 patients attending Ear Nose and Throat (ENT) clinics at Bugando Medical Centre (BMC) between October 2013 and March 2014. A standardized data collection tool was used to collect demographics and clinical characteristics of patients with CSOM. Ear swabs were collected using sterile cotton swabs and transported to the laboratory for culture and antibiotic susceptibility testing.

Results

Out of 301 patients with CSOM; 187 (62.1 %) had positive aerobic culture within 48 h of incubation. Disease complications and poor treatment outcome were observed in 114 (37.8 %, 95 % CI; 32.2–43.3) and 46 (15.3 %, 95 % CI; 11.2–19.3) respectively. On multivariate logistic regression analysis factors found independently to predict both disease complications and poor treatment outcome were otalgia, being infected by multi drug resistant bacteria and being HIV positive. Prolonged illness duration before seeking medical attention was also found to be associated with disease complications (OR 1.029, 95 % CI 1.007–1.05, p = 0.01). A total of 116 (61 %) of gram negative bacteria were isolated. Of 34 Staphylococcus aureus, 14 (41 %) were found to be methicillin resistant Staphylococcus aureus (MRSA) while of 116 g negative enteric bacteria, 49 (42 %) were extended spectrum beta lactamases producers (ESBL).

Conclusions

Findings of this study suggest that positive HIV status, infection due to multidrug resistant pathogens and otalgia are significantly associated with disease complications and poor treatment outcome. Of great importance this study confirms that prolonged illness duration without seeking medical attention significantly predicts disease complications. Urgent preventive measures and laboratory guided early treatment are necessary to reduce complications associated with CSOM.

Olfactory function in Australian aboriginal children and chronic otitis media

Chronic suppurative otitis media (CSOM), a severe form of middle ear infection, affects most Australian Aboriginal children with up to 50% in some communities suffering hearing loss as a consequence. To date, there is no information on whether repeated exposure to the pathogens that characterize CSOM and that are present in the upper respiratory airway affect olfactory function. Accordingly, this study aimed to determine whether 1) there was a high prevalence of olfactory loss in Aboriginal children and 2) hearing loss is a predictor of olfactory loss. Two hundred and sixty one 9- to 12-year-old Aboriginal children from 16 rural communities reported to have high prevalences of CSOM and hearing loss were assessed for olfactory loss using a 16-odor identification test and hearing loss. One child was found to be anosmic, 4 were slightly hyposmic, and 42 had hearing loss. No relationship was found between olfactory loss and hearing loss. The test-retest reliability of the 16-odor identification test was 0.98. It was concluded that CSOM does not appear to affect olfactory function in the long term and that hearing loss in Aboriginal children is not a predictor of olfactory loss.

Morphological sequence of Plastipore extrusion in experimental otitis media

OBJECTIVES

Plastipore prostheses are still used by many surgeons, although the functional results are controversial. The aim of this study was the morphological analysis of Plastipore material performance in the middle ear of rats, with special attention to extrusion.

METHODS

Twenty-four Wistar rats were given implants made of commercially available Plastipore and assigned to 3 groups: group A, with implantation in a healthy middle ear; group B, with implantation and cauterization of the nasopharyngeal orifice of the eustachian tube (hypoventilation); and group C, with implantation, cauterization of the eustachian tube, and bacterial inoculation with Pseudomonas aeruginosa.

RESULTS

The pathological study showed in nearly all cases the disintegration of the biomaterial. Adhesion between the biomaterial and bone could be seen in 1 rat from group C (hypoventilation and infection). In group C, the Plastipore was in contact with the tympanic membrane in 1 case and was extruding in 2 animals. Different phases of extrusion were defined. No extrusion was observed in the other groups.

CONCLUSIONS

The sequential stages of Plastipore extrusion are demonstrated. Infection seems to be the most important factor in Plastipore extrusion in our model.

Tissular changes induced by Pseudomonas aeruginosa in an otitis media rat model with tubal obstruction

CONCLUSIONS

This is a suitable model for the study of different features of middle ear inflammation. This model allows manipulations inside the middle ear while preserving relevant structures such as the tympanic membrane, and provides a useful model for the study of interactions between bacterial infection and eustachian tube dysfunction.

OBJECTIVES

Analysis of early and late histological features in an experimental model of Pseudomonas aeruginosa middle ear inoculation in the rat designed for the study of middle ear procedures.

MATERIALS AND METHODS

Thirty Wistar rats were inoculated with Pseudomonas aeruginosa in the tympanic bulla followed by the cauterization of the eustachian tube. Culturing of middle ear effusion was carried out at 7 days follow-up and at sacrifice. Processing of the temporal bones for light microscopy was performed at 7, 14, 30 and 60 days.

RESULTS

Early cultures were positive in most cases, thus proving that middle ear inflammation was due to the presence of inoculated Pseudomona aeruginosa. Mucoperiosteal inflammatory changes similar to those observed in human middle ear infection were seen. Acute inflammatory cell infiltration was seen at 7 and 14 days, gradually decreasing to chronic inflammatory changes with fibroplasia at 60 days. Bone resorption was observed at 7 and 14 days, changing to a bony deposition at 30 and 60 days.

Role of glucocorticoids in ototopical antibiotic-steroid preparations in the treatment of chronic suppurative otitis media

BACKGROUND

It is conventional to use antibiotic-steroid combination eardrops, although the advantage of steroid combination has not been substantiated. The present prospective randomized comparative study is designed to assess the role of glucocorticoids in ototopical antibiotic-steroid preparations in the treatment of chronic suppurative otitis media (CSOM).

METHODS

Pre-treatment clinical assessment, bacteriology of the middle ear discharge and pure tone audiogram were done. CSOM with organisms sensitive to gentamicin were treated either with plain gentamycin (GM) or gentamycin steroid combination (GM-S) eardrops for a period of 3 weeks. Post-treatment clinical, bacteriological and audiogram response was recorded 1 week after discontinuing the eardrops. The post-treatment clinical improvement, bacteriologic improvement and changes in hearing threshold at speech frequencies were analyzed by using unpaired Student's t test and chi(2) tests.

RESULTS

The most common organism associated with CSOM was Pseudomonas aeruginosa (33.92%). Clinical improvement was seen in 87.7 and 86.5% cases but bacteriological improvement in only 82.5 and 75% of cases treated with GM and GM-S (p >0.05), respectively. On comparing the pre- and post-treatment pure tone audiograms in 95 patients, 28.9% treated with GM and 30% with GM-S showed deterioration in bone conduction threshold above 5 dB (p >0.05) at speech frequencies. The mean increase in bone conduction in the two groups was 7.7 and 8.57 dB (p >0.05), respectively.

CONCLUSIONS

Our results indicate that there is no difference in the clinical and bacteriological improvement or ototoxicity either with topical GM or GM-S. Hence, we conclude that it is unnecessary to combine steroids with topical antibiotic preparations for the management of CSOM.

Tympanostomy tubes and otic suspensions: do they reach the middle ear space?

The treatment of patients with tympanostomy tubes (TTs) and otorrhea with medicated otic suspensions is well known, but confirmation of penetration into the middle ear is difficult. To address this question, we created an in vitro model of the human head and ear and then tested it with 5 different types of liquid exposure: tap water, soapy water, polymyxin B sulfate (Cortisporin), tobramycin and dexamethasone (TobraDex), and ciprofloxacin (Cipro) suspensions. A positive test result corresponded to liquids entering the middle ear through the TT. No positive test result was elicited with tap water (0/20), but soapy water did enter the middle ear (10/40) and was statistically significant (P = 0.0112). Without the use of slight tragal pressure, Cortisporin, TobraDex, and Cipro drops did not consistently pass through the TT (0/20, 1/25, 1/25). By placing the drops with the addition of tragal pressure, a statistically significant difference was obtained for each solution (20/20, 20/20, and 20/20, respectively [P < 0.0001]). We conclude that with a clean external auditory canal, patent TT, and no middle ear fluid, medicated otic suspensions enter the middle ear only when combined with slight tragal pressure.

Mastoidectomy in Noncholesteatomatous Chronic Suppurative Otitis Media: Is it Necessary?

Chronic suppurative otitis media (CSOM) without cholesteatoma, the surgical treatment of which is still controversial, is a common diagnosis in otologic practice. A retrospective analysis of 323 patients who underwent surgery for noncholesteatomatous chronic otitis media in the Gruppo Otologica, Piacenza, Italy, between April 1983 and December 1993 is presented. Cases were separated Into three groups according to different surgical treatment modalities and conditions of the ears at the time of operation. Group I ( n = 53) consisted of cases of CSOM treated by tympanoplasty without mastoidectomy (TLWOM). Group II ( n = 28) included cases of CSOM treated by tympanoplasty with mastoidectomy (TLWM). Intact canal wall technique was used in these cases. The ears in both these groups were discharging severely at the time of surgery. Group III ( n = 242) included patients whose ears were dry at the time of surgery but who had had previous recurrent episodes of suppuration and who were treated by TLWOM. At the last follow-up, graft success rates for groups I, II, and III were 90.5%, 85.7%, and 89.2%, respectively, and mean residual gaps were 17.2 dB, 20.1 dB, and 19.4 dB, respectively. There was no statistically significant difference between the three groups either on graft success rates ( p > 0.05) or on final functional hearing outcome ( p > 0.05). TLWM is the preferable treatment modality for most surgeons in noncholesteatomatous CSOM. Nevertheless, in our experience TLWOM yields comparable results for this group of patients. In addition, we could not find any significant difference in results of graft success and final functional hearing rates between dry and discharging ears ( p > 0.05).