Modern management of otitis media

Balloon Eustachian Tuboplasty Combined or Not with Myringotomy in Eustachian Tube Dysfunction

BACKGROUND

Eustachian tube dysfunction (ETD) is a common disorder causing ear pressure, pain, and hearing loss. Balloon Eustachian tuboplasty (BET) is an emerging technique for dilating the Eustachian tube and treating ETD. Whether adding myringotomy improves BET efficacy is controversial.

METHODS

This retrospective study included 95 ETD patients undergoing BET alone (n = 44) or BET with myringotomy (BET + M; n = 51) between June 2020 and August 2021 at a single medical center. The primary outcome was the change in ETDQ-7 symptom scores from baseline to 6 months after treatment. Secondary outcomes included audiometry, endoscopy, Valsalva maneuver, and complications.

RESULTS

The ETDQ-7 scores improved significantly after treatment in both groups (p < 0.001), without significant between-group differences (p = 0.417). No significant differences occurred in the audiometry, endoscopy, and Valsalva results or in most complications between groups. One BET + M patient had a persistent tympanic membrane perforation.

CONCLUSIONS

Both BET alone and BET + M effectively and safely improved the subjective and objective ETD outcomes. However, adding myringotomy did not further improve the outcomes over BET alone, while it incurred risks such as persistent perforation. BET alone may sufficiently treat ETD without requiring myringotomy in this cohort. Further randomized controlled trials should identify optimal candidates for BET alone versus combined approaches.

Effectiveness of Surgical Approach of Insertion Ventilation Tubes (Tympanostomy) and Adenoidectomy in Comparison with Non-Surgical Approach (Watchful Waiting Approach) in Children at the Age between 1 and 6 and Who Suffer from Otitis Media with Effusion (OME) in 12-Month Period of Observation-The Retrospective Analysis

(1) Background: Otitis media with effusion (OME) is one of the most common diseases in childhood. The objective was to assess clinically the effectiveness of the surgical approach (tube insertion with adenoidectomy) in comparison with the non-surgical approach (watchful waiting) during a 12-month observation period. (2) Methods: This study was retrospective and obtained approval from the bioethics committee. The criteria of inclusion in the first group (surgical approach) were: (1) a diagnosis of chronic otitis media with effusion in children aged between 1 and 6 years; (2) their medical history showed that they had undergone adenoidectomy and tympanostomy with the insertion of ventilation tubes (VTs). The criteria for inclusion in the second group (non-surgery) were similar to the first group except that their medical history showed they had not undergone adenoidectomy or tympanostomy with the insertion of VTs. There were 422 children included in the surgical group and 50 children in the non-surgical group, and the period of observation was 12 months. (3) Results: For the entire surgical group, the number of healthy days ranged from 20 to 365, with a mean of 328.0 days (SD = 91.4).In the non-surgical group, the number of healthy days ranged from 13 to 365, with a mean of 169.2 days (SD = 127.3). The difference in the number of healthy days was statistically significant (p < 0.001). The certainty of treatment in the first group was higher than in the second group, and the number of days without recurrence was significantly higher than in the second group. In the first group, there were 71 recurrences from 422 children (16.8%), and, in the second subgroup, there were 40 recurrences of acute otitis media (AOM) from 50 children (80%). The RR was 0.21. (4) Conclusions: The surgical approach in children aged 1-6 years who have been diagnosed with otitis media with effusion is reasonable and beneficial for the child.

Antibiotic modulation of mucins in otitis media; should this change our approach to watchful waiting?

BACKGROUND

Gel-forming mucins (GFMs) play important roles in otitis media (OM) pathogenesis. Increased mucin expression is activated by pathogens and proinflammatory cytokines. Bacterial biofilms influence inflammation and resolution of OM and may contribute to prolonged mucin production. The influence of specific pathogens on mucin expression and development of chronic OM with effusion (OME) remains an area of significant knowledge deficit.

OBJECTIVES

To assess the relationship between GFM expression, specific pathogens, middle ear mucosal (MEM) changes, biofilm formation, and antibiotic utilization.

METHODS

Mixed gender chinchillas were inoculated with nontypeable Haemophilus influenzae (NTHi) strain 86028NP or Streptococcus pneumoniae (SP) strain TIGR4 via transbulla injection. Antibiotic was administered on day 3-5 post inoculation. GFM expression was measured by quantitative PCR. Biofilm formation was identified and middle ear histologic changes were measured.

RESULTS

SP infection resulted in higher incidence of biofilm and ME effusion compared with NTHi infection. However, NTHi persisted in the ME longer than SP with no substantive bacterial clearance detected on day 10 compared with complete bacterial clearance on day 10 for 50-60% of the SP-infected chinchillas. Both infections increased MEM inflammatory cell infiltration and thickening. NTHi upregulated the Muc5AC, Muc5B and Muc19 expression on day 10 (p = 0.0004, 0.003, and 0.002 respectively). SP-induced GFM upregulations were trended toward significant. In both NTHi and SP infections, the degree of GFM upregulation had a direct relationship to increased MEM hypertrophy, inflammatory cell infiltration and biofilm formation. Antibiotic treatment reduced the incidence of ME effusion and biofilm, limited the MEM changes and reversed the GFM upregulation. In NTHi infection, the rate of returning to baseline level of GFMs in treated chinchillas was quicker than those without treatment.

CONCLUSIONS

In an animal model of OM, GFM genes are upregulated in conjunction with MEM hypertrophy and biofilm formation. This upregulation is less robust and more quickly ameliorated to a significant degree in the NTHi infection with appropriate antibiotic therapy. These findings contribute to the understanding of pathogen specific influences on mucin expression during OM pathogenesis and provide new data which may have implications in clinical approach for OM treatment.

Comparison of the serological responses to Moraxella catarrhalis immunoglobulin D-binding outer membrane protein and the ubiquitous surface proteins A1 and A2

Moraxella catarrhalis immunoglobulin D-binding protein (MID) is a complex antigen with unique immunoglobulin D (IgD)-binding, adhesion, and hemagglutination properties. Previous studies have shown that antibodies raised against MID764-913 in rabbits inhibited M. catarrhalis adhesion to human alveolar epithelial cells, and immunization with MID764-913 resulted in an increased pulmonary clearance in a murine model. Strong immune responses against MID have also consistently been shown in humans. Here, the MID-specified IgG responses were compared to those of ubiquitous surface proteins A1 and A2 (UspA1/A2) using a series of recombinant fragments that spanned all three proteins. Sera were obtained from young children, aged 6 months to 1 year (n=8) and 2 to 3 years (n=15), and healthy adults (n=16). Acute- and convalescent-phase sera from chronic obstructive pulmonary disease (COPD) patients with M. catarrhalis infective exacerbations (n=23) were also analyzed. Young children, who are at risk of M. catarrhalis infection, had low levels of anti-MID and anti-UspA1/A2 antibodies. Healthy adults and the majority of COPD patients (16/23) had high levels of antibodies directed against, among others, the adhesive domain of MID and the fibronectin- and C3-binding domains of UspA1/A2. Among eight COPD patients in whom a rise in antibody levels could be detected, these functional domains were also the main regions targeted by the antibodies. In addition, human IgG directed against MID was bactericidal and anti-MID antibodies were additive to antibodies targeting UspA1/A2. Hence, the functional domains in these three antigens may have significant potential in a future vaccine against M. catarrhalis.

Could one of the most widely prescribed antibiotics amoxicillin/clavulanate "augmentin" be a risk factor for autism?

Autism is an ever increasing problem in the United States. Characterized by multiple deficits in the areas of communication, development, and behavior; autistic children are found in every community in this country and abroad. Recent findings point to a significant increase in autism which can not be accounted for by means such as misclassification. The state of California recently reported a 273% increase in the number of cases between 1987 and 1998. Many possible causes have been proposed which range from genetics to environment, with a combination of the two most likely. Since the introduction of clavulanate/amoxicillin in the 1980s there has been the increase in numbers of cases of autism. In this study 206 children under the age of three years with autism were screened by means of a detailed case history. A significant commonality was discerned and that being the level of chronic otitis media. These children were found to have a mean number 9.96 bouts of otitis media (with a standard error of the mean of +/-1.83). This represents a sum total for all 206 children of 2052 bouts of otitis media. These children received a mean number of 12.04 courses of antibiotics (standard error of the mean of +/-.125). The sum total number of courses of antibiotics given to all 206 children was 2480. Of those 893 courses were Augmentin. with 362 of these Augmentin courses administered under the age of one year. A proposed mechanism whereby the production of clavulanate may yield high levels of urea/ammonia in the child is presented. Further an examination of this mechanism needs to be undertaken to determine if a subset of children are at risk for neurotoxicity from the use of clavulanic acid in pharmaceutical preparations.

Types and causes of otorrhea

INTRODUCTION

Otorrhea is a common symptom and sign of patients seeking examination in an ENT Department of a General Hospital. The objective of this review is to assess the cause of otorrhea according to the type of it.

METHODS

Retrospective review of 306 ears discharging some kind of fluid of 296 patients, who appeared in the ENT Department of our Hospital over a 58-month period.

RESULTS

The most common type of otorrhea was the purulent one: 276 ears among 306 discharging ears (90%). The most common cause of purulent otorrhea was otitis externa: 156 ears among 276 ears discharging purulent fluid (56%). The germ most commonly isolated in the cultures of purulent aural discharge was Pseudomonas aeruginosa: 67 isolations of P. aeruginosa among 256 cultures (26%).

CONCLUSIONS

Otomicroscopic examination and accurate culture of purulent discharge are mandatory for the clinician to establish a correct diagnosis and suggest a proper therapy in every case of otorrhea.

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.

Optimizing the diagnosis of gastroesophageal reflux in children with otolaryngologic symptoms

OBJECTIVES

Although many children with otolaryngologic (ENT) symptoms are being treated for gastroesophageal reflux (GER), how to diagnose GER in children with primarily or exclusively ENT symptoms has yet to be determined. This study compares the incidences of pathologic GER in the upper verses the lower esophagus in a cohort of children with ENT symptoms that were screened for GER.

METHODS

The results of extended dual channel intraesophageal pH probe monitoring obtained from 14 infants and 14 children with ENT symptoms were retrospectively analyzed. The percent of total monitoring time that the pH was less than 4, reflux index (RI) was determined. The upper limits of normal distal and proximal esophageal RI were based on published data. To evaluate our results, upper esophageal reflux (UER) was also determined in 27 infants and children without ENT or pulmonary symptoms, who had normal lower esophageal reflux (LER) values.

RESULTS

Mean upper esophageal RIs in the infants and children with normal LER were similar to previously published values for control infants and adults. Four (29%) of the ENT infants, 11 (79%) of the older ENT children, and 54% of the entire cohort had increased esophageal acid exposure. However, nine (60%) of the 15 pediatric ENT patients with GER had pH abnormalities limited to the upper esophagus.

CONCLUSIONS

Standard distal pH probe monitoring alone gives a false negative result in a substantial proportion of the infants and children with ENT symptoms being evaluated for GER. Beyond its value in clinical practice, UER testing should be employed in research studies that evaluate the impact of GER therapy on ENT symptoms.

Modern management of acute otitis media

Although recent clinical trials suggest that conjugate vaccination will be less effective for the prevention of AOM than for IPD, these trials have demonstrated impressive reductions in the incidence of AOM due to invasive and antibiotic-resistant pneumococcal serotypes. These data suggest that if serotype replacement does occur in immunized children, the causative agents are likely to be less virulent than vaccine strains. Furthermore, a recent cost-effectiveness analysis projected that immunization of healthy infants with the heptavalent conjugate vaccine could prevent over one million episodes of AOM and 12,000 cases of invasive pneumococcal disease. Because significant reductions have been demonstrated in the incidence of frequently recurrent AOM, children with the worst disease stand to benefit most from vaccination. Based on data currently available, however, the conjugate vaccine is not going to eradicate AOM. Consequently, there will continue to be a need to scrutinize the threshold for prescribing antibiotics. In addition, there will be an ongoing need for surgery in some cases of recurrent AOM and persistent OME.

Bacterial otitis media: current vaccine development strategies

Otitis media is the most common reason for children less than 5 years of age to visit a medical practitioner. Whilst the disease rarely results in death, there is significant associated morbidity. The most common complication is loss of hearing at a critical stage of the development of speech, language and cognitive abilities in children. The cause and pathogenesis of otitis media is multifactorial. Among the contributing factors, the single most important are viral and bacterial infections. Infection with respiratory syncytial virus, influenza viruses, para-influenza viruses, enteroviruses and adenovirus are most commonly associated with acute and chronic otitis media. Streptococcus pneumoniae, non-typeable Haemophilus influenzae and Moraxella catarrhalis are the most commonly isolated bacteria from the middle ears of children with otitis media. Treatment of otitis media has largely relied on the administration of antimicrobials and surgical intervention. However, attention has recently focused on the development of a vaccine. For a vaccine to be effective against bacterial otitis media, it must, at the very least, contain antigens that induce a protective immune response in the middle ear against the three most common infecting bacteria. Whilst over the past decade there has been significant progress in the development of vaccines against invasive S. pneumoniae disease, these vaccines are less efficacious for otitis media. The search for candidate vaccine antigens for non-typeable H. influenzae are well advanced whilst less progress has been made for M. catarrhalis. No human studies have been conducted for non-typeable H. influenzae or M. catarrhalis and the concept of a tribacterial vaccine remains to be tested in animal models. Only when vaccine antigens are determined and an understanding of the immune responses induced in the middle ear by infection and immunization is gained will the formulation of a tribacterial vaccine against otitis media be possible.

Management of chronic otitis media with effusion: the role of glutathione

BACKGROUND

The inflammatory cells documented in chronic otitis media with effusion (OME) spontaneously release oxidants which can induce middle ear (ME) epithelial cell damage. Glutathione (GSH), a major extracellular antioxidant in humans, plays a central role in antioxidant defense.

PURPOSE

To evaluate the effects of GSH treatment on chronic otitis media with effusion (OME).

SUBJECTS AND INTERVENTION

Sixty children with chronic OME were enrolled, 30 of whom were randomly assigned to the treatment group and 30 to the placebo group. Patients in the treatment group received 600 mg glutathione in 4 mL saline per day subdivided into five 2-minute administrations given by nasal aerosol every 3 or 4 waking hours for 2 weeks. Patients in the control group received 4 mL saline per day following the same procedure as for GSH treatment.

RESULTS

Three months after therapy improvement had occurred in 66.6% of patients in the GSH-treated group and in 8% of the control subjects (P <.01).

CONCLUSION

On the basis of these results, GSH treatment could be considered for the nonsurgical management of chronic OME.

The role of adjuvant adenoidectomy and tonsillectomy in the outcome of the insertion of tympanostomy tubes

BACKGROUND

Otitis media is the most common medical problem in young children. The usual surgical treatment is myringotomy with insertion of tympanostomy tubes. There is debate about the usefulness of concomitant adenoidectomy or adenotonsillectomy. We examined the effects of these adjuvant procedures on the rates of reinsertion of tympanostomy tubes and rehospitalization for conditions related to otitis media.

METHODS

Using hospital discharge records for the period 1995 through 1997, we examined the results of surgery for all 37,316 children (defined as persons 19 years of age or younger) in Ontario, Canada, who received tympanostomy tubes as their first surgical treatment for otitis media. We determined the time to the first readmission for conditions related to otitis media and the time to the first reinsertion of tympanostomy tubes.

RESULTS

As compared with treatment involving the insertion of tympanostomy tubes alone, adjuvant adenoidectomy was associated with a reduction in the likelihood of reinsertion of tympanostomy tubes (relative risk, 0.5; 95 percent confidence interval, 0.5 to 0.6; P<0.001) and the likelihood of readmission for conditions related to otitis media (relative risk, 0.5; 95 percent confidence interval, 0.5 to 0.6; P<0.001). The risk of these outcomes was further reduced if an adjuvant adenotonsillectomy was performed. The effect was age-related. Children as young as one year appeared to benefit from adjuvant adenotonsillectomy; the benefit of an adjuvant adenoidectomy was apparent in two-year-olds and was greatest for children three years of age or older.

CONCLUSIONS

Performing an adenoidectomy at the time of the initial insertion of tympanostomy tubes substantially reduces the likelihood of additional hospitalizations and operations related to otitis media among children two years of age or older.

Pneumococcal acute otitis media in children

OBJECTIVES

To evaluate the clinical and laboratory findings of Streptococcus pneumoniae acute otitis media in children during a 1 year period.

METHODS

From October 1995 to September 1996, 113 children aged 2 months to 14 years (median 18 months), with S. pneumoniae acute otitis media were studied. Susceptibility testing was performed by the Kirby-Bauer method and the E-test, and serotyping by the Quellung reaction.

RESULTS

E-test assays detected five isolates (4.4%) to be highly resistant to penicillin and 13 (11.5%) that had intermediate resistance. All isolates were found to be susceptible to vancomycin, rifampicin and cefotaxime. In total, 25 isolates (22.1%) were resistant to one or more drugs. Fifty per cent of the penicillin-resistant or intermediately resistant S. pneumoniae isolates were resistant to multiple drugs, whereas only 2.1% of the penicillin-susceptible isolates were resistant to multiple drugs. The predominating serogroups of the isolates with reduced susceptibility to penicillin were the 19 (61.1%), 9 (16.7%), 23 (11.1%), 6 (5.5%) and 14 (5.5%) whereas those of the susceptible isolates were the 19 (26.3%), 14 (13.7%), 3 (11.6%), 6 (11.6%), 9 (8.4%), 1 (5.3%) and 12 (5.3%).

CONCLUSIONS

Streptococcus pneumoniae isolates from children with acute otitis media were penicillin-insensitive in 15.9%. The multiresistant S. pneumoniae isolates belonged to serogroups: 19 (45.4%), 9 (27.3%), 6 (18.2%) and 23 (9.1%).

Use of an isogenic mutant constructed in Moraxella catarrhalis To identify a protective epitope of outer membrane protein B1 defined by monoclonal antibody 11C6

Moraxella catarrhalis-induced otitis media continues to be a significant cause of infection in young children, prompting increased efforts at identifying effective vaccine antigens. We have previously demonstrated that M. catarrhalis expresses specific outer membrane proteins (OMPs) in response to iron limitation and that this organism can utilize transferrin and lactoferrin for in vitro growth. One of these proteins, which binds human transferrin, is OMP B1. As the human host presents a naturally iron-limited environment, proteins, like OMP B1, which are expressed in response to this nutritional stress are potential vaccine antigens. In this study, we have developed monoclonal antibody (MAb) 11C6, which reacts to a surface-exposed epitope of OMP B1 expressed by M. catarrhalis 7169. This antibody was used to clone ompB1, and sequence analysis suggested that OMP B1 is the M. catarrhalis homologue to the transferrin binding protein B described for pathogenic Neisseriaceae, Haemophilus influenzae, Actinobacillus pleuropneumoniae, and M. catarrhalis. Expression of recombinant OMP B1 on the surface of Escherichia coli confers transferrin binding activity, confirming that this protein is likely involved in iron acquisition. In addition, ompB1 was used to construct an isogenic mutant in M. catarrhalis 7169. This mutant, termed 7169b12, was used as the control in bactericidal assays designed to determine if OMP B1 elicits protective antibodies. In the presence of MAb 11C6 and human complement, wild-type 7169 demonstrated a 99% decline in viability, whereas the ompB1 isogenic mutant was resistant to this bactericidal activity. Further analysis with MAb 11C6 revealed the presence of this OMP B1 epitope on 31% of the clinical isolates tested. These data suggest that OMP B1 is a potential vaccine antigen against M. catarrhalis infections.

Otitis media in children with vertically-acquired HIV infection: the Great Ormond Street Hospital experience

Human immunodeficiency virus (HIV) infection continues to be a vexing problem in the pediatric population. Otitis media, a common entity in immunocompetent as well as immunocompromised children, is prevalent in pediatric patients with HIV infection. Recurrent infections and complications secondary to otitis media are also common in this population. The purpose of this review was to evaluate the records of a large group of children with HIV infection undergoing treatment for otitis media at a tertiary care center. Incidence of infections, severity of infections, and pathogens responsible were the key points of data collection in relation to each patient's HIV clinical and immunologic classification. We reviewed 72 patients with vertically-acquired HIV infection undergoing treatment at the Hospital for Sick Children, Great Ormond Street, London. All patients were born to HIV infected mothers of sub-Saharan African origin. A total of 32 (44.4%) of these children presented to our institution with one or more episodes of otitis media, six of whom suffered systemic complications secondary to middle ear pathology. Middle ear culture data, when available from actively draining ears, was similar to those of immunocompetent children in the general population. The most common complications were systemic bacteremia and recalcitrant infections requiring intravenous antibiotic therapy. Severity of immunosuppression was associated with higher incidence and severity of otitis media. Otitis media in an HIV infected child must be treated aggressively at its outset in an attempt to minimize possible complications. Administration of prophylactic antibiotics to these children may reduce the frequency of acute and chronic infections. Improvement in immunologic status using antiretrovirals or protease inhibitors is a primary goal in diminishing the severity of otitis media as well as other infections in these children.

The transferrin binding protein B of Moraxella catarrhalis elicits bactericidal antibodies and is a potential vaccine antigen

The transferrin binding protein genes (tbpA and tbpB) from two strains of Moraxella catarrhalis have been cloned and sequenced. The genomic organization of the M. catarrhalis transferrin binding protein genes is unique among known bacteria in that tbpA precedes tbpB and there is a third gene located between them. The deduced sequences of the M. catarrhalis TbpA proteins from two strains were 98% identical, while those of the TbpB proteins from the same strains were 63% identical and 70% similar. The third gene, tentatively called orf3, encodes a protein of approximately 58 kDa that is 98% identical between the two strains. The tbpB genes from four additional strains of M. catarrhalis were cloned and sequenced, and two potential families of TbpB proteins were identified based on sequence similarities. Recombinant TbpA (rTbpA), rTbpB, and rORF3 proteins were expressed in Escherichia coli and purified. rTbpB was shown to retain its ability to bind human transferrin after transfer to a membrane, but neither rTbpA nor rORF3 did. Monospecific anti-rTbpA and anti-rTbpB antibodies were generated and used for immunoblot analysis, which demonstrated that epitopes of M. catarrhalis TbpA and TbpB were antigenically conserved and that there was constitutive expression of the tbp genes. In the absence of an appropriate animal model, anti-rTbpA and anti-rTbpB antibodies were tested for their bactericidal activities. The anti-rTbpA antiserum was not bactericidal, but anti-rTbpB antisera were found to kill heterologous strains within the same family. Thus, if bactericidal ability is clinically relevant, a vaccine comprising multiple rTbpB antigens may protect against M. catarrhalis disease.

Cloning and expression of the Moraxella catarrhalis lactoferrin receptor genes

The lactoferrin receptor genes from two strains of Moraxella catarrhalis have been cloned and sequenced. The lfr genes are arranged as lbpB followed by lbpA, a gene arrangement found in lactoferrin and transferrin receptor operons from several bacterial species. In addition, a third open reading frame, orf3, is located one nucleotide downstream of lbpA. The deduced lactoferrin binding protein A (LbpA) sequences from the two strains were found to be 99% identical, the LbpB sequences were 92% identical, and the ORF3 proteins were 98% identical. The lbpB gene was PCR amplified and sequenced from a third strain of M. catarrhalis, and the encoded protein was found to be 77% identical and 84% similar to the other LbpB proteins. Recombinant LbpA and LbpB proteins were expressed from Escherichia coli, and antisera raised to the purified proteins were used to assess antigenic conservation in a panel of M. catarrhalis strains. The recombinant proteins were tested for the ability to bind human lactoferrin following gel electrophoresis and electroblotting, and rLbpB, but not rLbpA, was found to bind lactoferrin. Bactericidal antibody activity was measured, and while the anti-rLbpA antiserum was not bactericidal, the anti-rLbpB antisera were found to be weakly bactericidal. Thus, LbpB may have potential as a vaccine candidate.

Clinical perspectives on sinusitis and otitis media

As the leading cause of physician office visits and loss of time from school as well as the cause of significant morbidity among young children, respiratory infections impose a major burden on the health care system. The most common causative pathogens are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. In young children acute otitis media and sinusitis may present with relatively nonspecific symptoms such as irritability. Older children may complain of more specific problems; for example those with otitis media may complain of otalgia. Upper respiratory tract infections are typically diagnosed by signs and symptoms and treated empirically with an antimicrobial agent that offers coverage of the usual causative respiratory pathogens.

Practical considerations when treating children with antimicrobials in the outpatient setting

Over the past decade new antimicrobial agents have been introduced used to treat common paediatric infectious diseases such as acute otitis media and sinusitis. These agents vary with respect to their mechanism of action, dosage and duration of therapy, cost, taste and type of adverse effects. More recently, there has been concern about the overuse of antibiotics and increasing bacterial resistance, particularly Streptococcus pneumoniae, to these agents. Dosage and duration of therapy, cost, taste, and adverse effects play important roles in determining success or failure of antimicrobial medications in paediatric patients. Use of potential alternatives and adjuncts to antimicrobial treatment, such as vaccination, control of environmental risk factors, surgical techniques and alternative medical therapies may also be employed, and the practitioner must ascertain if their paediatric patients are being treated by any of these methods. Rather than listing the therapeutic challenges for all common outpatient paediatric infectious diseases, acute otitis media (accounting for over 50% of the antimicrobial prescriptions dispensed in childhood) is used to illustrate each issue. Clinicians are faced with a growing number of possible antimicrobial choices; concomitantly, there is increasing concern that these agents are overused. When prescribing antimicrobial agents, we need to be familiar with what we can do to optimise the care we provide. By avoiding inappropriate or trivial use of antimicrobials, we can preserve and even strengthen our armamentarium against disease. Simple strategies can improve compliance with therapeutic regimens and improve parental satisfaction.

Intranasal beclomethasone as an adjunct to treatment of chronic middle ear effusion

BACKGROUND

Following otitis media, 10% to 50% of children develop residual middle ear effusion with concurrent hearing loss and potential cognitive, behavioral, and language impairment. Prophylactic antibiotics and tympanostomy tubes are currently recommended treatments for chronic middle ear effusion.

OBJECTIVE

In a double-blind, placebo-controlled, randomized study of chronic middle ear effusion, we assessed the effectiveness of topical intranasal beclomethasone as an adjunct to prophylactic antibiotic therapy.

METHODS

Sixty-one children, aged 3 to 11 years with persistent middle ear effusion greater than 3 months, were randomized into three treatment groups: (1) prophylactic antibiotics; (2) prophylactic antibiotics plus intranasal beclomethasone (336 micrograms/day); and (3) prophylactic antibiotics plus intranasal placebo. Patients were evaluated with aeroallergen skin tests at entry; and tympanogram, otoscopic examination, and symptom questionnaire at 0, 4, 8, and 12 weeks.

RESULTS

While middle ear pressures, otoscopic examinations, and symptom scores were improved for each treatment group over 12 weeks of therapy, the beclomethasone plus antibiotics group improved all three measures more rapidly than the antibiotics-alone and placebo nasal spray plus antibiotics groups over the first 8 weeks. Only the beclomethasone group significantly improved left (P = .004) and right (P = .01) middle ear pressures over 12 weeks. Resolution of chronic middle ear effusions was more frequent in the beclomethasone group (P < or = .05 at 4 and 8 weeks). No difference in response to nasal steroids was observed between atopic and nonatopic subjects.

CONCLUSIONS

We conclude that intranasal beclomethasone may be a useful adjunct to prophylactic antibiotic treatment of chronic middle ear effusion.

[Bacteriological study in acute otitis media]

AIM

A prospective study on bacteriological epidemiology in acute otitis media was conducted in a pediatric hospital emergency service from January 1993 to October 1995.

PATIENTS

One hundred and fifty-eight children, aged 6 months to 6 years, with an acute otitis media were included. Culturing and cleansing of the ear canal and tympanocentesis for aspiration and culture of the secretions were performed in 118 children (46 of whom had received antibiotics before for 48 hours).

MAIN RESULTS

Middle ear aspirates were sterile in 35% of the children who had not received antibiotics and in 64% of those already treated. Bacteria in middle ear were predominantly Haemophilus influenzae and Streptococcus pneumoniae. Fifty-nine percent of S pneumoniae strains were penicillin-resistant; however, they were responsible for clinical failure in only 8% of cases. No Staphylococcus strains, commensal of the ear canal, could be considered as pathogenic for the middle ear.

CONCLUSION

The preciseness with which secretions of middle ear are aspirated reduces the risk of contamination and comparison of ear canal and middle ear cultures allows to identify them. The high ratio of sterile middle ear aspirates after antibiotic treatment raises the question if other factors are responsible for persistent symptoms. The existence of penicillin-resistant S pneumoniae must be known to adjust treatment.

Overall cost in the treatment of otitis media

BACKGROUND

Numerous antimicrobial agents are available for treatment of otitis media (OM); however, little is known about the relative cost effectiveness of these drugs.

METHODS

We developed a noninvasive, observational model to assess the total costs (direct and indirect) associated with commonly used antibiotics in the therapy of OM. We also gathered data on recurrence rates, which can significantly affect costs.

RESULTS

The average total cost of treating an episode of OM in this study was $115.80. Treatment of a recurrent OM episode was significantly more costly than treatment of an initial episode ($124.64 vs. $107.81, P = 0.0001). This study suggests that significant costs are associated with OM treatment and that antibiotic price constitutes only a small portion of this cost. Recurrence rates appeared to vary with various antibiotic treatments.

CONCLUSION

We conclude that recurrence is a major determinant of OM treatment costs. Drugs associated with lower rates of recurrence will usually be the most cost-effective treatment options.

Acute otitis media in children

Acute otitis media (AOM) is the most common reason parents bring children into the primary care physician's office. It is diagnosed by clinical symptoms of otalgia and often fever and irritability and by clinical otoscopy. Organisms common to the nasopharynx usually cause AOM. Many episodes of AOM resolve spontaneously. Because it is uncertain how many and which children will resolve without therapy, it is reasonable to treat all children with AOM with antibiotics. The first choice of antibiotics is amoxicillin. Other choices rest on a variety of factors.

A randomized, double-blind, multicentre controlled trial of ibuprofen versus acetaminophen and placebo for symptoms of acute otitis media in children

Two hundred and nineteen children (boys: 56%, girls: 44%) were included in a randomized, double-blind, multicentre (4 centres) controlled trial designed to assess the efficacy and safety of ibuprofen (IBU) in the treatment of 1 to 6 year-old children with otoscopically proven acute otitis media (AOM), either unilateral or bilateral. They randomly received 10 mg/kg IBU (n = 71), or acetaminophen (PARA) (n = 73) or placebo (PLA) (n = 75), orally, tid, for 48 hours. All received oral cefaclor (Alfatil, Lilly, France) for seven days. They were evaluated before (D0) and at the end of treatment (D2). The main criterion of response was the aspect (landmarks and color) of the tympanic membrane assessed on a semi-quantitative scale from 0 to 6. Other criteria, assessed on semi-quantitative scales, included relief of pain (0 or 1), rectal temperature (0 to 2), and overall evaluation by parents of the improvement of quality of life on three items: appetite (0 to 2), sleep (0 to 2), and playing activity (0 to 2). The results at D2 were as follows: there was no significant difference between treatment groups as to the main criterion, but only a trend for IBU and PARA to do better than PLA but not for IBU to do better than PARA. From these data there is no argument to emphasize the utility of non-steroidal anti-inflammatory drugs (NSAIDs) in treating the inflammatory signs of the tympanic membrane in otitis. There was a statistically significant difference between treatment groups at D2 for pain, IBU being superior to PLA (P < 0.01): 7%, 10% and 25% of the children were still suffering at D2 in the IBU, PARA and PLA treatment groups, respectively. The difference between PARA and PLA for pain was not statistically significant. There was no significant difference between treatment groups for the other criteria. All treatments were well and equally tolerated. Although no significant difference was found between the treatment groups on the aspect of the tympanic membrane, the efficacy of IBU was evidenced on the relief of pain, the symptom that most disturbs the child.

Outcome-Oriented Managed Care Comparing Efficacies of Cefaclor and Amoxicillin in Acute and Recurrent Acute Otitis Media

A study utilizing outcome-oriented care is employed to show the effectiveness of a given medical treatment. A specific patient population is studied in order to determine the most effective treatment for a common clinical disorder. A total of 201 children were retrospectively studied to evaluate the efficacy and side effects of amoxicillin and cefaclor in the treatment of acute otitis media and recurrent acute otitis media. There were 456 episodes of acute otitis media; 245 episodes were treated with amoxicillin with an efficacy of 91%, while 211 episodes were treated with cefaclor with an efficacy of 97%. The dosage of 40mg/kg/day, divided in three equal doses, was employed for both antibiotics in the treatment of acute otitis media, while half of this amount was given once daily for the chemoprophylaxis of recurrent acute otitis media. In the 87 courses of chemoprophylaxis with cefaclor for recurrent otitis media, the efficacy was found to be 53%; while amoxicillin was found to be effective in 30% of the 33 patients studied. There were fewer side effects noted in the cefaclor group than in the amoxicillin group (4% vs. 12%). Both drugs caused diarrhea, while cefaclor also caused a mild maculopapular rash in two patients (1.67%).

While amoxicillin remains the drug of choice for acute otitis media (AOM), this study suggests that cefaclor may be a better selection in the chemoprophylaxis of recurrent acute otitis media.

Relationship of environmental tobacco smoke to otitis media in young children

Otitis media (OM) continues to be a major health problem of children in the United States. The role of environmental tobacco smoke (ETS) as a predisposing factor has not been completely discerned. This study and discussion is an investigation and review of the influence of passive cigarette smoking on OM in children, and its effect on the practice of otolaryngology within the pediatric population. A prospective study of 175 children with recurrent OM and requiring tympanostomy tubes (case group) was compared to an age-matched group of 175 children (controls) to determine the role passive cigarette smoking has on the incidence of this disease. The results revealed that the case group more commonly had exposure to ETS (P = .04). Prospective follow-up of the case group revealed no significant difference in the clinical course of the children who were exposed to ETS and those who were not.

Current indications for tympanostomy tubes

Current indications for TT placement are (1) persistent SOM that has not responded to a 6 to 12-week course of medical treatment. This includes full and prophylactic doses of antimicrobials (and corticosteroids, as indicated); (2) recurrent AOM (at least three episodes in 6 months or four episodes in 12 months) that does not respond to, or recurs after, antimicrobial prophylaxis; (3) complications of AOM such as meningitis, facial nerve paralysis, coalescent mastoiditis, or brain abscess; and (4) complications of eustachian tube dysfunction such as tympanic membrane retraction with hearing loss, ossicular erosion, and/or retraction pocket formation. It must be emphasized that TT placement in children does not "cure" the condition that led to the surgical intervention. Rather, the TT maintains aeration of the middle ear until the child grows and his eustachian tube function normalizes. These recommendations for TT placement are to be regarded as guidelines, not as absolute requirements. They must be applied individually to each patient and his/her unique situation. Certain factors may influence timing of TT placement and lead to modification of the guidelines as they apply to each child.

Update on otitis media. Part 2. Treatment

Currently the treatment of choice for OM is an oral antimicrobial agent, but selecting a specific agent should include consideration of efficacy, adverse effect profile, compliance, and cost. The use of adjunctive medications like decongestants for specific subtypes of OM has been debated in the literature, but efficacy has not been proven. As knowledge about the pathogenesis of OM is further refined, new treatment modalities for OM will be introduced. Because pharmacists are involved daily with pediatric patients who experience OM, they have an important role in making sure that patients receive appropriate therapy. A patient's profile should be checked for allergies and concurrent medications when a prescription for an antimicrobial agent is presented for a child with OM. The parents should be counseled about the administration, storage, and general product use as well as potential adverse effects, duration of use, and the need for compliance. An administration device for drug delivery like an oral syringe should be provided. Parents need advice from the pharmacist in making sure their children receive the best possible pharmaceutical care.

Cefpodoxime proxetil compared with amoxicillin-clavulanate for the treatment of otitis media

In a multicenter, randomized, investigator-blinded trial, patients were randomly selected to receive either cefpodoxime proxetil or amoxicillin-clavulanate potassium orally for the treatment of acute suppurative otitis media. Patients were seen before, during, and at the end of therapy, and 2 to 3 weeks after completion of therapy. A total of 229 patients, 153 receiving cefpodoxime and 76 receiving amoxicillin-clavulanate were entered into the study; all patients were examined to determine drug safety. A total of 146 patients, 98 in the cefpodoxime group and 48 in the amoxicillin-clavulanate group, completed the study and were examined to determine drug efficacy. End-of-therapy microbiologic eradication rates in assessable patients were 92% for cefpodoxime and 86% for amoxicillin-clavulanate (p = 0.14; 95% confidence interval (CI) on difference: -4.4%, 19.2%). End-of-therapy clinical response rates for assessable patients were as follows: cured, 68% for cefpodoxime and 65% for amoxicillin-clavulanate; improved, 24% for cefpodoxime and 23% for amoxicillin-clavulanate; and failed, 8% for cefpodoxime and 13% for amoxicillin-clavulanate (p = 0.57; 95% CI: -8.4%, 16.5%). Recurrence rates at long-term follow-up were 24% for cefpodoxime-treated patients and 25% for those given amoxicillin-clavulanate. Both drugs were well tolerated; 20.9% of those given cefpodoxime and 31.6% of amoxicillin-clavulanate-treated patients had drug-related adverse medical events (p = 0.102; 95% CI: -23.9%, 2.6%). Gastrointestinal complaints were the most frequently reported drug-related side effect in both groups: 11.8% of cefpodoxime-treated patients and 21.1% of those given amoxicillin-clavulanate (p = 0.076; 95% CI: -20.8%, 2.2%). Drug-related dermatologic side effects (e.g., diaper rash, pruritus, urticaria) were reported in 7.8% of cefpodoxime-treated patients and 14.5% of those who received amoxicillin-clavulanate (p = 0.160; 95% CI: -16.6%, 3.3%). Our findings suggest that clinical efficacy for cefpodoxime administered twice daily is equivalent to that of amoxicillin-clavulanate administered three times a day.

Antibiotic treatment failures in acute otitis media

When the clinician is presented with apparent treatment failure, noncompliance must be considered first. If this is the problem, the medication should be reinstituted after the parents are counseled. Next, the possibility of a superimposed viral illness also must be considered. When satisfied that these are not the problems, the clinician must consider whether the MEE has created so much positive pressure that antimicrobials cannot completely penetrate the middle ear space. If positive pressure is considered the problem, the same or another antimicrobial should be continued for a second 10-day course, allowing the pressure to decrease with time permitting more complete antibiotic penetration into the MEE. Alternately, clinicians with appropriate training may elect to relieve the pressure by tympanocentesis or myringotomy. If the clinician decides that it is more likely that the patient has a pathogen resistant to the initial choice of an antimicrobial agent, a second course of a more potent second-line antimicrobial is appropriate. Patients who fail a second course of antimicrobials should receive an alternate second-line antimicrobial or undergo drainage of the middle ear abscess. Those who fail a third course of antimicrobials should be referred to an otolaryngologist for evaluation or surgical intervention. Antimicrobials should be continued until the consultation occurs. This article has outlined potential clinical presentations for treatment failures as well as choices for second-line antibiotics. The relation of anatomic, environmental, microbial, and antimicrobial factors in persistent AOM must be considered in order to determine if the clinician should do more than merely prescribe second-line antibiotics.(ABSTRACT TRUNCATED AT 250 WORDS)

Pitfalls in diagnosing acute otitis media

The diagnosis of AOM in the infant and child requires an accurate history with special reference to fever, pain, and respiratory symptoms and a careful examination with particular attention to the appearance and movement of the TM. The practitioner must be wary of relying too heavily on any single physical finding, but instead consider all the variables that influence and alter the history and physical examination as summarized in Table 4. These variables include the reliability of the history, the history of previous infections, the age of the child, the appearance of the EAC, and the appearance and mobility of the TM. The importance of a correct diagnosis is crucial because of the immediate treatment and follow-up dictated by the diagnosis and because of the potential long-term effects on the child's health and development, which are described in the remaining articles in this issue of Pediatric Annals.