Antiinflammatory effects of a corticosteroid and protease inhibitor agents on antigen-induced otitis media in chinchillas

No evidence for the effectiveness of systemic corticosteroids in acute pharyngitis, community-acquired pneumonia and acute otitis media

Corticosteroids have been used to treat infectious diseases for more than 50 years but, although it has been shown that they are highly effective in improving the clinical course of some diseases, their effects have not been clearly defined in others. Nevertheless, they are still used by a considerable number of physicians. This review analyses the role of systemic corticosteroids in the treatment of acute pharyngitis (AP), community-acquired pneumonia (CAP) and acute otitis media (AOM). A number of trials involving patients with AP have been carried out, but most are marred by methodological flaws that do not allow any firm conclusions to be drawn. The number of trials involving CAP patients is even higher, and the data suggest that corticosteroids may reduce the risk of death only in patients with severe disease. There are very few data concerning AOM, and there is currently no reason for prescribing corticosteroids to treat it. Overall, the data showed that there is, currently, no indication for the universal use of systemic corticosteroids in any of the reviewed diseases and, further, high-quality studies of all of these respiratory tract infections are needed in order to identify the patients for whom the prescription of corticosteroids is rationally acceptable.

A randomized, placebo-controlled trial of the effect of antihistamine or corticosteroid treatment in acute otitis media

OBJECTIVES

To determine whether the adjunctive drugs antihistamine and corticosteroid improve immediate and long-term outcomes of acute otitis media (AOM).

STUDY DESIGN

Children with AOM (3 mos-6 y) were enrolled in a randomized, double-blind, placebo-controlled trial. All 179 children received one dose of intramuscular ceftriaxone and were assigned to receive either chlorpheniramine maleate (0.35 mg/kg/d) and/or prednisolone (2 mg/kg/day) or placebo for 5 days. Main outcome measures were rate of treatment failure during the first 2 weeks, duration of middle ear effusion, and rate of recurrences of AOM to 6 months.

RESULTS

Clinical outcomes and recurrence rates did not differ significantly with treatment. Children who received antihistamine alone had significantly longer duration of middle ear effusion (median, 73 days) than subjects in other treatment groups (median, 23 to 36 days, P=.04). Temporary normalization of tympanometric findings on day 5 occurred more frequently in the corticosteroid-treated group (P=.04).

CONCLUSIONS

Five-day treatment with antihistamine or corticosteroid, in addition to antibiotic, did not improve AOM outcomes. Antihistamine use during an acute episode of OM should be avoided, since the drug may prolong the duration of middle ear effusion. The efficacy of 7- to 10-day treatment of AOM with corticosteroid, in addition to antibiotic, deserves further investigation.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A guide to otolaryngology resources on the Internet

The number of valuable resources for otolaryngologist-head and neck surgeons on the Internet continues to grow at a rapid pace. This article is a comprehensive guide to resources currently available.

Inhibition of proteases in Pseudomonas otitis media in chinchillas

The treatment of chronic suppurative otitis media caused by Pseudomonas aeruginosa remains a challenging problem. The virulence of Pseudomonas is related to its secretion of two matrix metalloproteinases, alkaline protease and elastase. This experiment examines the effects of a synthetic inhibitor of matrix metalloproteinases GM 6001, or N-(2(R)-2(hydroxyamido carbonylmethyl)-4-methylpentanoyl)-L-tryptophane methylamide), in a chinchilla Pseudomonas otitis media model. Thirty chinchillas underwent bilateral subtotal tympanic membrane perforations. Twenty-four chinchillas underwent bilateral middle ear inoculation with P. aeruginosa. Chinchillas were divided into four groups of six animals after the establishment of otitis media. Animals in one group were controls; the other three groups received either gentamicin, GM 6001, or gentamicin plus GM 6001 into the external auditory canal three times daily for 4 weeks. Clearance of Pseudomonas infection occurred in three ears of three animals, all in gentamicin groups, with or without GM 6001. Otorrhea (p = 0.0014) and external canal erythema (p = 0.025) were mild in the two gentamicin groups and moderate in the GM 6001 group when compared with bacterial controls. Animals in the GM 6001 group had the highest survival rate, less severe facial paralysis, and less vestibular toxicity than the gentamicin, gentamicin plus GM 6001, or control groups, although these differences were not statistically significant. This pilot study showed encouraging results for a role of ototopical protease inhibitors in the treatment of Pseudomonas otitis media.

Arachidonic acid metabolites in experimental otitis media and effects of anti-inflammatory drugs

Previous studies have shown that arachidonic acid (AA) metabolites are important in the pathogenesis of otitis media with effusion. The AA metabolites in 4 different experimental models for otitis media were analyzed, and the effect of anti-inflammatory drugs was studied. Purulent otitis media was induced in rats by inoculation of Streptococcus pneumoniae in the tympanic bulla, serous otitis media by blocking the tympanal orifice of the eustachian tube, and mucoid otitis media by combining the two procedures. Middle ear effusion was also induced by stimulating the external auditory canal with cold air. Indomethacin and hydrocortisone were used to inhibit AA metabolism in the latter model. Lipoxygenase products dominated in the purulent and cold air otitis media models. Cyclooxygenase products dominated in the mucoid and serous models. Indomethacin inhibited accumulation of middle ear effusion in the cold air otitis media model, whereas hydrocortisone did not. Apart from AA metabolites, other mechanisms and mediators appear to be responsible for the increased vessel permeability observed in the cold air otitis media model, such as interactions between mast cells and nerves in the middle ear mucosa.

Summating potential/action potential ratio in perilymph fistula

A prospective study of electrocochleography in patients with clinically suspected perilymph fistula was undertaken to determine its predictive value in that disorder. One hundred forty-four patients suspected of having perilymph fistula had electrocochleography performed--34 of these (39 ears) had exploratory tympanotomy. Of the 19 ears with normal preoperative summating potential/action potential (SP/AP) ratio, ten had perilymph fistula identified at the time of surgery. Of the 20 ears with abnormal SP/AP ratio, 16 had perilymph fistula confirmed at exploration, 18 had resolution of symptoms after oval window and round membrane grafting, and only one ear had postoperative persistence of the abnormal SP/AP ratio. This study suggests that an abnormal SP/AP ratio is not only predictive of endolymphatic hydrops, but also of perilymph fistula (both problems of inner ear fluid imbalance). This study also suggests that, while abnormal SP/AP ratio is fairly specific for inner ear fluid imbalance, it is not sensitive.