Diagnosis and management of eosinophilic otitis media: a systematic review

Efficacy of biologics for eosinophilic otitis media

BACKGROUND

Eosinophilic otitis media (EOM) is an intractable condition primarily treated with steroids. Recently, biologics targeting IgE or IL-5 have been introduced.

OBJECTIVES

This study aimed to evaluate the efficacy of biologics for EOM.

MATERIALS AND METHODS

We retrospectively collected data on EOM patients treated from January 2008 to December 2020 from electronic medical records. Patients were classified into the steroid group, treated with systemic or local steroids, and the biologics group, treated with biologics with or without steroids.

RESULTS

The otorrhea remission rate was 63.33% in the steroid group, comparable to 58.82% in the biologics group (p = 0.760). Before treatment, the steroid group showed better bone-conduction (BC) thresholds at 0.5 kHz and 1 kHz than the biologics group. Post-treatment, the steroid group improved in air-conduction (AC) threshold and air-bone gap (ABG) at 1 kHz and 2 kHz. The biologics group exhibited stable audiological results. No significant differences were observed post-treatment between the groups, except for the BC threshold at 0.5 kHz, which remained as pre-treatment.

CONCLUSIONS AND SIGNIFICANCE

Biologics demonstrated similar efficacy in otorrhea remission as steroids and might help maintain hearing levels. Biologics can be considered for controlling EOM with active otorrhea and reducing systemic steroid use.

[Clinical observation of the course of eosinophilic otitis media against the background of biological therapy of chronic polypous rhinosinusitis]

RESUME

Eosinophilic otitis media (EoOM) is a variant of exudative otitis media characterized by a persistent persistent course, the presence of a very viscous effusion in the tympanic cavity, comorbidally associated with chronic polypous rhinosinusitis and bronchial asthma. The disease is characterized by a persistent progressive course, which can lead to a gradual decrease in hearing up to complete deafness. Conservative treatment methods for EoOM include local and systemic administration of glucocorticosteroids. Encouraging data on the effectiveness of biological therapy have appeared in recent publications. The above clinical observation examines the course of EoOM in a patient who received biological therapy with dupilamab.

Dupilumab improves eosinophilic otitis media associated with eosinophilic chronic rhinosinusitis

BACKGROUND

Eosinophilic otitis media (EOM) is a refractory condition associated with eosinophilic chronic rhinosinusitis and bronchial asthma. EOM is characterized by type-2 inflammation and is refractory to various treatments. We investigated the efficacy of dupilumab, interleukin-4 receptor alpha antagonist, for patients with EOM complicated by eosinophilic chronic rhinosinusitis (ECRS).

METHODS

Between April 2017 and April 2022, we treated 124 patients with dupilumab for refractory CRS or bronchial asthma. Of these, 14 had EOM concurrently, and 10 of them who had been treated for >6 months were included in our study. We retrospectively evaluated the efficacy of dupilumab by the amount of systemic corticosteroid used, the frequency of exacerbations, severity score of EOM, computed tomography (CT) score of temporal bones, and pure tone audiometry. We also enrolled 8 EOM patients without dupilumab treatment as a control group.

RESULTS

Dupilumab significantly improved the amount of systemic corticosteroid used and the frequency of exacerbation and compared with before dupilumab was used (p = 0.01 and <0.01, respectively). All patients could be weaned from systemic-corticosteroid therapy by 54 weeks of dupilumab use. The severity score of EOM and CT score for temporal bones were significantly lower than before the treatment (p = 0.01 and 0.01, respectively). Compared to the control group, the systemic corticosteroid used and severity scores were improved in the dupilumab group (p = 0.02 and < 0.01, respectively).

CONCLUSIONS

Dupilumab could be used to wean patients from systemic corticosteroids with the improvement of severity score in EOM associated with ECRS and bronchial asthma.

Proteomic Study of Middle Ear Effusion and Its Clinical Application for Otitis Media with Effusion

Background

Proteins found in middle ear effusion play crucial roles in the physiological and pathological processes of otitis media with effusion (OME), influencing the etiology and clinical characteristics of this disease. The qualitative and quantitative composition of these proteins depending on the underlying pathogenesis of middle ear effusion. Understanding their physiological and pathological functions is of great importance.

Methods

We collected samples from 19 volunteers diagnosed with OME. After offline separation using high-pH reversed-phase liquid chromatography (RPLC), the pooled sample was subjected to LC-MS/MS analysis to obtain a comprehensive profile of the OME proteome. Functional analysis was performed using Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and Ingenuity Pathway Analysis (IPA) annotations. Data-independent acquisition (DIA) technology was utilized to analyze samples and fix whether the OME proteome could replicate the pathophysiological features associated with this disease. We conducted a differential proteomic analysis between patients with simple OME and patients who had received radiotherapy. The radiotherapy-reduced group was further divided into two subgroups: nasopharyngeal carcinoma (NPC) and other types of carcinoma. Parallel reaction monitoring (PRM) technology was used for validation of 36 differentially expressed proteins (DEPs).

Results

A number of 732 proteins were identified in the OME proteome database. Among them, 527 proteins were quantified using peak intensity-based semi-quantification (iBAQ), covering a wide dynamic range of approximately 8 orders of magnitude. Based on the functional analysis, we proposed a hypothetical mechanism of OME.

Conclusion

This study managed to put up an inclusive analysis of the OME proteome, establishing the first human OME proteome database. We focused on differential proteomic analysis among different groups to gain a more comprehensive concept of the OME proteome and search for meaningful biomarkers.

[Intratympanic Drug Application - Indication and Procedure]

Neurootologic disorders of the inner ear associated with symptoms such as tinnitus, vertigo, and hearing loss are common and often cause significant distress to affected patients. Treatment options are usually limited. There are now some indications for which intratympanic drug application is a possible treatment option. Intratympanic drug administration is a simple, inexpensive therapy option with few side effects that can be used on an outpatient basis. Therefore, it should not be disregarded when indicated.

Improvement of Suspected Eosinophilic Otitis Media with Targeted Biologic Therapy

OBJECTIVE

To compare the responses of suspected eosinophilic otitis media to treatment with or without a targeted biologic therapy against interleukin-4 (IL-4), IL-5, or IL-13 signaling.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary referral center.

PATIENTS

Subjects with type 2 chronic rhinosinusitis with nasal polyposis (CRSwNP), asthma, and otitis media who underwent treatment between 2005 and 2021.

INTERVENTION

Treatment with targeted biologic therapy.

MAIN OUTCOME MEASURES

Pre- and posttreatment nasal endoscopy, ear examination, and audiologic evaluation.

RESULTS

Four hundred seventy-seven subjects with type 2 CRSwNP were treated between 2005 and 2021. Sixty-two had otitis media with pre- and posttreatment evaluation. Retrospective chart review assessed pre- and posttreatment exam findings, nasal endoscopy, audiometry, and tympanometry. Nineteen subjects received a biologic therapy, whereas 43 did not. Exam, endoscopy, and tympanometry were graded for severity and compared pre- and posttreatment. Subjective ear exam and tympanometry were significantly improved with biologic therapy (control = 0.05, biologic = 0.84, p = 9.3 × 10 -5 ; control = -0.1, biologic = 0.62, p = 0.0002). Conductive hearing loss as assessed by air-bone gaps did not change between groups (control = 1.2 dB better, biologic = 1.2 dB worse, p = 0.32). Nasal endoscopy findings improved with biologic therapy relative to the control group, although not statistically significant (control = 1.04, biologic = 1.36, p = 0.22).

CONCLUSIONS

Biologic therapies targeting interleukin-4 (IL-4), IL-5, and IL-13 signaling are potential new treatments for eosinophilic otitis media. This is the largest study demonstrating improvement in subjects with suspected eosinophilic otitis media in response to biologic therapy, and immune modulation represents a novel treatment strategy for this challenging condition.

PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED

Current treatment strategies for otologic symptoms in eosinophilic disease are not tremendously effective or durable, resulting in a need for improved treatment options.

LEARNING OBJECTIVE

To determine if targeted biologic therapy, often used for eosinophilic asthma and type 2 chronic rhinosinusitis with nasal polyposis, improves coexistent suspected eosinophilic otitis media.

DESIRED RESULT

Treatment of suspected eosinophilic otitis media with targeted biologic therapy will result in improvement of otologic symptoms with a durable response compared with current treatment options.

LEVEL OF EVIDENCE

Level IV.

INDICATE IRB OR IACUC

Exempt. HUM00182703.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Is Omalizumab Related to Ear and Labyrinth Disorders? A Disproportionality Analysis Based on a Global Pharmacovigilance Database

Introduction: Asthma is a chronic disease, characterized by reversible airway obstruction, hypersensitivity reactions, and inflammation. Oral corticosteroids are an important treatment option for patients with severe or steroid-resistant asthma. Biologics for asthma are recommended in patients with severe asthma, owing to their steroid-sparing effect as well as their ability to reduce the severity and aggravation of uncontrolled asthma. Most clinical trials of omalizumab in patients with asthma have suggested its tolerability and safety. However, some studies reported eosinophilic comorbidities in the ear, nose, and throat during omalizumab treatment, particularly eosinophilic otitis media. This study examined the relationship between ear disorders and omalizumab compared with that of other biologics for asthma using a large real-world database. Materials and Methods: Individual case safety reports from the Uppsala Monitoring Centre Vigibase of biologics for asthma (omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab) up to 29 December 2019, were used. A disproportionality analysis was performed using the proportional reporting ratio (PRR), reporting odds ratio (ROR), and information components (IC). A hierarchy analysis used the Medical Dictionary for Regulatory Activities Terminology. A tree map was generated using R studio version 4.2. Results: In 32,618 omalizumab reports, 714 adverse events (AEs) were detected as signals. Among the 714 signals, seventeen AEs were detected as signals of omalizumab-related ear and labyrinth disorders in 394 reports. Only three AEs (ear pain, ear disorder, and ear discomfort) were detected from mepolizumab. No signal was detected from reslizumab, benralizumab, and dupilumab. Conclusions: Careful monitoring of ear disorders is recommended when omalizumab treatment is started, with decreased oral corticosteroid use in patients with severe asthma. Further studies are necessary to confirm the omalizumab-related signals.