Topical Dexamethasone and Tympanic Membrane Perforation Healing in Otitis Media: A Short-Term Study

Microbiome and Otic Quinolone Levels Following Tympanoplasty Assessed by Gelatin Sponge Analysis

OBJECTIVE

To determine if absorbable gelatin sponge (AGS) can be used to assess the posttympanoplasty microbiome and otic antibiotic exposure.

STUDY DESIGN

Prospective.

SETTING

Tertiary hospital.

METHODS

Patients undergoing tympanoplasty were prospectively enrolled. Intraoperatively, AGS was applied to the medial ear canal/tympanic membrane (TM) for 1 minute after canal incision, then saved for analysis. Ear canals were packed with AGS at the end of surgery. Otic ofloxacin was administered until the first postoperative visit, when AGS was collected. Microbial presence was assessed by culture. Ofloxacin levels were assessed by liquid-chromatography mass-spectrometry.

RESULTS

Fifty-three patients were included. AGS was collected in 92.9% of patients seen within 21 days compared to 70.8% of those seen at 22 to 35 days. At surgery, AGS yielded bacteria and fungi in 81% and 11%, respectively, including Staphylococcus species (55%) and Pseudomonas species (25%). Postoperatively, AGS yielded bacteria in 71% and fungi in 21% at the meatus, (staphylococci 57% and pseudomonas 25%). TM samples yielded bacteria in 69%, fungi in 6%, staphylococci in 53%, and pseudomonas in 19%. Ofloxacin concentration at the meatus was 248 μg/mL (95% confidence interval [CI]: 119-377) and at the TM was 126 μg/mL (95% CI: 58-194). Ofloxacin-resistant colonies were found in 75% of patients.

CONCLUSION

Analysis of AGS is a viable technique for noninvasively studying healing metrics posttympanoplasty, including the microbiome and otic antibiotic exposure. Despite exposure to a high concentration of quinolones, the tympanoplasty wound is far from sterile, which may impact healing outcomes.

Surgical results and factors affecting outcome in patients with fat-graft myringoplasty

Objectives: We evaluated the closure rate after fat-graft myringoplasty (FGM) of perforations differing in size and location. We explored whether patient's factors and the FGM surgical technique influenced surgical outcomes. Methods: We retrospectively studied patients with tympanic membrane perforations who underwent FGM from March 2015 to March 2019. All procedures were performed by a single senior surgeon at our tertiary hospital. The patients who followed-up for at least 6 months after surgery were enrolled. We recorded hypertension and diabetes status, age, any prior ear surgery, any calcific plaques adjacent to the perforation, and perforation size and location. Results: A total of 150 patients were enrolled. Our success rate of FGM was 90%. Hypertension, diabetes, prior ear surgery history, and eardrum calcific plaques did not affect the surgical outcomes. There was no statistical difference in the surgical success rate according to the size (< 50%) or location of perforation. The closure rate was 97.2% in patients aged 1660 and 87.5% in patients aged > 60, respectively. However, FGM was successful in only two of six children (33.3%) aged ≤ 15 years, thus significantly less than in the other groups. Conclusion: FGM is a fast, safe, and efficient method for repairing tympanic membrane perforation. The surgical outcome is not significantly affected by underlying disease, perforation size or location, or by the condition of the tympanic membrane or older age. However, it may be poor in children with dysfunctional Eustachian tube.

Tympanoplasty Healing Outcomes With Use of Postoperative Otic Quinolones

OBJECTIVE

Tympanoplasty usually results in tympanic membrane perforation (TMP) closure, but healing may be suboptimal (e.g., excess scarring). Factors that have been linked to impaired TM healing have become widely adopted (especially, postoperative use of quinolone ear drops). The aim of this study is to assess the frequency of suboptimal tympanoplasty healing with the use of otic quinolones postoperatively.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care facility.

PATIENTS

One hundred patients undergoing tympanoplasty for TMP.

INTERVENTIONS

Tympanoplasty +/- canalplasty.

MAIN OUTCOME MEASURES

Healing complications (e.g., granulation tissue, TMP, myringitis, bone exposure, lateralization, anterior blunting, medial canal fibrosis, and canal stenosis) and hearing loss.

METHODS

Charts were reviewed for postoperative healing issues and hearing outcomes at 1 to 2 years postoperatively.

RESULTS

TMP closure was found in 93.2%, but 34.2% had healing issues at 1 to 2 years postoperatively, with 20.6% having adverse healing outcomes (perforation (6.9%), granulation tissue (6.9%), medial fibrosis (4.1%), and myringitis, bone exposure, and webbing (all 1.4%). Another 13.7% had notable postoperative issues, such as protracted otorrhea (11.0%), otitis externa (9.6%), otitis media (1.4%), and atelectasis (2.7%). No medical, surgical, or patient factors impacted outcomes. Average air-bone gap at 1 to 2 years did not differ between patients with and without healing issues and patients with other postoperative issues (p = 0.5).

CONCLUSIONS

Suboptimal healing is common after tympanoplasty. There may be significant opportunity to improve post-tympanoplasty healing beyond improving the TMP closure rate.

Does intraoperative ciprofloxacin-soaked gelfoam have adverse effects on graft success rate? A randomized, double-blind controlled trial

OBJECTIVES

The aim of this study was to evaluate whether intraoperative ciprofloxacin-soaked gelfoam is safe in tympanoplasty or not.

METHOD

In this randomized, double-blind controlled clinical study, we included 100 patients between 18 and 60 years old, having perforation ≥50% of the tympanic membrane and dry ear for at least 2 months who were a candidate for underlay tympanoplasty via postauricular approach. We used ciprofloxacin soaked gelfoam in the case group and betamethasone soaked gelfoam in the control group for packing the middle ear cavity and external auditory canal during their operation. The graft success rate and tympanogram after 6 months follow-up period was considered as the primary outcome. Also, we evaluated the postoperative hearing results 6 months after the surgery as the secondary outcomes.

RESULTS

Postoperative microscopic otoscopy showed a graft success rate of 100% (44/44) and 97.7% (42/43) in the case and control groups, respectively. The level of improvement between the two groups was not significant for air-bone gap (ciprofloxacin: 9.01 ± 7.89 dB, betamethasone 5.31 ± 10.53 dB, P = .160), and speech reception thresholds (SRT; ciprofloxacin: 10.23 ± 8.62 dB, betamethasone 7.33 ± 12.60 dB, P = .260). 93.2% of all the ears in the case group and 81.4% of those in the control group achieved postoperative air-bone gap within 20 dB, but the difference between them was not significant (P = .118).

CONCLUSIONS

We found that the application of ciprofloxacin impregnated gelfoam in the middle ear, and the external auditory canal had no adverse effect on the graft success rate in tympanoplasty.

LEVELS OF EVIDENCE

1b.

Residual Perforation Risk Assessment of Intratympanic Steroids via Tympanostomy Tube Versus Transtympanic Injections

OBJECTIVES/HYPOTHESIS

To investigate the risk of residual tympanic membrane (TM) perforation after intratympanic (IT) steroidal treatment administered via transtympanic injection compared with trans-tympanostomy tube (TyT).

STUDY DESIGN

Case series, systematic review and meta analysis.

METHODS

Data were retrieved from the medical files of an original cohort of all consecutive patients with sudden sensorineural hearing loss necessitating IT steroidal treatment in a tertiary medical center between January 1, 2016 and November 20, 2020. A systematic literature search of "MEDLINE" via "PubMed," "Embase," and "Web of Science" on comparable published cases was performed and meta-analysis was established.

RESULTS

Eighteen studies describing 818 ears were included in the quantitative meta-analysis in addition to a local cohort of 140 ears. The proportion of residual TM perforation was 1.11% and 1.14% (95% confidence interval: 0.01%-3.27% and 0.028%-2.38%) in the TyT and trans-tympanic groups, respectively, suggesting no significant difference in residual TM perforation risk between these techniques.

CONCLUSION

IT steroid therapy via trans-TyT is not associated with more residual perforations than IT steroid therapy via transtympanic injections.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:E2583-E2591, 2021.

The Effects of Steroids on Survival of Mouse and Human Tympanic Membrane Fibroblasts

OBJECTIVE

Tympanic membrane (TM) fibroblast cytotoxicity of quinolone ear drops is enhanced by dexamethasone and fluocinolone. Hydrocortisone has not been evaluated. We aimed to assess the effects of these 3 steroids on mouse and human TM fibroblast survival.

STUDY DESIGN

In vitro.

SETTING

Academic laboratory.

SUBJECTS AND METHODS

Mouse and human TM fibroblasts were exposed to hydrocortisone, dexamethasone, or fluocinolone at concentrations in commercial ear drops (1%, 0.1%, or 0.025%, respectively) and at steroid potency equivalents (1%, 0.033%, or 0.0033%, respectively), or dilute ethanol (control), twice within 24 hours or 4 times within 48 hours for 2 hours each time. Cells were observed with phase-contrast microscopy until the cytotoxicity assay was performed.

RESULTS

Mouse and human TM fibroblasts treated with any of the steroids had lower survival after 24 and 48 hours compared to control (all P < .0001). After 24 hours, viability of mouse fibroblasts treated with the steroids was not different (P > .05), while treatment with hydrocortisone decreased human TM fibroblast viability (P < .0001). After 48 hours, at concentrations found in ear drops and at equivalent steroid potency, dexamethasone and fluocinolone had similar survival in mouse and human fibroblasts (all P > .05), but hydrocortisone had lower survival in both mouse (P = .02 and P < .0001) and human (P < .0001) fibroblasts. Phase-contrast images mirrored the cytotoxicity findings.

CONCLUSION

Steroids found in commercial ear drops reduce survival of mouse and human TM fibroblasts. Hydrocortisone appears to be more cytotoxic than the more potent steroids, dexamethasone and fluocinolone. These findings should be considered when assessing clinical outcomes of ototopical preparations.

Cytotoxicity of Ciprofloxacin and Steroids in Mouse Tympanic Membrane Fibroblasts

Objective

Ciprofloxacin, commonly given as eardrops, has been shown to adversely affect tympanic membrane fibroblasts. Dexamethasone potentiates this effect. A newly available eardrop contains ciprofloxacin and fluocinolone, a more potent steroid. We evaluated the cytotoxic effects of this preparation on mouse tympanic membrane fibroblasts.

Study Design

Prospective, in vitro.

Setting

Academic laboratory.

Subjects and Methods

In experiment 1, fibroblasts were exposed to 1:10 dilutions of commercially available 0.3% ofloxacin, 0.3% ciprofloxacin, 0.3% ciprofloxacin + 0.1% dexamethasone, 0.3% ciprofloxacin + 0.025% fluocinolone, or dilute hydrochloric acid (control), twice within 24 hours. In experiment 2, cells were also treated with the dilutions of the pure form of dexamethasone 0.1% or fluocinolone 0.025%, alone and in combination with ofloxacin or ciprofloxacin. Cells were exposed to the solutions for 2 hours each time and were placed back in growth media after the treatments. Cells were observed with phase-contrast microscope until the cytotoxicity assay was performed.

Results

Survival of fibroblasts treated with ofloxacin was not different from the control. Fibroblasts treated with ciprofloxacin, ciprofloxacin + dexamethasone, or ciprofloxacin + fluocinolone had much lower survival (all P < .0001). Cells treated with ciprofloxacin + fluocinolone had lower survival than ciprofloxacin ( P < .0001) and ciprofloxacin + dexamethasone ( P = .0001). Steroids alone also decreased fibroblast survival compared to control ( P < .0001). The combination of dexamethasone or fluocinolone with ciprofloxacin, but not ofloxacin, further decreased fibroblast survival ( P < .0001). Phase-contrast images mirrored the cytotoxicity findings.

Conclusion

Tympanic membrane fibroblast cytotoxicity of ciprofloxacin is potentiated by corticosteroids. This effect may be deleterious when treating a healing perforation but beneficial when treating granulation tissue on the tympanic membrane.

Ciprofloxacin Decreases Collagen in Mouse Tympanic Membrane Fibroblasts

Objectives

To determine how collagen production by tympanic membrane fibroblasts is affected by ciprofloxacin at levels found in eardrops.

Study Design

Prospective, controlled, and blinded cell culture study.

Setting

Academic tertiary medical center.

Subjects

Cell culture of mouse fibroblasts.

Methods

A primary fibroblast culture was established from mouse tympanic membranes. Fibroblasts were cultured until they were 75% confluent, then treated with dilute hydrochloric acid (control) or ciprofloxacin (0.01% or 0.3%) for 24 or 72 hours for Western blotting and for 24 or 48 hours for cytotoxicity assay. Cells were observed with phase-contrast microscope. Western blotting was performed for collagen type 1 α1 (collagen 1A1) and α-tubulin.

Results

Fibroblasts treated with 0.01% and 0.3% ciprofloxacin for 24 hours had lower levels of collagen 1A1 ( P = .0005 and P < .0001, respectively) and α-tubulin (both P < .0001) than control fibroblasts. Collagen 1A1 and α-tubulin levels were lower in fibroblasts treated with 0.3% than with 0.01% ciprofloxacin ( P = .02 and P = .014). After 72 hours, 0.3% ciprofloxacin completely eliminated collagen 1A1 and α-tubulin ( P < .001). Cells treated with 0.01% ciprofloxacin for 72 hours also had lower collagen 1A1 ( P < .0001) and α-tubulin ( P = .005) as compared with the control. Seventy-two-hour incubation in 0.01% or 0.3% ciprofloxacin resulted in lower levels of collagen 1A1 ( P = .009 and P < .0001, respectively) and α-tubulin ( P = .007 and P < .0001, respectively) than 24-hour incubation. Cytotoxicity assay and phase-contrast microscopy mirrored these findings.

Conclusions

Treatment of tympanic membrane fibroblasts with 0.3% ciprofloxacin, as found in eardrops, reduces fibroblast viability and collagen and α-tubulin protein levels. These findings could explain tympanic membrane healing problems associated with quinolone eardrops.

Longitudinal results of intratympanic injection of budesonide for otitis media with effusion in children over 12 years and adults

OBJECTIVE

To assess the longitudinal curative effect and improvement of subjective symptoms by using intratympanic injection of Budesonide(BUD) for otitis media with effusion (OME) patients older than 12 years and adults.

STUDY DESIGN

A single-blind, randomized, parallel-controlled prospective study.

SETTING

Hospital, outpatient.

PATIENTS

Ninety patients (112 ears) who were diagnosed as having OME were recruited and then randomized to BUD, dexamethasone (DEX), and sodium chloride (NS) groups, the latter two served as controls.

INTERVENTIONS

The randomly allocated patients received intratympanic injection of BUD (0.5 mg/1 ml), DEX (2 mg/1 ml), or 0.9% NS solution (1 ml) once a week.

MAIN OUTCOME MEASURES

Survival analysis was applied to compare the longitudinal curative effects among the 3 groups. Meanwhile, the 6 main subjective symptoms were scored by 10-point visual scale, and physician's evaluations were preformed during treatment and follow-up.

RESULTS

After adjustment for course of disease, volume, and characters of effusion, the relative risk (RR) of BUD is 0.139 (95% CI, 0.054-0.358) when compared with NS. Survival curve demonstrated that the rank of longitudinal therapeutic efficacy was BUD, DEX, and NS (p < 0.05). Both BUD and DEX showed improvements in subjective symptoms and quality of life compared with NS (p < 0.05). In the aspect of improving the symptom of stuffy ear, BUD showed advantage over both DEX and NS. During and after treatment, no serious complications or sequelae were observed.

CONCLUSION

Intratympanic injection with BUD for OME patients showed advantages in improving long-term therapeutic efficacy, it was a safe and effective intervention for adolescents and adults with OME.