Central nervous system complications associated with acute otitis media in children

Arterial brain infarction in complicated acute otitis media

We report a rare case of acute otitis media (AOM) complicated by arterial brain infarction, meningitis and orbital cellulitis. Computed tomography (CT) initially showed suspected epidural abscess, coalescent mastoiditis, and orbital cellulitis. Further clinical deterioration occurred following mastoidectomy and evacuation of the abscess. Magnetic resonance imaging (MRI) revealed subacute brain infarction and an extra-axial brainstem abscess. Revision of the initial CT revealed subtle signs suggestive of arterial brain infarction. Although CT with contrast is the standard of care for suspected AOM complications, MRI should be considered as an adjunct when CT is not definitive and neurological signs are present.

Eustachian tube gland tissue changes are related to bacterial species in acute otitis media

BACKGROUND AND OBJECTIVE

Prior investigations have shown that the number of mucus producing goblet cells in the middle ear and Eustachian tube (ET) mucosa is highly increased during and up to at least six months after experimental acute otitis media (AOM) caused by Streptococcus pneumoniae (SP). Further, the volume of the mucus producing paratubal gland components is increased up to 3 months after the acute infection. These changes may in conjunction with a deteriorated ET function predispose a subsequent development of secretory otitis media. The present investigation compares changes in goblet cell density and gland structures of the ET during and after AOM caused by various bacteria typically encountered in this disease, with emphasis on potential differences due to bacterial species.

METHODS

Rat models of AOM caused by SP, non-typeable or type b Haemophilus influenzae (NTHI/HIB) or Moraxella catarrhalis (MC) were studied longitudinally up to 6 months after bacterial challenge. The ET was dissected and decalcified, paraffin embedded and serially sectioned, followed by PAS/alcian blue staining. The goblet cell density and the paratubal gland composition and volume were determined morphometrically in every 20th section, using a light microscope.

RESULTS

Regardless of bacterial species, the ET goblet cell density was increased from day 8 and peaked day 16, followed by some degree of normalisation, although not reaching normal numbers within the 6 month period, except for MC. The highest increase was seen in AOM caused by the non-typeable Haemophilus strain, followed by HIB, SP and MC. Except with MC, pathological intra-epithelial glands formed and goblet cells were found in mucosal areas normally devoid of these. In all species but MC, the volume of the paratubal glands progressed to peak 16 days post-inoculation, followed by a gradual normalisation. The volume was still increased 3 months after the acute infection, but completely normalised after 6 months. The increase was primarily due to hypertrophy of the mucous gland components and highest in AOM caused by the Haemophilus species, followed by SP.

CONCLUSION

The Eustachian tube goblet cell density is increased during and up to at least six months after AOM regardless of bacterial species, except when employing MC, by which the density was increased for a few weeks only. Except in AOM caused by MC, the volume of the ET glands increases during and up to at least 3 months after infection, primarily due to hypertrophy of the mucous gland components. The non-typeable Haemophilus strain induced the highest increase of both goblet cell density and mucous gland volume. The increased secretory capacity of the ET following AOM may by excessive mucus secretion contribute to the deteriorated ET function found after AOM and thus predispose, sustain or aggravate middle ear disease.

Histopathologic differences due to bacterial species in acute otitis media

OBJECTIVE

To compare selected features of histopathology in acute otitis media caused by various bacteria and examine potential differences due to bacterial species, as well as possible correlation to experimental and human clinical findings.

METHODS

Rat models of acute otitis media caused by Streptococcus pneumoniae (MC), non-typeable or type b Haemophilus influenzae (NTHI/HIB) or Moraxella catarrhalis (MC) were studied longitudinally up to 6 months after bacterial challenge. Findings related to dynamics of goblet cell density, modeling and remodeling of bone tissue structures and polyp, as well as fibrous adhesion formation and persistence are presented.

RESULTS

Middle ear goblet cell density progressed to peak 2 weeks after bacterial inoculation, thereafter gradually normalizing. However, density and accordingly middle ear secretory capacity was still significantly increased after 6 months in all bacteria, except MC. The HI species induced the highest increase. Initial osteoresorption was followed by massive osteoneogenesis, progressing to a peak after 2-3 months, followed by some degree of normalization, concurrently classic remodeling. Primarily SP, but also the HI species induced more new bone formation than MC. Mucosal polyp and fibrous adhesion formation occurred regardless of bacterial species. Most polyps appeared in the early phases and the HI species induced formation of more polyps and adhesions than the other bacteria.

CONCLUSION

Acute middle ear infection with the Haemophilus species induce the highest increase of mucosal secretory capacity, lasting for at least 6 months after the acute incident. Thus, a subsequent development of secretory otitis media seems more likely following infection with these bacteria. Equivalently, mucosal scarring observed as polyp and fibrous adhesion formation was more severe following Haemophilus infection. S. pneumoniae induced the most marked changes of bone tissue structures, seen as initial osteoresorption and subsequent osteoneogenesis. Overall, infection with M. catarrhalis induced the mildest changes.

Antibiotic theory in otitis media

Otitis media is currently the most common diagnosis made by clinicians, which has a major impact on managed care. The emergence of resistant bacterial pathogens has caused controversy over the use of antibiotics when acute otitis media (AOM) is diagnosed. All infants with AOM and all older children with severe AOM should be treated with antibiotics, despite concerns about rising rates of resistant bacterial pathogens. Some older children with nonsevere AOM may be candidates for initial observation, although this is not confirmed by clinical trials. Antimicrobial agents are not required for otitis media with effusion of recent onset but may be considered if this effusion becomes chronic; in these cases, tympanostomy tube placement may be indicated. Antimicrobial prophylaxis for prevention of recurrent AOM should be reserved for selected patients because of the possible emergence of resistant organisms. Tympanostomy tube placement is a more reasonable option today.

Complications of Acute Otitis Media and Sinusitis

Otitis media and sinusitis are clinically identifiable infections of the middle ear and sinuses. Both conditions should be regarded as dynamic processes with a clinical spectrum, which may extend from a self-limiting condition to a prolonged and sometimes complicated disease. With the advent of antibiotics, the natural course of these diseases has changed significantly. Severe complications once characterized by high mortality and morbidity have become rare. This has led to a generation of general practitioners, otolaryngologists, and pediatricians trained in an atmosphere of complacency in the treatment of otitis media and sinusitis. However, several recent publications report an increasing incidence of serious complications associated with otitis and sinusitis, probably due to rising antibiotic resistance. A high index of suspicion, based on clinical grounds, is therefore warranted. The ultimate goal in the approach of these conditions is pharmacotherapeutic management, resorting to surgery for the restoration of function rather than for the eradication of the infectious disease. As new information becomes available on the etiology, pathogenesis, and bacteriology of these conditions, new strategies are being used to improve treatment and to prevent complications. These measures should include a more appropriate choice of antibiotics, the determination of the role of adjuvant therapy and surgical procedures, and the development of new vaccines.

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%).