Sensorineural hearing loss in patients with chronic suppurative otitis media: Is there a significant correlation?

[Chronic mesotympanic Otitis media - Part 2: Surgical Therapy]

Chronic mesotympanal otitis media (CMOM) is a well-developed clinical presentation that is established in diagnostics and therapy. On closer inspection, however, this principle cannot be confirmed in all its facets. Already the physiology and pathophysiology of the middle ear mucosa leave questions unanswered, starting with the distribution of the ciliated epithelium in the middle ear and mastoid to the function of gas exchange.In addition, there are new diagnostic and therapeutic approaches. In the future, optical coherence tomography could help to determine the status of the middle ear mucosa. In addition, there are new findings on the effectiveness of local and systemic antibiotics as well as antiseptics in chronic otorrhea. Other new developments include minimally invasive surgical procedures using endoscopic techniques. All this gives reason to provide an update on the topic of chronic mesotympanal otitis media, which should contribute in preparation for the specialist examination or refreshing.Basics of physiology and pathophysiology as well as new diagnostic approaches and medical treatment were covered in Part 1 of this paper. In Part 2, in addition to established methods, new developments in surgical therapy with minimally invasive surgical procedures are described in more detail.

Identifying Health-Related Conditions Associated with Tinnitus in Young Adults

OBJECTIVE

The present study investigated the epidemic of tinnitus in college-aged young adults. Our first objective was to identify health conditions associated with tinnitus in young adults. The second objective was to evaluate the predictive utility of some known risk factors.

STUDY DESIGN

A cross-sectional design was used to investigate the prevalence and risk factors for tinnitus.

SETTING

A questionnaire was distributed, reaching out to a large college-aged population. A total of 2258 young adults aged 18-30 years were recruited from April 2021 to February 2022.

INTERVENTIONS

A questionnaire was administered to investigate the epidemiology of tinnitus in a population of college-aged young adults.

RESULTS

About 17.7% of young adults reported bothersome tinnitus perception lasting for ≥5 min in the last 12 months. The prevalence of chronic tinnitus (bothersome tinnitus for ≥1 year) and acute tinnitus (bothersome tinnitus for <1 year) was 10.6% and 7.1%, respectively. About 19% of the study sample reported at least one health condition. Individuals reporting head injury, hypertension, heart disease, scarlet fever, and malaria showed significantly higher odds of reporting chronic tinnitus. Meningitis and self-reported hearing loss showed significant associations with bothersome tinnitus. The prevalence of chronic tinnitus was significantly higher in males reporting high noise exposure, a positive history of reoccurring ear infections, European ethnic background, and a positive health history. Risk modeling showed that noise exposure was the most important risk factor for chronic tinnitus, followed by sex, reoccurring ear infections, and a history of any health condition. A positive history of COVID-19 and self-reported severity showed no association with tinnitus. Individuals reporting reoccurring ear infections showed a significantly higher prevalence of COVID-19.

CONCLUSIONS

While young adults with health conditions are at a higher risk of reporting tinnitus, the predictive utility of a positive health history remains relatively low, possibly due to weak associations between health conditions and tinnitus. Noise, male sex, reoccurring ear infections, European ethnicity, and a positive health history revealed higher odds of reporting chronic tinnitus than their counterparts. These risk factors collectively explained about 16% variability in chronic tinnitus, which highlights the need for identifying other risk factors for chronic tinnitus in young adults.

Evaluation of postural stability and vestibulo-ocular reflex in adults with chronic suppurative otitis media

PURPOSE

To evaluate the vestibulospinal reflex and vestibulo-ocular reflex (VOR) in patients with chronic suppurative otitis media (CSOM) using posturography and the video head impulse test (vHIT).

METHODS

Sixty-five patients with CSOM and 65 healthy participants as controls were included. Patients with CSOM were instructed to complete the dizziness handicap inventory (DHI). All participants underwent otoscopy, pure-tone audiometry, posturography sensory organization test (SOT), and vHIT.

RESULTS

Patients with CSOM exhibited a high prevalence of dizziness. The CSOM group had poor SOT vestibular scores compared to the control group. Patients with CSOM had worse sways in the antero-posterior and mediolateral planes. The CSOM group was divided into two subgroups according to the type of hearing loss. SOT vestibular scores were significantly poorer in the mixed hearing loss group than those in the conductive hearing loss group. We found a positive correlation between disease duration and poor SOT vestibular scores. Moreover, poor SOT vestibular scores correlated with high DHI scores. We found abnormalities in the vHIT results in the CSOM group in the form of low VOR gain and corrective saccades.

CONCLUSION

Our study provides clinical evidence of dizziness, poor postural control, and VOR abnormalities in patients with CSOM. The presence of sensory elements of hearing loss in patients with CSOM appears to be positively associated with vestibular dysfunction.

Chronic Otitis Media in Patients with Chronic Rhinosinusitis: A Systematic Review

Introduction: Chronic otitis media (COM) and chronic rhinosinusitis (CRS) are two of the most common otolaryngological disorders. CRS and COM share pathophysiological mechanisms such as bacterial infection, biofilm, and the persistence of the obstruction state of ventilation routes. The purpose of this systematic review was to evaluate all available information on the association between COM and CRS. Methods: The protocol of this investigation was registered on PROSPERO in November 2022. Pubmed, Scopus, Web of Science, and Cochrane databases were systematically searched according to the PRISMA statement. Results: After the application of inclusion-exclusion criteria, four manuscripts with adequate relevance to this topic were included in the review. The study population consisted of 20,867 patients with a diagnosis of CRS, of whom 991 were also diagnosed with COM (4.75%). Conclusions: The included studies have shown that CRS has become significantly associated with COMas: a global inflammatory process that involves the epithelium in both the middle ear and upper airway. The identification of a relationship between CRS and COM may contribute to preventing chronic inflammatory conditions through the early management of the associated disease. Further, carefully designed studies are necessary to demonstrate the relationship between COM and CRS.

Healthcare consumption among subjects with otitis media undergoing middle ear surgery-analysis of cost drivers

PURPOSE

To map healthcare utilized by subjects with chronic otitis media, with or without cholesteatoma and perform a cost analysis to determine key drivers of healthcare expenditure.

METHODS

A registry study of 656 adult subjects with chronic otitis media that underwent a middle ear surgery between 2014 and 2018. Healthcare contacts related to all publicly funded specialist ENT care, audiological care and primary care for a disease of the ear and mastoid process were extracted. The data are extracted from the Swedish National Patient Registry on subjects that reside in western Sweden.

RESULTS

Subjects made 13,782 healthcare contacts at a total cost 61.1 million SEK (6.0 million EUR) between 2014 and 2018. The mean cost per subject was 93,075 SEK (9071 EUR) and ranged between 3971 SEK (387 EUR) and 468,711 SEK (45,683 EUR) per individual. In the most expensive quartile of subjects, mean cost was 192,353 SEK (18,747 EUR) over the 5-year period. These subjects made 3227 ENT contacts (roughly four each year) and 60% of total costs were associated with in-patient ENT care.

CONCLUSION

Patients with chronic otitis media are associated with high ENT resource utilization that does not diminish after surgical intervention and the disease places a long-term burden on healthcare systems. Significant costs are attributed to revision surgeries, indicating that these patients could be managed more effectively. In many such cases, reoperation cannot be avoided, especially due to recurrence of cholesteatoma. However, in some patients, when the indication for subsequent surgery is only hearing improvement, alternative options, such as hearing aids or implants, should also be considered. This is especially true in difficult cases, where revision ossiculoplasty is likely.

Prognostic factors of hearing outcome in patients with chronic suppurative otitis media following tympanoplasty: a retrospective cohort study

Background

Research on the factors affecting the functional outcome of tympanoplasty in chronic suppurative otitis media (CSOM) is limited. This study aimed to investigate the prognostic factors of hearing outcome in CSOM patients following tympanoplasty. The multivariate logistic regression analysis is used to evaluate the influence of demographic, audiological, clinical and disease factors on the postoperative prognosis of CSOM.

Methods

A total of 179 CSOM patients who received surgery between January 2016 and December 2019 were retrospectively included. The inclusion criteria are mainly based on clinical classification of otitis media and surgical classification guidelines [2012]. These patients were divided into an effective group (n=132) and a non-effective group (n=47) according to their postoperative air-bone gap (ABG) value. Multivariate analysis was performed according to the pure tone hearing results 1 week before operation and 4 weeks after operation.

Results

The type of preoperative hearing impairment, middle ear cholesteatoma, ossicular chain status, tympanic perforation site, repair material, tympanum sclerosis, and surgical methods were significantly different between the effective and non-effective groups (all P<0.01). The speech reception threshold (SRT) (36.88±15.54 vs. 27.68±13.75, P<0.001) and ABG (18.53±9.30 vs. 10.89±5.07, P<0.001) values were markedly reduced after surgery in the effective group but not in the non-effective group. Furthermore, the postoperative decreases in the SRT (9.20±9.69 vs. 2.021±7.34, P<0.001) and ABG (7.64±8.57 vs. 0.45±7.322, P<0.001) values were considerably higher in the effective group than the non-effective group. After multivariate logistic regression analysis, we found that the type of preoperative hearing impairment [P=0.031; odds ratio (OR) =2.378], ossicular chain status (P=0.002; OR =4.430).

Conclusions

Our research shows that the curative effect of conductive deafness before operation is 2.378 times better than that of mixed deafness, the curative effect of complete and unfixed ossicular chain before operation is 1.080 times better than that of interrupted ossicular chain, and the curative effect of complete ossicular chain but fixed ossicular chain is 4.430 times better than that of interrupted ossicular chain. Our findings may help to predict the postoperative prognosis of patients, thus facilitating the development of corresponding treatment strategies.

Long-Term Health Utilization and Outcomes in Chronic Suppurative Otitis Media

OBJECTIVE

To report health utilization patterns and outcomes of medical and surgical management in patients with chronic suppurative otitis media (CSOM).

STUDY DESIGN

Retrospective cohort.

SETTING

Academic otology clinic.

METHODS

This study included 175 patients with CSOM with a first clinic visit at our institution between March 2011 and November 2016. All patients displayed a diagnosis of CSOM by International Classification of Diseases code, had at least 1 episode of active CSOM (defined as perforation with otorrhea), and had a documented history of chronic ear infections. The mean age was 49.5 ± 1.5 years, 53% were female, and mean follow-up time was 3.5 ± 0.3 years.

RESULTS

Patients had an average of 9.5 ± 0.5 otology visits, 4.7 ± 0.4 prescriptions, and 1.7 ± 0.1 surgeries, with estimated per patient cost ranging from $3927 to $20,776. Under medical management, 69% of patients displayed recurrence of disease, with a median time to recurrence of 4 months. For tympanoplasty and tympanomastoidectomy, median time to recurrence was similar at 5 and 7 years, respectively (P = .73). At the most recent visit, the prevalence of all patients with CSOM displaying moderate or worse sensorineural hearing loss (SNHL) was 41%.

CONCLUSIONS

CSOM represents a major public health issue with high health care utilization and associated costs. Surgery is superior to medical therapy for achieving short- to medium-term inactive disease. Patients with CSOM display a high SNHL burden.

Extended high frequency hearing loss in tinnitus-positive chronic suppurative otitis media patient

OBJECTIVES

To determine the association between extended high frequency hearing loss and tinnitus in normal cochlear function based on a conventional audiometry chronic suppurative otitis media (CSOM) patient.

DESIGN AND METHODS

A cross-sectional study was conducted on 220 ears diagnosed as having CSOM with an equal number of tinnitus and without tinnitus groups. Only those with normal cochlear function based on conventional pure tone audiometry (250 Hz to 8 kHz) were included. They were further tested for hearing at extended high frequencies of up to 16 kHz. The severity of tinnitus was tested using a tinnitus questionnaire.

RESULTS

The prevalence of extended high frequency hearing loss in the normal cochlear function CSOM patients with tinnitus was 81.8% (95% CI 74.5%, 89.1%), whereas the prevalence in the tinnitus negative group was 30.0% (95% CI 21.3%, 38.7%). There was a significant association between extended high frequency hearing loss and tinnitus in CSOM patients (P < .001). The average thresholds were significantly higher in the tinnitus group at all extended high frequencies tested with an increasing trend of significance toward the higher frequencies. However, this study did not observe any association between the severity of tinnitus and extended high frequency hearing loss.

CONCLUSION

The development of tinnitus among normal cochlear function CSOM patients indicates that the damage has occurred at a higher frequency level. However, the severity of tinnitus does not predict the degree of higher frequency hearing loss. Therefore, the presence of tinnitus warrants more aggressive monitoring and treatment to prevent sensorineural hearing loss from developing into the speech frequencies.

LEVEL OF EVIDENCE

4.

Relation between otitis media and sensorineural hearing loss: a systematic review

OBJECTIVES

This systematic review summarises the evidence on the correlation between recurrent acute otitis media (rAOM) or chronic suppurative otitis media (CSOM) and sensorineural hearing loss (SNHL).

RESEARCH METHODS

PubMed, Embase and Cochrane Library databases were searched from inception to 15 January 2021. Two authors independently identified articles, extracted data and performed quality assessment for included studies. Studies comparing the sensorineural hearing levels of patients with a history of rAOM/CSOM for >3 months to a control group were included.

RESULTS

Screening of 4168 articles lead to inclusion of two case-control studies (control-group: patients non-OM) and seven cohort-studies (control group: contralateral ear). Quality assessment indicated considerable risk of bias in all studies. Reported populations varied (sample size 13-607, mean age 22-41.5 years, mean duration of disease 6.1-12.4 years). The OR for SNHL in the OM-group was 3.30-7.86 (95% CI 1.16 to 9.40, p<0.05) in cohort studies (n=2), and 0.05 (95% CI 0 to 0.78, p<0.05) in a case-control study. Mean/median bone conduction thresholds were respectively 1.19-32.21/0-10 dB higher on all frequencies (0.5-4 kHz) for the OM-group in four cohort studies (p<0.05). Two other studies reported no statistical test outcomes.

CONCLUSION

Due to the high risk of bias of included studies, effect estimates heterogeneity and suboptimal research designs, no conclusion on the correlation between OM and SNHL can be made. It emphasises the need for future prognostic studies.

Success rates in restoring hearing loss in patients with chronic otitis media: A systematic review

OBJECTIVE

To assess the effectiveness of tympanoplasty in treating chronic otitis media-related hearing loss, published literature was systematically reviewed to determine the clinical success rate of tympanoplasty at restoring hearing in chronic otitis media patients at a minimum follow-up period of 12-months.

DATA SOURCES

PubMed, Embase and the Cochrane Library.

METHODS

Two independent reviewers performed literature searches. Publications reporting long-term (≥12-month) hearing outcomes and complications data on adult and pediatric patients with chronic otitis media were included and assessed for risk of bias and strength of evidence. To assess how tympanoplasty influences long-term hearing outcomes, data on pure tone audiometry (air-bone gap) and complications were extracted and synthesized.

RESULTS

Thirty-nine studies met the inclusion criteria. Data from 3162 patients indicated that 14.0% of patients encountered postoperative complications. In adult patients, mean weighted air-bone gap data show closure from 26.5 dB hearing level (HL) (preoperatively) to 16.1 dB HL (postoperatively). In studies that presented combined adult and pediatric data, the mean preoperative air-bone gap of 26.7 dB HL was closed to 15.4 dB HL. In 1370 patients with synthesizable data, 70.7% of patients had a postoperative air-bone gap ˂ 20 dB HL at long-term follow-up. Finally, subgroup analysis identified that mean improvement in ABG closure for patients with and without cholesteatoma was 10.0 dB HL and 12.4 dB HL, respectively.

CONCLUSION

In patients with chronic otitis media, tympanoplasty successfully closed the air-bone gap to within 20 dB HL in 7/10 cases and had an overall complication rate of 14.0%.

LEVEL OF EVIDENCE

2a.

Controlled release of ciprofloxacin and ceftriaxone from a single ototopical administration of antibiotic-loaded polymer microspheres and thermoresponsive gel

Acute otitis media (AOM) is the main indication for pediatric antibiotic prescriptions, accounting for 25% of prescriptions. While the use of topical drops can minimize the administered dose of antibiotic and adverse systemic effects compared to oral antibiotics, their use has limitations, partially due to low patient compliance, high dosing frequency, and difficulty of administration. Lack of proper treatment can lead to development of chronic OM, which may require invasive interventions. Previous studies have shown that gel-based drug delivery to the ear is possible with intratympanic injection or chemical permeation enhancers (CPEs). However, many patients are reluctant to accept invasive treatments and CPEs have demonstrated toxicity to the tympanic membrane (TM). We developed a novel method of delivering therapeutics to the TM and middle ear using a topical, thermoresponsive gel depot containing antibiotic-loaded poly(lactic-co-glycolic acid) microspheres. Our in vitro and ex vivo results suggest that the sustained presentation can safely allow therapeutically relevant drug concentrations to penetrate the TM to the middle ear for up to 14 days. Animal results indicate sufficient antibiotic released for treatment from topical administration 24h after bacterial inoculation. However, animals treated 72h after inoculation, a more clinically relevant treatment practice, displayed spontaneous clearance of infection as is also often observed in the clinic. Despite this variability in the disease model, data suggest the system can safely treat bacterial infection, with future studies necessary to optimize microsphere formulations for scaled up dosage of antibiotic as well as further investigation of the influence of spontaneous bacterial clearance and of biofilm formation on effectiveness of treatment. To our knowledge, this study represents the first truly topical drug delivery system to the middle ear without the use of CPEs.

Mucosal Type of Chronic Suppurative Otitis Media and the Long-Term Impact on Hearing Loss

Introduction

Worldwide the chronic suppurative otitis media (CSOM) is one of the most common infectious diseases in childhood and is a common cause of impaired hearing. The disease remains a challenging entity for the healthcare system of resource-limited nations despite the advances in modern medicine. The nature of hearing loss in CSOM is mainly conductive, the sensorineural hearing loss (SNHL) is also reported in such patients. The purpose of the study was to identify SNHL in patients with the mucosal type of CSOM and to find the impact of long-term discharging ears on bone conduction (BC) thresholds.

Methods

Patients with a diagnosis of the mucosal type of CSOM were identified from the record of ENT, Head and Neck Surgery clinic between January 2019 and January 2020. The patients were divided into three groups based on the duration of the disease: groups I, II, and III for 1-5 years, 5-10 years, and 10-15 years, respectively. Pure tone audiogram was reviewed, and data of BC was recorded for 500, 1000, and 2000 Hz. The descriptive frequency was calculated for SNHL in each group and group I was compared with other groups using a chi-square test. The mean BC threshold of group I was compared with other groups using a t-test. SPSS version 26 (IBM Corp., Armonk, New York) was used for statistical analysis.

Results

A total of 154 patients were included in the study. There were 73 males and 81 females. The mean age was 26 years. The minimum age was 12 years and the maximum age was 58 years. Active ear discharge was the presenting complaint in 84 patients. The right ear was involved in 88 patients, and the left ear was involved in 66 patients. SNHL was present in 30 out of 154 patients, i.e., 19.5%. The number of patients in each of the groups I, II, and III was 95, 28, and 31, respectively. The group I was compared with group II using the chi-square test, the p-value was found not significant, i.e., >0.05. The group I was then compared with group III using the same statistical test, and the p-value was found significant, i.e., <0.05.

The mean BC threshold for an average of three speech frequencies for each of the three groups was 16.9, 18.7, and 22.9, respectively. The mean BC threshold of group I was compared with that of group II using a t-test, and the p-value was found not significant, i.e., >0.05. The mean BC threshold of group I was then compared with that of group III using a t-test, and the p-value was found significant, i.e., <0.05.

Conclusions

The findings of our study reproduce the presence of SNHL in a sizable proportion of the patients with a mucosal type of CSOM. Furthermore, the elevation of the BC threshold also appears statistically significant on analysis in association with the protracted duration of CSOM, highlighting the adverse impact of delaying the surgical repair. However, the clinical importance remains unclear because the maximum losses in the BC threshold seen in the patients are not severe enough to necessarily make them hard of hearing. Nevertheless, these statistically significant results influence clinical thought process and measures for an early remedy, including surgery, and need to be considered in time to prevent progressively worsening hearing loss in such cases.

Correlation between recovery time of extended high-frequency audiometry and duration of inflammation in patients with acute otitis media

OBJECTIVES

To explore the rule of extended high-frequency (EHF) audiometry recovery in patients with acute otitis media.

METHODS

From January 2016 to July 2019, patients with acute otitis media in the outpatient department of otology were studied. The diagnosis was made according to the otoscopy and acoustic impedance tests, and antibiotics and other treatment programs were given. The patients were followed up to compare the effects of different recovery time on extended high-frequency audiometry in patients with acute otitis media.

RESULTS

146 patients with acute otitis media (69 in the left ear and 77 in the right ear) were selected for observation and follow-up. The patients were divided into three groups according to the time from the onset to the disappearance of hyperacusis and earache symptoms: ≤ 5 days group (26 patients, 17.8%), 6-10 days group (74 patients, 50.7%), and > 10 days group (46 patients, 31.5%). The threshold of EHF in the study group was significantly higher than that in the control group in the early stage. According to the study design for follow-up, we found that with the prolongation of the duration of acute otitis media, the extended high frequency of different groups had different changes.

CONCLUSIONS

Our results show that the recovery time of EHF in patients with acute otitis media was later than that of the standard audiogram and was closely related to the course of the disease. This is of great significance for discovering the hidden hearing loss of the patients and taking the treatment plan as soon as possible.

Canal wall down approach for tympano-mastoid cholesteatoma: long-term results and prognostic factors

The aim of this study is to analyse the long-term anatomical and functional outcomes and prognostic factors of the canal wall down (CWD) tympanoplasty for the treatment of tympano-mastoid cholesteatoma. A total of 895 patients treated for tympano-mastoid cholesteatoma with follow-up longer than 10 years were included. Recidivism (recurrent and residual) cholesteatoma rates and functional results were analysed. The rate of recidivism was 7.7% (6.7% persistence and 1% recurrent disease). Recidivism was higher in paediatric patients (10.1% versus 5.0% of adults). Pathological middle ear mucosa and pars tensa was associated with increased rates of recidivism. Postoperatively, air pure-tone-average (aPTA) ≤ 30 dB was achieved in 36.4% of patients. Of 895 patients, a revision CWD tympanoplasty for chronic otorrhoea was performed in 14 cases (1.5%) with complete recovery in all cases. Nine of those patients had a recurrence of cholesteatoma and five had cavity problems related to granulation, de-epithelisation or recurrent infection. Paediatric patients and absence of stapes superstructure were associated with the worst auditory outcomes. Six-month results were always better than long-term results. A CWD approach was demonstrated to be effective, achieving the goals of cholesteatoma treatment.