A survey of the burden of management of chronic suppurative otitis media in a developing country

Epidemiology of Chronic Suppurative Otitis Media in the United States

OBJECTIVE

This study aimed to evaluate the prevalence, incidence, and associated demographic factors of chronic suppurative otitis media (CSOM), utilizing a nationwide healthcare claims database.

METHODS

This retrospective study utilized outpatient administrative claims data from the IBM MarketScan Research Database from 2007 to 2021. The database (11 246 909 584 claims with 148 147 615 unique patients) includes health data from the private-sector, Medicare/Medicaid, managed care providers, and EMR providers. Included patients had a diagnosis of CSOM based on ICD-9-CM and ICD-10-CM codes. Prevalence and health utilization were estimated by age, gender, and geographic region.

RESULTS

In the United States, the estimated CSOM prevalence and incidence was 0.46% and 0.03%, respectively. Among CSOM patients (n = 679 906), mean age (SD) was 8.1 (15.4) years, and 52.8% were male. Most patients (81.1%) were aged 0 to 10 years. CSOM prevalence was lower in females (OR = 0.64, 95% CI 0.64-0.65, P < .001), less common in older age (OR = 0.94, 95% CI 0.94-0.94, P < .001), and highest in the South region (OR = 2.08, 95% CI 2.06-2.09, P < .001).

CONCLUSION

Our results show CSOM prevalence (0.46%) is similar to other developed countries. CSOM prevalence was highest in those aged 0 to 10 years, in males and in the South region. Of note, prevalence and cost are likely significantly underestimated given limitations in accurate ICD-CM coding and the exclusion of uninsured patients. Further epidemiological studies are warranted to characterize the impact of CSOM on the US healthcare system.

Janus mesoporous organosilica/platinum nanomotors for active treatment of suppurative otitis media

We report a Janus mesoporous organosilica/platinum (MOS/Pt) nanomotor for active targeted treatment of suppurative otitis media, as a new type of multi-functional ear drop. The efficient propulsion of MOS/Pt nanomotors in hydrogen peroxide ear-cleaning drops significantly improves their binding efficiency with Staphylococcus aureus and enhances their antibacterial efficacy.

Prognostic Parameters and Their Relevance in Outcome of Middle Ear Surgeries

To study various parameters, including Middle ear risk index (MERI) and their correlation with outcome of middle ear surgery. The study was conducted from September 2015 to May 2017 in Department of Otolaryngology at our institute. It included 185 cases of safe type of chronic suppurative otitis media. These patients were admitted and treated surgically and record was kept for at least 3 months follow-up in postoperated period. The study concluded that a good correlation exist between MERI and result of tympanoplasty.

Barriers to access to ear and hearing care services in low- and middle- income countries: A scoping review

People living in low- and middle- income countries (LMICs) meet significant challenges in accessing ear and hearing care (EHC) services. We conducted a scoping review to identify and summarise such barriers, to recognise gaps in the literature, and to identify potential solutions. Reviewers independently screened titles, abstracts and full-text articles and charted data. We undertook thematic analysis of supply and demand side dimensions of access, and summarised findings mapped against the Levesque framework. Of 3048 articles screened, 62 met inclusion criteria for review. Across the five access dimensions, supply-side constraints were more frequently described, the most common being a shortage of EHC workforce or appropriate facilities, despite high demand. We identified a thin geographical spread of literature on barriers to accessing EHC services in LMICs, reflecting low availability of such services. LMICs face a diverse range of demand and supply side challenges including workforce, equipment and resource shortages, and challenges for the majority of the population to pay for such services. There is a need for many LMICs to develop health policy and programmes in EHC, including integration into primary care, scaling up the EHC workforce through increased training and education, and improving EHC literacy through public health measures.

High-Throughput Sequencing Investigation of Bacterial Diversity in Chronic Suppurative Otitis Media and Middle Ear Cholesteatoma

Background

Chronic otitis media is a common middle ear disease in otolaryngology. Bacterial infection is considered as the cause of the disease, but relying on conventional bacterial cultures can be problematic for identifying specific pathogens. Current research suggests that bacteria in microbial communities can only be identified by rDNA sequencing of bacteria.

Methods

This cross-sectional study utilized broad-range PCR amplification of 16S rRNA genes with clone analysis to compare bacterial diversity in lesions from 6 patients with chronic suppurative otitis media (CSOM) and 10 patients with cholesteatoma of middle ear lesions. Bacteria were analyzed at the levels of phylum, order, family, genus, and species.

Results

The age and sex difference between the patients with chronic suppurative otitis media and the patients with middle ear cholesteatoma were comparable (P > 0.05). Bacterial species abundance and species diversity were greater in cholesteatoma of the middle ear lesions than in CSOM lesions. The total number of detected operational taxonomic units (OTU) was 838, comprising 788 OTU detected in cholesteatoma pathological tissues, 230 in CSOM pathological tissues, and 180 OTU common to both groups. Proteus is a major part of CSOM (99.46%, P = 0.000321). The phyla detected in the Cholesteatoma samples were Proteus (Proteobacteria) (35.77%), thikum (Firmicutes) (44.21%, P = 0.001071), and Actinomycetes (Actinobacteria) (16.66%, P = 0.032464). At all bacterial taxonomic levels, the epithelial tissue of middle ear cholesteatoma was complex in terms of bacterial diversity, covering many Gram-positive and Gram-negative bacteria, likely related to bacterial microbiome formation. In contrast, the bacteriology of the CSOM lesions was relatively simple at all taxonomic levels, with all sequences characterized as belonging to Gram-negative bacteria.

Conclusion

Our results suggest that persistent middle ear cholesteatoma infection may be a microbial flora disorder related to conditional pathogenic bacteria rather than a single bacterial infectious disease. The pathogen is relatively single in the diseased tissue of chronic suppurative otitis media, which is the main reason for its effective antiinfection treatment.

The broader impacts of otitis media and sequelae for informing economic evaluations of pneumococcal conjugate vaccines

INTRODUCTION

Otitis media (OM) is a common childhood infection. Pneumococcal conjugate vaccines (PCVs) prevent OM episodes, thereby reducing short- and long-term clinical, economic, humanistic, and societal consequences. Most economic evaluations of PCVs focus on direct health gains and cost savings from prevented acute episodes but do not fully account for the broader societal impacts of OM prevention.

AREAS COVERED

This review explores the broader burden of OM on children, caregivers, and society to better inform future economic evaluations of PCVs.

EXPERT OPINION

OM causes a substantial burden to society through long-term sequelae, productivity losses, reduced quality of life for children and caregivers, and contribution to antimicrobial resistance from inappropriate antibiotic use. The effect of PCVs on acute OM has been recognized globally, yet the broader impact has not been consistently quantified, studied, or communicated. Economic evaluations of PCVs must evolve to include broader effects for patients, caregivers, and society from OM prevention. Future PCVs with broader coverage may further reduce OM incidence and antimicrobial resistance, but optimal uptake will depend on increasing the recognition and use of novel frameworks that include broader benefits. Communicating the full value of PCVs to decision makers may result in wider access and positive societal returns.

Development and Validation of a Prognostic Model to Predict Hearing Recovery for Patients With Chronic Otitis Media

OBJECTIVE

To explore the factors affecting postoperative hearing recovery in chronic otitis media (COM) patients, establish a clinical prediction model for hearing recovery, and verify the accuracy of the model.

METHODS

Data of patients with COM who were admitted to our hospital between January 1, 2012 and September 30, 2020 were retrospectively analyzed. We collected data on relevant clinicopathological characteristics of patients. The patients were randomly divided into the development cohort and validation cohorts. A postoperative air-bone gap (ABG) ≤20 dB was defined as successful hearing recovery. Univariate and multivariable logistic regression analyses were used to investigate the association of several prognostic factors with hearing recovery. These factors were then used to establish a nomogram. The model was subjected to bootstrap internal validation and performance evaluation in terms of discrimination, calibration, and clinical validity.

RESULTS

This study included 2146 patients with COM: the development cohort comprised 1610 patients (mean [standard deviation; SD] age, 44.1 [14.7] years; 733 men [45.5%]) and the validation cohort included 536 patients (mean [SD] age, 42.9 [14.4] years; 234 men [43.7%]). Multivariable logistic regression analysis showed that age, duration of onset, styles of surgery (tympanoplasty, canal wall up-CWU, or canal wall down-CWD), ossicular prosthesis, granulation or calcified blocks around the ossicular chain, ossicular chain integrity, duration of drilling, eustachian tube dysfunction, mixed hearing loss, semicircular canal fistula, and second surgery were associated with hearing recovery. A nomogram based on these variables was constructed. The area under the curve was 0.797 (95% confidence interval [CI], 0.778-0.812) in the development cohort and 0.798 (95% CI, 0.7605-0.8355) in the validation cohort.

CONCLUSIONS

This study demonstrated the various clinical factors correlated with hearing recovery in patients with COM. The nomogram developed with these data could provide personalized risk estimates of hearing recovery to enhance preoperative counseling and help to set realistic expectations in patients.

Topical versus systemic antibiotics for chronic suppurative otitis media

BACKGROUND

Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and often polymicrobial infection (involving more than one micro-organism) of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Antibiotics are the most common treatment for CSOM, which act to kill or inhibit the growth of micro-organisms that may be responsible for the infection. Antibiotics can be administered both topically and systemically, and can be used alone or in addition to other treatments for CSOM such as ear cleaning (aural toileting).

OBJECTIVES

To assess the effects of topical versus systemic antibiotics for people with CSOM.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 16 March 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least a one-week follow-up involving patients (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The studies compared topical antibiotics against systemic (oral, injection) antibiotics. We separated studies according to whether they compared the same type of antibiotic in both treatment groups, or different types of antibiotics. For each comparison we considered whether there was background treatment for both treatment groups, for example aural toileting (ear cleaning).

DATA COLLECTION AND ANALYSIS

We used the standard Cochrane methodological procedures. We used GRADE to assess the certainty of the evidence for each outcome. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not, measured at between one week and up to two weeks, two weeks up to four weeks, and after four weeks), health-related quality of life using a validated instrument, ear pain (otalgia) or discomfort or local irritation. Secondary outcomes included hearing, serious complications and ototoxicity measured in several ways.

MAIN RESULTS

Six studies (445 participants), all with high risk of bias, were included. All but two studies included patients with confirmed CSOM, where perforation of the ear drum was clearly documented. None of the studies reported results for resolution of ear discharge after four weeks or health-related quality of life. 1. Topical versus systemic administration of the same type of antibiotics (quinolones) Four studies (325 participants) compared topical versus systemic (oral) administration of ciprofloxacin. Three studies reported resolution of ear discharge at one to two weeks and found that the topical administration may slightly increase resolution (risk ratio (RR) 1.48, 95% confidence interval (CI) 1.24 to 1.76; 285 participants; 3 studies; I2 = 0%; low-certainty evidence). In these studies, aural toileting was either not mentioned, or limited to the first visit. Three studies (265 participants) reported that they did not suspect ototoxicity in any participants, but it is unclear how this was measured (very low-certainty evidence). No studies reported the outcomes of ear pain or serious complications. No studies reported results for hearing, despite it being measured in three studies. 2. Topical versus systemic administration of different types of antibiotics (quinolones versus aminoglycosides) One study (60 participants) compared topical ciprofloxacin versus gentamicin injected intramuscularly. No aural toileting was reported. Resolution of ear discharge was not measured at one to two weeks. The study did not report any 'side effects' from which we assumed that no ear pain, suspected ototoxicity or serious complications occurred (very low-certainty evidence). The study stated that "no worsening of the audiometric function related to local or parenteral therapy was observed". 3. Topical versus systemic administration of different types of antibiotics (quinolones versus amoxicillin-clavulanic acid) One study compared topical ofloxacin with amoxicillin-clavulanic acid with all participants receiving suction ear cleaning at the first visit. It is uncertain if there is a difference between the two groups in resolution of ear discharge at one to two weeks due to study limitations and the very small sample size (RR 2.93, 95% CI 1.50 to 5.72; 56 participants; very low-certainty evidence). It is unclear if there is a difference between topical quinolone compared with oral amoxicillin-clavulanic acid with regards to ear pain, hearing or suspected ototoxicity (very low-certainty evidence). No studies reported the outcome of serious complications.

AUTHORS' CONCLUSIONS

There was a limited amount of low-quality evidence available, from studies completed over 15 years ago, to examine whether topical or systemic antibiotics are more effective in achieving resolution of ear discharge for people with CSOM. However, amongst this uncertainty there is some evidence to suggest that the topical administration of antibiotics may be more effective than systemic administration of antibiotics in achieving resolution of ear discharge (dry ear). There is limited evidence available regarding different types of antibiotics. It is not possible to determine with any certainty whether or not topical quinolones are better or worse than systemic aminoglycosides. These two groups of compounds have different adverse effect profiles, but there is insufficient evidence from the included studies to make any comment about these. In general, adverse effects were poorly reported.

Systemic antibiotics for chronic suppurative otitis media

BACKGROUND

Chronic suppurative otitis media (CSOM) is a chronic inflammation and infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Systemic antibiotics are a commonly used treatment option for CSOM, which act to kill or inhibit the growth of micro-organisms that may be responsible for the infection. Antibiotics can be used alone or in addition to other treatments for CSOM.

OBJECTIVES

To assess the effects of systemic antibiotics for people with CSOM.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 16 March 2020.

SELECTION CRITERIA

We included randomised controlled trials comparing systemic antibiotics (oral, injection) against placebo/no treatment or other systemic antibiotics with at least a one-week follow-up period, involving patients with chronic (at least two weeks) ear discharge of unknown cause or due to CSOM. Other treatments were allowed if both treatment and control arms also received it.

DATA COLLECTION AND ANALYSIS

We used the standard Cochrane methodological procedures. We used GRADE to assess the certainty of the evidence for each outcome. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not, measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks); health-related quality of life using a validated instrument; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes included hearing, serious complications and ototoxicity measured in several ways.

MAIN RESULTS

We included 18 studies (2135 participants) with unclear or high risk of bias. 1. Systemic antibiotics versus no treatment/placebo It is very uncertain if there is a difference between systemic (intravenous) antibiotics and placebo in the resolution of ear discharge at between one and two weeks (risk ratio (RR) 8.47, 95% confidence interval (CI) 1.88 to 38.21; 33 participants; 1 study; very low-certainty evidence). The study did not report results for resolution of ear discharge after two weeks. Health-related quality of life was not reported. The evidence is very uncertain for hearing and serious (intracranial) complications. Ear pain and suspected ototoxicity were not reported. 2. Systemic antibiotics versus no treatment/placebo (both study arms received topical antibiotics) Six studies were included of which five presented useable data. There may be little or no difference in the resolution of ear discharge at between one to two weeks for oral ciprofloxacin compared to placebo or no treatment when ciprofloxacin ear drops were used in both intervention arms (RR 1.02, 95% CI 0.93 to 1.12; 390 participants; low-certainty evidence). No results after two weeks were reported. Health-related quality of life was not reported. The evidence is very uncertain for ear pain, serious complications and suspected ototoxicity. 3. Systemic antibiotics versus no treatment/placebo (both study arms received other background treatments) Two studies used topical antibiotics plus steroids as background treatment in both arms. It is very uncertain if there is a difference in resolution of ear discharge between metronidazole and placebo at four weeks (RR 0.91, 95% CI 0.51 to 1.65; 40 participants; 1 study; very low-certainty evidence). This study did not report other outcomes. It is also very uncertain if resolution of ear discharge at six weeks was improved with co-trimoxazole compared to placebo (RR 1.54, 95% CI 1.09 to 2.16; 98 participants; 1 study; very low-certainty evidence). Resolution of ear discharge was not reported at other time points. From the narrative report there was no evidence of a difference between groups for health-related quality of life, hearing or serious complications (very low-certainty evidence). One study (136 participants) used topical antiseptics as background treatment in both arms and found similar resolution of ear discharge between the amoxicillin and no treatment groups at three to four months (RR 1.03, 95% CI 0.75 to 1.41; 136 participants; 1 study; very low-certainty evidence). The narrative report indicated no evidence of differences in hearing or suspected ototoxicity (both very low-certainty evidence). No other outcomes were reported. 4. Different types of systemic antibiotics This is a summary of four comparisons, where different antibiotics were compared to each other. Eight studies compared different types of systemic antibiotics against each other: quinolones against beta-lactams (four studies), lincosamides against nitroimidazoles (one study) and comparisons of different types of beta-lactams (three studies). It was not possible to conclude if there was one class or type of systemic antibiotic that was better in terms of resolution of ear discharge. The studies did not report adverse events well.

AUTHORS' CONCLUSIONS

There was a limited amount of evidence available to examine whether systemic antibiotics are effective in achieving resolution of ear discharge for people with CSOM. When used alone (with or without aural toileting), we are very uncertain if systemic antibiotics are more effective than placebo or no treatment. When added to an effective intervention such as topical antibiotics, there seems to be little or no difference in resolution of ear discharge (low-certainty evidence). Data were only available for certain classes of antibiotics and it is very uncertain whether one class of systemic antibiotic may be more effective than another. Adverse effects of systemic antibiotics were poorly reported in the studies included. As we found very sparse evidence for their efficacy, the possibility of adverse events may detract from their use for CSOM.

Associated factors, health-related quality of life, and reported costs of chronic otitis media in adults at two otologic referral centers in a middle-income country

Background

Despite the high prevalence of chronic otitis media (COM) in low to middle-income countries, there are few studies regarding its associated factors, health-related quality of life, and treatment costs. This study aimed to identify associated factors of COM, assess its impact on the quality of life as well as estimate the patients’ reported costs of COM treatment in Colombia.

Methods

Cross-sectional study. Two otology-referral centers in Bogotá (Colombia) were included. Questionnaires focusing on sociodemographic and clinical associated factors, quality of life, and patients’ reported costs were administered to 200 adults with COM diagnosis and 144 control adults. Otoscopic evaluation and audiometric data were collected.

Results

The mean age was 42.2 years (SD: 14.44). The median length of COM was 26.13 years (SD: 17.06), and 79.5% of the COM patients reported otorrhea during childhood (P-value: 0.01). The most frequently reported allergic disease among our study population was allergic rhinitis (26.5%). COM was less frequent in patients with a medium-high socioeconomic status (PR: 0.54; 95% CI: 0.39–0.72), and more frequent in patients who reported increased ear discharge due to upper respiratory tract infections (PR: 1.69; 95% CI: 1.68–1.70). The global score of the “Chronic Suppurative Otitis Media Questionnaire-12” showed a difference of 9 points between patients with active and inactive COM (P < 0.001). Patients spent between 12.07% to 60.37% of their household income on expenses related to COM.

Conclusions

Associated factors found in this study are consistent with previous reports. COM has a significant financial impact and affects patients’ quality of life. Worldwide research addressing these issues in poor-resource countries is scarce, further studies are needed.

Validation of a Spanish version of the health-related quality of life (HRQoL) measure for Chronic Otitis Media (COMQ-12)

BACKGROUND

Evaluation of health-related quality of life (HRQoL) is considered an important aspect of clinical assessment and health research. Chronic Otitis Media (COM) is related to the quality of life deterioration subsequent to COM symptoms, social communication impairments, and lower work performance. However, there is no reliable information regarding the impact of this disease on health and quality of life in many resource-poor countries. Therefore, we translated into Spanish the Chronic Otitis Media Questionnaire-12 (COMQ-12) for the evaluation of HRQoL of Chronic Otitis Media (COM) in adult patients. Also, we assessed the psychometric properties of the Spanish version of the questionnaire.

METHODS

Two otology referral centers in Bogotá, Colombia were included. The Spanish version of COMQ-12 was applied twice to 200 adult patients with confirmed COM diagnosis and 31 healthy controls to perform the validation process and assess the internal consistency of this questionnaire. Psychometric characteristics (internal consistency, test-retest reliability, and construct validity) of the COMQ-12 were assessed. Exploratory Factor Analysis and Confirmatory Factor Analysis were conducted via structural equation modeling to test the questionnaire's structure.

RESULTS

The Spanish version of the COMQ-12 showed good internal consistency (Cronbach's Alpha: 0.86, McDonald's Omega: 0.89). Coefficients corresponding to Lin's Concordance test and test-retest reliability were 0.95 and 0.83 respectively. Correlation between the Visual Analogue Scale (VAS) and the COMQ-12 was 0.68 (95% CI 0.59-0.75, p value < 0.001). Factor analysis of the Spanish version of the COMQ-12 indicated a questionnaire structure with three domains: smelly discharge related symptoms; hearing loss related symptoms; and impact on work, lifestyle, and health services.

CONCLUSION

This Spanish version of the COMQ-12 showed high reliability and high internal consistency. This questionnaire can be used as an objective clinical tool to assess the HRQoL of patients who have a COM diagnosis.

TRIAL REGISTRATION

Hospital Universitario Fundación Santa Fe, Ethical Committee Registration ID: CCEI-8807-2018. Hospital de San José, Ethical Committee: Record number 500, DI-I-0632-18.

Aural toilet (ear cleaning) for chronic suppurative otitis media

BACKGROUND

Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and often polymicrobial infection (involving more than one micro-organism) of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Aural toileting is a term describing a number of processes for manually cleaning the ear. Techniques used may include dry mopping (with cotton wool or tissue paper), suction clearance (typically under a microscope) or irrigation (using manual or automated syringing). Dry mopping may be effective in removing mucopurulent discharge. Compared to irrigation or microsuction it is less effective in removing epithelial debris or thick pus. Aural toileting can be used alone or in addition to other treatments for CSOM, such as antibiotics or topical antiseptics.

OBJECTIVES

To assess the effects of aural toilet procedures for people with CSOM.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 16 March 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least a one-week follow-up involving people (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. We included any aural toileting method as the intervention, at any frequency and for any duration. The comparisons were aural toileting compared with a) placebo or no intervention, and b) any other aural toileting method. We analysed trials in which background treatments were used in both arms (e.g. topical antiseptics or topical antibiotics) separately.

DATA COLLECTION AND ANALYSIS

We used the standard Cochrane methodological procedures. We used GRADE to assess the certainty of the evidence for each outcome. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health-related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and the adverse events of ear bleeding and dizziness/vertigo/balance problems.

MAIN RESULTS

We included three studies with a total of 431 participants (465 ears), reporting on two comparisons. Two studies included only children with CSOM in the community (351 participants) and the other study (80 participants) included children and adults with chronic ear discharge for at least six weeks. None of the included studies reported the outcomes of health-related quality of life, ear pain or the adverse event of ear bleeding. Daily aural toileting (dry mopping) versus no treatment Two studies (351 children; 370 ears) compared daily dry mopping with no treatment. Neither study presented results for resolution of ear discharge at between one and up to two weeks or between two to four weeks. For resolution of ear discharge after four weeks, one study reported the results per person. We are very uncertain whether there is a difference at 16 weeks (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.60 to 1.72; 1 study; 217 participants) because the certainty of the evidence is very low. No results were reported for the adverse events of dizziness, vertigo or balance problems. Only one study reported serious complications, but it was not clear which group these patients were from, or whether the complications occurred pre- or post-treatment. One study reported hearing, but the results were presented by treatment outcome rather than by treatment group so it is not possible to determine whether there is a difference between the two groups. Daily aural toileting versus single aural toileting on top of topical ciprofloxacin One study (80 participants; 95 ears) compared daily aural toileting (suction) with administration of topical antibiotic (ciprofloxacin) ear drops in a clinic, to a single aural toileting (suction) episode followed by daily self-administered topical antibiotic drops, in participants of all ages. We are unsure whether there is a difference in resolution of ear discharge at between one and up to two weeks (RR 1.09, 95% CI 0.91 to 1.30; 1 study; 80 participants) because the certainty of the evidence is very low. There were no results reported for resolution of ear discharge at between two to four weeks. The results for resolution of ear discharge after four weeks were presented by ear, not person, and could not be adjusted to by person. One patient in the group with single aural toileting and self administration of topical antibiotic ear drops reported the adverse event of dizziness, which the authors attributed to the use of cold topical ciprofloxacin. It is very uncertain whether there is a difference between the groups (RR 0.33, 95% CI 0.01 to 7.95; 1 study; 80 participants, very low-certainty). No results were reported for the other adverse events of vertigo or balance problems, or for serious complications. The authors only reported qualitatively that there was no difference between the two groups in hearing results (very low-certainty).

AUTHORS' CONCLUSIONS

We are very uncertain whether or not treatment with aural toileting is effective in resolving ear discharge in people with CSOM, due to a lack of data and the poor quality of the available evidence. We also remain uncertain about other outcomes, including adverse events, as these were not well reported. Similarly, we are very uncertain whether daily suction clearance, followed by antibiotic ear drops administered at a clinic, is better than a single episode of suction clearance followed by self-administration of topical antibiotic ear drops.

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.

Topical antibiotics with steroids for chronic suppurative otitis media

BACKGROUND

Chronic suppurative otitis media (CSOM) is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Topical antibiotics act to kill or inhibit the growth of micro-organisms that may be responsible for the infection. Antibiotics can be used alone or in addition to other treatments for CSOM, such as steroids, antiseptics or ear cleaning (aural toileting). Antibiotics are commonly prescribed in combined preparations with steroids.

OBJECTIVES

To assess the effects of adding a topical steroid to topical antibiotics in the treatment of people with chronic suppurative otitis media (CSOM).

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 16 March 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least a one-week follow-up involving participants (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any combination of a topical antibiotic agent(s) of any class and a topical corticosteroid (steroid) of any class, applied directly into the ear canal as ear drops, powders or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antibiotic and steroid compared to a) placebo or no intervention and b) another topical antibiotic.

DATA COLLECTION AND ANALYSIS

We used the standard Cochrane methodological procedures. We used GRADE to assess the certainty of the evidence for each outcome. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks and after four weeks; health-related quality of life; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes included hearing, serious complications and ototoxicity.

MAIN RESULTS

We included 17 studies addressing 11 treatment comparisons. A total of 1901 participants were included, with one study (40 ears) not reporting the number of participants recruited, which we therefore could not account for. No studies reported health-related quality of life. The main comparisons were: 1. Topical antibiotics with steroids versus placebo or no treatment Three studies (210 participants) compared a topical antibiotic-steroid to saline or no treatment. Resolution of discharge was not reported at between one to two weeks. One study (50 'high-risk' children) reported results at more than four weeks by ear and we could not adjust the results to by person. The study reported that 58% (of 41 ears) resolved with topical antibiotics compared with 50% (of 26 ears) with no treatment, but the evidence is very uncertain. One study (123 participants) noted minor side effects in 16% of participants in both the intervention and placebo groups (very low-certainty evidence). One study (123 participants) reported no change in bone-conduction hearing thresholds and reported no difference in tinnitus or balance problems between groups (very low-certainty evidence). One study (50 participants) reported serious complications, but it was not clear which group these patients were from, or whether the complications occurred pre- or post-treatment. One study (123 participants) reported that no side effects occurred in any participants (very low-certainty evidence). 2. Topical antibiotics with steroids versus topical antibiotics (same antibiotics) only Four studies (475 participants) were included in this comparison. Three studies (340 participants) compared topical antibiotic-steroid combinations to topical antibiotics alone. The evidence suggests little or no difference in resolution of discharge at one to two weeks: 82.7% versus 76.6% (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.96 to 1.21; 335 participants; 3 studies (4 study arms); low-certainty evidence). No results for resolution of discharge after four weeks were reported. One study (110 participants) reported local itchiness but as there was only one episode in each group it is uncertain whether there is a difference (very low-certainty evidence). Three studies (395 participants) investigated suspected ototoxicity but it was not possible to determine whether there were differences between the groups for this outcome (very low-certainty evidence). No study reported serious complications. 3. Topical antibiotics with steroids compared to topical antibiotics alone (different antibiotics) Nine studies (981 participants plus 40 ears) evaluated a range of comparisons of topical non-quinolone antibiotic-steroid combinations versus topical quinolone antibiotics alone. Resolution of discharge may be greater with quinolone topical antibiotics alone at between one to two weeks compared with non-quinolone topical antibiotics with steroids: 82.1% versus 63.2% (RR 0.77, 95% CI 0.71 to 0.84; 7 studies; 903 participants, low-certainty evidence). Results for resolution of ear discharge after four weeks were not reported. One study (52 participants) reported usable data on ear pain, two studies (419 participants) reported hearing outcomes and one study (52 participants) reported balance problems. It was not possible to determine whether there were significant differences between the groups for these outcomes (very low-certainty evidence). Two studies (149 participants) reported no serious complications (very low-certainty evidence).

AUTHORS' CONCLUSIONS

We are uncertain about the effectiveness of topical antibiotics with steroids in improving the resolution of ear discharge in patients with CSOM because of the limited amount of low-certainty evidence available. Amongst this uncertainty, we found no evidence that the addition of steroids to topical antibiotics affects the resolution of ear discharge. There is also low-certainty evidence that some types of topical antibiotics (without steroids) may be better than topical antibiotic/steroid combinations in improving resolution of discharge. There is also uncertainty about the relative effectiveness of different types of antibiotics; it is not possible to determine with any certainty whether or not quinolones are better or worse than aminoglycosides. These two groups of compounds have different adverse effect profiles, but there is insufficient evidence from the included studies to make any comment about these. In general, adverse effects were poorly reported.

Topical antiseptics for chronic suppurative otitis media

BACKGROUND

Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Topical antiseptics, one of the possible treatments for CSOM, inhibit the micro-organisms that may be responsible for the infection. Antiseptics can be used alone or in addition to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). Antiseptics or their application can cause irritation of the skin of the outer ear, manifesting as discomfort, pain or itching. Some antiseptics (such as alcohol) may have the potential to be toxic to the inner ear (ototoxicity), with a possible increased risk of causing sensorineural hearing loss, dizziness or tinnitus.

OBJECTIVES

To assess the effects of topical antiseptics for people with chronic suppurative otitis media.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL; 2019, Issue 4, via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 April 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least a one-week follow-up involving patients (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antiseptic agent of any class, applied directly into the ear canal as ear drops, powders or irrigations, or as part of an aural toileting procedure. Two main comparisons were topical antiseptics compared to: a) placebo or no intervention; and b) another topical antiseptic (e.g. topical antiseptic A versus topical antiseptic B). Within each comparison we separated studies where both groups of patients had received topical antiseptics a) alone or with aural toileting and b) on top of antibiotic treatment.

DATA COLLECTION AND ANALYSIS

We used the standard Cochrane methodological procedures. We used GRADE to assess the certainty of the evidence for each outcome. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health-related quality of life using a validated instrument; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes included hearing, serious complications and ototoxicity measured in several ways.

MAIN RESULTS

Five studies were included. It was not possible to calculate the total number of participants as two studies only provided the number of ears included in the study. A. Topical antiseptic (boric acid) versus placebo or no treatment (all patients had aural toileting) Three studies compared topical antiseptics with no treatment, with one study reporting results we could use (254 children; cluster-RCT). This compared the instillation of boric acid in alcohol drops versus no ear drops for one month (both arms used daily dry mopping). We made adjustments to the data to account for the intra-cluster correlation. The very low certainty of the evidence means it is uncertain whether or not treatment with an antiseptic leads to an increase in resolution of ear discharge at both four weeks (risk ratio (RR) 1.94, 95% confidence interval (CI) 1.20 to 3.16; 174 participants) and at three to four months (RR 1.73, 95% CI 1.21 to 2.47; 180 participants). This study narratively described no differences in suspected ototoxicity or hearing outcomes between the arms (very low-certainty evidence). None of the studies reported results for health-related quality of life, adverse effects or serious complications. B. Topical antiseptic A versus topical antiseptic B Two studies compared different antiseptics but only one (93 participants), comparing a single instillation of boric acid powder with daily acetic acid ear drops, provided any information for this comparison. The very low certainty of the evidence means that it is uncertain whether more patients had resolution of ear discharge with boric acid powder compared to acetic acid at four weeks (RR 2.61, 95% CI 1.51 to 4.53; 93 participants), or whether there was a difference between the arms with respect to ear discomfort due to the low number of reported events (RR 0.10, 95% CI 0.01 to 1.81; 93 participants). Narratively, the study reported no difference in hearing outcomes between the groups. None of the included studies reported any of the other primary or secondary outcomes.

AUTHORS' CONCLUSIONS

Due to paucity of the evidence and the very low certainty of that which is available the effectiveness and safety profile of antiseptics in the treatment of CSOM is uncertain.

Antibiotics versus topical antiseptics for chronic suppurative otitis media

BACKGROUND

Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Antibiotics and antiseptics kill or inhibit the micro-organisms that may be responsible for the infection. Antibiotics can be applied topically or administered systemically via the oral or injection route. Antiseptics are always directly applied to the ear (topically).

OBJECTIVES

To assess the effectiveness of antibiotics versus antiseptics for people with chronic suppurative otitis media (CSOM).

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL; 2019, Issue 4, via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 April 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least a one-week follow-up involving patients (adults and children) who had chronic ear discharge of unknown cause or CSOM, where ear discharge had continued for more than two weeks. The intervention was any single, or combination of, antibiotic agent, whether applied topically (without steroids) or systemically. The comparison was any single, or combination of, topical antiseptic agent, applied as ear drops, powders or irrigations, or as part of an aural toileting procedure. Two comparisons were topical antiseptics compared to: a) topical antibiotics or b) systemic antibiotics. Within each comparison we separated where both groups of patients had received topical antibiotic a) alone or with aural toilet and b) on top of background treatment (such as systemic antibiotics).

DATA COLLECTION AND ANALYSIS

We used the standard Cochrane methodological procedures. We used GRADE to assess the certainty of the evidence for each outcome. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health-related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes included hearing, serious complications and ototoxicity measured in several ways.

MAIN RESULTS

We identified seven studies (935 participants) across four comparisons with antibiotics compared against acetic acid, aluminium acetate, boric acid and povidone-iodine. None of the included studies reported the outcomes of quality of life or serious complications. A. Topical antiseptic (acetic acid) versus topical antibiotics (quinolones or aminoglycosides) It is very uncertain if there is a difference in resolution of ear discharge with acetic acid compared with aminoglycosides at one to two weeks (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.72 to 1.08; 1 study; 100 participants; very low-certainty evidence). No study reported results for ear discharge after four weeks. It was very uncertain if there was more ear pain, discomfort or local irritation with acetic acid or topical antibiotics due to the low numbers of participants reporting events (RR 0.16, 95% CI 0.02 to 1.34; 2 RCTs; 189 participants; very low-certainty evidence). No differences between groups were reported narratively for hearing (quinolones) or suspected ototoxicity (aminoglycosides) (very low-certainty evidence). B. Topical antiseptic (aluminium acetate) versus topical antibiotics No results for the one study comparing topical antibiotics with aluminium acetate could be used in the review. C. Topical antiseptic (boric acid) versus topical antibiotics (quinolones) One study reported more participants with resolution of ear discharge when using topical antibiotics (quinolones) compared with boric acid ear drops at between one to two weeks (risk ratio (RR) 1.56, 95% confidence interval (CI) 1.27 to 1.92; 1 study; 409 participants; moderate-certainty evidence). This means that one additional person will have resolution of ear discharge for every five people receiving topical antibiotics (compared with boric acid) at two weeks. No study reported results for ear discharge after four weeks. There was a bigger improvement in hearing in the topical antibiotic group compared to the topical antiseptic group (mean difference (MD) 2.79 decibels (dB), 95% CI 0.48 to 5.10; 1 study; 390 participants; low-certainty evidence) but this difference may not be clinically significant. There may be more ear pain, discomfort or irritation with boric acid compared with quinolones (RR 0.56, 95% CI 0.32 to 0.98; 2 studies; 510 participants; low-certainty evidence). Suspected ototoxicity was not reported. D. Topical antiseptic (povidone-iodine) versus topical antibiotics (quinolones) It is uncertain if there is a difference between quinolones and povidone-iodine with respect to resolution of ear discharge at one to two weeks (RR 1.02, 95% CI 0.82 to 1.26; 1 RCT, 39 participants; very low-certainty evidence). The study reported qualitatively that there were no differences between the groups for hearing and no patients developed ototoxic effects (very low-certainty evidence). No results for resolution of ear discharge beyond four weeks, or ear pain, discomfort or irritation, were reported. E. Topical antiseptic (acetic acid) + aural toileting versus topical + systemic antibiotics (quinolones) One study reported that participants receiving topical and oral antibiotics had less resolution of ear discharge compared with acetic acid ear drops and aural toileting (suction clearance every two days) at one month (RR 0.69, 95% CI 0.53 to 0.90; 100 participants). The study did not report results for resolution of ear discharge at between one to two weeks, ear pain, discomfort or irritation, hearing or suspected ototoxicity.

AUTHORS' CONCLUSIONS

Treatment of CSOM with topical antibiotics (quinolones) probably results in an increase in resolution of ear discharge compared with boric acid at up to two weeks. There was limited evidence for the efficacy of other topical antibiotics or topical antiseptics and so we are unable to draw conclusions. Adverse events were not well reported.

Topical antibiotics for chronic suppurative otitis media

BACKGROUND

Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and often polymicrobial infection (involving more than one micro-organism) of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Topical antibiotics, the most common treatment for CSOM, act to kill or inhibit the growth of micro-organisms that may be responsible for the infection. Antibiotics can be used alone or in addition to other treatments for CSOM, such as antiseptics or ear cleaning (aural toileting).

OBJECTIVES

To assess the effects of topical antibiotics (without steroids) for people with CSOM.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 April 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least a one-week follow-up involving participants (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antibiotic agent(s) of any class, applied directly into the ear canal as ear drops, powders or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antibiotic compared to a) placebo or no intervention and b) another topical antibiotic (e.g. topical antibiotic A versus topical antibiotic B). Within each comparison we separated studies where both groups of participants had received topical antibiotic a) alone or with aural toileting and b) on top of background treatment (such as systemic antibiotics).

DATA COLLECTION AND ANALYSIS

We used the standard Cochrane methodological procedures. We used GRADE to assess the certainty of the evidence for each outcome. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks and after four weeks; health-related quality of life using a validated instrument; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes included hearing, serious complications and ototoxicity measured in several ways.

MAIN RESULTS

We included 17 studies with a total of 2198 participants. Twelve studies reported the sample size in terms of participants (not ears); these had a total of 1797 participants. The remaining five studies reported both the number of participants and ears, representing 401 participants, or 510 ears. A: Topical antibiotics versus placebo or no treatment (with aural toilet in both arms and no other background treatment) One small study compared a topical antibiotic (ciprofloxacin) with placebo (saline). All participants received aural toilet. Although ciprofloxacin was better than saline in terms of resolution of discharge at one to two weeks: 84% versus 12% (risk ratio (RR) 6.74, 95% confidence interval (CI) 1.82 to 24.99; 35 participants, very low-certainty evidence), the very low certainty of the evidence means that it is very uncertain whether or not one intervention is better or worse than the other. The study authors reported that "no medical side-effects and worsening of audiological measurements related to this topical medication were detected" (very low-certainty evidence). B: Topical antibiotics versus placebo or no treatment (with use of oral antibiotics in both arms) Four studies compared topical ciprofloxacin to no treatment (three studies; 190 participants) or topical ceftizoxime to no treatment (one study; 248 participants). In each study all participants received the same antibiotic systemically (oral ciprofloxacin, injected ceftizoxime). In at least one study all participants received aural toilet. Useable data were only available from the first three studies; ciprofloxacin was better than no treatment, resolution of discharge occurring in 88.2% versus 60% at one to two weeks (RR 1.47, 95% CI 1.20 to 1.80; 2 studies, 150 participants; low-certainty evidence). None of the studies reported ear pain or discomfort/local irritation. C: Comparisons of different topical antibiotics The certainty of evidence for all outcomes in these comparisons is very low. Quinolones versus aminoglycosides Seven studies compared an aminoglycoside (gentamicin, neomycin or tobramycin) with ciprofloxacin (734 participants) or ofloxacin (214 participants). Whilst resolution of discharge at one to two weeks was higher in the quinolones group the very low certainty of the evidence means that it is very uncertain whether or not one intervention is better or worse than the other (RR 1.95, 95% CI 0.88 to 4.29; 6 studies, 694 participants). One study measured ear pain and reported no difference between the groups. Quinolones versus aminoglycosides/polymyxin B combination ±gramicidin We identified three studies but data on our primary outcome were only available in one study. Comparing ciprofloxacin to a neomycin/polymyxin B/gramicidin combination, for an unknown treatment duration (likely four weeks), ciprofloxacin was better (RR 1.12, 95% CI 1.03 to 1.22, 186 participants). A "few" patients experienced local irritation upon the first instillation of topical treatment (numbers/groups not stated). Others Other studies examined topical gentamicin versus a trimethoprim/sulphacetamide/polymixin B combination (91 participants) and rifampicin versus chloramphenicol (160 participants). Limited data were available and the findings were very uncertain.

AUTHORS' CONCLUSIONS

We are uncertain about the effectiveness of topical antibiotics in improving resolution of ear discharge in patients with CSOM because of the limited amount of low-quality evidence available. However, amongst this uncertainty there is some evidence to suggest that the use of topical antibiotics may be effective when compared to placebo, or when used in addition to a systemic antibiotic. There is also uncertainty about the relative effectiveness of different types of antibiotics; it is not possible to determine with any certainty whether or not quinolones are better or worse than aminoglycosides. These two groups of compounds have different adverse effect profiles, but there is insufficient evidence from the included studies to make any comment about these. In general, adverse effects were poorly reported.

Pediatric hearing screening in low-resource settings: Incorporation of video-otoscopy and an electronic medical record

OBJECTIVE

To develop a sustainable, comprehensive, intervention-based approach to pediatric hearing care in low- and middle income countries (LMICs) where global hearing loss is most heavily concentrated.

METHODS

Community health workers (CHWs) in Kilifi county, Kenya were trained to conduct hearing screening and video-otoscopy via a unified, smartphone-based platform using mobile electronic medical record (EMR) generation for children diagnosed with hearing loss or other pathology. Among at-risk students pre-selected by their teachers, the frequency of hearing loss and pathology in children with and without hearing loss was measured.

RESULTS

Of the 155 screened, 16 (10%) children were found to have hearing loss. 12 (5.9%) children with normal hearing had the following pathology: perforation (N = 5 ears), effusion (N = 9), retraction (N = 6), and infections (N = 7). CHWs were also adept at EMR creation without significant delay in workflow. Out of all those screened, 28 (18%) children were found to have hearing loss or other pathology and were referred to follow up. All 28 of 28 children referred were successfully entered into the EMR.

CONCLUSIONS

CHWs with little to no prior medical experience can provide a much needed public health service - hearing screening in LMICs where access to health care is limited. The incorporation of video-otoscopy provides a more comprehensive approach to hearing care by not only helping identify etiologies of existing hearing disability but also conditions that predispose to future hearing loss. It can easily be performed in conjunction with hearing screenings via the use of a unified, mobile platform. The addition of EMR supports follow-up and allows remote consultation.

A comprehensive review of otorhinolaryngological global health concerns

Background

ENT disease prevalence, risk factors and treatment vary between developed and developing countries. Health provision, particularly disease prevention strategies and surgery, in developing countries is poor, manifesting as a high frequency of common and preventable diseases. Healthcare systems in developing countries are unsustainable, and the technological advances that provide ENT surgery with novel diagnostic and treatment opportunities are inaccessible.

Conclusion

A multifaceted approach is essential to improve the care of patients with ENT diseases in developing countries. Public health efforts must focus on educating the local community, reducing high-risk behaviours and decreasing the frequency of preventable diseases. Governments must be pressured to prioritise the funding of long-term, sustainable efforts with effective disease prevention strategies. Providing local healthcare professionals with high-quality ENT training so that self-sustaining and low-cost care can be delivered, mainly in a primary care setting, is key.

Surgical treatment of chronic ear disease in remote or resource-constrained environments

Background

Surgery for chronic suppurative otitis media performed in low- and middle-income countries creates specific challenges. This paper describes the equipment and a variety of techniques that we find best suited to these conditions. These have been used over many years in remote areas of Nepal.

Results and conclusion

Extensive chronic suppurative otitis media is frequently encountered, with limited pre-operative investigation or treatment possible. Techniques learnt in better-resourced settings with good follow up need to be modified. The paper describes surgical methods suitable for resource-poor conditions, with rationales. These include methods of tympanoplasty for subtotal wet perforations, hearing reconstruction in wet ears and open cavities, large aural polyps, and canal wall down mastoidectomy with cavity obliteration. Various types of autologous ossiculoplasty are described in detail for use in the absence of prostheses. The following topics are discussed: decision-making for surgery on wet or best hearing ears, children, bilateral surgery, working with local anaesthesia, and obtaining adequate consent in this environment.

Models of service delivery for ear and hearing care in remote or resource-constrained environments

Background

There is poor availability of ear and hearing services globally, because of a lack of infrastructure, funding, equipment and appropriately trained personnel. When deciding upon delivery of ear and hearing services, an approach based upon community assessment is advocated, with subsequent asset mapping and acquisition.

Objectives

Some of the challenges to delivery of care in resource-constrained or remote environments are acknowledged, with discussion of several existing models of service delivery, and their advantages and disadvantages. Public health and telehealth are also mentioned. This article may assist those trying to set up new programmes in ear and hearing health.

Causes of Delayed Care Seeking for Chronic Suppurative Otitis Media at a Rwandan Tertiary Hospital

Background

Chronic suppurative otitis media causes serious lifelong consequences when treatment is delayed. Early detection and effective treatment result in a good outcome and possible complications are thus avoided. The aim of this study was to determine the factors resulting in delayed care seeking for treatment of CSOM.

Method and Patient

The study was a cross-sectional survey conducted at a tertiary teaching hospital in Rwanda. A questionnaire was used to collect data of patients diagnosed with CSOM who attended ENT Department during the study period. We defined delayed care seeking as seeking treatment 6 months after onset of symptoms. Data was entered and analysed using SPSS 16.0.

Result

This study enrolled 109 patients, 97 (88.9%) of whom had delays in care seeking. Majority were young adults ranging between 21 and 30 years (39.2%) while 58.8% were rural residents. Fifty-eight patients (56.9%) of those with delayed presentation used traditional medicine. The main reason for delayed care seeking was low knowledge of CSOM reported by 88 (90.7%) patients.

Conclusion

This study shows that majority of patients with delayed care seeking are young adult patients. There is low knowledge concerning this disease and this significantly contributes to delayed care seeking.

Prevalence of Middle Ear Infections and Associated Risk Factors in Children under 5 Years in Gasabo District of Kigali City, Rwanda

Middle ear infections are common in children, and delay in diagnosis and treatment may result in complications such as delays in speech and language development and deafness. The aim of this study was to determine the prevalence and care seeking behaviour for middle ear infections in children under five years in Kigali city. We conducted a cross-sectional study among 810 children aged 6-59 months in Gasabo district of Kigali city, Rwanda. The prevalence of middle ear infections was 5.8%, of whom 4% had chronic suppurative otitis media. A child was less likely to develop middle ear infections if they lived in an urban setting (OR = 0.52, 95% CI: 0.285-0.958) but more likely to develop middle ear infections if exposed to household smoke (OR = 2.54, 95% CI: 1.18-5.46). Parents were unlikely to know that their child had an ear infection (OR: 0.15, 95% CI: 0.06-0.34). Middle ear infection remains a public health problem in Rwanda but many parents were not aware of its presence in the affected children. There is a need to raise awareness of parents about ear infection and to promote early care seeking from qualified health workers.

Knowledge and care seeking practices for ear infections among parents of under five children in Kigali, Rwanda: a cross-sectional study

BACKGROUND

Infections affecting the middle ear are a common childhood occurrence. Some cases may present with ear discharge through a tympanic membrane perforation which may heal spontaneously. However, up to 5% or more cases of those affected have persistent ear discharge. A number of barriers contribute towards delayed presentation at health facilities for treatment of ear infections. We conducted a study to evaluate parents' and caregivers' knowledge and care seeking practices for ear infections in children under five in Gasabo district in Kigali, Rwanda.

METHODS

Parents/guardians (n = 810) were interviewed using a structured questionnaire to elicit their knowledge of ear infections in children under five and their attitude to seeking care for their children.

RESULTS

The mean age of the respondents was 31.27 years (SD = 7.88, range 17-83). Considering an average of knowledge parameters which included causes, symptoms, prevention, treatment and consequences of ear infections, we found that 76.6% (622) of respondents were knowledgeable about ear infections. We defined a positive practice as seeking medical treatment (community health workers or health facility) and this was found in 89.1% (722) respondents. Correlating knowledge with choice of seeking treatment, respondents were 33% less likely to practice medical pluralism (OR = 0.33, CI 0.11-0.97, P = 0.043) if they were familiar with infections. Moreover, urban dweller were 1.7 times more likely to know ear infections compared to rural dwellers (OR = 1.70, CI 1.22-2.38, P = 0.002).

CONCLUSION

The majority of respondents had good knowledge and positive attitudes and practices about ear infection. However, medical pluralism was common. There is need to improve the community's awareness and access to primary health care facilities for the care of ear infections especially in rural areas of Rwanda.

The changing epidemiological and complications profile of chronic suppurative otitis media in a developing country after two decades

To evaluate the shift in epidemiological and complication profiles of chronic suppurative otitis media (CSOM) over two decades in a resource-limited economy. A retrospective analysis of the prevalence of CSOM and its complications in tertiary health institution a over a period of 2 years were compared between 203 cases seen in 2009 and December 2010 (present era); and 343 cases seen in 1990 and 1991 (previous era). Data were collected on the demographic characteristics of the patients, age of onset of otorrhoea, the disease type, laterality and complications of CSOM. The prevalence of CSOM significantly reduced from 9 % in the previous era to 5.1 % in the present era (P < 0.0001). The mean age of the recent group was 27.6 ± 19.3 years, and was 21.6 ± 18.2 years in the previous group. (P = 0.009). Although both group had peak age prevalence at 11-20 years, recent group saw more significant adult population >20 years of age (P ≤ 0.001). More significant cases of cholesteatoma were documented in the recent group (3.4 %) than previous era (0.9 %) (P = 0.02). Although no significant change was noted regarding the rates of complication of CSOM in the two eras (P = 0.18), there was a notable shift toward predominant extracranial pattern of complication in the recent group (P = 0.04). The prevalence of CSOM has shown a significant reduction after two decades and it appears that there has been a shift in the epidemiology of CSOM towards a predominantly adult population in the recent years. Despite an overall reduction in the incidence of intracranial complications of CSOM in our series, its complication rates have not changed remarkably after 20 years.

Hearing loss assessment in primary and secondary acquired cholesteatoma

INTRODUCTION

Acquired middle ear cholesteatoma can be classified as primary or secondary. Although both can result in hearing loss, it is still controversial whether there is an association between the type of cholesteatoma and the degree of hearing loss.

OBJECTIVE

To analyze the association between hearing loss and the type of acquired cholesteatoma, and the status of the ossicular chain.

METHODS

This was a cross-sectional historical cohort study involving patients diagnosed with acquired cholesteatoma who were surgically treated. Air and bone conduction thresholds, air-bone gaps and the status of the ossicular chain were analyzed for both types of cholesteatoma.

RESULTS

Eighty patients aged 5-57 were included in the study. Fifty-one patients had primary cholesteatoma and 29 had secondary cholesteatoma. Both types of cholesteatoma determined greater air-bone gaps at 0.5kHz. Secondary cholesteatoma determined greater hearing loss in all analyzed frequencies and higher air conduction and air-bone gap means.

CONCLUSION

There was association between hearing loss and the type of cholesteatoma. Secondary cholesteatoma resulted in greater hearing impairment.

Immunity genes and susceptibility to otitis media: a comprehensive review

Otitis media (OM) is a middle ear infection associated with inflammation and pain. This disease frequently afflicts humans and is the major cause of hearing loss worldwide. OM continues to be one of the most challenging diseases in the medical field due to its diverse host targets and wide range of clinical manifestations. Substantial morbidity associated with OM is further exacerbated by high frequency of recurrent infections leading to chronic suppurative otitis media (CSOM). Children have greater susceptibility to, and thus, suffer most frequently from OM, which can cause significant deterioration in quality of life. Genetic factors have been demonstrated, in large part by twin and family studies, to be key determinants of OM susceptibility. In this review, we summarize the current knowledge on immunity genes and selected variants that have been associated with predisposition to OM. In particular, polymorphisms in innate immunity and cytokine genes have been strongly linked with the risk of developing OM. Future studies employing state-of-the-art technologies, including next-generation sequencing (NGS), will aid in the identification of novel genes associated with susceptibility to OM. This, in turn, will open up avenues for identifying high-risk individuals and designing novel therapeutic strategies based on precise targeting of these genes.