Search

To report health utilization patterns and outcomes of medical and surgical management in patients with chronic suppurative otitis media (CSOM).Retrospective cohort.Academic otology clinic.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 byPatients 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 (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.

Tympanoplasty outcomes are well established in high income nations, but less reported in low-middle income countries (LMICs). LMICs see a higher prevalence of chronic suppurative otitis media, with anecdotal evidence of greater disease severity at presentation. Here we find that tympanoplasty performed by local surgeons in the LMIC of Cambodia has 85.8% successful closure, which is comparable to other settings. For audiological outcomes, there was a mean reduction in the air-bone gap of 15.8dB, and improvement in the air-conduction average in 85.5% of participants. We find no evidence that tympanoplasty outcomes in LMICs should differ from those in other settings.

Objective To analyze the results of the subjective visual vertical test using the "bucket method" in patients with chronic suppurative otitis media (CSOM). Study design Cross-sectional, controlled study. Setting Outpatient otology clinic in a tertiary care hospital. Subjects and methods Patients had CSOM, defined as the presence of chronic infection or inflammation of the middle ear cleft, associated with a perforation of the tympanic membrane, frequent or intractable middle ear suppuration, with or without cholesteatoma. Controls were selected using a nonprobability, purposive sampling method. We excluded patients with neurologic or metabolic diseases, cognitive deficits, otosclerosis, vestibular migraine, Meniere's disease, past use of ototoxic medication, or head and neck cancer. The volunteers were subjected to the subjective visual vertical test using the "bucket method." The results obtained in our study and control groups were analyzed using nonparametric tests. Results Our study comprised 51 patients with CSOM and 50 controls. In the CSOM group, we observed that 72.5% of the patients had vestibular symptoms in the past year, and 70.5% had abnormalities identified in at least 1 vestibular function test. The subjective visual vertical test revealed that patients with CSOM (with and without cholesteatoma) had significantly higher deviations of the true vertical as compared with controls (CSOM, 3.66°; controls, 0.76°; P Conclusion Our results revealed that CSOM was associated with high rates of vestibular symptoms, abnormal vestibular function tests, and abnormal subjective vertical visual results.

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.

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.

Objectives/hypothesis Bilateral myringotomy and tympanostomy tube placement (BMT) is the most common pediatric surgery in the United States. Intraoperative middle ear effusion (MEE) is a risk factor for future BMTs in children with recurrent acute otitis media (RAOM). However, the impact of the type of MEE is unknown. Here, we assess otologic outcomes based on intraoperative MEE type and indication for surgery. Study design Case series chart review. Methods After institutional review board approval, we performed a review of children undergoing BMTs between 2008 and 2009. Included patients had their first BMT, preoperative visit, and an operative report. Patients with cleft palate or Down syndrome were excluded. Indications for surgery included RAOM and chronic otitis media with effusion (COME). Other variables evaluated were future BMT, acquired cholesteatoma, and otorrhea. Logistic regression was used for statistical analysis. Results Out of 1,045 patients reviewed, 680 were included and underwent their first BMT. There were 619 patients who had RAOM. Serous effusions were present in 22.2%, mucoid in 31.3%, purulent in 12.9%, undocumented or bloody in 2.3% of patients, and 31.2% of patients had dry middle ears. Moreover, 22.7% of patients underwent future BMTs. In RAOM patients, serous effusions decreased odds of perforation (odds ratio [OR]: 0.195, 95% confidence interval [CI]: 0.0438-0.867, P = .032), and purulent effusions increased the odds of in-office otorrhea suctioning (OR: 2.13, 95% CI: 1.20-3.77, P = .010) compared to dry. Mucoid effusions had no significant effect on outcomes in COME or RAOM patients. Conclusions Intraoperative MEEs were noted in 68.7% of cases; purulent effusions increase the odds of in-office suctioning in RAOM patients. Level of evidence 4 Laryngoscope, 131:E993-E997, 2021.

Objectives (1) Describe longitudinal trends in annual prevalence of hospital admission for pediatric acute otitis media (AOM) and complications of AOM (CAOM) since introduction of pneumococcal vaccination in 2000 and (2) describe the longitudinal trend of prevalence of hospital admission for pneumococcal meningitis in children with AOM-related diagnoses in the postvaccination era. Study Design Retrospective analysis of Kids' Inpatient Database from 2000 to 2012. Setting Community, nonrehabilitation hospitals. Subjects and Methods To determine annual prevalence of admission for AOM/CAOM, nationally weighted frequencies of children aged

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.

Objectives To study the occurrence of fever and the behaviours of inflammatory blood markers (C-reactive protein – CRP and procalcitonin – PCT) during episodes of otorrhea due to uncomplicated chronic otitis media in immunocompetent and immunocompromised patients. Design Prospective study of patients presenting with otorrhea over a 36-month period. Setting All patients were treated at Bonsucesso General Hospital, a tertiary referral hospital in Rio de Janeiro, Brazil. Participants A total of 84 participants, of which 50 were immunocompetent and 34 were immunocompromised. Immunocompetent patients had a total of 106 episodes of otorrhea, and immunocompromised patients had 117 episodes of otorrhea. Main outcome measures Occurrence of fever (axillary temperature over 38°C) and elevation of C-reactive protein and procalcitonin levels above the normal ranges. Results In the immunocompetent group, the levels of procalcitonin were elevated in five of 106 episodes of otorrhea. The C-reactive protein levels were above the normal range in nine of 106 episodes, the same number of episodes in which fever was observed. In the immunocompromised group, procalcitonin was elevated in 38 of 117 episodes of otorrhea, C-reactive protein levels were abnormal in 40 episodes, and fever was detected in 37 episodes. Cases of otorrhea with systemic inflammatory response were significantly more common in immunocompromised patients with associated rhinosinusitis. Conclusions Otorrhea due to uncomplicated chronic otitis media rarely causes a systemic inflammatory response in immunocompetent patients. Its occurrence in immunocompromised patients seems to be more related to concurrent rhinosinusitis than to the chronic middle ear inflammation itself.

Objectives Hearing impairment is a significant burden in the developing world. However, no suitable quality of life (QoL) measures exist for use in Nepal. We aimed to amend and translate the Glasgow Health Status Inventory (GHSI), assessing QoL at any given time, and the Glasgow Benefit Inventory (GBI), assessing change in QoL following intervention, into Nepali and to assess the impact of ear disease and effect of surgery on QoL. Methods The GHSI and GBI were translated into Nepali and independently verified. The GHSI was administered by interview to patients before surgery, and the GBI was administered 6 months after surgery. The Mann–Whitney U-test was used for hypothesis testing. Results The GHSI was administered to 242 patients. In total, 205 had chronic suppurative otitis media (CSOM) without cholesteatoma and 37 had cholesteatoma. The mean GHSI score was 47.9. There was no significant difference in GHSI scores between patients with CSOM without cholesteatoma and those with cholesteatoma. The GBI was administered to 161 patients, 73 of whom had also been in the GHSI group. In total, 130 had CSOM without cholesteatoma, 31 had cholesteatoma. The mean GBI score was +38.4 with no significant difference between disease groups. Conclusions Ear disease in Nepal is associated with reduced QoL, and surgical intervention is associated with improved QoL. There is no difference in QoL or benefit following surgery for CSOM between patients with or without cholesteatoma. There are few QoL measures suitable for the developing world. It is essential to invest in these measures to guide health interventions. Objectifs La deficience auditive est une charge importante dans les pays en developpement. Cependant, aucune mesure convenable de la qualite de vie (QV) n'existe pour etre utilisee au Nepal. Nous avons cherche a modifier et traduire l'Inventaire de Statut de Sante de Glasgow (GHSI), qui evalue la QV a un moment donne, et l'Inventaire de Benefice de Glasgow (GBI), qui evalue des changements dans la QV apres intervention, pour les nepalais et avons evalue l'impact de la maladie de l'oreille et de l'effet de la chirurgie sur la QV. Methodes Le GHSI et le GBI ont ete traduits en nepalais et verifies independamment. Le GHSI a ete administre par interview aux patients avant la chirurgie et le GBI a ete administre six mois apres la chirurgie. Le test U de Mann-Whitney a ete utilise pour les tests d'hypotheses. Resultats Le GHSI a ete administre a 242 patients. 205 avaient une otite moyenne chronique suppuree (CSOM) sans cholesteatome et 37 avaient une cholesteatome. Le score moyen GHSI etait de 47,9. Il n'y avait pas de difference significative dans les scores GHSI entre les patients avec une CSOM sans cholesteatome et ceux avec cholesteatome. Le GBI a ete administre a 161 patients, dont 73 provenant egalement du groupe GHSI. 130 avaient une CSOM sans cholesteatome et 31 avaient une cholesteatome. Le score moyen GBI etait de 38,4 sans difference significative entre les groupes de la maladie. Conclusions La maladie de l'oreille au Nepal est associee a une QV reduite et une intervention chirurgicale est associee a une amelioration de la QV. Il n'y a pas de difference dans la QV ou le benefice apres une chirurgie pour CSOM entre les patients avec ou sans cholesteatome. Il y a peu de mesures convenables de la QV pour les pays en developpement. Il est essentiel d'investir dans ces mesures pour guider les interventions de sante. Objetivos La discapacidad auditiva comporta una carga significativa en los paises en vias de desarrollo. Sin embargo, no existen medidas de Calidad de Vida (CdV) idoneas para su uso en Nepal. Nuestro objetivo era corregir y traducir al Nepali el Inventario del Estado de Salud de Glasgow (IESG), evaluando la CdV en cualquier momento, y el Inventario de Beneficios de Glasgow (IBG), evaluando el cambio en CdV despues de la intervencion, y evaluar el impacto de la discapacidad auditiva y el efecto de la cirugia en la CdV. Metodos El IESG y el IBG fueron traducidos al Nepali y verificados de forma independiente. El IESG se administro durante una entrevista a los pacientes antes de la cirugia, el IBG se administro durante seis meses despues de la cirugia. Se utilizo la prueba de U de Mann-Whitney para probar la hipotesis. Resultados EL IESG se administro a 242 pacientes. 205 tenian una otitis media cronica supurativa (OMCS) sin colesteatoma y 37 tenian colesteatoma. El puntaje medio del IESG era 47.9. No habia una diferencia significativa en los puntajes IESG entre pacientes con OMCS sin colesteatoma y aquellos con colesteatoma. El IBG se administro a 161 pacientes, 73 de los cuales tambien habian estado en el grupo IESG. 130 tenian OMCS sin colesteatoma, 31 tenian colesteatoma. El puntaje medio de IBG era +38.4 sin ninguna diferencia significativa entre grupos de enfermedad. Conclusiones La discapacidad auditiva en Nepal esta asociada con un CdV reducida y la intervencion quirurgica estaba asociada con una mejora en la CdV. No hay diferencias en la CdV o los beneficios despues de la cirugia para OMCS entre pacientes con o sin colesteatoma. Hay pocas medidas de CdV adecuadas para los paises en vias de desarrollo. Es esencial invertir en estas medidas para informar las intervenciones sanitarias.

To evaluate the patency of the aditus ad antrum in cases of tubotympanic chronic suppurative otitis media (CSOM) and to measure its dimensions. Also, to examine its mucosa histologically for the presence of granulation tissue or occult cholesteatoma.Prospective case series.Main Alexandria University Hospital (tertiary referral center).Fifty adult patients with tubotympanic CSOM without evidence of cholesteatoma, after adequate medical control of otorrhea, presented with mild or moderate conductive hearing loss. In all patients, tympanoplasty with cortical mastoidectomy was performed. The patency and dimensions of the aditus ad antrum were assessed using a 30° endoscope. Biopsies were obtained from unhealthy mucosa to detect the presence of granulation tissue or occult cholesteatoma.Ten cases (20%) had a blocked aditus ad antrum by unhealthy and edematous mucosa. Biopsies revealed granulation tissue in all cases. No occult cholesteatoma was detected. The results were further analyzed in relation to multiple variables to detect any clinical clues of a blocked aditus.Of the studied cases, 20% had a blocked aditus. The prevalence of an obstructed aditus was higher among older patients with a long history (1 year) of ear discharge. Marginal and subtotal central perforations and the presence of myringosclerosis increase the probability of an obstructed aditus ad antrum.

To determine the predictive value of preoperative clinical, audiological, and radiological factors in diagnosing incudal necrosis in patients with tubotympanic chronic suppurative otitis media (CSOM).Case series with planned data collection.Tertiary care referral center.Patients older than five years of age diagnosed with tubotympanic CSOM who underwent tympanomastoid surgery were recruited. Findings on otoscopy, x-ray mastoid, pure-tone audiometry, and intraoperative otomicroscopy were recorded.Incus necrosis occurred in 24 (16%) of a total of 150 patients. On bivariate analysis, findings of active ear discharge (P = 0.01), anterosuperior location of perforation (P = 0.03), exposure of incudostapedial joint (P = 0.05), edematous middle ear mucous membrane (P = 0.05), middle ear granulations (P = 0.004), foreshortening of the handle of malleus (P = 0.04), moderate to moderately severe hearing loss (41-70 dB HL) (P = 0.000), and air-bone gap40 dB (P = 0.001) were found to be associated with incus necrosis. Intraoperative findings of aditus block (P = 0.001) and mastoid granulations (P = 0.005) were also found to be significantly associated with incus necrosis. Mastoid pneumatization and perforation size and site were not associated with incus necrosis. On multivariate analysis, only middle ear granulations (P = 0.04; odds ratio [OR] 3.161; 95% confidence interval [95% CI] 1.087-9.196) and a moderate to moderately severe hearing loss (41-70 dB HL) (P = 0.03; OR 1.720; CI 1.064-2.782) were found to be significant risk factors.Incus necrosis is best predicted by the presence of middle ear granulations and moderate to moderately severe hearing loss (41-70 dB HL). Knowledge of this information preoperatively can influence surgical decision making and preparedness regarding ossiculoplasty and patient consent.

1) To measure prevalence of hearing impairment (HI) in schoolchildren living in poverty in Peru. 2) To identify risk factors for HI and assess its impact on academic performance.Cross-sectional.Elementary schools in an asentimiento humano (shantytown) near Lima, Peru, October 2008 to March 2009.Schoolchildren (n = 335), ages six to 19 years.Audiological health was assessed with pure-tone audiometry, tympanometry, and otoscopy. The primary outcome was HI, defined as average threshold25 dB HL for 0.5, 1, 2, and 4 kHz, in one or both ears (per World Health Organization/International Organization for Standardization). A questionnaire on health history was administered to parents. Statistical analysis included univariate analysis for chi(2) values and odds ratios (ORs), and multivariate logistic regression.HI prevalence: 6.9 percent (95% confidence interval [CI] 4.2%-9.6%). Risk factors for HI (OR, 95% CI, P value): neonatal jaundice (5.59, 1.63-19.2, 0.015), seizure (7.31, 2.50-21.4, 0.0013), hospitalization (4.01, 1.66-9.68, 0.003), recurrent otitis media (5.06, 1.98-12.9, 0.002), past otorrhea (4.70, 1.84-12.0, 0.003), family history of HI at35 years (2.91, 1.19-7.14, 0.026), tympanic membrane abnormality (13.8, 4.48-42.7,0.001), cerumen impaction (15.8, 4.71-53.1,0.001), and eustachian tube dysfunction (4.87, 1.74-13.7,0.001). HI was an independent predictor of academic failure (3.36, 1.15-9.82, 0.03).Impoverished Peruvian schoolchildren were four to seven times more likely to experience HI than children living in higher-income countries. Untreated middle ear disease in the context of limited access to pediatric care was a major risk factor for HI. Furthermore, HI was associated with worse scholastic achievement. These results support prioritization of pediatric ear health as an essential component of the global health agenda, especially in resource-poor countries.

Objective To study the presence of biofilm formation in humans with chronic suppurative otitis media (CSOM). Study Design Cross-sectional study. Setting Tertiary academic hospital. Subjects and Methods Patients undergoing middle ear surgery between July 2006 and March 2008. Tissue samples were obtained from 25 patients, of which 20 specimens were successfully processed for this study. The remaining samples were not analyzed due to sample damage or loss during preparation. Of the 20 specimens studied, 10 were harvested as the experimental group from patients with CSOM and the other 10 harvested as controls from patients undergoing otologic surgery for acoustic neuroma, cochlear implant, or routine tympanoplasty. Ages ranged from 26 to 74 years (mean 45 yrs). Male-to-female ratio was 2:3. Scanning electron microscopy and confocal laser scanning microscopy were used to identify the presence of biofilms. Live-dead staining was used to assess whether bacteria present were viable. The outcome measured was the presence of adherent biofilms on middle ear mucosa. Results Biofilms were present in six of 10 samples (60%) from the CSOM group, but only in one of 10 control samples (10%). Comparative analysis revealed a statistically significant difference (P Conclusion Biofilms were statistically more common in patients with CSOM compared with control patients.

Aim: To determine whether Australian Aboriginal Medical Service (AMS) practitioners treat otitis media (OM) more aggressively in Aboriginal than non-Aboriginal children and the factors influencing their management decisions. Methods: A case vignette questionnaire was sent to all AMS practitioners working in December 2006. We compared responses based on the child's Aboriginal status using χ2 analysis. Results: Questionnaires were returned from 63/87 (72%) of the AMSs by 131/238 (55%) eligible practitioners. Few practitioners (13%) reported using tympanometry or pneumatic otoscopy (9%) when examining children's ears. Practitioners were more likely to treat acute OM with antibiotics (92% vs. 49%, P < 0.01) and to treat with courses longer than 7 days (25% vs. 14%, P= 0.03) in Aboriginal than non-Aboriginal children. Most practitioners (60%) used oral antibiotics to treat chronic suppurative OM and OM with effusion in Aboriginal children (58%). Factors increasing the likelihood of antibiotic use included: the child being Aboriginal (67%), wet perforations (62%) and bulging eardrums (59%). No AMS or practitioner characteristics were significant predictors. Most practitioners (99%) were aware of Therapeutic Guidelines (Antibiotic). Only half (54%) were aware of the Australian Government guidelines for managing OM in Aboriginal and Torres Strait Islander populations and only 22% used them 'often' or 'always'. Conclusions: Australian AMS practitioners treat OM more aggressively in Aboriginal children, consistent with the Australian Government guidelines, despite half being unaware of them. Opportunities to improve management include increased use of pneumatic otoscopy and tympanometry, and decreased antibiotic usage for OM with effusion and chronic suppurative OM.

Objective: To compare the effectiveness of bioactive glass implants and conchal cartilage in reconstructing the posterior canal wall during tympanomastoidectomy. Study design: Prospective cohort clinical study. Setting: Teaching hospital. Patients: Patients with clinically diagnosed chronic suppurative otitis media and cholesteatoma awaiting tympanomastoidectomy were recruited. Intervention: All patients underwent tympanomastoidectomy by the same surgeon. A first cohort of 12 patients underwent posterior canal wall reconstruction with autogenous conchal cartilage. A second cohort of 12 patients underwent such reconstruction with prefabricated bioactive glass. Main outcome measures: Primary– All patients underwent out-patient review at 1, 3, 6 and 12 months postoperatively, after which a second-look procedure was performed. Reconstructions were inspected for evidence of epithelialization, granulation, infection, stenosis, depression and extrusion. Secondary– All patients had perioperative serial pure-tone audiometry to check for any change in hearing levels upto 1 year postoperatively. Results: By 1 year postoperatively, both reconstructive graft materials showed good epithelialization, no granulation, no infection, no ear canal stenosis, no depression and no extrusion. At operative second-looks, bioactive glass particularly showed good tissue bonding, including both neovascularization and connective tissue integration. Overall clinical outcome was equivalent for both materials. Both graft materials showed no statistically significant difference in postoperative hearing levels. Conclusions: Bioactive glass and conchal cartilage showed equivalent clinical outcome in reconstructing the posterior canal wall without significantly affecting hearing levels. As bioactive glass does not require second site morbidity and thus also reduces operative time, we prefer it for reconstructing the posterior canal wall following tympanomastoidectomy.

Objectives To investigate the epidemiologic and microbiological characteristics of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and hospital-acquired methicillin-resistant Staphylococcus aureus (HA-MRSA) infections in the otorrhea of chronic suppurative otitis media (COM) patients. Design Retrospective study of patients with newly identified MRSA infections from January 1998 through December 2006. A total of 2773 patients with a diagnosis of COM were included in this study. An antibiotic sensitivity test was performed for each isolate. Results The prevalence of MRSA in COM was 4.9 percent (137 of 2773 patients). The proportion of CA-MRSA rose from 0.7 percent in 1998 to 11.4 percent in 2006. However, the proportion of HA-MRSA did not change significantly, from 0.7 percent in 1999 to 1.3 percent in 2006. All of the CA-MRSA strains identified in our study were susceptible to trimethoprim/sulfamethoxazole (TMP/SMX). Rifampin susceptibility was also noted in 90 percent of the cases. Conclusions CA-MRSA infections have risen dramatically in the past decade. CA-MRSA and HA-MRSA in COM differed in both clinical and microbiological aspects.

Objective: The objective of this is to determine the incidence of otogenic complications of chronic suppurative otitis media (CSOM) and its management. Study Design: The authors conducted a retrospective study. Methods: The study was conducted at the tertiary referral and teaching hospital. An analysis was made about the clinical and operative findings, surgical techniques and approaches, the overall management and recovery of the patients. The data were then compared with the relevant and available literature. Results: Of the 70 cases, 47 (67%) had a single complication, of which eight (11%) had intracranial and 39 (56%) had extracranial complications. Twenty-three (33%) had two or more complications. The commonly encountered intracranial complications were otitic meningitis, lateral sinus thrombosis, and cerebellar abscess, which were seen in 13 (19%), 10 (14%), and 6 (9%) cases, respectively. Among the extracranial complications, mastoid abscess, postauricular fistula, and facial palsy were encountered in 26 (37%), 17 (24%) and 10 (14%) patients, respectively. Surgeries were the main mode of treatment for these conditions. According to severity, we found four different types of the lateral sinus involvement. Three patients with otitic facial palsy failed to regain full facial function despite surgery. A total of nine patients with the diagnosis of otitic meningitis, lateral sinus thrombosis and interhemispheric abscess expired. It constituted the mortality rate of 13% in our study. Conclusion: CSOM complications, despite its reduced incidence, still pose a great challenge in developing countries as the disease present in the advanced stage leading to difficulty in management and consequently higher morbidity and mortality.

The results of tympanoplasty may be reported in a variety of ways. Pure-tone audiometry underpins reporting, yet there is no constancy in the pure-tone threshold average used. We examine the relationship between the 0.5, 1, 2 kHz, 0.5, 1, 2, 3 kHz and 0.5, 1, 2, 4 kHz pure-tone audiometry averages. Using audiometric data collected for 77 patients, we have compared hearing threshold using three different frequency averages derived from pure-tone audiometry. The 0.5, 1, 2 kHz, 0.5, 1, 2, 3 kHz and 0.5, 1, 2, 4 kHz three- and four-frequency averages are significantly different, this difference being primarily determined by the changes in the 4-kHz threshold. Using an average including 4 kHz results in 8% few patients achieving an ABG closure to within either 10 dB or 20 dB. When comparing surgical results with others, surgeons should use reports employing comparable audiometric measures of analysis.

To undertake cost-utility analysis for tympanomastoid surgery to analyze its cost-effectiveness in treating adult chronic suppurative otitis media (CSOM).Seventy-seven patients with CSOM were evaluated with the Chronic Ear Survey (CES) before and 1 year after tympanomastoid surgery. Direct health care cost data during the 1st year after operation were retrieved. The utility gain was defined as change in the CES total score. The cost-utility ratio (CUR) was defined as cost per utility gain. Patients were stratified by disease type into wet-ear and dry-ear groups.The average total direct cost attributable to tympanomastoid surgery is (in New Taiwan dollars) 45,716.3 in the 1st postoperative year, and the average CUR is 1850.9 New Taiwan dollars. The lower CUR of 1280.9 New Taiwan dollars for the wet-ear group is due to the greater utility gain (37.6 +/- 3.4 versus 24.4 +/- 6.8, P0.05) despite its higher cost (48,163.2 New Taiwan dollars versus 38,419.7 New Taiwan dollars, P0.05).Treating continuously or intermittently draining ears is more cost-effective, as compared with managing a quiescent infection, because of its favorable utility gain.

Until recently the only available antibiotic eardrops for treatment of the discharging middle ear and mastoid cavity have been potentially ototoxic. With the advent of non-ototoxic fluoroquinolone eardrops, consensus panels in the USA, Canada and the UK have advocated the preferential use of these agents in the open middle ear. However, in Australia, no fluoroquinolone topical agent is approved for use with tympanic membrane perforations, and when used as an 'off label' eardrop, none is on the Pharmaceutical Benefits Scheme. This creates an ethical dilemma, particularly with best practice management of chronic suppurative otitis media in indigenous children. Despite concerns regarding resistance issues with ototopical use of systemic antibiotics, bacterial resistance has not been documented in major studies. For equity and ethical reasons, Australian regulatory authorities should consider approving a sterile non-ototoxic eardrop for use in the open middle ear.

•A comprehensive 5-year follow-up study of Paparella grommet use in UK. •Study group consists of children previously treated with short-term grommets and with persistent glue ear. •Mean functional period was 3.73 years with 52% being retainde for the full 5 year duration of the study. •Infection and perforation rates increased with the duration of grommet in-situ and this was especially marked after 36 months. •We advise the elective removal of these long-term grommets after 3 years of function to reduce compication rate.

OBJECTIVE: To determine if Pseudomonas aeruginosa (PA) otitis media (OM) increases the risk of sensorineural hearing loss (SNHL) with semicircular canal transection in the guinea pig model.METHODS: PA was injected transtympanically into both middle ears of pigmented guinea pigs. Saline-injected animals served as controls. Two to 4 days after injection, one horizontal semicircular canal was transected and sealed. Hearing was tested using electrocochleography before and after transection.RESULTS: PA-OM was induced in all PA-injected ears. Five days after semicircular canal transection, click-evoked thresholds were significantly elevated in ears with PA-OM (P = 0.00009) but not in saline-injected ears (P = 0.398).CONCLUSION: Violation of the inner ear in the presence of PA-OM is associated with increased risk of SNHL in the guinea pig.SIGNIFICANCE: Factors unique to PA infection may be responsible for SNHL with labyrinthine injury in humans with chronic otitis media.

Objectives/Hypothesis: The objective was to describe the morphological changes in the cochlea in chronic otitis media. Study Design: Retrospective human temporal bone analysis. Methods: Fifteen temporal bones with unilateral chronic otitis media were selected and compared with contralateral normal temporal bones. Standard cytocochleograms and spiral ganglion cell reconstructions were performed on all temporal bones. Spiral ligament was divided into four segments according to the locations of different types of fibrocytes. The average loss of fibrocytes in each segment was estimated. Morphometric measurements of areas of stria vascularis and spiral ligament were made in all turns of the cochlea on mid modiolar sections. Results: Loss of outer and inner hair cells was common in the basal turn of the cochlea in temporal bones with chronic otitis media compared with control ears. There was no difference in the number of spiral ganglion cells in the chronic otitis media and contralateral ears. The areas of stria vascularis and spiral ligament in the basal turn decreased significantly in the ears with chronic otitis media compared with control ears. There were no significant differences between the ears with chronic otitis media and the contralateral ears for any of the regions characterized by the presence of types I-IV fibrocytes. Conclusion: The results of the study are consistent with the hypothesis that chronic otitis media causes cochlear disease.

Objectives Proteases of both the serine and metalloproteinase families have been shown to play a role in the pathogenesis of otitis media (OM). Inhibitors of proteases from each of these families have been shown to beneficially impact disease progression in a number of related chronic inflammatory conditions, but their use has not been studied in OM. The purpose of this study was to assess the activity of the protease inhibitors recombinant alpha 1-antitrypsin (rAAT) and ilomastat on inflammatory proteases present in human middle ear effusions (MEEs), with a view to their potential utility in the treatment of OM. Study Design Prospective and ex vivo. Methods MEEs were collected from 100 patients presenting for middle ear surgery, most commonly tympanostomy tube placement or treatment of acute posttympanostomy otorrhea (APTO). MEEs were analyzed for the presence of matrix metalloproteinases (MMPs) and human neutrophil elastase (HNE) and the inhibitory activity of rAAT and ilomastat on these proteases, respectively. Results MMP levels were highest in APTO, and HNE was highest in chronic suppurative OM and APTO. High levels of MMP and HNE (>3 mAU/min) were found in 52% and 37% of MEEs, respectively. Ilomastat and rAAT demonstrated significant inhibition of MMP and HNE activity (>30% reduction), respectively, in 80% and 82% of MEEs with high levels of activity. Conclusions Proteases are commonly found in OM. Ilomastat and rAAT are potent inhibitors of proteases in MEEs across a wide range of OM in humans. Investigation into the potential therapeutic benefits of these protease inhibitors is warranted.

In light of the possible adverse effects of radiation on hearing, we conducted a study to evaluate the long-term sensorineural hearing status following radiotherapy (RT) in patients suffering from nasopharyngeal carcinoma. Audiologic examinations were performed at regular intervals before and after RT. We also analyzed the effects of age, chemotherapy, pre-RT hearing status, and post-RT otitis media with effusion (OME) on post-RT hearing change. A total of 150 patients (261 ears) were enrolled in this study and followed up for a mean of 43.8 months. After RT, 8.9-28.8% of ears had at least a 10 dB loss in bone conduction threshold at speech frequency, which was defined as an average of hearing threshold at 0.5 kHz, 1 kHz, and 2 kHz, while the percentage was 18-34.2% at 4 kHz. Patient age was related to these changes at speech frequency, and the presence of post-RT OME was related to significant loss at both speech frequency and 4 kHz. Pre-RT hearing status and chemotherapy did not influence hearing change. To sum up, sensorineural hearing loss began as early as after completion of RT. Early changes may be transient, but the effect of radiation on hearing tended to be chronic and progressive.

Otic drops of either ciprofloxacin 0.2% solution (CIP) or a combination of polymyxin B, neomycin, and hydrocortisone suspension (PNH) were administered for 6 to 12 days to patients (14-71 years old) with chronic suppurative otitis media in a randomized, nonblinded, multicenter clinical trial. Two hundred thirty-two enrolled patients were analyzed for efficacy on a "per protocol" basis. The most frequently identified causal agents were Staphylococcus aureus (28% of the patients), Pseudomonas aeruginosa (19%), and Staphylococcus sp (9%). Clinical success was observed in 91% and 87% of the CIP-and PNH-treated patients, respectively. At 1-month follow-up, 4% of CIP and 6% of PNH patients showed a relapse of otorrhea. Bacteriologic eradication was seen in 89% and 85% of patients in the CIP and PNH groups, respectively. At 1-month follow-up, reinfection or recurrence of infection appeared in 3 patients in the PNH group and in 1 patient in the CIP group. Both treatments were well tolerated. The most frequently reported adverse events were pruritus, stinging, and earache. Audiometric tests did not show changes attributable to study drugs in any but 1 patient in the PNH group. This clinical trial shows that topical 0.2% ciprofloxacin solution in single-dose containers is effective and well tolerated in patients with chronic suppurative otitis media.

The treatment of patients with tympanostomy tubes (TTs) and otorrhea with medicated otic suspensions is well known, but confirmation of penetration into the middle ear is difficult. To address this question, we created an in vitro model of the human head and ear and then tested it with 5 different types of liquid exposure: tap water, soapy water, polymyxin B sulfate (Cortisporin), tobramycin and dexamethasone (TobraDex), and ciprofloxacin (Cipro) suspensions. A positive test result corresponded to liquids entering the middle ear through the TT. No positive test result was elicited with tap water (0/20), but soapy water did enter the middle ear (10/40) and was statistically significant (P = 0.0112). Without the use of slight tragal pressure, Cortisporin, TobraDex, and Cipro drops did not consistently pass through the TT (0/20, 1/25, 1/25). By placing the drops with the addition of tragal pressure, a statistically significant difference was obtained for each solution (20/20, 20/20, and 20/20, respectively [P0.0001]). We conclude that with a clean external auditory canal, patent TT, and no middle ear fluid, medicated otic suspensions enter the middle ear only when combined with slight tragal pressure.

In this study we evaluated eustachian tube function in patients with chronic otitis media and compared the results with normal subjects. Two different eustachian tube function tests were applied to 60 ears of the chronic otitis media group and 146 ears of the control group. While eustachian tube dysfunction was observed in 71.7% of the chronic suppurative otitis media group, it was only seen in 34.9% of the control group.

Interleukin-8 (IL-8), a potent neutrophilic chemoattractant and inflammatory cytokine, is present in middle ear effusions (MEEs) of children with otitis media and is thought to be responsible for the accumulation of neutrophils in MEEs. We hypothesized that IL-8 concentration predicts the total number and proportion of neutrophils in MEEs. IL-8 concentration and total and differential cell counts were measured in MEEs of children undergoing tympanostomy tube placement for otitis media. IL-8 was present in 80 (98%) of 82 effusions. The mean +/- SEM value for IL-8 was 7342 +/- 847 pg/mL. The mean +/- SEM count and percentage of neutrophils were 1.34 x 10(6) +/- 3.44 x 10(5) and 70.6 +/- 3.1%, respectively. IL-8 concentrations correlated positively with the total number (r = +0.30; P = 0.02) and percentage of neutrophils (r = +0.32; P = 0.01) in the effusion. Additionally, purulent effusions had greater IL-8 concentrations (P = 0.003) and greater neutrophil count (P = 0.03) than mucoid or serous effusions. We conclude that IL-8 is consistently present in MEEs of children and IL-8 concentration predicts the total number and proportion of neutrophils. Furthermore, IL-8 concentration and the total number of neutrophils correlate positively with the type of effusion. These results support the hypothesis that IL-8 recruits neutrophils to the middle ear in MEEs.

Otitis media (OM) is one of the most common reasons for antibiotic treatment in children. Controversies regarding antibiotic treatment for OM have accumulated in the past decade, and there seem to be more dilemmas than certainties. The objectives of this article are to provide the state-of-the art review on achievements in treatment of all different stages of OM, including acute otitis media (AOM), otitis media with effusion (OME), and chronic suppurative otitis media, and to outline the future research areas.PubMed, Ovid Medline, the Cochrane Database, and Clinical Evidence (BMJ Publishing).All types of articles related to OM treatment published in English between January 2007 and June 2011 were identified. A total of 286 articles related to OM treatment were reviewed by the panel members; 114 relevant quality articles were identified and summarized.New evidence emerged on beneficial results of antibiotic treatment, compared with observation of AOM in young children who were diagnosed based on stringent criteria. In OME, the main results were related to a nonsignificant benefit of adenoidectomy versus tympanostomy tube placement alone in the treatment of chronic OME in younger children. Other modalities of OM treatment were studied and described herein.Significant progress has been made in advancing the knowledge on the treatment of OM. Areas of potential future research have been identified and outlined.

Middle ear adhesions are well-known to the ear surgeon, although data on etiology, pathogenesis, and significance are lacking in current literature. This study on experimental acute otitis media presents histopathological data on these aspects. Pneumococci were inoculated in the right middle ear bulla of 25 rats; the left ear served as control. At days 4, 8, 16, 90, and 180, respectively, 5 rats were decapitated, and the bullae were removed, opened, and stained with periodic acid-Schiff (PAS)/alcian blue. The entire middle ear mucosae were dissected from the bone, embedded as whole mounts in colophonium chambers, and examined by light microscopy. Representative parts of the mucosae were sectioned and examined in the same way. All inoculated ears from day 8 and later (20 in total), contained mucosal adhesions of various sizes, shapes, and locations. None were found in control ears. The site of predilection for the development of adhesions was the hypotympanum, followed by the anterior epitympanum, the attic, the drum, the interossicular spaces, and the tubal orifice. Based on present histopathological findings, we conclude that the middle ear adhesion is a pathological phenomenon caused by infection, and we propose a six-stage hypothesis of pathogenesis: 1. Localized epithelial rupture; 2. Prolapse of subepithelial tissue; 3. Epithelialization of the prolapse; resulting in a polypous/fold-like prominence; 4. Growth and elongation of the prominence; 5. Fusion of the end/tip of the prominence with another part of the mucosa; 6. Formation of an adhesion.

Every otologic procedure carries the risk of damage to the inner ear. On the other hand, cholesteatoma and uncontrolled tubotympanic disease can lead to partial or total sensorineural loss, as well as intracranial complications. Our experience of the surgical management of eight patients with an only hearing ear is presented. There were no dead ears in this series and no significant worsening of inner ear function. The air conduction pure-tone average was worse in two patients without change in bone conduction. Of the eight patients, six wear a hearing aid with success and two patients manage without an aid. The present small series confirms that patients at risk of anacusis from cholesteatoma or chronic suppurative otitis media can be offered, in experienced tertiary referral units, a safe method of stabilizing the ear and preserving useful hearing.

The middle ear mucociliary system has been shown to have an important function in the clearance of effusions. Little is known, however, about its role in chronic suppurative otitis media (CSOM). The ciliary beat frequencies of middle ear mucosal biopsies and nasal brushings of 27 patients with CSOM were analysed using a computerized photometric technique. The ciliary beat frequency in the middle ear mucosa was significantly less than that in nasal mucosa. Frequency in ears of smoking patients was significantly lower compared with non-smoking patients. Nasal brushings were taken from 27 otherwise healthy age and sex-matched non-smoking controls and the ciliary beat frequency was very similar to nasal samples from patients with CSOM. Ear controls were obtained from otosclerotic patients undergoing tympanotomy and the beat frequency was significantly higher than in the ear of patients with CSOM. It is concluded that middle ear ciliary function is significantly reduced in CSOM, particularly in patients who smoke.

Twenty patients awaiting mastoid surgery for chronic suppurative otitis media underwent preoperative high resolution computerized tomography (CT) of the temporal bones. The CT scans were compared with the intraoperative findings. CT was helpful in determining the anatomy of the middle ear and mastoid, and accurately predicted the extent of the disease process in the sinus tympani and facial recess. However, it was unable to distinguish between cholesteatoma, mucosal disease and fluid, and it contributed little to the surgical management of the patients. This suggests that routine preoperative CT scanning of patients before uncomplicated virgin mastoid surgery is of questionable value.

Background Adenoidectomy, surgical removal of the adenoids, is a common ENT operation worldwide in children with recurrent or chronic nasal symptoms. A systematic review on the effectiveness of adenoidectomy in this specific group has not previously been performed. Objectives To assess the effectiveness of adenoidectomy versus non-surgical management in children with recurrent or chronic nasal symptoms. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 30 March 2009. Selection criteria Randomised controlled trials comparing adenoidectomy, with or without tympanostomy tubes, versus non-surgical management or tympanostomy tubes alone in children with recurrent or chronic nasal symptoms. The primary outcome studied was the number of episodes, days per episode and per year with nasal symptoms and the proportion of children with recurrent episodes of nasal symptoms. Secondary outcomes were mean number of episodes, mean number of days per episode and per year, and proportion of children with nasal obstruction alone. Data collection and analysis Two authors assessed trial quality and extracted data independently. Main results Only one study included children scheduled for adenoidectomy because of recurrent or chronic nasal symptoms or middle ear disease. In this study no beneficial effect of adenoidectomy was found. The numbers in this study were, however, small (n = 76) and the quality of the study was moderate. The outcome was improvement in episodes of common colds. The risk differences were non-significant, being 2% (95% CI -18% to 22%) and -11% (95% CI -28% to 7%) after 12 and 24 months, respectively. A second study included children with recurrent acute otitis media (n = 180). As otitis media is known to be associated with nasal symptoms, the number of days with rhinitis was studied as a secondary outcome measure. The risk difference was non-significant, being -4 days (95% CI -13 to 7 days). Authors' conclusions Current evidence regarding the effect of adenoidectomy on recurrent or chronic nasal symptoms or nasal obstruction alone is sparse, inconclusive and has a significant risk of bias. High quality trials assessing the effectiveness of adenoidectomy in children with recurrent or chronic nasal symptoms should be initiated.

Acute otitis media (AOM) is diagnosed on the basis of acute onset of pain and fever; a red, bulging tympanic membrane; and middle ear effusion. AOM is managed with analgesia (paracetamol or non-steroidal anti-inflammatory drugs). Antibiotic therapy is minimally effective for most patients; it is most effective for children2 years with bilateral otitis media and for children with discharging ears. National guidelines recommend antibiotic therapy for Indigenous children with AOM. Evidence for corticosteroids, topical analgesia and xylitol are scant. Otitis media with effusion (OME) is diagnosed as the presence of middle ear effusion (type B tympanogram or immobile tympanic membrane on pneumatic otoscopy) without AOM criteria. Well children with OME with no speech and language delays can be observed for the first 3 months; perform audiological evaluation and refer to an ear, nose and throat (ENT) specialist if they have bilateral hearing impairment30 dB or persistent effusion. Children with effusions persisting longer than 3 months can benefit from a 2-4-week course of amoxycillin. Chronic suppurative otitis media is a chronic discharge through a tympanic membrane perforation. It is managed with regular ear cleaning (dry mopping or povidone-iodine [Betadine] washouts) until discharge resolves; topical ear drops (eg, ciprofloxacin); audiological evaluation; and ENT review.

The long-term results of surgery for chronic suppurative middle ear disease at a non-university ENT-clinic (Vasa Central Hospital, Finland) are reported. The material consisted of 273 ears, 65 of which had been operated on by open cavity techniques, 178 by the original Palva obliteration method, and 30 by the intact canal wall method. Post-operative cholesteatoma occurred equally frequently with the two canal wall down methods (7.7 and 7.3%, respectively) but was more frequent after intact canal wall surgery (23.3%). Hearing was better and the infection rate lower with obliteration than with open cavity techniques. Post-operative infection was the least frequent and the hearing result best in the intact canal wall ears, but compared to the other two groups the extent of disease found at surgery was considerably less in this group. The obliteration operation proved to be a safe method in the hands of a practising otologist outside university clinics.

Myringotomy with tube placement is the most frequently performed otolaryngologic procedure in the United States, and purulent otorrhea after this procedure is not uncommon. Believing that ototopical preparations have proved useful in treating this malady, our group was compelled to examine whether and in what quantities these preparations are able to penetrate tympanotomy tubes. To this end, models were constructed and in vitro testing carried out with several popular formulations. (Otolaryngol Head Neck Surg 1999;121:35-7.)

BACKGROUND: This is an update of a Cochrane review first published in The Cochrane Library in Issue 4, 2008 and previously updated in 2011. Acute suppurative otitis media is one of the most common infectious diseases in childhood. Recurrent acute otitis media is defined for the purposes of this review as either three or more acute infections of the middle ear cleft in a six‐month period, or at least four episodes in a year. Strategies for managing the condition include the assessment and modification of risk factors where possible, repeated courses of antibiotics for each new infection, antibiotic prophylaxis and the insertion of ventilation tubes (grommets). OBJECTIVES: To establish whether grommet insertion reduces the frequency of episodes of recurrent acute otitis media and the proportion of symptomatic children. SEARCH METHODS: The Cochrane Ear, Nose and Throat Disorders Group (CENTDG) Trials Search Co‐ordinator searched the CENTDG Trials Register; Central Register of Controlled Trials (CENTRAL 2014, Issue 10); PubMed; EMBASE; CINAHL; Web of Science; Clinicaltrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 6 November 2014. SELECTION CRITERIA: Randomised controlled trials comparing grommet insertion versus control (antibiotics/other treatments/no treatment) for recurrent acute otitis media in children aged from 0 to 16 years. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies. Three authors independently assessed study quality and extracted data. We synthesised data descriptively. MAIN RESULTS: Two randomised controlled trials with a total of 148 participants are included in this review. The overall risk of bias in the studies is unclear. The first study randomised 95 children to grommets or control (antibiotic treatment of acute otitis media episodes). For the primary outcome, this study showed that grommet insertion leads to a mean reduction of 1.5 episodes of acute otitis media in the first six months after treatment. In six months of follow‐up significantly more children in the grommet group had no episodes of acute otitis media (P value < 0.001). Complications of surgery included grommet blockage with acute otitis media requiring re‐operation within six months in 3/54 children who underwent grommet insertion. Adverse effects were not documented in the control group. The following pre‐defined secondary outcomes were not reported: change in symptom scores for otalgia or otorrhoea, alteration in the frequency of otalgia or otorrhoea, and number of days at nursery or school lost secondary to acute otitis media. The second study reported on 53 of 68 children who were randomised to grommet insertion or six months of once a day sulfamethoxazole and trimethoprim antibiotic prophylaxis. There was no significant difference in the primary outcome, number of episodes of acute otitis media, during the six‐month follow‐up between grommet insertion and antibiotic treatment groups (64.5% in the surgical group versus 45.4% in the antibiotic group had no recurrence, P value = 0.4). Two participants underwent grommet re‐insertion to replace extruded tubes during the follow‐up period. The only other adverse effect reported was the development of a skin rash in two patients in the medical group. Other pre‐defined secondary outcome measures were not reported. The study has a high risk of bias and the results should be interpreted cautiously. AUTHORS' CONCLUSIONS: Grommets significantly increase the number of acute otitis media‐free children in the first six months after insertion compared to children who receive no treatment. Grommet insertion maybe of equivalent efficacy to once a day antibiotic prophylaxis. Further research is required to confirm the advantage of grommets over no treatment, investigate the effect beyond six months, compare grommet effectiveness against alternative active treatments and confirm the low risk of adverse effects compared to no treatment and all active treatments in recurrent acute otitis media. In the interim clinicians should consider the possible adverse effects of grommet insertion and alternative treatments before recommending surgery.

Active mucosal chronic otitis media (COM) is notoriously difficult to treat. A randomized, non-blind trial of a drop vs spray preparation of neomycin sulphate (3250 units/ml) and dexamethasone 0.1% (Otomize) has been performed. The spray was significantly better than drops (91% vs 44%) in the resolution of activity in simple perforations (P = 0.002 chi 2 test, with continuity correction). In ears with an open mastoid cavity, 68% of those on the spray preparation became inactive compared with 42% on drops, a difference which just failed to achieve statistical significance (P = 0.06). It is concluded that the spray delivery system is a significant improvement over drops for the treatment of active mucosal COM particularly in the absence of a mastoid cavity.

Because other known pathogens are frequently isolated with AXX, its clinical significance may be overlooked. AXX should not be considered a colonizer or contaminant, particularly in the presence of clinical signs and symptoms of infection. For a pediatric patient with AXX in the ear fluid, the choice of an antibiotic regimen should be based on in vitro activity of both AXX and other concurrent pathogens. Although the sensitivity of AXX may be highly variable, a number of antibiotics appear to be clinically useful.

The authors present 15 patients with middle ear malignant tumours, of which 13 were squamous cell carcinomas, one was a rhabdomyosarcoma and one a malignant lymphoma. In 11 of 13 patients with squamous cell carcinoma, long-standing chronic otitis media preceded the malignant process and only in 2 patients did the tumour develop without previous chronic infection. Most of the patients presented at an advanced stage of the disease: in 6 the tumour had destroyed surrounding bone, commonly involving the endocranium; in 7 the facial nerve was paralysed and in 8 patients there was total hearing loss. The diagnosis of malignant tumour was established before surgery in 5 patients, but 8 patients were operated upon for suspected chronic otitis. Three patients died without treatment and 10 were treated: 3 with radiotherapy because the tumour was inoperable, 3 had surgery only and 4 patients had surgery and received radiotherapy post-operatively. Of 7 operated patients only 2 are alive without signs of tumour. Our findings suggest that otologists should bear in mind this disease in patients with chronic suppurative otitis and accompanying suspected symptoms. In 2 patients with rare types of sarcoma of the middle ear the diagnosis of tumour was established at an advanced stage and they could not be treated.

BACKGROUND Chronic suppurative otitis media (CSOM) is a serious bacterial infection of the middle ear that can follow untreated acute otitis media. OBJECTIVES To assess the effects of different treatments for CSOM. SEARCH STRATEGY We searched Medline from 1966 to 1996 and a bibliographic collection of the Hearing Impairment Research Group in Liverpool, UK. We handsearched two otolaryngology journals and contacted members of an international hearing network. SELECTION CRITERIA Randomized trials of any method of management for patients with eardrum perforation and persistent otorrhea. DATA COLLECTION AND ANALYSIS Three reviewers independently assessed eligibility and trial quality. One reviewer extracted data. We contacted investigators for clarifications. MAIN RESULTS Twenty-four trials involving 1660 people were included. Clinical definitions and severity of CSOM varied, methodological quality was generally low and follow-up was short. Treatment with antibiotics or antiseptics accompanied by aural toilet was more effective in resolving otorrhea than no treatment (two trials, odds ratio 0.37, 95% confidence interval 0.24 to 0. 57) or aural toilet alone (six trials, odds ratio 0.31, 95% confidence interval 0.23 to 0.43). Topical treatment with antibiotics or antiseptics was more effective than systemic antibiotics (six trials, odds ratio 0.46, 95% confidence interval 0.30 to 0.69). Combining topical and systemic antibiotics was not more effective than topical antibiotics. Topical quinolones were more effective than non-quinolones (five trials, odds ratio 0.26, 95% confidence interval 0.16 to 0.41). No difference in the effectiveness of topical antibiotics and topical antiseptics was found (three studies, odds ratio 1.34, 95% confidence interval 0.64 to 2.81). Some topical antibiotic combinations may be more effective than others in resolving otorrhea. Rates of adverse drug events were low and equal between groups. AUTHORS' CONCLUSIONS Treatment of CSOM with aural toilet and topical antibiotics, particularly quinolones, is effective in resolving otorrhea and eradicating bacteria from the middle ear. Longterm outcomes such as preventing recurrences, closure of tympanic perforation and hearing improvement need to be further evaluated.