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Objective: To present and evaluate the treatment of ciprofloxacin-resistant Pseudomonas mastoid cavity otorrhea with a ceftazidime thermosensitive poloxamer gel., Study Design: A retrospective clinical capsule report., Patients: Three patients diagnosed with ciprofloxacin-resistant Pseudomonas otorrhea in the setting of a previous canal-wall-down mastoidectomy between March 2019 and June 2023 visiting our tertiary care institution were retrospectively reviewed., Intervention: Application of a 2% ceftazidime thermosensitive poloxamer gel to mastoid cavity., Main Outcome Measures: No evidence of disease during microscopic inspection of the ear within a month of initial treatment or bacterial eradication on subsequent culture., Results: Two patients had complete resolution of symptoms and achieved a safe and dry ear after topical application of the hydrogel. The second patient had pseudomonal eradication on culture, but persistent otorrhea due to other multidrug-resistant bacteria and an anatomically unfavorable mastoid cavity, which ultimately resolved after revision surgery., Conclusions: This small case series suggests that topical treatment of mastoid cavity otorrhea with a 2% ceftazidime poloxomer gel is a potential therapeutic avenue in patients with ciprofloxacin-resistant Pseudomonas ., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2024, Otology & Neurotology, Inc.)

Purpose: We aimed to identify the role of bacterial biofilms in the chronicity of otitis media with effusion and its resistance to antibiotics. We illustrated this role by reviewing, analyzing, and correlating the findings with the results of the included studies to reach clear evidence., Methods: A comprehensive search of electronic databases (Scopus, PubMed, Web of Science, Cochrane, and GHL databases) was performed for all studies using the following strategy till April 2021 with the search terms: Biofilm and Middle ear effusion. We found 935 references, 421 were duplicates, and 514 were needed for further screening, and it was as follows: PubMed 215, Scopus 18, Cochrane 130, Web of Science 136, and GHL 15., Results: The pooled prevalence of culture-positive effusions was estimated to be 40% (95% CI [28%, 53%]) of the total OME population. Overall, the prevalence of PCR-positive effusions was estimated to be 97% (95% CI [95%, 99%]) of the total OME population. The pooled prevalence of EM-positive effusions was estimated to be 82% (95% CI [69%, 95%]) of the total OME population., Conclusion: The data presented in this study coincide with the significant role of bacterial biofilms in the pathogenesis of chronic otitis media with effusion. The involvement of bacterial biofilm as a component of the OME pathogenic process can help us to explain why antimicrobial therapy is not always effective in the eradication of the disease process and, also explain the recurrence of middle ear effusion after treatment with tympanostomy tubes either with or without adenoidectomy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Nanoparticles (NPs) are a promising alternative to antibiotics for targeting microorganisms, especially in the case of difficult-to-treat bacterial illnesses. Antibacterial coatings for medical equipment, materials for infection prevention and healing, bacterial detection systems for medical diagnostics, and antibacterial immunizations are potential applications of nanotechnology. Infections in the ear, which can result in hearing loss, are extremely difficult to cure. The use of nanoparticles to enhance the efficacy of antimicrobial medicines is a potential option. Various types of inorganic, lipid-based, and polymeric nanoparticles have been produced and shown beneficial for the controlled administration of medication. This article focuses on the use of polymeric nanoparticles to treat frequent bacterial diseases in the human body. Using machine learning models such as artificial neural networks (ANNs) and convolutional neural networks (CNNs), this 28-day study evaluates the efficacy of nanoparticle therapy. An innovative application of advanced CNNs, such as Dense Net, for the automatic detection of middle ear infections is reported. Three thousand oto-endoscopic images (OEIs) were categorized as normal, chronic otitis media (COM), and otitis media with effusion (OME). Comparing middle ear effusions to OEIs, CNN models achieved a classification accuracy of 95%, indicating great promise for the automated identification of middle ear infections. The hybrid CNN-ANN model attained an overall accuracy of more than 0.90 percent, with a sensitivity of 95 percent and a specificity of 100 percent in distinguishing earwax from illness, and provided nearly perfect measures of 0.99 percent. Nanoparticles are a promising treatment for difficult-to-treat bacterial diseases, such as ear infections. The application of machine learning models, such as ANNs and CNNs, can improve the efficacy of nanoparticle therapy, especially for the automated detection of middle ear infections. Polymeric nanoparticles, in particular, have shown efficacy in treating common bacterial infections in children, indicating great promise for future treatments., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Objectives: To analyze the role of factors that influence adenoid-related symptoms, and the influence of 3 months of isolation in preschool children who were qualified for adenoidectomy., Methods: This was a cohort study of the impact of 3 months of isolation on children aged 3 to 6 years with adenoid-related symptoms and endoscopically confirmed grade II and III adenoid hypertrophy. The children had previously qualified for adenoidectomy. After 3 months, 141 children were asked about their symptoms, 71 of whom were randomly chosen for medical examination, including endoscopic adenoid examination. Additionally, pre- and post-isolation tympanometry results were analyzed., Results: In our study, significant or mild improvements in health were observed in approximately 73% of the children; 92% of the surveyed parents reported that their children exhibited improved nasal patency, 63% of children discontinued snoring, and 30% of children showed a decrease in snoring. Data collected through surveys correlated with endoscopic findings wherein the size of the adenoid decreased by an average of 5.4%, but the amount of mucus covering the adenoid decreased more significantly in 76% of patients, which may be the main problem determining symptoms reported before isolation. In addition, the amount of residual mucus in the nasopharynx significantly affected the middle ear effusion in adenoid hypertrophy., Conclusions and Relevance: This study found that isolation in preschool children stabilizes the bacterial microbiome of the nose and nasopharynx, thereby having a significant effect not only on the number of recurrent infections of the upper respiratory tract but also on the patency of the nose. The only symptom that depended on the size of the pharyngeal tonsil hypertrophy was snoring. There was a weak correlation between prevalence of infections and adenoid size. During the isolation period, the adenoid size reduced by approximately 5.4% only, statistically more significant in the group with grade III adenoid hypertrophy, but the prevalence of infections rapidly decreased. Residual mucous in the nasopharynx found to be in correlation with middle ear effusion.

Objective: This study aimed to describe the microbiology of the middle ear and nasopharynx, determining the prevalence of Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis in a group of children vaccinated with pneumococcal conjugate vaccine (PCV) who underwent ventilation tube insertion for recurrent acute otitis media., Methods: We analyzed 278 middle ear effusion and 139 nasopharyngeal samples obtained from 139 children who underwent myringotomy and ventilation tube insertion for recurrent acute otitis media between June 2017 and June 2021. The children's ages ranged from 9 months to 9 years, 10 months, with a median of 21 months. The patients had no signs of acute otitis media or respiratory tract infection and were not on antibiotic therapy at the time of the procedure. The middle ear effusion and nasopharyngeal samples were collected with an Alden-Senturia aspirator and a swab, respectively. Bacteriological studies and multiplex PCR were performed for the detection of the three pathogens. Direct molecular determination of pneumococcal serotypes was performed by real-time PCR. The chi-square test was used to verify associations between categorical variables and measures of strength of association based on prevalence ratios, considering a 95% confidence interval a 5% significance level., Results: Vaccination coverage was 77.7% with the basic regimen plus booster dose and 22.3% with the basic regimen alone. Middle ear effusion culture identified H. influenzae in 27 children (19.4%), S. pneumoniae in 7 (5.0%), and M. catarrhalis in 7 (5.0%). PCR detected H. influenzae in 95 children (68.3%), S. pneumoniae in 52 (37.4%), and M. catarrhalis in 23 (16.5%), a three-to seven-fold increase compared to culture. In the nasopharynx, culture isolated H. influenzae in 28 children (20.1%), S. pneumoniae in 29 (20.9%), and M. catarrhalis in 12 (8.6%). PCR identified H. influenzae in 84 children (60.4%), S. pneumoniae in 58 (41.7%), and M. catarrhalis in 30 (21.5%), a two-to three-fold increase in detection. The most common pneumococcal serotype was 19A, both in the ears and the nasopharynx. In the ears, of the 52 children who had pneumococcus, 24 (46.2%) had serotype 19A. In the nasopharynx, of the 58 patients who had pneumococcus, 37 (63.8%) had serotype 19A. Of all 139 children, 53 (38.1%) had polymicrobial samples (more than 1 of the 3 otopathogens) in the nasopharynx. Of the 53 children who had polymicrobial samples in the nasopharynx, 47 (88.7%) also had 1 of the 3 otopathogens in the middle ear, mainly H. influenzae (40%-75.5%), especially when it was found in the nasopharynx in conjunction with S. pneumoniae., Conclusion: The prevalence of bacteria in a group of Brazilian children immunized with the PCV who required ventilation tube insertion for recurrent acute otitis media was similar to that reported in other parts of the world after the advent of PCV. H. influenzae was the most frequent bacteria, both in the nasopharynx and the middle ear, while S. pneumoniae serotype 19A was the most common pneumococcus in the nasopharynx and middle ear. Polymicrobial colonization of the nasopharynx was strongly associated with detection of H. influenzae in the middle ear., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Nontypeable Haemophilus influenzae (NTHi) is considered a major pathogen underlying middle ear infection. This study aimed to investigate the impact of IL-17 on chronic otitis media (COM) induced by NTHi in mice. NTHi was inoculated into the tympanic bulla with eustachian tubal obstruction. Middle ear effusions (MEEs) and tissues were collected on days 3, 14, and at 1, 2, and 6 months after injection. The expression of interleukin-17A (IL-17A) in MEEs was significantly elevated compared to that in the control group at the translational and transcriptional levels during the experiments. The quantities of IL-17-producing γδ T cells were significantly increased compared to that in the control group during COM, but that of Th17 cells did not. Depletion of γδ T cells by anti-γδ T-cell receptor (TCR) monoclonal antibody (mAb) administration significantly decreased the bacteria counts and the concentrations of IL-1β, IL-6, IL-17A, TNF-α, and IL-10 in MEEs. Our results suggest that IL-17 may play an important role in prolonging the inflammation in the middle ear in COM and that IL-17-producing γδ T cells may contribute to the exacerbated inflammatory response in the middle ear. In this study, anti-γδ TCR mAb administration was found to improve chronic middle ear inflammatory conditions., (© The Author(s) 2023. Published by Oxford University Press on behalf of FEMS.)

Aims: This study assessed the use of high-energy, visible light on the survival rates of three bacteria commonly found in middle ear infections (i.e. otitis media; Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae)., Method and Results: Bacteria were cultured and then subjected to a single, 4-h treatment of 405 nm wavelength light at two different intensities. All three bacteria species were susceptible to the light at clinically significant rates (>99.9% reduction). Bacteria were susceptible to the high-energy visible (HEV) light in a dose-dependent manner (lower survival rates with increased intensity and duration of exposure)., Conclusions: The results suggest that HEV light may provide a non-surgical, non-pharmaceutical approach to the therapeutic treatment of otitis media., Significance an Impact of the Study: Given the growing concerns surrounding antibiotic resistance, this study demonstrates a rapid, alternative method for effective inactivation of bacterial pathogens partly responsible for instances of otitis media., (© 2021 The Society for Applied Microbiology.)

To investigate the presence of respiratory viruses in the middle ear cavity of the individuals with a healthy middle ear and the children with otitis media with effusion (OME). A total of 72 middle ear samples were collected from 25 children with OME (Group 1) and 47 individuals with no middle ear disease (Group 2). Multiplex real-time polymerase chain reaction was used to investigate the presence of 20 different respiratory viruses. Virus results were compared with bacteriomes of the same populations. At least one respiratory virus was detected in 56% of the patients in Group 1 and 12.8% of the individuals in Group 2. The viral co-infection rate for Group 1 and 2 was 8% and 2.1%, respectively. In Group 1, adenovirus was the most frequently detected virus with a rate of 24%, either alone (16%) or concurrent with other viruses (8%), followed by influenza B (12%), rhinovirus, and bocavirus (8%) each. Parainfluenza 4, coronavirus OC43, and RSV A/B were detected in 4% of the sample each. In Group 2, rhinovirus was detected in two samples (4.3%) followed by adenovirus, coronavirus OC43, coronavirus E299, and coronavirus NL63 with a rate of 2.1% each. The detection rate of respiratory viruses was significantly higher in children aged 6 to 11 years. There was no positive association between virus and bacteria found in the middle ear cavity. The current study has provided comprehensive data indicating the presence of diverse respiratory viruses in the healthy middle ear cavity. Our results also suggest that respiratory viruses might have a contribution to OME pathogenesis., (© 2021 Wiley Periodicals LLC.)

Objectives: To present the otologic findings of a patient with COVID-19 and complicated acute otitis media, evaluate for the presence of SARS-CoV-2 in middle ear fluid, and assess whether suctioning of middle ear fluid may be aerosol- generating., Methods: The case of a man with SARS-CoV-2 infection and complicated acute otitis media with facial paralysis is presented to illustrate unique clinical decisions made in context of the COVID-19 pandemic. A cadaveric temporal bone was used to simulate droplet spread during suctioning of fluorescein-labelled middle ear fluid and visualized with a blue-light filter., Results: A 23-year-old male who presented with complicated acute otitis media with facial paralysis was found to have an acute infection with SARS-CoV-2, with positive viral PCR of nasopharyngeal swab, and a negative PCR of the middle ear fluid. He was placed on isolation precautions and treated with myringotomy, topical and systemic antibiotics, and antivirals. Consistent with observations during endonasal suctioning, suctioning of middle ear fluid was not found to be aerosol or droplet generating., Conclusion: The case of a patient with active COVID-19 presenting with complicated acute otitis media in whom middle ear fluid was sampled to evaluate the etiology of the infection and the potential middle ear predilection of SARS-CoV-2 is described. This study has implications for the clinical management of patients with both known and unknown SARS-CoV-2 infection who present with ear disease. While middle ear suctioning may not be aerosol-generating, the risk of coughing or prolonged close contact requires heightened precautions during otologic procedures in patients with suspected or confirmed COVID-19.

Studying the impact of antibiotic treatment on otitis media (OM), the leading cause of primary care office visits during childhood, is critical to develop appropriate treatment strategies. Tracking dynamic middle ear conditions during antibiotic treatment is not readily applicable in patients, due to the limited diagnostic techniques available to detect the smaller amount and variation of middle ear effusion (MEE) and middle ear bacterial biofilm, responsible for chronic and recurrent OM. To overcome these challenges, a handheld optical coherence tomography (OCT) system has been developed to monitor in vivo response of biofilms and MEEs in the OM-induced chinchilla model, the standard model for human OM. As a result, the formation of MEE as well as biofilm adherent to the tympanic membrane (TM) was longitudinally assessed as OM developed. Various types of MEEs and biofilms in the chinchilla model were identified, which showed comparable features as those in humans. Furthermore, the effect of antibiotics on the biofilm as well as the amount and type of MEEs was investigated with low-dose and high-dose treatment (ceftriaxone). The capability of OCT to non-invasively track and examine middle ear conditions is highly beneficial for therapeutic OM studies and will lead to improved management of OM in patients.

Secretory otitis media (SOM) is characterized by persistence of fluid in the middle ear, often following an episode of acute otitis media . Our hypothesis is that failure to eliminate bacterial or viral pathogens may result in persistent low-grade inflammation. In this study, we analyzed inflammatory mediators in middle ear fluids from 67 children with SOM. This was combined with determinations of viable bacteria by culture along with detection of bacterial and viral genetic material by real-time polymerase chain reaction (PCR). The inflammatory mediators found at the highest concentrations (>30 ng/mL) were stem cell growth factor-β (median 110 ng/mL), CXCL1, IL-16, IL-8, migration inhibitory factor, CXCL10, and CXCL9. Among bacterial pathogens, Moraxella catarrhalis and Haemophilus influenzae dominated, regardless of detection methods, while rhinovirus dominated among viral pathogens. Middle ear fluid levels of interleukin (IL)-1α, IL-17, IL-1β, fibroblast growth factor basic, and tumor necrosis factor correlated strongly with presence of bacteria detected either by culture or PCR, while IL-1RA, IL-3, IL-6, IL-8, CCL3, CCL4, and granulocyte-colony stimulating factor correlated significantly with real-time PCR values. CXCL10, CXCL9, CCL2, and TRAIL correlated significantly with viral nucleic acid levels. To conclude, persistence of viral and bacterial pathogens may fuel persistent inflammation in SOM. Bacteria caused a broad inflammatory response, while viruses chiefly elicited the interferon-induced chemokines CXCL9 and CXCL10.

Objective: Nearly half of children who undergo tympanostomy tube (TT) insertion may experience otorrhea following surgery. We sought to review the evidence for the role of bacterial biofilms in post-tympanostomy tube otorrhea (PTTO) and the accumulated experience regarding the preventive measures for biofilm formation/adhesion on TTs., Methods: English literature search for relevant MeSH keywords was conducted in the following databases: MEDLINE (via PubMed), Ovid Medline, Google Scholar, and Clinical Evidence (BMJ Publishing) between January 1, 1995, and December 31, 2019. Subsequently, articles were reviewed and included if biofilm was evident in PTTO., Results: There is an increased evidence supporting the role of biofilms in PTTO. Studies on TT design and material suggest that nitinol and/or silicone TTs had a lower risk for PTTO and that biofilms appeared in specific areas, such as the perpendicular junction of the T-tubes and the round rims of the Paparella-type tubes. Biofilm-component DNAB-II protein family was present in half of children with PTTO, and targeting this protein may lead to biofilm collapse and serve as a potential strategy for PTTO treatment. Novel approaches for the prevention of biofilm-associated PTTO include changing the inherent tube composition; tube coating with antibiotics, polymers, plant extracts, or other biofilm-resistant materials; impregnation with antimicrobial compounds; and surface alterations by ion-bombardment or surface ionization, which are still under laboratory investigation., Conclusions: Currently, there is no type of TT on which bacteria will not adhere. The challenges of treating PTTO indicate the need for further research in optimization of TT design, composition, and coating.

Objectives: Only a few medications have a United States Food and Drug Administration indications for prevention and/or treatment of infections in patients with tympanic perforations or tympanostomy tubes. We examined 3 off-label agents that have become important in tympanostomy tube care hoping to demonstrate the effectiveness and safety of each in experimental assays and human application., Methods: Computerized literature review., Results: (1) Oxymetazoline nasal spray applied at the time of surgery is equivalent to fluoroquinolone ear drops in the prevention of early postsurgical otorrhea and tympanostomy tube occlusion at the first postoperative visit. (2) Topical mupirocin 2% ointment is effective alone or in combination with culture-directed systemic therapy for the treatment of tympanostomy tube otorrhea caused by community-acquired, methicillin-resistant Staphylococcus aureus . (3) Topical clotrimazole 1% cream is highly active against the common yeast and fungi that cause otomycosis. A single application after microscopic debridement will cure fungal tympanostomy tube otorrhea in most cases. None of these 3 agents is ototoxic in animal histological or physiological studies, and each has proved safe in long-term clinical use., Conclusions: Oxymetazoline nasal spray, mupirocin ointment, and clotrimazole cream are safe and effective as off-label medications for tympanostomy tube care in children.

Objective: To investigate the potential correlation between Helicobacter pylori infection and otitis media with effusion (OME) risk in children., Data Sources: Electronic databases were searched, including Cochrane Library, PubMed, Embase, China Biology Medicine disc, China Science and Technology Journal Database, Wanfang Database, and China National Knowledge Infrastructure Database., Review Methods: A systematic review and meta-analysis were conducted with Revman 5.3 software. Combined odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to estimate infection-disease association., Results: In total, 11 studies from 9 articles regarding H pylori infection and OME risk were enrolled in this meta-analysis. A significant association between H pylori infection and OME was detected for both adenoid samples from the case group (OR, 2.75; 95% CI, 1.43-5.30; P = .002) and middle ear fluid samples from the case group (OR, 4.45; 95% CI, 2.52-7.88; P < .00001). Subgroup analyses suggested a stronger correlation in African and Asian populations., Conclusion: This study indicated the correlation between H pylori infection and increased risk of OME in children, especially in African and Asian populations. Further well-designed studies regarding the white population are strongly recommended in the future.

Otitis media with effusion (OME) is a common inflammatory disease that primarily affects children. OME is defined as a chronic low-grade inflammation of the middle ear (ME), without any signs of infection and with effusion persisting in the ME for more than 3 months. The precise pathogenesis is, however, not fully understood. Here, we comprehensively characterized and compared the host immune responses (inflammatory cells and mediators) and the overall microbial community composition (microbiota) present in matched middle ear effusion (MEE) samples, external ear canal (EEC) lavages, and nasopharynx (NPH) samples from children with OME. Female patients had significantly increased percentages of T lymphocytes and higher levels of a wide array of inflammatory mediators in their MEE compared to that of male patients, which were unrelated to microbiota composition. The relative abundances of identified microorganisms were strongly associated with their niche of origin. Furthermore, specific inflammatory mediators were highly correlated with certain bacterial species. Interestingly, some organisms displayed a niche-driven inflammation pattern in which presence of Haemophilus spp. and Corynebacterium propinquum in MEE was accompanied by proinflammatory mediators, whereas their presence in NPH was accompanied by anti-inflammatory mediators. For Turicella and Alloiococcus , we found exactly the opposite results, i.e., an anti-inflammatory profile when present in MEE, whereas their presence in the the NPH was accompanied by a proinflammatory profile. Together, our results indicate that immune responses in children with OME are highly niche- and microbiota-driven, but gender-based differences were also observed, providing novel insight into potential pathogenic mechanisms behind OME., (Copyright © 2020 Enoksson et al.)

Background: Middle ear effusion is common in brachycephalic dogs with similarities to otitis media with effusion in children. Association with the cranial and eustachian tube morphology and bacterial infection is suspected in both species., Hypothesis/objectives: To determine cytological and bacteriological features of middle ear effusions in dogs, provide information on histological features, and further assess the dog as a model of the human disease., Animals: Sixteen live dogs, 3 postmortem cases of middle ear effusion, and 2 postmortem controls., Methods: Prospective; clinical investigation using computed tomography, magnetic resonance imaging, video-otoscopy, myringotomy; cytological assessment of 30 and bacteriology of 28 effusions; histology and immunohistochemistry (CD3 for T-lymphocytes, Pax5 for B lymphocytes and MAC387 for macrophages) of 10 middle ear sections., Results: Effusions were associated with neurological deficits in 6/16 (38%) and concurrent atopic dermatitis and otitis externa in 9/16 (56%) of live cases. Neutrophils and macrophages predominated on cytology (median 60 [range 2%-95.5%] and 27 [2%-96.5%]) whether culture of effusions was positive or not. In histology sections, the mucosa was thickened in affected dogs but submucosal gland dilatation occurred in affected and unaffected dogs. There was no bacterial growth from 22/28 (79%) of effusions. Bacteria isolated from the other 6 (21%) were predominantly Staphylococcus pseudintermedius (4/6, 67%)., Conclusions and Clinical Importance: Clinical, morphological, and cytological findings in middle ear effusions of dogs and people suggest similar pathogeneses. Middle ear effusion of dogs could be a useful model of human otitis media with effusion. Such comparisons can improve understanding and management across species., (© 2020 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.)

Introduction: Otitis media with effusion (OME) is one of the most common pediatric diseases worldwide. Several studies have analyzed the diversity of the microbiomes found in the middle ear effusions (MEEs) of populations from developed countries. However, no microbiological studies of MEEs from Chinese children with OME have been reported. This study investigated the middle ear and adenoid microbiological profiles of children with OME, and compared the microbial flora of the adenoid between children with and without otitis media., Methods: MEEs and adenoid swabs were acquired from 15 children undergoing ventilation tube insertion and adenoidectomy. Adenoid swabs from 15 patients with no ear disease were used as controls. Samples were analyzed by 16S rRNA sequencing. Operational taxonomic units (OTUs) abundance information were normalized. Alpha diversity analyses were used to assess the richness and diversity of the microbial community for each sample. Beta diversity analyses were used to determine the inter-group variability between microbiome structure., Results: Based on the mean relative abundance, the MEEs were dominated by Haemophilus (14.75%), Staphylococcus (9.37%) and Halomonas (7.85%), and the bacterial compositions of the adenoids in the OME groups were dominated by Haemophilus (21.87%), Streptococcus (19.65%), and Neisseria (5.8%). The bacterial compositions in the adenoids of the controls were dominated by Haemophilus (15.96%), Streptococcus (13.33%), and Moraxella (12.28%). Alpha diversity analyses showed that there were no significant differences in microbiome richness or diversity between the middle ear effusions (TM) and adenoids (TA) of OME subjects. Adenoid samples from OME patients (TA) and control patients (CA) were also similar. Beta diversity analyses showed that the microbiomes of the adenoids in OME patients were also similar to that of controls. However, the microbiome structure of middle ear effusions was dissimilar to those of the adenoids in OME patients according to beta diversity analyses., Conclusions: Our results confirmed the microbial diversity of MEEs among Chinese children. However, the dissimilar microbiome composition between samples taken from the surface of the adenoids and from the middle ear effusions challenges the conventional theory that the adenoid serves as a microbial reservoir in children with otitis media with effusion., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Otitis media with effusion (OME) may occur spontaneously because of poor Eustachian tube function or as an inflammatory response following AOM. Bacterial involvement in OME has been widely reported, with various available methods to identify pathogens from middle ear effusion, including traditional culture methods and polymerase chain reaction (PCR)., Objectives: The primary goal of this study was to evaluate the bacteriological profile of middle ear effusion in OME. Risk factors of the bacterial OME aetiology were also identified., Methods: Middle ear effusions (MEF) from 50 children, aged 2-8 years, diagnosed by ENT and undergoing routine tympanostomy tube placement were collected. MEF samples were streaked on standard microbiological media. Next, DNA was isolated from MEF samples and analysed with multiplex PCR for Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Alloiococcus otitidis., Results: In multiplex PCR assay 37 (74%) of 50 children were positive for at least one of the four microorganisms. In 27.0% positive children multiple bacterial pathogens were identified. A. otitidis was the most frequently identified in positive MEF children (59.5%). By multiplex PCR, H. influenzae, S. pneumoniae and M. catarrhalis were detected in 24, 18 and 8% of OME patients, respectively. There was significant association between bilateral infection and H. influenzae aetiology of OME., Conclusions: Overall we found OME predominantly a single otopathogen infection caused mainly by A. otitidis, which is difficult in identification using standard culture method, ahead to S. pneumoniae and H. influenzae. However, one third of MEF samples had multiple bacterial pathogens.

Objective: To review and highlight significant advances made towards vaccine development and understanding of the immunology of otitis media (OM) since the 19th International Symposium on Recent Advances in Otitis Media (ISOM) in 2015, as well as identify future research directions and knowledge gaps., Data Sources: PubMed database, National Library of Medicine., Review Methods: Key topics were assigned to each panel member for detailed review. Draft reviews were collated, circulated, and thoroughly discussed when the panel met at the 20th ISOM in June 2019. The final manuscript was prepared with input from all panel members., Conclusions: Since 2015 there have been a number of studies assessing the impact of licensed pneumococcal vaccines on OM. While these studies have confirmed that these vaccines are effective in preventing carriage and/or disease caused by vaccine serotypes, OM caused by non-vaccine serotype pneumococci and other otopathogens remains a significant health care burden globally. Development of multi-species vaccines is challenging but essential to reducing the global burden of OM. Influenza vaccination has been shown to prevent acute OM, and with novel vaccines against nontypeable Haemophilus influenzae (NTHi), Moraxella catarrhalis and Respiratory Syncytial Virus (RSV) in clinical trials, the potential to significantly prevent OM is within reach. Research into alternative vaccine delivery strategies has demonstrated the power of maternal and mucosal vaccination for OM prevention. Future OM vaccine trials must include molecular diagnostics of middle ear effusion, for detection of viruses and bacteria that are persisting in biofilms and to enable accurate assessment of vaccine impact on OM etiology. Understanding population differences in natural and vaccine-induced immune responses to otopathogens is also important for development of the most effective OM vaccines. Improved understanding of the interaction between otopathogens will also advance development of effective therapies and encourage the assessment of the indirect benefits of vaccination., Implications for Practice: While NTHi and M. catarrhalis are the predominant otopathogens, funding opportunities to drive vaccine development for these species are limited due to a focus on prevention of childhood mortality rather than morbidity. Delivery of a comprehensive report on the high financial and social costs of OM, including the potential for OM vaccines to reduce antibiotic use and subsequent development of antimicrobial resistance (AMR), would likely assist in engaging stakeholders to recognize the value of prevention of OM and increase support for efforts on OM vaccine development. Vaccine trials with OM prevention as a clinical end-point are challenging, however a focus on developing assays that measure functional correlates of protection would facilitate OM vaccine development., Competing Interests: Declaration of competing interest LSK has received investigator-initiated grants and travel support from Pfizer and GSK to attend conferences that are not related to this work. LLH has received institutional funding from GSK, Pfizer, and Merck. TFM has patents for Moraxella catarrhalis vaccines and LSK holds patents for pneumolysin as a vaccine antigen. SIP has received investigator-initiated research grants through Boston Medical Center from Merck Vaccines and Pfizer and personal honorarium for participation in advisory boards, expert consultation and symposia from GlaxoSmithKline, Pfizer, and Merck Vaccines. All other authors declare no competing interests., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Introduction: It is proposed that Helicobacter pylori can be responsible for the development of otitis media with effusion., Objective: The aim of this study is to investigate the prevalence of H. pylori in the adenoid tissue and fluid of the middle ear in patients who suffer from adenoid hyperplasia and otitis media with effusion in comparison with those who suffer from adenoid hyperplasia without otitis media with effusion., Methods: This is a case-control study that was carried out in 50 children of age 2-7 years old who were admitted with adenoid hyperplasia. Patients were divided into case and control groups. The study group included 25 patients with adenoid hyperplasia and otitis media with effusion and the control group included 25 patients with adenoid hyperplasia without otitis media with effusion. The patients in both groups underwent surgical adenoidectomy. For the case group we carried out myringotomy and placement of tympanostomy tube, and fluid samples were collected under sterile conditions. The samples were sent to the laboratory for polymerase chain reactions., Results: In the case group H. pylori was found to be positive in 18 samples of the middle ear fluid (70%) and in 1 polymerase chain reaction adenoid tissue sample (4%). In the control group H. pylori was positive in 3 samples of adenoid tissues (12%). There was no gender difference., Conclusion: H. pylori is one of the important bacteria that plays a role in the pathogenesis of otitis media with effusion. Whether adenoid tissue may be a reservoir for H. Pylori is unclear., (Copyright © 2018 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.)

Objectives: Otitis media with effusion (OME) is a common disease of childhood that is largely asymptomatic. However, middle ear fluid can persist for months and negatively impact a child's quality of life. Many cases of OME remain chronic and require surgical intervention. Because biofilms are known to contribute to the persistence of many diseases, this study examined effusions collected from children with chronic OME for the presence of essential biofilm structural components, members of the DNABII family of bacterial DNA-binding proteins., Methods: Middle ear effusions were recovered from 38 children with chronic OME at the time of tympanostomy tube insertion. A portion of each specimen was submitted for microbiology culture. The remaining material was assessed by immunoblot to quantitate individual DNABII proteins, integration host factor (IHF), and histone-like protein (HU)., Results: Sixty-five percent of effusions (24 of 37) were culture-positive for bacterial species or yeast, whereas 35% (13 of 37) were culture-negative. IHF was detected in 95% (36 of 38) at concentrations from 2 to 481 ng/μL effusion. HU was detected in 95% (36 of 38) and quantitated from 13 to 5,264 ng/μL effusion (P ≤ 0.05 compared to IHF)., Conclusion: Because DNABII proteins are essential structural components of bacterial biofilms, these data lend further support to our understanding that biofilms are present in the vast majority of chronic middle ear effusions, despite negative culture results. The presence and ubiquity of DNABII proteins in OME specimens indicated that these proteins can serve as an important clinical target for our novel DNABII-directed strategy to treat biofilm diseases such as chronic OME., Level of Evidence: NA Laryngoscope, 130:806-811, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Streptococcus pneumonia, one of the major colonizers in nasopharyngeal adenoids, has been the predominant pathogen causing acute otitis media (AOM) in children. Recent evidence suggests an association between IL-17A-mediated immune response and the clearance of pneumococcal colonization in nasopharyngeal adenoids. Here, we evaluated the expressions of IL-17A and associated genes in hypertrophic adenoid tissues of children with sleep-disordered breathing (SDB) and otitis media with effusion (OME) and their association with pneumococcal carriage. Sixty-six pediatric patients with adenoid hypertrophy were enrolled. During adenoidectomy, nasopharyngeal swab and adenoid tissues were used to determine pneumococcal carriage and IL-17A expression. Our results revealed significantly higher levels of IL-17A and IL-17A:IL-10 mRNA in the SDB patients positive for nasopharyngeal pneumococcal carriage than those negative. However, these differences were not significant in the OME group. These results suggested, in OME patients, prolonged or chronic pneumococcal carriage may occur because of insufficient IL-17A-mediated mucosal clearance, and could further lead to AOM and OME development.

Recurrent and chronic otitis media (OM) are often refractory to antibiotics due to bacterial persistence in biofilm within the middle ear. In vitro and in vivo studies have demonstrated that antimicrobial proteins and peptides (AMPs) are bactericidal against otopathogens, indicating potential therapeutic value for recalcitrant OM. We measured concentrations of 6 AMPs and 14 cytokines in middle ear effusion (MEE) from 67 children undergoing ventilation tube insertion for recurrent acute OM. Sixty one percent of children had bacterial otopathogens detected in their MEE, 39% by PCR and 22% by PCR and culture. Groups were defined as: PCR-negative/culture-negative (absence of bacterial otopathogen), n = 26; PCR-positive/culture-negative (presence of nonculturable bacterial otopathogen), n = 26; PCR-positive/culture-positive (presence of culturable bacterial otopathogen), n = 15. Age, antibiotic usage, day-care attendance, presence of respiratory viruses in MEE and number of AOM episodes were similar between groups. AMP and cytokine concentrations were higher in children with bacterial otopathogens in their MEE compared to those with no bacterial otopathogens. Median concentrations of AMPs (except HBD2) were 3 to 56-fold higher in MEE from children with bacterial otopathogens detected in their MEE (P ≤ 0.01). Similarly, median cytokine concentrations (except TGFβ) were >16-fold higher in MEE with bacterial otopathogens detected (P ≤ 0.001). This is the first study to measure AMPs in MEE and together with the cytokine data, results suggest that elevated AMPs and cytokines in MEE are a marker of inflammation and bacterial persistence. AMPs may play an important role in OM pathogenesis., Competing Interests: Professor Peter Richmond has served on vaccine scientific advisory boards, and together with Dr Kirkham has received institutional funding for investigator-initiated grants from GlaxoSmithKline and Pfizer that are unrelated to this work. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Objectives: The adenoid pad, which is located between the orifice of the Eustachian tube (ET) and posterior nasal cavity, can affect the development of otitis media with effusion (OME) because of its anatomical location. The aim of the present study was to evaluate adenoid microbial colonization through 16S ribosomal RNA (rRNA) pyrosequencing, an advanced molecular technique, and to document the relationship with OME., Materials and Methods: Adenoid samples were collected using sterile cotton from 32 children during ventilation tube insertion. Sixteen children with OME who underwent tonsillectomy and adenoidectomy due to obstructive symptoms were assigned to the OME group and sixteen children without OME were assigned to the control group. We performed a 16S rRNA-based culture-independent survey of bacterial communities using the MiSeq platform., Results: The diversity index, mean operational taxonomic units, and Shannon index were lower in the OME group than those in the control group. A taxonomic analysis showed differences in microbiota distribution between the OME and control groups at the phylum, genus, and species levels. The analysis, which was based on weighted UniFrac distances, revealed differences in microbial composition between the two groups., Conclusion: Bacterial community analysis using 16S rRNA pyrosequencing allows us to understand the relationship between the microbial communities of adenoids and the development of OME better.

Objectives: Following the increased use of antibiotics, the emergence of antibiotic-resistant species in pediatric patients with otitis media has become a problem in recent years. The aim of this study was to investigate change in bacterial species, antibiotic resistance, and detection rate of highly pathogenic species, such as Methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa according to the number of repeated ventilation tube insertion (VTI) procedures in pediatric patients diagnosed with otitis media with effusion (OME)., Materials & Methods: From May 2010 to June 2018, 158 patients under 17 years of age who were admitted to the outpatient clinic of Kyung Hee Medical Center and diagnosed as OME and underwent unilateral or bilateral VTI were included in this study. Bacterial cultures were performed on aseptically collected middle ear effusion (MEF) at the time of VTI and antibiotic sensitivity tests were performed on the identified bacteria., Results: Bacteria were not identified in 195 (70.1%) cultures and identified in 83 (29.9%) cultures. Coagulase-negative staphylococci (CNS) was the most frequently detected species in both the non-recurrent group and the recurrent group. MRSA detection rate was found to be significantly higher in the recurrent group than in the non-recurrent group (p = 0.029). The two groups showed no significant difference in antibiotic resistance against all antibiotics (p > 0.05)., Conclusion: Staphylococcus species were detected most frequently in the MEF of pediatric OME patients, and the MRSA detection rate was higher in the recurrent group than in the non-recurrent group. There was no difference in antibiotic sensitivity between the two groups against all antibiotics, but resistance to penicillin G and cefoxitin was newly appeared in patients with repeated detection of same bacterial isolates., (Copyright © 2019. Published by Elsevier B.V.)

Nontypeable Haemophilus influenzae (NTHi) is a major pathogen causing acute otitis media (AOM). The pathology of AOM increases during long-term infection in the middle ear (ME), but the host cellular immune response to bacterial infection in this inflamed environment is poorly understood. Using the Junbo mouse, a characterized NTHi infection model, we analyzed the cellular response to NTHi infection in the Junbo mouse middle ear fluid (MEF). NTHi infection increased the total cell number and significantly decreased the proportion of live cells in the MEF at day 1, and this further decreased gradually on each day up to day 7. Flow cytometry analysis showed that neutrophils were the dominant immune cell population in the MEF and that NTHi infection significantly increased their proportion whereas it decreased the monocyte, macrophage, and dendritic cell proportions. Neutrophil and macrophage numbers increased in blood and spleen after NTHi infection. The T-cell population was dominated by T-helper (Th) cells in noninoculated MEF, and the effector Th (CD44 + ) cell population increased at day 2 of NTHi infection with an increase in IL-12p40 levels. Sustained NTHi infection up to 3 days increased the transforming growth factor β levels, decreasing the effector cell population and increasing the T-regulatory (T-reg) cell population. In the preinflamed ME environment of the Junbo mouse, neutrophils are the first responder to NTHi infection followed by T-reg immune suppressive cells. These data indicate that sustained NTHi infection in the ME induces the immune suppressive response by inducing the T-reg cell population and reducing immune cell infiltration, thus promoting longer-term infection., (© Crown copyright 2019.)

Objective: The aim of this study was to evaluate the composition and the diversity of bacteriome in middle ear effusion (MEE) and adenoid specimens of pediatric patients having otitis media with effusion (OME)., Materials and Methods: Sample collection from children with OME followed by next generation sequencing. Seventeen adenoid and 43 middle ear effusion specimens from 25 children having OME were evaluated. Microbiome analysis was performed via Ion 16S rRNA metagenomics kit., Results: Twenty-two different bacterial species were identified from all of the samples analyzed. There were variations in the prevalence and relative abundance of the bacteriome observed between adenoid and MEE samples. MEE microbiome was significantly dominated by Alloicoccus otitis (44%), Turicella otitidis (6%), and Staphylococcus auricularis (3%). Whereas, Rothia mucilaginosa (39%), R. dentocariosa (11%), S. aureus (5%), Veillonella rogosae (2%), Granulicatella elegans (2%), Granulicatella adiacens (2%), Eikenella corrodens (1%), and Prevotella nanceiensis (1%) had significantly higher relative abundance in adenoid samples. Overall, there was no statistically significant difference in alpha diversity of MEE and adenoid samples, whereas adenoid samples constituted a cluster in the beta diversity graph., Conclusion: Bacteriome of MEE is mostly dominated by A. otitis yet accompanied by other bacteria with lower relative abundances suggests that OME is likely to be a polymicrobial process. Despite similarities, significant differences in relative abundances of several predominant species between bacteriome in the MEE and adenoid put the theory that OME in children is originated from the adenoids under question., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Introduction: In Ethiopia, there is a lack of data on pneumococcal serotypes causing acute otitis media (AOM) in children. We aimed to study the etiology, pneumococcal serotypes and antimicrobial resistance patterns of isolates from children with AOM with spontaneous perforation of the tympanic membrane (SPTM)., Methods: We carried out a prospective observational study in children with AOM with SPTM, aged 0-15 years in Addis Ababa, Ethiopia. Middle ear fluid was collected using sterile swabs, cultured and antibiotic susceptibility testing was performed. Serotypes of Streptococcus pneumoniae were determined by sequencing the cpsB gene and by the Quellung reaction., Results: A total of 55 children were enrolled. Out of 55 samples that were cultured, 52 (94.5%) were culture positive for a total of 66 bacterial species, and 56.4% (31/55) samples were positive for 41 (62.1%) known pathogenic bacterial species. The most common pathogenic bacterial isolates were S. pneumoniae (36.6%), Staphylococcus aureus (19.5%), Streptococcus pyogenes (14.6%) and Haemophilus influenzae (12.2%). Serotype 19A (73.3%) was the predominant pneumococcal serotype. There was a high rate of non-susceptibility to penicillin (86.6%) and trimethoprim/sulfamethoxazole (80%) among pneumococcal isolates. Out of 21 different isolates tested for amoxicillin susceptibility, 15 (71.4%) were resistant., Conclusions: Pneumococcal serotype 19A was the predominant cause of AOM with SPTM in children in Addis Ababa, Ethiopia, 5 years after introduction of PCV10. There was a high rate of resistance to commonly prescribed antibiotics. The study highlights the need for wide scale surveillance of the etiology and antimicrobial susceptibility of AOM in Ethiopian children., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Chronic otitis media with effusion (COME) is a common childhood disease characterized by an accumulation of fluid behind the eardrum. COME often requires surgical intervention and can also lead to significant hearing loss and subsequent learning disabilities. Recent characterization of the middle ear fluid (MEF) microbiome in pediatric patients has led to an improved understanding of the microbiota present in the middle ear during COME. However, it is not currently known how the MEF microbiome might vary due to other conditions, particularly respiratory disorders. Here, we apply an amplicon sequence variant (ASV) pipeline to MEF 16S rRNA high-throughput sequencing data from 50 children with COME (ages 3-176 months) undergoing tube placement. We achieve a more detailed taxonomic resolution than previously reported, including species and genus level resolution. Additionally, we provide the first report of the functional roles of the MEF microbiome and demonstrate that despite high taxonomic diversity, the functional capacity of the MEF microbiome remains uniform between patients. Furthermore, we analyze microbiome differences between children with COME with and without a history of lower airway disease (i.e., asthma or bronchiolitis). The MEF microbiome was less diverse in participants with lower airway disease than in patients without, and phylogenetic β-diversity (weighted UniFrac) was significantly different based on lower airway disease status. Differential abundance between patients with lower airway disease and those without was observed for the genera Haemophilus, Moraxella, Staphylococcus, Alloiococcus , and Turicella . These findings support previous suggestions of a link between COME and respiratory illnesses and emphasize the need for future study of the middle ear and respiratory tract microbiomes in diseases such as asthma and bronchiolitis., (Copyright © 2019 Kolbe, Castro-Nallar, Preciado and Pérez-Losada.)

Objective: Two third of children in the world experience otitis media with effusion (OME) at least once in their life. According to the importance of knowing OME reason in pediatrics, beside introduced probable bacterial and viral causal agents, Pseudomonas aeruginosa was evaluated either., Methods: In this study, 42 middle ear fluid (MEF) samples were collected from pediatrics who confirmed OME by an ears, nose and throat (ENT) specialist. Samples were cultured on bacteriological media for bacterial growth and were either extracted for total DNA and RNA to be tested for introduced bacterial and viral agents with simple and Reverse Transcriptase PCR method within specific primers., Results: Total results from culture and molecular methods showed that the most prevalent infections were Pseudomonas aeruginosa and streptococcus pneumonia with 33.33% and 14.29% respectively. In total, 66.67% of patients were infected with bacteria, 11.9% with test viruses while in 21.42% of patients no infectious agents were detected. Influenza type A was the only virus was detected., Conclusion: Pseudomonas aeruginosa was the most prevalent agent while mostly detected in patients who were referred from the tropical and humid region. According to these results, it is highly recommended to know the pattern of OME infection in each area separately for more successful treatment., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Acute otitis media (AOM) is one of the most common childhood infections, generally thought to be caused by ascension of bacteria from the nasopharynx (NP) to the middle ear. Using 16S ribosomal RNA-based sequencing, we evaluated the relationship between the NP and middle ear fluid (MEF) microbiota in children with AOM with tympanostomy tubes (AOMT) as a proxy for AOM and explored whether microbiota profiling predicts natural disease course., Methods: Microbiota profiles of paired NP and MEF samples of 94 children below 5 years of age with uncomplicated AOMT were determined., Results: Local diversity (P < 0.001) and overall microbiota composition (P < 0.001) of NP and MEF samples differed significantly, although paired NP and MEF samples were much more similar than unpaired samples (P < 0.001). High qualitative agreement between the presence of individual bacteria in both niches was observed. Abundances of Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus pyogenes, Turicella otitidis, Klebsiella pneumoniae and Haemophilus spp. were strongly correlated between the 2 niches. Additionally, P. aeruginosa, S. aureus, T. otitidis and Streptococcus pneumoniae abundance in NP were predictive of the presence of a range of oral types of bacteria in MEF. Interestingly, there was no association between Moraxella catarrhalis in NP and MEF samples, which was highly present in NP but virtually absent in MEF. Finally, the NP microbiota composition could predict duration of AOMT, even better than MEF microbiota., Conclusions: We observed substantial correlations between paired NP and MEF microbiota in children with AOMT. Our data also suggest that NP microbiota profiling deserves further exploration as tool for future treatment decisions.

Background: Primary secretory otitis media (PSOM) in the cavalier King Charles spaniel (CKCS) is similar to otitis media with effusion (OME) in humans. A proposed aetiology of OME is inflammation of the middle ear mucosa, usually due to bacterial infection, leading to auditory tube dysfunction., Hypothesis/objectives: Our objective was to characterize the microbiological and cytological findings of otic exudates from the external ear canal (EEC) (n = 68) and middle ear (ME) (n = 69) from 41 CKCSs with PSOM., Methods and Materials: Swab samples from the EEC and mucus aspirated from the ME after performing a myringotomy were obtained for bacterial culture and cytological analysis., Results: Fifty-five of 68 (81%) EEC and 46 of 69 (67%) ME yielded no bacterial growth. Thirty-eight of the 68 (56%) ears had no microbial growth from neither the EEC nor ME; seven (10%) had bacteria isolated from the EEC only; 17 (25%) had bacteria isolated from the ME only, and six (8%) had bacteria isolated from both EEC and ME. Thirty-four total bacterial isolates were cultured from ME. The most common bacterial species isolated were coagulase-negative staphylococci, followed by Staphylococcus pseudintermedius. Otic cytology identified coccoid organisms in only three of 68 EEC and four of 69 ME., Conclusions: The role of bacteria in the pathogenesis of PSOM in CKCS is unclear. The majority of the EEC and ME of the CKCS with PSOM were negative by conventional bacterial culture and the cytological presence of bacteria was not correlated with culture positives. The potential role of noncultivable microbiota in PSOM requires exploration using molecular methods., (© 2019 ESVD and ACVD.)

Introduction: Adenotonsillar and middle ear diseases result in some of the most frequently performed operations in the pediatric population worldwide. The pathogen reservoir hypothesis (PRH) suggests that the adenoids act as a reservoir of bacteria which play a potential pathogenic role in otitis media. Evidence supporting this hypothesis is limited. This study sought to comprehensively determine and compare associations between the adenotonsillar and middle ear bacterial microbiota within individual patients via next-generation sequencing and microbial network analyses., Methods: Bacterial 16S rRNA gene-targeted amplicon sequencing was used to determine the bacterial composition of ten pediatric patients undergoing adenotonsillectomy and ventilation tube insertion for otitis media with effusion. At the time of surgery, swabs were taken from the adenoid surface, tonsil crypts and middle ear clefts (through the myringotomy incision)., Results: The most abundant sequences within the bacterial community at genus level across all anatomical sites were Fusobacterium, Haemophilus, Neisseria, and Porphyromonas. There was an observable difference in the relative abundance of bacterial communities, with a higher proportion of Haemophilus and Moraxella in the adenoid when compared with the middle ear. Furthermore, only one module (consisting of 4 bacterial OTUs) from one patient was identified through microbial network analyses to be significantly associated between middle ear and adenoid. In addition, microbial network analysis revealed that the adenoid and tonsil microbiota share greater similarity than do the adenoid and middle ear., Conclusion: The results of this study suggest that the adenoid microenvironment does not correlate to the middle ear microenvironment. A future study at the species level, and over time, is required to further investigate whether the differing relationship between the microbiota of the adenoid and middle ear rejects the pathogen reservoir hypothesis., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: Chronic otitis media with effusion (COME) in children can cause prolonged hearing loss, which is associated with an increased risk of learning delays and behavioural problems. Dispersal of bacterial pathogens from the nasal passages to the middle ear is implicated in COME. We sought to determine whether there is an association between nasal microbial composition and COME in children., Methods: A case-control study of children aged 3 and 4 years was conducted. Cases undergoing placement of tympanostomy tubes for COME were compared to healthy controls. Nasal swabs were collected and a questionnaire was administered. The V1-3 region of the 16S rRNA gene was amplified, and sequenced on the Illumina MiSeq., Results: 73 children with COME had a lower Shannon diversity index than 105 healthy controls (1.62 [.80] versus 1.88 [.84], respectively; P = .046). The nasal microbiota of cases and controls differed in composition using Bray-Curtis dissimilarity (p = 0.002). Children with COME had a higher abundance of otopathogens and lower abundance of commensals including alpha haemolytic Streptococci and Lactococcus. Cluster analysis revealed 4 distinct nasal microbial profiles. Profiles that were Corynebacterium-dominated (aOR 4.18 [95%CI, 1.68-10.39], Streptococcus-dominated (aOR 3.12 [95%CI, 1.08-9.06], or Moraxella-dominated (aOR 4.70 [95%CI, 1.73-12.80] were associated with COME, compared to a more mixed microbial profile when controlling for age, ethnicity, and recent antibiotics use., Conclusions: Children with COME have a less diverse nasal microbial composition with a higher abundance of pathogens, compared to healthy children who have a more mixed bacterial profile with a higher abundance of commensals. Further research is required to determine how nasal microbiota may relate to the pathogenesis or maintenance of COME, and whether modification of the nasal microbiota can prevent or treat children at risk of COME., Competing Interests: The authors have declared that no competing interests exist.

After pneumococcal conjugate vaccine (PCV) implementation, the number of acute otitis media (AOM) episodes has decreased, but AOM still remains among the most common diagnoses in childhood. From 2% to 17% of cases of AOM feature spontaneous perforation of the tympanic membrane (SPTM). The aim of this study was to describe the bacteriological causes of SPTM 5 to 8 years years after PCV13 implementation, in 2010. From 2015 to 2018, children with SPTM were prospectively enrolled by 41 pediatricians. Middle ear fluid was obtained by sampling spontaneous discharge. Among the 470 children with SPTM (median age 20.8 months), no otopathogen was isolated for 251 (53.4% [95% CI 48.8%;58.0%]): 47.1% of infants and toddlers, 68.3% older children (p<0.001). Among children with isolated bacterial otopathogens (n = 219), non-typable Haemophilus influenzae (NTHi) was the most frequent otopathogen isolated (n = 106, 48.4% [95% CI 41.6%;55.2%]), followed by Streptoccocus pyogenes (group A streptococcus [GAS]) (n = 76, 34.7% [95% CI 28.4%;41.4%]) and Streptococcus pneumoniae (Sp) (n = 61, 27.9% [95% Ci 22.0%;34.3%]). NTHi was frequently isolated in infants and toddlers (53.1%), whereas the main otopathogen in older children was GAS (52.3%). In cases of co-infection with at least two otopathogens (16.9%, n = 37/219), NTHi was frequently involved (78.4%, n = 29/37). When Sp was isolated, PCV13 serotypes accounted for 32.1% of cases, with serotype 3 the main serotype (16.1%). Among Sp strains, 29.5% were penicillin-intermediate and among NTHi strains, 16.0% were β-lactamase-producers. More than 5 years after PCV13 implementation, the leading bacterial species recovered from AOM with SPTM was NTHi for infants and toddlers and GAS for older children. In both age groups, Sp was the third most frequent pathogen and vaccine serotypes still played an important role. No resistant Sp strains were isolated, and the frequency of β-lactamase-producing NTHi did not exceed 16%., Competing Interests: The authors have declared that no competing interests exist.

In stratified bilateral studies, responses from two paired body parts are correlated. Confidence intervals (CIs), which reveal various features of the data, should take the correlations into account. In this article, five CI methods (sample-size weighted naïve Maximum likelihood estimation (MLE)-based Wald-type CI, complete MLE-based Wald-type CI, profile likelihood CI, MLE-based score CI and pooled MLE-based Wald-type CI) are derived for proportion ratios under the assumption of equal correlation coefficient within each stratum. Monte Carlo simulation shows that the complete MLE-based Wald-type CI approach generally produces the shortest mean interval width and satisfactory empirical coverage probability with close form solution; while the profile likelihood CI and the MLE-based score CI provide preferred ratio of non coverage probability and are more symmetric. Two real examples are used to demonstrate the performance of the proposed methods.

In recent years, OME in childhood tends to increase. The low efficiency of the currently used traditional methods of conservative therapy and the high rate of relapse of the disease make it necessary to develop new methods of treatment. It is important that there is a connection of development of OME and hypertrophy of the lymphoid tissue of the nasopharynx, which in childhood is considered as a response to the respiratory antigenic virus-bacterial load. The spread of the inflammatory process to the auditory tube with persistence of pathogenic microorganisms in the structure of lymphoid tissue leads to the further development of otitis media effusion; but it is still debatable. All living microorganisms that inhabit a certain anatomical niche (viruses, bacteria, fungi, etc.) are called 'microbiota'. This term includes both commensals and pathogens. 'Microbiome' means the totality of all genes of all microorganisms that inhabit the study area. Thus, the microbiome can be called the collective microbiota genome. Microbiota disorder is a change in the quantitative and qualitative composition of microorganisms, called dysbiosis, and is important in the development of inflammatory pathology. Some drugs (including antibacterial ones) adversely affect indigenous bacteria. Indigenous microbiota develops in abundance in the observed biotope and forms resistance to excessive growth of pathogenic microorganisms. Only NGS sequencing allows to analyze entire mixed bacterial communities ('microbiomes'), which cannot be performed by other diagnostic methods. The use of the NGS sequencing method has proved the important role of microbiota in the development of chronic adenoiditis and OME in children. One of the promising remedies is the inclusion of lysozyme in the treatment regimen. Recent studies indicate the antibacterial and antiviral effects of lysozyme. The use of NGS sequencing made it possible to identify the relationship of the composition of microbiota with the course of chronic adenoiditis and otitis media effusion in children. Inclusion of lysozyme-containing drug Lizobact into therapy promotes colonization of the nasopharynx by indigenous microbiota, while the clinical picture improves.

Objectives: We investigated the epidemiological and antibiotic resistance differences in methicillin-resistant Staphylococcus aureus (MRSA) infections in patients with otitis media with effusion (OME), acute otitis media (AOM), chronic suppurative otitis media (CSOM), and chronic cholesteatomatous otitis media (CCOM)., Materials and Methods: We conducted a retrospective study of patients with newly identified MRSA infections from January 2009 through January 2017. Overall, 3,522 patients from 10 tertiary referral hospitals were included in the study. An antibiotic sensitivity test was performed for each isolate., Results: MRSA infections in patients with CSOM and CCOM were more resistant to ciprofloxacin, clindamycin, erythromycin, gentamicin, levofloxacin, and tetracycline. Patients showed good susceptibility to rifampicin, trimethoprim/sulfamethoxazole (TMP/SMX), and vancomycin., Conclusion: MRSA infections in various otitis media cases showed different resistance patterns. MRSA infections in patients with COM and CCOM were more resistant to antibiotics than those in patients with OME and AOM.

Objective: One of the most common sequelae of tympanostomy tube (TT) placement is post-tympanostomy tube otorrhea (PTTO). Granulation tissue formation has been reported in 5-13.8% of patients with TT placement. The purpose of this study is to determine the biodistribution of microorganisms on TTs and middle ear fluid obtained from patients with PTTO., Methods: This was a prospective observational study of subjects (6-months-16-years) who underwent standard of care treatment for chronic PTTO. Data was collected on diagnosis, existence of antibiotic resistance, duration of tube placement, and evidence of recurrent infection and/or PTTO. TTs and middle ear fluid were subjected to pyrosequencing; additionally, ear fluid samples were sent for culture-based laboratory diagnostics., Results: DNA-pyrosequencing analysis of bacteria from fluid and TTs of pediatric subjects with PTTO revealed a mixture of both aerobic and anaerobic populations. Retained tubes with minimal otorrhea revealed a predominance of Staphylococcus species, normal external auditory canal (EAC) microbiome, within middle ear fluid as well as on TTs. However, TTs with active mucopurulent otorrhea and granulation tissue unveiled prominence of Gram-negative facultative anaerobes such as Pseudomonas and Eikenella. Discrepancies in prominent bacteria were seen between standard culture-based techniques versus pyrosequencing., Conclusion: Retained tympanostomy tubes are colonized primarily with normal flora of the EAC. However, mucopurulent otorrhea associated with granulation tissue formation revealed a prominence of Gram-negative facultative anaerobes. Standard culture-based diagnostics may identify bacteria, which are not predominant species of infection. Future studies are necessary to assess the association of Gram-negative facultative anaerobes with granulation tissue formation., (Published by Elsevier B.V.)

Bacterial pathogens must sense, respond and adapt to a myriad of dynamic microenvironmental stressors to survive. Adaptation is key for colonization and long-term ability to endure fluctuations in nutrient availability and inflammatory processes. We hypothesize that strains adapted to survive nutrient deprivation are more adept for colonization and establishment of chronic infection. In this study, we detected microevolution in response to transient nutrient limitation through mutation of icc. The mutation results in decreased 3',5'-cyclic adenosine monophosphate phosphodiesterase activity in nontypeable Haemophilus influenzae (NTHI). In a preclinical model of NTHI-induced otitis media (OM), we observed a significant decrease in the recovery of effusion from ears infected with the icc mutant strain. Clinically, resolution of OM coincides with the clearance of middle ear fluid. In contrast to this clinical paradigm, we observed that the icc mutant strain formed significantly more intracellular bacterial communities (IBCs) than the parental strain early during experimental OM. Although the number of IBCs formed by the parental strain was low at early stages of OM, we observed a significant increase at later stages that coincided with absence of recoverable effusion, suggesting the presence of a mucosal reservoir following resolution of clinical disease. These data provide the first insight into NTHI microevolution during nutritional limitation and provide the first demonstration of IBCs in a preclinical model of chronic OM., Competing Interests: The authors have declared that no competing interests exist.

Background: Acute otitis media is a leading cause of childhood morbidity and antibiotic prescriptions. We examined etiologic changes in acute otitis media after introduction of 13-valent pneumococcal conjugate vaccine as routine immunization for Japanese children in 2014. Serotypes, resistance genotypes, antibiotic susceptibilities and multilocus sequence typing of pneumococcal isolates were also characterized., Methods: Otolaryngologists prospectively collected middle ear fluid from 582 children by tympanocentesis or sampling through a spontaneously ruptured tympanic membrane between June 2016 and January 2017. Causative pathogens were identified by bacterial culture and real-time polymerase chain reaction for bacteria. Serotypes, resistance genotypes, sequence types and susceptibilities to 14 antimicrobial agents were determined for pneumococcal isolates., Results: At least 1 bacterial pathogen was identified in 473 of the samples (81.3%). Nontypeable Haemophilus influenzae (54.8%) was detected most frequently, followed by Streptococcus pneumoniae (25.4%), Streptococcus pyogenes (2.9%) and others. Pneumococci of current vaccine serotypes have decreased dramatically from 82.1% in 2006 to 18.5% (P < 0.001). Commonest serotypes were 15A (14.8%), 3 (13.9%) and 35B (11.1%). Serotype 3 was significantly less frequent among children receiving 13-valent pneumococcal conjugate vaccine compared with 7-valent pneumococcal conjugate vaccine (P = 0.002). Genotypic penicillin-resistant S. pneumoniae accounted for 28.7%, slightly less than in 2006 (34.2%; P = 0.393); the penicillin-resistant serotypes 15A and 35B had increased. Serotypes 15A, 3 and 35B most often belonged to sequence types 63, 180 and 558., Conclusions: Our findings are expected to assist in development of future vaccines, and they underscore the need for appropriate clinical choice of oral agents based on testing of causative pathogens.

Despite advances in treatment and prevention, the pneumococcus continues to be a dominant cause of severe pneumonia and sepsis and of otitis media, sinusitis, and nonbacteremic pneumonia. Lewnard and colleagues (Infect Immun 86:e00727-17, 2018, https://doi.org/10.1128/IAI.00727-17) used a unique data set of nasopharyngeal and middle ear fluid samples to provide further insight into the progression of nasopharyngeal pneumococcal colonization to disease. They report the comparative rate of progression from colonization to otitis media by serotype, providing insight into how conjugate vaccines that do not reduce the overall prevalence of pneumococci in the nasopharynx dramatically impact the incidence of acute and complex otitis media., (Copyright © 2018 American Society for Microbiology.)

Objectives: The role of autophagy in the pathophysiology of otitis media with effusion (OME) remains unclear, particularly regarding the difference between pediatric and adult patients. The present study analyzed the expression levels of autophagy-associated mRNAs in effusion fluids obtained from pediatric and adult patients with OME., Materials and Methods: Middle ear fluid samples were collected from 76 pediatric patients and 41 adult patients with OME, and the levels of mRNAs encoding autophagy-related genes were measured using real-time reverse transcription-polymerase chain reaction. The relationships between the levels of autophagy-associated mRNAs and the frequency of ventilation tube insertion, the characteristics of middle ear fluid, and the results of bacterial culture were analyzed., Results: Autophagy-associated mRNAs were present in the effusion fluid of all patients. The level of Beclin-1 mRNA was significantly lower in pediatric than in adult patients, regardless of the frequency of surgery or fluid characteristics (p < 0.05)., Conclusion: Autophagy-associated mRNAs were expressed in effusion fluids of both pediatric and adult patients with OME. However, the level of Beclin-1 mRNA was significantly lower in the effusion fluid of pediatric than adult patients.

Background: Recurrent acute otitis media (rAOM, recurrent ear infection) is a common childhood disease caused by bacteria termed otopathogens, for which current treatments have limited effectiveness. Generic probiotic therapies have shown promise, but seem to lack specificity. We hypothesised that healthy children with no history of AOM carry protective commensal bacteria that could be translated into a specific probiotic therapy to break the cycle of re-infection. We characterised the nasopharyngeal microbiome of these children (controls) in comparison to children with rAOM (cases) to identify potentially protective bacteria. As some children with rAOM do not appear to carry any of the known otopathogens, we also hypothesised that characterisation of the middle ear microbiome could identify novel otopathogens, which may also guide the development of more effective therapies., Results: Middle ear fluids, middle ear rinses and ear canal swabs from the cases and nasopharyngeal swabs from both groups underwent 16S rRNA gene sequencing. The nasopharyngeal microbiomes of cases and controls were distinct. We observed a significantly higher abundance of Corynebacterium and Dolosigranulum in the nasopharynx of controls. Alloiococcus, Staphylococcus and Turicella were abundant in the middle ear and ear canal of cases, but were uncommon in the nasopharynx of both groups. Gemella and Neisseria were characteristic of the case nasopharynx, but were not prevalent in the middle ear., Conclusions: Corynebacterium and Dolosigranulum are characteristic of a healthy nasopharyngeal microbiome. Alloiococcus, Staphylococcus and Turicella are possible novel otopathogens, though their rarity in the nasopharynx and prevalence in the ear canal means that their role as normal aural flora cannot be ruled out. Gemella and Neisseria are unlikely to be novel otopathogens as they do not appear to colonise the middle ear in children with rAOM.

Background: Clinical trials of vaccines for children to prevent acute otitis media (AOM) infections caused by the bacteria Streptococcus pneumonia (Spn) are in Phase I. The objective of this study was to use serum antibody measurements to pneumococcal purified protein candidate antigens that occurred after natural "immunization" to predict a correlate of protection response needed following an injectable vaccine against AOM in children., Methods: 590 nasal and serum samples were collected from 129 healthy children at 6, 9, 12, 15, 18, 24 and 30-36 months of age and when the child developed AOM. Middle ear fluid to detect Spn was collected at every episode of AOM. Quantitative ELISA was used to determine serum IgG against 7 Spn vaccine antigens: PspA clade 3, PspA clade 5, PhtD, PhtE, LytB, PcpA and Ply. A correlate of protection (COP) was estimated by regressing AOM events against age adjusted antibody levels induced by nasopharyngeal colonization and AOM infections, using logistic regression and generalized estimating equation methods., Results: A significant COP was found for Spn PhtD (p = 0.0015), PhtE (p = 0.00034), LytB (p = 0.004), PcpA (p = 0.002), and Ply (p = 0.007) between higher antibody levels and reduced frequency of AOM. We estimated that a 2-fold higher antibody level in a child than the mean antibody level induced by NP colonization (after adjusting for subject age) to PhtD, LytB, PcpA, PhtE or Ply reduced the risk of AOM by 14-21%, a 4-fold higher level reduced it by 25-38% and a 10-fold higher level reduced it by 39-54%., Conclusion: We developed a model to predict the necessary level of serum antibody and fold higher above a threshold to PhtD, PhtE, LytB, PcpA and Ply that would correlate with a reduced likelihood of AOM in children age 6-24 months old if enrolled in a Phase III clinical efficacy trial.

Otitis media with effusion (OME) is a biofilm driven disease and commonly accepted otopathogens, such as Haemophilus influenzae, Streptococcus pneumonia, and Moraxella catarrhalis , have been demonstrated to form polymicrobial biofilms within the middle ear cleft. However, Alloiococcus otitidis ( A. otitidis ), which is one of the most commonly found bacteria within middle ear aspirates of children with OME, has not been described to form biofilms. The aim of this study was to investigate whether A. otitidis can form biofilms and investigate the impact on antibiotic susceptibility and survivability in polymicrobial biofilms with H. influenzae in vitro . The ability of A. otitidis to form single-species and polymicrobial biofilms with H. influenzae was explored. Clinical and commercial strains of A. otitidis and H. influenzae were incubated in brain heart infusion with and without supplementation. Biofilm was imaged using confocal laser scanning microscopy and scanning electron microscopy. Quantification of biofilm biomass and viable bacterial number was assessed using crystal violet assays and viable cell counting in both optimal growth conditions and in adverse growth conditions (depleted media and sub-optimal growth temperature). Antimicrobial susceptibility and changes in antibiotic resistance of single-species and multi-species co-culture were assessed using a microdilution method to assess minimal bactericidal concentration and E-test for amoxicillin and ciprofloxacin. A. otitidis formed single-species and polymicrobial biofilms with H. influenzae . Additionally, whilst strain dependent, combinations of polymicrobial biofilms decreased antimicrobial susceptibility, albeit a small magnitude, in both planktonic and polymicrobial biofilms. Moreover, A. otitidis promoted H. influenzae survival by increasing biofilm production in depleted media and at suboptimal growth temperature. Our findings suggest that A. otitidis may play an indirect pathogenic role in otitis media by altering H. influenzae antibiotic susceptibility and enhancing growth under adverse conditions.

Background: Acute otitis media, an infection of the middle ear, can become chronic after multiple episodes. Microbial influence on chronic otitis media remains unclear. It has been reported that mucin glycoproteins are required for middle ear immune defense against pathogens. We aim to characterize the middle ear effusion (MEE) microbiome using high-throughput sequencing and assess potential associations in microbiome diversity with the presence of the secretory mucins MUC5B and MUC5AC. We hypothesize that MEEs containing MUC5B will exhibit a microbiome largely devoid of typical acute otitis media bacteria., Methods: Fifty-five MEEs from children undergoing myringotomy at Children's National Health System were recovered. Mucin was semiquantitatively determined through Western blot analysis. DNA was subjected to 16S rRNA amplicon sequencing using the Illumina MiSeq platform. Raw data were processed in mothur (SILVA reference database). Alpha- and beta-diversity metrics were determined. Abundance differences between sample groups were estimated., Results: MUC5B was present in 94.5% and MUC5AC in 65.5% of MEEs. Sequencing revealed 39 genera with a relative abundance ≥0.1%. Haemophilus (22.54%), Moraxella (11.11%) and Turicella (7.84%) were the most abundant. Turicella and Pseudomonas proportions were greater in patients older than 24 months of age. In patients with hearing loss, Haemophilus was more abundant, while Turicella and Actinobacteria were less abundant. Haemophilus was also more abundant in samples containing both secretory mucins., Conclusions: The microbiome of MEEs from children with chronic otitis media differs according to specific clinical features, such as mucin content, age and presence of hearing loss. These associations provide novel pathophysiologic insights across the spectrum of otitis media progression.

Acute otitis media (AOM) is a rapid-onset infection of the middle ear which results in middle ear pressure (MEP), middle ear effusion (MEE), and structural changes in middle ear tissues. Previous studies from our laboratory have identified that MEP, MEE, and middle ear structural changes are three factors affecting tympanic membrane (TM) mobility and hearing levels (Guan et al., 2014, 2013). Sound energy reflectance or absorbance (EA) is a diagnostic tool increasingly used in clinical settings for the identification of middle ear diseases. However, it is unclear whether EA can differentiate these three factors in an AOM ear. Here we report wideband EA measurements in the AOM model of chinchilla at three experimental stages: unopened, pressure released, and effusion removed. These correspond to the combined and individual effects of the three factors on sound energy transmission. AOM was produced by transbullar injection of Haemophilus influenzae in two treatment groups: 4 days (4D) and 8 days (8D) post inoculation. These time points represent the relatively early and later phase of AOM. In each group of chinchillas, EA at 250-8000 Hz was measured using a wideband tympanometer at three experimental stages. Results show that the effects of MEP, MEE, and tissue structural changes over the frequency range varied with the disease time course. MEP was the primary contributor to reduction of EA in 4D AOM ears and had a smaller effect in 8D ears. MEE reduced the EA at 6-8 kHz in 4D ears and 2-8 kHz in 8D ears and was responsible for the EA peak in both 4D and 8D ears. The residual EA loss due to structural changes was observed over the frequency range in 8D ears and only at high frequencies in 4D ears. The EA measurements were also compared with the published TM mobility loss in chinchilla AOM ears., (Copyright © 2017 Elsevier B.V. All rights reserved.)

AbstractParacoccidioidomycosis is a systemic mycosis caused by Paracoccidioides brasiliensis . It occurs more frequently in its chronic form, which particularly affects male adults from rural areas. These patients present with pulmonary involvement and systemic symptoms. Skin and mucosal lesions are rather typical and might suggest the diagnosis. The involvement of the upper airway mucosa is common and the patients usually complain of dysphagia and dysphonia. Nonetheless, in endemic areas, physicians should maintain a high level of suspicion even when faced with some atypical symptoms. We present the case of an adult diagnosed with nasopharyngeal paracoccidioidomycosis after presenting with an unusual otolaryngologic syndrome including unilateral soft palate paralysis with velopharyngeal insufficiency and hearing loss secondary to middle ear effusion.