Otitis media with effusion is not a sterile inflammatory process: scanning electron microscope evidence

[Current hypotheses on the development of chronic otitis media with effusion in childhood]

Chronic otitis media with effusion (COME) has a major impact on a child's physical and social development. Socioeconomic risk factors as well as new insights gained with modern laboratory technology and large demographic studies of COME in Central Europe are discussed. In total, 428 articles from the past 8 years on PubMed were reviewed as well as current guidelines of German- and English-speaking countries on COME in children. Problems of many original studies include small patient numbers and bias. In addition, a clear distinction between acute otitis media and COME is often missing. Microbiomic profiles and biofilms seem to play a major role in COME. Established theories on the multifactorial origin of COME are mostly supported by new studies, including new insights into immunological and nutritional risk factors. In addition, the socioeconomic background of a child with COME must not be underestimated, even in first-world countries.

Pediatric cochlear implantation in otitis media with effusion: Are ventilation tubes truly necessary?

OBJECTIVE

We aimed to evaluate the clinical findings of our cochlear implant (CI) patients with otitis media with effusion (OME) and CI patients treated with ventilation tube (VT) for OME.

METHODS

The medical records of patients who underwent CI surgery at Hacettepe University, Department of Otorhinolaryngology, between November 1997 and March 2023 were reviewed. Patients who had OME or VT in the implanted ear at the time of surgery were included in the study. Perioperative findings, complication status, revision status, and reasons for revision were recorded.

RESULTS

A total of 2945 ears were operated for cochlear implantation during this period. Of these cases, 169 (5.7 %) had OME and 55 (1.86 %) had VT at time of surgery (180 patients). There were no significant differences between the two groups regarding demographic parameters and follow-up time. None of the investigated parameters showed any significant differences between the two groups, except for revision status. The revision rate was significantly higher in the OME group than that in the VT group (10.65 % vs. null, p = 0.008). The total non-OME and non-VT patient cohort had a significantly lower revision rates than the OME group (5.29 % vs. 10.65 %, p = 0.003).

CONCLUSION

There is no significant difference in surgical difficulty and perioperative complications after CI between patients with VT and those with OME. The relationship between a higher rate of revision and OME in CI patients, and the optimal timing and necessity of VT insertion prior to CI surgery, should be further investigated.

The association of bacterial biofilm and middle ear mucosa in patients with mucosal chronic suppurative otitis media

OBJECTIVES

To evaluate the bacterial biofilm's role in mucosal chronic suppurative otitis media (CSOM) utilizing scanning electron microscopy (SEM).

METHODS

This study involved 123 participating patients with active and inactive mucosal CSOM who underwent tympanomastoid surgery. SEM was used to examine middle ear mucosa biopsies for the development of biofilms. Middle ear discharge or mucosal swabs from patients were cultured to detect any bacterial growth. The biofilm formation was correlated to the culture results.

RESULTS

The biofilm was present in 69.9 % of patients (59% of them were with active mucosal CSOM) and absent in 30.1% of the patients (70% of them were with inactive mucosal CSOM), being more statistically significant in active mucosal CSOM (p-value = 0.003). A correlation that was statistically significant was found between active mucosal CSOM and higher grades (3 and 4) of biofilms (p-value <0.05). The mucosal CSOM type and the results of the culture had a relationship that was statistically significant (p-value <0.001). 60% of patients had positive culture (70% of them were with active mucosal CSOM). There was a statistically significant relation between Pseudomonas aeruginosa bacterial growth and active mucosal CSOM (p-value = 0.004) as well as higher grades of biofilms in mucosal CSOM.

CONCLUSION

Mucosal CSOM, especially the active type, is a biofilm-related disease. There is a significant relation between the state of mucosal CSOM (active or inactive) and culture results with predominance of Pseudomonas aeruginosa bacterial growth in active mucosal CSOM and in higher grades of biofilms in mucosal CSOM.

The Prevalence and Association of Biofilms With Otitis Media With Effusion: A Systematic Review and Meta-Analysis

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.

ISOM 2023 research Panel 4 - Diagnostics and microbiology of otitis media

OBJECTIVES

To identify and review key research advances from the literature published between 2019 and 2023 on the diagnosis and microbiology of otitis media (OM) including acute otitis media (AOM), recurrent AOM (rAOM), otitis media with effusion (OME), chronic suppurative otitis media (CSOM) and AOM complications (mastoiditis).

DATA SOURCES

PubMed database of the National Library of Medicine.

REVIEW METHODS

All relevant original articles published in Medline in English between July 2019 and February 2023 were identified. Studies that were reviews, case studies, relating to OM complications (other than mastoiditis), and studies focusing on guideline adherence, and consensus statements were excluded. Members of the panel drafted the report based on these search results.

MAIN FINDINGS

For the diagnosis section, 2294 unique records screened, 55 were eligible for inclusion. For the microbiology section 705 unique records were screened and 137 articles were eligible for inclusion. The main themes that arose in OM diagnosis were the need to incorporate multiple modalities including video-otoscopy, tympanometry, telemedicine and artificial intelligence for accurate diagnoses in all diagnostic settings. Further to this, was the use of new, cheap, readily available tools which may improve access in rural and lowmiddle income (LMIC) settings. For OM aetiology, PCR remains the most sensitive method for detecting middle ear pathogens with microbiome analysis still largely restricted to research use. The global pandemic response reduced rates of OM in children, but post-pandemic shifts should be monitored.

IMPLICATION FOR PRACTICE AND FUTURE RESEARCH

Cheap, easy to use multi-technique assessments combined with artificial intelligence and/or telemedicine should be integrated into future practice to improve diagnosis and treatment pathways in OM diagnosis. Longitudinal studies investigating the in-vivo process of OM development, timings and in-depth interactions between the triad of bacteria, viruses and the host immune response are still required. Standardized methods of collection and analysis for microbiome studies to enable inter-study comparisons are required. There is a need to target underlying biofilms if going to effectively prevent rAOM and OME and possibly enhance ventilation tube retention.

The biofilm characteristics and management of skin flap infection following cochlear implantation

Objective

This study aims to assess the frequency, bacteriology, biofilm characteristics and management of skin flap infection (SFI) following cochlear implantation (CI).

Methods

The study enrolled 1,251 patients receiving CI in the First Affiliated Hospital of Fujian Medical University between August 2001 and March 2021. Scanning electron microscopy (SEM) was utilised to characterise the aetiology of infection. A proposed classification system was applied to optimise treatments for post-operative skin flap infection.

Results

After CI, SFI was reported in 16 patients (1.28%) and occurred more frequently in patients under 6 years of age. Of all SFI cases Staphylococcus aureus was the most common pathogen for flap infection, with 8 cases (50%) and bacterial biofilm was evident within the jelly-like substance on the surface of implanted devices in SFI patients. A two-stage classification was proposed to optimise the treatment schemes. Conservative therapy was recommended for stage I cases and surgical treatment for stage II patients.

Conclusions

Paediatric patients are more susceptible to SFI after CI, which may be attributed to the formation of bacterial biofilm. The proposed classification can facilitate the management of SFI.

Sustained Release of a Streptococcus pneumoniae Endolysin from Liposomes for Potential Otitis Media Treatment

Local delivery of antimicrobials for otitis media treatment would maximize therapeutic efficacy while minimizing side effects. However, drug transport across the tympanic membrane in the absence of a delivery system is challenging. In this study, the MSlys endolysin was encapsulated in deformable liposomes for a targeted treatment of S. pneumoniae, one of the most important causative agents of otitis media. MSlys was successfully encapsulated in liposomes composed of l-alpha-lecithin and sodium cholate (5:1) or l-alpha-lecithin and PEG2000 PE (10:1), with encapsulation efficiencies of about 35%. The PEGylated and sodium cholate liposomes showed, respectively, mean hydrodynamic diameters of 85 and 115 nm and polydispersity indices of 0.32 and 0.42, both being stable after storage at 4 °C for at least one year. Both liposomal formulations showed a sustained release of MSlys over 7 days. Cytotoxicity studies against fibroblast and keratinocyte cell lines revealed the biocompatible nature of both MSlys and MSlys-loaded liposomes. Additionally, the encapsulated MSlys showed prompt antipneumococcal activity against planktonic and biofilm S. pneumoniae, thus holding great potential for transtympanic treatment against S. pneumoniae otitis media.

Effects of the Traditional Mediterranean Diet in Patients with Otitis Media with Effusion

INTRODUCTION

Otitis media with effusion (OME) is common in pediatric primary care consultations. Its etiology is multifactorial, although it has been proven that inflammation factors mediate and that immunity is in a phase of relative immaturity. The objective of this study was to assess the effects of the Traditional Mediterranean Diet (TMD) modulating inflammation and immunity in patients diagnosed with OME.

MATERIALS AND METHODS

A analysis as a single-group pre-test/post-test was conducted on 40 girls and 40 boys between 18 months and 5 years old. Tympanometry normalization was the main test to control the benefit of diet. Clinical and therapeutic variables were studied through evaluation questionnaires, a quality test of the diet, as well as various anthropometric parameters.

RESULTS

At the end of one year, tympanometry had normalized in 85% of patients. The remaining 15% had normal audiometry and/or associated symptoms had decreased. Likewise, episodes of recurrent colds decreased from 5.96 ± 1.41 to 2.55 ± 0.37; bacterial complications of 3.09 ± 0.75 to 0.61 ± 0.06 and persistent nasal obstruction of 1.92 ± 0.27 to 0.26 ± 0.05. The degree of satisfaction of the families with the program was very high.

CONCLUSIONS

The application of the Traditional Mediterranean Diet could have promising effects in the prevention and treatment of otitis media with effusion.