Intracranial complications of CSOM in pediatric patients: A persisting problem in developing countries

Otogenic brain complications: a systematic review and meta-analysis

OBJECTIVE

This study aimed to form astute deductions regarding the presentation, treatment and mortality of otogenic brain complications.

METHODS

A systematic literature search of four medical databases (PubMed, Embase, Web of Science and Scopus) was conducted. Studies associated with otogenic brain complications were considered eligible. Fixed- and random-effects model meta-analysis was developed to assess the proportion estimate for each outcome individually.

RESULTS

Twenty-eight studies, with 1650 patients in total, were included. In 66 per cent of patients there was a known history of chronic otitis media. The most common symptoms were purulent otorrhoea (84 per cent), headache (65 per cent) and otalgia (45 per cent). A brain abscess was observed in 49 per cent of patients, followed by meningitis (34 per cent) and sinus thrombosis (22 per cent). A combination of surgical and conservative therapy was chosen in 84.3 per cent of cases and the mortality rate approached 11.1 per cent.

CONCLUSION

Otogenic brain complications are a possibly life-threatening condition. Prompt imaging examination may set the final diagnosis and lead to an effective treatment.

Thrombosis of sigmoid sinus, transverse sinus, and internal jugular vein in chronic otitis media in 9-year-old girl: a case report

Introduction and importance

Chronic otitis media can lead to dreadful intracranial complications, the most common being meningitis. A concomitant finding of thrombosis in more than one sinus with a cerebral vein is extremely rare. Septic sigmoid sinus thrombosis has an infectious origin and the treatment is debatable between antibiotics and surgery.

Case presentation

A case of 9-year-old female with prolonged symptoms of right sided ear discharge, fever, right sided neck pain, and vomiting. Examination revealed tachycardia and neck rigidity suggesting meningitis. The child developed shock, generalized seizure, and a persistent high grade fever in the course of hospital stay. Brain imaging revealed sigmoid, transverse, and internal jugular thrombosis. Blood culture grew both gram-positive and gram-negative bacteria, suggesting the infectious origin of the thrombus. The authors treated meningitis with cephalosporin and vancomycin at first, and then additional antibiotics to treat the septic sigmoid sinus thrombosis.

Clinical discussion

Sigmoid sinus thrombosis is a rare condition caused by infections, thrombophilia, head trauma, some types of cancer, and intravenous drug use. Cerebral vein or sinus thrombosis can lead to raised intracranial pressure and can cause fever, otalgia, headache, vomiting, cranial nerve palsies, papilledema altered mental status and may cause seizures, stupor, and coma. Prompt diagnosis by CT scan or MRI and prompt treatment with antibiotics are crucial.

Conclusion

Sigmoid sinus thrombosis with involvement of the transverse sinus and internal jugular vein is a rare complication of chronic otitis media, and should be suspected if a recurring fever with features of raised intracranial pressure is present in a child with chronic otitis media.

Nomogram Analysis of Clinical Characteristics and Mortality Risk Factor of Non-Fermentative Gram-Negative Bacteria-Induced Post-Neurosurgical Meningitis

Objective

To explore the clinical characteristics of post-neurosurgical meningitis (PNM) patients infected with nonfermenting Gram-negative bacilli (NFGNB) and to evaluate the related mortality risk factors.

Methods

A cohort analysis of PNM patients infected with NFGNB in Beijing Tiantan Hospital and Capital Medical University from 2012.1 to 2020.12. The microbial distribution, antimicrobial sensitivity and genotypes were tested, and potential mortality risk factors were evaluated using Mann–Whitney U or chi-squared tests. Independent risk factors for mortality were established by constructing a logistic model.

Results

A total of 2940 PNM patients were enrolled in this study, of whom 207 (17.1%) were infected with NFGNB. Among these patients, 29 died of NFGNB meningitis, with an overall mortality rate of 14.0%. The top three NFGNBs were Acinetobacter baumannii (105 cases, 50.7%), Pseudomonas aeruginosa (29 cases, 14.0%) and Acinetobacter lwoffii (20 cases, 9.7%). Nomogram analysis revealed that hypertension (OR 4.551, 95% CI: 1.464–14.154, P = 0.009), external ventricular drainage (EVD) (OR 3.944, 95% CI: 1.286–12.095, P = 0.016), and assisted mechanical ventilator (AMV) (OR 6.192, 95% CI: 1.737–22.081, P = 0.005) were independent risk factors for mortality. In addition, antibiotic prophylaxis was shown to play a vital role in NFGNB-induced PNM therapy.

Conclusion

PNM patients infected with NFGNB have a high mortality rate. Hypertension, EVD and AMV were independent mortality risk factors, and clinical attention should be paid to their prevention and treatment.

Chronic Suppurative Otitis Media leading to cerebellar brain abscess, still a problem in 21st century: A case report

Introduction and importance

Chronic suppurative otitis media (CSOM) is a chronic inflammation of the middle ear associated with tympanic membrane rupture and purulent discharge for at least 6 weeks. Owing to the proper use and easy availability of antibiotics, these types of cases are rare in developed regions, but they are still occasionally seen in the developing world with poor hygiene and a lack of availability of antibiotics and immunizations.

Case presentation

Patient presented with complaints of headache, yellow-colored discharge from ear, fever and vomiting. The patient's Glasgow Coma Scale (GCS) was 12/15, neck stiffness and positive Kernig's sign, horizontal nystagmus and exaggerated deep tendon reflexes. Positive CSF findings and Magnetic Resonance Imaging showing right sided cerebellar abscesses, led to the diagnosis of right-sided CSOM leading to cerebellar brain abscess. Patient was treated with anti-pyrectics, intravenous mannitol, IV and topical antibiotics and IV-dexamethasone. Abscess evacuation was performed in neurosurgery department while mastoidectomy was performed in ENT department. Patient's condition improved quickly and was discharged with regular follow-up.

Discussion

CSOM is a long-standing middle ear infection, associated with ear discharge and permanent perforation of the tympanic membrane. Divided into two main types, a) Tubo tympanic b) Atticoantral. CSOM occasionally presents with severe intracranial complications, especially in developing countries.

Conclusion

CSOM is a chronic inflammation of the middle ear. Without early and effective management, it can lead to serious intracranial complications. So, diagnosis of complications like cerebellar abscess should be on the differential while dealing with patients with CSOM in developing countries.

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CSOM is a chronic inflammation of the middle ear associated with tympanic membrane rupture and purulent discharge for at least 6 weeks.

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Commonly seen complications include infections leading to auricular sinus, subperiosteal abscess and meningitis.

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This case report deals with discussion of a patient who presented with symptoms of meningoencephalitis and cerebellar brain abscess.

The association of iron deficiency anemia on chronic suppurative otitis media in children: A case-control study

Background

Chronic suppurative otitis media (CSOM) is the most common infectious disease in the world and the leading cause of hearing loss in children in developing countries. Iron deficiency anemia (IDA) is often found in children with CSOM.

Objective

This study was conducted to determine the association between IDA and the incidence of CSOM in children.

Method

This research is a case-control study using consecutive sampling. Participants were divided into case group which are children diagnosed with CSOM (n = 42) and control group which are children with normal ear (n = 42). All participants were examined for serum iron (FE), hemoglobin (Hb), total iron-binding capacity (TIBC), and ferritin levels. The analysis used in this study includes the chi-square test or fisher extract test and independence t-test or Man Whitney test with p < 0.05.

Result

The measurement results obtained values of Hb (13.00 ± 1.34 g/dL; p < 0.001), FE (95.13 ± 40.84 g/dL; p < 0.001), TIBC (354.18 ± 62.44 g/dL; p = 0.016), and ferritin levels (17.57 ± 8.55 g/dL; p < 0.001). Participants who experienced IDA were 21.43% which in the case group was 31.0% and control group was 11.9% (OR = 3.32; p = 0.033).

Conclusion

IDA can increase the incidence of CSOM in children.

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Iron deficiency anemia is a risk factor for CSOM in Children.

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Children with iron deficiency anemia have a 3-fold risk of experiencing CSOM.

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Supplement iron needs to be given as a preventative for CSOM in children.

Identification of critical windows in early development of human upper respiratory tract and middle ear disease

Otitis media (OM) or middle ear disease is a prevalent pediatric condition generally related to early growth of the cartilaginous Eustachian tube (CET). This study used a developmental series of dry crania to reconstruct CET and dilator tubae (DT, the muscle opening the CET) morphology. Timing and directionality of CET and upper respiratory tract (URT) growth were investigated. Traditional and 3D geometric morphometrics (GM) were used to assess bony landmarks on the crania. The series was divided using dental eruption into seven growth stages ranging from before eruption of deciduous dentition (approximately the first 6 postnatal months) to eruption of the first permanent maxillary molar (after approximately 6 years). Bony endpoints of the CET and DT were used to calculate their morphology. GM analysis showed substantial shape differences between newborns, early infants, and all later developmental stages. Univariate measures showed the largest growth change between birth and 6 months. Subsequently, CET morphology changed little in the latter half of year 1, instead maturing gradually until approximately 3 years whereas DT relative length and orientation finish growth by the end of year 1. Incongruence in slower CET growth and faster DT growth could impact CET function between 6 and 12 months and be a contributing factor of OM. Tubal aeration may improve after this time when both CET and DT morphology mature, coinciding with clinically reported drop-off in ear infections.

Management of infective complications of otitis media in resource-constrained settings

PURPOSE OF REVIEW

Complications of otitis media are a cause of significant morbidity and mortality, compounded in resource-constrained settings in which human and physical resources to manage disease are suboptimal. Here, we examine the current best evidence to devise a protocol for management, in particular exploring the opportunity for conservative or nonspecialist management.

RECENT FINDINGS

Reviews of the literature suggest that intratemporal and extracranial infections can be managed with antibiotics in the first instance, with aspiration or incision and drainage of abscess. Failure to respond necessitates mastoidectomy, which need not be extensive, and can be performed with hammer and gouge. Suspected or possible intracranial extension requires referral for computed tomography (CT) imaging. Intracranial infection can in some instances be managed with antibiotics, but large or persistent intracranial abscess, or the presence of cholesteatoma requires management in a centre for specialist surgery.

SUMMARY

Many complications of otitis media could be managed by nonspecialists in appropriately equipped local or regional health facilities, and supported by appropriate training. However, regional centres with CT imaging and specialist surgery are required for assessment and treatment of cases that are suspected of having complex or advanced disease, or that fail to respond to initial treatment. Those involved in planning healthcare provision should look to develop infrastructure to support such management.

Phenotype, molecular characterisation and risk factors for postoperative meningitis caused by ESBL-producing-Enterobacteriaceae: a six years multi-Centre comparative cohort study

BACKGROUND

To determine the phenotype, molecular characterisation and risk factors of postoperative meningitis induced by Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae (EPE) in China.

METHODS

We performed a multi-centre comparative cohort study of postoperative meningitis patients infected with Enterobacteriaceae in 4 neurosurgical centres in China from January 2014 to December 2019. Phenotype and molecular characteristics of the isolates were reviewed and tested, and independent risk factors of the EPE meningitis were evaluated by binary logistic regression.

RESULTS

In total, 220 Enterobacteriaceae include 78 EPE were available in this study. 85.6% (67/78) ESBL-related genes were tested, and blaSHV (14.9%) and blaSHV + blaTEM + blaCTX-M-9 (20.9%) were found to be the most frequent mono and combined ESBL-related genes harboured by Enterobacteriaceae. On binary logistic analysis, craniotomy (OR. 2.583, 95% C.I. 1.274-5.235, P = 0.008) and malignancy (OR. 2.406, 95% C.I. 1.299-4.456, P = 0.005) were the associated independent risk factors to meningitis induced by EPE.

CONCLUSIONS

To the best of our knowledge, this is the largest series focusing on risk factors of EPE meningitis which has been conducted in China. Craniotomy and malignancy were independent risk factors for EPE meningitis. The risk factors identified may be further utilized in clinical practice and research to avoid and reduce the mortality in future.

Panel 6: Otitis media and associated hearing loss among disadvantaged populations and low to middle-income countries

OBJECTIVE:

Summarise the published evidence on otitis media and associated hearing loss in low to middle-income countries (LMIC) and disadvantaged populations.

DATA SOURCES:

PubMed and other databases.

REVIEW METHODS:

Firstly, sensitive search strategy using ‘otitis media’, combined with specific key words for each topic of the review, from January 2015 to June 2019. Then, restriction to LMIC and disadvantaged populations. Topics covered included prevention, epidemiology, risk factors, microbiology, prognosis, diagnosis, and treatment.

CONCLUSIONS:

There was a high degree of methodological heterogeneity and high risk of bias. The majority of studies were school-based. In Africa, Asia and Oceania (e.g., Australian Aboriginal populations) the prevalence of OM was respectively 8% (range 3–16%), 14% (range 7–22%) and 50% (4–95%). Prevalence of any hearing loss in these regions was 12% (range 8–17%), 12% (range 3–24%), and 26% (range 25–28%) respectively. Risk factors in LMIC and disadvantaged populations included age, gender, exposure to smoke and pollution. Microbiology was reported for otitis media with effusion at time of surgery or ear discharge (acute otitis media with perforation or chronic suppurative otitis media). Specimen handling and processing in hospital laboratories was associated with low detection of S. pneumoniae and H. influenzae. Case series described complicated cases of OM due to M. tuberculosis, multidrug resistance and HIV. QOL studies identified discrimination of persons with OM and hearing loss. Diagnostic methods varied greatly, from naked eye to tympanometry. Treatment interventions were reported from four RCTs. Non-RCTs included evaluations of guidelines, surgery outcomes, access to ENTs.

IMPLICATIONS FOR CLINICAL PRACTICE:

Chronic suppurative otitis media, otitis media with effusion and conductive hearing loss are common in LMIC and disadvantaged populations. Paucity of research, poor regional representation, non-standardised methods and low-quality reporting preclude accurate assessment of disease burden in LMIC and disadvantaged populations. Awareness and adherence to reporting Guidelines should be promoted.

Reconstructing the Neanderthal Eustachian Tube: New Insights on Disease Susceptibility, Fitness Cost, and Extinction

Neanderthals are among the best studied and yet most enigmatic fossil human groups with aspects of their anatomy and functional morphology remaining poorly understood. We present the first anatomical reconstruction of the Neanderthal cartilaginous Eustachian tube (CET), a vital component of the upper respiratory tract and nexus for the middle ear and postnasal airway. The Eustachian (auditory, pharyngotympanic) tube, comprised of a bony and cartilaginous (CET) portion, is integral to normal physiological functions such as middle ear aeration and pressure equilibration. Findings indicate that Neanderthal tubal morphology may have predisposed them to high rates of middle ear disease (otitis media [OM]). In living humans, mechanical CET dysfunction underlies OM in infants and young children, with sequelae including hearing loss, meningitis, and pneumonia. Despite proven linkage of CET malfunction with OM, the role of CET morphology in Neanderthal health and disease remains unstudied. We reconstructed Neanderthal CET morphology, comparing their crania to a modern human growth series. Methods included geometric morphometrics and univariate measures among Procrustes-fitted coordinates. Results showed Neanderthal adults exhibiting primitively tall and narrow nasopharynges with infant-like horizontal CET and choanal orientation. As horizontal CET orientation is associated with increased OM incidence in infants and children until around age six, its appearance in Neanderthal adults strongly indicates persistence of high OM susceptibility at this time. This could have compromised fitness and disease load relative to sympatric modern humans, affecting Neanderthals' ability to compete within their ecological niche, and potentially contributing to their rapid extinction. Anat Rec, 302:2109-2125, 2019. © 2019 American Association for Anatomy.

Otopathogenic Staphylococcus aureus Invades Human Middle Ear Epithelial Cells Primarily through Cholesterol Dependent Pathway

Chronic suppurative otitis media (CSOM) is one of the most common infectious diseases of the middle ear especially affecting children, leading to delay in language development and communication. Although Staphylococcus aureus is the most common pathogen associated with CSOM, its interaction with middle ear epithelial cells is not well known. In the present study, we observed that otopathogenic S. aureus has the ability to invade human middle ear epithelial cells (HMEECs) in a dose and time dependent manner. Scanning electron microscopy demonstrated time dependent increase in the number of S. aureus on the surface of HMEECs. We observed that otopathogenic S. aureus primarily employs a cholesterol dependent pathway to colonize HMEECs. In agreement with these findings, confocal microscopy showed that S. aureus colocalized with lipid rafts in HMEECs. The results of the present study provide new insights into the pathogenesis of S. aureus induced CSOM. The availability of in vitro cell culture model will pave the way to develop novel effective treatment modalities for CSOM beyond antibiotic therapy.

Brain abscess in pediatric age: a review

OBJECTIVE

The purpose of the paper is to examine the current state of the art about epidemiology, diagnosis, and treatment of this infection.

METHODS

A review of the literature was performed through a PubMed search of original articles, case reports, and reviews using the key words "brain abscess," "cerebral abscess," "brain infection," "intracranial suppuration," "otogenic brain abscess," "otitis complications," and "sinusitis complications."

RESULTS

Pediatric brain abscess is a rare but serious infection, often involving patients with specific risk factors and burdened by a high risk of morbidity and mortality. Brain abscess incidence and mortality decreased over the years, thanks to improved antibiotic therapy, new neurosurgical techniques, and the wide spread of vaccinations. There are no guidelines for the adequate diagnostic-therapeutic pathway in the management of brain abscesses; therefore, conflicting data emerge from the literature. In the future, multicentric prospective studies should be performed in order to obtain stronger evidences about brain abscesses management. Over the next few years, changes in epidemiology could be observed because of risk factors changes.

Preventative and medical treatment of ear disease in remote or resource-constrained environments

BACKGROUND

Important ear problems can affect the outer ear, the middle ear and the inner ear. Globally, the greatest burden of disease is due to ear conditions that are associated with otorrhoea and hearing loss.

METHODS

This study reviewed the literature on the prevention and treatment of common ear conditions that are most relevant to settings with high rates of ear disease and limited resources. The grading of recommendations assessment, development and evaluation ('GRADE') approach was utilised to assess interventions.

RESULTS

Accurate diagnosis of ear disease is challenging. Much of the preventable burden of ear disease is associated with otitis media. Nine otitis media interventions for which there is moderate to high certainty of effect were identified. While most interventions only provide modest benefit, the impact of treatment is more substantial in children with acute otitis media with perforation and chronic suppurative otitis media.

CONCLUSION

Disease prevention through good hygiene practices, breastfeeding, reducing smoke exposure, immunisation and limiting noise exposure is recommended. Children with acute otitis media with perforation, chronic suppurative otitis media, complications of otitis media, and significant hearing loss should be prioritised for medical treatment.