Bacterial etiology of acute myringitis in children less than two years of age

Incidence of Inner Ear Disorders in Various Forms of Acute Otitis Media in ENT Practices in Germany

OBJECTIVE

The aim of this study was to determine the incidence of inner ear involvement in various forms of acute otitis media (AOM) in ear, nose, and throat (ENT) practices in Germany.

METHODS

Patients who had been diagnosed with various forms of AOM in the years 2010 to 2017 were enrolled in the study from a nationwide, representative practice database (Disease Analyzer, IQVIA). In these patients, the incidence of simultaneous or subsequent inner ear disorders (IED) was determined within 7 days and within 12 months from the date of an AOM diagnosis.

RESULTS

A total of 286 186 patients with AOM were enrolled. The most frequent diagnoses were "nonsuppurative otitis media, unspecified" (47.6%) and "otitis media, unspecified" (39.0%). The diagnoses of hemorrhagic bullous myringitis (BM) or influenza-induced AOM were very rarely found in the database. The highest incidence of IED after 7 days and 12 months was found in "nonsuppurative otitis media, unspecified" (7.7% and 15.9%, respectively), followed by "otitis media, unspecified" (5.6% and 13.5%, respectively). The incidences of the most frequent IED "hearing loss, unspecified" and "sensorineural hearing loss, unspecified" increased proportionally with increasing patient age, while the rare diagnoses of "labyrinthitis" and "ototoxic hearing loss" were evenly distributed among the age groups.

CONCLUSION

In ENT practices in Germany, both various forms of AOM, as well as simultaneous or subsequent IED, are mostly being coded in an unspecific way, while specific forms such as hemorrhagic BM, influenza-induced AOM, and labyrinthitis are coded very rarely. Older patients have a higher risk of IED in AOM. A visit due to AOM seems to be a regular occasion for the initial diagnosis of hearing impairment in the elderly individuals. The highest risk of IED was found in nonsuppurative AOM.

Myringitis: An update

Myringitis can be acute or chronic. Though they commonly present with ear discharge with or without pain, the etiology and the management principles differ. Granular myringitis generally is an external ear pathology extending to tympanic membrane and present as painless otorrhea, whereas the bullous myringitis is commonly associated with acute inflammation of middle ear cleft and present with severe ear pain. This literature review discusses the clinical as well as the therapeutic aspects of these inflammatory conditions.

Otitis media: an update on current pharmacotherapy and future perspectives

INTRODUCTION

Acute otitis media (AOM) is the most common childhood bacterial infection and also the leading cause of conductive hearing loss in children. Currently, there is an urgent need for developing novel therapeutic agents for treating AOM.

AREAS COVERED

Structured search of current literature. PubMed was searched for published literature in areas of pharmacotherapeutics, preventive therapies and complementary treatments for OM. The intent of this review is to provide a comprehensive evaluation of therapeutics for AOM, including preventive modalities and complementary medicine.

EXPERT OPINION

the management of AOM in young children is still evolving and depends on patterns of bacterial colonization and antimicrobial resistance in the community. The introduction of vaccinations against potential respiratory tract pathogens has altered the frequency of recovery of pathogens causing ear infections in children. Even though not all patients require antimicrobial therapy to overcome their infection, these agents improve symptoms faster and lead to fewer treatment failures. Further studies are warranted to evaluate which patients would best benefit from antimicrobial therapy.

The diagnosis and management of acute otitis media

This evidence-based clinical practice guideline is a revision of the 2004 acute otitis media (AOM) guideline from the American Academy of Pediatrics (AAP) and American Academy of Family Physicians. It provides recommendations to primary care clinicians for the management of children from 6 months through 12 years of age with uncomplicated AOM. In 2009, the AAP convened a committee composed of primary care physicians and experts in the fields of pediatrics, family practice, otolaryngology, epidemiology, infectious disease, emergency medicine, and guideline methodology. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the new literature related to AOM since the initial evidence report of 2000. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM. The guideline provides a specific, stringent definition of AOM. It addresses pain management, initial observation versus antibiotic treatment, appropriate choices of antibiotic agents, and preventive measures. It also addresses recurrent AOM, which was not included in the 2004 guideline. Decisions were made on the basis of a systematic grading of the quality of evidence and benefit-harm relationships. The practice guideline underwent comprehensive peer review before formal approval by the AAP. This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.

Symptoms and otoscopic signs in bilateral and unilateral acute otitis media

OBJECTIVE

Bilateral acute otitis media (AOM) is considered more severe than unilateral AOM, and several guidelines recommend more active treatment and/or follow-up of bilateral AOM. We studied whether bilateral AOM is a clinically more severe illness than unilateral AOM by comparing symptoms and otoscopic signs between bilateral and unilateral AOM.

METHODS

Two hundred thirty-two children aged 6 to 35 months diagnosed with AOM were eligible. We surveyed the symptoms with a structured questionnaire and recorded the otoscopic signs systematically.

RESULTS

Ninety-eight children had bilateral and 134 children unilateral AOM. Children with bilateral AOM were more often <24 months than children with unilateral AOM (87% vs 75%; P = .032). Fever (≥38°C) occurred in 54% and 36% (P = .006) and severe conjunctivitis in 16% and 44% (P = .047) of children with bilateral and unilateral AOM, respectively. In 15 other symptoms, we found no overall differences even when adjusted with age. We observed the following severe otoscopic signs in the bilateral and unilateral AOM group, respectively: moderate/marked bulging of tympanic membrane (63% and 40%; P = .001), purulent effusion (89% and 71%; P = .001), bulla formation (11% and 10%; P = .707), and hemorrhagic redness of tympanic membrane (7% and 10%; P = .386).

CONCLUSIONS

Bilateral AOM seems to be a clinically only slightly more severe illness than unilateral AOM. Therefore, when assessing AOM severity, bilaterality should not be used as a determining criterion; instead, the child's symptomatic condition together with otoscopic signs should also be taken into consideration.

Clinical spectrum of acute otitis media complicating upper respiratory tract viral infection

BACKGROUND

acute otitis media (AOM) often occurs as a complication of upper respiratory tract infection (URI).

OBJECTIVE

to describe otoscopic findings during URI, the full clinical spectrum of AOM, and outcome of cases managed with watchful waiting.

METHODS

: In a prospective study of 294 healthy children (6 months-3 years), characteristics of AOM complicating URI were studied. Otoscopic findings were categorized by tympanic membrane (TM) position, color, translucency, and mobility. Otoscopic score was assigned based on McCormick otoscopy scale (OS)-8 scale.

RESULTS

during days 1 to 7 of URI, otoscopic findings at 1114 visits were consistent with AOM in 22%; myringitis (inflamed TM, no fluid) was diagnosed in 7%. In AOM episodes diagnosed within 28 days of URI onset, TM position was described as: nonbulging (19%), mild bulging (45%), bulging (29%), and TM perforation occurred in (6%). OS-8 scale showed mild TM inflammation (OS, 2-3) in 6%, moderate (OS, 4-5) in 59%, and severe (OS, 6-8) in 35%. In 54% of 126 bilateral AOM episodes, inflammation of both TMs was at different stages. Of 28 cases of nonsevere AOM managed with watchful waiting, 4 progressed and 3 later required an antibiotic.

CONCLUSIONS

AOM is a spectrum of infection that may present at various stages, even in the same child with bilateral disease. During URI, otoscopic changes are observed from the first day of onset. Understanding the wide clinical spectrum of AOM is needed to help with future clinical trial design and development of a scoring system to establish treatment criteria that will minimize antibiotic use.

No evidence of Mycoplasma pneumoniae in acute myringitis

Our aim was to discover Mycoplasma pneumoniae in bullous and hemorrhagic myringitis in children <2 years of age. Middle ear fluid samples (n = 37) and samples taken from the blisters of the tympanic membranes (n = 12) studied by polymerase chain reaction for M. pneumoniae were negative. This study does not support an important role for M. pneumoniae as an etiologic agent in acute myringitis.

Association of clinical signs and symptoms with bacterial findings in acute otitis media

In acute otitis media (AOM), a means of prediction of the bacterial pathogen based on symptoms and signs would be valuable in selecting appropriate antimicrobial treatment. Children in the control arm (n=831) in the Finnish Otitis Media Vaccine Trial were prospectively observed in a study clinic setting from the age of 2 to 24 months. In patients with AOM, myringotomy with aspiration was performed, and middle ear fluid samples were cultured for bacterial pathogens. Symptoms and signs of respiratory infections were thoroughly recorded. Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae were the most common bacterial pathogens. Pneumococcal AOM was associated with more-severe AOM characterized by fever and earache. AOM due to H. influenzae was associated with eye symptoms and findings. Accurate prediction of a bacterial cause of infection based on symptoms and signs of AOM was not possible, but a specific cause was predicted in some situations, with a high probability of applicability to clinical practice.

The epidemiology of acute bullous myringitis and its relationship to recurrent acute otitis media in children less than 2 years of age

OBJECTIVE

To evaluate the epidemiological characteristics of acute bullous myringitis (BM), i.e. inflammation of the tympanic membrane with blister(s) in children <2 years and study the relationship between bullous myringitis and recurrent acute otitis media.

METHODS

2028 children aged 7-24 months in a prospective longitudinal cohort study in the Finnish Otitis Media vaccine trial. The main outcome measures were the incidence of bullous myringitis and the incidence of acute otitis media (AOM) before and after the event of bullous myringitis.

RESULTS

82 children had a total of 86 events of acute bullous myringitis. The incidence of bullous myringitis was 5.7 per 100 person years (95% CI, 4.6-7.1 per 100 person years). The number of events with bullous myringitis was 4.6% of the number of all AOM events diagnosed during the follow-up. Recurrent AOM (> or =6 AOM events) occurred in 33% of children with bullous myringitis in comparison with 23% of control children with at least one event of AOM (RR 1.7; 95% CI, 1.01-2.7). The incidence of AOM in children with bullous myringitis was 1.8 per person year (95% CI, 1.4-2.2 per person year) before the event of bullous myringitis and 2.9 per person year (95% CI, 2.3-3.5 per person year) after the event of bullous myringitis. The higher incidence rate of AOM lasted for 2 months after the office visit of bullous myringitis.

CONCLUSIONS

Acute bullous myringitis is not a rare disease; it was diagnosed in 5.7% of children <2 years in a 1-year follow-up. It was present in almost 1 of every 20 AOM events. Acute bullous myringitis increases the subsequent risk of recurrent AOM.

Bullous myringitis: a case-control study

Prior studies have shown that bullous myringitis (BM) accounts for <10% of acute otitis media (AOM) cases, and that the distribution of viral and bacterial pathogens in BM is similar to that in AOM without BM, except for a relative increase in the proportion of Streptococcus pneumoniae in BM. We studied 518 cases of AOM in children aged 6 months to 12 years. Using tele-otoscopy to assist the diagnosis, we identified 41 cases (7.9%) with BM. Children who had AOM with BM were older than AOM patients without BM (median age: 4.3 years vs 18 months). We compared 41 cases of AOM with BM to 41 control cases of age-, race-, and gender-matched AOM patients without BM. When compared with this matched control group, children with BM had more severe symptoms at the time of diagnosis and were more likely to have bulging of the tympanic membrane in the quadrants that were not obscured by the bulla. Children with AOM and BM may require aggressive pain management. Although parents and clinicians may agree that a watchful waiting approach is appropriate for older children with mild AOM, children experiencing painful AOM with BM may not be successful candidates for a watchful-waiting approach, because parents may resist postponement of antibiotic therapy in children who are more symptomatic.

The symptoms and clinical course of acute bullous myringitis in children less than two years of age

OBJECTIVE

the most characteristic symptom of acute bullous myringitis (inflammation of the tympanic membrane) is a sudden onset of severe ear pain. However, in infants and young children a precise symptom history is more difficult to obtain and the symptoms may be less specific. Our objective was to determine the occurrence of different symptoms, signs and the recovery of symptoms during the course of acute bullous myringitis in children less than 2 years. We also evaluated whether there were any specific features in bullous myringitis in comparison with acute otitis media (AOM).

METHODS

2028 children (aged 7-24 months) at primary care level in a prospective longitudinal cohort study in the Finnish Otitis Media Vaccine Trial.

RESULTS

during the follow-up there were 86 office visits with bullous myringitis in 92 ears and 1876 office visits with acute otitis media in 2683 ears. Middle ear fluid developed in 97% of cases of bullous myringitis during the course of disease. Earache was present in 58% and fever (>or=38 degrees C) in 62% of cases of bullous myringitis. The symptoms of upper respiratory tract infection (rhinitis in 93% and cough in 73% of events) were present in a majority of cases. Earache, fever, rubbing of the ear, restless sleeping, excessive crying and poor appetite were present more often in bullous myringitis than in acute otitis media. The symptoms were relieved in 1-2 days in a majority of cases. There were no recognized cases of bullous myringitis in ears with patent tympanostomy tubes.

CONCLUSIONS

acute bullous myringitis in children represents a special form of AOM with more severe symptoms. Earache and fever were more common in bullous myringitis than in AOM. However, the condition resolved rapidly and the short-term outcome was good.

Evaluation of the role of respiratory viruses in acute myringitis in children less than two years of age

BACKGROUND

The etiology of acute myringitis remains controversial although it is usually encountered in connection with acute otitis media (AOM). In most cases of acute myringitis a bacterial pathogen has been detected in the middle ear fluid, but the role of respiratory viruses has remained unclear. Our objective was to investigate the etiologic role of viruses in the pathogenesis of acute bullous and hemorrhagic myringitis in children <2 years of age.

METHODS

A prospective longitudinal cohort study of 2028 children ages 7 to 24 months in primary care in the Finnish Otitis Media Vaccine Trial. Nasopharyngeal aspirate (NPA) and middle ear fluid (MEF) samples taken at the time of the diagnosis were examined by a time-resolved fluoroimmunoassay for antigen detection of adenoviruses; influenza viruses A and B; parainfluenza viruses 1, 2 and 3; and respiratory syncytial virus and by reverse transcription polymerase chain reaction for human rhinovirus and human enterovirus.

RESULTS

Eighty-two children with bullous myringitis and 37 children with hemorrhagic myringitis were diagnosed during the 18-month follow-up period. In bullous myringitis a respiratory virus was detected in 70% of NPA samples and in 27% of MEF samples. In hemorrhagic myringitis 57% of NPA samples and 28% of MEF samples were virus-positive. The viral distribution was similar to that of AOM (virus positive 64% of NPA and 37% of MEF).

CONCLUSIONS

We could not confirm any specific respiratory virus to be the etiologic agent in acute myringitis. The etiology of acute myringitis is similar to that of AOM in children <2 years of age.