Otitis media: viruses, bacteria, biofilms and vaccines

Chronic suppurative otitis media: disrupted host-microbial interactions and immune dysregulation

Recent research has uncovered new mechanisms that disrupt the balance between the host and microbes in the middle ear, potentially leading to dysbiosis and chronic suppurative otitis media (CSOM). Dysbiotic microbial communities, including core pathogens such as persister cells, are recognized for displaying cooperative virulence. These microbial communities not only evade the host's immune defenses but also promote inflammation that leads to tissue damage. This leads to uncontrolled disorder and pathogen proliferation, potentially causing hearing loss and systemic complications. In this discussion, we examine emerging paradigms in the study of CSOM that could provide insights into other polymicrobial inflammatory diseases. Additionally, we underscore critical knowledge gaps essential for developing a comprehensive understanding of how microbes interact with both the innate and adaptive immune systems to trigger and maintain CSOM.

Understanding Heritable Variation Among Hosts in Infectious Diseases Through the Lens of Twin Studies

Genetic factors have been hypothesized to contribute to the heterogeneity in the response to infectious diseases (IDs). The classical twin design provides a powerful tool to estimate the role of genetic contributions to variation in infection outcomes. With this design, the impact of heritability on the proneness as well as infection- and vaccine-induced immune responses have been documented for multiple infections, including tuberculosis, malaria, leprosy, otitis media, polio, mumps, measles, rubella, influenza, hepatitis B, and human papillomavirus infections, and recently, SARS-CoV-2. The current data show the heritable aspect in nearly all infections considered. In this contribution, we review and discuss human twin studies on the heritability of host characteristics in liability and response to IDs. This review emphasizes the importance of considering factors such as sex, disease stages, and disease presentation when assessing heritability and argues that the classical twin design provides a unique circumstance for exploring the genetic contribution as twins share levels of maternal antibodies, ancestral background, often the dates and number of vaccine doses, differences in vaccines' manufacturing and storage, age, family environment, and other exposures. Additionally, we highlight the value of twin studies and the usefulness of combining the twin model with contemporary genomics technologies and advanced statistical tools to grasp a comprehensive and nuanced understanding of heritability in IDs.

The Impact of COVID-19 Restrictions on Hospital Admissions of Common Head and Neck Infections

INTRODUCTION

Following the emergence of COVID-19, multiple preventative measures were implemented to limit the spread of the disease. This study aims to elucidate the impact of COVID-19 restrictions on hospital admissions of otolaryngology-related infections.

MATERIALS AND METHODS

A retrospective chart review was conducted to capture all admissions for otolaryngology-related infections in the 2 years pre- and post-COVID-19 at the Health Sciences Centre in Winnipeg, Manitoba. These infections included croup, tracheitis, neck abscess, peritonsillar abscess, otitis media, mastoiditis, sinus infection, orbital infection, pharyngotonsillitis, retro/parapharyngeal abscess, and acute epiglottitis. Demographic information and admission details were collected and analyzed to compare pre- and post-COVID-19 admissions. Further analysis was conducted to compare hospital admissions of patients from rural/remote regions.

RESULTS

Between March 2018 and March 2022, 253 pediatric patients and 197 adults were admitted for otolaryngology-related infections. Total pediatric admissions decreased post-COVID-19 (154 pre-COVID-19, 99 post-COVID-19; p < 0.001) whereas adult admissions remained stable (107 pre-COVID-19, 90 post-COVID-19; p = 0.25). No significant difference in mean patient age, admission duration, surgical rates or in the proportion of admissions from patients from rural/remote regions was observed in the pediatric or adult cohort when comparing pre-COVID-19 data to post-COVID-19 data. Diagnosis-specific changes in admissions were observed in pediatric croup (40 pre-COVID-19, 15 post-COVID-19; p < 0.001) and in adult orbital infections (30 pre-COVID-19, six post-COVID-19; p < 0.001).

CONCLUSION

Following the implementation of COVID-19 restrictions, there was a decrease in admissions due to pediatric croup and adult orbital infections with an overall decrease in pediatric Otolaryngology-infection related admissions.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3542-3547, 2024.

The Unneglectable Disease Burden of Otitis Media Among Children in China: A Systematic Review and Meta-analysis

BACKGROUND

Otitis media (OM) is one of the most commonly diagnosed infections among children yet with obscure disease burden.

METHODS

The literature published from 1980 to 2022 was retrieved in PubMed, Ovid-EMBASE, Web of Science, CNKI, Wanfang and VIP. Literature screening, quality assessment and data extraction were conducted by 2 independent reviewers. Heterogeneity and publication bias were detected by I2 , Egger's and Begg's tests. The data were pooled using the random-effects model. The number of OM cases was estimated by the multiplied model based on pooled results and the 2020 China census data.

RESULTS

A total of 28,378 literatures were identified with 67 finally included for data analysis. The OM incidence among children was 7.89% [95% confidence interval (CI): 5.43%-11.33%] and the prevalence of OM was 5.13% (95% CI: 3.49%-7.49%). The most common pathogen of the OM cases was Streptococcus pneumoniae ( S. pneumoniae ), with a positive rate of 33.52% (95% CI: 26.55%-41.29%). The most common serotypes of S. pneumoniae isolated from OM cases were serotypes 19F, 19A, 6B, 23F and 3, with 85.8% covered by the PCV13. We estimated that there were 8,950,797 (95% CI: 6,080,533-12,928,051) OM cases among under-fives in China in 2020, of which 3,374,451 (95% CI: 1,698,901-6,277,862) cases of OM were caused by S. pneumoniae .

CONCLUSIONS

The burden of OM in China was considerable yet neglected. To date, S. pneumoniae was the most frequently detected bacterial pathogen of OM. Vaccination may be effective to protect young children from OM.

Exploration of the Antibacterial and Anti-Inflammatory Activity of a Novel Antimicrobial Peptide Brevinin-1BW

Antibiotic resistance has emerged as a grave threat to global public health, leading to an increasing number of treatment failures. Antimicrobial peptides (AMPs) are widely regarded as potential substitutes for traditional antibiotics since they are less likely to induce resistance when used. A novel AMP named Brevinin-1BW (FLPLLAGLAASFLPTIFCKISRKC) was obtained by the Research Center of Molecular Medicine of Yunnan Province from the skin of the Pelophylax nigromaculatus. Brevinia-1BW had effective inhibitory effects on Gram-positive bacteria, with a minimum inhibitory concentration (MIC) of 3.125 μg/mL against Enterococcus faecalis (ATCC 29212) and 6.25 μg/mL against both Staphylococcus aureus (ATCC 25923) and multidrug-resistant Staphylococcus aureus (ATCC 29213) but had weaker inhibitory effects on Gram-negative bacteria, with a MIC of ≥100 μg/mL. Studies using scanning electron microscopy (SEM) and flow cytometry have revealed that it exerts its antibacterial activity by disrupting bacterial membranes. Additionally, it possesses strong biofilm inhibitory and eradication activities as well as significant lipopolysaccharide (LPS)-binding activity. Furthermore, Brevinin-1BW has shown a significant anti-inflammatory effect in LPS-treated RAW264.7 cells. In conclusion, Brevinin-1BW is anticipated to be a promising clinical agent with potent anti-Gram-positive bacterial and anti-inflammatory properties.

Detection of SARS-CoV-2 virus in middle ear effusions and its association with otitis media with effusion

A large-scale outbreak of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) occurred in Shanghai, China, in early December 2022. To study the incidence and characteristics of otitis media with effusion (OME) complicating SARS-CoV-2, we collected 267 middle ear effusion (MEE) samples and 172 nasopharyngeal (NP) swabs from patients. The SARS-CoV-2 virus was detected by RT-PCR targeting. The SARS-CoV-2 virus, angiotensin-converting enzyme 2 (ACE2), and transmembrane serine protease 2 (TMPRSS2) expression in human samples was examined via immunofluorescence. During the COVID-19 epidemic in 2022, the incidence of OME (3%) significantly increased compared to the same period from 2020 to 2022. Ear symptoms in patients with SARS-CoV-2 complicated by OME generally appeared late, even after a negative NP swab, an average of 9.33 ± 6.272 days after COVID-19 infection. The SARS-CoV-2 virus was detected in MEE, which had a higher viral load than NP swabs. The insertion rate of tympanostomy tubes was not significantly higher than in OME patients in 2019-2022. Virus migration led to high viral loads in MEE despite negative NP swabs, indicating that OME lagged behind respiratory infections but had a favorable prognosis. Furthermore, middle ear tissue from adult humans coexpressed the ACE2 receptor for the SARS-CoV-2 virus and the TMPRSS2 cofactors required for virus entry.

Fusobacterium necrophorum an Underrecognized Cause of Petrous Apicitis Presenting with Gradenigo Syndrome: A Case Report

BACKGROUND With the advent of antibiotics, petrous apicitis (PA), inflammation of the petrous temporal bone, has become a rare complication of otitis media. Even more uncommon is Gradenigo syndrome (GS), a result of PA, characterized by a triad of otitis media or purulent otorrhea, pain within the regions innervated by the first and second division of the trigeminal nerve, and ipsilateral abducens nerve palsy. Recent literature has demonstrated increasing reports of Fusobacterium necrophorum isolated in cases of GS. CASE REPORT A 21-year-old man presented with otalgia, reduced hearing, and severe headache. Examination revealed right-sided purulent otorrhea, anesthesia within the trigeminal nerve distribution, and an ipsilateral abducens nerve palsy. F. necrophorum was isolated from an ear swab and a blood culture. Computed tomography and magnetic resonance imaging (MRI) demonstrated otomastoiditis, PA, cavernous sinus thrombosis, and severe stenosis of the petrous internal carotid artery. He was treated with intravenous benzylpenicillin, underwent a mastoidectomy and insertion of a ventilation tube, and was started on a 3-month course of dabigatran. Interval MRI showed improved internal carotid artery caliber, persistent petrous apex inflammation, and normal appearance of both cavernous sinuses. Follow-up clinical review noted persistent abducens and trigeminal nerve dysfunction. CONCLUSIONS We identified 190 cases of PA; of these, 80 presented with the classic Gradenigo triad. Fusobacterium sp. were cultured in 10% of GS cases, making them the most frequent isolates. Due to the fastidious nature of F. necrophorum, it may be underrepresented in the historical literature, and we recommend that empiric antibiotics cover anaerobic organisms.

Acute labyrinthitis: a manifestation of COVID-19 in a teenager

Audiovestibular symptoms following COVID-19 have been long acknowledged, especially in adults. However, acute labyrinthitis presenting as an early manifestation of COVID-19 has not been reported in children. We report COVID-19-induced acute labyrinthitis in a teenager. We report on a boy in his early adolescence with a sudden onset of spinning sensation, imbalance and unilateral hearing loss with a positive SARS-CoV-2 test. Vestibular investigations point towards right labyrinthine hypofunction, and an audiometry test revealed right-sided severe hearing loss. Symptoms improved gradually with steroids and vestibular rehabilitation therapy. However, the long-term repercussions of post-COVID-19 acute labyrinthitis are unknown and must be followed up closely. To our knowledge, this is the first reported case of acute labyrinthitis secondary to COVID-19 in paediatrics. Additionally, we conducted a literature search to elucidate the outcome of COVID-19-induced acute vestibular syndrome in children.

Cochlear Implantation in Patients with Bilateral Sudden Sensorineural Hearing Loss after COVID-19 Infection

COVID-19 infection is associated with a variety of neurological manifestations. Since the inner ear is vulnerable to viruses, sensorineural hearing loss (SNHL) has been reported to occur following SARS-CoV-2 infection. We present here two cases of profound SNHL following SARS-CoV-2 infection. Pure-tone audiograms confirmed profound SNHL. The tympanogram and Auditory Brainstem Responses showed no abnormal symptoms. MRIs and CTs identified some changes but no significant anatomical nor physiological manifestations explaining the obvious cause for hearing loss. High doses of oral corticosteroids with additional conservative therapy were given with no therapeutic response, and therefore, cochlear implant surgery was performed. One case was bilaterally treated, and the other one received an implantation on one side. Both surgeries were carried out without intra- nor postoperative complications. Interestingly, in both cases, advanced fibrotic tissue was found during surgery. Both cases reported successful rehabilitation and are satisfied with their new sound perception following cochlear implantation.

Allan William Cripps: a mucosal immunologist and mentor from beginning to end

Allan Cripps was internationally recognized in the field of mucosal immunology, in particular the relationship between respiratory diseases and mucosal immunization strategies. Allan's career spanned scientific and applied research, commercialization, health education, and evolved into leadership roles in public-health and academic administration. Allan published over 400 papers and mentored over 40 research higher degree candidates. Allan was renowned for his mentorship, that did not end with the awarding of a PhD or Master's degree, but continued across a lifetime of professional engagement. Allan's key contributions to immunology included characterizing the ontogeny of the human mucosal immune system, understanding the impact of respiratory infections and otitis media in children, developing diagnostic technologies and mucosal vaccine strategies, and identifying the roles of the common mucosal immune system in human health. In this biography for the 100th anniversary of the Journal, we follow his journey of discovery and contributions to immunological research.

Factors Associated with Otitis Media Among Pediatrics in Two Government Hospitals in Arba Minch, Southern Ethiopia

Background

Bacterial otitis media (OM) is a common infection among the pediatric community worldwide and is the first reason for prescribing antibiotics in pediatric practices. However, if not promptly diagnosed and appropriately treated, it may persist and cause severe intra- and extra-cranial hard-to-cure complications. Hence, knowing the magnitude, etiology, and antibiotic susceptibility profile is very important for the proper management.

Methods

A cross-sectional study was carried out in 312 pediatrics (1 to 18 years) attending the Ear Nose Throat outpatient departments of the two title hospitals from 25 February to 30th August 2022. Patients were chosen through a systematic random sampling method. Data were obtained by means of a semi-structured questionnaire. Samples were collected to identify the causative bacteria as per microbiological guidelines. The antibiotic susceptibility test was done according to the Kirby-Bauer disc diffusion; SPSS version 25 was used for the analysis.

Results

The overall prevalence of otitis media was 67.3% (n=210); CSOM showed a slight preponderance (n=107) Gram-negative bacteria and Gram-positive bacteria were present in 59.8% (n=137) and 40.1% (n=92), respectively. Otitis media was predominantly caused by S. aureus (n=52, 56.5%), followed by Proteus spp. (n=33, 24%). Gram-negative bacteria were highly resistant to co-trimoxazole, amoxicillin-clavulanic acid, piperacillin, and tetracycline, whereas their positive counterparts were considerably penicillin and co-trimoxazole resistant. Overall, 61.5 and 19.2% of the isolates were MDR and XDR, respectively. MRSA, MR-CoNs, and VRE were 38.4% (n=20), 17.1% (n=5), and 58.3% (n=12), respectively; 19.7% (n=25) of Gram-negative bacteria produced ESBL, and 7% (n=9) were carbapenem-resistant. History of exposure to loud noise [AOR=3.4; CI=1.14-10.23; P-value=0.028] and family history of smoking at home [AOR=2.9; CI=1.18-7.25; P-value=0.020] have the greatest odds of otitis media.

Conclusion

Overall, the prevalence of otitis media is showing an upward trend, and MDR among bacterial isolates is increasing alarmingly.

Changes in antimicrobial resistance in acute otitis media and otitis externa

OBJECTIVES

Acute otitis media (AOM) and otitis externa (OE) are common ear infections which may warrant antibiotic therapy. For many infections, there is a rise in antimicrobial resistance, which is associated with treatment failure, morbidity, prolonged hospitalisation and mortality. This study aimed to identify longitudinal changes in microbiology and antimicrobial resistance in aural swabs taken from patients with AOM or OE.

DESIGN

Retrospective observational analysis.

SETTING

Aural samples processed at Manchester Medical Microbiology Partnership Laboratories between January 2008 and December 2018 were analysed to record organism isolated and antimicrobial sensitivity.

PARTICIPANTS

Individual aural swabs from 7200 patients.

MAIN OUTCOME MEASURES

Changes in the incidence of organisms and antimicrobial resistance between two time periods (2008-2012 and 2013-2018) were compared using the chi-squared test (alpha = 0.05).

RESULTS

From 7200 swabs, 2879 (40%) were from children. The most frequently isolated organisms were Staphylococcus aureus (25%), Pseudomonas aeruginosa (24.4%), yeast (9.1%), mixed anaerobes (7.9%) and Haemophilus influenzae (6.1%). In children aged 0-4 years, H. influenzae had particularly high incidence (25%). Overall, the incidence of P. aeruginosa decreased significantly with time (p = 0.05). Isolates displaying resistance to one or more antimicrobial agents increased significantly in number in the second time period for P. aeruginosa (p = 0.04) and H. influenzae (p =  0.03). There was increased resistance to amoxicillin for P. aeruginosa (p = 0.01) and to erythromycin for H. influenzae (p < 0.01).

CONCLUSION

Variations in type and frequency of organisms with increasing age likely result from differences in the preponderance of AOM compared to OE in children versus adults. We found increasing antimicrobial resistance for two organisms commonly isolated from AOM and OE infections, suggesting that aspects of current UK treatment practices and national recommendations may need to be revised.

Chronic Suppurative Otitis Media: A Comprehensive Review of Epidemiology, Pathogenesis, Microbiology, and Complications

Otitis media is a significant contributor to healthcare visits and the prescription of drugs. Its associated complications and consequences pose the primary factors for preventable hearing impairment, especially in developing nations. Chronic suppurative otitis media (CSOM) is prevalent among children globally as one of the commonest chronic infectious diseases during childhood. The subsequent complications and sequelae play a central role in causing avoidable hearing loss, particularly within developing countries. In addition to impaired hearing, this condition can lead to severe health complications, such as issues involving the intracranial region. Despite the involvement of microbial, immunological, and genetic factors as well as Eustachian tube characteristics, in the development of CSOM, there remains a need for further elucidation regarding its pathogenesis. Based on its microorganisms, the treatment of choice will be affected to prevent further complications in the child. The primary approach to treating acute otitis media (AOM) involves effectively addressing ear pain and fever symptoms, while antibiotics are only administered in cases where children experience severe, long-lasting, or frequent infections. Despite the extensive investigation on AOM pathogenesis, research is scarce regarding CSOM. Given that antibiotic resistance and drug-induced ear damage are growing problems and surgery-related complications, it is imperative to devise effective therapeutic interventions against CSOM arises. Therefore, comprehending the host's immune function concerning CSOM and identifying how bacteria sidestep these potent responses becomes crucial. Acquiring insight into molecular mechanisms associated with CSOM will enable scientists to formulate innovative treatment approaches to combat this disease, thereby averting hearing loss consequences. The management consists of watchful waiting, primarily for children with chronic effusions and hearing loss.

Gradenigo's Syndrome and Vernet Syndrome as Presenting Signs of Nasopharyngeal Carcinoma

Both Gradenigo's syndrome and Vernet syndrome are rare pathologies of the intracranial space; both involve compression of a particular anatomic location in the skull, thus affecting structures nearby or within that space. A patient presenting with one or both of these syndromes should raise concern for malignancy, head trauma, or an intracranial infection. We present a case of a 39-year-old female with three weeks of left-sided ear, face, and neck pain along with difficulty swallowing and reduced vision in the left eye. Magnetic resonance imaging of the brain revealed fullness in the left nasopharyngeal region, raising concern for malignancy or infection. Biopsy of the mass ultimately revealed Epstein-Barr virus positive nasopharyngeal carcinoma, nonkeratinizing undifferentiated type, along with culture data revealing methicillin-resistant Staphylococcus aureus positive left otomastoiditis. She received chemoradiation therapy along with six weeks of antibiotic therapy. A patient presenting with symptoms reflective of a sinus infection unrelieved by antibiotics with concomitant cranial nerve deficits should raise clinical concern for an intracranial pathology rather than a simple case of sinusitis.

On-Demand Synthesis of Antiseptics at the Site of Infection for Treatment of Otitis Media

Otitis media (OM) is the main reason for pediatric antibiotic prescriptions. The current treatment mandates a rigorous regimen of multidose antibiotics over 5-10 days. The systemic antibiotic exposure and often prematurely terminated treatment due to the challenge of drug administration to young patients are believed to breed antibiotic resistance. To address these challenges, we designed a local treatment that converted a metabolic product (H2O2) of an OM pathogen (Streptococcus pneumoniae) into a potent antiseptic (HOBr), a reaction catalyzed by locally administered vanadium pentoxide nanowires. The therapeutic, HOBr, was only synthesized in the presence of the pathogen, enabling on-demand generation of therapeutics for OM treatment. Hypohalous acids are broad-spectrum and have a long history in general disinfection applications without breeding substantial drug resistance. A single dose of the nanowire formulation eradicated OM in a standard chinchilla model in 7 days with no observable tissue toxicity or negative impact on hearing sensitivity.

Polymicrobial Infections and Biofilms: Clinical Significance and Eradication Strategies

Biofilms are population of cells growing in a coordinated manner and exhibiting resistance towards hostile environments. The infections associated with biofilms are difficult to control owing to the chronicity of infections and the emergence of antibiotic resistance. Most microbial infections are contributed by polymicrobial or mixed species interactions, such as those observed in chronic wound infections, otitis media, dental caries, and cystic fibrosis. This review focuses on the polymicrobial interactions among bacterial-bacterial, bacterial-fungal, and fungal-fungal aggregations based on in vitro and in vivo models and different therapeutic interventions available for polymicrobial biofilms. Deciphering the mechanisms of polymicrobial interactions and microbial diversity in chronic infections is very helpful in anti-microbial research. Together, we have discussed the role of metagenomic approaches in studying polymicrobial biofilms. The outstanding progress made in polymicrobial research, especially the model systems and application of metagenomics for detecting, preventing, and controlling infections, are reviewed.

Etiology, Diagnosis, Complications, and Management of Acute Otitis Media in Children

Acute otitis media (AOM) is the most common infectious disease encountered by children under the age of two years and the most common cause of antibiotic use in children in the United States. AOM causes irritability, sleeplessness, decreased appetite, imbalance, and dizziness in patients, especially young children. This assessment was conducted to measure the effectiveness of surgical interventions in treating AOM. We reviewed the present findings regarding the etiology, clinical presentations, diagnosis, treatment, and surgical treatment of complications of AOM. Pain associated with AOM (otalgia) can be severe enough to cause parents to seek treatment for their infants or children. Various suggested measures have been used to treat AOM; antibiotic treatment with amoxicillin is still the treatment of choice for AOM, yet other antibiotics may be used in cases of allergy to penicillin or recent use of amoxicillin. Surgical intervention has been introduced and studied as a diagnostic, therapeutic, and preventive measure for AOM; nevertheless, a few studies have shown that surgical interventions are beneficial in treating and preventing AOM compared to the common practice of using antibiotics. Overdiagnosis of AOM is widespread, leading to injudicious antibiotic use, which contributes to antibiotic resistance. Further management should be determined together with the parent, particularly if observation is the primary intervention.

Distribution and Antimicrobial Resistance Profiles of Bacterial Aetiologies of Childhood Otitis Media in Accra, Ghana

Background:

Otitis media (OM), also known as middle ear infection, is a clinically significant childhood disease. In sub-Saharan Africa, there is a paucity of contemporary reports on it is bacterial aetiologies and antimicrobial resistance among them.

Aim:

To investigate the OM bacterial aetiologies and their antimicrobial resistance patterns among children visiting the Ear, Nose, and Throat clinics of 3 healthcare facilities in Accra, Ghana – Princess Marie Louise Children’s Hospital, 37 Military Hospital, and Mamprobi Hospital.

Methods:

This cross-sectional study involved 100 children below 13 years old with suppurative otitis media. Following standard bacteriological methods, sterile ear swabs were used to take middle ear discharges from the study participants for culture and antimicrobial susceptibility testing. A standard questionnaire was also used to collect data on socio-demographic and clinical characteristics.

Results:

The major OM bacterial aetiologies were Pseudomonas aeruginosa (38.5%), Klebsiella pneumoniae (19.8%), Proteus mirabilis (11.5%), and Staphylococcus aureus (10.4%). The majority of the bacteria demonstrated low to moderate resistance (0%-33.3%) to most of the antibiotics. Eight of the bacteria (4 each of Klebsiella pneumoniae and Escherichia coli) were extended-spectrum beta-lactamase (ESBL) producers; 6 ampicillinase (Amp C)-producing organisms (4 Citrobacter spp. and one each of Morganella morganii and Serratia marcescens) were also identified, and they showed high antibiotic resistance.

Conclusions:

The predominant OM aetiologies were Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, and Staphylococcus aureus, and they were generally susceptible to most of the antibiotics tested. Amikacin, cefepime, ciprofloxacin, and meropenem could be valuable in the empirical management of childhood OM.

Isolation and Identification of Pathogenic Bacteria Causing Otitis Media in Misan Governorate

This study examined 150 ear swab samples from patients with otitis media who consulted at Al-Sadr Teaching Hospital from January to April 2021 in Misan, Iraq. The participants were aged 14–50 years, among which the infection rate was highest in participants aged 14–22 years and lowest in those aged 40–50 years. Subsequently, bacterial isolates were identified based on their morphology in various culture media and using biochemical tests. Six bacterial species were identified, namely Pseudomonas aeruginosa, Staphylococcus aureus, Escherichia coli, Streptococcus pneumoniae, Klebsiella pneumoniae, and Staphylococcus epidermidis. Staphylococcus aureus had the highest infection rate (30%), whereas Staphylococcus epidermidis had the lowest infection rate (8.55%). When the sensitivity of each isolate to antibiotics was determined, Escherichia coli was the most sensitive to trimethoprim (TMP), whereas Pseudomonas aeruginosa was the most resistant to 75% of the tested antibiotics.

Contribution of a Novel Pertussis Toxin-Like Factor in Mediating Persistent Otitis Media

Chronic otitis media (COM) is the long-term infection and inflammation of the middle ears typically caused by upper respiratory tract pathogens that are able to ascend the Eustachian tube. Our understanding of contributing factors is limited because human otopathogens cannot naturally colonize or persist in the middle ears of mice. We recently described a natural COM in mice caused by Bordetella pseudohinzii and proposed this as an experimental system to study bacterial mechanisms of immune evasion that allow persistent infection of the middle ear. Here we describe a novel pertussis toxin (PTx)-like factor unique to B. pseudohinzii, apparently acquired horizontally, that is associated with its particularly efficient persistence and pathogenesis. The catalytic subunit of this toxin, PsxA, has conserved catalytic sites and substantial predicted structural homology to pertussis toxin catalytic subunit PtxA. Deletion of the gene predicted to encode the catalytic subunit, psxA, resulted in a significant decrease in persistence in the middle ears. The defect was not observed in mice lacking T cells, indicating that PsxA is necessary for persistence only when T cells are present. These results demonstrate the role of a novel putative toxin in the persistence of B. pseudohinzii and its generation of COM. This PsxA-mediated immune evasion strategy may similarly be utilized by human otopathogens, via other PTx-like toxins or alternative mechanisms to disrupt critical T cell functions necessary to clear bacteria from the middle ear. This work demonstrates that this experimental system can allow for the detailed study of general strategies and specific mechanisms that otopathogens use to evade host immune responses to persist in the middle ear to cause COM.

Ear microbiota and middle ear disease: a longitudinal pilot study of Aboriginal children in a remote south Australian setting

BACKGROUND

Otitis media (OM) is a major disease burden in Australian Aboriginal children, contributing to serious long-term health outcomes. We report a pilot analysis of OM in children attending an outreach ear and hearing clinic in a remote south Australian community over a two-year period. Our study focuses on longitudinal relationships between ear canal microbiota characteristics with nasopharyngeal microbiota, and clinical and treatment variables.

RESULTS

Middle ear health status were assessed in 19 children (aged 3 months to 8 years) presenting in remote western South Australia and medical interventions were recorded. Over the two-year study period, chronic suppurative OM was diagnosed at least once in 7 children (37%), acute OM with perforation in 4 children (21%), OM with effusion in 11 children (58%), while only 1 child had no ear disease. Microbiota analysis of 19 children (51 sets of left and right ear canal swabs and nasopharyngeal swabs) revealed a core group of bacterial taxa that included Corynebacterium, Alloiococcus, Staphylococcus, Haemophilus, Turicella, Streptococcus, and Pseudomonas. Within-subject microbiota similarity (between ears) was significantly greater than inter-subject similarity, regardless of differences in ear disease (p = 0.0006). Longitudinal analysis revealed changes in diagnosis to be associated with more pronounced changes in microbiota characteristics, irrespective of time interval. Ear microbiota characteristics differed significantly according to diagnosis (P (perm) = 0.0001). Diagnoses featuring inflammation with tympanic membrane perforation clustering separately to those in which the tympanic membrane was intact, and characterised by increased Proteobacteria, particularly Haemophilus influenzae, Moraxella catarrhalis, and Oligella. While nasopharyngeal microbiota differed significantly in composition to ear microbiota (P (perm) = 0.0001), inter-site similarity was significantly greater in subjects with perforated tympanic membranes, a relationship that was associated with the relative abundance of H. influenzae in ear samples (rs = - 0.71, p = 0.0003). Longitudinal changes in ear microbiology reflected changes in clinical signs and treatment.

CONCLUSIONS

Children attending the ear and hearing clinic in a remote Aboriginal community present with a broad spectrum of OM conditions and severities, consistent with other remote Aboriginal communities. Ear microbiota characteristics align with OM diagnosis and change with disease course. Nasopharyngeal microbiota characteristics are consistent with the contribution of acute upper respiratory infection to OM aetiology.

Molecular Diagnosis of Fungal Sinusitis Using Limit of Detection

Background: As an inflammatory process that involves the paranasal sinuses, chronic sinusitis (CS) is one of the most prevalent chronic illnesses that affects all age groups. Parasitic fungi are involved in sinusitis infections. Objective: This study is aimed at the molecular detection of sinusitis caused by such fungi. Methods: Seventy-two samples were collected from the secretions of maxillary and frontal sinuses of patients from Rasoul-e Akram (PbUH) Hospital in Tehran during sinus operation. Fungal genomic DNA was extracted by a DNP kit. The detection of fungi was carried out by employing a sequence-specific target, namely mt cyte b gene locus, and using primers. Polymerase chain reaction (PCR) was optimized, and the limit of detection (LOD) and specificity tests were performed. The amplicon was cloned by the T/A cloning method, which was used for sequencing and positive control. Results: The 430-bp PCR product underwent appropriate propagation before being amplified and was observed on 1.5% electrophoreses gel. The evaluation of the selected primers with seven DNA constructs from another microorganisms demonstrated 100% specificity. The limit of detection of the optimized test was evaluated up to 50 fungi. Out of 72 samples, 9.7% were positive for fungi existence. Conclusions: This study indicated that molecular diagnosis of the target mt cyte b gene using LOD enhances clinical laboratory detection of fungal sinusitis.

Direct SARS-CoV-2 infection of the human inner ear may underlie COVID-19-associated audiovestibular dysfunction

BACKGROUND

COVID-19 is a pandemic respiratory and vascular disease caused by SARS-CoV-2 virus. There is a growing number of sensory deficits associated with COVID-19 and molecular mechanisms underlying these deficits are incompletely understood.

METHODS

We report a series of ten COVID-19 patients with audiovestibular symptoms such as hearing loss, vestibular dysfunction and tinnitus. To investigate the causal relationship between SARS-CoV-2 and audiovestibular dysfunction, we examine human inner ear tissue, human inner ear in vitro cellular models, and mouse inner ear tissue.

RESULTS

We demonstrate that adult human inner ear tissue co-expresses the angiotensin-converting enzyme 2 (ACE2) receptor for SARS-CoV-2 virus, and the transmembrane protease serine 2 (TMPRSS2) and FURIN cofactors required for virus entry. Furthermore, hair cells and Schwann cells in explanted human vestibular tissue can be infected by SARS-CoV-2, as demonstrated by confocal microscopy. We establish three human induced pluripotent stem cell (hiPSC)-derived in vitro models of the inner ear for infection: two-dimensional otic prosensory cells (OPCs) and Schwann cell precursors (SCPs), and three-dimensional inner ear organoids. Both OPCs and SCPs express ACE2, TMPRSS2, and FURIN, with lower ACE2 and FURIN expression in SCPs. OPCs are permissive to SARS-CoV-2 infection; lower infection rates exist in isogenic SCPs. The inner ear organoids show that hair cells express ACE2 and are targets for SARS-CoV-2.

CONCLUSIONS

Our results provide mechanistic explanations of audiovestibular dysfunction in COVID-19 patients and introduce hiPSC-derived systems for studying infectious human otologic disease.

Children with Secondary Care Episodes for Otitis Media Have Poor Literacy and Numeracy Outcomes: A Data Linkage Study

We examined the association between otitis media (OM) and educational attainment in a retrospective population cohort of Western Australian children who participated in the grade 3 National Assessment Program—Literacy and Numeracy in 2012 (N = 19,262). Literacy and numeracy scores were linked to administrative hospital and emergency department data to identify secondary care episodes for OM. Results of multivariate multilevel models showed that children with OM episodes had increased odds of poor performance on literacy and numeracy tests, compared to children without OM episodes (46–79% increase in odds for Aboriginal children; 20–31% increase in odds for non-Aboriginal children). There were no significant effects found for age at the first episode, nor for OM episode frequency (all ps > 0.05). Regardless of the timing or frequency of episodes, children with OM episodes are at risk of poor literacy and numeracy attainment. Aboriginal children with OM appeared to be particularly at risk of poor literacy and numeracy achievement. Intervention to reduce the prevalence of otitis media in young children, and early treatment of OM, are important for limiting the negative effects on academic outcomes.

Association of in utero antibiotic exposure on childhood ear infection trajectories: Results from a national birth cohort study

AIM

Most prescribed medicines during pregnancy are antibiotics, with unknown effects on a fetus and on the infant's acquired microbiome. This study investigates associations between in utero antibiotic exposure and ear infection trajectories over the first decade of life, hypothesising effects on early or persistent, rather than later-developing, ear infections.

METHODS

Design and participants: The Longitudinal Study of Australian Children birth cohort recruited a nationally-representative sample of 5107 infants in 2004.

MEASURES

Mothers reported antibiotic use in pregnancy when a child was 3-21 months old (wave 1), and ongoing problems with ear infection every 2 years spanning ages 0-1 to 10-11 years (waves 1-6).

ANALYSIS

Latent class models identified ear infection trajectories, and univariable and multivariable multinomial logistic regression determined odds of adverse trajectories by antibiotic exposure.

RESULTS

A total of 4500 (88.1% of original sample) children contributed (mean baseline age 0.7 years; 51.3% boys); 10.4% of mothers reported antibiotic use in pregnancy. Four probability trajectories for ear infection emerged: 'consistently low' (86.2%), 'moderate to low' (5.6%), 'low to moderate' (6.7%) and 'consistently high' (1.4%). Antibiotic use in pregnancy was associated with children following 'consistently high' (adjusted odds ratio 2.04, 95% confidence interval 1.08-3.88, P = 0.03) and 'moderate to low' (adjusted odds ratio 1.78, 95% confidence interval 1.25-2.53, P = 0.001) trajectories.

CONCLUSIONS

Antibiotic use in pregnancy is associated with an increased risk of persistent and early childhood ear infections. This highlights the wisdom of cautious antibiotic use during pregnancy, and the need for the study of potential mechanisms underlying these associations.

Otopathogen interactions in the nasopharynx of children, and the predictive value of nasopharyngeal aspirate culture for the aetiology of upper respiratory infections

AIM

To evaluate nasopharyngeal aspirate cultures for screening otopathogen carriage in the adenoid in children 2-7 years of age.

METHODS

Thirty-seven children, 2-7 years of age, scheduled for adenoidectomy were enrolled into this prospective study at Rockhampton, Australia. Adenoid biopsy and nasopharyngeal aspirate bacteriology were assessed by conventional culture. Demographic and environmental data were collected by questionnaire. Statistical analyses for descriptive, comparison and logistic regression tests between microbial, demographic, environmental and clinical groups were applied.

RESULTS

Streptococcus pneumoniae, Staphylococcus aureus, non-typeable Haemophilus influenzae and Moraxella catarrhalis were detected in 38, 38, 35 and 24% of cases, respectively. Streptococcus pneumoniae was an independent determinant for non-typeable H. influenzae and S. aureus colonisation, and S. aureus was an independent determinant for S. pneumoniae colonisation. The nasopharyngeal aspirate otopathogen cultures were strong predictors for otopathogens in the adenoid, with moderate-high test accuracy for all otopathogens (receiver operator characteristics area under the curve ranging from 71 to 97% for the otopathogens tested). Children with positive non-typeable H. influenzae, M. catarrhalis, S. pneumoniae and S. aureus nasopharyngeal aspirate cultures were more likely to have the equivalent species in adenoid cultures (positive likelihood ratios = undefined, 15.0, 9.09 and 5.85, respectively).

CONCLUSIONS

This study provides evidence that nasopharyngeal aspirate cultures are an indicator of otopathogens in the adenoid. Nasopharyngeal aspirate cultures may provide clinicians with information that informs clinical management. Strategies for improved management to reduce otopathogen carriage could reduce the prevalence of chronic upper respiratory infections that contribute to adenoidectomy.

Targeting host-microbial interactions to develop otitis media therapies

Otitis media (OM; middle ear infection) is the most common reason for pre-school children to visit a doctor, be prescribed antimicrobials, or undergo surgery. Recent Cochrane reviews of clinical trials have identified that antibiotics and grommet surgery are only moderately effective in treating OM, with recurrent or persistent infection observed in one-third of children. Research efforts are focusing on developing improved therapies to treat OM and prevent disease recurrence. The recurrent nature of OM is mostly due to the persistence of bacterial pathogens within established biofilm in the middle ear. Promising novel therapies are harnessing host-microbe interactions to disrupt middle ear biofilm and permit antibiotics to work more effectively. New approaches are also being developed to prevent OM, including new vaccines and mining the host respiratory microbiome to develop novel bacterial therapies. This review describes how our improved knowledge of human and microbial interactions is driving development of OM therapies to improve health outcomes for children in Australia and worldwide.

Awareness and attitudes of Saudi parents toward otitis media in children

Background:

An ear infection is a common health problem in children. Parents’ awareness about otitis media (OM) among children, varies across the world. We aimed to explore parents’ knowledge, attitude, and practices toward OM among their children.

Methods:

A quantitative cross-sectional study was done from May 1, 2020 to June 30, 2020, in Qassim, Saudi Arabia.

Results:

This study comprised 703 participants; Mothers comprised the majority (77.1%), 43.2% of the participants were aged between 31 and 40 years of age, and 73% of them had Bachelor's degrees or diplomas. More than half of the participants had suboptimal knowledge of OM. Although the result showed that 56% of them had positive attitudes, 86.6% did not view vaccination as a prevention measure of acute OM (AOM). Besides, 81.8% of parents were willing to follow the watchful waiting approach, in case their child had OM.

Conclusion:

Most of the parents in the Qassim region have inadequate knowledge regarding OM among children. Based on our result findings, we recommend further education programs to enhance the knowledge regarding OM and AOM, among the Qassim population, Saudi Arabia including family members of patients and the healthcare workers.

Respiratory Syncytial Virus-associated Acute Otitis Media in Infants and Children

Despite recent declines in the incidence of acute otitis media (AOM), more than 5 million cases and 5-6 million primary AOM visits still occur in young children in the United States, resulting in $4.4 billion direct medical costs annually. Our aims in this review are to describe the role of respiratory syncytial virus (RSV) in the etiology of AOM, discuss the prospect of prevention of RSV-associated AOM through immunization, and suggest future research strategies to assess the impact of immunization on RSV-associated AOM.

The international sinonasal microbiome study: A multicentre, multinational characterization of sinonasal bacterial ecology

The sinonasal microbiome remains poorly defined, with our current knowledge based on a few cohort studies whose findings are inconsistent. Furthermore, the variability of the sinus microbiome across geographical divides remains unexplored. We characterize the sinonasal microbiome and its geographical variations in both health and disease using 16S rRNA gene sequencing of 410 individuals from across the world. Although the sinus microbial ecology is highly variable between individuals, we identify a core microbiome comprised of Corynebacterium, Staphylococcus, Streptococcus, Haemophilus and Moraxella species in both healthy and chronic rhinosinusitis (CRS) cohorts. Corynebacterium (mean relative abundance = 44.02%) and Staphylococcus (mean relative abundance = 27.34%) appear particularly dominant in the majority of patients sampled. Amongst patients suffering from CRS with nasal polyps, a statistically significant reduction in relative abundance of Corynebacterium (40.29% vs 50.43%; P = .02) was identified. Despite some measured differences in microbiome composition and diversity between some of the participating centres in our cohort, these differences would not alter the general pattern of core organisms described. Nevertheless, atypical or unusual organisms reported in short-read amplicon sequencing studies and that are not part of the core microbiome should be interpreted with caution. The delineation of the sinonasal microbiome and standardized methodology described within our study will enable further characterization and translational application of the sinus microbiota.

Phase-based Eulerian motion magnification reveals eardrum mobility from pneumatic otoscopy without sealing the ear canal

Pneumatic otoscopy is the recommended diagnostic method for middle ear infections. Physicians use a pneumatic otoscope to assess the position of the eardrum (bulging or retraction) as well as the eardrum mobility while an insufflation bulb is squeezed to generate air pressure changes in a sealed ear canal. While pneumatic otoscopy provides increased sensitivity and specificity by detecting decreased eardrum mobility, there exist many challenges to correctly perform and interpret results. For example, the ear canal must be sealed using a specialized ear speculum to deliver sufficiently large pressure changes that can induce visible movements of an eardrum. To overcome this challenge, video motion magnification is proposed to amplify pneumatic-induced motions of the eardrum without sealing of the ear canal. Pneumatic otoscopy is performed on adult subjects using a smartphone camera with an otoscope attachment at 60 frames per second, with pressure inputs at 5 Hz. Phase-based Eulerian motion magnification is applied to magnify spatiotemporal dependent motions in the video. As a result, the motion magnification of unsealed pneumatic otoscopy reveals comparable eardrum motions as in standard pneumatic otoscopy with a sealed ear canal. Furthermore, the estimated motions (in pixels) are quantified to examine the spatial and the temporal variations of the eardrum motions. The motion magnification may avoid the need for sealing the ear canal as well as decrease patient discomfort in pneumatic otoscopy, improving the capability and the usability as a point-of-care diagnostic tool in primary care and otology.

Bacterial otitis media in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Otitis media is inflammation of the middle ear, comprising a spectrum of diseases. It is the commonest episode of infection in children, which often occurs after an acute upper respiratory tract infection. Otitis media is ranked as the second most important cause of hearing loss and the fifth global burden of disease with a higher incidence in developing worlds like Sub-Saharan Africa and South Asia. Therefore, this systematic review is aimed to quantitatively estimate the current status of bacterial otitis media, bacterial etiology and their susceptibility profile in sub-Saharan Africa.

METHODS

A literature search was conducted from major databases and indexing services including EMBASE (Ovid interface), PubMed/MEDLINE, Google Scholar, ScienceDirect, Cochrane Library, WHO African Index-Medicus and others. All studies (published and unpublished) addressing the prevalence of otitis media and clinical isolates conducted in sub-Saharan Africa were included. Format prepared in Microsoft Excel was used to extract the data and data was exported to Stata version 15 software for the analyses. Der-Simonian-Laird random-effects model at a 95% confidence level was used for pooled estimation of outcomes. The degree of heterogeneity was presented with I2 statistics. Publication bias was presented with funnel plots of standard error supplemented by Begg's and Egger's tests. The study protocol is registered on PROSPERO with reference number ID: CRD42018102485 and the published methodology is available from http://www.crd.york.ac.uk/CRD42018102485.

RESULTS

A total of 33 studies with 6034 patients were included in this study. All studies have collected ear swab/discharge samples for bacterial isolation. The pooled isolation rate of bacterial agents from the CSOM subgroup was 98%, patients with otitis media subgroup 87% and pediatric otitis media 86%. A univariate meta-regression analysis indicated the type of otitis media was a possible source of heterogeneity (p-value = 0.001). The commonest isolates were P. aeruginosa (23-25%), S. aureus (18-27%), Proteus species (11-19%) and Klebsiella species. High level of resistance was observed against Ampicillin, Amoxicillin-clavulanate, Cotrimoxazole, Amoxicillin, and Cefuroxime.

CONCLUSION

The analysis revealed that bacterial pathogens like P. aeruginosa and S. aureus are majorly responsible for otitis media in sub-Saharan Africa. The isolates have a high level of resistance to commonly used drugs for the management of otitis media.

Haemophilus influenzae and Haemophilus parainfluenzae occurrence in the ear effusion in pediatric patients prone to recurrent respiratory tract infections (RRTI) and with otitis media with effusion (OME)

Introduction. Haemophilus influenzae and Haemophilus parainfluenzae are known as human-restricted respiratory microbiota representatives. The aim of the present paper was to assay haemophili prevalence in middle ear effusion specimens in pediatric patients with otitis media with effusion (OME).

Methods. A total of 86 ear effusion specimens (from the left and right ear independently) were collected from 43 pediatric patients with OME. For comparison, 58 nasopharyngeal specimens were taken from 58 pediatric patients prone to recurrent respiratory tract infections (RRTI). Isolation and identification of haemophili biotypes and antimicrobial susceptibility was accomplished by standard microbiological methods. The cell surface hydrophobicity (CSH) of isolates was assayed by the method of aggregation in ammonium sulfate (SAT).

Results. Haemophili were isolated in 25.6% (11/43) of all OME patients: in 5/43 (11.6%)– H. influenzae (biotypes II, III), in 5/43 (11.6%) – H. parainfluenzae, in 1/43 (2.3%) – both species were found. Haemophili-positive nasopharyngeal specimen was found in 27/58 (46.6%) RRTI patients: in 19/58 (32.8%) – H. influenzae, in 8/58 (13.8%) – H. parainfluenzae. About 90% of all haemophili isolates were characterised by extreme to strong CSH. Antimicrobial resistance occurred mainly among H. parainfluenzae (80%) and to a much lower percentage among H. influenzae (33.3%) isolates. The obtained data suggest that both H. influenzae and H. parainfluenzae can be involved in pathology of OME in pediatric patients. The high cell surface hydrophobicity can affect on the haemophili prevalence and ear colonization, and induces predisposition to the presence of these bacteria as a biofilm that serves as a virulence factor with great importance for the survival of these opportunistic bacteria and their persistence in the ear environment.

Genetically Diversity of Pseudomonas aeruginosa Isolated from Chronic Suppurative Otitis Media with Respect to Their Antibiotic Sensitivity Pattern

Pseudomonas aeruginosa is an important chronic suppurative otitis media (CSOM) pathogen that exhibits multiple resistances to antibiotics with increasing frequency, making patient treatment more difficult. The aim of the study is to ascertain the genetically diversity of this clinically isolated P. aeruginosa with inter simple sequence repeat (ISSR) markers. All 25 P. aeruginosa were isolated from CSOM patients by taking their ear swabs and culturing on blood agar and MacConkey agar. All strains were identified with morphological characters and biochemical testing. The antimicrobial susceptibility testing was carried out according to National Committee for Clinical Laboratory Standards. ISSR was used to study the genetic diversity of P. aeruginosa. Clinically CSOM isolated 25 P. aeruginosa were 88% Ciprofloxacin resistant and similarly resistant to other antibiotics were documented. The study has been made using ISSR marker to find out the genomic relation among the strains/populations of P. aeruginosa. The result was shown that maximum similarity (80%) was between S-11 and S-13 and minimum (28.2%) was between S-4 and S-16 with an average similarity of 53.2%. The dendogram showed a distinct separation in between all the strains/populations of P. aeruginosa. The strains/populations were broken up into two main clusters in which small one bear two strains/populations (S-4 and S-9) and another cluster have another 23 strains/populations. These 23 strains were also separated to form subcluster by having different range of small clades. The genetically diversity of pathogenic P. aeruginosa present in CSOM at our hospital indicates the coexistence different strains due to different antibiotic sensitivity patterns. The conventional culture and sensitivity methods are time consuming whereas in PCR, it will detect within 4-6 h for effective antibiotic. Basing upon the banding pattern with ISSR primers, clinicians can prescribe the effective antibiotics accordingly for CSOM patients in the same day.

Parental Knowledge, Attitudes and Practices Towards Paediatric Ear Infections in Riyadh, Saudi Arabia: A quantitative study

Objectives

This study aimed to assess the knowledge, attitude and care-seeking practices of parents towards childhood ear infections in Riyadh, Saudi Arabia.

Methods

This quantitative cross-sectional study was conducted in Riyadh, Saudi Arabia, between April and June 2018. An online survey was sent to a random selection of parents who were ≥18 years old with children of ≤10 years old. Associations between parental knowledge, attitude, care-seeking practices, socioeconomic status, level of education and age were assessed using the chi square test and logistic regression analysis.

Results

A total of 782 subjects participated in this study (response rate: 78.2%). Most respondents were knowledgeable (76.2%), had a positive attitude (78.9%) and had positive care-seeking practices (89.5%). There was a statistically significant difference on both bivariate and multivariate analyses (P <0.05) between parental care seeking practice and knowledge. Parents who sought modern approaches to treatment were found to be almost nine times more likely to have a good attitude towards ear infections than those who did not seek treatment (odds ratio = 8.907, 95% confidence interval = 2.655–34.928; P <0.001). A statistically significant relationship was found between good care-seeking practice and age, as well as socioeconomic status (P <0.05 each).

Conclusion

This study showed that knowledge, attitude and practice regarding paediatric ear infections were positive in the majority of parents in Riyadh, Saudi Arabia. Future studies should assess other factors that enhance the knowledge, attitude and practices regarding ear infections.

Microbial otitis media: recent advancements in treatment, current challenges and opportunities

Otitis media (OM) is a common disease affecting humans, especially paediatric populations. OM refers to inflammation of the middle ear and can be broadly classified into two types, acute and chronic. Bacterial infection is one of the most common causes of OM. Despite the introduction of vaccines, the incidence of OM remains significantly high worldwide. In this mini-review article, we discuss the recent treatment modalities for OM, such as suspension gel, transcutaneous immunization, and intranasal and transtympanic drug delivery, including therapies that are currently undergoing clinical trials. We provide an overview of how these recent advancements in therapeutic strategies can facilitate the circumvention of current treatment challenges involving preadolescence soft palate dysfunction, biofilm formation, tympanic membrane (ear drum) barrier and the attainment of efficacious drug concentrations in the middle ear. While traditional first-line immunization strategies are generally not very efficacious against biofilms, new technologies that use transdermal or intranasal drug delivery via chitosan-PsaA nanoparticles have shown promising results in experimental animal models of OM. Sustained drug delivery systems such as penta-block copolymer poloxamer 407-polybutylphosphoester (P407-PBP) or poloxamer 407 (e.g. OTO-201, with the brand name 'OTIPRIO') have demonstrated that treatments can be reduced to a single topical application. The emergence of effective new treatment modalities opens up promising new avenues for the treatment of OM that could lead to improved quality of life for many children and their families.

Isolation and antimicrobial drug susceptibility pattern of bacterial pathogens from pediatric patients with otitis media in selected health institutions, Addis Ababa, Ethiopia: a prospective cross-sectional study

Background

Otitis media is inflammation of the middle ear and tympanic membrane, which often occurs after an acute upper respiratory tract infection. It is the most common episode of infection in children and the second most important cause of hearing loss affecting 1.23 billion people, thus ranked fifth global burden of disease with a higher incidence in sub-Saharan Africa. Thus, the aim of this study was to determine the isolation rate of bacterial pathogens from pediatric patients with otitis media.

Methodology

Institutional based cross-sectional study was conducted from January 2013–June 2014 in Addis Ababa among 210 pediatrics patients. Demographic, clinical and associated factors data was obtained in face to face interview with guardians/parents by 5 trained nurse data collectors using structured questionnaire. Middle ear drainage swab was collected following all aseptic procedures and transported to the microbiology laboratory. Culture and Antimicrobial sensitivity test were performed according to the standards. The data quality was assured by questionnaire translation, retranslation and pretesting. Reference strains were used as a positive and negative control for biochemical tests, and culture results were cross checked. Data was checked for completeness, consistency and then entered into Epi Info v3.5.1 and analyzed by SPSS v20. Data interpretation was made using graphs, tables, and result statements.

Result

A total of 196 middle ear drainage swab samples were analyzed from pediatric patients and of those 95 (48.5%) samples were positive for pathogenic organisms. The major isolate was S. aureus (15.8%) followed by P. aeruginosa (10.9%), Viridians streptococcus (9.9%), S. pneumoniae (8.9%) and S. pyogenes (7.9%). Upper respiratory tract infection history and living in the rural area have shown significant association with the isolation of pathogenic organism, (p-value = 0.035) and (p-value = 0.003) respectively. Most of the isolates show a high level of resistance to Trimethoprim-Sulfamethoxazole, Penicillin G, Ampicillin, Amoxicillin, and Chloramphenicol.

Conclusion

S. aureus and P. aeruginosa are the most common pathogens that contribute to otitis media as well most of the isolates show a high level of resistance to commonly used drugs to treat otitis media. Therefore, culture and susceptibility testes have paramount importance for the better management of otitis media and drug-resistant infections.

Microbiology of otitis media in Indigenous Australian children: review

OBJECTIVES

To review research addressing the polymicrobial aetiology of otitis media in Indigenous Australian children in order to identify research gaps and inform best practice in effective prevention strategies and therapeutic interventions.

METHODS

Literature review.

RESULTS

Studies of aspirated middle-ear fluid represented a minor component of the literature reviewed. Most studies relied upon specimens from middle-ear discharge or the nasopharynx. Culture-based middle-ear discharge studies have found that non-typeable Haemophilus influenzae and Streptococcus pneumoniae predominate, with Moraxella catarrhalis, Staphylococcus aureus and Streptococcus pyogenes isolated in a lower proportion of samples. Alloiococcus otitidis was detected in a number of studies; however, its role in otitis media pathogenesis remains controversial. Nasopharyngeal colonisation is a risk factor for otitis media in Indigenous infants, and bacterial load of otopathogens in the nasopharynx can predict the ear state of Indigenous children.

CONCLUSION

Most studies have used culture-based methods and specimens from middle-ear discharge or the nasopharynx. Findings from these studies are consistent with international literature, but reliance on culture may incorrectly characterise the microbiology of this condition. Advances in genomic technologies are now providing microbiologists with the ability to analyse the entire mixed bacterial communities ('microbiomes') of samples obtained from Indigenous children with otitis media.

Incidence and economic burden of acute otitis media in children aged up to 5years in three Middle Eastern countries and Pakistan: A multinational, retrospective, observational study

Epidemiological data on acute otitis media (AOM), an infectious disease frequently affecting children, are lacking in some countries. This study was undertaken to assess the incidence of AOM in children ≤5 years in Saudi Arabia, Oman, Pakistan, and Turkey, as well as the economic burden from a parent/caregiver perspective. Medical records of 4043 children (Saudi Arabia = 1023, Oman = 998, Pakistan = 1022, Turkey = 1000) were retrospectively reviewed and the incidence of AOM episodes calculated from suspected and confirmed cases. Using a standardized Health Economics Questionnaire, parents recorded resource use and expenses incurred per AOM episode [in local currency and converted to US dollars (USD)]. The overall incidence of AOM episodes per 1000 person–years was: Saudi Arabia, 207 [95% confidence interval (CI): 178–238]; Oman, 105 (95% CI: 85–127); Pakistan, 138 (95% CI: 116–163); and Turkey, 99 (95% CI: 79–123). The mean total out-of-pocket healthcare expense incurred by parents/caregivers per episode was: Saudi Arabia USD67.1 [standard deviation (SD) = 93.0], Oman USD16.1 (SD = 16.4), Pakistan USD22.1 (SD = 20.5), and Turkey USD33.6 (SD = 44.9). The incidence of AOM episodes varied across all four countries, probably due to different diagnostic and management practices. Nevertheless, our results confirm that AOM causes a substantial burden to public health, reinforcing the need for cost-effective prevention strategies.

Role of antibodies and IL17-mediated immunity in protection against pneumococcal otitis media

Widespread vaccination against Streptococcus pneumoniae (the pneumococcus) has significantly reduced pneumococcal disease caused by vaccine serotypes. Despite vaccination, overall pneumococcal colonization rates in children have not reduced and otitis media (OM) by non-vaccine serotypes remains one of the most common childhood infections. Pneumococcal surface protein A (PspA) has been shown to be a promising protein antigen to induce broad protection against pneumococcal colonization. However, its ability to protect against OM remains unclear. Using our previously established mouse model of influenza-virus induced pneumococcal OM, we here show that intranasal vaccination of mice with PspA together with the mucosal adjuvant CTB results in a decrease in pneumococcal load in the middle ears. This decrease correlated with the induction of PspA-specific IgA, a balanced IgG1:IgG2a antibody response and the induction of a mucosal Th17 response. Our data suggests that the IL-17 response to PspA is more important for protection against OM, whilst the presence of antibodies may be less important, as determined in mice deficient in IL-17 signaling or antibody production. Together, these results suggest that mucosal vaccination with PspA may not only protect against colonization, but also against the development of virus-induced pneumococcal OM.

MALDI-TOF mass spectrometry reveals a highly complex bacterial profile of otitis media with effusion

OBJECTIVES

With conventional microbiological methods, a significant proportion of middle ear effusion (MEE) proves to be sterile. Accurate molecular biological techniques have been used to identify only pathogenic bacteria. Matrix assisted laser desorption and ionization time-of-flight mass spectrometry (MALDI-TOF MS) is an adequate tool for the precise and simultaneous identification of a wide range of bacterial species from a small sample. The aim of this study was to explore the use of MALDI-TOF MS in revealing the frequency and complexity of bacterial flora in MEE in otitis media with effusion (OME).

METHODS

MEEs from 40 children with chronic otitis media with effusion were examined for 2000 pathogenic, facultative pathogenic and nonpathogenic bacterial species using MALDI-TOF MS. Two middle ear samples from children who underwent cochlear implantation with healthy middle ear were also examined in the same way.

RESULTS

No bacteria were found in healthy control samples and 92% of OME samples were positive for at least one bacterium. In 52% of the samples more than one bacterium was identified. In total 39 bacterial species were found in the middle ear samples. Of the positive samples 19% contained those pathogens which were previously thought to contribute OME.

CONCLUSION

MALDI-TOF MS is a suitable tool for identifying a wide range of bacterial species in MEE. Results show that bacterial flora of MEE in OME is more diverse and abundant than it was formerly thought. This previously unreported bacterial invasion may help to obtain proper understanding and therapy of OME.

Epidemiology of otitis media in children from developing countries: A systematic review

OBJECTIVE

This systematic review examined the epidemiology of otitis media (OM) in children <6 years within 90 developing and newly industrialised countries.

METHODS

Literature searches (1992-2011), based on MEDLINE, EMBASE, WHO, Index Medicus, country-specific websites, conferences, and the reference lists of included studies, yielded 11,413 records; 59 of 344 studies analysed were included in this review.

RESULTS

The majority of the identified studies provided only a single timepoint for OM. In children <6 years of age, OM prevalence was found to be 9.2% in Nigeria, 10% in Egypt, 6.7% in China, 9.2% in India, 9.1% in Iran and 5.1-7.8% in Russia. Few studies examined the etiology of OM and the antibacterial resistance. The most common bacterial pathogens were S. pneumoniae, H. influenzae and S. aureus. A high resistance to penicillin was reported in Nigeria and Turkey.

CONCLUSIONS

Despite the variability between the identified studies, this review indicates that OM and its various sub-types remain a significant burden in different settings. However, the heterogeneity of studies and a general lack of reliable data made generalisation very difficult.

Protective benefit of predominant breastfeeding against otitis media may be limited to early childhood: results from a prospective birth cohort study

OBJECTIVES

To examine the long-term effects of predominant breastfeeding on incidence of otitis media.

DESIGN

Prospective birth cohort study.

SETTING

The West Australian Pregnancy Cohort (Raine) Study recruited 2900 mothers through antenatal clinics at the major tertiary obstetric hospital in Perth, Western Australia, between 1989 and 1992.

PARTICIPANTS

In total, 2237 children participated in a 6-year cohort follow-up, and a subset of 1344 were given ear and hearing assessments.

MAIN OUTCOME MEASURES

OM diagnosis at 6 years of age (diagnosed by low-compliance tympanograms, 0-0.1 mmho). This was compared to OM diagnosed at the 3-year cohort follow-up using parent-report measures. Main exposure measures were duration of predominant breastfeeding (defined as the age other milk was introduced) and duration of partial (any) breastfeeding (defined as the age breastfeeding was stopped).

RESULTS

There was a significant, independent association between predominant breastfeeding (OR = 1.33 [1.04, 1.69]; P = 0.02) and OM, and breastfeeding duration (OR = 1.35 [1.08, 1.68]; P = 0.01) with OM at 3 years of age. However, at 6 years of age, this relationship was no longer statistically significant (predominant breastfeeding OR = 0.78 [0.48, 1.06]; P = 0.09; duration of breastfeeding, OR = 1.34 [0.81, 2.23]; P = 0.25).

CONCLUSIONS

Our findings are in line with a number of epidemiological studies which show a positive association between breastfeeding and OM in early childhood. However, the long-term follow-up of these children revealed that by 6 years of age, there was no significant influence of breastfeeding on presence of OM. These results suggest that the protective effect of predominant breastfeeding for at least 6 months does not extend to school-age children, where other social and environmental factors may be stronger predictors of OM.

Predominant Bacteria Detected from the Middle Ear Fluid of Children Experiencing Otitis Media: A Systematic Review

BACKGROUND

Otitis media (OM) is amongst the most common childhood diseases and is associated with multiple microbial pathogens within the middle ear. Global and temporal monitoring of predominant bacterial pathogens is important to inform new treatment strategies, vaccine development and to monitor the impact of vaccine implementation to improve progress toward global OM prevention.

METHODS

A systematic review of published reports of microbiology of acute otitis media (AOM) and otitis media with effusion (OME) from January, 1970 to August 2014, was performed using PubMed databases.

RESULTS

This review confirmed that Streptococcus pneumoniae and Haemophilus influenzae, remain the predominant bacterial pathogens, with S. pneumoniae the predominant bacterium in the majority reports from AOM patients. In contrast, H. influenzae was the predominant bacterium for patients experiencing chronic OME, recurrent AOM and AOM with treatment failure. This result was consistent, even where improved detection sensitivity from the use of polymerase chain reaction (PCR) rather than bacterial culture was conducted. On average, PCR analyses increased the frequency of detection of S. pneumoniae and H. influenzae 3.2 fold compared to culture, whilst Moraxella catarrhalis was 4.5 times more frequently identified by PCR. Molecular methods can also improve monitoring of regional changes in the serotypes and identification frequency of S. pneumoniae and H. influenzae over time or after vaccine implementation, such as after introduction of the 7-valent pneumococcal conjugate vaccine.

CONCLUSIONS

Globally, S. pneumoniae and H. influenzae remain the predominant otopathogens associated with OM as identified through bacterial culture; however, molecular methods continue to improve the frequency and accuracy of detection of individual serotypes. Ongoing monitoring with appropriate detection methods for OM pathogens can support development of improved vaccines to provide protection from the complex combination of otopathogens within the middle ear, ultimately aiming to reduce the risk of chronic and recurrent OM in vulnerable populations.

Changes in microbiota during experimental human Rhinovirus infection

Background

Human Rhinovirus (HRV) is responsible for the majority of common colds and is frequently accompanied by secondary bacterial infections through poorly understood mechanisms. We investigated the effects of experimental human HRV serotype 16 infection on the upper respiratory tract microbiota.

Methods

Six healthy volunteers were infected with HRV16. We performed 16S ribosomal RNA-targeted pyrosequencing on throat swabs taken prior, during and after infection. We compared overall community diversity, phylogenetic structure of the ecosystem and relative abundances of the different bacteria between time points.

Results

During acute infection strong trends towards increases in the relative abundances of Haemophilus parainfluenzae and Neisseria subflava were observed, as well as a weaker trend towards increases of Staphylococcus aureus. No major differences were observed between day-1 and day 60, whereas differences between subjects were very high.

Conclusions

HRV16 infection is associated with the increase of three genera known to be associated with secondary infections following HRV infections. The observed changes of upper respiratory tract microbiota could help explain why HRV infection predisposes to bacterial otitis media, sinusitis and pneumonia.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1081-y) contains supplementary material, which is available to authorized users.

Bacterial and Respiratory Viral Interactions in the Etiology of Acute Otitis Media in HIV-infected and HIV-uninfected South African Children

BACKGROUND

Bacteria and respiratory viruses are implicated in the pathogenesis of acute otitis media (AOM); however, data from low-middle income countries are sparse. We investigated the etiology of AOM in HIV-infected (HIV+), HIV-uninfected (HIV-) and HIV-exposed clinically asymptomatic for HIV-infection (HEU) South African children.

METHODS

Children ≥3 months to <5 years of age with AOM were enrolled between May 2009 and April 2010 (NCT01031082). Middle ear fluid samples were cultured for bacteria; antibacterial susceptibility was done and serotyping undertaken for Streptococcus pneumoniae and Haemophilus influenzae. Nasopharyngeal aspirates were analyzed for respiratory viruses using immunofluorescence assay and polymerase chain reaction.

RESULTS

Of 260 AOM episodes (HIV+:15; HIV-:182; HEU:63), bacteria were found in 54.6%, including Haemophilus influenzae (30.8%), 98.8% of which were nontypeable, and Streptococcus pneumoniae (20.4%), Staphylococcus aureus (15.8%), Moraxella catarrhalis (5.0%) and Streptococcus pyogenes (1.5%). Nonsusceptibility of Streptococcus pneumoniae to penicillin was 64.2%. Respiratory viruses were detected in 74.2% of cases. Human rhinovirus was most frequently detected (37.7%), followed by adenovirus (14.2%) and human bocavirus (11.5%) overall and irrespective of HIV status. Respiratory viruses were identified concurrently with S. pneumoniae, H. influenzae, M. catarrhalis (76.9-78.8%) and Staphylococcus aureus (63.4%) cultured from middle ear fluid, as well as in 72.0% of episodes negative for any bacteria.

CONCLUSION

The study suggests that respiratory viruses and pathogenic bacteria play an important role in the development of AOM in children. A similar spectrum of pathogens was observed independently of HIV status. Vaccines targeting both nontypeable Haemophilus influenzae and S. pneumoniae may have a broad impact on AOM in South Africa.

Assessment of the feasibility and clinical value of further research to evaluate the management options for children with Down syndrome and otitis media with effusion: a feasibility study

BACKGROUND

There is clinical uncertainty of the benefits and costs of different treatment options for children with Down syndrome who have glue ear. This study was designed to assess the extent of this lack of knowledge and determine if pursuing further information would be practical, beneficial and cost-effective.

OBJECTIVES

To assess the level and practical effect of current uncertainty around treatment options for children with Down syndrome and glue ear. To assess the feasibility of studying the options for management of glue ear in children with Down syndrome via a randomised controlled trial (RCT) or multicentre prospective cohort study by evaluating the willingness of (1) parents to agree to randomisation for their children and (2) clinicians to recruit participants to a definitive study. To undertake value of information analyses to demonstrate the potential economic benefit from undertaking further research.

DESIGN

A feasibility study exploring the views of parents of children with Down syndrome and professionals who have responsibility for the health and education of children with Down syndrome, on the participation in, and value of, future research into interventions for glue ear. Data were collected from parents via self-completed questionnaires, face-to-face interviews and focus groups and from professionals via online questionnaires and a Delphi review exercise. Development of economic models to represent clinical pathways of care and a RCT informed a value of information (VOI) analysis.

SETTING

UK (professionals); East Midlands region of the UK (parents).

PARTICIPANTS

Parents of children aged 1-11 years with Down syndrome (n = 156). Professionals including audiologists, ear, nose and throat surgeons, audiological physicians, speech and language therapists, and teachers of the deaf (n = 128).

MAIN OUTCOME MEASURES

Quantitative and qualitative data on parental views and experiences of glue ear and its effects; interventions and treatment received; taking part in research and factors that would encourage or discourage participation; and the importance of various outcome domains to them and for their children. For professionals: information on caseloads; approaches to clinical management; opinions on frequency and significance of the consequences of glue ear for this population; importance of different outcome measures; opinions of interventions and their role in future research; views on health research; facilitators and barriers to recruitment, and participation in research involving RCTs.

RESULTS

The complexity of the experience and individual characteristics of children with Down syndrome poses challenges for the design of any future research but these challenges were not considered by professionals to raise sufficient barriers to prevent it being undertaken. Parents were generally supportive of the need for, and value of, research but identified practical and emotional issues that would need addressing. Glue ear was considered to impact more on speech, language and communication than on hearing. Outcome measures for future research would need to evaluate these elements but measures should be designed specifically for the population. Parents and professionals identified randomisation as a significant barrier to participation. The VOI analyses identified lack of data as problematic but concluded that a future trial involving surgical intervention would be feasible at costs of < £650,000.

CONCLUSIONS

Future research into the benefits of interventions for glue ear in children with Down syndrome would be feasible and could be cost-effective but should be carefully designed to facilitate and maximise participation from parents and professionals responsible for recruitment.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Five-year prospective study of paediatric acute otitis media in Rochester, NY: modelling analysis of the risk of pneumococcal colonization in the nasopharynx and infection

During a 5-year prospective study of nasopharyngeal (NP) colonization and acute otitis media (AOM) infections in children during the 7-valent pneumococcal conjugate vaccine (PCV) era (July 2006-June 2011) we studied risk factors for NP colonization and AOM. NP samples were collected at ages 6, 9, 12, 15, 18, 24, and 30 months during well-child visits. Additionally, NP and middle ear fluid (MEF) samples were collected at onset of every AOM episode. From 1825 visits (n = 464 children), 5301 NP and 570 MEF samples were collected and analysed for potential otopathogens. Daycare attendance, NP colonization by Moraxella catarrhalis, and siblings aged <5 years increased the risk of Streptococcus pneumoniae NP colonization. NP colonization with S. pneumoniae, M. catarrhalis, or Haemophilus influenzae and a family history of OM increased the risk of AOM. Risk factors that increase the risk of pneumococcal AOM will be important to reassess as we move into a new 13-valent PCV era, especially co-colonization with other potential otopathogens.