Efficacy of mastoidectomy on MRSA-infected chronic otitis media with tympanic membrane perforation

OBJECTIVES: To retrospectively evaluate the efficacy of mastoidectomy on methicillin-resistant Staphylococcus aureus (MRSA)-infected chronic otitis media in comparison with methicillin-susceptible Staphylococcus aureus (MSSA)-infected otitis media. METHODS: Between January 1998 and October 2003, 18 ears underwent surgery for MRSA-infected chronic otitis media with tympanic membrane perforation at the Department of Otolaryngology, Hyogo College of Medicine. Another 33 ears underwent surgery for MSSA-infected chronic otitis media with tympanic membrane perforation during the same period. The postoperative results of graft success rate, hearing results and other complications were compared between MRSA-infected and MSSA-infected ears with or without mastoidectomy, and discharging or dry ears. RESULTS: In MRSA, the mastoidectomy group tended to have a better graft success rate than the non-mastoidectomy group. In MSSA, there were almost the same graft success rate and hearing results between the mastoidectomy and non-mastoidectomy groups regardless of the presence of discharge. In MRSA-infected discharging ears, the rate of postoperative complications (ear drum perforation, persistent otorrhea, and dehiscence of skin incision) were significantly lower in the mastoidectomy group than in the non-mastoidectomy group (p=0.046). CONCLUSION: Mastoidectomy had significantly better results concerning postoperative complications in discharging ears with MRSA-infected chronic otitis media. We recommend performing tympanoplasty with mastoidectomy in MRSA-infected chronic otitis media.     

Eustachian tube function and tympanic membrane findings after chronic secretory otitis media

OBJECTIVE: The etiology of secretory otitis media (SOM) is multifactorial. The main factors discussed are infection and tubal dysfunction. This study aimed to detect poor tubal function and tympanic membrane pathology in young adults after extremely long-standing SOM. METHODS: Thirty-four patients, 16-25 years old, with previous chronic SOM persisting at least 6 years (mean 11.2 years, range 6.2-18.6 years), were retrospectively examined at a mean of 18 years after their first myringotomy or tube insertion and comparison was made with 15 controls. The medical records were scrutinized, otomicroscopic examination was performed and the Eustachian tube function was studied in a mini pressure chamber. RESULTS: The mean age at SOM onset was 2.4 years (range 0.5-8.4 years) and the mean period from the last myringotomy or when the last tube had disappeared to follow-up was 6.7 years (range 1.3-12.8 years). Tympanic membrane pathology was found in 76% of the ears of SOM patients and in none (0%) of controls (P<0.001). The youngest patients had more atrophy than the older patients (P<0.05) and more myringosclerosis was observed in patients with shorter interval between SOM ending and examination. The patients were found to have significantly poorer active tubal function; i.e. higher inability to equilibrate negative or negative and positive middle ear pressure, compared with controls (P<0.001). The majority of the patients (74%) still experienced some kind of discomfort in their ears at the time of examination. CONCLUSIONS: Still in adulthood patients with chronic SOM during childhood exhibit dysfunction of the tube and tympanic membrane pathology to a high extent.     

Nature of spontaneous tympanic membrane perforation in acute otitis media in children

The study was undertaken to define the characteristics of spontaneous eardrum perforation in acute otitis media. Eighty (29.5 per cent) out of 271 children with acute otitis media had eardrums which perforated. An increased incidence of perforation was associated with a previous history of otitis media. All perforations were small and limited exclusively to the pars tensa. In 85 per cent of the patients, the perforation was located in the anterior-inferior quadrant. It had smooth margins enabling free drainage of pus-and was associated with a favourable clinical course. In the remaining 15 per cent of the cases, the perforation was located in the posterior-superior quadrant. It had a nipple-like shape with a tiny opening that did not allow pus to drain sufficiently from the middle ear. The perforation closed in 94 per cent of the patients within one month. The healing process was gradual and following perforation closure, there was evidence of middle ear effusion for some time before normal aeration was regained.     

Mongolian gerbil tympanic membrane. Normal and with induced otitis media

Otoscopic observation of the tympanic membrane is the most effective noninvasive means of diagnosing and following the course of experimental otitis media in animal models of the disease in both short-term and in longitudinal studies. Because of the difficulty of viewing the entire tympanic membrane of the gerbil model of otitis media without manipulation, we present methods of visualizing and color illustrations of the normal tympanic membrane of the Mongolian gerbil, Meriones unguiculatus. These are compared with illustrations of animals with acute experimental otitis media. An artist's rendition of the entire normal gerbil tympanic membrane is presented. These methods and illustrations will enable investigators to more rapidly and easily adopt the Mongolian gerbil as an animal model for studies of otitis media.     

Early structural changes in the rat tympanic membrane during pneumococcal otitis media

The early inflammatory reaction in the rat tympanic membrane was studied during the first 36h following inoculation of Streptococcus pneumoniae type 3 in the middle ear cavity. Otomicroscopic examination showed only minor signs of inflammation in the early stages although changes at the light microscopic level were pronounced. This reaction differed significantly between the pars flaccida and pars tensa of the tympanic membrane. Three hours after inoculation, edema and infiltration with polymorphonuclear leukocytes and macrophages were found in the pars flaccida whereas in the pars tensa no polymorphonuclear leukocytes were noted until after 12 h. This reaction was most prominent after 36h. In the pars flaccida, mitoses occurred frequently among the cells of the simple squamous epithelium, which changed into a double-layered cuboidal epithelium. These findings demonstrate that an inflammatory reaction starts earlier in the pars flaccida than in the pars tensa of the tympanic membrane.     

Bacteriologic evaluation of otitis externa and chronic otitis media

The authors present results of bacteriological examinations in 187 patients with chronic otitis media (OMC) and otitis externa treated in ENT Department, Medical University of Gdańsk in the years 1997-1998. Ear swabs and aspirates were investigated for aerobes and anaerobes 254 bacterial isolates were obtained. Among 150 patients with OMC aerobes were isolated in 130 (86.7%) in 13 (8.5%) mixed aero-anaerobes flore and in 20 (19.3%) no bacterial growth was observed. From patients with COM there were 199 bacterial isolates among them 177 aerobes cultures, 13 anaerobes and 9 fungal. From the external ear canal there were 55 cultures, among them 45 (81.8%) aerobes, 6 (10.9%) mixed aero-anerobes and 4 (7.3%) fungal. The most frequent observed bacteria were Staphylococcus aureus, Pseudomonas aeruginosa and Proteus mirabilis which showed the best susceptibility on ciprofloxacine and amikacine.     

Optimizing effectiveness of laser tympanic membrane fenestration in chronic otitis media with effusion. Clinical and technical considerations

OBJECTIVE: To describe the patient, disease and clinical characteristics that optimize the effectiveness of laser tympanic membrane fenestration (LTMF) to treat chronic otitis media with effusion (OME). SETTING: Four pediatric otolaryngology tertiary referral centers. IRB approved; participation by informed consent. METHODS: An observational clinical effectiveness trial was conducted in 164 ears (94 children), who had chronic OME. All patients were candidates for insertion of pressure equalization tubes (PETs) but agreed to undergo LTMF instead. Clinical and audiologic follow-up are reported at 90 days after LTMF. OUTCOME MEASURES: Clinical effectiveness was defined as an effusion free middle ear at otoscopy with A or C1 tympanogram and normal hearing. RESULTS: At 90 days, 66% of the 95 evaluable ears were effusion free, all with normal hearing. Children younger than 4 years (P<0.04), who had shorter durations of effusion (P<0.009), and who experienced longer duration of fenestration patency (FP) (P<0.009) correlated to improved outcomes. CONCLUSIONS: The use of LTMF to create 2--3 weeks of middle ear ventilation in patients with chronic OME (middle ear effusion (MEE) for 3 months or greater) is effective in 66% of 95 (58%) of ears evaluable at 90 days follow-up. This study provides basic information needed to optimize the use of LTMF today and enhance research efforts in the future.     

Transmeatal controlled barohydrodynamic diagnosis of otitis media with perforation of the tympanic membrane

The article presents a novel method of topical diagnosis and treatment of acute and chronic otitis media purulenta with perforation in the tympanic membrane; describes indications and contraindications for the method application, its technique with use of two devices: otobarohydroscope and transmeatal catheter. The treatment was performed in a group of patients with acute otitis media purulenta at the stage of tympanic membrane perforation complicated with exudative serous mastoiditis. Transmeatal controlled barohydrodynamic therapy proved its high efficacy in topical diagnosis and therapy of patients with the above condition.     

慢性化脓性中耳炎鼓膜紧张部大穿孔手术方法的选择

目的探讨慢性化脓性中耳炎鼓膜紧张部大穿孔手术方式选择的依据,明确乳突CT正常的患者进行乳突探查的必要性。方法病例材料来源于北京大学人民医院耳鼻咽喉科2014年至2015年收治的慢性化脓性中耳炎患者102例,所有患者均为鼓膜紧张部大穿孔,术前完善检查,102例患者中乳突CT异常的患者为85例(83.33%),乳突CT正常并且干耳2月以上患者17例(16.67%)。所有患者均全麻下进行乳突开放术及鼓室成形术。结果 102例患者术后随访鼓膜愈合均良好,乳突CT正常的患者在术中探查乳突、鼓窦、鼓室、听骨链、咽鼓管口区域,发现所有患者均存在一个及以上区域的病变,多处病变影响乳突鼓窦引流。结论乳突CT正常不能成为慢性化脓性中耳炎单纯鼓膜修补的标准,除外伤性鼓膜穿孔外均应进行乳突探查。     

Early structural tympanic membrane reactions to myringotomy: a study in an acute otitis media model

Myringotomy (Myr) is one of the most frequently performed surgical procedures in children. However, events occurring in the early phases, i.e. a matter of hours, following Myr in the acute otitis media (AOM) model have not been described. The aim of the present study was to evaluate the early otomicroscopic and histopathologic reactions of the tympanic membrane (TM) after Myr during the course of AOM (AOM-Myr). The left tympanic bulla from 36 healthy Sprague-Dawley rats was inoculated with Streptococcus pneumoniae type 3. Forty-eight h later, at Day 0, 4 randomized animals were immediately sacrificed and the remaining animals were treated with bilateral Myr. Otomicroscopy and sacrifices were performed in series of 4 animals at 3, 6, 9, 12, 24 and 48 h, and 4 and 7 days. The AOM-Myr TMs were compared to non-infected Myr TMs (non-AOM-Myr). The TMs were then dissected free and routinely processed for light and electron microscopy. AOM developed in all inoculated ears at Day 0. In the pars tensa of the AOM-Myr TMs the reaction of the keratinocyte layer of the perforation border was already evident at 6 h. The lamina propria exhibited a strong inflammatory reaction, which became more organized from 12 h onwards. At Day 4 the perforations were closed in three-quarters of cases. At Day 7 all perforations were healed with a distorted scar. In the non-AOM Myr TMs a strong degranulation of mast cells and edema were found in the pars flaccida at 6 h. A keratin spur at the perforation border was not seen until 24 h. All perforations were patent on Day 7 and myringosclerotic deposits were abundant in these TMs. The infected TMs regenerated faster and closed their perforations at an earlier stage. These findings favor the hypothesis that there is a low risk of chronic perforations when myringotomizing AOM TMs.     

Phenol anesthesia of the tympanic membrane in purulent otitis media: a structural analysis in the rat

Summary In the present study, local anesthetics were applied to the tympanic membrane (TM) of rats following experimentally evoked purulent otitis media (POM). The structure of the TM was evaluated 24 h, 2 weeks and 3 months after application of phenol to a discrete are of the right TM. The left ear was used as a control. POM induced swelling of all tissue layers of the pears tensa. The tissues were invaded by inflammatory cells and disintegrated. The fibrous layer also dissolved, leaving spontaneous perforations. However, phenol on inflamed TMs did not further alter the TM structure. These findings infer that the injurious effect of topical anesthesia on the intact TM is more or less negligible when applied to diseased TMs.     

Shape and displacement patterns of the gerbil tympanic membrane in experimental otitis media with effusion

This study assesses the visco-elastic properties of the tympanic membrane (TM) in isolated gerbilline temporal bones as a function of time after inducing experimental otitis media with effusion (OME). To do this we measured the TM displacements produced by application of sequences of static pressures across the TM, with a high resolution, real-time, differential moiré interferometer, and the results were compared with measurements on healthy ears. Two methods of producing OME were used: in one group tubal plugging was performed to produce mild OME (the ‘TP group’); in the other group electro-cauterization of the nasopharyngeal orifice of the Eustachian tube was used to cause a severe form of OME (the ‘EC group’). The measurements were performed from one day up to ten weeks after surgery. In the TP group the displacement fringe patterns were normal, i.e. qualitatively they resembled the patterns of the control group. Quantitatively there was a significant decrease of displacement for a given pressure on the first day after surgery, followed by a trend of increase with time; after seven to ten days the displacement was larger than in the control group. In the EC group the displacement was significantly reduced after half a week, followed by a trend of increase with time, similar to what was found in the TP group; at one week the displacement was larger than in the control group, and at ten weeks the largest displacement was recorded. In the EC group the displacement patterns were often irregular; in some cases with changes suggesting the presence of weak spots in the TM where retraction pockets most likely could develop. OME seems to affect the stiffness of the TM promptly so that it is a potential parameter for early diagnosis. The stiffness changes may, if measurable in the clinical situation, become prognostic parameters in the treatment of OME.     

Metronidazole uptake in the cholesteatomatous membrane in chronic otitis media

Previous investigations have demonstrated a good uptake of metronidazole in the middle ear mucosa. We have now presented a trial study in which there was also a significant uptake of metronidazole in the cholesteatomatous membranes of patients with chronic otitis media.     

Metronidazole uptake in the cholesteatomatous membrane in chronic otitis media

Summary Previous investigations have demonstrated a good uptake of metronidazole in the middle ear mucosa. We have now presented a trial study in which there was also a significant uptake of metronidazole in the cholesteatomatous membranes of patients with chronic otitis media.     

Comparison of bacteria in the tympanic cavity and the mastoid antrum in chronic otitis media

Materials collected from the tympanic cavity before operation and from the mastoid antrum during operation of 58 discharging ears of patients with chronic otitis media were cultured, and the bacteria in these two cavities were compared. Staphylococcus aureus was the commonest organism in the tympanic cavity, and S epidermidis in the mastoid antrum. Anaerobic bacteria were found only in the mastoid antrum of patient with cholesteatoma. In 32 (55 per cent) of the 58 ears examined, bacteria were detected in both the tympanic and mastoid cavities. In 17 ears (53 per cent), the bacterial strains in the two cavities differed. The results indicate the necessity of bacteriologic examination of the mastoid cavity during operation to select antibiotics for postoperative treatment.     

Evaluation and comparison of tympanoplasty efficacy with tympanic membrane perforation after chronic suppurative otitis media in dry ear with different microorganisms

ObjectiveTo investigate the distribution of pathogenic bacteria in patients with tympanic membrane perforation after chronic suppurative otitis media (CSOM) in dry ear and its influence on the success rate of tympanoplasty and postoperative infection.Methods740 patients with tympanic membrane perforation after CSOM underwent endoscopic tympanoplasty were selected. The mucosal surface secretion of middle-ear was collected for bacterial culture and drug sensitivity test. The patients were followed up several times from 1 week to 3 months after the surgery.Results740 cases of ear secretions samples, raise the pathogens of 208 cases (28.1%), the success rate of surgery with microorganism grown and with no grown was 93.8% and 91.5%. fungus (14.6%) was the most species among the patients with the positive result, followed by methicillin-sensitive Staphylococcus aureus (4.1%), Pseudomonas (2.0%), Staphylococcus epidermidis (1.9%), methicillin-resistant Staphylococcus aureus (1.6%) and so on. There was no statistical difference in the proportion of perforation and infection in each group. There were no statistically significant differences in gender, age and duration of disease among the groups.ConclusionThere were still microbial colonization in patients with tympanic membrane perforation after CSOM in dry ear, include fungus, Staphylococcus aureus and Pseudomonas aeruginosa. Different microbial colonization had no influence on the success rate of tympanoplasty and postoperative infection.     

Carcinoembryonic antigen in chronic otitis media: an immunohistochemical study of the middle ear mucosa

Carcinoembryonic antigen (CEA) has an important role as a tumor marker and also as a cell adhesion molecule. The expression and the role of CEA in chronic inflammation of middle ear mucosa has not been studied previously. Immunohistochemical analysis with monoclonal antibodies against human CEA was performed in order to detect CEA in formalin fixed and paraffin embedded biopsy specimens of middle ear mucosa in chronic otitis media. In this study 118 specimens of middle ear mucosa from different regions of the middle ear cleft were analysed. All specimens were taken during surgery of otitis media with and without cholesteatoma. The results showed that CEA expression was present in mucosal samples in chronic otitis media with cholesteatoma, predominantly in squamous epithelium, as well as in the subepithelial layer and among the connective tissue, especially on collagen fibres of fibroproliferative stroma. CEA was seen on endothelial cells of blood vessels. Occasionally it was present on the surface of columnar epithelium of the middle ear mucosa in chronic otitis media without cholesteatoma. The expression patterns of CEA in chronic inflammation of middle ear mucosa suggest potential functional activities similar to adhesion molecules and signal regulatory proteins which will be the subject of further study.     

Calcium deposition and expression of bone modelling markers in the tympanic membrane following acute otitis media

BACKGROUND AND OBJECTIVES: In accordance with clinical findings, myringosclerosis develops after otitis media (OM) and paracentesis in an experimental setting. The pathogenesis of this phenomenon of calcification is poorly understood. As the calcification process and the sclerotic plaques of the drum mimics features of bone tissue, this study explores tympanic membrane calcium deposition in association with the expression of three bone modelling markers: osteopontin (OPN), osteoprotegerin (OPG) and osteonectin (ON). OPN is secreted by osteoblasts and is found at calcification sites, e.g. during pathological calcification in chronic OM. The cytokine OPG is an inhibitor of bone resorption and consequently bone remodelling. ON is a calcium binding glycoprotein necessary for the maintenance of bone mass and remodelling. It is found in bone matrix and synthesized by osteoblasts. METHOD: A rat model of acute otitis media (AOM) caused by non-typeable Haemophilus influenzae was used. Four days following middle ear inoculation, a myringotomy was performed in six animals. Another group of ten animals was inoculated only. The drum was dissected in two animals from each group on day 4, 7, 14 and 28 post-inoculation, and the expression of OPN, OPG and ON was determined by immunohistochemistry. von Kossa staining determined the deposition of calcium and immune staining for CD68 identified macrophages. RESULTS: Calcium depositions were initially accumulated in the cytoplasm of macrophages and dispersed in the connective tissue layers of the pars flaccida and tensa. Late accumulation occurred in the lamina propria of pars tensa, more extensively in myringotomized ears. OPN expression was found early in inflammatory cells including especially macrophages and late in pars tensa fibrocytes. OPG expression was initially located to inflammatory cells and late to pars tensa fibrocytes and the inner basal membrane of pars flaccida. Some ears displayed a marked pars flaccida expression of ON in the connective tissue matrix on early days and at the inner basal membrane on later days. The latter cases were from myringotomized ears. Otherwise, no apparent differences of marker expression occurred between myringotomized and non-myringotomized animals. CONCLUSION: We conclude that osteopontin, osteoprotegerin and osteonectin are expressed by different cell types in the tympanic membrane during calcification in association with AOM, with or without myringotomy. These molecules may accordingly play a role in the pathogenesis of myringosclerosis, in which macrophages and fibrocytes appear as potential major players.