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PubMed2002

Strategies for decreasing multidrug antibiotic resistance: role of ototopical agents for treatment of middle ear infections.

Change in the susceptibility of bacterial pathogens to antimicrobial agents is constant. The efficacy of a new drug may change as it is used in clinical settings, and resistant bacterial clones result from the encounter of drug and organism. Soon after the introduction of the sulfonamides in the mid-1930s, the first effective agents of the antimicrobial era, resistance of pneumococci and group A streptococci was evident. In each of the following decades, a different problem in multidrug resistance occurred among common bacterial pathogens: beta-lactamase-producing staphylococci in the 1950s; highly resistant gram-negative enteric bacteria in the 1960s; beta-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis in the 1970s; and multidrug-resistant pneumococci in the 1980s. Antimicrobial resistance among respiratory pathogens is now a common clinical problem throughout the world, and its management is a part of routine office practice. Currently in the United States, about 25% of pneumococci are resistant to penicillin, and 25% of H influenzae and 90% of M catarrhalis produce beta-lactamase and would be inactivated by organisms producing the enzyme. The emergence of penicillin and multidrug-resistant pneumococci and beta-lactamase-producing strains of H influenzae and M catarrhalis have special importance for the management of infections of the middle ear. The widespread use of oral and parenteral antimicrobial drugs for appropriate and inappropriate uses has driven the emergence and spread of resistant organisms. This article discusses current susceptibility patterns of organisms involved in middle ear infections, risk factors associated with development of resistant strains, strategies for limiting the incidence and spread of resistant organisms and, as part of the strategy, use of ototopical rather than systemic antimicrobial drugs for chronic suppurative otitis media (CSOM) and acute otitis media (AOM) in children with tympanostomy tubes. Although many ototopical agents are approved by the Food and Drug Administration for the indication of otitis externa, only ofloxacin otic is approved for treatment of CSOM in patients older than 12 years of age and AOM in children with tympanostomy tubes who are 1 year of age or older.

Acute Disease↗
PubMed1990

[Internal occlusive hydrocephalus following cholesteatoma].

A 30-year-old Vietnamese patient is reported who was admitted with a resistant acute otitis externa, and who complained also of headache and fever. The symptoms were found to be caused by the intracranial complications (epidural abscess and bacterial meningitis) of an aural cholesteatoma. A secondary occlusive hydrocephalus developed in spite of successful otological surgery that preserved hearing and vestibular function.

Adult↗
PubMed2003

[Langerhans cell histiocytosis: petrosal remodelling after chemotherapy--case report and review of the literature].

We report the case of a child presented by her parents to the ENT outpatient service for swelling of the right temporal bone. The child had a history of recurrent bilateral inflammation of the middle ear. Tympanometry revealed a reduced compliance. Due to conductive hearing loss it was impossible to measure otoacustic emissions. Otherwise a normal ENT status was found. Imaging (MRI/CT) demonstrated bitemporal soft-tissue changes with extensive osseous destruction, but no typical imaging signs of an inflammatory, dysplastic or expansive process. The tentative diagnosis of Langerhans' cell histiocytosis (LCH) made on the basis of the clinical and imaging findings was confirmed by biopsy. After exclusion of disseminated LCH, chemotherapy was initiated, and the child underwent follow-up imaging after 3 months. CT showed clear signs of bitemporal reossification. The case reported here illustrates the problems encountered in diagnosing LCH which may present with unspecific clinical symptoms despite advanced osseous destruction. ENT specialists should be familiar with this very heterogeneous entity and think of LCH especially in children presenting with therapy-refractory otitis media, otitis externa, or mastoiditis in order to ensure a timely diagnosis and to thus improve the chances of successful therapy. Imaging modalities (CT, MRI) have a role in the early diagnosis and follow-up of this disorder.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2006

Otitis techniques to improve practice.

Successful management of otitis externa requires recognition of changes in the anatomy and physiology of the external and middle ear, as well as the adequate tools and examinations to detect changes from normal. Otoscopy and methods for assessing the normalcy of the tympanum, collection of samples for cytologic evaluation or culture, and myringotomy are diagnostic techniques important in practice. Treatment tubes and intralesional triamcinolone injections are techniques that improve the response in some cases.

Animals↗
PubMed2006

[Evaluation of intensity of angiogenesis in granulation tissue in chronic otitis media--preliminary report].

In chronic otitis media molecular pathogenetic mechanisms are still unknown, however, angiogenesis may play a role. The aim of the study was to determine the intensity of angiogenesis in granulation tissue in chronic otitis media of different clinical course. Twenty six granulation tissue specimens (twenty two--from chronic otitis media, four--from prolongated otitis externa) taken during surgery were analyzed. The angiogenesis (microvessel density) was measured in paraffin-embedded tissue by an immunohistochemical method, by staining for endothelial cells with a monoclonal antibody against CD 34. The presence of CD 34 was found in all specimens. The expression was more intense in tissue samples from the group with good clinical course (good healing and without recurrence) than those in the group with poor healing and recurrence (mean number of dots for mm2 589,2 vs 533,3, respectively) and from the group without bacterial infection by Pseudomonas aeruginosa than those with this infection (mean number of dots for mm2 645,5 vs 440,8, respectively), but differences were not significant. In conclusion it is suggested that angiogenesis may contribute to different clinical course of chronic otitis media.

Adult↗
PubMed2003

Types and causes of otorrhea.

INTRODUCTION: Otorrhea is a common symptom and sign of patients seeking examination in an ENT Department of a General Hospital. The objective of this review is to assess the cause of otorrhea according to the type of it. METHODS: Retrospective review of 306 ears discharging some kind of fluid of 296 patients, who appeared in the ENT Department of our Hospital over a 58-month period. RESULTS: The most common type of otorrhea was the purulent one: 276 ears among 306 discharging ears (90%). The most common cause of purulent otorrhea was otitis externa: 156 ears among 276 ears discharging purulent fluid (56%). The germ most commonly isolated in the cultures of purulent aural discharge was Pseudomonas aeruginosa: 67 isolations of P. aeruginosa among 256 cultures (26%). CONCLUSIONS: Otomicroscopic examination and accurate culture of purulent discharge are mandatory for the clinician to establish a correct diagnosis and suggest a proper therapy in every case of otorrhea.

Adolescent↗
PubMed1997

Potentiating effect of EDTA-Tris on the activity of antibiotics against resistant bacteria associated with otitis, dermatitis and cystitis.

Possible synergistic effects of the combination of EDTA-tromethamine (EDTA-Tris) and three antimicrobial agents (cephaloridine, kanendomycin and enrofloxacin) against resistant Gram-positive and Gram-negative bacteria are reported. Bacteria were isolated from eight cases of chronic otitis externa, five cases of chronic dermatitis and four cases of recurrent cystitis in dogs which had previously been treated with one of the three antibiotics without success. Animals exposed to EDTA-tromethamine plus the antibiotic recovered completely within 10 days, and were controlled clinically and bacteriologically for 180 days. Local irrigation with EDTA-tromethamine solution was well tolerated and no side effects were recorded.

Animals↗
PubMed1997

[Results of bacteriologic and mycologic investigations of otitis media in dogs].

This study describes the bacteriological and mycological investigation of 212 ear swab samples of dogs with an otitis externa. 11 samples were sterile. Malassezia pachydermatis could be cultivated in 72.1% of all samples, in 21.9% of these cases in pure culture. In 27.9% of all samples only bacteria were found. Coagulase-positive haemolytic Staphylococcus and Malassezia pachydermatis were isolated together in 31.8% of all ear swab samples. Pseudomonas aeruginosa could be detected in 22.9%, haemolytic Streptococcus in 8.0%. The evaluation of antibiograms showed little resistance of staphylococcus to most common antibiotics or chemotherapeutics respectively, but the growth of Pseudomonas aeruginosa and especially Proteus spec. was only inhibited by a few substances.

Animals↗
PubMed2002

[Histologic studies on otomycosis].

Fungal infections of the ear are mostly described as mycoses of the auditory canal. The aim of our investigations was to find out how fungi colonize the ear in immunocompetent patients. In the years from 1993 to 2000, 128 patients suspected of having otomycosis were examined. Of these 115 patients suffered from chronic otitis media with persisting tympanum perforation and otorrhea. A further 13 patients had clinical signs of otitis externa only. In 54 out of 139 samples, fungi were found in the auditory canal, in five on the tympanic membrane, and in five in the middle ear. Two-thirds were isolated as moulds and one-third as yeasts. Dominating species were Aspergillus niger and Candida parapsilosis. Samples of 15 patients suspected of having mastoiditis or cholesteatoma were examined histologically. Fungal hyphae were observed in the middle ear cavity and/or between horny lamellae of cholesteatoma in 4 patients. In the middle ear of immunocompetent patients chronic-hyperplastic (polypous) inflammation was detected with increased production of mucus, which probably promotes the colonization with pathogenic fungi as in the middle ear just like in the auditory canal.

Aspergillosis↗
PubMed2001

[Primary carcinoma of the ear canal. Clinical aspects, intratemporal growth behavior and surgical strategy].

BACKGROUND AND OBJECTIVE: The symptoms and microscopic findings in carcinoma of the external auditory meatus are often unspecific and misinterpreted as recurrent otitis externa. A definite diagnosis is therefore often delayed, frequently resulting in advanced tumor stages with unfavorable prognosis at the time of diagnosis. PATIENTS/METHODS: In a retrospective analysis of 11 of our own patients and four cases from the Wittmack collection, the clinical data and course of this disease were examined with particular focus on the intratemporal bone growth pattern and possible surgical strategies. RESULTS: Histopathologically, all cases consisted of squamous cell carcinoma of variable differentiation, with predomination of higher tumor stages (T2-T4: 93.3%) and little initial lymph node metastases (N+: 14.3%; M+: 0%). Osseous destruction was present (almost obligatory) in 93.3% (determined histopathologically and radiologically with CT). Follow-up (to a maximum of 6 years) after surgical resection and postoperative irradiation shows local recurrence at an average of 10 months in 40% of the cases, with a metastasis rate of 44.4%. Mean overall survival is 29.7 months, and 45.5% of the patients experience an average tumor-free period of 46.4 months. The most important prognostic factor in this context is the initial tumor stage. CONCLUSION: In regard to prognosis of external auditory meatus carcinoma, early diagnosis is of vital importance. Especially older patients (50-80 years) who previously have had no history of ear disease should undergo early computer tomographical examination and biopsy in cases of recurrent external otitis.

Aged↗
PubMed2004

The evolution of ototopical therapy: from cumin to quinolones.

A radical change has occurred in the management of otorrhea over the past decade. Multiple studies have supported the efficacy of topical quinolones in the management of acute otitis media, acute otitis externa, and CSOM. For the first time, otolaryngologists have a scientific foundation on which to base our treatment protocols for these conditions. We no longer must rely solely on our clinical experience and prejudices. The quinolone drops have a superior safety profile and a broad antimicrobial spectrum, their overall cost is lower than the alternatives, and their convenient dosing schedule is tolerated well by most patients. When one takes all these factors into consideration, it becomes clear that topical quinolone therapy, with or without a steroid additive, is the treatment of choice for otorrhea in patients with a tympanic membrane perforation or ventilating tube. The development of ototopical medications has followed along the lines of Darwinian evolution, and the quinolone drops have clearly demonstrated the concept of "survival of the fittest."

Administration, Topical↗
PubMed2003

Mycological and histological investigations in humans with middle ear infections.

The aim of our investigations was to characterize fungal colonization of the ear in immunocompetent patients. From 1993 to 2000, 128 patients supposed to suffer from otomycosis were included. Mycological examination conducted by direct microscopy and fungal cultures was performed on 139 specimens. Among these, 115 patients suffered from chronic otitis media with persisting tympanum perforation and otorrhea. A further 13 patients had clinical signs of an otitis externa only. Out of 139 samples, fungi were identified in the auditory canal (n = 54), on the tympanic membrane (n = 5), and in the middle ear (n = 5). Two-thirds were as moulds and one-third yeasts. The dominating species were Aspergillus niger and Candida parapsilosis. Samples from 15 patients supposed to have mastoiditis or cholesteatoma were examined histologically. Fungal hyphae were observed in the middle ear cavity and/or between horny lamellae of cholesteatoma in four patients. In the middle ear of immunocompetent patients chronic-hyperplastic (polypoid) inflammation was detected with increased production of mucus, which probably promotes colonization by pathogenic fungi in the middle ear as well as in the auditory canal. Invasive fungal growth into the subepithelial connective tissue was not observed.

Adult↗
PubMed2001

The significance of nasal carriage of Staphylococcus aureus as risk factor for human skin infections.

The present study was designed to investigate the significance and the relationship between nasal carriage of Staphylococcus aureus and staphylococcal skin infections. Thirty-one S. aureus strains, isolated from 12 patients with chronic and recurrent skin infections, one patient with septicemia and one patient with otitis externa were studied. The staphylococcal strains were isolated from the site of infection and from the anterior nares of each patient. The identity of both strains of each pair could be demonstrated by determination of phenotypic properties and by genotyping of the isolates. The phenotypic properties included hemolytic activities, antibiotic resistance data, and the production of enterotoxins. The identity was additionally confirmed by phage-typing, by determination of the size and the number of repeats of the X region of spa gene, by determination of gene polymorphisms of coa gene and by macrorestriction analysis of the chromosomal DNA of the isolates by pulsed-field gel electrophoresis. The present results showed an identity of the S. aureus obtained from anterior nares and from skin infection of each patient indicating the importance of nasal carriage of these bacteria for development of human skin infection.

Bacteriophage Typing↗
PubMed2006

Bone-anchored hearing aids: results of the first eight years of a programme in a district general hospital, assessed by the Glasgow benefit inventory.

OBJECTIVES: To report the clinical results of a bone-anchored hearing aid (BAHA) programme in a district general hospital, compared with those in an established, large, university teaching hospital centre. DESIGN: A retrospective postal questionnaire sent to BAHA patients, with two month waiting time and one reminder, combined with case note analysis. Results compared by appropriate statistical tests with published outcomes data from the largest UK series. SETTING: Public sector (National Health Service) district general hospital, England. Catchment population: 300,000 (mixed rural and small towns). PARTICIPANTS: Case note analysis of sixty-three patients implanted between 1994 and 2003 (age range, six to 88 years). The commonest indication was chronic otitis media, with inability to wear a conventional hearing aid. Otitis externa, otosclerosis and sensorineural hearing loss were other indications. The questionnaire was sent to 59 patients who had worn their aid for at least six months; it was returned by 41 (69 per cent). MAIN OUTCOME MEASURES: Glasgow benefit inventory (GBI, change in health status following otolaryngological intervention); incidence of complications. RESULTS: Bone-anchored hearing aid implantation significantly improved quality of life as measured by the GBI (p<0.001). The degree of improvement was similar to that achieved in Birmingham by Proops et al. (p>0.05, chi-squared test). Minor temporary skin infection was common (33 per cent). Thickening of the skin around the implant occurred in 17 per cent. One implant (2 per cent) failed. There were no serious complications. CONCLUSION: The BAHA is a safe, reliable and effective treatment for selected patients. A successful BAHA programme can be run in a district general hospital.

Adolescent↗
PubMed1975

[Clinical study on amoxicillin in otorhinolaryngological field (author's transl)].

Clinical effect of amoxicillin was evaluated in 29 cases of the acute infections of ear, nose and throat: 8 cases of acute purulent otitis media, one case of acute otitis externa, one case of furuncle of the ear, 2 cases of acute sinusitis, 12 cases of acute lacunar tonsillitis, 2 cases of pharyngolaryngitis, one case of acute cervical lymphadenitis, one case of phlegmon of the face and one case of acute gingivitis. The following results were obtained from the clinical and laboratory studies. 1) The therapeutic results were excellent in 18 cases, good in 5 cases, fair in 3 cases and poor in 3 cases. The effect was observed in 79.3% of the patients treated. 2) The causative bacteria were: 3 strains of beta-Streptococcus hemolyticus, 4 strains of Hemophilus, 4 strains of Staphylococcus aureus, one strain of Diplococcus pneumoniae, one strain of Gram-positive Diplococcus and Gram-negative Bacillus. Clinically good results were obtained in patients infected with beta-Streptococcus hemolyticus, Hemophilus and Diplococcus pneumoniae. 3) No side effect was observed with amoxicillin, except slight diarrhea in one case. This side effect disappeared by cessation of the administration. 4) No unfavourable influence was noticed on peripheral blood, liver function nor renal function by administration of amoxicillin. 5) From the results of this series, amoxicillin seems to be useful in the treatment of acute infections of the ear, nose and throat.

Adolescent↗
PubMed1985

Experience with ciprofloxacin in the treatment of various infections caused mainly by Pseudomonas aeruginosa.

Ciprofloxacin, a new quinolone carboxylic acid derivative with an enhanced spectrum of activity including P. aeruginosa, was given to 42 patients, 26 males and 16 females, ranging in age from 12 to 75 years. They were suffering from upper urinary tract infection (15), abscesses (hepatic 1, intra-abdominal 5, retroperitoneal 1, soft tissue, deep soft tissue infection (9), chronic otitis media in exacerbation (3), chronic osteomyelitis in exacerbation (3), bronchopneumonia (3) and otitis externa (1). Pathogens included P. aeruginosa (29), E. cloacae (7), P. mirabilis, E. coli (3) and S. marcescens (1), with MICs for ciprofloxacin ranging from 0.003-2 micrograms/ml. Over half of the isolates were multiresistant, also to amikacin, with almost all the Pseudomonas strains resistant to carbenicillin and the ureidopenicillins. In 21 patients ciprofloxacin was given orally at a dose of 500 mg or 750 mg 12-hourly, in 5 patients i.v. at a dose of 200 mg 12-hourly; while in 16 patients treatment was started i.v. and was continued by the oral route. Seventeen patients were given ciprofloxacin for 7-14 days, 5 for 15-22 days, 4 for 23-28 days, 8 for 29-42 days, and 8 for greater than 42 days. Treatment response was considered clinically as cure in 30 (71.5%) patients, improvement in 8 (19%) and failed in 4 (9.5%). Pathogens were eradicated during treatment in 34 (81%), persisted in 8 (19%) and recurred in 11 (26.2%) patients. Development of resistance was observed in one patient only. Adverse reactions in 12 patients were minimal and self-limited. It was concluded that ciprofloxacin is a very promising new antimicrobial which merits further clinical trials in systemic infections.

Abscess↗
PubMed2005

Topical antibiotics without steroids for chronically discharging ears with underlying eardrum perforations.

BACKGROUND: Chronic suppurative otitis media (CSOM) causes ear discharge and impairs hearing. OBJECTIVES: Assess topical antibiotics (excluding steroids) for treating chronically discharging ears with underlying eardrum perforations (CSOM). SEARCH STRATEGY: The Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 1, 2005), MEDLINE (January 1951 to March 2005), EMBASE (January 1974 to March 2005), LILACS (January 1982 to March 2005), AMED (1985 to March 2005), CINAHL (January 1982 to March 2005), OLDMEDLINE (January 1958 to December 1965), PREMEDLINE, metaRegister of Controlled Trials (mRCT), and article references. SELECTION CRITERIA: Randomised controlled trials; any topical antibiotic without steroids, versus no drug treatment, aural toilet, topical antiseptics, or other topical antibiotics excluding steroids; participants with CSOM. DATA COLLECTION AND ANALYSIS: One author assessed eligibility and quality, extracted data, entered data onto RevMan; two authors inputted where there was ambiguity. We contacted investigators for clarifications. MAIN RESULTS: Fourteen trials (1,724 analysed participants or ears). CSOM definitions and severity varied; some included otitis externa, mastoid cavity infections and other diagnoses. Methodological quality varied; generally poorly reported, follow-up usually short, handling of bilateral disease inconsistent. Topical quinolone antibiotics were better than no drug treatment at clearing discharge at one week: relative risk (RR) was 0.45 (95% confidence interval (CI) 0.34 to 0.59) (two trials, N = 197). No statistically significant difference was found between quinolone and non-quinolone antibiotics (without steroids) at weeks one or three: pooled RR were 0.89 (95% CI 0.59 to 1.32) (three trials, N = 402), and 0.97 (0.54 to 1.72) (two trials, N = 77), respectively. A positive trend in favour of quinolones seen at two weeks was largely due to one trial and not significant after accounting for heterogeneity: pooled RR 0.65 (0.46 to 0.92) (four trials, N = 276) using the fixed-effect model, and 0.64 (95% CI 0.35 to 1.17) accounting for heterogeneity with the random-effects model. Topical quinolones were significantly better at curing CSOM than antiseptics: RR 0.52 (95% CI 0.41 to 0.67) at one week (three trials, N = 263), and 0.58 (0.47 to 0.72) at two to four weeks (four trials, N = 519). Meanwhile, non-quinolone antibiotics (without steroids) compared to antiseptics were more mixed, changing over time (four trials, N = 254). Evidence regarding safety was generally weak. AUTHORS' CONCLUSIONS: Topical quinolone antibiotics can clear aural discharge better than no drug treatment or topical antiseptics; non-quinolone antibiotic effects (without steroids) versus no drug or antiseptics are less clear. Studies were also inconclusive regarding any differences between quinolone and non-quinolone antibiotics, although indirect comparisons suggest a benefit of topical quinolones cannot be ruled out. Further trials should clarify non-quinolone antibiotic effects, assess longer-term outcomes (for resolution, healing, hearing, or complications) and include further safety assessments, particularly to clarify the risks of ototoxicity and whether quinolones may result in fewer adverse events than other topical treatments.

Anti-Bacterial Agents↗