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Background: For children at high risk of chronic suppurative otitis media (CSOM), strategies to prevent acute otitis media with perforation (AOMwiP) may reduce progression to CSOM., Methods: In a double blind study in northern Australia, 103 Aboriginal infants with first detection of OME were randomised to receive either amoxicillin (50 mg/kg/d BD) or placebo for 24 weeks, or until bilateral aerated middle ears were diagnosed at two successive monthly examinations (success). Standardised clinical assessments and international standards for microbiology were used., Results: Five of 52 infants in the amoxicillin group and none of 51 infants in the placebo group achieved success at the end of therapy (Risk Difference = 9.6% [95% confidence interval 1.6,17.6]). Amoxicillin significantly reduced the proportion of children with i) perforation at the end of therapy (27% to 12% RD = -16% [-31,-1]), ii) recurrent perforation during therapy (18% to 4% RD = -14% [-25,-2]), and iii) reduced the proportion of examinations with a diagnosis of perforation during therapy (20% to 8% adjusted risk ratio 0.36 [0.15,0.83] p = 0.017). During therapy, the proportion of examinations with penicillin non-susceptible (MIC > 0.1 microg/ml) pneumococci was not significantly different between the amoxicillin group (34%) and the placebo group (40%). Beta-lactamase positive non-capsular H. influenzae (NCHi) were uncommon during therapy but more frequent in the amoxicillin group (10%) than placebo (5%)., Conclusion: Aboriginal infants receiving continuous amoxicillin had more normal ears, fewer perforations, and less pneumococcal carriage. There was no statistically significant increase in resistant pneumococci or NCHi in amoxicillin children compared to placebo children who received regular paediatric care and antibiotic treatment for symptomatic illnesses.

Objective: To describe a consecutive series of children with refractory tympanostomy tube otorrhea treated with linezolid and document its clinical effectiveness and adverse effects., Design: Retrospective, single institution case series., Methods: The records of children treated with linezolid for refractory gram-positive otorrhea from 2003 to 2007 were analyzed for causative organisms, antimicrobial sensitivities, history of prior medical treatments, time to cessation of otorrhea, adverse effects of linezolid and recurrence of infection., Results: Ten episodes of refractory gram-positive otorrhea treated with linezolid were documented among eight children during the study period. Seven were caused by methicillin-resistant Staphylococcus aureus and three by multiple-drug resistant Streptococcus pneumoniae. Prior treatment regimes included clindamycin, trimethoprim-sulfamethoxazole/rifampin, amoxicillin-clavulanate, and/or a third-generation cephalosporin. Seven of eight children had failed extended courses of fluoroquinolone ear drops. All children were free of otorrhea by the 14th day of twice-daily treatment with oral linezolid at 20mg/kg/day. One child developed two additional episodes of S. aureus otorrhea three and 10 months after initial treatment. Each was successfully controlled with linezolid. There were no adverse effects from linezolid treatment., Conclusion: Oral linezolid is highly effective in the treatment of refractory otorrhea caused by methicillin-resistant S. aureus and multiple drug-resistant S. pneumoniae. It has a low risk of serious side effects. It is one of only a few oral agents with activity against these organisms and is very expensive. Linezolid should be used only when otorrhea cannot be treated with conventional agents or when complications of otitis media pose a risk to life or function.

Objective: The American Academy of Pediatrics acute otitis media guidelines could reduce antibiotic use. The objective was to compare strategies for diagnosing and treating otitis: (1) a commonly used, 2-criteria strategy, (2) the guidelines' 3-criteria algorithm, and (3) initially watching without antibiotics., Methods: A decision analysis was performed with literature-based parameter. The target population was children presenting to primary care physicians with possible otitis media. Main outcomes were antibiotic use, sick days, mild adverse drug events, and number needed to treat/avoided sick day., Results: For children 2 to <6 months of age, compared with the 2-criteria strategy, guideline use predicted 21% less antibiotic use, 13% more sick days, and 23% fewer adverse drug events; the number needed to treat for the 2-criteria strategy versus the American Academy of Pediatrics strategy was 1.2 children per avoided sick day. For children 6 to <24 months of age, guideline use, compared with the 2-criteria strategy, predicted 26% less antibiotic use, 14% more sick days, and 28% fewer adverse drug events; the number needed to treat for the 2-criteria strategy versus the American Academy of Pediatrics strategy was 1.4 children per avoided sick day. For children >2 years of age, guideline use, compared with the 2-criteria strategy, predicted 67% less antibiotic use, 4% more sick days, and 68% fewer adverse drug events. The number needed to treat for the guideline strategy versus the watch strategy was 6.3 children per avoided sick day; that for the 2-criteria strategy versus the guideline strategy was 12.3. Guideline use for children <2 years implies that our number needed to treat to avoid a sick day is <1.4; for children >2, guideline use implies we are willing to treat at least 6.3 children to avoid a sick day. Thus, the guidelines imply a greater willingness to treat older children, compared with younger children., Conclusions: The American Academy of Pediatrics guidelines are inconsistent in their outcomes across age groups. Guideline implementation under age 2 reduces antibiotic use but at a relatively heavy cost of sick days and parental missed work days. This trade-off may be particularly unfavorable for working parents, who might reasonably prefer greater antibiotic use.

Objectives/hypothesis: A reliable model of allergy has been created in the Brown Norway rat. In this model, allergen presentation to the middle ear causes functional disruption of the eustachian tube, predisposing to the development of otitis media with effusion. The purpose of this study was to study the effects of ototopical antihistamine on lipopolysaccharide (LPS)-induced otitis media in the allergic rat model., Study Design: Prospective animal-based research study., Methods: Fifteen (n = 15) rats were made allergic via sensitization to ovalbumin (OVA) by subcutaneous injection and randomized into three groups: saline (SAL) + LPS, olopatadine (OLO) + LPS, and azelastine (AZE) + LPS. Allergic rats were transtympanically injected with OVA 24 hours prior to challenge, creating a subclinical inflammatory response in which there is no visible middle ear effusion. Thirty-five microliters of test substance (SAL + LPS, OLO + LPS, or AZE + LPS) were injected into the middle ear at 0, 2, and 4 hours. Effusion was collected at 2, 4, and 6 hours. Statistical analysis was performed on effusion volume and albumin concentration., Results: Significant increase in effusion volume with respect to time was noted for the SAL + LPS group, whereas the AZE + LPS group demonstrated a decrease. Intergroup comparison revealed a significant decrease in effusion volume at hour 6, with both AZE and OLO less than LPS alone. A significant decrease in albumin concentration over time was noted in the AZE group. Intergroup comparison revealed a significant difference inalbumin concentration at hour 6, with OLO significantly lower than LPS., Conclusions: Ototopical antihistamines are effective in reducing effusion volume and albumin concentration in LPS-induced otitis media in an allergic rat model. This finding supports the hypothesis that ototopic antihistamines may prove effective in treating patients with allergy-induced eustachian tube dysfunction.

Children who had acute otitis media and were treated with levofloxacin were assessed for the emergence of fluoroquinolone-resistant Streptococcus pneumoniae. Nasopharynx cultures were obtained from patients at the entry to and during levofloxacin therapy. All nasopharynx isolates (n = 59) from 12 children were levofloxacin susceptible without parC/E or gyrA/B mutations. Pneumococcal nasopharynx persistence was not associated with levofloxacin resistance.

Objective: The aim of the present study was to investigate the dose-related effectiveness of corticosteroids in the management of otitis media with effusion, by using the objective assessment techniques of tympanometry and cytokine measurement., Materials and Methods: The eustachian tubes of 42 male rats were obstructed. Thirty-six subjects with effusion were randomly divided into three equal groups: controls; 0.5 mg/kg/day corticosteroid; and 1 mg/kg/day corticosteroid. Concentrations of interleukin-1beta and tumour necrosis factor alpha in the middle-ear effusions were analysed using enzyme-linked immunosorbent assay., Results: An effusion occurred on the 14th post-operative day and was present on the 30th post-operative day in the control group. Otomicroscopic examination and tympanometric measurement showed an improvement in the intervention groups. There was a significant difference between both intervention groups and the control group for both interleukin-1beta and tumour necrosis factor alpha concentrations (p 0.05)., Conclusion: The study confirmed a short term beneficial effect of systemic steroids on resolution of otitis media with effusion in a rat model. Our results support the theory that corticosteroids significantly decrease concentrations of both interleukin-1beta and tumour necrosis factor alpha. In our model, the 0.5 mg/kg corticosteroid dose was as effective as the 1 mg/kg corticosteroid dose. Further studies should be carried out to determine the optimal dose and duration of corticosteroids in the treatment of otitis media with effusion.

Diagnostic criteria for acute otitis media include rapid onset of symptoms, middle ear effusion, and signs and symptoms of middle ear inflammation. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common bacterial isolates from the middle ear fluid of children with acute otitis media. Fever, otalgia, headache, irritability, cough, rhinitis, listlessness, anorexia, vomiting, diarrhea, and pulling at the ears are common, but nonspecific symptoms. Detection of middle ear effusion by pneumatic otoscopy is key in establishing the diagnosis. Observation is an acceptable option in healthy children with mild symptoms. Antibiotics are recommended in all children younger than six months, in those between six months and two years if the diagnosis is certain, and in children with severe infection. High-dosage amoxicillin (80 to 90 mg per kg per day) is recommended as first-line therapy. Macrolide antibiotics, clindamycin, and cephalosporins are alternatives in penicillin-sensitive children and in those with resistant infections. Patients who do not respond to treatment should be reassessed. Hearing and language testing is recommended in children with suspected hearing loss or persistent effusion for at least three months, and in those with developmental problems.

Today, 65 % of all infections are regarded as a consequence of local biofilms. In Otorhinolaryngology frequent diseases including chronic tonsillitis, chronic sinusitis, otitis media with effusion and cholesteatomas fulfill the clinical criteria of biofilm-associated diseases such as recalcitrant disease, inefficiently treated with long-term antibiotics. Apart from affecting a great proportion of our clinical spectrum, ENT-specialist frequently insert implants into ventilated area such as trachea, middle ear and paranasal sinuses, all susceptible for biofilm attachment. In short, relevant characteristics of biofilms and their development are summarized, clinical knowledge of otorhinolaryngologic diseases is presented and current and future therapeutic approaches are discussed.

Objective: Our main aim is to analyze the bacterial involvement in otitis media with effusion (OME) and its effect on antimicrobial therapy., Patients and Method: A prospective study is carried out on a total of 70 children from 1 to 12 years of age distributed in 2 groups: the first is a control group of 30 healthy children and the second group comprises 40 children with OME. The surgical samples obtained from the middle ear were processed for bacterial analysis., Results: In 72.5 % of OMEs, the bacterial cultures were positive. The micro-organisms isolated were: Alloiococcus otitidis (48.27 %), followed by Haemophilus influenzae not serotype B (17.24 %), Staphylococcus aureus (n = 2), and Streptococcus pneumoniae (n = 1)., Conclusions: In the healthy ear, the ear cavity is sterile. In most OMEs, bacteria such as Alloiococcus otitidis are identified. Knowing which bacterium is involved is essential for the prognosis and treatment of otitis media with effusion, as the high frequency of its presentation may be linked to the aetiology and/or course of the process in many patients.

Discharge from the ear is one of the commonest symptoms of infections of the ear. To study the major strains of bacteria encountered in ear discharges, this study was conducted from July 1999, to June 2001 in the microbiology laboratory of Om Hospital. A total of 115 patients, of 6-35 years of age clinically diagnosed as discharging otitis media were studied. In 60.9% single organism and in 26.08% two organisms were isolated. Results revealed that, Staphylococcus aureus (34.3%), Klebsiella pneumoniae (24.3%), Pseudomons aeruginosa (22.8%), Enterobacter sps (7.1%), Esch coli (4.3%), Citrobacter sps (1.4%), Proteus sps (1.4%), Acinetobacter sps (1.4%) and Pneumococci (1.4%) were the common organisms in the discharge. Candida albicans (2.8%) was the pathogen in two cases. In 27.8% of cases the causative agent was not demonstrated. About sixty percent (65.9%), 64.8% and 56.0% of the isolates were sensitive to amikacin, ciprofloxacin and gentamycin respectively.

Various topical preparations are widely used for treating external otitis, acute otitis media with perforation, post-tympanostomy tube otorrhea, and chronic suppurative otitis media. Solutions and suspensions that enter the middle ear through a perforated tympanic membrane can reach the inner ear by crossing through the round window membrane. The safety of various components of otic solutions used in this way, particularly aminoglycosides, corticosteroids, solvents, and preservatives, has been questioned in light of their ototoxic potential. The authors' objective is to review the literature discussing the safety of commonly used classes of otic preparations in settings in which the constituents can access the middle and inner ear in high concentrations and discuss their clinical experience with ototoxicity and experience with medical-legal issues.

The "wait and see" approach in acute otitis media (AOM), consisting of postponing the antibiotic administration for a few days, has been advocated mainly to counteract the increased bacterial resistance in respiratory infections. This approach is not justified in children less than 2 years of age and this for several reasons. First, AOM is an acute inflammation of the middle ear caused in about 70% of cases by bacteria. Redness and bulging of the tympanic membrane are characteristic findings in bacterial AOM. Second, AOM is associated with long-term dysfunction of the inflamed eustachian tube (ET), particularly in children less than 2 years of age. In this age group, the small calibre of the ET together with its horizontal direction result in impaired clearance, ventilation and protection of the middle ear. Third, recent prospective studies have shown poor long-term prognosis of AOM in children below 2 years with at least 50% of recurrences and persisting otitis media with effusion (OME) in about 35% 6 months after AOM. Viruses elicit AOM in about 30% of children. A prolonged course of AOM has been observed when bacterial and viral infections are combined because viral infection is also associated with ET dysfunction in young children. Bacterial and viral testing of the nasopharyngeal aspirate is an excellent tool both for initial treatment and recurrence of AOM. Antibiotic treatment of AOM is mandatory in children less than 2 years of age to decrease inflammation in the middle ear but also of the ET particularly during the first episode. The best choice is amoxicillin because of its superior penetration in the middle ear. Streptococci pneumoniae with intermediary bacterial resistance to penicillin are particularly associated with recurrent AOM. Therefore the dosage of amoxicillin should be 90 mg/kg per day in three doses. In recurrent AOM with beta-lactamase-producing bacilli, amoxicillin should be associated with clavulanic acid at a dose of 6.4 mg/kg per day. The duration of the treatment is not established yet but 10 days is reasonable for a first episode of AOM. OME may be a precursor initiating AOM but also a complication thereof. OME needs a watchful waiting approach. When associated with deafness for 2-3 months in children over 2 years of age, an antibiotic should be given according to the results of the bacterial resistance in the nasopharyngeal aspirate. The high rate of complications of tympanostomy tube insertion outweighs the beneficial effect on hearing loss. The poor results of this procedure are due to the absence of effects on ET dysfunction. Pneumococcal vaccination has little beneficial effects on recurrent AOM and its use in infants needs further studies. Treatment with amoxicillin is indicated in all children younger than 2 years with a first episode of AOM presenting with redness and bulging of the tympanic membrane. Combined amoxicillin and clavulanic acid should be given in patients with beta-lactamase-producing bacteria. The duration of treatment is estimated to be at least 10 days depending on the findings by pneumo-otoscopy and tympanometry. Bacterial and viral testing of the nasopharyngeal aspirate is highly recommended particularly in children in day care centres as well as for regular follow-up. The high recurrence rate is due to the long-lasting dysfunction of the eustachian tube and the immune immaturity of children less than 2 years of age.

Objectives: Honey has had a valued place in traditional medicine for centuries. Renewed interest in honey for various therapeutic purposes, including treatment of infected wounds, has led to the search for different types of honey with antibacterial activity. In this study, we have assessed the antibacterial activity of different types of honey (manuka honey from Australia, heather honey from the United Kingdom, and locally marketed Indian honey)., Methods: The agar dilution method was used to assess the antibacterial activity of honey against 152 isolates of Pseudomonas aeruginosa by determining minimum inhibitory concentrations., Results and Conclusions: The locally available (khadikraft) honey produced the best activity against Pseudomonas aeruginosa and was found to be better than all of the imported varieties of therapeutic honey.

Objective: Bacterial biofilm formation has been implicated in the high rate of persistent otorrhea after tympanostomy tube insertion. In this study, we evaluated Pseudomonal biofilm formation from intractable post tympanostomy tube otorrhea in children., Materials and Methods: Twelve patients (seven males, five females) with unilateral post tympanostomy tube P. aeruginosa otorrhea were evaluated prospectively. All patients were treated with ciprofloxacin otic drops but the otorrhea failed to resolve. Ear discharge for culture was collected from the external auditory canal using a swab. The tympanostomy tubes were removed and collected for evaluation of biofilm formation using a scanning electron microscopy., Results: In all cases, ciprofloxacin-resistant P. aeruginosa was the only organism grown. The surface of the silicone tube contained undulations or microfissures throughout. The thick biofilms present on most tube surfaces were densities with no intervening spaces, consistent with biofilms., Conclusion: Biofilms can be directly observed by scanning electron microscopy. Therefore, our results demonstrate that bacterial aggregates called biofilms, that are resistant to treatment by antibiotics, can be detected by standard culture techniques, and may play a major etiologic role in posttympanostomy otorrhea.

Background: Biofilms present a new challenging concept in sustaining chronic, common antibiotic-resistant ear, nose, and throat (ENT) infections. They are communities of sessile bacteria embedded in a matrix of extracellular polymeric substances of their own synthesis that adhere to a foreign body or a mucosal surface with impaired host defense. The aim of this paper is to review the literature on ENT diseases that can be attributed to biofilm formation and to discuss options for future treatment., Materials and Methods: Literature review from Medline and database sources. Electronic links and related books were also included., Study Selection: Controlled clinical trials, animal models, ex vivo models, laboratory studies, retrospective studies, and systematic reviews., Data Synthesis: Biofilm formation is a dynamic five-step process guided by interbacterial communicating systems. Bacteria in biofilms express different genes and have markedly different phenotypes from their planktonic counterparts. Detachment of cells, production of endotoxin, increased resistance to the host immune system, and provision of a niche for the generation of resistant organisms are biofilm processes that could initiate the infection process. Effective prevention and management strategies include interruption of quorum sensing, inhibition of related genes, disruption of the protective extrapolymer matrix, macrolides (clarithromycin and erythromycin), and mechanical debridement of the biofilm-bearing tissues. With regard to medical indwelling devices, surface treatment of fluoroplastic grommets and redesign of cochlear implants could minimize initial microbial colonization., Conclusion: As the role of biofilms in human infection becomes better defined, ENT surgeons should be prepared to deal with their unique and tenacious nature.

Objective: To evaluate the effects of the ciprofloxacin-dexamethasone (CDX) combination ototopical treatment after myringotomy on tympanic membrane (TM) healing in ears with eustachian tube obstruction (ETO) and unobstructed ears., Study Design: Prospective, randomized, masked, controlled., Methods: ETO was created in the left ear of 30 rats to induce a model of otitis media with effusion (OME). After 3 weeks, bilateral myringotomy was performed (day 0). Animals were randomized into three groups to receive no treatment or bilateral once daily ototopical treatment with balanced salt solution (BSS, vehicle) or CDX for 13 days. Bilateral otomicroscopy was performed on days 7, 14, and 28. On day 14, five randomly selected animals per group were humanely euthanized and the TM harvested for histology. Three additional rats provided normal negative control ears for histologic comparisons., Results: On day 14, TM perforation healing rates were 100% in all ears of untreated and BSS-treated animals, 89% (8/9) in CDX-treated obstructed ears, and 30% (3/10) in CDX-treated unobstructed ears (P < .05 vs. BSS). On day 28, 100% (5/5) of the CDX-treated unobstructed ears and 80% (4/5) of the CDX-treated obstructed ears were healed. Histology showed initial TM thickening postmyringotomy in all ears but no significant qualitative differences between groups on day 28., Conclusion: Myringotomy healing was transiently modulated by treatment with CDX but proceeded normally after CDX discontinuation. This early modulation might enhance middle ear drainage and middle ear concentrations of CDX when tympanostomy tube surgery is performed in patients with active OME and ETO, thus potentially reducing otorrhea and preventing or treating infection. It would not be expected to increase the risk of premature tube extrusion or adversely affect normal healing of the TM after usual spontaneous extrusion.

Objective/hypothesis: Laser eustachian tuboplasty (LETP) combined with appropriate medical management will eliminate the chronic presence of middle ear effusions in selected patients., Methods: The study population consisted of 13 adults with otitis media with effusion (OME). Patients underwent slow-motion video endoscopy to identify the location and extent of surgical resection. A diode or argon laser was used to vaporize areas of hypertrophic mucosa and submucosa along the cartilaginous eustachian tube. Patients were evaluated at 6, 12, and 24 months. Successful outcome was defined as absence of OME. Patients with evidence of reflux disease or allergic rhinitis were treated with medical therapy before surgery and throughout the follow-up period as indicated., Results: LETP combined with medical management eliminated OME in 36% (4 of 11) of patients at 6 months, 40% (4 of 10) at 1 year, and 38% (3 of 8) at 2 years. Failure of LETP correlated with presence of laryngopharyngeal reflux (P = .01) or allergic disease (P = .05) for the results at 1 year but not at 2 years., Conclusions: LETP combined with appropriate medical management may be an effective treatment in select patients with chronic persistent eustachian tube dysfunction. A controlled trial with a larger number of subjects will be necessary to determine the efficacy of LETP and identify those factors predictive of successful outcome.

Objective: To investigate the curative effect of corticosteroid on acute otitis media (AOM) with middle ear effusion., Method: Forty-three children (43 ears) with AOM and abnormal tympanogram were enrolled in a prospective, randomized trial. Twenty-three cases (23 ears) were treated with Dexamethasone and Cefuroxime Sodium, while the other 20 cases (20 ears) were only treated with Cefuroxime Sodium., Result: The period of normalization of tympanometric findings in Dexamethasone treatment group was (54.6+/-6.2) days, which was much longer than that in the group without Dexamethasone treatment (38.5+/-6.1). Three months after treatment, the curative rate of Dexamethasone treatment group was higher than that of the group without Dexamethasone treatment., Conclusion: Corticosteroid can obviously improve middle ear effusion and shorten the duration of middle ear effusion of AOM in the first 2 weeks. To some extent, corticosteroid can also improve middle ear effusion in long term. It indicates that corticosteroid be used as an effective adjunctive drug in treating AOM with middle ear effusion.

Objectives/hypothesis: Our aim was to evaluate the combined effect of 5-fluorouracil (5-FU) and myringotomy for the treatment of otitis media with effusion (OME). OME is usually treated with medication, myringotomy, or insertion of a ventilation tube (VT). Except for VT insertion, however, treatment effects are short-lived. VT insertion has numerous sequelae: increased susceptibility to infection, large perforation of the tympanic membrane, cholesteatoma, and eventual hearing deterioration. We estimated the depressant action of 5-FU on normal cell proliferation in vitro. In addition, clinically, we assessed whether 5-FU has the potential to prolong the effect of myringotomy., Study Design: An in vitro study and a clinical study were conducted., Materials and Methods: In study I, fibroblasts harvested from the peritoneum of three green fluorescent protein transgenic mice were cultured with different doses of 5-FU. After 2 weeks, their proliferation rates were compared. In study II, patients (54 males, 47 females) were selected randomly from a group of patients with intractable OME. Myringotomy with or without a single dose of 5-FU ointment (approximately 0.10-0.30 mg) was performed in group I (n = 64) and group II (n = 37), respectively. The natural closure rates of the tympanic membrane were assessed in both groups., Results: In vitro, 5-FU inhibited the growth of fibroblasts in a dose-dependent manner. The average time to tympanic membrane closure was 20.5 days in group I and 8.1 days in group II. No adverse events were observed in either group., Conclusions: Topical application of 5-FU ointment is useful in prolonging the effect of myringotomy. 5-FU ointment therapy is easy, safe, and cost-effective and may be of wide application.

Objective: The pathogenesis of eosinophilic otitis media is not yet fully understood. The purpose of this paper is to describe the clinical course of our two patients with eosinophilic otitis media and to discuss the pathogenesis and treatment of this intractable condition., Methods: Two cases of eosinophilic otitis media were treated with ramatroban., Results: The middle ear effusion has been well controlled in both patients for more than 1 year with minimal corticosteroid therapy., Conclusions: Our experience suggests that the pathogenesis of eosinophilic otitis media is related to the pharmaceutical effects of ramatroban, i.e., inhibition of the thromboxane A2 receptor (TP) and the chemoattractant receptor-homologous molecule expressed on Th2 cells (CRTH2).

Background: Eosinophilic otitis media (EOM) is a newly recognized middle ear disease found in asthmatic patients. EOM is characterized by a highly viscous middle ear effusion that contains many eosinophils and is extremely unresponsive to conventional treatments for common otitis media. To our knowledge, no systemic study regarding the efficacy of treatments for EOM has been performed., Objective: To determine the effectiveness of instillation of triamcinolone acetonide, which is a suspension of steroids, into the mesotympanum and eustachian tube as a treatment for patients with EOM., Methods: We studied the efficacy of the instillation of triamcinolone acetonide in 43 ears of 24 patients with EOM. Efficacy was evaluated according to the length of the period without middle ear effusion or otorrhea. We also determined the otomicroscopic findings and the hearing levels before and after therapy. For controls, 27 ears of 14 patients treated by topical administration of betamethasone were similarly evaluated., Results: The middle ear effusion or otorrhea was controlled for more than 3 weeks after 1 instillation of triamcinolone acetonide in 35 ears, and the efficacy rate (81%) was significantly higher than that in the controls (7 ears, 26%). In the triamcinolone acetonide group, the average air conduction hearing level at the speech frequency range was significantly improved, and deterioration of the bone conduction hearing threshold was rarely found during therapy., Conclusion: The instillation of triamcinolone acetonide into the mesotympanum and eustachian tube is an effective treatment for patients with EOM.

Background: Otitis media with effusion (OME) is common and may cause hearing loss with associated developmental delay. Treatment remains controversial. The effectiveness of antihistamines, decongestants and antihistamine/decongestant combinations in promoting the resolution of effusions has been assessed by randomized controlled trials., Objectives: The objective of this review is to determine whether antihistamine, decongestant, or combination therapy is effective in treating children who present with OME., 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 2006), EMBASE (1974 to 2006), MEDLINE (1951 to 2006) and a gray literature database were searched using a search strategy created by an experienced medical librarian. The date of the last search was March 2006. Reference lists from included studies and relevant reviews were searched by hand; pharmaceutical manufacturers of antihistamines and decongestants and first authors of included studies were contacted to identify other potentially relevant studies., Selection Criteria: Randomized controlled trials (RCTs) using antihistamines, decongestants or antihistamine/decongestant combinations as treatment for OME in children were selected. We excluded trials that randomized on the basis of acute otitis media (AOM) even though OME was also studied in follow up., Data Collection and Analysis: Data were extracted from the published reports by two authors independently using standardized data extraction forms and methods. The methodological quality of the included studies was independently assessed by two authors. Dichotomous results were expressed as a relative risk with 95% confidence intervals using a fixed-effect model when homogeneous and a random-effects model when heterogeneous. Nearly all outcomes analysed were homogeneous. Continuous results were discussed qualitatively. Statistical analysis was conducted using RevMan software., Main Results: No statistical or clinical benefit was found for any of the interventions or outcomes studied. However, treated study subjects experienced 11% more side effects than untreated subjects (number needed to treat to harm = 9)., Authors' Conclusions: Because the pooled data demonstrate no benefit and some harm from the use of antihistamines or decongestants alone or in combination in the management of OME, we recommend against their use.

Objective: A model of otitis media with effusion (OME) has been developed in the Sprague-Dawley (SD) rat. This model was used to study the effects of an ototopic steroid and nonsteroidal anti-inflammatory drug (NSAID) on lipopolysaccharide (LPS)-induced OME., Study Design: Twenty-six rats were randomized into 4 groups: saline solution, LPS, NSAID + LPS, and steroids + LPS. Test substance was injected into the middle ear at 0, 2, and 4 hours. The effusion was collected at 2, 4, and 6 hours. Statistical analysis of effusion volume and albumin concentration was performed., Results: The LPS group demonstrated statistically significant increase in both effusion volume and albumin concentration compared with saline solution. Intergroup comparison revealed significantly less effusion volume in the steroid group and less albumin concentration in the NSAID group when compared with the LPS group., Conclusions: Transtympanic steroid reduced LPS induced middle ear effusion while NSAID reduced albumin concentration in the rat model., Significance: Our results lend support to the current use of anti-inflammatory ototopicals in the treatment of inflammatory middle ear disease.

Objective: Inflammatory mediators (IMs) play a major role in the production of middle ear effusion (MEE). Tumor necrosis factor (TNF)-alpha and leukotrienes (LTs) appear to be important in the pathogenesis of otitis media with effusion (OME). The purpose of this study is to determine the effect of TNF-alpha and LT antagonist on the outcome of experimental immune-mediated OME., Study Design: Prospective., Methods: Otitis media was induced in rats by injecting keyhole limpet hemocyanin (KLH) transtympanically 7 days after systemic immunization. Experimental groups were treated with soluble TNF receptor type I (sTNF RI) or oxatomide simultaneously. Seventy-two hours after transtympanic injection, MEE was aspirated, and temporal bone was taken. Vascular permeability (VP) of the middle ear mucosa was measured using the Evans blue dye technique. Hematoxylin-eosin stain and immunohistochemical stain for leukocyte common antigen was performed., Results: In KLH, sTNF RI, and oxatomide groups, MEE was developed in 83%, 0%, and 66% of the ears, respectively. The sTNF RI group showed significant decrease in effusion production, inflammation, mucosal thickening, and VP compared with the KLH group. These parameters were less significant in the oxatomide group than in the sTNF RI group., Conclusion: Transtympanic administration of sTNF RI and oxatomide appears to suppress the development of immune-mediated MEE.

Conclusion: The lipopolysaccharide (LPS)-induced chinchilla otitis media (OM) model was proven useful in screening anti-inflammatory agents for topical use. Both 1% rimexolone and 1% dexamethasone are effective in reducing the volume of middle ear effusion and mucosal thickness compared with control groups. Topical corticosteroid therapy was efficacious in reducing middle ear mucosal inflammation., Objective: OM is one of the most common diseases in the pediatric population. Our previous studies have shown that treatment with systemic antibiotics and corticosteroids was more efficacious than antibiotics alone. The purpose of this study was to determine the effectiveness of topically applied corticosteroids on the outcome of OM. The long-term goal of this study was to develop a better method of OM treatment by demonstrating effectiveness of topically applied anti-inflammatory agents, such as corticosteroids, avoiding systemic side effects., Materials and Methods: Three experimental groups were studied in chinchillas. OM with effusion was induced in all groups by injecting LPS. Group 1 consisted of controls in three subgroups as follows. Control-LPS alone, vehicle of dexamethasone (control-dexa), vehicle of rimexolone (control-rimex). Group 2 was treated with dexamethasone and included subgroups of separate concentrations of dexamethasone: 0.1% and 1% suspensions. Group 3 was treated with rimexolone and included subgroups of separate concentrations of rimexolone: 0.1% and 1% suspensions. A total of 58 animals were used: 18 for controls and 40 for experimental groups. All test substances (saline, control-dexa, control-rimex, dexamethasone and rimexolone, 200 microl) were injected at -2, 48 and 60 h; LPS was injected at 0 h. Animals were monitored by daily otomicroscopy. After 4 days, samples of middle ear effusion (MEE) were collected for analysis and temporal bones were harvested for histopathological studies., Results: At the end of 4 days, only in five ears (3/20 with 1% dexamethasone, 1/20 with 1% rimexolone, and 1/20 with 0.1% rimexolone) had the fluid diminished to the point of being unobservable. The volume of MEE, thickness of mucoperiosteum, and the degree of inflammation of middle ear mucosa with 1% dexamethasone and 1% rimexolone was significantly less compared with other groups.

Objective: To study the relationship between the fibrinogen content in middle ear effusion (MEE) and the protracted inflammation of secretory otitis media (SOM) and to explore the possible mechanism of batroxobin in treatment of SOM., Methods: The fibrinogen content of middle ear effusion from 156 patients with SOM was investigated with concretion technique at different stages. After two times punctuation of tympanum, the recurrence patients were randomly divided into two groups: batroxobin and dexamethasone group, and 0.5 ml (2 BU/ml) batroxobin or dexamethasone (2 mg/ml) was injected into middle ear cavity. The therapeutic effects were investigated., Results: The concentration of fibrinogen in the recurrence group of SOM patients was higher than that in the cured group, and even higher in the second recurrence group than in the first recurrence group (P < 0.01). There was significantly different (P < 0.001) in the therapeutic efficacy between the batroxobin group (91.6%) and the dexamethasone group (62. 5%); the difference of the fibrinogen content in MEE and air conduction of pure tone audiometry at frequencies (0.5, 1.0, 2.0 kHz) between the two groups after treatment were also significant (P < 0.01)., Conclusions: Fibrinogen may play a significant role in the occurrence and development of secretory otitis media. Batroxobin had better therapeutic effect on SOM than dexamethasone. The mechanism of batroxobin in the treatment of SOM may be that the batroxobin can relief the depressant effect of fibrinogen on surface active agents of the Eustachian tube and prevent the fibrinogen from turning into insoluble fibrin polymer by means of fibrinolysis.

Background: Acute otitis media (AOM) is a spontaneously remitting disease for which pain is the most distressing symptom. Antibiotics are now known to have less benefit than previously assumed., Objectives: To assess the effectiveness of topical analgesia for AOM., Search Strategy: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006), MEDLINE (1966 to May Week 3 2006), EMBASE (1990 to December 2005) and LILACS (1982 to September 2005) without language restriction, and the reference lists of articles. We also contacted manufacturers and authors., Selection Criteria: Double-blind randomised or quasi-randomised controlled trials comparing an otic preparation with an analgesic effect (excluding antibiotics) versus placebo or an otic preparation with an analgesic effect (excluding antibiotics) versus any other otic preparation with an analgesic effect, in adults or children presenting at primary care settings with AOM without perforation., Data Collection and Analysis: Potential studies were screened independently and trial quality was assessed by three authors, and differences were resolved by discussion. Data was then independently extracted from the trials selected by two authors. We contacted the authors of three trials to acquire additional information not available in published articles., Main Results: Our searches yielded 356 records; four trials met our criteria. One trial with 54 participants compared treatment with anaesthetic ear drops versus an olive oil placebo immediately at diagnosis. All patients were also given paracetamol. There was a statistically significant pain reduction of 25% in those receiving anaesthetic drops 30 minutes after instillation. Three trials (with one common co-author) compared anaesthetic ear drops with naturopathic herbal ear drops in 274 patients. One of these trials also used antibiotics in both groups. There were statistically significant differences at instillation of drops, or 15 or 30 minutes after the instillation (or both) on one to three days after diagnosis, always favouring the naturopathic group in each trial., Authors' Conclusions: The evidence from these four randomised controlled trials, only one of which addresses the most relevant question of primary effectiveness, is insufficient to know whether ear drops are effective or not.

Background: Otitis media with effusion (OME) is common and may cause hearing loss with associated developmental delay. Treatment remains controversial., Objectives: To examine evidence for or against treating children with hearing loss associated with OME with systemic or topical intranasal steroids., Search Strategy: We searched the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 4 2005, MEDLINE (1966 to 2006), EMBASE (1974 to 2006), and the CINAHL, LILACS, Zetoc, IndMED, SAMED, KoreaMed, MEDCARIB and Cambridge Scientific Abstracts databases in January 2006., Selection Criteria: Randomised controlled trials of oral and topical intranasal steroids, either alone or in combination with another agent such as an antibiotic, were included., Exclusions: publications in abstract form only; uncontrolled, non-randomised or retrospective studies; studies reporting outcomes with ears (rather than children)., Data Collection and Analysis: Data were extracted from the published reports by the authors independently using standardised data extraction forms and methods. The methodological quality of the included studies was independently assessed by the authors as described in the Cochrane Handbook. Dichotomous results were expressed as an odds ratio using a fixed-effect model together with the 95% confidence intervals. Continuous data were analysed using the weighted mean difference in a fixed-effect model. Tests for heterogeneity between studies were performed using a Mantel-Haenszel approach. In trials with a cross-over design, post cross-over treatment data were not used., Main Results: No study prospectively documented hearing loss associated with OME prior to randomisation. Follow up was mainly short term. The odds ratio for OME persisting after short-term follow up in children treated with oral steroids compared to control was 0.22 (95% CI 0.08 to 0.63). The odds ratio for OME persisting after short-term follow up for children treated with oral steroids plus antibiotic compared to control plus antibiotic was 0.37 (95% CI 0.25 to 0.56). However, there was significant heterogeneity between studies included in the latter comparison (P < 0.01). Trends favoured steroids for most other comparisons, but confidence intervals included unity. There was no evidence of benefit for steroid treatment for OME or hearing loss associated with OME in the longer term., Authors' Conclusions: Both oral and topical intranasal steroids alone or in combination with an antibiotic lead to a quicker resolution of OME in the short term, however, there is no evidence of longer term benefit.

Allergy and otitis media with effusion are often considered as comorbidities. Evidence points to a role for allergy in the pathogenesis of otitis media with effusion in reports of increased prevalence of allergy in patients with otitis media with effusion and presence of late-phase allergic-response inflammatory mediators and cytokines in the middle-ear effusion of allergic subjects. However, the exact mechanism remains unknown. Many speculations have been made, but well-controlled studies to prove the efficacy of anti-allergic medication in the treatment of otitis media with effusion are lacking. Therefore, we do not recommend the use of glucocorticosteroids in allergic patients with otitis media with effusion.

Objective: Published data indicates that antibiotic use for pediatric respiratory tract infections has declined across the United States. We reviewed antibiotic use in 2 pediatrics practices in Memphis, Tennessee, to determine whether there has been a reduction in inappropriate antibiotic use in this region., Methods: Randomly selected charts in 7 offices of 2 practices were reviewed for respiratory tract infection visits during alternate years between 1992 and 2002. Antibiotics were considered inappropriate for viral respiratory tract and other viral syndromes, asthma, allergic rhinitis, and otitis media with effusion. Changes in inappropriate prescribing were evaluated by generalized estimating equations with year of visit as the explanatory variable and visits clustered by practice., Results: There were 1504 unique patient visits reviewed. The number of visits with an antibiotic prescription fell from 85% in 1992 to 67% in 2002. The likelihood of inappropriately prescribing an antibiotic declined between 1992 and 2002 (odds ratio 0.28, 95% confidence interval 0.20-0.38). Use of amoxicillin-clavulanic acid and azithromycin increased, and amoxicillin use decreased., Conclusions: There has been a marked decline in inappropriate antibiotic use in this region with high prescribing rates. Pediatricians have increased their use of broad-spectrum antibiotic agents for respiratory tract infections. Continuing education of physicians regarding appropriate use should continue to maintain and improve on the gains achieved in the last decade.

Objectives: Topical steroid treatment can be a powerful alternative to surgery in controlling adenoid hypertrophy and otitis media with effusion (OME)., Methods: A prospective, controlled, randomized, clinical study in an academic tertiary care center. A total of 122 children (3-15-year-old) on the waiting list for an adenoidectomy and/or ventilation tube placement were enrolled into the study and control groups. The study group (67 patients with adenoid hypertrophy, 34 of them with otitis media with effusion) received intranasal mometasone furoate monohydrate 100 mcg/day, and the control group (55 patients with adenoid hypertrophy, 29 of them with otitis media with effusion) was followed up without any treatment. All patients were evaluated at 0 and 6 weeks. The assessment of each patient included history, a symptom questionnaire, a skin prick test, a tympanogram, if possible a pure tone audiogram, and otoscopic and endoscopic examinations. The size of adenoid tissue was graded as a percentage according to obliteration of the choanae. The adenoid/choana ratio (A/C) was recorded for each patient. Symptoms were scored as 0 (absent), 1 (intermittent/periodic), or 2 (continuous). The data were analyzed with the "Statistical Package for the Social Sciences" (SPSS 9.0) using the appropriate nonparametric tests for nominal and ordinal data., Results: Resolution of otitis media with effusion in the study group (42.2%) was significantly higher than that in the control group (14.5%) (p<0.001). Forty-five patients (67.2%) with adenoid hypertrophy in the study group showed a significant decrease in adenoid size according to the endoscopic evaluation compared to the control group (p<0.001). A significant improvement in obstructive symptoms was seen in the study group (p<0.001). The endoscopically measured adenoid/choana ratio and degree of obstructive symptoms showed a significant correlation (r=0.838 p<0.001, r=0.879 p<0.001, r=0.838 p<0.001, r=0.879 p<0.001). The adenoid/choana ratio improved significantly in atopic patients in the study group (p<0.05), whereas in atopic patients in the control group there was no change (p=0.221)., Conclusion: Nasal mometasone furoate monohydrate treatment can significantly reduce adenoid hypertrophy and eliminate obstructive symptoms. It is a useful alternative to surgery, at least in the short term, for otitis media with effusion.

Conclusion: A high prevalence of penicillin-binding protein gene-mutated (PGM) strains of Haemophilus influenzae should be taken into account when treating otitis media in children., Objective: To evaluate the prevalence of beta-lactamase-non-producing ampicillin-resistant strains of H. influenzae with mutations in the ftsI gene encoding penicillin-binding protein 3 (PBP3) among children with otitis media., Material and Methods: A total of 644 nasopharyngeal isolates of H. influenzae were collected from pediatric acute otitis media patients with or without otitis media with effusion at the clinics of the Department of Otolaryngology-Head and Neck Surgery, Wakayama Medical University Hospital and 6 affiliated hospitals in Wakayama Prefecture between January 1999 and December 2003. MICs to ampicillin (AMP), cefdinir (CFD), cefaclor (CCL), cefpodoxime (CPD) and cefcapene (CFPN) were determined by a microbroth dilution method according to the recommendations of the National Committee for Clinical Laboratory Standards. Types of mutations in the PBP3 gene (ftsI) were evaluated by means of a polymerase chain reaction (PCR)-based genotyping method. The beta-lactamase gene (bla) was also identified by means of PCR., Results: Beta-lactamase-producing (BLP) strains having the bla gene were identified in 16 isolates (2.5%). PGM strains were identified in 279 isolates (43.3%). There were 242 PGM1-non-BLP strains (37.6%) with mutations in the variable mutated locus of ftsI, 35 PGM2-non-BLP strains (5.4%) with mutations in the highly mutated locus of ftsI and 2 BLP-PGM strains (0.3%) with mutations in ftsI that produced beta-lactamase. BLP-non-PGM strains producing beta-lactamase without mutations in ftsI were identified in 14 isolates (2.2%). MICs of PGM1-non-BLP strains to AMP were 0.5-2.0 microg/ml. The MIC90 of CDN to the PGM1-non-BLP strains was the lowest (0.06 microg/ml). The proportion of PGM1-non-BLP strains increased rapidly during 1999-2002 and then decreased in 2003. In contrast, the proportion of PGM2-non-BLP strains increased in 2003.

Objectives: We evaluated the in vitro antibacterial activity of amoxicillin against penicillin-susceptible and -nonsusceptible Streptococcus pneumoniae strains isolated from children with acute otitis media (AOM)., Methods: Children more than 3 months of age with AOM who were seen in the Dr Sótero del Rio and Luis Calvo Mackenna Hospitals in Santiago, Chile, between July 1998 and December 2002 were subjected to tympanic puncture for middle ear fluid culture. The penicillin and amoxicillin susceptibilities of the S pneumoniae isolates were determined by epsilometer test (E test)., Results: A bacterial pathogen was isolated in 432 of 543 children (80%) as follows: S pneumoniae, 40%; Haemophilus influenzae, 29%; Moraxella catarrhalis, 7%; and Streptococcus pyogenes, 4%. Penicillin-susceptible S pneumoniae strains were less common than amoxicillin-susceptible strains (60% versus 95%; odds ratio [OR], 0.08; 95% confidence interval [CI], 0.04 to 0.18). Both intermediate- and high-resistance strains were more common for penicillin (22% versus 4.5%; OR, 5.6; 95% CI, 2.5 to 12.7) than for amoxicillin (18% versus 0.5%; OR, 41.3; 95% CI, 6.0 to 821)., Conclusions: Penicillin resistance is not extrapolable to amoxicillin among S pneumoniae strains isolated from middle ear fluid of children with AOM. Our results support the recommendation to evaluate the minimal inhibitory concentrations of penicillin-nonsusceptible S pneumoniae for amoxicillin and to continue use of this antimicrobial as a first-line antimicrobial choice for children with AOM.

Background: Disappearance of middle ear effusion is one of the most important outcomes in the treatment of acute otitis media (AOM)., Aim: To evaluate the duration of effusion in AOM treated by antimicrobials and to find factors influencing it., Methods: Parents of 90 children with AOM monitored daily the disappearance of effusion with tympanometry. The children were randomly allocated to be treated with either oral amoxicillin or cefuroxime-axetil for 10 d. Daily monitoring lasted for 14 d or until the tympanogram was normal (curve A or C) in both ears. Pneumatic otoscopy was carried out every 2 wk., Results: Normal tympanograms were obtained after a median time of 7.5 d (range 1-58 d) among 75 successfully monitored patients. In two-thirds (69%) of them, effusion resolved in 14 d. The median duration of effusion did not differ significantly between the two treatment groups (8 vs 7 days, p=0.7). The children who had unilateral AOM cured more rapidly than those with bilateral AOM (5 vs 19 d, p<0.001). In logistic regression analysis adjusted for age, bilaterality explained treatment failure at 2 wk with an odds ratio of 28.1 (95% CI 4.6-169.5, p<0.001)., Conclusion: The choice of antimicrobials did not influence the duration of middle ear effusion, which was much shorter than had been thought previously. Children with unilateral AOM were cured much more quickly than those with bilateral AOM.

Acute otitis media (AOM) and otitis media with effusion (OME) are common diseases in childhood. Alloiococcus otitidis is a newly recognized species of gram-positive bacterium which was recently discovered as a pathogen associated with OME. Although some studies show that A. otitidis is frequently detected in children with OME, no study is available concerning the clinical efficiency of antibiotics against this organism. The prevalence of A. otitidis in 116 middle ear effusion specimens from 36 AOM and 52 OME patients was examined by culture and PCR. In addition, the prevalence of the bacterium was retrospectively investigated in relation to antibiotic use. A. otitidis was detected in 20 (50%) AOM and 47 (61%) OME specimens. The organism was the most frequent bacterium in AOM as well as in OME and was highly detected even in patients who had been treated with antibiotics, such as beta-lactams or erythromycin. The incidence of A. otitidis in our study was higher than that in Western countries, and our results suggest that drug-resistant strains of A. otitidis may be frequently spread in Japanese children. Our study suggests that antibiotics such as beta-lactams or erythromycin may not be sufficiently effective to eliminate this organism. Further investigation is expected to reveal the clinical role of the organism in otitis media.

Background: Given the relatively high prevalence of recurrent and persistent acute otitis media (AOM) and the prominent etiologic role of Streptococcus pneumoniae, especially penicillin-nonsusceptible strains in children with these conditions, new alternative treatments are desirable., Methods: Children 6 months-4 years of age with AOM considered to be at risk for recurrent or persistent infection received large dosage cefdinir 25 mg/kg oral suspension once daily for 10 days. Children were evaluated pretreatment (day 1), on therapy (days 4-6), end of therapy (days 12-14) and at follow-up (days 25-28). All children had tympanocentesis at enrollment. In culture-positive children, tympanocentesis was repeated after 3-5 days (days 4-6) unless evidence of absence of middle ear effusion was documented., Results: Of 447 children enrolled, 230 were clinically and bacteriologically evaluable (74% 2 years old or younger; 57% treated for AOM in previous 3 months). Bacteriologic eradication, based on repeat tympanocentesis on days 4-6, was achieved in 74% (170 of 230) of children; 76% (201 of 266) of AOM pathogens were eradicated. Eradication of penicillin-susceptible, -intermediate and -resistant S. pneumoniae was 91% (50 of 55), 67% (18 of 27) and 43% (10 of 23), respectively (P < 0.001); eradication of H. influenzae was 72% (90 of 125). Overall clinical response at days 12-14 was 83% (76 and 82% for children with S. pneumoniae and Haemophilus influenzae, respectively). Sustained clinical response at days 25-28 was 85%. Clinical response was 83% for culture-positive children versus 96% for culture-negative children at baseline tympanocentesis (P < 0.001)., Conclusions: In this study of AOM among children at risk for persistent or recurrent infection, large dose cefdinir resulted in an overall successful clinical response at end of treatment of 83%. This regimen was efficacious against penicillin-susceptible S. pneumoniae, but effectiveness was markedly decreased against nonsusceptible strains and was moderate for H. influenzae strains.

The inhibitory effects of ketotifen, a histamine H1-receptor antagonist and mast cell stabilizer, were examined on a non-IgE experimental model of middle ear effusion. Thirty rats were divided into three groups. Group A (n = 9) was subjected to mechanical stimulation of the external auditory canal (EAC); group B (n = 11) was pre-treated with intraperitoneal administration of 0.2 mg ketotifen, 90 min before mechanical stimulation of the EAC; and group C (n = 10), the control group, was neither exposed to mechanical stimulation nor given ketotifen. Thirty minutes after completion of the experiment, the eardrums were inspected, histamine levels were determined by a fluorometric assay, and the pars flaccida underwent histological assessment. An attic effusion was observed in group A; a similar phenomenon but to a lesser extent was also seen in group B. Statistical analysis confirmed that the mean histamine concentration of the rinsing fluid obtained from group A was significantly higher than that of group C (p = 0.004) or group B (p = 0.008). No significant difference was found between the mean histamine concentration of groups C and group B (p = 0.311). Histological assessment revealed that the thickness of the pars flaccida of group A was considerably greater than that of groups C and B and was characterized by marked edema. Furthermore, the pars flaccida mast cell population was significantly depleted compared with groups C and B. The data indicate that mechanical stimulation of the EAC triggered the pars flaccida mast cells to degranulate in a non-mediated IgE fashion and that histamine is implicated in most of these histological changes. It is concluded that administration of ketotifen before mechanical stimulation of the EAC had a stabilizing effect and abolished mast cell degranulation, therefore, may be considered as a potential therapeutic agent for the treatment of middle ear disease in the pediatric population.

Infection with methicillin-resistant Staphylococcus aureus (MRSA) is increasing. It may be community or hospital acquired and is characteristically difficult to eradicate. Here we report a case of a two-year-old girl who sustained a traumatic tympanic membrane perforation following a minor burns injury. She was seen as an out-patient in a burns unit and subsequently developed MRSA otorrhoea. This was treated with a two-week course of fusidic acid topical drops. At three-week follow up the tympanic membrane had healed and the infection had healed completely. Fusidic acid is safe and effective in the treatment of MRSA otorrhoea. We need to maintain vigilance in the treatment of otorrhoea, as MRSA may become an increasingly common pathogen in the future.

Background: Secretory otitis media is a common otological manifestation, that most of the time is left undiagnosed on account of unawarenes s and negligence in seeking early medical attention for trivial ailments. Untreated, it might end up in serious consequences in the form of poor speech and intellectual development and permanent anatomical disabilities within middle ear cleft. The objectives of the study were to determine most affected age group, the common etiological factors. to access the efficacy of medical and surgical treatment and finally to find out the coumplication associated with the surgical procedures., Methods: This study was conducted in the ENT, Head and Neck Surgery department of the Ayub Teaching Hospital, Abbottabad from January 2001 to December 2003. Only the diagnosed cases of SOM were included in the study. After detailed history, clinical examination, routine investigations and special investigations such as pure tone audiogram and tympanometry were carried out to confirm the diagnosis of SOM . All patients were initially treated by medical therapy. In cases of failure, underwent myringotomy with or without ventilation tube insertion and where indication present adenotonsillectomy and antial lavage was done. Follow up of cases was carried out from 18-24 months., Results: It included 87 patients, 58 were males (66.6%) and 29 females (33.3%). Majority of the patients were between 5-8 years (62%). The most common aetiological factor was rhinosinusitis (36.7%) followed by hypertrophic adenoids (34.5%). All patients were initially given medical treatment. Out of 87 patients,30 patients (34.4%) improved and 57 patients (65.5%) had no response and underwent surgery. Surgical procedures included myringotomy with and without ventilation tube insertion., adenotonsillectomy and antral lavage., Conclusion: lt is concluded from this study that conservative treatment has a definite role and should be tried before any surgical step is taken however surgery is the treatment of choice in more resistant cases.

The management of otitis media with effusion (OME) has received much attention recently as a result of, among other factors, the development of resistant bacteria and the finding of less long-term impact of middle-ear effusion (MEE) on development than previously believed. Guidelines have recently been published for the management of OME promoting more accurate diagnosis, particularly distinguishing acute otitis media from OME, and recommending the 'judicious' use of antibacterials. Today, more emphasis is being placed on prevention of disease by reducing risk factors and the development of vaccines. The identification of susceptibility genes may lead to better understanding of the pathogenesis of otitis media, which in turn may lead to the development of more innovative and satisfactory methods for prevention and treatment.

Cytomegalovirus (CMV) belongs to Herpesvirida family and it occurs quite frequently in the human environment. It is a very important pathogen in persons with suppressed or lowered resistance. Having special kindship with epithelium, it may cause primary infection or reveal secondary influence in the latent form. Congenital CMV infection is a major cause of sensorineural hearing loss and neurological impairment in children. Otogenic complications may develop in patients with viral infection immunodeficiency. Aim of the paper was assessment of lateral sinus thrombosis (LST) in children with acute otitis media (AOM) and CMV infection. Authors present a case of LST in 5-year old child with AOM with mastoiditis and acquired CMV infection. In the first phase a disease appeared as mononucleosis-like infection with developing neurological signs resulting from meningitis. In the second phase the signs of acute otitis media, mastoiditis and lateral sinus thrombosis increased. Despite broad spectrum antibiotics therapy the intracranial complication developed which was surgically treated with good outcome. All the symptoms resulting from mastoiditis, LST and meningitis ceased. Clinical symptoms of the secondary CMV infection are rare in children. Complications may develop despite proper treatment of the ear and throat infections, and may result from immunodeficiency after CMV infection.

Acute otitis media (AOM) is treated with antibiotics in the United States, but the changing distribution of bacterial pathogens that cause the disorder can present physicians with several challenges. Most physicians treat AOM empirically, and their treatment choice should target Streptococcus pneumonia, nontypeable Haemophilus influenzae, and Moraxella catarrhalis, as those bacteria are most often isolated in AOM. First-line treatment for new onset AOM remains amoxicillin (80-90 mg/kg/d, divided twice daily). For persistent or recurrent AOM, guidelines recommend high-dose amoxicillin-clavulanate, cefdinir, cefprozil, cefpodoxime, cefuroxime, or ceftriaxone. Improved diagnosis and optimizing the choice of therapy by considering in vitro and in vivo efficacy of the different antibiotics will improve patient outcomes. Improved patient outcomes will result in fewer AOM episodes, decreased antibiotic resistance, and reduced direct and indirect health care costs.

Objective: To observe the clinical efficacy of Qingqiao Capsule (QQC) in treating patients with secretory otitis media (SOM)., Methods: A total of 90 patients were randomly assigned into the treated group (n = 45) and the control group (n = 45). Patients in the treated group were administrated with QQC, 5 capsules each time, 3 times a day for totally 10-14 days, and those in the control group were given per os cefaclor capsules 0.5 g each time for adult, 3 times a day, or 20 mg/(kg.d) for children, for 10-14 days. The therapeutic efficacy of treatment on the patients was observed and compared after treatment and followed up for 3-6 months., Results: (1) The clinical efficacy in the treated group was superior to that in the control group with significant statistical difference (P < 0.01); (2) Comparison of the efficacies in patients of three different TCM syndrome types (the external pathogenic wind invasion caused auditory orifice stuffiness type, the Gan-Dan damp-heat steaming up auditory orifice type and the Pi-deficiency dysfunction induced dirty dampness blocking ear type) showed no statistically significant difference (P > 0.05); (3) The vanishing rate and time needed of the main symptoms and signs in the treated group were superior to those in the control group on ear muffle, tinnitus, hearing impairment, hydrotypanum, pure tone threshold and abnormal tongue figure, and the difference was statistically significant (P < 0.05 or P < 0.01), only those of earache, otopiesis and abnormal pulse figure were insignificantly different between the two groups (P > 0.05)., Conclusion: QQC is an effective Chinese composite medicine on patients with SOM, and shows no obvious adverse reaction.