Treatment Protocol for Management of Bacterial and Fungal Malignant External Otitis

High rates of negative microbiologic test results highlight the potential role of empiric antimicrobial agents in management of malignant otitis externa (MOE) | Annals of Otology, Rhinology & Laryngology

Aims: This study investigates the clinical presentation, laboratory findings, and response to empiric treatment in a large group of patients admitted to a tertiary academic hospital in Tehran, Iran.

Methods and Materials: We recruited 224 patients diagnosed with MOE in a prospective observation from 2009 through 2015. All patients received a 2-agent antibacterial regimen at baseline (phase I). Patients with no improvement within 10 days and/or nonresponders to a second course of antibacterials were switched to antifungals (phase II). Response to treatment was observed and documented in both groups.

Results: All patients had physical symptoms for more than 12 weeks before admission. In total, 127 patients responded well to antibacterials. Eighty-seven out of 97 patients who were switched to antifungals had complete response to treatment; patients in the latter group had significantly higher A1C levels at baseline.

Conclusion: Our findings provide evidence to develop clinical guidelines that accelerate diagnosis and treatment of MOE to improve patient outcomes.

Full reference: Hasibi, M. et al. (2017) A Treatment Protocol for Management of Bacterial and Fungal Malignant External Otitis: A Large Cohort in Tehran, Iran. Annals of Otology, Rhinology & Laryngology. 126(7) pp. 561 – 567

Effectiveness of Tympanostomy Tubes for Otitis Media

Tympanostomy tube placement is the most common ambulatory surgery performed on children in the United States| Pediatrics

Objectives: The goal of this study was to synthesize evidence for the effectiveness of tympanostomy tubes in children with chronic otitis media with effusion and recurrent acute otitis media.

Results: Children with chronic otitis media with effusion treated with tympanostomy tubes compared with watchful waiting had a net decrease in mean hearing threshold of 9.1 dB (95% credible interval: −14.0 to −3.4) at 1 to 3 months and 0.0 (95% credible interval: −4.0 to 3.4) by 12 to 24 months. Children with recurrent acute otitis media may have fewer episodes after placement of tympanostomy tubes. Associated adverse events are poorly defined and reported.

Conclusions: Tympanostomy tubes improve hearing at 1 to 3 months compared with watchful waiting, with no evidence of benefit by 12 to 24 months. Children with recurrent acute otitis media may have fewer episodes after tympanostomy tube placement, but the evidence base is severely limited. The benefits of tympanostomy tubes must be weighed against a variety of associated adverse events.

Full reference: Steele, D.W. (2017) Effectiveness of Tympanostomy Tubes for Otitis Media: A Meta-analysis. Pediatrics. 139 (6) e20170125

Outcome and cost analysis of bilateral sequential same-day cartilage tympanoplasty

Olusesi, A.D. et al. & Oyeniran, O. (2017) The Journal of Laryngology & Otology. 131(5)  pp. 399-403

Few studies have compared bilateral same-day with staged tympanoplasty using cartilage graft materials.

A prospective randomised observational study was performed of 38 chronic suppurative otitis media patients (76 ears) who were assigned to undergo bilateral sequential same-day tympanoplasty (18 patients, 36 ears) or bilateral sequential tympanoplasty performed 3 months apart (20 patients, 40 ears). Disease duration, intra-operative findings, combined duration of surgery, post-operative graft appearance at 6 weeks, post-operative complications, re-do rate and relative cost of surgery were recorded.

Tympanic membrane perforations were predominantly subtotal (p = 0.36, odds ratio = 0.75). Most grafts were harvested from the conchal cartilage and fewer from the tragus (p = 0.59, odds ratio = 1.016). Types of complication, post-operative hearing gain and revision rates were similar in both patient groups.

Surgical outcomes are not significantly different for same-day and bilateral cartilage tympanoplasty, but same-day surgery has the added benefit of a lower cost.

Read the full abstract here

Paediatric hearing loss

Nieto, H. et al. (2017) BMJ. 356:j803

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What you need to know:

  • Take paediatric hearing loss seriously, especially if neonatal screening has been missed

  • Conductive hearing loss is most commonly caused by glue ear, usually a transient disease

  • All children who have had bacterial meningitis should have a follow-up hearing test

Paediatric hearing loss is a common problem; diagnosis and appropriate intervention are central to the child’s development. It is estimated that one in five children of around 2 years will have been affected by glue ear and eight in 10 will have been affected once or more by the age of 10.

Read the full ’10-Minute Consultation’ article here

Cost-Effectiveness of Watchful Waiting in Acute Otitis Media

Sun, D. et al. (2017) Pediatrics. 139(4) e20163086

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Background: American Academy of Pediatrics guidelines for acute otitis media (AOM) allow for children meeting certain criteria to undergo watchful waiting (WW). The cost-effectiveness of this policy has not been evaluated in the United States.

 

Conclusions: WW for AOM management is cost-effective. Implementing WW may improve outcomes and reduce health care expenditures.

Read the full abstract here

Shortened Antimicrobial Treatment for Acute Otitis Media

Vincen, D.R. (2017) New England Journal of Medicine. 376:e24

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Hoberman et al. (Dec. 22 issue)1 conducted a well-designed trial that showed that a 10-day course of amoxicillin–clavulanate was superior to a 5-day regimen in children 6 to 23 months of age with acute otitis media. The investigators explain that they chose to study amoxicillin–clavulanate because it “is currently the most efficacious oral antimicrobial agent for the treatment of acute otitis media.”

But efficacy is not the only variable influencing such a treatment decision. High-dose amoxicillin is effective against common bacterial pathogens. It also has a favorable safety profile, a taste acceptable to children, a relatively low cost, and a narrower microbiologic spectrum than amoxicillin–clavulanate. It is this collective argument that professional societies around the world give for their recommendation of amoxicillin as the first-line agent for the treatment of acute otitis media in children.

Is it valid to infer that because a 10-day course of amoxicillin–clavulanate outperformed a 5-day course that similar results would follow if the antimicrobial agent under investigation were high-dose amoxicillin instead? If this inference is weak, why then did the investigators not study amoxicillin directly?

Read the full letter to the editor here

The original research article abstract is available here

Endoscopy-Assisted Ear Surgery for Treatment of Chronic Otitis Media

Ulku, H. The Journal of craniofacial surgery. Published online: March 2017

11574-2The objective of this study was to analyze the results of endoscopy-assisted ear surgery for the treatment of chronic otitis media with cholesteatoma, adhesion, or retraction pockets.

Oto-endoscopic eradication of the cholesteatoma or epithelial tissue from hidden area after the all visible cholesteatoma removal by oto-microscope improves the quality of surgery, significantly decreases the frequency of the canal wall-down procedure and posterior tympanotomy requirements with acceptable residual cholesteatoma rates.

Read the full abstract here