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Acute
mastoiditis: increase in the incidence and complications.Int
J Pediatr Otorhinolaryngol. 2007
Jul;71(7):1007-11. Epub 2007 May 9.
OBJECTIVE:
Acute mastoiditis is a serious complication of acute otitis media,
but it can be treated successfully in most of the cases with broad
spectrum intravenous antibiotics and myringotomy. In the last 5
years we have perceived that there have been more complicated cases
in the otic infectious pathology and the frequency was also higher.
METHODS: We reviewed the cases of mastoiditis in the last 10 years
(1996-2005) in The Niño Jesús University Children Hospital in Madrid
to confirm the clinic impression, the bacteriology, treatments and
evolution of the children and analyze the causes of this clinic
situation. RESULTS: We have studied 215 cases of mastoiditis (0.6-17
years), 67.4% less than 3 years old and 69.3% males. The number of
cases every year was the double since 1999 with the same percentage
of admissions in the Pediatric service, and the triple in 2005. The
percentage of surgical treatment grew from 4.3% to 33% in the last
years and to 70% in 2005. Most cases (80%) have received prior
antibacterial agent therapy, but individual pathogens and current
complications of periostitis or subperiosteal abscess formation were
equally distributed between the two groups. We have detected a
28.57% of Streptococcus pneumoniae and a significative high rate of
Staphylococcus aureus (16.32%). A 53.68% of cases had negative
cultures. CONCLUSIONS: There is a progressive increase in the
incidence of acute mastoiditis in our medium, and an increase of the
surgical treatments. Ten years ago the process was controlled with
antibiotic therapy only, but now the number of interventions has
been eight times the previous years. Most cases of acute mastoiditis
have responded well to medical management alone. But if higher
levels of resistance predominate, more severe forms of pneumococcal
or other pathogen like S. aureus disease are likely to be seen,
these would be less likely to respond to oral or parenteral
antibiotic therapy, so, tympanocentesis for middle ear culture may
become more valuable and more frequently used in cases of antibiotic
treatment failures, and surgical therapy may be necessary more often
in the future. Our hospital seems to be in this tendency now.
Adenoid mast cells
and their role in the pathogenesis of otitis media with effusion.J
Laryngol Otol. 2006 Jul;120(7):556-60.
INTRODUCTION:
Otitis media with effusion (OME) is an inflammation of the middle
ear in which a collection of liquid is present in the middle-ear
space while the tympanic membrane is intact. The association between
adenoid inflammation and OME has long been noted but the exact
mechanism is still much debated. We studied the role of adenoid mast
cells in the causation of OME. OBJECTIVE: To study the distribution
and role of adenoid mast cells in the causation of OME. METHODOLOGY:
A cross-sectional, prospective study was carried out in the
otorhinolaryngologic clinic, department of otorhinolaryngology (ORL),
Science University of Malaysia, from June 1999 to September 2001. A
total number of 50 cases were studied. Twenty-five of these patients
underwent adenoidectomy, while another 25 patients underwent
adenoidectomy and myringotomy with ventilation tube insertion. The
adenoid specimens from all patients were examined for the number of
adenoid mast cells present, using light microscopy and toluidine
blue as the staining agent. The results were analysed using SPSS
version 10.0 computer software. RESULT: The population of adenoid
mast cells in children with OME was significantly greater than that
in children without OME (p=0.000). CONCLUSION: The increased number
of adenoid mast cells in patients with OME suggests that
inflammation may play a role in this condition.
Otitis media with
effusion: an effort to understand and clarify the uncertainties.Expert
Rev Anti Infect Ther. 2005 Feb;3(1):117-29.
Otitis media
with effusion--defined as the accumulation of middle-ear effusion
behind an intact tympanic membrane without signs or symptoms of
acute infection--is one of the most common causes of hearing loss in
children in developed countries, potentially leading to language
deficits. Although treatment of chronic or relapsing otitis media
with effusion is considered imperative, none of the preventative or
nonsurgical management measures currently available have proven
effective. Tympanostomy tube placement remains the recommended
treatment option for high-risk children or for cases of unresponsive
otitis media with effusion. This can be attributed to the
uncertainties surrounding its pathogenesis. Multiple factors and
several possible pathogenetic models have been proposed to explain
the production and persistence of middle-ear effusion; only a few of
them are supported by sufficient evidence. In this review, the
authors will present current knowledge on the pathogenesis,
consequences, diagnosis and management of otitis media with
effusion. An effort will be made to clarify those aspects
sufficiently supported by evidence-based studies, and to underline
those that remain unfounded.
Otitis media with effusion.Pediatrics.
2004 May;113(5):1412-29.
The clinical
practice guideline on otitis media with effusion (OME) provides
evidence-based recommendations on diagnosing and managing OME in
children. This is an update of the 1994 clinical practice guideline
"Otitis Media With Effusion in Young Children," which was developed
by the Agency for Healthcare Policy and Research (now the Agency for
Healthcare Research and Quality). In contrast to the earlier
guideline, which was limited to children 1 to 3 years old with no
craniofacial or neurologic abnormalities or sensory deficits, the
updated guideline applies to children aged 2 months through 12 years
with or without developmental disabilities or underlying conditions
that predispose to OME and its sequelae. The American Academy of
Pediatrics, American Academy of Family Physicians, and American
Academy of Otolaryngology-Head and Neck Surgery selected a
subcommittee composed of experts in the fields of primary care,
otolaryngology, infectious diseases, epidemiology, hearing, speech
and language, and advanced-practice nursing to revise the OME
guideline. The subcommittee made a strong recommendation that
clinicians use pneumatic otoscopy as the primary diagnostic method
and distinguish OME from acute otitis media. The subcommittee made
recommendations that clinicians should 1) document the laterality,
duration of effusion, and presence and severity of associated
symptoms at each assessment of the child with OME, 2) distinguish
the child with OME who is at risk for speech, language, or learning
problems from other children with OME and more promptly evaluate
hearing, speech, language, and need for intervention in children at
risk, and 3) manage the child with OME who is not at risk with
watchful waiting for 3 months from the date of effusion onset (if
known) or diagnosis (if onset is unknown). The subcommittee also
made recommendations that 4) hearing testing be conducted when OME
persists for 3 months or longer or at any time that language delay,
learning problems, or a significant hearing loss is suspected in a
child with OME, 5) children with persistent OME who are not at risk
should be reexamined at 3- to 6-month intervals until the effusion
is no longer present, significant hearing loss is identified, or
structural abnormalities of the eardrum or middle ear are suspected,
and 6) when a child becomes a surgical candidate (tympanostomy tube
insertion is the preferred initial procedure). Adenoidectomy should
not be performed unless a distinct indication exists (nasal
obstruction, chronic adenoiditis); repeat surgery consists of
adenoidectomy plus myringotomy with or without tube insertion.
Tonsillectomy alone or myringotomy alone should not be used to treat
OME. The subcommittee made negative recommendations that 1)
population-based screening programs for OME not be performed in
healthy, asymptomatic children, and 2) because antihistamines and
decongestants are ineffective for OME, they should not be used for
treatment; antimicrobials and corticosteroids do not have long-term
efficacy and should not be used for routine management. The
subcommittee gave as options that 1) tympanometry can be used to
confirm the diagnosis of OME and 2) when children with OME are
referred by the primary clinician for evaluation by an
otolaryngologist, audiologist, or speech-language pathologist, the
referring clinician should document the effusion duration and
specific reason for referral (evaluation, surgery) and provide
additional relevant information such as history of acute otitis
media and developmental status of the child. The subcommittee made
no recommendations for 1) complementary and alternative medicine as
a treatment for OME, based on a lack of scientific evidence
documenting efficacy, or 2) allergy management as a treatment for
OME, based on insufficient evidence of therapeutic efficacy or a
causal relationship between allergy and OME. Last, the panel
compiled a list of research needs based on limitations of the
evidence reviewed. The purpose of this guideline is to inform
clinicians of evidence-based methods to identify, monitor, and
manage OME in children aged 2 months through 12 years. The guideline
may not apply to children more than 12 years old, because OME is
uncommon and the natural history is likely to differ from younger
children who experience rapid developmental change. The target
population includes children with or without developmental
disabilities or underlying conditions that predispose to OME and its
sequelae. The guideline is intended for use by providers of health
care to children, including primary care and specialist physicians,
nurses and nurse practitioners, physician assistants, audiologists,
speech-language pathologists, and child-development specialists. The
guideline is applicable to any setting in which children with OME
would be identified, monitored, or managed. This guideline is not
intended as a sole source of guidance in evaluating children with
OME. Rather, it is designed to assist primary care and other
clinicians by providing an evidence-based framework for
decision-making strategies. It is not intended to replace clinical
judgment or establish a protocol for all children with this
condition and may not provide the only appropriate approach to
diagnosing and managing this problem.
Histopathologic differences due to bacterial
species in acute otitis media.Int
J Pediatr Otorhinolaryngol. 2002 Apr
25;63(2):99-110.
OBJECTIVE: To
compare selected features of histopathology in acute otitis media
caused by various bacteria and examine potential differences due to
bacterial species, as well as possible correlation to experimental
and human clinical findings. METHODS: Rat models of acute otitis
media caused by Streptococcus pneumoniae (MC), non-typeable or type
b Haemophilus influenzae (NTHI/HIB) or Moraxella catarrhalis (MC)
were studied longitudinally up to 6 months after bacterial
challenge. Findings related to dynamics of goblet cell density,
modeling and remodeling of bone tissue structures and polyp, as well
as fibrous adhesion formation and persistence are presented.
RESULTS: Middle ear goblet cell density progressed to peak 2 weeks
after bacterial inoculation, thereafter gradually normalizing.
However, density and accordingly middle ear secretory capacity was
still significantly increased after 6 months in all bacteria, except
MC. The HI species induced the highest increase. Initial
osteoresorption was followed by massive osteoneogenesis, progressing
to a peak after 2-3 months, followed by some degree of
normalization, concurrently classic remodeling. Primarily SP, but
also the HI species induced more new bone formation than MC. Mucosal
polyp and fibrous adhesion formation occurred regardless of
bacterial species. Most polyps appeared in the early phases and the
HI species induced formation of more polyps and adhesions than the
other bacteria. CONCLUSION: Acute middle ear infection with the
Haemophilus species induce the highest increase of mucosal secretory
capacity, lasting for at least 6 months after the acute incident.
Thus, a subsequent development of secretory otitis media seems more
likely following infection with these bacteria. Equivalently,
mucosal scarring observed as polyp and fibrous adhesion formation
was more severe following Haemophilus infection. S. pneumoniae
induced the most marked changes of bone tissue structures, seen as
initial osteoresorption and subsequent osteoneogenesis. Overall,
infection with M. catarrhalis induced the mildest changes.
Cytology of
middle ear fluid during acute otitis media.Pediatr
Infect Dis J. 2002 Jan;21(1):57-61.
BACKGROUND:
Limited information is available on the cellular characteristics of
the middle ear fluid (MEF) during acute otitis media (AOM).
OBJECTIVES: To determine the white blood cell (WBC) composition of
the MEF in AOM before and during antibiotic therapy. MATERIALS AND
METHODS: Total WBC and differential counts were determined in the
MEF of 96 infants and children (ages 2 weeks to 3 years) with AOM
who were receiving antibiotics. WBC counts were reported as number
of WBC/mg MEF (mean +/- sd). RESULTS: One hundred forty-five MEF
samples were obtained by tympanocentesis at enrollment (Day 1), and
36 samples were collected on Days 4 to 5 after initiation of
antibiotic therapy. Sixty-one percent of the patients were <1 year
of age, and 38% were receiving antibiotic therapy at enrollment.
Twenty-eight MEF samples were paired (same ear, Day 1 and Days 4 to
5). One hundred twelve pathogens were isolated from 95 of 145 (66%)
culture-positive samples obtained on Day 1: 67 Haemophilus
influenzae, 40 Streptococcus pneumoniae and 5 others. MEF WBC counts
were lower on Day 1 in patients who had received previous antibiotic
therapy than in those who had not (432.4+/- 412.8 vs. 590.5 +/-
436.8, P = 0.03). WBC counts were higher on Day 1 in
culture-positive than in culture-negative samples (603.9 +/- 504.9
vs.421.4 +/- 373.4, P = 0.02). WBC counts were higher on Day 1 in
MEF samples positive for S. pneumoniae than in those positive for H.
influenzae (799.2 +/- 641.5 vs.506.4 +/- 401.9, P = 0.04). There
were no differences in the number of neutrophil WBC present in the
samples obtained on Day 1 vs.Days 4 to 5 or between samples positive
vs.samples negative for bacterial pathogens. CONCLUSIONS: WBC counts
were higher in the MEF of patients with culture-positive AOM than in
those with culture-negative AOM and in those with AOM caused by S.
pneumoniae.
Infiltration of immunocompetent cells
in the middle ear during acute otitis media: a temporal study.Am
J Otol. 1999 Mar;20(2):152-7.
HYPOTHESIS: The
inflammatory response to acute otitis media (AOM) is a chain
reaction involving, among others, macrophages, B lymphocytes, and T
lymphocytes that vary in number on different days during the
infection. The response is thought to eventually contribute to
tympanosclerosis (TS). BACKGROUND: In humans, TS and
myringosclerosis (MS) are obscure sequelae of chronic otitis media.
MS is also commonly seen in children who have had acute purulent
otitis media or secretory otitis media or after treatment with
ventilation tubes in the tympanic membrane (TM). It causes hearing
disability, especially if the ossicles or the inner ear are
affected. No successful treatment is available. This study was
performed to evaluate the inflammatory stages that may lead to TS or
MS. METHODS: Sprague Dawley rats were exposed to a Pneumococcus type
3 solution into the middle ear. Groups of rats were killed at 3, 6,
and 10 days after inoculation. Sections from the TM specimen were
stained immunohistochemically according to the avidin-biotin method.
Antibodies used were directed against macrophages, T cells, and B
cells. Positive cells were counted and a mean value was estimated
for each slide and section for each antibody in each rat. RESULTS:
Results showed that macrophages, T cells, and B cells were presented
time-dependently in the acute inflammatory response in AOM. At day
3, dendritic cells, macrophages, T cells, B cells, and other major
histocompatibility complex (MHC)-restricted cells were richly
expressed in the whole submucosal layer and especially in the
annulus fibrosus. At day 6, the amount of all positive cells
decreased except for B cells and other MHC-restricted cells, which
slightly increased in number. At day 10, all of the cells were lower
in number than at days 3 and 6. Macrophages and possible T cells
could be detected in the TM, which has not been observed earlier.
Large osteoclastlike cells were present close to the bone.
CONCLUSIONS: Macrophages were the first cells to invade the tissue
after AOM induction. Some cells were found in the TM. Large
osteoclastlike cells could be seen adjacent to the bone in the
submucosa. T cells and B cells were seen in the submucosa.
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