Validation and cross-cultural adaptation of the Arabic version of the Ear Outcome Survey-16 (EOS-16).

Background: The Ear Outcome Survey-16 (EOS-16) has been validated according to the health-related quality of life (HRQol) survey guidelines. It has important compatible aspects in evaluating patients with chronic otitis media (COM) suitable for consultation. This study aimed to develop and standardize the Arabic version of the EOS-16 to be used by clinicians in the Arab world while maintaining the conceptual equivalence. Methods: A prospective cross-sectional study was conducted in Damascus between July 2023 and November 2023 to develop an Arabic version of the EOS-16. The translation was produced according to the cross-cultural adaptation guidelines. Both experts' and participants' opinions as regards face validity were obtained in this study. Internal consistency was evaluated by the Cronbach alpha coefficient. Test-retest reliability was assessed using the intraclass correlation coefficient (ICC) and Pearson correlation. Results: A total of 81 patients enrolled in the study, with an average age of 34.75 years and a standard deviation of 11.84 years with a sex ratio of 0.62 for females. All had inactive mucosal COM (dry perforation). The overall score of the EOS-16 survey was 31.72 with a standard deviation of 13.42 suggesting bothering and influencing symptoms in COM patient's daily life. Excellent internal consistency was noted (Cronbach α = .89). Robust correlation was found between test-retest overall scores (r = .90). Reallocation of the items of the EOS-16 improved the internal consistency of the subdivisions in COM patients. Conclusion: The Arabic version of the EOS-16 is a simple, clear, reliable, reproducible, and valid HRQoL survey. It is a useful and important instrument that helps physicians in making decisions regarding the patient's treatment and follow-up.

Different Bacteria and their Antibiotic Sensitivity Patterns in Patients of Chronic Otitis Media-Active Mucosal Disease at a Secondary Care Centre in Delhi.

Chronic Otitis Media is characterized by distinct bacteriology compared with Acute Otitis Media, with COM being highly likely to harbor multiple bacteria of anaerobic and aerobic types of organisms (Cameron and Hussam K. El-Kashlan, xxx). In some patients, chronic infection with otorrhea will persist despite aggressive medical therapy. With the large number of cases of COM which presents to Sanjay Gandhi Memorial Hospital, and a majority being resistant to the common medications, we decided to undertake this study to have a better understanding of the bacterial epidemiology, the resistance, and what antibiotic to use in such cases. To determine the prevalence of different bacteriological agents and their antibiotic sensitivity pattern in patients of Chronic Otitis Media-Active Mucosal Disease presenting to ENT OPD at Sanjay Gandhi Memorial Hospital, Mangolpuri, Delhi. An observational cross-sectional study of 200 patients. After an initial examination, two sterile cotton swab sticks were introduced to collect pus samples from the medial part of the external auditory canal. The swabs were sent to the microbiology lab for Gram Staining, Culture, and Biochemical Tests, for identification of the different bacteriological agents and their antibiotic sensitivity patterns. Most common organism seen was Pseudomonas aeruginosa, followed by Staphylococcus aureus, Klebsiella pneumoniae, Proteus mirabilis, mixed bacterial growth, and Candida spp. If regular monitoring of bacteriological profile is done in each hospital, this will help us to choose the antibiotics in a better manner and hence prevent the appearance of newer resistant strains.

The Impact of Topical Application of Platelet-Rich Fibrin on Graft Survival in Surgeries for Chronic Otitis Media.

OBJECTIVE: This study aims to evaluate the efficacy of platelet-rich fibrin (PRF) application in tympanoplasty procedures for patients with chronic otitis media (COM), assessing its influence on graft survival and healing time. METHODS: In this prospective interventional study, conducted between January 2022 and June 2023, 80 patients diagnosed with COM were enrolled and divided into two groups. Group A underwent standard tympanic membrane repair using temporal fascia grafts (TFG), while Group B received TFG with adjunctive PRF application. The patients were observed and assessed over a 20-week postoperative period. RESULTS: The study showed a significant enhancement in graft survival rates in Group B (TFG+PRF), with only one residual perforation compared to seven in Group A (TFG alone) at 20 weeks (p=0.02534). Furthermore, Group B patients experienced faster healing, achieving 97.5% graft integrity at 10 and 20 weeks, in contrast to Group A's 87.5%. CONCLUSION: The application of PRF in tympanoplasty procedures for COM notably enhances graft stability and expedites the healing process. These findings suggest that PRF can be a valuable adjunct in otolaryngological surgeries, offering potential improvements in patient outcomes and surgical efficacy.

Gram-negative Bacteria are Associated With Sensorineural Hearing Loss in Chronic Otitis Media.

OBJECT: Chronic otitis media (COM) is an inflammatory disease that commonly presents with otorrhea and hearing loss. Bacteria-induced inflammation can cause inner ear damage, leading to sensorineural hearing loss (SNHL). This study aimed to compare the prevalence and severity of SNHL in patients with gram-negative versus gram-positive cultures and examine associations between the concentrations of circulating monocytes and neutrophils with bacteria species and SNHL. METHODS: This was a retrospective study. Cholesteatoma or chronic suppurative otitis media patients with otorrhea were enrolled. Middle ear secretions were collected using sterile swabs under an otoscope, and sent for bacterial detection within 30 min. Pure tone audiometry and circulating leukocyte counts were recorded and analyzed in patients infected with different pathogens. Logistic regression analysis was used to identify the risk factors associated with SNHL. RESULTS: A total of 137 patients were enrolled, including 45 patients infected with gram-negative bacteria, 41 with gram-positive bacteria, 20 with polymicrobial infection, and 31 with no bacterial growth. Logistic regression analysis showed that bacterial culture positive infections (OR = 7.265, 95% CI 2.219-23.786, p = 0.001) were an independent risk factor for SNHL. Patients with gram-negative bacteria had higher risks of SNHL (p < 0.0001) and more severe hearing loss (p = 0.005) than those with gram-positive bacteria. COM patients infected with gram-negative bacteria showed an increase in circulating monocytes, which correlated with the occurrence of SNHL (p = 0.0343). CONCLUSION: Gram-negative bacteria are associated with elevated circulating monocyte counts and have a higher risk of severe SNHL. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:3335-3341, 2024.

Application of lipid and polymeric-based nanoparticles for treatment of inner ear infections via XGBoost.

Taking hearing loss as a prevalent sensory disorder, the restricted permeability of blood flow and the blood-labyrinth barrier in the inner ear pose significant challenges to transporting drugs to the inner ear tissues. The current options for hear loss consist of cochlear surgery, medication, and hearing devices. There are some restrictions to the conventional drug delivery methods to treat inner ear illnesses, however, different smart nanoparticles, including inorganic-based nanoparticles, have been presented to regulate drug administration, enhance the targeting of particular cells, and decrease systemic adverse effects. Zinc oxide nanoparticles possess distinct characteristics that facilitate accurate drug delivery, improved targeting of specific cells, and minimized systemic adverse effects. Zinc oxide nanoparticles was studied for targeted delivery and controlled release of therapeutic drugs within specific cells. XGBoost model is used on the Wideband Absorbance Immittance (WAI) measuring test after cochlear surgery. There were 90 middle ear effusion samples (ages = 1-10 years, mean = 34.9 months) had chronic middle ear effusion for four months and verified effusion for seven weeks. In this research, 400 sets underwent wideband absorbance imaging (WAI) to assess inner ear performance after surgery. Among them, 60 patients had effusion Otitis Media with Effusion (OME), while 30 ones had normal ears (control). OME ears showed significantly lower absorbance at 250, 500, and 1000 Hz than controls (p < 0.001). Absorbance thresholds >0.252 (1000 Hz) and >0.330 (2000 Hz) predicted a favorable prognosis (p < 0.05, odds ratio: 6). It means that cochlear surgery and WAI showed high function in diagnosis and treatment of inner ear infections. Regarding the R2 0.899 and RMSE 1.223, XGBoost shows excellent specificity and sensitivity for categorizing ears as having effusions absent or present or partial or complete flows present, with areas under the curve (1-0.944).

Microbial Etiologies of Otitis Media with Resistance Pattern in a Tertiary Care Hospital in North India.

Aim: The study aimed to evaluate the bacterial and fungal profiles in Otitis Media (OM), Acute Otitis Media (AOM), and Chronic Otitis Media (COM) and the sensitivity patterns to antibiotics available in our hospital settings. Materials and Methods: A total of 150 clinically diagnosed cases of OM (AOM or COM) with ear discharge were enrolled. Swabs were cultured for microbial flora. Drug susceptibility testing was conducted using the Kirby-Bauer disc diffusion method. Results: The most common bacteria isolated in AOM was Streptococcus spp., and in COM it was Staphylococcus aureus. Among fungal isolates, Candida albicans dominate. The antimicrobial profile of the organisms revealed maximum sensitivity to Fluoroquinolones. Conclusions: Correct diagnosis and precise antibiotic prescription reduce the load of antibiotic resistance.

Nrf2 orchestrates transition from acute to chronic otitis media through inflammatory macrophages.

Introduction: Acute and chronic otitis media (AOM and COM) are common middle ear infections that can lead to hearing loss and other complications. Recent research has shown that both macrophages and nuclear factor erythroid 2-related factor 2 (Nrf2) signaling pathway are involved in the immune response to and the resolution of otitis media. However, the specific effects of Nrf2 on macrophages in the transition of AOM to COM are not well understood, and a practical approach to prevent this transition by targeting Nrf2/macrophages has not been established. Methods: In an AOM mouse model using lipopolysaccharide (LPS) injection into the middle ear, middle ear effusion (OME)-macrophages were isolated and analyzed for Nrf2 expression. M2-like polarization of macrophages was induced by Nrf2 activation and its effects on inflammatory resolution were studied by examining inflammatory neutrophils and macrophages, proinflammatory cytokines, and oxidative levels. The survival of human middle ear epithelial cells (HMMECs) co-cultured with Nrf2-modified macrophages was also evaluated. Furthermore, restoration of Nrf2 in macrophages with adeno-associated virus (AAV) vectors was performed to determine the effect on the transition of AOM to COM in experimental mice. Results: Reduced Nrf2 in OME-macrophages during the recovery phase was associated with uncured AOM or its development into COM, demonstrated by persistent increases in inflammatory neutrophils and macrophages, proinflammatory cytokines, and oxidative levels. Nrf2 activation induced M2-like polarization of macrophages, which improved the survival of co-cultured HMMECs treated with LPS in vitro. Restoration of Nrf2 in OME-derived low-Nrf2-expressing macrophages with AAV vectors significantly inhibited the transition of AOM to COM in experimental mice. Discussion: Nrf2 in macrophages plays a critical role in the immune response to and resolution of otitis media Restoration of Nrf2 expression in OME-macrophages could be a promising therapeutic approach to prevent the development of COM in AOM patients.

A Review of the Middle Ear Risk Index as a Prognostic Tool for Outcome in Middle Ear Surgery.

This review article aims to scrutinize the studies conducted to determine a relationship between preoperative Middle Ear Risk Index (MERI) factors and postoperative graft acceptance and audiological gain in patients undergoing tympanoplasty procedures in middle ear surgeries. Critical analysis is done on numerous research and types of studies that were done in this area during the past years. The clinical and technical aspects connected to disease and its care have a variety of effects on the morphological and functional outcome of tympanoplasty. A better comprehension of these characteristics aids in better disease prognostication, surgical planning, and patient counseling. At the end of this review, we can conclude that the MERI score is inversely proportional to the post-operative graft acceptance and audiological gain. The accumulated MERI is hence a good prognostic factor for the hearing outcome of surgery.

Which is Better for Management of Tympanic Membrane Perforation Temporalis Fascia or Fascia Lata Graft?

A good graft material is the one which is easily available and harvestable, tough and is easy to be handling and survival is good. Both temporalis fascia and fascia lata graft satisfy all these criteria. Keeping all these factors in mind, the comparative study of temporalis fascia and fascia lata graft in tympanoplasty is undertaken. All the patient reporting to ENT OPD with tympanic membrane perforation who are fit for surgery were advised tympanoplasty or tympanoplasty with mastoidectomy were included in the study. Our observation and data analysis have shown that fascia lata is definitely better than temporalis fascia in terms of intactness of graft (95.1% in fascia lata and 90.24% in temporalis fascia) and PTA average improvement is higher in fascia lata graft (11.56 ± 5.005) as compared to temporalis fascia graft (10.32 ± 4.634) and ABG improvement is higher in fascia lata graft (2.7317 ± 1.118) as compared to temporalis fascia graft (2.634 ± 1.089). Fascia lata has better dimensional stability, easy handling and thickness of the graft and it provides more resistant to negative middle ear pressure. Hence, fascia lata is one of the good choices in otologist's armentorium for tympanoplasty graft material.

Evaluation of Eustachian Tube Function in Cases of Chronic Otitis Media by Dynamic Slow Motion Videoendoscopy and Impedance Audiometry.

Eustachian tube (ET) dysfunction is known to be a cause for various middle ear diseases. Dynamic slow motion videoendoscopy (DSVE) and impedance audiometry (IA) can both be employed to evaluate ET dysfunction. To assess the role of DSVE and IA for diagnosing ET dysfunction in cases of middle ear disorders. It is a prospective case control study. 102 ears with chronic otitis media were taken as cases and 102 healthy ears as controls. IA and DSVE were performed to assess ET function in both the groups. Sensitivity/ specificity of both the diagnostic tests were evaluated in case and control groups. Out of 102 ET of case group exposed to both tests, 87 were found to have ET dysfunction by DSVE and 80 by IA. Among 102 ET of control group 78 were identified as normal by DSVE while 87 by IA. On applying chi square test in both these groups, the associations were significant. (p value < 0.0001). Patients with grade 2B or higher on DSVE endoscopy had abnormal IA findings, indicating that higher the grade on DSVE, higher the chance of abnormal IA. DSVE and IA are potentially useful tools in evaluation of cases of COM and which provide information regarding functional and pathological factors responsible for ET dysfunction.

A Prospective Study on Middle Ear Risk Index (MERI) and Outcome of Tympanoplasty with a Note on quality-of-Life (QOL).

Chronic Otitis Media (COM) is a major indication for tympanoplasty. It is important to predict the outcome of surgery and give proper counselling for the patient. This avoids untoward expectations. To measure the outcome of patients who underwent tympanoplasty for mucosal type of chronic otitis media (COM) using Middle ear risk index (MERI) score. Any possible correlation of MERI score with outcomes? Assess quality-of-life. Prospective analytical comparative cohort study. Sample size was 75. All patients underwent tympanoplasty for mucosal type of COM with hearing loss. The patients were categorised into mild, moderate and severe groups based on the MERI score. The hearing benefit was calculated from the pre- and post-op difference in PTA. The graft uptake status was graded. The relation between MERI score, graft status and hearing benefit were analysed and compared. QOL was assessed by COMOT-15 questionnaire. Patients with a high MERI score had lower rate of graft uptake, whereas, patients with mild MERI had greater hearing benefit and those with severe MERI had lesser hearing benefit postoperative. MERI score is a prognostic tool to predict the outcome of tympanoplasty. It has an inverse relation with graft uptake and hearing benefit. Based on MERI score, the chances for surgical success and hearing benefit could be explained to the patient to give them realistic expectations.

Contribution of a Novel Pertussis Toxin-Like Factor in Mediating Persistent Otitis Media.

Chronic otitis media (COM) is the long-term infection and inflammation of the middle ears typically caused by upper respiratory tract pathogens that are able to ascend the Eustachian tube. Our understanding of contributing factors is limited because human otopathogens cannot naturally colonize or persist in the middle ears of mice. We recently described a natural COM in mice caused by Bordetella pseudohinzii and proposed this as an experimental system to study bacterial mechanisms of immune evasion that allow persistent infection of the middle ear. Here we describe a novel pertussis toxin (PTx)-like factor unique to B. pseudohinzii, apparently acquired horizontally, that is associated with its particularly efficient persistence and pathogenesis. The catalytic subunit of this toxin, PsxA, has conserved catalytic sites and substantial predicted structural homology to pertussis toxin catalytic subunit PtxA. Deletion of the gene predicted to encode the catalytic subunit, psxA, resulted in a significant decrease in persistence in the middle ears. The defect was not observed in mice lacking T cells, indicating that PsxA is necessary for persistence only when T cells are present. These results demonstrate the role of a novel putative toxin in the persistence of B. pseudohinzii and its generation of COM. This PsxA-mediated immune evasion strategy may similarly be utilized by human otopathogens, via other PTx-like toxins or alternative mechanisms to disrupt critical T cell functions necessary to clear bacteria from the middle ear. This work demonstrates that this experimental system can allow for the detailed study of general strategies and specific mechanisms that otopathogens use to evade host immune responses to persist in the middle ear to cause COM.

Outcomes of Totally Endoscopic Versus Microscopic Techniques in Middle Ear Cholesteatoma: A Systematic Review and Meta-Analysis.

Endoscopes have revolutionized the field of otology for the past two decades due to its minimally invasive technique and improved visualization. The advantage of endoscope during surgery for middle ear cholesteatoma both for diagnosing and aiding in removal of residual disease from the hidden areas and the resulting lower recurrence rates have been proven in the past by many authors. But the feasibility of totally endoscopic ear surgery and its surgical and patient related outcomes are yet to be explored in detail. We conducted this systematic review and meta-analysis to compare the surgical and patient related outcomes between totally endoscopic and microscopic technique in cases of acquired middle ear cholesteatoma. This meta-analysis has been conducted as per Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Search engines used to identify the eligible articles were Pubmed, Web of Science, Cochrane Library, Virtual Health Library databases. The studies that compared the outcomes of microscopic and endoscopic techniques in case of acquired middle ear cholesteatoma and with more than 10 patients were included. Outcomes like recurrence, residual disease, graft uptake rate, audiological outcome, conversion rate, pain score, surgery duration, complications and quality of life outcomes were compared.The quality of the included studies was assessed by Methodological Index for Non-randomized studies criteria in case of non-randomized studies and by means of Cochrane Risk of Bias Tool in case of randomized controlled studies. A random effects model was used to calculate pooled estimates. The ODDS ratio and 95% confidence interval were calculated. The heterogeneity among the studies was represented by the Q statistic and Higgins I2 statistic. The test for overall effect was calculated by Z test and a p value of < 0.05 was considered as statistically significant. 11 studies were included in this meta-analysis. Out of 11 included studies, 4 were prospectively designed and 7 were retrospective studies. The overall effect showed recurrence rate (Z:2.69, P:0.007) was lower among endoscopic technique. Post-operative pain was less among the endoscopic technique and there was no difference between the groups with respect to surgical duration. Although endoscopic technique showed lower residual rate and post-operative vertigo with better graft success rate among the individual studies, the overall analysis showed that the difference was not statistically significant. Endoscope has been an invaluable tool in the cholesteatoma surgery over the past 20 years due to its excellent optics and minimally invasive technique. Evaluation of the present data available in the literature reveals that both the techniques have similar outcomes except for a definite advantage of endoscopic technique in reducing the recurrence and post-operative discomfort.

Is HRCT Temporal Bone Necessary in All Cases of Active Squamous Chronic Otitis Media?

To assess the usefulness of high resolution computed tomography (HRCT) temporal bones in cases of active squamous chronic otitis media (COM). Comparison of HRCT findings with operative findings. A prospective study of 104 clinically diagnosed patients with COM were included. Each patient was subjected to full clinical evaluation and HRCT temporal bone was done. Preoperative HRCT finding were correlated with surgical findings. The sensitivity of HRCT temporal bone in detecting cholesteatoma was 91.81%. However it could not differentiate cholesteatoma from other soft tissue density like granulation or hypertrophic mucosa or discharge, but soft tissue attenuation content with bone erosion was considered as hallmark of cholesteatoma. The sensitivity and specificity of HRCT for detecting malleus, incus and stapes erosion was 71.5 and 88.5%, 86.3 and 95% and 53.1 and 64.7% respectively. The sensitivity and specificity for detecting erosion of lateral semicircular canal (LSCC) was 77.78 and 98.2%. The sensitivity and specificity for facial canal was 80 and 100%. HRCT gives excellent details about the extent of cholesteatoma with reasonable accuracy in expert hands. It helps to warn the surgeon about anatomical variations preoperatively and detects complications if any. It effectively depicts integrity or erosion of dural plate, sinus plate, LSCC, facial nerve. Malleus and incus are seen reasonably well but status of stapes are not recorded effectively.

Hearing Improvement After Type III Tympanoplasty: A Prospective Observational Study.

To analyse the postoperative hearing results of patients undergoing type III tympanoplasty using sculptured homologous spur cartilage. This prospective study included 156 patients of chronic otitis media (COM), between the ages 10-60 years. All cases underwent type III tympanoplasty with ossiculoplasty using homologous spur cartilage. The study sample of 156 patients contained 107 cases of mucosal type and 49 cases of squamosal type COM. Type III A tympanoplasty was done for 71 cases and type III B tympanoplasty was done for 85. Pure tone audiometry (PTA) was done pre and postoperatively, in all the cases. The patients were followed up for 6 months postoperatively. The average preoperative mean air-bone-gap (ABG) was 43.64 dB, whereas in type III A cases it was 39.7 dB and in type III B it was 46.9 dB. The mean ABG at 6th month follow up was 18.9 dB in the study group. In type III A cases, mean ABG was 15.2 dB and in type III B cases it was 22.11 dB. Homogenous spur cartilage graft can be used for ossicular chain reconstruction with the advantage of very low extrusion rate, technically easy to perform with less risk of residual disease.

Evaluation and significance of Eustachian tube angles and pretympanic diameter in HRCT temporal bone of patients with chronic otitis media.

OBJECTIVE: To evaluate the significance of Eustachian tube (ET) angles and ET pretympanic diameter on high resolution computed tomography (HRCT) Temporal bone in patients with chronic otitis media (COM). METHODS: A retrospective study was carried out at Tertiary care centre. Group A included 92 ears with COM (38 patients with bilateral COM and 16 with unilateral COM); and Group B included 108 normal ears (54 patients with bilateral normal ears). Reid plane-ET angle, Tubotympanic angle and the ET pretympanic diameter was evaluated by HRCT temporal bone, and compared in the two groups. Patients with chronic otitis media (Group A) were subdivided into Group A1 (Blocked ET) and Group A2 (Patent ET). The parameters were evaluated and compared in the subgroups too. RESULTS: The mean Reid plane-ET angle and Tubotympanic angle in Group A was 25.41 ± 2.57 and 148.12 ± 3.43 respectively; whereas in Group B it was 27.56 ± 3.62 and 145.14 ± 4.34 respectively. Reid plane-ET angle was significantly less in patients with COM and Tubotympanic angle was significantly more obtuse in COM patients. ET pretympanic diameter was (5.37 ± 2.10) mm in Group A and (6.47 ± 2.40) mm in Group B. It was significantly less in patients with COM. A significant correlation was found between the ET patency and the two ET parameters (Reid plane-ET angle and pretympanic diameter). CONCLUSIONS: Eustachian tube angles in adults may play a significant role in the etiology of chronic otitis media. Decrease in Reid plane-ET angle and pretympanic diameter on HRCT temporal bone can be used to predict ET dysfunction and to plan the surgical management of chronic otitis media.

Aural Polyp is not Always Due to Chronic Otitis Media (COM): Preoperative Computed Tomographic Scan is Good Pointer for Sinister Lesions.

Twenty five patients of aural polyp who underwent canal wall down mastoidectomy were analysed retrospectively. Histopathological examination revealed cholesteatoma in 22 (88%) patients. However, histopathological diagnosis in 3 of these patients was unusual and rare benign tumors of the middle ear cleft-meningioma, neurilemmoma and capillary hemangioma. Review of the preoperative High Resolution Computed Tomography (HRCT) temporal bone revealed an unusual picture in all of the three cases. Features noted were: widening of the jugular foramen (meningioma), destruction of the anterior wall of mesotympanum (neurilemmoma), enhancing soft tissue density lesion (capillary hemangioma). Further, there was only partial loss of pneumatisation of the mastoid air cells in all of the 3 cases. It was observed that though HRCT temporal bone is a commonly advised investigation in patients of chronic otitis media (COM) with aural polyp, meticulous interpretation may reveal unusual features pointing towards sinister diagnosis. Conclusion: Aural polyp with preservation of pneumatisation of mastoid air cells points towards diagnosis other than COM.