Role of Chlamydia pneumoniae and Helicobacteria pylori in the development of tympanosclerosis.

The etiology of tympanosclerosis (TS) is not known, but TS commonly develops secondary to acute and chronic otitis media (COM). Since calcification process in TS resembles that of atherosclerosis (AS), pathogens that are related to pathogenesis of AS may be involved in development of TS. This prospective and controlled study, performed at a tertiary referral center, investigated a possible relationship between the presence of Chlamydia (C.) pneumoniae and Helicobacter (H.) pylori and the development of a tympanosclerotic plaque. The presence of C. pneumoniae was examined in the surgical specimens of 62 patients (29 females and 33 males; age range 10-70 years, mean age 30.8 ± 13.3 years), including 30 patients with TS, 14 patients with cholesteatoma, and 18 patients with chronic suppurative otitis media (CSOM). The presence of H. pylori was examined in the surgical specimens of 88 patients (41 females and 47 males; age range 6-70 years, mean age 32.5 ± 14.8 years), including 35 patients with TS, 22 patients with cholesteatoma, 20 patients with CSOM, and 11 patients with otosclerosis. Tympanosclerotic plaques and control specimens from the cholesteatoma, polypoid mucosa, or mucosal portion of the perforations and stapes supra structure were examined for the presence of H. pylori and/or C. pneumoniae using real-time polymerase chain reaction analysis. The analysis demonstrated that specimens from the tympanosclerotic plaques and the other types of COM were all negative for C. pneumoniae and H. pylori. An association between C. pneumoniae or H. pylori infection and the development of TS or other types of COM could not be established.

Optical absorbance of the tympanic membrane in rat and human samples.

Chronic infections are often connected to biofilm formation. In presence of implants, this can lead to loss of the implant. Systemic or local application of drugs is relatively ineffective in case of biofilm formation. One technique to provide antibacterial properties on demand is the antibacterial photodynamic therapy (aPDT). Using this technique, these properties can be "switched on" by light illumination. In the middle ear with the semitransparent tympanic membrane, it might be possible in future to activate the antibacterial effect without opening the membrane. Therefore, we investigated the optical absorbance spectra of the tympanic membrane. Optical absorbance spectra were measured in ex vivo preparations from neonatal and adult rats with the membrane still being attached to the surrounding bony ring and four human samples. After performing area scans, the spot with the lowest absorbance being surrounded by a ring like structure with higher absorbance was chosen as region of interest for scanning wavelengths between 300 and 900 nm. Absorbance is generally higher at lower wavelengths with a local absorbance maximum at 420 nm and a weak second maximum with two neighbouring peaks at 540 / 580 nm and is significantly higher in adult rats compared to neonatal rats where about 10% of light was transmitted. The human samples show similar characteristics with a little higher absorbance. For activation of aPDT through the tympanic membrane, larger wavelengths are more promising. Whether the amount of light transmitted through the membrane would be sufficient to induce aPDT remains to be tested in further experiments.

Longitudinal optical coherence tomography to visualize the in vivo response of middle ear biofilms to antibiotic therapy.

Studying the impact of antibiotic treatment on otitis media (OM), the leading cause of primary care office visits during childhood, is critical to develop appropriate treatment strategies. Tracking dynamic middle ear conditions during antibiotic treatment is not readily applicable in patients, due to the limited diagnostic techniques available to detect the smaller amount and variation of middle ear effusion (MEE) and middle ear bacterial biofilm, responsible for chronic and recurrent OM. To overcome these challenges, a handheld optical coherence tomography (OCT) system has been developed to monitor in vivo response of biofilms and MEEs in the OM-induced chinchilla model, the standard model for human OM. As a result, the formation of MEE as well as biofilm adherent to the tympanic membrane (TM) was longitudinally assessed as OM developed. Various types of MEEs and biofilms in the chinchilla model were identified, which showed comparable features as those in humans. Furthermore, the effect of antibiotics on the biofilm as well as the amount and type of MEEs was investigated with low-dose and high-dose treatment (ceftriaxone). The capability of OCT to non-invasively track and examine middle ear conditions is highly beneficial for therapeutic OM studies and will lead to improved management of OM in patients.

[Peculiarities of clinical course of chronic purulent epitympanitis].

Wide application of antibiotics in bacterial infections have caused selection and prominent dissemination occurrence of antibioticoresistant strains of microorganisms. Etiological and pathogenetic peculiarities of chronic purulent epitympanitis (CHPE) were studied, rational curative scheme of 69 therapy patients was elaborated, which included sanation, the earpreserving operations on middle ear, performed for CHPE.

Bacterial causes of otitis media with spontaneous perforation of the tympanic membrane in the era of 13 valent pneumococcal conjugate vaccine.

After pneumococcal conjugate vaccine (PCV) implementation, the number of acute otitis media (AOM) episodes has decreased, but AOM still remains among the most common diagnoses in childhood. From 2% to 17% of cases of AOM feature spontaneous perforation of the tympanic membrane (SPTM). The aim of this study was to describe the bacteriological causes of SPTM 5 to 8 years years after PCV13 implementation, in 2010. From 2015 to 2018, children with SPTM were prospectively enrolled by 41 pediatricians. Middle ear fluid was obtained by sampling spontaneous discharge. Among the 470 children with SPTM (median age 20.8 months), no otopathogen was isolated for 251 (53.4% [95% CI 48.8%;58.0%]): 47.1% of infants and toddlers, 68.3% older children (p<0.001). Among children with isolated bacterial otopathogens (n = 219), non-typable Haemophilus influenzae (NTHi) was the most frequent otopathogen isolated (n = 106, 48.4% [95% CI 41.6%;55.2%]), followed by Streptoccocus pyogenes (group A streptococcus [GAS]) (n = 76, 34.7% [95% CI 28.4%;41.4%]) and Streptococcus pneumoniae (Sp) (n = 61, 27.9% [95% Ci 22.0%;34.3%]). NTHi was frequently isolated in infants and toddlers (53.1%), whereas the main otopathogen in older children was GAS (52.3%). In cases of co-infection with at least two otopathogens (16.9%, n = 37/219), NTHi was frequently involved (78.4%, n = 29/37). When Sp was isolated, PCV13 serotypes accounted for 32.1% of cases, with serotype 3 the main serotype (16.1%). Among Sp strains, 29.5% were penicillin-intermediate and among NTHi strains, 16.0% were ß-lactamase-producers. More than 5 years after PCV13 implementation, the leading bacterial species recovered from AOM with SPTM was NTHi for infants and toddlers and GAS for older children. In both age groups, Sp was the third most frequent pathogen and vaccine serotypes still played an important role. No resistant Sp strains were isolated, and the frequency of ß-lactamase-producing NTHi did not exceed 16%.

Topical application of calcium channel blockers to reduce the progression of experimentally induced myringosclerosis and tympanosclerosis.

OBJECTIVES: This study aimed to evaluate the ability of topically applied calcium channel blockers (diltiazem) to reduce the progression of experimentally induced myringosclerosis and tympanosclerosis. STUDY DESIGN: Animal model. Experimental prospective study. METHODS: The study included 25 adult albino guinea pigs that were bilaterally myringotomized and inoculated with a suspension of Streptococcus pneumonia type 3. The right ears were treated with topical application of diltiazem, and the untreated left ears served as the control group. Otomicroscopy and remyringotomy were conducted every week. One animal was sacrificed after 1 week and the remaining at the end of 6 weeks. Temporal bones were dissected, and tympanic bullae were analyzed with light microscopy. RESULTS: The untreated control ears showed evidence of extensive myringosclerosis on otomicroscopy, and the ears treated with calcium channel blockers did as well although to a lesser degree. Under light microscopy, the lamina propria of both tympanic membranes and middle ear mucosae of the control group exhibited thicker (P < .1 and P < .05, respectively) and larger (P < .01 and P < .01, respectively) sclerotic tissue in comparison with the treatment group. CONCLUSION: The results suggest that calcium channel blockers had an influence in the prevention of tympanosclerosis.

Direct Analysis of Pathogenic Structures Affixed to the Tympanic Membrane during Chronic Otitis Media.

Objective To characterize otitis media-associated structures affixed to the mucosal surface of the tympanic membrane (TM) in vivo and in surgically recovered in vitro samples. Study Design Prospective case series without comparison. Setting Outpatient surgical care center. Subjects and Methods Forty pediatric subjects scheduled for tympanostomy tube placement surgery were imaged intraoperatively under general anesthesia. Postmyringotomy, a portable optical coherence tomography (OCT) imaging system assessed for the presence of any biofilm affixed to the mucosal surface of the TM. Samples of suspected microbial infection-related structures were collected through the myringotomy incision. The sampled site was subsequently reimaged with OCT to confirm collection from the original image site on the TM. In vitro analysis based on confocal laser scanning microscope (CLSM) images of fluorescence in situ hybridization-tagged samples and polymerase chain reaction (PCR) provided microbiological characterization and verification of biofilm activity. Results OCT imaging was achieved for 38 of 40 subjects (95%). Images from 38 of 38 (100%) of subjects observed with OCT showed the presence of additional microbial infection-related structures. Thirty-four samples were collected from these 38 subjects. CLSM images provided evidence of clustered bacteria in 32 of 33 (97%) of samples. PCR detected the presence of active bacterial DNA signatures in 20 of 31 (65%) of samples. Conclusion PCR and CLSM analysis of fluorescence in situ hybridization-stained samples validates the presence of active bacteria that have formed into a middle ear biofilm that extends across the mucosal layer of the TM. OCT can rapidly and noninvasively identify middle ear biofilms in subjects with severe and persistent cases of otitis media.

Prediction of upper respiratory tract bacteria in acute otitis media.

CONCLUSIONS: Thorough otomicroscopical examination of the tympanic membrane in acute otitis media (AOM) might distinguish AOM episodes caused by different bacteria. It thus might be a way to select appropriate treatment for each patient without raising the number of dangerous complications. OBJECTIVES: The aim of this study was to see if it might be possible to predict the causative bacterium by judging the otomicroscopical appearance of the tympanic membrane in episodes of AOM. PATIENTS AND METHODS: The study was prospective. Patients suffering from non-perforated AOM were included. The tympanic membrane was photographed. A prediction of the causative bacterium was made and tympanocentesis was performed. Effusion from the middle ear and a nasopharyngeal swab were obtained for bacterial culturing. The causative bacteria were categorized into gram-positive (Streptococcus pneumoniae and S. pyogenes) or gram-negative (non-typable Haemophilus influenzae and Moraxella catarrhalis). RESULTS: A total of 82 patients were included in the study. A correct prediction was made in 47/63, a false prediction in 16/63 (kappa 0.48, p<0.001).

Factors affecting sound energy absorbance in acute otitis media model of chinchilla.

Acute otitis media (AOM) is a rapid-onset infection of the middle ear which results in middle ear pressure (MEP), middle ear effusion (MEE), and structural changes in middle ear tissues. Previous studies from our laboratory have identified that MEP, MEE, and middle ear structural changes are three factors affecting tympanic membrane (TM) mobility and hearing levels (Guan et al., 2014, 2013). Sound energy reflectance or absorbance (EA) is a diagnostic tool increasingly used in clinical settings for the identification of middle ear diseases. However, it is unclear whether EA can differentiate these three factors in an AOM ear. Here we report wideband EA measurements in the AOM model of chinchilla at three experimental stages: unopened, pressure released, and effusion removed. These correspond to the combined and individual effects of the three factors on sound energy transmission. AOM was produced by transbullar injection of Haemophilus influenzae in two treatment groups: 4 days (4D) and 8 days (8D) post inoculation. These time points represent the relatively early and later phase of AOM. In each group of chinchillas, EA at 250-8000 Hz was measured using a wideband tympanometer at three experimental stages. Results show that the effects of MEP, MEE, and tissue structural changes over the frequency range varied with the disease time course. MEP was the primary contributor to reduction of EA in 4D AOM ears and had a smaller effect in 8D ears. MEE reduced the EA at 6-8 kHz in 4D ears and 2-8 kHz in 8D ears and was responsible for the EA peak in both 4D and 8D ears. The residual EA loss due to structural changes was observed over the frequency range in 8D ears and only at high frequencies in 4D ears. The EA measurements were also compared with the published TM mobility loss in chinchilla AOM ears.

Otomicroscopic findings and systemic interleukin-6 levels in relation to etiologic agent during experimental acute otitis media.

The aim of the present study was to explore whether it was possible to differentiate the clinical course and the otomicroscopic appearance of acute otitis media (AOM) caused by common otitis pathogens in an animal model. Systemic interleukin (IL)-6 levels as early markers for bacterial AOM were also studied. Four groups of rats were inoculated with either Streptococcus pneumoniae, Streptococcus pyogenes, non-typeable Haemophilus influenzae or Moraxella catarrhalis. The animals were monitored by otomicroscopy, photos of the tympanic membrane, cultures and IL-6 detection in serum the following 4 days. The gram-positive S. pneumoniae and S. pyogenes induced severe AOM with opaque effusion behind the tympanic membrane, pronounced dilation of the vessels and spontaneous perforations. The gram-negative H. influenzae and M. catarrhalis induced a less severe infection with cloudy, sometimes foamy effusion, and no spontaneous perforations. With the otomicroscopic findings it was possible to distinguish between infections induced by gram-positive bacteria and gram-negative bacteria. Detection of interleukin-6 in serum appeared to be of limited use for all infections except the pneumococcal AOM, but this needs to be further investigated.

Pseudomonas aeruginosa infection in the hypoventilated middle ear: an experimental model.

CONCLUSION: This is a suitable model for studying different aspects of the pathophysiology of chronic suppurative otitis media. OBJECTIVE: To analyze the methodological features of an animal model of chronic suppurative otitis media induced by intratympanic inoculation of Pseudomonas aeruginosa. MATERIAL AND METHODS: Otitis media was induced by inoculation of P. aeruginosa through the inferior aspect of the rat bulla and cauterization of the Eustachian tube via a transpalatal approach. Inspection of the tympanic membrane, culturing of middle ear effusion and processing of the temporal bones for light microscopy were performed. RESULTS: Abnormal otomicroscopic findings and persistence of infection were correlated with the histopathological changes found in middle ear tissues.

Morphological changes in the tympanic membrane associated with Haemophilus influenzae-induced acute otitis media in the chinchilla.

OBJECTIVE: The tympanic membrane (TM) couples sound waves entering the outer ear canal to mechanical vibrations of the ossicular chain in the middle ear. During acute otitis media (AOM), dynamic structural changes in the TM can occur, which potentially affect sound transmission. It has remained unclear whether TM changes contribute significantly to the conductive hearing loss associated with human AOM. Studies that systematically and quantitatively assess the impact of morphological and mechanical characteristics of the TM on hearing in animal models of AOM have been few in number and lack detail. Our current study focused on the identification of quantitative morphological changes in the TM of the adult chinchilla. METHOD: AOM was produced by transbullar injection of the nontypeable (acapsular) Haemophilus influenzae strain 86-028NP into two treatment groups of chinchillas: one 4 days (4D) post bacterial challenge, and a second treatment group after 8 days (8D) post challenge. Structure and thickness were examined histologically at nine locations over the TM in untreated controls and in animals from both AOM treatment groups. RESULTS: TM thickness was found to have increased significantly (110-150%) at all measured locations of H. influenzae-infected ears when compared with uninfected (normal) TMs at 4D post bacterial challenge. Cellular proliferation and infiltration in the outer epithelial layer were primary contributors to this thickening. In ears infected for 8D, the TM was substantially thicker, a 200-300% increase from uninfected control values, due to edema and cell proliferation in both the outer and inner epithelial layers. In both 4D and 8D ears, thickening of the TM was more prominent in the superior-anterior quadrant. CONCLUSION: This study provides unequivocal structural evidence that significant TM thickness increases are associated with AOM induced by a well characterized H. influenzae human clinical isolate of low passage number. These and additional thickness data from early and later stages in middle ear infection will be used to derive the mechanical properties of the TM in a future study from our laboratory.

No evidence of Mycoplasma pneumoniae in acute myringitis.

Our aim was to discover Mycoplasma pneumoniae in bullous and hemorrhagic myringitis in children <2 years of age. Middle ear fluid samples (n = 37) and samples taken from the blisters of the tympanic membranes (n = 12) studied by polymerase chain reaction for M. pneumoniae were negative. This study does not support an important role for M. pneumoniae as an etiologic agent in acute myringitis.

Otoscopic and tympanometric findings in acute otitis media yielding dry tap at tympanocentesis.

BACKGROUND: The value of tympanometry in detection of middle ear effusion (MEE) has been widely studied in otitis media with effusion. There has been no direct comparison of tympanometric and tympanocentesis (TAP) findings in acute otitis media (AOM). We compared otoscopic, tympanometric and TAP findings in AOM including cases of AOM without effusion. METHODS: In a study of AOM treatment of 90 children, a tympanogram was obtained, and TAP was performed before and after 5 days of treatment. Subjects were followed with otoscopy and tympanometry every 2 weeks for 3 months or until the MEE cleared. RESULTS: In 130 AOM ears, otoscopic, tympanometric and TAP findings were available; MEE was obtained from 110 ears. Of 20 ears with a dry tap, 18 had abnormal tympanogram and otoscopic findings. With TAP findings as the standard, sensitivity and positive predictive value of type B tympanogram were 97 and 87%, respectively. Of 18 AOM ears yielding dry tap, 2 yielded MEE 5 days later, and 8 continued with evidence of MEE 5 days-12 weeks later. Five subjects with 8 AOM ears yielding dry tap were lost to follow-up; all had short duration of clinical symptoms. CONCLUSIONS: Although otoscopic and tympanometric findings suggested the presence of MEE in AOM, MEE was unobtainable by TAP in 14% of cases. Dry tap cases likely represent early AOM before accumulation of detectable MEE. However, technical difficulty in obtaining small amounts of or highly viscous MEE could not be excluded. Sensitivity and positive predictive value of abnormal tympanograms in detection of MEE in AOM cases are comparable with those in otitis media with effusion.

Acute otitis media develops in the rat after intranasal challenge of Streptococcus pneumoniae.

OBJECTIVES/HYPOTHESIS: The rat is a frequently used animal model for middle ear research. To date, acute otitis media (AOM) has been evoked after instillation of bacteria directly into the middle ear cavity or after traumatizing the tympanic membrane. The purpose of the study was to examine whether, with an intact tympanic membrane and middle ear cavity, intranasally deposited bacteria cause AOM and how tympanic membrane stimulation influences this procedure. STUDY DESIGN: In vivo, murine model. METHODS: In a rat model, Streptococcus pneumoniae, type 3, was intranasally inoculated for 5 consecutive days. The tympanic membrane was treated with saline or with compound 48/80 or was left untreated. The development of AOM was evaluated by otomicroscopy, light microscopy, and middle ear culture. RESULTS: Ninety percent of the ears developed AOM. However, when the tympanic membranes were treated with saline or compound 48/80, only 40% and 57%, respectively, developed AOM. In all, 23 of 40 ears developed AOM and 20 ears showed growth of bacteria. CONCLUSION: Repeated intranasal deposition of S. pneumoniae, type 3, causes AOM in the rat. The development of AOM can be influenced by tympanic membrane stimulation.

Middle ear effusions and structure of the tympanic membrane.

OBJECTIVE: To study the effect of various middle ear effusions on the structure of the lamina propria of the tympanic membrane. METHODS: Sterile and infective middle ear effusions were induced by obstruction of the eustachian tube in specific pathogen-free (SPF) rats and in rats with upper airway infections (URI), respectively. The condition of the tympanic membrane was monitored at regular intervals. After varying survival times, the animals were killed and the tympanic membranes processed for light and electron microscopy. RESULTS: Sterile effusions always resulted in tympanosclerotic lesions. These lesions did not develop in the presence of primary-infected effusions. These effusions had a severe destructive effect on the lamina propria, followed by fibrosis. Generally, secondary infection did not markedly affect preexisting tympanosclerotic lesions. Moreover, calcification disappeared when re-aeration of the middle ear occurred, but the abnormal collagen depositions persisted. CONCLUSIONS: Both sterile and infective effusions result in comprehensive irreversible changes in the lamina propria of the pars tensa. The development of tympanosclerosis is confined to sterile effusions. Mechanical injury and compromised vascularization of the lamina propria are likely to be important etiological factors in the development of tympanosclerosis.

Pars flaccida displacement pattern in purulent otitis media in the gerbil.

HYPOTHESIS: Our hypothesis is that purulent otitis media and otitis media with effusion cause stiffness loss of the tympanic membrane. This loss of stiffness may be persistent and precede the development of retraction pockets and cholesteatoma. BACKGROUND: Postinflammatory changes such as retraction pockets and cholesteatoma develop in the pars flaccida and in the pars tensa of the tympanic membrane. In our previous experimental studies, stiffness changes were shown to develop early in the pars tensa in response to purulent otitis media and otitis media with effusion. These changes are suggested to be precursors to a later development of retraction pockets and cholesteatoma. In the clinical situation, retraction pockets are often found in the pars flaccida only. The aim of the current study was thus to investigate whether stiffness changes appear also in the pars flaccida during purulent otitis media. METHODS: Streptococcus pneumoniae type 3 was injected into the middle ear to induce purulent otitis media. As a measure of pars flaccida stiffness, peak displacement versus middle ear pressure was used. The peak displacement measurements were obtained from full-field moiré; interferometry, which is a noncontacting optical technique for deformation measurements. RESULTS: Ears with purulent otitis media showed increased peak displacement of the pars flaccida at a middle ear pressure of 200 daPa, compared with normal controls. CONCLUSION: There was a decreased mechanical stiffness of the pars flaccida in acute purulent otitis media. This decreased stiffness may predispose for future retraction pocket formation and cholesteatoma development.

Chronic myringitis: prevalence, presentation, and natural history.

OBJECTIVE: The aim of this study was to examine the clinical presentation and natural history of chronic myringitis (CM). STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Chronic myringitis is defined as a loss of tympanic membrane epithelium for >1 month without disease within the tympanic cavity. Seven hundred fifty patient records were reviewed to determine the prevalence of CM in an academic otology practice. The records of 40 patients (45 ears) with CM seen between 1995 and 1999 inclusive were reviewed. MAIN OUTCOME MEASURES: The series was reviewed with attention to previous medical and otologic history, the nature and duration of symptoms, the physical findings, and management. RESULTS: The prevalence of CM was found to be -1% (approximately one fourth as common as cholesteatoma). Symptoms were often present for many years before the diagnosis of CM, with CM often mistaken for chronic otitis media. Sixty percent of patients had undergone previous otologic procedures. There did not appear to be an association between CM and systemic disease. Physical findings were varied, with granulation tissue and tympanic membrane perforations often occurring transiently. The clinical course of CM is typified by recurrent episodes of symptoms, often interspersed with long asymptomatic periods. A subset of CM can result in an acquired atresia. The most effective treatment appeared to be prolonged topical medications, surgery being reserved for only the most refractory cases. CONCLUSIONS: Chronic myringitis is often mistaken for chronic otitis media. Such confusion prolongs the initiation of appropriate management and sometimes leads to needless tympanomastoid surgery. The otologist should be aware of this clinical entity and its varied presentation.

Tuberculous otitis media: a significant diagnostic challenge.

OBJECTIVE: This study was undertaken to revise the diagnostic characteristics of tuberculous otitis media (TOM), a disorder that is often diagnosed late, leading to delay in specific treatment. STUDY DESIGN AND SETTING: Retrospective study of a longitudinal series of 10 TOM patients over a 7-year period at an institutional referral center. RESULTS: Most patients showed intractable otorrhea, moderately severe hearing loss, and necrotic eardrums with granulation tissue and single perforations. Multiple perforations, facial palsy, and cervical adenopathies were rare (<10% of patients). CT generally showed soft tissue involvement of the middle ear without bone erosion. The most effective laboratory test microbiological culture of exudate (diagnostic efficacy 71%). Specific antibiotic treatment was effective in all cases. CONCLUSION: The diagnosis of TOM remains a significant challenge for otorhinolaryngologists. SIGNIFICANCE: If there are strong clinical grounds for suspicion, standard laboratory tests for tuberculosis should be repeated even if initially negative.