化脓性中耳炎病原菌感染的研究进展

化脓性中耳炎是耳鼻喉科临床常见疾病,可导致听力下降、鼓膜充血、鼓膜穿孔、耳鸣、耳痛及流脓等。化脓性中耳炎主要由微生物进入中耳引起感染,使中耳黏膜发生化脓性病变,且不同患者感染的病原菌不同。本文从化脓性中耳炎的发病机制、病原菌及其耐药性和治疗方法等几个方面进行综述,以期为临床化脓性中耳炎的诊断及合理用药提供参考。     

PROPER USE OF ANTIBIOTICS IN TREATMENT OF ACUTE OTITIS MEDIA

The problem of preventing loss of hearing following acute otitis media has been made more complex by the use of penicillin and other antibiotic agents which may apparently cure yet leave dangerous residual disease. The causes of loss of hearing must be recognized early if remedial treatment is to be effective. In children particularly, loss of hearing may go unnoticed for some time.Physicians who treat otitis media should feel the responsibility not only of bringing an acutely ill child back to health but of preserving the function of the hearing mechanism. Careful examination of the ear after apparent subsidence of infection is mandatory. It is of the utmost importance to be able to recognize the ear drum in its normal state and its various pathological states and to be alert to the early signs of changes associated with loss of hearing. Antibiotics should not be expected to do more than help combat the acute infection in otitis media. Adequate follow-up demands strong suspicion of residual pathologic process in the ear. The prevention of loss of hearing still requires knowledge of the established clinical facts and therapeutic procedures and the application of this knowledge to treatment of acute infections of the middle ear.     

Complicaciones de la otitis media con parálisis del sexto par craneal contralateral en pediatría

Otitis media is a frequent infection during childhood. Complications may be present in up to 4 of 100 children including serious neurological complications, particularly in developing countries.We report the case of a 9-year-old girl with no disease history who presented with otitis media, otorrhea, intracranial hypertension syndrome, and paralysis of the VI cranial nerve contralateral to the lesion. A computed tomography scan of the skull and a brain magnetic resonance imaging revealed chronic otomastoiditis, petrous apicitis, and thrombosis of the transverse and sigmoid sinus, the jugular bulb, and the right internal jugular vein. She received antibiotics and surgical treatment.This case shows the spectrum of intra and extracranial complications associated with acute otitis media in the antibiotic era. The physical examination allows early identification of intracranial hypertension with signs such as papilledema and sixth contralateral nerve palsy as an unusual finding.     

儿童腺样体肥大程度与分泌性中耳炎发生的相关性研究(英文)

目的:探讨儿童腺样体肥大程度与分泌性中耳炎发生及预后的相关性,指导临床医师对分泌性中耳炎作出早期诊断和治疗。方法:239例住院手术切除腺样体的儿童,常规行鼻咽侧位片、声导抗检查;部分伴耳部症状、声导抗显示C型曲线或查体可疑鼓室积液征者行颞骨CT检查或术中行鼓室穿刺。经统计学分析,比较分泌性中耳炎与腺样体肥大程度及咽鼓管咽口情况的相关性。结果:在239例腺样体肥大儿童中,经鼓室穿刺证实合并分泌性中耳炎者34例(63耳,14.2%),其中鼓室曲线呈B型者33耳(52.4%),C型(-200 dapa)者10耳(15.9%),C型(-200 dapa)者20耳(31.7%)。结果表明分泌性中耳炎的发生与腺样体肥大程度及咽鼓管园枕受压迫的程度呈正相关。结论:声导抗检查不能作为分泌性中耳炎诊断的金标准,必要时可行颞骨CT明确诊断;对腺样体肥大伴分泌性中耳炎的儿童鼻内镜下腺样体切除为其主要疗法,配合鼓室穿刺多可治愈,对反复发作的分泌性中耳炎行鼓室置管术,避免术后并发症的发生。     

Role of Toll-like receptor 4 in innate immune responses in a mouse model of acute otitis media

Nontypeable Haemophilus influenzae (NTHi) is considered a major pathogen underlying middle ear infection. This study characterized the role of Toll-like receptor 4 in the innate immune responses to acute otitis media induced by NTHi in mice. We used C3H/HeJ mice, which have nonfunctional Toll-like receptor 4, and normal wild-type C3H/HeN mice. NTHi were injected into the tympanic bulla, and middle ear effusions and tissues were collected. In C3H/HeN mice, the severity of acute otitis media decreased promptly with a significant reduction in bacterial recovery from middle ear effusions 48 h after injection. In contrast, all C3H/HeJ mice had otitis media at all time points examined, and increasing bacterial counts from middle ear effusions were detected in C3H/HeJ mice 72 h after injection. Expression of intracellular adhesion molecule-1 by the middle ear mucosa paralleled the number of polymorphonuclear cells in the middle ear in both strains. The findings of transmission electron microscopy revealed that phagocytosis and phagosome maturation of polymorphonuclear cells was impaired in C3H/HeJ mice. Our findings indicate that Toll-like receptor 4 plays a part in the early accumulation and functional promotion of polymorphonuclear cells in the middle ear for eradicating NTHi infection.     

Computed tomography in the diagnosis of exudative otitis media

Temporal bone computed tomography (CT) was used to examine 37 patients aged 2 to 55 years who had exudative otitis media; in 27 patients of them, a pathological process was bilateral. An analysis of 58 temporal bone CT scans identified the CT signs of chronic exudative otitis media. These included a partial or complete block of the osseous foramen of the auditory tube; impaired pneumatization of the tympanic cavity, mastoid process fenestrae, and antrum; pathological drawing-in of the tympanic membrane. The preservation of the auditory ossicles and the absence of destructive changes in the walls of the cavities of the middle ear were observed in most cases. Repeated temporal bone CT study was performed in 10 patients (14 temporal bones) in different periods (from 2 months to 3 years) after surgery. The results of tympanostomy were visually assessed. These included recovered pneumatization of middle ear cavities (7 temporal bones), a cicatricial process in the tympanic cavity (5 temporal bones), recurrence of the CT manifestations of exudative otitis media (2 temporal bones).     

Policies on antibiotics of south east London general practitioners for managing acute otitis media in children.

Questionnaires on antibiotic treatment of acute otitis media in children were sent to the general practitioners who make regular referrals to clinics in the King''s College Hospital group. The most popular first choice of drug was amoxycillin (44%), but 37% of general practitioners said that they often used oral phenoxymethylpenicillin. This drug has relatively low activity against Haemophilus influenzae and many strains of Staphylococcus aureus. It is poorly absorbed from the stomach, does not penetrate the middle ear well, and its use may be one factor in the development of chronic middle ear effusions after acute otitis media. Sixty two per cent of the doctors who replied never treated acute otitis media with intramuscular antibiotics, but 57% used oral loading doses. Ninety seven per cent never treated their patients without antibiotics.     

Potentialities of temporal bone computed tomography in the study of the facial nerve and in the diagnosis of peripheral pareses of thr 7th pair of cranial nerves

Computed tomography (CT) was used to examine 200 patients (400 temporal bones) aged 3 to 74 years who had no signs of facial nerve lesion and 28 patients who had clinical manifestations of peripheral paresis of the facial nerve of varying genesis. Multipositional CT of the temporal bone is the most informative mode of visualization of the fallopian canal which is embodied on tomographic scans in 100% of cases irrespective of the age of a patient. CT data indicate that the formation of the facial nerve canal brings to completion by the age of 6 years. The following causes of n. facialis paresis were identified: facial neuroma; sarcoma of the temporal bone sarcoma; dehiscence of the canal wall in otitis media acuta; destruction of the tympanic wall of the canal in otitis nedia chronica, fractures of the temporal bone, anomalies of the fallopian canal in temporal bone malformations; stenosis of the canal in fibrous dysplasia. The detected alterations of the n. facialis canal permits further policy of management of a patient to be defined.     

改良乳突根治术联合后上壁重建对上鼓室胆脂瘤型中耳炎患者听力改善及复发率的影响

摘要 目的：探讨改良乳突根治术联合后上壁重建对上鼓室胆脂瘤型中耳炎患者听力改善及复发率的影响。方法：选取本院2015年5月-2020年10月收治的62例上鼓室胆脂瘤型中耳炎患者作为研究对象,随机将其分为改良组（n=31）和对照组（n=31）。改良组采用改良乳突根治术联合后上壁重建进行治疗,对照组采用乳突根治术进行治疗,对比两组患者手术前后听力情况、术后干耳所需时间等指标。结果：治疗前两组患者的气骨导差、气导听阀对比无明显差异（P>0.05）,治疗后均降低,并且改良组低于对照组（P＜0.05）;改良组患者术后并发症发生率较对照组低（P＜0.05）;改良组患者的术后2周、4周、8周干耳率较对照组高（P＜0.05）,术后干耳所需时间低于对照组（P＜0.05）;改良组治疗总有效率较对照组高（P＜0.05）。结论：将改良乳突根治术联合后上壁重建应用于上鼓室胆脂瘤型中耳炎患者当中,可提高患者听力,降低并发症,还可提高患者干耳率,缩短干耳时间,降低复发率,提高临床疗效,本研究值得临床借鉴。     

耳内镜与显微镜下Ⅰ型鼓室成形术治疗慢性化脓性中耳炎的疗效比较及术后短期内听力恢复效果的影响因素分析

摘要 目的：比较耳内镜与显微镜下Ⅰ型鼓室成形术治疗慢性化脓性中耳炎的疗效,并分析术后短期内听力恢复效果的影响因素。方法：选取2019年3月~2022年2月期间我院收治的158例慢性化脓性中耳炎患者,均接受Ⅰ型鼓室成形术治疗,根据手术方式不同分为耳内镜组（81例）和显微镜组（77例）,比较两组临床疗效及术后6个月的听力恢复不良发生率。收集相关资料,采用多因素Logistic回归分析术后短期内听力恢复效果的影响因素。结果：两组鼓膜穿孔发生例数组间对比无统计学差异（P>0.05）。耳内镜组的手术时间、住院时间短于显微镜组,术中出血量、医疗费用、干耳时间>1个月例数、耳廓麻木发生例数少于显微镜组（P<0.05）。耳内镜组、显微镜组术后6个月的听力恢复不良发生率组间对比无统计学差异（P>0.05）。单因素分析结果显示,慢性化脓性中耳炎患者术后6个月听力恢复效果与鼓室黏膜、鼓膜张肌腱、咽鼓管情况、是否鼓室硬化、听小骨周围是否肉芽包裹、术前鼓室内是否有脓性分泌物有关（P<0.05）。多因素Logistic回归分析显示,鼓膜张肌腱缺损、咽鼓管不通、鼓室硬化、听小骨周围肉芽包裹、术前鼓室内有脓性分泌物是慢性化脓性中耳炎患者术后短期内听力恢复不良的危险因素（P<0.05）。结论：与显微镜下Ⅰ型鼓室成形术治疗慢性化脓性中耳炎相比,耳内镜下进行手术可缩短手术时间、住院时间,减少术中出血量和住院费用,降低并发症发生率。此外,患者术后短期内听力恢复效果受到鼓膜张肌腱、咽鼓管、鼓室硬化、听小骨周围肉芽包裹、术前鼓室内脓性分泌物等多种因素的影响。     

Potentialities of temporal bone computed tomography in the identification of causes of hypoacusis of postinflammatory genesis

Temporal bone computed tomography (CT) was used to examine 64 patients with impaired hearing due to inflammatory diseases of the middle year. In 21 patients, the pathological process was bilateral. A total of 85 series of temporal bone CT scans were analyzed. The patients' age ranged from 2 to 66 years. CT verified adhesive otitis media in 62 cases, otosclerosis in 7, local malformation of the auditory ossicles and/or the labyrinthine fenestrae in 11. No CT changes were revealed in 5 cases. The CT symptoms of adhesive otitis media were identified. These included soft tissue bands and/or soft tissue-density portions that fix the auditory ossicles or block the niches of the labyrinthine fenestrae (31 temporal bones); sclerosis or ossification of the ligaments and tendons of the middle ear (7 temporal bones); calcification foci in the tympanic cavity (9 cases); osteosclerotic changes in the epitympanus (2 cases); cicatricial changes in the tympanic membrane (24 cases); destructive changes in the auditory ossicles (19 temporal bones). There has been evidence that CT may be used for the differential diagnosis of adhesive otitis media from otosclerosis and congenital malformations of the structures of the middle ear.     

Classification of Different Tympanic Membrane Conditions Using Fused Deep Hypercolumn Features and Bidirectional LSTM

Objectives: Middle ear inflammatory diseases are global health problem that can have serious consequences such as hearing loss and speech disorders. The high cost of medical devices such as oto-endoscope and oto-microscope used by the specialists for the diagnosis of the disease prevents its widespread use. In addition, the decisions of otolaryngologists may differ due to the subjective visual examinations. For this reason, computer-aided middle ear disease diagnosis systems are needed to eliminate subjective diagnosis and high cost problems. To this aim, a hybrid deep learning approach was proposed for automatic recognition of different tympanic membrane conditions such as earwax plug, myringosclerosis, chronic otitis media and normal from the otoscopy images.Materials and methods: In this study we used public Ear Imagery dataset containing 880 otoscopy images. The proposed approach detects keypoints from the otoscopy images and following the obtained keypoint positions, extracts hypercolumn deep features from 5 different layers of the VGG 16 model. Classification of tympanic membrane conditions were realized by feeding the deep hypercolumn features to Bi-LSTM network in the form of non-time related data.Results: The performance of the proposed model was evaluated in three different color spaces as Red-Green-Blue (RGB), Hue-Saturation-Value (HSV) and Haematoxylin-Eosin-Diaminobenzidine (HED). The proposed model achieved acceptable results in all color spaces, moreover it showed a very successful performance in classifying tympanic membrane conditions especially in RGB space. Experimental studies showed that the proposed model achieved Acc of 99.06%, Sen of 98.13% and Spe of 99.38%.Conclusion: As a result, a robust model with high sensitivity was obtained for classification of tympanic membrane conditions and it was shown that Bi-LSTM network, which is generally used with time-related data, could also be used successfully with non-time related data for diagnosis of tympanic membrane conditions.     

The human otitis media with effusion: a numerical-based study

Otitis media is a group of inflammatory diseases of the middle ear. Acute otitis media and otitis media with effusion (OME) are its two main types of manifestation. Otitis media is common in children and can result in structural alterations in the middle ear which will lead to hearing losses. This work studies the effects of an OME on the sound transmission from the external auditory meatus to the inner ear. The finite element method was applied on the present biomechanical study. The numerical model used in this work was built based on the geometrical information obtained from The visible ear project. The present work explains the mechanisms by which the presence of fluid in the middle ear affects hearing by calculating the magnitude, phase and reduction of the normalized umbo velocity and also the magnitude and phase of the normalized stapes velocity. A sound pressure level of 90 dB SPL was applied at the tympanic membrane. The harmonic analysis was performed with the auditory frequency varying from 100 Hz to 10 kHz. A decrease in the response of the normalized umbo and stapes velocity as the tympanic cavity was filled with fluid was obtained. The decrease was more accentuated at the umbo.     

Smartphone‐based spectral imaging otoscope: System development and preliminary study for evaluation of its potential as a mobile diagnostic tool

We develop a novel smartphone‐based spectral imaging otoscope for telemedicine and examine its capability for the mobile diagnosis of middle ear diseases. The device was applied to perform spectral imaging and analysis of an ear‐mimicking phantom and a normal and abnormal tympanic membrane for evaluation of its potential for the mobile diagnosis. Spectral classified images were obtained via online spectral analysis in a remote server. The phantom experimental results showed that it allowed us to distinguish four different fluids located behind a semitransparent membrane. Also, in the spectral classified images of normal ears (n = 3) and an ear with chronic otitis media (n = 1), the normal and abnormal regions in each ear could be quantitatively distinguished with high contrast. These preliminary results thus suggested that it might have the potentials for providing quantitative information for the mobile diagnosis of various middle ear diseases.     

The immunoregulatory and allergy-associated cytokines in the aetiology of the otitis media with effusion

Inflammation in the middle ear mucosa, which can be provoked by different primary factors such as bacterial and viral infection, local allergic reactions and reflux, is the crucial event in the pathogenesis of otitis media with effusion (OME). Unresolved acute inflammatory responses or defective immunoregulation of middle inflammation can promote chronic inflammatory processes and stimulate the chronic condition of OME. Cytokines are the central molecular regulators of middle ear inflammation and can switch the acute phase of inflammation in the chronic stage and induce molecular-pathological processes leading to the histopathological changes accompanying OME. In this review we present cytokines identified in otitis media, immunoregulatory [interleukin (IL)-2, IL-10, transforming growth factor-beta]) and allergy associated (IL-4, IL-5, granulocyte-macrophage colony-stimulating factor), as crucial molecular regulators, responsible for chronic inflammation in the middle ear and the chronic condition of OME.     

Chronic Conductive Hearing Loss Leads to Cochlear Degeneration

Synapses between cochlear nerve terminals and hair cells are the most vulnerable elements in the inner ear in both noise-induced and age-related hearing loss, and this neuropathy is exacerbated in the absence of efferent feedback from the olivocochlear bundle. If age-related loss is dominated by a lifetime of exposure to environmental sounds, reduction of acoustic drive to the inner ear might improve cochlear preservation throughout life. To test this, we removed the tympanic membrane unilaterally in one group of young adult mice, removed the olivocochlear bundle in another group and compared their cochlear function and innervation to age-matched controls one year later. Results showed that tympanic membrane removal, and the associated threshold elevation, was counterproductive: cochlear efferent innervation was dramatically reduced, especially the lateral olivocochlear terminals to the inner hair cell area, and there was a corresponding reduction in the number of cochlear nerve synapses. This loss led to a decrease in the amplitude of the suprathreshold cochlear neural responses. Similar results were seen in two cases with conductive hearing loss due to chronic otitis media. Outer hair cell death was increased only in ears lacking medial olivocochlear innervation following olivocochlear bundle cuts. Results suggest the novel ideas that 1) the olivocochlear efferent pathway has a dramatic use-dependent plasticity even in the adult ear and 2) a component of the lingering auditory processing disorder seen in humans after persistent middle-ear infections is cochlear in origin.     

Twice-daily antibiotics in the treatment of acute otitis media: trimethoprim-sulfamethoxazole versus amoxicillin-clavulanate.

Twice-daily trimethoprim-sulfamethoxazole has been shown to be effective in the treatment of acute otitis media except that caused by group A beta-streptococci. Amoxicillin-clavulanate potassium is effective in vitro against all bacterial pathogens causing acute otitis media and has been reported to be effective when given twice daily for urinary tract infections, acute otitis media and respiratory tract infections. To determine whether the in-vitro efficacy of amoxicillin-clavulanate carries over clinically, we conducted a prospective randomized double-blind trial in 219 children presenting at a pediatric walk-in clinic. Diagnosis and follow-up assessments were made by means of examination of the tympanic membrane and acoustic otoscopy. Of the 219 children 202 (101 in either group) were assessed by a specially trained nurse at a follow-up visit 12 to 16 (mean 14) days after treatment was begun. Cure was defined as absence of symptoms and normal results of both visual inspection of the tympanic membrane and acoustic reflectometry; improvement was defined as absence of symptoms and either normal appearance of the tympanic membrane or normal results of acoustic reflectometry; treatment failure was defined as abnormal appearance of the tympanic membrane along with an acoustic reflectometry reading of 5 units or more. There were no differences in age (mean 60 months), sex or proportion of subjects with unilateral versus bilateral disease between the two groups. The combined rate of cure an improvement was significantly higher with trimethoprim-sulfamethoxazole (93%) than with amoxicillin-clavulanate (82%) (p = 0.03). The rate of compliance (more than 80% of the drug taken) did not differ significantly between the two groups. Gastrointestinal side effects were more common with amoxicillin-clavulanate (p less than 0.0001). Our results suggest that for acute otitis media twice-daily trimethoprim-sulfamethoxazole is more effective clinically and produces fewer side effects than twice-daily amoxicillin-clavulanate.