Earaches Homeopathic Remedies

Natures Amazing Ear Infection Cures By Naturopath Elizabeth Noble

Little Known Secrets To Cure An Ear Infection Fast! Here's A Taste Of What's Revealed In The Nature's Amazing Ear Infection Cures e-book: What type of ear infection do you or your loved one have? The 9 ear infection symptoms you can't afford to ignore. Danger at the drugstore what drugs you should never buy. Why antibiotics are useless and possibly dangerous for most ear infections. The problems with surgery. The causes and triggers of an ear infection everything from viruses, bacteria and fungi to allergies, biomechanical obstruction, environmental irritants, nutrient deficiencies, poor infant feeding practices and more. How to relieve even the most excruciating ear ache with a hot onion poultice. An ancient Ayurvedic recipe to control an ear infection. The herbal ear drops you can make in your own kitchen that are renowned for soothing ear pain. The wonderful essential oil ear rubs you can make to ease ear congestion and discomfort. The simplicity of homeopathy for treating an ear infection great for babies and young children. User-friendly acupressure, massage and chiropractic to relieve ear pain, enco. How to relieve problem ears with air travel.

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Acute Otitis Media Microbiology

Other organisms that less frequently cause AOM include group A beta-hemolytic streptococci (GABHS), Staphylococcus aureus, Turicella otitidis, Alloiococcus otitis Chlamydia spp., and Staphylococcus epidermidis, and various aerobic and faculatative gram-negative bacilli (7) including Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Proteus spp. Gram-negative bacilli and staphylococci are implicated as dominant etiologic agents in otitis media of the neonate. However, even among very young infants, S. pneumoniae and H. influenzae constitute the most common etiologic agents. Viruses were recovered in the middle-ear fluid of 14.3 of children (8). TABLE 1 Bacteria Isolated from 186 Cases of Acute Otitis Media TABLE 1 Bacteria Isolated from 186 Cases of Acute Otitis Media

Adhesive Otitis Media

Adhesive Otitis Media

Adhesive Otitis Media 69 Fig. 5.9 Inactive adhesive otitis media, with deep posterosuperior retraction pocket and incus erosion. (Source Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart Thieme 1999) A patient with a quiescent retraction pocket posterosuperiorly may have the usual complaints related to negative pressure, or none at all. On examination, one will see an indentation of the drum over the incus-stapes joint, sometimes outlining these structures in sharp relief (Fig. 5.9). Sometimes, the pocket is hard to distinguish from a perforation, and in fact, a perforation may be present within the pocket. Diagnostically, negative pressure with the pneumatic otoscope may lift the drum off the ossicles if the pocket is not too deep, adherent, or perforated. If the drum is deeply adherent, then there is probably no mobility. The term for this occurrence is adhesive otitis media. (On Fig. 5.9, a deep retraction, adherent to the incus and stapes head, is shown. The end of...

Malignant Otitis Externa

Malignant otitis externa is also known as necrotizing otitis externa or skull base osteomyelitis in its full-blown form. Obviously, the second name is the gentlest one, but the other two imply its ominous characteristics. This type of infection is typically seen in elderly diabetics or immunocompromised patients. It can spread from the external canal to cause osteomyelitis in the temporal bone with potentially fatal complications. Characterisically, the patient presents with an external earache similar to other forms of external otitis. However, examination of the ear shows something different. The canal may be swollen and tender, but a small area of red granulation tissue is seen posteroinferiorly in the canal at the junction of cartilage with bone, one-third inward. This finding, plus the type of patient described, points to the diagnosis. Otitis Externa 41 Acute diffuse otitis externa ( swimmer's ear ) is much more common than the localized furuncle, and should be recognized by its...

Acute Otitis Externa Swimmers

External otitis is defined as a varying degree of an inflammation of the auricle, external ear canal, or outer surface of the tympanic membrane (67). The etiology of the inflammation can be an infection, inflammatory dermatoses, trauma, or a combination of these. Sudden onset of diffuse infection involving the external auditory canal is termed acute otitis externa (68). The most predominant cause of the acute infection is P. aeruginosa. The diffuse infection needs to be differentiated from a localized furunculosis of the hair follicles that is caused by aerobic gram-positive bacteria. Chronic otitis externa results from persistence of the infection that causes thickening of the canal skin. Extension of the infection that encompasses the bone and cartilage is termed necrotizing otitis externa (69,70).

Mycotic Otitis Externa

This disorder is also known as fungal otitis externa or chronic diffuse otitis externa. It differs from the previously mentioned infections in that it is not quite so painful, but more indolent, yet persistent. The usual complaints are of blockage, thick drainage, dull pain, and itching. These infections occur more often than most clinicians expect, and they are often treated inappropriately with antibiotic drops. The most notable finding on ear examination is the presence of matter thick moist debris in the canal (Fig. 4.7). Fig. 4.7 Fungal otitis externa. (Source Hughes GB, Pensak ML. Clinical Otology. New York Thieme 1977) Fig. 4.7 Fungal otitis externa. (Source Hughes GB, Pensak ML. Clinical Otology. New York Thieme 1977) Treatment of these fungal infections keys on complete removal, so that no spores are present for regrowth. If there is no perforation of the TM, gentle irrigation and suction may be the best way to clear the canal. (Caution irrigating an infected ear is not...

Ear Infections

Otitis media is one of the most common diseases of early childhood. The incidence is highest between 6 and 18 months. There are four defined types of otitis media (1) (z) acute otitis media (AOM) is characterized by a rapid onset of signs and symptoms of middle-ear inflammation. Earache, bulging of the tympanic membrane, and purulent exudate characterize the early phase of infection. Even though clinical signs and symptoms resolve rapidly, the effusion can persist (ii) otitis media with effusion (OME) refers to the presence of asymptomatic effusion. It may follow acute otitis media with effusion (AOME) or appear as silent or secretory otitis media (iii) chronic otitis media with effusion (COME) denotes a persistence of fluid for three months or longer. The fluid is more mucoid, so-called glue ear and (iv) chronic suppurative otitis media (CSOM) signifies chronic drainage through a perforation of the tympanic membrane.

Otitis Externa

We will now discuss several forms of external otitis. At this point, it is important to introduce two key clinical concepts. The first is that with an acute earache the presence of tenderness helps to distinguish between otitis externa and otitis media. If you are called on the phone at an inconvenient time by a mother whose child is screaming with an earache, ask her to pull backward on the auricle or press on the tragus. This will hurt if the problem is external, but will not if only the middle ear is infected. At least you can get a feel for the cause, and perhaps the treatment. This leads to the second point. The bacterial organisms causing Otitis externa are usually Pseudomonas, Staphylococcus, Proteus, Enterobacter, or other Gram-negatives. On the other hand, the bacterial offenders for acute otitis media are usually Pneumococcus, Haemophilus influenza, and Morax-ella catarrhalis, the ones that are often seen in acute sinusitis or other bacterial respiratory infections. This...

Acute Otitis Media

Acute otitis media is classically described in several stages. The first is that of inflammation. Here, the patient complains of earache and fullness, and the drum shows red injection along the most vascular areas behind the manubrium of the malleus, and at the annular periphery. This proceeds quickly to the stage of exudation, where the middle ear fills with pus. Pain increases, with a decrease in hearing. The reddened drum appears thick, opaque, and bulging. There is some controversy regarding the antibiotics recommended to treat acute otitis media. A number of the organisms mentioned above have developed resistance to the traditional antibiotics. However, in the interest of cost-saving, many sources still recommend amoxicillin as the first-line treatment for newly diagnosed, uncomplicated infections. Penicillin-allergic individuals may be given trimethoprim sulfa combinations or the macrolides (e.g. Biaxin), although there are more resistant bacteria than to amoxicillin. However,...

Middle Ear Infection

Otitis23 media (middle-ear infection) is common in children because their auditory tubes are relatively short and horizontal. Upper respiratory infections can easily spread from the throat to the tympanic cavity and mastoidal air cells. Fluid accumulates in the cavity and produces pressure, pain, and impaired hearing. If otitis media goes untreated, it may spread from the mastoidal air cells and cause meningitis, a potentially deadly infection (see insight 14.1). Otitis media can also cause fusion of the middle-ear bones and result in hearing loss. It is sometimes necessary to drain fluid from the tympanic cavity by lancing the eardrum and inserting a tiny drainage tube a procedure called myringotomy.24 The tube, which is eventually sloughed out of the ear, relieves the pressure and permits the infection to heal.

Virulence of Anaerobic Bacteria and the Role of Capsule

Anaerobic Organisms

Clinical and animal studies showed bacterial synergy between anaerobic and aerobic or other anaerobic bacteria (12,13). Data derived from therapy of mixed infection also provided support for the importance of anaerobic bacteria. Polymicrobial infection involving aerobic and anaerobic bacteria responded to therapy directed at the eradication of only the anaerobic component of the infection with either metronidazole or clindamycin (14). However, for complete eradication of the infection, animal and patient studies have demonstrated that unless therapy is directed against both aerobic and anaerobic bacteria, the untreated organisms will survive (15-18). Bartlett et al. (15) demonstrated in an intra-abdominal abscess model in rats that combined therapy of clindamycin and gentamicin was needed to prevent mortality caused by Escherichia coli sepsis and abscesses caused by B. fragilis. Thadepalli et al. (16) showed that in patients with intra-abdominal trauma, clindamycin and kanamycin were...

Collection Transportation and Processing of Specimens for Culture

Transport Specimen For Culture Test

Earlier studies of chronic otitis media (1) and human and animal bites (2), which did not employ methods for anaerobes found these organisms in a small number of cases. However, when better techniques were used, anaerobes were recovered in the majority of the cases (3,4). Because anaerobes may invade any body site, and they have been recovered in a variety of infections in children, anaerobes' potential role in an infectious site should be assessed individually. The prevalence of anaerobic bacteria in an infection is a major factor in deciding which clinical specimens should be processed for anaerobes. Because anaerobic bacteria frequently can be involved in various infections, ideally, all properly collected specimens should be cultured for these organisms. The physician should make special efforts to isolate anaerobic organisms in infections in which these organisms are frequently recovered, such as abscesses, wounds in and around the oral and anal cavities, chronic otitis media and...

Bacteroides fragilis Group

Bacteroides Fragilis Group

Although B. fragilis group is the most common species found in clinical specimens, it is the least common Bacteroides present in fecal flora, comprising only 0.5 of the bacteria present in stool. The pathogenicity of this group of organisms probably results from its ability to produce capsular material, which is protective against phagocytosis (57). Because of its presence in normal flora of the gastrointestinal tract, this organism is predominant in bacteremia associated with intra-abdominal infections (2,32), peritonitis and abscesses following rupture of viscus (18,19), and subcutaneous abscesses or burns near the anus (58,59). Although B. fragilis is not generally found as part of the normal oral flora, it can colonize the oral cavity of patients with poor oral hygiene or of those who previously received antimicrobial therapy, especially penicillin. Following the colonization of the oropharyngeal cavity, these organisms also can be recovered from infections that originate in this...

Introduction to Anaerobes

Gram Stai Bilophila

Neck infections Shunt infections (cardiac, intracranial) Chronic otitis media, cervical lymphadenitis Clostridia strains (C. perfringens, C. butyricum, and C. difficile) have been recovered from blood and peritoneal cultures of necrotizing enterocolitis and from infants with sudden death syndrome (8-10). Strains of Clostridium were recovered from children with bacteremia of gastrointestinal origin (11) and with sickle cell disease (12). Clostridial strains have been recovered from specimens obtained from patients with acute (13) and chronic (14) otitis media, chronic sinusitis and mastoiditis (15,16), peritonsillar abscesses (17), peritonitis (18,19), liver and spleen abscesses (20), abdominal abscesses (21), and neonatal conjunctivitis (22,23). Eubacterium spp. are part of the flora of the mouth and the bowel. They have been recognized as pathogens in chronic periodontal disease (29) and in infections associated with intra-uterine devices (30), and have been isolated from patients...

Historical Perspective

In the first three decades of the 20 th century there were numerous reports of PTS occurring in conjunction with chronic suppurative otitis media and mastoiditis to the extent that Symonds 170 in 1931 felt able to define a condition of otitic hydrocephalus in which CSF excess due to over-production or impaired absorption followed cranial venous sinus, particularly but not exclusively transverse sinus obstruction, occurring secondary to chronic middle ear or other infection. In addition, Liedler in 1928 102 was probably the first to describe PTS after ligation of one or both internal jugular veins in the treatment of chronic ear disease. Symonds' concept did not, however, survive the neuroradiological developments of the 1930s when the newly introduced techniques of encephalography and ventriculography showed that there was no demonstrable increase in the volume of fluid in the intracranial CSF-containing spaces in these cases. This has, of course, been an enduring difficulty in...

Other Chronic External Ear Disorders

Some patients suffer from another disorder, chronic stenosing otitis externa. These individuals have repeated infections sometimes cultures are positive for bacteria or fungi, and sometimes there is no identifiable pathogen. The dermatoses may be involved. The external canal itches, drains repeatedly, and becomes chronically swollen, with progressively severe narrowing of the lumen. This problem responds temporarily to office cleansing and wick eardrop insertions, but it is often relentless. Severe cases may eventually need surgery to widen the canal. Canalplasty with skin grafting, or even limited mastoidectomy, can be performed to open the canal and regain the hearing. Other individuals have problems with ongoing or recurrent acute otitis externa without the complication of stenosis. These patients often create their own problems and should be cautioned regarding the cause and prevention of external otitis. Many individuals feel the need to dowse their ears daily with water in the...

Infection and Facial Paralysis

As mentioned in Chapter 3, acute otitis media may rarely cause paresis, possibly by way of a bony dehiscence in the fallopian canal. If a face becomes rapidly weak on the side of an acute infection, myringotomy and aspiration, with a culture and appropriate antibiotics, are the accepted treatments. Most of these patients will recover. If facial weakness occurs 2 or 3 weeks after an acute otitis, be suspicious for acute coalescent mastoiditis. A thorough ear examination and work-up, with a CT of the mastoid, would be indicated. Chronic mastoiditis, either with granulation tissue or cholesteatoma, can also cause facial paralysis.

Guidelines for Empirical Therapy

Because the magnitude of PK PD parameters determined in animal infection models can be predictive of antimicrobial efficacy in human infections, it is easy to understand why pharmacodynamics is being used more and more in establishing guidelines for empirical therapy. Recently published guidelines for otitis media, acute bacterial rhinosinusitis, and community-acquired pneumonia have used the ability of antimicrobials to reach the magnitude of PK PD parameters required for efficacy for both susceptible pathogens and those with decreased susceptibility to rank or select antimicrobials for empirical therapy of these respiratory infections 36,50,78 .

Presentations Localized tetanus

Cephalic tetanus is a peculiar form of local tetanus, presenting as trismus plus paralysis of one or more cranial nerves. Facial paresis and dysphagia are common presentations. Abnormal ocular movements including ophthalmoplegic tetanus can appear. Cephalic tetanus is usually associated with infections of paracranial structures, especially chronic otitis media or dental infection.

Differential Diagnosis

The diagnosis can be even more difficult in a number of clinical settings. Patients who are immunocompromised, through diseases or medications, and patients at both extremes of age commonly have atypical histories and physical findings. Radiographic studies can be helpful in these patients. Gynecological conditions can be distracting in female patients. A pelvic examination, if not a pelvic ultrasound, is always warranted in this population. Young patients with conditions such as otitis media, streptococcal pharyngitis, meningitis, and mesenteric lymphadenitis may have abdominal complaints which can masquerade as appendicitis. Inflammatory bowel disease should always be considered in a patient with right lower quadrant abdominal pain. A final important consideration is the differential diagnosis of typhlitis, or neutropenic enterocolitis, in neutropenic patients undergoing chemotherapy for onco-logic conditions.

Abscesses Of The Head And Neck General Considerations

Staphylococcus aureus and Group A beta-hemolytic streptococci (GABHS) were established as the predominant pathogens in abscesses of the head and neck in most studies done until 1970 (1). However, when methodologies suitable for recovery of anaerobic bacteria were used, these organisms were found to predominate especially in infections that originated from sites where these organisms are the predominant flora (i.e., dental, sinus, and tonsillar infections) (2,3). The recovery of anaerobes from abscesses and other infections of the head and neck is not surprising because anaerobic bacteria outnumber aerobic bacteria in the oral cavity by a ratio of 10 1 (4). Furthermore, these organisms were recovered from chronic upper respiratory infections such as otitis and sinusitis, and from periodontal infections (1).

BL in Clinical Infections

BL activity was detected in 46 of 88 (55 ) ear aspirates that contained BLPB (184). Brook et al. found BL activity in ear aspirates of 30 of 38 (79 ) children with chronic otitis media (209), in 17 of 19 (89 ) ear aspirates of children with acute otitis media who failed amoxicillin (AMX) therapy (210), and in 12 sinus aspirates (three acute and nine chronic infection) of the 14 aspirates that contained BLPB. The predominant BLPBs in acute sinusitis were H. influenzae, and Moraxella catarrhalis those in chronic sinusitis were S. aureus, Prevotella spp., Fusobacterium spp., and B. fragilis (see Table 5, chapter 14) (211).

Chronic Mastoiditis

Chronic suppurative otitis media that often acompanies chronic M is treated with topical antimicrobial therapy and thorough aural toilet and system antimicrobials are given if this approach fails. The empirical choice of systemic antimicrobials for chronic M is directed at the eradication of both aerobic and anaerobic bacteria. Some of the anaerobic organisms, such as B. fragilis, and many pigmented Prevotella and Porphyromonas and Fusobacterium spp. are resistant to penicillins through the production of the enzyme beta-lactamase.

Microbiology Acute Mastoiditis

Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, Haemophilus influenzae are the most common organisms recovered (4-8). Rare organisms are Pseudomonas aeruginosa and other gram-negative aerobic bacilli, and anaerobes (6-12). Several studies demonstrated the predominance of P. aeruginosa in acute M. This organism is a known pathogen in chronic otitis media and chronic M (13). Since this organism is a common colonizer of the ear canal (14) it is possible that some of these isolates recovered from pus collected from the ear canal do not represent a true infection. Mastoiditis is rarely caused by tuberculosis.

Carbenicillin Ticarcillin Piperacillin and Mezlocillin

Carbenicillin was effective in the treatment of pulmonary and intra-abdominal anaerobic infections in adults (26,27) and active alone or in combination with an aminoglycoside in treatment of aspiration pneumonia (28) and chronic otitis media (29) in children. Carbenicillin has a particular advantage in these infections because of its synergistic quality with aminoglycosides against Pseudomonas aeruginosa, which was also present in these infections.

Pathogensesis And Pathology

Actinomyces species are agents of low pathogenicity and require disruption of the mucosal barrier to cause disease. Actinomycosis usually occurs in immunocompetent persons but may afflict persons with diminished host defenses. Oral and cervicofacial diseases commonly are associated with dental caries and extractions, gingivitis and gingival trauma, infection in erupting secondary teeth, chronic tonsillitis, otitis or mastoiditis, diabetes mellitus, immunosuppression, malnutrition, and local tissue damage caused by surgery, neoplastic disease, or irradiation. Pulmonary infections usually arise after aspiration of oropharyngeal or gastrointestinal secretions. Gastrointestinal infection frequently follows loss of mucosal integrity, such as with surgery, appendicitis, diverticulitis, trauma, or foreign bodies (1). The use of intrauterine contraceptive devices (IUDs) was linked to the development of actinomycosis of the female genital tract. The presence of a foreign body in this setting...

Measles Edmonston virus MeV

Prodromal stage 4-5 days, followed by mounting fever, the appearance of Koplik's spots on the buccal mucosa and rash on head and neck spreading to the trunk and limbs. Recovery usually rapid but the disease can be fatal, especially in poorly nourished children. The rash is dependent on the presence of a specific immune response and is absent from certain immunodeficient patients. The patient is most infectious in the prodromal period and transmission is by airborne droplets. Respiratory complications and otitis media due to secondary bacterial infection are common. Encephalitis occurs rarely but is a serious complication with high mortality and incidence of sequelae. Subacute sclerosing panencephalitis, a rare progressive degenerative disease of the CNS, is associated with chronic infection. Virion ether-sensitive, roughly spherical, 150 nm in diameter, buoyant density in CsCl about 1.27g ml, and contains a helical nucleocapsid of about 17 x 1100nm. The...

Production of BL by Anaerobic Gram Negative Bacilli in Clinical Infections

One-hundred and eleven of 387 (29 ) pigmented Prevotella and Porphyromonas spp., which accounted for 12 of BLPB, were isolated in 15 of the patients with BLPB. The highest frequency of recovery of BL-producing pigmented Prevotella and Porphyromonas spp. isolates was found in URTI (38 of all pigmented Prevotella and Porphyromonas spp. isolates) the isolates were recovered in 28 of patients with URTI, mostly in those with recurrent tonsillitis and chronic otitis media. In pulmonary infections, 22 of the pigmented Prevotella and Porphyromonas spp. isolates produced BL and they were isolated in 16 of the patients. Although 22 of the isolates of the pigmented Prevotella and Porphyromonas spp. produced BL in skin and soft tissue infections, these organisms were isolated only in 7 of patients with these infections, mostly in those that were in close proximity or originated from the oral cavity.

Lincomycin and Clindamycin

Not be administered in CNS infections (61,62). Because of the effectiveness of its activity against anaerobes, it is frequently used in combination with aminoglycosides for the treatment of mixed aerobic-anaerobic infection of the abdominal cavity and obstetric infection (63). The side effect of most concern with clindamycin is colitis (64). It should be noted that colitis has been associated with a number of other antimicrobial agents, and has been described in seriously ill patients in the absence of previous antimicrobial therapy. Colitis following clindamycin therapy was associated with recovery of C. difficile strains in adults and children (65). The occurrence of colitis in pediatric patients is very rare, however (66). Clinical studies using clindamycin in a pediatric population showed it to be effective in the treatment of intraabdominal infections (67), aspiration pneumonia (68), chronic otitis media (69), and chronic sinutis (70). Clindamycin has also an important role in...

Correlation To In Vitro Resistance

Although resistance data for pneumococcal pneumonia do not correlate well with clinical outcomes, studies in acute otitis media (AOM) have produced more predictable outcomes. In a comparative study utilizing either cefuroxime axetil or cefaclor for the treatment of AOM, Dagan et al. 110 found that cefuro-xime axetil consistently produced better outcomes. These data showed that increasing penicillin resistance correlated with statistically significant (P 0.001) bacteriological failures despite cephalosporin therapy. The penicillin MIC ranges of

Lateral Pharyngeal Space

The lateral pharyngeal space is continuous with the carotid sheath. Involvement of this space may follow pharyngitis, tonsillitis, otitis, parotitis, and odontogenic infections. Anterior compartment involvement is characterized by fever, chills, pain, tremors, and swelling below the angle of the jaw. Posterior compartment infection is characterized by septicemia, often with few local signs. Other complications include edema of the larynx, asphyxiation, internal carotid artery, and erosion internal jugular vein thrombosis. Close observation is mandatory and tracheostomy may be required. Surgical drainage and parenteral antibiotic therapy are needed.

Microbiology and Pathogenesis

Meningitis caused by F. necrophorum has been associated with chronic otitis media and an episode of upper respiratory infection (4,5). C. perfringens is a cause of meningitis following head injuries or surgery (2,6), that is fatal in about a third of patients despite therapy. Contamination of these wounds with environmental or endogenous flora would explain the entry of C. perfringens into the CNS.

Bacterial Interactions With Mucosal Surfaces

S. pneumoniae is responsible for several localized and systemic infections such as otitis media, meningitis, sepsis, and pneumonia. There is a well-established relationship between pneumococcal bacteremia associated with pneumonia and mortality of aging subjects (38). Among patients with bacteremia, the fatality rate has been related to age as follows 17-18 among

The Tympanic Membrane and its Landmarks

Scar Tympanic Membrane

The vascular strip of vessels, not visible in Figure 3.3, but very prominent in Figure 5.5. This is seen on the upper drum just posterior to the manubrium, giving off vessels that course down the TM just behind the manubrium, as well as posteriorly, running along the peripheral annulus. These vessels may become bright red and inflamed in the early stages of acute otitis media. However, they may also be somewhat prominent in the normal individual.

The External Auditory Canal

Santorini Fissure Ear

The fissures of Santorini (discontinuities in the cartilage of the outer canal) enable infection or neoplasm to easily spread down and forward into the adjacent parotid gland. Hence, a patient with a severe external otitis can develop cellulitis and parotitis adjacent to the ear. The outer third of the canal can be very narrow in width in some patients, limiting good access to the inner two-thirds and the TM. However, these individuals usually have normal-caliber bony canals further in. In general, the external canal is about 9 mm in height and 7 mm in width (due to the anterior bony hump). It is significant that other areas innervated by these four cranial nerves can transmit referred pain to the ear. Examples include post-tonsillectomy otalgia (ear pain) via cranial nerve IX or, more ominously, otalgia from malignancies in the tonsil, hypopharynx, or supraglottic larynx via cranial nerves IX and X. Several years ago I was referred a patient whose only complaint was a left earache,...

Diagnosis Investigation And Discussion

Rhinitis with sinusopathy was diagnosed based on rhinoscopy showing hyperaemia with no focal lesion and perinasal sinuses CT-scan images compatible with chronic pansinusopathy of ethmoido-maxilar predomination, with destructive characteristics (amputation of the conchae and sept perforation). ENT findings were normal otoscopy positive hearing tests for mixed conductive and sensory hearing loss of light degree on the left side and of moderate degree on the right side. CT scan of the temporal bones showed bilateral middle ear involvement right side occlusion of the oval and round windows by liquid collection no signs of cholesteatoma or of ossicle destruction, compatible with bilateral medial chronic otitis, particularly on the right ear. It is known that sensory hearing loss is common in Behget s syndrome as part of neural involvement and that in several diseases, external, middle or inner ear structures are subject to immunological injury4. What seems strikingly new in this case is...

Overview of Mastoiditis

Acute mastoiditis or acute coalescent mastoiditis refers to the purulent type that may occur following untreated severe acute otitis media. It is rare nowadays, but can be diagnosed by the physical findings and CT scanning. 2. Chronic mastoiditis refers to two types of ongoing infection in the mastoid antrum and or air cells a) One type is the erosive, expanding epidermal cyst cholesteatoma. b) A second type occurs with chronic draining middle ear perforations. Here, purulent material and or granulation are present in the middle ear and adjacent mastoid cavity. The term chronic suppurative otitis media overlaps this entity. Rockley TJ. Family studies in serous otitis media. In Lim DJ, Bluestone CD, Klein JO, Nelson JD, eds. Recent Advances in Otitis Media. Philadelphia BC Decker 1988 22-23. Rosenfeld RM. Comprehensive management of otitis media with effusion. Otolaryngol Clin North Am. 1994 27 3 443-455. Pulec JL, Horwitz MJ. Diseases of the eustachian tube. In Paparella MM, Shumrick...

Therapeutic Implications of Indirect Pathogenicity

A similar study evaluated the effects of AMX-C and AMX therapy on the nasopharyngeal flora of 50 children with acute otitis media (248). After therapy, 16 (64 ) of the 25 patients treated with AMX and 23 (92 ) of the 25 patients treated with AMX-C were considered clinically cured. A significant reduction in the number of both aerobic and anaerobic isolates occurred after therapy in those treated with either agent. The number of all isolates recovered after therapy in those treated with AMX-C was significantly lower (60 isolates) than in those treated with AMX (133 isolates, p 0.001). The recovery of known aerobic pathogens (e.g., S. pneumoniae, S. aureus, GABHS, Haemophilus spp., and M. catarrhalis) and penicillin-resistant bacteria after therapy was lower in the AMX-C group than in the AMX group (p 0.005).

Anaerobic Bacteria Pathogenesis

The demonstration of synergy between the anaerobic and aerobic bacteria commonly recovered in ear infections further suggests their pathogenic role in these infections. The microbial dynamics of persistent otitis media that eventually became chronic was also investigated (61). The study was done over a period of 36 to 55 days when the aerobic-anaerobic microbiology of ear aspirate was established for children who presented with AOM with spontaneous perforation, did not respond to initial empiric therapy, and developed a persistent infection. Repeated aspirates of middle-ear fluid revealed the dynamic of emergence of new microbial pathogens and the response of the patients to antimicrobials. FIGURE 1 Dynamics of the microbiology and therapy of persistent otitis media. Abbreviations AMX, amoxicillin BL +, beta-lactamase producer CFC, cefaclor CIPR, ciprofloxacin CLN, clindamycin TMS, trimethoprim. Source. From Ref. 61.

Pathogenesis and Microbiology

The adenoids are believed to play a role in several infectious and noninfectious upper airway illnesses. They may be implicated in the etiology of otitis media (87-91), rhinosinusitis (92,93), adenotonsillitis (94), and chronic nasal obstruction due their hypertrophy (95,96). Brook et al. (98) determined the qualitative and quantitative microbiology of core adenoid tissue obtained from four groups of 15 children each with recurrent otitis media (ROM), RAT, obstructive adenoid hypertrophy (OAH), and occlusion or speech abnormalities (controls).

Complications

These include acute otitis media (that is related to eustachian tube dysfunction or due to the presence of nasogastric tube), aspiration pneumonia, hypoxic encephalopathy, hyponatremia due to excretion of antidiuretic hormone in response to decreased atrial filling because of venous pooling in the paralyzed infant, urinary tract infection due to indwelling bladder catheter, Clostridium difficile collitis due to colonic stasis with manifestations of toxic megacolon and necrotizing enterocolitis (47), and septicemia associated with intravascular catheters.

Clinical Studies

Human studies to determine the optimal pharmacodynamics of P-lactams have focused on infections in acute otitis media (AOM) or continuous infusion (CI) settings. AOM is an attractive model because of the relative ease of fluid collection that can be used for determining antibiotic concentation or MIC over time. A more in-depth discussion of AOM is presented in Section 7. Clinical data with continuous infusion provide important information because the pharmacodynam-ics are maximized with a prolonged time above the MIC. The following section presents a summary of relevant continuous infusion studies.

Incidence

The incidence of M parallels that of AOM, peaking in those aged 6 to 13 months. The incidence of M has decreased since the advent of antimicrobial agents and has become quite rare. The incidence of M from AOM in the U.S.A., and other developed countries is currently 0.004 (1-3). However, developing countries have a higher incidence of M, mostly as a consequence of untreated otitis media. Although the incidence of the disease has significantly declined in the U.S.A., it is still a significant infection with the potential of life-threatening complications. Of great concern is the sharp increase noted in the last decade in the incidence of acute M in several locations (2). This increase may be due to the greater recovery rate of resistant organisms, increased virulence of the pathogens and a lower use of antibiotics for the therapy of AOM (3).

Deafness

Deafness means any hearing loss, from mild and temporary to complete and irreversible. Conductive deafness results from any condition that interferes with the transmission of vibrations to the inner ear. Such conditions include a damaged eardrum, otitis media, blockage of the auditory canal, and otosclerosis.32 Otosclerosis is the fusion of auditory ossicles to each other or fusion of the stapes to the oval window, which prevents the bones from vibrating freely. Sensorineural (nerve) deafness results from the death of hair cells or any of the nervous elements concerned with hearing. It is a common occupational disease of factory and construction workers, musicians, and other people. Deafness leads some people to develop delusions of being talked about, disparaged or cheated. Beethoven said his deafness drove him nearly to suicide.

Computed tomography

In inoperable patients, the usual treatment consists of drainage with a nasogastric tube associated with parenteral hydration. A nasogastric tube can cause great discomfort to the patient and several complications (for instance, erosion of the nasal cartilage, otitis media, aspiration pneumonia, oesophagitis and bleeding). Therefore, it should be considered a temporary measure to reduce the gastric distension when drugs are ineffective for symptom control or when gastrostomy cannot be carried out. If continued drainage is required, operative or percutaneous endoscopic gastrostomy are much better for decompression of the GI tract.

Myringitis

Bullous myringitis is an acute disorder that presents with rapid onset of a severe earache. One or more blebs, resembling the bulge of an inner tube through a worn tire, are seen on the drum (Fig. 5.1). They may be clear, or red and hemorrhagic. There is great sensitivity when the pneumatic otoscope is used. The disease is a self-limited viral one and thus analgesics, both systemic and topical (antipyrene benzocaine drops), are the recommended treatment.

Cephalic tetanus

Cephalic Tetanus

May occur in lesions of the head and neck (e.g., otitis). Symptoms are unilateral facial paralysis, trismus, facial stiffness, nuchal rigidity, and pharyngeal spasms. Caudal cranial nerves and oculomotor nerves may be affected. The incubation period is short, and it may progress to generalized tetanus.

Acute Mastoiditis

Mastoiditis

An individual who has rapid-onset earache following a respiratory infection, and a red or bulging drum, probably has acute otitis media Antibiotic choices are discussed in the text. The extremely rare complication of acute mastoiditis may be recognized by persistent drainage through a nipple-like perforation in the drum for several weeks following an untreated acute infection, with mastoid swelling and tenderness. The primary clinician should follow up on a treated middle ear infection until it is resolved. A CT scan and ENT consultation should be obtained if mastoiditis is suspected, or if middle ear fluid persists.

Human Infections

Bacteriological cure in patients with acute otitis media and acute maxillary sinusitis provides a sensitive model for determining the relationship between outcome and time above MIC for multiple P-lactam antibiotics. A variety of clinical trials have included pretherapy and repeat sinus puncture or tympanocentesis of middle ear fluid after 2-7 days of therapy to determine whether the initial organism isolated had been eradicted 25,32,33,48,54,77,79 . Figure 6 demonstrates the Commonly used parenteral doses of ceftriaxone, cefotaxime, penicillin G, and ampicillin provide free-drug concentrations above the MIC90 for penicillin-intermediate strains of S. pneumoniae for at least 40-50 of the dosing interval. A variety of clinical trials in severe pneumococcal pneumonia including bacter-emic cases have demonstrated that these P-lactams are as effective against these organisms as against fully susceptible strains 43,50,72 . Thus, the magnitude of the PK PD parameter determining efficacy for...

Studies in Children

Brook et al. (31) correlated the microbiology of concurrent chronic otitis media with effusion and chronic maxillary sinusitis in 32 children. Two-third of the patients had a bacterial etiology. The most common isolates were H. influenzae (9 isolates), S. pneumoniae (7), Prevotella spp. (8), and Peptostreptococcus spp. (6). Microbiological concordance between the ear and sinus was found in 22 (69 ) of culture-positive patients.