Protective Characteristics of Human Breast Milk on Early Childhood Otitis Media: A Narrative Review.

Introduction: Human breast milk (HBM) contains a complex and dynamically changing variety of factors that contribute to the infant's developing immune system's ability to fight upper respiratory tract infections, including otitis media (OM). We sought to summarize the current evidence on the protective characteristics of HBM, through direct or donated feeding, toward early childhood OM. Methods: For this narrative review, we performed a literature search on OM in the context of HBM feeding in the PubMed, Embase, and Google Scholar databases, between January 1, 2008, and July 1, 2023. Results: Immunoglobulin A (IgA) provides a short-term immunity of 2-3 days against otopathogens causing OM. IgA-mediated immunity is effective against OM up to 7 months of age if breastfeeding continues. The role of transferred IgM and IgG in HBM is unclear. Although there is a potential protective value of microRNA, hormones, oligosaccharides, stem cells, and interleukins present in HBM, their role is unclear. Any duration of breastfeeding is superior to no breastfeeding in OM risk reduction, with a big variability among studies (odds ratio 0.23-0.81, depending on the duration). Duration of breastfeeding ≥6 months was found to be the most effective in OM risk reduction, but there was no evidence of continued benefits after 2 years of age. Expressed breastfeeding was not shown to be more beneficial. The protective values of donor HBM against OM are still undetermined. Conclusion: HBM has numerous components that contribute to protection against early childhood OM.

What are the risk factors for acute otitis media treatment failure?

OBJECTIVE: To identify risk factors associated with acute otitis media treatment failure (AOMTF) among 13-valent pneumococcal conjugate vaccine (PCV) immunized children. METHODS: In this retrospective study, we identified children <12 years who were admitted to our hospital November 2017-October 2020. Children were categorized either as acute otitis media treatment failure (AOMTF), if they received adequate pre-admission antibiotics, or as AOM without treatment failure (AOMwTF), if they did not receive any pre-admission antibiotics. We collected demographics, clinical behavior, laboratory results, length and hospitalization course. Hospitalization was justified if previously treated properly. RESULTS: The AOMTF group included 84 children (43 boys, mean age: 1.30 ± 0.83 years), whereas the AOMwTF group included 251 children (132 boys, mean age: 1.20 ± 0.89 years). AOMTF accounted for 25% of all AOM admissions. Among the AOMTF group, 46 (54.8%) were treated with amoxicillin and 24 (28.6%) with amoxicillin/clavulanic acid. Risk factors for AOMTF included recurrent AOM episodes history (30.9% vs 5.5%, OR 7.6, 95%CI 3.5-15.4, p < 0.001), otorrhea (29.4% vs 9.5%, OR 4, 95%CI 2.1-7.5, p < 0.001), tympanic membrane perforation (14.2% vs 4.3%, OR 3.6, 95%CI 1.5-8.6, p < 0.0019). Children with AOMTF were treated more with 2nd- or 3rd-line antibiotics (90.2% vs 65.9%, OR 4, 95%CI 2.2-10.4, p < 0.001), and underwent more myringotomy/ventilation tube insertions (14.4% vs 6.9%, OR 2.3, 95%CI 1.0-5.0, p = 0.037). Mean admission durations were similar: 3.83 ± 1.6 days in the AOMTF group vs 3.37 ± 2.77 days in the AOMwTF group (p = 0.15). CONCLUSION: Risk factors associated with AOMTF should be identified early during the AOM course to reduce complication rates and surgery referral.

[SENSORINEURAL HEARING LOSS AND VERTIGO DUE TO INTRA-COCHLEAR HEMORRHAGE].

INTRODUCTION: Intra-cochlear hemorrhage is a rare cause of sudden sensorineural hearing loss (SSNHL) which may be accompanied by diverse labyrinthine symptoms. In these cases, we expect magnetic resonance imaging (MRI) to demonstrate a high signal intensity in the labyrinth on unenhanced T1-weighted images as well as in fluid-attenuated inversion recovery (FLAIR) images. AIMS: To describe an experience with a case of intra-cochlear hemorrhage in a patient treated with anticoagulation, causing SSNHL and vertigo. METHODS: Case report and literature review. RESULTS: An 85-year old patient treated with anticoagulation therapy presented with right SSNHL, tinnitus and vertigo. Physical examination revealed: bilateral normal otoscopic examination, lateralized left Weber tuning fork test and a spontaneous left horizontal nystagmus. MRI performed demonstrated a high signal intensity inside the cochlea on unenhanced T1-weighted images. CONCLUSIONS: Performing an MRI is necessary in order to rule out frequent causes of SSNHL including benign as well as malignant tumors, malformations, trauma and more. The finding of an intra-labyrinthine hemorrhage causing SSNHL is rare, and should be taken into consideration when treated by anticoagulation therapy.

Treatment failure in pediatric acute otitis media: How do you define?

INTRODUCTION: Reaching the point of treatment failure in the management of pediatric acute otitis media (AOM) is decision-changing, and is often associated with switching to a broader coverage antibiotic with/without middle ear surgical drainage. Yet, still there is no consensus on the definition of what is treatment failure, which may lead to confusion for clinical decision-making purposes. We sought to review the heterogeneity of treatment failure definitions in AOM. METHODS: We searched for relevant English language manuscripts using the following key-words: ['otitis media' (OM) or (AOM)] AND ['treatment failure' or 'failure' or 'response failure' or 'response'] AND 'human' in various electronic databases from 1/1/2005 through 10/31/2020. RESULTS: In the 60 retrieved papers, treatment failure was considered only when antibiotics had been prescribed beforehand, but not when watchful waiting had been adopted. We categorized the manuscripts into 5 major treatment failure definition subgroups, which occasionally overlapped: unimprovement or worsening of symptoms or signs of failure in otoscopy (n = 36), specialist(s) referral or hospital admission (n = 12), changing or adding antibiotic treatment (n = 22), failure to eradicate causative bacteria (n = 7) and failure as perceived by parents (n = 4). CONCLUSIONS: We suggest a broader definition of AOM treatment failure including physical examination findings and degree of initial treatment response, which will enable an unbiased, uniform comparison of treatments for pediatric AOM.

Are Children Scheduled for Ventilation Tubes Insertion Overweight? A Cohort of Israeli Children.

OBJECTIVE: To study the hypothesis that children scheduled for ventilation tube insertion (VTI), a surrogate procedure reflecting otitis media (OM) presence, are overweight or obese. PATIENTS AND METHODS: Charts of Israeli children aged 0 to 9 years undergoing VTI with or without adenoidectomy between 9/1/17 and 3/31/19 in a secondary level hospital were retrospectively identified. We compared their mean body mass index (BMI, kg/m2) to the mean BMI of a control group comprised of children who underwent surgeries unrelated to OM (fracture fixation/reduction, inguinal/umbilical hernia repair, meatotomy, appendectomy). BMI measurements were plotted on gender- and age-matched curves to determine BMI percentile, and were also compared to the national pediatric overweight/obesity data. Normal weight was defined as BMI percentile <85%, overweight was BMI percentile between 85% and 97%, and obesity was BMI percentile >97%. RESULTS: The VTI group included 83 children (mean age: 3.5 ± 1.8 years). The control group included 77 children (mean age: 6.3 ± 1.9 years). No statistically significant difference was found in the mean BMI values between both groups (P = .22). When compared to age- and gender-adjusted 50th BMI percentile of the general pediatric population, the mean BMI of the VTI group was significantly higher: for boys, 16.9 versus 15.2 (P < .01), and for girls, 16.6 versus 15.3 (P = .03), but not in the control group: P = .16 (boys) and P = .11 (girls). CONCLUSION: Children undergoing VTI were overweight when compared to their age- and gender-matched peers. This observation was more noticeable in boys.

Fish Bone Foreign Body: The Role of Imaging

Abstract Introduction Fish bone foreign body (FFB) impaction in the upper aerodigestive tract is a common cause for emergency department referral. Its management varies in both diagnosis and treatment paradigms. Fish bone foreign bodies are more commonly found in the oropharynx in cases of patients < 40 years old, and in the esophagus in cases of patients > 40 years old. Symptoms are typically non-indicative for the location of the FFB, with the exception of foreign body sensation at/superior to the cervical esophagus. A lack of findings during the physical examination is routinely followed by imaging, with computed tomography (CT) being the preferred modality. In practice, many patients undergo unnecessary imaging studies, including CT scans. Objectives To identify patients with suspected fish bone impaction who do not require CT imaging and can be safely discharged. Data Synthesis We have searched the PubMed database for the following medical subject headings (MeSH) terms: fish bone, fish foreign body AND oropharynx, hypopharynx, esophagus, flexible esophagoscopy, and rigid esophagoscopy. Our search in the English language yielded 32 papers. Case reports were included, since they highlighted rare and serious complications. Conclusion In patients > 40 years old suspected of fish bone impaction, noncontrast CT is recommended and should be urgently performed, even in the presence of ambiguous symptoms. However, in patients < 40 years old presenting within 24 hours from ingestion, imaging has little diagnostic value due to the low probability of esophageal fish bones. For this specific subgroup, in the absence of clinical findings, discharge without imaging studies may be considered safe. (AU)

Fish Bone Foreign Body: The Role of Imaging.

Introduction Fish bone foreign body (FFB) impaction in the upper aerodigestive tract is a common cause for emergency department referral. Its management varies in both diagnosis and treatment paradigms. Fish bone foreign bodies are more commonly found in the oropharynx in cases of patients < 40 years old, and in the esophagus in cases of patients > 40 years old. Symptoms are typically non-indicative for the location of the FFB, with the exception of foreign body sensation at/superior to the cervical esophagus. A lack of findings during the physical examination is routinely followed by imaging, with computed tomography (CT) being the preferred modality. In practice, many patients undergo unnecessary imaging studies, including CT scans. Objectives To identify patients with suspected fish bone impaction who do not require CT imaging and can be safely discharged. Data Synthesis We have searched the PubMed database for the following medical subject headings (MeSH) terms: fish bone , fish foreign body AND oropharynx , hypopharynx , esophagus , flexible esophagoscopy , and rigid esophagoscopy . Our search in the English language yielded 32 papers. Case reports were included, since they highlighted rare and serious complications. Conclusion In patients > 40 years old suspected of fish bone impaction, non-contrast CT is recommended and should be urgently performed, even in the presence of ambiguous symptoms. However, in patients < 40 years old presenting within 24 hours from ingestion, imaging has little diagnostic value due to the low probability of esophageal fish bones. For this specific subgroup, in the absence of clinical findings, discharge without imaging studies may be considered safe.

Effect of general anesthesia and intubation on parathyroid levels in normal patients and those with hyperparathyroidism.

BACKGROUND: Induction of general anesthesia and endotracheal intubation may precipitate parathyroid hormone (PTH) elevation in patients with primary hyperparathyroidism (HPT). The purposes of this study were to revisit this observation and to study its impact in healthy patients. METHODS: Patients with primary HPT who underwent parathyroidectomy were retrospectively studied. The PTH was sampled and compared: before, immediately after general anesthesia and endotracheal intubation, and 15 minutes after parathyroidectomy. Healthy adults who underwent elective operations were prospectively studied. The PTH was sampled before general anesthesia and endotracheal intubation, immediately after, and 15 minutes later. RESULTS: Thirty-one patients, aged 28-89 years (mean 60.1 ± 13 years), were retrospectively studied. The PTH was significantly elevated after general anesthesia and endotracheal intubation (P = .014). Fifty patients, aged 21-86 years (mean 54 ± 15 years), were prospectively studied. The PTH elevation after general anesthesia and endotracheal intubation was not significant. CONCLUSION: General anesthesia and endotracheal intubation causes an immediate, steep, and significant PTH elevation in patients with primary HPT but only a minor change in healthy adults. The difference may be attributed to an impaired adrenergic response in patients with primary HPT.

Cardiovascular Risk Factors Among Patients With Vestibular Neuritis.

OBJECTIVE: To investigate the correlation between cardiovascular risk factors (CVRFs) and vestibular neuritis (VN) in hospitalized adult patients. METHODS: A cross-sectional retrospective study was conducted in a tertiary hospital setting. The medical records of patients (aged over 18 years old) who were hospitalized between the years 2005 and 2014 with the diagnosis of VN were retrieved. Inclusion criteria were: (1) acute vertigo lasting for at least 24 hours, (2) absence of auditory complaints, (3) horizontal unidirectional nystagmus present during physical examination, and (4) absence of neurological symptoms or signs. The ratio of CVRFs among VN patients was compared to the ratio of those among the general Israeli population. RESULTS: A significantly higher prevalence of CVRFs was found among VN hospitalized patients in comparison to the general population ( P < .05). Furthermore, a significant correlation ( P < .001) was found between the patients' age and the number of CVRFs (r = .387). A positive correlation (r = .643) was found between the number of CVRFs and VN in each age group ( P = .119). CONCLUSION: There may be a possible interrelation between CVRFs and VN. This correlation can be caused by occlusion of small blood vessels leading to labyrinthine ischemia and apparition of symptoms of VN.

Adherence to acute otitis media diagnosis and treatment guidelines among Israeli otolaryngologists.

INTRODUCTION: The recent Israeli acute otitis media (AOM) guidelines, drafted mainly by pediatricians and family physicians in 2013, addressed diagnostic and therapeutic issues, in order to reduce over-diagnosis and treatment. These guidelines are considered as the 'standard of care' for AOM management. While the adherence rate of pediatricians to previous Israeli AOM guidelines (2004) was reported to be high (>85%), the compliance of otolaryngologists has not been studied. METHODS: An anonymous 19-item questionnaire was circulated among practicing Israeli otolaryngologists (residents [n = 93], specialists [n = 283]). All the items were scored according to the number of correct answers in line with the guidelines, and summed on a 0-100 scale. RESULTS: Response rate was 34% (n = 127). Overall, scores of correct answers of residents (n = 48, 52% of all residents) and specialists (n = 79, 28% of all specialists) were similar, and showed comparable moderate adherence to both guidelines: 55.7 vs 58.3 (p = 0.26). Residents were more likely to adhere to the U.S. guidelines, when compared to specialists (score difference 6.1 vs 2.8, p = 0.008). Responders preferred the microscope for diagnosis (48%), over the recommended (pneumatic) otoscope (62%) (p = 0.05), and were more likely to start antibiotic therapy (62%), rather than the 'watchful waiting' (38%) (p = 0.03). Concerning antibiotic treatment, 50% of otolaryngologists prescribed amoxicillin as recommended, at 60-80 mg/kg/d. CONCLUSION: The moderate adherence rate suggests that the guidelines were partially adopted by otolaryngologists, who use different instrumentation than recommended, and treat more severe/complicated cases. Over-treatment with antibiotics and inaccurate dosing regimens are still common. Better implementation of the AOM guidelines among otolaryngologists should be performed in designated training platforms.

Acute otitis media guidelines in selected developed and developing countries: uniformity and diversity.

BACKGROUND: Acute otitis media (AOM) is a common childhood disease, with an enormous economic and healthcare-related burden. Guidelines and consensus papers for AOM diagnosis and management were published in many countries. Our objective was to study the differences and similarities between these protocols in developing and developed countries. METHODS: The keywords: 'acute otitis media' AND 'children' AND ['treatment' or 'management'] AND ['guideline' or 'consensus'] were used in various electronic databases between 1 January 1989 through 31 December 2015. Overall, 99 sources from 62 countries were retrieved: 53 from 22 developed countries, and 46 from 40 developing countries. Representative guidelines from America (the USA, Argentina), Europe (Italy, Moldova), Africa (South Africa, Tanzania, Ethiopia), Asia (Japan, Afghanistan, Sri Lanka),and Oceania (South Australia, Fiji) were compared. RESULTS: Paediatric societies publish guidelines in most developed countries; in developing countries, the Ministry of Health usually initiates guideline formulation. Most guidelines use the same diagnostic criteria and offer watchful waiting in mild-moderate scenarios. Amoxicillin is the suggested first-line antibiotic, whereas options for second-line and third-line therapies vary. Duration of therapy varies and is usually age dependent: 5-7 days for children <2 years and 10 days for children >2 years in developed countries, while duration and age groups vary greatly in developing countries. Reduction of AOM risk factors is encouraged in developed countries, but rarely in developing countries. CONCLUSIONS: Guidelines for AOM from developing and developed countries are similar in many aspects, with variation in specific recommendations, due to local epidemiology and healthcare accessibility. Formulation of regional guidelines may help reduce AOM burden.

Pseudomonal Biofilm Topographic Distribution on Tympanostomy Tubes: An In Vitro Model.

In vitro growth of Pseudomonas aeruginosa biofilm on tympanostomy tubes showed that in Armstrong T-tubes, biofilm colonies were mainly located in the perpendicular junction between the body and the flanges, but in Paparella-type tube, they concentrated on the round rims. These "weakness" zones can be the future target areas for geometry changes, and can be specifically coated with antibiofilm materials.

Acute Mastoiditis in Children: Necessity and Timing of Imaging.

BACKGROUND: Acute mastoiditis (AM) can be clinically diagnosed, with an option for supplemental imaging: computed tomography (CT) scan and magnetic resonance imaging (MRI). Debate widely exists whether clinical diagnosis alone is sufficient, in view of the risk of missing undetected complications. We sought to study the reasons leading to the performance of an imaging study during AM course. METHODS: Medical records of children younger than 8 years who were admitted from 2005 to 2014 with AM were retrospectively reviewed. Data included medical history, signs and symptoms, laboratory results, imaging studies, treatment methods and final outcomes. RESULTS: Eighty-six children were diagnosed with 88 AM episodes. Of the AM episodes, 55 (63%) were in boys and 46 (52%) were in children younger than 2 years. All children were treated with parenteral antibiotics, and 82 (95%) underwent myringotomy on admission. Only 20 (23%) children underwent imaging studies, on the 6th median day. Of those, 20 (100%) children underwent CT scans, and 3 (15%) underwent additional MRI studies. The reasons for imaging studies included suspected subperiosteal abscess (9 of 20, 45%), lack of improvement despite adequate medical therapy (7, 35%) and focal neurological signs (4, 20%). Sixteen (16%) children underwent surgery for these pathologies: subperiosteal abscesses (n = 12,), jugular vein thrombosis (n = 2), perisinus empyema (n = 2), epidural abscess (n = 2) and Luc abscess (n = 1). CONCLUSIONS: Most children presenting with AM can be diagnosed clinically and do well with intravenous antibiotics and myringotomy. CT and MRI imaging should be reserved for children with suspected AM-related intracranial complications.

Laryngeal Side Effects of Tyrosine Kinase Inhibitors.

OBJECTIVES: Tyrosine kinase inhibitors (TKIs) are common targeted drugs, used in the treatment of hematological and solid malignancies. These drugs present a multitude of potential adverse effects. Laryngeal manifestations, including laryngeal edema, secondary to TKIs treatment have not been well studied, despite their potential lethality. METHODS: This cross-sectional study included adult patients (>18 years) treated with TKIs who were followed in a secondary medical center and underwent a voluntary otolaryngological examination, which included laryngeal fiber-optic laryngoscopy (FOL). FOL was independently performed by two senior otolaryngologists, and results were recorded and evaluated by two grading systems, to assess the degree of laryngeal edema. In addition, medical files were reviewed, and data collected included past medical history, signs and symptoms, physical examination, laboratory results, treatment type, and duration. RESULTS: Sixteen patients, aged 68.2 ± 13.6 years, were examined during October 2014 to December 2014. Of them, three (19%) were males. Eleven (68%) patients presented with varying degrees of laryngeal edema. A significant correlation was found between gastroesophageal reflux symptoms and laryngeal edema (P = 0.02). TKI treatment was stopped in one patient, because of symptomatic laryngeal edema, which completely resolved within 2 weeks. CONCLUSIONS: Laryngeal edema was common in our study group. This edema was most often not life threatening. Yet, because of the potential severity of this side effect, we propose a routine FOL examination of patients before commencing TKI treatment and a reevaluation performed during treatment.

Adult supraglottitis: changing trends.

There is no clinical dynamic staging system which scores according to severity all the anatomical regions in adult supraglottitis. The objective of the study was to describe the demographics, clinical presentation, interventions and outcomes of adult patients diagnosed with acute supraglottitis (AS), and to study the correlation of a new AS classification with the need for airway intervention, in comparison with the current classification. This was a retrospective, cohort study conducted at a secondary medical care center. Adults diagnosed with AS from the years 1990-2013 were identified. Data were extracted for demographic and clinical information and there was no intervention. The main outcome and measures were the need for airway intervention. 288 eligible patients were enrolled. AS incidence rate was 4.3/100,000 patients/year. The mean age was 50 ± 16 years. Sore throat (94 %) and dysphagia (88 %) were the most common presenting symptoms. Patients were hospitalized either in the Otolaryngology Department (n = 255, 89 %) or in the Intensive Care Unit (n = 33, 11 %). Of the latter, 19 (58 %) had an airway securing intervention procedure. Our suggested classification was more sensitive than the current one for predicting the need for intubation (p = 0.03). Signs and symptoms of AS in adults are different from those in children. Adult patients presenting with oropharyngeal complaints should be suspected for AS and treated appropriately.