|Year : 2020 | Volume
| Issue : 4 | Page : 1367-1371
Correlation between nasopharyngeal bacteria in the Eustachian tube area and that in middle ear effusion
Ayman A Abdel-Fattah1, Yaser A Khalil1, Mohamed A Fathallah2
1 Otorhinolaryngology Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Otorhinolaryngology Department, Police Hospital, Menoufia, Egypt
|Date of Submission||31-Aug-2015|
|Date of Decision||02-Oct-2015|
|Date of Acceptance||12-Oct-2018|
|Date of Web Publication||24-Dec-2020|
Mohamed A Fathallah
MBBCH, Otorhinolaryngology Department, Police Hospital, Mahmoud Darwesh St, Quesna, Menoufia
Source of Support: None, Conflict of Interest: None
Otitis media with effusion is a pathological condition characterized by the accumulation of nonpurulent fluid within the middle ear cleft with an intact tympanic membrane.
Materials and Methods
This study included 40 patients with otitis media with effusion. After obtaining consent from all patients, they were subjected to detailed history, full clinical examination, especially ear examination, audiological assessment, radiological assessment, swab from nasopharynx at the Eustachian tube areas for bacteriological examination, and samples from middle ear fluid in both ears for bacteriological examination.
There was a highly significant relation between right ear sample and nasopharyngeal swap in the right tubal area in the study group (P < 0.01). Moreover, there was a highly significant relation between left ear sample and nasopharyngeal swap in the left tubal area in the study group (P < 0.01).
There was a highly significant relation between bacteria in middle ear fluid (if present) and that in the corresponding tubal area in the nasopharynx.
Keywords: middle ear effusion, nasopharyngeal bacteria in the Eustachian tube area, otitis media with effusion
|How to cite this article:|
Abdel-Fattah AA, Khalil YA, Fathallah MA. Correlation between nasopharyngeal bacteria in the Eustachian tube area and that in middle ear effusion. Menoufia Med J 2020;33:1367-71
|How to cite this URL:|
Abdel-Fattah AA, Khalil YA, Fathallah MA. Correlation between nasopharyngeal bacteria in the Eustachian tube area and that in middle ear effusion. Menoufia Med J [serial online] 2020 [cited 2021 Apr 19];33:1367-71. Available from: http://www.mmj.eg.net/text.asp?2020/33/4/1367/304504
| Introduction|| |
Otitis media with effusion (OME) is a pathological condition characterized by the accumulation of nonpurulent fluid within the middle ear cleft with an intact tympanic membrane. OME has been referred to as glue ear, mucoid otitis media, secretory otitis media, and serous otitis media.
OME mostly arises following a recognized or unrecognized acute otitis media (AOM); less commonly, it may occur in association with Eustachian tube More Details obstruction without prior clinical infection. Because of the frequency of episodes of AOM during the first year of life, a young child may spend a significant proportion of these years with OME and associated conductive hearing loss. There is no doubt that moderate-to-severe hearing loss will have a serious impact on the child's development. Permanent hearing loss during childhood interferes with the normal development of speech perception, production, language literacy skills, and social-emotional development.
Thus, symptoms of OME usually involve diminution of hearing or aural fullness typically without pain or fever. In children, hearing loss is generally mild and is often detected only with an audiogram.
The pathogenesis of OME is usually multifactorial and includes factors such as unresolved infection (either viral or bacterial) Eustachian tube dysfunction, immunological status, and/or environmental factors. An inflammatory process in the middle ear caused by bacteria or bacterial products emanating from the nasopharynx is one etiological factor considered in the unknown pathogenesis of OME. Middle ear fluid was thought to be sterile until Senturia et al.first reported the presence of bacteria. Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella More Details catarrhalis are frequently cultured from middle ear fluid. Moreover, many of the isolates are identical to those found in the nasopharynx. Adenoids play an important role in the etiology of OME. Although there are many studies on the role of allergy in OME, the role of adenoids in the pathogenesis of OME is not clear still. Cleft palate, Down's syndrome, Kartagner's syndrome, and nasopharyngeal neoplasm, all have a role in Eustachian tube dysfunction causing OME.
The mechanism for the development of recurrent OME should be known, because this condition may cause hearing loss, especially at a critical time for language and speech development in children. The insertion of ventilation tube and adenoidectomy are the most common operations performed in the pediatric age group for the treatment of OME.
The knowledge of factors that influence the outcome of OME in children in long term is only limited. Despite adequate treatment, the recurrence and chronicity of OME turns it into a more difficult problem compared with uncomplicated OME.
Chronic OME in children is associated with an increased pathogen load in the nasopharynx, suggesting a role of these pathogens in the etiology of OME.
The aim of this study was to find out whether there is a relation between nasopharyngeal bacteria in the Eustachian tube area and that in middle ear effusion in patients with OME, regardless of the presence or absence of inflammatory cells, which may provide insight into the management of OME.
| Materials and methods|| |
This study included 40 patients with OME (16 male and 24 female) with a mean of age 6.475 ± 5.906 years attending the Otorhinolaryngology Department in Menoufia University Hospitals and Shiben El-Kom Teaching Hospital. The study was conducted after approval of the institutional review board of the faculty.
After obtaining consent from the patients, they were subjected to detailed history taking, full clinical examination, especially ear, nose, and paranasal sinus examination, audiological assessment (tympanogram and Pure tone audiometry (PTA) for older children), radiological assessment (plain radiograph of the nasopharynx for the assessment of the size of adenoid in relation to the nasopharyngeal space, considering positive findings if it is 50% or more), swab from the nasopharynx at the Eustachian tube area (Torus tuborius) taken through the oropharynx after elevation of soft palate using a rubber catheter under visualization through the nose using pediatric sinoscopy lense (2.7 mm diameter) for bacteriological examination, and a sample from middle ear fluid after sterilization of the external auditory canal with alcohol 70% and after myringotomy using a suction device connected to a sterile syringe for bacteriological examination. Swabs from the nasopharynx and samples from middle ear fluid were left in transport medium (trypticase soy broth) in incubator for 6–18 h to allow for multiplication of bacteria. Thereafter, they were cultured on nutrient agar, blood agar, chocolate agar, Saubaroud agar, and McCkonky agar. Afterward, colonies of bacteria were identified by means of microscopic examination and biochemical reactions.
Statistical analysis of the collected data
The data collected were tabulated and analyzed using SPSS (Statistical Package for the Social Science software) statistical package, version 16, Chicago, USA). Quantitative data were expressed as mean and SD (X + SD) and analyzed by applying Student's t-test for comparison of two groups of normally distributed data. Qualitative data were expressed as number and percentage [n (%)] and analyzed by applying the c2-test.
All these tests were used as tests of significance at P value less than 0.05.
| Results|| |
Results of the current study show that 30 (75%) patients had a history of recurrent attacks of AOM and six (15%) patients had a family history of OME.
The complaint in the study group was bilateral hearing loss in 34 (85%) patients, delayed speech in four (10%) patients, and unilateral hearing loss and tinnitus in two (5%) patients.
Otoscopic findings of OME (air fluid level, air bubbles, yellowish fluid behind intact Tympanic membrane (TM), or restricted mobility of the TM on pneumatic otoscopy) were positive (present) in 40 (100%) patients in the left ear and only 38 (95%) patients showed positive findings in the right ear.
Thirty-four (85%) cases had positive findings in nasopharyngeal imaging and six (15%) patients had negative findings, considering an adenoid size more than 50% of the space of the nasopharynx in lateral view radiograph as a positive finding.
Thirty-eight (95%) patients had bilateral type B tympanogram and two (5%) patients had left type B and right type A tympanogram.
The bacteria cultured from swabs from tubal areas in the nasopharynx were a mixure of different types; the most common was H. influenzae (85% of patients), followed by S. pneumoniae (80% of patients) and M. catarrhalis (25% of patients), with a nonsignificant difference between the right and left tubal areas (P > 0.05) [Table 1].
|Table 1: Bacterial finding in culture of nasopharyngeal swab of both tubal areas|
Click here to view
Culture results from ear samples were sterile in 16 (40%) patients. Different mixtures of bacteria were found in 24 (60%) patients. The most common bacteria were H. influenzae (35%) and S. pneumoniae (35%), followed by M. catarrhalis (10%), with a nonsignificant difference between the two ears (P > 0.05) [Table 2].
|Table 2: Bacterial finding in culture of middle ear samples of both ears|
Click here to view
There was a highly significant relation between right ear sample and nasopharyngeal swap in the right tubal area in the study group (P < 0.01). Moreover, there was a highly significant relation between left ear sample and nasopharyngeal swap in the left tubal area in the study group (P < 0.01). This was observed only in patients who had bacteria in middle ear fluid, but in those who had sterile middle ear fluid we could not correlate because of the absence of bacteria in middle ear effusion despite their presence in tubal areas in the nasopharynx.
| Discussion|| |
This study included 40 patients with OME (16 male and 24 female) with a mean age of 6.475 ± 5.906 years.
Similar to our results, Khayat and Shareef found that OME was slightly higher among female patients (54.2%) than among male patients (45.8%), with a female-to-male ratio of 1.18 to 1. This was comparable to another study by Dewey et al., which showed no significant difference in the prevalence of OME between male and female sex. However, another study by Da Costa and colleagues demonstrated that male patients had a significantly higher proportion of OME; the proportion was greater in male (37.6%) than in female patients (29.8%).
Results of the current study show that age of the study group ranged between 2.5 and 13 years, with a mean of 5.5 ± 2.6 years. Similar to our results, Daniel et al. found that OME is the most common middle ear disease in young children, with peak prevalence around the first and fifth year of life. It accounts for 25–30% of all cases of otitis media. Moreover, Khayat and Shareef found that the mean age of patients with OME was 9.7 ± 2.5 years, and most cases with OME were among children who were 7 and 12 years of age.
Da Costa et al. found that, as regards the proportion of OME per age group, the prevalence of OME was low for younger children (22%) but sharply increased in children aged 3–7 years to 49.2%, and then fell and remained stable in the age groups that follow at around 35–39%.
Results of the current study show that 30 (75%) patients had recurrent attacks of AOM and six (15%) had a family history of OME.
Similar to our results, Boston et al. examined family history of otorhinolaryngologic diseases as a risk factor for OME, demonstrating that family history of AOM, adenoidectomy/adenotonsillectomy/or ventilation tube placement is directly correlated with the incidence of OME.
Results of the current study show that the complaint in the study group was bilateral hearing loss in 34 (85%) patients, delayed speech in four (10%) patients, and unilateral hearing loss and tinnitus in two (5%) patients.
Although in the majority of cases OME is transient, a proportion of children develop persistent symptoms that may affect hearing, education, language, or behavior.
Results of the current study show that otoscopic findings of OME were positive for 40 (100%) patients in the left ear and only 38 (95%) patients showed positive results in the right ear.
Khayat and Shareef found that, among 48 students, OME was affecting both ears in 32 (66.7%) cases and involved only the left ear in 10 (20.8%) cases. OME affecting only the right ear was found in six (21.5%) cases.
Results of the current study showed that 34 (85%) cases had positive findings in nasopharyngeal imaging and six (15%) cases had negative findings, considering an adenoid size more than 50% of the space of the nasopharynx in lateral view radiograph as a positive finding.
Some authors report that radiographs of the nasal cavity are as important as clinical examination. Similar to our results, radiological examination of the lateral soft tissue of the nasopharynx has been chosen as the criterion standard for measuring adenoid size by Paradise et al. and Khayat and Shareef, because they correlate well with the volume of adenoid tissue removed during surgery.
Van den Aardweg et al. found that adenoidectomy is one of the most commonly performed surgical procedures in children with recurrent OME. They found that 16.3 per 1000 children aged 0–4 years and 5.5 per 1000 children aged 5–9 years underwent adenoidectomy due to adenoid enlargement complicated by OME.
Results of the current study show that the most common bacteria cultured from swabs from tubal areas in the nasopharynx were H. influenzae (85% of patients), followed by S. pneumoniae (80–85% of patients) and M. catarrhalis (20–25% of patients), with a nonsignificant difference between the right and left tubal areas (P > 0.05).
Similar to our results, Broides et al. and Casey et al. found that S. pneumoniae, H. influenzae, and M. catarrhalis are the predominant bacterial OME pathogens.
Results of the current study show that culture results from ear samples were sterile in 16 (40%) patients. Different mixtures of bacteria were found in 60% of patients. The most common bacteria were H. influenzae (25–35% of patients) and S. pneumoniae (35% of patients), followed by M. catarrhalis (5–10%), with a nonsignificant difference between the two ears (P > 0.05).
The typical bacteria implicated in OME are S. pneumoniae, M. catarrhalis, and H. influenzae, but in most studies bacteria were culturable in less than half of the samples, ranging from 21 to 70%. Although this may suggest that bacteria are not important in OME, it contrasts with studies examining effusions for the presence of bacterial nucleic acids by PCR, which have demonstrated bacterial DNA typically in excess of 80% of effusions. However, the presence of bacterial nucleic acids does not necessarily equate to the presence of viable bacteria, as components of effusion samples have been shown to inhibit nuclease activity, and this has been postulated to cause the persistence of RNA and DNA even if bacteria are no longer viable. A possible explanation for the discrepancy between high PCR-positive rate and low culture-positive rate in OME is the involvement of biofilms in the progression of this pathology.
Results of the current study show that there was a highly significant relation between right ear sample and nasopharyngeal swap in the right tubal area in the study group (P < 0.01). Moreover, there was a highly significant relation between left ear sample and nasopharyngeal swap in the left tubal area in the study group (P < 0.01).
Chonmaitree et al. found that most AOM episodes occur as a secondary bacterial infection concomitant to viral respiratory tract infection (Tables 1 and 2).
| Conclusion|| |
There is a highly significant relation between bacteria in middle ear fluid (if present) and that in the corresponding tubal area in the nasopharynx in patients with OME. Thus, we can chose antibiotic used for the treatment of OME according to cultures from tubal areas of the nasopharynx. Even if chosen empirically, it should be active against S. pneumoniae, H. influenzae, and M. catarrhalis, which are the most common bacteria isolated from both Eustachian tube areas in the nasopharynx and middle ear effusions in this study.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Berger G. Nature of spontaneous tympanic membrane perforation in acute otitis media in children. J Laryngol Otol 1989; 103
Bluestone CD, Cantekin EI. Design factors in the characterization and identification of otitis media and certain related conditions. Ann Otol Rhinol Laryngol Suppl 1979; 88
(Pt 2 Suppl 60
MK El-Sharnouby, MM El-Mousely, AAE Ragab, AMZ El-Abedein. Assessment of limited stage reconstruction of auricular deformities using autogenous costal cartilage. Menoufia Med J 2015; 28
Dodson KM, Cohen RS, Rubin BK. Middle ear fluid characteristics in pediatric otitis media with effusion. Int J Pediatr Otorhinolaryngol 2012; 76
Ehrlich GD, Veeh R, Wang X,
Costerton JW, Hayes JD, Hu FZ, et al.
Mucosal biofilm formation on middle-ear mucosa in the chinchilla model of otitis media. JAMA 2002; 287
Senturia BH, Gessert CF, Carr CD, Baumann ES. Studies concerned with tubotympanitis. Ann Otol Rhinol Laryngol 1958;67
Heinonen S, Silvennoinen H, Lehtinen P, Vainionpää R, Vahlberg T, Ziegler T, et al.
Early oseltamivir treatment of influenza in children 1–3 years of age: a randomized controlled trial. Clin Infect Dis 2010; 51
Kreiner-Møller E, Chawes BL, Caye-Thomasen P, Bønnelykke K, Bisgaard H. Allergic rhinitis is associated with otitis media with effusion: a birth cohort study. Clin Exp Allergy 2012; 42
Khayat FL, Shareef LAT. Association between size of adenoid and otitis media with effusion among a sample of primary school age children in Erbil city. Diyala J Med 2013; 5
Dewey C, Midgeley E, Maw R. The relationship between otitis media with effusion and contact with other children in a British cohort studied from 8 months to 3 1/2 years. The ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood. Int J Pediatr Otorhinolaryngol 2000; 55
Daniel M, Imtiaz-Umer S, Fergie N, Birchall JP, Bayston R. Bacterial involvement in otitis media with effusion. Int J Pediatr Otorhinolaryngol 2012; 76
Da Costa JL, Navarro A, Branco Neves J, Martin M. Otitis medias with effusion: association with the Eustachian tube dysfunction and adenoiditis. The case of the Central Hospital of Maputo. Acta Otorrinolaringol Esp 2005; 56
Boston M, McCook J, Burke B, Derkay C. Incidence of and risk factors for additional tympanostomy tube insertion in children. Arch Otolaryngol Head Neck Surg 2003; 129
National Collaborating Centre for Women's and Children's Health (UK). Surgical Management of Otitis Media with Effusion in Children. London: RCOG Press; 2008 Feb.
Haapaniemi JJ. Adenoids in school-aged children. J Laryngol Otol 1995; 109
Paradise JL, Bernard BS, Colborn DK, Janosky JE. Assessment of adenoidal obstruction in children: clinical signs versus Roentgenographic findings. Pediatrics 1998; 101
Van den Aardweg MTA, Boonacker CWB, Rovers MM,
Hoes AW, Schilder AG. Effectiveness of adenoidectomy in children with recurrent upper respiratory tract infections: open randomised controlled trial. Br Med J 2011; 343
Broides A, Dagan R, Greenberg D, Givon-Lavi N, Leibovitz E. Acute otitis media caused by Moraxella catarrhalis
: epidemiologic and clinical characteristics. Clin Infect Dis 2009; 49
Casey JR, Adlowitz DG, Pichichero ME. New patterns in the otopathogens causing acute otitis media six to eight years after introduction of pneumococcal conjugate vaccine. Pediatr Infect Dis J 2010; 29
Kubba H, JP Pearson, JP Birchall. The aetiology of otitis media with effusion: a review. Clin Otolaryngol Allied Sci 2000; 25
LP Schousboe, T Ovesen, L Eckhardt, LM Rasmussen, CB Pedersen. How does endotoxin trigger inflammation in otitis media with effusion? Laryngoscope 2001; 111
L Peizhong, K Whatmough, JP Birchall, JA Wilson, JP Pearson. Does the bacterial DNA found in middle ear effusions come from viable bacteria? Clin Otolaryngol 2000; 25
Flint PW, Haughey BH, Lund VJ, Niparko JK, Richardson MA, Robbins K, et al
. Cummings otolaryngology head and neck surgery
ed. Philadelphia: Mosby; 2013.
Chonmaitree T, Revai K, Grady JJ, Clos A, Patel JA, Nair S, et al
. Viral upper respiratory tract infection and otitis media complication in young children. Clin Infect Dis 2008; 46
[Table 1], [Table 2]