James M. Coticchia

Identification of adenoid biofilms with middle ear pathogens in otitis-prone children utilizing SEM and FISH

OBJECTIVES Biofilms have been implicated in the development of several chronic infections. We sought to demonstrate middle ear pathogens in adenoid biofilms using scanning electron microscopy (SEM) and fluorescent in situ hybridization (FISH) with confocal laser scanning microscopy (CLSM). METHODS Comparative micro-anatomic investigation of adenoid mucosa using SEM and FISH with confocal scanning laser microscopic (CLSM) imaging from patients with recurrent acute otitis media (RAOM). RESULTS All otitis-prone children demonstrated biofilm surface area presence greater than 85% by SEM. FISH accompanied by CLSM imaging also demonstrated patchy biofilms All biofilms contained middle ear pathogens and were frequent in polymicrobial distributions: 4 of 6, 4 of 6 and 3 of 6 samples contained Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis, respectively. CONCLUSIONS Dense adenoid biofilms may act as a reservoir for reinfection of the tubotympanum. Aspiration of planktonic middle ear pathogens existing in resistant adenoid biofilms during a viral upper respiratory tract infection may be an important event in the development of RAOM.

Demonstration of Nasopharyngeal and Middle Ear Mucosal Biofilms in an Animal Model of Acute Otitis Media

Objectives: We performed this study to determine the role of nasopharyngeal and middle ear (ME) biofilms in acute otitis media (AOM). Methods: Sixty female 6-month-old chinchillas, free of ME disease, were utilized. Experimental animals were inoculated with influenza A followed by Streptococcus pneumonia 7 days later. Control animals were inoculated with Sorensens phosphate buffer. Daily otoscopy and tympanometry was performed, and the animals were painlessly sacrificed on days 1, 2, 5, 8, and 14. All mucosae were harvested and prepared for scanning electron microscopy. Results: The ME inflammation, initially detected on day 2 after bacterial inoculation, peaked on day 8. Eight percent of the dually inoculated chinchillas displayed type B tympanograms, and 40% displayed type C. Otoscopic evaluation of tympanic membrane inflammation was rated from 0 to 4 (0 = normal and 4 = severe drainage and/or inflammation) according to an otoscopic grading system. Ten percent of the experimental chinchillas had a grade 2 score, 20% had grade 3, and 6.7% had grade 4. The controls demonstrated no abnormal tympanometric or otoscopic findings. Scanning electron microscopic imaging showed dense biofilms on 83% of the nasopharynges and 67% of the MEs on day 8 in the experimental animals. All animals with ME biofilms had biofilms in the nasopharynx. The controls did not demonstrate biofilm formation. Conclusions: The study parallels the natural pathogenesis of AOM in humans. The demonstration of mucosal biofilms in both the nasopharynx (58%) and the ME (47%) of animals with ME inflammation and/or infection lends further support to the importance of mucosal biofilms in the pathogenesis of AOM.

Systematic Review of Endoscopic Airway Findings in Children with Gastroesophageal Reflux Disease

Objectives: We performed a systematic review of published literature correlating findings on endoscopic evaluation of the larynx and trachea in the pediatric population with the incidence of gastroesophageal reflux disease. Methods: Eight articles were identified through a structured PubMed search of English-language literature using the key terms laryngopharyngeal reflux, extraesophageal reflux, and gastroesophageal reflux. A systematic review was performed relating the presence of reflux in the pediatric population to findings on endoscopic airway evaluation. A covariant analysis was performed, and each study was weighted according to the number of available samples in that study as a fraction of the total. Overall odds ratios and confidence intervals were computed for each endoscopic finding on the basis of the documented absence or presence of gastroesophageal reflux disease. Results: A correlation was seen between the endoscopic findings and the presence of reflux. Conclusions: Arytenoid, postglottic, and vocal fold edema and erythema, lingual tonsil hypertrophy, laryngomalacia, and subglottic stenosis are among the endoscopic findings most frequently identified in patients with gastroesophageal reflux disease. Certain findings commonly encountered on endoscopic evaluation of the larynx and trachea in children who present with respiratory symptoms do indeed demonstrate a correlation with the presence of laryngopharyngeal reflux disease and may indicate the need for antireflux therapy.

Biofilm density in the pediatric nasopharynx: recurrent acute otitis media versus obstructive sleep apnea.

Objectives: We compared the biofilm surface density of adenoids removed from children with recurrent acute otitis media (RAOM) to that of adenoids removed from children with a diagnosis of obstructive sleep apnea (OSA). Methods: We performed a comparative microanatomic study of adenoid mucosa using scanning electron microscopy in patients with diagnoses of RAOM and OSA (27 female and 41 male; age range, 3 months to 15 years). Results: The adenoids removed from patients with RAOM had dense, mature biofilms covering nearly their entire mucosal surfaces. More specifically, the adenoids removed from patients with RAOM had an average of 93.53% of their mucosal surface covered, versus an average of 1.01% coverage on the adenoids removed from patients with OSA. These differences were statistically significant (p < 0.0001). Conclusions: The adenoids removed from patients with RAOM had almost their entire mucosal surface covered with biofilms, versus scant coverage for patients with OSA. Recurrent acute otitis media is notoriously resistant to antibiotic treatment, and aspirates of middle ear fluid repeatedly yield negative cultures. It is these properties that have led biofilms to become increasingly implicated in the pathogenesis of RAOM. Thus, the resistance of biofilms to antimicrobials, together with their planktonic shedding of organisms, may be an important mechanism in the development of RAOM.

Auditory Brainstem Response and Distortion-Product Otoacoustic Emission Studies in Neonates at High-Risk for Hearing Loss:

Objectives: 1) Recognize that preterm infants less than 1300g have a well-described and markedly increased incidence of hearing loss, possibly attributed to reversible early middle ear pathology. 2) Analyze if distortion product oto-acoustic emissions (DPOAE) and/or auditory brainstem response (ABR) could be useful adjuncts when used in addition to tympanometry and otoendoscopy in evaluation of neonatal hearing and middle ear. Methods: Institutional review board approved prospective study at a tertiary care center neonatal intensive care unit with subjects undergoing ABR, DPAOE, tympanometry, and otoendoscopy studies within 72 hours of birth and in scheduled increments until discharge. From January 2010 to date, 77 neonates have been examined. Results: Our results confirmed that DPOAE could be a reliable and repetitive study from 24 weeks of gestational age and onward. When comparing traditional tympanometry to DPOAE, 85.7% of examinations with type B or C tympanometry also had an abnormal DPOAE result. Conversely, 62.5% of patients with type A tympanometry had a normal DPOAE result. Furthermore, in patients with a clinical diagnosis of AOM or OME, 66.7% percent had an abnormal DPAOE result. Regarding ABR threshold studies, there were several limitations with data acquisition due to incubator interference and background noise; thus, the potential of ABR in this population remains to be determined. Conclusions: This study suggests that DPOAE can be used as a reliable hearing evaluation in the neonatal population. Additionally, it may serve as a useful adjunct and insight into evaluating neonatal middle ear pathology, especially when combined with tympanometry and otoendoscopy.

Incidence of Otitis Media in Preterm Infants

Objectives: 1) Determine if objective tympanometry findings correlate with the subjective endoscopy finding in diagnosing middle ear disease (AOM or OME) in premature infants. 2) Determine if the incidence of middle ear disease increases with lower gestational weight in premature infants. Methods: Our prospective study includes 76 preterm infants, (< 36wks) admitted to the Neonatal Intensive Care Unit (NICU) at Harper Hospital. Endoscopic otoscopy and tympanometry were performed to detect the presence of otitis media within the first 4 days of birth. The Fisher exact test was used for statistical analysis. Results: 1) 44 ears had normal otoendoscopic findings, of which 35 had normal tympanometry findings (79.54 %). 63 ears had middle ear disease, of which 48 showed abnormal reading on tympanometry (76.19 %). 2) 26 babies weighed less than 1300 grams at birth (average gestational age 26.99 weeks), 23 of which had middle ear disease on otoendoscopy. 25 babies weighed more than 1300 grams (average gestational age 31.85 weeks), 12 of which had middle ear disease on otoendoscopy. A P value of 0.0025 suggests a significant correlation between low birth weight and middle ear disease. Conclusions: We demonstrate that endoscopic otoscopy technique correlates with objective tympanometry data, although there are several limitations to comparing these techniques. We provide evidence that the incidence of otitis media in LBW preterm infants is higher based on otoendoscopy.

S266 – Review of Endoscopic Findings in Children with GERD

Objectives Many children with gastroesophageal reflux will initially present with respiratory symptoms including cough, stridor, increased work of breathing, apneic events, and recurrent episodes of croup. Despite a growing body of literature that suggests a correlation between airway pathology and GERD, there still remains much controversy. Our objective is to systematically review published literature correlating findings on endoscopic evaluation of the larynx and trachea in the pediatric population with the incidence of gastroesophageal reflux disease. Methods A systematic review was performed of 19 articles relating the presence of gastroesophageal reflux disease in the pediatric population to findings on endoscopic airway evaluation. These were identified through a structured PubMed search of English language literature using the key terms laryngopharyngeal reflux, extraesophageal reflux, and gastroesophageal reflux. Only those articles studying endoscopic findings in the pediatric population were included. Results All studies evaluated the subjects for the presence of gastroesophageal reflux. The most commonly utilized methods of diagnosis include barium esophagram, video fluoroscopy, gastric scintiscan, 24 hour pH probe, and esophageal biopsy. Arytenoid, postglottic and vocal fold edema and erythema, lingual tonsil hypertrophy, laryngomalacia, and subglottic stenosis are among the endoscopic findings most frequently identified in disease-positive patients. Conclusions Certain commonly encountered findings on endoscopic evaluation of the larynx and trachea performed in children presenting with respiratory symptoms do indeed demonstrate a correlation with presence of gastroesophageal reflux and may indicate that antireflux therapy should be considered in the treatment of this population of patients.

08:10: Craniocervical Necrotizing Fasciitis with Thoracic Extension

OBJECTIVES: 1. Identify hemorrhage rates following coblation tonsillectomy. 2. Establish if a learning curve exists with the technique with respect to hemorrhage rates. 3. Identify surgeons’ perceptions of the technique with respect to pain and bleed rates. METHODS: Following the Australian National Tonsillectomy Audit of 2005, in early 2006 a supplementary data sheet was sent to all surgeons identified as having experience with coblation for some or all of their tonsillectomies. Hemorrhage events were recorded and surgeons were asked about how they learned the technique and about their perceptions with respect to pain and bleeding rates following coblation tonsillectomy. RESULTS: Data were obtained for 1,740 coblation tonsillectomies with a 70% response rate from targeted surgeons. Inital primary hemorrhage rates were 1.3% initially, falling to 0% with experience (p 0.001; mean 0.3%). Secondary hemorrhage rates were 3.4% initially, falling to 1.0% with experience (p 0.05; mean 2.1%). Only 10% of surgeons attended a formal course or workshop to learn the technique; 65% of surgeons felt the technique was less painful than other methods with only 25% perceiving coblation-produced lower hemorrhage rates. CONCLUSIONS: In Australian practice, the introduction of coblation tonsillectomy occured with a significant learning curve with respect to hemorrhage rates. This can possibly be explained by the low number of surgeons gaining proper experience with the technique prior to performing it on patients. This has implications for the future introduction of new surgical techniques into otolarynology.