dr.

Dwi Ayu Nilamsari

dr. Fitri Fatimatuzzahra
dr. Fransiska Anggriani Salim
dr. Idama AsidoRohana Simanjuntak
Introduction
• The human body harbors numerous microorganisms, including bacteria, viruses,
fungi, and archaea, which form microbiotas that together with their environment
form microbiomes
• In a normal, healthy situation this host – microbe interaction is mutualistic,
beneficial to both microbe and host
• The human body contains many habitats for microorganisms differing considerably
in humidity, temperature, exposure to sunlight, acidity, and quantity of sebum.
• These factors lead to significant intrapersonal divergence in the microbiomes in
different parts of the human body
• The human microbiome is unique to every individual. It begins to develop during
birth and stabilizes in the first years of life with exposure to the microorganisms of
the surrounding environment.
• The compositions of microbiomes are affected by many factors, such as the host
genome, age, sex, family members’ microbiotas, nutrition, and hormones. Usually
the healthy adult microbiome remains stable
Introduction
• Dysbiosis, a disturbance of the micro- biome, caused e.g. by
antimicrobials, damage to the epithelium or altered immunological
defense mechanisms, may lead to disease of the host
• It is hypothesized that the loss of environmental biodiversity may
affect human microbiota and increase the prevalence of asthma,
allergies, and other inflammatory diseases
Introduction
• The average length of the human external auditory canal (EAC) is 2.5 cm.
• The outer third consists of cartilage and is covered with thick and mobile skin.
• This cartilaginous part of the EAC contains sebaceous and ceruminous apocrine glands and hair
follicles.
• The inner two-thirds form a bony part where the skin is thin, immobile, and contains no glands
or hair follicles; this skin is continuous with the epithelium of the tympanic membrane.
• It harbours various bacteria and the health of the external auditory canal is decided by the
interplay of various factors like moisture, pH, cerumen and trauma to skin
• The EAC has a unique self- cleaning mechanism, where the sloughed epithelium slowly migrates
outward to the membranous part and mixes with glandular secretions to form cerumen
• Cerumen has two distinct types: 1) wet-type, common in Europeans and Africans, brown and
sticky, rich in lipids and 2) dry-type, prevalent in East Asians, grayish and rich in protein
• The role of cerumen is disputed, from only expelling the slought epithelium to various functions
such as moistening, lubrication, protection, and acting as an antimicrobial by maintaining the
acidic environment of the EAC
Introduction
• Traditionally, staphylococci and coryneforms were assumed to be the
predominant colonizers of the EAC. In a newer culture study, staphylococci
were the most abundant taxon, followed by coryneforms and streptococci
• The few culture-independent studies suggest Alloiococcus otitis,
Corynebacterium otitidis, and Staphylococcus auricularis as the three
dominating commensal microbes in the healthy EAC
• To better understand the pathologies behind different ear diseases,
deepened knowledge regarding microbiota of the normal EAC is needed.
• In the future, this knowledge may enable development of new treatments,
including modulation of the EAC microbiome with probiotics or
transplantation of healthy microbiome.
The Aim
• To investigate the microbiome of the healthy EAC.
• To understand the microbiological flora of the normal ear, compare it
with the flora of an ear with AOE and to study their significance in
etiology.
Acute Otitis Externa (AOE)
• AOE is the inflammation of the external auditory canal mostly due to
bacterial aetiology that results in acute pain and discomfort in the ear.
• The first case of AOE was described by Toulmousch in 1838 and later
systematically described by Mayer in 1844. It was initially thought to
be a fungal infection
• Investigations initiated during World War II firmly established
bacterial aetiology of otitis externa
Acute Otitis Externa (AOE)
• Menurut penelitian Ghapur et al:
• 64 patients, 34 patients males, 30 females
• Youngest patient was 10 years old (male), the oldest was 66 years old (male), mean age
group 32 years old. Incidence was more in the second decade of life.
• AOE in right ear was seen in 38 (59.37%) and left ear in 26 (40.62%) subjects
• The relation between handedness of the patient and the side on which the subjects
commonly developed AOE due to habitual ear fingering was considered
• It was found that out of 54 right handed subjects, 36 developed disease in right ear and
among 10 left handed persons eight developed disease in left ear.
• The above numbers indicated that the dominant hand might have a role in causation of
the disease but statistically, the p-value was 0.074 (> 0.05) and considered as not
significant.
Acute Otitis Externa (AOE)
• The most common symptom at the time • There were four individuals who
of presentation was ear pain that was grew anaerobes (two subjects with
seen in 62 subjects. Forty subjects had Clostridium along with Methicillin
isolated ear pain and 24 subjects had pain Sensitive Staphylococcus aureus
(MSSA), two subjects with
with associated symptoms. Finegoldia).
• The symptoms and signs were found to be
more severe in individuals infected with
MRSA
• It was also noted that symptoms and signs
were severe when the individual had an
anaerobic organism growing in the culture
Acute Otitis Externa
(AOE)
• A single organism (either
aerobic/anaerobic/fungus) was cultured in 50
subjects and more than one organism
(polymicrobial growth) was seen in 10 subjects
(13%) and no growth was seen in cultures of four
subjects in the study
• In this study, there was no co-existent organism
with MRSA. It was noted that Staphylococcus was
the most common organism at a genus level as it
includes MRSA, MSSA and Coagulase Negative
Staphylococci (CoNS) isolated in 28 subjects. At a
species level, Pseudomonas aeruginosa was the
most common species isolated in 22 subjects
Acute Otitis Externa (AOE)
• It was noted that all subjects who grew MRSA, MSSA, Morganella and
Pseudomonas (with co-existent E. coli) were resistant to the routine antibiotic
treatment given i.e., oral amoxycillin - clavulanate and topical ciprofloxacin drops
• These bacteria were more sensitive to cotrimoxazole when compared Amox-clav.
Cotrimoxazole is not preferred most of the times for the fear of Stevens-Johnson
syndrome. Pseudomonas was found to be sensitive to aminoglycosides. CoNS
were considered as normal skin commensals, so sensitivity was not done.
Aspergillus spp. was isolated in four subjects and was effectively treated with IG
pack and needed no further treatment. Antibiotic sensitivity for fungus was not
done in our study as they required specific panels. Subjects with anaerobes,
Finegoldia magna (2) and Clostridium isolated along with MSSA (2) had more
severe symptoms and had to be started on systemic antibiotics as the IG pack
did not give much relief
Acute Otitis Externa (AOE)
• The American Academy of Otolaryngology – Head and Neck Surgery
Foundation (AAO-HNSF) developed a Clinical Practice Guideline in 2006 for the treatment of AOE. The
group recommends use “topical preparations for initial therapy of diffuse, uncomplicated AOE;
systemic antimicrobial therapy should be used if there is extension outside of the ear canal or the
presence of risk factors like diabetes, prior radiotherapy, or immune compromise
• In present study, IG pack was inserted and used as initial therapy to relieve itching and other
symptoms related to AOE. Ichthammol is ammonium bituminosulfonate, which has anti-inflammatory,
bactericidal, and fungicidal properties
• Roland PS et al., performed one of the few randomized multicenter studies comparing ototopical
antibiotics in which ciprofloxacin/dexamethasone showed higher bacterial eradication rates and more
rapid symptom improvement compared with neomycin/polymyxin B/hydrocortisone
• In December 2014, the FDA approved the fluoroquinolone antimicrobial finafloxacin otic suspension
for the treatment of AOE caused by Pseudomonas aeruginosa and Staphylococcus aureus
• In present study, if the IG topical did not improved the CAS score, empirical antibiotics with topical
ciprofloxacin (a fluoroquinolone) were prescribed to the patients
Menurut yg mikrobiom
• the most common bacterial
species inhabiting the healthy EAC
were Staphylococcus auricularis,
Propionibacterium acnes,
Alloiococcus otitis, and Turicella
otitidis
Conclusion
• that the most common genera of the healthy EAC include Staphylococcus, Alloiococcus, and
Turicella, Propionibacterium
• In addition, many other bacteria colonize the healthy EAC, and the normal flora is unique in
every individual.
• Pseudomonas aeruginosa and Staphylococcus aureus are the most common causative
bacteria for AOE however, it may be due to other bacteria as well
• Interestingly, manipulation of the EAC and sex seem to alter the EAC microbiome
• To develop novel EAC microbiome modulating treatments, further studies with larger
sample sizes, and different patient groups, are needed.
• Whenever the standard topical medication is not helping to alleviate the symptoms of AOE,
tackling the predisposing factors and a culture directed treatment would be very effective in
treating AOE so that spread of resistance among pathogens can be prevented.
Thank You