Failed ear tubes and antibiotics? Think eosinophilic otitis media

 

ATLANTA – By the time adults with severe, chronic ear pain end up at the Mayo Clinic in Rochester, Minn., it’s not uncommon for them to have failed antibiotics and gone through a dozen or more sets of ear tubes that didn’t work, followed by surgery – mastoidectomy – to no avail.

“When they get to us, they are struggling. It’s miserable,” said allergist Erin Willits, MD, of Mayo’s division of allergy and immunology inRochester, Minn.

What all those patients have in common is a recently described disease entity called eosinophilic otitis media (EOM). “People aren’t that aware of it. It’s underrecognized,” she said.

Dr. Willits and her colleagues described the first cohort ever assembled in the United States at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. Most of the research into EOM has been done in Japan, but Mayo has recognized the problem and ENT doctors and allergists there are working together to identify and treat patients. So far, interferon injections seem to be the best option.

The common denominator in all 32 patients was a history of asthma and nasal polyps. Perhaps in EOM, eosinophilic lung and sinus inflammation extends to the eustachian tubes, but that’s not clear yet. Some of the patients also had polyps in their ear canals, and 13 (41%) had a convincing history of aspirin sensitivity. They also had viscous middle-ear effusions, which is why ear tubes don’t help.

In short, the researchers found that a history of asthma and nasal polyps should trigger investigation for EOM in adults with chronic, refractory ear pain.

Of 25 patients, 19 (76%) also had ear disease on CT scan, most commonly inner ear or mastoid opacification. Eighteen patients tested had eosinophilic cationic protein levels above 1,000 ng/mL in their middle-ear effusions, which is high, and 12 out of 30 (40%) were markedly eosinophilic on CBC. The average age of EOM onset was 55.5 years. There were 17 women and 15 men in the cohort.

There was some degree of bilateral hearing loss in nearly every patient, generally a mix of conductive and sensorineural deficits.

“A lot of them start off with conductive hearing loss and progress to sensorineural hearing loss, which can be permanent,” Dr. Willits said. “That’s the biggest thing I want people to recognize: If you start to work with an ENT to try to [identify and] treat these patients, you hopefully can prevent hearing loss.”

Many patients have a robust response to pegylated interferon-alpha. “It kind of dries up their ears, and they feel better,” Dr. Willits noted. Usually it’s given every 2-4 weeks, but some patients can get away with every 6 weeks and lower doses. The side effects are rough, however, and symptoms come back if it’s stopped. It’s also hard to get insurance companies to cover it for EOM (Laryngoscope. 2016 Sep 26. doi: 10.1002/lary.26303).

“It’s not a great treatment, but it’s about all we have,” she said. Omalizumab (Xolair) “has been tried, but it doesn’t help a lot of patients. We are hopeful some of these newer biologics” – such as dupilumab or mepolizumab (Nucala) – “will give these patients relief.”

Dr. Willits had no relevant disclosures.

[email protected]

 

ATLANTA – By the time adults with severe, chronic ear pain end up at the Mayo Clinic in Rochester, Minn., it’s not uncommon for them to have failed antibiotics and gone through a dozen or more sets of ear tubes that didn’t work, followed by surgery – mastoidectomy – to no avail.

“When they get to us, they are struggling. It’s miserable,” said allergist Erin Willits, MD, of Mayo’s division of allergy and immunology inRochester, Minn.

What all those patients have in common is a recently described disease entity called eosinophilic otitis media (EOM). “People aren’t that aware of it. It’s underrecognized,” she said.

Dr. Willits and her colleagues described the first cohort ever assembled in the United States at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. Most of the research into EOM has been done in Japan, but Mayo has recognized the problem and ENT doctors and allergists there are working together to identify and treat patients. So far, interferon injections seem to be the best option.

The common denominator in all 32 patients was a history of asthma and nasal polyps. Perhaps in EOM, eosinophilic lung and sinus inflammation extends to the eustachian tubes, but that’s not clear yet. Some of the patients also had polyps in their ear canals, and 13 (41%) had a convincing history of aspirin sensitivity. They also had viscous middle-ear effusions, which is why ear tubes don’t help.

In short, the researchers found that a history of asthma and nasal polyps should trigger investigation for EOM in adults with chronic, refractory ear pain.

Of 25 patients, 19 (76%) also had ear disease on CT scan, most commonly inner ear or mastoid opacification. Eighteen patients tested had eosinophilic cationic protein levels above 1,000 ng/mL in their middle-ear effusions, which is high, and 12 out of 30 (40%) were markedly eosinophilic on CBC. The average age of EOM onset was 55.5 years. There were 17 women and 15 men in the cohort.

There was some degree of bilateral hearing loss in nearly every patient, generally a mix of conductive and sensorineural deficits.

“A lot of them start off with conductive hearing loss and progress to sensorineural hearing loss, which can be permanent,” Dr. Willits said. “That’s the biggest thing I want people to recognize: If you start to work with an ENT to try to [identify and] treat these patients, you hopefully can prevent hearing loss.”

Many patients have a robust response to pegylated interferon-alpha. “It kind of dries up their ears, and they feel better,” Dr. Willits noted. Usually it’s given every 2-4 weeks, but some patients can get away with every 6 weeks and lower doses. The side effects are rough, however, and symptoms come back if it’s stopped. It’s also hard to get insurance companies to cover it for EOM (Laryngoscope. 2016 Sep 26. doi: 10.1002/lary.26303).

“It’s not a great treatment, but it’s about all we have,” she said. Omalizumab (Xolair) “has been tried, but it doesn’t help a lot of patients. We are hopeful some of these newer biologics” – such as dupilumab or mepolizumab (Nucala) – “will give these patients relief.”

Dr. Willits had no relevant disclosures.

[email protected]

 

ATLANTA – By the time adults with severe, chronic ear pain end up at the Mayo Clinic in Rochester, Minn., it’s not uncommon for them to have failed antibiotics and gone through a dozen or more sets of ear tubes that didn’t work, followed by surgery – mastoidectomy – to no avail.

“When they get to us, they are struggling. It’s miserable,” said allergist Erin Willits, MD, of Mayo’s division of allergy and immunology inRochester, Minn.

What all those patients have in common is a recently described disease entity called eosinophilic otitis media (EOM). “People aren’t that aware of it. It’s underrecognized,” she said.

Dr. Willits and her colleagues described the first cohort ever assembled in the United States at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. Most of the research into EOM has been done in Japan, but Mayo has recognized the problem and ENT doctors and allergists there are working together to identify and treat patients. So far, interferon injections seem to be the best option.

The common denominator in all 32 patients was a history of asthma and nasal polyps. Perhaps in EOM, eosinophilic lung and sinus inflammation extends to the eustachian tubes, but that’s not clear yet. Some of the patients also had polyps in their ear canals, and 13 (41%) had a convincing history of aspirin sensitivity. They also had viscous middle-ear effusions, which is why ear tubes don’t help.

In short, the researchers found that a history of asthma and nasal polyps should trigger investigation for EOM in adults with chronic, refractory ear pain.

Of 25 patients, 19 (76%) also had ear disease on CT scan, most commonly inner ear or mastoid opacification. Eighteen patients tested had eosinophilic cationic protein levels above 1,000 ng/mL in their middle-ear effusions, which is high, and 12 out of 30 (40%) were markedly eosinophilic on CBC. The average age of EOM onset was 55.5 years. There were 17 women and 15 men in the cohort.

There was some degree of bilateral hearing loss in nearly every patient, generally a mix of conductive and sensorineural deficits.

“A lot of them start off with conductive hearing loss and progress to sensorineural hearing loss, which can be permanent,” Dr. Willits said. “That’s the biggest thing I want people to recognize: If you start to work with an ENT to try to [identify and] treat these patients, you hopefully can prevent hearing loss.”

Many patients have a robust response to pegylated interferon-alpha. “It kind of dries up their ears, and they feel better,” Dr. Willits noted. Usually it’s given every 2-4 weeks, but some patients can get away with every 6 weeks and lower doses. The side effects are rough, however, and symptoms come back if it’s stopped. It’s also hard to get insurance companies to cover it for EOM (Laryngoscope. 2016 Sep 26. doi: 10.1002/lary.26303).

“It’s not a great treatment, but it’s about all we have,” she said. Omalizumab (Xolair) “has been tried, but it doesn’t help a lot of patients. We are hopeful some of these newer biologics” – such as dupilumab or mepolizumab (Nucala) – “will give these patients relief.”

Dr. Willits had no relevant disclosures.

[email protected]