|Year : 2018 | Volume
| Issue : 1 | Page : 1-8
Systematic review and meta-analysis of otitis media in Iran: Prevalence, etiology, antibiotic susceptibility, and complications
Safar-Ali Amiri-Andy1, Diana Sarokhani1, Milad Azami2, Hossein Vazini3, Mostafa Rezaei-Tavirani4, Ali Hasanpour Dehkordi5
1 Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran
2 Student Research Committee, Faculty of Medicine, Ilam University of Medical Sciences, Ilam, Iran
3 Department of Nursing, Basic Sciences Faculty, Hamedan Branch, Islamic Azad University, Hamedan, Iran
4 Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
5 Department of Medical-Surgical, Faculty of Nursing and Midwifery, Shahrekord University of Medical Sciences, Shahrekord, Iran
|Date of Web Publication||24-May-2018|
Dr. Mostafa Rezaei-Tavirani
Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
Otitis media (OM) is a relatively common infectious disease, and its chronic form may lead to complications such as hearing impairment. This study aims to determine the prevalence, etiology, antibiotic susceptibility, and complications of OM in Iran through meta-analysis. English language databases, including Science Direct, PubMed, Scopus, Web of Science, and Persian language databases, including SID, Magiran, Iranmedex, Medlib, as well as the Google Scholar search engine, were searched from 1994 to 2017, using the Mesh keywords: Otitis media, Middle ear, Causality, Etiology, and Iran. The heterogeneity assessment of the studies was done using Q-Cochran test and I2 index. Considering the high heterogeneity of the studies, the random effects model was used to estimate the point prevalence with 95% confidence interval. Data were analyzed using STATA version 11.1 software. Fifty-one articles with a sample size of 10,675 were reviewed in this study, the most common types of OM involvement were right otitis (51% [95% confidence interval (CI): 33–68]), left otitis (44% [95% CI: 36–52]), and bilateral otitis (33% [95% CI: 7–59]). The most common bacterial etiologies involved in OM were Pseudomonas aeruginosa (26% [CI 95%: 17–35]), Proteus (21% [95% CI: 0%–45%]), and Staphylococcus (20% [95% CI: 0–42]). The fungal etiology of OM was estimated to be 22% (95% CI: 4–40). The most common OM pathologies were ossicular changes (56%[95% CI, 27–85]), granulation (49% [95% CI: 18–80]), cholesteatoma (32% [95% CI: 13–51]), tympanosclerosis (17% [95% CI: 10–23]), and cholesterol granuloma (11% [95% CI: 0–26]). The results of this meta-analysis provide useful information on the epidemiology of OM in Iran to otorhinologists and health policymakers.
Keywords: Infection, Iran, meta-analysis, otitis media
|How to cite this article:|
Amiri-Andy SA, Sarokhani D, Azami M, Vazini H, Rezaei-Tavirani M, Dehkordi AH. Systematic review and meta-analysis of otitis media in Iran: Prevalence, etiology, antibiotic susceptibility, and complications. Indian J Otol 2018;24:1-8
|How to cite this URL:|
Amiri-Andy SA, Sarokhani D, Azami M, Vazini H, Rezaei-Tavirani M, Dehkordi AH. Systematic review and meta-analysis of otitis media in Iran: Prevalence, etiology, antibiotic susceptibility, and complications. Indian J Otol [serial online] 2018 [cited 2020 Jun 1];24:1-8. Available from: http://www.indianjotol.org/text.asp?2018/24/1/1/233128
| Introduction|| |
Otitis media (OM) is a general term for the expression of infections with various complications in the middle-ear region. OM are divided into three categories: acute OM, OM with effusion, and chronic suppurative OM (CSOM). CSOM account for a large number of patients referring to the ear, nose, and throat clinics and include a large number of surgical procedures.,
In industrial countries, hearing loss (conductive and sensorineural) is the third-most common chronic illness after hypertension and arthropathy among the elderly, which has led to physical and mental problems for these people. Furthermore, according to our estimates, every year, around 21,000 people (33/10 million people) die due to OM complications. Chronic illnesses lead to increased living costs, social problems, and impact on quality of life.,,,,
Chronic OM may cause ossicular erosion and as a result lead to major hearing loss. Hearing loss and otorrhea are common side effects of these diseases., Hearing loss occurs almost in all cases of chronic OM, which may reach 50–60 dB if ossicular erosion occurs. Considering the complications of OM, the recognition of causes and factors of OM is necessary.
The basis for the treatment of acute OM is the administration of antibiotics. Selective treatment of chronic OM is a surgical procedure and usually occurs after a common cold.,
Different studies have suggested various pathologies as the causes of OM, most notably, granulation tissue, granulomatosis with polyangiitis (Wegener's), diabetes, vasculitis, cholesteatoma, cholesterol granuloma, tympanosclerosis, various viral infections, and ossicular changes.,,,,, The ear cholesteatoma is referred to as epidermal inclusion cyst in the middle ear or mastoid. Due to the importance of the presence of cholesteatomas in the ear and the complications of its existence and failure to treat this problem, chronic inflammation of the middle ear is divided into two groups with cholesteatoma and without cholesteatoma. Due to the presence of creatine in a tissue space, cholesteatoma is prone to frequent infection, and Pseudomonas aerogenosa is its most common aerobic bacteria, while bacteroide species is the most common anaerobic bacteria.
Cholesterol granuloma as a foreign object causes granulation tissue. Granulation tissue is one of the most common pathologic findings in the ears in patients with chronic OM, which includes more than 2.3 cases of chronic OM without cholesteatoma. Tympanosclerosis is the formation of hyaline or calcified cartilage in the tympanic membrane and middle-ear cavity and is created secondary to inflammation of the middle ear or trauma, and histologically, hyaline deposition in the connective tissue is below the epithelium of the tympanic membrane and the middle ear.
Other chronic inflammatory pathologies of the middle ear are changes in the ossicular chain, which is often secondary to other pathologies., Bacteria and viruses also contribute to the development of OM. Common bacterial pathogens include Pneumococcus, Haemophilus influenzae and Moraxella More Details catarrhalis.,,,, Of common viruses, rhinoviruses and the bacterial respiratory viruses can be mentioned, alone or as a pathogen.,,
Several researches have been conducted in Iran to study the etiology of OM, and the results are very different and, on the other hand, no systematic and meta-analytic reviews have been conducted on them. Therefore, performing a meta-analysis seems necessary. In the systematic review and meta-analysis, by combining different studies and increasing the number of studies and sample size involved in the analysis process, the 4confidence intervals are reduced, and thus the results are more reliable. Therefore, the present study aims to investigate the OM etiology in Iran through systematic review and meta-analysis.
| Materials and Methods|| |
The present study is a meta-analysis of the causes of OM in Iran. This study was conducted in accordance with the PRISMA protocol  for systematic review and meta-analysis. All the stages of this study were conducted independently by two researchers.
English language databases, including Science Direct, PubMed, Scopus, Web of Science, and Persian language databases, including SID, Magiran, Iranmedex, Medlib, as well as the Google Scholar search engine, were searched from 1994 to 2017, using the MeSH keywords: Otitis media, Middle ear, Causality, Etiology, and Iran. The combination of keywords was also performed using the AND/OR operator. The Persian equivalent of the keywords was also used for Persian language databases.
Inclusion and exclusion criteria
The main exclusion criterion of the study was the studies that examined the etiology of OM in Iran. Exclusion criteria were: (1) Irrelevance to the subject, (2) non-Iranian studies, (3) Studies with nonrandom sample size, (4) studies not conducted during the years 1994–2017, and (5) intervention articles, letters to editor, review articles, and case reports.
Qualitative assessment of studies
In order to assess the quality of studies, the standard and international STROBE checklist  was used. This checklist contains 22 parts. Zero to two points were given to each part; therefore, the lowest and highest attainable points were 0 and 44, respectively. Studies that attained at least a score of 16 from the checklist entered the meta-analysis process.
To reduce reporting bias and data collection errors, two researchers independently performed data extraction and extracted data into a checklist that included the name of the first author, the study title, the sample size, the year and location of the study, the prevalence of each etiology involved in OM, the prevalence of complications of OM, and the sensitivity of OM.
In this study, the variances of each study were calculated using the binomial distribution formula. The heterogeneity evaluation was done by Q-Cochran test and I2 index (I2 index below 25% is low heterogeneity, between 25% and 75% is average heterogeneity, and 75% or above is high heterogeneity). Considering the high heterogeneity of the studies, a random effects model was used to estimate the point prevalence with 95% confidence interval (CI). All statistical analyses were performed using Streamline your internal and consumer-facing platforms with KitelyTech's industry leading custom software development services in Chicago. The significance level of the tests was considered to be P < 0.05.
| Results|| |
Search results and properties of the studies that entered the meta-analysis process
In this systematic review and meta-analysis, 337 studies were identified in the initial search. After applying the inclusion and exclusion criteria and qualitative assessment of the studies, 51 articles conducted from 1994 to 2017 entered the meta-analysis [Figure 1]. The properties of the studies are listed in [Table 1].
|Table 1: Data extracted from articles that entered the meta-analysis process|
Click here to view
In this study, the most common types of OM involvement were right otitis (51% [95% CI: 33–68]), left otitis (44% [95% CI: 36–52]), and bilateral otitis (33% [95% CI: 7–59]) [Table 2].
|Table 2: Results of the meta-analysis of articles: Causes of otitis media in Iran|
Click here to view
Otitis media etiology
The most common bacterial etiologies involved in OM were Pseudomonas aeruginosa (26% [CI 95%: 17–35]), Proteus (21% [95% CI: 0%–45%]), and Staphylococcus (20% [95% CI: 0–42]). The fungal etiology of OM was estimated to be 22% (95% CI: 4–40).
Otitis media pathology
The most common OM pathologies were ossicular changes (56% [95% CI: 27–85]), granulation (49% [95% CI: 18–80]), cholesteatoma (32% [95% CI: 13–51]), tympanosclerosis (17% [95% CI: 10–23]), and cholesterol granuloma (11% [95% CI: 0–26]) [Table 2].
Otitis media complications
Among the complications of OM, the lowest prevalence was related to aural fullness (16% [95% CI: 9–23]) and dizziness (16% [95% CI: 5–28]), and the highest prevalence was associated with ottorhea (50% [95% CI: 0–1.32]) and moderate hearing loss (56% [95% CI: 49–62]) [Table 2].
In the assessment of antibiotic susceptibility of OM in Iran, the highest susceptibility was for gentamycin (86% [95% CI: 81–90]) and ciprofloxacin (81% [95% CI: 65–97]) and the lowest sensitivity was for penicillin (36% [95% CI: 14–59]) and amikacin (41% [95% CI: 0–88]) [Table 3].
|Table 3: Antibiotic susceptibility administered for patients with otitis media|
Click here to view
Prevalence of surgical interventions
In the assessment of surgical interventions for chronic OM, the prevalence of high mastoidectomy was 47% (95% CI: 30–65), while the prevalence of low mastoidectomy and tympanoplasty was 24% (95% CI: 16–32) and 18% (95% CI: 14–23), respectively [Table 2].
| Discussion|| |
The results of this meta-analysis on 51 articles with a sample size of 10,675 showed that the prevalence of right OM was more common than left otitis and bilateral otitis. The most common bacterial etiologies involved in OM were P. aeruginosa (26%), Proteus (21%), and Staphylococcus (20%), and the most common pathologies were ossicular changes (56%) and granulation (49%). Among the complications of OM, the lowest prevalence was associated with aural fullness (16%) and dizziness (16%) and the highest prevalence was associated with ottorhea (50%) and moderate hearing loss (56%). On investigating the antibiotic susceptibility for OM in Iran, the highest susceptibility was estimated for gentamicin (86%) and ciprofloxacin (81%) antibiotics and the lowest susceptibility was for penicillin (36%) and amikacin (41%) antibiotics.
OM is considered an indigenous disease in the northern region of Australia and, in the villages of this area, all children develop the infection several days after birth, and the pathogens of Streptococcus pneumoniae, H. influenzae, and M. catarrhalis are observed in them. In a study in Israel, the prevalence of chronic OM was 95% and 41% of those with chronic OM had cholesteatoma. In another study by Sommerfleck in Argentina in 2012, 324 patients were diagnosed with acute OM. The most significant pathogens in patients were S. pneumoniae (39.5%), H. influenza (37.4%), M. catarrhalis (6.1%), and S. pneumoniae (3%). In a study in Malaysia in 1999, which was conducted among 382 patients, the most common organisms were P. aeruginosa (27.2%) and Staphylococcus aureus (23.6%).
In Japan, golden Staphylococcus has grown more and more significantly over 16 years in Chronic suppurative otitis media (CSOM) patients, compared with other microorganisms. A study by Nyembu et al. in Congo in 2003 on ear effusions of children showed that Proteus mirabilis (23%), P. aeruginosa (22%), and Citrobacter koseri (20%) had the highest prevalence of microorganism in CSOM children. In a study by Moshi et al. in Tanzania in 2000, by investigating 176 effusions from 150 patients with CSOM, P. aeruginosa (51%), S. aureus (17.2%), P. mirabilis (13.2%), Klebsiella pneumoniae (8%), and Escherichia More Details coli (5.8%) were isolated from culture media. Sharma et al. in Nepal investigated 322 effusions from 250 patients with CSOM and showed that P. aeruginosa (36.4%) and S. aureus (30.2%) had the highest prevalence of microorganisms in patients with CSOM.
One of the limitations of this study was the limited statistical population of Iran, and some studies only focused on the prevalence of OM.
| Conclusion|| |
According to the results of this study, continuing education for community members and stakeholders in relation to OM, antibiotic susceptibility to effective treatment, prevention of complications, antibiotic resistance, and reduction of treatment costs are essential.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gates GA, Klein JO, Lim DJ, Mogi G, Ogra PL, Pararella MM, et al.
Recent advances in otitis media 1. Definitions, terminology, and classification of otitis media. Ann Otol Rhinol Laryngol Suppl 2002;188:8-18.
Chole R, Sudhoff H. Chronic otitis media, mastoiditis, and petrositis. In: Cummings CW, Flint PW, Haughey BH, Robbins KT, Thomas JR, Harker LA, et al
., editors. Cummings Otolaryngology Head and Neck Surgery. 4th
ed. Philadelphia: Elsevier; 2005. p. 2988-3012.
Wang HM, Lin JC, Lee KW, Tai CF, Wang LF, Chang HM, et al.
Analysis of mastoid findings at surgery to treat middle ear cholesteatoma. Arch Otolaryngol Head Neck Surg 2006;132:1307-10.
Monasta L, Ronfani L, Marchetti F, Montico M, Vecchi Brumatti L, Bavcar A, et al.
Burden of disease caused by otitis media: Systematic review and global estimates. PLoS One 2012;7:e36226.
Hasanpour Dehkordi A. Influence of yoga and aerobics exercise on fatigue, pain and psychosocial status in patients with multiple sclerosis: A randomized trial. J Sports Med Phys Fitness 2016;56:1417-22.
Hasanpour-Dehkordi A, Khaledi-Far A, Khaledi-Far B, Salehi-Tali S. The effect of family training and support on the quality of life and cost of hospital readmissions in congestive heart failure patients in Iran. Appl Nurs Res 2016;31:165-9.
HassanpourDehkordi A, Mohammadi N, NikbakhatNasrabadi A. Hepatitis-related stigma in chronic patients: A qualitative study. Appl Nurs Res 2016;29:206-10.
Mohammadi N, HassanpourDehkordi A, NikbakhatNasrabadi A. Iranian patients with chronic hepatitis struggle to do self-care. Life Sci J 2013;10:457-62.
Ghiasi B, Sarokhani D, Dehkordi AH, Sayehmiri K, Heidari MH. Quality of Life of patients with chronic kidney disease in Iran: Systematic Review and Meta-analysis. Indian Journal of Palliative Care. 2018;24:104.
Ghiasi S, Seyed Toutounchi J. Prevalence of ossicular lesions in chronic otitis media. Med J Tabriz Univ Med Sci Health Serv 2014;36:66-9.
Ibrahim SI, Cheang PP, Nunez DA. Incidence of meningitis secondary to suppurative otitis media in adults. J Laryngol Otol 2010;124:1158-61.
Block SL, Schmier JK, Notario GF, Akinlade BK, Busman TA, Mackinnon GE 3rd
, et al.
Efficacy, tolerability, and parent reported outcomes for cefdinir vs. high-dose amoxicillin/clavulanate oral suspension for acute otitis media in young children. Curr Med Res Opin 2006;22:1839-47.
Arroll B. Common cold. BMJ Clin Evid 2008. pii: 1510.
Yingxi L, Sheng L, Xiuzhen S. Numerical analysis of ossicular chain lesion of human ear. J Acta Mech Sin 2008;25:241-7.
Javadi M, Mohebi S. Pathologic findings in 100 patients with chronic otitis media in Hazrat-e-Rasool Akram Hospital. J Iran Univ Med Sci 2007;14:81-7.
Amiri M. Diabetes mellitus type 2; an international challenge. Ann Res Dial. 2016;1:e04.
Dey B, Dange P, Ganesh RN, Parameswaran S, Pillai PP. Immune-complex deposits in anti-neutrophil cytoplasmic antibody associated crescentic glomerulonephritis; a report of two cases. Immunopathologia Persa, 2017;3:e09, 10.15171/ipp.2017.01.
Kronbichler A. Boon and bane of remission induction with rituximab in ANCA-associated vasculitis: Lessons learned from the RAVE-ITN follow-up study. J Renal Inj Prev 2014;3:9-10.
Mortazavi M, Nasri H. Granulomatosis with polyangiitis (Wegener's) presenting as the right ventricular masses: A case report and review of the literature. J Nephropathol 2012;1:49-56.
Rodríguez-Morales AJ, Sánchez-Duque JA. Preparing for next arboviral epidemics in Latin America; who can it be now? – Mayaro, Oropouche, West Nile or Venezuelan equine encephalitis viruses. J Prev Epidemiol 2018;3:e01.
da Costa SS, Paparella MM, Schachern PA, Yoon TH, Kimberley BP. Temporal bone histopathology in chronically infected ears with intact and perforated tympanic membranes. Laryngoscope 1992;102:1229-36.
Chole RA, Faddis BT. Evidence for microbial biofilms in cholesteatomas. Arch Otolaryngol Head Neck Surg 2002;128:1129-33.
Dew L, Shelton C. Complication of temporal bone infection. In: Cummings CW, Flint PW, Harker LA, Haughey BH, Richardson MA, Robinson KT, et al
., editors. Otolaryngology Head and Neck Surgery. 3rd
ed. St. Louis: Mosby; 1998. p. 3013-38.
Shahreza FD. From oxidative stress to endothelial cell dysfunction. J Prev Epidemiol 2016;1:e04.
Couloigner V, Levy C, François M, Bidet P, Hausdorff WP, Pascal T, et al.
Pathogens implicated in acute otitis media failures after 7-valent pneumococcal conjugate vaccine implementation in France: Distribution, serotypes, and resistance levels. Pediatr Infect Dis J 2012;31:154-8.
Wen R, Deng Q, Sun C, Gao S, Tao J, Luo R, et al
. Pathogenic bacteria distribution and drug susceptibility in children with acute otitis media in pearl river Delta. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2011;25:884-7.
Casey JR, Pichichero ME. Changes in frequency and pathogens causing acute otitis media in 1995-2003. Pediatr Infect Dis J 2004;23:824-8.
Faden H. The microbiologic and immunologic basis for recurrent otitis media in children. Eur J Pediatr 2001;160:407-13.
Pumarola F, Marès J, Losada I, Minguella I, Moraga F, Tarragó D, et al
. Microbiology of bacteria causing recurrent acute otitis media (AOM) and AOM treatment failure in young children in Spain: Shifting pathogens in the post-pneumococcal conjugate vaccination era. Int J Pediatr Otorhinolaryngol 2013;77:1231-6.
Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al
. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015;4:1.
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al.
Strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies. BMJ 2007;335:806-8.
Malakooti B, Mahdizadeh J, Amani Gashnigani S, Fathsami S. Effects of eustachian tube function in outcome of graft in tympanoplasty or tympanomastoidectomy for chronic otitis media. Tehran Univ Med J 2000;58:11-3.
Pirzadeh A, Ettehad G. A study of etiologies of chronic otitis media at patients referring to ear, throat and nose clinics of Ardabil University of Medical Sciences, 2000-2001. J Ardabil Univ Med Sci 2002;2:10-3.
Toutounchi SJ, Abbaszadeh P, Barzgar M. Degree of hearing loss and different pathology of middle ear. J Ardabil Univ Med Sci 2005;5:119-23.
Mozafari N, Talaei S, Amirmoghadami H, Talaei S. Culture and antibiogram of aerobic bacteria causing chronic otitis media in Zanjan. ZUMS J 2006;14:52-9.
Sadooghi M, Soofizade M. Evaluation of chronic otitis media in patients refered to Amir Alam hospital during the first six month of 2001. An analysis of 212 cases. J Arc 2003;16:39-42.
Rajati Haghi M, Ghasemi M, Bakhshaee M, Taghati A, Shahabi Poor A. Audiometry and ossicles in patients with chronic otitis media. Iran J Otorhinolaryngol 2009;21:73-7.
Naeimi M, Ghazvini K, Shakeri M, Kaboli M, Bagheri M. Study of bacteremia incidence after middle ear surgery. Iranian journal od ears, throat, nose and larynx. Iran J Otorhinolaryngol 2008;20:177-82.
Nahaei M, Kazem Nejad M. The prevalence of various lesions in the middle ear and their relationship with preoperative ODM resultsin 50 surgeries performed on middle ear of adolescents and adults admitted to Imam Khomeini hospital in Tabriz in 1998. Med J Tabriz Univ Med Sci 2000;34:63-70.
Iranfar K, Ragha M, Abtahi S. The effect of middle ear surgery on sensorineural hearing in patients with chronic otitis media. J Kermanshah Univ Med Sci 2004;8:22-8.
Soltan Dallal M, Rahimi Forushani A, Heidarzadeh S, Jabbari H, Sedigh Maroufi S, Sharifi Yazdi M. Identification and determination antimicrobial resistance pattern of Haemophilus influenza
isolated from patients with otitis media. RJMS 2014;21:17-24.
Soltan Dallal M, Jabari H, Rahimi Forushani A, Heidarzadeh S, Afrogh P, Sharifi Yazdi M. Frequency and resistance patterns of Streptococcus pneumoniae
in acute otitis media. J Mazandaran Univ Med Sci 2013;23:28-35.
Asadi A, Gudarzi M, Gudarzi H, Houri H, Ebrahimi N, Delsoz Bahri T. Investigating the frequency and resistance to treatment of Streptococcus pneumoniaeis
in patients with otitis. Koomesh 2016;17:814-20.
Nader Poor M, Musavi Aghdas M. Cholesteatoma surgery results in 166 patients. Med J Tabriz Univ Med Sci 2010;22:73-7.
Aynol Ghozati S, Sharifi Dalooei M, Adami Dehkordi M, Nikzade M. Examining secretory chronic otitis media in teaching hospitals of Islamic Azad University, Mashhad, 2001-2003. Med J Islamic Azad Univ Mashhad 2005;3:36-42.
Khoshdel A, Imani R, Saedi A, Kheire S, Hamidi M, Kasiri K, et al
. The prevalence of Streptococcus pneumonia
and its penicillin resistance pattern in children less than five years old from Shahrekord Iran 2007. J Shahrekord Univ Med Sci 2009;10:89-95.
Sabory T, Ghadiri K, Abiri R, Elahi A, Poormohammadi S, Gharib A. Incidence of nasopharyngeal carriers of Streptococcus pneumoniae
and antibiotic resistance in the children in Kermanshah 2012. J Nurs Educ 2016;4:90-7.
Delsouz Bahri T, Goudarzi M, Dabiri Satri S, Ebrahimi N, Asadi A, Ghafoori S, et al
. Comparison of culture and multiplex PCR in detection of fastidious bacteria associated with otitis media among suspected patient admitted to Amir-Alam Hospital. Res Med 2017;40:192-6.
Kafshdar Jalali A, Salamat Zade A. Examining bacterial causes of chronic otitis media and their antibiotic susceptibility in Lahijan hospitals. Tabriz University of Medical Sciences and Health Services First International Congress and 4th
Conference on Health and Education; 2011.
Jolodarian P, Abshirini H. Evaluation of Epidemiological Findings of Cholesteatomas in Patients with Chronic Otitis Media Admitted to Going Under Surgery in the Ear and Nose Centers of Imam Khomeini Hospital in Ahvaz between 2002 and 2006 Jundishapur University of Medical Sciences & Health Services; 2009.
Asadi A, Gudarzi M, Gudarzi H, Houri H, Ebrahimi N, Delsoz Bahri T. Investigating the frequency and resistance to treatment of Streptococcus pneumoniaeis in patients with otitis. Koomesh 2016;17:814-20.
Namaei M, Mehramiz M, Ghannadkafi M, Mofatteh MR. Prevalence of bacterial causes of chronic otitis media with effusion and their drug resistance in Birjand. J Birjand Univ Med Sci 2015;22:59-66.
Yeganeh Moghadam A, Namazi M, Moravveji S, Khorshidi A, Abbasi Moghadam A. Bacteriological assessment of resistant effusional otitis media discharge among the 2-16 year-old children admitted to Matini Hospital in Kashan, 2011-2013. Feyz 2014;18:469-76.
Karimi G, Moradi A. Study of microbial effusion of the ear in chronic otitis media and its prevalence among 120 hospitalized patients and outpatients. J Shahid Sadoughi UniV Med Sci Yazd 2001;9:53-6.
Ebrahimi N, Goudarzi H, Goudarzi M, Asadi A, Delsouz Bahri T. Frequency of alloiococus otitis in patients with otitis media by culture and PCR method. Res Med 2015;39:36-40.
Asiri S, Hasham A, al Anazy F, Zakzouk S, Banjar A. Tympanosclerosis: Review of literature and incidence among patients with middle-ear infection. J Laryngol Otol 1999;113:1076-80.
Farhadi M, Tabatabai A, Shamshiri A, Maleki A, Masjedian F, Bojary Nassrabadi M, et al
. Comparative study of Aerobic and anaerobic bacteria and fungi involved in sinusitis and otits media cases from patients under operated in ENT ward at Rasool Hospital. Razi J Med Sci 2000;7:44-9.
Mirvakili A, Baradaranfar M, Hasani A, Jafari R. Sensorineural hearing loss in chronic otitis media. JSSU 2008;15:21-8.
Ghaznavi Rad E, Zareie R, Jafari A, Palizvan MR, Jourabchi A, Moini L, et al
. Frequency and risk factors of Moraxella catarrhalis
infection in patients at Vali-Asr and Amirkabir hospitals since August 2003 to March 2004. Yafte 2006;7:117-22.
Gharibpour F, Khoramrooz S, Mirsalehian A, Emaneini M, Jabalameli F, Darban-Sarokhalil D, et al
. Isolation and detection of Alloiococcus otitidis
in children with otitis media with effusion using culture and PCR methods. J Mazand Univ Med Sci 2013;23:52-60.
Salehe F, Abshirini H. To Evaluate the Relationship Between Auditory Findings and Status of Ossicular Chain During Surgery in Patients with Chronic Otitis Media. These is of Jundishapur University of Medical Sciences and Health Services, Ahvaz; 2012.
Saki N, Nik Akhlagh S, Modarres Dezfuli S. Determination of the prevalence of otitis media with effusion in the first grade elementary school students of Ahvaz in the winter of 1996. J Med Sci 2005;4:211-5.
Nourizadeh N, Ghazvini K, Gharavi V, Nourizadeh N, Movahed R. Evaluation of nasopharyngeal microbial flora and antibiogram and its relation to otitis media with effusion. Eur Arch Otorhinolaryngol 2016;273:859-63.
Khoramrooz SS, Mirsalehian A, Imaneini H, Jabalameli F, Sharifi A, Aligholi M, et al.
Characterization of Alloiococcus otitidis
strains isolated from children with otitis media with effusion by pulsed-field gel electrophoresis. Int J Pediatr Otorhinolaryngol 2012;76:1658-60.
Farajzadah Sheikh A, Saki N, Roointan M, Ranjbar R, Yadyad MJ, Kaydani A, et al.
Identification of Alloiococcus otitidis
, Streptococcus pneumoniae
, Moraxella catarrhalis
and Haemophilus influenzae
in children with otitis media with effusion. Jundishapur J Microbiol 2015;8:e17985.
Abshirini H, Khosravi A, Ghazipour A, Yavari M, Hashemzade M, Salehi F. Evaluation of cholesteatoma microbiologic finding in patients with chronic. Health Med 2012;6:1684-7.
Emaneini M, Gharibpour F, Khoramrooz SS, Mirsalehian A, Jabalameli F, Darban-Sarokhalil D, et al.
Genetic similarity between adenoid tissue and middle ear fluid isolates of Streptococcus pneumoniae
, Haemophilus influenzae
and Moraxella catarrhalis
from Iranian children with otitis media with effusion. Int J Pediatr Otorhinolaryngol 2013;77:1841-5.
Khoramrooz SS, Mirsalehian A, Emaneini M, Jabalameli F, Aligholi M, Saedi B, et al.
Frequency of Alloiococcus otitidis
, Streptococcus pneumoniae
, Moraxella catarrhalis
and Haemophilus influenzae
in children with otitis media with effusion (OME) in Iranian patients. Auris Nasus Laryn×2012;39:369-73.
Jalali M, Rezaie A, Kousha A, Saadat F, Banan R. Detection of fungal DNA in the middle ear effusion of patients suffering from otitis media with effusion. Iran J Public Health 2008;37:109-13.
Ettehad G, Refahi S, Nemmati A, Pirzadeh A, Daryani A. Microbial and antimicrobial susceptibility patterns from patients with chronic otitis media in Ardebil. Int J Trop Med 2006;1:62-5.
Mozafari Nia K, Sepehri G, Khatmi H, Shakibaie MR. Isolation and antimicrobial susceptibility of bacteria from chronic suppurative otitis media patients in Kerman, Iran. Iran Red Crescent Med J 2011;13:891-4.
Faramarzi A, Motasaddi-Zarandy M, Khorsandi MT. Intraoperative findings in revision chronic otitis media surgery. Arch Iran Med 2008;11:196-9.
Gibney KB, Morris PS, Carapetis JR, Skull SA, Smith-Vaughan HC, Stubbs E, et al.
The clinical course of acute otitis media in high-risk Australian Aboriginal children: A longitudinal study. BMC Pediatr 2005;5:16.
Fliss DM, Shoham I, Leiberman A, Dagan R. Chronic suppurative otitis media without cholesteatoma in children in Southern Israel: Incidence and risk factors. Pediatr Infect Dis J 1991;10:895-9.
Pellegrini S, Gonzalez Macchi ME, Sommerfleck PA, Bernáldez PC. Intratemporal complications from acute otitis media in children: 17 cases in two years. Acta Otorrinolaringol Esp 2012;63:21-5.
Indudharan R, Haq JA, Aiyar S. Antibiotics in chronic suppurative otitis media: A bacteriologic study. Ann Otol Rhinol Laryngol 1999;108:440-5.
Nakagawa T, Yaduhisa O, Komunes S. A 19-year survey of changes in bacterial isolate associated with chronic suppurative otitis media. Ear Arch Otorhinolaryngol 1994;1:27-32.
Nyembue DT, Tshiswaka JM, Sabue MJ, Muyunga CK. Bacteriology of chronic suppurative otitis media in Congolese children. Acta Otorhinolaryngol Belg 2003;57:205-8.
Moshi NH, Minja BM, Ole-Lengine L, Mwakagile DS. Bacteriology of chronic otitis media in Dar es Salaam, Tanzania. East Afr Med J 2000;77:20-2.
Sharma S, Rehan HS, Goyal A, Jha AK, Upadhyaya S, Mishra SC, et al
. Bacteriological profile in chronic suppurative otitis media in Eastern Nepal. Trop Doct 2004;34:102-4.
Fattahi Bafghi A, Paeyvandi A. The study of pathogens in the secretion of chronic infectious diseases in the middle ear. Sci J Med Organ Islam Repub Iran 2010;28:397-402.
Sharifi Yazdi M, Heidarzade S, Vahedi S, Rahimi Forushani A, Jabari H, Soltan Dallal M. Identification and determination antimicrobial resistance pattern of Staphylococcus aureus
and Pseudomonas aeruginosa
isolated from patients with otitis media. J Islam Repub Iran Med Counc 2015;33:91-100.
Mohammadi GA, Sayah Melli M. The efficacy of tympanomastoid surgery for prevention of infection in active chronic otitis media. Med J Tabriz Univ Med Sci Health Serv 2002;55:55-9.
Abtahi S, Hashemi S. Bacteriological study of middle ear discharge in secretory otitis media. Iran J Otorhinolaryngol 2002;14:30-3.
Abshirini H. Culturing and antibiogram of aerobic bacteria causing chronic otitis media. Iran J Otorhinolaryngol 2004;16:28-37.
Nyembu D, Tshiswaska J, Sabue M, Mu yunga C. Bacteriology of chronic suppurative otitis media in Congolese children. Acta otorhonolaryngol Belg 2003;57:205-9.
Maymane Jahromi A, Nezhad Aryani FH, Arab Khani R, Nezhad Aryani SH. Investigating the frequency of cholesteatoma in patients with chronic otitis media referring to the eardrum, throat and nose center of imam reza hospital of Mashhad during 2004-2009. Iran J Otorhinolaryngol 2009;21:21-4.
Sharma S, Rehan H, Goyla A, Jha A, Upadhayuya S, Mishra S. Bacteriological profile in chronic suppurative otitis media in Eastern Nepal. Trop Doct 2004;34:102-4
[Table 1], [Table 2], [Table 3]