Category: Illness or disabilities
Introduction and description
The ear is the organ of hearing and, in mammals, balance.
The ears of vertebrates are placed somewhat symmetrically on either side of the head, an arrangement that aids sound localisation.
In mammals, the ear is usually described as having three parts—the outer ear, middle ear and the inner ear.
- The outer ear consists of the pinna and the ear canal.
- The middle ear includes the tympanic cavity and the three ossicles.
- The inner ear sits in the bony labyrinth, and contains structures which are key to several senses:
- the semicircular canals, which enable balance and eye tracking when moving;
- the utricle and saccule, which enable balance when stationary; and
- the cochlea, which enables hearing.
As can be seen from the diagrams, the ear is an exceptionally complex organ with a lot of parts that could go wrong. If attacked by pathogens, each part could be damaged, inflamed, or even destroyed. The ear is also vulnerable to attack as it is open to the air – an external organ – and thus more easily attacked.
Otitis is the general term for inflammation or infection of the ear, in both humans and other animals. It is subdivided into the following:
- Otitis externa, external otitis, involves the outer ear and ear canal.
- Otitis media or middle ear infection involves the middle ear.
- Otitis interna or labyrinthitis involves the inner ear. The inner ear includes sensory organs for balance and hearing.
In external otitis, the ear hurts or the canal is blocked. Specific problems include:
- Otomycosis is a fungal ear infection, a mycotic infection of the outer ear canal. The infection may be either subacute or acute and is characterized by “malodorous discharge, inflammation, pruritus, scaling, and severe discomfort”. The mycosis results in “inflammation, superficial epithelial exfoliation, masses of debris containing hyphae, suppuration, and pain.”
- Ear wax problems – Ear wax may block the ear and cause partial deafness. It may be itchy, or profuse and ‘embarrassing’ in its quantity. And we may think we need to go to the doctor to get rid of it, but first perhaps we might be better understanding something about what ear wax does in the body and why it may be running out of our ears by the bucket full, or not, as the case may be! Follow the link
- Cauliflower ear is a condition that occurs when the external portion of the ear is hit and develops a blood clot or other collection of fluid under the perichondrium. This separates the cartilage from the overlying perichondrium that supplies its nutrients, causing it to die and resulting in the formation of fibrous tissue in the overlying skin. As a result, the outer ear becomes permanently swollen and deformed, resembling a cauliflower. The condition is common in martial arts like boxing, mixed martial arts or wrestling, and in full-contact sports such as rugby union football.
In otitis media, the ear is infected or clogged with fluid behind the ear drum, in the normally air-filled middle-ear space. Example conditions include:
- Otosclerosis - or otospongiosis is an abnormal growth of bone near the middle ear. It can result in hearing loss. “The term otosclerosis is somewhat of a misnomer. Much of the clinical course is characterised by lucent rather than sclerotic bony changes.”
- Cholesteatoma - is a destructive and expanding growth consisting of ‘keratinizing squamous epithelium’ in the middle ear and/or mastoid process. Although cholesteatomas are not classified as either tumours or cancers, they can still cause significant problems because of their erosive and expansile properties resulting in the destruction of the bones of the middle ear (ossicles), as well as their possible spread through the base of the skull into the brain. They are also often infected. The majority (98%) of patients with cholesteatoma have ear discharge or hearing loss or both in the affected ear.
Labyrinthitis is also known as vestibular neuritis. It results in vertigo and also possible hearing loss or ringing in the ears. It can occur as a single attack, a series of attacks, or a persistent condition that diminishes over three to six weeks. The causes are discussed below, however it is recognised there are multiple possibilities – viruses, fungi, bacterial infection, parasites, head injury, and pharmaceuticals
- Ménière's disease (MD) - is a disorder of the inner ear that is characterized by episodes of feeling like the world is spinning (vertigo), ringing in the ears (tinnitus), hearing loss, and a fullness in the ear.
- Sensorineural hearing loss (SNHL) is a type of hearing loss, or deafness, in which the root cause lies in the inner ear or sensory organ (cochlea and associated structures) or the vestibulocochlear nerve (cranial nerve VIII) or neural part. SNHL accounts for about 90% of hearing loss reported. SNHL is generally permanent and can be mild, moderate, severe, profound, or total. Various other descriptors can be used such as high frequency, low frequency, U-shaped, notched, peaked or flat depending on the shape of the audiogram, the measure of hearing. It is sometimes further classified into Idiopathic sudden sensorineural hearing loss (ISSNHL) or Rapidly progressive sensorineural hearing loss (RPSNHL)
- Benign paroxysmal positional vertigo (BPPV) is a disorder arising from a problem in the inner ear, more specifically it involves a small calcified otolith moving around loose in the inner ear. Symptoms are repeated brief periods of vertigo with movement, that is, of a spinning sensation caused by changes in the position of the head. This can occur with turning in bed or changing position. Each episode of vertigo typically lasts less than one minute. Nausea is commonly associated.
- A labyrinthine fistula is an abnormal opening in the bony capsule of the inner ear, resulting in leakage of the perilymph from the semicircular canals into the middle ear. This includes specifically a perilymph fistula (PLF), an abnormal connection between the fluid of the inner ear and the air-filled middle ear. This connection is caused by a rupture of the oval window or round window that separate the inner and middle ear.
- Mastoiditis - is an infection that extends to the air cells of the skull behind the ear. Specifically, it is an inflammation of the mucosal lining of the mastoid antrum and mastoid air cell system inside the mastoid process. The mastoid process is the portion of the temporal bone of the skull that is behind the ear which contains open, air-containing spaces.
- A vestibular schwannoma is a benign primary intracranial tumour of the myelin-forming cells of the vestibulocochlear nerve (8th cranial nerve). The primary symptoms of vestibular schwannoma are unexplained unilateral hearing loss and tinnitus, and vestibular (disequilibrium) symptoms. Treatment of the condition is by surgery or radiation, and often results in substantial or complete hearing loss in the affected ear.
One of the symptoms of ear disease can be deafness and/or tinnitus, but it needs to be recognised that not all cases of deafness or tinnitus are caused by ear disease, some can be caused by various problems with the parts of the brain or the nerves leading to the brain, thus deafness is not a disease of the ear, but a possible symptom of ear disease.
The pain tends to centre around the fluid filled middle ear, although pain can be experienced from inflammation of outer and inner ear as well. The degree of pain is occasionally influenced by the configuration of the ear, for example:
Experimental infection of adults with influenza A virus, rhinovirus or RSV causes abnormal ME pressure in some, but not all subjects. The hypothesis tested in this study is that the response variability is caused by constitutional differences in the functioning of the Eustachian tube…. These results support the hypothesis that pre-existing good Eustachian tube function reduces the otological complications of viral upper respiratory tract infection. PMID: 10996490
Not just feeling sick, but being sick. Vomiting. Generally this symptom is associated with attacks on the inner ear, where the sensory organs for balance are located.
Vertigo refers to the ‘inappropriate perception of motion’. It is classified in many medical textbooks as a form of hallucination. It is the result of a dysfunction of the vestibular system. When the inner ear is inflamed, vertigo is a common symptom. One common type of vertigo is ‘benign paroxysmal positional vertigo’, when an otolith is displaced from the ventricles to the semicircular canal. The displaced otolith rests on the cupola, causing a sensation of movement when there is none. Ménière's disease, and labyrinthitis, can produce vertigo, but so can strokes - brain damage again.
Many attacks on the inner ear including conditions such as Vestibular neuronitis may also be associated with eye nystagmus.
Usually in the outer ear. Itchiness is often caused by parasites – especially tiny ones you cannot see.
There may be a foul smelling discharge – suppuration, indicating severe infection. It may be similar to the pus that exudes from blisters and boils, meaning the body is trying to expel the pathogens via the discharge. The key here is to mop up the pus frequently with a sterile dressing and burn the dressing.
All the major pathogens are implicated in causing ear disease – Bacteria, fungi, viruses, parasites, toxins and heavy metals, nanoparticles, pharmaceuticals, as well as radiation and physical damage. The source can sometimes be other animals and sometimes just the environment For example:
Zoonoses are infections transmitted from animal to man, either directly (through direct contact or contact with animal products) or indirectly (through an intermediate vector, such as an arthropod). The causative agents include bacteria, parasites, viruses, and fungi. The purpose of this review is to make an accurate examination of all zoonotic diseases that can be responsible of ear, nose, and throat (ENT) involvement…….. A total of 164 articles were selected and examined. Larynx was the most commonly involved ENT organ, followed by oral cavity, pharynx, and neck. Bacteria were the most representative microorganisms involved. Nose and major salivary glands were affected most frequently by protozoa; paranasal sinus, oral cavity, ear, neck, nerves and upper airway by bacteria; and larynx by fungi. CONCLUSIONS: … Appreciation of the possible occurrence of these diseases is important for a correct microbiological approach, which often requires special culture media and diagnostic techniques. PMID: 24423708
As we will see in the papers, however, the other ENT organs can be reservoirs for pathogens that then travel at times of low immunity to the ear.
Bacterial infection is a known cause of inner ear infection and the bacteria in patients with an intact ear drum, comes from ‘inside’ the body, not external to it, as is to be expected. For example:
Eighteen pediatric patients with chronic OME [otitis media with effusion] were recruited prospectively, with 34 paired MEF [Middle ear fluid] and EAC [external auditory canal] samples.
The MEF microbiota … consisted of
- Alloiococcus otitidis (37.5% [40.0%]),
- Haemophilus (14.4% [29.1%]),
- Moraxella (10.0% [26.4%]),
- Staphylococcus (8.2% [21.9%]), and
- Streptococcus (3.8% [13.1%]).
The mean relative abundance (SD) microbiota of the EAC demonstrated a sparsity of classic otopathogens, including Haemophilus (0.3% [0.8%]), Moraxella (0.3% [0.7%]), and Streptococcus (0.2% [0.6%]), but had a high abundance of
- Alloiococcus (58.0% [44.1%]),
- Staphylococcus (20.8% [34.0%]), and
- Pseudomonas (3.2% [17.1%]).
In contrast, based on previously collected data, the microbiota of the adenoid pad showed a high abundance of the classic otopathogens with a sparsity of EAC genera for
- Alloiococcus (0.1% vs 28.9%, respectively; P < .001),
- Haemophilus (25.2% vs 18.2%, respectively; P = .002),
- Staphylococcus (0.2% vs 10.8%, respectively; P = .02),
- Streptococcus (12.7% vs 4.2%, respectively; P < .001), and
- Pseudomonas (0 vs 2.1% respectively; P < .001).
The microbiota of the MEF collected during 2 consecutive years were similar (Alloiococcus, 22.7% vs 37.5%; Haemophilus, 22.5% vs 14.0%; Staphylococcus, 10.9% vs 10.7%; Moraxella, 5.0% vs 9.7%; Corynebacteria, 6.2% vs 3.1%; Streptococcus, 4.8% vs 3.7%; and Pseudomonas, 1.1% vs 3.0%; P ≥ .05). Conclusions: The EAC and the nasopharynx could serve as reservoirs for microbiota of the middle ear. Furthermore, the microbiota of the middle ear with effusion appear to be relatively stable over time and between populations with OME. PMID: 27812691
Thus in this interesting study they showed that the adenoids, along with a number of nasal organs had the role of protecting the inner ear by trapping pathogens, so that they could be handled by the immune system. The adenoids have a mucosal layer in which pathogens can be subdued and held captive. Needless to say, by removing the adenoids, one lays oneself completely open to pathogenic attack and ear infections – serious ones.
Both middle and inner ear infections can be caused by viruses. The viruses may get there via the nose or via the blood stream
Human enteroviruses (HEVs) and rhinoviruses (HRVs) have been linked to acute otitis media (AOM). The present study evaluates the aforementioned association in a birth cohort setting. The cohort included 286 healthy infants (191 boys) followed from birth up to the age of 2 years in …. Finland. …
Altogether 610 AOM episodes were reported during the follow-up. 9.8% of the stool samples were positive for HRV and 6.8% for HEV. ….Having an older sibling, short breast-feeding and maternal smoking during pregnancy were also significantly associated with AOM.
HRV and HEV infections are frequent during the first months of life. The observed trend for increased risk of AOM in HRV and HEV positive children is in line with the results from hospital series suggesting that these viruses may play an independent role in the pathogenesis of AOM. PMID: 27780081
But there are other viruses implicated, especially for inner ear infections:
The key signs and symptoms of vestibular neuritis are rotatory vertigo with an acute onset lasting several days, horizontal spontaneous nystagmus (with a rotational component) toward the unaffected ear, a pathologic head-impulse test toward the affected ear, a deviation of the subjective visual vertical toward the affected ear, postural imbalance with falls toward the affected ear, and nausea. …. The reactivation of a latent herpes simplex virus type 1 (HSV-1) infection is [one] likely cause, as HSV-1 DNA and RNA have been detected in human vestibular ganglia. PMID: 19834862
All the herpes family of viruses exhibit latency – the ability to lie low and hidden only to re-emerge when the immune system has been compromised. The paper above shows that herpes simplex 1 can cause ear infections, so can the other members of the family
Viral labyrinthitis has been postulated to play a role in the pathophysiology of ISSHL. Circumstantial evidence is pointing at members of the herpes virus family.…. When comparing cochlear histopathology in ISSHL to experimental viral HSV-1 labyrinthitis, strong similarities were found: degeneration of the stria vascularis, destruction of the organ of Corti, loosening of the tectorial membrane, and inflammatory changes in neural structures. PMID: 9661753
Herpesviridae is a large family of DNA viruses that cause latent, recurring infections typical of this group of viruses. At least five species of Herpesviridae – HSV-1 and HSV-2 (both of which can cause orolabial herpes and genital herpes), Varicella zoster virus (which causes chicken-pox and shingles), Epstein-Barr virus (which causes mononucleosis), and Cytomegalovirus can cause ear disease– as well as possibly human herpesvirus 6A and 6B (HHV-6A and HHV-6B), human herpesvirus 7 (HHV-7), and Kaposi's sarcoma-associated herpesvirus (KSHV).
Which brings us neatly on to vaccines.
Many vaccines use live viruses – what are called attenuated viruses, but live nevertheless. Perhaps more alarming is that they are administered in some cases via the nose as a nasal spray or drops. The ear, nose and throat are connected and viruses can travel throughout this system as well as get into the blood stream. And it is very clear that the influenza virus can cause ear infections, along with the chicken pox virus:
Human-derived normal middle ear mucosal cells …. will support influenza A virus (INF A) infection. Primary cultures of human middle ear mucosal cells have been established. Two distinctly different cell culture systems have been developed: 1) middle ear epithelial cells and 2) either dedifferentiated epithelial cells or fibroblasts. Exposure of both cell types to INF A demonstrates that each can support cellular infection and viral replication. These models should be useful for studies of the pathogenesis of virus-mediated otitis media. PMID: 11037837
And it gets worse
Streptococcus pneumoniae (pneumococcus) is both a widespread nasal colonizer and a leading cause of otitis media, one of the most common diseases of childhood. ….. coinfection with influenza A virus has been strongly associated epidemiologically with the dissemination of pneumococci from the nasopharynx to the middle ear. Using a mouse infection model, we demonstrated that coinfection with influenza virus and pneumococci enhanced both colonization and inflammatory responses within the nasopharynx and middle ear chamber. … [The data indicates] that despite inherent differences in colonization, the influenza A virus exacerbation of experimental middle ear infection is independent of the pneumococcal phase. PMID: 25156728
Parasites including mites, appear to attack from both inside the body and external to the body, working their way down the ear canal. There has been an increase in the cases of ear damage done by bed bugs for example:
There is a resurgence of interest in the biology and clinical disease associated with Cimex lectularius, as the common bed bug is becoming more prevalent in well-developed countries. A patient presented with complaints of right ear irritation for several days' duration. A foreign body was lavaged from the ear canal, which proved to be an engorged nymphal form of Cimex lectularius. The parasite had apparently obtained a blood feed from the tympanic membrane. The resolution of the illness was unremarkable. This ectoparasite is currently re-emerging as a human pest worldwide. PMID: 23277805
Toxoplasma gondii is a parasite carried by cats. It can be caught by adults and passed from mother to fetus in the womb. At worst it kills the fetus, but if the fetus survives, the baby may be deaf and have parasitic infection:
Toxoplasmosis is a parasitic infection caused by Toxoplasma gondii. If fetal infection occurs early in gestation, severe inflammation and necrosis can cause brain lesions, chorioretinitis, and hearing loss. ….The temporal bones of 9 subjects with congenital toxoplasmosis were removed at autopsy and studied ….Three (33%) of 9 subjects were found to have parasites in the temporal bone. The organism was identified in the internal auditory canal, the spiral ligament, stria vascularis, and saccular macula. PMID: 23598697
There are many more other parasites that can do damage, another example:
Leishmaniasis comprises a group of diseases caused by a protozoan parasite belonging to the genus Leishmania and transmitted by the bite of infected female sand flies. Leishmaniasis is endemic in 88 countries and causes significant morbidity and mortality worldwide. Phenomena such as globalization and human migration, as well as the increased volume of international travel have extended its prevalence in developed countries. ….. In humans, there are three possible clinical syndromes of leishmaniasis: cutaneous, mucocutaneous and visceral.
Mucocutaneous disease is due to extension of local skin disease into the mucosal tissue via direct extension, bloodstream or lymphatics. Lesions affect mainly the oral and nasal mucosa and occasionally the laryngeal and pharyngeal mucosa. ….. Because of the invariable involvement of the areas pertaining otorhinolaryngologists, it is important for ENT specialists and family physicians to have awareness of this condition and its clinical manifestations. PMID: 24897964
Oto = ear.
The parasite that causes acne can also cause itchiness in the ear and no doubt in time it might cause further damage
To investigate the frequency of demodex species in the external acoustic meatus in patients with an itchy ear canal. …Patients were assigned to one of three groups. Group one consisted of 54 patients with an itchy ear canal who were using a local agent, while group two was composed of 51 patients with an itchy ear canal who were not using a local agent. Group three consisted of 50 healthy individuals without an itchy ear canal…. Demodex species test results were positive in nine (5.8 per cent) of the cases. Six of these positive cases were in group one, two in group two and one in group three. The frequency of demodex species in the external acoustic meatus was … significantly higher in those using a local steroid compared with those not using a local agent CONCLUSION: …. use of a local steroid increased the parasite frequency in the external ear canal of affected patients. PMID: 25033419
Notice the fact that using immunosuppressants was a major cause.
Candida auris is a relatively new pathogen, or at least its identification as a pathogen is relatively new:
Since being first reported in an ear swab in 2009, and in blood cultures in 2011, invasive infections with Candida auris have been reported in many countries across several continents. We review current knowledge of the epidemiology of this emerging multidrug-resistant pathogen. The importance of species identification and the inadequacies of many widely used identification systems are considered. We recommend that hospitals develop their own policies for the prevention and control of infections with this pathogen. Elements of such policies and the limitations of the existing knowledge base are discussed. PMID: 27634564
Then we find a great number of other fungi:
The aim of this study was to determine the prevalence of fungal agent, ..in otomycosis…. Samples from the 118 clinically suspected patients of otomycosis were collected between January 2008 and February 2009, with an age group of 6 and 75 years. Mycological examination of all the samples was done to isolate the fungal agents involved …. Mycological examination revealed … fungal otomycosis in 78% of the suspected patients. Pruritus has been found as the most common symptom. …. The fungi involved in [were] Aspergillus niger, A. flavus, A. fumigatus, A. luchuensis, A. terreus, Candida albicans and Penicillium sp. Of these, A. niger followed by A. flavus were the dominant fungi. PMID: 20347163
We are ‘programmed' genetically to be able to handle certain diseases and pathogens and it seems that foreign travel, the mingling of people world-wide, the introduction of pathogens into areas that did not have them, and the migration of people into new areas, has meant that some people ‘programmed’ for some pathogens are unable to handle the pathogens of that region. For example:
The indigenous Filipino population has a ~50% prevalence of otitis media. …. In multivariate analyses, A2ML1 genotype is the strongest predictor of otitis media, with an odds ratio of 3.7 (95% confidence interval: 1.3-10.8; P = .005). When otitis media diagnoses were plotted across ages, otitis media was observed within the first year of life, and chronic otitis media persisted up to adulthood, particularly in A2ML1-variant carriers. PMID: 27484237
The production of ear wax, and the production of the fluids and other substances used to heal and ensure the effective operation of the ear, relies on good nutrition. Minerals, vitamins, amino acids, fatty acids and cholesterol are all used in ensuring the ear keeps working, and both overdose or deprivation can upset the delicate balance needed. This example shows that potassium deprivation affects the inner ear
Experimental and clinical data made us consider some types of perceptive hearing loss secondary to an alteration of the secretory structures of the cochlea including stria vascularis, spiral ligament and supporting cells. These structures are responsible for the secretion of endolymph, a fluid characterized by a high potassium concentration (150-180 mM), a low sodium concentration (<1 mM) and a positive potential (80-100 mV). This intracellular-like fluid fills the endolymphatic compartment and is essential in the transduction process which takes place in the organ of Corti. PMID: 12021503
Earwax is absolutely essential to our protection from pathogens. We have a section on ear wax and its protective role. Ear wax varies its composition, but the one common substance that all ear wax contains and is made from is cholesterol. At which point you should be realising that our rather unwise use ofstatins and other cholesterol lowering medication, not to mention the insistence that children have ‘low fat’ spreads, opens them, and us, up to a host of infections via the ear, as we have effectively scuppered our only defence.
The eHealthme site collects the Adverse Drug reports submitted by doctors to the FDA and SEDA in the USA. It then summarises them for ease of use. We originally provided a direct link to the various ear diseases listed on this site and the pharmaceuticals that can cause them, but the eHealthme website developers frequently reorganise the site and thus break the links. Thus in order to find out which pharmaceuticals are implicated in ear diseases of various sorts
- Follow the LINK to the eHealthme website
- Using the ‘All conditions’ index find the appropriate entries
- Now scroll down until you get to the section marked ‘Drugs that could cause ”
The list shows you all the drugs implicated in CAUSING each type of disease as well as the number of people who have made a complaint to their doctor and had their case reported by him. Note that it is up to the doctor whether he reports or not.
As of October 2016, about 1,050 pharmaceuticals were implicated in causing Otitis, for example.
Immunosuppressants [which suppress the immune system] also called 'steroids' , statins, lipid lowering drugs, and anti-histamines as well as numerous types of nasal spray, have a particularly poor record at inducing ear disease. But there are many others:
Experimental studies have shown that drugs such as loop diuretics induced marked histological lesions in the stria vascularis and profound alterations in the electrochemical features of endolymph. Histopathological data have demonstrated that several entities such as prebyacusis, sudden deafness, and congenital or acquired progressive hearing loss could be related to strial abnormalities. …. All these arguments suggest that among the various types of so-called 'sensorineural' deafness, several entities including .. diuretic-induced ototoxic deafness, … and sudden deafness should be classified as endolymphatic deafness. PMID: 12021503
All three are implicated in causing various sorts of otitis. For example:
Cadmium (Cd(2+)) exposure can occur through passive smoking, ambient air pollution, and food. Even low exposure can affect hearing and cause lung disease. Here we investigated whether cadmium causes cytotoxicity, induces inflammation, or increases mucin gene expression in immortalized human middle ear epithelial cells (HMEECs)…. Our findings suggest that environmental cadmium exposure is related to the development of otitis media. PMID: 26915146
Head trauma and surgery
Traumatic events, with excessive pressure changes to the inner ear such as in scuba diving, head trauma, or an extremely loud noise can lead to rupture, damage and leakage in the ear. Pressure differences between the middle ear and the outside, if not released, can result in a burst eardrum.
A number of activities increase intracranial pressure - weightlifting, valsalva, scuba diving, flying in airplanes, freediving/spearfishing, skydiving, fast descent in an aircraft, fast descent in a mine cage, and being put into pressure in a caisson or similar pressure-bearing structure, or sometimes even simply travelling at fast speeds in an automobile - all these can cause ear damage caused by unequal pressures in the ear.
Ear clearing or clearing the ears or equalization [yawning, swallowing etc] is recommended to equalize the pressure in the middle ear with the outside pressure, by letting air enter along the Eustachian tubes.
FIND THE CAUSE
And never underestimate the power of ear wax to heal – see Ear wax .
References and further reading
- J Infect Dev Ctries. 2014 Jan 15;8(1):17-23. doi: 10.3855/jidc.4206. Ear, nose and throat (ENT) involvement in zoonotic diseases: a systematic review. Galletti B1, Mannella VK, Santoro R, Rodriguez-Morales AJ, Freni F, Galletti C, Galletti F, Cascio A. 1University Hospital G. Martino, Messina, Italy. email@example.com.
- J Laryngol Otol. 2014 Aug;128(8):698-701. doi: 10.1017/S0022215114001510. Epub 2014 Jul 17. Investigation of demodex species frequency in patients with a persistent itchy ear canal treated with a local steroid. Cevik C1, Kaya OA2, Akbay E1, Yula E3, Yengil E4, Gulmez MI1, Akoglu E1. Mustafa Kemal University School of Medicine,Antakya,Turkey.
- J Hosp Infect. 2016 Aug 15. pii: S0195-6701(16)30318-8. doi: 10.1016/j.jhin.2016.08.004. [Epub ahead of print] Multidrug-resistant Candida auris: 'new kid on the block' in hospital-associated infections? Chowdhary A1, Voss A2, Meis JF2.
- J Clin Aesthet Dermatol. 2012 Dec;5(12):43-5. Otitis from the common bedbug. Cimolai N1, Cimolai TL. 1The University of British Columbia, Vancouver, British Columbia, Canada;
- Int J Pediatr Otorhinolaryngol. 2010 Jun;74(6):604-7. doi: 10.1016/j.ijporl.2010.03.001. Epub 2010 Mar 26. Fungal infection of the ear: a common problem in the north eastern part of Haryana. Aneja KR1, Sharma C, Joshi R. 1Department of Microbiology, Kurukshetra University, Kurukshetra 136 119, Haryana, India. firstname.lastname@example.org
- Otolaryngol Head Neck Surg. 2016 Nov;155(5):856-862. Epub 2016 Aug 2. Genetic and Environmental Determinants of Otitis Media in an Indigenous Filipino Population. Santos-Cortez RL et al
- Semin Neurol. 2009 Nov;29(5):509-19. doi: 10.1055/s-0029-1241040. Epub 2009 Oct 15. Vestibular neuritis. Strupp M1, Brandt T.
- Otol Neurotol. 2013 Aug;34(6):1165-9. doi: 10.1097/MAO.0b013e31828297b6. Otopathology in congenital toxoplasmosis. Salviz M1, Montoya JG, Nadol JB, Santos F. 1Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts 02114, USA.
- ORL J Otorhinolaryngol Relat Spec. 2002 Mar-Apr;64(2):120-4. Endolymphatic deafness: a particular variety of cochlear disorder. Tran BH1. 1Service ORL, Hôpital Lariboisière, Paris, France. email@example.com
- Laryngoscope. 2000 Oct;110(10 Pt 1):1739-44. Influenza A virus infection of human middle ear cells in vitro. Buchman CA1, Fregien N. 1Department of Otolaryngology, University of Miami School of Medicine, Florida, USA. firstname.lastname@example.org
- Infect Immun. 2014 Nov;82(11):4802-12. doi: 10.1128/IAI.01856-14. Epub 2014 Aug 25. Influenza A virus alters pneumococcal nasal colonization and middle ear infection independently of phase variation. Wren JT et al; Department of Microbiology and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
- Am J Otol. 1998 Jul;19(4):447-52. The etiology of idiopathic sudden sensorineural hearing loss. Experimental herpes simplex virus infection of the inner ear. Stokroos RJ1, Albers FW, Schirm J. 1Department of Otorhinolaryngology, University Hospital Groningen, The Netherlands.
- Auris Nasus Larynx. 2000 Oct;27(4):323-6. Abnormal middle ear pressures during experimental influenza A virus infection--role of Eustachian tube function. Doyle WJ1, Seroky JT, Angelini BL, Gulhan M, Skoner DP, Fireman P. 1Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh and the University of Pittsburgh School of Medicine, 3705 Fifth Avenue, Pittsburgh, PA 15213-2583, USA. email@example.com
- BMC Infect Dis. 2016 Sep 2;16:464. doi: 10.1186/s12879-016-1796-4. Aspergillus fumigatus carrying TR34/L98H resistance allele causing complicated suppurative otitis media in Tanzania: Call for improved diagnosis of fungi in sub-Saharan Africa. Mushi MF1, Buname G2, Bader O3, Groß U3, Mshana SE4. PMID: 27589956
- J Int Adv Otol. 2015 Dec;11(3):183-7. doi: 10.5152/iao.2015.756. Effect of Cadmium on Human Middle Ear Epithelial Cells. Song JJ1, Kim JY, Jang AS, Kim SH, Rah YC, Park M, Park MK.
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- Obsessive-compulsive disorder presenting with musical obsessions in otosclerosis: a case report 023395
- The mind with a radio of its own: a case report and review of the literature on the treatment of musical hallucinations 023397
- The neurologic aspects of vertigo: analysis of 400 cases 023392