Chronic pediatric middle ear disease is commonly ascribed to Eustachian tube dysfunction (ETD). This article reviews the role of obstructive and patulous ETD in otitis media with effusion, tympanic membrane retraction, cholesteatoma, and perforation. It highlights the lack of reliable diagnostic tests to measure ETD. The contribution of different causes of obstructive ETD is discussed, including the influence of mechanical obstruction, inflammation, allergy, mucociliary dysfunction, and craniofacial anomalies. ETD management has traditionally bypassed the Eustachian tube, for example, with tympanostomy tubes. Balloon dilatation remains controversial in children due to unproven efficacy and safety and the heterogeneous underlying mechanisms of ETD.

The treatment of suppurative auricular perichondritis secondary to surgery for chronic otitis media is characterized by prolonged duration and complexity. Combining the use of physiotherapy alongside surgery and antimicrobial therapy enhances therapeutic efficacy and shortens recovery time. A multidisciplinary approach warrants wider adoption for this disease.

Multidrug-resistant Achromobacter xylosoxidans infections in pediatric patients with primary ciliary dyskinesia (PCD) often require prolonged intravenous therapy. We evaluated the pharmacokinetics of continuous infusion piperacillin/tazobactam (16 g/2 g daily) in a 13-year-old male with situs inversus and chronic otitis media transitioned from hospital-based electronic infusion to home-based Outpatient Parenteral Antimicrobial Therapy (OPAT) using elastomeric pumps. Plasma concentrations were measured by Therapeutic Drug Monitoring (TDM), and tissue exposure was estimated using conservative penetration coefficients. Drug concentrations consistently remained above the MIC (≤2 mg/L). During hospitalization, steady-state concentrations were stable (27.2-29.0 mg/L; CV 4.5%), whereas during OPAT they were higher and more variable (53.9-80.1 mg/L; CV 20.1%), consistent with the known non-linear delivery profiles of elastomeric devices. Despite this variability, TDM confirmed sustained supratherapeutic exposure, with estimated tissue concentrations remaining >5-fold above the MIC. Clinical resolution was achieved without adverse events, supporting the role of TDM-guided OPAT in difficult-to-treat infections.

Cardiofaciocutaneous (CFC) syndrome is characterized by cardiac abnormalities (pulmonic stenosis and other valve dysplasias, septal defects, hypertrophic cardiomyopathy, rhythm disturbances), distinctive craniofacial appearance, and cutaneous abnormalities (including xerosis, hyperkeratosis, ichthyosis, keratosis pilaris, ulerythema ophryogenes, eczema, pigmented moles, hemangiomas, and palmoplantar hyperkeratosis). The hair is typically sparse, curly, fine or thick, and woolly or brittle; eyelashes and eyebrows may be absent or sparse. Nails may be dystrophic or fast growing. Affected individuals typically have some form of neurologic and/or cognitive delay (ranging from mild to severe). Most individuals have severe feeding issues, which can contribute to poor growth, and many require nasogastric or gastrostomy tube feeding. Many affected individuals have eye findings, including strabismus, nystagmus, refractive errors, and optic nerve hypoplasia. Seizures may be present and can be refractory to therapy.

Obstructive Eustachian tube dysfunction (ETD) commonly complicates chronic otitis media (COM), yet microbial factors at the Eustachian tube (ET) openings remain poorly understood. In this prospective cohort study, we characterized the microbiota at both the middle ear (ME) and nasopharyngeal (NP) ET openings in COM patients undergoing ear surgery and examined associations with obstructive ETD over one year of follow-up. Using 16S rRNA gene sequencing and functional inference, we profiled microbial communities from the ME-side ET opening and the torus tubarius on both surgical-side and contralateral nasopharynx. Among 37 patients (18 with ETD, 19 without), ME and NP microbiota differed significantly in composition. Ears with ETD showed increased ME microbial diversity and enrichment of Neobacillus, Agrobacterium, and Sphingomonas. Paired NP-ME analyses indicated an altered NP-ME microbial relationship in ETD, with Neobacillus showing a nasopharyngeal source signal. Functional prediction revealed increased porphyrin metabolism and decreased pyruvate metabolism in ME microbiota with ETD, suggesting a shift toward biofilm formation and altered redox states. Anaerococcus was increased in the nasopharynx of patients with bilateral COM. These findings identify distinct microbial and metabolic features of COM with obstructive ETD, supporting a role for nasopharyngeal-microbial influence on ME pathology.IMPORTANCEChronic otitis media (COM) is a common and often persistent ear disease, especially when complicated by Eustachian tube dysfunction (ETD). By profiling microbiota at both Eustachian tube openings, this study links upper-airway microbial ecology with middle-ear microbial states in COM and helps clarify where clinically relevant signals may arise along the Eustachian tube pathway. The paired nasopharyngeal-middle ear design revealed that nasopharyngeal microbes may be linked to middle-ear community shifts in COM with obstructive ETD, consistent with a potential upper airway contribution to the middle-ear microbiota, generating testable hypotheses about microbial exchange and persistence. These findings highlight the upper airway microbiome as a potential target for developing new preventive and therapeutic strategies in COM.