For this reason, in fact, we expected to find a higher biofilm rate in this region. However, in our study, ossicles were the locations on which the least biofilm was observed. Nevertheless, we did not observe a disruption depending on infection on the ossicle surfaces. selleckchem This condition may also help prevent biofilm adhesion. The granulated tissue may be produced as a response to microbial biofilm adhesion to alloplastic materials such as tympanostomy tubes and partial or total ossicular replacement prosthesis or as a secondary consequence of bacterially induced inflammation in the middle ear. Chole and Faddis reported that recurrent infections or hypertrophy raises the possibility that the bacteria are sequestered from the host defenses [21]. In addition, hypertrophy is thought to be caused by multiple and sometimes resistant bacteria.

In our study, we also determined that the biofilm rates were higher in hypertrophic and granulated tissue samples than in normal mucosa. A limitation of the present study is the lack of a control group. Tissue from an appropriate control group is ethically problematic to obtain because it should be composed of tissue from age-matched control subjects who have never had an infection of the upper airways. Thus, the inclusion of controls was not feasible in our study. Although SEM has been widely used by investigators to identify and characterize biofilms, we have experienced some drawbacks in using this method. For example, although our sample size is too small, surveying the entire specimen for biofilm detection was difficult.

Occasionally, because of the rough topographic structure of the surface or crypts, these regions could not be examined in detail. Recently, newer techniques, such as confocal laser scanning microscopy, have also been used in biofilm research. These methods allow for further elucidation of the structure-function relationships in biofilms. However, we were unable to find any studies in the literature comparing the sensitivity and specificity of the microscopic techniques used to detect human host biofilms.In conclusion, our research supports the hypothesis in which biofilms are involved in CSOM, cholesteatoma, and, to a lesser degree, CNSOM. In this situation, the careful use of topical or systemic antimicrobials is essential. The first choice is surgery, and, during the surgery, hypertrophic tissue must be carefully removed from the normal tissue.

There are many reasons for failure after the operation. If the tissue with the potential to harbor biofilms, such as granulated tissue, cannot be cleaned sufficiently, residual biofilms may be one reason for the surgery failure.Conflict of InterestsThe authors declare that there is no conflict of interests.AcknowledgmentThis work was supported by a grant from Eskisehir Osmangazi Brefeldin_A University (Project no. 201141045).