Dear Editors,

I came across a very interesting study published in your prestigious journal titled ‘Outcome evaluation of clarithromycin, metronidazole and lansoprazole regimens in Helicobacter pylori positive or negative children with resistant otitis media with effusion’ by Mel-Hennawi et al.Reference Mel-Hennawi and Ahmed¹ The authors have conducted a very meticulous study and I would like to appreciate their effort; however, I have some concerns regarding the methodology and conclusion, which I would like to express through your esteemed journal.

The role of H pylori in the pathogenesis of otitis media with effusion (OME) is a matter of debate, with studies both in favour of itReference Yilmaz, Ceylan, Akyön, Ozçakýr and Gürsel² and against it.Reference Sudhoff, Rajagopal, Baguley, Ebmeyer, Schmelzer and Schreiber³ The aspirated fluid from the middle ear has been used for the detection of H pylori in most of the studies as it is confirmatory for the presence of the bacteria in the middle ear. However, in the present study only the stool antigen has been used. The detection of H pylori in stool samples, although cheap and non-invasive, does not confirm the presence of the bacteria in the middle ear. In addition, the prevalence of H pylori in children ranges from 15 to 70 per cent;Reference Oderda, Marietti and Pellicano⁴ therefore, the detection of H pylori in stool samples is non-specific and may not be significant.

A few studies have explored the role of gastroesophageal reflux in the pathogenesis of otitis media.Reference Doğru, Kuran, Haytoğlu, Dengiz and Arıkan⁵ In such a scenario, it is possible that the children in the present study could have benefitted primarily from a reduction in the gastroesophageal reflux by lansoprazole. This needs to be proven in future prospective trials. If proven, then clarithromycin and metronidazole can be omitted, thereby reducing the cost of treatment and avoiding the side effects of these antibiotics.

A further concern is the rising incidence of development of clarithromycin resistance in H pylori. Therefore, misuse of clarithromycin should be prevented at all costs, and its use should be based on clear scientific evidence. The evidence for the use of clarithromycin in OME is still unclear. Future randomised, controlled trials with larger sample populations are warranted before a conclusion can be drawn.