Eye and Ear Microbiome – Normal Flora of Eye & Ear

What is Eye and Ear Microbiota (Microbiome) or Normal Flora of Eye & Ear?

  • The microbiota of the eye and ear, also known as the microbiome or normal flora of the eye and ear, is the assemblage of microorganisms that inhabit these areas naturally. The eye and ear, like other regions of the body, have their own distinct microbial communities, which play vital roles in maintaining health and preventing infections.
  • In addition to bacteria, other microorganisms such as fungi and viruses may also be present in the eye microbiota. Staphylococcus, Streptococcus, Corynebacterium, and Propionibacterium are the bacterial genera most commonly detected in the eye. Typically, these bacteria reside on the surface of the conjunctiva, the mucous membrane that borders the inside of the eyelids and covers the front of the eye.
  • The majority of the ear microbiota consists of microorganisms. In the ear, the most common bacterial genera are Staphylococcus, Streptococcus, Corynebacterium, and Pseudomonas. These bacteria are commonly located in the external ear canal, which connects the external ear to the eardrum.
  • The microbiota of the eye and ear contribute to maintaining the local environment’s equilibrium and bolstering the immune system. They prevent hazardous microorganisms from colonizing by competing for nutrients and space. Microbiota also interact with the immune system of the host, influencing the immune response and maintaining the eye and ear’s overall health.
  • Noting that disruptions in the normal microbiota can result in infections is essential. For instance, an overgrowth of certain bacteria or the introduction of pathogenic microorganisms can lead to conditions such as conjunctivitis and otitis externa. In such circumstances, appropriate medical treatment may be required to restore the microbiota’s homeostasis and eliminate the infection.
  • Overall, the microbiota of the eye and ear contribute to the health and function of these organs, highlighting the significance of sustaining a balanced microbial community in these areas.

Normal Flora of the Ear

MicroorganismTypeCategory
Staphylococcus spp.Gram-positiveBacteria
Alloiococcus otitisGram-positiveBacteria
Corynebacterium spp.Gram-positiveBacteria
Microbacterium spp.Gram-positiveBacteria
Bacillus spp.Gram-positiveBacteria
Arthrobacter spp.Gram-positiveBacteria
Turicella otitidisGram-positiveBacteria
Micrococcus spp.Gram-positiveBacteria
Moraxella spp.Gram-negativeBacteria
StreptococcusGram-positiveBacteria
CorynebacteriumGram-positiveBacteria
PseudomonasGram-negativeBacteria
Candida———Fungi
Malassezia———Fungi

Norma Flora of the Eye

Streptococcus spp.Gram-positiveBacteria
Staphylococcus spp.Gram-positiveBacteria
Corynebacterium speciesGram-positiveBacteria
Propionibacterium acnesGram-positiveBacteria
Haemophilus influenzaeGram-negativeBacteria
Neisseria speciesGram-negativeBacteria
Fusobacterium speciesGram-negativeBacteria
Candida speciesNot applicableFungi
Malassezia speciesNot applicableFungi
Aspergillus spp.Fungi
Penicillium sppFungi

Bacterial Normal Flora of the Ear and Eye

Staphylococcus spp.

  • Staphylococcus spp. refers to a collection of microorganisms from the genus Staphylococcus. This genus contains several species of spherical, Gram-positive bacteria that are commonly found in various environments, including the epidermis and mucous membranes of humans.
  • Staphylococcus bacteria are facultative anaerobes, indicating they can survive both with and without oxygen. When cultivated in laboratory cultures, they are renowned for their ability to form clusters or chains resembling grape clusters. Staphylococcus aureus and Staphylococcus epidermidis are the most prevalent species of Staphylococcus that induce human infections.
  • Staphylococcus aureus (S. aureus) is an important pathogen that can cause a variety of infections, ranging from mild cutaneous and soft tissue infections to more severe conditions like pneumonia, bloodstream infections (bacteremia), and endocarditis. It produces numerous virulence factors, such as toxins and enzymes, which contribute to its pathogenesis. Some strains of S. aureus have also developed resistance to multiple antibiotics, resulting in difficult-to-treat methicillin-resistant Staphylococcus aureus (MRSA) infections.
  • Staphylococcus epidermidis (S. epidermidis) is a normal resident of human epidermis and mucous membranes and is considered part of the microbiome of the skin. It typically does not cause disease in healthy people, but it can be a significant opportunistic pathogen in immunocompromised patients or those with indwelling medical devices such as catheters or prosthetic implants. S. epidermidis is frequently associated with infections of medical devices, such as bloodstream infections caused by catheters and infections of prosthetic joints.
  • Other species of Staphylococcus, such as Staphylococcus saprophyticus, Staphylococcus haemolyticus, and Staphylococcus lugdunensis, can also cause infections in humans, albeit less frequently than S. aureus and S. epidermidis.
  • Staphylococcus spp. infections are typically treated with antibiotics. Due to the increasing prevalence of antibiotic-resistant strains, however, it is crucial to conduct antimicrobial susceptibility testing to determine the most effective treatment. In order to prevent the spread of Staphylococcus infections, proper hand hygiene, wound care, and infection control measures are crucial.

Alloiococcus otitis

CharacteristicDescription
Gram StainingGram-positive
Cell ShapeSpherical (cocci)
Oxygen RequirementFacultative anaerobe
Spore FormationNon-spore forming
MotilityNon-motile
Growth TemperatureMesophilic (typically between 30-37°C)
HabitatPrimarily associated with the human ear
Pathogenic PotentialConsidered an opportunistic pathogen in certain conditions
Clinical AssociationAssociated with chronic otitis media in some individuals
Virulence FactorsNot well-characterized
Antibiotic SusceptibilitySusceptibility patterns may vary
Biochemical PropertiesMay exhibit diverse metabolic capabilities
Genetic DiversityAlloiococcus otitis is a specific species within the genus

Corynebacterium spp.

CharacteristicDescription
Gram StainingGram-positive
Cell ShapeRod-shaped (bacillus)
Oxygen RequirementFacultative anaerobe
Spore FormationNon-spore forming
MotilityNon-motile
Growth TemperatureMesophilic (typically between 25-37°C)
HabitatWidespread in nature, including soil, water, and animals
Pathogenic PotentialSome species can cause infections in humans
Pathogenic SpeciesCorynebacterium diphtheriae, Corynebacterium jeikeium, etc.
Virulence FactorsToxins, adhesins, and other factors vary by species
Antibiotic SusceptibilityVaries among species and strains
Biochemical PropertiesDiverse metabolic capabilities, some ferment carbohydrates
Genetic DiversityGenetically diverse with multiple species within the genus

Microbacterium spp.

CharacteristicDescription
Gram StainingGram-positive
Cell ShapeRod-shaped (bacillus)
Oxygen RequirementAerobic
Spore FormationNon-spore forming
MotilityGenerally non-motile
Growth TemperatureMesophilic (typically between 25-40°C)
HabitatSoil, water, plants, animals, and occasionally human skin
Pathogenic PotentialGenerally low pathogenicity, opportunistic in some cases
Role in BiotechnologySome species have biotechnological applications
Antibiotic SusceptibilityVaries among species and strains
Biochemical PropertiesCan exhibit diverse metabolic capabilities
Genetic DiversityGenetically diverse with multiple species within the genus

Bacillus spp.

CharacteristicDescription
Gram StainingGram-positive
Cell ShapeRod-shaped (bacillus)
Oxygen RequirementFacultative anaerobe (can grow with or without oxygen)
Spore FormationSpore-forming (produce endospores for survival)
MotilityMost species are motile, propelled by flagella
Growth TemperatureMesophilic (typically between 20-45°C)
HabitatUbiquitous in nature, found in soil, water, and environments
Pathogenic PotentialSome species are pathogenic, causing infections in humans
Pathogenic SpeciesBacillus anthracis, Bacillus cereus, etc.
Virulence FactorsToxins, enzymes, and other factors vary by species
Antibiotic SusceptibilityVaries among species and strains
Biochemical PropertiesDiverse metabolic capabilities, can ferment various sugars
Genetic DiversityGenetically diverse with multiple species within the genus

Arthrobacter spp.

CharacteristicDescription
Gram StainingGram-positive
Cell ShapeRod-shaped (bacillus)
Oxygen RequirementAerobic or facultative anaerobic
Spore FormationNon-spore forming
MotilityGenerally non-motile
Growth TemperatureMesophilic (typically between 15-30°C)
HabitatWidespread in nature, found in soil, water, and environments
Metabolic DiversityExhibits diverse metabolic capabilities
Antibiotic SusceptibilitySusceptibility patterns may vary
Biochemical PropertiesCan utilize a wide range of carbon sources
Genetic DiversityGenetically diverse with multiple species within the genus
Enzyme ProductionProduces various extracellular enzymes

Turicella otitidis

CharacteristicDescription
Gram StainingGram-positive
Cell ShapeRod-shaped (bacillus)
Oxygen RequirementObligate aerobic
Spore FormationNon-spore forming
MotilityNon-motile
Growth TemperatureMesophilic (typically between 30-37°C)
HabitatPrimarily associated with the human ear
Pathogenic PotentialConsidered a potential pathogen in certain conditions
Clinical AssociationAssociated with otitis media and other ear infections
Virulence FactorsNot well-characterized
Antibiotic SusceptibilitySusceptibility patterns may vary
Biochemical PropertiesCan exhibit diverse metabolic capabilities
Genetic DiversityTuricella otitidis is a specific species within the genus

Micrococcus spp.

Spore FormationNon-spore forming
MotilityGenerally non-motile
Growth TemperatureMesophilic (typically between 20-37°C)
HabitatUbiquitous in nature, found in soil, water, and environments
PigmentationSome species exhibit pigmentation (e.g., yellow or pink)
Pathogenic PotentialGenerally considered non-pathogenic to humans
Antibiotic SusceptibilitySusceptibility patterns may vary
Biochemical PropertiesCan ferment various sugars and exhibit diverse metabolism
Genetic DiversityGenetically diverse with multiple species within the genus

Moraxella spp.

CharacteristicDescription
Gram StainingGram-negative
Cell ShapeCocci or short rods (pleomorphic)
Oxygen RequirementAerobic or facultative anaerobic
Spore FormationNon-spore forming
MotilityGenerally non-motile
Growth TemperatureMesophilic (typically between 20-40°C)
HabitatUbiquitous in nature, found in soil, water, and environments
Pathogenic PotentialSome species are pathogenic to humans and animals
Pathogenic SpeciesMoraxella catarrhalis, Moraxella bovis, etc.
Virulence FactorsAdhesins, capsule, pili, and other factors vary by species
Antibiotic SusceptibilitySusceptibility patterns may vary
Biochemical PropertiesCan ferment various sugars and exhibit diverse metabolism
Genetic DiversityGenetically diverse with multiple species within the genus

Streptococcus

CharacteristicDescription
Gram StainingGram-positive
Cell ShapeSpherical (cocci), occurring in chains or pairs
Oxygen RequirementFacultative anaerobe (can grow with or without oxygen)
Spore FormationNon-spore forming
MotilityGenerally non-motile
Growth TemperatureMost species are mesophilic (typically between 20-40°C)
HabitatWidespread in nature, found in various environments
GroupingClassified based on Lancefield serotyping (A, B, C, etc.)
Pathogenic PotentialSome species are pathogenic to humans and animals
Pathogenic SpeciesStreptococcus pyogenes, Streptococcus pneumoniae, etc.
Virulence FactorsAdhesins, toxins, capsules, and other factors vary by species
Antibiotic SusceptibilitySusceptibility patterns may vary
Biochemical PropertiesCan ferment various sugars and exhibit diverse metabolism
Genetic DiversityGenetically diverse with multiple species within the genus

Corynebacterium

CharacteristicDescription
Gram StainingGram-positive
Cell ShapeRod-shaped (bacillus), occurring in palisades
Oxygen RequirementFacultative anaerobe (can grow with or without oxygen)
Spore FormationNon-spore forming
MotilityGenerally non-motile
Growth TemperatureMost species are mesophilic (typically between 25-37°C)
HabitatWidespread in nature, found in soil, water, and environments
Pathogenic PotentialSome species are pathogenic to humans and animals
Pathogenic SpeciesCorynebacterium diphtheriae, Corynebacterium jeikeium, etc.
Virulence FactorsToxins, adhesins, and other factors vary by species
Antibiotic SusceptibilitySusceptibility patterns may vary
Biochemical PropertiesDiverse metabolic capabilities, some ferment carbohydrates
Genetic DiversityGenetically diverse with multiple species within the genus

Propionibacterium acnes

CharacteristicDescription
Gram StainingGram-positive
Cell ShapePleomorphic, typically rod-shaped (bacillus)
Oxygen RequirementObligate anaerobe (grows in the absence of oxygen)
Spore FormationNon-spore forming
MotilityGenerally non-motile
Growth TemperatureMesophilic (typically between 30-37°C)
HabitatNormal microbiota of human skin and sebaceous glands
Pathogenic PotentialCan cause opportunistic infections in certain conditions
Pathogenicity FactorsLipases, proteases, and other enzymes
Clinical AssociationAssociated with acne vulgaris and certain infections
Antibiotic SusceptibilitySusceptibility patterns may vary
Biochemical PropertiesFerments carbohydrates, produces propionic acid
Genetic DiversityGenetically diverse strains within the species

Haemophilus influenzae

CharacteristicDescription
Gram StainingGram-negative
Cell ShapeCoccobacillus (pleomorphic, varying between spherical and rod-shaped)
Oxygen RequirementFacultative anaerobe (can grow with or without oxygen)
Spore FormationNon-spore forming
MotilityNon-motile
Growth TemperatureTypically requires enriched media and incubation at 35-37°C
HabitatNormal microbiota of the upper respiratory tract
Capsule FormationCan have encapsulated and non-encapsulated strains
Pathogenic PotentialCan cause a variety of infections, including respiratory tract infections
Pathogenicity FactorsCapsule, adhesins, toxins, and other virulence factors
Clinical AssociationAssociated with conditions such as otitis media, pneumonia, meningitis
Antibiotic SusceptibilitySusceptibility patterns may vary
Biochemical PropertiesRequires factors such as hemin and NAD for growth
Genetic DiversityGenetically diverse strains, including different serotypes

Neisseria species

CharacteristicDescription
Gram StainingGram-negative
Cell ShapeCocci, occurring in pairs (diplococci)
Oxygen RequirementStrictly aerobic
Spore FormationNon-spore forming
MotilityNon-motile
Growth TemperatureTypically mesophilic, around 35-37°C
HabitatPrimarily colonize mucosal surfaces of humans and animals
Capsule FormationSome species can form capsules
Pathogenic PotentialSome species are pathogenic to humans
Pathogenic SpeciesNeisseria gonorrhoeae, Neisseria meningitidis, etc.
Virulence FactorsAdhesins, pili, capsule, and other factors vary by species
Antibiotic SusceptibilitySusceptibility patterns may vary
Biochemical PropertiesFastidious, requiring complex growth factors
Genetic DiversityGenetically diverse with multiple species within the genus

Fusobacterium species

CharacteristicDescription
Gram StainingGram-negative
Cell ShapePleomorphic, typically spindle-shaped or filamentous
Oxygen RequirementStrict anaerobe (grows in the absence of oxygen)
Spore FormationNon-spore forming
MotilityTypically motile with flagella
Growth TemperatureMost species are mesophilic (typically between 35-37°C)
HabitatPrimarily found in the oral cavity and gastrointestinal tract
Pathogenic PotentialCan be opportunistic pathogens in certain conditions
Pathogenic SpeciesFusobacterium nucleatum, Fusobacterium necrophorum, etc.
Virulence FactorsAdhesins, toxins, and other factors vary by species
Antibiotic SusceptibilitySusceptibility patterns may vary
Biochemical PropertiesFerments carbohydrates, produces various metabolic products
Genetic DiversityGenetically diverse strains within the species

Fungal Normal Flora of the Ear and Eye

Candida spp.

CharacteristicDescription
KingdomFungi
MorphologyOval-shaped yeast cells
Oxygen RequirementFacultative anaerobe (can grow with or without oxygen)
Spore FormationNon-spore forming
MotilityNon-motile
Growth TemperatureTypically mesophilic, around 25-37°C
HabitatWidely distributed in nature, including human microbiota
Pathogenic PotentialSome species can cause opportunistic infections in humans
Pathogenic SpeciesCandida albicans, Candida glabrata, Candida krusei, etc.
Virulence FactorsAdhesins, biofilm formation, secretion of hydrolytic enzymes
Antifungal SusceptibilitySusceptibility patterns may vary
Biochemical PropertiesFerments sugars, produces ethanol and carbon dioxide
Genetic DiversityGenetically diverse strains within the species

Malassezia spp.

CharacteristicDescription
KingdomFungi
MorphologyOval-shaped yeast cells
Oxygen RequirementObligate aerobes (require oxygen for growth)
Spore FormationNon-spore forming
MotilityNon-motile
Growth TemperatureTypically mesophilic, around 25-37°C
HabitatFound on the skin of humans and animals
Pathogenic PotentialCan cause skin and scalp disorders
Pathogenic SpeciesMalassezia furfur, Malassezia globosa, Malassezia restricta, etc.
Role in DiseaseAssociated with conditions such as dandruff and seborrheic dermatitis
Lipid DependenceRequire lipids for growth and survival
Biochemical PropertiesCapable of metabolizing various lipids and fatty acids
Genetic DiversityGenetically diverse strains within the species

Aspergillus spp.

CharacteristicDescription
KingdomFungi
MorphologyFilamentous molds
Oxygen RequirementAerobic (require oxygen for growth)
Spore FormationForm conidia (asexual spores)
MotilityNon-motile
Growth TemperatureTypically mesophilic, around 20-37°C
HabitatUbiquitous in nature, commonly found in soil and decaying organic matter
Pathogenic PotentialSome species can cause infections in humans, particularly in immunocompromised individuals
Pathogenic SpeciesAspergillus fumigatus, Aspergillus flavus, Aspergillus niger, etc.
Virulence FactorsProduction of mycotoxins, ability to invade host tissues
Antifungal SusceptibilitySusceptibility patterns may vary
Biochemical PropertiesCapable of degrading complex organic compounds
Genetic DiversityGenetically diverse strains within the species

Penicillium spp.

CharacteristicDescription
KingdomFungi
MorphologyFilamentous molds with branched hyphae
Oxygen RequirementAerobic (require oxygen for growth)
Spore FormationForm conidia (asexual spores)
MotilityNon-motile
Growth TemperatureTypically mesophilic, around 20-30°C
HabitatUbiquitous in nature, commonly found in soil, decaying organic matter, and indoor environments
Role in IndustryUsed in the production of various foods (cheeses) and antibiotics (penicillin)
Pathogenic PotentialSome species can cause opportunistic infections in immunocompromised individuals
Pathogenic SpeciesPenicillium marneffei, Penicillium chrysogenum, etc.
Antibiotic ProductionSome species produce antibiotics such as penicillin
Biochemical PropertiesCapable of degrading complex organic compounds
Genetic DiversityGenetically diverse strains within the species

Importance of Eye and Ear Microbiome

The microbiomes of the eye and ear are the communities of microorganisms, such as bacteria, fungi, and viruses, that reside on and within these sensory organs. Although the gut microbiome has received considerable attention in recent years, the study of other microbiomes, such as those in the eye and ear, is a relatively novel area of study. Although our comprehension is still evolving, it is becoming increasingly apparent that the microbiomes of these organs play crucial roles in preserving their health and function.

  • Protection against pathogens: The microbiomes of the eye and ear provide protection against potential pathogens. They prevent hazardous microorganisms from colonizing the available ecological niches by occupying them. By competing for resources and producing antimicrobial substances, resident beneficial bacteria contribute to the maintenance of a balanced microbial community, thereby reducing the risk of infections.
  • Immune modulation: The microbiomes of the eye and ear influence the development, function, and response to pathogens of the local immune system. These microbiomes contain microorganisms that stimulate immune cells, thereby fostering an appropriate immune response and preventing excessive inflammation or autoimmune responses.
  • Maintenance of tissue health: The presence of a diverse and well-balanced microbiome in the eye and ear is associated with healthy tissue maintenance. The microbiome contains microorganisms that regulate the integrity and function of the organ-lining epithelial cells. They aid in the production of mucus and other substances that contribute to the physical barrier and overall health of the tissues.
  • Nutrient metabolism: Microbes within the microbiomes of the eye and ear can metabolize specific nutrients and produce beneficial metabolites. For instance, bacteria in the eye can produce necessary vitamins and metabolize detritus, thereby contributing to the eye’s overall health and function.
  • Impact on ocular and auditory diseases: Impact on ocular and auditory diseases Imbalances or disruptions in the microbiomes of the eye and ear have been linked to a variety of ocular and auditory conditions. Comparing individuals with dry eye disease, blepharitis (eyelid inflammation), and otitis media (middle ear infection) to healthy individuals has revealed differences in their microbiomes. Understanding the composition of the microbiome and its interaction with these diseases can aid in the development of targeted interventions and therapeutic strategies.
  • Potential therapeutic applications: manipulating the ocular and otologic microbiomes may have therapeutic applications. In cases of microbial dysbiosis or disease, researchers are investigating the use of probiotics, prebiotics, and other strategies to modulate the microbiome and restore homeostasis.

FAQ

What is the eye microbiome?

The eye microbiome refers to the collection of microorganisms that inhabit the surfaces of the eye, including the conjunctiva and eyelids.

What is the normal flora of the eye?

The normal flora of the eye consists of various bacteria, fungi, and viruses that typically colonize the ocular surfaces in a healthy individual. These microorganisms contribute to maintaining a balanced and healthy eye environment.

What is the ear microbiome?

The ear microbiome encompasses the microorganisms residing in the ear canal, including the external auditory canal and the skin lining it.

What is the normal flora of the ear?

The normal flora of the ear includes a diverse range of bacteria that commonly reside in the ear canal. Some common bacterial species found in the ear include Staphylococcus epidermidis, Corynebacterium spp., and Propionibacterium spp.

How does the eye microbiome protect against infections?

The eye microbiome helps protect against infections by occupying the ecological niches on the ocular surface, thereby preventing the colonization of potentially harmful microorganisms. The resident beneficial bacteria also compete for resources and produce antimicrobial substances.

Does the eye microbiome vary among individuals?

Yes, the eye microbiome can vary among individuals due to factors such as genetics, environment, hygiene practices, and overall health status. However, certain core microbial species are commonly found across healthy individuals.

Can disruption of the eye microbiome lead to ocular diseases?

Imbalances or disruptions in the eye microbiome have been associated with ocular diseases such as dry eye disease, blepharitis, and conjunctivitis. Dysbiosis of the microbiome may contribute to inflammation and compromise the ocular surface health.

What factors can affect the composition of the ear microbiome?

Factors such as age, environmental exposures, use of hearing aids or earplugs, earwax composition, and personal hygiene practices can influence the composition of the ear microbiome.

Can the ear microbiome be linked to ear infections?

There is emerging evidence suggesting a connection between the composition of the ear microbiome and the risk of ear infections, particularly otitis media (middle ear infection). Imbalances in the microbiome may increase susceptibility to infections.

Can probiotics be used to promote a healthy eye and ear microbiome?

Probiotics are being investigated as a potential strategy to modulate the eye and ear microbiomes and promote a healthy microbial balance. However, further research is needed to establish their efficacy and safety for these specific applications.

References

  1. Cavuoto KM, Zutshi D, Karp CL, Miller D. Microbiome in Ocular Health and Disease. Ophthalmology. 2017 Nov;124(11):1430-1435. doi: 10.1016/j.ophtha.2017.04.026.
  2. Doan T, Akileswaran L, Andersen D, et al. Paucibacterial Microbiome and Resident DNA Virome of the Healthy Conjunctiva. Invest Ophthalmol Vis Sci. 2016 May 1;57(6):5116-26. doi: 10.1167/iovs.16-19559.
  3. Huang Y, Yang B, Li W. Defining the normal core microbiome of conjunctival microbial communities. Clin Microbiol Infect. 2016 Jul;22(7):643.e7-12. doi: 10.1016/j.cmi.2016.03.022.
  4. Dong Q, Brulc JM, Iovieno A, et al. Diversity of bacteria at healthy human conjunctiva. Invest Ophthalmol Vis Sci. 2011 Nov 3;52(12):5408-13. doi: 10.1167/iovs.11-7269.
  5. Ramakrishnan VR, Hauser LJ, Feazel LM, et al. The microbiome of the middle meatus in healthy adults. PLoS One. 2013 Aug 19;8(8):e85507. doi: 10.1371/journal.pone.0085507.
  6. Man WH, de Steenhuijsen Piters WA, Bogaert D. The microbiota of the respiratory tract: gatekeeper to respiratory health. Nat Rev Microbiol. 2017 Dec;15(5):259-270. doi: 10.1038/nrmicro.2017.14.
  7. Li J, Zheng H, Zhang Q, et al. A comprehensive survey of soil acidobacterial diversity using pyrosequencing and clone library analyses. PLoS One. 2012;7(7):e42136. doi: 10.1371/journal.pone.0042136.
  8. Valdez PA, Vithayathil PJ, Janelsins BM, et al. Prophylactic probiotics to prevent death and nosocomial infection in critically ill adults: a systematic review and meta-analysis. Crit Care. 2018 Dec 19;22(1):10. doi: 10.1186/s13054-017-1933-3.
  9. https://biotecharticles.com/Biology-Article/Microbial-Flora-of-ENT-Ear-nose-and-throat-708.html#:~:text=Despite%20Cerumen%2C%20external%20ear%20contains,and%20filled%20with%20lymph%20fluid.
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