Surfactant in the middle ear and eustachian tube: a review

Advantages of the classical thermodynamic analysis of single-and multi-component Langmuir monolayers from molecules of biomedical importance-theory and applications

The Langmuir monolayer technique has been successfully used for decades to model biological membranes and processes occurring at their interfaces. Classically, this method involves surface pressure measurements to study interactions within membrane components as well as between external bioactive molecules (e.g. drugs) and the membrane. In recent years, surface-sensitive techniques were developed to investigate monolayers in situ; however, the obtained results are in many cases insufficient for a full characterization of biomolecule-membrane interactions. As result, description of systems using parameters such as mixing or excess thermodynamic functions is still relevant, valuable and irreplaceable in biophysical research. This review article summarizes the theory of thermodynamics of single- and multi-component Langmuir monolayers. In addition, recent applications of this approach to characterize surface behaviour and interactions (e.g. orientation of bipolar molecules, drug-membrane affinity, lateral membrane heterogeneity) are presented.

Allergy in pathogenesis of Eustachian Tube Dysfunction

Eustachian tube dysfunction (ETD) is a condition where the Eustachian tube (ET) fails to function normally, resulting in symptoms such as aural fullness, tinnitus, autophony, and hearing loss. ETD can further lead to middle ear diseases such as otitis media effusion and adhesive otitis media, which is becoming more common in the field of otology. Although the pathogenesis of ETD remains unclear, recent animal studies and clinical experiments have found allergic reactions and allergic diseases are closely related to the occurrence of ETD. As the mucosa of the ET is continuous with that of the nasopharynx and tympanic cavity, it is reasonable to assume that the immunological basis of the ET itself is similar to that of respiratory allergic diseases. However, due to the special anatomical location and complex pathogenesis of the ET, there is still no unified diagnostic gold standard. Additionally, there is an ongoing debate regarding whether ETD can be classified as a distinct disease or even an allergic disease. Furthermore, the effectiveness of anti-allergic therapy in patients with ETD is yet to be fully understood. Therefore, this review elaborates on the possible mechanisms of allergic reactions in the occurrence and development of ETD, and explores the potential role of anti-allergic therapy in managing this condition, in order to provide new insights into the pathogenesis and prevention of ETD.

Surfactant proteins and innate immunity of otitis media

Otitis media (OM) is the most common disease among young children and one of the most frequent reasons to visit the pediatrician. Development of OM requires nasopharyngeal colonization by a pathogen which must gain access to the tympanic cavity through the eustachian tube (ET) along with being able to overcome the defense mechanisms of the immune system and middle ear mucosa. OM can be caused by viral or bacterial infection. The three main bacterial pathogens are Streptococcus pneumoniae, nontypeable Haemophilus influenzae (NTHi), and Moraxella catarrhalis. Innate immunity is important in OM resolution as the disease occurs in very young children before the development of specific immunity. Elements of innate immunity include natural barriers and pattern recognition receptors such as Toll like receptors (TLRs), and Nod like receptors (NLRs). Surfactant proteins A (SP-A) and D (SP-D) act as pattern recognition receptors and are found in the lung and many other tissues including the ET and the middle ear where they probably function in host defense. Surfactant has a potential for use in the treatment of OM due to surface tension lowering function in the ET, and the possible immune functions of SP-D and SP-A in the middle ear and ET.

Serial histological changes in the cartilaginous eustachian tube in the rat following balloon dilation

Although balloon dilation has shown promising results in the treatment of dilatory Eustachian tube (ET) dysfunction, the histological effects of ET balloon dilation (ETBD) is unknown because histological examination of the whole human cartilaginous ET is impossible. Animal studies are needed to elucidate the effect of ETBD so we evaluated the histological changes after ETBD in a rat model. The left ET of 20 Wistar rats was dilated with a balloon catheter and the right ET was used as a control. Five rats were sacrificed immediately after ETBD, at 1, 4 and 12 weeks after the procedure for histological examination. The epithelial cells, presence of epithelial hyperplasia, and the proportion of the goblet cells in the epithelium; the vascular structures and dimensions of the submucosa; and presence of cartilage fracture and the area of the ET lumen were evaluated and compared between the groups. Desquamation of nearly all epithelial cells and the fracture of tubal cartilages were observed immediately after ETBD. At 1-week post-ETBD, the ciliated epithelial cells started to recover with epithelial hyperplasia. The goblet cells recovered by 4 weeks post-ETBD and epithelial hyperplasia decreased but was still present at 12 weeks post-ETBD. The depth of the submucosa increased and neovascularization in this region was observed at 1-week post-ETBD and persisted up to 12 weeks post-ETBD. The lumen of the cartilaginous ET increased immediately after ETBD but decreased at 1-week post-ETBD. The cartilaginous ET lumen recovered to the normal value at 4 weeks post-ETBD. This study is the first to describe the serial histological changes to the cartilaginous ET after ETBD and helps our understanding of the histological changes that occur after an ETBD intervention for intractable ET dysfunction.

Intranasal Surfactant for Acute Otitis Media: A Randomized Trial

BACKGROUND

Acute otitis media (AOM) is the most frequent reason for children to be prescribed antimicrobial treatment. Surfactants are naturally occurring substances that may restore the eustachian tube's function and potentially enhance resolution of AOM.

METHODS

This was a phase 2a, single-center, double-blind, randomized, placebo-controlled, parallel group clinical trial to assess safety, tolerability, and efficacy of 20 mg per day intranasal OP0201 as an adjunct therapy to oral antimicrobial agents for treating AOM in young children. We randomly assigned 103 children aged 6 to 24 months with AOM to receive either OP0201 or placebo twice daily for 10 days. All children received amoxicillin-clavulanate 90/6.4 mg/kg per day in 2 divided doses for 10 days. Participants were managed for up to 1 month. Postrandomization visits occurred between days 4 and 6 (visit 2), days 12 and 14 (visit 3), and days 26 and 30 (visit 4). Primary efficacy endpoints were resolution of a bulging tympanic membrane at visit 2 and resolution of middle-ear effusion at visit 3.

RESULTS

No clinically meaningful differences between treatment groups were apparent for primary or secondary endpoints. There were no safety concerns identified.

CONCLUSIONS

In young children with AOM, intranasally administered surfactant (OP0201) did not improve clinical outcomes. Further research may be warranted among children with persistent middle-ear effusion.

Role of Surfactant Protein D in Experimental Otitis Media

Surfactant protein D (SP-D) is a C-type collectin and plays an important role in innate immunity and homeostasis in the lung. This study studied SP-D role in the nontypeable Haemophilus influenzae (NTHi)-induced otitis media (OM) mouse model. Wild-type C57BL/6 (WT) and SP-D knockout (KO) mice were used in this study. Mice were injected in the middle ear (ME) with 5 μL of NTHi bacterial solution (3.5 × 105 CFU/ear) or with the same volume of sterile saline (control). Mice were sacrificed at 3 time points, days 1, 3, and 7, after treatment. We found SP-D expression in the Eustachian tube (ET) and ME mucosa of WT mice but not in SP-D KO mice. After infection, SP-D KO mice showed more intense inflammatory changes evidenced by the increased mucosal thickness and inflammatory cell infiltration in the ME and ET compared to WT mice (p < 0.05). Increased bacterial colony-forming units and cytokine (IL-6 and IL-1β) levels in the ear washing fluid of infected SP-D KO mice were compared to infected WT mice. Molecular analysis revealed higher levels of NF-κB and NLRP3 activation in infected SP-D KO compared to WT mice (p < 0.05). In vitro studies demonstrated that SP-D significantly induced NTHi bacterial aggregation and enhanced bacterial phagocytosis by macrophages (p < 0.05). Furthermore, human ME epithelial cells showed a dose-dependent increased expression of NLRP3 and SP-D proteins after LPS treatment. We conclude that SP-D plays a critical role in innate immunity and disease resolution through enhancing host defense and regulating inflammatory NF-κB and NLRP3 activation in experimental OM mice.

The Emerging Role of Small Extracellular Vesicles in Inflammatory Airway Diseases

Extracellular vesicles (EVs) are produced and released by all cells and are present in all body fluids. They exist in a variety of sizes, however, small extracellular vesicles (sEVs), the EV subset with a size range from 30 to 150 nm, are of current interest. By transporting a complex cargo that includes genetic material, proteins, lipids, and signaling molecules, sEVs can alter the state of recipient cells. The role of sEVs in mediating inflammatory processes and responses of the immune system is well-documented, and adds another layer of complexity to our understanding of frequent diseases, including chronic rhinosinusitis (CRS), asthma, chronic obstructive pulmonary disease (COPD), and upper airway infections. In these diseases, two aspects of sEV biology are of particular interest: (1) sEVs might be involved in the etiopathogenesis of inflammatory airway diseases, and might emerge as attractive therapeutic targets, and (2) sEVs might be of diagnostic or prognostic relevance. The purpose of this review is to outline the biological functions of sEVs and their capacity to both augment and attenuate inflammation and immune response in the context of pathogen invasion, CRS, asthma, and COPD.

Oral seeding and niche-adaptation of middle ear biofilms in health

The entrenched dogma of a sterile middle ear mucosa in health is incongruent with its periodic aeration and seeding with saliva aerosols. To test this, we sequenced 16S rRNA-V4 amplicons from otic secretions collected at the nasopharyngeal orifice of the tympanic tube and, as controls, oropharyngeal and buccal samples. The otic samples harbored a rich diversity of oral keystone genera and similar functional traits but were enriched in anaerobic genera in the Bacteroidetes (Prevotella and Alloprevotella), Fusobacteria (Fusobacterium and Leptotrichia) and Firmicutes (Veillonella) phyla. Facultative anaerobes in the Streptococcus genus were also abundant in the otic and oral samples but corresponded to distinct, and sometimes novel, cultivars, consistent with the ecological diversification of the oral migrants once in the middle ear microenvironment. Neutral community models also predicted a large contribution of oral dispersal to the otic communities and the positive selection of taxa better adapted to growth and reproduction under limited aeration. These results challenge the traditional view of a sterile middle ear in health and highlight hitherto unknown roles for oral dispersal and episodic ventilation in seeding and diversifying otic biofilms.

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The middle ear mucosa harbors a rich bacterial community in health.

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Oral migration is the primary mechanism for seeding otic biofilms.

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Periodic aeration of the middle ear enriches for anaerobic taxa and promotes the ecological diversification of oral migrants.

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Our study challenges the entrenched dogma of a sterile middle ear in health.

Fighter Pilots With Nasopharyngeal Carcinoma Successfully Returning to Flight After Radiotherapy: A Case Series

For nasopharyngeal carcinoma (NPC), radiotherapy is the primary treatment. However, complications occur after radiation to the nasopharynx, which could potentially affect the flying safety. Four fighter pilots with NPC were reported. With early to locally advanced NPC, they received radiotherapy with or without concurrent chemotherapy. The prescribed radiation dose was 70 Gy to the primary tumor over the nasopharynx. Before treatment, all patients presented with various degrees of hearing loss on pure tone audiometry (main frequencies of 20-45 dB at 3-4.5 kHz for affected ears). After the full course of radiotherapy, tumor regression was noticed during months to years of follow-ups. The follow-up audiometry evaluation showed gradually recovered hearing function (average improvement of 5 dB at pretreatment frequencies) in all pilots. They then returned back to the flight line on annual waiver points. Here, we conclude that fighter pilots with NPC could successfully return to the flight line after radiotherapy. However, detailed physical examinations and confirmation of adaptation to flying condition are warranted.

The mechanism of balloon Eustachian tuboplasty: a biomechanical study

Obstructive Eustachian tube dysfunction (OETD) is a common condition resulting from inadequate opening of the Eustachian tube (ET). A new surgical treatment involves high-pressure inflation of a balloon within the ET, with the aim of dilating the soft tissue structure. However, the mechanical effects of this intervention have not been established, nor the impact of changing device size or other technical parameters. A novel experimental technique allowed quantification of plastic and elastic tissue deformation in model materials and then human cadaver ETs during balloon dilation, based on the measured balloon inflation pressure-volume relationship. Plastic tissue deformation was found to be greater using larger balloons and deeper device insertion, but increasing the inflation pressure had a more limited effect, with most deformation occurring well below the clinically used pressures. Histological assessment of ET tissue suggested that mucosal tearing and cartilage cracking were in part responsible for the mechanical changes. Balloon dilation of the ET has huge potential if found to be clinically effective, but currently there is a need to understand and develop the technique further. The novel methods employed in this study will be valuable in future laboratory and in vivo studies of ET balloon dilation. Pressures are reported in Bar as this unit is used for medical balloon dilation procedures in clinical practice. 1 Bar = 100,000 Pa.

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Innate immunity of surfactant protein A in experimental otitis media

Surfactant protein A (SP-A) plays an important role in innate immune response and host defense against various microorganisms through opsonization and complement activation. To investigate the role of SP-A in non-typeable Haemophilus influenzae (NTHi)-induced acute otitis media, this study used wild type C57BL/6 (WT) and SP-A knockout (KO) mice. We divided mice into an infection group in which the middle ear (ME) was injected with NTHi and a control group that received the same treatment using normal saline. Mice were sacrificed on d 1, 3, and 7 after treatment. Temporal bone samples were fixed for histological, cellular, and molecular analyses. Ear washing fluid (EWF) was collected for culture and analyses of pro-inflammatory cytokines and inflammatory cells. SP-A-mediated bacterial aggregation and killing and phagocytosis by macrophages were studied in vitro. SP-A expression was detected in the ME and Eustachian tube mucosa of WT mice but not KO mice. After infection, KO mice showed more severe inflammation evidenced by increased ME mucosal thickness and inflammatory cell infiltration and higher NF-κB activation compared to WT mice. The levels of IL-6 and IL-1β in the EWF of infected KO mice were higher compared to infected WT mice on d 1. Our studies demonstrated that SP-A mediated NTHi aggregation and killing and enhanced bacterial phagocytosis by macrophages in vitro and modulated inflammation of the ME in otitis media in vivo.

Subversion of host immune responses by otopathogens during otitis media

Otitis media (OM) is one of the most common ear diseases affecting humans. Children are at greater risk and suffer most frequently from OM, which can cause serious deterioration in the quality of life. OM is generally classified into two main types: acute and chronic OM (AOM and COM). AOM is characterized by tympanic membrane swelling or otorrhea and is accompanied by signs or symptoms of ear infection. In COM, there is a tympanic membrane perforation and purulent discharge. The most common pathogens that cause AOM are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis whereas Pseudomonas aeruginosa and Staphylococcus aureus are commonly associated with COM. Innate and adaptive immune responses provide protection against OM. However, pathogens employ a wide arsenal of weapons to evade potent immune responses and these mechanisms likely contribute to AOM and COM. Immunologic evasion is multifactorial, and involves damage to host mucociliary tract, genetic polymorphisms within otopathogens, the number and variety of different otopathogens in the nasopharynx as well as the interaction between the host's innate and adaptive immune responses. Otopathogens utilize host mucin production, phase variation, biofilm production, glycans, as well as neutrophil and eosinophilic extracellular traps to induce OM. The objective of this review article is to discuss our current understanding about the mechanisms through which otopathogens escape host immunity to induce OM. A better knowledge about the molecular mechanisms leading to subversion of host immune responses will provide novel clues to develop effective treatment modalities for OM.

Isolation and Culture of Primary Mouse Middle Ear Epithelial Cells

Epithelial abnormalities underpin the development of the middle ear disease, otitis media (OM). Until now, a well-characterized in vitro model of the middle ear (ME) epithelium that replicates the complex cellular composition of the middle ear has not been available. This chapter describes the development of a novel in vitro model of mouse middle ear epithelial cells (mMECs), cultured at the air-liquid interface (ALI). This system enables recapitulation of the characteristics of the native murine ME epithelium. We demonstrate that mMECs undergo differentiation into the varied cell populations seen within the native middle ear. Overall, our mMEC culture system can help better understand the cell biology of the middle ear and improve our understanding of the pathophysiology of OM. The model also has the potential to serve as a platform for validation of treatments designed to reverse aspects of epithelial remodeling underpinning OM development.

An in vitro model of murine middle ear epithelium

Otitis media (OM), or middle ear inflammation, is the most common paediatric disease and leads to significant morbidity. Although understanding of underlying disease mechanisms is hampered by complex pathophysiology it is clear that epithelial abnormalities underpin the disease. There is currently a lack of a well-characterised in vitro model of the middle ear (ME) epithelium that replicates the complex cellular composition of the middle ear. Here, we report the development of a novel in vitro model of mouse middle ear epithelial cells (mMECs) at an air–liquid interface (ALI) that recapitulates the characteristics of the native murine ME epithelium. We demonstrate that mMECs undergo differentiation into the varied cell populations seen within the native middle ear. Proteomic analysis confirmed that the cultures secrete a multitude of innate defence proteins from their apical surface. We showed that the mMECs supported the growth of the otopathogen, nontypeable Haemophilus influenzae (NTHi), suggesting that the model can be successfully utilised to study host–pathogen interactions in the middle ear. Overall, our mMEC culture system can help to better understand the cell biology of the middle ear and improve our understanding of the pathophysiology of OM. The model also has the potential to serve as a platform for validation of treatments designed to reverse aspects of epithelial remodelling that underpin OM development.

Summary: Development and systematic characterisation of an in vitro otopathogenic infection model of the murine middle ear epithelium as a tool to better understand the complex pathophysiology of Otitis media.

A new theory on the pathogenesis of acquired cholesteatoma: Mucosal traction

OBJECTIVES/HYPOTHESIS

Although the migration of its squamous outer surface of the tympanic membrane has been well characterized, there is a paucity of data available concerning the migratory behavior of its medial mucosal surface. Existing theories of primary acquired cholesteatoma pathogenesis do not adequately explain the observed characteristics of the disease. We propose a new hypothesis, based upon a conjecture that mucosal membrane interactions are the driving force in cholesteatoma.

STUDY DESIGN

A retrospective chart review and a prospective observational cohort study in rats.

METHODS

After developing the new theory, it was tested through both clinical and experimental observations. To evaluate whether impairment of middle ear mucociliary migration would influence cholesteatoma formation, a retrospective chart review evaluating cholesteatoma occurrence in a sizable population of patients with either primary ciliary dyskinesia (PCD) or cystic fibrosis (CF) was performed. To study mucosal migration on the medial aspect of the tympanic membrane, ink tattoos were monitored over time in a rat model.

RESULTS

No cholesteatomas were identified in either PCD patients (470) or in CF patients (1,910). In the rat model, mucosa of the posterior pars tensa migrated toward the posterior superior quadrant, whereas the mucosa of the anterior pars tensa migrated radially toward the annulus.

CONCLUSION

Mucosal coupling with traction generated by interaction of migrating opposing surfaces provides the first comprehensive theory that explains the observed characteristics of primary acquired cholesteatoma. The somewhat counterintuitive hypothesis that cholesteatoma is fundamentally a mucosal disease has numerous therapeutic implications.

Influence of lipid coatings on surface wettability characteristics of silicone hydrogels

Insoluble lipids serve vital functions in our bodies and interact with biomedical devices, e.g., the tear film on a contact lens. Over a period of time, these naturally occurring lipids form interfacial coatings that modify the wettability characteristics of these foreign synthetic surfaces. In this study, we examine the deposition and consequences of tear film lipids on silicone hydrogel (SiHy) contact lenses. We use bovine meibum, which is a complex mixture of waxy esters, cholesterol esters, and lipids that is secreted from the meibomian glands located on the upper and lower eyelids of mammals. For comparison, we study two commercially available model materials: dipalmitoylphosphatidylcholine (DPPC) and cholesterol. Upon deposition, we find that DPPC and meibum remain closer to the SiHy surface than cholesterol, which diffuses further into the porous SiHy matrix. In addition, we also monitor the fate of unstable thin liquid films that consequently rupture and dewet on these lipid-decorated surfaces. This dewetting provides valuable qualitative and quantitative information about the wetting characteristics of these SiHy substrates. We observe that decorating the SiHy surface with simple model lipids such as DPPC and cholesterol increases the hydrophilicity, which consequently inhibits dewetting, whereas meibum behaves conversely.

Surface tension in human pathophysiology and its application as a medical diagnostic tool

Introduction: Pathological features of disease appear to be quite different. Despite this diversity, the common feature of various disorders underlies physicochemical and biochemical factors such as surface tension. Human biological fluids comprise various proteins and phospholipids which are capable of adsorption at fluid interfaces and play a vital role in the physiological function of human organs. Surface tension of body fluids correlates directly to the development of pathological states.

Methods: In this review, the variety of human diseases mediated by the surface tension changes of biological phenomena and the failure of biological fluids to remain in their native state are discussed.

Results: Dynamic surface tension measurements of human biological fluids depend on various parameters such as sex, age and changes during pregnancy or certain disease. It is expected that studies of surface tension behavior of human biological fluids will provide additional information and might become useful in medical practice. Theoretical background on surface tension measurement and surface tension values of reference fluids obtained from healthy and sick patients are depicted.

Conclusion: It is well accepted that no single biomarker will be effective in clinical diagnosis. The surface tension measurement combined with routine lab tests may be a novel non-invasive method which can not only facilitate the discovery of diagnostic models for various diseases and its severity, but also be a useful tool for monitoring treatment efficacy. We therefore expect that studies of surface tension behavior of human biological fluids will provide additional useful information in medical practice.

Lipopolysaccharide-induced expression of surfactant proteins A1 and A2 in human renal tubular epithelial cells

Background

Surfactant protein A (SP-A), encoded by two functional genes, SP-A1 and SP-A2, is essential for the inflammatory process and host defence in the lungs. Recent studies have demonstrated the extrapulmonary expression of SP-A. Similar to the lungs, the kidneys are organs exposed to external pathogens. The present study evaluated the expression and location of SP-A in the kidneys. The effect of lipopolysaccharide (LPS) on the expression of SP-A subtypes was also studied in renal tubular epithelial (HK-2) cells.

Methods

Immunohistochemical staining was performed using polyclonal antibody against SP-A. RT-PCR was also performed using mRNA from normal human renal tissues and HK-2 cells. The expressions of the SP-A1 and SP-A2 genes were determined by PCR-based RFLP analysis, gene-specific amplification, and direct sequencing of RT-PCR products. Western blot was conducted to analyse the SP-A protein. HK-2 cells were treated with LPS at various concentrations (0, 0.1, 1, 2, 5, and 10 μg/mL) for 8 h and at 5 μg/mL at various time points (0, 2, 4, 8, 16, and 24 h). The LPS-induced expressions of SP-A1 and SP-A2 mRNA and protein were analysed by RT-PCR and Western blot.

Results

SP-A was localised in the renal tubular epithelial cells in the proximal and distal convoluted tubules. SP-A1 and SP-A2 mRNA and protein were expressed in HK-2 cells and human renal tissues, which were significantly increased in time- and dose-dependent manners after LPS treatment (P < 0.05).

Conclusions

Human renal tubular epithelial cells can express both SP-A1 and SP-A2 genes, which may play important roles in the inflammatory modulation of the kidney.

The multifunctional host defense peptide SPLUNC1 is critical for homeostasis of the mammalian upper airway

Otitis media (OM) is a highly prevalent pediatric disease caused by normal flora of the nasopharynx that ascend the Eustachian tube and enter the middle ear. As OM is a disease of opportunity, it is critical to gain an increased understanding of immune system components that are operational in the upper airway and aid in prevention of this disease. SPLUNC1 is an antimicrobial host defense peptide that is hypothesized to contribute to the health of the airway both through bactericidal and non-bactericidal mechanisms. We used small interfering RNA (siRNA) technology to knock down expression of the chinchilla ortholog of human SPLUNC1 (cSPLUNC1) to begin to determine the role that this protein played in prevention of OM. We showed that knock down of cSPLUNC1 expression did not impact survival of nontypeable Haemophilus influenzae, a predominant causative agent of OM, in the chinchilla middle ear under the conditions tested. In contrast, expression of cSPLUNC1 was essential for maintenance of middle ear pressure and efficient mucociliary clearance, key defense mechanisms of the tubotympanum. Collectively, our data have provided the first in vivo evidence that cSPLUNC1 functions to maintain homeostasis of the upper airway and, thereby, is critical for protection of the middle ear.

TLR4-mediated induction of TLR2 signaling is critical in the pathogenesis and resolution of otitis media

Otitis media is the most prevalent childhood disease in developed countries. The involvement of Toll-like receptors (TLRs) in otitis media pathophysiology has been implicated by studies in cell lines and association studies of TLR gene polymorphisms. However, precise functions of TLRs in the etiology of otitis media in vivo have not been examined. We investigated the inflammatory response to nontypeable Haemophilus influenzae using a model of otitis media in wild-type, TLR2(- /-) and TLR4(-/ -) mice by gene microarray, qPCR, immunohistochemistry, Western blot analysis and histopathology. Toll-like receptor-2(- /-) and TLR4(- /-) mice exhibited a more profound, persistent inflammation with impaired bacterial clearance compared to controls. While wild-type mice induced tumor necrosis factor-a (TNF) after non-typeable H. influenzae challenge, TLR2(-/-) and TLR4(-/-) mice lack TNF induction in the early phase of otitis media. Moreover, lack of TLR2 resulted in a late increase in IL-10 expression and prolonged failure to clear bacteria. Toll-like receptor-4(-/- ) mice showed impaired early bacterial clearance and loss of TLR2 induction in early otitis media. Our results demonstrate that both TLR2 and TLR4 signalling are critical to the regulation of infection in non-typeable H. influenzae-induced otitis media. Toll-like receptor-4 signalling appears to induce TLR2 expression, and TLR2 activation is critical for bacterial clearance and timely resolution of otitis media.

Latherin: a surfactant protein of horse sweat and saliva

Horses are unusual in producing protein-rich sweat for thermoregulation, a major component of which is latherin, a highly surface-active, non-glycosylated protein. The amino acid sequence of latherin, determined from cDNA analysis, is highly conserved across four geographically dispersed equid species (horse, zebra, onager, ass), and is similar to a family of proteins only found previously in the oral cavity and associated tissues of mammals. Latherin produces a significant reduction in water surface tension at low concentrations (≤1 mg ml⁻¹), and therefore probably acts as a wetting agent to facilitate evaporative cooling through a waterproofed pelt. Neutron reflection experiments indicate that this detergent-like activity is associated with the formation of a dense protein layer, about 10 Å thick, at the air-water interface. However, biophysical characterization (circular dichroism, differential scanning calorimetry) in solution shows that latherin behaves like a typical globular protein, although with unusual intrinsic fluorescence characteristics, suggesting that significant conformational change or unfolding of the protein is required for assembly of the air-water interfacial layer. RT-PCR screening revealed latherin transcripts in horse skin and salivary gland but in no other tissues. Recombinant latherin produced in bacteria was also found to be the target of IgE antibody from horse-allergic subjects. Equids therefore may have adapted an oral/salivary mucosal protein for two purposes peculiar to their lifestyle, namely their need for rapid and efficient heat dissipation and their specialisation for masticating and processing large quantities of dry food material.

Host's response in otitis media: understanding genetic susceptibility

Increasing evidence is emerging on genetic factors affecting host's response to infection in the middle ear. This review summarizes current knowledge on the field and on the contribution of nonspecific barriers, innate, and adaptive immunity. Better understanding of susceptibility to this very common disease will facilitate identification of high-risk individuals and optimization of prevention and treatment.

Intranasal phenylephrine-surfactant treatment is not beneficial in otitis media with effusion

BACKGROUND

Otitis media is the most common reason for non-well-child visits to the primary care physician. Various treatments are in use to try to ameliorate the pain arising from Eustachian tube (ET) dysfunction. One such treatment is topical phenylephrine spray, despite clinical evidence disputing its use. Previous research by this laboratory has demonstrated the beneficial effect of topical surfactant treatment in reducing ET opening pressure, allowing the tube to open. This study is designed to test the effectiveness of topical phenylephrine, delivered with surfactant, in reducing days of effusion in OME, in an animal model.

METHODS

OME was generated by injecting Klebsiella pneumoniae lipopolysaccharide into the right bullae of 28 gerbils. After frank OME resulted, the animals were divided into four groups. Group 1 received no treatment or propellant spray alone (placebo). Group 2 received intranasal surfactant spray once daily. Group 3 received intranasal surfactant-phenylephrine spray once daily. Group 4 received intranasal surfactant-phenylephrine spray twice daily. All animals were evaluated on a daily basis by both otomicroscopy and tympanometry, and treatment was ceased when the ear returned to normal appearance. Evaluations were continued for a total of 30 days. Chi-squared analysis with significance set at .05 was performed.

RESULTS

In the untreated and placebo groups, middle ear effusion resolved at 16.25 days by otomicroscopy and 28.26 days by tympanometry. In Group 2 (surfactant alone), effusion resolved at 10.57 days and 15.71 days, respectively. In Group 3 (surfactant-phenylephrine once daily), effusion resolved at 15.67 days and 28.33 days. In Group 4 (surfactant-phenylephrine twice daily), effusion resolved at 18.67 days and 28.33 days. These results were statistically significant.

CONCLUSIONS

Intranasal phenylephrine-surfactant treatment is shown to be at least ineffective, and possibly detrimental, in the resolution of OME, in this animal model. The hypothesis is that surfactant potentiates the drying effect of phenylephrine at the ET by allowing it to get to the ET more easily; in addition, the drying effect of phenylephrine prevents full surfactant action. We believe that these results can be extrapolated to humans and that phenylephrine should be avoided in these cases.

Mucus and the mare: How little we know

Uterine infections are a major cause of infertility, but the role of mucus in equine uterine defense is not well understood. Mucociliary currents play an important role in protecting mucous membranes, including the upper and lower respiratory tracts of mammals, and are required for feeding and oxygenation of many aquatic invertebrates. Although phagocytosis has long been considered the first line of uterine defense in the mare, there are concerns about its efficacy in the uterine lumen. Additional local defenses, such as mucociliary currents, have therefore been proposed. The uterine epithelium exhibits alternating mucus-secreting and ciliated cells supporting a mucopolysaccharide blanket, features shared with mucociliary membranes throughout the animal kingdom. Gross uterine anatomy, such as continuity of uterine and cervical folds, may indicate adaptations to mucociliary clearance. In addition, ciliated cells obtained in uterine lavages often display motility. Disruptions of mucociliary clearance play major roles in pathogenesis of mucosal infections in humans, including pneumonia, chronic sinusitis, and otitis media. Establishing drainage is a major goal of therapy in treatment of chronic sinusitis, hastening return of mucociliary function. Similar disruptions may occur in equine uterine infections, associated with accumulations of uterine fluid, loss of endometrial folds, and cervical trauma. Possible clinical implications of mucociliary clearance in the mare are discussed, however the role of mucociliary clearance in the mare remains speculative.

Expression and localization of surfactant proteins in human nasal epithelium

Surfactant proteins (SPs), designated SP-A, SP-B, SP-C, and SP-D, play an important role in surfactant metabolism and host defense mechanisms in the lung. This study investigates expression of the different SP types in human nasal mucosa and cultured normal human nasal epithelial (NHNE) cells and whether the expression of SP mRNA is influenced by the degree of mucociliary differentiation. RT-PCR was performed with mRNA from cultured NHNE cells and nasal mucosa. Immunohistochemical staining for SPs was performed on nasal mucosa specimens. Western blot analysis was performed on cell lysates from cultured NHNE cells. SP-A2, SP-B, and SP-D mRNAs were expressed in normal NHNE cells and human nasal mucosa. SPs were localized in ciliated cells of the surface epithelium and serous acini of the submucosal glands. SP-A, SP-B, and SP-D proteins were expressed in cultured NHNE cells. The degree of mucociliary differentiation influenced expression of the SP gene. We demonstrate that SP-A, SP-B, and SP-D are expressed in human nasal mucosa and cultured NHNE cells. Further study of the functional role of SPs in the upper airway is required.

Genetic susceptibility to otitis media

PURPOSE OF REVIEW

Otitis media is a disease that is prevalent in the pediatric population, and recent twin and triplet studies have confirmed that there is a strong genetic component to susceptibility. Here, we summarize the status of current efforts to identify the specific genes underlying otitis media susceptibility and presentation.

RECENT FINDINGS

Recent studies have focused on identifying candidate genes. For example, IFN-gamma polymorphisms, allotypes of the leukocyte IgG (FcgammaR) receptors and certain haplotypes of surfactant genes were linked in pilot studies to otitis media susceptibility. The pattern of gene expression during an episode of otitis media is also being elucidated with the overall goal of providing clues as to which of these modulated genes are polymorphic and thus potentially capable of affecting otitis media susceptibility. Mucin and cathepsin protease genes were shown to exhibit these characteristics.

SUMMARY

In addition to the simple searches for linkages between known genes and otitis media, work is progressing within the context of genome-wide linkage studies. These efforts promise to answer some of the many questions remaining in otitis media susceptibility and pathogenesis.

Otitis media: concepts and controversies

PURPOSE OF REVIEW

Otitis media is the most common bacterial infection among children, accounting for as many as 30 million office visits annually. Proper treatment has become critical as offending pathogens become increasingly resistant to antibiotics and the cost of managing the disorder has exceeded 3 billion dollars per year. However, data suggest that many practitioners still struggle with the diagnosis of otitis media and often recommend medical and surgical intervention inappropriately. This article presents recent advances in the otitis media literature and an evidence-based approach to its management.

RECENT FINDINGS

Recent investigations have resulted in the following findings: (1) bacterial biofilms may account for the persistence of middle ear disease; (2) there is increasing evidence that heredity and reflux are risk factors for otitis media; (3) primary care providers may be receiving poor otitis media training, leading to inadequate diagnostic skills; (4) medical and surgical therapy are of limited utility in the management of acute and recurrent acute otitis media; (5) antibiotics and steroids are of limited value in the treatment of chronic middle ear effusion; (6) delayed management of effusion may not adversely affect development in children; (7) vaccination for pneumococcus may alter the serotypes responsible for otitis media; and (8) vaccine candidates for other middle ear pathogens are under investigation.

SUMMARY

Management of otitis media is constantly evolving, based on research from a variety of medical subspecialties. It is incumbent on the otolaryngologist and primary care providers treating otitis media to keep pace with and synthesize these findings into a rational approach to treatment.