Clinical and biochemical studies of bone destruction in cholesteatoma

Long-term facial nerve outcome in surgically treated petrous bone cholesteatoma patients

INTRODUCTION

The term petrous bone cholesteatoma (PBC) represents a slow-growing epidermal lesion arising from the petrous part of the temporal bone. It is a rare incidence accounting for only 4-9% of all petrous bone lesions. PBC represents a real surgical challenge due to its complex relationship with critical neurovascular structures.

OBJECTIVE

To demonstrate our experience in using various options of facial nerve (FN) management during surgical treatment of PBC and analyze the long-term facial function outcomes.

STUDY DESIGN

Retrospective medical record review in a quaternary skull-base center.

MATERIALS AND METHODS

Medical records of 298 PBC cases operated between the years 1983 and 2024 were thoroughly evaluated. Sanna's classification scheme was used to classify cases into the appropriate class and the House-Brackmann (HB) grading system of the FN was used to assess the facial function pre- and postoperatively.

RESULTS

A total of 298 PBC cases were surgically treated at our center. Males constitute 68% (n = 203) of total operated PBC patients while the rest 32% (95) were females, making the male-to-female ratio 2.2:1. The age in this series ranged from 9 to 85. According to updated Sanna's PBC classification, 44% were supralabyrinthine, 33% were massive, 9% were infralabyrinthine-apical, 8% were infralabyrinthine, and 5% were apical. On preoperative FN function examination, 45% (n = 133) of patients had various degrees of paresis and complete paralysis whereas 55% (n = 165) had normal FN function. The commonest degree of paresis observed was HB-III (18.5%) followed by HB-IV (5.7%). A total of 40(13.4%) patients, however, had complete facial paralysis at the initial presentation. The facial function was compromised more frequently in supralabyrinthine and massive PBCs. Among the total patients who had an abnormal facial function at presentation, 52% had paresis/paralysis for less than a year whereas 48% had FN paresis/paralysis for greater than one year. The most commonly used surgical approaches at our center were transotic (TO), modified transcochlear type A (MTCA) with rerouting of the FN, and translabyrinthine (TLAB) with external auditory canal (EAC) closure. Intraoperatively an intact fallopian canal was found only in 33% (n = 99) cases whereas the rest 67% (n = 199) had erosion of the fallopian canal either with intact (n = 24) or infiltrated FN (n = 175). The FN was maintained in the bony fallopian canal in 35% (n = 104) cases. An active form of FN management, however, was required in 65% (n = 194) of cases either intraoperatively or as a second-stage procedure. Factors affecting postoperative FN function include age, preoperative FN function (HB), duration of paralysis, class of PBC, surgical approach, and method of active FN management.

CONCLUSION

PBCs represent diagnostically and surgically challenging lesions of temporal bone which are usually frustrating to the treating surgeon. Preoperative anatomic classification of the lesion enables the physician to choose the appropriate surgical approach. Sanna's classification is the most widely accepted system used to classify PBC. This classification is based on the relation of the lesion to the labyrinthine block. Active FN management, including rerouting, end-to-end anastomosis, cable nerve grafting, and masseteric-to-FN anastomosis routinely come into play in the surgical management of PBCs, and the postoperative FN results after such interventions can be satisfactory in most cases.

Next-generation Sequencing of MicroRNA in Acquired Middle Ear Cholesteatoma

OBJECTIVES/HYPOTHESIS

The pathophysiology of cholesteatoma is not precisely understood, and research on the associated microRNAs (miRNAs) is also deficient. We demonstrated the expression of miRNA in normal skin and middle ear cholesteatoma by next-generation sequencing (NGS) technology. The profiles of miRNA and relevant molecular interaction pathways were investigated.

STUDY DESIGN

Case-control experimental study.

METHODS

Middle ear cholesteatoma and post-auricular skin tissue specimens were collected from 13 adult patients. Total RNA was extracted, and miRNA expression profiles were analyzed by NGS technology. Functional gene classification to predict target genes and relevant biological pathways was performed using DIANA-microT-CDS and the Kyoto Encyclopedia Gene and Genome database (KEGG) pathways.

RESULTS

The expression of 2588 miRNAs from middle ear cholesteatoma and skin tissue samples was analyzed. The expression of 76 upregulated and 128 downregulated miRNAs was identified in the cholesteatoma samples compared to normal skin (FC ≥2 and p < 0.05). Ninety-nine differentially expressed miRNAs (FC ≥4 and p < 0.05) were used to explore the biological pathways involved in the etiopathogenesis of cholesteatoma. The most predicted pathway in cholesteatoma in the upregulated miRNA group was the ErbB signaling pathway and it was extracellular matrix (ECM)-receptor interaction in the downregulated miRNA group.

CONCLUSIONS

This was the first study investigating small miRNAs in human acquired cholesteatoma using NGS technique. We were able to identify new miRNAs and pathways related to cholesteatoma. The results of this study are expected to be helpful in revealing new pathophysiologies of cholesteatoma.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:4374-4382, 2024.

Incidence of Hip Fractures among Patients with Chronic Otitis Media: The Real-World Data

Chronic otitis media (COM) has been considered as a localized disease, and its systemic impact is poorly understood. Whether COM-induced inflammation could be associated with systemic bone loss and hip fracture is unknown at present. Our study tried to determine the risk of hip fracture among COM patients. We selected the comparison individuals without the COM coding and paired the controls with COM patients by gender, age, and comorbidities (including osteoporosis) by about a one-to-two ratio. Our study showed that the incidence of hip fracture was 4.48 and 3.92 per 1000 person-years for comparison and COM cohorts respectively. The cumulative incidence of hip fracture is higher in the COM cohort (p < 0.001). After adjustment for gender, age, and comorbidities, the COM patients had a 1.11-fold (aHR = 1.11; 95% CI = 1.05−1.17) risk of hip fracture than the control subjects. Among COM patients, a history of hearing loss is associated with higher (aHR = 1.21; 95% CI = 1.20−1.42) fracture risk. Our study showed that COM patients, especially those with hearing loss, are susceptible to a higher risk for hip fracture.

Facial nerve repair: the impact of technical variations on the final outcome

OBJECTIVES

To analyze the outcome of facial nerve (FN) reconstruction, the impact of technical variations in different conditions and locations, and the importance of additional techniques in case of suboptimal results.

STUDY DESIGN

Retrospective study.

SETTING

University-based tertiary referral center.

PATIENTS

Between 2001 and 2017, reconstruction of the FN was performed on 36 patients with varying underlying diseases.

INTERVENTIONS

FN repair was performed by direct coaptation (n = 3) or graft interposition (n = 33). Microsurgical sutures were used in 17 patients (47%) and fibrin glue was used in all cases. Additional reinnervation techniques (hypoglossal-facial or masseter-facial transfers) were performed in five patients with poor results after initial reconstruction.

MAIN OUTCOME MEASURES

FN function was evaluated using the House-Brackmann (HB) and the electronic clinician-graded facial function (eFACE) grading systems. Minimum follow-up was 12 months.

RESULTS

FN reconstruction yielded improvement in 83% of patients, 21 patients (58.3%) achieving a HB grade III. The eFACE median composite, static, dynamic and synkinesis scores were 69.1, 78, 53.2, and 88.2 respectively. A tendency towards better outcome with the use of sutures was found, the difference not being significant. All patients undergoing an additional reinnervation procedure achieved a HB grade III, eFACE score being 74.8.

CONCLUSIONS

FN reconstruction offers acceptable functional results in most cases. No significant differences are expected with technical variations, different locations or conditions. In patients with poor initial results, additional reinnervation techniques should be always considered. The eFACE adds substantial information to the most used HB scale.

Spontaneous Resolution of Cholesteatoma in a Patient on Long-Term Infliximab

Objective:

To describe an observed case of spontaneous regression of cholesteatoma in a patient on chronic anti-tumor necrosis factor-alpha (TNF-a) therapy and inspire further research into the role of TNF-a in cholesteatoma.

Methods:

Clinical assessment of disease in a single-patient case report.

Results:

A 49-year-old woman suffered a severe case of Stevens-Johnson syndrome when she was 12 years old, leaving her with bilateral corneal opacification and tympanic membrane perforations with extensive cholesteatoma. For her corneal opacification, a corneal prosthesis was placed, which was complicated by a foreign body reaction necessitating long-term therapy with infliximab, a monoclonal antibody against TNF-a that is therapeutic in some chronic inflammatory diseases. She was otherwise healthy and took no other medications. While on infliximab, the patient had spontaneous and complete resolution of her cholesteatoma without any surgical intervention.

Conclusions:

This surprising case suggests that there may be a prominent role of TNF-a in cholesteatoma pathophysiology and that TNF-a may be an effective target for nonsurgical therapy.

Surgical technique and results of cable graft interpositioning of the facial nerve in lateral skull base surgeries: experience with 213 consecutive cases

OBJECTIVE The aim in this study was to review the technique and outcomes of cable graft interpositioning of the facial nerve (FN) in lateral skull base surgeries. METHODS The authors retrospectively evaluated data from patients who had undergone cable graft interpositioning after nerve sacrifice during skull base tumor removal between June 1987 and May 2015. All patients had undergone lateral skull base approaches to remove tumors at a quaternary referral center in Italy. Facial nerve function was evaluated before and after surgery using the House-Brackmann (HB) grading system. RESULTS Two hundred thirteen patients were eligible for study. The mean follow-up was 44.3 months. The most common pathology was vestibular schwannoma (83 cases [39%]), followed by FN tumor (67 cases [31%]). Facial nerve tumors had the highest incidence of nerve interruption (67 [66%] of 102 cases). Preoperative FN function was normal (HB Grade I) in 105 patients (49.3%) and mild (HB Grade II) in 19 (8.9%). At the last postoperative follow-up, 108 (50.7%) of the 213 patients had recovered to Grade III nerve function. Preoperative HB grading of the FN was found to have a significant effect on outcome (p = 0.002). CONCLUSIONS Cable graft interpositioning is a convenient and well-accepted procedure for immediate restoration of the FN. The study results, over a large number of patients, showed that the stitch-less fibrin glue-aided coaptation technique yields good results. The best possible postoperative result achieved was an HB Grade III. The chances of a good postoperative result increase when FN function is normal preoperatively. Slow-growing tumors of the cerebellopontine angle had a favorable outcome after grafting.

Increased Acquired Cholesteatoma Risk in Patients with Osteoporosis: A Retrospective Cohort Study

Objective

Clinically, we found the increased incidence of acquired colesteatoma in the patients with osteoporosis. In this study, we used a retrospective cohort to examine this association and to investigate the possible mechanism.

Methods

We conducted a population-based retrospective cohort study by using the National Health Insurance Research Database (NHIRD). We identified an osteoporosis cohort comprising 37 124 patients newly diagnosed with osteoporosis aged 20 years or older. Patients in the comparison cohort had no history of osteoporosis and were frequency matched with the patients in the osteoporosis cohort according to sex, age, and index year.

Results

The acquired cholesteatoma incidence rates for the osteoporosis and comparison cohorts were 1.12 and 0.83 per 1000 person-years, respectively. After we adjusted for confounding factors, the osteoporosis cohort exhibited a 1.32-fold increased acquired cholesteatoma risk relative to the comparison cohort (hazard ratio [HR] = 1.32, 95% confidence interval [CI] = 1.11–1.57). In addition, patients with no history of otitis media (HR = 1.33, 95% CI = 1.11–1.59), cancer (HR = 1.34, 95% CI = 1.12–1.60), or COPD (HR = 1.26, 95% CI = 1.05–1.52) in the osteoporosis cohort exhibited an increased risk of subsequent acquired cholesteatoma relative to those in the comparison cohort.

Conclusions

Our cohort study indicated that patients with osteoporosis had a 1.31-fold increased acquired cholesteatoma risk relative to the comparison cohort. This risk was further increased in patients with comorbid otitis media. Hence, we recommend that otolaryngologists evaluate the condition of the middle ear of patients with osteoporosis.

Induction of cytokine production in cholesteatoma keratinocytes by extracellular high-mobility group box chromosomal protein 1 combined with DNA released by apoptotic cholesteatoma keratinocytes

High-mobility group box chromosomal protein 1 (HMGB-1), a nuclear DNA binding protein, was recently rediscovered as a new proinflammatory cytokine. The purpose of this study was to determine HMGB-1 expression in vivo and to identify the effect of extracellular HMGB-1 in inflammatory process associated with bone destruction in cholesteatoma. We investigated the expression and location of HMGB-1 in the cholesteatoma and healthy skin using an immunofluorescence assay. We also detected apoptosis and DNA fragments in the cholesteatoma by TUNEL staining. HMGB-1 concentration in apoptotic supernatants from UV light-treated cells, culture supernatants and its translocation in cholesteatoma keratinocytes stimulated by supernatants from UV light-treated cells were measured by immunoblot analysis and immunofluorescence assay. Cultures of human cholesteatoma keratinocytes were exposed to CpG-DNA, HMGB-1, or CpG-DNA complexed to HMGB-1 for 24 h. Cytokines in the culture supernatant were measured by ELISA. In addition, levels of proinflammatory cytokines released by cholesteatoma keratinocytes stimulated by supernatants from UV light-treated cells with or without anti-HMGB-1 antibodies and supernatants from UV light-treated cells with DNase 1 were measured by enzyme-linked immunosorbent assay. The expression of HMGB-1 in cholesteatoma increased and it translocated both to the cytoplasm and extracellular space. Furthermore, the HMGB-1 concentration in supernatants increased significantly after addition of supernatants from UV light-treated cells. TNF-α and IL-1β can be induced by purified HMGB-1 combined with CpG-DNA in the cholesteatoma keratinocytes. In addition, supernatants of apoptotic cells containing HMGB-1-DNA were effective in inducing TNF-α and IL-1β secretion. This study suggested that persistent expression of extracellular HMGB-1 and DNA fragments in cholesteatoma leads to TNF-α and IL-1β production, causing bone resorption and destruction. Thus, we have implicated that HMGB-1-DNA complexes might act as a key molecule involved in bone resorption associated with cholesteatoma.

Genome-wide association study to identify the genetic determinants of otitis media susceptibility in childhood

Background

Otitis media (OM) is a common childhood disease characterised by middle ear inflammation and effusion. Susceptibility to recurrent acute OM (rAOM; ≥3 episodes of AOM in 6 months) and chronic OM with effusion (COME; MEE ≥3 months) is 40–70% heritable. Few underlying genes have been identified to date, and no genome-wide association study (GWAS) of OM has been reported.

Methods and Findings

Data for 2,524,817 single nucleotide polymorphisms (SNPs; 535,544 quality-controlled SNPs genotyped by Illumina 660W-Quad; 1,989,273 by imputation) were analysed for association with OM in 416 cases and 1,075 controls from the Western Australian Pregnancy Cohort (Raine) Study. Logistic regression analyses under an additive model undertaken in GenABEL/ProbABEL adjusting for population substructure using principal components identified SNPs at CAPN14 (rs6755194: OR = 1.90; 95%CI 1.47–2.45; P_adj-PCA = 8.3×10⁻⁷) on chromosome 2p23.1 as the top hit, with independent effects (rs1862981: OR = 1.60; 95%CI 1.29–1.99; P_adj-PCA = 2.2×10⁻⁵) observed at the adjacent GALNT14 gene. In a gene-based analysis in VEGAS, BPIFA3 (P_Gene = 2×10⁻⁵) and BPIFA1 (P_Gene = 1.07×10⁻⁴) in the BPIFA gene cluster on chromosome 20q11.21 were the top hits. In all, 32 genomic regions show evidence of association (P_adj-PCA<10⁻⁵) in this GWAS, with pathway analysis showing a connection between top candidates and the TGFβ pathway. However, top and tag-SNP analysis for seven selected candidate genes in this pathway did not replicate in 645 families (793 affected individuals) from the Western Australian Family Study of Otitis Media (WAFSOM). Lack of replication may be explained by sample size, difference in OM disease severity between primary and replication cohorts or due to type I error in the primary GWAS.

Conclusions

This first discovery GWAS for an OM phenotype has identified CAPN14 and GALNT14 on chromosome 2p23.1 and the BPIFA gene cluster on chromosome 20q11.21 as novel candidate genes which warrant further analysis in cohorts matched more precisely for clinical phenotypes.

Oxidative stress in chronic otitis media

Chronic otitis media usually presents with a benign tumor-like lesion of the temporal bone known as a cholesteatoma. The role of oxidative stress in the pathogenesis of chronic otitis media and cholesteatoma has not yet been fully explored. Therefore, the aim of this study was to investigate the oxidative stress markers and antioxidant enzymes in patients with cholesteatomatous and noncholesteatomatous chronic otitis media and in healthy subjects. A prospective controlled trial was performed on cholesteatomatous and noncholesteatomatous chronic otitis media patients in a tertiary referral center in a university hospital. A total of 75 subjects, including 25 cholesteatomatous and 25 noncholesteatomatous chronic otitis media patients and 25 healthy subjects participated in this study. Serum total oxidant status (TOS) and oxidative stress index (OSI) levels were significantly increased in the patient groups with or without cholesteatoma compared with the control group. Serum total antioxidant status (TAS) levels and Paraoxonase and arylesterase activity were significantly lower in the patient groups with or without cholesteatoma compared with the control group. Serum TOS and OSI levels were lower in the noncholesteatomatous group, whereas serum TAS levels were higher compared with the cholesteatomatous group. Serum arylesterase activity was significantly lower in the noncholesteatomatous group compared with the control group. The results of this study reveal that in cholesteatoma cases, the oxidative stress and antioxidant enzyme imbalance were more significant than in cases of chronic otitis media without cholesteatoma.

Cholesteatoma of the nose and maxillary and ethmoid sinuses: a rare complication of palatal surgery

A 10-year-old boy presented with a complaint of a left-sided nasal obstruction with an associated foul-smelling discharge. Physical examination and anterior rhinoscopy revealed that a whitish, friable mass had completely filled the left nasal cavity. On computed tomography, a soft-tissue mass was seen filling the cavity and extending to the paranasal sinuses with bone erosion. A biopsy of the mass suggested that it represented a cholesteatoma. The lesion was removed via nasal endoscopy, and histopathology confirmed the diagnosis of a cholesteatoma. No recurrence was noted during 6 months of follow-up. Cholesteatoma of the paranasal sinuses is a rare entity, as only a few dozen cases have been reported in the literature.

Expression of tumor necrosis factor-α, interleukin-1α, interleukin-6 and interleukin-10 in chronic otitis media with bone osteolysis

The purpose of this study was to evaluate the expression of proinflammatory and immunoregulatory cytokines in chronic otitis media. The expression levels of TNF-α, IL-1α, IL-6 and IL-10 were determined by Western blot analysis of tissue samples obtained during ear surgery. The expression levels of TNF-α, IL-1α and IL-6 in cholesteatoma tissues were substantially higher compared to those determined in the granulation tissue. The highest levels of TNF-α, IL-1 and IL-6 proteins were observed in patients with bone destruction. There were no significant differences in the expression of IL-10 levels in cholesteatoma and normal skin, but in the granulation tissue its level was substantially higher. The level of IL-10 in cholesteatoma tissues inversely correlated with the expression of proinflammatory cytokines, the degree of bone destruction and cholesteatoma invasion. Increased expressions of TNF-α, IL-1α and IL-6 in chronic otitis media and a strong positive correlation between these cytokine levels and the degree of bone destruction indicate the destructive behavior of cholesteatoma or granulation tissue.

Expression of the receptor activator for nuclear factor-κB ligand and osteoprotegerin in chronic otitis media

BACKGROUND

The receptor activator for nuclear factor-κB ligand (RANKL) and osteoprotegerin (OPG) are the key factors controlling the osteoclast and osteoblast action in the bone.

PURPOSE

The study objective was to investigate the expression level of RANKL and OPG in cholesteatoma and granulation tissue, and to assess the relationship between their expression levels and osteolysis.

MATERIAL AND METHODS

Patients with chronic otitis media with cholesteatoma (n = 28) and without cholesteatoma (n = 24) treated surgically at the Department of Otolaryngology of the Medical University of Gdańsk were included in the study. RANKL and OPG expressions were analyzed by immunohistochemistry and Western blot.

RESULTS

RANKL and OPG were expressed in all cholesteatoma and granulation tissues. RANKL expression was mainly observed in cholesteatoma subepithelial stroma, whereas OPG-positive cells originated from the epithelium. The number of OPG-positive cells in the normal skin was significantly higher than in cholesteatoma tissues. The RANKL protein level in cholesteatoma tissues was 1.8- and 1.5-fold higher than in the auditory canal skin and granulation tissues, respectively. The number of RANKL-positive cells in cholesteatoma tissues was significantly higher than in the normal skin. No substantial differences were found in average OPG protein levels between cholesteatoma tissues and the normal auditory canal skin. The ratio of RANKL/OPG was significantly higher in cholesteatoma tissues (2.93 ± 0.79) than in the skin samples (1.36 ± 0.34).

CONCLUSIONS

Altered ratio of RANKL/OPG protein level in cholesteatoma tissues suggests that these proteins might be somehow involved in the pathogenesis of cholesteatoma. However, to resolve this issue a study on a larger group of patients should be conducted.

Comparative analysis of the epithelium stroma interaction of acquired middle ear cholesteatoma in children and adults

In the clinical setting, pediatric cholesteatomas frequently behave more aggressively than similar lesions in adults. The reason for the difference in behavior is still unclear. The purpose of the present study was to investigate the cell to cell and epithelial-stroma interaction of acquired cholesteatoma in adults and children and search for differences on the cellular level, which might explain the different behavior of these lesions. Operative specimens of 54 patients [40 adults (average age of 39.7 years), 14 children (average age of 8.3 years)] who underwent primary surgery for an acquired cholesteatoma of the middle ear were examined by histopathology and DNA-image cytometry (DNA-ICM). Immunohistochemical investigations included expression of proliferation markers (proliferation cell nuclear antigen and MIB-1) along with cell surface markers reflecting the cell-to-cell interaction (i.e. alpha1beta6-integrin, E-cadherin, I-CAM = CD54), and the epithelial to stroma interaction (i.e. alphav and beta3 intergin chains, V-CAM = CD106, CD44v6 and fibronectin). Pediatric cholesteatomas demonstrated higher incidence of acute inflammation and more extensive disease relative to those from the adults. Indices of DNA-ICM, however, revealed normal diploid DNA content in both groups. Higher proliferation scores occurred in the pediatric group compared to adult cholesteatoma. Cell surface markers and cell adhesion molecules were equally expressed in both groups except alpha1beta6-integrin and fibronectin, which were over expressed in pediatric cholesteatomas. Statistically, however, these differences showed only a trend towards significance. According to the results of the present study, pediatric and adult cholesteatomas do not show any marked differences on the cellular level. Thus the observed clinical more aggressive behavior of pediatric cholesteatoma is likely due to other secondary factors such as more intense inflammation, disturbed middle ear ventilation or the diminished calcium salt content of pediatric bone.

Massive cholesteatoma of the frontal sinus: case report and review of the literature

A case of a massive cholesteatoma of the frontal sinus in an 80-year-old female is reported. This lesion is very uncommon and a review of the English literature revealed only 12 reported cases. Characteristically, these tumors present unilaterally as a painless, slow-growing mass, often accompanied by frontal headache, proptosis and diplopia, and without a history of frontal sinus infection. Curative treatment includes total excision of the cholesteatoma with adequate drainage, which leaves the patient with an excellent prognosis although late recurrence has been reported. While this type of lesion is very rare, it is nevertheless an important differential diagnosis of frontal sinus tumors, due to the associated destruction of bone.

O papel do Fator de Necrose Tumoral Alfa (TNF-alfa) no processo de erosão óssea presente no colesteatoma adquirido da orelha média

O colesteatoma adquirido da orelha média causa erosão óssea, com altas taxas de morbidade e mortalidade. O TNF-alfa (TNF-alfa) lambda uma das principais citocinas envolvidas neste processo. OBJETIVO: Avaliar o papel do TNF-alfa na reabsorsão óssea e a ação dele no colesteatoma. MATERIAL E MÉTODOS: Foi realizado um levantamento e uma revisão crítica da literatura. RESULTADOS: Todos os autores estudados concordam com a importância do TNF-alfa no processo de reabsorção óssea presente no colesteatoma e com o grau de destruição observado. Diferentes trabalhos demonstraram que o TNF-alfa é capaz de provocar erosão óssea, através de diferentes vias de ação. Ele pode estimular a diferenciação e a maturação dos osteoclastos ou, ainda, agir na matriz óssea expondo-a à ação dos osteoclastos. Existe a possibilidade de inibir a ação do TNF-alfa, diminuindo seus efeitos e prevenindo a perda óssea em doenças como a artrite reumatóide. Não existe, entretanto, trabalhos específicos em colesteatoma. Não existe consenso sobre a sua localização. Estas diferenças, provavelmente, ocorrem devido à distribuição dos receptores. CONCLUSÃO: O TNF-alfa, presente no colesteatoma promove a reabsorsão óssea, juntamente com outras citocinas (RANKL e IL-1), estando relacionado com a presença de complicações.

The pathophysiology of cholesteatoma

The pathogenesis of middle ear cholesteatoma continues to be highly debated. In recent years, there has been a substantial improvement in the understanding of the pathophysiology of this disease. This chapter provides a summary of the history and evolution of cholesteatoma and a review of the recent literature that pertains to the pathophysiology of congenital and acquired cholesteatoma. An emphasis is placed on the mechanism of osteolysis and the factors predictive of aggressiveness and recidivism.

The role of Tumor Necrosis Factor -Alpha (TNF-α) in bone resorption present in middle ear cholesteatoma

Summary

Cholesteatoma may cause bone erosion, with high morbidity and mortality rates. Tumor Necrosis Factor - Alpha (TNF-a) is one of the main cytokines involved in this process. Our goal was to evaluate the role of TNF-a in Bone Resorption and its effect on cholesteatoma.

Material and Methods

analysis and critical literature review.

Results

Different studies have demonstrated that TNF-a is capable of causing bone erosion. It may stimulate the differentiation and maturation of osteoclasts or it may act on the bone matrix, exposing it to the action of the osteoclasts. It is possible to inhibit TNF-a, reducing its effects and prevent bone loss in illnesses such as rheumatoid arthritis, and there has been no specific investigation regarding cholesteatomas. All studies agree on the importance of TNF-a in the bone resorption process present in cholesteatomas, and on the degree of destruction observed; however, there is no consensus as to its location. These differences are probably due to receptor site.

Conclusion

TNF-a, present in cholesteatomas, promotes bone resorption, along with other cytokines (RANKL and IL-1) related to complications.

Analysis of gene expression profiles in cholesteatoma using oligonucleotide microarray

CONCLUSION

Microarray analysis may be a useful tool to identify some candidate genes related to the pathogenesis of cholesteatoma.

OBJECTIVE

The aim of this study was to investigate gene expression profiles in human cholesteatoma using an oligonucleotide chip including 10,115 genes.

MATERIALS AND METHODS

Gene expression from five cholesteatoma matrices and five normal retroauricular skins was analyzed by Macrogen human oligo-chip and the expression levels of some selected genes were also confirmed by RT-PCR.

RESULTS

In all, 1327 up-regulated or 767 down-regulated genes that were over 3 times more prominent in cholesteatoma than in skin were identified by 5 samples of microarray data. Among these up-regulated or down-regulated genes in cholesteatoma, 291 genes were identified in 3 samples or more out of 5 samples as up-regulated expression more than threefold in density and 191 genes were down-regulated more than threefold in density. RT-PCR of 21 selected genes revealed that those expression levels were higher in choleasteatoma than retroauricular skin.

Fistula of the Cochlear Labyrinth in Noncholesteatomatous Chronic Otitis Media

OBJECTIVE

To discuss the clinical aspects and management of promontory fistula of the cochlear labyrinth.

STUDY DESIGN

Case report and review of the literature.

SETTING

University hospital, tertiary referral center.

PATIENT, INTERVENTION, AND RESULTS

The authors describe an unusual case of cochlear fistula localized to the promontory discovered during tympanoplasty for noncholesteatomatous chronic otitis media in a 59-year-old woman. Bone conduction was slightly impaired after operation and hearing improved after a revision myringoplasty performed for reperforation.

CONCLUSION

Erosion of the bone of the labyrinth can also be observed in noncholesteatomatous otitis media. The presence of a fistula is not always associated with profound hearing loss. Overlying pathologic tissue can be removed without damaging the membranous labyrinth.

Lipopolysaccharide concentration and bone resorption in cholesteatoma

HYPOTHESIS

There is a relationship between the local lipopolysaccharide (LPS) concentration in cholesteatoma and local bone resorption in chronic otitis media (COM) with cholesteatoma.

BACKGROUND

During the past decade, it has become known that the recruitment of osteoclasts is the main causative factor that induces bone destruction in COM with cholesteatoma. Cellular inflammation factors like cytokines may trigger the osteoclast. Sequel to this, LPS is able to up-regulate cytokines. This makes it of interest to study whether the local LPS concentration is related to bone resorption in cholesteatoma.

MATERIALS AND METHODS

Twenty-four cholesteatoma samples and control tissue from COM patients without cholesteatoma were collected. During surgery, the degree of bone resorption was established and classified. Retrospectively, the authors checked whether patients had chronic purulent otorrhea. LPS concentration of the tissue samples was measured by the limulus amebocyte lysate test. The one-way analysis of variance test was used to determine the relation between LPS concentration, otorrhea, and local bone resorption.

RESULTS

A significantly higher concentration of LPS was measured in samples from patients with cholesteatoma with bone resorption and otorrhea compared with cholesteatoma without bone resorption and control tissue. There were no significant differences between the LPS levels of the different groups of patients with bone resorption.

CONCLUSION

It is suggested that LPS is one of the first factors in the cascade of bone resorption in COM with cholesteatoma.

Tympanic Membrane Metalloproteinase Inflammatory Response

OBJECTIVE: The goal of this study was to determine whether expression of matrix metalloproteinases (MMP) in tympanic membranes (TM) is stimulated by host tumor necrosis factor-± (TNF-±) and bacterial toxin (lipopolysaccharide, LPS), which may play a role in the pathogenesis of cholesteatoma.

STUDY DESIGN: Gerbil TMs (n = 48) were cultured in the presence of either TNF-± or LPS. Quantitative analysis of TNF-± and MMPs was performed on both the homogenized TMs and the culture media supernatant.

RESULTS: Levels of TNF-± and MMPs did not increase significantly in TMs with exposure to inflammatory mediators. TNF-± levels in supernatant were elevated ( P < 0.007) with more concentrated LPS exposure. Supernatant levels of MMP2 were increased ( P < 0.007) at most concentrations of LPS and TNF-±.

CONCLUSION: Cultured TMs expressed MMPs in response to bacterial and host inflammatory mediators. These findings support a link between inflammation and the secretion of potentially destructive MMPs in the TM, which may contribute to the pathogenesis of cholesteatoma.

Gene expression analysis of human middle ear cholesteatoma using complementary DNA arrays

OBJECTIVE

To identify genes regulated in human cholesteatoma compared with normal skin tissue using complementary DNA arrays.

STUDY DESIGN

In vitro analysis.

METHODS

Eight cholesteatoma and retroauricular skin samples were obtained from the same patients during surgery. Upregulated and downregulated genes were highlighted using complementary DNA arrays for screening. Reverse transcriptase-polymerase chain reaction and immunohistochemical staining were performed to confirm the results of the complementary DNA array.

RESULTS

Twelve genes were found to be induced or upregulated in cholesteatoma compared with skin samples. These included genes involved in cell proliferation and differentiation (eg, calgranulin A, calgranulin B, psoriasin, thymosin beta-10) and cell invasion (eg, cathepsin C, cathepsin D, cathepsin H). Analyses by means of reverse transcription-polymerase chain reaction showed enhanced expression of several genes including calgranulin A, calgranulin B, psoriasin, thymosin beta-10, cathepsin C, cathepsin D, and cathepsin H in cholesteatoma, supporting the findings from the gene array. In addition, it was verified by immunohistochemical analysis that the expressions of Calgranulin A, Calgranulin B, and Cathepsin D were mainly located in cholesteatoma epithelium.

CONCLUSION

The observed alteration in gene expression may play a role in various mechanisms of pathogenesis in cholesteatoma.

Aggressiveness and quantification of epithelial proliferation of middle ear cholesteatoma by MIB1

OBJECTIVE

To assess an easy method that predicts cholesteatoma aggressiveness.

STUDY DESIGN

An experimental prospective study.

METHODS

Monoclonal antibody MIB1 was used to determine epithelium proliferation in 91 cholesteatomatous ears. Clinical and surgical parameters were compared with proliferation activity to determine pathological and clinical correlation.

RESULTS

Statistical correlations were established between hyperproliferation of the cholesteatoma and severe bone erosion (leading to major cholesteatoma complications) and between hyperproliferation and middle ear inflammation (associated with more surgical difficulties and a higher risk of recurrence). A high proliferation index was also found in children's cholesteatoma, which is known to have more aggressive behavior.

CONCLUSION

Immunohistochemical use of the MIB1 antibody is a simple technique that can help to determine the aggressiveness of a cholesteatoma.

Expression of epidermal growth factor, tumor necrosis factor-alpha, and interleukin-1alpha in chronic otitis media with or without cholesteatoma

OBJECTIVE

The object of this study was to compare the expression of epidermal growth factor, interleukin-1alpha, and tumor necrosis factor-alpha in chronic otitis media with or without cholesteatoma.

BACKGROUND

It has been reported that cytokines and epidermal growth factor are effective in the bone resorption process in chronic otitis media. Bone resorption can also occur in chronic otitis media without cholesteatoma. However, comparative analysis is lacking. This issue has been investigated in a blind, controlled and prospective analysis.

METHOD

The activities of interleukin-1alpha, tumor necrosis factor-alpha, and epidermal growth factor were determined by commercially available enzyme-linked immunosorbent assay kits in tissue biopsy samples from 16 patients without cholesteatoma and from 23 patients with cholesteatoma (cholesteatoma epithelium). To establish a control group, external auditory canal skin was randomly collected from two groups (21 patients). The Mann-Whitney and Kruskal-Wallis tests were used for statistical analysis.

RESULTS

The levels of interleukin-1alpha, tumor necrosis factor-alpha, and epidermal growth factor in tissue samples from the group with cholesteatoma were significantly greater than those in the group without cholesteatoma and the control group. No correlation was observed with other clinical factors such as age, sex, and antibiotic coverage.

CONCLUSION

Higher levels of cytokines in patients with cholesteatoma confirm that the destructive behavior of cholesteatoma is likely mediated by cytokines and epidermal growth factor and is the result of keratinocyte activity. Antibiotic treatment does not affect the level of cytokine concentration in patients with chronic otitis media and cholesteatoma, although the ear discharge subsides and inflammation-related symptoms regress in some cases.

Expression of matrix-degrading cysteine proteinase cathepsin K in cholesteatoma

Cholesteatoma is a nonneoplastic lesion of the middle ear space or mastoid that is histologically characterized by a progressive bone erosion of the ossicles and surrounding bone. Several matrix-degrading enzymes have been implicated as mediators of this bone erosion. Because the novel cysteine proteinase cathepsin K has been shown to play a central role in bone resorption, we examined the expression of this enzyme in tissue specimens of cholesteatoma. Tissue specimens of 9 patients with cholesteatoma were obtained during middle-ear surgery. Expression of cathepsin K mRNA was determined by RT-PCR using specific primers. Immunohistochemical analysis of cathepsin K protein expression in tissue sections was performed by using the streptavidin-alkaline phosphatase technique. Expression of both cathepsin K mRNA and protein was detected in areas affected by cholesteatoma, whereas specimens of nonaffected ear cartilage and surrounding tissue were not positive. In addition, cathepsin K was detected in numerous multinucleated giant cells, particularly osteoclasts at the site of bone degradation. In contrast, keratinized squamous epithelium was negative for cathepsin K. These data demonstrate that the matrix-degrading cysteine proteinase cathepsin K may be involved in bone erosion in cholesteatoma. Strong expression of this collagenolytic enzyme in osteoclasts suggests that these cells are mainly involved in cathepsin K-mediated bone destruction.

The incidence of facial nerve dehiscence at surgery for cholesteatoma

OBJECTIVE

Facial paralysis can occur after surgery for cholesteatoma. The risk of facial nerve injury is great when the nerve is not covered by its normal bony Fallopian canal. The objective of this study was to identify the incidence of facial nerve dehiscence in patients undergoing surgery for cholesteatoma.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral hospital.

PATIENT POPULATION

An assessment of all cases performed by the senior author from 1991 to 1999 revealed 59 patients with adequate data available for analysis. These patients ranged in age from 3 to 92 years. In all, 67 surgical procedures.

INTERVENTION

Surgery for cholesteatoma, including tympanoplasty and mastoidectomy.

MAIN OUTCOME MEASURE

The presence of facial nerve bony dehiscence after exenteration of disease, and postoperative facial nerve function.

RESULTS

In 33% of the total procedures analyzed, 30% of the initial procedures, and 35% of the revision procedures, the patients were found to have facial nerve bony dehiscence. The dehiscence was present in the tympanic portion of the facial nerve in the vast majority of patients. Of the 97% of patients with normal preoperative facial nerve function, all retained normal function postoperatively.

CONCLUSIONS

Facial nerve dehiscence in our series was far greater than that reported in the literature, underscoring the fact that this is an under-appreciated condition. These findings suggest that surgeons should be highly vigilant when dissecting near the facial nerve. Intraoperative facial nerve monitoring has been shown to be of value in facial nerve preservation during acoustic neuroma resections, and may have a role during surgery for cholesteatoma.

Origin and spread of allergic fungal disease of the nose and paranasal sinuses

Although expansion of bony walls occurs in allergic fungal disease of the nose and paranasal sinuses by increased mucus secretion and fungal growth, the latter is apparently confined to the lumen and does not invade the tissues. Nevertheless, spread of the disease process from paranasal sinuses to orbit, cheek and intracranial cavity is well described. An imaging and histopathological study was carried out in 16 cases to determine how the disease originates and spreads. The infection starts in the nasal cavity, the lumen of a sinus or in a seromucinous gland or duct. A thin vascular zone of intense allergic inflammation surrounds the infected mucin. Erosion of bone takes place focally, probably by substances produced by the inflammatory tissue, allowing intromission by the thin vascular layer together with its underlying fungus-containing mucus and so extension of the disease process through the eroded bone.

The pathogenic activation of calpain: a marker and mediator of cellular toxicity and disease states

Over-activation of calpain, a ubiquitous calcium-sensitive protease, has been linked to a variety of degenerative conditions in the brain and several other tissues. Dozens of substrates for calpain have been identified and several of these have been used to measure activation of the protease in the context of experimentally induced and naturally occurring pathologies. Calpain-mediated cleavage of the cytoskeletal protein spectrin, in particular, results in a set of large breakdown products (BDPs) that are unique in that they are unusually stable. Over the last 15 years, measurements of BDPs in experimental models of stroke-type excitotoxicity, hypoxia/ischemia, vasospasm, epilepsy, toxin exposure, brain injury, kidney malfunction, and genetic defects, have established that calpain activation is an early and causal event in the degeneration that ensues from acute, definable insults. The BDPs also have been found to increase with normal ageing and in patients with Alzheimer's disease, and the calpain activity may be involved in related apoptotic processes in conjunction with the caspase family of proteases. Thus, it has become increasingly clear that regardless of the mode of disturbance in calcium homeostasis or the cell type involved, calpain is critical to the development of pathology and therefore a distinct and powerful therapeutic target. The recent development of antibodies that recognize the site at which spectrin is cleaved has greatly facilitated the temporal and spatial resolution of calpain activation in situ. Accordingly, sensitive spectrin breakdown assays now are utilized to identify potential toxic side-effects of compounds and to develop calpain inhibitors for a wide range of indications including stroke, cerebral vasospasm, and kidney failure.

Structural changes and protein expression in the mastoid bone adjacent to cholesteatoma

OBJECTIVE

Cholesteatoma of the mastoid and middle ear causes erosion of nearby bone. In this study we examined the mastoid bone adjacent to cholesteatoma and compared it with normal mastoid bone. In particular, noncollagenous proteins, which have a special structural and functional role in bone, were addressed.

STUDY DESIGN

Nine mastoid specimens with cholesteatoma and four normal specimens obtained at surgery were examined.

METHODS

Histological and immunohistochemical methods were employed to evaluate the nature of structure and noncollagenous protein content changes in the mastoid bone affected by cholesteatoma.

RESULTS

The bone associated with cholesteatoma had structural changes as a noncontinuous periosteum, empty lacunae, irregular cement lines, and, specifically, the appearance of eosinophilic vesicles at the interface between the bone and cholesteatoma Immunohistochemistry demonstrated that noncollagenous proteins were apparently absent in the affected mastoid bone. Bone remote from the cholesteatoma seemed normal.

CONCLUSIONS

These findings demonstrate for the first time the changes in the noncollagenous protein content in the mastoid bone affected directly by cholesteatoma These changes could be a result of a direct influence of cholesteatoma-derived products on the osteoblast.

Congenital maxillary sinus cholesteatoma

Cholesteatoma of the paranasal sinuses is a rare condition. The purpose of this paper is to present a child with a congenital maxillary sinus cholesteatoma. An 18-month-old girl presented with a 4-week history of right cheek and intraoral swelling. Examination revealed a smooth swelling of the right hard palate in association with the facial swelling in the maxillary region. An inferior meatal antrostomy revealed pultaceous debris in the right maxillary antrum and biopsy confirmed a maxillary sinus cholesteatoma. The inferior meatal antrostomy was enlarged to allow exteriorisation of the disease. Recurrence of the disease has not presented on follow-up. An exteriorisation procedure as performed, in child of this age, allows normal facial growth. If recurrence develops then further treatment may be instituted in a more mature facial skeleton.