A comprehensive model for the aetiology of otitis media with effusion

Otitis media with effusion: The role of Helicobacter Pylori in its pathogenesis

BACKGROUND

Otitis Media with Effusion (OME) is the most common disease of the middle ear. Different factors play a role in its pathogenesis, such as viral and bacterial infections, allergy, morphological and functional changes of nasal passage, Eustachian Tube (ET), and cleft palate. This study aims to investigate the Helicobacter Pylori presence in middle ear effusions from patients with OME through RT-PCR and compare our results with results from other published articles.

METHODS

The study was carried out from October 2007 to February 2009, in the Department of Otorhinolaryngology of SS. Annunziata Hospital, Chieti, Italy. 132 consecutive patients with OME were included in the study. Fluid in the middle ear was assessed for the presence of Helicobacter Pylori through RT-PCR.

RESULTS

132 consecutive patients with OME were included in the study. The patients were between ages 8 and 78 (median 50); 62 were males (47%), 70 were females (53%), and 53 patients had bilateral OME (40%). 185 samples were collected from 132 patients. Of the 185 samples taken from the ear, 21 (11.35%) were not adequate for the correct execution of the DNA extraction procedure. The remaining 167 samples, subjected to RT-PCR, did not show in any case an increase in fluorescence linked to the FAM fluorophore, thus demonstrating the complete absence of Helicobacter Pylori.

CONCLUSION

Based on the results obtained, we can affirm that although a third of the cases of OME is correlated to the presence of reflux, Helicobacter Pylori does not seem to play any role in the pathophysiology of OME as it cannot be found in endo-tympanic exudate.

Prevalence of Eustachian Tube Dysfunction in the US Elderly Population

Objective

To investigate the prevalence of eustachian tube dysfunction (ETD) in elderly adults in the United States and its association with other upper aerodigestive inflammatory processes.

Study Design

Cross-sectional study.

Setting

Population based.

Subjects and Methods

In total, 147,805 patients without malignancy were compared to 13,804 demographically matched patients with malignancy of the upper aerodigestive tract (UADT) by querying the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked database for patients aged 66 to 99 years between 2003 and 2011. The prevalence of ETD and inflammatory diseases among these patients was compared. Association between ETD, other upper aerodigestive inflammatory processes, and UADT malignancies was evaluated.

Results

The prevalence of ETD was 5.44% among patients without malignancy and 9.08% in those with cancer (odds ratio [OR], 1.73; 95% CI, 1.63-1.84). Patients with ETD in the control population were more likely (OR, 95% CI) to be diagnosed with chronic rhinitis (5.00, 4.70-5.33), chronic sinusitis (4.20, 3.98-4.43), allergic rhinitis (4.27, 4.08-4.47), and gastroesophageal reflux disease (GERD) (2.42, 2.31-2.53). Patients with ETD and chronic rhinitis (1.43, 1.24-1.65), chronic sinusitis (1.57, 1.38-1.78), and acute otitis media (1.33, 1.08-1.65) were associated with higher rates of UADT malignancy.

Conclusion

Over 5% of patients older than 65 in the United States are diagnosed with ETD in the absence of UADT malignancy. Associations between ETD and chronic rhinitis, chronic sinusitis, allergic rhinitis, and GERD in the absence of UADT malignancy suggest that some patients may benefit from treatment of inflammatory disease as a cause of ETD.

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.

The role of tensor veli palatini muscle (TVP) and levetor veli palatini [corrected] muscle (LVP) in the opening and closing of pharyngeal orifice of Eustachian tube

CONCLUSION

This study developed an easy way to induce otitis media in an animal model and find the relation between tensor veli palatini muscle (TVP) and levetor veli palatini [corrected] muscle (LVP) in the opening and closing of the pharyngeal orifice of Eustachian tube. It was proved that otitis media is caused due to the dysfunction of Eustachian tube and the only muscle responsible for opening and closing of ETPO (Eustachian tube pharyngeal orifice) is TVP and LVP has no role in the opening and closing of the Eustachian tube pharyngeal orifice.

OBJECTIVE

To develop valid animal model for otitis media of effusion and to study the relation of paratubular muscles in the functioning of Eustachian tube.

METHODS

Two different methods were used to induce middle ear disease: (1) Excision of tensor veli palatini and levetor veli palatini [corrected] muscles (TVP and LVP); and (2) Injection of botulinum toxin type A on TVP and LVP.

RESULT

Otomiscroscopic, tympanograph, and pathological examination showed the presence of middle ear disease in those animals whose TVP was excised and paralyzed, but on those groups of animals whose LVP was excised and paralyzed, abnormalities were seen.

Diagnosis of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a rather common disease in children, but its symptoms are often subtle and non-specific and this may result in overlooking a correct diagnosis. In turn, a missed diagnosis of CRS prevents a correct management to be performed and is associated with uneffective investigations and improper treatments. Actually, when CRS symptoms, which are mainly nasal congestion and obstruction, nasal discharge, facial pain, cough, and halitosis, are correctly assessed, the clinical diagnosis of CRS may be achieved, and confirmation may be obtained by imaging criteria or nasal fibroendoscopy. In imaging, computed tomography (CT) is the first choice technique for the evaluation of CRS and is able to provide an anatomic road map when surgery is required. Magnetic resonance imaging (MRI) of the sinuses, orbits, and brain should be performed whenever extensive or multiple complications of sinusitis are suspected. Also for middle ear disorders, CT is the first choice because it detects opacification of the middle ear cavity and mastoid cells, presence of fluids or debris, and allows the ossicular chain and the cortical bone of the mastoid to be evaluated. Another important diagnostic issue is the need to look for disorders that are frequently associated with CRS, such as obstructive sleep apnea syndrome (OSAS), that has some recognized risk factors in adenotonsillar hypertrophy, craniofacial anomalies, obesity, and neuromuscular disorders. Other associated disorders requiring investigation are recurrent or persistent otitis media and difficult asthma.

TLR-9, NOD-1, NOD-2, RIG-I and immunoglobulins in recurrent otitis media with effusion

OBJECTIVES

Pattern recognition receptors (PRRs) induce appropriate immune responses after recognizing certain molecular characteristics of pathogens. It is not known, however, whether PRRs are expressed in middle ear infections and whether the expression of PRRs and immunoglobulins is correlated in recurrent otitis media with effusion (OME). We therefore investigated the expression of PRRs and immunoglobulins in children with OME.

MATERIALS AND METHODS

The study population consisted of 66 children with OME, of whom 27 had more than 4 episodes in 12 months or more than 3 episodes in 6 months (otitis-prone group), and 39 had fewer than 4 episodes in 12 months or 3 episodes in 6 months (non-otitis-prone group). The expression in middle ear effusion of Toll-like receptor (TLR)-9, nucleotide-binding oligomerization domain (NOD)-1, NOD-2, and retinoic acid-inducible gene (RIG)-I mRNA, as determined by real-time PCR, and the concentrations of IgG, IgA, and IgM, as determined by ELISA, were compared between the two groups.

RESULTS

The levels of TLR-9, NOD-1 and RIG I mRNAs were significantly lower in the otitis-prone than in the non-otitis-prone group (p<0.05 each). The concentrations of IgG, IgA and IgM in effusion fluid did not differ significantly between the two groups (p>0.05), and there were no correlations between immunoglobulin concentration and the expression of PRPs (p>0.05).

CONCLUSIONS

Decreased expression of PRRs may be associated with increased susceptibility to OME.

Craniofacial morphology and otitis media with effusion in children

Otitis media with effusion (OME) affects 28-38% of pre-school children, and it occurs due to the dysfunction of the auditory tube. Anatomical development of the auditory tube depends on the craniofacial growth and development. Deviations of normal craniofacial morphology and growth using cephalometric studies, may predict the evolution of otitis. Our goal in this paper is to determine if there are differences in craniofacial morphology between children with adenoid enlargement, with and without otitis media with effusion. This is a prospective study in which the sample consisted of 67 children (male and female) from 5 to 10 years old. All patients presented chronic upper airway obstruction due to tonsil and adenoid enlargement (>80% degree of obstruction). Thirty-three patients presented otitis media with effusion, for more than 3 months and 34 did not. The latter composed the control group. Standardized lateral head radiographs were obtained for all subjects. Radiographs were taken with patient positioned by a cephalostat and stayed with mandibles in centric occlusion and lips at rest. Radiographs were digitalized and specific landmarks were identified using a computer program Radiocef 2003, 5th edition. Measurements, angles and lines were taken of the basicranium, maxilla and mandible according to the modified Ricketts analysis. In addition, facial height and facial axis were determined. Children with otitis media with effusion present differences in the morphology of the face, regarding these measures: N-S (anterior cranial base length), N-ANS (upper facial height), ANS-PNS (size of the hard palate), Po-Or.N-Pog (facial depth), Ba-N.Ptm-Gn (facial axis), Go-Me (mandibular length) and Vaia--Vaip (inferior pharyngeal airway).

Reproducibility of sonotubometry as Eustachian tube ventilatory function test in healthy children

OBJECTIVES

To devise a simple and reliable diagnostic procedure to test Eustachian tube function routinely in an ENT outpatient setting. One method to measure ET ventilatory function is sonotubometry. The reproducibility of a recently updated sonotubometry set-up was tested in healthy children.

METHODS

The test population comprised 61 school children aged from 6 to 8 years. Only otologically healthy children were included. Health state was established by means of a 12-item questionnaire. To test reproducibility, sonotubometric testing took place in two sessions of 10 acts of swallowing each. Spearman's coefficient was used to test the correlation between the two sets of measurements. All testing took place at a primary school in a nearby village.

RESULTS

Opening of the ET was recorded in at least one of the two measurement sessions in 82% of the children. The first and second sessions were highly correlated, with a Spearman's coefficient of 0.89.

CONCLUSIONS

In otologically healthy children, opening of the ET was recorded frequently using the updated sonotubometry set-up. Measurement results had high reproducibility. Therefore, the test forms a useful method to assess ET ventilatory function in otologically healthy children. The performance of this updated version needs to be established in children with otological diseases.

Impact of genetic variants in IL-4, IL-4 RA and IL-13 on the anti-pneumococcal antibody response

BACKGROUND

Significant differences in immune responses upon vaccination have been described, suggesting genetics are important in determining the magnitude of vaccine responses. The interleukin (IL)-4 pathway, including IL-4, IL-13 and the IL-4 receptor alpha chain (IL-4 Ralpha), is central to humoral responses and therefore could have an impact on vaccine responsiveness.

OBJECTIVE

To investigate whether single nucleotide polymorphisms (SNPs) in the IL-4, IL-13 and IL-4 RA genes influence pneumococcal serotype-specific IgG antibody responses.

METHODS

SNPs in the IL-4 gene (C -589T, G2979T), the IL-13 gene (G -1112A, Arg130Gln) and in the IL-4 RA gene (Ile50Val, Gln551Arg) were investigated in isolation and in combination, for their influence on serotype-specific IgG antibody responses upon combined pneumococcal conjugate and polysaccharide vaccinations in children with a history of recurrent otitis media.

RESULTS

Lower antibody responses were observed for alleles previously associated with atopy, IL-4 -589T, IL-4 2979T and IL-4 Ralpha 551Gln. Effects were stronger in gene haplotype combinations or in multiple haplotype combination analyses.

CONCLUSION

This study highlights the importance of host genetic factors in vaccine responses. Furthermore, it supports the approach of studying the effect of combinations of multiple alleles, in haplotypes or in combinations of haplotypes, on complex phenotypes within a biological pathway.

Association of CD14 promoter polymorphism with otitis media and pneumococcal vaccine responses

Innate immunity is of particular importance for protection against infection during early life, when adaptive immune responses are immature. CD14 plays key roles in innate immunity, including in defense against pathogens associated with otitis media, a major pediatric health care issue. The T allele of the CD14 C-159T polymorphism has been associated with increased serum CD14 levels. Our objective was to investigate the hypothesis that the CD14 C-159T allele is protective against recurrent acute otitis media in children. The association between the CD14 promoter genotype and the number of acute otitis media episodes was evaluated both retrospectively and prospectively in a cohort of 300 children. Serotype-specific immunoglobulin G (IgG) antibody responses after pneumococcal vaccinations were examined according to CD14 genotype to compare immune responsiveness across genotypes. An age-dependent association was found: compared with that for CC homozygotes aged between 12 to 24 months, TT homozygotes had fewer episodes of acute otitis media (79 versus 41%, respectively; P = 0.004); this relationship was absent in older children. Additionally, TT homozygotes showed higher serotype-specific anti-pneumococcal IgG antibody levels. Our data suggest that genetic variation in CD14, a molecule at the interface of innate and adaptive immune responses, plays a key role in the defense against middle ear disease in childhood and in pneumococcal vaccine responsiveness. These findings are likely to be important to these and other immune-mediated outcomes in early life.

Advances in understanding the pathogenesis of pneumococcal otitis media

In this review, a state of the art on otitis media research is provided with emphasis on the role of Streptococcus pneumoniae in the pathogenesis of this disease. Articles have been selected by MEDLINE search supplemented with a manual crosscheck of bibliographies. Pathogenic mechanisms in middle ear and eustachian tube are described. Furthermore, pneumococcal characteristics and pneumococcus-host interactions are highlighted as well as the possible role of biofilms in persistence or recurrence of otitis media. Because of the availability of new techniques, an increasing number of pneumococcal features contributing in the pathogenesis of otitis media are identified and in-depth knowledge of pneumococcus-host interactions has been gained. The present advances in research on otitis media open up new perspectives for therapeutic or preventive strategies.

Effect of combined pneumococcal conjugate and polysaccharide vaccination on recurrent otitis media with effusion

BACKGROUND

Otitis media with effusion (OME) is very common during childhood. Because Streptococcus pneumoniae is one of the most common bacterial pathogens involved in OME, pneumococcal vaccines may have a role in the prevention of recurrent OME.

OBJECTIVE

We sought to assess the effect of combined pneumococcal conjugate and polysaccharide vaccinations on the recurrence of OME.

METHODS

A randomized, controlled trial was performed with 161 children, 2 to 8 years of age, with documented persistent bilateral OME. All subjects were treated with tympanostomy tubes (TTs). One half of the subjects were assigned randomly to additional vaccination with a 7-valent pneumococcal conjugate vaccine 3 to 4 weeks before and a 23-valent pneumococcal polysaccharide vaccine 3 months after tube insertion. Blood samples were drawn at the first vaccination, at the time of TT placement, and 1 and 3 months after the second vaccination. Levels of IgA and IgG serum antibody against the 7-valent pneumococcal conjugate vaccine serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F were measured with enzyme-linked immunosorbent assays. All children were monitored for recurrence of OME for 6 months after spontaneous extrusion of the TTs.

RESULTS

The overall recurrence rate of bilateral OME was 50%. Pneumococcal vaccinations induced significant 4.6- to 24.4-fold increases in the geometric means of all conjugate vaccine serotype antibody titers but did not affect recurrence of OME.

CONCLUSIONS

Combined pneumococcal conjugate and polysaccharide vaccination does not prevent recurrence of OME among children 2 to 8 years of age previously known to have persistent OME. Therefore, pneumococcal vaccines are not indicated for the treatment of children suffering from recurrent OME.

Immunological status in the aetiology of recurrent otitis media with effusion: serum immunoglobulin levels, functional mannose-binding lectin and Fc receptor polymorphisms for IgG

The objective was to study the role of serum immunoglobulin levels, mannose-binding lectin (MBL), and Fc gamma receptor (FcgammaR) polymorphisms on the development of recurrent otitis media with effusion (OME). Children aged between two and seven years with persisting OME received bilateral tympanostomy tubes and immunological parameters were investigated in relation with OME recurrence within six months after tube extrusion. No statistically significant differences in serum immunoglobulin levels were present between children with and without OME recurrence. In children with bilateral recurrence (n = 56), median levels of MBL were 1.39 mg/L compared to 2.48 mg/L in children with OME recurrence (n = 17) (p = 0.29). In addition, 34% of the children with bilateral recurrence were homozygous for the genotype FcgammaRIIa-R/R131, whereas less than 20% of the children with unilateral recurrence or those without recurrence were homozygous for this Fcgamma receptor (p = 0.26). Serum mannose-binding lectin and FcgammaRIIa-R/R131 polymorphism may play a role in the aetio-pathogenesis of recurrent OME.

Functional tubal therapy for persistent otitis media with effusion in children: myth or evidence?

Otitis media with effusion (OME), a form of inflammatory middle ear disease, is a common reason for young children to visit their family doctor and to have surgery. Tubal dysfunction plays a major role in the pathogenesis. In case of persistent OME, there seems to be a logical rationale for a favourable effect on the tubal dysfunction of a functional active motoric approach combined with behavioral changes (hygiene), and as a consequence for a therapeutic effect on the middle ear disease. The basic principles of this functional treatment are: active ventilation of the middle ear, correction of immature and undesirable deviant mouth habits, increasing swallowing frequency, activating jaw and palate movements, and encouraging the use of chewing gum. The bases for this functional therapy are critically analysed, and it may be concluded that all of these principles rely upon evidence based physiological mechanisms. However, the limited available clinical data from the literature are reviewed, and appear as methodologically weak. The results of an own prospective randomized pilot study comparing functional treatment with watchful waiting may be considered encouraging, since a borderline significance level was reached with a small amount of subjects.

Birth characteristics and recurrent otitis media with effusion in young children

OBJECTIVE

To study the association between birth characteristics and the recurrence of otitis media with effusion (OME).

METHODS

Prospective cohort study on 136 children aged 2-7 years, who received tympanostomy tubes for bilateral otitis media with effusion. Checkups were planned 1 week after tube insertion and once every 3 months thereafter. An otologist examined the ear status to assess tube extrusion and otitis media with effusion recurrence. Outcome measure was the recurrence of otitis media with effusion within 6 months after documentation of spontaneous tube extrusion. Birth characteristics were investigated in relation with the recurrence of otitis media with effusion in 90 children with known clinical outcome.

RESULTS

No statistically significant associations were found between various birth characteristics and the recurrence of otitis media with effusion. Multivariate analyses showed positive but fairly weak associations between recurrence of otitis media with effusion and low birth weight (<2500 g) and/or low gestational age (<37 weeks) and/or a history of incubator care (odds ratio (OR) 1.95, 95% confidence interval (CI): 0.21-18.2), male sex (OR 1.85, 95% CI: 0.56-6.13) and maternal medication use during pregnancy (OR 4.80, 95% CI: 0.57-40.72). A remarkable finding was the asymmetrical distribution of certain birth characteristics within the group of children with recurrence of otitis media with effusion: children with unilateral recurrence had a relatively lower gestational age, lower birth weight, lower 'birth length to birth weight' ratio than the children with bilateral recurrence.

CONCLUSION

These findings suggest that determination of birth characteristics cannot help us in the treatment strategy for recurrent otitis media with effusion in childhood.

The effect of a pneumococcal conjugate vaccine on the risk of otitis media with effusion at 7 and 24 months of age

OBJECTIVE

To explore the effect of a pneumococcal conjugate vaccine on the risk of otitis media with effusion and to search for subgroups in which the vaccine had a higher or lower effect.

METHODS

Analyses were performed on data from the Finnish Otitis Media Vaccine Trial, a randomised controlled double-blind trial to evaluate the efficacy of pneumococcal conjugate vaccination against acute otitis media. Data on the vaccination effect against otitis media with effusion were obtained by means of symptom interview and pneumatic otoscopy during pre-scheduled follow-up visits at the age of 7 and 24 months. Two endpoint definitions were considered: otitis media/tube (otitis media or tympanostomy tube in situ (OM/T)) as the primary endpoint and otitis media with effusion as the secondary endpoint. No evidence was found of an age-dependent association with vaccination effect. Therefore, the final marginal logistic regression analyses were performed on the combined data from the two follow-up visits.

RESULTS

The risk of otitis media tended to be lower in the pneumococcal vaccine group. The odds ratio for otitis media/tube was 0.94 (95% confidence interval 0.77-1.14) and the odds ratio for otitis media with effusion was 0.90 (95% confidence interval 0.69-1.19). Presence of older siblings increased the risk of otitis media/tube and otitis media with effusion at 7 months of age. In addition, it appeared that children without older siblings and attending day-care at 24 months of age tended to benefit more from the pneumococcal conjugate vaccine. In this subgroup, the odds ratio for otitis media/tube was 0.81 (95% confidence interval 0.55-1.20) and for otitis media with effusion the odds ratio was 0.43 (95% confidence interval 0.22-0.86).

CONCLUSION

The effect of pneumococcal conjugate vaccination on the risk of otitis media with effusion was concordant with the efficacy seen against acute otitis media, although not distinguishable from no effect in the overall analysis. In children without older siblings, vaccination appeared to reduce the point prevalence of otitis media with effusion; this effect was not apparent in children with older siblings.

Left-right differences in Eustachian tube function in children with ventilation tubes

OBJECTIVE

To study the intraindividual variation in Eustachian tube (ET) function in children with ventilation tubes.

METHODS

The forced response test, the pressure equilibration test and the sniff test were performed on both ears of 148 children. The results of both ears were compared.

RESULTS

No systematic differences were found between the left and the right ears. However, the intraindividual variation was very pronounced. The variation in passive ET function within children was of similar magnitude as the variation in passive ET function between children. Twenty-eight percent of the children had different active ET function in both ears and 15% had an opposite result in each ear with respect to the sniff test.

CONCLUSIONS

This study shows that ET function is much more a characteristic of the individual ear than of the individual child. These findings also question the validity of trials on ET function or middle ear disease that use the opposite ear as a control (split level design).

Long-term ventilation tubes: results of 726 insertions

Patients with chronic or recurrent otitis media with effusion who do not respond to treatment with conventional ventilation tubes are often treated with long-term ventilation tubes. The aim of this retrospective study was to determine the extrusion and complication rates of long-term ventilation tubes. The median ventilation time of the tubes was 31.5 months. The most common complication was otorrhoea. One episode of otorrhoea occurred after 24% of all tube insertions, and recurrent otorrhoea occurred in 29%. A persisting perforation developed in 19% after extrusion or removal of the tube. Other, mostly minor, complications occurred in 36% with the tube in situ and in 3% after extrusion or removal of the tube. Long-term ventilation tubes provided prolonged ventilation of the middle ear, but also resulted in a considerable number of complications. For each individual case, one should therefore determine whether the advantages of long-term ventilation tubes outweigh the possible complications in view of the available alternatives for middle ear ventilation.