Management of chronic otitis media with effusion: the role of glutathione

The Role of Oxidants and Antioxidants in Otitis Media with Effusion in Children

OBJECTIVE: Determine the possible role of oxidants and antioxidants in the pathogenesis of otitis media with effusion in children.

STUDY DESIGN AND SETTING: Randomized controlled trial, tertiary referral center. The study group was made up of children with otitis media with effusion who were to undergo bilateral ventilation tube insertion and adenoidectomy. The control group was comprised of otherwise healthy children. The blood levels of antioxidants (retinol, β-carotene, (α-tocopherol, laycopene, ascorbic acid, superoxide dismutase, glutathione peroxidase, GSH) and oxidation products (malondialdehyde) were determined before and 1 month after the operation in the study group and once only in the control group. These substances were also measured in the adenoid tissue and middle ear fluids.

RESULTS: In the study group, the blood levels of antioxidants and oxidants before and after the operation were significantly different when compared with the control group ( P < 0.05). In the study group, the blood antioxidant levels increased and oxidant levels decreased significantly after the operation ( P < 0.05). The levels after the operation never reached those of the control group.

CONCLUSIONS AND SIGNIFICANCE: Oxidants and antioxidants played a significant role in the pathogenesis of otitis media with effusion in children. These children are under significant oxidative stress. Insertion of a ventilation tube and adenoidectomy significantly decreased the oxidative stress in these patients, but could not normalize it completely. Additional studies are necessary in the clinical use of antioxidants in otitis media with effusion.

Advanced oxidation protein product level in children with chronic otitis media with effusion

OBJECTIVE

To determine the level of advanced oxidation protein products (AOPPs) in children with chronic otitis media with effusion (COME), in an effort to elucidate the multifactorial etiology of this disease.

METHODS

This study involved 25 COME patients and 30 healthy children (control group) recruited from the Ear, Nose and Throat (ENT) and Pediatric Departments, respectively, of the Haseki Research and Training Hospital. In the COME group, blood samples were collected before a middle ear operation, and middle ear fluid was sampled during the operation. Blood samples were also obtained from the control subjects. AOPP levels in the plasma and effusion fluid were measured by the spectrophotometric method.

RESULTS

In the COME group, the mean AOPP levels in plasma and effusion fluid were 168.08 μmol/l and 412.75 μmol/l, respectively. In the control group, the mean plasma AOPP level was 141.54 μmol/l. The plasma AOPP levels did not significantly differ between the COME and control groups (p>0.05). In the COME group, however, the effusion fluid AOPP level (412.75 ± 204.54 μmol/l) was significantly higher than the plasma AOPP level (168.08 ± 68.45 μmol/l; p<0.01).

CONCLUSION

We found that AOPP levels were elevated in the effusion fluid, but not in the plasma, of COME patients. Thus, COME was associated with protein oxidation abnormalities. Oxidative stress may play a role in the etiopathogenesis of COME, and AOPPs may be used as markers of oxidative stress; however, further studies are required to confirm these findings.

The treatment of pulmonary diseases and respiratory-related conditions with inhaled (nebulized or aerosolized) glutathione

Reduced glutathione or simply glutathione (γ-glutamylcysteinylglycine; GSH) is found in the cytosol of most cells of the body. GSH in the epithelial lining fluid (ELF) of the lower respiratory tract is thought to be the first line of defense against oxidative stress. Inhalation (nebulized or aerosolized) is the only known method that increases GSH's levels in the ELF. A review of the literature was conducted to examine the clinical effectiveness of inhaled GSH as a treatment for various pulmonary diseases and respiratory-related conditions. This report also discusses clinical and theoretical indications for GSH inhalation, potential concerns with this treatment, its presumed mechanisms of action, optimal doses to be administered and other important details. Reasons for inhaled GSH's effectiveness include its role as a potent antioxidant, and possibly improved oxygenation and host defenses. Theoretical uses of this treatment include Farmer's lung, pre- and postexercise, multiple chemical sensitivity disorder and cigarette smoking. GSH inhalation should not be used as a treatment for primary lung cancer. Testing for sulfites in the urine is recommended prior to GSH inhalation. Minor side effects such as transient coughing and an unpleasant odor are common with this treatment. Major side effects such as bronchoconstriction have only occurred among asthma patients presumed to be sulfite-sensitive. The potential applications of inhaled GSH are numerous when one considers just how many pulmonary diseases and respiratory-related conditions are affected by deficient antioxidant status or an over production of oxidants, poor oxygenation and/or impaired host defenses. More studies are clearly warranted.

A review of the mechanism of injury and treatment approaches for illness resulting from exposure to water-damaged buildings, mold, and mycotoxins

Physicians are increasingly being asked to diagnose and treat people made ill by exposure to water-damaged environments, mold, and mycotoxins. In addition to avoidance of further exposure to these environments and to items contaminated by these environments, a number of approaches have been used to help persons affected by exposure to restore their health. Illness results from a combination of factors present in water-damaged indoor environments including, mold spores and hyphal fragments, mycotoxins, bacteria, bacterial endotoxins, and cell wall components as well as other factors. Mechanisms of illness include inflammation, oxidative stress, toxicity, infection, allergy, and irritant effects of exposure. This paper reviews the scientific literature as it relates to commonly used treatments such as glutathione, antioxidants, antifungals, and sequestering agents such as Cholestyramine, charcoal, clay and chlorella, antioxidants, probiotics, and induced sweating.

Safety survey of intranasal glutathione

PURPOSE

Glutathione depletion has been documented in several disease states, and exogenous administration has been hypothesized to have therapeutic potential for some conditions. In an effort to reach target tissues of the sinuses and central nervous system (CNS), glutathione is being prescribed as an intranasal spray, although no literature exists to support this mode of administration. The objective of this study was to describe patient-reported outcomes in a population of individuals who have been prescribed intranasal reduced glutathione, (in)GSH.

METHODS

A survey was designed to assess individuals' perception of tolerability, adverse events, and health benefits associated with (in)GSH use. Using a pharmacy database, 300 individuals were randomly selected to receive a survey; any individual who had received one or more prescriptions for (in)GSH between March 2009 and March 2011 was eligible for participation.

RESULTS

Seventy (70) individuals returned the survey (23.3% response rate) from 20 different states. Reported indications for (in)GSH prescriptions were multiple chemical sensitivity (MCS) (n=29), allergies/sinusitis (n=25), Parkinson disease (PD) (n=7), Lyme disease (n=3), fatigue (n=2), and other (n=10). Of the respondents, 78.8% (n=52) reported an overall positive experience with (in)GSH, 12.1% (n=8) reported having experienced adverse effects, and 62.1% (n=41) reported having experienced health benefits attributable to (in)GSH use. Over 86% of respondents considered the nasal spray to be comfortable and easy to administer.

CONCLUSIONS

This is the first study to evaluate patient-reported outcomes among individuals across the country who have been prescribed (in)GSH. The majority of survey respondents considered (in)GSH to be effective and without significant adverse effects. (in)GSH should be further evaluated as a method of treating respiratory and CNS diseases where free-radical burden is a suspected contributor to disease progression.

Glutathione redox control of asthma: from molecular mechanisms to therapeutic opportunities

Asthma is a chronic inflammatory disorder of the airways associated with airway hyper-responsiveness and airflow limitation in response to specific triggers. Whereas inflammation is important for tissue regeneration and wound healing, the profound and sustained inflammatory response associated with asthma may result in airway remodeling that involves smooth muscle hypertrophy, epithelial goblet-cell hyperplasia, and permanent deposition of airway extracellular matrix proteins. Although the specific mechanisms responsible for asthma are still being unraveled, free radicals such as reactive oxygen species and reactive nitrogen species are important mediators of airway tissue damage that are increased in subjects with asthma. There is also a growing body of literature implicating disturbances in oxidation/reduction (redox) reactions and impaired antioxidant defenses as a risk factor for asthma development and asthma severity. Ultimately, these redox-related perturbations result in a vicious cycle of airway inflammation and injury that is not always amenable to current asthma therapy, particularly in cases of severe asthma. This review will discuss disruptions of redox signaling and control in asthma with a focus on the thiol, glutathione, and reduced (thiol) form (GSH). First, GSH synthesis, GSH distribution, and GSH function and homeostasis are discussed. We then review the literature related to GSH redox balance in health and asthma, with an emphasis on human studies. Finally, therapeutic opportunities to restore the GSH redox balance in subjects with asthma are discussed.

Oxidative stress in chronic otitis media with effusion

CONCLUSIONS

The high oxidant levels in chronic otitis media with effusion (OME) observed in our research and the improvement seen in children with chronic OME after antioxidant treatment suggest that oxygen-derived free radicals play an important role in chronic OME.

OBJECTIVES

OME is a common pathologic condition characterized by nonpurulent fluid in the middle ear (ME) that leads to moderate conductive hearing loss and flat tympanogram. During OME inflammatory cells generate large amounts of superoxide radicals to improve bactericidal activity. Overproduction of oxygen-derived free radicals induces oxidative damage in humans. Glutathione (GSH) is one of the major components of the antioxidant system that protects cells from oxidative stress. The aim of the study was to evaluate oxidative stress in chronic OME by investigation of ME fluids collected during myringotomy.

METHODS

During myringotomy, fluid was collected from the ME to evaluate lipid peroxide levels in the effusion. Fifty-nine children with ME effusion without any resolution after repeated medical treatments were enrolled in the study.

RESULTS

Lipid peroxide levels in all samples were high (mean 11.5 nmole/million cells), similar to the values found in other chronic diseases. GSH might be employed during surgery while applying ventilation tubes and after surgery to prevent oxidative stress.

Do mucosal folds in the eustachian tube function as microturbinates?

OBJECTIVES/HYPOTHESIS

Mucosal folds in the eustachian tube (ET) may function as microturbinates and provide protection and clearance.

STUDY DESIGN

Descriptive study.

METHODS

Nineteen whole-mount temporal bone ET specimens (nine pediatric and 10 adult) were evaluated in the present study. Five specific localizations for each case were selected. The cartilaginous segment of the ET was divided vertically and the length of mucosal surfaces and the number of mucosal folds of anterior and posterior walls on the histological sections were analyzed with MetaMorph 7.5.2.0 software.

RESULTS

The length of the mucosal surface of the posterior wall of the ET was longer than the anterior wall (P < .05). In pediatric specimens, the posterior wall had more mucosal folds than adult specimens (P < .05).

CONCLUSIONS

Microturbinates in the posterior wall of the ET may provide important protection and clearance functions for children and play a role in the pathogenesis of eustachian tube dysfunction

Lymphocyte subpopulations in middle ear effusions: flow cytometry analysis

OBJECTIVE

The aim of this study was to identify lymphocyte subpopulations in middle ear effusions, peripheral blood, and adenoids in children suffering from otitis media with effusion.

SETTING

Tertiary referral center.

PATIENTS

Thirty-three children (55 ears) undergoing myringotomy for otitis media with effusion.

METHODS

CD3, CD4, CD8, CD19, and natural killer cell populations were investigated in middle ear effusion, peripheral blood, and adenoids using a three-color monoclonal antibody and flow cytometry method for quantitative estimation.

RESULTS

T cells (CD3) are dominating lymphocytes in middle ear effusion. Among T lymphocytes, the majority are those of the helper type (CD4). The dominating isoform among CD4 lymphocytes are memory cells (CD4CD45RO); among CD8 lymphocytes, naive cells (CD8CD45RA). The percentage of CD4 cells, CD8 cells, and the CD4/CD8 ratio was significantly higher in middle ear effusions than in blood. The percentage of memory CD4 lymphocytes and naive CD8 lymphocytes was significantly lower in the middle ear effusion. Lymphocyte subsets were compared between 22 pairs of effusions from each patient. The percentage of each type of cell did not differ significantly.

CONCLUSION

The results of this study indicate local regulation of the lymphocyte profile in middle ear effusions and the same phase of immune response in two ears of the same patient.

Squamous cell metaplasia of the nasopharyngeal epithelium and its association with adult-onset otitis media with effusion

CONCLUSION

The common association between adult-onset otitis media with effusion (AO-OME) and squamous cell metaplasia (SCM) of the epithelium of Rosenmüller's fossa, which is near the Eustachian tube orifice, implies the predictive role of metaplasia, which probably compromises the drainage function of the middle ear.

OBJECTIVE

To determine the effects of nasopharyngeal epithelial changes (SCM) on AO-OME. AO-OME is a multifactorial and insidious disease that may necessitate detailed investigation, i.e. biopsy of the nasopharynx, because of possible underlying nasopharyngeal malignancy.

MATERIAL AND METHODS

Fifty-two patients with AO-OME (study group) and 29 with a unilateral neck mass in the posterior triangle without AO-OME (control group) were enrolled. Nasopharyngeal biopsies taken from all subjects were evaluated with regard to surface epithelial changes of the nasopharynx.

RESULTS

Nasopharyngeal biopsies revealed SCM in 34/52 patients (65%) in the study group and 9/29 (31%) in the control group (p<0.05). During the follow-up period, recurrence of effusion occurred in 56% of the group with SCM and 22% of the group without it.

Oxidant and antioxidant levels in children with acute otitis media and tonsillitis: a comparative study

OBJECTIVE

Recurrent episodes of acute otitis media (AOM) and acute tonsillitis (AT) are a common problem in infectious disorders during childhood and are major cause of morbidity in children. The organism maintains defense systems including nonenzymatic antioxidants such as Vitamins A, E and C and reduced glutathione (GSH) against reactive oxygen species (ROS). In the present study, lipid peroxidation status and nonenzymatic antioxidant capacity were investigated in children with AOM and AT. Our aim was to compare the lipid peroxidation and responses of the body's antioxidant status in the closely associated infections such as AOM and acute tonsillitis.

METHODS

The study included 23 (14 males, 9 females) children with AOM, 27 (14 males, 13 females) with AT and 29 (16 males, 13 females) healthy control subjects. The ages of the study and control subjects were between 2 and 7 years. Serum beta-carotene, retinol, Vitamin E, Vitamin C, and whole blood malondialdehyde (MDA) (as an indicator of lipid peroxidation) and GSH levels were studied in all subjects.

RESULTS

There was a statistically significant difference between the groups for all parameters (P<0.05). All of the antioxidant vitamins such as beta-carotene, retinol, Vitamin E, and Vitamin C levels were observed to be significantly decreased in the both patient groups. Nevertheless, GSH levels were also decreased in the patient groups. MDA levels were found to be higher in children with AOM and AT than in the healthy control subjects. When compared the AOM and AT groups, there was statistically significant difference between the groups for whole blood MDA (P<0.05).

CONCLUSION

Even though they seem to react in a similar way against ROS, in the cases of AOM and AT, it is possible to see the different approaches in these tissues for the oxidative stress.

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.

Practicalities of glutathione supplementation in nutritional support

New nutraceutical products for nutritional support and antioxidant therapy such as glutathione require practical advice and information on the indications, methods and routes of administration, dosing (therapeutic drug monitoring), stability and physicochemical compatibility. This review is based on recent clinical and experimental publications in which glutathione has been used as a drug.