Quantitative Experimental Assessment of the Factors Contributing to Hearing Loss in Serous Otitis Media

Association of Pepsin With Inflammatory Signaling and Effusion Viscosity in Pediatric Otitis Media

OBJECTIVE

Otitis media (OM) is a common inflammatory disease spectrum. Cytokine signaling, neutrophil activity, and mucin hypersecretion during recurrent and chronic OM contribute to persistent, viscous middle ear (ME) effusions, hearing loss, and potential for developmental delay. Extraesophageal reflux (EER), specifically pepsin, triggers inflammatory signaling in respiratory mucosa and is associated with OM. The objective of this study was to investigate the association of pepsin with ME inflammatory signaling and the outcomes and examine causality in vitro.

STUDY DESIGN

Cross-sectional study.

METHODS

ME fluid (MEF) and preoperative audiometric data were collected from 30 pediatric subjects undergoing tympanostomy tube placement for recurrent OM or OM with effusion. MEF viscosity was characterized by the surgeon. Pepsin, inflammatory molecules, and mucin were assayed by enzyme-linked immunosorbent assay (ELISA). ME epithelial primary culture was exposed to 0.1 to 1 mg/ml pepsin at pH 5, 6, and 7 for 30 minutes, and cytokine expression was assayed via qPCR.

RESULTS

Pepsin was observed in the MEF of 77% of patients (range 71-2,734 ng/ml). Pepsin correlated with effusion viscosity, interleukins -6 and -8, neutrophil elastase, and mucin 5B (P < .05). Pepsin-negative MEF was more frequently absent of interleukin 8 or mucin 5B (P < .05). Weak acid was generally insufficient to elicit cytokine expression in ME cells in vitro, however, pepsin induced IL6, IL8, and TNF at pH 7 (P < .05) and weak acid (pH 6) facilitated a response at lower pepsin concentration.

CONCLUSIONS

Pepsin may contribute to inflammatory signaling, persistent viscous effusion, and poorer OM outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Mechanical damage of tympanic membrane in relation to impulse pressure waveform - A study in chinchillas

Mechanical damage to middle ear components in blast exposure directly causes hearing loss, and the rupture of the tympanic membrane (TM) is the most frequent injury of the ear. However, it is unclear how the severity of injury graded by different patterns of TM rupture is related to the overpressure waveforms induced by blast waves. In the present study, the relationship between the TM rupture threshold and the impulse or overpressure waveform has been investigated in chinchillas. Two groups of animals were exposed to blast overpressure simulated in our lab under two conditions: open field and shielded with a stainless steel cup covering the animal head. Auditory brainstem response (ABR) and wideband tympanometry were measured before and after exposure to check the hearing threshold and middle ear function. Results show that waveforms recorded in the shielded case were different from those in the open field and the TM rupture threshold in the shielded case was lower than that in the open field (3.4 ± 0.7 vs. 9.1 ± 1.7 psi or 181 ± 1.6 vs. 190 ± 1.9 dB SPL). The impulse pressure energy spectra analysis of waveforms demonstrates that the shielded waveforms include greater energy at high frequencies than that of the open field waves. Finally, a 3D finite element (FE) model of the chinchilla ear was used to compute the distributions of stress in the TM and the TM displacement with impulse pressure waves. The FE model-derived change of stress in response to pressure loading in the shielded case was substantially faster than that in the open case. This finding provides the biomechanical mechanisms for blast induced TM damage in relation to overpressure waveforms. The TM rupture threshold difference between the open and shielded cases suggests that an acoustic role of helmets may exist, intensifying ear injury during blast exposure.

Conductive hearing loss induced by experimental middle-ear effusion in a chinchilla model reveals impaired tympanic membrane-coupled ossicular chain movement

Otitis media with effusion (OME) occurs when fluid collects in the middle-ear space behind the tympanic membrane (TM). As a result of this effusion, sounds can become attenuated by as much as 30-40 dB, causing a conductive hearing loss (CHL). However, the exact mechanical cause of the hearing loss remains unclear. Possible causes can include altered compliance of the TM, inefficient movement of the ossicular chain, decreased compliance of the oval window-stapes footplate complex, or altered input to the oval and round window due to conduction of sound energy through middle-ear fluid. Here, we studied the contribution of TM motion and umbo velocity to a CHL caused by middle-ear effusion. Using the chinchilla as an animal model, umbo velocity (V U) and cochlear microphonic (CM) responses were measured simultaneously using sinusoidal tone pip stimuli (125 Hz-12 kHz) before and after filling the middle ear with different volumes (0.5-2.0 mL) of silicone oil (viscosity, 3.5 Poise). Concurrent increases in CM thresholds and decreases in umbo velocity were noted after the middle ear was filled with 1.0 mL or more of fluid. Across animals, completely filling the middle ear with fluid caused 20-40-dB increases in CM thresholds and 15-35-dB attenuations in umbo velocity. Clinic-standard 226-Hz tympanometry was insensitive to fluid-associated changes in CM thresholds until virtually the entire middle-ear cavity had been filled (approximately >1.5 mL). The changes in umbo velocity, CM thresholds, and tympanometry due to experimentally induced OME suggest CHL arises primarily as a result of impaired TM mobility and TM-coupled umbo motion plus additional mechanisms within the middle ear.

Mechanisms of tympanic membrane and incus mobility loss in acute otitis media model of guinea pig

Acute otitis media (AOM) is a rapid infection of middle ear due to bacterial or viral invasion. The infection commonly leads to negative pressure and purulent effusion in the middle ear. To identify how these changes affect tympanic membrane (TM) mobility or sound transmission through the middle ear, we hypothesize that pressure, effusion, and structural changes of the middle ear are the main mechanisms of conductive hearing loss in AOM. To test the hypothesis, a guinea pig AOM model was created by injection of Streptococcus pneumoniae. Three days post inoculation, vibration of the TM at umbo in response to input sound in the ear canal was measured at three experimental stages: intact, pressure-released, and effusion-drained AOM ears. The vibration of the incus tip was also measured after the effusion was removed. Results demonstrate that displacement of the TM increased mainly at low frequencies when pressure was released. As the effusion was removed, the TM mobility increased further but did not reach the level of the normal ear at low frequencies. This was caused by middle ear structural changes or adhesions on ossicles in AOM. The structural changes also affected movement of the incus at low and high frequencies. The results provide new evidence for understanding the mechanism of conductive hearing loss in AOM.

The conductive hearing loss due to an experimentally induced middle ear effusion alters the interaural level and time difference cues to sound location

Otitis media with effusion (OME) is a pathologic condition of the middle ear that leads to a mild to moderate conductive hearing loss as a result of fluid in the middle ear. Recurring OME in children during the first few years of life has been shown to be associated with poor detection and recognition of sounds in noisy environments, hypothesized to result due to altered sound localization cues. To explore this hypothesis, we simulated a middle ear effusion by filling the middle ear space of chinchillas with different viscosities and volumes of silicone oil to simulate varying degrees of OME. While the effects of middle ear effusions on the interaural level difference (ILD) cue to location are known, little is known about whether and how middle ear effusions affect interaural time differences (ITDs). Cochlear microphonic amplitudes and phases were measured in response to sounds delivered from several locations in azimuth before and after filling the middle ear with fluid. Significant attenuations (20-40 dB) of sound were observed when the middle ear was filled with at least 1.0 ml of fluid with a viscosity of 3.5 Poise (P) or greater. As expected, ILDs were altered by ~30 dB. Additionally, ITDs were shifted by ~600 μs for low frequency stimuli (<4 kHz) due to a delay in the transmission of sound to the inner ear. The data show that in an experimental model of OME, ILDs and ITDs are shifted in the spatial direction of the ear without the experimental effusion.

Effect of middle ear effusion on the brain-stem auditory evoked response of Cavalier King Charles Spaniels

Brain-stem auditory evoked responses (BAER) were assessed in 23 Cavalier King Charles Spaniels with and without middle ear effusion at sound intensities ranging from 10 to 100 dB nHL. Significant differences were found between the median BAER threshold for ears where effusions were present (60 dB nHL), compared to those without (30 dB nHL) (P=0.001). The slopes of latency-intensity functions from both groups did not differ, but the y-axis intercept when the x value was zero was greater in dogs with effusions (P=0.009), consistent with conductive hearing loss. Analysis of latency-intensity functions suggested the degree of hearing loss due to middle ear effusion was 21 dB (95% confidence between 10 and 33 dB). Waves I-V inter-wave latency at 90 dB nHL was not significantly different between the two groups. These findings demonstrate that middle ear effusion is associated with a conductive hearing loss of 10-33 dB in affected dogs despite the fact that all animals studied were considered to have normal hearing by their owners.

Association of otoscopic findings and hearing level in pediatric patients with otitis media with effusion

OBJECTIVE

To find the association between the abnormalities of tympanic membrane characteristics and the hearing level in pediatric patients with otitis media with effusion.

METHODS

Sixty-three pediatric patients with otitis media with effusion had undergone ear examinations by pneumatic otoscopy to assess the color, transparency, mobility, fluid level and retraction of the tympanic membrane. An audiogram was done in the same setting, average hearing threshold and air-bone gap were measured. Otoscopic findings and the result of the hearing test were analyzed to identify the association between the abnormalities of the tympanic membrane characteristics and elevated hearing threshold.

RESULTS

Hearing loss was found in 92.1% of the patients. Mean hearing level was 31.7+/-10.3 dB. From linear regression analysis, the patients with dull or opaque tympanic membrane had a significantly higher hearing threshold of 7.2 dB than the patient with translucent ear drum after adjusting for mobility and retraction. The patients with tympanic membrane retraction had a higher hearing threshold of 5.1 dB than the patient who had no retraction after adjusting for transparency and mobility. Mobility had a significant relationship to elevated hearing threshold in the univariate analysis but not in multivariable analysis.

CONCLUSION

Opacity and retraction were the two characteristics of abnormal tympanic membrane that were associated with elevated hearing threshold in the patients with otitis media with effusion. Hearing test is suggested if opacity or retraction of the tympanic membrane is found.

The Effects of Positive and Negative Middle Ear Pressures on Auditory Threshold

HYPOTHESIS

To assess the effects of positive and negative middle ear pressures on auditory threshold.

BACKGROUND

Nonatmospheric middle ear pressures can alter auditory threshold by their effects on tympanic membrane and ossicular chain mobility.

METHODS

Experiments were conducted on guinea pigs by inducing alterations in pressure (positive and negative) with a syringe connected to the middle ear bulla cavity, the magnitude of the pressure being assessed with a water manometer. Elevated middle ear fluid pressures were also induced by attaching a saline-filled vertical tube to the saline-filled middle ear. The effect of these altered middle ear air and fluid pressures were assessed by recording auditory nerve-brainstem evoked responses.

RESULTS

There was no effect on auditory threshold of positive middle ear air pressures (up to 250 mm H2O). A negative middle ear air pressure of -50 mm H2O induced a significant 9.5-dB threshold elevation, whereas more negative pressures (up to -150 mm H2O) did not induce an additional threshold elevation. Filling the middle ear cavity with saline induced a 10- to 16-dB elevation, whereas additional fluid pressures (up to 200 mm H2O) did not induce further elevations.

CONCLUSION

The major factor inducing threshold elevation in serious otitis media is not the alteration in middle ear pressure but rather the reduction in the volume of compressible air in the middle ear by the fluid.