Intractable otitis media with eosinophils: Importance of diagnosis and validity of treatment for hearing preservation

[Clinical observation of the course of eosinophilic otitis media against the background of biological therapy of chronic polypous rhinosinusitis]

RESUME

Eosinophilic otitis media (EoOM) is a variant of exudative otitis media characterized by a persistent persistent course, the presence of a very viscous effusion in the tympanic cavity, comorbidally associated with chronic polypous rhinosinusitis and bronchial asthma. The disease is characterized by a persistent progressive course, which can lead to a gradual decrease in hearing up to complete deafness. Conservative treatment methods for EoOM include local and systemic administration of glucocorticosteroids. Encouraging data on the effectiveness of biological therapy have appeared in recent publications. The above clinical observation examines the course of EoOM in a patient who received biological therapy with dupilamab.

IgG4 Expression in Patients with Eosinophilic Otitis Media

OBJECTIVE

Eosinophilic otitis media (EOM) is an intractable middle ear disease recognized by an eosinophil enriched middle ear effusion and mucosa. Although precise pathogenesis of EOM remains unclear, it is characterized by type 2 inflammation. Since IgG4 is an IgG subclass induced by type 2 cytokines such as IL-4 and IL-13, we sought to characterize and compare local IgG4 expression in patients with and without EOM.

METHODS

Twelve patients with bilateral profound hearing loss, 9 of which underwent a cochlear implant surgery, were enrolled in this study (6 with EOM and 6 without EOM). The surgical specimens were harvested during surgery and were subjected to IgG4 immunostaining.

RESULT

The middle ear mucosa showed the presence of a large number of IgG4-positive cells in patients with EOM, which was significantly higher than that in patients without EOM.

CONCLUSION

Local IgG4 expression was observed in patients with EOM in comparison to those without EOM, suggesting that IgG4 contributes to EOM pathogenesis.

The expression of thymic stromal lymphopoietin in patients and animal models with eosinophilic otitis media

OBJECTIVE

In the present study, we aimed to clarify the expression of thymic stromal lymphopoietin (TSLP), a key trigger of Th2-type allergic disease, in the middle ear mucosa of eosinophilic otitis media (EOM).

METHODS

An immunohistological study of TSLP was conducted in patients with EOM and in animal models of EOM constructed by intraperitoneal and intratympanic injection of ovalbumin for 7 and 14 days. In addition, the messenger RNA (mRNA) expression of TSLP in the middle ear mucosa of the animal models was analyzed using real-time PCR, and was compared with that of the control animals.

RESULTS

Immunoreactivities for TSLP were observed in the middle ear mucosa around the tympanic ostium of the eustachian tube of patients with EOM. In the animal model, strong immunoreactivity for TSLP was also observed in the eustachian tube epithelium, and mRNA expression of TSLP in the seven-day stimulated animals was significantly higher than that in the controls.

CONCLUSION

The present study indicates that the presence of epithelium-derived TSLP in the eustachian tubes plays an important role in the onset of EOM.

Otitis media with effusion and atopy: is there a causal relationship?

Otitis Media with Effusion (OME) is an inflammatory condition of the middle ear cleft, acute or chronic, with collection of fluid in the middle ear with an intact tympanic membrane. It is a very common disease in childhood, the most frequent cause of hearing loss in childhood and often requiring surgery. OME is called chronic when the fluid in the middle ear persists for more than three months or when the episodes recur six or more times in one year. The current article covers various aspects of OME including definition, epidemiology. Pathomechanisms, risk factors, role of allergy in OME, impact of upper airway disease on OME, eosinophilic otitis media and management of OME.

Eosinophilic Otitis Media: the Aftermath of Eosinophil Extracellular Trap Cell Death

PURPOSE OF REVIEW

Eosinophilic otitis media (EOM) is a refractory disease characterized by the accumulation of eosinophils in middle ear effusion and mucosa. We summarize current knowledge regarding the clinical characteristics and management of EOM. Although eosinophil activation in inflamed foci is involved in the pathogenesis of EOM, little is known about the fate of the eosinophils and aftermath of their cell death. We discuss the possibility that eosinophils undergo non-apoptotic cell death that worsens tissue damage and increases effusion viscosity.

RECENT FINDINGS

Unlike chronic otitis media, EOM is strongly associated with an allergic background. Corticosteroids are currently the only effective pharmacological treatment, and surgical intervention is often required. Mucosal eosinophils infiltrate extensively into the middle ear cavity where they are stimulated by locally produced activators including interleukin-5 and eotaxin. The eosinophils undergo cytolysis in the effusion, which represents a major fate of activated eosinophils in vivo. Recent data revealed cytolysis could be renamed as extracellular trap cell death (ETosis). ETosis represents suicidal cell death involving total cell degranulation and development of sticky chromatin structures (extracellular traps (ETs)). The characteristics of eosinophil- and neutrophil-derived ET polymers might contribute to the difference in viscosity of secretions between EOM and common chronic otitis media. The extracellular products remaining after eosinophil ETosis are an important aspect of EOM pathology. The concept of ETosis also has novel implications for potential therapeutic modalities in various eosinophilic disorders.

Immunohistological analysis of eotaxin and RANTES in the model animal of eosinophilic otitis media

BACKGROUND

The most crucial clinical problem of Eosinophilic Otitis Media (EOM) is sensorineural hearing loss. A previous report revealed that repeated antigen stimulation of middle ear causes eosinophilic inflammation not only in the middle ear but also in the inner ear.

OBJECTIVE

The purpose of the present study was to elucidate the mechanism of eosinophil infiltration to the inner ear in the animal model of EOM.

METHODS

Continuous OVA stimulation to the middle ear of guinea pigs was performed for 7 days, 14 days, and 28 days. Histological observation was made for eosinophil infiltration and morphological change of the inner ear. Immunostaining for eotaxin and RANTES was performed to study immunoreactivity of those chemokines.

RESULTS

In the 7-day stimulation side, a few eosinophils were found in the scala tympani, without obvious morphological damage of the inner ear. Moreover, immunoreactivity of both eotaxin and RANTES was significantly higher in the OVA stimulation sides than control sides. For both eotaxin and RANTES, the number of immunopositive cells was significantly increased in the 14-day stimulation side over the 7-day stimulation side.

CONCLUSIONS

Eotaxin and RANTES seem to play some important roles for the eosinophil infiltration in the middle and inner ear of model animal of EOM.

New Insights into Eosinophilic Otitis Media

Eosinophilic otitis media (EOM) is a type of intractable otitis media that occurs mainly in patients with bronchial asthma (BA). In 2011, the diagnostic criteria for EOM were established. EOM is characterized by the presence of a highly viscous yellowish effusion containing eosinophils and immunoglobulin E (IgE), eosinophil chemoattractants, such as eosinophil cationic protein, interleukin-5, and eotaxin. Local sensitization against foreign agents such as fungi or bacteria (e.g., Staphylococcus aureus) may result in local IgE production in the middle ear and may be responsible for the severity of EOM. The clinical features of EOM closely resemble localized eosinophilic granulomatosis polyangiitis, therefore it is necessary to be vigilant to the symptoms of mononeuritis, polyneuritis, and skin purpura during diagnosis. Standard treatment for EOM is the instillation of triamcinolone acetonide into the mesotympanum. However, severe cases exhibiting strong inflammation and otorrhea are not easily controlled with antibiotics and/or corticosteroids. We proposed the introduction of a severity score to evaluate the severity of EOM. This score correlated with local IgE levels in middle ear effusion. Clinically, the risk factors associated with this severity score were body mass index, and the duration of bronchial asthma (from the onset of BA to the age of the first consultation of otitis media to our hospital). We emphasize that early diagnosis and adequate treatment are vital in preventing progressive and sudden hearing loss resulting from EOM.

Thrombophlebitis of the head and neck caused by eosinophilic otitis media

OBJECTIVE

To describe the clinical course and treatment of a patient presenting with thrombophlebitis of the head and the neck with eosinophilic otitis media (EOM).

PATIENT

The patient was a 32-year-old woman with bronchial asthma and chronic sinusitis. She was treated for EOM, which presented as intractable otitis media with viscous effusion. Subsequently, she experienced sudden onset of nausea and headache. No signs of improvement were observed after the intravenous administration of several antibiotics. Magnetic resonance imaging (MRI) revealed right thrombophlebitis extending from the sigmoid sinus to the jugular vein.

INTERVENTIONS

Systemic administration of adrenocortical steroid hormone after intravenous antibiotic therapy.

MAIN OUTCOME MEASURES

Radiologic features and patient symptoms.

RESULTS

Intravenous antibiotic therapy was ineffective, but the patient's symptoms were relieved less than 1 day after the initiation of prednisolone treatment (30 mg/d for 5 d). MRI performed 3 days after treatment revealed that thrombophlebitis of the head and neck had disappeared.

CONCLUSION

Adrenocortical steroid hormone therapy may be an effective treatment for thrombophlebitis with EOM. Chemoattractants activated by EOM might be associated with the pathogenesis of thrombophlebitis of the head and neck.

An experimental study of inner ear injury in an animal model of eosinophilic otitis media

Conclusion:

As the periods of intratympanic injection of ovalbumin (OVA) to the middle ear became longer, marked eosinophil infiltration in the perilymphatic space was observed. Moreover severe morphological damage of the organ of Corti was observed in the 28-day antigen-stimulation side. These results indicate that eosinophilic inflammation occurred in the inner ear and caused profound hearing loss.

Objective:

The purpose of the present study was to elucidate the inner ear damage in a new animal model of eosinophilic otitis media (EOM) which we recently constructed.

Methods:

We constructed the animal model of EOM by intraperitoneal and intratympanic injection of OVA. Infiltrating cells and the inner ear damage were examined by histological study.

Results:

In the inner ear, a few eosinophils were seen in the scala tympani of the organ of Corti and the dilation of capillaries of the stria vascularis was observed in the 7-day stimulation side. In the 14-day antigen stimulation side, some eosinophils and macrophages were seen in not only the scala tympani but also the scala vestibule. In the 28-day antigen-stimulation side, severe morphological damage of the organ of Corti and many eosinophils, red blood cells, and plasma cells infiltrating the perilymph were observed.

The role of periostin in eosinophilic otitis media

CONCLUSION

We investigated the localization of periostin in middle ear specimens from patients with eosinophilic otitis media (EOM) and from a newly constructed animal model for EOM. Periostin-positive immunostaining was observed in the middle ear sections obtained from the EOM patients. Immunoreactivity for periostin was also seen in the animal model. These results suggest that periostin plays an important role in subepithelial fibrosis in the middle ear in EOM.

OBJECTIVE

The purpose of the present study was to investigate the role of periostin in the middle ear of EOM patients and an animal model.

METHODS

Histological and immunohistochemical analyses for periostin were carried out in the middle ear specimens of six EOM patients with/without asthma. An animal model of EOM was constructed by intraperitoneal and topical sensitization with ovalbumin (OVA). Histological and immunocytochemical analyses for periostin were also performed in this model.

RESULTS

Immunoreactivities for periostin were observed in the basement membrane and extracellular matrix of the middle ear sections obtained from all EOM patients with/without asthma. In the animal model, eosinophil infiltration and middle ear mucosa thickness were observed. Moreover, periostin-positive immunostaining was shown in the extracellular matrix of the middle ear mucosa on the side topically boosted by OVA.

Is there an association between otitis media and nasal polyposis?

The association between otitis media with effusion (OME) and nasal polyposis (NP) is poorly described. However, two different approaches to this problem seem to come from the few studies concerning both otitis media and NP in the literature. One study was based on the assessment of a population of patients presenting with NP, with the authors interested in patients among the studied population who complained of ear-related symptoms and developed OME (rhinologic approach). Other studies were based on the assessment of a population of patients developing a particular OME, with the authors interested in characterizing this condition they named eosinophilic otitis media (otologic approach). The article reviews currents concepts in the relationship between OME and NP. It appears that regardless of the approach to the problem of interest (rhinologic or otologic approach), OME and NP seem to be closely related. Moreover, some striking similarities can be noted between the different entities described in the different studies reviewed, and all authors seem to agree that the middle ear has a central role in the concept of united airways inflammatory disease. Otologists and rhinologists should work together on a single approach that allows for better management of inflammatory disease leading to the formation of polyps, development of concurrent asthma, appearance of aspirin intolerance, and finally involvement of the middle ear.

Diagnostic criteria of eosinophilic otitis media, a newly recognized middle ear disease

OBJECTIVE

Eosinophilic otitis media (EOM) is a newly recognized intractable middle ear disease, characterised by the accumulation of eosinophils in middle ear effusion and middle ear mucosa. Since EOM patients show gradual or sudden deterioration of hearing, it is important to properly diagnose EOM and to start adequate treatment for EOM. We aimed to investigate the clinical risk factors of EOM and to establish the diagnostic criteria of EOM.

PATIENTS AND METHODS

We reviewed 138 patients with EOM and 134 age-matched patients with the common type of otitis media with effusion or chronic otitis media as controls. We analyzed the incidence of the following clinical variables in both groups: bilaterality of otitis media, viscosity of middle ear effusion, formation of granulation tissue in the middle ear, response to the treatment for otitis media, deterioration of bone conduction hearing level, and association with other diseases such as bronchial asthma, chronic rhinosinusitis, nasal polyposis, and allergic rhinitis.

RESULTS

A high odds ratio was obtained from an association with bronchial asthma (584.5), resistance to conventional treatment for otitis media (232.2), viscous middle ear effusion (201.6), association with nasal polyposis (42.17), association with chronic rhinosinusitis (26.49), bilaterality (12.93), and granulation tissue formation (12.62). The percentage of patients with EOM who were positive for two or more among the highest four items was 98.55%.

CONCLUSION

A patient who shows otitis media with effusion or chronic otitis media with eosinophil-dominant effusion (major criterion) and with two or more among the highest four items (minor criteria), can be diagnosed as having EOM. Patients with ear symptoms should have the proper diagnosis of EOM using the proposed diagnostic criteria, and then can receive adequate treatment, resulting in prevention of deterioration of hearing and quality of life.

Role of IgE in eosinophilic otitis media

Eosinophilic otitis media (EOM) is an intractable otitis media characterized by the presence of a highly viscous yellow effusion containing eosinophils. It mainly occurs in patients with bronchial asthma and is resistant to conventional treatments for otitis media. Here we discuss the role of IgE in the pathogenesis of EOM. In middle ear effusion, a significantly higher IgE level was detected in EOM patients than in control patients with common otitis media with effusion. This IgE level was significantly higher (about 10 fold) than the serum IgE level. In addition, many IgE-immunopositive cells were found in the middle ear mucosa. The IgE staining was mainly observed on mast cell surfaces, but also partially in the cytoplasm of cells that appeared to be plasma cells. These results suggested that IgE is produced locally in the middle ear mucosa. The existence of high-level IgE may exacerbate eosinophilic inflammation in the middle ear. One of the most distinct characteristics of EOM is the high incidence of sensory hearing loss independent of age. High-tone hearing loss is more frequently found and more severe in EOM patients than in control patients with common chronic otitis media. The concentration of IgE in middle ear effusion significantly and positively correlated with bone conduction hearing levels at 2 kHz and 4 kHz in EOM patients. Overproduction of IgE locally in the middle ear may be related to the pathological condition of EOM and eventually cause inner ear damage.

Eosinophilic inflammation in the middle ear induces deterioration of bone-conduction hearing level in patients with eosinophilic otitis media

OBJECTIVE

Eosinophilic otitis media (EOM) is characterized by the extensive accumulation of eosinophils in the middle ear mucosa and middle ear effusion and is usually associated with bronchial asthma. Eosinophilic otitis media patients show gradual or sudden deterioration of hearing. In our previous study, we reported that high-tone loss was more frequently found and more severe in EOM patients than in control patients with chronic otitis media. These findings suggest that not only bacterial infection but also eosinophilic inflammation in the middle ear may damage the inner ear. The present study was performed to determine whether eosinophilic inflammation is indeed related to deterioration of bone-conduction hearing level (BCHL).

PATIENTS

Fifty-five ears of 28 patients with EOM associated with bronchial asthma were included in this study. Middle ear effusion (MEE) samples were collected from all the patients, and the concentrations of eosinophilic cationic protein (ECP) and immunoglobulin E (IgE) were measured by fluorescence enzyme immunoassay. The BCHLs at 2 and 4 kHz for the worse-hearing ear of each patient were correlated with the concentrations of ECP and IgE.

RESULTS

The concentration of IgE in MEE significantly and positively correlated with BCHL at 2 and 4 kHz. The ears with a higher concentration of ECP in MEE also tended to show deterioration of BCHL at 4 kHz. Other clinical risk factors for BCHL deterioration were male sex, long duration of EOM, association with bacterial infection, severe inflammatory changes of the middle ear mucosa, and high serum IgE concentration.

CONCLUSION

Eosinophilic-inflammation-related substances such as ECP and IgE are closely related to the deterioration of BCHL at high frequencies. Particularly, IgE concentration in MEE is a good indicator of BCHL elevation. We should always pay attention to the hearing acuity of EOM patients with the risk factors.

Bone conduction hearing level in patients with eosinophilic otitis media associated with bronchial asthma

OBJECTIVE

Eosinophilic otitis media (EOM) is characterized by the extensive accumulation of eosinophils in the middle ear mucosa and middle ear effusion and is usually associated with bronchial asthma. EOM patients show gradual deterioration of hearing and sometimes become deaf suddenly. However, there have been no systemic studies of bone conduction hearing level (BCHL) of patients with EOM.

PATIENTS

Seventy-one ears of 38 patients with EOM associated with bronchial asthma were included in this study. For controls, 65 ears of age-matched 60 patients with chronic otitis media (COM), who underwent tympanoplasty, were similarly studied. The BCHLs at 250, 500, 1,000, 2,000 and 4,000 Hz of EOM patients were compared with those of COM patients, and the clinical risk factors for the deterioration of BCHL in EOM were analyzed.

RESULTS

Two patients became profoundly deaf unilaterally after the onset of EOM. High-tone loss was more frequently found and more severe in EOM patients than in COM patients. The clinical risk factors for high-tone loss were older age, male sex, presence of pathogens, and condition of the middle ear mucosa.

CONCLUSION

High-tone hearing loss and profound hearing loss were frequently associated with EOM, suggesting that inflammatory products of the middle ear invade the inner ear via the round window to cause inner ear damage. To prevent the deterioration of BCHL, the control of eosinophilic inflammation and bacterial infection is mandatory.

Eosinophilic otitis media: a new middle ear disease entity

Eosinophilic otitis media (EOM) is intractable otitis media characterized by the presence of a highly viscous yellow effusion containing eosinophils. It occurs mainly in patients with bronchial asthma and is resistant to conventional treatments for otitis media. Here we discuss the clinical features, pathogenesis, and management of EOM. EOM predominantly affects women and presents most often in patients in their 50s. The clinical features of the middle ear in EOM are roughly divided into the otitis media with effusion type and chronic otitis media type. The latter is further divided into two subtypes: simple perforation and granulation tissue formation. EOM is often complicated by rhinosinusitis (eosinophilic sinusitis). High-tone loss is more frequently found and more severe in EOM patients than in chronic otitis media control patients, and EOM patients sometimes become deaf suddenly. Systemic or topical steroid administration is the most effective treatment for patients with EOM. The instillation of triamcinolone acetonide, a suspension of steroids, into the middle ear is very effective for controlling eosinophilic inflammation. It is very important to explain to patients with EOM that the disease may last for a long period and that progressive and sudden hearing loss may occur.