Role of atopic allergy in chronic otitis media. Evaluation based on serum IgE and nasal/aural cytologic findings in patients with operated chronic ears

The role of allergy in otitis media with effusion

The role of allergy in chronic otitis media with effusion (OME) is controversial. New evidence from cellular biology and immunology explain the basics of allergic reactions and allow more accurate diagnosis of allergies and inflammatory disease throughout the unified airway. This article examines the epidemiologic, methodological, and immunologic studies of allergic causes of OME, including (1) evidence for and against OME as an allergic disease, (2) allergy as a cause for eustachian tube obstruction, (3) examination of the most sensitive diagnostic tests for allergy, and (4) the effect of treatment of underlying allergies in improving and resolving middle ear disease.

Relationships between atopy and bacterial infections

Atopy in its most common forms (asthma, allergic rhinitis, and atopic dermatitis) has a significant impact on society in terms of health care costs and quality of life. Aside from having significant morbidity from these diseases, patients with atopy have also been noted to have a high incidence of comorbidities, including bacterial infections such as otitis media and sinusitis. In this paper, current evidence is reviewed that supports the close associations among allergic rhinitis and the two commonly diagnosed bacterial diseases, otitis media and sinusitis.

T(H)2 cytokine expression in atopic children with otitis media with effusion

BACKGROUND

Otitis media with effusion (OME) is more common in atopic children. Few studies have looked for the presence of inflammatory mediators in the middle-ear effusions of this population.

OBJECTIVE

We hypothesize that atopic children with OME have a different inflammatory cell and cytokine profile than nonatopic patients with the disease.

METHODS

Twenty-six patients with OME undergoing myringotomy and ventilation tube placement were recruited at the McGill University Hospital Center. The atopic status was determined for each patient by using standard skin testing. By means of immunocytochemistry, fluid specimens were assessed for T lymphocytes (CD3), eosinophils (major basic protein), neutrophils (elastase), mast cells (tryptase), and basophils (BB1). By using in situ hybridization, the expression of IL-4, IL-5, and IFN-gamma was assessed.

RESULTS

There is a higher percentage of eosinophils and T lymphocytes in atopic patients with OME (n = 8) compared with that seen in nonatopic patients (n = 18, P <.01). There is a higher percentage of neutrophils in nonatopic patients with OME compared with that seen in atopic patients (P <.01). In examining cytokine profiles, there is a higher percentage of cells expressing IL-4 and IL-5 in atopic patients with OME compared with that seen in nonatopic patients (P <.01).

CONCLUSION

The predominance of eosinophils, T lymphocytes, and T(H)2 mediators in the middle-ear effusions of atopic children provides evidence that allergy might play a role in the pathogenesis of OME.

Cetirizine and astemizole in allergic rhinitis a comparative study

The efficacy, safety and side effects of Cetirizine and Astemizole were compared with Pheniramine maleate in sixty cases of allergic rhinitis. All medications were stopped one week prior to treatment. Cetirizine, Astemizole or Pheniramine maleate were given as a single daily dose for 15 days. On completion of treatment results were evaluated subjectively as well as objectively, Cetirizine and Astemizole were found to be more effective than Pheniramine maleate. The side effects were minimum with Cetirizine.

Epidemiology and pathogenesis of chronic suppurative otitis media: implications for prevention and treatment

Despite advances in public health and medical care, chronic suppurative otitis media is still prevalent around the world. It is most common in developing countries and in certain high risk populations in developed nations, as well as among children who have tympanostomy tubes inserted. Since this chronic infection is caused by persistent acute otorrhea, which in turn is usually secondary to acute otitis media, prevention should be directed toward prompt and appropriate treatment of the acute middle-ear infection. Repair of chronic perforations should prevent recurrence, since reinfection is due either to reflux of pathogenic organisms from the nasopharynx into the middle ear, or water contamination from the external canal. Information from epidemiological studies, which show that populations can be categorized into highest, high, low and lowest prevalence, can be helpful in setting national priorities for prevention and treatment.

Eosinophil cationic protein in mucosal biopsies from patients with allergy and otitis media with effusion

Nine patients with persistent middle ear effusion and allergy confirmed by skin testing were evaluated for eosinophils by histochemical staining of middle ear mucosal biopsy specimens for eosinophil cationic protein. The study was designed to determine whether eosinophils were present in the middle ear mucosa of these patients and whether the elevated levels of eosinophil cationic protein reported in effusion from patients with chronic otitis media with effusion and allergy might originate within the mucosa itself. Seven of nine patients with otitis media with effusion had eosinophil cationic protein containing eosinophils (12 to 15 per high-power field) and degranulated eosinophil cationic protein material in the stroma of their mucosal biopsy specimens. Positive and negative biopsy findings correlated directly with respective high and low effusion levels of eosinophil cationic protein ( p = 0.03), reflecting an intrinsic immune-mediated process occurring within the middle ear mucosa.

Association of otitis media with effusion and allergy as demonstrated by intradermal skin testing and eosinophil cationic protein levels in both middle ear effusions and mucosal biopsies

This study was performed to ascertain the role of allergy, as defined by skin testing and histochemical markers, in the pathogenesis of otitis media with effusion (OME). A historical perspective of allergy as it relates to OME is presented. The study included 89 patients: 48 with persistent effusion but no recent acute infection, 25 with purulent OME complicated by a superimposed infection, and 16 control subjects. All 89 patients had persistent effusion for more than 2 months and subsequently required the placement of tympanostomy tubes. Allergy was defined using the radioallergosorbent test (RAST), serum immunoglobulin E (IgE) levels, and skin tests. Allergies were present in 97% of the patients with nonacute OME. The relationship between allergy and OME was corroborated clinically in 89% of patients and was also substantiated by elevated levels of effusion eosinophil cationic protein (ECP) in 87.5% of OME patients. Histologically, polyclonal antibody staining for ECP demonstrated the presence of eosinophils in middle ear mucosal biopsy specimens. This study confirms that OME is a sign of allergic inflammation in the middle ear that is associated with an increase in eosinophils and a concomitant release of ECP into the effusion in individuals with allergy demonstrated by skin testing.

Levels of Eosinophil Cationic Protein and Myeloperoxidase from Chronic Middle Ear Effusion in Patients with Allergy and/or Acute Infection

BACKGROUND AND OBJECTIVE: Allergy may play a role in the middle ear inflammation that leads to otitis media with effusion. The purpose of this study was to determine whether an elevated mediator correlated with the patient's disease and thus could be used to differentiate allergy vs. infection as the cause of the middle ear inflammation.

METHODS: We evaluated 57 individuals with otitis media with effusion, 32 with persistent effusion but no recent acute infection, 14 with recent infection and purulent otitis media with effusion, and 11 healthy subjects. The mediator activity of eosinophils and neutrophils in effusion was studied in patients characterized as having allergy by positive intradermal skin test results and positive radioallergosorbent test results. Eosinophils were characterized by measurement of eosinophil cationic protein in the effusion. Neutrophils were characterized by measurement of myeloperoxidase in the effusion. The levels of eosinophil cationic protein and myeloperoxidase in patients with and without allergy were correlated to patient history.

RESULTS: Significantly elevated levels of both eosinophil cationic protein and myeloperoxidase indicated that inflammation in the ear of patients with otitis media with effusion was characterized by a pronounced involvement of both eosinophils and neutrophils. Eighty-nine percent of all patients with disease had allergy. A higher ratio of myeloperoxidase to eosinophil cationic protein in patients with purulent otitis media with effusion indicated that in patients with a superimposed acute infection, neutrophil activity was increased even further. The level of eosinophil cationic protein was elevated only during the effusion of patients with allergies as compared with controls ( p < 0.01). Among 29 cases of nonpurulent otitis media with effusion, 96.5% had allergic immune-mediated disease proved by skin testing, which was related clinically to their ear disease. Eighty-nine percent (89.6%) of these patients had eosinophil cationic protein levels greater than 10 μg/L.

CONCLUSION: Middle ear eosinophil cationic protein may be used as a marker of related allergy.

Otitis media: relationship to tonsillitis, sinusitis and atopic diseases

In order to estimate the co-morbidity between ear infections and related childhood diseases, data about the occurrence of recurrent ear infections, tonsillitis, sinusitis and atopic diseases from a population based sample of 7992 Norwegian twins were analysed. Correlational results revealed two general clusters, one consisting of upper respiratory tract infections (URI), the other defined by the atopic diseases. Overall, associations between the diseases were greater in males. The sizes of the correlations within each subgroup of infections were moderate, but significant, ranging from 0.191 to 0.363. Similar results were found for the relationship within the subgroup of atopies, with correlations ranging from 0.134 to 0.466. The correlations between the infectious and atopic diseases were weak. Both ear infections and tonsillitis seemed to be predisposing factors for sinusitis. The relative risk of sinusitis among individuals with a history of ear infections was 3.4 (1.9-6.2) and 1.9 (1.2-3.0) for males and females, respectively. Ear infections conferred an increase in tonsillitis, estimated at 2.3 (1.6-3.0) and 2.0 (1.2-3.6) for males and females, respectively. In conclusion, the present study finds evidence for a common predisposition of upper respiratory infections as well as for atopic diseases, but only moderate correlation between the subgroups. Specifically, between ear infections and hay fever there was no covariation.

The presence of eosinophil cationic protein in middle ear effusion

Eosinophil cationic protein (ECP) is probably responsible for the underlying inflammatory mechanisms seen in asthma. It can be modulated in vivo by immunotherapy or steroids, with an appropriate reduction in symptoms of respiratory tract diseases. ECP is an identifiable mediator in additional target organs involved in allergic reactions, making it of potential interest in the study of otitis media with effusion. A qualitative prospective study was designed to discover the relationship of ECP and serum IgE in patients with middle ear effusion and allergy, as demonstrated by RAST and skin testing. The concentrations of ECP in the middle ear fluid from 23 consecutive patients with otitis media with effusion undergoing the placement of tympanostomy tubes ranged from 2 to 1248 micrograms (normal serum ECP, 5 to 15 micrograms), with 87% being abnormally elevated. There was no correlation between an individual's ear and serum levels of ECP (r = 0.1672; p = 0.6232), suggesting a more localized process. There was no relation between effusion ECP and serum IgE (p = 0.0040). ECP from middle ear effusion did correlate with a patient's having allergy, as confirmed by RAST and skin testing (p = 0.0095). Mechanisms involving immune mediated disease in the middle ear, of which the eosinophil may be one participant, are presented.

Allergy management of refractory serous otitis media

Twenty patients classified as having otitis media with effusion (OME) refractory to all previous medical and surgical therapy were entered into a prospective study to see if classic allergy techniques could diagnose and treat otherwise unresolved effusion and persistent hearing loss in lieu of the re-insertion of tympanostomy tubes. RAST testing, skin end point titration and food elimination diets identified a possible allergic etiology in all patients. Among those choosing allergy immunotherapy, 65% maintained normal hearing, normal tympanograms, and the elimination of recurrent infections for three years. The remaining 35% resolved on appropriate food elimination diets. None of the control's symptoms resolved. The history of chronic disease is defined. The pathophysiology of allergic mechanisms and studies attempting to prove or disprove an allergic effect on the middle ear and eustachian tube are reviewed.

Finnish approach to the treatment of acute otitis media. Report of the Finnish Consensus Conference

The theme of the first consensus conference to be held in Finland was the treatment of acute otitis media. The statements and recommendations accepted by the conference, which was organized according to the National Institutes of Health model, are presented in this report. On the basis of scientific knowledge, clinical experience, and conditions in Finland, the conference delegates concluded that penicillin V, in large doses, is still the drug of first choice in this disease. The importance of surgical drainage of the middle ear was stressed, as was the necessity of careful follow-up of the patient until the condition is completely healed. Decongestants were considered rather useless. In the prevention of recurrent attacks, adenoidectomy but not tonsillectomy was regarded as being of help, tympanostomy of probable benefit, antimicrobial (sulfonamide) prophylaxis worth considering in selected cases, but the effect of pneumococcal vaccination poor. The conference delegates agreed that uncomplicated acute otitis media should, as before, usually be treated by physicians taking care of children at the primary health care level.

Inflammatory cells in mucoid effusion of secretory otitis media

Inflammatory cells were studied in 269 mucoid middle ear effusions of 202 patients with secretory otitis media (SOM). Although the effusions contained inflammatory cells in all cases, the number of cells, the proportion of viable cells and the proportions of different cell types showed marked heterogeneity. However, the effusions formed a sliding scale with regard to the above cellular parameters. We suggest that these differences in the cellular picture might reflect differences in immune mechanisms and responses in the different effusions, possibly representing different phases of the course of an established SOM. In the subgroups of patients with cleft palate (22) or atopy (16) the cellular picture resembled that seen in the other patients (164), with the exception that the effusions of the cleft palate patients were somewhat more lymphocytic. Thus, from the immunological point of view, the effusions in established SOM seem to behave similarly, irrespective of the differences in the etiological background of SOM.