HLA class I polymorphisms in Tunisian patients with otosclerosis.

BACKGROUND: Otosclerosis is a common form of hearing impairment among Western-Eurasian adults. The cause of otosclerosis remains unknown. Autoimmune reaction against the otic capsule has been suggested as a possible aetiologic factor in otosclerosis. AIM: The present study is the first report to evaluate the relationship between class I major histocompatibility complex (MHC) genes (HLA-A, HLA-B and HLA-Cw) and genetic susceptibility to otosclerosis in Tunisian patients. SUBJECTS AND METHODS: Fifty unrelated Tunisian patients exhibiting clinical otosclerosis were typed for HLA-A, HLA-B and HLA-Cw antigens and compared with 100 ethnically-matched healthy controls. RESULTS: Increased frequencies of HLA-A*03 (OR = 4.16, Pc < 0.043), HLA-B*35 (OR = 2.76, Pc < 0.043) and HLA-Cw*03 (OR = 4.57, Pc < 0.043) antigens were found in the patients with otosclerosis compared with healthy controls. Individuals with HLA-A*30 (OR=0.25, Pc < 0.043), HLA-B*51 (OR = 0.11, Pc < 0.043), HLA-Cw*16 (OR = 0.08, Pc < 0.043) and Cw*06 (OR=0.32, Pc < 0.043) antigens have a protective effect against otosclerosis. CONCLUSIONS: In conclusion, the data suggest that a variation in class I HLA antigens could be a genetic factor involved in susceptibility to otosclerosis in the Tunisian population.

The etiology of otosclerosis: a combination of genes and environment.

Otosclerosis is a common form of hearing loss characterized by abnormal bone remodeling in the otic capsule. It is a complex genetic disease, caused by a combination of genetic and environmental factors. During the past decade, several attempts have been made to identify factors for otosclerosis. This review provides an overview of the current understanding of the etiology of otosclerosis and describes the genetic and environmental factors that have been implicated in the disease. Environmental factors include fluoride and viral factors, particularly measles. Genetic association studies for otosclerosis have reported several associations of genetic variants that influence the risk of disease, mainly involving bone remodeling pathways, although their individual risk contributions are small. Rare monogenic forms of otosclerosis also exist, which are caused by a mutation in a single gene leading to a clear familial segregation of the disease. Linkage analysis of large otosclerosis families has led to the identification of seven loci, and recently evidence was found that T cell receptor beta is a gene responsible for familial otosclerosis, suggesting an underlying immunological pathway. However, this might also represent an autoimmune process, a hypothesis that is supported by other data as well. In conclusion, a variety of pathways have been identified to be involved in the development of otosclerosis, showing that distinct mechanisms involving both genetic and environmental risk factors can influence and contribute to a similar disease outcome.

Otosclerosis: an autoimmune disease?

OBJECTIVES: To review our current knowledge of the etiopathogenesis of otosclerotic bone remodeling including genetics, viral infection, autoimmunity and inflammation and to discuss disease pathogenesis with relevance for pharmacotherapy. SYSTEMATIC REVIEW METHODOLOGY: Relevant publications on the etiopathogenesis, molecular biology, genetics and histopathology of otosclerosis from 1984 to 2009 were analyzed. RESULTS AND CONCLUSIONS: Otosclerosis is a bone remodeling disorder of the human otic capsule, however, the etiopathogenesis remains unclear. Genetic predisposition, disturbed bone metabolism, persistent measles virus infection, autoimmunity, hormonal and environmental factors also may play contributing roles in the pathogenesis of otosclerosis. Since, diagnosis of otosclerosis is still based on histopathological examination of the removed stapes footplate, systemic prospective studies based on comprehensive histopathological and molecular biological analysis are necessary to get further information about the background of disease.

Disease-associated novel CD46 splicing variants and pathologic bone remodeling in otosclerosis.

OBJECTIVE/HYPOTHESIS: Otosclerotic bone is supposed to show unique CD46 expression pattern because otosclerosis is an organ-specific disease with viral etiology. STUDY DESIGN: Otosclerosis is a complex bone remodeling disorder of the human otic capsule, which is associated with persisting measles virus infection. The general cellular receptor of measles virus is the CD46, which has 14-known splicing isoforms. METHODS: Nucleic acid was extracted from ankylotic stapes footplates (N = 99) removed during stapedectomies. Consecutive histological, CD46 specific immunohistologic analysis, and multiple polymerase chain reaction (PCR) amplifications were performed. Measles virus was detected by seminested reverse transcriptase-PCR. Splicing variants of CD46 were identified by nested reverse transcriptase-PCR and finally determined by mass sequencing of complementary DNA. RESULTS: Measles virus RNA was detectable only in histologically otosclerotic stapes footplates. Virus negative-fixed stapes represent degenerative disorders of variable histopathology. Otosclerosis is featured by an increased number of osteoclasts showing strong CD46 immunoreaction in contrast to nonotosclerotic stapes fixations. Normal and nonotosclerotic stapes footplates show consistent expression of "c," "d," "e," "f," and "l" CD46 splicing isoforms. In contrast, four novel CD46 splicing variants were additionally detected in otosclerosis: os1, os2, os3, and os4. CONCLUSIONS: Newly described CD46 isoforms have shorter or missing transmembrane domain and a rare cytoplasmic tail with pathological or uncommon signal transduction; however, virus binding ability remains equal and invariable. These changes may be responsible for the smooth virus replication. A special expression pattern and altered functions of CD46 could explain the organ-specific and virus-associated pathogenesis of otosclerosis.

Some remarks on the histopathology of otosclerosis.

The histopathology of otosclerosis is described in detail in classical textbooks like Schuknecht's Histopathology of the Ear or Friedmann and Arnold's Pathology of the Ear. In this article, some of the important and new facts will be summarized which might affect the understanding of the pathomechanism of this unique measles-virus-associated inflammatory disease of the temporal bone.

Measles virus and otosclerosis.

Measles virus (MeV) might play an important role as an environmental stimulus in the etiopathogenesis of otosclerosis. Chronic inflammation was shown in morphologic investigations of otosclerotic foci and MeV N, P, and F proteins were detected within cells of the otosclerotic focus by immunohistochemical investigations. MeV RNA was extracted from fresh-frozen otosclerotic tissue by the use of in vitro RT-PCR. This result was validated through amplification of MeV genome sequences by RT-PCR from celloidin-embedded sections with morphologically ascertained otosclerotic foci. In searching for an immune response of the inner ear immune system against MeV proteins, elevated anti-MeV IgG levels were detected in the perilymph of patients with otosclerosis in comparison with the serum levels. In situ RT-PCR allowed the localization of MeV sequences in osteoclasts, osteoblasts, chondrocytes, macrophages, and epithelial cells in middle ear mucosa of otosclerotic tissue. Further evidence for MeV persistence has recently been given. Genotyping of MeV in otosclerotic foci demonstrated the presence of MeV genotype A, which circulated in Europe around 1960. All the above results confirm a strong association between MeV and otosclerosis.

Antimeasles immunoglobulin G and virus-neutralizing activity in sera of patients with otosclerosis.

Otosclerosis is considered as an organ-specific measles virus (MV)-induced disease. The majority of people are infected with MV during childhood, and the immune activation is characterized by a lifelong persistence. Any kind of depressed systemic antimeasles reaction can lead to induction of a local immune response in the inner ear. MV proteins were resolved by conventional polyacrylamide gel electrophoresis in the presence of a denaturing detergent. In subsequent Western blot, healthy blood donors demonstrated a stronger reaction against most proteins than age- and sex-matched otosclerotic patients. Different serum dilutions were tested for neutralizing activity against constant MV concentration. Nearly complete viral neutralization was achieved with samples containing inactivated complement and in immunoglobulin-G-containing fractions, and activity in sera from patients with confirmed otosclerosis was significantly weaker than in healthy individuals. Our observations are consistent with viral participation in otosclerotic pathogenesis, but it is difficult to say if the diminished antimeasles humoral response is a consequence of or the cause for a local measles infection.

Current research in otosclerosis.

PURPOSE OF REVIEW: The aim of this article is to summarize and put into historical perspective current advances in research in otosclerosis, a disorder of the human temporal bone with a hereditary predisposition that is among the most common causes of acquired hearing loss. RECENT FINDINGS: Genetic studies have revealed that otosclerosis is heterogeneous, with evidence for defects in at least seven genes associated with six distinct chromosomal loci. Measurements of high levels of osteoprotegerin expression in the normal otic capsule and soft tissues of the cochlea provide the first molecular insight as to why the normal otic capsule remodels minimally, if at all. Osteoprotegerin knockout mice provide the best available animal model to date to study abnormal otic capsule remodeling that closely resembles otosclerosis. There is mounting evidence that the measles virus plays an important role in pathogenesis of otosclerosis although the mechanisms by which the virus results in otosclerosis remain unknown. Quantitative measures of angiogenesis can reliably distinguish between clinical and histological otosclerosis. Advances in the emerging field of osteoimmunology will likely impact and benefit from the research in otosclerosis. SUMMARY: Insights into molecular mechanisms that inhibit extensive remodeling in the normal otic capsule, and understanding of how these mechanisms are dysregulated in otosclerosis will allow future design of rational treatment strategies for otosclerosis.

Activated osteoclasts with CD51/61 expression in otosclerosis.

HYPOTHESIS: Stapes ankylosis is supposed to be a disease with variable histopathology caused by otosclerosis or pseudo-otosclerosis. Persistent measles virus infection of the otic capsule could induce reactivation of quiescent embryonic osteoclasts in otosclerosis. BACKGROUND: Presence of measles virus RNA was demonstrated in the footplates of otosclerotic patients by reverse-transcription polymerase chain reaction (RT-PCR). Histology of active otosclerosis is featured by the presence of numerous osteoclasts with unknown phenotype. METHODS: Nucleic acid was extracted from stapes footplates of clinically otosclerotic patients (n = 261). Genomic RNA of measles virus was amplified by RT-PCR. Amplification results were correlated to postoperative histologic and CD51/61 specific immunohistologic findings. A parallel alcalic phosphatase activity assessment was performed to evaluate the metabolic activity of osteoclasts in each section. RESULTS: Among 261 stapes fixation cases, 175 otosclerotic stapes contained measles virus RNA. Histology for virus negative stapes (n = 86) represented nonotosclerotic, degenerative disorders. Histologically confirmed otosclerosis was featured by the presence of osteoclasts with renewed, embryonic phenotype. In otosclerosis, alcalic phosphatase activity was significantly higher compared with nonotosclerotic stapes ankylosis (P < .001). CONCLUSION: The presence of CD51/61 positive osteoclasts in otosclerotic bone containing viral sequences provides the basis for an inflammatory bone remodeling disorder. Otosclerosis is a disease caused by persistent measles virus infection and reactivation of resting embryonic osteoclasts in the otic capsule.

Otosclerosis--do we have a viral aetiology?

The etiology of otosclerosis remains an enigma though there are evidences suggesting a viral involvement. This study aimed to find out the relationship between viral infections and otosclerosis. Twenty two patients with otosclerosis and 10 healthy controls were included in the study. IgM antibodies to varicella zoster virus (VZV), measles, rubella, human cytomegalovirus (HCMV) and herpes simplex virus (HSV) were detected using micro ELISA. Paul Bunnel Davidsohn test was performed to rule out Ebstein Barr virus (EBV) infection. Overall, 5(22.7%) patients showed antibodies to one or more viruses. IgM antibodies against measles and VZV could be demonstrated in 4(18.1%) and 1(4.5%) patients respectively. None of the samples were found to be positive for HSV, HCMV, rubella and EBV antibodies. Controls were negative for all the viruses tested. The difference in seropositivity between the patient and control group was not statistically significant (p>0.05). Thus, this study suggests that otosclerosis is not commonly associated with a systemic viral infection.

Decreased measles virus-neutralizing activity in sera from otosclerotic patients.

HYPOTHESIS: Any kind of depressed systemic anti-measles reaction can lead to the induction of a local immune response in the inner ear and possibly to reactivation of bone turnover in this region. METHODS: Different dilutions of sera were tested for neutralizing activity against a constant viral concentration. The ability of measles virus to infect and replicate in the cell monolayer was detected by enumeration of living and growing cells with a colored reaction. RESULTS: Virus-neutralizing activity in the sera of patients with confirmed otosclerosis was significantly weaker than in that of healthy controls. When age- and sex-matched pairs were compared, the neutralizing activity in the healthy counterpart was higher in 5 cases. Nearly complete viral neutralization was achieved with samples containing inactivated complement and in IgG-containing fractions, but not in immunoglobulin-depleted samples. CONCLUSION: The present study is consistent with measles virus participation at least in the initiation of some cases of otosclerosis.

Delayed hypersensitivity reaction to topical aminoglycosides in patients undergoing middle ear surgery.

Repeated exposure to a topical aminoglycoside in patients with ear discharge can induce a delayed hypersensitivity reaction eventually. A postal survey conducted by the authors showed that 75% of UK otolaryngologists routinely prescribe topical aminoglycosides to their patients following ear surgery. This is a prospective study on the result of skin patch testing on 119 patients with chronic otitis media and 30 patients with otosclerosis who were scheduled for otosurgery. Any history of previous exposure to antibiotic eardrops for each patient was recorded. Overall, 14.1% of the patients had a positive skin reaction to one of the aminoglycosides (13.4% for Gentamicin; 12.8% for Neomycin and 4.5% for Framycetin). Sixteen per cent (16%) of the patients with chronic otitis media and 6.7% of the patients with otosclerosis were allergic to one of the aminoglycosides commonly found in antibiotic eardrops. Patients who received more than five courses of antibiotics eardrops previously had a greater tendency of developing allergy to the aminoglycosides (35.3%).

Etiopathogenesis of otosclerosis.

Otosclerosis is a frequent cause of nonsyndromic hearing loss which affects exclusively the human temporal bone. Various etiopathogenetic hypotheses have been proposed. The major hypotheses considered are genetic factors, immunologic factors and viral infection. Since the familial incidence of otosclerosis is known a recent genetic analysis has given evidence of three otosclerosis genes (OTSC1-3). Mutations in the collagen gene COL1A1 have been found in one large family with several cases of otosclerosis. Concerning an immunologic etiopathogenetic process, the presence of serum antibodies against collagen II and IX in patients with otosclerosis confirms the hypothesis of a collagen autoimmune mechanism. Finally as a possible cause of this chronic inflammatory disease morphologic and biochemical investigations have revealed a measles virus association. In conclusion, various etiopathogenetic factors may contribute to the genesis of otosclerosis.

Antimeasles immunoglobulin G in sera of patients with otosclerosis is lower than that in healthy people.

BACKGROUND: There is some evidence for an inflammatory process as a driving force in otosclerosis. Two popular hypotheses for the induction of this chronic inflammation have been proposed: an autoimmune phenomenon induced by an otic capsule specific antigen and measles virus infection. METHODS: Antibodies against measles virus hemagglutinin, polymerase, nucleocapsid, and matrix proteins were evaluated in sera from otosclerotic patients and in sera from healthy age-and sex-matched controls by use of the Western blot analyses. RESULTS: Significant differences were not detected between healthy men and women or between otosclerotic men and women. There were significantly stronger reactions against all viral proteins in the group of healthy women as compared with otosclerotic women despite a high standard deviation. The group of healthy male blood donors demonstrated significantly stronger reactions against polymerase and nucleocapsid proteins. Healthy blood donors again demonstrated stronger reaction compared with respective otosclerotic patients in a separate reaction for viral matrix protein. CONCLUSION: Our observation is consistent with viral participation in otosclerotic pathogenesis, but it is difficult to say if the diminished antimeasles humoral response is a consequence or the cause for a local measles infection. In light of the present data, we can discuss autoantibodies in otosclerosis as a sign of autoimmunity triggered by measles virus.

[Detection of humoral immune response to inner ear proteins in patients with sensorineural hearing loss]. / Nachweis einer humoralen Immunreaktivität gegen Innenohrproteine bei Patienten mit einer sensorineuralen Schwerhörigkeit.

BACKGROUND: The precise mechanism of inner ear disease is still unknown. An autoimmune reaction could be one of several possible pathogenic factors involved in progressive sensorineural hearing loss. Heat shock protein 70 is suggested to play an important role in the development of autoimmune diseases. The aim of this study is the investigation of humoral immune reactivity to inner ear components in patients with sensorineural hearing loss. METHODS: The presence of antibodies to inner ear components was determined by immuno-blotting extracted bovine or human inner ear proteins. Study groups consisted of patients with idiopathic progressive sensorineural hearing loss (group A), patients with Menière's disease (group B), patients with sudden hearing loss (group C), patients with otosclerosis (group D), patients with Cogan's disease (group E), and individuals without hearing problems (group F). RESULTS: 40% of the patients with progressive sensorineural hearing loss showed reactivity against a 68-kDa protein extracted from bovine inner ear. In contrast to this, only 5% of healthy individuals and 10% with Menière's disease showed reactivity against the 68-kDa protein from bovine inner ear or against bovine heat shock protein 70. Some of the patients who showed reactivity against bovine inner ear proteins were tested with human inner ear and human heat shock protein 70; all of these showed reactivity. Approximately 6% of the patients with sudden hearing loss (group C), otosclerosis (group D), and Cogan's disease (group E) showed reactivity to inner ear proteins. A non-specific humoral immune reaction against inner ear proteins with molecular weights of 30, 40, 50, 60, and 220 kDa was observed in all patients. DISCUSSION: These results indicate a humoral immune reactivity against heat shock protein 70, which might be responsible for the pathogenesis of progressive sensorineural hearing loss.

Persistent measles virus infection as a possible cause of otosclerosis: state of the art.

The etiopathogenesis of otosclerosis is still largely unexplained and remains controversial. Morphologic examinations have shown the presence of a chronic inflammation in otosclerotic tissue. Among the proposed explanations for this inflammation are an immunologic reaction against collagen, mutations of collagen gene 1A1, and a viral infection. In this paper, we focus on the role of measles virus in otosclerosis, and we review the current literature, devoting particular attention to a suspected paramyxoviral etiopathogenesis in Paget's disease. Our examination of footplate fragments by reverse transcription polymerase chain reaction testing in 95 patients with otosclerosis revealed the presence of measles virus RNA in 83% of cases. Quantification of measles virus immunoglobulin G (IgG) in otosclerosis patients indicated that the ratio of antimeasles virus IgG in total IgG was higher in perilymph than in serum. Furthermore, an almost identical incidence of otosclerosis and measles virus-caused mortality in women suggests that women are more susceptible to measles virus infection. Finally, since the introduction of the measles virus vaccination program in Europe, there has been a decline in the incidence of otosclerosis. Moreover, the average age of patients at diagnosis and surgery at our hospital has increased to 54 years. Our findings, when they are considered along with findings regarding the presence of paramyxoviral RNA in Paget's disease, support the hypothesis that measles virus is involved in the etiopathogenesis of otosclerosis.

Oral vaccine in otosclerosis.

Otosclerosis is a genetically based disease in which the development of autoimmune mechanisms can lead to its clinical expression. Anti-type II collagen antibodies have been found in otosclerotic patient serum. The first clinically unexpressive phase of the disease can be diagnosed from a family history and ON-OFF stapedial reflexes with evidence of an autoimmune disorder. The use of antigenic oral hyposensitization is accepted, based on autoimmune pathogenesis. Hyposensitization should be initiated during this subclinical period of otosclerosis with a type II collagen oral vaccine.

An immunohistochemical study of inducible nitric oxide synthase in the rat middle ear, with reference to tympanosclerosis.

Tympanosclerosis and myringosclerosis are well-known sequelae after acute and chronic otitis media and are also often seen after treatment of secretory otitis media with ventilation tubes. They sometimes cause serious hearing disability. There is no successful treatment for these conditions. There might be factors triggering an immunological or autoimmune chain reaction, which leads to tympanosclerosis. Intervention with the aim of abolishing this type of response might be possible if an interruption of the chain reaction can be found. Nitric oxide is a radical molecule with the ability to kill pathogens and is produced by the enzyme nitric oxide synthase. Expression of inducible nitric oxide synthase (iNOS) was analysed immunohistochemically in a rat model of acute otitis media. In rats sacrificed at days 3 and 6 after inoculation. iNOS was also strongly expressed in the middle ear mucosa and in the tympanic membrane as well as in the inner ear. In control specimens as well as in infected ones. iNOS was expressed in the tissue of the external ear canal. In rats sacrificed at day 10 and after 3 months, iNOS was expressed at the same locations, although less frequently. These data indicate that iNOS expression is induced during acute otitis media and suggest that nitric oxide may be important in the host defence against ear infections.

Elevated autoantibodies in sera from otosclerotic patients are related to the disease duration.

In this study an indirect ELISA with patients' sera was performed using human collagen type II, double- (dsDNA) and single-stranded DNA (ssDNA), thyroid microsomal antigen, insulin and lysozyme as antigens. Since many preoperated otosclerotic patients demonstrated the signs of myringosclerosis (n=7). they were classified separately and compared with otosclerotic patients without myringosclerosis (n=28), with healthy controls (n=42) and with patients with tympanosclerosis (n=5) of other origin. The otosclerotic patients had serum antibodies to antigens tested similar to normal controls. However, elevated antibody levels to human collagen type II, dsDNA and ssDNA were observed only in patients with a disease duration between 3 and 5 years as compared to other otosclerotic patients. The same duration association was observed in the level of the total serum alkaline phosphatase activity. These observations would suggest that the enzymatic bone resorption is the driving force in human otosclerosis. Elevated serum autoantibodies during tissue reparation in the otosclerotic stage may be a transient response to sustained excess antigen turnover in the primary lesion.