[Dysfunction of the Eustachian tube and endothelial dysfunction: the present view of the problem (Part 1)].

This paper is focused on the topical otorhinolaryngological problem of Eustachian tube dysfunction, a pathological condition preceding or accompanying exudative otitis media. Based on the results of modern fundamental research, the author considers for the first time the role of endotoxins of Gram-negative microorganisms and endothelial dysfunction in etiology and pathogenesis of tubal disorders, exudative otitis media, and the related complications of sensorineural impairment of hearing.

[Exudative otitis media. Modern concepts and the importance of the problem].

The objective of the present work was to analyse current concepts of etiology, pathogenesis, and classification of exudative otitis medium (EOM) in conjunction with the methods for the treatment of this pathology. Views of the problem expressed by different authors (both Russian-speaking and foreign) are discussed. Complications of the disease developing as a result of the untimely or inadequate treatment are described.

Transforming growth factor-beta expression in otitis media with effusion.

OBJECTIVE: To characterize the existence and role of transforming growth factor-beta (TGF-beta) in otitis media with effusion (OME). STUDY DESIGN: Retrospective. METHODS: The levels of two major TGF-beta isoforms, TGF-beta1 and TGF-beta2, in the middle ear effusions (MEEs) of 44 children were evaluated using enzyme-linked immunospecific assays (ELISAs). Forty-eight MEEs were separated into three clinically relevant groups (i.e., serous, mucoid, and purulent), and TGF-beta levels were correlated with clinical parameters of disease for these MEEs. RESULTS: Both TGF-beta1 and TGF-beta2 were present in the samples. Mean levels of TGF-beta1 (920.36 +/- 437.75 pg/mg total protein) were generally 100-fold greater than those of TGF-beta2 (9.65 +/- 11.19 pg/mg total protein). TGF-beta1 levels were elevated in association with a history of previous tympanostomy tube placements (TTPs) (P = .029) and mucoid effusions (P = .042). TGF-beta2 levels were elevated in association with a history of previous TTPs (P = .100) and chronic (i.e., serous or mucoid) effusions (P = .003). CONCLUSIONS: TGF-beta1 is present in the MEEs of children with OME. Furthermore, TGF-beta1 and TGF-beta2 levels were elevated differentially in the presence of chronic disease indicators in OME, suggesting that these isoforms may have differing roles in the inflammatory processes that characterize OME.

Middle ear pressures of children with otitis media with effusion.

Middle ear (ME) pressures were measured in 30 children with chronic otitis media with effusion (OME) transtubally with the use of a catheter pressure transducer (Mikro-tip, PC-330F). They were found to range from 40 to -185 mm H2O, the average being mildly negative (-54.33 +/- 59.04 mm H2O). About two thirds of these children had pulsating changes of ME pressure; the range of the pressure change was between 10 and 50 mm H2O. The ME pressure tended to be lower in ears with serous effusion than in those with mucoid effusion, but there was no significant difference between them.

Endotoxin and lysosomal protease activity in acute and chronic otitis media with effusion.

Endotoxin levels and lysosomal protease (collagenase, cathepsin B, and lysozyme) activity were measured in 104 middle ear effusions (MEEs) from patients with otitis media with effusion (OME). The MEE samples were classified into four groups: pediatric serous, mucoid, and acute, and adult serous. Endotoxin levels and lysosomal protease activity in MEEs were significantly different in the following order: adult less than serous less than mucoid less than acute groups, indicating that both endotoxin and lysosomal proteases are more closely related to the pathogenesis of pediatric chronic OME than to adult OME. In pediatric serous and mucoid effusions, endotoxin level had a significant correlation with activity of the lysosomal proteases. In conclusion, endotoxin enhances leukocyte infiltration into the middle ear, and lysosomal proteases released from leukocytes damage the middle ear mucosa and thereby prolong mucosal inflammation, which may be responsible for delayed recovery from acute OME.

A correlative manometric and endoscopic study of tubal function in chronic otitis media with effusion.

Since return of normal ventilation of the middle ear is a prerequisite for maintenance of an effusion-free ear state after tube fallout, it was our policy to study the tubal function in patients with chronic otitis media with effusion that had been treated with ventilation tubes (VT), and to correlate the manometric with the endoscopic findings. Normal manometric and endoscopic results indicated good tubal function, with an effusion recurrence rate of 11.1%. Abnormal manometric and endoscopic results indicated organic tubal obstruction that was, in most cases, correctable. Nasal endoscopy proved to be indispensable in diagnosing, localizing and even treating "hidden" lesions in their key areas that may be responsible for the obstruction. Thus, correction of the organic tubal obstruction must precede VT removal if recurrence of effusion is to be prevented. Whenever tubal obstruction is diagnosed as functional or idiopathic, ventilation of the middle ear should be maintained by frequent intubation or the insertion of long-term VT, and a guarded prognosis given.

Serum antibodies specific to CD outer membrane protein of Moraxella catarrhalis, P6 outer membrane protein of non-typeable Haemophilus influenzae and capsular polysaccharides of Streptococcus pneumoniae in children with otitis media with effusion.

We measured the levels of serum IgG antibodies to CD outer membrane protein of Moraxella catarrhalis, P6 outer membrane protein of non-typeable Haemophilus influenzae and capsular polysaccharides of Streptococcus pneumoniae in 168 children with otitis media with effusion (OME) who were followed prospectively, using ELISA. Serum IgG antibodies to CD, P6 and pneumococcal capsular polysaccharides were detected in all samples. The anti-pneumococcal polysaccharides antibody level was highest, followed by the anti-P6 antibody level and anti-CD antibody was lowest (median:interquartile ranges were 45.9:19.1-100 microg/ml, 15.6:9.70-23.2 microg/ml and 1.06:0.73-1.87 microg/ml, respectively). In children aged 0-6 years, there were positive correlations among the antibody levels (anti-CD vs anti-P6, r=0.325, p <0.001; anti-CD vs anti-polysaccharide, r=0.397, p <0.0001; anti-P6 vs anti-polysaccharide, r=0.175, p=0.057). However, no relationship was seen in children aged 7-15 years. Children were classified according to severity of OME during the 1-year follow-up. In children aged 0-6 years, the severity of OME correlated inversely with the levels of anti-CD antibody (r=-.23, p=0.012), of anti-P6 antibody (r=-0.292, p=0.0015), and of anti-pneumococcal polysaccharides antibody (r=-0.25, p=0.0064). However, no correlation was found between antibody levels and severity of OME in children aged 7-15 years. These data suggest that persistence and/or recurrence of OME may be due to an insufficient serum antibody response to middle ear pathogens in young children.

Otitis media with effusion: components which contribute to the viscous properties.

Middle ear effusions from children undergoing myringotomy were classified into thick (mucoid) and thin (serous) on the basis of their flow properties. Their composition was analysed and their rheological properties measured. The viscosity of the effusions was measured using a Contraves low shear viscometer and expressed as specific viscosity per mg/ml of non-dialysable solids present. In order to measure the effusion viscosity it was necessary to solubilize the effusion by mild homogenisation in a phosphate buffer pH 6.7 containing a cocktail of proteolytic inhibitors. The viscosity of mucoid effusions was significantly greater than that of the serous effusions. There was a small but measurable amount of proteolytic activity in the effusions, range 0.05-1.79 micrograms/mg of non-dialysable solids. This proteolytic activity was not significantly different between the thick and thin effusions and was therefore unlikely to explain the difference in viscosity. Analysis of the constituents of the effusions showed that glycoprotein and DNA but not protein nor lipid were significantly higher in the mucoid effusions compared to the serous effusions. The viscosity of the effusions correlated with the glycoprotein concentration but not with the protein or lipid concentration. Under certain circumstances the DNA concentration did correlate with the viscosity of the effusion. However, digestion with a proteinase free DNase did not reduce the viscosity of the effusion. These results demonstrate that classifying effusions as thick and thin based on visual inspection and flow properties is valid and that the only constituent present in the effusions that determines viscosity is mucin.

Relationship between severity of middle ear mucosal lesion and middle ear pneumatic space volume in patients with otitis media with effusion.

If we assume that the state of suppression of pneumatic cells is the result of suppression of pneumatic cell growth by inflammatory stimulation in the middle ear pneumatic space, it is possible to improve the state of suppression by performing sufficient treatment during the growth period of the pneumatic cells. We indwelt a tympanic membrane ventilation tube (hereinafter referred to as tube) for treatment of otitis media with effusion (OME) in child patients aged 3-13 years and investigated the following points: i) relationship between the severity of inflammation of the lamina propria of middle ear mucosal specimens (hereinafter referred to as lamina propria) collected at the time of tube indwelling and the degree of growth of the pneumatic space; and ii) changes in the pneumatic space associated with treatment by tube indwelling, which was studied by comparing the above-described mucosal severity with the pneumatic space area of 2 years after tube indwelling, and with increase in the pneumatic space volume measured periodically after tube indwelling. The results indicated that mastoid cell growth suppression is higher in patients with a higher degree of inflammatory changes in the lamina propria. In association with treatment by tube indwelling, effusion accumulated in the pneumatic space and mucosal swelling disappeared early after the treatment, or 2 months of tube indwelling. After that, in patients with severe mucosal lesion, a long time, 1.5-2 years, was found to be required for repneumatization accompanying regrowth of the temporal bone. We confirmed that the severity of inflammation of the lamina propria is deeply involved in the growth and repneumatization of the pneumatic cells.

Tympanic membrane perforations and tympanostomy tubes.

Tympanoplasty and tympanostomy tubes were developed at the same time and have dramatically changed the treatment of chronic middle ear disease. One hundred forty-nine children who had tubes inserted between ages 6 months and 8 years for chronic otitis media with effusion have been prospectively followed up for an average of 4 years. Fourteen percent developed tympanic membrane perforations. No preoperative factor completely predicted the development of perforation. A majority of the perforations closed spontaneously. Three ears had noncontiguous observations of perforations during follow-up. The implications of these findings are discussed with respect to tympanoplasty.

Sinonasal symptoms in adults with ear disease.

BACKGROUND: The association between eustachian tube dysfunction and middle-ear effusion is well established. Studies have also demonstrated pathological changes affecting the middle-ear mucosa associated with chronic sinonasal inflammation. No previous studies have evaluated symptoms related to sinonasal inflammatory disease in different ear diseases. OBJECTIVE: To assess the presence of sinonasal symptoms in ear diseases using the Dundee Rhinogram. METHODS: Data were collected prospectively in the period February-October 2011. Sinonasal symptoms were graded using the Dundee Rhinogram. Student's t-test analyses were performed to identify any statistically significant associations. RESULTS: In total, 164 patients were assessed. There was a statistically significant association between sinonasal symptoms and mucosal middle-ear diseases (p < 0.005). The mean sinonasal symptoms score for mucosal middle-ear disease patients was 5.94 (range, 0-32). CONCLUSION: Assessment of sinonasal symptoms is paramount in patients presenting with an ear symptom; inflammatory sinonasal disease treatment may become necessary in the management of middle-ear mucosal disease for better patient outcome.

[Classification of secretory otitis based on cytological analysis of middle ear transudate]. / Tipizacija sekretornog otitisa na temelju citoloske analize transudata iz srednjeg uha.

On the basis of the number of cell elements in the cytologic smear of the transudate from the middle ear, secretory otitis media was divided into four groups providing indication for therapeutic procedures. The first group is characterized by a mass of mucus and very scarce cell elements, suggesting a relatively short duration of illness and the healing by conservative therapy and adenoidectomy. The second group contained somewhat more cell elements in the cytologic smear, suggesting a longer duration of illness and requiring the use of a ventilation tubule in the therapeutic procedure. The third group showed a considerable cell infiltration and the appearance of individual collagenic fibres scattered in disorder in the smear. The transudate is dense, sticky, and dark. Its aspiration from the cavum is not easy. The finding suggests a long duration of illness, requiring a more active approach of the otosurgeon. The fourth group is characterized by a very scarce but dense aspirate from the middle ear. The cytologic smear shows an intense cell infiltration and a mass of collagenic fibres, which speaks for a very long duration of illness and for the necessity, in view of the formation of connective tissue in the middle ear, of an explorative tympanotomy coupled with adhesiolysis and the use of the ventilatory tubule.

A model to refine the selection of children with otitis media with effusion for adenoidectomy.

The selection of children with otitis media with effusion for adenoidectomy has been criticized on a number of grounds. In spite of the widespread popularity of the procedure there are few objective guidelines to help the otolaryngologist make a decision which is therefore usually subjective. We present a scientifically derived model using a Generalized Linear Interactive Modelling (GLIM) technique from a population of 122 children who underwent either adenoidectomy or no pharyngeal surgery. The outcome parameter studied was otoscopic clearance in an unoperated ear 1 year after treatment. This was related principally to the operation type (P < 0.001) and to the age at which the operation was performed (P < 0.005). Using a probability of clearance threshold of 50% the model was tested on a prospective population of 166 children and outcome was correctly predicted in over 72%. This model enables the surgeon to determine the probability of clearance of effusion following adenoidectomy in an individual child. At a probability threshold of 50% adenoidectomy would be offered to children with bilateral otitis media with effusion aged between 4.33 and 8.00 years. Over the age of 8 years the probability of clearance occurring spontaneously increases beyond 50%. By careful selection of the probability of clearance thresholds it was possible to produce otoscopic resolution in over 80% of those selected to undergo adenoidectomy. The model also enables the otolaryngologist to determine the proportion of children with established disease that require adenoidectomy at his own chosen probability thresholds which will ensure that a more effective resource allocation is achieved.

Findings at initial surgery for childhood otitis media with effusion and subsequent outcome.

The outcome of initial surgical treatment in children with otitis media with effusion (OME) was analysed in a prospective study involving 225 new patients. The presence or absence of effusion in each ear and type of effusion present were recorded at surgery. The outcome measure studied was resolution or recurrence of middle ear effusions necessitating further surgical intervention. The outcome was significantly more favourable in children with unilateral effusions at surgery as opposed to bilateral effusions (P > 0.03) but was unrelated to the type of effusion (serous or mucoid). Patients with unilateral effusions at surgery appear to have a fluctuating form of OME in which effusions are present in either or both ears at different times.

The role of IgE-mediated hypersensitivity in otitis media with effusion.

INTRODUCTION: The role of immunoglobin (Ig) E-mediated hypersensitivity in otitis media with effusion (OME) has been the subject of much controversy and personal bias. Uncontrolled studies report the incidence of respiratory allergy in children with OME to range from 4% to over 90%. MATERIALS AND METHODS: Children 1 to 18 years old who had OME requiring a myringotomy and tubes from January 1, 1987, through July 1, 1988, were the subjects of this study. The history of allergic and radioallergosorbent test (RAST) analysis of specific serum IgE levels was undertaken for 26 allergens on 89 children in the study group and 59 children in the control group. RESULT: The incidence of allergen as diagnosed by RAST score was higher in children with OME than children in the control group (P > .05). There was no correlation between positive RAST scores and the number of polyethylene-ventilating (PE) tubes previously placed, history of tonsillectomy, history of adenoidectomy, or the character of the effusion (mucous v serous). CONCLUSION: Respiratory allergy is a factor involved in the pathogenesis of OME.

Language learning in a prospective study of otitis media with effusion in the first two years of life.

We report cross-sectional findings on children's early experience with otitis media with effusion (OME) related to hearing over time and emerging receptive and expressive language skills on the Sequenced Inventory of Communication Development Scale (SICD). Tympanometry and otoscopy on the same day are combined to diagnose OME. Hearing from 6 to 12 months is significantly related to scores on the SICD beginning with receptive language at 12 months. At 18 and 24 months, both receptive and expressive language are significantly related to average hearing from 6 to 18 months. Better language is associated with better average hearing levels. These findings suggest that the relationship between OME and language is mediated by hearing. It remains to be seen whether these relationships persist as the children continue to develop language.