Development Of Chronic Otitis Media Research Articles

Changes in Coagulation Study and Risk of Developing Cholesteatoma: Is There a Link?

The etiopathogenesis of acquired pediatric cholesteatoma has not yet been fully clarified. Recent studies and modern technologies have led researchers to look for explanations at a molecular level. This study aims to understand if the origins of cholesteatoma could be related to dysfunctions in coagulation factors, thereby emphasizing its role in angiogenesis. Subjects and. This was a retrospective case-control study carried out at a tertiary hospital center between January 2010 and December 2020. The study included 92 children. The variables of the summary coagulation study (partial thromboplastin time, prothrombin time, and international normalized ratio) were compared among children with and without development of chronic otitis media with cholesteatoma. The cases and controls were comparable in terms of age, type, and number of times that ventilation tubes were placed. Partial thromboplastin times tended to be higher in children who developed cholesteatoma, with a statistically significant difference between the two groups in terms of normal and abnormal partial thromboplastin times (p=0.029). The results of this case control study indicate that slight extension of partial thromboplastin times in the coagulation study may not meet the criteria for diagnosis of certain hematological pathologies or clinical significance, but at a molecular level may already have implications for activation of angiogenesis and other growth factors involved in the onset, growth, and expansion of acquired pediatric cholesteatoma.

Status of the mastoid antrum and the eustachian tube function in cases of chronic otitis media

Introduction: Chronic otitis media (COM) is now synonymous with chronic suppurative otitis media, which is not actively used since COM is seldom associated with “the collection of pus.” Acute suppuration of the ear which transcends 6 weeks is considered to be COM which suggests an abnormality of the ear drum. With a prevalence incidence of 1%, Eustachian tube (ET) dysfunction is among the most important factors in the development of COM. Recently, mastoid air cells have been acknowledged as an essential compounding factor for the pathogenesis of middle ear disease. Since ET, mastoid air cell system, and nasopharyngeal mass like adenoids can play a pivotal role in the causation and persistence of COM, the current study will be taken to observe the status of ET, mastoid air cells system, nasopharynx in general, and adenoids in particular in patients of COM. Aim: This study aims to study the status of the mastoid antrum on surgical exploration, the status of ET, and nasopharynx for adenoids in patients of large, subtotal perforation, and posterosuperior retraction pockets (PSRPs). Study Design: This study was an observational, cross-sectional study. Study Setting: All the patients with large, subtotal perforation, and PSRPs visiting the Outpatient Department and Inpatient Department of ENT in Acharya Vinoba Bhave Rural Hospital (AVBRH) between 2022 and 2023 will be studied. Methods: All the selected patients of large, subtotal perforation, and posterosuperior retraction pocket (PSRP) in the age bracket of 15–65 years and satisfying the inclusion criteria will be considered and accrued in this study. We plan to look at a sample size of 50 patients (50 ears). Diagnostic nasal video endoscopy to get insight into ET function, size, and grade of adenoids by grading system given by Cassano et al. and pure-tone audiometry by ALPS AD2000 to know the type and amount of hearing loss will be carried out. Status of the mastoid antrum, the extent of the disease, status of ossicles, and associated abnormalities of temporal bone along with any other incidental findings will be noted intraoperatively. Expected Results: The data will be tabulated, analyzed statistically, and will be discussed in the context of existing research. Conclusion: The purpose of the present study is to help the surgeon have a better insight into the status of the mastoid antrum, ET in cases of large and subtotal perforation, and PSRP and nasopharynx in general with significance to adenoids in patients of COM in rural area.

The role of thymic stromal lymphopoietin in the development of chronic otitis media with effusion.

To investigate the effect of thymic stromal lymphopoietin on the development of chronic otitis media with effusion MATERIALS AND METHODS: This study was conducted on 40 patients who had adenoidectomy operation. The objects were divided into two groups. Group 1; adenoidectomy with chronic serous otitis media, group 2; adenoidectomy without chronic serous otitis media. Serum and tissue thymic stromal lymphopoietin levels were measured by ELISA. Serum and tissue TLSP levels, mast cell count, adenoid size were compared between the groups. Twenty-four (60%) of patients were female and 16 (40%) were male. Twenty patients (55%) had adenoid hypertrophy with chronic serous otitis media, and 18 (45%) had adenoid hypertrophy without chronic serous otitis media. The mean age of the patients was 6.21 ± 2.31years. The mean mast cell count was significantly higher in group 1 compared with group 2 (p = 0.017). The mean tissue thymic stromal lymphopoietin measurement was also significantly higher in group 1 than group 2 (p = 0.023). However, there was no significant difference in regards to serum levels between the groups (p = 0.480). The number of mast cells as well as thymic stromal lymphopoietin levels in the adenoids of children was significantly high in the chronic serous otitis media patients. The release of thymic stromal lymphopoietin from the adenoid tissue plays a role in initiating and maintaining a local inflammatory reaction in the eustachian tube that may lead eventually to middle ear effusion in non-atopic patients.

Does Ostmann's fat pad size correlate with development of chronic otitis media in children?

ObjectiveTo compare Ostmann's fat pad (OFP) size between healthy ears and ears with chronic otitis media with cholesteatoma (COMwC) in children, to assess its role in the disease. MethodsMRI scans of 29 children with unilateral COMwC with conductive hearing loss were used to measure OFP, represented by the maximal diameter of the high intensity area medial to the tensor veli palatini muscle (TVP): M1. A reference diameter was defined from the medial border of OFP reaching the medial border of the medial pterygoid muscle: M2.Values of M1, M2 and the ratio of M1:M2 were compared between the healthy and pathological ear in each patient. ResultsNo difference in OFP size was observed between healthy (H) ears (mean M1H:M2H ratio 0.72 ± 2.28) compared to ears with COMwC pathology (P) (mean M1P:M2P ratio .68 ± 1.57; P = .943) in children, suggesting that OFP size abnormalities do not have a role in pediatric COMwC. ConclusionOFP size was not correlated to the development of unilateral COMwC in children.

Factors associated with the development of paediatric chronic otitis media by age nine: a prospective longitudinal cohort study of 6560 children.

This study aimed to analyse social, health and environmental factors associated with the development of chronic otitis media by age nine. This was a prospective, longitudinal, birth cohort study of 6560 children, reviewed at age nine. Chronic otitis media defined as previous surgical history or video-otoscopic changes of tympanic membrane retraction, perforation or cholesteatoma. Non-affected children were used as the control group. Univariate analysis demonstrated an association between chronic otitis media and otorrhoea, snoring, grommet insertion, adenoidectomy, tonsillectomy, hearing loss, abnormal tympanograms and preterm birth. Multivariate analysis suggests many of these factors may be interrelated. The association between chronic otitis media and otorrhoea, abnormal tympanograms and grommets supports the role of the Eustachian tube and otitis media (with effusion or acute) in the pathogenesis of chronic otitis media. The role of snoring, adenoidectomy and tonsillectomy is unclear. Associations suggested by previous studies (sex, socioeconomic group, parental smoking, maternal education, childcare, crowding and siblings) were not found to be significant predictors in this analysis.

Study of the Reliability of High Resolution CT Scan Evaluation of Eustachian Tube as Predictor of Predisposition for Chronic Otitis Media.

Eustachian tube (ET) dysfunction is one of the predisposing factors for chronic otitis media (COM). This study looks at two parameters in High Resolution Computed Tomography of temporal bone namely tubotympanic angle (TTA) and pretympanic diameter (PTD) and its relationship with COM. The objectives of the study were tocompare the tubotympanic angle and pretympanic diameter of the affected ear in patients with unilateral COM with that of healthy controls, and with contralateral non-COM ear. This was a retrospective study done at a tertiary referral hospital. Database of patients who underwent high resolution CT scan of temporal bone over a period of three and half years, was studied. The TTA and PTD of ET were measured with the help of a senior radiologist well-versed in the imaging of temporal bone. Group A consisted of 45 patients with unilateral COM, while Group B comprised 50 patients without COM. Group A was further subgrouped as A1 (COM with cholesteatoma) and A2 (COM without cholesteatoma). The TTA and PTD in COM with cholesteatoma in the affected ear were 147.98 ± 5.89° and 2.84 ± 0.82mm respectively, and in the unaffected ear, 144.81 ± 6.43° and 3.32 ± 1.19mm respectively. In Group A, the TTA and PTD in the affected ear of unilateral COM were 146.17 ± 6.11°, 2.97 ± 0.87mm and in Group B, it was 143.17 ± 6.01° and 3.48 ± 0.85mm respectively. All these were statistically significant (p value < 0.05). Increased TTA and reduced PTD of ET may be a predisposing factor for the development of COM and cholesteatoma.

Ostmann's Fat Pad-Does it Really Matter?

To compare the size of Ostmann's fat pad (OFP) between healthy ears and ears with chronic otitis media with cholestatoma (COMwC) using magnetic resonance imaging (MRI). Twenty-six patients with unilateral COMwC underwent mastoidectomy. Pre-operative MRI records were reviewed retrospectively. The healthy ears served as the control group. OFP is represented by the maximum diameter of the high intensity area medial to the tensor veli palatini muscle (TVP); M1. A reference diameter was defined from the medial border of OFP reaching the medial border of the medial pterygoid muscle; M2. Values of M1, M2 and the ratio of M1:M2 was compared between the healthy and pathological ear in each patient. All 26 patients (16 females,10 males) had unilateral cholestatoma. Mean age was 37.6 years (range 19-83). In the healthy (H) ears group, mean M1H was 2.04 ± 0.53 mm, mean M2H was 9.57 ± 2.57 mm.In the pathological (P) ears group; mean M1P was 2.03 ± 0.55 mm, mean M2P was 9.86 ± 2.37 mm. A comparison of M1 and M2 values between the healthy and pathological ear groups was not statistically significant (P = .853 and P = .509, respectively).Mean M1H:M2H ratio in the healthy ears group was 0.22 ± 0.05, mean M1P:M2P ratio in the pathological ear group was 0.21 ± 0.06. A comparison between these ratios found no significant statistical correlation (P = .607). The size of Ostmann's fat pad does not affect the development of chronic otitis media with cholestatoma in adults.

Antibiotic modulation of mucins in otitis media; should this change our approach to watchful waiting?

BackgroundGel-forming mucins (GFMs) play important roles in otitis media (OM) pathogenesis. Increased mucin expression is activated by pathogens and proinflammatory cytokines. Bacterial biofilms influence inflammation and resolution of OM and may contribute to prolonged mucin production. The influence of specific pathogens on mucin expression and development of chronic OM with effusion (OME) remains an area of significant knowledge deficit. ObjectivesTo assess the relationship between GFM expression, specific pathogens, middle ear mucosal (MEM) changes, biofilm formation, and antibiotic utilization. MethodsMixed gender chinchillas were inoculated with nontypeable Haemophilus influenzae (NTHi) strain 86028NP or Streptococcus pneumoniae (SP) strain TIGR4 via transbulla injection. Antibiotic was administered on day 3–5 post inoculation. GFM expression was measured by quantitative PCR. Biofilm formation was identified and middle ear histologic changes were measured. ResultsSP infection resulted in higher incidence of biofilm and ME effusion compared with NTHi infection. However, NTHi persisted in the ME longer than SP with no substantive bacterial clearance detected on day 10 compared with complete bacterial clearance on day 10 for 50–60% of the SP-infected chinchillas. Both infections increased MEM inflammatory cell infiltration and thickening. NTHi upregulated the Muc5AC, Muc5B and Muc19 expression on day 10 (p = 0.0004, 0.003, and 0.002 respectively). SP-induced GFM upregulations were trended toward significant. In both NTHi and SP infections, the degree of GFM upregulation had a direct relationship to increased MEM hypertrophy, inflammatory cell infiltration and biofilm formation. Antibiotic treatment reduced the incidence of ME effusion and biofilm, limited the MEM changes and reversed the GFM upregulation. In NTHi infection, the rate of returning to baseline level of GFMs in treated chinchillas was quicker than those without treatment. ConclusionsIn an animal model of OM, GFM genes are upregulated in conjunction with MEM hypertrophy and biofilm formation. This upregulation is less robust and more quickly ameliorated to a significant degree in the NTHi infection with appropriate antibiotic therapy. These findings contribute to the understanding of pathogen specific influences on mucin expression during OM pathogenesis and provide new data which may have implications in clinical approach for OM treatment.

Decreased Aquaporin 4 and 6 mRNAs in Patients With Chronic Otitis Media With Otorrhea.

ObjectivesAquaporins (AQPs) are integral membrane proteins engaged in the modulation of water homeostasis, but the roles they play in chronic otitis media (COM) have not been well investigated. Accordingly, we undertook document relations between the mRNA expressions of AQPs and COM, and explored the relation between these expressions and otorrhea, which is one of the most common symptoms of COM.MethodsLevels of the mRNAs of AQP 1, 2, 3, 4, 5, 6, 8, and 10 were assayed by real-time polymerase chain reaction in inflammatory tissue samples from 81 patients with COM with or without otorrhea. Relationships between AQP mRNA levels and the presence or absence of otorrhea, the presence or absence of bacteria, hearing threshold levels, types of hearing loss, and clinical manifestations were also evaluated.ResultsAQP 1, 2, 3, 4, 5, 6, 8, and 10 mRNAs were expressed in inflammatory tissues obtained from all 81 patients with COM with or without otorrhea. AQP 5 mRNA was most expressed in, followed in descending order by AQP 3, 1, 10, 6, 8, 2, and 4. There were no significant intergroup differences in terms of age, sex, duration of illness, levels of hearing loss in both ears, or incidences of conductive or sensorineural hearing loss. However, AQP 4 (P=0.035) and 6 (P=0.085) mRNA levels were significantly lower in the otorrhea group. In addition, bacteria culture positivity (P=0.014) and the incidence of sensorineural hearing loss (P=0.020) were higher in the otorrhea group.ConclusionAQP 1, 2, 3, 4, 5, 6, 8, and 10 are involved in the development of COM. Specifically, it shows reductions in AQP 4 and 6 mRNA levels, as observed in the otorrhea group, have an effect on the clinical manifestations of COM.

Multi-scale finite element modeling of Eustachian tube function: influence of mucosal adhesion.

The inability to open the collapsible Eustachian tube (ET) leads to the development of chronic Otitis Media (OM). Although mucosal inflammation during OM leads to increased mucin gene expression and elevated adhesion forces within the ET lumen, it is not known how changes in mucosal adhesion alter the biomechanical mechanisms of ET function. In this study, we developed a novel multi-scale finite element model of ET function in adults that utilizes adhesion spring elements to simulate changes in mucosal adhesion. Models were created for six adult subjects, and dynamic patterns in muscle contraction were used to simulate the wave-like opening of the ET that occurs during swallowing. Results indicate that ET opening is highly sensitive to the level of mucosal adhesion and that exceeding a critical value of adhesion leads to rapid ET dysfunction. Parameter variation studies and sensitivity analysis indicate that increased mucosal adhesion alters the relative importance of several tissue biomechanical properties. For example, increases in mucosal adhesion reduced the sensitivity of ET function to tensor veli palatini muscle forces but did not alter the insensitivity of ET function to levator veli palatini muscle forces. Interestingly, although changes in cartilage stiffness did not significantly influence ET opening under low adhesion conditions, ET opening was highly sensitive to changes in cartilage stiffness under high adhesion conditions. Therefore, our multi-scale computational models indicate that changes in mucosal adhesion as would occur during inflammatory OM alter the biomechanical mechanisms of ET function. Copyright © 2016 John Wiley & Sons, Ltd.

Prevalence and risk factors of chronic otitis media: the Korean National Health and Nutrition Examination Survey 2010-2012.

BackgroundThe performance of nationwide studies of chronic otitis media (COM) in adults has been insufficient in Korea. We evaluated the prevalence and risk factors of COM in Korea.MethodsThis study was conducted using data from the fifth Korean National Health and Nutrition Examination Survey (n = 23,621). After excluding the subjects under 20 year old and suffered from cancers, 16,063 patients were evaluated for COM. Participants underwent a medical interview, physical examination, endoscopic examination, and blood and urine test. COM was diagnosed by trained residents in the Department of Otorhinolaryngology using an ear, nose, and throat questionnaire and otoendoscopy findings. Data on the presence and absence of COM were collected. Multivariate logistic regression analyses were performed to identify its risk factors.ResultsOf the 16,063 participants aged above 20 year old, the weighted prevalence of COM was 3.8%. In the multivariate analyses, the following factors showed high odds ratios (ORs) for COM: pulmonary tuberculosis (adjusted OR, 1.78; 95% confidence interval [CI], 1.06-3.01), chronic rhinosinusitis (adjusted OR, 1.87; 95% CI, 1.17-2.98), mild hearing impairment (adjusted OR, 1.95; 95% CI, 1.34-2.85), moderate hearing impairment (adjusted OR, 4.00; 95% CI, 2.21-7.22), tinnitus (adjusted OR, 1.82; 95% CI, 1.34-2.49), increased hearing thresholds in pure tone audiometry in the right ear (adjusted OR, 1.02; 95% CI, 1.01-1.03), and left ear (adjusted OR, 1.03; 95% CI, 1.02-1.04). The following factors showed low odds ratios for COM: hepatitis B (adjusted OR, 0.28; 95% CI, 0.08-0.94) and rhinitis (adjusted OR, 0.60; 95% CI, 0.42-0.88). In addition, high levels of vitamin D, lead, and cadmium, EQ-5D index; and low red blood cell counts were associated with development of COM (Student’s t-test, P < 0.01).ConclusionsOur population-based study showed that COM is not rare in Korea, and its development may be associated with various host and environmental factors. Further research on its relationships and the pathogenesis are needed.

PAI-1 inhibits development of chronic otitis media and tympanosclerosis in a mouse model of otitis media

Conclusion: Bullae of type 1 plasminogen activator inhibitor (PAI-1) knockout (KO) mice showed low levels of inflammation against nontypable Haemophilus influenzae (NTHi) at the early stage of otitis media (OM). However, PAI-1 KO mice fail to terminate inflammation, which may significantly contribute to the development of tympanosclerosis in PAI-1 KO mice. Objective: To investigate the role of PAI-1 in the pathogenesis of OM and subsequent tympanosclerosis. Methods: OM was induced with NTHi in PAI-1 KO and background control C57BL/6 mice. mRNA expression of PAI-1, tissue-type plasminogen activator (tPA), and urokinase-type plasminogen activator (uPA) was measured in the bullae of C57BL/6 mice. mRNA expression of interleukin (IL)-1β, tumor necrosis factor (TNF) α, macrophage inflammatory protein (MIP-2), tPA, and uPA in PAI-1 KO and C57BL/6 mice was compared. Histological changes produced by OM were compared at 1, 3, and 7 days after NTHi inoculation. Results: NTHi up-regulated the expression of PAI-1 and tPA in the bullae of C57BL/6 mice, but not uPA. mRNA expression of IL-1β, TNFα, and MIP-2 was low in PAI-1 KO mice at early time points, but significantly higher at the later stage of OM. Similarly to the gene expression results, histological changes associated with OM were less at days 1 and 3 in PAI-1 KO mice. However, unlike the gradual resolution of OM pathologies in C57BL/6 mice, PAI-1 KO mice showed significant pathological changes of tympanosclerosis.

Comparison of Anti-pneumococcal Antibodies in Cord Blood From Australian Indigenous and Gambian Neonates and the Implications for Otitis Media

Australian indigenous infants experience the highest incidence of chronic suppurative and acute otitis media in the world with many babies developing disease in the early postnatal period. Streptococcus pneumoniae is the major cause of otitis media in this population. Infants are protected against bacterial disease in the first months of life by passive transfer of maternal antibody across the placenta during the late stages of gestation. We hypothesized that reduced passive immunity may contribute to increased disease risk in this population. We compared the concentrations and function of serotype-specific IgG in cord serum from Australian indigenous neonates and Gambian neonates, the latter experiences a similar socioeconomic status to Australian indigenous neonates. Serotype-specific IgG, IgG1 and IgG2 were measured using a modified 3rd generation enzyme linked immunosorbent assay based on World Health Organization recommendations. Antibody avidity was measured using a modified sodium thiocyanate elution method. Australian indigenous neonates had significantly increased levels of serotype-specific IgG compared with Gambian populations for 6 of 12 serotypes (P < 0.02). There was no significant difference in antibody function, as measured by antibody avidity, between the 2 groups. An increased risk for otitis media in Australian indigenous neonates is not primarily determined by specific antibody titers against pneumococcal bacteria. Further investigation into the possible roles of the innate immune response and Eustachian tube dysfunction in the development of chronic otitis media amongst Australian indigenous infants is warranted.

Genetic susceptibility to chronic otitis media with effusion: Candidate gene single nucleotide polymorphisms

The genetic factors leading to a predisposition to otitis media are not well understood. The objective of the current study was to develop a tag-single nucleotide polymorphism (SNP) panel to determine if there is an association between candidate gene polymorphisms and the development of chronic otitis media with effusion. A 1:1 case/control design of 100 cases and 100 controls was used. The study was limited to the chronic otitis media with effusion phenotype to increase the population homogeneity. A panel of 192 tag-SNPs was selected. Saliva for DNA extraction was collected from 100 chronic otitis media with effusion cases and 100 controls. After quality control, 100 case and 79 control samples were available for hybridization. Genomic DNA from each subject was hybridized to the SNP probes, and genotypes were generated. Quality control across all samples and SNPs reduced the final SNPs used for analysis to 170. Each SNP was then analyzed for statistical association with chronic otitis media with effusion. Eight SNPs from four genes had an unadjusted P value of <.05 for association with the chronic otitis media with effusion phenotype (TLR4, MUC5B, SMAD2, SMAD4); five of these polymorphisms were in the TLR4 gene. Even though these results need to be replicated in a novel population, the presence of five SNPs in the TLR4 gene having association with chronic otitis media with effusion in our study population lends evidence for the possible role of this gene in the susceptibility to otitis media.

Math1, retinoic acid, and TNF-α synergistically promote the differentiation of mucous cells in mouse middle ear epithelial cells in vitro

BackgroundA key issue in otitis media (OM) is mucous cell metaplasia in the middle ear mucosa, a condition for hyperproduction of mucus in the middle ear mucosa and development of chronic OM. However, little is known about the driving force for the differentiation of mucous cells in OM.MethodsMouse middle ear epithelial cells (mMEEC) were used in this study to test whether Math1, a critical transcription factor for the development of mucous cells in the intestine, synergize with inflammatory cytokines (tumor necrotic factor alpha, TNFα) and other epithelial differentiation factors (retinoid acid, RA) to induce the differentiation of mMEEC into mucus-like cells in vitro. Simultaneously, Math1 was transduced into the middle ear mucosa and see whether it induces mucous cell hyperplasia in vivo.ResultsMath1 significantly increased the mucus cell numbers in the middle ear mucosa of mice. Math1, in the presence of TNFα and epithelial differentiation factor retinoic acid (RA), synergistically promoted the differentiation of mMEEC into mucus-like cells via upregulation of mucins and their chaperones:trefoil factors (TFFs) in vitro. RA treatment for 12 hours activated Math1 although RA alone had very limited effects on mucus-like cell differentiation.ConclusionMath1 plays a critical role in the pathogenesis of OM by induction of mucous cell differentiation, in the presence of TNFα and RA.

The improvement of middle ear ventilation by laser ablation of the epipharyngeal eustachian tube: a prospective study

A long-lasting dysfunction of the eustachian tube seems to be the etiologic origin for development of chronic otitis media (COM) with mesotympanic perforation, otitis media with effusion (OME), and chronic atelectasis of the middle ear. Surgical interventions in the middle ear generally treat the sequelae of the tube dysfunction but not the dysfunction itself. This prospective clinical study investigated how far fiber-guided laser ablation of the posterior half of the epipharyngeal tubal ostium led to better middle ear ventilation in the otologic disease patterns mentioned below. There were 38 adult patients included in the analysis. The patients in one group had a perforated tympanic membrane [COM before primary tympanoplasty (n = 14) or revision tympanoplasty (n = 5)]; the patients in a second group had an intact eardrum [OME resistant to therapy (n = 3), with an atelectasis of the middle ear (n = 2) or problems of pressure equalization with fast changes in ambient pressure (diving, flying) (n = 14)]. Laser ablation of the posterior half of the epipharyngeal tubal ostium was performed, generally with local anesthesia, if tubal function testing was pathologic (Valsalva maneuver, passive tube opening, tympanogram). In patients with COM the procedure was performed 8 weeks before the middle ear surgery. All patients were checked 8 weeks postoperatively and in the course of the following year. The intervention seemed to have had a positive effect on tube function in 68.4% of patients operated on (P = 0.001). In 26 of the 38 patients that had undergone operation, an improvement the results of tubal function tests could be seen in the postoperative follow-up. In the COM group the Valsalva maneuver improved in 14 of 19 patients (73.6%) (P = 0.001), and the passive tube opening improved in nine of 18 patients (50%). In the group with an intact eardrum the Valsalva maneuver improved in 13 of 18 patients (72.2%) (P = 0.001). The resulting condition remained stable after 1 year. None of the patients showed any complications as a result of the therapy. Minimally invasive shaping of the distal eustachian tube under topical anesthesia can be recommended for patients with the above-mentioned diagnoses who have pathologic middle ear ventilation. Especially prior to tympanoplasties, and especially in otologic revision procedures, where middle ear ventilation is a prerequisite for successful otologic surgery, the function of the eustachian tube can be optimized in 70% of the patients, particularly if there are pathological findings (tubal tonsil, narrow orifice of the tubal ostium, adenoids). The placement of permanent ear tubes in adults with recurrent OME can also be avoided by the procedure described. The resultant conditions remained stable for the next year. Patients with tympanic ventilation problems due to rapid pressure changes (flying, diving) can also benefit from this procedure.

A Comparison of Outcomes following Tympanostomy Tube Placement or Conservative measures for Management of Otitis Media with Effusion

We obtained the charts of 183 patients (197 ears) who had undergone surgery for chronic otitis media (COM), and we reviewed their otic histories to analyze the series of events that ultimately culminated in surgery. All ears had originally been treated for otitis media with effusion (OME); 125 ears had been treated with tympanostomy tube placement, and 72 ears had been treated with conservative measures. Our goal was to compare the influence that these two strategies had on the subsequent development of COM and its sequelae (i.e., retraction pockets, tympanic membrane perforations, and cholesteatomas) and thereby determine which strategy is preferable. We found that although retraction pockets developed in a significantly higher proportion of the tympanostomy-treated ears than the conservatively treated ears (58 vs. 35%; p < 0.01), a significantly greater percentage of retractions in the tympanostomy-treated ears were mild and situated in the anterior part of the tympanic membrane (52 vs. 32%; p < 0.05). Moreover, severe retractions were significantly more common in the conservatively treated ears (40 vs. 16%; p < 0.02); the incidence of complete retractions in the two groups of ears was similar (tympanostomy: 32%; conservative treatment: 28%). Cholesteatomas developed in a significantly lower percentage of tympanostomy-treated ears (67 vs. 81%; p < 0.05), and the incidence of large cholesteatomas that involved the tympanic and mastoid cavities was likewise significantly lower in these ears (44 vs. 69%; p < 0.05). There was no significant difference in the incidence of tympanic membrane perforations. Finally, even though all of these ears eventually required surgery for COM, the tympanostomy-treated ears required significantly fewer repeat surgeries (16 vs. 28%; p < 0.05) and significantly fewer radical modified tympanomastoidectomies (30 vs. 44%; p < 0.05). Therefore, we conclude that myringotomy with insertion of tympanostomy tubes to treat OME is superior to conservative treatment.

Treatment of chronic tube dysfunction

Chronic tube dysfunction plays a major part in the development of chronic otitis media. Owing to the complex structure of the Eustachian tube, the development of successful therapeutic approaches to the treatment of tube function disorders is still difficult even today. The application of a gold tube wire (tube conductor) was reported in 1991, but no studies have yet been performed on the postoperative success rates achieved with tube conductors. In a retrospective study, the data relating to 125 patients who were operated on from 1996 to 1999 for treatment of different forms of chronic otitis media and also underwent transtympanic tube conductor implantation to improve tube ventilation disorder were evaluated. Data on pre- and postoperative tube function were available for 96 patients after a mean follow-up period of 18 months. All tube implantations were achieved without complications. Tube function normalized in 8 patients (8.3%), while the tube ventilation disorder remained unaffected in 88 patients (91.7%). A total of 23 (18.4%) tube conductors have so far been removed. The reasons for removal include persistent tube ventilation disorder, dislocation of the tube conductor in 7 patients (5.6%) and granulation around the tube wire in 7 cases (5.6%). The chronic tube ventilation disorder was improved by implantation of a tube conductor in only 8.3% of the patient population investigated. We are therefore of the opinion that this is not a suitable treatment for chronic tube ventilation disorders. The development of new, effective therapeutic approaches to the treatment of chronic tube ventilation disorders remains a priority.

Spontaneous development of otitis media in plasminogen-deficient mice

Inflammatory conditions of the ear, otitis media, are one of the most common disease entities in children. In this study, the role of the plasminogen (plg)/plasmin system for the spontaneous development of chronic otitis media was investigated by the analysis of plg-deficient mice. Whereas essentially all of the wild-type control mice kept a healthy status of the middle ear, all the plg-deficient mice gradually developed chronic otitis media with various degrees of inflammatory changes during an 18-week observation period. Five bacterial strains were identified in materials obtained from the middle ear cavities of six plg-deficient mice. Morphological studies revealed the formation of an amorphous mass tissue and inflammatory changes in the middle ears of plg-deficient mice. Immunohistochemical studies further indicate a mass infiltration of neutrophils and macrophages as well as the presence of T and B cells in the middle ear mucosa of these mice. Extensive fibrin deposition and an abnormal keratin formation were also observed in the tympanic membrane, the middle ear cavity and external ear canal in these mice. These results suggest that plg plays an essential role in protecting against the spontaneous development of chronic otitis media. Our findings also suggest the possibility of using plg for clinical therapy of certain types of otitis media.

Finite element analysis of active Eustachian tube function.

The inability to open the collapsible Eustachian tube (ET) has been related to the development of chronic otitis media. Although ET dysfunction may be due to anatomic and/or mechanical abnormalities, the precise mechanisms by which these structural properties alter ET opening phenomena have not been investigated. Previous investigations could only speculate on how these structural properties influence the tissue deformation processes responsible for ET opening. We have, therefore, developed a computational technique that can quantify these structure-function relationships. Cross-sectional histological images were obtained from eight normal adult human subjects, who had no history of middle ear disease. A midcartilaginous image from each subject was used to create two-dimensional finite element models of the soft tissue structures of the ET. ET opening phenomena were simulated by applying muscle forces on soft tissue surfaces in the appropriate direction and were quantified by calculating the resistance to flow (R(v)) in the opened lumen. A sensitivity analysis was conducted to determine the relative importance of muscle forces and soft-tissue elastic properties. Muscle contraction resulted in a medial-superior rotation of the medial lamina, stretching deformation in the Ostmann's fatty tissue, and lumen dilation. Variability in baseline R(v) values correlated with tissue size, whereas the functional relationship between R(v) and a given mechanical parameter was consistent in all subjects. ET opening was found to be highly sensitive to the applied muscle forces and relatively insensitive to cartilage elastic properties. These computational models have, therefore, identified how different tissue elements alter ET opening phenomena, which elements should be targeted for treatment, and the optimal mechanical properties of these tissue constructs.