Mucoid Effusions Research Articles

Effect of Blood and Mucus on Tympanostomy Tube Biofilm Formation

Tympanostomy tube (TT) biofilm formation may lead to refractory otorrhea and occlusion. The aim of this study was to determine whether TT biofilm formation may be promoted by mucus or blood exposure. In vitro, controlled. Fluoroplastic TTs were exposed to blood, mucoid effusion, or saline. Half were allowed to dry. TTs were cultured with Pseudomonas aeruginosa. After 4 days, gentamicin was added to kill planktonic bacteria. Biofilm formation was assessed by quantitative bacterial counts and scanning electron microscopy. Mucus pretreatment (dry and wet) did not increase biofilm formation. Both dry and wet blood exposure increased biofilm formation by bacterial counts (P < .0001). Biofilm formation was demonstrated by electron microscopy in all groups. P. aeruginosa biofilm formation on fluoroplastic TTs is enhanced by blood exposure. Care should be taken to minimize bleeding with TT placement to reduce the risk of biofilm formation.

The method of application and short term results of tympanostomy tubes for the treatment of primary secretory otitis media in three Cavalier King Charles Spaniel dogs

Primary secretory otitis media is an uncommon disease affecting predominantly Cavalier King Charles Spaniel dogs. Current treatment recommendations include repeated manual removal of the mucoid effusion from the tympanic cavity through a myringotomy incision and topical or systemic corticosteroids. The aim of this study was to assess the efficacy of tympanostomy tubes to provide continual tympanic cavity ventilation and drainage for the treatment of primary secretory otitis media in three dogs. Tympanostomy tubes were placed within a myringotomy incision in the pars tensa with the aid of an operating microscope. Clinical signs resolved rapidly in all cases following the procedure and all cases were asymptomatic at the time of follow-up, 8, 6 and 4 months later. Results of this study indicate that tympanostomy tubes provide continual tympanic cavity ventilation and drainage and may be an acceptable alternative to repeated myringotomy for the treatment of primary secretory otitis media.

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In this issue

Factors of the blockage of ventilation tubes in the immediate postoperative period

Postoperative ventilation tube (VT) blockage is relatively common with a reported incidence of 0.0-13.1%. The purpose of this study was to evaluate the factors that contribute to postoperative VT blockage. A retrospective chart review was carried out to compare rates of VT blockage within 2 weeks postsurgery. Analyzed factors included: otic drop, nature, and amount of middle ear (ME) effusion, presence of ME mucosa edema or granulation, bleeding during surgery, number of prior VT insertion, and the status of the tympanic membrane (TM). One hundred and twenty-eight ears from 79 patients were enrolled in this study. Eleven VTs (8.6%) were obstructed within 2 weeks postsurgery. Ears using ciprobay and tarivid otic drops showed a significantly higher rate of tube blockage (14.1%) compared to ears that were not exposed to otic drops (1.8%). Glue effusion caused the highest rates (14.8%) of tube blockage compared to mucoid (9.6%) and serous (3.0%) effusions. The amount of effusion, the presence of mucosal edema or granulation, bleeding during surgery, number of prior VT insertions and the status of the TM were not associated with postoperative VT blockage. The results of this study suggest that the routine use of antibiotic-containing otic drops after the insertion of VT may not be useful. Viscosity of the effusion appears to have an effect on the postoperative VT blockage. Thus, more attention should be focused on the ears with glue or mucoid effusions after surgery.

Ultrasonic Detection of Middle Ear Effusion

To assess the ability to detect and characterize middle ear effusion in children using A-mode ultrasonography. Prospective nonblinded comparison study. Tertiary children's hospital. Forty children (74 ears) scheduled to undergo bilateral myringotomy with pressure equalization tube placement. Before myringotomy, ultrasound examination of the tympanic membrane and middle ear space was performed on each ear. Afterward, myringotomy was performed and the type of effusion (serous, mucoid, or purulent) was recorded. Pressure equalization tubes were then placed. Comparison of ultrasound findings with the visual assessment of the type of middle ear effusion present. Of the 74 ears tested, 45 (61%) had effusion on direct inspection. The effusion was purulent in 8 ears (18%), serous in 9 ears (20%), and mucoid in 28 ears (62%). Ultrasound identified the presence or absence of effusion in 71 cases (96%) (P = .04). Ultrasound distinguished between serous and mucoid effusion with 100% accuracy (P = .04). The probe did not distinguish between mucoid and purulent effusion. Ultrasonography is an accurate method of diagnosing middle ear effusion in children. Moreover, it can distinguish thin from mucoid fluid. Further refinements in probe design may further improve the sensitivity of fluid detection and allow differentiation of sterile vs infectious effusion.

Expression of mucins in mucoid otitis media.

A hallmark of mucoid otitis media (MOM, i.e., chronic otitis media with mucoid effusion) is mucus accumulation in the middle ear cavity, a condition that impairs transduction of sounds in the ear and causes hearing loss. The mucin identities of mucus and the underlying mechanism for the production of mucins in MOM are poorly understood. In this study, we demonstrated that the MUC5B and MUC4 were major mucins in MOM that formed distinct treelike polymers (mucus strands). The MUC5B and MUC4 mRNAs in the middle ear mucosa with MOM were up regulated 5-fold and 6-fold, compared with the controls. This upregulation was accompanied by the extensive proliferation of the MUC5B- and MUC4-producing cells in the middle ear epithelium. Further study indicated that the mucin hyperproduction was significantly linked to CD4+ and CD8+ T cells and/or CD68+ monocyte macrophages. It suggests that MUC5B and MUC4 expression may be regulated by the products of these cells.

Defining tympanostomy tube plugs.

To define the composition of tympanostomy tube plugs because selecting or developing effective solvents depends on such knowledge. Prospective, in vitro laboratory study. Luminal contents of 105 plugged, microscopically removed tympanostomy tubes were expressed, pooled, acid hydrolyzed, and passed through a high-performance liquid chromatography column. Retention times were compared with high-performance liquid chromatography standards to develop free amino acid and monosaccharide profiles. Cerumen, blood, and chronic mucoid effusion (collected during myringotomy) were pooled and subjected to the same analysis. The elution profiles of each substance were compared to determine which substance most closely matched the plugs. High-performance liquid chromatography amino acid and monosaccharide analysis demonstrated greatest similarity between tympanostomy tube plugs and mucoid effusion. Tympanostomy tube plug composition is more similar to mucoid effusion than to blood or cerumen. Solvents to open plugged tympanostomy tubes should be directed against the components of mucoid effusion.

Induction of Mucous Cell Metaplasia in the Middle Ear of Rats Using a Three-step Method: An Improved Model for Otitis Media with Mucoid Effusion

Otitis media with mucoid effusion, characterized by mucous cell metaplasia in the middle ear cleft and thick fluid accumulation in the middle ear cavity, is a common otological disease that frequently affects young children. Multiple factors are involved in the development of this disease, especially middle ear infection and Eustachian tube dysfunction. In this study, in order to induce otitis media with effusion in rats, we introduced a three-step method, namely inoculation of Streptococcus pneumoniae at 10 7 colony-forming units (CFU) ear or Haemophilus influenzae at 5 ½ 10 7 CFU ear into the middle ear cavity twice at 2-week intervals, followed by Eustachian tube obstruction (ETO) for 4 and 8 weeks. Animals inoculated with phosphate-buffered saline (PBS) twice in the same manner followed by ETO served as controls. Middle ear effusion and mucosa were harvested for evaluation of carbohydrate concentrations and mucous cell density, respectively. We found that rats inoculated with S. pneumoniae twice, followed by ETO at 8 weeks, yielded the highest carbohydrate concentration in middle ear effusion and the highest goblet cell density in the middle ear cavity compared to the H. influenzae and PBS groups. It is tentatively concluded that inoculation of S. pneumoniae at 10 7 CFU ear into the middle ear cavity of rats twice at 2-week intervals, followed by ETO for 8 weeks, is a promising animal model for otitis media with mucoid effusion which may be valuable for studying the human counterpart.

Compositional difference in middle ear effusion: mucous versus serous.

Serous otitis media is usually responsive to medical treatment, whereas mucoid otitis media is not. The present study was undertaken to elucidate the compositional difference between serous and mucoid effusion and to investigate whether MUC5AC acts as a major mucin in the middle ear mucosa with mucoid otitis media. This study involved a chemical analysis of middle ear effusion and immunostaining of the middle ear mucosa. Middle ear effusion samples were collected from 27 patients with mucoid otitis media and 18 patients with serous otitis media. The levels of mucin, lysozyme, secretory immunoglobulin A, and interleukin-8 were measured by dot blotting or enzyme-linked immunosorbent assay. Periodic acid-Schiff and immunohistochemical staining with monoclonal anti-MUC5AC antibody were performed on the serial sections of middle ear mucosa with mucoid otitis media. Mucoid effusions contained higher levels of mucin, lysozyme, secretory immunoglobulin A, and interleukin-8 than did serous effusions. Immunohistological study revealed that MUC5AC mucin was expressed in only a small portion of the goblet cells of middle ear mucosa with mucoid otitis media. The study suggests that both serous secretions and mucin might make the middle ear effusion more viscous and that mucins other than MUC5AC might have a major role in the viscosity of middle ear effusion. Further study is necessary to identify the major mucins in the middle ear effusion of otitis media with effusion.

Serous or mucoid effusion in the course of secretory otitis media: influence of ion transport modulation

Objective: Secretory otitis media is defined by a chronic effusion in the middle ear cavities, behind an intact tympanic membrane without acute infection. In the course of secretory otitis media, the effusion is sometimes thick (or mucoid) and other times thin (or serous). For several authors, these differences might be related to different inflammatory levels rather than to distinct pathophysiological mechanisms. The purpose of this study was to determine whether the modulation of ion transport by inflammation could account for the differences observed in the aspect of ME effusion. Methods: Hydrogen peroxide (H 2O 2), used as an inflammation model was tested on a middle ear cell line (MESV) in culture. Results: Results show that low and high concentrations of H 2O 2 have opposite effects on ion (and then water) absorption by the middle ear epithelium. Conclusion: the modulation of ion and water absorption by inflammation could modify the mucins concentration in the effusion, and explain observed viscosity differences in the course of secretory otitis media.

Induction of Mucin Gene Expression in Middle Ear of Rats by Tumor Necrosis Factor–α: Potential Cause for Mucoid Otitis Media

Mucoid otitis media (MOM) is characterized by viscous fluid, high in mucin concentration, which accumulates in the middle ear cavity. Recent studies suggest that initial infection in the middle ear cleft may be key to the development of MOM. However, factors of the initial infection attributed to the stimulation of mucin production are not clearly understood. This study demonstrated that tumor necrosis factor (TNF)-alpha, a proinflammatory cytokine in mucoid effusion, markedly increased Muc2 mucin mRNA expression in middle ear epithelium, in a time- and dose-dependent manner. Parallel to this was a marked increase in mucin glycoprotein in middle ear fluid. Also, TNF-alpha demonstrated an autocrine and/or paracrine effect on the expression of endogenous TNF-alpha gene in the middle ear, which may contribute to the production of mucin in this study. These findings suggest that TNF-alpha plays an important role in the development of MOM by stimulating mucin metabolism.

Evidence of oxygen free radical damage in human otitis media

Recent work with a guinea pig model of otitis media has demonstrated evidence of oxygen free radical damage to the middle ear mucosa. However, the relevance of an animal model to human disease is uncertain. Accordingly, the following pilot study was conducted to examine human middle ear fluid for lipid hydroperoxides as evidence of free radical damage. Thirty-five specimens of middle ear fluid from children with chronic otitis media were collected and described as mucoid (n = 19), purulent (n = 10), or serous (n = 6); specimens were weighed and analyzed for lipid hydroperoxide content. The results demonstrated the presence of lipid hydroperoxide in all 3 types of middle ear fluid. Additionally, there was a statistically significant elevation of total lipid hydroperoxide content in mucoid effusions compared with serous effusions, as well as a significant elevation of lipid hydroperoxide divided by weight of purulent effusions compared with serous effusions. This is the first study to document free radical damage in human otitis media. (Otolaryngol Head Neck Surg 1999;120:638-42.)

Otorrhea After Insertion of Silver Oxide–Impregnated Silastic Tympanostomy Tubes

Silver oxide-impregnated tympanostomy tubes have been shown to decrease the incidence of postoperative otorrhea, but without a significant effect in the first postoperative week. To evaluate prospectively our results with silver oxide-impregnated tympanostomy tubes and to identify factors associated with a higher incidence of early postoperative otorrhea. Prospective nonrandomized study. University referral center. Six hundred thirty patients with chronic otitis media with effusion or recurrent otitis media. Silver oxide-impregnated Silastic tympanostomy tubes were inserted in 1254 ears. Subjects with mucoid or purulent effusions or blood at the myringotomy site at surgery were treated with topical antibiotic prophylaxis (sulfacetamide sodium-prednisolone acetate or neomycin sulfate-polymyxin B sulfate-hydrocortisone) for 5 days after tympanostomy tube placement. Incidence of otorrhea after tympanostomy tube insertion at 1 week and 1, 3, 6, 9, and 12 months after surgery. The overall incidence of postoperative otorrhea was 1.9%. The incidence of otorrhea in the first postoperative week was 5.6%; the incidence of otorrhea after the first postoperative week was 1.2% (P<.001). Within the first postoperative week, a significantly greater incidence of otorrhea was noted in patients younger than 3 years (7.8%), in patients with mucoid effusions at surgery (8.6%), and in patients younger than 3 years with mucoid effusions at surgery (15.2%). Silver oxide-impregnated tympanostomy tubes are associated with a low overall incidence of postoperative otorrhea. A significantly higher incidence of otorrhea is seen during the first postoperative week, compared with the incidence after the first week. Patients with thick middle ear effusions and age younger than 3 years have a significantly greater incidence of early otorrhea after tympanostomy tube placement.

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

To characterize the existence and role of transforming growth factor-beta (TGF-beta) in otitis media with effusion (OME). Retrospective. 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. 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). 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.

Soluble adhesion molecules in middle ear effusions from patients with chronic otitis media with effusion

Soluble forms of intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) have been identified in the peripheral blood and other body fluids. These soluble adhesion molecules have been reported to reflect the upregulation of cell surface ICAM-1 and VCAM-1 expression in inflammatory diseases. The levels of soluble ICAM-1 and soluble VCAM-1 in 37 middle ear effusions from 37 patients with chronic otitis media with effusion (OME) were quantitatively determined with enzyme-linked immunosorbent assays. The levels of soluble ICAM-1 in mucoid effusions were significantly higher than those in serous effusions, but the levels of soluble VCAM-1 did not differ significantly between the two types of effusion. The levels of soluble VCAM-1 in effusions from atopic patients were significantly higher than those from non-atopic patients, whereas the levels of soluble ICAM-1 in samples from atopic patients were significantly lower than those from non-atopic patients. Therefore, our data suggest that an increase in soluble VCAM-1 plays a more important role in the pathogenesis of OME in atopic patients than in non-atopic patients. In addition, soluble ICAM-1 is likely to play a more important role in the pathogenesis of OME in nonatopic patients than soluble VCAM-1.

中耳炎に伴う骨導聴力低下

In chronic otitis media, bone conduction hearing impairments at high frequencies are common. However, it is unclear whether the raised bone conduction thresholds are a reflection of inner ear damage or an artificial elevation of bone conduction thresholds associated with a conductive disorder. Bone conduction measurements were performed on 7 ears from patients with acute mastoiditis, on one ear from an OME patient, and on two ears from cholesterol granuloma patients. In these ears, the raised bone conduction thresholds were characteristically demonstrated at 2000Hz before treatment. After the insertion of a tympanostomy tube, the bone conduction hearing improved in a few days. Therefore, the raised bone conduction thresholds are not likely to reflect the damage to the inner ear. The characteristic findings in these cases were of purulent and mucoid effusion in the middle ear and the mastoid cavity, and granulation tissue around the incus and stapes.The cause of the bone conduction hearing loss was considered to be related to an abnormal sound conduction mechanism, such as the suppression of the resonant point of ossicle, rather than to disease damage to the inner ear.

Neutrophil elastase-alpha 1-antitrypsin in middle ear fluid in chronic otitis media with effusion.

Neutrophil elastase-alpha 1-antitrypsin was quantified in samples taken from middle ear effusions collected at operation from 17 children attending for elective myringotomy and grommet insertion. At the time of surgery the effusion was classified as serous or mucoid. Children with a recent history of infection or antimicrobial therapy were excluded. The quantification of immunoreactive neutrophil elastase was by means of enzyme-linked immunosorbant assay (ELISA). The mean value of neutrophil elastase-alpha 1-antitrypsin was 50.6 +/- 38.3 (SD) micrograms/ml in mucoid effusions, which was significantly higher (P < 0.05) than that in serous effusions (5.3 +/- 4.8 micrograms/ml). These results indicate that a mucoid effusion may reflect a more severe inflammatory response and that persistence of neutrophil activity in the middle ear mucosa may contribute to the persistence of at least one group of middle ear effusions.

Biochemical evidence of platelet-activating factor (PAF) in human middle ear effusions.

Platelet-activating factor (PAF) is one of the most potent biological lipid mediators. This is especially true in relation to inflammation. In order to characterize the biochemical features of otitis media with effusion, the authors characterized and determined the concentration of the PAF present in human middle ear effusions obtained from 23 patients with otitis media with effusion. Each sample of middle ear effusion was divided into two groups: serous (n = 12) and mucoid effusions (n = 11). The platelet-activating factor activity was found mainly in mucoid middle ear effusions, and the amounts of PAF were higher in mucoid type (3.55 +/- 1.19 ng/g, mean +/- standard deviation [SD]) than in the serous type (0.44 +/- 0.19 ng/g). Phospholipids obtained from the middle ear effusions contained a large amount of lyso-platelet-activating factor, the biologically inactive precursor or breakdown product of platelet-activating factor. Based on these findings, it is suggested that platelet-activating factor may play an important role as a mediator of the inflammatory responses in the pathogenesis of otitis media with effusion.

OCCURRENCE OF STREPTOCOCCUS PNEUMONIAE AND HAEMOPHILUS INFLUENZAE IN OTITIS MEDIA WITH EFFUSION

Eighty mucoid effusion samples obtained from 56 patients with otitis media with effusion (OME) were subjected to quantitative and qualitative bacteriological analysis using standard culturing methods, direct microscopy and immunofluorescent assay. 30% of the samples contained culture-positive pathogens (H. influenzae, S. pneumoniae, B. catarrhalis), with counts never exceeding 5 times 105 per ml. In addition, 19% of the samples had dormant H. influenzae and S. pneumoniae, which did not grow on standard agar plates. Viable and dormant bacteria, as well as bacterial remnants, play a crucial role in the pathogenesis of OME and similarities between OME and reactive arthritis, i.e. Lyme arthritis, Reiter's syndrome and rheumatic fever, are evident.

浸出性中耳炎と鼓膜切開

Myringotomy is commonly performed in the treatment of otitis media with effusion (OME). However, it has been reported that the effect of myringotomy is limited and that OME recurs frequently after this procedure.In this investigation, the recurrence rate of OME 6 months after myringotomy and factors which affect the recurrence were examined in 94 patients with OME, aged 6 to 83 years. Forty-six patients had paranasal sinusitis, and 9 had allergic rhinitis. Nasal mucociliary function was examined with the saccharin test, described in a previous report.The recurrence rate of OME was 68.1%, similar to that in previous reports. Patients with mucoid effusions had more frequent recurrences than did those with serous effusions (p<0.01). The recurrence rate was significantly higher in children than in adults (p<0.05). Patients with OME for more than 3 months (p<0.001) or bilateral OME (p<0.001) had higher recurrence rates than did those with OME for less than 3 months or those with unilateral OME. OME recurred more frequently in patients with paranasal sinusitis (p<0.001) or allergic rhinitis (p<0.05) than in those without these nasal diseases. The incidence of markedly prolonged saccharin time (over 30 minutes) was significantly higher (p<0.001) in the recurrent group than in the cured group.