Mucoid Otitis Media Research Articles

Ayurvedic Management of Serous Otitis Media -Case Report

Serous otitis media is also called secretory otitis media or mucoid otitis media. It is characterized by accumulation of nonpurulent effusion in the middle ear cleft and mastoid air cells due to negative pressure produced by dysfunction of the eustachian tube or incomplete resolution of acute otitis media. It is more common occur in children as eustachian tube that connect nasopharynx and anterior wall of middle ear is small and straight. It is characterized by fullness in the ear, mild hearing loss, loss of balance. Symptomatically it can be correlated with Kapha Vataja Badhirya. This case report discusses the Ayurvedic treatment of a case diagnosed as otitis media with effusion, which was posted for myringotomy with grommet insertion. A 42 Year old male patient with complaints of fullness and heaviness of B/L ears along with mild hearing loss since 9 days. The features suggestive of otitis media with effusion were diagnosed by pure tone audiometry and tympanogram. . Management done with OPD based treatment i.e. Vyoshadi Vataka with honey ,Khadridai Vati for chushnarth. Shadabindu Taila for Nasya, Virechana Dhoompaan, gargle with Triphala Yavkut and advised for steam inhalation. Significant result was observed with this treatment protocol in the management of Serous otitis media

Formations of Host Fibers and Bacteria in Human Temporal Bones With Otitis Media.

In temporal bones with otitis media, fibrin and neutrophil extracellular traps (NETs) form a fibrous network with bacteria, which is involved in growth of bacterial clusters/biofilms and chronicity of disease. NETs and fibrin are important in host defense against pathogens; however, their role in otitis media is not well understood. Eight human temporal bones with serous otitis media, 30 with serous-purulent otitis media, 7 with mucoid otitis media, 23 with mucoid-purulent otitis media (OM), 30 with purulent OM, and 30 with chronic otitis media were selected based on histopathologic findings. Fibrous material with bacteria was detected with hematoxylin-eosin, Gram-Weigert, and propidium iodide stains; and its composition was analyzed with immunohistochemistry. Extensive formations of fibrous material with bacteria were observed in 30% of temporal bones with serous-purulent otitis media, 29% with mucoid otitis media, 50% with mucoid-purulent OM, 57% with purulent OM, and 67% of temporal bones with histological evidence of chronic otitis media. Some of these formations showed large bacterial clusters or biofilms. Immunohistochemical analysis showed that fibrous structures were composed of fibrin or NETs. Formations of fibrous material with bacteria were detected in human temporal bones with different types of otitis media. Inflammatory cells were observed mostly in areas with low presence of fibrous structures. The network of fibrous material seems to prevent clearance of bacteria by phagocytic cells and thus influences growth of bacterial clusters or biofilms. Fibrin and NETs may be important for the recurrences and chronicity of disease, and contribute to clogging of tympanostomy tubes in children.

The Continuum of Biofilms in Different Types of Otitis Media

Objective: It is recognized that the various types of otitis media (OM) follow a continuum with early forms of the disease leading to more chronic forms over time. This study investigates if biofilms play a role in conjunction with the continuum of pathological changes in different stages of OM. Method: Thirty human temporal bones of each type, sero- purulent OM (SPOM), purulent OM (POM), chronic OM with purulent effusion (PCOM), and fourteen mucoid OM (MOM), were selected. We defined “web-like structures” with host defense cells and bacterial bodies as biofilm. We examined the occurrence, frequency, and anatomic locations of biofilms. Results: Biofilms were observed in 10 (33.3%) of the 30 temporal bones with SPOM, 19 (63.3%) with POM, and 20 (66.7%) with PCOM. A significant difference of biofilms’ frequency between SPOM and POM ( P = .038), and SPOM and PCOM ( P = .017), was observed. The most common anatomic location was mastoid antrum and mastoid cells (35 of 49 temporal bones, 71.4%). The number of anatomic locations with biofilms was 2.20 ± 1.03 in SPOM, 2.89 ± 1.70 in POM, and 4.15 ± 1.60 in PCOM. There was a significant difference of locations between PCOM and SPOM ( P < .001), and PCOM and POM ( P = .022). Conclusion: The frequency of biofilms suggests that the presence of biofilms is associated with the severity of OM. The growth and development of biofilms may play an important role in the progression of chronicity of OM.

Experimental evidence suggestive of early intervention in mucoid otitis media

Conclusions. Mucoid effusion can undergo a process of organization related to the inflammatory process and hypoventilation; organized effusion in the presence of epithelial breaks is a potential source for formation of granulation tissue and cholesterol granuloma within 3 months of evolution. Objectives. The aim of this study was to investigate the evolution of mucoid otitis media and its relationship with the organized effusion within a time-span of 3 months. Materials and methods. Two groups of animals were selected. In group I, 15 chinchillas had a chemically modified bovine collagen type 2 gelatin membrane placed through a mechanically induced tympanic membrane perforation, bridging the external auditory canal and the promontory. In group II, 75 cats underwent eustachian tube obstruction with soft grade silastic sponges. Experimental phases and animal sacrifices were performed under general anesthesia. After sacrifice, temporal bones were prepared, stained with hematoxylin and eosin and evaluated under light microscopy. Results. The experimental ears in both groups were observed to undergo gradual pathological changes with increasing survival times. The acute inflammatory phase turned into chronic irreversible changes, which correlated directly with the initial amount of effusion and the areas of epithelial breaks, granulation tissue, cholesterol granuloma, and epithelial migration.

IL-1β promotes the ciliogenesis of human middle ear epithelial cells: possible linkage with the expression of mucin gene 8

ConclusionsThese findings suggest that IL-1β increases ciliogenesis in NHMEE cells and that MUC8 protein may play a role in this process. ObjectivesThe morphology of the middle ear epithelium changes under various pathologic conditions. We compared the density of ciliated cells and the level of mucin gene 8 (MUC8) mRNA in the middle ear epithelial cells of mucoid otitis media (MOM) patients with those of normal controls. We also investigated the effect of IL-1β on the ciliogenesis and expression of MUC8 mRNA in cultured normal human middle ear epithelial (NHMEE) cells. In addition, we localized the MUC8 protein in cultured NHMEE cells. Material and methodsThe surface morphology of NHMEE cells was examined using scanning electron microscopy. Reverse transcriptase polymerase chain reaction was performed to determine the level of MUC8 mRNA expression. After synthesis of MUC8 polyclonal antibody, we performed immunohistochemical staining. ResultsThe density of ciliated cells was increased in the middle ear epithelium of both MOM patients and IL-1β-treated cultures. Similarly, the expression of MUC8 was increased in both cases. MUC8 antibody was primarily stained on the ciliated cells of NHMEE cells.

ペニシリン耐性菌によるムコーズス中耳炎例

A 65-year-old man complained of severe otalgia, occipital pain, hearing loss and otorrhea was referred to our hospital. Otoscopic examination demonstrated hyperemia and bulging of the left ear drum. The bacteria isolated from otorrhea was a mucoid type of Streptococcus pnemoniae. It was also penicillin-resistant Streptococcus pneumoniae (PRSP). The patient was diagnosed as having mucoid otitis media. Intravenous administration of piperacillin sodium (PIPC) diminished otalgia, occipital pain and otorrhea. However, the patient continued complain of hearing loss and a sensation of ear fullness. Due to acute sensorineural hearing loss, the patient was administered steroids. Nevertheless, bone conduction hearing loss persisted. This is the first report of otitis media demonstrating not only the mucoid type of Streptococcus pnemoniae but also PRSP.

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.

Characterization of mucins in human middle ear and Eustachian tube.

Mucins are important glycoproteins in the mucociliary transport system of the middle ear and Eustachian tube. Little is known about mucin expression within this system under physiological and pathological conditions. This study demonstrated the expression of MUC5B, MUC5AC, MUC4, and MUC1 in the human Eustachian tube, whereas only MUC5B mucin expression was demonstrated in noninflamed middle ears. MUC5B and MUC4 mucin genes were upregulated 4.2- and 6-fold, respectively, in middle ears with chronic otitis media (COM) or mucoid otitis media (MOM). This upregulation of mucin genes was accompanied by an increase of MUC5B- and MUC4-producing cells in the middle ear mucosa. Electron microscopy of the secretions from COM and MOM showed the presence of chainlike polymeric mucin. These data indicate that the epithelium of the middle ear and Eustachian tube expresses distinct mucin profiles and that MUC5B and MUC4 mucins are highly produced and secreted in the diseased middle ear. These mucins may form thick mucous effusion in the middle ear cavity and compromise the function of the middle ear.

Detection of Mucin Gene Expression in Normal Rat Middle Ear Mucosa by Reverse Transcriptase-Polymerase Chain Reaction

Hypersecretion of mucin is a common feature of chronic and mucoid otitis media which may play an important role in hearing loss. The mechanisms controlling mucin secretion in the middle ear are not completely understood. Our reverse transcriptase-polymerase chain reaction results demonstrate that mRNAs of MUC1, MUC2, MUC3, MUC4 and MUC5AC are expressed in normal rat middle ear mucosa. Moreover, the expression of mRNA of the secretory mucins MUC2, MUC3 and MUC5AC was threefold lower in normal middle ear mucosa than that in the intestine or trachea. In contrast, expression of the membrane-bound mucins MUC1 and MUC4 was approximately the same in both middle ear mucosa and the intestine or trachea. MUC5AC proteins were also identified immunohistochemically in normal rat middle ear epithelium. The methodology used in this study provides useful baseline information for investigation of the mechanisms of regulation of mucin gene expression during otitis media.

Tympanic membrane and middle ear pathologic correlates in mucoid otitis media

Objective: The goal of this study was to correlate tympanic membrane (TM) and middle ear (ME) pathologies in mucoid otitis media (MOM). Methods and Material: Forty ears with MOM and 56 control ears were retrospectively evaluated for TM and ME pathologies. Comparisons of TM thicknesses in MOM versus control ears were correlated with the Student t test; χ 2 analysis was used to correlate pathologic findings of the TM and ME. Results: Thicknesses in all quadrants except the umbo were increased in MOM because of infiltration of inflammatory cells and fibrosis. The most common ME pathologies were granulation tissue and fibrosis. Significant correlations included (1) TM retraction and ME granulation tissue and fibrosis and (2) pars flaccida, posterosuperior, and anteroinferior thickness and ME granulation tissue and fibrosis. Conclusion: TM changes are likely to occur in patients with otitis media with effusion (MOM), and their presence is a strong indication of underlying ME pathology. (Otolaryngol Head Neck Surg 2000;123:258–62.)

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.

Expression of glycoconjugates in human eustachian tubes with otitis media.

To characterize glycoconjugate expression in normal human eustachian tubes and study the alterations in glycoconjugate expression found in eustachian tubes with otitis media. Using lectin histochemistry, alterations in glycoconjugates were studied in three normal temporal bones, in four temporal bones with mucoid otitis media (MOM), and in five with serous otitis media (SOM). Sections of previously processed temporal bones were decelloidinized, and then incubated with seven biotinylated lectins--WGA, SNA, MAA, BPA, PNA, UEA-1, and LcH--that reflect seven carbohydrate residues of glycoconjugates, respectively: GlcNAc/NeuNAc, NeuNAc alpha(2-6)GalNAc, NeuNAc alpha(2-3)GalNAc, Gal beta(1-3) GalNAc, L-fucose, and alpha-mannose residues. Control sections were incubated with inhibitory carbohydrates or without biotinylated lectins. In the normal temporal bones, five carbohydrate residues in goblet cells and cilia of the eustachian tube demonstrated moderate to strong activity--NeuNAc alpha(2-6)GalNAc, NeuNAc alpha(2-3)GalNAc, GalNAc, Gal beta(1-3)GalNAc, and L-fucose. Two residues demonstrated weak activity--GlcNAc/NeuNAc and alpha-mannose. Temporal bones with MOM revealed increases in sialic acid and alpha-mannose, and a decrease in L-fucose. Residues of carbohydrates in the cilia of bones with SOM were notably decreased, especially for GalNAc, Gal beta(1-3)GalNAc, and NeuNAc alpha(2-6)GalNAc. Glycoconjugates in the normal human eustachian tube are rich in GalNAc, Gal beta(1-3)GalNAc, L-fucose, and NeuNAc alpha(2-3/2-6) GalNAc, but low in alpha-mannose and sialic acid. Eustachian tubes from cases with SOM or MOM demonstrated alterations in glycoconjugate expression in cilia and goblet cells, which may reflect disorder of the carbohydrate metabolism during otitis media, especially in SOM.

Dexamethasone Inhibits Mucous Glycoprotein Secretion via a Phospholipase A2 -Dependent Mechanism in Cultured Chinchilla Middle Ear Epithelial Cells

Lin J, Juhn SK, Adams GL, Giebink GS, Kim Y. Dexamethasone inhibits mucous glycoprotein secretion via a phospholipase A2-dependent mechanism in cultured Chinchilla middle ear epithelial cells. Acta Otolaryngol (Stockh) 1997; 117: 406-413.Inhibition or attenuation of mucous hypersecretion in middle ear epithelium is a key step toward resolution of mucoid otitis media. Mucous hypersecretion induced by platelet-activating factor (PAF) in cultured Chinchilla middle ear epithelial cells is dependent on arachidonic acid metabolites via PAF receptors, suggestive of the role of phospholipase A2 (PLA2) in mucous glycoprotein (MGP) secretion. In this study, dexamethasone added to cultured Chinchilla middle ear epithelial cells inhibited baseline and PAF-induced MGP secretion in a concentration-dependent manner. A definite time lag (16 h) was observed between administration of dexamethasone and MGP inhibition. This inhibition was reversed by the addition of exogenous PLA, (the rate-limiting enzyme of arachidonic acid metabolism) and actinomycin D (an inhibitor of mRNA synthesis). This suggests that dexamethasone inhibits baseline and PAF-induced MGP secretion via a PLA2-dependent mechanism.

Quantitative Analysis of Soluble Cell Adhesion Molecules in Otitis Media with Effusion

The levels of the soluble intercellular adhesion molecule 1 (sICAM-1) and soluble granule membrane protein-140 (sGMP-140) were measured in middle ear effusions (MEEs) of otitis media (OM) with ELISA. MEEs of chronic serous and mucoid OM in children contained significantly higher levels of sICAM-1 and sGMP-140 compared with normal serum. sGMP-140 in acute and chronic OM in children was higher than in adult chronic serous OM, and in acute purulent OM higher chronic serous OM in children. Cytologic analysis showed that the mean level of sGMP-140 was significantly higher in the neutrophil dominant group than in other groups except the few cells type. sICAM-1 showed no differences among the cytologic classifications. Copious amounts of sICAM-1 and sGMP-140 in MEEs were observed in this study, and were probably the result of shedding from the cells expressed cell adhesion molecules. These cell adhesion molecules in MEEs were thought to modify the inflammatory response in OM.

Arachidonic Acid Metabolites in Experimental Otitis Media and Effects of Anti-Inflammatory Drugs

Previous studies have shown that arachidonic acid (AA) metabolites are important in the pathogenesis of otitis media with effusion. The AA metabolites in 4 different experimental models for otitis media were analyzed, and the effect of anti-inflammatory drugs was studied. Purulent otitis media was induced in rats by inoculation of Streptococcus pneumoniae in the tympanic bulla, serous otitis media by blocking the tympanal orifice of the eustachian tube, and mucoid otitis media by combining the two procedures. Middle ear effusion was also induced by stimulating the external auditory canal with cold air. Indomethacin and hydrocortisone were used to inhibit AA metabolism in the latter model. Lipoxygenase products dominated in the purulent and cold air otitis media models. Cyclooxygenase products dominated in the mucoid and serous models. Indomethacin inhibited accumulation of middle ear effusion in the cold air otitis media model, whereas hydrocortisone did not. Apart from AA metabolites, other mechanisms and mediators appear to be responsible for the increased vessel permeability observed in the cold air otitis media model, such as interactions between mast cells and nerves in the middle ear mucosa.

Morphometric Studies of the Continuum of Otitis Media

Morphometric changes in the epithelium and subepithelium of the middle ear mucosa from children younger than 10 years of age were measured at the promontory in 85 temporal bones with otitis media and in 29 normal temporal bones by use of quantitative and semiquantitative methods. Comparisons of morphologic analysis in different otitis media types showed that acute inflammatory changes were usually seen in purulent otitis media with effusion and serous otitis media with effusion, and chronic inflammatory changes were more severe in mucoid otitis media with effusion and chronic otitis media. There were overlaps, however, in histopathologic findings between different types of otitis media that suggest a continuum of otitis media types, with one type of otitis media changing into another type.

Pathology and pathogenesis of tympanic membrane retraction

Temporal bones without evidence of otitis media, as well as temporal bones with various types of otitis media, were examined for the presence of retractions of the tympanic membrane and their related histopathologic progression to the formation of cholesteatoma. Retractions were not present in non-otitis media, purulent, or mucoid otitis media. Retractions were observed in 2.1% of temporal bones with serous otitis media and 19.5% of temporal bones with chronic otitis media. All temporal bones with retractions demonstrated evidence of current or previous otitis media. Histopathologic changes of the middle ear cleft were associated with the type and degree of retraction. This study supports the continuum theory according to which otitis media with effusion eventually leads to a variety of sequelae and/or to chronic otitis media. The tympanic membrane appears to follow progressive changes, from simple retraction to retraction pockets and finally to cholesteatoma.

Bacteriology of chronic otitis media with effusion

Samples of middle ear effusions from 102 children with serous and mucoid otitis media were cultured for mycoplasmas and bacteria. No sample yielded mycoplasmas but bacteria were cultured from 48 (47 per cent). Organisms commonly regarded as pathogens were present in 25 samples (Haemophilus influenzae 17, Streptococcus pneumoniae four, other streptococci four). The only sample from which anaerobic bacteria were isolated was from a patient with cholesteatoma.

Prostaglandins and Other Arachidonic Acid Metabolites in the Middle Ear Fluids

Prostaglandins (PGs) and other arachidonic acid (AA) metabolites have been recognized as mediators of inflammation and bone resorption, chemotactic agent to polymorphonuclear leukocytes (PMN), and regulators of inflammatory response. Although assays of some PGs in the middle ear fluid (MEF) were reported, there has been no report on comprehensive assay of PGs and other AA metabolites in MEF. Concentrations of PGs were measured by radioimmunoassay in human MEF. The data on human MEF were analyzed according to age group. In addition, levels of lipoxygenase-products, 5- and 15-hydroxyeicosatetraenoic acid (HETE) and leukotriene (LT)C4 were measured in human MEF. Levels of PGE2 in MEF from human serous otitis media (SOM) were highest in younger age group (below the age of 10) then the levels drop down to lower level in older age group. In human mucoid otitis media (MOM) the levels of PGE2 are lower than SOM in younger age group then become higher than SOM in older age group. Levels of 6-keto-PGF1 alpha were higher in SOM than in MOM overall. The age breakdown of data showed progressive increase in the 6-keto-PGF1 alpha levels with older age group. Levels of TxB2 in SOM were higher than in MOM overall. The age breakdown of SOM data remained almost the same in all the age groups but the MOM data showed lowest levels in 6-10 year-old group and highest in 11-15 year-old group. Concentrations of 15-HETE in human MOM were over two times higher than in SOM. LTC4 levels in MOM were higher than SOM.(ABSTRACT TRUNCATED AT 250 WORDS)

Children with persistent otitis media. Audiometric and tympanometric findings.

Audiometric and tympanometric findings were compared among 129 patients with clinically manifest persistent otitis media (OM) with effusion. Ears with thick effusion (mucoid OM) had significantly larger air-bone gaps and higher prevalence of flat tympanograms than either of the thin effusion types (purulent [POM] or serous OM [SOM]) or ears with no effusion (dry). Ears with thin effusion (POM and SOM) had similar air-bone gaps, thresholds for air and bone conduction, and prevalences of flat and underpressure tympanograms. Ears with no effusion had significantly smaller air-bone gaps, slightly poorer bone conduction thresholds, and lower prevalence of flat tympanograms than ears with effusion (MOM, POM and SOM). Ears with clinically manifest OM and no effusion at tympanocentesis appear to represent patients with a spontaneously resolved episode of OM with thin effusion (POM or SOM) or with ears that evacuated during anesthesia prior to tympanostomy.