ANALYSIS OF SINONASAL, PHARYNGEAL AND ALLERGY-RELATED RISK FACTORS FOR CHRONIC SUPPURATIVE OTITIS MEDIA

Size: px

Start display at page:

Download "ANALYSIS OF SINONASAL, PHARYNGEAL AND ALLERGY-RELATED RISK FACTORS FOR CHRONIC SUPPURATIVE OTITIS MEDIA"

Angelina Greene
6 years ago
Views:

1 Acta Medica Mediterranea, 2013, 29: 47 ANALYSIS OF SINONASAL, PHARYNGEAL AND ALLERGY-RELATED RISK FACTORS FOR CHRONIC SUPPURATIVE OTITIS MEDIA FERHAT BOZKUS 1, NAZIM BOZAN 2, ISMAIL IYNEN 1, YUNUS FEYYAT SAKIN 3, MUZAFFER KıRıS 4 1 Department of Otorhinolaryngology, Harran University, Faculty of Medicine, Sanliurfa, Turkey - 2 Van Yüzüncü Yıl University, Faculty of Medicine, Department of Otorhinolaryngology - 3 Department of Otorhinolaryngology, Van Akademi Medical Center, Van, Turkey - 4 Department of Otorhinolaryngology Yıldırım Beyazıt University, Faculty of Medicine, Ankara, Turkey ABSTRACT [Analisi dei fattori di rischio nasosinusale, faringe e allergie correlate per otite media cronica suppurativa] Aim: To evaluate potential sinonasal, pharyngeal and allergy-related risk factors that may be associated with the risk of chronic otitis media development. Methods: After a detailed anamnesis, serum eosinophilic cationic protein levels, total and allergen-specific IgE levels and nasal smear samples were assessed for allergy-related findings. Paranasal sinus computed tomography was performed for rhinologic abnormalities. Results: The present study showed more frequently in patients suffering from chronic otitis media, several abnormalities in different allergic parameters such as eosinophil levels in the smear, serum eosinophilic cationic protein, total and specific serum IgE levels, which might cause nasal stuffiness, as hypertrophy of adenoid tissue, and presence of imaging findings consistent with obstruction of osteomeatal unit. Conclusion: This study demonstrates that the role of sinonasal abnormalities and allergic rhinitis in the pathogenesis of chronic otitis media is still prevalent. We have concluded that although medical history, and physical examination are considered mandatory procedures during the initial evaluation of the patients with chronic otitis media, radiological, endoscopic, and other auxillary diagnostic tools should be used in the objective assessment of the patients, and lesions of the nasal cavity, and the nasopharynx must be always taken into consideration in the differential diagnosis. Key words: Sinonasal, pharyngeal, chronic otitis media, otitis media. Received January 31, 2013; Accepted February 12, 2013 Introduction Chronic suppurative otitis media (CSOM) is a persistent inflammation that causes irreversible changes of the mucosa in the middle ear and mastoid cavity. Chronic suppuration can occur with or without cholesteatoma, and the clinical history of both conditions can be very similar. CSOM affects approximately 2% of the population and it is associated with significant functional limitations of hearing, speech and learning (1). Its pathophysiology begins with irritation and subsequent inflammation of the middle ear mucosa. The most important pathological factors in CSOM are dysfunction of the Eustachian tube and bacterial infection. There is no consensus regarding the most effective treatment for CSOM, and both medical and surgical therapies have substantial failure rates (2). Therefore, prevention or early treatment of CSOM is important. This requires knowledge of the risk factors in CSOM, even if there is a substantial lack of these data in international literature (3). Since it is thought that CSOM begins with an episode of chronic otitis media with effusion (COME), it is likely that prognostic factors for COME also play a role in the development of CSOM. These include intrinsic factors such as race, age, previous upper respiratory tract infections and/or acute otitis media, educational level of the parents, and extrinsic (environmental) factors such as parental smoking, and bottle feeding (4,5). The aim of the present study was to evaluate potential sinonasal, pharyngeal and allergy related risk factors that may be associated with CSOM.

2 48 Ferhat Bozkus, Ismail Iynen et Al Materials and methods Study Design: Subjects suffering from CSOM were recruited from patients referred to the Department of Otorhinolaryngology between May 2005 and January 2006 for reasons related to otitis media. As a control group, 103 patients, who had no otologic relevant disease at paranasal sinus computed tomography, were recruited. Prior to study, written informed consents were obtained from all subjects or their proxies. These patients were outpatients of neurology department with a diagnosis of non-infectious, non-cancer illness. The diagnosis of CSOM was made by anamnesis and otoscopic findings in the examination of the ears. Children with a cleft palate (submucosal or overt), patients with neurologic deficits, Down syndrome, craniofacial abnormalities, or other immune dysfunction were excluded from the study. Methods: All subjects underwent a standard otolaryngologist and otomicroscopic examination. After a detailed anamnesis, the patients were also asked about typical symptoms of gastroesophageal reflux, such as pyrosis, regurgitation, dysphagia and emesis. Serum eosinophilic cationic protein (ECP) levels, total and allergen-specific IgE levels and nasal smear samples were assessed for allergy-related findings. Total and allergen-specific IgE levels were measured by using the Immulite 2000 Immunoassay System (Diagnostic Products Corporation, Los Angeles, CA). Patient serum was analysed with an Immulite AlaTop Allergy Screen (Diagnostic Products Corporation) for the detection of IgE antibodies specific to inhalant allergens in serum. IgE determination was performed using an Immulite total IgE system (Diagnostic Products Corporation), which is a solid phase, two-site chemiluminescent immunometric assay. The range of normal values for total IgE was adjusted to age (0-52 IU/ml for 3-9 years; 0-87 IU/ml for adults). Regarding specific IgE antibody, a value of 1.1 U/ml or greater was considered to be positive. Levels of ECP were measured via the chemiluminescent enzyme immunoassay method with immulite ECP (DPC, Los Angeles, Calif., USA). The range of normal values in this method was found to be between 0 and 24 ng/ml. Nasal smear samples were collected by the scraping technique from both inferior nasal turbinates. The fixed samples were stained by hematoxylin-eosin, and were examined using a light microscope (Olympus BX50, 20X and 40X objective) in order to visualize inflammatory cell infiltration (especially eosinophil). Paranasal sinus computed tomography was performed. An independent radiologist reviewed the examinations. The left and right sides of each of the frontal, ethmoid, sphenoid, and maxillary sinuses were assessed separately for the presence of mucosal thickening, opacification, and air fluid level. These findings were evaluated as either being present or absent. Deviation of the nasal septum, inferior turbinate hypertrophy, and osteomeatal complex obstruction were also assessed as being present or absent. Adenoid tissue obstruction was assessed as being mild, moderate or severe. Statistical Analyses: Data were analysed using the Statistical Package for Social Sciences (SPSS) software (version 10.0 for Windows). All differences associated with a chance probability of.05 or less were considered statistically significant. Continuous variables are presented as mean±sd. Statistical methods chi-square test, z test, and correlation test are used. Results Seventy-four patients (31 males, 43 females) met the eligibility criteria for the study. Of these, the average age was 21.3±8.4 (range 5 to 60) years. Of the 103 control group patients (48 males, 55 females) whose charts were reviewed, the average age was 17.9±14.2 (range 4 to 58) years. The characteristics of patients with CSOM are presented in Table 1. The most common symptoms reported were hearing loss (93.24%), otorrhea (71.62%), headache (60.81%), and second-hand smoking (56.75%). When CSOM, and the control groups were compared with respect to reported symptoms, a statistically significant difference was found as for headache, nasal obstruction, nasal discharge, mouth breathing, regurgitation, retrosternal burning, hoarseness, sneezing, second-hand smoking and sleep apnoea (p<0.05). There was significant difference in nasal ECP, total IgE serum levels and specific IgE serum levels between CSOM and the control groups (p<0.01 for all) (Table 2). When COME, and the control groups were compared for paranasal CT findings, statistically significant difference was detected among incidences of closed osteomeatal unit, and moderateadvanced degrees of adenoid vegetation (p<0.05 for both) (Table 3).

3 Analysis of sinonasal, pharyngeal and allergy-related COM group (n=74) Control group (n=103) n (%) n (%) Otorrhea 53/74 (71.62%) - Hearing loss 69/74 (93.24%) - Otalgia 33/74 (44.59%) - Aural fullness 31/74 (41.89%) - Vertigo 23/74 (31.08%) - Nausea 7/74 (9.45%) - Vomiting 1/74 (1.35%) - Fever 10/74 (13.51%) - Headache 45/74 (60.81%) 35/103 (33.98%) Nasal obstruction 41/74 (55.40%) 32/103 (31.07%) Nasal bleeding 9/74 (12.16%) 8/103 (7.76%) Nasal discharge 20/74 (27.02%) 25/103 (24.27%) Mouth breathing 27/74 (36.48%) 33/103 (32.04%) Snoring 22/74 (29.72%) 32/103 (31.07%) Facial numbness 17/74 (22.97%) 13/103 (12.62%) Coughing 20/74 (27.02%) 30/103 (29.12%) Hyposmia 15/74 (20.27%) 16/103 (15.53%) Postnasal drip 24/74 (32.43%) 21/103 (20.38%) Sore throat 25/74 (33.78%) 23/103 (22.33%) Throat ache 13/74 (17.56%) 9/103 (8.73%) Regurgitation 16/74 (21.62%) 7/103 (6.79%) Retrosternal burning 20/74 (27.02%) 11/103 (10.67%) Smoking 12/74 (16.21%) 15/103 (14.56%) Hoarseness 20/74 (27.02%) 14/103 (13.59%) Frequent throat clearing 19/74 (25.67%) 14/103 (13.59%) Frequent tonsillitis 11/74 (14.86%) 13/103 (12.62%) Sneezing 32/74 (43.24%) 29/103 (28.15%) Malocclusion 5/74 (6.75%) 2/103 (1.94%) Second-hand smoking 42/74 (56.75%) 27/103 (26.21%) Bottle feeding anamnesis 11/74 (14.86%) 12/103 (11.65%) Allergic background 12/74 (16.21%) 11/103 (10.67%) Sleep apnoea 8/74 (10.81%) 8/103 (7.76%) Table 1: The characteristics of patients with chronic otitis media. COM= Chronic otitis media

4 50 Ferhat Bozkus, Ismail Iynen et Al COM group (n=74) Control group (n=103) p Value n (%) n (%) Nasal smear 40/74 (38.83%) 18/103 (17.48%) p<0.01* ECP 54/74 (52.43%) 25/103 (24.27%) p<0.01* Total IgE 59/74 (57.28%) 25/103 (24.27%) p<0.01* Allergen-specific IgE 16/74 (15.53%) 7/103 (6.80%) p<0.01* Table 2: Allergy-related findings in the study and the control groups. *= p< 0.05; COM= Chronic otitis media; ECP= Eosinophilic cationic protein COM group (n=74) Control group (n=103) p Value n (%) n (%) Septal deviation 51/74 (68.9%) 57/103 (55.3%) p>0.05 Inferior turbinate hypertrophy 25/74 (24.27%) 18/103 (17.47%) p>0.05 Osteomeatal complex obstruction 28/74 (27.18%) 16/103 (15.53%) p<0.05* Moderate or severe adenoid tissue obstruction 34/74 (33.0%) 17/103 (16.50%) p<0.05* Mucosal thickening 27/74 (25.24%) 17/103 (16.50%) p>0.05 Maxillary sinus Opacification 15/74 (14.56%) 10/103 (9.70%) p>0.05 Air fluid level 4/74 (3.88%) 4/103 (3.88%) p>0.05 Mucosal thickening 13/74 (12.62%) 7/103 (6.79%) p>0.05 Ethmoid sinus Opacification 7/74 (6.79%) 6/103 (5.82%) p>0.05 Air fluid level 1/74 (0.97%) - p>0.05 Mucosal thickening 4/74 (3.88%) 3/103 (2.92%) p>0.05 Fronthal sinus Opacification 3/74 (2.92%) 4/103 (3.88%) p>0.05 Air fluid level - - p>0.05 Mucosal thickening 5/74 (4.85%) 3/103 (2.92%) p>0.05 Sphenoid sinus Opacification 3/74 (2.92%) 1/103 (0.97%) p>0.05 Air fluid level 1/74 (0.97%) - p>0.05 Table 3: Paranasal computed tomography findings in the study and the control groups. *= p< 0.05; COM= Chronic otitis media

5 Analysis of sinonasal, pharyngeal and allergy-related Discussion In this study, we attempted to demonstrate whether there was a relationship between CSOM and potential sinonasal, pharyngeal and allergyrelated risk factors. The present study showed that, when compared with the control group, parameters of allergy such as eosinophil levels in the smear, serum ECP, serum total and specific IgE, abnormalities which might cause nasal stuffiness as hypertrophy of adenoid tissue, and presence of imaging findings consistent with obstruction of osteomeatal unit were more frequently detectable in patients with CSOM. For the first time, in 1931, Proetz suggested the role of allergic diseases in the development of CSOM. Rhinitis is influential in the occurrence of CSOM via two mechanisms which include Eustachian tube dysfunction secondary to allergic reactions effective on nasal mucosa, and decrease in the frequency of ciliary whipping motions.6 Mion et al. had detected nasal diseases, and eosinophilia in nasal smears in nearly 50% of the patients with CSOM (allergic, and non-allergic rhinitis syndromes were found in 3.33, and 15.69% of the cases respectively) (7). Tomanaga et al. reported the presence of allergic rhinitis in 50% of 259 paediatric cases with OME, and also detected otitis media with effusion in 21% of 605 children with allergic rhinitis (8). Hurst and Venge revealed higher levels of ECP in the COME group in comparison with the control group (9). In the present study only physical examination for the evaluation of the patients with CSOM as for the presence of allergic disorders has not proved sufficient to obtain a final conclusion. However, a statistically significant difference was found between CSOM, and the control groups as for parameters of allergy such as nasal smear, higher ECP, total IgE and specific IgE serum levels. These results support the potential role of allergy in the etiology of CSOM. Several studies have proposed nasal septum deviation as a predisposing factor in patients with CSOM. Van-Cauwenberge et al. demonstrated that increase in nasal resistance leads to higher static middle ear, and closing pressures of the Eustachian tube pressure with resultant formation of mucosal edema and finally Eustachian tube dysfunction (10). Gutierrez-Marcos showed that obstructive septal deviation induces Eustachian tube dysfunction (11). Deron et al. detected that opening pressure of the Eustachian tube recovers in the early, and late postoperative period surgical repair of the septal deviation (12). Using paranasal CT procedures, Gocmen et al. reported septal deviations in 52% of 52 patients with adhesive otitis, and 17% of 60 control subjects (13). In the present study, frequency of nasal obstruction was found to be statistically significantly higher in the patient group because of the presence of inferior, and middle concha hypertrophy, and adenoid vegetation. Besides, septal deviation was observed during paranasal CT examination at a frequency of 50.4% in the CSOM, and 55.3% in the control group without any statistically significant difference between groups. In the literature, detection of sinusitis at rates ranging between 43 and 78% in the patients with OME, supports the prevalent finding of inflammation in the upper respiratory tract as a culprit of OME (14). Fireman et al. emphasized that otitis media is a multifactorial disease which was effected by many etiologies including nasal, and paranasal sinus abnormalities (15). Eryilmaz et al. reported the presence of chronic rhinosinusitis in patients with (57.7%) and without (25%) COME with a significant difference between groups (16). Grote and Kuijpers detected maxillary sinusitis in 47% of 1252 pediatric cases with COME (17). In the present study, maxillary sinusitis was present in 44.8% of cases and when compared with the control group the difference was statistically significant. In the present study osteomeatal unit pathology existed in both CSOM, and the control group (27.18 and 15.53%, respectively) with a statistically significant intergroup difference. Majority of investigators have revealed the important role of upper respiratory tract abnormalities as causative factors for Eustachian tube obstruction in the etiopathogenesis of CSOM.11 Stammberger et al. reported serious loss in Eustachian tube functions as a consequence of impaired function of nasal, and paranasal sinuses (18). Gocmen et al. detected chronic inflammation of the osteomeatal unit in 27% of 52 patients with adhesive otitis, and revealed that nasal, and paranasal sinus abnormalities were significantly different relative to the control group (13). Takashi et al. demonstrated that inflammatory processes of nasal, and paranasal sinuses ensued in obstruction, inflammation, and resultant dysfunction of Eustachian tube (19). Yuceturk et al. compared Eustachian tube functions in the patients with CSOM relative to the normal population (20). In the present study, adenoid vegetations, and allergic rhinitis which might result

6 52 Ferhat Bozkus, Ismail Iynen et Al in Eustachian tube dysfunction were statistically significantly higher than those of the control group. Adenoid tissue which causes nasal stuffiness constricts nasopharyngeal ring, and during swallowing initially positive pressure in this closed system is followed by negative pressure. These pressure variations increase negative pressure inside middle ear leading to retraction of the tympanic membrane, and this viscious circle repeats itself (10). For ages adenoid vegetation has been recognized as an important factor in the pathogenesis of COME (16). Eryilmaz et al. determined the presence of adenoid hypertrophy in patients with (92.3%), and without (68.8%) COME (16). Chantzi et al. detected adenoid hypertrophy in 68% of 88 COME, and 67.5% of 88 control patients (21). In the present study, the presence of adenoid vegetation was investigated by paranasal CT examinations, and significantly higher rates were observed. Conclusion This study demonstrates that the role of sinonasal abnormalities, and allergic rhinitis in the pathogenesis of CSOM is still prevalent. These abnormalities cause Eustachian tube dysfunction which contributes to the development of CSOM. As a result, we have concluded that although medical history, and physical examination are considered mandatory procedures during the initial evaluation of the patients with COME, radiological, endoscopic, and other auxillary diagnostic tools should be used in the objective assessment of the patients, and lesions of the nasal cavity, and the nasopharynx must be always taken into consideration in the differential diagnosis. References 1) Nadol JB Jr, Staecker H, Gliklich RE. Outcomes assessment for chronic otitis media: the Chronic Ear Survey. Laryngoscope 2000; 110: ) Verhoeff M, van der Veen EL, Rovers MM, Sanders EA, Schilder AG. Chronic suppurative otitis media: a review. Int J Pediatr Otorhinolaryngol 2006; 70: ) Fliss DM, Shoham I, Leiberman A, Dagan R. Chronic suppurative otitis media without cholesteatoma in children in southern Israel: incidence and risk factors. Pediatr Infect Dis J 1991; 10: ) Roland PS. Chronic suppurative otitis media: a clinical overview. Ear Nose Throat J 2002; 81: ) Bluestone CD. Epidemiology and pathogenesis of chronic suppurative otitis media: implications for prevention and treatment. Int J Pediatr Otorhinolaryngol. 1998; 42: Acuin J. Chronic suppurative otitis media. Clin Evid 2006; (15): Review. 6) Hurst DS. The role of allergy in otitis media with effusion. Otolaryngol Clin North Am 2011; 44(3): ) Mion O, de Mello JF Jr, Lessa MM, Goto EY, Miniti A. The role of rhinitis in chronic otitis media. Otolaryngol Head Neck Surg 2003; 128(1): ) Tomanaga K, Krono Y, Mogi G. The role of nasal allergy in otitis media with effusion: A clinical study. Acta Otolaryngol Suppl 1988; 458: ) Hurst DS, Venge P. Evidence of eosinophil, neutrophil and mast-cell mediators in the effusion of OME patients with atopy and without atopy. Allergy 2000; 55: ) van Cauwenberge PB, Vander Mijnsbrugge AM, Ingels KJ. The microbiology of acute and chronic sinusitis and otitis media:a review. Eur Arch Otorhinolaryngol. 1993; 250 Suppl 1: S ) Gutierrez-Marcos JA, Fandinoizun-Degui J, Garcia- Palmer R. Deviations of the nasal septum and their relation to tubal physiopathology. Rev Laryngol Otol Rhinol Bord 1992; 113(5): ) Deron P, Clement PA, Derde MP. Septal surgery and tubal fuction: Early and late results. Rhinology 1995; 33(1): ) Gocmen H, Ceylan K. Burun ve paranazal sinus patolojilerinin timpanik membran patolojileri uzerinde etkisi var mıdır? Otoscope 2004; 1: ) Fujita A, Honjo I, Kurata K, Gan I, Takahashi H. Refractory otitis media with effusion from viewpoints of eustachian tube dysfunction and nasal sinusitis. Am J Otolaryngol 1993; 14(3): ) Fireman P. Otitis media and nasal disease: a role for allergy. J Allergy Clin Immunol 1988; 82(5): ) Eryilmaz A, Akmansu H, Dursun E, Dagli M, Acar A, Turkay M, et al. Is there a relationship between chronic rhinosinusitis and otitis media with effusion in pediatric patients? Turk Otolarengoloji Arşivi 2004; 42(3): ) Grote JJ, Kuljpers W. Middle ear effusion and sinusitis. J Laryngol Otol 1980; 94: ) Stammberger H. An endoscopic study of tubal function and the diseased ethmoid sinus. Arch Otol Rhinol Laryngol ) Takahashi H, Miura M, Honjo I, Fujita A. Cause eustachian tube constriction during swallowing in patients with otitis media with effusion. Ann Otol Rhinol Laryngol 1996; 105(9): ) Yuceturk AV, Unlu H, Filiz U, Yildiz T, Okumus M. Kronik otitli hastalarda östaki tüpü fonksiyonlarının objektif metotla değerlendirilmesi ve normal kişilerle karşılaştırılması. KBB ve Baş Boyun Cerrahisi Dergisi 4: ) Chantzi FM, Kafetzis DA. IgE sensitization, respiratory allergy symptoms, and heritability indepently increase the risk of otitis media with effusion. Allergy 2006: 61: Request reprints from: Ferhat BOZKUS MD Department of Otolaryngology Head and Neck Surgery, Harran University Sanliurfa Turkey

Upper Respiratory Tract Infections / 42

Upper Respiratory Tract Infections 1 Upper Respiratory Tract Infections Acute tonsillitispharyngitis Acute otitis media Acute sinusitis Common cold Acute laryngitis Otitis externa Mastoiditis Acute apiglottis