Mechanical obstruction of the eustachian tube by the benign tumor of the parapharyngeal space does not cause otitis media with effusion.

OBJECTIVE: We are reporting on eustachian tube and middle ear pathologic findings in patients with parapharyngeal tumors. PATIENTS: Eleven cases of eustachian tube involvement as indicated by obstruction due to compression of the tumor were assessed in this study. MAIN OUTCOME MEASURES: Each patient underwent otoscopy, nasopharyngoscopy, a pure-tone hearing test, impedance audiometry, and sonotubometry. RESULTS: All of the tumors were diagnosed benign according to the histologic examination. In 9 of the 11 patients, the pharyngeal opening of the eustachian tube narrowed or was blocked by the tumor. None of the patients showed any response on the tumor side in the sonotubometry. Therefore, gas exchange was prevented through the eustachian tube by the tumor; however, they also showed an intact tympanic membrane and normal hearing tests. CONCLUSION: According to our data, if there is drainage of middle ear fluid through the eustachian tube and the exchange of gas in the middle ear is preserved, otitis media with effusion will not occur even in cases such as these.     

Eustachian tube function in patients with eosinophilic otitis media associated with bronchial asthma evaluated by sonotubometry

OBJECTIVE: To determine eustachian tube function in patients with asthma and with or without eosinophilic otitis media (EOM), a new middle ear disease entity with a highly viscous middle ear effusion containing many eosinophils and usually associated with bronchial asthma. One of the most important causes of otitis media (OM) is eustachian tube dysfunction. DESIGN: Retrospective case review. SETTING: A referral center. PATIENTS: Twenty patients with EOM and patients with asthma but without OM. MAIN OUTCOME MEASURES: We studied eustachian tube function using sonotubometry and a questionnaire. Sonotubometry was also performed on 13 control patients with chronic otitis media (COM) and 7 normal controls. RESULTS: The tubal opening duration was significantly longer in patients with EOM than in patients with asthma but without OM, controls with COM, and normal controls, indicating the presence of patulous eustachian tubes in patients with EOM. Responses to the questionnaire also supported the presence of patulous eustachian tubes in the patients with EOM. CONCLUSIONS: The presence of a patulous eustachian tube may be a major cause of EOM in patients with bronchial asthma. In patients with asthma who have a helper T-cell 2-dominant predisposition, a patulous eustachian tube easily allows the entry of antigenic materials into the middle ear, causing eosinophil-dominant inflammation.     

局麻下咽鼓管球囊扩张术加鼓膜置管术治疗顽固性分泌性中耳炎

目的：探讨局麻下咽鼓管球囊扩张术加鼓膜置管术治疗顽固性分泌性中耳炎的临床疗效。方法收集顽固性分泌性中耳炎患者20例（24耳）,于门诊局麻下,结合鼻内镜经鼻腔径路行咽鼓管咽口球囊扩张,并行鼓膜置管。所有患者均于术后3个月拔出T型管。结果术后随访6个月,18例患者耳闷塞感、听物朦胧感症状明显减轻,未再出现鼓室内积液。2例术后仍有耳内闷胀及听力下降,耳内镜检查示鼓室积液未吸收,再次置入T型通气管后症状改善。结论局麻下行咽鼓管球囊扩张术加鼓膜置管术治疗顽固性分泌性中耳炎疗效显著,对于改善咽鼓管功能方法安全可行,并发症极小,是一种微创的新方法。     

Cochlear implantation in a patient with eosinophilic otitis media

Eosinophilic otitis media is an intractable middle ear disease with gelatinous mucoid fluid containing eosinophils associated with bronchial asthma and nasal allergy that sometimes induces deterioration of sensorineural hearing loss. Here, we report a case of eosinophilic otitis media in a 50-year-old woman who received a Nucleus 22 multi-channel cochlear implant in the right ear at the age of 42 years. She had received treatment for bronchial asthma, chronic sinusitis with nasal allergy and otitis media with effusion since the age of 30 years and had noted bilateral sudden deafness and vertigo at the age of 35 years. Preoperative CT and MRI showed cochlear ossification in the left ear, in which mastoidectomy was performed as treatment of eosinophilic otitis media. Long-term follow-up revealed that cochlear implant is indicated for deafness induced by eosinophilic otitis media, and an early decision for cochlear implant surgery is necessary. Steroid administration was remarkably useful in controlling eosinophilic otitis media in patients with bronchial asthma and chronic sinusitis with nasal allergy.     

鼻内镜下咽鼓管扩张导管治疗慢性分泌性中耳炎13例分析

目的 探讨鼻内镜下咽鼓管扩张导管治疗慢性分泌性中耳炎的方法和疗效。方法 对13例(15耳)慢性分泌性中耳炎患者采用经鼻内镜下插入咽鼓管扩张导管至其峡部,加压并持续扩张其球囊2min,然后经外耳道行鼓膜穿刺抽液,用地塞米松冲洗鼓室,再用含丝裂霉素C明胶海绵涂擦鼓膜穿刺部5min。结果 全部病例均一次插管成功,随访4~5个月,11例(11耳)疗效满意,耳闷胀感消失,声阻抗提示鼓室图由“B”型恢复为“A”型,纯音听阈测试提示听力提高10~20dB,内镜检查鼓室无积液,无感染、出血、鼓膜穿孔等并发症。2例伴有过敏性鼻炎患者(4耳)于术后3个月又出现闷胀感,轻度听力下降,但无鼓室积液,经抗炎和抗过敏治疗后症状消失。结论 鼻内镜下咽鼓管扩张导管治疗分泌性中耳炎操作简便、微创,疗效好。     

Characteristics of migrating cells in effusion of the middle ear in patients with "eosinophilic otitis media"

Otitis media with effusion (OME) is known to be a disease that frequently afflicts children. Recently, numerous reports of intractable OME associated with bronchial asthma have been reported, generally referred to as "eosinophilic otitis media". To comprehend the cause and pathogenesis of this disease, we conducted an electron-microscope analysis of the effusion. The subjects were 5 male and 1 female patients, 4 had aspirin-induced asthma and 2 had adult-onset asthma. The number of collapsed and intact eosinophils and other inflammatory cells in the middle ear effusion were counted, and their characteristics were reviewed. Most eosinophils in the middle ear effusion were collapsed, and a high percentage of eosinophils in the nasal discharge were also collapsed. The inflammatory cells were phagocytosed by macrophages at a high frequency in cases of otitis media with effusion, but only a low rate of phagocytosis was observed in cases with eosinophilic otitis media. It is known that necrotic cells are phagocytosed with difficulty, while apoptotic cells are phagocytosed easily by macrophages. Therefore, collapsed eosinophils persist for a long time in middle ear effusion and the released granule proteins from the eosinophils cause the tissue failure. Threfore, we believe that treatment directed at causing apoptosis of eosinophils can prevent exacerbation of the intractable inflammation in this condition.     

Implications of laser assisted tympanostomy in adults.

OBJECTIVES: To assess outcome in adult individuals undergoing laser-assisted tympanostomy without ventilation tube placement. STUDY DESIGN: Case series with 2-month follow-up. SETTING: Faculty practice, research protocol, tertiary care academic medical center. PATIENTS AND METHOD: Laser-assisted tympanostomy was performed on a total of 142 ears (108 individuals). Indications included serous otitis media with effusion (66 ears/47 patients), functional eustachian tube dysfunction (48 ears/36 patients), acute otitis media (19 ears/16 patients), and endoscopic visualization of the middle ear (9 ears/9 patients). INTERVENTION: The laser-assisted tympanostomy procedure is performed with a CO2 laser under local anesthesia on an outpatient basis. MAIN OUTCOME MEASURES: Patency time of the tympanostomy, presence of fluid after the closure of the tympanostomy, tympanometry and tone audiometry findings, relief of symptoms. RESULTS: Middle ear disease was resolved after the closure of tympanostomy in 47.9% of patients with serous otitis media with effusion. In 79.1% of patients with functional eustachian tube dysfunction, symptoms were diminished. All patients with acute otitis media had a satisfactory outcome. Laser-assisted tympanostomy was found to be quite helpful in patients undergoing middle ear endoscopy. CONCLUSIONS: Laser-assisted tympanostomy without ventilation tubes provides a safe alternative surgical option in adult patients in certain cases. The selection criteria for this procedure are addressed in detail.     

Diagnostic criteria of eosinophilic otitis media, a newly recognized middle ear disease

Objective

Eosinophilic otitis media (EOM) is a newly recognized intractable middle ear disease, characterised by the accumulation of eosinophils in middle ear effusion and middle ear mucosa. Since EOM patients show gradual or sudden deterioration of hearing, it is important to properly diagnose EOM and to start adequate treatment for EOM. We aimed to investigate the clinical risk factors of EOM and to establish the diagnostic criteria of EOM.

Patients and methods

We reviewed 138 patients with EOM and 134 age-matched patients with the common type of otitis media with effusion or chronic otitis media as controls. We analyzed the incidence of the following clinical variables in both groups: bilaterality of otitis media, viscosity of middle ear effusion, formation of granulation tissue in the middle ear, response to the treatment for otitis media, deterioration of bone conduction hearing level, and association with other diseases such as bronchial asthma, chronic rhinosinusitis, nasal polyposis, and allergic rhinitis.

Results

A high odds ratio was obtained from an association with bronchial asthma (584.5), resistance to conventional treatment for otitis media (232.2), viscous middle ear effusion (201.6), association with nasal polyposis (42.17), association with chronic rhinosinusitis (26.49), bilaterality (12.93), and granulation tissue formation (12.62). The percentage of patients with EOM who were positive for two or more among the highest four items was 98.55%.

Conclusion

A patient who shows otitis media with effusion or chronic otitis media with eosinophil-dominant effusion (major criterion) and with two or more among the highest four items (minor criteria), can be diagnosed as having EOM. Patients with ear symptoms should have the proper diagnosis of EOM using the proposed diagnostic criteria, and then can receive adequate treatment, resulting in prevention of deterioration of hearing and quality of life.     

Influence of nasal allergic reactions on the clearance of middle ear effusion

In order to investigate the influence of nasal allergic reactions on the clearance of middle ear effusion, an animal model of nasal allergy and otitis media with effusion was produced in the same guinea pigs simultaneously by passive sensitization with serum of homologous animals containing IgE antibodies (for nasal allergy) and by inoculation of immunocomplex into the tympanic cavity (for otitis media with effusion). Usually, middle ear effusion appeared within 2 to 3 days and disappeared within 7 to 9 days after the inoculation of immunocomplex. Three days after the inoculation of immunocomplex, intranasal antigen challenge was performed three times daily and continued until the animals were killed. Disappearance of middle ear effusion appeared to be delayed in animals in which nasal allergic reactions were induced. Middle ear effusion was not found in those ears that were not inoculated with immunocomplex. Findings of the present study indicate that IgE-mediated allergic reactions of the mucous membrane lining the nose, nasopharynx, and eustachian tube constitute a factor indicative of a chronic state of disease, rather than a cause of otitis media with effusion.     

Mechanism of hearing loss in irradiated ears: a long-term longitudinal study

A 10-year longitudinal follow-up study of hearing was conducted in patients with nasopharyngeal carcinoma (NPC) in order to elucidate the mechanism of hearing loss in irradiated ears. Ten NPC patients were subjected to a battery of audiological tests before irradiation and 6 months, 5 years, and 10 years after irradiation. The tests included pure tone audiometry, tympanometry, eustachian tube function testing, and myringotomy to confirm middle ear effusion. The prevalences of otitis media with effusion (OME) were 25%, 25%, 40%, and 25% at the 4 testing periods described above, respectively. The prevalences of chronic otitis media were 0%, 0%, 15%, and 25%, respectively. In myringotomized ears (n = 17), the mean hearing levels for both air conduction and bone conduction were preserved from the preirradiation period to 10 years after irradiation. In contrast, in grommeted ears (n = 3), the mean hearing levels for both air conduction and bone conduction deteriorated progressively from the preirradiation period to 10 years after irradiation. We conclude that hearing can be preserved in NPC patients 10 years after irradiation if middle ear inflammation is well controlled. We do not recommend grommet insertion in irradiated NPC patients with OME, as it may result in persistent otorrhea and hearing deterioration.     

The role of allergic rhinitis in the development of otitis media with effusion: effect on eustachian tube function

PURPOSE: The pathogenesis of otitis media with effusion (OME) is considered multifactorial, with viral upper respiratory tract infection and eustachian tube dysfunction. Allergy may be related to the pathogenesis of OME or to another etiological factor. We investigated the role of allergic rhinitis (AR) in children with OME and evaluated eustachian tube function in patients with AR. MATERIALS AND METHODS: We prospectively analyzed the prevalence of AR, serum eosinophil count, and serum total IgE concentrations in 123 children with OME and in 141 controls. IgE concentration in middle ear effusion was compared in children with OME with and without AR, and eustachian tube function after a nasal provocation test was compared between patients with AR and controls. RESULTS: The prevalence of AR in children with OME (28.4%) and control subjects (24.1%) did not differ significantly. These 2 groups also showed no differences in total eosinophil count and serum and middle ear effusion IgE concentration. Abnormalities in eustachian tube function were the same in patients with AR and controls. CONCLUSIONS: Allergic rhinitis may not be related to the development of OME in children.     

A 14-year prospective follow-up study of children treated early in life with tympanostomy tubes: Part 2: Hearing outcomes

OBJECTIVE: To determine hearing outcomes in young children receiving early and repeated tympanostomy tube insertion for recurrent acute otitis media or otitis media with effusion. DESIGN: Prospective 14-year follow-up. SETTING: Central Hospital of Central Finland, a tertiary care hospital.Patients Three hundred five consecutive infants and young children with otitis media received initial tympanostomy tube insertion at the age of 5 to 16 months. The final study group comprised 237 patients (77.7%) attending the 14-year checkups. MAIN OUTCOME MEASURES: At the 14-year checkups, children received clinical examinations and audiometric testing for the determination of bone and air conduction pure-tone thresholds. RESULTS: The mean pure-tone average of 177 healed ears was 4.3 dB. The mean pure-tone average of all ears was 5.8 dB, with significantly poorer results in ears with abnormal outcomes such as grade II or higher pars tensa retraction, otitis media with effusion, and tympanic membrane perforation. Thirteen (5.5%) of 237 ears had a hearing level worse than 15 dB, and the better ear hearing level was poorer than 15 dB in 3 patients. CONCLUSIONS: The hearing level of healed ears was comparable to that of age-matched normal ears. Hearing losses were infrequent, of slight grade, and, when present, almost exclusively conductive and related to unsuccessful otological outcomes. From the hearing point of view, repeated tympanostomy tube insertion for recurrent acute otitis media or otitis media with effusion early in life is a safe treatment.     

Laser eustachian tuboplasty: a preliminary report

OBJECTIVES/HYPOTHESIS: Surgical correction of eustachian tube dysfunction remains an elusive challenge. Repeat ventilation tube placement is often inadequate to prevent tympanic membrane and middle ear complications. Endoscopic analyses of eustachian tube dynamics have localized the site of primary pathophysiology to within the cartilaginous tube. The study investigated the feasibility, safety, and efficacy of a new endoluminal eustachian tube operation for the treatment of eustachian tube dysfunction. STUDY DESIGN: Prospective, institutional review board-approved surgical trial in a tertiary-care medical center. METHODS: Ten patients with more than 5 consecutive years of intractable otitis media with effusion recurring after two or more tympanostomy tube placements were treated with unilateral laser eustachian tuboplasty. Surgery was performed on an outpatient basis with the use of general anesthesia and combined both transnasal and transoral approaches. A 980-nm diode or argon laser was used to vaporize an appropriate amount of mucosa and cartilage on the posterior wall of the tubal lumen. Preoperative and postoperative dynamic video eustachian tube function analyses were compared. Outcome measures were presence or absence of middle ear effusion and impedance tympanograms. RESULTS: Five patients had at least 12 months of follow-up, and three of them had absence of any effusion (60%). Two patients had recurrence of their otitis media with effusion and required tympanostomy tubes again. Five patients had at least 6 months of follow-up, and four of them had absence of any effusion. The remaining patient had recurrence of otitis media with effusion and received a tympanostomy tube again. Overall results for all 10 patients after 6 months were 7 free of effusion (70%). There were no intraoperative complications. Postoperative complications were limited to minimal peritubal adhesions and one intranasal synechia. CONCLUSIONS: Preliminary results suggest that laser eustachian tuboplasty is safe and efficacious in the treatment of intractable eustachian tube dysfunction. Further study will be necessary to determine whether laser eustachian tuboplasty is a suitable alternative to repeated tympanostomy tube placement in selected patients.     

Update on eustachian tube dysfunction and the patulous eustachian tube

PURPOSE OF REVIEW: The purpose of this review is to summarize the recent knowledge on eustachian tube dysfunction and the patulous eustachian tube. RECENT FINDINGS: A clinically useful test for eustachian tube function is still lacking. Narrowing of the isthmus alone was demonstrated to be an insufficient cause of otitis media. Inflammatory mediators identified within the eustachian tube and middle ear cells were causally linked with otitis media with effusion. Increasing evidence was found that allergic disease and reflux may be two of the most important contributors of tubal inflammation causing otitis media with effusion. The adenoid size and proximity to the torus tubaris may also be important in considering which patients with persistent otitis media with effusion may benefit from adenoidectomy. Computed tomography scan has documented loss of soft tissue within the cartilaginous eustachian tube in patients with patulous eustachian tubes. An endoscopic approach to seal the tubal lumen has been found to be effective in relieving patulous symptoms. SUMMARY: These studies suggest that allergic rhinitis and gastroesophageal reflux should be investigated in patients with eustachian tube dysfunction. Adenoidectomy should also be considered in patients who have adenoids that obstruct the torus tubaris. Patients with a patulous eustachian tube may benefit from an endoscopic closure. Further research is needed to identify a clinically useful test for eustachian tube dysfunction.     

Patulous eustachian tube following otitis media

Loss of weight, dehydration, pregnancy, fatigue, and otitis media are among the factors proposed as causes of a patulous eustachian tube, but true details remain obscure. We studied patients who developed a patulous eustachian tube following otitis media and discuss the relationship between these 2 conditions. Subjects were 12 patients diagnosed with otitis media at our department who later developed a patulous eustachian tube. The initial middle ear disease progressed from acute otitis media to otitis media with effusion in 2, acute otitis media in or acute mastoiditis in 1 each, and otitis media with effusion in the remaining 8 patients. Seven patients evidenced a low body mass index (BMI), weight loss, and underlying disease, but 5 with a patulous eustachian tube following otitis media did not. We retrospectively analyzed 119 patients diagnosed with a patulous eustachian tube in our department for whether they had been diagnosed by an ENT physician as having otitis media, i.e., acute otitis media or otitis media with effusion. Some 42 (35.3%) had a history of otitis media. At acute otitis media or otitis media with effusion, the tympanic cavity becomes inflamed, accompanied by inflammation of the eustachian tube mucosa and a stenotic tendency. Healing from otitis media is accompanied by decreased eustachian tube mucosa inflammation. We surmise that, depending on how inflammation disappears, fibrosis of the eustachian tube mucosa occurs, leading to a pathologically patulous eustachian tube. Many aspects of the causation of this condition remain unclear, but we surmised that in patients with earlier otitis media, a pathological patulous eustachian tube develops during resolution of inflammation. Our findings indicate the involvement of otitis media as a causative factors in a patulous eustacian tube.     

Type I allergic reactions of the middle ear and eustachian tube: an experimental study

To clarify the role of type I allergic reactions in etiology and pathogenesis of otitis media with effusion and to determine whether or not the middle ear is an allergic "shock" organ, we made animal models of nasal allergy in guinea pigs by passive sensitization with serum of homologous animals containing specific IgE antibodies. We also examined the eustachian tube, tympanic cavity (histologically), and tubal function after the induction of type I allergic reactions of the nose. However, the involvement of histologic changes was limited only up to the area near the pharyngeal orifice. The tubal dysfunction evoked by nasal allergic reactions was transient, culminating in no middle ear effusion. Upon direct antigen-challenge into the tympanic cavity, allergic changes were observed in the mucosa lining the tympanic bulla, even though no microscopic effusion was present. Findings of the present study suggest that type I allergic reactions of the nose are not an etiologic factor for otitis media with effusion, although the middle ear is potentially an allergic shock organ.     

Tympanometry in the detection of hearing impairments associated with otitis media with effusion

The monitoring of children with otitis media with effusion ties up considerable resources in audiology departments. Impedance audiometry is frequently used when investigating these children. It has been shown to be highly sensitive in detecting middle ear effusion, but its value in identifying those children with a significant hearing impairment secondary to this is in question because of the wide range of hearing impairments possible with a type B tympanogram. This study quantified the sensitivity and specificity of impedance audiometry in detecting a hearing impairment greater than or equal to 25 dB HL due to otitis media with effusion. The subjects were 285 children of whom 20% had hearing thresholds greater than or equal to 25 dB HL. A peaked tympanogram (types A or C) virtually eliminated the possibility (98% confidence) of such a hearing impairment. A flat type B tympanogram was satisfactorily sensitive (93%) in detecting a hearing impairment, but non-specific (76%). The positive predictive value was 49%, i.e. 51% of ears with this type of tympanogram had hearing within acceptable limits. Assuming that a sensorineural impairment has been excluded and a population is being monitored for hearing impairment associated with otitis media with effusion, it is suggested that the presence of a peaked tympanogram indicates normal hearing, whereas those children with a flat tympanogram would require their hearing to be evaluated. Increased use of impedance audiometry to monitor children with otitis media with effusion would reduce the number requiring full pure-tone audiometry with a subsequent reduction in the workload of an audiology department.     

Histo-morphological changes of eustachian tube of guinea pigs with effusion after being treated by pulmonary surfactant]

OBJECTIVE: To study the effect of pulmonary surfactant on otitis media with effusion in guinea pigs to find a new way to manage otitis media with effusion. METHODS: Nonviable heat-killed pneumococci (HKP) solution was inoculated into the middle ear cavity in guinea pigs via a transeardrum approach to set up a model of otitis media with effusion in guinea pigs. Seven days after being injected with pulmonary surfactant (PS) by transeardrum approach, ABR threshold and histomorphological changes of eustachian tube mucosa of guinea pigs were examined by light microscopy and scanning microscopy. RESULTS: Five days following inoculation of HKB serous effusion were present in the middle ear cavity of guinea pigs, but disappearance of light cone. Response (mean +/- s) threshold raised from (14.0 +/- 3.1) dB to (45.0 +/- 5.7) dB. The eustachian tube mucosa was thickened and lined eosin-stained structureless matter over mucosa, while cilia of eustachian tube mucosa irregularly arranged. Seven days after being treated by PS, serous effusion of tympanum was reduced or disappeared, and response threshold decreased from (45.0 +/- 5.7) dB to (23.5 +/- 6.3) dB. There was significantly difference between them (P < 0.001). Eustachian tube mucosa was thinned, Cilia of eustachian tube mucosa regularly arranged to the nasopharynx. CONCLUSION: Pulmonary surfactant plays a important role in otitis media with effusion of guinea pigs.     

鼻内镜下导管法咽鼓管吹张及鼓室给药治疗非化脓性中耳炎

目的 观察鼻内镜下导管法咽鼓管吹张及鼓室给药治疗非化脓性中耳炎的疗效。方法 30例由咽鼓管功能不良引起的、以鼓膜内陷为主要表现的慢性分泌性中耳炎患者，在鼻内镜引导下行导管法咽鼓管吹张，并经导管吹人泼尼松龙和玻璃酸钠混合液体2ml，隔日1次，共7～lO次，检查咽鼓管功能及鼓膜形态，检测听力．评估耳鸣及耳闭塞感变化。结果30例咽鼓管功能明显改善或恢复正常，鼓膜内陷不同程度缓解，无粘连发生。纯音听阈（0．5，1．0，2．0，4．0kHz平均听阈）下降10-30dB28例，无变化2例；耳鸣消失19例，减轻7例，无效4例：耳闭塞感消失26例，明显减轻4例。结论 鼻内镜下导管法咽鼓管吹张及鼓室给药治疗由咽鼓管功能不良引起的、以鼓膜内陷为主要表现的慢性分泌性中耳炎，能改善听力，缓解耳鸣及耳闭塞感症状。其操作简单，患者痛苦小，易于接受。