经颅中窝入路内耳道的定位研究

目的:探讨经颅中窝入路确认内耳道的定位方法。方法:12例成人头颅湿标本,在手术显微镜下解剖观察,辨认颧弓根后点、棘孔后唇、锤骨头和内耳道间的位置关系。结果:锤骨头的位置相对恒定,其与颧弓根后点和棘孔后唇距离分别为(19.44±1.48)mm和(17.74±1.32)mm。以颧弓根后点和棘孔为原点,分别在颅中窝做内径18mm弧线,两弧交叉处外侧钻5mm骨孔,即可辨认锤骨头。颧弓根后点至锤骨头连线,向内延长则落在内耳门内外侧界之间,在此磨除岩嵴即可打开内耳道内侧份,内耳门距锤骨头约(19.71±1.97)mm。结论:经颅中窝手术时,锤骨头可作为确认内耳道的安全可靠的解剖标志。     

颅中窝进路内耳道手术的应用解剖学

为经颅中窝进入内耳道施行手术提供更简便的方法,在100侧成人颅骨标本上.对棘孔、岩大神经管裂孔、弓状隆起和内耳门等表面标志进行了观测,运用几何知识、找出形态规律;在20侧成人整颅标本上进行了摹拟手术;讨论了与临床应用有关的问题.     

Indigenous nasopharyngeal, auditory canal, and middle ear bacterial flora of gerbils: animal model for otitis media.

The indigenous microbial flora of the middle ear cavity of Mongolian gerbils, Meriones unguiculatus, was isolated, characterized, and identified, showing it to be sparse and transitory. Organisms, when found in the middle ear cavity, were most likely to be Staphylococcus epidermidis-like organisms. Cerumen from the external auditory canal of these animals yielded mostly staphylococci, coryneforms, and other gram-positive rods, including some anaerobic species. The nasopharynx supported a flora consisting mainly of staphylococci, lactobacilli, and coryneforms, with a smaller incidence and numbers of many other species. No mycoplasmas were cultured or seen in scanning electron microscope studies. None of the major pathogens of human otitis media were found; therefore, Mongolian gerbils are microbiologically acceptable candidates as a model for induced otitis media, using organisms isolated from human otitic infections.     

Neuroendocrine adenoma of the middle ear with extension into the external auditory canal

We report a case of middle ear adenoma (neuroendocrine adenoma of the middle ear) protruding into the external ear canal. The patient was a 65-year-old man with hearing alterations and a headache in whom an otoscopy disclosed a sessile, pea-sized, brown-reddish, focally bleeding mass located in the posterior-superior aspect of the right external auditory canal. Histopathologically, there was a neoplasm composed of closely packed, sometimes back-to-back glandular structures formed by small uniform cuboidal or cylindrical cells. Small solid islands were also present. Following the histopathologic examination, a high resolution computed tomography was performed showing an extensive osteolytic defect mostly involving the mastoid air cells of the mastoid process with a partial destruction of the middle ear cavity. This defect was filled with a mass-like lesion with the density of soft tissue which bulged to the external auditory canal. Histopathologic examination of the mass in the middle ear cavity revealed findings identical to those seen in the original biopsy, confirming diagnosis of middle ear adenoma extending into the external ear canal. Keywords: skin - external auditory canal - neuroendocrine adenoma of the middle ear - carcinoid tumor.     

Mixed tumor of the external auditory canal

A mixed tumor with apocrine differentiation seen in the r external auditory canal of a 39 year old male is reported. The i well demarcated polypoid tumor showed proliferation of elongated gland-like or duct-like structures lined by two rows of epithelial cells, occasionally accompanied by foci of kera-tinization. There were fat cells in the myxoid stroma, in which no chondroid elements were seen. This neoplasm is considered to have arisen from the ceruminous gland, the modified apocrine gland of the skin.     

Up-regulation of beta-catenin in external auditory canal cholesteatoma

The external auditory canal cholesteatoma (EACC) is a rare disease with hyperproliferation and destructive growth in the adjacent structures. Down-regulation of beta-catenin (key component of the zonula adherens) is a pivotal factor for loose tissue integrity and invasiveness. Transforming growth factor beta1 (TGF-beta1) was reported to decrease beta-catenin in mammary epithelium. We investigated the abrogation of TGF-beta1 and beta-catenin expression in EACC culture cells. Cultured EACC-specimens were incubated with 6 micromol TGF-beta1 antisense. After 48 h, expression of beta-catenin was determined by means of immunohistochemistry. The cells showed an increased mural reactivity to beta-catenin, and intracellular reactivity was unchanged. The untreated cells showed a loss of beta-catenin expression at the membranes. The predominant membranous location after treatment with TGF-beta1 antisense suggests increased tendency of the cells for tissue formation and strong cell-cell adhesion rather than migratory and invasive character, and thus TGF-beta1 antisense application is a useful therapeutical strategy.     

Prevalence of human papillomavirus in middle ear carcinoma associated with chronic otitis media.

Squamous cell carcinoma of the middle ear (MESCC) is an uncommon tumor and is associated with a history of long-term chronic otitis media (COM) in most cases. Although the human papillomaviruses (HPVs) have been implicated in many human neoplasms, its role in the pathogenesis of MESCC has not been studied. Polymerase chain reaction (PCR) using consensus primers for the detection of HPV types 6, 11, 16, 18, 31, 33, 52b, and 58 was applied in screening fourteen cases of MESCC from archival material. Further subtyping was performed by restriction enzyme digestion of PCR products and by in situ hybridization method on tissue sections. Of the fourteen cases of MESCC, eleven were found to have HPV DNA. HPV-16 was detected in all positive cases. Five cases revealed both HPV-16 and -18. A history of long-term COM (> 3 years) was found in thirteen of the cases. This is the first report to localize HPV-16/18 in MESCC on both the tissue level and the molecular level. The high prevalence of HPV in COM-associated MESCC therefore provides a good model to explain the pathogenesis of chronic-inflammation-related human malignancies.     

Attenuated TLRs in middle ear mucosa contributes to susceptibility of chronic suppurative otitis media

The variability in the recovery of otitis media (OM) is not well understood. Recent data have shown a critical role for toll-like receptors (TLRs) in inflammatory responses to bacteria. It remains unclear whether TLRs-mediated mucosal immunity plays a role in the OM recovery. The etiology, pathological profile, expression levels of TLR2, TLR4, TLR5, TLR9 and proinflammatory cytokines were measured in human middle-ear mucosae sampled from three subject groups: non-OM group, chronic otitis-media (COM) group, and chronic suppurative otitis-media (CSOM) group. Of the 72 ears, 86.11% CSOM patients were positive for bacteria. The cellular makeup of the middle ear mucosa differs among the three groups. Mucosae from the CSOM group presented chronic inflammation or suppurative inflammation in the rudimentary stroma, mainly with infiltration of monocytes and macrophages. The mRNA and protein levels of TLR2, TLR4, and TLR5 exhibited no difference between the non-OM and COM groups but were significantly lower in the CSOM group. Conversely, there was no significant difference in the TLR9 level among the three groups. Furthermore, proinflammatory cytokines TNF-α, IL-1β, IFN-γ, IL-6 were up-regulated in the CSOM group. This study provides evidence that the variability in clinical otitis media recovery might be associated with the variability in the expression of mucosal TLRs. Reduced TLR levels in the middle-ear mucosa might cause weak host response to bacteria, persistent inflammation and susceptibility to CSOM.     

Comparative study of the external auditory canal in humans and large mammals

Given the limited source of human external auditory canal (EAC) skin, animal experiments remain an important approach for studying functional EAC reconstruction. However, differences between humans and animals in terms of the general EAC structure, histological characteristics of EAC skin, and cell markers of its specific glands in cartilaginous EAC skin remain unknown. We compared the characteristics of the EAC between humans and large animals, as a basis for appropriate animal model selection. Temporal bone computed tomography was used to compare the EACs of humans, goats, pigs, and dogs. EAC skin samples were harvested and their histological characteristics evaluated. The skin's ultrastructure and the histological structure of specific glands and cell markers related to cell phenotype and function were further identified. The EAC structure in goats was similar to that in humans in terms of diameter, length, and cartilaginous segment ratio of the EAC, while that of pigs and dogs differed markedly. Furthermore, histological evaluation showed that there were abundant ceruminous and sebaceous glands in the goat's cartilaginous skin, while dogs and pigs showed notably fewer of these glands in cartilaginous skin than humans. Nevertheless, ceruminous glands in all species studied showed similar expression of cell biomarkers and secretion function. Goats might have advantages in terms of surgery and reconstruction of the functional EAC skin compared to dogs and pigs and can be a useful candidate for ceruminous gland cell sources.     

面神经管垂直部与颈静脉窝之间距离的MSCT测量

目的:提供面神经管乖直部至颈静脉窝之间水平距离正常值并分析其变异情况.方法:采用64层螺旋CT对4具干颅标本进行扫描,将锯开剖面测量值与相同影像平面测量值对照后取得测链平面.以同样方法对随机入选无耳部疾患的118人行颌面部CT扫描.在MPR影像上测量而神经管垂直部至颈静脉窝之间的水平距离,并行统计学分析.结果:而神经管垂直部至颈静脉窝之间的距离,右侧(4.75±2.33)mm,左侧(6.06±2.52)mm,侧别间差异有统计学意义(P<0.05),右侧小于左侧.男性(5.54±2.58)mm,女性(5.29±2.44)mm,性别间差异无统计学意义(P>0.05).结论:多层螺旋CTMPR技术是研究面神经管垂直部与颈静脉窝影像解剖的良好方法,可为耳鼻喉科、颅脑外科及显微外科手术术式的选择提供可靠信息.     

The role of nasal allergy in chronic secretory otitis media.

BACKGROUND: Chronic secretory otitis media (SOM) has multifactorial causes, and nasal allergy is suspected as one of these causative factors. OBJECTIVES: To investigate the possible role of nasal allergy in SOM in adults and to determine the diagnostic value of nasal challenges with allergens (nasal provocation tests) combined with tympanometry for the diagnosis of this disorder. METHODS: In 69 young adults with chronic or recurrent SOM, 173 nasal challenges with allergens were performed by anterior rhinomanometry combined with tympanometry (pure-tone air conduction tympanometry). In 42 control subjects with only allergic rhinitis and no history of middle ear disease, 42 nasal challenges with allergens were repeated and combined with tympanometry. The study design was a placebo-controlled comparison. RESULTS: Of the 69 patients, 54 developed 129 positive nasal responses of various types (P < .01), 117 of which were accompanied by significant changes in middle ear pressure (P < .01). No significant tympanometric changes (P > .10) were recorded during the 42 positive nasal responses in control subjects. CONCLUSIONS: These results may confirm the occurrence of chronic SOM in some adult patients and the possible involvement of nasal allergy in chronic SOM. The nasal challenges with allergen performed by rhinomanometry, combined with tympanometry, seem to be a valuable supplementary tool for the diagnosis of this disorder.     

Eosinophil chemoattractants in the middle ear of patients with eosinophilic otitis media

BACKGROUND: Patients with intractable otitis media associated with bronchial asthma have an extensive accumulation of eosinophils in the effusion and mucosa of the middle ear; this condition is called eosinophilic otitis media (EOM). It remained to be determined how eosinophils accumulate in the middle ear. OBJECTIVES: To clarify the pathogenesis of middle ear diseases, we measured the concentration of eosinophil chemoattractants in middle ear effusion (MEE), and carried out immunohistochemical studies of middle ear mucosa specimens to demonstrate the expression of eosinophil chemoattractants. METHODS: Middle ear effusion samples were obtained from 15 EOM patients with bronchial asthma and from six controls for the measurement of eosinophil cationic protein (ECP), IL-5, eotaxin and regulated on activation, normal T expressed and secreted concentrations. Middle ear mucosa samples were also taken from 14 EOM patients and 16 controls for immunohistochemical study. In 10 EOM patients, the numbers of immunoreactive cells as well as apoptotic cells were determined before and after the topical application of triamcinolone acetonide into the middle ear. RESULTS: In EOM, significantly higher ECP and IL-5 concentrations were detected in MEE than in serum, and ECP, IL-5 and eotaxin concentrations in MEE were higher in the EOM patients than in the controls. ECP concentration positively correlated with that of IL-5. Immunohistochemically, the numbers of cells positive for EG2 and ecalectin were significantly higher in the EOM patients than in the controls. After the topical application of triamcinolone acetonide, the numbers of infiltrating cells and immunoreactive cells distinctly decreased, whereas the number of apoptotic cells significantly increased. CONCLUSION: In EOM, locally produced IL-5 may play a crucial role in the accumulation of eosinophils in the middle ear. Chemokines such as ecalectin and eotaxin are also produced in the middle ear, and help activate and enhance the survival of eosinophils to induce the intractable condition in the middle ear. The topical application of triamcinolone acetonide induces the apoptosis of not only eosinophils but also eosinophil chemoattractant-producing cells, thereby improving the middle ear condition.     

Eosinophils and neutrophils in biopsies from the middle ear of atopic children with otitis media with effusion

OBJECTIVE AND DESIGN: The majority of patients with otitis media with effusion (OME) and atopy have been shown to have elevated levels of eosinophil cationic protein (ECP) in their middle ear fluid. The mechanism underlying these elevated levels of ECP is not clear. The purpose of this study was to investigate the feasibility of a quantitative determination of eosinophils and neutrophils in the middle ear lining by specific immunocytochemical markers, in order to study the extent of the involvement of these cells in patients with OME. METHODS: Bilateral middle ear biopsies from five children with persistent OME and atopy confirmed by in vitro testing were evaluated for the presence of eosinophils and neutrophils with monoclonal antibodies against specific granule proteins. Five subjects who had no signs of effusion or infection but were undergoing routine tympanoplasty for dry perforations served as controls. The biopsies were embedded in a plastic resin to improve the structural preservation of the target cells and to increase the resolution in the light microscope. Dual markers were used to determine which marker was better for eosinophils and neutrophils, respectively. The following markers were used: eosinophil cationic protein (EG2), and eosinophil peroxidase (EPO) for eosinophils and myeloperoxidase (MPO) and human neutrophil lipocalin (HNL) for neutrophils. RESULTS: Antibodies against EPO gave a more localized and intense staining than antibodies against EG2. Antibodies against HNL appear more specific to neutrophils than antibodies against MPO that also recognize monocytes. The number of cells was determined both in the tissue and in the mucus covering the epithelium. Eosinophils and neutrophils were present in the subepithelial connective tissue and in the mucus blanket in the middle ear of patients with OME in significantly higher number than in the control group. In general, there were more inflammatory cells in the mucus than in the tissue itself, but the number of inflammatory cells in the mucus showed a significant positive correlation with the number of inflammatory cells in the tissue. There was a significant positive correlation between the number of neutrophils and the number of eosinophils in the tissue as well as in the mucus, irrespective of which marker was used. CONCLUSION: The results of this study show the feasibility of using specific antibodies to identify eosinophils and neutrophils in the middle ear. The initial data suggest that atopic children with OME have higher numbers of such cells as compared to non-OME controls.     

Expression of vascular endothelial growth factor in external auditory canal cholesteatoma

External ear canal cholesteatoma (EACC) is an invasive and destructive chronic inflammation based on the uncontrolled proliferation of the keratinocytes with an osteolytic character predominantly present in the inferior part of the auditory canal. EACC is a rare otologic entity and the incidence is estimated about 1 patient per 1000 new otologic patients. Although, EACC was described already in 1850, the cause is still unknown. Poor blood supply resulting in hypoxia is assumed to be the major etiologic factor for establishing EACC. VEGF is known to be one of the most important regulators of angiogenesis predominantly released in hypoxic conditions. VEGF is thought to play an important role in many regulatory pathways besides angiogenesis. In order to reveal the role of VEGF in the pathogenesis of EACC we determined the difference of the VEGF-expression in EACC and normal auditory meatal skin (AMS). EACC samples showed an increased expression of VEGF in all layers of the EACC-epithelium whereas AMS was predominantly reactive in the basal layers. The underlying stroma exhibited different stain-intensity which was correlating to the density of inflammatory cells. In summary poor blood supply results in hypoxic conditions which supports epithelial migratory disturbances of the auditory meatal duct. In order to improve hypoxia VEGF is released to induce angiogenesis. One of the results is migration of the keratinocytes proliferating into adjacent tissue. This study revealed an increased expression of VEGF in all layers of the EACC-epithelium. Therefore it is considered that up-regulation of VEGF enables and supports the pathogenesis of EACC, and VEGF seems to be a pivotal factor for the manifestation of EACC. This is the first study describing VEGF expression in EACC and its difference to AMS.     

Recovery of a unique bacterial organism in human middle ear fluid and its possible role in chronic otitis media

The middle ear fluids of 10 children with persistent otitis media with effusion (OME) were found to contain an unclassified, slow-growing, gram-positive organism. Large gram-positive cocci, often present as diplococci or tetrads, were readily seen in each effusion. Culture of the fluid on a blood agar plate required 2 to 5 days of incubation at 37 degrees C and yielded a slow-growing coccus in pure culture in 70% of cases and in mixed culture in 30% of cases. The organism in question was unique and could be distinguished from aerococci, gemellas, enterococci, and micrococci. It grew in 6.5% saline and on bile esculin agar. It did not grow at 45 degrees C or anaerobically. It was uniformly catalase and hippurate positive. It gave negative reactions with tellurite, tetrazolium, and pyruvate and did not utilize any of the carbohydrates tested. Reactions to bile esculin were variable. The episodes of OME associated with the bacterium in question were asymptomatic, had been present from 1 to 8 months, and occurred in children who had previously experienced OME. The middle ear fluids were typically serous or seromucinous and contained inflammatory cells. The data suggest that the gram-positive coccus is a newly described middle ear pathogen and may be responsible, in part, for persistent middle ear effusion. The characteristically slow growth of the organism in vitro could hinder recovery of the organism from clinical specimens and may therefore have prevented its earlier recognition.     

Endotoxin in middle-ear effusions from patients with chronic otitis media with effusion

Endotoxin concentrations were determined in middle-ear effusions (MEEs) from 89 children with chronic otitis media by using the Limulu's amoebocyte lysate assay. Mean concentrations of endotoxin in Haemophilus influenzae-positive and Streptococcus pneumoniae-positive MEEs were 157 and 21.8 ng/ml, respectively, and were significantly different (P less than 0.01). Endotoxin was also found in Gram stain-positive, culture-negative and Gram stain-negative, culture-negative MEEs, but the levels were not significantly different (P greater than 0.05). However, the endotoxin concentrations in both groups of culture-negative MEEs significantly lower than those found in MEEs that grew either H. influenzae or S. pneumoniae (P less than 0.05). These results show that endotoxin is present in a high percentage of human MEEs, including those that are culture negative, and may contribute to the pathogenesis of otitis media with effusion.     

耳内镜在治疗外耳道胆脂瘤中的应用

目的 探讨耳内镜下治疗外耳道胆脂瘤的可行性和效果。方法 对26例外耳道胆脂瘤患者，在局麻耳内窥镜下清除胆脂瘸。结果 随访1—5年，仅有1例胆脂瘤复发。结论 耳内镜下治疗外耳道胆脂瘤有较好的效果，其有清晰度高、照明度好、保留结构功能好等优点，值得临床推广应用。