The immunoregulatory and allergy-associated cytokines in the aetiology of the otitis media with effusion

Inflammation in the middle ear mucosa, which can be provoked by different primary factors such as bacterial and viral infection, local allergic reactions and reflux, is the crucial event in the pathogenesis of otitis media with effusion (OME). Unresolved acute inflammatory responses or defective immunoregulation of middle inflammation can promote chronic inflammatory processes and stimulate the chronic condition of OME. Cytokines are the central molecular regulators of middle ear inflammation and can switch the acute phase of inflammation in the chronic stage and induce molecular-pathological processes leading to the histopathological changes accompanying OME. In this review we present cytokines identified in otitis media, immunoregulatory [interleukin (IL)-2, IL-10, transforming growth factor-beta]) and allergy associated (IL-4, IL-5, granulocyte-macrophage colony-stimulating factor), as crucial molecular regulators, responsible for chronic inflammation in the middle ear and the chronic condition of OME.     

Detection of soluble interleukin-2 receptor and soluble intercellular adhesion molecule-1 in the effusion of otitis media with effusion

We measured sIL-2R, TNF-alpha and sICAM-1 in the sera and middle ear effusions (MEEs) of patients with otitis media with effusion (OME). Although there was no signmcant difference between the sIL-2R levels of the serous and mucoid MEEs, they were significantly higher than serum sIL-2R levels of OME patients and healthy controls. TNF-alpha levels of the mucoid MEEs were significantly higher than those of the serous type. However, TNF-alpha was rarely detected in the sera of OME patients or healthy controls. We observed significant differences between the serous and mucoid MEEs with respect to their sICAM-1 levels, which were also higher than serum slCAM-1 levels of OME patients and healthy controls. Our findings suggested that IL-2, TNF-alpha and ICAM-1 could be significantly involved in the pathogenesis of OME through the cytokine network.     

Bacterial etiology of otitis media with effusion; focusing on the high positivity of Alloiococcus otitidis

The etiology of otitis media with effusion (OME) is unclear. The bacterial analyses of middle ear effusion (MEE) in OME may reveal important information regarding its etiology. Alloiococcus otitidis, Heamophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis were investigated by using microbiologic culture and a multiplex PCR method in the middle ear fluid of 32 children (54 samples) with chronic OME. PCR yielded positive results in 18 (33.3%) middle ear effusions while culture resulted positive for 3 (5.6%). The PCR method detected A. otitidis in 10 (18.5%) specimens, H. influenzae in 7 (13%), M. catarrhalis in 4 (7.4%) and S. pneumoniae in 2 (3.7%) specimens. The multiplex PCR method enhances the detection rate significantly compared to that of the conventional culture method. A. otitidis is the most common detected pathogen in the MEE of the OME.     

Effect of Alloiococcus otitidis and three pathogens of otitis media in production of interleukin-12 by human monocyte cell line

Alloiococcus otitidis is detected in middle ear effusion of otitis media with effusion (OME). Only a limited number of studies are available concerning the immunological profile of A. otitidis. We have studied the ability of A. otitidis and three other representative pathogens of otitis media to stimulate the production of interleukin-12 (IL-12) from a monocytic cell line THP-1. Viable A. otitidis induced the production of IL-12 in THP-1 cells but IL-12 production was reduced if glutaraldehyde-fixed bacteria were used as stimulants. When viable bacteria were physically separated from THP-1 cells during the stimulation period, remarkable reductions of IL-12 secretion were shown after challenge with gram-positive bacteria A. otitidis and S. pneumoniae. When stimulated with soluble extracts of A. otitidis, THP-1 secreted IL-12 in a dose-dependent manner. The subfraction with a molecular mass over 100 kDa showed a strong ability to induce IL-12 production. Our results show that A. otitidis has immunostimulatory capacity with regard to IL-12 production. We also show that soluble antigen(s) of A. otitidis can modulate the immune response in OME.     

The human otitis media with effusion: a numerical-based study

Otitis media is a group of inflammatory diseases of the middle ear. Acute otitis media and otitis media with effusion (OME) are its two main types of manifestation. Otitis media is common in children and can result in structural alterations in the middle ear which will lead to hearing losses. This work studies the effects of an OME on the sound transmission from the external auditory meatus to the inner ear. The finite element method was applied on the present biomechanical study. The numerical model used in this work was built based on the geometrical information obtained from The visible ear project. The present work explains the mechanisms by which the presence of fluid in the middle ear affects hearing by calculating the magnitude, phase and reduction of the normalized umbo velocity and also the magnitude and phase of the normalized stapes velocity. A sound pressure level of 90 dB SPL was applied at the tympanic membrane. The harmonic analysis was performed with the auditory frequency varying from 100 Hz to 10 kHz. A decrease in the response of the normalized umbo and stapes velocity as the tympanic cavity was filled with fluid was obtained. The decrease was more accentuated at the umbo.     

Interleukin-1beta upregulates Na+-K+-2Cl- cotransporter in human middle ear epithelia

Disruption of periciliary fluid homeostasis is the main pathogenesis of otitis media with effusion (OME), one of the most common childhood diseases. Although the underlying molecular mechanisms are unclear, it has been suggested that the altered functions of ion channels and transporters are involved in the fluid collection of middle ear cavity of OME patients. In the present study, we analyzed the effects of a major cytokine interleukin (IL)-1beta, which was known to be involved in the pathogenesis of OME, on Na(+)-K(+)-2Cl(-) cotransporter (NKCC) in human middle ear cells. Intracellular pH (pH(i)) was measured in primary cultures of normal human middle ear epithelial (NHMEE) cells using a double perfusion chamber, which enabled us to analyze the membrane-specific transporter activities. NKCC activities were estimated by the pH(i) reduction due to bumetanide-sensitive intracellular uptake of NH(4) (+). In NHMEE cells, NKCC activities were observed only in the basolateral membrane, and immunoblotting using specific antibodies revealed the expression of NKCC1. Interestingly, IL-1beta treatments augmented the basolateral NKCC activities and increased NKCC1 expression. In addition, IL-1beta treatments stimulated bumetanide-sensitive fluid transport across the NHMEE cell monolayers. Furthermore, an elevated NKCC1 expression was observed in middle ear cells from OME patients when compared to those from control individuals. The above results provide in vitro and in vivo evidence that the inflammatory cytokine IL-1beta upregulates NKCC1 in middle ear epithelial cells, which would be one of the important underlying mechanisms of excess fluid collection in OME patients.     

Study of middle ear disease using tympanometry in general practice.

Tympanometry was used to provide evidence of middle ear effusions in a prospective study of middle ear disease in 264 children aged 3 months to 6 years in general practice. Adequate measurements on both ears were obtained in 220 children, of whom 68 (31%) had evidence of middle ear effusion in one ear (29 children) or both ears (39 children) at entry to the study. In 28 (42%) of the 68 children persistence of the tympanometric findings was recorded for at least three months. Children of European descent were more likely to have evidence of middle ear effusion at the initial examination compared with African and West Indian children, as were those children whose siblings had a positive history of otitis media compared with those whose siblings had no such history. Children under 3 years were more likely to have evidence of an effusion than older children. Middle ear effusion as shown by tympanometry was not associated with a previous history of otitis media in the child but was associated with recent symptoms of respiratory infection or otalgia. A previous consultation for otitis media was, however, strongly associated with a greater likelihood of a consultation for otitis media during the follow up period. Comparing evidence of effusion by tympanometry with that by pneumatic otoscopy showed that using the appearance of the eardrum alone the sensitivity of otoscopy was 55%; the addition of mobility improved the sensitivity to 76% with little reduction in specificity. Further studies on populations using tympanometry are needed to determine the natural history, aetiology, and indications for referring children with middle ear effusion.     

TNF-alpha in the regulation of MUC5AC secretion: some aspects of cytokine-induced mucin hypersecretion on the in vitro model

TNF-alpha has been implicated in the aetiology of otitis media with effusion (OME), where goblet cells proliferate in a modified respiratory epithelium, leading to the accumulation of a mucin-rich effusion in the middle-ear cleft. The MUC5AC mucin gene product has been identified as a component of these effusions. Here we have used the HT29-MTX goblet cell line, which secretes MUC5AC mucin, as a model to study the effect of TNF-alpha on goblet cells. MUC5AC mucin was identified and quantitated with a monoclonal antibody NCL-HGM-45M1. TNF-alpha stimulates MUC5AC mucin secretion in a dose-dependent manner, with 20 ng/ml producing maximal stimulation. Both pre-confluent and confluent cells showed peak stimulation after 7 h, however the pre-confluent cells showed twice the level of mucin hypersecretion. These results suggest that TNF-alpha stimulation of mucin secretion could play an important role in the early acute phase of the development of OME. This hypersecretion of mucin could then lead to the failure of the mucociliary clearance system, resulting in the accumulation of a mucin-rich effusion in the middle ear and the movement to a more chronic phase of the disease.     

PCR analysis of Actinobacillus actinomycetemcomitans,Porphyromonas gingivalis,Treponema denticola andFusobacterium nucleatum in middle ear effusion

Anaerobes contribute to the severity and chronicity of infections that occur in and around the oral cavity. One of the factors involved in the pathogenesis of otitis media with effusion (OME) is the retrograde movement of bacteria from the oropharynx into the middle ear cavity. OME is one of the most common causes of hearing loss in children. We have used a PCR-based method to identify Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Treponema denticola andFusobacterium nucleatum in 65 middle ear effusion (MEE) samples obtained from paediatric patients seen for myringotomy and tube placement. DNA was extracted from MEE samples and PCR was initially done with DNA extracts by using the universal primers within the 16S rRNA gene sequence common to all bacterial species. The positive samples were further assessed with four species-specific primers. With the universal primers, 27 of 65 samples (41.5%) showed positive reaction indicating the presence of bacterial DNA. F. nucleatum was present in 10 out of 27 PCR-positive samples (37%) while one sample was positive for both T. denticola and F. nucleatum (3.7%). A. actinomycetemcomitans and P. gingivalis were not detected in any of the samples. The results of this study suggest that oral bacterial species may also play a role in the aetiopathogenesis of paediatric MEE.     

Characteristics of the hearing loss in unilateral cleft lip and palate-influence on communication

Etiology of otitis media with effusion (OME) is still unclear and often described as multi-factorial. It is very usual finding in cleft palate population. We tested relationship between the hearing level, audiometric frequencies, aging and ear side in unilateral cleft lip and palate 101 children (UCLP) and subgroups of left (UCLP)(L) and right cleft side (UCLP)(R). Group of left ears is prone to higher frequency and more severe hearing disturbances than groups of right ears, with less chance of normalizing hearing level with aging. Characteristics of hearing loss level and its improvement, in UCLP children depend of cleft type, ear side and age group.     

儿童腺样体肥大程度与分泌性中耳炎发生的相关性研究(英文)

目的:探讨儿童腺样体肥大程度与分泌性中耳炎发生及预后的相关性,指导临床医师对分泌性中耳炎作出早期诊断和治疗。方法:239例住院手术切除腺样体的儿童,常规行鼻咽侧位片、声导抗检查;部分伴耳部症状、声导抗显示C型曲线或查体可疑鼓室积液征者行颞骨CT检查或术中行鼓室穿刺。经统计学分析,比较分泌性中耳炎与腺样体肥大程度及咽鼓管咽口情况的相关性。结果:在239例腺样体肥大儿童中,经鼓室穿刺证实合并分泌性中耳炎者34例(63耳,14.2%),其中鼓室曲线呈B型者33耳(52.4%),C型(-200 dapa)者10耳(15.9%),C型(-200 dapa)者20耳(31.7%)。结果表明分泌性中耳炎的发生与腺样体肥大程度及咽鼓管园枕受压迫的程度呈正相关。结论:声导抗检查不能作为分泌性中耳炎诊断的金标准,必要时可行颞骨CT明确诊断;对腺样体肥大伴分泌性中耳炎的儿童鼻内镜下腺样体切除为其主要疗法,配合鼓室穿刺多可治愈,对反复发作的分泌性中耳炎行鼓室置管术,避免术后并发症的发生。     

Duration and recurrence of otitis media with effusion in children from birth to 3 years: prospective study using monthly otoscopy and tympanometry.

OBJECTIVE: To monitor the natural course of otitis media with effusion. DESIGN: Prospective, longitudinal assessment of the state of the middle ear by otoscopy and tympanometry at monthly intervals from birth to 3 years. SETTING: Domiciliary visits to family homes. SUBJECTS: 95 full term infants born between August 1991 and November 1993. MAIN OUTCOME MEASURES: Observed and simulated data (Monte Carlo) for the duration of single episodes of otitis media with effusion. RESULTS: 17 of the children had unilateral or bilateral otitis media with effusion for more than half of their first three years of life. Thirty three of the 95 children had tympanograms suggestive of otitis media with effusion at more than a third of observations; the remaining 62 had such tympanograms at less than a third of observations. The data of each group were described by a first order Markov model, yielding a mean duration of unilateral effusion episodes of 5-6 weeks in both groups; the mean duration of bilateral effusion was 6 and 10 weeks in the low and high incidence groups, respectively. However, the main difference between the groups was the time spent between episodes of effusion: effusion free periods were, on average, three times longer in the children who experienced less otitis media with effusion. CONCLUSION: Children who are susceptible to otitis media with effusion tend to have more separate episodes of effusion rather than an increased overall duration of episodes. Such children are primarily distinguished by the likelihood with which they acquire the disease than by their ability to recover from it.     

Presence of dipeptidyl peptidase II, dipeptidyl peptidase IV, and prolyl endopeptidase in effusion from patients with serous otitis media

We have measured for the first time, using specific substrates and specific fluorometric analyses, activities of three pathophysiologically important peptidases, i.e., dipeptidyl peptidase II, dipeptidyl peptidase IV, and prolyl endopeptidase in effusions from 45 patients with chronic otitis media with effusion. In 20 patients, DPP II and DPP IV were assayed simultaneously in effusions and sera. Activity of PEP was also estimated in effusions and sera from 25 patients. The mean values (+/- SD) of DPP II and DPP IV (n = 45) and PEP (n = 25) in effusion from patients with OME were 0.020 +/- 0.007, 0.66 +/- 0.04, and 0.040 +/- 0.006 nmole/min/mg protein, and 0.21 +/- 0.01, 16.2 +/- 1.87, and 1.90 +/- 0.23 nmole/min/ml of effusion, respectively. The mean values (+/- SD) for DPP II, DPP IV, and PEP in sera were 2.82 +/- 0.18, 54.8 +/- 1.23, and 3.73 +/- 0.33 nmole/min/ml of serum, respectively, which were similar to our previously reported values. Activities of DPP II, DPP IV, and PEP of serous effusions were comparable to those in serum. However, there was no significant correlation between their activities in serum and effusion. This may suggest that the major source of these enzymes in effusions may not be serum but the cells in the middle ear.     

HIF-VEGF pathways are critical for chronic otitis media in Junbo and Jeff mouse mutants

Otitis media with effusion (OME) is the commonest cause of hearing loss in children, yet the underlying genetic pathways and mechanisms involved are incompletely understood. Ventilation of the middle ear with tympanostomy tubes is the commonest surgical procedure in children and the best treatment for chronic OME, but the mechanism by which they work remains uncertain. As hypoxia is a common feature of inflamed microenvironments, moderation of hypoxia may be a significant contributory mechanism. We have investigated the occurrence of hypoxia and hypoxia-inducible factor (HIF) mediated responses in Junbo and Jeff mouse mutant models, which develop spontaneous chronic otitis media. We found that Jeff and Junbo mice labeled in vivo with pimonidazole showed cellular hypoxia in inflammatory cells in the bulla lumen, and in Junbo the middle ear mucosa was also hypoxic. The bulla fluid inflammatory cell numbers were greater and the upregulation of inflammatory gene networks were more pronounced in Junbo than Jeff. Hif-1α gene expression was elevated in bulla fluid inflammatory cells, and there was upregulation of its target genes including Vegfa in Junbo and Jeff. We therefore investigated the effects in Junbo of small-molecule inhibitors of VEGFR signaling (PTK787, SU-11248, and BAY 43-9006) and destabilizing HIF by inhibiting its chaperone HSP90 with 17-DMAG. We found that both classes of inhibitor significantly reduced hearing loss and the occurrence of bulla fluid and that VEGFR inhibitors moderated angiogenesis and lymphangiogenesis in the inflamed middle ear mucosa. The effectiveness of HSP90 and VEGFR signaling inhibitors in suppressing OM in the Junbo model implicates HIF-mediated VEGF as playing a pivotal role in OM pathogenesis. Our analysis of the Junbo and Jeff mutants highlights the role of hypoxia and HIF-mediated pathways, and we conclude that targeting molecules in HIF-VEGF signaling pathways has therapeutic potential in the treatment of chronic OM.     

Detection of Alloiococcus otitidis in the nasopharynx and in the outer ear canal

Alloiococcus otitidis has been recovered from the middle ear of children with otitis media with effusion, but its natural habitat is not known. To determine whether the nasopharynx and the outer ear canals are the natural habitats of A. otitidis, 145 swabs (50, nasopharynx; 95 outer ear canal) collected from 50 children were screened by polymerase chain reaction. A. otitidis DNA was detected in seven (4.8%) of the 145 specimens, of which four were nasopharynx, and three outer ear canal. These results indicate that the nasopharynx and outer ear canal may be the body sites for localization of A. otitidis.     

Ectopic mineralization in the middle ear and chronic otitis media with effusion caused by RPL38 deficiency in the Tail-short (Ts) mouse

Inflammation of the middle ear cavity (otitis media) and the abnormal deposition of bone at the otic capsule are common causes of conductive hearing impairment in children and adults. Although a host of environmental factors can contribute to these conditions, a genetic predisposition has an important role as well. Here, we analyze the Tail-short (Ts) mouse, which harbors a spontaneous semi-dominant mutation that causes skeletal defects and hearing loss. By genetic means, we show that the Ts phenotypes arise from an 18-kb deletion/insertion of the Rpl38 gene, encoding a ribosomal protein of the large subunit. We show that Ts mutants exhibit significantly elevated auditory-brain stem response thresholds and reduced distortion-product otoacoustic emissions, in the presence of normal endocochlear potentials and typical inner ear histology suggestive of a conductive hearing impairment. We locate the cause of the hearing impairment to the middle ear, demonstrating over-ossification at the round window ridge, ectopic deposition of cholesterol crystals in the middle ear cavity, enlarged Eustachian tube, and chronic otitis media with effusion all beginning at around 3 weeks after birth. Using specific antisera, we demonstrate that Rpl38 is an ～8-kDa protein that is predominantly expressed in mature erythrocytes. Finally, using an Rpl38 cDNA transgene, we rescue the Ts phenotypes. Together, these data present a previously uncharacterized combination of interrelated middle ear pathologies and suggest Rpl38 deficiency as a model to dissect the causative relationships between neo-ossification, cholesterol crystal deposition, and Eustachian tubes in the etiology of otitis media.     

The effect of palate repair on otitis media with effusion.

Cleft palate in children is very frequently associated with otitis media with effusion. In this prospective study of 150 cleft palate children aged between 2 and 18 months, the prevalence of otitis media with effusion at myringotomy before palate repair was 92 percent. Otoscopic and tympanometric follow-up assessments for 140 children indicate that there is minimal improvement in middle ear status after palate repair. The condition is persistent in 70 percent of children up to 4 years of age. Furthermore, there is no evidence that age at repair or type of cleft is influential. These findings have implications for otologic management of cleft palate children. Early routine unilateral ventilation to ensure adequate hearing but minimize the morbidity of ventilation tubes is advocated.     

MRI Findings of Otic and Sinus Barotrauma in Patients with Carbon Monoxide Poisoning during Hyperbaric Oxygen Therapy

Background and Purpose

To study the MRI findings of otic and sinus barotrauma in patients with carbon monoxide(CO) poisoning during hyperbaric oxygen (HBO) therapy and examine the discrepancies of otic and sinus abnormalities on MRI between barotrauma and acute otitis media with effusion.

Materials and Methods

Eighty patients with CO-poisoning diagnosed with otic and sinus barotrauma after HBO therapy were recruited. Brain MRI was performed to predict delayed encephalopathy. Over the same period, 88 patients with acute otitis media with effusion on MRI served as control. The abnormalities of the middle ear and paranasal sinuses on MRI were noted and were compared between groups. Nine patients with barotrauma were followed up by MRI.

Results

In the barotrauma group, 92.5% of patients had bilateral middle ear abnormalities on MRI, and 60% of patients had both middle ear cavity and mastoid cavity abnormalities on MRI in both ears. Both rates were higher than those in the control group (p = 0.000). In the two groups, most abnormalities on MRI were observed in the mastoid cavity. The rate of sinus abnormalities of barotrauma was 66.3%, which was higher than the 50% in the control group (p = 0.033). In the nine patients with barotrauma followed up by MRI, the otic barotrauma and sinus abnormalities had worsened in 2 patients and 5 patients, respectively.

Conclusion

MRI is able to depict the abnormalities of otic and sinus barotrauma in patients with CO-poisoning during HBO therapy and to differentiate these from acute otitis media with effusion.     

Up-regulation of mucin secretion in HT29-MTX cells by the pro-inflammatory cytokines tumor necrosis factor-alpha and interleukin-6

The pro-inflammatory cytokines IL-6 and TNF-alpha have been implicated in the pathogenesis of otitis media with effusion (OME). A disease where goblet cells proliferate in a modified respiratory epithelium, leading to the accumulation of a mucin-rich effusion in the middle ear cleft. The MUC5AC and MUC5B mucin gene products have been identified as components of these effusions. To determine the effect of IL-6 and TNF-alpha on MUC5AC and MUC5B secretion we have used HT29-MTX goblet cells, which secrete both types of mucins. MUC5AC and MUC5B mucin secretion was measured by an enzyme-linked immunosorbent assay (ELISA) using a specific monoclonal antibody NCL-HGM-45M1 and polyclonal antiserum TEPA, respectively. Time response (0-72 hours) and dose response (1.5-150 ng/ml) studies were carried out. IL-6 and TNF-alpha stimulated MUC5AC and MUC5B mucin secretion in a time dependent manner, both in pre-confluent and post-confluent cells. IL-6 (15 ng/ml and 20 ng/ml) produced a low and prolonged stimulation of mucin secretion that persisted for 72 hours, with peak response at 24 hours after induction. The IL-6-mediated mucin secretion at 24 hours was concentration-dependent, with a maximal effect at 15 ng/ml. TNF-alpha (20 ng/ml) induced rapid stimulation of mucin secretion within the first 24 hours, with peak response at 7 hours after induction. IL-6 and TNF-alpha exposure significantly increased MUC5AC secretion, but not MUC5B secretion. Maximal levels of cytokine-induced mucin secretion were detected in pre-confluent cells that showed one and a half- and two-fold increases in MUC5AC secretion after IL-6 and TNF-alpha stimulation, respectively, in comparison with post-confluent cells. The results presented here suggest that IL-6 and TNF-alpha generate a differential up-regulation of mucin secretion and thus contribute to the expression of mucin genes in inflammatory responses.