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

Eosinophilic mucus diseases

Eosinophilic inflammation is primarily characterized by type 2 immune responses against parasitic organisms. In the contemporary human being especially in developed countries, eosinophilic inflammation is strongly associated with allergic/sterile inflammation, and constitutes an undesired immune reaction. This situation is in stark contrast to neutrophilic inflammation, which is indispensable for the host defense against bacterial infections. Among eosinophilic inflammatory disorders, massive accumulation of eosinophils within mucus is observed in certain cases, and is often linked to the distinctive clinical finding of mucus with high viscosity. Eosinophilic mucus is found in a variety of diseases, including chronic allergic keratoconjunctivitis, chronic rhinosinusitis encompassing allergic fungal sinusitis, eosinophilic otitis media, eosinophilic sialodochitis, allergic bronchopulmonary aspergillosis/mycosis, eosinophilic plastic bronchitis, and eosinophilic asthma. In these pathological conditions, chronic inflammation and tissue remodeling coupled with irreversible organ damage due to persistent adhesion of toxic substances and luminal obstruction may impose a significant burden on the body. Eosinophils aggregate in the hyperconcentrated mucus together with cell-derived crystals, macromolecules, and polymers, thereby affecting the biophysical properties of the mucus. This review focuses on the clinically significant challenges of mucus and discusses the consequences of activated eosinophils on the mucosal surface that impact mucus and persistent inflammation.

Myringoplasty for Eosinophilic Otitis Media

OBJECTIVE

Surgical intervention of eosinophilic otitis media (EOM) has been considered contraindicated because middle ear surgery is associated with a risk of deafness. Myringoplasty is believed to be less invasive. Therefore, we analyzed the surgical results of myringoplasty for perforated eardrums in patients with EOM treated by biological drugs (biologics).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Nine ears of seven patients with EOM with eardrum perforation associated with bronchial asthma were treated with add-on biologics; myringoplasty was then performed. The controls comprised 17 ears of 11 patients with EOM treated by myringoplasty without biologics.

INTERVENTIONS

The EOM status of each patient of both groups was assessed using severity scores, hearing acuity, and temporal bone computed tomography scores.

MAIN OUTCOME MEASURES

Preoperative and postoperative changes in severity scores and hearing acuity, postoperative closure of the perforation, and relapse of EOM.

RESULTS

Severity scores significantly decreased after the use of biologics but did not change after myringoplasty. One patient developed postoperative relapse of middle ear effusion (MEE); in the control group, however, 10 ears developed recurrence of MEE. Significant improvement of the air conduction hearing level was obtained in the biologics group. No patients showed deterioration of the bone conduction hearing level.

CONCLUSIONS

This is the first report to describe successful surgical interventions with add-on biologics for patients with EOM. In the era of biologics, surgical interventions such as myringoplasty will be indicated to improve hearing and to avoid recurrence of MEE in patients with EOM with perforated eardrums, with the use of biologics.

Intractable otitis media - Pathogenesis and treatment of Eosinophilic otitis media (EOM) and otitis media with Antineutrophil cytoplasmic antibody (ANCA) -associated vasculitis (OMAAV)

Intractable otitis media is resistant to antimicrobial therapy, tympanostomy ventilation tube insertion, and surgery. In children, intractable acute otitis media, pathological tympanic membrane due to prolonged otitis media with effusion (OME), tympanic membrane atelectasis, and adhesive otitis media are common. Contrarily, in adults, otitis media caused by drug-resistant pathogens, tuberculous otitis media, cholesterol granuloma, malignant otitis externa (skull base osteomyelitis), eosinophilic otitis media (EOM), and otitis media with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (OMAAV) are common and require differentiation. Among them, EOM is increasing along with eosinophilic upper respiratory tract diseases, such as bronchial asthma and eosinophilic chronic rhinosinusitis (ECRS), a subgroup of chronic rhinosinusitis with nasal polyps (CRSwNP). EOM is associated with adult-onset bronchial asthma and is characterized by viscous middle ear effusion and middle ear mucosa thickness with eosinophilic infiltration, which requires treatment with glucocorticoids according to disease activity and symptoms. Recently, OMAAV was proposed because of the similarities in clinical features and therapeutic effects. The clinical course of OMAAV is characterized by a relatively rapid increase in the bone conductive hearing threshold, which progresses over 1-2 months, without response to antimicrobial agents or tympanostomy ventilation tube insertion, and in some cases, is complicated by facial paralysis and hypertrophic pachymeningitis. This new concept may explain the pathogenesis and clinical presentation of many cases of intractable otitis media, the cause of which was previously unknown. Although making a diagnosis of OMAAV is relatively easy based on the clinical course, such as vascular dilatation of the tympanic membrane and positive ANCA titer, it is often difficult because the ANCA titer becomes negative with previous administration of glucocorticoids. In adults with intractable otitis media, ANCA titers must be measured before glucocorticoid administration. Treatment consisted of remission induction therapy with a combination of glucocorticoids and immunosuppressive drugs.

Eosinophilic Otitis Media: Modern Aspects of Pathogenesis, Clinical Features, Diagnosis and Treatment

Eosinophilic otitis media (EOM) is an inflammatory chronic disease of the middle ear, characterized by the presence of a particularly viscous effusion with a high content of protein toxins of eosinophilic origin in the middle ear cavity. The pathology has relationship with bronchial asthma, allergic rhinitis and chronic rhinosinusitis with nasal polyps. EOM is characterized by a sluggish course, a tendency to relapse, which can lead to a gradual hearing decrease up to complete deafness. In this paper, we reviewed the international literature with special attention to pathogenesis and treatment management.

Eosinophilic otitis media and comorbid asthma

PURPOSE OF REVIEW

Eosinophilic otitis media (EOM) is an intractable otitis media characterized by numerous eosinophils infiltrating the middle ear cavity, which is part of the upper airway. EOM shows a high rate of comorbidity with asthma. They are considered to have a 'one airway, one disease' relationship. Here, we summarize our current knowledge regarding the characteristics of EOM, EOM's relationship with asthma and the efficacy of optimal treatments for EOM.

RECENT FINDINGS

The greater the severity of asthma, the more pronounced the development of EOM. Asthma control is usually inadequate in asthmatics who develop EOM, and appropriate strengthening of asthma inhalation therapy leads to improvement in the EOM. EOM severity can be divided into mild, moderate, and severe. Intratympanic infusion therapy using a topical steroid such as triamcinolone acetone is effective for mild EOM, whereas moderate EOM requires a systemic steroid in addition to triamcinolone acetone, and severe EOM forms granulation tissue that requires surgical removal. Recently, the effectiveness of molecularly targeted drugs is being reported, but more data need to be accumulated.

SUMMARY

EOM and asthma are closely related. Optimal asthma treatment is important for treating EOM. Treatments commensurate with the severity of EOM are being developed.

Chronic otorrhoea, otalgia and hearing loss not responding to antibiotics and tympanoplasty surgery

Chronic otorrhoea from a tympanic membrane perforation is common. We present the case of a patient who had already received seemingly adequate treatment for his condition in the past. Yet, he presented to our outpatient clinic with worsening otalgia and otorrhoea, progressive hearing loss and a new tympanic membrane perforation. After a thorough otological evaluation, the patient's medical history and the histological specimen from a previous operation were reviewed. The findings met the diagnostic criteria of eosinophilic otitis media. After treatment with topic triamcinolone through the perforated tympanic membrane, the patient's otalgia subsided, hearing levels were improved and the size of the tympanic membrane perforation decreased.

CD11c(+) dendritic cells coexpressing thymic stromal lymphopoietin receptor in animal model of eosinophilic otitis media

Background

Eosinophilic otitis media (EOM) is an intractable middle ear disease often associated with eosinophilic inflammatory airway conditions. Recently, dendritic cells (DCs) have been indicated as an essential component of Th2 allergic inflammation, such as bronchial asthma. DCs are activated by thymic stromal lymphopoietin (TSLP), an epithelial cell-derived cytokine. However, the relationship between TSLP and DCs in EOM remains unknown.

Objective

This study aimed to investigate the relationship between DCs and TSLP and to determine the involvement of DCs in EOM in an animal model.

Methods

Hartley guinea pigs were used as the animal model. Daily ovalbumin (OVA) stimulation of the middle ear was performed for 7 or 14 days. The temporal bone was dissected on the last day of stimulation, and paraffin-embedded sections were prepared. Immunostaining and immunofluorostaining for TSLP receptor (TSLPR) and CD11c, a surface marker of DCs, were performed.

Results

We found CD11c-immunopositive cells in the submucosal area of the middle ear epithelium, particularly around the eustachian tube. TSLPR-immunopositive cells exhibited a similar distribution as CD11c-positive cells.

Conclusion

CD11c positive DCs coexpressing TSLPR were recruited after OVA challenge which might activate Th2 allergic reaction.

Dupilumab therapy for patients with refractory eosinophilic otitis media associated with bronchial asthma

OBJECTIVES

Eosinophilic otitis media (EOM) is an intractable otitis media mostly associated with bronchial asthma. Dupilumab, an anti-interleukin (IL)-4 receptor (R)α, is effective and has been approved for use in patients with moderate to severe bronchial asthma, atopic dermatitis and chronic rhinosinusitis with nasal polyposis, whose diseases are not controlled by previous treatments including other molecular targeted drugs. We aimed to assess efficacy of dupilumab in three EOM patients with associated bronchial asthma, who were poor responders to previous topical and systemic corticosteroid therapy and molecular targeted therapies.

PATIENTS AND METHODS

Three patients with severe, refractory EOM (two with a granulation type) associated with bronchial asthma received dupilumab as add-on therapy for at least 6 months. The efficacy of dupilumab therapy was evaluated using severity scores, symptom scores, hearing acuities, temporal bone computed tomography (CT) scores, and surrogate markers before and after therapy.

RESULTS

Severity scores in all patients were dramatically reduced to 2 points or less (full score: 16 points) after initiation of therapy. Air conduction hearing levels were improved in all patients. Temporal bone CT scores in two patients were reduced, and serum IgE levels in all three patients also decreased following therapy.

CONCLUSION

We provide the first report that add-on dupilumab therapy was effective in patients with severe, refractory EOM who did not respond to the treatments including other molecular targeted therapy. Patients with severe middle ear mucosal change may benefit particularly from dupilumab therapy.

Risk factors for bacterial infection to cause sensorineural hearing loss in eosinophilic otitis media

OBJECTIVE

Eosinophilic otitis media (EOM) is an intractable type of otitis media in which sensorineural hearing loss (SNHL) progresses over time. Clinically, bacterial infection complicates the course of EOM, making it challenging to control otorrhea/middle ear effusion (MEE) from infected ears, and accelerates the progression of SNHL. In this study, we focused on infection, one of the risk factors for SNHL in EOM, and analyzed factors associated with it.

METHODS

In this cohort study, we evaluated 144 ears of 72 patients diagnosed with bilateral EOM. Patients visited our hospital once every 1-3 months and received intratympanic or systematic administration of steroids when otorrhea/MEE was observed. Several investigations, including blood tests, otorrhea/MEE cytology, bacterial culture tests, and respiratory function tests, were performed. In the otorrhea/MEE cytology, the leukocyte fraction was measured.

RESULTS

Two risk factors for SNHL in EOM were middle ear mucosal thickening (p <0.01) and infection (p <0.05). Compared to the group with <40% neutrophils in otorrhea/MEE samples, groups with 40-70% and ≥70% neutrophils had a significantly higher bone conduction hearing level (p <0.01, p <0.05, respectively). Two risk factors associated with the occurrence of infection in EOM were tympanic membrane (TM) perforation (p <0.01) and the coincidence of otorrhea/MEE and rhinorrhea in bacterial culture test results (p <0.001). A positive correlation was observed between TM perforation and infection (p <0.001). Our analysis of the relationship between the frequency of intratympanic corticosteroids administration and the time-period until the occurrence of TM perforation showed that >4 intratympanic administrations/year significantly increased the risk of perforation (p<0.001). Pseudomonas aeruginosa was isolated from otorrhea/MEE samples, while Pseudomonas aeruginosa and fungi, detected in cultures of rhinorrhea samples, were significantly related to the deterioration of bone conduction hearing levels.

CONCLUSION

The risk factors associated with the occurrence of infection in patients with EOM were TM perforation and the coincidence of otorrhea/MEE and rhinorrhea in bacterial culture test results. Since TM perforation is likely to occur even due to intratympanic corticosteroids administration, it is necessary to confirm whether the frequency of treatment is appropriate and try a less invasive technique of administration. Furthermore, Pseudomonas aeruginosa infection poses a high risk for the development of SNHL, and clinicians should be alert to this possibility, even if the bacteria were identified only in cultures of rhinorrhea samples.

The expression of thymic stromal lymphopoietin in patients and animal models with eosinophilic otitis media

OBJECTIVE

In the present study, we aimed to clarify the expression of thymic stromal lymphopoietin (TSLP), a key trigger of Th2-type allergic disease, in the middle ear mucosa of eosinophilic otitis media (EOM).

METHODS

An immunohistological study of TSLP was conducted in patients with EOM and in animal models of EOM constructed by intraperitoneal and intratympanic injection of ovalbumin for 7 and 14 days. In addition, the messenger RNA (mRNA) expression of TSLP in the middle ear mucosa of the animal models was analyzed using real-time PCR, and was compared with that of the control animals.

RESULTS

Immunoreactivities for TSLP were observed in the middle ear mucosa around the tympanic ostium of the eustachian tube of patients with EOM. In the animal model, strong immunoreactivity for TSLP was also observed in the eustachian tube epithelium, and mRNA expression of TSLP in the seven-day stimulated animals was significantly higher than that in the controls.

CONCLUSION

The present study indicates that the presence of epithelium-derived TSLP in the eustachian tubes plays an important role in the onset of EOM.

The Role of Allergy in Otologic Disease

Allergy is commonly associated with conditions such as rhinitis, sinusitis, and asthma, but the relationship between allergy and otologic diseases is less clear. This article examines the evidence for a relationship between allergic disease and several common otologic conditions, including otitis media with effusion, eosinophilic otitis media, and Ménière's disease.

Eosinophilic Otitis Media: the Aftermath of Eosinophil Extracellular Trap Cell Death

PURPOSE OF REVIEW

Eosinophilic otitis media (EOM) is a refractory disease characterized by the accumulation of eosinophils in middle ear effusion and mucosa. We summarize current knowledge regarding the clinical characteristics and management of EOM. Although eosinophil activation in inflamed foci is involved in the pathogenesis of EOM, little is known about the fate of the eosinophils and aftermath of their cell death. We discuss the possibility that eosinophils undergo non-apoptotic cell death that worsens tissue damage and increases effusion viscosity.

RECENT FINDINGS

Unlike chronic otitis media, EOM is strongly associated with an allergic background. Corticosteroids are currently the only effective pharmacological treatment, and surgical intervention is often required. Mucosal eosinophils infiltrate extensively into the middle ear cavity where they are stimulated by locally produced activators including interleukin-5 and eotaxin. The eosinophils undergo cytolysis in the effusion, which represents a major fate of activated eosinophils in vivo. Recent data revealed cytolysis could be renamed as extracellular trap cell death (ETosis). ETosis represents suicidal cell death involving total cell degranulation and development of sticky chromatin structures (extracellular traps (ETs)). The characteristics of eosinophil- and neutrophil-derived ET polymers might contribute to the difference in viscosity of secretions between EOM and common chronic otitis media. The extracellular products remaining after eosinophil ETosis are an important aspect of EOM pathology. The concept of ETosis also has novel implications for potential therapeutic modalities in various eosinophilic disorders.

Treatment of eosinophilic otitis media with pegylated interferon-α 2a and 2b

OBJECTIVE/HYPOTHESIS

Eosinophilic otitis media (EOM) is a variant of chronic otitis media that is characterized by the development of thick mucoid middle ear effusion, adult onset bronchial asthma, sinonasal polyposis, and aspirin sensitivity. EOM is typically refractory to corticosteroid therapy and surgical intervention. Pegylated interferon (PEG-IFN) has effectively treated hypereosinophilic syndrome in clinical trials; however, the efficacy of this medication for EOM treatment remains undefined.

STUDY DESIGN

Retrospective, case series, tertiary academic center.

METHODS

A retrospective chart review was performed on EOM patients from 2008-2014. A total of 32 patients met the clinical criteria for EOM according to established diagnostic guidelines. Outcomes of all patients with severe, refractory EOM who initiated PEG-IFN therapy are reported.

RESULTS

Eight patients were treated with pegylated interferon-α 2a or 2b for refractory EOM. Half of the patients had significant side effects with interferon treatment. Three of these were able to continue at a reduced dosage without side effect reoccurrence, and one patient stopped the medication permanently. Four of eight (50%) patients had a complete clinical response with total resolution of otorrhea and normalization of middle ear mucosa, and were able to discontinue corticosteroid treatment. Two patients attempted to stop PEG-IFN therapy after prolonged symptom remission and had recurrent otorrhea. Both patients had symptom resolution after PEG-IFN reinitiation.

CONCLUSIONS

These data demonstrate that pegylated interferon-α 2a and 2b therapy may benefit patients with severe, refractory EOM. Further larger studies with long-term follow-up are required to validate these early but promising results.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1208-1216, 2017.

Cytokine profile of nasal and middle ear polyps in a patient with Woakes' syndrome and eosinophilic otitis media

Woakes' syndrome is characterised by severe recurrent nasal polyps in early childhood with broadening of the nose, nasal dyscrinia, frontal sinus aplasia and bronchiectasis. Eosinophilic otitis media (EOM) is an intractable condition that can cause gradual or sudden deterioration of hearing and is associated with comorbid asthma. For these reasons, both diseases must be recognised and treated appropriately. We present a case of a 20-year-old man with Woakes' syndrome complicated by EOM, with polyps in both middle ears; this condition has so far not been described as an entity of eosinophilic disease in the literature. We have, from reviewing the literature, learned that this is the first time that results of tissue examination on nasal polyposis with respect to tissue IgE, eosinophil-cationic protein, interleukin (IL)-17 and IL-5 in a patient with Woakes' syndrome and EOM, has been reported and discussed.

New Insights into Eosinophilic Otitis Media

Eosinophilic otitis media (EOM) is a type of intractable otitis media that occurs mainly in patients with bronchial asthma (BA). In 2011, the diagnostic criteria for EOM were established. EOM is characterized by the presence of a highly viscous yellowish effusion containing eosinophils and immunoglobulin E (IgE), eosinophil chemoattractants, such as eosinophil cationic protein, interleukin-5, and eotaxin. Local sensitization against foreign agents such as fungi or bacteria (e.g., Staphylococcus aureus) may result in local IgE production in the middle ear and may be responsible for the severity of EOM. The clinical features of EOM closely resemble localized eosinophilic granulomatosis polyangiitis, therefore it is necessary to be vigilant to the symptoms of mononeuritis, polyneuritis, and skin purpura during diagnosis. Standard treatment for EOM is the instillation of triamcinolone acetonide into the mesotympanum. However, severe cases exhibiting strong inflammation and otorrhea are not easily controlled with antibiotics and/or corticosteroids. We proposed the introduction of a severity score to evaluate the severity of EOM. This score correlated with local IgE levels in middle ear effusion. Clinically, the risk factors associated with this severity score were body mass index, and the duration of bronchial asthma (from the onset of BA to the age of the first consultation of otitis media to our hospital). We emphasize that early diagnosis and adequate treatment are vital in preventing progressive and sudden hearing loss resulting from EOM.

Eosinophilic otitis media is associated with asthma severity and smoking history

PURPOSE

Eosinophilic otitis media (EOM) is an intractable otitis media characterized by an accumulation of eosinophils in the middle ear and a strong association with asthma. We investigated the relationship between EOM and asthma severity, asthma risk factors, lung function, and airway structural changes assessed by high-resolution computed tomographic (HRCT) scanning.

MATERIALS AND METHODS

Forty-one asthma patients with chronic rhinosinusitis (18 men and 23 women; mean age 56 years; age range 25-82 years) were included in this study. EOM was diagnosed according to the published diagnostic criteria. Asthma severity and risk factors for asthma, such as smoking history (Brinkman index, BI), were examined. Airway wall thickness and emphysema were assessed with HRCT scanning by a blinded respiratory specialist using a validated method. Lung function was measured using standard procedures.

RESULTS

EOM was diagnosed in 34% of the patients. Asthma severity, BI and airway wall thickness were each statistically greater in patients with EOM than in patients without EOM.

CONCLUSION

There was a close relationship between EOM and asthma severity in asthma patients with chronic rhinosinusitis. Cessation of smoking might help prevent EOM by reducing airway wall thickness.

Risk factors associated with severity of eosinophilic otitis media

OBJECTIVE

Eosinophilic otitis media (EOM) is an intractable otitis media associated with bronchial asthma. Clinical characteristics of EOM are apparent, but severe EOM, which is unresponsive to ongoing treatments, can occur. The present study aimed to investigate potential risk factors associated with the severity of EOM.

METHODS

We scored the EOM severity of 26 patients according to quantity of middle ear effusion (MEE), thickness of the middle ear mucosa, use of topical and oral corticosteroids, and use of antibiotics, all measured over a 3-month period. The scores for four 3-month periods (1 year) were averaged. We analyzed the prevalence of clinical variables by partial regression: sex, age, body mass index (BMI), duration of bronchial asthma, association of aspirin-intolerant asthma, Lund-Mackay score for sinusitis, mastoid pneumatization, width of the bony Eustachian tube at the tympanic orifice, percentage of eosinophils and immunoglobulin E in peripheral blood, and association of allergic rhinitis. Duration of bronchial asthma was defined as the period from onset of bronchial asthma to the age of first consultation at our hospital. Samples of MEE were taken for bacterial culture.

RESULTS

The average severity score was 6.6 (out of 16). The severity score in the pathogen-positive MEE group was significantly higher than that in the pathogen-negative MEE group (p<0.05). The score was not significantly different between the seasons. Linear multiple regression analysis showed that BMI and the duration of bronchial asthma significantly affected the EOM severity score (p<0.05). The presence of aspirin intolerant asthma tended to be correlated with the severity score. The Lund-Mackay score tended to be negatively correlated with it.

CONCLUSIONS

There is a significant association between the severity of EOM and obesity, as well as with the duration of bronchial asthma.

Antigen-specific IgE in middle ear effusion of patients with eosinophilic otitis media

BACKGROUND

Eosinophilic otitis media (EOM) is an intractable otitis media characterized by a highly viscous effusion that contains eosinophils. We previously reported that high levels of IgE were detected in middle ear effusion (MEE) of patients with EOM.

OBJECTIVE

To examine antigen-specific IgE in MEE of patients with EOM to clarify the pathogenesis of EOM.

METHODS

Twenty-six patients with EOM associated with bronchial asthma were included in this study. Antigen-specific IgE against inhalant and bacterial antigens were measured in the serum and MEE of these patients.

RESULTS

In patients with EOM, 1 or more antigen-specific IgEs were detected from the MEE of 16 of 26 patients (62%), whereas 1 of 9 control patients (11%) had antigen-specific IgE (P < .01). Total serum IgE concentrations were not different between the groups who tested positive (16 patients) and negative (10 patients) for antigen-specific IgE. None of the fungi-specific IgEs were detected in serum even though 11 patients tested positive for 1 or more fungal antigens detected in MEE. The severity score of EOM in the antigen-specific IgE-positive group was significantly higher than that in the antigen-specific IgE-negative group (P < .05).

CONCLUSION

Antigen-specific IgE against inhalant and bacterial antigens may be locally produced in the middle ear mucosa in patients with EOM. In particular, local sensitization against fungi together with Staphylococcus aureus could result in local IgE production in the middle ear and may be responsible for the severity of EOM.

The role of periostin in eosinophilic otitis media

CONCLUSION

We investigated the localization of periostin in middle ear specimens from patients with eosinophilic otitis media (EOM) and from a newly constructed animal model for EOM. Periostin-positive immunostaining was observed in the middle ear sections obtained from the EOM patients. Immunoreactivity for periostin was also seen in the animal model. These results suggest that periostin plays an important role in subepithelial fibrosis in the middle ear in EOM.

OBJECTIVE

The purpose of the present study was to investigate the role of periostin in the middle ear of EOM patients and an animal model.

METHODS

Histological and immunohistochemical analyses for periostin were carried out in the middle ear specimens of six EOM patients with/without asthma. An animal model of EOM was constructed by intraperitoneal and topical sensitization with ovalbumin (OVA). Histological and immunocytochemical analyses for periostin were also performed in this model.

RESULTS

Immunoreactivities for periostin were observed in the basement membrane and extracellular matrix of the middle ear sections obtained from all EOM patients with/without asthma. In the animal model, eosinophil infiltration and middle ear mucosa thickness were observed. Moreover, periostin-positive immunostaining was shown in the extracellular matrix of the middle ear mucosa on the side topically boosted by OVA.

Eosinophilic otitis media: CT and MRI findings and literature review

Eosinophilic otitis media (EOM) is a relatively rare, intractable, middle ear disease with extremely viscous mucoid effusion containing eosinophils. EOM is associated with adult bronchial asthma and nasal allergies. Conventional treatments for otitis media with effusion (OME) or for chronic otitis media (COM), like tympanoplasty or mastoidectomy, when performed for the treatment of EOM, can induce severe complications such as deafness. Therefore, it should be differentiated from the usual type of OME or COM. To our knowledge, the clinical and imaging findings of EOM of temporal bone are not well-known to radiologists. We report here the CT and MRI findings of two EOM cases and review the clinical and histopathologic findings of this recently described disease entity.

Evaluation of Eustachian tube function with perfect sequences: technical realization and first clinical results

The aim of this study was the introduction of a specific class of signals, the so-called perfect sequences (PSEQ), in a novel approach for sonotubometry of the Eustachian tube (ET). Sonotubometry using PSEQ stimuli was performed on 20 healthy subjects in order to gauge its potential for clinical applications. In a series of 320 measurements ET opening was probed, which was induced by dry and water swallowing, Toynbee maneuver, and yawning. All sonotubograms were analyzed with respect to their shape, increase of sound intensity, and opening duration. In 298/320 measurements (>93%) the subjects reported subjective ET openings. The evaluation of the recorded sonotubograms showed good detection of ET opening for the inducing maneuvers of swallowing (dry and water swallowing) and the Toynbee maneuver, with 90, 86, and 80% valid sonotubograms, respectively. Yawning led to only 40% valid sonotubograms. In total, 237/320 (~74%) sonotubograms were classified as valid. The evaluation of the sound level increase during ET openings showed that it was significantly higher in measurements with dry and water swallowing, as well as Toynbee maneuvers (mean 17.1, 19.0 and 17.2 dB, respectively), than with yawning (mean 10.17 dB; P < 0.0001). Nasal decongestion was found to have little influence on the results (P > 0.05). Sonotubometry using PSEQ stimuli is a novel sonotubometry methodology that provides valuable information regarding the auditory tube patency. By further technical refinements of the method, a diagnostic tool with high sensitivity and specificity could be developed.

Eosinophilic otitis media: a new middle ear disease entity

Eosinophilic otitis media (EOM) is intractable otitis media characterized by the presence of a highly viscous yellow effusion containing eosinophils. It occurs mainly in patients with bronchial asthma and is resistant to conventional treatments for otitis media. Here we discuss the clinical features, pathogenesis, and management of EOM. EOM predominantly affects women and presents most often in patients in their 50s. The clinical features of the middle ear in EOM are roughly divided into the otitis media with effusion type and chronic otitis media type. The latter is further divided into two subtypes: simple perforation and granulation tissue formation. EOM is often complicated by rhinosinusitis (eosinophilic sinusitis). High-tone loss is more frequently found and more severe in EOM patients than in chronic otitis media control patients, and EOM patients sometimes become deaf suddenly. Systemic or topical steroid administration is the most effective treatment for patients with EOM. The instillation of triamcinolone acetonide, a suspension of steroids, into the middle ear is very effective for controlling eosinophilic inflammation. It is very important to explain to patients with EOM that the disease may last for a long period and that progressive and sudden hearing loss may occur.

Postoperative results of simple underlay myringoplasty in better hearing ears

CONCLUSIONS

Simple underlay myringoplasty with fibrin glue (SUM) is indicated for repair of tympanic membrane (TM) perforation in the better hearing ear because postoperative hearing deterioration is extremely rare.

OBJECTIVE

To evaluate the postoperative results, including the hearing and the re-perforation rate, in the better hearing ear.

MATERIALS AND METHODS

The procedure of SUM is removal of the perforation edge and bonding of the graft to the remnant TM with a few drops of fibrin glue by underlay technique. This method was applied to 75 patients with a perforated TM in the better hearing ear. The postoperative hearing and the re-perforation rate were investigated.

RESULTS

The mean of the postoperative hearing gain was 10.3 dB and no cases of postoperative hearing loss were observed. Although postoperative re-perforation was found in 18 cases (24.0%), the re-perforation was closed in 16 of these cases in the outpatient department by the same procedure using frozen autologous tissue that had been harvested previously in surgery. Including these cases, the total success rate was 97.3%.