Eustachian tube obstruction after provocative nasal antigen challenge

Effect of Topical ucb 28754 on Rhinitis Provoked by Intranasal Histamine and Ascaris Suum in the Monkey

A monkey model was used to evaluate intranasal ucb-28754, a newly developed H1 antagonist in attenuating nasal obstruction following intranasal challenge with either histamine or Ascaris in a dose response protocol. Nasal patency was measured with computer assisted anterior rhinomanometry. Eight female, feral, Ascaris sensitive, juvenile cynomolgus monkeys were pretreated with 100 ul of 0.075% ucb-28754 or placebo in a crossover study protocol before intranasal histamine provocation. Three of the animals also received 100 ul of 0.075% or 0.3% ucb-28754 or placebo before intranasal Ascaris challenge. Statistically significant (P < 0.05) improvement was observed for the ucb-28754 treated monkeys in nasal conductance and in mean nasal work/L following histamine challenge. Pharmacologic efficacy (50% reduction of nasal obstruction) was achieved for the medication on three of four histamine dosages. In the Ascaris challenged animals, pharmacologic efficacy was achieved for four of five doses for the animals receiving 0.075% ucb-28754 and two of five doses when they were pretreated with 0.3% ucb-28754. Measurement of heart rate, respiratory rate, and blood pressure, as well as visual examination of the monkeys indicated that ucb-28754 had no adverse effects. These studies indicate that ucb-28754 administered intranasally is a potentially safe and effective antihistamine in this monkey experimental model.

Priming of the Nose and Eustachian Tube during Natural Pollen Exposure

Previous studies have suggested that seasonal allergen exposure in allergic individuals “primed” or increased the response of nasal mucosa to subsequent allergen challenge. The purpose of this study was to document the specificity of nasal “priming” and to determine if this effect extends to the eustachian tube (ET). Eight subjects with ragweed allergic rhinitis were challenged intranasally with increasing doses of ragweed (0.05, 0.125, 0.25, 0.5, 2.5, and 5.0 mg) and histamine (0.01, 0.1, 0.5, 1.0, 5.0, and 10 mg) before, during, and 4–6 weeks and 3–5 months after ragweed season. Nasal conductance and ET function were evaluated by computerized posterior rhinomanometry and sonotubometry, respectively. The dose that decreased nasal conductance below a threshold value of 0.1 L/sec/cm H2O was defined as the nasal obstructing (NO) dose and that which resulted in an inability to open the ET by swallowing was the ET obstructing (ETO) dose. For ragweed and histamine mean NO doses decreased during and up to 6 weeks after ragweed season compared to preseason and 3–5 months postseason doses. The ETO doses showed similar patterns for histamine challenges, but ET hyperresponsiveness to ragweed was limited to the ragweed season. Patients’ responses did not correlate with serum IgE antibody level. These data show that both the nose and ET can be primed by allergen exposure to manifest heightened responses to both specific allergen and a nonspecific substance.

Intranasal Challenge of Cynomolgus Monkeys with Ascaris, Ragweed, Bradykinin, and Histamine

Seven feral monkeys with Ascaris hypersensitivity confirmed by intradermal skin test were challenged with single doses of Ascaris extract (105 PNU/nostril), ragweed extract (103 PNU/nostril) and diluent; with increasing doses of bradykinin (0.1, 1, and 5 mg/nostril) and histamine (0.1, 1, and 5 mg/nostril), and with repeated doses of PBS diluent. Total mean nasal resistance (TMNR) was measured by rhinomanometry and eustachian tube function by the forced-response test. For single dose challenges, testing was conducted before and 5, 15, 40, and 50 minutes after the challenge and for multiple dose challenges before, 5 and 15 minutes after each dose, and 40 and 50 minutes after the final dose. Mean TMNR (cm H2O/L/sec) was increased from 28.9 ± 9 at baseline to peak at 124 ± 46 after Ascaris challenge. In contrast, TMNR was unaffected in six of seven monkeys challenged with diluent and in all monkeys challenged with ragweed. Progressive TMNR increases from baseline (25 ± 8) were observed for bradykinin (peak = 64 ± 46) and histamine (peak 108.4 ± 59) challenges. Eustachian tube function data showed no significant changes after intranasal provocation with either allergens or mediators. Provocative intranasal allergen challenge in actively sensitized monkeys is an effective method for evaluating the pathophysiology of allergic rhinitis and the effect of inflammatory mediators on nasal resistance.

Histamine Applied Topically to the Nasal Mucosa Increases the Transmucosal Nitrous Oxide Exchange for the Middle Ear

OBJECTIVE

Determine if the middle ear transmucosal nitrous oxide (N₂O) exchange rate is affected by nasal inflammation caused by topical application of histamine.

METHODS

In a randomized, double-blind, crossover study, 20 adults were challenged intranasally with histamine (5 mg) and placebo on separate occasions. At each session, the subjects were fitted with a non-rebreathing mask and breathed room air for 20 minutes, 50% N₂O:50% O₂ for 20 minutes, and 100% O₂ for 10 minutes. Throughout, heart rate, blood pressure, and blood O₂ saturation were monitored, and bilateral middle ear pressure was recorded by tympanometry every minute. The primary outcome measure was the slope of the middle ear pressure-time function for the 50% N₂O:50% O₂ breathing period, which is a measure of the transmucosal N₂O exchange-constant. The effects of challenge substance, session, and period on the measured vital signs and of treatment, session, ear disease history, and test ear on the pressure-time slopes were evaluated using repeated measures ANOVAs.

RESULTS

The post-challenge total symptom score and the slope of the middle ear pressure-time function were greater after histamine when compared to placebo challenge. Of the signs, only heart rate was affected, responding to challenge substance and study period.

CONCLUSION

The transmucosal N₂O exchange rate for the middle ear is increased during inflammation caused by nasal histamine exposure.

Craniofacial shape in children with and without a positive otitis media history

OBJECTIVES

Past studies using traditional morphometric approaches have reported a handful of differences in craniofacial dimensions between individuals with and without otitis media (OM). In this study, a geometric morphometry (GM) approach was used to determine if craniofacial shape is different among children with no history of OM and a history of recurrent acute OM (RAOM) at two different ages.

METHODS

Nineteen standard landmarks were identified on lateral cephalometric radiographs from 79 children (41 Control, 38 RAOM) at 4 years and 52 children (27 Control, 25 RAOM) at 6 years of age. Following Procrustes superimposition of the landmark coordinate data, comparisons of group differences in overall size and shape were performed. Discriminant function analysis and principal component analysis were used to determine which, if any, aspects of shape variation distinguished RAOM from Control groups.

RESULTS

At 4 years of age, craniofacial size and shape were significantly different between RAOM and Control groups (p<0.05). Shape differences were evident in the relative positions of the mandible, cranial base, external acoustic meatus, sphenoid and palate. Those shape differences were not found in the 6-year old group.

CONCLUSIONS

At 4 years of age, the RAOM and Control groups have distinct craniofacial morphologies, but by 6 years of age these differences have largely disappeared. This is consistent with the clinical observation that excess RAOM risk resolves around 6 years of age and the hypothesis that this resolution is partially a result of age-related craniofacial changes.

Antihistamine Use for Otitis Media with Effusion

Objectives

The otitis media with effusion (OME) clinical practice guideline endorsed by the American Academy of Otolaryngology—Head and Neck Surgery Foundation, the American Academy of Pediatrics, and the American Academy of Family Physicians recommends against using antihistamines. Avoiding antihistamines was previously endorsed as a performance measure by the National Quality Foundation, but data regarding current practice patterns are lacking. Thus, our objectives were to evaluate (1) antihistamine usage in association with OME, (2) whether practice varies according to visit setting, and (3) if usage patterns are such that a future change would be measurable.

Study Design

Cross-sectional analysis.

Setting

Ambulatory visits in the United States.

Subjects and Methods

National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys, 2005-2010; univariate, multivariate, and stratified analyses of antihistamine usage were performed.

Results

A total of 133,968 observations representing 1.49 × 109 pediatric visits met inclusion criteria. Antihistamines were used in 9.5% of OME visits, as opposed to 5.5% of visits without OME (univariate odds ratio, 1.83; 95% confidence interval, 1.02-3.29; P = .042). Multivariate analysis confirmed that OME was associated with a significant increase in nonsedating antihistamine usage (odds ratio, 3.53; 95% confidence interval, 1.62-7.71; P = .002), when adjusted for age, sex, race/ethnicity, allergic conditions and nasal inflammatory diagnoses.

Conclusions

Oral antihistamines are significantly more likely to be administered when OME is diagnosed. Although antihistamine use for OME is proportionally low, the high prevalence of OME creates an opportunity for quality improvement. Future changes in clinician behavior in response to an updated guideline or related performance metric could be monitored.

Effect of combination of montelukast and levocetirizine on otitis media with effusion: a prospective, placebo-controlled trial

CONCLUSION

This study demonstrated that treatment with montelukast in combination with levocetirizine may have a beneficial effect on clinical improvement of middle ear fluid in children with otitis media with effusion (OME).

OBJECTIVE

To evaluate the effect of the combination of montelukast and levocetirizine on shortening the duration of effusion in successfully treated OME in children.

METHODS

This was a randomized, prospective, double-blind, placebo-controlled trial. The study group consisted of 120 children (age range 2-6 years), who were diagnosed with OME of at least 2 months duration. The children were randomized into one of four groups. The treatment packs containing montelukast 4 mg (tablet) and/or levocetirizine 2.5 mg/5 ml as the active drug or placebo were prepared, numbered, and distributed by the second author.

RESULTS

The amelioration of bilateral otoscopic sign scores in the combination therapy group was statistically significantly greater than in all the other groups (p < 0.05). Improvement in bilateral tympanometric findings in the combination therapy group and montelukast group was greater than in the other groups. However, this difference was not statistically significant (p > 0.05). When we compared the difference between otoscopic sign scores before and after treatment we found that it was statistically significant in every group (p > 0.05). However, the significant improvement in tympanometric findings occurred in all groups except the levocetirizine group (p > 0.05).

The link between otitis media with effusion and allergy: a potential role for intranasal corticosteroids

We reviewed the evidence linking otitis media with effusion (OME) and atopy, with the goal of clarifying the possible role of intranasal corticosteroids (INSs) in OME treatment. In August 2009, the MEDLINE database was searched for primary studies on OME epidemiology, pathophysiology, and treatment. Relevant clinical guidelines were obtained. Interpreting OME research is complicated by variable disease definitions, patient populations, methodologies, and outcomes assessments, along with the possibility of spontaneous resolution. However, evidence links OME with atopic conditions including allergic rhinitis; observed prevalence of allergic rhinitis in patients with chronic or recurrent OME ranges from 24% to 89%. Such findings have prompted evaluations of common allergy medications for OME treatment. While short-term use of INSs alone or combined with antibiotics has shown benefit in some studies, more prolonged treatment protocols and long-term clinical outcomes will require critical assessment. Evidence suggesting epidemiologic and pathophysiologic links between allergy and OME has prompted investigation into a potential role for INSs in OME management, with promising initial results. Benefits of considering medical treatment in patients with OME prior to surgery include both the potential reductions in allergic inflammation and the naturally occurring spontaneous resolution of OME in these patients.

Expression of GATA3, T-bet, IL-4, and IFN-gamma mRNA in the effusion of OME patients

OBJECTIVE

The role of allergy in the pathophysiology of otitis media with effusion (OME) remains unclear. We evaluated the role of allergy and the Th1/Th2 balance in OME patients.

METHOD

Middle ear fluid was collected from 46 OME patients who had a ventilating tube inserted, and expression of GATA3, T-bet, IL-4, and IFN-gamma mRNA was assessed by RT-PCR. Expression of transcription factors and cytokines was compared in patients with and without allergy.

RESULTS

The levels of GATA3 and T-bet mRNA in effusion fluid correlated positively with the levels of IL-4 and IFN-gamma mRNA, respectively. However, the allergy and non-allergy groups showed no significant differences in expression of any of these transcription factors and cytokines. The T-bet:GATA3 ratio was higher in the non-allergy than in the allergy group, but the difference was not statistically significant.

CONCLUSION

Although we observed a significant positive correlation between GATA3 and IL-4 mRNA levels, we cannot conclude that OME with allergy is related to a Th-2 driven immune response.

The link between allergic rhinitis and chronic otitis media with effusion in atopic patients

The significant incidence of atopy associated with otitis media with effusion (OME) has suggested a role of allergy in the pathogenesis of OME. Analysis of inflammatory mediators indicates that the mucosa of the middle ear can respond to antigen in the same way as does the mucosa of the lower respiratory tract. Recent characterization of the mucosa and effusion from atopic patients with OME reveals a Th2 cytokine and cellular profiles consistent with an allergic response, supporting the role of allergy in OME. In addition, animal studies demonstrate that inhibiting characteristic allergy cytokines can prevent the production of middle ear effusion. As the understanding of allergy and its role in the inflammation of OME continues to deepen, this will introduce focused treatments of OME in the atopic population.

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.

Total serum IgE and IgE antibodies specific to house dust mite found in two aged-matched cohorts of children with and without otitis media with effusion

OBJECTIVES

To determine whether otitis media with effusion (OME) is associated with elevated serum immunoglobulin E (IgE) and IgE specific for house dust mite.

DESIGN

Forty-seven children who had evidence of bilateral OME, both otoscopically and on tympanometry, on two separate occasions, 3 months apart were admitted for ventilation tubes. Forty-eight children admitted for minor eye surgery who had otoscopically normal ears and no history of middle ear problems were used as controls. Bloods samples were taken under anaesthesia. Total IgE and IgE radioallergosorbent test (RAST) to house dust mite was measured by the Pharmacia Unicap 100 system. The results from the two groups were compared.

SETTING

Birmingham Children's Hospital.

PARTICIPANTS

Children between the ages of 3 and 10. Children with Down's syndrome, cleft lip and palate, ciliary abnormalities, known immunodeficiencies and cardiac abnormalities were excluded.

MAIN OUTCOME MEASURES

Total IgE and RAST to house dust mite. A RAST of >0.35 was taken to be positive.

RESULTS

There was no statistical difference between the control and study groups for the total IgE. Six children from both study and control groups had a raised house dust mite RAST. There was no difference in the levels between either group.

CONCLUSIONS

Our findings indicate that there is no direct relationship between OME and biochemical evidence of allergy, specifically to house dust mite.

Studies in otitis media: Children's Hospital of Pittsburgh-University of Pittsburgh progress report--2004

OBJECTIVES/HYPOTHESIS

The present Progress Report has summarized the key otitis media clinical trials and laboratory studies conducted since 1969 by investigators at the Children's Hospital of Pittsburgh-University of Pittsburgh (Pittsburgh, PA).

STUDY DESIGN

Review.

METHODS

Included in the discussion are the following: 1) studies of the epidemiology and risk factors; 2) anatomy and pathology of the eustachian tube-middle ear from human temporal bone histopathological specimens; 3) physiology and pathophysiology of the eustachian tube-middle ear in humans and animal models; 4) pathogenesis; 5) otitis media in special populations (e.g., patients with cleft palate, Native Americans, patients with Down syndrome); 6) microbiology; 7) diagnosis; 8) outcomes of randomized clinical trials that evaluated efficacy of nonsurgical and surgical methods of treatment and prevention; 9) studies of certain complications and sequelae (e.g., effect of middle-ear effusion on hearing, early child development, and the vestibular system; chronic suppurative otitis media). Also included are relevant summary tables and 256 references.

Effect of intranasal histamine challenge on Eustachian tube function

OBJECTIVE

To show a relationship between intranasal histamine challenge, the development of middle ear effusion and Eustachian tube (ET) dysfunction in a rat model.

METHODS

Non-allergic Sprague-Dawley rats weighing between 450-600 g were randomly assigned to receive an intranasal infusion of 16 microl of 10% histamine or normal saline. ET function was assessed by using the forced-response test to measure passive and active opening and closing pressures at time intervals of 6, 10, 14, 18, 22, and 26 min and 24 h post-infusion. Mucociliary clearance times (MCCTs) of the tubotympanum at 18 min post-infusion were measured by timing the transit of dye from the middle ear to the nasopharynx. Outcome measures were ET dysfunction and evidence of clinical effusion.

RESULTS

Intranasal histamine caused acute ET dysfunction when introduced into the nasopharynx demonstrated by significant elevations in passive and active opening and closing pressures (P < or = 0.001) compared to controls. The largest difference was seen at 26 min post-infusion. Furthermore, MCCTs were 2.4 times longer after infusing intranasal histamine than after saline infusion. No clinically significant effusions were evident in either group at any time interval.

CONCLUSION

These data demonstrate a successful development of an intranasal histamine rat model, in addition to a relationship between intranasal histamine challenge and development of acute ET dysfunction.

The link between allergic rhinitis and otitis media

Past studies implicated allergy in the pathogenesis of otitis media. However, definitive proof of the assertion is lacking. Epidemiologic studies, including one recently published by Rylander and Megevand, consistently identify allergy as a risk factor for otitis media. Also, higher than expected frequencies of allergy are reported for patients with otitis media, but it is unclear if this is an epiphenomenon associated with referral bias. This possibility is exemplified by the results of two reviewed papers where Velepic and colleagues reported a 25% prevalence of allergy in otitis media patients while Alles and colleagues reported a prevalence of 89%. Other studies documented biochemical components of allergic inflammation in the effusions recovered from children with otitis media, and Hurst and colleagues published a recent paper continuing on that theme. However, it is not known if a local allergic reaction is required for the production of these components and if they are produced exclusive of other inflammatory products. Three published studies explored mechanisms by which allergy could cause otitis media. Tikkanen and colleagues reexamined at age 10 a group of 56 subjects with previously diagnosed milk allergy and showed that despite decreased reactivity to milk protein a high prevalence of otitis media was retained. This suggests that it is the allergic condition, not the specific allergy to milk that increases otitis media risk. Downs and colleagues exposed the middle ears of rats to histamine and provoked changes in the pressure regulating and clearance functions of the Eustachian tube. Those changes could prolong an otitis media episode, but middle ear histamine is not limited to the allergic condition. Gentile and colleagues challenged the nose of allergic and nonallergic subjects with histamine followed by interleukin-6 or placebo and measured nasal, pulmonary, Eustachian tube and middle ear functions. Interleukin-6 did not change the Eustachian tube or middle ear functions but did cause increased secretions in allergic patients.

Late-phase allergy and eustachian tube dysfunction

OBJECTIVE

This study investigated the role of late-phase allergy in the development of otitis media with effusion.

METHODS

Brown Norway rats were sensitized to ovalbumin and later challenged transtympanically. Eustachian tube ventilatory function was assessed 2, 4, 8, 24, 28, and 32 hours postchallenge by measuring passive opening and closing pressures, active clearance of positive and negative middle ear pressure, and mucociliary clearance.

RESULTS

The results demonstrate that exposure to transtympanic allergen induces eustachian tube dysfunction and subsequent formation of effusion. Allergic animals showed significant increases in passive and active opening pressures, as well as a decreased ability to actively clear middle ear pressure. Finally, the mucociliary was significantly impaired in all sensitized rats exposed to transtympanic allergen.

CONCLUSION

These findings demonstrate that late-phase allergy leads to significant eustachian tube dysfunction and subsequent formation of effusion by impairing the ventilatory and clearance functions of the eustachian tube.

Middle Ear Effusion—Allergy Relationships

Middle ear effusion (MEE), in its various forms, is one of the most common disorders of childhood. There are several possible etiologies, depending on the makeup of the effusion. However, the common factor in many middle ear effusions is eustachian tube dysfunction, and the role of allergy, although only one of many possible causes, is significant. A relatively large number of children with MEE are found to have atopic disorders. Nonetheless, allergy treatment alone must not preclude the use of conventional medical and surgical therapy. Optimal results will be obtained if recurrent or persistent MEE is managed in a coordinated manner by the otologist, pediatrician and allergist.

The role of IgE-mediated hypersensitivity in otitis media with effusion

INTRODUCTION

The role of immunoglobin (Ig) E-mediated hypersensitivity in otitis media with effusion (OME) has been the subject of much controversy and personal bias. Uncontrolled studies report the incidence of respiratory allergy in children with OME to range from 4% to over 90%.

MATERIALS AND METHODS

Children 1 to 18 years old who had OME requiring a myringotomy and tubes from January 1, 1987, through July 1, 1988, were the subjects of this study. The history of allergic and radioallergosorbent test (RAST) analysis of specific serum IgE levels was undertaken for 26 allergens on 89 children in the study group and 59 children in the control group.

RESULT

The incidence of allergen as diagnosed by RAST score was higher in children with OME than children in the control group (P > .05). There was no correlation between positive RAST scores and the number of polyethylene-ventilating (PE) tubes previously placed, history of tonsillectomy, history of adenoidectomy, or the character of the effusion (mucous v serous).

CONCLUSION

Respiratory allergy is a factor involved in the pathogenesis of OME.

The presence of eosinophil cationic protein in middle ear effusion

Eosinophil cationic protein (ECP) is probably responsible for the underlying inflammatory mechanisms seen in asthma. It can be modulated in vivo by immunotherapy or steroids, with an appropriate reduction in symptoms of respiratory tract diseases. ECP is an identifiable mediator in additional target organs involved in allergic reactions, making it of potential interest in the study of otitis media with effusion. A qualitative prospective study was designed to discover the relationship of ECP and serum IgE in patients with middle ear effusion and allergy, as demonstrated by RAST and skin testing. The concentrations of ECP in the middle ear fluid from 23 consecutive patients with otitis media with effusion undergoing the placement of tympanostomy tubes ranged from 2 to 1248 micrograms (normal serum ECP, 5 to 15 micrograms), with 87% being abnormally elevated. There was no correlation between an individual's ear and serum levels of ECP (r = 0.1672; p = 0.6232), suggesting a more localized process. There was no relation between effusion ECP and serum IgE (p = 0.0040). ECP from middle ear effusion did correlate with a patient's having allergy, as confirmed by RAST and skin testing (p = 0.0095). Mechanisms involving immune mediated disease in the middle ear, of which the eosinophil may be one participant, are presented.

Eustachian tube function in the ferret

The role of viral upper respiratory tract infections (URI) in the pathogenesis of otitis media (OM) may be related to Eustachian tube (ET) dysfunction. Preliminary experimental evidence suggests that the ferret may be an appropriate animal for modeling of pathophysiologic process related to URI's and ET dysfunction. In an effort to determine the applicability of this animal model, normal ET function was evaluated in 10 ferrets using the inflation-deflation and forced-response testing protocols. The results indicate that the ET of the ferret functions as a small-scale version of its rhesus monkey and human counterparts. The ET-middle ear (ME) system could maintain applied positive and negative ME pressures in all instances. Nearly complete swallow-induced pressure equilibrations were demonstrated in all ears tested. Elevated passive function parameters suggested a small tubal lumen. The efficiency of the tubal dilatory mechanism as expressed by the normalizing calculation (R0/RA) was shown to be quite similar to that in primates and man. These findings suggest that the ferret's ET functions in a manner similar to humans and is, therefore, an appropriate animal to study the pathogenesis of otitis media in the context of ET dysfunction.

Allergy management of refractory serous otitis media

Twenty patients classified as having otitis media with effusion (OME) refractory to all previous medical and surgical therapy were entered into a prospective study to see if classic allergy techniques could diagnose and treat otherwise unresolved effusion and persistent hearing loss in lieu of the re-insertion of tympanostomy tubes. RAST testing, skin end point titration and food elimination diets identified a possible allergic etiology in all patients. Among those choosing allergy immunotherapy, 65% maintained normal hearing, normal tympanograms, and the elimination of recurrent infections for three years. The remaining 35% resolved on appropriate food elimination diets. None of the control's symptoms resolved. The history of chronic disease is defined. The pathophysiology of allergic mechanisms and studies attempting to prove or disprove an allergic effect on the middle ear and eustachian tube are reviewed.

Otitis media and its relationship to allergy

The importance of infection in the etiology of otitis media and the role of eustachian tube obstruction in the pathogenesis of otitis media with effusion are well known. Recently, allergic rhinitis has been documented to induce eustachian tube obstruction. When allergic rhinitis is diagnosed in a child with recurrent or chronic middle ear disease, allergy should be considered as another risk factor for the development of otitis media with effusion.