Secretory Immunoglobulin a in Oral and Respiratory Passages in Man

Secretory IgA (SIgA) is the predominant immunoglobulin in certain external secretions and may have an important role in immunological mucosal resistance. SIgA differs in chemical and immunological properties from serum IgA. The present study was undertaken to investigate the antigenic relationship between SIgA, free secretory component (FSC) and serum IgA and the localization of SIgA as well as other immunological classes in tissues of oral and respiratory passages by use of immunofluorescence technique. SIgA and FSC were highly purified from human colostrum and rabbit anti-SIgA and anti-SC antisera were prepared. On the basis of antigenic relationships between SIgA, FSC and serum IgA, it was emphasized that individual specific antisera for SC and IgA and/or SIgA should be used in immunochemical or immunohistological investigations for SIgA. The present study failed to detect SC determinants in palatine and lingual tonsils. However, it was evident that cells present in the pharyngeal tonsillar epithelium contain SC determinants. SC molecules may be synthesized in certain secretory cells of mucous membrane and glandular epithelium and the combining of SC with IgA could occur in the cytoplasm of epithelial cells, the intercellular spaces and/or in the lumens of glandular acini and ductules.

Intranasal immunization with outer membrane protein P6 and cholera toxin induces specific sinus mucosal immunity and enhances sinus clearance of nontypeable Haemophilus influenzae

Nontypeable Haemophilus influenzae (NTHi) is one of the leading pathogens in sinusitis. One of the outer membrane proteins of NTHi, P6, is a common antigen to all strains and is an attractive candidate for a subunit bacterial vaccine. In this study, we characterized normal sinus mucosa (SM) and investigated the potential of intranasal immunization with P6 and cholera toxin (CT) for induction of mucosal protective immunity against NTHi in the maxillary sinuses of rats. Intranasal immunization induced P6-specific sinus mucosal and systemic immunological responses, mainly of the IgA and IgG isotype. The protective effect of intranasal immunization was demonstrated by enhancement of sinus clearance of NTHi. The present study showed that unilateral intranasal immunization has a capacity to induce protective immunity against NTHi in the bilateral maxillary sinuses. Systemic administration of the vaccine did not affect sinus clearance of NTHi. These findings suggest that a nasal vaccine might be useful for preventing sinusitis.

Cytokine Expression in Experimental Chronic Otitis Media With Effusion in Mice

OBJECTIVES

Although otitis media with effusion (OME) is still a common disease in children and adults, the pathogenesis is not yet fully understood. We studied the effects of intratympanic injection with endotoxin purified from nontypeable Haemophilus influenzae on the characteristics of middle ear effusion (MEE).

METHODS

Murine model of OME was developed by eustachian tube (ET) blockage followed by intratympanic inoculation with endotoxin (endotoxin group) or saline (control group). The mice were decapitated and histological changes and the production of inflammatory cytokines in MEEs were examined 3 days, 2 weeks, and 2 months after injection.

RESULTS

All mice showed OME until 2 months after ET blockage. Most MEEs in the control group were serous, and mucoid or pultaceous MEEs were found only in the endotoxin group. Subepithelial space of middle ear mucosa was severely thickened with the infiltration of a large number of mononuclear cells in the endotoxin group. The levels of tumor necrosis factor-alpha (TNF-alpha) in MEEs were significantly higher in the endotoxin group than in the control group at all time points. Further, in situ hybridization showed that TNF-alpha messenger RNA was expressed not only by leukocytes and macrophages in MEEs but mononuclear cells present in the subepithelial space of middle ear mucosa.

CONCLUSIONS

These results indicate that ET blockage is essential for the induction of serous MEE and additional administration of endotoxin is associated with the production of mucoid MEE accompanied by histological changes with inflammatory cell infiltration and cytokine production in the tympanic cavity.

Expression of adhesion molecules by cultured spiral ligament fibrocytes stimulated with proinflammatory cytokines

Secondary cultures from murine spiral ligament (SL) fibrocytes were stimulated with proinflammatory cytokines interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha), and expression of various adhesion molecules was investigated. Cultures without cytokine stimulation did not show positive immunostaining for vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), or mucosal addressin cell adhesion molecule-1 (MAdCAM-1). Although staining was also negative after stimulation with IL-1beta, VCAM-1 and ICAM-1 staining was observed after the cells were stimulated with TNF-alpha. Reverse transcription-polymerase chain reaction analysis showed messenger RNAs for both VCAM-1 and ICAM-1 expression to be present after fibrocytes were stimulated with TNF-alpha. These data suggest that activated fibrocytes may cause inflammatory cells to persist in the SL. Given that SL fibrocytes may play a role in homeostasis of cochlear fluid and ion concentrations, prolongation of the inflammatory response could lead to fibrocyte damage that might ultimately result in cochlear malfunction.

Single cell analysis of adenoid CD5+ B cells and their protective contributions to nasopharyngeal immunity

OBJECTIVES

CD5+ B cells are phenotypically and functionally distinct from the conventional (CD5-) B cells, and the function of CD5+ B cells in the upper respiratory tract remains unknown. A previous study showed that immunoglobulin A-producing cells in the adenoid play a protective role in the nasopharynx. In the present study, the contribution of adenoid CD5+ B cells to nasopharyngeal immunity at the single cell level was investigated.

STUDY DESIGN

In vitro laboratory study.

METHODS

Mononuclear cells were isolated from adenoids of children aged 1 to 12 years, and the frequency of CD5+ B cells was determined by flow cytometry. The numbers of cells producing immunoglobulin M, immunoglobulin G, and immunoglobulin A in sorted adenoid CD5+ B cells were determined by enzyme-linked immunospot assay. Further, to characterize adenoid CD5+ B cells, the expression of various surface molecules was analyzed by flow cytometry.

RESULTS

The results showed that adenoids of young children contain a relatively large number of CD5+ B cells, which have a greater capacity for antibody production than do CD5- B cells. CD5+ B cells also differed from CD5- B cells in the expression of interleukin receptors Il-4R, IL-5R, and IL-10R as well as CD27, B7-1, B7-2, Fas, and Bcl-2.

CONCLUSIONS

These findings suggest that adenoid CD5+ B cells contribute to protective immunity by forming a first line of defense in the upper respiratory tract of young children and that they are probably regulated in a manner that differs from that of CD5- B cells.

Localization of glucocorticoid receptors in the murine inner ear

We performed an immunohistochemical investigation of the distribution of glucocorticoid receptors (GRs) in the murine inner ear and found that GRs were expressed extensively, but with various degrees of immunoreactivity in different regions. We observed the strongest GR expression in the type III fibrocytes of the spiral ligament. Although the immunoreactivity of the cochlear hair cells and of the vestibular sensory epithelia was weak, the neighboring cochlear supporting cells and the subepithelial regions of the vestibular sensory epithelia were immunostained. Staining for GRs was also positive in the spiral ganglia and vestibular ganglia, as well as in the endolymphatic sac. The role of GRs in the inner ear is discussed.

[Three cases of carotid body tumor--the usefulness of preoperative radiological studies and embolization]

We report 3 cases of carotid body tumor, computed tomography (CT), magnetic resonance imaging (MRI), and preoperative embolization were conducted in all cases. Carotid body tumor is best treated by surgical removal to ensure a definitive cure. Carotid artery preservation and bleeding control are critical. Although preoperative diagnosis by CT and MRI is relatively easy, the degree of adhesion between a tumor and the carotid artery cannot be determined precisely. Preoperative superselective embolization of the feeding arteries appears useful in decreasing potential intraoperative bleeding and shortening the time required for resection, facilitating the surgical field.

Primary lymphoma of bilateral external auditory canals

We report a rare case of primary lymphoma originating in the bilateral external auditory canals. A 49-year-old man presented with cauliflower-like tumors on both of his external auditory canals. Immunohistopathologic examination and immunoglobulin heavy chain gene rearrangement studies led to a diagnosis of B-cell lymphoma. He had no other systemic involvement. After chemotherapy, total gross tumor removal by surgery was achieved, and no recurrence has been detected during 1 year of follow-up. To our knowledge, this is the third case of malignant lymphoma originating in the external auditory canal to be reported in the literature, and this is the first report that includes immunohistochemical findings of fresh tissue.

Role of interleukin-1beta in a murine model of otitis media with effusion

To clarify the role of interleukin-1beta (IL-1beta) in the pathogenesis of otitis media with effusion (OME), we developed and investigated a murine model of this disease. Specific pathogen-free male BALB/c mice received intratympanic injections of 20 microg of endotoxin derived from nontypeable Haemophilus influenzae. Three days after injection, middle ear effusions were observed through the eardrum. Similar pathological changes were observed after inoculation with 100 ng of recombinant IL-1beta. Anti-IL-1 receptor antibodies inhibited the pathological changes induced by the endotoxin. In situ hybridization showed expression of IL-1beta messenger RNA in the epithelium of the middle ear mucosa. These results suggest that IL-1beta might be associated with endotoxin-induced inflammation in the middle ear and might play an important role in the induction of otitis media with effusion.

Intranasal immunization enhances clearance of nontypeable Haemophilus influenzae and reduces stimulation of tumor necrosis factor alpha production in the murine model of otitis media

Nontypeable Haemophilus influenzae (NTHi) is a major pathogen causing otitis media (OM). One of the outer membrane proteins of NTHi, P6, is a common antigen to all strains and is considered a candidate for mucosal vaccine. We have previously reported that intranasal immunization with P6 and cholera toxin (CT) could induce P6-specific immunoglobulin A (IgA) antibodies in the middle ear. In the present study, we assessed the effect of intranasal immunization for the protection against NTHi-induced OM. Mice were immunized intranasally with P6 and CT as an adjuvant on days 0, 7, and 14. Control mice were given phosphate-buffered saline (PBS) without antigen. One week after the final immunization, a suspension of live NTHi (10(7) CFU) was injected into the tympanic cavity to induce experimental OM. On days 3 and 7 after bacterial challenge, mice were killed and middle ear effusions (MEEs) were collected. All immunized mice showed elevated titers of P6-specific antibodies in MEEs. The rank order of specific antibody included, from highest to lowest levels, IgG, IgA, and IgM. In addition, immunized mice showed enhanced clearance of NTHi from the middle ear and the number of NTHi in MEEs of immunized mice was reduced by 97% on day 3 and by 92% on day 7 after bacterial challenge relative the number in the MEEs of control mice. The protective effect of intranasal immunization on the incidence of NTHi-induced experimental OM was evident on day 7 after challenge. By day 7, the number of MEEs in immunized mice was 64% less than that in control mice and the incidence of NTHi culture-positive MEEs in immunized mice was 56% less than that in control mice. Less stimulation of tumor necrosis factor alpha (TNF-alpha) production in the middle ear was evident on day 3 after challenge. Immunized mice showed lower concentrations of TNF-alpha in MEEs. These results indicate that intranasal immunization affords protection against experimental OM as evidenced by enhanced clearance of NTHi and less stimulation of TNF-alpha production in the middle ear. These findings suggest that a nasal vaccine might be useful for preventing OM.

Mucosal immunity of the middle ear: analysis at the single cell level

OBJECTIVE

Studies have suggested that the middle ear is a potential site of immunological regulation and that the middle ear mucosa constitutes a part of the mucosal immune system. We clarify the characteristics of the middle ear mucosa with respect to immune potential.

STUDY DESIGN

We investigated lymphocyte subsets, mRNA of cytokines, and induction of antigen-specific IgA-producing cells in the middle ear mucosa in specific pathogen-free C57BL/6 mice.

RESULTS

Flow cytometric analysis showed a certain amount (10%-15%) of gammadelta T cells among CD3+ T cells. P6-specific IgA-producing cells were induced by intranasal immunization with P6 together with cholera toxin. RT-PCR assay of mucosal T cells detected mRNA of Th2 type cytokines such as IL-5 and IL-10.

CONCLUSION

These findings support the fact that the middle ear is potentially an effector site of the mucosal immunity.

Increase in tonsillar germinal centre B-1 cell numbers in IgA nephropathy (IgAN) patients and reduced susceptibility to Fas-mediated apoptosis

IgAN is a common form of primary glomerulonephritis and also a disease of tonsillar focal infection. The comprehensive mechanism underlying this disease remains to be defined. To better understand its pathogenesis, we investigated tonsillar CD5+ B cells (B-1 cells) with respect to IgA synthesis. Germinal centre (GC) B cells were isolated from the tonsils of IgAN patients and the number of B-1 cells in the GC determined by flow cytometry. GC B-1 and B-2 (CD5- B) cells were purified by cell sorter, the cells were incubated with agonist anti-CD40 MoAb and the ability for antibody production by B-1 and B-2 cells determined by ELISPOT assay. GC B-1 cells and B-2 cells were incubated with agonist anti-Fas MoAb, and apoptosis in GC B-1 cells and B-2 cells was analysed by flow cytometry. Although B-1 cells do not usually take part in the GC reaction, an increase in B-1 cell numbers was observed in the GC of tonsils from IgAN patients. These B-1 cells were likely IgA1 antibody-producing cells, since the prominent IgA subclass in IgAN is generally considered to be IgA1. Although Fas-dependent apoptosis is essential for the elimination of activated B cells, these B-1 cells showed a reduced susceptibility to Fas-mediated apoptosis. It is conceivable that activated B-1 cells may survive in the GC due to impaired apoptosis and thus produce abnormal antibodies. These findings suggest that the immune responses of B-1 cells in the tonsillar GC could thus have an impact on the pathogenesis of IgAN.

Significance of spiral ligament fibrocytes with cochlear inflammation

It has been recently suggested that the spiral ligament fibrocytes, which interconnect with the basal cells of the stria vascularis via gap junctions, may be critical in maintaining cochlear homeostasis. In animal models of pathological conditions such as labyrinthitis and otitis media, reduced immunostaining for gap junction protein connexin 26 is observed in the spiral ligament. This suggests that disruption of the spiral ligament fibrocytes could be among the causes of cochlear dysfunction due to cochlear inflammation. Cultured spiral ligament fibrocytes have been shown to secrete chemokines and other mediators after stimulation of proinflammatory cytokine TNF-alpha or IL-1beta. Each of these mediators might induce inflammatory cell movement, which would prolong the inflammatory response. It is reasonable that such enhanced biological defense ability could be the cause of spiral ligament fibrocyte damage.

A case of giant keratoacanthoma of the auricle

Although keratoacanthomas are not rare in the head and neck area, patients with this type of tumor rarely consult an otolaryngologists for treatment. Keratoacanthoma should be considered in the differential diagnosis of squamous cell carcinoma. This tumor grows rapidly, usually attaining a size of about 10-20 mm in approximately 6 weeks. This is followed by slow involution over a period of 2-6 months. A keratoacanthoma larger than 20-30 mm is called as 'giant keratoacanthoma' and it is scarce. We encountered a case of giant keratoacanthoma (50 mm in diameter) on the right auricle of 84-year-old Japanese woman with a 3-year history of gradual tumor growth. Several clinical and histopathological factors made the diagnosis difficult. The tumor was completely removed by surgery and diagnosed as a keratoacanthoma by histopathological examination.

Induction of specific immunoglobulin A and Th2 immune responses to P6 outer membrane protein of nontypeable Haemophilus influenzae in middle ear mucosa by intranasal immunization

Nontypeable Haemophilus influenzae (NTHI) is a major pathogen of otitis media. One of the outer membrane proteins of NTHI, P6, is an antigen common to all strains and is considered as a candidate for mucosal vaccine. To elucidate the possibility of developing a nasal vaccine against nontypeable Haemophilus influenzae (NTHI) and to investigate mucosal immune responses in the middle ear, mice were immunized intranasally with the P6 outer membrane protein of NTHI, and P6-specific immune responses in the middle ear mucosa were examined. Mice were given with P6 and cholera toxin intranasally as an adjuvant on days 0, 7, and 14 and were killed on day 21. The P6-specific immunoglobulin A (IgA) antibody titer in ear wash was significantly elevated. Mononuclear cells were isolated from middle ear mucosa, and an increase in P6-specific IgA-producing cells was shown with an enzyme-linked immunospot assay. In addition, an increase in memory T cells in middle ear mucosa was detected with flow cytometric analysis after intranasal immunization. Moreover, in vitro stimulation with P6 resulted in proliferation of purified CD4(+) T cells from immunized mice, and these T cells expressed Th2 cytokine mRNA. These results indicate that P6-specific IgA-B-cell immune responses and selected Th2 cytokine expressing Th cells were induced in middle ear mucosa by intranasal immunization. These findings suggest that a nasal vaccine is useful for preventing otitis media with effusion.

Classification and culture of spiral ligament fibrocytes from mice

In this study, we established an immunocytochemical strategy to classify the fibrocytes of the murine spiral ligament (SL), and SL cultures were characterized. Similar to those in other mammals, three different types of fibrocytes were identified. Type I fibrocytes, which are found lateral to the stria vascularis, showed positive immunoreactivity for caldesmon and S-100 protein and were not stained for sodium-potassium-adenosinetriphosphatase (Na-K-ATPase). Type II fibrocytes are located lateral to the spiral prominence epithelium and suprastrial region, and they were distinguishable by their positive staining for Na-K-ATPase. Type III fibrocytes, which are found adjacent to bone in the inferior region of the SL, contained caldesmon but not S-100 or Na-K-ATPase. Secondary cultures from the SL were positive for caldesmon and S-100 and negative for Na-K-ATPase, suggesting that these cells were type I fibrocytes. The present immunocytochemical approach was useful for the classification of murine fibrocyte cultures, and these cultures may benefit future immunological studies of the inner ear because mice have been well characterized immunologically.

Age-related changes in the murine cochlear lateral wall

Cochleas from C57BL/6 mice were investigated electrophysiologically and histochemically to evaluate the pathology of presbycusis. The average auditory brainstem response thresholds from 6-week-old mice were significantly lower than those of 6-month-old mice and those of 1-year-old mice. Histologic observation revealed changes in the cochlea after age 6 months. Conventional hematoxylin and eosin (H&E) staining showed disorganization of the organ of Corti, a decrease in the number of spiral ganglion cells, and atrophy of the stria vascularis. Although H&E staining and type II collagen immunolabeling did not show obvious changes in the spiral ligament (SL), the density of connexin 26 staining was reduced in this region. Sodium-potassium-adenosinetriphosphatase immunolabeling was increased in the SL, whereas its average density was not significantly altered in the stria vascularis. These results suggest that the SL could be among the regions responsible for cochlear malfunction with aging.

Effects of influenza A virus on lectin-binding patterns in murine nasopharyngeal mucosa and on bacterial colonization

To clarify the role of viral infection in otitis media, we intranasally inoculated mice with influenza A virus and examined histologic changes in the nasopharyngeal mucosa using a battery of lectins. Additionally, live Haemophilus influenzae or Streptococcus pneumoniae was injected into the nasopharynx after virus inoculation, and the clearance of bacteria from the nasopharynx was examined. Staining of the mucous blanket and epithelial cell surfaces in the nasopharynx with peanut agglutinin, succinyl wheat-germ agglutinin, and Bandeiraea simplicifolia agglutinin was significantly enhanced with intranasal virus inoculation when compared with that in control animals. The nasopharynx was moderately stained with Maachia amurensis agglutinin and wheat-germ agglutinin in control animals, and the staining was enhanced after virus inoculation. These findings were most remarkable 5 and 9 days after virus inoculation. The numbers of bacteria cultured from the nasopharynx were significantly increased when bacteria were injected 5 days after virus inoculation. These results suggest that an alteration in the glycoconjugate structure lining the nasopharyngeal mucosa caused by the influenza virus might be associated with the reduction in bacterial clearance.

Effect of proinflammatory cytokines on cultured spiral ligament fibrocytes

To clarify the effect of proinflammatory cytokines on spiral ligament (SL) fibrocytes, in vitro studies were performed using secondary cell cultures. Cultures from murine SL fibrocytes were stimulated by interleukin (IL)-1beta or tumor necrosis factor (TNF)-alpha, and secretion of various mediators was measured by enzyme-linked immunosorbent assay. After stimulation with the proinflammatory cytokines, IL-6, TNF-alpha, monocyte chemoattractant protein-1, KC, macrophage inflammatory protein-2, soluble intercellular adhesion molecule-1, and vascular endothelial growth factor levels were elevated. Secretion of these chemokines and other mediators could induce inflammatory cell movement, which would prolong the inflammatory response, leading to fibrocyte damage. Given that SL fibrocytes may play a role in cochlear fluid and ion homeostasis, such fibrocyte disruption could cause cochlear malfunction.

Effects of intranasal immunization on protective immunity against otitis media

It has been reported that intranasal immunization can induce mucosal immune responses. However, the efficacy of intranasal immunization on otitis media caused by non-typeable Haemophilus influenzae (NTHi) is not yet elucidated. Mice were intranasally, orally, intratracheally or intraperitoneally immunized with outer membrane protein (OMP) isolated from NTHi, and antigen-specific immune responses were determined by enzyme-linked immunosorbent assay (ELISA) and enzyme-linked immuno-spot assay (ELISPOT). Cytokine production from splenic CD4+ T cells was examined by ELISA. Following the immunization, the clearance of NTHi from the nasal and nasopharyngeal cavity was examined. OMP-specific IgA antibody titers in nasal washes and the numbers of specific IgA-producing cells in nasal passages were significantly increased in intranasally immunized mice. Cytokine analysis showed that interferon-gamma (IFN-gamma) and interleukins IL-6 and IL-10 were predominantly produced from CD4+ T cells. The clearance of NTHi was significantly enhanced in the intranasal immunization group. Intranasal immunization is an effective vaccination regimen for the induction of OMP-specific mucosal immune responses.

[Clinical study of bilateral parotid tumors]

We studied retrospectively 212 patients with parotid tumors who were treated in our hospital between October 1981 and March 1998. One hundred seventy-two of the tumors were benign, and 40 of them were malignant. The tumors were bilateral in 13 patients. Since 1992, we have treated at least 1 bilateral parotid tumor patient per year, and the number of patients with bilateral parotid tumors has tended to increase. Histologically, adenolymphomas occurred in 11 patients, and there was one occurrence of pleomorphic adenoma and one occurrence of basal cell adenoma. Eighty-five percent of all bilateral parotid tumors were adenolymphomas, and the bilateral parotid tumors comprised twenty percent (11 of 53 patients) of all adenolymphomas that we encountered. Among the 13 patients with bilateral parotid tumors, 1 patient experienced them heterochronously. In 7 of the 13 patients the tumor on the opposite side was found by diagnostic imaging. One patient showed recurrence in both parotid glands 4 years after initial surgery. Comparing bilareral adenolymphomas with unilateral adenolymphomas, there was no significant difference in the age or sex of the patients. Regarding bilateral adenolymphoma, 4 patients showed a solitary tumor on either side, 4 patients showed a solitary tumor on one side and multiple tumors on the other side, and 4 patients showed multiple bilateral tumors. Regarding unilateral adenolymphoma, 38 patients showed solitary tumors and 4 patients showed multiple tumors. Bilateral adenolymphomas were more multicentric than unilateral adenolymphomas. Epstein-Barr virus-encoded RNA (EBER) was detected in 11 of the 12 bilateral adenolymphomas and in 18 of 35 patients with unilateral adenolymphoma, by in situ hybridization. EBER was detected more frequently in the multiple unilateral adenolymphomas than in the solitary unilateral adenolymphomas. Based on our experience, the bilateral parotid tumor is not rare. Care should be taken to observe the other side of the parotid gland with parotid tumors that are suspected adenolymphomas. Imaging may be helpful for the detection of bilateral tumors. A relationship may exist between Epstein-Barr virus and adenolymphoma multicentricity.

Nasal immunization induces Haemophilus influenzae-specific Th1 and Th2 responses with mucosal IgA and systemic IgG antibodies for protective immunity

To determine the efficacy of a mucosal vaccine against nontypeable Haemophilus influenzae (NTHi), mice were immunized nasally, orally, intratracheally, or intraperitoneally with NTHi antigen together with cholera toxin. Antigen-specific IgA antibody titers in nasal washes and the numbers of antigen-specific IgA-producing cells in nasal passages showed the greatest increases in mice immunized nasally. Cytokine analysis showed that interferon-gamma, interleukin (IL)-2, IL-5, IL-6, and IL-10 were induced by nasal immunization, suggesting that Th2- and Th1-type cells were generated. Furthermore, bacterial clearance of a homologous strain of NTHi from the nasal tract was significantly enhanced in the nasal immunization group. These findings suggest that nasal immunization is an effective vaccination regimen for the induction of antigen-specific mucosal immune responses, which reduce the colonization of NTHi in the nasal tract.

Primary non-Hodgkin's lymphoma of brachial plexus

We report the case of a 65-year-old man with non-Hodgkin's lymphoma (NHL) not only in the brachial plexus but also in the central nervous system and parotid gland. He was referred to our hospital for evaluation of a right parotid mass. He also presented with bilateral facial palsy and paralysis of the left superior limb. Computed tomography scan and magnetic resonance imaging revealed mass lesions in the right parapharyngeal space, the deep lobe of the right parotid gland. and the left brachial plexus. A gallium-67 citrate scan demonstrated abnormal uptake in the left brachial plexus. These symptoms and lesions improved during steroid therapy. However, the symptoms worsened again after steroid therapy was discontinued. We performed a right parotidectomy to confirm the diagnosis. Histopathological study revealed NHL. He was treated with combination chemotherapy, and most of the lesions and symptoms, except bilateral facial palsy, improved. Despite follow-up treatment, a brain metastasis occured, and he died 16 months after the onset of symptoms.

Immediate tonsillectomy for peritonsillar abscess

OBJECTIVE

Peritonsillar abscess (PTA) is one of the most common infectious diseases of the head and neck region requiring surgical intervention to relieve symptoms such as severe throat pain, fever, dysphagia, and trismus. However, the appropriate management of PTA is still controversial. In Europe and the US, immediate tonsillectomy under general anesthesia has been accepted as the treatment for PTA. But in Japan, immediate tonsillectomy has been regarded as contraindicated for PTA because of difficulties encountered in the operation during the acute stage, as well as possible postoperative complications.

METHODS

A total of 103 cases of PTA treated at our clinic during the past 16 years were reviewed; immediate tonsillectomies had been performed in 99 of them. Surgical findings, postoperative course, and bacteriological examination were surveyed.

RESULTS

The results showed that immediate tonsillectomy under general anesthesia was carried out safely without complications. Dramatic relief of the symptoms was obtained within a few days following each operation. A high incidence of anaerobes was observed by bacteriological examination, suggesting that sufficient drainage is required to treat this disease.

CONCLUSION

We conclude that immediate tonsillectomy should be performed for peritonsillar abscess.

Efficacy of an antiallergic drug on otitis media with effusion in association with allergic rhinitis. An experimental study

The effect of an antiallergic drug on the evacuation of middle ear effusion (MEE) from the tubotympanum was investigated by means of an animal model with both otitis media with effusion (OME) and allergic rhinitis. Azelastine hydrochloride (AZ), an oral antiallergic drug, was administered and the presence of MEE was investigated. Serous MEE was seen in 12 of the 13 untreated control animals on the 11th day after the experimental OME was induced, whereas MEE was detected in 9 of the 13 animals administered 1 mg/kg of AZ, but only in 4 of the 13 animals administered 2 mg/kg of AZ. In addition, the effect of AZ on MEE production was also examined in an experimental OME animal model without allergic rhinitis. Middle ear effusion was observed in all OME animals that received 2 mg/kg AZ for 5 consecutive days, before and 3 days after the experimental OME was induced. Results of the present study indicate that AZ promotes the evacuation of MEE from the tubotympanum in the OME animal model associated with nasal allergy. These data suggest that an antiallergic drug may contribute to the therapy of OME patients in association with nasal allergy indirectly, by promoting evacuation of MEE due to inhibition of type I allergic reactions in the nasopharynx.

Comparison of sinusitis with and without allergic rhinitis: characteristics of paranasal sinus effusion and mucosa

PURPOSE

The relationship between chronic sinusitis and allergy has been discussed for many years. Type I allergies are believed to be involved in chronic sinusitis. However, there is not enough evidence to allow allergic sinusitis to be distinguished as an exact entity. This study was designed to examine the role of immunoglobulin E-mediated allergic reactions in allergic sinusitis.

PATIENTS AND METHODS

We investigated the differences between 31 patients with allergic rhinitis and chronic sinusitis (allergic sinusitis) and 48 control subjects with nonallergic chronic sinusitis (chronic sinusitis). The pathological features of paranasal sinus effusion and mucosa were examined and compared in these two groups.

RESULTS

The number of eosinophils, activated eosinophils, and neutrophils was higher in paranasal sinus effusion from patients with allergic sinusitis. The concentration of interleukin-5 was higher in the effusion of allergic sinusitis patients. In addition, more eosinophils and activated eosinophils infiltrated into the sinus mucosa of patients with allergic sinusitis.

CONCLUSION

The type I allergic reaction has a significant role in the pathogenesis of sinusitis arising in patients with allergic rhinitis.

The influence of pneumococcal otitis media on the cochlear lateral wall

The cochlear influence of otitis media was investigated in order to identify damaged regions causing cochlear malfunction. BALB/c mice were challenged with viable Streptococcus pneumoniae into the middle ear cavity and were killed 1 day to 1 month later for immunohistochemical analysis. Otitis media was induced in all of the animals, and some showed inflammatory cells in the cochlea. Although other changes were not obvious by hematoxylin and eosin staining, immunohistochemistry showed the presence of fibrinogen in the cochlea, mainly in the lower portion of the spiral ligament and in the spiral limbus. Immunostaining for connexin 26 was decreased in the spiral ligament, accompanied by marked fibrinogen staining. Immunostaining for sodium-potassium-adenosine triphosphatase in the stria vascularis and in the type II fibrocytes of the spiral ligament was not affected obviously. The presence of fibrinogen in the cochlea suggests disruption of the blood-labyrinth barrier caused by the middle ear inflammation. Changes in connexin 26 staining suggest the possibility that the spiral ligament could be among the regions responsible for the cochlear malfunction.

[Report of two rare cases of fungal sinusitis]

Two cases of aspergillosis of the paranasal sinuses are reported. The first case was a 30-year-old man who had a 5-month history of bilateral proptosis. Physical examination revealed nasal polyps in both middle meatus. A skin test for Aspergillus was positive. Laboratory study showed levels of serum IgE and IgE specific for Aspergillus level to be elevated significantly. Computed tomography (CT) and magnetic resonance imaging (MRI) showed pansinusitis with some bone erosion. The patient underwent bilateral Caldwell-Luc procedures and external sinus surgery (frontal, ethmoid and sphenoid sinuses). Histopathological examination showed thin septate hyphae in allergic mucin. The patient is now being treated with sinus irrigation and oral administration of fluconazole and suplatast tosilate. The second case was a 78-year-old man who had a 2-month history of nasal obstruction and a 3-week history of headaches. He also had a history of diabetes mellitus. Physical examination showed swelling of the nasal septum due to abscess. CT showed an abscess in the nasal septum and opacification of the left sphenoid sinus. There was no bone destruction. The patient underwent left sphenoid sinus surgery, and histopathological examination revealed aspergillosis of the sphenoid sinus. He presented with left visual disturbance and blepharoptosis 2 months after surgery. Ocoulusion of the internal carotid artery was revealed by MR angiography and it was thought to be caused by intracranial invasion of aspergillus. Loss of consciousness and right hemiplegia ensued despite antifungal chemotherapy. The patient died about 1 year after the onset of symptoms. Case 1 was thought to involve allergic aspergillus sinusitis, and Case 2 invasive aspergillus sinusitis. We emphasize the significance of headache, diabetes mellitus and lesion in the sphenoid sinus as a sigh of intracranial aspergillus invasion, based on our experience as well as findings reported by other clinicians in the Japanese literature.

Clinical efficacy of an antiallergic drug on otitis media with effusion in association with allergic rhinitis

OBJECTIVE

The effect of azelastine hydrochloride (AZ), an oral antiallergic drug, was evaluated in patients displaying otitis media with effusion (OME) accompanying allergic rhinitis.

METHODS

A total of 53 patients diagnosed with OME accompanied by symptomatic perennial allergic rhinitis were randomized to receive in an open fashion 2 mg of AZ in combination with 750 mg of S-carboxymethyl cysteine (SCMC) per day, or 750 mg of SCMC only (controls) for 8 weeks. Efficacy was assessed according to the global improvement rating (GIR) of six nasal or four ear symptoms or signs.

RESULTS

Patients treated with AZ and SCMC had superior improvements in their nasal symptom GIRs compared to controls overall across the 8 week trial, but not in their ear symptom GIRs. However, the clinical course of patients treated with AZ and SCMC tended to be better than that of patients treated with SCMC only, and the nasal and ear symptom GIRs were significantly correlated in the AZ-treated group.

CONCLUSION

These data suggest that AZ may not provide direct efficacy on the ear symptoms in OME patients with allergic rhinitis, but that there might be a possibility of its indirect efficacy in the patients in part by relieving the allergic rhinitis.

Clinical, bacteriological, and histological study of adenoids in children

PURPOSE

The adenoid has long been recognized as an important factor in the pathogenesis of otitis media with effusion (OME). However, there is still considerable debate concerning how the condition of the adenoid tissue is involved in the cause of OME. The purpose of this study is to investigate whether the adenoid is an active agent of OME.

PATIENTS AND METHODS

One hundred forty-six patients aged from 3 to 6 years who underwent adenoidectomy at Oita Medical University (Japan) were retrospectively compared with patients with and without OME regarding macroscopic size of the adenoid, adenoidal-nasopharyngeal ratio (AN ratio), incidence of sinusitis and nasal allergy, bacteriological examination of adenoid tissues, reticular formation of the epithelium, and the percent of ciliated epithelium.

RESULTS

There was no significant difference in the size of adenoids. Haemophilus influenzae (HI) was cultured more frequently in adenoid specimens from patients with OME. A tendency toward increased stratified squamous epithelium and decreased ciliated epithelium was apparent in patients with OME. Reticular epithelium extension was greater in patients with than without OME.

CONCLUSION

Adenoid inflammation is implicated in the pathogenesis of OME and the adenoids have an important role in the cause of OME by being a reservoir for HI.

The leaking labyrinthine lesion resulting from direct force through the auditory canal: report of five cases

The leaking labyrinthine lesion is treated by conservative methods or surgical procedures. With respect to the stapes, the surgical treatment is controversial. Five cases of middle ear injuries accompanying oval window rupture are reported herein. In each case, direct force through the auditory canal damaged not only the ossicular chain but also the oval window. Initial symptoms were sudden hearing loss with significant conductive disturbance and various degrees of unsteadiness. Spontaneous horizontal nystagmus directed toward the uninvolved ear was observed in each case. Tympanic cavities were promptly explored under general anesthesia and oval window injuries were confirmed. In each case, the damaged stapes was temporally removed from the oval window. Perilymphatic leakage was recognized in each case. Two patients had subluxation of the stapes with a paucity leakage. Three had complete luxation of the stapes with a relatively huge oval window fistula. Disrupted oval windows were repaired with temporalis muscle fascial grafts that were inserted under the middle ear mucosae surrounding the oval windows. The stapes were replaced in the repaired oval windows, and the ossicular chains were reconstructed without artificial grafts. Vestibular dysfunctions disappeared within 7 days, and satisfactory audiologic results were obtained in each case.

Enhancement of nasal clearance of nontypeable Haemophilus influenzae by oral immunization with outer membrane proteins

BALB/c mice were orally immunized with liposomes containing outer membrane proteins (OMPs) isolated from nontypeable Haemophilus influenzae (NTHi) and GM-53 as an adjuvant daily for 14 days. Anti-OMP IgA antibody titers in nasal wash, saliva, and fecal extract were significantly increased after the immunization. Although anti-OMP IgM and IgG antibodies were detected in serum, serum IgA antibodies specific to OMPs were not found. Enzyme-linked immunospot assay showed an increased number of OMP-specific IgA-secreting cells in nasal passages, intestinal lamina propria lymphocytes, and the spleen. Following oral immunization, a suspension of live NTHi was injected into the nose; nasal washes were collected 12 h after the inoculation. The number of NTHi in nasal washes was significantly reduced in mice immunized with liposomes containing OMPs and GM-53 compared to that in mice immunized with liposomes containing GM-53 alone. There was a significant negative correlation between the number of NTHi and anti-OMP IgA antibody titers in nasal washes. These findings suggest that antigen-specific IgA responses in the nose can be induced by oral immunization with OMPs and might be associated with the ability to clear NTHi from the nose.

Histological features and prognosis of patients with mucoepidermoid carcinoma of the parotid gland

Histological features and prognosis of patients with mucoepidermoid carcinoma of the parotid gland were analysed. Tumours from 13 patients were classified according to histological grades and immunoreactivity for HER-2/neu. Surgical resection of the tumour was performed for all patients, and the overall five-year survival rate was 69 per cent. The patients whose histological grades were 1 or 2 showed a 100 per cent five-year survival rate, but no patient with grade 3 survived five years. Also, patients who had tumours that overexpressed HER-2/neu had a lower survival rate (25 per cent) than patients with tumours that had weaker immunostaining (89 per cent). We considered tumours classified as grade 3 plus strong HER-2/neu expression to be 'high malignancy', and compared them with 'low malignancy' tumours that were grade 1 or 2 and had weaker HER-2/neu staining. Patients with high malignancy tumours had shorter recurrence-free intervals and shorter overall survival than patients with low malignancy tumours. The overall survival period of the low malignancy cases was much longer than the recurrence-free interval; unlike that in the high malignancy tumour patients. These results suggest that the combination of histological grades and expression of HER-2/neu may be a useful predictor of the prognosis for mucoepidermoid carcinomata.

[The role of IL-1 beta in murine model of otitis media with effusion]

Recent studies have demonstrated the presence of inflammatory cytokines such as IL-1 beta, TNF-alpha, IL-6, and IL-8 in the middle ear effusion (MEE) of patients with otitis media with effusion (OME). IL-1 beta is known to be produced from macrophages and monocytes in an early stage of inflammation by stimulation with microorganisms and endotoxins. Also, these studies have shown that endotoxins frequently are found in MEE and can induce OME in experimental animal model. These findings suggest that endotoxins in MEE cause a chain reaction of cytokines through IL-1 beta. However, the precise role of IL-1 beta in the pathogenesis of OME has not yet been clarified. In the present study, a murine model of OME was developed by intra-tympanic injection with endotoxin or recombinant mouse IL-1 beta (rIL-1 beta) and the effects of IL-1 beta on the production of MEE were investigated. OME was induced in specific pathogen-free male BALB/c mice by intra-tympanic inoculation with endotoxin purified from nontypeable Haemophilus influenzae or with rIL-1 beta. The presence of MEE in the subjects was observed through the ear drum under a microscope and samples of MEE were collected by aspiration and washing with phosphate-buffered saline. The concentrations of IL-1 beta in each sample of MEE were determined by ELISA and the histological changes were compared. The mice inoculated with endotoxin showed signs of the production of MEE and it was noted that the levels of IL-1 beta in MEE were significantly increased on day 3. Intra-tympanic inoculation with rIL-1 beta also produced MEE and these cytological findings of MEE as well as the histological findings of middle ear mucosa were similar to those found in the endotoxin-induced OME. Further, the influence of anti-IL-1 receptor antibodies on the production of OME was examined 3 days after intra-tympanic injection with anti-IL-1 receptor antibodies together with endotoxin or rIL-1 beta. The incidence of OME was lower in mice injected with anti-IL-1 receptor antibodies than that in mice injected with endotoxin or rIL-1 beta only. These findings suggest that IL-1 beta may play an important role in the pathogenesis of OME.

Immune responses of adenoidal lymphocytes specific to Haemophilus influenzae in the nasopharynx

OBJECTIVES

Investigate immune responses of adenoidal lymphocytes against outer-membrane protein P6 purified from nontypeable Haemophilus influenzae (HI). Clarify the role of adenoids in regulating the colonization of HI in the nasopharynx.

STUDY DESIGN

Microbiological and immunological examinations of adenoids obtained from 21 children, 15 boys and five girls, from 1 to 13 years of age (median, 5 y), suffering from adenoidal hypertrophy complicated by otitis media with effusion (OME).

METHODS

The incidence of HI in adenoids was compared with the number of P6-specific immunoglobulin (Ig) A-secreting cells in adenoids, determined by enzyme-linked immunoassay.

RESULTS

Quantitative culture assay showed significant correlation between the numbers of HI in adenoids and those in nasopharyngeal secretions (NS). In children aged 5 years and younger, the numbers of P6-specific IgA-secreting cells in adenoids were significantly correlated with IgA antibody titers in NS (r = 0.68, P < .05). The numbers of P6-specific IgG- and IgA-secreting cells were lower in children aged 6 years and older than in children aged 5 years and younger. Furthermore, the number of P6-specific IgA-secreting cells was significantly increased in HI-negative subjects when compared with HI-positive subjects (P < .05).

CONCLUSIONS

Adenoids play an important role as an effector site of the mucosal immune system in the upper respiratory tract. IgA immune responses in adenoids are responsible for the clearance of HI from the nasopharynx.

[Clinical features and characteristics of paranasal sinus effusion in allergic sinusitis]

Plain paranasal sinus radiographs including occipitofrontal and occipitomental views often show abnormal shadows in patients with allergic rhinitis. For that reason, the relationship between chronic sinusitis and allergy has been discussed for many years. Type I allergy is thought to be involved in the sinusitis which is called allergic sinusitis. However, there is not enough information pertaining to this disorder. In order to determine the clinical feature and the characteristics of paranasal sinus effusion in allergic sinusitis, we investigated the differences between 20 patients with allergic sinusitis and 20 with non-allergic chronic sinusitis used as controls. Clinical symptoms (nasal discharge, nasal obstruction, headache, postnasal discharge) and anterior rhinoscopic findings (nasal discharge, nasal edema), clinical examinations (type of x ray maxillary sinus shadow, bacteriology of nasal discharge), and pathological features of the paranasal sinus effusion were examined and compared in the two kind of sinusitis. Pathological findings of the effusion sampled from 14 patients with allergic sinusitis and 15 with non-allergic sinusitis included the number of eosinophils, activated eosinophils and neutrophils, concentrations of interleukin (IL)-1 beta, IL-4, IL-5, IL-8, and concentrations of leukotriene C4/D4/E4 and prostaglandin E2. The incidence and degree of postnasal discharge as a symptom and a nasal finding were lower in allergic sinusitis patients than in the controls. Microorganisms were detected less frequently in the allergic group. The number of eosinophils, activated eosinophils and neutrophils was higher in the paranasal sinus effusion of the patients with allergic sinusitis. The concentrations (ng/mg of protein) of IL-1 beta and IL-8 showed no difference between the two groups, but IL-4, and IL-5 were more prevalent per mg of protein in the effusion of allergic sinusitis patients. These findings suggest that the clinical features of allergic sinusitis include a low incidence and degree of postnasal discharge and a low rate of detection of bacteria, and that the sinus effusion is characterized by the presence of more eosinophils, activated eosinophils, and IL-5 than in those of chronic sinusitis.

Role of superoxide dismutase in otitis media with effusion

The concentration of superoxide dismutase (SOD) in middle ear effusion (MEE) was measured by the electron spin resonance trapping method in order to clarify the role of SOD in otitis media with effusion (OME) in children. The SOD levels in mucoid MEEs were significantly higher than those in serous and purulent MEEs. There was no significant difference in the levels of SOD between neutrophil-dominant MEEs and mononuclear cell-dominant MEEs, and the levels were negatively correlated with the number of neutrophils in the MEEs. Moreover, the levels were significantly increased in patients having recurrence of MEE within 3 months compared with patients without recurrence of MEE. Although it is known that SOD plays an important role in protecting the host from oxygen radicals, the findings in this study suggest that SOD might be related to the chronicity of OME.

Changes in immunostaining of inner ears after antigen challenge into the scala tympani

To study the mechanisms of immune responses and immune injuries in inner ears, labyrinthitis was induced by inoculation of keyhole limpet hemocyanin (KLH) into the scala tympani of systemically sensitized guinea pigs. Inner ears were then immunostained for KLH, immunoglobulin G (IgG), albumin, connexin26 (Cx26), and sodium-potassium adenosine triphosphate (Na,K-ATPase). Inflammatory cells containing KLH were observed in the scala tympani and in the collecting venule of the spiral modiolar vein (SMV). Spiral ligament, spiral limbus, and blood vessels including the SMV were diffusely positive for IgG and albumin. Immunoreactivity for Cx26 and Na,K-ATPase was decreased compared with the normal ears in the fibrocytes of the spiral ligament. These results suggest that inflammatory cells and blood constituents could extravasate into the cochlea from blood vessels and that fibrocyte damage in the spiral ligament could cause cochlear dysfunction.