Similar Allergic Inflammation in the Middle Ear and the Upper Airway: Evidence Linking Otitis Media With Effusion to the United Airways Concept
Nguyen LHP, Manoukian JJ, Sobol SE, et al. J Allergy Clin Immunol. 2004;114:1110–1115
Purpose of the Study.
To determine if the middle-ear compartment may be a component of the united airways in allergic disease by comparing the inflammatory profiles of the middle ear to the upper airway.
Children (aged 2–18 years) undergoing myringotomy, tympanostomy tube placement, and adenoidectomy were recruited prospectively and consecutively for the study. All children had documented conductive hearing loss, flat tympanograms, and middle-ear effusions that persisted for >3 months and were unresponsive to antibiotics and symptomatic nasal obstruction caused by adenoid hypertrophy.
Middle-ear effusions, torus tubarius (eustachian tube mucosa at the nasopharyngeal orifice), and adenoidal tissue biopsies were obtained from 45 patients undergoing simultaneous tympanostomy tube placement for otitis media with effusion (OME) and adenoidectomy for adenoid hypertrophy. The cellular and cytokine profiles of each site were investigated by using immunocytochemistry (elastase, CD3, major basic protein) and in situ hybridization (interleukin [IL]-4, IL-5, interferon [IFN]-γ mRNA). Allergic sensitization to 12 common perennial and seasonal airborne allergens was determined with skin-prick testing.
Of the 45 patients with OME, 11 (24%) were atopic. The middle-ear effusions of atopic patients had significantly higher levels of eosinophils, T lymphocytes, and IL-4 mRNA+ cells (P < .01) and significantly lower levels of neutrophils and IFN-γ mRNA+ cells (P < .01) compared with nonatopic patients. The nasopharyngeal tissue biopsies revealed similar cellular and cytokine profiles.
In atopic patients with OME, the allergic inflammation occurs on both sides of the eustachian tube, in both the middle ear and the nasopharynx. The results of this study support the concept that the middle ear may be part of the united airway in atopic individuals
OME affects 15% to 20% of children and is a major pediatric health care issue as well as a substantial economic burden (estimated costs are in the billions of dollars annually). Current management of OME is often unsuccessful, and significant numbers of refractory cases require surgical intervention. Extensive research has supported the concept of a “united airway,” in which a tight connection exists between the upper and lower airways in allergic disease. For example, local treatment of allergic rhinitis leads to a reduced bronchial hyperresponsiveness in patients with coexisting asthma. The results of this study support the concept that the middle ear might be part of the united airway in atopic individuals. Therefore, an integrated management approach to allergic OME should take into consideration the common underlying systemic inflammation and the unity of airways.