ADVOCATING THE USE OF THE TERM EOSINOPHILIC OTITIS MEDIA (EOM)

Sachiko Tomioka-Matsutani

Department of Speech-pathology and Audiology, Faculty of Medical Science and Welfare, Tohoku Bunka University, Sendai, Miyagi, Japan

In 1993, we reported intractable otitis media in three cases with bronchial asthma.1 In 1997, we reported on seven adults, including three previously reported patients, who suffered from a combination of bronchial asthma and intractable otitis media.2 These conditions were initially characterized by retention of serous effusion, such effusion soon being replaced by a gelatin-like secretion. A heavy infiltration of eosinophils was observed in the otorrhea, middle ear effusion, and inflammatory granulation tissue. Tympanoplasty without attention to mucosal abnormality was ineffective. Frequent severe hearing loss included sudden onset of deafness. This type of otitis media usually lasted for a long period and was progressive. Progression of otitis media in these patients was controllable to a certain degree with systemic steroid therapy. However, long-term administration of systemic steroids required considerations of side effects. Therefore, we considered it necessary to detect this type of otitis media.

The condition suffered by our patients seems to be quite similar to what Shambaugh4 and Derlacki3 termed middle-ear allergy or allergic otitis media. However, these terms were used before the detection of IgE in 1967 Tomonaga et al.5 reported that an immune response in the middle-ear cavity was generated by antigen via the ear drum, but not by antigen via the Eustachian tube due to the barrier of the tube.

In 2006, Iino reported that the tubal opening duration was significantly longer in eosinophilic otitis media (EOM) patients than in the control group.6 She pointed out that a patulous Eustachian tube in EOM patients easily allows the entry of antigenic materials into the middle ear. However, IgE-mediated hypersensitivity by antigen via the Eustachian tube had not yet been confirmed. Also, extremely viscous gelatin-like effusion was another intractable factor. Such a gelatin-like effusion was difficult to remove from the middle-ear cavity, and such remaining viscous effusion included harmful granules from eosinophiles which caused mucosal damage. Another problem is the complication due to bacterial infection. Methicillin-resistant Staphylococcus aureus (MRSA) infection is associated with a high incidence of EOM. It is difficult to treat EOM in the face of such repeated bacterial infections. Hence, simple IgE-mediated hypersensitivity for the pathogenesis of this type of otitis media still seems debatable. So, I concluded that the term allergic otitis media is inadequate. The most characteristic features of these cases were the presence of significant infiltration of eosinophiles in the inflammatory granulation tissue and middle-ear effusion. In the etiopathology of this otitis media, eosinophiles are thought to play an important role. Therefore, we advocated the term of eosinophilic otitis media (EOM) in 1997.2

Early-stage Churg-Strauss syndrome limited to the middle ear is difficult to differentiate from EOM. Generally, over the years, various vasculitic symptoms have become associated with middle-ear lesions in Churg-Strauss syndrome. However, no patients suffering from vasculitic symptoms were included in our over 25-year series of EOM. Thus, we considered EOM to be another middle ear disease entity. Churg-Strauss syndrome should be necessary to exclude after development of vasculitis.

Lino7 declared EOM to be the new middle ear disease entity in 2008. Her analysis was based on retrospective clinical data of patients in a study by an EOM study group, i.e., a Japanese multi-centre study involving five referral centers. The EOM study group is composed of Yukiko Iino (Department of Otolaryngology, Jichi Medical University), Atsushi Matsubara (Department of Otolaryngology, Hirosaki University), Takashi Nakagawa (Department of Otolaryngology, Fukuoka University), Manabu Nonaka (Department of Otolar-yngology, Nippon Medical School) and me (Department of Otolaryngology, Sendai Red Cross Hospital). Diagnostic criteria of EOM by this study group are the following.

Major: Otitis media with effusion or chronic otitis media containing eosinophils in the effusion.

Minor: Association with bronchial asthma; extremely gelatinous middle ear effusion; resistance to conventional treatment of otitis media with effusion or chronic otitis media; association with eosinophil dominant nasal polyposis.

Definitive case: positive for major + two minor criteria.

Exclusion criteria: Churg-Strauss syndrome; Hypereosinophilic syndrome.

Lino et al.8 reported the results of the analysis of 138 patients with EOM and 134 age-matched patients with the common type of otitis media with effusion or chronic otitis media as control. High odds ratios were obtained from an association with bronchial asthma (584.5), resistance to conventional treatment for otitis media (232.2), viscous middle ear effusion (201.6), association with nasal polyposis (42.17), association with chronic rhinosinusitis (26.49), bilaterality (12.93), and granulation tissue formation (12.62). The percentage of patients with EOM who were positive for two or more of the highest four items was 98.55%. A patient who shows otitis media with effusion or chronic otitis media containing eosinophils in the effusion and two or more minor criteria can be diagnosed as having EOM.

An efficacious to achieve stability over a long period of time has not been established. However, the proper detection of EOM is the first step towards adequate treatment, resulting in prevention of severe hearing loss. It is hoped that better management of EOM can be established in the near future.

References

1.Tomioka S, Yuasa R, Iino Y. Intractable otitis media in cases with bronchial asthma. Recent advances in otitis media. In: Mogi G, Honjo I, Ishii T, Takasaka T (eds), Proceedings of the second extraordinary international symposium on recent advances in otitis media, pp. 183. Amsterdam/New York: Kugler Publications, 1993

2.Tomioka S, Kobayashi T, Takasaka T. Intractable otitis media in patients with bronchial asthma (eosinophilic otitis media). In: Sanna M (ed), Cholesteatoma and mastoid surgery, pp. 851. Roma: CIC Edizioni Internationali, 1997

3.Derlacki EL. Aural manifestations of allergy. Ann Otol Rhinol Laryngol 61(1):179–188, 1952

4.Shambaugh GE. Surgery of the ear, 2nd ed, pp. 210, 222, 255, 272. Philadelphia: WB Saunders Co, 1967

5.Tomonaga K, Kurono Y, Mogi G. The role of allergy in the pathogenesis of otitis media with effusion. A clinical study. Acta Otolaryngol Suppl 458:41–47, 1988

6.Lino Y, Kakizaki K, Saruya S, Katano H, Komiya T, Kodera K, Ohta K. Eustachian tubal function in patients with eosinophilic otitis media associated with bronchial asthma evaluated by sonotubometry. Arch Otolaryngol Head Neck Surg 132(10):1109–1114, 2006

7.Lino Y. Eosinophilic otitis media: a new middle ear disease entity. Curr Allergy Asthma Rep 8(6):525–530, 2008

8.Lino Y, Tomioka Matsutani S, Matsubara A, Nakagawa T, Nonaka M. Diagnostic criteria of otitis media, a newly recognized middle ear disease. Auris Nasus Larynx 38(4)456–461, 2011


Address for correspondence: Sachiko Tomioka-Matsutani, 6–45-1 Kunimi, Aoba-ku, Sendai 981–8551, Japan.

Cholesteatoma and Ear Surgery – An Update, pp. 77–78

Edited by Haruo Takahashi

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