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Chronic otitis media with effusion and Helicobacter pylori
International Journal of Pediatric Otorhinolaryngology (2006) 70, 829—834
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Chronic otitis media with effusion and Helicobacter pylori Bulent V. Agirdir *, Selami Bozova, Alper T. Derin, Murat Turhan Akdeniz University, Medical Faculty, ENT & HNS, Arapsuyu, Akdeniz, Antalya 07070, Turkey Received 22 July 2005; received in revised form 17 September 2005; accepted 17 September 2005
KEYWORDS Chronic otitis media with effusion; Helicobacter pylori; CLO testing; Urease test
Summary Objective: The aim of this study is to investigate the presence of Helicobacter pylori (HP) in the middle ear effusion by Campylobacter-like organism (CLO) test and whether it has a role in the ethiopathogenesis of chronic otitis media with effusion (OME). Study design: A prospective randomized and controlled study. Methods: This study was performed with 45 patients with the diagnosis of chronic OME and adenoid hypertrophy, between the ages 3 and 13 (median 6). Thirty patients constituted the study group (18 male (60%) and 12 (40%) female). Adenoidectomy with myringotomy with ventilation tube insertion were performed to this group. Middle ear effusion and adenoid tissue pieces were collected and H. pylori presence was investigated by ‘‘CLO’’ testing. Fifteen patients of the matching age group (9 male (66.7%) and 6 (33.3%) female) constituted the control group to whom adenoidectomy with myringotomy were performed but no middle ear effusion could be determined (empty myringotomy patients). The wash out liquid of middle ear and pieces of adenoid tissue samples were also collected from the control group. By using CLO testing, the presence of H. pylori was investigated in the adenoid tissues and middle ear of the empty myringotomy patients. Results: In 20 (66.6%) patients of the study group, CLO testing was positive in the middle ear effusions. None of the patients demonstrated positive CLO test in the wash out liquid of middle ear. There was significant difference of positive CLO testing in the middle ear effusions of two groups ( p < 0.001). Conclusions: These findings showed us that presence of HP in the middle ear effusion using CLO testing and this may be responsible for the ethiopathogenesis of chronic OME. # 2005 Elsevier Ireland Ltd. All rights reserved.
* Corresponding author. Tel.: +90 242 227 4343/24106. E-mail address: [email protected] (B.V. Agirdir). 0165-5876/$ — see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2005.09.026
830
B.V. Agirdir et al.
1. Introduction
2. Materials and methods
The non-suppurative form of otitis media with middle ear effusion is called as otitis media with effusion (OME) or secretory otitis media (SOM). OME is one of the most frequent diseases of the ear in childhood [1]. Helicobacter pylori (HP) was isolated firstly in the stomachs of gastric ulcer patients in 1983 by Marshall et al. [2]. This bacterium causes antral gastritis (type B) in the early periods of the infection and gastric ulcer, more over gastric carcinoma or MALT lymphoma in the late periods [3]. In the patients younger than the age 10, the findings of the gastritis and gastric ulcer are not obvious [3]. The disease presents itself merely by recurrent abdominal pain [3]. It is one of the most frequent infections all over the world. The prevalence of the disease is 30—40% in the developed countries and 80—90% in the underdeveloped countries. Crowded families, ethnical status, migration to the endemic places, the frequency in the family and general condition of the patient are the risk factors. It is not so clear how the disease infects somebody but oral—oral, fecal—oral or gastro—oral contamination may be possible. There are many clues of colonization in the dental plaques, tonsils and adenoid tissues [3—5]. Causes of OME are believed to be multifactorial, including viruses, allergy, bacteria and their products, and dysfunction of the eustachian tube. Gastroesophageal reflux (GER) could also be a cause of this disease [6,7]. Reflux of gastric contents from the nasopharynx to the middle ear is possible because of the angle between them and immaturity of the eustachian tube in children and infants and the supine position in which infants are often placed [8]. Urease test or Campylobacter-like organism (CLO, Ballard Medical Products) testing is the most frequently used method by gastroenterologists for demonstrating the HP in the world. On a single biopsy, CLO test was as sensitive as histology and more sensitive than culture [9]. When a little piece of tissue containing HP was added into the CLO test kit including urea and phenol red, Campylobacterlike organisms (that is HP) diverse urea to ammonia (NH3). The pH value of the environment increases and the color of the test kit turns to red from yellow. This specifically shows the presence of HP in the material. As a safe, easy to perform, and cheap method, CLO test is one of the most frequently used method in the world. Thus we used this method in the current study. The aim of this study is to investigate the presence of HP in the middle ear effusion by CLO test and whether it has a role in the ethiopathogenesis of chronic OME.
A prospective randomized and controlled study was carried out from March 2000 to April 2003 in the Otolaryngology Head and Neck Surgery Department of a tertiary referral center. Forty-five patients with the diagnosis of chronic OME and adenoid hypertrophy were included in the study. The patients were between ages 3 and 13 (median 6). Of the 30 patients consisting the study group, 18 (60%) were male, 12 (40%) were female. Fifteen age-matched patients constituted the control group; 9 (66 and 7%) male and 6 (33 and 3%) female. Adenoidectomy with myringotomy were performed to both groups for the diagnosis of adenoid hypertrophy and chronic OME. In the control group, no middle ear effusion could be determined, though preoperative operation criteria were fulfilled (empty myringotomy). Empty myringotomy is reported to be present in 6—44% of all myringotomy patients [10,11]. The exact reason is not known but the probability of illness recovery from the time of diagnosis to operation or liquid’s passing to nasopharynx throughout from the eustachian tube during general anesthesia may be the cause. We used such a control group because it would be an ethical problem to use healthy subjects. Adenoidectomy and bilateral myringotomy and/or ventilation tube insertion was performed to the patients who had fulfilled at least two of the following criteria: (1) adenoid hypertrophy symptoms, (2) OME findings in physical examination, (3) adenoid hypertrophy confirmed by nasal endoscopy or lateral nasopharyngeal soft tissue radiogram and (4) C2 or B curves in the tympanogram. All patients took two courses of antibiotic (amoxicillin/ clavulanate potassium, Augmentin, GlaxoSmithKline, 40 mg/kg), anti-inflammatory and systemic or topical decongestant agents (not >5 days) revision treatment for at least 10 days before the operation for 3 months follow up). After the decision of operation, the patients did not take any medications for at least 1 month. None of the patients had acute infection on the day of the operation. All of the patients were sedated by intranasal dormicum (0.2 mg/kg) preoperatively. The induction of the general anesthesia was performed via thiopental and continued with the combination of nitrogen protoxide, oxygen and sevoflorane, and then adenoidectomy and myringotomy was performed for each patient. The superficial and deep parts of the adenoid tissue were transected as 1—3 mm3 thickness specimens and washed with sterile saline solution. Then the tissue was put in the CLO test apparatus. When small pieces of infected tissues were added to the test kit containing urea and phenol red, HP converts urea
Chronic otitis media with effusion and Helicobacter pylori to ammonia and this turns the color of testing kit from yellow to red. After performing myringotomy, the middle ear effusions were collected in the Juhn Tym-Taps (Xomad, Jackson-ville, FL, USA), which is a commercially available suction and collection device. These effusions were poured into sterile saline solution and washed out from blood waste. The mucous layer floating over the sterile saline solution was put again into another CLO testing apparatus. Bilateral middle ear effusions in the first 10 patients showed exactly the same CLO test results. For this reason, in the next 20 patients’ middle ear effusions were collected randomly from the right and left ears equally (10 from right and 10 from left). Only one ear result of all patients was included in the statistical analysis. The adenoid samples of the control group were collected in the same way. In this group, 0.5 cm3 of saline was injected into the middle ear through the hole of myringotomy and aspirated into the sterile reservoir as mentioned before. Some of the liquid was aspirated from the empty middle ear and put into the CLO testing apparatus. The CLO tests were evaluated by different residents who did not know whether the patient was in the study or control group. The results were checked at the 1st, 2nd and 24th h at the room temperature (18—22 8C). The changes in the color of the tests after 24 h were not considered. The colors which turned to red and pink, were considered into the study as for test positivity and no change in the color was considered as test negativity. The positive reactions in the color of the test at the first minutes were not considered as positive for possible blood contamination (Picture 1). It is simple to perform, cheap and has a specifity and sensitivity as the other methods have. Thus CLO test is a rapid reliable and convenient method for diagnosis of HP [9]. Permission of the patients’ parents and approval from the local Ethic Committee were obtained for the use of the specimens. For statistical analysis, Fisher’s exact test was used; the analysis was performed using SPSS 12
Picture 1 Color changes in CLO test. Turning to red or pink in the first 24 h demonstrates Helicobacter pylori presence in the middle ear effusion on the left-sided disc.
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software (SPSS, Chicago, IL, USA). A p-value <0.05 were considered to indicate significance.
3. Results Two populations as a total (control and study group) 18 (40%) patients were female, 27 (60%) were male. The age range was 3—13 years (median 8). Female/ male ratio was 2/3. From the total of 30 patients, 20 (66 and 6%) had positive CLO testing in the middle ear effusions. Ten (33.3%) patients had positive test in the adenoid tissue. In the CLO testing of the study group, if adenoid tissue was positive then middle ear effusion was always positive. If one ear’s test was positive then the other ear’s test was always positive in the first 10 patients. In the study group; of the 18 male patients, 10 (55.5%) had CLO test positivity in the middle ear effusions, 5 (28%) patients had a positive test in the adenoid tissue, 10 (83%) female patients of 12 had CLO test positivity in the middle ear effusions and 5 (50%) had test positivity in the adenoid tissues. In the control group, only four (26.6%) patients showed CLO test positivity in the adenoid tissue. No patient showed CLO positivity in the wash out solution of empty ear. The difference between CLO test positivity in the middle ear effusions of the study group and wash out solution of the control group was statistically significant ( p < 0.001, Graph 1). There was no significance between CLO positivity in the adenoid tissues of two groups (Graph 2). Although CLO test positivity was higher in the middle ear effusions in females it was not statistically significant.
4. Discussion HP is one of the most frequent infection agents all over the world. It is not only accepted as an agent responsible for gastritis but also for systemic infection. In a recently published study from England, HP was found to be localized in the atherom plaques of the coronary arteries [12]. The primary reservoir of HP is thought to be stomach but it is shown that it may be present in dental plaques, tonsil and adenoid tissue and squamous cell carcinoma of the larynx [13—15]. In order to reproduce itself, HP needs microaerophylic environment (5% of CO2). This microaerophylic environment is also present in the middle ears of OME patients. The mechanism of the colonization of HP in the gastric mucosa is still unclear. In fact, it is impossible for the bacteria to live and reproduce in such an acidic environment. By
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Graph 1 CLO test result in the middle ear effusions. Fisher’s exact test cross table p < 0.001 Fisher’s exact test was significant.
implanting itself under the gastric mucosal layer, inside the mucosal epithelium, the bacterium is protected by the help of impermeable mucus layer to the gastric acids. The pH value of the luminal side of the mucus layer is 1.0—2.0 and mucosal side is approximately 7.4. The pH value of the middle ear
Graph 2
effusions of the chronic OME patients is also between 7.0 and 9.0 [16,17]. In HP infections, mucosal metaplasia (as in the Barret esophagitis) and goblet cell hyperplasia occurs. A similar situation in OME [1,16,18]. There is inflammatory response predominantly with
CLO test results in the adenoid tissues. Fisher’s exact test was not significant.
Chronic otitis media with effusion and Helicobacter pylori lymphocytic infiltration both in the gastritis and OME [16,19,20]. OME is most frequently seen in crowded families, societies that have low socioeconomic conditions and in specific climate conditions. These are very similar for HP infection [5,16,21,22]. HP is a bacterium that may live in the middle ear. In our study we found the rate of presence of the bacterium as 66.6% in the middle ear effusions. In 2004, Yilmaz et al. [23] has found that 67% of chronic OME patients showed HP presence in the middle ear effusions. But, they did not find any HP presence in the adenoid tissues of the same patient group. Unver et al. [15] found that HP presence is 25% in the adenoid tissue and 62.5% in the tonsil tissue of 19 patients of ages between 4 and 38. When the patients older than age 13 are neglected, the ratio is 28%. In our study, HP presence ratio in the adenoid tissue was 33% in the study group and 26.6% in the control group. In a study of Rozmanic et al. the incidence of gastroesophageal reflux disease (GERD) was found as 55.6% in the patients of chronic tubotympanic disease [24]. Velepic et al. [25] also noted that GERD was present in 60% of chronic tubotympanic patients and Tasker et al. [26] showed that gastric fluid reflux was present in 83% of the middle ear effusions of glue ears. In our study, we found that HP presence in the middle ear effusions was twice as frequent as in the adenoid tissues. This may be due to the available environment for the bacterium in the effusion of OME patients. The inoculation of the HP into the middle ear may be through the hematogenous way or by the help of GER. Especially for the patients of adenoid vegetation, gastroesophageal reflux disease is a frequent problem. Carr et al. [27] demonstrated that 42% of 95 children smaller than 2 years old who underwent adenoidectomy had GERD. HP-contaminated gastric fluid enters to nasopharyngeal cavity by the GERD and colonizes in the dental plaques, adenoid tissues and tonsils. From these localizations the bacterium ascends to the middle ear and the paranasal sinuses directly or by the reflux and may trigger some pathological changes, but the exact mechanism remains unclear [28]. In an animal study, White et al. [29] have demonstrated that nasopharyngeal exposure to HCl and pepsin in concentrations similar to that found in gastric reflux leads to impairment of ventilatory function and mucociliary clearance of the eustachian tube. GERD has been considered a contributing factor for many nasopharyngeal disease processes occurring anterior to the eustachian tube [28]. Morinaka et al. [30] demonstrated that HP may exist in the nasal and maxillary sinus tissue specimens of some patients with chronic sinusitis with
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gastric HP infection. How HP infection is transmitted remains unclear, and little is known about the role of HP in extra gastric disease [31,32]. In the previous studies, the efforts for isolating any bacterial agents in the middle ear effusion of OME by cultural studies were failed. This may be due to the HP’s reproduction characters, which does not permit the production in the classical culture methods. As previously mentioned, HP needs microaerophylic environment and special agar such as Skirrow medium. Karma noted that it should not be accepted that the OME effusion is sterile when looking at classical culture studies [33]. The agents as b-lactamase-resistant penicillin and macrolids are used for the treatment of HP but antibiotic treatment alone is not enough both for HP and OME. Proton pump inhibitors, H2 receptor blockers and bismuth compounds are added for a reliable treatment for GERD. In recent studies of Poelmans et al. [34] and Tasker et al. [26] in 2002, they showed independently that GERD is a major pathology in intractable chronic OME and antireflux treatment was effective in dissolving the problem. There is no golden standard treatment protocol for OME. Most of the chronic OME patients could not be treated by standard medical therapy and they should be operated. The effectivity of the operation may be due to the change of microaerophylic environment thus inhibiting the colonization of HP. Although the aim of our study was to demonstrate the presence of HP in middle ear effusion of chronic OME with a safe, easy to perform and cheap method, demonstrating the presence of HP is not an enough argument for pathogenesis of the OME. To show whether HP is one of the causes of chronic OME, more studies are required. After then protocols of the HP eradication may be used in the treatment of the disease.
5. Conclusions To our knowledge this is the first study that showed the HP presence in the middle ear effusions using CLO testing and HP may be responsible for the ethiopathogenesis of OME. To demonstrate whether HP presence in the effusions of OME is as a result of gastroesophageal reflux and/or direct transmission, hematogenous way or translocation, further investigations are necessary.
Acknowledgement This study was supported by Akdeniz University Scientific Research.
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References [1] N.A. Akyıldız, Sekretuvar otitis media, in: N.A. Akyıldız (Ed.), Kulak Hastalıkları ve Mikrocerrahisi, Bilimsel Tıp, Ankara, 1988, pp. 275—280. [2] B.J. Marshall, J.R. Warren, G.J. Francis, S.R. Langton, C.S. Goodwin, E.D. Blincow, Rapid urease test in the management of Campylobacter pyloridis-associated gastritis, Am. J. Gastroenterol. 82 (1987) 200—210. [3] M. Czesnikiewicz-Guzik, E. Karczewska, W. Bielanski, T.J. Guzik, P. Kapera, A. Targosz, S.J. Konturek, B. Loster, Association of the presence the Helicobacter pylori in the oral cavity and in the stomach, J. Physiol. Pharmacol. 55 (Suppl. 2) (2004) 105—115. [4] A.M. Nguyen, F.A. el-Zaatari, D.Y. Graham, Helicobacter pylori in the oral cavity. A critical review of the literature, Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 79 (1995) 705—709. [5] G. Oderda, Transmission of Helicobacter pylori infection, Can. J. Gastroenterol. 13 (1999) 595—597. [6] P. Contencin, C. Maurage, M.J. Ployet, A.B. Seid, M. Sinaasappel, Gastroesophageal reflux and ENT disorders in childhood, Int. J. Pediatr. Otorhinolaryngol. Suppl. 32 (1995) S135— S144. [7] W.S. Gibson Jr., W. Cochran, Otalgia in infants and children–— a manifestation of gastroesophageal reflux, Int. J. Pediatr. Otorhinolaryngol. 28 (1994) 213—218. [8] K. Ruhani, S. Raisanen, G.S. Simonsen, L.E. Stenfors, Bacterial behaviour in middle ear effusion material: an in vitro study, Acta Otolaryngol. 116 (1996) 64—68. [9] K.M. Chu, R. Poon, H.H. Tuen, S.Y. Law, F.J. Branicki, J. Wong, A prospective comparison of locally made rapid urease test and histology for the diagnosis of Helicobacter pylori infection, Gastrointest. Endosc. 46 (1997) 503—506. [10] A.R. Maw, F. Herod, Otoscopic, impedance, and audiometric findings in glue ear treated by adenoidectomy and tonsillectomy. A prospective randomised study, Lancet 1 (1986) 1399—1402. [11] J.G. Toner, B. Mains, Pneumatic otoscopy and tympanometry in the detection of middle ear effusion, Clin. Otolaryngol. 15 (1990) 121—123. [12] M. Kowalski, Helicobacter pylori (H. pylori) infection in coronary artery disease: influence of H. pylori eradication on coronary artery lumen after percutaneous transluminal coronary angioplasty. The detection of H. pylori specific DNA in human coronary atherosclerotic plaque, J. Physiol. Pharmacol. 52 (2001) 3—31. [13] E. Aygenc, A. Selcuk, S. Celikkanat, C. Ozbek, C. Ozdem, The role of Helicobacter pylori infection in the cause of squamous cell carcinoma of the larynx, otolaryngol, Head Neck Surg. 125 (2001) 520—521. [14] H.G. Desai, H.H. Gill, K. Shankaran, P.R. Mehta, S.R. Prabhu, Dental plaque: a permanent reservoir of Helicobacter pylori? Scand. J. Gastroenterol. 26 (1991) 1205—1208. [15] S. Unver, U. Kubilay, O.S. Sezen, T. Coskuner, Investigation of Helicobacter pylori colonization in adenotonsillectomy specimens by means of the CLO test, Laryngoscope 111 (2001) 2183—2186. [16] S. Suerbaum, P. Michetti, Helicobacter pylori infection, N. Engl. J. Med. 347 (2002) 1175—1186.
B.V. Agirdir et al. [17] A. Tasker, P.W. Dettmar, M. Panetti, J.A. Koufman, P. Birchall, J.P. Pearson, Is gastric reflux a cause of otitis media with effusion in children? Laryngoscope 112 (2002) 1930—1934. [18] H. Koop, Gastroesophageal reflux disease and Barrett’s esophagus, Endoscopy 34 (2002) 97—103. [19] M.F. Go, D.T. Smoot, Helicobacter pylori, gastric MALT lymphoma, and adenocarcinoma of the stomach, Semin. Gastrointest. Dis. 11 (2000) 134—141. [20] R.J. Owen, Bacteriology of Helicobacter pylori, Baillieres Clin. Gastroenterol. 9 (1995) 415—446. [21] O.P. Alho, H. Oja, M. Koivu, M. Sorri, Risk factors for chronic otitis media with effusion in infancy. Each acute otitis media episode induces a high but transient risk, Arch. Otolaryngol. Head Neck Surg. 121 (1995) 839—843. [22] S. Kaya, Ankara ili ve c¸evresinde okul c¸ocuklarında orta kulak hastalıkları insidansı, Tu ¨rk Otolaringoloji Ars¸ivi 25 (1997) 184. [23] M.D. Yilmaz, O. Aktepe, Y. Cetinkol, A. Altuntas, Does Helicobacter pylori have role in development of otitis media with effusion?, Int. J. Pediatr. Otorhinolaryngol. 69 (6) (2005) 745—749. Epub 2005 Feb 16. [24] V. Rozmanic, M. Velepic, V. Ahel, D. Bonifacic, M. Velepic, Prolonged esophageal pH monitoring in the evaluation of gastroesophageal reflux in children with chronic tubotympanal disorders, J. Pediatr. Gastroenterol. Nutr. 34 (2002) 278—280. [25] M. Velepic, V. Rozmanic, M. Velepic, M. Bonifacic, Gastroesophageal reflux, allergy and chronic tubotympanal disorders in children, Int. J. Pediatr. Otorhinolaryngol. 55 (2000) 187—190. [26] A. Tasker, P.W. Dettmar, M. Panetti, J.A. Koufman, J.P. Birchall, J.P. Pearson, Reflux of gastric juice and glue ear in children, Lancet 359 (2002) 493. [27] M.M. Carr, C.P. Poje, D. Ehrig, L.S. Brodsky, Incidence of reflux in young children undergoing adenoidectomy, Laryngoscope 111 (2001) 2170—2172. [28] C.D. Phipps, W.E. Wood, W.S. Gibson, W.J. Cochran, Gastroesophageal reflux contributing to chronic sinus disease in children: a prospective analysis, Arch. Otolaryngol. Head Neck Surg. 126 (2000) 831—836. [29] D.R. White, S.B. Heavner, S.M. Hardy, J. Prazma, Gastroesophageal reflux and eustachian tube dysfunction in an animal model, Laryngoscope 112 (2002) 955—961. [30] S. Morinaka, M. Ichimiya, H. Nakamura, Detection of Helicobacter pylori in nasal and maxillary sinus specimens from patients with chronic sinusitis, Laryngoscope 113 (2003) 1557—1563. [31] P. Ekstrom, Non-gastric effects of H. pylori infection: a literature review with respect to non gastric diseases which might be associated with H. pylori infection, Eur. J. Surg. Suppl. (1998) 32—34. [32] H.M. Nabwera, R.P. Logan, Epidemiology of Helicobacter pylori: transmission, translocation and extragastric reservoirs, J. Physiol. Pharmacol. 50 (1999) 711—722. [33] P.H. Karma, Bacteriological aspect of acute otitis media and secretory otitis media, in: J. Sade (Ed.), Acute and Secretory Otitis Media, Kugler Publications, Amsterdam, 1986 , pp. 181—182. [34] J. Poelmans, J. Tack, L. Feenstra, Prospective study on the incidence of chronic ear complaints related to gastroesophageal reflux and on the outcome of antireflux therapy, Ann. Otol. Rhinol. Laryngol. 111 (2002) 933—938.
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Chronic otitis media with effusion and Helicobacter pylori Bulent V. Agirdir *, Selami Bozova, Alper T. Derin, Murat Turhan Akdeniz University, Medical Faculty, ENT & HNS, Arapsuyu, Akdeniz, Antalya 07070, Turkey Received 22 July 2005; received in revised form 17 September 2005; accepted 17 September 2005
KEYWORDS Chronic otitis media with effusion; Helicobacter pylori; CLO testing; Urease test
Summary Objective: The aim of this study is to investigate the presence of Helicobacter pylori (HP) in the middle ear effusion by Campylobacter-like organism (CLO) test and whether it has a role in the ethiopathogenesis of chronic otitis media with effusion (OME). Study design: A prospective randomized and controlled study. Methods: This study was performed with 45 patients with the diagnosis of chronic OME and adenoid hypertrophy, between the ages 3 and 13 (median 6). Thirty patients constituted the study group (18 male (60%) and 12 (40%) female). Adenoidectomy with myringotomy with ventilation tube insertion were performed to this group. Middle ear effusion and adenoid tissue pieces were collected and H. pylori presence was investigated by ‘‘CLO’’ testing. Fifteen patients of the matching age group (9 male (66.7%) and 6 (33.3%) female) constituted the control group to whom adenoidectomy with myringotomy were performed but no middle ear effusion could be determined (empty myringotomy patients). The wash out liquid of middle ear and pieces of adenoid tissue samples were also collected from the control group. By using CLO testing, the presence of H. pylori was investigated in the adenoid tissues and middle ear of the empty myringotomy patients. Results: In 20 (66.6%) patients of the study group, CLO testing was positive in the middle ear effusions. None of the patients demonstrated positive CLO test in the wash out liquid of middle ear. There was significant difference of positive CLO testing in the middle ear effusions of two groups ( p < 0.001). Conclusions: These findings showed us that presence of HP in the middle ear effusion using CLO testing and this may be responsible for the ethiopathogenesis of chronic OME. # 2005 Elsevier Ireland Ltd. All rights reserved.
* Corresponding author. Tel.: +90 242 227 4343/24106. E-mail address: [email protected] (B.V. Agirdir). 0165-5876/$ — see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2005.09.026
830
B.V. Agirdir et al.
1. Introduction
2. Materials and methods
The non-suppurative form of otitis media with middle ear effusion is called as otitis media with effusion (OME) or secretory otitis media (SOM). OME is one of the most frequent diseases of the ear in childhood [1]. Helicobacter pylori (HP) was isolated firstly in the stomachs of gastric ulcer patients in 1983 by Marshall et al. [2]. This bacterium causes antral gastritis (type B) in the early periods of the infection and gastric ulcer, more over gastric carcinoma or MALT lymphoma in the late periods [3]. In the patients younger than the age 10, the findings of the gastritis and gastric ulcer are not obvious [3]. The disease presents itself merely by recurrent abdominal pain [3]. It is one of the most frequent infections all over the world. The prevalence of the disease is 30—40% in the developed countries and 80—90% in the underdeveloped countries. Crowded families, ethnical status, migration to the endemic places, the frequency in the family and general condition of the patient are the risk factors. It is not so clear how the disease infects somebody but oral—oral, fecal—oral or gastro—oral contamination may be possible. There are many clues of colonization in the dental plaques, tonsils and adenoid tissues [3—5]. Causes of OME are believed to be multifactorial, including viruses, allergy, bacteria and their products, and dysfunction of the eustachian tube. Gastroesophageal reflux (GER) could also be a cause of this disease [6,7]. Reflux of gastric contents from the nasopharynx to the middle ear is possible because of the angle between them and immaturity of the eustachian tube in children and infants and the supine position in which infants are often placed [8]. Urease test or Campylobacter-like organism (CLO, Ballard Medical Products) testing is the most frequently used method by gastroenterologists for demonstrating the HP in the world. On a single biopsy, CLO test was as sensitive as histology and more sensitive than culture [9]. When a little piece of tissue containing HP was added into the CLO test kit including urea and phenol red, Campylobacterlike organisms (that is HP) diverse urea to ammonia (NH3). The pH value of the environment increases and the color of the test kit turns to red from yellow. This specifically shows the presence of HP in the material. As a safe, easy to perform, and cheap method, CLO test is one of the most frequently used method in the world. Thus we used this method in the current study. The aim of this study is to investigate the presence of HP in the middle ear effusion by CLO test and whether it has a role in the ethiopathogenesis of chronic OME.
A prospective randomized and controlled study was carried out from March 2000 to April 2003 in the Otolaryngology Head and Neck Surgery Department of a tertiary referral center. Forty-five patients with the diagnosis of chronic OME and adenoid hypertrophy were included in the study. The patients were between ages 3 and 13 (median 6). Of the 30 patients consisting the study group, 18 (60%) were male, 12 (40%) were female. Fifteen age-matched patients constituted the control group; 9 (66 and 7%) male and 6 (33 and 3%) female. Adenoidectomy with myringotomy were performed to both groups for the diagnosis of adenoid hypertrophy and chronic OME. In the control group, no middle ear effusion could be determined, though preoperative operation criteria were fulfilled (empty myringotomy). Empty myringotomy is reported to be present in 6—44% of all myringotomy patients [10,11]. The exact reason is not known but the probability of illness recovery from the time of diagnosis to operation or liquid’s passing to nasopharynx throughout from the eustachian tube during general anesthesia may be the cause. We used such a control group because it would be an ethical problem to use healthy subjects. Adenoidectomy and bilateral myringotomy and/or ventilation tube insertion was performed to the patients who had fulfilled at least two of the following criteria: (1) adenoid hypertrophy symptoms, (2) OME findings in physical examination, (3) adenoid hypertrophy confirmed by nasal endoscopy or lateral nasopharyngeal soft tissue radiogram and (4) C2 or B curves in the tympanogram. All patients took two courses of antibiotic (amoxicillin/ clavulanate potassium, Augmentin, GlaxoSmithKline, 40 mg/kg), anti-inflammatory and systemic or topical decongestant agents (not >5 days) revision treatment for at least 10 days before the operation for 3 months follow up). After the decision of operation, the patients did not take any medications for at least 1 month. None of the patients had acute infection on the day of the operation. All of the patients were sedated by intranasal dormicum (0.2 mg/kg) preoperatively. The induction of the general anesthesia was performed via thiopental and continued with the combination of nitrogen protoxide, oxygen and sevoflorane, and then adenoidectomy and myringotomy was performed for each patient. The superficial and deep parts of the adenoid tissue were transected as 1—3 mm3 thickness specimens and washed with sterile saline solution. Then the tissue was put in the CLO test apparatus. When small pieces of infected tissues were added to the test kit containing urea and phenol red, HP converts urea
Chronic otitis media with effusion and Helicobacter pylori to ammonia and this turns the color of testing kit from yellow to red. After performing myringotomy, the middle ear effusions were collected in the Juhn Tym-Taps (Xomad, Jackson-ville, FL, USA), which is a commercially available suction and collection device. These effusions were poured into sterile saline solution and washed out from blood waste. The mucous layer floating over the sterile saline solution was put again into another CLO testing apparatus. Bilateral middle ear effusions in the first 10 patients showed exactly the same CLO test results. For this reason, in the next 20 patients’ middle ear effusions were collected randomly from the right and left ears equally (10 from right and 10 from left). Only one ear result of all patients was included in the statistical analysis. The adenoid samples of the control group were collected in the same way. In this group, 0.5 cm3 of saline was injected into the middle ear through the hole of myringotomy and aspirated into the sterile reservoir as mentioned before. Some of the liquid was aspirated from the empty middle ear and put into the CLO testing apparatus. The CLO tests were evaluated by different residents who did not know whether the patient was in the study or control group. The results were checked at the 1st, 2nd and 24th h at the room temperature (18—22 8C). The changes in the color of the tests after 24 h were not considered. The colors which turned to red and pink, were considered into the study as for test positivity and no change in the color was considered as test negativity. The positive reactions in the color of the test at the first minutes were not considered as positive for possible blood contamination (Picture 1). It is simple to perform, cheap and has a specifity and sensitivity as the other methods have. Thus CLO test is a rapid reliable and convenient method for diagnosis of HP [9]. Permission of the patients’ parents and approval from the local Ethic Committee were obtained for the use of the specimens. For statistical analysis, Fisher’s exact test was used; the analysis was performed using SPSS 12
Picture 1 Color changes in CLO test. Turning to red or pink in the first 24 h demonstrates Helicobacter pylori presence in the middle ear effusion on the left-sided disc.
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software (SPSS, Chicago, IL, USA). A p-value <0.05 were considered to indicate significance.
3. Results Two populations as a total (control and study group) 18 (40%) patients were female, 27 (60%) were male. The age range was 3—13 years (median 8). Female/ male ratio was 2/3. From the total of 30 patients, 20 (66 and 6%) had positive CLO testing in the middle ear effusions. Ten (33.3%) patients had positive test in the adenoid tissue. In the CLO testing of the study group, if adenoid tissue was positive then middle ear effusion was always positive. If one ear’s test was positive then the other ear’s test was always positive in the first 10 patients. In the study group; of the 18 male patients, 10 (55.5%) had CLO test positivity in the middle ear effusions, 5 (28%) patients had a positive test in the adenoid tissue, 10 (83%) female patients of 12 had CLO test positivity in the middle ear effusions and 5 (50%) had test positivity in the adenoid tissues. In the control group, only four (26.6%) patients showed CLO test positivity in the adenoid tissue. No patient showed CLO positivity in the wash out solution of empty ear. The difference between CLO test positivity in the middle ear effusions of the study group and wash out solution of the control group was statistically significant ( p < 0.001, Graph 1). There was no significance between CLO positivity in the adenoid tissues of two groups (Graph 2). Although CLO test positivity was higher in the middle ear effusions in females it was not statistically significant.
4. Discussion HP is one of the most frequent infection agents all over the world. It is not only accepted as an agent responsible for gastritis but also for systemic infection. In a recently published study from England, HP was found to be localized in the atherom plaques of the coronary arteries [12]. The primary reservoir of HP is thought to be stomach but it is shown that it may be present in dental plaques, tonsil and adenoid tissue and squamous cell carcinoma of the larynx [13—15]. In order to reproduce itself, HP needs microaerophylic environment (5% of CO2). This microaerophylic environment is also present in the middle ears of OME patients. The mechanism of the colonization of HP in the gastric mucosa is still unclear. In fact, it is impossible for the bacteria to live and reproduce in such an acidic environment. By
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Graph 1 CLO test result in the middle ear effusions. Fisher’s exact test cross table p < 0.001 Fisher’s exact test was significant.
implanting itself under the gastric mucosal layer, inside the mucosal epithelium, the bacterium is protected by the help of impermeable mucus layer to the gastric acids. The pH value of the luminal side of the mucus layer is 1.0—2.0 and mucosal side is approximately 7.4. The pH value of the middle ear
Graph 2
effusions of the chronic OME patients is also between 7.0 and 9.0 [16,17]. In HP infections, mucosal metaplasia (as in the Barret esophagitis) and goblet cell hyperplasia occurs. A similar situation in OME [1,16,18]. There is inflammatory response predominantly with
CLO test results in the adenoid tissues. Fisher’s exact test was not significant.
Chronic otitis media with effusion and Helicobacter pylori lymphocytic infiltration both in the gastritis and OME [16,19,20]. OME is most frequently seen in crowded families, societies that have low socioeconomic conditions and in specific climate conditions. These are very similar for HP infection [5,16,21,22]. HP is a bacterium that may live in the middle ear. In our study we found the rate of presence of the bacterium as 66.6% in the middle ear effusions. In 2004, Yilmaz et al. [23] has found that 67% of chronic OME patients showed HP presence in the middle ear effusions. But, they did not find any HP presence in the adenoid tissues of the same patient group. Unver et al. [15] found that HP presence is 25% in the adenoid tissue and 62.5% in the tonsil tissue of 19 patients of ages between 4 and 38. When the patients older than age 13 are neglected, the ratio is 28%. In our study, HP presence ratio in the adenoid tissue was 33% in the study group and 26.6% in the control group. In a study of Rozmanic et al. the incidence of gastroesophageal reflux disease (GERD) was found as 55.6% in the patients of chronic tubotympanic disease [24]. Velepic et al. [25] also noted that GERD was present in 60% of chronic tubotympanic patients and Tasker et al. [26] showed that gastric fluid reflux was present in 83% of the middle ear effusions of glue ears. In our study, we found that HP presence in the middle ear effusions was twice as frequent as in the adenoid tissues. This may be due to the available environment for the bacterium in the effusion of OME patients. The inoculation of the HP into the middle ear may be through the hematogenous way or by the help of GER. Especially for the patients of adenoid vegetation, gastroesophageal reflux disease is a frequent problem. Carr et al. [27] demonstrated that 42% of 95 children smaller than 2 years old who underwent adenoidectomy had GERD. HP-contaminated gastric fluid enters to nasopharyngeal cavity by the GERD and colonizes in the dental plaques, adenoid tissues and tonsils. From these localizations the bacterium ascends to the middle ear and the paranasal sinuses directly or by the reflux and may trigger some pathological changes, but the exact mechanism remains unclear [28]. In an animal study, White et al. [29] have demonstrated that nasopharyngeal exposure to HCl and pepsin in concentrations similar to that found in gastric reflux leads to impairment of ventilatory function and mucociliary clearance of the eustachian tube. GERD has been considered a contributing factor for many nasopharyngeal disease processes occurring anterior to the eustachian tube [28]. Morinaka et al. [30] demonstrated that HP may exist in the nasal and maxillary sinus tissue specimens of some patients with chronic sinusitis with
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gastric HP infection. How HP infection is transmitted remains unclear, and little is known about the role of HP in extra gastric disease [31,32]. In the previous studies, the efforts for isolating any bacterial agents in the middle ear effusion of OME by cultural studies were failed. This may be due to the HP’s reproduction characters, which does not permit the production in the classical culture methods. As previously mentioned, HP needs microaerophylic environment and special agar such as Skirrow medium. Karma noted that it should not be accepted that the OME effusion is sterile when looking at classical culture studies [33]. The agents as b-lactamase-resistant penicillin and macrolids are used for the treatment of HP but antibiotic treatment alone is not enough both for HP and OME. Proton pump inhibitors, H2 receptor blockers and bismuth compounds are added for a reliable treatment for GERD. In recent studies of Poelmans et al. [34] and Tasker et al. [26] in 2002, they showed independently that GERD is a major pathology in intractable chronic OME and antireflux treatment was effective in dissolving the problem. There is no golden standard treatment protocol for OME. Most of the chronic OME patients could not be treated by standard medical therapy and they should be operated. The effectivity of the operation may be due to the change of microaerophylic environment thus inhibiting the colonization of HP. Although the aim of our study was to demonstrate the presence of HP in middle ear effusion of chronic OME with a safe, easy to perform and cheap method, demonstrating the presence of HP is not an enough argument for pathogenesis of the OME. To show whether HP is one of the causes of chronic OME, more studies are required. After then protocols of the HP eradication may be used in the treatment of the disease.
5. Conclusions To our knowledge this is the first study that showed the HP presence in the middle ear effusions using CLO testing and HP may be responsible for the ethiopathogenesis of OME. To demonstrate whether HP presence in the effusions of OME is as a result of gastroesophageal reflux and/or direct transmission, hematogenous way or translocation, further investigations are necessary.
Acknowledgement This study was supported by Akdeniz University Scientific Research.
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