- Email: [email protected]
Cytological and Histopathological Studies of Otitis Media with Effusion
Auris·Nasus·Larynx (Tokyo) 12 (Supp!. I) S 166-S 168, 1985
CYTOLOGICAL AND HISTOPATHOLOGICAL STUDIES OF OTITIS MEDIA WITH EFFUSION Mikiko TAKAYAMA, M.D., Tetsuo ISHII, M.D., and Eiko HATANAKA, M.D. Department of Otolaryngology, Tokyo Women's Medical College, Tokyo, 162 Japan
Middle ear fluid contains such cells as neutro- cytic cellular components have been observed phils, macrophages, and lymphocytes. There in the fluid and these cellular components are have been numerous reports dealing with these considered to play an important role in the cellular components in the fluid. This study was defense mechanism against infection. undertaken to investigate interrelation between In this study, we categorized the stage in the type of predominant cells in the fluid and the otitis media with effusion according to the stage of disease in adults and children. The study also included bacterial isolation from fluid for international classification (SENTURIA et al., comparison of detection rates between adults 1980) of cellular components from the fluid and children, and microscopic examination of of adults and children, and discussed the rate temporal bone from 2 adult patients with otitis of bacterial detection. Furthermore, we carmedia with effusion complicating tumors of head ried out observations in microscopic histoand neck. Thirty-two ears of adult patients and pathological findings of the temporal bone of 40 ears of children both having received my- adults with middle ear effusion. ringotomy were studied. The fluid specimens were obtained from middle ears examined micro- Materials and Methods scopically with May-Giemsa stain and with aThe patient population was comprised of Naphthyl butyrate esterase and Naphtohol AS32 adult ears and 40 child ears, diagnosed D chloroacetate double stains for identification of macrophages. Histopathologica studies of the otitis media with effusion in our out-patient temporal bone were examined with hematoxylin- clinic. Myringotomy was performed on all eosin stain. In adults, neutrophils were predomi- the patients under iontophoresis or general nant in the fluid of 54.5 % of subacute cases while anesthesia. The fluid in middle ear was suctioned into the predominant cell type was macrophages in 45 % of chronic cases. Neutrophils were the a sterilized disposable syringe. It was mixed predominant type in 62.2 ~Ya of children with with phosphate-buffer solution and washed chronic stage. Bacteria were demonstrated in several times before centrifuge. The cellular 26.0 % of the adult cases and in 21.6 % of the components were smeared onto a slide glass children. By histopathological examination of and were stained with May-Giemsa stain. the temporal bones, neutrophils were found in Furthermore, double staining with a-Naphthe fluid of case 1, and a large number of macrophages in the fluid and fibrosis of the tympanic thyl butyrate esterase and Naphthol AS-D cWoracetate was carried out. cavity were found in case 2. The histopathological microscopic specimens of the temporal bone were obtained In recent years, various investigations have from 2 patients having otitis media with effubeen performed to elucidate the etiology and sion associated with head and neck tumor. pathogenesis of otitis media with effusion These specimens were stained with hemabecause of its increased incidence and its toxilineosin staining. retractibility. Neutrophilic, macrophagic, and lympho-
Lecture
Morphology
S 167
Results The neutrophils, Cytological findings. macrophages (Fig. I), and lymphocytes were calculated from the cytological study in the fluid. The cellular component with the highest appearance rate among these 3 entities was taken to be the dominant cell. The stages of these cases were classified into acute, subacute, and chronic, in accordance with the international classification. In the adult group of 32 ears, the abovementioned study was not carried out for acute cases since there were only a few cases. In the subacute cases, there were 6 ears with neutrophilic dominance (54.5%). As for the chronic cases, 9 ears showed macrophagic dominance (45%). In the pediatric group of 40 ears, the above-
mentioned study was not carried out for acute and subacute cases due to the small number of C:lses. As for the chronic cases, there were 23 ears (62.2%) with neutrophilic dominance, which was clearly the most numerous (Table 1). Bacterial detection. As for the rate of bacterial detection, there was a detection rate of 26% for the chronic cases in the adult group, with opportunistic pathogens forming the main proportion. The detection rate in the pediatric group was 21.6%, and similarly to the adult group, opportunistic pathogens formed the main proportion of the bacterial population. Histophathological findings. In case I, neutrophils which were sparsely found in the fluid comprised the main cell population of
Fig. 1. Macrophages were identified by the dark reddish coloration of the cytoplasma by means of the double staining. (a-naphthyl butyrate esterase and naphthol AS-D chloracetate, x 4(0)
Fig. 2. (case 2) Tympanic cavity of right ear with numeral cysts accumulated with macrophages (arrows). H&E, x 12.
Table 1.
Cytological patterns of effusion in children .
Dominant cell type of effusion
No.
Chronic
Subacute
Adults
Neutrophil Macrophage Lymphocyte Total
14 10 8 32
7 (35.0%) 9 (45.0%) 4 (20.0%) 20 ( 100%)
6 (54.4%) 1(9.1%) 4 (36.4%) 11 ( 100%)
Children
Neutrophil Macrophage Lymphocyte Total
25 13
23 (62.2 %) 13 (35 .1 %) 1 ( 2.7%) 37 ( 100%)
1
40
2
2
Acute
S 168
M. TAKAYAMA el al.
the fluid in the tympanic cavity. Similarly to the tympanic cavity, the fluid from the mastoid cells contained neutrophils and a small number of macrophages. In the mastoid cells, these cells were distributed close to the one side of mucosal membrane. In case 2, proliferation of the connective tissue which mostly consisted of fibrous tissue, was observed within the middle ear cavity, and numerous small cysts formation was found among these connective tissues. Macrophages were accumulated in the cysts which were formed in the tympanic cavity and mastoid cells.
Discussion Obvious neutrophilic dominance was observed at a high frequency in the chronic stage in our pediatric patients, and it may be implied from this observation that bacterial infection continues even in chronic stage. Our bacterial detection rate was lower than other reports. In recent years, high detection rate of bacteria in fluid has been reported according to LIU et al. (1975), where bacteria were detected in 52% by means of cultures and in 77% by smears. In the case of adults, neutrophil dominant cases were frequently observed in the subacute stage. However, in the chronic stage, macrophage dominance began to be observed more frequently. These findings are in agreement with the observation of MCGHEE et at. (1983) and CATANZARO et al. (1982), whereby macrophages increased with time in their experiments. Fibrosis with macrophages was also found in the middle ear cavity. It is well known that fibrosis is generally observed in the chronic phase. PALVA et al.
(1981) described that fibrosis is observed at the end stage of active secretion. According to ISHII et al. (1980), fibrosis was found generally after repetitive inflammation. On the other hand, YAMANAKA et al. (1982) by investigating macrophages in the middle ear, found reduced, absent or even suppressed lymphoproliferative function, and suggested that disturbing the defence system of macrophage lead to chronic middle ear effusion. Thus, from our result, macrophage dominance began to appear more frequently in adult group in the chronic stage. The existence of macrophages not only means phagocytic reaction, but also suggests strongly occurrence of local immune response.
References CATANZARO, A., RYAN, A. F., and ROBB, J. A.: Immunologically mediated and nonspecific inflammatory responses in the middle ear. Clin. Immunol. Immunopathol. 24: 361-376, 1982. ISHII, T., TORIYAMA, M., and SUZUKI, J.: Histopathological study of otitis media with effusion. Ann. 0101. Rhinal. Laryngol. suppl. 68: 83-86, 1980. Lm, Y. S., LIM, D. J., LANG, R. W., and BIRCK, H. G.: Chronic middle ear effusions. Arch. 010laryngol. 101: 278-286, 1975. MCGHEE, R. B., DEMARIA, T. F., OKAZAKI, N., and LIM, D. J.: Selective induction of macrophages in the middle ear. Ann. 0101. Rhinal. Laryngol. 92: 510-517, 1983. PALVA, T., MAKINEN, J., and RINNE, J.: Middle ear mucosa in chronic effusions. ORL. 43: 241247, 1981. SENTURIA, B. H., BLUESTONE, D., KLEIN, J. 0., LIM, D. J., and PARADISE, J. L.: Report of the ad hoc committee on definition and classification of otitis media and otitis media with effusion. Ann. 0101. Rhinal. Laryngo!. suppl. 68: 3-4, 1980. YAMANAKA, T., BERNSTEIN, J. M., and OGRA, P.: Cited from LIM, D. J.: Pathogenesis of otitis media with effusion. Pediatr. Infect. Dis. 82: 14-37, 1982.
CYTOLOGICAL AND HISTOPATHOLOGICAL STUDIES OF OTITIS MEDIA WITH EFFUSION Mikiko TAKAYAMA, M.D., Tetsuo ISHII, M.D., and Eiko HATANAKA, M.D. Department of Otolaryngology, Tokyo Women's Medical College, Tokyo, 162 Japan
Middle ear fluid contains such cells as neutro- cytic cellular components have been observed phils, macrophages, and lymphocytes. There in the fluid and these cellular components are have been numerous reports dealing with these considered to play an important role in the cellular components in the fluid. This study was defense mechanism against infection. undertaken to investigate interrelation between In this study, we categorized the stage in the type of predominant cells in the fluid and the otitis media with effusion according to the stage of disease in adults and children. The study also included bacterial isolation from fluid for international classification (SENTURIA et al., comparison of detection rates between adults 1980) of cellular components from the fluid and children, and microscopic examination of of adults and children, and discussed the rate temporal bone from 2 adult patients with otitis of bacterial detection. Furthermore, we carmedia with effusion complicating tumors of head ried out observations in microscopic histoand neck. Thirty-two ears of adult patients and pathological findings of the temporal bone of 40 ears of children both having received my- adults with middle ear effusion. ringotomy were studied. The fluid specimens were obtained from middle ears examined micro- Materials and Methods scopically with May-Giemsa stain and with aThe patient population was comprised of Naphthyl butyrate esterase and Naphtohol AS32 adult ears and 40 child ears, diagnosed D chloroacetate double stains for identification of macrophages. Histopathologica studies of the otitis media with effusion in our out-patient temporal bone were examined with hematoxylin- clinic. Myringotomy was performed on all eosin stain. In adults, neutrophils were predomi- the patients under iontophoresis or general nant in the fluid of 54.5 % of subacute cases while anesthesia. The fluid in middle ear was suctioned into the predominant cell type was macrophages in 45 % of chronic cases. Neutrophils were the a sterilized disposable syringe. It was mixed predominant type in 62.2 ~Ya of children with with phosphate-buffer solution and washed chronic stage. Bacteria were demonstrated in several times before centrifuge. The cellular 26.0 % of the adult cases and in 21.6 % of the components were smeared onto a slide glass children. By histopathological examination of and were stained with May-Giemsa stain. the temporal bones, neutrophils were found in Furthermore, double staining with a-Naphthe fluid of case 1, and a large number of macrophages in the fluid and fibrosis of the tympanic thyl butyrate esterase and Naphthol AS-D cWoracetate was carried out. cavity were found in case 2. The histopathological microscopic specimens of the temporal bone were obtained In recent years, various investigations have from 2 patients having otitis media with effubeen performed to elucidate the etiology and sion associated with head and neck tumor. pathogenesis of otitis media with effusion These specimens were stained with hemabecause of its increased incidence and its toxilineosin staining. retractibility. Neutrophilic, macrophagic, and lympho-
Lecture
Morphology
S 167
Results The neutrophils, Cytological findings. macrophages (Fig. I), and lymphocytes were calculated from the cytological study in the fluid. The cellular component with the highest appearance rate among these 3 entities was taken to be the dominant cell. The stages of these cases were classified into acute, subacute, and chronic, in accordance with the international classification. In the adult group of 32 ears, the abovementioned study was not carried out for acute cases since there were only a few cases. In the subacute cases, there were 6 ears with neutrophilic dominance (54.5%). As for the chronic cases, 9 ears showed macrophagic dominance (45%). In the pediatric group of 40 ears, the above-
mentioned study was not carried out for acute and subacute cases due to the small number of C:lses. As for the chronic cases, there were 23 ears (62.2%) with neutrophilic dominance, which was clearly the most numerous (Table 1). Bacterial detection. As for the rate of bacterial detection, there was a detection rate of 26% for the chronic cases in the adult group, with opportunistic pathogens forming the main proportion. The detection rate in the pediatric group was 21.6%, and similarly to the adult group, opportunistic pathogens formed the main proportion of the bacterial population. Histophathological findings. In case I, neutrophils which were sparsely found in the fluid comprised the main cell population of
Fig. 1. Macrophages were identified by the dark reddish coloration of the cytoplasma by means of the double staining. (a-naphthyl butyrate esterase and naphthol AS-D chloracetate, x 4(0)
Fig. 2. (case 2) Tympanic cavity of right ear with numeral cysts accumulated with macrophages (arrows). H&E, x 12.
Table 1.
Cytological patterns of effusion in children .
Dominant cell type of effusion
No.
Chronic
Subacute
Adults
Neutrophil Macrophage Lymphocyte Total
14 10 8 32
7 (35.0%) 9 (45.0%) 4 (20.0%) 20 ( 100%)
6 (54.4%) 1(9.1%) 4 (36.4%) 11 ( 100%)
Children
Neutrophil Macrophage Lymphocyte Total
25 13
23 (62.2 %) 13 (35 .1 %) 1 ( 2.7%) 37 ( 100%)
1
40
2
2
Acute
S 168
M. TAKAYAMA el al.
the fluid in the tympanic cavity. Similarly to the tympanic cavity, the fluid from the mastoid cells contained neutrophils and a small number of macrophages. In the mastoid cells, these cells were distributed close to the one side of mucosal membrane. In case 2, proliferation of the connective tissue which mostly consisted of fibrous tissue, was observed within the middle ear cavity, and numerous small cysts formation was found among these connective tissues. Macrophages were accumulated in the cysts which were formed in the tympanic cavity and mastoid cells.
Discussion Obvious neutrophilic dominance was observed at a high frequency in the chronic stage in our pediatric patients, and it may be implied from this observation that bacterial infection continues even in chronic stage. Our bacterial detection rate was lower than other reports. In recent years, high detection rate of bacteria in fluid has been reported according to LIU et al. (1975), where bacteria were detected in 52% by means of cultures and in 77% by smears. In the case of adults, neutrophil dominant cases were frequently observed in the subacute stage. However, in the chronic stage, macrophage dominance began to be observed more frequently. These findings are in agreement with the observation of MCGHEE et at. (1983) and CATANZARO et al. (1982), whereby macrophages increased with time in their experiments. Fibrosis with macrophages was also found in the middle ear cavity. It is well known that fibrosis is generally observed in the chronic phase. PALVA et al.
(1981) described that fibrosis is observed at the end stage of active secretion. According to ISHII et al. (1980), fibrosis was found generally after repetitive inflammation. On the other hand, YAMANAKA et al. (1982) by investigating macrophages in the middle ear, found reduced, absent or even suppressed lymphoproliferative function, and suggested that disturbing the defence system of macrophage lead to chronic middle ear effusion. Thus, from our result, macrophage dominance began to appear more frequently in adult group in the chronic stage. The existence of macrophages not only means phagocytic reaction, but also suggests strongly occurrence of local immune response.
References CATANZARO, A., RYAN, A. F., and ROBB, J. A.: Immunologically mediated and nonspecific inflammatory responses in the middle ear. Clin. Immunol. Immunopathol. 24: 361-376, 1982. ISHII, T., TORIYAMA, M., and SUZUKI, J.: Histopathological study of otitis media with effusion. Ann. 0101. Rhinal. Laryngol. suppl. 68: 83-86, 1980. Lm, Y. S., LIM, D. J., LANG, R. W., and BIRCK, H. G.: Chronic middle ear effusions. Arch. 010laryngol. 101: 278-286, 1975. MCGHEE, R. B., DEMARIA, T. F., OKAZAKI, N., and LIM, D. J.: Selective induction of macrophages in the middle ear. Ann. 0101. Rhinal. Laryngol. 92: 510-517, 1983. PALVA, T., MAKINEN, J., and RINNE, J.: Middle ear mucosa in chronic effusions. ORL. 43: 241247, 1981. SENTURIA, B. H., BLUESTONE, D., KLEIN, J. 0., LIM, D. J., and PARADISE, J. L.: Report of the ad hoc committee on definition and classification of otitis media and otitis media with effusion. Ann. 0101. Rhinal. Laryngo!. suppl. 68: 3-4, 1980. YAMANAKA, T., BERNSTEIN, J. M., and OGRA, P.: Cited from LIM, D. J.: Pathogenesis of otitis media with effusion. Pediatr. Infect. Dis. 82: 14-37, 1982.