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The Pathology of Otitis Media By J Clin Pathol: first published as 10.1136/jcp.9.3.229 on 1 August 1956. Downloaded from J. clin. Patn. (1956), 9, 229. THE PATHOLOGY OF OTITIS MEDIA BY I. FRIEDMANN From the Department of Pathology of the Institute of Laryngology and Otology, London (RECEIVED FOR PUBLICATION NOVEMBER 11, 1955) Knowledge of the pathology of otitis media is 350 Cases of Chronic Mastoiditis conflicting in spite of the vast amount of relevant Evidence of inflammatory changes has been literature. noted in 270 cases. In 80 specimens there was One of the objects of the present investigation no evidence of infection and they were rejected has been to re-examine this field in relation to the for this study (these were cortical bone chips). question as to whether the pathology of otitis The positive findings were (1) granulation tissue media and maistoiditis has changed since the in the bone fragments; (2) signs of bone recon- advent of the antibiotics as often suggested. For struction; (3) mucosal changes; (4) aural chole- this purpose bone-chips removed at recent mas- steatoma; (5) cholesterol-granuloma. toidectomy operations have been studied. (1) Granulations when present lay freely, covered the bone fragments, or filled the cells, the antrum, or eroded bone. They consisted of non- Materials and Methods specific inflammatory granulation tissue infiltrated Three hundred and seventy five samples of bone by plasmacytes, lymphocytes and enclosing gland- copyright. chips removed at mastoidectomy operations were like structures. The granulations were on the decalcified, embedded in paraffin-wax, and sec- whole identical with the structure of the so-called tioned. Sections were stained with haemotoxylin and aural eosin, Van-Gieson, Gram, Ziehl-Neelsen, and Mas- polyp. son's trichrome. The periodic-acid-Schiff reaction (2) There was much evidence of reconstruction was used for the demonstration of mucus-secreting of bone indicated by dark-blue staining lines of apposition of various thickness resembling the sur- cells or glands. http://jcp.bmj.com/ face of glaciers (Fig. 6), and irregular cement lines forming an intricate mosaic pattern (Figs. 7 and 8). 25Cases of Acute Mastoiditis (3) The mucosa of the mastoid cells whether The number of acute infections was, as ex- oedematous or fibrotic was infiltrated by round pected, fairly small. The pathological changes cells and frequently lined by ciliated columnar were, however, intensive and characteristic. epithelium which formed gland-like structures (Figs. 9 and 10). The " glands" contained mucus In the early stages the mucosa of the air cells giving a positive periodic-acid-Schiff reaction. on September 24, 2021 by guest. Protected was congested and swollen, lined with flat or (4) Stratified squamous epithelium, lining chole- cuboidal cells (Fig. 1). The lumen was filled with steatoma cavities, was often seen covering the pus, replaced later by fibrous granulation tissue bone chips (Fig. 11). From the inverted keratin- (Figs. 2 and 3). There was evidence of osteoclastic ized surface, multiple layers of epidermoid kerat- activity and already, at an early stage about five inized epithelium were desquamated filling the to 10 days after infection, of intensive formation cholesteatoma cavity proper. Sometimes only of new bone (Figs. 3, 4, and 5). fragments of keratinized matter surrounded by There was great variation in a given specimen giant cells were found (Fig. 12). and neighbouring mastoid air-cells presented (5) Frequently no true epidermoid cholestea- different stages from suppuration to fibroblastic toma was found but only rich deposits of choles- organization and ossification. terol crystals surrounded by giant cells embedded In some cases, of streptococcal aetiology, there in fibrous granulation tissue (Figs. 13 and 14). was considerable haemorrhage and destruction of bone. Equally, an occasional acute case caused by Discussion B. proteus showed evidence of widespread It has been suggested that the pathology of suppuration. otitis media may have undergone some basic J Clin Pathol: first published as 10.1136/jcp.9.3.229 on 1 August 1956. Downloaded from copyright. FIG. 1 F'G. 3 vS~~~~~~~~~~St..1 http://jcp.bmj.com/ .,,, .2 4 . i-aA * ..~ ~ - on September 24, 2021 by guest. Protected 'Cr,~~~~~~~~~~~~~o *3 ;. ..w*ovcr FIn. 4 FIG. 1(1224 54).-Mastoid cell showing congested muicosa and healthy laminated bone. Haematoxylin and eosin, 150. FIG. 2 (837 53).-Acute mastoiditis (10 days' history). Note pus- filled mastoid cell, thickened lining. Haematoxylin and eosin, x 45. FIG. 3.Neighbouring mastoid cell showing fibrous organization and intensive new-bone formatin. Haematoxylin and eosin. 30. As Fig. 2. FIG. 4 (1582 53).-Acute mastoiditis (14 days' history). Newly formed reticular bone obliteratingell. Haematoxylin and eosin, FIG. 2 60. J Clin Pathol: first published as 10.1136/jcp.9.3.229 on 1 August 1956. Downloaded from FIo. 5 (120/55).-Acute mastoiditis (10 days', history), showing 'network of reticular bone replacing fibrous granulation tissue. ,* Haematoxylin and eosin, x 95. S copyright. http://jcp.bmj.com/ FiG. 5 on September 24, 2021 by guest. Protected FIG. 6 (441/53).-Glacier-like arrangement of lines of apposition. Haematoxylin and eosin, x 52. FIG. 6 J Clin Pathol: first published as 10.1136/jcp.9.3.229 on 1 August 1956. Downloaded from ji: S IW.....7N: :N-.- ..i.. .1R w.. ;.4. .5.:9:..4 ....i *: p.:e :.rQ.: S .. v - ...... IL "r !..... IL :...: .: ...: 'R* ,W:: 11 l%..-- ft copyright. FIG. 7 (1055 53).-Sclerotic bone fragment showing irregular cement lines. Haematoxylin and eosin, - 170. A'' 49 4 0 1 http://jcp.bmj.com/ ,g, 4 .5 R-. i.- ..: 8.;:i: : ...:T on September 24, 2021 by guest. Protected *.':'1 A::. i.: t :.:s ...p;'. FIG. 8 (1998i54).-Sclerotic bone fragment showing irregular cement lines. Haematoxylin and eosin, x 325. J Clin Pathol: first published as 10.1136/jcp.9.3.229 on 1 August 1956. Downloaded from FIG. 9 (181/53).-Sclerotic bone lined by pseudostratified ciliated columnar epithelium. Haematoxylin and eosin, x 490. FIG. 10 (1693,154).-Gland in granulation tissue. Haematoxylin and eosin, x 400. PI ll-. .!e 1-4 p - ".AbLm - 11 4 It -16- -A'r.-* v APVF "77. .1w - - , ., A " 16 .1-1 :,,..-..dw I4 4 ..: AW -,"AWdw- -I.- -:.906. 7m copyright. -7 1: 1. .-( I FIG. 9 FIG. 10 :I http://jcp.bmj.com/ on September 24, 2021 by guest. Protected ,2 _P4 FiG I I-Ara coleteto2a ?r .4 I Adof 4 .1& _X ;d w -4v4 _1 w Note epidermoid squamous epithelium and lamellated keratinized material in the lumen. Haematoxylin and eosin, x 72. J Clin Pathol: first published as 10.1136/jcp.9.3.229 on 1 August 1956. Downloaded from 234 1. FRIEDMANN *46 i i '~ .w s WSo~~~*,'e''t %Uss. v I'~~~~~~~~~~~~t FIG. 12 (279 55).-Chronic inflammatory granulation tissue containing lamellated " cholesteatomatous" material surrounded by foreign-body giant cells. Haematoxylin and eosin, 150. copyright. http://jcp.bmj.com/ on September 24, 2021 by guest. Protected FIG. 13(1251 53).-Chronic otitis and mastoiditis. Chronic inflammatory granulation tissue with cholesterol granuloma. Haematoxylin and eosin, >x 72. J Clin Pathol: first published as 10.1136/jcp.9.3.229 on 1 August 1956. Downloaded from THE PATHOLOGY OF OTITIS MEDIA 235 copyright. 4,9APP, FIG. 14 (865!53).-Chronic otitis and mastoiditis with cholesterol granuloma. Hatematoxylin and eosin, x 110. http://jcp.bmj.com/ change in recent years, and that the success of Bone Formation and Bone Reconstruction the antibiotic treatment of the disease might have been due in some degree to changes of the patho- Evidence has been presented in this paper first logy of otitis media. of all of conspicuous new bone formation in acute The histopathology of human otitis media and and chronic mastoiditis. This was found in almost mastoiditis has been studied in detail by, among every instance of acute mastoiditis. Equally, in on September 24, 2021 by guest. Protected others, Stewart (1928), who gave a detailed descrip- bone-chips obtained from mastoidectomy opera- tion of the clinical, bacteriological, and histologi- tions for chronic otitis new bone formation and cal conditions found in 50 cases of acute mastoid- signs of bone reconstruction occurred regularly. itis. Stewart's material consisted of bone-chips of An interesting feature of the bone-fragments in diseased tissue removed by the Schwartze opera- chronic otitis was the bizarre irregularity of the tion. At about the same time Lange (1928) ex- cement Lnes which produced a mosaic-like pattern amined about 100 temporal bones showing various resembling that found in Paget's disease. This is stages of the disease. Both authors agree in their evidence of bone reconstruction developing in the description of the pathological changes in the course of infection and leading to osteosclerosis. mastoid cell. This pattern is sufficiently characteristic to assist From the present investigations it can be stated in the differentiation of sclerotic bone from healthy that my observations do not differ fundamentally compact bone; ceteris paribus in the differentia- from those of Stewart and Lange. Nevertheless, tion of a sclerotic mastoid process rendered acellu- some of my principal findings merit discussion as lar through infection from a congenital compact their significance has not been fully appreciated or ivory mastoid process with intact Haversian (Watkyn-Thomas, 1953). systems in the latter. J Clin Pathol: first published as 10.1136/jcp.9.3.229 on 1 August 1956. Downloaded from 236 1. FRIEDMANN In the present studies, the controversial prob- ture. There were cholesterol deposits surrounded lem of pneumatization of the human mastoid pro- by foreign-body giant-cells in the granulation cess has only been touched upon. Experimental tissue filling the middle ear. At operation these evidence (Opheim, 1944; Friedmann, 1955a and b), structures, here called "cholesterol-granuloma " and the bone changes in acute and chronic may often be mistaken for aural cholesteatoma.
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