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Adenoiditis and Otitis Media with Effusion: Recent Physio-Pathological and Terapeutic Acquisition

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Adenoiditis and Otitis Media with Effusion: Recent Physio-Pathological and Terapeutic Acquisition Acta Medica Mediterranea, 2011, 27: 129 ADENOIDITIS AND OTITIS MEDIA WITH EFFUSION: RECENT PHYSIO-PATHOLOGICAL AND TERAPEUTIC ACQUISITION SALVATORE FERLITO, SEBASTIANO NANÈ, CATERINA GRILLO, MARISA MAUGERI, SALVATORE COCUZZA, CALOGERO GRILLO Università degli Studi di Catania - Dipartimento di Specialità Medico-Chirurgiche - Clinica Otorinolaringoiatrica (Direttore: Prof. A. Serra) [Adenoidite e otite media effusiva: recenti acquisizioni fisio-patologiche e terapeutiche] SUMMARY RIASSUNTO Otitis media with effusion (OME) deserves special atten- L’otite media effusiva (OME) merita particolare atten- tion because of its diffusion, the anatomical and functional zione per la diffusione, le alterazioni anatomo-funzionali e le abnormalities and the complications which may result. complicanze cui può dare luogo. The literature has been widely supported for a long time In letteratura è stato ampiamente sostenuto da tempo il the role of hypertrophy and/or adenoid inflammation in the ruolo della ipertrofia e/o delle flogosi adenoidee nell’insorgen- development of OME. za di OME. Although several clinical studies have established the Anche se diversi lavori clinici hanno constatato l’effica- effectiveness of adenoidectomy in the treatment of OME, there cia dell’adenoidectomia nel trattamento dell’OME, le opinioni are discordant opinions about. sono discordi. The fundamental hypothesis that motivates this study is L’ipotesi fondamentale che motiva questo studio è che that the OME in children is demonstration of subacute or l’OME in età pediatrica è una manifestazione di flogosi suba- chronic inflammation of the upper airway that has its epicenter cuta o cronica delle vie aeree superiori che ha il suo epicentro in the rhinopharynx. nel rinofaringe. Per tali ragioni abbiamo effettuato una revi- Because of these reasons we effectuated a critical review sione critica delle problematiche collegate alle flogosi adenoi- of issues related to the adenoid inflammation in the pathogene- dee nella patogenesi dell’OME e all’indicazione dell’interven- sis of the OME and the indication of adenoidectomy surgery in to di adenoidectomia nell’intento di tracciare un quadro il più order to define the relationship between OME and adenoiditis. completo possibile della relazione tra adenoidite e OME. Key words: Otitis media with effusion, adenoiditis, therapy Parole chiave: Otite media secretiva, adenoidite, terapia Otitis media with effusion (OME) authors(3); the persistence of secretion in the tym- panic chest after AOM is almost considered normal OME, middle ear disease with many denomi- and is attributed mainly to the presence of nations, is a subacute or chronic inflammation by immunecomplexes(4). multifactorial etiology, characterized by the pres- Inflammation of the middle ear and tubal dys- ence of serous, mucous, or mixed, non-infected functionare the most important etiopathogenic fac- secretion, persistent for more than three months in tors: were identified a number of established risk fac- the middle ear(1). tors (infection of upper airway-UA, adenoid hyper- The incidence is higher in children (ratio chil- trophy, seasonality, inadequate antibiotic therapy, dren / adults = 10/1), particularly pre-school (61%) genetic and racial factors) and risk factors acces- than school age (22%), occurs mainly in winter and sories (familiarity allergic, mild immunodeficiency, spring coinciding with infectious and/or allergic sex, geographical and environmental factors). inflammation of Upper Airway and Digestive Tract The role of upper airway inflammation in the (U.A.D.T.)(2). onset of middle ear inflammation is documented in The incidence of OME after acute otitis media the most recent data highlight the importance of (AOM) is high, with a percentage between 6-10% bacterial and viral infection, allergy, immune- for some authors or even 42%-60% for others inflammation and tubal dysfunction. 130 S. Ferlito - S. Nanè et Al The bacterial infection is brought to the atten- An assumption that the adenoids correlated tion by the finding, in patients with SOM, of a pre- with middle ear disease in patients with OME vious acute episode of bacterial or viral infections requires that the adenoids tend to be larger (ade- of the UA (65-78%) and relief in endotympanic noidal hypertrophy) and so tend to close the secretion microcolture of infectious agents includ- Eustachian tube. ing Haemophilus influentiae, Staphylococcus In normal children the size and appearence of aureus and Streptococcus pneumoniae, and less fre- the adenoids varies from year to year. Particularly quently, Branhamella catarrhalis Enterococci, the adenoids are rapidly increased from three to anaerobes absent(5). five years of age, with a consequent increase in Viral infections, which etiological diagnosis is mouth breathing, and thereafter remain relatively not easy for the presence of inhibitory substances constant, while the size of the nasopharynx and air- and antibodies in the endotympanic secretion, will way gradually enlarge. be borne mainly by Respiratory Syncytial Virus, Some authors assert that there is no correlation Influentia Virus A and B, Parainfluentia Viruses 1- between adenoid volume and frequency of OME, in 2-3, Adenovirus, Rhinovirus , Herpes simplex, particular, there was no difference in weight of ade- Coxsachie B4(6). noids among a group of patients with OME and a The role of allergy, considered relevant in normal(11). 10%, has been emphasized by some authors 48%- Recent study show the role of inflammation in 74% and reduced by others. the onset of OME, highlight the importance of the In the tympanic mucosa was documented the role of bacterial infection and immunological possibility of allergic-iperergic reaction, even if changes. there is a discrepancy of data: finding in the endo- The nasopharynx of many newborns are colo- tympanic versement of the amount of IgE higher nized by potential respiratory pathogens: than those found in serum according to some Streptococcus pneumoniae and Haemophilus authors(7) and lower for other authors(8). influenzae. These bacteria were considered to be OME caused by adenoids does not differ much implicated in the pathogenesis of the OME(12). from the usual clinical appearance of OME: it Bacteriological studies on adenoids of children should however be noted that this complication of predisposed and not predisposed to inflammation of the adenoids has a more frequent incidence in the the middle ear suggests that there may be an impor- seasons most favorable to the onset of events tant relationship between the normal flora, which is inflammatory nasopharyngeal a greater predilection represented mainly by Streptococcus viridans, and toward pediatric age, a common connection with potential pathogens that frequently coexist in the nasal symptom, which sometimes precedes the adenoid tissue(13). onset. In particular, they showed that the S. Viridans Diagnosis of OME caused by adenoiditis must (alpha-hemolytic Streptococcus) is predominant in consider both ear images, both nasopharyngeal the microbial flora of the nasopharynx in normal among which are particularly important nasopha- subjects, whereas in susceptible otitis percentage of ryngeal endoscopy and allergy investigations. S. Viridans decreases and, simultaneously, increase Otoscopy shows the usual clinical appearence: the percentage of S. Pneumoniae and Haemophilus the effusion can be either serous, mucous or influentiae untyped and Moraxella catarrhalis. mixed(1,9). Endoscopy allows us to observe the condi- The mechanisms responsible for this alteration tions of the nasal cavity and nasopharynx mucosa, of the bacterial microenvironment of the nasophar- particularly tubal region(10); endoscopic study here ynx may be related in part to factors that alter the shows swollen mucosa, translucent appearance, with muco-ciliary function. Factors that may be associat- features of allergic and bacterial inflammation. ed with increased colonization in the nasopharynx and perhaps the increase of adhesion to the mucosa Adenoiditis of the nasopharynx, are viral infections, allergy, local and systemic immune deficiency and indis- Adenoiditis, acute and chronic inflammatory criminate use of antibiotics(13). processes of the adenoids usually affecting child From these studies results a positive response under 10-12 years old, have among the most com- with regard to the influence of adenoids on etio- mon complications otitis media with effusion. phatogenesis of OME. Adenoiditis and otitis media with effusion: recent physio-pathological and terapeutic acquisition .. 131 Knowledge of immunological reactions of the and inflammatory processes in the nasopharyngeal adenoids of patients with OME are limited to a few district; the insertion of a ventilation tube and studies(14). antrum-attic-mastoidectomy when the otological A study to identify differences in immune disease remains unchanged despite various treat- responses of adenoids in children with OME ments. showed a significantly higher number of PCA-1 positive cells (presumably plasma-cells) compared Therapeutic protocol of the Institute of with a normal control group, while no differences Otolaryngology, University of Catania were found concerning the distribution of T and B cells. The therapeutic approach of OME of our Some authors support the hypothesis that the school is to carry out at least two cycles of medical OME was associated with an immune response that treatment before to consider any other types of influences the production of Immunoglobulin in the
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