Title Page Biocultural Analysis of Otitis Media and its Relationship to Traditional Skeletal Stress Markers in the Assessment of Structural Violence by Allison P. Gremba B.S. Biology, Duquesne University, 2007 M.S. Forensic Science and Law, Duquesne University, 2008 Submitted to the Graduate Faculty of The Dietrich School of Arts and Sciences in partial fulfillment of the requirements for the degree of Doctor of Philosophy University of Pittsburgh 2020 Committee Membership Page UNIVERSITY OF PITTSBURGH DIETRICH SCHOOL OF ARTS AND SCIENCES This dissertation was presented by Allison P. Gremba It was defended on December 10, 2019 and approved by Dr. J. Douglas Swarts, Associate Professor, Department of Otolaryngology Dr. Mark Mooney, Professor, Department of Anthropology Dr. Michael Siegel, Professor, Department of Anthropology Thesis Advisor: Dr. Margaret Judd, Associate Professor, Department of Anthropology ii Copyright © by Allison P. Gremba 2020 iii Abstract Title Page Biocultural Analysis of Otitis Media and its Relationship to Traditional Skeletal Stress Markers in the Assessment of Structural Violence Allison P. Gremba, PhD University of Pittsburgh, 2020 This dissertation explored the relationship between traditional skeletal stress markers and mastoid air cell system (MACS) hypopneumatization, as a measure of otitis media (OM), using the proposed biocultural skeletal stress marker pathway to examine structural violence. Low socioeconomic status and marginalization are known risk factors of OM resulting from immunosuppression and increased pathogen exposure. Structural violence, which is the unequal distribution of resources in a society, is expected to create stressful conditions resulting in an increase in OM prevalence among the marginalized segment of the society. Structural violence was examined using skulls from the Hamann-Todd Human Osteological Collection (n=20) and Robert J. Terry Anatomical Skeletal Collection (n=105). The Tigara, Point Hope Skeletal Collection (n=69) was a control group that did not experience structural violence and was expected to have a low prevalence of OM. The skeletal stress markers included in this dissertation were limited to the cranium and included porotic hyperostosis, cribra orbitalia, sinusitis, antemortem tooth loss, periapical granulomatous lesions, periodontal disease and dental enamel hypoplasia. Correlations between MACS hypopneumatization, measured skeletal stress markers and skeletal collections were made using the Chi-square test of independence, Student’s t-test and analysis of variance (p<0.05). The results suggest that MACS hypopneumatization is a skeletal stress marker capable of delineating differences in marginalization and structural violence. MACS hypopneumatization iv was lower than expected in the Terry collection and co-occurred with porotic hyperostosis, which is a measure of anemia. Clinical data suggests that anemia exacerbates OM resulting in more frequent OM episodes. The results suggest that structural violence created conditions, such as anemia, in the marginalized group which increased OM prevalence. However, it is also likely that some individuals experienced OM complications of hearing loss and language delays which were perceived as learning disabilities and were carried into adulthood resulting in lower socioeconomic status and incorporation into the skeletal collections examined. The relationship between OM and anemia should continue to be tested within other populations, using additional theoretical models and incorporating postcranial skeletal stress markers using the proposed biocultural skeletal stress marker pathway. v Table of Contents Preface ......................................................................................................................................... xvi 1.0 Introduction ............................................................................................................................. 1 1.1 Statement of the Research Question ............................................................................. 3 1.2 Impact .............................................................................................................................. 4 1.3 Chapter Contents ............................................................................................................ 5 2.0 Otitis Media ............................................................................................................................. 7 3.0 Biocultural Framework ........................................................................................................ 20 3.1 Biocultural Stress Model .............................................................................................. 24 3.1.1 Biocultural Skeletal Stress Marker Pathway ................................................. 26 3.2 Structural Violence ....................................................................................................... 28 3.3 Application of Structural Violence to the Biocultural Skeletal Stress Marker Pathway ............................................................................................................................... 30 3.4 Evolution and Adaptation to Chronic Cold ............................................................... 39 3.5 Application of Evolution and Adaptation to Chronic Cold to the Biocultural Skeletal Stress Marker Pathway ...................................................................................................... 41 4.0 Skeletal Stress Markers ........................................................................................................ 47 4.1 Porotic Hyperostosis ..................................................................................................... 47 4.2 Cribra Orbitalia ............................................................................................................ 50 4.3 Sinusitis .......................................................................................................................... 50 4.4 Dental Enamel Hypoplasia .......................................................................................... 52 4.5 Periodontal Disease ...................................................................................................... 55 vi 4.6 Antemortem Tooth Loss .............................................................................................. 58 4.7 Granulomatous Periapical Lesion ............................................................................... 58 5.0 Materials and Methods ......................................................................................................... 61 5.1 Anatomical Collections ................................................................................................ 61 5.1.1 Hamann-Todd Human Osteological Collection ............................................. 61 5.1.2 Robert J. Terry Anatomical Skeletal Collection ............................................ 62 5.1.3 Tigara, Point Hope Skeletal Collection ........................................................... 63 5.2 Pathologies ..................................................................................................................... 63 5.2.1 Dietary Deficiencies ........................................................................................... 64 5.2.1.1 Porotic Hyperostosis and Cribra Orbitalia ...................................... 64 5.2.2 Infectious Diseases ............................................................................................. 66 5.2.2.1 Sinusitis ................................................................................................ 66 5.2.2.2 Otitis Media ......................................................................................... 67 5.2.3 Dental Pathology ............................................................................................... 70 5.2.3.1 Antemortem Tooth Loss ..................................................................... 70 5.2.3.2 Granulomatous Periapical Lesion ..................................................... 72 5.2.3.3 Periodontal Disease ............................................................................. 73 5.2.3.4 Dental Enamel Hypoplasia ................................................................. 74 5.3 Statistical Analyses ....................................................................................................... 75 5.3.1 Demographic Analysis ...................................................................................... 75 5.3.2 Analysis by Pathology ....................................................................................... 76 5.3.3 Analysis of OM as a Skeletal Stress Marker .................................................. 76 6.0 Results .................................................................................................................................... 77 vii 6.1 Demographics ............................................................................................................... 77 6.2 Dietary Deficiencies ...................................................................................................... 80 6.2.1 Porotic Hyperostosis ......................................................................................... 80 6.2.2 Cribra Orbitalia ................................................................................................ 84 6.3 Infectious Diseases .......................................................................................................