www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Is
there
any
association
between
Helicobacter
pylori
and
otitis
media
with
effusion?
夽
Mohammad
Ali
Damghani,
Elham
Dehghan
∗KermanUniversity,FacultyofMedicine,DepartmentofOtolaryngology,Kerman,Iran Received17April2018;accepted10November2018
Availableonline19December2018
KEYWORDS
Otitismediawith effusion;
Helicobacterpylori;
Polymerasechain reaction
Abstract
Introduction:ItisproposedthatHelicobacterpyloricanberesponsibleforthedevelopment ofotitismediawitheffusion.
Objective: TheaimofthisstudyistoinvestigatetheprevalenceofH.pyloriintheadenoid tissueandfluidofthemiddleearinpatientswhosufferfromadenoidhyperplasiaandotitis mediawith effusionincomparisonwiththosewho sufferfrom adenoidhyperplasia without otitismediawitheffusion.
Methods:This isacase---control study thatwascarried outin50 children ofage2---7years oldwhowereadmittedwithadenoidhyperplasia.Patientsweredividedintocaseandcontrol groups.Thestudygroupincluded25patientswithadenoidhyperplasiaandotitismediawith effusionandthe controlgroup included25patients withadenoid hyperplasiawithoutotitis mediawitheffusion.Thepatientsinbothgroupsunderwentsurgicaladenoidectomy.Forthe casegroupwecarriedoutmyringotomyandplacementoftympanostomytube,andfluidsamples werecollectedundersterileconditions.Thesamplesweresenttothelaboratoryforpolymerase chainreactions.
Results:InthecasegroupH.pyloriwasfoundtobepositivein18samplesofthemiddleear fluid(70%)andin1polymerasechainreactionadenoidtissuesample(4%).Inthecontrolgroup
H.pyloriwaspositivein3samplesofadenoidtissues(12%).Therewasnogenderdifference.
Conclusion: H.pyloriisoneoftheimportantbacteriathatplaysaroleinthepathogenesisof otitismediawitheffusion.WhetheradenoidtissuemaybeareservoirforH.Pyloriisunclear. © 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
夽 Pleasecitethisarticleas:DamghaniMA,DehghanE.IsthereanyassociationbetweenHelicobacterpyloriandotitismediawitheffusion?
BrazJOtorhinolaryngol.2020;86:217---21.
∗Correspondingauthor.
E-mail:dehghanelham90@yahoo.com(E.Dehghan).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.
https://doi.org/10.1016/j.bjorl.2018.11.002
1808-8694/©2018Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE
Otitemédiacom efusão;
Helicobacterpylori;
Reac¸ãoemcadeiada polimerase
Háassociac¸ãoentreHelicobacterpylorieotitemédiacomefusão? Resumo
Introduc¸ão:Propõe-sequeoHelicobacterpylori possaserresponsávelpelodesenvolvimento deotitemédiacomefusão.
Objetivo:Investigar aprevalênciadeH.pylorinotecidoadenoideanoenofluidodaorelha médiaempacientescomhiperplasiadeadenoideeotitemédiacomefusãoemcomparac¸ão àquelescomhiperplasiadeadenoidesemotitemédiacomefusão.
Método: Esteéumestudodecaso-controlefeitoem50crianc¸asde2a7anosdeidade,com sinaisesintomasdehiperplasiadeadenoide.Ospacientesforamdivididosemgrupodeestudo egrupocontrole.Ogrupodeestudoincluiu25pacientescomhiperplasiadeadenoideeotite médiacomefusãoeogrupocontroleincluiu25pacientescomhiperplasia deadenoidesem otitemédiacomefusão.Ospacientesdosdoisgruposforamsubmetidosaadenoidectomiae, nogrupodeestudo,realizou-setambémmiringotomiacomcolocac¸ãodetubodeventilac¸ãoe amostrasdefluidosforamcoletadassobcondic¸õesestéreis.Asamostrasforamenviadaspara olaboratório,parainvestigac¸ãoporreac¸ãodepolimeraseemcadeia.
Resultados: Nogrupodeestudo,houvepositividadeparaH.pyloriem18amostrasdofluidode orelhamédia(70%)eumaamostradetecidoadenoideanofoipositivanareac¸ãodepolimerase emcadeia(4%).Nogrupocontrole,houvepositividadeparaH.pyloriem3amostrasdetecido adenoideano(12%).Nãohouvediferenc¸aentreosgêneros.
Conclusão:H.pyloriéumadasbactériasimportantesquedesempenhamumpapelna patogê-nese da otite médica com efusão. Se o tecido adenoideano pode ou não representar um reservatórioparaH.pyloriaindanecessitaseresclarecido.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http://
creativecommons.org/licenses/by/4.0/).
Introduction
Otitismedia witheffusion (OME)is defined asmiddle ear effusion without signs and symptoms of acute inflamma-tion found in acute otitis media.1 The pathophysiology
ofthe disease is multifactorial,includingallergy, autoim-munity, gastroesophageal reflux disease, bacteria, viral and eustachian tube dysfunction. From ears with chronic OME,Haemophilusinfluenzaewasthesinglemostcommon pathogen,andothercommonbacteriaincluded Streptococ-cus pneumonia and Moraxella catarrhalis. Other bacteria accountfor a small percentage of cases.2 Recent studies
haveinvestigatedthepossibilityofarelationshipbetween OMEandthepresenceofHelicobacterpylori(H.pylori)in themiddleear.3Bytheageof10yearsapproximately75%
ofchildrenareinfected withH.pylori.Manybodyregions otherthanthegastrointestinaltracthavebeeninvestigated forthepresenceofthismicroorganism.Inrecentyears,H. pylorihasbeen foundinadenoidtissue,nasalpolyptissue andthemiddle ear.4 H.pylori hasalso been showntobe
presentinhighratiosinnasalpolyps,laryngealsamples,and vocal cordlesions usingreal-time polymerase chain reac-tion (PCR) method.5,6 One potential cause of OME is the
refluxofgastriccontentsintotheregionofthe nasopharyn-gealmucosa,whichinitiatesaninflammatoryprocess.7This
pathophysiological mechanism has been frequently ques-tionedin recent study.8,9 Animal studies have shown that
refluxleadstoeustachiantubedysfunction.Theeustachian tubeisimmatureanditsangleiswiderinchildren.Therefore gastriccontentscanmoreeasilyreachthemiddleearand
induceaninflammatoryprocess.10Fewstudieshave
investi-gatedtherelationshipbetweenOME,pepsinogenlevelsand
H.pylori presenceseparately.11 Severalmethodsareused
forthedetectionofH.pylori. Ithasbeenshown thatPCR method has almost 100% sensitivity andspecificity in the detection,identificationandquantitationofH.pyloriin bio-logicalsamples.12Theaimofthisstudyistoinvestigatethe
presenceofH.pyloriinadenoidtissueofpatientswith ade-noidhyperplasiawithout OMEincomparisonwithpatients whohaveadenoidhyperplasiawithOME.
Methods
Ourstudyisacase---controlstudythatwasperformedon50 childrenbetween theages2and7yearsoldwithadenoid hyperplasia,withmedianageof4.5years,whowere admit-tedtotheENTdepartmentofShafahospital(Kerman,Iran) betweenOctober2013andMarch2015.Thepatientswere enrolledinthestudybynon-randomeasysamplingmethod. Inclusioncriteria were signs and symptoms of adenoid hyperplasiathatwereconfirmedbylateralneckradiography in theextension position.Thepatients have been divided intotwogroupsofcaseandcontrol,basedonthepresence orabsenceofsignsandsymptomsofOME.Afterhistory tak-ingandclinicalexaminationincludingotoscopy,diagnosisof OMEwasconfirmedaswellastympanometryfor confirma-tionofOME.ThepatientsinthecasegrouphadOMEbutthe patientsinthecontrolgroupdidnot.
Table1 Helicobacterpylori(H.pylori)positivityincaseandcontrolgroupsandcomparisonbetweengroups,bychi-square test.
Groups Control Case
Adenoid Adenoid Middleearfluid Numberofpatients 25
H.pyloripresence Present Absent Present Absent Present Absent DetectionrateofH.pylori 3(12%) 22(88%) 1(4%) 24(96%) 18(72%) 7(28%)
p-ValueofcomparingH.pyloriinadenoidtissuesofthecaseandcontrolgroupsis0.609.
p-ValueofcomparingH.pyloriinadenoidtissueandmiddleeareffusionofthecasegroupis0.000.
p-ValueofcomparingH.pyloriinadenoidtissueofthecontrolgroupandmiddleeareffusionofthecasegroupis0.001.
Exclusioncriteriaincludedpatientswhodidnotconsent to enter the study, a history of previous adenoidectomy, neurological disorders, genetic syndromes, craniofacial abnormalitiessuchasDownsyndrome,andothercausesof airwayobstructionsuchasdeviatedseptum,nasalpolyps, andturbinatehypertrophy.Inadditionpatientswithactive infectionwereexcluded.Wedescribedobjectivesand meth-odsof thestudytoparentsofthe patientsandtheywere askedquestionstoensurethattheyunderstoodthe proce-dure. Afterwards,theywereallowedtoask theirpossible questions. Later, written permissions were obtained from allparents.Thenallpatientsunderwentsurgical adenoidec-tomyunderthesameconditions,andadenoidsampleswere preparedwithcurette. Acore biopsyspecimenwastaken fromeach adenoidtissue; collectedsamples were placed immediatelyinPSBbuffer.Inaddition,forthecasegroup, samplesfromthemiddleeareffusionweretaken.Forthis purpose, outer ear canal was cleaned with 70% alcohol solution, then an incision wasmade at the anterior infe-riorquadrantoftheeardrum.Sampleswerecollectedfrom middle earfluid and wereplaced in the PSBtransmission medium. The effusion and adenoid tissue samples were transportedtomicrobiologylaboratory. Thesamples were frozen immediately after removal and stored at −20◦C; whenrequired,specimenswerethawed,andsupernatants ofcentrifugedspecimenswereassayed.TomeasuretheDNA ofH.pylori,genomicisolationkitwasused.
Measurement was performed by a spectrophotometer. ThustheexistenceoftheDNAofH.pyloriwasdetermined inthebandsof260---280nmbyabsorptionrate.Attheend, all patients’ information was entered the checklist. Data wasreportedbydescriptivestatisticsandanalysiswasdone bychi-squareandFisherexacttestsandSPSSsoftwarewas applied.
TheethicalcodeofthisarticleisIR.KMU.REC.1395.344.
Results
The number of patients who entered the study was 50
children whowere studied in twogroups of 25 cases and 25controls.24patients(48%)weremaleand26(52%)were female.Outof50patients, 18patients(70%), inthecase grouphadH.pyloriinthemiddleearfluid,3patients(12%) in the control group had H. pylori in adenoid tissue and 1patient(4%),inthecase grouphadH.pylori inadenoid tissue.Thus the frequency of H.pylori in the middle ear fluidinthecasegroupismorethanit’sfrequencyinadenoid
0 5 10 15 20 25 30 Ad e n oi d + Ad e n oi d -Ea r + Ea r -Case Control
Figure1 ThefrequencyofH.pyloriinadenoidsandmiddle eareffusionsofcaseandcontrolgroups.
tissuesofbothcaseandcontrolgroups(Table1andFig.1). Out of 26 girls, two patients (7.7%) (one patient in the case groupand one patientin the controlgroup), hadH. pyloriinadenoidtissue.Outof24boys,two(8.3%)inthe controlgrouphad H.pyloriin adenoidtissueandnone of theboysincasegrouphadbacteriainadenoidtissue.Eight girls(30.8%)inthecasegrouphadH.pyloriinthemiddle ear fluid samples and 10 boys (41.7%) in the case group hadH.pyloriinthemiddle earfluid.Resultsarereported inTable2.SoaccordingtoTable2wecansay thereis no significantgenderdifferenceinourcomparison(Fig.2).
Discussion
OMEisoneofthemostcommoncausesofhearinglossamong children in developed countries.OME is characterized by fluidaccumulationin themiddleearwithnoactive infec-tion;ifthediseasepersistsformorethanthreemonths,it iscalled chronic OME.In severalstudies, the relationship between H.pylori and the pathogenesisof variousupper aerodigestive tractproblems have been shown. H. pylori
forreproductionneedsamicroaerophilicenvironment.This environmentis presentinthemiddleearofOMEpatients. Themechanismofthecolonizationofthesebacteriainthe gastricmucosaisstillunclear.Itissaidthisbacteriagrows byimplantinginsidethemucosalepitheliumofthestomach, protectedbyimpermeablemucuslayertothegastricacid. The PH of theluminal side of themucus layer is 1.0---2.0 andthePHofthemucosalsideisapproximately7.4.ThePH ofthemiddleeareffusionsisalsobetween7.0---9.0.InH. pyloriinfectionsmucosalmetaplasiaandgobletcell hyper-plasiaoccurs,asimilarsituationinOME.7,13Inthisstudy,we
appliedPCRforthedetectionofH.pyloribyspecimen col-lectionfrommiddle ear.WecalculatedH.pylori positivity
Table2 TherelationshipbetweenHelicobacterpylori(H.pylori)andgenderamongcontrolandcasestudygroupsdoneby fisher’sexacttest.
Group Gender H.pyloripresenceinadenoid p-Value
Negative Positive Case Female 1(9.1%) 10(90.9%) 0.44 Male 0(0%) 14(100%) Control Female 1(6.7%) 14(93.3%) 0.54 Male 2(20%) 8(80%) Total Female 2(7.7%) 24(92.3%) 1 Male 2(8.3%) 22(91.7%)
ratenotonthebasisofthenumberofears,butthe num-berofpatientsbecausewewouldliketoknowtheexistence rateofH.pyloriin eachindividual.Wefound H.pyloriin 70%ofthemiddleeareffusionsispositive,andthisis rel-ativelyhigh incomparisonwithother studiessuchasChul Vonetal.14 (theprevalence of H.pylori was30%), sowe
suggestthatH.pyloricouldbeanimportantetiologic fac-torfor developmentof OME.Agirdir etal.15 reportedthat
H.pyloripositivitywas66.6%ineffusionof30patientswith OMEandtheadenoidofthepatientgroupandthecontrol groupshowednosignificantdifferenceintheprevalenceof
H.pylori.Yilmaseetal.10 reportedthatthePCRofmiddle
eareffusionwaspositiveforH.pyloriin45%ofthepatients withOME.InanotherstudybyYilmazetal.16eighteen
sub-jects with OME and adenoid hyperplasia and 20 subjects withonlyadenoidhyperplasiawerecompared.Theresults showedthat in thestudy group, H.pylori waspositive in 67%ofchildren.None ofthetissuesamplesobtainedfrom adenoids of study group and only one of the tissue sam-plesinthecontrolgroupwaspositivewithPCR.Thereare twopossible explanationsfor why H.pylori hasbeen dis-coveredintheeffusion ofthemiddleear.Thefirstisthat thetonsilandadenoidactasareservoirforH.pylori.Since thetonsil,adenoid,andEustachiantube areanatomically close,this can allow for H. pylori tospread directly.17,18
The second possibility is due to gastroesophageal reflux, sincethe gastric fluid can affect the middle ear through the Eustachian tube, and H. pylori that is mixedin with thegastric fluidcan then be detected in the middle ear. Thereis an association betweenchronic middle ear prob-lemsandgastroesophagealreflux.Higherconcentrationof pepsin/pepsinogeninthemiddleearthanserumofpatients withOMEhasbeenreportedbyTaskeretal.7
Ina studythat publishedin2008 byFancyetal.3 they
reported,incomparisonof45patientswithadenoid hyper-plasia and OME with 35 patients who just had adenoid hyperplasia,therewasnosignificantdifferenceinthe inci-denceofthisinfectionbetweenthetwogroups.
In another study by Saki et al.19 the prevalence of H.
pyloriinpatientswithOMEwasstudied.Eighty-fourpatients who were subjected to adenoidectomy and myringotomy wereincludedinthestudygroup.Ninety-onepatientswho hadonlyadenoidectomywereselectedasthecontrolgroup. AdenoidsampleswerepositiveforH.pyloriin25%patients inthestudygroupand19.8%patientsinthecontrolgroup. Inthestudygroup,42.8%effusionsamples(OtitisMedia)of
0 2 4 6 8 10 12 14 Ad e n o id + Ad e n o id -Ea r + Ea r -Female (Case) Male (Case Female (Control) Male (Control)
Figure 2 H.pylori frequency basedon genderin caseand controlgroups.
thepatientswerepositiveforH.pylori.Theyshowedthat the colonization of H.pylori in adenoid tissueand in the middleearmaybeinvolvedinthepathogenesisofOME.
Inthepresentstudy,we foundthatthepresence ofH. pylori in adenoid samples of study group was 4% and in controlgroupwas12%;thisfindingisnotsignificantin com-parisonofH.pyloripositivityofpatientswithOMEthatwas 70%indicating thatadenoidtissueisnotareservoir forH. pylori.Wehopefuturestudieswillbedoneonthe relation-shipbetweenOMEandH.pyloriintheworldpopulation.
Conclusion
OurstudyshowedthatthereissignificantH.pyloripresence inmiddleearofthechildrenwithchronicOME,indicatingH. pylorihaveapossibleroleinOMEpathogenesis.Inaddition we detected H.pylori presence in 4of 50 adenoid speci-mens,supportingtheideathatadenoidtissuedoesnotact asareservoirforH.pylori.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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