Allergy Is It A Risk Factor For Secretory Otitis Media - Research Paper Example

Introduction Every year, in developing countries and advanced ones alike parents have to watch their children carefully so that any ailments can be taken care of by appropriate medical health authorities; even with the best medical help available it is the rare parent who would declare that he or she likes going to the hospital. It is disheartening for parents, in particular, when their children suffer from something that might have easily been prevented. For example, parents who know that cigarette smoking would affect their child badly are likely to take precautions so that the child in question does not have to go through any unnecessary suffering due to ill health. In addition to asthma which is one of the more common ailments children suffer in large numbers, there is secretory otitis media, which is also called otitis media with effusion or OME, which, according to Dahl (1998) affects 46% of all children, with at least three serious ear infections by the time they are three years of age (Dahl 1998). According to Ryding (2005), between 57% and 91% of preschool children experience secretory otitis media. As they get older, however, the prevalence of secretory otitis media decreases. Doctors and researchers who have had the opportunity to study this condition, which results in a effusion in the middle ear without any symptoms of infection (Sade et al. 2003), wonder whether it is a single etiologic entity or whether it can be caused by many different factors. This paper examines the question of whether allergy, in particular, is a risk factor for secretory otitis media. If it is, it stands to reason that ensuring that children’s allergies are not triggered could also help them avoid the discomfort of possibly being affected by secretory otitis media. Literature review/Discussion Among the significant risk factors that have been identified as contributing to otitis media include children’s exposure to childcare or parental smoking (Juntti et al. 1999), along with heredity, male gender, and atopy (Ryding 2005). Some researchers believe that atopy, which according to the MerriamWebster dictionary, is “probably [a] hereditary allergy characterized by symptoms (as asthma, hay fever, or hives) produced upon exposure especially by inhalation to the exciting environmental antigen,” may affect the immune system or block the Eustachian tube. Juntti et al. wonder if “Chronic inflammation of the nasopharynx and obstruction of the Eustachian tube may result in inability to equilibrate pressure in the middle ear cavity, a build-up of negative pressure and, finally, effusion” (Juntti et al. 1999). While some researchers still do not accept the link between allergies and otitis media, there are an increasing number of researches that point in that direction. The acute form of otitis media could be accompanied by fluid in the middle ear behind the tympanic membrane or no. It usually happens after there has been some kind of respiratory infection and symptoms include earache, fever, possible hearing loss or irritability (Dahl 1998). While antibiotics have traditionally been used to treat otitis media because of its association with infection, some researchers are beginning to take a closer look at the element of allergy and to see how control of allergies might hamper the onset of otitis media. In this regard, Juntti et al., in 1999, set out to find out whether children with cow’s milk allergy are at a greater risk for ear problems, that is, recurrent acute otitis media and secretory otitis media. This study, which was conducted in Finland, where patients with milk allergies are registered nationally in order to take advantage of a Finnish government program that provides allowance for patients who cannot eat basic food and have to go on special diet. From a cohort of 108 children, 56 children, comprising 21 girls between the ages of 9 and 11 were enrolled in the study. All of these children had avoided taking in milk products prior to turning two because of allergic reactions to the product. A control group of 204 completed the research questionnaire and 90 participated in blood eosinophil count and serum IgE determination. The researchers also made use of medical records along with the questionnaire to ascertain subject’s history of atopic manifestations such as allergic rhinitis, asthma, and atopic dermatitis. Parents were involved to ensure as much accuracy as possible. The researchers did not press the parents for accurate timelines or dates of secretory otitis episodes but distinguished between recurrent otitis media and secretory otitis media. “We thought that using a criterion of 15 episodes in 10 years, would specify those children who would definitely have suffered from ROM” (Juntti et al. 1999). To ensure accuracy various methods were used to diagnose cow’s milk allergy, including skin test or milk-RAST, a positive elimination test done in a hospital, or two elimination-challenge tests done in the patient’s home. Doctors also had to verify cases of asthma. Taking the group as a whole, 34 children were found to have been diagnosed for asthma though only 10 were continuing to take medicine for the condition. Of the cohort, 73 were diagnosed for allergic rhinitis while 79 had atopic dermatitis. In addition, 45, or 22% of those in the control group had some form of respiratory atopy. It was found that “The CMA children with respiratory atopy showed a significant risk for both ROM and tympanostomy/adenoidectomy, but not for secretory otitis media. In contrast, among the children without respiratory atopy, CMA of infancy was not a risk factor for any ear problems” (Juntti et al. 1999). Juntti et al. found it difficult to make a clear link because the ear infections sometimes came before the respiratory symptoms. Juntti et al. seem to have done as rigorous a piece of research as possible, having made sure to confirm the diagnoses of the children. Even so, the researchers admit that the ages of the children, at ten, may have made it difficult for the parents to properly recall accurately all the information that was necessary to make a proper determination. In summary, Juntti et al. (1999) found that, There was a trend for an increasing incidence of both ROM and secretory otitis media I the tests with food allergens were positive, but the children with positive SPT with inhaled allergens had no more ear problems than those with negative tests. The finding suggests that a child needs to have clinical allergy with manifest respiratory symptoms and not mere atopy as defined with a positive SPT to pose a risk for ROM…as the development of secretory otitis media showed a close relationship to clinical atopic manifestations (including atopic dermatitis), the result suggests that immunological factors are also significant in its development. (Juntti et al. 1999) Evidence gathered by Dahl (1998) regarding the problem of otitis media and its treatment revealed that the control of food allergies is one of the most important elements for dealing with recurrent serous or secretory otitis media. In one study examined by Dahl, “104 children with recurrent ear infections were evaluated for food allergies by skin prick testing, IgE tests and food challenge. Eighty one children were found to have food allergies, most typically to milk and wheat. When the offending foods were removed from their diet for 16 weeks the ear problems improved significantly and returned in the majority of children when the foods were reintroduced” (Dahl 1998). Another study conducted in Sweden appears to give strong support to the link between allergies and secretory otitis media. As cited by Dahl (1998), Swedish patients with secretory otitis media, 97% were found to have allergies following tests done by radioallergosorbent (RAST), along with IgE levels and skin tests. As Dahl writes, “Nasal allergic inflammation has been shown to play a role in otitis media with effusion so the possibility of allergic sensitization must always be considered in patients with serous otitis media” (Dahl 1998). Among the common allergenic foods that have been found to pose a problem for some children are dairy products and wheat. Among the most challenging for some children are cow’s milk, ice cream, and cheese. Of course, food allergy is not the only problem one has to watch out for. For some children, there are other allergies such as hay fever, eczema, or chronic nasal congestion to contend with. The use of the Elisa test, which provides a count of IgE and IgG4 antibody levels, can be useful in pinpointing allergies. It appears that the issue of allergy is also linked to the strength of the immune system. This is important because other foods such as sugar and even fruit juices, which in excess, can compromise the immune system, could also open up a child to problems related to otitis media. It has also been determined that children who are deficient in zinc “suffer from more otitis media than children with normal zinc status. When trace mineral status was measured in 28 children ten months to ten years of age who were susceptible to otitis media, their levels of zinc were significantly lower than the 13 healthy controls. Zinc deficiency has been associated with many aspects of immune function such as decreased natural killer cell activity and decreased phagocytosis” (Dahl 1998). This also highlights the issue that it is a mistake to finger only one source with respect to the etiology of otitis media. Though for some children the incidence and course of otitis media might be only a matter of days, weeks, or months, in some cases, secretory otitis media may persist for years. Ryding et al. therefore did a long-term study in order to try to understand the long term outcome of secretory otitis media. In this research, they also looked at some of the risk factors associated with the condition. When secretory otitis media persists for six years or more it is referred to as refractory, When lead researcher, Ryding. Found out that some of the young patients in his care had had a long bout of secretory otitis media he took an interest in studying such patients. Records showed that there were 56 that fulfilled the criteria. The ages ranged from 16 to 36 years for the 22 women in the study and the range was from 15 to 34 for the 30 men in the study. There were a few dropouts either because a sibling was participating or the subject simply did not want to participate. The research was questionnaire based and delved into the medical history of the patients. Hospital records were used to confirm the reports of the patients. The range of experience of secretory otitis media ranged from 6 to 26 years with a mean of 12 years. For some of the patients, not surprisingly, the condition had started when they were around 2 years. In some cases, the onset was much earlier. In the Ryding group, it was found that 10 out of the 52 subjects had had allergic manifestations such as asthma either as children or later on in life. In this case, it is clear that while some of the patients have allergies, it is not necessarily a predominant element link. As suggested by Ryding there are other factors that appear to play a stronger role, in particular, when it comes to the kind of acute form of otitis media known as refractory. Though the Ryding study does not make an attempt to gauge the extent to which allergies might factor into the onset and development of otitis media Bachert et al (1989), attempted to do just that when they examined 27 children that had adenoids and secretory otitis media. As Bachert et al. write, We documented the patients’ history of allergy and determined the IgE-levels in the serum, the middle ear effusions and the adenoid tissue. [Five] out of 27 children suffered from an allergy of the upper respiratory tract, but only in one child we found an elevated level of IgE in middle ear effusion. On the basis of our investigations and recent literature, we suggest that an allergic rhinitis might cause an Eustachian tube dysfunction in a few patients. (Bachert et al. 1989) While some researchers make a clear link between allergy, including food allergies to otitis media, JM Berstein, has noted both in the researcher’s own laboratory and in other studies that as many as two thirds of patients that have chronic recurrent otitis media do not have any allergies. The other third, however, according to Bernstein may have allergic rhinitis “and this allergic rhinitis could play a direct role in producing Eustachian tube dysfunction in recurrent otitis media” (Bernstein 1988). Bernstein does not discount the element of food allergies, however, in particular among the very young otitis affected child whose case is chronic. The theme of how allergy might play a role in otitis media is taken up in much greater detail by Alles et al. (2001) in the article “The prevalence of atopic disorders in children with chronic otitis media with effusion.” For the sake of clarification Alles et al., note that the label “chronic” is attached to otitis media when the middle ear has been inflamed for more than three months, in particular, when the fluid is retained for that long. The seriousness of this problem is evident when one considers that otitis media does in some cases lead to loss of hearing. As noted earlier, one factor alone may not account for the incidence of otitis media. This view is shared by Alles et al. (2001) who note that the etiology of otitis media is “probably multifactorial” (Alles 2001). Keeping in mind that the link between allergies and otitis media had persisted for a while, Alles et al. conducted their own research to either confirm or disconfirm that notion. Over a period of two years, children in the Glue Ear Clinic which focused on otitis media were recruited into the study. Some of the participants in the study were also referred by General Practitioners and by specialists in the Ear, Nose and Throat department of the hospital in question. Because the subjects were between 3 and 8 years old their parents were asked to fill a questionnaire that asked for detailed information on complaints that the child had made, problems with hearing, symptoms that may have been caused by allergies, surgery, medication, and the family’s history with asthma. The children were themselves examined and their weights and heights taken. In addition, skin sensitivity tests were taken and eight common aeroallergens were tested for, including feathers, tree pollen, grass pollen, and house dust mite. Furthermore, through a nasal smear, eosinophil counts were estimated. Following that, blood tests were done to determine eosinophil counts and immunoglobulin E(IgE) counts. Pure tone audiometry and impedance audiometry were used to find out the children’s middle ear compliance while pressure was estimated through the use of a GSI screening tympanometer. In terms of the diagnostic criteria, it emerged that allergic rhinitis was present, in some cases, these were clearly allergic in nature. Asthma was also diagnosed among some of the participants by means of some of the more common diagnostic methods such as persistent cough that could be triggered by laugher or exertion. Eczema, characterized by dry scaly and itchy skin was also common among some of the children. In total, two hundred and nine children were enrolled into the study. The average age of the children was 5.37 years, with a standard deviation of 1.63. In terms of distribution between male and female the ratio was 1.3:1; this difference, however, was not statistically significant. Of these children, 189, or 89.5% had already received one treatment or another for otitis media. As many as 36% or seventy-five had had the benefit of surgical interventions and forty had high blood levels of eosinophil. In 94% of the cases, there were symptoms of rhinitis, with symptoms of allergy showing up in as many as 89% of the children. Seventy-six patients were also known to have a history of asthma while eczema was found in 24% of the children. Eighty-three percent of the children had a family history of atopy with 50% having maternal allergies while 32% of paternal allergies were recorded. In 31% of cases, siblings had allergies. One hundred and nineteen of the patients tested positive in a pin-prick test. Among the more common allergens to which the children registered positive were feathers, 45%; cat, 40%; and pollen (35%). As many as 52.2% of the children had middle ear effusion and for a minority of patients (4.1%), it was not possible to see the tympanic membrane. The use of flat tympanogram showed that 106 children had middle ear effusion. Of the 209 children examined, who were between the ages of 3 and 8, the prevalence of atopic disease was quite high. When compared to the general population of children, the prevalence of atopic disease among this group was considerably high. Even though the children are a highly selected group, “The results…do raise the intriguing possibility that the development of chronic OME and atopy are closely linked, an association that warrants further study” (Alles et al 2001). But how does allergic rhinitis play a part in the so-called glue ear? According to Alles et al. allergic rhinitis usually affects the middle ear through the dysfunction of the Eustachian tube. While the Eustachian tube is normally closed, when one yawns or swallows, it opens to equalize the middle ear pressure to that of its surroundings. “If opening is reduced, the air from the middle ear space is absorbed and a negative middle ear pressure results. This could occur in allergic rhinitis owing to swelling of the Eustachian tube lining, which is similar and in continuity with that of the nose and nasopharynx” (Alles et al. 2001). Those who suffer from allergic rhinitis develop a serious negative middle ear pressure if there is a nasal allergen challenge. During the hay fever season, there is a great increase of such negative pressure. When this happens, there is no development of middle ear effusion. This suggests that the negative pressure on the middle ear by itself is not enough to cause otitis media. “However, in patients with uncontrolled perennial allergic rhinitis, ongoing inflammation will chronically affect the tube. This reduces opening, and the resulting compromised mucociliary function could delay clearance of an acute infective middle ear effusion contributing to the chronicity of OME” (Alles et al. 2001). Also, allergic rhinitis may make the subjects susceptible to tract infections. For example, the intracellular adhesion molecule 1 (ICAM-1), has been “found to be a receptor for rhinoviruses, which cause 30% of childhood upper respiratory tract infections. Secondary bacterial infection is common following viral colds, and in the presence of negative middle ear pressure and nasopharyngeal colonization with infective organisms, Eustachian tube opening may lead to a siphoning effect into the middle ear, precipitating an acute otitis media and a subsequent effusion” (Alles et al. 2001). For children under age three infective rhinitis is believed to be the “commonest predisposing cause of OME” (Alles et al. 2001). With children between 3 and 8, as was the case with those in the Alles et al. sample, there were other confounding diagnoses, including asthma, eczema, and conjunctivitis. Alles et al. make a very important statement when they advice doctors to make sure that they take a full medical history and in particular to ensure that they are apprised of the patient’s history as it relates to rhinitis. “The importance of making the diagnosis is that the possibility exists that by treating the allergic rhinitis the chronic OME will resolve” (Alles et al. 2001). Conclusion Taking all the research together, it would be difficult to dismiss allergy completely as playing a part in secretory otitis media. Researchers are trying to understand clearly how allergy plays a role but it seems that there are enough studies pointing to some kind of link that it would be folly for doctors to discount this element. At the same time, it is important for doctors and researchers to acknowledge that secretory otitis media does not seem to have a single etiology, meaning that there may be a number of factors that can either trigger or aggravate the subject’s condition as far as the possibility of getting full blown secretory otitis media is concerned. Even though there is still a little bit of uncertainty surrounding the link between allergy and secretory otitis media, there is enough correlation that it would be foolish for any doctor or researcher not to take a good hard look at allergies when it comes to treating a patient or when it comes to learning more about this condition – secretory otitis media. Bibliography Alles, R. et al. 2001, ‘The prevalence of atopic disorders in children with chronic otitis media with effusion’, Pediatric Allergy and Immunology, 12, pp 102-106. Bachert, C et al. Apr 1989, ‘Middle ear effusion and allergy in childhood.’ Laryngorhinootologie, 4, p. 201-203. Bernstein, J.M. May 1998, ‘Recent advances in immunologic reactivity in otitis media with effusion.’ Journal of Allergy and Clinical Immunology, 81.5, p1004-1009. Dahl, I. L. 1998. ‘Naturopathic Treatment of Acute and Chronic Otitis Media,’ Journal of Naturopathic Medicine, 2, p35-40. Juntti, H et al. 1999, Cow’s Milk Allergy is Associated with Recurrent Otitis Media During Childhood,’ Acta Otoloaryngol (Stockh), 119, P 867-873. Nguyen, LH et al., Dec. 2004. ‘Evidence of allergic inflammation in the middle ear and nasopharynx in atopic children with otitis media with effusion. Journal of Otolaryngoly. 2004 33.6, p345-51. Ryding, M.; White, P.; Kalm, Olof. Feb 2005, ‘Course and long-term outcome of ‘refractory’ secretory otitis media.’ 119.2, p 113-118. Sade, J. et al. Apr 2003, ‘Is Secretory otitis media a single disease entity?’ The Annals of Otology, Rhonology & Laryngology, 112.4, p342. Read More