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Introduction:
Chronic suppurative otitis media (CSOM) is considered one of the most common causes of
acquired hearing impairment in developing countries. CSOM is a multifactorial persistent
inflammatory disease of the middle ear. A distinct pathophysiologic mechanism linking
allergic rhinitis (AR) and CSOM remains to evolve. The purpose of this study was to
investigate the association between AR and CSOM in adults.This was a case-control study.
Results:
The prevalence of clinical rhinitis (allergic and non-allergic) was significantly higher among the
cases compared with controls (62.5% vs. 37.5%, P=0.02). The prevalence of AR (proven by
positive skin-prick test) was also significantly higher among affected adults than controls (24.6%
and 13.8%, respectively). Adjusting for age, a logistic regression model showed that there was a
significant difference between the two groups. Patients with AR and non-AR were at 3.27- (95%
CI=1.15–9.29; P=0.036) and 2.57-(95% CI=1.01–6.57; P=0.048) fold increased risk of developing
CSOM, respectively, compared with healthy individuals.
Conclusion:
The study showed a higher prevalence of AR in CSOM patients than in controls. It may be
valuable to evaluate and control this factor in these patients.
Keywords:
Allergic, Hypersensitivity, Otorhinolaryngologic diseases, Otitis Media, Rhinitis, Suppurative,
Skin test.
1
Sinonasal Diseases Research Centre, Amiralmomenin Hospital, Guilan University of Medical Sciences, Rasht, Iran.
2
Department of Immunology, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran.
3
Department of Epidemiology, School of Public Health, Shahid Beheshti University of medical Sciences, Tehran, Iran.
4
Department of Otolaryngology, Amiralmomenin Hospital, Guilan University of Medical Sciences, Rasht, Iran.
*
Corresponding Author:
Sinonasal Diseases Research Centre, Amiralmomenin Hospital, Guilan University of Medical Sciences, Rasht, Iran.
Tel: +98-9113379430, E-mail: sz.azimi@yahoo.com
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Nemati S, et al
auditory canal or middle ear and/or than 0.05 was defined as significant. Odds
perforated tympanic membrane on otoscopy. ratio and 95% confidence intervals were also
AR was defined as the presence of signs calculated.
and symptoms of clinical rhinitis, including
watery anterior rhinorrhea, nasal obstruction Results
or congestion, nasal pruritus, and sneezing, A total of 61 cases (22 male and 39 female)
especially paroxysmal (according to with a mean age of 37.1±14.3 years (range
standard questionnaire (19)). Post-nasal drip, 15–70 years) and 58 controls (27 male and
pallor and swelling of the nasal and turbinate 31 female) with mean age of 28.3±11.7
mucosa not due to a recent common cold years (range 15–70 years) completed the
could improve the clinical diagnosis. study. There was a statistically significant
Patients with two or more of the mentioned difference between the groups in terms of
suggestive symptoms for more than 1 hour age (P=0.047). Among the 61 cases with
on most days were clinically diagnosed as CSOM, 26 (42.6%) patients had right ear, 25
having AR (19). Clinical rhinitis was then (41%) had left ear, and 10 (16.4%) had
confirmed by a positive skin-prick test bilateral involvement. The female–to-male
(SPT). The diagnosis of AR was performed ratio was 1.7:1, but the difference was not
by a separate ENT specialist who was blind statistically significant. Thirty-seven
to the otologic situation of the patients. (60.7%) patients had a history of CSOM
All subjects underwent a SPT for 23 from childhood (<18 years); others
common allergens (AllergoPharma developed the disease in adulthood. The
Products, Reinbeck, Germany) relevant in exact time of presenting CSOM symptoms
the north of Iran by a single immunologist, for those who developed CSOM from
who was blind to both the otologic and childhood was unavailable.
rhinologic situation of participants. The proportion of patients with clinical
Allergens included six types of grass, four rhinitis (allergic and non-allergic) was
weeds, nine trees, two mites, cat allergen significantly higher in the cases compared
and Cladosporium. with the control group (62.5% vs. 37.5%,
The positive control was histamine P=0.02). The prevalence of AR (i.e. clinical
hydrochloride (10 mg/mL) and the negative rhinitis with positive SPT) was 24.6%
control was diluent (AllergoPharma). The (n=15) and 13.8% (n=8) among cases and
mean wheal size was evaluated after 15 controls, respectively. However AR was
minutes, and SPT was determined as more prevalent among patients with CSOM
positive when observing a wheal with a compared with controls, although the
mean diameter at least 3 mm larger than difference was not statistically significant
wheals at the site of the negative control. All (P=0.065) (Table.1).
subjects who were pregnant or had a history Using a logistic regression model, after
of recent consumption of antihistamines, correcting for the age factor, the difference
immunotherapy with a specific allergen, or between the two groups became significant.
dermographism were excluded from the Patients with AR and non-AR had a 3.27-
study. A positive SPT result could confirm (95% CI=1.15-9.29; P=0.036) and 2.57-
the robust clinical diagnosis of AR, and (95% CI=1.01-6.57; P=0.048) fold increased
negative results were considered as non-AR. risk of developing CSOM, respectively,
All data were analyzed using SPSS version compared with healthy individuals.Patients
16. The χ2 and Fisher exact tests were used with a history of childhood CSOM were
to test the significance of the differences more likely to have AR than the control
between the two groups. A p-value less group (29.7% vs.13.8%, P=0.038).
Table 1: Distribution of findings on clinical examination and SPT 1 in cases and controls
CSOM2 Control P-value
N=61 N=58
Among all participants with AR, 52.2% especially mites (dermatophagoides farina
(n=12) had a posterior nasal drip, 34.8% and dermatophagoides pteronyssinus) were
(n=8) had lower turbinate hypertrophy, and the most prevalent allergens in both groups,
60.7% (n=14) had pallor and swelling of the while outdoor allergens such as grass pollen
turbinate mucosa. Indoor allergens, and weeds were less prevalent (Table. 2).
Table 2: Comparison of the frequency of the sensitivity to common allergens among case and control group.
AR. In Lasisi’s study, serum total the best of our knowledge this is the first
immunoglobulin E (IgE) concentrations study in this region that categorized patients
were regarded as allergic assessment tests with CSOM into two groups according to
(18), while recent investigations show that the time of onset of disease. In our study,
because of low sensitivity and specificity, AR was more common in those who
serum total IgE level is not a reliable developed CSOM from childhood. In
parameter for screening atopic diseases addition, most of the previous studies
(25). Bakhshaee et al. reported a 29.41% evaluating the relationship of AR and
prevalence of AR among adults with chronic otitis media had studied children. In
CSOM, which was higher than the contrast, our study, like the one conducted
reported prevalence in our study; however by Mion (17), studied adults. We could find
they used serum total IgE level as an no association between positive SPT per se
assessment tool for allergy diagnosis. In and CSOM (Table 1), although we reported
this study, the diagnostic criteria for AR an association between AR and CSOM in
consisted of a positive SPT to at least one our study. These findings are consistent with
allergen and/or a high level of serum total the results of a study by Caffarelli and
IgE, as well as a positive clinical colleagues (27) who demonstrated that only
examination and a history for rhinitis. the presence of AR and not a positive SPT
Total IgE levels higher than 100 IU/ml demands evaluation for otitis media with
were considered as a complementary test effusion. In our study, the prevalence of
in cases with an established history of positive SPT in CSOM was also similar to
AR (24). the mentioned study (26.2% and 26.74%,
Fliss and colleagues collected data during respectively). Furthermore, in the present
the children’s visit to the clinic by means study, indoor allergens were more prevalent
of a structured interview with the parents in the CSOM cases. This high prevalence
using an appropriate questionnaire and by may be due to the humid climate in the north
extracting from the records if necessary part of Iran, as shown previously (28).
(23). Gorgulu et al. measured total and
allergen-specific IgE levels, as well as Conclusion
blood eosinophil counts. Endoscopic AR is more frequent in CSOM patients,
evaluations of the rhinopharynx were and may be a risk factor for CSOM.
performed as well. In addition, a positive Avoidance of recognized allergens may
reaction to at least one of the 20 regional reduce this risk and improve the outcome
aero-allergens was accepted alongside of surgical therapy. Further studies in this
allergen-specific IgE tests or total IgE regard are warranted.
level >300 IU/ml or a positive rate of
blood eosinophil count (5). Hong and Acknowledgements
colleagues performed allergy tests which The authors are grateful to Dr. Esmaeel
included total IgE and multiple Asgari for his scientific support in
radioallergosorbent chemiluminescence performing this study. Our thanks also go to
assays to check for the presence of IgE- Sinonasal Research center of
mediated hypersensitivity (22). Amiralmomenin hospital and the Research
CSOM could be a complication of acute Office of GUMS for their support.
otitis media or otitis media with effusion,
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