Congenital cholesteatomas in the tympanic membrane

The etiology of congenital middle ear (ME) cholesteatomas is unclear. One etiologic possibility of ME cholesteatoma may be progression of a congenital tympanic membrane (TM) cholesteatoma. We recently have encountered three cases of congenital tympanic membrane cholesteatoma. Each child, ages 1, 3, and 14 years, presented with cholesteatoma of the tympanic membrane extending into the middle ear. These children have not had previous otologic surgery including myringotomy, nor had they had repeated middle ear infections, perforation, or trauma. Neither the 3-year-old nor 14-year-old child complained of hearing loss. Audiograms demonstrated only a mild conductive loss. Each child underwent excision with tympanoplasty. Although the middle ear component of the cholesteatoma was always more extensive than the pearl seen, the point of attachment was the TM and not the middle ear. This demonstrates one possible source for congenital cholesteatomas.     

Inhibition of parietal cell acid secretion is mediated by the classical epidermal growth factor receptor

Epidermal growth factor (EGF) and transforming growth factor-alpha (TGF-alpha) inhibit gastric acid secretion both in vivo and in vitro. Previous studies have indicated that EGF and TGF-alpha bind to the same EGF/TGF-alpha receptor. Nevertheless, we and others have previously demonstrated that inhibition of acid secretion by these growth factors requires concentrations of the peptides that are 10-fold higher than those necessary for induction of mitogenesis. Therefore, we have sought to investigate whether gastric parietal cells may possess a second EGF/TGF-alpha receptor class. Two systems were studied: First, [125I]TGF-alpha was cross-linked to the receptor in isolated rabbit parietal cell membranes, and labeled species were resolved on SDS-PAGE. Second, acid secretion was evaluated in pylorus-ligated waved-2 mutant mice, which carry a disabling point mutation in their classical EGF/TGF-alpha receptor. In isolated parietal cells, [125I]TGF-alpha was cross-linked into a single species of 170 kDa. Cross-linking was inhibited in the presence of unlabeled TGF-alpha with an IC50 of 80 nM. In the pylorus-ligated mice, control littermate mice demonstrated a dose-dependent inhibition of acid secretion by EGF with an IC50 of 20 micrograms/kg. In contrast, EGF had no inhibitory effect on acid secretion in waved-2 mice at concentrations up to 100 micrograms/kg. No alterations in parietal cell or gastrin cell numbers were observed. These results in both isolated rabbit parietal cells and waved-2 mice support the existence of only a single class of EGF/TGF-alpha receptors in parietal cells. Differences in growth factor affinity are likely due to the modification of the receptor or one of its coordinate regulators.     

Interleukin 1 (IL-1) and IL-1-receptor antagonist (IL-1-RA) in middle ear cholesteatoma: an analysis of protein production and biological activity

Cytokine networks are now presumed to play an essential role in the pathogenesis of middle ear cholesteatoma. Of the factors identified in cholesteatoma, interleukin-I (IL-1)-alpha appears to be especially important because of its stimulation of keratinocyte proliferation as well induction of bone resorption. To further characterize the possible role of IL-1 in the pathogenesis of cholesteatoma, we quantified the levels of IL-1 and IL-1-receptor antagonist (IL-1-RA) present using the bicinchonic acid protein assay and enzyme-linked immunosorbent assay (ELISA) on tissue extracts from 20 cholesteatoma specimens. The presence of biologically active IL-1 was also analyzed, using the cell line LBRM-33 and an ELISA for the detection of interleukin-2 (IL-2). Human skin obtained from the external ear canal was used as control. The amounts of IL-1-alpha in cholesteatoma (34.9 +/- 19.5) were higher than in human skin (6.7 +/- 2.8). The observed differences were statistically significant by Student's t-test (P < 0.01). Skin samples showed elevated concentrations of IL-1-RA (248.3 +/- 30.2) in comparison to that in the cholesteatoma (80.8 +/- 13.5). This was also statistically significant (P < 0.01). Whereas IL-1 activity was not detected in skin samples, all cholesteatoma specimens studied showed a stimulation effect on the production of IL-2 when incubated with the cell line LBRM-33. The results point to an over-expression of IL-1 concurrent with a decreased secretion of IL-1-RA in middle ear cholesteatoma. Furthermore IL-1-RA production is deficient relative to total IL-1 production, resulting in the presence of active IL-1.     

Benign intracerebellar cyst without epithelial lining

Platelet-derived growth factor (PDGF) was localized in human middle ear cholesteatoma tissue by an immunoperoxidase technique using rabbit anti-human PDGF IgG. PDGF was found mainly in basal cells and in granulation tissue, and especially involved monocytes and fibroblast-like cells. The external ear canal epithelium was not significantly stained by anti-human PDGF. Findings demonstrate that the presence of PDGF in cholesteatoma is in response to inflammation and wound healing in the middle ear. PDGF in vitro was found to stimulate protein synthesis and cellular terminal differentiation of basal keratinocytes. PDGF also stimulated monocytes to form multinucleated osteoclast-like cells. These multinucleated cells, in turn, induced the resorption of devitalized bovine bone. This bone resorption was seen in co-cultures of osteoblasts and multinucleated osteoclast-like cells in the presence of PDGF, suggesting that cell-to-cell interaction plays a role in bone resorption. The present study suggests that PDGF takes part in the clinical development and the destructive effect of cholesteatoma.     

Echocardiographic spectrum of supracardiac total anomalous pulmonary venous connection

We report an unusual case of a 13-year-old girl with a benign osteoma associated with a cholesteatoma in the external auditory canal and serous otitis media. The osteoma was located in the antero-inferior wall of the right external auditory canal. A cholesteatoma was present between the osteoma and the tympanic membrane. Computed tomography revealed a soft tissue density within the external auditory canal and in the middle ear cleft. The shadow in the middle ear cleft was considered to represent the serous otitis media. Surgical removal of the osteoma and cholesteatoma proved successful, and no recurrences or complications have occurred in the first year postoperatively.     

Infraclavicular brachial plexus block effects on respiratory function and extent of the block

Epidermal growth factor (EGF) and transforming growth factor-alpha (TGF-alpha) promote the differentiation and proliferation of epithelia as well as the proliferation and chemotaxis of fibroblasts. Additionally, EGF promotes wound healing in tissues composed largely of epithelial cells and fibroblasts. We hypothesized that EGF and TGF-alpha regulate the differentiation and proliferation of the epithelial lining and the migration and proliferation of fibroblasts in the subepithelial space of the middle ear mucosa in children with otitis media. As an initial test of this hypothesis, EGF and TGF-alpha concentrations were measured in 82 middle ear effusions of children undergoing tympanostomy tube placement. EGF was present in 45% of these effusions, and TGF-alpha was present in 6%. The mean concentration +/- SEM values for EGF and TGF-alpha were 19+/-7.6 and 3.7+/-7.9 pg/mL, respectively. In addition, neutrophils, macrophages, and lymphocytes in middle ear effusions stained for EGF by immunocytochemistry. We conclude that growth factors are frequently present in middle ear effusions of children with otitis media.     

Influence of the concentration of ions and foramen diameter on the accuracy of electronic root canal length measurement--an experimental study

The controversy regarding the best procedure for treating middle ear cholesteatoma has lasted over 100 years. This paper discusses our current methods for dealing with cholesteatoma, always through external ear or transmeatal mastoidectomy. We present the results of three years of follow-up. MATERIAL AND METHODS: A prospective study was made of 215 ears operated for cholesteatoma using a transcanal approach with one of three techniques: "on demand" DAA mastoidectomy, modified radical mastoidectomy, and radical mastoidectomy with obliteration. Three parameters were used to evaluate results: stability of the mastoid cavity, integrity of the neotympanum, and evolution of hearing. RESULTS: The rate of cholesteatoma recurrence in ears operated with these techniques was much lower than that found in canal-wall-up techniques. Only 3 of the 215 cases (1.4%) remained unstable due to different causes three years after surgery. DISCUSSION AND CONCLUSIONS: Due to the high rate of cholesteatoma recurrence, canal-wall-up mastoidectomy has been abandoned in our clinic. Open techniques using a transmeatal approach, with or without obliteration, and the so-called "on demand" mastoidectomy, have yielded more stable results, although postoperative care is more critical.     

Indications for middle ear obliteration within the scope of cochlear implant management

BACKGROUND: Cochlear implants have gained worldwide acceptance as a reliable method of rehabilitation of profoundly hearing-impaired patients. Due to thorough patient selection major postoperative complications rarely occur and are flap related in most cases. Deafness can develop during chronic suppurative otitis media, either coincidentally or secondary to the medical treatment; normally this condition is regarded as a contraindication for cochlear implantation. In cases with a mastoid cavity after surgical treatment for cholesteatoma, the electrode covered only by the epithelial lining will likely become exposed or extruded. Therefore we suggest the obliteration of the middle ear cleft with abdominal fat and the blindsac closure of the external ear canal before cochlear implantation in these conditions. PATIENTS: The average age of our 12 patients was 48 years, whereas the youngest was 2 1/2 years of age. Due to chronic inflammatory ear disease. 11 patients had a mastoid cavity on both ears. Eight patients had a cholesteatoma, the chronic bone destroying process in the temporal bone of two female patients was considered as a fibroinflammatory pseudotumor. The child had a congenital deafness in both ears with a Mondini dysplasia in CT scan. She had already developed two episodes of pneumococcal meningitis which was caused by a defect in the stapes footplate through which a liquor-filled cystic sac herniated in the middle ear. Because of a massive liquorrhoea after opening of the sac, we decided to obliterate the middle ear cleft after successful insertion of the electrode array. RESULTS: All active electrodes of 10 Nucleus implants (Cochlear) and two Clarion devices (Advanced Bionics Corp.) were successfully inserted in the cochlea of the 12 patients. After an average follow-up of 15 months, a temporary facial palsy in one patient and an insufficient closure of a retroauricular fistula over the mastoid cavity in two cases were observed as postoperative complications. One patient with a fibroinflammatory pseudotumor developed a massive inflammatory reaction in the implanted ear two months after cochlear implantation, which could not be controlled by conservative treatment. The implant had to be removed and local conditions settled after administration of immunosuppressive treatment with cyclophosphamide. The patient received a new implant seven months ago. CONCLUSIONS: Implantation of a foreign body in a potentially infected space which communicates intracranially means a surgical challenge which can be managed by obliteration of the middle ear after subtotal petrosectomy with abdominal wall fat combined with a reliable closure of the external ear canal. In case of massive inflammation we would prefer a two-stage procedure.     

Methodical aspects of pneumatic segment plethysmography. III. Measuring tourniquet problems

A retrospective study was made of 200 chronic otitis media patients. Simple chronic otitis media was observed in 76 per cent of cases; the rest were associated with cholesteatoma. In about one third of the patients, the contralateral ear showed some inflammatory middle ear disease as well. The average time lapse between initial symptoms and hospitalization was about 10 years. The events leading to the tympanic perforation were difficult to ascertain, but included probably acute otitis media, possibly external otitis, trauma, and a rather large group (35-40 per cent) of insidious 'essential perforations'. The aetiology of the 'essential perforations' is so far not known, but might be non-inflammatory in nature but related to insufficient middle ear aeration and hypo-pneumatization as well as to what is termed atelectatic ears. The bacteria isolated from chronic otitis media ears (usually gram negative bacteria and staphylococcus aureus) are usually not the types of micro-organisms found in association with any primary or acute otitis media. It is proposed that the bacterial infection encountered in what is termed 'chronic otitis media' is often a secondary infection of a primary perforated tympanic membrane, the perforation originating or persisting in underventilated ears, and having arisen from various causes--some of them as yet unknown.     

Keratinocyte differentiation in acquired cholesteatoma and perforated tympanic membranes

OBJECTIVE: To evaluate the type of differentiation of keratinocytes of acquired cholesteatoma and its significance for cholesteatoma invasiveness. DESIGN: Forty acquired cholesteatomas and 10 tympanic membranes with persisting perforations were snap frozen and processed for immunohistochemical studies. Cytokeratin antibodies that represented all subgroups and antibodies that were directed against collagen components of the basal lamina were applied. Expression of these constituents was scored by using light microscopy. RESULTS: The phenotype of the matrix was generally characterized by an extension of expression of basal cell cytokeratin 14 and hyperproliferation-associated cytokeratins 6, 16, and 17 into the suprabasal cell layers, while the expression of keratinization marker cytokeratin 10 was down-regulated. These features varied greatly at different sites of the matrix and were most marked at the advancing front of the cholesteatoma. A comparable expression pattern, but less pronounced, was observed at the epidermal front of the mucocutaneous junction of the tympanic membrane perforations. This phenomenon was invariably associated with a mononuclear cell infiltrate in the dermis at both junctions. The basal lamina was always intact. CONCLUSIONS: Acquired cholesteatomas show hyperproliferative features. There is a striking similarity between the pronounced expression of this phenotype and the associated inflammation at the mucocutaneous junctions of cholesteatomas and tympanic membrane perforations and those that are observed after epidermal injury. This indicates that epidermis and middle ear epithelium do not form stable junctions and the front can be considered to be a persisting epidermal defect. This involves the permanent presence of "activated keratinocytes" in the junction area that will lead to proliferation and migration, when additional triggers are present.     

Middle ear lipoma

We report a case of primary middle ear lipoma diagnosed in the right ear of a five-year-old child with concurrent bilateral middle ear effusions. The lipoma occupied a site favoured by congenital cholesteatoma and was occlusive to the eustachian tube contributing to its dysfunction. This is the first case of de novo middle ear lipoma diagnosed in the UK, and the third in world literature. Our CT scans are suggestive of a similar but smaller lesion in the left ear of the same child.     

Interaction between bile salts and beta-adrenoceptor antagonists

Chronic suppurative otitis media (CSOM) in profoundly deaf patients is a contraindication for cochlear implantation. Eight (6%) of the 126 patients referred to cochlear implantation at this center between 1986 and 1992 became deafened as a result of bilateral CSOM but were otherwise suitable candidates. This study details the methods used in four patients to prepare the septic ear for a sterile device. Two patients had wet radical cavities with residual cholesteatoma, and two had discharging safe perforations resistant to surgical repair. Obliteration of the middle ear cleft with blind pit closure of the ear canal was attempted in all four patients, and cochlear implants were installed at a second operation 3 to 6 months later. The hearing results were as good as in implanted patients without CSOM, and the only complication has been the finding of a cholesteatoma pearl at the second operation in one patient. Fat obliteration of the mastoid and middle ear with blind pit closure of the ear canal can be adapted to make most chronic ears fit for implantation, if the patient is prepared to undergo two operations.     

In vitro production of parathyroid hormone-related protein by cholesteatoma and normal skin

Severe inflammation and infection of the middle ear occasionally results in clinical evidence of bone resorption but with the addition of the cholesteatoma epithelium it becomes inevitable. This study examined production by the cholesteatoma epithelium of a bone resorbing factor, namely parathyroid hormone-related protein (PTH-rP), which would not be expected in inflammatory states alone. PTH-rP was detected in the conditioned medium of primary and secondary cell cultures derived from 12 cholesteatoma biopsies. The levels of PTH-rP were significantly greater than in control cultures of cells derived from normal scalp tissue. Production by the cholesteatoma epithelium may explain the increased incidence of bone resorption in this disease, particularly in cases where inflammation is minimal.     

Immunohistochemical localization of epidermal growth factor receptors, epidermal-growth-factor-like and transforming-growth-factor-alpha-like peptides in chicken ovarian follicles

The purpose of this study was to determine the presence of epidermal growth factor receptor and its potential ligands epidermal growth factor (EGF) and transforming growth factor alpha (TGF-alpha) in the tissues of the maturing follicles in the ovary of laying ISA-Brown hens using peptide-specific immunohistochemical methods. Cryostat sections, 6-8 microns thick, were made from fresh-frozen tissues of F1-F4 (largest to fourth largest) and large white follicles and they were immunostained for epidermal growth factor receptor, epidermal growth factor or transforming growth factor alpha using specific polyclonal antibodies. The EGF receptor and both ligands were detected in the granulosa, theca interna and theca externa layers of the follicles. The EGF receptor was localized both in the plasma membrane and cytoplasm of all cell types. EGF was predominantly cytosolic, whereas TGF-alpha was found in the plasma membranes and perinuclear areas of all cell types. The concentration of the receptor and both ligands decreased with follicular maturation. This observation is consistent with our previous observation that the response to EGF and TGF-alpha decreases as follicles mature, and thus provides further evidence that the receptor or the ligands may have a regulatory role in avian ovarian function.     

Autonomous growth in serum-free medium and production of hepatocellular carcinomas by differentiated hepatocyte lines that overexpress transforming growth factor alpha 1

Transforming growth factor alpha (TGF-alpha) is a polypeptide closely associated with hepatocyte proliferation in vivo and in vitro. In order to investigate the mechanisms by which TGF-alpha contributes to hepatocyte replication and transformation, we isolated hepatocytes from mice bearing a human TGF-alpha transgene and examined their growth properties and gene expression in defined, serum-free culture. The transgenic hepatocytes continued to overexpress human TGF-alpha mRNA and peptide, and were able to proliferate without exogenous growth factors in primary culture, in contrast to nontransgenic mouse hepatocytes. In short-term culture the transgenic hepatocytes underwent 1 wave of DNA replication at 72-96 h in culture before senescing, similar to nontransgenic hepatocytes supplemented with epidermal growth factor. Constitutive expression of TGF-alpha rendered the transgenic hepatocytes unresponsive to further growth stimulation by exogenous TGF-alpha, as well as other mitogens such as epidermal growth factor and hepatocyte growth factor. However, it did not alter their sensitivity to growth inhibition by TGF beta 1, 2 and 3. The addition of nicotinamide to the culture medium enabled both transgenic and epidermal growth factor-supplemented normal hepatocytes to replicate repeatedly and survive for > or = 2 months in primary culture while maintaining differentiated traits. From these long-term primary cultures of transgenic and nontransgenic hepatocytes, we established immortalized cell lines (designated TAMH and NMH lines, respectively). Both lines continued to express differentiated adult hepatocytic markers such as albumin, alpha-1-antitrypsin, transferrin, and connexin 26 and 32 mRNAs, but also expressed mRNAs for the oncofetal markers alpha-fetoprotein and insulin-like growth factor II. Unlike the near-diploid NMH hepatocyte line, the transgenic TAMH hepatocyte line was quasi-tetraploid, strongly expressed human TGF-alpha mRNA, and was highly tumorigenic in nude mice. Well-differentiated hepatocellular carcinomas developed in nude mice given injections of the TAMH line, and these appeared similar to the primary liver tumors seen in TGF-alpha transgenic mice with regard to histology and strong expression of mouse and human TGF-alpha, insulin-like growth factor II, and alpha-fetoprotein mRNAs. Our data show that TGF-alpha overexpression causes autonomous hepatocyte proliferation and contributes to neoplasia but that additional cellular alterations must occur for carcinogenesis. Inappropriate expression of insulin-like growth factor II may constitute one of these steps. The TGF-alpha transgenic mouse hepatocyte line TAMH appears to undergo transformation in a similar manner to that of hepatocytes overexpressing TGF-alpha in vivo, and should serve as an ideal system in which to study hepatocarcinogenesis.     

Lateralized changes in tympanic membrane temperature in relation to different cognitive tasks in chimpanzees (Pan troglodytes).

Lateralized changes in tympanic membrane (TM) temperature were assessed in chimpanzees. Subjects were engaged in 1 of 3 different cognitive tasks, including matching-to-sample, visual-spatial discrimination, and a motor task. During execution of each task, TM temperatures were taken from each ear over a 20-min time period. The TM temperatures at each time interval were subtracted from a baseline measure to assess relative change in blood flow. For the matching-to-sample and visual-spatial discrimination tasks, significant lateralized changes in TM temperature were found, with left-ear temperature increasing and right-ear temperature decreasing. No laterality effects were found for the motor or control tasks. These data provide the first evidence of laterality in physiological functioning in chimpanzees and suggest that transient asymmetries in cognitive functions are associated with changes in cerebral blood flow as assessed by TM temperature change. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interleukin-17 and interferon-gamma synergize in the enhancement of proinflammatory cytokine production by human keratinocytes

OBJECTIVES: To investigate the correlation of epidermal growth factor receptor (EGFR) expression and its ligands EGF and transforming growth factor-alpha (TGF-alpha) with disease outcome in a cohort of patients with superficial bladder cancer. METHODS: Tumor samples of 21 patients with transitional cell carcinoma of the bladder were analyzed by immunohistochemistry for expression of EGFR, EGF, and TGF-alpha. Disease-related events were recorded during a routine clinical follow-up and analyzed for possible correlation with the expression status of the above-mentioned proteins. RESULTS: All Stage pT1 transitional cell carcinomas expressed EGFR, and 10 of 21 (48%) tumors showed focal areas of strong EGF and/or TGF-alpha expression. Of these, 80% with EGF positivity (8 of 10) had recurrences, whereas only 9% of patients without EGF staining (1 of 11) did so. The same pattern was observed with TGF-alpha. A strong association was confirmed between EGF/TGF-alpha positivity and tumor recurrence (P <0.005). We also found that EGF and TGF-alpha were expressed in stroma and/or around the vessels of tumor tissue in 48% and 38% of the tumors, respectively. No association was found between the recurrence rate/vascular invasion and the stromal/vascular wall expression of the growth factors. CONCLUSIONS: Expression of EGF and TGF-alpha is correlated with tumor recurrence. Also, there is the ability of vessel walls to express EGF and TGF-alpha in superficial bladder cancer. Further clarification of the impact of this expression on angioinvasion of tumor cells may be helpful in understanding the nature of local invasion and metastasis.     

Analysis of the ability of 12-O-tetradecanoylphorbol-13-acetate to induce epidermal hyperplasia, transforming growth factor-alpha, and skin tumor promotion in wa-1 mice

Wa-1 mutant mice possess a defect in the production of transforming growth factor-alpha (TGF-alpha) that leads to a phenotype characterized by wavy hair and curly whiskers. In light of recent evidence indicating the importance of TGF-alpha in epithelial tumorigenesis, this study characterizes the responsiveness of wa-1 mice to skin tumor promotion by the phorbol ester, 12-O-tetradecanoylphorbol-13-acetate (TPA). The responsiveness of wa-1 mice to TPA was compared with that of SENCAR and C57BL/6 mice, representing mouse lines highly sensitive and resistant to skin tumor promotion, respectively. Wa-1 mice were found to be very resistant to skin tumor promotion by TPA after initiation with 10 nmol DMBA, similar to C57BL/6 mice. TPA failed to induce a dramatic increase in TGF-alpha mRNA and protein in the skin of wa-1 mice, whereas TGF-alpha mRNA and protein were dramatically induced in the skin (both epidermis and dermis) of SENCAR and C57BL/6 mice. TPA treatment dramatically increased mRNA levels of two other EGF receptor ligands, amphiregulin and heparin binding-EGF, however, in the skin of all three mouse lines. Comparison of histologic changes in skin revealed that wa-1 mice exhibited only modest sustained epidermal hyperplasia after multiple treatments with TPA, similar in magnitude to that of C57BL/6 mice and significantly lower than that of SENCAR mice. The current data indicate that wa-1 mice are relatively resistant to TPA promotion. Possible mechanisms for this resistance are discussed.     

Predictive factors of residual cholesteatoma in children

The decision on the appropriate surgical technique for treating cholesteatoma in children raises a number of controversial questions, most because of personal convictions rather than because of established data. We attempted to determine which patients are at risk of residual cholesteatoma in order to propose the most rational therapeutic strategy. A retrospective study of 250 children with cholesteatoma or severe retraction underwent surgery between 1986 and 1992. During this period 69 cases of residual cholesteatoma were recorded during a second intervention. After a mean follow-up of 33 months after the final operation, the Kaplan-Meier plot shows a rate of 31% and 34% at 3 and 5 years respectively. The univariate and multivariate (Cox regression) analysis was performed to search for a correlation between residual cholesteatoma development and past history including type of process involved, peroperative findings and surgical technique. Three factors were closely and independently related (p < 0.003) to residual cholesteatoma: invasion of the posterior middle ear, presence of ossicular erosion after excision and presumption of incomplete ablation. Inversely, age, surgical history, extension and nature of the process involved as well as surgical technique had no effect on development of residual cholesteatoma. Only one comparable study has been published where only ossicular erosion was found to be significant on multivariate analysis. The presence of one or more of the three of the factors mentioned above should lead to a second intervention, perhaps after a short delay, whatever the initial technique (open or closed).