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Allergic rhinitis and chronic suppurative otitis media

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Eur Arch Otorhinolaryngol
DOI 10.1007/s00405-010-1290-3
RHINOLOGY
Allergic rhinitis and chronic suppurative otitis media
Mehdi Bakhshaee • Mohsen Rajati •
Mohammad Fereidouni • Ehsan Khadivi •
Abdolreza Varasteh
Received: 30 December 2009 / Accepted: 20 May 2010
Ó Springer-Verlag 2010
Abstract Allergic inflammation in upper airways can act
as a predisposing factor for infectious ear diseases. There are
some evidences about the role of allergic rhinitis in chronic
otitis media with effusion, but its role in establishing chronic
suppurative otitis media (CSOM) has not been clearly
shown. 68 adult patients with established CSOM, who were
candidates for ear surgery, and 184 age- and sex-matched
controls were evaluated for the presence of allergic rhinitis.
Standard questionnaire was filled out for all participants. All
patients and controls underwent skin prick test for 28 com-
mon regional aeroallergens, and serum total IgE was mea-
sured by means of ELISA method. Allergic rhinitis were
defined as a positive responses to the questionnaire, positive
skin prick test to at least one allergen, and/or high level of
serum total IgE. Allergic rhinitis was diagnosed in 20
(29.41%) and 41 (22.28%) of patients and controls,
respectively (P = 0.241) (OR = 1.28, CI = 0.69–2.36).
M. Bakhshaee (&)
E. Khadivi
The Ear, Nose and Throat Research Center,
Mashad University of Medical Sciences, Mashad, Iran
e-mail: bakhshaeem@mums.ac.ir
URL: http://www.mbakhshaee.com
M. Rajati
Otorhinolaryngology, Head and Neck Surgery Department,
Educational Ghaem Hospital, Mashad University of Medical
Sciences, Mashad, Iran
M. Fereidouni
Medical School, Birjand University of Medical Sciences,
Birjand, Iran
A. Varasteh
Immunobiochemistry Lab, Immunology Research Center,
Mashad University of Medical Sciences, Mashad, Iran
Outdoor allergens, especially grass pollen, were the most
prevalent allergens among both groups, but indoor allergens
like mites and molds have a low prevalence. The study did
not show a significant difference in the prevalence of AR in
the CSOM patients compared to the controls. The inter-
mittent nature of allergy and other less known intervening
factors in the etiopathogenesis of CSOM make such a con-
clusion difficult.
Keywords Ear
Allergy
Allergic rhinitis

Suppurative chronic otitis media
Introduction
Chronic suppurative otitis media (CSOM) is one of the
most common chronic infectious diseases worldwide,
affecting people in not only developing but also industri-
alized countries. It is defined as a chronic inflammation of
the middle ear and mastoid mucosa accompanying tym-
panic membrane perforation and otorrhea [1]. It should be
distinguished from chronic otitis media with effusion
(COME), where no perforation or active infection is pres-
ent [1]. Despite the prevalence, there are still many unex-
plored facts about the pathogenesis and consequently the
optimal management. Fliss et al. [2] have identified a his-
tory of acute and recurrent otitis media, parental history of
COM, and crowded circumstances as significant risk fac-
tors for CSOM. However, allergy was not related signifi-
cantly. It seems that the pathogenesis of CSOM is
multifactorial, and the more relevant factor in the evolution
of this disorder is supposed to be the eustachian tube
dysfunction.
Allergic rhinitis, which affects 10–30% and up to 40% of
all adults and children, respectively [3–5], has a well-known
123

effect on eustachian tube function. A recent study on the
prevalence of AR among normal population in our geo-
graphic area showed the rate of 22.4% [6]. The hallmark of
allergic rhinitis is an IgE-mediated, type 1 hypersensitivity
reaction, which is most common as a result of inhaling
incitant antigens, which results in a cascade of immunologic
events leading to the wide-spectrum clinical presentation.
Among them, eustachian tube dysfunction, ear fullness, and
otalgia are signs and symptoms which indicate the effect of
this condition on ear [7].
Despite many studies, there is no established cause–
effect relationship of rhinitis with recurrent otitis media
and OME [8]. Few studies have focused on the association
of AR and CSOM, and this motivated us to try to further
clarify the subject. In this study, we tried to explore the fact
in a controlled condition using strict criteria for both AR
and CSOM.
Materials and methods
Study population and design
In a prospective cross-sectional case–control study, 252
cases including 68 patients (mean age 30 years, range
10–50 years, male/female 24/44), who were candidates for
ear surgery due to established chronic suppurative otitis
media, and 184 age- and sex-matched healthy controls,
who were chosen randomly from the community of
Mashhad (mean age 29 years, range 12–48 years, male/
female 68/116), were enrolled. They had no history of
CSOM or ear symptoms accordingly.
The study was conducted in Imam Reza and Ghaem
educational hospitals and Immunology Research Centre of
Mashhad University of Medical Sciences (MUMS) in
Mashhad, Iran. The study protocol was fully explained to
patients and controls, and written informed consent was
obtained from them. In addition, our survey was approved
by the ethics committee of MUMS.
For both groups, a detailed medical history was
obtained, and physical examinations including anterior
rhinoscopy, otoscopy, impedance audiometry, pure tone
audiometry, and speech audiometry, as indicated, were
performed.
The CSOM were diagnosed by history of malodor
chronic otorrhea, perforation of the tympanic membrane or
whitish secretion due to cholesteatoma, determined by
otoscopy which was last for at least 1 year.
Both groups were evaluated for the presence of allergic
rhinitis. The criteria for diagnosis of allergic rhinitis were
symptoms such as sneezing, watery rhinorrhea, nasal
obstruction (according to standard questionnaire) [9], and
pale or watery nasal mucosa as detected by physical
123
Eur Arch Otorhinolaryngol
examination in the absence of common cold in the past
12 months; in addition, a positive reaction to at least one of
the 28 common regional aeroallergens in skin tests or total
IgE level more than 100 UI were essential to mark allergic
rhinitis to a person.
Data about demographic variables, smoking history,
family history of otitis media, and allergic diseases were
obtained by a questionnaire. Exclusion criteria were as
follows: (1) the recent consumption of antihistamine drugs
(based on the wash out period of each drug), (2) history of
allergen specific immunotherapy, and (3) positive skin test
response to negative control.
Skin prick test
Skin prick test (SPT) with 28 common regional allergen
extracts (HollisterStir, USA) was performed in all partici-
pants by a physician and according to European guidelines
[10].
Allergens used in this study included six grasses, eight
weeds, eight trees, three molds, two mites, and one mix
cockroach extract (Tables 1, 2). Histamine hydrochloride
(10 mg/mL) and glycerol saline were used as positive and
negative controls, respectively. The mean wheal size was
recorded after 15 min, and SPT was regarded as positive
with a mean wheal diameters of at least 3 mm larger than
the negative control.
Total IgE
Venous blood was collected from cases and centrifuged at
2,500 rpm for 10 min. Serum samples were stored at
–20°C until the analysis. Total IgE was determined in
serum samples in duplicate with a commercially available
enzyme linked immunoassay kit (Radim, Italy). Based on
the kit’s manual, all values higher than 100 IU/mL con-
sidered as high total IgE.
Statistical analysis
All statistical analyses were performed using SPSS Version
15 (SPSS, Inc, Chicago, IL, USA). The v2 test was used to
compare the incidence of AR in the CSOM and control
groups. Statistical significance was defined as P values less
than 0.05.
Results
Allergic rhinitis was diagnosed in 20 (29.41%) and 41
(22.28%) of patients and controls, respectively. Although
allergic rhinitis was more prevalent among patients
(CSOM) comparing to controls, the difference was not
Eur Arch Otorhinolaryngol

Table 1 Comparison of the frequency of the sensitivity to common outdoor allergens among COM cases and healthy controls
Scientific name Common name Cases frequency (%) Controls frequency (%) P value

Ailanthus altissima Tree of heaven 5 (7.35) 19 (10.33) 0.475

Amaranthus pelmeri Careless weed 15 (22.06) 36 (19.56) 0.662
Amaranthus retroflexus Rough pigweed 19 (27.94) 35 (19.02) 0.126
Artemisia douglasiana Douglas’ sagewort 4 (5.88) 20 (10.87) 0.231
Chenopodium album Lambsquarters 10 (14.70) 33 (17.93) 0.545
Cupressus arizonica Arizona Cypress 5 (7.35) 8 (4.35) 0.338
Cynodon dactylon Bermuda grass 7 (10.29) 20 (10.87) 0.896
Dactylis glomerata Orchard grass 5 (7.35) 18 (9.78) 0.552
Fraxinus americana White ash 6 (8.82) 24 (13.04) 0.359
Kochia scoparia Burning bush 13 (19.12) 36 (19.56) 0.936
Poa pratensis Kentucky blue grass 12 (17.64) 25 (13.59) 0.419
Lolium perenne Perennial rye grass 11 (16.18) 17 (9.24) 0.120
Populus deltoides Eastern cotton wood 6 (8.82) 22 (11.96) 0.482
Rumex acetosella Garden sorrel 3 (4.41) 17 (9.24) 0.208
Salsola kali Russian thistle 15 (22.06) 38 (20.65) 0.808
Sorghum halopense Johnson grass 13 (19.12) 18 (9.78) 0.045
Xanthium strumarium Cocklebur 5 (7.35) 12 (6.52) 0.860

Table 2 Distribution of skin prick test sensitivity to common indoor allergens

Scientific name Common name Cases frequency (%) Controls frequency (%) P value

Alternaria tenuis Alternaria tenuis 10 (14.70) 5 (2.72) \0.001

Aspergillus fumigatus Aspergillus fumigates 11 (16.18) 5 (2.72) \0.001
Cockroach mix Periplaneta americana blattella germanica 4 (5.88) 10 (5.43) 0.890
Dermatophagoides farinae House dust mite 11 (16.18) 9 (4.89) 0.003
Dermatophagoides pteronyssinus House dust mite 10 (14.70) 10 (5.43) 0.016
Mold mix Ten different molds 5 (7.35) 5 (2.17) 0.094

statistically significant (P = 0.241) (OR = 1.28, CI = Discussion

0.69–2.36).
Outdoor allergens (Table 1), especially grass pollen,
were the most prevalent allergens in both groups, while
indoor allergens (Table 2) such as mites and molds were
less prevalent; however, the indoor allergens were more
prevalent among patients with CSOM compared to
controls.
The mean level of IgE in cases and controls was 105 and
82 IU/ml, respectively. The mean level of IgE in the AR
group compared to none ARs was 138 and 70, respectively.
Fifteen percent of the CSOM patients were smokers
while only 10% of the controls smoked. We used the
logistic regression test to control the smoking effect as a
confounding factor; it did not show any significant differ-
ence in AR patients compared to the others (P = 0.43).
A sample size of 252 achieves 19% power to detect an
effect size (W) of 0.0670 using a 1 degree of freedom
Chi-Square test with a significance level (alpha) of 0.05000.
Identifying the risk factors and pathogenesis of CSOM is
evolving. It seems the pathogenesis is multifactorial.
Anatomical and functional characteristics of the eustachian
tube are proposed to be the most important factors.
Although the effect of AR on the eustachian tube function
is well established, there is still a lack of evidence on the
effect of the AR in development of the CSOM.
Numerous epidemiologic studies have identified allergy
as a risk factor for chronic otitis media with effusion
(COME). Alles et al. [11] reported an 89% prevalence of
allergic rhinitis among COME patients which was signifi-
cantly higher than the reported prevalence of allergic
rhinitis in the general population [12, 13] In other study,
otologic symptoms were reported in 32.8% of the children
with AR. Comparing otologic and nasal symptoms showed
a significant association between allergic rhinitis and otitis
media (P \ 0.05) [14].

123

Although from the clinical point of view some of the
proposed risk factors for COME and AOM (acute otitis
media) are likely to play a role in pathogenesis of CSOM
[15–17], there are two separate studies by Fliss et al. [2]
and Lasisi et al. [18] which could not establish such an
association. They showed many risk factors but not allergy
as a predisposing factor for CSOM in the children. In both
studies, the diagnostic criteria for allergy were as follows:
presence of history of persistent sneezing on exposure to
irritants, prominent nasal eosinophilia with or without
elevated serum IgE.
The allergic assessment tests such as serum total IgE
concentration have some limitations; it is high in adults and
children with AR and asthma, whereas many patients with
atopy have serum IgE concentrations lower than normal
individuals; therefore, it is not a useful parameter for
screening atopic diseases [19]. In the current study, IgE
was also used as a complementary test in cases who had a
well-known history of allergic rhinitis.
In the present study, we used clear criteria for AR
according to standard questionnaire and complementary
tests and selected a matched-control group in adults to
enhance the validity of our study. Although there is a higher
rate of AR among CSOM compare to controls, the difference
was not statistically significant. One of the differences of our
study was the case group; our cases were adults whereas the
previous studies [2, 18] selected children. We know most of
the CSOM initiate during childhood (when the AR is more
prevalent than adulthood [3–5]), but it may present years
later in the adulthood; therefore, in our survey there might be
some recall bias during history taking for AR; however,
there is such a bias for the controls as well. It is to note that
indoor allergens were more prevalent in the CSOM cases
although it did not affect our results; it could be concluded
that long-term exposure to such allergens might have a role
in the development of this condition.
Up to now, there is long way to explore more relevant
factors which could finally prevent the morbidity and costs
caused by CSOM, and more knowledge on its pathophys-
iology may provide new treatment avenues.
The association of tobacco smoke with the prevalence of
asthma and rhinitis has not been well characterized in
adolescents. Gomez et al. [20] showed that active and
passive smoking are both risk factors for asthma and rhi-
nitis in adolescents. We controlled this confounding factor
in our study, and concluded that smoking had no influence
on our results.
Conclusion
Chronic suppurative otitis media is a condition with dif-
ferent possible etiologies. Using a prospective design and
123
Eur Arch Otorhinolaryngol
applying strict diagnostic standard criteria for AR, we
could not show a significant difference in the prevalence of
AR in the affected adults compared to the controls.
Acknowledgments This study was supported by the research vice
chancellor of Mashed University of Medical Sciences (MUMS). The
authors wish to thank Dr. Kamran Khazaeni for his valuable help in
editing.
Conflict of interest statement None.
References
1. Cummings CW, Fredrickson JM, Harker LA et al (1998) Oto-
laryngology head and neck surgery, 3rd edn. Mosby-Yearbook,
Inc., St. Louis
2. Fliss DM, Shoham I, Leiberman A et al (1991) Chronic suppu-
rative otitis media without cholesteatoma in children in southern
Israel: incidence and risk factors. Pediatr Infect Dis J 10(12):895–
899
3. Settipane RA (2003) Rhinitis: a dose of epidemiological reality.
Allergy Asthma Proc 24(3):147–154
4. Druce H (1998) Allergic and nonallergic rhinitis. In: Middleton
E, Reed CE, Ellis EF, Adkinson NF Jr, Yunginger JW, Busse
WW (eds) Allergy principles and practice, 5th edn. Mosby-Year
Book, St Louis, pp 1005–1016
5. Smith JM (1971) A five-year prospective survey of rural children
with asthma and hay fever. J Allergy 47:23–30
6. Varasteh AR, Fereidouni M, Shakeri MT et al (2009) Prevalence
of allergic disorders among the population in the city of Mashhad,
Northeast Iran. J Public Health 17:107–112
7. Ahmad N, Zacharek MA (2008) Allergic rhinitis and rhinosi-
nusitis. Otolaryngol Clin North Am 41(2):267–281
8. Wallace DV, Dykewicz MS, Bernstein DI et al (2008) The
diagnosis and management of rhinitis: an updated practice
parameter. J Allergy Clin Immunol 122(2 Suppl):S1–S84
9. Bousquet J, Reid J, van Weel C et al (2008) Allergic rhinitis
management pocket reference 2008. Allergy 63:990–996
10. The European Academy of Allergology and Clinical Immunology
(1993) Position paper: allergen standardization and skin tests.
Allergy 48(14 Suppl):48–82
11. Alles R, Parikh A, Hawk L et al (2001) The prevalence of atopic
disorders in children with chronic otitis media with effusion.
Pediatr Allergy Immunol 12(2):102–106
12. Newacheck PW, Stoddard JJ (1994) Prevalence and impact of
multiple childhood chronic illnesses. J Pediatr 124(1):40–48
13. Sly RM (1999) Changing prevalence of allergic rhinitis and
asthma. Ann Allergy Asthma Immunol 82(3):233–248
14. Umapathy D, Alles R, Scadding GK (2007) A community based
questionnaire study on the association between symptoms sug-
gestive of otitis media with effusion, rhinitis and asthma in primary
school children. Int J Pediatr Otorhinolaryngol 71(11):705–712
15. Schaefer O (1971) Otitis media and bottle-feeding. An epidemi-
ological study of infant feeding habits and incidence of recurrent
and chronic middle ear disease in Canadian Eskimos. Can J
Public Health 62(6):478–489
16. Coates H (2002) Chronic suppurative otitis media in indigenous
populations: the Australian Aborigine. Ear Nose Throat J 81(8
Suppl 1):11–12
17. Hasselt PV, Kregten EV (2002) Treatment of chronic suppurative
otitis media with ofloxacin in hydroxypropyl methylcellulose ear
drops: a clinical/bacteriological study in a rural area of Malawi.
Int J Pediatr Otorhinolaryngol 63(1):49–56
Eur Arch Otorhinolaryngol
18. Lasisi AO, Olaniyan FA, Muibi SA et al (2007) Clinical,
demographic risk factors associated with chronic suppurative
otitis media. Int J Pediatr Otorhinolaryngol 71(10):1549–1554
19. Zeiss CR, Pruzansky JJ (1997) Immunology of IgE-mediated and
other hypersensitivity states. In: Patterson R, Grammer LC,
View publication stats
Greenberger PA (eds) Allergic disease: diagnosis and manage-
ment, 5th edn. Lippincott-Raven, Philadelphia, pp 27–40
20. Gómez M, Vollmer WM, Caceres ME et al (2009) Adolescent
smokers are at greater risk for current asthma, rhinitis. Int J
Tuberc Lung Dis 13(8):1023–1028
123