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Year : 2017  |  Volume : 23  |  Issue : 4  |  Page : 256-259

Inflammation-Based prognostic factor in different forms of chronic suppurative otitis media

1 Department of Hematology, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey
2 Department of Otolaryngology, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey
3 Department of İnternal Medicine, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey

Date of Web Publication2-May-2018

Correspondence Address:
Dr. Emine Elif Altuntaş
Department of Otolaryngology, Faculty of Medicine, Cumhuriyet University, 58140 Sivas,
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.INDIANJOTOL_87_16

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Objective: The aim of the present study was to investigate whether several blood tests could be used as inflammatory indicators in active or inactive chronic suppurative otitis media patients. Methods: Between 2007 to 2014, this study was conducted in 358 consecutive patients having chronic suppurative otitis media were included in the present retrospective clinical study. Patients were divided into two groups based on the clinical history, otologic examination, audiological evaluation and intraoperative finding. Group 1 consisted of 163 patients who had inactive chronic suppurative otitis media, while group 2 was comprised of 195 patients who had active chronic suppurative otitis media and cholesteatomatous otitis media. Results: With respect to the neutrophil-lymphocyte ratio (P = 0 .001), the platelet-lymphocyte ratio (P = 0 .001), absolute lymphocytes (P = 0.001), absolute neutrophil (P = 0.001), platelet (P = 0,001) and white blood cell (P = 0,02), Group 1 and Group 2 showed statistically significant differences. Conclusion: The results we obtained showed that markers such as neutrophil-lymphocyte ratio, the platelet-lymphocyte ratio, platelet, absolute neutrophil and white blood cell could be used as guide in evaluation of the prognosis of chronic suppurative otitis media.

Keywords: Chronic suppurative otitis media, inflammatory indicators, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio

How to cite this article:
Terzi H, Durmuş K, Karataş TD, Şencan M, Altuntaş EE. Inflammation-Based prognostic factor in different forms of chronic suppurative otitis media. Indian J Otol 2017;23:256-9

How to cite this URL:
Terzi H, Durmuş K, Karataş TD, Şencan M, Altuntaş EE. Inflammation-Based prognostic factor in different forms of chronic suppurative otitis media. Indian J Otol [serial online] 2017 [cited 2020 Oct 21];23:256-9. Available from: https://www.indianjotol.org/text.asp?2017/23/4/256/231650

  Introduction Top

Chronic otitis media (COM) is a common disease with a worldwide incidence of 2%–4%.[1] COM is characterized by inflammation of the middle ear which leads to long-term or permanent changes in the tympanic membrane. The changes in the tympanic membrane include atelectasis, perforation, tympanosclerosis, retraction, and cholesteatoma. The classification of COM is based on whether it is associated with cholesteatoma or involves active inflammation.[2] Otitis media has a multifactorial nature. Development of chronic suppurative otitis media (CSOM) is associated with inadequate antibiotic treatment, frequent upper respiratory tract infections, nasal disease, multiple episodes of acute otitis media (AOM), being a member of a large family, hygiene, nutrition, poor living conditions with poor access to medical care, passive exposure to smoking, attendance in congested centers such as day-care facilities, and a family history of otitis media.[3] The pathogenesis of COM is not fully understood. However, inflammatory and allergic factors are thought to be involved. Knowing the risk factors of COM would contribute to an effective treatment and control of this disease.

Blood platelets are the smallest cells of the peripheral blood, and they are involved in hemostasis. Considered as an important source of prothrombotic agents associated with inflammatory markers, platelets are also involved in the initiation and propagation of vascular and inflammatory diseases.[4] In clinical practice, systemic inflammation is evaluated using the neutrophil-lymphocyte ratio (NLR) and the platelet-lymphocyte ratio (PLR).[5]

Two recent studies have pointed out an association between otitis media and various hematological parameters.[1],[6] The aim of the present study was to investigate whether several blood tests could be used as inflammatory indicators in active or inactive CSOM patients.

  Materials and Methods Top

The study was conducted in 358 consecutive patients having CSOM and treated at our ENT department between 2007 and 2014. All of the patients underwent surgery due to the symptoms of chronic middle ear disease. An ethical committee approval was obtained, and the study was conducted in accordance with the Helsinki Declaration (protocol number: 2015–07/06). Informed consent was obtained from all the participants.

Having a concomitant inflammatory disease such as cardiovascular disorders, malignancies, asthma, cystic fibrosis, allergic rhinitis, immune deficiencies, metabolic disorders, and renal or liver disease were the exclusion criteria as these diseases could affect the hematological parameters.

Patients were divided into two groups based on the clinical history, otologic examination, audiological evaluation, and intraoperative finding. Group 1 consisted of 163 patients (96 [58.9%] females, 67 [41.1%] males; mean age 29.30 ± 11.09 years; [range 10–62 years]) who had inactive CSOM, while Group 2 was comprised of 195 patients (95 [48.7%] females, 100 [51.3%] females; mean age 33.46 ± 12.96 years; [range 11–67 years]) who had active CSOM and cholesteatomatous otitis media.

The following data were collected and recorded from the hospital records: age, sex, clinical history, and blood samples for biochemical and hemogram analysis.

Statistical analyses were performed using SPSS v22 (SPSS Inc., Chicago, IL, USA). The data obtained were evaluated using independent-sample t-test (Kolmogorov–Smirnov). Chi-square test was used when the parametric test assumptions were met. P < 0.05 was considered statistically significant.

  Results Top

The study population consisted of 358 patients, 191 of which were females (53.4%) and 167 of which were males (46.6%). The average age was 31.41 ± 12.10 years (range 11–63 years) in females and 31.74 ± 12.57 years (range 10–67 years) in males. The groups were similar in terms of age and sex (P = 0.058, P = 0.084).

With respect to the NLR (P = 0.001), PLR (P = 0.001), absolute lymphocytes (P = 0.001), absolute neutrophil (P = 0.001), platelet (PLT) (P = 0.001), and white blood cell (WBC) (P = 0.02), Group 1 and Group 2 showed statistically significant differences. Average blood urea nitrogen, glucose, creatinine, hemoglobin (HGB), plateletcrit (PCT), platelet distribution width (PDW), and mean platelet volume (MPV) values were not significantly different between two groups (P > 0.05) [Table 1].
Table 1: The demographic and clinical characteristics of the study populations

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  Discussion Top

The present study investigated the relationship between CSOM and the results of several blood tests including glucose, blood urea nitrogen (BUN), creatinine, PLR, NLR, HGB, red blood cell (RBC), PDW, PLT, MPV, PCT, WBC, absolute lymphocytes, and absolute neutrophil. To the best of our knowledge, this is the first study investigating the relationship between CSOM and certain hematological parameters. In terms of glucose, BUN, creatinine HGB, MPV, PCT, PDW, and RBC levels, no statistically significant differences were identified between the patients diagnosed with inactive and active CSOM. The most important finding of our study was that NLR, PLR, platelet count, WBC, and absolute neutrophil levels were significantly higher in patients having active CSOM when compared with those having inactive CSOM.

CSOM is a multifaceted and complex disease where infections, anatomy, physiology, and environmental factors may all play a role. In CSOM, where the middle ear and mastoid are infected and inflamed chronically, inflammation results in the production of platelet-activating factor, prostaglandins, leukotrienes and histamine, and pro-inflammatory cytokines in the middle ear.[7] These inflammatory mediators and cytokines have been identified in both animal studies and human clinical studies of otitis media with effusion (OME).[8],[9],[10],[11] The increased levels of pro-inflammatory cytokines in patients with OME suggest that the driver of the diseases could be the abnormalities in the immune system triggering chronic and uncontrolled inflammation.[12] This dysfunction or dysregulation of the immune system may affect expression of the pro-inflammatory cytokines, which may lead to an inflammation progressing to a chronic state.[13] Zielnik-Jurkiewicz and Stankiewicz-Szymczak [7] investigated the role of cytokines in the local development of chronic OME and studied the differences in the cytokine profiles of 84 atopic and nonatopic children with chronic OME. They showed that inflammatory cytokines had a role in the pathogenesis of OME and suggested that their role should be evaluated further with further studies as to the prevention and treatment of the disease.

In our study, the results we obtained by a simple hemogram from peripheral blood showed that WBC, PLT, NLR, PLR, and absolute neutrophil values were higher in active patients when compared to the inactive patients, which suggested that these parameters could be used in following the prognosis of the diseases. However, it should not be forgotten that the WBC and absolute neutrophil may rise in any inflammatory event.

RBC can be easily obtained from the complete blood count test and are simple markers of inflammation. These markers are also an indicator of the overall inflammatory status of our body.[14] In a study conducted in Korea, Park et al.[1] evaluated the risk factors and prevalence of COM. They concluded that there was an association between COM and the results of several blood tests including blood levels of heavy metals. Park et al. also showed that COM was associated with decreased RBC counts (Student's t-test, P < 0.0001) and increased levels of Vitamin D, lead, and cadmium (Student's t-test, P < 0.0172). Unlike the results obtained by Park et al.,[1] we found no statistical difference between RBC values of two groups.

Platelets which are anucleate blood cells are known to be critically involved in hemostasis and thrombosis. In addition, there are evidences showing their significant roles for platelets in inflammation and immunity.[15] MPV is an indicator of platelet activation. Development of inflammation is associated with increased platelet activation, and platelets have been found to contribute to chronic inflammation. Somuk et al.[6] studied the association between COM with effusion and MPV. They didn't found a statistically significant difference between chronic effusion otitis media and the healthy control individuals in WBC, RBC, HGB, Hct, PLT, and MPV levels. However, they indicated that the said results could have been affected by some limitations such as conducting a retrospective study and not evaluating the possible changes in MPV before and after the treatment.

As a result, although not shown statistically, Somuk et al.[6] indicated that inflammatory mediators have an important role in the pathogenesis of chronic effusion otitis media. In the present study, we evaluated PLT and MPV values in cases having active and inactive CSOM. The results we obtained showed that PLT levels were statistically significantly higher in active CSOM patients when compared to inactive CSOM patients. MPV values of the active CSOM cases were higher compared to the inactive group too.

In a disease with chronic inflammation, it is natural to expect a statistically significant increase in MPV values parallel to an increase in PLT values. However, neither Somuk et al.'s results [6] nor our results showed this clearly. We believe that this was related with using different techniques to measure MPV, just like stated in the editorial letter written by Varol [16] as a response to the study conducted by Somuk et al.[6] We also believe that future studies taking into account standard MPV techniques would yield statistically increased PMV values.

The systemic inflammatory response and alterations in circulating white blood cells are associated with each other. In clinical practice, systemic inflammation is evaluated based on NLR, PLR, and PLT.[5] NLR and PLR, namely the NLR and PLR in the peripheral blood, can be easily calculated and they are practical, inexpensive, and as valuable as high-cost pro-inflammatory markers including Interleukin (IL)-6, IL-1b, IL-8, and TNF-alpha.[17],[18]

The association between these hematological parameters and inflammation has been shown in many studies previously.[19],[20] CSOM is a disease defined by chronic infection or inflammation in the middle ear and mastoid. We evaluated whether there was an association between the prognosis and clinical progress of CSOM and NLR, PLR, and PLT levels as observed in diseases of systemic inflammation. The results we obtained showed that all three parameters were significantly higher in active cases when compared to inactive cases.

As a result, our literature review did not yield any studies using NLR, PLR, PLT, absolute neutrophil, and WBC in evaluation of the clinical progress and prognosis of the disease in patients having CSOM. Thus, this is the first study to evaluate CSOM patients in terms of inflammation-based prognostic factors.

  Conclusion Top

The present study was conducted to investigate whether various inflammation markers could be used as markers for the prognosis or as a general indicator of the disease in patients having CSOM. However, ıncrease in WBC and neutrophil count is basic property of any inflammation. Even if these indicators provide general information about CSOM's prognosis, more detailed studies are needed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Park M, Lee JS, Lee JH, Oh SH, Park MK. Prevalence and risk factors of chronic otitis media: The Korean National Health and Nutrition Examination Survey 2010-2012. PLoS One 2015;10:e0125905.  Back to cited text no. 1
Nadol JB Jr. Revision mastoidectomy. Otolaryngol Clin North Am 2006;39:723-40, vi-vii.  Back to cited text no. 2
Elsayed Yousef Y, Abo El-Magd EA, El-Asheer OM, Kotb S. Impact of educational program on the management of chronic suppurative otitis media among children. Int J Otolaryngol 2015;2015:624317.  Back to cited text no. 3
Kilciler G, Genc H, Tapan S, Ors F, Kara M, Karadurmus N, et al. Mean platelet volume and its relationship with carotid atherosclerosis in subjects with non-alcoholic fatty liver disease. Ups J Med Sci 2010;115:253-9.  Back to cited text no. 4
Balta S, Demırkol S, Kucuk U. The platelet lymphocyte ratio may be useful inflammatory indicator in clinical practice. Hemodial Int 2013;17:668-9.  Back to cited text no. 5
Somuk BT, Soyalıç H, Koc S, Gürbüzler L, Doǧru S, Eyibilen A, et al. Mean platelet volume as an inflammatory marker of chronic otitis media with effusion. Int J Pediatr Otorhinolaryngol 2014;78:1958-60.  Back to cited text no. 6
Zielnik-Jurkiewicz B, Stankiewicz-Szymczak W. Pro-inflammatory interleukins in middle ear effusions from atopic and non-atopic children with chronic otitis media with effusion. Eur Arch Otorhinolaryngol 2016;273:1369-78.  Back to cited text no. 7
Jung TT, Park YM, Schlund D, Weeks D, Miller S, Wong O, et al. Effect of prostaglandin, leukotriene, and arachidonic acid on experimental otitis media with effusion in chinchillas. Ann Otol Rhinol Laryngol Suppl 1990;148:28-32.  Back to cited text no. 8
Rhee CK, Jung TT, Miller S, Weeks D. Experimental otitis media with effusion induced by platelet activating factor. Ann Otol Rhinol Laryngol 1993;102:600-5.  Back to cited text no. 9
Smirnova MG, Kiselev SL, Gnuchev NV, Birchall JP, Pearson JP. Role of the pro-inflammatory cytokines tumor necrosis factor-alpha, interleukin-1 beta, interleukin-6 and interleukin-8 in the pathogenesis of the otitis media with effusion. Eur Cytokine Netw 2002;13:161-72.  Back to cited text no. 10
Sato K, Liebeler CL, Quartey MK, Le CT, Giebink GS. Middle ear fluid cytokine and inflammatory cell kinetics in the chinchilla otitis media model. Infect Immun 1999;67:1943-6.  Back to cited text no. 11
Lee HY, Kim YI, Lee JW, Byun JY, Park MS, Yeo SG, et al. Decreased expression of TLR-9 and cytokines in the presence of bacteria in patients with otitis media with effusion. Clin Exp Otorhinolaryngol 2013;6:195-200.  Back to cited text no. 12
Matković S, Vojvodić D, Baljosevic I. Cytokine levels in groups of patients with different duration of chronic secretory otitis. Eur Arch Otorhinolaryngol 2007;264:1283-7.  Back to cited text no. 13
Lippi G, Targher G, Montagnana M, Salvagno GL, Zoppini G, Guidi GC, et al. Relation between red blood cell distribution width and inflammatory biomarkers in a large cohort of unselected outpatients. Arch Pathol Lab Med 2009;133:628-32.  Back to cited text no. 14
Lam FW, Vijayan KV, Rumbaut RE. Platelets and their interactions with other immune cells. Compr Physiol 2015;5:1265-80.  Back to cited text no. 15
Varol E. Letter to the editor regarding “mean platelet volume evaluation in patients with chronic otitis media with effusion: Methodological drawbacks”. Int J Pediatr Otorhinolaryngol 2015;79:629.  Back to cited text no. 16
Bhat T, Teli S, Rijal J, Bhat H, Raza M, Khoueiry G, et al. Neutrophil to lymphocyte ratio and cardiovascular diseases: A review. Expert Rev Cardiovasc Ther 2013;11:55-9.  Back to cited text no. 17
Özler GS, Günak G. Neutrophil-lymphocyte ratio: A new predictive and prognostic factor in patients with bell palsy. J Craniofac Surg 2014;25:944-5.  Back to cited text no. 18
Imtiaz F, Shafique K, Mirza SS, Ayoob Z, Vart P, Rao S, et al. Neutrophil lymphocyte ratio as a measure of systemic inflammation in prevalent chronic diseases in Asian population. Int Arch Med 2012;5:2.  Back to cited text no. 19
Gary T, Pichler M, Belaj K, Hafner F, Gerger A, Froehlich H, et al. Platelet-to-lymphocyte ratio: A novel marker for critical limb ischemia in peripheral arterial occlusive disease patients. PLoS One 2013;8:e67688.  Back to cited text no. 20


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