今日の臨床サポート

滲出性中耳炎・好酸球性中耳炎

著者: 飯野ゆき子 東京北医療センター 耳鼻咽喉科

監修: 森山寛 東京慈恵会医科大学附属病院

著者校正/監修レビュー済:2016/12/28
患者向け説明資料

概要・推奨   

疾患のポイント:
  1. 幼小児期に高頻度に認められる。また高齢者にもみられることがある。
 
滲出性中耳炎:
  1. ポイント:
  1. 滲出性中耳炎とは、耳痛がなく、中耳に貯留液がたまり、難聴や耳閉感を引き起こす病態と定義される。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
飯野ゆき子 : 特に申告事項無し[2021年]
監修:森山寛 : 特に申告事項無し[2021年]

まとめ

疾患情報(疫学・病態)  
  1. 滲出性中耳炎は耳痛がなく、中耳に貯留液がたまり、難聴や耳閉感を引き起こす病態と定義される。
  1. 幼小児期に高頻度に認められる。また高齢者にもみられることがある。
  1. 滲出性中耳炎は鼻咽腔や耳管の炎症や耳管機能障害で生じる。
  1. 小児における滲出性中耳炎は新鮮例であればその6割が3カ月以内に自然治癒する[1]
  1. 好酸球性中耳炎は主に気管支喘息に合併する難治性中耳炎である。
  1. 滲出性中耳炎が初発であることが多く、その後、永久穿孔が生じれば慢性穿孔性中耳炎型、肉芽の増殖が起これば肉芽性中耳炎型となる。
  1. ほとんどが成人発症である。
  1. 中耳貯留液は非常に粘稠で貯留液には多数の好酸球が認められる。
  1. 自然治癒は見込めず、従来の中耳炎に対する治療にも抵抗する。
  1. 適切な治療が施されない場合、耳漏が継続し、骨導閾値の上昇をみる。ときにはろうとなる[2]
問診・診察のポイント  
問診:
  1. 滲出性中耳炎:耳閉感・難聴の有無、その経緯

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文献 

著者: Richard M Rosenfeld, David Kay
雑誌名: Laryngoscope. 2003 Oct;113(10):1645-57.
Abstract/Text OBJECTIVE/HYPOTHESIS: Data from cohort studies and untreated groups in randomized controlled trials can be identified through systematic literature review and synthesized with meta-analysis to estimate natural history of acute otitis media (AOM) and otitis media with effusion (OME).
STUDY DESIGN: Systematic literature review and meta-analysis.
METHOD: Source articles were identified by MEDLINE search through August 2002 plus manual crosschecks of bibliographies and published meta-analyses. Data were abstracted independently by two investigators and combined with random effects meta-analysis to estimate spontaneous resolution, 95% confidence intervals (CI), and heterogeneity. Sensitivity analysis was performed.
RESULTS: Sixty-three articles met inclusion criteria. AOM symptoms improved within 24 hours without antibiotics in 61% of children (95% CI, 50-72%), rising to 80% by 2 to 3 days (95% CI, 69-90%). Suppurative complications were comparable if antibiotics were withheld (0.12%) or provided (0.24%). Children entered recurrent AOM trials with a mean rate of 5.5 or more annual episodes but averaged only 2.8 annual episodes while on placebo (95% CI, 2.2-3.4). No AOM episodes occurred in 41%, and only 17% remained otitis prone (3 or more episodes). OME after untreated AOM had 59% resolution by 1 month (95% CI, 50-68%) and 74% resolution by 3 months (95% CI, 68-80%). OME of unknown duration had 28% spontaneous resolution by 3 months (95%, CI 14-41%), rising to 42% by 6 months (95% CI, 35-49%). In contrast, chronic OME had only 26% resolution by 6 months and 33% resolution by 1 year.
CONCLUSIONS: The natural history of otitis media is very favorable. Combined estimates of spontaneous resolution provide a benchmark against which to judge new or established interventions. The need for surgery in children with recurrent AOM or chronic OME should be balanced against the likelihood of timely spontaneous resolution and the potential risk of learning, language, or other adverse sequelae from persistent middle ear effusion. Further research is needed to identify prognostic factors that can target children unlikely to improve spontaneously for earlier intervention.

PMID 14520089  Laryngoscope. 2003 Oct;113(10):1645-57.
著者: Yukiko Iino, Hajime Usubuchi, Kozue Kodama, Katsumi Takizawa, Takeharu Kanazawa, Yasushi Ohta
雑誌名: Otol Neurotol. 2008 Oct;29(7):949-52. doi: 10.1097/MAO.0b013e318185fb0d.
Abstract/Text OBJECTIVE: Eosinophilic otitis media (EOM) is characterized by the extensive accumulation of eosinophils in the middle ear mucosa and middle ear effusion and is usually associated with bronchial asthma. EOM patients show gradual deterioration of hearing and sometimes become deaf suddenly. However, there have been no systemic studies of bone conduction hearing level (BCHL) of patients with EOM.
PATIENTS: Seventy-one ears of 38 patients with EOM associated with bronchial asthma were included in this study. For controls, 65 ears of age-matched 60 patients with chronic otitis media (COM), who underwent tympanoplasty, were similarly studied. The BCHLs at 250, 500, 1,000, 2,000 and 4,000 Hz of EOM patients were compared with those of COM patients, and the clinical risk factors for the deterioration of BCHL in EOM were analyzed.
RESULTS: Two patients became profoundly deaf unilaterally after the onset of EOM. High-tone loss was more frequently found and more severe in EOM patients than in COM patients. The clinical risk factors for high-tone loss were older age, male sex, presence of pathogens, and condition of the middle ear mucosa.
CONCLUSION: High-tone hearing loss and profound hearing loss were frequently associated with EOM, suggesting that inflammatory products of the middle ear invade the inner ear via the round window to cause inner ear damage. To prevent the deterioration of BCHL, the control of eosinophilic inflammation and bacterial infection is mandatory.

PMID 18758390  Otol Neurotol. 2008 Oct;29(7):949-52. doi: 10.1097/MAO.・・・
著者: Yukiko Iino, Keiko Kakizaki, Shoji Saruya, Hiroaki Katano, Takashi Komiya, Kazuoki Kodera, Ken Ohta
雑誌名: Arch Otolaryngol Head Neck Surg. 2006 Oct;132(10):1109-14. doi: 10.1001/archotol.132.10.1109.
Abstract/Text OBJECTIVE: To determine eustachian tube function in patients with asthma and with or without eosinophilic otitis media (EOM), a new middle ear disease entity with a highly viscous middle ear effusion containing many eosinophils and usually associated with bronchial asthma. One of the most important causes of otitis media (OM) is eustachian tube dysfunction.
DESIGN: Retrospective case review.
SETTING: A referral center.
PATIENTS: Twenty patients with EOM and patients with asthma but without OM.
MAIN OUTCOME MEASURES: We studied eustachian tube function using sonotubometry and a questionnaire. Sonotubometry was also performed on 13 control patients with chronic otitis media (COM) and 7 normal controls.
RESULTS: The tubal opening duration was significantly longer in patients with EOM than in patients with asthma but without OM, controls with COM, and normal controls, indicating the presence of patulous eustachian tubes in patients with EOM. Responses to the questionnaire also supported the presence of patulous eustachian tubes in the patients with EOM.
CONCLUSIONS: The presence of a patulous eustachian tube may be a major cause of EOM in patients with bronchial asthma. In patients with asthma who have a helper T-cell 2-dominant predisposition, a patulous eustachian tube easily allows the entry of antigenic materials into the middle ear, causing eosinophil-dominant inflammation.

PMID 17043260  Arch Otolaryngol Head Neck Surg. 2006 Oct;132(10):1109-・・・
著者: Yukiko Iino, Sachiko Tomioka-Matsutani, Atsushi Matsubara, Takashi Nakagawa, Manabu Nonaka
雑誌名: Auris Nasus Larynx. 2011 Aug;38(4):456-61. doi: 10.1016/j.anl.2010.11.016. Epub 2011 Jan 19.
Abstract/Text OBJECTIVE: Eosinophilic otitis media (EOM) is a newly recognized intractable middle ear disease, characterised by the accumulation of eosinophils in middle ear effusion and middle ear mucosa. Since EOM patients show gradual or sudden deterioration of hearing, it is important to properly diagnose EOM and to start adequate treatment for EOM. We aimed to investigate the clinical risk factors of EOM and to establish the diagnostic criteria of EOM.
PATIENTS AND METHODS: We reviewed 138 patients with EOM and 134 age-matched patients with the common type of otitis media with effusion or chronic otitis media as controls. We analyzed the incidence of the following clinical variables in both groups: bilaterality of otitis media, viscosity of middle ear effusion, formation of granulation tissue in the middle ear, response to the treatment for otitis media, deterioration of bone conduction hearing level, and association with other diseases such as bronchial asthma, chronic rhinosinusitis, nasal polyposis, and allergic rhinitis.
RESULTS: A high odds ratio was obtained from an association with bronchial asthma (584.5), resistance to conventional treatment for otitis media (232.2), viscous middle ear effusion (201.6), association with nasal polyposis (42.17), association with chronic rhinosinusitis (26.49), bilaterality (12.93), and granulation tissue formation (12.62). The percentage of patients with EOM who were positive for two or more among the highest four items was 98.55%.
CONCLUSION: A patient who shows otitis media with effusion or chronic otitis media with eosinophil-dominant effusion (major criterion) and with two or more among the highest four items (minor criteria), can be diagnosed as having EOM. Patients with ear symptoms should have the proper diagnosis of EOM using the proposed diagnostic criteria, and then can receive adequate treatment, resulting in prevention of deterioration of hearing and quality of life.

Copyright © 2011. Published by Elsevier Ireland Ltd.
PMID 21251776  Auris Nasus Larynx. 2011 Aug;38(4):456-61. doi: 10.1016・・・
著者: MRC Multi-centre Otitis Media Study Group
雑誌名: Clin Otolaryngol Allied Sci. 2001 Apr;26(2):147-56.
Abstract/Text Otitis media with effusion (OME) is a common, episodic condition in childhood. The subset that has persistent bilateral OME is important to identify so that their management can be targeted. Most guidelines suggest a watchful-waiting period before a decision is made on the appropriateness of surgical intervention. In the UK this usually takes place in a specialist setting (otorhinolaryngology) over a period of 12 weeks. A cohort of children (n = 639), between the ages of 3.25 and 6.75 years with bilateral OME that had no previous ear or throat surgery, was followed up over 12 weeks during the recruitment phase of a multi-centre, randomised controlled study. This allowed multiple factors for persistence to be assessed. The overall spontaneous resolution rate in this cohort was between 26% and 65%, depending on the audiometric cut-off by which a persisting condition was defined. Three significant risk factors-time of year when first seen (July to December); hearing level (>or= 30 dB HL in the better ear); and a route of referral that included prior audiometry--were identified in the multivariate analysis for persistent OME both in isolation and when accompanied by each of three audiometric cut-offs (>or= 15, >or= 20 and >or= 25dB HL). In this age group, parental report of duration of OME, history of acute otitis media, parental smoking and pars tensa retractions were not significant factors for persistence. These risk factors in combination can increase the odds ratio of persistence more than sixfold. However, the proportion persisting is insufficient to bypass a period of watchful waiting, except perhaps in extreme combinations which apply to less than 7% of the cohort.

PMID 11309057  Clin Otolaryngol Allied Sci. 2001 Apr;26(2):147-56.
著者: Yukiko Iino, Hisayo Nagamine, Keiko Kakizaki, Takashi Komiya, Hiroaki Katano, Shoji Saruya, Kazuoki Kodera
雑誌名: Ann Allergy Asthma Immunol. 2006 Dec;97(6):761-6. doi: 10.1016/S1081-1206(10)60967-2.
Abstract/Text BACKGROUND: Eosinophilic otitis media (EOM) is a newly recognized middle ear disease found in asthmatic patients. EOM is characterized by a highly viscous middle ear effusion that contains many eosinophils and is extremely unresponsive to conventional treatments for common otitis media. To our knowledge, no systemic study regarding the efficacy of treatments for EOM has been performed.
OBJECTIVE: To determine the effectiveness of instillation of triamcinolone acetonide, which is a suspension of steroids, into the mesotympanum and eustachian tube as a treatment for patients with EOM.
METHODS: We studied the efficacy of the instillation of triamcinolone acetonide in 43 ears of 24 patients with EOM. Efficacy was evaluated according to the length of the period without middle ear effusion or otorrhea. We also determined the otomicroscopic findings and the hearing levels before and after therapy. For controls, 27 ears of 14 patients treated by topical administration of betamethasone were similarly evaluated.
RESULTS: The middle ear effusion or otorrhea was controlled for more than 3 weeks after 1 instillation of triamcinolone acetonide in 35 ears, and the efficacy rate (81%) was significantly higher than that in the controls (7 ears, 26%). In the triamcinolone acetonide group, the average air conduction hearing level at the speech frequency range was significantly improved, and deterioration of the bone conduction hearing threshold was rarely found during therapy.
CONCLUSION: The instillation of triamcinolone acetonide into the mesotympanum and eustachian tube is an effective treatment for patients with EOM.

PMID 17201235  Ann Allergy Asthma Immunol. 2006 Dec;97(6):761-6. doi: ・・・
著者: Satoshi Iwasaki, Mitsuyoshi Nagura, Kunihiro Mizuta
雑誌名: Eur Arch Otorhinolaryngol. 2006 Apr;263(4):365-9. doi: 10.1007/s00405-005-1006-2. Epub 2005 Dec 3.
Abstract/Text Eosinophilic otitis media is an intractable middle ear disease with gelatinous mucoid fluid containing eosinophils associated with bronchial asthma and nasal allergy that sometimes induces deterioration of sensorineural hearing loss. Here, we report a case of eosinophilic otitis media in a 50-year-old woman who received a Nucleus 22 multi-channel cochlear implant in the right ear at the age of 42 years. She had received treatment for bronchial asthma, chronic sinusitis with nasal allergy and otitis media with effusion since the age of 30 years and had noted bilateral sudden deafness and vertigo at the age of 35 years. Preoperative CT and MRI showed cochlear ossification in the left ear, in which mastoidectomy was performed as treatment of eosinophilic otitis media. Long-term follow-up revealed that cochlear implant is indicated for deafness induced by eosinophilic otitis media, and an early decision for cochlear implant surgery is necessary. Steroid administration was remarkably useful in controlling eosinophilic otitis media in patients with bronchial asthma and chronic sinusitis with nasal allergy.

PMID 16328408  Eur Arch Otorhinolaryngol. 2006 Apr;263(4):365-9. doi: ・・・

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