Yoshida Naohiro
Department of Otolaryngology- Head and Neck Surgery, Jichi Medical University Saitama Medical Center, Saitama, Japan.
Auris Nasus Larynx. 2023 Apr;50(2):171-179. doi: 10.1016/j.anl.2022.07.005. Epub 2022 Aug 5.
Intractable otitis media is resistant to antimicrobial therapy, tympanostomy ventilation tube insertion, and surgery. In children, intractable acute otitis media, pathological tympanic membrane due to prolonged otitis media with effusion (OME), tympanic membrane atelectasis, and adhesive otitis media are common. Contrarily, in adults, otitis media caused by drug-resistant pathogens, tuberculous otitis media, cholesterol granuloma, malignant otitis externa (skull base osteomyelitis), eosinophilic otitis media (EOM), and otitis media with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (OMAAV) are common and require differentiation. Among them, EOM is increasing along with eosinophilic upper respiratory tract diseases, such as bronchial asthma and eosinophilic chronic rhinosinusitis (ECRS), a subgroup of chronic rhinosinusitis with nasal polyps (CRSwNP). EOM is associated with adult-onset bronchial asthma and is characterized by viscous middle ear effusion and middle ear mucosa thickness with eosinophilic infiltration, which requires treatment with glucocorticoids according to disease activity and symptoms. Recently, OMAAV was proposed because of the similarities in clinical features and therapeutic effects. The clinical course of OMAAV is characterized by a relatively rapid increase in the bone conductive hearing threshold, which progresses over 1-2 months, without response to antimicrobial agents or tympanostomy ventilation tube insertion, and in some cases, is complicated by facial paralysis and hypertrophic pachymeningitis. This new concept may explain the pathogenesis and clinical presentation of many cases of intractable otitis media, the cause of which was previously unknown. Although making a diagnosis of OMAAV is relatively easy based on the clinical course, such as vascular dilatation of the tympanic membrane and positive ANCA titer, it is often difficult because the ANCA titer becomes negative with previous administration of glucocorticoids. In adults with intractable otitis media, ANCA titers must be measured before glucocorticoid administration. Treatment consisted of remission induction therapy with a combination of glucocorticoids and immunosuppressive drugs.
难治性中耳炎对抗菌治疗、鼓膜切开置管术及手术均无反应。在儿童中，难治性急性中耳炎、因长期中耳积液（OME）导致的病理性鼓膜、鼓膜萎缩及粘连性中耳炎较为常见。相反，在成人中，由耐药病原体引起的中耳炎、结核性中耳炎、胆固醇肉芽肿、恶性外耳道炎（颅底骨髓炎）、嗜酸性粒细胞性中耳炎（EOM）以及抗中性粒细胞胞浆抗体（ANCA）相关血管炎伴发的中耳炎（OMAAV）较为常见，需要进行鉴别诊断。其中，EOM随着嗜酸性上呼吸道疾病如支气管哮喘和嗜酸性慢性鼻-鼻窦炎（ECRS，慢性鼻-鼻窦炎伴鼻息肉（CRSwNP）的一个亚组）的增多而增加。EOM与成人发病的支气管哮喘相关，其特征为黏稠的中耳积液和伴有嗜酸性粒细胞浸润的中耳黏膜增厚，需根据疾病活动度和症状使用糖皮质激素进行治疗。最近，由于临床特征和治疗效果相似，OMAAV被提出。OMAAV的临床病程特征为骨导听力阈值相对快速升高，在1 - 2个月内进展，对抗菌药物或鼓膜切开置管术无反应，且在某些情况下会并发面瘫和肥厚性硬脑膜炎。这一新概念可能解释了许多先前病因不明的难治性中耳炎病例的发病机制和临床表现。尽管基于临床病程，如鼓膜血管扩张和ANCA滴度阳性，诊断OMAAV相对容易，但由于先前使用糖皮质激素会使ANCA滴度变为阴性，所以诊断往往很困难。在患有难治性中耳炎的成人中，必须在使用糖皮质激素之前检测ANCA滴度。治疗包括使用糖皮质激素和免疫抑制药物联合进行诱导缓解治疗。
