Original Article

Iranian Journal of Otorhinolaryngology, Vol.27 (4), Serial No.81, Jul 2015

Allergic Rhinitis in Adults with Chronic Suppurative Otitis Media

Shadman Nemati1, Reza Jafari Shakib2, Maryam Shakiba3, Nematollah Araghi4,
*
Seyyede Zeinab Azimi1
Abstract
Introduction:
Chronic suppurative otitis media (CSOM) is considered one of the most common causes of
acquired hearing impairment in developing countries. CSOM is a multifactorial persistent
inflammatory disease of the middle ear. A distinct pathophysiologic mechanism linking
allergic rhinitis (AR) and CSOM remains to evolve. The purpose of this study was to
investigate the association between AR and CSOM in adults.This was a case-control study.
Materials and Methods:
The subjects were 62 adults (23 male, 39 female) with established CSOM and 61 healthy controls.
CSOM was diagnosed when there was a history of chronic (persisting for at least 3 months)
otorrhea, accumulation of mucopurulent exudates in the external auditory canal or middle ear
and/or perforated tympanic membrane on otoscopy. All participants were evaluated for the
presence of AR by clinical evaluation of allergic symptoms, and underwent a skin-prick test for 23
common regional allergens. Statistical analysis was performed using SPSS version 16.
Results:
The prevalence of clinical rhinitis (allergic and non-allergic) was significantly higher among the
cases compared with controls (62.5% vs. 37.5%, P=0.02). The prevalence of AR (proven by
positive skin-prick test) was also significantly higher among affected adults than controls (24.6%
and 13.8%, respectively). Adjusting for age, a logistic regression model showed that there was a
significant difference between the two groups. Patients with AR and non-AR were at 3.27- (95%
CI=1.159.29; P=0.036) and 2.57-(95% CI=1.016.57; P=0.048) fold increased risk of developing
CSOM, respectively, compared with healthy individuals.
Conclusion:
The study showed a higher prevalence of AR in CSOM patients than in controls. It may be
valuable to evaluate and control this factor in these patients.
Keywords:
Allergic, Hypersensitivity, Otorhinolaryngologic diseases, Otitis Media, Rhinitis, Suppurative,
Skin test.
Received date: 24 Agu 2014
Accepted date: 15 Oct 2014

Sinonasal Diseases Research Centre, Amiralmomenin Hospital, Guilan University of Medical Sciences, Rasht, Iran.
Department of Immunology, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran.
3
Department of Epidemiology, School of Public Health, Shahid Beheshti University of medical Sciences, Tehran, Iran.
4
Department of Otolaryngology, Amiralmomenin Hospital, Guilan University of Medical Sciences, Rasht, Iran.
*
Corresponding Author:
Sinonasal Diseases Research Centre, Amiralmomenin Hospital, Guilan University of Medical Sciences, Rasht, Iran.
Tel: +98-9113379430, E-mail: sz.azimi@yahoo.com
2

261

Nemati S, et al

Introduction
Chronic supportive otitis media (CSOM) is
a major problem facing health systems
around the world. The condition is
characterized by persistent inflammation of
the middle ear and mastoid cavity associated
with otorrhea through a perforated tympanic
membrane, persisting for more than 6 weeks
(1). The worldwide burden of CSOM is 65
330 million people, and approximately 60%
suffer from clinically significant hearing
impairment (2,3).
The pathogenesis of CSOM is considered
multifactorial, and most patients with
CSOM have a history of recent acute onset
of otitis media, risk factors associated with
acute otitis media, or otitis media with
effusion. The pathogenesis is thought to
include Eustachian tube (ET) dysfunction,
immature or impaired immunologic status,
upper
respiratory
allergy,
familial
predisposition, presence of other siblings,
male sex, passive smoking and other factors
(4,5). However, the risk factor for CSOM
have not yet been fully defined (6).
With the prevalence of 1030%, allergic
rhinitis (AR) is the most common allergic
disorder. AR occurs in association with a
number of other disorders, principally
sinusitis, asthma, allergic conjunctivitis , and
atopic dermatitis (7-10). Studies show an
increased prevalence of migraine headache
in patients with AR (11,12). A relationship
between AR and CSOM has been postulated
for years. Evidence of a common
pathophysiologic mechanism linking these
two diseases continues to evolve (13).
Because of the close anatomical relationship
between ET and the nasopharynx, allergic
disorders such as AR may cause ET
dysfunction by inflammation and swelling in
this region (14,15), and some studies have
shown that an allergic challenge causes ET
obstruction. Analysis of inflammatory
mediators indicates that the mucosa of the
middle ear can respond to antigens in the
same way as does the mucosa of the lower

respiratory tract (16). Although a definitive

causal relationship between AR and CSOM
remains to be demonstrated, a number of
studies support the plausibility of this link
(5,15,17,18).
Despite the existence of a few studies, there
remains controversy about the relationship
of AR and CSOM, and more studies are
needed relating to the prevalence and role of
allergy in the pathogenesis of CSOM
(5,13,15,17,18). Therefore, we carried out
the current study to investigate the
association between allergic rhinitis and
CSOM in a population of adult patients
referring to the ENT-HNS University
Hospital in Rasht, the most populated city in
the north of Iran.
Materials and Methods
In a case-control study, 62 patients who
were candidates for tympanoplasty and
mastoidectomy due to established CSOM
were chosen, as well as 61 controls. The
controls were selected from patients who
were referred to the same hospital for
minor head and neck trauma, with no
history of CSOM or ear symptoms.
One of the cases and three of the controls
were excluded from the study due to an
inability to discontinue current medication
or the presence of dermographism.
All subjects were examined by ear, nose
and throat (ENT) specialists, and a thorough
medical history and physical examination
including anterior rhinoscopy and otoscopy,
were performed.
The study was performed in Amiralmomenin Educational Hospital and ENT
Research Center of Guilan University of
Medical Sciences (GUMS) in Rasht, Iran.
Written informed consent was obtained from
all the participants. The study protocol was
approved by the ethics committee of GUMS.
CSOM was diagnosed when there was a
history of chronic (persisting at least 3
months)
otorrhea,
accumulation
of
mucopurulent exudates in the external

262 Iranian Journal of Otorhinolaryngology, Vol.27(4), Serial No.81, Jul 2015

Allergic Rhinitis in Chronic Suppurative Otitis Media

auditory canal or middle ear and/or

perforated tympanic membrane on otoscopy.
AR was defined as the presence of signs
and symptoms of clinical rhinitis, including
watery anterior rhinorrhea, nasal obstruction
or congestion, nasal pruritus, and sneezing,
especially paroxysmal (according to
standard questionnaire (19)). Post-nasal drip,
pallor and swelling of the nasal and turbinate
mucosa not due to a recent common cold
could improve the clinical diagnosis.
Patients with two or more of the mentioned
suggestive symptoms for more than 1 hour
on most days were clinically diagnosed as
having AR (19). Clinical rhinitis was then
confirmed by a positive skin-prick test
(SPT). The diagnosis of AR was performed
by a separate ENT specialist who was blind
to the otologic situation of the patients.
All subjects underwent a SPT for 23
common
allergens
(AllergoPharma
Products, Reinbeck, Germany) relevant in
the north of Iran by a single immunologist,
who was blind to both the otologic and
rhinologic situation of participants.
Allergens included six types of grass, four
weeds, nine trees, two mites, cat allergen
and Cladosporium.
The positive control was histamine
hydrochloride (10 mg/mL) and the negative
control was diluent (AllergoPharma). The
mean wheal size was evaluated after 15
minutes, and SPT was determined as
positive when observing a wheal with a
mean diameter at least 3 mm larger than
wheals at the site of the negative control. All
subjects who were pregnant or had a history
of recent consumption of antihistamines,
immunotherapy with a specific allergen, or
dermographism were excluded from the
study. A positive SPT result could confirm
the robust clinical diagnosis of AR, and
negative results were considered as non-AR.
All data were analyzed using SPSS version
16. The 2 and Fisher exact tests were used
to test the significance of the differences
between the two groups. A p-value less

than 0.05 was defined as significant. Odds

ratio and 95% confidence intervals were also
calculated.
Results
A total of 61 cases (22 male and 39 female)
with a mean age of 37.114.3 years (range
1570 years) and 58 controls (27 male and
31 female) with mean age of 28.311.7
years (range 1570 years) completed the
study. There was a statistically significant
difference between the groups in terms of
age (P=0.047). Among the 61 cases with
CSOM, 26 (42.6%) patients had right ear, 25
(41%) had left ear, and 10 (16.4%) had
bilateral involvement. The femaleto-male
ratio was 1.7:1, but the difference was not
statistically
significant.
Thirty-seven
(60.7%) patients had a history of CSOM
from childhood (<18 years); others
developed the disease in adulthood. The
exact time of presenting CSOM symptoms
for those who developed CSOM from
childhood was unavailable.
The proportion of patients with clinical
rhinitis (allergic and non-allergic) was
significantly higher in the cases compared
with the control group (62.5% vs. 37.5%,
P=0.02). The prevalence of AR (i.e. clinical
rhinitis with positive SPT) was 24.6%
(n=15) and 13.8% (n=8) among cases and
controls, respectively. However AR was
more prevalent among patients with CSOM
compared with controls, although the
difference was not statistically significant
(P=0.065) (Table.1).
Using a logistic regression model, after
correcting for the age factor, the difference
between the two groups became significant.
Patients with AR and non-AR had a 3.27(95% CI=1.15-9.29; P=0.036) and 2.57(95% CI=1.01-6.57; P=0.048) fold increased
risk of developing CSOM, respectively,
compared with healthy individuals.Patients
with a history of childhood CSOM were
more likely to have AR than the control
group (29.7% vs.13.8%, P=0.038).

Iranian Journal of Otorhinolaryngology, Vol.27(4), Serial No.81, Jul 2015 263

Nemati S, et al
Table 1: Distribution of findings on clinical examination and SPT 1 in cases and controls
CSOM2
N=61

Control
N=58

P-value

Atopy

Atopy with Rhinitis

Without Atopy
Atopy without Rhinitis

15 (24.6%)
45 (73.8%)
1 (1.6%)

8 (13.8%)
48 (82.8%)
2 (3.4%)

0.28

Rhinitis

Allergic Rhinitis
Non-Allergic Rhinitis
Without Rhinitis

15 (24.6%)
20 (32.8%)
26 (42.6%)

8 (13.8%)
13 (22.4%)
37(63.8%)

0.065

10(17.2)
48(82.8)

0.23

SPT
1.Skin Prick Test

Positive
16(26.2)
Negative
45(73.8)
2. Chronic Suppurative Otitis Media

Among all participants with AR, 52.2%

(n=12) had a posterior nasal drip, 34.8%
(n=8) had lower turbinate hypertrophy, and
60.7% (n=14) had pallor and swelling of the
turbinate mucosa. Indoor allergens,

especially mites (dermatophagoides farina

and dermatophagoides pteronyssinus) were
the most prevalent allergens in both groups,
while outdoor allergens such as grass pollen
and weeds were less prevalent (Table. 2).

Table 2: Comparison of the frequency of the sensitivity to common allergens among case and control group.
Common Allergens
2

Grasses
Trees

Trees

CSOM1

Control

1(6.25%)

1(10%)

1(6.25%)

0(0%)

2(12.5%)

3(30%)

Weed5

1(6.25%)

1(10%)

Dermatophagoides farina

12(75%)

9(90%)

Dermatophagoides pteronyssinus

8(50%)

6(60%)

1(6.25%)

0(0%)

Cladosporium

Cat & dog epithelia

1(6.25%)
0(0%)
1. Chronic Suppurative Otitis Media
2. Grasses (Orchard grass, Velvet grass, Rye grass, Timothy grass, Kentucky grass, Meadow grass)
3. Trees (Alder, Hazel, Poplar, Elm, Willow tree)
4. Trees (Birch, Beech, Oak, Plane tree) 5. Weed (Mugwort, Nettle, Dandelion, Engl. Plantain)

Discussion
As CSOM is associated with recurrent
attack of otitis media and allergy and
contributes to chronic otitis media with
effusion, it is plausible that allergy also
contributes to CSOM. Previous studies
have reported wide prevalence of AR in
otitis media with effusion, ranging from
2489% (14,20,21). There are a number of
studies investigating the association of
CSOM and allergy, but they are

controversial and there is no wellestablished link between AR and CSOM

(5,18,22-24). The findings of this study
revealed that there is a relationship
between CSOM and AR. This finding is
congruent with the results of some
previous studies (5,18,22), but is in
contrast with the studies of Fliss et al. and
Bakhshaee et al. (23,24). A possible
explanation is that these differences may
be due to different methods of evaluating

264 Iranian Journal of Otorhinolaryngology, Vol.27(4), Serial No.81, Jul 2015

Allergic Rhinitis in Chronic Suppurative Otitis Media

AR. In Lasisis study, serum total

immunoglobulin E (IgE) concentrations
were regarded as allergic assessment tests
(18), while recent investigations show that
because of low sensitivity and specificity,
serum total IgE level is not a reliable
parameter for screening atopic diseases
(25). Bakhshaee et al. reported a 29.41%
prevalence of AR among adults with
CSOM, which was higher than the
reported prevalence in our study; however
they used serum total IgE level as an
assessment tool for allergy diagnosis. In
this study, the diagnostic criteria for AR
consisted of a positive SPT to at least one
allergen and/or a high level of serum total
IgE, as well as a positive clinical
examination and a history for rhinitis.
Total IgE levels higher than 100 IU/ml
were considered as a complementary test
in cases with an established history of
AR (24).
Fliss and colleagues collected data during
the childrens visit to the clinic by means
of a structured interview with the parents
using an appropriate questionnaire and by
extracting from the records if necessary
(23). Gorgulu et al. measured total and
allergen-specific IgE levels, as well as
blood eosinophil counts. Endoscopic
evaluations of the rhinopharynx were
performed as well. In addition, a positive
reaction to at least one of the 20 regional
aero-allergens was accepted alongside
allergen-specific IgE tests or total IgE
level >300 IU/ml or a positive rate of
blood eosinophil count (5). Hong and
colleagues performed allergy tests which
included total IgE and multiple
radioallergosorbent
chemiluminescence
assays to check for the presence of IgEmediated hypersensitivity (22).
CSOM could be a complication of acute
otitis media or otitis media with effusion,
both of which are more prevalent in the early
childhood (4). Also, AR more commonly
develops before the age 20 years (26). To

the best of our knowledge this is the first

study in this region that categorized patients
with CSOM into two groups according to
the time of onset of disease. In our study,
AR was more common in those who
developed CSOM from childhood. In
addition, most of the previous studies
evaluating the relationship of AR and
chronic otitis media had studied children. In
contrast, our study, like the one conducted
by Mion (17), studied adults. We could find
no association between positive SPT per se
and CSOM (Table 1), although we reported
an association between AR and CSOM in
our study. These findings are consistent with
the results of a study by Caffarelli and
colleagues (27) who demonstrated that only
the presence of AR and not a positive SPT
demands evaluation for otitis media with
effusion. In our study, the prevalence of
positive SPT in CSOM was also similar to
the mentioned study (26.2% and 26.74%,
respectively). Furthermore, in the present
study, indoor allergens were more prevalent
in the CSOM cases. This high prevalence
may be due to the humid climate in the north
part of Iran, as shown previously (28).
Conclusion
AR is more frequent in CSOM patients,
and may be a risk factor for CSOM.
Avoidance of recognized allergens may
reduce this risk and improve the outcome
of surgical therapy. Further studies in this
regard are warranted.
Acknowledgements
The authors are grateful to Dr. Esmaeel
Asgari for his scientific support in
performing this study. Our thanks also go to
Sinonasal
Research
center
of
Amiralmomenin hospital and the Research
Office of GUMS for their support.
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