TRANSFORMATION OF EFFUSION AND FORMATION OF GRANULATION TISSUE IN PATHOLOGIC PROCESS OF OTITIS MEDIA

ACADJ XJTU 2003,15(2):170- 172TRANSFORMATION OF EFFUSION AND FORMATION OF GRANULATIONTISSUE In PATHOLOGIC PROCESS OF OTITIS MEDIA WITH EFFUSIONWei Junrong(韦俊荣)*，Zhang Qing(张青)“，Zhang Quanan(张全安)*De partment of Otorhinolaryngology，Second Hospital of Xi'an Jiaotong University， Xi 'an 710004,China.ABSTRACT: Objective To explore the diversity of stagnant effusions and the pathologic processes leading togranulation tissue formation in otitis media with effusion( OME). MethodsTemporal bone slides from 306 ears withOME were studied histopathologically under the light microscope. Results Results of this study revealed a pathologicprocess in witch the type and the condition of stagnant effusion in the middle ear cleft was a variable in the dynamics ofOME progression from an early stage to an advanced stage. The location of granulation tissue and retentive effusion werefound to be closely related. Conclusion Early stage granulation tissue formation exhibited a pathologic process in whichgranulation tissue formation occurred only in areas where effusion had stagnated or was absorbed. The incidence of theretentive effusion and formation of granulation tissue was much higher and the pathologic changes most extensive in thearea around the ossicular chain.KEY WORDS: transformation; formation; effusion; granulation tssue; otitis mediaCLC number: R764Document code:AArticle ID:1671-8267( 2003)02-0170-03Except for in a minority of the cases with carlyted，decalci fied，dechydrated, embedded in celloi-stage otitis media (OM) or sequelac, effusion is thedin, and sectioned at a thickness of 20 μm、Everymost common inflammatory product among the va-tenth section was stained with hematoxylin and eo-rious OM type. It is not clear whether untreated ef-sin for histologic observation.fusion results in chronic， irreversible pathologicThe temporal bones selected for this study werechanges in the middle ear cleft and mastoid-classi fied into two groups: Group A, as early patho-Chronic otitis media (COM) is mainly indicated bylogic stage OME, had evidence of effusion，swollenthe formation of granulation tissue. Granulation tis-mucosa, and infiltration of inflammatory cells, butsue is the most common L5.6 and significant repre-no granulation tissue and other intractable pathologicsentative pathologic tissue of COM. Studies on thetissues; Group B， as advanced pathologic stagefactors promoting granulation tissue formation, theOME，had evidence of effusion and granulation tis-pathologic mcchanisms， the pathologic behavior ofsue or other intractable pathologic tissue.granulation tissue formation， and on how the areasTemporal bone slides with evidence of effusionof granulation tissue formation are related to thewere classi fied histopathologically, and labeled aspathologic transformation or retentive effusion ,serous ( SOM )，purulent( POM )， mucoidwhich are important to further understand the com-(MOM)，sero-purulent ( SPOM)，and mucoid-pu-plex pathologic process involved and to develop ef-rulent ( MPOM)，according to their de finitions .fective methods of trcatment.The incidence of retentive effusion and granu-lation tissue was compared for each of the followingMATERIALS AND METHODSareas of the middle ear cavity: The anterior semi-From the human temporal bone collection ofmiddle ear cavity (ASMC), the area around the osthe Otopathology Laboratory at the University oficu中国煤化工antrum-mastoid areaMinnesota Otitis Media Research Center，temporal(AMche area (RWN)，and:THCNM H G,bone slides from 306 ears were selected from overfacial recess (FK) 1ne ASMC area was defined as500 cars with various types of OM and studied un-bounded posteriorly along a perpendicular line fromder the light microscopy. Temporal bones had beenthe top of the cone of the tympanic membranc to theremoved芳閂数据YFixed in 10% formalin, defat-promontory, anteriorly by the isthmus of the eustachian-一171-tube (ET)，and superiorly by tympanic diaphragm.RESULTSThe OC arca included the attic and posterior-superi-In Group A (155 ears), the incidence of POMor tympanic cavity above the level of the inferiorwas much higher and that of SOM much lower thanedge of the stapes footplate.in Group B (sce Fig. 1). SPOM was the most com-The incidence of retentive effusion was investi-mon effusion type found in Group A，whereas .gated histopathologically and the quantity of granu-SOM was found most often in Group B.lation tissue in the different areas was evaluated andThe overall incidence of retentive effusion wassemiquantified as mild (十)，moderate (++)， or sC-lowest in the ASMC but much higher in the OC,vere (卅) to determine the severity of pathologicAM，RWN and FR areas (see Table 1). In Group B .changes. Histopathological observation focused on(151 ears)，the incidence of the granulation tissuethe pathologic behavior of retentive effusion trans-was lowest in the ASMC，but much higher andformation and the formation of granulation tissue,more extensive in the OC and other areas (see Tableand the relationship between effusion retention and2，Fig. 2). The incidence of granulation tissue wasgranulation tissue formation in the above mentionedconsistently associated with retentive effusion inarcas of the midle car cleft.same area of the middle ear cleft (see Fig. 2).Table 1 The incidence of retentive effusion in different areas of the middle ear cleftASMCOCRWNFRAMGroup%Group A (155 cars)7145. 814895.513788.412681.313687.8Group B (151 ears)7650.314092.711676.810166.814294.0 .Table 2 The incidence of granulation tssue in different areasRelmtive Kilusionof the middle ear cleft for group B[n(%)]■Framdatim 1wmr90% tLocation+++ and卅80%11(7.3) 5(3.3)0(0)5(3.3)70%47(31.1) 56(37.1) 34(22.5) 90(59. 6)60%50%6R WN39(25.8) 48(31.8) 33(21.9) 81(53. 6)402R26(17.22)37(24.5) 20(13.3) 57(37.8)30953(35.1) 52(34.4) 22(14.6) 74(49.0)20%10%+: mild; H: moderate; 世: severe0C40%GrupBFig.2 Relationship between the incidence of retentive30%effusion and granulation tissue in different259areas of the middle ear cleftal layer into the retentive effusion，forming granu-15%lation tissue in the retentive effusion (see Fig. 3).In some cases with this kind of proliferation, the fi-5%broblasts looked like a“bamboo shoot” inserted di-POMSOMMOM SPOM PMOMrectle into the retentive effusion, forming a“lumpshape”of granulation tissue (see Fig. 4). In someFig. 1 The incidence of various forms of OMEIn the temporal bone slides with early-stagecases，the proliferating fibroblasts grew first alonggranulation tissue formation ( immature granulationthe中国煤化工e effusion to form antissue)，the granulation tissue was primarily formedencaYHC N M H Give effusion. In someby two types of fibroblast proliferation in subepi-temporal bonc slides， mature granulation tissucthelial space. One type of fibroblast proliferateformed by proliferative fibroblasts took the place offrom the subepithelial space， with or without newthe retentive effusion. Among all 151 cars of Groupvessel deVei6熬攝t, through the gap of the epitheli-B，however, there was no evidence of proli ferativefibroblasts growing into any area of the middle earIn group B (COME)，many slides showed that ma-cleft where there was no retentive cffusion .ture granulation tissue took the place of the arcaswhere effusion used to retain in. These results sug-gest that during OME，granulation tissue originatesin the subepithelial space during the absorption/ cganizing process of retentive effusion, and that ab-sorption and trans formation of retentive effusion .and the formation of granulation tissue occur simul-taneously, and that granulation tissue can form onlywhere effusion has stagnated or is being absorbed.Fig.3 Chronic serous otitis media ，proliferating fibro-Therefore，retentive effusion is a prerequisite forblasts under the epithelium grow through the epitheliumgranulation tissue formation.(arrow) into effusion (E) retained in a big air cell aroundthe antrum, beginning to form early- stage granulation tis-Our investigation showed that in the areas aroundsue (G). (HE， X14)the ossicular chain above and below the tympanic dia-phragm, the granulation tissue was most apparent (Table2). The reason may be that in the inflammatory processof OM，swollen mucosal folds attached to the ossicularchain can casily encase effusion, and lcad to the forma-tion of granulation tissue. Since the most importantfunctional structures of the middle car cleft are locatedin the area of the OC，future studics should focus onways to prevention formation of intractable tissue pa-Fig.4 Chronic mucoid-prulent otitis media, note prolifer-thology in this area.ating fibroblasts formed granulation tissue (G) in subepi-This study also showed that various carly forms .thelial space and extended through the epithelium ( arrow )into effusion (E) retained in a big mastoid cell, formingof OME progressed into advanced form of otitisgranulation tissue (G) in the effusion.( HE，X14)media，and that the absorptive process of retentiveThe second type of proli ferative fibroblast formedeffusion into the subepithelium can lead to granula-granulatiohn tissue by widening subepithelial space irtion tissue formation. The longer the effusion stag-the mucosa, especially in the cul- de- sac areas such asnates，the greater the opportunity for devclopmentperiphery of mastoid cells where the efusion tended toof granulation tissue. Therefore, in the treatmentbe retained. In the ASMC arca where the incidence ofof OME，it may be important to drain the retentiveretentive effusion was lowest, there was lttle fibroblastcffusion, especially from posterior arca of the mid-proliferation in the subepithelial layer, and less granula-dle ear cleft before granulation tissue formation， intion tissuc formation.order to prevent progression of the disease toward amore advanced pathologic stage.DISCUSSIONAcknowledgmentsIn this study，we first in the world found thatWe gratefully thank Noriko Morizino for thegranulation tissue was primatily formed by prolifer-presentation of histologic sections， Sherry Fultonation of fibroblasts in the subepithelial space break-for her photographic work, and Ginny Hansen anding the epithelial layer and growing into the reten-JoAnn Knox for tvping the manuscript.tive effusion，with granulation tissue gradually o-REF中国煤化工vertaking the retentive effusion， or by fibroblastY片CNMHGproliferation with widening the subepithelial space[1]CD，Klein JO (Eds). 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