慢性中耳炎病人耳膜破孔邊緣的組織病理學研究

The histopathological study in the edge of perforated eardrum in patients with chronic otitis media

黃鈞鼎(Chun-Ding Huang)

指導教授 ： 李飛鵬

臺北醫學大學/醫學院/臨床醫學研究所/碩士(2010年)

https://doi.org/10.6831/TMU.2010.00113

摘要

中文摘要

研究背景及動機
慢性中耳炎病人的耳膜破孔，大多不會自然癒合，其原因尚未完全被了解。一般認為是由於耳膜破孔邊緣的耳膜外層上皮及內層上皮形成連合(muco-epithelial junction, MEJ)所致。但在臨床的觀察，慢性中耳炎病人耳膜破孔除了反覆感染或耳漏之外，我們常會見到所謂永久性破孔，在不同的時間，會有不同的型態變化；有的形成新的肉芽組織，有的呈現角質上皮移行，有的破孔甚至會自行癒合。過去所知的「永久」的瘢痕性破孔，或是MEJ造成的的癒合作用停滯，似乎不足以解釋這些臨床變化。本研究希望藉觀察耳膜破孔邊緣的組織病理學，進一步探討影響耳膜癒合的因素。

研究材料與方法
本研究目前共收集43例慢性中耳炎合併中心型耳膜破孔的病人檢體，將鼓室成形術中耳膜破孔邊緣切除的組織標本，作成系列組織切片，以Hematoxylin、Eosin、cytokeratin 7及19免疫抗體染色，以及Collagen type I與III免疫抗體染色，觀察耳膜破孔邊緣MEJ的分布，組織形態的變化。並追蹤病人的手術後耳膜的表皮移行完整程度，再與臨床表現及病理組織觀察等變項互相印證。

結果
本研究的43個案例中，19例為男性，24例為女性，年齡介於到20歲到77歲之間，平均為45歲。其中年輕組有15例，年長組有28例。術後表皮移行完整的有36例，不完整的有7例。其中有28例的MEJ在檢體的系列切片觀察不到，有5例檢體具有連續的的MEJ，有10例檢體的MEJ在檢體的系列切片見到不連續的分布。Cytokeratin 7及19免疫抗體染色大多數的結果一致，染在切片中耳膜內側的mucosa層，但有10例檢體的Cytokeratin 19更出現在麟狀上皮的基底層；Collagen type I與III免疫抗體染色也顯示，在不同的傷口癒合狀態下，Collagen type I與III的分布多寡會有差異。各變項與術後表皮移行完整之間，年齡分組具有顯著差異( p=0.037)，其餘有collagen type III/I ratio (p=0.02)及MEJ (p=0.047)達顯著差異，經多變項回歸檢視後，對術後表皮移行完整與否，也只有collagen III/I ratio及MEJ足以達到顯著差異(p=0.007)。與年齡分組呈顯著相關的有術後表皮移行完整與否( p=0.037)、collagen type III/I ratio (p=0.0)及wound healing stage等，而其餘各個變項未達顯著程度。

結論
本研究的結果顯示慢性中耳炎耳膜破孔邊緣MEJ的變化，即表皮在耳膜破孔邊緣的變化，和纖維層Collagen type III/I比例，會影響術後的表皮移行完整程度。而MEJ的位置，並非一成不變的存在於耳膜破孔邊緣，至少與先前的研究結果有所差異。同時本研究也發現有10個案例的複層麟狀上皮，在基底層對CK-19抗體呈濃染，這也是第一次在人類耳膜組織的研究中，證實耳膜破孔邊緣也有幹細胞的存在。這些結果應具有更進一步研究及應用的價值。

關鍵字

中耳炎 ； 組織病理學

並列摘要

Abstract

Introduction
Eardrum perforation in patients with chronic otitis media results from failure in spontaneous healing process when it ruptured. The hypothesis of muco-epithelail junction (MEJ) formation over the perforation edge is widely accepted to explain the persistent pathophysiological state. However, clinically there are still dynamic changes noted in some chronic perforations. The aim of this study is to investigate the possible factors engaged in healing process of perforated eardrum from chronic otitis media through observation of the histopathological sections.

Material and Methods
In our study, 43 specimens from the eardrum of chronic otitis media were enrolled. Series section and immunohistochemical stain with Hemotoxylin, Eosin, Cytokeratin 7 and 19 antibody, and Collagen type I and III antibody were performed each case. Statistic analysis was done to compare these variables with the postoperative epithelial migration ability.

Result
There were 43 cases enrolled in this study. Nineteen cases were male and 24 cases were female. The age ranged from 20 to 77 years with average 45 years. Fifteen cases were in the young group; twenty-eight cases were in the aged group. Thirty-six cases showed complete postoperative re-epithelialization of squamous epithelium on the eardrum surface and others not. Histopathological examination revealed 28 cases without MEJ, 5 cases with continuous MEJ, and 8 cases with interrupted MEJ. The basal layer of squamous epithelium was positive stained with CK-19 in 10 cases. Collagen type I and III showed different in distribution with different wound healing stage. Statistically, age group ( p=0.037), collagen type III/I ratio (p=0.02) and MEJ (p=0.047) showed a significant correlation with the postoperative re-epithelialization of squamous epithelium. However, multiple linear regression model showed only the MEJ and collagen type III/I ratio significant correlated with the postoperative re-epithelialization of squamous epithelium (p=0.007). On the other hand, collagen type III/I ratio (p=0.0) and wound healing stage were also significant correlated with the age group.

Conclusions:
The result in this study showed a significant correlation between the MEJ distribution, collagen type III/I ratio and the postoperative re-epithelialization of squamous epithelium. And the MEJ distribution in our study is quite different from the previous studies. The 10 cases, with CK-19 positive stained basal layer of squamous epithelium, showed an evidence of stem cells in the perforated edge in patients with chronic otitis media in a very first time. These results may contribute to further investigations and studies in this field.

並列關鍵字

otitis media ； histopathology ； muco-epithelial junction

參考文獻

1. Somers, T., et al., Histology of the perforated tympanic membrane and its muco-epithelial junction. Clin Otolaryngol Allied Sci, 1997. 22(2): p. 162-6.

2. Boedts, D. and B. Ars, Histopathological research on eardrum perforations. Arch Otorhinolaryngol, 1977. 215(1): p. 55-9.

3. Berger, G., Nature of spontaneous tympanic membrane perforation in acute otitis media in children. J Laryngol Otol, 1989. 103(12): p. 1150-3.

4. Graham, M.D., A Longitudinal Study of Ear Disease and Hearing Loss in Patients with Cleft Lips and Palates. Ann Otol Rhinol Laryngol, 1964. 73: p. 34-47.

6. Karma, P., Middle ear epithelium and chronic ear disease. Acta Otolaryngol Suppl, 1972. 307: p. 1-107.