|Year : 2015 | Volume
| Issue : 4 | Page : 238-242
Myringosclerosis in children with chronic renal failure on regular hemodialysis
Mohammad Waheed El-Anwar1, Ahmed Shaker El-Aassar1, Hany El-Sayed2
1 Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Pediatric, Faculty of Medicine, Zagazig University, Zagazig, Egypt
|Date of Web Publication||16-Oct-2015|
Mohammad Waheed El-Anwar
Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Zagazig University, Zagazig
Source of Support: None, Conflict of Interest: None
Objective: To find out a possible association between children with chronic renal failure (CRF) on regular hemodialysis and myringosclerosis (MS). Materials and Methods: This study included 41 patients with CRF on regular hemodialysis 3 times weekly who were compared with 41 normal children without history of ear problems matched for age and sex serving as a control. Children were assessed by history, otoscopic examination, and laboratory assessment, at the time of ear examination. Results: The incidence of affected (MS) ears in CRF children was 9/82 (10.976%). While in healthy control was 4.878% (4/82 ears) with nonstatistically significant difference (P = 0.148). Regular hemodialysis for >3 years showed significantly more MS with no significant relation to the serum levels of calcium, phosphorus, parathyroid hormone, or other recorded laboratory findings. Conclusion: Regular hemodialysis for CRF more than 3 years is associated with significantly more MS incidence when dialysis duration exceeds 3 years with no significant relation laboratory findings.
Keywords: Calcium, Chronic renal failure, Hemodialysis, Myringosclerosis, Tympanic membrane
|How to cite this article:|
El-Anwar MW, El-Aassar AS, El-Sayed H. Myringosclerosis in children with chronic renal failure on regular hemodialysis. Indian J Otol 2015;21:238-42
| Introduction|| |
Tympanosclerosis (TS) is characterized by sclerotic plaques in the tympanic membrane (TM), middle ear cavity, ossicular chain, and/or rarely in the mastoid cavity caused by hyaline degeneration and deposition of calcified collagen fibrils in the submucosa. Myringosclerosis (MS) is TS involving only the TM.,
The cause and pathogenesis of TS are not clearly understood, but middle ear infections, tympanic injuries, myringoplasty, myringotomy, and/or ventilation tube insertion were attributed as initiators of TS. Various cells were demonstrated in MS, mainly macrophages and fibrocytes, express osteopontin, osteoprotegerin, and osteonectin molecules, which share in the pathogenesis of MS. TS has been also suggested as an autoimmune ear disease as decreased plasma fibronectin level has implicated the role of autoimmunity in TS pathogenesis.
The low phosphate excretion, reduced hydroxylation of 25-hydroxyvitamin D to calcitriol (1,25-dihydroxyvitamin D) and resulting hypocalcemia in chronic renal failure (CRF) patients affect the bone, gut, and parathyroid glands. Hypersecretion of parathyroid hormone (PTH) is initially appropriate by elevated calcium phosphate release from bone and increasing urinary phosphate excretion (through a diminution in proximal reabsorption). In early stages, PTH can correct both hypocalcemia and hyperphosphatemia. With worsening kidney function, decline phosphate retention is closely to the common development of secondary hyperparathyroidism. The high circulating PTH levels are intimately associated with osteodystrophy and cardiovascular disease in dialysis patients.
Various forms of calcifications are demonstrated in systemic conditions, including CRF as a result of calcium and phosphorus dysmetabolism.
The aim of the current study was to find out a possible association between children with CRF on regular hemodialysis and MS and to check relation of MS to laboratory findings of those patients.
| Materials and Methods|| |
This cross-sectional study was conducted on 41 CRF patients (aged ≤18 years) who underwent regular hemodialysis for 6 months at least in pediatric nephrology unit from October 2014 to December 2014 (group A), comparing them with 41 normal children with no previous history of ear problems matched for age (P = 0.2968) and sex (P = 0.8248) [Table 1] at the same duration serving as a control (group B). Both groups is of the same race and nationality.
|Table 1: Differences between in CRF (study group) and normal children (control group)|
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A written formal consent to participate in the study was signed by the relatives of the patients. The study was approved by the University Institutional Review Board and was performed in accordance with the Declaration of Helsinki. Syndromic patients and subjects who underwent any type of ear intervention before were excluded.
All patients were subjected to full history taking, general and local examination, routine laboratory tests for CRF (Ca, PO4, Mg, PTH, serum iron, complete blood count, serum urea, serum creatinine, etc.), at time of ear examination. All patients are on regular hemodialysis 3 times weekly by low flux membrane dialyzers. Otoscopic assessment for MS was performed.
The MS size was graded as: Grade I: MS involving <1 quadrant (25%) of the pars tensa, grade II: Involving from 1 quadrant (25%) up to 2 quadrants (50%) of the pars tensa, grade III: Involving more than 2 quadrants (50%) up to 3 quadrants (75%) of the pars tensa, and grade IV: Involving more than 3 quadrants (75%) of the pars tensa.
Results were compared statistically using the SPSS program version 17.0 (Chicago, Illinois, USA). The Chi-square test was used as a nonparametric test to compare between qualitative data, and t-test was used to compare between mean and standard deviation (SD) values. When P < 0.05 it is considered statistically significant.
| Results|| |
This study included 41 Patients suffered from CRF and on regular hemodialysis 3 times weekly by low-flux membrane dialyzers. Group A had age ranged from 5 to 18 years (mean, 11.88 ± 3.59). There were 19 (46.34%) male and 22 (53.66%) female, while the control group (group B) comprised 41 normal children, the age range was from 4 to 18 years (mean age = 10.97, SD = 4.23); 18 (43.9%) male and 23 (56.1%) female. Control and study groups were matched for age (P = 0.2968) and sex (P = 0.8248) [Table 1].
According to the duration of dialysis, 17 (41.5%) patients (6 males and 11 females) started dialysis since ≤3 years and 24 (58.5%) patients (13 males and 11 females) started dialysis for duration more than 3 years [Table 2].
After examination, we found 8 cases suffer from MS (4 males with 4 ears and 4 females with 5 ears [total = 9 ears]), so the incidence of affected ears in CRF children (9/82 ears) was 10.976%. While in healthy control was 4.878% (4/82 ears) with nonsignificant difference (P = 0.148).
In CRF children, 6 ears (3 male and 3 female) showed mild MS, 2 ears (1 male and 1 female) showed moderate MS, and one female ear had sever MS. While in healthy children, 3 mild and 1 moderate MS were detected with nonsignificant difference with group A [Table 1].
After we compare our results with laboratory results, duration of dialysis, and other medical problems, we reported that only one female systemic lupus erythematosus with duration of dialysis <3 years had moderate MS at one ear, while the rest (8 ears) started dialysis for more than 3 years which make significant difference (P = 0.0364). Also, the comparison with serum iron showed near significant difference, while other laboratory results showed nonsignificant differences. Results are shown in [Table 2].
After comparing healthy children with CRF patients on hemodialysis for >3 years, a significant statistical difference was detected reflecting significant cumulative effect of dialysis on the ears (P = 0.0001) [Table 3].
| Discussion|| |
TS is the final stage of a process that begins as an acute or chronic inflammation of lamina propria of the middle ear. The pathology that results in TS was described to start with excessive collagen deposition in the lamina propria of the middle ear mucosa, followed by hyalinization, calcification, and bone or cartilage metaplasia.,,
Few studies have tried to find out etiological and pathogenic relations with certain factors. Schiff et al. and Schiff and Yoo  described an association between TS and the autoimmune reaction, while Koç and Uneri  have supposed a genetic predisposition.
The MS plaque calcification process is similar to other forms of pathological calcification. Ectopic calcification has long been investigated structurally and ultrastructurally. Basically, two methods for calcium crystals deposition in tissues other than bone are defined, namely metastatic, and dystrophic calcification. Metastatic calcification develops passively by precipitation of serum calcium phosphate crystal in patients had high serum levels of such crystals. It appears that, this type of calcification depends on hypercalcemia and hyperphosphatemia, which have an important role in the process. Dystrophic calcification comprises a complex active cell mechanism that has been widely studied without obvious success. In CRF, it is noticed as calcification of arteries and viscera.,,,,
In CRF, altered glomerular filtration rate results in phosphate retention in the serum. Excess serum phosphorus has a tendency to bind to free calcium-producing precipitates that may initiate ectopic calcification. This precipitation diminishes serum calcium levels stimulating the parathyroid glands to produce PTH. PTH works on bone metabolism and could demineralize bone. The released minerals reach the blood stream and may create new calcification.
In this study, the male/female ratio of MS in both groups was 4/5 near to previous reports.,,
In this study, there was no significant difference between the children with CRF on hemodialysis and healthy children in MS, while there was significant difference between children with CRF on hemodialysis >3 years in comparison to healthy children.
Unlike our results, Neto et al. found statistically significant higher MS incidence among CRF patients with no influence on the duration of hemodialysis on the occurrence of MS, but they include both children and adults in their study.
Kabaya et al. and Leskinen et al. were also unable to find any effect related to the duration of dialysis on the incidence of vascular calcification in hemodialyzed patients. However, examination at this trial had been done once, so we need regular examinations to follow-up the new cases and the severity changes in the affected cases.
This study reported that there was no influence of serum calcium, phosphorus, magnesium, and parathormone levels on the incidence of MS, which is similar to the results of Neto et al. and Alfrey.
Caldas et al. observed significantly higher rates of MS in CRF patients relative to the control group with no significant relation to serum calcium, phosphorous, and parathormone levels.
Kahnooj et al. and Qunibi et al. found a positive relationship between the calcium phosphate product value and the severity of aortic insufficiency. Türkcü et al. and Abrams  found that corneo-conjunctival calcifications were higher in patients with CRF.
However, serum calcium, phosphorus, magnesium, and parathormone levels were measured only once in this trial upon inclusion of patients; these measurement, therefore, are a picture of the metabolic situation at a given moment, rather than a well-established dysmetabolic pattern in these patients. Their calcium, phosphorus, and PTH levels may vary significantly according to the progression of kidney failure, to dialysis and to other associated conditions such as diabetes, diet, and others.
So, MS was detected significantly more in children on regular hemodialysis for >3 years with no significant relation to the serum levels of calcium, phosphorus, PTH, or other recorded laboratory findings. Also, there is no significant effect of gender or CRF on the incidence of MS. Therefore, regular examination and follow-up for sites of calcium deposition is recommended. The role of different methods and protocols of dialysis, filters, dialysis fluid, and life style on calcium deposit need to be investigated.
| Conclusion|| |
Regular hemodialysis for more than 3 years is associated with significantly more MS in CRF children with no significant relation to the serum levels of calcium, phosphorus, PTH, or other recorded laboratory findings. Also, there is no significant effect of gender or CRF on the incidence of MS.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]