| Part 1:Construction and verification of a clinical prediction model for hearing recovery in chronic otitis mediaBackgroundOtitis media is a common disease and frequently-occurring disease in our country.It has a huge impact on hearing and affects people’s quality of life and health.Otologists have never stopped their research on otitis media and audiology.In the United States,hearing impairment is the third most common chronic disease,after hypertension and arthritis.Guidelines for clinical classification and surgical classification of otitis media in our country(2012 edition),otitis media is divided into secretory otitis media,suppurative otitis media,middle ear cholesteatoma and special types of otitis media.Suppurative otitis media can be divided into acute suppurative otitis media and chronic suppurative otitis media.Patients with otitis media requiring surgical treatment account for a large proportion,especially chronic suppurative otitis media and middle ear cholesteatoma are common types of otitis media that require surgical treatment in clinical practice.These patients often have urgent desire to seek medical treatment and have relatively high expectations for hearing recovery after surgery.To a certain extent,doctors also need to predict the patient’s hearing recovery after surgery,which requires proper evaluation of possible risk factors before surgery,and proper handling of factors that may have a greater impact on hearing during surgery.However,there are many factors that affect hearing recovery.According to literature reports and our clinical experience,we know that the patient’s age,the presence or absence of rhinitis,the integrity of the ossicular chain,whether the artificial ossicle is implanted,the function of the eustachian tube,whether the ears are wet,whether there is calcification or granulation around the ossicular chain,the operation method,etc,can affect the postoperative hearing.There are many studies to prove the relationship between these factors and hearing recovery,but there are relatively few studies on the relationship between multiple factors and the prognosis of hearing recovery.Therefore,it is urgent to find a method to evaluate these influencing factors and make appropriate judgments on the prognosis of hearing.Nowadays,clinical research is receiving more and more attention.Clinicians often have a large amount of patient data.If they can synthesize,summarize and count these data,they can often achieve better research results.This often requires more requirements for trial design and statistics.With the development of precision medicine and individualized treatment,and the advent of the era of big data,our treatment of patient diseases has become more and more refined.As a quantitative tool for risk and benefit assessment,clinical predictive models are becoming more and more common in daily medical research and practice.Clinical prediction models are also called risk assessment models,including diagnostic models and prognostic models.With the help of clinical prediction models,researchers can more accurately screen out more suitable research subjects,patients and doctors can better make some favorable medical decisions,and health managers and government departments can better manage medical quality.Reasonable allocation of medical resources,based on the R language,the method of constructing a nomogram prediction model has gained more and more in-depth understanding of the majority of researchers,and has made great progress in recent years.Of course,any forecasting model also has its limitations and shortcomings,and it also needs to be dynamically updated and improved.In the current special period of the global epidemic of COVID-19,prediction models have also played a major role in the field of public health.In May 2020,Lanzhou University developed and launched the "Global New Crown Epidemic Forecast System"(http://covid-19.lzu.edu.cn/index.htm)for the first time.And the prediction of newly confirmed cases in the region.Academician Zhong Nanshan commented that the system "some of their predictive models are still quite reliable." It can be seen that the prediction model is also closely related to our daily life.The practical application of clinical prediction models in otolaryngology has gradually received more and more attention,including the establishment of survival prediction models for hypopharyngeal cancer,and the establishment of prognostic models for maxillary sinus cancer.Chronic otitis media in our article refers to most of our common chronic suppurative otitis media and middle ear cholesteatoma that require surgery.We established a predictive model of hearing recovery after chronic otitis media by analyzing the data and calculating statistics.Objective:To explore the factors affecting the hearing recovery of patients with chronic otitis media(herein referred to as chronic suppurative otitis media and middle ear cholesteatoma),establish a clinical prediction model for hearing recovery,and verify the accuracy of the model.Provide personalized risk estimates for hearing recovery to strengthen preoperative consultation and help patients set realistic expectations.To provide doctors with preoperative hearing predictions and respond to possible high-risk factors during the operation.Provide a new idea for evaluating postoperative hearing.Methods:Retrospective analysis of the data of patients with chronic suppurative otitis media and middle ear cholesteatoma who were hospitalized in our hospital from January 1,2012 to September 30,2020.Collect the patient’s pure tone hearing threshold measurement results,basic information,medical history,surgical methods,the integrity of the ossicular chain,the type of artificial ossicular prosthesis implanted,whether there is calcification and granulation tissue around the ossicular chain,and whether there is the eustachian tube dysfunction,whether there is neurological deafness or mixed deafness,dry or wet ears before surgery,semicircular canal fistula,secondary surgery,diabetes,rhinosinusitis,etc.These patients were randomly divided into modeling group and verification group.Univariate analysis and multivariate logistic regression analysis were used to investigate the association of patients with hearing loss recovery.Use prognostic factors to establish a nomogram to predict the postoperative recovery of otitis media.The model is internally validated by the guided program and its performance is evaluated in terms of identification,calibration,and clinical validity.All statistical analysis was performed using Empower Stats software based on R language,and P<0.05 indicated that the difference was statistically significant.Results:This study finally included 2146 patients with chronic suppurative otitis media and middle ear cholesteatoma;the modeling group included 1610 patients(44.1[14.7]years;733 men[45.5%]),the validation group included 536 patients(234 males[43.7%]).Multivariate logistic regression analysis showed age,duration of disease,surgical method,implantation of ossicular prosthesis,granulation or calcification around the ossicular chain,integrity of the ossicular chain,eustachian tube dysfunction,mixed hearing loss,semicircular canal fistulas and secondary operations are related to hearing recovery.A nomogram based on these variables is constructed.The area under the curve was 0.797(95%CI,0.778-0.812)in the modeling group and 0.798(95%CI,0.7605-0.8355)in the validation group.Conclusion:This study proved the clinical factors related to hearing recovery in patients with chronic suppurative otitis media and middle ear cholesteatoma.The nomogram developed using these data can provide personalized risk estimates for hearing recovery to enhance preoperative consultation and help patients set realistic expectations.Part 2:The expression and significance of periosteal protein in middle ear cholesteatomaBackground:Middle ear cholesteatoma has attracted much attention in the inflammatory diseases of the middle ear.It is characterized by the presence of highly proliferated keratinized squamous epithelium in the middle ear cavity and its damage to adjacent bone.According to the guidelines for clinical classification and surgical classification of otitis media(2012),middle ear cholesteatoma specifically refers to acquired cholesteatoma,excluding congenital cholesteatoma.Squamous epithelial tissue grows in the middle ear and mastoid cavity,and its growth mechanism,pathology and outcome are different from those of chronic suppurative otitis media.The disease can be accompanied by otitis media with bacterial growth.Middle ear cholesteatoma also has a greater impact on hearing,especially the ossicles and surrounding bones are often damaged to varying degrees,and surgical intervention is usually required.At present,there are four theories about the pathogenesis of middle ear cholesteatoma,including ① invaginated pocket theory;② epithelial migration theory;③basal cell layer hyperplasia theory,④metaplasia theory.The specific pathogenesis is still inconclusive.In 2016,the European Society of Otology and Neurology(EAONO)and the Japanese Society of Otology(JOS)also defined,categorized and staged middle ear cholesteatoma[3],and issued a joint consensus statement,which defined cholesteatoma is formed by keratinized squamous epithelium and keratinous fragments in the subepithelial connective tissue that accumulate in the tympanum and(or)papillae to form masses,with or without peripheral inflammation.It also pointed out that the repeated infection and inflammation of the connective tissue under the epithelium of cholesteatoma resulted in bone resorption in the adjacent area,and it was staged according to the different parts of the cholesteatoma(STAM system).But despite this,the pathogenesis and pathophysiological process of cholesteatoma are still unclear.The current research on cholesteatoma focuses on the molecular biology of epithelial cell proliferation and apoptosis.Bone destruction of middle ear cholesteatoma is activated and regulated by inflammation.Bone destruction of middle ear cholesteatoma is activated and regulated by inflammatory response.Otitis media is A highly activated inflammatory process that releases a variety of cytokines.Osteoclasts degrade bones,but at the same time they are also protected by cytokines,growth factors,adhesion molecules and osteostimulating hormones.Tumor necrosis factor,interleukin(IL)-1,IL-6 and OPG/RANKL present in cholesteatoma and granulation tissues promote osteolysis,increase the damage to the middle ear,and are heard in patients with middle ear cholesteatoma The incidence of bone chain damage is higher than that of chronic suppurative otitis media.Research by Mustafa A et al,also found that patients with middle ear cholesteatoma have a higher rate of damage to the ossicular chain than those with otitis media without cholesteatoma.The most commonly damaged ossicular component is the incus,followed by the stapes and malleus.It can also be seen from the first part of our research that the probability of damage to the ossicular chain in patients with middle ear cholesteatoma,which affects hearing recovery higher.Periostin,also known as POSTN,is an extracellular matrix protein with a molecular mass of about 90kDa.It has been found to be expressed in various organs and tissues of the human body and is involved in the pathogenesis and pathological processes of different diseases.In osteoarthritis,bone metabolism,diabetic nephropathy,asthma,skin repair,tissue fibrosis,tendon remodeling,a variety of tumor diseases,rhinitis and other diseases,periostin is involved in the pathological mechanism and has a certain regulatory effect.In otolaryngology diseases,periostin has also been studied.Nobuo et al.found that it is widespread in chronic inflammatory diseases,such as bronchial asthma,atopic dermatitis,myocardial repair and remodeling after myocardial infarction,eosinophilic esophagitis,proliferative diabetic retinopathy,bone marrow fibrosis and fibrosis remodeling play an important role.Periostin is involved in the process of disease changes in allergic rhinitis,chronic sinusitis with nasal polyps,and eosinophilic otitis media.In the nasal mucosa of patients with chronic rhinosinusitis and nasal polyps,Th2 cytokines often have a distribution advantage.It is speculated that periostin may be an important mediator and participate in Th2 helper T lymphocyte-mediated inflammation and extracellular pathological processes such as matrix remodeling,fibrosis,tumor angiogenesis and tissue remodeling.Researchers such as Hisanori found that positive expression of periostin was found in the basement membrane and extracellular matrix of immunohistochemical sections of the middle ear in all patients with eosinophilic otitis media with or without asthma.Because cholesteatoma also has many tumor-like features including abnormal proliferation,migration and invasion,and can damage bone(especially the damage to the ossicular chain is more serious),abnormal bone hyperplasia sometimes occurs.Therefore,we speculate that the expression of periostin in middle ear cholesteatoma may change.However,there is no report on the expression of periostin in middle ear cholesteatoma tissue,so we have done further research on its expression in middle ear cholesteatoma.Objective:To find new histological predictors for the predictive model of postoperative hearing recovery in middle ear cholesteatoma,to improve the accuracy of the model further more.To study the expression of periostin in the skin of the external auditory canal and the epithelial components of cholesteatoma in different degrees of ossicular chain destruction,and to explore its significance.To provide a new entry point for further research on the pathogenesis and progression of middle ear cholesteatoma.Methods:The skin of the external auditory meatus of patients with chronic suppurative otitis media was used as a control group.Observe the ossicles under a microscope during the operation,and according to the classification strategy of Maresh et al.[9],the cholesteatoma epithelium of patients with middle ear cholesteatoma is further divided into groups:group A(normal ossicular chain group),group B(ossicular chain Partially damaged group),group C(completely damaged ossicular chain,including those with lack of upper stapes).HE staining determines the tissue composition.The cholesteatoma epithelium of 15 cases in the control group,11 cases in group A,13 cases in group B,and 12 cases in group C were taken to make paraffin blocks,HE staining,immunohistochemical staining,and positive scores.Four cases from each group were subjected to Western-Blot(WB)immunoblotting to determine the expression of periostin at the protein level.Take 15 cases of external auditory canal skin of control group,13 cases of group A,15 cases of group B,and 16 cases of group C cholesteatoma epithelium for fluorescence qPCR to observe the expression of mRNA level.Results:1.The results of immunohistochemistry showed that in healthy external auditory canal skin,periostin was mainly expressed at the junction of epidermis and dermis,as well as the peripheral parts of hair follicles and glands;in cholesteatoma epithelium,periosteal protein was mainly expressed in epithelial cells.In the basal layer,it is also expressed in the connective tissue under the epithelium.The positive score of the control group:1.13335±0.33995,the score of the normal ossicular chain group was 1.18180±0.38570,the score of the ossicular chain partial destruction group was 2.00000±0.67935,and the ossicular chain complete destruction group(absent upper stapes)score was 2.08335±0.85940,P>0.05 between the control group and the normal ossicular chain group,there is no statistical difference,but the comparison between the control group and the ossicular chain partial destruction group,and the control group and the complete ossicular chain destruction group(the upper stapes structure is absent),P<0.05,the difference was statistically significant.The difference between the partial destruction of the ossicular chain and the complete destruction of the ossicular chain(absence of the upper stapes)was P>0.05,and the difference was not statistically significant.2.The results of WB and qPCR showed that the protein level and mRNA level of the control group and the normal ossicular chain were P>0.05,and the difference was not statistically significant;the ossicular chain was partially destroyed and the ossicular chain was completely destroyed.Group(absence of upper stapes)P>0.05,the difference was not statistically significant;but between the control group and the partial destruction of the ossicular chain group,the control group and the complete destruction of the ossicular chain group(absence of the upper stapes)all P<0.05,the difference was statistically significant;the ossicular chain complete group and the ossicular chain partial destruction group,and the ossicular chain complete group and the ossicular chain complete destruction group P<0.05,the difference was statistically significant.Conclusion:1.Periostin is expressed in middle ear cholesteatoma epithelium,and is more strongly expressed in cholesteatoma epithelial tissue with damaged ossicular chain.2.As one of the inflammatory mediators,periostin promotes and participates in the chronic inflammatory process of middle ear cholesteatoma,which provides a new direction for further research on the occurrence and progression of middle ear cholesteatoma.3.There are differences in the expression of periostin in cholesteatoma epithelium with different degrees of ossicular chain destruction,which may be used as a predictor of hearing recovery in patients with middle ear cholesteatoma,and further improve the accuracy of the prediction model. |
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