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Detection of gastric pepsin in middle ear fluid of children with chronic otitis media with effusion



To study the possible relationship between gastroesophageal reflux and chronic middle ear effusion by (i) evaluating the presence of pepsin/pepsinogen in middle ear fluid of children with chronic otitis media with effusion (OME) and to (ii) differentiate between pepsin from gastric juice and pepsin derived from plasma pepsinogen.

Patients and methods

This was a prospective study carried out in the Departments of Otorhinolaryngology and Clinical Pathology, Alexandria University. Middle ear effusions and blood samples were collected from 25 patients undergoing bilateral myringotomy with tube placement for chronic OME. These samples were prepared for pepsin assay. The total pepsin/pepsinogen concentrations of effusions and serum samples were measured with an enzyme-linked immunosorbent assay using human pepsin-specific antibody.


Pepsin was detected in 22 of 25 (88%) patients and in 42 of 50 (84%) of the ears, and it was detected in all serum samples. A total of seven of 25 (28%) patients and nine of 50 (18%) ears were found to have higher pepsin levels in their middle ear effusion samples than the cut-off value of serum. The average pepsin level in all effusion samples was 109.99 ng/ml, whereas it was 55.72 ng/ml in serum samples.


The gastroesophageal reflux is one of the contributing factors in the etiopathogenesis of middle ear effusion as gastric pepsin reaches the middle ear through the nasopharynx and Eustachian tube to cause OME.


  1. 1

    Martines F, Bentivegna D, Maira E, Sciacca V, Martines E. Risk factors for otitis media with effusion: case-control study in Sicilian school children. Int J Pediatr Otorhinolaryngol 2011; 75: 754–759.

    Article  CAS  Google Scholar 

  2. 2

    He Z, O’Reilly RC, Mehta D. Gastric pepsin in middle ear fluid of children with otitis media: clinical implications. Curr Allergy Asthma Rep 2008; 8: 513–518.

    Article  Google Scholar 

  3. 3

    Orenstein SR. Infantile reflux: different from adult reflux. Am J Med 1997; 103: 114S–119S.

    Article  CAS  Google Scholar 

  4. 4

    Bouchard S, Lallier M, Yazbeck S, Bensoussan A. The otolaryngologic manifestations of gastroesophageal reflux: When is a pH study indicated? J Pediatr Surg 1999; 34: 1053–1056.

    Article  CAS  Google Scholar 

  5. 5

    McGuirt Jr WF. Gastroesophageal reflux and the upper airway. Pediatr Clin North Am 2003; 50:487–502.

    Article  Google Scholar 

  6. 6

    O’Reilly RC, He Z, Bloedon E, Papsin B, Lundy L, Bolling L, et al. The role of extraesophageal reflux in otitis media in infants and children. Laryngoscope 2008; 118:1–9.

    Article  Google Scholar 

  7. 7

    Tasker A, Dettmar PW, Koufman JA, Panetti M, Birchall JP. Does gastro-oesophageal reflux have a role in otitis media with effusion? Gastroenterology 2001; 120: A119.

    Article  Google Scholar 

  8. 8

    Caruso G, Passali FM. ENT manifestations of gastro-oesophageal reflux in children. Acta Otorhinolaryngol Ital 2006; 26: 252–255.

    PubMed  PubMed Central  CAS  Google Scholar 

  9. 9

    Heavner SB, Hardy SM, White DR, Mcqueen CT, Prazma J, PillsburyIII HC. Function of the Eustachian tube after weekly exposure to pepsin/hydrochloric acid. Otolaryngol Head Neck Surg 2001; 125: 123–129.

    Article  CAS  Google Scholar 

  10. 10

    Nair S, Kumar M, Nair P. Role of GERD in children with otitis media with effusion. Indian J Pediatr 2012; 79:1328–1332.

    Article  Google Scholar 

  11. 11

    Zielhuis GA, Rach GH, Van den Bosch A, Van den Broek P. The prevalence of otitis media with effusion: a critical review of the literature. Clin Otolaryngol Allied Sci 1990; 15:283–288.

    Article  CAS  Google Scholar 

  12. 12

    Tasker A, Dettmar PW, Panetti M, Koufman JA, Birchall JP, Pearson JP. Is gastric reflux a cause of otitis media with effusion in children? Laryngoscope 2002; 112:1930–1934.

    Article  Google Scholar 

  13. 13

    He Z, O’Reilly RC, Bolling L, Soundar S, Shah M, Cook S. Detection of gastric pepsin in middle ear fluid of children with otitis media. Otolaryngol Head Neck Surg 2007; 137:59–64.

    Article  Google Scholar 

  14. 14

    White DR, Brett Heavner S, Hardy SM, Prazma J. Gastroesophageal reflux and Eustachian tube dysfunction in an animal model. Laryngoscope 2002; 112:955–961.

    Article  Google Scholar 

  15. 15

    Butehorn HF III, Downs BW, Prazma JP. Acute gastroesophageal reflux and Eustachian tube function. Abstracts of the 1999 Midwinter Meeting of the Association for Research in Otolaryngology. Mt. Royal, NJ: Association for Research in Otolaryngology; 1999. 808.

    Google Scholar 

  16. 16

    Lieu JEC, Muthappan PG, Uppaluri R. Association of reflux with otitis media in children. Otolaryngol Head Neck Surg 2005; 133:357–361.

    Article  Google Scholar 

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Corresponding author

Correspondence to Yasser Shewel MD.

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None declared.

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Shewel, Y., Bassiouny, M. & Rizk, M.M. Detection of gastric pepsin in middle ear fluid of children with chronic otitis media with effusion. Egypt J Otolaryngol 30, 78–81 (2014).

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  • gastroesophageal reflux
  • otits media with effusion
  • pepsin