A N A L E S fflSTORICO-NATURALES MUSEI NATIONALIS HUNGARICI Tomus 82. Budapest, 1990 p. 249-257.

Occurrence of otitis media, mastoiditis and alterations of auditory ossicles in some early Medieval series (Hungary) *

by I . PAP & L. JÓZSA, Budapest

I . PAP & L. JÚZSA: O c c u r r e n c e o f o t i t i s m e d i a , m a s t o i d i t i s and a l t e r a t i o n s o f a u d i t o r y o s s i c l e s i n some e a r l y M e d i e v a l s e r i e s ( H u n g a r y ) . - A n n l s h i s t . - - n a t . Mus, n a t n . h u n g . 1 9 9 0 , 82: 2 4 9 - 2 5 7 .

A b s t r a c t - 46 p a r i e t a l b o n e s , 74 e a r o s s i c l e s o f 25 i n d i v i d u a l s were exam­i n e d g r o s s l y , by B i o p l a s t s t e r e o m i c r o s c o p e and by X - r a y . H a l f o f t h e a n v i l s , o n e - t h i r d o f t h e hammers and o n e - f i f t h o f t h e s t i r r u p s d e m o n s t r a t e d p a t h o ­l o g i c a l a l t e r a t i o n s . The i n d i v i d u a l s r e p r e s e n t e d by t h e s e s k u l l s must h a v e s u f f e r e d f r o m a g r e a t number o f r e c u r r i n g , c h r o n i c i n f l a m m a t i o n s o f t h e p a ­r i e t a l b o n e . A t l e a s t h a l f o f t h e i n d i v i d u a l s a n a l y z e d w e r e h a r d o f h e a r i n g , and one o f them had u n i l a t e r a l d e a f n e s s ( c a u s e d by s t a p e s f o o t p l a t e f i x a ­t i o n ) . P r e d o m i n a n t l y a d u l t - and m a t u r e - a g e i n d i v i d u a l s w e r e a f f l i c t e d w i t h i n f e c t i o u s m i d d l e e a r d i s e a s e s , a l m o s t a l l t h e c a s e s p r o v e d t o be b i l a t e r a l . No e v i d e n c e o f s e v e r e , s e p t i c c o m p l i c a t i o n s , o t o g e n i c p y e n c e p h a l u s , c h o l e s ­t e a t o m a , o r s u r g i c a l i n t e r v e n t i o n was f o u n d . W i t h 3 t a b l e s and 3 p h o t o -p l a t e s .

INTRODUCTION

Even i n o u r t i m e s i n f l a m m a t i o n s o f t h e m i d d l e e a r and o f t h e e a r r e g i o n a r e t h e m o s t f r e q u e n t i n f e c t i o u s d i s e a s e s . O n l y s p o r a d i c a nd much d i f f e r i n g d a t a a r e a v a i l a b l e on t h e o c c u r r e n c e o f t h e s e i l l n e s s e s i n A n c i e n t and M e d i ­e v a l t i m e s (MOREL & LER0I-G0URHAN 1958, GREGG e t a l . 1 9 6 5 , LYNN & BENITEZ 1974, RATHBUN & MALLIN 1 9 7 7 , SCHULTZ 1979 a , 1 9 7 9 b , GREGG & STEELE 1 9 8 2 ) . MO­REL & LER0I-G0URHAN ( 1 9 5 8 ) f o u n d no t r a c e o f i n f l a m m a t i o n o f t h e m i d d l e e a r on t h e r e m a i n s o f M e r o v i n g i a n F r a n k s . SCHULTZ ( 1 9 7 9 b ) s u c c e s s f u l l y d i s c o v e r e d s u c h d i s e a s e s on t h e s k e l e t a l m a t e r i a l o f two F r a n k i s h - A l e m a n n i c c e m e t e r i e s and t h r e e p r e - C o l u m b i a n p o p u l a t i o n s . He p o i n t e d o u t t h e most p r o b a b l e i n t e r ­r e l a t i o n s o f t h e s e d i s e a s e s t o s o c i a l s t a n d i n g , w o r k i n g and l i v i n g c o n d i ­t i o n s . 3 9 - 5 1 % o f t h e e x a m i n e d t e m p o r a l bones f r o m p r e - and p o s t - C o l u m b i a n I n d i a n b u r i a l s showed e v i d e n c e o f p n e u m a t i c d i s t u r b a n c e o f p r o c e s s u s m a s t o i -deus (GREGG e t a l . 1965, GREGG & STEELE 1 9 8 2 ) . N ot a s i n g l e o t o s c l e r o s i s w i t h s t a p e s f o o t p l a t e f i x a t i o n was f o u n d i n t h e s e I n d i a n p o p u l a t i o n s (HOLZHUETER e t a l . 1 9 6 5 ) . 40% o f t h e s k u l l s s t u d i e d had d e f i n i t e e v i d e n c e o f m i d d l e e a r d i s e a s e i n p r e h i s t o r i c I r a n i a n p o p u l a t i o n s (RATHBUN & MALLIN 1 9 7 7 ) . LISONEK and h i s te a m (LISONEK 1 9 8 3 a , 1 9 8 3 b , 1984 LISONEK e t a l . 1 9 8 6 ) a n a l y z e d i n ­f l a m m a t o r y and d e g e n e r a t i v e a l t e r a t i o n s o f a u d i t o r y o s s i c l e s ( m a i n l y ) f r o m t h e M i d d l e Ages. R E G Ö L Y - M É R E I ( 1 9 6 2 ) f o u n d no m a s t o i d a b s c e s s and f i s t u l a . LUZSA e t a l . ( 1 9 8 8 ) d i s c o v e r e d c h r o n i c m a x i l l a r y s i n u s i t i s on one o f 15 s k e l ­e t o n s f o u n d i n t h e r o y a l tombs o f S z é k e s f e h é r v á r ( H u n g a r y ) . They m e n t i o n e d no o t i t i s m e d i a o r m a s t o i d i t i s .

P a per p r e s e n t e d a t t h e " 3 r d C o n g r e s s u s A n t h r o p o l o g i c u s A. H r d l i c k a e " , P r a g u e - H u m p o l e c , 1989.

I n h i s t o r i c a l t i m e s e n v i r o n m e n t a l f a c t o r s p r o b a b l y had a much more d e f i ­n i t e e f f e c t on the development of t h e s e d i s e a s e s t h a n t h e y have nowadays (SCHULTZ 1979, GREGG & S T E E L E 1 9 8 2 ) . We a r e unaware of any a n a l y s i s of t h e mid d l e e a r r e g i o n of C o n q u e s t and Á r p á d p e r i o d m a t e r i a l from Hungary.

MATERIAL AND METHOD

The m a t e r i a l o r i g i n a t e s from M e d i e v a l Hungary. I n t o t a l 25 i n d i v i d u a l s ( 6 s u b a d u l t s and 19 a d u l t s : 12 m a l e s and 7 f e m a l e s ) were examined. Of t h e s e 22 i n d i v i d u a l s from V ö r s - P a p k e r t B ( 9 - l l t h c . ) b u r i a l s , 3 i n d i v i d u a l s from c e m e t e r i e s of F é s z e r l a k ( 8 t h c ) , K a r o s - E p e r j e s s z ö g ( 1 0 t h c . ) and N a g y k ő r ö s ( l l - 1 3 t h c ) . 74 o s s i c l e s of 47 t e m p o r a l bones were examined m a c r o s c o p i c a l l y , by B i o p l a s t s t e r e o m i c r o s c o p e ( m a g n i f i c a t i o n 6.3-160x) and by X - r a y ( M e d i c o r GT-2 e q u i p m e n t ) ( T a b i e 1 ) .

T a b l e 1 D i s t r i b u t i o n by age of t h e m a t e r i a l

Age group Male Female Undet. M a l l e u s I n c u s S t a p e s

I n f ans I . I n f a n s I I . J u v e n i l i s A d u i t u s Maturus

3 1 2

B 3 4 4 -

4 4 2 16 9 7 12 10 10

T o t a l 12 7 6 32 23 19

T o t a l 25 74

RESULTS

No p a t h o l o g i c a l a l t e r a t i o n c o u l d be found e i t h e r by X - r a y or by m i c r o ­s c o p i c a n a l y s i s on 12 of t h e 25 s k u l l s ( 5 0 t e m p o r a l b o n e s ) ( P l a t e 1 . 1 ) . More t h a n h a l f of a l l t h e c a s e s p r e s e n t e u marks i n d i c a t i n g i n f l a m m a t i o n of t h e m i d d l e e a r . Ther e were 3 u n i l a t e r a l c a s e s and 10 b i l a t e r a l ones of o t i t i s media and/or m a s t o i d i t i s . We o b s e r v e d i r r e g u l a r s u r f a c e and f o c a l e r o s i o n of t h e w a l l of tympa n i c c a v i t y . F o o t p l a t e f i x a t i o n of t h e s t a p e s t o t h e o v a l window was p e r c e i v e d i n one t y m p a n i c c a v i t y .

The p r o c e s s u s m a s t o i d e u s showed s c l e r o t i z a t i o n and abnormal p n e u m a t i c s t r u c t u r e s i n 9 c a s e s ( P l a t e 1 . 2 ) . I n a n o t h e r 4 c a s e s c o m p l e t e o s s i f i c a t i o n of both m a s t o i d p r o c e s s , t h e t o t a l l a c k of p n e u m a t i z a t i o n c o u l d be found ( P l a t e 1 . 3 ) . I n two of t h e s e c a s e s X - r a y i n d i c a t e d t r a c e s of c h r o n i c m a x i l ­l a r y s i n u s i t i s , t.oo.

One c h i l d of t h e f o u r i n f a n t c a s e s had u n i l a t e r a l w h i l e a n o t h e r b i l a ­t e r a l o t i t i s . O t i t i s media and a l t e r a t i o n s of p r o c e s s u s m a s t o i d e u s c o u l d be d e t e c t e d w i t h 3 of t h e 11 a d u l t s and w i t h 7 of t h e 8 m a t u r e s . I n d i c a t i o n s of d i s t u r b a n c e of t h e m i d d l e e a r were p r e s e n t w i t h 6 of t h e 12 m a l e s and w i t h 4 of t h e 7 f e m a l e s ( T a b l e 2 ) .

From 74 o s s i c l e s t h e r e were 32 hammers, 23 a n v i l s and 19 s t i r r u p s ( T a b l e 3 ) . D e f o r m i t i e s of t h e neck and head of 3 s t i r r u p s c o u l d be s e e n ( P l a t e I I I . 8 ) . The o s s i f i c a t i o n of o v a l window and s t a p e s a p p e a r e d i n one c a s e . 7 a n v i l s had s e v e r e a r t h r o s i s i n t h e i r i n c u s - s t a p e s j o i n t s ( P l a t e I I I . 9 ) . T h e s e 7 and a n o t h e r 5 a n v i l s had i r r e g u l a r s u r f a c e s on t h e i r c o r p o r a . 2 a n v i l s had a r t h r o s i s i n t h e m a l l e u s - i n c u s j o i n t ( P l a t e I I I . 1 0 ) . One t h i r d of t h e hammers

P l a t e I . 1= Normal, w e l l p n e u m a t i z e d mastoideum. - 2= S c l e r o t i c a l , b a d l y p n e u m a t i z e d p r o c e s s u s m a s t o i d e u s . - 5= C o m p l e t e l y s c l e r o t i z e d , e b u r n i f i c -

a t e d mastoideum

Plate I .

Plate I I .

T a b l e 2. D i s t r i b u t i o n of m i d d l e e a r r e g i o n and p a r a n a s a l s i n u s d i s e a s e s by age and sex

Age group Normal

O t i t i s a n d / o r m a s t o i d i t i s Naso-s i n u s i t i s

Age group Normal

Male U n i - B i ­l a t e r a l

F e m a l e U n i - B i ­l a t e r a l

Undet. U n i - B i ­l a t e r a l

Naso-s i n u s i t i s

Age group Male Fe- Un-

male d e t .

Male U n i - B i ­l a t e r a l

F e m a l e U n i - B i ­l a t e r a l

Undet. U n i - B i ­l a t e r a l

Male Fe­rna l e

I n f a n s I . I n f a n s I I . J u v e n i l i s A d u l t u s Maturus

5 1

2

1 3 1 2

3 1 3

1 1 1

- -1

1

T o t a l 6 3 3 . i 5 1 3 • 1 2 1 1

T o t a l 12 6 4 3 2

(11 c a s e s ) had s u r f a c e damage. D i s t a l end of one manubrium o f s t a p e s had a 40 d e g r e e a x i a l d e v i a t i o n i n one c a s e ( P l a t e I I I . 1 1 ) . A l l i n a l l p a t h o l o g i c a l a l t e r a t i o n s were p r e s e n t on 34.4% of hammers, 52.2% of a n v i l s .and 21.1% o f s t i r r u p s .

More t h a n h a l f of a l l hammers ( 5 3 . 1 % ) o r i g i n a t e d f r o m m i d d l e e a r s w i t h e v i d e n t o t i t i s and/or m a s t o i d i t i s . We d i s c o v e r e d l e s i o n s on more t h a n h a l f o f t h e hammers ( 5 8 . 8 % ) i n t h e o t i t i s a f f e c t e d m a t e r i a l . T h r e e - q u a r t e r s ( 7 3 . 9 % ) of a n v i l s came from m i d d l e e a r s w i t h o t i t i s and 64.7% of them p r e s e n t e d pa­t h o l o g i c a l a l t e r a t i o n s . More t h a n h a l f of t h e s t i r r u p s ( 6 3 . 2 % ) came f r o m a b ­normal tympanum and o n e - t h i r d ( 3 3 . 3 % ) < of t h e s e b ore some c h a n g e s ( T a b l e 3 ) . Only a s i n g l e m a l l e u s and a . s i n g l e i n c u s had p a t h o l o g i c a l d e f o r m a t i o n f r o m t h e ones o r i g i n a t i n g from m i d d l e e a r s w i t h no e s t a b l i s h e d d e f o r m a t i o n f r o m t h e normal ( T a b l e 3 ) .

No e v i d e n c e of f i s t u l a , s e v e r e , s e p t i c c o m p l i c a t i o n s , o t o g e n i c p y e n c e -p h a l u s , c h o l e s t e a t o m a - f o r m a t i o n , or s u r g i c a l i n t e r v e n t i o n was found.

T a b l e 3. The f r e q u e n c y of a u d i t o r y o s s i c l e l e s i o n s i n o t i t i s m e d i a and m a s t o ­i d i t i s a f f e c t e d e a r s

O t i t i s or P a t h o l o ­ O u t w a r d l y P a t h o l o ­E a r T o t a l m a s t o i d i t i s g i c a l normal g i c a l o s s i c l e s a f f e c t e d of t h e s e o f t h e s e

M a l l e u s 32 17 10 15 1 I n c u s 23 17 11 6 1 S t a p e s 19 12 4 7 -T o t a l 74 46 25 2B 2

( 5 4 % ) ( 7 % )

P l a t e I I . X-ray p i c t u r e s of p r o c e s s u s m a s t o i d e u s : 4= Normal, w e l l pneuma­t i z e d , 5= s c l e r o t i a l , b a d l y p n e u m a t i z e d , 6= c o m p l e t e l y s c l e r o t i z e d , e b u r n i f i -c a t e d

J

DISCUSSION

The l a c k o f p n e u m a t i z a t i o n and e b u r n i f i c a t i o n o f p r o c e s s u s m a s t o i d e u s , d e s t r u c t i o n o f m i d d l e e a r ' s w a l l a r e t h e r e s u l t s o f r e c u r r i n g and c h r o n i c o t i t i s m e d i a ( a n d i t s s p r e a d i n g on t h e m a s t o i d e u m ) (GREGG e t a l . 1965, SCHULTZ 1 9 7 9 a , GREGG & STEELE 1 9 8 2 ) .

As h a l f o f t h e e x a m i n e d s k u l l s showed t r a c e s o f o t i t i s a n d / o r m a s t o i d i ­t i s we assume t h a t h a l f o f t h e p o p u l a t i o n a n a l y z e d must have s u f f e r e d f r o m a f r e q u e n t l y r e c u r r i n g c h r o n i c i n f l a m m a t i o n o f t h e t e m p o r a l bone. T h i s i n c i ­d ence i s a p p r o x i m a t e l y t h e same as t h e f r e q u e n c y e s t a b l i s h e d by GREGG & STEELE ( 1 9 6 5 , 1 982) f o r p r e - and p o s t - C o l u m b i a n I n d i a n m a t e r i a l .

On a r e c e n t p o p u l a t i o n BECSKE ( 1 9 8 9 ) f o u n d a c o r r e l a t i o n b e t w e e n t h e l o c a t i o n o f e a r drum p e r f o r a t i o n and t h e f r e q u e n c y o f o s s i c l e damage. He, as w e l l as we, c o n c l u d e d t h a t i n c u s s u f f e r e d damage t h e most f r e q u e n t l y w h i l e s t a p e s d i d i t t h e l e a s t f r e q u e n t l y . Of c o u r s e i t i s n o t p o s s i b l e t o l o c a t e t h e d e s t r u c t i o n o f t h e e a r drums i n s k e l e t a l m a t e r i a l b u t t h e h i g h f r e q u e n c y o f o s s i c l e damage ( i n c u s : 5 2 . 2 % , m a l l e u s : 3 4 . 4 % , s t a p e s : 2 1 . 1 % ) i n d i c a t e s t h e S h r a p n e l l - m e m b r a n e as i t s most p r o b a b l e l o c a t i o n .

The u n i l a t e r a l l o c a l i z a t i o n was c o m p a r a t i v e l y r a r e . The m a j o r i t y o f t h e c a s e s c a r r i e d t r a c e s o f b i l a t e r a l p r o c e s s e s . We f o u n d u n i l a t e r a l d i s o r d e r w i t h an a p p r o x i m a t e l y t w o - y e a r - o l d c h i l d and w i t h one a d u l t male and one ma­t u r e f e m a l e i n d i v i d u a l . M a l e s were a f f e c t e d as much as f e m a l e s . C h r o n i c o t i ­t i s and m a s t o i d i t i s w e r e t h e most f r e q u e n t among i n d i v i d u a l s who d i e d i n ma­t u r e a g e. SCHULTZ ( 1 9 7 9 ) f o u n d t h a t t h e f r e q u e n c y o f d i s e a s e s o f p r o c e s s u s m a s t o i d e u s and m i d d l e e a r a p p e a r s t o r i s e w i t h i n c r e a s i n g age.

Ear o s s i c l e damage d e s e r v e s s p e c i a l e m p h a s i s among t h e r e s u l t s o f c h r o n ­i c o t i t i s m a s t o i d i t i s . H a l f o r t w o - t h i r d s o f t h e o s s i c l e s b e l o n g i n g t o o t i t i s a f f e c t e d m i d d l e e a r s p r e s e n t e d p a t h o l o g i c a l c h a r a c t e r i s t i c s . I n c u s l e s i o n s were t h e most f r e q u e n t . The c o m b i n e d a n a l y s i s o f m i d d l e e a r , p r o c e s s u s mas­t o i d e u s and e a r o s s i c l e s l e d us t o c o n c l u d e t h a t a t l e a s t h a l f o f a l l i n d i ­v i d u a l s w e r e h a r d o f h e a r i n g , and one o f them had u n i l a t e r a l d e a f n e s s i n c o n ­s e q u e n c e o f s t a p e d i a l f o o t p l a t e f i x a t i o n . O t o s c l e r o s i s w i t h f o o t p l a t e a n k y l o ­s i s i s f r e q u e n t l y r e s u l t i n g i n a c o n d u c t i o n t y p e o f h e a r i n g l o s s and d e a f n e s s (HOLZHUETER e t a l . 1 9 6 5 , BIRKBY & GREGG 1 9 7 5 ) . O t h e r e a r l y Árpád p e r i o d d a t a i n d i c a t e d a 2.5% r a t i o o f d e a f n e s s (JÓZSA 1 9 8 8 ) . I t r o u g h l y c o r r e s p o n d s t o t h e 4% f r e q u e n c y we f o u n d .

SCHULTZ ( 1 9 7 9 b ) c o n s i d e r s p o r o t i c h y p e r o s t o s i s c a u s e d by i r o n d e f i c i e n c y a n aemia f o u n d i n a f o u r - y e a r - o l d p r e - C o l u m b i a n c h i l d (EL-NAJJAR e t a l . 1 9 7 6 ) a p r o b a b l e e t i o l o g i c a l f a c t o r i n p n e u m a t i c d i s t u r b a n c e o f p r o c e s s u s m a s t o i ­d e u s . We a g r e e w i t h t h e o p i n i o n t h a t r e c u r r i n g and c h r o n i c o t i t i s m e d i a c a u s ­es t h e l a c k o f p n e u m a t i z a t i o n o f m a s t o i d e u m (GREGG & STEELE 1965, 1 9 8 2 ; LYNN & BENITEZ 1 9 7 4 , SCHULTZ 1 9 7 9 b ) , a d d i n g t h a t c h r o n i c o t i t i s m edia c o u l d p l a y a p a r t i n t h e o c c u r r e n c e o f i r o n d e f i c i e n c y a naemia and t h e r e f o r e i n t h e d e v e l ­opment o f p o r o t i c h y p e r o s t o s i s .

We f o u n d no t r a c e o f s e v e r e , s e p t i c c o m p l i c a t i o n s : s u c h as m a s t o i d ab­s c e s s , f i s t u l a o r o t o g e n i c p y e n c e p h a l u s . T h e r e was no c o r r e l a t i o n b e t w e e n c h r o n i c n a s o s i n u s i t i s and o t i t i s m e d i a . The r e s u l t s o f c h r o n i c i n f l a m m a t i o n o f m a x i l l a r y s i n u s were t r a c e a b l e o n l y w i t h 2 o f t h e 13 o t i t i s a f f e c t e d c a s ­es .

P l a t e I I I . 7= N o r m a l o s s i c l e s ( m a g n i f i c a t i o n 2 0 x ) . - 8= C l e a r l y v i s i b l e a r t h r o s i s on t h e neck and j o i n t s u r f a c e o f a s t a p e s ( m a g n i f i c a t i o n 4 0 x ) . 9= A r t h r o s i s o f p r o c e s s u s a r t i c u l a r i s o f i n c u s ( m a g n i f i c a t i o n l O O x ) . 10= A r t h r o t i c f a c i e s a r t i c u l a r i s o f i n c u s ( m a g n i f i c a t i o n 4 0 x ) . - 11= 40 de­

g r e e s a x i a l d e v i a t i o n o f m a n u b r i u m o f m a l l e u s ( m a g n i f i c a t i o n 4 0 x )

Annls hist.-nat. Mus. natn. hung.. 82, 1990

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