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ANALES 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: Occurrence of otitis media, mastoiditis and alterations of auditory ossicles in some early Medieval series (Hungary). - Annls hist.- -nat. Mus, natn. hung. 1990, 82: 249-257. Abstract - 46 parietal bones, 74 ear ossicles of 25 individuals were exam- ined grossly, by Bioplast stereomicroscope and by X-ray. Half of the anvils, one-third of the hammers and one-fifth of the stirrups demonstrated patho- logical alterations. The individuals represented by these skulls must have suffered from a great number of recurring, chronic inflammations of the pa- rietal bone. At least half of the individuals analyzed were hard of hearing, and one of them had unilateral deafness (caused by stapes footplate fixa- tion). Predominantly adult- and mature-age individuals were afflicted with infectious middle ear diseases, almost all the cases proved to be bilateral. No evidence of severe, septic complications, otogenic pyencephalus, choles- teatoma, or surgical intervention was found. With 3 tables and 3 photo- plates . INTRODUCTION Even in our times inflammations of the middle ear and of the ear region are the most frequent infectious diseases. Only sporadic and much differing data are available on the occurrence of these illnesses in Ancient and Medi- eval times (MOREL & LER0I-G0URHAN 1958, GREGG e t al. 1965, LYNN & BENITEZ 1974, RATHBUN & MALLIN 1977, SCHULTZ 1979a, 1979b, GREGG & STEELE 1982). MO- REL & LER0I-G0URHAN (1958) found no trace of inflammation of the middle ear on the remains of Merovingian Franks. SCHULTZ (1979b) successfully discovered such diseases on the skeletal material of two Frankish-Alemannic cemeteries and three pre-Columbian populations. He pointed out the most probable inter- relations of these diseases to social standing, working and living condi- tions. 39-51% of the examined temporal bones from pre- and post-Columbian Indian burials showed evidence of pneumatic disturbance of processus mastoi- deus (GREGG et al. 1965, GREGG & STEELE 1982). Not a single otosclerosis with stapes footplate fixation was found in these Indian populations (HOLZHUETER et al. 1965). 40% of the skulls studied had definite evidence of middle ear disease in prehistoric Iranian populations (RATHBUN & MALLIN 1977). LISONEK and his team (LISONEK 1983a, 1983b, 1984 LISONEK et al. 1986) analyzed in- flammatory and degenerative alterations of auditory ossicles (mainly) from the Middle Ages. REGÖLY-MÉREI (1962) found no mastoid abscess and fistula. LUZSA et al. (1988) discovered chronic maxillary sinusitis on one of 15 skel- etons found in the royal tombs of Székesfehérvár (Hungary). They mentioned no otitis media or mastoiditis. Paper presented at the "3rd Congressus Anthropologicus A. Hrdlickae", Prague - Humpolec, 1989.

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Page 1: Occurrence of otitis media, mastoiditis and alterations of ...publication.nhmus.hu/pdf/annHNHM/Annals_HNHM_1990_Vol_82_249.pdf · Occurrence of otitis media, mastoiditis and alterations

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.

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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

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Plate I .

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Plate I I .

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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

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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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