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MastoiditisЧPaleopathological evidence of a rarely reported disease.

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AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 138:266–273 (2009)
Mastoiditis—Paleopathological Evidence
of a Rarely Reported Disease
Stefan Flohr1,2* and Michael Schultz1,2
1
2
Department of Biology, University of Hildesheim, D-31141 Hildesheim, Germany
Department of Anatomy, Georg-August-University, D-37075 Goettingen, Germany
KEY WORDS
early medieval; mastoid process; otitis media; paleopathology
ABSTRACT
Since antibiotics have become available,
mastoiditis has become a rare disease in modern Western societies. However, it is still common in developing
countries. It can be hypothesized that in earlier historical and prehistoric times, mastoiditis must have posed a
serious threat to people’s lives, and that the prevalence
of this disease is probably underrepresented in the
paleopathological literature. The present study identifies
pathological changes in the pneumatized cells of the
mastoid process in human skeletal samples from two
early medieval cemeteries from Germany (Dirmstein:
n 5 152 mastoids, Rhens: n 5 71 mastoids), using macroscopic, endoscopic, low-power microscopic, scanningelectron and light microscopic techniques, and draws
some epidemiological conclusions as to the frequency
of the disease diagnosed in the archaeological samples.
Osseous changes because of mastoiditis were diagnosed
in 83.4% of the temporal bones. The frequency in the
skeletal sample from Dirmstein was higher than in the
sample from Rhens. In both populations, males were
more often affected than females and older individuals
more often than younger individuals. The high frequency
of mastoiditis observed was most likely due to an accumulation of osseous changes during individual lifetimes
and supports the hypothesis that mastoiditis was a serious health problem in pre-antibiotic times. It may be
assumed that subclinical forms of mastoiditis and their
osseous manifestations may even nowadays occur more
often than was previously thought. It is suggested that
the disease should be given more consideration in paleopathological investigations. Am J Phys Anthropol
138:266–273, 2009. V 2008 Wiley-Liss, Inc.
Anatomically speaking, the middle ear region consists
of the Eustachian tube, the middle ear (tympanic) cavity
with the antrum above and the connected pneumatized
spaces (cells) in the mastoid, the pyramid, and, more or
less well developed, the temporal squama and the zygomatic process of the temporal bone.
Even today, diseases of the middle ear region are
among the most frequent diseases of humans. Acute otitis media (AOM) is typically caused by invasion of bacteria through the Eustachian tube into the tympanic cavity. AOM can, however, also be caused by viral or fungal
pathogens, for example following influenza or herpes
infections (Boenninghaus and Lenarz, 2005). In AOM,
not only the mucous membrane of the tympanic cavity is
affected by inflammation. Rather, from the start of AOM,
the inflammation also affects the mucous membrane of
the connected pneumatized spaces, for example, in the
mastoid process (Schätzle and Haubrich, 1975; Fleischer,
1979; Boenninghaus and Lenarz, 2005). In clinical
usage, inflammation of the mucous membrane in the
pneumatized mastoid cells alone does not justify the diagnosis mastoiditis. Rather, in clinical parlance the term
mastoiditis is used only in cases of inflammation of both
the mucous membrane and the underlying bone tissue.
Mastoiditis is thus defined as a sequela to otitis media
(OM) (for further discussion about differences in pathological and clinical terminologies concerning middle ear
diseases see Fleischer, 1979). Radiologically, mastoiditis
is characterized by osteoclastic resorption in the pneumatized cells (Boenninghaus and Lenarz, 2005). The
changes in mastoiditis are, however, not only of a resorptive nature. Also bone proliferation is a characteristic
feature, which can lead to complete filling of former
pneumatized cells with newly formed bone (Krainz,
1926; Ziegler, 1936; Friedmann, 1957; Fleischer, 1979).
Mastoiditis most commonly results from acute forms of
OM, but the condition can also be caused by chronic or
recurrent acute forms of OM (Leskinen and Jero, 2005).
Since antibiotics have become available, AOM is a relatively well manageable disease, and mastoiditis has
become a rare sequela in modern Western societies
(Leskinen and Jero, 2005). However, it is still common in
developing countries. For instance, frequencies of up to
18% are reported in children from Ruanda (Berman,
1995). Rudberg diagnosed mastoiditis in 17.2% of children with untreated OM (Rudberg, 1954). It can be
hypothesized that in earlier historical and prehistoric
times, diseases of the middle ear region and mastoiditis
must have posed a serious threat to people’s health.
However, compared with other parts of the skeleton, relatively few paleopathological studies have focused on
this region (Schultz, 1979; Mays and Holst, 2006) and it
may, therefore, be hypothesized that osseous changes in
the pneumatized cells of the mastoid process because of
mastoiditis are underreported in the paleopathological
literature.
In living patients, radiological findings support the diagnosis of mastoiditis, especially by documenting bone
C 2008
V
WILEY-LISS, INC.
C
*Correspondence to: Dr. Stefan Flohr, Department of Biology, University of Hildesheim, Marienburger Platz 22, D-31141 Hildesheim,
Germany. E-mail: [email protected]
Received 10 March 2008; accepted 21 July 2008
DOI 10.1002/ajpa.20924
Published online 4 September 2008 in Wiley InterScience
(www.interscience.wiley.com).
MASTOIDITIS—PALEOPATHOLOGICAL EVIDENCE
resorption processes (Fleischer, 1979; Boenninghaus and
Lenarz, 2005). Corresponding to clinical practice, also in
investigations on ancient skeletal remains, radiographs
are most commonly used to identify pathological conditions in the middle ear region, including the mastoid
process (e.g., Gregg et al., 1965; Rathbun and Mallin,
1977; Titche et al., 1981; Homøe and Lynnerup, 1991;
Schultz, 1993; Homøe et al., 1994, 1995, 1996). However,
many of these studies focus on the degree of pneumatization in the mastoid region as an indicator for the occurrence of a chronic disease in the middle ear (COM).
Indeed, an exceedingly strong correlation between hypocellularity and COM has been repeatedly reported,
including studies on individuals from pre-antibiotic
times (Albrecht, 1924; Hanse, 1930; Stix, 1935; Weber,
1943; Fleischer, 1979; Homøe et al., 1994). Hypocellularity resulting from an inhibition of the pneumatization
process or strongly asymmetrically developed pneumatization of the mastoids is related to the presence of a
pathologically altered mucous membrane because of
severe or recurrent middle ear infections during early
childhood. As a consequence, the mucous membrane,
which plays an important role in the process of pneumatization, loses its ability to proliferate and the mastoid
remains unpneumatized (Wittmaack, 1918, 1926). The
altered mucous membrane is also less resistant to pathogens. In most cases the combination of a pathologically
altered mucous membrane and reduced resistance will
cause COM. Thus, hypocellularity in adult individuals
can be used as an indicator for severe middle ear diseases in early childhood. Using this approach, Homøe et
al. (1996) documented significant differences in the frequencies of infectious middle ear diseases in early childhood between Greenland Inuits from the time before and
after European colonialization.
As described, hypocellular mastoids can result from an
inhibition of the pneumatization process and, thus, indicate a disease in early childhood that leads to COM, but
can also be caused by a secondary filling of originally
pneumatized cells because of mastoiditis (Krainz, 1926;
Ziegler, 1936; Friedmann, 1957). The latter reflects a
condition after the pneumatization has reached an
advanced stage in older individuals. Using terms, such
as, ‘‘pneumatic,’’ ‘‘diploetic,’’ ‘‘mixed,’’ and ‘‘sklerotic’’ to
describe the internal morphology of the mastoids based
on radiographs (e.g., Titche et al., 1981; Gregg and
Steele, 1982) might confuse these two possibilities. Consequently, Titche et al. (1981), in diagnosing middle ear
diseases, considered ‘‘any type other than a pneumatic
mastoid . . . as being the result of an infectious process’’
(p 271). Following this approach, the authors found up
to 82.7% of normally pneumatized mastoids in a sample
of prehistoric Arizona Indians, which seemed to them a
surprisingly low rate of diseased cases. Rathbun and
Mallin (1977) described cases of ‘‘depneumatization’’
because of OM and mastoiditis from ancient Iran at
much higher frequencies, namely at a minimum of 6 of
15 (40%) skulls. However, the authors defined the terms
OM and mastoiditis in the sense of ‘‘inflammation of the
middle ear and mastoid’’ as a general diagnosis since
‘‘gross and radiological observations of the skeletal
changes cast no light upon the cause, pathogenesis, or
even the specific type of middle-ear disease’’ (p 901).
In our study, we diagnosed mastoiditis by identifying
pathological changes in the pneumatized mastoid cells,
not by evaluating the stage of pneumatization because
the latter might cover different causes and thus mix up
267
different types of disease. Major destruction because of
resorptive processes as an indicator for mastoiditis can
be diagnosed by radiological investigation. However,
minor changes—resorptive as well as proliferative—are
difficult to identify by radiographic examination, both in
living patients and in archaeological samples. Additionally, postmortem processes such as invasion of soil or
destruction caused by plant roots or microorganisms can
alter the bone and might easily be confused with a pathological condition (Schultz, 1979; Qvist and Grøntved,
2001). Analysis of the sectioned mastoids has been demonstrated to be a valid approach to distinguish between
osseous proliferations because of mastoiditis and a
primary inhibition of the pneumatization, between diagenetic changes and intra vitam changes, and for the
identification of minor osseous changes because of mastoiditis (Flohr and Schultz, in press). The aim of the
present study was to test the hypothesis that mastoiditis
as a sequela of OM was common in the early medieval
times in Germany.
MATERIALS AND METHODS
The skeletal material consisted of temporal bones from
two early medieval cemeteries located in the cities of
Rhens, district Mayen-Koblenz, and Dirmstein, district
Bad Dürkheim, federal state of Rhineland–Palatinate,
Germany. The site Rhens has not been completely excavated, since a recent graveyard around a christian
church covers a wide area of the ancient burials. However, the 111 skeletons, excavated in 1990 and 1991, are
well documented. Archaeological findings date the
burials to a quite narrow time span in the 7th century
AD (Eveline Saal, personal communication). From the
cemetery from Dirmstein, 350 skeletons were recovered.
Several single burials from the graveyard have been
known, and even partly destroyed, since 1912 (Leithäuser, 2006). Most of the skeletons used for this investigation came from excavation campaigns between 1986
and 1990. Archaeological findings indicate that the
cemetery was in use between the middle of the 6th century AD and the middle of the 8th century (Leithäuser,
2006).
Sex determination was performed on the skeletons
according to common anthropological procedures, using
gross morphological characteristics of the pelvis and the
skull (Ferembach et al., 1979; Buikstra and Ubelaker,
1994). Age at death estimation was based on gross morphological features, including closure of the cranial
sutures (Acsádi and Nemeskéri, 1970; Meindl and Lovejoy, 1985), changes to the auricular surface (Lovejoy
et al., 1985), to the symphyseal face of the pubis
(McKern and Stewart, 1957), and to the sternal rib end
_can et al., 1984).
(Is
Temporal bones from subadult individuals were
included only when the estimated age at death was at
least 6 years because the process of pneumatization of
the mastoid region is usually completed at this age
(Wittmaack, 1926), and thus hypocellularity or osseous
changes in the pneumatized cells because of mastoiditis
can be diagnosed as signs of pathological conditions.
Fragmented or poorly preserved bones were excluded
from the study.
The total sample used for this investigation consisted
of 223 temporal bones (Dirmstein: 152 temporal bones
from 103 individuals; Rhens: 71 temporal bones from 42
indviduals; Table 1). Eighty-seven bones originated from
American Journal of Physical Anthropology
268
223
15
14
49
33
4
2
8
87
2
2
24
72
1
1
14
6
0
0
1
25
8
9
2
L
R
58
43
44
b
0
14
6
5
25
3
13
5
2
24
Age estimation and sex determination were made by M. Lebschy, J. Kauppert, and one of the authors (SF).
Age estimation and sex determination were made by A. Sindermann, E.N. Stifter, and one of the authors (SF).
3
3
15
12
18
20
12
34
46
11
0
0
0
3
8
12
1
7
10
12
2
15
19
2
3
6
7
0
10
13
0
1
0
0
0
0
1
0
1
2
1
7
8
1
1
0
1
Children
(6–12 years)
Juveniles
(13–20 years)
Adults
(21–40 years)
Mature/senile
([40 years)
Age
indeterminable
Total
American Journal of Physical Anthropology
a
12
5
2
1
1
0
26
16
17
0
0
9
16
20
20
1
1
4
2
0
3
0
0
1
1
1
1
2
2
2
Male
L
Female
R
L
R
L
R
L
R
L
L
R
Temporal
bones
Female
Male
R
Sex
indeterminable
Female
R
Male
L
Sex
indeterminable
Rhensb
Dirmsteina
TABLE 1. Distribution of sex and age class for the temporal bones used in this study
R
Total
L
Sex
indeterminable
Total
S. FLOHR AND M. SCHULTZ
females (Dirmstein: 49 from 35 individuals; Rhens: 38
from 22 individuals) and 107 from males (Dirmstein: 80
from 54 individuals; Rhens: 27 from 16 individuals). For
29 of the mastoids, sex determination was not possible
(Dirmstein: 23 from 19 individuals; Rhens: 6 from 4 individuals).
Radiographs of the isolated temporal bones were taken
in the medio-lateral direction (Faxitron, Hewlett & Packard). Afterwards, the temporal bones were cut with a
band saw in the frontal plane from the parietal incisure
to the tip of the mastoid process. Pneumatized cells were
inspected with a low-power microscope (Leica Wild M3Z)
and an endoscope (Volpi; 08 optical system) at up to 40fold magnification. To detect probable cases of acute resorptive processes at the time of death based on the
presence of Howship’s lacunae, some samples with massively enlarged pneumatized cells were investigated by
scanning-electron microscopy (SEM; CamScan CS 24).
Thin ground sections of unstained and undecalcificated
samples, prepared as described previously (Schultz,
1988), were studied by light microscopy (Axioskop 2
Plus, Zeiss) using normal and polarized light with and
without a hilfsobject red 1st order (quartz) as compensator to identify bone remodeling processes because
of pathological conditions, which had occurred long
before death, and thus to differentiate normal variability
from pathological changes in bone morphology (Schultz,
2001).
The diagnoses of osseous changes because of mastoiditis were performed according to the criteria of Flohr and
Schultz (in press). This required sectioning of the bones
because it is possible to diagnose even minor changes in
sectioned bone using endoscopy and low power-microscopy. As mentioned before, osseous changes because of
mastoiditis are characterized by concomitant proliferation and resorption. Pronounced resorptive processes
result in massively enlarged cells and in spicular bone
formations representing remnants of former septa
between pneumatized cells (Fig. 1). Osseous proliferations in the mastoid air cells can be found in manifold
and distinct forms. The spectrum of changes ranges from
plate-like and spicular formations with thickened or
even rootstock-like tips to reticular bone formations,
caused by hemorrhagic processes (Flohr and Schultz, in
press.), and complete filling of originally pneumatized
cells with compact bone mass (Fig. 2).
Statistical analyses were performed and graphs were
drawn with the software Statistica 7.1 (StatSoft). Differences between groups were tested for significance by
using the v2-square-test. P-values \ 0.05 were considered to indicate significance.
RESULTS
To obtain larger sample sizes for each age class, individuals with an age at death between 6 and 12 years
were grouped in the category ‘‘children’’, and those with
an age of death between 13 and 20 years in the category
‘‘juvenile.’’ The category ‘‘adult’’ included individuals
with an age at death of 21–40 years. Individuals with
ages at death of more than 40 years were grouped in the
category ‘‘mature/senile.’’
According to the criteria desribed above, osseous
changes because of pathological processes were present
in 83.4% of the investigated mastoids (Table 2). No
changes were found in 12.6% of the cases, while in 4.0%
the diagnosis was not certain. Because cases with no
MASTOIDITIS—PALEOPATHOLOGICAL EVIDENCE
Fig. 1. Dirmstein 67b; right mastoid from a woman at least 50
years old. Osseous changes due to a resorptive process in the
pneumatized cells. Note the gap in the rim originally separating
two pneumatized cells (arrow). Bar: 2 mm. [Color figure can be
viewed in the online issue, which is available at www.interscience.
wiley.com.]
clear diagnosis could have been either healthy or diseased, a calculation of the maximum and minimum
frequencies was made for further comparison. Thus, the
minimum frequency of diseased mastoids ranged from
73.7% in females from Rhens to 91.3% in males from
Dirmstein (Table 2). Addition of the cases with no clear
diagnosis to the certainly affected ones, yields a (maximum) frequency of affected cases ranging between 81.6%
in females from Rhens and 95.1% in males from Dirmstein (Table 2). In both populations, males were more often affected than females. However, differences in maximum and minimum frequencies of disease were not statistically significant between the sexes (Dirmstein:
maximum frequency of diseased cases P 5 0.07, minimum frequency of diseased cases P 5 0.19, Rhens: maximum frequency of diseased cases P 5 0.20, minimum
frequency of diseased cases P 5 0.13). A comparison of
the frequencies in females from both populations and in
males from both populations revealed a slightly higher
frequency in the population from Dirmstein than from
Rhens for both sexes (Table 2). Again, however, the differences were not statistically significant in the two calculations using either maximum or minimum values
(Females: maximum frequency of diseased cases P 5
0.60, minimum frequency of diseased cases P 5 0.25;
Males: maximum number of diseased cases P 5 0.64,
minimum number of diseased cases P 5 0.72). The frequency of cases with pathological changes in the pneumatized air cells increased with age in both populations
(Fig. 3).
DISCUSSION
Studies on ancient skeletal remains can provide interesting and useful insights into diseases, with respect to
their history, occurrence, and epidemiology, and even
regarding recent medical problems (Metcalfe, 2007).
In the analyzed samples, high percentages of the mastoids showed pathological changes in the pneumatized
269
Fig. 2. Dirmstein 1/1; left mastoid from a man at least
50 years old. Irregular bone proliferations in a pneumatized
cell. Note the different types of proliferations: compact bone
mass (white arrow) and trabecular-like bone (black arrow). Lowpower image. Bar: 1 mm. [Color figure can be viewed in the
online issue, which is available at www.interscience.wiley.com.]
mastoid cells. If these changes are interpreted as signs
of mastoiditis, the findings seem to be at variance with
the prevalence of mastoiditis commonly reported in otological studies. Despite the observation that mastoiditis
has become a rare disease since antibiotics have been
available, frequencies of 17.2% (Rudberg, 1954) and 18%
(Berman, 1995) have been reported in children without
antibiotic treatment. How can this apparent disagreement and the high frequency of osseous changes in the
pneumatized mastoid cells in the skeletal samples investigated in this study be explained?
How plausible are the high
frequencies of disease?
First of all, the criteria used for diagnosing the historical bone samples need to be scrutinized. The osseous
changes in the pneumatized mastoid cells, which have
been used as an indicator for a pathological condition in
this study, conform to the descriptions given by earlier
anatomists and pathologists, who recorded mastoiditis
cases either at autopsies or in extracted bone flakes
obtained by mastoidectomy from living patients (Manasse, 1917; Krainz, 1926; Ziegler, 1936; Friedmann,
1957).
General considerations on the developmental and
remodeling processes suggest that, for example, rootstock-like proliferations do not conform to ‘‘normal’’ osseous growth and most probably represent a pathologic
condition. The presence of Howship’s lacunae, seen in
microscopic investigations, provides evidence for a rapid
resorption process, presumably related to a pathological
condition (Urago, 1982; Chole, 1988; Jung and Chole,
2002).
Disease frequencies derived from studies on skeletal
samples cannot be compared directly with results from
recent clinical studies. Disease incidence, defined as the
number of new cases per total population at risk, cannot
be determined in paleopathology (Waldron, 1994). HowAmerican Journal of Physical Anthropology
270
S. FLOHR AND M. SCHULTZ
TABLE 2. Distribution of mastoiditis according to sex
Dirmstein
Osseous changes due to mastoiditis
Not present
Questionable
Present
Total
Rhens
Female
7
1
41
49
(14.3%)
(2.0%)
(83.7%)
(100.0%)
Male
4
3
73
80
(5.0%)
(3.8%)
(91.3%)
(100.0%)
Female
7
3
28
38
(18.4%)
(7.9%)
(73.7%)
(100.0%)
Male
2
1
24
27
(7.4%)
(3.7%)
(88.9%)
(100.0%)
Fig. 3. Distribution of the diagnoses in the mastoids depending on the age class, and the population. Individuals whose age
could not be estimated were not considered in this graph. DS, Dirmstein; Rh, Rhens.
ever, also disease prevalence, defined in a paleopathological context as the number of cases per total skeletal
sample, does not necessarily represent the prevalence of
disease in living population from which this sample originated (Waldron, 1994). Unlike in recent epidemiological studies, investigations on historical skeletons include
a number of individuals who were affected sometime
throughout their lives. In other words, frequencies
reported from skeletal remains represent an accumulation of changes occuring throughout the lives of the individuals. Accordingly, higher frequencies of diseased cases
compared with recent epidemiological studies are
expected in studies of historical and prehistoric skeletal
samples.
An important question is what actually is diagnosed
when using the criteria of the present study? Traditionally, AOM is defined as a disease affecting the mucous
membranes of the tympanic cavity and that of the connected pneumatized spaces, but not leading to bone
alterations in the mastoid cells. These alterations occur
only as a sequela of OM and represent a major criterion
to diagnose mastoiditis. However, in clinical usage this
feature is in most instances diagnosed radiologically.
Studies on archaeological (macerated) bones allow the
researcher to apply techniques that cannot be applied to
living patients, in particular, microscopic techniques
such as SEM and light microscopy. While these techniques provide more reliable diagnoses than macroscopic
and radiological ones, their destructive nature will certainly limit their widespread application. However,
minor changes of internal bone structure can only be
American Journal of Physical Anthropology
recorded by using microscopic techniques (Schultz, 2001,
2003). We, therefore, disagree with Aufderheide and
Rodrı́guez-Martin (1998) who stated that ‘‘radiological
evaluation may be the most sensitive method for detection of mastoiditis’’ (p 254).
Homøe and coworkers observed frequencies of AOM of
75–90% in recent Inuit children younger than 3 years
(Homøe et al., 1994). These frequencies are similar to
those for the osseous changes in the pneumatized mastoid cells observed in the present study and reflect the
widely accepted view that middle ear diseases are among
the most common diseases of children in general. It
might be possible that, in contrast to the aforementioned
definition of AOM, minor osseous changes might even
nowadays also occur in an earlier stage in AOM, when
typical clinical signs of mastoiditis are not present. However, this hypothesis cannot be tested in this study.
According to the given definition of AOM, this disease
can, as a rule, not be diagnosed in macerated bone because
AOM only affects soft tissues. Primary inhibition of the
pneumatization process because of severe OM in early
childhood and associated COM in aduldhood can be distingushed from secondarily built bone formations in the sectioned bone and be excluded as a diagnosis in these cases.
Consequently, the osseous changes observed in this study
are indeed most probably signs of mastoiditis.
What did ‘‘mastoiditis’’ mean to the people?
In contrast to studies on living patients, the severity
and the symptoms of the diseases cannot be diagnosed
MASTOIDITIS—PALEOPATHOLOGICAL EVIDENCE
271
Fig. 4. Rhens 99; right mastoid. Dorsal view of the sectioned mastoid. The pneumatized cells demonstrate severe and agressiv
changes due to mastoiditis. Note the massively enlarged cell (a) and the irregular bone proliferations (b). [Color figure can be
viewed in the online issue, which is available at www.interscience.wiley.com.]
in archaeological bones in each individual. Thus, cases of
mastoiditis diagnosed in this study might also include
mild forms (Paparella et al., 2002) that remained more
or less without clinical symptoms (‘‘silent mastoiditis’’).
These silent forms were reported more than hundred
years ago by Bezold (1906) in individuals from autopsies
who had not shown any clinical symptoms of mastoiditis
during their lifetimes. Thus, it is again important to distinguish between morphological evidence of pathological
processes and clinical pictures of a disease. The osseous
changes documented in this study might often tell us
only little about the clinical symptoms that resulted
from the underlying disease in an individual case.
Nevertheless, many cases demonstrate rather dramatic
changes that can only have been caused by a severe
course of disease and might have been fatal in several
cases (Fig. 4a,b).
Interestingly, in contrast to Loveland et al. (1990),
who described several different cases of abscess formation in ancient skulls from North America and in contrast to Schultz (1979), who also reported such cases
from the Merovingian cemetery in Kleinlangheim (Germany), no case of a perforation of the outer surface of
the mastoid because of abscessation (Bezold’s mastoiditis) could be diagnosed in the present sample. This can
probably be explained by taphonomical considerations,
because a well preserved outer bone surface should be
present to avoid ‘‘pseudopathological’’ diagnoses (cf.,
Schultz, 1979). Accordingly, we decided to be more ‘‘conservative’’ in our diagnoses. Moreover, archaeological
investigations suggest that people from the sites of
Dirmstein and Rhens seemed to have lived under fairly
good economical conditions (Leithäuser, 2006; Eveline
Saal, personal communication). Nevertheless, the frequency of mastoiditis is high in both populations. This
might also be a consequence of the phenomenon known
as the osteological paradox (Wood et al., 1992), which
states that osseous changes can be diagnosed because
people were strong enough to survive the disease.
Weaker people might have died at a much earlier stage
of disease and osteological manifestations would not
have occurred and the frequencies of cases diagnosed as
being diseased would have been lower. Further investigations on other populations with different living conditions might help to escape from this paradox.
The increase in the frequency of pathological changes
because of mastoiditis with age in the present sample
indicates that OM and its sequelae were not just a disease of early childhood but were also common in adults.
Possible causes of OM and mastoiditis
It is widely recognized that AOM is a complication
because of upper respiratory tract infections (Schätzle
and Haubrich, 1975). However, a number of risk factors
can influence the occurrence of OM. Lubianca Neto et al.
(2006) analyzed 257 articles on risk factors associated
with OM and identified nine main risk factors linked to
the host (for example allergy, craniofacial abnormalities,
gastroesophagial reflux, and the presence of adenoids)
and eight main factors linked to the environment (for
example upper airway infection, day care center attendance, presence of siblings/family size, passive smoking,
breastfeeding, and use of pacifiers). These risk factors
influence the occurrence of AOM especially in children.
Some recent clinical studies documented higher frequencies in the occurrence of OM and accociated diseases in
male children (Lanphear et al., 1997; Paradise et al.,
1997). The reasons for the differences are largely
unknown. However, significant sex related differences in
the frequency of disease cannot be found in the present
study. This might be explained by the age, at which the
disease occurs. The sex of an individual does not seem to
be a risk factor for AOM and mastoiditis at higher ages.
Investigations on pathological changes in the paranasal
sinuses, as another indicator for inflammation diseases
in the respiratory tract (Roberts, 2007), also did not provide significant differences between females and males
in the population from Rhens (Stifter, 2007).
Paleopathological investigations demonstrated that
members of lower social classes showed significantly
higher frequencies of signs of OM (Schultz, 1979). The
reconstruction of the social level of the indivduals is
problematical because of plundering of a high number of
the graves in historical times in both populations (Leithäuser, 2006; Eveline Saal, personal communication).
Nevertheless, some of the graves possessed rich goods
and thus demonstrated high social status of the buried
individuals. The absence of rich grave goods, on the
other hand, does not evidence a lower social status, since
American Journal of Physical Anthropology
272
S. FLOHR AND M. SCHULTZ
it is not clear whether the graves were disturbed in ancient times.
CONCLUSIONS
The high frequencies of osseous changes because of
mastoiditis in the investigated historical populations
appear plausible in the light of methodological considerations. First, even today diseases of the middle ear region
are among the most frequent diseases in general. For
pre-antibiotic times, a high frequency of complications
due to OM has to be expected. Second, poor living conditions in early medieval times certainly supported a
severe course of the disease (Schultz, 1979). Third, a
direct comparison of the presented data with those of
clinical investigations is not possible, since the latter
usually include only cases with clinically relevant symptoms within a well defined time period, whereas paleopathological data represent frequencies of disease that
were accumulated throughout life, including ‘‘silent’’
forms. Fourth, the methods used for diagnosing mastoiditis differ in clinical and paleopathological investigations.
Sectioning the bone and using microscopic techniques
allows a much higher ‘‘resolution’’ to identify osseous
changes because of pathological processes than radiological techniques. Cadaver studies on recent samples using
criteria similar to those of the present study would possibly also reveal much higher frequencies of disease than
do clinical studies on living people. However, the present
study demonstrates that mastoiditis was a common disease in ancient times and must have posed a serious
threat to people’s lives. Osseous changes because of mastoiditis should, therefore, be given more attention in
future paleopathological investigations.
ACKNOWLEDGMENTS
The authors thank Christopher Ruff, the Associate
Editor, and two anonymous reviewers for their helpful
comments on the article. They also thank Uwe Kierdorf
for spending a lot of time in helpful discussions and corrections, and Eveline Saal for her archaeological information about the cemetery from Rhens. For linguistic
corrections of the article they thank Cyrilla Maelicke.
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