10.14639/0392-100X-N1392
Objective. The aim of this study was to investigate the inhibitory effect of different doses of sodium- 2-mercaptoethanesulphonate (MESNA) and 5-fluorouracil on cholesteatoma formation.Methods. Fifty-six Wistar albino male rats were divided into seven groups with eight rats in each. On the first, eighth and fifteenth days, 0.2 ml of saline was administered to the group 1 (control group), and propylene glycol to induce cholesteatoma the other groups. On the 22nd day of the study, 0.2 ml saline was given to Group 1 and Group 2. Groups 3 to 7 were treated with 0.2 ml 100% MESNA, 0.2 ml 50% MESNA, 0.2 ml 20% MESNA, 0.2 ml 5-fluorouracil and 0.1 ml 100% MESNA plus 0.1 ml 5-fluorouracil, respectively, with all applications performed by intratympanic injection.Results. Significant differences were found between Group 1 and all other groups except Group 3. Significant differences were also found between Group 3 and Groups 2, 5 and 6 (P &lt; 0.05). Conclusions. According to the results of this study, experimental cholesteatoma induced with propylene glycol may be inhibited by MESNA at 100% concentration.
text/xml
1827-675X
1392
en
Mahmut Tayyar Kalcioglu
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
cholesteatoma
Inhibitory effect of mesna and 5-fluorouracil on propylene glycol-induced cholesteatoma in rats
Text.Serial.Journal
https://www.actaitalica.it/
41
Otology
2021-11-05
2021-01-16
2021-11-02
2021-11-02
481-486
1
Mahmut Tayyar Kalcioglu
2021/11/05
10.14639/0392-100X-N1392
481
Istanbul Medeniyet University, Faculty of Medicine, Goztepe Training and Research Hospital, Department of Otorhinolaryngology, Istanbul, Turkey
1827-675X
cholesteatoma
486
Inhibitory effect of mesna and 5-fluorouracil on propylene glycol-induced cholesteatoma in rats
https://www.actaitalica.it/article/download/1392/685
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:481-486; doi: 10.14639/0392-100X-N1392




Otology


Inhibitory effect of mesna and 5-fluorouracil
on propylene glycol-induced cholesteatoma in rats
Gli effetti inibitori del mesna e 5-fluorouracile nel colesteatoma indotto
dal glicol-propilene nei topi
Numan Kokten1, Ozan Tuysuz1, Tulay Zenginkinet2, Fatih Mehmet Hanege1, Mahmut Tayyar Kalcioglu1
1
  Istanbul Medeniyet University, Faculty of Medicine, Goztepe Training and Research Hospital, Department of Otorhinolaryngology,
Istanbul, Turkey; 2 Istanbul Medeniyet University, Faculty of Medicine, Goztepe Training and Research Hospital Department of
Pathology, Istanbul, Turkey


SUMMARY
Objective. The aim of this study was to investigate the inhibitory effect of different doses of so-
dium-2-mercaptoethanesulphonate (MESNA) and 5-fluorouracil on cholesteatoma formation.
Methods. Fifty-six Wistar albino male rats were divided into seven groups with eight rats in
each. On the first, eighth and fifteenth days, 0.2 ml of saline was administered to the group
1 (control group), and propylene glycol to induce cholesteatoma the other groups. On the
22nd day of the study, 0.2 ml saline was given to Group 1 and Group 2. Groups 3 to 7 were
treated with 0.2 ml 100% MESNA, 0.2 ml 50% MESNA, 0.2 ml 20% MESNA, 0.2 ml
5-fluorouracil and 0.1 ml 100% MESNA plus 0.1 ml 5-fluorouracil, respectively, with all
applications performed by intratympanic injection.                                                    Received: January 16, 2021
Results. Significant differences were found between Group 1 and all other groups except Group         Accepted: April 19, 2021
3. Significant differences were also found between Group 3 and Groups 2, 5 and 6 (P < 0.05).
Conclusions. According to the results of this study, experimental cholesteatoma induced               Correspondence
with propylene glycol may be inhibited by MESNA at 100% concentration.                                Mahmut Tayyar Kalcioglu
                                                                                                      Istanbul Medeniyet University, Faculty of Medici-
KEY WORDS: sodium-2-mercaptoethanesulphonate, MESNA, 5-fluorouracil, cholesteatoma                    ne, Department of Otorhinolaryngology, Goztepe
                                                                                                      Training and Research Hospital, 34722 Istanbul,
                                                                                                      Turkey
RIASSUNTO                                                                                             Tel. +90 216 5709070. Fax +90 216 566 6614
Obiettivo. Lo scopo di questo studio era di indagare l’effetto inibitorio dell’applicazione di        E-mail: mtkalcioglu@hotmail.com
diverse dosi di sodio-2-mercaptoetansolfonato (MESNA) e 5-fluorouracile sulla formazione
di colesteatoma.                                                                                      Funding
Metodi. Cinquantasei ratti maschi albini Wistar sono stati divisi in sette gruppi da otto             None.
ratti ciascuno. Il primo, l’ottavo e il quindicesimo giorno, sono stati somministrati 0,2 ml
di soluzione salina al gruppo 1 (gruppo di controllo) e glicole propilenico per indurre il            Conflict of interest
colesteatoma negli altri gruppi. Il 22° giorno dello studio, sono stati somministrati 0,2 ml          The Authors declare no conflict of interest.
di soluzione salina al Gruppo 1 e al Gruppo 2. I gruppi da 3 a 7 sono stati trattati con 0,2
ml di MESNA al 100%, 0,2 ml di MESNA al 50%, 0,2 ml di MESNA al 20%, 0,2 ml di                          How to cite this article: Kokten N, Tuysuz
5-fluorouracile e 0,1 ml di MESNA al 100% più 0,1 ml di 5-fluorouracile, rispettivamente,               O, Zenginkinet T, et al. Inhibitory effect of
con tutte le applicazioni eseguite mediante iniezione intratimpanica.                                   mesna and 5-fluorouracil on propylene glycol-
Risultati. Sono state trovate differenze significative tra il Gruppo 1 e tutti gli altri gruppi         induced cholesteatoma in rats. Acta Otorhi-
eccetto il Gruppo 3. Differenze significative sono state trovate anche tra il Gruppo 3 e i              nolaryngol Ital 2021;41:481-486. https://doi.
Gruppi 2, 5 e 6 (P < 0,05).                                                                             org/10.14639/0392-100X-N1392
Conclusioni. Secondo i risultati di questo studio, il colesteatoma sperimentale indotto con
glicole propilenico può essere inibito da MESNA a una concentrazione del 100%.                        © Società Italiana di Otorinolaringoiatria
                                                                                                      e Chirurgia Cervico-Facciale
PAROLE CHIAVE: sodio-2-mercaptoetansolfonato, MESNA, 5-fluorouracile, colesteatoma
                                                                                                                     OPEN ACCESS

                                                                                                      This is an open access article distributed in accordance with
                                                                                                      the CC-BY-NC-ND (Creative Commons Attribution-Non-
Introduction                                                                                          Commercial-NoDerivatives 4.0 International) license. The
                                                                                                      article can be used by giving appropriate credit and mentio-
                                                                                                      ning the license, but only for non-commercial purposes and
Cholesteatoma consists of a matrix of keratinised squamous epithelium, sub-                           only in the original version. For further information: https://
epithelial connective tissue and a perimatrix of keratin debris 1. The treatment                      creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                              481
N. Kokten et al.




of cholesteatoma is surgical, but recent research into agents      Wistar albino male rats weighing 225 to 360 grams, divided
such as sodium-2-mercaptoethanesulfonate (MESNA) and               into seven groups of eight rats each. Weight measurements
5-fluorouracil (5-FU) have been carried out 2-5.                   were made to create standard rat groups. A total of 100 ears
The synthetic sulphur compound MESNA is the sodium                 (50 right and 50 left) were evaluated. Group 1 was the sa-
salt of the 2-thiosulphonate anion and acts by breaking            line control group in which 0.2 ml of saline was applied to
down disulphide bonds 2,6,7 and is widely used in medicine         both ears of the rats on days 1, 8 and 15. Rats in the other
because of its protective, mucolytic and antioxidant ef-           groups were treated with 0.2 ml of 100% propylene glycol
fects 7. It has been safely used in the treatment of various       on days 1, 8 and 15 to induce cholesteatoma. On the 22nd
conditions, including cyclophosphamide-induced hemor-              day of the study, 0.2 ml saline was administered to Groups
rhagic cystitis as a cell protector, respiratory diseases such     1 and 2. Group 3 was treated with 0.2 ml 100% MESNA
as asthma, laryngitis, chronic bronchitis and rhinitis as a        (Uromitexan, 400 mg Eczacibasi-Baxter Oncology Drug,
mucolytic agent, as a protective agent in pulmonary dis-           Istanbul, Turkey), Group 4 was treated with 0.2 ml 50%
eases against the toxicity of some chemotherapeutics and in        MESNA, Group 5 was treated with 0.2 ml 20% MESNA,
the surgery of chronic otitis media with cholesteatoma. As         Group 6 was treated with 0.2 ml 5-FU (5-fluorouracil Bio-
a thiol compound, it acts by breaking the disulphide bonds         syn 5 Ml 250 Mg, Orna Drug, Istanbul, Turkey) and Group
of the epithelium and facilitating dissection and is used in       7 was treated with 0.1 ml 100% MESNA plus 0.1 ml 5-FU.
the surgery of atelectatic ears and chronic otitis media with      During these procedures, rats were anaesthetised by intra-
cholesteatoma 2,8,9. It helps lateralisation of the eardrum in     peritoneal injection with 100 mg/kg ketamine and 10 mg/
atelectatic ears, easier dissection of cholesteatoma matrix        kg xylazine hydrochloride. In this study, all applications
and decreases residual cholesteatoma risk 2-4,6,7. It was re-      were performed by intratympanic injections with a surgical
cently reported that use of MESNA in tympanosclerosis              microscope.
surgery provided easy dissection of plaques and prevented          Only 4 rats were lost due to respiratory arrest during the
new sclerotic plaque formation due to its antioxidant and          procedures and 2 rats were lost during follow-up, and thus
dissector effects 10. The main concern of any drug appli-          the study was completed with 50 rats. Twelve weeks after
cation is the possibility of complications and toxicity, and       the last intratympanic injection, animals were euthanised
MESNA application does not seem to have any side effects           with a high dose of intraperitoneal ketamine. Both the right
on the middle ear, hearing, cochlea, or facial nerve 7-9.          and left temporal bones of each animal were removed for
The antimetabolite 5-FU is used in cancer chemotherapy,            histopathological examination.
precancerous lesions and benign skin lesions and exerts its
effect by inhibiting thymidylate synthase, which converts          Histopathological examination
ribonucleotides into deoxyribonucleotides, blocking DNA            After the temporal bones were fixed with 10% formalde-
synthesis 11,12. It affects cells in the growth phase synthesis-   hyde, they were decalcified with 10% nitric acid. The sec-
ing DNA and RNA and has no effect on static cells 12. There        tions were embedded in paraffin using standard techniques,
are studies suggesting the use of 5-FU as an antineoplastic        and the 4 mm thick sections were prepared and stained with
agent that suppresses cell proliferation in the treatment of       haematoxylin-eosin (H&E). All specimens were evaluated
otitis media with cholesteatoma 5,12.                              by a pathologist blinded to each group. Tympanic mem-
Cholesteatoma treatment is important in otologic surgery           brane, middle ear mucosa and bulla were histopathologi-
and treatment modalities need to be improved.                      cally evaluated with a microscope (Olympus BX 51, Olym-
The aim of this study was to investigate the inhibitor ef-         pus, Japan), with samples evaluated for parameters such as
fects of MESNA and 5-FU on cholesteatoma created by                cholesteatoma characterised by the presence of keratinised
propylene glycol. Although the effects of these chemicals          squamous epithelium in the middle ear cavity (Fig. 1),
on cholesteatoma were discussed in different studies, we           granulation tissue (Fig. 2), and cyst formation, fibrosis and
aimed to investigate the effects of these agents at different      acute inflammation in the bulla (Fig. 3). The presence of
concentrations as well as investigating possible synergistic       keratinised squamous epithelium in the middle ear cavity
effects by using them together.                                    was accepted as positive for cholesteatoma and vice versa
                                                                   as negative. Any suspicious finding was also evaluated as
                                                                   negative.
Materials and methods
The approval was obtained from the Local Experimental              Statistical analysis
Animals Ethics Committee (YUHDEK:639-01.02.2018).                  Data were evaluated using SPSS 20.0. Percentage, mean,
The study was performed in the animal laboratory on 56             standard deviation and frequency values were calculated.



482
                                                                                            Inhibitory effect of mesna and 5-fluorouracil in cholesteatoma




Figure 1. Cholesteatoma and keratin debris characterised by the presence      Figure 3. Cyst formation in the bulla, fibrosis, appearance of acute inflam-
of keratinised squamous epithelium in the middle ear cavity (Haematoxylin &   mation (Haematoxylin & Eosin, 200X). Left marked arrow: Cystic space view,
Eosin, 100X).                                                                 Right marked arrow: Fibrosis.


                                                                              (85.7%) in Group 6 and seven ears (58.3%) in Group 7.
                                                                              Significant differences were found between Group 1 and all
                                                                              other groups except Group 3, which was treated with 100%
                                                                              MESNA. Significant differences were also found between
                                                                              Group 3 and Groups 2, 5 and 6 (P < 0.05). The difference
                                                                              was not statistically significant in all other pairwise com-
                                                                              parisons (P > 0.05) as shown in Table I.

                                                                              Other findings
                                                                              When epithelial hyperplasia was compared, significant dif-
                                                                              ferences were found between Group 1 and all other groups
                                                                              (p < 0.05) except group 3 (p = 0.140). Significant differences
                                                                              were also found between Group 3 and Group 2 (p = 0.001)
                                                                              (Tab, II). While there was a significant difference between
                                                                              the Group 1 and all of the other groups in terms of fibrosis
Figure 2. Granulation tissue formation (Haematoxylin & Eosin, 200X).          except Group 4 and 5 (p < 0.05), no significant difference
                                                                              was found when the groups were compared with Group 2
The relationship between categorical variables was evalu-                     (p > 0.05) as shown in Table II. There were significant dif-
ated using the Chi-square test. P < 0.05 was considered sig-                  ferences between Group 1 and all groups in terms of granu-
nificant in all analyses.                                                     lation tissue formation (p < 0.05). However, no significant
                                                                              difference was observed when all groups were compared
Results                                                                       to Group 2 (p > 0.05) (Tab. II). There was a significant dif-
                                                                              ference in cyst formation between the Group 1 and all of
Cholesteatoma development                                                     the other groups except Groups 2, 4 and 6 (p < 0.05), and
As mentioned in the Methods, the presence of keratinised                      no significant difference was found when all groups were
epithelium in the middle ear was accepted as cholesteato-                     compared with Group 2 (P > 0.05) (Tab. II).
ma. In Group 1, the saline control, cholesteatoma was not
observed in any of the 16 ears. Cholesteatoma development
was observed in 13 (81.2%) ears of Group 2 as the propyl-
                                                                              Discussion
ene glycol control, three ears (21.4%) in Group 3, nine ears                  Cholesteatoma, as a hyperplastic keratinised flat epithelium
(64.3%) in Group 4, 11 ears (78.6%) in Group 5, 12 ears                       located in the middle ear and mastoid bone, causes osteo-



                                                                                                                                                    483
N. Kokten et al.




Table I. Results of control and treatment groups for cholesteatoma formation.
                            1. Group           2. Group          3. Group                4. Group            5. Group            6. Group            7. Group
 1. Group                                         0.000               0.225               0.001               0.000               0.000               0.005
 2. Group                       0.000                                 0.003               0.417               1.00                 1.00               0.231
 3. Group                       0.225             0.003                                   0.054               0.007               0.002               0.105
 4. Group                       0.001             0.417               0.054                                   0.678               0.385               0.756
 5. Group                       0.000              1.00               0.007               0.678                                    1.00               0.401
 6. Group                       0.000              1.00               0.002               0.385               1.00                                    0.190
 7. Group                       0.005             0.231               0.105               0.756               0.401               0.190



Table II. Comparison results of control and treatment groups for epithelial hyperplasia, fibrosis, granulation tissue and cyst formation in bulla.
 Chi-square test                        Groups             2                   3                   4                  5                6                 7
 Epithelial hyperplasia                     1               0.000             0.140               0.001            0.000             0.000             0.007
                                            2                                 0.001               0.263            0.605             0.567             0.183
 Fibrosis                                   1                0.01             0.013               0.14             0.280             0.013             0.002
                                            2                                 0.961               0.183            0.086             0.961             0.445
 Granulation tissue formation               1               0.001             0.000               0.000            0.000             0.002             0.000
                                            2                                 0.648               0.552            0.552             0.433             0.611
 Cyst formation                             1               0.441             0.021               0.133            0.021             0.462             0.034
                                            2                                 0.116               0.426            0.116             0.550             0.160



clastic activity and bone resorption. Because of these ef-                          treated with 50% propylene glycol applied three times with
fects, it can lead to hearing loss, facial paralysis, vestibular                    an interval of five days in rats 14. The number of propylene
disorders and even fatal complications such as meningitis                           glycol applications is also important in the formation of
and brain abscessation 1,2,4. The treatment for cholesteato-                        cholesteatoma, in most of these studies, propylene glycol
ma is surgical dissection, but non-surgical treatment mo-                           was applied more than three times 4,11,13,16,17,19. In most of
dalities for cholesteatoma have been the subject of research                        these studies, propylene glycol was applied to the middle
in recent years.                                                                    ears of experimental animals, reaching the bulla surgically
Cholesteatoma can be induced in laboratory animals by                               and the rate of cholesteatoma development had been re-
applying propylene glycol to the middle ear 4,11,13-20. The                         ported as 0 to 100% 4,11,13-20. Intratympanic application is
irritation caused by propylene glycol in the middle ear                             another choice. By using this method, Melo et al. 15 and
mucosa creates an inflammatory response and leads to hy-                            Ismi et al. 4 reported cholesteatoma development rates of
perplasia of the epidermal and connective tissue layers of                          63.6% and 88%, respectively.
the tympanic membrane. Hyperplastic epidermis reaches                               In the current study with the same method, a cholesteatoma
the middle ear cavity by penetrating the intact tympanic                            development rate of 81.2% was observed. In experimental
membrane, proliferation and keratinisation continues and                            studies, inhibitory effects of several compounds have been
cholesteatoma develops 11,20. The success rate of induced                           investigated in propylene glycol-induced cholesteatoma.
cholesteatoma varies depending on the propylene glycol                              Chemicals such as trans-retinoic acid, MESNA, 5-FU,
concentration, the number of applications and the species                           intratympanic corticosteroid have been shown to inhibit
of laboratory animal used 20. Vassalli et al. reported chole-                       propylene glycol-induced cholesteatoma 4,11,13,14. No sig-
steatoma in four of seven ears treated with 10.5% of pro-                           nificant inhibitory effects of mitomycin C, hyaluronic acid,
pylene glycol and no cholesteatoma treated with 2% pro-                             systemic naproxen sodium, cyclophosphamide, isotreti-
pylene glycol in chinchillas 21. Kayhan et al. reported no                          noin, or systemic corticosteroid have been demonstrated on
cholesteatoma formation treated with 60% propylene gly-                             propylene glycol-induced cholesteatoma 15-20.
col in nine ears of guinea pigs. They attributed this result                        MESNA breaks down the disulphide bonds in the chole-
to single dose administration and the low concentration of                          steatoma matrix, allowing the cholesteatoma to be removed
propylene glycol in the middle ears of the guinea pigs 20.                          more easily and reduces residual cholesteatoma risk 2. Ismi
Sennaroglu et al. reported 33% cholesteatoma formation                              et al. reported that development of propylene glycol-in-



484
                                                                                 Inhibitory effect of mesna and 5-fluorouracil in cholesteatoma




duced cholesteatoma was inhibited by a single dose of 10%           range of propylene glycol concentrations from two to 100%,
MESNA 4. Ismi et al. also found a cholesteatoma formation           different application intervals, different experimental animals
rate of 88% and this was very low in the MESNA group.               including chinchillas, guinea pigs and rats and different sur-
They reported single dose intratympanic MESNA applica-              gical techniques, including bulla and intratympanic 4,11,13-20,
tion inhibited propylene glycol-induced cholesteatoma via           and thus it is difficult to compare the results. All studies have
its antioxidant effect and disturbing the disulphide bonds of       shown that the irritation caused by propylene glycol produces
keratin filaments 4.                                                chronic inflammation in the middle ear, bulla, the tympanic
Smith used 5-FU in the treatment of cholesteatoma for               membrane and all tissues of the ear. These changes vary from
the first time in the literature and reported its clinical ef-      inflammatory mucosal changes to bone erosion such as epi-
fects, where 76 open mastoid or middle ear cholesteatoma            thelial hyperplasia, fibrosis, oedema, haemorrhage, effusion,
patients were treated with topical use of 5-FU in addition          granulation tissue formation, cochlear bone erosion, cyst for-
to surgery 22 and concluded that topical 5-FU can be used           mation, cholesteatoma development, perforation of tympanic
in hyperkeratosis, external ear canal, mastoid and middle           membrane, thickening of tympanic membrane, osteogenesis,
ear cholesteatoma management with very few side effects.            thickening of bone, fibrous adhesions and erosion of inner ear
Wright et al. reported that 5-FU inhibited the development          structures 4,11,13-20. Several chemicals have been investigated to
of experimental cholesteatoma induced by propylene glycol           find a protective effect against these changes. Ismi et al. report-
in chinchillas by reducing the proliferation of the epidermal       ed single dose MESNA application inhibited cholesteatoma
and connective tissue of tympanic membrane 11. Takahashi            development in propylene glycol-induced cholesteatoma,
et al. reported that topical 5-FU cream was applied to 50           but they did not find significant differences in granulation
ears of 50 patients with various types of cholesteatoma, two        tissue formation, cyst formation, epithelial hyperplasia and
or five times at two-week intervals. It was concluded that          fibrosis 4. In this study, the inhibitory effect of single dose
topical 5-FU cream was effective in the clinical treatment          100% MESNA against cholesteatoma (p = 0.003) and epi-
of cholesteatoma; no serious side effects were observed             thelial hyperplasia (p = 0.001) was significant. There were
and the cream could be used in the treatment of early stage         no significant differences in granulation tissue formation,
disease or in patients who could not be operated on for vari-       cyst formation, and fibrosis (P > 0.05). It is hypothesised
ous reasons 23. No side effects related to ototoxicity have         that the inhibition of epithelial hyperplasia by 100% MES-
been reported in high-dose intravenous 5-FU applications            NA is due to its antioxidant properties. This study agrees
in chemotherapy 12, and minimal doses of topical use of             with Ismi et al. 4 that MESNA application inhibits propyl-
5-FU should be safe. Yamamato et al. showed that after the          ene glycol-induced cholesteatoma via its antioxidant effect
use of topical 5-FU in attic cholesteatoma, clinical inhibi-        and during cholesteatoma development, it blocks formation
tion of cholesteatoma occurred due to downregulation of             of a stable structure by disrupting the stabilisation and or-
keratinocyte growth factor in cholesteatoma stromal cells           ganisation of filaments by breaking down disulphide bonds.
and a decrease in proliferative activity in epithelial cells.       In this study, the effects of 100%, 50%, and 20% MES-
They suggested to use 5-FU in early stage cholesteatoma             NA, 5-FU and 100% MESNA plus 5-FU administration
patients with computed tomography follow-up 24.                     on cholesteatoma development were investigated. Only
Successful results of the use of 5-FU and MESNA alone in            100% MESNA administration produced significant re-
the treatment and prevention of cholesteatoma formation             sults in inhibition of propylene glycol-induced experimen-
have been reported in several studies 2-4,11,22-24. In our study,   tal cholesteatoma development and epithelial hyperplasia
we wanted to observe whether using these drugs togeth-              (P < 0.05). Other MESNA concentrations and combination
er would create a synergistic effect. However, unlike that          with 5-FU did not produce a significant inhibitory effect
reported in the literature, we could not detect the inhibi-         against cholesteatoma development.
tory effect of 5-FU alone by itself or in combination with
MESNA.
This study investigated the use of 0.2 ml 5-FU (Group 6)
                                                                    Conclusions
and 0.1 ml 100% MESNA plus 0.1 ml 5-FU combination                  According to the results of the current study, experimental
(Group 7), against cholesteatoma development. A sig-                cholesteatoma induced with propylene glycol can be in-
nificant inhibitory effect of 5-FU alone and in combina-            hibited by MESNA at 100% concentration. Diluted doses
tion with MESNA against cholesteatoma development                   of MESNA, 5-FU, and the combination of these two have
(P > 0.05) could not be shown.                                      insufficient inhibitory effects against cholesteatoma. This
The effects of propylene glycol on the middle ear have been         study shows that the use of undiluted MESNA may prevent
investigated by several researchers 4,11,13-20. These have used a   cholesteatoma development and pave the way for medical



                                                                                                                                         485
N. Kokten et al.




treatment of cholesteatoma. These results should be sup-                            ryngoscope         2007;117:215-219.          https://doi.org/10.1097/01.
ported by further experimental studies and clinical trials.                         mlg.0000248231.62834.e3
                                                                               13
                                                                                    Antunes ML, Fukuda Y, Penido Nde O, et al. Effect of trans-
                                                                                    retinoic acid in the inhibition of cholesteatoma in guinea pigs.
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