title: The palaeopathology of maxillary sinusitis, otitis media and mastoiditis in Medieval Iceland: assessing the prevalence and aetiology of chronic upper respiratory disease and the presence of tuberculosis using microscopy, endoscopy and CT
Creators: name: Collins, Cecilia
Publisher: name: University of Reading
Year: 2019

description: As a measure of chronic episodes of infection, the maxillary sinuses and temporal bones, particularly the middle ear compartment and auditory ossicles, are known to remodel or erode with pathological change. Studies of maxillary sinusitis have outpaced those of the ear in palaeopathology, but have generally used only adolescent or adult material with accessible views of the sinuses (thereby sometimes excluding intact crania). Tese studies have focused on environment and air quality as major aetiologies for respiratory disease. Burgeoning evidence reveals that tuberculosis is a major contributor to disease of the respiratory tract in endemic areas with poor indoor environment. Chronic ear infections are recognised as the most common sequela of sinus infection and thus the ears and sinuses should be studied together. Te clinical literature firmly places tuberculous otitis media as a serious outcome of tuberculosis, with evidence for tuberculosis affecting the middle ear more frequently than other specific infections known to affect the cranio-facial region and the oral mucosa (i.e. leprosy and treponemal infections). Spread of disease via the mucosal, lymphatic and haematogenous systems are major aetiological factors and disease of the sinuses and middle ears may not be adequately explained if the only relationship considered in disease aetiology is mucosal pathogenesis. Tis study addresses the gap in the literature by analysing skeletons of all ages and examines the sinuses and ears together. Te aims of this study were to detail the prevalence rates of maxillary sinusitis and otitis media and test for significance and strength of effect in the relationship between the two conditions. Additionally, this project assesses the prevalence and effect of tuberculosis on chronic upper respiratory infection. Te Icelandic context is an especially useful one for honing questions concerning the indoor environment as there are fewer confounding aetiological factors than might be found in other populations. Iceland was not impacted by industrial pollution to the same degree as other contemporaneous locales in medieval Europe. Microscopic and endoscopic examination of 305 crania from medieval Icelandic skeletons from four locations: Hofstaðir, Keldudalur, Skeljastaðir and Skriðuklaustur, revealed high rates of both sinusitis (56.3%, 144 of 256) and otitis media (69.3%, 210 of 303). A new scoring system, applicable to the sinuses and temporals alike, was devised to reflect disease severity and estimated impact on anatomical function. Sinusitis was detected in children as young as 4.5-5.5 years of age. Spicule formation in otitis media was also observed in 56% of infants. Across all ages, those with both otitis media and sinusitis number 109 of 258 (42.2%) and the two conditions were significantly correlated (x2 (1)=11.277, p=0.001). Mastoiditis was observed using CT scans of 73 crania from two of the four sites; 29.9% (40 of 134) of mastoids observed were sclerotic or diploïc, a rate consistent with the prevalence of mastoiditis in other archaeological populations. In ordinal and binary logistic regression tuberculosis was shown to effect higher grades of severity in the sinuses and middle ear. Tis thesis addresses a shortfall in our understanding of health in Iceland in the period following settlement through to the medieval period, which can best be assessed when examining the skeletal record as a primary source. Finally, high prevalence rates of sinusitis and otitis media in any sample with definite or probable examples of tuberculosis should be considered highly suspect for tuberculous sinusitis and otitis media.