International Journal of Pediatric Otorhinolaryngology 78 (2014) 280–284

Efficacy of Curcumin in the healing of paracentesis in rats

Leman Birdane a, Turhan San b, Nuray Bayar Muluk c,*, Dilek Burukoglu d, Cemal Cingi e

a Yunus Emre State Hospital, ENT Department, Eskisehir, Turkeyb Istanbul Medeniyet University, Goztepe Training and Research Hospital, ENT Department, Istanbul, Turkeyc Kırıkkale University, Faculty of Medicine, ENT Department, Kırıkkale, Turkeyd Eskisehir Osmangazi University, Faculty of Medicine, Histology Department, Eskisehir, Turkeye Eskisehir Osmangazi University, Faculty of Medicine, ENT Department, Eskisehir, Turkey

A R T I C L E I N F O

Article history:

Received 17 July 2013

Received in revised form 21 November 2013

Accepted 21 November 2013

Available online 1 December 2013

Keywords:

Curcumin (CMN) drop

Paracentesis

Rats

Histological examination

A B S T R A C T

Objectives: The present study was designed to investigate the possible beneficial effect of Curcumin

(CMN) in healing of paracentesis in terms of wound thickness, sclerosis and closure by histological

evaluation. To evaluate the efficacy of CMN, paracentesis was performed experimentally in the rats; and

the results were presented histologically.

Methods: Sixteen, each 270–310 g weighted, healthy Sprague-Dawley female rats were included into the

study. In both groups, paracentesis was performed into the eardrum bilaterally. In Group 1

(Paracentesis + Saline Group), saline drop was applied; and in Group 2 (Paracentesis + Curcumin

group), Curcumin drop treatment was applied. Paracentesis area did not healed bilaterally in two rats

(one in Group 1 and one in Group 2). Therefore, these two rats were excluded from the study. Histological

examination performed in 14 rats and 28 temporal bones on the 15th day after the completion of drop

treatment and closure of the paracentesis-area and wound healing were evaluated according to the

histological examination criteria: Thickening of the tympanic membrane (ThicTM); and sclerosis.

Results: Both tympanic membrane thickening and sclerosis values of Paracentesis + Curcumin Group

(Group 2) were significantly lower than those of the Paracentesis + Saline Group’s (median: 2.0)

(p = 0.001). Histological examination by light microscopy showed that in Paracentesis + Curcumin Group

(Group 2), the structure of the tympanic membrane is near to the normal and decreased sclerosis was

observed in connective tissue. Whereas in Paracentesis + Saline Group (Group 1), tympanic membrane

thickening and connective tissue sclerosis were observed.

Conclusions: Curcumin improves wound healing process in paracentesis of TM. By using Curcumin

drops, the closured paracentesis area was observed near to the normal eardrum; and thickness of the TM

and sclerosis were less than the control, showing the improved healing at 15th day. The possible

mechanisms may be anti-inflammatory effect, improving collagen deposition, and increasing fibroblast

and vascular density in wounds thereby enhancing impaired wound healing.

� 2013 Elsevier Ireland Ltd. All rights reserved.

Contents lists available at ScienceDirect

International Journal of Pediatric Otorhinolaryngology

jo ur n al ho m ep ag e: ww w.els evier . c om / lo cat e/ i jp o r l

1. Introduction

Curcumin (diferuloylmethane), a major active component ofthe dietary spice turmeric, has been used in Indian and Chinesemedicine for treatment of various disease conditions. Curcumin isa polyphenol and possesses anti-inflammatory, antioxidant,antiproliferative, and wound healing properties [1,2]. The diseaseportfolio for this traditional medicine includes pain disorders,digestive diseases, menstrual difficulties, skin conditions, sprains,

* Corresponding author at: Birlik Mahallesi, Zirvekent 2. Etap Sitesi, C-3 blok, No:

62/43, 06610 Cankaya/Ankara, Turkey. Tel.: +90 312 4964073/532 7182441; fax:

+90 312 4964073.

E-mail addresses: nbayarmuluk@yahoo.com, nurayb@hotmail.com

(N.B. Muluk).

0165-5876/$ – see front matter � 2013 Elsevier Ireland Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ijporl.2013.11.024

wounds, and liver disorders [3]. Curcumin has the potential topreserve food through its antioxidant property [4]. Laboratorystudies have also confirmed that Curcumin possess antioxidant,anti-inflammatory, antiviral, antibacterial, antifungal, and anti-cancer activities [5–7].

In vivo, wound healing is considerably more complex than in

vitro, involving three (partially overlapping) phases: inflammation,tissue formation and remodeling [8]. Specific cell types migrateinto the wound and then interact with other cells and theenvironment. During the inflammatory phase, neutrophils andmacrophages migrate into the wound, removing foreign particlesand bacteria and releasing cytokines which promote fibroblastmigration and proliferation.

Another important aspect in wound healing is neovasculariza-tion which re-establishes perfusion to sustain the new tissues. It is

Fig. 1. In Paracentesis + Saline Group, tympanic membrane thickening (!) and

connective tissue sclerosis are seen (H & E, scale bar: 500 mm).

L. Birdane et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 280–284 281

thus important to emphasize that fibroblast migration in vivo coulddepend on factors that cannot be included in an in vitro assay.Nevertheless, the strength of in vitro studies is in isolating effects ofthe tested NMs on direct biomechanical measures of the migrationkinematics, since e.g. these substances could potentially interactwith cytoskeletal activation proteins that control cell spreading,contraction or directionality, such as Rac, Rho and Cdc42 [6,9,10].

Curcumin has a beneficial effect on nuclear factor-kappa B (NF-kB). Curcumin inhibits NF-kB, subsequently reducing inflammationand thereby providing benefits for various skin diseases. Recentstudies as reviewed here are unraveling previously unidentifiedpathways, unique molecular targets and novel mechanisms throughwhich Curcumin may perform as a skin protectant [2,11].

The present study was designed to investigate the possiblebeneficial effect of CMN in the healing of paracentesis. To evaluatethe efficacy of CMN, paracentesis was performed experimentally inthe rats; and the results were presented histologically.

2. Materials and method

The study was conducted in University Faculty of Medicine ofEskis ehir Osmangazi University. Adaptation and care of the animalsand experimental study were performed at TICAM (ExperimentalStudies Center of Eskis ehir Osmangazi University). During bothadaptation and experiment periods, the animals were treated incompliance with the principles of the Declaration of Helsinki [12].

2.1. Animal subjects

Sixteen, each 270–310 g weighted, healthy Sprague-Dawleyfemale rats were used in the present study but two were laterexcluded due to the fact that the paracentesis area were not healed atthe time of the examination (day 15). The experimental protocol wasreviewed and approved by Ethique Committee of OsmangaziUniversity, Medical and Surgical Experimental Research Center(date: February 23, 2012 and number: 265). All the animal procedureswere performed in accordance with the approved protocol.

Female rats were housed under the same conditions intemperature and humidity controlled room (20 � 1 8C, 50 � 10%relative humidity) and 14–16 h light/dark cycle conditions. Tap waterand standard pelletized food are provided ad libitum.

2.2. Experimental design

Sixteen Sprague-Dawley female rats were randomizely dividedinto two groups:

1. Group 1 (Paracentesis + Saline group): The rat group, in whichparacentesis was performed bilaterally; and after then salinedrop treatment was applied (n = 8)

2. Group 2 (Paracentesis + Curcumin group): The rat group, inwhich paracentesis was performed bilaterally; and after thenCurcumin drop treatment was applied (n = 8).

2.3. Method

1. Operation: During the experimental process, rats were sedatedby 10 mg/kg xylazine and 30 mg/kg intraperitoneal injection ofketamine were used. In all rats, in both ears of each rats,paracentesis was performed (2 mm in length).

2. Treatment modalities in Groups:- Group 1: After paracentesis procedure, saline drop (0.9% NaCl,

3 drops) was given to these rats onto the gelfoam twice a dayon the 1st day; and only saline drop was given twice a day onthe 2nd and 3rd days.

- Group 2: After paracentesis procedure, Curcumin drop (3 drops)was given to these rats onto the gelfoam twice a day on the 1stday; and only Curcumin drop was given twice a day on the 2ndand 3rd days (11 mg of powdered Curcumin was mixed with1 ml DMSO (dimethylsulfoxide); and solution was prepared.Curcumin Extract (Sigma catalog number: C1386) was used).

3. Paracentesis area did not healed bilaterally in one rat of Group 1;and in one rat of Group 2. Therefore, these two rats wereexcluded from the study. At the end, 7 rats (14 temporal bones)in Group 1 and 7 rats (14 temporal bones) in Group 2 were takento the next step of the study: Histological ExaminationProcedure described below.

2.4. Histological examination procedure

Fifteen days after the completion of saline or Curcumin droptreatments, all rats were sacrificed by giving 80 mg/kg pentothal asanesthetic agent (Fig. 1). Immediately after death, the temporalbones were removed, the otic bullae opened and placed in fixative(10% formalin). The temporal bones were decalcified in 5% formicacid [13]. They were deparaffinized and dehydrated by immersioninto xylene twice for 10 min. Following dehydration in ascendingseries of ethanol (70, 80, 96, 100%), tissue samples were cleared inxylene and embedded in paraffin. Tissue sections of 5 mm werestained with hematoxylin–eosin (H–E). A minimum of 3–4 fields foreach samples were examined and assigned for severity of changes byan observer blinded to the treatments of the animals [14]. Slides wereexamined by light microscopy with Entella Olympus BH-2 micro-scope; and photos were taken with Olympus DP-70 digital camera.

During histological examination, Thickening of the tympanicmembrane (ThicTM); and Sclerosis (Sc) were evaluated by lightmicroscopy. Severity of changes was assigned using scores of none(�), mild (+), Moderate (++) and Severe (+++) [14].

2.5. Statistical analysis

Statistical packet for SPSS (Version 16.0) was used for statisticalevaluation. Mann–Whitney U was used to analyze the differencebetween Groups 1 and 2.

p-value <0.05 was considered as statistically significant.

3. Results

The histological examination results of the tympanic mem-brane (TM) in Groups 1 and 2 were demonstrated on Table 1. For

Table 1The histological examination results of the tympanic membrane in Groups 1 and 2.

Group 1 (Paracentesis + Saline) Group 2 (Paracentesis + Curcumin) p*

Median Min Max Median Min Max

Thickening of the tympanic membrane (ThicTM) 2.0 1.0 3.0 1.0 0.0 2.0 0.001

Sclerosis (Sc) 2.5 1.0 3.0 1.5 1.0 2.0 0.003

* p-Value shows the results of Mann–Whitney U test.

L. Birdane et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 280–284282

each of the histological examination criteria [thickening of thetympanic membrane (ThicTM); and Sclerosis (Sc)], the differencebetween Groups 1 and 2 was analyzed by Mann–Whitney U Test.For all of the histological examination criteria, statisticallysignificant difference was detected (p < 0.05):

- Thickening of the tympanic membrane value of Paracentesis + -Curcumin Group (median: 1.0) was significantly lower than thatof the Paracentesis + Saline Group (median: 2.0) (p = 0.001).

- Sclerosis value of Paracentesis + Curcumin Group (median: 1.5)was significantly lower than that of the Paracentesis + SalineGroup (median: 2.5) (p = 0.003).

Fig. 2. In Paracentesis + Saline Group, tympanic membrane thickening (!) and

connective tissue sclerosis are seen. Malleus (M) attached to the tympanic

membrane structure (H & E, scale bar: 500 mm).

Fig. 3. In Paracentesis + Saline Group, tympanic membrane thickening (!) and

connective tissue sclerosis are seen (H & E, scale bar: 100 mm).

3.1. Histological examination results

Histologic examination results by light microscopic evaluationwas written below:

1. In Paracentesis + Saline Group (Group 1), tympanic membranethickening (!) and connective tissue sclerosis were observed(Figs. 1–5).

2. In Paracentesis + Curcumin Group (Group 2), the structure of thetympanic membrane is near to the normal and decreasedsclerosis is seen in connective tissue (Figs. 6–9).

Fig. 5. In Paracentesis + Saline Group, significant thickening of the tympanic

membrane (!) and connective tissue sclerosis are seen (H & E, scale bar: 50.0 mm).

Fig. 4. In Paracentesis + Saline Group, significant thickening of the tympanic

membrane (!) and connective tissue sclerosis are seen (H & E, scale bar: 50.0 mm).

Fig. 6. In Paracentesis + Curcumin Group, the structure of the tympanic membrane

is near to the normal (!) (H & E, scale bar: 500 mm).

Fig. 9. In Paracentesis + Curcumin Group, in tympanic membrane, the structure is

near to the normal and decreased sclerosis is seen in connective tissue (!) (H & E,

scale bar: 100 mm).

Fig. 7. In Paracentesis + Curcumin Group, in tympanic membrane, the structure is

near to the normal and decreased sclerosis is seen in connective tissue (!) (H & E,

scale bar: 200 mm).

Fig. 8. In Paracentesis + Curcumin Group, in tympanic membrane, the structure is

near to the normal and decreased sclerosis is seen in connective tissue (!) (H & E,

scale bar: 500 mm).

L. Birdane et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 280–284 283

4. Discussion

Curcumin, an active substance in the Turmeric shrub, was firstused in Indian ayurvedic and traditional Chinese medicine. It issaid to have anti-bacterial/viral/fungal/inflammatory qualities [6].Wound healing is a complex and dynamic process of restoringcellular structures and tissue layers. In general, wound healingprogresses in an arranged and conventional fashion such asinflammation (reactive), proliferation (regenerative), and matura-tion (remodeling). There are several factors that contribute toimpaired wound healing including diabetes and oxidative stress.Various investigators showed that Curcumin treatment reduceswound-healing time, improved collagen deposition, and increasedfibroblast and vascular density in wounds thereby enhancingimpaired wound healing. It has also been shown that Curcuminacts as a proangiogenic agent in wound healing by inducing TGF-b,in both normal and impaired healing wounds [3,15,16].

Wound healing involves many cell types, such as epidermal,fibroblastic, and endothelial cell, and various processes such asproliferation, cell migration, matrix synthesis, and contraction. Inembryos, wound healing involves repair processes that essentiallyresult in perfect regeneration of damaged tissue [17]. Thecontribution of each cell types and how these signals controlwound cell activities during the healing in the skin are not welldefined. Inflammation and oxidative stress during wound healinggenerally inhibits tissue remodeling [18].

In the present study, we investigated the effects of Curcumindrop on the healing process of paracentesis into the tympanicmembrane. In Group 1, saline drop and in Group 2 Curcumin dropwas used. Histological examination performed 15-day after thecompletion of drop treatment and closure of the paracentesis-areaand wound healing were evaluated according to the histologicalexamination criteria: Thickening of the tympanic membrane; andsclerosis. Both tympanic membrane thickening and sclerosisvalues of Paracentesis + Curcumin Group (Group 2) were signifi-cantly lower than those of the Paracentesis + Saline Group’s(median: 2.0) (p = 0.001).

Histological examination by light microscopy showed that inParacentesis + Curcumin Group (Group 2), the structure of thetympanic membrane is near to the normal and decreased sclerosiswas observed in connective tissue. Whereas in Paracentesis + Sa-line Group (Group 1), tympanic membrane thickening andconnective tissue sclerosis were observed.

L. Birdane et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 280–284284

Curcumin that has anti-inflammatory effect by inhibiting NF-jB,acts as a supportive matrix for the regenerative tissue whenincorporated in collagen matrix thereby supporting dermal woundhealing [19]. It has also been shown by Jagetia and Rajanikant [20]that pretreatment with Curcumin may accelerate the healing ofirradiated wound by enhancing the synthesis of collagen,hexosamine, DNA, and nitrate [20].

Sidhu et al. observed faster wound closure, re-epithelializationof the epidermis and increased migration of various cells includingmyofibroblasts, fibroblasts, and macrophages in the wound bed ofCurcumin-treated animals [15]. They also observed greatercollagen deposition, increase in TGF-b1, and fibronectin inCurcumin-treated wounds [16].

In wound healing, Curcumin improves noevascularization andfaster wound healing and was effective both orally and topically[21]. Curcumin also regulated TGF-b signaling and inducible nitricoxide synthase levels to significantly accelerate healing of woundswith or without dexamethasone treatment. Angiogenesis, theformation of new blood vessels play a pivotal role during woundhealing and Curcumin acts as a proangiogenic agent during thecritical process of wound repair by regulating TGF-b [16].

During the healing process of TM, thickening occurs at first andthen it decreases to the normal thickness values as the woundhealing is completed. In the present study, in the Curcumin group,the closured paracentesis area was observed near to the normaleardrum; and thickness of the TM and sclerosis were less than thecontrol, showing the improved healing at 15th day. It may be saidthat Curcumin helps to wound healing. It improves the healingprocess; and tissue thickening and sclerosis were observed lessthan the control group. The possible mechanisms may be anti-inflammatory effect, improving collagen deposition, and increas-ing fibroblast and vascular density in wounds thereby enhancingimpaired wound healing.

According to these results we recommend the use of Curcumindrops in traumatic tympanic membrane perforations; and alsoperforations of ear drum due to acute otitis media. However, asmost perforations in association with acute otitis media are healedwithin 24–48 h and traumatic perforations of the eardrum alsoheal spontaneously to a high extent, Curcumin drops may beconsidered in cases, not healed in spontaneous manner.

For this purpose, detailed studies to determine the optimumdose for eardrops should be performed by researchers; and theideal production form for drops should be studied by drug-manufacturers. Another an important item would be to investigatewhether there are ototoxic effects or not by objective methodssuch as Distortion Product Otoacoustic Emissions (DPOAE).

5. Conclusion

As a conclusion Curcumin improves wound-healing process inparacentesis of TM. By using Curcumin drops, the closuredparacentesis area was observed near to the normal eardrum;and thickness of the TM and sclerosis were less than the control,showing the improved healing at 15th day. The possiblemechanisms may be anti-inflammatory effect, improving collagendeposition, and increasing fibroblast and vascular density inwounds thereby enhancing impaired wound healing.

Conflict of interest

The authors declare that there is no conflict of interest.

Acknowledgement

Except data collection, preparation of this paper including

designing and planning was supported by Continuous Education and

Scientific Research Association.

References

[1] P. Anand, A.B. Kunnumakkara, R.A. Newman, B.B. Aggarwal, Bioavailability ofcurcumin: problems and promises, Mol. Pharm. 4 (2007) 807–818.

[2] R.L. Thangapazham, S. Sharad, R.K. Maheshwari, Skin regenerative potentials ofcurcumin, Biofactors 39 (1) (2013) 141–149.

[3] R.L. Thangapazham, A. Sharma, R.K. Maheshwari, Beneficial role of curcumin inskin diseases, Adv. Exp. Med. Biol. 595 (2007) 343–357.

[4] P. Basnet, N. Skalko-Basnet, Curcumin: an anti-inflammatory molecule from acurry spice on the path to cancer treatment, Molecules 16 (2011) 4567–4598.

[5] R.L. Thangapazham, A. Sharma, R.K. Maheshwari, Multiple molecular targets incancer chemoprevention by curcumin, AAPS J. 8 (2006) 443–449.

[6] R.K. Maheshwari, A.K. Singh, J. Gaddipati, R.C. Srimal, Multiple biological activitiesof curcumin: a short review, Life Sci. 78 (2006) 2081–2087.

[7] R. Kuttan, P.C. Sudheeran, C.D. Josph, Turmeric and curcumin as topical agents incancer therapy, Tumori 73 (1987) 29–31.

[8] A.J. Singer, R.A. Clark, Cutaneous wound healing, N. Engl. J. Med. 341 (1999)738–746.

[9] J.K. Ko, C.C. Leung, Ginger extract and polaprezinc exert gastroprotective actionsby anti-oxidant and growth factor modulating effects in rats, J. Gastroenterol.Hepatol. 25 (2010) 1861–1868.

[10] D. Demirovic, S.I. Rattan, Curcumin induces stress response and hormeticallymodulates wound healing ability of human skin fibroblasts undergoing ageing invitro, Biogerontology 12 (2011) 437–444.

[11] K.D. Tsai, J.C. Lin, S.M. Yang, M.J. Tseng, J.D. Hsu, Y.J. Lee, et al., Curcumin protectsagainst UVB-induced skin cancers in SKH-1 hairless Mouse: analysis of earlymolecular markers in carcinogenesis, Evid. Based Complement. Alternat. Med.(2012) 593952.

[12] 52nd WMA General Assembly, World Medical Association Declaration ofHelsinki: ethical principles for medical research involving human subjects,J. Am. Med. Assoc. 284 (2000) 3043–3049.

[13] R.A. Chole, C.A. Quick, Experimental temporal bone histopathology in rats de-prived of dietary retinol and maintained with supplemental retinoic acid, J. Nutr.108 (6) (1978) 1008–1016.

[14] N. Tirkey, G. Kaur, G. Vij, K. Chopra, Curcumin, a diferuloylmethane, attenuatescyclosporine-induced renal dysfunction and oxidative stress in rat kidneys, BMCPharmacol. 15 (5) (2005) 15.

[15] G.S. Sidhu, A.K. Singh, D. Thaloor, K.K. Banaudha, G.K. Patnaik, R.C. Srimal, et al.,Enhancement of wound healing by curcumin in animals, Wound Repair Regen. 6(1998) 167–177.

[16] H. Mani, G.S. Sidhu, R. Kumari, J.P. Gaddipati, P. Seth, R.K. Maheshwari, Curcumindifferentially regulates TGF-beta1, its receptors and nitric oxide synthase duringimpaired wound healing, Biofactors 16 (2002) 29–43.

[17] M.C.Y. Heng, Wound healing in adult skin: aiming for perfect regeneration, Int.J. Dermatol. 50 (2011) 1058–1066.

[18] N. Bhagavathula, R.L. Warner, M. DaSilva, S.D. McClintock, A. Barron, M.N. Aslam,et al., A combination of curcumin and ginger extract improves abrasion woundhealing in corticosteroid impaired hairless rat skin, Wound Repair Regen. 17(2009) 360–366.

[19] D. Gopinath, M.R. Ahmed, K. Gomathi, K. Chitra, P.K. Sehgal, R. Jayakumar, Dermalwound healing processes with curcumin incorporated collagen films, Biomater-ials 25 (2004) 1911–1917.

[20] G.C. Jagetia, G.K. Rajanikant, Acceleration of wound repair by curcumin in theexcision wound of mice exposed to different doses of fractionated c radiation, Int.Wound J. 9 (2012) 76–92.

[21] G.S. Sidhu, H. Mani, J.P. Gaddipati, A.K. Singh, P. Seth, K.K. Banaudha, et al.,Curcumin enhances wound healing in streptozotocin induced diabetic rats andgenetically diabetic mice, Wound Repair Regen. 7 (1999) 362–374.