Original articleNasal septum deviation and Eustachian tube function: A prospective case-control study based on tympanometry, tubomanometry, and ETDQ-7Desviación del septo nasal y función de la trompa de Eustaquio: estudio prospectivo de control de casos basado en timpanometría, tubomanometría y ETDQ-7
Introduction
Eustachian tube (ET) dysfunction includes disorders in which ET fails to close or open properly. These are named patulous and obstructive ETD (OETD), respectively, the latter being the most common of the two.1 Patients with ET dysfunction may complain of different otologic symptoms related to the persistent negative middle ear pressure, such as otalgia, aural fulness, hearing impairment, and tinnitus. Moreover, ET dysfunction can contribute to middle ear effusion and chronic otitis media, in the form of tympanic membrane retraction and cholesteatoma.
ET dysfunction has been associated with different conditions. Less common conditions are related to mechanic obstruction of the ET opening, namely by extrinsic compression – adenoids and tumors, and fibrosis, for example, as a consequence of trauma or radiotherapy for head and neck cancer.2, 3 More often, ET dysfunction is related to an inflammatory response of the epithelium within the lumen of the tube.4 Inflammation may have different etiologies, frequently divided into irritant and infectious reactions. Proven irritant substances to the ET – such as smoke, acid from pharyngolaryngeal gastric reflux – and infections – viral or bacterial –, may stimulate the release of proinflammatory cytokines which promote edema leading to an inability for an adequate ET opening. Nasal pathology such as allergic rhinitis and chronic rhinosinusitis are also a cause of inflammatory changes in ET opening and have also been associated with ET dysfunction. Nevertheless, the impact of nasal septum deviation (NSD) alone in ET function is not a consensual subject.
Although some researchers have supported that NSD could worsen the middle ear ventilation by negative influence on airflow parameters, and advocate that severe NSD can be the cause of failure of ear surgery for chronic otitis media, other studies failed to prove the association.5, 6, 7, 8, 9, 10 Different authors have previously investigated the influence of isolated NSD in the ET function using distinct methodologies: most authors used impedanciometry, through tympanometry or Valsalva and Toynebee tubal function tests to assess tubal function, evaluating patients before and after septal surgery, and comparing results in different moments; one author used a control population (without NSD) and one evaluated ET dysfunction symptomatology evaluation (and none used a validated symptoms scale).5, 6, 7, 8, 10
Given the absence of a gold-standard exam to evaluate ET function studies that address the impact of NSD on ET use different methods for its evaluation, which can also make their results difficult to interpret and compare.6, 7, 8, 9
Although there are several papers about the subject, the best test to accurately evaluate ET function is still a matter of debate.
A recent review from Smith et al. abridged all the current concepts about ET function evaluation.11 Patient-reported outcome measures (PROMs), such as ET dysfunction questionnaire 7 (ETDQ-7) and 10-item Cambridge ET dysfunction Assessment (CETDA) are repeatable, being valuable to assess the presence and to quantify the severity of ET dysfunction-related symptoms; on the other hand, they are not valuable for diagnostic purposes.1, 11, 12, 13 In fact, these PROMs are helpful, above all, to evaluate the impact of different interventions (such as baloon Eustachian tuboplasty) in symptoms and quality of life, and have been added to some recent consensuses regarding the ET dysfunction treatment approach.11, 12, 14
Clinical assessment, including PROMs, should be complemented with objective exams. Regarding the latter, they are further divided in indirect measures of ET function (for which tympanometry is the most widely used), tests of ET opening (such as evaluation of the tympanic membrane movement or external auditory canal – tubo-tympano-aerodynamic graph – TTAG – pressure to Valsalva and Toynebee maneuvers, tubomanometry, inflation-deflation tests, or sonotubometry) and tests of ET closure (TTAG, sonotubometry or tubomanometry).11 Tympanometry, sonotubometry, and tubomanometry (TMM) are the ones with greater value in patients in which obstructive pathology of the ET is suspected.11 On the other hand, to evaluate patulous ET dysfunction besides the observation of a breathing-synchronous tympanic membrane movement, exams such as TTAG, sonotubometry and TMM can be valuable. Although none is considered the gold-standard of ET evaluation, they all are reliable and objective, with different sensitivities and specificities.1, 13, 15, 16
Section snippets
Objective
The first objective of this paper is to compare ET function between patients with NSD and patients with adequate bilateral nasal patency using PROMs and evaluation through objective exams. The second objective is to assess the change in ET function following septal surgery in patients with severe septal deviation.
Results
For each group, 35 patients were selected, with a total of 70 patients.
Discussion
Sinonasal pathology has been associated with ET dysfunction through inflammation of peritubal mucosa. Conditions such as upper respiratory tract infection, allergic rhinitis, chronic rhinosinusitis can be the trigger of ET dysfunction symptomatology.2 Several authors have argued that NSD alone could be a cause of ET dysfunction.
Different physiopathologic mechanisms tried to explain the influence of NSD on ET function: a deviated septum could cause ciliary disturbances, resulting in nasal
Conclusion
According to our results grade III NSD according to Cottle's classification has an impact on ET function. In the absence of other conditions usually related to ET dysfunction, if a patient with severe septal deviation has symptomatology and ET objective function exams compatible with ET dysfunction, septal surgery should be considered in the treatment.
Conflict of interests
The authors have no conflict of interests to declare.
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