Original article
Nasal 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

https://doi.org/10.1016/j.otoeng.2020.11.003Get rights and content

Abstract

Introduction

The influence of isolated nasal septum deviation (NSD) in the Eustachian Tube (ET) function is still undetermined.

Objective

compare ET function between patients with severe NSD and patients with adequate nasal patency in terms of symptomology and objective exams and assess the impact of septoplasty in ET function in patients with severe NSD.

Methods and methodology

a prospective study was conducted. In the first phase of the study, two opportunistic samples were selected: 35 patients with severe NSD for group A and 35 patients with adequate nasal patency for group B. Both groups were evaluated through Nasal obstruction Subjective Questionnaire (NOSE) and ET dysfunction questionnaire 7 (ETDQ7) –, and through two objective exams to assess ET function – tympanometry, and tubomanometry (TMM); results were compared between group A and B. In the second phase of the study, the patients from group A underwent septoplasty and were re-evaluated through ETDQ7, tympanometry and TMM; results were compared before and after surgery.

Results

we found a statistically significant difference between patients with NSD and patients with adequate nasal patency in NOSE and ETDQ7 (higher scores in the latter), and TMM (worse results in patients with NSD); the difference in tympanometry was not statistically significant. The side of the NSD did not correlate with the side of the dysfunction. After septoplasty, patients from group A had statistically significant lower scores in ETDQ7 and a lower proportion of patients with findings compatible with ET dysfunction using TMM.

Conclusion

according to our results, severe NSD alone is a cause of ET dysfunction; septal surgery might improve ET function in these patients.

Resumen

Introducción

Aún sigue sin determinarse la influencia aislada de la desviación del septo nasal (DSN) en la función de la trompa de Eustaquio (TE).

Objetivo

Comparar la función de la TE entre los pacientes con DSN grave y los pacientes con patencia nasal adecuada, en términos de sintomatología y exámenes objetivos, y evaluar el impacto de la septoplastia en la función de la TE en pacientes con DSN grave.

Métodos y metodología

Se realizó un estudio prospectivo seleccionándose 2 muestras oportunistas en la primera fase del mismo: 35 pacientes con DSN grave en el grupo A, y 35 pacientes con patencia nasal adecuada en el grupo B. Se evaluó a ambos grupos utilizando los cuestionarios Nasal Obstruction Subjective Questionnaire (NOSE) y disfunción de TE (ETDQ7), así como mediante 2 exámenes objetivos, para evaluar la función de la TE: timpanometría y tubomanometría (TMM), comparándose los resultados entre los grupos A y B. En la segunda fase del estudio, los pacientes del grupo A fueron sometidos a septoplastia y reevaluados mediante ETDQ7, timpanometría y TMM, comparándose los resultados de antes y después de la cirugía.

Resultados

Encontramos una diferencia estadísticamente significativa en NOSE y ETDQ7 entre los pacientes con DSN y los pacientes con patencia nasal adecuada (con puntuaciones superiores en este último), y TMM (con peores resultados en los pacientes con DSN), no siendo estadísticamente significativa la diferencia en la timpanometría. El lado de DNS no se correlacionó con el lado de la disfunción. Tras la septoplastia, los pacientes del grupo A reflejaron puntuaciones menores en ETDQ7 con significación estadística, y existió una menor proporción de pacientes con hallazgos compatibles con la disfunción de la TE utilizando TMM.

Conclusión

Con arreglo a nuestros resultados, la DNS en solitario es una causa de disfunción de la TE, pudiendo mejorar la septoplastia la función de la TE en estos pacientes.

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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