AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 5 ( 2 0 14 ) 32 9–3 3 1
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Upper airway obstructions and chronic otitis media: A clinical study☆,☆☆ Ahmet Ural a,⁎, Amir Minovi b , Bengü Çobanoğlu a a b
Department of Otorhinolaryngology, School of Medicine, Karadeniz Technical University, Trabzon, Turkey Department of Otorhinolaryngology, School of Medicine, St. Elisabeth Hospital, Ruhr University, Bochum, Germany
ARTI CLE I NFO
A BS TRACT
Article history:
Purpose: To investigate if pathologies causing upper airway obstructions are correlated with
Received 6 November 2013
chronic otitis media. Materials and methods: One hundred fourteen patients with chronic otitis media and 114 healthy controls were enrolled in this study. Nasal septal deviation, Friedman and Mallampati scores were assessed for upper airway obstructions. Chronic suppurative otitis media was classified into tubotypmanic (n = 80) and atticoantral (n = 34) subtypes. Number of patients with septal deviation with a convexity to the same side as the affected ear in each CSOM subgroup was compared with chi-square test. The mean Mallampati and Friedman scores in tubotympanic disease group, atticoantral disease group and healthy controls were compared using Kruskal–Wallis test. Results: Septal deviation occurred more frequently on the same side of ear pathology in patients with tubotympanic chronic suppurative otitis media (p = 0.0005). Such a difference was not observed between the controls and patients with atticoantral chronic suppurative otitis media (p = 0.718). No significant difference was noted between patients and controls in terms of Mallampati and Friedman scores (p = 0.602 and p = 0.836, respectively). Subtypes of chronic suppurative otitis media were not different from each other in terms of Mallampati and Friedman scores either (p = 0.718 and p = 0.708). Conclusion: Our results indicate that septal deviations may commonly occur on the same side with chronic otitis media. Therefore, septal deviations must be carefully investigated during the preoperative assessment of patients with CSOM. Elucidation of any possible causal relationship calls for further trials in larger series. © 2014 Elsevier Inc. All rights reserved.
1.
Introduction
1.1.
Purpose
Chronic suppurative otitis media (CSOM) is a chronic inflammation of the middle ear and mastoid mucosa accompanied
by perforation of the tympanic membrane and discharge [1]. Despite the improvements in patient care and medical technology, medical and surgical treatment options for CSOM still have substantial failure rates [1]. Septal deviation (SD), palatine tonsil hypertrophy (PTH), and enlargement of base of the tongue (EBT) are common
☆
The authors declare no competing interest. No financial support was received for this paper. ⁎ Corresponding author at: Department of Otorhinolaryngology, School of Medicine, Karadeniz Technical University, Kalkinma Mah. 61080, Trabzon, Turkey. Tel.: +90 505 273 06 26; fax: +90 462 325 05 18. E-mail address: [email protected] (A. Ural). ☆☆
0196-0709/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjoto.2014.01.012
330
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 5 ( 2 0 14 ) 32 9–3 3 1
causes of upper airway obstructions. To our knowledge, the association of upper airway obstructions with tubotympanic and atticoantral subtypes of CSOM had not been studied up to now. A few postulates had been speculated on the association of SD with CSOM. Septal deviation can interfere with Eustachian tube function and therefore may not only be involved in CSOM but also may worsen surgical outcomes. Inflammatory disorders of middle ear are suggested to be related with inadequate ventilation through Eustachian tube (ET). In other words, pathological processes involving nasal cavity and paranasal sinuses may disturb ET function [2]. The decrease in air influx through Eustachian tube may lead to diminished aeration of middle ear cavity. This may be the initiation of subsequent reactions contributing to the development of chronic otitis media. Septal deviations may cause tubal diysfunction and middle ear depression subsequently. Similarly, correction of an SD may reduce the tubal opening pressure and can interrupt the process leading to CSOM [2]. Many authors believe that nasal surgery should be performed prior to tympanoplasty for patients with CSOM, since nasal surgery can provide proper Eustachian tube function and help to achieve more satisfactory outcomes from middle ear surgery consequently. On the other hand, a septoplasty before tympanoplasty cannot be recommended routinely to all patients with CSOM and SD. It is suggested that ET tube function must be assessed to decide the necessity of nasal surgery before tympanoplasty [3]. However, to our knowledge a separate assessment for tubotympanic and atticoantral subtypes of CSOM and SD had not been performed in the literature. Palate and the base of tongue are two common locations for upper airway obstructions. Friedman and Mallampati scores are two measures developed to scale the degree of obstruction at these locations [4,5]. Involvement of paratubal muscle function in PTH and EBT may be involved in pathogenesis of CSOM due to possible disturbance of ET function [6,7]. Therefore, we aimed to investigate if patients with PTH and EBT of tongue were more likely to suffer from CSOM. All in all, this study was performed to investigate any correlation between upper airway obstructions (such as septal deviation, hypertrophy of the palatine tonsils, and enlargement of the base of the tongue) and chronic suppurative otitis media.
2.
Methods
This prospective study was conducted in Karadeniz Technical University, School of Medicine, Department of Otorhinolaryngology and Ruhr University, School of Medicine, St. Elisabeth's Hospital, Department of Otorhinolaryngology between December 2009 and January 2011. This study was approved by the local institutional review board (report no. 2009/72) and was performed in accordance with the principles of the Helsinki Declaration. Written informed consent was obtained from all patients prior to involvement in the study. In this study, 113 patients with chronic otitis media (male, female) and 114 controls (male, female) were assessed in terms of SD, PTH and EBT. Patients with bilateral CSOM, and those with a history of nasal, middle ear or oropharyngeal surgery were excluded from this study. Septal deviation was assessed via anterior rhinoscopy, and nasal endoscopy. Three
groups were formed with respect to the assessment for septal deviation: i) convexity to the same side with affected ear, ii) septal deviation with convexity to the other side than the affected ear, or iii) no septal deviation. Friedman and Mallampati scores were derived from oropharyngeal examination findings [4,5]. Septal deviation was diagnosed via anterior rhinoscopy and nasal endoscopic examination. In addition, temporal CT scans allowed visualization of the axis of the nasal septum. Chronic suppurative otitis media patients were subdivided into two subgroups with respect to otomicroscopy and temporal bone computerized tomography findings: i) tubotympanic disease and ii) atticoantral disease [6]. These subgroups were compared in terms of occurence of septal deviation, Mallampati scores and Friedman scores. Results for septal deviation were compared using chi-square test, whereas Kruskall–Wallis test was performed for the comparison of Mallampati and Friedman scores.
3.
Results
The ear disease was unilateral in all cases included in the study. Only 50.4% of patients (57/113) complained of subjective nasal dyspnea. The ear disease was more frequently (101/ 113, 89.4%) encountered on the same side of septal deviation. In CSOM group, septal deviation with its convexity to the same side as the affected ear was more likely to occur (p = 0.0005). No statistically significant difference was observed between the CSOM group and controls in terms of Mallampati and Friedman scores (p = 0.650 and p = 0.714 respectively). Within CSOM group, no difference was observed between tubotympanic and atticoantral subgroups with respect to Mallampati and Freidman scores (p = 0.602 and p = 0.836 respectively). Septal deviation was statistically significantly more common in tubotympanic-type CSOM patients than in atticoantral-type (p < 0.0001).
4.
Discussion
It is known that ET dysfunction in correlation with adenoid vegetation, and allergy may lead to recurrent otitis media or otitis media with effusion. it had been reported that most important prognostic factor for CSOM in children was recurrent episodes of otitis media with effusion [1]. Contribution of the nasal and oropharyngeal problems to pathogenesis of CSOM had not been fully understood yet. Even moderate SDs had been reported to have unfavourable effects on ET function and more negative middle ear pressures were detected in these patients compared to those with straight nasal septum [8]. In another study, blockage of a nasal passage had resulted in changes in epithelium and secretions of middle ear mucosa in rats [7,9]. Our findings are similar with these data, but a septoplasty should not be suggested routinely to all CSOM patients with a SD. Our results imply that SD statistically significantly accompanies tubotympanic CSOM but not the atticoantral CSOM. Eustachian tube function can be more important in the pathogenesis of tubotympanic disease rather than the atticoantral CSOM. Therefore, we state
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 5 ( 2 0 14 ) 32 9–3 3 1
that septal deviations accompanying tubotympanic type CSOM that are likely to interfere with Eustachian tube function must be corrected before the middle ear surgery. In a study conducted on pediatric population, prevalence of recurrent otitis media was found to be increased in habitual snorers [10]. Palatine tonsils and lingual tonsils are two important lymphoid tissues of upper airway which may proliferate in response to infections. Hence, they may serve as a reservoir of microorganisms that may contribute to pathogenesis of recurrent acute otitis media or CSOM. in addition to that, overgrowth of these lymphoid tissues may be responsible for disturbance of proper ET function. Upper airway obstruction due to PTH and EBT may result in hypoxia and hypercarbia. A suitable medium for anaerobic microorganisms that may colonize the middle ear cavity will be created and pathogenesis of CSOM may be trigerred [11]. It is reported that CSOM can be accompanied by adenoids, tubal tonsillitis, hypertrophic tonsils or grossly deviated nasal septum [12]. We suggest that upper airway obstructions may facilitate CSOM through two possible mechanisms: 1) interfering with ET function (in case of SD) and 2) facilitating development of upper respiratory tract infection, and creating a focus of infections. Our results imply that SD is more commonly detected in patients with CSOM compared to controls. Septal deviations may interfere with ET function and in selected cases, septoplasty must be performed a few months prior to the middle ear surgery. Septal deviations with convexity to the same side of CSOM gains more importance in these circumstances. In a study dealing with the relationship between craniofacial morphology and otitis media, a shallower maxilla (a maxilla that is less capable of moving downward and forward) was found to be more frequent in otitis media group compared to controls [12]. This may be attributed to the diminished nasopharyngeal and oropharyngeal space size in otitis media group of patients. Narrowing of maxilla may be a consequence of muscular compression due to open-mouth breathing and atrophy of nasal cavity [13]. Patients with chronic nasal obstruction display a typical facial morphology: longer anterior face, relatively short posterior height, steeper mandibular plane, malocclusion, small nasopharyngeal depth and dolicocephalic head type [13]. Hence we thought that obstructive PTH and EBT might affect ET function and contribute to the pathogenesis of CSOM. It is known that oral breathing may result in altered relationship between mandible, upper maxilla and related muscles, which in turn leads to weakening of peritubal muscles. This may cause ET dysfunction, that in turn permits the access of viruses and bacteria into middle ear cavity and promotes the pathogenetic process of CSOM [7]. Our results indicate that upper airway obstructions at the level of palate or base of the tongue are not likely to result in the dysfunction of Eustachian tube. We think that that obstructions at nasal level may be more important in tubotympanic type CSOM pathogenesis than obstructive pathologies at palatal or lingual level. In atticoantral type disease, SDs and dysfunction of ET seem not to be involved as involved. Further studies can be directed to investigate the relationship between functioning of the nose and the Eustachian tube; and the contribution of this relationship to middle ear physiology. It also turned out that obstructions at palatal or lingual level do not contribute to the colonization of pathogens responsible for CSOM. According to our results, SD and ET dysfunction seems to be more important
331
in the pathogenesis of tubotympanic type CSOM. Such an effect could not be observed in patients with atticoantral-type CSOM. Limitations of our study are retrospective design, relatively small size of our series and lack of definite criteria for elimination of some systemic and local problems which may affect ET function. In addition, exclusion of bilateral CSOM patients and S-shaped septal deformities restricts the extrapolation of our results to larger series. Due to these limitations, associations should be interpreted with caution.
5.
Conclusion
We observed that septal deviations may commonly occur on the same side with chronic otitis media. Therefore, septal deviations must be carefully investigated during the preoperative assessment of patients with CSOM. Elucidation of any possible causal relationship calls for further trials in larger series.
REFERENCES
[1] van der Ween EL, Schilder AGM, van Heerbeek N, et al. Predictors of chronic suppurative otitis media in children. Otolaryngol Head Neck Surg 2006;132:1115–8. [2] Salvinelli F, Casale M, Greco F, et al. Nasal surgery and Eustachian tube dysfunction: effects on middle ear ventilation. Clin Otolaryngol 2005;30:409–13. [3] Maier W, Krebs A. Is surgery of the inner nose indicated befor tympanoplasty? Effects of nasal obstruction and reconstruction on the Eustachian tube. Laryngorhinootologie 1998;77:682–8. [4] Mallampati SR, Gatt SP, Gugino LD. A clinical sign to predict difficult intubation: a prospective study. Can Anaesth Soc J 1985;32:429–34. [5] Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg 2002;127:13–21. [6] Chowdhury MA, Alauddin M. Comparative study between tubotympanic and atticoantral types of chronic suppurative otitis media. Bangladesh Med Res Counc Bull 2002;28:36–44. [7] Maurizi M, Scarano E, Frusoni F, et al. Clinical-morphological correlation of nasal obstruction with skull base development and otitis media. ORL J Otorhinolaryngol Relat Spec 1998;60:92–7. [8] Van Cauwenberge P, Derycke A. The relationship between nasal and middle ear pathology. Acta Otorhinolaryngol Belg 1983;37:830–41. [9] Scarano E, Fetoni AR, Picciotti P, et al. Can chronic nasal obstruction cause dysfunction of the paratubal muscles and otitis media? An experimental study in developing wistar rats. Acta Otolaryngol 2003;123:288–91. [10] Gozal D, Kheirandish-Gozal L, Capdevila OS, et al. Prevalence of recurrent otitis media in habitually snoring school-aged children. Sleep Med 2008;9:549–54. [11] Vikram BK, Khaja N, Udayashankar SG, et al. Clinico-epidemiological study of complicated and uncomplicated chronic suppurative otitis media. J Laryngol Otol 2008;122:442–6. [12] Di Francesco R, Sampaio PL, Bento RF. Correlation between otitis media and craniofacial morphology in adults. Ear Nose Throat J 2007;86:738–43. [13] Kemaloğlu YK. Relationship between chronic nasal obstruction and craniofacial growth. Int J Pediatr Otorhinolaryngol 1999;51:57–9.
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Upper airway obstructions and chronic otitis media: A clinical study☆,☆☆ Ahmet Ural a,⁎, Amir Minovi b , Bengü Çobanoğlu a a b
Department of Otorhinolaryngology, School of Medicine, Karadeniz Technical University, Trabzon, Turkey Department of Otorhinolaryngology, School of Medicine, St. Elisabeth Hospital, Ruhr University, Bochum, Germany
ARTI CLE I NFO
A BS TRACT
Article history:
Purpose: To investigate if pathologies causing upper airway obstructions are correlated with
Received 6 November 2013
chronic otitis media. Materials and methods: One hundred fourteen patients with chronic otitis media and 114 healthy controls were enrolled in this study. Nasal septal deviation, Friedman and Mallampati scores were assessed for upper airway obstructions. Chronic suppurative otitis media was classified into tubotypmanic (n = 80) and atticoantral (n = 34) subtypes. Number of patients with septal deviation with a convexity to the same side as the affected ear in each CSOM subgroup was compared with chi-square test. The mean Mallampati and Friedman scores in tubotympanic disease group, atticoantral disease group and healthy controls were compared using Kruskal–Wallis test. Results: Septal deviation occurred more frequently on the same side of ear pathology in patients with tubotympanic chronic suppurative otitis media (p = 0.0005). Such a difference was not observed between the controls and patients with atticoantral chronic suppurative otitis media (p = 0.718). No significant difference was noted between patients and controls in terms of Mallampati and Friedman scores (p = 0.602 and p = 0.836, respectively). Subtypes of chronic suppurative otitis media were not different from each other in terms of Mallampati and Friedman scores either (p = 0.718 and p = 0.708). Conclusion: Our results indicate that septal deviations may commonly occur on the same side with chronic otitis media. Therefore, septal deviations must be carefully investigated during the preoperative assessment of patients with CSOM. Elucidation of any possible causal relationship calls for further trials in larger series. © 2014 Elsevier Inc. All rights reserved.
1.
Introduction
1.1.
Purpose
Chronic suppurative otitis media (CSOM) is a chronic inflammation of the middle ear and mastoid mucosa accompanied
by perforation of the tympanic membrane and discharge [1]. Despite the improvements in patient care and medical technology, medical and surgical treatment options for CSOM still have substantial failure rates [1]. Septal deviation (SD), palatine tonsil hypertrophy (PTH), and enlargement of base of the tongue (EBT) are common
☆
The authors declare no competing interest. No financial support was received for this paper. ⁎ Corresponding author at: Department of Otorhinolaryngology, School of Medicine, Karadeniz Technical University, Kalkinma Mah. 61080, Trabzon, Turkey. Tel.: +90 505 273 06 26; fax: +90 462 325 05 18. E-mail address: [email protected] (A. Ural). ☆☆
0196-0709/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjoto.2014.01.012
330
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 5 ( 2 0 14 ) 32 9–3 3 1
causes of upper airway obstructions. To our knowledge, the association of upper airway obstructions with tubotympanic and atticoantral subtypes of CSOM had not been studied up to now. A few postulates had been speculated on the association of SD with CSOM. Septal deviation can interfere with Eustachian tube function and therefore may not only be involved in CSOM but also may worsen surgical outcomes. Inflammatory disorders of middle ear are suggested to be related with inadequate ventilation through Eustachian tube (ET). In other words, pathological processes involving nasal cavity and paranasal sinuses may disturb ET function [2]. The decrease in air influx through Eustachian tube may lead to diminished aeration of middle ear cavity. This may be the initiation of subsequent reactions contributing to the development of chronic otitis media. Septal deviations may cause tubal diysfunction and middle ear depression subsequently. Similarly, correction of an SD may reduce the tubal opening pressure and can interrupt the process leading to CSOM [2]. Many authors believe that nasal surgery should be performed prior to tympanoplasty for patients with CSOM, since nasal surgery can provide proper Eustachian tube function and help to achieve more satisfactory outcomes from middle ear surgery consequently. On the other hand, a septoplasty before tympanoplasty cannot be recommended routinely to all patients with CSOM and SD. It is suggested that ET tube function must be assessed to decide the necessity of nasal surgery before tympanoplasty [3]. However, to our knowledge a separate assessment for tubotympanic and atticoantral subtypes of CSOM and SD had not been performed in the literature. Palate and the base of tongue are two common locations for upper airway obstructions. Friedman and Mallampati scores are two measures developed to scale the degree of obstruction at these locations [4,5]. Involvement of paratubal muscle function in PTH and EBT may be involved in pathogenesis of CSOM due to possible disturbance of ET function [6,7]. Therefore, we aimed to investigate if patients with PTH and EBT of tongue were more likely to suffer from CSOM. All in all, this study was performed to investigate any correlation between upper airway obstructions (such as septal deviation, hypertrophy of the palatine tonsils, and enlargement of the base of the tongue) and chronic suppurative otitis media.
2.
Methods
This prospective study was conducted in Karadeniz Technical University, School of Medicine, Department of Otorhinolaryngology and Ruhr University, School of Medicine, St. Elisabeth's Hospital, Department of Otorhinolaryngology between December 2009 and January 2011. This study was approved by the local institutional review board (report no. 2009/72) and was performed in accordance with the principles of the Helsinki Declaration. Written informed consent was obtained from all patients prior to involvement in the study. In this study, 113 patients with chronic otitis media (male, female) and 114 controls (male, female) were assessed in terms of SD, PTH and EBT. Patients with bilateral CSOM, and those with a history of nasal, middle ear or oropharyngeal surgery were excluded from this study. Septal deviation was assessed via anterior rhinoscopy, and nasal endoscopy. Three
groups were formed with respect to the assessment for septal deviation: i) convexity to the same side with affected ear, ii) septal deviation with convexity to the other side than the affected ear, or iii) no septal deviation. Friedman and Mallampati scores were derived from oropharyngeal examination findings [4,5]. Septal deviation was diagnosed via anterior rhinoscopy and nasal endoscopic examination. In addition, temporal CT scans allowed visualization of the axis of the nasal septum. Chronic suppurative otitis media patients were subdivided into two subgroups with respect to otomicroscopy and temporal bone computerized tomography findings: i) tubotympanic disease and ii) atticoantral disease [6]. These subgroups were compared in terms of occurence of septal deviation, Mallampati scores and Friedman scores. Results for septal deviation were compared using chi-square test, whereas Kruskall–Wallis test was performed for the comparison of Mallampati and Friedman scores.
3.
Results
The ear disease was unilateral in all cases included in the study. Only 50.4% of patients (57/113) complained of subjective nasal dyspnea. The ear disease was more frequently (101/ 113, 89.4%) encountered on the same side of septal deviation. In CSOM group, septal deviation with its convexity to the same side as the affected ear was more likely to occur (p = 0.0005). No statistically significant difference was observed between the CSOM group and controls in terms of Mallampati and Friedman scores (p = 0.650 and p = 0.714 respectively). Within CSOM group, no difference was observed between tubotympanic and atticoantral subgroups with respect to Mallampati and Freidman scores (p = 0.602 and p = 0.836 respectively). Septal deviation was statistically significantly more common in tubotympanic-type CSOM patients than in atticoantral-type (p < 0.0001).
4.
Discussion
It is known that ET dysfunction in correlation with adenoid vegetation, and allergy may lead to recurrent otitis media or otitis media with effusion. it had been reported that most important prognostic factor for CSOM in children was recurrent episodes of otitis media with effusion [1]. Contribution of the nasal and oropharyngeal problems to pathogenesis of CSOM had not been fully understood yet. Even moderate SDs had been reported to have unfavourable effects on ET function and more negative middle ear pressures were detected in these patients compared to those with straight nasal septum [8]. In another study, blockage of a nasal passage had resulted in changes in epithelium and secretions of middle ear mucosa in rats [7,9]. Our findings are similar with these data, but a septoplasty should not be suggested routinely to all CSOM patients with a SD. Our results imply that SD statistically significantly accompanies tubotympanic CSOM but not the atticoantral CSOM. Eustachian tube function can be more important in the pathogenesis of tubotympanic disease rather than the atticoantral CSOM. Therefore, we state
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 5 ( 2 0 14 ) 32 9–3 3 1
that septal deviations accompanying tubotympanic type CSOM that are likely to interfere with Eustachian tube function must be corrected before the middle ear surgery. In a study conducted on pediatric population, prevalence of recurrent otitis media was found to be increased in habitual snorers [10]. Palatine tonsils and lingual tonsils are two important lymphoid tissues of upper airway which may proliferate in response to infections. Hence, they may serve as a reservoir of microorganisms that may contribute to pathogenesis of recurrent acute otitis media or CSOM. in addition to that, overgrowth of these lymphoid tissues may be responsible for disturbance of proper ET function. Upper airway obstruction due to PTH and EBT may result in hypoxia and hypercarbia. A suitable medium for anaerobic microorganisms that may colonize the middle ear cavity will be created and pathogenesis of CSOM may be trigerred [11]. It is reported that CSOM can be accompanied by adenoids, tubal tonsillitis, hypertrophic tonsils or grossly deviated nasal septum [12]. We suggest that upper airway obstructions may facilitate CSOM through two possible mechanisms: 1) interfering with ET function (in case of SD) and 2) facilitating development of upper respiratory tract infection, and creating a focus of infections. Our results imply that SD is more commonly detected in patients with CSOM compared to controls. Septal deviations may interfere with ET function and in selected cases, septoplasty must be performed a few months prior to the middle ear surgery. Septal deviations with convexity to the same side of CSOM gains more importance in these circumstances. In a study dealing with the relationship between craniofacial morphology and otitis media, a shallower maxilla (a maxilla that is less capable of moving downward and forward) was found to be more frequent in otitis media group compared to controls [12]. This may be attributed to the diminished nasopharyngeal and oropharyngeal space size in otitis media group of patients. Narrowing of maxilla may be a consequence of muscular compression due to open-mouth breathing and atrophy of nasal cavity [13]. Patients with chronic nasal obstruction display a typical facial morphology: longer anterior face, relatively short posterior height, steeper mandibular plane, malocclusion, small nasopharyngeal depth and dolicocephalic head type [13]. Hence we thought that obstructive PTH and EBT might affect ET function and contribute to the pathogenesis of CSOM. It is known that oral breathing may result in altered relationship between mandible, upper maxilla and related muscles, which in turn leads to weakening of peritubal muscles. This may cause ET dysfunction, that in turn permits the access of viruses and bacteria into middle ear cavity and promotes the pathogenetic process of CSOM [7]. Our results indicate that upper airway obstructions at the level of palate or base of the tongue are not likely to result in the dysfunction of Eustachian tube. We think that that obstructions at nasal level may be more important in tubotympanic type CSOM pathogenesis than obstructive pathologies at palatal or lingual level. In atticoantral type disease, SDs and dysfunction of ET seem not to be involved as involved. Further studies can be directed to investigate the relationship between functioning of the nose and the Eustachian tube; and the contribution of this relationship to middle ear physiology. It also turned out that obstructions at palatal or lingual level do not contribute to the colonization of pathogens responsible for CSOM. According to our results, SD and ET dysfunction seems to be more important
331
in the pathogenesis of tubotympanic type CSOM. Such an effect could not be observed in patients with atticoantral-type CSOM. Limitations of our study are retrospective design, relatively small size of our series and lack of definite criteria for elimination of some systemic and local problems which may affect ET function. In addition, exclusion of bilateral CSOM patients and S-shaped septal deformities restricts the extrapolation of our results to larger series. Due to these limitations, associations should be interpreted with caution.
5.
Conclusion
We observed that septal deviations may commonly occur on the same side with chronic otitis media. Therefore, septal deviations must be carefully investigated during the preoperative assessment of patients with CSOM. Elucidation of any possible causal relationship calls for further trials in larger series.
REFERENCES
[1] van der Ween EL, Schilder AGM, van Heerbeek N, et al. Predictors of chronic suppurative otitis media in children. Otolaryngol Head Neck Surg 2006;132:1115–8. [2] Salvinelli F, Casale M, Greco F, et al. Nasal surgery and Eustachian tube dysfunction: effects on middle ear ventilation. Clin Otolaryngol 2005;30:409–13. [3] Maier W, Krebs A. Is surgery of the inner nose indicated befor tympanoplasty? Effects of nasal obstruction and reconstruction on the Eustachian tube. Laryngorhinootologie 1998;77:682–8. [4] Mallampati SR, Gatt SP, Gugino LD. A clinical sign to predict difficult intubation: a prospective study. Can Anaesth Soc J 1985;32:429–34. [5] Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg 2002;127:13–21. [6] Chowdhury MA, Alauddin M. Comparative study between tubotympanic and atticoantral types of chronic suppurative otitis media. Bangladesh Med Res Counc Bull 2002;28:36–44. [7] Maurizi M, Scarano E, Frusoni F, et al. Clinical-morphological correlation of nasal obstruction with skull base development and otitis media. ORL J Otorhinolaryngol Relat Spec 1998;60:92–7. [8] Van Cauwenberge P, Derycke A. The relationship between nasal and middle ear pathology. Acta Otorhinolaryngol Belg 1983;37:830–41. [9] Scarano E, Fetoni AR, Picciotti P, et al. Can chronic nasal obstruction cause dysfunction of the paratubal muscles and otitis media? An experimental study in developing wistar rats. Acta Otolaryngol 2003;123:288–91. [10] Gozal D, Kheirandish-Gozal L, Capdevila OS, et al. Prevalence of recurrent otitis media in habitually snoring school-aged children. Sleep Med 2008;9:549–54. [11] Vikram BK, Khaja N, Udayashankar SG, et al. Clinico-epidemiological study of complicated and uncomplicated chronic suppurative otitis media. J Laryngol Otol 2008;122:442–6. [12] Di Francesco R, Sampaio PL, Bento RF. Correlation between otitis media and craniofacial morphology in adults. Ear Nose Throat J 2007;86:738–43. [13] Kemaloğlu YK. Relationship between chronic nasal obstruction and craniofacial growth. Int J Pediatr Otorhinolaryngol 1999;51:57–9.
