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ORIGINAL ARTICLE
Year : 2012  |  Volume : 18  |  Issue : 4  |  Page : 179-183

Evaluation of Eustachian tube function in chronic suppurative otitis media (tubotympanic type) with reference to its treatment outcome


Department of ENT, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India

Date of Web Publication19-Dec-2012

Correspondence Address:
Kanagamuthu Priya
Department of ENT, Mahatma Gandhi Medical College and Research Institute, Pondicherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.104794

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  Abstract 

Aims and Objectives: To assess the eustachian tube function (ETF) and to evaluate the treatment outcome of chronic suppurative otitis media (CSOMtubotympanic type) in relation to eustachian tube dysfunction. Materials and Methods: Prospective study for a period of 2 years; the study comprises of 100 patients diagnosed to have CSOM (tubotympanic type). ETF was assessed by Toynbee's test. Patients with normal ETF were taken up for myringoplasty. Patients with totally impaired ETF irrespective of middle ear mucosal status (dry or wet) were taken up for cortical mastoidectomy with tympanoplasty. Patients with partially impaired ETF, with dry middle ear mucosa were taken up for myringoplasty and those with wet middle ear were taken up for cortical mastoidectomy with tympanoplasty. Results and Analysis: The ETF in these patients was analyzed and graft uptake was assessed clinically in reference to ETF status. The results are tabulated and analyzed using Chi-square test using number cruncher statistical system (NCSS) software. In our study, preoperative ETF had a highly significant P value = 0.0005. Conclusion: Methodology of treatment adapted for CSOM patients based on ETF proves that the eustachian tube plays a major role in the uptake of graft.

Keywords: Chronic suppurative otitis media, Eustachian tube, Tubotympanic disease


How to cite this article:
Priya K, Karthikeyan P, Coumare VN, Sambandan AP. Evaluation of Eustachian tube function in chronic suppurative otitis media (tubotympanic type) with reference to its treatment outcome. Indian J Otol 2012;18:179-83

How to cite this URL:
Priya K, Karthikeyan P, Coumare VN, Sambandan AP. Evaluation of Eustachian tube function in chronic suppurative otitis media (tubotympanic type) with reference to its treatment outcome. Indian J Otol [serial online] 2012 [cited 2019 Oct 16];18:179-83. Available from: http://www.indianjotol.org/text.asp?2012/18/4/179/104794


  Introduction Top


Chronic suppurative otitis media (CSOM) is of two types tubotympanic (mucosal) and atticoantral (squamous). The atticoantral type (squamous type) is due to cholesteatomatous lesions. Tubotympanic type (mucosal) is mainly due to infection from the oropharynx and the nasopharynx and sources like Gastro esophageal reflux diseases travels via the eustachian tube into the middle ear. [1] Not all patients with oropharyngeal and nasopharyngeal sources of infection develop CSOM. Three main functions of eustachian tube are ventilation and regulation of middle ear pressure, middle ear clearance of secretions, and protection against nasopharyngeal sound pressure and reflux of nasopharyngeal secretions. A normal aerated middle ear cavity and normal antrum are important for middle ear functions. [2] Impedance audiometry (Toynbee's test) is an essential tool to assess eustachian tube function (ETF) in perforated tympanic membrane and William's test is an essential tool to assess the ETF in intact tympanic membrane. Our present study is undertaken to assess the ETF in patient with CSOM with reference to its treatment outcome. Based on impedance audiometry findings, patients of tubotympanic disease are categorized as totally impaired, partially impaired, and normal ETF. Patients with normal ETF were taken up for myringoplasty. Patients with totally impaired ETF irrespective of middle ear mucosal status (dry or wet) were taken up for cortical mastoidectomy with tympanoplasty. Patients with partially impaired ETF, with dry middle ear mucosa were taken up for myringoplasty and those with wet middle ear were taken up for cortical mastoidectomy with tympanoplasty.


  Materials and Methods Top


This prospective clinical study was conducted at the department of Otolaryngology-Head and Neck surgery, Mahatma Gandhi Medical College and Research Institute for a period of 2 years from July 2008 to July 2010. The study group comprised of 100 patients who were diagnosed to have CSOM of tubotympanic type. Detailed history and clinical examination as per the proforma were performed.

Inclusion criteria

CSOM (all tubotympanic type)

Exclusion criteria

  1. Congenital anomaly
  2. Atticoantral disease
  3. Age less than 12 years
  4. Serous otitis media
A complete otolaryngological examination was performed to rule out any associated pathologies and focus of infection, which could influence the result of tympanoplasty. Each patient was subjected to the following procedures like blood investigations, pus culture and sensitivity, plain X-ray both mastoids-Law's view, pure tone audiometry, impedance audiometry, otoendoscopy, diagnostic nasal endoscopy. [3]

Assessment of eustachian tube function

William's test

  1. Done in patients with intact ear drum.
  2. Measure middle ear pressure at the start of test (resting pressure), after patient swallows (with nose and mouth closed), and finally after performing valsalva.
  3. Pressure should become negative on swallowing and positive on valsalva.
  4. Normal ambient middle ear pressure is slightly negative.
  5. If middle ear pressure becomes negative on swallowing but does not become positive on valsalva or vice versa partially impaired.
  6. If middle ear pressure does not change at all on swallowing or on valsalva - grossly impaired. [4]
Toynbee's test

  1. Done in patients of perforated ear drum.
  2. The impedance audiometer is programmed to artificially increase or decrease the air pressure at the middle ear and then record the change of air pressure in the middle ear each time when the patient swallows.
  3. The patient is asked to swallow repeatedly and recorded graphically by impedance audiometer.
  4. Change of pressure during swallowing is recorded as step ladder type of graph, that is, normal [Graph 1[Additional file 1]].
  5. If some residual pressure persists even after five swallows, the tubal function is considered to be partially impaired [Graph 2[Additional file 2]].
  6. If positive or negative pressure built up by the impedance audiometer cannot be neutralized at all by repeated swallowing, then the ETF is considered to be grossly impaired [Graph 3[Additional file 3]]. [5]


Surgical procedures

  1. Patients with normal ETF were taken up for myringoplasty.
  2. Patients with totally impaired ETF irrespective of middle ear mucosal status (dry or wet) were taken up for cortical mastoidectomy with tympanoplasty.
  3. Patients with partially impaired ETF, with dry middle ear mucosa were taken up for myringoplasty and those with wet middle ear were taken up for cortical mastoidectomy with tympanoplasty.


Post operative management

Patients were started on suitable antibiotics. Antibiotics were given for 1 week along with analgesics, antihistamine, and multivitamins.

Mastoid bandage was changed on the 2 nd postoperative day and dressing applied. The sutures were removed on the 7 th postoperative day.

Patients were reviewed 2 weeks after discharge and second and third review on 1 st and 3 rd month postoperatively

[Figure 1] and [Figure 2]. Patients were evaluated postoperatively using otoscopy.
Figure 1: Endoscopic picture of pre- and postoperative tympanic membrane, Toynbee's test partially impaired ET function, Toynbee's test totally impaired ET function, Eustachian tube function and graft status

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Figure 2: Microscopic picture of pre- and postoperative tympanic membrane

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On the basis of ear findings following cortical mastoidectomy with tympanoplasty and myringoplasty, patients were divided into two outcome groups:-

  1. Successful outcome, defined as healed graft with good middle ear function.
  2. Graft failure or perforation secondary to otitis media during follow up period were considered as failures.
The study was approved by Institutional Human Ethical Committee, MGMCRI, Puducherry.


  Results and Analysis Top


The study was conducted at the department of otolaryngology-Head and neck surgery, Mahatma Gandhi Medical College and Research Institute, Pondicherry, spanned over 2 years from July 2008 to July 2010. The study group comprised of 100 patients who were diagnosed to have CSOM of tubotympanic type. The ETF in these patients was analyzed [Figure 3] and [Figure 4] and graft uptake was assessed clinically in reference to ETF status. The results are tabulated and analyzed using Chi-square test using number cruncher statistical system (NCSS) software.
Figure 3: Endoscopic view of eustachian tube at closed resting stage

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Figure 4: Endoscopic view of eustachian tube at dilated active stage

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In our study we tried to find the association between the graft uptake and age, gender, middle ear mucosa status, type of perforation and duration of ear discharge applied statistically by using Chi square test, P value was >0.05 not significant, thus proving that there was no association between above mentioned factors and graft uptake.


  Discussion Top


In our study on 100 patients with CSOM (tubotympanic type), the preoperative ETF significantly correlated with the outcome after surgery.Patients with normal ETF showed a good graft uptake when compared with those with impaired ETF.

Earlier studies of ETF have mainly employed the technique of politzeration, which is insensitive and difficult to quantitate. In 1963, Palva and Siedentop et al. worked out quantitative methods for measuring preoperative tubal function in patients with perforation of the drum. These methods have subsequently been used by a number of authors.They are based upon the capability of the eustachian tube to equilibrate an induced negative or positive pressure in the middle ear by deglutition. However, these methods do not evaluate one of the most important function of the eustachian tube, the drainage function, which may be impaired even though the tube is anatomically open. [6],[7],[8]

The ETF has been the center of focus as a prognostic factor because of its presumed primary role in the pathogenesis of otitis media and in the aeration of middle ear cavity.

The ETF is the most important determinant of surgical outcome in patients with CSOM (tubotympanic type). [9]

A properly functioning eustachian tube is an integral part of a normally functioning middle ear and the existence of good tubotympanic mucociliary drainage constitutes a favorable prognostic factor in the outcome of reconstructive surgery of the middle ear. [10] A functioning eustachian tube is an integral part of a normal middle ear and is thus an essential requirement for optimum results in tympanoplastic operations . A preoperative test of tubal function is, therefore, of great interest, especially if such a test provides a possibility of estimating the chances of achieving a satisfactory result of tympanoplasty.

Cohn et al. in 1979 assessed ETF by using impedance audiometry (Toynbee's test). Those with normal ETF showed a graft uptake of 95%, 75% graft uptake in partially impaired ETF, and 69% graft uptake in totally impaired ETF. [11]

Sen et al. in 1998 assessed ETF by using impedance audiometry. Those with normal ETF a graft uptake of 80%, 80% graft uptake in partially impaired ETF, and 66% graft uptake in totally impaired ETF. In our study we had a similar results showing 100% success rate in patients with normal ETF, 98% in partially impaired ETF, and 76% in totally impaired ETF [Table 1]. [12]
Table 1: Success rate

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Kurein in 2009 found that diseased or edematous mucosa had a graft uptake of 50% when compared with dry middle ear mucosa which showed an uptake of 69.5% and in his study, he claimed that the preoperative factors such as dry or wet ear, site of perforation do not affect the graft take up rate [13] Our study also showed a similar result.

Kurein in 2009 found that no relationship between mastoid pneumatization and graft uptake. Likewise in our study there was no relationship between mastoid pneumatization and graft uptake. [13]

Simple mastoidectomy in all tympanoplasties is a good practice. It increases the middle ear cleft space and that this is the good idea if there is compromised ETF. [14]


  Conclusions Top


In our study the correlation between ETF and the graft uptake was statistically analyzed using a Chisquare test, which showed P value is <0.01 (i.e.0.0005) thus proving to be statistically highly significant. Hence, there is a strong association between ETF and graft uptake [Graph 4[Additional file 4]]. This proves that eustachian tube plays a major role in the graft uptake. In case of CSOM with totally impaired ETF patients, cortical mastoidectomy has been done to improve ventilation.

There was no association between the graft uptake and age, gender, middle ear mucosa status, type of perforation, and duration of ear discharge.

 
  References Top

1.Paparella MM, Shumrick DA, Gluckman JL, Meyerhoff WL. Physiology of middle ear and Eustachian tube. Otolaryngology 1991;1:163-97.  Back to cited text no. 1
    
2.Andreasson L, Harris S. Tympanoplasty and Eustachian tube function. Clin Otolaryngol Allied Sci 1978;3:421-30.  Back to cited text no. 2
[PUBMED]    
3.EI-Gunindy A Manometric and endoscopic study of tubal function in drum perforation. Am J Otol 1993;14:580-4.  Back to cited text no. 3
    
4.Srivastav SC, Gupta SC, Singh AP. Efficacy of various methods in evaluation of Eustachian tube function. Indian J Otolaryngol Head Neck Surg 1993;2:188-90.  Back to cited text no. 4
    
5.Blue Stone CD. Assessment of Eustachian tube function. In: Jerger J, Norther J, editors. Clinical Impedance Audiometry. New York: American Electromedics Corporation; 1980. p. 83-108.  Back to cited text no. 5
    
6.Palva T. Surgical treatment of chronic middle ear disease, myringoplasty and tympanoplasty. Acta Otolaryngol 1987;104:179-84.  Back to cited text no. 6
[PUBMED]    
7.Siedentop KH. Eustachian tube dynamics, size of the mastoid air cell system, and results with tympanoplasty. Otolaryngol Clin North Am 1972;5:33-44.  Back to cited text no. 7
[PUBMED]    
8.Siedentop KH, Hamilton LR, Osenar SB. Predictability of tympanoplasty results. Preoperative Eustachian tube function and size of mastoid air cell system. Arch Otolaryngol 1972;95:146-50.  Back to cited text no. 8
[PUBMED]    
9.Tos M. Importance of Eustachian tube function in middle ear surgery. Ear Nose Throat J 1998;77:744-7.  Back to cited text no. 9
[PUBMED]    
10.Gimenez F, Algarra M. The prognostic value of mucociliary clearance in predicting success in tympanoplasty. J Laryngol Otol 1993;107:895-7.  Back to cited text no. 10
    
11.Cohn AM, Schwaber MK, Anthony LS, Jerger JF. Eustachain tube function and tympanoplasty. Ann Otol 1979;88:339-47.  Back to cited text no. 11
[PUBMED]    
12.Sen S, Guha S, Biswas A, Ghosh LM. A comparative study of methods of evaluation of Eustachian tube functions in chronic otitis media. Indian J Otol 1998;4:147-9.  Back to cited text no. 12
    
13.Paparella M, Kurein SR, Christolyte S, Rupa V. Inflation-deflation test as a predictor of aditus patency in patients with chronic suppurative otitis media. Indian J Otolaryngol Head Neck Surg 2009;61:169-72.  Back to cited text no. 13
    
14.Brackmann DE, Shelton C, Arriaga MA. Otologic surgery. Vol 1. 3 rd ed, Chapter 16. Philadelphia: Elsevier; 2010. p. 197.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]


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