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ORIGINAL ARTICLE
Year : 2018  |  Volume : 24  |  Issue : 1  |  Page : 16-19

Otoscopic, radiological, and audiological status of the contralateral ears in patients with unilateral chronic suppurative otitis media


Department of Otolaryngology, College of Medicine, Mustansiriyah University, Baghdad, Iraq

Date of Web Publication24-May-2018

Correspondence Address:
Dr. Mohammed Radef Dawood
Department of Otolaryngology, College of Medicine, Mustansiriyah University, Baghdad
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_81_17

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  Abstract 


Context and Aims: Since unilateral chronic suppurative otitis media (CSOM) does not look to be an isolated entity, but rather a series of constitutional events that affecting both ears, so this study aimed to evaluate the otoscopic, radiological, and audiological status of the contralateral ears (CLEs) in patients with unilateral CSOM. Patients and Methods: A prospective, observational study recruited 96 consecutive patients with unilateral CSOM with or without cholesteatoma, in whom their CLEs revealed an intact tympanic membrane (TM) were categorized as “Group 1” and “Group 2” respectively, they were evaluated with otomicroscopy, computed tomography (CT) scanning of temporal bones, pure tone audiometry and tympanometry. All above-mentioned observations were recorded and analyzed. Results: The incidence of otoscopic CLEs structural abnormalities was 47.91% in both groups; being 45.83% in “Group 1” mostly 25% of TM retraction, and 50% in “Group 2” mainly (20.84%) of thinning TM. Mastoid CT scan showed (35.41%) air cell abnormalities in both groups; being 37.5% in “Group 1” and 33.33% in “Group 2,” while tympanic cavity mucosal thickening was 33.33% “in Group 1” and 25% in “Group 2.” Conductive hearing loss was found (39.58%) in both groups; being 45.83% in “Group 1” and 33.33% in “Group 2,” while C-curve tympanometry curve was 63.63% and 36.36% in both groups, respectively. Conclusions: The incidence of otoscopic structural abnormalities of CLEs was mainly in the form of TM retraction in squamous type and thinning TM in mucosal type; also, the radiological and audiological abnormalities of the CLEs were shown more event in squamous than in mucosal type of CSOM.

Keywords: Chronic suppurative otitis media, contralateral ear, tympanic membrane


How to cite this article:
Dawood MR. Otoscopic, radiological, and audiological status of the contralateral ears in patients with unilateral chronic suppurative otitis media. Indian J Otol 2018;24:16-9

How to cite this URL:
Dawood MR. Otoscopic, radiological, and audiological status of the contralateral ears in patients with unilateral chronic suppurative otitis media. Indian J Otol [serial online] 2018 [cited 2018 Jun 25];24:16-9. Available from: http://www.indianjotol.org/text.asp?2018/24/1/16/233134




  Introduction Top


Chronic suppurative otitis media (CSOM) refers to chronic irreversible inflammatory pathological tissue damage of the middle ear cleft mucosal lining in the setting of a permanent tympanic membrane (TM) perforation, clinically presented with ear discharge and deafness.[1]

There were various theories about the pathogenesis of chronic otitis media (COM), the most common model that named “continuum theory” which adopted by Minneapolis group, where it based on the development of a continuous series of events in the subepithelial and epithelial levels in middle ear cleft.[2]

Hence, this continuum model explained the progressive manner in the development of COM where the “pathology started first as a simple abnormalities then progress to severe changes, as in the following sequences; the TM retraction, middle ear effusion, or even perforation, or might lead to formation of the cholesteatoma,” so it represent various pathological stages but of the same disease, and this evolution concept of the continuum theory could be even detected in the contralateral ear (CLE).[2]

CLEs is defined as asymptomatic ear in cases of unilateral COM, as along with other studies reports, a COM is rarely an isolated entity, because the responsible factors for its development in one ear were in similar way will impact the CLEs, since both ears had a common “nasopharyngeal” drainage egress; therefore, the assessment of the CLEs will come up with guidelines information about the etiology and the evolution of the disease pathological process, as these changes which had been detected in the affected ear might represent the terminus of the pathological process what found in the CLEs.[3]

However, it also stated that, if the development of the pathological process of COM was based on this continuum hypothesis, so the query is raised about the reason for only small percentages of otitis media with effusion will progress to CSOM, and another question is since high prevalence of bilateral otitis media with effusion was reported, so why there were not a similar high prevalence of COM?[4]

Depend on the a aforementioned arguments and the limited data obtained from various literatures,[5],[6] the current study was aimed to record and analyzed otoscopic, radiological, and audiological status of CLEs in series of patients with unilateral CSOM with or without cholesteatoma.


  Patients and Methods Top


A prospective, observational study of 96 consecutive patients have unilateral CSOM with or without cholesteatoma in whom their CLEs were revealed an intact TM, attending ear-nose-throat clinic, Baghdad, Iraq, from August 1, 2016, to September 1, 2017.

After institutional review board approval as well as patients consents were obtained, a relevant medical history was taken, followed by clinical examination both ears with Welch Allyn Halaogen Hex pneumatic otoscope, and simutanously to assess CLEs TM mobility, in additional to Carl Zeiss 200 mm lenses otomiscroscopy for better evaluation, the TM of CLEs and the middle ear cavity of CSOM ears, after that they were sent to the radiology department for computed tomography (CT) scan of temporal bones for the assessment of detailed middle ear clefts and mastoid air cells status as indicated; finally, the hearing status was evaluated with pure tone audiometry, as well as tympanometry to the CLEs. While patients with previous ear surgery, congenital ear malformation, temporal bone disease and trauma were excluded from the study.

For the purpose of study analysis, the ears with CSOM were categorized into two Groups; those with choleasteatoma (squamous type) were tagged as “Group 1,” and those without choleasteatoma (mucosal type) were tagged as “Group 2,” while the retraction of TM was classified according to Sadé and Berco [7] classification for pars tensa, and to Tos and Poulsen [8] classification in case of pars flaccida retraction.

Assessment of their hearing level was conducted in a soundproof sound using “Maico-MA 33” clinical diagnostic pure tone audiometer which recently calibrated according to the “International Organization of Standardization,” using Jerger's technique through air and bone conduction at frequencies 250, 500, 1000, 2000, 4000 Hz with masking whenever it necessary, and the mean or average hearing loss was classified into mild, moderate, severe, and profound degrees.[9]

The tympanometry of the CLEs was performed with “Welch Allyn Micro tymp3” port type tympanometer, in which the tympanometric curves Types A, B, and C were evaluated, and considering type A-curve as normal, while the other tympanometric curves Types B and C were considered as abnormal findings.

The all aforementioned observations through the different modalities of evaluation were recorded and analyzed.


  Results Top


Among 96 patients with unilateral CSOM, about 48 ears (50%) with choleasteatoma “Group 1” and 48 ears (50%) without choleasteatoma “Group 2,” there were 56 males (58.33%), and 40 females (41.66%), with mean age was 22.658 years, and the mean duration of the disease was 4.157 years.

The incidence of abnormal TM of CLEs was (47.91%) in both groups, where TM retraction (27.08%) was the most common structural abnormality detected. In “Group 1,” the CLEs structural abnormalities was 45.83%, where TM retraction (25%) was the most common finding found, being mainly 16.66% of pars flaccida retraction in which 39.76% of them were of Grade 2, while in “Group 2,” the abnormal CLEs was (50%), where thinning of TM (20.84%) was the most common abnormality finding. [Table 1] shows the distribution of the otoscopic findings of the CLEs among the patients with unilateral CSOM, separately and together.
Table 1: Distribution of otoscopic findings in contralateral ears among patients with unilateral chronic supportive otitis media

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The evaluation of the CT scan of the mastoid air cells status of the CLEs revealed the mastoid air cells abnormalities were found in 34 ears (35.41%) in both groups, in which 20 ears (58.82%) were detected in “Group 1” in which there 12 ears (60%) were found to be sclerotic, and 8 ears (40%) shown with diminution of mastoid air cells aeration. In “Group 2,” there were 14 ears (41.17%), in which 8 ears (57.14%) had been found to be sclerotic and 6 ears (42.86%) with diminution mastoid air cells of aeration.

Evaluation the CT scan of the tympanic cavity status of the CLEs revealed an opacification or the mucosal thickening of the tympanic cavity was detected in 28 ears (29.16%) in both groups, being 16 ears (33.33%) in “Group 1” and 12 ears (25%) in “Group 2.”

Nevertheless, the ossicular chain was found to be in continuity in all cases (100%) of both groups.

Hearing level assessment of the CLEs was performed by pure tone audiometry revealed the mean conductive hearing loss 31.15 dB air-bone gap (ABG) was detected in 38 ears (39.58%) in both groups, in which in “Group 1,” the mean hearing loss of 33.76 dB ABG was detected in 22 ears (45.83%), distributed as follows; mild degree of hearing loss in 14 ears (63.63%), moderate degree in 6 ears (27.27%), and severe degree of hearing loss was found in 2 ears (9.09%).

In “Group 2,” the mean conductive hearing loss 28.54 dB ABG was detected in 16 ears (33.33%), being of mild degree in 10 ears (62.5%), moderate degree in 4 ears (25%), and severe degree of hearing loss was detected in 2 ears (12.5%) of the cases.

The abnormal tympanometric curves of the CLEs were detected in 34 ears (35.41%) of both groups, being most commonly of type C-curve in 22 ears (64.7%) in both groups, in which 14 ears (63.63%) was detected in “Group 1” and 8 ears (36.36%) in “Group 2.”


  Discussion Top


Few number of data were available in the previous literatures about the information in studying the pathological process of the CLEs in unilateral COM; however, it is thought that this information can substantially enhance the interpretation of the pathogenesis of COM,[5],[6] also a careful analytic study of this pathology in both ears can help in setup of the understanding the three crucial aspects in the process of COM development; as “the etiology (cause), current status (established pathology), as well as the speed and the direction of the evolution of the disease process (natural history)” through the evaluation of the condition of the CLEs which give us the possibility to detect “now” that what happened to the diseased ear “yesterday.”[2]

In this study, unilateral CSOM, mainly found in young age males, and these findings found to be almost comparable with Damghani and Barazin study.[10] The average duration of the disease was 4.157 years, and this looks almost agreed with Mirvakili et al. study.[11]

So for better understanding of the proper clinical description and the evolution of the disease process in cases of unilateral COM, the current study evaluated data of the CLEs status in the form of otoscopic, radiological, and audiological analysis.

The incidence of abnormal CLEs detected in the current study was (47.91%); however, this range seems to be little lower than what had been detected in other international studies [3],[4],[6],[10] which were >(60%), this was probably attributed to our cultural characteristic and single center study. The most common pathology detected in the current study was the TM retraction in “Group 1” (squamous type), and the thinning of the TM in “Group 2” (mucosal type), and these finding were agreed with the findings of the other studies.[3],[4],[6]

Also, detected the pars flaccida retraction had been found to be at higher rate and more severe in “Group 1” than in “Group 2,” and these observations were agreed with other studies,[3],[4],[5],[12] so these findings propose that the pathological process of COM is started in both ears and liable to attend approximately a standard course, especially more noticeable in cases of COM with cholesteatoma, the same conjecture regarding hypothesis of these observations was also adopted by Selaimen da Costa et al.[4] in their study.

The abnormalities of the mastoid air cells and the tympanic cavity detected by CT scan of the temporal bone of the CLEs in the current study had been found more prevalence in “Group 1” than in “Group 2,” these CT abnormalities were also seen in other studies [2],[3],[10] but with a variation in the prevalence rates between the different studies. The deficiency of mastoid pneumatization of the CLEs could be forewarning sign of COM, especially in those patients with unilateral disease of cholesteatoma.[12]

The occurrence of mastoid status abnormalities of the CLEs has some imputation in the COM pathophysiology, as the data propose that some disturbance in the mastoid development had considerable impact on both ears, so it is crucial to call attention to that many of radiological CT changes that had been detected in the CLEs were the result of the entire otitis media disease process in both ears, especially when considered in conjunction with other clinical otoscopic findings as retraction of TM.[2]

Hearing impairment was detected in the CLEs in about 39.58% of all cases, and these observation was also found in other studies,[3],[10],[12],[13] the type of hearing loss detected in the current study was of conductive type and being much worse in “Group 1,” also the most common tympanometric curve detected of the CLEs was C-curve in about 64.7% in both groups; however, a study performed by Mirvakili et al.[11] showed the type B-curve was the most common curve detected in their study. Since both ears had a common nasopharyngeal portal drainage, so the factors that affect one ear might likewise affect the CLEs.[3]

Therefore, a thorough examination of the CLEs in cases of unilateral COM may come up with data that lead us to understand the “aetiology and the evolution of the disease process, since the affected ear is thought to be the end point of the pathology in the CLE,” this so-called “crystal ball effect” theory.[14]


  Conclusions Top


There was a incidence of structural abnormalities of the CLEs in cases of unilateral CSOM of both squamous, and mucosal types were detected by otoscopic findings as being mainly in the form of TM retraction in the squamous type and of thinning TM in the mucosal type, and also the radiological and the audiological abnormalities were shown more event in the squamous than the mucosal type. Hence, comprehensive evaluation of the CLEs in cases of unilateral CSOM should be always, considered to the achievement of the efficiently diagnosis of the pathological process of the disease and the establishment of schedule for effective therapeutic planning.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Costa SS, Dornelles CC, Netto FLS, Braga ME. Otitis media. In: Costa SS, Cruz OL, Oliveira JA. Otorrinolaringologia: Principos e Pratica. 2nd ed. Poto Alegre: Artmed; 2006. p. 254-73.  Back to cited text no. 1
    
2.
Silva MN, Muller Jdos S, Selaimen FA, Oliveira DS, Rosito LP, Costa SS, et al. Tomographic evaluation of the contralateral ear in patients with severe chronic otitis media. Braz J Otorhinolaryngol 2013;79:475-9.  Back to cited text no. 2
    
3.
Shireen AK, Mubeena, Mohammed NA. Status of contralateral ear in unilateral chronic otitis media. Int J Otorhinolaryngol Head Neck Surg 2017;3:135-9.  Back to cited text no. 3
    
4.
Selaimen da Costa S, Rosito LP, Dornelles C, Sperling N. The contralateral ear in chronic otitis media: A series of 500 patients. Arch Otolaryngol Head Neck Surg 2008;134:290-3.  Back to cited text no. 4
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5.
Chalton RA, Stearns MP. The incidence of bilateral chronic otitis media. J Laryngol Otol 1984;98:337-9.  Back to cited text no. 5
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Vartiainen E, Kansanen M, Vartiainen J. The contralateral ear in patients with chronic otitis media. Am J Otol 1996;17:190-2.  Back to cited text no. 6
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7.
Sadé J, Berco E. Atelectasis and secretory otitis media. Ann Otol Rhinol Laryngol 1976;85:66-72.  Back to cited text no. 7
    
8.
Tos M, Poulsen G. Attic retractions following secretory otitis. Acta Otolaryngol 1980;89:479-86.  Back to cited text no. 8
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9.
Baiduc RR, Poling GL, Hong O, Dhar S. Clinical measures of auditory function: the cochlea and beyond. Dis Mon 2013;59:147-56.  Back to cited text no. 9
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Damghani MA, Barazin A. Alterations in the contra lateral ear in chronic otitis media. Iran J Otorhinolaryngol 2013;25:99-102.  Back to cited text no. 10
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11.
Mirvakili SA, Baradaranfar MH, Hasani A, Jafary R. Evaluation of sensorineural hearing loss in patients with chronic otitis media. Mag Yazd Univ Med Sci 2007;15:21-8.  Back to cited text no. 11
    
12.
Chung JH, Lee SH, Min HJ, Park CW, Jeong JH, Kim KR, et al. The clinical and radiological status of contralateral ears in unilateral cholesteatoma patients. Surg Radiol Anat 2014;36:439-45.  Back to cited text no. 12
    
13.
Bayir O, Uluat A, Tulgar M, Sancaktar ME, Ozdek A, Saylam G, et al. Evaluation of contralateral ear in patients with chronic otitis media. J Clin Anal Med 2017;8:36-9.  Back to cited text no. 13
    
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Yoon TH, Paparella MM, Schachern PA, Lindgren BR. Morphometric studies of the continuum of otitis media. Ann Otol Rhinol Laryngol Suppl 1990;148:23-7.  Back to cited text no. 14
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