|Year : 2011 | Volume
| Issue : 1 | Page : 8-11
Otitis media: Does the onus lie on sinonasal pathology?
Aditya M Yeolekar, KS Dasgupta
Department of ENT, Indira Gandhi Government Medical College, Nagpur, India
|Date of Web Publication||11-Oct-2011|
Aditya M Yeolekar
A-306, Dhanwantari CHS, Sector II, Mun. Hsg. Complex, Deonar, Mumbai - 400 043
Source of Support: None, Conflict of Interest: None
Background: Although most of the literature refers to sinusitis and upper respiratory tract as causative factor of otitis media (OM), only few articles refer to actual nasal pathologies that can lead to it. Objective: To study the influence of sinonasal disease on the middle ear condition (OM). Material and Methods: 200 patients of otitis media attending ENT Services of teaching institution in Central India were included.In 340 ears detailed ENT examination was carried out. Results: Of the 200 patients of otitis media 50% had chronic suppurative otitis media tubotympanic type, 41% had retraction and remaining had cholesteatoma and otitis media with effusion. Sinonasal evaluation revealed deviated nasal septum in 80%, sinusitis in 13.5% and polyp in 10.5% patients. Multiple sinonasal pathologies were present in some patients. On treatment of sinonasal disease signiﬁcant improvement of middle ear disease was found in 79.31% ears after septal correction (Wilcoxon Signed rank test, P<0.05), 82.35% ears after treatment of sinusitis and in 76.92% ears after polypectomy. Conclusion: On the basis of these results we recommend evaluation and treatment of sinonasal disease before surgical treatment of ear disease is undertaken.
Keywords: Nasal disease, Otitis media, Sinus disease
|How to cite this article:|
Yeolekar AM, Dasgupta K S. Otitis media: Does the onus lie on sinonasal pathology?. Indian J Otol 2011;17:8-11
| Introduction|| |
Otitis media (OM) is the inflammation of the middle ear (m.e.) cleft. Middle ear cleft constitutes a continuous air space contained in bone, lined by epithelium and in continuity with the atmosphere of the nose and nasopharynx.  The pathogenesis of OM has been related to the presence of prior or concurrent nasal disease.  Infection of the nose and paranasal sinuses (PNS) can involve the Eustachian tube More Details (ET) leading to its obstruction. Obstruction of ET in turn leads to OM. Diseases of the nose and PNS can thus influence the m.e. condition. Although most of the literature refers to sinusitis and upper respiratory tract as causative factor of OM, only few articles refer to actual nasal pathologies that can lead to it. Those patients who have OM secondary to nasal and /or PNS pathology need to have both problems addressed. Those who need to undergo surgery on the ear should have nasal and/ or PNS problems attended to first, if an ear operation is to be successful. 
The present study was undertaken to evaluate the nose and PNS for the presence of any pathology in patients suffering from OM. It also aims at knowing whether the treatment of nose and PNS pathology will improve m.e. disease.
| Materials and Methods|| |
The series consists of 340 ears in 200 patients. 86 were males and 114 were females aged between 11 to 60 years. Thorough history with particular reference to muffled hearing, hard of hearing, ear discharge and tinnitus was taken. History regarding nasal complaints was also specifically noted. Detailed ear nose and throat (ENT) examination was carried out.
Patients suffering from
- Acute Suppurative OM
- Chronic Suppurative OM
- OM with effusion
- Adhesive OM
- Retraction of tympanic membrane
- Traumatic perforation
- Traumatic dislocation of ossicles
- Acute infection of nose and PNS
- Age less than 10 years
- X-ray both mastoids lateral oblique view
- X-ray PNS water's view
- Nasal endoscopy
- Pure tone audiometry
- Computed tomography (CT) scan of PNS (wherever indicated)
Diagnostic nasal endoscopy was done to
- Identify any disease in the nose and PNS.
- Know condition of septum, turbinate and ostiomeatal complex.
- Rule out presence of any nasopharyngeal lesion.
- Evaluate the condition of the pharyngeal end of Eustachian tube (ET).
| Results|| |
Two hundred patients of otitis media were studied. The commonest ear disease was chronic suppurative otitis media (CSOM) tubotympanic type in 100 patients (50%). This was followed by retraction in 41%, CSOM atticoantral type in 11.5%, acute suppurative otitis media (ASOM) in 7.5%, failed Type I tympanoplasty in 4.5% and otitis media with effusion (OME) in 2%. Some patients had bilateral ears affected with different pathologies.
Tympanic membrane findings in 340 ears were as follows:
In patients having CSOM 88.43% ears had ear discharge while 11.57% ears were dry.
Distribution of sinonasal disease was studied in these 200 patients. The commonest sinonasal pathology found was deviated nasal septum in 160 (80%) patients. This was followed by sinusitis (13.5%), allergic rhinitis (17%), nasal polyp (10.5%). Some patients had multiple sinonasal pathologies. Septal deviation was associated with compensatory hypertrophy of inferior turbinate in 32% patients. No sinonasal disease was found in 10% patients.
Relationship between each type of ear disease and sinonasal pathology is depicted in [Table 1].
|Table 1: Relationship between ear diseases and sinonasal pathology (N=200 patients)|
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Of 160 patients having deviated nasal septum (DNS) 82.5% were symptomatic and 17.5% were asymptomatic.
Relationship between each type of ear disease and deviated nasal septum is depicted in [Table 2].
|Table 2: Relationship between ear diseases and deviated nasal septum (N=160 patients)|
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Septal correction was performed in patients having significant deviation of septum. One hundred and twenty patients underwent septal correction. The commonest ear disease for which septal correction was done to remove the focus of infection was CSOM tubotympanic type. Septal correction was done in 57.5% (69/120) cases for CSOM, in 35% (42/120) patients for retraction of tympanic membrane, in 5% (6/120) patients for failed Type I tympanoplasty and for OME in 2.5% (3/120) patients.
Overall effect of septal correction on diseased ears (CSOM + retraction) is depicted in [Table 3].
|Table 3: Overall effect of septal correction on diseased ears (CSOM + retraction) (N=174 ears)|
Click here to view
The effect of septal correction was seen on 97 discharging ears with tubotympanic disease; 63.91% (62/97) ears became dry and healing of perforation was seen in 20.61% (20/97) after septal surgery.
In 77 ears having retracted drum, 72.72% (56/77) became normal after septal correction. The remaining 27.27% (21/77) ears had Grade III and Grade IV retraction of tympanic membrane. Appropriate management of ear disease was done in these patients.
Thus overall improvement of ear disease was observed in 79.31% ears (P=0.00) after septal correction.
Of the total 34 diseased ears treated for sinusitis, medically and surgically, complete resolution of the disease occurred in 82.35% (28/34) ears.
Of the 26 diseased ears treated for nasal polyps, resolution of ear disease was seen in 76.92% (20 ears) while persistent ear disease was present in 23.07% (6 ears). In all these patients polyposis was treated endoscopically.
All the patients had minimum three months follow-up.
| Discussion|| |
Sinonasal pathology frequently leads to ear disease. Improvement of m.e. pathology following septoplasty was noted by Dwight Grady MD.  Of the 75 septoplasty cases reviewed by Dwight Grady, 13% had associated disease of the m.e., 70% amongst these patients showed significant improvement of their ear disease following septoplasty. In the present study of 200 patients, septal correction was done in 120 patients. Of these 79.31% ears showed improvement in m.e. disease in the form of dry ear, healing of perforation and resolution of m.e. fluid (Wilcoxon signed rank test, P=0.00). The findings of the present study are comparable with the Dwight Grady study.
P. Von Cauwenberge and A. Derycke studied the relationship between nasal and m.e. pathology in school-going children.  They also found a well-defined influence (P<0.05) of septal deviation on m.e. status. Higher number of flat curves and negative m.e. pressure in children having septal deviation was demonstrated by them.
A nationwide survey was carried out by Chong Sun Kim MD et al.,  in 1991 on the prevalence of OM and allied diseases in Korea. The survey revealed more (P<0.05) prevalence of OM in patients having septal deviation. Otitis media was also more prevalent (P<0.01) in subjects suffering from allergic symptoms. However, the presence of OM was not significantly correlated with nasal polyposis.
The effect of the medical and surgical management of the nose and PNS on m.e. disease was not observed in the two studies mentioned above. In the present study sinusitis was present in 13.5%, allergic rhinitis in 11.5%, and nasal polyp in 10.5% patients. Some patients had multiple sinonasal pathologies. Significant improvement of m.e. disease was found in 82.35% ears after treatment of sinusitis and in 76.92% ears after polypectomy.
In the study 20.48% ears had no improvement of m.e. disease after management of the sinonasal disease.
Causes of no improvement of m.e. disease after septal correction could be:
We recommend careful examination of the anterior mesotympanum during m.e. surgery. Aditus blockage if found should be taken care of for achieving ventilation of the mastoid.
- Presence of granulation, polyp, fibrosis or epithelization in the protympanum.
- Mastoid infection and aditus blockage.
| Conclusion|| |
The potential interaction between the m.e. mucosa, Eustachian tube, pharynx and nasal cavities has been studied by several authors. Eustachian tube dysfunction was related to m.e. disease but little connection was made between m.e. disease and sinonasal pathology. The concept of a relationship between sinonasal pathology and m.e. disease is supported by the present study and could explain the pathogenic effect on the m.e. Medically, educationally, psychologically and from the social point of view, OM should be discovered at the earliest possible opportunity so that treatment may be initiated.  Sinonasal disease being one of the important focuses of infection leading to OM, detection and management of sinonasal disease is equally important. All the patients of OM should undergo a thorough sinonasal examination. Sinonasal disease must be treated before any surgical management of ear disease is undertaken.
| Acknowledgment|| |
The authors thank the Dean, Indira Gandhi Government Medical College, Nagpur for encouraging and facilitating their work.
| References|| |
|1.||Ludman H, Wright A. Diseases of Ear; 6 th ed. First Indian Edition. Hodder Arnold. New Delhi: Jaypee Brothers Medical Publishers; 2006. p. 56. |
|2.||Salvinelli F, Casale M, Greco F, D'Ascanio L, Petitti T, Di Peco V. Nasal surgery and eustachian tube function: Effects on middle ear ventilation. Clin Otolaryngol 2005;30:409-13. |
|3.||De Souza C, Bhaya M. The role of nasal and sinus surgery in otitis media. Operative techniques in Otolaryngology. Head Neck Surg 1996; 7:16-9. |
|4.||Grady D, Mathias P, Anderson R, Snider G, Sprinkle PM. Improvement of middle ear disease following septoplasty. Am J Otol 1983;4:327-31. |
|5.||Van Cauwenberge P, Deryeke A. The relationship between nasal and middle ear pathology. Acta Otorhinolaryngol Belg 1983;37:830-41. |
|6.||Kim CS, Jung HW, Yoo KY. Prevalence of otitis media and allied diseases in Korea- Results of a nation-wide survey 1991. J Korean Med Sci 1993;8:34-40. |
[Table 1], [Table 2], [Table 3]
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