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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 20  |  Issue : 4  |  Page : 219-221

Eustachian dysfunction in chronic otitis media with bilateral concha bullosa: Is it chance finding?


Department of Otorhinolaryngology and Head and Neck Surgery, Jawaharlal Nehru Medical College, DMIMSU, Wardha, Maharashtra, India

Date of Web Publication13-Dec-2014

Correspondence Address:
Shraddha Jain
Department of Otorhinolaryngology and Head and Neck Surgery, Jawaharlal Nehru Medical College, DMIMSU, Sawangi, Wardha 442 004, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.146944

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  Abstract 

Concha bullosa is reported to have a role in paranasal sinus infections. Role of asymptomatic concha bullosa in causation of Eustachian dysfunction and chronic otitis media is not well established with only few reports. Here, we report a case of a 42-year-old female patient who presented with bilateral hearing loss with no nasal complaints. On otoscopy, her tympanic membranes showed bilateral retractions with reduced mobility on the right side. Nasal endoscopy revealed incidental finding of bilateral concha bullosa confirmed on computed tomography scan of paranasal sinuses. Bilateral conchoplasty was done. In immediate postoperative period, patient had subjective as well as objective improvement in hearing status and Eustachian function. Consequently, we inferred that bilateral concha bullosa has etiological role in Eustachian dysfunction due to increased nasal resistance. Hence, conchoplasty provides immediate improvement in a dilatory function of Eustachian tube with hearing improvement.

Keywords: Chronic otitis media, Chronic sinusitis, Concha bullosa, Eustachian tube dysfunction, Nasal resistance


How to cite this article:
Jain S, Gupta M, Deshmukh PT. Eustachian dysfunction in chronic otitis media with bilateral concha bullosa: Is it chance finding?. Indian J Otol 2014;20:219-21

How to cite this URL:
Jain S, Gupta M, Deshmukh PT. Eustachian dysfunction in chronic otitis media with bilateral concha bullosa: Is it chance finding?. Indian J Otol [serial online] 2014 [cited 2020 Oct 27];20:219-21. Available from: https://www.indianjotol.org/text.asp?2014/20/4/219/146944


  Introduction Top


Concha bullosa is reported to have a role in paranasal sinus infections. Hence endoscopic turbinoplasty for concha bullosa as a part of functional endoscopic sinus surgery (FESS) is indicated mainly for patients with chronic or recurrent sinusitis attributable to concha bullosa. [1] However, there is controversy whether to operate asymptomatic concha bullosa. Chronic otitis media alone has not been listed in the indications for FESS for an asymptomatic concha bullosa without nasal complaints. Role of asymptomatic concha bullosa in causation of Eustachian dysfunction and chronic otitis media is not well established with only few reports. [2]

Here, we report a case of chronic otitis media with bilateral concha bullosa diagnosed incidentally on nasal endoscopy. The patient had immediate postoperative hearing improvement after conchoplasty highlighting the probable relationship between concha and Eustachian dysfunction due to increased nasal resistance rather than chronic sinusitis.


  Case Report Top


The 42-year-old female patient presented with bilateral conductive hearing loss and intermittent earache of 1-year duration. There was no history of ear discharge at the time of presentation. There was no history of headache, nasal discharge, recurrent sneezing, and nasal obstruction, anterior or postnasal discharge. Otoscopic examination revealed bilateral retracted tympanic membranes - Sade's Grade 3 on the right side with reduced mobility on Siegelization and Grade 2 on left side with postero-superior retraction. Pure tone audiometry (PTA) revealed bilateral mixed hearing loss of 68.1 dB on the right side and 73.1 dB on the left side with an air - bone gap of up to 40 dB bilaterally [Figure 1]. Impedance audiometry showed bilateral "A type" curve with Eustachian dysfunction more on the right side. Eustachian videoendoscopy by rigid 30° endoscope revealed bilateral edematous torus tubaris with inability to open the Eustachian orifice on swallowing bilaterally [Figure 2]. Septum showed mild posterior deviation to the left with bilateral concha bullosa [Figure 3]. Bilateral osteomeatal complex were completely blocked. No discharge was seen in middle meatus or nasopharynx. Computed tomography scan of paranasal sinuses confirmed bullous type of concha bullosa [Figure 4] and [Figure 5].
Figure 1: Preoperative audiogram

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Figure 2: Video-endoscopic picture of  Eustachian tube More Details (E.T.) orifice showing dysfunctional E.T. with luminal edema

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Figure 3: Endoscopic picture of concha bullosa in left nasal cavity

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Figure 4: Axial computed tomography - scan of paranasal sinuses showing bilateral concha bullosa with minimal mucosal edema of left maxillary sinus

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Figure 5: Coronal computed tomography - scan of paranasal sinuses showing bilateral concha bullosa

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Patient received a course of antibiotics, systemic decongestants and antihistaminics and topical steroids for 5 days with no improvement in hearing. She was posted for FESS for surgical correction of bilateral concha bullosa with bilateral evacuation conchoplasty as a method of turbinoplasty. A sickle knife was used to make a vertical incision into the anterior face of the concha bullosa and extended along its inferior surface. A dissector was carefully used to create a plane between the bony walls of the concha and its covering medial and lateral mucoperiosteal surfaces. This created superiorly and posteriorly based medial and lateral mucosal flaps. Evacuation of the bony concha was then done with Blakesley forceps. Both medial and lateral mucoperiosteal flaps were then laid over their raw surfaces closing the evacuated conchal cavity. Gelfoam was placed in the middle meatus and the nasal cavity to help hold flaps in place. In immediate postoperative period (by 3 rd postoperative day), there was subjective improvement in hearing given by the patient and objective improvement in hearing as evidenced by closure of air-bone gap on PTA of approximately 15 dB and better hearing noticed by her husband. PTA showed 53.1 dB and 58.1 dB of mixed hearing loss on the right and left side respectively [Figure 6]. Eustachian videoendoscopy showed reduced edema of torus and bilateral orifice opened on swallowing.
Figure 6: Postoperative audiogram after bilateral endoscopic conchoplasty

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  Discussion Top


Concha bullosa has been found to be a factor of predisposition for paranasal sinus infections and consequently the middle ear infections. [2] However, according to some authors, the presence of concha bullosa does not show statistically significant association with chronic sinusitis. [3],[4]

We found an association between Eustachian dysfuction and bilateral concha bullosa as evidenced by immediate postoperative improvement in subjective and objective hearing status of the patient and Eustachian function both on endoscopic examination and impedance audiometry after conchoplasty. The patient did not have any nasal complaints attributable to concha bullosa. Bilateral concha bullosa was diagnosed incidentally on nasal endoscopy done for Eustachian function. There was no purulent discharge, but osteomeatal complex was obstructed on both sides by large concha bullosa. This highlights the importance of nasal endoscopy in every case of chronic otitis media.

The cause of Eustachian dysfunction in our case was presumably due to increased nasal resistance attributable to bilateral concha bullosa. Previous studies have supported that nasal obstruction associated with a Toynbee phenomenon, like a partial vacuum, can also be viewed as a factor of great impact in tubal dysfunction. Hence, even an anterior obstruction of the nostrils, with a negative pressure behind the obstacle, can cause the Eustachian tube (E.T.) dysfunction. [5] Nasal obstruction and E.T. dysfunction are related is also made from the fact that the severity of the nasal airway resistance can influence the grade of E.T. dysfunction. This has been supported by significant statistical correlation that has been observed between the results of tubal manometric measurements for Eustachian dysfunction and increased nasal resistance by rhinomanometric and constant body plethysmography (Jaeger), respectively, in two separate studies. [5],[6]

Different techniques for turbinoplasty include endoscopic partial lateral middle turbinectomy [7] and evacuation conchoplasty [8] for surgical management of concha bullosa. We used the latter technique in our patient.


  Conclusion Top


Indications of FESS should include chronic otitis media with Eustachian dysfunction due to bilateral concha bullosa even in the absence of clinical features of sinusitis.

Further studies need to be undertaken to study the mechanism of causation of Eustachian dysfunction in chronic otitis media due to asymptomatic concha bullosa. Is it the osteomeatal complex block with asymptomatic sinusitis or increased nasal resistance due to space occupied by the pneumatized middle turbinate, or both?

 
  References Top

1.
Mehta R, Kaluskar SK. Endoscopic turbinoplasty of concha bullosa: long term results. Indian J Otolaryngol Head Neck Surg 2013;65:251-4.  Back to cited text no. 1
[PUBMED]    
2.
Uguz MZ, Önal K, Deniz A, Arslanoglu S. The role of concha bullosa in the pathogenesis of chronic otitis media. Otoscope 2005;1:22-8.  Back to cited text no. 2
    
3.
Lam WW, Liang EY, Woo JK, Van Hasselt A, Metreweli C. The etiological role of concha bullosa in chronic sinusitis. Eur Radiol 1996;6:550-2.  Back to cited text no. 3
    
4.
Stallman JS, Lobo JN, Som PM. The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. AJNR Am J Neuroradiol 2004;25:1613-8.  Back to cited text no. 4
    
5.
Enache R, Sarafoleanu D, Negrila AM. The impact of nasal obstruction upon Eustachian tube function - A correlation between rhinomanometric and tubal manometric measurements. Rom J Rhinol 2011;1:22-5.  Back to cited text no. 5
    
6.
Filipoviæ SA, Janoseviæ L, Andriæ V, Ugrinoviæ A. Clinical evaluation of Eustachian tube transience and function in patients with different types of increased nasal resistance. Vojnosanit Pregl 2009;66:353-7.  Back to cited text no. 6
    
7.
Badran HS. Role of surgery in isolated concha bullosa. Clin Med Insights Ear Nose Throat 2011;4:13-9.  Back to cited text no. 7
[PUBMED]    
8.
Albirmawy OA, Elsherif HS, Shehata EM, Younes A. Middle turbinate evacuation conchoplasty in management of contact-point rhinogenic headache in children. Int J Clin Pediatr 2012;1:115-23.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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