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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 21  |  Issue : 1  |  Page : 19-24

Role of dynamic slow motion video endoscopy in etiological correlation between eustachian dysfunction and chronic otitis media: A case-control study


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

Date of Web Publication10-Mar-2015

Correspondence Address:
Dr. 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: 10.4103/0971-7749.152853

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  Abstract 

Objective: To assess the role of dynamic slow motion video endoscopy (DSVE) for diagnosing eustachian tube (ET) dysfunction in the cases of middle ear disorders and to classify eustachian dysfunction into mechanical and functional for the purpose of systematic management of middle ear disorders. Materials and Methods: A prospective, case-control study was carried out on total 84 patients (168 ears) of whom 64 patients with ear complaints (total 95 ears) having middle ear disease was taken as cases. Remaining 20 patients without any ear and nasal complaints (40 ears) and the normal ears among the case group (33 ears) were taken as controls (total 73 ears). DSVE was performed in cases and controls to compare the incidence of eustachian dysfunction in the two groups. Tubal movements were classified into four grades depending on: (1) Appearance of tubal mucosa, (2) movements of medial and lateral cartilaginous lamina, (3) lateral excursion and dilatory waves of the lateral pharyngeal wall, (4) whether tubal lumen opened well or not and (5) presence of patulous tubes (concavity in the superior third of tube). Results: On correlating the DSVE findings of ET in both case and control group, 4 times higher incidence of abnormal ET dysfunction was obtained in cases of middle ear disorders as compared to controls (P = 0.001, odds ratio of 4.0852). We found that 29 tubes had mechanical type of dysfunction (Grades 2A and 3A), whereas 30 tubes had functional type of dysfunction (Grades 2B and 3B and patulous). Conclusion: There is a positive etiological correlation between eustachian dysfunction and chronic otitis media by DSVE. It provides valuable information regarding the structural and functional status of the pharyngeal end of the ET and in classifying the type of eustachian dysfunction into mechanical or functional, which has management implications.

Keywords: Chronic otitis media, Dynamic slow motion endoscopy, Eustachian tube function


How to cite this article:
Gupta M, Jain S, Gaurkar S, Deshmukh PT. Role of dynamic slow motion video endoscopy in etiological correlation between eustachian dysfunction and chronic otitis media: A case-control study. Indian J Otol 2015;21:19-24

How to cite this URL:
Gupta M, Jain S, Gaurkar S, Deshmukh PT. Role of dynamic slow motion video endoscopy in etiological correlation between eustachian dysfunction and chronic otitis media: A case-control study. Indian J Otol [serial online] 2015 [cited 2022 Sep 26];21:19-24. Available from: https://www.indianjotol.org/text.asp?2015/21/1/19/152853


  Introduction Top


 Eustachian tube More Details (ET) dysfunction has been found to have a causal relationship with the middle ear pathology. One of the early sequelae seen is tympanic membrane retraction. This state when becomes chronic leads to adhesive otitis media followed by debris collection and fulminant cholesteatoma. [1] The etiology of middle ear disease is multifactorial, but an abnormal function of the ET appears to be the most important factor in the pathogenesis of middle ear disease. [2] ET dysfunction is defined as an inadequate dilatory function causing secondary ear pathology. It can result from mechanical obstruction or functional causes. [3]

Eustachian tube dysfunction leads to an inability to equalize negative middle ear pressure. The active rather than the passive tubal function has been found to be more important with respect to proneness to recurrent acute otitis media and secretory otitis media in children. When compared to adults, in children with otitis media with effusion, as well as healthy children, active tubal function has been found to be poor. ET opening dysfunction or muscular opening hypo function in children is considered to be a primary endogenous etiologic factor for chronic otitis media. [4] Patients with cholesteatoma also have been found to have varying degrees of functional rather than mechanical obstruction of the ET. The acquired cholesteatoma seems to be the result of the following sequence of events: Functional ET obstruction, high negative middle ear pressure, atelectasis of the tympanic membrane-middle ear, a retraction pocket in either the posterosuperior or attic portion of the tympanic membrane, and adhesive otitis media. [5]

Most tests of ET dysfunction do not differentiate between the type of eustachian dysfunction, whether it is mechanical or functional. This differentiation is extremely important from the management point of view, the mechanical obstruction being mainly due to infective, allergic or obstructive causes in nasal, nasopharyngeal region or in paranasal sinuses, warranting management accordingly. [3] The functional dysfunction is due to inherent tubal muscle weakness and is an indication for eustachian tuboplasty.

Because of the relative inaccessibility of the region and high variability in results among different tympanometeric eustachian function tests; there is still a search for an ideal method of assessing eustachian dysfunction. Recently, dynamic slow motion video endoscopic (DSVE) analysis of ET has emerged as a new tool in the quest for understanding the pathophysiology of tubal dysfunction. It helps in direct visualization of active opening of the nasopharyngeal end of the ET during rest, swallowing, and yawning and hence aids classification of eustachian dysfunction into functional and mechanical. [6] It also assesses nasal anatomy, nasal mucosa and surrounding structures, sinonasal diseases such as rhino sinusitis and adenoid hypertrophy at the same time. It can also be used to evaluate the improvement in eustachian function following medical or surgical treatment for sinonasal lesions. [7]

The present study was undertaken to assess whether DSVE analysis of ET (DSVE) is a useful tool for classification of eustachian dysfunction into mechanical and functional in cases of chronic otitis media and also to confirm the etiological correlation between eustachian dysfunction and different types of chronic otitis media by comparing with the control group.


  Materials and Methods Top


The case control study was done on total 84 patients (168 ears) of whom 64 patients with ear complaints having middle ear disease was taken as cases. Among these 64 patients from the case group, 31 patients had complaints of both ear (62 ears) and 33 patients had complaints of only one ear (33 ears). Hence in the case group, total 95 diseased ears were included having middle ear pathology after complete otoscopic and under microscopic evaluation. Remaining 20 patients without any ear and nasal complaints (40 ears) and the normal ears among the case group (33 ears) were taken as controls (total 73 ears), was presumed to have normal eustachian function for studying normal ET physiology. A detailed history was noted.

Depending on otoscopic and examination under microscopes findings, middle ear diseased were classified using the classification adapted from Browning. All the patients were subjected for routine investigations, relevant radiological investigation.

Video endoscopy was done under local anesthesia by 30°, rigid Henke Sass Wolf nasal endoscope of 4 mm diameter. Recording was done with the help of Honestech TV tunner card. Endoscopy was done by introducing endoscope along the floor of the nasal cavity facing superiorly and advanced just beyond the posterior end of the inferior turbinate and was rotated laterally to face the nasopharyngeal orifice of ET. Transnasal endoscopic examination of the nasopharyngeal opening of ET during rest, swallowing and yawning carried out to study its dilatory movements.

Tubal movements were classified into four grades: (1) Depending upon appearance of tubal mucosa, (2) movement of medial and lateral cartilaginous lamina, (3) lateral excursion and dilatory wave of the lateral pharyngeal wall as estimates of tensor veli palatine and dilator tube muscle function, (4) whether tubal lumen opened well or not with maneuvers, (5) presence of patulous tubes (concavity in the superior third of tube).

Grading of ET opening was done. [6]

  • Grade 0: Normal ET with no mucosal edema or congestion. Medial cartilaginous lamina and lateral wall motion are normal. Tubal lumen opens well on swallowing
  • Grade 1: Edema and congestion of the mucosa limited to the pharyngeal orifice of ET with normal lateral wall motion. Tubal lumen opens with swallowing
  • Grade 2A: Reduced lateral wall motion secondary to edema and congestion involving lumen. Tubal lumen opens partly with swallowing
  • Grade 2B: Reduced lateral wall motion secondary to abnormal tubal muscular contraction. Tubal lumen opens partly with swallowing
  • Grade 3A: Tubal lumen fails to open with swallowing secondary to gross edema
  • Grade 3B: Tubal lumen fails to open with swallowing secondary to abnormal tubal muscle contraction
  • Patulous (P): Patulous tube showed noticeable concavity in the superior portion of the lateral wall of ET lumen, with persistent patency of the lumen, extending towards the isthmus with medial and lateral cartilaginous lamina remaining separate even at rest.


Grade 0 and Grade 1 were considered as normal in our study, Grades 2A and 3A as mechanical cause for the dysfunction, whereas Grades 2B, 3B and patulous as functional cause for ET dysfunction.

Statistical analysis was performed by using Chi-square test and odds ratio.


  Observations and Results Top


In this study, there were total 84 patients (168 ears), of whom 64 patients with ear complaints (total 95 ears) and middle ear disease comprised the case group. Remaining 20 patients without any ear and nasal complaints (40 ears) and the normal ears among the case group (33 ears) were taken as controls (total 73 ears).

Mucosal chronic otitis media including, both active and inactive were found in 47 ears (49.47%), whereas 28 ears had chronic suppurative otitis media (CSOM) with cholesteatoma, that is, active squamosal disease (13 ears [13.86%] had active squamosal pars tensa cholesteatoma and 15 ears [15.79%] had active squamosal pars flaccida cholesteatoma). Remaining 20 ears (21.05%) had inactive squamosal disease of pars tensa (adhesive otitis media and posterosuperior retraction pocket without cholesteatoma) [Table 1]. Hence in the study, total 48 ears (49.47%) were diagnosed as squamosal chronic otitis media and remaining 47 ears (50.53%) were diagnosed as mucosal chronic otitis media.
Table 1: Distribution of middle ear disease in case group with diseased ear (n=95)


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On endoscopic analysis of 95 ET s in case group, 25 ET (26.32%) were graded as Grade 0, 11 tubes as Grade 1 (11.58%), 19 as Grade 2A (20%) tubes, while 10 tubes as Grades 2B and 3A each (10.53%), 16 tubes as Grade 3B (16.48%) and only 4 tubes (4.21%) were patulous [Table 2] and [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]. Out of total 95 diseased ears, abnormal ETs were found in 59 (62.11%) and normal ET s in 36 ears (37.89%) [Table 3] and [Figure 9]. On endoscopic analysis of 73 tubes in the control group, 52 tubes (71.23%) were found to have normal function and 24 tubes (28.77%) were found to be abnormal [Table 4] and [Figure 10].
Figure 1: At rest (slit like opening)

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Figure 2: Grade 0: Normal eustachian tube with no mucosal oedema or congestion. Tubal lumen opens well on swallowing

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Figure 3: Grade 1: Edema and congestion of mucosa limited to pharyngeal orifice of eustachian tube with normal lateral wall motion. Tubal lumen opens with swallowing

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Figure 4: Grade 2A: Reduced lateral wall motion secondary to edema and congestion involving lumen. Tubal lumen opens partly with swallowing

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Figure 5: Grade 2B: Reduced lateral wall motion secondary to abnormal tubal muscular contraction. Tubal lumen opens partly with swallowing

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Figure 6: Grade 3A: Tubal lumen fails to open with swallowing secondary to gross edema

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Figure 7: Grade 3B: Tubal lumen fails to open with swallowing secondary to abnormal tubal muscle contraction

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Figure 8: Patulous (P): Patulous tube, with persistent patency of the lumen, with medial and lateral cartilaginous lamina remaining separate even at rest

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Figure 9: Distribution of video endoscopic finding of ET function in case group

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Figure 10: Distribution of video endoscopic finding of ET in control group (n=73)

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Table 2: Sub classification of grading of dynamic ET endoscopy finding in case group (n=95)


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Table 3: Classification of video endoscopic finding of ET function in case group into normal and abnormal (n=95)


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Table 4: Distribution of video endoscopic finding of ET in control group (n=73)


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Correlation of dynamic On correlating the DSVE findings of ET in both case and control groups, in case group, 36 (37.89%) tubes had normal ET finding while abnormal ET was found in 59 (62.11%) tubes. Whereas, in the control group, 52 (71.23%) tubes had normal ET finding while, abnormal ET was found only in 21 (28.76%) tubes, [Table 5] and [Figure 11]. On applying Chi-square test, P = 0.001 (Chi-square = 17.08) was obtained, which is suggestive of the higher incidence of abnormal ET dysfunction in cases of middle ear disorders as compared to controls. Odds ratio was found to be 4.0852 (95% confidence interval limits: −2.1086-7.8103), implying 4 times higher incidence of eustachian dysfunction in case group as compared to the control group.
Figure 11: Correlation between dynamic ET endoscopy findings and middle ear disease in cases and control group (n=168)

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Table 5: Correlation between dynamic ET endoscopy findings and middle ear disease in cases and control group (n=168)


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Among the 59 dysfunctional ET in case group, considering Grade 0 and Grade 1 as normal, it was found that 29 tubes had mechanical cause for dysfunction (Grades 2A and 3A), whereas 30 tubes had functional cause for ET dysfunction (Grades 2B, 3B and patulous).

In this study, it was found that, in all cases of mechanical dysfunction, some underlying nasal causes of dysfunction were found.


  Discussion Top


Eustachian tube dysfunction has been suspected as the primary cause of chronic otitis media, which has been corroborated by several independent studies. [8],[9] In this study, we have compared ET findings of DSVE in cases of chronic otitis media with the controls without middle ear disease. At the same time, we have also attempted to classify the type of ET dysfunction into mechanical or functional and tried to correlate it with nasal pathology.

Eustachian tube dysfunction was classified into mechanical (Grades 2A and 3A) or functional (Grades 2B and 3B and patulous tube), on the basis of finding of edema and congestion around the eustachian orifice along with closure of the lumen (mechanical). Similar to study of Poeet al., Grade 0 and Grade 1 were considered as normal ET function in our study. [10]

A significant correlation was found between middle ear disease and dysfunctional ET by DSVE findings. Our findings were similar to the study conducted by Mathew et al. but they found a higher incidence of dysfunction in their case group in that only 10 tubes were normal out of total 63 ET tubes studied, rest all other tubes were found to be dysfunctional. [6]

On correlating the DSVE findings of ET in both case and control groups and after applying Chi-square test of significance, P - 0.001 (Chi-square = 17.08) was obtained and odds ratio was found to be 4.0852 (95% confidence interval limits: −2.1086-7.8103), implying 4 times higher incidence of eustachian dysfunction in case group as compared to control group.

Similarly in the study conducted by Yücetürk et al., ET dysfunction was observed in 71.7% of the CSOM group, and it was seen in only 34.9% of the control group. [11]

Hence, we found that DSVE is a useful tool for diagnosing ET dysfunction in cases of chronic otitis media. Similarly, Mathew et al. and Chauhan and Chauhan also found nasal endoscopy and videonasopharyngoscopy as highly accurate and reliable tests for ET function as compared to other existing tests of eustachian function as they help in better understanding of pathophysiology of tubal dysfunction. [6],[12]

It helps in grading and classifying types of ET dysfunction. Moreover, associated nasal pathology can be diagnosed in the same sitting. Diagnosing nasal pathology helps in deciding proper management of patient with middle ear disease. For a successful outcome of middle ear surgery, good ET function is required, as also emphasized by Farrior and Tos. [13],[14]


  Conclusion Top


From the present study, we conclude that: DSVE can be used as a diagnostic tool for ET function evaluation. On endoscopic analysis, cause for ET dysfunction, whether mechanical or functional, can be evaluated. Mechanical type of dysfunction is mostly associated with some underlying nasal pathology.

 
  References Top

1.
Seibert JW, Danner CJ. Eustachian tube function and the middle ear. Otolaryngol Clin North Am 2006;39:1221-35.  Back to cited text no. 1
    
2.
Lindeman P, Holmquist J. Mastoid volume and eustachian tube function in ears with cholesteatoma. Am J Otol 1987;8:5-7.  Back to cited text no. 2
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3.
Poe DS, Gopen Q. Endoscopic diagnosis and surgery of eustachian tube dysfunction. Ch. 12. Middle ear. Ch. 25. Glasscock-Shambaugh Surgery of the Ear. 6 th ed. USA: People's Medical Publishing House; 2010. p. 245-53.  Back to cited text no. 3
    
4.
Bylander-Groth A, Stenström C. Eustachian tube function and otitis media in children. Ear Nose Throat J 1998;77:762-4, 766, 768-9.  Back to cited text no. 4
    
5.
Bluestone CD, Cantekin EI, Beery QC, Stool SE. Function of the Eustachian tube related to surgical management of acquired aural cholesteatoma in children. Laryngoscope 1978;88:1155-64.  Back to cited text no. 5
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6.
Mathew GA, Kuruvilla G, Job A. Dynamic slow motion video endoscopy in eustachian tube assessment. Am J Otolaryngol 2007;28:91-7.  Back to cited text no. 6
    
7.
Berlucchi M, Pedruzzi B, Sessa M, Nicolai P. Diagnostic and therapeutic sinonasal endoscopy in paediatric patient. Cornel Iancu, editor. Advances in Endoscopic surgery. InTech Under CC BY 3.0 License - Open Access; 2011; p. 345-75.  Back to cited text no. 7
    
8.
Skotnicka B, Hassmann-Poznanska E. Video endoscopic analysis of eustachian tube function in children with middle ear pathology. Otolaryngol Pol 2007;61:301-6.  Back to cited text no. 8
    
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Asenov DR, Nath V, Telle A, Antweiler C, Walther LE, Vary P, et al. Sonotubometry with perfect sequences: First results in pathological ears. Acta Otolaryngol 2010;130:1242-8.  Back to cited text no. 9
    
10.
Poe DS, Abou-Halawa A, Abdel-Razek O. Analysis of the dysfunctional eustachian tube by video endoscopy. Otol Neurotol 2001;22:590-5.  Back to cited text no. 10
    
11.
Yücetürk AV, Unlü HH, Okumus M, Yildiz T, Filiz U. The evaluation of eustachian tube function in patients with chronic otitis media. Clin Otolaryngol Allied Sci 1997;22:449-52.  Back to cited text no. 11
    
12.
Chauhan B, Chauhan K. A comparative study of eustachian tube functions in normal and diseased ears with tympanometry and videonasopharyngoscopy. Indian J Otolaryngol Head Neck Surg 2013;65:468-76.  Back to cited text no. 12
    
13.
Farrior JB. Total tympanoplasty type V. Eustachian tube patency in tympanoplasty. Arch Otolaryngol 1965;81:398-409.  Back to cited text no. 13
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Tos M. Importance of eustachian tube function in middle ear surgery. Ear Nose Throat J 1998;77:744-7.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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Indian Journal of Otolaryngology and Head & Neck Surgery. 2018;
[Pubmed] | [DOI]



 

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