4 Discussion
Referred otalgia is often attributed to ETD, particularly in the presence of chronic nasal symptoms.5 Association of aural symptoms in CRS and nasal obstruction has led to its inclusion in symptom assessment tools such as SNOT-22; however, the etiology of these symptom correlations remains poorly understood. A number of interventions have aimed at relieving chronic nasal obstruction refractory to medical management such as balloon dilation, but response to these interventions remains difficult to predict.6,21 Septoplasty with ITR is a well-established procedure for relief of nasal obstruction; however, to our knowledge no previous study has prospectively examined the effect of septoplasty on the ear pair or aural fullness.
Patients in this study experienced significant relief of aural symptoms following septoplasty compared to controls. Preoperative ETDQ-7 scores were greater than 28, suggestive of ETD among the case group.21 Mean ETDQ-7 scores were higher among the case group (31.8±9.2) compared to controls (12.2±1.5), and ETDQ-7 scores decreased 17.4 (p=0.016) in the case group without a significant decrease in middle ear pressures. Overall presence of aural symptoms was not predictive of negative pressures in the middle ear. These findings suggest that the secondary aural symptoms experienced in patients with nasal obstruction may be attributed to more than the inability to equalize middle ear pressures.
Secondary outcomes for the study included QOL assessments using SNOT-22 questionnaires. As SNOT-22 contains a nasal congestion, sleep questions, and two ear complaints, the results have shown that total scores were high. We do not believe that this was related to allergies but related to the deviated nasal septum and turbinate hypertrophy that did not respond originally to the nasal steroid sprays. Overall patients in this study reported significant improvement in QOL measures following septoplasty in nasal obstruction (-23.2, p=0.018). Our data corroborated previous studies22,23,24, showing correlation between SNOT-22 and ETDQ-7 in QOL measures; however, when analyzing the groups separately, correlation was only seen in patients presenting with severe aural symptoms.24 This suggests ETDQ-7 as a valid tool for patient recorded outcome measure for patients with referred otalgia who undergo septoplasty.
It appears that ETD can be induced by a deviated nasal septum, and furthermore this could affect the pressure in the middle ear. It is, therefore, suggested that patients with ETD be evaluated for nasal obstruction prior to entertaining eustachian balloon dilation. We believe that septoplasty with possible turbinate reduction should be considered prior to balloon dilation in these patients (Figure 1 ). Further studies that look specifically at the role of balloon dilation in patients with deviated nasal septum are also needed. Due to the small sample size, more studies are needed to investigate the role of septoplasty and balloon dilation in patients with ETD. Likewise, further understanding is needed for the etiology of aural symptoms in patients with chronic nasal obstruction before directing interventions towards improving eustachian tube function.
Our study had several limitations. Primarily the study was small, featuring a limited cohort of patients from within a single academic practice. Due to the prospective nature of this study, we experienced loss to follow-up particularly in the tympanometry readings. Third, patients with any previous intranasal or middle ear surgery were excluded despite whether their septum was corrected. Lastly the study was dependent on questionnaires administered during follow-up visits, which might alter the response of patients who would answer differently to someone not involved in their care.