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.