Zusammenfassung
Hintergrund: Vor der Sanierung einer chronischen Mittelohrentzündung müssen die potentiellen Interaktionen zwischen Mittelohrschleimhaut und Ohrtrompete einerseits sowie Nase und Nasopharynx andererseits bedacht werden. Im Schrifttum wird die Sanierung der inneren Nase vor Durchführung der Tympanoplastik empfohlen, um so deren Erfolgsaussichten zu erhöhen. Patienten und Methoden: Wir bestimmten an 50 ohrgesunden Patienten bei bestehender Septumdeviation und Muschelhypertrophie, bei denen wegen chronisch-behinderter Nasenatmung Septumplastik und Conchotomie durchgeführt wurden, in der Druckkammer die Tubenfunktion mit dem Dual-Impedanz-Verfahren. Ergebnisse: In vielen Fällen ergaben sich deutlich über dem Normbereich liegende Meßwerte für die Parameter der aktiven und passiven Tubenöffnung. Eine Woche postoperativ hatten sich die Werte meist noch verschlechtert und auch 6 - 8 Wochen sowie 4 - 6 Monate später kam es nur bei einem Teil der Patienten zu einer Besserung einzelner Funktionsparameter. Bei einigen Patienten verschlechterte sich die Tubenfunktion postoperativ gegenüber dem präoperativen Wert, ohne dass dies mit einem unbefriedigenden Ergebnis der Nasenoperation verbunden gewesen wäre. Eine generelle Normalisierung der Tubenfunktion konnten wir nicht beobachten. Diskussion: Wir ziehen aus unseren Beobachtungen folgende Schlußfolgerungen: 1. Störungen der Tubenfunktion treten vermehrt bei Patienten mit Septumdeviation und Muschelhyperplasie auf. 2. Eine Septumkorrektur und Conchotomie kann in begründeten Fällen vor Tympanoplastik sinnvoll sein, kann aber nicht generell empfohlen werden. 3. Eine präoperative Tubenfunktionsanalyse ist dringend zu empfehlen. 4. Wird eine Sanierung der Nase durchgeführt, sollte die Tympanoplastik erst mehrere Wochen oder Monate später erfolgen.
Summary
Background: When tympanoplasty is to be done in a patient suffering from chronic otitis media, usually potential interactions between middle ear mucosa, Eustachian tube function, and the nose and nasopharynx are considered. Poor tubal function goes along with a diminished success rate of tympanoplasty. On the other hand, pathological findings in the nose or the nasopharynx are often said to be responsible for inadaequate tubal function. Consequently, many authors feel that surgery of the nose should be performed before tympanoplasty if septal deviation or hypertrophy of the conchae is seen in a patient with chronic otitis media. Patients and Methods: In order to better understand interactions between nasal pathology and Eustachian tube function, we utilized a pressure chamber to examine 50 patients undergoing septoplasty and conchotomy. Besides insufflation tests (Toynbee, Valsalva), we performed dynamic tubal examination with the dual-impedance method. Active parameters (positive and negative residual pressure) and passive parameters (tubal opening and tubal closing pressure) were recorded as the chamber pressure was varied. The aim of our investigation was to test if surgery of the nasal septum and the conchae really improves tubal function, thus evaluating indications for septoplasty before tympanoplasty. In addition, we explored the early and the late consequences of nasal surgery on tubal function. This was done to find out the optimal postoperative period during which tympanoplasty could be performed following septoplasty. Results: In many of the patients, insufflation tests were negative and dynamic tubal parameters were outside normal value range before surgery of the nose. One week after surgery, active and passive parameters and insufflation tests even deteriorated in the majority of our patients. Six to 8 weeks after surgery, we observed a tendency towards normalization of tubal parameters. This was significant for tubal closing pressure, but not for the other parameters. Whereas passive tubal parameters showed considerable improvement in many patients, there was no real improvement of active tubal parameters in most patients. This tendency was observed several months after surgery of the nose as well. Despite this improvement of passive tubal function, we did not observe a complete normalization of mean values even after 4 to 6 months. In several patients (who were satisfied with functional results of septoplasty) tubal parameters were even worse some weeks or months after nasal surgery, but this was not subjectively registered by our patients. Discussion: We conclude from our data that dysfunction of the Eustachian tube frequently occurs in patients with deviation of the nasal septum and the conchae. Septoplasty and conchotomy worsen tubal function during the early postoperative period, lasting for at least one week. In a later period, improvement of tubal function may occur but in many patients no effects of nasal surgery on Eustachian tube can be measured. Thus, septoplasty before tympanoplasty cannot be generally recommended in all patients with septal deviation. We suggest that it may be useful in cases with severe nasal pathology or chronic infection of the nose or the nasopharynx, if this is accompanied by poor tubal function. We recommend analysis of Eustachian tube function before deciding on therapeutic management. Individual findings in the specific patient should be the leading criteria in all cases. If septoplasty and conchotomia are done, tympanoplasty should not be performed in the same session or in the early postoperative period, but several months after nasal surgery.
Schlüsselwörter
Chronische Otitis media - Septumplastik - Tubenfunktion - Tympanoplastik
Key words
Septoplasty - Eustachian tube function - Chronic otitis media - Tympanoplasty
