Introduction
Chronic otitis media is a widespread disease of the developing countries, especially
the rural areas. The etiology and pathogenesis of chronic otitis media mucosal type
(COMMD) are multifactorial. The more relevant factor in the evolution of this disorder
is the Eustachian tube dysfunction. The sinonasal predisposing disease foci present
as extrinsic factors to influence the function of the Eustachian tube. However, their
precise role and influence on the latter are one of the many gray areas in the pathogenesis
of otitis media. Even the duration of influence of these foci on the middle ear function
is a matter of controversy. In few cases, dormant foci in the nose and throat can
become clinically significant after surgery and lead to recurrence of ear disease
and failure of ear surgery.[1]
Preoperative evaluation of the predisposing focus in the nose and throat in COMMD
will be helpful in determining the potential results of tympanoplasty and mastoid
surgery and hence the need for study.
Materials and Methods
This study was conducted in the department of ear-nose-throat (ENT) in a tertiary
care public hospital. Ethical clearance from institutional review board was obtained.
Patients in the age group of 14 to 70 years attending the outpatient clinic of the
department in a span of 1 year were recruited into the study. Equal number of age
and sex matched controls were also recruited. This was a prospective case–control
study with two arms. The cases included the patients having COMMD without complications.
The controls were those patients who had no symptoms and signs of ear disease. Patients
with acute otitis media, adhesive otitis media, and otitis media with effusion, chronic
otitis media squamosal type, or tympanic perforation of traumatic etiology were excluded.
Every consecutive eligible patient was recruited into the study. All patients underwent
a detailed clinical ENT examination. They were subjected to rigid diagnostic nasal
endoscopy (DNE) and findings noted in each case with respect to adenoid enlargement,
tubal tonsil hypertrophy, movement of eustachian tube pharyngeal opening, inferior
turbinate hypertrophy, bullous concha, deviated nasal septum, discharge in middle
meatus, nasal polyp, atrophic rhinitis, etc. One hundred controls were also recruited
at random who were age and sex matched with the cases. DNE was also performed in controls
to search for the same foci. Both cases and controls were subjected to other investigations
when needed such as computed tomographic (CT) scan of the nose and paranasal sinuses
only after DNE.
In all cases, ear and nasal swabs were taken at the first visit for microbiological
analysis. The pathology in the nose and throat and its side in relation to COMMD was
the primary outcome. Bacterial flora of the nose and ear was the secondary outcome.
Observations and Results
A total of 100 patients with COMMD and 100 age and sex matched controls were recruited
into the study. There were 34 cases of right-sided, 34 cases of left-sided, and 32
cases of bilateral COMMD.
Age Distribution in Study Population
In this study, presence of predisposing disease foci was evaluated in patients in
the age group of 14 to 70 years. The youngest patient was 14 years, and the oldest
was 67 years in cases, and the youngest and oldest patients in control group were
14 years and 65 years, respectively. Mean age of the case and control groups were
26.41 and 29.21, respectively. There was no significant difference between the two
groups in age distribution.
Predisposing Foci and Chronic Otitis Media Mucosal Disease
In our study, 93% of cases and 73% of controls had predisposing foci. Out of 32 bilateral
COMMD cases, only one case had no predisposing foci. Symptomatic predisposing foci
were present in 52% of cases and 55% of controls ([Table 1]). There was extremely significant association between predisposing factors and COMMD.
There was 4.9 times increased risk of developing COMMD in the presence of predisposing
foci.
Table 1
Comparison of cases and controls with respect to predisposing foci
|
Status
|
Cases
|
Controls
|
Total
|
|
Chi-square = 14.1743, p = 0.0000, p < 0.05.
Odds ratio = 4.91, 95% CI = 2.05–11.78.
|
|
Predisposing focus present
|
93
|
73
|
166
|
|
Predisposing focus absent
|
7
|
27
|
34
|
|
Total
|
100
|
100
|
200
|
Single and Multiple Foci in Cases and Controls
In this study, 82% of cases had multiple foci compared with 65% in controls. The association
was significant. There was 2.5 times increased risk of developing COMMD in the presence
of multiple foci ([Table 2]). [Table 3] compares the risk of COMMD with increase in number of foci. With increase in number
of foci, odds ratio increased, which suggested the increasing risk of developing COMMD.
[Table 4] compares the association of bilateral and unilateral COMMD with and without sinonasal
focus. There was no significant difference in their association even though the chance
of finding a focus was three times more in bilateral COMMD as compared with unilateral
COMMD. Association between the various sinonasal pathologies and COMMD and also the
risk factor in their presence are given in [Table 5]. The percentages within brackets indicate the patients who had symptoms linked to
the focus.
Table 2
Comparison of single and multiple foci in cases and controls
|
Foci in nose and throat
|
Cases with foci
(n = 93)
|
Percentage
|
Controls with foci
(n = 73)
|
Percentage
|
|
Chi-square = 6.3872, p = 0.0121, p < 0.05.
Odds ratio = 2.51, 95% CI = 1.22–5.15.
|
|
Single focus
|
16
|
17.20
|
25
|
34.25
|
|
Multiple foci
|
77
|
82.80
|
48
|
65.75
|
Table 3
The odds ratio for the number of sinonasal foci
|
Number of foci
|
Odds ratio
|
|
One
|
2.46
|
|
Two
|
3.65
|
|
Three
|
11.95
|
|
More than
three
|
42
|
Table 4
Comparison of bilateral and unilateral COMMD in relation to the presence or absence
of sinonasal focus
|
Cases with foci
(n = 93)
|
Percentage
|
Cases without focus
(n = 7)
|
Percentage
|
|
Abbreviation: COMMD, chronic otitis media mucosal disease.
Chi-square = 1.0854, p = 0.2974, p < 0.05.
Odds ratio = 3.
|
|
Bilateral COMMD
|
31
|
33.33
|
1
|
14.28
|
|
Unilateral COMMD
|
62
|
66.66
|
6
|
85.71
|
Table 5
Comparison of foci in cases and controls
|
Adenoid enlargement
|
Tubal tonsil
|
Sinusitis
|
DNS
|
ITH
|
Bullous concha
|
|
Abbreviations: DNS, deviated nasal septum; ITH, inferior turbinate hypertrophy.
|
|
Cases
|
34%
(58%)
|
39%
|
14%
|
77%
(48%)
|
47%
(45%)
|
13%
|
|
Controls
|
16%
(48%)
|
6%
|
12%
|
63%
(52%)
|
32%
(40%)
|
5%
|
|
p-Value
|
0.0030
|
0.000
|
0.674
|
0.031
|
0.003
|
0.0482
|
|
Odds ratio
|
2.70
|
10.02
|
1.19
|
1.97
|
1.88
|
2.84
|
Side of Deviated Nasal Septum, Inferior Turbinate Hypertrophy, and Side of Chronic
Otitis Media Mucosal Disease
In this study, 26 patients with right-sided, 24 with left-sided, and 27 with bilateral
COMMD had deviated nasal septum. In patients with right COMMD, 46% had right deviated
nasal septum (DNS); in left COMMD cases, 50% had left DNS; and in bilateral cases,
40% had right DNS and 33% had left DNS. Even though right COMMD cases with right DNS
and left COMMD cases with left DNS were more, the association was not statistically
significant.
The side of COMMD was compared with the side of inferior turbinate hypertrophy (ITH).
No significant association was found between side of COMMD and side of ITH.
Microbiology of Ear and Nasal Swabs
Out of 100 patients examined, positive ear swab was obtained in 59 ears and positive
nasal swab was obtained in 20 cases ([Table 6]). In 8 (13%) cases, same organism was found in both nasal and ear swabs. Number
of organisms isolated from ear and nasal swabs were 64 and 22, respectively. Staphylococcus aureus was the most common organism isolated from both ear (51%) and nose (65%), followed
by Pseudomonas (27% in the ear and 20% in the nose). More than one organism was isolated in four
ear swabs and two nasal swabs.
Table 6
Microbiological organisms found in ear and nasal swabs
|
Organism
|
Ear swab
|
Nasal swab
|
|
Staphylococcus aureus
|
38
|
16
|
|
Pseudomonas
|
16
|
4
|
|
Klebsiella
|
4
|
1
|
|
Proteus
|
2
|
1
|
|
Escherichia coli
|
3
|
0
|
|
Nonfermenting gram-negative bacilli
|
1
|
0
|
|
No organism
|
73
|
112
|
Discussion
COMMD is one of the most common causes of conductive hearing loss in the tropical
developing nations. The most important factor in the evolution of this disorder is
supposed to be the Eustachian tube dysfunction. Patients with chronic ear disease
frequently have coexistent sinonasal pathology, which can trigger the middle ear problems
secondary to dysfunction of the Eustachian tube.
The relationship between sinonasal disease foci and COMMD is complicated, and even
today it remains poorly understood. This understanding is crucial not only for the
cure of middle ear disease but also for the prevention of its recurrence. Unfortunately,
the demarcation between anatomical variation and pathological disease is narrow and
poorly defined in many structures in the sinonasal region. What constitutes an active
pathological focus in the nose with regard to DNS, concha bullosa, and a few other
anatomical variations is difficult to identify. These so-called anatomical variations
in the nose can become pathological at times or indirectly contribute to some other
pathology and hence transform into an actual “contributing” predisposing focus. However,
the remedial surgery for these foci is controversial and justified mostly in the presence
of symptoms linked to the focus. Foci in the nose and throat can become active and
inactive at various times. Hence, they may not appear and present as a disease focus
at the point of time of DNE. Even though a disease focus may not appear to be active
and pathological at the time of DNE, it could have been active enough in the past
to have triggered and sustained suppurative otitis media up to the point of chronic
perforation syndrome.
In our own study[2] comprising 187 ears with complicated and uncomplicated COMMD, a contributing disease
focus in the nose or throat was found in 70.96% of complicated cases and in 84% of
uncomplicated cases, but its presence did not increase the risk for complications.
In yet another study[1] of ours involving 68 patients with COMMD, we found that most of surgical failures
in tympanoplasty had a reactivated, predisposing focus in the nose and throat that
included persistent adenoid, sinusitis, nasal polyp, allergic rhinitis, and atrophic
rhinitis.
The covariation between ear infection and tonsillitis, sinusitis, and atopic diseases
was studied in 1996 by Kvaerner et al.[3] They found a clustering tendency among the upper respiratory tract infections.
In 2011 Yeolekar and Dasgupta[4] studied the influence of sinonasal disease on the middle ear condition. Out of 100
COMMD cases, 80 had DNS. Significant improvement of middle ear disease was found in
84.53% ears after septal correction, 82.35% ears after treatment of sinusitis, and
76.92% ears after polypectomy.
Improvement of middle ear pathology following septoplasty was noted by Grady et al[5] in 1983. Of the 75 septoplasty cases reviewed, 13% had associated middle ear pathology,
and 70% among these patients showed significant improvement of their ear disease following
septoplasty.
In 1983 Van Cauwenberge et al[6] studied the relationship between nasal and middle ear pathology in school going
children. They found a well-defined influence of septal deviation on middle ear status.
In our study, significant association was found between DNS and COMMD. Seventy seven
percent of cases and 63% of controls had DNS that was comparable with the above studies.
In the presence of DNS, there was two times increased risk of developing COMMD. Significant
association was also found between ITH, bullous concha, and COMMD.
Güçlü et al[7] evaluated nasal airways by objective methods in chronic otitis media. They found
significantly higher nasal airway resistance in chronic otitis media cases than control
group. There was no statistical difference between the measurements on each side in
unilateral chronic otitis media.
In our study, no significant association was found between sides of COMMD and DNS
or side of ITH. DNS does not cause Eustachian tube dysfunction due to mechanical obstruction,
but it causes pressure changes in nasopharynx and causes functional obstruction. As
the nasopharynx is one cavity, whichever side the septum is deviated, it will cause
pressure changes in nasopharynx and can cause disease in either ear. Other mechanism
may be the compensatory ITH on the side opposite to DNS. In our study 77 patients
had DNS, out of whom 43 (56%) had ITH.
Singh and Arora[8] in 1977 in India studied 100 patients in the age group 4 to 16 years, who were divided
into three groups: 25 normal patients without any adenoid hypertrophy symptoms or
ear discharge, 25 patients with adenoid hypertrophy symptoms, and 50 patients with
COMMD. They compared the mean adenoid mass area, mean bony nasopharynx, and the ratio
between these areas. They found that in adenoid hypertrophy with COMMD, the ratio
of adenoid mass area to the bony nasopharynx was more than 50% and concluded that
adenoids were etiological in COMMD and advocated their removal. de Aquino et al[9] in 2007 studied 30 patients with chronic otitis media. Nasal endoscopy was done
to look for the pharyngeal end of the Eustachian tube. They found that 33% had modified
pharyngeal ostium, and among the modified ostiums, 19% had tubal tonsil hypertrophy.
In our study 39% of cases and 6% controls had tubal tonsil hypertrophy, and the association
was found to be extremely significant. In presence of tubal tonsil hypertrophy, there
was 10 times increased risk of developing COMMD. The location of the tubal tonsils
logically suggests that a potential inflammation obstructs the proximal end of the
Eustachian tube and in turn causes negative middle ear pressure and influx of nasopharyngeal
secretion into the middle ear.
No significant association was found between sinusitis and COMMD, not in agreement
with other studies like Brook et al[10] and Mills et al.[11] It may be because our study population had less cases of sinusitis and it was equally
present in controls too.
When one, two, and three foci were compared with no focus ([Table 3]), there was an increase in odds ratio with an increase in the number of foci (dose
response relationship), which probably hinted toward causation. The other findings
in this study that supported causation included
-
Very few cases of COMMD did not have any sinonasal predisposing disease focus. This
was truer with bilateral COMMD. There was only one case of bilateral COMMD without
a focus.
-
There was a temporal relationship between presence of focus and development of COMMD.
-
Very strong association existed between certain foci such as tubal tonsil hypertrophy,
adenoid hypertrophy, and COMMD.
Though many previous studies by Yeolekar et al[4] and Grandy et al[5] concluded that surgical correction of DNS improved middle ear disease, none of studies
mentioned whether it was isolated DNS or with other risk factors.
Rao and Reddy[12] in 1994 studied 120 cases of chronic suppurative otitis media and found S. aureus (42.5%) as the predominant organism, followed by Pseudomonas (21%) and Proteus species (18.33%). A single pathogen was isolated from 68.52% cases and mixed growth
from the rest.
Baruah et al[13] in 1972 in their study found out that the predominant organism was S. aureus (33.98%), followed by Pseudomonas (25%) and Proteus species. They compared the nasal and ear swabs and concluded that correlation between
the organism present in the nasopharynx and throat was much better in acute suppurative
otitis media and poor (15%) in chronic suppurative otitis media.
Grewal et al[14] in 1982 studied 50 cases of chronic suppurative otitis media. Bacteriological study
of the nasopharynx and ear was done and compared. They could not demonstrate any appreciable
agreement between the organisms isolated from the nasopharynx and ear (6%).
In this study too, no agreement was found between flora of the nose and ear. Same
organism in nasal and ear swabs was demonstrated in only eight (13%) ears. These results
were comparable with the above studies.
Conclusion
Sinonasal predisposing foci play a complex role in the pathogenesis of COMMD. A significant
proportion of these foci remain clinically silent and undiagnosed. Also, most (91%)
of the COMMD cases with unilateral disease have some or the other predisposing focus
and more so (97%) in cases with bilateral disease. As the number of foci increases,
the risk of developing COMMD also increases substantially. The chance of finding a
potential sinonasal focus is much more in bilateral than unilateral COMMD. There is
a significant association between tubal tonsil hypertrophy, adenoid hypertrophy, DNS,
ITH, bullous concha, and COMMD. They also pose a risk factor for the pathogenesis
of COMMD. Hence, every case of COMMD must undergo investigations such as DNE to discover
these foci. There is no association between the sides of focus (DNS and ITH) and of
COMMD. The flora in the sinonasal region and COMMD are not the same in most cases.
In the background of all these revelations, we recommend that symptomatic sinonasal
foci be adequately treated before surgically treating COMMD.
