Eustachian tube dysfunction, a journal Club presentation

Eustachian tube dysfunction in patient of allergic rhinitis

1. Prevalence of Eustachian Tube Dysfunction in Patients with Allergic Rhinitis: An Observational Cross‐sectional Study Published by Wolters Kluwer - Medknow 29 feb 2024 Journal of Marine Medical Society Department of ENT, AFMC, Pune, Maharashtra, India

2. IntroductIon Allergic rhinitis ( AR ) is defined as inflammation of the nose that results due to overreactivity of the immune system in response to allergens present in the environment. The disease may be labeled as mild to severe depending on symptomatology and it reduces the productivity and affects the social life of the patient. The symptomatology includes nasal itching, repeated episodes of sneezing, nasal congestion, and rhinorrhea .

3. The prevalence of AR is about 20%. It may lead to disturbed sleep, decreased output at the workplace, and the inability to concentrate in studies for the students. The disease may be seasonal or perennial and may be associated with triad of diseases such as allergic conjunctivitis, bronchial asthma, or atopic dermatitis as a result of Type 1 hypersensitivity reactions.

4. It is generally triggered by common household allergens such as dust mites, pollens, or fungal molds. There may be a genetic predisposition which may contribute to the development of allergies. The mechanism of action of allergies includes IgE antibodies attaching to the allergen and thereby releasing histamines from mast cells.

5. Routine hematology and other blood investigations are seldom important. L ong‐standing AR in certain predisposed individuals leads to polyp formation, and if the facilities of diagnosis and management are not available, it could lead to a preventable aggravation of the relatively easily treatable disease. AR is divided into mild and moderate to severe on the basis of severity of symptoms andquality of life indices. The social impact and quality oflife are more affected by moderate to severe AR than mild AR

6. The Eustachian tube (ET) should function optimally to equalise pressures and maintain healthy middle ear conditions. ETdysfunction (ETD) is the most common condition associatedwith AR. T he symptoms of ETD are masked by the nasal symptoms. The persistent nasal allergy causes chronic ETD, which may require medical treatment or intervention in the form of balloon dilatation of the tube.

7. The investigations available to test the function of ET are tympanometry , Valsalva maneuver, Politzer’s test, Williams test, Toynbee test, pneumatic otoscopy , and ET catheterization. The study assessed the prevalence of ETD using tympanometry and Williams test in patients with AR with intact tympanic membranes.

8. Inclusion criteria All consenting patients of AR age above 18 years Patients with intact tympanic membrane bilateral. Exclusion criteria Patients with coexisting acute otitis media, acute and chronic rhinosinusitis , nasopharyngeal mass, craniofacial abnormality, otitis media effusion (Type B curve), and postadenoidectomy cases were excluded from the study. Once the patients were enrolled for the study, a thorough history and physical examination was done.

9. The diagnostic criteria for the diagnosis of AR consisted of two or more of the following symptoms for >1 h during most days (at least 4 out of 7 days) of the week for 4 weeks. Watery rhinorrhea . Paroxysmal sneezing . Nasal obstruction. Nasal pruritus . ENT examination including nasal endoscopy, tympanometry , and Williams test was carried out for all patients .

10. Tympanometry and Williams test The patients were seated comfortably in the impedance audiometer room for 10–15 min and the procedure was explained to them in detail. Tympanometry test was done and was classified as type A (normal), type B (fluid in the middle ear), and type C (significant negative middle ear pressure).

11. The patients with type B curve were excluded from the study (to exclude all patients with middle ear disease). The ET function was then evaluated using AT235 Clinical Audiometer and Williams test was performed . The middle ear pressure was calculated by finding the peak in the tympanogram .

12. Initially, the static middle ear pressure (also called as resting middle ear pressure) was measured (P1). After this, a positive canal pressure of +400 mm H2O was applied and the patient was asked to perform the Toynbee maneuver (negative pressure swallow) and the middle ear pressure was calculated (P2).

13. Finally, a negative canal pressure of −400 mm H2O was applied and the patient was asked to perform Valsalva maneuver (positive pressure swallow) and the middle ear pressure was calculated (P3). In a normal patient, middle ear pressure should become negative on Toynbee maneuver and positive on Valsalva maneuver. middle ear pressure becomes negative on Toynbee, but does not become positive on Valsalva or vice versa, the function of ET is considered to be partially impaired. If the middle ear pressure does not change on both Valsalva and Toynbee, the ET function is completely impaired.

14. Statistical analysis Unpaired t‐test was used to compare the study groups and the association among the groups was extracted with the help of Fisher’s test and Chi‐square test. P < 0.05 was considered statistically significant.

15. results Male‐to‐female ratio was 172 by 230, i.e., more females were participants of the study even though there is no male or female preponderance for AR. Mild AR was seen in 44.5% of cases, while moderate to severe AR was seen in 55.5% of cases. Tympanometry revealed a type A curve in 61.4% of cases, while 38.1% had a type C curve [Graph 1]. 38.1% of cases had ETD present, bilateral were 28.6%, while unilateral were 9.5%.

16. 3.7% of cases had left side dysfunction,while 5.7% had right sided dysfunction [Graph 2a]. Partial dysfunction and complete dysfunction were 22.2% and 15.9%, respectively [Graph 2b]. Smoking history was present in more cases with moderate to severe AR (24.2%), while present in 19% of cases with mild AR even though there was no significant association statistically.

17. dIscussIon ETD is defined as failure of the ET to close or open adequately. The major causes of the ETD are AR , laryngopharyngeal reflux, obstruction of ET by adenoids or any other nasopharyngeal mass, ciliary motility disorders, ET catarrh, and neuromuscular dysfunction. The impedance audiometer was introduced five decades back to assess the ET function and is still a useful tool in diagnosing ETD. Both tympanometry and Williams test are useful to diagnose ETD.

18. The opening of the ET is a passive phenomenon and is evaluated in automatic Williams test using a tympanometer and it helps us to determine middle ear pressure indirectly by measuring the change in peaks during swallowing. Williams test gives us the additional advantage in evaluating partial and complete obstruction of ET.

19. The surgical management of ETD is difficult because of its less accessible anatomical site and few reports for catastrophic consequences such as rupture of internal carotid artery. In our study, we evaluated all patients of AR with both Tympanometry and Williams test. ETD was detected in 38.1% of cases using Williams test and 38.6% of cases on tympanometry (Type C curve). The results with both tests were comparable and statistically not significant.

20. The present study concludes that AR patients have a higher risk of developing ETD and the dysfunction is usually bilateral. In cases of moderate to severe AR , the presence of ETD is more marked in comparison to mild AR. A tympanometry will only provide information regarding ETD, whether present or absent, whereas ET function tests such as Williams test provide us with the information regarding the functionality of ET and severity of ETD. Conclusions

21. By assessing the severity, patients with different levels of ETD can be followed up appropriately. Therefore, it is recommended to evaluate all newly diagnosed cases of AR for ETD using Williams test, which helps in identifying and follow‐up of those patients who are prone to its sequelae like chronic middle ear disease. Further, a repeat evaluation of all these cases with ETD should be done after appropriate medical management of AR.

22. 1) Eustachian tube dysfunction in patients with house dust mite-allergic rhinitis Department of Otorhinolaryngology, Sun Yat-sen Memorial Hospital , china Yun Ma et.al Ma et al. Clin Transl Allergy (2020) Cross reference

23. AR patients, especially those with severe nasal obstruction, could have ETD. The local conditions of the pharyngeal orifices of the eustachian tubes are closely related to the symptoms of ETD. After treatment with nasal glucocorticoids and oral antihistamines, eustachian tube function can significantly improve as nasal symptoms subside. Conclusions

24. 2) Endoscopy Guided Eustachian Tube Balloon Dilation: Our Experiences Santosh-Kumar Swain Iranian Journal of Otorhinolaryngology Sep 2020 Department of Otorhinolaryngology, IMS and SUM Hospital Bhubaneswar, Odisha, India.

25. Endoscopy guided balloon dilatation of eustachian tube is a novel technique to perform minimal invasive eustachian tube dilation for improvement of the ET dysfunction. The objective of the balloon eustachiantuboplasty is to widen the cartilaginous part of the eustachian tube and enhances the physiological functions with minimal or no complications. Conclusions

26. This minimally invasive technique for ET dysfunction is proved to be feasible and safe in the treatment of the ET dysfunction. This is a low risk surgical procedure where postsurgical pain is minimal and patients can return to normal activities following a day.