INTRODUCTION

Rhinosinusitis is a group of disorders characterized by inflammation of

the mucosa of the nose and the paranasal sinuses .Rhinitis and sinusitis
usually coexist and are concurrent in most individuals thus the correct
terminology is now rhinosinusitis1.
Rhinosinusitis has an incidence of 135 per 1,000 of the population per
year and is the principle reason for physician office visits. 2-5
Rhinosinusitis significantly impacts quality of life measures with decrements in
general health perception, vitality and social functioning comparable with that
observed in patients who have angina or chronic obstructive pulmonary
disease.6
Rhinosinusitis is classified by duration as acute (<4 wk), subacute (4
12 wk), or chronic (>12 wk, with or without exacerbations) , recurrent (4 or
more episodes per year, each episode of 7 days duration).

Classification of Adult Rhinosinusitis 7

CLASSIFICATIO

HISTORY,

DURATION

EXAMINATION

SPECIAL NOTES

Acute

Up to four

The presence

Fever or facial

weeks

of two or more

pain/pressure

Major signs

does not

and

constitute a

symptoms;

suggestive

one Major and

history in the

two or more

absence of other

Minor signs or

nasal signs and

symptoms; or

symptoms.

nasal

Consider acute

purulence on

bacterial

examination

rhinosinusitis if
symptoms
worsen after five
days, if
symptoms persist
for 10 days or
with symptoms
out of proportion
to those typically
associated with
viral infection.

Subacute

Four to < 12

Same

weeks

Complete
resolution after
effective medical
therapy.

Recurrent acute

Four or
more
episodes
per year
with each
episode of
at least
seven days

Same

duration;
absence of
intervening
signs and
symptoms
Chronic

12 weeks or
more

Same

Facial
pain/pressure
does not
constitute a
suggestive
history in the
absence of other
nasal signs and
symptoms.

Chronic rhinosinusitis has been recently classified into: Chronic

rhinosinusitis without nasal polyps and Chronic rhinosinusitis with nasal polyps 8,9.
Chronic rhinosinusitis with or without nasal polyps is defined as an
inflammation of the nose and the paranasal sinuses mucosa, characterized by at
least two or more of the following symptoms: nasal obstruction, nasal discharge
(anterior or posterior nasal drip), facial pain or pressure, and reduction or loss of
smell. Endoscopic examination includes edema and erythema of the middle
meatus mucosa, mucopurulent discharge from the middle meatus, or polyps.
Computed tomography (CT) of the paranasal sinuses should confirm the
presence of mucosal changes within the osteomeatal complex (OMC) and/or the
sinuses10 -12.

Impairment of sinus drainage caused by obstruction of the osteomeatal

complex results in a pathologic accumulation of mucus in the sinuses that may
serve as a medium for bacterial growth. The sinus cavity develops an acidic pH
and an anaerobic environment evolves.
Inflammation of the sinonasal mucosa provokes a further swelling of nasal
and osteomeatal mucosa, damaging of the mucosal layer, impairing of the
mucociliary function and leading to poor or absent sinus ventilation with negative
intrasinus pressure. Thus, the obstruction triggers the development of a vicious
cycle of ciliary dysfunction, retention of secretions as well as mucosal
hyperplasia, which may lead to chronic inflammation 13,14 .
The most common anatomical variations with partial or complete
osteomeatal complex obstruction include severe nasal septal deviations,
hypertrophied and pneumatised middle turbinate (concha bullosa) and atypical
migration of ethmoid air cells during sinus development.
Rhinosinusitis Task Force guidelines has given the combination of major
and minor symptoms to diagnose rhinosinusitis.

Signs and Symptoms Associated with the Diagnosis of Rhinosinusitis 15

Major

Minor

Facial pain/pressure/fullness

Headaches

Nasal obstruction/blockage

Fever (other than acute

Nasal or postnasal discharge/purulence (by

rhinosinusitis)

history or physical examination)

Halitosis

Hyposmia/anosmia

Fatigue

Fever (in acute rhinosinusitis only)

Dental pain
Cough

Ear pain/pressure/fullness
Rhinosinusitis is diagnosed by 2 major
or 1 major and 2 minor symptoms along with:
Endoscopic signs of:
- polyps;
- mucopurulent discharge from middle meatus;
-: or oedema/mucosal obstruction primarily In middle meatus;
CT changes such as irreversible mucosal changes within the osteomeatal
complex and/or sinuses .
Eustachian tube maintains middle ear pressure equal to that of
atmospheric pressure and allows normal respiratory secretions to pass to
nasopharynx. Its function is deranged due to various nasal, nasopharyngeal and
palatal causes. Nasal causes include recurrent rhinosinusitis, deviated Nasal
Septum (DNS), nasal polyps and other nasal masses. Nasopharyngeal causes
comprise of enlarged adenoids, nasopharyngeal angiofibroma, nasopharyngeal
carcinoma. Eustachian tube function may also get deranged transiently during
nasal packing and introduction of nasogastric tube and nasopharyngeal
intubation16 -18.
Chronic Rhinosinusutis is associated with inflammatory changes ranging
from polypoid mucosa to gross nasal polypi. Nasal polypi cause post nasal drip
which is considered to cause eustachian tube dysfunction. The tube is frequently
involved in different pathological conditions of the nasal, paranasal and
nasopharyngeal cavities. Therefore, nasal obstruction can alter eustachian tube
function.
Most inflammatory disorders of the middle ear are thought to be due to
inadequate ventilation through the eustachian tube 19. The lymphatics of the

middle ear and eustachian tube course along the posterior-inferior aspect of the
eustachian tube, getting afferent from nasal cavity, paranasal sinuses,
nasopharynx and adenoids. Efferent from plexus terminate in retropharyngeal
lymph nodes. Inflammation and edema in these areas causes obstruction to the
flow, resulting in retrograde obstruction of tympanic and tubal lymphatics
producing tubal dysfunction and middle ear effusion. Although tubal dysfunction
and middle ear effusion may occur simultaneously, but effusion can occur in the
absence of frank obstruction of eustachian tube lumen and development of
middle ear vacuum20.
Given that the eustachian tube and the middle ear cavity also contain the
same epithelial lining as that of nasal mucosa, it is likely that the
pathophysiological processes that give rise to rhinosinusitis will also affect the
middle ear function.
Although the common link between these areas have been realized for
decades21,22, the studies that have examined this interaction 23 between
rhinosinusitis and middle ear function and the effects of any interventions are
few. The extent of the problem and the effect of any treatment are yet to be
studied.
This study will therefore assess the patients of chronic rhinosinusitis with
eustachian tube dysfunction pre and post treatment.

AIMS AND OBJECTIVES

To evaluate the eustachian tube function in adults with chronic

rhinosinusitis.

To examine the impact of treatment (medical or surgical) on eustachian

tube dysfunction.

MATERIAL AND METHODS

After obtaining approval from the college ethics committee at GGSMCH, Faridkot
all patients with chronic rhinosinusitis presenting to the department of
otorhinolaryngology from January 2016 to Dec 2016 and fulfilling the inclusion
and exclusion criteria shall be chosen for the study.
Inclusion criteria

Chronic rhinosinusitis ( with /without polyps

)as defined above and

present for atleast 12 weeks (includes subgroup of allergic fungal

rhinosinusitis.

Age between 15 to 50 years.

Exclusion criteria

Age less than 15 years and above 50 years as adenoid hypertrophy and
presbycusis may act as confounding factor respectively.

Patients with pre existing middle ear pathology as CSOM, otosclerosis,

ossicular discontinuity.

Immune deficiency or suppression.

Systemic disease (e.g. cancer, cardiovascular disease).

Chronic rhinosinusitis is diagnosed by 2 major or 1 major and 2 minor

symptoms and with endoscopic signs of polyps, mucopurulent discharge from
middle meatus or oedema/mucosal obstruction primarily in middle meatus,CT
changes such as irreversible mucosal changes within the osteomeatal complex
and/or sinuses.
All patients will be provided with an informed consent and will complete a
detailed questionnaire i.e. SNOT22 questionnaire addressing to the severity of

symptoms.
Each patient will be subjected to full history taking and complete
examination of the nose,ear and throat.

Anterior rhinoscopy with a nasal speculum.

Endoscopic examination:
Technique: Diagnostic nasal endoscopy will be done for all patients at the

time of initial evaluation in the outpatient clinic and the findings will be recorded.
Diagnostic nasal endoscopy is done while the patient is seated in the upright
position and the examiner is standing on his right side. Examination is performed
with the 0 degree wide angle 4mm telescope. The first endoscopical examination
is done before vasoconstrictor application to differentiate between mucosal
disease and anatomical disease. Then the nose is packed with 4 % lignocaine
packs for local anesthesia and vasoconstriction. First the telescope is introduced
along the floor of the nose to the nasopharynx. This allows inspecting the
septum, the inferior turbinate, the inferior meatus, the nasolacrimal duct, and the
Eustachian tube orifice. In the second step the telescope is advanced between
the inferior and middle turbinate to the sphenoethmoidal recess. This allows
visualizing the middle, superior, and supreme turbinate with their corresponding
meati. The third step includes visualizing the middle meatus,theuncinate process,
bulla ethmoidalis, accessory maxillary sinus ostia.

Plain film radiographs of the paranasal sinuses will be done which shows
sinus opacification or reveal an air fluid level .

Computed tomographic (CT) scan, performed in a coronal plane with cuts

of 2 mm or less,

Eustachian tube function of each patient will be measured with an acoustic

impedance audiometer and pure tone audiometer in both the ears.

On complete ENT Examination, CT Scan of Para nasal Sinuses, patients
with eustachian tube dysfunction will be categorized into two groups ( group A
and group B).
Group A will comprise patients of chronic rhinosinusitis without nasal polyps
or any anatomical variations like nasal septal deviations, concha bullosa ,
turbinate hypertrophy and will undergo medical treatment only.
Group B will have patients of chronic rhinosinusitis with nasal polyps, nasal
septal deviations, concha bullosa, turbinate hypertrophy and will undergo surgical
treatment (endoscopic sinus surgery, septoplasty).
Patients diagnosed with eustachian tube dysfunction will be further
followed up in the study and their eustachian tube function will be reassessed at
4weeks and 12 weeks post treatment.

REVIEW OF LITERATURE
In 1992,Knight LC24 et al conducted a study in which middle ear pressure
was recorded from 396 ears and aural symptoms inquired of 198 adult subjects
with seasonal allergic rhinitis. Evidence of eustachian tube dysfunction was found
in 24% of subjects. Increased duration of exposure to pollen over a further 2

weeks increased the incidence of eustachian tube dysfunction to 48%. The

development of eustachian tube dysfunction did not correlate with the severity of
nasal symptoms.
In 1993,Low WK

25

et al conducted a study to see the effect

of the

deviated nasal septum on middle ear problems, particularly on the side of nasal
obstruction. This study aims to find out whether middle ear pressure (MEP)
correlates with the degree of nasal obstruction secondary to a deviated nasal
septum, and to examine changes in MEP following septal surgery. Patencies of
the nasal passages (measured with a peak nasal inspiratory flowmeter) and MEP
(measured with a tympanometer) of 55 patients were obtained prior to surgery
and 7.5 (6-10) months post-operatively [median (range)]. Forty patients
completed the study. Results were analysed by linear regression. In the ear on
the side of nasal blockage, MEP was -25.7 +/- 28.4 mm water pre-operatively,
and following surgery increased significantly to -2.9 +/- 30.4 mm water (mean +/SD) (P < 0.001). Pre-operatively, it was inversely related to the difference in
patencies between the two nasal passages (r = -0.32, P < 0.02). Post-operatively,
its improvement correlated with the degree of reduction of asymmetry of airway
patency (r = 0.56, P < 0.001).
In 2000, Lin Chuang Er Bi Yan HouKeZaZhi

26

et al conducted a study on

56 patients to observe the effect of chronic rhinosinusitis on middle ear functions

Eustachian tube function, tympanogram and air hearing threshold were
measured with an acoustic impedance audiometer and pure tone audiometer in
56 patients (112 ears). Eustachian tube function was disturbed in 48.3% cases,
tympanogram was abnormal in 42.0% cases, and air hearing threshold was
increased in 33.9% cases. Comparison of middle ear function between anterior
sinusitis and pan-sinusitis showed significant difference (P < 0.01), middle ear
function between the course of less 5 years and of more than 5 years had

significant difference (P < 0.05).

In 2005,Lazo-Senz JG

27

et al conducted a study to see the effect of

allergic rhinitis on Eustachian tube function and compared it with the control
group. Tympanometry was performed in 130 patients (260 ears), divided into 2
groups: 80 cases with allergic rhinitis and 50 healthy controls. Cases underwent
skin hypersensitivity tests. Cases, age 21.1 +/- 14.9; Controls, age 23.9 +/- 15.6.
Tympanometry of cases showed negative values of peak tympanometric
pressure in both children and adults (P < or = 0.05). Among children under 11
years of age, 15.5% tympanograms showed abnormal curves (13% C curves and
3% B curves); among the control group only normal curves were found (type A).
so, they concluded that allergic rhinitis patients have a higher risk of eustachian
tube dysfunction, particularly during childhood.
In 2011,Karabulut H 28et alstudied hearing function in patients with allergic
rhinitis. Fifty-eight patients with positive skin prick test (Group 1) (116 ears) and
31 subjects with negative skin prick test (62 ears) as group 2 were included. Pure
tone audiometry at 250, 500, 1000, 2000, 4000 and 8000 Hz and immittance
measures, including tympanometry and acoustic reflex tests, were performed in
both groups. There was statistically significant difference between pure-tone
threshold of the group 1 and group 2 at 8000 Hz (p< 0.05). Based on our study,
the patients with allergic rhinitis had better hearing than the control group at 8000
Hz.
In 2014, Duran K 29et al conducted a study to determine the level of middle
ear pressure and alterations in middle ear pressure levels after septoplasty
among the individuals having advanced degree isolated nasal septal deviation.
A prospective randomized study was conducted. The study included 72
adult patients who had severely deviated septum. The middle ear pressure
values at both sides of nasal obstruction and opposite side were determined

using tympanometry before the surgery and at postoperative week 3. The middle
ear pressure values were divided into 2 groups, side of nasal obstruction (group
1) and opposite nonaffected side (group 2). The middle ear pressure values
obtained before and after septoplasty were compared. Before the septoplasty,
the median middle ear pressure value was -54 dPa at the side of nasal
obstruction, and -46 dPa at the opposite side. Three weeks after the septoplasty,
it was -38 dPa at the side of nasal obstruction, and -40 dPa at the opposite side.
The middle ear pressure improved by approximately 30% at the side of nasal
obstruction and by 11% at the non affected side; a statistically significant
decrease was found at the side of nasal obstruction (P < 0.05).They
concludedthat In adult patients with isolated nasal septum deviation, the middle
ear pressure is lower at the side of nasal obstruction,
But it remains within reference ranges. An approximately 30% improvement
occurs in the middle ear pressure after septoplasty.

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