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ORIGINAL ARTICLE
Year : 2022 | Volume
: 28
| Issue : 3 | Page : 223-227
Status of the mastoid antrum and the eustachian tube function in cases of chronic otitis media
Farhat Khan, Prasad T Deshmukh, Sagar Gaurkar
Department of Otorhinolaryngology, Datta Meghe Institute of Medical Sciences, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
Correspondence Address:
Dr. Farhat Khan
Department of Otorhinolaryngology, Datta Meghe Institute of Medical Sciences, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/indianjotol.indianjotol_64_22
Introduction: Chronic otitis media (COM) is now synonymous with chronic suppurative otitis media, which is not actively used since COM is seldom associated with “the collection of pus.” Acute suppuration of the ear which transcends 6 weeks is considered to be COM which suggests an abnormality of the ear drum. With a prevalence incidence of 1%, Eustachian tube (ET) dysfunction is among the most important factors in the development of COM. Recently, mastoid air cells have been acknowledged as an essential compounding factor for the pathogenesis of middle ear disease. Since ET, mastoid air cell system, and nasopharyngeal mass like adenoids can play a pivotal role in the causation and persistence of COM, the current study will be taken to observe the status of ET, mastoid air cells system, nasopharynx in general, and adenoids in particular in patients of COM. Aim: This study aims to study the status of the mastoid antrum on surgical exploration, the status of ET, and nasopharynx for adenoids in patients of large, subtotal perforation, and posterosuperior retraction pockets (PSRPs). Study Design: This study was an observational, cross-sectional study. Study Setting: All the patients with large, subtotal perforation, and PSRPs visiting the Outpatient Department and Inpatient Department of ENT in Acharya Vinoba Bhave Rural Hospital (AVBRH) between 2022 and 2023 will be studied. Methods: All the selected patients of large, subtotal perforation, and posterosuperior retraction pocket (PSRP) in the age bracket of 15–65 years and satisfying the inclusion criteria will be considered and accrued in this study. We plan to look at a sample size of 50 patients (50 ears). Diagnostic nasal video endoscopy to get insight into ET function, size, and grade of adenoids by grading system given by Cassano et al. and pure-tone audiometry by ALPS AD2000 to know the type and amount of hearing loss will be carried out. Status of the mastoid antrum, the extent of the disease, status of ossicles, and associated abnormalities of temporal bone along with any other incidental findings will be noted intraoperatively. Expected Results: The data will be tabulated, analyzed statistically, and will be discussed in the context of existing research. Conclusion: The purpose of the present study is to help the surgeon have a better insight into the status of the mastoid antrum, ET in cases of large and subtotal perforation, and PSRP and nasopharynx in general with significance to adenoids in patients of COM in rural area.
Keywords: Adenoid hypertrophy, Eustachian tube, large perforations, mastoid antrum, nasopharynx, posterosuperior retraction pockets, subtotal perforations
Otitis media (OM) is a constellation inflammatory disease afflicting the middle ear cleft (MEC) which is complicated as partial or total loss of the tympanic membrane and ossicles and also causes permanent sequelae which manifest as deafness and ear discharge. OM is broadly divided into two subtypes, acute and chronic.[1] Acute OM is defined as instantaneous emergence onset of infection accompanied by one or more signs of acute illness of the middle ear such as inflammation, ear pain, irritability, otorrhea, or/and fever.[2] Occasionally, even with adequate antimicrobial therapy, the disease may fester to chronic suppurative OM (CSOM) characterized by persevering otorrhea from the middle ear surpassing a term of 6 weeks associated with a persistent perforated tympanic membrane.[3]
CSOM is no longer in vogue and is replaced by the term chronic OM (COM).[4] The implication of otorrhea as a compelling cause of infirmity was recognized by Hippocrates in 460 BC who considered it secondary to “suppuration of the brain.”[5]
As the traditional terminology of CSOM tubotympanic and atticoantral has been abandoned, this disease is further categorized into healed COM, COM (mucosal) active and inactive, and COM (squamous) active and inactive. Complications can occur in any instance of CSOM, including those labeled as “safe.” As a result, the term “safe” is insufficient to describe any case of CSOM.[6]
COM is a common condition affecting 0.5%–30% of any community. It is most common in developing countries. Its incidence varies from 0.5% to 2% in developed countries, whereas in developing countries like India, the range is as high as 3%–57%, and the incidence rate is 30% with a prevalence of 16/1000 population in urban and 46/1000 among the countryside.[7],[8]
Age, bacterial and viral exposure, seasonal and environmental variables, maternal smoking, overcrowding, genetic predisposition, innate and adaptive immune status, and hypertrophied adenoids are all factors that contribute to OM.[2]
Reduced hearing is the most dreaded sequelae of COM, leading to a negative impact on a child's scholastic and behavioral growth.
Understanding the pathophysiology and pathogenesis of CSOM is crucial for anticipating the disease's treatment, prognosis, and consequences. The Eustachian tube More Details (ET), mastoid air cell system, and nasopharyngeal mass such as adenoids can all play a role in the etiology and persistence of COM; hence, the objective of this study is to evaluate the condition of the ET and mastoid air cell system in COM patients.
Rationale
Avoiding extensive ear surgery when a satisfactory functional result cannot be expected, as well as the recommendation of such a procedure when a good result can be predicted would indeed be an important improvement in the ethical care of patients in ENT. When searching for ways to improve the long-term surgical success rate for tympanoplasties, we began to explore possible methods of predicting results for this type of operation. Attempts to foretell surgical outcomes in the past have been limited and unconvincing. Holmquist was the first to investigate the association between Eustachian tubal function (ETF), the size of the mastoid air cell system, and postoperative result in patients of COM. We observed ETF and status of the mastoid antrum in the ears with COM before and during tympanoplasty with mastoidectomy hoping that, by assessing and relating these two factors, we could arrive at facts which would help us to predict surgical success or failure. Since there is a need to establish successful relationships between the mastoid air cell system, ET, and nasopharyngeal mass like adenoids as it can play a vice role in the causation of COM due to their proximity and continuity of the mucosal mattress. The current study is thus undertaken to examine the status of the mastoid antrum, ET, nasopharynx in general, and adenoids in particular in patients of COM.
Aim and objectives
Aim
This study aims to study the status of the mastoid antrum, ET function, and adenoid size in cases of large, subtotal perforations, and posterosuperior retraction pockets (PSRPs).
Objectives
To study the status of the mastoid antrum on surgical exploration in patients of large, subtotal perforation, and PSRPsTo analyze the ET function by diagnostic nasal video endoscopy (DNVE) in patients of large, subtotal perforation, and PSRPsTo study and grade adenoids by diagnostic nasal endoscopy (DNE) in patients of large, subtotal perforation, and PSRPsTo correlate the status of the mastoid antrum, ET function, and grade of adenoid enlargement with large, subtotal perforation, and posterior superior retraction pockets. MethodsStudy design
This study was an observational, cross-sectional study.
Study setting
All the patients with large, subtotal perforation, and PSRPsvisiting the Outpatient Department (OPD), Inpatient Department (IPD) of ENT in AVBRH between 2019 and 2022 will be studied.
Study setup
All the patients with COM visiting OPD and IPD of ENT in AVBRH will be studied.
Study size
Sixty patients (60 ears).
Twenty patients – large perforationTwenty patients – subtotal perforationTwenty patients – posterosuperior retraction pocket.Participants
Inclusion criteria
All patients of COM with large, subtotal perforation between the age group of 15–65 yearsAny genderSquamosal COM with PSRPs with/without cholesteatoma.Exclusion criteria
All the patients of OM above 65 years and below 15 years of ageKnown immunodeficiency disorderPatients with SNHLCraniofacial anomalies.Methodology
All the selected patients of large, subtotal perforation, and PSRP in the age bracket of 15–65 years and satisfying the inclusion criteria will be considered and accrued in this study. We plan to look at a sample size of 60 patients (60 ears).
Patients will be comprehensively and diligently examined as per the pro forma enclosed and baseline investigations will be done. Specific investigations like examination of the ear under a microscope with help of KarlKaps D 35614 AsslarEuropastrasse to know more about perforation and retraction, DNVE to get insight into ET function, size, and grade of adenoids by grading system given by Cassano et al.[9] and pure-tone audiometry by ALPS AD 2000 to know the type and amount of hearing loss will be carried out. The mastoid antrum will be drilled and opened, attic and antrum inspected for any pathology, i.e., condition of the mucosa, presence of granulation tissue or cholesteatoma, the extent of the disease, status of ossicles, and associated abnormalities of temporal bone along with any other incidental finding will be noted intraoperatively.
A predesigned pro forma will be used to record the above information obtained by clinical examination, specific investigations, and surgical exploration. Photographic documentation will be done wherever necessary.
IEC clearance from the ethical committee will be obtained.
Statistical analysis
Statistical analysis of the data obtained will be done by Chi-square test.
Scope
Comprehensive and correlative study.
It may influence positively the surgical approach to this entity.
Limitation
Correlation of antrum depth with HRCT needs to be done. Sample size of the patients could be increased.
Implication
This study may help in designing and developing a protocolThis study may bring precision to intervention. Expected OutcomesOur result will show the relation between the type of COM, the status of mastoid air cells, and mastoid antrum disease (normal, edematous, granulation tissue, or cholesteatoma) with its correlation to ET functioning.
DiscussionThe tympanic membrane is one of the most important entities in determining the pathological disease of the ear as its study encompasses the study of the mastoid air cell system, the ET, and even the embryogenesis of the ear, i.e., the routes of aeration. There are various factors like ear infections in childhood to recurrent upper respiratory infections in adults that not only contribute to the formation of perforation or retraction pockets but also affect the outcome of an already formed one.
The WHO defines COM as exceeding 6 weeks of discharge. The infection usually occurs during the first 6 years of life, peaking around the age of two.[8]
A study done by Lakshmi et al. and Shrestha et al. showed a slight female preponderance.[10],[11] Some studies have found males to have a higher and more recurrent episode of OM than females like Teele et al. and Agrawal et al.[12],[13] in which males were 53.6% and females were 46.4%. Differences in sexual preponderance are incidental and have no anatomical factors predisposing either sex to the development of COM.
The WHO study showed that 7.8% of Indians are evaluated to be suffering from chronic ear disease which is significantly higher than the incidence rate of 1.8% in Western countries. In India, the incidence rate is 30% with a prevalence of 16/1000 population in urban and 46/1000 in the countryside.[7],[8] Rural population is affected more than the urban due to a variety of reasons such as illiteracy, lack of awareness, poor sanitation, lack of health facilities, and differences in lifestyle like people in rural India are still taking baths in ponds, rivers, and wash clothes and utensils in the same water. These factors can be attributed to a higher incidence in rural areas.
According to the study by Shaheen et al., more than half of the study samples were from a low-income group where COM was also more prevalent. It also showed that the children, who used to take baths in the pond or river water, were affected more by CSOM, which was statistically significant.[14]
Mastoidectomy is one of the most common otological operations performed today. Indications for mastoidectomy range from the eradication of chronic infection to approaches for various neurotological procedures. Mastoidectomy was first described by Louis Petit in the 1700s, although the concept did not gain wider acceptance until 1958, the cortical mastoidectomy was popularized by William House. This procedure attempted to avoid the common problems with radical mastoidectomy.[15]
Myringoplasty is an operative procedure, in which the reconstructive procedure is limited to the repair of tympanic membrane perforation. Implicit in the definition is that the ossicular chain is intact and mobile, and the middle ear is disease free. There are a number of studies in the literature highlighting the advantages and disadvantages of performing mastoidectomy in the surgical treatment of a mucosal type of COM. Balyan et al. in 1997 did a retrospective study of 323 patients to evaluate the role of mastoidectomy in noncholesteatomatous COM. They observed no statistically significant difference in hearing outcomes when mastoidectomy was done. Similarly, Mishiro et al. in 2001 reviewed 251 cases of noncholesteatomatous COM and found no statistically significant difference between the two groups.[16],[17]
The majority of the patients undergoing mastoid exploration studied by Solanki and Sharma had the presence of granulation tissue in the antrum as the most frequent intraoperative finding (55.07%). The incidence of cholesteatoma and both cholesteatoma and granulations together was (21.73%) and (23.18%), respectively.[18] Yeolekar and Dasgupta suggested granulation (63%) to be more common than cholesteatoma (21%) in unsafe diseases.
In a study by Yeolekar and Dasgupta, out of 50 cases, 18 (36%) each had cholesteatoma and granulation tissue, whereas 14 (28%) had a polyp in the middle ear and mastoid cavity peroperatively.[19]
According to Sharma et al.'s study among 100 patients, on otoscopy, perforation was seen in 80% of cases and retraction pockets were seen in 20% of cases which were most common in the posterosuperior quadrant (PSRP). Large central perforations involving all the quadrants were seen in 50% of cases, whereas 27% had subtotal perforations. COM cases with retraction pockets showed granulations (50%) as the most common findings followed by cholesteatoma (42.9%) in the antrum.[20]
Middle ear ventilation is an important predictor of functional recovery after middle ear reconstruction. The precise role of mastoid aeration is unknown, but it serves as an air reservoir and a surge tank to reduce pressure function. Many researchers have looked into the pattern of pneumatization. According to Wittmack's endodermal hypothesis, proper pneumatization requires a healthy middle ear mucosa, which can be impeded by inflammation or tubal dysfunction, resulting in recurrent middle ear infections and diminished pneumatization in newborns and children.
Sade found an 82.3% correlation between low or nonpneumatized mastoid and squamosal COM, whereas Gomaa et al. found a 60.7% association.[21] Rei et al. found well-pneumatized mastoid in 44%, sclerotic in 50%, and diploic in the remaining 6%.[22] In a study conducted by Sunita et al., HRCT temporal bone revealed pneumatized mastoid in 33.3%, diploic in 3.7%, and sclerosed in 53.7%.[23]
The ET and mastoid process (MP) are strongly linked to middle ear infections, with an incidence of approximately 1% among adults.[4]
The ET is an extension of the dorsal end of the first pharyngeal pouch, stretching from the nasopharynx to the anterior wall of the MEC, whereas the MP is formed from the second branchial arch and forms the MEC's posterior wall. Both structures are vital in aeration and gas exchange in the ear, which is the most significant physiological requirement for normal middle ear function.
Sadé and Ar in their remarkable work describe the MEC as “miniature lung” with an air-filled space that acquires gas “inhalation” through the auditory tube.[4]
According to Siedentop et al.'s study when both good ETF and large mastoid air cell system are present in an ear the anticipated success can be predicted to occur in better than 85% of cases.[24]
Because the ET, mastoid air cell system, and nasopharyngeal mass such as adenoids can all play a role in the onset and progression of COM, the current study will examine the condition of the ET and mastoid air cell system in COM patients.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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