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THE EAR AND SINUSITIS
Anand Shah
Hon. Otologist, Bombay Hospital & Medical Research Centre, Mumbai 400 020.
The nose and paranasal sinuses by their situation are the cause of most ear diseases. Diagnosis and treatment of nasal condition is important for successful treatment of the ear pathology. Proper evaluation of the nasal and sinus condition in relation to the ear pathology can avoid many unnecessary nasal and otological surgeries. Patience in trying out conservative treatment before suggesting surgery is a necessary virtue. Very often, chronic otitis media with effusion (COME) is a sequelae of acute otitis media particularly in a child who persists in sniffing resulting in thick fluid obstructing the eustachian tube (ET) preventing ventilation of the middle ear. 70% of middle ear effusions can be traced to URTI. Untreated, it may also result in sequelae that form the basis of many ear pathologies and there are many questions in its management that are unanswered. The article discusses the author’s views in management of ear diseases. As otologists, our primary aim is resolution of ear pathology and successful outcome in cases of surgical intervention. Very often, overlooking the basic pathology in the nose or sinus may result in compromising these results.Normal functioning of the ear is closely related to, and depends on the health status of the nose, paranasal sinuses and the throat. Upper respiratory tract infection is the commonest cause of otitis media. Pathology in the nose, sinuses and nasopharynx has a very important role to play in the cause, treatment and sequelae of ear disease. The nose and paranasal sinuses by their situation in front of the nasopharynx can affect the functioning of the eustachian tube (ET). Otologists do understand the pathophysiology but need to diagnose and suggest treatment for the underlying cause whenever necessary. It is therefore mandatory for every otologist to be able to carry out a good diagnostic nasal endoscopy. As otologists, our primary aim is resolution of ear pathology and successful outcome in cases of surgical intervention. Very often, overlooking the basic pathology in the nose or sinuses may result in compromising these results.
Pathophysiology
Politzer first suggested abnormal function of the ET as a cause of ear pathology more than a 100 years ago. The exact mechanism could be in one of the three possible ways. [1] ET dysfunction or blocking resulting in negative pressure and fluid accumulation. Nasal obstruction followed by sniffing results in high negative middle ear pressure. [2] Followed by swallowing, this results in Toynbee phenomenon pushing the secretions up the ET. [3] Vigorous nose blowing with increased nasopharyngeal pressure resulting in pushing the postnasal secretion up the ET.Although most literature refers to sinusitis and upper respiratory infection as a cause of otitis media, we need to look at specific aetiological causes when discussing treatment. Other than symptoms and signs relating to the nose, symptoms that require nasal investigation, are unexplained headaches or a past history of chronic nasal problems.
Treatment
The treatment of the nasal condition is rarely discussed in detail, when discussing management of ear diseases. It is usually in the form of "treat the U.R.T.I".The first line of treatment would be a ten days course of Amoxycillin with antihistaminics and nasal decongestants. It is difficult to lay down clear-cut time frames or definite guidelines for treatment of the nose. The nose, tonsil and adenoid need to be treated on their own merit. Surgery is considered for the nose or throat only if the patient has definite symptoms and the ear fails to show expected improvement or has recurrent problems.
Functional endoscopic sinus surgery (FESS) could be advised if conservative management with medical line of treatment and antral washouts fails, and nasal symptoms persist in a case of chronic sinusitis. If the patient has no nasal complaints or signs in the form of nasal obstruction and the ear is dry and can be maintained as such, then even if the CT scan shows extensive mucosal changes, direct treatment of ear pathology without FESS may be contemplated. The most important aim of nasal surgery when undertaken should be to relieve nasal obstruction and if the airway can be maintained well, nasal surgery is unlikely to be necessary.
Sinus disease and active upper respiratory infection can result in various ear conditions, the commonest of which is otitis media with effusion. Untreated it may result in sequelae that form the basis of many ear pathologies. It also has many questions in its management that are unanswered.
1. Otitic Barotrauma
The primary function of the ET is to ventilate the middle ear and maintain the same gas pressure in the middle ear as the surrounding atmosphere. In the presence of respiratory infection or chronic ET dysfunction, any sudden change in atmospheric pressure as may occur in flying or diving, may result in severe negative pressure in the ear. The patient presents with pain and blocking in the ear which may even be accompanied by tinnitus or vertigo. On examination, there is mild congestion of the tympanic membrane (TM) with retraction and occasionally haemotympanum or serous effusion. In a crying child it can be mistaken for acute otitis media with effusion (AOME). Ear microscopy confirms the diagnosis. Treatment is basically to control the URTI and improve middle ear ventilation by the valsalva manoeuvre or occasionally politzerisation. In case of recurrent problem it is necessary to treat the nose or throat more aggressively and may require restricting activities that result in acute pressure changes.2. AOME
This is the next stage resulting from ET dysfunction usually following viral URTI. It is more common in children who have a shorter and more horizontal ET with a flaccid cartilage. Sniffing in presence of a blocked nose followed by swallowing resulting in Toynbee’s phenomenon with pushing of secretions up the ET appears to be a very important cause. Forceful blowing of nose in presence of infection is the more likely cause in adults.Severe pain in the ear accompanied by fever in presence of rhinitis is generally the rule. Ear microscopy shows the presence of a congested and bulging TM. Differential diagnosis can be viral myringitis bullosa.
Here again the treatment is medical with a course of antibiotics and decongestants. It is important to follow the patient till the ear has cleared completely, particularly in case of a child where the possibility of the fluid persisting as chronic otitis media with effusion (COME) is very high.
3. COME
Very often, chronic otitis media with effusion (COME) is a sequelae of acute otitis media particularly in a child who persists in sniffing resulting in thick fluid obstructing the ET preventing ventilation of the middle ear. 70% of middle ear effusions can be traced to URTI. There are many possibilities put forward for its frequent occurrence.i) It may be that better diagnosis and awareness has resulted in more cases being identified.
ii) Use of antibiotics early in the disease could cause control of symptoms and partial control of disease.
iii) Chronic infection may be responsible.
iv) Post inflammatory alteration in middle ear mucosa and ET with goblet cell metaplasia and hyper secretions.
The diagnosis in children is very often without symptoms diagnosed on a routine visit for recurrent URTI or recurrent AOME with earaches and occasionally deafness. Adults complain of deafness, autophony or fluctuant hearing loss if the ear is partially full with fluid. Clinical examination of the nose may be normal. Ear microscopy shows presence of fluid behind the TM with reduced or no mobility on siegelization. Management consists of preventing sniffing and establishing ventilation with valsalva (forced expiration with glottis and nose closed) or if necessary politzerization (inflation with Politzer bag with nozzle in the nose and air pushed when the patient swallows). I am a strong advocate of sensible use of politzerization to clear COME. There are cases where a block of few weeks clears up by one successful politzerization. Politzerization opens the block resulting from thick secretions. Antibiotics may be necessary if the ventilation is not possible or nasal obstruction or URTI persists. Amoxycillin, 2nd generation cephalosporins, or erythromycin are preferred antibiotics.
If the fluid persists in absence of active sinus or tonsillar infection, I believe a short course of steroid gives excellent results. Though there is no general consensus on the use of steroids, Rosenfeld has shown 3.6 times better clearance with steroids in a controlled trial. [4] In carefully selected patients, a reasonable trial of antibiotics and politzerization yields excellent results in a high percentage of patients. The risk of side effects due to a onetime use of steroids for a short period is also negligible. Use of Otovent in children to encourage them to learn blowing their nose and inflate the ears is also useful in clearing the ear and preventing recurrences.
Surgical treatment in the form of myringotomy with or without a grommet is to be reserved for children where
a) Tympanic membrane shows signs of permanent changes with thinning or retraction
b) Fluid that persists bilaterally for more than three months (as this results in deafness and can affect progress). In case of unilateral fluid, if there are no signs of permanent changes in the tympanic membrane, the child can be observed.
c) If the child needs tonsil or adenoid surgery on their own merit and has persistent fluid at the time of surgery, it would be advisable to take advantage of anaesthesia and do a myringotomy. A grommet should be introduced if the fluid aspirated is thick. Maw [5] has shown that 33% of patients improve after tonsil and adenoid resection (TAR). I believe that if decision for tonsil or adenoid resection is taken on basis of complaint related to these structures rather than presence of OME, the percentage of cures of OME following TAR will be much higher. Unfortunately this type of study is extremely difficult and hence has not yet been done.
Adults rarely need a myringotomy if treated well as described earlier. When needed, it tends to be required repeatedly in a large percentage of patients, as very often the causes are less amenable to treatment.
a)Following carcinoma nasopharynx before or after treatment with irradiation
b)Kartagener’s syndrome due to mucociliary failure
c)Obstructed ET
d)Untreated chronic sinus infection and polypi, can be done at the time of FESS
e)Permanent mucosal changes in middle ear and mastoid
f)Idiopathic
Whenever a grommet is introduced, it is essential to follow-up the patient till the grommet extrudes, and ventilation of the ear is established. This is done to ensure that the benefit is not short lived, as the purpose of grommet is to ventilate the ear and prevent sequelae till such time that the primary aetiological factor is well controlled. It may have to be repeated wherever primary aetiological factors persist e.g. in cleft palate patients.
Adhesive Otitis Media
This is an enigma, and once established is difficult to treat. It is probably the result of an unresolved glue ear resulting in a thick adherent tympanic membrane. Whenever undertaken for surgery, the ET is usually found to be anatomically patent but the probability of re-establishing ventilation and improving hearing is very low. It is generally recommended to use Hearing Aids in bilateral cases.Otitis Media with Perforation
The patient generally complaints of recurrent ear discharge (particularly at times of URTI) and deafness. On examination there is a perforation of pars tensa. Though considered safe it is now established that it can produce complications in a small percentage of patients.Small perforations may close spontaneously or with the help of repeated chemical cauterisation, larger perforations will need surgical closure. It is important to treat the nose and sinuses adequately before the perforation can close spontaneously or surgical closure is recommended. The ear should be cleaned under microscope followed by use of oral and topical antibiotics to achieve a dry ear. Surgery is preferred in dry state. Closure of perforation using temporalis fascia and underlay technique for graft placement, with ossiculoplasty if need be, is the preferred method. In children tympanoplasty is recommended after control of tonsil and adenoid, and should be done early in bilateral cases with more than 30 dB conductive deafness.
Otitis Media with Cholesteatoma
Recurrent ear discharge, with deafness is usually the presenting symptom. There is either an attic retraction with cholesteatoma or postero-superior retraction of pars tensa with cholesteatoma. Granulation tissue at the edge of pocket is commonly observed. Once established, treatment is always surgical though close observation and repeated aural toilet may be done if surgery is refused or contra-indicated.Surgery is in the form of an atticotomy with canal wall reconstruction in cases of small cholesteatoma, or open cavity with reconstruction of the middle ear in cases of large cholesteatoma. Staging by using silastic in the middle ear may be necessary in presence of extensive middle ear disease if good hearing improvement is to be achieved. It is particularly mandatory that nose and sinus infection be well controlled if extrusion of silastic is to be avoided in a large percentage of cases.
Conclusion
Diseases of the nose and paranasal sinuses are the main aetiological causes of most ear pathologies, particularly otitis media. Treatment should therefore be primarily for the cause whenever possible. Good control of this will result in cure of many ear diseases. It is my firm belief that success of middle ear surgery is as much if not more dependent on good control of nasal conditions prior to surgery, as on the technical expertise of the surgeon. Most surgeons will improve their results significantly if they paid extra attention to these factors. The ET is a very most important structure with a highly complex physiological function and the exact nature of its failure is still a cause for future research. For the present, ET dysfunction as the cause of otitis media would suffice. On a practical front, a blocked nose with sniffing appears to be the most common cause. Conservative treatment should be given a proper trial before surgery is contemplated in cases of OME. Patience is the key in successful conservative treatment of OME. Routine use of steroid is to be avoided in these cases but when used after other modes of treatment have been tried, it gives excellent results and is to be recommended. Surgery is to be advised after due attention is paid to causative pathology and when definite indications exist. Each patient has to be treated on an individual basis to re-establish normal anatomy and physiology for best functional and long lasting results. This in my opinion, is the most important reason why treatment of ear diseases is such an interesting and challenging field.
REFERENCES
- Politzer A, A Textbook of Diseases of the Ear. Philadelphia Henry C. Lea’s Son. 1883; 107
- Magnusson B, On the origin of the high negative pressure in the middle ear space. Am J Otolaryngol 1981; 2 : 1-12.
- Jorgensen F and Holmquist J, Toynbee phenomenon and middle ear disease. Am J Otol 1984; 5 : 291-294.
- Rosenfeld RM, Mandel EM, Bluestone CD, Systemic steroids for otitis media with effusion in children. Arch. Otolaryngol, Head Neck Surg 1991; 117 : 984-989.
- Maw AR, Age and adenoid size in relation to adenoidectomy in otitis media with effusion. Am. J. Otolaryngol 1985; 6 : 245-248.
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