AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 5 ( 2 0 14 ) 32 93 3 1

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Upper airway obstructions and chronic otitis

media: A clinical study,

Ahmet Ural a,, Amir Minovi b , Beng obanolu a

a
Department of Otorhinolaryngology, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
b
Department of Otorhinolaryngology, School of Medicine, St. Elisabeth Hospital, Ruhr University, Bochum, Germany

ARTI CLE I NFO A BS TRACT

Article history: Purpose: To investigate if pathologies causing upper airway obstructions are correlated with
Received 6 November 2013 chronic otitis media.
Materials and methods: One hundred fourteen patients with chronic otitis media and 114
healthy controls were enrolled in this study. Nasal septal deviation, Friedman and
Mallampati scores were assessed for upper airway obstructions. Chronic suppurative
otitis media was classified into tubotypmanic (n = 80) and atticoantral (n = 34) subtypes.
Number of patients with septal deviation with a convexity to the same side as the affected
ear in each CSOM subgroup was compared with chi-square test. The mean Mallampati and
Friedman scores in tubotympanic disease group, atticoantral disease group and healthy
controls were compared using KruskalWallis test.
Results: Septal deviation occurred more frequently on the same side of ear pathology in
patients with tubotympanic chronic suppurative otitis media (p = 0.0005). Such a difference
was not observed between the controls and patients with atticoantral chronic suppurative
otitis media (p = 0.718). No significant difference was noted between patients and controls in
terms of Mallampati and Friedman scores (p = 0.602 and p = 0.836, respectively). Subtypes of
chronic suppurative otitis media were not different from each other in terms of Mallampati
and Friedman scores either (p = 0.718 and p = 0.708).
Conclusion: Our results indicate that septal deviations may commonly occur on the same
side with chronic otitis media. Therefore, septal deviations must be carefully investigated
during the preoperative assessment of patients with CSOM. Elucidation of any possible
causal relationship calls for further trials in larger series.
2014 Elsevier Inc. All rights reserved.

1. Introduction by perforation of the tympanic membrane and discharge [1].

Despite the improvements in patient care and medical
1.1. Purpose technology, medical and surgical treatment options for
CSOM still have substantial failure rates [1].
Chronic suppurative otitis media (CSOM) is a chronic inflam- Septal deviation (SD), palatine tonsil hypertrophy (PTH),
mation of the middle ear and mastoid mucosa accompanied and enlargement of base of the tongue (EBT) are common

The authors declare no competing interest.

No financial support was received for this paper.

Corresponding author at: Department of Otorhinolaryngology, School of Medicine, Karadeniz Technical University, Kalkinma Mah. 61080,
Trabzon, Turkey. Tel.: +90 505 273 06 26; fax: +90 462 325 05 18.
E-mail address: ahmetural2001@yahoo.com (A. Ural).

0196-0709/$ see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjoto.2014.01.012
330 AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 5 ( 2 0 14 ) 32 93 3 1
causes of upper airway obstructions. To our knowledge, the
association of upper airway obstructions with tubotympanic and
atticoantral subtypes of CSOM had not been studied up to now.
A few postulates had been speculated on the association of
SD with CSOM. Septal deviation can interfere with Eustachian
tube function and therefore may not only be involved in CSOM
but also may worsen surgical outcomes. Inflammatory disor-
ders of middle ear are suggested to be related with inadequate
ventilation through Eustachian tube (ET). In other words,
pathological processes involving nasal cavity and paranasal
sinuses may disturb ET function [2]. The decrease in air influx
through Eustachian tube may lead to diminished aeration of
middle ear cavity. This may be the initiation of subsequent
reactions contributing to the development of chronic otitis
media. Septal deviations may cause tubal diysfunction and
middle ear depression subsequently. Similarly, correction of an
SD may reduce the tubal opening pressure and can interrupt the
process leading to CSOM [2]. Many authors believe that nasal
surgery should be performed prior to tympanoplasty for
patients with CSOM, since nasal surgery can provide proper
Eustachian tube function and help to achieve more satisfactory
outcomes from middle ear surgery consequently. On the other
hand, a septoplasty before tympanoplasty cannot be recom-
mended routinely to all patients with CSOM and SD. It is
suggested that ET tube function must be assessed to decide the
necessity of nasal surgery before tympanoplasty [3]. However, to
our knowledge a separate assessment for tubotympanic and
atticoantral subtypes of CSOM and SD had not been performed
in the literature.
Palate and the base of tongue are two common locations for
upper airway obstructions. Friedman and Mallampati scores are
two measures developed to scale the degree of obstruction at
these locations [4,5]. Involvement of paratubal muscle function
in PTH and EBT may be involved in pathogenesis of CSOM due to
possible disturbance of ET function [6,7]. Therefore, we aimed to
investigate if patients with PTH and EBT of tongue were more
likely to suffer from CSOM.
All in all, this study was performed to investigate any
correlation between upper airway obstructions (such as septal
deviation, hypertrophy of the palatine tonsils, and enlargement
of the base of the tongue) and chronic suppurative otitis media.
2. Methods
This prospective study was conducted in Karadeniz Technical
University, School of Medicine, Department of Otorhinolar-
yngology and Ruhr University, School of Medicine, St.
Elisabeth's Hospital, Department of Otorhinolaryngology
between December 2009 and January 2011. This study was
approved by the local institutional review board (report no.
2009/72) and was performed in accordance with the principles
of the Helsinki Declaration. Written informed consent was
obtained from all patients prior to involvement in the study. In
this study, 113 patients with chronic otitis media (male,
female) and 114 controls (male, female) were assessed in
terms of SD, PTH and EBT. Patients with bilateral CSOM, and
those with a history of nasal, middle ear or oropharyngeal
surgery were excluded from this study. Septal deviation was
assessed via anterior rhinoscopy, and nasal endoscopy. Three
groups were formed with respect to the assessment for septal
deviation: i) convexity to the same side with affected ear, ii)
septal deviation with convexity to the other side than the
affected ear, or iii) no septal deviation. Friedman and
Mallampati scores were derived from oropharyngeal exami-
nation findings [4,5].
Septal deviation was diagnosed via anterior rhinoscopy
and nasal endoscopic examination. In addition, temporal CT
scans allowed visualization of the axis of the nasal septum.
Chronic suppurative otitis media patients were subdivided
into two subgroups with respect to otomicroscopy and
temporal bone computerized tomography findings: i) tubo-
tympanic disease and ii) atticoantral disease [6]. These sub-
groups were compared in terms of occurence of septal
deviation, Mallampati scores and Friedman scores. Results
for septal deviation were compared using chi-square test,
whereas KruskallWallis test was performed for the compar-
ison of Mallampati and Friedman scores.
3. Results
The ear disease was unilateral in all cases included in the
study. Only 50.4% of patients (57/113) complained of subjec-
tive nasal dyspnea. The ear disease was more frequently (101/
113, 89.4%) encountered on the same side of septal deviation.
In CSOM group, septal deviation with its convexity to the
same side as the affected ear was more likely to occur (p =
0.0005). No statistically significant difference was observed
between the CSOM group and controls in terms of Mallampati
and Friedman scores (p = 0.650 and p = 0.714 respectively).
Within CSOM group, no difference was observed between
tubotympanic and atticoantral subgroups with respect to
Mallampati and Freidman scores (p = 0.602 and p = 0.836
respectively). Septal deviation was statistically significantly
more common in tubotympanic-type CSOM patients than in
atticoantral-type (p < 0.0001).
4. Discussion
It is known that ET dysfunction in correlation with adenoid
vegetation, and allergy may lead to recurrent otitis media or
otitis media with effusion. it had been reported that most
important prognostic factor for CSOM in children was
recurrent episodes of otitis media with effusion [1]. Contribu-
tion of the nasal and oropharyngeal problems to pathogenesis
of CSOM had not been fully understood yet. Even moderate
SDs had been reported to have unfavourable effects on ET
function and more negative middle ear pressures were
detected in these patients compared to those with straight
nasal septum [8]. In another study, blockage of a nasal passage
had resulted in changes in epithelium and secretions of
middle ear mucosa in rats [7,9]. Our findings are similar with
these data, but a septoplasty should not be suggested
routinely to all CSOM patients with a SD. Our results imply
that SD statistically significantly accompanies tubotympanic
CSOM but not the atticoantral CSOM. Eustachian tube function
can be more important in the pathogenesis of tubotympanic
disease rather than the atticoantral CSOM. Therefore, we state
 AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 5 ( 2 0 14 ) 32 93 3 1
that septal deviations accompanying tubotympanic type
CSOM that are likely to interfere with Eustachian tube
function must be corrected before the middle ear surgery.
In a study conducted on pediatric population, prevalence of
recurrent otitis media was found to be increased in habitual
snorers [10]. Palatine tonsils and lingual tonsils are two
important lymphoid tissues of upper airway which may
proliferate in response to infections. Hence, they may serve as
a reservoir of microorganisms that may contribute to patho-
genesis of recurrent acute otitis media or CSOM. in addition to
that, overgrowth of these lymphoid tissues may be responsible
for disturbance of proper ET function. Upper airway obstruction
due to PTH and EBT may result in hypoxia and hypercarbia. A
suitable medium for anaerobic microorganisms that may
colonize the middle ear cavity will be created and pathogenesis
of CSOM may be trigerred [11]. It is reported that CSOM can be
accompanied by adenoids, tubal tonsillitis, hypertrophic tonsils
or grossly deviated nasal septum [12]. We suggest that upper
airway obstructions may facilitate CSOM through two possible
mechanisms: 1) interfering with ET function (in case of SD) and 2)
facilitating development of upper respiratory tract infection, and
creating a focus of infections. Our results imply that SD is more
commonly detected in patients with CSOM compared to controls.
Septal deviations may interfere with ET function and in selected
cases, septoplasty must be performed a few months prior to the
middle ear surgery. Septal deviations with convexity to the same
side of CSOM gains more importance in these circumstances.
In a study dealing with the relationship between craniofa-
cial morphology and otitis media, a shallower maxilla (a
maxilla that is less capable of moving downward and forward)
was found to be more frequent in otitis media group compared
to controls [12]. This may be attributed to the diminished
nasopharyngeal and oropharyngeal space size in otitis media
group of patients. Narrowing of maxilla may be a consequence
of muscular compression due to open-mouth breathing and
atrophy of nasal cavity [13]. Patients with chronic nasal
obstruction display a typical facial morphology: longer anterior
face, relatively short posterior height, steeper mandibular
plane, malocclusion, small nasopharyngeal depth and dolico-
cephalic head type [13]. Hence we thought that obstructive PTH
and EBT might affect ET function and contribute to the
pathogenesis of CSOM. It is known that oral breathing may
result in altered relationship between mandible, upper maxilla
and related muscles, which in turn leads to weakening of
peritubal muscles. This may cause ET dysfunction, that in turn
permits the access of viruses and bacteria into middle ear cavity
and promotes the pathogenetic process of CSOM [7]. Our results
indicate that upper airway obstructions at the level of palate or
base of the tongue are not likely to result in the dysfunction of
Eustachian tube. We think that that obstructions at nasal level
may be more important in tubotympanic type CSOM pathogen-
esis than obstructive pathologies at palatal or lingual level. In
atticoantral type disease, SDs and dysfunction of ET seem not to
be involved as involved. Further studies can be directed to
investigate the relationship between functioning of the nose
and the Eustachian tube; and the contribution of this relation-
ship to middle ear physiology. It also turned out that obstruc-
tions at palatal or lingual level do not contribute to the
colonization of pathogens responsible for CSOM. According to
our results, SD and ET dysfunction seems to be more important
331
in the pathogenesis of tubotympanic type CSOM. Such an effect
could not be observed in patients with atticoantral-type CSOM.
Limitations of our study are retrospective design, relatively
small size of our series and lack of definite criteria for
elimination of some systemic and local problems which may
affect ET function. In addition, exclusion of bilateral CSOM
patients and S-shaped septal deformities restricts the extrap-
olation of our results to larger series. Due to these limitations,
associations should be interpreted with caution.
5. Conclusion
We observed that septal deviations may commonly occur on the
same side with chronic otitis media. Therefore, septal de-
viations must be carefully investigated during the preoperative
assessment of patients with CSOM. Elucidation of any possible
causal relationship calls for further trials in larger series.
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