Content uploaded by Catherine Rennie
Author content
All content in this area was uploaded by Catherine Rennie on Jun 17, 2019
Content may be subject to copyright.
ORIGINAL CONTRIBUTION
Investigation of the incidence of Eustachian tube
dysfunction in patients with sinonasal disease*
Abstract
Background: Rhinosinusitis is characterised by inflammation affecting the respiratory mucosa of the nose and sinuses. Since the
Eustachian tube and the middle ear cavity are also lined by the same mucosa, it is likely that the pathophysiological processes
that give rise to rhinosinusitis will also affect these areas. Eustachian tube dysfunction (ETD) is a common condition, but it is often
dismissed as a "minor" symptom in rhinology patients.
Objective: The aim of this study was to determine the frequency of otologic symptoms in patients attending the rhinology clinic.
The seven-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7), a validated disease-specific instrument was used to assess
symptoms with respect to ETD7.
Study design: 119 patients attending the rhinology outpatient clinic completed ETDQ-7, a SNOT 22 and had their PNIF measured.
Results: The results showed a significantly higher rate of ETD (p<0.01 paired t-test) in the rhinology patients (mean score 3.1, SD
1.64) as compared to a control population (mean 1.3, SD 0.3).
Conclusion: Eustachian tube dysfunction is more common in rhinology patients then the general population, and within the
rhinology population. The classification of this as a "minor" symptom of rhinosinusitis should be re-evaluated and the effect of
treatment of sinonasal disease on ETD needs to be investigated.
Key words: Eustachian tube dysfunction, paranasal sinuses, rhinosinusitis, questionnaire
C.E. Rennie1, M. Gutierrez2, Y. Darby1, V.J. Lund1
1 Royal National Throat Nose and Ear Hospital, ENT, London, United Kingdom
2 University of North Carolina, Medical student, North Carolina, USA
Rhinology Online, Vol 1: 85 - 89, 2018
http://doi.org/10.4193/RHINOL/18.050
*Received for publication:
August 12, 2018
Accepted: August 14, 2018
Published: August 19, 2018
85
Introduction
Rhinosinusitis is characterised by inflammation affecting the
respiratory mucosa of the nose and sinuses. The Eustachian tube
and the middle ear cavity are also lined by the same mucosa.
It is therefore, likely that the pathophysiological processes that
give rise to rhinosinusitis will also affect these areas.
Although the connection between these adjacent areas has
been realised for decades, there is a lack of research examining
this interaction and the effects of any interventions. Most stu-
dies in this area focus on otitis media with effusion in children
(1-3).
Eustachian tube dysfunction (ETD) is a common symptom, it is
estimated to have a prevalence of 0.9% in the UK population 4),
however it is often dismissed as a "minor" symptom in rhinology
patients. This may in part be due to the difficulty diagnosing
ETD as its symptoms are often vague and non-specific, also
there is a perceived lack of efficacy of any treatment for ETD. Un-
til recently there has been no consensus on the definition and
diagnosis of this disorder (5,6). The lack of definition of ETD along
with the paucity of outcome measures has hampered our ability
to determine the epidemiology and efficacy of treatments for
ETD.
86
Eustachian tube dysfunction in sinonasal disease
The development of the first international consensus on the
definition, clinical presentation and diagnosis of ETD should
enable better studies of the epidemiology of Eustachian tube
dysfunction, psychosocial impact, and treatment (6).
The Eustachian tube has three main functions:
1. Pressure equalisation and ventilation of the middle ear
2. Mucociliary clearance of secretions from the middle ear
3. Protection of the middle ear from sounds as well as from
pathogens and secretions from the nasopharynx (7,8).
In health the Eustachian tube is normally closed but is pulled
open briefly by the paratubal muscles during swallowing or
yawning, which enables the above functions to take place (9,10).
Disruption of this intermittent opening leads to ETD with the
typical symptoms of ear fullness, ‘popping’ or ‘crackling’, discom-
fort or pain, muffled hearing or tinnitus (5,11).
Over the last 40 years there have been a number of attempts
to develop an objective measure for ETD (12) however, as yet no
single test has been found to be a reliable diagnostic tool (13,14).
The recently developed Eustachian Tube Dysfunction Question-
naire (ETDQ- 7) scores symptoms of Eustachian tube dysfunction
and is currently the only patient-reported outcomes tool to have
undergone initial validation studies (6).
Therefore, in this study we use the ETDQ-7 to determine the
incidence of Eustachian tube dysfunction symptoms in patients
attending a tertiary referral rhinology clinic. The ETDQ-7 is short
and simple to use, and the respondent burden is minimal. It has
been shown to be reliable and valid for the cross-sectional as-
sessment of ETD-related symptoms in adults. We have compa-
red the results in our rhinology population to literature quoted
values for ETD patient and control groups from the validation
studies.
Methods
Patients were prospectively and consecutively enrolled from the
clinical practice of the senior author (VJL) over a 6 month period
in the latter half of the year to minimise effects of seasonal al-
lergy (Appendix). All subjects were outpatients who were refer-
red with chronic rhinologic symptoms (>3months) to a tertiary
referral centre and participated as part of an institutional audit.
All patients included in this study were at least 18 years old. All
had symptoms and signs consistent with a diagnosis of chronic
rhinosinusitis (15) but patients with known otological disease and
previous ear surgery were excluded. Each patient completed
an ETDQ-7, a SNOT 22, a visual analogue score (VAS) for nasal
obstruction, and had their peak nasal inspiratory flow (PNIF)
measured as part of their initial assessment. The ETDQ-7 is com-
prised of seven questions on ETD symptoms each of which is
scored out of 7 for severity over the last month (Table 1). This dif-
fers from the SNOT 22 questionnaire, which scores 22 symptoms
of rhinosinusitis out of 5 over the previous 2 weeks.
Results
A total of 119 patients were enrolled for the study, 65 female
and 54 male, with a mean age of 52. Over half (54%) of the
patients had had previous endoscopic sinus surgery, which is
typical of the tertiary referral practice. There was also a wide
range of pathologies within the patient group also reflecting the
nature of a tertiary referral practice (Figure 1).
The ETDQ-7 results for the rhinology patients were compared to
the results quoted in the literature for control populations and
patients with ETD (Table 2, Figures 2 and 3) (11). The overall ETDQ-
7 score among the 119 rhinology patients was significantly
greater than the score among the literature control group (P <
0.001). The mean (standard deviation) overall score was 2.8 (1.6)
for the rhinology patients, 4.0 (1.1) for the ETD group and 1.3
(0.3) for the control group. The mean individual score for each of
the seven items of the ETDQ-7 was significantly greater for the
rhinology group compared to the control group. As expected
the rhinology patients scored highest on Question 4 of the
ETDQ-7 “ear symptoms when you have a cold or sinusitis?”.
Table 1. Eustachian tube dysfunction questionnaire ETDQ-7.
Figure 1. Distribution of pathology within the rhinology patient group.
87
Rennie et al.
nus surgery (17). Maniakas et al. also confirmed that for most CRS
patients, ETD symptoms will decrease post-endoscopic sinus
surgery to a level comparable with a non-CRS population (16).
The use of the ETDQ-7 has the potential to enhance clinical care
by highlighting the impact of ETD as well as guiding and evalu-
ating appropriate management. Further prospective testing of
patients being treated for ETD may establish the ETDQ-7 in the
assessment of treatment outcomes.
Limitations of this study
A potential confounding factor is that a small number of the
rhinology patients in this cohort had systemic disease with
known otological manifestations, which could bias these results.
As expected higher ETDQ-7 scores were seen in patients with
primary ciliary dyskinesia (PCD), eosinophilic granulomatosis
with polyangitis (EGPA) and immunodeficiency (Figure 4) who
nonetheless were suffering from chronic rhinosinusitis. There-
fore, further analysis was undertaken excluding these patients
and the results still demonstrated significantly higher scores in
the rhinology population as compared to control groups.
In validity studies the optimal total item score cutpoint of ≥14.5
versus <14.5 (for categorising a patient as having ETD) provided
100% sensitivity and 100% specificity. This equated to an ETDQ-
7 mean item score of ≥2.1 to indicate the presence of ETD. 74
of the 119 rhinology patients in this study had total item scores
≥14.5, meaning that 62% of these rhinology patients would be
diagnosed as having ETD based on this outcome measure.
SNOT 22 scores of >28.5 were associated with higher ETDQ-7
scores, which is not surprising as the SNOT 22 has 3 otological
questions pertaining to ear fullness, dizziness and ear pain/
pressure which overlaps with the ETDQ-7 questions 1, 2 and
3. (Table 2) There is also an overlap between Question 4 of the
ETDQ-7 (“ear symptoms when you have a cold or sinusitis”) with
symptoms of rhinosinusitis. The SNOT-22 alone had a moderate
specificity and sensitivity for detecting ETD on validity tes-
ting11, although the ETDQ-7 performed significantly better as a
disease-specific instrument.
VAS scores >5 for nasal obstruction were associated with higher
ETDQ-7 scores and NIPF scores < 80 were also associated with
higher ETDQ-7 scores.
Discussion
These results illustrate that ETD, as manifested by otologic
symptoms, is common in patients attending the rhinology clinic.
This has been confirmed recently in a combined multi-centre
cohort of 131 patients with CRS based on responses to the
SNOT-22 questions on ear fullness and ear pain (16). Therefore,
the classification of ETD as a "minor" symptom of rhinosinusitis
should be re-evaluated.
What remains to be determined is if treatment for sinus
symptoms will improve the symptoms of Eustachian tube dys-
function? An earlier retrospective questionnaire study by Stoikes
et al. suggests the ETD symptoms associated with CRS improve
or resolve in the majority of patients undergoing endoscopic si-
Table 2. Eustachian Tube Dysfunction Scores by Item. SD = standard
deviation. * Literature values given by McCoul et al. (11).
Figure 2. Mean ETDQ-7 scores. There was a significantly higher rate of
ETD symptoms (p<0.01 paired t-test) in the rhinology patients (mean
score 3.1, SD 1.64) as compared to a control population (mean 1.3, SD
0.3). The error bars show the standard deviation.
Item Rhinology
patients
Mean (SD)
Control
Group*
Mean (SD)
ETD
Group *
Mean (SD)
1. Pressure 2.6 (1.8) 1.1 (0.4) 4.3 (1.5)
2. Pain 2.3 (1.7) 1.3 (0.6) 3.2 (1.7)
3. Feeling clogged 2.8 (1.9) 1.2 (0.5) 4.8 (1.5)
4. Cold/sinusitis
problems 3.4 (2.8) 2.2 (1.1) 5.0 (1.6
5. Crackling or
popping 2.8 (2.0) 1.1 (0.4) 4.0 (1.8)
6. Ringing 2.6 (2.1) 1.1 (0.3) 3.2 (2.1)
7. Feeling muffled 3.1 (2.1) 1.3 (0.3) 4.8 (1.5)
Figure 3. Mean ETDQ-7 scores by item.
88
Eustachian tube dysfunction in sinonasal disease
The recent consensus document on ETD recommends that the
diagnosis of ETD be based on the presentation with symptoms
of pressure disequilibrium in either ear, specifically symptoms of
‘aural fullness’ or ‘popping’ or discomfort/pain (6). Evidence of ne-
gative pressure in the middle ear could be supported on clinical
assessment, either by:
1. otoscopic evidence of tympanic membrane retraction and/or
2. tympanogram indicating negative middle ear pressure.
Unfortunately neither in this study nor that of Maniakas et al. (17)
the rhinology patients have not been assessed for evidence of
negative pressure in the middle ear. However, the ETDQ-7 is a
valid and reliable disease-specific symptom score for adult pa-
tients with ETD. The criterion validity for the test was established
by the exclusive presence of normal tympanograms in control
subjects and abnormal tympanograms in subjects with ETD. The
advantage of the ETDQ-7 is that it is quick and easy to adminis-
ter in the clinical setting and is simple for the patients to fill out.
Another limitation of the study related to the ETDQ-7 is that the
questions are based on disease burden and timing of events.
In addition, whether they may be intermittent is not represen-
ted and therefore, the questionnaire may underestimate the
incidence of ETD. Furthermore, there is a possibility of bias by
comparing our patients with historical controls from the United
States rather than providing our own control data.
Conclusion
Symptoms of eustachian tube dysfunction are prevalent in the
rhinology patient population and are often overlooked in sino-
nasal-orientated outpatient consultations. The development of a
consensus on the definition and diagnosis of ETD and its adopti-
on by the ENT community should lead to an improvement in the
diagnosis of ETD and will provide the basis for further research
into the epidemiology and treatment of ETD. The development
and validation of disease specific patient recorded outcome
measures such as the ETDQ-7 allows comparison of the efficacy
of treatments for ETD and an understanding of the interaction
between the nose and Eustachian apparatus could lead to a bet-
ter overall management of our patients.
Key Points
• Symptoms of eustachian tube dysfunction are more com-
mon in rhinology patients then in the general population.
• The ETDQ-7 is a simple easy to use validated disease speci-
fic outcome measure for ETD.
• The classification of this as a "minor" symptom of rhinosinu-
sitis should be re-evaluated.
• The effect of treatment of sinonasal disease on ETD needs
to be investigated.
Authorship contribution
MG, YD and CR were involved in the design and data collection
for the study, VJL designed the study and edited the manuscript
and approved the final version. CR processed the results, drafted
the manuscript, reviewed the available literature and approved
the final version.
Availability of data and materials
Curated by first author and available on reasonable request.
Conflict of interest
The authors declare that they have no competing interests.
Figure 4. Mean ETDQ-7 score by diagnosis. The number of patients
with each diagnosis is as follows; Polyps (CRSwNP) 69, No polyps
(CRSsNP) 28, EGPA (Eosinophilic granulomatosis with polyangitis) 3,
Immunodeficiency 2 and PCD (Primary ciliary dyskinesia) 1.
References
1. Leo G, Piacentini E, Incorvaia C, Consonni
D. Sinusitis and Eustachian tube dysfunc-
tion in children. Pediatr Allergy Immunol
2007;Supplement 18: 35-39.
2. Hong CK, et al. Effect of paranasal sinusitis
on the development of otitis media with
effusion: influence of eustachian tube func-
tion and adenoid immunity. Int J Pediatr
Otorhinolaryngol 2008;72:1609-1618 .
3. Fujita A, Honjo I, Kurata K, Gan I, Takahashi
H. Refractory otitis media with effusion from
viewpoints of eustachian tube dysfunc-
tion and nasal sinusitis. Am J Otolaryngol
1993;14: 187-190.
4. Browning GG, Gatehouse S. The prevalence
of middle ear disease in the adult British
population. Clin Otolaryngol Allied Sci
1992;17: 317-321.
5. Llewellyn A, et al. Interventions for adult
Eustachian tube dysfunction: a systemat-
ic review. Health Technol Assess 2014;18:
1-180, v-vi.
6. Schilder AG, et al. Eustachian tube dysfunc-
tion: consensus statement on definition,
types, clinical presentation and diagnosis.
Clin Otolaryngol 2015;40:407-411.
7. Bluestone CD. Eustachian Tube. Structure,
Function, Role in Otitis Media, (BC Decker,
Hamilton, London., 2005).
89
Rennie et al.
8. Sade J, Ar A. Middle ear and auditory tube:
middle ear clearance, gas exchange, and
pressure regulation. Otolaryngol Head Neck
Surg 1997;116:499-524.
9. Alper CM, Swarts JD, Singla A, Banks J, Doyle
WJ. Relationship between the electromyo-
graphic activity of the paratubal muscles
and eustachian tube opening assessed by
sonotubometry and videoendoscopy. Arch
Otolaryngol Head Neck Surg 2012;138: 741-
746.
10. Poe DS, Pyykko I, Valtonen H, Silvola J.
Analysis of eustachian tube function by
video endoscopy. Am J Otol 2000;21: 602-
607.
11. McCoul ED, Anand VK, Christos PJ.
Validating the clinical assessment of eus-
tachian tube dysfunction: The Eustachian
Tube Dysfunction Questionnaire (ETDQ-7).
Laryngoscope 2012;122: 1137-1141.
12. Holmquist J, Olen L. Evaluation of
Eustachian tube function. J Laryngol Otol
1980;94: 15-23.
13. Norman G, et al. Systematic review of the
limited evidence base for treatments of
Eustachian tube dysfunction: a health
technology assessment. Clin Otolaryngol
2014;39: 6-21.
14. Todd NW. There are no accurate tests for
eustachian tube function. Arch Otolaryngol
Head Neck Surg 2000;126: 1041-1042.
15. Fokkens W, Lund V, Mullol J, et al. European
Position Paper On Rhinosinusitis And Nasal
Polyps 2012 Rhinology Supplement 23:1-
298.
16. Maniakas A, Desrosiers M, Asmar M-H,et al..
Eustachian tube symptoms are frequent
in chronic rhinosinusitis and respond well
to endoscopic sinus surgery. Rhinology
2018;56:118-121.
17. Stoikes NF, Dutton JM. The effect of endo-
scopic sinus surgery on symptoms of eus-
tachian tube dysfunction. Am J Rhinol
2005;19;199-202.
Valerie J Lund
RNTNEH
Grays Inn Road
London WC1X 8DA
United Kingdom
Tel: +44 (0)7860 873 726
E-mail: v.lund@ucl.ac.uk
Inclusion and exclusion criteria for control group and ETD group
McCoul et al (11).
“Patients were diagnosed as having ETD if they had a retracted or
poorly mobile tympanic membrane on pneumatic otoscopy, with
a history of at least two of the following symptoms in one or both
ears over the previous 1 month period: aural fullness or pressure,
a sensation of clogged or muffled hearing, recurrent or persistent
middle ear effusion (defined as an effusion present on examinations
at least 1 month apart), or the inability to rapidly self-equilibrate
middle ear pressure following changes in ambient atmospheric
pressure. Abnormal impedance audiometry was used as a criterion
standard to verify the diagnosis at the time of enrolment.
Exclusion criteria included surgery of the head or neck within 3
months; a history of radiation therapy to the head and neck; sino-
nasal malignancy; evidence of acute upper respiratory infection,
including sinusitis and acute otitis media; adenoid hypertrophy;
nasal polyposis; cleft palate or history of cleft palate repair; cranio-
facial syndrome, including Down syndrome; cystic fibrosis; ciliary
dysmotility syndrome; or other systemic immunodeficiency.
A second group of patients who did not meet these inclusion criteria
and who had presented with medical complaints not related to ETD
were consecutively enrolled for use as a control group. Presenting
complaints for these patients included voice disturbance, tonsil hy-
pertrophy, and intraoral lesions. All of these patients had a normal
examination of the tympanic membrane, middle ear, nasal cavity,
and nasopharynx. Normal impedance audiometry was used as a
criterion standard to verify the absence of ETD.”
APPENDIX
