Evaluation of the effect of nasal septal deviation on the middle ear with wideband acoustic immitancemetry

Nilufer Bal; Yasin Kulaksiz; Alper Yenigun; Emre Polat; Orhan Ozturan; Ali Toprak; Selahattin Tugrul

doi:10.4103/sjoh.sjoh_1_23

ORIGINAL ARTICLE

Year : 2023 | Volume : 25 | Issue : 1 | Page : 7-11

Evaluation of the effect of nasal septal deviation on the middle ear with wideband acoustic immitancemetry

Nilufer Bal¹, Yasin Kulaksiz², Alper Yenigun², Emre Polat², Orhan Ozturan², Ali Toprak³, Selahattin Tugrul²
¹ Department of Audiology, Faculty of Health Science, Bezmialem Vakif University, Fatih, Istanbul, Turkey
² Department of Otorhinolaryngology, Faculty of Medicine, Bezmialem Vakif University, Fatih, Istanbul, Turkey
³ Department of Biostatistics, Bezmialem Vakif University, Fatih, Istanbul, Turkey

Date of Submission	02-Jan-2023
Date of Decision	21-Jan-2023
Date of Acceptance	22-Jan-2023
Date of Web Publication	20-Mar-2023

Correspondence Address:
Dr. Emre Polat
Department of Otorhinolaryngology, Faculty of Medicine, Bezmialem Vakif University, Fatih 34093, Istanbul
Turkey

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjoh.sjoh_1_23

Abstract

Objectives: This study aimed to objectively reveal the effects of nasal septal deviation (NSD) and its subgroups on normal middle ear physiology by wideband acoustic immitancemetry (WAI), (it is also known as Wideband Tympanometry). Methods: Eighty-five participants with normal hearing were included in the study. Types of NSD finalized with the paranasal CT. The group without NSD was taken as the control group. Wideband absorbance and resonance frequency values were measured at ambient pressure and in the frequency range of 0.25–8.0 kHz. Results: Normal WAI results were obtained in 20 (31%) participants in the NSD group, compared to 13 (72%) in the Control group. The peak pressure values, resonance frequencies, and absorbance at ambient pressure were significantly different between the NSD and the control groups. Conclusion: WAI may be used as an objective method to evaluate middle ear involvement in patients with NSD problems.

Keywords: Absorbance, Eustachian tube, nasal septum, nasal turbulence

How to cite this article:
Bal N, Kulaksiz Y, Yenigun A, Polat E, Ozturan O, Toprak A, Tugrul S. Evaluation of the effect of nasal septal deviation on the middle ear with wideband acoustic immitancemetry. Saudi J Otorhinolaryngol Head Neck Surg 2023;25:7-11

How to cite this URL:
Bal N, Kulaksiz Y, Yenigun A, Polat E, Ozturan O, Toprak A, Tugrul S. Evaluation of the effect of nasal septal deviation on the middle ear with wideband acoustic immitancemetry. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2023 [cited 2023 Jun 4];25:7-11. Available from: https://www.sjohns.org/text.asp?2023/25/1/7/372138

Introduction

The nasal septum (NS) is one of the most important supporting elements of nasal structures. The left and right nasal cavities and airways are separated by NS, and it extends from the nares to the choanae anterior to posterior. NS has a critical role in nasal obstruction.^[1],[2] The prevalence of nasal septal deviation (NSD) is reported up to %90 in the adult population.^[3] Seven subtypes of NSD were proposed by Mladina according to their rhinoscopic findings.^[4] NSD with or without nasal obstruction changes the inspiratory airflow. In the 3-D model of airflow in the nasal cavity, the location of turbulence with high kinetic energy moves to the dorsal part close to the olfactory regions in the deviated cavity.^[5] However main effects of this turbinate airflow are not fully understood. A strong correlation between NSD and acute otitis media was shown in much research.^[6],[7],[8] NSD patients have significantly more Eustachian tube ^{More Details} (ET) dysfunction than normal.^[8]

The ET anatomically sets in the petrous bone of the temporal bone and extends from the anterior wall of the middle ear to the nasopharynx. While the medial two-thirds of ET consists of cartilage, the lateral one-third consists of bone.^[9] The bony part of the ET is open, but the cartilaginous portion of the ET normally remains closed at rest and opens by the action of the levator veli palatini and the tensor veli palatini.^[10] For the middle ear to function optimally, the ET must equalize the air pressure and the “atmospheric” air pressure within the middle ear. For this function, only nasally inhaled air passes through to the middle ear.^[9]

Wideband acoustic immitancemetry (WAI) is a noninvasive method based on the evaluation of the middle ear's ability to transmit sounds within the audiometric frequency range during a dynamic pressure sweep.^[11] WAI provides objective data on the physiological structures of the middle ear. WAI tests utilize stimuli with broad frequency spectra to assess middle ear status, whereas, for conventional tympanometry, only a single pure tone is generally used. Unlike conventional tympanometry measurements, a broad spectral view of middle ear function can be obtained at ambient ear canal pressure. Measurement theory is based on when the broadband sound is presented to the external ear canal, some of the sounds are absorbed by the middle ear and transferred to the inner ear (absorbance), and some are not (reflectance).WAI absorbance changes as a function of frequency and ranges from 1, meaning much of the acoustic power is absorbed to 0, meaning little of the acoustic power is absorbed.^[12]

We hypothesized that changes in middle ear physiological status with NSD could be demonstrated objectively with WAI. The aim of the study objectively reveals the effects of NSD and its subgroups on normal middle ear physiology by WAI.

Methods

Subjects

Ethical committee approval was obtained from the local ethics committee. A minimum of 10 patients in each type of NSD except type 6 NSD and a total of 67 participants were enrolled for WAI analysis. Additionally, 18 participants without septal deviation were included as the Control group ©. Participants with a history of nasal or otologic surgery, history of trauma to the nose or temporal bone, hearing loss, and atrophic rhinitis were excluded from the study. The otoscopic, rhinoscopic examination was performed on all participants.

NSD types were classified according to the method proposed by Mladina,^[3],[4] and NSD types were determined by paranasal CT.

Type 1 NSD is a unilateral vertical septal ridge in the valve region that does not reach the valve itself. The physiologic valve angle (15°) does not change
Type 2 NSD is a unilateral vertical septal ridge in the valve region, thus diminishing the physiologic valve angle (15°)
Type 3 NSD is a unilateral “C” type vertical ridge located more deeply in the nasal cavity, opposite the head of the middle turbinate
Type 4 NSD is a bilateral deformity that consists of type 2 NSD on one side and type 3 NSD on the other side (S-Shape septum)
Type 5 NSD is the horizontal septal spur that laterally sticks deeply into the nasal cavity
Type 6 NSD is bilateral deformities in the horizontal plane. There is anterior dislocation to one side and a deviation to the other side
Type 7 NSD is a combination of multiple deformities.

Wideband acoustic immitancemetry (WAI)

WAI was measured using a Titan Suite (Interacoustics; Assens, Denmark) device. It is also known as Wideband Tympanometry. Wideband absorbance and resonance frequency values were measured at ambient pressure and in the frequency range of 0.25–8.0 kHz by using a 90 ± 3 decibel sound stimulus. Absorbance rates in ambient pressure range from 0 to 1. The higher the amount absorbed by the middle ear, the closer the value is to 1. These values are between 0 and 1, i.e., the absorbance rates can be evaluated as %. WAI results were recorded as frequency-specific absorbance values (AV) at 10 different frequencies in the 0.25–8.0 kHz range. To access 1.2.1 (Interacoustics; Assens, Denmark) software was used to calculate the data. The first two digits after 0 give the percentage value of the sound energy absorbed by the middle ear.

Statistical analysis

Descriptive statistics, correlations analysis, and gain asymmetry calculations were made with IBM SPSS Statistics (Version 24.0. Armonk, NY: IBM Corp.). The independent samples t-test was used to compare gain means and the Mann–Whitney U-test was used to compare gain asymmetry medians. To compare intergroup differences Independent-Samples Kruskal–Wallis's test was used.

Results

Totally 85 participants were included in the study. Puretone average of all included participants was below 26 dB HL. The study and C groups showed no difference in terms of age and gender distribution (P > 0.05) [Table 1].

Table 1: Demographic features of the patients

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In 226 Hz tympanometry, there was no pathology in the C group. In the study group, only ten ears (6.4%) show pathology four Type C tympanogram, and six Type As Tympanogram. In the Type 1 NSD group, there were one Type C tympanogram and two Type As tympanogram; in the Type 2 NSD there was one Type C tympanogram; in the Type 5 NSD there was one Type C tympanogram, three Type As tympanogram, and in Type 7 NSD there were one Type C tympanogram and one Type As tympanogram.

The peak pressure values (PPV) significantly decreased in the NSD group compared with controls (p<0.05: NSD -14.81 ± 42.08; N -9.28 ±8.97). PPV was decreased especially in Type 4 NSD (p<0.05: -22.25±19.57) and Type 7 NSD (p<0.05: -29.29±36.97).

Resonance frequencies (RF) were different between NSD and Cs (p<0.001: NSD 745.93 ±180.63; N 747.89 ±99.29). High RF and Low RF had been seen mostly in type 5 NSD [Table 2]. RFs were not different between intergroup (p>0.05).

The absorbance at ambient pressure (WBAo) decreased in NSD (p<0.005 NSD 0.448±0.103; N 0.526±0.065). Type 2 NSD (p<0.001), Type 3 NSD (p<0.001), Type 4 NSD (p<0.05), Type 5 NSD (p<0.05), and Type 7 NSD (p<0.001) values were significantly different from C group values. The absorbance at peak pressure was also significantly lower in NSD compared with the C group [Table 2].

Table 2: Wideband Acoustic Immitancemetry results results

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The AV at the main audiometric frequency results were shown in [Table 3]. Intergroup differences were found especially in the high-frequency region [Figure 1]. Type 1 NSD AVs were lower than the C group after 3563.59, and Type 2 NSD AVs were lower at nearly all frequencies. Type 3 NSD and Type 4 NSD AVs were found to be lower than the normal group at the middle-frequency region. Type 5 NSD AVs were found lower between 4117.21 Hz and 5822.61 Hz. Type 7 NSD AVs were found lower than Cs between 2448.11 Hz and 5993.23 Hz. Absorbance graphics as shown in [Figure 2].

Figure 1: WBAo: Black line indicates the C group, grey lines indicate NSD group mean values of absorbance percentage at ambient pressure. NSD: Nasal septal deviation

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Figure 2: The black lines indicate the C group, bordeaux line type 1 NSD, Purple line Type 2 NSD, green Type 3 NSD, Light blue type 4 NSD, red line Type 5 NSD, and brown line Type 7 NSD mean values of absorbance percentage at ambient pressure. NSD: Nasal septal deviation

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Table 3: WBA_o values at conventional audiometry frequencies

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In general, normal WBI results were obtained in 20 (31%) participants in the NSD group, compared to 13 (72%) in the C group.

Discussion

This study aimed to objectively reveal the effects of NSD and its subgroups on normal middle ear physiology. For this purpose, instead of the conventional 226 Hz tympanometric evaluation, we used WBI, which has been shown to have higher sensitivity and specificity in literature.^{[13],[14],[15],[16],[17]}

The 3-D dimensional model of NSD showed changes in nasal airflow patterns. Additionally, they reported that these changes also resulted in large shear stress distribution over the cavity walls, increasing the possibilities of local tissue damage. The damage to the nasopharyngeal mucosal area could impact the function of the Eustachian tubal orifice.^[5] The more negative PPV compared to the C group in our study may be because of airflow in the ET. However, the number of Type C tympanogram was low in conventional tympanometry in the NSD group because of the inclusion criteria. However, the PPV significantly increased in the NSD group.

Although Sistani et al.^[18] could not find a relationship between mastoid pneumatization and NSD, they found a decrease in mastoid air cells in NSD. A decrease in resonance frequency was observed in our study, similar to middle ear problems combined with mastoid problems.^[18] In the intergroup analysis, although RF averages were not found to be significantly different from the C group according to NSD types, high RF was mostly seen in type 5 NSD (40%) and type 3 NSD (30%) and type 7 NSD (33%) Low RF seen in Type 2 NSD (35%), Type 3 NSD (35%), and Type 4 NSD (30%) [Table 2]. When the whole NSD group is considered, the incidence of high RF is 28%, while the incidence of low RF is 31%. These results support changes due to impaired middle ear aeration.

In ET dysfunction, WBA0 is reduced especially at 0.8 and 1.5 kHz.^[16] The NSD group generally showed reduced absorbance in all frequencies except the 1 kHz region in our study. However, this study included participants with normal hearing and no significant ET dysfunction. Kim et al.^[19] showed middle ear pathologies combined with mastoid problems had similar findings in WBA. In addition, our study's decrease in absorbance at peak pressure also supports this hypothesis.

The decrease in absorbance in the high-frequency region is also associated with the increase in the middle ear stiffness effect.^[20] Although the highest decrease in WBAo in the high-frequency domain (3–5 kHz) was observed in the type 3 NSD group, the decrease was statistically significant in all NSD groups. It was supposed that the impedance mismatch due to the reduced dampening system could result in low stiffness at these high frequencies according to the stages of pathological changes.

Abnormal WAI findings were shown in all types of NSD. Although the decrease in absorbance at peak pressure and ambient pressure was the most common type 2 and type 3 NSD, it emerged as a primary abnormality in all groups. The resonance frequency averages did not differ significantly between the groups and the C; a decreasing trend was generally observed in RF. However, the rate of elevated RF in type 1 NSD, type 2 NSD, and type 5 NSD groups was also substantial.

Limitations of our study included the small number of patients in NSD types. The nasal obstruction degree was not included as an influencing factor.

Conclusion

Wideband Acoustic Immitancemetry may be used as an objective method sensitive to middle-ear physiological changes to evaluate middle ear involvement in patients with NSD problems.

Ethical approval

The study protocol was conducted following ethical principles stated in the “Declaration of Helsinki” and approved by the Ethical Committee of Bezmialem Foundation University Hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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