The effect of inferior turbinate surgery on ear symptoms

Balloon Eustachian Tuboplasty-A Feasible Double-Blinded Sham Surgery Randomized Clinical Trial Protocol to Study Efficacy

INTRODUCTION

Balloon Eustachian tuboplasty (BET) is used to treat obstructive Eustachian tube dysfunction (OETD) and recurrent otitis media with effusion (OME). However, there are no indisputable evidence of its efficacy. Here, we present a multicenter, double-blinded, randomized, placebo-controlled trial (MDRCT) design to evaluate the efficacy of BET, and the results of a pilot trial with 3- and 12-months' follow-up.

MATERIAL AND METHODS

This was a prospective MDRCT. For a pilot study, OETD (n = 10) and OME (n = 5) patients were recruited and followed. Detailed inclusion and exclusion criteria were used. Participants were randomized at beginning of the operation to active or sham surgery. All procedures were performed under local anesthesia. Controls were performed in double-blinded manner (both patient and physician), at 3 and 12 months after the procedure.

RESULTS

Altogether, 20 ears were treated and followed for 12 months, including 14 active BETs and 6 sham surgeries. Both the active and sham surgery were performed under local anesthesia without problems or deviations from the protocol. There were no differences in the preoperative symptoms (ETDQ-7) or objective measures (tympanometry, Valsalva and Toynbee maneuvers, tubomanometry, Eustachian tube score) between active and sham surgery arms. During follow-up, we noticed largely similar reduction in subjective symptoms and improvement in Eustachian tube score both in active and sham surgery arms.

CONCLUSIONS

The pilot study demonstrates that our MDRCT protocol is feasible, and that blinded RCTs are dearly needed to objectively measure the efficacy of BET.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:1874-1881, 2024.

Surgical and instrumental options for chronic rhinitis: A systematic review and PRISMA meta-analysis

BACKGROUND

There is no consensus on the role of surgery in the treatment of chronic rhinitis (CR). Should it be considered when nasal symptoms are not controlled by medical treatment? Various targets (turbinates and secretory nerves) and techniques (surgical, laser, cryotherapy, radiofrequency and phototherapy) have been reported, but benefit varies between reports. The aim of this systematic review and meta-analysis was to evaluate results of surgical and instrumental procedures in CR care.

METHODS

Two systematic reviews of the US National Library of Medicine, Cochrane Library, Web of Science and Embase databases were conducted in October 15, 2021 (registration numbers CRD42021284257 and CRD42021295227). A database watch was performed until submission of the manuscript. The review focuses on total nasal symptom score (TNSS) and quality of life (QoL) after treatment. All controlled studies reporting nasal surgery/instrumental procedures in adult patients with CR were included.

RESULTS

The database search yielded a total of 5628 articles; after eligibility screening, 2091 patients were included from 21 studies. QoL results favored surgery/instrumental procedures over medical treatment (SMD -1.27; 95% CI [-2.38; -0.16]; I2=97%), as did TNSS (SMD -1.40; 95% CI [-2.30; -0.50]; I2=98%). The small number of studies and their heterogeneity did not allow meta-regression to be performed.

CONCLUSION

This systematic review supports the use of surgical/instrumental procedures to improve nasal symptom score and QoL of adult patients with CR poorly controlled by medical treatment.

A Systematic Review of Eustachian Tube Procedures for Baro-challenge Eustachian Tube Dysfunction

OBJECTIVE

To examine the effectiveness of Eustachian tube procedures for the treatment of baro-challenge Eustachian tube dysfunction.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, databases, including PubMed (National Library of Medicine, National Institutes of Health), Scopus (Elsevier), and CINAHL (EBSCO), were searched for articles examining the effectiveness of Eustachian tube procedures for baro-challenge Eustachian tube dysfunction. Outcome measures included symptom resolution, ability to return to work, equalization problems (EP) scores, Eustachian Tube Dysfunction Questionnaire (ETDQ-7) scores, and pressure chamber testing parameters. Pooled meta-analysis was performed for dichotomous measures and ETDQ-7 scores.

RESULTS

Eleven articles with 81 patients were included. Seventy-two patients from 10 articles underwent balloon Eustachian tube dilation; nine patients in 1 study underwent laser Eustachian tuboplasty (LET). All 81 patients were preoperatively symptomatic with barometric pressure change, and 26/30 (86.7%) were unable to work due to symptoms. On meta-analysis, after balloon dilation Eustachian tuboplasty (BDET), 82.5% (n = 30 [95% confidence interval: 42%-100%]) had improvement in ability to valsalva, 79.1% (n = 16 [57.9%-94.1%]) in ability to return to work, and 84.3% (n = 69 [69.8%-94.7%]) in any symptom. Of 25 patients with individual ETDQ-7 scores, 79.1% [51.4, 96.9] had improvements after BDET. For four case series with 36 patients, ETDQ-7 scores decreased by 1.2 [0.7, 1.7] (p < 0.00001). Of 20 patients with preoperative ETDQ-7 scores >2.0, there was a mean decrease of 2.1 [1.3, 2.8] (p < 0.00001).

CONCLUSION

From the available evidence, Eustachian tube procedures appear to be effective at improving symptoms of baro-challenge Eustachian tube dysfunction. However, higher quality evidence is needed to support making definite recommendations for the use of balloon Eustachian tube dilation or LET for these patients. Laryngoscope, 132:2473-2483, 2022.

Turbinate Hypertrophy, Allergic Rhinitis, and Otitis Media

PURPOSE OF REVIEW

Otitis media (OM) is a disease with high prevalence in infancy; it has a substantial burden on healthcare resources, and a relevant impact on the quality of life of families. The link between OM and allergic rhinitis (AR) is still debated. However, there is agreement about the relevance of type 2 inflammation on turbinate hypertrophy (TH) generation. There is also evidence that TH is associated with middle ear dysventilation: a pathogenic factor promoting OM. Therefore, a vicious circle among AR, TH, and OM may occur.

RECENT FINDINGS

There are some recent studies exploring this issue through different approaches, such as epidemiological, mechanistic, and therapeutic. Identifying allergy as a pathogenic factor for OM could improve the management of OM patients. Vice versa, suspecting AR in OM patients, could be reasonable in selected patients. The current narrative review provides an overview of the evidence concerning the potential role of AR, and associated TH, in OM patients.

Placebo comparator group selection and use in surgical trials: the ASPIRE project including expert workshop

BACKGROUND

The use of placebo comparisons for randomised trials assessing the efficacy of surgical interventions is increasingly being considered. However, a placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges.

OBJECTIVES

To provide a summary of knowledge on placebo controls in surgical trials and to summarise any recommendations for designers, evaluators and funders of placebo-controlled surgical trials.

DESIGN

To carry out a state-of-the-art workshop and produce a corresponding report involving key stakeholders throughout.

SETTING

A workshop to discuss and summarise the existing knowledge and to develop the new guidelines.

RESULTS

To assess what a placebo control entails and to assess the understanding of this tool in the context of surgery is considered, along with when placebo controls in surgery are acceptable (and when they are desirable). We have considered ethics arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be carried out and interpreted. The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with a high risk of bias, particularly because of the placebo effect.

CONCLUSIONS

The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. An outline for best practice was produced in the form of the Applying Surgical Placebo in Randomised Evaluations (ASPIRE) guidelines for those considering the use of a placebo control in a surgical randomised controlled trial.

LIMITATIONS

Although the workshop participants involved international members, the majority of participants were from the UK. Therefore, although every attempt was made to make the recommendations applicable to all health systems, the guidelines may, unconsciously, be particularly applicable to clinical practice in the UK NHS.

FUTURE WORK

Future work should evaluate the use of the ASPIRE guidelines in making decisions about the use of a placebo-controlled surgical trial. In addition, further work is required on the appropriate nomenclature to adopt in this space.

FUNDING

Funded by the Medical Research Council UK and the National Institute for Health Research as part of the Medical Research Council-National Institute for Health Research Methodology Research programme.

Turbinate Hypertrophy, Allergic Rhinitis, and Otitis Media

PURPOSE OF REVIEW

Otitis media (OM) is a disease with high prevalence in infancy; it has a substantial burden on healthcare resources and a relevant impact on the quality of life of families. The link between OM and allergic rhinitis (AR) is still debated. However, there is agreement about the relevance of type 2 inflammation on turbinate hypertrophy (TH) generation. There is also evidence that TH is associated with middle ear dysventilation: a pathogenic factor promoting OM. Therefore, a vicious circle among AR, TH, and OM may occur.

RECENT FINDINGS

There are some recent studies exploring this issue through different approaches, such as epidemiological, mechanistic, and therapeutic. Identifying allergy as a pathogenic factor for OM could improve the management of OM patients. Vice versa, suspecting AR in OM patients could be reasonable in selected patients. The current narrative review provides an overview of the evidence concerning the potential role of AR, and associated TH, in OM patients.

Predictive value of the Eustachian Tube Dysfunction Questionnaire-7 for identifying obstructive Eustachian tube dysfunction: A systematic review

OBJECTIVE

To perform a systematic review to determine if a total score of ≥14.5 (mean score ≥ 2.1) on the ETDQ-7 accurately identifies patients with obstructive Eustachian tube dysfunction (OETD) on impedance tympanometry (peak compliance <0.2 mL or middle ear pressure of -100 daPa) or other objective measures of OETD.

METHODS

A systematic review without a meta-analysis was performed of studies in four electronic databases (Pubmed, Embase, Web of Science, and Scopus) that used the ETDQ-7 and at least one objective measure of OETD.

RESULTS

Six-hundred and fifty-two studies were identified in the initial literature search. Abstracts from 337 studies were screened, followed by full-text review of 61 studies, and qualitative synthesis of 12 studies. Tympanometry was used as an objective measure in ten studies. Eight of the 12 included studies had patient cohort selection bias. Eight studies administered the ETDQ-7 in cohorts of patients with or without OETD, already confirmed on tympanometry, and found a sensitivity of 91%-100% and specificity of 67%-100%. Four studies administered the ETDQ-7 to patients who had not previously undergone objective testing and found a sensitivity of 49%-80% and specificity of 24%-78%.

CONCLUSIONS

The ETDQ-7 is an important patient-reported outcome measure. However, based upon existing literature, the ETDQ-7 appears limited as a diagnostic tool for OETD or as an objective measure of Eustachian tube function.

Eustachian Tube Function Assessment after Radiofrequency Turbinate Reduction in Atopic and Non-Atopic Patients

(1) Background: Inferior turbinates’ hypertrophy is often associated with Eustachian tube dysfunction (ETD); radiofrequency turbinate reduction (RTR) may provide a long-term improvement of nasal obstruction and ETD-related symptoms. (2) Aim: The study aimed to compare ETD in atopic and non-atopic patients before and after RTR and to investigate the correlation between tympanometry and Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7). (3) Methods: Ninety-seven patients, ranging from 33 to 68 years old, were screened by skin tests and divided into atopic (G1) and non-atopic (G2). Eustachian tube function (ETF) was evaluated through tympanometry, William’s test and ETDQ-7. (4) Results: A moderate to severe subjective ETDQ-7 was found in the 35.42% of G1 and in the 22.45% of G2 patients before RTR. William’s test resulted normal in 141 ears (72.68%), partially impaired in 15 (7.73%), and grossly impaired in 38 (19.59%) before surgery. A grossly ETD was evidenced in the 19.59% of cases before surgery and decreased to 6.18% after surgery with a significant difference among atopic patients (p < 0.001). (5) Conclusion: RTR may be considered a treatment option in patients suffering from ETD and inferior turbinates’ hypertrophy; RTR reduced the percentage of grossly impaired ET function (p < 0.001). ETDQ-7 and William’s test may represent valuable tools to assess ET function before and after surgery.

Balloon Dilation of the Eustachian Tube for Baro-Challenge-Induced Otologic Symptoms in Military Divers and Aviators: A Retrospective Analysis

OBJECTIVE

To evaluate the effectiveness of balloon dilation (tuboplasty) of the Eustachian tube (BET) in active duty military personnel working in hyper- and hypobaric environments suffering from baro-challenge-induced ETD using functional outcomes.

METHODS

Military divers and aviators diagnosed with persistent baro-challenge-induced ETD resulting in disqualification from performing flight and dive duties and who elected for treatment with BET were included for analysis. Posttreatment follow-up assessments were undertaken at 1, 6, and 12 months. Outcome measures included successful hyperbaric chamber testing or return to the hyper- or hypobaric environment without significant baro-challenge-induced ETD symptoms and pre- and postdilation Eustachian Tube Dysfunction Questionnaire (ETDQ-7) scores.

RESULTS

Mean pretreatment duration of symptoms was 48 months (range: 3-120 months). Following treatment, 92% (12/13) of patients successfully returned to operational duties with resolution of limiting symptoms. Average return to duty time was 8.5 weeks (range: 6-24 weeks). The ETDQ-7 scores improved from a mean of 4.33 (2.57-6.57) predilation to 2.19 (1.00-4.43) postdilation (Z = 2.73, W = 70, P = .0063). Mean duration of follow-up was 38 weeks (range: 13-70 weeks).

CONCLUSION

Eustachian tube balloon dilation appears to be a safe and highly effective treatment option for baro-challenge-induced ETD in affected military divers and aviators who work in hyper- and hypobaric environments. Further study is needed to determine whether similar results can be achieved in more diverse subject populations and to assess long-term effectiveness.