UNILATERAL CHRONIC SUPPURATIVE OTITIS MEDIA: EFFECT OF NASAL SEPTAL DEVIATION

Background: Otitis media is an inflammation of part or all of the mucoperiosteal lining of the middle ear cleft. It can be acute, subacute and chronic otitis media infection. Septal deviation has got many unwanted changes such as: nasal obstruction, mucosal changes. Methodology: A descriptive clinical study, carried out on adult patients consulting ENT department at medical city. Those patients have a unilateral chronic suppurative otitis media. Results: The unilateral CSOM can affect any age group, with a slightly higher prevalence in the age group (21-30) year forming 29% of the total patients.Male to female ratio was 1.2:1. Eighty-nine patients presented with aural discharge. Patients with tubotympanic having only perforation and associated with septal deviation forming 68.1% of the patients. Patients with atticoantral having only perforation and associated with septal deviation 63.2% of patients. Conclusion: Unilateral chronic suppurative otitis media can affect all age group and both sexes. The tubotympanic type is mor prevalent. Nasal septal deviation is commonly found in patients with unilateral chronic suppurative otitis media.


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Nasal deviation is either of C-shape or of S-shape deviation depending on the plane of occurrence whether vertical or horizontal (8) .Septal deviation has got many unwanted changes such as: mucosal changes (9) , nasal obstruction, and neurological changes which can cause pain (8) .
The aim of this study was to assess the association between unilateral CSOM and nasal septal deviation in adult patients.

Material and methods:-
This work is a descriptive clinical study, carried out on patients consulting Ear, Nose and Throat (ENT) department at "Medical City"which is a large multispecialty teaching hospital. Over a period of one year from 1 st September 1998 to 1 st September 1999.Patients having unilateral CSOM were enrolled in the study.
One hundred patients included in the study, 44 were male and 56 were female. All of them were treated previously at different time. Data about sociodemographic characteristics of the patients in addition to subjective information about nasal and ear states and complaintswere collected. These data were collected through a questionnaire designed for the purpose of the study.
The clinical findings after full otorhinolaryngological examination were recorded too. The tympanic membrane perforation was classified to central, marginal, and attic types. Operative microscope (using a lens with focal length of 20 mm) for further assessment of the ontological findings.
Nasal septal state was assessed by anterior rhinoscopybefore and after using vasoconstrictor nasal drop (Oxymeclazoline HCL, 0.05%)septal deviation was classified according to its side (ipsilateral, and contralateral to the diseased ear). Post nasal space was inspected for any obstructing pathology and discharge using post nasal mirror.
Auroscope was used to examine the nose of child below 3 years.
Forty-five patients were diagnosed as tubotympanic disease with only central perforation. They were classified into two groups: 1. Group 1: Patients with septal deviation 30 patients; 2. Group 2: Patients without septal deviation 15 patients.
All of them were treated conservatively by the followings: Aural toilet (mopping and/or aspiration); Proper systemic and local antibiotic according to culture and sensitivity; Treatment of any focus of infection in the upper respiratory tract if present. In addition to instructions to patients about cleaning of their ears at home, prevention of water entering to the ear).
Re-examination of the patients after two weeks to find the response to treatment and report them as well response and poor response, depending on the change in the middle ear state and the change in the amount and the characteristics of the discharge. The patients were followed up over three months period in two weeks interval. Times of discharging from the diseased ear were noted and recorded.

Results:-
The unilateral CSOM can affect any age group, with a slightly higher prevalence in the age group (21-30) year forming 29% of the total patients. At the same time the disease is less common among older age group those above 50 years. The distribution of the diseases between male and female nearly similar with a ratio of 1.2:1 (Table-1).      During the period of follow up, 87% of patients in group 2 (with no septal deviation) showed good response to ear management and only 13% showed poor response, while 60% of patients from group 1 (with septal deviation) showed good response and 40% showed poor response to ear management (Table-5). Discussion:-Unilateral chronic suppurative otitis media can affect any age group. Al-Agelly 1993 found nearly same distribution of the diseases according to sex and age, but he included both unilateral and bilateral CSOM (10) .
Presentation: Majority of patients presented with aural discharge which is the main symptom of CSOM. Although deafness is important presenting symptom in CSOM, but they were few in our study because of the unilaterality of the disease and presence of other intact ear making the patients unaware about the hearing impairment.
Evaluation of nasal septum: To our knowledge, this is the first study in our country about the relation between nasal septum and CSOM. This put a difficulty in comparing our results with similar studies. Some studies touch our subject indirectly, such as Mastchke RG in 1985 who stated that there is a relation between nasal obstruction due to septal deformity and disease of paranasal sinuses (11) . Stammberger H. forwarded in his study in 1986 a hypothesis for ear infection in patients with sinusitis through direct transformation of the infected mucus over the tubal orifice cause its obstruction and promote ascending infection in to the middle ear (12) .
Sookmundum in his study in 1986 reported that septal deviation if left without treatment may associated with ear ache and ear discharge (13) . Nasal obstruction is significantly determinant in unilateral CSOM the major components of their obstruction appear due to an associated mucosal change with septal deviation (14) . That is why Wayne W 1982,and C Gary Jackson 1985 both included correction of deviated septum in the course of treatment of chronic discharging ear (15) (16) .

Conclusion:-
Unilateral CSOM can affect all age group and both sexes. The tubotympanic type of CSOM is mor prevalent. Nasal septal deviation is commonly found in patients with unilateral CSOM. Response of patients with tubotympanic type of CSOM to conservative treatment impaired by presence of septal deviation and have high rate of re-discharge in comparison to those who had normal nasal septum.