Page 34 - Revista SPORL - Vol 58. Nº1

outcome measure, validated in Portuguese – Eustachian Tube
Dysfunction Questionnaire-7 (ETDQ-7), tympanometry T;
and tubomanometry (TMM). Sensitivity (Se), specificity (Sp),
positive predictive value (PPV) and negative predictive value
(NPV) were calculated. Pearson correlation was used to test the
correlation between them. Receiver-operating characteristic
(ROC) curves were created and the area-under the curve
(AUC) was used to compare between them. Statistical analysis
was performed with macOS, and a p-value < 0,05 was used to
reject the null hypothesis.
Results: the group of obstructive ETD was comprised by 36
patients; the control group by 27 patients. ETDQ-7 had a high
Se (94,4%), but low Sp (40,7%); the opposite was verified
regarding tympanometry (Se of 61,1% and Es of 92,6%); TMM
had a high Se and Sp, of 91,7% and 67,7%, respectively. Despite
a statistically significant correlation between the three used
tests, they were weak, except for tympanometry and TMM,
that was moderate. The AUC of TMM was the highest of the
three (0,8 ± 0,06), followed by tympanometry (0,71 ± 0,07).
Discussion and conclusion: our results are compatible with
the most recent literature, that means that no test or exam is
sufficient when used alone. If, on one hand, all the tests can be negative predictive values, but none is considered the
useful, when isolated, tympanometry is insufficient, ETDQ-7
may overestimate, and TMM is the most accurate of the three.
Keywords: Eustachian Tube Dysfunction; tubomanometry;
tympanometry; Eustachian Tube Dysfunction Questionnaire-7
INTRODUCTION
Eustachian tube (ET) is a tubular structure that connects
the nasopharynx to the middle ear (ME).1,2 The main
functions of the ET comprise pressure equalization
between ME and the nasopharynx and clearing
secretions from the ME when they open, and prevention
of the passage of sound, pathogens, and reflux from the
nasopharynx when it is closed.2,3 ET dysfunction (ETD)
is thought to be the most important causative factor of
ME pathology.2
There are two main types of ETD, namely obstructive
ETD (OETD) and patulous ETD (PETD), and some authors
argue that there is a third type, a subtype of OETD, the
baro-challenge induced.3,4 The former, OETD, refers to
the inability to open after a proper stimulus. It may
have different etiologies, but inflammation of the
mucosa lining ET during episodes of upper respiratory
tract infections (URTI) is the most common. The baro-
challenge induced ETD happens with a change of
pressures (most commonly flying or diving).2 On the
other hand, PETD refers to a persistently patent ET, and
its characterized by autophony and aural fullness; it
may improve with URTI.
Despite its clinical importance, the best method to
establish the diagnosis of ETD is still a matter of great
controversy in the literature. In 2015, a consensus
statement proposed that the diagnosis of ETD should be
defined by clinical evaluation: symptoms, namely aural
fullness, popping or discomfort/ pain, in a defined time
frame, accompanied by specific signs, such as tympanic
membrane (TM) retraction (for OETD) or excursion of
the TM induced by breathing (for PETD).4
32 REVISTA PORTUGUESA DE OTORRINOLARINGOLOGIA E CIRURGIA DE CABEÇA E PESCOÇO
More recently, Smith et al. (2019) emphasized the
need to objectively evaluate ET function (ETF) given
the rise in procedures that address ET, such as balloon
dilation tuboplasty, that demands an adequate patient
selection.3
Patient-reported outcome measures (PROMs) are
useful for symptom evaluation, resulting in a score
that enables standardization and comparison of the
results between patients. There are several used in ETD
evaluation, but the most widely-employed is Eustachian
Tube Dysfunction Questionnaire-7 (ETDQ7) and the 10-
item Cambridge Assessment (CETDA).
On the other hand, regarding other exams that evaluate
ETF, they are divided in: indirect measures of ET function,
which includes the most used one, the tympanometry;
tests that evaluate ET opening, such as evaluation
of the TM movement, inflation-deflation tests, tubo-
tympano-aerodynamic graph (TTAG) sonotubometry,
and tubomanometry (TMM); and tests that evaluate ET
closure, such as TTAG, sonotubometry and TMM. They
all have different sensitivities, specificities, positive and
gold standard.
OBJECTIVE
This study aims to assess the accuracy of the available
methods in a Portuguese tertiary hospital to evaluate
ET function considering a standard clinically-based
diagnosis. It also aims to verify the correlation between
the exams available.
METHODS AND METHODOLOGY
This study was developed in the Department of
Otorhinolaryngology of a tertiary hospital after Ethics
Committee approval.
Nonconsecutive patients > 18 years-old were selected
for two convenience groups from the routine outpatient
clinic of Otorhinolaryngology:
- OETD group: One cohort of patients with symptoms
(aural fullness or popping, or discomfort/pain) and
findings in physical exam (TM retraction and/or retraction
pocket) compatible with unilateral OETD. These patients
were evaluated by three Otorhinolaryngologists that
confirmed the clinical diagnosis according to symptoms
and signs in physical examination. Only the ones that
gathered total consensus between the three observers
were included.
- Control group: One cohort of control patients without
symptoms or signs of ETD.
The exclusion criteria included: former ear surgery, TM
perforation, ME effusion, and patients who were unable
to complete all the evaluation protocol.
Demographic features were collected.
The patients were further evaluated through the
following protocol:
- The ETD questionnaire-7, validated in Portuguese,
that comprises 7 questions, in which a score > 14.5 is