Impact of chronic rhinosinusitis with nasal polyps on Eustachian tube dysfunction

Abstract

Introduction

Adequate nasal patency has been classically considered a crucial factor in middle ear ventilation. We valued the influence of nasosinusal polyposis on Eustachian tube (ET) function.

Material and methods

A prospective follow-up with all cases of chronic rhinosinusitis with nasal polyps (CRSwNP) assisted between January 2019 and October 2024 was carried out. Their endoscopic, radiological and clinical characteristics were noted, as well as the presence of a type 2 inflammation context (T2I) and the incidence of middle ear pathology. Polypoid involvement and tubal dysfunction were studied using several scores: Lidholdt’s scale, Lund-McKay nasal polyp grading, Lund-Kennedy endoscopic scoring system, SNOT-22 and Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7) score.

Results

Information was collected from 155 patients, with an incidence of 15,1 cases/100,000 inhabitants. 70,9% showed an T2I profile. This group showed a higher average of cases with acute otitis media and effusion (18,1% vs. 4,4%; P < .001), tympanometric alterations (12,7% vs. 4,4%; P < 0.01), conductive hearing loss (17,2%. vs 4,4%; P < 0.001) and needing for transtympanic drains (9,1% vs. 2,2%; P < .01) than the group without an eosinophilic profile or elevated IgE. The ETDQ-7 score correlated well with the SNOT-22 and Lund-Kennedy scales.

Conclusions

Regression analysis revealed that an T2I profile might play a more important role in tubal patency than nasal obstruction. Polyposis may alter ET function, but more likely due to its inflammatory-allergic aetiopathogenesis than to its obstructive nature.

Resumen

Introduccion

La adecuada permeabilidad nasal ha sido clásicamente considerada factor fundamental en la ventilación del oído medio. Este estudio ha evaluado la influencia de la poliposis nasosinusal en la funcionalidad de trompa de Eustaquio (TE).

Material y metodos

Se efectuó seguimiento prospectivo de todos los casos con rinosinusitis crónica con pólipos nasales (RSCcPN) atendidos entre enero de 2019 y octubre de 2024. Se anotaron sus características endoscópicas, radiológicas y clínicas, si existió un contexto de inflamación tipo 2 (IT2) y la incidencia de patología del oído medio detectada. La afectación polipoidea y la disfunción tubárica se estudiaron mediante las escalas de Lidholdt, Lund-McKay, Lund-Kennedy, SNOT-22 y Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7).

Resultados

Se recogió información de 155 pacientes, con una incidencia de 15,1 casos/100.000 habitantes. El 70,9% presentó un perfil IT2. Este grupo mostró un mayor porcentaje de casos con otitis media aguda y serosa (18,1% vs. 4,4%; P < ,001), alteraciones timpanométricas (12,7% vs. 4,4%; P < ,01), hipoacusia conductiva (17,2% vs. 4,4%; P < ,001) y necesidad de drenajes transtimpánicos (9,1% vs. 2,2%; P < ,01) que el grupo sin perfil eosinofílico ni IgE elevada. La puntuación del ETDQ-7 se correlacionó bien con el SNOT-22 y la escala de Lund-Kennedy.

Conclusiones

El análisis de regresión reveló que el perfil IT2 podría desempeñar un papel más importante en la permeabilidad tubárica que la obstrucción nasal. La poliposis puede alterar la función de la TE, pero probablemente se deba más a su etiopatogenia alérgica-inflamatoria que a su naturaleza obstructiva.

Introduction

Middle ear tubal hypoventilation is a well-documented sequela of nasopharyngeal obstruction of inflammatory or neoplastic origin. However, other conditions of nasal blockage, such as septal deviations, surgical procedures, iatrogenic packing, or nasal polyposis, and their relationship with Eustachian tube (ET) dysfunction remain a matter of debate.¹

The ET is essentially a bidirectional gas exchange valve system that balances physiological pressure in the middle ear. Its functionality is crucial in the aetiopathogenesis of acute and chronic otitis media and can be compromised by upper respiratory tract infections and hypersensitivity inflammation.^2–4 The respiratory tract acts as a functional unit from the middle ear to the pulmonary tree, and is susceptible to complete involvement by local or systemic inflammatory mediators.^5,6

Chronic rhinosinusitis with nasal polyps (CRSwNP), a well-known cause of nasal obstruction, is frequently associated with conditions such as cystic fibrosis, asthma, eosinophilia, Churg-Strauss syndrome, and sarcoidosis, but its underlying mechanism remains unclear.⁷ It can be subclinical or markedly symptomatic, and although its sinonasal manifestations are well studied, otic involvement in this context is not as well studied, neither in its incidence nor pathophysiology. Scientific evidence for the efficacy of systemic corticosteroids in sinonasal polyposis and lower respiratory tract diseases is significantly high, but weak or nonexistent for ET dysfunctions,^7,8 reinforcing the idea that nasal obstruction per se does not predispose to tubal distortion.

Eustachian tube dysfunction is highly common in otorhinolaryngology practice, with a wide variety of tests available for its assessment, all of which are acceptable and complementary. In this regard, the ETDQ-7 (Eustachian Tube Dysfunction Questionnaire-7) was introduced by McCoul et al. in 2012 in an attempt to elicit patient self-reported symptom severity from inadequate middle ear aeration. It provides a quantitative assessment that correlates well with tympanometric charts and allows for adequate monitoring of various treatments.⁹

This study aimed both to assess the incidence of tubal dysfunction in patients with CRSwNP, and also to determine whether there is a causal relationship between them, using procedures that diagnose, quantify, or categorise both entities.

Materials and methods

Study design

A prospective, longitudinal, descriptive, interventional study was conducted, including all cases diagnosed with CRSwNP treated between January 2019 and October 2024 in the Otorhinolaryngology Department of our hospital, covering a population of 56,000. Data collection followed the criteria predetermined by the hospital's Ethics Committee (registration CEI-2018/080161R), respecting patient anonymity by identifying them by numeric code, after obtaining written informed consent for all cases.

The information was stored in computerised health records by filtering personal information and consultation dates on the hospital's intranet for review of the electronic medical record and comprehensive management of administrative and healthcare activities. This facilitated the control and monitoring of patient volume, comorbidities, and clinical manifestations of the nasal sinuses and hearing. Diagnostic imaging tests, serum IgE levels, and blood and polyp eosinophilia were also collected. Intraepidermal skin prick tests were performed according to European guidelines, using a panel of commercially available extracts of the most common and relevant aeroallergens in our setting. Specific IgE to the same allergens was also determined using ImmunoCAP, following the manufacturer's recommendations (Thermo Fisher Inc., Uppsala, Sweden). Results were considered positive when they were greater than .35 kU/L. Finally, the volume of surgical procedures performed was recorded.

Cases with associated nasopharyngeal pathology or craniofacial disorders, individuals with simultaneous significant septal deviation, and patients who did not comply with the recommended therapeutic indications or did not complete their visits within the agreed timeframes were excluded from the study.

Data on ototubal function

The number of clinical episodes consistent with suppurative or non-suppurative acute otitis media was recorded, as well as the cases of serous otitis media detected and the cases with eosinophilic otitis media according to the criteria of Iino et al.,¹⁰ as presented in Table 1, and the corresponding treatments. The degree of tubal dysfunction was quantified using the ETDQ-7, which could be obtained during different visits from each patient before and after any surgical intervention, as it is very quick to complete. It has recently been validated in Spanish by Herrera et al. on 25 controls, 25 patients with nasal involvement, and another 75 with otic pathology.¹¹

Table 1.

Diagnostic criteria for eosinophilic otitis media described by Iino et al. in 2011. A case is described if it meets one major criterion and two or more minor criteria. Exclusion criteria include Churg-Straus syndrome and hypereosinophilic syndrome.

Major.- Otitis media with effusion

Chronic otitis media with predominantly eosinophilic otorrhea.

Minor.- Highly viscous middle ear discharge.

Resistance to conventional treatment.

Association with bronchial asthma.

Association with nasal polyposis.

When the otoscopic image was relevant or the ETDQ-7 score was greater than 14.5, a tubal function test was performed with a 226 Hz impedance probe. This test was only discontinued in cases of tympanic perforation or the installation of transtympanic drainage. Three tympanometric measurements were recorded: a routine tympanogram in which the patient keeps their mouth closed without speaking or swallowing; a second measurement with the Valsalva manoeuvre, which causes bulging of the membrane and records a shifted curve at positive pressures; and a final measurement with the Toynbee manoeuvre, which records a shifted curve at negative pressures. Normal tubal function was considered if there was a variation between 10 and 15 daPa after each manoeuvre, or more than a 50% change in amplitude. In the absence of this shift, tubal dysfunction was suspected (Table 2a).

Table 2a.

Description of the staging tables: 2a.- Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7), with questions about personal impressions for each of the 7 items. Each response scores from 1 (the mildest sensation) to 7 (the most severe). The scale scores from 7 to 49.

Over the past month, to what extent has each of the following been a problem for you?	Slight problem			Moderate problem			Severe problem	Total
Pressure in the ears	1	2	3	4	5	6	7
Pain in the ears	1	2	3	4	5	6	7
Feeling of blocked ears or hearing “underwater”	1	2	3	4	5	6	7
Ear symptoms with a cold or sinusitis	1	2	3	4	5	6	7
Cracking or popping sounds in the ears	1	2	3	4	5	6	7
Ringing in the ears	1	2	3	4	5	6	7
Feeling of weak, muffled, or dull hearing	1	2	3	4	5	6	7
Discomfort in one or both ears			Left	Right	Both		Total

Data on CRSwNP

The time of diagnosis of the sinonasal process and the surgical interventions undergone were recorded for each case. Each patient had at least one annual visit. Episodes of nasal discharge and their duration were recorded. A purulent discharge was considered infectious, and a mucoid or serous discharge was considered non-infectious in asymptomatic cases. When imaging studies were performed, the radiological severity of rhinosinusitis was scored according to the Lund-MacKay (LM) scale (Table 2b).

Table 2b.

Lund-Mackay staging to assess the tomographic severity of CRS by the presence of disease in each paranasal sinus and osteomeatal complex of each nasal fossa. The scale scores proportionally to the radiological severity from 0 to 24.

	Right			Left			Total
Maxilla (Grade 0: no abnormalities; Grade 1: partial opacity; Grade 2: complete opacity)	0	1	2	0	1	2
Anterior ethmoid (Grade 0: no abnormalities; Grade 1: partial opacity; Grade 2: complete opacity)
Posterior ethmoid (Grade 0: no abnormalities; Grade 1: partial opacity; Grade 2: complete opacity)	0	1	2	0	1	2
Frontal (Grade 0: no abnormalities; Grade 1: partial opacity; Grade 2: complete opacity)	0	1	2	0	1	2
Frontal (Grade 0: no abnormalities; Grade 1: partial opacity; Grade 2: complete opacity)	0	1	2	0	1	2
Sphenoid (Grade 0: no abnormalities; Grade 1: partial opacity; Grade 2: complete opacity)	0	1	2	0	1	2
Osteomeatal complex (Grade 0: no obstruction; Grade 2: obstructed)	0		2	0		2
						Total

If more visits were made, the impact of chronic rhinosinusitis on quality of life was assessed at least once a year by completing the SNOT-22 (Sinonasal Outcome Test) questionnaire, which measures the severity of symptoms in patients with CRS across four domains: ear and facial symptoms, nasal symptoms, sleep function, and psychological problems. The score ranges from 0 to 110, with lower scores indicating better quality of life and lower clinical severity (this questionnaire is not illustrated in the tables due to its widespread use and understanding). At each visit, the fossae and cavum were examined using fiberoptic scanning, establishing a grading of occupation according to the Lidholdt scale (Table 2c) and the Lund-Kennedy scale for other endoscopic findings (LK) (Table 2d), and the type of medical treatment applied was verified.

Table 2c.

Lildholdt staging scale for the observation of nasal polyps by endoscopy. Scored from 0 to 3.

0	Absence of polyps.
1	Mild polyposis: polyps that do not reach the spine of the inferior turbinate or are confined to the middle meatus.
2	Moderate polyposis: polyps that extend beyond the plane of the middle meatus, between the cranial and caudal borders of the inferior turbinate.
3	Severe polyposis: polyps that extend beyond the caudal border of the inferior turbinate, with complete obstruction of the fossa.

Table 2d.

Lund-Kennedy CRSwNP staging scale based on nasal endoscopic findings, with measurements in each nostril. The scale scores proportionally according to clinical-endoscopic severity from 0 to 20.

	Right			Left			Total
	0	1	2	0	1	2
Nasal polyps	Absent	Limited to the middle meatus.	Protruding beyond the middle meatus, non-obastructive	Absent	Limited to the middle meatus.	Protruding beyond the middle meatus, non-obastructive
Oedema	Absent	Slight	Intense	Absent	Slight	Intense
Secretion	Absent	Slight	Intense	Absent	Slight	Intense
Adherences	Absent	Slight	Intense	Absent	Slight	Intense
Scabs	Absent	Slight	Intense	Absent	Slight	Intense
						Total

Statistical treatment of the data

With this information, we aimed to verify the hypothesis that CRSwNP affects tubal function and can compromise middle ear aeration. The dichotomous variable “presence or absence of type 2 inflammation (TI2)” was chosen as the basis for developing two cohorts for meaningful comparisons.

Data analysis for the study population was performed using the SPSS 27.0 statistical package for Windows. The Student’s t-test was used to compare the means of quantitative variables from two subpopulations based on a normal distribution of data, with independence of cases and equal variance. The chi-square distribution was chosen for independent random variables with a standard normal distribution expressed as a ratio. A statistically significant relationship was considered to be one with a P value <.001. To detect correlations between quantitative variables derived from the staging scales and the ETDQ-7 questionnaire, the simple linear regression model was used, calculating the equations of the fit lines and their correlation coefficients. A coefficient between –0.7 and +0.7 indicated low dependence between variables.

Results

General group

During the 58-month follow-up, data were collected from 166 patients with CRSwNP, 41 of whom were diagnosed de novo during the course of the study (24.7%). This represented 2.3% of the patients treated and 7.2% of the visits made to the ENT clinics, with a mean of 2.1 ± 1.5 visits per patient-year, ranging from 1 to 8 visits. The incidence was 15.1 cases/100,000 population-years and prevalence in the last year of 262 cases/100,000 population. The final sample size was reduced to 155 patients for various reasons of exclusion.

The mean age of the group was 60.2 ± 48.7 years, ranging from 31 to 88, and the time period from diagnosis to the present was 12.5 ± 7.8 years, ranging from 0 to 35 years. Of the 155 patients monitored, 140 underwent at least one surgical procedure (90.3%). The mean number of surgical procedures per patient was 2.1 ± 1.4, with a range of 0−5. The most frequently performed techniques were endoscopic maxilloethmoid cleansing (36.4%), anteroposterior ethmoidectomy (21.7%), and ethmoidosphenotomy (18.4%). The ETDQ-7 was performed in 632 visits, the SNOT-22 in 768, radiological staging of LM in 253, endoscopic Lidholdt grading in 1334, and the LK score in 1004.

Of the 155 patients included in the study, 91 were diagnosed with allergic rhinitis (58.7%) with positive skin prick test and serum specific IgE levels, 44 had bronchial asthma (24.5%), and 19 cases presented aspirin-exacerbated respiratory disease (AERD, 12.25%). One hundred and ten patients (70.9%) met some criteria for TI2 (total serum IgE > 100 IU/ml, blood eosinophils ≥ 300/µl or tissue eosinophils ≥ 10 in high-power field).

Analysis by IT2 condition

Table 3 shows the comparative analysis of the basic clinical-epidemiological characteristics of the CRSwNP group according to whether or not they presented the IT2 condition. The subgroup with this pattern had more visits/patient per year and showed a higher proportion of cases with chronic rhinitis, AERD, and upper rhinosinusal infectious exacerbations, with statistically significant differences. They also had a higher percentage of cases with asthma and patients requiring two or more cycles of oral corticosteroids per year, but there was no statistical significance compared to the subgroup without the IT2 profile.

Table 3.

Clinical-epidemiological characteristics of patients with CRSwNP considered according to whether or not they showed a type 2 inflammatory profile (*P < .001).

	Inflammation type 2+ (n = 110)	Inflammation type 2– (n = 45)	Total (n = 155)
IgE total (UI/ml)	197.6 ± 88.1 (69−303)	26.2 ± 20.8 (1−52)*	147.3 ± 91.3 (1−303)
Blood eosinophilia (/µl)	461.3 ± 158.1 (246−673)	98.9 ± 114.4 (17−222)*	355.2 ± 141.6 (17−673)
Polyp eosinophilia (/high-power field)	35.2 ± 22.7 (in27 patients, range 12−59)	1.8 ± 3.9 (in 15 patients, range 0−8)*	21.7 ± 17.7 (in 42 patients, range 0−59)
Patients undergoing surgery	107 (97.2%)	33 (73.3%)*	140 (90.3%)
Surgical procedure volume:	220	112	332
• Unilateral/bilateral maxilloethmoid antrostomy	88	33	121 (36.4% of all surgeries)
• Unilateral/bilateral anteroposterior ethmoidectomy	46	26	72 (21.7% of all surgeries)
• Unilateral/bilateral ethmoidosphenotomy	42	19	61 (18.4% of all surgeries)
• Simple polypectomy	28	29	57 (17.2% of all surgeries)
• Unilateral/bilateral Cadwell-Luc	12	3	15 (4.5% of all surgeries)
• Draf IIa frontal opening	4	2	6 (1.8% of all surgeries)
Surgeries/patient	1.9 ± 1.28 (0−5)	2.5 ± 1.53 (0−5)	2.1 ± 1.4 (0−5)
Visits/patient and year	2.3 ± 1.4 (1−6)	1.7 ± 0.8 (1−5)*	2.1 ± 1.5 (1−6)
Patients with associated rhinitis	91 (82.7%)	11 (24.4%)*	102 (65.8%)
Patients with associated asthma	35 (31.8%)	9 (20%)	44 (28.3%)
Patients with associated AERD	19 (17.2%)	0 (0%)*	19 (12.2%)
Patients with ≥1 acute infectious rhinosinusitis per year	94 (85.4%)	11 (24.4%)*	105 (67.7%)
Patients with ≥2 courses of oral corticosteroids per year	23 (20.9%)	6 (13.3%)	29 (18.7%)

Table 4 shows the comparative scores on the radiological, endoscopic, and clinical scales used between the two established subgroups, as well as the aspects related to the ototubal pathology detected. In the longitudinal analysis of the scores between the pre- and postoperative states, patients with the IT2 profile showed improvement on all five scales studied, with statistically significant differences. This improvement was only observed in Lidholdt, LK, and SNOT-22 staging among patients without TI2. The cross-sectional analysis of the five questionnaires revealed that the preoperative LM scale and ETDQ-7 scores were significantly higher in the TI2 subgroup. These patients also had a higher incidence of cases with pathological ETDQ-7 scores (greater than 14.5), conductive hearing loss, and altered tubal function tests. More cases of acute and serous otitis media were also detected in these patients, as well as a higher number of patients requiring transtympanic drainage, with statistically significant differences. This need for ventilation tube adaptation included six cases of eosinophilic otitis media—according to the criteria of Iino et al.—in the TI2 group, of which only 50% experienced hearing recovery. There were no differences between the two subgroups in the findings of pathological tympanometric curves.

Table 4.

Variation in each of the scales and questionnaires in patients with pre- and postoperative CRSwNP and comparative analysis of the findings suggestive of tubal dysfunction considered according to whether or not they showed a type 2 inflammatory profile (longitudinal statistical significance +P < .001; cross-sectional statistical significance *P < .001 and **P < .01).

	Inflammation type 2+ (n = 110)	Inflammation type 2– (n = 45)	Total
Lund-MacKay scale (prior to surgery)	9.7 ± 5.4 (3−21)	6.3 ± 3.5 (3−19)*	8.7 ± 5.2 (3−21)
Lund-MacKay scale (one year after surgery)	3.6 ± 1.8 (en 39 patients, range 1−10)^+	4.2 ± 2.7 (en 11 patients, range 0−11)	3.8 ± 2.1 (en 50 patients, range 0−11)^+
Lilholdt scale(prior to surgery)	1.91 ± .65 (1−3)	1.93 ± .75 (1−3)	1.92 ± .66 (1−3)
Lilholdt scale (one year after surgery)	1.06 ± .89 (0−3)^+	1.17 ± 1.05 (0−3)^+	1.09 ± .93 (0−3)^+
Lund-Kennedy scale (prior to surgery)	7.9 ± 2.9 (3−16)	7.1 ± 4.4 (2−16)	7.7 ± 3.4 (2−16)
Lund-Kennedy scale (one year after surgery)	3.8 ± 1.9 (1−7)^+	2.8 ± 1.9 (0−7)^+	3.5 ± 1.9 (0−7)^+
SNOT-22 prior to surgery	53.4 ± 18.9 (20−94)	45.1 ± 17.1 (19−90)	51.1 ± 18.7 (19−94)
SNOT-22 one year after surgery	29.1 ± 12.7 (8−45)^+	27.2 ± 11.2 (10−46)^+	28.6 ± 12.3 (8−46)^+
Patients with ETDQ-7 ≥ 14 prior to surgery	31 (28.1%)	7 (15.5%)*	38 (24.5%)
ETDQ-7 prior to surgery	14.3 ± 8.3 (7−36)	10.5 ± 6.3 (7−31)*	12.2 ± 8.2 (7−36)
ETDQ-7 Three months after surgery	7.9 ± 1.4 (7−13)^+	8.4 ± 1.7 (7−12)	8.1 ± 1.5 (7−12)^+
Patients with ≥1 annual OMA or a history of OMS	20 (18.1%)	2 (4.4%)*	22 (14.1%)
Patients with tympanic perforation	2 (1.8%)	0 (0%)	2 (1.3%)
Patients with conductive hearing loss	19 (17.2%)	2 (4.4%)*	21 (13.5%)
Patients with a B (flat) or C (negative pressure) tympanometric curve	15 (13.6%)	6 (13.3%)	21 (13.5%)
Patients with a tubal test with a variation < 15 daPa	14 (12.7%)	2 (4.4%)**	16 (10.3%)
Patients requiring transtympanic drainage	10 (9.1%)	1 (2.2%)**	6 (3.8%)
Patients with symptoms consistent with eosinophilic otitis media	6 (5.4%)	0 (0%)**	6 (3.8%)

Correlation between questionnaires and ETDQ-7 scale

The graphic representation of the relationship between the independent variable, ETDQ-7, and the other dependent variables obtained from the SNOT-22, Lidholdt, LM, and LK scales is shown in Fig. 1. The correlation coefficient obtained from ETDQ-7 with SNOT-22 was good and with the LK scale it was adequate, both with positive slope. The lines drawn from ETDQ-7 with the Lidholdt and LM scales did not show a good fit and cannot be considered valid to confirm the relationship of dependence between variables.

Figure 1.

Footnotes: Scatter plots and estimated regression line with their equations for assessing dependence between the ETDQ-7 (abscissa) and the other scales (ordinate).

Discussion

At rest, the ET is closed, with the mucous membranes of its anterior and posterior walls in contact. However, through it, the air pressure in the middle ear balances with the external air pressure, allowing drainage of any accumulated fluid into the throat. During phonation and swallowing, the ET opens periodically due to the action of the peristaphylin, elevator, and tensor veli muscles. Two-thirds of the population do so with a single swallow, generating a nasopharyngeal hyper pressure of 5 cm of water.^7,12

Serous otitis media is widely documented in patients with nasal cavity pathology, but there is little literature accurately correlating tubal dysfunction with CRSwNP. Bakhshaee et al. observed a greater predisposition to otitis media with effusion in patients with nasal polyps compared to control subjects, but they did not relate this to the polypoid mass itself, but rather to its generating inflammatory mechanism. This observation had also been made in the paediatric population with polyps, concluding that functional changes in the ET in children have a stronger correlation compared to adults.¹⁴

Nasal polyposis affects patients worldwide, with a predominance in adult males, a prevalence between 1.1% and 4.4%, and a pathophysiological basis that implicates IT2 in up to 80% of cases.^6,13,15,16 Its nasal obstructive symptoms are often the main reason for consultation and diagnosis.

The longitudinal design of the study allowed for the detection of postoperative improvement in all questionnaires and scales related to clinical, endoscopic, and radiological status and also generated two well-differentiated population cohorts according to their pathophysiological mechanism. The predisposition to sinonasal exacerbations, AERD, and otitis media in the TI2 group has already been noted by other authors,^6,17,18 but we observed that it generates more frequent medical consultations and reinforces the concept of functional and reactive unity of the entire respiratory tree. A significantly higher preoperative ETDQ-7 score in the TI2 group has not been previously documented.

This decrease in tympanic compliance, the greater clinical expression detected in the ETDQ-7 questionnaire, and the increase in otic pathology in the group with eosinophilia or elevated IgE are suggestive of the potential immuno-inflammatory effect of allergy on ET function, rather than nasal polyp obstruction itself. Various authors suggest along the same lines that inflammatory nasosinusal diseases have a greater impact on the type of tympanogram compared to obstructive diseases,^13,14 with allergic rhinitis being a circumstance of special predisposition to ET disorders, with alterations in 17% of the tympanometric curves and pathological ETDQ-7 in up to 33% of the population with this diagnosis.^7,17–19

Others minimise this effect and prioritise surgical correction of obstructive nasal pathologies through turbinectomy or septoplasty in cases of tubal dysfunction and chronic otitis media, emphasizing that aeration of the middle ear is achieved after these procedures.^20,21 The difference in opinion may be explained by the different methods used to measure tubal dysfunction. Several objective measures have been proposed: simple Valsalva and Toynbee manoeuvres, otoscopic and audiometric findings, tympanometric recordings, tubomanometry, or scores on quality-of-life questionnaires. No definitive gold standard strategy has been identified.

The ETDQ-7 is a self-administered test based on a 7-question scale referring to the level of perceived severity of the hearing disorder. It was designed to address the need for a validated and specific instrument to support the clinical diagnosis of tubal dysfunction, which can present with multiple symptoms, such as a sensation of ear blockage, otalgia, autophony, or ear pressure, among others. This scale demonstrates high reproducibility, supports diagnosis and treatment, and facilitates rapid information between professionals. It is a health survey for a specific pathology and helps clarify the clinical diagnosis in conditions where consensus is difficult to reach, as is the case here. The use of an optimal cut-off point of a total item score of ≥14.5 to categorise a patient as having tubal dysfunction provides sensitivity and specificity close to 100%.²²

This tool cannot discriminate between different types of tubal dysfunction but has a high specificity for detecting individuals without it, significantly higher than the SNOT-22 for diagnosing the disease. Its score supports a previous history of the disorder and can be used as an additional tool for post-treatment follow-up, even in the Spanish version.¹¹ In fact, in this study, the scores of both questionnaires correlated well and positively with R = .822, a finding already documented and justified by the fact that the SNOT-22 considers the patient as a whole in their physical, functional and emotional repercussions, including a mastery of their auditory context.^22,23 The ETDQ-7 also correlated positively with LK staging (R = .701), which confers more impact on the presence of oedema, secretion and crusting reaction than on the presence of polyps. In this sense, Carroll et al. had already warned that eosinophilia behaves as a poor prognostic factor by favouring pansinusal occupation, increasing the score on the LK scale, and they suggest TI2 as a mechanism generating obstruction in the paranasal ostia and ET.²⁴

The ETDQ-7 score did not correlate with LMK staging or the endoscopic Lidholdt scale. Linear regression offers a strategy to verify whether one variable is dependent on the others, and this study ruled out the hypothesis that patients with more extensive polypoid masses and greater radiographic involvement of the sinuses were more likely to suffer from tubal dysfunction. This analysis shows that obstruction per se is not a significant predictor of alterations in ET function; however, allergy-generating mechanisms increase the likelihood of inadequate ventilation of the middle ear and promote its transition to tympanic retraction and effusion.

The main strength of this study is its prospective design, which allowed for targeted data collection under defined follow-up strategies, providing pre- and postoperative assessments on each defined scale. Its cross-sectional component helped to make comparisons with a large sample size, obtaining a high number of values ​​for each parameter studied, and to generate a highly reliable linear regression analysis for the selected variables. The study compares cases of CRSwNP with and without IT2 profile, but not with healthy controls without sinonasal polyposis. Although this was not the objective of the trial, it constitutes a weakness of the study. Other limitations relate to the systematic use of the ETDQ-7, since its response items primarily refer to disease severity, and the timing of the events assessed could influence the questionnaire score, as these symptoms are potentially intermittent. Furthermore, the desirable recall period for assessing ETDQ-7 symptoms was arbitrarily set at 1 month, so longer recall periods could have generated higher scores. Although this would increase the test's sensitivity in detecting positive symptoms, it also increases the likelihood of recall bias.

Conclusions

Sinonasal polyposis appears to generate a significant spectrum of middle ear diseases depending on the ventilatory limitations in the ET. Up to 24.5% of diagnosed patients show tubal symptoms. This percentage increases when an underlying allergic trigger is present.

Patients with CRSwNP and an IT2 profile require fewer surgical procedures to control the disease than patients without this profile. However, the incidence of acute rhinosinusal symptoms and otitis media is significantly higher in the former, and they have a higher number of medical consultations, including the need for fitting transtympanic drains.

The polypoid severity score that best correlated with the ETDQ-7 tubal dysfunction test was the LK score, which places more emphasis on the nasal inflammatory-oedematous reaction than on the detection of nasal polyps.