© Borgis - New Medicine 3/2006, s. 82-86
Lechosław P. Chmielik
Nasal septum deviation and conductivity hearing loss in children
Department of Paediatric Otorhinolaryngology, Medical University, Warsaw, Poland
Head of Department: Prof. Mieczysław Chmielik, MD, PhD
Summary
Summary
Introduction: Respiration is a basic function of every living organism. The human respiratory system is extremely complicated. The complicated functioning of this system has been extensively investigated, yet the system has not been fully recognized. Deviation of the nasal septum, which changes the airflow in this part of the respiratory tract, can affect the state of the paranasal sinuses as well as the functions of the auditory tube. It can also cause adenoids. In the available literature on skeletal deviations of the nasal septum and their influence on the state of hearing and, particularly, on the state of the auditory tube and middle ear, there are no uniform views.
Aim: The aim of this work is to analyse the frequency of changes in tympanometry in children with a deviated nasal septum with regard to their location, shape and associated diseases.
Material and method: We analysed the medical history of 162 nasal septum patients who were treated or operated on at the Clinic of Paediatric ENT, Medical University of Warsaw, in the years 1999-2004. The analysis concerned morphology of nasal septum deviation (division according to Mladina and Cottle), establishment of frequency of occurrence of conductional hypoacusia on the basis of parents´ information, audiometry examination and tympanometry performed on all children and analysis of accompanying symptoms which can cause hypoacusia in children with a deviated nasal septum.
Results: In the examined group 57.69% of patients with a deviated nasal septum had no additional complications as checked in the examination. All the children had satisfactory hearing. With tympanometry type A and good hearing in the examined group were 88 (84.62%) children. In this group 28 (31.82%) children had some other problems.
Conclusions: Nasal septum deviation does not immediately cause disturbance of auditory tube function, and hence it does not cause hypoacusia in children.
INTRODUCTION
Respiration is a basic function of every living organism. The human respiratory system is extremely complicated, and enables precise control of oxygen requirements in almost all climatic conditions. The complicated functioning of this system has been extensively investigated, yet the system has not been fully recognized. Particular parts of the respiratory system cooperate with one another, which, in normal health conditions, ensures efficient ventilation of the alveoli. A healthy upper respiratory system is a functional entity. Certain abnormalities of specific parts can have a negative influence on both neighbouring and distant organs. Deviation of the nasal septum, which changes the airflow in this part of the respiratory tract, can affect the state of the paranasal sinuses as well as the functions of the auditory tube. It can also cause adenoids. One should take into account that the type of deviation of the nasal septum, and the location of the deviation, can have a larger or smaller influence on the organs mentioned above [6, 7].
The literature defines several divisions of the types of nasal septum deviation, with respect to their location.
One of these classifications is Cottle´s (Fig. 1) division of the nasal septum. It describes operational and functional implications of this deviation [4].
Fig. 1. Cotlle´s classification.
Mladina´s (Fig. 2) classification is another, more modern approach which includes the morphology of changes [11].
Fig. 2. Mladina´s classification.
Type I is described as a unilateral crest which does not disturb the function of the nasal valve. It is situated in the area of the valve.
In type II, disturbance of the valve function is caused by the unilateral crest. Positive Cottle´s symptom can be observed after raise of the nostril, which gives a subjective and objective improvement in nose patency.
Type III – one unilateral crest at the level of the head of the middle nasal concha.
Type IV defines two crests – one at the level of the head of the middle nasal concha, and the other on the opposite side in the valve area, disturbing the valve functions.
Type V is a unilateral ridge on the base of the septum, while on the other side the septum is straight.
Type VI shows a unilateral sulcus running through the caudal-ventral part of the septum, while on the other side there is a ridge and accompanying asymmetry of the nasal cavity.
Type VII is a mix of types from I to VI.
In the last few decades there has been dynamic development of nose surgery in the developmental age. In the first half of the 20th century most laryngology manuals, describing Killian´s method, stated that the operation should be postponed until the age of 16 or 18. After introducing Cottle´s method for surgery of the septum, nose operations were carried out regardless of age, in any situation where deformation made breathing difficult. A deviated septum in children impairs patency of the upper air passages, and so can cause recurring infections in this area. The infections, resulting from various not fully-recognized mechanisms, can lead to adenoiditis.
Evaluation of the influence of septum deviation on adenoid hypertrophy or prolonged inflammatory sinus disease has been mentioned many times in numerous scientific publications. However, reports describing how septum deviation affects the auditory tube, and hence the state of hearing, are very few and poorly documented.
In the available literature on skeletal deviations of the nasal septum and their influence on the state of hearing and, particularly, on the state of the auditory tube and middle ear, there are no uniform views. In some current manuals, septum deviations are said to have responsibility for causing conductional hypoacusia. However, the manuals do not link the commonly-occurring middle ear diseases with these deviations [1, 2, 3, 5, 8, 9, 11, 13].
Contemporary diagnostic possibilities provide a way to assess precisely the size and localisation of septum deviations. On the other hand, there are methods which allow evaluation of the state of the auditory tube as well as the state of hearing via audiometry and tympanometry. Hearing loss diseases are divided with regard to quantity: socially efficient hearing (to 30dB), hearing loss (from 30dB to 80dB), and deafness (above 80dB).
AIM
The aim of this work is to analyse the frequency of changes in tympanometry in children with a deviated nasal septum with regard to their location, shape, and associated diseases.
MATERIAL AND METHOD
We analysed the medical history of 162 nasal septum patients who were treated or operated on at the Clinic of Paediatric ENT of Medical University of Warsaw in the years 1999-2004.
The analysis concerned morphology of nasal septum deviation (division according to Mladina and Cottle)
– establishment of frequency of occurrence of conductional hypoacusia on the basis of parents´ information, audiometry examination and tympanometry performed on all children and analysis of accompanying symptoms which can cause hypoacusia in children with a deviated nasal septum.
The control group consisted of 80 secondary and primary school pupils chosen at random from schools whose headteachers approached the Medical University of Warsaw to carry out control laryngological examinations. Laryngological and audiometry and tympanometry examination was carried out on those children.
In the examined group as well as in the control group coexistence of associated diseases which could influence the pathology of the auditory tube and tympanic cavity was assessed. Hence, the coexistence of adenoids was assessed. This recognition was based on medical and subject examination as well as on additional examinations (x-ray examination of nasopharynx or computer tomography of the paranasal sinuses and nasopharynx). Radiological examinations were performed on the examined group as well as on the control group, on subjects whose clinical examination suggested impairment of nasopharyngeal patency. The examinations were carried out in the Department of Children´s Radiology of Warsaw. Nasal sinusitis was recognized on the basis of acknowledged clinical and radiological changes fulfilling Lund´s definition of this disease [10].
The medical histories of one hundred and four patients were submitted for analysis with respect to laryngological examination (descriptions of nasal septum deviation and otoscopic ear description, in particular), results of audiometry (tone audiogram and tympanogram), results of rhinomanometric and radiological examination of the nasopharynx and paranasal sinuses or CT of paranasal sinuses.
Authors who claim that nasal septum deviation can cause hypoacusia maintain that the complication is caused by dysfunction of the auditory tube. This complication can follow the appearance of the hypoacusis itself. That is why, while evaluating the audiological consequences of nasal septum deviation, adenoids and chronic inflammatory sinusitis, mainly tympanometric curves were taken into consideration. It is noteworthy that all children with hearing loss in the examined group could be classified in the section which the audiometrists described as „hypoacusia”. The only exception was a patient with conductive deafness after oncological chemotherapy, who was therefore not connected with nasal septum deformation. In order to analyse the audiological results of nasal septum deformation, adenoiditis, chronic inflammatory sinusitis and allergy of the upper air passages, tympanometric curve was mainly adopted for the above-mentioned reasons.
Statistical analysis was done by chi-squared test.
RESULTS AND discussions
The ultimate analysis included only those children from both groups for whom we had full documentation (described above). There were one hundred and four patients from the examined group and forty-one from the control group. Both groups were statistically comparable, c2=2.387.
In the examined group 57.69% of patients with a deviated nasal septum had no additional complications as checked in the examination. All the children had satisfactory hearing. With tympanometry type A and good hearing in the examined group were 88 (84.62%) children. In this group 28 (31.82%) children had some other problems as specified below and in Table 1.
- 5 cases with hypertrophy of the adenoids
- 4 cases with sinusitis
- 7 cases with allergies
- 1 case with hypertrophy of the adenoids and sinusitis
- 2 cases with hypertrophy of the adenoids, sinusitis and allergy
- 7 cases with sinusitis and allergy
- 2 cases with hypertrophy of the adenoids and allergy.
Table 1. Problems in children with good hearing (n=88).
| Pathology | Number | % |
| Adenoidal hypertrophy | 5 | 5.68 |
| Sinusitis | 4 | 4.55 |
| Allergy | 7 | 7.95 |
| Adenoidal hypertrophy and sinusitis | 1 | 1.14 |
| Adenoidal hypertrophy and allergy | 2 | 2.27 |
| Sinusitis and allergy | 7 | 7.95 |
| Adenoidal hypertrophy sinusitis and allergy | 2 | 2.27 |
| All | 28 | 31.82 |
In the control group there were 71.43% of children who did not have complications. No case of hypoacusia was found in this group. In the examined group there were 15.38% of children with hypoacusia. In the control group this number was 12%. Statistical analysis showed that there were no statistically significant differences between the two groups (c2=0.294).
In the examined group there were 22.12% of patients in whom the Nasal Septum Deviaton was adenoidal complications. Among them, hypoacusia was detected in 12.5% of the examined group. In the control group hypertrophy of the adenoids was found in 11.9% of cases, of whom 9.52% of the whole control group had hypoacusia. Analysis of the relationship between adenoidal hypertrophy and hypoacusia found that it is crucial, c2=38.389.
In the examined group sinusitis complicated the nasal septum deviation in 22.12% of cases. Among these, hypoacusia was detected in 8.65% of the examined group. In the control group sinusitis was found in 11.9% of cases,of whom 2.38% of the whole control group had hypoacusia. Statistical analysis revealed an important relationship between the existence of sinusitis and hypoacusia, c2=12.791 (Table 2).
Table 2. Results in the examined group and control group.
While analysing hypoacusia with regard to the location of deviations (according to Cottle´s division), no important statistical differences were recognized among particular Cottle´s areas, but the number of cases with deviations in areas I, III and V was too small to undergo statistical assessment.
Analysis of the configuration of septum deformations according to Mladina´s scheme revealed that there were no special predispositions of particular forms of deviation to create hypoacusis. A full statistical analysis was carried out for type V, c2=0.002, and type VII, c2=1.007. It must be noted that deviations of types, I, IV and VI are rare forms, and in the given data there are too few cases to draw statistical conclusions. In the researched material, the percentage of patients with adenoids was not substantially greater than in the control group, c2 =2.012. However, this is not the main subject of this study and to prove this thesis would require wider clinical data.
The percentage of children with sinusitis and a deviated nasal septum was not statistically different from the percentage of patients with both diseases in the control group, X2=2.012.
All existing literature reports are not unequivocal, but drawing further conclusions from the above material would involve enlarging the number of cases of this type.
CONCLUSIONS
1. Nasal septum deviation does not immediately cause disturbance of auditory tube function, hence it does not cause hypoacusia in children.
2. In children with a nasal septum deviation, the coexistence of adenoidal hypertrophy and sinusitis has an important influence on the development of hypoacusia.
3. The most common pathological condition accompanying nasal septum deviation in the upper passages is adenoids.
4. The location and configuration of the nasal septum deviation has no influence on development of auditory tube dysfunction.
5. The most common locations of nasal septum deviation in children are regions II and IV according to Cottle´s division.
6. The most common configurations of nasal septum deviation in children are types VII and V according to Mladina´s classification.
Piśmiennictwo
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