Effect Of Endoscopic Sinus Surgery on Eustachian Tube Function in Adult Patients with Chronic Rhinosinusitis

Effect Of Endoscopic Sinus Surgery on Eustachian Tube Function in Adult Patients with Chronic Rhinosinusitis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect Of Endoscopic Sinus Surgery on Eustachian Tube Function in Adult Patients with Chronic Rhinosinusitis Mahmoud Atef Abdelghaffar youssef, Nassim Talaat Nassim, MohamedNourEddin Bashir Alkeeb, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5255715/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Chronic rhinosinusitis (CRS) is a frequent chronic heterogeneous inflammatory disease of the upper airways and paranasal sinuses persistent for ≥ 12 weeks causing considerable healthca,re expenses and reduction of patients’ quality of life due to severe tiredness, disappointment, as well as diminished cognitive function. CRS is commonly associated with eustachian tube (ET) dysfunction. Aim of the study: To evaluate the effect of endoscopic sinus surgery on ET function in the form of (tympanogram, Valsalva maneuver, and total ET dysfunction questionnaire score), in adult patients with CRS. Method This non-randomized clinical trial study was conducted at the Otorhinolaryngology department, the Faculty of Medicine, Cairo University on 40 patients > 18 years old, suffering from CRS with or without Sino-nasal polyposis who are indicated for endoscopic sinus surgery (ESS) and were recruited from Otorhinolaryngology department’s outpatient clinic in the period from November 2022 to June 2023. All selected patients were subjected to a full history taken, a full general examination, and a local otorhinolaryngology examination. Routine preoperative laboratory investigation including complete blood count (CBC), liver and kidney function tests, and coagulation profile. An electrocardiogram (ECG) examination was done routinely for all patients above 40 years old. Radiological examination included; preoperative CT nose & paranasal sinus, axial and coronal cuts soft tissue & bone windows. Assessment of ET function was done using The ET Dysfunction Questionnaire (ETDQ-7), Valsalva maneuver, and Tympanogram. ET function was reevaluated 6 weeks post-operative in the form of an ETDQ-7, Valsalva maneuver, and tympanogram. Results The ages of selected patients ranged from 21–45 years old with mean ± SD = 30.98 ± 10.24 years old. 52.5% of patients were males. Our results showed a statistically significant postoperative improvement in the Valsalva maneuver and the tympanogram type of both ears compared to preoperative with a p-value < 0.001. Similar results were found regarding the assessment of ET function using ETDQ-7 items and the total score (15.35 ± 4.92 vs 26.12 ± 7.79 respectively) with p-value: < 0.001. Conclusion A significant improvement in ET function in the form of (tympanogram, Valsalva maneuver, and total ET dysfunction questionnaire score), following endoscopic sinus surgery in adult patients with CRS with or without sinonasal polyposis. Chronic Rhinosinusitis Eustachian Tube Dysfunction Endoscopic Sinus Surgery Introduction Eustachian tube (ET) dysfunction, is the inability of the ET to adequately perform at least one of its functions, to protect the middle ear from sources of disease, to ventilate the middle ear and to help drain secretions away from the middle ear [ 1 ] . There are three subtype’s ET dysfunction; which include dilatory ET dysfunction; baro-challenge-induced ET dysfunction; and patulous ET dysfunction [ 2 ] . The ET, connects the middle ear with the paranasal sinuses, and nasal cavity, so diseases in these areas can affect each other. Long standing paranasal sinusitis can cause swelling in the area of the eustachian -tube orifice, which can result in deterioration of the eustachian -tube function and consequently disease in the middle ear, direct flow of the postnasal, drip in paranasal sinusitis into the eustachian -tube can give rise to diseases in the eustachian -tube or the middle ear, inflammatory responses of the mucosa and loss of the mucociliary transport, as well as deterioration of eustachian -tube function [ 3 ] . The ET function has been the subject of many clinical and experimental studies to identify currently available tests for assessment ET function such as tympanometry, valsalva test, inflation and deflation test, toynbee's test, tubo-tympano-aerodynamic-graphy, and sonotubometry [ 4 ] . Chronic rhinosinusitis (CRS): It represents a group of disorders characterized by inflammation of the nasal mucosa and paranasal sinuses for at least 12 weeks duration. CRS with or without nasal polyps is defined as inflammation of the nose characterized by two or more symptoms, one of which should be either nasal blockage, obstruction, congestion, or nasal discharge (anterior/posterior nasal drip); with or without facial pain/pressure; and/or with or without reduction or loss of smell [ 5 ] . The standard diagnostic procedures include medical history, nasal endoscopy, CT of the paranasal sinus. The classification of disease severity ranges from mild, moderate to severe this was complemented with a concept of symptom control in the form of controlled, partly controlled and uncontrolled. The choice of therapy depends upon symptom intensity. In patients with moderate and severe symptoms, usually several weeks of conservative treatment including topical steroids are administered. In non-responders, surgical treatment (functional endoscopic sinus surgery) is indicated [ 6 ] . Functional endoscopic sinus surgery is the minimal-invasive standard procedure for surgical treatment of patients with CRS. Functional endoscopic sinus surgery follows the principle to remove all pathologies within the paranasal sinuses while sparing normal mucosa and all functionally relevant anatomical structures [ 7 ] . The aim of this work was to evaluate the effect of endoscopic sinus surgery on ET function in form of (tympanogram, valsalva maneuver and total ET dysfunction questionnaire score), in adult patients with CRS. Patients and Methods This non-randomized clinical trial study was conducted on 40 patients, older than 18 years old, suffering from CRS with or without sinonasal polyposis who are indicated for endoscopic sinus surgery according to the following indication (recurrent acute bacterial sinusitis, chronic bacterial sinusitis, polypoid rhinosinusitis and not responding to medical treatment in the form of (oral corticosteroids for 3 weeks (1mg/kg/day) gradually tapered dose over days, broad spectrum antibiotics for 1–2 weeks, steroid nasal spray for 1 month, saline nasal irrigation for 1 month and nasal decongestant for 5 days) on the period from November 2022 to June 2023. The study was done after approval from the Ethical Committee Cairo University Hospitals. An informed written consent was obtained from the patients. Exclusion criteria were nasopharyngeal mass, sinonasal tumors, previous ear surgery, previous nasal surgery, previous head and neck radiation and patient refused. Preoperative assessment included History taking, full general examination and full local otorhinolaryngology examination including anterior rhinoscopy & endoscopic nasal examination and ear examination. Radiological investigation: Preoperative CT nose and paranasal sinus, axial and coronal cuts soft tissue & bone windows. Routine investigation: complete blood count (CBC), coagulation profile, kidney function, liver function and ECG for every patients older than 40 years old or cardiac patients. Assessment of ET function: Subjective test for assessment ET function was done using ET dysfunction questionnaire, ETDQ-7, symptoms questionnaire, which consisted of seven items of the symptoms including; pressure in the ear, pain in the ear, feeling that your ear clogged or under water, ear symptoms when you have a cold or sinusitis, crackling or popping sound in the ear, ringing in the ear and feeling that your hearing is muffled. After finishing questionnaire all the patients were asked to score from 1 (no problem) to 7 (severe problem) for each item. The questionnaire was performed twice one day before the surgery and 6 weeks after surgery. Valsalva maneuver was performed by a forceful attempt of exhalation against a closed airway, we assessed ear drum mobility or changes in the ear fullness or the ear “pop” sensation. If patients felt a decrease in ear fullness or a more ventilated sense in one ear after the valsalva maneuver, we classified the function of the ET in that ear as normal. When felt no change in symptoms, we considered thee tube to be obstructed. Tympanogram: is an acoustic evaluation of the condition of the tympanic membrane and the conduction bones by creating variations of air pressure in the ear canal. Tympanogram and valsalva maneuver was recorded and analyzed twice one day before the surgery and 6 weeks after surgery. Analysis of tympanogram: Type (A): there was a normal pressure in the middle ear with normal mobility of the eardrum and ossicles. Patients were operated on under general hypotensive anesthesia, patients were placed in supine position with elevation of the head, a slight reverse trendelenburg position with patients otation toward. The approach used in this study was Messerklinger Technique as functional endoscopic sinus surgery by 0° & 30° 4 mm rod endoscopes attached to camera connected to a video screen. It includes following steps, when the anatomy is visualized, the polyp tissue may be removed with polyp forceps, through cutting instruments or microdebrider. Removal of uncinate process and exposure of infundibulum (uncinectomy), don were with the help of either back-biting forceps or sickle knife and blakesley forceps widening of maxillary sinus ostium. Anterior ethmoidectomy by removal of ethmoidal bulla was performed with curette or blakesley forceps, Frontal sinustomy by exposure and cleaning of frontal sinus ostium is done in the event of frontal sinus disease. Identification of roof of ethmoid by removing the remaining anterior ethmoidal cells and identify the middle turbinate, basal lamella. Posterior ethmoidectomy done by removing of posterior ethmoidal cells. Then sphenoid sinusotomy done by opening of the anterior wall of the diseased sphenoid sinus. The polyp tissue in all sinuses may be removed with polyp forceps, secretion and pus was aspirated. At the end of surgery small temporary Merocel pack or antibiotic soaked gauze pack was placed in the surgical cavity. None of the patients in our study had ventilation tube insertion . Postoperative care and assessment. Patients were discharged 48 hours after the surgery, while the nasal packs was removed. All patients received Amoxicillin clavulanic acid 1g antibiotic tablets every 12 hours for 10–14 days. Analgesic (paracetamol 500mg tab) 1to 2 tablets taken every 4 to 6 hours as required as well as topical vasoconstriction nasal drops for 5 days and saline nasal wash for 1 month, which started after remove of nasal packs. All patients with CRS with sinonasal polyposis received local steroid nasal spray, 1 sprays into each nostril twice daily for 4 to 6 weeks. Routine follow- up after 2 days, 2 weeks, 4 weeks and 6 weeks included, detailed history taking included history of new nasal or ear symptoms. Anterior rhinoscopy and nasal endoscopy examination for nasal crustations, nasal synachiae, signs of sinusitis and nasal polyps. Examination of ear included otoscopy and detection of tympanic membrane abnormalities. ET function was evaluation 6 weeks post-operative in form of ET dysfunction questionnaire, valsalva maneuver and tympanogram. Statistical analysis Statistical analysis was done by SPSS v26 (Inc., Chicago, IL, USA). Quantitative variables were presented as mean and standard deviation (SD) and were compared by independent t- test for the same group. Qualitative variables were presented as frequency and percentage (%) and were compared by Chi-square (X2). A two tailed P value < 0.05 was considered significant. Results Demographic data and Onset of chronic rhinosinusitis in months: Age ranged from 21 to 54 with mean±SD = 30.98±10.24. Number of males was 21 (52.50%) while the number of female was 19 (47.50%). Onset (m) in ranged from 4 to 72 with mean ± SD = 25.6 ± 21.94 (Table 1). (Table 1): Baseline demographic data and Onset of chronic rhinosinusitis in months among the study population Study population (n = 40) Age Mean ± SD. 30.98 ± 10.24 Median (IQR) 27 ( 23 - 42.25 ) Range (Min-Max) 33 ( 21 - 54 ) Sex Male 21 ( 52.50% ) Female 19 ( 47.50% ) Onset (m) Mean ± SD. 25.6 ± 21.94 Median (IQR) 24 ( 6 - 36 ) Range (Min-Max) 68 ( 4 - 72 ) Pre and post-operative tympanogram : There was a highly significant difference between the two studied groups (p= <.001) regarding Pre and post-operative tympanogram in the right and left ear of study group (Table 2). (Table 2): Pre and post-operative tympanogram in the right and left ear of study group Pre-operative (n = 40) Post-operative (n = 40) Test of Sig. p-value Tympanogram type in the right ear X2 = 19.371 <0.001 A 12 (30% ) 31 ( 77.50% ) B 15 ( 37.50% ) 7 ( 17.50% ) C 13 ( 32.50% ) 2 ( 5% ) Tympanogram type in the left ear X2 = 31.746 <0.001 A 10 (25%) 35 (87.50%) B 18 (45%) 3 (7.50%) C 12 (30%) 2 (5%) Pre and post-operative valsalva maneuver :There was a highly significant difference between the two studied groups (p= <.001) regarding pre and post-operative valsalva maneuver in the right and left ear among the study population (Table 3). (Table 3): Comparison between pre and post-operative valsalva maneuver in the right and left ear among the study population. Pre-operative (n = 40) Post-operative (n = 40) Test of Sig. p-value Valsalva maneuver right ear X2 = 21.164 <0.001 Positive 28 (70%) 16 (40%) Negative 12 (30%) 24 (60%) Valsalva maneuver left ear X2 = 22.064 <0.001 Positive 30 (75%) 13 (32.5%) Negative 10 (25%) 27 (67.5%) Regarding ET dysfunction questionnaire (ETDQ-7) items score, there was a highly significant difference between the two groups (Table 4). (Table 4): Comprison between pre and post-operative ET dysfunction questionnaire (ETDQ-7) items score among the study population Pre-operative (n = 40) Post-operative (n = 40) Test of Sig. p-value Pressure in the ear χ2 = 34.6 <0.001 Score 1 0 ( 0% ) 7 ( 17.50% ) Score 2 10 ( 25% ) 20 ( 50% ) Score 3 3 ( 7.50% ) 7 ( 17.50% ) Score 4 10 ( 25% ) 6 ( 15% ) Score 5 17 ( 42.50% ) 0 ( 0% ) Score 6 0 ( 0% ) 0 ( 0% ) Score 7 0 ( 0% ) 0 ( 0% ) Pain in the ear χ2 = 37.3 <0.001 Score 1 5 ( 12.50% ) 13 ( 32.50% ) Score 2 10 ( 25% ) 21 ( 52.50% ) Score 3 2 ( 5% ) 6 ( 15% ) Score 4 12 ( 30% ) 0 ( 0% ) Score 5 11 ( 27.50% ) 0 ( 0% ) Score 6 0 ( 0% ) 0 ( 0% ) Score 7 0 ( 0% ) 0 ( 0% ) "Feeling that your ear clogged or under water" χ2 = 32.3 <0.001 Score 1 4 ( 10% ) 11 ( 27.50% ) score 2 4 ( 10% ) 18 ( 45% ) Score 3 5 ( 12.50% ) 5 ( 12.50% ) Score 4 16 ( 40% ) 6 ( 15% ) Score 5 11 ( 27.50% ) 0 ( 0% ) Score 6 0 ( 0% ) 0 ( 0% ) Score 7 0 ( 0% ) 0 ( 0% ) "Ear symptoms when you have a cold or sinusitis" χ2 = 45.3 <0.001 Score 1 0 ( 0% ) 0 ( 0% ) Score 2 2 ( 5% ) 17 ( 42.50% ) Score 3 6 ( 15% ) 17 ( 42.50% ) Score 4 2 ( 5% ) 4 ( 10% ) Score 5 7 ( 17.50% ) 0 ( 0% ) Score 6 13 ( 32.50% ) 2 ( 5% ) Score 7 10 ( 25% ) 0 ( 0% ) Crackling or popping sound in the ear χ2 = 34.5 <0.001 Score 1 0 ( 0% ) 5 ( 12.50% ) Score 2 13 ( 32.50% ) 29 ( 72.50% ) Score 3 6 ( 15% ) 4 ( 10% ) Score 4 21 ( 52.50% ) 2 ( 5% ) Score 5 0 ( 0% ) 0 ( 0% ) Score 6 0 ( 0% ) 0 ( 0% ) Score 7 0 ( 0% ) 0 ( 0% ) Ringing in the ear Score 1 0 (0%) 2 (5%) χ2 = 39.8 <0.001 Score 2 10 (25%) 32 (80%) Score 3 16 (40%) 6 (15%) Score 4 14 (35%) 0 (0%) Score 5 0 (0%) 0 (0%) Score 6 0 (0%) 0 (0%) Score 7 0 (0%) 0 (0%) Feeling that you hearing is muffled Score 1 2 (5%) 7 (17.50%) χ2 = 36.8 <0.001 Score 2 8 (20%) 27 (67.50%) Score 3 2 (5%) 2 (5%) Score 4 18 (45%) 4 (10%) Score 5 10 (25%) 0 (0%) Score 6 0 (0%) 0 (0%) Score 7 0 (0%) 0 (0%) Total score in Pre-operative data ranged from 11 to 35 with mean ± SD = 26.12 ± 7.79 while in Post-operative data the total score ranged from 9 to 26 with mean ± SD = 15.35 ± 4.92 with highly statistical significant difference (p= <.001) between the two groups (Table 5). (Table 5): Comparison between pre and post-operative total ET dysfunction questionnaire (ETDQ-7) score among the study population Pre-operative (n = 40) Post-operative (n = 40) Test of Sig. p- value Total ETDQ-7 score t = 7.393 <0.001 Mean ± SD. 26.12 ± 7.79 15.35 ± 4.92 Median (IQR) 30 (19.75 - 32) 15 (13 - 16) Range (Min-Max) 24 (11 - 35) 17 (9 - 26) Discussion Direct flow of the postnasal drip in paranasal sinusitis into the ET can give rise to diseases in the ET or the middle ear. Inflammatory responses of the mucosa and loss of the mucociliary transport function are also reported as the underlying patho-mechanism of chronic sinusitis that led to the deterioration of the ET function [ 8 ] . Treatment is primarily medical in the form of intra nasal steroids and a short course of systemic steroids and antibiotics. Functional endoscopic sinus surgery (FESS) is a surgical therapy held for cases not responding to medical treatment to remove all pathologies within the paranasal sinuses while sparing normal mucosa and all functionally relevant anatomical structures [ 9 ] . Our study can be supported by Choi et al., [ 3 ] who reported that patients involved in their study were aged between 20 and 85 years of age with a mean age of 49.2 ± 17.83 years of age. Among the 60 cases, male patients were 42 and female patients were 18. Moreover, Chen et al., [ 10 ] reported that the mean ± SD age of the enrolled patients was 46.4 ± 15.7 years old, however, 67.4% were women. The preoperative ETDQ-7 and SNOT-22 scores of the entire cohort were 13.3 ± 8.3 and 40.0 ± 20.9, respectively. Concerning onset of CRS, it ranged from 4 to 72 with mean ± SD = 25.6 ± 21.94. Marino et al., [ 11 ] found a 43.3% prevalence of significant ETD symptoms in patients visiting a tertiary rhinology clinic for the treatment of rhinologic problems. A previous study by Maniakas et al., [ 12 ] have found that in cases of CRS, the prevalence of otologic symptoms was 15%-61%. Ear fullness of equal/greater than 1 was reported in 80/131 CRS patients compared to 45/251 control patients. Ear Pain of equal/greater than 1 was reported in 39/131 CRS patients compared to 33/251 control patients. Following ESS, mean ear fullness and ear pain scores decreased to 1.17 and 0.73, respectively. Moreover, Rennie et al., [ 13 ] showed a significantly higher rate of ETD (p < 0.01 paired t-test) in the rhinology patients (mean score 3.1, SD 1.64) as compared to a control population (mean 1.3, SD 0.3). Regarding tympanogram in our study, the pre-operative tympanogram for right ear was type A (30%), type B (37.50%) and type C (32.50%) and differed significantly p-value < 0.001 post-operative to be type A (77.50%), type B (17.50%) and type C (5%). Also, the same trend of results in the left ear, the pre-operative tympanogram was type A (25%), type B (45%) and type C (30%) and differed significantly p-value < 0.001 post-operative to be type A (87.50%), type B (7.50%) and type C (5%). In concordance with our results Chen et al., [ 14 ] showed that After ESS, the proportion of normal tympanic membrane significantly increased to 68.4% (P < 0.05). ETDQ-7 score of the diagnosed patients with tympanogram significantly reduced at 8–12 weeks postoperatively (P < 0.001). Meanwhile, 58.3% of type B tympanogram preoperatively changed to type A or type C after ESS (P < 0.05). These results suggested that at least a certain subset of CRS patients with OME could benefit from ESS alone. Also, Bowles et al., [ 15 ] reported that type A tympanograms increased from 76.6% pre-operatively, to 94.5% at 3 months and 96% at 9 months also revealed that positive Valsalva increased from 38% pre-operatively to 96% at 3 and 9 months. Our results showed that there was a highly significant difference between the pre- and post-operative Valsalva maneuver in the right and left ear (p < 0.001). In line with our findings Chen et al., [ 14 ] reported that the proportion of positive Valsalva maneuver increased remarkably from 14.3% preoperatively to 75.7% at 8–12 weeks (P < 0.001). In harmony with our results Choi et al., [ 3 ] revealed that compared with the group without sinusitis, the ESS group showed significant improvement of eustachian-tube function after surgery in the ETDQ-7 (p = 0.002), right Valsalva test (p = 0.015), right deflation test (p = 0.005), and left deflation test (p = 0.006). A binary logistic regression analysis revealed that ESS significantly improved eustachian-tube function in the right Valsalva test in a univariate (p = 0.021) and multivariate analysis (p = 0.008), and eustachian-tube function in the left deflation test in a univariate (p = 0.021) and multivariate analysis (p = 0.039). These findings indicate that eustachian-tube function is significantly improved after ESS in adult sinusitis patients, and that the presence of sinusitis and implementation of ESS should be considered (if sinusitis is present) in managing patients with ear diseases that are affected by eustachian-tube function. For the symptom score, the median total postoperative ETDQ-7 symptom score was 9.67 in the ESS group and 12.0 in the control group. Also, Chen et al., [ 14 ] reported that ETDQ-7 score in CRS patients with ETD statistically decreased exceeding the MCID postoperatively at 8–12 weeks (20.13 ± 6.18 VS 8.63 ± 3.62, P = 0.002). In addition, 85.7% of patients reached a normalization of ETDQ-7 score at this follow-up time point, which indicated they were totally free of ETD symptoms. Additionally, the mean ETDQ-7 and SNOT-22 scores decreased significantly to 8.2 and 17.0, respectively (p < 0.001 for all). There were 23 patients who reported ETD before ESS. The mean preoperative, postoperative 3-month, 6-month, 9-month, and 1-year ETDQ-7 score was 25.2, 10.6, 8.4, 8.0, and 7.7, respectively. The ETDQ-7 score was significantly decreased from preoperative to postoperative 3 month (p < 0.001) and from postoperative 3 month to postoperative 6 month (p = 0.028). One- year post-ESS, 18 patients (78.3%) reported no otologic symptoms, five patients (21.7%) reported some otologic symptoms, and no patients reported ETD. Also, Wu et al., [ 16 ] who aimed to study ET quality of life and severity of disease in patients with CRS, reported that thirty-nine (47.6%) patients had ETDQ-7 score ≥ 14.5, signifying clinically significant ETD symptoms. The mean ETDQ-7 score of the study population was 15.8 ± 8.8 and the mean SNOT-22 score was 37.5 ± 19.7. The Pearson and Spearman correlation coefficients between ETDQ-7 and the total SNOT-22 score were 0.52 (P > .0001) and 0.51 (P < .0001), respectively. There was significant improvement in ETDQ-7 scores postoperatively. A meta-analysis by Chen et al., [ 10 ] reported that sixteen studies were included: nine studies with 1336 consecutive patients with CRS and seven studies with 161 patients with primary ETD. In studies with specific data, 225 (47.2%) patients with CRS had a score > 14.5, consistent with ETD. In CRS + ETD, baseline mean ± standard deviation (SD) ETDQ-7 score was 20.7 ± 8.4 and did not differ by polyp status. In primary ETD, mean ETDQ-7 score was significantly higher than CRS + ETD (29.5 ± 8.1, p < 0.0001). Regarding treatment outcomes, CRS + ETD treated with endoscopic sinus surgery (ESS) alone resulted in mean ETDQ-7 in the normal range (13.2 ± 5.3), with a mean change of − 7.4 (95% confidence interval [CI], − 10.82 to − 3.99) (p < 0.00001). Patients with primary ETD treated with ETBD had postoperative ETDQ7 scores of 14.9 ± 7.5 with mean change of − 13.9 (95% CI, − 18.01 to − 9.88), p < 0.00001. A recently published study by Bowles et al., [ 15 ] prospectively assessed changes in ETDQ-7 after ESS for CRS, reporting that mean ETDQ-7 scores were significantly lower at 3 months; mean equals 11.4 (SD plus or minus 5.65) (P less than 0.0001) and 9 months mean equals 11.4 (SD plus or minus 6.15) (P less than 0.0001). Mean ETDQ-7 scores were higher in the CRSwNP group; 24.34 (SD plus or minus 9.2) compared to the CRSsNP group; 18.11 (SD plus or minus 10.3), (p equals 0.6101). Higgins et al., [ 17 ] who aimed to assess predictors of ET dysfunction improvement and normalization in a sample of CRS patients after endoscopic sinus surgery, reported that overall, the mean preoperative ETDQ-7 score of 3.450 (standard deviation [SD] ± 1.061) statistically significantly improved to a mean postoperative ETDQ-7 score of 2.164 (SD ± 1.206, P < 0.001). Eighty-three percent (83%) of the patients had ETDQ-7 improvement exceeding the MCID and 63% of the patients had ETDQ-7 normalization. Lee et al., [ 18 ] retrospectively reviewed patients who underwent ESS and/or septoplasty. The patients were divided into 3 groups according to the type of surgery: group A, septoplasty alone (76 patients); group B, ESS alone (209 patients); and group C, septoplasty + ESS (74 patients). Their study reported that the prevalence of ETD was 28.9% (22 patients) in group A, 27.3% (57 patients) in group B and 31.1% (23 patients) in group C. The ETDQ-7 score decreased significantly after surgery: total patient population, 12.47 ± 7.0 to 8.2 ± 2.48 (p < 0.001); group A, 12.76 ± 6.62 to 8.47 ± 2.66 (p < 0.001); group B, 12.05 ± 6.89 to 8.35 ± 2.73 (p < 0.001); and group C, 13.24 ± 7.72 to 7.55 ± 1.25 (p < 0.001). Conclusions This nonrandomized clinical trial phase revealed a significant improvement in ET function in form of (tympanogram, valsalva maneuver and total ET dysfunction questionnaire score), following endoscopic sinus surgery in adult patients with CRS with or without sinonasal polyposis. Declarations Ethics Approval and Consent to participate: is taken from ethical committee kasralainy cairo university number;Ms 5662023 Funding : No funding Author Contribution Authors' contributions: MY ,NT was mainly involved in doing the surgical part of the research. TA designed the work, the acquisition, analysis, interpretation of data. MA prepared the patients preoperatively and followed their up postoperatively and was responsible for following and obtaining the audiology investigations. All the authors approved the submitted version. References Llewellyn A, Norman G, Harden M, Coatesworth A, Kimberling D, Schilder A et al (2014) Interventions for adult Eustachian tube dysfunction: a systematic review. Health Technol Assess (Winchester Eng) 18:1–180 Schilder A, Bhutta M, Butler C, Holy C, Levine L, Kvaerner K et al (2015) Eustachian tube dysfunction: consensus statement on definition, types, clinical presentation and diagnosis. Clin Otolaryngol 40:407 Choi KY, Jang S, Seo G, Park S-K (2021) Effect of endoscopic sinus surgery on Eustachian tube function in adult sinusitis patients: a prospective case-control study. J Clin Med 10:4689 Smith M, Tysome J (2015) Tests of Eustachian tube function: a review. Clin Otolaryngol 40:300–311 Settipane RA, Peters AT, Chandra R (2013) Chronic rhinosinusitis. Am J Rhinol Allergy 27:S11–S5 Riechelmann H (2013) Chronische Rhinosinusitis–EPOS 2012 Teil I. Laryngo-rhino-otologie. ;92:193–204 Bitter T, Guntinas-Lichius O (2019) Funktionelle endoskopische Nasennebenhöhlenchirurgie (FESS). Laryngo-rhino-otologie. ;98:429 – 43 Van Roeyen S, Van de Heyning P, Van Rompaey V (2015) Value and discriminative power of the seven-item eustachian tube dysfunction questionnaire. Laryngoscope 125:2553–2556 Gohar MS, Niazi SA, Niazi SB (2017) Functional Endoscopic Sinus Surgery as a primary modality of treatment for primary and recurrent nasal polyposis. Pak J Med Sci 33:380–382 Chen T, Shih MC, Edwards TS, Nguyen SA, Meyer TA, Soler ZM et al (eds) (2022) Eustachian tube dysfunction (ETD) in chronic rhinosinusitis with comparison to primary ETD: a systematic review and meta-analysis. International Forum of Allergy & Rhinology Marino MJ, Ling LC, Yao WC, Luong A, Citardi MJ (eds) (2017) Eustachian tube dysfunction symptoms in patients treated in a tertiary rhinology clinic. International Forum of Allergy & Rhinology Maniakas A, Desrosiers M, Asmar M-H, Al Falasi M, Mfuna Endam L, Hopkins C et al (2018) Eustachian tube symptoms are frequent in chronic rhinosinusitis and respond well to endoscopic sinus surgery. Rhinology 56:118–121 Rennie C, Gutierrez M, Darby Y, Lund V (2018) Investigation of the incidence of eustachian tube dysfunction in patients with sinonasal disease. Rhinol Online 1:85–89 Chen X, Dang H, Chen Q, Chen Z, Ma Y, Liu X et al (2021) Endoscopic sinus surgery improves Eustachian tube function in patients with chronic rhinosinusitis: a multicenter prospective study. Rhinology 59:560–566 Bowles PF, Agrawal S, Salam MA (2019) Eustachian Tube dysfunction in chronic rhinosinusitis: pre and post-operative results following endoscopic sinus surgery, a prospective study. Rhinology 57:73–77 Wu AW, Walgama ES, Higgins TS, Borrelli M, Vardanyan N, Hopp S et al (2020) Eustachian tube quality of life and severity of disease in patients with chronic rhinosinusitis. Am J Rhinol Allergy 34:532–536 Higgins TS, Cappello ZJ, Wu AW, Ting JY, Sindwani R (2020) Predictors of eustachian tube dysfunction improvement and normalization after endoscopic sinus surgery. Laryngoscope 130:E721–E6 Lee IH, Kim DH, Kim SW, Kim SW (2022) Changes in symptoms of Eustachian tube dysfunction after nasal surgery. Eur Arch Otorhinolaryngol 279:5017–5023 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Dec, 2024 Editor assigned by journal 31 Oct, 2024 Submission checks completed at journal 31 Oct, 2024 First submitted to journal 13 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5255715","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":372571143,"identity":"f58ba077-7531-43ab-91c5-47bfd6f58fa7","order_by":0,"name":"Mahmoud Atef Abdelghaffar youssef","email":"data:image/png;base64,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","orcid":"","institution":"Cairo University","correspondingAuthor":true,"prefix":"","firstName":"Mahmoud","middleName":"Atef Abdelghaffar","lastName":"youssef","suffix":""},{"id":372571144,"identity":"1aeaab4b-492e-4136-90cd-d9c15c94a762","order_by":1,"name":"Nassim Talaat Nassim","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Nassim","middleName":"Talaat","lastName":"Nassim","suffix":""},{"id":372571145,"identity":"26076806-f930-4363-94e9-34fca1f9bb6c","order_by":2,"name":"MohamedNourEddin Bashir Alkeeb","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"MohamedNourEddin","middleName":"Bashir","lastName":"Alkeeb","suffix":""},{"id":372571146,"identity":"98849560-9a50-4acb-8027-47306a01f661","order_by":3,"name":"Tareq Muhammad Algarf","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Tareq","middleName":"Muhammad","lastName":"Algarf","suffix":""}],"badges":[],"createdAt":"2024-10-13 14:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5255715/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5255715/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":68844295,"identity":"c2908443-37eb-4135-a06d-093a5996ecc0","added_by":"auto","created_at":"2024-11-12 15:38:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":653218,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5255715/v1/96c65ca4-7c7d-4e1d-8465-33a90cc22618.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect Of Endoscopic Sinus Surgery on Eustachian Tube Function in Adult Patients with Chronic Rhinosinusitis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEustachian tube (ET) dysfunction, is the inability of the ET to adequately perform at least one of its functions, to protect the middle ear from sources of disease, to ventilate the middle ear and to help drain secretions away from the middle ear \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere are three subtype\u0026rsquo;s ET dysfunction; which include dilatory ET dysfunction; baro-challenge-induced ET dysfunction; and patulous ET dysfunction \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe ET, connects the middle ear with the paranasal sinuses, and nasal cavity, so diseases in these areas can affect each other. Long standing paranasal sinusitis can cause swelling in the area of the eustachian -tube orifice, which can result in deterioration of the eustachian -tube function and consequently disease in the middle ear, direct flow of the postnasal, drip in paranasal sinusitis into the eustachian -tube can give rise to diseases in the eustachian -tube or the middle ear, inflammatory responses of the mucosa and loss of the mucociliary transport, as well as deterioration of eustachian -tube function \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe ET function has been the subject of many clinical and experimental studies to identify currently available tests for assessment ET function such as tympanometry, valsalva test, inflation and deflation test, toynbee's test, tubo-tympano-aerodynamic-graphy, and sonotubometry \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eChronic rhinosinusitis (CRS): It represents a group of disorders characterized by inflammation of the nasal mucosa and paranasal sinuses for at least 12 weeks duration. CRS with or without nasal polyps is defined as inflammation of the nose characterized by two or more symptoms, one of which should be either nasal blockage, obstruction, congestion, or nasal discharge (anterior/posterior nasal drip); with or without facial pain/pressure; and/or with or without reduction or loss of smell \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe standard diagnostic procedures include medical history, nasal endoscopy, CT of the paranasal sinus. The classification of disease severity ranges from mild, moderate to severe this was complemented with a concept of symptom control in the form of controlled, partly controlled and uncontrolled. The choice of therapy depends upon symptom intensity. In patients with moderate and severe symptoms, usually several weeks of conservative treatment including topical steroids are administered. In non-responders, surgical treatment (functional endoscopic sinus surgery) is indicated \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFunctional endoscopic sinus surgery is the minimal-invasive standard procedure for surgical treatment of patients with CRS. Functional endoscopic sinus surgery follows the principle to remove all pathologies within the paranasal sinuses while sparing normal mucosa and all functionally relevant anatomical structures \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe aim of this work was to evaluate the effect of endoscopic sinus surgery on ET function in form of (tympanogram, valsalva maneuver and total ET dysfunction questionnaire score), in adult patients with CRS.\u003c/p\u003e "},{"header":"Patients and Methods","content":"\u003cp\u003eThis non-randomized clinical trial study was conducted on 40 patients, older than 18 years old, suffering from CRS with or without sinonasal polyposis who are indicated for endoscopic sinus surgery according to the following indication (recurrent acute bacterial sinusitis, chronic bacterial sinusitis, polypoid rhinosinusitis and not responding to medical treatment in the form of (oral corticosteroids for 3 weeks (1mg/kg/day) gradually tapered dose over days, broad spectrum antibiotics for 1\u0026ndash;2 weeks, steroid nasal spray for 1 month, saline nasal irrigation for 1 month and nasal decongestant for 5 days) on the period from November 2022 to June 2023.\u003c/p\u003e \u003cp\u003e The study was done after approval from the Ethical Committee Cairo University Hospitals. An informed written consent was obtained from the patients.\u003c/p\u003e \u003cp\u003eExclusion criteria were nasopharyngeal mass, sinonasal tumors, previous ear surgery, previous nasal surgery, previous head and neck radiation and patient refused.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePreoperative assessment included\u003c/strong\u003e \u003cp\u003eHistory taking, full general examination and full local otorhinolaryngology examination including anterior rhinoscopy \u0026amp; endoscopic nasal examination and ear examination.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eRadiological investigation: Preoperative CT nose and paranasal sinus, axial and coronal cuts soft tissue \u0026amp; bone windows.\u003c/p\u003e \u003cp\u003eRoutine investigation: complete blood count (CBC), coagulation profile, kidney function, liver function and ECG for every patients older than 40 years old or cardiac patients.\u003c/p\u003e \u003cp\u003eAssessment of ET function:\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubjective test for assessment ET function\u003c/b\u003e was done using ET dysfunction questionnaire, ETDQ-7, symptoms questionnaire, which consisted of seven items of the symptoms including; pressure in the ear, pain in the ear, feeling that your ear clogged or under water, ear symptoms when you have a cold or sinusitis, crackling or popping sound in the ear, ringing in the ear and feeling that your hearing is muffled. After finishing questionnaire all the patients were asked to score from 1 (no problem) to 7 (severe problem) for each item. The questionnaire was performed twice one day before the surgery and 6 weeks after surgery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eValsalva maneuver\u003c/strong\u003e \u003cp\u003ewas performed by a forceful attempt of exhalation against a closed airway, we assessed ear drum mobility or changes in the ear fullness or the ear \u0026ldquo;pop\u0026rdquo; sensation. If patients felt a decrease in ear fullness or a more ventilated sense in one ear after the valsalva maneuver, we classified the function of the ET in that ear as normal. When felt no change in symptoms, we considered thee tube to be obstructed.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eTympanogram: is an acoustic evaluation of the condition of the tympanic membrane and the conduction bones by creating variations of air pressure in the ear canal. Tympanogram and valsalva maneuver was recorded and analyzed twice one day before the surgery and 6 weeks after surgery.\u003c/p\u003e\n\u003ch3\u003eAnalysis of tympanogram:\u003c/h3\u003e\n\u003cp\u003eType (A): there was a normal pressure in the middle ear with normal mobility of the eardrum and ossicles.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePatients were operated on under general hypotensive anesthesia, patients were placed in supine position with elevation of the head, a slight reverse trendelenburg position with patients otation toward. The approach used in this study was Messerklinger Technique as functional endoscopic sinus surgery by 0\u0026deg; \u0026amp; 30\u0026deg; 4 mm rod endoscopes attached to camera connected to a video screen. It includes following steps, when the anatomy is visualized, the polyp tissue may be removed with polyp forceps, through cutting instruments or microdebrider.\u003c/p\u003e \u003cp\u003eRemoval of uncinate process and exposure of infundibulum (uncinectomy), don were with the help of either back-biting forceps or sickle knife and blakesley forceps widening of maxillary sinus ostium. Anterior ethmoidectomy by removal of ethmoidal bulla was performed with curette or blakesley forceps, Frontal sinustomy by exposure and cleaning of frontal sinus ostium is done in the event of frontal sinus disease. Identification of roof of ethmoid by removing the remaining anterior ethmoidal cells and identify the middle turbinate, basal lamella. Posterior ethmoidectomy done by removing of posterior ethmoidal cells. Then sphenoid sinusotomy done by opening of the anterior wall of the diseased sphenoid sinus. The polyp tissue in all sinuses may be removed with polyp forceps, secretion and pus was aspirated. At the end of surgery small temporary Merocel pack or antibiotic soaked gauze pack was placed in the surgical cavity.\u003c/p\u003e \u003cp\u003eNone of the patients in our study had ventilation tube insertion .\u003c/p\u003e \u003cp\u003ePostoperative care and assessment.\u003c/p\u003e \u003cp\u003ePatients were discharged 48 hours after the surgery, while the nasal packs was removed. All patients received Amoxicillin clavulanic acid 1g antibiotic tablets every 12 hours for 10\u0026ndash;14 days. Analgesic (paracetamol 500mg tab) 1to 2 tablets taken every 4 to 6 hours as required as well as topical vasoconstriction nasal drops for 5 days and saline nasal wash for 1 month, which started after remove of nasal packs. All patients with CRS with sinonasal polyposis received local steroid nasal spray, 1 sprays into each nostril twice daily for 4 to 6 weeks.\u003c/p\u003e \u003cp\u003eRoutine follow- up after 2 days, 2 weeks, 4 weeks and 6 weeks included, detailed history taking included history of new nasal or ear symptoms. Anterior rhinoscopy and nasal endoscopy examination for nasal crustations, nasal synachiae, signs of sinusitis and nasal polyps. Examination of ear included otoscopy and detection of tympanic membrane abnormalities. ET function was evaluation 6 weeks post-operative in form of ET dysfunction questionnaire, valsalva maneuver and tympanogram.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was done by SPSS v26 (Inc., Chicago, IL, USA). Quantitative variables were presented as mean and standard deviation (SD) and were compared by independent t- test for the same group. Qualitative variables were presented as frequency and percentage (%) and were compared by Chi-square (X2). A two tailed P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDemographic data and Onset of chronic rhinosinusitis in months:\u0026nbsp;Age ranged from 21 to 54 with mean\u0026plusmn;SD = 30.98\u0026plusmn;10.24. Number of males was 21 (52.50%) while the number of female was 19 (47.50%). Onset (m) in ranged from 4 to 72 with mean \u0026plusmn; SD = 25.6 \u0026plusmn; 21.94 (Table 1).\u003c/p\u003e\n\u003cp\u003e(Table 1): Baseline demographic data and Onset of chronic rhinosinusitis in months among the study population\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"97%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 44.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5556%;\"\u003e\n \u003cp\u003eStudy population (n = 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1717%;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.2727%;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5556%;\"\u003e\n \u003cp\u003e30.98 \u0026plusmn; 10.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1717%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.2727%;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5556%;\"\u003e\n \u003cp\u003e27 ( 23 - 42.25 )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1717%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.2727%;\"\u003e\n \u003cp\u003eRange (Min-Max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5556%;\"\u003e\n \u003cp\u003e33 ( 21 - 54 )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1717%;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.2727%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5556%;\"\u003e\n \u003cp\u003e21 ( 52.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1717%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.2727%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5556%;\"\u003e\n \u003cp\u003e19 ( 47.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1717%;\"\u003e\n \u003cp\u003e\u0026nbsp;Onset (m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.2727%;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5556%;\"\u003e\n \u003cp\u003e25.6 \u0026plusmn; 21.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1717%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.2727%;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5556%;\"\u003e\n \u003cp\u003e24 ( 6 - 36 )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1717%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.2727%;\"\u003e\n \u003cp\u003eRange (Min-Max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5556%;\"\u003e\n \u003cp\u003e68 ( 4 - 72 )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePre and post-operative tympanogram\u0026nbsp;: There was a highly significant difference between the two studied groups (p= \u0026lt;.001) regarding Pre and post-operative tympanogram in the right and left ear of study group\u0026nbsp;(Table 2).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;(Table 2): Pre and post-operative tympanogram in the right and left ear of study group\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"97%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003ePre-operative\u003cbr\u003e\u0026nbsp;(n = 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22%;\"\u003e\n \u003cp\u003ePost-operative\u003cbr\u003e\u0026nbsp;(n = 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17%;\"\u003e\n \u003cp\u003eTest of Sig.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11%;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28%;\"\u003e\n \u003cp\u003eTympanogram type in the right ear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 17%;\"\u003e\n \u003cp\u003eX2 = 19.371\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 11%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eA\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e12 (30% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22%;\"\u003e\n \u003cp\u003e31 ( 77.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eB\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e15 ( 37.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22%;\"\u003e\n \u003cp\u003e7 ( 17.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eC\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e13 ( 32.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22%;\"\u003e\n \u003cp\u003e2 ( 5% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28%;\"\u003e\n \u003cp\u003e\u0026nbsp;Tympanogram type in the left ear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 17%;\"\u003e\n \u003cp\u003eX2 = 31.746\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 11%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eA\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e10 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22%;\"\u003e\n \u003cp\u003e35 (87.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eB\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e18 (45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22%;\"\u003e\n \u003cp\u003e3 (7.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eC\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e12 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22%;\"\u003e\n \u003cp\u003e2 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003ePre and post-operative valsalva maneuver :There was a highly significant difference between the two studied groups (p= \u0026lt;.001) regarding pre and post-operative valsalva maneuver in the right and left ear among the study population (Table 3).\u003c/p\u003e\n\u003cp\u003e(Table 3): Comparison between pre and post-operative valsalva maneuver in the right and left ear among the study population.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"98%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21%;\"\u003e\n \u003cp\u003ePre-operative\u003cbr\u003e\u0026nbsp;(n = 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 22%;\"\u003e\n \u003cp\u003ePost-operative\u003cbr\u003e\u0026nbsp;(n = 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17%;\"\u003e\n \u003cp\u003eTest of Sig.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11%;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27%;\"\u003e\n \u003cp\u003eValsalva maneuver\u0026nbsp;\u003cstrong\u003eright ear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 22%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 17%;\"\u003e\n \u003cp\u003eX2 = 21.164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 11%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27%;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePositive\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21%;\"\u003e\n \u003cp\u003e28 (70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 22%;\"\u003e\n \u003cp\u003e16 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNegative\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21%;\"\u003e\n \u003cp\u003e12 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 22%;\"\u003e\n \u003cp\u003e24 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27%;\"\u003e\n \u003cp\u003eValsalva maneuver\u0026nbsp;\u003cstrong\u003eleft ear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" valign=\"top\" style=\"width: 18%;\"\u003e\n \u003cp\u003eX2 = 22.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 11%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27%;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePositive\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21%;\"\u003e\n \u003cp\u003e30 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e13 (32.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNegative\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21%;\"\u003e\n \u003cp\u003e10 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e27 (67.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 188px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding ET dysfunction questionnaire (ETDQ-7) items score, there was a highly significant difference between the two groups (Table 4).\u003c/p\u003e\n\u003cp\u003e(Table 4): Comprison between pre and post-operative ET dysfunction questionnaire (ETDQ-7) items score among the study population\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-operative\u003cbr\u003e\u0026nbsp;(n = 40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-operative\u003cbr\u003e\u0026nbsp;(n = 40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest of\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSig.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePressure in the ear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026chi;2 = 34.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 1\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e7 ( 17.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 2\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e10 ( 25% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e20 ( 50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 3\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 ( 7.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e7 ( 17.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 4\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e10 ( 25% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e6 ( 15% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 5\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e17 ( 42.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 6\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 7\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain in the ear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026chi;2 = 37.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 1\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5 ( 12.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e13 ( 32.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 2\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e10 ( 25% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e21 ( 52.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 3\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 ( 5% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e6 ( 15% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 4\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e12 ( 30% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 5\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11 ( 27.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 6\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 7\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026quot;Feeling that your ear clogged or under water\u0026quot;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026chi;2 = 32.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 1\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 ( 10% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e11 ( 27.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003escore 2\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 ( 10% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e18 ( 45% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 3\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5 ( 12.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e5 ( 12.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 4\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e16 ( 40% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e6 ( 15% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 5\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11 ( 27.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 6\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 7\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026quot;Ear symptoms when you have a cold or sinusitis\u0026quot;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026chi;2 = 45.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 1\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 2\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 ( 5% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e17 ( 42.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 3\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6 ( 15% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e17 ( 42.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 4\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 ( 5% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e4 ( 10% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 5\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e7 ( 17.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 6\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e13 ( 32.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e2 ( 5% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 7\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e10 ( 25% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCrackling or popping sound in the ear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026chi;2 = 34.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 1\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e5 ( 12.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 2\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e13 ( 32.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e29 ( 72.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 3\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6 ( 15% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e4 ( 10% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 4\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e21 ( 52.50% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e2 ( 5% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 5\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 6\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eScore 7\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 ( 0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"606\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRinging in the ear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScore 1\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e2 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026chi;2 = 39.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScore 2\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e10 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e32 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScore 3\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e16 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e6 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScore 4\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e14 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScore 5\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScore 6\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScore 7\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFeeling that you hearing is muffled\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScore 1\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e7 (17.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026chi;2 = 36.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScore 2\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e8 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e27 (67.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScore 3\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e2 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScore 4\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e18 (45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e4 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScore 5\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e10 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScore 6\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScore 7\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTotal score in Pre-operative data ranged from 11 to 35 with mean \u0026plusmn; SD = 26.12 \u0026plusmn; 7.79 while in Post-operative data the total score ranged from 9 to 26 with mean \u0026plusmn; SD = 15.35 \u0026plusmn; 4.92 with highly statistical significant difference (p= \u0026lt;.001) between the two groups (Table 5).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;(Table 5): Comparison between pre and post-operative total ET dysfunction questionnaire (ETDQ-7) score among the study population\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ePre-operative\u003cbr\u003e\u0026nbsp;(n = 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ePost-operative\u003cbr\u003e\u0026nbsp;(n = 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eTest of Sig.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003ep- value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eTotal ETDQ-7 score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003et = 7.393\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e26.12 \u0026plusmn; 7.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;15.35 \u0026plusmn; 4.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e30 (19.75 - 32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e15 (13 - 16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eRange (Min-Max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e24 (11 - 35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;17 (9 - 26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eDirect flow of the postnasal drip in paranasal sinusitis into the ET can give rise to diseases in the ET or the middle ear. Inflammatory responses of the mucosa and loss of the mucociliary transport function are also reported as the underlying patho-mechanism of chronic sinusitis that led to the deterioration of the ET function \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTreatment is primarily medical in the form of intra nasal steroids and a short course of systemic steroids and antibiotics. Functional endoscopic sinus surgery (FESS) is a surgical therapy held for cases not responding to medical treatment to remove all pathologies within the paranasal sinuses while sparing normal mucosa and all functionally relevant anatomical structures \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur study can be supported by Choi et al., \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e who reported that patients involved in their study were aged between 20 and 85 years of age with a mean age of 49.2\u0026thinsp;\u0026plusmn;\u0026thinsp;17.83 years of age. Among the 60 cases, male patients were 42 and female patients were 18.\u003c/p\u003e \u003cp\u003eMoreover, Chen et al., \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e reported that the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD age of the enrolled patients was 46.4\u0026thinsp;\u0026plusmn;\u0026thinsp;15.7 years old, however, 67.4% were women. The preoperative ETDQ-7 and SNOT-22 scores of the entire cohort were 13.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3 and 40.0\u0026thinsp;\u0026plusmn;\u0026thinsp;20.9, respectively.\u003c/p\u003e \u003cp\u003eConcerning onset of CRS, it ranged from 4 to 72 with mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u0026thinsp;=\u0026thinsp;25.6\u0026thinsp;\u0026plusmn;\u0026thinsp;21.94.\u003c/p\u003e \u003cp\u003eMarino et al., \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e found a 43.3% prevalence of significant ETD symptoms in patients visiting a tertiary rhinology clinic for the treatment of rhinologic problems.\u003c/p\u003e \u003cp\u003eA previous study by Maniakas et al., \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e have found that in cases of CRS, the prevalence of otologic symptoms was 15%-61%. Ear fullness of equal/greater than 1 was reported in 80/131 CRS patients compared to 45/251 control patients. Ear Pain of equal/greater than 1 was reported in 39/131 CRS patients compared to 33/251 control patients. Following ESS, mean ear fullness and ear pain scores decreased to 1.17 and 0.73, respectively.\u003c/p\u003e \u003cp\u003eMoreover, Rennie et al., \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e showed a significantly higher rate of ETD (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 paired t-test) in the rhinology patients (mean score 3.1, SD 1.64) as compared to a control population (mean 1.3, SD 0.3).\u003c/p\u003e \u003cp\u003eRegarding tympanogram in our study, the pre-operative tympanogram for right ear was type A (30%), type B (37.50%) and type C (32.50%) and differed significantly p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001 post-operative to be type A (77.50%), type B (17.50%) and type C (5%). Also, the same trend of results in the left ear, the pre-operative tympanogram was type A (25%), type B (45%) and type C (30%) and differed significantly p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001 post-operative to be type A (87.50%), type B (7.50%) and type C (5%).\u003c/p\u003e \u003cp\u003eIn concordance with our results Chen et al., \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e showed that After ESS, the proportion of normal tympanic membrane significantly increased to 68.4% (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). ETDQ-7 score of the diagnosed patients with tympanogram significantly reduced at 8\u0026ndash;12 weeks postoperatively (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Meanwhile, 58.3% of type B tympanogram preoperatively changed to type A or type C after ESS (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). These results suggested that at least a certain subset of CRS patients with OME could benefit from ESS alone.\u003c/p\u003e \u003cp\u003eAlso, Bowles et al., \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e reported that type A tympanograms increased from 76.6% pre-operatively, to 94.5% at 3 months and 96% at 9 months also revealed that positive Valsalva increased from 38% pre-operatively to 96% at 3 and 9 months.\u003c/p\u003e \u003cp\u003eOur results showed that there was a highly significant difference between the pre- and post-operative Valsalva maneuver in the right and left ear (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eIn line with our findings Chen et al., \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e reported that the proportion of positive Valsalva maneuver increased remarkably from 14.3% preoperatively to 75.7% at 8\u0026ndash;12 weeks (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eIn harmony with our results Choi et al., \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e revealed that compared with the group without sinusitis, the ESS group showed significant improvement of eustachian-tube function after surgery in the ETDQ-7 (p\u0026thinsp;=\u0026thinsp;0.002), right Valsalva test (p\u0026thinsp;=\u0026thinsp;0.015), right deflation test (p\u0026thinsp;=\u0026thinsp;0.005), and left deflation test (p\u0026thinsp;=\u0026thinsp;0.006). A binary logistic regression analysis revealed that ESS significantly improved eustachian-tube function in the right Valsalva test in a univariate (p\u0026thinsp;=\u0026thinsp;0.021) and multivariate analysis (p\u0026thinsp;=\u0026thinsp;0.008), and eustachian-tube function in the left deflation test in a univariate (p\u0026thinsp;=\u0026thinsp;0.021) and multivariate analysis (p\u0026thinsp;=\u0026thinsp;0.039).\u003c/p\u003e \u003cp\u003eThese findings indicate that eustachian-tube function is significantly improved after ESS in adult sinusitis patients, and that the presence of sinusitis and implementation of ESS should be considered (if sinusitis is present) in managing patients with ear diseases that are affected by eustachian-tube function. For the symptom score, the median total postoperative ETDQ-7 symptom score was 9.67 in the ESS group and 12.0 in the control group.\u003c/p\u003e \u003cp\u003eAlso, Chen et al., \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e reported that ETDQ-7 score in CRS patients with ETD statistically decreased exceeding the MCID postoperatively at 8\u0026ndash;12 weeks (20.13\u0026thinsp;\u0026plusmn;\u0026thinsp;6.18 VS 8.63\u0026thinsp;\u0026plusmn;\u0026thinsp;3.62, P\u0026thinsp;=\u0026thinsp;0.002). In addition, 85.7% of patients reached a normalization of ETDQ-7 score at this follow-up time point, which indicated they were totally free of ETD symptoms.\u003c/p\u003e \u003cp\u003eAdditionally, the mean ETDQ-7 and SNOT-22 scores decreased significantly to 8.2 and 17.0, respectively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all). There were 23 patients who reported ETD before ESS. The mean preoperative, postoperative 3-month, 6-month, 9-month, and 1-year ETDQ-7 score was 25.2, 10.6, 8.4, 8.0, and 7.7, respectively. The ETDQ-7 score was significantly decreased from preoperative to postoperative 3 month (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and from postoperative 3 month to postoperative 6 month (p\u0026thinsp;=\u0026thinsp;0.028). One- year post-ESS, 18 patients (78.3%) reported no otologic symptoms, five patients (21.7%) reported some otologic symptoms, and no patients reported ETD.\u003c/p\u003e \u003cp\u003eAlso, Wu et al., \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e who aimed to study ET quality of life and severity of disease in patients with CRS, reported that thirty-nine (47.6%) patients had ETDQ-7 score\u0026thinsp;\u0026ge;\u0026thinsp;14.5, signifying clinically significant ETD symptoms. The mean ETDQ-7 score of the study population was 15.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8 and the mean SNOT-22 score was 37.5\u0026thinsp;\u0026plusmn;\u0026thinsp;19.7. The Pearson and Spearman correlation coefficients between ETDQ-7 and the total SNOT-22 score were 0.52 (P\u0026thinsp;\u0026gt;\u0026thinsp;.0001) and 0.51 (P\u0026thinsp;\u0026lt;\u0026thinsp;.0001), respectively. There was significant improvement in ETDQ-7 scores postoperatively.\u003c/p\u003e \u003cp\u003eA meta-analysis by Chen et al., \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e reported that sixteen studies were included: nine studies with 1336 consecutive patients with CRS and seven studies with 161 patients with primary ETD. In studies with specific data, 225 (47.2%) patients with CRS had a score\u0026thinsp;\u0026gt;\u0026thinsp;14.5, consistent with ETD. In CRS\u0026thinsp;+\u0026thinsp;ETD, baseline mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) ETDQ-7 score was 20.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4 and did not differ by polyp status. In primary ETD, mean ETDQ-7 score was significantly higher than CRS\u0026thinsp;+\u0026thinsp;ETD (29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003eRegarding treatment outcomes, CRS\u0026thinsp;+\u0026thinsp;ETD treated with endoscopic sinus surgery (ESS) alone resulted in mean ETDQ-7 in the normal range (13.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3), with a mean change of \u0026minus;\u0026thinsp;7.4 (95% confidence interval [CI], \u0026minus;\u0026thinsp;10.82 to \u0026minus;\u0026thinsp;3.99) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.00001). Patients with primary ETD treated with ETBD had postoperative ETDQ7 scores of 14.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5 with mean change of \u0026minus;\u0026thinsp;13.9 (95% CI, \u0026minus;\u0026thinsp;18.01 to \u0026minus;\u0026thinsp;9.88), p\u0026thinsp;\u0026lt;\u0026thinsp;0.00001.\u003c/p\u003e \u003cp\u003eA recently published study by Bowles et al., \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e prospectively assessed changes in ETDQ-7 after ESS for CRS, reporting that mean ETDQ-7 scores were significantly lower at 3 months; mean equals 11.4 (SD plus or minus 5.65) (P less than 0.0001) and 9 months mean equals 11.4 (SD plus or minus 6.15) (P less than 0.0001). Mean ETDQ-7 scores were higher in the CRSwNP group; 24.34 (SD plus or minus 9.2) compared to the CRSsNP group; 18.11 (SD plus or minus 10.3), (p equals 0.6101).\u003c/p\u003e \u003cp\u003eHiggins et al., \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e who aimed to assess predictors of ET dysfunction improvement and normalization in a sample of CRS patients after endoscopic sinus surgery, reported that overall, the mean preoperative ETDQ-7 score of 3.450 (standard deviation [SD]\u0026thinsp;\u0026plusmn;\u0026thinsp;1.061) statistically significantly improved to a mean postoperative ETDQ-7 score of 2.164 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;1.206, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Eighty-three percent (83%) of the patients had ETDQ-7 improvement exceeding the MCID and 63% of the patients had ETDQ-7 normalization.\u003c/p\u003e \u003cp\u003eLee et al., \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e retrospectively reviewed patients who underwent ESS and/or septoplasty. The patients were divided into 3 groups according to the type of surgery: group A, septoplasty alone (76 patients); group B, ESS alone (209 patients); and group C, septoplasty\u0026thinsp;+\u0026thinsp;ESS (74 patients). Their study reported that the prevalence of ETD was 28.9% (22 patients) in group A, 27.3% (57 patients) in group B and 31.1% (23 patients) in group C. The ETDQ-7 score decreased significantly after surgery: total patient population, 12.47\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0 to 8.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.48 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); group A, 12.76\u0026thinsp;\u0026plusmn;\u0026thinsp;6.62 to 8.47\u0026thinsp;\u0026plusmn;\u0026thinsp;2.66 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); group B, 12.05\u0026thinsp;\u0026plusmn;\u0026thinsp;6.89 to 8.35\u0026thinsp;\u0026plusmn;\u0026thinsp;2.73 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); and group C, 13.24\u0026thinsp;\u0026plusmn;\u0026thinsp;7.72 to 7.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis nonrandomized clinical trial phase revealed a significant improvement in ET function in form of (tympanogram, valsalva maneuver and total ET dysfunction questionnaire score), following endoscopic sinus surgery in adult patients with CRS with or without sinonasal polyposis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to participate:\u0026nbsp;\u003c/strong\u003eis taken from ethical committee kasralainy cairo university number;Ms 5662023\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding :\u003c/strong\u003e No funding\u003c/p\u003e\u003cp\u003e\u003cb\u003eAuthor Contribution\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAuthors' contributions: MY ,NT was mainly involved in doing the surgical part of the research. TA designed the work, the acquisition, analysis, interpretation of data. MA prepared the patients preoperatively and followed their up postoperatively and was responsible for following and obtaining the audiology investigations. All the authors approved the submitted version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLlewellyn A, Norman G, Harden M, Coatesworth A, Kimberling D, Schilder A et al (2014) Interventions for adult Eustachian tube dysfunction: a systematic review. Health Technol Assess (Winchester Eng) 18:1\u0026ndash;180\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchilder A, Bhutta M, Butler C, Holy C, Levine L, Kvaerner K et al (2015) Eustachian tube dysfunction: consensus statement on definition, types, clinical presentation and diagnosis. Clin Otolaryngol 40:407\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi KY, Jang S, Seo G, Park S-K (2021) Effect of endoscopic sinus surgery on Eustachian tube function in adult sinusitis patients: a prospective case-control study. J Clin Med 10:4689\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith M, Tysome J (2015) Tests of Eustachian tube function: a review. Clin Otolaryngol 40:300\u0026ndash;311\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSettipane RA, Peters AT, Chandra R (2013) Chronic rhinosinusitis. Am J Rhinol Allergy 27:S11\u0026ndash;S5\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiechelmann H (2013) Chronische Rhinosinusitis\u0026ndash;EPOS 2012 Teil I. Laryngo-rhino-otologie. ;92:193\u0026ndash;204\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBitter T, Guntinas-Lichius O (2019) Funktionelle endoskopische Nasennebenh\u0026ouml;hlenchirurgie (FESS). Laryngo-rhino-otologie. ;98:429\u0026thinsp;\u0026ndash;\u0026thinsp;43\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Roeyen S, Van de Heyning P, Van Rompaey V (2015) Value and discriminative power of the seven-item eustachian tube dysfunction questionnaire. Laryngoscope 125:2553\u0026ndash;2556\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGohar MS, Niazi SA, Niazi SB (2017) Functional Endoscopic Sinus Surgery as a primary modality of treatment for primary and recurrent nasal polyposis. Pak J Med Sci 33:380\u0026ndash;382\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen T, Shih MC, Edwards TS, Nguyen SA, Meyer TA, Soler ZM et al (eds) (2022) Eustachian tube dysfunction (ETD) in chronic rhinosinusitis with comparison to primary ETD: a systematic review and meta-analysis. International Forum of Allergy \u0026amp; Rhinology\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarino MJ, Ling LC, Yao WC, Luong A, Citardi MJ (eds) (2017) Eustachian tube dysfunction symptoms in patients treated in a tertiary rhinology clinic. International Forum of Allergy \u0026amp; Rhinology\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManiakas A, Desrosiers M, Asmar M-H, Al Falasi M, Mfuna Endam L, Hopkins C et al (2018) Eustachian tube symptoms are frequent in chronic rhinosinusitis and respond well to endoscopic sinus surgery. Rhinology 56:118\u0026ndash;121\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRennie C, Gutierrez M, Darby Y, Lund V (2018) Investigation of the incidence of eustachian tube dysfunction in patients with sinonasal disease. Rhinol Online 1:85\u0026ndash;89\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen X, Dang H, Chen Q, Chen Z, Ma Y, Liu X et al (2021) Endoscopic sinus surgery improves Eustachian tube function in patients with chronic rhinosinusitis: a multicenter prospective study. Rhinology 59:560\u0026ndash;566\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowles PF, Agrawal S, Salam MA (2019) Eustachian Tube dysfunction in chronic rhinosinusitis: pre and post-operative results following endoscopic sinus surgery, a prospective study. Rhinology 57:73\u0026ndash;77\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu AW, Walgama ES, Higgins TS, Borrelli M, Vardanyan N, Hopp S et al (2020) Eustachian tube quality of life and severity of disease in patients with chronic rhinosinusitis. Am J Rhinol Allergy 34:532\u0026ndash;536\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiggins TS, Cappello ZJ, Wu AW, Ting JY, Sindwani R (2020) Predictors of eustachian tube dysfunction improvement and normalization after endoscopic sinus surgery. Laryngoscope 130:E721\u0026ndash;E6\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee IH, Kim DH, Kim SW, Kim SW (2022) Changes in symptoms of Eustachian tube dysfunction after nasal surgery. Eur Arch Otorhinolaryngol 279:5017\u0026ndash;5023\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-otolaryngology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Otolaryngology](https://ejo.springeropen.com/)","snPcode":"43163","submissionUrl":"https://submission.springernature.com/new-submission/43163/3","title":"The Egyptian Journal of Otolaryngology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chronic Rhinosinusitis, Eustachian Tube Dysfunction, Endoscopic Sinus Surgery","lastPublishedDoi":"10.21203/rs.3.rs-5255715/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5255715/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChronic rhinosinusitis (CRS) is a frequent chronic heterogeneous inflammatory disease of the upper airways and paranasal sinuses persistent for \u0026ge;\u0026thinsp;12 weeks causing considerable healthca,re expenses and reduction of patients\u0026rsquo; quality of life due to severe tiredness, disappointment, as well as diminished cognitive function. CRS is commonly associated with eustachian tube (ET) dysfunction.\u003c/p\u003e\u003ch2\u003eAim of the study:\u003c/h2\u003e \u003cp\u003eTo evaluate the effect of endoscopic sinus surgery on ET function in the form of (tympanogram, Valsalva maneuver, and total ET dysfunction questionnaire score), in adult patients with CRS.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis non-randomized clinical trial study was conducted at the Otorhinolaryngology department, the Faculty of Medicine, Cairo University on 40 patients\u0026thinsp;\u0026gt;\u0026thinsp;18 years old, suffering from CRS with or without Sino-nasal polyposis who are indicated for endoscopic sinus surgery (ESS) and were recruited from Otorhinolaryngology department\u0026rsquo;s outpatient clinic in the period from November 2022 to June 2023. All selected patients were subjected to a full history taken, a full general examination, and a local otorhinolaryngology examination. Routine preoperative laboratory investigation including complete blood count (CBC), liver and kidney function tests, and coagulation profile. An electrocardiogram (ECG) examination was done routinely for all patients above 40 years old. Radiological examination included; preoperative CT nose \u0026amp; paranasal sinus, axial and coronal cuts soft tissue \u0026amp; bone windows. Assessment of ET function was done using The ET Dysfunction Questionnaire (ETDQ-7), Valsalva maneuver, and Tympanogram. ET function was reevaluated 6 weeks post-operative in the form of an ETDQ-7, Valsalva maneuver, and tympanogram.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe ages of selected patients ranged from 21\u0026ndash;45 years old with mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u0026thinsp;=\u0026thinsp;30.98\u0026thinsp;\u0026plusmn;\u0026thinsp;10.24 years old. 52.5% of patients were males. Our results showed a statistically significant postoperative improvement in the Valsalva maneuver and the tympanogram type of both ears compared to preoperative with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Similar results were found regarding the assessment of ET function using ETDQ-7 items and the total score (15.35\u0026thinsp;\u0026plusmn;\u0026thinsp;4.92 vs 26.12\u0026thinsp;\u0026plusmn;\u0026thinsp;7.79 respectively) with p-value: \u0026lt; 0.001.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eA significant improvement in ET function in the form of (tympanogram, Valsalva maneuver, and total ET dysfunction questionnaire score), following endoscopic sinus surgery in adult patients with CRS with or without sinonasal polyposis.\u003c/p\u003e","manuscriptTitle":"Effect Of Endoscopic Sinus Surgery on Eustachian Tube Function in Adult Patients with Chronic Rhinosinusitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-12 15:14:20","doi":"10.21203/rs.3.rs-5255715/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-06T16:59:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-31T09:48:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-31T09:46:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Journal of Otolaryngology","date":"2024-10-13T14:14:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-otolaryngology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Otolaryngology](https://ejo.springeropen.com/)","snPcode":"43163","submissionUrl":"https://submission.springernature.com/new-submission/43163/3","title":"The Egyptian Journal of Otolaryngology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"55bf48ed-6dd0-497e-89a1-2c6f46302276","owner":[],"postedDate":"November 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-01-17T16:38:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-12 15:14:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5255715","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5255715","identity":"rs-5255715","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}