Global Journal of Otolaryngology ISSN 2474-7556 Research Article Glob J Otolaryngol Volume 14 Issue 4 - April 2018 Copyright © All rights are reserved by Yazeed Ali Alshawi DOI: 10.19080/GJO.2018.14.555896 The Effect of Valsalva and Toynbee Maneuvers on Tympanometry Parameters in Normal and Retracted Tympanic Membrane Yazeed Alshawi1*, Abdulmalik Ismail2, Nora Almegil3 and Zaid almubarak4 1Department of Otology/ Neurotology, king Abdulaziz University Hospital, Saudi Arabia 2Department of Otolaryngology and Head and Neck, Prince Sultan Military Medical City, Riyadh, Saudi Arabia 3Department of Audiology, Security Forces Hospital, Riyadh, Saudi Arabia 4Department of Otolaryngology and Head and Neck, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia Submission: March 26, 2018; Published: April 17, 2018 *Corresponding author: Yazeed Ali alshawi, Senior registrar at Prince Sultan Medical Military Center, Otology/ Neurotology fellow at king Abdulaziz University Hospital, Riyadh, Saudi Arabia, Email: Abstract It plays a major role in equalizing the pressure between the external environment and middle ear and in protecting the middle ear from nasopharyngealThe Eustachian secretions. tube, also Dysfunction known as auditoryof Eustachian tube, tubeis a bony may andcause fibro negative cartilagenous pressure tube to buildup that connects in the middlethe middle ear, earleading to the to nasopharynx. retraction of the pathogenesis of otitis media and in its management. Nowadays, numerous Eustachian tube function tests exist, one of the most commonly usedthe tympanic is tympanometry membrane which or collection may be combinedof fluid in withthe middle Valsalva ear. maneuver The diagnosis and Toynbee of Eustachian maneuver. tube Kumazawa dysfunction et isal. important diagnosed in Eustachian understanding tube pathologies by asking his patients to perform Valsalva and Toynbee maneuvers and took tympanogram measurements for his patients. He then categorized his patients, based on their readings, into patient with Eustachian tube dysfunction, patients with normal Eustachian tubes and patients with patulous Eustachian tube. The purposes of the present study were to evaluate the variation in middle ear pressure in patients with type A tympanogram (normal tympanic membrane) and type C tympanogram (retracted tympanic membrane) during Eustachian tube function tests. Additionally, to evaluate the time effectiveness of Valsalva maneuver on pressure parameter and to compare these effects between type on those with retracted tympanic. Although it did not in type A group, the effect of Valsalva maneuver lasted longer than 10 minutes in type C group.A and typeFurther C tympanogram. studies with a Welarger found sample that, size Valsalva and different maneuver tests had of aEustachian significant tube effect function on middle are recommended ear pressure in for both better normal understanding population of and the duration of the effect of Valsalva maneuver on middle ear pressure. Introduction be combined with Valsalva maneuver (blowing against a The Eustachian tube, also known as auditory tube, is a closed mouth and nostrils, increasing the middle ear pressure) and Toynbee maneuver (swallowing while the mouth and ear to the nasopharynx. It plays a major role in equalizing the bony and fibrocartilagenous tube that connects the middle nostrils are closed, decreasing the middle ear pressure) [4,5]. pressure between the external environment and middle ear and Kumazawa, et al. diagnosed Eustachian tube pathologies by to protect the middle ear from nasopharyngeal secretions [1]. asking his patients to perform Valsalva and Toynbee maneuvers Dysfunction of Eustachian tube may cause negative pressure to and took tympanogram measurements for his patients. He buildup in the middle ear, leading to retraction of the tympanic then categorized his patients, based on their readings, into patient with Eustachian tube dysfunction, patients with normal tube dysfunction is considered one of the main factors for otitis membrane or collection of fluid in the middle ear [2]. Eustachian Eustachian tubes and patients with patulous Eustachian tube media with effusion (OME), and secondary cholesteatoma [3]. [6]. The diagnosis of Eustachian tube dysfunction is important in understanding the pathogenesis of otitis media and in its The purposes of the present study is to evaluate the variation management. in middle ear pressure in patients with type A tympanogram (normal tympanic membrane) and type C tympanogram Nowadays, numerous Eustachian tube function tests exist, (retracted tympanic membrane) during Eustachian tube one of the most commonly used is tympanometry which may Glob J Otolaryngol 14(4): GJO.MS.ID.555896 (2018) 00118 Global Journal of Otolaryngology function tests, Valsalva, and Toynbee maneuvers. Additionally, to Sampling Technique: evaluate the time effectiveness of Valsalva maneuver on pressure The sampling technique we used is systemic randomization. parameter and to compare these effects between type A and type We included every third Saudi adult patient that presented to the C tympanogram. otology clinic. Methodology Data Collection Methods, Instruments Used, And Objectives of the study Measurements Aim of the Study: To study the difference in the duration of Instruments Used the effect of Valsalva maneuver on middle ear pressure between a. GSI TympStar Version 1 Middle-Ear Analyzer: type A and type C tympanograms. b. It is a computer-based admittance instrument designed Secondary Objectives: to be used in clinical or research settings. The TympStar is based a) To study the difference in effectiveness of Valsalva maneuver on middle ear pressure between type A and type C offering unparalleled testing capabilities. on the sophistication, functionality and flexibility of the GSI 33, tympanograms. In this study: b) To study the difference in effectiveness of Toynbee i. Admittance (Y) was measured with a probe tone maneuver on middle ear pressure between type A and type C frequency of 226 Hz in a Screening tympanometry mode tympanograms. (Automatic). Materials and Methods ii. P-RANGE daPa: Normal. This study is a cross sectional study which was done in iii. START daPa: +200. a tertiary hospital in Riyadh, Saudi Arabia in the outpatient department of otolaryngology and head & neck surgery, It was iv. Gradient: Tymp Width daPa. done by performing serial tympanograms and comparing the v. P-RATE daPa/s: 600/200. results between 2 groups Diagnostic Criteria a) Type A: Normal tympanic membrane (control group) and Tympanometry Normative Data Based on the British Society Of Audiology: b) Type C: Retracted tympanic membrane group. a) Study Subjects i. Tympanic peak pressure and middle ear pressure: Under carefully controlled conditions the 95 % range a) Inclusion Criteria: ii. in normal subjects is –20 to +20daPa, though pressures from –50 i. Every third Saudi adults (above age of 13) patient that to +50 daPa can be considered normal in adults; pressures down presented to the otology clinic. ii. Male and female patients. to –100iii. daPaAdmittance may be ofor acompliance: little clinical significance in isolation. iv. Compliance is normally in the range 0.3 to 1.6cm3 in October 2016 to end of march 2017. adults; 0.2 cm3 is acceptable as the lower limit in children aged iii. Patients that presented to the clinic from first of iv. Patients with tympanogram type A and C. less than 6 years but over 6 months. b) Exclusion Criteria: v. Ear-canal volume: i. pediatric (bellow 13 years of age) Patients. vi. Typical values for ear-canal volume (ECV) are between 0.6-1.5 cm3 for adults. ii. Patients with tympanogram type B. b) Based on studies reviewed in Hunter and Shahnaz iii. Any patient with craniofacial anomalies (2013). Study Design All Patients underwent 4 tympanograms This study is a cross-sectional study. i. Tympanogram I: patients underwent a baseline Sample Size tympanogram. ii. Tympanogram II: patients were asked to perform inclusion and exclusion criteria. Valsalva maneuver, then immediately underwent a second The sample size of this study is 161 years who fulfilled our tympanogram. How to cite this article: Yazeed Alshawi, Abdulmalik Ismail, Nora Almegil, Zaid almubarak. The Effect of Valsalva and Toynbee Maneuvers on Tympanometry 00119 Parameters in Normal and Retracted Tympanic Membrane. Glob J Oto, 2018; 14(4): 555896. DOI: 10.19080/GJO.2018.14.555896 Global Journal of Otolaryngology iii. Typanogram III: patients were asked to take a 10 minutes break, then underwent a third tympanogram. type C group with respect to demographic characteristics. The 1. There was no significant difference between the type A and tympanometry parameters for type A and C groups that were iv. Tympanogram IV: Patients were asked to perform obtained in pre-Valsalva (I), immediate post-Valsalva (II), 10 Toynbee maneuver, then underwent a fourth tympanogram. minutes post-Valsalva (III) and immediately post-Toynbee Data Management and Analysis maneuver (IV) are illustrated in Tables 2 & 3 respectively. The data was analyzed using SPSS. Tympanogram variables Table 2: Type A tympanogram Group. were analyzed which included: external auditory canal volume, Type A group E.C.V Pressure Compliance Gradient pressure, compliance and gradient. The mean, standard Tympanometry I 1.1577 8.9231 0.6438 83.6047 Tympanometry II 1.1985 22.3846 0.6815 79.5736 Ethical Consideration deviation, and confidence interval were calculated. Tympanometry III 1.1762 10.9231 0.6546 86.5116 Tympanometry IV 1.1754