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Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 60-64

Otological manifestations in oral submucous fibrosis: Our experiences

Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission29-Nov-2021
Date of Decision04-Dec-2021
Date of Acceptance06-Dec-2021
Date of Web Publication12-Apr-2022

Correspondence Address:
Dr. Santosh Kumar Swain
Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mtsm.mtsm_18_21

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Background: Oral submucous fibrosis (OSMF) is a chronic premalignant condition seen in the oral cavity, but sometimes extends to the pharynx, esophagus, or even the larynx. OSMF causes stiffness in the oral cavity leads to trismus and affects speech and swallowing. Sometimes this lesion affects the Eustachian tube opening at the nasopharynx which results in Eustachian tube dysfunction followed by middle ear diseases. The purpose of the present work is to evaluate otological manifestations in OSMF patients. Materials and Methods: Patients with OSMF were evaluated for otological manifestations such as hearing impairment and fullness in the ear. All of them were evaluated with pure tone audiometry and tympanometry. Results: In this study group of 58 patients of OSMF comprising 116 ears, the hearing was within the normal limit in 60 ears (51.72%), a mild degree of conductive deafness in 52 ears (44.82%), a mild degree of sensorineural deafness in 2 ears (1.72%) and a moderate degree of sensorineural deafness were present in 2 ears (1.72%). There is a significant difference in mean quantitative hearing impairment was seen in OSMF groups C and group D with respect to the control group. Conclusion: Involvements of palatal muscles in OSMF patients reduce the patency of the Eustachian tube, resulting in a conductive type of deafness. OSMF patients should be assessed for hearing impairment and suggested for proper management.

Keywords: Eustachian tube, hearing impairment, oral submucous fibrosis, otological manifestations

How to cite this article:
Swain SK, Agrawala R. Otological manifestations in oral submucous fibrosis: Our experiences. Matrix Sci Med 2022;6:60-4

How to cite this URL:
Swain SK, Agrawala R. Otological manifestations in oral submucous fibrosis: Our experiences. Matrix Sci Med [serial online] 2022 [cited 2022 Dec 2];6:60-4. Available from: https://www.matrixscimed.org/text.asp?2022/6/2/60/343048

  Introduction Top

Oral submucous fibrosis (OSMF) is a premalignant lesion that mostly affects the oral cavity, but can also affect the pharynx, esophagus, and even the larynx.[1] OSMF has traditionally been described as a chronic, insidious, scarring lesion of the oral cavity. It is characterized by a juxta-epithelial inflammatory reaction in the oral cavity which causes fibroelastic changes in the lamina propria with epithelial atrophy, leading to stiffness of the oral cavity resulting in trismus.[2] OSMF was first documented by Schwartz in 1952 among 5 East African women of Indian origin.[3] OSMF is commonly found in Asians those chew betel nut quid or its variant like gutkha, kiwam, zarda, and pan masala which are available as packaged dried products.[4] The traditional quid rolled in betel leaf (pan) is commonly chewed in Indian people, an important etiological agent for causing OSMF.[5] The easy availability of these OSMF producing ingredients resulting increase incidence of OSMF. The cartilaginous part of the Eustachian tube and its muscle are dynamic portions that help in ventilatory function and patency of the Eustachian tube.[6] The important muscles attached to the Eustachian tube and soft palate are tensor veli palatini and levator palatini.[7] These two muscles and few other accessory muscles are called as palatal or paratubal muscles, affected by the OSMF.[7] OSMF affect Eustachian tube function and result in middle ear diseases such as hearing impairment.

There is a paucity of studies related to OSMF with otological manifestations in the medical literature. The goal of this study is to see if there's a link between OSMF and otological symptoms like hearing loss.

  Materials and Methods Top

This is a retrospective study carried out at the department of otorhinolaryngology for the evaluation of otological manifestations in patients with OSMF from July 2019 to August 2021. This study was approved by the Institutional Ethics Committee (IEC) with reference number IEC/SOA/IMS/2019/11/22.6.2019. The written informed consent was taken from each participant of this study. Detail clinical profiles of the patients were taken through history taking along with a clinical examination of the patient. Patients of OSMF with hearing impairment or feeling of blockage sensations in-ear were included in this study. Detailed examinations of the ear, oral cavity, and oropharynx were done for each patient who participated in this study. The detailed ear and oral cavity examinations were done by senior authors. The otoscopic examination was done in each patient to rule out any infections and any other abnormalities of the ear. Patients diagnosed with OSMF were included in this study. Patients with pathology in the ear such as tympanic membrane perforation, otomycosis, otitis externa, cholesteatoma, or previous surgery were excluded from this study. Audiological assessment of each patient was done with help of an audiometer (ALPS International, New Delhi). Both right and left ears of all patients were evaluated for air conduction (AC) hearing loss and bone conduction (BC) hearing loss. The study group consisting of 58 patients with OSMF [Figure 1], who were classified into 4 groups such as Group A (Inter-incisional distance ≥35 mm), Group B (30–35 mm), Group C (20–30 mm), and Group D (<20 mm) using the clinical classification of OSMF by Lai.[8] Group A include 18 patients, Group B includes 15 patients, Group C include 15 patients and group D includes 10 patients. The control group comprised 40 healthy participants [Table 1]. The hearing impairment can be graded into different types by the AC threshold i.e., 10–25 decibel indicate normal hearing; 26–40 decibels indicate mild hearing loss; Moderate hearing loss indicate 41–55 decibel; severe indicates 56–70 decibel; very severe indicate 71–90 decibel and profound >90 decibels. Hearing impairment can be classified into normal, conductive, mixed, or sensorineural hearing loss. The overall degree and type of hearing loss were described in a single word by using the quantitative and qualitative types of hearing impairment together.
Figure 1: Oral cavity of oral submucous fibrosis patients

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Table 1: Demographic details of patients with oral submucous fibrosis participated in study (n=58)

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Statistical Package for the Social Science (SPSS) Statistics for Windows, version 20, was used for all statistical analyses (IBM-SPSS Inc., Chicago, IL, USA). P < 0.05 indicated that the difference was statistically significant.

  Results Top

In this study group of 58 patients of OSMF comprising 116 ears, the hearing was normal in 60 ears (51.72%), mild conductive hearing loss in 52 ears (44.82%), mild sensorineural hearing loss in 2 ears (1.72%), and moderate sensorineural hearing loss were present in 2 ears (1.72%) [Table 2]. Among the 80 ears in 40 patients of the control group, the hearing was normal in 76 ears (95%), and mild conductive hearing loss in 4 ears (5%). The mean age of the participants including the control is 34.62 ± 52 years. There were 36 (62.02%) male patients with OSMF and 22 (37.93%) female OSMF patients in the study group. The mean quantitative hearing loss in decibels in the right ear was 24.04 ± 8.91 decibel and that in the left ear was 24.16 ± 7.08 decibel. Paired t-test was applied to assess the association among OSMF groups and quantitative hearing impairment in the right and left ear respectively. There was no significant difference in mean quantitative hearing impairment found for OSMF groups A and B, whereas a significant difference of mean quantitative hearing impairment was seen in OSMF groups C and group D, relative to the control group [Table 3].
Table 2: Oral submucous fibrosis with hearing impairment

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Table 3: Mean quantitative hearing loss (decibels) in both ears among different oral submucous fibrosis groups and controls

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Tympanometry was done in all participating patients to find out Eustachian tube dysfunction [Figure 2] and middle ear diseases. Out of 116 ears examined, a normal tympanogram (Type-A) was found in 78 (%) ears, abnormal tympanograms such as a type-B curve in 22 (%) and type C curve in 16 (%) of the ears. In the control group, out of 80 ears, 75 ears showed normal tympanogram (Type A), 2 ears showed type B tympanogram and 3 ears showed type C tympanogram [Table 4]. There is a significant difference between type B and type C in the OSMF group relative to the control group (P < 0.001).
Figure 2: Fibrotic bands around Eustachian tube opening at nasopharynx

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Table 4: Comparison of tympanogram between oral submucous fibrosis group (n=116 ears) and normal group (n=80 ears)

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  Discussion Top

OSMF is a chronic insidious disease of the oral cavity and sometimes involves the pharynx.[9] OSMF is often associated with a juxta-epithelial inflammatory reaction with fibroelastic changes at the lamina propria, with atrophy of epithelium resulting in stiffness of the oral mucosa which causes trismus.[10] OSMF affects about 0.2%–1.2% of the Indian population and is predominantly found in people of India, Bangladesh, Pakistan, Sri Lanka, Taiwan, and Southern China where consumption of areca nut or its flavored formulations or as an ingredient in the betel quid is more common.[11] The diameter of the Eustachian tube is approximately 3 mm.[12] The cartilaginous part of the Eustachian tube provides support to the medial two-thirds, whereas the lateral third-get support by the bony part of the Eustachian tube.[12] Traditionally, there were 4 muscles are associated with the Eustachian tube such as the tensor veli palatini, levator veli palatini, salpingopharyngeus, and tensor tympani. Each muscle is directly or indirectly related to the Eustachian tube function. The Eustachian tube is usually closed, but it opens at the time of swallowing, yawning, or sneezing, so permitting the equalization of the atmospheric and middle ear pressure.[13] The ventilatory function and patency of the Eustachian tube may be defective if any of these muscles are affected by OSMF.[12] Involvement of the paratubal and palatal muscles (tensor veli palatini, tensor tympani, levator veli palatini, and salpingopharyngeus) affect the patency and function of the patency of the Eustachian tube. Narrowing of the Eustachian tube in OSMF patients causes failure to regulate the pressure of the middle ear. It leads to pain in the ear along with hearing impairment.[14]

OSMF is usually seen in the second and third decades of life with predominance in males.[15] OSMF patients often present with a burning sensation in the oral cavity, pain, ulcerations, decreased movement and depapillation of the tongue, leathery and blanching texture of the mucosal lining of the oral cavity, and progressive reduction of mouth opening.[16] Advanced cases of OSMF may present with hearing impairment because of Eustachian tube blockage and difficulty in swallowing due to esophageal fibrosis.[12] OSMF may be associated with vesicles formation and juxta-epithelial inflammation followed by fibroelastic changes in the lamina propria with epithelial atrophy resulting in stiffness of the oral mucosa leading to trismus.[17] Involvement of fibrosis at nasopharynx affects the pharyngeal orifice of the Eustachian tube and changes the muscles which are associated with functions of the Eustachian tube. The Eustachian tube (pharyngotympanic tube) connects the middle ear to the nasopharynx. Closing and opening of the Eustachian tube are important from the physiological point of view. Normal Eustachian tube opening serves to equalize the air pressure in the middle ear, whereas normal Eustachian tube closure protects the middle ear from nasopharyngeal secretion reflux and protects against loud sounds.[18] Dysfunction of the Eustachian tube may result in pathological changes in the middle ear. Eustachian tube dysfunction can result in hearing disabilities.[12] As the functions of the Eustachian tube worsens, air pressure in the middle ear decreases, and ear sounds are perceived as muffled and may result in hearing impairment and ear pain.[19] Hearing impairment can be correlated with the degree of fibrosis in palatal muscles, so decrease the patency of the Eustachian tube. The advanced stage of OSMF is directly associated with the degree of fibrosis of the palatal muscles. In OSMF patients with otological manifestations, the patient may get middle ear pathology where pure tone audiometry often presents the conductive type of hearing loss in the affected side of the Eustachian tube. The patients often show mild to the moderate conductive type of hearing loss.

Based on AC - BC gap values, the hearing impairment is usually quantified into different types such as 0–25 decibel-Normal hearing; 26–40 decibel-mild deafness; 41–55 decibel-moderate deafness; 56–70 decibel-moderate to severe hearing loss; 71–90 decibel-severe hearing loss and more than 90 decibel suggests profound hearing loss.[20],[21] Tympanometry test may show type B and C types of tympanograms in case of Eustachian tube dysfunction and otitis media with effusion respectively by OSMF patients.[22] All patients with OSMF with fibrotic bands and ulcerations in the oral cavity should undergo a biopsy to confirm the diagnosis and also correlate the clinical and histopathological findings. Incisional biopsy should be taken from these areas to rule out any atypia or malignancy. The confirmatory diagnosis of OSMF is done by a histopathological study from the fibrotic lesions in the oral cavity. Tissues from the buccal mucosa with restricted mouth opening show severe degenerative changes in a high proportion of muscle fibers. These muscle fibers contain large pools of homogenous material muscle cells or fibers showing complete loss of their plasma membrane.[23] These muscles fibers are usually surrounded by edematous fluid. Gupta et al. described the histopathological changes in the palatal or paratubal muscles in OSMF patients and showed atrophy and edematous infiltration of the tubal and paratubal muscles.[24] Depending based on the stage of OSMF, various management therapies are available which include medical and surgical approaches. There is no definitive treatment available for curing the OSMF other than several treatment options. No single medication or drug has effectively reversed the initiation and development of the OSMF.

The medical treatment is mainly symptomatic and aims to improve the opening of the mouth. Patients with OSMF who have trismus and/or a biopsy that reveals dysplastic or neoplastic change should have surgery. The medical treatment is usually often aimed to improve the mouth opening and hearing impairment in OSMF patients. Intralesional injection of steroids/betamethasone, placentrex, and hyaluronidase may help to relieve the restricted mouth opening and burn sensation in the mouth.[25] Surgical treatment in OSMF is suggested when the patient presents with OMSF with trismus and biopsy can be suggested to rule out any malignant or dysplastic lesions in the oral cavity. Release and excision of the fibrotic bands in the oral cavity are important surgical steps for preventing further complications and are often thought of as challenging tasks for surgeons. Although there are several surgical approaches are available, several morbid outcomes likely to be seen as raised fibrotic changes following the postsurgical period. Surgical excision of the fibrous bands in the oral cavity, excision of the bands with myotomy with or without coronoidectomy, or buccal pad of feet are commonly accepted procedures for the treatment of OSMF with trismus.[26]

Because of the lack of definitive curative treatment of OSMF and the precancerous nature of this disease, it is often essential to follow up with the patients on regular basis along with available treatment for decreasing the fibrosis bands in the oral cavity and pharynx.

  Conclusion Top

OSMF is a potentially malignant disorder. It can cause involvement of palatal muscles which reduce the patency of the Eustachian tube leading to conductive hearing loss. There is an association between OSMF and Eustachian tube dysfunction or hearing impairment. So, while managing OSMF, Eustachian tube dysfunction and hearing disability have to be kept in mind and vice versa, as treating otological manifestations without taking care of OSMF will not be successful. Further studies are needed to elucidate the association between the Eustachian tube dysfunctions with the staging of the OSMF and manifestations of hearing loss. Early diagnosis, treatment, and appropriate patient counseling help to improve the condition drastically. OSMF with hearing loss requires close monitoring and follow-up.

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Conflicts of interest

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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