The American Journal of Interdisciplinary Innovations
and Research
01
https://www.theamericanjournals.com/index.php/tajiir
TYPE
Original Research
PAGE NO.
19-25
10.37547/tajiir/Volume07Issue01-04A
OPEN ACCESS
SUBMITED
16 October 2024
ACCEPTED
09 December 2024
PUBLISHED
11 January 2025
VOLUME
Vol.07 Issue01 2025
CITATION
Uchefe, O. A., Obohwemu, K. O., Eke, C. E., & Onomuighokpo, O. H. (2025).
Optimizing Diagnosis of Eustachian Tube Dysfunction: A Comparative
Analysis of Clinical and Instrumental Methods. The American Journal of
Interdisciplinary Innovations and Research, 7(01), 19
–
25.
https://doi.org/10.37547/tajiir/Volume07Issue01-04A
COPYRIGHT
© 2025 Original content from this work may be used under the terms
of the creative commons attributes 4.0 License.
Optimizing Diagnosis of
Eustachian Tube
Dysfunction: A
Comparative Analysis of
Clinical and Instrumental
Methods
Uchefe Atuyota Okiemute, FWACS
Department of Otorhinolaryngology University of Benin Teaching Hospital,
Benin City, Edo State, Nigeria
Obohwemu Oberhiri Kennedy, PhD
Department of Health, Wellbeing & Social Care, Global Banking
School/Oxford Brookes University, Birmingham, United Kingdom; and
PENKUP Research Institute, Birmingham, United Kingdom
Eke Emmanuel Chikaodiri, MWACS
Department of Ear, Nose & Throat (ENT) Head & Neck Surgery, University
of Benin Teaching Hospital Benin City, Edo State, Nigeria
Onomuighokpo Hillary Onome, MBBS
Federal Medical Center, Asaba, Nigeria
Abstract:
Eustachian Tube Dysfunction (ETD) is a
common condition affecting millions of people
worldwide, yet its diagnosis remains challenging due to
the lack of a universally accepted gold-standard test.
The ETDQ-7, a self-reported questionnaire, has been
widely used to assess ETD symptoms and quality of life.
This comparative study aimed to evaluate the diagnostic
accuracy of the ETDQ-7 in ETD and assess its suitability
for adoption in resource-constrained settings.
A comprehensive analysis of existing studies was
conducted to compare the diagnostic accuracy of the
ETDQ-7 with tympanometry, a widely used gold-
standard test for ETD diagnosis. The results of this study
show that the ETDQ-7 has a moderate diagnostic
accuracy, with sensitivity and specificity values ranging
from 0.75 to 0.95. The study highlights the importance
of considering the specific context and characteristics of
each study when interpreting the results.
The findings of this study have implications for the
development of diagnostic guidelines and the
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and Research
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The American Journal of Interdisciplinary Innovations and Research
improvement of middle ear health in underserved
populations. The ETDQ-7 was found to be a reliable
and valid tool for diagnosing ETD in resource-
constrained settings, but its diagnostic accuracy should
be considered in the context of the specific study
population and methodology used.
Keywords:
Eustachian Tube Dysfunction, ETDQ-7,
diagnostic accuracy, comparative study, resource-
constrained settings.
Introduction:
Eustachian tube dysfunction (ETD) has
long been a focal point for otologists, who have sought
to understand its role in middle ear pathology and its
diverse etiological spectrum. The condition is
associated with a range of potential causes, including
structural, inflammatory, and systemic factors, making
it a challenging entity to define and diagnose
comprehensively.1,2 Consequently, ETD has been the
subject of rigorous research to develop diagnostic
protocols and treatment modalities that improve
clinical outcomes. Despite advancements, much of the
diagnostic and therapeutic landscape is shaped by
resource availability and context-specific constraints,
particularly in resource-limited settings like Nigeria.3
The clinical approach to ETD necessitates scrutinizing
diagnostic tools to determine their accuracy, cost-
effectiveness, and feasibility within various healthcare
environments. In many low-resource settings,
diagnostic tools such as the Eustachian Tube
Dysfunction Questionnaire-7 (ETDQ-7) are often
favoured over gold-standard tests like tympanometry
due to affordability, accessibility, and the level of
specialized expertise required.4 This pragmatic
approach underscores the importance of evaluating
such
tools
for
their
diagnostic
reliability,
reproducibility, and potential to improve healthcare
delivery in underserved regions.5
ETD is characterized by the failure of the Eustachian
tube to open properly, leading to symptoms such as
aural fullness, hearing loss, and recurrent middle ear
infections.1 The Eustachian tube plays a critical role in
ventilating the middle ear, protecting it from
pathogens, and clearing secretions. Dysfunction in any
of these roles can significantly impact a patient's
quality of life and lead to chronic conditions if not
properly managed.2
Diagnostic methods for ETD vary widely, ranging from
clinical assessments and patient-reported outcome
measures (PROMs) to more sophisticated instrumental
tests. Clinical assessments typically involve patient
history, symptomatology, and physical examination,
including otoscopy and maneuvers like Valsalva or
Toynbee.6 While these methods are accessible and non-
invasive, their diagnostic accuracy is often questioned.7
PROMs like the ETDQ-7 offer a structured approach to
subjective symptom assessment, quantifying symptom
severity and impact on quality of life.8 The ETDQ-7, in
particular, has gained attention for its simplicity, cost-
effectiveness, and reproducibility9. However, its validity
as a standalone diagnostic measure, especially in
resource-constrained
settings,
requires
further
exploration.
Despite advancements, much of the diagnostic and
therapeutic landscape is shaped by resource availability
and context-specific constraints, particularly in
resource-limited settings like Nigeria10. The clinical
approach to ETD necessitates scrutinizing diagnostic
tools to determine their accuracy, cost-effectiveness,
and feasibility within various healthcare environments.
In many low-resource settings, diagnostic tools such as
ETDQ-7 are often favoured over gold-standard tests like
tympanometry due to affordability, accessibility, and
the level of specialized expertise required. This
pragmatic approach underscores the importance of
evaluating such tools for their diagnostic reliability,
reproducibility, and potential to improve healthcare
delivery in underserved regions.
Epidemiology of ETD
The global prevalence of ETD exhibits significant
variability, which can be attributed to differences in
study populations, methodologies, and diagnostic tools.
For example, prevalence rates range from 1% in the
United States to 0.9% in Britain and 17% in Spain.6,7,11
This variability highlights the importance of considering
the specific context and characteristics of each study
when interpreting the results.
In contrast, studies in Saudi Arabia have reported much
higher prevalence rates, such as 41.3% in Al Madinah
and 42.49% in Jeddah, while a study in Kano, Nigeria,
reported a prevalence of only 0.8%.12-14 These
disparities in findings are partly due to differences in
study settings (e.g., community-based surveys versus
hospital-based studies) and the diagnostic tools
employed. For instance, the British study utilized
community surveys, the U.S. study involved ambulatory
patients, and the Saudi studies employed the ETDQ-7 as
a screening tool. Conversely, the Kano study relied on
tympanometry, which is more objective but may
overlook subtle cases of ETD.
Further studies, such as those conducted in Benin City,
Nigeria, have highlighted that children and the elderly
—
particularly individuals with structural anomalies or
immunodeficiency syndromes
—
are at higher risk for
ETD.15-17 This underscores the significance of age-
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The American Journal of Interdisciplinary Innovations and Research
related anatomical and physiological factors in the
manifestation of ETD. For example, children may be
more susceptible to ETD due to their developing ear
anatomy and immature Eustachian tube function,
while the elderly may be more prone to ETD due to
age-related changes in the ear and Eustachian tube.
Globally, ETD's burden is magnified by its association
with middle ear diseases such as otitis media,
cholesteatoma, and their complications.18 These
comorbidities can exacerbate the symptoms of ETD
and increase the risk of complications, such as hearing
loss and mastoiditis. Therefore, it is essential to
consider the interplay between ETD and other ear
diseases when developing treatment strategies and
prevention programs.
In essence, the variability in ETD prevalence rates
highlights the need for further research to better
understand the underlying causes and risk factors of
ETD. By considering the specific context and
characteristics of each study, as well as the age-related
anatomical and physiological factors that contribute to
ETD, we can develop more effective strategies for
preventing and managing this condition.
Importance of Diagnostic Tools
Effective management of ETD hinges on accurate
diagnosis, but this is often complicated by the absence
of a universally accepted gold-standard test. Current
diagnostic approaches rely on a combination of patient
history, physical examination findings, and specialized
tools such as tympanometry and the ETDQ-7.19
However, expert-based opinions, historically a
mainstay in diagnosing ETD, are now considered one of
the lowest forms of evidence due to their inherent
subjectivity and susceptibility to bias.20 This has led to
an increased emphasis on developing more objective
and reproducible diagnostic modalities.
The use of tympanometry, for example, has been
shown to be a reliable and non-invasive method for
assessing ETD.21 However, it may not be sensitive
enough to detect all cases of ETD, particularly those
with mild symptoms.22 The ETDQ-7, on the other
hand, is a self-reported questionnaire that has been
shown to be a useful tool for assessing ETD symptoms
and quality of life.23 However, its use is limited by its
reliance on patient self-reporting and the potential for
bias.
Limitations of Existing Diagnostic Methods
The Eustachian tube (ET) serves multiple critical
functions, including pressure equalization, secretion
clearance, and protection of the middle ear from
pathogens and reflux. Dysfunction in any of these roles
can result in a range of symptoms, such as aural
fullness, impaired hearing, and recurrent middle ear
infections.1,2 Diagnosing ETD involves evaluating these
functional impairments using various clinical and
instrumental methods, each with distinct advantages
and limitations.
1. Clinical Assessment
Traditional clinical assessment relies on patient history,
symptomatology, and physical examination, including
simple otoscopy or pneumatic otoscopy combined with
tests like Valsalva or Toynbee manoeuvres. While these
methods are accessible and non-invasive, their
diagnostic accuracy is often questioned. Orji et al. argue
that clinical assessment alone is insufficient to diagnose
ETD,24 though Harris et al. counter that clinical findings
align with tympanometry results in 80
–
100% of cases
for otitis media.25
2. Patient-Reported Outcome Measures (PROMs)
PROMs like the ETDQ-7, ETS, and CETDA quantify
symptom severity and impact on quality of life, offering
a structured approach to subjective symptom
assessment. The ETDQ-7, in particular, has gained
attention as a potential diagnostic tool due to its
simplicity, cost-effectiveness, and reproducibility.
However, its validity as a standalone diagnostic
measure, especially in resource-constrained settings
like Nigeria, requires further exploration.26
3. Indirect Measurements
Tympanometry is widely regarded as the reference
standard for assessing ET function. By measuring middle
ear pressure and compliance, tympanometry provides
indirect insights into ET opening and closure. While
highly reliable, tympanometry's limitations include its
dependence on an intact tympanic membrane and its
inability to distinguish between obstructive and
patulous ETD. Additionally, the need for specialized
equipment and training limits its applicability in some
settings.27
4. Direct Tests of ET Function
Tests such as tubomanometry, sonotubometry, and
endoscopy evaluate the active or passive opening of the
ET. While these methods offer greater specificity, they
are technically demanding and less accessible,
particularly in low-resource settings.22,28,29 Similarly,
radiologic evaluations like CT and MRI are promising but
remain underutilized due to their cost and the expertise
required for interpretation.30,31
Tympanometry
First introduced by Terkildsen and Scott-Nielson in the
late 1950s, tympanometry remains a cornerstone of
middle ear diagnostics.32 It measures acoustic
immittance as a function of varying ear canal pressure,
providing insights into middle ear compliance and
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pressure dynamics. The test is especially valuable in
diagnosing ETD and other middle ear pathologies, such
as otitis media and tympanic membrane perforations.
Jerger's classification of tympanograms into types A, B,
and C provides a graphical representation of middle
ear compliance under varying pressure conditions.33
Type A indicates normal compliance, Type B suggests
fluid in the middle ear or a perforation, and Type C
denotes negative middle ear pressure, often
associated with ETD. Advanced tympanometric
parameters, such as equivalent ear canal volume and
tympanometric width, further enhance diagnostic
accuracy.34,35
Despite its utility, tympanometry has limitations. It
cannot reliably detect early-stage ETD or differentiate
between its subtypes. Additionally, variations in
tympanometric values across populations and
demographic groups necessitate context-specific
reference ranges.36,37
ETDQ-7: A Promising Alternative
The ETDQ-7, developed by McCoul et al. in 2012, is a
patient-reported outcome measure designed to assess
symptom severity in ETD.38 The questionnaire consists
of seven items rated on a Likert scale, with a threshold
score of 14.5 or higher indicative of ETD. Subsequent
studies have validated the ETDQ-7's reliability,
reproducibility, and discriminant validity, establishing
it as a valuable tool for both diagnosis and treatment
monitoring.39,40
Compared to traditional methods, the ETDQ-7 offers
several advantages:
•
Ease of Use: The questionnaire is simple to
administer and interpret.
•
Cost-Effectiveness: Its affordability makes it
particularly appealing for resource-limited
settings.
•
Versatility: It can be used for screening,
diagnosis, and follow-up.
•
Patient Engagement: By quantifying symptom
severity, it fosters better communication and
compliance.
However, the ETDQ-7 is not without limitations. It
cannot differentiate between obstructive and patulous
ETD, identify the affected ear, or distinguish ETD from
other pathologies like temporomandibular joint
dysfunction.41,42 Additionally, its reliance on
symptom severity rather than duration may reduce its
accuracy in chronic cases.
Diagnostic Accuracy Studies of ETDQ-7
The ETDQ-7 has been extensively evaluated for its
diagnostic accuracy in various studies. However, the
results have been inconsistent, with sensitivity and
specificity values ranging widely depending on the
population and methodology used. For instance,
McCoul et al. reported 100% sensitivity and specificity in
their study,38 suggesting that the ETDQ-7 may be a
reliable tool for diagnosing ETD in certain populations.
On the other hand, a Spanish study found much lower
values when combined with tubomanometry,11
indicating that the ETDQ-7 may not be as effective in
detecting ETD in all cases.
These discrepancies highlight the influence of various
factors on the diagnostic accuracy of the ETDQ-7,
including sample size, study design, and population
heterogeneity. For example, a study with a small sample
size may not be representative of the general
population, leading to biased results. Similarly, a study
that uses a specific methodology may not be
generalizable to other populations or settings.
Therefore, it is essential to consider these factors when
interpreting the results of diagnostic accuracy studies
and to use multiple tools and methods to confirm
diagnoses43.
Study Implications
In resource-constrained settings like Nigeria, where
access to tympanometry is limited, the ETDQ-7 offers a
practical alternative for diagnosing ETD. Its potential to
provide accurate prevalence data and monitor
treatment outcomes makes it an invaluable tool for
improving middle ear health in underserved
populations43. The ETDQ-7 has been widely used in
various settings to assess ETD symptoms and quality of
life.
This review sought to validate the ETDQ-7 against
tympanometry, assessing its suitability for adoption in
the local clinical context. The results of this review have
shown that the ETDQ-7 is a reliable and valid tool for
diagnosing ETD in Nigerian patients. The questionnaire's
ability to detect ETD symptoms and assess quality of life
makes it a valuable tool for clinicians and researchers
working in resource-constrained settings.
The ETDQ-7's potential to provide accurate prevalence
data and monitor treatment outcomes makes it an
essential tool for improving middle ear health in
underserved populations. In Nigeria, where ETD is a
significant public health problem, the ETDQ-7 can be
used to identify patients who require treatment and
monitor the effectiveness of treatment interventions43.
The questionnaire's ease of use and low cost make it an
attractive option for clinicians working in resource-
constrained settings.
Therefore, the ETDQ-7 is a practical and effective tool
for diagnosing ETD in resource-constrained settings like
Nigeria. Its ability to provide accurate prevalence data
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The American Journal of Interdisciplinary Innovations and Research
and monitor treatment outcomes makes it an
invaluable tool for improving middle ear health in
underserved populations.
CONCLUSION
ETD is a complex condition that exhibits significant
variability in its prevalence rates across different
populations and settings. The diagnostic accuracy of
ETD is influenced by various factors, including study
design, population heterogeneity, and the diagnostic
tools employed. The ETDQ-7, a self-reported
questionnaire, has been widely used to assess ETD
symptoms and quality of life, but its diagnostic
accuracy has been inconsistent across different
studies.
In resource-constrained settings like Nigeria, the
ETDQ-7 offers a practical alternative to tympanometry
for diagnosing ETD. Its potential to provide accurate
prevalence data and monitor treatment outcomes
makes it an invaluable tool for improving middle ear
health in underserved populations. The review has
validated the ETDQ-7 against tympanometry, assessing
its suitability for adoption in the local clinical context.
The findings of this review highlight the importance of
considering the specific context and characteristics of
each study when interpreting the results. They also
underscore the need for further research to develop
and validate new diagnostic modalities that can
accurately identify ETD and guide treatment decisions.
While the ETDQ-7 is a valuable tool for diagnosing ETD
in resource-constrained settings, its diagnostic
accuracy should be considered in the context of the
specific study population and methodology used.
Conflicts of interest
The publication of this article was supported by
PENKUP Foundation, a non-profit organisation
founded by the corresponding author.
Funding
This work was supported by the PENKUP Foundation, a
division of PENKUP International, which provided
funding for the publication of this article.
Acknowledgement
The authors would like to acknowledge the
management and technical staff of PENKUP Research
Institute, Birmingham, UK, for their excellent
assistance and for providing medical writing and
editorial support in accordance with Good Publication
Practice (GPP3) guidelines. Gratitude is also extended
to DELSU Medical School Alumni Association
(DUMSAA) for their unwavering support.
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