Chronic Suppurative Otitis Media (CSOM) is the persistent or recurrent inflammation of middle ear and mastoid cavity associated with persistent or recurrent ear discharge (otorrhea) via a hole in the eardrum (tympanic membrane).(1, 2) It is a significant public health issue worldwide, especially in developing countries and low-resource areas.(3) The disease is a major cause of preventable hearing loss and has a profound impact on the life, communication, learning and economic contribution of the affected child.(4) The burden of CSOM is high in Pakistan with prevalence rates varying by region with the burden being further compounded by lack of access to healthcare, poor hygiene, and overcrowding.(5)

The pathogenesis of CSOM is complex with a multitude of host, environmental and microbial factors playing a role.(1, 6)  The most common route of CSOM is through unresolved acute otitis media (AOM) resulting in chronic inflammation of the ear, damage to the mucosa and eventual perforation of the tympanic membrane.(7) But the mechanism of the Eustachian tube failure is generally accepted to be the basis of the middle ear disease. The Eustachian tube is a dynamic tube that connects the nasopharynx to the middle ear and performs three very important functions: ventilating the middle ear to equalize pressure, draining secretions and protecting against nasopharyngeal pathogens. The absence of any of these functions allows a susceptible situation to arise that can lead to infection.(8)

The role of Eustachian tube in the process of CSOM cannot be neglected. Failure to ventilate the middle ear results in negative pressure which promotes transudation of fluid and provides a growth environment for bacteria. Inability to drain can lead to the buildup of these secretions, and poor clearance can lead to reflux of nasopharyngeal bacteria into the middle ear cavity.(6, 9) This vicious cycle of inflammation, fluid accumulation and infection results in mucosal hypertrophy, goblet cell hyperplasia, and finally, in chronic mucosal inflammation, which is the hallmark of mucosal CSOM.(10)

A deviated nasal septum (DNS) occurs when the nose's anatomical structure is skewed from the center.(11) A large DNS may cause nasal obstruction, which results in mouth breathing, snoring, and changes in airflow. Mouth breathing, snoring, and changes in airflow can occur with a large DNS, which may be asymptomatic, or may affect breathing. Most important, it can affect the nasopharyngeal space and the ability of the Eustachian tube to function.(12) The pharyngeal orifice of the Eustachian tube is in the lateral wall of nasopharynx. A compensatory hypertrophy of the other inferior turbinate can also develop, making the nasal cavity narrower and affecting the pressure gradients in the nasopharynx, which can also be affected by the deviation of the nasal septum.(13) This may lead to Eustachian tube dysfunction by direct blockage of the Eustachian tube's opening, by impairing the mucociliary clearance system, and by causing chronic inflammation of the nasopharynx, which may infect the middle ear.(14)

The direct relationship between DNS and mucosal CSOM is still somewhat uncertain. Some studies demonstrated a strong association, but some others have regarded it as an incidental finding.(6, 15) The present study is intended to give strong local evidence on this correlation as it is analyzed on data of a good sample size at a large tertiary care centre Ayub Teaching Hospital Hazara Division. This study aims to make it easy for clinicians to decide to treat patients with CSOM in a more comprehensive manner, suggesting that a septal correction should be considered when planning tympanoplasty to promote its success and minimize its recurrence.

The present study is a cross sectional, analytic study to see the correlation between deviated nasal septum (DNS) and mucosal Chronic Suppurative Otitis Media (CSOM) in population of Hazara Division. 2.1. Study Design and Setting Study Design: Cross sectional, Analysis (Observational) Study. Study Location: It was conducted in the Department of Otorrinolaryngology (ENT) Ayub Teaching Hospital Abbottabad. This tertiary care centre caters to a large catchment area and has a representative clinical population with regard to the entire Hazara Division.Research. Duration: The research period was 6 months (from 1st July 2025 to 31st December 2025). 2.2. Number of samples and sampling technique. The number of patients included: 100 patients were included in the study. The sample size was determined using a desired prevalence of about 65-70% for the population of CSOM patients, and a 95% confidence interval with a 10% margin of error. Sampling Technique: Non probability and consecutive sampling technique was used. Patients with the given inclusion criteria who attended the outpatient department of ear, nose and throat during the study period were enrolled sequentially till the required sample size was reached. 2.3. Inclusion and Exclusion Criteria Inclusion Criteria: Patients between the ages of 16-60, both female and male. Patients who have been diagnosed clinically with unilateral or bilateral mucosal (tubotympanic) type of CSOM. Otorrhoea (ear discharge) lasting more than three (3) months. Valid informed written consent by patients to enter the study. Exclusion Criteria: Those who have either a squamous (atticoantral) type of CSOM or who show evidence of cholesteatoma. Ear surgery patients (those who have had previous ear surgery such as tympanoplasty or mastoidectomy) and/or nasal surgery patients (those who had previous nasal surgery such as septoplasty or rhinoplasty). Patients with acute upper respiratory tract infections, acute sinusitis, chronic sinusitis or allergic rhinitis during presentation. Patients with any obvious nasopharyngeal mass (such as juvenile angiofibroma, carcinoma) or other craniofacial deformities. Patients with systemic diseases which may impact the immune system or healing (e.g., uncontrolled diabetes mellitus, immunocompromised states). 2.4. Data Collection Procedure Initial Assessment: A detailed demographic and clinical history was documented on a proforma which was pre-designed and structured with informed written consent for each patient. Age, gender, occupation, duration of ear discharge and history of nasal obstruction/mouth breathing was noted. Otological Examination: All patients received full ear examination with Binocular Operating Microscope (Otomicroscopy) and 4mm, 0 degree rigid Otoendoscope. The following parameters were done: Type and amount of ear discharge (mucoid, mucopurulent or purulent). Location and extent of the perforation of the TM. Mucosa of the middle ear (edema, granulation tissue or polyp). Diagnosis of "mucosal" (central perforation with healthy, non-cholesteatomatous) middle ear effusion confirmed. Nasal Examination: Two stages of thorough nasal examination was carried out: Anterior Rhinoscopy: Examination was performed with a headlight and a nasal speculum to see if there was any gross deviation, congestion of the nasal mucosa or discharge. Nasal Endoscopy: A 0-degree and 30-degree rigid nasal endoscope, 4mm in diameter, was used to thoroughly examine the nasal cavity, nasal septum, turbinates and the nasopharynx (Eustachian tube orifice). A deviated nasal septum was endoscopically confirmed. In the event of a deviated nasal septum, it was classified according to the morphological type and the side of the deviation: Either C-S shaped or S-S shaped or Bony Spur. Side of Deviation: Right-sided, left-sided or Bilateral (S-shaped). Side of max obstruction was recorded and this side was used as the "side of DNS" for correlation analysis. 2.5. Variables and data analysis. Three types of variables were assessed. The main exposure variable was the side and presence of the Deviated Nasal Septum (DNS) and the main outcome variable was the side and presence of Mucosal Chronic Suppurative Otitis Media (CSOM). The secondary variables were age and gender, the type of DNS, location and size of the TM perforation. All the collected data were entered and coded in Excel spreadsheet and then was transferred to IBM SPSS (Statistical Package for Social Sciences) version 26.0 for statistical analysis. Descriptive statistics were used including frequencies and percentages for all the categorical variables (e.g. gender, presence of DNS, type of DNS, side of DNS, side of CSOM) and mean and SD for the continuous variable, age. The inferential statistical tool used for testing the primary hypothesis in reference to the correlation between side of DNS and side of CSOM was the Chi-square test. Pre-determined p-values < 0.05 (p < 0.05) were used to determine significance. 2.6. Ethical Considerations Ethical approval was obtained from the Institutional Review Board (IRB) and Ethical Committee of Ayub Teaching Hospital, Abbottabad and the study was started. Patient confidentiality was carefully respected and personal identifiers were not used for data collection or analysis. All procedures were conventional, non-invasive diagnostic tests commonly used in ENT practice and were not experimental. Written informed consent was obtained from all participants or parents/guardians of minors explaining the study in Urdu/Hindko. The participants were made aware of their right to stop at any point, without impacting the care they receive.

Table 1: Demographic and Clinical Profile of Patients with Mucosal CSOM (n=100)

Table 2: Frequency and Type of Deviated Nasal Septum in CSOM Patients

Table 3: Correlation between Side of DNS and Side of Mucosal CSOM

A very significant correlation (p<0.001) was found between the side of DNS and the side of mucosal CSOM which is the side most commonly affected by the disease.

This study clearly revealed high positive and strong correlation between deviated nasal septum and mucosal CSOM in the people of Hazara Division. We were surprised that so many of our CSOM patients had a diagnosis of DNS (75%), much higher than what is typically reported in the literature for general populations (20-50% depending on the diagnostic criteria used and the population studied).(16) This high prevalence is indicative of a possible significant role of DNS as a predisposing or exacerbating factor in the development of mucosal CSOM. This study's findings are consistent with several other studies conducted in the region that have found similar high correlation, which supports the clinical significance of diagnosis and management of DNS if appropriate in patients with chronic ear disease. The most interesting is the strong ipsilateral relationship between the side of nasal septal deviation and the side of the CSOM, which is observed in our study. More than 82% of patients with unilateral DNS had the disease in the same ear. This discovery is of a pathophysiological nature and there is a strong argument for a cause-and-effect relationship. The mechanism is probably based on local effects of DNS on Eustachian tube function. The most common type of deviation, in our patients, is C-shaped and may lead to the septum bulging into one nasal cavity and pushing the middle and inferior turbinates into the other. This can result in a string of events: turbulent air, an over-drying of the mucous membranes, and chronic inflammation in that particular nasal cavity. This local inflammation may directly involve the mucosal lining of the Eustachian tube orifice causing edema and functional obstruction.(14) Additionally, the changed pressure in the blocked nose may result in a relative negative pressure in the nasopharynx on the same side that further inhibits the spontaneous opening of the Eustachian tube.(17) This is different from the other side where compensatory hypertrophy of the turbinates is often experienced as a result of the septal deviation. The main and direct injury, however, seems to be against the ipsilateral Eustachian tube. This local effect is an important distinction between this correlation and more systemic effects.(18) There is also a so-called "naso-tympanal" reflex, which occurs when the nose is irritated and leads to dysfunction of the Eustachian tube. These mechanisms together account for the fact that clinical side of the ear pathology always matches the side of the septal deviation, which is of clinical importance in the diagnosis and treatment planning.(19) The male predominance found in our study, as well as a higher percentage in the younger age group (16-30 years) corresponds to the findings of other epidemiological studies on CSOM. This age group is particularly susceptible as they are often more active in their social and educational lives, but also may have delayed or inadequate treatment for their ear infections. Most of the perforations in our study were unilateral and centrally located, also a characteristic of mucosal CSOM where the inflammation is usually limited to the inner lining of the middle ear and not to the attic or antrum, which would rather predominate with the squamous (cholesteatomatous) type.(20) This is a very significant clinical correlation. These findings highlight the importance of a holistic management strategy, particularly for ENT surgeons working in a health institution such as Ayub Teaching Hospital. Aural toileting and the use of appropriate antibiotics is the first step in treatment of the CSOM, however, in cases where the patient has a significant DNS, it is clear that the anatomical problem needs to be treated as well in order to achieve long-term success. It is especially important when thinking about surgical procedures such as a tympanoplasty or myringoplasty.(21) It is similar to fixing a leaky roof and not fixing the clogged downspout. The negative pressure and poor drainage can cause the graft to fail, re-perforate and cause continued middle ear disease.(22) Hence, in patients with serious nasal obstruction from DNS with a concurrent CSOM, a septoplasty (surgical correction of the septum) may be recommended as an additional procedure. It can be done in stages or sometimes at the same time as the ear surgery.(23) In addition to the normalizing of nasal airflow and the decrease in inflammation around the Eustachian tube orifice, septoplasty may help restore the Eustachian tube's function, normalize middle ear pressure, and create a more favorable environment for the success of tympanoplasty.(24) This is a two-pronged approach as it treats not the symptom (the ear discharge) but a root cause (the anatomical predisposition). This will likely improve the success of ear surgeries and the number of patients who develop recurrent or chronic disease in this population and therefore will improve their ability to hear and their quality of life.

This study concludes that there is significant positive correlation between the presence of deviated nasal septum and presence of mucosal Chronic Suppurative Otitis Media in the population of Hazara Division. The most convincing findings for this correlation are the high rate of ipsilateral disease, in which the ear with CSOM is most likely to be on the same side as the nasal septal deviation. Such a link is probably mediated by the local effect of DNS on Eustachian tube function, which results in decreased ventilation, drainage and protection of the middle ear. The results emphasize the significance of a full ENT examination in CSOM patients, and an assessment of the nasal cavity and nasopharynx should be performed. The management of nasal pathology, namely the large DNS (dogs nose syndrome) is an important part of the comprehensive management of CSOM to achieve an optimum long term medical and surgical outcome.

6. Limitations

The study has value for its findings, but is limited by the fact that it is a cross sectional design and therefore only an association can be found, not a cause. The number of samples collected, 100, may be small for this analysis and the results might not be representative for the entire Hazara Division or other populations. Moreover, the study did not use objective measures of Eustachian tube function (e.g., tympanometry, Eustachian tube function tests) or the degree of nasal obstruction (e.g., acoustic rhinometry), but only relied on clinical examination and endoscopy. Lastly, the length of the study period was six months and the follow-up was brief, thus the long-term results of patients with simultaneous DNS and CSOM were not evaluated.

7. Recommendations

t is desirable that all patients with chronic suppurative otitis media (CSOM) should have complete nasal endoscopic examination to detect any nasal anatomical abnormalities like deviated nasal septum (DNS). In patients with significant ipsilateral DNS and CSOM, Septoplasty might also be performed in addition to tympanoplasty. Comparative studies to determine the outcomes of tympanoplasty with and without septal correction should be performed in a long-term follow-up study. The results of this study should be supported with larger multicenter studies with hospitals from all over Hazara Division. Awareness programmes should also be conducted on public health to encourage early diagnosis and treatment of ear and nasal disorders to avoid complications especially hearing loss.

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