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By Bryan M. Davis, MD

The eustachian tube is the key player in chronic ear disease. Chronic ear disease with or without cholesteatoma can be considered the direct result of eustachian tube dysfunction. As such, efforts to optimize middle ear aeration and mucus clearance are integral adjuncts to definitive surgical disease clearance. Allergy management and adenoidectomy remain among the most widely accepted of these measures. Failure in this regard is strongly correlated with surgical failures.

Smoking is an established major risk factor for the development of many systemic diseases, including coronary artery disease, pulmonary disease, and head and neck cancer. Recent studies have also implicated smoking as an exasperating factor in eustachian tube dysfunction. Tobacco smoke affects mucosal function of the middle ear, causes eustachian tube obstruction and has immunosuppressive effects which may predispose a patient to recurrent infections. One could reasonably assume smoking cessation would therefore improve eustachian tube function and surgical outcomes.

A recent study that this writer participated in showed, in a large series, the effects smoking has on chronic ear surgery outcomes.

This study looked at 1531 surgeries in patients with a mean age of 34 years. Non-smokers accounted for 63% of patients. Twentyone percent were current smokers, 5% were former smokers and smoking status could not be determined in 11%. Several interesting observations were discovered:

• Smokers were significantly more likely to have cholesteatoma as their primary diagnosis compared to non-smokers (p=0.002).
• Smokers were more likely to have recurrent cholesteatomas (p=0.004).
• Smokers were significantly more likely to have a tympanoplasty with mastoidectomy and ossicular chain reconstruction (p=0.03) and tympanoplasty with ossicular chain reconstruction (p=0.01).
• Smokers are also significantly more likely to need a modified radical mastoidectomy than non-smokers (p=0.004).
• Patients who were former smokers but quit 5 years or less had significantly more need for ossicular chain reconstruction, with or without mastoidectomy (p=0.01 and 0.05, respectively) compared to non-smokers.
• Patients who quit longer than 5 years had no difference in types of surgeries performed compared to non-smokers.
• Smokers were found to have worse air conduction pure-tone averages (AC-PTA, p<0.001), bone conduction pure-tone averages (BC-PTA, p<0.001), air-bone gap (ABG, p=0.004) and speech discrimination scores (SDS, p=0.002) than non-smokers.
• Smokers were more likely than non-smokers to need revision surgery (p=0.01).
• Smokers were significantly more likely to have dural or facial nerve exposure (p=0.003 and 0.001, respectively), and oval window or lateral canal fistulae (p=0.03 and 0.006, respectively).
• Smokers were also significantly more likely to have a graft failure than non-smokers (p=0.03)

Tobacco use carries adverse prognostic implications in the chronic ear population. Patients with chronic ear disease who smoke or who quit within five years are more likely to have worse preoperative disease than their nonsmoking counterparts. Their hearing results after surgery are worse than non-smokers, and they more commonly suffer graft failures and require additional surgery. Smoking cessation has an indubitably beneficial effect on ear health and otologic surgical outcomes. Once smokers do definitively cease tobacco abuse and persist for five years, they return to the non-smoking baseline of disease severity at presentation, postoperative hearing outcomes and complication rates. The physician should therefore direct considerable effort into smoking cessation to minimize morbidity, optimize outcomes and improve patient health.

Adapted from: Otolaryngology - Head and Neck Surgery Volume 137, Issue 2, Supplement 1, August 2007, Page P91. Matthew Conoyer MD, David Kaylie MD, Bryan M. Davis MD, Marc Logan Bennett MD and C. Gary Jackson MD. Presented at Annual Meeting of the American Academy of Otolaryngology - Head and Neck Surgery 2007.