|Year : 2022 | Volume
| Issue : 2 | Page : 144-150
Eustachian tube dysfunctions due to mask among quarantined health-care professionals during COVID-19 pandemic
Rohit Kumar Phulsunga1, Sunil Kumar2, Avinash Surana3, Vikas Gupta4
1 Department of Nuclear Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, India
2 Department of Community Medicine, Government Doon Medical College, Dehradun, Uttarakhand, India
3 Deputy Assistant Director Health (DADH), Meerut, Uttar Pradesh, India
4 Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh, India
|Date of Submission||31-Mar-2021|
|Date of Decision||12-May-2021|
|Date of Acceptance||27-Dec-2021|
|Date of Web Publication||13-May-2022|
Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: The most effective preventive measures against COVID-19 among health-care personnel (HCP) are personal protective equipment (PPE) and hand hygiene. The documented side effects of continuous use of mask or PPE are dermatitis, but side effects on the Eustachian tube are untouched areas. The aim of this study was to investigate the Eustachian tube dysfunctions among HCP due to the continuous use of masks. Materials and Methods: This web-based cross-sectional study was conducted among 217 eligible HCP. The sample size was calculated as 97, considering the unknown prevalence of Eustachian tube dysfunctions among HCP (50%), so all HCP were included in the study. A structured questionnaire with close-ended responses was developed to collect study participants' responses. Results: Out of 217 participants, only 207 participants provided their written consent after understanding the study objectives and 206 were included in the analysis as one subject has pre-existing ear disease. The daily hours of mask usage among 52.4% of participants were between 4 and 8 h. About 2.6% of doctors experienced severe pain and pressure in the ear. Eustachian Tube Dysfunction Patient Questionnaire-7 score was significantly higher among females and masked usage of four or more hours (P < 0.05). Conclusion: The present study revealed that 42.3% of participants had Eustachian tube dysfunctions. The study findings might help local administration to provide practical recommendations for medical workers prior head supported masks instead of ear-supported masks, use of ear protectors.
Keywords: COVID-19 pandemic, Eustachian tube dysfunctions, health-care professionals
|How to cite this article:|
Phulsunga RK, Kumar S, Surana A, Gupta V. Eustachian tube dysfunctions due to mask among quarantined health-care professionals during COVID-19 pandemic. Adv Hum Biol 2022;12:144-50
|How to cite this URL:|
Phulsunga RK, Kumar S, Surana A, Gupta V. Eustachian tube dysfunctions due to mask among quarantined health-care professionals during COVID-19 pandemic. Adv Hum Biol [serial online] 2022 [cited 2023 Mar 30];12:144-50. Available from: https://www.aihbonline.com/text.asp?2022/12/2/144/345213
| Introduction|| |
The COVID-19 has emerged from the Wuhan province of China and took the form of a pandemic affecting all the continents, including most of the countries. As of now, worldwide, there is a total of 11,591,595 confirmed COVID-19 cases and 537,859 deaths from COVID-19, and in India count is rising exponentially, with total confirmed cases counting to 721,774 and deaths are 20,642., The mode of spread of COVID-19 is basically droplet-based, and infection is acquired after getting into contact with the droplets either present in the surroundings or settled on the objects.
Although the case fatality rates of COVID-19 (2.3%) are lower as compared to SARS (9.5%) and MERS (34.4%), infection transmission rates are far higher when compared to those diseases. As the transmission rates are higher, the health-care workers (HCWs) dispensing duties in the vicinity of COVID-19 infected or suspects are vulnerable to acquiring the infection very easily and will act as a potential source of infection to transmit it to other patients of the same or other wards or to the other colleagues. The recent literature has shown that high transmission rates have raised concern among HCWs, and they are sometimes over conscious while providing care to patients or suspects.
The most common preventive measures used against COVID-19 among HCWs are personal protective equipment (PPE) and hand hygiene. The Ministry of Health and Family Welfare (MoHFW), Government of India (GOI) have released guidelines for the use of PPE by HCWs. Each item of PPE is essential to prevent COVID-19 infection, but face masks (triple-layer surgical mask or N-95 mask) are being mostly used or worn for a longer duration when compared to other items. The most frequently occurring side effects of wearing a face mask continuously for a longer duration is facial skin complications which include mild erythema, rashes, swelling, severe inflammatory pustules, maceration and lichenification of the nasal bridge, forehead and post-auricle areas that come into contact with the mask.
The side effects of continuous use of a mask on Eustachian tube is untouched area and no literature (whether recent or past) were found after a rigorous search over Google scholar. The Eustachian tube dysfunction ranges from aural fullness or popping to pain which results in discomfort and affects the effective use of face masks. Moreover, recently, GOI has issued guidelines for the use of masks in public places.
As this global COVID-19 crisis provides a unique opportunity to work upon this untouched area, the present study was conducted with an aim to investigate the Eustachian tube disorders among quarantined health-care professionals due to continuous use of masks during the COVID-19 pandemic, which will be overall the first step in identifying such side effects and will complement other upcoming future studies.
| Materials and Methods|| |
Study setting and design
The present quantitative study was cross-sectional in design, conducted at a tertiary care teaching hospital of southern Haryana during the 3rd week of April 2020. Nuh was among the worst affected district among all 22 districts of Haryana state, with a maximum number of positive cases. A large number of persons were sent on quarantine, including health-care professionals.
Study population and sample size
The study participants included health-care personnel (HCP), including doctors and nurses who have completed the duration of the quarantine period as being sent on quarantine at home/hostels or in state-run facilities after discharging duties in close contact with COVID-19-positive patients. The list of those quarantined health-care professionals was obtained from the Office of Medical Superintendent along with their contact details and which counted to around 217 eligible participants. The study excluded the participants who had pre-existing ear disorders such as vestibular/inner ear pathology who may incur dizzy or vertigo symptoms as a result of an increase in middle ear pressure or having severe nasal obstruction, who developed COVID-19 disease during or after discharging duties and who was seriously ill such as malaria (fever in the evening hours associated with chills), high-grade fever (temperature of 39.4°C or more) and psychological distress (a score of three or more on general health questionnaire-12).
The sample size was calculated (n = 97) considering the proportion of HCP having Eustachian tube dysfunction as 50% (studies not found in Haryana) with confidence level of 95% and 10% absolute allowable error by applying the following formula: n = (Z1 − a/2)2 × p (1 − p)/d2; where Z = Standard normal variate for level of significance (at 5% type I error [P < 0.05), Z = 1.96 for 2-sided test), a = Level of significance (0.05), P = Prevalence (proportion- 50%), d = Absolute Allowable error (10%), n = sample size, so all eligible study participants which counted to be 217 were included in the study.
A structured questionnaire with close-ended responses was developed, which covered the domains of participant's characteristics, any pre-existing diseases, daily hours of mask usage, and symptoms related to Eustachian tube dysfunction during or after mask use over the past month. The questionnaire was piloted among a small number (n = 10) of health-care professionals and the average time taken to complete the survey was 8–10 min. The collected questions were subjected to content validation by a panel of 15 medical experts. The purpose was to identify the items with a high degree of agreement among experts. Aiken's V was used to quantify the concordance between experts for each item. Questions that had an Aiken's V >0.7 and were selected for the study. All efforts were made to keep the questions simple and unambiguous according to the objectives of the study. Refinements were made as required to facilitate better comprehension and to organise the questions before the final survey was distributed to the study participants.
The study questionnaire comprised three sections. Section 1 explored the demographic information of respondents, including age, gender and occupation (such as doctor and nurse). Section 2 collected information regarding any pre-existing disease among participants (such as any pre-existing ear disorders, asthma/chronic obstructive pulmonary disease, sinusitis, hypertension and diabetes mellitus) and daily hours of mask usage. Section 3 aimed to investigate the occurrence of symptoms related to Eustachian tube dysfunction during or after mask use over the past month using the Eustachian Tube Dysfunction Patient Questionnaire (ETDQ-7). The ETDQ-7 is brief and easy to use, and the subject burden is minimal. It has been shown to be reliable and valid for the cross-sectional assessment of ETD-related symptoms in adults, i.e. excellent sensitivity and specificity. In particular, the ability of the ETDQ-7 to discriminate between diseased and non-diseased groups is excellent. The seven statements regarding symptoms in ETDQ-7 were “Over the past 1 month, how much has each of the following been a problem for you” such as (A) pressure in the ears; (B) pain in the ears; (C) a feeling that your ears are clogged or underwater; (D) ear symptoms when you have a cold or sinusitis; (E) crackling or popping sounds in the ears; (F) ringing in the ears; and (G) a feeling that your hearing is muffled. Response to statements were noted on a 7-point Likert scale format (1,2 = no problem, 3, 4, 5 = moderate problem and 6,7 = severe problem).
The ETDQ-7 score ranged from a minimum of 7 to a maximum of 49, and a score of 14 or more was used as a cut-off for categorising the participant to have Eustachian tube dysfunction. Furthermore, pneumatic otoscopy was done among participants to confirm the Eustachian tube dysfunction (retracted or poorly mobile tympanic membrane) and impedance audiometry (abnormal tympanogram); and participants with moderate-to-severe disease were referred to hospital for further management.
Participation in this survey was voluntary and was not compensated. Informed consent was obtained from each participant before participation, and anonymity and confidentiality of the participants were maintained. Just after completion of their 14 days quarantine period, they were contacted telephonically for their availability to conduct this study. They were explained about the purpose of this study and were requested to participate. The questionnaire for participants was administered by the investigator himself by face-to-face interview technique. Furthermore, the filled questionnaires were then checked for completeness. The study was initiated after obtaining ethical approval from the IEC committee of the institute. (Letter number EC/OA-37/2020 dated October 14, 2020).
Collected data were entered in the MS Excel spreadsheet, coded appropriately and later cleaned for any possible errors. Analysis was carried out using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp. Armonk, NY, USA). During data cleaning, more variables were created to facilitate the association of variables. Clear values for various outcomes were determined before running frequency tests. Categorical data were presented as percentages (%), and quantitative data were presented as mean (standard deviation [SD]). An Independent T-test was used to evaluate differences between groups for categorised variables. Chi-square test analysis was carried to find out the strength of association between ETDQ-7 score and independent variables. All tests were performed at a 5% level of significance; thus, an association was statistically significant if the P < 0.05.
| Results|| |
Out of 217 participants, only 207 subjects provided their written consent after understanding the study objectives one subject (0.5%) had a history of pre-existing ear disorders, so 206 participants were included in the analysis. All study participants were wearing the N-95 mask, which was supported by ears while they were in the vicinity of COVID-19 suspected or positive patients. Female participants dominated the study as they constituted 62.6% of the total participants. Among HCP, the percentage of doctors was 55.3, whereas the percentage of nurses was 44.7. The overall mean age ± SD of participants was 32.05 ± 6.49, whereas the mean age for doctors and nurses was 33.82 ± 6.31 and 29.86 ± 6.04, respectively.
When asked specifically about the history of previous illness, 4.9% of participants responded history of asthma, 2.9% responded as sinusitis and 1.0% were hypertensives. [Figure 1] shows the daily hours of mask usage among more than half of the participants (52.4%) was for between 4 and 8 h. [Table 1] provides the distribution of responses ETDQ-7 Likert scale by the study participants, and the overall mean ETDQ-7 score was 14.71 ± 6.83. [Figure 2] shows the distribution of responses to the ETDQ-7 among doctors and nurses, and it was observed that 2.6% of doctors responded that they had a feeling of severe pain and pressure in the ear over the past month after the use of a mask. Similarly, 2.2% of nurses experienced severe ear symptoms during sinusitis, crackling or popping sound in the ear and feeling of ears clogged or underwater.
|Figure 2: Distribution of responses to the Eustachian Tube Dysfunction Patient Questionnaire-7 among health-care professionals (doctors and nurses) (N = 206).|
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|Table 1: Responses to Eustachian tube dysfunction questionnaire-7 Likert scale among study participants (n=206)|
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[Figure 3] shows the comparison of ETDQ-7 scores between doctors and nurses using independent T-test analysis, and the difference in the ETDQ-7 scores was not statistically significant (P > 0.05).
|Figure 3: Independent t-test analysis for Eustachian Tube Dysfunction Patient Questionnaire-7 score among study variables (N = 206).|
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Out of 206 study participants, 87 participants (42.3%) had an ETDQ-7 score of 14 or more, which means that 42.3% had Eustachian tube dysfunction during the COVID-19 pandemic due to the longer duration of mask usage. The otoscopy and tympanometry among those 87 participants with ETDQ-7 score of 14 or more showed that 61 participants (70.1%) had retracted or poorly mobile tympanic membrane and abnormal tympanogram, whereas participants with ETDQ-7 of less than 14 everyone had normal tympanic membrane and normal tympanogram. Chi-square test analysis in [Table 2] revealed that the Eustachian tube dysfunction was significantly higher among females and participants having daily mask usage of ≥4 h (P < 0.05).
|Table 2: Independent association of variables and Eustachian tube dysfunction questionnaire-7 score among study participants (n=206)|
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| Discussion|| |
Currently, COVID-19 is a global topic of discussion in the media, and among the public, especially among HCP and patients and; since widespread public measures are key to timely control the infection, the good perceptions and practices amongst HCP regarding COVID-19 are vital, and at present, there is no study being conducted to investigate the discomfort caused by to PPE, especially facial masks through this study, the investigator gained a deeper understanding into problems faced regarding Eustachian tube dysfunction due to facial mask and wearing a mask is a practice that is necessary for protection against infection.
The present study revealed that more than half of HCP (86.9%) were using the mask for 4 or more h. A study by Nepal et al. showed that there was a good practice of wearing masks among more than 80% of the study participants. Similarly, studies done by Asaad et al. and Alsahafi and Cheng have shown a positive attitude towards the usage of mask/PPE among more than 70% per cent of HCWs.,
The effectiveness of mask/PPE in preventing the COVID-19 infection have been documented in studies done by Brainard et al. and Leung et al. demonstrated that surgical face masks significantly reduced detection of influenza virus RNA in respiratory droplets and coronavirus RNA in aerosols, with a trend towards reduced detection of coronavirus RNA in respiratory droplets., However, in a study by Xiao et al. and Jefferson et al., it was stated that although mechanistic studies support the potential effect of hand hygiene or face masks, evidence from several randomised controlled trials of these measures did not support a substantial effect on the transmission of laboratory-confirmed influenza.,
In the present study, the ETDQ-7 score of 14 or more was observed among nearly two-fifth of study participants (42.3%). The reliability and validity of ETDQ-7 in screening for Eustachian tube dysfunction are well established. A validation study by Teixeira et al. has shown that the ETDQ-7 score had a higher correlation with the ET dysfunction (area under the curve: 0.64, 95% confidence interval [CI]: 0.50–0.77). Furthermore, Menezes et al. showed ETDQ-7 score had a higher correlation with the ET dysfunction (Pearson correlation coefficient between 0.724 and 0.897; P < 0.01).,
The Chi-square test analysis in the present study showed that Eustachian tube dysfunction was significantly higher among females and longer duration of mask usage. Apart from ear problems, a recent study by Zuo et al. has shown that nearly half of participants (49.0%) reported mask-related skin reactions such as acne, seborrhoeic dermatitis, rosacea exacerbation, around two-fifth (17.1%) reported respiratory tract problems and less than one-tenth (6.2%) had eye symptoms. Similarly, a study by Jiang et al. revealed that more than two-fifth of medical staff (42.8%) had skin injuries caused by PPE, with three distinct types reported such as device-related pressure ulcer; moist-associated skin damage; and skin tears. Furthermore, logistic regression indicated that daily wearing time (95% CI for odds ratio [OR] 1.61–3.21) and being male (95% CI for OR 1.11–2.13) were associated with these skin injuries.,
Other side effects include that quality and the volume of speech between people wearing masks is considerably compromised, and they may unconsciously come closer. Wearing a mask makes the exhaled air go into the eyes, which generates an impulse to touch the eyes.
Moreover, recently, there are guidelines for the use of masks in public places being introduced by the MoHFW, India and also, rational use of mask/PPE was advocated by Christopher et al. and Feng et al., but discomfort caused due to wearing facial masks will demotivate HCWs and the general population.,, Furthermore, the World Health Organisation has raised concerns regarding the shortage of PPE endangering health workers worldwide. To overcome such shortage, retailers have shifted production to make masks, gowns for HCWs in coronavirus pandemic.
| Conclusion|| |
Hence, the present study made an attempt to find out the facial mask-related Eustachian tube dysfunctions among HCP, and it was observed that 42.3% of participants suffered from it. The study findings might help local administration to provide practical recommendations for medical workers such as head supported masks (N-95 or triple layer surgical mask) instead of ear supported masks, use of ear protectors, the mask use shall be intermittent instead of continuous to avoid ETD. Before postings into COVID-19 wards or fever clinic, routine ear examination shall be performed, and instructions to reduce the chances of ETD shall be conveyed. The person with moderate-to-severe ETD shall be referred to ENT Outpatient Departments for further management.
As this study was novel in concept and attempted to reveal the facial mask-related Eustachian tube dysfunction among HCP, but the limitation of the present study is that due to novel in nature, comparable studies were not available, so comparison of ETDQ-7 score was not highlighted to that much extent.
This study has certain limitations as well. First, the small sample size is an evident limitation of this study. Second, lack of cohesion and discussion as this is a relatively new topic and gross lack of literature was the main reason behind this. Third, associations with certain risk factors like rhinitis, upper respiratory tract infection, gastro-oesophageal reflux disease, previous adenoidectomy, irritants exposure, environmental allergens, obesity, etc., were not studied which need to be explored further.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Phan T. Genetic diversity and evolution of SARS-CoV-2. Infect Genet Evol 2020;81:104260.
World Health Organization. Novel Coronavirus (COVID-19) Situation. Available from: https://covid19.who.int
[Last accessed on 2020 Jul 08].
Eurosurveillance Editorial Team. Note from the editors: World Health Organization declares novel coronavirus (2019-nCoV) sixth public health emergency of international concern. Euro Surveill 2020;25:200131e.
Petrosillo N, Viceconte G, Ergonul O, Ippolito G, Petersen E. COVID-19, SARS and MERS: Are they closely related? Clin Microbiol Infect 2020;26:729-34.
Kumar A, Nayar KR. COVID 19 and its mental health consequences. J Ment Health 2021;30:1-2.
Desai AN, Aronoff DM. Masks and Coronavirus disease 2019 (COVID-19). JAMA 2020;323:2103.
Lan J, Song Z, Miao X, Li H, Li Y, Dong L, et al.
Skin damage among health care workers managing Coronavirus disease-2019. J Am Acad Dermatol 2020;82:1215-6.
Schilder AG, Bhutta MF, Butler CC, Holy C, Levine LH, Kvaerner KJ, et al.
Eustachian tube dysfunction: Consensus statement on definition, types, clinical presentation and diagnosis. Clin Otolaryngol 2015;40:407-11.
McCoul ED, Anand VK, Christos PJ. Validating the clinical assessment of eustachian tube dysfunction: The eustachian tube dysfunction questionnaire (ETDQ-7). Laryngoscope 2012;122:1137-41.
Nepal R, Sapkota K, Adhikari K, Paudel P, Adhikari B, Paudyal N, et al
. Knowledge, Attitude and Practice Regarding COVID-19 among Healthcare Workers in Chitwan, Nepal, Research Sqaure; 2020. Available from: https://www.researchsquare.com/article/rs-26774/v1
. [Last accessed on 2020 Aug 24].
Asaad A, El-Sokkary R, Alzamanan M, El-Shafei M. Knowledge and attitudes towards Middle East respiratory sydrome-coronavirus (MERS-CoV) among health care workers in south-western Saudi Arabia. East Mediterr Health J 2020;26:435-42.
Alsahafi AJ, Cheng AC. Knowledge, attitudes and behaviours of healthcare workers in the Kingdom of Saudi Arabia to MERS Coronavirus and other emerging infectious diseases. Int J Environ Res Public Health 2016;13:E1214.
Brainard JS, Jones N, Lake I, Hooper L, Hunter P. Facemasks and Similar Barriers to Prevent Respiratory Illness Such as COVID-19: A Rapid Systematic Review, medRxiv; 2020.
Leung NH, Chu DK, Shiu EY, Chan KH, McDevitt JJ, Hau BJ, et al.
Respiratory virus shedding in exhaled breath and efficacy of face masks. Nat Med 2020;26:676-80.
Xiao J, Shiu EY, Gao H, Wong JY, Fong MW, Ryu S, et al.
Nonpharmaceutical measures for pandemic influenza in nonhealthcare settings-personal protective and environmental measures. Emerg Infect Dis 2020;26:967-75.
Jefferson T, Jones M, Al Ansari LA, Bawazeer G, Beller E, Clark J, et al.
Physical Interventions to Interrupt or Reduce the Spread of Respiratory Viruses. Part 1: Face Masks, Eye Protection and Person Distancing: Systematic Review and Meta-Analysis, medRxiv; 2020.
Teixeira MS, Swarts JD, Alper CM. Accuracy of the ETDQ-7 for identifying persons with eustachian tube dysfunction. Otolaryngol Head Neck Surg 2018;158:83-9.
Menezes AS, Ribeiro DC, Guimarães JR, Costa I, Moreira F, Dias L. Translation and validation of the “7-item eustachian tube dysfunction questionnaire” to European portuguese (PT). Acta Med Port 2020;33:191-7.
Zuo Y, Hua W, Luo Y, Li L. Skin reactions of N95 masks and medial masks among health-care personnel: A self-report questionnaire survey in China. Contact Dermatitis 2020;83:145-7.
Jiang Q, Song S, Zhou J, Liu Y, Chen A, Bai Y, et al.
The prevalence, characteristics, and prevention status of skin injury caused by personal protective equipment among medical staff in fighting COVID-19: A multicenter, cross-sectional study. Adv Wound Care (New Rochelle) 2020;9:357-64.
Lazzarino AI, Steptoe A, Hamer M, Michie S. Covid-19: Important potential side effects of wearing face masks that we should bear in mind. BMJ 2020;369:m2003.
Christopher DJ, Isaac BT, Rupali P, Thangakunam B. Health-care preparedness and health-care worker protection in COVID-19 pandemic. Lung India 2020;37:238-45.
] [Full text]
Feng S, Shen C, Xia N, Song W, Fan M, Cowling BJ. Rational use of face masks in the COVID-19 pandemic. Lancet Respir Med 2020;8:434-6.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]