Otology & Neurotology
28:44Y47 Ó 2006, Otology & Neurotology, Inc.
Influence of Chronic Middle Ear Diseases on
Gustatory Function: An Electrogustometric Study
Masaki Sano, Ken Ito, Keigo Suzukawa, Kimitaka Kaga, and Tatsuya Yamasoba
Department of OtorhinolaryngologyYHead and Neck Surgery, Graduate School of Medicine,
Faculty of Medicine, University of Tokyo, Tokyo, Japan
Objective: We aimed to quantitatively determine whether
middle ear inflammation associated with unilateral chronic
otitis media (COM), cholesteatoma, or otosclerosis affects gus-
tatory function.
Study Design: Prospective study.
Setting: University Hospital, Department of Otolaryngology.
Patients: Forty-two patients had unilateral COM (22 men, 20
women; mean age, 54.2 yr), 57 had unilateral cholesteatoma
(35 men, 22 women; mean age, 42.1 yr), and 19 had unilateral
otosclerosis (10 men, 9 women; mean age, 49.3 yr).
Main Outcome Measures: Patients underwent taste testing
using electrogustometry (EGM) and sensation thresholds
were compared in the affected and unaffected ears among
Several studies have investigated the influence of
middle ear surgery and that of aging on taste function
(1Y8). However, only a few studies have addressed the
influence of middle ear inflammation itself on taste
function. Landis et al. (9) studied taste function in
patients with chronic inflammatory middle ear disease
by means of filter paper strips and concluded that
chronic inflammatory middle ear disease affected taste
function. This method, however, provides qualitative
information regarding subjects’ ability to taste, rather
than quantitative data. Although electrogustometry
(EGM) is a more reliable and objective method to quan-
titatively evaluate taste function (10,11), it has not been
used to study this issue.
It is well known that cholesteatoma can cause taste
dysfunction by degenerating the chorda tympani nerve
within the middle ear space (12). Since the chorda tym-
pani nerve runs in the middle ear space and is therefore
readily exposed to middle ear inflammation, it can also
be affected in patients with chronic otitis media (COM).
The aim of the present investigation was to elucidate
Address correspondence and reprint requests to Masaki Sano, M.D.,
Department of OtorhinolaryngologyYHead and Neck Surgery,
Graduate School of Medicine, Faculty of Medicine, University of
Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; E-mail:
neurootolsano@ybb.ne.jp
44
Copyright @ 2006 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
groups and between affected and unaffected ears in each
group.
Results: Patients with COM and cholesteatoma exhibited an
increase in taste threshold in the affected ears compared to the
unaffected ears (p G 0.05), whereas otosclerosis patients did
not. The extent of the increase of the sensation thresholds in
the affected ears was very similar between patients with COM
and those with cholesteatoma (p = 0.548).
Conclusion: Our EGM study showed that cholesteatoma and
chronic middle ear inflammation affected gustatory function to
a similar degree. Key Words: Gustatory functionVOtitis
mediaVCholesteatoma.
Otol Neurotol 28:44Y47, 2007.
whether COM affects taste function. Preoperatively,
we performed taste testing using EGM for patients
with unilateral COM, cholesteatoma, and otosclerosis
and compared taste thresholds among groups.
PATIENTS AND METHODS
Patients
Subjects were 118 patients (61 men, 57 women; mean age,
48.5 yr) who had COM accompanied by central perforation of
the eardrum, cholesteatoma, or otosclerosis (all conditions uni-
lateral) and had no evidence or history of middle ear infection
in the contralateral ear. They were admitted to the Tokyo Uni-
versity Hospital for surgical intervention between April 2003
and May 2005. Diagnoses of COM, cholesteatoma, and oto-
sclerosis were based on the findings of preoperative otologic
examinations including high-resolution computed tomography
and on intraoperative findings. All patients were confirmed to
have no signs of contralateral middle ear inflammation such as
soft tissue density mass.
Forty-two patients had unilateral COM (22 men, 20 women;
mean age, 54.2 yr), 57 had unilateral cholesteatoma (35 men,
22 women; mean age, 42.1 yr), and 19 patients had unilateral
otosclerosis (10 men, 9 women; mean age, 49.3 yr). Patients
with subjective hyposmia were excluded because both hypos-
mia and hypogeusia can be caused by a variety of drugs or can
occur after an influenza-like infection. Patients underwent a
structured interview that included drug intake and history of
ear, nose, or throat surgery. Exclusion criteria consisted of
 INFLUENCE OF CHRONIC MIDDLE EAR DISEASE 45

FIG. 1. Chronic otitis media (COM) patients. Plots show the

median, 10th, 25th, 75th, and 90th percentiles as vertical boxes FIG. 2. Cholesteatoma patients. Plots show the median, 10th,
with error bars. 25th, 75th, and 90th percentiles as vertical boxes with error bars.

previous ear surgery and medication known to influence taste.

gate the differences between the affected and healthy sides in
All experimental procedures were explained and demonstrated
each group. One-way factorial analysis of variance (ANOVA)
in full, and all subjects provided informed consent.
was used to investigate the differences in thresholds among the
three groups, followed by Bonferroni’s multiple comparison
Gustatory Function Testing Using EGM tests for mutual comparison. A p value less than 0.05 denoted
We performed taste testing using EGM, which is widely the presence of a statistically significant difference.
used to measure taste function and whose reliability and valid-
ity are documented in clinical studies (10,11). The electrical
stimulus was delivered through an electrogustometer (EG-II B, RESULTS
Nagashima Medical Instrument Co., Tokyo, Japan) with a
single, flat, circular stainless steel stimulus probe (5-mm Thresholds on the affected side and unaffected side
diameter). for each group are shown in Figures 1, 2, and 3. The
Patients were tested before scheduled ear surgery. One hour thresholds in unaffected ears did not differ significantly
before testing, subjects were asked not to eat or drink anything among groups (p = 0.762). When the affected and un-
except water. The stimulus rod was placed on the tongue with affected sides were compared, patients with COM and
the stimulus probe resting 2 cm laterally from the anterior cholesteatoma showed significantly greater thresholds
midline and 2 cm from the tip of the tongue. This area is the on the affected side (p G 0.001 for each), whereas the
so-called intrinsic region dominated by the chorda tympani thresholds did not differ significantly between ears in
nerve. In normal subjects, electric stimulation usually causes
a metallic taste. At the beginning of electrogustometric thresh-
patients with otosclerosis (p = 0.689). Increase in thresh-
old measurement, some patients do not recognize a metallic old was calculated by subtracting the threshold on the
taste but only the touch sensation of the probe. To avoid this
technical error, patients were first acquainted with the feel and
faint taste of the stainless steel probe, as previously reported
(1). An ascending threshold procedure was used to measure the
threshold. A 500-ms anodal stimulation was presented unilat-
erally, beginning at j8 dB (8 KA) and proceeding to 34 dB
(400 KA); normal threshold is below 8 dB (20 KA) (2). The
value for the lowest stimulation for which the metallic or sour
taste was perceived was recorded, and the value obtained after
applying a stimulus three times with two positive answers was
defined as the threshold value.

Data Analysis
We compared thresholds on the affected side and those on
the contralateral healthy side in each subject, since it has been
reported that taste function deteriorates naturally with age (4,5)
and that this comparison between sides can control for the
aging influence on gustatory function (2Y6).
Results were analyzed using Sigma Stat for Windows
(Sigma Stat, Systat Software, Inc., CA, USA). Data are FIG. 3. Otosclerosis patients. Plots show the median, 10th,
expressed as mean T SE. Student’s t test was used to investi- 25th, 75th, and 90th percentiles as vertical boxes with error bars.

Otology & Neurotology, Vol. 28, No. 1, 2007

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46 M. SANO ET AL.
FIG. 4. Increases in taste threshold. Plots show means with
error bars. Increase in thresholds was 8.67 T 1.54 dB in COM,
7.53 T 1.34 dB in cholesteatoma (Chole), and 0.26 T 0.65 dB in
otosclerosis (OS).
unaffected side from that on the affected side. As shown
in Figure 4, the increase in threshold was 8.67 T 1.54 dB
in COM, 7.53 T 1.34 dB in cholesteatoma, and 0.26 T
0.65 dB in otosclerosis; a significant difference among
the three groups (one-way ANOVA, p = 0.0043) was
found.
Bonferroni’s multiple comparison test demonstrated
that increases in the thresholds in COM and choles-
teatoma were higher than those in otosclerosis (p =
0.0014 and p = 0.0039, respectively). No significant
difference was evident between COM and cholestea-
toma (p = 0.5480).
The increases in the thresholds on the affected side
and those on the contralateral healthy side were also
analyzed with respect to duration of disease and sepa-
rately with respect to type of COM or cholesteatoma.
Neither duration of COM nor that of cholesteatoma was
significantly correlated to taste function (COM: under
5 yr: n = 8, 5~10 yr: n = 11, 10~15 yr: n = 2, 15~20 yr:
n = 3, over 20 yr: n = 18, one-way ANOVA, p = 0.581;
cholesteatoma: under 5 yr: n = 42, 5~10 yr: n = 15, one-
way ANOVA, p = 0.698). Moreover, neither type of
COM nor type of cholesteatoma was significantly cor-
related to taste function [COM: central perforation: n =
30, tympanosclerosis: n = 12, one-way ANOVA, p =
0.207; cholesteatoma: attic cholesteatoma with retraction
(perforation) of Shrapnell’s membrane: n = 28, sinus
cholesteatoma with superioposterior retraction (perfora-
tion) of the pars tensa: n = 10, tensa retraction cholestea-
tomas extending from a retraction of the whole pars
tensa: n = 19, one-way ANOVA, p = 0.189].
DISCUSSION
The current study using EGM to measure gustatory
function demonstrates that the thresholds in unaffected
ears did not differ significantly among groups, support-
ing the reliability of this examination, as reported pre-
Otology & Neurotology, Vol. 28, No. 1, 2007
Copyright @ 2006 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
viously (10,11). Thresholds on the affected side were
increased in patients with COM and cholesteatoma
when compared with the healthy side, whereas they
were not increased in patients with otosclerosis. A pre-
vious study (3) demonstrated that the chorda tympani
nerve is not affected by pathological changes associated
with otosclerosis such as ossification of the stapes, sug-
gesting that patients with otosclerosis have normal taste.
The extent of the increase of the sensation thresholds in
the affected ears was very similar between patients with
COM and those with cholesteatoma. These findings
indicate that the presence of chronic middle ear inflam-
mation affects gustatory function in a similar manner to
cholesteatoma.
It is unknown how chronic middle ear inflammation
affects gustatory function. Since the chorda tympani
nerve in the middle ear is not protected by a bony
wall, it is readily exposed to purulent discharge and
inflammatory tissues. Although our study demonstrated
no correlation between taste function and either duration
of chronic middle ear inflammation or type of COM, a
histopathologic study of the temporal bone in patients
with COM (12) demonstrated the degeneration of the
chorda tympani nerve; the most striking feature was
the extent of perineural disease in the form of fibrosis
in ears with inactive disease and granulation tissue in the
more active conditions. These results seem to corrobo-
rate the present findings that damage to the chorda tym-
pani nerve depends on the extent of direct invasion of
inflammation rather than merely on duration or type of
COM. Although the cholesteatoma group demonstrated
no correlation between taste function and either duration
or type of cholesteatoma, cholesteatoma is able to
destroy bone and to cause facial palsy (12), and it there-
fore seems conceivable that the chorda tympani nerve
(and thereby taste function) would be affected to a
greater degree in cholesteatoma than in COM. However,
we did not find a difference in the degree of increased
taste threshold between COM and cholesteatoma, sug-
gesting that COM has a profound inflammatory effect
on taste. In cases of taste dysfunction, according to the
results of a human temporal bone study (12), one would
expect the chorda tympani nerve to be surrounded by
inflammatory tissues such as granulation tissue. There-
fore, examination of taste function before ear surgery is
useful to predict the condition of the chorda tympani
nerve, particularly within its course through the middle
ear space (13), regardless of the duration and type of
middle ear disease.
Although patients with COM and cholesteatoma
exhibited an increase in threshold on the affected side,
only a few of these patients noticed taste dysfunction
before ear surgery. This might be explained by the pos-
sibility that innervation from the unaffected side com-
pensates for taste dysfunction in the affected area of the
tongue. Another possibility is that it may not be easy for
subjects to detect subtle changes of taste function that
occur slowly due to chronic exposure of the chorda tym-
pani to middle ear inflammation.
 INFLUENCE OF CHRONIC MIDDLE EAR DISEASE
CONCLUSION
In patients with COM and cholesteatoma, gustatory
sensation thresholds measured with EGM in the region
of the tongue innervated by the chorda tympani nerve
were elevated on the affected side, whereas patients with
otosclerosis did not exhibit such elevation. These find-
ings indicate that chronic middle ear inflammation, as
well as cholesteatoma, can induce taste dysfunction.
Moreover, preoperative taste testing might help predict
the condition of the chorda tympani nerve.
REFERENCES
1. Saito T, Manabe Y, Shibanori Y, et al. Long-term follow-up
results of electrogustometry and subjective taste disorder after
middle ear surgery. Laryngoscope 2000;111:2064Y70.
2. Terada T, Sone M, Tsuji K, et al. Taste function in elderly patients
with unilateral middle ear disease. Acta Otolaryngol 2004;553:
S113Y6.
3. Sone M, Sakagami M, Tsuji K, et al. Younger patients have a
higher rate of recovery of taste function after middle ear surgery.
Arch Otolaryngol Head Neck Surg 2001;127:967Y9.
4. Murphy C. Taste and smell in the elderly. In: Meiselman H, Rivlin
RS eds. Clinical Measurement of Taste and Smell. New York,
NY: Macmillan Publishing Co; 1986:343Y71.
Copyright @ 2006 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
47
5. Endo S. Influence of aging on taste threshold. In: Kurihara K,
Suzuki N, Ogawa H, eds. Olfaction and Taste XI. New York,
NY: Springer-Verlag; 1993:547Y50.
6. Arey LB. The numerical and topographical relations of taste buds
to human circumvallate papillae throughout the life span. Anat Rec
1935;64:9Y25.
7. Arisson K. Location and variation in number of taste buds in
human fungiform papillae. Scand J Dent Res 1979;87:
435Y42.
8. Mistretta CM. Taste anatomy and neurophysiology in early devel-
opment and old age. In: Meiselman H, Rivlin RS, eds. Clinical
Measurement of Taste and Smell. New York, NY: Macmillan
Publishing Co; 1986:283Y304.
9. Landis BN, Beutner D, Frasnelli J, et al. Gustatory function in
chronic inflammatory middle ear diseases. Laryngoscope 2005;
115:1124Y7.
10. Murphy C, Quinonez C, Nordin S. Reliability and validity of
electrogustometry and its application to young and elderly per-
sons. Chem Senses 1995;20:499Y503.
11. Lobb B, Elliffe DM, Stillman JA. Reliability of electrogustometry
for the estimation of taste thresholds. Clin Otolaryngol Allied Sci
2000;25:531Y4.
12. Griffith IP. Observations on the pathology of chorda tympani
nerve in temporal bone sections. J Laryngol Otol 1977;91:
151Y7.
13. Yaginuma Y, Kobayashi T, Sai Y, et al. Predictive value of elec-
trogustometry in the preoperative diagnosis of severity of middle
ear pathology [in Japanese]. Nippon Jibiinkoka Gakkai Kaiho
1996;11:1635Y40.
Otology & Neurotology, Vol. 28, No. 1, 2007