Twelve-month outcomes of Eustachian tube procedures for management of patulous Eustachian tube dysfunction

Mid-term evaluation of the surgical management of patulous Eustachian tube dysfunction: a STROBE observational study

INTRODUCTION

Patulous Eustachian tube (PET) is a condition affecting approximately 0.3% to 6.6% of the population, with autophony being the predominant complain. The management of PET lacks a well-defined standard in the literature as no effective medical treatments have been documented but various surgical options are available. This study aims to report mid-term outcomes following surgical management of PET.

MATERIALS AND METHODS

All patients who underwent surgical intervention for PET between September 2017 and June 2022 were enrolled. Data encompassing general demographics, quality of life (GBI), and procedure-specific data were collected.

RESULTS

A total of 30 PET cases (in 19 patients) underwent surgical intervention including 9 injections of hyaluronic acid, 13 fat injections, 6 endoscopic shim insertions, 1 cartilage graft, and 1 injection of hydroxy apatite. After an average follow-up of 22 ± 14 months, 16 cases (53%) achieved complete symptom relief, while 8 cases (26.6%) reported partial relief. Additionally, 11(36%) cases required multiple surgeries. No specific surgical technique demonstrated superiority. Quality of life improved in 77% of cases based on 10 out of 13 GBI collected. Recurrence of PET symptoms occurred on average 10.6 ± 9.7 months after initial surgery, with an estimated global risk of 75% at 3 years. Transient serous otitis media was observed in only 4 cases (13.3%).

CONCLUSION

Surgical intervention for PET was found to be effective, achieving complete symptom relief in 53% of cases and significantly improving quality of life 2 years post-surgery. However, a substantial portion of cases necessitated one or more re-interventions. The durability of effectiveness appears to diminish over time.

Permanent occlusion of the Eustachian tube: a retrospective study on reopening procedures

PURPOSE

This study retrospectively evaluated the efficacy and versatility of reopening procedures for the permanent occlusion of the cartilaginous Eustachian tube (POET) by analyzing four consecutive cases.

METHODS

The study included all patients diagnosed with POET who suffered from Eustachian tube occlusion and glue ear. A combined approach of endoscopic transnasal/transoral laser surgery was utilized to reopen the POET. This was subsequently followed by balloon dilation (BET) and stenting for a duration of six weeks. In one distinct case, the Eustachian tube orifice was approached via a transtympanic method, where a balloon catheter was placed. The primary outcome measures targeted the success rate of reopening, which was quantified using audiological outcomes and Eustachian tube patency verified by a positive Valsalva maneuver.

RESULTS

Four patients, with an age range of 14-62 years (mean age of 29.3 years), were subject to Eustachian tube reopening. The duration of follow-up varied between 10 and 24 months, averaging at 16.2 months. Notably, 75% of the surgically treated ears displayed no evidence of glue ear upon their last follow-up and showed restoration of Eustachian tube patency. The procedures were executed without any surgical complications. The causes for POET in these patients were heterogeneous: two were attributed to scarring post adenoidectomy, one to occlusion following orthognathic surgery and the remaining one due to prior radiotherapy treatment for squamous cell carcinoma located at the soft palate.

DISCUSSION

Total occlusion of the cartilaginous Eustachian tube may be linked to persistent middle ear diseases. It is imperative to conduct nasopharyngeal endoscopy in these cases. The findings from this study suggest that the Eustachian tube reopening procedure is predominantly effective and safe for patients with POET stemming from a variety of pathologies. Future research should focus on exploring advanced stenting devices and necessitate longer follow-up periods for comprehensive understanding.

Tympanic membrane findings and Eustachian tube function after transtympanic plugging for the chronic patulous Eustachian tube

OBJECTIVE

To evaluate Eustachian tube (ET) function after Kobayashi plug surgery based on the tympanic membrane (TM) findings and active opening (AO) of the ET assessed with sonotubometry.

SUBJECTS AND METHODS

A retrospective survey of medical records identified 74 ears of 66 patients with patulous ET (PET) received transtympanic insertion of the Kobayashi plug. Excluding the six ears (6 patients) with abnormal preoperative TM, sixty-eight ears of 60 patients were found to have normal TM preoperatively. Among these 68 ears, there were 51 ears in which sonotubometry was performed both before and after surgery to evaluate whether the AO of the ET was positive or not.

RESULTS

Out of the 68 ears with normal preoperative TM, 52 ears (76.5%) were judged successful (sum of complete relief and significant improvement). The postoperative TM was normal in 41 ears (60.3%), while 27 ears (39.7%) had abnormal TM findings postoperatively. The success rate was 75.6% (31/41) in ears with normal postoperative TM, while it was 77.8% (21/27) in ears with abnormal TM. Success in maintaining normal postoperative TM was found in 45.6% (31/68) of the total ears treated. Out of the 51 ears in which sonotubometry was performed both before and after surgery, AO was preoperatively positive in 88.2% of the ears (45/51), while it was positive in 64.7% (33/51) postoperatively. In thirty-four ears with normal TM postoperatively, AO was positive in 24 ears (70.6%), while it was positive in 9 out of 17 ears (52.9%) with abnormal postoperative TM. The success rate was 70.6% (36/51) for the 51 ears in which AO was assessed both pre- and postoperatively, and it was 66.7% (22/33) in ears with positive AO postoperatively, while it was 77.8% (14/18) in ears without AO postoperatively. The incidence of ears either having normal postoperative TM or positive AO postoperatively was 84.3% (43/51). Abnormal postoperative TM findings without effectiveness were found in 8.8% (6/68).

CONCLUSION

The obstructive dysfunction of the ET is a calculated risk but did not occur in most ears after plugging with the Kobayashi plug. Therefore, routine insertion of the VT at the same time as the initial surgery is not recommended for PET cases that are adequately followed up.

Reconstruction of the Obliterated Eustachian Tube: A Pilot Case Series

OBJECTIVE

To investigate the safety and early efficacy of a procedure for reconstruction of the obliterated Eustachian tube (ET).

STUDY DESIGN

Retrospective case series.

METHODS

Patients with total obliteration of the cartilaginous ET, with intractable mucoid effusion causing repeated occlusion of tympanostomy tubes were included. Patients underwent endoscopic transnasal/transoral reconstruction of the obliterated ET using transtympanic illuminated guidewire guidance. A temporary stent (angiocatheter filled with bonewax) was placed to maintain patency while healing. In four cases an additional steroid-eluting propel stent was placed in the ET orifice. Main outcome measures were otomicroscopy results, absence of middle ear effusion, and nasopharyngoscopy showing patency of the ET orifice.

RESULTS

Nine ETs (seven patients), ages 17-68 years (mean 37.9) underwent ET reconstruction. Follow-up ranged from 4 to 56 months (mean 30.9 months). 89% of operated ears had no effusion at last follow-up. Two patients (three Eustachian tubes) underwent successful reoperation. There were no complications directly related to the procedure. Etiologies of obliteration included scarring after sinus surgery, obstruction after maxillo-mandibular advancement surgery (two patients), bullous pemphigus, gunshot trauma, and previous patulous obliteration (two patients).

CONCLUSIONS

Complete occlusion of the cartilaginous ET can be associated with intractable mucoid effusion; endoscopic examination should be considered in such cases. In this pilot study, ET reconstruction was found to be a safe and possibly effective procedure in patients with total obliteration of the ET from various etiologies. Larger studies with long term follow up are indicated.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Trans-tympanic insertion of an angiocatheter with a stopper for treatment of patulous Eustachian tube

BACKGROUND

Plugging of the Eustachian tube (ET) is an effective method for treating patulous Eustachian tube (PET). However, no material suitable for plugging is commercially available. A plugging material was made using an angiocatheter and a ventilating tube (VT).

METHODS

An 18-gauge angiocatheter was cut 25 mm from the tip, and the cut end was occluded and widened by melting using a candle. The angiocatheter was inserted into the hole of a Paparella type 1 VT, which was moved to the cut end of the catheter. The VT acted as a stopper at tympanic orifice of ET to prevent the angiocatheter from descending into nasopharynx. Two women with PET received ET-plugging surgery using this plugging material via trans-tympanic approach.

RESULTS

All symptoms of PET disappeared after surgery. There have been no postoperative complications, and the catheter has functioned well without extrusion.

CONCLUSION

A plug created from an angiocatheter and a VT is easy to make and is effective for the treatment of PET.

Patulous Eustachian Tube Patients With Oculopharyngeal Muscular Dystrophy

OBJECTIVES

To describe cases of patulous Eustachian tube (PET) or patent ET conditions in oculopharyngeal muscular dystrophy (OPMD).

PATIENTS

Four cases of PET or patent ET conditions with OPMD.

MAIN OUTCOME MEASURES

Clinical case records, objective ET function tests (tubo-tympano-aerodynamic graphy and sonotubometry), and swallowing function (videoendoscopic examination and Food Intake Level Scale) were analyzed.

RESULTS

Two cases of definite PET, one case of possible PET, and one case lacking aural symptoms with findings of patent ET. All patients have ptosis, and three cases have dysphagia. Body mass index indicated that three cases were underweight. Magnetic resonance imaging in case 4 showed atrophy and fat replacement of palatine and masticatory muscles.

CONCLUSIONS

It is important to consider PET or patent ET conditions when OPMD patients describe aural symptoms.

Enlargement of Eustachian Tube Lumen in Patulous Eustachian Tube Patients Compared to that by Aging

OBJECTIVE

To evaluate the Eustachian tube (ET) dimensions in patulous ET (PET) patients compared with that by aging using sitting 3D computed tomography (CT).

STUDY DESIGN

Retrospective study.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

A retrospective survey of medical records in Sen-En Rifu Hospital identified 105 ears of 76 PET patients and 65 ears of 34 patients without ET dysfunction findings (non-PET). Subjects in both PET and non-PET groups were then divided into two age groups. Groups A and C defined as non-PET and PET subjects respectively, who were under the age of 60 years, while Groups B and D defined of non-PET and PET subjects respectively, who were 60 years and above. 3D CT (Accuitomo; Morita, Kyoto, Japan) was performed on all subjects in the sitting position. The ET lumen from the ET pharyngeal orifice to 15 mm was analyzed.

RESULTS

No significant difference in the ET lumen near the pharyngeal orifice was found between Group A and C; however, there was a significant difference in the ET at points lateral to the pharyngeal orifice. The ET lumen was significantly larger at the site close to the pharyngeal orifice in Group B as compared to that of Group A. For the two groups of PET classified according to the size of the pharyngeal orifice and area close to the isthmus, age was only significantly different between two groups of pharyngeal orifice. On the contrary, sonotumometry and Ohta method were significantly different between the two groups of the area close to the isthmus.

CONCLUSION

The lumen of the ET is enlarged in both PET and aging. However, the responsible site was found to be different. While the enlargement of the ET lumen in 60 years and above subjects without PET mainly occurred near the pharyngeal orifice of the ET, it was near the isthmus in under 60 years PET patients. Further study of possible clinical implications of these findings as well as treatment strategy are required.

Patulous Eustachian tube: Deep breath for a diagnosis

Significance Statement: Eustachian tube disorders are common outpatient otologic presentations that can present a diagnostic challenge due to overlapping symptoms. This article will focus on patulous Eustachian tube, how the symptoms can overlap with those of Eustachian tube dysfunction, and the diagnostic insight offered by a close inspection of the tympanic membrane.

Repeat Eustachian Tube Balloon Dilation Outcomes in Adults With Chronic Eustachian Tube Dysfunction

OBJECTIVE

With increased focus on surgical management of the eustachian tube, clarifying management decisions benefits patients and surgeons. In this study, we examine the value of repeating the balloon dilation of the eustachian tube (BDET) procedure in patients who did not improve after the initial BDET.

STUDY DESIGN

Level IV retrospective review of 145 BDETs performed on 86 patients between January 1, 2014, and May 1, 2019, identified 10 patients who underwent BDET more than once.

SETTING

Managed care community otolaryngology practice.

METHODS

Demographic and outcome data were collected on both single and repeat BDET cohorts.

RESULTS

The Eustachian Tube Dysfunction Questionnaire 7 (ETDQ-7) was used as the primary outcome measure when comparing single vs repeat BDET cohorts. Generally, the 2 cohorts were similar in terms of sex and age distribution. Tobacco use and radioallergosorbent test-positive results were greater proportionally in the repeat BDET cohort. Preoperative ETDQ-7 scores were similar in both cohorts. Single BDET patients overall showed significant improvement in ETDQ-7 scores. ETDQ-7 scores for repeat BDET patients who did not improve after the first procedure similarly did not demonstrate improvement after the second procedure.

CONCLUSIONS

Inevitably, some patients will not improve after an initial BDET procedure. The utility of a repeated BDET procedure should be considered in determining how to manage such failures. The results of this limited study suggest that patients who fail to improve meaningfully on ETDQ-7 scores after the initial procedure are unlikely to show substantial improvements after a repeated procedure.

Endoscopy Guided Eustachian Tube Balloon Dilation: Our Experiences

Introduction:

Eustachian tube (ET) dysfunction is a common clinical entity but its treatment is still challenging to Otorhinolaryngologists. This study is done to know the effectiveness of transnasal endoscopic balloon dilatation of eustachian tube for treatment of chronic eustachian tube dysfunction.

Materials and Methods:

It is a retrospective observational study conducted between May 2018 to June 2019 at IMS and SUM Hospital, Siksha 'O' Anusandhan University, Bhubaneswar, Odisha, India. Twenty one patients were identified with diagnosis of ET dysfunction and assigned to this study. The transnasal endoscopic procedure was done to dilate the cartilaginous part of the eustachian tube with a balloon catheter. Preoperative computed tomography was done in all cases. All patients were post-operatively assessed in 1^st, 2^nd and 8^th weeks after the procedure.

Result:

Balloon dilatation of the eustachian tube was easily performed in all cases of this study. No abnormality including carotid canal was seen before this procedure. All except 2 cases revealed significant improvement in the ET functions. There was no damage to any vital structures like internal carotid artery in this study.

Conclusion:

The majority of the patients participated in this study showed positive outcome after balloon dilation of eustachian tube. It is a feasible and safe procedure for dilating the eustachian tube. This treatment is a very promising and requires more research on this aspect.

Current Treatment Options for Patulous Eustachian Tube: A Review of the Literature

OBJECTIVE

Patulous Eustachian tube (PET) is a clinical condition that is associated with troublesome aural symptoms and is difficult to be treated successfully. The purpose of this review is to examine the published literature regarding the therapeutic value of the current treatment options for PET.

METHODS

We searched Web of Science, PubMed and Medline from 1999 to 2019. The search focused on papers concerning the clinical evaluation of treatment methods in PET patients. Statistical techniques were not used.

RESULTS

Prospective and retrospective case series were the types of trials available for review. We included 28 articles that evaluated the efficacy of various conservative and surgical therapeutic options. The recovery rates ranged from 50% to 100%. In most studies the assessment of efficacy was based on the subjective improvement of patient symptoms as there is no validated outcome tool available. No severe adverse events were observed in any study.

CONCLUSION

On the basis of the available literature, it seems that conservative treatments can be considered as a primary therapeutic option for PET. Concerning the surgical interventions they seem to be a safe and valuable solution in patients with refractory disease. Finally, given the low level of evidence, prospective case-control studies with long follow-up and robust setting looking into the therapeutic approach of PET are required. The need for establishment of standard criteria of PET recovery should be underlined.

Patulous Eustachian tube (PET), a practical overview

Symptoms of patulous Eustachian tube (ET), particularly autophony, can overlap with other conditions, and can arise from a variety of causes. We review the pathophysiology of "speech hyper-resonance syndromes", and possible mechanisms, including resonances in the tympanic membrane, Eustachian tube and nasopharynx. Treatment can be directed at the eardrum or the ET depending on site of pathology. We review typical presentations, examination findings, and useful clinical tests to distinguish PET from other disorders, and our philosophy of management.

Plug size selection protocol for the treatment of intractable patulous Eustachian tube with Kobayashi Plug

Background: There have been no useful criteria for initial plug size selection protocol for the treatment of intractable patulous Eustachian tube (PET). Aims/objectives: To establish a method for appropriate plug size selection using tubal function test and subjective symptom severity in PET patients who were treated by Kobayashi Plug insertion. Material and methods: A retrospective survey of medical records identified 39 ears of 35 patients with PET who received insertion of the Kobayashi Plug and whose PET symptoms were thereafter controlled for at least 6 months after surgery. Method: The evaluation scale of PET handicap inventory-10 (PHI-10) was used to indicate PET subjective symptom severity. Tubal function tests (sonotubometry and tubo-tympano-aerodynamic-graphy: TTAG) were performed. Results: There was no correlation between the preoperative PHI 10 score and plug size (p = .157). There was a significant correlation between the preoperative sound attenuation from nostril to EAC measured by sonotubometry and plug size (p < .001). There was no correlation between the preoperative pressure transmission ratio estimated by TTAG and plug size (p = .271). Conclusions and Significance: Sonotubometry which evaluates sound attenuation from nostril to EAC can be a useful tool for selecting plug size.

Efficacy of a silicone plug for patulous eustachian tube: A prospective, multicenter case series

OBJECTIVES/HYPOTHESIS

To report the efficacy and safety of transtympanic plugging of the eustachian tube (ET) using a silicone plug (Kobayashi plug) for chronic patulous ET (PET).

STUDY DESIGN

Prospective and multicenter trial conducted in which 30 PET patients were resistant to at least 6 months of conservative treatment.

METHODS

The efficacy and safety of 28 and 27 patients, respectively, were analyzed. All patients fulfilled inclusion and exclusion criteria. The primary end point used the patulous eustachian tube handicap inventory-10 (PHI-10), and the secondary end point used ET function tests such as sonotubometry, tubo-tympano-aerodynamic-graphy, and respiratory movement of the tympanic membrane and auscultation of voice sounds transmitted from the nose through the ET to the external auditory canal at 3months after surgery.

RESULTS

PHI-10 scores were 34.4 ± 4.2, 6.4 ± 9, and 5.7 ± 8.6 at screening, and 3 and 6 months after surgery. Twenty-three cases (82.1%, 95% confidence interval: 63.1%-93.9%) were judged as successes. There were five cases (17.2%) of middle ear effusion, four cases (13.8%) of tympanic membrane perforation, and one case of tinnitus due to surgery to remove the plug. No severe or life-threatening complications were found.

CONCLUSIONS

This study revealed the efficacy and safety of silicone plug insertion for severe PET patients.

LEVEL OF EVIDENCE

2 Laryngoscope, 130:1304-1309, 2020.