Efficacy and safety of balloon dilation of eustachian tube in children: Systematic review and meta-analysis

Outcomes and Complications of Pediatric Eustachian Tube Dilation Surgery

OBJECTIVE

To determine whether balloon dilation of Eustachian tube (BDET) improves postoperative audiology and quality of life scores in children with chronic Eustachian tube dysfunction.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary care pediatric center.

METHODS

Eligible participants were patients 8 years or older, with a history of 2 prior tubes placement. Group 1-patients completed pre-and post-Eustachian Tube Dysfunction Quality of Life Survey (ETDQ-7) survey scores, Group 2-patients had available pre- and postdilation tympanogram data (TD), and Group 3-patients had both ETDQ-7 survey and TD. The average time for the first and subsequent follow-ups was 3.8 and 12.9 months, respectively.

RESULTS

A total of 43 patients (85 ears) underwent BDET. The mean age was 13.3 years (8-18 years). Twenty-four patients were male (55.8%) and over 80% were Caucasian. The average mean ETDQ-7 score before and after dilation was 3.9 and 2.5, respectively. Ninety-three percent experienced improvement of their postoperative ETDQ-7 scores and 53% had normal postdilation ETDQ-7 score (P < .0001). Thirty-seven ears in Group 2 (60.7%) had improvement in postdilation TD. A greater proportion of ears showed improvement of 62.3% with a 95% confidence interval (CI) [50.1%-74.5%] compared to 37.7% without improvement, 95% CI [25.5%-49.87%]. Ears with type A or B TD were more likely to show improvement than ears with type C, perforated, or with tubes (P < .0001). Eighteen out of 30 ears in Group 3 (60%) experienced an improvement in both ETDQ-7 and tympanogram.

CONCLUSION

BDET is a safe, efficacious alternative to tubes in selected pediatric patients.

Outcomes of Concurrent Balloon Eustachian Tuboplasty and Tympanostomy Tube Placement in Children

OBJECTIVES

Balloon dilation eustachian tuboplasty (BDET) has been proven to be a safe treatment option for children with eustachian tube dysfunction (ETD). This study aims to analyze the long-term outcomes of children who underwent concurrent BDET and tympanostomy tube (TT) placement. We hypothesize that patients who underwent simultaneous therapy have experienced a low overall rate of middle ear pathology and have consistent hearing quality at subsequent office visits.

METHODS

Retrospective chart review of 19 pediatric patients (36 ears) who previously underwent concurrent BDET and TT placement. Patient charts within the extended postoperative period were reviewed. Specific data points included need for reoperation, rates of middle ear pathology, audiological outcomes, and number of previous TT placements.

RESULTS

Pediatric patients who underwent concurrent BDET and TT placement had long-term success in 34/36 ears (94.4%). All postoperative tympanograms and audiograms (100%) were normal when performed within 12 months after the procedure. Notably, 34/36 ears (94.4%) had history of tube placement in the past. Patients had an average of three sets of tympanostomy tubes prior to undergoing concurrent BDET and TT.

CONCLUSION

Concurrent BDET and TT placement may be an effective treatment option for pediatric patients with persistent eustachian tube dysfunction. Specifically, BDET may be a useful adjunct tool in pediatric patients with refractory ETD despite having multiple sets of tympanostomy tubes. This study aims to strengthen the argument of performing multimodal therapy in pediatric patients with recurrent middle ear disease.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:4799-4802, 2024.

The case for balloon eustachian tuboplasty in children

PURPOSE OF REVIEW

Balloon dilation of the cartilaginous portion of the Eustachian tube has increasingly gained acceptance among otolaryngologists in the treatment of obstructive Eustachian tube dysfunction. There is however little data on the procedure performed in children. The purpose of this study is to review the recent developments regarding balloon dilation in pediatric patients.

RECENT FINDINGS

Balloon dilation of the Eustachian tube is safe in pediatric patients. The effects of the procedure are durable during long term follow-up. Diagnosing obstructive dysfunction remains challenging. There is no single test or questionnaire for diagnosing the condition; instead a series of appropriate tests should be used. The pediatric Eustachian tube is very responsive to the effects of balloon dilation. While the treatment is effective, overtreatment can have unwanted results such as patulous symptoms. Reducing the time of dilation should therefore be considered.

SUMMARY

Otolaryngologists performing the procedure should be familiar with the effects of balloon dilation on the pediatric Eustachian tube and consider altering the duration of dilation accordingly. Further studies are needed especially regarding patient selection, optimal age for dilation and balloon parameters for pediatrics (e.g. dimensions, inflation duration, inflation pressure).

MAUDE database and Eustachian tube balloon dilation: Evaluation of adverse events and sales data

STUDY DESIGN

Review of database.

SETTING

Tertiary care neurotology center.

PATIENTS

Patients undergoing adverse events.

INTERVENTION

MAUDE database evaluation of Eustachian tube balloon dilation (ETBD) for the treatment of Eustachian tube dysfunction.

MAIN OUTCOME MEASURES

Medical device reports (MDRs) from the MAUDE database were analyzed for adverse patient events (AE) and device malfunctions (DM) among different devices for ETBD. The objective of this analysis is to assess AE rates and compare them across different devices. Sales data was also used to calculate AE rates.

RESULTS

There were 18 MDRs noted in the MAUDE database for patients undergoing ETBD out of an initial 23 results. When separated into devices, the Aera had 9 total MDRs (50 %), Xpress had 8 (44.4 %) and Audion had 1 (5.6 %). There were 10 AE and 8 DM. When separated by device, Aera had 4 AEs and 5 DMs, Xpress had 5 AEs and 3 DMs, and Audion had 1 AE. The most common AE was subcutaneous emphysema (n = 4), in the head and neck region with one report of mediastinal involvement. Using this sales data, the Aera balloon has an MDR rate of 0.0128 % is established, with a rate of AE at 0.0058 %. The Audion balloon had an MDR and AE rate of 0.0164 %.

CONCLUSIONS

ETBD is a safe procedure with minimal complications, with subcutaneous emphysema being the most commonly reported adverse event, consistent with literature findings. A comprehensive analysis of AE, coupled with sales data, indicates a commendably low MDR rate of 0.0128 % for the Aera balloon while the Audion balloon had an MDR rate of 0.0164 %. These findings offer valuable insights on post-procedure expectations and engaging in informed consent discussions with patients, highlighting the overall safety of ETBD as an intervention.

Long-term efficacy of balloon dilation of the pediatric Eustachian tube: A six-year matched cohort study

PURPOSE

Balloon dilation of the Eustachian tube (BDET) has not been evaluated extensively in children outside of retrospective case series. The purpose of this study is to report the long-term safety and efficacy of this procedure in children with matched controls.

MATERIALS AND METHODS

This is a two-center retrospective matched cohort study. Children having undergone tympanostomy tube (TT) placement and adenoidectomy with recurrence of symptoms underwent BDET at an academic affiliated multi-specialty practice. Comparison was made with children receiving TT at a tertiary medical center, matching for number of prior TT, prior adenoidectomy, age, and sex. Outcome measures were risk of failure and the need for additional surgery. Kaplan-Meier survival plots were used to compare risk of failure.

RESULTS

Thirty-three Eustachian tubes were dilated in 20 patients, aged 14 months-14 years. All patients had previously undergone TT insertion and adenoidectomy. Patients undergoing BDET had normal post-operative tympanograms in 80 % of cases. Mean follow up was 6.7 years with 2 patients failing in the BDET group and 8 in the TT insertion group. Dilated patients had a significantly lower risk of failure than those who underwent TT insertion (adjusted HR: 0.18; 95 % CI: 0.04, 0.81; p = 0.03). The probability of being failure free at six years was 88 % (95 % CI: 71, 95 %) in the BDET cohort and 53 % (95 % CI: 33, 70 %) in the TT insertion cohort. There were no complications.

CONCLUSIONS

BDET appears to be safe and possibly superior to TT placement in children with refractory Eustachian tube dysfunction.

LEVEL OF EVIDENCE

2b.

Eustachian tube balloon dilation

Eustachian tube dysfunction is a frequent pathology of middle-ear ventilation, leading to many more or less disabling otologic symptoms. Severity varies from simple otitis media with effusion to aggressive chronic otitis or cholesteatoma. First-line treatment is medical, but surgery can also be proposed. It consists in balloon dilation of the Eustachian tube, in order to increase ventilation and improve symptoms. It is performed in second-line in patients with Eustachian tube dysfunction confirmed by tubomanometry, after failure of local drug treatment. It can be performed under general or local anesthesia but it is mandatory to use a medical device with market authorization for this indication. The main aim of this surgical note is to describe the technique of balloon dilation in the treatment of Eustachian tube dysfunction and the three balloon models with CE label and market authorization currently available in France and in Europe. Balloon dilation of the Eustachian tube appears to be a promising option to restore natural middle-ear ventilation in patients with chronic obstructive Eustachian tube dysfunction.

A manual of Eustachian tube function tests-illustration of representative test results obtained from healthy subjects and typical disorders with suggestion of the appropriate test method of choice

In the 19th century, Politzer devised a method to measure passage of the Eustachian tube (ET) by pressurizing the nasopharyngeal cavity, which marked the beginning of the ET function test. Since then, various examination methods have been developed. While ET function testing is important, recent advancements in diagnostic imaging and treatments have renewed interest on its importance. In Japan, the main objective methods used for examining ET function include tubotympanoaero-dynamic graphy (TTAG), sonotubometry, and the inflation-deflation test. The Japan Otological Society (JOS) Eustachian Tube Committee has proposed a manual of ET function tests, which presents typical patterns of the normal ear and typical diseases and suggests the ET function test of choice for each disease. However, the diagnosis of each disease should be made based on a comprehensive history and various examination findings, with ET function tests playing a supplemental role in the diagnosis.

Complications of eustachian tube balloon dilation: Manufacturer and User Facility Device Experience (MAUDE) database analysis and literature review

Objective

To provide an analysis of complications following eustachian tube balloon dilation as well as their treatments and outcomes.

Data Sources

PubMed, Ovid Embase, and MAUDE Database.

Review Methods

A systematic approach following PRISMA guidelines was used to identify publications pertaining to balloon dilation of the eustachian tube from PubMed and Ovid Embase databases was used. Once these publications were critically reviewed, the primary outcome extracted were reported complications. Additional complications were collected in the Manufacturer and User Facility Device Experience (MAUDE) database using the product class "eustachian tube dilation device" and searching through relevant manufacturers. Complications and outcomes were compared between these sources.

Results

Fifty five full-length manuscripts involving 7155 patients were included and 98 complications reported for a 1.4% complication rate. The most frequently reported adverse events were subcutaneous emphysema of the head and neck (19%), epistaxis (12%), and acute otitis media (11%). The MAUDE search returned 18 distinct patient entries, of which 12 (67%) reported complications. The most reported complications in the MAUDE database included subcutaneous emphysema (8, 67%) and pneumomediastinum (3, 25%). The most serious complication was a carotid artery dissection reported in one patient in the MAUDE database.

Conclusion

Eustachian tube dilation is rarely associated with complications, which nevertheless may lead to morbidity and medical emergencies. Patients and providers should recognize potential risks associated with this intervention as well as methods to manage complications.

Balloon Eustachian Tuboplasty Combined or Not with Myringotomy in Eustachian Tube Dysfunction

BACKGROUND

Eustachian tube dysfunction (ETD) is a common disorder causing ear pressure, pain, and hearing loss. Balloon Eustachian tuboplasty (BET) is an emerging technique for dilating the Eustachian tube and treating ETD. Whether adding myringotomy improves BET efficacy is controversial.

METHODS

This retrospective study included 95 ETD patients undergoing BET alone (n = 44) or BET with myringotomy (BET + M; n = 51) between June 2020 and August 2021 at a single medical center. The primary outcome was the change in ETDQ-7 symptom scores from baseline to 6 months after treatment. Secondary outcomes included audiometry, endoscopy, Valsalva maneuver, and complications.

RESULTS

The ETDQ-7 scores improved significantly after treatment in both groups (p < 0.001), without significant between-group differences (p = 0.417). No significant differences occurred in the audiometry, endoscopy, and Valsalva results or in most complications between groups. One BET + M patient had a persistent tympanic membrane perforation.

CONCLUSIONS

Both BET alone and BET + M effectively and safely improved the subjective and objective ETD outcomes. However, adding myringotomy did not further improve the outcomes over BET alone, while it incurred risks such as persistent perforation. BET alone may sufficiently treat ETD without requiring myringotomy in this cohort. Further randomized controlled trials should identify optimal candidates for BET alone versus combined approaches.

Outcomes and Prognostic Factors of Balloon Eustachian Tuboplasty Combined With Ventilation Tubes Insertion in Children: A Retrospective Study

Objective: To evaluate the efficacy and safety of balloon eustachian tuboplasty (BET) combined with ventilation tube (VT) insertion in pediatric population and to identify the predictive factors for symptom recurrence. Methods: We conducted a retrospective study between August 2018 and February 2022 at Shenzhen Children's Hospital. The study analyzed the data of pediatric patients who underwent BET + VT insertion, as well as the data of pediatric patients who underwent VT insertion alone. The outcomes were efficacy, safety, and predictive factors of BET combined with VT. Kaplan‒Meier curves were used to examine the failure-free survival rate. A multivariate Cox regression model was used to identify the independent predictors of BET failure. Results: We evaluated the data of 29 pediatric patients (48 ears) who underwent BET with VT insertion (BET + VT group) and the data of 29 pediatric patients (46 ears) who underwent VT insertion alone (VT group). The total effectiveness rates at the first follow-up after VT removal and at 12 months in the BET + VT group were 90.9% and 84.6%, respectively. The decrease in the air-bone gap (ABG) was more significant in the BET + VT group at 12 months (13.7 ± 10.8 vs 6.4 ± 15.3, P < .05). The subgroup analyses did not show any significant difference between the groups in high-risk. For non-high-risk patients, the decrease in the ABG was more significant in the BET + VT group (14.2 ± 10.6 vs 4.3 ± 13.1, P < .05) at 12 months. The multivariate analysis showed that a history of VT insertion was independently associated with a higher rate of recurrence in the BET + VT group (hazard ratio 3.177; 95% CI, 1.027-9.826; P < .05). Conclusions: BET + VT insertion is an effective procedure to decrease the ABG in pediatric patients with eustachian tube dysfunction (ETD) who have no risk factors for conventional therapy failure. Treatment of patients with ETDs who have coexisting risk factors remains a challenge that warrants further high-quality prospective research.

Is there a role for Eustachian tube balloon dilation in pediatric patients with refractory Eustachian tube dysfunction?

BACKGROUND

Eustachian tube dysfunction (ETD) is common in children. Over the past decade, eustachian tube balloon dilation (ETBD) has become a more widespread treatment for this condition. Data has been encouraging in the adult population, but data among the pediatric population has been sparser. This comprehensive review aims to assess current evidence for ETBD in pediatric patients.

REVIEW

Studies relevant to ETBD in the pediatric population were identified by utilizing the PubMed MEDLINE database. While multiple retrospective studies were found, this search yielded two systematic reviews focused on the pediatric population as the highest level of evidence assessing ETBD in children. There was overlap of included studies, but each review contained a unique set of studies. These reviews found that ETBD was safe in children.

BEST PRACTICE SUMMARY

Overall, ETBD appears safe and efficacious in children with refractory ETD. Future prospective trials confirming this conclusion are warranted. At this time, there appears to be a role for ETBD with or without ventilation tube placement in children with refractory ETD.

Characteristics of tympanogram in symptomatic Eustachian tube dysfunction

PURPOSE

To identify the characteristics of tympanogram in symptomatic Eustachian tube dysfunction (SETD) patients.

METHODS

One hundred and twenty-four unilateral SETD patients presenting with type A tympanograms who underwent balloon dilation of the Eustachian tube (BDET) were recruited and assigned into effective BDET group and ineffective BDET group based on treatment effect. The unaffected ear in the same patient served as normal control. Fifty-one patients with sudden sensorineural hearing loss (SSHL) and 46 patients with Meniere's disease (MD) were selected for cases of non-ETD ear fullness. Demographics, 7-item Eustachian Tube Dysfunction Questionnaire score (ETDQ-7), and tympanograms were recorded and analyzed preoperatively and postoperatively.

RESULTS

Of the 124 SETD patients included in the study 94 (75.8%) showed good response to BDET based on decreased ETDQ-7 scores. There were no significantly differences in the values of tympanometric peak pressure (TPP) between diseased ears and healthy ears in SETD patients, as well as in SSHL and MD patients. Instead, TPP shifts (the difference between two values of TPP obtained under a Valsalva and Toynbee maneuver) were remarkably reduced in affected ears compared with those in unaffected ears in effective BDET group at baseline. Moreover, TPP shifts in these SETD ears significantly raised and reached the levels in healthy ears postoperatively.

CONCLUSIONS

This study demonstrated TPP shifts are decreased in a subset of SETD patients presenting with type A tympanograms and these patients are more likely to show good response to BDET.

In-office Eustachian tube balloon dilation under local anesthesia as a response to operating room restrictions associated with the COVID-19 pandemic

Objective

To evaluate the feasibility of local anesthesia for Eustachian tube balloon dilation as an in-office procedure for the treatment of Eustachian tube dilatory dysfunction as a response to the restriction measures of the coronavirus disease 2019 pandemic.

Method

Patients with Eustachian tube dilatory dysfunction refractory to nasal steroids undergoing Eustachian tube balloon dilation in local anesthesia were enrolled in a prospective observational cohort between May 2020 and April 2022. The patients were assessed by using the Eustachian tube dysfunction questionnaire (ETDQ-7) score and Eustachian tube mucosal inflammation scale. They underwent clinical examination, tympanometry, and pure tone audiometry. Eustachian tube balloon dilation was performed in-office under local anesthesia. The perioperative experience of the patients was recorded using a 1-10 visual analog scale (VAS).

Results

Thirty patients (47 Eustachian tubes) underwent the operation successfully. One attempted dilation was aborded because the patient displayed anxiety. Local anesthesia was performed by using topical lidocaine and nasal packing for all patients. Three patients required an infiltration of the nasal septum and/or tubal nasopharyngeal orifice. The mean time of the operation was 5.7 min per Eustachian tube dilation. The mean level of discomfort during the intervention was 4.7 (on a 1-10 VAS scale). All patients returned home immediately after the intervention. The only reported complication was a self-limiting subcutaneous emphysema.

Conclusion

Eustachian tube balloon dilation can be performed under local anesthesia and is well tolerated by most patients. In the patients reported in this study, no major complications occurred. In order to free operation room capacities, the intervention can be performed in an in-office setting with satisfactory patient feedback.

The Eustachian Tube Dysfunction in Children: Anatomical Considerations and Current Trends in Invasive Therapeutic Approaches

The eustachian tube (ET) has a crucial role in the physiology of the middle ear. Thus, any condition that renders the tube dysfunctional is directly implicated with middle ear pathophysiology, like in the case of acute otitis media and otitis media with effusion. Children are more vulnerable to pathologies of the middle ear, primarily due to the immature development of their eustachian tubes. Otitis media with effusion, apart from being a burden for hearing, with direct consequences for speech development, may also be implicated in cholesteatoma formation. Medical therapy is not practically effective for the treatment of effusion. Moreover, the established surgical approaches, like grommets and adenoidectomy, deal only indirectly with the problem since they are not addressing the dysfunctional ET itself. An emerging interventional approach that intends to restore the function of the tube is the transnasal balloon dilation of the cartilaginous part of the ET. Growing international experience indicates that this promising technique is safe and effective. In the current review, we aim to provide background information on the anatomy, physiology, and pathophysiology of the ET and to present the progress of the balloon dilation technique with emphasis on pediatric patients.