Therapeutic improvement of Eustachian tube function: a review

Intra-operative Measurement of Eustachian Tube Orifice, and Its Correlation With Post-operative Surgical Outcome in Chronic Suppurative Otitis Media Patients

Background Chronic suppurative otitis media (CSOM) is the inflammation of the middle ear mucosa for more than two weeks, resulting in ear discharge. It is associated with hearing loss and the presence of a perforation in the tympanic membrane. Tympanoplasty is performed to place a graft and clear the disease in the middle ear. Despite adequate disease clearance and proper graft placement, graft failure and disease persistence occur due to Eustachian tube (ET) dysfunction. The ET plays a significant role in the ventilation of the middle ear. Hence, this study was conducted to determine the significance of ET size for post-operative graft uptake. Methodology A total of 55 patients with inactive CSOM were included in the study. Their demographic data were recorded. Patients previously operated on for CSOM, cases with traumatic perforation of the tympanic membrane, congenital anomalies (e.g., cleft lip/cleft palate), and atticoantral disease were excluded. Thorough history taking and examination, including otoscopy and examination of the nose, throat, and oropharynx, were conducted. Once the patient was deemed fit for surgery, they underwent tympanoplasty. Intraoperatively, the ET size was measured using the tip of the suction cannulas. They were followed up after three months to assess graft uptake. Results Out of 55 patients included in the study, 42 (76%) had good graft uptake, while 13 (24%) had defects in graft uptake. Graft uptake failed in patients with an ET diameter of <3 mm. Post-operative graft uptake was observed in the majority of patients with a wider ET diameter, ranging between 3 mm and 6 mm, with a statistically significant p-value of 0.00 (0.05), as determined by Pearson's Chi-square test. Conclusion In our study, we found that there is an association between the ET diameter and post-operative graft uptake. Hence, a wider ET may improve middle ear ventilation and play an important role in post-operative graft uptake.

Sirolimus-coated Eustachian tube balloon dilatation for treating Eustachian tube dysfunction in a rat model

Eustachian tube balloon dilatation (ETBD) has shown promising results in the treatment of ET dysfunction (ETD); however, recurrent symptoms after ETBD frequently occur in patients with refractory ETD. The excessive pressure of balloon catheter during ETBD may induce the tissue hyperplasia and fibrotic changes around the injured mucosa. Sirolimus (SRL), an antiproliferative agent, inhibits tissue proliferation. An SRL-coated balloon catheter was fabricated using an ultrasonic spray coating technique with a coating solution composed of SRL, purified shellac, and vitamin E. This study aimed to investigate effectiveness of ETBD with a SRL-coated balloon catheter to prevent tissue proliferation in the rat ET after ETBD. In 21 Sprague-Dawley rats, the left ET was randomly divided into the control (drug-free ETBD; n = 9) and the SRL (n = 9) groups. All rats were sacrificed for histological examination immediately after and at 1 and 4 weeks after ETBD. Three rats were used to represent the normal ET. The SRL-coated ETBD significantly suppressed tissue proliferation caused by mechanical injuries compared with the control group. ETBD with SRL-coated balloon catheter was effective and safe to maintain ET luminal patency without tissue proliferation at the site of mechanical injuries for 4 weeks in a rat ET model.

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.

The rat eustachian tube: Anatomical, histological, and radiological features

Purpose

This study investigated the anatomical and histological characteristics of the rat Eustachian tube (E-tube) and the feasibility of Eustachian tubography in a rat model.

Materials and methods

Fifteen male Wistar rats were used in this study, and the bilateral E-tubes of each rat were examined. Ten E-tubes were used for anatomical studies, another ten for histological analysis, and the other ten for Eustachian tubography. Five rats were euthanized and decapitated, and ten E-tubes were dissected to describe the anatomy of the E-tube. Ten E-tube specimens obtained from five other rats were sectioned to investigate E-tube histology. Eustachian tubography was performed on the bilateral E-tubes of the other five rats using the trans-tympanic approach.

Results

The rat E-tubes consisted of bony and membranous parts. Cartilage and bone tissue covered only the bony part. The E-tubes' mean diameter and overall length were 2.97 ​mm and 4.96 ​mm, respectively. The tympanic orifices' mean diameter was 1.21 ​mm. The epithelium of E-tubes was mainly composed of pseudostratified ciliated and goblet cells. Eustachian tubography was successfully performed on both sides of the E-tube for each rat. The technical success rate was 100%, the average running time was 4.9 ​min, and no procedure-related complications occurred. On tubography images, the E-tube, tympanic cavity, and nasopharynx could be identified because of the visualization of bony landmarks.

Conclusion

In this study, we described the anatomical and histological features of rat E-tubes. With the aid of these findings, E-tube angiography was successfully performed using a transtympanic approach. These results will facilitate further investigation of E-tube dysfunction.

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.

[Auditory tube dysfunction in children. Part 2]

The presented literature review examines in detail the methods for diagnosing the auditory tube, the history of development of studies of the Eustachian tube and the treatment of its dysfunction in children. The issue of dysfunction of the auditory tube as one of the causes of the formation of chronic hearing loss in childhood is increasingly being identified because of the rapid development of technologies and methods for examining patients. Aim is to study the multiple etiologic factors of the disease and the need for an integrated approach to the study of this condition.

Medical Management for Eustachian Tube Dysfunction in Adults: A Systematic Review and Meta-Analysis

OBJECTIVE

Medical treatment for eustachian tube dysfunction (ETD) is varied, with physician preference driving treatment choice and limited guidance for these options. An evaluation of the efficacy of medical management (MM) for ETD is warranted.

METHODS

A systematic review of three databases (PubMed, Scopus, and Embase) was performed through December 2020. Adults treated nonsurgically for ETD were included. Exclusion criteria were as follows: patulous ETD, ETD deriving from craniofacial anomalies, or surgical treatment. Data were extracted independently by two reviewers according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A meta-analysis of continuous measures, proportions, and risk ratio was conducted.

RESULTS

Twelve articles were identified by systematic review, with either level 2 or 3 evidence. A meta-analysis of available data was performed on nine studies. A pooled cohort found 50.3% (95% confidence interval [CI], 41.7-59.0) of patients experienced symptomatic improvement with MM. ETDQ-7 scores improved in a clinically nonsignificant manner by -0.88 (95% CI, -1.12 to -0.64) following medical treatment. Further, MM benefited from subacute and chronic symptoms in 30% to 64% and 11% to 50% of cases, respectively. Intranasal corticosteroids (INCS) were not efficacious, improving only 11% to 18% of chronic cases. Therapies such as Politzer devices and Valsalva therapy had minimally beneficial results.

CONCLUSION

Our review did not find any level 1 evidence for MM of ETD in adults. Available evidence indicates INCS are ineffective for chronic symptoms and the efficacy of nonsurgical options for subacute ETD has yet to be determined. Further randomized controlled trials are needed to discern efficacy of single-agent medical therapies. Laryngoscope, 2021.

[Auditory tube dysfunction in children (literature review, part 2)]

The presented literature review examines in detail the methods for diagnosing the auditory tube, the history of development of studies of the Eustachian tube and the treatment of its dysfunction in children. The issue of dysfunction of the auditory tube as one of the causes of the formation of chronic hearing loss in childhood is increasingly being identified because of the rapid development of technologies and methods for examining patients. Aim is to study the multiple etiologic factors of the disease and the need for an integrated approach to the study of this condition.

Eustachian tube balloon dilatation: a cross-sectional, survey-based study of 137 UK consultants

Objective

To explore the opinions of the UK consultant body on endoscopic Eustachian tube balloon dilatation in the context of Eustachian tube dysfunction.

Method

A 10-question online survey was distributed to ENT consultants currently practising in the UK (July–September 2018).

Results

A total of 137 ENT consultants responded. Twenty-three per cent reported experience of Eustachian tube balloon dilatation, with a further 10 per cent planning to start performing the procedure. Of those performing the procedure, 16 per cent had more than two years’ experience. Thirty-two per cent were performing zero to five procedures a year. Eustachian tube balloon dilatation was primarily conducted to treat Eustachian tube dysfunction symptoms, as well as retraction pockets, baro-challenge-induced Eustachian tube dysfunction and otitis media with effusion. The most common reason for not undertaking Eustachian tube balloon dilatation was insufficient evidence of efficacy (65 per cent). Seventy-two per cent of consultants thought that creating a national database for audit and monitoring purposes would benefit the specialty.

Conclusion

The majority of UK ENT consultants do not practise Eustachian tube balloon dilatation, citing a lack of high-level evidence to support its use. A national database for auditing and research could facilitate the creation of guidelines.

Buteyko breathing technique for obstructive Eustachian tube dysfunction: Preliminary results from a randomized controlled trial

PURPOSE

To assess the effectiveness of Buteyko breathing technique in patients with obstructive Eustachian tube dysfunction (ETD).

MATERIALS AND METHODS

Fifty-one patients (77 ears) aged between 21 and 62 years were randomized to Buteyko breathing in conjunction with medical management (nasal steroid) group or medical management alone group. The Eustachian Tube Dysfunction Questionnaire (ETDQ-7) symptom scores, tympanogram, positive Valsalva maneuver were evaluated at baseline, 6-week and 12-week follow-up.

RESULTS

Normalization of ETDQ-7 symptom scores at 6-week follow-up was observed in 30.0% (12/40) of the Buteyko breathing group versus 16.2% (6/37) of the controls (P > 0.05). At 12-week follow-up, the ratio rose to 50.0% (20/40) in the Buteyko breathing group and 24.3% (9/37) in the controls (P < 0.05). Tympanogram normalization at 12-week follow-up was observed in 53.6% (15/28) of the Buteyko breathing group versus 26.9% (7/26) of the controls (P < 0.05). The Buteyko breathing group showed slight improvement in positive Valsalva maneuver at 6- and 12-week follow-up (P > 0.05).

CONCLUSIONS

Our study shows that Buteyko breathing technique might be an effective adjunctive intervention in treatment of obstructive ETD, especially for those patients who are refractory to medical treatment and cannot afford Eustachian tube balloon dilation surgery.

Impact of Septoplasty on Eustachian Tube Functions

OBJECTIVE

To evaluate the impact of nasal septum deviation (NSD) and septoplasty on eustachian tube (ET) functions.

MATERIAL AND METHODS

The study was designed as a prospective controlled study and conducted in a tertiary referral center. A study group of 25 patients who were scheduled for septoplasty for NSD; and a control group of 25 healthy individuals having no ear or nose symptoms were formed. Tympanometric analysis of ET function, subjective and objective analysis of nasal functions with acoustic rhinometry and rhinomanometry were performed. Patients in study group underwent nasal surgery and tests were repeated at postoperative 1st and 3rd months.

RESULTS

Eustachian tube functions of study group were significantly worse than the control group (P = 0.032). ET functions were found to be poorer as the nasal airway resistances increase which was found to be close to significance (P = 0.056). One and 3 months after corrective surgery, both nasal airway functions and ET functions improved significantly reaching to the level of control group.

CONCLUSIONS

Nasal septum deviation was associated with higher rates of ET dysfunction, which could be improved by the nasal surgery. However, in some patients, nasal surgery itself caused ET dysfunction in the early postoperative period.

Efficacy of balloon dilation in the treatment of symptomatic Eustachian tube dysfunction: One year follow-up study

PURPOSE

Eustachian tube balloon dilation (ETBD) has been recently described as feasible treatment for patients with refractory Eustachian tube dysfunction (ETD). The aim of this study was to evaluate the efficacy of ETBD in the treatment of symptomatic Eustachian tube dysfunction (SETD) by subjective and objective analysis.

MATERIALS AND METHODS

Forty patients who underwent ETBD were included in the study. Subjects' inclusion criteria were as follows: symptoms of ETD (aural fullness predominantly, with or without otalgia, muffle hearing and tinnitus), normal tympanic membrane, type A or C tympanograms, and without a history of any middle ear diseases. Main outcomes including subjective improvement, otoscopy, pure-tone audiometry, impedance audiometry, R-value in tubomanometry (TMM) at three pressure measurements (30, 40, and 50 mbar), Eustachian Tube Score (ETS) and the ability to perform a Valsalva maneuver were assessed preoperatively, 1 week, 3 months and 12 months postoperatively.

RESULTS

All cases were dilated successfully. A significant effect of treatment was documented when measuring subjective improvement, impedance audiometry, R-value in TMM, ETS and the ability to perform a Valsalva maneuver 1 week, 3 months and 12 month postoperatively. Subjective symptoms were not relieved only in one patient. The overall success rate for all patients was 98%.

CONCLUSIONS

ETBD can provide both short- and long-term benefits to those who are diagnosed SETD and refractory to medical management. SETD might be an optimal indication for ETBD in the treatment of ETD.

Systematic review of the limited evidence base for treatments of Eustachian tube dysfunction: a health technology assessment

BACKGROUND

The Health Technology Assessment programme commissioned a wide-ranging review of treatments for adult Eustachian tube dysfunction. Treatments range from advice and observation and pharmacological treatments to surgical options.

OBJECTIVE

(i) To assess the evidence for interventions for adults with a clinical diagnosis of Eustachian tube dysfunction and (ii) to identify priorities for future research.

TYPE OF REVIEW

Systematic review (PROSPERO registration CRD42012003035) adhering to PRISMA guidance.

SEARCH

An extensive search of 15 databases including MEDLINE, EMBASE and CENTRAL (up to October 2012).

EVALUATION METHOD

Controlled and uncontrolled studies of interventions for adult Eustachian tube dysfunction were included. Because of insufficient data, the protocol was amended to also include controlled studies with mixed adult/child populations. Risk of bias was assessed. Narrative synthesis was employed due to high clinical heterogeneity.

RESULTS

Interventions assessed were pharmacological treatments [two randomised controlled trials (RCTs), one controlled non-randomised trial (CCT), 159 patients]; mechanical pressure equalisation devices (one randomised controlled trial, one CCT, 48 patients); and surgery, including laser tuboplasty (seven case series, 192 patients), balloon dilatation (three case series, 103 patients), myringotomy without grommet insertion (two case series, 121 patients), transtubal steroids (one case series, 11 patients) and laser coagulation (one retrospective controlled study, 40 patients). All studies had high risk of bias except two pharmacological trials; one had low risk and one unclear risk. No evidence was found for many treatments. The single low risk of bias RCT (n = 91; 67% adults) showed no effect of nasal steroids and favoured placebo for improved middle ear function (RR 1.20, 95% CI 0.91-1.58) and symptoms (P = 0.07). Other studies showed improvements in middle ear function for mechanical devices, antihistamine/ephedrine and nasal decongestant, but they had significant methodological weaknesses including insufficient length of follow-up. None of the surgical studies were adequately controlled, and many reported high levels of co-intervention. Therefore, observed benefits for tuboplasty and balloon dilatation in symptoms, middle ear function or hearing could not be reliably attributed to the interventions assessed. There was variability in definitions of the condition.

CONCLUSION

Eustachian tube dysfunction is a poorly defined condition. Due to the limited and poor-quality evidence, it is inappropriate to make conclusions on the effectiveness of any intervention; the evidence base is insufficient to guide recommendations for a trial of any particular intervention. Consensus on diagnostic criteria for Eustachian tube dysfunction is required to inform inclusion criteria of future trials.

Rationale and feasibility of intranasal delivery of drugs to the eustachian tube orifice

Intranasal medication for eustachian tube dysfunction (ETD) is an established practice in otolaryngology through the effects of steroids, decongestants, antihistamines or a combination of the above in reducing tubal oedema. The author has previously argued that a double-blind, randomised control trial would be helpful in determining effectiveness of treatment, if a standardised head position, chiefly Mygind or Ragan, was adopted to maximise intranasal drop delivery into the eustachian tube orifice. One recent paper suggests that intranasal treatment is not very effective, but ultimately does not state whether a standardised head position was adopted. Although a large body of evidence supports the hypothesis that the nasal passages are the route to middle ear disease, there is as yet no paper that has been published that has specifically addressed this issue, therefore the author must conclude that evidence to support intranasal treatment for ETD is still lacking and further research is desirable.

Patulous eustachian tube in bariatric surgery patients

OBJECTIVE: Patulous eustachian tube (PET) is associated with several factors, including weight loss. Rapid and significant weight loss in bariatric surgery patients may be risk factors for developing PET. The aim of this study is to provide information about the prevalence of PET after bariatric surgery and its association to weight loss.

STUDY DESIGN: Case series with planned data collection. SETTING: Tertiary center.

SUBJECTS AND METHODS: We recruited 163 patients who had undergone bariatric surgery at the Clinical Hospital of the University of Chile between 2006 and 2009. One hundred fortyone patients were finally analyzed by clinical interview and physical examination. Two groups were formed, with and without PET. The degree, time, and velocity of weight loss were compared between groups. Demographic information and clinical presentation are also presented.

RESULTS: The mean age was 38.9 years, and 76.6 percent of the patients were female. We found PET in 21.28 percent of the patients. Autophony was present in 96.6 percent of patients diagnosed with PET. Patients without PET experienced weight loss at an average of 39.54 kg during 16.59 months, while patients with PET experienced weight loss at an average of 48.63 kg in 12.11 months. The weight loss velocity in the PET group had a mean of 5.34 ±3.4 kg/month versus 2.98 ±1.3 kg/month in patients without PET. Time ( P = 0.0037), magnitude ( P = 0.0002), and velocity ( P = 0.0005) of weight loss was higher in patients with PET.

CONCLUSION: Our case series shows a significant prevalence of PET in bariatric surgery patients, which has a correlation with weight loss velocity and magnitude.

The Mechanical Reduction of Early Acquired Cholesteatomas in Children: Indications and Limitations

The standard treatment/or acquired cholesteatoma involves surgical removal of the lesion and reconstruction of the tympanic membrane. In some children, these lesions can be treated more conservatively. We conducted a retrospective study of 29 ears in 24 children who had been treated for early acquired cholesteatoma with mechanical reduction and a tympanostomy tube. Outcomes measures included hearing status, the postoperative appearance of the tympanic membrane, and the need for additional surgery. We found that anterior and inferior pars tensa lesions, with or without squamous debris, can be successfully reduced, but that posterosuperior retractions respond less well when the ossicular chain has been eroded. None of the children who responded to mechanical reduction required major reconstructive surgery later. We conclude that mechanical reduction of retraction pocket cholesteatomas with tympanostomy tube placement is sufficient to restore normal hearing and a normal tympanic membrane appearance in selected children with early lesions. We also identified several important prognostic features, including the patient's age, the specific location of the retraction pocket on the tympanic membrane, the extent of the pocket, ossicular chain involvement, and the patient's adenoid status.

Long-term follow-up evaluation of mastoidectomy in children with non-cholesteatomatous chronic suppurative otitis media

OBJECTIVE

In spite of declining prevalence chronic suppurative otitis media without cholesteatoma (CSOM) still poses a significant health problem. Randomized clinical trials comparing medical and surgical intervention are not available. Hence, the treatment of CSOM is almost exclusively based on empirical experience. The purpose of the present study was to evaluate the long-term effects of mastoidectomy combined with myringotomy and exploration of the middle ear in children with CSOM.

METHODS

47 children with CSOM underwent surgery including mastoidectomy. Ear status was investigated peri-operatively and at a long-term follow-up (5-21 years post-operatively).

MAIN OUTCOME MEASURES

Final success rate, FS (dry ears for several years) and the optimal final success rate, OFS (dry ears for several years without re-operations and without retractions/perforations) were estimated.

RESULTS

No serious surgical complications occurred. Post-operatively re-mastoidectomy was performed in 13% and re-myringoplasty/tympanoplasty in 21%. At the long-term follow-up the FS rate was 94% and the OFS rate was 61%.

CONCLUSIONS

Surgery alone did not entirely cure CSOM which may justify randomized studies comparing conservative treatment and myringoplasty with/without mastoidectomy. Finally, mastoidectomy in these patients must be considered as a last resort when intense conservative treatment fails.

Otitis Media: Treatment With Intranasal Aerosolized Surfactant

OBJECTIVES/HYPOTHESIS

The objective was to determine the effect of intranasal surfactant alone and with other medications administered by metered dose inhaler aerosol on the function of the eustachian tube and on the resolution of experimentally induced otitis media with effusion (OME) and acute otitis media (AOM).

STUDY DESIGN

Randomized, experimental, controlled animal studies.

METHODS

Previously unreported (experiment 4) as well as published (experiments 1-3) data were detailed so that the reader could understand the continuum of information leading to the conclusions. In experiment 1, after a live-animal technique of measuring eustachian tube passive opening pressure was developed and validated, eustachian tube passive opening pressure was determined in 61 adult gerbils and 34 mice at baseline and 5 and 10 minutes after delivery of aerosolized intranasal metered dose inhaler surfactant. In experiments 2 and 3 (Klebsiella pneumoniae), lipopolysaccharide-induced OME was developed in gerbils. Thirty-five animals were randomly assigned to control, placebo, surfactant, surfactant with betamethasone, and surfactant with phenylephrine groups. Seventy animals were randomly assigned to control, placebo once daily (QD) and twice daily (BID), surfactant QD and BID, surfactant with betamethasone QD and BID, and surfactant with phenylephrine QD and BID groups. Intranasal aerosolized MDI medications were administered from postinfection day 2 until the effusion resolved. Otomicroscopy and tympanometry were performed on alternate days for 30 days. In experiment 4, AOM was developed in 39 chinchillas via transbullar injection of nontypeable Haemophilus influenzae on day 1. Thirteen animals each received placebo BID or surfactant BID, beginning on day 1. Thirteen animals received surfactant BID beginning on day 3. All administrations were continued for 10 days. Examinations were performed on seven occasions until day 27. Appropriate statistical measurements were employed, including one- and two-way ANOVA, strength-of-association measure (omega) calculation, chi, and Newman-Keuls post hoc multiple comparison tests. Significance was set as P value of less than.05.

RESULTS

In experiment 1, a significant reduction in passive opening pressure was seen in both 5- and 10-minute postsurfactant measurements. Propellant alone was not effective. In experiments 2 and 3, OME resolved after an average period of 16 to 16.5 days in control, placebo QD and BID, and surfactant with phenylephrine QD groups. A significant decrease in OME days was seen in the surfactant QD (10.57 d) and BID (8.57 d), and surfactant with betamethasone QD (8.57 d) and BID (6.3 d) groups. A significant increase was seen in the phenylephrine BID group (18.67 d). In experiment 4, tympanometry was normal or near-normal in 62% and 48% of treated ears and in only 24% of placebo ears on day 12. Sixty-seven percent of placebo ears were culture positive at day 27, compared with 10% and 16% in surfactant groups 1 and 2. Seventy-five percent of untreated animals developed severe labyrinthitis, compared with 15% in groups 1 and 2. On day 27, 58% of placebo group middle ears had fluid, whereas 61% and 62% of ears in groups 1 and 2, respectively, were dry. These findings were significant.

CONCLUSION

Intranasal application of aerosolized metered dose inhaler surfactant alone or with steroid reduced eustachian tube passive opening pressure in normal animals and duration of effusion in animals with experimental OME. Intranasal surfactant reduced the severity and duration of middle ear infection in AOM in this animal model.