Clinical evaluation of balloon dilation eustachian tuboplasty surgery in adult otitis media with effusion

The long-term efficacy and safety of balloon dilation eustachian tuboplasty combined with tympanostomy tube insertion for patients with otitis media with effusion: study protocol for a prospective randomized controlled trial

BACKGROUND

Otitis media with effusion (OME) is a common disease in ear, nose, and throat clinics characterized by aural fullness and hearing loss and mainly caused by eustachian tube dysfunction (ETD). Tympanostomy tube insertion (TTI) is a conventional surgical treatment option that can alleviate symptoms but does not provide a definitive cure, and it is prone to recurrence. Balloon dilation eustachian tuboplasty (BDET) has become a novel procedure for the treatment of ETD, demonstrating significant potential in addressing the aforementioned limitations. However, it is not widely available in the clinic and few high-quality randomized clinical trials was conducted to investigate its long-term efficacy and security in OME. Therefore, the purpose of this study is to verify the efficacy of BDET combined with TTI for patients with OME and its prospects for providing a definitive cure.

METHODS AND ANALYSIS

This is a prospective, parallel-group, single-blind, randomized controlled prospective trial. Totally 124 patients with OME will be randomized into either group A or B. Group A will receive conventional therapy (TTI) while group B will use BDET therapy in addition to TTI. Outcome assessments will take place at baseline and at the 3rd, 6th, 12th, and 24th months after surgery. The primary outcome is eustachian tube function, which will be measured by the eustachian tube dysfunction questionnaire (ETDQ-7) and eustachian tube score (ETS). The secondary outcomes include middle ear function, hearing situation, and quality of life, which will be measured by acoustic impedance measurement, pure-tone audiometry, and Chinese-version Chronic Ear Survey (CCES). The main analysis of change in the outcomes will use mixed-model with repeated measures (MMRM) analyses of variance (ANOVAs).

DISCUSSION

This is the first prospective trial in Chinese populations that aims to validate the long-term efficacy and safety of BDET-combined TTI therapy in patients with OME. This parallel-group, single-blind, randomized controlled trial may provide an opportunity to decrease the recurrence rate of OME and explore a definitive cure for patients with OME. This trial's rigorous design enhances the reliability of the findings, ensuring a robust answer to the research question. In the future, the research team will further expand upon the clinical evidence and applications of the BDET combined therapy.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2400079632. Registered on 8 January 2024, https://www.chictr.org.cn/bin/project/edit?pid=214452 .

Informed consent in balloon Eustachian tuboplasty: a systematic review of possible complications and preventive measures

OBJECTIVE

To systematically identify the complications associated with balloon Eustachian tuboplasty and their frequency of occurrence. This study will also highlight the measures that can be employed to avoid these complications and perform this procedure more safely.

METHODS

Systematically reviewed relevant papers published until January 2023. Each reference was checked and evaluated for any potential manuscripts. There was no registered protocol; the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used.

RESULTS

Sixty-nine publications were found, from which 14 publications met our inclusion criteria: 2 randomised clinical trials, 5 retrospective studies, 2 systematic reviews, 2 case series and 3 case reports. Studies with balloon Eustachian tuboplasty procedure only were included, regardless of ethnicity, gender and age. All studies were excluded in which more than one procedure was performed.

CONCLUSION

Balloon Eustachian tuboplasty is a relatively safe procedure with an overall complication risk of 1.66 per cent. Major complication rate was 0.43 per cent. Surgical emphysema was the most common, around 0.40 per cent.

Balloon Eustachian tuboplasty for obstructive Eustachian tube dysfunction: retrospective multicentre cohort study of 248 patients

OBJECTIVE

To present the results after balloon eustachian tuboplasty (BET) in patients with obstructive Eustachian tube dysfunction (OETD) grouped up into: baro-challenge, chronic serous otitis media and adhaesive otitis media.

METHODS

A retrospective study was carried out on patients who underwent BET surgery. As outcome measures, otoscopy, tympanometry, Eustachian tube dysfunction questionnaire-7 (ETDQ-7) and ability to perform the Valsalva manoeuvre were recorded at baseline and at 3, 12 and 24 months after BET. A p value of 0.05 was used to indicate a statistically significant difference for all statistical tests.

RESULTS

Three hundred and nineteen ears (248 patients) were included with a 3-month follow-up, 272 ears had a 12-month follow-up, and 171 ears had 24-month follow-up. Globally, a statistical significance improvement in all groups in all outcome measures was found. According to BET indication, in the baro-challenge group, there was no improvement in otoscopy, but ETDQ-7, Valsalva manoeuvre and tympanogram improved significantly. In the chronic serous otitis media group, otoscopy, ETDQ-7 and Valsalva manoeuvre were significantly improved in all the three timelines, including the avoidance of a new transtympanic tube after the BET in over 80% of cases. In the adhaesive otitis media group, Valsalva manoeuvre improved significantly, ETDQ-7 decreased and tympanogram improved but not significantly. Few mild complications were reported.

CONCLUSIONS

BET is an effective method for the treatment of OETD in all etiologic groups. The greatest benefit was observed in patients with baro-challenge. A long-term follow-up is recommended since the benefit seems to increase over time.

Multiparametric Measurements of the Eustachian tube and Peritubal Region Using Computed Tomography as a Preoperative Workup for Tuboplasty

Background

Eustachian tube dysfunction (ETD) is considered a causative factor for middle ear disease as well as treatment failure. The pathogenesis may be a result of chronic infection, allergy, laryngopharyngeal reflux, primary mucosal disease, dysfunction of the dilation mechanism and anatomical obstruction. Hence, it becomes essential to know the structure and anatomical variations of the Eustachian tube(ET), particularly with the advent of novel therapeutic options such as tuboplasty to ensure optimal therapeutic outcome.

Aims

This cross-sectional study is done to perform multiparametric measurements of the ET and peritubal region using computed tomography and develop a structured protocol for pre-tuboplasty workup.

Materials and methods

This study was done for a period of 20 months, in 100 normal subjects aged between 18 and 60 years, who underwent computed tomography (CT) study of the head and face region, for indications other than nasal/ pharyngeal and sinus disease.

Results

The mean bony, cartilaginous and overall ET lengths were higher in males. In females, the mean ET angles with Reid's plane were higher. Higher mean craniocaudal diameters of the ET lumen were observed in males. Carotid canal dehiscence was seen in equal prevalence on both sides (5%), with no significant gender differences.

Conclusion

Therapeutic interventions such as eustachian tuboplasty will benefit from preoperative imaging based planning. This structured protocol provides standardization of pre-operative workup for tuboplasty.

Functional aspects of the Eustachian tube by means of 3D-modeling

The extent of dysfunction of the Eustachian tube (ET) is relevant in understanding the pathogenesis of secondary otological diseases such as acute or chronic otitis media. The underlying mechanism of ET dysfunction remains poorly understood except for an apparent genesis such as a nasopharyngeal tumor or cleft palate. To better describe the ET, its functional anatomy, and the biomechanical valve mechanism and subsequent development of diagnostic and interventional tools, a three-dimensional model based on thin-layer histology was created from an ET in this study. Blackface sheep was chosen as a donor. The 3-D model was generated by the coherent alignment of the sections. It was then compared with the cone-beam computed tomography dataset of the complete embedded specimen taken before slicing. The model shows the topographic relation of the individual components, such as the bone and cartilage, the muscles and connective tissue, as well as the lining epithelium with the lumen. It indicates a limited spiraling rotation of the cartilaginous tube over its length and relevant positional relationships of the tensor and levator veli palatine muscles.

Efficacy of balloon dilatation of the eustachian tube in patients with refractory otitis media with effusion after radiotherapy for nasopharyngeal carcinoma

PURPOSE

To investigate the efficacy of balloon dilatation of the eustachian tube (BDET) in patients with refractory otitis media with effusion (OME) after radiotherapy for nasopharyngeal carcinoma.

MATERIALS AND METHODS

A total of 58 patients (74 ears) who had received BDET for treatment of refractory OME after radiotherapy for nasopharyngeal carcinoma were enrolled. The efficacy was evaluated by seven-item eustachian tube scores (ETS-7), tympanogram type and air-bone gap, and the total effective rate was also calculated. All patients were followed up for 2 years.

RESULTS

ETS-7 scores at every postoperative visit were significantly higher than preoperative scores (all P < 0.05). ETS-7 score 6 months after surgery was the highest, which declined sharply from the 6th to the 24th month after surgery. Air-bone gap from the 1st to the 18th month after surgery was significantly smaller than preoperative one (all P < 0.05). Air-bone gap 6 months after surgery was the smallest, followed by that 12 months after surgery. The improvement in tympanogram type 6 months after surgery was the highest. The improvement of tympanogram type declined sharply from 12 to 24 months after surgery. According to evaluation of efficacy, only one patient completely recovered, and five patients partially recovered during the 2-year follow-up.

CONCLUSION

BDET can only significantly improve efficacy of refractory OME after radiotherapy for nasopharyngeal carcinoma for a certain period of time during the 2-year follow-up.

Eustachian Tube Balloon Dilation: A Systematic Review and Meta-analysis of Treatment Outcomes

OBJECTIVE

To examine the effectiveness of eustachian tube balloon dilation for the treatment of eustachian tube dysfunction.

DATA SOURCES

PubMed, Scopus, and Google Scholar.

REVIEW METHODS

A systematic review of eustachian tube balloon dilation for the treatment of eustachian tube dysfunction was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to identify randomized control trials and prospective and retrospective studies published prior to January 31, 2019. Meta-analysis of proportions evaluated 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ7) scores, tympanometry, otoscopy findings, and the ability to perform a Valsalva maneuver.

RESULTS

The systematic review identified 35 studies. Twelve studies met inclusion for meta-analysis (448 patients). Mean ETDQ7 scores decreased by 2.13 from baseline to 6 weeks (95% CI, -3.02 to -1.24; P < .001). From baseline to 6 weeks, 53.0% of patients had improvement in tympanograms (P < .001). At the long-term point (3-12 months), 50.5% of patients had improved tympanograms from baseline (P < .001). There was no significant difference in the proportion of improved tympanograms at 6 weeks compared to long term (P = .535). Normal otoscopy exams at baseline increased by 30.0% at 6 weeks (P < .001) and 55.4% in the long term (P < .001). There was a 67.8% increase in proportion of patients able to perform a Valsalva maneuver in the long term compared to baseline (P < .001).

CONCLUSION

Eustachian tube balloon dilation appears to be associated with improvement in subjective and objective treatment outcome metrics. The improvement appears stable at 3 to 12 months after dilation. Patients with eustachian tube dysfunction are likely to benefit from balloon dilation, particularly those with medication-refractory disease.

Can Reflux Symptom Index and Reflux Finding Score Be Used to Guide the Treatment of Secretory Otitis Media in Adults?

BACKGROUND

At present more attention is paid to the treatment of secretory otitis media in children, but there is also a high incidence of adult patients. The etiology of secretory otitis media in adults is complex and related to many factors.

OBJECTIVES

The aim of this study was to evaluate the correlation between the Reflux Symptom Index (RSI)/Reflux Finding Score (RFS) and secretory otitis media in adults, and to explore further treatment methods.

MATERIAL AND METHODS

Taking outpatients in the otology department from January 2017 to May 2019 as the object of study, acoustic immittance tests were performed and the results analyzed. Patients with secretory otitis media received tympanocentesis or tympanotomy and the related components were analyzed.The patients were followed up and the curative effects of different treatment schemes were compared.

RESULTS

There were 67 patients with secretory otitis media. The prevalence of secretory otitis media in patients with RSI >13 was significantly higher than that in patients with RSI <13. The prevalence of secretory otitis media in patients with RFS >7 was significantly higher than that in patients with RFS <7 (p < 0 05). The RSI/RFS score of B tympanogram was significantly higher than that of A and C maps (p < 0.05). Among the patients with type B, the serous type was higher in those with an RSI score <13, and the mucus was higher in those with an RSI score >13 (p < 0.05). There was no significant difference in the proportion of glue patients (p > 0.05). In type B patients, the detection rate of pepsin in the experimental group was significantly higher than that in the control group (p < 0.05), and the scores of RSI/RFS in the pepsin-positive group were significantly higher than those in the negative group (p < 0.05). Treatment with acid-suppressive drugs in patients with abnormal RSI/RFS achieved better results (p < 0.05).

CONCLUSIONS

RSI/RFS may be related to the development of secretory otitis media in adults, and could play a guiding role in its treatment.

Balloon Eustachian Tuboplasty: Systematic Review of Long-term Outcomes and Proposed Indications

Balloon Eustachian tuboplasty (BET) aims to improve the function of the Eustachian tube (ET). The objective of this study was to review the long-term outcome of BET and present the process and results of outlining indications for BET by the Finnish Otosurgical Society. The literature review is based on a database search performed in May 2017. The search resulted in 100 individual articles, which were screened for relevance. Five articles fulfilled the inclusion criteria (follow-up ≥12 months). Five additional articles (follow-up, 6-11 months) were analyzed to obtain supportive information. The proposed BET indications were constituted in the 2016 annual meeting of the Finnish Otosurgical Society. The workshop included a review of the Eustachian tube physiology, middle ear aeration mechanisms, and BET outcome studies. Thereafter, the members of the Society first voted and then discussed 14 cases in order to conclude whether BET was indicated in each case, and subsequently, a consensus statement on the indications for BET was outlined. The long-term follow-up studies were heterogeneous regarding the Eustachian tube dysfunction (ETD) definition, patient selection, follow-up duration, additional treatments, and outcome measures. The current, but limited, evidence suggests that BET is effective in the long-term. However, more long-term studies with uniform criteria and outcome measures as well as placebo-controlled studies are needed. The proposed indications for BET by the Finnish Otosurgical Society include chronic bothersome symptoms referring to ETD, ETD-related symptoms when pressure changes rapidly, or recurring serous otitis media. With the current evidence, we suggest treating only adults with BET.

Effect of balloon dilation eustachian tuboplasty combined with tympanic tube insertion in the treatment of chronic recurrent secretory otitis media

PURPOSE

To investigate the long-term clinical effect of balloon dilation eustachian tuboplasty (BET) combined with tympanic tube insertion (TTI) in the treatment of chronic recurrent secretory otitis media (CRSOM).

MATERIALS AND METHODS

A retrospective study of 30 cases of CRSOM treated with BET combined with TTI under general anesthesia between August 2014 and September 2016. Thirty cases of CRSOM treated with TTI in the same period were taken as the control group. All cases were followed over 24 months. The scores of eustachian tube (ET) function preoperation, 1 month, 6 months, 12 months, and 24 months postoperation were collected and analyzed, respectively. A satisfaction questionnaire was used to evaluate the therapy at 24-months postoperation.

RESULTS

The symptoms were significantly improved and the ET score was obviously increased postsurgery in most cases treated with BET plus TTI compared with those treated with TTI alone. The highest ET score was obtained at 6 months post BET. Five (14%) cases (6 ears) of CRSOM recurred. The 24-month postoperation follow-up questionnaire showed that 84.6% of the patients were satisfied with the treatment, while ten cases (25%) in the TTI group recurred.

CONCLUSION

BET combined with TTI surgery is an effective therapy for patients with CRSOM.

Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube

OBJECTIVE

To develop a clinical consensus statement on the use of balloon dilation of the eustachian tube (BDET).

METHODS

An expert panel of otolaryngologists was assembled with nominated representatives of general otolaryngology and relevant subspecialty societies. The target population was adults 18 years or older who are candidates for BDET because of obstructive eustachian tube dysfunction (OETD) in 1 or both ears for 3 months or longer that significantly affects quality of life or functional health status. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus.

RESULTS

After 3 iterative Delphi method surveys, 28 statements met the predefined criteria for consensus, while 28 statements did not. The clinical statements were grouped into 3 categories for the purposes of presentation and discussion: (1) patient criteria, (2) perioperative considerations, and (3) outcomes.

CONCLUSION

This panel reached consensus on several statements that clarify diagnosis and perioperative management of OETD. Lack of consensus on other statements likely reflects knowledge gaps regarding the role of BDET in managing OETD. Expert panel consensus may provide helpful information for the otolaryngologist considering the use of BDET for the management of patients with OETD.

Histopathology of the Mucosa of Eustachian Tube Orifice at the Middle Ear in Chronic Otitis Media With Effusion: Possible Insight Into Tuboplasty Failure

INTRODUCTION

Balloon dilation of the cartilaginous segment of the Eustachian tube has emerged as a means to directly augment tubal dilatory function, and this has been applied as a potential treatment for otitis media with effusion (OME). Although results of clinical studies involving this modality appear promising, there are still a moderate number of ears affected by OME that do not respond. The purpose of this study was to investigate the status of mucosa of the Eustachian tube at the middle ear orifice in OME as it may relate to some cases of tuboplasty failure.

METHODS

Twenty-three temporal bone specimens with OME were identified within an institutional archived collection. Each specimen was inspected for the presence of a fixed obstruction at the level of the Eustachian tube orifice at the protympanum. In addition, the mucosa at the tubal orifice was graded on a 4-point scale.

RESULTS

Overall, 3 cases (13%) were normal (Grade 1), 6 cases (26%) were mildly thickened (Grade 2), 11 (48%) were severely thickened (Grade 3), and 3 (13%) were severely thickened with polypoid degeneration (Grade 4). A single case was noted to have a complete fixed obstruction in the form of a mucosal web.

CONCLUSION

In ears affected by OME, the mucosa of the Eustachian tubal orifice at the middle ear is most often severely thickened. Normal mucosa, mucosa with severe polypoid changes, or a complete fixed obstruction are possible but uncommon. The majority of specimens studied had sufficiently diseased mucosa to raise questions regarding whether thickened mucosa in the tubal orifice may act as a barrier to middle ear ventilation that would not be directly addressed by cartilaginous Eustachian tube balloon dilation.

A pilot study to investigate the therapeutic effect of Valsalva maneuver on otitis media with effusion in adults

OBJECTIVE

This pilot study was performed to investigate the therapeutic effect of Valsalva maneuver on otitis media in adults and to evaluate the prognostic factors for the good response.

METHODS

Thirty nine ears of 32 adult patients who were diagnosed as otitis media with effusion and managed by one-week Valsalva maneuver (>20/day) without any other medication were included in this study. Its therapeutic efficacy was evaluated and the prognostic factors which predict the response of Valsalva maneuver were analyzed by comparing various clinical and audiological factors between success and failure groups.

RESULTS

Mean duration of otitis media in the study subjects was 30.9 days (SD 31.6 days). A success rate of 1-week Valsalva maneuver as a single therapeutic modality was up to 64.1% (25/39 ears) and hearing was significantly recovered in success group. No recurrence or side effects were observed. Successful Valsalva maneuver checked and confirmed as bulging of the tympanic membrane by otoendoscopic examination was an excellent indicator of therapeutic response in a week (p<0.05). Age, sex, duration of otitis media, history of previous upper respiratory tract infection, initial hearing levels and type of audiogram were not significant prognostic factors for the therapeutic efficacy of Valsalva maneuver.

CONCLUSION

One-week Valsalva maneuver seems to be considered as a first line therapeutic modality in otitis media with effusion in adult patients who demonstrate the successful maneuver result on oto-endoscopic examination.