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BackTable / ENT / Article
Managing & Treating Chronic Eustachian Tube Disorders
Varun Sagi • Dec 29, 2020 • 581 hits
Identifying and treatming chronic eustachian tube disorders is challenging. While objective measures like tympanograms aid in the diagnosis, patient history is often the most important piece of information when evaluating patients with chronic eustachian tube disorders. One easily missed diagnosis is patulous eustachian tube which presents with similar features to chronic eustachian tube dysfunction. Otolaryngologists Dr. Gopi Shah, Dr. Ashley Agan, and Dr. Walter Kutz discuss the essentials of caring and providing treatment for patients with chronic eustachian tube disorders and outline the approach to differentiating between patulous eustachian tube and chronic eustachian tube dysfunction.
We’ve provided the highlight reel here, and you can listen to the full podcast below.
The BackTable ENT Brief
• Identification of patients with chronic eustachian tube disorders can be challenging. The use of tympanograms coupled with a careful focus on patient history can help discern between other conditions with similar presentations such as temporomandibular joint dysfunction and cervical spine issues. A trial of a myringotomy can often identify patients for whom placement of a tympanostomy tube would be beneficial.
• The characteristic presentation of patulous eustachian tube is autophony with respiration. This can be confirmed by observation of movement of the ear drum with respiration on otoscopy. It is best to have patients sitting up when looking for patulous on otoscopy. With flexible nasal scope exam, the eustachian tube is best visualized by advancing the scope through the contralateral nasal cavity and rotating as necessary. With rigid nasal scope, a 30-degree scope can offer the best visualization of the eustachian tube orifice. A gap in the orifice may be visualized along with symptoms of sniffing which can temporarily close the orifice.
• Dr. Agan and Dr. Kutz discuss the different treatment options for patulous eustachian tube including weighting of the ear drum, topical nasal drops, as well as an endoscopic transnasal shim procedure. They both report limited effectiveness with topical nasal drops. Dr. Agan reports favorable outcomes with the shim technique which involves the use of a 30-degree rigid scope and 40 mm angiocatheter to insert bone wax into the lumen of the eustachian tube. A delicate balance between plugging and over-plugging of the eustachian tube must be achieved, with the latter being the most common complication which can be remedied by placement of a tympanostomy tube.
Table of Contents
(1) Identification and Treatment of Chronic Eustachian Tube Disorders
(2) Patulous Eustachian Tube Diagnosis
(3) Patulous Eustachian Tube Disorder Management
Identification and Treatment of Chronic Eustachian Tube Disorders
Dr. Shah, Dr. Agan, and Dr. Kutz discuss the challenges associated with diagnosing and providing treatment for chronic eustachian tube disorders. They describe the utility of tympanograms in their diagnostic process but emphasize that the history of symptoms often guides their evaluation. Common conditions with similar presenting symptoms include TMJ dysfunction, as well as cervical spine issues. Dr. Kutz also mentions his use of a myringotomy as a trial for potential tympanostomy tube placement.
[Gopi Shah]
Today we're going to talk about chronic eustachian tube dysfunction and how to diagnose, manage, treat these patients. They are difficult.
[Walter Kutz]
Yeah. I agree with that. They can be challenging.
[Gopi Shah]
Yeah. So just to kind of take it to basics, I find that sometimes it's hard to diagnose chronic eustachian tube dysfunction. You have the patient, kids that need ear tubes. You have maybe an adult that comes into your clinic and has some ear fluid that never had problems before. At what point do they become a chronic eustachian tube player?
[Walter Kutz]
Yeah. I mean, you sort of get the sense of it, right? You get the history. If they've seen their pediatricians over and over and they've had ear infections, and you see them and they have a serous effusion, but I guess the ... Technically they need to have the eustachian tub dysfunction greater than three months, so if you want to look at the strict definition. But you kind of get an idea of the patients that are going to have the chronic eustachian dysfunction.
[Ashley Agan]
Yeah, and I think the easy ones are the patients who come in and have a type C tympanogram and you say "Okay. You have ear pain because you have eustachian tube dysfunction, and we have an objective measure of it," but I think it can be kind of tricky, patients who maybe have some intermittent eustachian tube dysfunction, but you see them and they have type A tympanograms, and then you kind of are wondering whether they could be a candidate for tubes or not, and maybe they have a history of saying they have ear infections, but you've never actually seen fluid and it looks normal when you see it. You know, I think those can be kind of tricky too.
[Walter Kutz]
Yeah. I mean, I think the first patient you're describing, the ones that ... They have ear fullness. They have some intermittent pain. It's suggestive of eustachian dysfunction. They come in, but every time they come in, their tympanograms are normal. You don't see fluid. You don't see retraction. At that point, I'm probably thinking about other problems. Do they have ... Most commonly, temporomandibular joint dysfunction, or TMJ dysfunction, is what I'm really thinking about if they have a normal exam. Actually, if a patient has cervical spine issues, sometimes that can radiate to the ear and they may have ear fullness and ear pain from that.
[…]
One thing you could try ... I don't know if you've ever tried this, Ashley or Gopi, but you can offer somebody just do a myringotomy. You can just say "Hey. Let's just make a small incision of the ear drum. Why don't you kind of test drive that for a week or so by the time it heals?" and if their symptoms are better with that, then you can place a tympanostomy tube, and you really haven't placed a tube with really not needing one. So I think that's a good technique to try on some of these patients.
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Patulous Eustachian Tube Diagnosis
Dr. Shah and Dr. Agan discuss the key differences between eustachian tube dysfunction and patulous eustachian tube. A defining symptom of patulous is the presence of autophony with respiration, which is commonly accompanied by movement of the ear drum with respiration on otoscopy. For accurate ear evaluation, patients must be sitting up as opposed to laying down to avoid any eustachian tube edema. On flexible nasal scope exam, it is best to advance through the contralateral nasal cavity and rotate as needed to visualize the orifice of the eustachian tube. Whereas with the rigid scope, a 30-degree scope can be advanced through the ipsilateral nasal cavity for visualization of the eustachian tube. A gap in the orifice of eustachian tube may be visualized on nasal scope exam, coupled with symptoms of sniffing which temporarily closes the opening.
[Gopi Shah]
In terms of patulous, in terms of diagnosis, for the difference between eustachian tube dysfunction and patulous eustachian tube dysfunction, what are the two or three things in the history that you find that are different, and then do you end up scoping them, and what do you find on your scope findings?
[Ashley Agan]
Well, they definitely can come in and look the same at the beginning with that clogged, stuffy ear feeling. So they both can have that. For patulous patients, the autophony to either their breath or to their voice and having symptoms better when they're laying down is pretty unique to patulous. The eustachian tube dysfunction patients, in my experience, aren't going to have those. So if you can ask the right questions and kind of pull that out, it's helpful. But similar to our dizzy patients, I think, sometimes our patulous patients don't always know how to describe what they're feeling or experiencing. Sometimes I've had patients lately ... I've had a couple that say their ear feels heavy, so they may not even ... If you say "Is your ear clogged or stuffy?" they're like "No. Just it feels heavy." So sometimes they don't know how to describe what they're feeling.
[Ashley Agan]
On exam, if I can see the ear drum moving when they sniff, that's awesome. I'm like "Oh, yep. There it is. This is what you have," but I don't always see that. Then our audiologists have actually started doing some testing when they're doing tympanometry where they can measure whether the ear drum is patulous, and they also have a test that they do that measures eustachian tube dysfunction where they're having the patient basically try to Valsalva and clear their ears while they're doing the tympanometry, and so that's been helpful to try to get some sort of objective information. It doesn't always show up on that either, but if we're going to the operating room, I really like to be able to see the ear drum move, but if I can't ... I mean, if we've ruled out everything else and their history is consistent with patulous, then I've had good success with that.
[…]
Then the other thing about being able to see the ear drum move when they're breathing ... They need to be sitting up. So if you lay them down to look with a microscope like you normally would when you're doing otoscopy in the clinic, you probably won't see it, because usually their symptoms are better when they're laying down, because you get that kind of edema of eustachian tube when they're supine.
[…]
[Gopi Shah]
Then on your nasal endoscopies, do you do that pretty much for all of these patients?
[Ashley Agan]
Yeah. I usually scope all patulous and eustachian tube dysfunction just to kind of see what's going on back there, and the more I look for patulous patients, the more I can start to see it. You really need to be looking up into the eustachian tube, so you either need to use a flexible scope and look around the back of the septum so you have the right angle ... So if I'm looking at the right eustachian tube, I'll go in through the left side and turn and look around so I'm kind of got the angle ... or use a 30-degree scope to be able to look up.
[Gopi Shah]
Okay. So you'll do opposite side with your flex and snake it up, and then with a rigid, you're doing a 30-degree?
[Ashley Agan]
Yeah.
[Gopi Shah]
Okay, and when you're looking up into the orifice, is it a couple millimeters in, and are you seeing that there's space, and so you're like "Oh. That's patulous"? Or is it-
[Ashley Agan]
Yeah. I don't know if I have a perfect way. It's very much like a feeling. You kind of look at it and you're like "That looks kind of patulous." I mean, some patients, you will see a gap, and when they sniff, you might see it kind of come together. Sniffers. That's a common patulous symptom too, patients who are sniffing a lot, because when they sniff, it kind of pulls the eustachian tube closed and they'll get relief of symptoms.
Patulous Eustachian Tube Disorder Management
Dr. Shah, Dr. Agan, and Dr. Kutz discuss the various options for patulous eustachian tube treatment. These include weighting of the drum, topical nasal drops, as well as an endoscopic transnasal shim procedure. Dr. Agan and Dr. Kutz both state that they have had minimal success with topical nasal drops, which also require precise patient positioning for effectiveness. Dr. Agan describes her favorable outcomes with the shim technique, for which she uses a 30-degree rigid scope and 40 mm angio-catheter to insert bone wax into the lumen of the eustachian tube. The most common complication of the procedure is over-plugging the eustachian tube which may then necessitate placement of tympanostomy tube.
[Walter Kutz]
…One of the treatments for patulous eustachian tube is… you can place a paper patch with some bacitracin ointment, make the tympanomembrane heavy, and sometimes that'll improve the symptoms. Then you can consider doing a cartilage graft tympanoplasty as part of the treatment for patulous eustachian.
[Ashley Agan]
Yeah. I've done that in clinic to kind of try to just figure out if it is patulous before…I've tried to just weight the ear drum to see if that helps with their symptoms, and I think that can be helpful for sure.
[Walter Kutz]
Hey, Ashley. Do you have good success using topicals? People will use topical estrogen nasal drops, or there's this PatulEND. Do you try those with the patients that have patulous eustachian tube, and what is your success?
[Ashley Agan]
I do usually have them try PatulEND. I have not had a lot of success personally, but there are some patients who I haven't seen back. So it may be that there are some that use it and then don't come back to see me, because maybe they're doing better. Or I'll have some patients who say they use it and maybe it helps a little bit, but usually the ones that I'm seeing again are ... It's because it's not working, and it does burn. So it's uncomfortable to use, because the whole point is that it's try to create some inflammation and puff up those tissues, the eustachian tube.
[Gopi Shah]
…Can you explain the drops, the pathophys, what it's supposed to do?
[Ashley Agan]
Yeah. PatulEND is …just a proprietary formula that is meant to create some inflammation in the mucosa [of the eustachian tube] and make it kind of…puffy so that it’ll close.
[Walter Kutz]
… I think part of it is that you have to place the drops the correct way. You have to have your head sort of turned to the side so that the drops actually stay on the eustachian tube orifice. If not, they'll just go right down the nasal pharynx. So I think it's important that, if you're going to try those drops, which I haven't had a lot of success with, I think it's important that the patient administers in the correct way or it's definitely not going to work.
[….]
[Ashley Agan]
...Placing a shim [transnasal endoscopic eustachian tube plugging with bone wax], I would say, works great.
[Gopi Shah]
How long does the bone wax stay there for? When you're counseling the patient and you're discussing the shim surgery, what do you tell them? Like "Hey. This is good for a year" or six months, five years? Or do we know yet?
[Ashley Agan]
The longest study that looked at outcomes looked at patient outcomes at 12 months, and about half of patients had recurrence of symptoms, and that's with the shim…So with the other techniques, there was recurrence of symptoms earlier. So it's meant to be there for a long time. It can fall out. One complication that's really common is that you kind of over-plug it, and then they get fluid, and you end up putting in a tube. I've had that happen.
[Ashley Agan]
It's a very fine line, because you're trying to plug it just enough so they don't have symptoms but that they still have some way to kind of move air around it. But most of them are willing to try anything because they're just so frustrated and annoyed by hearing their voice echo all the time, voice and breath.
[Gopi Shah]
So when you place the shim, you're using a rigid scope?
[Ashley Agan]
Mm-hmm.
[Gopi Shah]
A 30-degree or a zero [rigid scope]?
[Ashley Agan]
30 [degree].
[Gopi Shah]
Are you using just a cold knife to make an incision in the-
[Ashley Agan]
Oh, no. There's no incision.
[Gopi Shah]
Oh. You just inject it?
[Ashley Agan]
Yeah. You just kind of insert it into the lumen of the eustachian tube, and then it wedges at the bony eustachian tube.
[Gopi Shah]
It's a special catheter?
[Ashley Agan]
It's an angiocatheter. Yeah.
[Gopi Shah]
Okay. Is there a certain length to it?
[Ashley Agan]
I do 40 millimeters.
Podcast Contributors
Dr. Joe Walter Kutz
Dr. Joe Walter Kutz is a neurotologist and Professor of Otolaryngology and Neurosurgery at the University of Texas Southwestern Medical Center in Dallas, TX.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2020, August 20). Ep. 4 – Managing Eustachian Tube Disorders [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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