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Eustachian Tube Dysfunction in Adults vs Pediatrics

Author Iman Iqbal covers Eustachian Tube Dysfunction in Adults vs Pediatrics on BackTable ENT

Iman Iqbal • May 22, 2024 • 34 hits

The eustachian tubes are crucial for equalizing pressure and draining fluids from the middle ear. There are notable differences between adult and pediatric eustachian tubes. In adults, the eustachian tube is longer, wider, and more angled compared to children, facilitating efficient ventilation and drainage. Conversely, in pediatric cases, the tube is shorter, narrower, and relatively horizontal, rendering children more susceptible to middle ear infections and fluid buildup. These anatomical differences play a significant role in understanding and addressing ear-related issues across different age groups, emphasizing the importance of tailored approaches in diagnosis and treatment.

Otolaryngologist Dr. Dennis Poe, an expert in the field, highlights crucial differences between adult and pediatric eustachian tubes and explains the significance of these differences when it comes to clinical assessment and surgical intervention. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable ENT Brief

• Adult eustachian tubes are longer, wider, and more angled, whereas pediatric eustachian tubes are shorter, narrower, and relatively horizontal.

• During development, pediatric eustachian tubes elongate, typically reaching adult length by the age of 8.

• Chronic allergic rhinitis and rhinosinusitis are common etiologies of eustachian tube dysfunction in adults; while also prevalent in children, factors such as viral infections, persistent nasal congestion, and reflux of pathogens are significant.

• The suitability of interventions like balloon dilations in pediatric cases requires careful consideration due to concerns about exacerbating reflux.

• Comprehensive history-taking is essential, and should include questions about previous treatments, symptoms of occlusion, and comorbidities such as allergies and reflux.

• Distinguishing between patulous and obstructive eustachian tube dysfunction is critical as management strategies differ.

Eustachian Tube Dysfunction in Adults vs Pediatrics

Table of Contents

(1) Anatomical Differences in Adult vs Pediatric Eustachian Tubes

(2) Etiologies of Eustachian Tube Dysfunction in Adult vs Children

(3) Clinical Assessment of Pediatric Eustachian Tubes

Anatomical Differences in Adult vs Pediatric Eustachian Tubes

Understanding the anatomical disparities between adult and pediatric eustachian tubes is paramount in clinical practice. Pediatric eustachian tubes undergo lengthening during development, with most reaching the adult length of 25 millimeters by age 8. This is a primary target in many surgeries in both age groups, so its length is a crucial factor to bear in mind during procedures in order to avoid getting too close to the bony part, which is close to the internal carotid artery.

Moreover, height differences from the floor of the eustachian tube to the orifice impact the angle of approach during procedures, particularly in younger children, where the orifice may sit lower than expected, altering the angle of approach. The presence of robust adenoid and torus tubarius tissue can also obscure the eustachian tube orifice, requiring additional caution and precision during examination and treatment.

[Dr. Dennis Poe]
Yes, so in the adult eustachian tube, we know it's the cartilaginous portion which is the target of surgery; it's the cartilaginous portion that serves as a functional valve, and that's where the pathology is, and that's true in the children as well. In an adult, it's about 25 millimeters in length. That's an important thing to keep in mind because when you're working with your balloon catheter, you want to be aware of the length of the balloon. We don't want these to get up into the bony part of the eustachian tube. First of all, most of the pathology is not there, and that's also where the internal carotid lies, so we don't want to get our balloons up into that portion. We're thinking about 25 millimeters.

We looked at the CT scans over the age ranges, pediatric age ranges, from under 2 years old all the way up to 18, and the tube does lengthen. We've been previously taught from Bluestone's work that the eustachian tube is mostly full-length by age 8. It actually can continue to grow a little bit farther, but the steepest curve is in that underage group. The indication for pediatric balloon dilation is going to be 8 and above because most of them are going to be close to full adult length, and from the measurements that we took, it was about 25 millimeters. Now by the time you get to age 15 and above, it goes up to maybe 27 millimeters on average. Remember, that's a range, but this is a rough guide, so think about that 25 millimeters.

The other important difference between the kids, just anatomically, is the height from the floor of the eustachian tube up to the orifice of the eustachian tube; this also gets larger as we age in our development. In younger kids, we've been taught that the eustachian tube orifice is going to be taken up at a flatter angle, and it's very true. You'll have to be looking a little bit lower. In the younger kids, the orifice may be a little lower than you think. There's a bit of a height difference, and that's going to change the angle that you go from the floor of the nose. These balloon catheters travel on the floor, and then you angle up toward the eustachian tube orifice.It's going to be a flatter angle in some of these kids, and that's a little variable in that 8 to 12-year range.

The other big difference is there's a lot more inflammation in kids. They've got the adenoid hypertrophy, there's adenoid tissue that sometimes is spilling over onto the torus tubarius. The torus, the tubal tonsil tissue can be very robust, with lots of cobblestones, so it can sometimes be hard to find the orifice.



The anatomy is a little trickier in the children, so just take extra caution.

Listen to the Full Podcast

Eustachian Tube Dilation In The Pediatric Population with Dr. Dennis Poe on the BackTable ENT Podcast)
Ep 159 Eustachian Tube Dilation In The Pediatric Population with Dr. Dennis Poe
00:00 / 01:04

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Etiologies of Eustachian Tube Dysfunction in Adult vs Children

Chronic allergic rhinitis, rhinosinusitis, and reflux are prominent causes of eustachian tube dysfunction in both adults and children; however, pediatric cases can exhibit additional complexities. Heightened inflammatory exposure in children, particularly those in daycare settings, predisposes them to recurrent viral infections and persistent nasal congestion. In younger children, aged four and under, infectious problems, including reflux of pathogens, become more prominent, while in older children, allergic disease is prevalent.

[Dr. Ashley Agan]
When we think about the main causes of eustachian tube dysfunction in children compared to adults, in adults I'm thinking of chronic allergic rhinitis, chronic rhinosinusitis, and reflux. In children, there's also the extra inflammatory exposure with the recurrent viral infections. I think of the kids who go to daycare and are just sick and snotty all the time. Their anatomy maybe sets them up for more issues because the eustachian tube hasn't quite matured yet. What else do you think about in that age group?

[Dr. Dennie Poe]
Right. Surprisingly, from about age six above, it's the same etiologies that you just mentioned. Allergic disease, reflux, rhinosinusitis, general snottiness. It's more robust in the kids. Their inflammatory reactions are greater. When I see a six-year-old and they're still having trouble with their ears, allergies are the most common cause. There's been good work on that; David Hurst and others have seen a very high percentage of allergic disease in kids who have not outgrown the need for tubes. We do a lot of allergy testing, allergy management, and thinking about reflux and those other pathologies.

Under age six, you start getting into more of the infectious problems. Particularly age four and under, there may be reflux of pathogens as a cause.

Clinical Assessment of Pediatric Eustachian Tubes

Gathering comprehensive historical information is crucial, including the efficacy of previous tubes, symptoms of occlusion, and associated comorbidities such as allergies and reflux. Notably, patulous eustachian tubes are prevalent in pediatric patients and often overlooked unless patients are specifically asked about symptoms like autophony, which may be difficult for them to grasp. Furthermore, distinguishing between patulous and obstructive dysfunction is also important because management varies.

Meanwhile, pediatric physical examination involves using pediatric scopes for patients aged eight and older, along with decongestant sprays to facilitate visualization. This helps with assessing eustachian tube valve function, severity of pathology, and the presence of patulous defects or adenoid hypertrophy, guiding diagnostic and treatment decisions.

[Dr. Ashley Agan]
When you're seeing these patients in your clinic, any particular questions in your history gathering that is different from any other patient that you're seeing, any particular questions that you're asking that are really important to that workup?



[Dr. Dennie Poe]
One of the first questions, when they've already had a tube, I want to know how well they did with that tube. Was it getting infected? Was it draining? Did it help? Was their speech getting better? Were there any problems with the tubes? Were they getting occluded? If you've got a lot of adenoid tissue up against the eustachian tube, that's a good indication for adenoidectomy, and so ask about snoring, nasal obstruction, and rhinitis. Definitely asking about allergies. Why didn't they outgrow this problem with one round of tubes? Asking about allergies, reflux, upper respiratory infections. I want to know, have they ever been patulous?

It's incredibly common. Kids get patulous eustachian tubes far more commonly than we realize. They're sniffing. It gets passed off as their allergies, but they're sniffing to cover it up frequently. They just say they've got a blocked ear. Unless you ask about autophony, hearing their voice echoing in their ears, hearing their breathing like Darth Vader's breathing in their ears, all the kids get that. You have to ask. One of the things I've seen in these kids who've had multiple tympanostomy tubes, a tube will treat a pediatric patulous eustachian tube, in my experience, more effectively than it will treat an adult's patulous eustachian tube. It'll relieve the symptoms. We can miss this.

These kids are getting multiple tubes. They fall out and their patulous symptoms come back. They're sniffing. They're complaining about blocked ears. They can come into your office. They can have negative pressure because they're sniffing. They can even have an effusion because they're sniffing so strongly. We just automatically put another tube in, assuming it's obstructive dysfunction, without ever asking about autophony. Some of these patients will get sent to me for a balloon dilation. I see this about once a week. It's very common. Patulous eustachian tubes in kids is very common. It's not rare at all. We just have been missing it. You absolutely do not want to do a balloon dilation on one of those patients.



[Dr. Ashley Agan]
Do you decongest their nose? Do you spray anything to help with that or does--

[Dr. Dennie Poe]
Yes, I do. It's a combination of the oxymetazoline and the topical lidocaine. We do a quick spray in each nostril and I tell them that's the worst of it. Now that that's over, the rest will be easy.

[Dr. Ashley Agan]
When you're looking at the eustachian tube, what does that look like or describe your exam, what are your thoughts when you're kind of looking at that?

[Dr. Dennie Poe]
Once the scope's in the nasopharynx, I'll turn it sideways so I can go back and forth across the vomer. I'll look at each eustachian tube, have them say, ka-ka-ka, just to move the torus with the action of the levator muscle. Because the eustachian tube opens with the action of the two muscles, the levator immediately rotates the torus, setting the stage for the tensor muscle to open the valve. You've got to have both of them working. The ka-ka-ka moves the levator. That's a normal physiological opening. Then saying ah or a big yawn, that's a maximal sustained dilatory effort. What I'm looking for is how well does that valve open or not.

What's the severity of the pathology in the lumen of the eustachian tube? Is contact with the torus interfering with opening of the valve? Typically, it traps the torus when they swallow. You get what I call anterior thrusting. The torus gets pushed forward anteriorly and blocks the valve when they're swallowing. Very common with adenoid hypertrophy and particularly in kids. And then I'm looking at the valve for a patulous defect because it's so common in kids, especially if they've got allergic disease.

Podcast Contributors

Dr. Dennis Poe discusses Eustachian Tube Dilation In The Pediatric Population on the BackTable 159 Podcast

Dr. Dennis Poe

Dr. Dennis Poe is an Associate in the Department of Otolaryngology and Communication Enhancement at Boston Children's Hospital, specializing in heotology/neurotology and skull base surgery.

Dr. Ashley Agan discusses Eustachian Tube Dilation In The Pediatric Population on the BackTable 159 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2024, February 20). Ep. 159 – Eustachian Tube Dilation In The Pediatric Population [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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