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Myringotomy for Eustachian Tube Dysfunction
Taylor Spurgeon-Hess • Nov 9, 2022 • 39 hits
For patients with eustachian tube dysfunction, a myringotomy may help to provide symptom relief via a surgical incision in the eardrum, allowing fluid trapped in the middle ear to drain while also relieving pressure. It can also be performed to help exclude diagnosis if the patient’s presentation of the symptoms has a myriad of potential causes. The procedure can be done by itself, but it is typically performed in combination with an ear tube placement.
Dr. Seilesh Babu discusses his experiences with myringotomy on the BackTable ENT Podcast and describes how his patients often respond to the treatment. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• A thorough history comprises the majority of the evaluation when working with patients with eustachian tube dysfunction. The typical presentation includes baro-challenge symptoms, such as pain when flying or scuba diving.
• Patients with ear fullness pose a challenge when determining treatment as they may or may not have eustachian tube dysfunction. Performing a myringotomy and placing an ear tube may provide answers as the cause is likely something else if the patient finds no symptom relief.
• Some patients with eustachian tube dysfunction that undergo a myringotomy report no improvement or even feel as though sound echoes and reverberates post-procedure.
• In auditory-inclined patients (e.g. musicians, sound engineers, etc.), extensive counseling should be conducted prior to any intervention as they may be more sensitive to small changes in their hearing.
Table of Contents
(1) The Role of Myringotomy in Evaluating Patients with Eustachian Tube Dysfunction
(2) Indications for Myringotomies With or Without a Tube
(3) Myringotomy in Auditory-Inclined Patients
The Role of Myringotomy in Evaluating Patients with Eustachian Tube Dysfunction
Eustachian tube dysfunction can manifest in a variety of ways and patient history often provides the most information to physicians during their diagnostic process. Despite normal examination in the office, patients that present with baro-challenge symptoms, such as pain while scuba diving or flying in an airplane, likely have eustachian tube dysfunction and will likely do well with first-line interventions. For others with a history of multiple ear tubes and serous effusions, otolaryngologists can begin looking at next steps. When ear fullness is the primary complaint, determining the proper therapy is more difficult. If a myringotomy or tympanostomy tube do not provide symptom relief, the underlying issue is likely something other than eustachian tube dysfunction.
After obtaining a history, a thorough physical exam should follow. Components include a nasopharyngoscopy and an audiogram, as well as assessment for tympanic membrane retraction, eustachian tube movement, middle ear space fluid, and evidence of adenoid tissue. Tympanograms may be conducted, but often come back normal, even though the patient could benefit from treatment.
[Ashley Agan MD]
That's a good segue to talking about how you're evaluating these patients. And so when you have someone coming to your office, and, it looks like eustachian tube dysfunction might be the underlying disorder, or let's just say they're coming in and they have, either hearing loss or ear fullness or trouble when they fly, or a lot of these symptoms that we see in this patient population, walk us through what your evaluation looks like.
[Seilesh Babu MD]
Let's even start back with like, when a patient does come in, like you're alluding to, what symptoms should we be looking for? So I think, certain subsets of patients come in with easy decision-making as to what do we do. A patient who has baro challenges. They go scuba diving, they fly in an airplane, and they have. And then when you see them in the office, of course, they're going to have more of a normal examination because they're not having that problems, but you can trust their history enough. And experience has taught us that I think those type of patients do well with this type of intervention. Whether it's a tube in the ear or a balloon dilation, they'll actually do well in that scenario. And then you have some patients that come in with multiple serous effusions and they've had multiple tubes in their ears. And I think that also is a good candidate for their hearing loss, their ear fullness, multiple tubes that have helped their symptoms. I think that's a good candidate also to be looking at next steps. And in the patients who come in with ear fullness, I think that becomes a harder challenge to delineate what therapy is going to help that patient with ear fullness and ear fullness is a tough one. I have found myself putting them in categories and trying to figure out is it eustachian tube related or not? Is it Meneire’s disease? Is it superior canal dehiscence? Is it maybe masseter or pterygoid muscle tension that may be causing some of this? Is it anxiety? Are there other factors that we have to take into account? I think one of my main things that I do is I try doing either a myringotomy or a tympanostomy tube in that scenario to see, does that give them relief? My opinion is if it does not give them relief, then I don't think eustachian tube dysfunction is their main issue. And therefore, I don't think a balloon dilation would be indicated in that scenario, but that's a long-winded sort of way of saying what do these patients present with?
But the next steps then we think about evaluation is I think we should do a good thorough examination of their ears. See if there's retraction of the tympanic membrane and see if there's fluid in the middle ear space. I think all of these patients should have nasopharygoscopy, as we had talked about to really look at the nasal pharynx. See, is there adenoid tissue? Is there adenoid in the eustachian tube? Is there hypertrophy of the torus tubarius? Is there mucosal edema? Is there cobblestoning? What is the movement of the eustachian tube look like? Some of that over time will give you a sense of maybe this is a good one to intervene on. All of them will get audiograms. I don't always get tympanograms, but many times tympanograms will help decide. There was a time where insurance coverage was an issue. And so you'd have to get a tympanogram on everybody to show that it was a flat or poor, but that has changed a bit now. So it's not as critical to get that, but many places will still get it. It's a good way to follow objectively. What do they do afterwards if it became normal.
[Ashley Agan MD]
So you don't always have a tympanogram pre procedurally?
[Seilesh Babu MD]
I don't usually. I feel like my trend was many of patients are baro challenge patients. And so if you do a tympanogram, it's normal. And so there was a time where you're having normal tympanograms and normal exam, and then I'm doing a balloon dilation it doesn't quite make sense, but of course these patients then love it because then you can fly with any problems. So that's what changed my opinion about why do I need a tympanogram on everybody to go do it?
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Indications for Myringotomies With or Without a Tube
Patients with clear eustachian tube dysfunction, who should theoretically benefit most from a myringotomy, may dislike the feeling or report no symptom relief at all. Despite the removal of fluid, noises may still seem muffled or the patient could experience echoing and reverberation of the sounds around them. Dr. Babu believes that making an incision and changing the tightness of the eardrum leads to a noticeable difference in acoustics for patients. If a patient is referred to a specialist after undergoing a general myringotomy without relief, but their symptoms still look like eustachian tube dysfunction, placing an ear tube in at that point can often provide noticeable improvement. Myringotomy alone may not supply concrete answers or relief.
[Ashley Agan MD]
I want to back up just a tad because in your evaluation of these patients coming in and their histories, I experienced lot of the same thoughts as far as like how to put these patients in the different categories and figure out what's going on. And I echo that the ones that have that history of multiple tubes or every time I fly or every time I'm pressure challenged, it hurts or you have symptoms, those are the slam dunks, right? Like you feel like, okay, I really think this is going to help you. I can say confidently, you're a great candidate for this. And then there's the ear fullness patients, those can be such a puzzle sometimes. And when we were on the panel together, you talked about, the utility of a trial myringotomy or a myringotomy with a tube to say, okay, if this helps with your symptoms, then I feel pretty confident that this is a eustachian tube issue. And when you were talking about it, you talked about the difference between a myringotomy by itself and a myringotomy with a tube. And I wanted to talk to you more about, and have you expand on that because I have also had this situation in patients where, almost a hundred percent sure, like maybe this is eustachian tube issue, but let's try a myringotomy. And then we do a myringotomy, and then they hate it. But then, you mentioned that sometimes, the myringotomy by itself may not help the way a myringotomy with a tube is. I wanted to pick your brain on that.
[Seilesh Babu MD]
So there's certain patients I've learned over time that when you do a myringotomy sometimes I'll step away from the microscope and just say, how do you feel? And the patient universally says, I don't know it still seems muffled or plugged. And then you realize that well you just sucked all this fluid in their ear, they should've said I hear great, and then maybe about by the time I put the tube in their ear, and then you give it to 5, 10, 15 minutes. And they're like, you know what? It does feel better. I can hear louder. But then there's a couple of times where a patient has to come in maybe a day later, two days later because the tube got plugged or something and I'll ask them how they're doing. And they keep saying, there's a lot of this echoing and just reverberation. So my opinion in a long-winded way is I think when we change the acoustics of the eardrum and we make an incision and change, either the radial fibers, the circumferential fibers of the TM. We changed the tightness of that eardrum. I think it affects the acoustics in us, in humans. And that change in acoustics is annoying to patients in the sense that when you do it that first two, three days, I think the patients just getting over the fact that they have this ear fullness, this weird hearing it doesn't sound right. It's muffled. And then by the time you do a myringotomy and it closes within two days and you say, hey, did that help you? I think the patient's so stunned by everything else. I don't know if they get a sense of did that actually make their ear fullness or pressure better because they were dealing with these other symptoms. This is my theory. And so I tend to, if a general otolaryngologist sends me a patient and they tried a myringotomy, it didn't help it. My gut feeling, like you said, is that I think this is eustachian tube dysfunction, I will put a tube actually in the eardrum. And I've definitely found differences that when I put the tube in the patient will say, oh my gosh, this is so much better, and may not right away, but when they come back and see me in two weeks, they'll say, oh, it's so much better since you put the tube in. And then we'll make some decisions about, okay, now we have some options to talk about other therapies, but yeah, I don't think a myringotomy in and of itself tells me the answer, enough to give me the guidance is what I've learned over the years.
Myringotomy in Auditory-Inclined Patients
Because myringotomies have the propensity to create noticeable acoustic changes in the patient’s perception of sound, extra care must be exercised when determining if the procedure is right for those who heavily rely on their hearing. These populations include singers, musicians, sound engineers, and more. While the hearing loss reported on audiograms is often only a 5 to 10 decibel loss, the change may seem more noticeable for these patients. Dr. Babu believes that no long-term acoustic changes must be compensated for, and the short-term changes caused by the altered vibratory sensation of the tympanic membrane will resolve with time. Therefore, the procedure can still be performed and benefit the patient, but they should be heavily counseled.
[Ashley Agan MD]
That really blows up a lot of my algorithms. Do you find that patients who are singers or musicians are more in tune with their hearing, and may notice it or be bothered by it more?
[Seilesh Babu MD]
If they're even sound engineers or they're recording artists, or if they do perform or if they're somehow musically inclined, for sure they're more in tune to their hearing and any change causes them to have problems. I don't know if they have more issues with the eustachian tube, or seem to complain more about that type of symptom because of that field, but when they have ear problems, there's no question that I may be a little reluctant to maybe go down some pathways with them. Because they will complain quite a bit about different scenarios. If you do a myringotomy or do a tube in their ear, they will definitely be more sensitive and they can't “hit certain registers” or they can't hear certain things that they could hear before. And so you have to be a little cautious in that scenario.
[Ashley Agan MD]
That little, maybe 10-decibel difference after we put the tube in is more heightened in some of these patients that I've had where they're like, if my hearing is muffled, I can't hear out of this ear and your audiogram is like essentially normal, but it's like maybe 10 decibels, worse than it was before. So I don't know. I feel like I'm always over counseling in that population. Like it could change your hearing a little bit.
[Seilesh Babu MD]
On a side note, when you go down that same path and you think about that same scenario, and then you have, they have otosclerosis or they have superior canal dehiscence, or they have an acoustic tumor. Yeah. Then of course those things are magnified tremendously than the idea of a tube in the ear. So yeah, probably in my world of otology, the perspective I have is it's a tube, you'll be fine. It'll change your acoustics, just live with it. And because if they started going down that path, I said, well, in comparison to all these other patients, I have, it's not a big deal. You have a five-decibel loss. It'll go away in a little bit. Just you can tolerate trust me.
[Ashley Agan MD]
Do you feel like, over time, patients, that their brain gets used to it a little bit more and that difference becomes less obvious to them? They habituate a little bit to that little change after they get a tube.
[Seilesh Babu MD]
I think actually the flanges even of the tube, create a little bit of acoustics that allow it to be better. So that over time as it just settles in place and maybe scars, adheres a little bit, that's what affects the acoustics. I don't think there's central changes that need to occur because our audiograms are quite good in these patients with tubes. So I don't think there's an actual acoustic phenomenon that occurs long-term that they have to then compensate for. I think it's just a short-term change in acoustics. Cause you change the vibratory sensation of the tympanic membrane.
Dr. Seilesh Babu
Dr. Seilesh Babu is an adult and pediatric neurotologist, otologist, and skull base surgeon with Michigan Ear Institute in Farmington Hills, Michigan.
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). (2022, September 8). Ep. 69 – Balloon Dilation of the Eustachian Tube [Audio podcast]. Retrieved from https://www.backtable.com
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