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Patulous Eustachian Tube Dysfunction: Presentation, Comorbidities & Treatment

Author Taylor Spurgeon-Hess covers Patulous Eustachian Tube Dysfunction: Presentation, Comorbidities & Treatment on BackTable ENT

Taylor Spurgeon-Hess • Jan 7, 2022 • 453 hits

When diagnosing eustachian tube dysfunction, physicians previously thought the problem most often stemmed from obstructive issues, but it turns out that patulous eustachian tube dysfunction occurs much more commonly than expected. Patulous dysfunction refers to an issue in which the valve of the eustachian tube remains open when it should not be. This condition can cause severe discomfort in patients through common symptoms such as autophony and aural fullness.

This article features excerpts from the BackTable ENT Podcast and dives deeper into the presentation, associations, and treatment of patulous eustachian tube dysfunction. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable ENT Brief

• The most common symptoms experienced by patulous patients include hearing clicking or popping noises and experiencing autophony of one’s voice or breath.

• To simulate what it feels like to be patulous, a physician can place a stethoscope’s diaphragm up to his or her mouth and speak or breathe into it.

• Allergic rhinitis presents as the most common comorbidity with patulous eustachian tube dysfunction, more so than rapid large weight loss or reflux.

• Patulous eustachian tube dysfunction treatment involves treating the underlying etiology first, followed by the administration of hypertonic saline solution, then the use of PatulEND if symptoms persist, with surgery considered as a last resort.

Physician inspecting for patulous eustachian tube dysfunction

Table of Contents

(1) Patient Presentation and How to Simulate Symptoms

(2) Clinical Association of Patulous Eustachian Tube Dysfunction With Allergic Rhinitis

(3) Patulous Eustachian Tube Dysfunction Treatment

Patient Presentation and How to Simulate Symptoms

While most eustachian tube dysfunction will cause aural fullness, the details of the symptoms, and the problems that they cause, can aid in distinguishing patulous dysfunction from other common types. Patients who hear popping or clicking noises or who are experiencing autophony likely have a patulous or temporomandibular disorder as opposed to an obstructive condition. In patulous patients, however, the autophony specifically involves hearing one’s breathing or voice, as opposed to other sounds like bone cracking, chewing, or footsteps. To simulate what it sounds like to a patulous patient, take the diaphragm of a stethoscope, place it at the mouth, and breathe or speak. The results mimics the volume and aural fullness that patients experience.

[Ashley Agan MD]
And it's such a common thing. And so if we're thinking about how these patients are presenting to your clinic. Maybe they've got the ear fullness or clogged stuffiness. What other types of symptoms will they usually report to you?

[Dennis Poe MD]
Oh, are you talking about eustachian tube patients in general? Or obstructive or patulous?

[Ashley Agan MD]
Yeah, eustachian tube in general. And then we can kind of like, maybe separate them into, which ones do you have a higher index of suspicion for patulous versus obstructive.

[Dennis Poe MD]
So the patient’s principle complaint is typically ear fullness, aural fullness. And so we try to immediately separate that out. What kinds of problems is it causing? And on the obstructive side, they may have otitis media issues. they may have had actual infections or fluid or just negative pressure. They're baro challenged, trouble with rapid ambient pressure changes, flights diving, and they may have had a history of tympanic membrane retraction that's being followed. They may have had a history of tympanostomy tubes as a young child. So that's the group. That's the most common, our standard, what's been traditionally called eustachian tube dysfunction, what I now like to call obstructive eustachian tube dysfunction.

So we immediately try to sort those out by their history and then in the process, I will always ask nowadays about autophony. If you ever have a situation where you have a pop or a click in your ear, and it's, you're suddenly hearing your voice echoing, your breathing is like Darth Vader is in your ear, and you'll be surprised at how many patients with obstructive dysfunction will also tell you, oh yeah, I've had that, , I was exercising, it happened. We really have to specifically ask about it.

[Ashley Agan MD]
And do you feel like the popping and clicking, is that more specific to a patulous phenomenon because they're hearing their eustachian tube open? Is that basically what that popping and clicking is?

[Dennis Poe MD]
Yes, that's absolutely right. And so when I hear a patient talking about popping and clicking as a big part of their complaint, it's much more likely to be patulous or possibly temporomandibular disorders. And far less likely to be obstructive eustachian tube dysfunction. So that's a very common symptom that misleads us when they start talking about the popping and clicking. They are steering us to think about obstructive dysfunction. When in fact it's probably patulous or temporomandibular disorder. In fact, popping and clicking is one of the questions on the eustachian tube dysfunction questionnaire. The seven questions, I did not participate in how that was developed, but it was done very systematically.


[Dennis Poe MD]
…Sometimes the tube will treat a patulous eustachian tube. Particularly, if they have more autophony of their breathing than the voice, it's more likely to help. So just simply knowing that a tube helped doesn't help us sort out patulous versus obstructive dysfunction. It's all about the autophony and looking at the tympanic membrane to see if it's moving with their breathing, particularly if you block the opposite nostril. So ipsilateral nasal breathing to look for it.

[Ashley Agan MD]
And do you have to have autophony to be patulous like, if a patient says, oh, I hear myself swallow. Like I'm hearing clicking every time I swallow. Is that enough to be, maybe patulous when they, but they don't truly have the breath and voice autophony.

[Dennis Poe MD]
The hearing of their voice and breathing is almost universal, but not always. Occasionally patients will have difficulty expressing their symptoms. And when you tease it out, you get that, on a rare occasion, I'll even put a stethoscope in the patient's ears and have them talk into the diaphragm and say, is that what it sounds like? And well, yeah, that's it. But I rarely do that. Most of the time, if you really ask about it, they will tell you, or you can have them put their head down between their knees, not propped up on their elbows way down, chest on the knees. And if their symptoms go away, that’s really helpful. To add to the confusion you got to watch out for semicircular canal dehiscence, otic capsule dehiscence minor syndrome. Because they can also get better when they put their heads down. so you have to sort that out also. Now that's far more rare.

[Ashley Agan MD]
Yeah, I didn't realize that they got better with their head down as well. That's tricky.

[Dennis Poe MD]
It is tricky. The key points for semicircular canal dehiscence is they typically have autophony of bone conductive sounds. Their voice. That's where they hear their eyes moving. Their necks creaking. They're hearing they're chewing. Footsteps hit the ground. They don't have autophony of their breathing. That's a big distinction with patulous.

[Ashley Agan MD]
Can you talk a little bit about the physiology? What is happening? I feel like one symptom that all eustachian tube patients tend to kind of have in common is the pressure, clogged ear, stuffiness, ear pressure sensation. I feel like in the patients that have a dilatory dysfunction, where it really is obstructed, and if we see negative pressure, it makes sense like, oh, there's negative pressure, pulling the eardrum in and that's causing pressure.

How do you explain a patulous patient feeling that or do we know?

[Dennis Poe MD]
Yeah, if you ever want to simulate a patulous eustachian tube, you take a stethoscope, and hold the diaphragm up to your mouth, right in front of your mouth and you talk and breathe into it. It's extraordinarily loud. And this is exactly what they hear. I can tell you that because if I exercise vigorously enough, I can get the symptoms.

It's really annoying. So that's a remarkable simulation and you will experience this sort of head-in-the-barrel fullness that they talk about. And actually, if it's really bad, your breathing is pushing air back and forth in the ear and giving them a true pressure, variable pressure sensation, which they won't describe unless you specifically ask about it. So, eustachian tube fullness really is a pressure phenomenon, or it can be just an auditory sense. They'll describe that. We see people with sensorineural hearing loss and they tell us their ears are full, blocked. If you could only take that cotton out of their ear, they'd be hearing better. So it's this aural fullness is a very wide description that patients will use. And it's up to us to sort that out.

Listen to the Full Podcast

Diagnosis & Management of Eustachian Tube Disorders with Dr. Dennis Poe on the BackTable ENT Podcast)
Ep 40 Diagnosis & Management of Eustachian Tube Disorders with Dr. Dennis Poe
00:00 / 01:04

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Clinical Association of Patulous Eustachian Tube Dysfunction With Allergic Rhinitis

In practice, allergic rhinitis often presents alongside patulous eustachian tube dysfunction. In patients who first experienced obstructive dysfunction but later experience patulous involvement, the most common etiology indicates chronic allergic rhinitis. While physicians previously believed that sudden weight loss most commonly occurred with patulous dysfunction, research now shows that allergic rhinitis is actually the most common comorbidity.

[Ashley Agan MD]
And when you're talking to these patients, do you get patients who can sound like they have both? So, you ask them, have you ever had issues with your ears clearing when you fly? And they say, oh yeah, it's really painful to fly. And then you say, do you ever hear your own voice echoing or do you hear your breath? And they're like, oh yeah, sometimes I do. What do you make of that? Can people kind of fluctuate from one side of the spectrum to the other.

[Dennis Poe MD]
Yes, they can. And they do. And it's much more common than we thought, which makes our diagnostic lives very difficult. The most common etiology that will start out with obstructive dysfunction and then eventually lead to patulous is chronic allergic rhinitis. We know that chronic allergic disease can cause patulous of atrophy in the mucosa and submucosa and the nose and sinuses.

So I have the hypothesis that it also occurs within the valve of the eustachian tube, which is an extension of our other sinuses. And that would certainly correlate with what we see on endoscopic examinations. So, in fact, you can have intense inflammation in the nose and adenoid, torus tubarius, orifice of eustachian tube, but then you look into the lumen and you can see this marked atrophy and the patient can be frankly patulous when they have a runny nose with allergic disease.

If you get this kind of patch of atrophy in the valve, you can become patulous, even though you still have even active allergic rhinitis or sinusitis. Now, if in the allergic patient, if they are active with their symptoms and congested, they may be completely blocked and obstructed even to the point of middle ear effusion. But then if their disease is quiescent or they're overmedicated, dehydrated, they can switch over to patulous and they can go back and forth, which is very confusing. Because the patient's always going to say my ears is chronically blocked. It's always blocked. So we have to sort those out. Short answer is yes, people can definitely have both, or they can have a long history of obstructive and then they transition to patulous, which is more common. It's not as common to have patients going back and forth, but we have to look out for it.



[Ashley Agan MD]
What other questions are you asking as far as on the history side of it before we move on to physical exam? I think historically for patulous we thought about patients who had had like a sudden weight loss, like they had lap band surgery or something and lost a hundred pounds and now they have autophony. But I've found, I have maybe a couple of patients where that's the history, but it's not nearly as common as just someone who's had chronic allergic rhinitis for forever.

[Dennis Poe MD]
Yeah, that's wonderful that you're noticing that. That's exactly what we've noticed too and published on that. Allergic rhinitis is the most common comorbidity that we found with patulous- 50%. Weight loss, rapid large weight loss was 35% in our series. Reflux was the next in line. And further down, we have stress, anxiety. When you're stressed-

People have for a long time noticed that these patulous patients can have a lot of stress and anxiety, and it's always been a chicken versus the egg question, is the stress causing their patulous or is the patulous making them stressed? So what we've observed is that the muscles of mastication, especially the medial pterygoid, it can act as a secondary dilator of the eustachian tube. It will literally distract the membranous wall out laterally and can contribute to patulous. So if they're clenching their muscles, they can provoke patulous, which makes them more stressed. And you get into that vicious cycle. So that was like number four on our list of comorbidities.

[Ashley Agan MD]
So you could have patients that have both patulous and TMD too, like those can overlap.

[Dennis Poe MD]
Commonly. Very much so. And they feed each other.

Patulous Eustachian Tube Dysfunction Treatment

The first line treatment for patulous eustachian tube dysfunction involves addressing the underlying etiology and treating that first. Underlying factors may include caffeine, dehydration, allergic disease or temporomandibular disorders. If symptoms persist, patients may benefit from administration of hypertonic saline drops, or, in more severe cases, PatulEND, an ascorbic acid solution. In the event that all of these modalities fail, surgery should be considered as a treatment option.

[Ashley Agan MD]
Yeah, well just rounding this out, I think we could probably talk about this forever, but I want to make sure that we just touch on treatments for patulous. So in your patulous patients, once you've decided solidified that diagnosis, what is your treatment algorithm for that set of patients? What does that look like?

[Dennis Poe MD]
Well, again, it starts with looking for the etiology. If it's weight loss, we don't have them gain weight that usually goes wherever else you don't want. But if there are other things that are treatable, they're on diuretics, they're on particularly oral contraceptive with spironolactone. Other oral contraceptives are okay, but that particular combination seems to be prone. Caffeine, dehydration, allergic disease. If they're over-medicating on antihistamines, and nasal sprays we’ll convert them to nasal rinses and Nasalcrom, immunotherapy when possible. So trying to control all of these other factors, temporomandibular disorders, muscular treatments, relaxation therapy, etc. We try all those things.

If those don't work or we resort to topical drops, saline drops, hypertonic saline drops for something more irritating. Four teaspoons of salt and a cup of water will give you a nice hypertonic solution. It's cheap. you have to instruct the patients how to do it. So you've got a lie supine, hang your head 15 degrees apply the drops, and turn 45 degrees toward the floor. So it's kind of like a, not as severe, head hanging hallpike position and the drops when they touch the eustachian tube will give a twinge that radiates to the ear. If they don't get the twinge they missed. So you have to carefully coach them in all of those things.

Hypertonic they can do as often as they like. If none of this works, my go-to is PatulEND. PatulEND you can get over the internet. It's ascorbic acid solution. It's vitamin C in a bottle. It really stings a lot of the people. Some people say it's too powerful for them, but if they do that three drops two to three times a day for two straight months to try to get a lasting benefit really can work in a lot of the patients. So those are the go-to things. If they've failed the hypertonic or the PatulEND with a rigid protocol like that, those are the ones I'm considering surgery, if we have to.

[Ashley Agan MD]
And real quick, what's the most common surgical option for these patients?

[Dennis Poe MD]
Yeah. The most common thing I do is, we don't have any commercial device, so off-label inserting an angio catheter that's filled with molten bone wax, let it harden, cut it to size and put it up the full length of the eustachian tube, and if they're out of town, I even put a stitch to it. We get great results with that.

I can't do that if they've got a dehiscent carotid artery. So for those patients we have to do cartilage implants, making an incision in the walls of the eustachian tube and packing cartilage pieces into the sidewalls to bulk it up.

[Ashley Agan MD]
I've done that once. It's very challenging working back that far in the nose.

[Dennis Poe MD]
Congratulations. I hope you had the instruments.

[Ashley Agan MD]
Yeah. We had them order a special kind of eustachian tube needle driver instruments to get to the back of the nose, but it is very challenging, throwing stitches in that part of the nose. So putting the shim is much preferred, much easier.

[Dennis Poe MD]
Right. And you're talking about a shim, so we call it a shim. It's a plumber shim to help try to plug the leak of the valve without intentionally plugging it completely. So we do call it a shim.

Podcast Contributors

Dr. Dennis Poe discusses Diagnosis & Management of Eustachian Tube Disorders on the BackTable 40 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 Diagnosis & Management of Eustachian Tube Disorders on the BackTable 40 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). (2021, December 21). Ep. 40 – Diagnosis & Management of 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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