BackTable / ENT / Podcast / Transcript #159

Podcast Transcript: Eustachian Tube Dilation In The Pediatric Population

with Dr. Dennis Poe

In this episode, host Dr. Ashley Agan discusses eustachian tube (ET) dilation with Dr. Dennis Poe, neurotologist and Professor of Otolaryngology at Harvard Medical School. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Anatomical Differences: Adult vs Pediatric Eustachian Tubes

(2) Etiologies of Eustachian Tube Dysfunction in Children

(3) The Clinic Visit: History Taking & Physical Exam

(4) Adenoid Hypertrophy and Adenoidectomies in Children

(5) Medical Management Prior to Eustachian Tube Dilation

(6) Indications for Tubes vs Balloon Dilation

(7) Measuring Outcomes of Balloon Dilation

(8) Contraindications to Balloon Dilation

(9) Risks & Complications of Balloon Dilation

(10) Post-Op Instructions for Balloon Dilation

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[Dr. Ashley Agan]
Hi, everybody. Welcome to the BackTable ENT podcast, we're a podcast that focuses on all things otolaryngology, and we've got a really great show for you today. Thanks for stopping by. I'll be your host today. My name is Ashley Agan, I'm a general ENT, and I have the distinct pleasure of getting to interview Dr. Dennis Poe. He's our guest today. You may recognize him from Episode 40, where we talked about eustachian tube disorders.

Go back and check that one out if you missed it. He's back today to talk more about the eustachian tube, specifically in the context of the pediatric patient this time. Welcome to the show, Dr. Poe.

[Dr. Dennis Poe]
Dr. Agan, thank you very much. It's a real joy to be back with you. It's a real privilege to be able to speak with all of you today about this topic. Previously, we weren't able to talk about the pediatric indications that we'll discuss today.

[Dr. Ashley Agan]
Yes. Let me give you a proper introduction for those who don't know you. Dr. Poe is a professor in the Department of Otolaryngology at Harvard Medical School. He specializes in neurotology and skull-based surgery and has worked to develop minimally invasive endoscopic surgical techniques in this field. In 2011, he completed a PhD at the University of Tampere, Finland in pathophysiology and surgical treatment of the eustachian tube. Based on his research work confirming that the cartilaginous eustachian tube is the site of most pathology where it serves as a functional valve, he has developed new diagnostic methods and procedures for eustachian tube disorders.

He runs the International Eustachian Tube Study Group and served as the principal investigator for the first multi-center clinical trial of balloon dilation of the eustachian tube. He provides education to surgeons, physicians, patients, and payers about eustachian tube disorders and treatments, including balloon dilation. I see you as the expert, the godfather of eustachian tube treatment, so I'm always so geeked and excited to get to pick your brain and talk to you.

[Dr. Dennis Poe]
I'm just one of many who's contributed to this, but I'm happy to try to distill it down and bring it to everybody.

(1) Anatomical Differences: Adult vs Pediatric Eustachian Tubes

[Dr. Ashley Agan]
Getting started, we're focusing on the pediatric eustachian tube today. Set the stage about how you think about differences between the adult eustachian tube vs the pediatric eustachian tube, thinking about anatomy and some of the different pathology you see when you compare and contrast those groups.

[Dr. Dennis Poe]
Thank you. First, I should just let folks know that I am a consultant for the Acclarent Corporation. As a consultant, I'm paid for my time and expenses, so I have no equity interest in the products and no royalties from any of the products. I'm going to speak to you about my academic experience with this.

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. Sometimes you have to probe around there to actually figure out where's the anterior pillar, where's the torus tubarius, and then somewhere in between there is a lumen. It can be very friable in the kids too. The anatomy is a little trickier in the children, so just take extra caution.

(2) Etiologies of Eustachian Tube Dysfunction in Children

[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. This is where there's got to be a lot of research before we know that we can uniformly do balloon dilations in the future in those kinds of age ranges. Obviously, we wouldn't want to make refluxing of pathogens worse.

(3) The Clinic Visit: History Taking & Physical Exam

[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]
Are you asking just about the otitis media workup in general, or you mean specifically who I'm thinking about ballooning?

[Dr. Ashley Agan]
I think both, yes. For your pediatric patients who are coming in, and let's say they've had tubes before and we are starting to think about ballooning, are there particular questions that you need to ask?

[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.

In that case, if the tubes have worked great for them, fine, put another tube in until the TM starts to fall apart. Then you can do a cartilage tympanoplasty, reinforce it in the future, and that might help. We have to be really careful to sort out the patulous patients from the obstructive dysfunction. That's probably the single most important thing. Chronic allergic rhinitis is the most frequent comorbidity that we see with patulous tubes. If you've got a kid who's allergic and they're needing more than one tube here, you've got to ask about autophony -- Has your ear popped and all of a sudden you're hearing your voice and breathing echoing in your ears, you will be amazed how common that is. Got to ask and then decide on treatment.

[Dr. Ashley Agan]
Wow. I had no idea that pediatric patients were patulous to that extent.

[Dr. Dennie Poe]
It is incredibly common.

[Dr. Ashley Agan]
I would imagine. Sometimes the adult patients have trouble describing the sensation of patulous. I would imagine kids also would, unless you're asking about it, would they be able to describe the feeling of their ear being clogged and stuffy and blocked. What is your exam like when you're seeing these patients in the clinic? With adults, I'll frequently do a scope exam so that I can really look at the eustachian tube opening. In kids, are you able to do that in clinic? Are they letting you put a scope in their nose or is it variable?

[Dr. Dennie Poe]
Yes. It's a little variable, but the kids eight and older, most of them are fine doing it. Just go with a pediatric scope. These are typically 2.7 millimeters in diameter. I flop it in front of their eyes, say, "You can see, it looks like a piece of spaghetti." They're generally very good with that. Just go in slow. Now, not everybody's up for it. If they get a tear in their eye, I'll quickly not do it and just defer that to the operating room if it comes to that.

[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.

You can see robust inflammation in the whole nasopharynx, the orifice of the eustachian tube, and even this cobblestoning down into the lumen, adenoid-like tissue in the lumen and yet in the membranous wall, not the cartilaginous torus wall, but the opposite anterolateral membranous wall, you can actually see a defect in the valve sometimes where it's beginning to get atrophic. Chronic allergic disease is associated with patches of atrophy in the nose, sinuses, and the valve of the eustachian tube. That's why so many of these patients become patulous. I'm looking for those things. Inflammation in the lumen, the severity, how well does it open or not, patulous defect, and the adenoid.

(4) Adenoid Hypertrophy and Adenoidectomies in Children

[Dr. Ashley Agan]
Yes, it is. I've seen that too where they can have impressive lymphoid hypertrophy and mucus, everything looks super swollen and then you look right down the barrel of the eustachian tube and you're like, "Oh, wait, maybe that’s it. Maybe you're patulous." You really have to look closely. Have you ever had situations where there's so much adenoid tissue that you can't sneak around and look across to the other side because that whole back nasopharynx is just completely full of adenoids?

[Dr. Dennie Poe]
Absolutely, that's pretty common. Great patient to do an adenoidectomy. I do a lateral adenoidectomy with endoscopic guidance. I actually nowadays put a 70-degree scope in the mouth instead of a mirror. You get a much better view. In a lateral adenoidectomy, I'll even trim tubal tonsil tissue, 15 watts. You just trim some of the, not the orifice, but the medial half that faces the adenoid. You can trim that with a light 15-watt monopolar suction cautery just to clear all of that inflammatory tissue away from the lumen. Then I'll look at the lumen which previously I wouldn't have been able to see even with an endoscopy in the office.

If the patient has consented for a balloon dilation, I'll make a decision at that time, looking in the lumen, do I want to balloon this patient or not or was that adenoid really the biggest problem?

[Dr. Ashley Agan]
When you're doing your adenoidectomy, so the classic way you have a headlight and a mirror and a suction bovie or coblator or microdebrider or something that you're taking down that adenoid tissue with. For you, you're actually using your 70-degree endoscope to look around the corner instead of a mirror so that you can see a lot better, but you're still going through the mouth?

[Dr. Dennie Poe]
Yes, exact same technique, except I'm using the endoscope. Boy, when the residents are doing that, I can see everything.

[Dr. Ashley Agan]
Yes, an adenoidectomy in the beginning can be really challenging, especially if you have a lot of adenoid tissue and trouble being able to see. Having a scope makes a lot of sense. What's your instrument of choice to take down adenoid tissue? Do you use a curette or do you suction bovie?

[Dr. Dennie Poe]
The suction bovie, unless it's very large, then I'll use the coblator to get the big stuff off. It's just quicker.

[Dr. Ashley Agan]
Backing up, so for example, let's say you have a patient that you weren't able to scope. Maybe they're very young or they just weren't going to tolerate that. Do you ever get an X-ray, like a nasopharynx X-ray to look for adenoid tissue? Is that helpful at all, or you know you're going to the operating room anyway, so maybe you just do an exam under anesthesia and make some decisions at that time? How do you think about that?

[Dr. Dennie Poe]
Yes, I've stopped doing the X-rays for just what you said. We're going to the OR at any rate, so we're going to do a flexible scope at the beginning of the procedure, take a quick look at the adenoid situation, and decide whether to do adenoidectomy or not. I just do it in the OR.

[Dr. Ashley Agan]
Yes, because these kids are getting another set of tubes, plus or minus adenoidectomy, plus or minus balloon.

[Dr. Dennie Poe]
Exactly.

(5) Medical Management Prior to Eustachian Tube Dilation

[Dr. Ashley Agan]
Okay, moving on to treatment options, is there any medical management that you like to do a trial of first before you move on? You mentioned allergies. Is it important to say, "Hey, like we're going to do four to six months of allergy treatment and see if that helps"? Just thinking about this out loud, in adults, four to six weeks is not as long of a time frame as in a six-year-old because I think if they're struggling and they have an infusion and they can't hear, the longer we delay treatment, the more I worry about just their hearing. I don't know. What do you think about that?

[Dr. Dennie Poe]
Absolutely. I'll follow the clinical practice guidelines from the American Academy. First time around, three months, middle ear effusion, or really within the X number of episodes they’ve had, six episodes in a year or something like that. I'll follow those guidelines. However, I will concurrently get them started on medication. If I think they've got allergies, I'll get them concurrently started on that and we might recheck them before they get to the operating room. If they clear up, great, we cancel the case. No, I completely agree with you. Let's not delay it. If they've been getting speech delays or repeated infections, go ahead and let's get them booked and we can always cancel if they're getting better.

[Dr. Ashley Agan]
Yes, and with allergy management in children, a lot of it is still the same, correct? Nasal sprays are still effective. Over-the-counter antihistamines, you might do allergy testing and immunotherapy.

[Dr. Dennie Poe]
Right. Immunotherapy, of course, is a long-term thing. We do send them up for a lot of allergy testing, but that all takes a long time. The majority come back all negative on the tests. We have to remind them that doesn't mean you don't have an allergy. There are lots of false negatives, in which case we're treating generically, just like you said, antihistamines and nasal steroid sprays and occasional azelastine antihistamine nasal spray.

(6) Indications for Tubes vs Balloon Dilation

[Dr. Ashley Agan]
For tubes, tubes work great. I think they're basically creating a shortcut so that if the eustachian tube is edematous and swollen and not working, then you have a shortcut for the middle ear to aerate is how I talk about it with patients. It works really well, but it's not actually addressing the underlying issue. At that point, if patients are like, "Let's just keep putting in tubes," at some point you do say, "Maybe we need to think about balloon dilation." A lot of times with the second or third tube, you think about the adenoidectomy. Is there a certain amount of tubes where you'd say, "Okay, we've reached our limit. We can't put in tubes anymore." Do you think about T-tubes at a certain point?

[Dr. Dennie Poe]
Totally agree. Generally, first time around, kids are going to get a tube. If you've got a frequent swimmer, who's on a swim team or something, they don't really want a tube. Most of the time, you're going to get a tube up front first. The tube worked. Everything was good. But it didn't do the job. As you said, it's just treating the symptom. It's not treating the source, the underlying etiology. When it comes time to explain, well, now we have to do something again, you could place another tube or the balloon is an option. For the exact same indications, I think they're equally good options from that point of view. Equally indicated, I should say. The balloon, obviously, is treating the source.

Hopefully, and we've got a couple studies that have been showing this, if you do a balloon, your chances of needing further tubes is significantly reduced. That's one thing to consider. Because you're treating the source, you may be reducing the chance of needing further tubes. If I see a child who's had multiple tubes, first of all, I've got to make sure they weren't patulous. Once we've ruled that out, then yes, then I will favor a balloon over multiple tubes. Absolutely. With multiple tubes, as you know, the tympanic membrane can eventually start to break down. Then you're dealing with a thin portion. It might turn into a pocket in the future or they get perforations.

The risk of a permanent perforation is going up each time you put in yet another tube. I try to avoid the T-tubes. A primary tube, you put in a primary short-term tube, that's about a 2% incidence of a permanent perforation. That goes up each time you put in more tubes. A T-tube, longer duration tubes, 16% risk of a permanent hole. It's a big difference.

[Dr. Ashley Agan]
Yes, I think we've all had that patient where we put in a T-tube and then you see them in follow-up and the T-tube is just sitting in a perf and you're just like, "Ah," it's really frustrating. You could start thinking about a balloon dilation even with the second set of tubes.

[Dr. Dennie Poe]
Sure. Our studies, I've tried to look at patients who had two or more tubes. Most of them had quite a number as well as a previous adenoidectomy. We were looking at worst-case scenario types to see what the balloon would do vs continuing to place more tubes. In general, yes, once they're looking at yet another tube, a balloon's a really great option. That's been the most common indication in my practice. I think the majority of these indications are probably going to be, yes, they got a tube that worked, now that we're facing yet another tube indication, the balloon might be a better option. Now that may change in the future, as research goes on, maybe we can get away from tubes. That is actually a goal.

[Dr. Ashley Agan]
That's really interesting. With that, we're talking about kids who are basically older than eight?

[Dr. Dennie Poe]
The indication's eight and above.

[Dr. Ashley Agan]
Eight and above. Back to our balloon dilation patient, we've talked about patients who might also benefit from having adenoidectomy because they have a lot of that inflammatory response in adenoid tissue in the back of the nose. You would combine adenoidectomy maybe plus balloon if you're getting there and you're seeing that there's some inflammation within the lumen of the eustachian tube as well. Is that a decision you make intraoperatively if you aren't able to get that exam beforehand?

[Dr. Dennie Poe]
Exactly. If it looks like the adenoid is pretty robust, it's significantly impacting onto the torus and maybe even spilling over onto the torus, sure, we'll trim that back, at least with a lateral adenoidectomy. I do a lot of revision adenoidectomies because the lateral portion is not always taken out the first time around. Adenoidectomy is a common part of taking a kid back to the OR for either tubes or a balloon. That's frequently a part of it. Now again, we're not going to trim adenoid-like tissue going down the lumen of the eustachian tube. If you think that's the problem, that's what the balloon does.

The balloon, histologically we've seen from specimens in patients, it's basically doing an adenoidectomy on adenoid-like tissue that's gotten down the lumen. It crushes that tissue and it grows back very healthy.

[Dr. Ashley Agan]
Think of the balloon as your tool for addressing intraluminal disease.

[Dr. Dennie Poe]
Exactly. It's just extending your reach of doing an adenoidectomy on adenoid-like tissue that's gotten down the lumen.

[Dr. Ashley Agan]
When you're addressing, let's say, like the lymphoid hypertrophy of that posterior cushion on that medial aspect outside of the lumen, are you doing that through the nose? Are you looking through the nose with a scope or do you also do that through the mouth?

[Dr. Dennie Poe]
You're talking about trimming the tubal tonsil tissue?

[Dr. Ashley Agan]
Yes.

[Dr. Dennie Poe]
No, I do that. I've still got that 70-degree scope in the mouth, so I'm typically doing that. I was doing it through the nose with an endoscope for a while, but you just don't need to. The view's quite good with that 70-degree scope. Going through the nose, if you get any bleeding, it runs right over your eustachian tube.

[Dr. Ashley Agan]
You're staying medially and you're addressing all of that lymphoid hypertrophy and tonsil tissue that is on the medial aspect of that posterior cushion and you're not creeping it into the lumen because you're going to use your balloon to treat the lumen.

[Dr. Dennie Poe]
Exactly. We don't want the cautery in the lumen. that could cause unpredictable injury, scar.

[Dr. Ashley Agan]
Yes, okay. That makes sense. For kids who may have, maybe they do have a little bit of adenoid tissue, but on your exam, it appears that the main issue is the lumen, inflammation within the lumen of the eustachian tube. Do you ever just say, "We're just going to do a eustachian tube dilation. I don't think we really need to treat the adenoid tissue. It's there, but it's minimal"?

[Dr. Dennie Poe]
Absolutely. Yes. As a surgeon, you're going to target the disease that you see. Whatever is relevant.

[Dr. Ashley Agan]
Right. Okay. Then working through our patients, we talked about the patient who's got a lot of adenoids and inflammation in the back of the nose. Every now and then I'll have patients who have had a cholesteatoma, they had a cartilage graft and panoplasty, and now they've got some fluid behind that cartilage graft or they've got maybe like some retraction or basically they're symptomatic in their ear that's been operated on and they don't have recurrent cholesteatoma. Have you used the balloon very much in those patients? Does that help?

[Dr. Dennie Poe]
Sure. That's a really good indication. You closed their perforation or took out their cholesteatoma and now they're getting middle ear effusion. That's a great indication for the balloon rather than putting a tube right through your freshly healed tympanoplasty. We do a fair number of balloons at the time of doing tympanoplasty. If it looks like the eustachian tube is still compromised and I might scope them at the time of the surgery, sure you can do a balloon at the same time. Do the balloon first if you're going to do that and then do your tympanoplasty just so if there's any back pressure from blowing up the balloon, it doesn't mess up with your graft. We do a fair amount of that.

[Dr. Ashley Agan]
Yes. I would imagine that you're doing that a lot more than you used to as far as just doing it at the same time and treating that underlying issue altogether.

[Dr. Dennie Poe]
Right.

[Dr. Ashley Agan]
The only tricky part about that is especially if you use a cartilage graft, you're not going to get that Type A tympanogram, maybe to be able to see the improvement. If the fluid is gone, then you've fixed the problem, right?

[Dr. Dennie Poe]
Yes. You don't get the satisfying Type A. If you insufflate them and you see the non-cartilaginous part of the drum moving freely, this feels pretty good.

[Dr. Ashley Agan]
Yes. You'll take it, right?

[Dr. Dennie Poe]
Right.

[Dr. Ashley Agan]
Let's see here. Most of these procedures you're doing in the operating room, correct?

[Dr. Dennie Poe]
I am, yes. Particularly with kids, that would be really tough in the office. Adults, you can do in the office pretty readily with the right patients, and many, many people are doing that very successfully.

(7) Measuring Outcomes of Balloon Dilation

[Dr. Ashley Agan]
Looking at your outcomes, you're hoping to have normalization of that tympanogram, moving from either a type C or B to a Type A. Do you also measure a patient's ability to perform Valsalva or Modified Valsalva, is that one of your outcome measures as well?

[Dr. Dennie Poe]
Yes, it is. All the kids we take to, even when I see them in the office and I'm just evaluating them right from the beginning, I try to teach all of them a modified Valsalva. Not holding your nose and blowing hard because people have blown out and destroyed their sensorineural hearing and gotten vertigo from that. A Mmodified Valsalva, nose and mouth closed, gently blown, only gently, so there's just a little positive pressure, and they swallow hard at the same time. That's a little tricky. Not everybody can do it. You'd be surprised how many kids can do that. I try to teach all of them to do it. That's actually a really important part of the exam, to see if they can do that modified Valsalva.

If they can do it, they don't usually need the balloon. Now if they're just too young to coordinate that or they just can't get it, then we have them do these Otovent balloons, which are actually pretty good, and that's recommended in the CPGs as well, or that eustachi device, a little air pump that goes up to your nose. They can work too, but the younger kids are scared of that one, but they do really well with that nasal balloon.

[Dr. Ashley Agan]
Okay. Are you looking at the eardrum while they're doing that modified Valsalva just to see if the eardrum lateralizes, or do you just ask them if they feel that change in their ear?

[Dr. Dennie Poe]
Yes, I generally just ask, "Do you feel a change?" If they say, "Yes, I felt the change, my ears popped," then I'll quickly look again to see if there's a difference.

[Dr. Ashley Agan]
Okay, great. Any other outcomes that you're looking for, tympanograms, ability to Valsalva, or Modified Valsalva?

[Dr. Dennie Poe]
Yes, the clinical exam, ability to insufflate, the audiogram as well, I want to see their conductive hearing loss has gotten better and I want to see that modified Valsalva. All of those, yes.

(8) Contraindications to Balloon Dilation

[Dr. Ashley Agan]
Okay. Any absolute contraindications? When you talked about how the balloon is going to prevent, based on the way it's designed, it's going to prevent you from getting up into the middle ear. Any contraindications for a balloon other than patulous, I guess? That would be the big one.

[Dr. Dennie Poe]
Yes, that is the big one. Not really, unless they've had some anatomical problem, I've seen a few cases where the eustachian tube orifice has been completely obliterated from a past scar or something, previous surgery, turbinectomy, adenoidectomy. If they don't have an orifice, you're not going to successfully balloon them. If you can see that in the office with an endoscopy earlier, you can spare them going to the operating room and having a failed attempt at a balloon. Then relative contraindications, of course, you want to try to have any active disease like allergies under control, reflux under control. We're not routinely doing syndromic kids, so they've got anatomical issues that the balloon may not be able to treat.

That's still a research area. I have had some success in older kids, teens and adults, young adults with clefts who've been repaired well, their levator muscle is not blocking the eustachian tube, and they've got a fair burden of inflammation, which I think I can treat. Very selected cleft patients I have had success with. I've only done very few Down syndrome patients and they were not successful.

[Dr. Ashley Agan]
Going back to what you mentioned, if we think about just the balloon as a device to treat inflammation within the lumen of the eustachian tube. If patients have a problem that's related to a craniofacial abnormality and not inflammation, then it's maybe less likely to work. Looking for that inflammation sounds like that's key.

[Dr. Dennie Poe]
Exactly. That's really what you're going to be treating as a surgeon.

[Dr. Ashley Agan]
Yes. When you're performing the procedure, is it pretty much the same as when you're doing it in adults? Are you doing it through the nose? Do you need to go transoral? Is the device different or is it the same device?

[Dr. Dennie Poe]
The device is the same. Again, much of the anatomy is already fully developed in the eight-year-old. Although the orifice might become a little bit higher in the small eight-year-olds with time. Acclarent balloon has a guide catheter and the flexible balloon goes through the guide.

[Dr. Ashley Agan]
Would you say that the biggest difference with kids is just being able to find the lumen of the eustachian tube because of all that inflammation?

[Dr. Dennie Poe]
The answer is yes. Let me repeat that. Yes, it can be tough to find the orifice sometimes because of all this robust inflammation. You gently, very gently just touch it to try to move the tissues around, see if you can find the lumen. It's so friable, it can just bleed. Yes, you just have to be a little patient with it in the kids. The moral is to go slow with the whole procedure. Just go a little slow and you'll find the lumen and don't push it.

[Dr. Ashley Agan]
Yes. That bleeding really helps you find the lumen then, huh?

[Dr. Dennie Poe]
Yes. It can block it pretty well.

[Dr. Ashley Agan]
Okay. Then how do you decide how long to inflate the balloon?

[Dr. Dennie Poe]
Great question.

[Dr. Ashley Agan]
Does everybody get two minutes?

[Dr. Dennie Poe]
No. Again, the duration of the balloon is commensurate with how severe the inflammation is. That's true in adults. Two minutes is the max. If you've got a patient who's got minimal inflammation, I'll typically do like one minute. Sometimes I do a minute and a half. Now 18 and below, I never go above a minute and a half anymore because we started getting some patulous kids. They are more sensitive to the effect of the balloon than the adults. Need research on this, but there's no question they are more sensitive. They have more inflammation, they’re more sensitive to the effect of the balloon.

Fortunately, I've never had to fix the patulous symptoms that we got. They were self-limited, but it got my attention. I never go beyond a minute and a half in pediatrics, and we've not had any problems since.

[Dr. Ashley Agan]
Okay. If you did, let's say you under dilated, let's say you were concerned, so you only did a minute, and a patient comes back and it seems like they didn't have the improvement that you were hoping, do you ever go back and say, "Maybe we'll do that minute and a half"? How often does that happen?

[Dr. Dennie Poe]
Not very often. The balloon is usually very successful, but the more common issue would be you did the balloon and they got better for a period of time, but now they're having trouble again, or they had a bad cold and their effusion is back. The most common scenario is that they have allergic disease or reflux disease and they didn't keep it under appropriate control, environmental or diet, or medications. They were doing great. They slipped on their chronic medical management. They're failing again. You get them back on their medical management, it's not getting them over the hump. Okay, we'll bite the bullet and we could do a repeat dilation in those patients.

If it doesn't work upfront, I usually am not going to do another balloon. There may be a problem higher up. It could be in the bony eustachian tube. I'm not typically going to repeat it. Now, the scenario you mentioned where, okay, that would be unusual, but okay, so they got a borderline improvement, almost there, and maybe I only gave them one minute. I might, if I look, they'll let me look and I see, yes, there's some inflammation I just didn't get. Let's go back and do yet maybe another minute. You could justify that. I'll leave it up to the surgeons and that scenario. That hasn't come up often.

(9) Risks & Complications of Balloon Dilation

[Dr. Ashley Agan]
Can you talk about other risks and complications that you've seen and how to avoid them?

[Dr. Dennie Poe]
Yes, there was actually a paper that just came out recently looking at the MAUDE, M-A-U-D-E. This is the self-reported complications to the FDA with these devices. The most common one was subcutaneous emphysema. That is a laceration or false passage through the membranous wall. The membranous wall is only a few cells thick. Again, surgeons can penetrate that. In our labs or clinically, when it's happened, no one has ever felt it, it's so thin. The only way to avoid that is to have a direct view down the lumen of the eustachian tube. This is why I always recommend that you've got to be able to see both walls. With your clinical exam, you want to see both walls of the valve, not just one.

It would be like looking at the vocal cords. If you don't see the valve at all, it's equivalent to looking at the epiglottis and you don't even see the vocal cords. You're going to operate on the vocal cords, you wouldn't do it. In this case, if you use a zero-degree scope and you don't get an angled view and all you're seeing is the torus, you're seeing maybe one wall of the valve, it's like seeing one vocal cord and you're going to operate on both. You want to see both walls, evaluate both walls, and you want to see both walls when you're putting the balloon up there, and as you run the balloon up, you hug the membranous wall. You're running tangential to it, so you're not going to penetrate it.

What commonly happens is the surgeons are confident, I can see everything I need to with a zero degree. They don't see the membranous wall, but they say, "Well, I've got the torus there." If you angle off of the torus, it actually takes you through the membranous wall. That's how it happens. In fact, there was a carotid injury, which I'm sad to say. This was in one of the rail-based devices where there's a bendable rail and the balloon slides up on that. You put the rail up into the lumen and you slide the balloon up there to do your balloon dilation. I didn't discuss it in the article, but we've duplicated this in the lab years ago.

We knew this could happen with anything rigid. That's why we don't put rigid things in the eustachian tube. If you angle off the torus, what probably happened in that case was the rail went right through the membranous wall. That takes you in a vector straight toward the carotid. In the article, they talked about the bony portion of the eustachian tube where the carotid is in proximity. That's probably not where this injury happened. It was a stroke a week after the balloon, so there was an intimal injury and a pseudoaneurysm. They probably poked the carotid with this rail, and undoubtedly that's a membranous wall injury.

The balloon has safety devices for all of this. It's got a soft, round, 2-millimeter diameter tip that if you don't push it in fast and you watch it go up the membranous wall, now the eustachian tube curves initially, medially, it actually dives behind the adenoid a little bit, and then it curves off toward the ear. A lot of surgeons don't realize that because they haven't looked up that far. The balloon is flexible for just that reason, so it's going to navigate that turn, and it's got that ball tip so that it'll push the mucosa aside as you get up out of sight. As a surgeon, you're going to set it along the membranous wall, tangential to it so you won't penetrate it, and then as it disappears out of sight, it's going to just curve around.

The cartilage becomes increasingly circumferential, and so it'll just guide along there. The other safety features are, so you're normally going to feel the isthmus when that ball tip contacts it, and there's a little mark at 31 millimeters. This yellow mark should never disappear into the lumen because the average eustachian tube cartilaginous length is 25mm. It should normally be sticking out about a half a centimeter from the orifice. In the smaller kids, maybe stick out even more than that, maybe up to a centimeter in the smallest 8-year-olds. You want to see that yellow mark is not going to go into the orifice, you're going to feel that little ball tip touch the isthmus, and so that's how you do it.

You insert it under direct view, typically you need an angled endoscope, but not necessarily. If you can see both walls, you're fine. If you can see both walls with a zero degree, you're fine, but if you can't, get out the angled scope. That's how you avoid this problem of air emphysema, there's actually been reported cases of pneumomediastinum. This happens from the patient getting a false passage, didn't get recognized, and the patient blew their nose within the first week. We always recommend that you don't blow your nose in the first week, no modified valsalvas in the first week.

Fortunately, no complications came of those, they all were self-limited, some of them got antibiotics, but not all of them did, and there haven't been any other significant adverse complications. There have been some reports of tinnitus and sensorineural hearing loss in devices outside of the US. I'm not aware-- I'm sorry, there was one case of tinnitus in the MAUDE report, that's the only one I know of reported with a US device. Actually, we've got several approved devices now in the States, but of the reports that I'm familiar with, that's the only case of tinnitus I've seen in a US product.

[Dr. Ashley Agan]
You mentioned that in a kid, you might tolerate the balloon sticking out more than you're used to seeing in an adult.

[Dr. Dennie Poe]
Yes, so if you run to the stop of the isthmus, you feel it, and it's sticking out more than you're used to with the adults, that's okay.

(10) Post-Op Instructions for Balloon Dilation

[Dr. Ashley Agan]
With your post-op instructions, other than not blowing their nose or doing a modified Valsalva in the first week, any other instructions that you give them? In my experience with adults, there's not a ton of post-operative pain to treat. If they're getting an adenoidectomy, they're going to probably need some Tylenol Motrin, but any other post-op instructions that are specifically related to the balloon portion?

[Dr. Dennie Poe]
Not really. It's extremely well tolerated. I warn the parents they're going to complain more of a sore throat from their endotracheal intubation than they'll complain about their ear or the back of their nose. It's very, very well tolerated. If they have any soreness in the nasopharynx or ear, it's really temporary, a day or two. We talk about keeping the nose humidified if needed for comfort measures, but no, it's really the modified Valsalva nose blow, that's the main post-op instruction. Oh, and then after, older kids, adults, after a week, I do encourage them to do the modified valsalva. Let's get that ear aerated as quickly as possible.

The swelling from the balloon is going to decrease over about four to six weeks after the procedure. You do want to try to get that eustachian tube aerated. We wait a week, and then I start having them do their Otovent balloon or the modified valsavas if they can coordinate that.

[Dr. Ashley Agan]
You tell them it could take you four to six weeks to notice a difference?

[Dr. Dennie Poe]
That's right. Yes. I'll encourage them, wait a little bit of time before you jump on an airplane, for instance, if you've been baro-challenged.

[Dr. Ashley Agan]
Okay. Then for kids, they've got a lot of life to live, right? Is this expected? Should we be able to do a dilation when they are eight years old and expect that this should last for the rest of their life as long as if we're assuming that other factors are controlled for? If they stay on top of their allergies or reflux or whatever else is going on?

[Dr. Dennie Poe]
Absolutely. Think of it as adenoidectomy in the eustachian tube. You don't normally have to repeat an adenoidectomy. Occasionally it happens. Most common indication for repeat adenoidectomy is allergic disease. They didn't keep it under control. You generally are not going to need to do a repeat dilation.

[Dr. Ashley Agan]
Yes. This is just another tool. Just another tool in our toolbox, right?

[Dr. Dennie Poe]
Absolutely. We've just got a technology which turns out to be very effective on treating adenoid-like disease inside the eustachian tube.

[Dr. Ashley Agan]
Awesome. As we round things out, in summary, balloon dilation is an effective additional tool to treat inflammation in the lumen of the eustachian tube and can be used safely in kids as young as eight years old, correct?

[Dr. Dennie Poe]
Correct.

[Dr. Ashley Agan]
What else?

[Dr. Dennie Poe]
It's indicated down to age eight, and so it's all about, like everything else, choosing the right patients, making sure that you've got the correct diagnosis. These patients have issues with negative pressure, so it's middle ear effusion. Picking the right patient, it's a wonderful addition to our being able to treat a very common problem, and it gets to the source of the problem. The rate of needing further treatments in our studies was very significantly reduced compared to just the natural history of repeated tubes. Repeated tubes don't treat the problem.

[Dr. Ashley Agan]
Fantastic. All right. The FDA approval or FDA indication for using this in kids, this is a new development, is that right?

[Dr. Dennie Poe]
That's right.

[Dr. Ashley Agan]
Because it used to be off-label.

[Dr. Dennie Poe]
That's right. It's just recently been approved.

[Dr. Ashley Agan]
Usually that means that once FDA approval is going to lead to hopefully insurers covering it and this being a tool that we can offer to our pediatric patients now.

[Dr. Dennie Poe]
That's right. We already have CPT codes for this, for unilateral and bilateral balloon dilation. What's new is the pediatric indication, and yes, it's going to take some time for the payers to accept that. They'll have to change their payer approval processes, and that's usually on a one-year cycle. There will be a delay, and I'm sorry to everybody, but there always is a delay with some new indication. Be patient. It will happen.

[Dr. Ashley Agan]
Yes. It's exciting for patients, too, to have another option that really gets at the source of where the inflammation is happening. It's exciting.

[Dr. Dennie Poe]
Yes. To be able to treat the source. Again, I look forward to the day when we don't usually have to do tubes. We may resort to these other techniques that treat the problem right in the beginning.

[Dr. Ashley Agan]
Yes. Won't that be fascinating when we talk about, back in the day, we used to put tubes in. Yes. That's amazing. This has been a pleasure. Thank you so much for coming on. It's always just such a joy to speak to you and get to pick your brain about all of this. I really appreciate it. Any final words or parting words for our listeners before I let you go?

[Dr. Dennie Poe]
Thank you. It's been a real joy to be able to talk with all of you, and Ashley, it's great to be on your show again. I really appreciate the opportunity. Yes, I think this is the dawn of a really exciting era and better ways of treating otitis media, one of the most common problems that we deal with in our practices and globally. I'm really excited to be at the beginning of a new era here. Pick your right patients and review all those safety features of your device and how to use them properly. Good luck to all of you. Thank you.

[Dr. Ashley Agan]
Awesome. Fantastic. Thank you so much for listening.

Podcast Contributors

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

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.