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BackTable / ENT / Podcast / Transcript #4
Podcast Transcript: Managing Eustachian Tube Disorders
with Dr. Joe Walter Kutz
Dr. Ashley Agan and Dr. Gopi Shah talk with Dr. Joe Walter Kutz about the management of Eustachian Tube Disorders, including pearls and pitfalls on treating the "clogged ear". You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Identifying Chronic Eustachian Tube Dysfunction (ETD) Patients
(2) Patulous Eustachian Tube vs Eustachian Tube Dysfunction
(3) Diagnosis and Treatment of Eustachian Tube Dysfunction
(4) Understanding Eustachian Tube Mechanics and Physiology
(5) Surgical management of Eustachian Tube Dysfunction
(6) Tympanostomy Tube Placement Efficacy in Eustachian Tube Dysfunction
(7) Allergy Consultation and Evaluation in Eustachian Tube Dysfunction Patients
(8) Other Causes of Eustachian Tube Dysfunction
(9) Superior Canal Dehiscence vs Eustachian Tube Dysfunction
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[Ashley Agan]
Welcome back to the BackTable ENT Podcast. We are your hosts. I'm [Ashley Agan].
[Gopi Shah]
And I'm Gopi Shah.
[Ashley Agan]
And we have a very special guest with us today. We have Dr. Walter Kutz joining us. We've both known Dr. Kutz for a long time. He's the associate program director for our residency program here at UT Southwestern.
[Gopi Shah]
And the fellowship director for neurotology. Ashley was a resident under him. I was a pediatric ENT fellow and got to work with Dr. Kutz as an attending doing pediatric ears.
[Ashley Agan]
He taught us a lot about ear surgery and otology, and he did his residency down in Baylor in Houston and then did his fellowship at the House Clinic.
[Gopi Shah]
He's super accomplished clinically as well as academically. He's part of the Triological Society, the American Neurotology Society, teaches multiple courses annually at the AAO on CSF fistulas. He's a reviewer of multiple journals, including The Laryngoscope as well as Otology & Neurotology, and he's a dad, a softball coach, as well as a tuba player. He's a musician.
[Ashley Agan]
He does it all, wears all the hats.
[Gopi Shah]
Yeah. So welcome to the show, Walt.
[Walter Kutz]
Hey. That was an awesome introduction, more than I deserve for sure, but I appreciate it, and it's great to be part of the podcast. I've enjoyed listening to the BackTable Podcast, so it's great to be part of it.
[Ashley Agan]
Well, thank you for being here. Today we're going to talk about chronic eustachian tube dysfunction and how to diagnose, manage, treat these patients. They are difficult.
[Walter Kutz]
Yeah. I agree with that. They can be challenging.
(1) Identifying Chronic Eustachian Tube Dysfunction (ETD) Patients
[Ashley Agan]
Yeah. So just to kind of take it to basics, I find that sometimes it's hard to diagnose chronic eustachian tube dysfunction. You have the patient, kids that need ear tubes. You have maybe an adult that comes into your clinic and has some ear fluid that never had problems before. At what point do they become a chronic eustachian tube player?
[Walter Kutz]
Yeah. I mean, you sort of get the sense of it, right? You get the history. If they've seen their pediatricians over and over and they've had ear infections, and you see them and they have a serous effusion, but I guess the ... Technically they need to have the eustachian tub dysfunction greater than three months, so if you want to look at the strict definition. But you kind of get an idea of the patients that are going to have the chronic eustachian dysfunction.
[Ashley Agan]
Yeah, and I think the easy ones are the patients who come in and have a type C tympanogram and you say "Okay. You have ear pain because you have eustachian tube dysfunction, and we have an objective measure of it," but I think it can be kind of tricky, patients who maybe have some intermittent eustachian tube dysfunction, but you see them and they have type A tympanograms, and then you kind of are wondering whether they could be a candidate for tubes or not, and maybe they have a history of saying they have ear infections, but you've never actually seen fluid and it looks normal when you see it. You know, I think those can be kind of tricky too.
[Gopi Shah]
I think there's that patient, and then there's patients that come in where everything is sucked down, their ear drum is on the promontory, the audio looks normal, and they don't have symptoms, and those, to me, are also difficult in how to manage those.
[Ashley Agan]
Are those some of the types of patients that you see? Or what other type of phenotypes do you see, Walt?
[Walter Kutz]
Yeah. I mean, I think the first patient you're describing, the ones that ... They have ear fullness. They have some intermittent pain. It's suggestive of eustachian dysfunction. They come in, but every time they come in, their tympanograms are normal. You don't see fluid. You don't see retraction. At that point, I'm probably thinking about other problems. Most commonly, temporomandibular joint dysfunction, or TMJ dysfunction, is what I'm really thinking about if they have a normal exam. If a patient has cervical spine issues, sometimes that can radiate to the ear and they may have ear fullness and ear pain from that.
Of course, you always want to make sure they don't have any sort of neoplasm, so a good head-neck exam is always important, especially if they have persistent otalgia. But in the patients that say "Well, my ear is full all the time" or "My ears are full all the time" but their tympanograms are normal and their exams are normal, I'd be very hesitant to do any more than talk to them about allergies and allergy treatments. You may think about "Well, should I place a tympanostomy tube or not?" In my experience, seeing patients that have had that done on the outside coming in ... A lot of times they're not very happy with the tube. They sort of feel there's a tube there and their symptoms worsen.
One thing you could try ... I don't know if you've ever tried this, Ashley, or Gopi, but you can offer somebody just do a myringotomy. You can just say "Hey. Let's just make a small incision of the ear drum. Why don't you kind of test drive that for a week or so by the time it heals?" and if their symptoms are better with that, then you can place a tympanostomy tube, and you really haven't placed a tube with really not needing one. So, I think that's a good technique to try on some of these patients.
[Gopi Shah]
Yeah. I agree. I would favor that route as well, as opposed to putting in a tube, just to kind of see how things go, because if they do ... If the discomfort of the fullness truly is due to eustachian tube dysfunction, they should feel relief with a myringotomy, right?
[Walter Kutz]
Yeah. You would think so. Exactly, and then you can just let them try the myringotomy, and that's going to heal just about every time, and-
[Ashley Agan]
Then you'll just see them back at three, four weeks, and then if the symptoms return, offer a tube in clinic? Or how do you gauge the response and then what the next steps are in a patient like that?
[Walter Kutz]
I usually will tell them to call me in a week or two. They'll known probably within a few days even. I use a little phenol on the tympanic membrane and going through all that can give the sensation of fullness for a day or two. But after that, I think they'll kind of know is it helpful or not, and I just tell them "Hey. Give me a call in a week or two, and if that improved your symptoms, you could come back in and we can place a tube." If it didn't really help their symptoms, then we sort of start over with what is causing their fullness.
[Ashley Agan]
Yeah, but it certainly rules out eustachian tube dysfunction, I would think, and you can kind of ... That way you can kind of assure them that you're moving towards figuring out what's going on.
(2) Patulous Eustachian Tube vs Eustachian Tube Dysfunction
[Walter Kutz]
I think one thing that you must think about that's easily missed is do they have patulous eustachian tube, where they're going to get fullness, but you look in their ear ... It's normal. Their tympanogram is normal, but they sure have a history consistent with that, and then you dig a little further and you ask them about things like hearing their own voice or having autophony. Sometimes if they're exercising, they'll hear the wind in their ear. Then on exam if you look under microscopy, often if you have them occlude their nostril and breathe, you'll see the tympanic membrane moving back and forth with their respiration. I know, Ashley, you certainly have carved out a niche with patulous eustachian tube, and I'd be interested in seeing if you have more comments about that.
[Ashley Agan]
Yeah. I mean, now that I'm looking for it, it's everywhere.
[Walter Kutz]
That's right. That's how that works.
[Ashley Agan]
I don't think I ever diagnosed it in residency, and then now I've seen so many patients with it, and sometimes ... Speaking of patients who get a tube and then still have symptoms, I've had some patients who come in and that's their presentation is that "I had stuffy ear, and then I got a tube, and now I just feel like I'm still stuffy and I feel like I'm talking in a barrel, and it's terrible," and usually it's because they have patulous eustachian tube.
Then the other thing about being able to see the ear drum move when they're breathing ... They need to be sitting up. So if you lay them down to look with a microscope like you normally would when you're doing otoscopy in the clinic, you probably won't see it, because usually their symptoms are better when they're laying down, because you get that kind of edema of eustachian tube when they're supine. But as far as taking care of those patients, I've been doing just transnasal endoscopic eustachian tube plugging with a shim, which is just an angiocatheter filled with bone wax, and those are probably my happiest patients. I've had really good results so far. So it's pretty incredible.
[Walter Kutz]
Those patients with patulous eustachian tube ... Often times it takes a long time or see multiple doctors to be diagnosed, and they're very frustrated, and I could see, if you're able to improve that, they could be very appreciative. Very annoying symptoms.
[Ashley Agan]
Yeah. Absolutely.
[Gopi Shah]
In terms of patulous, in terms of diagnosis, for the difference between eustachian tube dysfunction and patulous, what are the two or three things in the history that you find that are different, and then do you end up scoping them, and what do you find on your scope findings?
[Walter Kutz]
Yeah. I'm going to let Ashley ... I think Ashley really has expertise in this, so I'm going to ... I mean, I'm curious to learn a little bit, so what do you do, Ashley?
(3) Diagnosis and Treatment of Eustachian Tube Dysfunction
[Ashley Agan]
Well, they definitely can come in and look the same at the beginning with that clogged, stuffy ear feeling. So they both can have that. For patulous patients, the autophony to either their breath or to their voice and having symptoms better when they're laying down is pretty unique to patulous. The eustachian tube dysfunction patients, in my experience, aren't going to have those. So if you can ask the right questions and kind of pull that out, it's helpful. But similar to our dizzy patients, I think, sometimes our patulous patients don't always know how to describe what they're feeling or experiencing. Sometimes I've had patients lately ... I've had a couple that say their ear feels heavy, so they may not even ... If you say, "Is your ear clogged or stuffy?" they're like "No. Just it feels heavy." So sometimes they don't know how to describe what they're feeling.
On exam, if I can see the ear drum moving when they sniff, that's awesome. I'm like "Oh, yep. There it is. This is what you have," but I don't always see that. Then our audiologists have actually started doing some testing when they're doing tympanometry where they can measure whether the ear drum is patulous, and they also have a test that they do that measures eustachian tube dysfunction where they're having the patient basically try to Valsalva and clear their ears while they're doing the tympanometry, and so that's been helpful to try to get some sort of objective information. It doesn't always show up on that either, but if we're going to the operating room, I really like to be able to see the ear drum move, but if I can't ... I mean, if we've ruled out everything else and their history is consistent with patulous, then I've had good success with that.
[Gopi Shah]
Then on your nasal endoscopies, do you do that pretty much for all these patients?
[Ashley Agan]
Yeah. I usually scope all patulous and eustachian tube dysfunction just to kind of see what's going on back there, and the more I look for patulous patients, the more I can start to see it. You really need to be looking up into the eustachian tube, so you either need to use a flexible scope and look around the back of the septum so you have the right angle ... So if I'm looking at the right eustachian tube, I'll go in through the left side and turn and look around so I'm kind of got the angle ... or use a 30-degree scope to be able to look up.
[Gopi Shah]
Okay. So you'll do opposite side with your flex and snake it up, and then with a rigid, you're doing a 30-degree?
[Ashley Agan]
Yeah.
[Gopi Shah]
Okay, and when you're looking up into the orifice, is it a couple millimeters in, and are you seeing that there's space, and so you're like "Oh. That's patulous"? Or is it-
[Ashley Agan]
Yeah. I don't know if I have a perfect way. It's very much like a feeling. You kind of look at it and you're like "That looks kind of patulous." I mean, some patients, you will see a gap, and when they sniff, you might see it kind of come together. Sniffers. That's a common patulous symptom too, patients who are sniffing a lot, because when they sniff, it kind of pulls the eustachian tube closed and they'll get relief of symptoms. But Dr. Kutz, an interesting patulous patient would be the patulous patient that also has retraction or cholesteatoma. That can happen too, right?
[Walter Kutz]
Yeah. I mean, you were mentioning these chronic sniffers. I think they like having the kind of negative pressure. It kind of relieves some of that autophony, and so yeah. If someone is constantly sniffing and that tympanic membrane get pulled in enough to create a cholesteatoma ... We often times think cholesteatoma occurs only from eustachian tube dysfunction where you have this chronic negative pressure, but I've seen it in patients that are chronic sniffers as well, and the challenging thing about that is getting them to stop that habit. It is a very hard habit to break.
[Ashley Agan]
It's almost like your throat-clearing patients or your chronic-cough patients. It just becomes something that they're just kind of doing without-
[Gopi Shah]
So if you have a cholesteatoma and a patulous patient who's a chronic sniffer, in terms of ... Let's say you have to do a tympanoplasty and you have to repair the drum. Are you always pretty much using cartilage at that time? I guess my question is, what's the success rate for repairing the drum with a chronic sniffer?
[Walter Kutz]
I mean, I think it's probably similar. I think I worry more about, if they don't break that habit, that they may create another cholesteatoma. So I would certainly use cartilage in those patients. I've never thought about, if they're still sniffing, trying a shim or something like that. I mean, I guess that's something you could try. If they're starting to retract, you could put a tympanostomy tube in. Hopefully they'll tolerate that being with the patulous eustachian tube. In some patients actually it helps them somewhat, but yeah. I think you just have to use a lot of cartilage and then try to convince them to stop that habit. I've had a few patients that have actually stopped the habit, made it pretty seldom, where it's not causing problems.
[Ashley Agan]
You would think that, if you're using cartilage for your tympanoplasty, that that would help with the patulous symptoms too, right? Because the ear drum is kind of heavier and less likely to move when they're sniffing maybe.
[Walter Kutz]
Yeah. That's a great point. That's actually one of the treatments for patulous eustachian tube if they have a ... You can actually do a cartilage tympanoplasty. Sometimes you can place a paper patch with some bacitracin ointment, make the tympanic membrane heavy, and sometimes that'll improve the symptoms. Then you can consider doing a cartilage graft tympanoplasty as part of the treatment for patulous eustachian, even without a cholesteatoma. I've really not done that often, but-
[Ashley Agan]
Yeah. I've done that in clinic to kind of try to just figure out if it is patulous before. If it kind of sounds like patulous but everything I can check is negative, I've tried to just weight the ear drum to see if that helps with their symptoms, and I think that can be helpful for sure.
[Walter Kutz]
Hey, Ashley. Do you have good success using topicals? People will use topical estrogen nasal drops, or there's this PatulEND. Do you try those with the patients that have patulous eustachian tube, and what is your success?
[Ashley Agan]
I do usually have them try PatulEND. I have not had a lot of success personally, but there are some patients who I haven't seen back. So it may be that there are some that use it and then don't come back to see me, because maybe they're doing better. Or I'll have some patients who say they use it and maybe it helps a little bit, but usually the ones that I'm seeing again are ... It's because it's not working, and it does burn. So it's uncomfortable to use, because the whole point is that it's try to create some inflammation and puff up those tissues, the eustachian tube.
(4) Understanding Eustachian Tube Mechanics and Physiology
[Gopi Shah]
So Ashley, going back ... Because I do peds, I don't really see much patulous eustachian tube. Can you explain the drops, the pathophysiology, what it's supposed to do?
[Ashley Agan]
Yeah. PatulEND is a drop that was developed by a physician in Santa Barbara, California, and you put it in your nose, and you kind of hold your head such that your eustachian tube is kind of the most dependent part of your head and put the drops in your nose so that the drops are kind of going down and sitting right at the orifice of the eustachian tube, and it's a compounded medication like a supplement, so it's not a prescription. It's just a proprietary formula that is meant to create some inflammation in the mucosa and make it kind of... puffy so that it'll close. Yeah.
[Gopi Shah]
Got it.
[Ashley Agan]
Then I'm not actually sure how the physiology would work for the estrogen drops. I've heard of people using estrogen drops. I haven't prescribed them before myself. Do you know, Dr. Kutz?
[Walter Kutz]
I mean, I've tried them. I think it's the same sort of thing. It just irritates the eustachian tube and causes some swelling. I've had poor success. I think part of it is that you have to place the drops the correct way. You have to have your head sort of turned to the side so that the drops actually stay on the eustachian tube orifice. If not, they'll just go right down the nasal pharynx. So I think it's important that, if you're going to try those drops, which I haven't had a lot of success with, I think it's important that the patient administers in the correct way or it's definitely not going to work.
[Ashley Agan]
Right, and I've heard and read that a tube can be helpful for the clogged and stuffy feeling, but not so much the autophony. But I personally haven't had a lot of success with it. What about you?
[Walter Kutz]
I'm the same way. I mean, I haven't a lot of success with a tube. Again, you can try a myringotomy, see if they like that. Just you don't really have to commit to the tube, but I haven't had much success with placing tubes for patulous eustachian tube dysfunction.
[Ashley Agan]
Yeah. But placing a shim, I would say, works great.
[Walter Kutz]
That's awesome.
[Gopi Shah]
How long does the bone wax stay there for? When you're counseling the patient and you're discussing the shim surgery, what do you tell them? Like "Hey. This is good for a year" or six months, five years? Or do we know yet?
[Ashley Agan]
The longest study that looked at outcomes looked at patient outcomes at 12 months, and about half of patients had had recurrence of symptoms, and that's with the shim, which is kind of the best one. So with the other techniques, there was recurrence of symptoms earlier. So it's meant to be there for a long time. It can fall out. One complication that's really common is that you kind of over-plug it, and then they get fluid, and you end up putting in a tube. I've had that happen.
[Gopi Shah]
Yeah.
[Ashley Agan]
Yeah. It's a very fine line, because you're trying to plug it just enough so they don't have symptoms but that they still have some way to kind of move air around it. But most of them are willing to try anything because they're just so frustrated and annoyed by hearing their voice echo all the time, voice and breath.
[Gopi Shah]
So when you place the shim, you're using a rigid scope?
[Ashley Agan]
Mm-hmm (affirmative).
[Gopi Shah]
A 30-degree or a zero?
[Ashley Agan]
30.
[Ashley Agan]
Yeah. So you can see.
[Gopi Shah]
Are you using just a cold knife to make an incision in the-
[Ashley Agan]
Oh, no. There's no incision.
[Gopi Shah]
Oh. You just inject it?
[Ashley Agan]
Yeah. You just kind of insert it into the lumen of the eustachian tube, and then it wedges at the bony eustachian tube.
[Gopi Shah]
It's a special catheter?
[Ashley Agan]
It's an angiocatheter. Yeah.
[Gopi Shah]
Okay. Is there a certain length to it?
[Ashley Agan]
I do 40 millimeters.
[Gopi Shah]
Wow. That's cool. Okay.
[Ashley Agan]
Yeah. I'll show you.
[Ashley Agan]
No. But yeah. I mean, I think patulous isn't super common. But for the patients who are experiencing it, it's a big quality-of-life issue. So it's nice to be able to have some tools to help them. Flipping it back towards the opposite problem, when patients have eustachian tube dysfunction and their eustachian tubes just don't work, these can be really tricky patients too, and particularly I think about the ones who keep extruding their tubes or who have had T-tubes and then they get a perf or they just have chronic drainage. Dr. Kutz, talk to us about those patients, because those can be really tough.
[Gopi Shah]
Those are hard. We see them in adults, adolescence, craniofacial kids, which is different, but I'm just talking about ... I agree that otherwise healthy, adolescent, adult patient ... Those are tough. What are some pearls? How do you manage it?
(5) Surgical management of Eustachian Tube Dysfunction
[Walter Kutz]
Yeah. I don't know if I have any perfect pearls for that. I agree they're very challenging for sure. I don't like going to T-tubes too soon, I guess. I'll try grommet tubes for at least a few tries, and then if they're going to definitely need tubes, we'll put in a T-tube. I just think there's a high risk of a perforation. Honestly, if these patients have a perforation, it may be the best for them, right? It's kind of a permanent tube, I guess. There's really no such thing, but a perforation can kind of act like that. But the problem with a T-tube ... You get a pretty big perforation with those that can cause hearing loss.
[Ashley Agan]
I was going to say, yeah, they tend to be big. Yeah.
[Walter Kutz]
Yeah. They really do, and so I think you're just doing the best you can to manage the patients. You bring them in, keep putting tubes in them. I've had some patients I've placed so many tubes their tympanic membrane gets very atrophic, and you're worried, "Are they going to even be able to have a tube retained?" because of the thinness of the tympanic membrane.
On a few occasions, I've actually done a cartilage graft tympanoplasty where I've just placed a T-tube through cartilage, just lifted the drum, cut out a little bit of drum, and do that, and I've had good success with that. Again, that's somebody that's had multiple, multiple sets of tubes where there's really not much of a tympanic membrane to even retain a tube anymore, and that's kind of my approach to tubes.
I've really not done subannular tubes. People describe, you can make a small little passage in the ear canal under the annulus of the tympanic membrane, and you can place a T-tube through there, and that would probably last longer, but you still have the risk of the lumen of the tube becoming blocked, right? A T-tube's kind of long, kind of a small diameter, so they can get blocked. So those aren't perfect either. So I just manage them the best you can.
[Ashley Agan]
For the cartilage with the T-tube through them, how long do those tubes stay in for usually?
[Walter Kutz]
Well, the ones that I put in ... I've been in practice 13 years. I think they've all, that I can recall, stayed in. Again, I think the biggest risk is the tubes going to become blocked, and then you can just take the tube out and replace it, because now at least you're not going to get a larger perforation, right? Because you've made a small, controlled hole in the cartilage. So if you had to take the tube out and place another tube, I don't think it would be a very big deal. But so far I haven't had a problem with that. As far as I can tell, as long as the patient came back, I've had good success with those staying in place.
[Gopi Shah]
Speaking about atrophic drum, I've had kids that I've taken to the OR planning for regular tube or a T-tube, whatnot, and it just ... With the nitrous and just mask ventilation, that ear drum just turns into a balloon that's lost all elasticity and to the point where it's hard to make an incision or figure out where your incision was and things. That ear drum is kind of flopping in the breeze. Have you found yourself ever in situations like that, and do you decide to still try to get a tube in, or just call it? I find that that happens every once in a while, and I just feel like I'm not sure what the best thing to do is next.
[Walter Kutz]
Yeah. I've had that happen a few times. It seemed like I would go and place a tube ... I sort of look at it. Let's try the tube, and I don't recall the success of that, but if the tube takes and their drum becomes more normal with the tube, that's great. If they ended up a small perforation, then you can probably do a cartilage graft tympanoplasty, which it sounds like they may need anyway if the drum is that floppy. So I'd probably go and place a tube if I thought I could do it safely, I could see landmarks and those sort of things. I don't know. Ashley, have you had that situation?
[Ashley Agan]
Yeah. Yeah. I've seen that. It's frustrating.
[Gopi Shah]
Yeah.
[Walter Kutz]
It's just a tube, man. It's straightforward.
[Ashley Agan]
Right, and the anesthesiologist is looking at me like "You know I'm still masking, right?" I'm like "I know, but here we are 20 minutes later" sometimes.
[Gopi Shah]
Sometimes tubes can be very humbling, but I've heard of people do it using a laser to try to tighten the drum for things like this. Have you ever done that, Dr. Kutz?
[Walter Kutz]
Some people have done that. I believe a CO2 or carbon dioxide laser is a little bit better for that. I don't use carbon dioxide laser. I use a 532-nanometer diode laser. I haven't done that. I know Brandon Isaacson has tried that on a couple patients, and I don't think he had all that great of success, but it's been described in the literature. But I haven't had much success with that. I think, if it's that atrophic, you're probably going to create a hole in the drum anyway, and-
[Gopi Shah]
Yeah. Sometimes it's really flimsy.
[Ashley Agan]
Then do you all see how some of these patients ... I've had a handful where the tube medializes, and I feel like it's in some of these chronic ear eustachian tube patients, where literally they've had a tube and it's medialized into the middle ear. Do you feel like eustachian tube dysfunction or the severity of it is related to tubes occasionally getting medialized into the middle ear? Or is that just a bad outcome, just bad luck? It just happened?
[Walter Kutz]
I think it just happens. I've only seen that a handful of times, so I'm not really sure if it's a higher instance in somebody with eustachian dysfunction that's more severe than others. I typically will just leave the tube ... If it's not causing problems, I'll leave the tube in place. We leave titanium, Silastic, all kinds of materials in the middle ear space for a lifetime, and tubes are pretty inert, and so if they're not causing problems, I would just leave the tube in.
If they need another tube, you can make a small incision, retrieve the tube, and place a new tube. I did have one patient that had some kind of vague otalgia, some irritation, and she was really convinced it was from the tube. I just did a tympanotomy and just slid through the tympanic membrane and removed the tube, and she was better. I don't know if ... for whatever reason. Generally speaking, I'll just leave the tube in place unless it's causing some problems.
[Gopi Shah]
Yeah. I agree, because sometimes you could go in, try to get it out, and now you have a perf ... Yeah. I totally agree.
(6) Tympanostomy Tube Placement Efficacy in Eustachian Tube Dysfunction
[Ashley Agan]
So putting in tubes, it should theoretically relieve the eustachian tube dysfunction, right? Because you've kind of bypassed the need to have a eustachian tube. But if you have these patients who are still having issues where either their tubes are falling out or always clogged or they're having a lot of draining, at what point do you start to consider actually doing procedures directed at the eustachian tube or nasopharynx, things like that?
[Walter Kutz]
So like the balloon eustachian dilation procedure?
[Ashley Agan]
Yeah. Either adenoidectomy or balloon, or some people will do eustachian tuboplasty and get the microdebrider ... Sometimes you'll get some lymphoid hypertrophy of the …
[Gopi Shah]
The torus.
[Ashley Agan]
Of the torus. Yeah. I mean, how does that come into play in your practice? Or does it?
[Walter Kutz]
For adenoidectomy, I think, if it's their second set of tubes, I would do adenoidectomy. I think I should think about an adenoidectomy more frequently for these patients with chronic eustachian dysfunction that are older than your three-, four-, five-, six-year-old. I don't always think about that, but it's not a bad idea if they have adenoid hypertrophy and they're getting recurrent retraction. It's a pretty low risk to remove adenoids, and that could potentially help. If you're talking about lymphoid hyperplasia around the orifice of the eustachian ... I've never removed that before. I have no experience doing that. I'd probably try to treat them medically with nasal steroid sprays. Ashley, have you ever done that or had success with that?
[Ashley Agan]
I think that the balloon is probably the most helpful, but I've had patients where they have big adenoids and they also have ... It looks like their adenoids are just kind of continuing on to the mucosa of the eustachian tube, and I'll use the microdebrider to kind of trim that. It doesn't come up that often, but I have done that before.
[Gopi Shah]
I wonder if that helps it scar laterally or, I guess, medially. Do you think it helps the torus kind of scar medially to help it open up?
[Ashley Agan]
Maybe. I don't know. The more I look at eustachian tubes, the more I feel like most of the problem is intraluminal, and so I think that's why the balloon works so well is because ... When they did studies looking at the mucosa after balloon, there was actually change-
[Gopi Shah]
Shearing of the cartilage.
[Ashley Agan]
Yeah. There was a change in the inflammation within the mucosa, and so it's something about that squishing and crushing is actually changing how that tissue is acting, and so sometimes patients will have terrible eustachian tube dysfunction, and I look back in their nose, and there's not a ton of adenoid tissue. There's not an actual, physical obstruction blocking the tube. It's just within the lumen of the tube, it's just swollen and not working. I don't know.
[Walter Kutz]
Yeah. I think the balloon is intriguing, and the struggle now is getting insurance to approve it, and I've had ... I can recall one patient that had an acoustic neuroma and removed the acoustic neuroma, and it was a large tumor. They didn't have hearing. They lost the rest of their hearing with the surgery, and then on the other ear, they were getting recurrent serous otitis media. Of course, when they have that, their hearing will drop terribly, and they couldn't communicate, and I placed three tympanostomy tubes. At some point you're like "Do I want to keep placing a tube in an only hearing ear with the risk of a perforation and that very small risk of a secondary acquired cholesteatoma or some other issue?"
So they actually had paid cash for the balloon procedure, which, if you look at the literature, all-comers, it's maybe 60 percent successful. Somewhere around there is what I usually tell patients. But we did the balloon, and two years later, the patients had no further problems with serous otitis media. I think, in my opinion, the balloon is most effective for patients kind of mild to moderate eustachian dysfunction, like your flight attendant or your diver or somebody like this patient that is having recurrent serous otitis media in an only hearing ear. It seems like the balloon could be very useful for those patients.
I think the patients that have these just terrible eustachian tubes that get retraction pockets within six to nine months after surgery for cholesteatoma ... I don't know how well they'll do with the balloon. But the real frustrating thing is it's really hard to get reimbursed for it.
[Ashley Agan]
Right. Yeah. I've experienced that a lot lately too, which is unfortunate, because it's nice to have something to offer to patients. But then when they turn around and it's not covered, then it's frustrating for everyone because I feel like they're looking at you like "Why'd you-"
[Gopi Shah]
"Why are you trying to sell me something?" Yeah. "Why are you trying to sell me something?"
[Ashley Agan]
Yeah. "Why'd you recommend this if it's thousands of dollars?"
[Walter Kutz]
Yeah. It's a challenge, I'm sure.
[Ashley Agan]
It sounds like, in your experience, patients who just have these chronic ears where they have chronic retraction or cholesteatoma ... that you just kind of have to address the ear drum, and the eustachian tube itself may not have a good solution yet to fix that, but you kind of work around it by addressing the ear drum.
[Walter Kutz]
Yeah. I still think, unfortunately, we just have to address the problems that the chronic eustachian dysfunction causes. Maybe if we get more literature on the balloon we can figure out which patients would benefit or not from that. Not infrequently, if somebody has recurrent retraction, I've done two or three surgeries where they've retracted, I'll place a T-tube through cartilage just during a tympanoplasty, and again, I've had very good success with that. I can't tell you perfectly when I do that or when I don't do that. It's sort of a gestalt and knowing the patient, and usually it's on a recurrent retraction pocket thing like that. But that's always an option, and again, like Ashley was saying, you sort of bypass eustachian tube at that point.
(7) Allergy Consultation and Evaluation in Eustachian Tube Dysfunction Patients
[Gopi Shah]
One last question for you guys. How often do y'all think about allergy or do an allergy evaluation for these patients? I feel like in some of my ... more so my adolescents, as young as 10, once we're on a fourth, fifth set of ear tubes or just if their ear drum ... Every time I see them, it's medialized and retracted, and maybe they may or may not have a little bit of an ear bone gap. But how often do y'all maybe send them or do an allergy evaluation on these patients or think that's a contributory factor?
[Ashley Agan]
You read my mind. I was about to bring up allergies too. But for me, I send people for allergy testing in consideration of allergy immunotherapy when they're failing kind of the maximum medical therapy. So I like nasal steroids as a starting place, so like Flonase or Nasonex or something like that, and then sometimes I'll add on Azelastine nasal spray, which is a nasal antihistamine spray. I may have them use decongestants occasionally, like Sudafed behind the counter, depending on what kind of medical comorbidities they have. But once they're not getting any benefit out of those, I think it can be helpful to do allergy testing and consider allergy immunotherapy. What about you, Dr. Kutz?
[Walter Kutz]
Yeah. That's a similar approach I have. If they tried allergy therapy, you're going to probably do that before allergy testing, right? Allergy testing is going to be if you're going to consider immunotherapy as part of their treatment. I mean ... Some patients, you sort of think allergy, but they don't have the nasal congestion and the itchy eyes and the sneezing and things. Ashley, do you still think allergy sometimes? Or how do you differentiate? Do they just have eustachian dysfunction? Is that their only allergy symptom? Or do you more look for those other symptoms of allergies if they have nasal congestion and things?
[Ashley Agan]
Yeah. If patients don't have the sneezing, runny nose, itchy eyes, nasal congestion kind of symptoms, then I feel less confident that they're going to benefit from starting Flonase, but I will still talk to them about giving it a try, especially if they've had tubes and their tubes are falling out, or if they've had a tube and they're still having symptoms, or stuff like that. Do you ever have patients do the Otovent or the EarPopper or have them Valsalva and clear their ears several times a day?
[Gopi Shah]
Chew gum. Yawn.
[Walter Kutz]
Yeah. You know, that's actually a good point. Sometimes you'll see patients that have a chronic type-C tympanogram, they do have some fullness, or maybe they have a type-A but you're sort of convinced they have some mild eustachian dysfunction. I'll have them autoinsufflate in the clinic, do a Valsalva, and if I can see that drum moving and they're able to clear their ears, I'll tell them "Hey. Do that six, eight, 10 times a day," and then often times if they're doing that, you don't need to place a tympanostomy tube.
I mean, I have used some of the EarPopper, Otovents for some patients. I always feel that they're probably either going to be able to autoinsufflate on their own, or it's going to be so severe, even with the EarPopper, Otovent, that they're not going to be able to insufflate their ears. So I think it's reasonable to try that. I've had a few patients have success. They like using it. It makes their ears feel better. So I think it's worth a try, and I think these ... Now you can get these things for ... I think the Otovent's $15, $20, and the kind of EarPopper sort of devices are around $60 now. So I mean, patients can try these, and they're not $200 or $300 or anything of that sort.
[Gopi Shah]
Have y'all ever used these in your teenage patients or 10-year-old patients?
[Walter Kutz]
I was going to ask you, Gopi. Have you had experience? I haven't tried that.
[Gopi Shah]
I think I've recommended it before to that sort of eight-year-old and up where, again, they've had anywhere between two to five sets of tubes and the parents are just done with it. I think I've recommended it. A lot of times, because of cost, families may not get it. Once I'll show them a video, like a YouTube video, so they know what it is, that may or may not kind of intrigue them. So I haven't had too much experience with it. So I tend to just try the "Okay. Well, try to yawn, and pinch your nose and swallow, and chew sugar-free gum," but they end up coming back, most of them, and we end up having to do other things or just follow them and see how they do.
A lot of those families ... Even if the patient doesn't have allergy symptoms, some of them will take me up on "All right. Let's do an allergy eval, because maybe there's something mild," because it's usually spring to summer when there's an effusion, and it might clear up in the fall. So I still feel like it's kind of nebulous, and you end up kind of just trying to work with the parents and the child, and a lot of it is going to be other things, like school and how they're doing with hearing in class, and their grades, and at home, and quality of life as well. So it's definitely …
[Ashley Agan]
I think the Otovent's a good thing to try. We have it in our clinic, and we can just sell it to the patients kind of on the spot, and our nurse will ... Usually with the pediatric patients, our nurse will them how to do it, and since it has the balloon, it's kind of more ... They kind of make it like a game, and so I definitely think it's worth a try, and you're not losing much. But what do you say to patients, Dr. Kutz, who ... I've had patients ask me how hard they can try to clear their ears safely. Does that make sense?
[Walter Kutz]
No. It does make sense. I mean, I guess you worry about creating barotrauma or a perilymphatic fistula. You know, it'd be pretty difficult, I think, trying to clear their ears. If it's difficult to clear their ears, they're probably going to have a hard time causing harm by trying too hard. I can't recall a patient coming in that's harmed themselves trying to clear their ears, but I would probably tell them "Listen. I mean, just ... " Because there are some personalities out there that are going to ... "I'm going to win no matter what," right? "I'm going to pop this ear," and then ... I mean, I guess they could technically cause problems doing that, the really competitive patients, right?
[Ashley Agan]
Right.
[Walter Kutz]
But yeah. I mean, I agree. A lot of times I'll watch them in the clinic, and so I can say "Hey. Okay. That's good, and if you can't pop it trying that hard, you're not going to be able to clear your ears." But every now and then you'll have a patient that ... You get diving injuries. That's usually where they're not clearing their ears, but they just have so much negative pressure. I recall a patient that was doing really vigorous setups one time, and they caused a perilymph fistula. Again, not clearing their ears. A little different mechanism, but yeah. I cannot recall seeing a patient that's caused damage doing a Valsalva or insufflating their ears, but I guess it's possible. I don't know. Ash, have you ever seen that? Or do you recall that?
[Ashley Agan]
No. I'm kind of like you. If they're doing it in clinic and it looks like they're trying really hard and nothing is happening, then I'll just say "Okay. This looks like you're not going to be able to-"
[Walter Kutz]
"You win. You win. It's good."
[Ashley Agan]
Yeah. But some people talk about the middle ear as another sinus, right? Talk to us about topical steroid therapy for the middle ear in the same way that we use Flonase as a topical treatment for the nose and sinuses. There are some patients that I think benefit from having topical steroid therapy to the middle ear on a regular basis, usually patients who have a tube but just are kind of always having drainage or kind of always have that middle ear inflammation. Do you see that?
[Walter Kutz]
I do see that. Often times I'll treat them with a combination fluoroquinolone steroid, like Ciprodex, and I don't know if it's the cipro or the dexamethasone that's helping. I have patients that have eosinophilic otitis media. It's a very difficult condition to treat, and I'll place those patients on chronic steroid drops. I'll mention off-label use here sometimes because of cost. You can use ophthalmic dexamethasone. It's pretty inexpensive, because these patients are going to need these drops for maybe ever. So yeah. That's kind of what I think. These patients get a lot of polyp changes and granulation tissue. These chronic tube otorrhea patients are very challenging. Gopi, you may have more experience than I do with these patients. It seems like we see that more in the pediatric population. I'm curious. How do you treat those patients?
(8) Other Causes of Eustachian Tube Dysfunction
[Gopi Shah]
You know, it's oral. As much as I can, oral toilet. So I have two groups. I think of it as two groups. One is the otherwise healthy kid that has some tube otorrhea that you can do the oral toilet suction in clinic, try some mastoid powder, try a little Ciprodex, have them come back, maybe suction them out again, make sure it's not a fungal otitis externa, and depending on how they're doing, you might have tricks such as a little peroxide diluted with distilled water to kind of just ... You know what I mean? Thin out the junk, and then Ciprodex if you need it, versus "Hey. This is not bacterial," Valsalva, or white vinegar, distilled water type stuff, dry ear, hair dryer kind of thing.
Then I think, in my other patients that are my primary ciliary dyskinesia patients that just have that chronic, thick mucoid tube otorrhea ... That's a little bit different, right? There's a different reason for it. For those patients, it's hard because ... Actually, one of my younger patients comes to mind. She's four, and chronic tube otorrhea. Obviously she doesn't want to be papoosed every time she comes to clinic to get her ear suctioned out, and I don't want to do it either, just because otherwise she's not going to let me look in her ears in the future.
So what I have the family doing is ... You know those blue bulb syringes, the baby ones for the noses? Because it funnels out, they can't really put it in too deep, and I always tell them "Don't put it in more than five millimeters or so," but they ... She basically sucks out the child's ear before bed, and she'll also do, a couple times a week, a little diluted peroxide with distilled water. It doesn't burn. I always ask "Does it burn?" Sometimes she'll use Ciprodex, just something to thin out the mucous, and it seems to help. When I see her in clinic, there's always a little drainage around the tube, but you can actually see the tube, her audios are normal, and her speech is good. So that's what I do for her.
Every once in a while I'll just be like "This has been going on for a long time. We just need to take the tube out," and obviously we want to make sure we're not missing anything like a cholesteatoma or something underlying that, god forbid, like an acquired or something, and every once in a while that can happen too. I'm not quick to scan unless I'm really concerned for a cholesteatoma or something. Sometimes I'll have patients come to me for tube otorrhea after they've had a CT scan, which ... So I'm definitely not quick to scan, and then every once in a while, if it's a younger kid, again, four or under, and they have other recurrent history of pneumonias or other bacterial infections, so I think of maybe we need to consider something like cystic fibrosis or an immune workup. So that's kind of how I think of tube otorrhea in those little buckets, I guess.
[Walter Kutz]
Yeah. That's helpful. It's very challenging and frustrating. I think everybody needs some tricks to try, and certain things may work for different patients that may not work for another patient, but those are good, and I've learned something there for sure. I'll steal those ideas from you.
[Ashley Agan]
Dr. Kutz, you mentioned eosinophilic otitis media. How do you diagnose that?
[Walter Kutz]
Well, a lot of times they'll have asthma as well as part of their systemic illness, but they just get this really tenacious granulation tissue. A lot of times you'll place tympanostomy tubes and you'll have granulation tissues growing out of the tubes, and it can be somewhat resistant to even steroid drops. It's very challenging to treat. There's some systemic therapies that work for the asthma aspect of it that you can try that really haven't ... There really haven't been many studies for the otitis media aspect, but it's a challenging condition to treat, and you sort of ... Often time I'll send them to an allergist to kind of work all that up, but you kind of see these patients ... I mean, they have really thick, thick drainage and granulation tissue and just very unusual ... So when you see a couple of these patients, you go "Okay. That's what that is."
[Walter Kutz]
Yeah, and it's bilateral, right? Because it's a systemic problem.
[Ashley Agan]
Wow. Well, we've kind of been all up and down and around eustachian tube today.
[Gopi Shah]
I love it.
[Ashley Agan]
Have we missed anything, Dr. Kutz?
[Gopi Shah]
Yeah. Any pearls?
[Ashley Agan]
Or is there anything that you wanted to impart before we land this plane?
(9) Superior Canal Dehiscence vs Eustachian Tube Dysfunction
[Walter Kutz]
One other thing. These patients that present with ear fullness, probably the most common eustachian dysfunction, and then you need to think patulous eustachian. We talked a lot about that. TMJ dysfunction. But another condition to think about ... Super canal dehiscence, which we can go on for another hour about that. We won't do that.
[Ashley Agan]
Maybe for the next time.
[Walter Kutz]
Yeah. For next time, but those patients ... They can present with just fullness in their ear, and you looked at all these other problems, and typically, just real quickly, if you do a tuning fork exam, they'll typically hear the fork in that ear. A lot of times they'll have kind of a conductive hearing loss with intact reflexes, but think about super canal dehiscence as a much less common cause of chronic ear fullness, but one you don't want to miss. It won't harm the patient, but you're going to do all these sort of treatments for eustachian dysfunction and patulous eustachian tube, and really they just have super canal dehiscence. So I would add that in there as something to think about.
[Gopi Shah]
Yeah. For sure.
[Ashley Agan]
Yeah, and you get a CT temporal bone.
[Walter Kutz]
Yeah. Yeah, and then you're going to see a missing bone over the superior semicircular canal, and you can verify that with VEMP testing and go from there, but I think it's one diagnosis to keep in mind and differential diagnosis for chronic ear fullness.
[Gopi Shah]
Yeah.
[Ashley Agan]
Awesome. Sounds great. Well, thank you so much for your time, Walter. I learned a ton. I enjoyed it.
[Walter Kutz]
Thank you for having me, I enjoyed it. It's a difficult topic for sure, and I learned a lot. I think talking about people how they treat eustachian dysfunction is helpful.
[Gopi Shah]
Hey. Well, next time you're bringing your friend the Tuba. Okay?
[Walter Kutz]
Oh, yeah. We got to ... That's right. We'll bring in the tuba next time, so you got to look for the next episode.
[Ashley Agan]
If people want to look you up and learn more about you, where can they go?
[Walter Kutz]
I'm on Twitter for ... @Eardoc1 is my Twitter. Instagram is @walterkutzmd. Twitter is @EarDoc1, and then if you want to go to my website at UT Southwestern, it's drkutz.com.
[Gopi Shah]
Awesome.
[Ashley Agan]
Awesome. Very good. Thank you so much, Dr. Kutz. It's been fun.
[Walter Kutz]
I really enjoyed it. You guys have a great day.
[Gopi Shah]
All right. You too, Walt. See you later.
[Walter Kutz]
All right-y.
[Ashley Agan]
Bye.
[Gopi Shah]
Bye. So we just want to thank all of our listeners for tuning in today. We're excited for upcoming podcasts with you all. We are open to suggestions, topics, or if you want to come on the show and be a speaker, we'd love to have you.
[Ashley Agan]
Yeah. Please reach out to us. Let us know what you thought about Dr. Kutz and eustachian tube dysfunction, and we'll see you back here real soon. Find us on Twitter. Our handle is @_backtableENT, and we will see you next time. Be well.
[Gopi Shah]
And it's a wrap.
[Ashley Agan]
It's a wrap.
Podcast Contributors
Dr. Joe Walter Kutz
Dr. Joe Walter Kutz is a neurotologist and Professor of Otolaryngology and Neurosurgery at the University of Texas Southwestern Medical Center in Dallas, TX.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2020, August 20). Ep. 4 – Managing Eustachian Tube Disorders [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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