BackTable / ENT / Podcast / Episode #40
Diagnosis & Management of Eustachian Tube Disorders
with Dr. Dennis Poe
Dr. Ashley Agan sits down with the eustachian tube expert Dr. Dennis Poe to discuss his approach to management and treatment of eustachian tube dysfunction.
BackTable, LLC (Producer). (2021, December 21). Ep. 40 – Diagnosis & Management of Eustachian Tube Disorders [Audio podcast]. Retrieved from https://www.backtable.com
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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.
In this episode of BackTable ENT, Dr. Agan discusses eustachian tube disorders with Dr. Dennis Poe, professor of otolaryngology at Harvard Medical School.
First, the doctors discuss the difference between the two main types of Eustachian tube disorders: obstructive dysfunctions and Patulous dysfunctions. Obstructive dysfunctions are a result of pathologies that cause inflamed or clogged Eustachian tubes, while Patulous dysfunctions are a result of the Eustachian tube remaining perpetually open.
Obstructive and Patulous dysfunctions can be clinically differentiated. Patulous dysfunctions commonly experience extraordinary loud noises, variable pressure sensation, aural fullness, habitual sniffing, relief upon using the Valsalva maneuver, and autophony. Although autophony is not pathognomonic for Patulous dysfunction, it can give otolaryngologists a clue for a potential Patulous dysfunction diagnosis. Obstructive dysfunction patients commonly experience negative pressure in tympanic membrane, fluid in middle ear, scarring, and fixed retraction pockets.
Otolaryngologists can also insert an endoscope through the nose to perform a physical examination on Eustachian tube disorder patients. Dr. Poe recommends that otolaryngologists obtain a longitudinal view of the Eustachian tube lumen to observe the cartilaginous and membranous walls and the quality of the valve. He recommends using the MEELO assessment (mucus production, erythema, edema, lymphoid hyperplasia, and opening quality) to grade Eustachian tube disorder patients on a scale of 1-4, with 4 being the most severe dysfunction. He cautions against using tympanograms for diagnoses because of their inaccuracy.
Eustachian tube disorders can be treated with medication. Because the most common etiology of obstructive Eustachian tube disorder is allergic rhinitis, Dr. Poe starts with allergy testing to identify possible allergens. He notes that topical nasal steroids and nasal drops are effective, but may be difficult for patients to self-administer. For this reason, patient education is very important. If medications do not work after 6 weeks, Dr. Poe recommends performing a balloon dilation of the Eustachian tube. The length of balloon dilation depends on the MEELO grading scale. If obstructive Eustachian tube dysfunction patients are a grade 3 or 4 with moderate to severe inflammatory disease and a significantly compromised valve, he dilates for the full two minutes. If they are a grade 2 or low grade 3 with a lesser disease, he only dilates for one and a half minutes or even one minute. Because pediatric patients are very sensitive to balloons, he never goes above one and a half minutes in pediatric patients. Finally, he notes that Patulous Eustachian tube dysfunction patients can be surgically treated via a transtympanic tripod-shaped angiocatheter procedure.
Eustachian Tube Disorder Questionnaire:
Xhance Nasal Spray:
[Dennis Poe MD]
Right. So the first thing to notice is the condition of the tympanic membrane, in comparison to their symptoms on that day. So if they've got a retracted tympanic membrane. I'm talking about a non-fixed. You can see that it's retracted, by a negative pressure, not an adherence to type that's indicating negative pressure.
You can insufflate it. That's indicating negative pressure. Is there a middle ear fusion? So these are all obstructive eustachian tube dysfunction. Very clear signs. If there's evidence of negative pressure or middle ear fluid that's obstructive dysfunction. Now other possible hints would be scarring, sclerosis, fixed or traction pockets. That's indicating that they've at least in the past had obstructive dysfunction. It may not be current. So evidence of negative active pressure is the most common obstructive dysfunction finding, and then you'll cross correlate that with testing. Now, if the tympanic membrane is normal looking and their complaint is just a problem when they're baro challenged, I only have trouble when I fly. You can easily have a normal tympanic membrane. So in that case, your physical findings are not with just your otoscope and head neck exam, until you use an endoscope, you won't have any evidence of the problem with that one.
And then if you suspect patulous, they've given you a history that, oh yeah, this autophony, it clicks, it pops, I hear echoing. That's where we look for the ipsilateral nasal breathing movement of the tympanic membrane. So I have them hold their nostril closed on the opposite side, mouth closed, and they're breathing in and out kind of the rate and depth that you would for a lung examination.
If you're listening to the lungs, auscultating. So not super forceful because you can open your eustachian tube if you do it too forceful in a normal person. So we're looking for just some relatively deep breathing, relatively rapid. And can you see the tympanic membrane moving? And if you do that is pathognomonic of patulous. So if they have no history of otitis media baro challenge, no autophony, no findings on the tympanic membrane, that's what I'm thinking about. The other disorders. Number one is going to be temporomandibular disorders. And then you've got all the other stuff. Your related semicircular canal dehiscence, hydrops, sensorineural hearing loss, conductive, even some people will posit migraine which causes everything. Right?
So that's how we sort out. First the history and then looking for those key findings. Is there evidence of negative pressure? That's obstructive, if they've got autophony and the tympanic membrane moves that's patulous. Now, if they're not actively patulous in their office, if they're not actively having symptoms, it gets more complicated.
Sometimes we will literally have them run around the block. Or up And down some stairs work, a workup is sweat, come back and now their patulous, we will literally do that. Or sometimes I'll just have them do 15 deep knee bends and that's enough to get it going and then you can see it.
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