Podcast Transcript: Diagnosis & Management of Eustachian Tube Disorders

[Ashley Agan MD]
Yeah. Wow. So moving on to physical exam, what are you looking for? Take us through what your physical exam looks like for patients when you're trying to tease out, is this an obstructive pathology? Is this patulous, is this not even related to the eustachian tube? Is it something like TMD or superior canal dehiscence or something else?

[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.

[Ashley Agan MD]
Is it important to have the patient sitting up when you're examining for that? Because I would imagine that potentially if you're using like a microscope and you have them laying down, could that mask the patulous because most, cause gravity is kind of potentially pulling, pumping up the eustachian tube or do you usually see it when patients are laying down under the microscope?

[Dennis Poe MD]
Well, right. So, at first, I asked, are you having your symptoms right now? Are you having the autophony? If they say yes, I’ll keep them sitting in. I'll look with the otoscope first. Now, if I cannot see it, I may lay them down for the microscope and ask, did it go away? Yes, it went away. Okay. So now I know we're dealing either with patulous or possible semicircular canal dehiscence. Now, if the symptoms don't go away, then I continue with the microscope exam.
And if the drum does move visibly, that's pathognomonic for patulous. If the drum does not move and yet they have their symptoms. Now I'm thinking that could be otic capsule dehiscence, semicircular canal dehiscence. The final test is when we go to a tympanometry, which we can get to in a bit, where we do a patulous test. Now there's one other complicating diagnostic problem here. A lot of patulous patients actively sniff strongly to control their symptoms. And we've traditionally called this habitual sniffing. So I no longer think it's habitual sniffing. These are patulous patients controlling their symptoms with strong sniffs to try and get some temporary closure of the, of the station to, they can sniff so strongly that they will generate negative pressures in their middle ear, even to the point of tympanic membrane, retraction, and middle ear fluid.
So back to that original, here's the patient I've got the block, dear. I've got a hearing loss. I've got middle ear fluid. I've had lots of tubes. I look in the ear, looks retracted there’s middle ear fusion. Aha. Obstructive eustachian tube dysfunction, but the patient is sniffing before your very eyes. Why are you sniffing?
Oh, it unblocks my ears. The patient with negative pressure shouldn't be sniffing because that's going to make it worse. So I call that inappropriate instead of habitual, if they're sniffing to control their patulous. So that sniffing habit is a giveaway, aha this is a patulous patient who's sniffing that strongly. And they can even cause a retraction pocket that could progress to cholesteatoma. They're doing it so often. And so severely.

[Ashley Agan MD]
Thinking about patients like that, I've had maybe a handful of patients who have had tympanoplasties for cholesteatoma, and they are still symptomatic from a standpoint of either having autophony or feeling like they have fullness in their ears. So we're thinking maybe patulous, the tricky part with those patients is that a lot of times, if they've had a cartilage tympanoplasty, you're not going to see that eardrum move with their breath which is kind of like one of those physical exam findings that you like to see it, it kind of solidifies the diagnosis.
So in a patient like that, would you just kind of go on symptoms and the nasal endoscopy? I know that's a very specific situation, but I'm just curious if you've seen that at all.

[Dennis Poe MD]
Well sure. Typically we haven't done a cartilage tympanoplasty over the entire tympanic membrane. Sometimes we do, but the majority don't and you may be able to tease it out with a tympanic gram. On a reflex decay mode, the patient does the ipsilateral nasal breathing, and it's more sensitive than what you can see with a microscope. By the way, sometimes, I don't do it often, but sometimes I'll even have the patients sitting looking with a microscope in some of these difficult to diagnose patients. But the most common thing we do is that patulous test. So the tympanometer on the reflex decay mode. So you're not varying the pressure. You're just passively recording it. And if they are patulous, you can see these changes in the tympanogram tracing, coincident with their breathing. That's pathognomonic, and it's more sensitive than what you can see even with the microscope.
Now, if that doesn't work, they've got a full cartilage tympanoplasty. Do the symptoms get better when they put their head down? So if they do and you do the endoscopy and you see what it looks like, it could be a patulous defect. That may be the real thing.
[Ashley Agan MD]
Yeah. Do you ever have patients, while looking at their eardrum, do you have them, maybe try to hold their nose and do a modified Valsalva to see how well they can lateralize the tympanic membrane or where does pneumatic otoscopy come into play? Any of those types of exam maneuvers, are they helpful?

[Dennis Poe MD]
Very helpful.
We do a lot of pneumatic otoscopy under the microscope, And it's extremely helpful in determining is it negative pressure? Gives you a qualitative idea how much. If the tympanic membrane is retracted partially atelectasis, is it adherent or does it lateralize off?
That gives us an idea of, are we thinking we're going to have to do a cartilage tympanoplasty or do they need a tympanostomy tube or some other intervention? Will it reverse the retraction pocket if you can lateralize it off? So absolutely. I really do a lot of pneumatic otoscopy.

[Ashley Agan MD]
And then as far as having the patients, Valsalva or modified Valsalva, I find that some patients know exactly what I'm talking about and some patients have no clue. They're like, what do you, what do you mean? Like clear my ears, pop my ears, hold my nose? They're very confused by it.
But the ones that are able to do it, really easily, I feel like it gives me a sense of like, okay, when I'm trying to kind of figure out how obstructed they are, if they can lateralize the eardrum and push air across the eustachian tube pretty well, I'm judging the extent of how severe their delatorre dysfunction might be.
Because some of them might say, oh, I can do it, but it's painful. So maybe you think they have some mild dilatory dysfunction. But I think it gives me information. But then in the ones who can't do it, I'm not sure if they can't do it because it's blocked or if they can't do it because I'm not explaining that well how to do it. Does that make sense?

[Dennis Poe MD]
Well, you're absolutely right. Yes. When I’m trying to make that judgment. It looks like they've got obstructive dysfunction. How bad is it? I will frequently have them sit up because it's much harder to pop your ear when you're supine. Sit them up, have them try to do it. And I try to coach all of them, even the kids and how to do a modified Valsalva.
So we're, we're not thrilled with a standard Valsalva, which is what most patients will do: hold their nose and blow as hard as they can, blowing their brains out. I've literally had a couple of patients who have developed permanent sensorineural hearing loss injury, or vertigo, or both from doing that excessively, firmly.
So we teach a modified Valsalva, which is what the scuba divers do. That's the nose and mouth closed only gently blowing, just generating a little bit of positive pressure and then a simultaneous swallow. But as you say, that's tricky to blow and swallow at the same time and many of the patients just simply cannot do it.
So we try to teach them to do it. Frequently, if there's somebody else with the patient, I'll have them do it too. And if they get it, I tell them there's your coach. They can try to help you practice this. but if they tell me, Yeah, that worked, I popped my ear. That was easy.
I'm already thinking this is not a severe obstructive dysfunction, and then I'll lay them back down at the microscope and see what change had made.

[Ashley Agan MD]
Yeah, I think that's helpful. Definitely being able to correlate like, okay, does that help? Are your symptoms different now that you did that? Like, I think, sometimes that's helpful for patients to be able to give you that feedback.
So moving to the nose. So we've been looking at the eardrum, kind of watching how that's moving and seeing what's going on in that side of it.
Now, looking at the eustachian tube in the back of the nose, how does that proceed for you? What things are you looking for on that exam?

[Dennis Poe MD]
So I typically use a fiber optic, just the standard fiber optic for my exam?
I look at the nose, sinuses, larynx. I'm looking for all the different causes for inflammatory disease, which is by far the most common reason to have eustachian tube dysfunction of any sort, it's inflammatory disease in the cartilaginous portion most of the time.
So I'm looking for other evidence. Allergic disease, rhinosinusitis, reflux, et cetera. And then that's where I'll then turn the scope and look at the eustachian tubes. And I liked the fiber optic because I can do all of this with one endoscopic exam. Plus I can angle the scope by turning it 90 degrees sideways and flexing it back and forth across the back of the nasal pharynx.
I can align the scope with the lumen of the eustachian tube and get a longitudinal view, the same way you would look down the larynx and try to see into the subglottis. So that's really important. Most people have been trained to see the torus tubarius. And we've always thought that that's indicating what's going on inside eustachian tube.
There's actually been papers showing that does not correlate with eustachian tube function. There's a lot of lymphoid tissue in the torus that doesn't necessarily penetrate down into the lumen. So we have to train ourselves to actually look into the lumen. And I talk about looking at the two walls, the membranous wall, that's the anterolateral side, where the tensor muscle is and the cartilaginous wall. That's the extension of the torus tubarius. So you want to see those two walls where they meet. That's the valve that has to open and close and you want to see, is there a pathology in their valve? Is it inflamed? So it's not about the torus, it's what's in the valve. How well does it open and then how well does it close?
And if you see a gap that never closes. That could be a patulous defect. Now we can only see up about two thirds of a cartilaginous eustachian tube with an endoscope. We really cannot see the upper part adequately. And so you cannot make a final diagnosis of patulous just from the endoscopic.
But what you can say is, do you see a defect that could be patulous or not?

[Ashley Agan MD]
And, I feel like this year, when I was listening to you speak at the academy meeting, you had a scale or a mnemonic or a list of things that you're looking for on endoscopy. Can you tell us about that?