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Podcast Transcript: 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. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Defining Eustachian Tube Disorders and Eustachian Tube Dysfunction

(2) Patient Presentation

(3) Physical Examination

(4) Using the MEELO Assessment for Endoscopy Exams

(5) Standard Testing for Eustachian Tube Disorders

(6) Treatment for Dilatory Dysfunction Patients

(7) Treatment for Patulous Patients

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Diagnosis & Management of Eustachian Tube Disorders with Dr. Dennis Poe on the BackTable ENT Podcast)
Ep 40 Diagnosis & Management of Eustachian Tube Disorders with Dr. Dennis Poe
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[Ashley Agan MD]
Hi, everybody. Welcome to the BackTable ENT podcast. We are a podcast that focuses on all things otolaryngology, and we've got a really great show for you today. Thanks for stopping by.
Quick word from our sponsor Stryker. Stryker's ENT solutions offer the control you need, the flexibility you want, and enable you to deliver the experience your patients deserve. With Stryker, you gain access to the most complete suite of solutions to help make your vision of patient care a reality. From technology to training, from reimbursement tools to patient education, Stryker is there to help. Together with their customers they are driven to make healthcare better. Learn more at ent.stryker.com.
My name is Ashley Agan, and I'm a general ENT in Dallas, Texas at UT Southwestern.
My co-host Gopi Shaw is on call this weekend. So she's joining us in spirit and we are sending her lots of love and positive vibes. Dr. Dennis Poe is our guest today. He 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 as well as new procedures for eustachian tube disorders. In 2011, he completed a PhD at the University of Tampere, Finland in pathophysiology and surgical treatment of the eustachian tube. And did postdoctoral work with the NANOEAR European Union consortium on nanotechnology for targeted delivery of inner ear and middle ear therapy. Welcome to the show Dr. Poe.

[Dennis Poe MD]
Well, thank you very much, Ashley. And thank you all of you for tuning in. It's a real privilege to be here. So thank you for this.

[Ashley Agan MD]
Thank you. So we'd like to kick off the show just by asking you to tell us about you and your practice, how does a neurotologist find himself spending so much time in the back of the nose, looking at the eustachian tube? , how did you become the guy to go to about your eustachian tube disorders?

[Dennis Poe MD]
Oh, goodness. It's been a long road. I'm an otologist neurotologist. And my practice really was restricted to those fields. But as the eustachian tube was the root of many otologic evils, otitis media. And so I've increasingly had to turn back to studying that, and getting some training again and going back into the nasal cavity, nasal endoscopy, and ultimately working on developing eustachian tube types of procedures.
I started out in residency questioning why we were reconstructing so many years and not preventing the problems. So it was a frustrating situation that eustachian tube was thought of as a black box. And yet we knew that it was the root of many problems downstream in otitis media and all of the complications.
My original background is in engineering and there's nothing like an unsolved problem to stimulate an engineer to want to try and figure this out.

(1) Defining Eustachian Tube Disorders and Eustachian Tube Dysfunction

[Ashley Agan MD]
That makes sense. So setting the stage. So when we talk about eustachian tube disorders or when we say eustachian tube dysfunction, is that kind of like a broad term, meaning anything wrong with eustachian tube? How do you separate it in your mind?
Because I feel like there's, as most of us know, you can have problems with an obstructed eustachian tube or problems with a eustachian tube, that's maybe a little too open and maybe a lot of in between.

[Dennis Poe MD]
Well, yeah, you're absolutely right. We’ve in the past thought of eustachian tube dysfunction as being principally an obstructive problem. And we've traditionally thought that patulous eustachian tube, it was a rare problem. So it turns out patulous is far more common than we ever imagined.
It's actually very common and there's a spectrum of dysfunction. So I used the term eustachian tube dysfunction now to mean anything on this spectrum from complete obstruction, to just having trouble on an airplane diving and all the way to getting stuck open patulous. So I lump all of those together as eustachian tube disorders or eustachian tube dysfunction, and we separate them as a spectrum between obstructive and patulous.
[Ashley Agan MD] Yeah, I went to your course, you guys do a course up at Harvard in the spring. And I think I went back and it might've been 2018 or something. And after that I started looking more at the eustachian tube and looking for more patulous and I agree, once you start looking for it, I felt like, oh, maybe there's a lot of patulous patients that I just never caught.
[Dennis Poe MD] Well, it's true. And they fool us the way they described their problem. They always say my ears blocked. It's full. There's pressure. And then we'll talk about how they can't hear, but actually what they mean is their voice and their breathing is drowning out outside sounds. So they really set us up to miss it.
And that's where we have to have a high index of suspicion. When we see these people.

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

[Dennis Poe MD]
Yeah, if you ever want to simulate a patulous eustachian tube, you take a stethoscope, and hold the diaphragm up to your mouth, right in front of your mouth and you talk and breathe into it. It's extraordinarily loud. And this is exactly what they hear. I can tell you that because if I exercise vigorously enough, I can get the symptoms.
It's really annoying. So that's a remarkable simulation and you will experience this sort of head-in-the-barrel fullness that they talk about. And actually, if it's really bad, your breathing is pushing air back and forth in the ear and giving them a true pressure, variable pressure sensation, which they won't describe unless you specifically ask about it. So, eustachian tube fullness really is a pressure phenomenon, or it can be just an auditory sense. They'll describe that. We see people with sensorineural hearing loss and they tell us their ears are full, blocked. If you could only take that cotton out of their ear, they'd be hearing better.
So it's this aural fullness is a very wide description that patients will use. And it's up to us to sort that out.

[Ashley Agan MD]
Yeah, that's a good point. Like a sudden sensory loss or a Meniere’s patient will have that fullness too. So that's a good point. Maybe some of it's the sensation that's related to having that drop in your hearing.

[Dennis Poe MD]
Right. So it's up to us to sort out what's the fullness. Is it truly a pressure issue or is it something really different? Sensorineural loss, Meniere’s can have pressure because of the hearing loss or because of inner ear pressure. Semicircular canal dehiscence patients describe fullness, conductive hearing losses as well. And temporomandibular disorders. The list goes on.

(2) Patient Presentation

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

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

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

[Dennis Poe MD]
So the patient’s principle complaint is typically ear fullness, aural fullness. And so we try to immediately separate that out. What kinds of problems is it causing? And on the obstructive side, they may have otitis media issues. they may have had actual infections or fluid or just negative pressure.
They're baro challenged, trouble with rapid ambient pressure changes, flights diving, and they may have had a history of tympanic membrane retraction that's being followed. They may have had a history of tympanostomy tubes as a young child. So that's the group. That's the most common, our standard, what's been traditionally called eustachian tube dysfunction, what I now like to call obstructive eustachian tube dysfunction.
So we immediately try to sort those out by their history and then in the process, I will always ask nowadays about autophony. If you ever have a situation where you have a pop or a click in your ear, and it's, you're suddenly hearing your voice echoing, your breathing is like Darth Vader is in your ear, and you'll be surprised at how many patients with obstructive dysfunction will also tell you, oh yeah, I've had that, , I was exercising, it happened. We really have to specifically ask about it.

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

[Dennis Poe MD]
Yes, that's absolutely right. And so when I hear a patient talking about popping and clicking as a big part of their complaint, it's much more likely to be patulous or possibly temporomandibular disorders. And far less likely to be obstructive eustachian tube dysfunction. So that's a very common symptom that misleads us when they start talking about the popping and clicking. They are steering us to think about obstructive dysfunction. When in fact it's probably patulous or temporomandibular disorder. In fact, popping and clicking is one of the questions on the eustachian tube dysfunction questionnaire. The seven questions, I did not participate in how that was developed, but it was done very systematically.
Ed McCoul and Vijay Anand did a great study there, but the focus groups of patients would frequently talk about that as a symptom of eustachian tube disorder. It turns out that the ETDQ-7 cannot tell the difference between obstructive, patulous, or anything else that causes aural fullness like temporomandibular disorder, TMD.

[Ashley Agan MD]
So it's more of a questionnaire to just kind of assess the severity of the symptoms, would you say? So you can kind of follow things?

[Dennis Poe MD]
It's an excellent tool for outcomes measures, symptoms before and after treatment. So it's a very useful tool for that, but it's not diagnostic. It's not specific for ETD.

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

[Dennis Poe MD]
Yes, they can. And they do. And it's much more common than we thought, which makes our diagnostic lives very difficult. The most common etiology that will start out with obstructive dysfunction and then eventually lead to patulous is chronic allergic rhinitis. We know that chronic allergic disease can cause patulous of atrophy in the mucosa and submucosa and the nose and sinuses.
So I have the hypothesis that it also occurs within the valve of the eustachian tube, which is an extension of our other sinuses. And that would certainly correlate with what we see on endoscopic examinations. So, in fact, you can have intense inflammation in the nose and adenoid, torus tubarius, orifice of eustachian tube, but then you look into the lumen and you can see this marked atrophy and the patient can be frankly patulous when they have a runny nose with allergic disease.
If you get this kind of patch of atrophy in the valve, you can become patulous, even though you still have even active allergic rhinitis or sinusitis. Now, if in the allergic patient, if they are active with their symptoms and congested, they may be completely blocked and obstructed even to the point of middle ear effusion.
But then if their disease is quiescent or they're overmedicated, dehydrated, they can switch over to patulous and they can go back and forth, which is very confusing. Because the patient's always going to say my ears is chronically blocked. It's always blocked. So we have to sort those out.
Short answer is yes, people can definitely have both, or they can have a long history of obstructive and then they transition to patulous, which is more common. It's not as common to have patients going back and forth, but we have to look out for it.

[Ashley Agan MD]
Yeah. So, for example, they might've had tubes in the past or something that had helped. And then now they're having more of the talking in a barrel type of symptoms where it's more patulous, full-time that sort of thing, progression.

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

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

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

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

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

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

[Dennis Poe MD]
Yeah, that's wonderful that you're noticing that. That's exactly what we've noticed too and published on that. Allergic rhinitis is the most common comorbidity that we found with patulous- 50%. Weight loss, rapid large weight loss was 35% in our series. Reflux was the next in line. And further down, we have stress, anxiety. When you're stressed-
People have for a long time noticed that these patulous patients can have a lot of stress and anxiety, and it's always been a chicken versus the egg question, is the stress causing their patulous or is the patulous making them stressed? So what we've observed is that the muscles of mastication, especially the medial pterygoid, it can act as a secondary dilator of the eustachian tube.
It will literally distract the membranous wall out laterally and can contribute to patulous. So if they're clenching their muscles, they can provoke patulous, which makes them more stressed. And you get into that vicious cycle. So that was like number four on our list of comorbidities.

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

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

(3) Physical Examination

[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?

(4) Using the MEELO Assessment for Endoscopy Exams

[Dennis Poe MD]
Yeah, I call it a MEELO assessment. Is there a lot of mucus? Is there erythema? Edema? Lymphoid hyperplasia? And then finally what's the quality of the opening? So that's the meat, excess mucus edema, erythema, lymphoid hyperplasia, adenoid-like tissue penetrating into the lumen, or robust around the orifice and then that opening.
So those are the bullet points that I'm specifically looking for on the endoscopy exam.

[Ashley Agan MD]
And then are you grading them on like a, like with a number scale or like a mild, moderate, severe, or how do you use that in your treatment algorithm?

[Dennis Poe MD]
So that's exactly what we do. Yeah. There is now a validated scale that one of my fellows put together and it is a normal, mild, moderate, severe one through four. Mild is just some mild edema. The vessels are a little indistinct, but there's no compromise of the opening. Moderate, there's inflammatory disease. There is compromise of the opening and then severe, it never opens. So it's a rough qualitative scale, but it really does help in determining how severe is the problem and how aggressive do we need to be with treatment?

[Ashley Agan MD]
And so your score is like an overall score for all four categories. It's not like you would have a one under the mucus and a four under the opening. It's kind of like, overall, this is the score. Is that right?

[Dennis Poe MD]
Yes, we originally published something that was more complicated. Like you said, that way we were scaling every factor. Nobody used that. Too complicated. So this is a combined inflammatory quality of opening rough number.

[Ashley Agan MD]
And in looking at the eustachian tube, you also talk a lot about that band of mucosal edema that is common in your obstructive patients. Can you talk more about that?

[Dennis Poe MD]
So when you, when you look at eustachian tube have there, there commonly is a little redundant band that runs along the floor and the cartilaginous wall. So that's quite normal, but very early on it can become edematous and it will have this pale edema that can bulge into the lumen. If that becomes significant, that is the most common finding you see with the baro challenge patients.
Now, when you have more severe obstructive dysfunction, that band can just blend in with the rest of the edema, but that's why I pay attention to that band. It's the most common thing you'll see in the patients who are only baro challenged. But again, the band is normal, but then you'll see, that it’s not protruding significantly into the lumen. It's not a problem.

[Ashley Agan MD]
Gotcha. Yeah. I think the patients who are really swollen and you just barely see a little slit of eustachian tube and when they swallow and when they yawn, you don't see a lot of opening. Those are the more obvious ones. And then you've got the patients that are kind of in between.
And then can you talk a little bit about patulous patients where you might see concavity, or you might see that yellowish defect where you're maybe seeing some of the fat underneath the mucosa.

[Dennis Poe MD]
Right? Before we leave the baro challenge. so when we were talking about the patients who have got a baro challenge history, you look at the TM and tympanogram, it's all normal because they're not flying. It’s that band of redundant mucosa that I'm looking for on the endoscopy to help clinch the diagnosis.
Now, in contrast a patulous eustachian tube, if they've actively got symptoms, you will see a defect in the valve. There's going to be a chink in the valve somewhere. It's usually on the membranous wall. The membranous side, the more common defect is going to be typically right at the roof. The 12 o'clock position, they've got a defective lateral cartilaginous Lambda. It usually has a little triangular point that sticks into the lumen and helps close the valve at the very top where the mucosa is very thin. And if that's deficient than that's a really common location for the defect. Less commonly or, in conjunction with that, you can have a concavity in the whole membranous wall, and that's where they're missing a lot of the fat, the Ostmann’s fat that occupies much of the membranous wall.
If you've got mucosal, submucosal atrophy, then you'll see the yellow of the Ostmann’s fat, the more severe cases the fats disappearing are gone. And you look at the membranous wall, and you're just seeing that the naked tensor veli palatini muscle with a little strip of fat separating that from the floor where the lavatory veli palatini muscle.
So you can see these two red muscles, the levator and the floor, the tensor and the membranous wall, a little strip of Ostmann's fat has big concave defect in the membranous wall. So it's some kind of concavity.

[Ashley Agan MD]
A tympanic membrane exam that is consistent with obstruction, so maybe you see retraction or fluid and they can't lateralize with a modified Valsalva, kind of your classic patient history of tubes. And then you look in the back of the nose and it looks more patulous than it looks inflamed. Is the idea that maybe the disease is just kind of in that deeper one-third of the eustachian tube that you just can't see very well?

[Dennis Poe MD]
It certainly could be. So in that patient, I would want to make sure that they're not doing the inappropriate nasal sniffing that there's no, patulous history,no autophony, no sniffing to cause that, and typically these patients, very commonly they get middle ear fusion every time the tube comes out.
So yes, we do find that they have an obstruction higher in the valve then you can actually see, and those are the ones, it may be a scar band leftover from a past infection and they can even be obstructed in the bony eustachian tube. Now that's about maybe 10% of our obstructive eustachian tube dysfunction, may be in that category. They may have a problem in the bony portion.
So the way to diagnose that is at a time when they don't have an effusion. Typically they've got a tube, that's the time to get a CT. And if you see soft tissue density in the bony eustachian tube. That's telling you, that's where the problem is.
And then you have to decide, well, how do we get to that?

(5) Standard Testing for Eustachian Tube Disorders

[Ashley Agan MD]
Gotcha. And so you've done your physical exam. We talked a little bit about some of the tests, so I assume all patients are probably getting an audiogram, getting tympanograms. You mentioned some of the special tympanometry that can be done. So with patulous you can use the reflex decay mode.
Are you or your audiologists having them do like ipsilateral nasal breathing during that test or just breathing normally?

[Dennis Poe MD]
Specifically for the patulous test? Yes, they breathe normally. We have them do it with the mouth open because that's not going to be as stimulating, to reflecting any pressure changes into the ear. So that's our baseline and then mouth closed. And then ipsilateral nasal breathe.

[Ashley Agan MD]
And if you find it on that, then that's definitely patulous if you can pick it up on that and that should be more sensitive.

[Dennis Poe MD]
Exactly. Yeah. You see it, you see clear deflections, pressure changes. And the audiologist is watching to see that they are coincident with the nasal breathing.

[Ashley Agan MD]
And you guys, do you guys do eustachian tube dilatory dysfunction testing with your tympanometry as well?

[Dennis Poe MD]
We don't. It's too unreliable. It's not a physiological challenge. Typically your eustachian tube is going to open when you swallow and yawn, not necessarily just because you had a sudden pressure change applied to your eardrum. This is the reason that those tests have not been predictive of real live eustachian tube function.
So most of these tympanometers nowadays will be able to do that, but all of the studies have shown them to be unreliable. The only other test which has been shown to be really reliable with a tympanometer is the Bluestone nine step test where you serially pressurize or produce negative pressure against the tympanic membrane. You have the patient do a series of swallows. So it's a little more laborious. Most places don't do it, but it actually is the one tympanometry test that has correlated with some degree of performance after tympanoplasty, for instance.

[Ashley Agan MD]
Okay. Interesting. So that's good to know. So interpret those results with caution because a lot of our audiologists have started automatically doing that eustachian tube dysfunction test if they have a patient coming in with complaints of clogged stuffy ears. And I agree with you, the results have been kind of all over the place.
So that's helpful to know. Any other objective types of testing that can be done that kind of helps seal your diagnosis.

[Dennis Poe MD]
We've really covered the ones that are available, widespread in our country. In other countries, particularly Europe, they have a tubal nanometer, and the experience with that is increasingly showing that it does have some benefit. It can pin down the diagnosis with yet more data points.
It's not by itself, conclusively diagnostic. And that's one problem with eustachian tube testing. There's no single test that will give you the answer. So it's this whole process of the history, the physical, tympanogram, audiogram, and any other testing you do. It all gets put together to get a final impression.
The tubal nanometer is a complicated device. Basically think of a tympanometry probe but in your ear, and it actually generates pressure as you swallow. It ramps up the pressure as you swallow. In your nasal pharynx, you've got a pressure probe in your nose, and it then looks at the change on your eardrum from the probe in your ear. The newer version can even work if you have a perforation in your tympanic membrane, they can see that a little pressure just eked through. So stay tuned maybe we'll get one of those approved in the states. Not there yet.
Sonotubometry can also be used. There are some of those you can get them in the states, but almost nobody uses them. It's a microphone in the ear and a tone probe in the nose. When you swallow or yawn, if your eustachian tube opens, you'll get a louder sound in that microphone, in your ear. But it doesn't always open every time you swallow or yawn. So there's a lot of false negatives on that one. Or false positive, abnormal test results.
So you have to put all of this together to make a diagnosis.
Bottom line, the things we've talked about are pretty solidly diagnostic- history, physical, tympanometry, audiogram, and the endoscopy.

(6) Treatment for Dilatory Dysfunction Patients

[Ashley Agan MD]
All right. So, moving on to treatment then. So for your dilatory dysfunction patients, patients who are obstructed, what does your treatment algorithm look like? Medical, surgical, procedural, what kinds of things are you offering patients?

[Dennis Poe MD]
Well, so we're certainly looking for medical treatment first. And the underlying etiology, especially if they're smoking; really try hard to get them to stop. If they are serious about treating the condition, we do a tremendous amount of allergy testing. I send them out for that. I'm big on if it comes back, it's all negative. We understand that it doesn't mean they don't have allergies, we just haven't been able to nail it down. We will sometimes request intradermal testing to go with that one step further. So for anybody who's six or older, and especially the adults, there's a very high prevalence of allergies in that population. And that may be etiologic. So we're quite aggressive about that. Rhinosinusitis, all these other things we want to treat them, and the majority get better without surgery. We reserve the surgery for those failures.

[Ashley Agan MD]
As far as topical steroids. It seems like distribution of topical nasal steroids to getting all the way back into the nose, it seems like that would be difficult. Do you ever try any sort of other types of tricks to try to be able to get medications to the back of the nose so that they're treating that mucosa of the eustachian tubes specifically?

[Dennis Poe MD]
Yeah, that's a very significant issue you're bringing up. The nasal steroid sprays are beneficial in allergic rhinitis. And so we do have a lot of patients taking those, but you're right. It doesn't truly get all the way back to the nasal pharyngeal orifice or the eustachian tube. Occasionally I've used one of those. I'm blanking on the name of it now, but the newer device where, is it OptiNose-

[Ashley Agan MD]
When you're blowing into your nose? XHANCE is the brand name when you kind of put the one piece in your mouth, one piece in your nose and you're kind of blowing the medication into the nose.

[Dennis Poe MD]
Right. In some folks who I thought were, it was really a good to go that extra step. We have done that, and I think anecdotally the results have been better but as you know that's a lot harder to get through insurance.

[Ashley Agan MD]
Yeah, for sure. And how long of a trial do you want patients to try their medical therapy before you say, okay, it's time to move on and start thinking about other options.

[Dennis Poe MD]
I'm usually giving them six weeks.

[Ashley Agan MD]
As far as reflux, are you managing reflux as well? If you think that that could be the contributor or are you having them see GI or do any other testing?

[Dennis Poe MD]
I'll get them started on antacids and/or PPI's, but I certainly asked him to follow up with their primary or GI or their referring otolaryngologist.

[Ashley Agan MD]
And what about devices? Like an otovent or an ear popper? Are those helpful for them to be doing in the meantime or is it helpful for them to practice a modified Valsalva three times a day, per se? Like, are those types of things helpful for a patient that's got obstructive type symptoms?

[Dennis Poe MD]
Yeah. We love those mechanical devices there’s good evidence that they do work. So the balloon we use in the kids, and it really can make a difference. The adults don't like the balloon looks funny on an airplane. So you have your ear poppers for the folks who just cannot coordinate a modified Valsalva.
That is a go-to device that we frequently recommend that. They’ve become much more affordable.

[Ashley Agan MD]
And are you having them do it just as needed when they have symptoms or is it something where it could benefit from them doing it daily for awhile?

[Dennis Poe MD]
Yeah, it depends.
If we are contemplating surgery, like a balloon dilation. And they really want to try maximal conservative efforts. Then, I'll have some do it three times a day or more if they want, others, if they find that, Hey, that works for me, I only needed it on an airplane. Great. They take it along on the plane.

[Ashley Agan MD]
Yeah. So it's very variable depending on the patient. So you mentioned eustachian tube dilation that I would love to get into that. Recently, hearing you talk about eustachian tube dilation, you mentioned that patients may need a minute, a minute and a half or two minutes of dilation, depending on the severity of their pathology.
Can you talk about how you decide which patients go in which buckets for length of dilation?

[Dennis Poe MD]
Very important point. The device is approved for dilation up to two minutes, but not everybody needs the whole whack. So that grading scale that we talked about earlier, if they're a grade three or four moderate or severe inflammatory disease, the valves very significantly compromised, I'm going to do the full two minutes.
But if they have a lesser amount of disease that we see in the lumen, they've only got that baro challenge. The edematous band of mucosa on the floor, grade two or low grade three, I don't want to overdo it and you can make them patulous even permanently if you overdo it. The balloon can be very effective.
So based on how much inflammation I'm seeing I might turn it back to a one and a half minute or even one minute. There's a person who's got just minimal inflammation, baro challenged, just maybe one minute. I will also point out that it's FDA, labeled for 18 and above. We do in children's hospital.
I do children. We have some protocols for it and I never go above 1.5 minute in pediatrics. They are very sensitive to the balloon and we have had some patulous folks. Thankfully they've all gotten better, but it really made me aware that we have to turn down the duration of dilation, in pediatrics and also for lesser inflammatory disease.

[Ashley Agan MD]
What age are you starting to consider it for your pediatric patients?

[Dennis Poe MD]
They're usually patients who've had several tympanostomy tubes already and they're going to go for three or right or something, It just hasn't helped, they keep needing more tubes. We get there. It's usually allergic, try to get that under control and we can go for the balloon with those patients. In the pediatric group, almost all of them wind up having a lot of adenoid up against the torus tubarius and the torus itself is quite large and inflamed contributing to the problem.
So in the pediatric population, we frequently do a lateral adenoidectomy and trim some of the torus, lymphoid hyperplasia of the medial side of the torus only. The balloons for the lumen. So we do a lot of those combinations in the pediatric population. Again, off label using a balloon in that group. I've done as young as five, but also unusual.

[Ashley Agan MD]
And are you combining that with another set of tubes when you go do it? Would you just do that by itself and see how they do?

[Dennis Poe MD]
If they have a full of effusion. I will typically combine it with a short-term sub-millimeter tympanostomy too. Just so we can drain the fluid and make sure that everything's going to be okay, even in the short run. They don't always do that in other countries. maybe it's not necessary, but if I've got the kid under anesthesia or adult, if you've got a full effusion, I typically will put in an infant tube.
It'll stand a few weeks or maybe under six months.

[Ashley Agan MD]
Yeah. And the hope is that that'll be the last tube and things will get better on the station tube side. Yeah. And your adult patients who would like to proceed with a station tube dilation, does the fact that they've have occasional episodes of patulous type symptoms? Is that a contraindication to them getting a dilation? Or would you just say, maybe we need to shorten it to one minute?

[Dennis Poe MD]
Okay. If they've had patulous symptoms, red alert, you don't want to convert them to permanently patulous. So that patient is almost automatically going to, well, it depends on how, how often it's happened. How recent was it? Does it happen every time they're exercising, et cetera. If they've had significant episodes of patulous, I will do everything I can to avoid doing a balloon dilation at a wall.
Now if it's really indicated, I will turn down the a dilation time. Yes. Minute and a half, minute. You don't want to overdo it because patients hate being patulous.

[Ashley Agan MD]
Yeah, kind of create another problem. If you dilate a patient for one minute and they don't have as much success as you were hoping, do you ever consider doing a repeat and doing it a little bit longer, the next time?

[Dennis Poe MD]
So we have to decide, do we think it was a problem that it was an insufficient amount of time or does this patient have a problem higher up in the lumen, perhaps in the bony eustachian tube, that a repeat dilation isn't going to help. So we have to sort that out. I would probably do exactly what we said earlier.
Make sure to get a CT in that patient. Make sure they don't have an obstruction in the bony eustachian tube. But if everything looks like, yeah, the patient was better temporarily, but then symptoms came right back then I know the balloon did something and yeah, I could take them back and have to do it for longer.
That's actually very unusual. I’ve probably done that a handful of times if that, so a balloon's pretty effective even at one minute. a more common scenario with a one minute balloon would be that they had a benefit for weeks or months, and then it slowly started to slip back or they didn't keep their allergies under control or something.
That's the more common scenario where I would consider it. Okay. Let's get your medical condition back under control and we can do this again and maybe I will do it for a longer time.

[Ashley Agan MD]
And do you find that patients are wanting to kind of abandon all medical therapy after they do a dilation in hopes that they're cured and do they need to continue their medical therapies?

[Dennis Poe MD]
Yeah. Oh, they absolutely would love to just discontinue it. And we really have to emphasize very strongly that this is a medical condition. You've got to keep that under control. , we're all familiar with adenoid tissue growing back. If your allergies are not adequately controlled, if they're smoking. This is adenoid like tissue we're treating inside the lumen of the eustachian tube, it behaves the same way.
If you don't keep the underlying problem under control, you could ultimately fail. But if you have a patient with what you think is irreversible disease, the balloon will get you over that hump, but they've got to do the medical control to keep it under control.

(7) Treatment for Patulous Patients

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

[Dennis Poe MD]
Well, again, it starts with looking for the etiology. If it's weight loss, we don't have them gain weight that usually goes wherever else you don't want. But if there are other things that are treatable, they're on diuretics, they're on particularly oral contraceptive with spironolactone. Other oral contraceptives are okay, but that particular combination seems to be prone. Caffeine, dehydration, allergic disease. If they're over-medicating on antihistamines, and nasal sprays we’ll convert them to nasal rinses and Nasalcrom, immunotherapy when possible. So trying to control all of these other factors, temporomandibular disorders, muscular treatments, relaxation therapy, etc. We try all those things.
If those don't work or we resort to topical drops, saline drops, hypertonic saline drops for something more irritating. Four teaspoons of salt and a cup of water will give you a nice hypertonic solution. It's cheap. you have to instruct the patients how to do it. So you've got a lie supine, hang your head 15 degrees apply the drops, and turn 45 degrees toward the floor. So it's kind of like a, not as severe, head hanging hallpike position and the drops when they touch the eustachian tube will give a twinge that radiates to the ear. If they don't get the twinge they missed. So you have to carefully coach them in all of those things.
Hypertonic they can do as often as they like. If none of this works, my go-to is PatulEND. PatulEND you can get over the internet. It's ascorbic acid solution. It's vitamin C in a bottle. It really stings a lot of the people. Some people say it's too powerful for them, but if they do that three drops two to three times a day for two straight months to try to get a lasting benefit really can work in a lot of the patients.
So those are the go-to things. If they've failed the hypertonic or the PatulEND with a rigid protocol like that, those are the ones I'm considering surgery, if we have to.

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

[Dennis Poe MD]
Yeah. The most common thing I do is, we don't have any commercial device, so off-label inserting an angio catheter that's filled with molten bone wax, let it harden, cut it to size and put it up the full length of the eustachian tube, and if they're out of town, I even put a stitch to it. We get great results with that.
I can't do that if they've got a dehiscent carotid artery. So for those patients we have to do cartilage implants, making an incision in the walls of the eustachian tube and packing cartilage pieces into the sidewalls to bulk it up.

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

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

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

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

[Ashley Agan MD]
Yeah. And, there's no good way to kind of measure and know what size you would need ahead of time. Right. I mean, ideally, you're trying to partially occlude it, occluded enough, to where it's maybe still functions a little bit, that it's not too tight, but in general, you're trying out either 14, 16, or 18 gauge, angio caths, right?

[Dennis Poe MD]
Right?
Almost everybody takes a 14 gauge. But if it won't pass, then I immediately switched to a 16 and I've rarely used an 18. But we have a fair number of patients who get overly blocked with a 14, ultimately probably about 40% needed a tympanostomy tube, at least once. And it's made me wonder, should I be doing more 18 gauges?
Stay tuned. A lot of the folks who I see are coming from a distance and I really want to ensure the success. I think in the future, I might do some more of our local patients with an 18. May well work. I'm curious if you've had experience with the eighteens and how well it works.

[Ashley Agan MD]
I've had, maybe I can think of maybe one or two patients where I've had to go down to an 18. Because the other ones just wouldn't pass. And one patient that was fine with, the other patient that I'm thinking of we ended up going back and putting in a 16 because the 18 was too small, but very, very small cohort, challenging patient group.

[Dennis Poe MD]
Well, congratulations on taking on these procedures. We need a lot more folks doing this.

[Ashley Agan MD]
Well, thank you for being a resource because it is very challenging and you've been a great help and kind of figuring out how to take care of this group of patients. So thank you to you. And I think we have to kind of put a pin in it here. Maybe we'll have to bring you back to kind of get into some more of the ins and outs of treatments, maybe in the future, but it's been an honor and a pleasure to have you today.
So thank you so much for stopping by the podcast. Any final words or anything that you would want to leave with our listeners that we forgot to touch on?

[Dennis Poe MD]
Well, I think we've done a really good comprehensive discussion of the diagnosis and treatments, certainly medical treatment, which is really key. These are common problems. So I greatly appreciate the opportunity to participate with this. I'm honored by it. And I just want to say thanks to all of the many, many people, who have contributed to all of this work.
This has been a result of a lot of people's efforts over many years. I'm very happy to try and distill it down and try to bring it home.

[Ashley Agan MD]
Awesome. Well, thank you for being here today. Thank you to our listeners for stopping by the show. Please remember to subscribe, rate and share, and leave us your comments and feedback. We love to hear from you. Follow us on social media. We are on Instagram and Twitter at _BackTableENT.
That's a wrap.

Podcast Contributors

Dr. Dennis Poe discusses Diagnosis & Management of Eustachian Tube Disorders on the BackTable 40 Podcast

Dr. Dennis Poe

Dr. Dennis Poe is an Associate in the Department of Otolaryngology and Communication Enhancement at Boston Children's Hospital, specializing in heotology/neurotology and skull base surgery.

Dr. Ashley Agan discusses Diagnosis & Management of Eustachian Tube Disorders on the BackTable 40 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2021, December 21). Ep. 40 – Diagnosis & Management of Eustachian Tube Disorders [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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