BackTable / ENT / Podcast / Episode #69
Balloon Dilation of the Eustachian Tube
with Dr. Seilesh Babu
In this episode of BackTable ENT, Dr. Ashley Agan and Dr. Seilesh Babu discuss Eustachian tube dysfunction and balloon dilation as a therapeutic option.
BackTable, LLC (Producer). (2022, September 8). Ep. 69 – Balloon Dilation of the Eustachian Tube [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Seilesh Babu
Dr. Seilesh Babu is an adult and pediatric neurotologist, otologist, and skull base surgeon with Michigan Ear Institute in Farmington Hills, Michigan.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
First, Dr. Babu provides background on Eustachian tube dysfunction. In kids and adults, Eustachian tube dysfunction can present as a sensation of “ear fullness”, recurrent fluid in the ear, or discomfort with pressure challenges, such as flying or scuba diving. Medical management involves nasal steroids, allergy medications, anti-reflux medications, avoidance of allergens, and doing a modified Valsalva maneuver at home. Additionally, ear tubes and balloon dilation are procedural options.
Next, Dr. Babu explains his workup for Eustachian tube dysfunction patients. He takes a thorough patient history and examines the patient’s tympanic membrane, nasopharynx, and serous outflow using a flexible scope. He orders an audiogram for all of his patients but notes that tympanograms are not as critical. For patients with discomfort during pressure challenges, he will consider doing a balloon dilation or placing an ear tube. For patients presenting with “ear fullness”, a more in-depth examination must be done through a trial tympanostomy tube or a myringotomy.
He also looks for red flags, which indicate Eustachian tube dysfunction may not be the correct etiology for their ear symptoms. These red flags include: aggravation of symptoms upon tube insertion, symptoms of dizziness and vertigo, autophony, and pulsatile tinnitus. Although it is rare, a diagnosis of Patulous Eustachian tube dysfunction must be considered. If the patient does not have these red flags and has had multiple ear tubes without symptom relief, they may be a good candidate for balloon dilation.
Dr. Babu then delineates his procedure for a Eustachian tube balloon dilation. He performs this procedure in the OR using the Acclarent AERA Eustachian tube dilation system. He inflates the balloon to achieve a pressure of 12 atm, keeps it dilated for 2 minutes, then removes the instrument. Some procedural pearls he shares are: putting the scope and balloon in at the same time to minimize bleeding in the nasopharynx and guiding the instruments in a lateral direction towards the external ear canal. He usually waits 2-3 weeks before reassessing the patient for recurrent symptoms. Upon discharge, he encourages patients to avoid nose blowing and Valsalva maneuvers, as these actions can cause a pneumothorax or pneumomediastinum. Common postoperative symptoms include minor nose bleeds and the sensation of a sore throat. Dr. Babu usually performs the balloon dilation in conjunction with other OR procedures, such as myringotomies and tympanoplasties, for efficacy.
Finally, the doctors discuss the specifics of billing for the Eustachian tube dilation procedure. In recent years, a specific billing code has been assigned for balloon dilation, and insurance companies are beginning to authorize this procedure for a variety of patients.
Devices discussed in this podcast are currently available in the US only.
Acclarent, Inc. 223616-220810
AERA® Esutachian Tube Balloon Dilation System:
Howard, A., Babu, S., Haupert, M., & Thottam, P. J. (2021). Balloon Eustachian Tuboplasty in Pediatric Patients: Is it Safe?. The Laryngoscope, 131(7), 1657–1662. https://doi.org/10.1002/lary.29241
[Seilesh Babu MD]
Let's even start back with like, when a patient does come in, like you're alluding to, what symptoms should we be looking for? So I think, certain subsets of patients come in with easy decision-making as to what do we do. A patient who has baro challenges. They go scuba diving, they fly in an airplane, and they have. And then when you see them in the office, of course, they're going to have more of a normal examination because they're not having that problems, but you can trust their history enough. And experience has taught us that I think those type of patients do well with this type of intervention. Whether it's a tube in the ear or a balloon dilation, they'll actually do well in that scenario. And then you have some patients that come in with multiple serous effusions and they've had multiple tubes in their ears. And I think that also is a good candidate for their hearing loss, their ear fullness, multiple tubes that have helped their symptoms. I think that's a good candidate also to be looking at next steps. And in the patients who come in with ear fullness, I think that becomes a harder challenge to delineate what therapy is going to help that patient with ear fullness and ear fullness is a tough one. I have found myself putting them in categories and trying to figure out is it eustachian tube related or not? Is it Meneire’s disease? Is it superior canal dehiscence? Is it maybe masseter or pterygoid muscle tension that may be causing some of this? Is it anxiety? Are there other factors that we have to take into account? I think one of my main things that I do is I try doing either a myringotomy or a tympanostomy tube in that scenario to see, does that give them relief? My opinion is if it does not give them relief, then I don't think eustachian tube dysfunction is their main issue. And therefore, I don't think a balloon dilation would be indicated in that scenario, but that's a long-winded sort of way of saying what do these patients present with?
But the next steps then we think about evaluation is I think we should do a good thorough examination of their ears. See if there's retraction of the tympanic memory and see if there's fluid in the middle ear space. I think all of these patients should have nasopharygoscopy, as we had talked about to really look at the nasal pharynx. See, is there adenoid tissue? Is there adenoid in the eustachian tube? Is there hypertrophy of the torus tubarius? Is there mucosal edema? Is there cobblestoning? What is the movement of the eustachian tube look like? Some of that over time will give you a sense of maybe this is a good one to intervene on. All of them will get audiograms. I don't always get tympanograms, but many times tympanograms will help decide. There was a time where insurance coverage was an issue. And so you'd have to get a tympanogram on everybody to show that it was a flat or poor, but that has changed a bit now. So it's not as critical to get that, but many places will still get it. It's a good way to follow objectively. What do they do afterwards if it became normal.
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