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Surgical Management of
Eustachian Tube Dysfunction
M ARC DEAN, MD
M AY, 2ND 2014
Eustachian Tube Anatomy
Muscles
tensor veli palatini,
levator veli palatini,
salpingopharyngeus,
tensor tympani.
Blood supply
ascending pharyngeal and middle meningeal arteries.
pharyngeal and pterygoid plexus of veins.
The lymphatics drain into the retropharyngeal lymph nodes.
Inervation
Ostium - The pharyngeal branch of the sphenopalatine ganglion derived from
the maxillary nerve (V 1)
Cartilage - The nervus spinosus derived from the mandibular nerve (V 3)
Bone - tympanic plexus derived from the glossopharyngeal nerve (IX)
The physiologic functions of the
Eustachian Tube
Ventilation and pressure regulation of the middle ear
Protection of the middle ear from nasopharyngeal secretions and
sound pressures
Clearance and drainage of middle ear secretions into the
nasopharynx
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Ventilation and pressure regulation
of the middle ear
The eustachian tube opens frequently to maintain a middle ear
pressure between +50 mm and -50 mm H2 O.
The middle ear absorbs 1mL of air in 24 hours, and the adjacent
mastoid air cell system functions as a gas reservoir.
Significant negative middle ear pressure leads to stagnation of
secretions, and effusion collects in the middle ear as barotrauma
evolves.
High negative middle ear pressure (>-100 daPa) indicates eustachian
tube dysfunction.
Inflation of the eustachian tube by the Valsalva maneuver or by
politzerization can break the negative pressure and clears the effusion.
Protection of the middle ear
The eustachian tube is closed at rest, dampening Sudden loud
sounds before reaching the middle ear through the nasopharynx.
Closed system prevents reflux of secretions from the nasopharynx
A derangement (tubes, perforation, etc.) results in reflux of
nasopharyngeal secretions into the middle ear and can cause otorrhea.
The middle ear is protected by a pulmonary immunoreactive
surfactant protein as well as the local immunologic defense of the
respiratory epithelium of the eustachian tube
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Clearance and drainage of middle
ear
Drainage of secretions and occasional foreign material
from the middle ear via:
the mucociliary system of the mucosa
muscular clearance of the eustachian tube
surface tension within the tube lumen.
ETDQ-7
The responses between 50 adult patients with known ETD were compared with 25 controls.
Internal consistency was deemed adequate (Cronbach [alpha] = .71) and there was good
test-retest reliability.
The test was shown to discriminate between patients with ETD and those without (P < 0.001).
A ETDQ-7 score of 14.5 or higher provided 100% sensitivity and 100% specificity for categorizing
a patient with ETD, This equated to a mean item score of 2.1 to indicate the presence of ETD.
ETDQ-7
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Causes of Eustachian Tube Dysfunction
Inflammation
Anatomic abnormalities
Degenerative and metabolic diseases affecting
the tubal musculature
Causes of inflammation
Infections usually related to the adenoids, nasopharynx, nose, and
sinuses.
Allergies
Irritants - tobacco smoke, wood burning stoves, and pollution
Laryngopharyngeal and gastroesophageal reflux
Hormonal changes – particularly with increased Progesterone level in the
third trimester of pregnancy
Primary mucosal disease - granulomatous disease, Samter’s triad
Ciliary disorders - primary ciliary dyskinesia
Pressure dysregulation due to Baratrauma - scuba diving or descent
during air travel
Biofilms
92% of 26 children receiving tubes – Hall-Stoodley et al, JAMA
296:202.211 2006
54% of 9 children undergoing adenoidectomy for OM E - Kania et al,
Laryngoscope 118:128-134, 2008
Early evidence for biofilms in ET - Poe, Kinnuri, Aarnisalo 2010
(unpublished)
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Anatomic abnormalities
Nasal deformity
Nasopharyngeal masses, including neoplasms, can physically block the
orifice, inv ade or compress the lumen, interfere with the dilatory tensor v eli
palatini (TVP) and lev ator v eli palatini (LVP) muscles, or impinge on nerv e
supply.
Trauma,
Injury of the palatopterygoid bone
Injury to the eustachian tube itself.
Injury to the trigeminal nerve or its mandibular branch can lead to functional
obstruction.
Hypertrophied adenoids - functionally and/or, anatomically obstruct the
tubal orifice
Congenital abnormalities - dermoid cysts, cleft palates, Down’s, Crouzon,
Apert, Treacher-Collins, and Turner syndromes.
ET DYSFUNCTION
Slow Motion Video Endoscopy Results: n=82
http://w w w.sinusvideos.com/eustachian-tube-endoscopy-2/
Obstructive Dysfunction (92%)
Mucosal inflammation most common
Allergy, Rhino-sinusitis, Adenoiditis,Reflux
Other inflammation (Infection or Immune mediated -Samter’s, Mid ear primary disease, Wegener’s)
Adenoid hypertrophy compressing ET during swallow
Limited cartilage mobility
Neoplasm or anatomical obstruction (rare) Image with contrast
Dynamic Dysfunction (8%)
TVP & LVP dysfunction - hyper- hypo- dyskinesis
Dyscoordination between muscles
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Complications of untreated ETD
Early Stage
Hearing loss
Otitis media
Otalgia
Vertigo
Retraction Pockets
Late Stage
Tympanic membrane perforations
Ossicular Chain Discontinuity
Cholesteatomas
Real Life Cost of Untreated ETD
Otitis media (OM) accounted for 18% of physician visits from 19931995.
Acute otitis media (AOM) accounts for 13% of all emergency room
visits and 30 million clinic visits.
$5,000,000 is spent annually on antibiotics for the treatment of acute
otitis media (AOM).
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Medical Treatment of ETD
Initial medical management consist of autoinsufflation (eg, an Otovent, Valsalva) as
well as both oral and nasal steroids (budesonide, mometasone, prednisone,
methylprednisolone).
Leukotriene antagonists (eg, montelukast sodium [Singulair]) are helpful in some patients
when oral steroids are not an option.
Decongestants (eg, pseudoephedrine, oxymetazoline, phenylephrine)
Studies suggest that intranasal steroid sprays alone do not help eustachian tube dysfunction.
not as useful for chronic eustachian tube dysfunction (ETD).
Consider the cardiov ascular effects of oral decongestants and the early dev elopment of
tachyphylaxis observ ed w ith the use of nasal decongestants;
limit the use of the decongestant to short-term symptomatic relief (ie, no more than 3-5 d).
Nasal and oral antihistamines can also be beneficial in patients with allergic rhinitis.
Adequate control of laryngeal pharyngeal reflux helps to resolve eustachian tube
dysfunction (ETD) in patients with an associated peritubal inflammation from reflux.
Proton pump inhibitors (esomeprazole magnesium [Nexium], rabeprazole [Aciphex],
omeprazole [Prilosec]) administered tw ice a day are often used. Myringotomy w ith tube
insertion is reserv ed for the refractory patient w ith debilitating symptoms.
Indications for ET Surgery
Persistant OME or Non-adherent atelectasis after medical treatment
Type B or C tympanogram
Symptomatic
Conductive HL,
pain
blockage in ear with pressure changes
Symptoms improved with Valsalva or previous PE tube
Surgical treatment options for ETD
Myringotomy with tube placement
Septoplasty
Nasal Valve Repair
Adenoidectomy
Mastoidectomy
Eustachian tuboplasty
Posterior Septal spurs
Dynamic nasal valve collapse
If adenoid pathology is present (eg, chronic adenoiditis, adenoid
hypertrophy)
Late stage complications
Laser
Balloon
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Eustachian tube dysfunction in
submariners and divers.
McNicoll WD, Arch Otolaryngol. 1982 May;108(5):279-83.
Patients were unable to attain middle ear pressure
equilibration.
All patients had Eustachian tube dysfunction and
septal deviation
Six weeks after operation 51 subjects (94.4%) who
had had a submucosal resection were able to
equilibrate their middle ear pressures at 10 m H2O.
The Control group failed to equilibrate after 6 weeks
Middle ear pressure after rhinoplasty surgery
Koch, Laryngol Rhinol Otol (Stuttg). 1977 Aug;56(8):657-61.
ET M easurings were done in 94 patients (total of 177
ears) before the rhinoplasty operation
After the rhinoplasty in about 2/3 patients had
negative pressure up to 300 mm. This equalized after
the tamponade was removed 84.3% of the time
In some cases negative pressure persisted for 6 days
after the operation (9.8%); in few cases (5.9%) up to
three weeks.
In 13 out of 24 patients having negative middle ear
pressures together with rhinomanometrically objectified
impaired nasal ventilation rhinoplasty led to normal
middle ear pressure.
Systematic review of the limited evidence base for treatments of
Eustachian tube dysfunction: a health technology assessment
G. Norman et al. Clin. Otolaryngol. 2014, 39, 6–21
Eustachian tuboplasty using v arious techniques (sev en case series, 182 patients 26–32) w as associated
w ith improv ement in symptoms in 36–92% of patients (four studies).
Improvements in hearing (four studies) were small with limited clinical significance.26,28–30 Three studies
documented low rates (13–36%) of conversion to type A tympanogram. 26,29,32 33–35
laser point coagulation of the superior and posterior margin of the ET nasopharyngeal opening. 97%
Balloon dilatation studies (three case series, 107 patients) show ed improv ement in symptoms of 92% and
71% of patients/ears (tw o studies 33,34). Conv ersion to type A tympanogram ranged from 36 to 96% of
patients (three studies). 33–35
Myringotomy w ithout insertion of grommets (tw o case series, 121 patients) w as reported to be effectiv e
in permitting and in symptom allev iation in a subgroup of patients w ith ETD undergoing hyperbaric
oxygen therapy.
Surgical studies reported minor lacerations, discomfort, adhesions and granulomas. Single instances of
bleeding and radiculopathy w ere seen after balloon dilatations.
Most patients underwent additional sinonasal or otologic surgical procedures such as partial inferior turbinectomy
or submucous resection of the nasal septum.
topical application of steroids to the middle ear using a microwick following myringotomy
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Balloon dilatation of the Eustachian tube: an evidence based review of
case series for those considering its use.
M iller BJ1, Elhassan HA.
5 case series met the inclusion criteria.
Balloon dilatation has been performed on 375 Eustachian tubes (235 patients), and
demonstrates clear short-term (<6 month) benefits across all recorded outcome
measures in a majority of cases.
69/89 (78%) tympanogram profiles recorded preoperatively as abnormal (Type B/C/
open) resolved to type A profiles post-operatively. 40/46 (87%)
Otoscopy findings pre-operatively reported as abnormal (tympanic membrane
retraction, perforation, or otitis media with effusion) normalised post-operatively.
The ability to perform a consistently positive V alsalva manoeuvre improved from
15/139 (11%) to 89/139 (64%) cases following dilatation.
The two largest studies reported on 210 and 100 procedures, and described symptom
improvement in 67% of cases at 2 months, and 71% at 26.3 weeks respectively.
An overall complication rate of ≈3% was observed, and no major adverse events are
reported (0%). Cost and learning curve of the procedure were both deemed to be
acceptable.
German Society of ORL - 7 May
2013
6000 adult, 200 pediatric Balloon Eustachian Tuboplasties
Sudhoff, Bielefeld - HNO Aug 2012
3 mm balloon, 10 atm, 2-3 inflations
n = 616, 8-82 yo
86% significantly improved ET function
Complications: Air emphysema 1, Tinnitus 2, Epistaxis
Tisch & M aier, Military Hospital
N = 200, 20 mo – 14 yo
75 – 80% significantly improved, no M&T
Balloon Eustachian Tuboplasty
Silvola J, Poe D, Pyykkö I – Lahti, Finland
N = 49 patients
Indications: OME, Atelectasis (B,C tympanogram)
Initial Results
44/49 (89,8 %) initial relief of symptoms & signs,
able to Valsalva - Early failure 5/49 (10,2%)
>6 month follow up
35/49 (71,4%) continued complete relief
11/49 (22,5%) small or intermittent relief
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Balloon Tuboplasty
http://www.sinusvideos.com/balloon-eustachian-tuboplasty/
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ETD in Pediatric Population
Children have shorter, more horizontal tubes, immature floppy elastic
cartilage, and larger adenoids compared to adults.
The eustachian tube in children usually reaches adult length by age
six.
Higher risk for obstruction and reflux of nasopharyngeal secretions
and pathogens.
Otitis media (OM) is the most common diagnosis made by officebased physicians of children younger than 15 years, the most
common reason children are prescribed antibiotics and the most
common indication for surgery in children.
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Treatment of COM/ETD in Pediatric
patients
The rate of repeated surgery was significantly lower for children
undergoing adenoidectomy plus TT (17.2%) than for children
undergoing TT alone (31.8%), and the pooled odds of undergoing
repeat TT was 56% lower for adenoidectomy plus TT than for TT alone.
The benefits were even more marked when the authors excluded
articles that only included children younger than four years.
JAMA Otolaryngol Head Neck Surg 2013
INITIAL PEDIATRIC RESULTS
43 patients
39 bilateral
4 unilateral
82 total dilations
Longest follow up – 6 months
Age Range between 3 – 15 years old
All but one > 5
3yo had underwent 5 sets if tubes and developed granulation tissue every
time
Patient Population
All pts with COM and at least one prior set of tubes
37 patients with history of prior Adenoidectomy
20 underwent revision at time of dilation
5 with history of TM perforation and at least one failed tympanoplasty
23 with concurrent CRS, all underwent balloon assisted antrostomy
with irrigation
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Initial Outcomes
All patients had resolution of CHL
4/5 pt with TM perforation resolved with paper dilation at time of
dilation.
No episodes of OM within short follow up period
No episodes of Patulous ET
Complications and Management
1 pt with hemotympanum 2 weeks Post op
Occurred after adenoidectomy with debrieder
now
perform adenoidectomy transnasal with 8 fr suction cautery
Cleared with valsalva
3 pts complained of ear popping for first week post op
2 pts with effusions 2 weeks post op
continued nasal steroids, abx
1 pt still with effusion after 4 weeks post op
pt able to resolve on own with valsalva
Both pts with 40db CHL on pre op audio
If pt
with > 30db HL, perform myringotomy at time of dilation
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