Patulous eustachian tube following otitis media

Loss of weight, dehydration, pregnancy, fatigue, and otitis media are among the factors proposed as causes of a patulous eustachian tube, but true details remain obscure. We studied patients who developed a patulous eustachian tube following otitis media and discuss the relationship between these 2 conditions. Subjects were 12 patients diagnosed with otitis media at our department who later developed a patulous eustachian tube. The initial middle ear disease progressed from acute otitis media to otitis media with effusion in 2, acute otitis media in or acute mastoiditis in 1 each, and otitis media with effusion in the remaining 8 patients. Seven patients evidenced a low body mass index (BMI), weight loss, and underlying disease, but 5 with a patulous eustachian tube following otitis media did not. We retrospectively analyzed 119 patients diagnosed with a patulous eustachian tube in our department for whether they had been diagnosed by an ENT physician as having otitis media, i.e., acute otitis media or otitis media with effusion. Some 42 (35.3%) had a history of otitis media. At acute otitis media or otitis media with effusion, the tympanic cavity becomes inflamed, accompanied by inflammation of the eustachian tube mucosa and a stenotic tendency. Healing from otitis media is accompanied by decreased eustachian tube mucosa inflammation. We surmise that, depending on how inflammation disappears, fibrosis of the eustachian tube mucosa occurs, leading to a pathologically patulous eustachian tube. Many aspects of the causation of this condition remain unclear, but we surmised that in patients with earlier otitis media, a pathological patulous eustachian tube develops during resolution of inflammation. Our findings indicate the involvement of otitis media as a causative factors in a patulous eustacian tube.     

Eustachian tube function in patients with eosinophilic otitis media associated with bronchial asthma evaluated by sonotubometry

OBJECTIVE: To determine eustachian tube function in patients with asthma and with or without eosinophilic otitis media (EOM), a new middle ear disease entity with a highly viscous middle ear effusion containing many eosinophils and usually associated with bronchial asthma. One of the most important causes of otitis media (OM) is eustachian tube dysfunction. DESIGN: Retrospective case review. SETTING: A referral center. PATIENTS: Twenty patients with EOM and patients with asthma but without OM. MAIN OUTCOME MEASURES: We studied eustachian tube function using sonotubometry and a questionnaire. Sonotubometry was also performed on 13 control patients with chronic otitis media (COM) and 7 normal controls. RESULTS: The tubal opening duration was significantly longer in patients with EOM than in patients with asthma but without OM, controls with COM, and normal controls, indicating the presence of patulous eustachian tubes in patients with EOM. Responses to the questionnaire also supported the presence of patulous eustachian tubes in the patients with EOM. CONCLUSIONS: The presence of a patulous eustachian tube may be a major cause of EOM in patients with bronchial asthma. In patients with asthma who have a helper T-cell 2-dominant predisposition, a patulous eustachian tube easily allows the entry of antigenic materials into the middle ear, causing eosinophil-dominant inflammation.     

Ligation of eustachian tube for intractable patulous eustachian tube: a preliminary report

Pharyngeal orifice of the eustachian tube was ligated on ten patients, 15 ears with intractable patulous eustachian tube. While the eustachian tube orifice was observed by an endoscope inserted through the contralateral nostril, the orifice was ligated transnasally and/or transorally using instruments usually used in the endoscopic nasal surgery. Now 13–27 months after the surgery, the outcome was excellent (both symptoms and sonotubometry were normalized) in two ears, good (either symptoms or sonotubometry was improved) in seven ears, and unchanged in the remaining six ears. In one of the ears with an outcome of unchanged, the ligation was found to be spontaneously released soon after surgery, but the symptom was improved after the second operation 2.5 months after the first operation. Temporary otitis media with effusion was seen in one ear, mild inflammation around the ligated site also in one ear, but no other serious complication has been observed. Although further improvement in the surgical procedure and further discussion about its long-term outcome should be required, this procedure appeared to be one of the therapeutic options for intractable patulous eustachian tube.     

Patulous eustachian tube in long-term survivors of nasopharyngeal carcinoma

This article reports on 21 long-term (10 years) survivors of nasopharyngeal carcinoma, divided into 2 groups: those subjected to an inflation-deflation test and a clearance function test in a longitudinal study, and those receiving sonotubometry in a cross-sectional study. On the inflation-deflation test, 12 (55%) out of 22 ears had a patulous eustachian tube, and on sonotubometry, 10 (50%) out of 20 ears also revealed a patulous eustachian tube. Except for 4 ears with chronic otitis media, the ears had resolved to a normal eardrum appearance at 10 years postirradiation. The phenomenon might be attributed to both restoration of the impaired tubal function and the development of a patulous tube.     

Laser eustachian tuboplasty: a preliminary report

OBJECTIVES/HYPOTHESIS: Surgical correction of eustachian tube dysfunction remains an elusive challenge. Repeat ventilation tube placement is often inadequate to prevent tympanic membrane and middle ear complications. Endoscopic analyses of eustachian tube dynamics have localized the site of primary pathophysiology to within the cartilaginous tube. The study investigated the feasibility, safety, and efficacy of a new endoluminal eustachian tube operation for the treatment of eustachian tube dysfunction. STUDY DESIGN: Prospective, institutional review board-approved surgical trial in a tertiary-care medical center. METHODS: Ten patients with more than 5 consecutive years of intractable otitis media with effusion recurring after two or more tympanostomy tube placements were treated with unilateral laser eustachian tuboplasty. Surgery was performed on an outpatient basis with the use of general anesthesia and combined both transnasal and transoral approaches. A 980-nm diode or argon laser was used to vaporize an appropriate amount of mucosa and cartilage on the posterior wall of the tubal lumen. Preoperative and postoperative dynamic video eustachian tube function analyses were compared. Outcome measures were presence or absence of middle ear effusion and impedance tympanograms. RESULTS: Five patients had at least 12 months of follow-up, and three of them had absence of any effusion (60%). Two patients had recurrence of their otitis media with effusion and required tympanostomy tubes again. Five patients had at least 6 months of follow-up, and four of them had absence of any effusion. The remaining patient had recurrence of otitis media with effusion and received a tympanostomy tube again. Overall results for all 10 patients after 6 months were 7 free of effusion (70%). There were no intraoperative complications. Postoperative complications were limited to minimal peritubal adhesions and one intranasal synechia. CONCLUSIONS: Preliminary results suggest that laser eustachian tuboplasty is safe and efficacious in the treatment of intractable eustachian tube dysfunction. Further study will be necessary to determine whether laser eustachian tuboplasty is a suitable alternative to repeated tympanostomy tube placement in selected patients.     

Type I allergic reactions of the middle ear and eustachian tube: an experimental study

To clarify the role of type I allergic reactions in etiology and pathogenesis of otitis media with effusion and to determine whether or not the middle ear is an allergic "shock" organ, we made animal models of nasal allergy in guinea pigs by passive sensitization with serum of homologous animals containing specific IgE antibodies. We also examined the eustachian tube, tympanic cavity (histologically), and tubal function after the induction of type I allergic reactions of the nose. However, the involvement of histologic changes was limited only up to the area near the pharyngeal orifice. The tubal dysfunction evoked by nasal allergic reactions was transient, culminating in no middle ear effusion. Upon direct antigen-challenge into the tympanic cavity, allergic changes were observed in the mucosa lining the tympanic bulla, even though no microscopic effusion was present. Findings of the present study suggest that type I allergic reactions of the nose are not an etiologic factor for otitis media with effusion, although the middle ear is potentially an allergic shock organ.     

Use of calcium hydroxylapatite for management of recalcitrant otorrhea due to a patulous eustachian tube

We describe a medically complex 4-year-old child with a history of chronic unilateral myringotomy tube otorrhea and laryngopharyngeal reflux who was diagnosed with a patulous eustachian tube. The diagnosis was confirmed by nasopharyngoscopy, retrieval of food from the affected ear after oral challenges with green dye, and computed tomography. The child was effectively treated with an endoscopic transoral injection of calcium hydroxylapatite (Radiesse Voice) in the lateral pharyngeal wall and torus tubarius. She initially received a test injection with a temporary gel of synthetic polymers (Radiesse Voice Gel) with benefit lasting several months; she subsequently underwent a longer term injection with the hydroxylapatite and tube removal. She had complete resolution of otorrhea for 18 months with no subsequent ear infections or food matter in the ear despite persistent significant gastroesophageal reflux. The patulous eustachian tube is rarely identified in children and, when found, is a challenging condition to manage. Many current surgical treatments involve permanent occlusion of the eustachian tube. Our endoscopic transoral technique is a shorter-term alternative for management of complications related to this anatomic variation, and it allows time for eustachian tube growth.     

Site of eustachian tube dysfunction in patients with otitis media with effusion

This study was conducted to identify an exact site of ventilatory dysfunction within the eustachian tube among patients with otitis media with effusion (OME). Using 10 adults with OME, a fine polyethylene tube with a small pore at its tip was inserted into the eustachian tube via its pharyngeal orifice. Negative middle ear pressure was applied through a ventilation tube in the eardrum, and the patients were asked to swallow repeatedly at every 5-mm depth of insertion of the polyethylene tube toward the middle ear. Negative middle ear pressure could be equilibrated by swallowing within 10 mm of tube advancement from the pharyngeal orifice of the eustachian tube in seven of ten patients. It was concluded that the site of tubal ventilatory dysfunction is in the distal part of the cartilaginous portion of the eustachian tube in most adult patients with OME.     

Direct measurement of middle ear pressure through the eustachian tube

We report a method for measuring middle ear pressure through the eustachian tube. We used a 1-mm-diameter micro-tip catheter pressure transducer (Mikro-tip) and inserted this into the tympanic cavity through the eustachian tube. In preliminary studies, we measured four normal ears, two ears with tubal dysfunction, one ear with a dry perforation and 13 ears with otitis media with effusion (OME). Among those ears with OME, three showed negative middle ear pressure, three slight positive pressure and one normal pressure. These findings suggest that our transtubal method is reliable and useful for measuring middle ear pressure.     

Flexible endoscopy and radiologic evaluation of the eustachian tube in adults with eustachian tube dysfunction

This study was conducted on 20 adult patients presenting with eustachian tube dysfunction of about 6 months' duration. It included endoscopy of the pharyngeal end of the eustachian tube and contrast radiologic study. Both methods are now available because of technical progress and practical improvements. By these methods, physiologic movements of the soft palate, tubal torus, and tubal orifice can be observed and studied and anatomic variations and pathologic abnormalities can be detected. This study shows that eustachian tube dysfunction may be caused by salpingitis (acute or chronic) or adenoid or nasopharyngeal carcinoma. Scleroma affecting the lumen of the eustachian tube was reported in one case.     

Direct measurement of middle ear pressure through the eustachian tube

Summary We report a method for measuring middle ear pressure through the eustachian tube. We used a 1-mm-diameter micro-tip catheter pressure transducer (Mikro-tip) and inserted this into the tympanic cavity through the eustachian tube. In preliminary studies, we measured four normal ears, two ears with tubal dysfunction, one ear with a dry perforation and 13 ears with otitis media with effusion (OME). Among those ears with OME, three showed negative middle ear pressure, three slight positive pressure and one normal pressure. These findings suggest that our transtubal method is reliable and useful for measuring middle ear pressure.     

Surgical sequelae of abnormal eustachian tube function

Mechanical, neural, and immunologic factors controlling eustachian tube function are discussed in detail. Relationships of normal tubal function to the development of otitis media with effusion and its pathologic sequelae are reviewed.     

Transient inflammation and dysfunction of the eustachian tube secondary to multiple exposures of simulated gastroesophageal refluxant

Gastroesophageal reflux is a common problem in the newborn and preschool periods. Recent research suggests that it may be related to eustachian tube dysfunction and otitis media with effusion. The purpose of this experiment was to investigate the relationship between simulated gastroesophageal reflux and eustachian tube dysfunction. Rat middle ears were repeatedly exposed (transtympanically) to pepsin in hydrochloric acid or to phosphate-buffered saline solution. Their eustachian tube function was evaluated by assessing passive opening and passive closing pressures, and active clearance of positive and negative pressure. The passive pressure function tests showed variable results. The rats exposed to pepsin in hydrochloric acid had an impaired ability to clear positive and negative pressure from the middle ear as compared to the rats exposed only to phosphate-buffered saline solution. The results demonstrate that multiple middle ear exposures to pepsin in hydrochloric acid leads to eustachian tube dysfunction in rats.     

Impact of evolution on the eustachian tube

I posit that humans appear to be the only species that develops otitis media. If animals in the wild had developed middle‐ear disease to any significant degree, they would have been selected out during evolution because they would not have survived their predators given the associated hearing loss. Why do humans have otitis media? Evolution has had a significant impact. It is well known that humans are born 12 months too early, which is the result of adaptations to bipedalism and our big brain that, over time, resulted in a relatively small female pelvic outlet compared with nonhuman primates. As a consequence of too early a birth, not only is our immune system immature, but the eustachian tube is too short and floppy in the first year of life. But why is otitis media still common in older individuals? What other adaptation is uniquely human? We developed speech that was associated with descent of the larynx and hyoid bone, which, along with a decrease in prognathism (i.e., facial flattening), resulted in a change in palatal morphology as compared with other primates. Comparative anatomic and physiologic studies have demonstrated significant differences between humans and monkeys, especially in the muscles of the eustachian tube. Paradoxic constriction, as apposed to dilation, on swallowing is a common tubal dysfunction in humans and certain monkey models with chronic middle‐ear effusion. My hypothesis is that chronic otitis media with effusion in patients with tubal constriction is a consequence of adaptation for speech and that, most likely, the levator veli palatini muscle is the cause.     

The role of allergic rhinitis in the development of otitis media with effusion: effect on eustachian tube function

PURPOSE: The pathogenesis of otitis media with effusion (OME) is considered multifactorial, with viral upper respiratory tract infection and eustachian tube dysfunction. Allergy may be related to the pathogenesis of OME or to another etiological factor. We investigated the role of allergic rhinitis (AR) in children with OME and evaluated eustachian tube function in patients with AR. MATERIALS AND METHODS: We prospectively analyzed the prevalence of AR, serum eosinophil count, and serum total IgE concentrations in 123 children with OME and in 141 controls. IgE concentration in middle ear effusion was compared in children with OME with and without AR, and eustachian tube function after a nasal provocation test was compared between patients with AR and controls. RESULTS: The prevalence of AR in children with OME (28.4%) and control subjects (24.1%) did not differ significantly. These 2 groups also showed no differences in total eosinophil count and serum and middle ear effusion IgE concentration. Abnormalities in eustachian tube function were the same in patients with AR and controls. CONCLUSIONS: Allergic rhinitis may not be related to the development of OME in children.     

Update on functional anatomy and pathology of human eustachian tube related to otitis media with effusion

New anatomic and histopathologic information regarding the eustachian tube and its surrounding structure as well as possible mechanisms of opening and closing function and dysfunction are discussed in this article. In the past two decades, much light has been shed on the relationship between anomalies of the eustachian tube and the pathogenesis of otitis media with effusion. Now that a technique for obtaining specimens for any histopathologic study that includes the temporal bone as well as the eustachian tube is available, it is hoped that, by harvesting and examining a large number of such specimens, more information will be gained about the relation between eustachian tube pathology and eustachian tube dysfunction, particularly as it relates to otitis media effusion. Only in this way can the clinical management of otitis media be improved.     

Laser eustachian tuboplasty: two-year results

OBJECTIVE/HYPOTHESIS: Laser eustachian tuboplasty (LETP) combined with appropriate medical management will eliminate the chronic presence of middle ear effusions in selected patients. METHODS: The study population consisted of 13 adults with otitis media with effusion (OME). Patients underwent slow-motion video endoscopy to identify the location and extent of surgical resection. A diode or argon laser was used to vaporize areas of hypertrophic mucosa and submucosa along the cartilaginous eustachian tube. Patients were evaluated at 6, 12, and 24 months. Successful outcome was defined as absence of OME. Patients with evidence of reflux disease or allergic rhinitis were treated with medical therapy before surgery and throughout the follow-up period as indicated. RESULTS: LETP combined with medical management eliminated OME in 36% (4 of 11) of patients at 6 months, 40% (4 of 10) at 1 year, and 38% (3 of 8) at 2 years. Failure of LETP correlated with presence of laryngopharyngeal reflux (P = .01) or allergic disease (P = .05) for the results at 1 year but not at 2 years. CONCLUSIONS: LETP combined with appropriate medical management may be an effective treatment in select patients with chronic persistent eustachian tube dysfunction. A controlled trial with a larger number of subjects will be necessary to determine the efficacy of LETP and identify those factors predictive of successful outcome.     

Compliance of the eustachian tube in patients with otitis media with effusion

To analyze the compliance of the eustachian tube, we measured the decrease in tubal resistance (pressure/air flow) with increasing air flow rate through the eustachian tubal lumen. When the eustachian tube is compliant, the tubal resistance decreases greatly because of the high distensibility of the tube. The tubal compliance index (TCI), which is the ratio of the tubal resistance between two different air flow rates, was compared among three groups: 36 ears of children with otitis media with effusion (OME), 26 ears of adult OME patients, and 10 otherwise normal ears with traumatic perforations of the eardrum. Compared with normal subjects, OME children had a significantly higher TCI (P less than .005), whereas OME adults had a significantly lower TCI (P less than .05). From these results, we concluded that eustachian tubes are compliant in children with OME but rigid in adults with OME.     

咽鼓管-鼓室气流动态法对咽鼓管异常开放症的诊断价值

目的 :探讨咽鼓管异常开放症的检测方法。方法 :比较鼓室导抗图法、Morim itsu法和咽鼓管 -鼓室气流动态法 (TTAG法 )检测 2 0耳咽鼓管异常开放症患者的阳性率。结果 :鼓室导抗图法阳性者 5耳 ,阳性率 2 5 % ,Morim itsu法阳性者 12耳 ,阳性率 6 0 % ,TTAG法阳性者 2 0耳 ,阳性率 10 0 %。结论 :TTAG法是诊断和随访咽鼓管异常开放症最有价值的手段。     

Tubal compliance--changes with age and in tubal malfunction

OBJECTIVE: It is known that eustachian tubal compliance has influence on the tubal function. We applied the direct measurement method to ascertain whether or not aging and tubal diseases are related to the compliance of the cartilaginous part of the eustachian tube. METHODS: We developed a method for directly measuring tubal compliance by inserting a balloon catheter, which is inflated with water, into the eustachian tube and comparing the change in balloon pressure with the balloon volume. This method is advantageous in that one can directly measure tubal compliance in the cartilaginous part of the eustachian tube. Using this method we examined tubal compliance in 16 normal young volunteer ears, 21 normal elderly volunteer ears, 11 elderly ears with patulous tube and 12 elderly ears with stenotic tube including otitis media with effusion. RESULTS: In adults the tubal compliance increases in value with age. Tubal compliance of the elderly patulous tube was significantly higher than that of the normal elderly one, on the other hand the compliance of the elderly stenotic tube was significantly lower than that of the normal one. CONCLUSION: Tubal compliance was considered to be changed with aging and influence of the patulous and stenotic tubes.