Das Syndrom der klaffenden Tube – neue chirurgische Therapieansätze

A patulous eustachian tube (tuba aperta) may lead to an enormous reduction in quality of life. A patulous eustachian tube can cause symptoms such as autophony, breath synchronous tinnitus, pressure sensation in the ear, and hearing loss. In combination with so-called “sniffing”, it can trigger the development of cholesteatoma. Due to the diffuse symptoms the correct diagnosis of this disease can be challenging. A patulous eustachian tube can be best diagnosed through a well-structured examination including patient history, physical examination with thorough observation of movements of the tympanic membrane, and tympanometry with reflex decay. This publication reviews recent literature on the patulous eustachian tube. We focused on the evaluation of the different surgical strategies such as the patulous eustachian tube reconstruction, the Kobayashi plug or the injection of Vox® implants into the torus tubarius.     

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。     

Hyperbaric oxygen therapy: effect on middle ear and eustachian tube function.

Hyperbaric oxygen therapy (HBO) involves intermittent inhalation of 100% oxygen under a pressure greater than 1 atm. It is an important mode of adjuvant therapy for disease processes such as decompression sickness, osteomyelitis, carbon monoxide poisoning, and poorly healing wounds. Patients undergoing this therapy often complain of ear pain and/or fullness which can be transient or long standing. This prospective study objectively measured the changes in eustachian tube function before and after HBO treatment in 33 adult patients by the 9-step inflation-deflation test described by Bluestone. The results show 15 of the 33 patients (45%) had evidence of eustachian tube dysfunction after treatment was initiated. Of these, 15 (100%) developed the sensation of fullness, 13 (87%) developed serous otitis media, and 7 (47%) required tympanostomy tubes. The overall incidence of middle ear problems was 27 patients (82%) experiencing a sensation of fullness, 17 (52%) developing serous otitis media, and 8 (24%) requiring tympanostomy tubes. The middle ear complications reported in this study are much higher than those in previous reports in the literature. Twelve of 33 patients presented with a subjective history of eustachian tube dysfunction, and all 12 (100%) developed fullness in their ears and serous otitis media during the course of the treatment. The findings reveal that patients manifesting eustachian tube dysfunction after their first HBO treatment were at significantly greater risk toward developing symptoms of fullness and serous otitis media, often requiring tympanostomy tube placement. In addition, a history of eustachian tube dysfunction accurately predicted the development of fullness and serous otitis media.     

Update on eustachian tube dysfunction and the patulous eustachian tube

PURPOSE OF REVIEW: The purpose of this review is to summarize the recent knowledge on eustachian tube dysfunction and the patulous eustachian tube. RECENT FINDINGS: A clinically useful test for eustachian tube function is still lacking. Narrowing of the isthmus alone was demonstrated to be an insufficient cause of otitis media. Inflammatory mediators identified within the eustachian tube and middle ear cells were causally linked with otitis media with effusion. Increasing evidence was found that allergic disease and reflux may be two of the most important contributors of tubal inflammation causing otitis media with effusion. The adenoid size and proximity to the torus tubaris may also be important in considering which patients with persistent otitis media with effusion may benefit from adenoidectomy. Computed tomography scan has documented loss of soft tissue within the cartilaginous eustachian tube in patients with patulous eustachian tubes. An endoscopic approach to seal the tubal lumen has been found to be effective in relieving patulous symptoms. SUMMARY: These studies suggest that allergic rhinitis and gastroesophageal reflux should be investigated in patients with eustachian tube dysfunction. Adenoidectomy should also be considered in patients who have adenoids that obstruct the torus tubaris. Patients with a patulous eustachian tube may benefit from an endoscopic closure. Further research is needed to identify a clinically useful test for eustachian tube dysfunction.     

鼻咽癌放疗后咽鼓管功能障碍的几种类型

目的：了解鼻咽癌放疗后咽鼓管功能障碍的类型及其影响。方法：对32例(50耳)鼻咽癌放疗后有咽鼓管功能障碍的患者进行常规检查、听力计检查、鼓室导抗图法检查、咽鼓管一鼓室气流动态法(TTAG)检查、咽鼓管音响法检查和内镜检查咽鼓管咽口。结果：咽鼓管异常开放2例(4耳)，患者症状较轻。咽鼓管粘连5例(7耳)，咽鼓管完全阻塞17例(27耳)，咽鼓管不全阻塞8例(12耳)，后三者症状相似，主要导致分泌性中耳炎。结论：鼻咽癌放疗后可导致不同类型的咽鼓管功能障碍，对耳功能产生损害，对其了解将有助于针对性治疗方法的确定。     

The effects of mastoid aeration on autophony in patients with patulous eustachian tube

The effect of the mastoid pneumatization on sound transmission from the nasopharyngeal cavity to the inner ear, which is one of the important factors to indicate the severity of the patulous eustachian tube (ET), are investigated in patients with patulous ET. Twenty ears of 13 subjects with patulous ET were retrospectively analyzed. Sound transmission from the nasopharyngeal cavity to the inner ear was evaluated by observing the masking effects of noise presented in the nasopharyngeal cavity on the auditory threshold (nasal noise masking audiometry). The relationship between this masking effect and mastoid pneumatization were examined among the patients with similar conditions of ET patency. The masking effect of nasally presented noise was greater with less developed mastoid pneumatization. The present results indicate that the symptoms associated with patulous ET may be more distressful in patients with poorly developed mastoid cavity than in those with well-aerated mastoid under similar conditions of ET patency.     

Successful treatment of autophonia with botulinum toxin: case report

OBJECTIVES: We sought to treat autophonia due to a patulous eustachian tube using botulinum toxin. METHODS: Because we assumed that the patulous eustachian tube was caused by abnormal activity of paratubal muscles (tensor and levator veli palatini muscles and salpingopharyngeus muscle), paralysis was performed via injection of botulinum toxin type A in a 45-year-old female professional musician who had had chronic unilateral autophonia for 20 years. In addition to a patient interview, an endoscopic examination of the nasopharynx (posterior rhinoscopy), ear microscopy, and impedance audiometry were performed to verify the diagnosis and the outcome after treatment. RESULTS: The autophonia disappeared 1 week after treatment. Normalized tympanic ventilation was verified by impedance audiometry after 8 weeks. The period of symptom relief was 9 months. CONCLUSIONS: The administration of botulinum toxin type A provides a new option in the treatment of patulous eustachian tube. The reliability of this method and the effect of repeated injections remains to be proved in future studies.     

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.     

Audiometry with nasally presented masking noise: novel diagnostic method for patulous eustachian tube.

OBJECTIVE: Nasal-noise masking audiometry was developed to assess the acoustic transfer function from the nasopharyngeal cavity to the middle ear via patulous eustachian tube (ET). STUDY DESIGN: Prospective. SETTING: Tertiary referral center. PATIENTS: Twenty-seven ears of 18 patients with patulous ET and 20 ears of 10 healthy subjects with no history of ear disease or complaints of aural symptoms. MAIN OUTCOME MEASURES: Audiometric measurement was conducted with and without masking noise presented in the nasal cavity. RESULTS: The masking effect of nasally presented noise caused elevation of the threshold for the tone presented in the external auditory canal. This threshold elevation was significantly greater, particularly in the lower-frequency region, in ears with patulous ET and was decreased to the normal range after obstructive treatment of the patulous ET. CONCLUSION: Nasal-noise masking audiometry is a simple and effective way to identify patulous ET.     

鼻咽癌放疗后咽鼓管功能障碍的评估

目的 通过综合的检测方法对鼻咽癌放疗后的咽鼓管功能障碍进行评估。方法 用鼓室导抗图法、咽鼓管一鼓室气流动态法(TTAG)、咽鼓管音响法、正-负压平衡试验法和内镜检查咽鼓管口两端等综合方法，对23例(35耳)鼻咽癌放疗后有咽鼓管功能障碍的病人进行检查和评估。结果 23例35耳中，21例3l耳表现为咽鼓管阻塞，其中完全阻塞15例21耳，不完全阻塞6例10耳；2例4耳为咽鼓管异常开放。结论 简单的检查不足以了解鼻咽癌放疗后所导致的咽鼓管功能障碍，采取多种方法的综合检查才能对咽鼓管功能障碍的性质和程度进行准确的评估。     

Nasal surgery and eustachian tube function: effects on middle ear ventilation

Objectives: To investigate the effect of nasal obstruction surgery on eustachian tube function and middle ear ventilation. Design: Prospective study. Setting: University Campus Bio‐Medico of Rome. Participants: Forty consecutive patients who underwent nasal surgery were evaluated for middle ear ventilation and tubal function. Main outcome measures: Pre‐ and postoperative Valsalva and Toynbee tubal function tests, tympanometry and ear fullness sensation were evaluated for both ears of each patient. Results: Results of postoperative tubal function tests were significantly better than preoperative ones (90% versus 46%; P < 0.001). No significant difference in tympanometric values was found. The majority (95%) of the patients reported a postoperative improvement of ear fullness sensation compared with preoperative (25%; P < 0.001). Conclusions: Surgery for chronic nasal obstruction significantly improves clinical tubal function but 1‐month postoperative tympanometric findings remain almost the same.     

Clinical characteristics of so called eosinophilic otitis media.

OBJECTIVE: Although "eosinophilic otitis media" is not as uncommon a condition as was previously believed, its cause and pathogenesis are not yet fully understood. The purpose of this study was to describe the clinical characteristics in patients with "eosinophilic otitis media" to clarify its pathogenesis. METHODS: Seven adult patients with persistent and intractable otitis media with viscous middle ear effusion containing many eosinophils, who were also under treatment for bronchial asthma, were studied. The following examinations were conducted: nasopharyngeal endoscopy, pure-tone audiometry, eustachian tube function test, temporal bone CT scan, blood analysis, bacterial and fungal culture of middle ear effusion, histological study of the middle ear and nasal specimens, and measurement of eosinophilic cationic protein (ECP) in middle ear effusion. RESULTS: Some patients had persistent perforation with papillomatous granulation tissue arising from the mesotympanic mucosa, and all the patients had nasal polyposis. The pure-tone audiometry showed the mixed-type of hearing loss in all the patients, and the hearing level deteriorated progressively during the course in some patients. The eustachian tube function was not always poor but was patulous in some cases. The most severely diseased areas were in the eustachian tube and mesotympanum by temporal bone CT images. All the seven patients had the high levels of total serum IgE, but the RAST scores were negative in three patients and low grade in three patients. The accumulation of eosinophils was observed in middle ear effusion, middle ear mucosa and nasal polyps, and the eosinophils were highly activated with degranulation. High level of ECP was also recovered from middle ear effusion. CONCLUSIONS: Active eosinophilic inflammation occurs in the entire respiratory tract, including the middle ear in these patients. From our present investigation, we propose the criteria and clinical characteristics of "eosinophilic otitis media".     

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.     

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 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.     

Myringotomy and tube for relief of patulous eustachian tube symptoms

Reports on the effectiveness of myringotomy and tube for treatment of symptoms of the patulous eustachian tube are discouraging, even though there are no large series substantiating its ineffectiveness. To further investigate this problem, we have reviewed the charts of all patients at the Otologic Medical Group (OMG) from 1974 to 1981 with the diagnosis of patulous eustachian tube who underwent myringotomy and tube for their symptoms. We identified 60 ears of 46 patients with complaints consistent with patulous eustachian tube symptoms. The treatment either eliminated or substantially reduced symptoms in 32 ears (53%). For the other 28 ears, myringotomy and tube were of no benefit. Nine of 13 (70%) ears with a definitive diagnosis based on movement of the tympanic membrane with respiration or tympanometry showed relief of symptoms with myringotomy and tube. Myringotomy and tube will remain part of the treatment regimen because it is relatively simple to perform, reversible, and effective in the majority of patients.     

梅尼埃病的内淋巴积水显像

目的 采用无创性技术经咽鼓管鼓室内导入造影剂钆,进行内耳三维快速液体衰减反转恢复磁共振扫描(three dimensional fluid attenuated inversion recovery magnetic resonance imaging,3D-FLAIR MBI),探讨梅尼埃病内淋巴间隙的显像.方法 7例梅尼埃病患者患侧经咽鼓管鼓室内导入钆喷酸葡胺稀释液,24 h后进行内耳3D-FLAIR MRI.全部患者于造影剂导入前、导人后24 h及3个月时分别进行纯音测听和鼓室声导抗检查.结果 5例患者内耳3D-FLAIR MRI显示造影剂钆广泛分布于患侧耳蜗、前庭和(或)半规管的外淋巴,可以区分内、外淋巴间隙的边界,清晰显像内淋巴情况;2例患者患侧包围内淋巴的外淋巴间隙缩小或消失(即不显影),提示内淋巴积水的存在.5例患侧中耳鼓室腔内未见造影剂钆增强;2例患侧部分中耳乳突腔内可见造影剂钆增强,而内耳未见明显增强.所有患者造影剂给药前和给药后24 h纯音测听平均听阈无明显变化;给药前、给药后24 h及3个月时鼓室声导抗结果无明显变化.结论 经咽鼓管鼓室内导入造影剂钆进行内耳3D-FLAIR MRI扫描,可以了解梅尼埃病患者内淋巴间隙情况.     

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.     

局麻下咽鼓管球囊扩张术加鼓膜置管术治疗顽固性分泌性中耳炎

目的：探讨局麻下咽鼓管球囊扩张术加鼓膜置管术治疗顽固性分泌性中耳炎的临床疗效。方法收集顽固性分泌性中耳炎患者20例（24耳）,于门诊局麻下,结合鼻内镜经鼻腔径路行咽鼓管咽口球囊扩张,并行鼓膜置管。所有患者均于术后3个月拔出T型管。结果术后随访6个月,18例患者耳闷塞感、听物朦胧感症状明显减轻,未再出现鼓室内积液。2例术后仍有耳内闷胀及听力下降,耳内镜检查示鼓室积液未吸收,再次置入T型通气管后症状改善。结论局麻下行咽鼓管球囊扩张术加鼓膜置管术治疗顽固性分泌性中耳炎疗效显著,对于改善咽鼓管功能方法安全可行,并发症极小,是一种微创的新方法。     

Autologous cartilage injection for the patulous eustachian tube

The eustachian tube (ET) is normally closed, but it opens temporarily during swallowing. Patients with a patulous ET (PET) have various aural symptoms such as aural fullness, autophony, and hearing their own breathing. These symptoms are caused by abnormal transmission of sound from the pharynx to the middle ear via an open ET with little attenuation. We introduce a novel injection technique for the treatment of PET using autologous cartilage. This procedure is minimally invasive and has been successfully used to treat PET in 2 patients.