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.