Endoscopic ligation of the patulous eustachian tube as treatment for autophony

Transnasal Fluoroscopic-Guided Eustachian Tube Obliteration With a Liquid Embolic Agent for a Recurrent Cerebrospinal Fluid Leak After Translabyrinthine Schwannoma Surgery: A Case Series

OBJECTIVE

Postoperative cerebrospinal fluid (CSF) leak after schwannoma surgery occurs in up to 10% of patients. Conventional surgical treatment including fat and muscle packing can prove unsuccessful. We describe a minimally invasive, imaging-guided approach to CSF fistula treatment.

PATIENTS

We describe two patients and three procedures with recurrent CSF rhinorrhea after translabyrinthine vestibular or facial nerve schwannoma surgery. First-line procedures including CSF diversion and repeat middle ear packing failed to close the leaks.

INTERVENTION

Endonasal endoscopic, fluoroscopic-guided obliteration of the Eustachian tube with n -butyl cyanoacrylate.

MAIN OUTCOME MEASURE

Recurrence of a CSF leak.

RESULTS

After treatment, the CSF leak ceased with no recurrence. One patient's facial nerve dysfunction worsened after the procedure.

CONCLUSIONS

This case series highlights a recently described technique of imaging-guided Eustachian tube obliteration using liquid embolic agent. The procedure was effective in treating recurrent CSF leaks but might cause facial nerve dysfunction.

Bayesian nested frailty model for evaluating surgical management of patulous Eustachian tube dysfunction

BACKGROUND

The nested frailty model, a random effects survival model that can accommodate data clustered at two hierarchical levels, has been rarely used in practice. We aimed to evaluate the utility of the Bayesian nested frailty modeling approach in the context of a study to examine the effects of various surgical procedures for patients with patulous Eustachian tube dysfunction (PETD).

METHODS

A nested frailty model was employed to account for the correlation between each pair of ears within patients and the correlation between multiple event times within each ear. Some patients underwent multiple different surgical treatments in their affected ears. We incorporated two nested lognormal frailties into the Cox proportional hazards model. The Bayesian Monte Carlo Markov Chain approach was utilized. We examined the consequences of ignoring a multilevel structure of the data.

RESULTS

The variances of patient-level and ear-level random effects were both found to be significant in the nested frailty model. Shim insertion and patulous Eustachian tube reconstruction using Alloderm or cartilage were associated with a lower risk of recurrence of PETD symptoms than calcium hydroxyapatite injection.

CONCLUSIONS

Bayesian nested frailty models provide flexibility in modeling hierarchical survival data and effectively account for multiple levels of clustering. Our study highlights the importance of accounting for all levels of hierarchical clustering for valid inference.

Diagnosis and treatment of patulous eustachian tube

Symptoms of patulous Eustachian Tube (PET) were first described by Jago in 1858 and reported by Schwartze in 1864, recognizing PET as a clinical entity. This review summarizes the causes, epidemiology, diagnosis, and treatment of PET, with a particular emphasis on diagnosis and treatment, detailing the diagnostic criteria and silicone plug (Kobayashi plug) surgery proposed or developed in Japan. PET is often linked to weight loss from chronic illnesses, dieting, anorexia nervosa, hemodialysis, and bariatric surgery. It is also associated with pregnancy, oral contraceptive use, nasopharyngeal and muscular atrophy or scarring, and neuromuscular diseases. Interestingly, many PET cases lack an identifiable cause. The prevalence of PET ranges from 0.3 % to 7.0 %, with a higher incidence in females and typically occurring in adolescents and adults. Diagnosis relies on a combination of clinical history, physical examination, ET function test, and imaging. The Japan Otological Society (JOS) proposed standardized diagnostic criteria, where a "definite PET" diagnosis requires all three criteria (aural symptoms, tubal obstruction procedures, and objective findings), while "possible PET" requires two. Treatment includes conservative and surgical interventions. For persistent and severe cases that do not improve with conservative treatments, surgical options are explored. These surgical procedures are classified by the type of intervention, which includes tympanic membrane manipulation (such as tympanostomy tube insertion and mass loading of the tympanic membrane), plug surgery, ET injection, shim surgery, tuboplasty, and ET closure. The Kobayashi plug, a 23 mm long silicone plug, is specifically designed for PET treatment. Indications for its use include "definite PET," a PHI-10 score of 26 or higher, and lack of improvement after six months of conservative treatment. Preoperative evaluations include CT scans to assess ET patency and confirm the bony portion. Surgery, mostly performed under local anesthesia, involves inserting the plug into the ET via a myringotomy, ensuring the correct size and position with endoscopic guidance. In conclusion, PET is a challenging condition with diverse etiologies and symptoms. Effective management requires a comprehensive diagnostic approach and tailored treatment plans, with the Kobayashi plug offering a promising solution for refractory cases. Further research and advancements in diagnostic techniques and therapeutic interventions will continue to enhance the management of PET.

Salvage Eustachian Tube Cartilage Chip Insertion After Multiple Transnasal Shim Operations in Intractable Patulous Eustachian Tube

This article presents 2 cases of extremely intractable patulous Eustachian tube following multiple transnasal shim insertion. These cases highlight the disadvantages of repeat transnasal shim operations, including enlargement of the Eustachian tube lumen, frequent dislocation, repeat surgery, recurrent middle ear infection, and shim misswallowing. The patients in these cases were successfully treated with Eustachian tube cartilage chip insertion through a postauricular approach. We describe the surgical technique and advantages of this promising management method.

Trans-tympanic insertion of an angiocatheter with a stopper for treatment of patulous Eustachian tube

BACKGROUND

Plugging of the Eustachian tube (ET) is an effective method for treating patulous Eustachian tube (PET). However, no material suitable for plugging is commercially available. A plugging material was made using an angiocatheter and a ventilating tube (VT).

METHODS

An 18-gauge angiocatheter was cut 25 mm from the tip, and the cut end was occluded and widened by melting using a candle. The angiocatheter was inserted into the hole of a Paparella type 1 VT, which was moved to the cut end of the catheter. The VT acted as a stopper at tympanic orifice of ET to prevent the angiocatheter from descending into nasopharynx. Two women with PET received ET-plugging surgery using this plugging material via trans-tympanic approach.

RESULTS

All symptoms of PET disappeared after surgery. There have been no postoperative complications, and the catheter has functioned well without extrusion.

CONCLUSION

A plug created from an angiocatheter and a VT is easy to make and is effective for the treatment of PET.

Current Treatment Options for Patulous Eustachian Tube: A Review of the Literature

OBJECTIVE

Patulous Eustachian tube (PET) is a clinical condition that is associated with troublesome aural symptoms and is difficult to be treated successfully. The purpose of this review is to examine the published literature regarding the therapeutic value of the current treatment options for PET.

METHODS

We searched Web of Science, PubMed and Medline from 1999 to 2019. The search focused on papers concerning the clinical evaluation of treatment methods in PET patients. Statistical techniques were not used.

RESULTS

Prospective and retrospective case series were the types of trials available for review. We included 28 articles that evaluated the efficacy of various conservative and surgical therapeutic options. The recovery rates ranged from 50% to 100%. In most studies the assessment of efficacy was based on the subjective improvement of patient symptoms as there is no validated outcome tool available. No severe adverse events were observed in any study.

CONCLUSION

On the basis of the available literature, it seems that conservative treatments can be considered as a primary therapeutic option for PET. Concerning the surgical interventions they seem to be a safe and valuable solution in patients with refractory disease. Finally, given the low level of evidence, prospective case-control studies with long follow-up and robust setting looking into the therapeutic approach of PET are required. The need for establishment of standard criteria of PET recovery should be underlined.

Comparison of patulous Eustachian tube patients with and without a concave defect in the anterolateral wall of the tubal valve

OBJECTIVE

Patulous Eustachian tube appears to be caused by a concave defect in the anterolateral wall of the tubal valve of the Eustachian tube. This study aimed to compare the clinical features of patulous Eustachian tube patients with or without a defect in the anterolateral wall of the tubal valve.

METHODS

Sixty-six patients with a patulous Eustachian tube completed a questionnaire, which was evaluated alongside endoscopic findings of the tympanic membrane, nasal cavity and Eustachian tube orifice.

RESULTS

Females were more frequently diagnosed with a patulous Eustachian tube, but the valve defect was more common in males (p = 0.007). The ratio of patulous Eustachian tube patients with or without defects in the anterolateral wall of the tubal valve was 1.6:1. Weight loss in the previous six months and being refractory to conservative management were significantly associated with the defect (p = 0.035 and 0.037, respectively). Symptom severity was significantly higher in patients with the defect.

CONCLUSION

Patulous Eustachian tube patients without a defect in the anterolateral wall of the tubal valve can be non-surgically treated more often than those with the defect. Identification of the defect could assist in making treatment decisions for patulous Eustachian tube patients.

Diagnostic approaches to and management options for patulous eustachian tube

OBJECTIVES

To systematically review the literature and to summarize all evidence related to the diagnosis and management of patulous eustachian tube.

METHODS

The present study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

Overall, 59 articles were retrieved and included in the analysis. Studies investigating treatments enrolled 1279 patients collectively, with follow-up duration varying from few days and up to 2 years. Eight studies reported medical treatments with intranasal saline instillation as the most frequently studied option. Other studies reported various surgical treatments varying from simple tympanostomy to invasive procedures targeting the orifice of the ET or the anatomical features surrounding it. In addition, 10 studies including 367 subjects investigated different diagnostic methods.

CONCLUSION

Currently, there is a wide spectrum of diagnostic and therapeutic interventions with minimal clinical efficacy, a persistent lack of systematic guidelines, and several gaps in previous research endeavours.

A novel computed tomography guided, transcutaneous approach to treat refractory autophony in patients with a patulous Eustachian tube - a case series

BACKGROUND

Patulous Eustachian tube is a benign but notoriously difficult condition to treat successfully. Symptoms include autophony of voice and breathing, and aural fullness.

METHODS

This paper presents a series of 8 patients (12 ears) for whom a novel computed tomography guided injection of silicone elastomer suspension implant (Vox) was used to treat patulous Eustachian tube. This is the largest and only series in the current literature using this technique.

RESULTS

The combined complete and partial symptom resolution rate was 91 per cent. Complications related to the procedure are described. The pros and cons of this novel approach are also discussed in relation to traditional endoscopic transnasal techniques.

CONCLUSION

Computed tomography guided injection of Vox for the treatment of patulous Eustachian tube is suggested to be a feasible alternative to endoscopic transnasal approaches, particularly for refractory cases.

Twelve-month outcomes of Eustachian tube procedures for management of patulous Eustachian tube dysfunction

OBJECTIVE

To determine the 12-month effectiveness of transnasal-transoral endoscopic surgical procedures for eliminating symptoms of patulous Eustachian tube dysfunction (PETD).

STUDY DESIGN

Retrospective chart review METHODS: Patients with medically refractory PETD underwent one of the following procedures: 1) shim (catheter) insertion, 2) calcium hydroxyapatite injection, 3) patulous Eustachian tube (ET) reconstruction, or 4) obliteration of the ET lumen. Time to recurrence of any PETD symptoms was recorded, and success was determined as complete symptom resolution at 12 months. The frailty model, an extension of the Cox proportional hazards model, was used for the survival analysis.

RESULTS

A total of 241 procedures were performed in 80 patients. Median duration of symptom relief after surgery was 5.0 months (interquartile range [IQR]: 1.1-15.5 months) and varied by procedure type, ranging from 3.0 months (IQR: 0.7-7.0 months) for calcium hydroxyapatite injection to 20.6 months (3.4-35.9 months) for obliteration. Compared to shim insertion, the risk of 12-month failure was significantly higher for calcium hydroxyapatite injection (hazard ratio [HR] = 2.18; 95% confidence interval [CI] 1.29, 3.67; P = 0.004) and patulous ET reconstruction (HR = 1.62; 95% CI 1.04, 2.52; P = 0.035). Patients undergoing shim insertion (52.2%) and obliteration (81.8%) were likely to require pressure equalization tubes or to have had otitis media with effusion.

CONCLUSION

Although all procedures potentially resulted in symptom resolution, placement of a shim or obliteration of the ET lumen was more likely to achieve 12-month resolution of PETD symptoms and more likely to result in otitis media with effusion than hydroxyapatite injection or patulous ET reconstruction.

LEVEL OF EVIDENCE

Level 4 Laryngoscope, 129:222-228, 2019.

[The patulous Eustachian tube syndrome: the current state-of-the-art and an original clinical observation. Second communication]

The choice of the treatment strategy for the patients presenting with the patulous Eustachian tube syndrome constitutes a serious challenge for an otorhinolaryngologist. Despite the considerable progress achieved during the past years in the development of modern pharmacotherapy and functional endoscopic surgery, the specialists often encounter difficulties in the management of the patients suffering from this disease. The present article (continuing the previous communication) contains information concerning the historical and modern approaches to the treatment of the patients with the patulous Eustachian tube syndrome. The authors describe the conservative and surgical methods employed for the treatment of this condition and the approaches to the choice of the treatment strategies depending on the etiology, pathogenesis, and severity of the disorder being considered, its duration, and the character of the morphological changes identified during the diagnostic procedures. The authors emphasize the importance of the wait-and-see strategy for the treatment of the patients presenting with the patulous Eustachian tube syndrome. In conclusion, they present the concrete results of four original observations of such patients.

Minimally invasive endoscopic repair of refractory lateral skull base cerebrospinal fluid rhinorrhea: case report and review of the literature

Cerebrospinal fluid (CSF) leaks occur in approximately 10% of patients undergoing a translabyrinthine, retrosigmoid, or middle fossa approach for vestibular schwannoma resection. Cerebrospinal fluid rhinorrhea also results from trauma, neoplasms, and congenital defects. A high degree of difficulty in repair sometimes requires repetitive microsurgical revisions-a rate of 10% of cases is often cited. This can not only lead to morbidity but is also costly and burdensome to the health care system. In this case-based theoretical analysis, the authors summarize the literature regarding endoscopic endonasal techniques to obliterate the eustachian tube (ET) as well as compare endoscopic endonasal versus open approaches for repair. Given the results of their analysis, they recommend endoscopic endonasal ET obliteration (EEETO) as a first- or second-line technique for the repair of CSF rhinorrhea from a lateral skull base source refractory to spontaneous healing and CSF diversion. They present a case in which EEETO resolved refractory CSF rhinorrhea over a 10-month follow-up after CSF diversions, wound reexploration, revised packing of the ET via a lateral microscopic translabyrinthine approach, and the use of a vascularized flap had failed. They further summarize the literature regarding studies that describe various iterations of EEETO. By its minimally invasive nature, EEETO imposes less morbidity as well as less risk to the patient. It can be readily implemented into algorithms once CSF diversion (for example, lumbar drain) has failed, prior to considering open surgery for repair. Additional studies are warranted to further demonstrate the outcome and cost-saving benefits of EEETO as the data until now have been largely empirical yet very hopeful. The summaries and technical notes described in this paper may serve as a resource for those skull base teams faced with similar challenging and otherwise refractory CSF leaks from a lateral skull base source.

Diagnostic criteria for Patulous Eustachian Tube: A proposal by the Japan Otological Society

Patulous Eustachian Tube (PET) is of increasing importance in otology. However, despite the abundance of diseases requiring a differential diagnosis from PET, such as superior semicircular canal dehiscence syndrome, perilymphatic fistula, acute low-tone sensorineural hearing loss, etc., there are currently no established diagnostic criteria for PET. In view of these circumstances, the Japan Otological Society (JOS) Eustachian Tube Committee proposed the diagnostic criteria for Patulous Eustachian Tube in 2012, in order to promote clinical research on PET. A revision was made in 2016, maintaining the original concept that the criteria should be very simple, avoid any contamination of "Definite PET" with uncertain cases. Moreover, it was also intended to minimize the number of cases that could be accidentally excluded even in the presence of some suspected findings ("Possible PET"). The criteria can be used by all otolaryngologists even without using the Eustachian tube function test apparatus. However, the use of such an apparatus may increase the chances of detecting "Definite PET". The algorithm for the diagnosis of PET using the criteria has also been described. The JOS diagnostic criteria for Patulous Eustachian Tube will further promote international scientific communication on PET.

The Middle Ear Cleft Status in a "Natural" Cohort With Eustachian Tube Dysfunction

BACKGROUND

The Eustachian tube (ET) has a major role in the middle ear (ME) pressure homeostasis. ET dysfunction is the accepted paradigm for pressure-related ME disorders. We studied the ME status in patients with severely diminished ET opening abilities, and anticipated to find ME disorders in most of them.

PATIENTS AND METHODS

ME status was evaluated in unconscious adults, who were hospitalized in a rehabilitation center with severe brain damage, requiring tracheotomy and gastrostomy. These patients were unable to swallow, produce valsalva, yawn, and needed oral suctioning. Examination included fiberoptic nasopharyngoscopy, gag reflex and soft palate assessments, otoscopy, and tympanometry.

RESULTS

Nineteen patients (38 ears) were evaluated: 14 men and 5 women, aged 18 to 93 years (average 59). Duration of gastrostomy and tracheotomy were between 3 months and 18 years. All the patients lacked gag reflex, palatal movements, or supraglottic sensation. Eighteen ears (47%) had otitis media with effusion (OME) (versus ∼3% in the general population, p = 0.00001), none had significant tympanic membrane atelectasis, but 20 (53%) ears were normal. Twenty-two ears (59%) had tympanometry types B/C and 16 (41%) had type A. Cerumen impaction incidence (26 ears, 68%) was significantly higher than in normal adults (10%), mentally retarded (36%), and nursing homes residents (57%).

CONCLUSIONS

A dysfunctional ET predisposed ME disorders. Yet, ∼50% of the ears were normal, in contrast to the current paradigm. This implies that ME pressure homeostasis is maintained by factors that can compensate for ET dysfunction. Treating cerumen impaction and OME may be beneficial for rehabilitation.

Panel 2: Anatomy (Eustachian Tube, Middle Ear, and Mastoid-Anatomy, Physiology, Pathophysiology, and Pathogenesis)

Objective In this report, we review the recent literature (ie, past 4 years) to identify advances in our understanding of the middle ear-mastoid-eustachian tube system. We use this review to determine whether the short-term goals elaborated in the last report were achieved, and we propose updated goals to guide future otitis media research. Data Sources PubMed, Web of Science, Medline. Review Methods The panel topic was subdivided, and each contributor performed a literature search within the given time frame. The keywords searched included middle ear, eustachian tube, and mastoid for their intersection with anatomy, physiology, pathophysiology, and pathology. Preliminary reports from each panel member were consolidated and discussed when the panel met on June 11, 2015. At that meeting, the progress was evaluated and new short-term goals proposed. Conclusions Progress was made on 13 of the 20 short-term goals proposed in 2011. Significant advances were made in the characterization of middle ear gas exchange pathways, modeling eustachian tube function, and preliminary testing of treatments for eustachian tube dysfunction. Implications for Practice In the future, imaging technologies should be developed to noninvasively assess middle ear/eustachian tube structure and physiology with respect to their role in otitis media pathogenesis. The new data derived from these structure/function experiments should be integrated into computational models that can then be used to develop specific hypotheses concerning otitis media pathogenesis and persistence. Finally, rigorous studies on medical or surgical treatments for eustachian tube dysfunction should be undertaken.

Effectiveness of Kobayashi plug for 252 ears with chronic patulous Eustachian tube

CONCLUSIONS

Trans-tympanic plugging of the Eustachian tube (ET) with the silicone plug (Kobayashi Plug) induced long-term effectiveness for over 80% of chronic and severe patulous ET (PET) patients. The New Kobayashi Plug was more effective with fewer complication of plug descent to the pharyngeal orifice.

OBJECTIVE

To investigate the effectiveness and complications of trans-tympanic plugging of the ET using a Kobayashi Plug for chronic PET.

METHOD

Trans-tympanic plugging of the ET using the Kobayashi Plug was performed for 252 ears of 191 patients. The Prototype Plug (115 ears of 82 patients in 2001-2007) and the New Plug (137 ears of 109 patients in 2008-2013) were inserted for chronic PET patients.

RESULTS

The success rate of the Kobayashi Plug for PET was 83.0% of a total (Prototype Plug 80.0%, New Plug 85.4%). In 26 ears, the Prototype Plugs were found to have descended toward the nasopharynx. Conversely, this did not happen with the New Plug. The rate of TM perforation (Prototype 22.6%, New 17.5%), middle ear effusion (Prototype 20.2%, New 10.2%) and ventilation tube placement (Prototype 14.8%, New 4.4%) decreased after transition to the New Plug.

Polydimethylsiloxane elastomer injection in the management of the patulous eustachian tube

OBJECTIVE

To determine the effectiveness of augmentation surgery using polydimethylsiloxane elastomer injection for the management of patulous eustachian tube.

METHOD

All patients were treated with eustachian tube injection augmentation performed via a combined transnasal-transoral endoscopic approach. Clinical presentation, volume of injection, complications and initial response were all prospectively recorded. Longer-term follow up was conducted through structured telephone interviews using previously described patient-reported outcome measures.

RESULTS

Overall, 8 of 11 patients (73 per cent) derived complete or significant symptom improvement; 1 patient had significant improvements but was dissatisfied, and in 2 patients the symptoms were unchanged. The eight satisfied patients showed improvement in their quality-of-life scores.

CONCLUSION

This study describes an effective treatment option for patulous eustachian tube. Unlike many prior published reports, previously described patient-reported outcome measures were utilised in order to allow more direct comparison.

Treatment Effectiveness for Symptoms of Patulous Eustachian Tube: A Systematic Review

OBJECTIVES

To determine the effectiveness of currently available medical and surgical interventions for treating symptoms of Patulous Eustachian Tube (PET).

DATA SOURCES

A comprehensive search of MEDLINE (January 1948 to July 8, 2015), EMBASE (January 1974 to July 8, 2015), gray literature, hand searches, and cross-reference checking.

STUDY SELECTION

Original published reports evaluating an intervention to treat the symptoms of patulous eustachian tube in patients 18 years and older.

DATA EXTRACTION

Quality-of-case reviews were assessed with the National Institute of Health (NIH) Quality Assessment Tool for Case Series Studies.

DATA SYNTHESIS

The search strategy identified 1,104 unique titles; 39 articles with 533 patients are included. The available evidence consists of small case series and case reports. The most common medical treatment was nasal instillation of normal saline. Surgical treatments were categorized as mass loading of the tympanic membrane, eustachian tube plugging, and manipulation of eustachian tube musculature.

CONCLUSIONS

The available evidence for management of patients with PET is poor in quality and consists predominantly of small case series. Further research is needed to determine the comparative efficacy of the current treatments.

The effect of ventilation tube insertion or trans-tympanic silicone plug insertion on a patulous Eustachian tube

Conclusions This study suggests that long-term ventilation tube insertion is the first-choice surgical treatment for a 'sniff-type' patulous Eustachian tube (PET). When treating a refractory PET, it is important to determine whether the patient had a habitual sniff. Objectives PET patients were divided into two groups: patients with a habitual sniff (sniff-type PET) and those without a habitual sniff (non-sniff-type PET). This study examined the effects of ventilation tube insertion or silicone plug insertion in each group. Methods Surgical procedures such as ventilation tube insertion or trans-tympanic silicone plug insertion were performed for these patients. Tubotympanoaero-dynamic graphy (TTAG) was also performed to determine the mechanisms underlying these treatments. Results There were 11 cases (17 ears) of sniff-type PET and 20 cases (27 ears) of non-sniff-type PET. An improvement in symptoms was found in 72.7% of the patients who underwent silicone plug insertion (66.7% for sniff-type PET and 74.1% for non-sniff-type PET) and in 90.9% of the patients who underwent ventilation tube insertion for sniff-type PET. In TTAG assessments, many sniff-type PET patients showed significant synchronous changes at high levels of pressure (over 40 daPa) in the external auditory meatus and nasopharynx when performing a slight Valsalva manoeuvre (below 200 daPa).

Eardrum thickening approach for the treatment of patulous Eustachian tube

This study aims to explore the eardrum thickening approach via cartilage myringoplasty for the cessation of symptoms of patulous Eustachian tube (PET), including autophony, aural fullness and breathing synchronous tinnitus. A total of 12 patients who met the diagnosis criteria of PET were included and given an eardrum patching test preoperatively. Then, myringoplasty with ipsilateral full-thickness tragus cartilage under general anesthesia was performed. All patients were followed up for at least 6 months postoperatively. Gross movements of the eardrum under deep respiration disappeared and symptoms were relieved in all patients during the patching test and at 1 month after surgery. All patients were followed up for a length that varied from 6 months to 5 years postoperatively, which demonstrated sustained satisfactory symptom cessation. PET symptoms may have been possibly caused by the gross outward movements of the acoustic transmission system. The eardrum thickening approach via myringoplasty with full-thickness tragus cartilage can be an accessible choice for PET with permanent satisfactory control of symptoms. Furthermore, the preoperative patching test could be a valid way to predict the outcome of the surgery.

Surgical management of Patulous Eustachian tube: A systematic review

OBJECTIVES

Patulous Eustachian tube (PET) is a challenging clinical problem with limited medical and surgical options. The current study systematically reviews the literature to determine the safety and efficacy of surgical treatments for PET.

DATA SOURCES

Medline, Google Scholar, and Cochrane databases.

METHODS

Studies evaluating the surgical management of PET were extracted based on defined inclusion criteria. Data including surgical techniques, outcomes, and complications were extracted and analyzed.

RESULTS

A total of 1,616 studies were retrieved from the initial search. Of these, 14 studies comprising a total of 226 patients (253 sides) met inclusion criteria and were evaluated for surgical techniques, patient outcomes, and complications. As defined by the Oxford Center for Evidence-Based Medicine (Oxford, UK), all studies were classified as level 4 evidence. The most commonly reported techniques were ET plugging (3 studies), PE tube placement (2 studies), and suture ligation (2 studies). Postoperative follow-up ranged from 2 to 60 months (mean, 20.6 months). Outcome measures varied significantly between individual studies, with overall symptom improvement reported between 22% and 100% (mean 72.4%; 95% CI, 62.5%-81.2%). A low incidence of minor complications was reported in nine of 14 studies.

CONCLUSIONS

Current literature evaluating the surgical management of PET is limited and comprised entirely of level 4 studies. Comparisons between techniques were not possible due to the small number of studies and variable outcome measures. Future larger studies evaluating defined outcomes and quality-of-life measures are needed to determine the comparative efficacy of surgical treatments for this challenging condition.

What is the full range of medical and surgical treatments available for patients with Eustachian tube dysfunction?

PURPOSE OF REVIEW

To present the current medical and surgical treatment options for Eustachian tube dysfunction.

RECENT FINDINGS

Balloon dilation or microdebrider Eustachian tuboplasty are feasible treatment options for patients with refractory dilatory dysfunction as an alternative to tympanostomy tube placement. There is increasing evidence that repair of patulous Eustachian tubes by the insertion of a shim or fat graft reconstruction within the lumen of the Eustachian tube orifice may be effective.

SUMMARY

In patients with Eustachian tube dysfunction that is refractory to medical management, newer surgical techniques may provide symptomatic relief with a reasonable duration. Continued basic science research into the cause of dysfunction, the mechanisms of benefit from intervention and long-term clinical outcomes are necessary.

A novel, computed tomography guided, trans-cutaneous approach to treat refractory autophony in a patient with a patulous eustachian tube

OBJECTIVE

We report a novel, computed tomography guided treatment for autophony associated with a patulous eustachian tube.

METHODS

Case report and literature review of the management of patulous eustachian tube.

RESULTS

A 36-year-old woman presented with disabling autophony. Otoscopic examination revealed a poorly mobile right tympanic membrane. High resolution temporal bone computed tomography excluded superior semicircular canal dehiscence. The patient was diagnosed with patulous eustachian tube but failed to achieve therapeutic benefit from conventional endoscopic placement of a silicone elastomer suspension implant adjacent to the eustachian tube. Subsequently, she underwent further silicone elastomer suspension implant placement via a trans-cutaneous, computed tomography guided approach. The patient achieved prompt symptomatic relief and remained symptom-free at six-month follow up.

CONCLUSION

This is the first published description of treatment of patulous eustachian tube using a computed tomography guided, trans-cutaneous approach. It serves to highlight to otolaryngologists the fact that computed tomography guided treatment of patulous eustachian tube may control disabling symptoms in patients who have failed to respond to convention endoscopic management.

Technical feasibility of endoscopic eustachian tube catheter placement: a cadaveric analysis

BACKGROUND

Patulous eustachian tube (pET) can result in transmission of sound from the pharynx to the middle ear (ME) via an abnormally patent ET. The objective of this study was to evaluate the technical feasibility of a reversible transnasal procedure for pET using an occluded silastic catheter to close the ET.

METHODS

Ten sides were evaluated in five cadaver heads. Size 14, 16, and 18G catheters were occluded with bone wax to create a semirigid solid tube. They were placed transnasally, under endoscopic guidance through the ET orifice to span the entire ET length. Proper placement in the ME was confirmed by tympanotomy. Each attempt was graded on a four-point scale based on ease of placement: 3+, 2+, 1+, and 0.

RESULTS

The 16G was the easiest to place with the best fit and was confirmed in the ME in eight cases. The 14G catheter was next easiest to place and was observed in the ME in seven cases. It generally had an extremely tight fit and propensity to impart mucosal trauma. The 18G was the most difficult to place and was observed in the ME in six cases. The catheter was noted to displace easily because of a loose fit. Tympanic membrane or ossicular injury was not noted in any trial.

CONCLUSION

These cadaveric data suggest that a semirigid catheter provides the technical capability to reversibly occlude the ET via the transnasal endoscopic route. Further confirmation is necessary in human studies to determine its effectiveness for management of pET.

Endoscopic hydroxyapatite augmentation for patulous Eustachian tube

OBJECTIVES/HYPOTHESIS

To evaluate the safety and efficacy of endoscopic calcium hydroxyapatite injection in patients with patulous Eustachian tube.

STUDY DESIGN

Retrospective case series.

METHODS

Fourteen patients diagnosed with patulous Eustachian tube (PET) underwent endoscopic hydroxyapatite injection under general anesthesia. All patients had at least two of three major PET symptoms including voice autophony, breathing autophony, or aural fullness/pressure. Patients were evaluated postoperatively with nasal endoscopy and a symptom questionnaire.

RESULTS

Endoscopic Eustachian tube injection was performed in a total of 23 sides in 14 patients with an average volume of 2.1 cc injected per side. Mean follow-up was 17.5 months. The most common symptoms reported preoperatively were voice autophony (96%), breathing autophony (91%), and ear fullness (83%). A complete or significant response to treatment was noted in 13/22 sides with voice autophony (59%), 12/21 sides with breathing autophony (57%), and 12/19 sides with ear fullness (63%). All complete or significant symptom improvements remained durable through the entirety of the follow-up period. Four sides that had temporary or no improvement with treatment underwent repeat injection but did not achieve additional improvement. No intraoperative or postoperative complications were observed.

CONCLUSION

Endoscopic hydroxyapatite injection of the Eustachian tube is a minimally invasive procedure that provided significant or complete relief of autophony and ear fullness in 57% to 63% of sides treated. The procedure is well tolerated and can be performed safely under endoscopic visualization. Hydroxyapatite injection may be a satisfactory alternative to more invasive treatments for PET.