[Therapy of chronic obstructive eustachian tube dysfunction: evolution of applied therapies]

Sirolimus-coated Eustachian tube balloon dilatation for treating Eustachian tube dysfunction in a rat model

Eustachian tube balloon dilatation (ETBD) has shown promising results in the treatment of ET dysfunction (ETD); however, recurrent symptoms after ETBD frequently occur in patients with refractory ETD. The excessive pressure of balloon catheter during ETBD may induce the tissue hyperplasia and fibrotic changes around the injured mucosa. Sirolimus (SRL), an antiproliferative agent, inhibits tissue proliferation. An SRL-coated balloon catheter was fabricated using an ultrasonic spray coating technique with a coating solution composed of SRL, purified shellac, and vitamin E. This study aimed to investigate effectiveness of ETBD with a SRL-coated balloon catheter to prevent tissue proliferation in the rat ET after ETBD. In 21 Sprague-Dawley rats, the left ET was randomly divided into the control (drug-free ETBD; n = 9) and the SRL (n = 9) groups. All rats were sacrificed for histological examination immediately after and at 1 and 4 weeks after ETBD. Three rats were used to represent the normal ET. The SRL-coated ETBD significantly suppressed tissue proliferation caused by mechanical injuries compared with the control group. ETBD with SRL-coated balloon catheter was effective and safe to maintain ET luminal patency without tissue proliferation at the site of mechanical injuries for 4 weeks in a rat ET model.

Investigation of Stent Prototypes for the Eustachian Tube in Human Donor Bodies

Chronic otitis media is often connected to Eustachian tube dysfunction. As successful treatment cannot be guaranteed with the currently available options, the aim is to develop a stent for the Eustachian tube (ET). Over the course of this development, different prototypes were generated and tested in ex vivo experiments. Four different prototypes of an ET stent and one commercially available coronary stent were implanted in the ET of seven human donor bodies. The position of the stents was verified by cone beam CT. The implanted ETs were harvested, embedded in resin and ground at 200 µm steps. Resulting images of the single steps were used to generate 3D models. The 3D models were then evaluated regarding position of the stent in the ET, its diameters, amount of squeezing, orientation of the axes and other parameters. Virtual reconstruction of the implanted ET was successful in all cases and revealed one incorrect stent placement. The cross-section increased for all metal stents in direction from the isthmus towards the pharyngeal orifice of the ET. Depending on the individual design of the metal stents (open or closed design), the shape varied also between different positions along a single stent. In contrast, the cross-section area and shape remained constant along the polymeric prototype. With the current investigation, insight into the behavior of different prototypes of ET stents was gained, which can help in defining the specifications for the intended ET stent.

The rat eustachian tube: Anatomical, histological, and radiological features

Purpose

This study investigated the anatomical and histological characteristics of the rat Eustachian tube (E-tube) and the feasibility of Eustachian tubography in a rat model.

Materials and methods

Fifteen male Wistar rats were used in this study, and the bilateral E-tubes of each rat were examined. Ten E-tubes were used for anatomical studies, another ten for histological analysis, and the other ten for Eustachian tubography. Five rats were euthanized and decapitated, and ten E-tubes were dissected to describe the anatomy of the E-tube. Ten E-tube specimens obtained from five other rats were sectioned to investigate E-tube histology. Eustachian tubography was performed on the bilateral E-tubes of the other five rats using the trans-tympanic approach.

Results

The rat E-tubes consisted of bony and membranous parts. Cartilage and bone tissue covered only the bony part. The E-tubes' mean diameter and overall length were 2.97 ​mm and 4.96 ​mm, respectively. The tympanic orifices' mean diameter was 1.21 ​mm. The epithelium of E-tubes was mainly composed of pseudostratified ciliated and goblet cells. Eustachian tubography was successfully performed on both sides of the E-tube for each rat. The technical success rate was 100%, the average running time was 4.9 ​min, and no procedure-related complications occurred. On tubography images, the E-tube, tympanic cavity, and nasopharynx could be identified because of the visualization of bony landmarks.

Conclusion

In this study, we described the anatomical and histological features of rat E-tubes. With the aid of these findings, E-tube angiography was successfully performed using a transtympanic approach. These results will facilitate further investigation of E-tube dysfunction.

Tapered self-expandable metallic stent optimized for Eustachian tube morphology in a porcine ET model

Several investigations on the feasibility of stent placement into the Eustachian tube (ET) are being conducted. However, stents optimized for the anatomical structure of the ET have not yet been developed. In this study, the efficacy and safety of a self-expandable metallic stent (SEMS) optimized for porcine ET morphology was investigated. Silicone was injected into a cadaveric porcine ET to analyze the ET morphology. The three-dimensional-reconstructed porcine ET phantom images obtained after a computed tomography scan were measured to determine the dimensions of the porcine ET. The SEMS was designed as a tapered structure on the basis of the morphological findings of the porcine ET. The tapered SEMS (T-SEMS) and conventional SEMS (C-SEMS) were placed into the porcine ET to compare the safety and efficacy of the two types of SEMSs. Stent-induced tissue hyperplasia in the T-SEMS group was significantly lower than that in the C-SEMS group (p < 0.001). The T-SEMS optimized for the porcine ET was effective in maintaining stent patency. T-SEMS seems to be better than C-SEMS in suppressing stent-induced tissue hyperplasia, owing to the reduced stent-mediated mechanical injuries and maintaining ET patency.

The role of Eustachian tubography and Valsalva CT in Eustachian tube balloon dilation

BACKGROUND

Not many imaging techniques have been reported in Eustachian tube imaging.

PURPOSE

To investigate the role of selective Eustachian tubography (SET) and Valsalva computed tomography (CT) in patients who underwent Eustachian tube balloon dilation (ETBD).

MATERIAL AND METHODS

Eligible patients were aged 18 years and older with chronic Eustachian tube dysfunction who had failed medical treatment. On the day of the procedure, Valsalva CT and SET were performed. Participants underwent fluoroscopic ETBD with a 6×20-mm balloon catheter. Clinical examinations to check for the ability to perform the Valsalva maneuver and ETDQ-7 score change were conducted at one week and then at one, two, and six months. Follow-up Valsalva CT was performed in the one-month follow-up.

RESULTS

A total of 30 ears in 23 patients (16 right ears, 14 left ears; 10 women, 13 men) underwent ETBD from August 2018 to November 2019. Positive CT patency was higher in follow-up Valsalva CT than baseline Valsalva CT (40% and 23.3%, respectively) (P = 0.006). In SET, positive patency was observed in 13 of 25 ears. Response to balloon dilation was observed in 18 of 25 patients. Clinical success was achieved in 16 of 27 ears. Response to balloon dilation was the only significant predictor of clinical success (P = 0.012).

CONCLUSION

SET depicted the lumen of the Eustachian tube; thereby, it could be a potentially valuable tool in ETBD. Valsalva CT provides additional information about the cartilaginous portion of the Eustachian tube.

Perilymph Fistula as a Complication of Eustachian Tube Dilation and Tympanoplasty

Eustachian tube dilation (ETD) is an established, minimally invasive therapeutic approach for chronic eustachian tube dysfunction. The complications associated with performing a ETD are rare. A 22-year-old female patient presented with chronic otitis media on the right side and chronic obstructive tube dilation disorder on both sides. A type I tympanoplasty was performed on the right side because of a tympanic membrane perforation after a ETD on both sides without apparent complications. On the 5th postoperative day, she presented with headache, dizziness and hearing loss on the right side. There was a decrease of hearing threshold on the right side in the pure-tone audiogram and vHIT, cVEMP, and SVV were irregular. The β-2-transferrin test was positive. Since a right-sided perilymph fistula was suspected, an emergency tympanotomy was performed with a round window membrane cover with fascia on the right side. Intraoperatively, a regular, intact ossicular chain was found with a slightly moist middle ear mucosa. The round window membrane was covered by the promontorial lip. Under these measures, the patient’s dizziness regressed. The right ear pure-tone threshold vHIT, cVEMP, and SVV normalized.

Outcome of Eustachian Tube Balloon Dilation in Children: A Systematic Review

OBJECTIVE

Eustachian tube dysfunction (ETD) is a chronic entity that has been historically managed with adenoidectomy and ventilation tube insertion. Recently, balloon dilation of the eustachian tube has shown promising results in recalcitrant eustachian tube dysfunction. We reviewed the literature to determine the outcome of eustachian tube balloon dilation in children.

METHODS

A literature search was conducted for the period from 1990 to 2020 by searching several databases over a 1-month period (January 2021) according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook for Systematic Reviews for Interventions. Primary outcome was defined as the success of the intervention determined by the resolution of symptoms, and secondary outcome was determined by revisions surgery and presence of complications.

RESULTS

Only 7 articles were identified based on our objectives and selection criteria. All studies included are retrospective cohort case series (Level IV) and 1 cohort of matched controls (Level III). A total of 284 patients were included in this review, with a mean age of 7.8 years. A total of 463 balloon dilation were performed either bilaterally or unilaterally. The most common finding of ETD is middle ear effusion in 5 studies. Balloon dilation of eustachian tube was second-line treatment in 6 studies and first-line treatment in 1 study. Improvement of symptoms was identified in all studies through various assessments performed. Revision surgery was performed in 1 study with no major complications reported.

CONCLUSIONS

Balloon dilation of the eustachian tube may be considered as an alternative procedure following failed standard treatment in children. The quality of evidence is inadequate to recommend widespread use of the technique until a better-quality study has been completed. Future randomized controlled studies with a large sample size are warranted to determine the efficacy of this procedure amongst children.

Sensorineural Hearing Loss After Balloon Eustachian Tube Dilatation

Objective: Eustachian tube function is of central importance for the ventilation of the middle ear. A dysfunction can be associated with chronic otitis media, and cholesteatoma. Balloon Eustachian tube dilatation (BET) is a treatment option used to solve eustachian tube dysfunction. Although BET is widely performed, little is known about the occurrence rate of the complications associated with BET. The aim of the present study was to observe the rate of sensorineural hearing loss (SNHL) after BET.

Methods: We retrospectively evaluated in a chart review 1,547 patients and 2,614 procedures of BET performed in a single center between 2015 and 2019 using the Spiggle and Theis, Overath, Germany eustachian tube dilatation system.

Results: We observed seven cases of SNHL after BET. In two cases, the SNHL persisted, and in five cases, the SNHL was transient. In two cases of SNHL, a simultaneous tympanoplasty was performed. The overall rate of SNHL per procedure is 0.3%. The rate of permanent SNHL is 0.08%.

Conclusion: BET has a low rate of SNHL. Rapid middle ear pressure changes are assumed to cause BET-related hearing loss.

Chronic obstructive Eustachian tube dysfunction: CT assessment with Valsalva maneuver and ETS-7 score

Chronic obstructive Eustachian tube dysfunction (ETD) is a common disorder of the middle ear. In recent years, two main diagnostic tools have become available: Eustachian tube score (ETS-7) and computed tomography (CT) combined with Valsalva maneuver. The aim of this study is to evaluate the outcomes of ETS-7 and CT in a group of patients affected by middle ear atelectasis with a strong suspicion of ETD. Three males and nine females, affected by middle ear atelectasis with retraction of the TM were enrolled. Each patient underwent to Eustachian tube dysfunction evaluation adopting the ETS-7 score and a temporal bone CT with Valsalva maneuver. The ears analyzed at steady state were divided into 2 groups: ETS<7 group and ETS≥ 7 group. The same division was applied for the ears analyzed after the Valsalva maneuver: ETS<7 group and ETS≥ 7 group. ETs were categorized as “well defined” (WD) and “not defined” (ND). The results of the analysis of the ETS-7 score in all 24 ears showed that 42% presented ETS ≥7, while 58% had ETS <7, indicating a diagnosis of ETD. In the ETS<7 group after Valsalva, ET was visualized in 33% of patients. In the ETS≥7 group it was WD in 29% after the Valsalva manoeuver. In both groups the comparison between the visualization of the ET before and after the Valsalva manoeuver did not present a statistical difference. No correlation emerged between ET evaluation with CT scan during Valsalva maneuver and ETS-7 score. It confirms that there is not a gold standard for the study of ET dysfunction.

A novel technique for patulous Eustachian tube augmentation

OBJECTIVE

To determine the effectiveness of a soft-tissue bulking agent comparing novel approaches of Eustachian tube (ET) augmentation procedures: transpalatinatal Eustachian tube augmentation in local and general anesthesia versus an augmentation with velotraction under general anesthesia. The clinical endpoint was the resolution of symptoms related to unilateral patulous Eustachian tube dysfunction (PETD) requiring no additional revision augmentations.

STUDY DESIGN

Combined retrospective clinical chart review.

SETTING

Tertiary referral center.

METHODS

Patients suffering from PETD underwent one of the following procedures: Group (A) transpalatinatal soft-tissue bulking agent with infiltration/augmentation under local anesthesia in a sitting position, group (B) transpalatinatal soft-tissue bulking agent infiltration/augmentation under general anesthesia in the flat position or group (C) infiltration/transoral augmentation of the ET with velotraction under general anesthesia in a flat position. The requirement to repeat the procedure due to recurrence of any PETD-related symptoms was recorded and retrospectively analyzed.

RESULTS

A total of 50 procedures were executed in 50 patients with unilateral PETD. The necessity to perform a second procedure has analyzed a mean of 6 months postoperatively (range: 6-17 months). Compared to the transpalatinatal augmentation in local anesthesia (group A) (100% success rate), the 6-month failure rate was significantly higher for transpalatinatal augmentation under general anesthesia (group B) (80% success rate) and velotraction augmentation under general anesthesia (group C) (67% success rate). Patient cohort with transpalatinatal augmentation under general anesthesia required 20% and augmentation with velotraction under general anesthesia in 33% revision augmentation procedures reviewed at 6 months follow-up (mean follow-up 11.2 months).

CONCLUSIONS

Although all different approaches resulted in a reduction of PETD related symptoms, the transpalatinatal ET augmentation in local anesthesia achieved a statistically significant superior clinical improvement. A complete resolution of PETD related symptoms was obtained and required additional procedures. This improvement may be related to the intraoperative "feedback" by the patients in local anesthesia in the sitting position eliminating the necessity for repeated procedures.

Eustachian tuboplasty and shrinkage of ostial mucosa with new devices : Including a proposal of a classification system

OBJECTIVE

A new combined approach to Eustachian tube dysfunction (ETD) employing new minimally invasive devices is described.

STUDY DESIGN

An anatomoclinical classification of ETD was conceived to allow correct categorization of patients and enable comparative studies to be performed. Herein, the authors report on their experience with a consecutive series of obstructive ETD patients treated by balloon dilation of the Eustachian tube using AERA (Acclarent, Menlo Park, CA, USA), combined with a quantic molecular resonance (QMR)-mediated rhinopharyngeal tubal ostial mucosa shrinkage technique with a dedicated "Mitto" hand piece (Telea, Sandrigo-Vicenza, Italy).

METHODS

A prospective study was conducted in 102 patients with ETD. Medical history, complete clinical ENT evaluation and oto-functional examinations were performed in all patients. In all cases, balloon dilatation of the Eustachian tube was performed via the transnasal approach under video-endoscopic control. This was followed by decongestion of the torus tubarius and the inferior turbinate by QMR, with immediate shrinkage of the mucosa of the turbinate and a reduction of the prolapse of the mucosal plica on the tubal ostium.

RESULTS

Comparison of pre- and postoperative oto-functional examinations revealed a significant improvement. The postoperative hearing symptoms were reduced in a statistically significant manner on the visual analog scale (VAS). It was possible to perform the postoperative "swallowing-opening-Toynbee-Valsalva" (SOTV) test in a significant percentage of cases compared to the preoperative test.

CONCLUSION

The combined surgical procedure of balloon tubodilation with simultaneous QMR-mediated shrinkage of the tubal ostial mucosa and reduction of the posterior portion of the inferior turbinate was found to be an effective, safe, and complete treatment for tubal dysfunction in the majority of patients.

Eustachian tube balloon dilation in treatment of equalization problems of freediving spearfishermen

BACKGROUND

Eustachian tube balloon dilation is a minimally invasive surgical procedure used to treat Eustachian tube dysfunction which is not responsive to conventional therapies.

METHODS

In this cohort intervention series we report the results of balloon dilation in treating refractory equalization problems in 20 freediving spearfishermen; in 19 cases the problem was unilateral and in one case bilateral. All the patients had already received medical and insufflation therapy and four patients had also had nasal surgery. None of these treatments or procedures had achieved improvement. We used a 20 mm x 3 mm disposable balloon catheter inserted through a 70-degree guide catheter and inflated up to 12 ATM three times at three different depths of insertion within the Eustachian tube. Every inflation lasted 120 seconds.

RESULTS

Fifteen out of 20 patients improved. Ten patients reported a complete resolution of equalization problems, five showed improvement with persistence of a slight equalization delay on the treated side. Five patients did not report any improvement. Two complications occurred: subcutaneous emphysema of the parotid region in one case; and a mild high frequency (4-8 KHz) sensorineural hearing loss in another patient.

CONCLUSION

Balloon dilation of the Eustachian tube is an effective therapy in the treatment of equalization problems with a good success rate.

Fluoroscopy-guided balloon dilation in patients with Eustachian tube dysfunction

OBJECTIVES

To prospectively evaluate the technical feasibility and safety of fluoroscopy-guided balloon dilation in patients with Eustachian tube (ET) dysfunction.

METHODS

Patients who could not do a Valsalva manoeuvre for more than 6 months and diagnosed with chronic otitis media or ET dysfunction were prospectively enrolled. A 0.035-in. guide wire and 6-mm long balloon catheter with a diameter of 2 mm were used to dilate the cartilaginous portion of the ET under fluoroscopic guidance. The balloon was inflated by manual injection twice for 1 min each time. Clinical outcomes were assessed by the patient's ability to perform a Valsalva manoeuvre, and symptoms were assessed using the 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) score.

RESULTS

Balloon dilation was attempted in a total of ten adult patients from October 2016 to March 2017. Technical success was achieved in all procedures (10/10). Ninety percent (9/10) of the balloons were fully dilated without waist deformity. There were no major complications. All patients were able to perform a Valsalva manoeuvre at the time of their last visit and/or improvement of at least one ETDQ-7 score.

CONCLUSION

Fluoroscopy-guided balloon dilation seems to be technically feasible and safe in the treatment of ET dysfunction.

KEY POINTS

• Fluoroscopy-guided balloon dilation without general anaesthesia was well-tolerated in all patients. • Location of the balloon catheter can be monitored during the procedure. • Inflation state of the balloon catheter can be monitored during the procedure. • Using guide-wire during the procedure would prevent false passage creation. • All patients had clinical improvement within 3 months after balloon dilation.

Treatment of pharyngotympanic tube dysfunction

Eustachian tube dysfuntion intends to describe a variety of signs, symptoms, and physical findings that result from the impairment of ET function. A large variety of methods have been employed to assess ET function in the literature. Due to the lack of high level evidence, it is difficult to draw conclusions on the effectiveness of medical and surgical treatments. There are various medical and surgical interventions available for chronic obstructive ET dysfunction including balloon Eustachian tuboplasty (BET) and laser or microdebrider tuboplasty. Consensus on diagnostic criteria for ETD is required to define inclusion criteria of future trials. There is however emerging work with reassuring, but preliminary, results that suggest evidence for safety in the surgical management of ETD. Like many newly introduced techniques the current data remains limited to non-controlled case-series, with heterogeneous data collection methods and lacking substantial long-term outcomes. Nevertheless, short-term data provide favorable results. Current treatment options comprising BET and patulous ET surgery may be offered as a treatment possibility to selected patients.

Measurement of middle ear pressure changes during balloon eustachian tuboplasty: a pilot study

CONCLUSION

The middle ear pressure changes detected during BET can be directly attributed to the balloon inflation and may represent a second, immediate, mechanism of action of BET. BET seems to be safe with respect to the risk of a barotrauma. Further human studies are now necessary to confirm the results and gain more insight into the mechanism of action of BET.

OBJECTIVE

Since the introduction of Balloon Eustachian Tuboplasty (BET) as a treatment of chronic Eustachian tube dysfunction, the precise mechanism of action is unknown. Long-term effects of BET may be related to observed microfractures of the Eustachian tube cartilage. However, clinical observations indicate a second, immediate mode of action. Therefore, this study investigated and characterized middle ear pressure changes occurring directly during BET procedure.

METHODS

Using a micro-optical pressure sensor, pressure changes during BET were monitored transtympanically in a cadaveric animal study using heathland sheep.

RESULTS

Middle ear pressure amplitudes during BET are dependent on the speed of balloon inflation as well as the maximum inflation pressure. A 10-bar inflation pressure yielded a mean middle ear pressure of 5.34 mmHg (71.0 daPA). Negative pressure amplitudes occurring on withdrawal of the balloon catheter are influenced by the speed of withdrawal. No pressure amplitudes capable of causing barotrauma to membranous ear structures could be detected.

Reliability of Eustachian tube function measurements in a hypobaric and hyperbaric pressure chamber

OBJECTIVES

Measurement of the Eustachian tube (ET) function is a challenge. The demand for a precise and meaningful diagnostic tool increases-especially because more and more operative therapies are being offered without objective evidence. The measurement of the ET function by continuous impedance recording in a pressure chamber is an established method, although the reliability of the measurements is still unclear.

METHODS

Twenty-five participants (50 ears) were exposed to phases of compression and decompression in a hypo- and hyperbaric pressure chamber. The ET function reflecting parameters-ET opening pressure (ETOP), ET opening duration (ETOD) and ET opening frequency (ETOF)-were determined under exactly the same preconditions three times in a row. The intraclass correlation coefficient (ICC) and Bland and Altman plot were used to assess test-retest reliability.

RESULTS

ICCs revealed a high correlation for ETOP and ETOF in phases of decompression (passive equalisation) as well as ETOD and ETOP in phases of compression (active induced equalisation). Very high correlation could be shown for ETOD in decompression and ETOF in compression phases. The Bland and Altman graphs could show that measurements provide results within a 95 % confidence interval in compression and decompression phases.

CONCLUSIONS

We conclude that measurements in a pressure chamber are a very valuable tool in terms of estimating the ET opening and closing function. Measurements show some variance comparing participants, but provide reliable results within a 95 % confidence interval in retest. This study is the basis for enabling efficacy measurements of ET treatment modalities.

Balloon Eustachian Tuboplasty in children

Endonasal ballon dilatation of the Eustachian tube (BET) is a promising treatment for Eustachian tube dysfunction with encouraging results over the last years in adults. In addition, in children, single studies demonstrated promising results, but revealed the necessity for broader and additional studies. Our retrospective analysis presents outcomes with BET in children with chronic obstructive dysfunction of the Eustachian tube, showing resistance to the conventional therapy after adenotomy with paracentesis or grommets (ventilation tubes). The data of 52 children, having undergone BET from April 2011 to April 2016, were retrospectively evaluated. Most children in our study presented middle ear effusion (47%), adhesive (21%), chronic otitis media (13%), or recurrent acute otitis media (11%). In 24 (37%) children, we combined BET with a paracentesis, in 5 (8%) patients with a tympanoplasty type I and in 3 (5%) patients with a type III. All children were assessed using an audiogram, tympanometry, and tubomanometry (50 mbar) before and after BET. In addition, we evaluated the results of the Lübecker questionnaire, which we performed before and after BET. The childrens' ear-related and quality of life-related symptoms, such as pressure equalization, ear pressure, hearing loss, pain and limitation in daily life, and satisfaction pre- and postoperatively, were analyzed. In the majority of patients, we could see an improvement in the ear pressure, hearing loss, limitation in daily life, and satisfaction with recurrent inflammations, underlined by better outcomes in the tubomanometry and the tympanogram. BET in children is a safe, efficient, and promising method to treat chronic tube dysfunction, especially as a second line treatment, when adenotomy, paracentesis, or grommets failed before.

Balloon Eustachian tuboplasty under local anesthesia: Is it feasible?

OBJECTIVE

To study whether balloon Eustachian tuboplasty (BET) is a feasible and safe procedure under local anesthesia.

STUDY DESIGN

Prospective multicenter case-control study.

METHODS

Patients undergoing either BET (n = 13) or endoscopic sinus surgery (ESS) (n = 12) under local anesthesia, with the possibility of sedation and analgesia, were monitored during the procedure and recovery period for possible adverse effects. After the procedure, the patients responded to a questionnaire assessing their experience.

RESULTS

No adverse effects were detected in the BET group. Patients in the BET group reported similar Visual Analog Scale scores for pain during the operation as the ESS group (5.0 ± 0.7 vs. 3.2 ± 0.7, mean ± standard error of the mean). However, patients in the BET group experienced more discomfort (4.2 ± 0.6 vs. 2.5 ± 0.3, respectively, P = 0.049). Seventy-seven and 92% of the patients in the BET and ESS groups, respectively, considered the anesthesia and pain relief to be sufficient. Patients from both the BET and ESS groups were almost devoid of pain 1 to 2 hours postoperatively (0.8 ± 0.2 and 1.4 ± 0.3, respectively). In total, 12 of 13 patients in the BET group, and all 12 patients in the ESS group, would choose local anesthesia with sedation and analgesia if they needed to undergo the same procedure again.

CONCLUSION

BET is a safe and feasible procedure under monitored anesthesia care, including local anesthesia along with sedation and analgesia. There is need for further methodological improvement to reduce pain and discomfort during the operation.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1021-1025, 2017.

[Balloon dilatation of the Eustachian tube during middle ear surgery : Study planning and first experiences during recruitment]

BACKGROUND

Eustachian tube dysfunction is considered a major contributor to chronic middle ear disease. In clinical case series, the results of balloon dilation (balloon Eustachian tuboplasty, BET) as a treatment for Eustachian tube dysfunction have been reported.

OBJECTIVE

This study aims to analyze whether patients undergoing planned surgery for chronic middle ear disease would benefit from additional BET.

METHODS

In a randomized controlled, patient and observer (not surgeon)-blind clinical study, 100 adult patients with planned surgery for chronic middle ear disease will be investigated. Patients will be randomized into two groups, one of which (50%) will receive additional BET of the affected side during the planned surgery. Eustachian tube function will be evaluated using the Valsalva maneuver and tubomanometry according to Estève, as well as on the basis of patient reports. Various scores will be used as outcome measures, including ETS-5 (Eustachian Tube Score 5), the extended version ETS-7, and the ETDQ-7 (Seven-Item Eustachian Tube Dysfunction Questionnaire). Follow-up is at 3, 6, and 12 months.

RESULTS

From June to December 2015, 162 patients underwent microscopic ear surgery. Inclusion criteria were not fulfilled by 90 patients. Of the remaining 72 patients with chronic middle ear disease, 12 patients (17%) have been randomized so far, 28 (39%) did not exhibit Eustachian tube dysfunction, and 32 (44%) patients could not be included for other reasons.

CONCLUSION

The rate of recruitment was lower than expected. Depending on the case number calculations for the patient groups identified in the study for whom BET might be particularly beneficial, multicenter studies in specific disease groups may follow.

[The pressure-equalizing function of the Eustachian tube : Evaluation in a hypo-/hyperbaric pressure chamber]

BACKGROUND

The Eustachian tube connects the tympanic cavity (cavum tympani) and the nasopharynx, and enables pressure equalization between the middle ear and ambient pressure. Functional pressure compensation is very important for flying and diving in particular, due to non-physiologically large pressure differences.

OBJECTIVE

Evaluation of the pressure-equalizing function of the Eustachian tube is still a clinical challenge. This review article evaluates the existing data.

METHODS

Based on a selective literature search, different methods for evaluation of tube function are presented and evaluated, with special reference to evaluation of the pressure-equalizing function in a hypo-/hyperbaric pressure chamber.

RESULTS

The pressure chamber enables the dynamics of active and passive pressure compensation to be provoked and also permits accurate measurement of pressures in the millibar range.

CONCLUSION

A pressure chamber seems to be suitable to evaluate Eustachian tube function and therapeutic approaches to tube dysfunction. Further studies are needed to assess the value of the pressure chamber in combination with other functional tests.

Eustachian tube evaluation in aviators

The aim of the study is to evaluate the Eustachian tube functionality in a group of aviators to underline a subclinical dysfunction and the related risk of ear fullness or barotitis. Hypobaric chamber allows to simulate the pressure variation of the flight. This prospective study enrolled 42 aviation pilots, members of the Italian Air Force, to whom were evaluated Eustachian tube functionality by Tubomanometry, patients subjective assessments concerning feasibility of Valsalva's and Toynbee's clinical symptoms, tympanometry, and objective Valsalva before and after exposure to hypobaric chamber. The new Eustachian tube score (ETS-7) was also calculated for each pilot before and after exposure to hypobaric chamber. Results of our examination showed that: before chamber exposition, in 92.8 % of pilots, an ETS-7 of eight or more was found bilaterally. In three (7.2 %) cases, a unilateral ETS-7 ≤ 7 was found and two of those had a positive history. After undergoing the hypobaric chamber session, the evaluation of ETS-7 showed only 19 % of pilots with an ETD score ≤7, in particular three bilateral and five unilateral cases. Three of those pilots were clinically positive: two airmen reported persistent fullness, while the other one had a barotitis. Therefore, the combined use of TMM and ETS-7 before and after hypobaric chamber exposure appears to be a reliable method for assessing the functional capacity of the Eustachian tube in aviators, the stressful effect of flight on it, to exclude subjects at increased risk of ear pain, fullness, or barotrauma.

[Does balloon dilatation represent a breakthrough for Eustachian tube disorders – even in children?]

Balloon dilatation is a promising new treatment for Eustachian tube dysfunction which is becoming more and more popular in Germany. There are a number of single publications and even meta-analyses on this topic, which demonstrate good results but also reveal the need for better studies. Initially tube dilatation was applied only in adults with tube dysfunctions but recently some centers even recommend it for children with long-lasting or frequently recurring middle ear effusion, which is resistant to conventional therapy. This article provides a critical appraisal based on the current literature and emphasizes the need for controlled studies. Due to the poor definition of tube dysfunctions it may be difficult to establish informative studies but in terms of evidence-based medicine there is need for a precise definition of indications and inclusion criteria. Most important is that such studies must include control groups, which has so far not been the case. Moreover, there should be a consensus about the criteria for defining success. Although all publications claim that balloon tuboplasty is a safe method, the question whether or not preoperative computed tomography (CT) scans are needed should be considered in each individual case. Nevertheless, balloon dilatation is a very promising method offering a new approach to the problem of Eustachian tube dysfunction.

Characterizing the active opening of the eustachian tube in a hypobaric/hyperbaric pressure chamber

OBJECTIVE

Active and passive opening of the Eustachian tube (ET) enables direct aeration of the middle ear and a pressure balance between middle ear and the ambient pressure. The aim of this study was to characterize standard values for the opening pressure (ETOP), the opening frequency (ETOF), and the opening duration (ETOD) for active tubal openings (Valsalva maneuver, swallowing) in healthy participants.

DESIGN/PARTICIPANTS

In a hypobaric/hyperbaric pressure chamber, 30 healthy participants (19 women, 11 men; mean age, 25.57 ± 3.33 years) were exposed to a standardized profile of compression and decompression. The pressure values were recorded via continuous impedance measurement during the Valsalva maneuver and swallowing. Based on the data, standard curves were identified and the ETOP, ETOD, and ETOF were determined.

RESULTS

Recurring patterns of the pressure curve during active tube opening for the Valsalva maneuver and for active swallowing were characterized. The mean value for the Valsalva maneuver for ETOP was 41.21 ± 17.38 mbar; for the ETOD, it was 2.65 ± 1.87 seconds. In the active pressure compensation by swallowing, the mean value for the ETOP was 29.91 ± 13.07 mbar; and for the ETOD, it was 0.82 ± 0.53 seconds.

CONCLUSION

Standard values for the opening pressure of the tube and the tube opening duration for active tubal openings (Valsalva maneuver, swallowing) were described, and typical curve gradients for healthy subjects could be shown. This is another step toward analyzing the function of the tube in compression and decompression.

Balloon Eustachian Tuboplasty

Objective

A systematic review and meta-analysis of the evidence on balloon Eustachian tuboplasty (BET) as a treatment modality for Eustachian tube dysfunction (ETD). We followed the PRISMA guideline and registered with PROSPERO No. CRD42014009461.

Data Sources

We searched 12 databases including PubMed and Embase from January 1, 2010, to April 7, 2014, for studies of BET. Endpoints: change in symptoms, middle ear pathology, eardrum status, Eustachian tube function tests, hearing, adverse events, complications, and health-related quality of life.

Review Methods

Study quality was assessed using the modified Delphi technique quality appraisal tool for case series studies. Risk of bias was assessed using the Cochrane Collaboration’s tool for assessing risk of bias.

Results

Nine case series studies with 443 patients (642 tubes) were included. Population size n = 4 (7 tubes) to n = 210 (320 tubes). All studies were of poor quality and featured a high risk of bias. We found reduction of patient symptoms in ETD questionnaire ( P < .001), postoperative normalization of the tympanic membrane, conversion of type B or type C into type A tympanograms, reduced mucosal inflammation, increased number of positive Valsalva test and Swallowing tests, improvement in Eustachian tube score, reduction in Sino-Nasal Outcome Test (SNOT)-22 score ( P = .001), and increased quality of life ( P = .001). No serious adverse events were found.

Conclusion

The evidence of BET is poor and biased. No firm conclusions can be made to identify patients who will benefit from the procedure or to accurately predict surgical results. Randomized controlled trials or case-control trials are needed.

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.