Balloon dilation of the cartilaginous portion of the eustachian tube: initial safety and feasibility analysis in a cadaver model

Eustachian Tube Dysfunction in Adhesive Otitis Media: Obstructive Versus Patulous Types

OBJECTIVE

Understanding the distinct subtypes of adhesive otitis media (AdOM) is crucial for appropriate treatment such as balloon Eustachian tuboplasty (BET), particularly in distinguishing between patulous and obstructive Eustachian tube (ET) function. Nevertheless, AdOM caused by patulous Eustachian tube dysfunction (ETD) remains underexplored. This study aims to describe the detailed characteristics and define the patulous type of AdOM associated with patulous ETD (PET).

STUDY DESIGN

A prospective cohort study.

SETTING

A total of 62 ears of patients diagnosed with AdOM, PET, and traumatic perforation were included from a tertiary referral center (university hospital).

METHODS

Obstructive-AdOM, patulous-AdOM, PET, and a control group with traumatic perforation patients underwent endoscopic examinations, completed symptom questionnaires, and had passive ET opening pressure evaluated using a modified inflation-deflation test following tympanostomy tube insertion.

RESULTS

Patulous-AdOM was identified in 43% of the patients and was characterized by significantly lower median opening pressures (222 daPa) than those in patients with obstructive-AdOM (400 daPa) and PET (below 100 daPa). Habitual sniffing was reported in 92.3% of patients with patulous-AdOM, and reduced mastoid pneumatization was observed in both the patulous and obstructive subtypes.

CONCLUSION

Accurate differentiation between patulous-AdOM and obstructive-AdOM is essential because BET may exacerbate symptoms in patients with patulous characteristics. A comprehensive evaluation of ET function is critical before initiating treatment, underscoring the need for tailored approaches to manage AdOM.

Balloon dilatation of the Eustachian tube for obstructive Eustachian tube dysfunction in adults

BACKGROUND

Eustachian tube dysfunction (ETD) causes symptoms and signs of pressure dysregulation in the middle ear, and is associated with tympanic membrane retraction, otitis media with effusion, and chronic otitis media. Interventions aiming to improve symptoms can be non-surgical or surgical, including balloon dilatation of the Eustachian tube, also known as balloon eustachian tuboplasty (BET) for obstructive ETD. However, existing published evidence for the effectiveness and safety of BET remains unclear.

OBJECTIVES

To evaluate the effects of balloon dilatation of the Eustachian tube in adults with obstructive Eustachian tube dysfunction.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid M>DLINE; Ovid Embase; Web of Science; Clinicaltrials.gov; ICTRP and additional sources for published and unpublished trials. The final search was updated on 18th January 2024. There were no restrictions on language, publication date or study setting.

SELECTION CRITERIA

Randomised controlled trials were included if they allocated adult participants with chronic obstructive ETD to treatment randomly and compared BET with non-surgical treatment, no treatment, or other surgical treatment. Studies with other designs were excluded.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials using predetermined inclusion criteria, assessed the risk of bias, extracted data, and rated the certainty of evidence (CoE) according to GRADEpro. Statistical analyses were performed using a random-effects model and interpreted according to the most recent version of the Cochrane Handbook. Predefined primary outcomes were obstructive ETD symptoms, Eustachian tube function (objective or semi-objective tests), or serious adverse events. Secondary outcomes were hearing, tympanic membrane abnormalities, quality of life, and other adverse events.

MAIN RESULTS

Nine trials were identified with 684 randomised participants across three comparisons: BET versus non-surgical treatment (five trials, 422 participants), BET versus no treatment (sham surgery; one trial, 17 participants), and BET versus other surgery (four trials, 275 participants). None of the studies were rated with an overall low risk of bias. Comparing BET to non-surgical treatment up to three months, there is low-certainty evidence showing that BET may reduce patient-reported ETD symptoms (change in ETDQ-7: mean difference (MD) -1.66 (95% CI -2.16 to -1.16; I2 = 63%; 4 RCTs, 362 participants)). There is very low-certainty evidence that BET may improve ETD as assessed by objective or semi-objective measures (improvement in tympanometry: RR 2.51 (95% CI 1.82 to 3.48; I2 = 0%; 3 RCTs, 369 participants). Between three and 12 months, the evidence is very uncertain whether BET reduces ETDQ-7: MD -0.55 (-1.31 to 0.21; 1 RCT, 24 participants). The evidence is very uncertain whether BET improves ETD as assessed by objective or semi-objective measures (improvement in tympanometry: RR 2.54 (95% CI 0.91 to 7.12)). Evidence was downgraded for risk of bias, imprecision, indirectness, or a combination of these. Comparing BET to no treatment (sham surgery trial) up to three months, there is very low-certainty evidence that BET improves ETD as assessed by patient-reported ETD symptoms (change in ETDQ-7: MD -0.54 (95% CI -2.55 to 1.47; 1 RCT, 17 participants)). Between three and 12 months, the evidence is very uncertain whether BET improves ETD as assessed by ETDQ-7 (MD 0.16 (95% CI -0.75 to 1.07; 1 RCT, 17 participants)). Evidence was downgraded for indirectness and twice for imprecision. Although there were no serious adverse events reported, these studies were underpowered to detect adverse events and were performed by highly trained and experienced investigators under strict study protocols. This could underestimate the true risk of adverse events by less experienced clinicians in everyday clinical practice. Evidence was rated as very low certainty, downgraded for risk of bias, imprecision, and indirectness.

AUTHORS' CONCLUSIONS

BET may lead to a clinically meaningful improvement in ETD symptoms compared to non-surgical or no treatment (in the form of sham surgery) at up to three months. The effects of BET on ETD compared to non-surgical treatment are very uncertain beyond three months. However, the certainty of evidence ranged from low to very low, with the studies being underpowered to detect adverse events. The findings of this review should help to inform further BET research and guidelines. Future research should focus on longer-term outcomes and the incidence of adverse events or complications in real-world practice settings.

MAUDE database and Eustachian tube balloon dilation: Evaluation of adverse events and sales data

STUDY DESIGN

Review of database.

SETTING

Tertiary care neurotology center.

PATIENTS

Patients undergoing adverse events.

INTERVENTION

MAUDE database evaluation of Eustachian tube balloon dilation (ETBD) for the treatment of Eustachian tube dysfunction.

MAIN OUTCOME MEASURES

Medical device reports (MDRs) from the MAUDE database were analyzed for adverse patient events (AE) and device malfunctions (DM) among different devices for ETBD. The objective of this analysis is to assess AE rates and compare them across different devices. Sales data was also used to calculate AE rates.

RESULTS

There were 18 MDRs noted in the MAUDE database for patients undergoing ETBD out of an initial 23 results. When separated into devices, the Aera had 9 total MDRs (50 %), Xpress had 8 (44.4 %) and Audion had 1 (5.6 %). There were 10 AE and 8 DM. When separated by device, Aera had 4 AEs and 5 DMs, Xpress had 5 AEs and 3 DMs, and Audion had 1 AE. The most common AE was subcutaneous emphysema (n = 4), in the head and neck region with one report of mediastinal involvement. Using this sales data, the Aera balloon has an MDR rate of 0.0128 % is established, with a rate of AE at 0.0058 %. The Audion balloon had an MDR and AE rate of 0.0164 %.

CONCLUSIONS

ETBD is a safe procedure with minimal complications, with subcutaneous emphysema being the most commonly reported adverse event, consistent with literature findings. A comprehensive analysis of AE, coupled with sales data, indicates a commendably low MDR rate of 0.0128 % for the Aera balloon while the Audion balloon had an MDR rate of 0.0164 %. These findings offer valuable insights on post-procedure expectations and engaging in informed consent discussions with patients, highlighting the overall safety of ETBD as an intervention.

Effect of balloon dilatation among adult population with eustachian tube dysfunction: a systematic review

PURPOSE

This study aimed to assess the efficacy and safety of ballon dilation of the eustachian tube (BDET) in adult population suffering from Eustachian tube dysfunction (ETD).

METHODS

Following PRISMA criteria, a systematic review was conducted by searching PubMed, Cochrane, and Embase databases from January 2015 to March 2024. The primary outcomes included Eustachian Tube Score (ETS), tympanometry, and Valsalva maneuver. The quality of studies was assessed using the Quality in Prognostic Studies (QUIPS) instrument.

RESULTS

Overall, 11 studies were incorporated into the systematic review: two RCTs, three prospective investigations, and six retrospective studies. The balloon dilation in all investigations was performed using either Spiggle & Theis or Acclarent catheters for balloon dilation. There was heterogeneity across studies examining the effect of BDET on persistent ETD in terms of patient selection, period of follow-up, administration of conservative or surgical therapies, and use of assessment methods. Overall, the treatment yielded alleviation of symptoms, which either exhibited stability over time or demonstrated further improvement after an average duration of follow-up. Moreover, the incidence of complications was categorized as low and resolving spontaneously. The majority of the studies exhibited a high risk of bias related to confounding variables, and consequently, the overall risk of bias across most studies was considered high.

CONCLUSION

The findings suggest BDET holds promise for ETD treatment, reducing symptom severity with minimal complications. Nonetheless, there is a need for improved studies that adhere to established indications, methodologies, and outcomes to establish a more robust body of evidence.

Dilatation Eustachian tuboplasty with a Eustachian tube video endoscope and supporting balloon

OBJECTIVE

To evaluate the feasibility and safety of employing a Eustachian tube video endoscope with a supporting balloon as a viable treatment and examination option for patients with Eustachian tube dysfunction.

METHODS

A study involving nine fresh human cadaver heads was conducted to investigate the potential of balloon dilatation Eustachian tuboplasty using a Eustachian tube video endoscope and a supporting balloon catheter. The Eustachian tube cavity was examined with the Eustachian tube video endoscope during the procedure, which involved the dilatation of the cartilaginous portion of the Eustachian tube with the supporting balloon catheter.

RESULTS

The utilisation of the Eustachian tube video endoscope in conjunction with the supporting balloon catheter demonstrated technical ease during the procedure, with no observed damage to essential structures, particularly the Eustachian tube cavity.

CONCLUSION

This newly introduced method of dilatation and examination of the Eustachian tube cavity using a Eustachian tube video endoscope and the supporting balloon is a feasible, safe procedure.

Patulous Eustachian Tube Dysfunction Symptoms Following Balloon Dilation

OBJECTIVE

Clinicians increasingly perform balloon dilation of the Eustachian tube (BDET) to treat obstructive Eustachian tube dysfunction (OETD) refractory to medical management. Reported complications have been limited and include patulous Eustachian tube dysfunction (PETD). This multicenter study investigates the incidence of PETD and associated factors.

METHODS

Consecutive patients at three academic centers undergoing BDET (January 2014-November 2019) for OETD refractory to medical therapy were included. PETD was diagnosed by patient-reported symptoms of autophony of voice and/or breathing. Associated factors studied include age, sex, comorbidities, balloon size, duration of inflation, repeat BDET, and adjunctive procedures.

RESULTS

BDET procedures (n = 295 Eustachian tubes) were performed on 182 patients. Mean age was 38.4 years (SD 21.0; range 7-78) and 41.2% were female. Twenty cases of PETD (6.8% of procedures; 9.3% of patients) occurred following BDET. Risk of PETD did not vary by institution, comorbidities, or adjunctive procedure. Age ≤18 years (adjusted risk ratio [RR] = 3.26; 95% confidence interval [CI]: 1.24, 8.54; p = 0.02), repeat BDET (RR = 3.26; 95% CI: 2.15, 4.96; p < 0.001), and severe preoperative Eustachian tube inflammation (RR = 2.83; 95% CI: 1.10, 7.28; p = 0.03) were associated with increased risk of developing PETD in the multivariable model. Most symptoms were reported as mild or intermittent.

CONCLUSION

BDET caused PETD symptoms in approximately 7% of dilated Eustachian tubes in this study with increased risk for younger patients and those with severe inflammation or undergoing repeat dilations. Although most cases were self-limited, symptoms can persist. Awareness of risk factors may aid clinicians in limiting this complication.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:3152-3157, 2023.

Balloon Eustachian Tuboplasty Combined or Not with Myringotomy in Eustachian Tube Dysfunction

BACKGROUND

Eustachian tube dysfunction (ETD) is a common disorder causing ear pressure, pain, and hearing loss. Balloon Eustachian tuboplasty (BET) is an emerging technique for dilating the Eustachian tube and treating ETD. Whether adding myringotomy improves BET efficacy is controversial.

METHODS

This retrospective study included 95 ETD patients undergoing BET alone (n = 44) or BET with myringotomy (BET + M; n = 51) between June 2020 and August 2021 at a single medical center. The primary outcome was the change in ETDQ-7 symptom scores from baseline to 6 months after treatment. Secondary outcomes included audiometry, endoscopy, Valsalva maneuver, and complications.

RESULTS

The ETDQ-7 scores improved significantly after treatment in both groups (p < 0.001), without significant between-group differences (p = 0.417). No significant differences occurred in the audiometry, endoscopy, and Valsalva results or in most complications between groups. One BET + M patient had a persistent tympanic membrane perforation.

CONCLUSIONS

Both BET alone and BET + M effectively and safely improved the subjective and objective ETD outcomes. However, adding myringotomy did not further improve the outcomes over BET alone, while it incurred risks such as persistent perforation. BET alone may sufficiently treat ETD without requiring myringotomy in this cohort. Further randomized controlled trials should identify optimal candidates for BET alone versus combined approaches.

Balloon Eustachian tuboplasty for obstructive Eustachian tube dysfunction: retrospective multicentre cohort study of 248 patients

OBJECTIVE

To present the results after balloon eustachian tuboplasty (BET) in patients with obstructive Eustachian tube dysfunction (OETD) grouped up into: baro-challenge, chronic serous otitis media and adhaesive otitis media.

METHODS

A retrospective study was carried out on patients who underwent BET surgery. As outcome measures, otoscopy, tympanometry, Eustachian tube dysfunction questionnaire-7 (ETDQ-7) and ability to perform the Valsalva manoeuvre were recorded at baseline and at 3, 12 and 24 months after BET. A p value of 0.05 was used to indicate a statistically significant difference for all statistical tests.

RESULTS

Three hundred and nineteen ears (248 patients) were included with a 3-month follow-up, 272 ears had a 12-month follow-up, and 171 ears had 24-month follow-up. Globally, a statistical significance improvement in all groups in all outcome measures was found. According to BET indication, in the baro-challenge group, there was no improvement in otoscopy, but ETDQ-7, Valsalva manoeuvre and tympanogram improved significantly. In the chronic serous otitis media group, otoscopy, ETDQ-7 and Valsalva manoeuvre were significantly improved in all the three timelines, including the avoidance of a new transtympanic tube after the BET in over 80% of cases. In the adhaesive otitis media group, Valsalva manoeuvre improved significantly, ETDQ-7 decreased and tympanogram improved but not significantly. Few mild complications were reported.

CONCLUSIONS

BET is an effective method for the treatment of OETD in all etiologic groups. The greatest benefit was observed in patients with baro-challenge. A long-term follow-up is recommended since the benefit seems to increase over time.

CT Imaging of Eustachian Tube Balloon Dilation: Method Development on Cadaver Heads

Objective: To develop a methodology for the measurement of balloon dilation (BD) effects on Eustachian Tube (ET) structure using Computerized Tomography (CT) images. Methods: The BD of the ET was performed on three cadaver heads (five ears) through the nasopharyngeal orifice. The axial CT images of the temporal bones were obtained before dilation, while an inflated balloon was in the lumen of ET, and after balloon removal in each ear. Utilizing Dicom images captured by the ImageJ software 3D volume viewer function, the anatomical landmark coordinates of the ET were matched with their pre- and post-dilation counterparts, and the longitudinal axis of the ET was captured with serial images. The histograms of the regions of interest (ROI) and three different lumen width and length measurements were obtained from captured images. The densities of air, tissue, and bone were determined with histograms as a baseline to determine the BD rate as a function of increased air in the lumen. Results: The small ROI box included the area of prominently dilated ET lumen after BD and best represented the visually obvious changes in the lumen, compared to the ROIs that extended the wider areas (longest and longer). Air density was the outcome measure for comparison with each corresponding baseline value. The average increase in air density in the small ROI was 64%, while the longest and long ROI boxes showed 44 and 56% increases, respectively. Conclusion: This study describes a method to image the ET and quantify the outcomes of BD of the ET using anatomical landmarks.

Caution in Transnasal Balloon Dilation of the Eustachian Tube: Middle Ear Penetration of Catheter Tip in a Cadaveric Model

OBJECTIVE

To investigate the degree to which transnasal eustachian tube (ET) dilation balloon catheters are able to be passed through the ET in a cadaver model.

PATIENTS AND INTERVENTIONS

A cadaveric study of 8 cadaver heads (16 ears), which underwent transnasal ET insertion with a 3 × 20-mm balloon catheter with transtympanic endoscopic visualization and grading.

RESULTS

Catheter tip incursion into the protympanum or mesotympanum occurred in all ears. Radiological validation was obtained with correlation to published ET length data.

CONCLUSION

Middle ear incursion of balloon catheter tips can be demonstrated in a cadaver model and highlights the ongoing need for both caution in novel surgical techniques and evolution in device design.

The feasibility and safety of eustachian tube dilation with a standard endovascular balloon: a clinical pilot study

BACKGROUND

Obstructive eustachian tube dysfunction is a common pathology, generally accepted as the underlying cause for chronic ear diseases. Eustachian tube dilation has shown promising results in randomized controlled trials, but is a costly procedure. The aim of the current study was to assess the feasibility of transnasal balloon dilatation of the eustachian tube with an endovascular balloon in the context of ease of use, maneuverability, and safety.

METHODS

Clinical pilot study carried out at a university tertiary care facility. In total, twelve patients, were included over a period of 6 months. All patients underwent tympanoplasty or tympanomastoidectomy surgeries. Eustachian tube dilation was carried out transnasal using an endovascular balloon. A computed tomography was carried out after surgery to assess for any potential damages and compared to preoperative imaging studies. Postoperative endoscopy was performed intraoperatively and at follow up to assess for any potential damages.

RESULTS

All eustachian tube dilations were carried out successfully. No severe adverse events were noted during the procedure, in the postoperative period, or on imaging studies. Minor adverse events such as mild intraoperative bleeding was managed in a routine fashion.

CONCLUSIONS

Balloon dilation of the eustachian tube with the endovascular balloon was feasible and safe in all cases. It is likely a more cost-effective alternative to commercially available balloons with similar designs and specifications. Trial registration The study was registered at clinicaltrials.gov; NCT04809753, initial release February 24th, 2021.

[Effectiveness of baloon dilation of Eustachian tube in children with otitis media with effusion]

Otitis media with effusion is one of the most common ENT diseases in childhood. Absence of acute symptoms, prevalence of pathology among preschoolers, who often cannot complain on discomfort in the ears and hearing loss, lead to late diagnosis and treatment. Standard surgery is highly effective, but it is not able to help all patients. A new, minimally invasive technique of surgical treatment of otitis media with effusion - balloon dilation of the Eustachian tube provides additional opportunities in solving these problems.

OBJECTIVE

To evaluate the effectiveness and possibilities of its increasing in balloon dilation of the auditory tube in children with chronic otitis media with effusion. 34 children with chronic otitis media with effusion were under observation, who underwent 54 operations using a balloon catheter for the auditory tubes. The mismatch between the pressure value and the baloon diameter has been experimentally shown, and therefore a technique for intraoperative control of the effectiveness of the procedure has been developed. The effectiveness of balloon dilation in the study was 30.8-64.3%, depending on the following factors: the stage of otitis media at which the treatment was carried out, the combination of balloon dilation with tympanostomy, the use of intraoperative efficiency control technique. The high safety of the operation and the possibility of its effective implementation in patients with an operated cleft-palate are shown.

In-office Eustachian tube balloon dilation under local anesthesia as a response to operating room restrictions associated with the COVID-19 pandemic

Objective

To evaluate the feasibility of local anesthesia for Eustachian tube balloon dilation as an in-office procedure for the treatment of Eustachian tube dilatory dysfunction as a response to the restriction measures of the coronavirus disease 2019 pandemic.

Method

Patients with Eustachian tube dilatory dysfunction refractory to nasal steroids undergoing Eustachian tube balloon dilation in local anesthesia were enrolled in a prospective observational cohort between May 2020 and April 2022. The patients were assessed by using the Eustachian tube dysfunction questionnaire (ETDQ-7) score and Eustachian tube mucosal inflammation scale. They underwent clinical examination, tympanometry, and pure tone audiometry. Eustachian tube balloon dilation was performed in-office under local anesthesia. The perioperative experience of the patients was recorded using a 1-10 visual analog scale (VAS).

Results

Thirty patients (47 Eustachian tubes) underwent the operation successfully. One attempted dilation was aborded because the patient displayed anxiety. Local anesthesia was performed by using topical lidocaine and nasal packing for all patients. Three patients required an infiltration of the nasal septum and/or tubal nasopharyngeal orifice. The mean time of the operation was 5.7 min per Eustachian tube dilation. The mean level of discomfort during the intervention was 4.7 (on a 1-10 VAS scale). All patients returned home immediately after the intervention. The only reported complication was a self-limiting subcutaneous emphysema.

Conclusion

Eustachian tube balloon dilation can be performed under local anesthesia and is well tolerated by most patients. In the patients reported in this study, no major complications occurred. In order to free operation room capacities, the intervention can be performed in an in-office setting with satisfactory patient feedback.

Management of Eustachian Tube Dysfunction: A Review

The Eustachian tube is a crucial pneumatic component of the head and neck region and is often neglected as an important site of insidious pathologies. In our literature review, we negotiate the management of eustachian tube dysfunction and explore the various therapeutic and surgical options available at our disposal. We begin by investigating the physiological nature of the eustachian tube and its role in the body's functioning. We also list and elaborate on the various pathologies affecting the Eustachian tube and its associated structures. The review then outlines eustachian tube dysfunction and discusses the pathophysiology involved in the genesis of the condition and its progression. Further, the review explores the tools most commonly used to diagnose or alleviate the condition, including, but not limited to, the Valsalva maneuver, Toynbee maneuver, tympanometry, pressure chamber test, and video nasopharyngoscopy. We also touch on The ETS-7 questionnaire and then on the various surgical interventions that may be used to manipulate the condition. The review also describes conventional tympanostomy and myringotomy, along with more novel techniques such as microwave ablation, laser eustachian tuboplasty, and balloon eustachian tuboplasty. We conclude by establishing the most favorable course of treatment in cases of eustachian tube dysfunction.

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.

Development of an In Vivo Model for Eustachian Tube Dysfunction

Otitis media is often connected to Eustachian tube dysfunction (ETD). Until now, there was no large animal model available for the examination of new treatment methods such as stents for the Eustachian tube (ET). Thus, the aim of the study was to develop a method to reproducibly induce ETD by injection of fillers and without permanent closure of the ET. Tools for safe injection of hyaluronic acid (HA) in the surrounding of the ET were developed. In ex vivo experiments, HA mixed with Imeron® was injected close to the nasopharyngeal orifice of the ET of blackface sheep. The established depot was visualized using cone beam computer tomography and magnetic resonance imaging, and stents could be placed into the ET. A reliable position of the HA depot was achieved. This method was transferred to in vivo, and middle ear ventilation was investigated by tympanometry. ETD was achieved with amounts of 2.5 mL HA or higher. None of the animals showed any sign of discomfort or complications. The induced ETD lasted for 3 to 13 (maximum observation period) weeks and was also combined with middle ear effusion. A model of ETD based on injection of HA next to the ET was successfully established and is now available to test novel treatment options for ET functionality.

Patulous eustachian tube after balloon eustachian tuboplasty in a post-radiation patient

BACKGROUND

Balloon eustachian tuboplasty (BET) is a minimally invasive surgical treatment that is effective and safe for obstructive eustachian tube dysfunction. However, BET complications include excessive widening of the eustachian tube, causing a patulous eustachian tube (PET). Herein, we report a case of PET following BET in a patient who underwent radiation therapy and reviewed the literature on considerations for reducing complications after BET.

CASE PRESENTATION

A 63-year-old woman complained of bilateral ear fullness after concurrent chemoradiation therapy for nasopharyngeal lymphoma. BET was performed on the left side because the left-sided serous otitis media persisted. A left-sided PET was performed two weeks after the BET, along with eustachian tube silicone plug insertion on the left side. The patient became asymptomatic immediately after the surgery, with no recurrence reported after a 12-month follow-up period.

CONCLUSIONS

To our knowledge, there has been no report of PET following BET in a post-radiation patient, and it was successfully treated via ET silicone plug insertion.

The Feasibility of Eustachian Tube Dilation With a Standard Endovascular Balloon: A Comparative Cadaver Study

BACKGROUND

Balloon dilation of the eustachian tube is a new therapeutic option for eustachian tube dysfunction. One of the limiting factors of wider adoption of this technique in many parts of the world is the high cost of the devices, in spite of regulatory approval of safety.

OBJECTIVE

Evaluate the performance and usability of standard less-expensive endovascular balloons for eustachian tube dilation in comparison to an approved device in a preclinical study.

STUDY DESIGN

Comparative cadaver feasibility study.

SETTING

University tertiary care facility.

METHODS

Ten eustachian tube dilations were performed with an approved eustachian tube dilation device. Ten other procedures were carried out with an endovascular balloon of similar dimensions. Cone beam computerized tomography was performed to evaluate the extent of dilation and possible damages. The lumen and mucosal lining were inspected endoscopically post-dilation. Volume measurements were compared before and after the procedure in both groups using contrast enhancement.

RESULTS

All 20 eustachian tube dilations were carried out successfully. No tissue damages could be identified on cone-beam computerized tomography or via endoscopic examination. There was a statistically significant difference of eustachian tube volumes between pre- and post-dilations, with no statistically significant difference between the devices.

CONCLUSION

Eustachian tube dilation with a less costly endovascular balloon achieved similar results to an approved eustachian tube dilation device. No damages or any other safety concerns were identified in a cadaver study.

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.

[Evaluation of standardized questionnaires for diagnosis and differentiation of obstructive and patulous Eustachian tube dysfunction]

Hintergrund

Eine klaffende Tube kann insbesondere durch Autophonie, Druckgefühl und gestörten Höreindruck zu einer Einschränkung der Lebensqualität führen. Bei fehlenden spezifischen Symptomen kann die Diagnose der klaffenden Tube schwierig sein. Insbesondere die Abgrenzung zur chronisch obstruktiven Tubenfunktionsstörung stellt eine Herausforderung dar. Da derzeit kaum standardisierte Diagnostik- und Therapieoptionen zur Verfügung stehen, ist eine strukturierte Untersuchung zur sicheren Diagnostik und wissenschaftlichen Aufarbeitung dieser Erkrankung erforderlich. Für die Diagnostik der chronisch obstruktiven Tubenfunktionsstörung wurde 2012 bereits der „Eustachian Tube Dysfunction Questionnaire“ (ETDQ-7-Fragebogen) nach McCoul entwickelt. Für die klaffende Tube existiert seit 2017 der PHI-10-Fragebogen („patulous Eustachian tube handicap inventory“) nach Kobayashi.

Material und Methoden

Der PHI-10-Fragebogen wurde ins Deutsche übersetzt und an 41 Gesunden, 13 Patienten mit Tinnitus auris, 11 Patienten mit klaffender Tube und 18 Patienten mit chronisch obstruktiver Tubenventilationsstörung getestet. Zusätzlich erfolgte im Vergleich die Auswertung des ETDQ‑7 nach McCoul.

Ergebnisse

Es erfolgt die Präsentation der deutschen Übersetzung des PHI-10 und der Ergebnisse von PHI-10 und ETDQ‑7 in allen Patientengruppen. Der ETDQ‑7 hat das Risiko falsch-positiver Ergebnisse bei Patienten mit klaffender Tube und der PHI-10 bei Patienten mit obstruktiver Tubenfunktionsstörung. Beide untersuchten Fragebögen sind falsch-positiv bei Tinnituspatienten.

Schlussfolgerung

Der PHI-10 (deutsch) und ETDQ‑7 (deutsch) sind eine nützliche Unterstützung der Anamnese bezüglich Tubenfunktionsstörungen. Sie unterscheiden jedoch nur unzureichend zwischen klaffenden und obstruktiven Tubenfunktionsstörungen und eignen sich nicht für Patienten mit Tinnitus. Die Stärke der Fragebögen ist in der Verlaufskontrolle und dem Monitoring von Therapieergebnissen zu sehen.

Balloon Eustachian Tuboplasty in Pediatric Patients: Is it Safe?

OBJECTIVES/HYPOTHESIS

The objective of this study is to demonstrate that balloon eustachian tuboplasty (BET) is safe and had limited complications in the pediatric patient population.

STUDY DESIGN

Retrospective chart review.

METHODS

This study analyzed the medical records of 43 consecutive encounters of patients under the age of 18 years old who underwent attempted BET. Charts of patients' postoperative appointments and appointments 30 days following the procedure were reviewed. Any complications that were reported by the surgeons' operative report or documented postoperatively were stratified by the Classification of Surgical Complications as outlined by the American College of Surgeons. Additional data points that were analyzed included concomitant surgical procedures, estimated blood loss, and demographic information.

RESULTS

A cohort of 43 pediatric patient encounters were investigated. There was a total of two complications from BET (4.7%) and one aborted case. The complications included epistaxis controlled with oxymetazoline and pressure, and vertigo that was later attributed to vestibular migraines. One case was aborted due to inadequate exposure. The average age of patients evaluated was 12.4 ± 3.2 years old with a range of 6.6 to 17.7 years old.

CONCLUSIONS

In this retrospective cohort, BET was demonstrated to be a relatively safe intervention with an overall complication rate of 4.7% in patients as young as 6.6 years old with recurrent or chronic eustachian tube dysfunction and/or related issues.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1657-1662, 2021.

Efficacy of balloon dilatation of the eustachian tube in patients with refractory otitis media with effusion after radiotherapy for nasopharyngeal carcinoma

PURPOSE

To investigate the efficacy of balloon dilatation of the eustachian tube (BDET) in patients with refractory otitis media with effusion (OME) after radiotherapy for nasopharyngeal carcinoma.

MATERIALS AND METHODS

A total of 58 patients (74 ears) who had received BDET for treatment of refractory OME after radiotherapy for nasopharyngeal carcinoma were enrolled. The efficacy was evaluated by seven-item eustachian tube scores (ETS-7), tympanogram type and air-bone gap, and the total effective rate was also calculated. All patients were followed up for 2 years.

RESULTS

ETS-7 scores at every postoperative visit were significantly higher than preoperative scores (all P < 0.05). ETS-7 score 6 months after surgery was the highest, which declined sharply from the 6th to the 24th month after surgery. Air-bone gap from the 1st to the 18th month after surgery was significantly smaller than preoperative one (all P < 0.05). Air-bone gap 6 months after surgery was the smallest, followed by that 12 months after surgery. The improvement in tympanogram type 6 months after surgery was the highest. The improvement of tympanogram type declined sharply from 12 to 24 months after surgery. According to evaluation of efficacy, only one patient completely recovered, and five patients partially recovered during the 2-year follow-up.

CONCLUSION

BDET can only significantly improve efficacy of refractory OME after radiotherapy for nasopharyngeal carcinoma for a certain period of time during the 2-year follow-up.

Endoscopy Guided Eustachian Tube Balloon Dilation: Our Experiences

Introduction:

Eustachian tube (ET) dysfunction is a common clinical entity but its treatment is still challenging to Otorhinolaryngologists. This study is done to know the effectiveness of transnasal endoscopic balloon dilatation of eustachian tube for treatment of chronic eustachian tube dysfunction.

Materials and Methods:

It is a retrospective observational study conducted between May 2018 to June 2019 at IMS and SUM Hospital, Siksha 'O' Anusandhan University, Bhubaneswar, Odisha, India. Twenty one patients were identified with diagnosis of ET dysfunction and assigned to this study. The transnasal endoscopic procedure was done to dilate the cartilaginous part of the eustachian tube with a balloon catheter. Preoperative computed tomography was done in all cases. All patients were post-operatively assessed in 1^st, 2^nd and 8^th weeks after the procedure.

Result:

Balloon dilatation of the eustachian tube was easily performed in all cases of this study. No abnormality including carotid canal was seen before this procedure. All except 2 cases revealed significant improvement in the ET functions. There was no damage to any vital structures like internal carotid artery in this study.

Conclusion:

The majority of the patients participated in this study showed positive outcome after balloon dilation of eustachian tube. It is a feasible and safe procedure for dilating the eustachian tube. This treatment is a very promising and requires more research on this aspect.

Navigation-Assisted Balloon Eustachian Tuboplasty for Eustachian Tube Dilatory Dysfunction

Objectives.

Balloon Eustachian tuboplasty (BET) is a novel treatment method for Eustachian tube dilatory dysfunction (ETD). However, surgeons cannot identify the insertion depth of the catheter during BET, resulting in potential risks such as internal carotid artery (ICA) injury. Therefore, we developed an image-guided navigation balloon catheter to identify the insertion depth of the catheter and to establish awareness of the proximity of the ICA. This study aimed to evaluate the technical feasibility of this image-guided navigation balloon catheter system in patients with ETD.

Methods.

Twenty-nine patients (38 ears; nine bilateral; 21 right ears, and 17 left ears) diagnosed with ETD were assessed. All patients who showed no improvement despite medical therapy with topical steroids, anti-reflux medication, and the Valsalva maneuver for a minimum of 6 weeks received image-guided navigation-assisted BET. The 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) score and Valsalva maneuver were used to evaluate patients’ symptoms preoperatively and at the postoperative follow-up.

Results.

Image-guided navigation-assisted BET was safely performed in all patients. The mean total ETDQ-7 score was 25.4±7.1 preoperatively, 17.5±6.2 at 1 month, and 15.2±7.0 at 6 months (P<0.001). In total, a Valsalva maneuver was possible for 28 of 38 ears (73.7%) at the time of the patient’s final visit at 6 months post-procedure.

Conclusion.

Image-guided navigation balloon catheters are a potentially valuable tool in patients with ETD. Their use is also technically feasible and safe when performing BET to treat ETD.

The mechanism of balloon Eustachian tuboplasty: a biomechanical study

Obstructive Eustachian tube dysfunction (OETD) is a common condition resulting from inadequate opening of the Eustachian tube (ET). A new surgical treatment involves high-pressure inflation of a balloon within the ET, with the aim of dilating the soft tissue structure. However, the mechanical effects of this intervention have not been established, nor the impact of changing device size or other technical parameters. A novel experimental technique allowed quantification of plastic and elastic tissue deformation in model materials and then human cadaver ETs during balloon dilation, based on the measured balloon inflation pressure-volume relationship. Plastic tissue deformation was found to be greater using larger balloons and deeper device insertion, but increasing the inflation pressure had a more limited effect, with most deformation occurring well below the clinically used pressures. Histological assessment of ET tissue suggested that mucosal tearing and cartilage cracking were in part responsible for the mechanical changes. Balloon dilation of the ET has huge potential if found to be clinically effective, but currently there is a need to understand and develop the technique further. The novel methods employed in this study will be valuable in future laboratory and in vivo studies of ET balloon dilation. Pressures are reported in Bar as this unit is used for medical balloon dilation procedures in clinical practice. 1 Bar = 100,000 Pa.

Graphical abstract caption

Endoscopic transtympanic Eustachian tube dilatation: An overview of evaluation methods and dilatation technique

Endoscopic technique in patients undergoing chronic ear surgery allows visualization of protympanic (proximal) segment of the Eustachian tube (ET). The proximal cartilaginous ET is a common site of anatomical Obstruction in chronic otitis media and it is this proximal end of ET that is being observed, instrumented and dilated with transtympanic methods. The aim of this article is to discuss our approach to the assessment of the Eustachian tube using opening pressure measurement, endoscopic assessment of the protympanic segment of ET and Valsalva CT. And also to discuss detailed technique of transtympanic Eustachian tube dilatation.

A Randomized Controlled Trial of Balloon Dilation as a Treatment for Persistent Eustachian Tube Dysfunction With 1-Year Follow-Up

Objective:

Compare Eustachian tube balloon dilation versus continued medical therapy (control) for treating persistent Eustachian tube dysfunction (ETD).

Study Design:

Prospective, multicenter, randomized controlled trial.

Setting:

Tertiary care academic center and private practice.

Patients:

Diagnosed with medically refractory persistent ETD.

Interventions:

1:1 Randomization to balloon dilation or control. After 6 weeks, control participants had the option to undergo balloon dilation if symptoms persisted.

Main Outcome Measures:

Primary efficacy endpoint was the comparison between treatment arms in the mean change from baseline in the 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) score. Primary safety endpoint was complication rate.

Results:

Sixty participants were randomized (31 balloon dilation, 29 control). Mean (SD) change in overall ETDQ-7 score at 6 weeks was −2.9 (1.4) for balloon dilation compared with −0.6 (1.0) for control: balloon dilation was superior to control (p < 0.0001). No complications were reported in either study arm. Among participants with abnormal baseline assessments, improvements in tympanogram type (p < 0.006) and tympanic membrane position (p < 0.001) were significantly better for balloon dilation than control. Technical success was 100% (91 successful dilations/91 attempts) and most procedures (72%) were completed in the office under local anesthesia. Improvements in the ETDQ-7 scores were maintained through 12 months after balloon dilation.

Conclusions:

Balloon dilation is a safe and effective treatment for persistent ETD. Based on improved ETDQ-7 scores, balloon dilation is superior to continued medical management for persistent ETD. Symptom improvement is durable through a minimum of 12 months. Procedures are well tolerated in the office setting under local anesthesia.

Fluoroscopic Balloon Dilation Using a Flexible Guide Wire to Treat Obstructive Eustachian Tube Dysfunction

PURPOSE

To prospectively evaluate the midterm outcomes of fluoroscopic eustachian tube (E-tube) balloon dilation by using a flexible guide wire in patients with obstructive E-tube dysfunction.

MATERIALS AND METHODS

From October 2016 to September 2017, adult outpatients with persistent otitis media who were unable to perform the Valsalva maneuver were prospectively enrolled. The analysis included 32 E-tubes from 31 patients (18 women, 13 men; mean age, 47 years old, range 25-72 years). Participants underwent fluoroscopic E-tube balloon dilation with a 0.035-inch flexible guide wire and a 6- × 20-mm balloon catheter. Clinical examinations to check for the ability to perform the Valsalva maneuver and otomicroscopy were conducted at 1 week and then at 1, 3, 12, and 18 months after the procedure.

RESULTS

Balloon dilation was technically successful in all E-tubes. The mean time required for the procedure was 6.9 minutes (range, 5.8-10.3 minutes). The Valsalva maneuver was successful in opening 25 of 32 E-tubes (78.1%) at 3 months after balloon dilation. During the median follow-up of 15.9 months, failure of the Valsalva maneuver occurred in 4 of 25 improved E-tubes (16%), yielding a 2-year patency rate of 84%.

CONCLUSIONS

The fluoroscopic balloon dilation results were encouraging, and using a flexible guide wire for E-tube balloon dilation did not cause a false passage.

Consensus on treatment of obstructive Eustachian tube dysfunction with balloon Eustachian tuboplasty

OBJECTIVE

There is a great variability in diagnosis of obstructive Eustachian tube dysfunction and its treatment by balloon Eustachian tuboplasty (BET). The aim of this paper was to present a consensus on indications, contraindications, methodology, complications and results after BET.

MATERIAL AND METHODS

We obtained a consensus on BET, after a systematic review of the literature on BET from 1966 to November 2018, using MESH terms «Eustachian tube and (dilation or dysfunction)», including a total of 1.943 papers in Spanish, English, German and French. We selected 139 papers with a relevant abstract, including two international consensuses, seven systematic revisions, and two randomised control trials on BET.

RESULTS

The indications for BET are barotrauma, serous otitis media, adhesive otitis, atelectatic middle ear and failure after tympanoplasty, once obstructive Eustachian tube dysfunction is confirmed. BET is more effective in barotrauma and serous otitis media. There are high- evidence reports on BET showing good results that persist long-term, as compared to conservative medical treatment.

CONCLUSIONS

BET is a surgical, minimally invasive treatment that has shown its effectiveness and safety in obstructive Eustachian tube dysfunction in adults and children. It is most effective in barotrauma and serous otitis media.

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.

Establishment of a Large Animal Model for Eustachian Tube Functional Study in Miniature Pigs

This study was performed to investigate whether miniature pigs are a suitable animal model for studies of the Eustachian tube (ET). Sixteen Chinese experimental miniature pigs were used in this investigation. Ten animals were used for anatomical and morphometric analyses to obtain qualitative and quantitative information regarding the ET. Three animals were used for histological analysis to determine the fine structure of ET cross-sections. Three animals were used to investigate the feasibility of balloon dilation of the Eustachian tube (BDET). The anatomical study indicated that the pharyngeal orifice and tympanic orifice of the miniature pig ET are located at the posterior end of the nasal lateral wall and anterior wall of the middle ear cavity, respectively. The cartilaginous tube was seen to pass through the whole length of the ET, the length of the cartilaginous part of the ET and the diameter of the isthmus were similar between humans and miniature pigs. The inclination of the ET in miniature pigs was larger than that in humans. The gross histology seemed to be slightly different between miniature pig and human, but the fine structures were essentially the same in both species. BDET experiments verified that the miniature pig model is suitable as a model for clinical operations. The miniature pig ET corresponds very well to that of humans. In addition, the miniature pig ET is suitable as a model for clinical operations. Therefore, the miniature pig is a valid animal model for ET study. Anat Rec, 302:1024-1038, 2019. © 2019 Wiley Periodicals, Inc.

Balloon dilation of the Eustachian tube: clinical experience in the management of 126 children

Balloon dilation of the Eustachian tube has been recently introduced as a novel and minimally invasive method for treating chronic obstructive Eustachian tube dysfunction. For the first time worldwide, we assessed the role of this technique in the treatment of children with Eustachian tube dysfunction who did not respond to other treatments. We retrospectively analysed the medical records of 60 children (mean age: 6.3 years, range: 28 months to 12 years) who underwent balloon dilation of the Eustachian tube using the Bielefeld balloon catheter. In addition, the parents of a further 66 children who underwent balloon dilation (mean age: 8 years, range: 4 to 13 years) were asked to complete a standardised written questionnaire and were interviewed by telephone about the postoperative course of their children. There were no complications during surgery. Clinical symptoms improved in more than 80% of patients. No patient reported a deterioration of symptoms. Of the participating parents, 81.3% were very satisfied or satisfied with the outcome of treatment. Balloon dilation is a rapid, simple and safe method for the treatment of both adults and children with Eustachian tube dysfunction that does not respond to other treatments. Further studies, ideally multicentre studies, are required in order to optimise the definition of existing and potential new indications for this treatment approach and to establish this treatment in the management of children with refractory chronic Eustachian tube dysfunction.

Eustachian Tube Balloon Dilation: Emerging Practice Patterns for a Novel Procedure

OBJECTIVES

To review the role of eustachian tube balloon dilation (ETBD) in the setting of chronic Eustachian tube dysfunction (ETD) and ascertain how ETBD is currently being used in practice today.

METHODS

An online survey included 20 questions designed by 3 investigators to examine how otolaryngologists utilize ETBD in the management of ETD. The survey was distributed to the members of the American Rhinologic Society (ARS), American Otological Society (AOS), and American Neurotology Society (ANS) in their respective annual electronic mailings in April and May of 2017.

RESULTS

A total of 1105 and 633 surveys were sent to ARS and AOS/ANS members, respectively. Of those, 157 surveys were returned (126 from ARS and 31 from AOS/ANS). Of those returning the survey, 72 (50%) had not performed ETBD and were excluded from subsequent analysis. Forty-four (66%) respondents consider ETBD after failure of medical management; conversely, 18 (27%) and 26 (39%) consider ETBD after failure of 1 or more trial of myringotomy tube placement. Routine testing for ETBD includes audiogram with tympanometry 64 (96%) and preoperative computer tomography (CT) 38 (57%). Fifty-three (80%) practitioners only perform ETBD in adults 18 years and older. Thirty-four (53%) respondents describe ETBD as "great" or "good," while 27 (42%) were unsure, and only 3 (5%) did not like ETBD.

CONCLUSIONS

Eustachian tube balloon dilation is a novel technique for the treatment of chronic ETD, and its role continues to evolve and develop. Current practice patterns demonstrate wide variability in the assessment of ETD, heterogeneity in the timing of ETBD, and controversy in preoperative CT screening.

Transnasal Placement of a Balloon-Expandable Metallic Stent: Human Cadaver Study of the Eustachian Tube

PURPOSE

To investigate the technical feasibility of stent placement in the cartilaginous portion of the Eustachian tube (ET).

MATERIALS AND METHODS

Twelve ETs of 6 cadavers were used. Two different-sized stents were placed on either the right (2.5 mm in diameter) or left (3.5 mm in diameter) side of the ET. The procedural feasibility was assessed by subtraction Eustachian tubography, computed tomography before and after the procedure, and fluoroscopic and endoscopic images. The stent location, inner luminal diameter of the stented ET, radiation dose, procedural time, and fluoroscopy time were analyzed.

RESULTS

Stent placement was successful in 11 of 12 cadaveric specimens without procedure-related complications. In the 1 specimen, the balloon catheter with crimped stent was passed into the bony canal of the ET without any resistance. The distal end of the stent was located in the middle ear cavity. Stents were located within the cartilaginous portion of the ET (n = 1), the proximal tip bridging the nasopharyngeal orifice of the ET (n = 5), or the proximal end of the stent protruded from the tubal orifice (n = 5). The mean luminal diameter in the outer segment was significantly smaller than in the middle (P < .001) and inner (P < .001) segments. The mean procedure time was 128 ± 37 seconds. The mean radiation dose and fluoroscopy time of each cadaver were 3235.4 ± 864.8 cGy/cm² and 139 ± 49 seconds, respectively.

CONCLUSIONS

Stent placement of the ET under endoscopic and fluoroscopic guidance is technically feasible in a human cadaver model.

The cartilaginous Eustachian tube: Reliable CT measurement and impact of the length

PURPOSE

Balloon dilation of the Eustachian tube is a treatment option for obstructive Eustachian tube dysfunction. The desired balloon position is in the cartilaginous portion. However, the balloon catheter may slide into the bony portion without the surgeon's knowledge. Knowing the length of the cartilaginous portion may improve catheter positioning, but there is no published research on measuring this portion selectively or on whether the length has an impact on development of disease or treatment outcome. To evaluate whether a measurement obtained from CT images is valuable and accurate, to standardize the manner of which the length is measured, and to compare our radiologic measurements to procedural findings, we designed a combined study. Further, we tested the length's influence on development of disease and treatment outcome.

METHODS

Anatomical end points of the cartilaginous part of the Eustachian tube were unambiguously defined. The length was retrospectively measured bilaterally in 29 CT examinations by two radiologists, and repeated by one after two weeks. New reformats and measurements were made after 18 months for 10 of the patients. Prospectively 10 patients were included in a study where the length measured on CT was compared to per-procedural measurements based on catheter insertion depth to isthmus. Various parameters including length and treatment outcome were measured in 69 patients and 34 controls.

RESULTS

Correlation was adequate to excellent in all comparisons. The length of the cartilaginous Eustachian tube did not predict treatment outcome or disease development. The lengths were significantly shorter in females.

CONCLUSION

Measuring the cartilaginous portion of the Eustachian tube on CT images is precise and reproducible, and reflects the length measured intraoperatively. However, it does not seem have a prognostic value.

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.

Balloon dilation of the eustachian tube for dilatory dysfunction: A randomized controlled trial

OBJECTIVES/HYPOTHESIS

To assess balloon dilation of the Eustachian tube with Eustachian tube balloon catheter in conjunction with medical management as treatment for Eustachian tube dilatory dysfunction.

STUDY DESIGN

In this prospective, multicenter, randomized, controlled trial, we assigned, in a 2:1 ratio, patients age 22 years and older with Eustachian tube dilatory dysfunction refractory to medical therapy to undergo balloon dilation of the Eustachian tube with balloon catheter in conjunction with medical management or medical management alone.

METHODS

The primary endpoint was normalization of tympanogram at 6 weeks. Additional endpoints were normalization of Eustachian Tube Dysfunction Questionaire-7 symptom scores, positive Valsalva maneuver, mucosal inflammation, and safety.

RESULTS

Primary efficacy results demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter + medical management compared to medical management alone. Tympanogram normalization at 6-week follow-up was observed in 51.8% (72/139) of investigational patients versus 13.9% (10/72) of controls (P < .0001). Tympanogram normalization in the treatment group was 62.2% after 24 weeks. Normalization of Eustachian Tube Dysfunction Questionaire-7 Symptom scores at 6-week follow-up was observed in 56.2% (77/137) of investigational patients versus 8.5% (6/71) controls (P < .001). The investigational group also demonstrated substantial improvement in both mucosal inflammation and Valsalva maneuver at 6-week follow-up compared to controls. No device- or procedure-related serious adverse events were reported for those who underwent balloon dilation of the Eustachian tube.

CONCLUSIONS

This study demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter + medical management compared to medical management alone to treat Eustachian tube dilatory dysfunction in adults.

LEVEL OF EVIDENCE

1b. Laryngoscope, 128:1200-1206, 2018.

[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.

Endoscopically Guided Transtympanic Balloon Catheter Dilatation of the Eustachian Tube: A Cadaveric Pilot Study

OBJECTIVE

To assess the feasibility, safety, and efficacy of transtympanic balloon catheter dilatation of the Eustachian tube (ET) in a cadaver model.

PATIENTS AND INTERVENTIONS

A cadaveric study of 10 cadaver heads, which underwent unilateral transtympanic dilatation of the ET with a 3 × 20 mm balloon catheter with full endoscopic guidance and visualization.

RESULTS

Procedural safety was demonstrated, with no damage to any essential structures found. Feasibility of the procedure was demonstrated in all cadavers with 100% success rate, despite a small number of encountered difficulties. Statistically significant efficacy was also demonstrated in both radiologic and manometric data.

CONCLUSION

With full endoscopic visualization, the transtympanic approach to balloon catheter dilatation of the ET seems to be a feasible and safe procedure in the cadaver model.

[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.

Effect of the combination of balloon Eustachian tuboplasty and tympanic paracentesis on intractable chronic otitis media with effusion

OBJECTIVE

To evaluate the effect of the combination of balloon Eustachian tuboplasty (BET) and tympanic paracentesis (TP) on intractable chronic otitis media with effusion (COME).

METHODS

Ninety patients with intractable COME were included and randomly assigned to three groups: BET only (30 patients), BET+paracentesis (30 patients), and paracentesis only (30 patients). Otic endoscopic findings and tympanograms were recorded before the surgery and at the month 1, month 3, and month 6 follow-up evaluations.

RESULTS

Both the BET only and BET+paracentesis groups achieved better outcomes than the paracentesis group. The BET+paracentesis group exhibited better otic endoscopic scores than the BET only group (p<0.05) at 1month post-operation. However, no significant difference was found at month 3 or month 6 post-operation. No significant difference in the tympanograms was observed between these two groups at month 1, month 3, or month 6 post-operation. The otic endoscopic sign scores improved from month 1 to month 6 in the BET only group and from month 1 to month 3 in the BET+paracentesis group. The conversion of type B tympanograms improved from month 1 to month 6 in the BET and BET+paracentesis groups but not in the paracentesis only group.

CONCLUSIONS

Our results suggested that the combination of BET and TP was effective for intractable COME and can help shorten the recovery period for middle ear effusion.

Balloon dilation for eustachian tube dysfunction: systematic review

Background:

Eustachian tube dysfunction is a disorder for which there are limited medical and surgical treatments. Recently, eustachian tube balloon dilation has been proposed as a potential solution.

Method:

A systematic literature review was performed. Abstracts were selected for relevance, and pooled data analysis and qualitative analysis was conducted.

Results:

Nine prospective studies, describing 713 eustachian tube balloon dilations in 474 patients (aged 18–86 years), were identified. Follow-up duration ranged from 1.5 to 18 months. Ability to perform a Valsalva manoeuvre improved from 20 to 177 out of 245 ears following eustachian tube balloon dilation and, where data were reported in terms of patient numbers, from 15 to 189 out of 210 patients. Tympanograms were classified as type A in 7 out of 141 ears pre-operatively and in 86 out of 141 ears post-operatively.

Conclusion:

Prospective case series can confirm the safety of eustachian tube balloon dilation. As a potential solution for chronic eustachian tube dysfunction, further investigations are warranted to establish a higher level of evidence of efficacy.

Clinical evaluation of balloon dilation eustachian tuboplasty surgery in adult otitis media with effusion

CONCLUSION

BDET might be effective for the patients with OME, and proved to be an efficacious and mini-invasive treatment for OME.

OBJECTIVES

To evaluate the therapeutic benefits of balloon dilation eustachian tuboplasty (BDET) in the treatment of adult patients with otitis media with effusion (OME) caused by eustachian tube dysfunction (ETD).

METHODS

After informed consent, eight adult patients with OME were included in this study. After investigated patients' case history and oto-function, all patients underwent BDET treatment. Then four criteria including tympanic membrane, pure tone audiometry (PTA), tympanometry, and subjective symptoms were adopted to evaluate the therapeutic benefits of BDET.

RESULTS

None of the involved patients complained of problems or complications during the post-operative period, or with absence of pain and bleeding after the operation. Prominent post-operative improvement was observed in tympanic membrane and otoscopic appearance. In addition, cure rates after 3 months and 6 months post-operatively were gradually increased.

Transtympanic balloon dilatation of the eustachian tube: systematic review

OBJECTIVE

To investigate the evidence for balloon dilatation of the eustachian tube using a transtympanic approach.

METHODS

A systematic search of several databases was conducted (using the search terms 'dilation' or 'dilatation', and 'balloon' and 'eustachian tube'). Only studies that used a transtympanic approach for the procedure were included. These studies were then assessed for risk of bias.

RESULTS

Three studies were included. Each of these studies was a limited case series, with two performed on human subjects and one on human cadavers. Results of safety and efficacy are conflicting. There is a high risk of bias overall.

CONCLUSION

At present, there is a very narrow evidence base for transtympanic balloon dilatation of the eustachian tube. There are a number of advantages and disadvantages of the technique. Previously identified and theoretical safety concerns will need to be addressed thoroughly in future studies prior to wider clinical use.