Calcium hydroxylapatite injection for the patulous Eustachian tube

Mid-term evaluation of the surgical management of patulous Eustachian tube dysfunction: a STROBE observational study

INTRODUCTION

Patulous Eustachian tube (PET) is a condition affecting approximately 0.3% to 6.6% of the population, with autophony being the predominant complain. The management of PET lacks a well-defined standard in the literature as no effective medical treatments have been documented but various surgical options are available. This study aims to report mid-term outcomes following surgical management of PET.

MATERIALS AND METHODS

All patients who underwent surgical intervention for PET between September 2017 and June 2022 were enrolled. Data encompassing general demographics, quality of life (GBI), and procedure-specific data were collected.

RESULTS

A total of 30 PET cases (in 19 patients) underwent surgical intervention including 9 injections of hyaluronic acid, 13 fat injections, 6 endoscopic shim insertions, 1 cartilage graft, and 1 injection of hydroxy apatite. After an average follow-up of 22 ± 14 months, 16 cases (53%) achieved complete symptom relief, while 8 cases (26.6%) reported partial relief. Additionally, 11(36%) cases required multiple surgeries. No specific surgical technique demonstrated superiority. Quality of life improved in 77% of cases based on 10 out of 13 GBI collected. Recurrence of PET symptoms occurred on average 10.6 ± 9.7 months after initial surgery, with an estimated global risk of 75% at 3 years. Transient serous otitis media was observed in only 4 cases (13.3%).

CONCLUSION

Surgical intervention for PET was found to be effective, achieving complete symptom relief in 53% of cases and significantly improving quality of life 2 years post-surgery. However, a substantial portion of cases necessitated one or more re-interventions. The durability of effectiveness appears to diminish over time.

Transtympanic Tripod-shaped Angiocatheter Insertion for Patients With Intractable Patulous Eustachian Tube

OBJECTIVE

Despite the efforts to treat patients with patulous Eustachian tube (PET), intractable symptoms of PET may require surgical intervention. In this study, we introduce our surgical technique of "transtympanic tripod-shaped angiocatheter" (TTA) insertion and evaluate the safety and efficacy of the procedure in patients with intractable PET.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Thirty-two cases (26 patients) diagnosed with intractable PET between the years 2011 and 2019 were included in this study.

INTERVENTION

All cases were surgically treated with TTA insertion.

MAIN OUTCOME MEASURES

The clinical characteristics, surgical results, complication rates, and the level of satisfaction by questionnaires were analyzed for evaluation.

RESULTS

The mean age of enrolled patients was 40.9 ± 19.5 years, with slight male gender predominance (59.4% vs. 40.6%). Both ears were operated in six patients, simultaneously in three. All patients successfully received the insertion of TTA, with no immediate complication. Eleven cases were re-inserted after the first insertion due to the recurrence of symptoms or spontaneous extrusion of TTA. No major complications were observed during the follow-up period of 1 to 115 months (mean 37.7 mo). The average Visual Analogue Scale score of PET symptoms was significantly decreased (p < 0.05), along with 92% of patients with relief from autophony symptoms.

CONCLUSIONS

TTA insertion is a relatively simple procedure that can be performed in a short period under local anesthesia. Surgical intervention of TTA insertion for patients with intractable PET symptoms seems promising with a high success rate.

Diagnostic approaches to and management options for patulous eustachian tube

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

PROSPERO REG. NO. CRD: 1644000

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

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

Prevalence and incidence of clinically significant patulous Eustachian tube: A population-based study using the Korean National Health Insurance Claims Database

OBJECTIVES

The aim of this study is to estimate the entire population-based prevalence and incidence of Patulous Eustachian tube (PET) using the Korean National Health Insurance (NHI) claims database. The annual trends of prevalence and incidence of PET were also investigated.

METHODS

Retrospective analysis of PET patients was performed between 2010 and 2016, from the NHI claims database. PET patients were defined as those who had at least one service claim with a primary diagnosis under an ICD-10-based PET code (H69.0).

RESULTS

During the study period, there were 20,533 new PET patients in Korea. In 2016 there were 4482 incident cases, and the standardized annual incidence rate was 8.8 per 100,000 persons. The standardized annual prevalence rate increased significantly from 7.2 per 100,000 persons in 2010 to 10.3 per 100,000 persons in 2016. The prevalence increased significantly on annual basis, whereas the incidence rate fluctuated over time. Interestingly, the incidence and prevalence of PET in women was almost twice as high as that in men, and peaked in their 20s.

CONCLUSIONS

This study demonstrated the substantial annual increase of the NHI claims with PET code (H69.0) in Korea from 2010 to 2016. Statistical results based on the NHI claims, we confirmed the high prevalence and incidence rates of clinically significant PET in women than in men. This study only covered patient using the medical service for PET and missed PET sufferers not seeking medical service. However, this study can provide basic epidemiological information on clinically significant PET.

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

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

Trans-tympanic Cartilage Chip Insertion for Intractable Patulous Eustachian Tube

Background and Objectives

Patulous Eustachian tube (PET) causes troublesome autophony. We treated PET using tragal cartilage chip insertion to fill in the concavity within the tubal valve and evaluated the feasibility of this method.

Subjects and Methods

This study used a prospective design. Eleven patients with PET disorder were included. Tragal cartilage chip insertion via a transcanal approach into the Eustachian tube (ET) was performed in 14 ears of those patients. They were followed-up for at least 12 months after surgery and were evaluated by symptom questionnaire scores.

Results

The average follow-up was 16.4 months. Thirteen of fourteen ears received immediate complete relief of autophony symptoms. Autophony symptoms at the last follow-up were as follows: four ears (28.6%) had complete relief; five ears (35.7%) showed satisfactory improvement; four ears (28.6%) showed significant but unsatisfactory improvement; and one ear (7.1%) was unchanged. The PET symptom questionnaire in the affected ears showed a significant reduction in autophony (p=0.047) and improvement in breathing sound conduction (p=0.047). There were no complications such as otitis media or occlusion symptom.

Conclusions

Transtympanic cartilage chip insertion into the ET provides a safe and accessible surgical option for the treatment of PET.

Polydimethylsiloxane elastomer injection in the management of the patulous eustachian tube

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

Endoscopic autologous cartilage injection for the patulous eustachian tube

Patulous eustachian tube (PET) can have a significant negative impact on a patient's quality of life. Several methods of surgical management can be an option to treat PET, and our objective is to evaluate the safety and efficacy of autologous cartilage injection in patients with PET. Thirty-three ears of twenty-five patients with chronic PET refractory to conservative treatment were enrolled to this study. Autologous tragal cartilage was harvested, and chopped into fine pieces to allow its injection using a 1 cc Bruening syringe. Endoscopic cartilage injection was performed submucosally into the anterior (0.5 mL) and posterior aspects (0.5 mL) of the nasopharyngeal ET under local anesthesia in an operating room. Patients were evaluated postoperatively by nasal endoscopy and by interview to document symptoms. Successful treatment was defined as complete relief or significant improvement plus satisfaction with treatment. The only complication that occurred was temporary otitis media with effusion in one ear. Inferior turbinate reduction was performed in three ears with accompanying nasal septal deviation or turbinate hypertrophy to allow better nasopharyngeal ET visualization. After autologous cartilage injection, the successful treatment rate, as determined by subjective autophony symptoms, was 69.7% (23/33). The average follow-up period was 25.2 months. Autologous cartilage injection is a minimally invasive technique that has been used by the authors to successfully treat patulous eustachian tube. The described procedure was found to provide a good overall success rate without long-term complications.

Trans-tympanic catheter insertion for treatment of patulous eustachian tube

OBJECTIVES

To evaluate the safety and therapeutic efficacy of trans-tympanic catheter insertion (TCI) in patients with refractory patulous eustachian tube (PET).

METHODS

TCI was attempted in thirty-six ears of twenty-nine patients with chronic PET refractory to conservative treatment. The catheter was inserted under local anesthesia in an operating room through the bony orifice of the eustachian tube (ET) to occlude the isthmus of the tube via a myringotomy site on the tympanic membrane. Patients were evaluated postoperatively by nasal endoscopy and by interview to document symptoms. Successful treatment was defined as complete relief or significant improvement plus satisfaction with treatment. Patients had no concurrent disease and did not undergo any additional surgical procedure.

RESULTS

TCI was performed in all except one ear, in which it failed because of an abnormally narrow tympanic ET orifice. Follow-up durations ranged from 6 to 37 months, with an average of 19.3 months. Successful treatment of subjective autophony was achieved in twenty-nine (82.4%) of the thirty-five ears. Ventilation tube (VT) placement was performed in the two ears because of otitis media with effusion (OME) after TCI. In one ear, the inserted catheter was finally removed due to additional unilateral mastoiditis after VT extrusion.

CONCLUSION

TCI seems to be a minimally invasive and was used successfully to treat PET. The procedure had a good overall success rate and complications were rare in the long-term.