Endoscopic autologous cartilage 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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Seasonal variation of patulous Eustachian tube diagnoses using climatic and national health insurance data

OBJECTIVES

This study aimed to analyse if there were any associations between patulous Eustachian tube occurrence and climatic factors and seasonality.

METHODS

The correlation between the monthly average number of patients diagnosed with patulous Eustachian tube and climatic factors in Seoul, Korea, from January 2010 to December 2016, was statistically analysed using national data sets.

RESULTS

The relative risk for patulous Eustachian tube occurrence according to season was significantly higher in summer and autumn, and lower in winter than in spring (relative risk (95 per cent confidence interval): 1.334 (1.267-1.404), 1.219 (1.157-1.285) and 0.889 (0.840-0.941) for summer, autumn and winter, respectively). Temperature, atmospheric pressure and relative humidity had a moderate positive (r = 0.648), negative (r = -0.601) and positive (r = 0.492) correlation with the number of patulous Eustachian tube cases, respectively.

CONCLUSION

The number of patulous Eustachian tube cases was highest in summer and increased in proportion to changes in temperature and humidity, which could be due to physiological changes caused by climatic factors or diet trends.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Diagnostic approaches to and management options for patulous eustachian tube

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Paper patching for patulous eustachian tube

BACKGROUND

Paper patching, a method that places cigarette paper over the most mobile quadrants of the tympanic membrane, is one of the treatment options for patulous eustachian tube (PET).

AIMS/OBJECTIVES

The objective of this study was to compare the outcomes of two different treatment strategies for PET.

MATERIAL AND METHODS

Twenty-three patients underwent paper patching of the tympanic membrane and 16 patients were treated with nasal saline irrigation with or without ipratropium bromide nasal spray. Medical records were reviewed for resolution of PET symptoms as categorical variables (complete remission, partial remission, or no improvement) with a minimum follow-up of 3 months.

RESULTS

Immediately after undergoing paper patching, 20 of the 23 patients (87.0%) reported complete remission (CR). The percentage of CR after paper patching was 82.6% at 1 month and 65.2% at 3 months. A greater percentage of patients reported CR of aural symptoms in the paper patching group than in the nasal irrigation group at both 1 and 3 months after treatment (p < .05).

CONCLUSIONS AND SIGNIFICANCE

Repetitive paper patching resolves aural discomfort in most PET patients for at least 3 months and can be considered as a first-line treatment option for PET in the outpatient setting.

Saline injection to determine the volume required for personalised patulous Eustachian tube augmentation with long-standing material

OBJECTIVE

There is currently no general consensus on patulous Eustachian tube management. Injection of autologous fat, cartilage or hydroxylapatite has been described for Eustachian tube occlusion, with promising results. However, complete resolution of symptoms is not achieved in all cases. This could be connected to the amount of material injected into the surroundings of the Eustachian tube, as this greatly differs among existing studies. Identifying the appropriate volume of injected material could be challenging because anatomical conditions vary among patients, and there is always a risk of chronic Eustachian tube obstruction and its related complications when too much long-standing material is injected.Case reportA case is presented wherein saline was injected under local anaesthesia to determine the volume required and to predict the success of patulous Eustachian tube augmentation with long-standing material.

CONCLUSION

This approach could allow more personalised treatment and help identify patients likely to benefit from the procedure.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

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

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

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

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.