Patulous Eustachian tube (PET), a practical overview

Radiation-induced rhinosinusitis: Mechanism research and clinical progress review

Objectives

Radiation-induced rhinosinusitis is a vital dose-limiting reaction in patients with head and neck malignancy. Unlike oral mucositis during or after radiotherapy, radiation-induced sinusitis is easily overlooked in clinical practice and rarely included in experimental studies. Herein, we review the literature to date on radiation-induced rhinosinusitis.

Methods

Relevant studies published between 1995 and 2022 were determined through a detailed search using open keywords from PubMed, with manual search of the reference list of the identified articles. Keywords searched were "ionizing radiation," "radiotherapy," "intensity-modulated radiotherapy," "head and neck tumor," "nasopharyngeal carcinoma," "nasal epithelium," "radiation damage," and "radiation-induced rhinosinusitis." Full-text articles that clearly stated the pathogenesis, clinical manifestation, predictors, treatment, and prognosis of radiation-induced rhinosinusitis were included.

Results

Radiation-induced rhinosinusitis occurs during radiotherapy and can last for months or even years after radiotherapy. A mixture of cellular outcomes caused by ionizing radiation and persistent damage of the epithelial and submucosal tissues after the treatment result from the radiotherapy itself. Endoscopic sinus surgery improves symptoms but can be accompanied by intraoperative and postoperative complications. Nasal irrigation, steroids, and antibiotics appear to reduce inflammation and relieve symptoms to a certain extent. Studies on other potentially useful drugs are underway and in the exploration stage, without clinical application.

Conclusions

Despite its high incidence, radiation-induced rhinosinusitis is a type of dose-limiting toxicity that theoretically does not produce fatal effects at controlled doses and with adequate follow-up care. In moderate-to-severe cases, toxicity may be present. Currently, radiation-induced rhinosinusitis has potential prevention and treatment strategies. However, no unified management protocol has shown significant improvement in radiation-induced rhinosinusitis. Further research is necessary.

Patulous Eustachian tube: Deep breath for a diagnosis

Significance Statement: Eustachian tube disorders are common outpatient otologic presentations that can present a diagnostic challenge due to overlapping symptoms. This article will focus on patulous Eustachian tube, how the symptoms can overlap with those of Eustachian tube dysfunction, and the diagnostic insight offered by a close inspection of the tympanic membrane.

The Prevalence of Hearing Symptoms Associated With Patulous Eustachian Tube Dysfunction Following Bariatric Surgery at King Khalid University Hospital, Saudi Arabia

Background A patulous Eustachian tube (PET) is defined as a persistent tubal opening, which affects 0.3-6.6% of the population, with a female preponderance. PET is caused by the loss of subcutaneous adipose tissue enclosing the cartilaginous portion of the Eustachian tube (Ostmann's pad) as a result of acute, rapid, and substantial loss of weight which occurs during bariatric surgery. The most common complaint of PET is autophony, in which patients hear their own voices or breaths, with additional symptoms including crackling sounds, tinnitus, and aural congestion. In this study, we aimed to determine the prevalence of symptoms associated with PET dysfunction subsequent to bariatric surgery at King Khalid University Hospital (KKUH). Methodology A cross-sectional study was conducted at KKUH, Saudi Arabia. The presence of symptoms consistent with the diagnosis of PET dysfunction was assessed through in-person and telephonic interviews of bariatric surgery patients using a standardized questionnaire. Results A total of 450 patients were evaluated. The preoperative body mass index (BMI) of evaluated patients ranged from 28 to 117 kg/m2 (mean = 46.07 kg/m2), with no significant difference between symptomatic and asymptomatic groups (p = 0.303). The postoperative BMI ranged from 16 to 100 kg/m2 (mean = 29.37 kg/m2), with no significant difference between symptomatic and asymptomatic groups (p = 0.263). Hypertension was the most prevalent comorbid condition (12.2%), followed by diabetes (9.3%). In total, 91 (20.22%) patients exhibited symptoms (aural fullness and autophony) compatible with patent auditory tube dysfunction. Conclusions Overall, 20.22% of the bariatric surgery patients in our study sample displayed symptoms consistent with patulous auditory tubal dysfunction. The preoperative and postoperative BMI of symptomatic and asymptomatic patients did not differ significantly. To improve patient outcomes and satisfaction following bariatric surgery hearing symptoms associated with PET need to be included in postoperative follow-ups after bariatric surgery.

[Anomalous bony portion of the Eustachian tube]

Reports of congenital anomalies of the Eustachian tube are scare. These anomalies are usually associated with chromosomal abnormalities, most often in oculoauriculovertebral spectrum. We present a case of completely bony widened Eustachian tube, entering the cells of sphenoid sinus lateral recess. No wall defect between the sphenoid sinus and the tube was found, nevertheless the tube and middle ear had normal pneumatisation. The anatomy of the outer ear, otoscopy and hearing thresholds were normal on the ipsilateral side. At the same time, there were microtia, atresia of the external auditory canal, underdeveloped tympanic cavity and cochlea hypoplasia and deafness on the contralateral side, although the majority of previous published cases described ipsilateral temporal bone anomalies. The patient had no facial asymmetry and was not given a syndrome diagnosis.

Effectiveness of stellate ganglion block for the treatment of patulous eustachian tube: A case report

A 56-year-old woman presented with a 2 months history of patulous eustachian tube. She had sudden weight loss after developing a cold, after which she had been experiencing disabling autophony and a sensation of blockage in the ear. She underwent stellate ganglion block in 8 months; her symptoms resolved subsequently.

The Eustachian Tube Dysfunction in Children: Anatomical Considerations and Current Trends in Invasive Therapeutic Approaches

The eustachian tube (ET) has a crucial role in the physiology of the middle ear. Thus, any condition that renders the tube dysfunctional is directly implicated with middle ear pathophysiology, like in the case of acute otitis media and otitis media with effusion. Children are more vulnerable to pathologies of the middle ear, primarily due to the immature development of their eustachian tubes. Otitis media with effusion, apart from being a burden for hearing, with direct consequences for speech development, may also be implicated in cholesteatoma formation. Medical therapy is not practically effective for the treatment of effusion. Moreover, the established surgical approaches, like grommets and adenoidectomy, deal only indirectly with the problem since they are not addressing the dysfunctional ET itself. An emerging interventional approach that intends to restore the function of the tube is the transnasal balloon dilation of the cartilaginous part of the ET. Growing international experience indicates that this promising technique is safe and effective. In the current review, we aim to provide background information on the anatomy, physiology, and pathophysiology of the ET and to present the progress of the balloon dilation technique with emphasis on pediatric patients.

Bilateral idiopathic temporal bone meningoencephaloceles - An unusual presentation

Meningoencephaloceles (MECs) occur due to herniation of brain tissue through a bony defect in the skull base. They can be spontaneous or acquired. These are secondary to trauma, infection or neoplasia. Adult-onset spontaneous or idiopathic MECs are rare. Temporal bone MECs can present with watery discharge from the ear, conductive hearing loss or symptoms of meningitis like headache, fever, vomiting or seizures. These symptoms mimic chronic suppurative or serous otitis media. Computed tomography scan and magnetic resonance imaging differentiate between them. Awareness of this disease entity is necessary for early detection to avoid complications. We report a case of bilateral idiopathic temporal bone MECs with a rare presentation of autophony as the chief complaint. The differentiating features on computed tomography scan and magnetic resonance imaging and the surgical management are discussed.

Role of Allergy in Eustachian Tube Dysfunction

PURPOSE OF REVIEW

Eustachian tube dysfunction (ETD) presents with symptoms of aural fullness and pressure, muffled hearing, tinnitus, and otalgia. When severe, it can lead to many common ear disorders such as otitis media with effusion, tympanic membrane retraction/perforation, and cholesteatoma. These diseases are prevalent in both the pediatric and adult population and significantly impact quality of life. The pathophysiology of ETD in the absence of an obstructive lesion has long been debated but is thought to be related to functional obstruction (i.e., inefficient tensor veli palatini muscle) and/or nasal cavity and nasopharyngeal inflammation. In the acute setting, the most common cause of nasal inflammation is an upper respiratory infection. When symptoms become chronic, however, the inflammation is thought to be associated with nasal irritants such as nasal allergens, i.e., allergic rhinitis (AR). The purpose of this review is to summarize our current understanding of the relationship between allergy and ETD.

RECENT FINDINGS

Past studies are either lacking or have reported equivocal findings regarding the relationship between allergy and ETD, and the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis has deemed the current level of evidence linking AR and ETD as low quality. A more recent study using a large adult population dataset did support an association between AR and ETD, but did not find that all cases of ETD are related to allergies. Furthermore, current evidence suggests that the use of medications that can decrease intranasal inflammation, such as intranasal corticosteroids or oral antihistamines, does not result in significant symptomatic improvement in patients with ETD. However, these studies included all patients with ETD, and evidence is lacking regarding the treatment effect of these medications on the subset of patients with concurrent AR and ETD. Current best evidence does support an association between AR and ETD; however, not all patients with ETD suffer from AR, and vice versa. Further research is necessary to understand the mechanism behind this positive association and to elucidate the cause of chronic ETD in patients without associated allergies.

The impact of bariatric surgery on eustachian tube dysfunction

PURPOSE

We aimed to evaluate the relationship between acute loss of weight after 6 months of bariatric surgery and the occurrence of tubal dysfunction symptoms METHODS: We recruited 76 patients who had undergone bariatric surgery between 2018 and 2019. It was planned to see if the change in Body Mass Index (BMI) caused changes in the Eustachian Tube Dysfunction Questionnaire (ETDQ-7) scores of individuals. Regardless of the questionnaire, patients were also asked for 3 symptoms (autophony, fullness in the ear, hearing their own breath in the ear) before and 6 months after bariatric surgery.

RESULTS

The mean age of the study group was 39.32 ± 11.09 years and 80.3% percent of the patients were female. The mean weight loss of the patients at the 6th month was 44.67 ± 13.10 kg, and mean weight loss rate was % 35.06 ± 8.01. The incidence of hearing their own breath, autophony and fullness of the ear were 25%, 22.4% and 11.8%, respectively. The proportion of those experiencing any of these three complaints was 30.3% (n = 23). The ETDQ scores of the cases ranged from 7 to 27, with an average of 9.38 ± 4.28. There are 10.5% (n = 8) paints with a score of ≥ 14.5 as regarded as patients with Eustachian tube dysfunction (ETD). The mean age of patients with ETD was significantly higher (p < 0.05) than patients without ETD. Gender distributions, weight loss rates, smoking, previous operation and additional disease distributions do not show statistically significant differences between patients with and without ETD (p > 0.05).

CONCLUSION

Present study indicated a 10.5% ETD incidence after bariatric surgery. ETDQ questionnaire can be used for ETD screening in patients who underwent bariatric surgery, which will be an overlooked complication in this group of subjects.

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.