A multicenter, randomized, active-controlled, clinical trial study to evaluate the efficacy and safety of navigation guided balloon Eustachian tuboplasty

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DLINE; Ovid Embase; Web of Science; Clinicaltrials.gov; ICTRP and additional sources for published and unpublished trials.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.

A Multicenter, Single-Arm, Objective Performance Criteria-Controlled Clinical Study of the Safety and Efficacy of the Double-Lumen Eustachian Tube Balloon Catheter

BACKGROUND

To prospectively evaluate the technical efficacy and safety of the double-lumen eustachian tube (ET) balloon catheter in patients with ET dysfunction.

METHODS

Patients who were diagnosed with ET dysfunction and needed balloon eustachian tuboplasty (BET) were prospectively enrolled. A double-lumen ET balloon catheter was used to dilate the ET and inject medicine. Efficacy results were assessed by the injection channel patency (ICP) rate, the injection reached the expected site (IRES) rate, and the improvement in eustachian tube function was evaluated by the seven-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) score. Safety results were assessed in terms of adverse events and device defects.

RESULTS

BET was successfully attempted in 87 patients from April 2022 to August 2022 at two academic medical centers in China (01, 02). The ICP rate was 100%, and the IRES rate was 88.51%. The overall ETDQ-7 score was significantly reduced ( p < 0.001) postsurgically at both centers. There were no major complications or device defects.

CONCLUSION

The double-lumen ET balloon catheter is technically effective and safe for the treatment of ET dysfunction.

[The effect of different degrees of Eustachian tube dysfunction on hearing threshold in patients with acquired primary middle ear cholesteatoma after balloon eustachian tuboplasty]

Objective:To investigate the changes in hearing threshold of the acquired primary cholesteatoma of the middle ear with different degrees of eustachian tube dysfunction after balloon eustachian tuboplasty. Methods:This retrospective study included forty cases with middle ear cholesteatoma and eustachian tube dysfunction who underwent open mastoidectomy + tympanoplasty + balloon eustachian tuboplasty were enrolled. All patients were admitted from November 2020 to April 2022. The preoperative eustachian tube score of 0-2 were defined as the lower group, and the scores of 3-5 were defined as the higher group. Pure tone audiometry was measured preoperatively and 1, 3, 6 and 12 months postoperatively. The average value of bone conduction threshold and air conduction threshold of 250-4 000 Hz were calculated, and the air-bone gap was calculated simultaneously. SPSS 25.0 was used for statistical analysis. P<0.05 was considered statistically significant. Results:In the lower group, the air conduction threshold and air-bone gap at 3 months postoperatively were significantly decreased in comparison with those preoperatively（P<0.05），as was the air-bone gap at 6 months postoperatively（P<0.05）. In the higher group, the air conduction threshold and air-bone gap were significantly decreased at 3, 6 and 12 months postoperatively（P<0.05）. Conclusion:The air conduction threshold and air-bone gap of patients with the acquired primary cholesteatoma of the middle ear and eustachian tube dysfunction were significantly decreased after eustachian tube balloon dilatation. Hearing improvement lasted longer in patients with slight eustachian tube dysfunction.

Balloon Eustachian Tuboplasty-A Feasible Double-Blinded Sham Surgery Randomized Clinical Trial Protocol to Study Efficacy

INTRODUCTION

Balloon Eustachian tuboplasty (BET) is used to treat obstructive Eustachian tube dysfunction (OETD) and recurrent otitis media with effusion (OME). However, there are no indisputable evidence of its efficacy. Here, we present a multicenter, double-blinded, randomized, placebo-controlled trial (MDRCT) design to evaluate the efficacy of BET, and the results of a pilot trial with 3- and 12-months' follow-up.

MATERIAL AND METHODS

This was a prospective MDRCT. For a pilot study, OETD (n = 10) and OME (n = 5) patients were recruited and followed. Detailed inclusion and exclusion criteria were used. Participants were randomized at beginning of the operation to active or sham surgery. All procedures were performed under local anesthesia. Controls were performed in double-blinded manner (both patient and physician), at 3 and 12 months after the procedure.

RESULTS

Altogether, 20 ears were treated and followed for 12 months, including 14 active BETs and 6 sham surgeries. Both the active and sham surgery were performed under local anesthesia without problems or deviations from the protocol. There were no differences in the preoperative symptoms (ETDQ-7) or objective measures (tympanometry, Valsalva and Toynbee maneuvers, tubomanometry, Eustachian tube score) between active and sham surgery arms. During follow-up, we noticed largely similar reduction in subjective symptoms and improvement in Eustachian tube score both in active and sham surgery arms.

CONCLUSIONS

The pilot study demonstrates that our MDRCT protocol is feasible, and that blinded RCTs are dearly needed to objectively measure the efficacy of BET.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:1874-1881, 2024.

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.

Balloon Dilation Eustachian Tuboplasty for Dilatory Dysfunction With and Without Effusion: A Comprehensive Outcome Analysis

OBJECTIVE

This study aimed (1) to demonstrate the efficacy of balloon dilation Eustachian tuboplasty (BDET) for dilatory Eustachian tube dysfunction (ETD) and (2) to determine whether adjunctive ventilation tube insertion (VTI) is superior to myringotomy in relieving symptoms for patients with ETD and concurrent middle ear effusion (MEE) treated with BDET.

STUDY DESIGN

A retrospective cohort study.

SETTING

Tertiary care academic center.

METHODS

Patients with dilatory ETD undergoing BDET with a ≥6-month follow-up period were enrolled and evaluated mainly using Eustachian tube function (ETF) tests and Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7). Participants with concurrent MEE were further classified into 2 subgroups, BDET with VTI and BDET with myringotomy. An intergroup comparison and comprehensive outcome evaluation were performed.

RESULTS

In total, 35 patients with 50 symptomatic ears were enrolled. According to ETF test results, the normalized ETF rate was 94% on the last visit. The mean ETDQ-7 scores decreased significantly from 3.7 ± 1.4 to 2.0 ± 0.9 after interventions, with the most improvement in symptoms occurring for "ear fullness" and "muffled hearing." For the final visit, strong correlations among ETF tests, tympanometry, and Valsalva results were noted. The aforementioned assessment results did not significantly differ between (1) the patients with MEE and patients without MEE and (2) "BDET with VTI" subgroup and "BDET with myringotomy" subgroup.

CONCLUSION

BDET was effective for dilatory ETD, even in cases with concurrent MEE. For patients with ETD and MEE, further research is required to evaluate the benefits of adjunctive myringotomy with or without VTI.

CT and MRI in the Preoperative Planning of Balloon Dilation of the Eustachian Tube: Literature Review

Balloon dilatation of the Eustachian tube (BET) is a surgical treatment method for Eustachian tube dysfunction (ETD), which relieves the symptoms in the majority of cases. However, there are potential intraoperative risks associated with BET; the decision-making process with regard to indications for BET is not standardized up to date. The objective of this study was to review the role of computed tomography (CT) and magnetic resonance imaging (MRI) in the preoperative planning of BET. The literature review is based on a database search performed in August 2022. BET is classified into transtympanic and nasopharyngeal. CT of the temporal bone provides good visualization of the site of obstruction, which allows to choose the adequate approach. Transtympanic approach is associated with risks of internal carotid artery damage due to possible carotid canal anomalies. This risk can be prevented with preoperative CT scan of the temporal bone. In case of nasopharyngeal BET, there is no sufficient data considering risks of possible artery damage, although CT can provide accurate measurements of ET. MRI is useful for differential diagnosis of conditions imitating ETD, such as endolymphatic hydrops and nasopharyngeal carcinoma. Thus, it is feasible to perform CT and MRI before BET to personalize the management of ETD patients.

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

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