The Performance of Patient-reported Outcome Measures as Diagnostic Tools for Eustachian Tube Dysfunction

The Usefulness of ETDQ-7 Score in Assessing ETD

INTRODUCTION

The ETDQ-7 questionnaire has been validated for diagnosing Eustachian tube dysfunction (ETD) and a minimal clinically important difference (MCID) of > 3.5 has been suggested. We aim to assess the use of ETDQ-7 for assessing ETD and a potential correlation between ETDQ-7 and the Sino-Nasal Outcome Test 22 (SNOT-22).

METHODS

ETD was based on relevant ear symptoms and objective signs of negative middle ear pressure in 75 consecutive adult patients. Ventilation tube insertion (VTi) was performed on affected ears. ETDQ-7 and SNOT-22 scores before and 1 month after VTi were compared to 75 healthy controls.

RESULTS

Mean ETDQ-7 score decreased from 31.9 to 15.8 (p < 0.0001), remained stable on unaffected ears, and was 9.6 in controls. MCID was achieved on all affected ears after VTi. A cut-off score of > 14.5 for diagnosing ETD yielded 100% sensitivity and 94.2% specificity for ETDQ-7. Spearman's ρ for total score test-retest was 0.878 (p = 0.000). Cronbach alpha for total score varied from 0.6807 to 0.7266. SNOT-22 and ETDQ-7 were correlated at baseline (0.12, p = 0.012). ETD patients scored significantly higher in the nasal, otologic and sleep domains in SNOT-22 compared to controls.

CONCLUSION

ETDQ-7 is a very valid tool for ETD diagnostics and assessing the ear-related effects of VTi. ETDQ-7 scores reveal residual symptoms after VTi, indicating symptom relief but no cure for the underlying pathophysiology. For future investigation, we suggest assessing ETDQ-7 scores for each ear separately, higher MCID values, and integration of quality of life measures.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05055115.

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.

Chronic Nasal Disease and Eustachian Tube Function: What Is the Role of Tubomanometry?

Background/objectives: Eustachian tube dysfunction (ETD) presents complex diagnostic challenges in otolaryngology, compounded by concurrent chronic nasal disease. Patient-reported outcome measures (PROMs) often assess ETD severity due to its elusive diagnosis. Tubomanometry (TMM) emerges as a promising diagnostic tool, yet its application alongside chronic nasal disease remains unclear. Our study aims to elucidate TMM's role in ETD diagnosis within the context of chronic nasal diseases, integrating subjective assessments, clinical examination, and TMM results. Methods: A prospective observational study was conducted with patients suffering from ETD and chronic nasal disease allocated in three different groups according to their nasal pathology. Clinical examination, PROMs in the form of ETDQ-7, and NOSE questionnaires as well as TMM were performed. Results of the above subjective and objective measurements were analysed and correlated statistically to determine the value of TMM in chronic nasal disease patients. Results: All recruited patients suffered from ETD and chronic nasal disease, with similarly affected ETDQ-7 scores across all groups, while NOSE scores differed significantly based on the underground nasal pathology. TMM values confirm the presence of ETD in all three groups, confirming the role of TMM within this cohort. Interestingly, TMM values can still confirm the presence of ETD in patients with chronic nasal disease but cannot discriminate among chronic nasal pathology patients, making TMM a diagnostic tool with uniformity among the chronic nasal pathologies. Conclusions: ETD in individuals with chronic nasal disease presents distinct complexities, requiring a tailored diagnostic approach. In this context, a thorough clinical assessment, integrating ETDQ-7 and NOSE questionnaires, supplemented by TMM where accessible, is crucial to confirm diagnosis. This study confirms that TMM can diagnose ETD in all nasal pathology patients without being influenced by the nature of the disease. This research endeavours to refine diagnostic strategies, enriching clinical decision-making, and enhancing ETD management in patients suffering with chronic nasal diseases.

Eustachian Tube Dysfunction Diagnostic Pathway-What Is the Current State of the Art and How Relevant Is Chronic Nasal Disease?

Background: Eustachian tube dysfunction (ETD) presents a complex diagnostic challenge in otolaryngology, compounded by its multifaceted nature and overlapping symptoms with chronic nasal disease. This article examines the intricacies of ETD diagnosis, emphasising the necessity for a consensus on diagnostic procedures. Methods: A review of the literature was performed through the OVID research tool in the Pubmed/Medline databases to identify relevant articles that discuss eustachian tube dysfunction diagnostics as well as its correlation with chronic nasal disease. Results: The literature review harvested 201 articles, and only 51 of them were included in the full text review. A consensus statement was identified on eustachian tube dysfunction, function and diagnostics. It appears that there is significant variability in the diagnostic tools used to identify eustachian tube dysfunction. The main diagnostic approaches used are tympanometry, tubomanometry and sonotubometry, combined with the Patient-Reported Outcome Measure ETDQ-7 questionnaire to support the diagnosis of the condition. Nasal pathology is mostly absent from the retrieved studies, while ear pathology is more commonly mentioned in the current literature. Conclusions: There is no gold standard diagnostic tool to determine the presence of eustachian tube dysfunction. Further discussion, large multicentre studies and focused research are required to achieve a consensus on a diagnostic approach. The authors suggest a diagnostic pathway that combines subjective and objective diagnostic tools to determine the presence of eustachian tube dysfunction. This pathway is simple and can be used in district ENT departments, highlighting the nasal pathology relevance to ETD.

A Nomogram Diagnostic Model for Eustachian Tube Dysfunction in Patients with Tympanic Membrane Perforation

OBJECTIVES

Eustachian tube dysfunction (ETD) is a common disease associated with chronic otitis media. A standard diagnostic tool for ETD in patients with tympanic membrane perforation is still lacking. We developed and validated a new diagnostic model for ETD in patients with tympanic membrane perforation.

METHODS

A prospective study was conducted in patients who had tympanic membrane perforation from February to August 2023. We collected clinical characteristics and examination results including otoscopy, nasal endoscopy, tubomanometry, and 5-item Eustachian Tube Score (ETS-5). Univariate and multivariate logistic regression analysis was performed to determine the independent diagnostic factors. Based on this, the nomogram model was constructed. The discrimination and calibration of the nomogram were evaluated using the area under the curve (AUC), the C-index, the calibration curve, and the decision curve analysis (DCA).

RESULTS

A total of 40 participants were enrolled in the study. ETS-5 score and Eustachian tube opening mucosa inflammation in the nasopharynx were significant predictors in identifying ETD. Based on the above independent predictors, a diagnostic nomogram was successfully established. The sensitivity and specificity of the diagnostic model were 80.0% and 90.0%, respectively. The AUC and the C-index of the diagnostic model were both 0.901, which suggested that the model had a good discrimination power. The calibration curve indicated a good calibration degree of the model. DCA showed that the proposed model was useful for clinical practice.

CONCLUSION

The nomogram model is effective and reliable in identifying ETD in patients with tympanic membrane perforation.

Outcomes of Spontaneous Cerebrospinal Fluid Leak Repair With Concurrent Eustachian Tube Dysfunction

OBJECTIVE

To compare the presentation and outcomes of patients with and without obstructive eustachian tube dysfunction (oETD) undergoing repair of lateral skull base spontaneous cerebrospinal fluid (sCSF) leaks.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Adults with lateral skull base sCSF leaks who underwent repairs from January 1, 2011, to December 31, 2020, were collected.

MAIN OUTCOME MEASURE

Comparative statistics and effect sizes were used to compare clinical features, operative findings, and outcomes between groups.

RESULTS

Of 92 ears from 89 patients included, 51.1% (n = 47) had oETD. There were no differences in demographics between patients with and without oETD. Mean age was 60.7 ± 13.1 versus 58.5 ± 12.8 years ( d = -0.17 [-0.58 to 0.24]), mean body mass index was 33.8 ± 8.5 versus 36.0 ± 8.0 kg/m 2 ( d = 0.27 [-0.14 to 0.68]), and female sex preponderance was 59.6% (n = 28) versus 68.8% (n = 31; Φ = -0.09), respectively. There were no differences in the radiologic number, size, and locations of defects. Patients with oETD had less pneumatized mastoids than those without oETD ( p = 0.001; Φ = 0.43). Mean change from preoperative to postoperative air pure-tone average for those with and without oETD was -1.1 ± 12.6 versus 0.1 ± 17.2 dB ( d = 0.09 [-0.04 to 0.58]), respectively. Six ears (6.5%; three with and three without oETD) underwent revisions for rhinorrhea/otorrhea between 5 and 28 months postoperatively, during which four leaks were found, the two patients without leaks had oETD.

CONCLUSIONS

The presentation of sCSF leaks and outcomes of repairs in patients with oETD do not differ from those without oETD. Although postoperative otorrhea might represent an inflammatory or infectious process in patients with oETD, reexploration is warranted if patients do not improve with conservative treatment.

Assessment of the Eustachian tube: a review

BACKGROUND

Dysfunction of the Eustachian tube (ET) can lead to negative pressure within the middle ear, which, in turn, causes various pathological changes. Multiple testing methods for ET function have been devised, each with its own advantages and disadvantages. Knowing the characteristics of each ET function test and the unique characteristics of ET dysfunction (ETD) in children are prerequisites for choosing the optimal assessment method. For a comprehensive diagnosis, assessment should also include the localisation of any sites of obstruction. This review aims to summarise the methods of evaluating ET function and locating sites of ET lesions.

METHODS

Articles evaluating ET function, localising lesions in the ET, and ETD in children were collected from the PubMed database. We selected only relevant English publications.

RESULTS

ETD in children has different characteristics to those in adults. The appropriate tests for assessing ET function depend on the specific conditions of the individual patient. Valsalva computed tomography can provide information on the soft and bony anatomy of the ET to facilitate identification of lesion sites.

CONCLUSION

An accurate diagnosis should be based on a combined analysis of objective and subjective results, with interpretation made in conjunction with clinical history and physical examination. A comprehensive assessment should include lesion localisation. When assessing ETD in children, it is important to take into account the characteristics of this population.

Transient patulous eustachian tube in severe anorexia nervosa: A prospective observational study

Objectives

To understand the presence of transient autophony symptoms in patients being treated for severe anorexia nervosa (AN), and whether those symptoms were due to patulous eustachian tube (PET).

Methods

A prospective observational study was performed in patients requiring admission for treatment of severe AN. All enrolled patients completed The Eustachian Tube Dysfunction Questionnaire (ETDQ-7) and were screened for symptoms of autophony. If patients reported autophony and had a score of ≥14.5 on the ETDQ-7 they were asked to undergo comprehensive audiological testing and an evaluation with an otolaryngologist.

Results

Of the 73 patients enrolled in the study, 35 patients (44%) reported autophony and 36 (49%) scored 14.5 or higher on the ETDQ-7. Of the 16 (22%) patients who had both autophony and an ETDQ-7 score of 14.5 or higher, 7 patient s (representing 11 symptomatic ears) underwent evaluations by audiology and otolaryngology. Every evaluation of a symptomatic ear revealed objective evidence of PET. Nine of 11 (81.8%) symptomatic ears had subjectively resolved within 12 days of admission after nutritional rehabilitation and weight gain.

Conclusion

Transient autophony in severe AN patients is due to PET, and was present in at least 8% of patients within our cohort. Further study is warranted to understand the quality of life impact and pathophysiology of transient PET in this patient population.

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.

Impact of endoscopic sinus surgery on Eustachian tube dysfunction in patients with chronic rhinosinusitis: systematic review and meta-analysis

Background: Eustachian tube dysfunction (ETD) has been associated with inflammatory conditions (1). Many studies have identified a high prevalence of ETD in patients with chronic rhinosinusitis (CRS) (2). However, there is a paucity of higher-level evidence assessing the impact of endoscopic sinus surgery (ESS) on patients with ETD concurrent disease. Methods: Systematic review and meta-analysis of non-randomised studies on the impact of ESS on ETD in patients with CRS, based on the eustachian tube dysfunction questionnaire (ETDQ-7) scores. PRISMA guidelines were followed according to a priori study protocol (PROSPERO Registration number: CRD42021245677). A random-effects model was employed. Results: 21 results were obtained using our search strategy. Four studies met our inclusion criteria. 501 patients were identified in the included studies. The prevalence of ETD in CRS patients in our review was 55.1%. Pooled estimates showed a statistically significant reduction in ETDQ-7 scores. Conclusions: The evidence to date suggests there is a high prevalence of concurrent ETD in CRS patients, the symptoms of which improved following ESS for CRS in this patient group. However, the current evidence base is comprised of uncontrolled case series. High-quality, randomised controlled studies with long-term follow-up are lacking.

Autophony in inpatients with anorexia nervosa or avoidant restrictive food intake disorder

OBJECTIVE

To assess for the prevalence of autophony, a distressing auditory symptom commonly attributed to patulous eustachian tube, in a cohort of individuals with severe malnourishment due to an eating disorder.

METHOD

A cross-sectional survey study was performed. Patients admitted for inpatient medical stabilization of an eating disorder, who were also at low body weight, were asked to complete a survey assessing aural symptoms present in the previous 24 hr, including autophony. Anthropometric data and prealbumin levels were collected.

RESULTS

Of 101 patients enrolled, 43 (42.6%) reported symptoms of autophony. The presence of autophony was associated with lower serum prealbumin levels and lower body weight as measured by percentage of ideal body weight.

DISCUSSION

Autophony is a commonly reported, albeit rarely discussed, symptom in individuals with severe eating disorders and correlates with degree of malnutrition.

Screening for Eustachian Tube Dysfunction in Clinical Practice Using the Eustachian Tube Dysfunction Questionnaire-7

OBJECTIVES/HYPOTHESIS

To evaluate the ability of the Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7) to discriminate between patients with Eustachian tube dysfunction (ETD) and Non-ETD diagnoses, and identify symptom information to improve ability to discriminate these groups.

STUDY DESIGN

Cohort study.

METHODS

Pilot retrospective study with consecutive adult patients presenting to otology clinics and one general otolaryngology clinic in an academic health system. Patients were administered ETDQ-7 with eight additional symptom items. Electronic health records were reviewed for demographic and diagnostic information. Patients were grouped into diagnosis categories: 1) True ETD, 2) experiencing ear fullness (EF) not due to ETD, and 3) Control patients without ETD-related disorders or EF. ETDQ-7 and symptom item scores were compared by the diagnosis group. Receiver-operative characteristics curves and area under the curve (AUC) were generated for each ETD diagnosis group based on ETDQ-7 and symptom scores.

RESULTS

Of the 108 patients included in this study 74 (68.5%) were diagnosed with ETD. Patients with ETD had higher (indicating worse symptom burden) overall ETDQ-7 scores than Control group (Median [Q1, Q3] 3.0, [1.7, 4.1]; versus 1.5 [1.0, 3.4] P = .008). There was no statistically significant difference between overall ETDQ-7 scores for ETD and Non-ETD EF patients (P = .389). The AUC for the ETDQ-7 in discriminating ETD from other conditions that cause EF was 0.569; the addition of 8 symptom questions to the ETDQ-7 improved AUC to 0.801.

CONCLUSION

Additional patient-reported symptom information may improve the ability to discriminate ETD from other similarly presenting diagnoses when using ETDQ-7.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

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.

[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.

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.

Eustachian Tube Function in Patients with Symptoms on Baro-Challenge

OBJECTIVES

To explore the relationship between aural symptoms during baro-challenge and the underlying measured Eustachian tube (ET) function. Two key questions were addressed. (1) In patients who have features of obstructive ET dysfunction, is there a measurable underlying difference in ET function between those who experience severe symptoms on baro-challenge and those that do not? (2) What is the diagnostic value of ET function tests in the identification of patients with severe symptoms on baro-challenge?

METHODS

Patients with symptoms of obstructive ET dysfunction were recruited, with the presence of aural symptoms on baro-challenge established via the clinical history and analysis of the Cambridge ET Dysfunction Assessment, a patient-reported outcome measure (PROM). ET function tests were assessed in each patient: 9 objective and semi-objective measures of ET opening, and 2 symptom-based PROMs. The tests' results were grouped by type of ET opening assessed, generating passive and active dysfunction scores. Individual test results were assessed for diagnostic accuracy in reference to features in the history or PROM-based evidence of symptoms on baro-challenge.

RESULTS

Both passive and active opening of the ET was significantly reduced in ears with a history of pain on baro-challenge. Some patients had apparent severe obstructive ET dysfunction without symptoms on baro-challenge, whilst others had symptoms but normal test results. No individual test of ET opening was of diagnostic value in predicting those ears likely to experience pain or exacerbated symptoms on baro-challenge.

CONCLUSION

The relationship between aural pain during baro-challenge and ET function appears more complex than had been assumed, with pain possibly related to factors other than just ET function.

The Effect of Endoscopic Sinus Surgery on Eustachian Tube Dysfunction Symptoms

OBJECTIVE

We assessed how eustachian tube dysfunction (ETD) changed with endoscopic sinus surgery (ESS) and identified factors associated with improvement.

STUDY DESIGN

Retrospective chart review.

SETTING

Academic center.

SUBJECTS AND METHODS

Patients undergoing ESS for chronic rhinosinusitis with and without nasal polyposis (CRSwNP, CRSsNP) or recurrent acute rhinosinusitis (RARS) completed the Eustachian Tube Dysfunction Questionnaire 7 (ETDQ-7) preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months. Included in analyses were demographics, comorbidities, Sinonasal Outcome Test 22 (SNOT-22), radiographic score, endoscopy score, procedure, and medication use. Regression analysis identified factors associated with improvement, defined as ΔETDQ-7 >3.5.

RESULTS

In total, 302 patients were studied. ETD prevalence was 68% in CRSsNP, 48% in CRSwNP, and 88% in RARS. Patients with ETD had a mean baseline ETDQ-7 of 25.8 ± 8.0 and improved postoperatively at 2 weeks (19.9 ± 8.1, P < .001), 6 weeks (17.8 ± 9.3, P < .001), 3 months (16.8 ± 8.5, P < .001), and 6 months (16.4 ± 7.9, P < .001). At 6 months, ETD improved in 89% of patients with CRSsNP, 68% with CRSwNP, and 78% with RARS. On multivariate analysis, ETD improvement was associated with higher preoperative ETDQ-7 score (adjusted odds ratio [aOR], 1.12; 95% confidence interval [CI], 1.04-1.22; P = .030), higher preoperative SNOT-22 score (aOR, 1.02; 95% CI, 1.02-1.08; P = .001), higher preoperative SNOT-22 ear subscore (aOR, 1.27; 95% CI, 1.02-1.65; P = .034), posterior ethmoidectomy (aOR, 1.59; 95% CI, 1.22-4.92; P = .025), and postoperative corticosteroid spray use (aOR, 1.57; 95% CI, 1.17-1.66; P = .008).

CONCLUSION

ETD symptoms often improve following ESS. Factors associated with improvement include higher preoperative disease burden, posterior ethmoidectomy, and postoperative corticosteroid spray.

LEVEL OF EVIDENCE

4.

Advances in Eustachian tube function testing

Obstructive and patulous Eustachian tube dysfunction provide a significant diagnostic and management challenge. The development of new treatments such as balloon Eustachian tuboplasty has generated renewed interest in measuring Eustachian tube function, as a method of selecting appropriate patients for intervention, and measuring their treatment outcomes.

This review summarises recent findings relating to Eustachian tube function assessment. Increasingly it is recognised that patient reported outcome measures based on symptoms are highly non-specific and non-diagnostic, and clinical assessment alone may not permit the selection of individuals with abnormal Eustachian tube opening. Tests of Eustachian tube opening therefore may represent a practical and objective addition to patient assessment in clinic, allowing the identification of individuals with abnormal (patulous or obstructive) Eustachian tube function. A diagnostic pathway is described on this basis.

More work is required to validate the described Eustachian tube function tests, and there remain individuals, such as those with dysfunction limited to pressure challenges, in whom function tests have yet to fully characterise the disorder.

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 dysfunction: A diagnostic accuracy study and proposed diagnostic pathway

Background and aims

Eustachian tube dysfunction (ETD) is a commonly diagnosed disorder of Eustachian tube opening and closure, which may be associated with severe symptoms and middle ear disease. Currently the diagnosis of obstructive and patulous forms of ETD is primarily based on non-specific symptoms or examination findings, rather than measurement of the underlying function of the Eustachian tube. This has proved problematic when selecting patients for treatment, and when designing trial inclusion criteria and outcomes. This study aims to determine the correlation and diagnostic value of various tests of ET opening and patient reported outcome measures (PROMs), in order to generate a recommended diagnostic pathway for ETD.

Methods

Index tests included two PROMs and 14 tests of ET opening (nine for obstructive, five for patulous ETD). In the absence of an accepted reference standard two methods were adopted to establish index test accuracy: expert panel diagnosis and latent class analysis. Index test results were assessed with Pearson correlation and principle component analysis, and test accuracy was determined. Logistic regression models assessed the predictive value of grouped test results.

Results

The expert panel diagnosis and PROMs results correlated with each other, but not with ET function measured by tests of ET opening. All index tests were found to be feasible in clinic, and acceptable to patients. PROMs had very poor specificity, and no diagnostic value. Combining the results of tests of ET function appeared beneficial. The latent class model suggested tympanometry, sonotubometry and tubomanometry have the best diagnostic performance for obstructive ETD, and these are included in a proposed diagnostic pathway.

Conclusions

ETD should be diagnosed on the basis of clinical assessment and tests of ET opening, as PROMs have no diagnostic value. Currently diagnostic uncertainty exists for some patients who appear to have intermittent ETD clinically, but have negative index test results.