Trans-tympanic catheter insertion for treatment of patulous eustachian tube

Tympanic membrane findings and Eustachian tube function after transtympanic plugging for the chronic patulous Eustachian tube

OBJECTIVE

To evaluate Eustachian tube (ET) function after Kobayashi plug surgery based on the tympanic membrane (TM) findings and active opening (AO) of the ET assessed with sonotubometry.

SUBJECTS AND METHODS

A retrospective survey of medical records identified 74 ears of 66 patients with patulous ET (PET) received transtympanic insertion of the Kobayashi plug. Excluding the six ears (6 patients) with abnormal preoperative TM, sixty-eight ears of 60 patients were found to have normal TM preoperatively. Among these 68 ears, there were 51 ears in which sonotubometry was performed both before and after surgery to evaluate whether the AO of the ET was positive or not.

RESULTS

Out of the 68 ears with normal preoperative TM, 52 ears (76.5%) were judged successful (sum of complete relief and significant improvement). The postoperative TM was normal in 41 ears (60.3%), while 27 ears (39.7%) had abnormal TM findings postoperatively. The success rate was 75.6% (31/41) in ears with normal postoperative TM, while it was 77.8% (21/27) in ears with abnormal TM. Success in maintaining normal postoperative TM was found in 45.6% (31/68) of the total ears treated. Out of the 51 ears in which sonotubometry was performed both before and after surgery, AO was preoperatively positive in 88.2% of the ears (45/51), while it was positive in 64.7% (33/51) postoperatively. In thirty-four ears with normal TM postoperatively, AO was positive in 24 ears (70.6%), while it was positive in 9 out of 17 ears (52.9%) with abnormal postoperative TM. The success rate was 70.6% (36/51) for the 51 ears in which AO was assessed both pre- and postoperatively, and it was 66.7% (22/33) in ears with positive AO postoperatively, while it was 77.8% (14/18) in ears without AO postoperatively. The incidence of ears either having normal postoperative TM or positive AO postoperatively was 84.3% (43/51). Abnormal postoperative TM findings without effectiveness were found in 8.8% (6/68).

CONCLUSION

The obstructive dysfunction of the ET is a calculated risk but did not occur in most ears after plugging with the Kobayashi plug. Therefore, routine insertion of the VT at the same time as the initial surgery is not recommended for PET cases that are adequately followed up.

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.

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

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.

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.

Research on Inner Gas Inflation Improvements in Double-layer Gas-assisted Extrusion of Micro-tubes

Micro-tubes have small diameters and thin wall thicknesses. When using double-layer gas-assisted extrusion (DGAE) technology to process micro-tubes, due to the influence of flow resistance, airflow from the inner gas-assisted layer cannot flow into the atmosphere through the lumen. Over time, it will inflate or even fracture the micro-tubes intermittently and periodically. To solve this problem, a new double-layer micro-tube gas-assisted extrusion die was designed in this study. Its mandrel has an independent airway leading to the lumen of the extrudate, with which the gas flow into the lumen of the extrudate can be regulated by employing forced exhaust. Using the new die, we carried out extrusion experiments and numerical calculations. The results show a significant positive correlation between micro-tube deformation and gas flow rate in the lumen of a micro-tube. Without considering the refrigerant distortion of the microtube, the flow rate of forced exhaust should be set equal to that of the gas from the inner gas-assisted layer flow into the micro-tube lumen. By doing this, the problem of the micro-tube being inflated can be eliminated without causing other problems.

Plug size selection protocol for the treatment of intractable patulous Eustachian tube with Kobayashi Plug

Background: There have been no useful criteria for initial plug size selection protocol for the treatment of intractable patulous Eustachian tube (PET). Aims/objectives: To establish a method for appropriate plug size selection using tubal function test and subjective symptom severity in PET patients who were treated by Kobayashi Plug insertion. Material and methods: A retrospective survey of medical records identified 39 ears of 35 patients with PET who received insertion of the Kobayashi Plug and whose PET symptoms were thereafter controlled for at least 6 months after surgery. Method: The evaluation scale of PET handicap inventory-10 (PHI-10) was used to indicate PET subjective symptom severity. Tubal function tests (sonotubometry and tubo-tympano-aerodynamic-graphy: TTAG) were performed. Results: There was no correlation between the preoperative PHI 10 score and plug size (p = .157). There was a significant correlation between the preoperative sound attenuation from nostril to EAC measured by sonotubometry and plug size (p < .001). There was no correlation between the preoperative pressure transmission ratio estimated by TTAG and plug size (p = .271). Conclusions and Significance: Sonotubometry which evaluates sound attenuation from nostril to EAC can be a useful tool for selecting plug size.

Efficacy of a silicone plug for patulous eustachian tube: A prospective, multicenter case series

OBJECTIVES/HYPOTHESIS

To report the efficacy and safety of transtympanic plugging of the eustachian tube (ET) using a silicone plug (Kobayashi plug) for chronic patulous ET (PET).

STUDY DESIGN

Prospective and multicenter trial conducted in which 30 PET patients were resistant to at least 6 months of conservative treatment.

METHODS

The efficacy and safety of 28 and 27 patients, respectively, were analyzed. All patients fulfilled inclusion and exclusion criteria. The primary end point used the patulous eustachian tube handicap inventory-10 (PHI-10), and the secondary end point used ET function tests such as sonotubometry, tubo-tympano-aerodynamic-graphy, and respiratory movement of the tympanic membrane and auscultation of voice sounds transmitted from the nose through the ET to the external auditory canal at 3months after surgery.

RESULTS

PHI-10 scores were 34.4 ± 4.2, 6.4 ± 9, and 5.7 ± 8.6 at screening, and 3 and 6 months after surgery. Twenty-three cases (82.1%, 95% confidence interval: 63.1%-93.9%) were judged as successes. There were five cases (17.2%) of middle ear effusion, four cases (13.8%) of tympanic membrane perforation, and one case of tinnitus due to surgery to remove the plug. No severe or life-threatening complications were found.

CONCLUSIONS

This study revealed the efficacy and safety of silicone plug insertion for severe PET patients.

LEVEL OF EVIDENCE

2 Laryngoscope, 130:1304-1309, 2020.

Management of Acquired Cholesteatoma Associated With Patulous Eustachian Tube and Habitual Sniffing

OBJECTIVES

To investigate the effect of surgical treatment with eustachian tube (ET) catheter insertion in patients with acquired cholesteatoma associated with patulous eustachian tube (PET) and habitual sniffing.

METHODS

Nine ears of nine patients (two men and seven women; age, 20 to 65 years; average, 37.9±12.0 years) of acquired cholesteatoma associated with PET and habitual sniffing who underwent cholesteatoma surgery with simultaneous additional ET catheter insertion were examined in this study. Successful treatment was defined as stoppage of sniffing, a relief of a PET handicap inventory-10 (PHI-10), an improvement of autophony grade and no cholesteatoma recurrence.

RESULTS

ET catheter insertion was performed in all ears. Follow-up duration ranged from 16 to 37 months (average, 25.4 months). Cases consisted of nine pars flaccida type (100%). All patients obtained relief from aural symptoms and stopped sniffing. Postoperative PHI-10 scores were significantly lower than preoperative scores (P<0.001). During an average follow-up of 25.4 months, no cholesteatoma recurrence has occurred to date. One patient developed otitis media with effusion (OME) post-catheterization; OME resolved spontaneously without treatment. Four patients had a consecutive ET catheter insertion on the other side to resolve PET-related aural symptoms.

CONCLUSION

In case of acquired cholesteatoma with PET and habitual sniffing, ET catheter insertion performed simultaneously with cholesteatoma surgery could help reduce aural symptoms and stop sniffing. Moreover, the procedure might help in preventing cholesteatoma recurrence.

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.

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.

Surgical treatments for a case of superior canal dehiscence syndrome associated with patulous Eustachian tube

OBJECTIVES

The patulous Eustachian tube (PET) and superior semicircular canal dehiscence syndrome (SCDS) have similarity in their symptoms and similar effects caused by positional changes, causing difficulty in the differentiation between the two disorders. This report describes a case of both SCDS and PET that was eventually successfully treated.

METHODS

A 68-year-old man presented with hyperacusis to his own footsteps and gait disturbance. He had been diagnosed as PET two years before and had been treated by insertion of a silicone plug (Kobayashi plug) at the other hospital. Clinical case records, audiological data, cervical vestibular-evoked myogenic potential (cVEMP), Eustachian tube function tests and computed tomography (CT) were taken in the sitting position.

RESULTS

While the CT confirmed superior semicircular canal dehiscence, the results of cVEMP was not typical of SCD likely due to preexisting hearing impairment in the right ear with a history of middle ear surgeries for the treatment of PET. He received round window reinforcement (RWR) and achieved relief from his symptoms but six months after the surgery, he visited again with complaints of autophony of his own voice and breathing. The tympanic membrane was found to move synchronous with respiration, and Eustachian tube function tests and the sitting CT confirmed the recurrence of severe PET. He had his silicone plug exchanged (increase in size of the Kobayashi plug) and achieved relief from symptoms.

CONCLUSIONS

The present case was a rare instance showing that PET and SCDS can occur simultaneously in a patient. The patient achieved relief from symptoms after treatment with RWR and insertion of the Kobayashi plug.

The protympanum, protiniculum and subtensor recess: an endoscopic morphological anatomy study

Objectives

An anatomical study was performed to describe the endoscopic anatomy and variations of the protympanum, including classification of the protiniculum and subtensor recess.

Methods

A retrospective review was conducted of video recordings of cadaveric dissections and surgical procedures, which included visualisation of the protympanum, across 4 tertiary university referral centres over a 16-month period. A total of 97 ears were used in the analysis.

Results

A quadrangular conformation of the protympanum was seen in 60 per cent of ears and a triangular conformation in 40 per cent. The protiniculum was type A (ridge) in 58 per cent, type B (bridge) in 23 per cent and type C (absent) in 19 per cent. The subtensor recess was type A (absent) in 30 per cent, type B (shallow) in 48 per cent and type C (deep) in 22 per cent.

Conclusion

The protympanum is an area that has been ignored for many years because of difficulties in visualising it with an operating microscope. However, modern endoscopic equipment has changed this, providing detailed anatomical knowledge fundamental to ensuring the safety of endoscopic surgical procedures in the region.

Effectiveness of Kobayashi plug for 252 ears with chronic patulous Eustachian tube

CONCLUSIONS

Trans-tympanic plugging of the Eustachian tube (ET) with the silicone plug (Kobayashi Plug) induced long-term effectiveness for over 80% of chronic and severe patulous ET (PET) patients. The New Kobayashi Plug was more effective with fewer complication of plug descent to the pharyngeal orifice.

OBJECTIVE

To investigate the effectiveness and complications of trans-tympanic plugging of the ET using a Kobayashi Plug for chronic PET.

METHOD

Trans-tympanic plugging of the ET using the Kobayashi Plug was performed for 252 ears of 191 patients. The Prototype Plug (115 ears of 82 patients in 2001-2007) and the New Plug (137 ears of 109 patients in 2008-2013) were inserted for chronic PET patients.

RESULTS

The success rate of the Kobayashi Plug for PET was 83.0% of a total (Prototype Plug 80.0%, New Plug 85.4%). In 26 ears, the Prototype Plugs were found to have descended toward the nasopharynx. Conversely, this did not happen with the New Plug. The rate of TM perforation (Prototype 22.6%, New 17.5%), middle ear effusion (Prototype 20.2%, New 10.2%) and ventilation tube placement (Prototype 14.8%, New 4.4%) decreased after transition to the New Plug.

Computed tomography findings of the bony portion of the Eustachian tube with or without patulous Eustachian tube patients

To investigate the bony segment of the Eustachian tube (ET) using sitting 3D-computed tomography (CT) scans in Patulous Eustachian tube (PET) patients. A retrospective survey of medical records in Sen-En Hospital identified 43 patients and 43 ears with PET and 30 patients and 30 ears with sensorineural hearing loss or vertigo patients as the control. Diagnosis of PET was based on the Proposal on PET Diagnosis Criteria announced by the Otological Society of Japan in 2012. Patients were examined by cone beam CT (Accuitomo; Morita, Kyoto, Japan) in the sitting position. The heights and widths at the tympanic orifice, the middle portion, and isthmus were measured. The lumen of the bony portion was divided into three shapes: peritubal cells (PTC) poor type, PTC good with prominence type, and PTC good without prominence type. In PET patients and the control group, the PTC poor type was identified in nine (21%) and seven ears (23%), PTC good with prominence type was identified in 14 (33%) and seven ears (23%), and PTC good without prominence type was identified in 19 (45%) and 16 ears (53%), respectively. There was no significant difference between the two groups. At the tympanic orifice portion, the average height of the ET lumen was 5.99 ± 1.29 and 6.04 ± 1.41 mm, and the average width of the ET lumen was 2.81 ± 0.82 and 2.78 ± 0.57 mm in the PET and control groups, respectively. The PTC good with prominence type had a significantly smaller width in the tympanic orifice portion than the other types in each group (p < 0.05). The width of the ET lumen in the tympanic orifice averaged 2.87 ± 0.38 and 3.10 ± 0.45 mm in the PTC poor type, 2.23 ± 0.70 and 2.22 ± 0.48 mm in the PTC good with prominence type, and 3.21 ± 0.87 and 2.90 ± 0.50 mm in the PTC good without prominence type in the PET and control groups, respectively. The shape of the bony portion of the ET in PET patients is almost identical to that of controls. Thus, the bony portion has no influence on the pathology of patulous Eustachian tube syndrome. The PTC good with prominence type has a significantly smaller tympanic orifice portion width than the other types. Preoperative evaluation of the bony portion of the ET could provide useful information for ET surgeons.