The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
How I Do It
Endoscopic Transnasal Shim Technique for Treatment of Patulous Eustachian Tube Brian Rotenberg, MD, MPH, FRCSC; Benjamin Davidson, BSc
INTRODUCTION An abnormally patent Eustachian tube, known as a patulous Eustachian tube (pET), can cause disabling autophony as well as annoying transmitted sounds of breathing and swallowing.1 The elegant work of Poe’s group has shown that the anatomical defect is found in the anterolateral tubal valve of the nasopharyngeal end of the Eustachian tube (ET).2 To the frustration of both patients and their caregivers, current medical and surgical treatments are relatively inconsistent in their ability to eliminate the symptoms of pET. Numerous treatments have been proposed, including silicone plugs,2 rolled catheters,2 mass loading material on the tympanic membrane,3 silver nitrate cautery,2 conjugated estrogen drops,4 electrocauterization,4 Teflon/fat injection,2 and cartilaginous luminal reconstruction.5 In 2012, our group from Western University published the results of suture ligation of the torus tubaris for treatment of pET.6 Over time, however, we found that the sutures eventually worked themselves out of place in several cases, presumably due to the strong muscular forces acting on the ET during swallow. In these cases, revision surgery via placement of a suturefixated shim filled with bone wax to block the ET lumen in the resting position, thereby restoring the competency of the closing mechanism, immediately improved the pET symptoms—and did so both consistently and for the long term. Herein we describe our shim technique and its effectiveness in eliminating autophony.
SURGICAL METHOD A CT scan of the temporal bones is performed in all cases to rule out petrous carotid dehiscence, which From the Department of Otolaryngology–Head & Neck Surgery, University of Western Ontario, London, Ontario, Canada. Editor’s Note: This Manuscript was accepted for publication April 26, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Brian Rotenberg, MD, Associate Professor, Department of Otolaryngology–Head & Neck Surgery, St. Joseph’s Health Centre, 268 Grosvenor Street, Rm E3-104, London, Ontario, N6A 4V2, Canada. E-mail: [email protected] DOI: 10.1002/lary.24751
Laryngoscope 124: November 2014
2466
would be a contraindication to shim placement. Endoscopic shim placement is performed under general anesthetic in all cases. The patient is placed supine and prepared in standard fashion for endoscopic sinus surgery. The nasal cavity is decongested and visible landmarks infiltrated with local anesthesia with epinephrine, using a narrow-gauge spinal needle to reach the nasopharynx and torus tubaris. The torus is visualized with a 45-degree endoscope. The shim is constructed using an irrigation catheter (Med-Rx, Oakville, Canada) that is comprised of semirigid rubberized plastic and measures 19-gauge in width. The catheter is trimmed to 3.5 cm in length (to allow for transit up the cartilaginous ET and wedging in the isthmus, with 5 mm still protruding into the nasopharynx), after which melted bone wax is drawn up into the catheter and then allowed to cool, which consequently turns the catheter into a shim with a solid outside and semisolid interior. As the first step in placing the suture ligation, a 4-0 Ethibond Excel TF braided suture (Ethicon; Johnson & Johnson, Markham, Canada) is securely sutured through-and-through the shim 5-mm along its length. The shim is then grasped with an angled forceps, placed into the nasopharynx, and gently inserted into the lumen of the torus, after which it is advanced up the ET lumen until it firmly wedges in the ET isthmus. The 3.5cm length is designed such that approximately 5-mm of the shim protrudes into the nasopharynx to facilitate future removal, if necessary. The needle end of the Ethibond suture is now endoscopically placed into the nasopharynx and sutured to the anterior cushion of the torus using an endoscopic needle driver. This second suture firmly secures the shim in place in an attempt to prevent dislodgement during cough, swallow, or sneeze, but still allows freedom of removal by cutting the suture, if necessary. Figure 1 and Figure 2 show illustrations of shim placement in axial and coronal cuts, respectively, with Figure 3 showing an endoscopic photograph taken at 2 weeks postoperatively. Placement of nasal packing is not necessary; placement of a myringotomy tube is not routine. Postoperatively, patients are instructed to gently irrigate their nose with a fine spray and if possible avoid nose blowing for several weeks. Patients are followed up initially at 2 weeks after surgery to check
Rotenberg and Davidson: Shim Placement for Patulous Eustachian Tube
TABLE I. Results of Shim Placement. Patient Number
Age (years)
Sex
Duration of Follow-up (months)
Preoperative Autophony
Postoperative Autophony
1
27
F
21
5
1
2 3
36 43
F F
18 9
3 4
1 1
4
21
M
12
5
1
5 6
39 42
F F
14 18
4 4
2 1
7
41
M
6
3
1
surgical healing, and then at 3 to 6 months after surgery to ascertain the success of repair by both history and exam of ear and nose. For the purposes of this article, patients were asked to go to the clinic to be assessed. If this was not possible, they were surveyed over the phone.
RESULTS AND REPRESENTATIVE CASES From 2011 to 2013, the bone-wax shim technique was employed in seven patients (five female; two male) with pET who were suffering from moderate-to-disabling autophony that had proven resistant to several previous attempts at surgical repair. The mean age was 35.6 years old. No ear effusions were noted for any patient. Should an effusion have been present, it would have been drained by ventilating tube placement. No problematic crusting or infection was noted, despite the suture being a braided one. Over the maximal duration of follow-up, to date no catheters have spontaneously extruded. Autophony severity was assessed preoperatively and postoperatively with the same self-reported scale used in our previous publication6 and adapted from Poe.5 The patient-reported symptoms were scored as 1) no autophony, 2) mild autophony (not affecting activities of daily living), 3) moderate autophony
Fig. 1. Axial illustration of shim placement.
Laryngoscope 124: November 2014
Fig. 2. Coronal illustration of shim placement.
(consistent throughout activities of daily living), 4) severe autophony (affecting ability to perform activities of daily living), and 5) disabling autophony (patient unable to cope on a daily basis). At follow-up, all patients reported complete resolution of autophony and had no associated hearing loss or ear effusion from the procedure. There were no observed surgical complications within this small series. Most patients reported that they could not even feel the shim in place; however, two (28.6% of the series) patients noted that in the immediate postoperative period there was an ache, described as “deep in the ear,” on the ipsilateral side. In both cases, this resolved rapidly after surgery with only routine pain medication. One patient’s catheter (Fig. 3) was found to be a little bit too long in the clinic; it could be felt touching the palate and was trimmed in the clinic setting using a fine scissor. There was immediate resolution of the problem. No patients have noticed feeling the sutures in their nose. At last recorded autophony check, mean duration of follow-up was 14 months after surgery. Table I lists the results of our cases to date. Three representative cases are described in more detail below.
Fig. 3. Photograph of suture ligated shim in situ. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Rotenberg and Davidson: Shim Placement for Patulous Eustachian Tube
2467
Patient 1 was a 30-year-old female who had suffered from autophony for several years. The patient was first treated with ET augmentation using periumbilical fat grafting, suction cauterization of the torus tubarius, and purse string closure of the ET orifice. Although the patient experienced diminished autophony, it was still bothersome; therefore, the patient elected to have a catheter bone-wax repair. Preoperatively, the patient endorsed disabling (4/5) autophony. Postoperatively, the patient reported mild (2/5) autophony with exertion, which then resolved completely (1/5) by 3-month followup. There were no complications or hearing loss from the procedure, and at 1 year the patient remains symptom-free. Patient 2 was a 36-year-old female who had suffered from autophony and hyperacusis due to a rightsided pET for over 10 years. The patient had undergone a course of estrogen drops and placement of a myringotomy tube to no effect. Endoscopic augmentation of the ET orifice with an abdominal fat graft was performed. Initially, the patient autophony decreased substantially but soon returned sufficiently to be bothersome. The patient had secondary and tertiary revision surgeries, both of which followed a similar pattern of symptom recurrence postoperatively. Following both of the revision procedures, sneezing out the sutures precipitated symptom recurrence. Therefore, a bone wax-filled catheter was inserted, but ultimately forceful swallowing and sneezing caused it to be dislodged. Finally, the patient had a fifth surgery in which we inserted a bone-wax stent and sutured it to the anterior cushion as per the above technique. Prior to this last operation, the patient endorsed moderate (3/5) autophony. Postoperatively, the patient reported complete resolution of the autophony (1/5), which was sustained. A repeat audiogram at 6 months after the shim placement demonstrated resolution of the conductive hearing loss, and the autophony at the same visit was still graded at 1/5. Patient 3 was a 64-year-old female who had suffered from recent onset autophony due to a left-sided patulous Eustachian tube. Initially, the patient had an endoscopic augmentation of the ET with an abdominal fat graft with total symptom resolution. However, 3 weeks after surgery the patient felt a pop in the ear and symptoms unfortunately returned. A bone-wax shim was subsequently inserted without suture, but the patient coughed it out. Finally we performed the bone-wax shim suture placement, as described above. Preoperatively, the patient endorsed severe (4/5) autophony. Postoperatively, autophony was completely gone (1/5). The patient remains symptom-free at 6 months after surgery.
has written on mass loading of the tympanic membrane.3 Unfortunately, at present these techniques can be time- and resource-intensive, demonstrate mixed results in the literature, or may be straightforward but only show temporary results. Although we acknowledge that some form of luminal reconstruction will likely be the ideal approach in the future, in this report we have demonstrated a simple procedure to correct pET that is both consistently effective and easily reversible. Conceivably, the simple technique we have described herein could be used as a first-line surgical therapy (after failure of medical management), with some of the more involved procedures being offered for salvage. The first report of an occluded catheter used as a shim to treat pET was published by Bluestone and Cantekin in an 1981 article.7 This, as well as a more recent series from Kobayashi (the largest shim series to date) both made use of a transtympanic approach—inserting the shim through a myringotomy incision.7,8 Both groups used a shim flared at one end to prevent it from sliding through the ET into the nasopharynx. Kobayashi’s work resulted in consistent improvement, although 25% of patients required further treatment for some residual autophony.8 There are several advantages to a transnasal approach. Because 5 mm of the shim is left protruding into the nasopharynx, the catheter’s position can be readily assessed in clinic. The location also allows the catheter to be sutured in place, decreasing the chance of dislodgement but also affording the ability to remove the catheter without a myringotomy incision. Finally, transnasal shim insertion avoids myringotomy and its complications. Recent work of Manes et al. used cadaveric heads to demonstrate the technical feasibility of an endoscopic transnasal approach to place a 16G-semirigid catheter filled with bone wax in the ET as a shim.9 This in-vitro conceptual study lends credence to our in-vivo clinical work. A potential limitation of the shim technique, or any other that attempts to obliterate the ET, is the possibility of an OME—a complication dating back to the work of Brookler and Pulec.10 Interestingly, the literature has shown great variability in the incidence of these events. In our previous study, as well as the current one, we found a very low rate of effusion. This can be explained by either a small lumen remaining sufficiently patent, or the epithelial mucosa lining the middle ear being proficient enough in the role of gas and fluid exchange to prevent an effusion—a theory that has been put forward previously.11,12
CONCLUSION DISCUSSION The concept of how to best repair a symptomatic pET remains largely unresolved. Poe’s group out of Boston has demonstrated some success with a technical patulous Eustachian tube reconstruction technique designed to restore tubal competence using cartilage grafts5; our group has described endoscopic suture ligation with fat packing6; and Bance’s group from Halifax Laryngoscope 124: November 2014
2468
This endoscopic shim technique involves using an irrigation catheter filled with bone wax to occlude a symptomatically patent ET. Suturing the shim in place prevents dislodgement, and it also allows for easy reversal of the surgery should that prove necessary. In our series, the shim consistently eliminated intractable moderate-to-severe autophony in all cases. In the future, a method to consistently eliminate autophony through
Rotenberg and Davidson: Shim Placement for Patulous Eustachian Tube
restoration of the ET valve function would be ideal. However, at present the endoscopic shim sutureplacement technique offers an efficient and reproducible repair for patulous Eustachian tube.
4. 5. 6.
Acknowledgment The authors would like to acknowledge the work of Mr. Arvand Barghi, BSc, in preparing the fine illustrations used in this article.
7. 8.
9.
BIBLIOGRAPHY 1. O’Connor AF, Shea JJ. Autophony and the patulous eustachian tube. Laryngoscope 1981:91:1427–1435. 2. Grimmer JF, Poe DS. Update on eustachian tube dysfunction and the patulous eustachian tube. Curr Opin Otolaryngol Head Neck Surg 2005: 13:277–282. 3. Bartlett C, Pennings R, Ho A, Kirkpatrick D, van Wijhe R, Bance M. Simple mass loading of the tympanic membrane to alleviate symptoms of
Laryngoscope 124: November 2014
10. 11.
12.
patulous eustachian tube. J Otolaryngol Head Neck Surg 2010;39:259– 268. Dyer RK Jr, McElveen JT Jr. The patulous eustachian tube: management options. Otolaryngol Head Neck Surg 1991;105:832–835. Poe DS. Diagnosis and management of the patulous eustachian tube. Otol Neurotol 2007;28:668–677. Rotenberg BW, Busato GM, Agrawal SK. Endoscopic ligation of the patulous eustachian tube as treatment for autophony. Larygnoscope 2013; 123:239–243. Bluestone CD, Cantekin EI. Management of the patulous eustachian tube. Laryngoscope 1981;91:149–152. Sato T, Kawase T, Yano H, Suetake M, Kobayashi T. Trans-tympanic silicone plug insertion for chronic patulous eustachian tube. Acta Otolaryngol 2005;125:1158–1163. Manes RP, Kutz JW, Isaacson B, Batra PS. Technical feasibility of endoscopic eustachian tube catheter placement: a cadaveric analysis. Am J Rhinol Allergy 2013;27:314–316. Brookler KH, Pulec JL. Auditory tube patency after injection of the Teflon paste: an investigation in dogs. Arch Otolaryngol 1969;90:296–300. Takano A, Takahashi H, Hatachi K, et al. Ligation of eustachian tube for intractable patulous eustachian tube: a preliminary report. Eur Arch Otorhinolaryngol 2007;264:353–357. Proud, G.O., Odoi, H., Toledo, P.S. Bullar pressure changes in eustachian tube dysfunction. Ann Otol Rhino Larngol 1971;80: 835–837.
Rotenberg and Davidson: Shim Placement for Patulous Eustachian Tube
2469
Rhinological and Otological Society, Inc.
How I Do It
Endoscopic Transnasal Shim Technique for Treatment of Patulous Eustachian Tube Brian Rotenberg, MD, MPH, FRCSC; Benjamin Davidson, BSc
INTRODUCTION An abnormally patent Eustachian tube, known as a patulous Eustachian tube (pET), can cause disabling autophony as well as annoying transmitted sounds of breathing and swallowing.1 The elegant work of Poe’s group has shown that the anatomical defect is found in the anterolateral tubal valve of the nasopharyngeal end of the Eustachian tube (ET).2 To the frustration of both patients and their caregivers, current medical and surgical treatments are relatively inconsistent in their ability to eliminate the symptoms of pET. Numerous treatments have been proposed, including silicone plugs,2 rolled catheters,2 mass loading material on the tympanic membrane,3 silver nitrate cautery,2 conjugated estrogen drops,4 electrocauterization,4 Teflon/fat injection,2 and cartilaginous luminal reconstruction.5 In 2012, our group from Western University published the results of suture ligation of the torus tubaris for treatment of pET.6 Over time, however, we found that the sutures eventually worked themselves out of place in several cases, presumably due to the strong muscular forces acting on the ET during swallow. In these cases, revision surgery via placement of a suturefixated shim filled with bone wax to block the ET lumen in the resting position, thereby restoring the competency of the closing mechanism, immediately improved the pET symptoms—and did so both consistently and for the long term. Herein we describe our shim technique and its effectiveness in eliminating autophony.
SURGICAL METHOD A CT scan of the temporal bones is performed in all cases to rule out petrous carotid dehiscence, which From the Department of Otolaryngology–Head & Neck Surgery, University of Western Ontario, London, Ontario, Canada. Editor’s Note: This Manuscript was accepted for publication April 26, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Brian Rotenberg, MD, Associate Professor, Department of Otolaryngology–Head & Neck Surgery, St. Joseph’s Health Centre, 268 Grosvenor Street, Rm E3-104, London, Ontario, N6A 4V2, Canada. E-mail: [email protected] DOI: 10.1002/lary.24751
Laryngoscope 124: November 2014
2466
would be a contraindication to shim placement. Endoscopic shim placement is performed under general anesthetic in all cases. The patient is placed supine and prepared in standard fashion for endoscopic sinus surgery. The nasal cavity is decongested and visible landmarks infiltrated with local anesthesia with epinephrine, using a narrow-gauge spinal needle to reach the nasopharynx and torus tubaris. The torus is visualized with a 45-degree endoscope. The shim is constructed using an irrigation catheter (Med-Rx, Oakville, Canada) that is comprised of semirigid rubberized plastic and measures 19-gauge in width. The catheter is trimmed to 3.5 cm in length (to allow for transit up the cartilaginous ET and wedging in the isthmus, with 5 mm still protruding into the nasopharynx), after which melted bone wax is drawn up into the catheter and then allowed to cool, which consequently turns the catheter into a shim with a solid outside and semisolid interior. As the first step in placing the suture ligation, a 4-0 Ethibond Excel TF braided suture (Ethicon; Johnson & Johnson, Markham, Canada) is securely sutured through-and-through the shim 5-mm along its length. The shim is then grasped with an angled forceps, placed into the nasopharynx, and gently inserted into the lumen of the torus, after which it is advanced up the ET lumen until it firmly wedges in the ET isthmus. The 3.5cm length is designed such that approximately 5-mm of the shim protrudes into the nasopharynx to facilitate future removal, if necessary. The needle end of the Ethibond suture is now endoscopically placed into the nasopharynx and sutured to the anterior cushion of the torus using an endoscopic needle driver. This second suture firmly secures the shim in place in an attempt to prevent dislodgement during cough, swallow, or sneeze, but still allows freedom of removal by cutting the suture, if necessary. Figure 1 and Figure 2 show illustrations of shim placement in axial and coronal cuts, respectively, with Figure 3 showing an endoscopic photograph taken at 2 weeks postoperatively. Placement of nasal packing is not necessary; placement of a myringotomy tube is not routine. Postoperatively, patients are instructed to gently irrigate their nose with a fine spray and if possible avoid nose blowing for several weeks. Patients are followed up initially at 2 weeks after surgery to check
Rotenberg and Davidson: Shim Placement for Patulous Eustachian Tube
TABLE I. Results of Shim Placement. Patient Number
Age (years)
Sex
Duration of Follow-up (months)
Preoperative Autophony
Postoperative Autophony
1
27
F
21
5
1
2 3
36 43
F F
18 9
3 4
1 1
4
21
M
12
5
1
5 6
39 42
F F
14 18
4 4
2 1
7
41
M
6
3
1
surgical healing, and then at 3 to 6 months after surgery to ascertain the success of repair by both history and exam of ear and nose. For the purposes of this article, patients were asked to go to the clinic to be assessed. If this was not possible, they were surveyed over the phone.
RESULTS AND REPRESENTATIVE CASES From 2011 to 2013, the bone-wax shim technique was employed in seven patients (five female; two male) with pET who were suffering from moderate-to-disabling autophony that had proven resistant to several previous attempts at surgical repair. The mean age was 35.6 years old. No ear effusions were noted for any patient. Should an effusion have been present, it would have been drained by ventilating tube placement. No problematic crusting or infection was noted, despite the suture being a braided one. Over the maximal duration of follow-up, to date no catheters have spontaneously extruded. Autophony severity was assessed preoperatively and postoperatively with the same self-reported scale used in our previous publication6 and adapted from Poe.5 The patient-reported symptoms were scored as 1) no autophony, 2) mild autophony (not affecting activities of daily living), 3) moderate autophony
Fig. 1. Axial illustration of shim placement.
Laryngoscope 124: November 2014
Fig. 2. Coronal illustration of shim placement.
(consistent throughout activities of daily living), 4) severe autophony (affecting ability to perform activities of daily living), and 5) disabling autophony (patient unable to cope on a daily basis). At follow-up, all patients reported complete resolution of autophony and had no associated hearing loss or ear effusion from the procedure. There were no observed surgical complications within this small series. Most patients reported that they could not even feel the shim in place; however, two (28.6% of the series) patients noted that in the immediate postoperative period there was an ache, described as “deep in the ear,” on the ipsilateral side. In both cases, this resolved rapidly after surgery with only routine pain medication. One patient’s catheter (Fig. 3) was found to be a little bit too long in the clinic; it could be felt touching the palate and was trimmed in the clinic setting using a fine scissor. There was immediate resolution of the problem. No patients have noticed feeling the sutures in their nose. At last recorded autophony check, mean duration of follow-up was 14 months after surgery. Table I lists the results of our cases to date. Three representative cases are described in more detail below.
Fig. 3. Photograph of suture ligated shim in situ. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Rotenberg and Davidson: Shim Placement for Patulous Eustachian Tube
2467
Patient 1 was a 30-year-old female who had suffered from autophony for several years. The patient was first treated with ET augmentation using periumbilical fat grafting, suction cauterization of the torus tubarius, and purse string closure of the ET orifice. Although the patient experienced diminished autophony, it was still bothersome; therefore, the patient elected to have a catheter bone-wax repair. Preoperatively, the patient endorsed disabling (4/5) autophony. Postoperatively, the patient reported mild (2/5) autophony with exertion, which then resolved completely (1/5) by 3-month followup. There were no complications or hearing loss from the procedure, and at 1 year the patient remains symptom-free. Patient 2 was a 36-year-old female who had suffered from autophony and hyperacusis due to a rightsided pET for over 10 years. The patient had undergone a course of estrogen drops and placement of a myringotomy tube to no effect. Endoscopic augmentation of the ET orifice with an abdominal fat graft was performed. Initially, the patient autophony decreased substantially but soon returned sufficiently to be bothersome. The patient had secondary and tertiary revision surgeries, both of which followed a similar pattern of symptom recurrence postoperatively. Following both of the revision procedures, sneezing out the sutures precipitated symptom recurrence. Therefore, a bone wax-filled catheter was inserted, but ultimately forceful swallowing and sneezing caused it to be dislodged. Finally, the patient had a fifth surgery in which we inserted a bone-wax stent and sutured it to the anterior cushion as per the above technique. Prior to this last operation, the patient endorsed moderate (3/5) autophony. Postoperatively, the patient reported complete resolution of the autophony (1/5), which was sustained. A repeat audiogram at 6 months after the shim placement demonstrated resolution of the conductive hearing loss, and the autophony at the same visit was still graded at 1/5. Patient 3 was a 64-year-old female who had suffered from recent onset autophony due to a left-sided patulous Eustachian tube. Initially, the patient had an endoscopic augmentation of the ET with an abdominal fat graft with total symptom resolution. However, 3 weeks after surgery the patient felt a pop in the ear and symptoms unfortunately returned. A bone-wax shim was subsequently inserted without suture, but the patient coughed it out. Finally we performed the bone-wax shim suture placement, as described above. Preoperatively, the patient endorsed severe (4/5) autophony. Postoperatively, autophony was completely gone (1/5). The patient remains symptom-free at 6 months after surgery.
has written on mass loading of the tympanic membrane.3 Unfortunately, at present these techniques can be time- and resource-intensive, demonstrate mixed results in the literature, or may be straightforward but only show temporary results. Although we acknowledge that some form of luminal reconstruction will likely be the ideal approach in the future, in this report we have demonstrated a simple procedure to correct pET that is both consistently effective and easily reversible. Conceivably, the simple technique we have described herein could be used as a first-line surgical therapy (after failure of medical management), with some of the more involved procedures being offered for salvage. The first report of an occluded catheter used as a shim to treat pET was published by Bluestone and Cantekin in an 1981 article.7 This, as well as a more recent series from Kobayashi (the largest shim series to date) both made use of a transtympanic approach—inserting the shim through a myringotomy incision.7,8 Both groups used a shim flared at one end to prevent it from sliding through the ET into the nasopharynx. Kobayashi’s work resulted in consistent improvement, although 25% of patients required further treatment for some residual autophony.8 There are several advantages to a transnasal approach. Because 5 mm of the shim is left protruding into the nasopharynx, the catheter’s position can be readily assessed in clinic. The location also allows the catheter to be sutured in place, decreasing the chance of dislodgement but also affording the ability to remove the catheter without a myringotomy incision. Finally, transnasal shim insertion avoids myringotomy and its complications. Recent work of Manes et al. used cadaveric heads to demonstrate the technical feasibility of an endoscopic transnasal approach to place a 16G-semirigid catheter filled with bone wax in the ET as a shim.9 This in-vitro conceptual study lends credence to our in-vivo clinical work. A potential limitation of the shim technique, or any other that attempts to obliterate the ET, is the possibility of an OME—a complication dating back to the work of Brookler and Pulec.10 Interestingly, the literature has shown great variability in the incidence of these events. In our previous study, as well as the current one, we found a very low rate of effusion. This can be explained by either a small lumen remaining sufficiently patent, or the epithelial mucosa lining the middle ear being proficient enough in the role of gas and fluid exchange to prevent an effusion—a theory that has been put forward previously.11,12
CONCLUSION DISCUSSION The concept of how to best repair a symptomatic pET remains largely unresolved. Poe’s group out of Boston has demonstrated some success with a technical patulous Eustachian tube reconstruction technique designed to restore tubal competence using cartilage grafts5; our group has described endoscopic suture ligation with fat packing6; and Bance’s group from Halifax Laryngoscope 124: November 2014
2468
This endoscopic shim technique involves using an irrigation catheter filled with bone wax to occlude a symptomatically patent ET. Suturing the shim in place prevents dislodgement, and it also allows for easy reversal of the surgery should that prove necessary. In our series, the shim consistently eliminated intractable moderate-to-severe autophony in all cases. In the future, a method to consistently eliminate autophony through
Rotenberg and Davidson: Shim Placement for Patulous Eustachian Tube
restoration of the ET valve function would be ideal. However, at present the endoscopic shim sutureplacement technique offers an efficient and reproducible repair for patulous Eustachian tube.
4. 5. 6.
Acknowledgment The authors would like to acknowledge the work of Mr. Arvand Barghi, BSc, in preparing the fine illustrations used in this article.
7. 8.
9.
BIBLIOGRAPHY 1. O’Connor AF, Shea JJ. Autophony and the patulous eustachian tube. Laryngoscope 1981:91:1427–1435. 2. Grimmer JF, Poe DS. Update on eustachian tube dysfunction and the patulous eustachian tube. Curr Opin Otolaryngol Head Neck Surg 2005: 13:277–282. 3. Bartlett C, Pennings R, Ho A, Kirkpatrick D, van Wijhe R, Bance M. Simple mass loading of the tympanic membrane to alleviate symptoms of
Laryngoscope 124: November 2014
10. 11.
12.
patulous eustachian tube. J Otolaryngol Head Neck Surg 2010;39:259– 268. Dyer RK Jr, McElveen JT Jr. The patulous eustachian tube: management options. Otolaryngol Head Neck Surg 1991;105:832–835. Poe DS. Diagnosis and management of the patulous eustachian tube. Otol Neurotol 2007;28:668–677. Rotenberg BW, Busato GM, Agrawal SK. Endoscopic ligation of the patulous eustachian tube as treatment for autophony. Larygnoscope 2013; 123:239–243. Bluestone CD, Cantekin EI. Management of the patulous eustachian tube. Laryngoscope 1981;91:149–152. Sato T, Kawase T, Yano H, Suetake M, Kobayashi T. Trans-tympanic silicone plug insertion for chronic patulous eustachian tube. Acta Otolaryngol 2005;125:1158–1163. Manes RP, Kutz JW, Isaacson B, Batra PS. Technical feasibility of endoscopic eustachian tube catheter placement: a cadaveric analysis. Am J Rhinol Allergy 2013;27:314–316. Brookler KH, Pulec JL. Auditory tube patency after injection of the Teflon paste: an investigation in dogs. Arch Otolaryngol 1969;90:296–300. Takano A, Takahashi H, Hatachi K, et al. Ligation of eustachian tube for intractable patulous eustachian tube: a preliminary report. Eur Arch Otorhinolaryngol 2007;264:353–357. Proud, G.O., Odoi, H., Toledo, P.S. Bullar pressure changes in eustachian tube dysfunction. Ann Otol Rhino Larngol 1971;80: 835–837.
Rotenberg and Davidson: Shim Placement for Patulous Eustachian Tube
2469
