PRACTICE 11 Ben Amar M. Cannabinoids in medicine: a review of their therapeutic potential. J Ethnopharmacol 2006;105:1-25. 12 Lutge EE, Gray A, Siegfried N. The medical use of cannabis for reducing morbidity and mortality in patients with HIV/AIDS. Cochrane Database Syst Rev 2013;4:CD005175. 13 Lynch ME, Campbell F. Cannabinoids for treatment of chronic non-cancer pain; a systematic review of randomized trials. Br J Clin Pharmacol 2011;72:735-44. 14 Svendsen KB, Jensen TS, Bach FW. Does the cannabinoid dronabinol reduce central pain in multiple sclerosis? Randomised double blind placebo controlled crossover trial. BMJ 2004;329:31. 15 Rog DJ, Nurmikko TJ, Friede T, Young CA. Randomized, controlled trial of cannabis-based medicine in central pain in multiple sclerosis. Neurology 2005;65:812-9. 16 Wade DT, Robson P, House H, Makela P, Aram J. A preliminary controlled study to determine whether whole-plant cannabis extracts can improve intractable neurogenic symptoms. Clin Rehabil 2003;17:21-9. 17 Wade DT, Makela P, Robson P, House H, Bateman C. Do cannabis-based medicinal extracts have general or specific effects on symptoms in multiple sclerosis? A double-blind, randomized, placebo-controlled study on 160 patients. Mult Scler 2004;10:434-41. 18 Collin C, Davies P, Mutiboko I, Ratcliffe S. Randomized controlled trial of cannabis-based medicine in spasticity caused by multiple sclerosis. Eur J Neurol 2007;14:290-6. 19 Collin C, Ehler E, Waberzinek G, Alsindi Z, Davies P, Powell K, et al. A double-blind, randomised, placebo-controlled, parallel-group study of Sativex, in subjects with symptoms of spasticity due to multiple sclerosis. Neurol Res 2010;32:451-9. 20 Wade DT, Collin C, Stott C, Duncombe P. Meta-analysis of the efficacy and safety of Sativex (nabiximols), on spasticity in people with multiple sclerosis. Mult Scler 2010;16:707-14. 21 Podda G, Constantinescu CS. Nabiximols in the treatment of spasticity, pain and urinary symptoms due to multiple sclerosis. Expert Opin Biol Ther 2012;12:1517-31. 22 Langford RM, Mares J, Novotna A, Vachova M, Novakova I, Notcutt W, et al. A double-blind, randomized, placebo-controlled, parallel-group study of THC/CBD oromucosal spray in combination with the existing treatment regimen, in the relief of central neuropathic pain in patients with multiple sclerosis. J Neurol 2013;260:984-97. 23 Corey-Bloom J, Wolfson T, Gamst A, Jin S, Marcotte TD, Bentley H, et al. Smoked cannabis for spasticity in multiple sclerosis: a randomized, placebocontrolled trial. CMAJ 2012;184:1143-50. 24 Snedecor SJ, Sudharshan L, Cappelleri JC, Sadosky A, Desai P, Jalundhwala YJ, et al. Systematic review and comparison of pharmacologic therapies for neuropathic pain associated with spinal cord injury. J Pain Res 2013;6:539-47.
25 Rintala DH, Fiess RN, Tan G, Holmes SA, Bruel BM. Effect of dronabinol on central neuropathic pain after spinal cord injury: a pilot study. Am J Phys Med Rehabil 2010;89:840-8. 26 Phillips TJ, Cherry CL, Cox S, Marshall SJ, Rice AS. Pharmacological treatment of painful HIV-associated sensory neuropathy: a systematic review and meta-analysis of randomised controlled trials. PLoS One 2010;5:e14433. 27 Selvarajah D, Gandhi R, Emery CJ, Tesfaye S. Randomized placebocontrolled double-blind clinical trial of cannabis-based medicinal product (Sativex) in painful diabetic neuropathy: depression is a major confounding factor. Diabetes Care 2010;33:128-30. 28 Toth C, Mawani S, Brady S, Chan C, Liu C, Mehina E, et al. An enrichedenrolment, randomized withdrawal, flexible-dose, double-blind, placebocontrolled, parallel assignment efficacy study of nabilone as adjuvant in the treatment of diabetic peripheral neuropathic pain. Pain 2012;153:207382. 29 Richards B, Whittle S, Buchbinder R. Neuromodulators for pain management in rheumatoid arthritis. Cochrane Database Syst Rev 2011;1:CD008921. 30 De Souza Nascimento S, Desantana JM, Nampo FK, Ribeiro EAN, Da Silva DL, Araujo-Junior JX, et al. Efficacy and safety of medicinal plants or related natural products for fibromyalgia: a systematic review. Evid Based Complement Alternat Med 2013;2013:149468. 31 Ware MA, Fitzcharles MA, Joseph L, Shir Y. The effects of nabilone on sleep in fibromyalgia: results of a randomized controlled trial. Anesth Analges 2010;110:604-10. 32 Skrabek RQ, Galimova L, Ethans K, Perry D. Nabilone for the treatment of pain in fibromyalgia. J Pain 2008;9:164-73. 33 Pini LA, Guerzoni S, Cainazzo MM, Ferrari A, Sarchielli P, Tiraferri I, et al. Nabilone for the treatment of medication overuse headache: results of a preliminary double-blind, active-controlled, randomized trial. J Headache Pain 2012;13:677-84. 34 Martin-Sanchez E, Furukawa TA, Taylor J, Martin JL. Systematic review and meta-analysis of cannabis treatment for chronic pain. Pain Med 2009;10:1353-68. 35 Portenoy RK, Ganae-Motan ED, Allende S, Yanagihara R, Shaiova L, Weinstein S, et al. Nabiximols for opioid-treated cancer patients with poorly-controlled chronic pain: a randomized, placebo-controlled, gradeddose trial. J Pain 2012;13:438-49. 36 Johnson JR, Burnell-Nugent M, Lossignol D, Ganae-Motan ED, Potts R, Fallon MT. Multicenter, double-blind, randomized, placebo-controlled, parallelgroup study of the efficacy, safety, and tolerability of THC:CBD extract and THC extract in patients with intractable cancer-related pain. J Pain Symptom Manage 2010;39:167-79. 37 Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet 2009;374:1383-91.
10-MINUTE CONSULTATION
Eustachian tube dysfunction in adults Rhona Sproat,1 Christopher Burgess,1 Tim Lancaster,2 Pablo Martinez-Devesa1 1
Ear, nose, and throat department, John Radcliffe Hospital, Oxford OX3 9DU, UK 2 Jericho Health Centre—Primary Care, Oxford, UK Correspondence to: R Sproat [email protected] Cite this as: BMJ 2014;348:g1647 doi: 10.1136/bmj.g1647
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
USEFUL RESOURCES FOR PATIENTS Patient.co.uk. www.patient.co.uk/ health/Eustachian-TubeDysfunction.html 36
A 56 year old woman presents with a history of fullness in her ears and reduced hearing, which has persisted for three weeks. She often hears clicking when she swallows.
What is eustachian tube dysfunction? The eustachian tube is a cartilaginous and bony tube providing a connection between the nasopharynx and the middle ear. At rest, the eustachian tube is closed, but it opens on swallowing, yawning, sneezing, and the Valsalva manoeuvre due to contraction of palatine muscles. When the eustachian tube opens it facilitates equalisation of pressures between the external environment and the middle ear by allowing a bolus of air to pass through. Dysfunction of the eustachian tube results in development of negative pressures within the middle ear, leading to transudation of fluid and a pro-inflammatory response. Consequentially, eustachian tube dysfunction is an important component of pathology of the middle ear, particularly acute otitis media and otitis media with effusion.
What you should cover History Feeling of fullness in the ears—Eustachian tube dysfunction classically presents with a feeling of fullness in the ear, often associated with hearing loss. Eustachian tube dysfunction should be a diagnosis of exclusion as ear fullness can be the presenting feature in a wide variety of clinical entities of the external, middle, and inner ears. There is a requirement for a wide differential and thorough history taking (box). Preceding symptoms and precipitating factors Screening for the following precipitating factors within the history can lead to a diagnosis: Rhinosinusitis is a common precipitant of reversible and transient eustachian tube dysfunction. This can be allergic or viral in cause. Smoking is an environmental factor that contributes to rhinosinusitis.2 Nasopharyngeal carcinoma can mechanically obstruct the eustachian tube orifices, resulting in Eustachian tube dysfunction. Although its incidence is less than 1:100 000, exclusion of nasopharyngeal carcinoma is important in all BMJ | 3 MAY 2014 | VOLUME 348
PRACTICE
Differential diagnosis of feeling of fullness in the ears and associated symptoms1 External ear Otitis externa—Pain on moving the pinna, itching from external ear Wax impaction Middle ear Eustachian tube dysfunction—Associated hearing loss in some cases Otitis media with effusion—May present with reduced hearing, sensation of imbalance Chronic suppurative otitis media—Otorrhoea, hearing loss Acute otitis media—Pyrexia, otalgia, hearing loss, pressure build-up in ear Inner ear Sensorineural hearing loss Ménière’s disease—Associated with vertigo, hearing loss, tinnitus
bmj.com Previous articles in this series ЖЖDiagnosis and management of chronic heart failure (BMJ 2014;348:g1429) ЖЖBaby with an abnormal head (BMJ 2014;348:f7609) ЖЖA feeling of a lump in the throat (BMJ 2014;348:f7195) ЖЖTremor (BMJ 2013;347:f7200) ЖЖDental pain (BMJ 2013;347:f6539)
cases of persistent eustachian tube dysfunction.3 The incidence of this tumour is higher in the native population of southern China and South East Asia. Ask about symptoms of nasal obstruction or epistaxis. Adenoidal hypertrophy can result in obstruction of the eustachian tube orifices in children, but this is not common in adults.
Examination Primary care A thorough ear, nose, and throat (ENT) examination should be carried out to exclude differential diagnoses. Otoscopy—In isolated eustachian tube dysfunction, one would expect a normal or retracted tympanic membrane, or evidence of effusion in more severe cases. Neck examination—To exclude cervical lymphadenopathy, which may be associated with nasopharyngeal carcinoma. Valsalva manoeuvre—Ask the patient to blow whilst holding their nose. This may transiently relieve the feeling of pressure in the ears. Consider if available in primary care Pure tone audiometry—This may show the presence of conductive hearing loss, although this may not always be present. Tympanometry—A tympanogram tests compliance of the tympanic membrane and can indicate presence of negative middle ear pressure or effusion. What you should do Treatment in primary care In a recent study, a third of patients with eustachian tube dysfunction showed spontaneous improvement at six months’ follow-up.4 Management in primary care with trial of the below treatments and regular follow-up may be appropriate for patients with eustachian tube dysfunction without risk factors for malignancy. Auto-inflation devices (Otovent, Ear Popper) There is good evidence to suggest these devices, which apply positive pressure through the nose during swallowing, are safe and improve tympanogram and audiometry results at follow-up.5 These devices can be bought over the counter and are recommended for use two or three times a day for at least two weeks initially. Intranasal preparations There is no proven benefit of intranasal medications for symptomatic relief of eustachian tube dysfunction, although
BMJ | 3 MAY 2014 | VOLUME 348
studies are limited in number.4 Use is recommended if rhinosinusitis is thought to be a precipitating factor.6 Nasal decongestants—Topical nasal decongestants may be used, but only for a maximum of seven days because of the risk of rebound rhinitis medicamentosa associated with long term use. Intranasal steroids—There is no evidence that these improve eustachian tube dysfunction.4 They are safe for use on a longer term basis than decongestants, although the lowest possible dose should be prescribed, and the patient should be warned of local side effects such as nasal crusting and dryness. Intranasal antihistamines—These may be used when an allergic cause of rhinitis is thought to have precipitated eustachian tube dysfunction. If the allergen can be identified, avoidance or limitation of exposure can be advocated.
Referral to ENT services Referral is indicated if there is suspicion of nasopharyngeal carcinoma (this should include all patients with persistent unilateral eustachian tube dysfunction without a clear precipitant) or if conservative or medical therapy in primary care has failed to resolve the patient’s symptoms. Secondary care Further investigations Nasendscopy allows the nasal cavities and eustachian tube orifices to be inspected in order to assess for nasal or nasopharyngeal pathology causing secondary eustachian tube dysfunction. Treatment Conservative—Once a malignant cause for symptoms has been excluded, it may be prudent to continue with a period of observation. Tympanostomy tube (grommets)—Ventilation tubes for the middle ear are surgical option if conservative measures have failed. Careful consideration of adverse effects should be weighed against short term symptomatic benefits. Eustachian tuboplasty (balloon dilatation)—A balloon catheter is used to dilate the eustachian tube. This treatment is relatively novel and was assessed by the National Institute for Health and Care Excellence (NICE) in 2011.6 From early data, this technique is thought to be safe and has the advantage over tympanostomy of being relatively non-invasive, and may have greater longevity of results. Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. 1 2 3 4
5 6
Park SP, Lee HY, Kang HM, Ryu EW, Lee SK, Yeo SG. Clinical manifestations of aural fullness. Yonsei Med J 2012;53:985-91. Reh DD, Higgins TS, Smith TL. Impact of tobacco smoke on chronic rhinosinusitis: a review of the literature. Int Forum Allergy Rhinol 2012;2:362-9. Yu MC, Yuan J-M. Epidemiology of nasopharyngeal carcinoma. Semin Cancer Biol 2002;12:421-9. Gluth MB, McDonald DR, Weaver AL, Bauch CD, Beatty CW, Orvidas LJ. Management of eustachian tube dysfunction with nasal steroid spray. a prospective, randomized, placebo-controlled trial. Arch Otolaryngol Head Neck Surg 2011;137:449-55. Perera R, Glasziou PP, Heneghan CJ, McLellan J, Williamson I. Autoinflation for hearing loss associated with otitis media with effusion. Cochrane Database Syst Rev 2013;31(5):CD006285. National Institute for Health and Clinical Excellence. Balloon dilatation of the eustachian tube. (Interventional procedure guidance 409.) 2011. guidance. nice.org.uk/ipg409.
Accepted: 03 December 2013
37
Copyright of BMJ: British Medical Journal is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
25 Rintala DH, Fiess RN, Tan G, Holmes SA, Bruel BM. Effect of dronabinol on central neuropathic pain after spinal cord injury: a pilot study. Am J Phys Med Rehabil 2010;89:840-8. 26 Phillips TJ, Cherry CL, Cox S, Marshall SJ, Rice AS. Pharmacological treatment of painful HIV-associated sensory neuropathy: a systematic review and meta-analysis of randomised controlled trials. PLoS One 2010;5:e14433. 27 Selvarajah D, Gandhi R, Emery CJ, Tesfaye S. Randomized placebocontrolled double-blind clinical trial of cannabis-based medicinal product (Sativex) in painful diabetic neuropathy: depression is a major confounding factor. Diabetes Care 2010;33:128-30. 28 Toth C, Mawani S, Brady S, Chan C, Liu C, Mehina E, et al. An enrichedenrolment, randomized withdrawal, flexible-dose, double-blind, placebocontrolled, parallel assignment efficacy study of nabilone as adjuvant in the treatment of diabetic peripheral neuropathic pain. Pain 2012;153:207382. 29 Richards B, Whittle S, Buchbinder R. Neuromodulators for pain management in rheumatoid arthritis. Cochrane Database Syst Rev 2011;1:CD008921. 30 De Souza Nascimento S, Desantana JM, Nampo FK, Ribeiro EAN, Da Silva DL, Araujo-Junior JX, et al. Efficacy and safety of medicinal plants or related natural products for fibromyalgia: a systematic review. Evid Based Complement Alternat Med 2013;2013:149468. 31 Ware MA, Fitzcharles MA, Joseph L, Shir Y. The effects of nabilone on sleep in fibromyalgia: results of a randomized controlled trial. Anesth Analges 2010;110:604-10. 32 Skrabek RQ, Galimova L, Ethans K, Perry D. Nabilone for the treatment of pain in fibromyalgia. J Pain 2008;9:164-73. 33 Pini LA, Guerzoni S, Cainazzo MM, Ferrari A, Sarchielli P, Tiraferri I, et al. Nabilone for the treatment of medication overuse headache: results of a preliminary double-blind, active-controlled, randomized trial. J Headache Pain 2012;13:677-84. 34 Martin-Sanchez E, Furukawa TA, Taylor J, Martin JL. Systematic review and meta-analysis of cannabis treatment for chronic pain. Pain Med 2009;10:1353-68. 35 Portenoy RK, Ganae-Motan ED, Allende S, Yanagihara R, Shaiova L, Weinstein S, et al. Nabiximols for opioid-treated cancer patients with poorly-controlled chronic pain: a randomized, placebo-controlled, gradeddose trial. J Pain 2012;13:438-49. 36 Johnson JR, Burnell-Nugent M, Lossignol D, Ganae-Motan ED, Potts R, Fallon MT. Multicenter, double-blind, randomized, placebo-controlled, parallelgroup study of the efficacy, safety, and tolerability of THC:CBD extract and THC extract in patients with intractable cancer-related pain. J Pain Symptom Manage 2010;39:167-79. 37 Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet 2009;374:1383-91.
10-MINUTE CONSULTATION
Eustachian tube dysfunction in adults Rhona Sproat,1 Christopher Burgess,1 Tim Lancaster,2 Pablo Martinez-Devesa1 1
Ear, nose, and throat department, John Radcliffe Hospital, Oxford OX3 9DU, UK 2 Jericho Health Centre—Primary Care, Oxford, UK Correspondence to: R Sproat [email protected] Cite this as: BMJ 2014;348:g1647 doi: 10.1136/bmj.g1647
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
USEFUL RESOURCES FOR PATIENTS Patient.co.uk. www.patient.co.uk/ health/Eustachian-TubeDysfunction.html 36
A 56 year old woman presents with a history of fullness in her ears and reduced hearing, which has persisted for three weeks. She often hears clicking when she swallows.
What is eustachian tube dysfunction? The eustachian tube is a cartilaginous and bony tube providing a connection between the nasopharynx and the middle ear. At rest, the eustachian tube is closed, but it opens on swallowing, yawning, sneezing, and the Valsalva manoeuvre due to contraction of palatine muscles. When the eustachian tube opens it facilitates equalisation of pressures between the external environment and the middle ear by allowing a bolus of air to pass through. Dysfunction of the eustachian tube results in development of negative pressures within the middle ear, leading to transudation of fluid and a pro-inflammatory response. Consequentially, eustachian tube dysfunction is an important component of pathology of the middle ear, particularly acute otitis media and otitis media with effusion.
What you should cover History Feeling of fullness in the ears—Eustachian tube dysfunction classically presents with a feeling of fullness in the ear, often associated with hearing loss. Eustachian tube dysfunction should be a diagnosis of exclusion as ear fullness can be the presenting feature in a wide variety of clinical entities of the external, middle, and inner ears. There is a requirement for a wide differential and thorough history taking (box). Preceding symptoms and precipitating factors Screening for the following precipitating factors within the history can lead to a diagnosis: Rhinosinusitis is a common precipitant of reversible and transient eustachian tube dysfunction. This can be allergic or viral in cause. Smoking is an environmental factor that contributes to rhinosinusitis.2 Nasopharyngeal carcinoma can mechanically obstruct the eustachian tube orifices, resulting in Eustachian tube dysfunction. Although its incidence is less than 1:100 000, exclusion of nasopharyngeal carcinoma is important in all BMJ | 3 MAY 2014 | VOLUME 348
PRACTICE
Differential diagnosis of feeling of fullness in the ears and associated symptoms1 External ear Otitis externa—Pain on moving the pinna, itching from external ear Wax impaction Middle ear Eustachian tube dysfunction—Associated hearing loss in some cases Otitis media with effusion—May present with reduced hearing, sensation of imbalance Chronic suppurative otitis media—Otorrhoea, hearing loss Acute otitis media—Pyrexia, otalgia, hearing loss, pressure build-up in ear Inner ear Sensorineural hearing loss Ménière’s disease—Associated with vertigo, hearing loss, tinnitus
bmj.com Previous articles in this series ЖЖDiagnosis and management of chronic heart failure (BMJ 2014;348:g1429) ЖЖBaby with an abnormal head (BMJ 2014;348:f7609) ЖЖA feeling of a lump in the throat (BMJ 2014;348:f7195) ЖЖTremor (BMJ 2013;347:f7200) ЖЖDental pain (BMJ 2013;347:f6539)
cases of persistent eustachian tube dysfunction.3 The incidence of this tumour is higher in the native population of southern China and South East Asia. Ask about symptoms of nasal obstruction or epistaxis. Adenoidal hypertrophy can result in obstruction of the eustachian tube orifices in children, but this is not common in adults.
Examination Primary care A thorough ear, nose, and throat (ENT) examination should be carried out to exclude differential diagnoses. Otoscopy—In isolated eustachian tube dysfunction, one would expect a normal or retracted tympanic membrane, or evidence of effusion in more severe cases. Neck examination—To exclude cervical lymphadenopathy, which may be associated with nasopharyngeal carcinoma. Valsalva manoeuvre—Ask the patient to blow whilst holding their nose. This may transiently relieve the feeling of pressure in the ears. Consider if available in primary care Pure tone audiometry—This may show the presence of conductive hearing loss, although this may not always be present. Tympanometry—A tympanogram tests compliance of the tympanic membrane and can indicate presence of negative middle ear pressure or effusion. What you should do Treatment in primary care In a recent study, a third of patients with eustachian tube dysfunction showed spontaneous improvement at six months’ follow-up.4 Management in primary care with trial of the below treatments and regular follow-up may be appropriate for patients with eustachian tube dysfunction without risk factors for malignancy. Auto-inflation devices (Otovent, Ear Popper) There is good evidence to suggest these devices, which apply positive pressure through the nose during swallowing, are safe and improve tympanogram and audiometry results at follow-up.5 These devices can be bought over the counter and are recommended for use two or three times a day for at least two weeks initially. Intranasal preparations There is no proven benefit of intranasal medications for symptomatic relief of eustachian tube dysfunction, although
BMJ | 3 MAY 2014 | VOLUME 348
studies are limited in number.4 Use is recommended if rhinosinusitis is thought to be a precipitating factor.6 Nasal decongestants—Topical nasal decongestants may be used, but only for a maximum of seven days because of the risk of rebound rhinitis medicamentosa associated with long term use. Intranasal steroids—There is no evidence that these improve eustachian tube dysfunction.4 They are safe for use on a longer term basis than decongestants, although the lowest possible dose should be prescribed, and the patient should be warned of local side effects such as nasal crusting and dryness. Intranasal antihistamines—These may be used when an allergic cause of rhinitis is thought to have precipitated eustachian tube dysfunction. If the allergen can be identified, avoidance or limitation of exposure can be advocated.
Referral to ENT services Referral is indicated if there is suspicion of nasopharyngeal carcinoma (this should include all patients with persistent unilateral eustachian tube dysfunction without a clear precipitant) or if conservative or medical therapy in primary care has failed to resolve the patient’s symptoms. Secondary care Further investigations Nasendscopy allows the nasal cavities and eustachian tube orifices to be inspected in order to assess for nasal or nasopharyngeal pathology causing secondary eustachian tube dysfunction. Treatment Conservative—Once a malignant cause for symptoms has been excluded, it may be prudent to continue with a period of observation. Tympanostomy tube (grommets)—Ventilation tubes for the middle ear are surgical option if conservative measures have failed. Careful consideration of adverse effects should be weighed against short term symptomatic benefits. Eustachian tuboplasty (balloon dilatation)—A balloon catheter is used to dilate the eustachian tube. This treatment is relatively novel and was assessed by the National Institute for Health and Care Excellence (NICE) in 2011.6 From early data, this technique is thought to be safe and has the advantage over tympanostomy of being relatively non-invasive, and may have greater longevity of results. Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. 1 2 3 4
5 6
Park SP, Lee HY, Kang HM, Ryu EW, Lee SK, Yeo SG. Clinical manifestations of aural fullness. Yonsei Med J 2012;53:985-91. Reh DD, Higgins TS, Smith TL. Impact of tobacco smoke on chronic rhinosinusitis: a review of the literature. Int Forum Allergy Rhinol 2012;2:362-9. Yu MC, Yuan J-M. Epidemiology of nasopharyngeal carcinoma. Semin Cancer Biol 2002;12:421-9. Gluth MB, McDonald DR, Weaver AL, Bauch CD, Beatty CW, Orvidas LJ. Management of eustachian tube dysfunction with nasal steroid spray. a prospective, randomized, placebo-controlled trial. Arch Otolaryngol Head Neck Surg 2011;137:449-55. Perera R, Glasziou PP, Heneghan CJ, McLellan J, Williamson I. Autoinflation for hearing loss associated with otitis media with effusion. Cochrane Database Syst Rev 2013;31(5):CD006285. National Institute for Health and Clinical Excellence. Balloon dilatation of the eustachian tube. (Interventional procedure guidance 409.) 2011. guidance. nice.org.uk/ipg409.
Accepted: 03 December 2013
37
Copyright of BMJ: British Medical Journal is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
