The patulous eustachian tube: Management options R. KENT DYER, JR.,MD, and JOHN T. McELVEEN, JR.,MD, Durham, North Carolina
The patulous eustachian tube is a benign, yet annoying condition that may be overlooked or misdiagnosed. If is frequently associated with peritubal atrophy, and usually responds to conservative measures such as weight gain or mucus-producing agents. In patients not responding to these measures, a variety of surgical options are available. We have been using a technique that avoids elevating a tympanomeatal flap, is reversible, and is effective. This technique, as well as other surgical options, are reviewed. The advantages and disadvantages inherent in them are discussed. (OTOLARYNGOL HEAD NECK SURG 1991;105:832.]
T h e patulous eustachian tube is a benign, yet annoying condition that may be overlooked or misdiagnosed. The condition was initially described by Schwartz’ in 1864, after he observed the synchronous movement of a patient’s scarred tympanic membrane with respiration. In 1870, Jago’ further characterized the patulous eustachian tube after reporting that he himself was afflicted with this condition. Between 1870 and 1929, little was written on this entity. However, Pittman3 in 1929, and Z ~ l l n e r Shambaugh,’ ,~ and Perlman6 in the 1930s revived interest in the patulous eustachian tube. The symptoms of a patulous eustachian tube are similar in some respects to serous otitis media. Patients experience aural fullness and autophony, as do patients with serous otitis. In contrast, however, patients with patulous eustachian tubes hear their own breath sounds (tympanophonia). The sound is synchronous with nasal respiration and often resolves when the patient is in a supine position or nasopharyngeal congestion develops. The condition is relatively rare in its severe form, although its milder form may be seen more frequently. Zollnef‘ estimated that 0.3% of his patients were afflicted with this condition, whereas Munker and Arnold’ observed a 6.6% incidence.
From the Department of Surgery, Division of Otolaryngology, Duke University Medical Center. Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, San Diego, Calif., Sept. 913, 1990. Received for publication Dec. 17, 1990; revision received Aug. 3, 1991; accepted Aug. 20, 1991. Reprint requests: John T. McElveen, Jr., MD, Box 3805, Duke University Medical Center, Durham, NC 27710. 23 I 1 133533
As first noted by Toynbee* (1853), the eustachian tube is normally closed. This occurs despite the eustachian tube having no active constrictors. Only the elasticity of its cartilage, its mucosal lining, and extrinsic factors such as the peritubal fat pad serve to maintain tubal closure. Conditions that alter these factors, such as radiation therapy, hormonal therapy, and weight loss, may produce inadequate tubal closure, resulting in symptoms of a patulous tube. MANAGEMENT
The otolaryngologist treating these patients has several management options from which to choose. Most patients require no treatment other than reassurance. The symptoms are often transient, and a careful explanation of the condition is all that is needed. In 1938, Perlman6 suggested that a patient with this condition is “in need of a hearty meal.” Since weight loss is one of the most common causes of this condition, there is some truth to Perlman’s statement. Patients failing these measures may benefit from agents that produce intraluminal or extraluminal mucosal swelling. Numerous agents have been tried and include the following: insufflation of boric acid and salicylate powder into the eustachian tube orifice (Bezold’s treatment), application of nitric acid and phenol into the eustachian tube, oral administration of saturated solution of potassium iodide (SSKI) (10 drops in a glass of juice three times per day), and instillation of Premarin nasal spray (25 mg in 30 cc normal saline solution) 3 drops three times per day. We have found the latter two treatments to be effective, well tolerated by patients, and free of complications. Patients are initially given a trial of the SSKI. If the mucosal swelling produced by SSKI is insufficient to occlude the eustachian tube, Premarin nasal spray is
832
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Volume 105 Number 6 December 1991
Patulous eustachian tube: Management options 833
Fig. 1. Bluestone technique: an anterior tympanomeatal flap is elevated, followed by insertion of an eustochian tube catheter.
Fig. 2. Modification of Bluestone technique: an anterior myringotomy is created and location of the eustachian tube is confirmed with lacrimal Drobe.
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OtolaryngologyHead and Neck Surgery
834 DYER, JR. and McElveen. JR
Fig. 3. A section of 18-gauge Medicut angiocoth is occluded with bone wax and passed through the myringotorny into the eustachian tube.
added to the treatment regimen. The peritubal irritation produced by Premarin. in conjunction with the mucosal swelling caused by SSKI, is usually sufficient to occlude the patulous eustachian tube. A limited number of patients may have unsuccessful medical therapy and require one of the surgical treatment options. A number of techniques have been tried with varying success. These include the following: electrocauterization of the eustachian tube orifice, peritubal injection with Gelfoam or Teflon paste (presently contraindicated as a result of inadvertent injection of paste into the carotid artery), transposition of the tensor veli palatini muscle medial to the pterygoid hamulus, myringotomy with ventilation tube placement. and occlusion of the bony eustachian tube by insertion of an indwelling catheter and subsequent ventilation tube placement. It is a modification of the latter technique, taught to one of the authors (J.T.M.) by Derald Brackmann, that we have found particularly effective in treating our patients who are refractory to medical therapy. SURGICAL TECHNIQUE
The technique originally described by Bluestone and Cantekin' involved raising an anterior tympanomeatal flap, inserting a catheter into the eustachian tube, and then placing a ventilation tube in the tympanic membrane (Fig. 1). The modification of the Blirestorie tech-
nique used at Duke University Medical Center involves placement of the catheter through a myringotomy. The ear is prepared and draped in the normal sterile fashion. A standard tympanomeatal block, using I % xylocaine with 1 / 100,000epinephrine, is administered. An anterior myringotomy is made and the location of the bony eustachian tube orifice is confirmed with a lacrimal probe (Fig. 2). A section of an 18-gauge Medicirt angiocath is occluded with bone wax and bent to produce a slight curvature of the catheter. The catheter is then passed through the myringotomy and placed blindly into the bony eustachian tube orifice (Fig. 3). Once the eustachian tube is cannulated, the catheter is firmly pushed into the orifice to ensure a tight fit. A ventilation tube is then placed into the myringotomy incision (Fig. 4). One can evaluate the adequacy of occlusion by placing the patient in a seated position and having him or her forcefully inhale and exhale while the contralateral nostril is occluded. If the patient continues to hear his or her respirations in the ear operated on, the occlusion is inadequate and the occluding catheter is revised. CASE REPORT
In the past 3 years, four patients at Duke University Medical Center have been treated by J.T.M.. using the modified technique. Typical of these patients was B.B., a 75-year-old
Downloaded from oto.sagepub.com at Bobst Library, New York University on July 11, 2015
Volume 105 Number 6 December 1991
Potulous eustochion tube: Management options 835
Fig. 4. A ventilation tube is then placed into the myringotomy incision.
man with a history of sensorineural hearing loss in whom right aural fullness and tympanophonia developed of approximately 6 months duration. Two outside evaluations by otolaryngologists were nondiagnostic, and the patient was referred to Duke University Medical Center for further cvaluation. Examination of the nose. oral cavity. and neck were within normal limits. Otologic examination revealed movement of the right tympanic membrane synchronous with respiration, and a diagnosis of right patulous eustachian tube was made. There was no evidence of middle ear effusion, and examination of the left ear was normal. The paticnt was placed on a treatment of SSKI solution. followed by a trial of Premarin nasal spray for 2 months. Despite the combined medical therapy. his symptoms persisted. Consequently, under local anesthesia, the patient underwent a right eustachian tube catheterization with placement of a right PE tube. After completion of the procedure. the patient was placed in a seated position and noted complete resolution of autophony and tynipanophonia. To date, B.B. and the other three patients in our series are free of symptoms.
to placement of a ventilation tube in conjunction with eustachian tube occlusion. The catheter technique for occluding t h e eustachian tube has several advantages over other surgical options. It can be performed with the patient under local anesthesia, is effective, and is reversible.
CONCLUSION A number of medical and surgical options are available to patients with a patulous eustachian tube. We have found the SSKI treatment or the SSKI in combination with Premarin nasal spray to be adequate medical therapy for the majority of patients. Patients refractory to these medical measures have responded well
6.
REFERENCES 1 . Schwartz H. Respiralarische bewegung des tromnielfelles. Arch
Ohrenheilk 1861:1:139. 2 . Jago J . The funclions of the tympanum. Br Foreign Med Chir Rev 1867:39:175. 3. Pittman LK. The open eustachian tube. Arch Otolaryngol
I929:9:494-500. 4. Zollner F. Widerstandsmessungen an der ohnrapeie zui prufung ihrer weg sankeit: Eine news verfakren und bisherige ergeanisse
5.
7.
8.
9.
an ohrgesunden undkranken. Arch Ohren Nasen Kehlkapheilk 1939;140:137. Shambaugh GE, Jr. Continuously open eustachian tube. Arch Otolaryngol 1938:17:420-5. Perlnian HB. The eustachian tube: abnormal patency and normal physiologic state. Arch Otolaryngol 1939:30:212. Munker G. Arnold W, eds. Physiology and pathophysiology of eustachian tube and middle ear. New York: Theme Stratton. Inc.. Toynbee J . On the muscles which open the eustachian tube. Proc Royal Soc 1853:6:286. Bluestone CD, Cantekin El. Management of the palulous eustachian tube. Laryngoscope 1981:91:149-52.
Downloaded from oto.sagepub.com at Bobst Library, New York University on July 11, 2015
The patulous eustachian tube is a benign, yet annoying condition that may be overlooked or misdiagnosed. If is frequently associated with peritubal atrophy, and usually responds to conservative measures such as weight gain or mucus-producing agents. In patients not responding to these measures, a variety of surgical options are available. We have been using a technique that avoids elevating a tympanomeatal flap, is reversible, and is effective. This technique, as well as other surgical options, are reviewed. The advantages and disadvantages inherent in them are discussed. (OTOLARYNGOL HEAD NECK SURG 1991;105:832.]
T h e patulous eustachian tube is a benign, yet annoying condition that may be overlooked or misdiagnosed. The condition was initially described by Schwartz’ in 1864, after he observed the synchronous movement of a patient’s scarred tympanic membrane with respiration. In 1870, Jago’ further characterized the patulous eustachian tube after reporting that he himself was afflicted with this condition. Between 1870 and 1929, little was written on this entity. However, Pittman3 in 1929, and Z ~ l l n e r Shambaugh,’ ,~ and Perlman6 in the 1930s revived interest in the patulous eustachian tube. The symptoms of a patulous eustachian tube are similar in some respects to serous otitis media. Patients experience aural fullness and autophony, as do patients with serous otitis. In contrast, however, patients with patulous eustachian tubes hear their own breath sounds (tympanophonia). The sound is synchronous with nasal respiration and often resolves when the patient is in a supine position or nasopharyngeal congestion develops. The condition is relatively rare in its severe form, although its milder form may be seen more frequently. Zollnef‘ estimated that 0.3% of his patients were afflicted with this condition, whereas Munker and Arnold’ observed a 6.6% incidence.
From the Department of Surgery, Division of Otolaryngology, Duke University Medical Center. Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, San Diego, Calif., Sept. 913, 1990. Received for publication Dec. 17, 1990; revision received Aug. 3, 1991; accepted Aug. 20, 1991. Reprint requests: John T. McElveen, Jr., MD, Box 3805, Duke University Medical Center, Durham, NC 27710. 23 I 1 133533
As first noted by Toynbee* (1853), the eustachian tube is normally closed. This occurs despite the eustachian tube having no active constrictors. Only the elasticity of its cartilage, its mucosal lining, and extrinsic factors such as the peritubal fat pad serve to maintain tubal closure. Conditions that alter these factors, such as radiation therapy, hormonal therapy, and weight loss, may produce inadequate tubal closure, resulting in symptoms of a patulous tube. MANAGEMENT
The otolaryngologist treating these patients has several management options from which to choose. Most patients require no treatment other than reassurance. The symptoms are often transient, and a careful explanation of the condition is all that is needed. In 1938, Perlman6 suggested that a patient with this condition is “in need of a hearty meal.” Since weight loss is one of the most common causes of this condition, there is some truth to Perlman’s statement. Patients failing these measures may benefit from agents that produce intraluminal or extraluminal mucosal swelling. Numerous agents have been tried and include the following: insufflation of boric acid and salicylate powder into the eustachian tube orifice (Bezold’s treatment), application of nitric acid and phenol into the eustachian tube, oral administration of saturated solution of potassium iodide (SSKI) (10 drops in a glass of juice three times per day), and instillation of Premarin nasal spray (25 mg in 30 cc normal saline solution) 3 drops three times per day. We have found the latter two treatments to be effective, well tolerated by patients, and free of complications. Patients are initially given a trial of the SSKI. If the mucosal swelling produced by SSKI is insufficient to occlude the eustachian tube, Premarin nasal spray is
832
Downloaded from oto.sagepub.com at Bobst Library, New York University on July 11, 2015
Volume 105 Number 6 December 1991
Patulous eustachian tube: Management options 833
Fig. 1. Bluestone technique: an anterior tympanomeatal flap is elevated, followed by insertion of an eustochian tube catheter.
Fig. 2. Modification of Bluestone technique: an anterior myringotomy is created and location of the eustachian tube is confirmed with lacrimal Drobe.
Downloaded from oto.sagepub.com at Bobst Library, New York University on July 11, 2015
OtolaryngologyHead and Neck Surgery
834 DYER, JR. and McElveen. JR
Fig. 3. A section of 18-gauge Medicut angiocoth is occluded with bone wax and passed through the myringotorny into the eustachian tube.
added to the treatment regimen. The peritubal irritation produced by Premarin. in conjunction with the mucosal swelling caused by SSKI, is usually sufficient to occlude the patulous eustachian tube. A limited number of patients may have unsuccessful medical therapy and require one of the surgical treatment options. A number of techniques have been tried with varying success. These include the following: electrocauterization of the eustachian tube orifice, peritubal injection with Gelfoam or Teflon paste (presently contraindicated as a result of inadvertent injection of paste into the carotid artery), transposition of the tensor veli palatini muscle medial to the pterygoid hamulus, myringotomy with ventilation tube placement. and occlusion of the bony eustachian tube by insertion of an indwelling catheter and subsequent ventilation tube placement. It is a modification of the latter technique, taught to one of the authors (J.T.M.) by Derald Brackmann, that we have found particularly effective in treating our patients who are refractory to medical therapy. SURGICAL TECHNIQUE
The technique originally described by Bluestone and Cantekin' involved raising an anterior tympanomeatal flap, inserting a catheter into the eustachian tube, and then placing a ventilation tube in the tympanic membrane (Fig. 1). The modification of the Blirestorie tech-
nique used at Duke University Medical Center involves placement of the catheter through a myringotomy. The ear is prepared and draped in the normal sterile fashion. A standard tympanomeatal block, using I % xylocaine with 1 / 100,000epinephrine, is administered. An anterior myringotomy is made and the location of the bony eustachian tube orifice is confirmed with a lacrimal probe (Fig. 2). A section of an 18-gauge Medicirt angiocath is occluded with bone wax and bent to produce a slight curvature of the catheter. The catheter is then passed through the myringotomy and placed blindly into the bony eustachian tube orifice (Fig. 3). Once the eustachian tube is cannulated, the catheter is firmly pushed into the orifice to ensure a tight fit. A ventilation tube is then placed into the myringotomy incision (Fig. 4). One can evaluate the adequacy of occlusion by placing the patient in a seated position and having him or her forcefully inhale and exhale while the contralateral nostril is occluded. If the patient continues to hear his or her respirations in the ear operated on, the occlusion is inadequate and the occluding catheter is revised. CASE REPORT
In the past 3 years, four patients at Duke University Medical Center have been treated by J.T.M.. using the modified technique. Typical of these patients was B.B., a 75-year-old
Downloaded from oto.sagepub.com at Bobst Library, New York University on July 11, 2015
Volume 105 Number 6 December 1991
Potulous eustochion tube: Management options 835
Fig. 4. A ventilation tube is then placed into the myringotomy incision.
man with a history of sensorineural hearing loss in whom right aural fullness and tympanophonia developed of approximately 6 months duration. Two outside evaluations by otolaryngologists were nondiagnostic, and the patient was referred to Duke University Medical Center for further cvaluation. Examination of the nose. oral cavity. and neck were within normal limits. Otologic examination revealed movement of the right tympanic membrane synchronous with respiration, and a diagnosis of right patulous eustachian tube was made. There was no evidence of middle ear effusion, and examination of the left ear was normal. The paticnt was placed on a treatment of SSKI solution. followed by a trial of Premarin nasal spray for 2 months. Despite the combined medical therapy. his symptoms persisted. Consequently, under local anesthesia, the patient underwent a right eustachian tube catheterization with placement of a right PE tube. After completion of the procedure. the patient was placed in a seated position and noted complete resolution of autophony and tynipanophonia. To date, B.B. and the other three patients in our series are free of symptoms.
to placement of a ventilation tube in conjunction with eustachian tube occlusion. The catheter technique for occluding t h e eustachian tube has several advantages over other surgical options. It can be performed with the patient under local anesthesia, is effective, and is reversible.
CONCLUSION A number of medical and surgical options are available to patients with a patulous eustachian tube. We have found the SSKI treatment or the SSKI in combination with Premarin nasal spray to be adequate medical therapy for the majority of patients. Patients refractory to these medical measures have responded well
6.
REFERENCES 1 . Schwartz H. Respiralarische bewegung des tromnielfelles. Arch
Ohrenheilk 1861:1:139. 2 . Jago J . The funclions of the tympanum. Br Foreign Med Chir Rev 1867:39:175. 3. Pittman LK. The open eustachian tube. Arch Otolaryngol
I929:9:494-500. 4. Zollner F. Widerstandsmessungen an der ohnrapeie zui prufung ihrer weg sankeit: Eine news verfakren und bisherige ergeanisse
5.
7.
8.
9.
an ohrgesunden undkranken. Arch Ohren Nasen Kehlkapheilk 1939;140:137. Shambaugh GE, Jr. Continuously open eustachian tube. Arch Otolaryngol 1938:17:420-5. Perlnian HB. The eustachian tube: abnormal patency and normal physiologic state. Arch Otolaryngol 1939:30:212. Munker G. Arnold W, eds. Physiology and pathophysiology of eustachian tube and middle ear. New York: Theme Stratton. Inc.. Toynbee J . On the muscles which open the eustachian tube. Proc Royal Soc 1853:6:286. Bluestone CD, Cantekin El. Management of the palulous eustachian tube. Laryngoscope 1981:91:149-52.
Downloaded from oto.sagepub.com at Bobst Library, New York University on July 11, 2015
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