© Spencer Sutton / Science Source
If the ancient Greek Alcmaeon of Croton could only see the Eustachian tube now.
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June 2018The man said to have discovered the tube around 450 BC would likely be amazed at the work that now goes into discerning patulous versus dilatory dysfunction. In fact, our growing understanding of the cartilaginous portion of the Eustachian tube interests many otolaryngologists.
Hence, this year’s otology/neurotology panel, “Is the Eustachian Tube the Key?” Unlike panel discussions in which each participant made a presentation, these four panelists participated in more of a round-table discussion.
Aural Fullness Roadmap
Otolaryngologist Sujana Chandrasekhar, MD, has had as many patients complaining of aural fullness as any other physician in the field. But is it dilatory Eustachian tube dysfunction (ETD)? Patulous ETD? Or something altogether different, such as superior canal dehiscence?
“All of us have seen patients referred in for Eustachian tuboplasty or dilatation because, based on symptoms, they’re thought to have dilatory dysfunction,” said Dr. Chandrasekhar, a past president of the American Academy of Otolaryngology–Head and Neck Surgery and a member of ENTtoday’s Editorial Advisory Board. “And I know that anecdotally we’ve all told each other that some of those patients have patulous ET dysfunction … or other things that cause a feeling of fullness in your ear.
But, despite the challenges, the roadmap to making the right differential diagnosis for aural fullness has guideposts, said Dr. Chandrasekhar. “If (a patient’s tympanic membrane) is retracted, then you’re looking for negative pressure, you’re looking for an effusion, maybe a flat or negative pressure tympanogram,” she added. “A myringotomy or a myringotomy with a tube insertion relieves symptoms. I’ll tell you, if I’m thinking about this, I’ll actually do office myringotomy and see if that works rather than just go ahead and do a full myringotomy with tube insertion.”
Dr. Chandrasekhar urged physicians to pay close attention to their endoscopies and “not just blow by the nasopharynx, but stop and turn and look as far into the lumen of the Eustachian tube as possible to see if the patient is having a dilatory dysfunction or not.”
Patients presenting with a normal tympanic membrane go down a road of questions that more often lead to patulous ETD, Dr. Chandrasekhar said. For example, she said she has patients who only have pressure equalization issues intermittently.
“I practice in New York City,” she said. “Some of my patients who live or work on very high floors have to actually pause their elevator and get off, [and then] equalize and finish coming back down.”
Those patients might complain of aural fullness, but their primary problem is autophony of voice or breath. Sniffing inappropriately might also be a warning sign for patulous ETD.
For those patients who complain of aural fullness but lack major warning signs—no barorestriction, autophony, or tympanic membrane excursion—otolaryngologists should look at alternatives to ETD such as TMJ dysfunction or inner ear hydrops.
Valsalva Pros and Cons
There is a fine line when it comes to how often a patient can Valsalva. “The dilatory dysfunction patient can try Valsalva-ing so frequently that they in fact give themselves patulous dysfunction,” Dr. Chandrasekhar said. “You can actually keep sniffing and keep Valsalva-ing and end up patulous.”
Eric Smouha, MD, a clinical professor of otolaryngology at Icahn School of Medicine at Mount Sinai in New York, also preaches the usefulness of the Valsalva maneuver to patients. “I spend a lot of time explaining this to patients because I think that in the end, we’re going to treat the majority of these people conservatively,” he said. “I think that the Valsalva maneuver … is really an essential part of the physical exam in these patients and helps determine the degree of severity.”
Many of Dr. Smouha’s patients struggle to properly Valsalva in the office, so, in addition to sending them home with nasal decongestants or steroids, he also makes sure to “instruct them on doing these procedures repeatedly at home,” he said. “They often say something like, ‘I tried and I tried and it doesn’t work.’ My instruction to them is to keep performing the maneuver. Once they’re able to persuade that valve to open, they’ll start to achieve some relief.”
Dr. Chandrasekhar said it’s worth otolaryngologists’ time to work with patients as much as necessary to teach the proper methods for the Valsalva maneuver, so that it’s done correctly and not to excess. “If you spend a few minutes in your office teaching people how to Valsalva, I think a lot of these problems can be ameliorated,” she said.
Dennis Poe, MD, PhD, associate professor of otology and laryngology at Harvard Medical School and Boston Children’s Hospital, both in Boston, said a modified version of the Valsalva maneuver could be helpful. The approach is to hold the nose and mouth closed, gently performing an auto-insufflation and simultaneously swallowing, which uses the dilatory muscles while the patient is generating some mild positive pressure.
That version helps protect patients, particularly those who might hurt themselves by trying too hard or improperly performing the maneuver. Dr. Poe disclosed consulting work for Acclarent Corp., and Otodyne Inc.
The modified maneuver “can be more effective than forcible Valsalva and obviously less dangerous,” Dr. Poe said. “We’ve seen (patients) injure … their ears over forceful Valsalva.”
Testing
The ETD Patient Questionnaire is useful, but don’t rely too much on it, said William Slattery III, MD, president of House Ear Clinic in Los Angeles. Ask your own questions instead.
“I’ve got my standard set of questions that I like to go through,” he said. “The first is, ‘Let’s rule out patulous. Do you hear yourself breathe? Do you hear your voice echo inside your head? Is it positional change? Was there recent weight loss?’ Those four questions are very helpful and I find, many times, no one has asked them (those) questions.”
When he’s trying to determine whether to do a balloon inflation, Dr. Slattery continues with what may seem basic techniques. “I’m putting my fingers on their (TMJ), asking them to open and close their mouth,” he said. “This may seem pretty straightforward. But what I find is there’s so many patients that I get referred in that have seen several people and nobody’s ever tested them … nobody’s done that before. And that helps rule out some of the more simple diagnoses.”
Still, Dr. Slattery, who disclosed speaking fees for J&J and Acclarent Corp., said that his fellows give the ETDQ-7 to all patients complaining of aural fullness. He just cautions otolaryngologists not to base decisions solely on its results. “You can’t just rely on one piece of information alone,” he said. “You’ve got to put all of this together to make your diagnosis.”
Dr. Smouha, who practices with ENT & Allergy Associates in Manhattan, said that while research has validated the effectiveness of the ETDQ-7 questionnaire at assessing symptoms, it is not a differential diagnosis tool. “It’s an outcomes measure for before and after,” he said. “It was never intended for diagnostic measures. … It can’t differentiate between a patulous ET or TMD or any other types of aural fullness.”
Treatment Options
The panel also discussed treatment options for ETD. Dr. Chandrasekhar discussed the potential value of surfactants, while disclosing her role as a board member and shareholder for a biotech company developing an ETD surfactant. “The problem at the Eustachian tube is not at (its) orifice, but actually in the lumen, in the cartilaginous portion,” she said. “Some of that problem is actually at the bony Eustachian tube orifice in the middle ear on the other side. The concept being that in the future we may be able to treat conservatively. In the future, we may be able to treat … with something like a surfactant and open up the Eustachian tube and allow for normal physiology.”
In the meantime, otolaryngologists treating dilatory ETD can consider temporary or longer-term tube insertions or devices that provide airflow into the ear. The panelists agreed that those over-the-counter devices can be more useful for children who may struggle to do a Valsalva maneuver.
For patulous ETD, Dr. Chandrasekhar suggests to patients that they discontinue nasal decongestants/steroids, hydration, and the administration of mucosal irritants to induce mucosal edema.
Balloon inflation is also an option for some patients, though its FDA approval remains narrow to date, said Dr. Slattery. “In my mind, these are the patients who are having to come in every couple of years to have a tube placed,” he said. “And so I’ll talk to these individuals about, ‘Rather than extending a tube … consider a balloon dilation.’”
Richard Quinn is a freelance medical writer based in New Jersey.