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Patulous Eustachian Tube

Patulous eustachian tube is a benign condition, in which an open eustachian tube results in an increase of the air pressure in the middle ear, with resulting clinical symptoms.


Presentation

Patulous eustachian tube can be diagnosed with history alone, although the physical exam may also be helpful. Prominent symptoms include audible respiratory sounds, a sensation of plugged ear, a feeling of aural fullness with fluctuations, tinnitus synchronous with respiration and autophony (defined as the perception of sounds coming from one's own voice and breath). Autophony is the most common and bothersome reported symptom [5]. The disease is also characterized by relief from symptoms when the patient has an upper respiratory infection, lies down or puts the head between the knees. Symptoms are worsened with the use of decongestants or ventilation tubes in the drum. They also vary with the changes in the mucosa of the eustachian tube. Patients can attempt to control symptoms by sniffing repeatedly, resulting in long-term negative pressure in the middle ear. In addition to the above, pressure transmission between the middle and the inner ear through movement of the ossicular bones can eventually result in vertigo and hearing loss. Furthermore, some affected individuals can have trouble eating because of the transmission of the sounds of eating. Because of similar presentations, patulous eustachian tube is often confused with middle ear effusion.

Physical exam findings are usually not significant, although atrophy can sometimes be noticed in the eardrum due to repeated sniffing and the associated constant motion of the drum. Examination of the tympanic membrane with an operating microscope reveals that it moves in a medial direction on inspiration and laterally with expiration. Its movements are exaggerated and are in synchrony with respiration, particularly with forced expiration or with breathing through the nose in only one nostril. The canals and eardrums usually look normal.

Asymptomatic
  • CONCLUSION: Patulous eustachian tube (ET) shows a wide range of manifestations from asymptomatic to severe disturbance in quality of life. Nasal instillation of saline should be attempted as the initial treatment for patulous ET.[ncbi.nlm.nih.gov]
  • Because the auditory feedback can be disturbingly loud, there is a wide range of cognitive and emotional responses ranging from asymptomatic to suicidal ideation.[clinicalgate.com]
Anorexia
  • We report on a female adolescent, who presented to an otologist for autophonia and was finally diagnosed with anorexia nervosa. The occurrence and relevance of this symptom in eating-disorder patients is discussed.[ncbi.nlm.nih.gov]
Nasal Voice
  • The patient complained of sudden onset of ear fullness and nasal voice as well as typical orthostatic headache. Patulous Eustachian tube was identified by observation of synchronous movement of the tympanic membrane with respiration and swallowing.[ncbi.nlm.nih.gov]
Tinnitus
  • The evaluation scale of PHI was modified from the Japanese version of the tinnitus handicap inventory-12 (THI-12).[ncbi.nlm.nih.gov]
  • Abstract This study aims to explore the eardrum thickening approach via cartilage myringoplasty for the cessation of symptoms of patulous Eustachian tube (PET), including autophony, aural fullness and breathing synchronous tinnitus.[ncbi.nlm.nih.gov]
  • OBJECTIVE: A patulous Eustachian tube ([ET] tuba aperta) may cause symptoms as autophony, breath synchronous tinnitus, pressure sensation, and conductive hearing loss and thus lead to an enormous cutback in quality of life.[ncbi.nlm.nih.gov]
  • Common symptoms included voice autophony (93%), breath autophony (92%), aural fullness (57%), pulsatile tinnitus (17%), and crackling or rumbling sounds (14%).[ncbi.nlm.nih.gov]
  • BACKGROUND: Patulous Eustachian tube is the uncommon condition of a persistently open Eustachian tube, which causes the disturbing symptoms of autophony and respiratory-synchronous tinnitus.[ncbi.nlm.nih.gov]
Aural Fullness
  • CONCLUSION: Cartilage tympanoplasty provides a safe and accessible surgical option for the treatment of PET and significantly reduces the symptoms of autophony, conducted breath sounds, and aural fullness.[ncbi.nlm.nih.gov]
  • Patients with the pET disorder are disturbed to the point of mental illness by their symptoms of aural fullness and autophony, especially the echo of their own voice. Thus far, described treatment methods are often temporary or ineffective.[ncbi.nlm.nih.gov]
  • METHOD: Case report of a 44-year-old woman who was referred to our ENT clinic complaining of autophonia and bilateral aural fullness.[ncbi.nlm.nih.gov]
  • The present patient (a 55-year-old woman) reported aural fullness and autophony were often experienced after HD.[ncbi.nlm.nih.gov]
  • Patients with a patulous ET (PET) have various aural symptoms such as aural fullness, autophony, and hearing their own breathing.[ncbi.nlm.nih.gov]
Hearing Impairment
  • Sweetow has written fourteen textbook chapters and over 80 scientific articles on counseling, tinnitus, and amplification for the hearing impaired published.[audiologyonline.com]
Trigeminal Neuralgia
  • These symptoms appeared two weeks after percutaneous balloon microcompression performed to treat severe trigeminal neuralgia secondary to multiple sclerosis.[ncbi.nlm.nih.gov]
Neuralgia
  • These symptoms appeared two weeks after percutaneous balloon microcompression performed to treat severe trigeminal neuralgia secondary to multiple sclerosis.[ncbi.nlm.nih.gov]

Workup

Several tests may be used to assist in establishing and confirming the diagnosis. In particular, CT scanning can be used to verify the presence of a patulous eustachian tube. Other useful tests include tympanometry and sonotubometry. Tympanometry is useful in the detection of movements of the tympanic membrane when the patient is standing [6]. Sonotubometry consists of inserting a microphone in the external auditory meatus and introducing a sound in the nasal vestibule. Patients with patulous eustachian tube will show no drop in the transmitted sound in the external ear because of the very high pressure in the external canal. Furthermore, a microphone located at the external auditory meatus can reveal distorted sounds originating from speech and nasal respiration.

Other rarely used specific tests are transnasal endoscopy and direct nasopharyngoscopy. Nasopharyngoscopy verifies the presence of a triangular opening in the orifice of the eustachian tube, whereas transnasal endoscopy with video analysis can assess the opening of the eustachian tube during swallowing, yawning and at rest.

Treatment

Both medical and surgical treatments are available for patients with a patulous eustachian tube, but they are only reserved for those with severe symptoms that last for more than six weeks. Mild symptoms generally only necessitate reassurance. The use of decongestants and nasal steroids should be discouraged [7]. They are rarely beneficial and may sometimes exacerbate symptoms. Medical treatment options include hydration, nasal saline drops and potassium iodine [8]. Saline nasal drops are instilled through the nose, followed by tilting the head to the direction of the affected ear. This allows the saline solution to reach the orifice of the eustachian tube. In case the drops are ineffective, they can be substituted with saline nasal irrigation. Potassium iodine is only prescribed if hydration and saline drops or irrigation are ineffective. It works by thickening the mucus and is generally taken with a glass of juice three times every day [8].

Patients who do not respond to medical treatment can be considered for surgery. Tympanostomy is the first line treatment and can resolve some symptoms in approximately half of the patients [9]. Unfortunately, the procedure only helps in improving the sensation of tympanic membrane movement with respiration but is ineffective with autophony, which tends to be the primary complaint. Another available method is intraluminal catheter placement. An intravenous catheter is sealed with bone wax and inserted to block the eustachian tube, but it allows the passage of a small amount of air. Because it is inert, it does not require frequent removal and substitution. Studies show that this method may be effective in reducing the bothersome symptoms of autophony [10]. Patients who do not respond to tympanostomy or intraluminal catheter placement may be referred to cartilage grafting. The procedure consists of using conchal or septal cartilage to close the defect in the anterolateral wall of the eustachian tube. It remains unclear whether cartilage grafting is effective in the long term, but early reports reveal improvement of symptoms, although up to 50% of patients report recurrence after two years of treatment. Finally, patients who remain unresponsive undergo a complete occlusion of the eustachian tube. This is a very effective method but can result in serious complications such as cholesteatoma, tympanic membrane retraction, and permanent middle ear effusion. This necessitates the use of permanent tympanostomy tubes to avoid the development of these complications.

Prognosis

Treatment of patulous eustachian tube improves vertigo in patients who have vestibular symptoms.

Etiology

Patulous eustachian tube is idiopathic in most cases with no identifiable cause. Nonetheless, several predisposing risk factors have been identified. They include neurological diseases (multiple sclerosis, cerebrovascular accident and motor neuron disease), medications (diuretics and oral contraceptives, among others), pregnancy, weight loss, stress, exercise, fatigue, anxiety and temporomandibular joint syndrome [2]. Furthermore, radiotherapy and adenoidectomy can significantly increase the risk because of their propensity to cause adhesions.

Epidemiology

Patulous eustachian tube tends to target more females than males. Individuals affected are frequently adolescents or adult, but rarely children. Incidence has been estimated to range between 0.3 and 6.6%, although up to 20% do not seek medical treatment because of very mild symptoms.

Sex distribution
Age distribution

Pathophysiology

The eustachian tube is composed of both cartilage and bone and runs from the anterior wall of the middle ear to the nasopharynx. It is wide at its junction with the middle ear and the nasopharynx and is narrow in its middle portion. The length of the eustachian tube in adults varies from 36 to 38 mm and reaches its adult length around approximately age six. Eustachian tubes in children tend to have more elastic cartilage and are more horizontal. Due to the large adenoids in its proximity, the eustachian tube is more significantly prone to obstruction, reflux and infection [3] [4].

The eustachian tube usually stays closed and only opens during swallowing or chewing. Many factors help to maintain the tube closed, such as surface tension of its moist surface, pressure coming from the tissue outside the lumen, as well as the elasticity inherent in the tube. The tensor veli palatini acts to dilate the lumen of the tube. Pregnancy can result in the development of patulous eustachian tube due to the increase in estrogen, which exerts its effect through prostaglandin E, ultimately resulting in reduced surfactant production and decreased surface tension. Weight loss, on the other hand, decreases extraluminal pressure due to loss of fat and tissue around the tube. Adenoidectomy can result in scarring in the postnasal space, which may act to keep the tube in the open position.

Prevention

Preventive measures may include removal of eustachian tube obstruction, such as hypertrophied adenoids, if present.

Summary

Patulous eustachian tube is a medical condition in which the eustachian tube remains in the open position, leading to increased air pressure in the middle ear. It tends to be more common among women, adults and adolescent. Prevalence ranges from 0.3 to 6.6%. It is associated with several conditions, including multiple sclerosis, motor neuron disease, cerebrovascular accidents, intake of diuretics or oral contraceptives, pregnancy and weight loss.

The eustachian tube is a bony and cartilaginous tube that links the middle ear with the nasopharynx. Normally, it remains closed except during swallowing. Surface tension, extraluminal tissue pressure and intrinsic elasticity all help to keep the tube closed. One or many of those factors are disturbed in a patulous eustachian tube. In pregnancy, for example, increased estrogen activates prostaglandin E, which in turns results in decreased surfactant production and surface tension. On the other hand, weight loss results in the loss of fat and tissue around the tube, with resulting depression of extraluminal pressure.

Patients with patulous eustachian tube present with a range of symptoms that include autophony, audible respiratory sounds, and feelings of fluctuating aural fullness [1]. Some patients may also report hearing loss and vestibular symptoms, due to the pressure on the bony ossicles in the middle ear that is transmitted to the inner ear. Patients usually have a sense of relief when they lie down or put their head between the knees or when they have an upper respiratory infection. Diagnosis is established with history although findings on a physical exam can also be helpful. These include abnormal exaggerated movements of the tympanic membrane that are synchronized with breathing. Computed tomography (CT) scanning can aid in visualizing the open tube in case the diagnosis is difficult to establish, although in the majority of cases it is unnecessary.

Patulous eustachian tube is a benign condition. Patients do not need treatment if symptoms are not bothersome or if they have not been present for more than 6 weeks. Medical treatment is the first line of treatment. It consists of hydration, saline nasal drops, and potassium iodine. Saline nasal drops are instilled within the nose. Subsequently, the patient tilts his/ her head towards the affected ear, allowing the solution to reach the opening of the eustachian tube. In case saline drops are not useful, saline irrigation can be used. Potassium iodine is only employed in patients who do not respond to hydration or saline nasal drops and is ingested with juice thrice daily. It works by thickening the mucus in the eustachian tube.

In case patients do not respond to medical treatment, surgical options are also available. They include tympanostomy, intraluminal catheter placement, cartilage grafting and complete occlusion of the eustachian tube. The latter is only used when all options fail. It results in good outcomes, although it has serious complications and usually necessitates the permanent placement of tympanic tubes.

Patient Information

Patulous eustachian tube is a disorder that affects the eustachian tube. The eustachian tube is a bony tube that connects the middle ear with the nasal cavity. Normally, it remains in the closed position but in patulous eustachian tube, it is open most of the time. This results in increased air pressure in the middle ear and the appearance of bothersome clinical symptoms.

Patulous eustachian tube tends to affect women more than men. It is also associated with numerous conditions, such as multiple sclerosis, strokes, diseases of the motor neurons, weight loss, pregnancy and the intake of certain drugs such as oral contraceptives or diuretics. It is found mostly in adults and adolescents and is rare in children.

The most prominent symptom of patulous eustachian tube is autophony. Autophony refers to the perception of the noise of breathing, as well as the sounds of one's own voice. Other symptoms can also be present, such as a feeling of fluctuating aural fullness and a sensation of a plugged ear. Diagnosis can be established with history alone, although physical exam findings may also be helpful. Imaging studies are rarely used to confirm the condition.

Patulous eustachian tube is a benign condition, and only severe symptoms that last more than 6 weeks require treatment. Medical management is the first line of treatment. Surgical options are reserved for resistant cases.

References

Article

  1. Rotenberg BW, Busato GM, Agrawal SK. Endoscopic ligation of the patulous eustachian tube as treatment for autophony. Laryngoscope. 2013;Jan. 123(1):239-43.
  2. Doherty JK, Slattery WH 3rd. Autologous fat grafting for the refractory patulous eustachian tube. Otolaryngol Head Neck Surg 2003; 128:88.
  3. Bluestone CD. Studies in otitis media: Children's Hospital of Pittsburgh-University of Pittsburgh progress report--2004. Laryngoscope 2004; 114:1.
  4. Poe DS, Abou-Halawa A, Abdel-Razek O. Analysis of the dysfunctional eustachian tube by video endoscopy. Otol Neurotol 2001; 22:590.
  5. O'Connor AF, Shea JJ. Autophony and the patulous eustachian tube. Laryngoscope. 1981; Sep. 91(9 Pt 1):1427-35.
  6. Henry DF, DiBartolomeo JR. Patulous eustachian tube identification using tympanometry. J Am Acad Audiol. 1993; Jan. 4(1):53-7.
  7. van Heerbeek N, Ingels KJ, Rijkers GT, Zielhuis GA. Therapeutic improvement of Eustachian tube function: a review. Clin Otolaryngol Allied Sci 2002; 27:50.
  8. Dyer RK Jr, McElveen JT Jr. The patulous eustachian tube: management options. Otolaryngol Head Neck Surg 1991; 105:832.
  9. Luxford WM, Sheehy JL. Myringotomy and ventilation tubes: a report of 1,568 ears. Laryngoscope 1982; 92:1293.
  10. Poe DS. Diagnosis and management of the patulous eustachian tube. Otol Neurotol 2007; 28:668.

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Last updated: 2018-06-21 22:20