You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > MIDDLE EAR AND MASTOID Patulous Eustachian TubeArticle Last Updated: Feb 15, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Alpen A Patel, MD, Assistant Professor, Department of Otolaryngology, Emory University; Consulting Staff, Division of Otolaryngology, Veterans Affairs Medical Center of Atlanta Alpen A Patel is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Association of Physicians of Indian Origin, American Rhinologic Society, Phi Beta Kappa, and Society of University Otolaryngologists-Head and Neck Surgeons Coauthor(s): Samuel C Levine, MD, Associate Professor, Departments of Otolaryngology, Neurosurgery, and Pediatrics, University of Minnesota; Consulting Staff, Regions Hospital, Hennepin County Medical Center, and University of Minnesota Medical Center at Fairview Editors: Carol A Bauer, MD, FACS, Associate Professor of Surgery, Division of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Gerard J Gianoli, MD, Clinical Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine; Vice President, The Ear and Balance Institute; Chief Executive Officer, Ponchartrain Surgery Center; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: patulous eustachian tube, open eustachian tube, eustachian tube patency, roaring tinnitus, vertigo, hearing loss, patulous tube, PET INTRODUCTIONSection 2 of 10
  History of the ProcedureSchwartze first described patulous eustachian tube in 1864 when he noted a scarred atrophic eardrum moving synchronously with respiration. This condition was first fully described in 1867 by Jago, who had a patulous eustachian tube. ProblemPatulous tube is a troublesome but benign condition in which the eustachian tube remains abnormally patent. FrequencyIncidence of patulous eustachian tube is 0.3-6.6%, and 10-20% of persons who have it are bothered enough by symptoms to seek medical attention. This condition is more common in females than in males and is usually present in adolescents and adults; it is rarely found in young children. EtiologyIn most instances, patulous eustachian tube is idiopathic. Weight loss (sometimes caused by chronic illness) and pregnancy are identified as important predisposing factors. Neurologic disorders that may cause muscle atrophy (eg, stroke, multiple sclerosis, motor neuron disease) have been implicated. Adhesion formation in the nasopharynx following adenoidectomy or radiotherapy may also predispose individuals to a patulous tube. The condition is sometimes associated with medications (eg, oral contraceptives, diuretics). Other predisposing factors include fatigue, stress, anxiety, exercise, and temporomandibular joint syndrome. PathophysiologyUnder normal resting conditions, the eustachian tube is closed and only opens with swallowing or autoinflation. In unaffected individuals, closure of the eustachian tube is maintained by luminal and extraluminal factors, which include intrinsic elasticity of the tube, surface tension of moist luminal surface, and extraluminal tissue pressure. Muscle tone of tensor veli palatini dilates the lumen; damage to tensor veli palatini following cleft palate surgery may produce a patulous tube. Weight loss can also lead to abnormal patency caused by reduced tissue pressure and loss of fat deposits in the eustachian tube region. Pregnancy alters opening pressures of the eustachian tube because of the change in surface tension; estrogens acting on prostaglandin E affect surfactant production. Scarring in the postnasal space following adenoidectomy may result in traction of the tube in a patent position. ClinicalHistory Major symptoms of patulous eustachian tube include fluctuating aural fullness, roaring tinnitus synchronous with nasal respiration, audible respiratory sounds, distorted autophony (ie, the abnormal perception of one's own breath and voice sounds) with echoing occasionally severe enough to interfere with speech production, and sensation of plugged ear. Autophony is the most frequent symptom associated with patulous tube. Vertigo and hearing loss can also occur because patulous eustachian tube allows excessive pressure changes to occur in the middle ear; these pressure changes are then transmitted to the inner ear through ossicular movement. Some patients may have difficulty eating because the noise of chewing is transmitted to the ear. Patulous eustachian tube is often misdiagnosed because symptoms mimic those of middle ear effusion. Symptoms may relate to cyclical changes occurring in the mucosa of the eustachian tube. Some patients find relief from the associated increased mucosal congestion by lying down, by putting the head between the knees, or during upper respiratory tract infection. Compression of the jugular veins produces peritubular venous congestion and may relieve symptoms. Patients sometimes sniff repetitively to close the eustachian tube, and this may lead to long-term negative middle ear pressure. Decongestants or a ventilation tube in the drum can worsen symptoms. Diagnosis can often be made based on history alone. Physical examination Examination findings are usually unremarkable; canals and eardrums appear normal. The eardrum can be atrophic secondary to the constant drum motion from breathing or sniffling. Synchronous movement of the tympanic membrane with respiration is exaggerated with forced respiration or with the patient breathing in and out through the nose with one nostril occluded; the tympanic membrane moves medially on inspiration and laterally on expiration. With the patient sitting upright, small movements of pars flaccida occur, which disappear when the patient is supine. Examine the ear with an operating microscope to detect subtle movements. INDICATIONSSection 3 of 10
Surgery is indicated if the patient continues to have significant otologic symptoms despite medical therapy. CONTRAINDICATIONSSection 4 of 10
Surgical therapy is contraindicated in patients who are pregnant or have mild symptoms. These patients need informative reassurance alone (see Medical therapy). WORKUPSection 5 of 10
Imaging Studies
Other Tests
Diagnostic Procedures
TREATMENTSection 6 of 10
Medical therapyPatients who are pregnant and those with mild symptoms (most patients) need informative reassurance alone. Patients who have symptoms during pregnancy are symptom-free after delivery. Advise patients to do the following:
Topical administration (nasal preparation) with anticholinergics may be effective for some patients. Estrogen (Premarin) nasal drops (25 mg in 30 mL normal saline, 3 gtt tid) or oral administration of saturated solution of potassium iodide (10 gtt in glass of fruit juice tid) has been used to induce swelling of the eustachian tube opening. Nasal medication containing diluted hydrochloric acid, chlorobutanol, and benzyl alcohol has been demonstrated to be effective in some patients. This has been reported to be well tolerated with little or no adverse effects. Approval by the Food and Drug Administration (FDA) is pending. Surgical therapyThe following methods may be used for treatment of a narrow lumen caused by inflammatory response or scar tissue:
Electrocoagulation has been discarded because of morbidity (ie, damage to middle cranial fossa dura, damage to mandibular nerve). The following methods may be used for treatment of a narrow lumen caused by extrinsic compression:
COMPLICATIONSSection 7 of 10
Eustachian tube diathermy has been associated with complications such as intermittent secretory otitis media, trigeminal nerve damage, and middle cranial fossa dural burns. Serous effusions have developed in patients treated by silver nitrate or Teflon injections. Teflon injections are also associated with serious complications, including cerebral thrombosis and death. These complications followed inadvertent injection of Teflon into the internal carotid artery, which occurred in the era before the common use of endoscopic placement. Gelfoam or Teflon injections can also result in total obstruction of the eustachian tube. Middle ear effusions can develop in patients undergoing tensor veli palatini transection and/or transposition with or without pterygoid hamulotomy. OUTCOME AND PROGNOSISSection 8 of 10
Patients with vestibular symptoms experience improvement of vertigo with treatment of patulous tube. FUTURE AND CONTROVERSIESSection 9 of 10
A discussion of the merits of different treatments is restricted by insufficient numbers and by lack of adequate long-term follow-up data to allow valid conclusions to be drawn. Very little basic research has been performed to investigate mechanisms responsible for normal eustachian tube function. Until more basic research and properly conducted trials are performed, this situation is likely to remain. REFERENCESSection 10 of 10
Patulous Eustachian Tube excerpt Article Last Updated: Feb 15, 2007 |
