Logo for University of Iowa Health Care This logo represents the University of Iowa Health Care

Patulous Eustachian Tube - Management of the Symptom of Autophony

last modified on: Tue, 07/23/2019 - 08:37

Click on image above to enlarge, advance with cursor over border

Patulous Eustachian Tube  Management of Autophony

return to: Otology - Neurotology

return to: Botulinum Toxin Protocols

ET Injection Radiesse Gel

  1. Definition -- Abnormally patent eustachian tube
    1. Autophony
      1. Abnormal sound of one's own voice (voice sounds abnormally loud and low-pitched)
      2. Abnormal sound of one's own breathing
      3. Abnormal sound of one's chewing
    2. Aural fullness (sensation of fullness in the ear)
    3. Fluctuating sensation of the tympanic membrane with respiration
    4. Credited by Poe (2007), O'Connor (1981) and others as first being described by Jago in 1858 (Jago subsequently published his own personal experience with the process)
  2. Proposed Etiology
    1. Longitudinal concave defect in the mucosal valve of the anterolateral wall of the eustachian tube (Poe 2007)
    2. Normal pressure in middle ear is slightly negative relative to atmospheric (O'Connor 1981)
      1. High absorption rate of nitrogen from middle ear cleft explains passive movement of air into middle ear with ET opening
      2. Perceived sensation of normal pressure in the middle ear cavity is due to a slight relative negative pressure
      3. When the ET is patulous, the middle ear pressure is nearly continually atmospheric and perceived as abnormal
    3. Associated disorders (Pulec et al 1970)
      1. Significant weight loss with depletion of soft tissue around eustachian tube (Munoz 2010)
      2. Neuromuscular disorders (strokes, polio, multiple sclerosis, and Parkinsons) (Perlman 1939)
      3. Other disorders associated: pregnancy / use of high dose oral contraceptives / scarring in nasopharynx (adenoidectomy, irradiation)
      4. 1/3 with patulous eustachian tube have no identifiable cause (Doherty 20003)
  3. Differential diagnosis
    1. Superior semicircular canal dehiscence syndrome (Poe 2007 and Crane 2009)
      1. Autophony of voice but not breathing sounds more common in patients with superior semicircular canal dehiscence syndrome
      2. Associated with identifiable dehiscence in the superior or posterior semicircular canal on CT
      3. Associated with low thresholds on Vestibular-Evoked Myogenic Potential testing (Poe 2007)
    2. As per Pulec et al (1970): they identified one fifth of patients with the condition had been labeled as neurotic or psychotic
  4. Diagnosis
    1. Symptoms of autophony
      1. Often relieved with reclining or lowering the head between the knees (increase venous/lymphatic congestion about E.T.)
      2. Often relieved during period of a head cold
      3. May occur spontaneously or activated by exercise, use of nasal decongestants
    2. Signs
      1. Observe movement of TM (otoscopy) during rapid nasal breathing 
        1. Best done with patient sitting (lying down may cause venous congestion to close the tube)
        2. May improve symptoms with ipsilateral internal jugular vein compression
      2. Nasopharyngeal endoscopy may show concave longitudinal defect in superior anterolateral wall of tubal valve (Poe 2007, Rotenberg 2013 and others) where it is normally convex
      3. Impedance tympanometry may document successful fluctuations in tracings synchronous with breathing and breath-holding (Bluestone 1999)
      4. CT to rule out superior semicircular canal dehiscence syndrome
  5. Trans-nasal anatomy of eustachian tube (click on video to active)
    1. Flexible transnasal endoscope for view of nasopharyx

Video of eustachian tube opening with a swallow maneuver

  1. Management
    1. Observation, reassurance and address underlying process (Pulec et al 1970 and many others)
    2. Medical therapy
      1. Weight gain (recommended only if underweight)
      2. Discontinue decongestants and nasal steroids
      3. Good hydration
      4. Premarin nasal solution as nasal drops (Poe 2007)
      5. Mucus thickening agent: SSKI 1 g/cc of saturated potassium iodide oral solution in a 30-mL dropper bottle with 7 to 10 drops in 8 ounces of juice or water taken orally three times a day has been advocated by others (Dyer 1991)
    3. Procedures (without or without local anesthesia)
      1. Repeated insufflation to the eustachian tube orifice with a mixture of boric acid and salicylic acid powder (4:1 ration) (from Pulec 1970 - Bezold 1908)
        1. As reported in 1970, done after cocaine (5%) nasal spray without direct imaging with curved catheter tip
        2. "Edema produced by irritation by the powder will close the eustachian tube in less than a minute - preventing symptoms for several days"
        3. Pulec (1970) reported training patients to self administer with the observation that continued use of this practice becomes less effective after which 'it must be used more than once daily"
      2. Pulec (1970) advocated injection of Teflon paste anterior to the orifice of the eustachian tube to offer definitive treatment (he cites Zollner as the first to inject the E.T for this purpose - using paraffin)
        1. Breuning syringe with 19 gauge needle
        2. Most often done with patient sitting in chair with palate retracted upward to expose the eustachian tube orifice.
        3. May do transnasally with nasopharyngoscope placed through opposite nostril; he identifies occasionally general anesthesia may be warranted
        4. 0.75 to 1.5 cc of paste in injected 5 mm anterior and 5 mm inferior to the nasopharyngeal orifice of the eustachian tube to a depth of 5mm.
        5. more paste can be injected, but best to wait several weeks between injections.
        6. Pulec reported 50 patients (71 eustachian tubes - some bilateral) treated with teflon injection over a 5 year period
          1. 15 with no established etiology; 14 with debilitating illness; 5 with rheumatoid disease; 3 each with cancer/recent illness/surgery)
          2. 27 'cured'; 15 'improved'; 8 'temporary relief'; 9 'unimproved'; 12 'no followup'
          3. Only 17 of the 27 'cured' patients were cured with a single injection - the others requiring 2-4 injections.
          4. Adverse symptoms: localized discomfort (up to two weeks); no serous otitis media nor foreign body reaction identified
      3. Others have reported injection into the ET region
        1. Gelfoam and glycerin in saline - good results but recurrence in one month (Ogawara 1976)
        2. Teflon into dogs (Brookler 1969)
          1. Optimal results with injection into the anterolateral wall, just anterior to the tensor veli palatini muscle
          2. Injection of 0.5 cc into the posterior cushion in the postero-medial wall consistently produced a serous effusion without improvement in opening pressures
        3. Cases of cerebral thrombosis and death have been reported with Teflon injection in the ET region
          1.  (presumed by O'Connor to have been directed posteriorly into the carotid artery) and the practice of teflon injection to treat patulous eustachian tube symptoms discontinued (O'Connor 1981)
          2. Thought to be due to injection directly into the internal carotid artery (which runs posterior to the posteromedial wall at the level of the Rosenmuller's fossa)
      4. Myringotomy with or without placement of tympanostomy tube (Luxford 1982)
        1. Reported as helpful in 50% of cases
        2. Most effective in relieving the sensation of TM moving during breathing
      5. Mass loading of the eardrum was performed with Blu Tack, a clay-like, nontoxic substance (Bartlett 2010).
        1. Placement of material on the tympanic membrane was useful for short periods providing relief
      6. Botulinum toxin A (Botox) injection to peritubal muscles (tensor and levator veli palatini and salpingopharyngeus muscles) (Olthoff 2007)
        1. Single case report of 2.5 units of Botulinum toxin A (Allergan) with symptom relief for 9 months
    4. General Anesthesia procedures
      1. Complete obstruction of the eustachian tube with a catheter and bone wax (Bluestone 1981)
      2. Cauterization of the lumen of the E.T. with insertion of a fat graft (Doherty 2003)
      3. PETR - "Patulous ET reconstruction"
        1. Designed specifically to augment the concave or scaphoid defect within the tubal valve (Poe 2007)
        2. Designed to re-establish the valve's competence without inducing tubal dysfunction
        3. Employs autologous cartilage or AlloDerm implant
        4. In this series by Poe, one of the 11 patients treated with PETR subsequently underwent Radiesse (Bioform Medical Co.;Franksville, WI,) injection to the ET including a remaining concave defect in the anterolateral wall (also in the opposing posteromedial wall) with a total of 0.9 cc injected - with a 20 gauge 45-degree angled needle.
      4. Surgery on the tensor veli palatini muscle (cited by Poe 2007)
        1. Transposition of the muscle tendon off the hamulus (Stroud 1974)
        2. Fracture or removal of the hamulus (Virtanen 1982)
      5. Endoscopic Ligation of the Patulous Eustachian Tube (Rotenberg 2013)
        1. All patients receive preoperative CT to r/o
          1. Ipsilateral semicircular canal dehiscence (refer to neuro-otology for management)
          2. Petrous carotid dehiscence (not a candidate due to altered anatomy
        2. All patients in their series had failed either prior myringotomy tube placement or transnasal conjugated estrogen drops.
        3. All had endoscopically observed characteristic concave longitudinal defect in the anterolateral wall of the eustachian tube valve
        4. All patients had baseline audiogram and tympanometry
        5. First 8 ears had myringotomy tubes placed at time of surgery; latter 6 had myringotomies without tubes; of those w/o tubes, one developed an effusion 4 months post-op warranting tympanostomy tube placement
  2. Proposed management in office
    1. Equipment

View through left nostril with flexible endoscope placed with and without 90 degree bend (and rotation) to demonstrate en face view of right E.T. through left nostril

 

Retrospective chart review by Ward et al (Ward 2019) compared treatment of 80 patients with 241 patients (further selected for those with adequate followup)  with patulous eustachian tube among 340 patients accessed through a single surgeons clinic over a 12 years period. The diagnosis of patulous eustachian tube dysfunction (PETD) was based on autophony with synchronous movement of the tympanic membrane identified. Four classes of treatment (all under general anesthesia) were used with selection of the procedure used based on the size and location of the concave defect within the valve and whether previous procedures had been performed.  The initial procedure selected was most commonly insertion of a shim - chosen preferentially over injection if the 'mucosa was thin and tightly bound to the cartilage' - in which case the anticipation was that injection would be unfavorable due to the submucosa anticipated to be unable to hold much of the filler. The single reported complication from injection (calcium hydroxyapatite) was the development of an 'infratemporal fossa hematoma resulting in lingual nerve hypesthesia' and altered taste that improved over time. There reported results are condensed into the table below with their finding that injection of larger volume of filler was associated with lower likelihood of enduring symptom relief - with conjecture offered that more injection was needed for the larger defects - with the injection diffusing away from the lumen. These investigators identified that 1/4 of the patients evaluated with PETD were refractory to medical management and underwent surgery - with multiple procedures (~ 3 per patient) indicating that none of the procedures resulted in a perfect outcome. They additionally concluded that 'most patients with PETD can be treated medically with a reasonable rate of successful symptom control"

HA injection = hydroxyapatite injection; PETR = patulous eustachian tube reconstruction; PET = pressure equalizing tube; OME = otitis media with effusion

Procedure type

(adapted from Ward et al 2019)

Median duration of relief (months) Symptom recurrence within 1 year Required PET or developed OME
All (N=241) 5.0 (1.1-21.1) 50.6% 33.6%
Shim (N=115) 6.0 (1.9-18.0) 39.1% 52.2%

HA Injection (N=38)

3.0 (0.7-7.0) 68.4% 10.5%
PETR (N=77) 4.6 (0.7-15.0) 66.2% 10.4%
Obliteration (N=11) 20.6 (3.4-35.9) 0%  81.8%

 

References:

  1. Rotenberg B, Busato G, Agrawal S: Endoscopic ligation of the patulous eustachian tube as treatment for autophony. Laryngoscope 2013 Jan;123(1):239-43
  2. Poe D: Diagnosis and Management of the Patulous Eustachian Tube. Otology & NeurotologyVol 28, No.5 pp 668-677
  3. O'Connor AF and Shea JJ: Autophony and the Patulous Eustachian Tube. Laryngoscope 91:1427-1435 Sept 1981
  4. Bluestone CD. Management of the abnormally patulous eustachian tube. In: Myers EN, Bluestone CD, Brackmann DE et al eds. Advances in Otolaryngology-Head and Neck Surgery .12. St. Louis MO: Mosby, Inc., 1998:205-34
  5. Doherty JK and Slattery WH: Autologous fat grafting for the refractory patulous eustachian tube. Otolaryngol Head and Neck Surg 2003;128:88-91
  6. Luxford WM and Sheehy JL Myringotomy and ventilation tubes: a report of 1568 cases. Laryngoscope 1982;92:1293-7
  7. Bluestone CD, Cantekin EI.l Management of the patulous eustachian tube. Laryngoscope 1981;91:149-52
  8. Dyer RK, McElveen JT: The patulous Eustachian tube: management options. Otolaryngol Head Neck Surg 1991;105:832-5
  9. Bartlett C, Pennings R, Ho A, Krikpatric D, van Wijhe R, Bance M. Simple mass loading of the tympanic membrane to alleviate symptoms of patulous Eustachian tube. J Otolaryngol Head Neck Surg 2010;39:259-268
  10. Oshima T, Kikuchi T, Kawase T and Kobayashi T: Nasal instillation of physiological saline for patulous eustachian tube. Acta Oto-Laryngologica 2010; 130:550-553
  11. Munoz D, Aedo C, and Der C: Patulous eustachian tube in bariatric surgery patients. Otolaryngol Head Neck Surg 2010 Oct;143(4):521-4
  12. Crane BT, Lin FR, Minor LB, and Carey JP: Improvement in autophony symptoms after superior canal dehiscence repair. Otol Neurotol 2010 Jan;31(1):140-6
  13. Olthoff A, Laskawi R, Kruse E: Successful Treatment of Autophonia With Botulinum Toxin: Case Report Annals of otology, Rhinology & Laryngology 116(8):594-598
  14. Ward BK, Chao WC, Abiola G, Kawai K, Ashry Y, Rasooly T, Poe DS.Twelve-month outcomes of Eustachian tube procedures for management of patulous Eustachian tube dysfunction Laryngoscope. 2019 Jan;129(1):222-228. doi: 10.1002/lary.27443. Epub 2018 Oct 16.
    1. references being solicited:
      1. Pitman LK: The open Eustachian tube . Arch Otolaryngol 9:494-500, 1929
      2. Shambaugh GE Jr: Continuously open Eustachian tube . Arch Otolaryngol 27:420-425, 1938
      3. Perlman HB: The eustachian tube: Abnormal patency and normal physiologic state. Arch Otolaryngol 30:212-238, 1939
      4. Bezold F and Siebenmann F: Text-book of Otology for Physicians and Students. (Translated by J. Holinger.) Chicago, E.H. Colgrove Co.,1908, p. 151
      5. Zollner F: Die klaffende Ohrtrompete, Storungen dadurch und Vorschlage zu ihrer Behebung. Z. Hals-Nas Ohr, 42:287-297, 1937
      6. Jago J. on the functions of the tympanum. Proc R Soc Lond B Biol Sci 1858;9:134-40.
      7. Stroud MH, Spector GT, maisel RH. The patulous eustachian tube syndrome. Arch Otolaryngol 1974;99:419-21
      8. Virtanen H, Palva T: Surgical Treatment of patulous Eustachian tube. Arch otolaryngol 1982;108;735-9
      9. Ogarawara S, SatohI, Tanaka H: Patulous eustachian tube: a new treatment with infusion of absorbable gelatin sponge solution. Arch Otolaryngol 1976;102:276-80