Patulous Eustachian Tube Treatment & Management

Patients with a patulous eustachian tube 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:

• Increase or regain lost weight
• Avoid diuretics
• Recline or lower head when symptoms occur

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.

The following methods may be used for treatment of a narrow lumen caused by inflammatory response or scar tissue:

• Bezold's remedy of insufflation of a solution of salicylic acid and boric acid (1:4 ratio) (Repeat treatments are always necessary.)
• Eustachian tube diathermy with sequential application of ureteric diathermy probe
• Cautery with 20% silver nitrate

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:

• Paraffin injection
• Teflon injection anterior to the eustachian tube orifice: Serious complications may occur.
• Gelfoam injection: Results are good, but temporary; very little morbidity is associated. Autologous fat or cartilage graft plugging of the eustachian tube at its nasopharyngeal orifice, in conjunction with myringotomy and ventilation tube placement, has been successful in some patients.^[3]
• Alter function of palatal muscles with or without pterygoid hamulotomy: Stroud et al (1974) described transposition of tensor veli palatini tendon medial to pterygoid hamulus (transpalatal approach). Transection of tensor veli palatini is another option.
• Occlusion of the eustachian tube: Bluestone and Cantekin (1981) recommend occlusion of bony eustachian tube with an intravenous indwelling catheter via anterior tympanotomy. A catheter is filled with methyl methacrylate glue, and the tympanostomy tube is inserted to aerate the middle ear and prevent development of serous effusion. The catheter can be removed at any time. A modification of the Bluestone technique involves placement of the catheter through myringotomy.
• Myringotomy and insertion of a ventilating tube: This may provide temporary relief for some patients. These steps are relatively simple to perform and reversible and have minimal complications. Occasionally, myringotomy and insertion of a ventilating tube result in increasing the patient's discomfort.
• Surgical scar tissue removal in nasopharynx: This may benefit patients with adhesions from a prior operation.

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.

Patients with vestibular symptoms experience improvement of vertigo with treatment of patulous tube.

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.