Medical Therapy

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.

Surgical Therapy

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.^[5]
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.

Calcium hydroxyapatite injection represents another therapy for patulous eustachian tube, being used to manage incompetent tubal valves via mass effect.^[6]

Oh et al described the successful treatment of patulous eustachian tube with autologous tragal cartilage, finely chopped and endoscopically injected submucosally into the anterior and posterior portions of the nasopharyngeal eustachian tube.^[7]

Similarly, a study by Jeong et al indicated that insertion of a tragal cartilage chip into an intractably patulous eustachian tube to fill in the tubal valve concavity can significantly reduce autophony. At average 16.4-month follow-up, four of 14 ears (28.6%) experienced complete relief of autophony, with satisfactory improvement found in another five ears (35.7%). No complications, such as otitis media or occlusion symptoms, occurred in any of the treated ears.^[8]

Rotenberg et al reported on the successful use of multilayer endoscopic ligation for the treatment of autophony in patulous eustachian tube. Transnasal endoscopy was used in 14 ears to guide treatment combining fat plugging, endoluminal cauterization, and suture ligation, with complete subjective resolution of autophony in nine ears (64.3%) and partial, but sustained and satisfactory, subjective improvement in three others (21.4%).^[9]

In a study of 21 patients with patulous eustachian syndrome, Boedts reported that 76.2% obtained relief from autophony via paper patching of the tympanic membrane, with relief being permanent in a portion of these cases. Such patching may reduce autophony by adding greater stiffness to the tympanic membrane.^[10]

Complications

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 Prognosis

A retrospective study by Ward et al indicated that patients with patulous eustachian tube dysfunction who undergo treatment with shim (catheter) insertion or obliteration of the eustachian tube lumen are more likely to have symptom resolution at 12 months than are those who are treated with calcium hydroxyapatite injection or eustachian tube reconstruction. However, the shim and obliteration treatments are also associated with a higher rate of otitis media with effusion.^[11]

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

A literature review by Ikeda et al reported mean symptom improvement for the following patulous eustachian tube procedures^[12]:

Ventilation tube insertion - 58%
Mass loading of the tympanic membrane - 50%
Eustachian tube injection - 47%
Plug surgery - 81%
Shim surgery - 62%
Tuboplasty - 41%
Eustachian tube closure - 66%

Future and Controversies

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.

Bance M, Tysome JR, Smith ME. Patulous Eustachian tube (PET), a practical overview. World J Otorhinolaryngol Head Neck Surg. 2019 Sep. 5 (3):137-42. [QxMD MEDLINE Link]. [Full Text].
Henry DF, DiBartolomeo JR. Patulous eustachian tube identification using tympanometry. J Am Acad Audiol. 1993 Jan. 4(1):53-7. [QxMD MEDLINE Link].
Ikeda R, Kikuchi T, Oshima H, et al. Computed tomography findings of the bony portion of the Eustachian tube with or without patulous Eustachian tube patients. Eur Arch Otorhinolaryngol. 2017 Feb. 274 (2):781-6. [QxMD MEDLINE Link].
O'Connor AF, Shea JJ. Autophony and the patulous eustachian tube. Laryngoscope. 1981 Sep. 91(9 Pt 1):1427-35. [QxMD MEDLINE Link].
Doherty JK, Slattery WH. Autologous fat grafting for the refractory patulous eustachian tube. Otolaryngol Head Neck Surg. 2003 Jan. 128(1):88-91. [QxMD MEDLINE Link]. [Full Text].
Ginat DT, Moonis G, Mukherji SK, Gluth MB. Imaging of the postoperative ear and temporal bone. Ginat DT, Westesson PLA, eds. Atlas of Postsurgical Neuroradiology: Imaging of the Brain, Spine, Head, and Neck. 2nd ed. Cham, Switzerland: Springer; 2017. 384.
Oh SJ, Lee IW, Goh EK, Kong SK. Endoscopic autologous cartilage injection for the patulous eustachian tube. Am J Otolaryngol. 2016 Mar-Apr. 37 (2):78-82. [QxMD MEDLINE Link].
Jeong J, Nam J, Han SJ, Shin SH, Hwang K, Moon IS. Trans-tympanic Cartilage Chip Insertion for Intractable Patulous Eustachian Tube. J Audiol Otol. 2018 Jul. 22 (3):154-9. [QxMD MEDLINE Link]. [Full Text].
Rotenberg BW, Busato GM, Agrawal SK. Endoscopic ligation of the patulous eustachian tube as treatment for autophony. Laryngoscope. 2013 Jan. 123(1):239-43. [QxMD MEDLINE Link].
Boedts M. Paper patching of the tympanic membrane as a symptomatic treatment for patulous eustachian tube syndrome. J Laryngol Otol. 2014 Mar. 128(3):228-35. [QxMD MEDLINE Link].
Ward BK, Chao WC, Abiola G, et al. Twelve-month outcomes of Eustachian tube procedures for management of patulous Eustachian tube dysfunction. Laryngoscope. 2019 Jan. 129 (1):222-8. [QxMD MEDLINE Link]. [Full Text].
Ikeda R, Hidaka H, Kikuchi T, et al. Systematic Review of Surgical Outcomes Following Repair of Patulous Eustachian Tube. Otol Neurotol. 2020 Sep. 41 (8):1012-20. [QxMD MEDLINE Link].
Yoshida H, Takahashi H, Morikawa M. Anatomy of the Surrounding Tissue of the Eustachian Tube in Patulous Eustachian Tube: 3 Tesla Magnetic Resonance Imaging Approach. Otol Neurotol. 2019 Feb. 40 (2):e107-14. [QxMD MEDLINE Link].

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Anatomy of the ear.

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Author

Alpen A Patel, MD, FACS Lead Physician for Hospital Utilization, Mid-Atlantic Permanente Medical Group; Staff Physician, Department of Otolaryngology, Towson Medical Center

Alpen A Patel, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Society of University Otolaryngologists-Head and Neck Surgeons, American Association of Physicians of Indian Origin, American Academy of Otolaryngic Allergy, Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Samuel C Levine, MD Professor of Otolaryngology and Neurosurgery, University of Minnesota Medical School

Samuel C Levine, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Otological Society, Minnesota Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Gerard J Gianoli, MD Clinical Associate Professor, Departments of Otolaryngology-Head and Neck Surgery and Pediatrics, Tulane University School of Medicine; President, The Ear and Balance Institute; Board of Directors, Ponchartrain Surgery Center

Gerard J Gianoli, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Neurotology Society, American Otological Society, Society of University Otolaryngologists-Head and Neck Surgeons, Triological Society

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Ryte; Neosoma; MI10<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10.