Slide 1

Good afternoon dear all respected supervisors… (nama2nya), all my senior residents,
and all participants for today’s journal reading presentation. My name is Herbert
Mosses and my supervisor is dr. Sri Wartati, Sp. THT-KL. I am going to present my
journal reading about Indications for Eustachian Tube Dilation from Current Opinion
Otolaryngology Head Neck Surgery, 2020.

Slide 2-6
First of all, the abstract of this journal is…. (bacain abstractnya)

Slide 7
For the introduction,
 Eustachian Tube Dilation refers to surgical procedures aimed at relieving
obstruction of the Eustachian tube with the intention of restoring middle ear
cleft ventilation
 Since 2004, there are 3 surgical procedures that have been performed, laser
tuboplasty, microdebrider tuboplasty and balloon dilation eustachian tuboplasty
(BDET).
 However, laser and microdebrider tuboplasty did not become widely utilized.
 The aim of this review study is to identify the patients who will benefit from
BDET by an analysis of the two RCTs

Slide 5

Slide 11
 ETD is the inability of the Eustachian tube to adequately perform its function,
results in faulty ventilation of the middle ear cleft.
 As you can see in here (pointer ke eustachian tube yang ada obstruksi), ETD may
occur when the mucosal lining of the tube is swollen, or does not open or close
properly.
Slide 13
There are 3 categories for ETD
 Obstructive ETD, which is the most common ETD. It is an inability of the
Eustachian Tube to open appropriately, leading to a negative pressure in the
middle ear
 Patulous ETD is inability to close the Eustachian tube, leading to autophony (an
echoing sound of the person’s own heartbeat, breathing, and speech) which is an
uncommon condition
 And the last one is Barometric Challenge ETD, Inability of the Eustachian tube to
open appropriately when there are acute changes of environmental air pressure,
e.g. flying, diving, or rapid descent in an elevator within a tall building

Slide 15
 Symptoms that occurs in ETD are aural fullness, muffled hearing, otalgia, tinnitus
and hearing loss
 Signs of ETD can be routinely elicited include otoscopic observation of tympanic
membrane retraction, immobility of the tympanic membrane with pneumatic
otoscopy, and negative pressure elicited on tympanometry.

Slide 17
 There are a few factors and etiology of ETD such as, microbial, immunological,
environmental, and genetic factors
 These factors are possible consequential development in the short term of otitis
media with effusion, tympanic membrane retraction or perforation, and in the
long term, they could lead to middle ear atelectasis, chronic suppurative otitis
media and cholesteatoma.
 Common conditions that causing ETD are allergic rhinitis, rhinosinusitis, or
laryngopharyngeal reflux

Slide 19
This the algorithm of diagnosis to ETD
Slide 20
 Now I will briefly discuss about the balloon dilation eustachian tuboplasty
(BDET).
 BDET is the trans-nasal endoscopic-assisted placement of a balloon catheter
through the Eustachian tube opening for the purpose of transient dilation of the
lumen of the cartilaginous segment of the Eustachian tube
 It is indicated for obstructive ETD and barometric challenge ETD, however for it
is contraindicated for patulous ETD

Slide 22 (video)
 This is a short video of BDET procedure
 During surgery, a small lighted tube called an endoscope is passed through the
nose to the opening of the Eustachian tube.
 A small catheter is then passed through the nose to where the Eustachian tubes
drain.
 A small balloon is passed through the catheter.
 The balloon is then gently inserted into the opening of the Eustachian tube and
then inflated for two minutes.
 It is then deflated and removed.
 Depending on the side of the symptoms, either one or both tubes can be dilated.
 Often patients with Eustachian tube dysfunction will have nasal inflammation
that blocks the Eustachian tubes.

For some patients with persistenly clogged ears, rather placing a tube in the
eardrum, a balloon can be used to open up the estachian tube which connects the ear
to the back of the nose. By enlarging this tunnel, any pressure or fluid that is in the
ear can be allowed to come out the normal way. With this procedure, a ballon guide
is inserted through the nose to where the eustachian tube opening is located, a
balloon is than inserted into this tunnel and inflated in order to open up the
eustachian tube.
Th balloon is than deflated and removed. With this procedure, the hope is that the
eustachian tube can now open normally to allow a person to easily pop their ear if
any pressure or fluid builds up. Here is another view what is happening when
 balloon dilation is performed in the eustachian tubethe patient at this point
hopefully wil now be able to pop their ears easily whenever they feel cloged

Slide 23
 This is the assessment questionnaire for ETD. We need to evaluate all of these
symptoms that occurs for the past 1 month.
 Minimum score is 7 and maximum score is 49.
 The overall score is the mean of the 7 item scores.
 Severity of the symptoms is categorized as no to mild (score 1-2), moderate
(score 3-5), and severe (score 6-7)
 These are the lists of symptoms that needed to be asked to patients (baca dari
ppt list nya)

Slide 24 (baca aja slidenya)

Slide 26
 The first RCT using symptomatic relief as their BDET treatment response and the
second one using normalization of tympanogram as their BDET treatment
response.
 Inclusion criteria for both RCTs were described in the table (baca slide)

Slide 27
 This is the table for exclusion criteria of the studies
 Both of the studies excluded … (baca slide)

Slide 28
 According to this figure, the decrease in ETDQ-7 score is significantly greater for
the group undergoing balloon dilation compared with the control group (p
<0.0001), therefore that balloon dilation is superior to the control

Slide 29
 This is the result table for middle ear function assessment from baseline to 6
weeks post treatment.
  As we can see in this table, there are statistically significant improvement of
tympanic membrane position and tympanogram in patient with balloon dilation
treatment with p value less than 0.001 and p value 0.006, respectively
 And the valsava manuever also improved in patient with balloon dilation
treatment, however it’s not statistically significant

Slide 30
 This table presents the changes from baseline for the middle ear function
assessments for follow-ups through 12 months postprocedure for all
participants undergoing balloon dilation. The percentage of participants with
normal tympanic membrane position improved from 51% to over 80% ( p <
0.001 at all follow-ups).
 Ability to clear the ears with a Valsalva maneuver improved from 33% of
participants to over 60% ( p < 0.01 at all follow-ups).
 The percent of participants with type A tympanograms increased from 71 to
80% or more through 12-months with p < 0.05 at all but the 6-month time point
( p = 0.139).
Slide 31
 ETDQ-7 scores in participants with normal baseline middle ear function
assessments were compared with those of participants with abnormal baseline
assessments. The changes from baseline to 12-month follow-up are presented in
this table and demonstrate that both groups experienced clinically and
statistically significant ( p < 0.0001) improvements in all assessments.

Slide 32
 This is the result for the second RCT which the goal is improvement of
tympanogram.
 Significantly more patients in the investigational arm compared to the control
arm had a normal tympanogram at 6-week follow-up (51.8% [72/139] vs. 13.9%
[10/72]; P<0.0001).
 Improvement in tympanometry was associated with normalization of ETDQ-7 at
6-week follow up; significantly more patients in the investigational (77/137;
 56.2%) versus control (6/71; 8.5%; p <0.0001) arm had normal ETDQ-7 scores
(<2.1)

Slide 33
 In a follow up of the above cohort, normal type A tympanogram at 52 weeks was
55.5% (71/ 128) compared to 6 weeks 51.8% (72/139), ETDQ-7 reported as
normal (<2.1) at 52 weeks was 55.6% (79/142) compared to 6 weeks 56.2%
(77/137). However, in 52 weeks follow up study, they did not provide the p
value so we did not know whether there is statistically significant differences or
not.
 The difference of patients number is because some patients were lost to follow
up or exited from the study or died or did not complete the study

Slide 34 (conclusion)
In conclusion, according to this journal, they suggest that the indication for eustachian
tube dilation by BDET is for patients who have ALL of the following:
 Aural fullness >12 weeks
 Type B or C tympanogram
 ETDQ-7 mean score >2
 Failed medical management including Valsava maneuver and either 4 weeks of
nasal steroids or 1 week of oral steroids