8/8/2020 Patulous Eustachian Tube Treatment & Management: Medical Therapy, Surgical Therapy, Complications

Patulous Eustachian
Tube Treatment & Management
Updated: Mar 14, 2019
Author: Alpen A Patel, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA more...

TREATMENT

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).
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8/8/2020 Patulous Eustachian Tube Treatment & Management: Medical Therapy, Surgical Therapy, Complications

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. [4]

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. [5]

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. [6]

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. [7]

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%). [8]

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. [9]

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8/8/2020 Patulous Eustachian Tube Treatment & Management: Medical Therapy, Surgical Therapy, Complications

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. [10]

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

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.

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