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Contents lists available at ScienceDirect

Auris Nasus Larynx

journal homepage: www.elsevier.com/locate/anl

Guideline

Diagnostic criteria for Patulous Eustachian Tube: A proposal

by the Japan Otological Society
Toshimitsu Kobayashi a,*,1, Masahiro Morita b,1, Satoshi Yoshioka c,1,
Kunihiro Mizuta d,1, Shigeto Ohta e,1, Toshiaki Kikuchi f,1, Tatsuya Hayashi g,1,
Akihiro Kaneko h,1, Nobumasa Yamaguchi i,1, Sho Hashimoto j,1, Hiromi Kojima k,1,
Shingo Murakami l,1, Haruo Takahashi m,1
a
Sen-En Rifu Otologic Surgery Center, Rifu, Miyagi, Japan
b
Osaka Ear & Eustachian Tube Clinic, Osaka, Japan
c
Department of Otolaryngology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
d
Ear Surgery Center, Hamamatsu Medical Center, Hamamatsu, Shizuoka, Japan
e
Department of Otolaryngology – Head and Neck Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
f
Department of Otolaryngology, Japan Community Health Care Organization Sendai Hospital, Sendai, Miyagi, Japan
g
Department of Otolaryngology – Head and Neck Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
h
Kaneko Ear, Nose & Throat Clinic, Suita, Osaka, Japan
i
Yamaguchi Internal Medicine & ENT Clinic, Tokyo, Japan
j
National Sendai Medical Center, Sendai, Miyagi, Japan
k
Department of Otorhinolaryngology, Jikei University School of Medicine, Tokyo, Japan
l
Department of Otolaryngology, Head and Neck Surgery, Nagoya City University, Nagoya, Aichi, Japan
m
Department of Otolaryngology – Head and Neck Surgery, Nagasaki University Institute of Biomedical Sciences, Nagasaki, Japan

A R T I C L E I N F O A B S T R A C T

Article history: Patulous Eustachian Tube (PET) is of increasing importance in otology. However, despite the
Received 26 August 2017 abundance of diseases requiring a differential diagnosis from PET, such as superior semicircular
Accepted 29 September 2017 canal dehiscence syndrome, perilymphatic fistula, acute low-tone sensorineural hearing loss, etc.,
Available online xxx
there are currently no established diagnostic criteria for PET.
In view of these circumstances, the Japan Otological Society (JOS) Eustachian Tube Committee
Keywords:
proposed the diagnostic criteria for Patulous Eustachian Tube in 2012, in order to promote clinical
Patulous Eustachian Tube
Superior semicircular canal dehiscence
research on PET. A revision was made in 2016, maintaining the original concept that the criteria
Perilymphatic fistula should be very simple, avoid any contamination of “Definite PET” with uncertain cases. Moreover,
Acute low-tone sensorineural hearing loss it was also intended to minimize the number of cases that could be accidentally excluded even in the
Cholesteatoma presence of some suspected findings (“Possible PET”).
Adhesive otitis media The criteria can be used by all otolaryngologists even without using the Eustachian tube function
test apparatus. However, the use of such an apparatus may increase the chances of detecting
“Definite PET”. The algorithm for the diagnosis of PET using the criteria has also been described.
The JOS diagnostic criteria for Patulous Eustachian Tube will further promote international
scientific communication on PET.
© 2017 Elsevier B.V.. All rights reserved.

* Corresponding author.
E-mail address: kobyhh@houju.org (T. Kobayashi).
1
All authors belong to the Eustachian Tube Committee of the Japan Otological Society (JOS).

https://doi.org/10.1016/j.anl.2017.09.017
0385-8146/© 2017 Elsevier B.V.. All rights reserved.

Please cite this article in press as: Kobayashi T, et al. Diagnostic criteria for Patulous Eustachian Tube: A proposal by the Japan Otological
Society. Auris Nasus Larynx (2017), https://doi.org/10.1016/j.anl.2017.09.017
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1. Background platform. A revision was made in 2016, while maintaining the

The Patulous Eustachian Tube (PET) has long been
considered a unique but relatively rare disorder [1–5]. In
recent years, however, there has been a remarkable increase in
the number of clinical reports and studies on PET [6–67], with
regards to its clinical features, pathogenesis, diagnosis and
treatments. In addition, the insufficiently closed Eustachian
tube, a type of PET, is now regarded as an important etiologic
factor for retraction type middle ear diseases such as
cholesteatomas and adhesive otitis media [68–75]. It has also
been postulated that PET may cause inner ear damage
(sensorineural hearing loss and vestibular symptoms) due to
excessive middle ear pressure changes [18]. Additionally,
several reports have speculated that PET may be an aggravating
factor for vertigo including Ménière’s disease. PET is important
in the differential diagnosis of disorders such as superior
semicircular canal dehiscence syndrome (SCDS) [76], peri-
lymphatic fistulas, acute low-tone sensorineural hearing loss,
etc.
Despite the increasing importance of PET in otology, it has
been challenging to fully understand the various clinical cases
presented from different institutions under the diagnosis of PET
or to compare studies published. These problems are mainly due
to the lack of an established diagnostic criteria for PET.
In view of these circumstances, the Japan Otological Society
(JOS) Eustachian Tube Committee first proposed diagnostic
criteria for Patulous Eustachian Tube in 2012, in order to
promote clinical research on PET by providing a common
original concept of a set of simple criteria. These diagnostic
criteria were written in Japanese.
Here, we have proposed the English version of the JOS
diagnostic criteria of Patulous Eustachian Tube to aid
international scientific communication on PET.
2. Concept of the JOS diagnostic criteria for Patulous
Eustachian Tube 2016
The JOS diagnostic criteria for Patulous Eustachian Tube
2016 was formulated to avoid any contamination of “Definite
PET” with uncertain cases, so that “Definite PET” accurately
reflects PET cases. Moreover, it was also intended to minimize
the number of cases that could be accidentally excluded even in
the presence of some suspected findings (“Possible PET”).
The criteria can be used by all otolaryngologists even
without using the Eustachian tube function test apparatus.
However, the use of such an apparatus could increase the
possibility of detecting “definite PET”.
3. JOS diagnostic criteria for Patulous Eustachian
Tube 2016
The JOS diagnostic criteria for Patulous Eustachian Tube
2016 (Fig. 1), the notes for the criteria (Table 1, Figs. 2 and 3)
and the algorithm for diagnosis of PET using the criteria (Fig. 4)
are shown.

Fig. 1. JOS diagnostic criteria for Patulous Eustachian Tube 2016.

Fig. 2. Representative TTAG recording obtained from a patient with PET.

Please cite this article in press as: Kobayashi T, et al. Diagnostic criteria for Patulous Eustachian Tube: A proposal by the Japan Otological
Society. Auris Nasus Larynx (2017), https://doi.org/10.1016/j.anl.2017.09.017
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T. Kobayashi et al. / Auris Nasus Larynx xxx (2017) xxx–xxx 3

Table 1
Notes for JOS diagnostic criteria for Patulous Eustachian Tube 2016.
1. General principles
- Diagnosis may be confirmed after several consultations.
Example 1) “Possible PET” at first visit (1 + 2 or 3). 2 or 3 added at the time of a follow-up examination to ensure “Definite PET” (1 + 2 + 3).
Example 2) Not applicable at first visit (1 only). “Possible PET” at revisit (1 + 2 or 3).
2. Regarding “Tubal obstruction procedures (A or B) clearly improves symptoms"
- Symptoms of Patulous Eustachian Tube should be eliminated or alleviated by obstructing the open Eustachian tube when there are aural symptoms.
If this finding is absent, Patulous Eustachian Tube is excluded (for example, in autophony seen as sequelae of acute sensorineural hearing loss, there is no remarkable improvement in
symptoms even if the Eustachian tube is occluded).
- A posture change to supine/lordotic position (2A) may also be considered as a tubal occlusion procedure, but some Patulous Eustachian Tubes does not close
(2A negative) even in the supine position (several %). In this case, you can diagnose it as positive by confirming 2B.
- 2A can be done by interview, so even patients without symptoms at the time of consultation can be diagnosed through inquiries.
If the patient's condition is obviously alleviated, it is taken as 2A positive, and if the answer is ambiguous, it is regarded to be unknown.
If there are aural symptoms at that time and the answer is ambiguous, you should turn the examination chair back so the patient is in the supine position and then ask the question again, in
order to judge it positive or negative.
- Even when there are no symptoms at the time of consultation, and the answer is ambiguous so a diagnosis cannot be made, tell the patient that the symptom change accompanying the
change of body position is important for diagnosis of this disease, and by asking again at the next visit, if a clear answer is obtained, it is assumed to be 2A positive.
3. About “objective findings”
- The criteria were formulated in order to facilitate diagnosis of PET even without using the Eustachian tube function test apparatus. However, the use of Eustachian tube function test
apparatus may increase the chance of diagnosing “Definite PET”.
- 3A should be performed in the sitting position. Use an endoscope or microscope. Instruct the subject to breathe deeply through the nostril on the examination side, during which the mouth is
closed and the nostril on the other side is closed with a finger. If the tympanic membrane is retracted, or if there is a Eustachian tube lock due to nasal sniffing, autoinflation (Valsalva maneuver)
or Eustachian tube catheter inflation at low pressure is performed, since it is easy to obtain a 3A positive finding after the retraction of the tympanic membrane is released.
- 3B can be detected using the tubo-tympano-aerodynamic-graphy (TTAG) [10], manometry [23], or the stapedial reflex (SR) mode of the impedance audiometer. These methods can
objectively record synchronous change of the pressure or impedance induced by movement of the tympanic membrane upon respiration (Fig. 2) or sniffing in patients with PET,
regarded as a finding to prove patent Eustachian tube.
- 3C can be detected by sonotubometry [11,64]. Sonotubometry can provide objective evidence of patent ET by acoustical method. It is performed using commercial medical equipment.
A probe tone (7 kHz band noise) is presented using a special speaker-phone with an olive-shaped tip placed at the nostril, and the sound pressure level of probe tone is monitored by a
microphone inserted into the external auditory canal (EAC). After the level of the probe tone was adjusted so that monitored probe tone level at the EAC was automatically calibrated at
a pre-set level (50 dB), the relative probe tone level compared to 50 dB at the EAC was monitored with time. Two findings (Fig. 3) were adopted as positive indication of patent ET, (1)
lowering of probe tone sound pressure level to below 100 dB or (2) so-called “open plateau pattern” obtainable when Eustachian tube opens upon swallowing and remains open
thereafter.
4. Other (diseases to be distinguished from “Possible PET” cases)
- Reduction of symptoms in the supine/lordotic positon can also occur in superior canal dehiscence syndrome, perilymph fistulas, cerebrospinal fluid hypovolemia, and the like, therefore
in the absence of objective findings (3A, B, C), and if diagnosed as “Possible PET”, it is desirable to exclude these diseases.

Fig. 3. Representative sonotubometry recordings obtained from patients with PET. (1) Lowering of probe tone (speaker) sound pressure level to below 100 dB. (2) “Open
plateau pattern”. (3) A normal sonotubometry recording from a healthy subject, indicating an instant opening and closure of the Eustachian tube upon swallowing.

Fig. 4. JOS diagnostic criteria for Patulous Eustachian Tube 2016 (Algorithm).

Please cite this article in press as: Kobayashi T, et al. Diagnostic criteria for Patulous Eustachian Tube: A proposal by the Japan Otological
Society. Auris Nasus Larynx (2017), https://doi.org/10.1016/j.anl.2017.09.017
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4. Conclusion
The JOS diagnostic criteria for Patulous Eustachian Tube
will further promote international scientific communication on
PET.
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