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Eustachian Tube Dysfunction and Surgery
Built from Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
What’s inside
14 sections · 154 slides
Overview
- Scope of this presentation
Anatomy of the Eustachian Tube
- Historical milestones
- Dimensions and the functional valve
- The bony portion
- The cartilaginous portion
- The valve segment
- The four peritubal muscles
- Levator veli palatini
- Tensor veli palatini
- Endoscopic landmarks of the tubal orifice
Physiology of Tubal Dilation
- Intermittent dilation and pressure equilibration
- Mechanics of active dilation
- Middle ear gas exchange
- Surfactant, clearance and protection
- The three functions of the Eustachian tube
Defining Eustachian Tube Dysfunction
- Consensus definition of obstructive dysfunction
- Eustachian tube dysfunction as a spectrum
- Barochallenge: the mildest obstructive form
- Migration from obstructive to patulous
- Consequences of a valve that will not open
- Prevalence of obstructive and patulous dysfunction
- Symptom profile of the patulous tube
- Risk factors for the patulous tube
Luminal and Video Endoscopy
- Limits of trans-Eustachian endoscopy
- Pathology localises to the cartilaginous portion
- Transnasal endoscopy of the tubal orifice
- Preparation and initial examination
- What to look for before reaching the tube
- Choosing flexible or rigid endoscopes
- Rigid endoscope: sequence of landmarks
- Dynamic manoeuvres during the examination
- Normal dilation sequence on video endoscopy
- Closure and the pumping hypothesis
- Electromyographic validation of the sequence
Endoscopy of the Dysfunctional Tube
- Four mechanisms of obstructive dysfunction
- Video analysis of dysfunctional tubes
- Pathological findings in 58 clinically dysfunctional Eustachian tubes
- From negative pressure to cholesteatoma
- Components of the cartilaginous tube and their defects
- Dynamic muscular dysfunction
- Eustachian tube mucosal inflammation scale
- Common causes of obstructive dysfunction
- Adenoid hypertrophy with anterior thrusting of the torus tubarius
- Anterior thrusting of the torus tubarius
- Intraluminal polyps obstructing the tubal valve
- Concave anterolateral defect of the patulous tube
- What the patulous defect represents
- The atrophy and inflammation paradox
Clinical Assessment
- History
- Physical examination and audiology
- Dynamic endoscopic assessment
Medical Treatment
- Principles of medical treatment
- Managing allergic disease
- Nasal, sinus, adenoid and reflux management
- Differential diagnosis for co-morbidities associated with chronic Eustachian tube dysfunction
- Excluding a neoplasm
- Differential diagnosis for aural fullness
- Fullness with a normal ear is not obstructive ETD
- Findings in chronic obstructive dysfunction
- The mucosal band in barochallenge
Diagnosing the Patulous Tube
- Clinical diagnosis of the patulous tube
- Enhancing and confirming the diagnosis
- The sniffing cycle in patulous dysfunction
- Inappropriate sniffing as a diagnostic clue
Mimics of Eustachian Tube Dysfunction
- Otic capsule dehiscence syndrome
- Confirming superior semicircular canal dehiscence
- Temporomandibular disorders
- Palpating the muscles of mastication
Surgery for Obstructive Dysfunction
- When surgery is indicated
- Adjunctive procedures on the upper airway
- Indications for lateral adenoidectomy
- Lateral adenoidectomy technique
Balloon Dilation of the Eustachian Tube
- Histological effect of balloon dilation
- Balloon dilation as an adenoidectomy of the lumen
- Evidence for efficacy across outcome measures
- Durability and the randomised trials
- First randomised trial: outcomes at six weeks
- Balloon dilation in chronic otitis media with effusion
- Approaches and contraindications
- Indications for balloon dilation of the cartilaginous Eustachian tube
- Anaesthesia and preparation
- Topical anaesthesia of the tubal orifice
- Instrumentation and insertion of the guide
- Avoiding sword-fighting between instruments
- Following the anterolateral wall into the lumen
- Negotiating obstruction during insertion
- Depth control and the internal carotid artery
- Inflation parameters
- Extrusion, deflation and adjuncts
- Intraoperative steps of balloon dilation
- Postoperative instructions
- Modified Valsalva after the first week
- Long-term control of comorbidities
- Complications: bleeding and false passage
- Subcutaneous emphysema and pneumomediastinum
- Postoperative patulous Eustachian tube
- Avoiding an iatrogenic patulous tube
- Synechia and carotid injury
- Balloon dilation in children
- Paediatric aetiology and unanswered questions
- Obstruction within the bony portion
Treating the Patulous Eustachian Tube
- Objectives and first steps
- Conservative measures
- Medications that thicken the tubal mucosa
- Correct technique for instilling drops
- Procedures directed at the tympanic membrane
- Mass loading of the tympanic membrane
- The intraluminal shim: concept
- Shim: preparation and sizing
- Shim: the mandatory preoperative CT
- Shim: insertion technique
- Shim: seating and final position
- Shim: outcomes and dislodgement
- Catheter shim secured at the anterior pillar
- Variants of the shim technique
- The Kobayashi silicone plug
- Calcium hydroxyapatite injection: technique
- Injection volumes and case selection
- Injection: outcomes and counselling
- Cartilage augmentation of the tubal wall
- Cartilage augmentation: technique and expectations
- Total obliteration as a last resort
Summary
- Key points: the organ and its failure
- Key points: the allergic patient and sniffing
- Key points: treatment ladder
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- Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
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