Patulous Eustachian Tube A New Treatment With Infusion of Absorbable Gelatin Shigehisa Ogawa, MD;
Isei
Sponge
Solution
Satoh, MD; Hiroaki Tanaka, MD
\s=b\ For the treatment of abnormally patent Eustachian tube, we had previously employed repeated tubal insufflation of salicylic acid-boric acid powder (1:4) through a Eustachian tube catheter. Such treatments, however, usually were associated with uncertain results and numerous complications. Therefore, treatment of this condition was changed to employment of an infusion of absorbable gelatin sponge solution directly into the Eustachian tube. Twenty-two ears in 16 patients recovered successfully when this method was used.
(Arch Otolaryngol 102:276-280, 1976) first described the Eustachian tube as being normal¬ ly closed, opening only during the process of swallowing. The pathologic entity of the widely open or patulous Eustachian tube was well documented at that time. Schwartze- observed that a scarred ear drum moved synchro¬ nously with respiration. A more com¬ plete report of the condition was given by Jago,3 who had himself had rightsided patulous Eustachian tube trou¬ ble. Despite occasional reports, little attention had been paid to the condi¬ tion until the 1930s, when it was discussed in detail by Pitman,4 Zöll¬ ner,3" Shambaugh,7 and Perlman/" Patulous Eustachian tube, while not a common condition, is much more prevalent than is usually supposed. It is, in all probability, frequently over¬ looked and has seldom been dis¬ cussed.1"14 Metz11 observed seven cases in about five years. Suehs11 encountered 31 cases in about seven years. Miller13 reported 30 cases that had occurred over a period of nine years since his original report in 1951.
In 1853, Toynbee1
Accepted for publication Nov 17, 1975. From the Department of Otolaryngology, School of Medicine, Nagasaki University, Naga-
saki, Japan. Reprint requests to Department of Otolaryngology, School of Medicine, 7-1, Sakamoto Machi, Nagasaki, Nagasaki 852, Japan (Dr Ogawa).
Pulec14 stated that the diagnosis was made only 41 times at the Mayo Clinic in the 20-year period of 1940 through 1959, but, with more awareness of the condition, it was made 95 times between 1960 and 1966. The symptoms include autophony, feeling one's own breathing in the ear, a feeling of the head "as in an empty barrel," and an uncomfortable full¬ ness in the ear. Tinnitus may or may not be present. Hearing may not be impaired except when feeling of one's own breathing in the ear is present. Physical examination may reveal a normal tympanic membrane. Synchro¬ nous movement of a tympanic mem¬ brane with respiration was observed by Schwartze," Hartmann,1" and Vol¬ tolini.17 Pathophysiologic aspects of the condition are not sufficiently understood. The diagnosis is usually suggested by the history and can be made easily. Various methods of treatment for the patulous Eustachian tube have been tried from time to time; these include both nonsurgical and surgical techniques. Among nonsurgical meth¬ ods, McAuliffe18 used nitric acid and phenol applied to the Eustachian tube orifice. Bezold and Siebenmann1" first advocated the insufflation of salicylic acid-boric acid powder (1:4) through catheter. Eustachian an tube Halsted-" believed that electrocautery to the Eustachian tube orifice might be helpful. Shambaugh7 advocated irrigation of the nose and nasophar¬ ynx with normal saline solution for patients with atrophie mucosa. In an attempt to treat the condition surgi¬ cally, Zöllner3" infiltrated paraffin around the Eustachian tube orifice. Adhesions in the fossa of Rosenmüller have been divided surgically by Moore and Miller1" and by Simonton1L' with no lasting benefit. Simonton1-' also tried electrocoagulation of the lumen of the tube, incision of the cartilage at the
junction
of medial and lateral lamel¬
lae, and removal of cartilage from the pharyngeal end of the tube. However,
of these procedures was success¬ ful. Suehs" and Thaler and Yanagisawa!1 inserted a polyethylene tube into the middle ear in the manner described by Armstrong.-- Pulec14 injected polytef (Teflon) paste in the form of PTFE Paste for Injection into the Eustachian tube orifice. Recently, Stroud et al-' performed the tensor veli palatini transposition procedure in ten patients, resulting in improve¬ ment or complete relief. We describe here a method of treat¬ ment of patulous Eustachian tube by injection of absorbable gelatin sponge solution directly into the tube. none
MATERIALS AND METHODS To prepare the solution, 1 gm of absorb¬ able gelatin sponge (Gelfoam) is added to 10 ml of glycerin; the mixture is stirred and becomes turbid. Ten milliliters of physio¬ logical saline solution is further added and the mixture stirred again. Immediately a mushy solution is obtained. A solution of higher viscosity, obtained by the addition of 1 gm of carbomethylcellulose sodium, is effective in the treatment of severe cases.
For the infusion of the absorbable
gelatin sponge solution into the Eustachian tube, the solution is prepared by means of the previously described procedure in a vial containing 1 gm of the gelatin powder. Approximately 1 ml of solution is suctioned into a 2-ml syringe to which a cutdown tube of 1 mm in external diameter is connected. This cutdown tube is already filled with the solution. The cutdown tube is inserted into the Eustachian tube with the use of a nasopharyngoscope provided with a side tube or the use of a Eustachian tube cath¬ eter (Fig 1 and 2). As the edge of the cutdown tube is inserted 1.0 to 1.5 cm into the Eustachian tube orifice, 0.3 to 0.5 ml of solution is infused slowly. After removing the cutdown tube, only absorbable gelatin sponge solution remains in the Eustachian tube. Usually, the use of a Eustachian tube
Downloaded From: http://archotol.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/22/2015
catheter facilitates the introduction of a cutdown tube into the Eustachian tube. It is practical to provide a mark on the cutdown tube at a point (A) that is 1.0 to 1.5 cm longer than the Eustachian tube cath¬ eter (Fig 2). The cutdown tube should not be inserted deeper than this mark. The infusion requires the following considera¬ tions: (1) the cutdown tube should not be too large; (2) the cutdown tube should not be inserted up to the isthmus; and (3) rapid infusion of a large quantity of solution should be avoided.
SUBJECTS The Table summarizes the analysis of 16 of patulous Eustachian tube, ten unilateral and six bilateral, in a total of 22 ears. Patients included seven men and nine women ranging in age from 20 to 75 years. The symptoms included autophony, which was complained of by all patients, feeling one's own breathing in the ear, feeling of the head "as in an empty barrel," hearing loss, and uncomfortable fullness in the ear. Patient 3 had severe atrophy of the masseter muscle caused by trigeminal nerve palsy (first through third nerves) on the affected side. Patient 11 had onset of patulous Eustachian tube in the ninth month of pregnancy. Patient 14 had onset when serous otitis media was alleviated and effusion disappeared. Patient 16 had diabetes insipidus, and his total 24-hour urine volume was 4 to 5 liters. These complications were considered to be causes of or contributing factors to patulous Eustachian tube. Patients 1 and 2 had repeatedly been treated with insufflation of salicylic acidboric acid powder (1:4) for approximately four years prior to receiving our new treat¬ ment with infusion of absorbable gelatin sponge solution. Repeated insufflations had been required for several days before the alleviation of symptoms in each case, and the symptoms recurred approximately one week after treatment. Patient 1 had often shown complications of otitis media and tubotympanic catarrh during the course of treatment with insufflation. Patients 3 through 16 received the new form of treatment without previous insufflation. cases
RESULTS A
new
treatment with absorbable
gelatin sponge solution was used in 16 cases (22 ears). In all cases, symptoms disappeared immediately after in¬ fusion. The more severe the subjective and objective symptoms, the more dramatic the improvement of the
symptoms.
not
The interval from
subsequent
an
recurrence
infusion to the varied greatly
week to over one year (fol¬ is still being conducted). low-up Recurrence within one month was observed in six ears (27%). Of these cases, patients who received the second infusion (patients 2, 9, 11, and 13) demonstrated a notable elongation of the interval before recurrence from
one
(Table).
The infusion led to tinnitus in two (patients 2 and 8). In these cases, the external diameter of the cutdown tube used was too big and the cutdown tube was inserted up to the isthmus; moreover, a large quantity of solution was infused rapidly. Consequently, the solution might have flowed into the tympanic cavity and caused tinni¬ tus. In either case, tinnitus disap¬ peared approximately one month la¬ ter. The patulous Eustachian tube in patient 2 was accompanied by hearing loss, but this patient's condition showed appreciable improvement both subjectively and objectively after infusion (Fig 4). Eustachian tube function was tested by means of sonometry before and after infusion for all cases. Fig 5 shows samples of the sonometric wave pattern before and after infusion. The upper three samples show the sono¬ metric wave pattern before infusion, which demonstrates a high basic amplitude almost proportional to the sound pressure. The basic amplitude is greatly lowered after infusion, as seen in the lower samples (Fig 5). ears
COMMENT
The insufflation of salicylic acidboric acid powder (1:4) is most commonly used as a conservative treatment for patulous Eustachian tube particularly because it is readily feasible and considerably effective in some cases. However, this method also involves various problems. The effect of this treatment is apparent only after it produces reactive edema to the mucous membrane of the Eusta¬ chian tube. It is rare that one or two insufflations are adequate, but re¬ peated insufflations for several days are required in most cases. Moreover, it is often noted that symptoms are
sufficiently alleviated. This meth¬
od, because of the use of an inflamma¬ tory agent, fails to take into account the excretory process of the Eusta¬ chian tube
by means of ciliary move¬ Accordingly, the repeated in¬ sufflations are likely to cause compli¬ ment.
cations such as otitis media and tubotympanic catarrh. Although a lasting effect is reported in some cases, a temporary effect can usually be expected. In our experience, the effect was only temporary in most cases. In contrast to this, the infusion of absorbable gelatin sponge solution into the Eustachian tube is technically easy and available for all cases that can be treated with usual Eustachian catheterization. The effect of treat¬ ment can be determined immediately after an infusion of solution, and,
therefore,
a
concurrent
performance
of differential diagnosis and treat¬ ment is available. This method rarely produces side-effects such as reaction against foreign bodies and inflamma¬ tory reaction, causing little pain to patients. An effect lasting for one week to over one year may well be expected from one infusion of solu¬ tion. A lasting effect from this treat¬ ment method is available also for patients who had previously experi¬ enced temporary effects from re¬ peated insufflations of salicylic acidboric acid powder (1:4). We have been conducting sono¬ metric examination of Eustachian tube function for the patients with patulous Eustachian tube. This son¬ ometric technique was devised by Perlman-4 in 1951, and the apparatus was made compact after some me¬ chanical improvement by Satoh et al-3 in 1970. This portable apparatus intro¬ duces the pure tone of 2,000 hertz 120 dB into the nasal cavity from a small speaker connected to an oscillator and picks up the sound wave passing through the Eustachian tube on deglu¬ tition with a microphone provided in the external ear canal. The picked-up sound wave is converted electrically, amplified, and recorded by a penrecorder. The sonometric wave pattern shown on the pen-recorder for the patients with patulous Eustachian tube has some typical characteristics (Fig 5).
Downloaded From: http://archotol.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/22/2015
Mark
Fig 1.—At upper left is vial containing 1 gm of absorbable gelatin powder. Nasopharyngoscope with side tube (center) or Eusta¬ chian tube catheter (bottom) is used for induction of cutdown tube into Eustachian tube.
(A)
2.—Infusion of absorbable gelatin sponge solution into Eusta¬ chian tube. Upper part of figure shows infusion by means of Eustachian tube catheter. Lower part of figure shows nasopha¬ ryngoscope method.
Fig
Ear
SRT
PB Max
Isthmus
-10
Eustachian Tube
0 CD
O)
O -C
60
en
Fig 3.—Precautions in infusion of absorbable gelatin sponge solution into Eustachian tube include the following: (1) cutdown tube should not be too large; (2) cutdown tube should not be inserted up to the isthmus; and (3) rapid infusion of large quantities of solution should be avoided.
>
c
80
3
100
8,000 2,000 4,000 1,000 Frequency in Hz Bonec—-n-Right Air Conduction O-O-Right Conduction a----: Left X—X-Left 250
Fig 4.—Audiograms before and after treatment in patient 2 with hearing loss. Auditory improvement, particularly in low tone area, is characteristic.
500
Downloaded From: http://archotol.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/22/2015
(1) The basic amplitude is high, almost
proportion to the sound pressure produced by the microspeaker appara¬ tus. (2) The basic amplitude pattern (baseline) tends to be flat with
Summary of Cases and
in
Complica¬ Age (yr), Patient
negative wave patterns. relationship of the sonometric wave pattern and the nasopharyngeal pressure in patients with patulous Eustachian tube is shown in Fig 6. The negative wave in the sonometric wave pattern seems to merely reflect the negative pressure of the nasopharynx due to deglutition and does not seem to be caused by the opening and shut¬ ting movement of the Eustachian tube (Fig 6). We have observed several patients with patulous Eustachian tube that showed improvement of symptoms and finally became asymptomatic without receiving any treatment. The onstrate
The
asymptomatic.
Patient 5 had been receiving air inflation for over a dozen years for the treatment of tubai stenosis. The sonometric wave pattern during that period was typical of the stenosis type, and tubai patency was quite poor even by Eustachian catheterization. This patient showed a gradual im¬ provement of tubai patency during the course of repeated air inflation treatment but began to complain of autophony and feeling of the head "as in an empty barrel." Eustachian cath¬ eterization showed excessive tubai patency, and sonometry demonstrated the characteristic wave pattern of the patulous Eustachian tube. By analyzing these cases and con¬ ducting Eustachian tube function tests for these patients, we have reached some conclusions concerning the pathophysiology of patulous Eu¬ stachian tube. It is likely that the mucous membrane of the cartilagi¬ nous portion of the Eustachian tube or its surrounding tissue has become sclerotic while being patulous (we call
+, +++++ +,++
43, M 61, M
Right
40, 75, 23, 47, 32, 23,
Left +,++ Bilateral +, +++ + Left Left + Left Bilateral +, ++++
Left
F F F F F M
10 11
41, M 24, F
Left Bilateral
+, ++
12 13
34, M 60, F
Left Bilateral
+, ++++ +,++
14
72, M
Left
+
Trigeminal nerve (1-3) palsy, left
*
Bilateral
37, M
Right
Symptoms: +
of head "as in loss.
an
Tinnitus
>1 yr
>11 mo >10 mo >1 yr >1 yr >1 yr
Tinnitus
Right side,
>1 yr; left side, 1 wk
to>11 mo >1 yr Right side >10 mo; left side, 1 wk to >10 mo >9 mo ,
Right side, Serous otitis left
32, F
Reactions
3 mo; left side, 1 mo 1 mo to >1 yr
media, 15 16
Secondary
Right side,
Pregnancy
+,++
Duration of Relief After Treatment
tions or Cause
Ear Involved Symptoms* Bilateral +, ++
Sex 20, F
minimal fluctuation before and after deglutition. (3) While normal subjects show positive wave patterns at the time of deglutition, the patients with patulous Eustachian tube often dem¬
sonometric wave pattern in these patients showed the previously men¬ tioned characteristics, but the pattern became more like that of normal subjects when these patients became
Results
K+++ Diabetes
2 mo; left side, 2 to 6 wk 2 wk (recur¬ rence of mid¬ dle ear ef¬
fusion) >8 >8
mo
mo
insipidus
autophony; ++ feeling of one's own breathing in ear; +++ feeling empty barrel" ++++ = uncomfortable fullness in ear; -H-+-H- = hearing =
=
:
Fig 5.—Changes in sonometric wave pattern before and after treatment. Upper three samples show sonometric wave patterns before treatment; lower three samples show pattern after treatment, demonstrating remarkable drop of basic amplitude. Swallowing
-nr
luiih»
Isei
Sponge
Solution
Satoh, MD; Hiroaki Tanaka, MD
\s=b\ For the treatment of abnormally patent Eustachian tube, we had previously employed repeated tubal insufflation of salicylic acid-boric acid powder (1:4) through a Eustachian tube catheter. Such treatments, however, usually were associated with uncertain results and numerous complications. Therefore, treatment of this condition was changed to employment of an infusion of absorbable gelatin sponge solution directly into the Eustachian tube. Twenty-two ears in 16 patients recovered successfully when this method was used.
(Arch Otolaryngol 102:276-280, 1976) first described the Eustachian tube as being normal¬ ly closed, opening only during the process of swallowing. The pathologic entity of the widely open or patulous Eustachian tube was well documented at that time. Schwartze- observed that a scarred ear drum moved synchro¬ nously with respiration. A more com¬ plete report of the condition was given by Jago,3 who had himself had rightsided patulous Eustachian tube trou¬ ble. Despite occasional reports, little attention had been paid to the condi¬ tion until the 1930s, when it was discussed in detail by Pitman,4 Zöll¬ ner,3" Shambaugh,7 and Perlman/" Patulous Eustachian tube, while not a common condition, is much more prevalent than is usually supposed. It is, in all probability, frequently over¬ looked and has seldom been dis¬ cussed.1"14 Metz11 observed seven cases in about five years. Suehs11 encountered 31 cases in about seven years. Miller13 reported 30 cases that had occurred over a period of nine years since his original report in 1951.
In 1853, Toynbee1
Accepted for publication Nov 17, 1975. From the Department of Otolaryngology, School of Medicine, Nagasaki University, Naga-
saki, Japan. Reprint requests to Department of Otolaryngology, School of Medicine, 7-1, Sakamoto Machi, Nagasaki, Nagasaki 852, Japan (Dr Ogawa).
Pulec14 stated that the diagnosis was made only 41 times at the Mayo Clinic in the 20-year period of 1940 through 1959, but, with more awareness of the condition, it was made 95 times between 1960 and 1966. The symptoms include autophony, feeling one's own breathing in the ear, a feeling of the head "as in an empty barrel," and an uncomfortable full¬ ness in the ear. Tinnitus may or may not be present. Hearing may not be impaired except when feeling of one's own breathing in the ear is present. Physical examination may reveal a normal tympanic membrane. Synchro¬ nous movement of a tympanic mem¬ brane with respiration was observed by Schwartze," Hartmann,1" and Vol¬ tolini.17 Pathophysiologic aspects of the condition are not sufficiently understood. The diagnosis is usually suggested by the history and can be made easily. Various methods of treatment for the patulous Eustachian tube have been tried from time to time; these include both nonsurgical and surgical techniques. Among nonsurgical meth¬ ods, McAuliffe18 used nitric acid and phenol applied to the Eustachian tube orifice. Bezold and Siebenmann1" first advocated the insufflation of salicylic acid-boric acid powder (1:4) through catheter. Eustachian an tube Halsted-" believed that electrocautery to the Eustachian tube orifice might be helpful. Shambaugh7 advocated irrigation of the nose and nasophar¬ ynx with normal saline solution for patients with atrophie mucosa. In an attempt to treat the condition surgi¬ cally, Zöllner3" infiltrated paraffin around the Eustachian tube orifice. Adhesions in the fossa of Rosenmüller have been divided surgically by Moore and Miller1" and by Simonton1L' with no lasting benefit. Simonton1-' also tried electrocoagulation of the lumen of the tube, incision of the cartilage at the
junction
of medial and lateral lamel¬
lae, and removal of cartilage from the pharyngeal end of the tube. However,
of these procedures was success¬ ful. Suehs" and Thaler and Yanagisawa!1 inserted a polyethylene tube into the middle ear in the manner described by Armstrong.-- Pulec14 injected polytef (Teflon) paste in the form of PTFE Paste for Injection into the Eustachian tube orifice. Recently, Stroud et al-' performed the tensor veli palatini transposition procedure in ten patients, resulting in improve¬ ment or complete relief. We describe here a method of treat¬ ment of patulous Eustachian tube by injection of absorbable gelatin sponge solution directly into the tube. none
MATERIALS AND METHODS To prepare the solution, 1 gm of absorb¬ able gelatin sponge (Gelfoam) is added to 10 ml of glycerin; the mixture is stirred and becomes turbid. Ten milliliters of physio¬ logical saline solution is further added and the mixture stirred again. Immediately a mushy solution is obtained. A solution of higher viscosity, obtained by the addition of 1 gm of carbomethylcellulose sodium, is effective in the treatment of severe cases.
For the infusion of the absorbable
gelatin sponge solution into the Eustachian tube, the solution is prepared by means of the previously described procedure in a vial containing 1 gm of the gelatin powder. Approximately 1 ml of solution is suctioned into a 2-ml syringe to which a cutdown tube of 1 mm in external diameter is connected. This cutdown tube is already filled with the solution. The cutdown tube is inserted into the Eustachian tube with the use of a nasopharyngoscope provided with a side tube or the use of a Eustachian tube cath¬ eter (Fig 1 and 2). As the edge of the cutdown tube is inserted 1.0 to 1.5 cm into the Eustachian tube orifice, 0.3 to 0.5 ml of solution is infused slowly. After removing the cutdown tube, only absorbable gelatin sponge solution remains in the Eustachian tube. Usually, the use of a Eustachian tube
Downloaded From: http://archotol.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/22/2015
catheter facilitates the introduction of a cutdown tube into the Eustachian tube. It is practical to provide a mark on the cutdown tube at a point (A) that is 1.0 to 1.5 cm longer than the Eustachian tube cath¬ eter (Fig 2). The cutdown tube should not be inserted deeper than this mark. The infusion requires the following considera¬ tions: (1) the cutdown tube should not be too large; (2) the cutdown tube should not be inserted up to the isthmus; and (3) rapid infusion of a large quantity of solution should be avoided.
SUBJECTS The Table summarizes the analysis of 16 of patulous Eustachian tube, ten unilateral and six bilateral, in a total of 22 ears. Patients included seven men and nine women ranging in age from 20 to 75 years. The symptoms included autophony, which was complained of by all patients, feeling one's own breathing in the ear, feeling of the head "as in an empty barrel," hearing loss, and uncomfortable fullness in the ear. Patient 3 had severe atrophy of the masseter muscle caused by trigeminal nerve palsy (first through third nerves) on the affected side. Patient 11 had onset of patulous Eustachian tube in the ninth month of pregnancy. Patient 14 had onset when serous otitis media was alleviated and effusion disappeared. Patient 16 had diabetes insipidus, and his total 24-hour urine volume was 4 to 5 liters. These complications were considered to be causes of or contributing factors to patulous Eustachian tube. Patients 1 and 2 had repeatedly been treated with insufflation of salicylic acidboric acid powder (1:4) for approximately four years prior to receiving our new treat¬ ment with infusion of absorbable gelatin sponge solution. Repeated insufflations had been required for several days before the alleviation of symptoms in each case, and the symptoms recurred approximately one week after treatment. Patient 1 had often shown complications of otitis media and tubotympanic catarrh during the course of treatment with insufflation. Patients 3 through 16 received the new form of treatment without previous insufflation. cases
RESULTS A
new
treatment with absorbable
gelatin sponge solution was used in 16 cases (22 ears). In all cases, symptoms disappeared immediately after in¬ fusion. The more severe the subjective and objective symptoms, the more dramatic the improvement of the
symptoms.
not
The interval from
subsequent
an
recurrence
infusion to the varied greatly
week to over one year (fol¬ is still being conducted). low-up Recurrence within one month was observed in six ears (27%). Of these cases, patients who received the second infusion (patients 2, 9, 11, and 13) demonstrated a notable elongation of the interval before recurrence from
one
(Table).
The infusion led to tinnitus in two (patients 2 and 8). In these cases, the external diameter of the cutdown tube used was too big and the cutdown tube was inserted up to the isthmus; moreover, a large quantity of solution was infused rapidly. Consequently, the solution might have flowed into the tympanic cavity and caused tinni¬ tus. In either case, tinnitus disap¬ peared approximately one month la¬ ter. The patulous Eustachian tube in patient 2 was accompanied by hearing loss, but this patient's condition showed appreciable improvement both subjectively and objectively after infusion (Fig 4). Eustachian tube function was tested by means of sonometry before and after infusion for all cases. Fig 5 shows samples of the sonometric wave pattern before and after infusion. The upper three samples show the sono¬ metric wave pattern before infusion, which demonstrates a high basic amplitude almost proportional to the sound pressure. The basic amplitude is greatly lowered after infusion, as seen in the lower samples (Fig 5). ears
COMMENT
The insufflation of salicylic acidboric acid powder (1:4) is most commonly used as a conservative treatment for patulous Eustachian tube particularly because it is readily feasible and considerably effective in some cases. However, this method also involves various problems. The effect of this treatment is apparent only after it produces reactive edema to the mucous membrane of the Eusta¬ chian tube. It is rare that one or two insufflations are adequate, but re¬ peated insufflations for several days are required in most cases. Moreover, it is often noted that symptoms are
sufficiently alleviated. This meth¬
od, because of the use of an inflamma¬ tory agent, fails to take into account the excretory process of the Eusta¬ chian tube
by means of ciliary move¬ Accordingly, the repeated in¬ sufflations are likely to cause compli¬ ment.
cations such as otitis media and tubotympanic catarrh. Although a lasting effect is reported in some cases, a temporary effect can usually be expected. In our experience, the effect was only temporary in most cases. In contrast to this, the infusion of absorbable gelatin sponge solution into the Eustachian tube is technically easy and available for all cases that can be treated with usual Eustachian catheterization. The effect of treat¬ ment can be determined immediately after an infusion of solution, and,
therefore,
a
concurrent
performance
of differential diagnosis and treat¬ ment is available. This method rarely produces side-effects such as reaction against foreign bodies and inflamma¬ tory reaction, causing little pain to patients. An effect lasting for one week to over one year may well be expected from one infusion of solu¬ tion. A lasting effect from this treat¬ ment method is available also for patients who had previously experi¬ enced temporary effects from re¬ peated insufflations of salicylic acidboric acid powder (1:4). We have been conducting sono¬ metric examination of Eustachian tube function for the patients with patulous Eustachian tube. This son¬ ometric technique was devised by Perlman-4 in 1951, and the apparatus was made compact after some me¬ chanical improvement by Satoh et al-3 in 1970. This portable apparatus intro¬ duces the pure tone of 2,000 hertz 120 dB into the nasal cavity from a small speaker connected to an oscillator and picks up the sound wave passing through the Eustachian tube on deglu¬ tition with a microphone provided in the external ear canal. The picked-up sound wave is converted electrically, amplified, and recorded by a penrecorder. The sonometric wave pattern shown on the pen-recorder for the patients with patulous Eustachian tube has some typical characteristics (Fig 5).
Downloaded From: http://archotol.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/22/2015
Mark
Fig 1.—At upper left is vial containing 1 gm of absorbable gelatin powder. Nasopharyngoscope with side tube (center) or Eusta¬ chian tube catheter (bottom) is used for induction of cutdown tube into Eustachian tube.
(A)
2.—Infusion of absorbable gelatin sponge solution into Eusta¬ chian tube. Upper part of figure shows infusion by means of Eustachian tube catheter. Lower part of figure shows nasopha¬ ryngoscope method.
Fig
Ear
SRT
PB Max
Isthmus
-10
Eustachian Tube
0 CD
O)
O -C
60
en
Fig 3.—Precautions in infusion of absorbable gelatin sponge solution into Eustachian tube include the following: (1) cutdown tube should not be too large; (2) cutdown tube should not be inserted up to the isthmus; and (3) rapid infusion of large quantities of solution should be avoided.
>
c
80
3
100
8,000 2,000 4,000 1,000 Frequency in Hz Bonec—-n-Right Air Conduction O-O-Right Conduction a----: Left X—X-Left 250
Fig 4.—Audiograms before and after treatment in patient 2 with hearing loss. Auditory improvement, particularly in low tone area, is characteristic.
500
Downloaded From: http://archotol.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/22/2015
(1) The basic amplitude is high, almost
proportion to the sound pressure produced by the microspeaker appara¬ tus. (2) The basic amplitude pattern (baseline) tends to be flat with
Summary of Cases and
in
Complica¬ Age (yr), Patient
negative wave patterns. relationship of the sonometric wave pattern and the nasopharyngeal pressure in patients with patulous Eustachian tube is shown in Fig 6. The negative wave in the sonometric wave pattern seems to merely reflect the negative pressure of the nasopharynx due to deglutition and does not seem to be caused by the opening and shut¬ ting movement of the Eustachian tube (Fig 6). We have observed several patients with patulous Eustachian tube that showed improvement of symptoms and finally became asymptomatic without receiving any treatment. The onstrate
The
asymptomatic.
Patient 5 had been receiving air inflation for over a dozen years for the treatment of tubai stenosis. The sonometric wave pattern during that period was typical of the stenosis type, and tubai patency was quite poor even by Eustachian catheterization. This patient showed a gradual im¬ provement of tubai patency during the course of repeated air inflation treatment but began to complain of autophony and feeling of the head "as in an empty barrel." Eustachian cath¬ eterization showed excessive tubai patency, and sonometry demonstrated the characteristic wave pattern of the patulous Eustachian tube. By analyzing these cases and con¬ ducting Eustachian tube function tests for these patients, we have reached some conclusions concerning the pathophysiology of patulous Eu¬ stachian tube. It is likely that the mucous membrane of the cartilagi¬ nous portion of the Eustachian tube or its surrounding tissue has become sclerotic while being patulous (we call
+, +++++ +,++
43, M 61, M
Right
40, 75, 23, 47, 32, 23,
Left +,++ Bilateral +, +++ + Left Left + Left Bilateral +, ++++
Left
F F F F F M
10 11
41, M 24, F
Left Bilateral
+, ++
12 13
34, M 60, F
Left Bilateral
+, ++++ +,++
14
72, M
Left
+
Trigeminal nerve (1-3) palsy, left
*
Bilateral
37, M
Right
Symptoms: +
of head "as in loss.
an
Tinnitus
>1 yr
>11 mo >10 mo >1 yr >1 yr >1 yr
Tinnitus
Right side,
>1 yr; left side, 1 wk
to>11 mo >1 yr Right side >10 mo; left side, 1 wk to >10 mo >9 mo ,
Right side, Serous otitis left
32, F
Reactions
3 mo; left side, 1 mo 1 mo to >1 yr
media, 15 16
Secondary
Right side,
Pregnancy
+,++
Duration of Relief After Treatment
tions or Cause
Ear Involved Symptoms* Bilateral +, ++
Sex 20, F
minimal fluctuation before and after deglutition. (3) While normal subjects show positive wave patterns at the time of deglutition, the patients with patulous Eustachian tube often dem¬
sonometric wave pattern in these patients showed the previously men¬ tioned characteristics, but the pattern became more like that of normal subjects when these patients became
Results
K+++ Diabetes
2 mo; left side, 2 to 6 wk 2 wk (recur¬ rence of mid¬ dle ear ef¬
fusion) >8 >8
mo
mo
insipidus
autophony; ++ feeling of one's own breathing in ear; +++ feeling empty barrel" ++++ = uncomfortable fullness in ear; -H-+-H- = hearing =
=
:
Fig 5.—Changes in sonometric wave pattern before and after treatment. Upper three samples show sonometric wave patterns before treatment; lower three samples show pattern after treatment, demonstrating remarkable drop of basic amplitude. Swallowing
-nr
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