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BackTable / ENT / Article
Treating Eustachian Tube Dysfunction with Eustachian Tube Balloon Dilation
Taylor Spurgeon-Hess • Updated Oct 30, 2022 • 521 hits
Treatment for eustachian tube dysfunction incorporates a variety of modalities, including antihistamines, decongestants, ear tubes, and most recently, eustachian tube balloon dilation. In 2016, the FDA approved the use of a balloon catheter in the eustachian tube which has since allowed a large number of patients to find relief from their symptoms. Otologist, Dr. Seilesh Babu, discusses his strategy for both performing the procedure and counseling qualified patients.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Eustachian tube balloon dilation involves opening the space in order to promote better opening and closing of the tube, thereby providing patients with symptom relief.
• Procedurally, a eustachian tube balloon dilation device, such as the Acclarent Aera, is guided through the nasal cavity into the eustachian tube where the balloon is dilated to 12 atm of pressure and held there for 2 minutes.
• Whether performed in the operating room or in-office, eustachian tube balloon dilation takes only a few minutes and patients can expect to return home and resume normal activities the same day.
• After eustacian tube balloon dilation, patients can expect to have a sore throat and may experience nose bleeding, but the symptoms often resolve on their own within 3 days. Patients are advised to refrain from blowing their nose or performing a Valsalva maneuver for 10 days post-procedure.
Table of Contents
(1) Explaining Eustachian Tube Balloon Dilation
(2) Counseling Patients on the Eustachian Tube Balloon Dilation Procedure
(3) Performing Eustachian Tube Balloon Dilation
Explaining Eustachian Tube Balloon Dilation
While ear tubes remain a mainstay of treatment for eustachian tube dysfunction, patients may find additional relief with eustachian tube balloon dilation. The procedure utilizes a balloon catheter, similar to those used for coronary artery balloon dilation, but with a different bend and more flexibility, making it suitable for placement in the eustachian tube. Otolaryngologists gain access to the eustachian tube through the nasal cavity in the nasopharynx in order to stretch and dilate the tube allowing it to open and close effectively. This not only provides symptom relief for patients in the short term but may also eliminate the need for further tubes or other interventions.
[Seilesh Babu MD]
As many people know, you have chronic eustachian tube dysfunction that occurs in kids, and then it can exacerbate problems in adults and lead to many ear-related issues, whether it's recurrent fluid, whether it's retracted tympanic membranes. But we think the bottom issue, the main issue that's causing these problems is eustachian tube dysfunction. And for a long period of time, the only solution we had was maybe some medical therapy that may or may not help with nasal steroid sprays or allergy medications. And then we would put tubes in people's ears as the mainstay of treating eustachian tube dysfunction. And then several years ago, we finally had an FDA-approved procedure and technique where you could use a balloon catheter similar to coronary artery balloons. But now it's happened to be designed for the eustachian tube. It has a different bend to it. It's a little more flexible. It gains access to the eustachian tube through the nasal cavity in the nasal pharynx so that we can place this catheter into the eustachian tube opening and stretch it, dilate it, maybe crush some lymphoid follicles to improve the eustachian tube, to open and close better so that patients can get relief of their symptoms and potentially not need further tubes or other interventions for ear related problems.
[Ashley Agan MD]
When this was first introduced, you're an otologist. You are usually coming at the ear laterally. What were your thoughts on moving towards working on the other side of the ear and being in the back of the nose? Did everything just come, back naturally from residency? Or was there a little bit of a hump to get over to be doing that again and being in that part of the nose?
[Seilesh Babu MD]
Yeah, that's a great question because it is a struggle, to be honest, especially in the beginning when we're so used to going in from the ear side and making postauricular incisions and drilling mastoids which is clearly what we're good at doing, to then go back and remember putting a scope in the nose, being able to decongest the nasal cavity enough to get access, to prevent bleeding, to then get back in there and be able to place the eustachian. But yeah, there definitely is a little bit of a learning curve. With practice, it can get better, but there's certain times in certain, nasal cavities that I have a tough time still to this day that the septums really pushed over one way, the turbinates are really boggy and edematous and, my residents or fellows will say, why don't you just do a septoplasty? Why don’t you just do a turbinate reduction?
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Counseling Patients on the Eustachian Tube Balloon Dilation Procedure
Patients with eustachian tube dysfunction that is refractory to typical treatments may benefit from eustachian tube balloon dilation. Once candidacy has been determined, the otologist/otolaryngologist explains the relatively short and easy procedure, which can be performed in the operating room or in-office depending on the physician’s typical practices. Commonly, the procedure is performed in conjunction with others, often a myringotomy and/or an ear tube. In a matter of roughly 10-20 minutes after a patient wakes up from the procedure, they can return home and can resume normal activity. Common eustachian balloon dilation side effects include a sore throat and small amounts of blood from the nose, but both issues should resolve within a few days. Patients should avoid blowing their nose or performing a Valsalva maneuver for 7 to 10 days in order to avoid rare complications such as pneumothorax or pneumomediastinum. Additionally, sleep apnea patients who utilize a CPAP or BiPAP machine are advised not to use their machine for 10 days following the procedure.
[Ashley Agan MD]
Yeah. Let's say you, you have the patient who's tried, they've done lots of medical therapy and maybe they're on allergy shots or they're treating their allergies. They're doing lots of these other things and maybe they've even had a tube before. And so you are thinking that they're a good candidate for eustachian tube dilation. What is your counseling? How do you talk about the procedure to them?
[Seilesh Babu MD]
Well, assuming they got relief from their tube before, and they're saying, hey, it felt great. I could either do another tube or let's do a dilation and we're getting ready to say, let's do a dilation. I wish I probably had the luxury that you do of being able to just do this in the office. I think that would change my paradigm a little bit of what I want to do and what I feel comfort with, but because I'm too old school now, and I'm probably not going to change my ability to do this in the office because I'm too impatient myself probably to wait for something. But let's just say if, cause if I had that, the reason I'm saying it is because right now the decision is, should we go to the operating room for this quick three-minute procedure, which is safe, easy, but it does impact not only my schedule, but then it impacts, the patient's day because they have to do all this versus a tube in the ear, there is some reasons to offer one or the other, but if they say they want to have surgery, so my discussion is, you're going to have this procedure. It’s a relatively short, easy procedure. I have to put a scope in the back part of your nose. We then put this balloon catheter into the eustachian tube. We dilate it up to 12 atmospheres of pressure because data has said that's the right amount of pressure we need to put on the eustachian tube. We do it for two minutes because that's what we seem to think is the right amount of time based on all the data that's in the literature. No one really knows if these two numbers are exactly right, but that's what we do around the world. And then we take everything out and you go home within 10, 15, 20 minutes after waking up. You may have a little bit of a sore throat for a couple of days. You may have a little bit of blood from your nose for a couple of days, but all of that should resolve. And then we have to wait about two, three weeks to see how your symptoms resolved over time. I tell them to avoid nose blowing or a Valsalva maneuver for about a week to 10 days. There have been cases of either pneumothorax or pneumomediastinum from air tracking, maybe around a false passage and it may have created, I don't know exactly how it would happen, but because of that reason, I just say, just be gentle about any nose blowing or Valsalva afterwards. And they can always go back to work, of course, the next day. They can resume all their normal activities. So it's not a big deal, but if I could give them the option of let's do this tube in the office versus let's do a balloon dilation in the office, I could see myself saying, why don't we do both actually, or let's really lean you towards one way or another. So maybe in my practice, maybe I'm not giving them as fair of a comparison as I could because I'm biased because of this general anesthesia.
[Ashley Agan MD]
When you, as far as post-op expectations, after three weeks or after a certain amount of time, when they can blow their nose again, are you having them do some modified Valsalva to start moving air a little bit better through the eustachian tube? Or do you tell them to just wait and see?
[Seilesh Babu MD]
No, I prefer them to start doing it. If I had my way, I'd tell them to do it right away, but I'm a little concerned about this issue. So I tell them to wait, whatever I think is appropriate, seven, 10 days, two weeks, and then start doing it. The question comes up. If they use C-PAP or Bi-PAP, when can they start that again? And I don't really know the right answer in that scenario. So I tell them, 10 days, because I don't know what that positive pressure is going to do, but I think these patients start it on day number three and they do what they want to do. I just have to medically tell them to do it, but it actually be an interesting study that we were talking about here about looking at, C-PAP and Bi-PAP usage after balloon dilation. And is it safe? So if we had a couple other centers that were doing it, there may be something to look at.
[Ashley Agan MD]
Yeah. I would be down, let me know. Maybe we can do that, because it's so common for patients to be on, C-PAP these days. I feel like almost half of patients are talking about are asking when they can resume C-PAP after surgery.
[Seilesh Babu MD]
I wonder if there's even a correlation between C-PAP users, obstructive sleep apnea, needing C-PAP or Bi-PAP and eustachian tube dysfunction. Is there a spectrum and are they all somehow related or risk factors for one or the other?
[Ashley Agan MD]
When you do your dilation procedures, is it common that you're doing it just that's it, that one procedure, or are you ever doing it in combination with something else like a tympanoplasty or since you're seeing more of that, I'm just curious if you're ever doing a combo.
[Seilesh Babu MD]
Yeah, it seems to be it's rare that I just do a dilation by itself. Probably the most common I do is probably a dilation and a myringotomy and tube. Maybe 30% of the time I'm doing a cartilage tympanoplasty or a tymp mastoid in a severely retracted eardrum. And then I'll do a balloon dilation at the same time in that scenario. But that's probably a smaller percentage than the majority of cases that I'm doing it for.
Performing Eustachian Tube Balloon Dilation
Prior to dilation, physicians may place pledgets with Afrin in the nasal cavity in order to decongest the area and will likely utilize a 30-degree rigid nasal endoscope to evaluate the floor of the nose. After scoping the area and placing the balloon catheter into the eustachian tube, the device dilates the balloon up to 12 atmospheres of pressure and is held there for 2 minutes. Various medical device companies, including Acclarent, Stryker, and Medtronic, offer a similar product suitable for performing the procedure. Some devices have a stopper on the end to prevent the user from entering too far into the eustachian tube and hitting the bony portion.
[Seilesh Babu MD]
It’s a relatively short, easy procedure. I have to put a scope in the back part of your nose. We then put this balloon catheter into the eustachian tube. We dilate it up to 12 atmospheres of pressure because data has said that's the right amount of pressure we need to put on the eustachian tube. We do it for two minutes because that's what we seem to think is the right amount of time based on all the data that's in the literature. No one really knows if these two numbers are exactly right, but that's what we do around the world. And then we take everything out and you go home within 10, 15, 20 minutes after waking up.
…
[Ashley Agan MD]
It'd be nice to be able to figure out a way to create a study. Let's talk a little bit about doing the procedure itself. You're doing it in the operating room. Walk me through what your setup is. If you prefer a particular device. We talked about you're blowing it up to 12 atmospheres. You're holding it for two minutes, any other pearls around the actual performing the procedure.
[Seilesh Babu MD]
Yeah. So I think I probably do it similarly to many people who do it. I put pledgets in the nasal cavity with Afrin. If I'm going to do any ear procedures, we do that as the Afrin is working to decongest the nasal cavities. We use a 30-degree rigid nasal endoscope, to evaluate the floor of the nose and get back there. I tend to always tell the residents or fellows, right when you put the scope in there and you're going to suction, right when you put the scope in, then put the balloon in there at the same time. Cause I see them all the time. Like they put a scope in and they take a look and then they come out and they get the balloon, they put the balloon in and I say, why don't you just do them both at the same time? What did the look tell you? And they're like, I don't know. I think they just want to practice doing it, which again is fine. As you can probably tell I'm all about like efficiency and like don't do something if you're not going to do something differently based on it.
[Ashley Agan MD]
Yeah. They're like, we just want to stir up some bleeding first.
[Seilesh Babu MD]
That's what I'm always worried about because I'm always worried you're going to make this three-minute procedure into a 12-minute procedure because of bleeding. So let's just do it all at the same time. So then we take the balloon and then really, the key is falling along the floor of the nose and the turbinates definitely get in the way and occasionally you have to out fracture the turbinate just a little bit to get it out of the way. Sometimes I'll just push it with the balloon itself, the inserter, and I'll put it in the nasal pharynx and then get into the eustachian tube and the orientation opening, we have to make sure you're guiding it towards where you think the external ear canal would be. So you really have to push it out more lateral than you probably think. And you really want to embed that stylette in there. And I'm talking about the Acclarent AERA device, which is the most common one that I use. I think it's soft, it's flexible. It's easy for me to manipulate. So as an otologist, the easier you make it for me to get access in the nasal cavity, the easier it is for me to, do the surgery. So then by gaining access there, I can put that insert or into the eustachian tube. I can hold it with firm pressure and then I can advance the balloon. There's a little marker on there that tells you when I've inserted it far enough. And then it's got a stopper to prevent it from going too deep into the eustachian tube. And so it's worked out really well for me, to get there. It'd be nice if there was a suction on there because I would help with some of these bleeding that we get back there. And so if we could suction at the same time it would then accelerate the process even more. And so I think there's some reiterations that are going to come out in the future to add those types of things, but it works out great. I know there's other products that are out there and many people have had success with them also, but I think once we find a product that works out pretty well, you can just keep using that same one for the majority of the cases.
[Ashley Agan MD]
Yeah. I have used the Stryker advice. I think Medtronic might have one too now. I like the Acclarent one, cause it is small. Like the balloon is inside the device. And so as you're putting the device in the nose, I feel like it's a lot smaller, and easier to get back there. So you're doing this last, if you're doing it in combination, meaning you would do your tympanoplasty first and then do this procedure at the end.
[Seilesh Babu MD]
Yeah. So it's interesting that you bring that up because just a week ago we were doing a case. And did it in that order. And my fellow is asking, if you change the pressure of the eustachian tube, let's say you put this in there and you've just had your graft in there. You put your prosthesis in there and now you're ballooning up these eustachian tubes with the end, is that moving anything around in your ear because of the pressure changes? And my answer was it'd be no different than if the patient's sneezed tomorrow or coughed tomorrow. What difference would it make? Like they're going to get the same amount of pressure. So I don't think it's an answer, but then it made me start thinking like, I don't know, should we do it in the beginning of the case, as opposed to the end of the case, but from a decongestant and from just a time, procedures, the overlap, I think it makes sense to do it the way I'm talking about and acoustically, I don't know if it makes a big difference or placement of the graft makes a big difference, but it does make you think. So, yes. To answer your question, we do the balloon dilation at the end of the year procedures.
[Ashley Agan MD]
And as you mentioned, there's a cap, like a thicker part on the end of it. So there's no way you could guide this up into the middle ear, right? The device is made to prevent you from being able to really go beyond the bony isthmus of the eustachian tube.
[Seilesh Babu MD]
Yeah, correct. Yeah. I would have no concerns about that. I'm going to hit the prosthesis or hit the cartilage graft or something because there's a stopper that prevents it from going into the bony portion of it.
Podcast Contributors
Dr. Seilesh Babu
Dr. Seilesh Babu is an adult and pediatric neurotologist, otologist, and skull base surgeon with Michigan Ear Institute in Farmington Hills, Michigan.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2022, September 8). Ep. 69 – Balloon Dilation of the Eustachian Tube [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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