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BackTable / ENT / Article
Eustachian Tube Balloon Dilation in Pediatrics: Indications & Contraindications
Iman Iqbal • Updated May 28, 2024 • 65 hits
Eustachian Tube Dysfunction (ETD) poses a common challenge in pediatric patients, often managed with tympanostomy tubes. However, this approach provides only transient relief without addressing the underlying cause, leading to potential complications such as tympanic membrane perforation. Otolaryngologist Dr. Dennis Poe advocates for balloon dilation as an alternative intervention, emphasizing its ability to address the root cause of ETD and reduce the need for repeated tube placements. This article covers the indications and contraindications for pediatric balloon dilation.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Tympanostomy tubes provide a temporary solution for eustachian tube dysfunction, addressing symptoms but not the underlying pathology.
• Balloon dilation is an alternative intervention to tympanostomy tubes, treating the source of ETD and potentially reducing the need for further tube insertions.
• Consideration of adenoidectomy alongside balloon dilation is essential, particularly in cases where adenoid hypertrophy contributes to eustachian tube dysfunction symptoms.
• Eustachian tube balloon dilation can be performed concurrently with tympanoplasty in select cases, especially when addressing persistent middle ear effusion post-surgery.
• A patulous eustachian tube is the primary absolute contraindication for balloon dilation.
• Balloon dilation is ineffective if the eustachian tube orifice is entirely obstructed due to scarring from surgeries like turbinectomy or adenoidectomy.
• Besides anatomical issues, uncontrolled allergies or reflux are also considered contraindications for balloon dilation.
Table of Contents
(1) Indications for Eustachian Tube Balloon Dilation vs Tubes
(2) Contraindications for Eustachian Tube Balloon Dilation in Pediatrics
Indications for Eustachian Tube Balloon Dilation vs Tubes
Tympanostomy tubes are a common management strategy for pediatric patients with eustachian tube dysfunction. However, the effect of tubes is usually transient in the alleviation of symptoms as they do not address the underlying cause of ETD, but rather just provide immediate relief by aerating the middle ear. Repeated tube insertions may become necessary, leading to potential complications such as tympanic membrane perforation. Dr. Poe advocates for considering eustachian tube balloon dilation as an alternative intervention, highlighting its ability to address the root cause of ETD and reduce the need for subsequent tube placements.
Moreover, ETD may involve both extraluminal and intraluminal pathology. Dr. Poe discusses that in these instances, combining a balloon dilation with an adenoidectomy will be a more precise method as balloon dilation targets the intraluminal pathology, while adenoidectomies target the extraluminal pathology associated with ETD.
Eustachian tube balloon dilation is especially useful in patients with postoperative middle ear effusion following cholesteatoma treatment, as it preserves tympanoplasty integrity.
[Dr. Dennie Poe]
Totally agree. Generally, first time around, kids are going to get a tube. If you've got a frequent swimmer, who's on a swim team or something, they don't really want a tube. Most of the time, you're going to get a tube up front first. The tube worked. Everything was good. But it didn't do the job. As you said, it's just treating the symptom. It's not treating the source, the underlying etiology. When it comes time to explain, well, now we have to do something again, you could place another tube or the balloon is an option. For the exact same indications, I think they're equally good options from that point of view. Equally indicated, I should say. The balloon, obviously, is treating the source.
Hopefully, and we've got a couple studies that have been showing this, if you do a balloon, your chances of needing further tubes is significantly reduced. That's one thing to consider. Because you're treating the source, you may be reducing the chance of needing further tubes. If I see a child who's had multiple tubes, first of all, I've got to make sure they weren't patulous. Once we've ruled that out, then yes, then I will favor a balloon over multiple tubes. Absolutely. With multiple tubes, as you know, the tympanic membrane can eventually start to break down. Then you're dealing with a thin portion. It might turn into a pocket in the future or they get perforations.
The risk of a permanent perforation is going up each time you put in yet another tube. I try to avoid the T-tubes. A primary tube, you put in a primary short-term tube, that's about a 2% incidence of a permanent perforation. That goes up each time you put in more tubes. A T-tube, longer duration tubes, 16% risk of a permanent hole. It's a big difference.
…
[Dr. Ashley Agan]
Eight and above. Back to our balloon dilation patient, we've talked about patients who might also benefit from having adenoidectomy because they have a lot of that inflammatory response in adenoid tissue in the back of the nose. You would combine adenoidectomy maybe plus balloon if you're getting there and you're seeing that there's some inflammation within the lumen of the eustachian tube as well. Is that a decision you make intraoperatively if you aren't able to get that exam beforehand?
[Dr. Dennie Poe]
Exactly. If it looks like the adenoid is pretty robust, it's significantly impacting onto the torus and maybe even spilling over onto the torus, sure, we'll trim that back, at least with a lateral adenoidectomy. I do a lot of revision adenoidectomies because the lateral portion is not always taken out the first time around. Adenoidectomy is a common part of taking a kid back to the OR for either tubes or a balloon. That's frequently a part of it. Now again, we're not going to trim adenoid-like tissue going down the lumen of the eustachian tube. If you think that's the problem, that's what the balloon does.
The balloon, histologically we've seen from specimens in patients, it's basically doing an adenoidectomy on adenoid-like tissue that's gotten down the lumen. It crushes that tissue and it grows back very healthy.
…
[Dr. Ashley Agan]
Right. Okay. Then working through our patients, we talked about the patient who's got a lot of adenoids and inflammation in the back of the nose. Every now and then I'll have patients who have had a cholesteatoma, they had a cartilage graft and panoplasty, and now they've got some fluid behind that cartilage graft or they've got maybe like some retraction or basically they're symptomatic in their ear that's been operated on and they don't have recurrent cholesteatoma. Have you used the balloon very much in those patients? Does that help?
[Dr. Dennie Poe]
Sure. That's a really good indication. You closed their perforation or took out their cholesteatoma and now they're getting middle ear effusion. That's a great indication for the balloon rather than putting a tube right through your freshly healed tympanoplasty. We do a fair number of balloons at the time of doing tympanoplasty. If it looks like the eustachian tube is still compromised and I might scope them at the time of the surgery, sure you can do a balloon at the same time. Do the balloon first if you're going to do that and then do your tympanoplasty just so if there's any back pressure from blowing up the balloon, it doesn't mess up with your graft. We do a fair amount of that.
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Contraindications for Eustachian Tube Balloon Dilation in Pediatrics
The primary absolute contraindication for balloon dilation in treating eustachian tube dysfunction is a patulous eustachian tube. Dr. Poe emphasizes that if the eustachian tube orifice is completely obstructed due to past scarring from surgeries like turbinectomy or adenoidectomy, balloon dilation would not be successful. Hence, pre-screening with endoscopy in the office can prevent failed attempts in the operating room.
Other contraindications include uncontrolled allergies or reflux and syndromic conditions with anatomical issues that may not respond well to balloon dilation. In these instances, repeat dilations may be considered if initial improvement is insufficient, while ongoing medical management for conditions like allergies or reflux is also necessary to maintain long-term efficacy.
[Dr. Ashley Agan]
Okay. Any absolute contraindications? When you talked about how the balloon is going to prevent, based on the way it's designed, it's going to prevent you from getting up into the middle ear. Any contraindications for a balloon other than patulous, I guess? That would be the big one.
[Dr. Dennie Poe]
Yes, that is the big one. Not really, unless they've had some anatomical problem, I've seen a few cases where the eustachian tube orifice has been completely obliterated from a past scar or something, previous surgery, turbinectomy, adenoidectomy. If they don't have an orifice, you're not going to successfully balloon them. If you can see that in the office with an endoscopy earlier, you can spare them going to the operating room and having a failed attempt at a balloon. Then relative contraindications, of course, you want to try to have any active disease like allergies under control, reflux under control. We're not routinely doing syndromic kids, so they've got anatomical issues that the balloon may not be able to treat.
…
Not very often. The balloon is usually very successful, but the more common issue would be you did the balloon and they got better for a period of time, but now they're having trouble again, or they had a bad cold and their effusion is back. The most common scenario is that they have allergic disease or reflux disease and they didn't keep it under appropriate control, environmental or diet, or medications. They were doing great. They slipped on their chronic medical management. They're failing again. You get them back on their medical management, it's not getting them over the hump. Okay, we'll bite the bullet and we could do a repeat dilation in those patients.
Podcast Contributors
Dr. Dennis Poe
Dr. Dennis Poe is an Associate in the Department of Otolaryngology and Communication Enhancement at Boston Children's Hospital, specializing in heotology/neurotology and skull base surgery.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2024, February 20). Ep. 159 – Eustachian Tube Dilation In The Pediatric Population [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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