Eustachian Tube Dysfunction in Adults vs Pediatrics

[Dr. Dennis Poe]
Yes, so in the adult eustachian tube, we know it's the cartilaginous portion which is the target of surgery; it's the cartilaginous portion that serves as a functional valve, and that's where the pathology is, and that's true in the children as well. In an adult, it's about 25 millimeters in length. That's an important thing to keep in mind because when you're working with your balloon catheter, you want to be aware of the length of the balloon. We don't want these to get up into the bony part of the eustachian tube. First of all, most of the pathology is not there, and that's also where the internal carotid lies, so we don't want to get our balloons up into that portion. We're thinking about 25 millimeters.

We looked at the CT scans over the age ranges, pediatric age ranges, from under 2 years old all the way up to 18, and the tube does lengthen. We've been previously taught from Bluestone's work that the eustachian tube is mostly full-length by age 8. It actually can continue to grow a little bit farther, but the steepest curve is in that underage group. The indication for pediatric balloon dilation is going to be 8 and above because most of them are going to be close to full adult length, and from the measurements that we took, it was about 25 millimeters. Now by the time you get to age 15 and above, it goes up to maybe 27 millimeters on average. Remember, that's a range, but this is a rough guide, so think about that 25 millimeters.

The other important difference between the kids, just anatomically, is the height from the floor of the eustachian tube up to the orifice of the eustachian tube; this also gets larger as we age in our development. In younger kids, we've been taught that the eustachian tube orifice is going to be taken up at a flatter angle, and it's very true. You'll have to be looking a little bit lower. In the younger kids, the orifice may be a little lower than you think. There's a bit of a height difference, and that's going to change the angle that you go from the floor of the nose. These balloon catheters travel on the floor, and then you angle up toward the eustachian tube orifice.It's going to be a flatter angle in some of these kids, and that's a little variable in that 8 to 12-year range.

The other big difference is there's a lot more inflammation in kids. They've got the adenoid hypertrophy, there's adenoid tissue that sometimes is spilling over onto the torus tubarius. The torus, the tubal tonsil tissue can be very robust, with lots of cobblestones, so it can sometimes be hard to find the orifice.

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The anatomy is a little trickier in the children, so just take extra caution.

[Dr. Ashley Agan]
When you're seeing these patients in your clinic, any particular questions in your history gathering that is different from any other patient that you're seeing, any particular questions that you're asking that are really important to that workup?

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[Dr. Dennie Poe]
One of the first questions, when they've already had a tube, I want to know how well they did with that tube. Was it getting infected? Was it draining? Did it help? Was their speech getting better? Were there any problems with the tubes? Were they getting occluded? If you've got a lot of adenoid tissue up against the eustachian tube, that's a good indication for adenoidectomy, and so ask about snoring, nasal obstruction, and rhinitis. Definitely asking about allergies. Why didn't they outgrow this problem with one round of tubes? Asking about allergies, reflux, upper respiratory infections. I want to know, have they ever been patulous?

It's incredibly common. Kids get patulous eustachian tubes far more commonly than we realize. They're sniffing. It gets passed off as their allergies, but they're sniffing to cover it up frequently. They just say they've got a blocked ear. Unless you ask about autophony, hearing their voice echoing in their ears, hearing their breathing like Darth Vader's breathing in their ears, all the kids get that. You have to ask. One of the things I've seen in these kids who've had multiple tympanostomy tubes, a tube will treat a pediatric patulous eustachian tube, in my experience, more effectively than it will treat an adult's patulous eustachian tube. It'll relieve the symptoms. We can miss this.

These kids are getting multiple tubes. They fall out and their patulous symptoms come back. They're sniffing. They're complaining about blocked ears. They can come into your office. They can have negative pressure because they're sniffing. They can even have an effusion because they're sniffing so strongly. We just automatically put another tube in, assuming it's obstructive dysfunction, without ever asking about autophony. Some of these patients will get sent to me for a balloon dilation. I see this about once a week. It's very common. Patulous eustachian tubes in kids is very common. It's not rare at all. We just have been missing it. You absolutely do not want to do a balloon dilation on one of those patients.

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[Dr. Ashley Agan]
Do you decongest their nose? Do you spray anything to help with that or does--

[Dr. Dennie Poe]
Yes, I do. It's a combination of the oxymetazoline and the topical lidocaine. We do a quick spray in each nostril and I tell them that's the worst of it. Now that that's over, the rest will be easy.

[Dr. Ashley Agan]
When you're looking at the eustachian tube, what does that look like or describe your exam, what are your thoughts when you're kind of looking at that?

[Dr. Dennie Poe]
Once the scope's in the nasopharynx, I'll turn it sideways so I can go back and forth across the vomer. I'll look at each eustachian tube, have them say, ka-ka-ka, just to move the torus with the action of the levator muscle. Because the eustachian tube opens with the action of the two muscles, the levator immediately rotates the torus, setting the stage for the tensor muscle to open the valve. You've got to have both of them working. The ka-ka-ka moves the levator. That's a normal physiological opening. Then saying ah or a big yawn, that's a maximal sustained dilatory effort. What I'm looking for is how well does that valve open or not.

What's the severity of the pathology in the lumen of the eustachian tube? Is contact with the torus interfering with opening of the valve? Typically, it traps the torus when they swallow. You get what I call anterior thrusting. The torus gets pushed forward anteriorly and blocks the valve when they're swallowing. Very common with adenoid hypertrophy and particularly in kids. And then I'm looking at the valve for a patulous defect because it's so common in kids, especially if they've got allergic disease.