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BackTable / ENT / Article
Eustachian Tube Dysfunction Test: A Comprehensive Guide
Taylor Spurgeon-Hess • Updated Jan 13, 2022 • 5.3k hits
Previously eustachian tube dysfunction primarily referred to obstructive dysfunction, but today the term is used to describe a spectrum of disorders including obstructive dysfunction, patulous dysfunction, as well as pressure-related issues, such as flying on an airplane. The eustachian tube dysfunction test helps to identify the location and severity by combining information from patient history, physical exam findings, and testing, including audiograms and tympanograms. Dr. Dennis Poe shares his approach to eustachian tube dysfunction testing, highlighting the many subtleties of arriving at the correct eustachian tube dysfunction differential.
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
• The eustachian tube dysfunction test begins with a history and physical which help to determine where along the dysfunction spectrum a patient exists. The two ends of the spectrum represent complete obstructive dysfunction and complete patulous eustachian tube dysfunction.
• Signs of obstructive eustachian tube dysfunction include middle ear fluid, scarring, sclerosis, and a retracted tympanic membrane, while signs of patulous eustachian tube dysfunction include hearing popping or clicking noises, as well hearing one’s own voice or breathing.
• A eustachian tube dysfunction test includes looking at the findings from multiple tests, such as the patient's history, physical exam, audiogram, tympanogram, and endoscopy.
• Dr. Poe’s MEELO assessment for endoscopy helps to determine the severity of eustachian tube dysfunction based on the eustachian tube dysfunction exam findings related to five categories: mucus, erythema, edema, lymphoid hyperplasia, and quality of the opening.
Table of Contents
(1) Differentiating Between Obstructive and Patulous Eustachian Tube Dysfunction
(2) Standard Eustachian Tube Dysfunction Testing
(3) Dr. Poe’s Eustachian Tube Dysfunction Exam Findings Method
Differentiating Between Obstructive and Patulous Eustachian Tube Dysfunction
Before ordering any specific tests, physicians often perform a thorough history and physical exam in order to determine the type of eustachian tube dysfunction present. While varying conditions create a spectrum of dysfunction, the problem can be broadly categorized as either obstructive or patulous. Some key signs pointing toward obstructive eustachian tube dysfunction include a retracted tympanic membrane, scarring, sclerosis, or middle ear fluid. Conversely, hearing popping or clicking noises, experiencing autophony, and habitually sniffing indicate patulous eustachian tube dysfunction.
[Dennis Poe MD]
… We’ve in the past thought of eustachian tube dysfunction as being principally an obstructive problem. And we've traditionally thought that patulous eustachian tube, it was a rare problem. So it turns out patulous is far more common than we ever imagined.
It's actually very common and there's a spectrum of dysfunction. So I used the term eustachian tube dysfunction now to mean anything on this spectrum from complete obstruction, to just having trouble on an airplane diving and all the way to getting stuck open patulous. So I lump all of those together as eustachian tube disorders or eustachian tube dysfunction, and we separate them as a spectrum between obstructive and patulous.
[Ashley Agan MD]
…So moving on to physical exam, what are you looking for? Take us through what your physical exam looks like for patients when you're trying to tease out, is this an obstructive pathology? Is this patulous, is this not even related to the eustachian tube? Is it something like TMD or superior canal dehiscence or something else?
[Dennis Poe MD]
Right. So the first thing to notice is the condition of the tympanic membrane, in comparison to their symptoms on that day. So if they've got a retracted tympanic membrane. I'm talking about a non-fixed. You can see that it's retracted, by a negative pressure, not an adherence to type that's indicating negative pressure.
You can insufflate it. That's indicating negative pressure. Is there a middle ear fusion? So these are all obstructive eustachian tube dysfunction. Very clear signs. If there's evidence of negative pressure or middle ear fluid that's obstructive dysfunction. Now other possible hints would be scarring, sclerosis, fixed or traction pockets. That's indicating that they've at least in the past had obstructive dysfunction. It may not be current. So evidence of negative active pressure is the most common obstructive dysfunction finding, and then you'll cross correlate that with testing. Now, if the tympanic membrane is normal looking and their complaint is just a problem when they're baro challenged, I only have trouble when I fly. You can easily have a normal tympanic membrane. So in that case, your physical findings are not with just your otoscope and head neck exam, until you use an endoscope, you won't have any evidence of the problem with that one.
And then if you suspect patulous, they've given you a history that, oh yeah, this autophony, it clicks, it pops, I hear echoing. That's where we look for the ipsilateral nasal breathing movement of the tympanic membrane. So I have them hold their nostril closed on the opposite side, mouth closed, and they're breathing in and out kind of the rate and depth that you would for a lung examination.
If you're listening to the lungs, auscultating. So not super forceful because you can open your eustachian tube if you do it too forceful in a normal person. So we're looking for just some relatively deep breathing, relatively rapid. And can you see the tympanic membrane moving? And if you do that is pathognomonic of patulous. So if they have no history of otitis media baro challenge, no autophony, no findings on the tympanic membrane, that's what I'm thinking about. The other disorders. Number one is going to be temporomandibular disorders. And then you've got all the other stuff. Your related semicircular canal dehiscence, hydrops, sensorineural hearing loss, conductive, even some people will posit migraine which causes everything. Right? So that's how we sort out. First the history and then looking for those key findings. Is there evidence of negative pressure? That's obstructive, if they've got autophony and the tympanic membrane moves that's patulous. Now, if they're not actively patulous in their office, if they're not actively having symptoms, it gets more complicated.
Sometimes we will literally have them run around the block. Or up And down some stairs work, a workup is sweat, come back and now their patulous, we will literally do that. Or sometimes I'll just have them do 15 deep knee bends and that's enough to get it going and then you can see it.
[Ashley Agan MD]
Is it important to have the patient sitting up when you're examining for that? Because I would imagine that potentially if you're using like a microscope and you have them laying down, could that mask the patulous because most, cause gravity is kind of potentially pulling, pumping up the eustachian tube or do you usually see it when patients are laying down under the microscope?
[Dennis Poe MD]
Well, right. So, at first, I asked, are you having your symptoms right now? Are you having the autophony? If they say yes, I’ll keep them sitting in. I'll look with the otoscope first. Now, if I cannot see it, I may lay them down for the microscope and ask, did it go away? Yes, it went away. Okay. So now I know we're dealing either with patulous or possible semicircular canal dehiscence. Now, if the symptoms don't go away, then I continue with the microscope exam.
And if the drum does move visibly, that's pathognomonic for patulous. If the drum does not move and yet they have their symptoms. Now I'm thinking that could be otic capsule dehiscence, semicircular canal dehiscence. The final test is when we go to a tympanometry, which we can get to in a bit, where we do a patulous test. Now there's one other complicating diagnostic problem here. A lot of patulous patients actively sniff strongly to control their symptoms. And we've traditionally called this habitual sniffing. So I no longer think it's habitual sniffing. These are patulous patients controlling their symptoms with strong sniffs to try and get some temporary closure of the, of the station to, they can sniff so strongly that they will generate negative pressures in their middle ear, even to the point of tympanic membrane, retraction, and middle ear fluid.
So back to that original, here's the patient I've got the block, dear. I've got a hearing loss. I've got middle ear fluid. I've had lots of tubes. I look in the ear, looks retracted there’s middle ear fusion. Aha. Obstructive eustachian tube dysfunction, but the patient is sniffing before your very eyes. Why are you sniffing? Oh, it unblocks my ears. The patient with negative pressure shouldn't be sniffing because that's going to make it worse. So I call that inappropriate instead of habitual, if they're sniffing to control their patulous. So that sniffing habit is a giveaway, aha this is a patulous patient who's sniffing that strongly. And they can even cause a retraction pocket that could progress to cholesteatoma. They're doing it so often. And so severely.
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Standard Eustachian Tube Dysfunction Testing
After conducting a history and physical, ENTs usually order an audiogram and a tympanogram, which tests a patient’s ability to hear different frequencies and how well his or her eardrum moves, respectively. A special tympanogram can be utilized for difficult to diagnose patients who may be patulous. Setting the tympanogram to reflex decay mode without changing the pressure, and observing changes in tympanogram tracing indicates patulous dysfunction. In other countries, including many European nations, the tubal nanometer can be an additional tool utilized to more easily diagnose in the eustachian tube dysfunction test process. However, no single test provides a definitive diagnosis and physicians must take into account each part of the overarching process.
[Ashley Agan MD]
Gotcha. And so you've done your physical exam. We talked a little bit about some of the tests, so I assume all patients are probably getting an audiogram, getting tympanograms. You mentioned some of the special tympanometry that can be done. So with patulous you can use the reflex decay mode.
Are you or your audiologists having them do like ipsilateral nasal breathing during that test or just breathing normally?
[Dennis Poe MD]
Specifically for the patulous test? Yes, they breathe normally. We have them do it with the mouth open because that's not going to be as stimulating, to reflecting any pressure changes into the ear. So that's our baseline and then mouth closed. And then ipsilateral nasal breathe.
[Ashley Agan MD]
And if you find it on that, then that's definitely patulous if you can pick it up on that and that should be more sensitive.
[Dennis Poe MD]
Exactly. Yeah. You see it, you see clear deflections, pressure changes. And the audiologist is watching to see that they are coincident with the nasal breathing.
…
[Ashley Agan MD]
Thinking about patients like that, I've had maybe a handful of patients who have had tympanoplasties for cholesteatoma, and they are still symptomatic from a standpoint of either having autophony or feeling like they have fullness in their ears. So we're thinking maybe patulous, the tricky part with those patients is that a lot of times, if they've had a cartilage tympanoplasty, you're not going to see that eardrum move with their breath which is kind of like one of those physical exam findings that you like to see it, it kind of solidifies the diagnosis.
So in a patient like that, would you just kind of go on symptoms and the nasal endoscopy? I know that's a very specific situation, but I'm just curious if you've seen that at all.
[Dennis Poe MD]
Well sure. Typically we haven't done a cartilage tympanoplasty over the entire tympanic membrane. Sometimes we do, but the majority don't and you may be able to tease it out with a tympanic gram. On a reflex decay mode, the patient does the ipsilateral nasal breathing, and it's more sensitive than what you can see with a microscope. By the way, sometimes, I don't do it often, but sometimes I'll even have the patients sitting looking with a microscope in some of these difficult to diagnose patients. But the most common thing we do is that patulous test. So the tympanometer on the reflex decay mode. So you're not varying the pressure. You're just passively recording it. And if they are patulous, you can see these changes in the tympanogram tracing, coincident with their breathing. That's pathognomonic, and it's more sensitive than what you can see even with the microscope.
Now, if that doesn't work, they've got a full cartilage tympanoplasty. Do the symptoms get better when they put their head down? So if they do and you do the endoscopy and you see what it looks like, it could be a patulous defect. That may be the real thing.
…
[Ashley Agan MD]
And you guys, do you guys do eustachian tube dilatory dysfunction testing with your tympanometry as well?
[Dennis Poe MD]
We don't. It's too unreliable. It's not a physiological challenge. Typically your eustachian tube is going to open when you swallow and yawn, not necessarily just because you had a sudden pressure change applied to your eardrum. This is the reason that those tests have not been predictive of real live eustachian tube function.
So most of these tympanometers nowadays will be able to do that, but all of the studies have shown them to be unreliable. The only other test which has been shown to be really reliable with a tympanometer is the Bluestone nine step test where you serially pressurize or produce negative pressure against the tympanic membrane. You have the patient do a series of swallows. So it's a little more laborious. Most places don't do it, but it actually is the one tympanometry test that has correlated with some degree of performance after tympanoplasty, for instance.
[Ashley Agan MD]
Okay. Interesting. So that's good to know. So interpret those results with caution because a lot of our audiologists have started automatically doing that eustachian tube dysfunction test if they have a patient coming in with complaints of clogged stuffy ears. And I agree with you, the results have been kind of all over the place. So that's helpful to know. Any other objective types of testing that can be done that kind of helps seal your diagnosis.
[Dennis Poe MD]
We've really covered the ones that are available, widespread in our country. In other countries, particularly Europe, they have a tubal nanometer, and the experience with that is increasingly showing that it does have some benefit. It can pin down the diagnosis with yet more data points.
It's not by itself, conclusively diagnostic. And that's one problem with eustachian tube testing. There's no single test that will give you the answer. So it's this whole process of the history, the physical, tympanogram, audiogram, and any other testing you do. It all gets put together to get a final impression. The tubal nanometer is a complicated device. Basically think of a tympanometry probe but in your ear, and it actually generates pressure as you swallow. It ramps up the pressure as you swallow. In your nasal pharynx, you've got a pressure probe in your nose, and it then looks at the change on your eardrum from the probe in your ear. The newer version can even work if you have a perforation in your tympanic membrane, they can see that a little pressure just eked through. So stay tuned maybe we'll get one of those approved in the states. Not there yet.
Sonotubometry can also be used. There are some of those you can get them in the states, but almost nobody uses them. It's a microphone in the ear and a tone probe in the nose. When you swallow or yawn, if your eustachian tube opens, you'll get a louder sound in that microphone, in your ear. But it doesn't always open every time you swallow or yawn. So there's a lot of false negatives on that one. Or false positive, abnormal test results. So you have to put all of this together to make a diagnosis.
Bottom line, the things we've talked about are pretty solidly diagnostic- history, physical, tympanometry, audiogram, and the endoscopy.
Dr. Poe’s Eustachian Tube Dysfunction Exam Findings Method
Dr. Poe shares his eustachian tube dysfunction test exam findings method for assessing an endoscopy during the test. MEELO is an acronym standing for mucus, erythema, edema, lymphoid hyperplasia, and quality of the opening. Each of these categories represents a key area that physicians should be examining during endoscopy. To utilize the MEELO assessment, physicians should award each category a numerical value 1-4 which represents four categories: normal, mild, moderate, and severe. The overall score may assist in understanding the severity of the issue as well as determining the aggressivity of treatment.
[Dennis Poe MD]
Yeah, I call it a MEELO assessment. Is there a lot of mucus? Is there erythema? Edema? Lymphoid hyperplasia? And then finally what's the quality of the opening? So that's the meat, excess mucus edema, erythema, lymphoid hyperplasia, adenoid-like tissue penetrating into the lumen, or robust around the orifice and then that opening. So those are the bullet points that I'm specifically looking for on the endoscopy exam.
[Ashley Agan MD]
And then are you grading them on like a, like with a number scale or like a mild, moderate, severe, or how do you use that in your treatment algorithm?
[Dennis Poe MD]
So that's exactly what we do. Yeah. There is now a validated scale that one of my fellows put together and it is a normal, mild, moderate, severe one through four. Mild is just some mild edema. The vessels are a little indistinct, but there's no compromise of the opening. Moderate, there's inflammatory disease. There is compromise of the opening and then severe, it never opens. So it's a rough qualitative scale, but it really does help in determining how severe is the problem and how aggressive do we need to be with treatment?
[Ashley Agan MD]
And so your score is like an overall score for all four categories. It's not like you would have a one under the mucus and a four under the opening. It's kind of like, overall, this is the score. Is that right?
[Dennis Poe MD]
Yes, we originally published something that was more complicated. Like you said, that way we were scaling every factor. Nobody used that. Too complicated. So this is a combined inflammatory quality of opening rough number.
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). (2021, December 21). Ep. 40 – Diagnosis & Management of Eustachian Tube Disorders [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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