Patulous Eustachian Tube Dysfunction Presentation & Treatment

[Ashley Agan MD]
And it's such a common thing. And so if we're thinking about how these patients are presenting to your clinic. Maybe they've got the ear fullness or clogged stuffiness. What other types of symptoms will they usually report to you?

[Dennis Poe MD]
Oh, are you talking about eustachian tube patients in general? Or obstructive or patulous?

[Ashley Agan MD]
Yeah, eustachian tube in general. And then we can kind of like, maybe separate them into, which ones do you have a higher index of suspicion for patulous versus obstructive.

[Dennis Poe MD]
So the patient’s principle complaint is typically ear fullness, aural fullness. And so we try to immediately separate that out. What kinds of problems is it causing? And on the obstructive side, they may have otitis media issues. they may have had actual infections or fluid or just negative pressure. They're baro challenged, trouble with rapid ambient pressure changes, flights diving, and they may have had a history of tympanic membrane retraction that's being followed. They may have had a history of tympanostomy tubes as a young child. So that's the group. That's the most common, our standard, what's been traditionally called eustachian tube dysfunction, what I now like to call obstructive eustachian tube dysfunction.

So we immediately try to sort those out by their history and then in the process, I will always ask nowadays about autophony. If you ever have a situation where you have a pop or a click in your ear, and it's, you're suddenly hearing your voice echoing, your breathing is like Darth Vader is in your ear, and you'll be surprised at how many patients with obstructive dysfunction will also tell you, oh yeah, I've had that, , I was exercising, it happened. We really have to specifically ask about it.

[Ashley Agan MD]
And do you feel like the popping and clicking, is that more specific to a patulous phenomenon because they're hearing their eustachian tube open? Is that basically what that popping and clicking is?

[Dennis Poe MD]
Yes, that's absolutely right. And so when I hear a patient talking about popping and clicking as a big part of their complaint, it's much more likely to be patulous or possibly temporomandibular disorders. And far less likely to be obstructive eustachian tube dysfunction. So that's a very common symptom that misleads us when they start talking about the popping and clicking. They are steering us to think about obstructive dysfunction. When in fact it's probably patulous or temporomandibular disorder. In fact, popping and clicking is one of the questions on the eustachian tube dysfunction questionnaire. The seven questions, I did not participate in how that was developed, but it was done very systematically.
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[Dennis Poe MD]
…Sometimes the tube will treat a patulous eustachian tube. Particularly, if they have more autophony of their breathing than the voice, it's more likely to help. So just simply knowing that a tube helped doesn't help us sort out patulous versus obstructive dysfunction. It's all about the autophony and looking at the tympanic membrane to see if it's moving with their breathing, particularly if you block the opposite nostril. So ipsilateral nasal breathing to look for it.

[Ashley Agan MD]
And do you have to have autophony to be patulous like, if a patient says, oh, I hear myself swallow. Like I'm hearing clicking every time I swallow. Is that enough to be, maybe patulous when they, but they don't truly have the breath and voice autophony.

[Dennis Poe MD]
The hearing of their voice and breathing is almost universal, but not always. Occasionally patients will have difficulty expressing their symptoms. And when you tease it out, you get that, on a rare occasion, I'll even put a stethoscope in the patient's ears and have them talk into the diaphragm and say, is that what it sounds like? And well, yeah, that's it. But I rarely do that. Most of the time, if you really ask about it, they will tell you, or you can have them put their head down between their knees, not propped up on their elbows way down, chest on the knees. And if their symptoms go away, that’s really helpful. To add to the confusion you got to watch out for semicircular canal dehiscence, otic capsule dehiscence minor syndrome. Because they can also get better when they put their heads down. so you have to sort that out also. Now that's far more rare.

[Ashley Agan MD]
Yeah, I didn't realize that they got better with their head down as well. That's tricky.

[Dennis Poe MD]
It is tricky. The key points for semicircular canal dehiscence is they typically have autophony of bone conductive sounds. Their voice. That's where they hear their eyes moving. Their necks creaking. They're hearing they're chewing. Footsteps hit the ground. They don't have autophony of their breathing. That's a big distinction with patulous.
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[Ashley Agan MD]
Can you talk a little bit about the physiology? What is happening? I feel like one symptom that all eustachian tube patients tend to kind of have in common is the pressure, clogged ear, stuffiness, ear pressure sensation. I feel like in the patients that have a dilatory dysfunction, where it really is obstructed, and if we see negative pressure, it makes sense like, oh, there's negative pressure, pulling the eardrum in and that's causing pressure.

How do you explain a patulous patient feeling that or do we know?

[Dennis Poe MD]
Yeah, if you ever want to simulate a patulous eustachian tube, you take a stethoscope, and hold the diaphragm up to your mouth, right in front of your mouth and you talk and breathe into it. It's extraordinarily loud. And this is exactly what they hear. I can tell you that because if I exercise vigorously enough, I can get the symptoms.

It's really annoying. So that's a remarkable simulation and you will experience this sort of head-in-the-barrel fullness that they talk about. And actually, if it's really bad, your breathing is pushing air back and forth in the ear and giving them a true pressure, variable pressure sensation, which they won't describe unless you specifically ask about it. So, eustachian tube fullness really is a pressure phenomenon, or it can be just an auditory sense. They'll describe that. We see people with sensorineural hearing loss and they tell us their ears are full, blocked. If you could only take that cotton out of their ear, they'd be hearing better. So it's this aural fullness is a very wide description that patients will use. And it's up to us to sort that out.

[Ashley Agan MD]
Yeah, well just rounding this out, I think we could probably talk about this forever, but I want to make sure that we just touch on patulous eustachian tube dysfunction treatments. So in your patulous patients, once you've decided solidified that diagnosis, what is your treatment algorithm for that set of patients? What does that look like?

[Dennis Poe MD]
Well, again, it starts with looking for the etiology. If it's weight loss, we don't have them gain weight that usually goes wherever else you don't want. But if there are other things that are treatable, they're on diuretics, they're on particularly oral contraceptive with spironolactone. Other oral contraceptives are okay, but that particular combination seems to be prone. Caffeine, dehydration, allergic disease. If they're over-medicating on antihistamines, and nasal sprays we’ll convert them to nasal rinses and Nasalcrom, immunotherapy when possible. So trying to control all of these other factors, temporomandibular disorders, muscular treatments, relaxation therapy, etc. We try all those things.

If those don't work or we resort to topical drops, saline drops, hypertonic saline drops for something more irritating. Four teaspoons of salt and a cup of water will give you a nice hypertonic solution. It's cheap. you have to instruct the patients how to do it. So you've got a lie supine, hang your head 15 degrees apply the drops, and turn 45 degrees toward the floor. So it's kind of like a, not as severe, head hanging hallpike position and the drops when they touch the eustachian tube will give a twinge that radiates to the ear. If they don't get the twinge they missed. So you have to carefully coach them in all of those things.

Hypertonic they can do as often as they like. If none of this works, my go-to is PatulEND. PatulEND you can get over the internet. It's ascorbic acid solution. It's vitamin C in a bottle. It really stings a lot of the people. Some people say it's too powerful for them, but if they do that three drops two to three times a day for two straight months to try to get a lasting benefit really can work in a lot of the patients. So those are the go-to things. If they've failed the hypertonic or the PatulEND with a rigid protocol like that, those are the ones I'm considering surgery, if we have to.

[Ashley Agan MD]
And real quick, what's the most common surgical option for these patients?

[Dennis Poe MD]
Yeah. The most common thing I do is, we don't have any commercial device, so off-label inserting an angio catheter that's filled with molten bone wax, let it harden, cut it to size and put it up the full length of the eustachian tube, and if they're out of town, I even put a stitch to it. We get great results with that.

I can't do that if they've got a dehiscent carotid artery. So for those patients we have to do cartilage implants, making an incision in the walls of the eustachian tube and packing cartilage pieces into the sidewalls to bulk it up.

[Ashley Agan MD]
I've done that once. It's very challenging working back that far in the nose.

[Dennis Poe MD]
Congratulations. I hope you had the instruments.

[Ashley Agan MD]
Yeah. We had them order a special kind of eustachian tube needle driver instruments to get to the back of the nose, but it is very challenging, throwing stitches in that part of the nose. So putting the shim is much preferred, much easier.

[Dennis Poe MD]
Right. And you're talking about a shim, so we call it a shim. It's a plumber shim to help try to plug the leak of the valve without intentionally plugging it completely. So we do call it a shim.