Diagnosis & Management of Eustachian Tube Disorders

[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.