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BackTable / ENT / Podcast / Transcript #69
Podcast Transcript: Balloon Dilation of the Eustachian Tube
with Dr. Seilesh Babu
In this episode of BackTable ENT, Dr. Ashley Agan and Dr. Seilesh Babu discuss Eustachian tube dysfunction and balloon dilation as a therapeutic option. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) The Basics of Eustachian Tube Dilation
(2) Evaluating Patients with Eustachian Tube Dysfunction
(3) Indications for Myringotomies
(4) Considerations for Special Populations
(5) Utility of the Eustachian Tube Dysfunction Questionnaire
(6) Patulous Eustachian Tube Dysfunction
(7) Medical Therapies for Eustachian Tube Dysfunction
(8) Counseling Patients About Balloon Dilation
(9) The Evolution of Procedure Reimbursement
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[Ashley Agan MD]
I'm your host today. My name is Ashley Agan. I'm a general ENT practicing in Dallas, Texas. Gopi couldn't make it today. She's here in spirit, we’re sending her love and thoughts and good vibes. But I do have a great guest today. Dr. Seilesh Babu, he is a board certified otologist. He is certified in adult and pediatric otology, neurotology, otolaryngology and skull-based surgery, and he specializes in medical and surgical treatment of ear and skull-based disorders in adults and children. His clinical interests include ear infections, hearing loss, dizziness, facial weakness, cochlear implants, and acoustic neuromas. Today, we're going to talk about eustachian tube dysfunction, eustachian tube dilation. We're going to get into a lot of specifics around the topic. I'm really excited for it. Welcome to the show Sei.
[Seilesh Babu MD]
Ashley. Thank you very much. Thank you for the invitation. It's great to see you again.
[Ashley Agan MD]
Yeah, Seilesh and I were on a panel together on eustachian tube dilation back at COSM in end of April. But we get to meet each other there but didn't get to chat much because we were both on the panel, so met each other in passing. So I'm glad that we have the opportunity today to, get into it and compare techniques and thoughts on this topic.
[Seilesh Babu MD]
Yes, it'll be good to go through some of these things.
[Ashley Agan MD]
So before we get into it, we always like our guests to tell our listeners a little bit about yourself and your background and what your practice is like. Tell us about you.
[Seilesh Babu MD]
Yeah. So I did my residency in downtown Detroit. That's what brought me to Michigan. And I did it at Henry Ford Hospital. I did my fellowship at the Michigan Ear Institute and stayed on ever since practicing otology and neurotology there. We have a busy residency program. We have a busy fellowship.
We do the breadth of otology neurotology and do very simple TM perforation repairs to very complex skull based tumors at epidermoids. I've been doing it for 20 years now and it's been a very busy, healthy practice, and we love the impact we have on our community. We love the impact that we have on the training program of the future of our society.
[Ashley Agan MD]
That's awesome. So let's get into eustachian tube dilation. For listeners who may not be familiar with that, can you give a little background on what does that mean? What are we talking about? What patients is this for?
(1) The Basics of Eustachian Tube Dilation
[Seilesh Babu MD]
Sure as many people know, you have chronic eustachian tube dysfunction that occurs in kids, and then it can exacerbate problems in adults and lead to many ear related issues, whether it's recurrent fluid, whether it's retracted tympanic membranes. But we think the bottom issue, the main issue that's causing these problems is eustachian tube dysfunction. And for a long period of time, the only solution we had was maybe some medical therapy that may or may not help with nasal steroid sprays or allergy medications. And then we would put tubes in people's ears as the mainstay of treating eustachian tube dysfunction. And then several years ago, we finally had an FDA approved procedure and technique where you could use a balloon catheter similar to coronary artery balloons. But now it's happened to be designed for the eustachian tube. It has a different bend to it. It's a little more flexible. It gains access to the eustachian tube through the nasal cavity in the nasal pharynx so that we can place this catheter into the eustachian tube opening and stretch it, dilate it, maybe crush some lymphoid follicles to improve the eustachian tube, to open and close better so that patients can get relief of their symptoms and potentially not need further tubes or other interventions for ear related problems.
[Ashley Agan MD]
When this was first introduced, you're an otologist. You are usually coming at the ear laterally. What were your thoughts on moving towards working on the other side of the ear and being in the back of the nose? Did everything just come, back naturally from residency? Or was there a little bit of a hump to get over to be doing that again and being in that part of the nose?
[Seilesh Babu MD]
Yeah, that's a great question because it is a struggle, to be honest, especially in the beginning when we're so used to going in from the ear side and making postauricular incisions and drilling mastoids which is clearly what we're good at doing, to then go back and remember putting a scope in the nose, being able to decongest the nasal cavity enough to get access, to prevent bleeding, to then get back in there and be able to place the eustachian. But yeah, there definitely is a little bit of a learning curve. With practice, it can get better, but there's certain times in certain, nasal cavities that I have a tough time still to this day that the septums really pushed over one way, the turbinates are really boggy and edematous and, my residents or fellows will say, why don't you just do a septoplasty? Why don’t you just do a turbinate reduction? Cause it's not my–
[Ashley Agan MD]
You're like, cause I don't, want to.
[Seilesh Babu MD]
I don't want patients coming into my office with a nose bleed or their septum isn't what they thought it was going to be. So yeah, it there's a little bit of that occurs, but I think that's the small proportion of them. I think the majority of people as an otologist, you can get used to it and be able to gain access and really treat them. If nothing else need to learn again, to go back in time as residents, when we had patients with eustachian tube problems, we didn't do a lot of evaluation and the nasal pharynx and the eustachian tube. It wasn't part of at least my training, as much, to look at it. And probably the reason why is you couldn't do anything about it. So what difference does it make to go look? But now we've gotten to the point where we don't ever look, unless you have a unilateral serous effusion, which we know to look for nasal pharyngeal masses, or lesions or carcinoma, but that's rare in of itself, but really what we should be looking at is, what does eustachian tube look like? And if we scope a lot of people and get a good sense of what is normal look like, then we get a sense of what abnormal looks like. And we can now say this may be a good candidate for a balloon dilation based on certain features that we can see in the nasal pharynx that would help us.
(2) Evaluating Patients with Eustachian Tube Dysfunction
[Ashley Agan MD]
That's a good segue to talking about how you're evaluating these patients. And so when you have someone coming to your office, and, it looks like eustachian tube dysfunction might be the underlying disorder, or let's just say they're coming in and they have, either hearing loss or ear fullness or trouble when they fly, or a lot of these symptoms that we see in this patient population, walk us through what your evaluation looks like.
[Seilesh Babu MD]
Let's even start back with like, when a patient does come in, like you're alluding to, what symptoms should we be looking for? So I think, certain subsets of patients come in with easy decision-making as to what do we do. A patient who has baro challenges. They go scuba diving, they fly in an airplane, and they have. And then when you see them in the office, of course, they're going to have more of a normal examination because they're not having that problems, but you can trust their history enough. And experience has taught us that I think those type of patients do well with this type of intervention. Whether it's a tube in the ear or a balloon dilation, they'll actually do well in that scenario. And then you have some patients that come in with multiple serous effusions and they've had multiple tubes in their ears. And I think that also is a good candidate for their hearing loss, their ear fullness, multiple tubes that have helped their symptoms. I think that's a good candidate also to be looking at next steps. And in the patients who come in with ear fullness, I think that becomes a harder challenge to delineate what therapy is going to help that patient with ear fullness and ear fullness is a tough one. I have found myself putting them in categories and trying to figure out is it eustachian tube related or not? Is it Meneire’s disease? Is it superior canal dehiscence? Is it maybe masseter or pterygoid muscle tension that may be causing some of this? Is it anxiety? Are there other factors that we have to take into account? I think one of my main things that I do is I try doing either a myringotomy or a tympanostomy tube in that scenario to see, does that give them relief? My opinion is if it does not give them relief, then I don't think eustachian tube dysfunction is their main issue. And therefore, I don't think a balloon dilation would be indicated in that scenario, but that's a long-winded sort of way of saying what do these patients present with?
But the next steps then we think about evaluation is I think we should do a good thorough examination of their ears. See if there's retraction of the tympanic memory and see if there's fluid in the middle ear space. I think all of these patients should have nasopharygoscopy, as we had talked about to really look at the nasal pharynx. See, is there adenoid tissue? Is there adenoid in the eustachian tube? Is there hypertrophy of the torus tubarius? Is there mucosal edema? Is there cobblestoning? What is the movement of the eustachian tube look like? Some of that over time will give you a sense of maybe this is a good one to intervene on. All of them will get audiograms. I don't always get tympanograms, but many times tympanograms will help decide. There was a time where insurance coverage was an issue. And so you'd have to get a tympanogram on everybody to show that it was a flat or poor, but that has changed a bit now. So it's not as critical to get that, but many places will still get it. It's a good way to follow objectively. What do they do afterwards if it became normal.
[Ashley Agan MD]
So you don't always have a tympanogram pre procedurally?
[Seilesh Babu MD]
I don't usually. I feel like my trend was many of patients are baro challenge patients. And so if you do a tympanogram, it's normal. And so there was a time where you're having normal tympanograms and normal exam, and then I'm doing a balloon dilation it doesn't quite make sense, but of course these patients then love it because then you can fly with any problems. So that's what changed my opinion about why do I need a tympanogram on everybody to go do it?
(3) Indications for Myringotomies
[Ashley Agan MD]
I want to back up just a tad because in your evaluation of these patients coming in and their histories, I experienced lot of the same thoughts as far as like how to put these patients in the different categories and figure out what's going on. And I echo that the ones that have that history of multiple tubes or every time I fly or every time I'm pressure challenged, it hurts or you have symptoms, those are the slam dunks, right? Like you feel like, okay, I really think this is going to help you. I can say confidently, you're a great candidate for this. And then there's the ear fullness patients, those can be such a puzzle sometimes. And when we were on the panel together, you talked about, the utility of a trial myringotomy or a myringotomy with a tube to say, okay, if this helps with your symptoms, then I feel pretty confident that this is a eustachian tube issue. And when you were talking about it, you talked about the difference between a myringotomy by itself and a myringotomy with a tube. And I wanted to talk to you more about, and have you expand on that because I have also had this situation in patients where, almost a hundred percent sure, like maybe this is eustachian tube issue, but let's try a myringotomy. And then we do a myringotomy, and then they hate it. But then, you mentioned that sometimes, the myringotomy by itself may not help the way a myringotomy with a tube is. I wanted to pick your brain on that.
[Seilesh Babu MD]
So there's certain patients I've learned over time that when you do a myringotomy sometimes I'll step away from the microscope and just say, how do you feel? And the patient universally says, I don't know it still seems muffled or plugged. And then you realize that well you just sucked all this fluid in their ear, they should've said I hear great, and then maybe about by the time I put the tube in their ear, and then you give it to 5, 10, 15 minutes. And they're like, you know what? It does feel better. I can hear louder. But then there's a couple of times where a patient has to come in maybe a day later, two days later because the tube got plugged or something and I'll ask them how they're doing. And they keep saying, there's a lot of this echoing and just reverberation. So my opinion in a long-winded way is I think when we change the acoustics of the eardrum and we make an incision and change, either the radial fibers, the circumferential fibers of the TM. We changed the tightness of that eardrum. I think it affects the acoustics in us, in humans. And that change in acoustics is annoying to patients in the sense that when you do it that first two, three days, I think the patients just getting over the fact that they have this ear fullness, this weird hearing it doesn't sound right. It's muffled. And then by the time you do a mirror economy and it closes within two days and you say, hey, did that help you? I think the patient's so stunned by everything else. I don't know if they get a sense of did that actually make their ear fullness or pressure better because they were dealing with these other symptoms. This is my theory. And so I tend to, if a general otolaryngologist sends me a patient and they tried a myringotomy, it didn't help it. My gut feeling, like you said, is that I think this is eustachian tube dysfunction, I will put a tube actually in the eardrum. And I've definitely found differences that when I put the tube in the patient will say, oh my gosh, this is so much better, and may not right away, but when they come back and see me in two weeks, they'll say, oh, it's so much better since you put the tube in. And then we'll make some decisions about, okay, now we have some options to talk about other therapies, but yeah, I don't think a myringotomy in and of itself tells me the answer, enough to give me the guidance is what I've learned over the years.
(4) Considerations for Special Populations
[Ashley Agan MD]
That really blows up a lot of my algorithms. Do you find that patients who are singers or musicians are more in tune with their hearing, and may notice it or be bothered by it more?
[Seilesh Babu MD]
If they're even sound engineers or they're recording artists, or if they do perform or if they're somehow musically inclined, for sure they're more in tune to their hearing and any change causes them to have problems. I don't know if they have more issues with eustachian tube, or seem to complain more about that type of symptom because of that field, but when they have ear problems, there's no question that I may be a little reluctant to maybe go down some pathways with them. Because they will complain quite a bit about different scenarios. If you do a myringotomy or do a tube in their ear, they will definitely be more sensitive and they can't “hit certain registers” or they can't hear certain things that they could hear before. And so you have to be a little cautious in that scenario.
[Ashley Agan MD]
That little, maybe 10 decibel difference after we put the tube in is more heightened in some of these patients that I've had where they're like, if my hearing is muffled, I can't hear out of this year and your audiogram is like essentially normal, but it's like maybe 10 decibels, worse than it was before. So I don't know. I feel like I'm always over counseling in that population. Like it could change your hearing a little bit.
[Seilesh Babu MD]
On a side note, when you go down that same path and you think about that same scenario, and then you have, they have otosclerosis or they have a superior canal dehiscence, or they have an acoustic tumor. Yeah. Then of course those things are magnified tremendously than the idea of a tube in the ear. So yeah, probably in my world of otology, the perspective I have is it's a tube, you'll be fine. It'll change your acoustics, just live with it. And because if they started going down that path, I said, well, in comparison to all these other patients, I have, it's not a big deal. You have a five decibel loss. It'll go away in a little bit. Just you can tolerate trust me.
[Ashley Agan MD]
Do you feel like over time, patients, that their brain gets used to it a little bit more and that difference becomes less obvious to them. They habituate a little bit to that little change after they get a tube.
[Seilesh Babu MD]
I think actually the flanges even of the tube, create a little bit of acoustics that allow it to be better. So that over time as it just settles in place and maybe scars, adheres a little bit, that's what affects the acoustics. I don't think there's central changes that need to occur because our audiograms are quite good in these patients with tubes. So I don't think there's an actual acoustic phenomenon that occurs long-term that they have to then compensate for. I think it's just a short term change in acoustics. Cause you change the vibratory sensation of the tympanic membrane.
[Ashley Agan MD]
So you just tell him, give it some more time before you pull out the tube. Have you ever had to pull out a tube, if people don't like it?
[Seilesh Babu MD]
I've never pulled out a tube. It's very rare, but that'd be someone who has patulous eustachian tube, for example. And I tried a tube and then they came in and said, that's worse to me. That's actually a red flag of like, yeah, I shouldn't put a tube in someone's ear and then it bothers them. If it bothers them then I think about patulous eustachian tube because I also tell you rarely would I have a patient I put a tube in their ear and they're so “bothered” that I have to remove it to me. That's an anxiety component. That's a stress-related component. There's other factors as to why. I can probably count on one hand in 20 years how many times have I taken a tube out of someone's ear?
[Ashley Agan MD]
Speaking of red flag symptoms, are there any other things in the history of the patients will bring up that tend to be more of a red flag, oh, hey, maybe this isn't eustachian tube dysfunction, maybe this is patulous or something else?
[Seilesh Babu MD]
Yeah, I think if they start complaining of any type of dizziness, vertigo, sound, induced symptoms, pressure induced symptoms, they really shouldn't have any vertigo symptoms typically, unless they have really bad eustachian dysfunction and severe retraction of the tympanic membrane. Maybe it's sitting on the oval window or retracted down to the stapes because maybe in that scenario, but if you don't see that and they're complaining of dizziness and I would look for other options. And I think if they have autophony, if they have pulsatile tinnitus, if they have reverberations, when they talk or breathe, I do think those are issues that you have to investigate further and be leery about patulous eustachian tube. As we know, the majority of patients are going to have eustachian tube dysfunction if they have ear complaints. Meaning in the spectrum of patulous eustachian tube versus eustachian tube dysfunction, the majority of people are gonna have eustachian tube dysfunction, but 2-4 or 5% of the population may have this patulous type symptoms that we want to pick up on those. And we especially wanna pick up on those long before we think about a dilation for them because you'll make their symptoms obviously worse.
I think going down that path of patulous eustachian tube, like these patients usually have a typical body habitus they're thin. I think females seem to be more common, especially in my practice, but I have a lot of young, thin men, young thin women who may have lost a pound or two pounds. And to them, that's not a big deal that they would notice weight loss, but they started at such a low number to begin with it. I think that actually does push them over the edge. And I universally, universally’s hard to say, but they always seem to have some anxiety component somewhere in their background. That seems to also make them pay attention to this a little bit more too. I don't know if they're red flags, but definitely things that put me on notice to say, hey, pay attention to this one a little bit more, because there's other things that may be contributing to their ear fullness that they're complaining of, if that's their main complaint.
(5) Utility of the Eustachian Tube Dysfunction Questionnaire
[Ashley Agan MD]
Absolutely. do you use any like questionnaires? Do you use the eustachian tube dysfunction questionnaire, the seven question one?
[Seilesh Babu MD]
Yeah. When we're doing research or studies and we tend to use that a little bit more probably in my day to day practice. I use it, but it’ll have to be one of the things that I have to remember, like, hey, can you fill this out? And we're going to do it. Yeah, probably if you talked to my MA or residents, they’ll say he doesn't use that all the time.
[Ashley Agan MD]
Well, it's not, I mean I think, I'm the same, it's hard for me to remember to do it. But I think, its intention is more for research and following outcomes. At least for me, I feel like it hasn't been super helpful for making the diagnosis or deciding what their treatment could be.
[Seilesh Babu MD]
Right. And the tool was designed for, monitoring patients for therapy outcomes, as opposed to making diagnosis. So it does work out well from that you can monitor these patients. Unless I'm going to publish a paper on it we have used it and published on it, but if I'm not going to publish on it, then I probably don't collect the data. And then it makes us exclude a lot of patients. So we have to, think about that when we're doing it to make sure, we can include as many as we can. Because the problem is that eustachian tube dysfunction is a subjective problem. And so when you start researching and trying to do research on a subjective problem, it's hard to know what was that intervention and how effective was that intervention? And so at least this questionnaire, maybe tympanograms, as we talked about earlier, can help us get that objective information. But we also know those who clinically practice and see a lot of these patients like those don't always correlate. And so what we find is that if I knew for sure that would help me make the diagnosis, we'd always get it. The problem is it never actually seem to help me clinically decide, oh, was that a problem that I needed to intervene differently? And the answer was, no, it never changed my management. So if it doesn't change my management, why do I order the test or do the test? If you tell me for research, I'd say but that's not what I clinically do all the time. Cause it doesn't alter what I'm going to do next.
[Ashley Agan MD]
And sometimes patients take a while doing it because they're really thinking about yeah, pop, cause it asks about popping and clicking. It asks about tinnitus, ear symptoms when you're sick, when you have sinusitis, they're like, but I've only had one sinus infection this year, you know? So sometimes it takes time and it doesn't help with what we're trying to accomplish.
[Seilesh Babu MD]
Do you find that if they score a certain number, like greater than 2.1 or 2.4, I think is considered abnormal on a test, so seven is the worst. Do you, find yourself that if it let's say they're a six, do you say, oh, maybe I will treat this eustachian tube issues. Does it guide you at all? Or do you just use it for therapy purposes?
(6) Patulous Eustachian Tube Dysfunction
[Ashley Agan MD]
Yes. Sometimes, like I just, we'll talk and they'll talk about how bad things are. And then you look down at the questionnaire and it's like all ones or twos, it's really low. And you're like, oh, maybe this isn't that big of an issue for you. Or, if it looks like they're all sixes, like they're really high scores all on one side, then it's oh, this is really, maybe it is severe. Maybe this is something that could help, but I think the exam is a lot more helpful.
So segueing into that when you're looking at these patients in clinic, we talked about looking at the eardrum and looking for retraction. And again, the patients that are more difficult are the ones that have a normal type A tymp, normal looking eardrum, but maybe there's some issues when they fly or we're trying to decide, could they be on the edge of eustachian tube dysfunction? Do you do anything as far as evaluating, the movement of the eardrum, do you do pneumatic otoscopy? Do you have them do a modified Valsalva? Do you look at that at all?
[Seilesh Babu MD]
Yeah, those are good questions. I think I do try to do pneumatic otoscopy. I think the majority of times it doesn't seem to give me as much information as I really want to know. Where it's really helpful is, to pick up on pressure induce vertigo. So I probably use it way more for that for superior canal dehisence or a perilymph fistula or something like that, but for movement to the tympanic membrane it's so subtle that whether or not going to be a pickup on a negative or positive, I probably would tell you, I don't do it often enough to know if I can pick up on those subtleties. So that's probably a good adjunct, doesn't help me make a decision going forward. The more important one is having them naturally being able to perform a Valsalva And even having the patient historically, can you pop your ears normally? Do they pop in if they say yes, then that also leads me away from eustachian tube dysfunction just based on that history, if they'll say, oh, I've never been able to all my life I've always had trouble and I just, they never a pop, I have trouble on flights historically, then that then guides me like, yeah, that's a classic example of this type of a scenario.
There is a scenario, just to go back a second. We were talking about patulous eustachian tubes, which I think is important to pick up on. And I've learned, from some experts in the field as well as from literature is that there are certain patients that will have this retraction of the eardrum. They can even develop a cholesteatoma, but they actually have been sniffing to try to relieve patulous type symptoms that they've artificially created this retraction. And I didn't really believe that would happen, but it's happened to me twice now where I've done, tymp mastoid surgery found a cholesteatoma, cleaned out the ear, and the patient would continue to complain of ear fullness and pressure and hearing loss. And of course had all the issues that go along with a cholesteatoma type presentation. But, not until maybe the patient's third or fourth surgery did I finally pick up on that there must be some patulous component. And then when I addressed the patulous component, their symptoms got much better. And so I'm not saying we missed it, but it definitely was one of those things that I didn't think about. You could have a patulous eustachian tube and a retracted attic region and cholesteatoma. But I think Dr. Poe has talked about this and published on this too as well. And that's the first one or two times I've ever encountered that. So it’s something that as otolaryngologists and definitely as otologist neurotology, we should pay attention to that. That can happen. And, be cognizant of that.
[Ashley Agan MD]
Beware of the sniffers. Can create a lot of negative pressure.
[Seilesh Babu MD]
Do you get that?
[Ashley Agan MD]
Sometimes. Yeah. Yeah, it's pretty interesting. I've definitely had patients who don't complain of autophony, or maybe they're used to it because when you ask about echoing of voice or breath, they don't mention it, but then you like look in their ear I've had patients where I just see the eardrum just moving in and out, right with their breath. And I think maybe it just happens so slowly over time that they don't notice it as much. I don't know. But I've seen that too.
[Seilesh Babu MD]
Yeah, there are patients I've seen where they're your ear drum does move excursion with respirations and they don't have any symptoms. They have no problem at all. And it just happened to be coincidentally. I happened to be looking at their ears and I'm watching their eardrum and it moves. And I say, do you have any of these other symptoms? They say no. And my mind I'm like, that's weird. I didn't know that it just happened naturally, but I think I would almost say it happens more commonly, so it's not very common, but more commonly that I've seen a eardrum that moves with no symptoms than the other way around patient with classic patulous eustachian tube symptoms and then has excursion. I'd actually see it the opposite way around.
[Ashley Agan MD]
It's fun to see when you catch it. But yeah, I agree. The ones that I've caught it incidentally are usually like, not bothered by it at all. They're just like, yeah. Okay. Whatever you say, I guess I have patulous.
Okay. Moving back to, we're talking about moving through your evaluation in clinic. Just want to make sure we don't miss anything. We talked about looking at the ear and looking at the eustachian tube and the nasal pharynx. We talked about adenoid tissue and inflammation and edema within the lumen of the eustachian tube. Does that part of the exam, affect your decision for whether or not the patient's a good candidate for a dilation? Do they need to have a really swollen eustachian tube with the lymphoid hypertrophy and does it need to look really edematis? Because I feel like sometimes if you were just putting the scope back there and you looked and you're like, oh, it looks normal ish. You might not think that dilation would work, but then you start looking at how their ears working and clearly their eustachian tube doesn't work, but maybe the issue is further down in the lumen of the eustachian tube. I don't know. Talk to me about what you're thinking when you're looking at it.
[Seilesh Babu MD]
I think it is probably multifactorial, as you know in your medical practice, my medical practice, we don't use one piece of information to sort of guide us. We use the whole picture. So we use the history, what the patient tells us historically, what has a patient have gone through. And in this case with eustachian tube dysfunction, probably what they tell us will be enough of us to guide our clinical suspicions. And then I think things like the evaluation of the ear and the nasal pharynx and the eustachian tube and audiograms, and tympanograms confirm that. And so there are probably many times I look in the nasal pharynx and it doesn't look as bad as I thought it was going to, but I'm still telling the patient, I still think we should consider a dilation based on everything else you've told me, but I would say that there are more times than not that there is some type of either allergic changes in the nasal pharynx, you see some cobblestoning, some edema of the mucosa and the eustachian tube orifice definitely seems thickened and just not normal. But again, if you don't scope a lot of people and you don't look at a lot of eustachian tubes, you'd have a tough time comparing normal to abnormal or the mild variations that can occur. And so I think the more you get used to scoping, the more you'll get a sense of like, oh, this is mild to moderate type edema or swelling. And this would be a good candidate. And if it's normal, it doesn't mean you can't do it or shouldn't do it. It's just that it makes you wonder, did you miss something or is it not as bad as you're thinking. I'm not sure, as you brought up the point, is it more proximal because you didn't see it in the nasal pharyngeal opening? I'm not sure. I would say if you didn't see it in the nasal pharyngeal opening, I don't know if I would think, oh, the disease must be more proximal and that's why I don't see it. I don’t have any data on that, but that's just my gut feeling.
[Ashley Agan MD]
Do you use a rigid scope, flexible scope? How do you do your nasopharygoscopy?
[Seilesh Babu MD]
I'm not gonna lie to you. I have such a tough time in the office doing a rigid scope that I use a flexible scope in the office all day long to evaluate the nasal pharynx. We have access to a zero degree and a 30 degree in the office, but they're probably brand new crystal clean and no broken fibers or anything because rarely would use it.
[Ashley Agan MD]
I like it. I use flexible too. I think the flexible is nice. So you can drive it around. I scope both sides and I look at the eustachian tube, Same side. And then also like contralateral side, where I like turn the scope and look at it across just cause it gives you a slightly different angle. I don't know. Do you feel like that's important or helpful?
[Seilesh Babu MD]
Actually, I probably even do less than you do, because if I go on one side and I can look at the ipsilateral and then I can look across the midline and see the contralateral, I get a sense of okay, this is what I thought it was going to be. And I actually won't even put the scope in the other side because it won't make a big difference to me as if I didn't see any masses lesions. And I think there's, let's say mild to, edema already. Then what difference does it make? So I don't want to torture the patient through more scoping at that point.
(7) Medical Therapies for Eustachian Tube Dysfunction
[Ashley Agan MD]
Yeah. That makes sense. It doesn't change your decision-making. What about medical management? Like let's say this is the first time the patient's being evaluated, which probably isn't as common for you because you're probably getting referrals, since you're the tertiary referral center probably, but let's say a patient hasn't been on anything, and this is their first eval. What medical therapies are worth trying?
[Seilesh Babu MD]
There's a handful of things I'll tell people that I think they should do is a avoidance of allergens, if they can. Even if they say I'm not allergic to anything, I still think there's probably a component of that. Maybe is food or even a food diary is going to be of some benefit to these patients. If they have a somewhat unusual history, that's not just baro challenge type situations, should they be allergy tested and maybe even treated? Then we talk about nasal steroid sprays, allergy medications, potentially anti-reflux medications, performing modified Valsalva at home to see if they can relieve any of their symptoms by doing conservative management. So many patients will seem to talk about, oh, I would like a holistic approach, a non surgical type options. So then I'll throw this at them and they'll say, oh, well, that seems like it's going to take awhile. Or we can try a tube and it'll make it better right away. Or we can talk about a balloon dilation. So that's how the discussion goes. And I get a sense for like how bothered or impatient are these patients that have this problems? Some patients are just coming in because they have this ear fullness and they're scared that there's something bad or serious going on. And at the end of the day, if you tell them, you're great, you're fine. And you switch it around to like, what? You should be really happy. Like of all the patients I'm seeing today, you don't even have a problem that requires a surgery or any intervention. Like that's great. Your hearing test is perfect. Your exam is normal and your ear fullness, you seem to be living with, or, maybe it's related to TMJ issues and you should use warm compresses and massage the jaw and go see a oral surgeon, et cetera, et cetera. And they seem to be very content with that. So I found myself when I say, there's not much therapy I can offer you. If I flip the script a little bit and make it seem more like a positive, they definitely walk out of there with, wow, that was great. I don't have to have any interventions done. That's the honest answer. Like there's not a surgery, I'm going to do anything to make it better, but that's good news. And sometimes they like it that way. And sometimes of course, they want to get another opinion and go somewhere else and there'll be chasing this ear fullness for other reasons.
(8) Counseling Patients About Balloon Dilation
[Ashley Agan MD]
Yeah. Let's say you, you have the patient who's tried, they've done lots of medical therapy and maybe they're on allergy shots or they're treating their allergies. They're doing lots of these other things and maybe they've even had a tube before. And so you are thinking that they're a good candidate for eustachian tube dilation. What is your counseling? How do you talk about procedure to them?
[Seilesh Babu MD]
Well, assuming they got relief from there tube before, and they're saying, hey, it felt great. I could either do another tube or let's do a dilation and we're getting ready to say, let's do a dilation. I wish I probably had the luxury that you do of being able to just do this in the office. I think that would change my paradigm a little bit of what I want to do and what I feel comfort with, but because I'm too old school now, and I'm probably not going to change my ability to do this in the office because I'm too impatient myself probably to wait for something. But let's just say if, cause if I had that, the reason I'm saying it is because right now the decision is, should we go to the operating room for this quick three minute procedure, which is safe, easy, but it does impact not only my schedule, but then it impacts, the patient's day because they have to do all this versus a tube in the ear, there is some reasons to offer one or the other, but if they say they want to have surgery, so my discussion is, you're going to have this procedure. It’s a relatively short, easy procedure. I have to put a scope in the back part of your nose. We then put this balloon catheter into the eustachian tube. We dilate it up to 12 atmospheres of pressure because data has said that's the right amount of pressure we need to put on the eustachian tube. We do it for two minutes because that's what we seem to think is the right amount of time based on all the data that's in the literature. No one really knows if these two numbers are exactly right, but that's what we do around the world. And then we take everything out and you go home within 10, 15, 20 minutes after waking up. You may have a little bit of a sore throat for a couple of days. You may have a little bit of blood from your nose for a couple of days, but all of that should resolve. And then we have to wait about two, three weeks to see how your symptoms resolved over time. I tell them to avoid nose blowing or a Valsalva maneuver for about a week to 10 days. There have been cases of either pneumothorax or pneumomediastinum from air tracking, maybe around a false passage and it may have created, I don't know exactly how it would happen, but because of that reason, I just say, just be gentle about any nose blowing or Valsalva afterwards. And they can always go back to work, of course, the next day. They can resume all their normal activities. So it's not a big deal, but if I could give them the option of let's do this tube in the office versus let's do a balloon dilation in the office, I could see myself saying, why don't we do both actually, or let's really lean you towards one way or another. So maybe in my practice, maybe I'm not giving them as fair of a comparison as I could because I'm biased because of this general anesthesia.
[Ashley Agan MD]
When you, as far as post-op expectations, after three weeks or after a certain amount of time, when they can blow their nose again, are you having them do some modified Valsalva to start moving air a little bit better through the eustachian tube? Or do you tell them to just wait and see?
[Seilesh Babu MD]
No, I prefer them to start doing it. If I had my way, I'd tell them to do it right away, but I'm a little concerned about this issue. So I tell them to wait, whatever I think is appropriate, seven, 10 days, two weeks, and then start doing it. The question comes up. If they use C-PAP or Bi-PAP, when can they start that again? And I don't really know the right answer in that scenario. So I tell them, 10 days, because I don't know what that positive pressure is going to do, but I think these patients start it on day number three and they do what they want to do. I just have to medically tell them to do it, but it actually be an interesting study that we were talking about here about looking at, C-PAP and Bi-PAP usage after balloon dilation. And is it safe? So if we had a couple other centers that were doing it, there may be something to look at.
[Ashley Agan MD]
Yeah. I would be down, let me know. Maybe we can do that, because it's so common for patients to be on, C-PAP these days. I feel like almost half of patients are talking about are asking when they can resume C-PAP after surgery.
[Seilesh Babu MD]
I wonder if there's even a correlation between C-PAP users, obstructive sleep apnea, needing C-PAP or Bi-PAP and eustachian tube dysfunction. Is there a spectrum and are they all somehow related or risk factors for one or the other?
[Ashley Agan MD]
When you do your dilation procedures, is it common that you're doing it just that's it, that one procedure, or are you ever doing it in combination with something else like a tympanoplasty or since you're seeing more of that, I'm just curious if you're ever doing a combo.
[Seilesh Babu MD]
Yeah, it seems to be it's rare that I just do a dilation by itself. Probably the most common I do is probably a dilation and a myringotomy and tube. Maybe 30% of the time I'm doing a cartilage tympanoplasty or a tymp mastoid in a severely retracted eardrum. And then I'll do a balloon dilation at the same time in that scenario. But that's probably a smaller percentage than the majority of cases that I'm doing it for.
[Ashley Agan MD]
And the idea being that since the eustachian tube is the underlying issue that maybe long-term outcomes for that new eardrum will be better if the eustachian tube part is dealt with.
[Seilesh Babu MD]
Yeah. Could the ear fullness get better? Could the hearing results be better? Could prevention of future retraction be better? We actually tried to study this and tried to pull data and the problem was, it's hard to know what data are we going to look at that's going to make the difference in these two patient populations. Is it hearing outcomes, which is so variable in these scenarios anyway? If I do a cartilage tympanoplasty for the same symptoms, I get great results with that, patient's ear fullness will go better. Their hearing will go away. So did the dilation make a difference? Anecdotally, I feel even though I haven't figured out a way to really study it, that these patients do better because they will tell me that their ear feels less plugged less pressure and way better than when I just did a cartilage with a tube, for example, or, a mastoid even. But when I do that dilation, either as a staged procedure or at the same time, that they feel some relief from that.
[Ashley Agan MD]
Yeah. And if you do cartilage, your tympanograms are always going to be, maybe type B after that. So that's not going to be helpful as far as giving you that information. So it can be tough, but it makes sense. Just thinking about it, if you address like the true underlying issue, if you imagine that the retracted eardrum is a result of the eustachian tube dysfunction if we’re fixing the underlying eustachian tube dysfunction, that should be better.
[Seilesh Babu MD]
That would be the theory. yeah,
[Ashley Agan MD]
It'd be nice to be able to figure out a way to create a study. Let's talk a little bit about doing the procedure itself. You're doing it in the operating room. Walk me through what your setup is. If you prefer a particular device. We talked about you're blowing it up to 12 atmospheres. You're holding it for two minutes, any other pearls around the actual performing the procedure.
[Seilesh Babu MD]
Yeah. So I think I probably do it similar to many people who do it. I put pledgets in the nasal cavity with Afrin. If I'm going to do any ear procedures, we do that as the Afrin is working to decongest the nasal cavities. We use a 30 degree rigid nasal endoscope, to evaluate the floor of the nose and get back there. I tend to always tell the residents or fellows, right when you put the scope in there and you're going to suction, right when you put the scope in, then put the balloon in there at the same time. Cause I see them all the time. Like they put a scope in and they take a look and then they come out and they get the balloon, they put the balloon in and I say, why don't you just do them both at the same time? What did the look tell you? And they're like, I don't know. I think they just want to practice doing it, which again is fine. As you can probably tell I'm all about like efficiency and like don't do something if you're not going to do something differently based on it.
[Ashley Agan MD]
Yeah. They're like, we just want to stir up some bleeding first.
[Seilesh Babu MD]
That's what I'm always worried about because I'm always worried you're going to make this three minute procedure into a 12 minute procedure because of bleeding. So let's just do it all at the same time. So then we take the balloon and then really, the key is falling along the floor of the nose and the turbinates definitely get in the way and occasionally you have to out fracture the turbinate just a little bit to get it out of the way. Sometimes I'll just push it with the balloon itself, the inserter, and I'll put it in the nasal pharynx and then get into the eustachian tube and the orientation opening, we have to make sure you're guiding it towards where you think the external ear canal would be. So you really have to push it out more lateral than you probably think. And you really want to embed that stylette in there. And I'm talking about the Acclarent AERA device, which is the most common one that I use. I think it's soft, it's flexible. It's easy for me to manipulate. So as an otologist, the easier you make it for me to get access in the nasal cavity, the easier it is for me to, do the surgery. So then by gaining access there, I can put that insert or into the eustachian tube. I can hold it with firm pressure and then I can advance the balloon. There's a little marker on there that tells you when I've inserted it far enough. And then it's got a stopper to prevent it from going too deep into the eustachian tube. And so it's worked out really well for me, to get there. It'd be nice if there was a suction on there because I would help with some of these bleeding that we get back there. And so if we could suction at the same time it would then accelerate the process even more. And so I think there's some reiterations that are going to come out in the future to add those types of things, but it works out great. I know there's other products that are out there and many people have had success with them also, but I think once we find a product that works out pretty well, you can just keep using that same one for the majority of the cases.
[Ashley Agan MD]
Yeah. I have used the Stryker advice. I think Medtronic might have one too now. I like the Acclarent one, cause it is small. Like the balloon is inside the device. And so as you're putting the device in the nose, I feel like it's a lot smaller, and easier to get back there. So you're doing this last, if you're doing it in combination, meaning you would do your tympanoplasty first and then do this procedure at the end.
[Seilesh Babu MD]
Yeah. So it's interesting that you bring that up because just a week ago we were doing a case. And did it in that order. And my fellow is asking, if you change the pressure of the eustachian tube, let's say you put this in there and you've just had your graft in there. You put your prosthesis in there and now you're ballooning up these eustachain tubes with the end, is that moving anything around in your ear because of the pressure changes? And my answer was it'd be no different than if the patient's sneezed tomorrow or coughed tomorrow. What difference would it make? Like they're going to get the same amount of pressure. So I don't think it's an answer, but then it made me start thinking like, I don't know, should we do it in the beginning of the case, as opposed to the end of the case, but from a decongestant and from just a time, procedures, the overlap, I think it makes sense to do it the way I'm talking about and acoustically, I don't know if it makes a big difference or placement of the graft makes a big difference, but it does make you think. So, yes. To answer your question, we do the balloon dilation at the end of the year procedures.
[Ashley Agan MD]
And as you mentioned, there's a cap, like a thicker part on the end of it. So there's no way you could guide this up into the middle ear, right? The device is made to prevent you from being able to really go beyond the bony isthmus of the eustachian tube.
[Seilesh Babu MD]
Yeah, correct. Yeah. I would have no concerns about that. I'm going to hit the prosthesis or hit the cartilage graft or something because there's a stopper that prevents it from going into the bony portion of it.
[Ashley Agan MD]
Are you doing adenoidectomy ever, or cauterizing or shaving off any of that lymphoid tissue on the posterior cushion? Or you stick with dilation?
[Seilesh Babu MD]
The least enjoyable thing that I could possibly do is put a scope in the nose and find adenoid tissue and right away after I turn to one of the residents would say, hey, look, you got to get this tissue out of here because I don't know what to do. Yeah, so it does happen every now and again, we have to get rid of this tissue, but it becomes a procedure, where actually I will wonder, wait, did I not scope this patient in the office to see this? And usually it's a younger patient so that, we didn't, and we were just like going by the history and didn't want to torture the kid. And then we get there and we're finding out this. So we'll board that for a possible adenoidectomy at the same time. And I'm crossing my fingers that possible isn't going to happen.
[Ashley Agan MD]
Yeah. It can take a lot of time when you get a lot of adenoid tissue.
[Seilesh Babu MD]
That's right. Yeah. And then I won't do an adenoidectomy specifically because again, I don't want to deal with this in my practice, so we will do the cauterization. We'll just try to shrink it down a little bit. Try to open up that eustachian tube opening. See if that makes it better. If it doesn't, I'll send them back to their referring otolaryngologist to say they may need more, evaluation of the adenoid tissue to get taken care
[Ashley Agan MD]
Yeah. Yeah. And that can turn a three minute case into a 30 minute case real quick.
[Seilesh Babu MD]
For sure.
(9) The Evolution of Procedure Reimbursement
[Ashley Agan MD]
So, just rounding this out, can you talk about any reimbursement comments, any issues that you've had or anything that would be helpful to know as far as, that side of it?
[Seilesh Babu MD]
So I think I've been doing it long enough that I've run the whole gamut. Now where 10 years ago, when there was no FDA indication, let alone the idea of a code or the idea of reimbursement we were doing these with sinus balloons and ballooning up the eustachian tube to see if it would make a difference and we would send a bill out for an unlisted procedure code and we maybe got paid on the tube that we put in the ear. And then it progressed on, now there's newer technology. We have a balloon that's designed for the eustachian tube. We're all excited about it. So we started doing it. Same problem. There's an unlisted code. You may not get paid on it. Maybe you get paid on the scope. Maybe you get paid on the tube. So really wasn't a big ability to reimburse when we're doing these types of things. And then the academy did all the right things, a lot of good people who worked hard to make sure there was a code that was developed for this. And now we have a code, and the insurances now have, accepted the fact that there's this code. They not necessarily have accepted the fact they're going to pay for it. But you can. So we went from a time where we were getting prior authorizations on all these patients, now with this code, to in order to get reimbursed, I don't know what the percentage is, but there's many times we weren't getting paid on this. Even after the fact they still would not reimburse us for that. And so then a hospital or the surgery center may be losing money on the balloon. I think now it seems to be there's more, especially in Michigan, more payers that are accepting of this technology. The evidence is showing that it's got usefulness. And I think we haven't had to go the pre-authorization route as much anymore as we used to. I haven't checked recently as to what's the reimbursement percentage actually look like. I know there's times where they're not, I'm still paying for that, even though there's a code in certain insurance, it still won't cover it. So my office does a fight that I think to some degree, but it's changed quite a bit. And I think now office space procedures, the way you get reimbursed in the office, the way the cost of these balloons is changed. I think the reimbursement and the benefits financially to these can make more sense than it ever did in the past.
[Ashley Agan MD]
Yeah, I've seen the same thing, once we had a code and insurances started picking it up, it's been a lot easier to offer it to patients because before that it was basically a cash procedure for patients in the office. And, most people don't have thousands of dollars to try a balloon. So that was a hard sell, but things are a lot better now.
[Seilesh Babu MD]
In the office, when you do it, do you do it isolated? You'll just do a balloon dilation in certain patients, or do you seem to combine them with sinus procedures at the same time?
[Ashley Agan MD]
Most of the time it's just doing a balloon. Yeah. Just doing the eustachian tube dilation. And yeah, it's nice. I mean when you think about doing things in the operating room and the whole rigmarole that comes with coming in and being in PO and being in pre-op and coming through all that, when you contrast that to being able to do it in the office, it is a lot quicker, from a logistic standpoint, it's a lot less time off for the patient. Some of them, if they want to take like a benzo beforehand, I mean they're still gonna be out for that day potentially. I tell them, if you are taking Triazolam, it is short acting, but still I tell them they need a driver and they should plan to be off work and things like that. But some of them, if they don't want to take anything, then theoretically, they could just go back to regular activity that day. So it is nice to be able to offer for sure.
[Seilesh Babu MD]
And your reimbursement has changed over the time to the office-based being reimbursed relatively well, from what I understand?
[Ashley Agan MD]
Yeah, absolutely. It makes financial sense, they let me do it, the powers that be say that it makes financial sense for us to do it in the office. It's nice.
[Seilesh Babu MD]
How long does it take you? Let's say patient comes in and you're done with your procedure. What is that timeframe?
[Ashley Agan MD]
Maybe 30 minutes to an hour, like right now I still spend a lot of time with the anesthesia part. So they'll come in and as far as just numbing up the nose, I have like a series of steps that I do, and I take my time with that part of it, because if I rush through that, then that two minutes of dilation, like the actual procedure part, it can make that part obviously more difficult and make that part last longer. So if I do it right and get everything numbed up really well, then when we are doing the balloon, it really is just five minutes. it's really short. We probably need to wrap it up. Although I feel like I could probably geek out about this with you for a little bit longer, but anything that I have failed to ask you, or any tips or tricks, pearls that you feel like our listeners really need to take home?
[Seilesh Babu MD]
No, no. I think you hit on all the major topics that seem to come up when we discuss this. I think identifying the correct patients and what symptoms they come in with, maybe trying out a objective testing just to make sure that the nasal pharynx look clear. Is there any tympanogram evidence of issues? Trying a myringotomy and/or tube in the certain patients. And I think, doing it and seeing how well these patients do for your first five to six patients. I think it's a little bit of a trial. You have to see well is it going to make a difference. And as long as you're not finding patulous eustachian tube, and you're able to identify those patients. Those are the ones that are really at risk of making their symptoms worse. And now you've got a real headache on your hands, cause those are tough problems to treat after the fact, especially. So I think as long as you're cognizant of that, I think it is a safe, reliable procedure with good evidence that it in the indicated patients that'll do well.
[Ashley Agan MD]
Yeah. And I'm glad you brought that up. Cause I think that is one of the complications that I stress the most is like the potential to cause patulous eustachian tube and then to discussing, okay if that were to happen, then this is what we need to do. Do you think that we'll see more patulous now that the balloon is becoming more widely used?
[Seilesh Babu MD]
Yeah, I can say I see it already. I see patients who come in and they'll say, oh, I had this balloon dilation done, six months ago, four months ago. And ever since then, I've had these types of symptoms. So I have seen it, not at a big number, but definitely more commonly than I've seen it 10 years ago. And so I think it is that we just have to make sure as a group, as otolaryngologists, we're very cognizant of that fact or there is going to be a 1-5% increase, I think, in these patulous eustachian tube symptoms that we sort of iatrogenically created that we want to be very cautious of. I actually I don't think that you can take a patient with eustachian tube dysfunction and make them patulous. I think what it was, you had someone who was just on the borderline, you didn't quite realize you, you heard the word ear fullness, and then you went in and did it. Now you took that patient and put them over the edge. But I think if they have eustachian tube dysfunction, I don't think you can make them patulous. So I'm not worried about that again, that general population, I think you have to be those couple of red flags that we were talking about before when a patients complaining about those symptoms. Just make sure you pay attention to those and don't do those type of procedures.
[Ashley Agan MD]
That makes sense. Good advice. Well, thank you so much for taking time out of your Saturday to talk to us and to share your expertise with our listeners. Are you on any social media platforms? Like if people want to find you or connect with you, do you do any of the socials?
[Seilesh Babu MD]
I'd love to say yes, but my answer is no I don't.
[Ashley Agan MD]
So maybe your website then if listeners want to learn more about you.
[Seilesh Babu MD]
Yeah. Usually our website at michiganear.com, or my email is sbabu@michiganear.com. And so I have patients who reach out quite frequently with questions or concerns. They can always reach out that way. Yeah. I don't adhere to any of these things. I don't know why, I've tried it and I just find myself like going down these rabbit holes that are just not useful to me. So I've deleted them all off my phone.
[Ashley Agan MD]
That's probably for the best.
[Seilesh Babu MD]
Yeah.
[Ashley Agan MD]
All right. Very good. Thanks again. And, to our listeners, check us out @ _BackTableENT on Instagram and Twitter. And let us know how the show landed for you.
Podcast Contributors
Dr. Seilesh Babu
Dr. Seilesh Babu is an adult and pediatric neurotologist, otologist, and skull base surgeon with Michigan Ear Institute in Farmington Hills, Michigan.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2022, September 8). Ep. 69 – Balloon Dilation of the Eustachian Tube [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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