Eustachian tube is commonly overlooked even by many physicians as effect of chronic otitis media rather than a cause. this is a humble attempt to explain the role eustachian tube dysfunction and interventions to reduce the same

1. EUSTACHIAN TUBE
DYSFUNCTION
Dr. Prathyusha
PG in ENT
Narayana Medical College
Nellore

2. INTRODUCTION
• Anatomist Bartholomeus Eustachius in 1562,
• explained about eustachian tube
• dynamically links the middle ear and the nasopharynx.

3. MORE EMPHASIS
• improved understanding of the
• anatomy,
• physiology and
• pathophysiology
• Leads to ………..

4. Improved understanding of
eustachian tube dysfunction

5. ANATOMY AND
PHYSIOLOGY IN BRIEF
• The ET, measures approximately 31–38 mm in length
• it comprised of two portions,
• a proximal osseous portion about one-third in length
contained within the temporal bone (petrosal part),
• a distal cartilaginous portion of about two-third in length.

7. • The bony portion is lined with cuboidal respiratory epithelium
• becomes progressively narrow until reaching the narrowest at
isthmus
• fixed conduit and is always patent under normal conditions.

9. CARTILAGINOUS PORTION
• 20 mm in length in adults and is anchored superiorly to the basisphenoid
bone.
• Ciliated pseudostratified columnar respiratory epithelium
• abundant mucin secreting goblet cells, in the inferior aspect of ET orifice
• closed at rest and opens through active muscular action
• The pharyngeal end of the tube is slit-like, vertically with an elevation
called torus tubarius
• 1.25 cm behind the posterior end of inferior turbinate.

12. • There are four peritubal muscles,
• the tensor veli palatini (TVP),
• the levator veli palatini (LVP),
• the tensor tympani,
• the salpingopharyngeus.,
• TVP originates directly along the anterolateral membranous
wall of the ET and is important for active tubal dilation as well
as tubal closure

15. CONCEPT OF FUNCTIONAL VALVE
• the mucosal surfaces of the anterolateral and posteromedial walls
are in apposition to close the lumen when in resting position.
• 8 mm long section is termed the “functional valve”
• comprised of the mucosa,
• sub mucosa,
• Ostmann fat pad,
• lateral cartilaginous lamina and
• the relaxed bulk of the tensor veli palatini muscle

17. OPENING OF FUNCTIONAL VALVE
• occurs in two distinct phases
• Tubal dilation is initiated through palatal elevation as the LVP muscle
contracts.
• This also results in medial rotation of the torus tubarius and
the posteromedial wall of the cartilaginous Eustachian tube.
• The LVP contraction is maintained throughout the tubal dilation cycle.

18. • The second phase follows the contraction of the TVP,
• results in a rounded ET tube lumen.
• Tubal dilation propagates from the orifice toward the isthmus of
the ET.
• The closing proceeds in the opposite direction, from the
isthmus to the nasopharynx.
• When closed, the valve creates an air- and water-
tight seal.

19. LEFT ET DEPICTING THE TORUS TUBARIUS
(ARROWHEAD),
ORIFICE (ARROW), ANTEROLATERAL WALL (ASTERISK).
Closed resting position Open dilated position

20. • the Eustachian tube dilates approximately 1.4 times per
minute throughout waking hours, lasts 400 milliseconds,
• substantially decreased during sleep.

21. FUNCTIONS OF ET
• Middle ear gas exchange
• Clearance of the middle ear
• Protection of middle ear

22. MIDDLE EAR GAS EXCHANGE
• gas exchange results in a progressively lower
pressure within the middle ear.
• Nitrogen as part of the middle ear air diffuses very slowly
• The slower diffusion of nitrogen creates a greater
percentage of nitrogen within the air of the middle ear
space compared to ambient air.

23. • the middle ear pressure remains negative and with a
higher ratio of nitrogen compared to ambient air.
• The gradient of nitrogen relative to the ambient air is
believed to play an important role in the regulation of
pressure in ET dysfunction. (lo t of studies and research
and research going on…!)

24. • The Eustachian tube actively dilates by
• voluntary actions such as yawning and swallowing,
• involuntary actions of autonomic reflex stimulation
• due to alterations in gas composition and pressure that
are detected by baroreceptors and chemo receptors

25. CLEARANCE OF THE MIDDLE
EAR
• The distal cartilaginous portion actively moves secretions,
fluids and debris toward the nasopharyngeal opening of the
tube through mucociliary transport.
• However, in the presence of extremely viscous secretions
mucociliary clearance can be hindered

26. . Surfactants in the ET may serve to help reduce surface
tension within the lumen,
• aiding mucociliary clearance,
• tubal dilation,
• exchange of gases across the mucosal barrier.

27. • muscular pumping action during the tubal closing process
that additionally facilitates tubal clearance.
• In the closing process after dilation as the ET closes in a proximal-
to-distal direction,
• creates an expelling force from the relaxing cartilage and peritubal
muscles

28. PROTECTION OF MIDDLE
EAR
• The valve of the ET protects the middle ear against the reflux of
sounds and material from the nasopharynx
• the existing air pressure within the middle ear and mastoid
cavity provides a gas cushion that further inhibits the reflux of
material from reaching the middle ear

29. ETIOLOGY
• Inflammation due to infection or allergy in upper respiratory
tract

30. • Children with frequent URTI
• reflux disease in younger children
• exposure to tobacco smoke (Smoke impairs the
mucociliary function)
• primary ciliary disorders (Increased viscosity)
• Pregnancy and OCPs (high progesterone states)

31. • Anatomical obstruction of the ET from neoplasms (less common).
• adenoid hypertrophy that encroaches on the torus tubarius causes
mechanical obstruction.
• The contraction of pharyngeal constrictors during swallowing can press
an enlarged adenoid into the torus tubarius and force it anteriorly to
close the tubal orifice instead of dilating it open

32. RIGHT EUSTACHIAN TUBE WITH
INFLAMED ADENOID IN UPPER
CORNER
Closed resting position Attempt to open the
tube by swallowing

33. DYNAMIC CAUSES OF ET
• dilatory dysfunction may be due to hypoactive, hyperactive or
uncoordinated contraction of TVP or LVP muscles.
• Hypoactive TVP muscle causes decrease in anterolateral
wall dilatory movement.
• reduces lateral excursion of the anterolateral wall in the final
step of dilation.

34. • Excessive contractions have been observed in both TVP
and LVP muscles
• This leads to a bulky mass effect thereby paradoxically
impairing the valve dilation

35. RARE CAUSES
• A structural compromise or defect of the ET
• familial predisposition for tubal dysfunction
• cleft lip or palates,
• craniofacial anomalies.

36. • Primary disorders of the mucosa or submucosa such as
• Wegener’s disease,
• Samter’s triad
• granulomatous diseases are less common etiologies.

37. PATHOLOGY OF EUSTACHIAN TUBE
DYSFUNCTION
• Endoscopy of the ET in patients with ET dysfunction have
identifiable pathology within the cartilaginous portion.
• Insufficient dilation of the Eustachian tube (dilatory dysfunction
(most common type )
• patulous Eustachian tube, the failure of proper closure of the
tubal valve next common

38. • Dilatory dysfunction is most commonly due to insufficient dilation
rather than true blockage of the lumen.
• The most common finding in is mucosal inflammation within the
cartilaginous ET.
• The inflammation involves the lymphoid tissues in the torus tubarius
and the glandular mucosal surfaces of the nasopharyngeal orifice.
• The mucosa closer to the isthmus is typically much less inflamed.

39. INFLAMED TORUS TUBARIUS AND
LYMPHOID HYPERPLASIA

40. STUDY
• mucosal edema near the orifice was found in 83%
• reduced anterolateral wall movement of the ET due to the
thickness of the inflamed mucosa in 74%
• Adjacent inflammation in the adenoid is common. (values not
available)

41. TESTS FOR ET PATENCY
• 1. Valsalva test
• 2. Politzer test
• 3. Catheterisation
• 4. Toynbee's test

42. TESTS
• 5. Tympanometry
• 6. Radiological test
• 7. Saccharine or methylene blue test
• 8. Sonotubometry

43. MEDICAL TREATMENT FOR ET
DILATORY DYSFUNCTION
• Mucosal disease is the most common cause of dilatory
dysfunction.
• Identifying the underlying etiology
• Allergies are a common cause of dilatory dysfunction.
• Allergen avoidance,
• Oral or nasal antihistamines,
• nasal topical steroid drops and sprays
• mast cell stabilizer sprays,
• leukotriene inhibitors,

44. • Recurrent nasal or sinus infections should be maximally treated
as indicated.
• Granulomatous diseases usually require immunosuppressant
therapy
• Laryngopharyngeal reflux should be treated with
• behavioral and dietary modifications
• anti-reflux medications.
• fundoplication surgery (severe cases )

45. • True anatomical obstruction requires contrast
enhanced imaging to determine the etiology.
• Identified benign or malignant lesions may be indicated for
excision as the definitive therapy

46. ADENOIDECTOMY
• Adenoidectomy in dilatory dysfunction especially if the
hypertrophied adenoid tissue reaches the torus tubarius
endures good results.
• Endoscopic-assisted adenoidectomy permits more
complete removal of the tissue encroaching the torus.
• It further allows for some debulking of the hyperplastic
tissue of the torus, if considered necessary.

47. • Persistence of dilatory dysfunction despite optimal
medicaland surgical management indicates……..
• IRREVERSIBLE MUCOSAL INJURY

48. OPTIONS LEFT
• Tympanostomy tubes
• Corticosteriods
• Eustachian tuboplasty
• Balloon dilation

49. TYMPANOSTOMY TUBE
• tympanostomy tube
alleviate the negative pressure
relieve TM retraction, effusion and atelectasis.
• Effusion or inflammation that continues despite tubes in place
may indicate a primary mucosal disorder.
• Thick glue-like effusions are associated with up regulation of
the MUC genes causing increased protein production.
• These conditions will frequently respond to oral or topical
corticosteroids.

50. EUSTACHIAN
TUBOPLASTY
• In recent years, Eustachian tuboplasty is a safe and
possibly effective surgical option patients with dilatory
dysfunction.
• Candidates for Eustachian tuboplasty are
• chronic tubal dilatory dysfunction despite maximum
medical therapy.
• Recur rent tube placements due to either extrusion or
recurrence of symptoms

51. RATIONALE OF
TUBOPLASTY
• Dilation of the lumen by surgical debulking facilitates the
dilatory action of the TVP muscle
• removes irreversibly diseased mucosal tissue allowing for
regrowth of healthy mucosa.
• Submucosal tissue and cartilage within the valve region
may be removed, but the mucosa is conserved to
prevent synechiae.
• This is accomplished using either a laser or microdebrider

52. • inflamed soft tissue and cartilage removal as indicated
from the luminal side of the posteromedial wall,
beginning from the leading edge of the torus tubarius
and extending up to or into the valve.
• avoid injury to the anterolateral wall (TVP IS PRESENT)
• avoid contact with the internal carotid artery.

54. LASER TUBOPLASTY RT.ET
edematous torus
tubarius
KTP laser, fiber mucosa
and soft tissue is removed

55. A portion of cartilage that protruded into
the lumen has been divided with scissors,
and cup forceps are used for removal
The completed operative field with
tmucosal and submucosal defect. An olive
tipped curved suction is retracting the torus
tubarius medially for exposure

56. PRE AND POSTOP LEFT ET LASER
EUSTACHIAN TUBOPLASTY.
Preoperative, resting
position
Preoperative, dilated
position

57. POST OP LASER
Resting position;the torus shows a scaphoid
defect on the luminal surface; the
inflammation is markedly reduced;
Postoperative, dilated position; the
lumen is now
exposed with dilatory effort

58. • In the senior author’s two-year follow-up study of Eustachian
tuboplasty
• 38% of 13 adults had remission of their effusion.
• overall improvement rate of 68%.
• There were no significant complications.

59. FAILURE OF LASER
TUBOPLASTY
• correlated with the presence of allergies or
laryngopharyngeal reflux.
• need to continue to manage any underlying conditions
postoperatively.

60. BALLOON TUBOPLASTY
• Most recently balloon dilation of the cartilaginous ET has
• feasibility,
• safety and
• early clinical application.
• Cadaveric studies using balloon dilation catheters for
tubal dilation proved to be effective with minimal risks.

61. ADVERSE EVENTS
• minor tears in the mucosal lumen
• Failure to rotate the torus medially before inserting the
catheter results in mucosal laceration with bleeding or
a false passage into the submucosal tissues
• neither osseous cartilaginous fracture nor trauma to the
internal carotid

62. BALLOON DILATION OF A
LT. ET
Preoperative resting position of the auditory tube
with
edema and inflammation of the torus tubarius
A guide catheter is inserted into the
tubal lumen

63. The balloon catheter inserted up to 16
mm depth,
and inflated to 12 atm for two minutes
widened lumen and minimal mucosal
lacerations are appreciated

64. PATULOUS EUSTACHIAN TUBE
DYSFUNCTION
• refers to persistent patency of the tubal lumen.
• Air and sound pass unrestricted between the
nasopharynx and the middle ear space.
• disturbing amplified perception of one’s own voice and
nasal breathing sounds (autophony),
• sensation of aural fullness,
• otalgia.
• Worsens with nasal steroids or decongestants

65. ETIOLOGY
• a dramatic and substantial weight loss
• during post-pregnancy,
• cachectic diseases,
• dietary weight loss
• bariatric surgery.
• one-third have an associated systemic rheumatologic disorder
• remaining third are idiopathic.

66. ENDOSCOPIC EXAMINATION
• loss of convex bulge in anterolateral wall
• Underdeveloped lateral cartilaginous lamina
• less Ostmann’s fat
• Exercise frequently initiates or exacerbates symptoms.
• They tend to abate in the supine or head dependent
positions.

67. OTOSCOPY
• excursions of the tympanic membrane during nasal
breathing while the opposite nostril is held shut.

68. IMPEDANCE TYMPANOMETRY
• It shows ventilatory fluctuations
• sawtooth-like perturbations of the baseline
• tympanogram tracing.
• The breathing is performed irregularly not to confuse the
tracing with the regular sawtooth waveforms that can
occur from intracranial pulsations.

69. MEDICAL MANAGEMENT
• restoration of the healthy humidified mucosa and
competence
• Discontinuation of decongestants
• Discontinue topical nasal corticosteroid,
• increase their fluid intake
• adding nasal saline drops or irrigations to improve
hydration of the mucosa.

70. THERAPEUTIC OPTIONS
• saturated solution of potassium iodide (SSKI), enhances
the viscosity of the mucus.
• boric acid, salicylic acid powder, silver nitrate, nitrate
acid and phenol cause tissue inflammation and thus
increased mucus production.
• The off-label use of Premarin or depo-estradiol estrogens
cause localized mucosal hypertrophy and thus
temporary closure of the open Eustachian tube.

71. SURGICAL TREATMENT OF
PATULOUS EUSTACHIAN TUBE
DYSFUNCTION
• with tympanostomy tube placement is effective for
• aural fullness and tympanic membrane excursions.
• To alleviate autophony, complete occlusion of the
• Eustachian tube lumen can be considered.

72. • Occluding them with bone wax
• occluding it with a fat graft.
• Alternatively, autologous cartilage
• An intravenous catheter filled with bone wax can be
employed in this off-label application.

73. LEFT PATULOUS ET SHOWING
INSERTION OF IV CATHETER
The left tubal orifice
before intervention
The catheter is housed in an
introducer tool. It is being
positioned into the tubal orifice

74. The catheter is firmly
wedged into the bony-
cartilaginous isthmus
The catheter is in the final
position at the level of the
torus tubarius

75. CONCLUSION 1
• Proper function of the ET is essential for
• aeration,
• clearance
• protection of the middle ear space.

76. CONCLUSION 2
• Disorders of the ET commonly have identifiable
pathology within the cartilaginous portion of the
tube.

77. CONCLUSION 3
• In the majority of cases, these can be managed
conservatively.
• In selected cases, surgical intervention for
Eustachian tube Disorders is now possible.

78. CONCLUSION 4
• However, more data from controlled clinical trials
are needed to determine the long-term benefit of
the procedures.
• Additionally, basic science investigations are
required to better understand the etiology of
Eustachian tube dysfunction as well as the impact
of the surgical therapies.

79. BIBILIOGRAPHY
• Recent Advances in Otolaryngology Head and Neck Surgery
, Anil K Lalwani md JAYPEE BROTHERS MEDICAL PUBLISHERS
(P) LTD 2012
• Scott and Brown Otolaryngology and Head and Neck
Surgery, 7th Edition Miachel Gleeson
• Otologic Surgery 3rd edition Brackman and Shelton,
Saunders, an imprint of Elsevier publications 2010.
• Diseases of Ear, Nose, and Throat, 5th edition,
P.L.Dhingra, Elsevier publications 2012.