ET TUBE DISORDERS

1. DISORDERS OF EUSTACHIAN
TUBE
DR V RACHIT

2. INTRODUCTION
• Eustachian tube also called as auditory
or pharyngotympanic tube connects
nasopharynx with tympanic cavity
• About 36mm in length
• It is divided into 2 parts
1) Bony part - Lateral 1/3rd
2)Fibrocartilagenous part - Medial 2/3rd
• Bony part is always open
• Fibrocartilagenous part is closed at rest
but opens during swallowing, yawning,
sneezing and forceful inflation

3. FUNCTIONS OF EUSTACHIAN TUBE
1) Ventilation and regulation of middle ear pressure
2) Protection of middle ear against pressure changes(nose blowing)
and loud sounds from nasopharynx
3) Drainage of middle ear secretions into the nasopharynx by
mucociliary clearance
4) Prevention of autophony
Eustachian tube dysfunction(ETD) affects the above functions
Eustachian tube dysfunction can be
A) ACUTE - Common cold or allergic rhinitis
B) CHRONIC (More than 3 months) - Patulous eustachian tube

4. TUBAL BLOCKAGE
• Tubal blockage results in negative
pressure in the middle ear and
retraction of tympanic membrane
• If negative pressure further increases
it causes locking of the tube with
collection of transudate and later
exudate
• Blockage can be
a) Mechanical
- Intrinsic causes- URTI, Allergy, Sinusitis
-Extrinsic causes - DNS, Nasopharyngeal
tumors, Hypertrophic adenoids

5. b) Functional - Functional obstruction is
caused by collapse of tube due to poor
function of tensor veli palatini
SYMPTOMS OF TUBAL OCCLUSION
• Otalgia
• Tinnitus
• Hearing loss
• Popping sensation
SIGNS OF TUBAL OCCLUSION
• Retracted tympanic membrane
• Congestion along the handle of
malleus and pars tensa
• Transudate behind tympanic
membrane

7. ADENOIDS AND EUSTACHIAN TUBE FUNCTION
• Adenoid hypertrophy is one of the most
common cause of eustachian tube
dysfunction in children
• Adenoids cause tubal dysfunction by
1)Mechanical obstruction of the tubal
opening
2)Acting as a reservoir for pathogenic
organisms
3)Inflammatory mediators in allergy
causes tubal blockage
• Adenoids can cause otitis media with
effusion or recurrent acute otitis media
• Adenoidectomy can help both these
conditions

9. CLEFT PALATE AND TUBAL FUNCTION
• Tubal function is disturbed in cleft palate
patients due to
a) Abnormalities of torus tubarius leading
to difficulty in tubal opening
b) Tensor veli palatini does insert into the
torus
• Otitis media with effusion is common in
these patients
• Even after reapir of cleft palate, many of
them require require grommet insertion
to ventilate middle ear

10. DOWN SYNDROME AND TUBAL FUNCTION
• Eustachian tube dysfunction occurs due
to
1)Poor tone of tensor veli palatini
2)Abnormal shape of nasopharynx
• Children with down syndrome are more
prone to otitis media with effusion or
recurrent acute otitis media

11. AERO-OTITS MEDIA(OTITIC BAROTRAUMA)
• Non suppurative condition
• Due to failure of ET to maintain middle ear
pressure at ambient atmospheric level
MECHANISM
- ET allows passive egress of air from middle
ear to nasopharynx if middle ear pressure is
high
-But when nasopharyngeal pressure is high air
cannot enter the middle ear unless tube is
actively opened as in swallowing, yawning or
Valsalva manoeuvre

12. - When atmospheric pressure is higher than
middle ear by critical level of 90mm Hg ET gets
locked
- In locked ET, soft tissues of pharyngeal end of
tube are forced into the lumen
- In presnece of ET edema, even smaller
pressure changes causes locking of the tube
SYMPTOMS
1) Earache
2) Conductive hearing loss
3) Tinnitus
4) Vertigo and SNHL rarely which occurs when
there is rupture of labyrinthine membranes

13. SIGNS
1) Retracted and congested tympanic
membrane
2) Middle ear may show air bubbles or
hemorrhagic effusion
TREATMENT
The main aim is to restore middle ear
aeration
- In mild cases, decongestant nasal drops
or oral antihistaminics are helpful
- In presence of fluid in middle ear,
myringotomy may be done

14. PREVENTION
1) Avoiding air travel in upper respiratory infections
2) Swallowing repeatedly during descent or chewing gum
3) Avoiding sleep during descent as swallowing decreases during sleep
4) Performing Valsalva during descent
5) Using decongestant nasal drops or antihistaminics half an hour
before descent in patients with previous episode of barotrauma
OTHER CAUSES OF BAROTRAUMA
1)Underwater diving
2)Compression in pressure chamber

15. RETRACTION POCKES AND EUSTACHIAN TUBE
• In ventilation of middle ear cleft, air
passes from eustachian tube to
mesotympanum
• From mesotympanum to attic, aditus,
antrum and mastoid air cells
• Mesotympanum communicates with
attic through anterior and posterior
isthmi
• Anterior isthmus is situated between
tendon of tensor tympani and stapes
• Posterior isthmus is situated between
tendon of stapedius and short
process of incus

16. • Any obstruction in the pathways of ventilation
can cause retraction pockets or atelectasis of
tympanic membrane
1) Obstruction of ET → Total atelectasis of
tympanic membrane
2) Obstruction in middle ear → Retraction
pocket in posterior part of middle ear
3) Obstruction of isthmi → Attic retraction
pocket
4) Obstruction at aditus → Cholesterol
granuloma and collection of mucoid
discharge in mastoid air cells
• Principles of mangement of retraction
pockets and atelectasis of middle ear
would dend on the repair of the irreversible
pathologic process and establishment of
ventilation

17. PATULOUS EUSTACHIAN TUBE
• In this condition, ET is abnormally patent
• Most of the time it is idiopathic
• Predisposed etiology
- It may become patent during exercise or rapid
weight loss due to reduction of Ostmann's pad
of fat which contributes to the closure of
eustachian tube
- Longitudinal concave defect in the mucosal
valve of the anterolateral wall of the eustachian
tube
- Neuromuscular disorders (strokes, polio,
multiple sclerosis, and Parkinsons)
- Scarring in nasopharynx (Adenoidectomy,
irradiation)

18. CLINICAL FEATURES
- Autophony
- Breath synchronous tinnitus
- Aural fullness
- Decreased hearing
- Movement of tympanic membrane in synchrony with respiration(Diagnostic)
DIAGNOSIS
- Patulous ET can be mostly diagnosed by history and examination of tympanic
membrane
- Tympanometry with refex decay is helpful in diagnosis but requires an intact
tympanic membrane
- Tubomanometry is also useful in diagnosis and moreover does not require an
intact tympanic
- Nasal endoscopy may be done to rule out longitudinal defect in superior
anterolateral wall of tubal valve

19. MANAGEMENT
1) MEDICAL MANAGEMENT
- Mucus thickening agent : 1 g/cc of saturated potassium iodide oral
solution in a 30-mL dropper bottle with 7 to 10 drops in 8 ounces of
juice or water taken orally three times a day - induce swelling of ET
opening
- Nasal steroids
- Antihistamines
- Inhaled and systemic decongestants
2) PROCEDURES
- Repeated insufflation to the eustachian tube orifice with a mixture of
boric acid and salicylic acid powder
- injection of Teflon paste anterior to the orifice of the eustachian tube
- Myringotomy
- Botulinum toxin A (Botox) injection to peritubal muscles

20. 3) SURGERIES
A) Cauterization of the lumen of the E.T. with insertion of a fat graft
B) Patulous ET reconstruction - Autologous cartilage is used to re-
establish the valve's competence without inducing tubal dysfunction
C) Surgery on the tensor veli palatini muscle - Transposition of the
muscle tendon off the hamulus or removal of the hamulus
D) Endoscopic Ligation of the Patulous Eustachian Tube
E) Politzerisation/Otovent/Ear popper - Automated device applied to
the nose and delivers a regulated flow of air into the nasal cavity under
physiological conditions
F) Laser tuboplasty - Using a KTP laser(Potassium titanium phosphate),
inflammed or hyperplastic tissue is removed from ET orifice
G) Balloon Dilation Eustachian Tuboplasty - A balloon catheter is
introduced into ET via the nose under transnasal endoscopic vision and
is then filled with saline upto a pressure of 10 bars for about 2 minutes

23. OTITIS MEDIA WITH EFFUSION
• Also called as
- Serous otitis media
- Mucoid otitis media
- Secretory otitis media
- Glue ear
• Insidious condition characterised by
accumulation of non purulent effusion
in middle ear cleft
• Effusion is thick and viscid
• Fluid is sterile

24. PATHOGENESIS
• Malfunctioning of eustachian tube - Failure of middle ear aeration
• Increased secretory activity of middle ear mucosa
AETIOLOGY
• Malfunctioning of eustachian tube
1. Adenoid hyperplasia
2. Chronic rhinitis and sinusitis
3. Chronic tonsillitis - Obstruct soft palate movement and interfere with
physiological opening of eustachian tube
4. Benign and malignant tumours of nasopharynx - unilateral serous otitis
media in adults
5. Cleft palate
• Allergy
• Unresolved otitis media- Inadequate antibiotic therapy in ASOM may lead to
residual infection which

25. SYMPTOMS
1) Conductive type of hearing loss
2) Delayed and defective speech in children
3) Mild ear pain
SIGNS
1) Dull and opaque tympanic membrane
2) Loss of light reflex
3) Grey or bluish tympanic membrane
4) Fluid levels and air bubbles may be seen
5) Restricted mobility of TM
6) Thin leash of blood vessels along the
handle of malleusor at TM periphery unlike
ASOM where there is marked congestion
7) Varying degree of TM retraction

26. HEARING TESTS
1) Tuning fork tests - Shows conductive hearing loss
2) Audiometry - Conductive hearing loss of 20 - 40db
3) Impedance audiometry - Presence of fluid is indicated by reduced
compliance and flat curve with a shift to negative side (B - type curve)
4) X ray mastoid - Clouding of mastoid air cells
TREATMENT
1)MEDICAL
a) Topical or systemic decongestants relieve edema of ET
b) Antihistaminics in allergy
c) Steroids in allergy
d) Antibiotics in URTI and unresolved ASOM
e) Valsalva manouvre at regular intervals

27. 2)SURGICAL
a) Myrgotomy and aspiration - A small radial
incision is given in postero-inferior or antero-
inferior quadrant and fluid is sucked out
b) Grommet insertion - A grommet is usually
inserted after aspirating the fluid to provide
continuos aeration of middle ear
c) Tympanotomy/cortical mastoidectomy -
Required to remove loculated thick fluid or
any cholesterol granuloma if present
d) Surgical treatment of causative factor -
Such as adenoidectomy or tonsillectomy

28. SEQUELAE OF CHRONIC SECRETORY OTITIS MEDIA
1) Atrophic tympanic membrane and atelectasis of middle ear
2) Ossicular necrosis
3) Tympanosclerosis
4) Retraction pockets and cholesteatoma
5) Cholesterol granuloma