Download Clinical Forum: Patulous Eustachian Tube Identification Using

J Am Acad Audiol 4 : 53-57 (1993)
Patulous Eustachian Tube Identification
Using Tympanometry
David F. Henry*
Joseph R. DiBartolomeo t
Abstract
The patulous, or nonclosing, eustachian tube is believed to affect as many as 7 percent of all
adults, causing physical and psychological difficulties . This paper provides a brief review of
the literature regarding the patulous eustachian tube (PET), its symptoms, precipitating
conditions, incidence, diagnosis, and current medical management . Several case studies are
also presented to illustrate the use of tympanometry in PET identification .
Key Words:
P
Patulous eustachian tube, tympanometry
roblerns associated with failure of the
eustachian tube to open are well known
and have been the subject of considerable research (e .g ., Bluestone and Doyle, 1985).
However, problems related to the failure of the
eustachian tube to close have received much
less attention. Yet patulous, or nonclosing,
eustachian tubes can cause physical and psychological problems (Pulec and Simonton,1964),
and may be present in a sizeable part of the
clinical population (O'Conner and Shea, 1981).
The purpose of this paper is to provide a brief
tutorial and several cases as examples of
normal and patulous eustachian tube (PET)
function .
CLINICAL FACTORS OF PATULOUS
EUSTACHIAN TUBE
Symptoms
The most common PET symptom is a feeling of aural fullness and/or a plugged or blocked
ear. Unfortunately, this is also a common com-
plaint of persons experiencing a variety of middle and inner ear disorders. Auditory symptoms
include the report of autophony, or the phenomenon of being able to hear one's own voice more
loudly than usual, and hearing a loud crackling
sound when chewing. Robinson and Hazell (1989)
reported that vestibular symptoms and hearing
loss can also occur because the PET allows
excessive pressure changes to occur in the middle ear which are then transmitted to the inner
ear through ossicular movement . They reported
reducing vestibular symptoms in five of six
patients by treatment of their PET condition.
We have encountered two PET patients with
little or no hearing loss who complained of
difficulty hearing, presumably due to the masking effects of sound transmitted via the
eustachian tube to the middle ear. PET symptoms can either be continuous or episodic, occurring in one or both ears, and typically diminishing or disappearing when the patient is supine
(O'Conner and Shea,1981) . Pulec and Simonton
(1964) reported that patients can be so disturbed by PET symptoms that they give the
impression of being "psychoneurotic."
Etiology
*School of Communicative Disorders, University of
Wisconsin-Stevens Point, Stevens Point, Wisconsin ;
and t Medical Director, The Ear Foundation of Santa
Barbara, Santa Barbara and Department of Otolaryngology,
University of California, Los Angeles, California
Reprint requests : David F. Henry, School of Communicative Disorders, University of Wisconsin-Stevens Point,
Stevens Point, WI 54481
Factors that may influence the occurrence of
a PET include sudden weight loss, hormonal
changes (e .g ., as in pregnancy or use of birth
control pills), stress, fatigue, the inappropriate
use of decongestants, and temporomandibular
joint (TMJ)syndrome (O'ConnerandShea,1981) .
Journal of the American Academy of Audiology/Volume 4, Number 1, January 1993
Prevalence
The prevalence of PETs is not well known.
Munker (1980) reported finding a PET in 6
percent of a group of 100 female patients "with
normal ears" in one study, and 6.6 percent of 181
persons "with normal hearing" in a second study.
Plate et al (1979), identified a PET in 28 of 270
(10%) pregnant women tested . Kumazawa
(1985a) found that 30 percent of 100 "normal
ears" tested had abnormally patent eustachian
tubes.
The reports of prevalence contrast with the
small number ofpeople diagnosed by physicians
as having a PET. Pulec and Simonton (1964)
reviewed the records of the Mayo clinic from
1940 to 1959 and found 41 diagnoses of PET.
Munker (1980) estimated that only 10 to 20
percent of all persons with PET are bothered
enough by the symptoms to seek medical attention, while O'Conner and Shea (1981) concluded
that PETs were frequently misdiagnosed because their symptoms were very similar to serous otitis .
Diagnosis
Diagnosis of a PET by the physician is
usually made through a combination of history
and otoscopic or microscopic examination of the
tympanic membrane (TM) . It is usually possible
to observe TM movements occurring synchronously with inspiration and expiration ; the result of transmission of intraoral air pressure
changes to the middle ear through the patent
eustachian tube .
Use of Tympanometry in Identification
Although not common in audiology literature, the use of tympanometry to identify PETs
is not new (Metz, 1953 ; Bluestone, 1975 ; Rock,
1976 ; Kumazawa,1985a, b) . Kumazawa (1985b)
described three methods for using acoustic impedance for evaluating eustachian tube function . Bluestone (1975), Rock (1976), and Martin
(1991) all recommended asking the subject to
breathe through their nose while a tympanogram
was being obtained. The resulting tympanogram,
when printed, would show superimposed fluctuations in impedance occurring synchronously
with the patient's respiratory cycle. Plate et al
(1979) used a Madsen ZO-70 impedance bridge
with the sensitivity selector in position "2"
(slightly more sensitive than the setting for
obtaining a tympanogram) in their study of
54
pregnant women. With the patient breathing
through her nose, they noted the occurrence of
impedance changes synchronous with respiratory cycles . They did not specify the amount of
change necessary to indicate a PET. Kumazawa
(1985a) used a tympanometer modified to measure impedance changes simultaneously with
changes in nasopharyngeal pressure . Patients
were instructed to first perform a valsalva
maneuver, establishing a higher than normal
middle ear pressure, then swallow several times,
equalizing middle ear with ambient pressure .
Kumazawa labeled eustachian tube function as
"normal" when middle ear pressure was restored to normal with several swallows, "occluded" when pressure failed to return to normal, and "patent" or "patulous" when middle
ear pressure immediately returned to normal
without the need for swallowing .
All of the above methods for identifying
PETs with tympanometry have been reported
either in the medical research literature or in
books devoted to immittance testing. We are
aware of only one audiology textbook (Martin,
1991) that briefly describes PETs and the use of
impedance in identification of PETs .
Treatment
Fortunately, PETs are frequently transient,
resolving when the condition causing them (e .g .,
weight loss or hormonal changes) resolves (Pulec
and Simonton, 1964 ; Bluestone and Cantekin,
1981) . When PET is a chronic problem requiring
medical intervention, several methods of treatment have been reported ; none have been shown
to be effective in all cases . Methods of treatment
attempted over the years include boric acid/
salicylic acid insufflation at the pharyngeal
opening of the eustachian tube ; cauterization
with silver nitrite or diathermy ; injection of
paraffin, gelatine sponge, or Teflon ; myringotomy and insertion of ventilating tubes ; and
surgical alteration of the palatal muscles
(Misurya, 1974 ; Robinson and Hazell, 1989) .
Bluestone and Cantekin (1981) recommend
myringotomy and ventilating tubes in conjunction with insertion of a small plugged catheter
in the middle ear end of the eustachian tube .
While all of the above methods have had some
success, we have found no consensus in the
literature as to which is the best method of
treatment . We are currently experimenting with
drops, which can be applied nasally by the
patient when a PET condition is experienced .
Early results with a few patients have been
promising and a larger study is now in progress .
Patulous Eustachian Tube/Henry and DiBartolomeo
Because PETs occur in a sizeable portion of
the population and coverage of this phenomenon is sparse in the audiology literature, the
following case studies are presented to heighten
audiologists' and physicians' awareness ofPETs.
The patients in the following four case studies
were part of an ongoing study (DiBartolomeo
and Henry, 1992) of the effectiveness of a new
method of treating PETs .
instructed to close one nostril with a finger and
repeat the forced respiration cycles when asked,
as in the second condition. Closing one nostril
and performing forced breathing was requested
to increase the nasopharyngeal pressure
changes, thereby accentuating the effects of a
PET, if one was present.
CASE STUDIES
Figure 1 represents the right and left ear
admittance changes (in mmhos) of a 21-year-old
female . The top line for each ear represents the
admittance changes seen during the baseline
condition ofquiet respiration through the mouth.
The middle line for each ear represents admittance changes during forced respiration through
both nostrils . The bottom line for each ear represents admittance change during forced respiration through one nostril. No change in admittance synchronous with breathing occurred,
indicating a middle ear system with a normally
closed eustachian tube . This is consistent with
a normal response to a PET test, bilaterally .
P
atients were referred for tympanometry
after an otolaryngological examination revealed historical or physical indications of a
possible PET in at least one ear. Immittance
tympanometry was performed on all patients
using a Virtual Model 310 Digital Impedance
System controlled by a Macintosh SE/30 microcomputer . All patients were tested according to
the following protocol .
With the patient seated, testing was performed with the probe in one ear first, then in
the other ear. The order of ears tested was not
controlled . Prior to performing the PET test,
tympanograms and acoustic reflexes were obtained to evaluate middle ear function .
The Virtual acoustic reflex adaptation test
was used to test for PETs . In this test mode, up
to four separate 20-second measures of admittance changes can be obtained and displayed on
one graph. To prevent eliciting an acoustic reflex, which might obscure subtle admittance
changes, a contralateral stimulus was presented
at 60 dB HL, the lowest intensity possible with
this system. Three 20-second measures of admittance change were obtained under three
different breathing conditions . During the first
condition, the patient was instructed to sit quietly, breathing through the mouth or not at all,
while a 20-second baseline measure was obtained . The baseline served two functions. The
first was to provide a measure of TM admittance
changes when little or no nasopharyngeal pressure changes were occurring. The second purpose of the first condition was to ascertain that
the acoustic reflex stimulus tone was not eliciting a reflex response . We observed no admittance changes that occurred as a result of the
relatively low intensity contralateral stimulus
in any patient.
During the second condition, the patient
was instructed to breathe in and out through
the nose as deeply as possible when the examiner indicated. Patients usually performed three
forced respiration cycles in the 20-second period . During the third condition, the patient was
Case 1
'Case 2
Figure 2 shows the right and left ear admittance changes of a 38-year-old female . The right
ear PET results are similar to the normal ear
results shown in Figure 1. Left ear admittance
changes for the forced respiration conditions
were at least .05 mmhos, and occurred synchronously with each respiratory cycle . This patient
was diagnosed as having a normally functioning right eustachian tube and a patulous left
eustachian tube .
Right Far: 21-year-old female .
u
0.60
mmho
0 .50
Quiet Breathing
0 .40
E 0
.30
°a
Deep Breathing; Both Nostrils
0.20
Deep Breathing; One Nostril
0.10
0.00
0 .0
2.0
4 .0
6.0
8.0
10.0
12.0
14 .0
Time (seconds)
16 .0
18 .0
20 .0
Left Eac 21-year-old-female.
mhn
0.60
r 0.50
Quiet Breathing
0.40
q 0 .30
a
Deep Breathing; Both Nostrils
0.20
0 .10
0 .00
0.0
Deep Breathing One Nostril
y
2.0
Figure 1
4 .0
6.0
8.0
10 .0
12 .0
14.0
Time (seconds)
16.0
18.0
20.0
Admittance changes of a 21-year-old female
duringthree different breathing tasks; normal responses .
55
Journal of the American Academy of Audiology/Volume 4, Number 1, January 1993
Case 3
left Ear : 33-year-old female .
Admittance changes from the left ear of a
33-year-old female are shown in Figure 3. In
this case she held her breath for the first test
and breathed quietly through the nose for the
second test. The admittance changes during
quiet breathing occurred synchronously with
her respiratory cycles and were greater with
forced respiration through one nostril. This patient has a history of chronic otitis media as an
adult, which might seem paradoxical given her
concurrent history of bilateral PETs . However,
she has a habit of constantly sniffing, which
created a negative pressure in the middle ear
that helped to keep the eustachian tube closed
and relieve her PET symptoms . We believe this
precipitated build-up of fluid and infection, resulting in episodes ofchronic otitis media, which
this patient has had for several years. Sniffing
in order to minimize symptoms has been reported by other investigators (Suehs, 1960 ;
O'Conner and Shea, 1981).
Case 4
Figure 4 presents the right ear responses of
an 18-year-old male during forced respiration
through both nostrils . The patient reported
having a temporomandibular joint (TMJ) problem and only experiencing PET symptoms-when
his jaw was in certain positions. The top line
represents admittance changes with the jaw in
Bight Ear: 38-year-old female .
0.68
mmho
0 .s0 J
Quiet Breathing
0 .40
E
Q
Forced Inspiration/Explratlon ;
Both Nostrils
0 .30
0 .20 -`
Forced Inspiration/Expiration;
One Nostril
0.10
0.110
0 .0
2 .0
4 .0
6 .0
8 .0
10.0
12 .0
14 .0
Time (seconds)
16 .0
18.0
+= Begin Inspiration
Figure 3 Left ear admittance changes of a 33-year-old
female with a history of chronic otitis media.
a position in which no symptoms were experienced. The bottom line represents admittance
changes when the jaw was deviated laterally to
a position at which the patient reported increased PET symptoms .
Case 5
Figure 5 shows the right ear admittance
changes of a 23-year-old female without PET
symptoms . This patient was being tested as a
normal subject and had a negative history of
hearing loss or otologic problems . Admittance
changes synchronous with respiration were
obtained in all three conditions . Immediately
after obtaining these results, visual examination of the tympanic membrane (TM) under
microscope was performed. TM movement was
observed, visually confirming bilateral PETS .
Even after we identified the presence of PETS,
this patient was not bothered enough by them to
seek medical treatment.
This patient was one of five patients originally tested as a normal subject for vestibular
research who also underwent PET testing. As
part of the research protocol, each had under-
20 .0
Bight Ear : 18-year-old male .
Left Ear: 38-year-old female .
0.60
mho
(1.50
°m
0.40
Both Nostrils
Forced Inspiration/Expiration
;
Both Nostrils
Forced Insplrarlon/Expiration;
One Nostril
0.00
0.0
d0
2 .0
4 .0
6 .0
8 .0
10.11
12 .0
14 .0
Time (seconds)
16 .0
18.0
20 .0
2.0
4 .0
6 .0
8 .0
10 .0
12.0
14 .11
'Time (seconds)
v
16.0
Forced Inspiration/Expiration ;
Bolh Nostrils
18.0
20 .0
+= Begin Inspiration
+= Begin Inspiration
Figure 2 Admittance changes of a 38-year-old female .
Right ear responses are normal, while admittance changes
occurring in conjunction with forced inspiration indicate
the presence of a PET.
56
jaw set to maximize symptoms
Figure 4 Right ear admittance changes of an 18-yearold male with abnormal TMJ function . Movement ofjaw
to a position that increased symptoms resulted in increased admittance changes with forced inspirationexpiration .
Patulous Eustachian Tube/Henry and DiBartolomeo
Right Ear: 23-year-old female.
0 .0
2 .0
4 .0
6.0
8.0
should trigger at least additional questioning
by the audiologist or physician, and when appropriate, a PET test.
10 .0
12 .0
14 .0
11- m-ondsl
16 .11
18.0
20.0
+- Begin 1nphati",
Figure 5 Right ear admittance changes of a 23-yearold female with no complaints or reported symptoms of a
patulous eustachian tube . Note admittance changes that
occurred in conjunction with respiratory cycles during
quiet breathing.
gone an initial otoscopic examination, and on a
medical history questionnaire reported a negative history of hearing or balance problems
otitis media, or noise exposure . Of the five, two
exhibited signs of a PET condition. A perplexing
question for researchers is why some people are
very aware of and upset by this condition while
others are not.
DISCUSSION
T
hese case studies were selected because
they demonstrate both normal and abnormal responses, and represent some of the more
common causes and complaints of the chronic
PET condition. It should be noted that immittance testing is not diagnostic, it only indicates abnormal function . A positive PET immittance test in isolation should be followed up
medically.
The case of the "normal" patient with no
complaints demonstrates some of the perplexing questions regarding this condition. Why
some patients exhibit the objective signs of a
PET, yet do not complain of the subjective
symptoms of the disorder is a question not yet
answered .
We believe PET is underdiagnosed, and
through greater physician and audiologist
awareness, more cases will be identified . The
results presented above demonstrate the role
that audiologist and tympanometry can play in
identifying PETS. While these results were obtained using a sophisticated computer controlled system, the test itself can be performed with
most immittance equipment . Subjective complaints of poor hearing in conjunction with normal hearing sensitivity, fullness ofthe ears with
normal tympanograms, and report of hearing
voice and breathing more loudly than normal
Acknowledgment. Presented at the American Speech,
Language and Hearing Association National Convention, November, 1991 .
This research was supported by the Ear Foundation
of Santa Barbara.
Special appreciation is expressed to Dr . Jeffrey L.
Danhauer for his valuable comments on this manuscript .
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