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Personal Report
Medical references to hearing loss and injuries
And long term dysfunction of audio antimony
As reported by
Mr Michael Stewart Parnell
This report is for submission before
Stockport Magistrates Court
and is for the purpose to give information
as to the medical condition that explains the
difficulties of the expelling of air under force
through the nasal openings.
In the case of
R v Parnell 14th May 2009
Introduction
My name is Mr Michael Stewart Parnell. I am writing up this report to
present before Stockport Magistrates Court for submission in my defence
to the case R v Parnell 14th May 2009.
This case being, contrary to section 39 Criminal Justice Act 1988 of the
malicious allegation of common assault, sneezing/blowing nose on
person.
The writing of this report is to give a full account to the information that
would be required on the grounds of a medical basis.
This report is to help understand the reasoning why medically and also
dignifiedly could not happen, so to show that, the allegation is fabricated.
The sneeze or the blowing of my nose to that which under is alleged,
“exhaling very strongly through the nose“, could not be performed on the
grounds that medically it would cause severe pain and further damage to
my hearing anatomy.
My writing of this report will inform you of my encounters of the medical
problems that had congenially developed before birth, and since then had
deteriorated, and also the further associated trauma’s has complicated the
medical condition further.
The research that has now been read has only been done so, as to write
this report, and the readings of reports and research is that my condition is
now confirming that which I have suffered, my GP’s medically have very
little understanding to what my general hearing problems are.
This report will guide you through, my accounts of what I know, and will
also make reference to other person accounts of what they suffer, and will
draw upon medical research and reports, and will be reporting this in a
format that’s in plain English, and I hope will help to show and inform
anybody, and I mean anybody who is not medically competent, as to how
my or their hearing and nasal autonomy works.
In this report I will try to show through diagrams and writing, a simple
explanation, as to why I know that the allegation was fabricated, and
without a full understanding of the facts was uninformatively compiled.
To understand the anatomy
The above picture shows the relation of the Ear Canal and the Eustachian
tube and that they are separated by the Tympanic Membrane(ear drum).
In simple understanding, the Eustachian Tube connects the inner ear to
the nasal passage, (nose to ear) we all know that when we blow our nose
we feel pressure in our ears, and when we change altitude or swim
underwater that external pressure being greater than internal pressure
causes pain in the ear, and this is sometimes counteracted by holding and
blowing down your nose, if in the instance when one sneezes or blows
down ones nose hard, the internal pressure then being greater than
external pressure, this causes pain to the ear drum or the middle ear, then
how can this pain be counteracted, well in simple terms this cant when
there is a Eustachian Tube Dysfunction, and this can be any number of
medical reasons, therefore pain relief, might not be forthcoming without
other interventions, (an action that might seem daft is lying down or
standing on ones head (upside down relieves pain with some conditions),
how many people have you seen sneeze or blow their nose hard, and then
lie down or put their head between their knees or do cartwheels, a less
dignified why of sneezing or blowing your nose is with your mouth open,
this is the only way that some condition sufferers can prevent pain from
accruing, the open mouth could counteract pressure in the nasal cavity.
What we all take as every day common activities, like breathing, seeing,
hearing, touching, smelling, tasting or thinking, might for some sufferers
effect their every day normal activities, and in ways which most of us
could or would not ever understand, this from my point is that I have had
to adapt things which I do every day and night, to that which is only
possible to do with that what I have been given or has been sustained.
As far back as I can remember I have always had problems with my
hearing, that is with both hearing loss or associated conditions, and the
pain caused with congenial condition or associated sustained trauma’s.
To start with what I can remember, I had to have prolonged courses of
radiation treatment as a child before the age of 3 and hearing test to 6, this
was because there was under development in my bones, and one
condition was, being very badly bowlegged and under sized for my age.
As a child there was things I remember, ear pain, common ailments,
colds, sore throats, runny noses, sore eyes and all which most children go
through, the difference what I remember and what I have been told by
relatives is that with myself it was continuous, and with all the things that
made me unwell I was continuously being treated by doctors for my
physical development and hearing tests.
When as a child what do I remember the most, well I look to my
childhood as events that happened, and these things seen only to be
feeling hurt, pain, and not being able to explain how, and what was
happening to me physically and emotionally, when I cried because my
ears hurt, why did nobody help to make it stop, and why when I would try
to explain, would people just say stop your crying and grow up.
Now as an adult what do I see as my childhood, I don’t see anything that
corrected my hearing, there was no relief I just took this was the way it
was to be, and that would be the best I was going to have, and so I just
had to get on with it, this I went along with until now, and this is on the
readings to do this report that I have found there should have been more
done, and how things were just covered over, because people couldn’t
explain why or was unable to understand adequately, in a way this was
fifty years ago, if things were happening now, adults would be brought to
task as failing to adequately care for a child’s welfare.
As a adult I can now say, without doubt and the understanding why, I can
without question confirm, that I cant forcefully exhale down my nose.
Hearing tests at the age of 6 years old confirmed that there was a
perforation to the left Tympanic Membrane, it is now known to me that at
this age because of the perforation, I now believe was down to internal
pressure rupturing the ear drum outwards, was with the effect to relieve
the pressure it was to insert a grommet, this type of treatment was
common in young children at my time, but as I know now it was only a
short term cure, the grommet could block or heal over, thus being back to
square one, with a added danger of risk of tearing to the scaring area
where the perforation or the incision of the grommet was in the ear drum.
As a young child in primary school I always remember having my right
ear flicked because it stuck out, and also being ear slapped by boys who
would pick on me because I was small with a stuck out ear, (someone to
make fun of who could not and would not fight back), I was made
ridicule of, and this followed on into secondary school.
At the age of 11 years in secondary school I was attacked by two 15/16
year old boys, (who were expelled for what they did to me) they attacked
me with a baseball bat, beating me about the head and body, splitting the
cartilage of the right ear and bursting the skin, cut repaired 5 stitches,
damage to bone upper left eye socket and of left cheek to temporal bone,
I was beaten all about the body and my outer clothes were ripped from
me, the beating lasted a long time, I was found lying on the ground with
concussion, dizziness, and ringing in ears continually suffered (thinking
now the ear ache I still feel or imagine now is to what had happened then,
this is worst after than that I felt before this attack), hearing loss in school
means I now know that this is with the consequences to a failing of
hearing and understanding what was being spoken in classroom with
echoing sounds, hissing, ringing, drumming dull hums all affected my
concentration, effecting subjects that require multi contact and
concentration on others, such as English, maths and science.
I excelled in things that if I was left on my own with, this is now where I
believe I get my logical skills from, I have a proven ability to work things
out, and understand how they are or how things have happened, this past
ability that I have gained reaffirms, that I can work out from the facts,
along with the knowing that I would not, or am able to sneeze or exhale
strongly through my nostrils, this inability and the capability to work
things out I will prove beyond reasonable doubt that the sneezing
allegation has been fabricated, and I will prove that this has been done as
to cover over, all the accusers past malicious allegations, and that has
been done which was to hide and cover up their and their employers own
past unlawfulness.
When entering my adult life I went into the working world of a noisy
industrial working environment, this in turn as had its tolls with further
deterioration of my hearing.
When the prospects of that working job coming to a close, I decided to
pursue an activity and job together, I love driving and would have loved a
job driving anything that held the responsibility of trust in competently
driving a large vehicle proficiently, and applied for a heavy goods vehicle
driving licence, with that what’s required in a medical, and with one
being requested from my GP, of that what was required to apply for a
licence, the medical being completed and being passed as approved, my
GP had only commented to wax in my left ear, would prescribe some ear
drops to soften the wax and to come back and the nurse to remove the
remnants.
What next is when things went wrong to the worst they could be, my GP
decided as he had a free appointment to syringe my ears there and then,
and has I was paying to have the HGV medical this would be a way to
justify his cost that was to be charged, he got a kidney bowl made of
stainless steel, a syringe the biggest I have ever seen, like one used to ice
a cake, also made of stainless steel, good and solid no chance of breaking,
he got a towel put it on my left shoulder under my ear, filled the kidney
bowl with water from one tap, took the syringe and drew water into it by
pulling up on the plunger, placed the syringe tip in my ear canal it was
tight the tip was icy cold and I started to feel pain I pulled away but my
GP just forced the syringe down harder, he then with one forceful
unrelenting movement depressed the plunger, pain, excruciating pain the
worst pain one could ever describe, cold ice of a frozen knife cut through
my ear, it felt like it was ripping my head apart from inside of my brain I
could not control my cry, the towel on my shoulder was no use the icy
cold water had in an instant made its way, where to, my nose with the
force of a runaway locomotion with no driver at the controls (I’ve
watched a film when a train crash through a station buffers), well this was
my nose water exploded from my nostrils, spray blasted a good distance,
and the back pressure was forcing water like a ripping iceberg down my
throat, choking me in the process, what has just happened disaster
derailment I was knocked of my seat and down to the floor, on the ground
with the force that seemed like an explosion, I tried to get up, choking
and getting my footing, I could not stand my balance was knocking me
back, the GP lifted me to the chair and commented that doesn’t seem
right, and he suggested he would make an appointment to send me to
hospital.
while sat on the chair he gave me the towel to wipe myself, and then gave
me some paper towels to hold to my ear, and suggested when the water
had dried up I would feel a lot better, he said I would get the report and a
letter for the hospital through the post, and as his next appointment was
now waiting, I was done and should leave, and asked me to wait for a
while in the waiting room until my awareness came back and ask if
anyone could come to collect me, my wife was in work and I was making
my own way home, after what seemed a lifetime of pain I had to leave
and get out of there to go somewhere and lie down, it was hard to stand
and keep my balance, I got home and lay on the bed.
The next day I couldn’t attend work as I kept falling down, work
informed me as I was in PPP the private patient plan I was covered to go
private, and with which my wife phoned BUPA and made an
appointment, I went to hospital and had surgery to repair the damage
done, this was performed before I even got a letter to go hospital as
referred by my GP, this GP we had kept with after leaving that area and
moving 15 miles away, so as not to lose the opportunity of the infertility
treatment we had been going through for the previous 12 years, with what
had happened we changed our Doctor to where we then lived, and the
reaction from the old GP was “it was chance that I’d gone to him, as if I
hadn’t, I wouldn’t have known if there was anything wrong with my
ears“, (this is not what you want to hear from your GP, what was in my
records that were there before I went to him of when I was a child he
must never had read), my mother at this time informed me that she knew
of that in my health records it stated I was never to have my ears
syringed.
How does the past condition and the subsequent trauma’s effect me now,
firstly there is always a dull ache from my left ear that goes down to my
left shoulder that constantly reminds me how I react to normal daily and
night time conditions, I have to sleep in a way that is comfortable, on my
right side, I suffer dizziness when lay on my back, and if I sleep with
little or no pillow I wake with a bad headache sometimes as severe as a
migraine, because of being deaf in the left ear and lying with the right ear
to the pillow means I can now only hear little muffled sounds through the
pillow, this is always a worry, in case something happens during the
night, this is something I constantly worry about, I have two girls who are
not the best of sleepers one does sleepwalk regularly, and they are both
known to be smoking, and do this in their bedroom, the dispute with the
local authority is over the care for the children who are from the care
system, the children have taken not to listen to guidance we give them, as
they see this as us stopping them doing what they choose to do.
The worry has not always been the case, I could sleep on my left side
with my good ear listening, this was before the doctor damaged my left
ear and I could also sleep on either side or my back, and as it was on one
night when sleeping I was woken by a woman’s frantic cries she was
trapped in her house which was a raging inferno, and on being woken
from hearing her cries took action to rescue her and prevent the fire
spreading, and suppressed it enough to stop its course to the next house, I
was commended for my quick thinking and taking action to rescue the
lady by ladder from an upstairs window after which I again climbed to
put in the upstairs room bedding round the door, less oxygen to feed the
fire, gathering the ladies bag on the way out that she was requesting me to
recover, then going round to the rear of the property to rescue her dog
from the kitchen and blocking the doors and windows and alerting the
family and couple on either side, this was all before the fire brigade
arrived, a senior fire officer said I saved the ladies life through my quick
thinking and prevented any further loss of life by my actions in
suppressing the fire course, this I am extremely proud of, I know how
easily it can happen, and a constant worry, while I cant hear when I sleep.
The effects suffered, has on me during the day, is the annoyance of the
uncomfortable feeling I have in my ears, mostly the left side, but I also
can say as with your eyes you can feel them as being tired, this type of
feeling is also with my right ear, the more I try to listen the harder its is
used the harder it is to hear the sounds, I also feel fullness in my ears, and
the muffled sound of breathing down my nose, the ringing and humming
in my ears, there is also sometime when the wind blows to the right side
that if I close my mouth I would say it feels like it blows straight through
and comes out the left side, there is pressure that is like a mild headache,
the state of deafness is with my left ear, sounds that are not directional
come to my right side, if I face that side to the sound is directional, but is
hard to tell where it comes from if I don’t face it with my right ear,
speaking to someone is difficult I don’t lip read but it helps me to hear
what they say while I see their lips move, and I am only able to listen to
what one person is saying, when a lot of people talk or make noise in one
place the sounds merge together, get muffled and distorted.
It is my body and I know best what happens to it, I would say I am the
expert, and those of us who are able to think straight, are all experts on
our own bodies, even the expert doctors ask us what is wrong with us
when we go to see them, thus meaning they have to know if we know
what could be wrong before they can, so that they can get a true
understanding of what is wrong, the doctors or the experts as to what type
of treatment.
EUSTACHIAN TUBE PROBLEMS
MECHANISM OF HEARING
The ear is divided into three parts: an external ear, a middle ear and an
inner ear. Each part performs an important function in the process of
hearing.
The external ear consists of an auricle (outer ear) and ear canal. These
structures gather the sound and direct it toward the eardrum membrane.
The middle ear chamber lies between the external and inner ear. This
chamber is connected to the back of the throat by the Eustachian tube
which serves as a pressure equalizing valve. The middle ear consists of an
eardrum and three small ear bones (ossicles): malleus (hammer), incus
(anvil), and stapes (stirrup). These structures transmit sound vibrations to
the inner ear. They act as a transformer, converting sound vibrations in
the external ear canal into fluid waves in the inner ear. a disturbance of
the Eustachian tube, eardrum or the bones may result in a conductive
hearing impairment. This type of impairment is usually correctable
medically or surgically.
The inner ear chamber contains the microscopic hearing nerve endings
bathed in fluid. Inner ear fluid waves stimulate the delicate nerve endings
which in turn transmit sound energy to the brain where it is interpreted. a
disturbance in the inner ear fluids or nerve endings may result in a
sensorineural (nerve) hearing impairment. This type of impairment is
usually not correctable.
Eustachian Tube Function and Dysfunction
July 11, 1996
Ronald B. Kuppersmith, M.D.
The eustachian tube is an 3-4 cm tubular structure which links two of the
major areas of interest the nose and the ear. Dysfunction of the eustachian
tube causes many common symptoms that present many important
management implications. This report will consists of a review of the
history, anatomy and physiology of the eustachian tube, and the role of
the eustachian tube in clinical situations.
History
The first description of the eustachian tube is attributed to Alcmaceon of
Sparta in 400 BC. It was his belief that the eustachian tube allowed goats
to breath through their ears as well as their noses.
In 1562, Bartolomeus Eustachius, the Chair of Anatomy in Rome,
published the first detailed description in his thesis Epistola de Auditus
organis, accurately describing the structure, course, and relations
eustachian tube.
Antonio Valsalva, Professor of Anatomy at Bologna, applied the name
"Eustachian Tube" to the pharyngotympanic tube, which was described
by Eustachius.
In 1724, around the time of Valsalva, Edme-Gilles Guyot, a postmaster at
Versailles, described the technique of eustachian tube catheterization. He
succeeded in relieving his own deafness by passing a curved pewter tube
through his mouth into the opening.
Since that time many noted otolaryngologists, including Drs. Politzer,
Bezold, and Bluestone, have contributed significantly to our
understanding of the intricacies of eustachian tube anatomy and function,
and management of the various disorders that it is embroiled in.
Development and Anatomy
Understanding the development and anatomy of the eustachian tube
provides insight into its role in several pathologic processes. The
eustachian tube develops as a persistence of the first pharyngeal pouch.
At 10 weeks post conception only the epithelial lining of the lumen has
differentiated. Between the 10th and 12th weeks post conception the
levator veli palatini and tensor veli palatini muscles develop. At 14 weeks
the tensor tympani muscle becomes apparent, cartilage differentiation
begins and rugae begin to develop within the tube.
The tube increases in length from 1 mm at 10 weeks post conception to
13 mm at birth. Also, the angle between the eustachian tube and the skull
base is 10 degrees at birth.
This is in contrast to the adult length of 35 mm and angle of 45 degrees in
adults. Vertical development of the skull, and increases in the angle of the
skull base, allow the eustachian tube to reach its adult length and angle by
age 7.
Basic Anatomy
In the adult, the eustachian tube can be visualized as two truncated cones
attached at their narrowed ends. It runs from the middle ear to the
nasopharynx and is approximately 31-38 mm in length. Its lumen is
roughly triangular and has average diameter of 2-3 mm. The lumen is
lined by ciliated psuedostratified, columnar epithelium, which sweeps
material from the middle ear to the nasopharynx. Mucous glands
predominate near the pharyngeal orifice, and there is a gradual change to
a mixture of goblet, columnar, and ciliated cells as the middle ear is
approached.
The eustachian tube is composed of an osseous and a cartilaginous
portion. The osseous eustachian tube or protympanum measures 11 to 14
mm and extends from the anterior and medial portion of the petrous
temporal bone. Its orifice is oval shaped, measures 5 x 2 mm and is
located above the floor of the middle ear space. When healthily, the
osseous portion of the eustachian tube is always patent. The cartilaginous
portion measures 20-25 mm and opens into the nasopharynx
approximately 10 mm above the plane of the hard palate. The cartilage
protrudes into the nasopharynx, and the protruding portion is known as
the torus tubarius. The fossa of Rosenmuller is this area in the
nasopharynx superior to the torus tubaris.
The cartilaginous portion is composed of one main piece of cartilage and
can be accompanied by several accessory cartilages. Its composition and
elasticity is similar to that found in the pinna and nose. It is attached at
the sphenoid sulcus on the base of skull superiorly and its anteriomedial
end is attached to a small tubercle on the posterior edge of the medial
pterygoid plate.
Blood Supply and Innervation
The blood supply to the eustachian tube is from branches of the internal
maxillary artery, ascending pharyngeal artery, and the ascending palatine
artery. Sensory and motor innervation of the eustachian tube is provided
by a branch from the otic ganglion, sphenopalatine nerve, and the
pharyngeal plexus, predominately through branches of the
glossopharyngeal nerve. Sympathetic branches reach the eustachian tube
from the sphenopalatine ganglion, otic ganglion, glossopharyngeal nerve,
petrosal nerves, and the carticotympanic nerve. Parasympathetic
innervation is from the tympanic branch of the glossopharyngeal nerve.
The multiple nerves innervating the eustachian tube, may be a source for
referred pain to other anatomic regions of the head and neck.
Muscles of the Eustachian Tube
There are four muscles associated with the eustachian tube. These include
the tensor veli palatini, levator veli palatini, salpingopharyngeus, and the
tensor tympani.
The tensor veli palatini is composed of two distinct bundles of muscle
fibers mediolateral to the tube. The lateral bundle takes its origin from the
scaphoid fossa, and the lateral osseous ridge of the sulcus tubae for the
course of the eustachian tube. It descends anteriorly and lateral and
inferiorly, to converge in a tendon which passes around the hamulus and
inserts on the posterior border of the horizontal process of the palatine
bone and into the palatine aponeurosis of the velum.
The medial most portion of the tensor veli palatini originates on the
lateral membranous wall of the eustachian tube and blends with the
lateral bundle of the tensor veli palatini. This medial portion of the tensor
veli palatini, referred to as the dilator tubae muscle, is probably
responsible for active dilation of the eustachian tube by inferolateral
displacement of the membranous wall.
The levator veli palatini arises from the inferior aspect of the petrous
apex, passes inferomedially, paralleling the tubal cartilage, and attaches to
the dorsal surface of the soft palate. It is thought to assist in active
dilation and provide support.
The salpingopharyngeus arises from the medial and inferior portion of
the eustachian tube and descends posterior and inferior to blend with the
palatopharyngeus muscle. Its physiologic function is undefined.
The tensor tympani muscle arises from fibers common to the tensor veli
palatini. The tendon of the tensor tympani rounds the cochleaform
process and inserts into the manubrium of the malleus. It is not thought to
play a role in eustachian tube function.
Normal Function
The normal eustachian tube is functionally collapsed at rest, with slight
negative pressure present in the middle ear. It opens during swallowing,
sneezing, and yawning. The eustachian tube is thought to close through
passive reapproximation of the tubal walls by extrinsic forces and recoil
of the elastic fibers.
The eustachian tube has three functions: ventilation, drainage, and
protection. When the eustachian tube is patent it allows ventilation of the
middle ear and equalization of middle ear and atmospheric pressure. It
also allows the middle ear to clear unwanted secretions. By staying
physiologically obstructed, it protects the middle ear from
nasopharyngeal secretions and sound.
Conditions interfering with normal eustachian tube function cover the
pathologic spectrum from benign to malignant. Resultant middle ear
complications can be the primary condition that the clinician needs to
address, may be a sign of something more serious, or may have
implications that will affect the outcome of surgical interventions.
Eustachian Tube Dysfunction
Bluestone has classified eustachian tube disorders into obstructive
disorders, and disorders of abnormal patency.
Obstructive disorders can be mechanical or functional. Mechanical
obstruction can be intrinsic due to intraluminal factors such as mucosal
inflammation due to allergy or infection, or extrinsic obstruction resulting
in compromise of the lumen. Extrinsic obstruction can be physiologic
such as when the patient is supine, or may be caused by a mass lesion
such as a neoplasm or an adenoidal mass.
Functional obstruction results from persistent collapse of the eustachian
tube due to increased tubal compliance, an abnormal opening mechanism,
or both. Functional obstruction is more common in infants and young
children, and in many cases can be related to normal or abnormal
developmental factors.
Evaluating Eustachian Tube Function
There are many methods for evaluating the condition of the eustachian
tube, which reflect its deep location and complex physiology.
During the physical examination, otoscopy, pneumatic otoscopy, indirect
nasopharyngoscopy, and endoscopy of the nasopharynx can provide clues
to the condition of the eustachian tube.
Several maneuvers can be easily performed that may indicate patency of
the eustachian tube. These include the Valsalva test, the Toynbee test, the
Politzer test, and eustachian tube catheterization.
The Valsalva test is performed by visual inspection of the tympanic
membrane while the eustachian tube and middle ear are inflated by a
forced expiration with the mouth closed and the nose occluded by the
thumb and forefinger. The test is positive when an intact tympanic
membrane is observed moving, or by air heard through a perforated TM.
A positive valsalva test only indicates an anatomically patent and
probably distensible eustachian tube.
The Politzer test is performed by visual inspection of the tympanic
membrane while compressing one naris into which the end of a rubber
tube attached to an air bag has been inserted while the opposite naris is
compressed with digital pressure. The patient is asked to repeat the letter
K or to swallow while air is injected into the nasal cavity. When positive,
the overpressure that develops in the nasopharynx is transmitted to the
middle ear, and only indicates an anatomically patent ET tube.
Both the Politzer and Valsalva test may be beneficial as a temporary
treatment of effusion or high negative middle ear pressure.
The Toynbee Test is performed by visual inspection of the tympanic
membrane while the patient swallows with their nose manually occluded.
This generates a positive pressure within the nasopharynx, followed by a
negative pressure phase and is considered positive when there is an
alteration in middle-ear pressure as assessed by pneumatic otoscopy
before and after the manoeuvre. Negative middle-ear pressure or
temporary negative middle ear pressure followed by return to ambient
pressure after the Toynbee test usually is indicative of normal eustachian
tube function. This is in contrast to the Politzer and Valsalva tests which
only test patency. The results of this manoeuvre can often be equivocal,
since several studies have shown that a significant portion of normal
adults and children can not open their eustachian tubes with this
manoeuvre, and patients with patulous eustachian tube often can not
maintain a negative pressure within their middle ears.
Eustachian tube catheterization can be performed, and also can indicate
eustachian tube patency.
Radiographic evaluation includes computed tomography, and magnetic
resonance imaging. The use of contrast materials to evaluate patency has
been described in the past, but is infrequently used today.
There are several more complex methods of evaluating eustachian tube
function that have been described and most involve the use of
manometry, sonometry, of tympanometry. Besides tympanometry most of
these tests require complex equipment, and are mainly used in a research
setting.
Non-intact Tympanic Membrane Tests
 The Inflation-Deflation test
 Forced Response test
 clearance test
Intact Tympanic membrane tests
 pressure chamber technique
 sonometry
 tympanometry
Clinical Examples Of Eustachian Tube Dysfunction
Here are a small sample of the clinical scenarios where eustachian tube
dysfunction is important:
OTITIS MEDIA WITH EFFUSION
Obstruction may result in persistent high negative middle-ear pressure. If
pressure equalization does not occur, atelectasis of the tympanic
membrane-middle ear, sterile otitis media with effusion, or both can
occur. If the negative pressure is overcome, it can aspirate secretions from
the nasopharynx resulting in an acute otitis media.
Serous otitis media with effusion can result from either inadequate
ventilation of the middle ear or from reflux of unwanted nasopharyngeal
secretions into the middle ear. Both types of eustachian tube dysfunction
can result in otitis media, abnormal patency and obstruction.
This is common in children and infants probably due to the configuration
of their eustachian tube, shorter length, and lower efficiency of their
tensor veli palantini.
While serous otitis media is something that many of us treat on a daily
basis, Dr. Gacek of Syracuse reminds us, in an article entitled "A
Differential Diagnosis of Unilateral Serous Otitis Media", of the
potentially serious nature of this condition. Clinicians need to maintain a
high index of suspicion, particularly in adults, in unilateral cases, and in
persistent or recurrent cases. From Dr. Gacek's article, it is important to
remember:
1 The Eustachian tube lumen can be obstructed and this is usually from
inflammatory, allergic or functional disorders.
2 The nasopharynx is usually obstructed by adenoid hypertrophy, but
extensive nasal polyposis, benign neoplasms, and malignant neoplasms
also may present in this location.
3 Obstruction may occur from laterally in the infratemporal fossa, by
parapharyngeal space masses and neoplasms, or skull base lesions.
4 Medial obstruction from the petrous apex may be caused by solid or cystic
lesions, including congenital epidermoids, cholesterol granulomas,
neurofibromas, internal carotid artery aneurysms and other rare petrous
apex lesions.
5 Effusion of CSF from the middle ear and mastoid caused by temporal
bone trauma, surgery, or congenital defects may mimic otitis media with
effusion and must be remembered as part of the differential diagnosis.
Dr. Gacek reinforces the importance of a thorough head and neck
examination including the nasopharynx, CT scan of the head including
the neck, and myringotomy as the minimal workup in any pediatric or
adult patient with unilateral recurrent or persistent serous otitis media
without an obvious explanation for eustachian tube obstruction.
He also emphasizes that in pediatric patients, the eustachian tube lumen
and nasopharynx are the anatomic locations most frequently responsible,
but congenital CSF leaks should be suspected in patients with a history of
meningitis, or if the fluid after myringotomy resembles CSF.
In adults, all levels should be suspected.
NASOPHARYNGEAL CARCINOMA
Patients with nasopharyngeal carcinoma frequently have complications
that relate to their eustachian tube. The frequently present with serous
otitis media. Also, high-dose radiation therapy, the treatment for
nasopharyngeal carcinoma, causes edema, vasodilation, mucosal damage,
and fibrosis of the eustachian tube and middle ear resulting in damage to
the middle ear contents and poor middle ear ventilation.
While it seems intuitive that serous otitis media with effusion in patients
with nasopharyngeal carcinoma would be caused by mechanical
obstruction of the pharyngeal orifice of the eustachian tube, several
studies question whether nasopharyngeal tumors, actually obstruct the
lumen of the eustachian tube, and instead propose that eustachian tube
dysfunction and resulting otitis media with effusion is caused by
infiltration of the tensor veli palatini muscle.
With regard to patients after radiation, a study by Hsu, et al, in 1995,
showed that 95% of 38 eustachian tubes were patent prior to radiotherapy,
34% where patent at 6 months after radiotherapy, and 60% were patent at
5 years after radiotherapy using the passive opening test. They also
showed decreased dynamic function and clearance at six months after
radiotherapy and improved at 5 years. They attributed these findings to
inflammation caused by radiation rather than tumor obstruction.
Electromyographic evaluation of the tensor veli palatini in patients with
nasopharyngeal carcinoma status post radiation indicated neurogenic
paralysis.
These authors have also found that in patients treated with ventilation
tube insertion for post-irradiation OME tend to develop a chronic
draining ear, and deterioration of hearing. They suggest myringotomy,
avoidance of ventilating tubes, and frequent local treatment of infections
of the nose, sinuses, and nasopharynx to avoid this outcome.
PATULOUS EUSTACHIAN TUBE
Patulous eustachian tubes often present a frustrating problem for patients
and clinicians. The incidence is reported to be between 0.3-6.6% of the
general population.
Patients with patulous eustachian tubes complain of aural fullness,
humming tinnitus, and autophony. They also may hear their own breath
sounds, which is known as tympanophonia. The sound is synchronous
with nasal respiration and resolves when the patient is supine or when
upper respiratory tract inflammation occurs. The sounds may be
aggravated by mastication.
Symptoms are usually absent when the patient is supine or relieved when
the patient bends forward with the head between the knees. For this
reason, patients should not be examined in a supine position. Physical
examination may reveal a tympanic membrane that moves during forced
breathing through one nostril, and an amorphic sound may be heard using
a diagnostic tube in the patient's ear.
The Eustachian tube is usually closed, and closure is maintained by the
elasticity of its cartilage, mucosal lining, surrounding muscles and fat.
Alteration of any of these anatomic components may cause patulous
eustachian tubes.
Conditions associated with patulous eustachian tubes include: radiation
therapy, hormonal therapy, pregnancy, nasal decongestants, fatigue,
stress, and weight loss.
Patulous eustachian tubes in the most severe form may be patent at all
times, whereas a less severe form has been reported, where the tube is
anatomically closed at rest, but may open easily during exercises or in
association with a decrease in peritubal extracellular fluid.
Many patients can be treated with simple reassurance after a thorough
history and physical examination. Treatment or removal of underlying
factors may reverse the problem. Such as weight gain by patients who
have lost weight.
Many medical regimens have been described including agents which
produce intraluminal and extraluminal swelling, including: insufflation of
boric acid and salicylate powder as described by Bezold, application of
nitric acid and phenol, oral administration of saturated solution of
potassium iodide (10 drops in juice TID), premarin nasal spray (25 mg in
30 cc NS).
New medications are currently under investigation including a herbal
combination being evaluated in Japan, and a medication reported Dr.
DiBartolomeo of Santa Barbara, California that is composed of
chlorobutanol, benzyl alcohol, diluted hydrochloric acid, and propylene
glycol. In the initial report, complete elimination of symptoms was
reported by 8 of 10 patients. This formulation was derived from
chlorinated pool water based on the observation that several patients had
eustachian tube congestion proportional to the frequency of time they
spent in a public pool. In letter to the editor in American Journal of
Otology, Dr. DiBartolomeo indicated that the medication was held up
with the FDA.
In patients who do not improve with medical therapy and who want
further treatment, several surgical interventions have been used including
electrocauterization of the eustachian tube orifice, peritubal injection with
gelfoam, paraffin, avitene, or teflon paste, transposition of the tensor veli
palatini muscle medial to the pterygoid hamulus, myringotomy with
ventilation tube placement, and insertion of an indwelling catheter and
subsequent ventilation tube placement. Catheter placement is through
either an anterior tympanomeatal flap or through a myringotomy.
The close anatomic relationship of the eustachian tube and the carotid
artery should be noted by clinicians who plan inject materials into the
eustachian tube orifice, as injection of telfon paste into the carotid artery
has been reported.
HYPERBARIC OXYGEN THERAPY
Another clinical situation where proper eustachian tube function is
important is in the use of hyperbaric oxygen therapy, particularly in
patients who require multiple sessions.
Hyperbaric oxygen therapy involves intermittent inhalation of 100%
oxygen under greater than 1 atmosphere of pressure and is being used
increasingly in patients with decompression sickness, osteomyelitis,
carbon monoxide poisoning, crush injuries, radiation necrosis, and poorly
healing wounds. Many of these patients develop otalgia and aural fullness
that may be long-standing. Reports in the literature indicate that the
incidence of middle ear barotrauma ranges from 5% to 28% of all
patients.
Fernau, et al suggest patients should be taught clearing techniques such as
the Valsalva or Politzer manoeuvre, supplemented with topical and/or
systemic decongestants, subjected to slower compression rates, or
possibly have ventilation tubes placed.
In a study of 33 patients undergoing hyperbaric oxygen therapy by
Fernau, et al. in 1992, 82% of patients developed fullness in their ears,
52% developed serous otitis media, and 21% developed otalgia requiring
ventilation tubes. Of 11 patients managed with decongestants,10 patients
resolved their effusion and pain and did not require further therapy. 45%
of 33 patients had evidence of pre-existing eustachian tube dysfunction
using the inflation-deflation test. Of these patients 100% developed aural
fullness, 87% developed serous otitis media, and 47% required
tympanostomy tubes. Fernau, et al, identified a history of eustachian tube
dysfunction as a risk factor for serous otitis media in patients undergoing
hyperbaric oxygen therapy.
An article by Presswood, et al, points out that the middle ear complication
rate in intubated patients receiving hyperbaric oxygen therapy is 94%
compared to 46% of non-intubated patients. They state that the use of
nasal decongestants in this population is controversial, and probably of no
value in patients who are intubated. They recommend ventilation tubes
should be placed in their ears prophylactically.
OTHER CLINICAL SITUATIONS
Obviously, there are many more clinical situations that the role of
eustachian tube dysfunction is important. Disorders of the eustachian tube
present important issues that in diagnosis and management that are faced
in daily clinical practice. Despite the large volume of literature on
eustachian tube dysfunction, the lack of well-designed prospective studies
make the literature difficult to decipher, and these disorders continue to
represent some of the most challenging management problems we face as
otolaryngologists.
Summary
The eustachian tube is an important anatomic structure that ventilates,
protects, and drains the middle ear.
During development the eustachian tube lengthens and the angle between
it and the skull base increases from 10 degrees in infancy to 45 degrees in
adulthood.
Eustachian tube dysfunction can be caused by mechanical obstruction,
which may be intrinsic or extrinsic, by functional obstruction, or by the
presence of patulous eustachian tubes.
Otitis media with effusion is a common sequalae of eustachian tube
dysfunction, but a high index of suspicion must be maintained in adults,
in unilateral cases, and in patients with recurrent or persistent disease
without an obvious explanation.
Case Presentation
A 54-year-old male was referred to the Bobby R. Alford Department of
Otorhinolaryngology and Communicative Sciences for evaluation and
management of a right patulous eustachian tube. The patient had
previously undergone a right myringotomy and ventilation tube
placement without resolution of his symptoms.
He complained of right aural pressure and autophony for over one year.
The autophony was particularly bothersome while singing. The patient
had a history of high pitched noise exposure while in the military, and
wears ear protection while at work. He denied headaches, nausea,
vomiting, vertigo, otorrhea, otalgia, ear trauma, or ear surgery. He had no
history of recent weight loss, and the remainder of his medical history
was unremarkable.
Physical examination revealed his left tympanic membrane to be clear,
intact, and mobile. The right tympanic membrane had a scar in the
anterior inferior quadrant, but was otherwise unremarkable. The right
tympanic membrane did not move with swallowing or Valsalva
manoeuvre. There were no masses noted in the nasopharynx. The rest of
physical examination was unremarkable.
The patient had an audiogram which was remarkable for symmetric
severe sensorineural hearing loss above 2000 hertz bilaterally. He had
Type A tympanograms bilaterally.
The patient was reassured of his condition and Premarin nose drops were
started, but the patient failed to respond. The patient was given the option
of surgical intervention, and has noted an improvement in symptoms 2
weeks status post eustachian tube obliteration and ventilating tube
placement.
Bibliography
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Finding a solution for people with Patulous Eustachian Tube
What is Patulous Eustachian Tube?
Patulous Eustachian tube, also known as patent Eustachian tube, is the
name of a rare physical disorder where the Eustachian tube, which is
normally closed, instead stays intermittently open. As a result, when it is
open, all of the patient's breathing, talking, swallowing, heart beat, etc.
vibrates directly on the ear drum creating an effect that sounds like the
patient has a bucket on his/her head. The medical term for this
phenomenon is autophony, the hearing of self-generated sounds.
Diagnosis
Many patients will be misdiagnosed with this disorder due to the fact that
the symptoms closely resemble those of standard congestion (due to cold
or allergies) or Eustachian tube dysfunction. The problem with this is that
treatment for congestion or Eustachian tube dysfunction will make
Patulous Eustachian Tube worse because the disorders are opposite one
another. The use of tympanometry or even the use of nasally delivered
masking noise when conducting a hearing assessment is highly sensitive
to this condition
What it Sounds Like
With Patulous Eustachian Tube you hear ALL of your breaths echo on
your ear drum, and they aren't muffled. (2) Everything on the outside
world sounds the same. Some people are very debilitated by the perceived
volume of their voice, causing them to speak very quietly. You may find
that lying down or bending over closes the tube and eliminates the
problem. Many people lie down to speak on the phone.
What others will notice
Your voice will sound lower to other people because with the Eustachian
tube open the trachea has more volume. Most people will ask if you have
a cold because your voice sounds "stuffed up."
Pet systems and consequences
At the beginning, patients hear their own voice “from inside”, amplified
and unpleasant. Patients avoid to speak and retire in a rising solitude.
They enjoy lying with the head down (it increases venous blood pressure
and congestion of the mucosa). With time, appears the respiratory
autophonia. At this stage, they hear “from inside” also their respiration. It
starts to be unbearable. They may develop a true depression with
sometimes suicide feelings. A psychological supervision should be
systematic.
Eustachian Tube Blockage
Do you have Eustachian Tube Blockage?
In order to hear, we have an ear drum that vibrates with the sound and 3
little bones located in the middle ear that move back and forth in order to
transmit the sound to the inner ear where the nerves are. In order for the
ear drum and the bones to move properly, the middle ear space has have a
pressure equal to that of the air outside the ear. But if you change altitude,
the pressure outside changes and you have to adjust the middle ear
pressure. This is done through the Eustachian tube (ET), which connects
the middle ear to the nose and the outside. When people blow the nose
too hard, this can close the ET. Any nasal congestion, swelling can do
this. A growth in the back of the nose can press on this opening too. This
is why we are concerned when the ET is blocked on one side without an
obvious cause, we must look for the cause. Inhaled toxins can injure the
ET system too.
With blockage, patients are aware that they can't hear as well; this is
because the closure of the ET causes a vacuum to form in the middle ear
that prevents the normal vibration of the ear drum. If this closure persists,
the body tries to fill this vacuum and the normal air containing cells of the
mastoid bone change to mucous making cells and give a condition called
Serous Otitis Media or fluid filling the middle ear.
When the ET is blocked, a nasal decongestant such a Zephrex LA is
useful. Proteolytic enzyme preparations with papin and bromelain (make
sure you use a formula with calibrated enzyme activity) are especially
helpful. Drink huge amounts of hot tea. The important thing is to be
VERY gentle on trying to clear the ears because you can do more harm
by forcing. You may hold the nose and try to gently force air out the ear.
Or put your tongue to the top of the mouth and swallow. In my office we
use the" cookie machine", a tank of helium with a nasal adapter. When
the patient says "cookie" we deliver a jet of helium to inflate the ears.