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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 Bluestone CD. Current concepts in eustachian tube function as related to otitis media. Auris Nasus Larynx 1985, 12 (Suppl 1): S1-S4. Bluestone CD. Eustachian tube obstruction in the infant cleft palate. Ann Otol Rhinol Laryngol 1971, 80: 1-30. Deron P, Clement PA, Derde MP. Septal surgery and tubal function. Rhinology 1995, 33: 7-9. DiBartolomeo JR, Henry DF. A new medication to control patulous eustachian tube disorders. Am J Otol 1992, 13: 323-327. Dyer RK, McElveen JT. The patulous eustachian tube: management option. Otolaryngology Head Neck Surg 1991, 105: 832-835. Fernau JL, Hirsch BE, Derkay C, Ramasastry S, Schaefer SE. Hyperbaric oxygen therapy: effect on middle ear and eustachian tube function. Laryngoscope 1992, 102: 48-52. Gacek RR. A differential diagnosis of unilateral serous otitis media. Laryngoscope 1992, 102: 461-468. Halsted TH. Pathology and surgery of the eustachian tube. Arch Otolaryngol 1926, 4: 189-195. Henry DF, DiBartolomeo JR. Patulous eustachian tube identification using tympanometry. J Am Acad Audiol 1993, 4: 53-57. Holborow C. Eustachian tubal function: changes throughout childhood and neuromuscular control. J Laryngol Otol 1975, 89:47. Hsu MM, Young YH, Lin KL. Eustachian tube function of patients with nasopharyngeal carcinoma. Ann Otol Rhinol Laryngol 1995, 104: 453455. Iwano T, Kinoshita T, Hamada E, Doi T, Ushiro K, Kumazawa T. Otitis media with effustion and eustachian tube dysfunction in adults and children. Acta Otolaryngol 1993, Suppl 500, 66-69. Presswood G, Zamboni WA, Stephenson LL, Santos P. Effect of artificial airway on ear complications from hyperbaric oxygen. Laryngoscope 1994, 104: 1383-1384. Proctor B. Embryology and anatomy of the eustachian tube. Arch Otolaryngol 1967, 86: 503-514. Sade J. The nasopharynx, eustachian tube and otitis media. J Laryngol Otol 1994, 108: 105-110. Sakakihara J, Honjo I, Fujita A, Kurata K, Takahashi. Eustachian tube compliance in sniff-induced otitis media with effusion. Acta Otolaryngol 1993, 113: 187-190. Sakikawa Y, Kobayashi H, Normura Y. Changes in middle ear pressure in daily life. Laryngoscope 1995, 105:1353-1357. Shambaugh GE. Continuously open eustachian tube. Arch Otolaryngol 1938, 27: 420-425. Young Y, Lin KL, Ko JY. Otitis media with effusion in patients with nasopharyngeal carcinoma, postirradiation. Arch Otolaryngol 1995, 121: 765-768. 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.