What are the treatment options for a patulous Eustachian tube?

Treatment Options for Patulous Eustachian Tube

The most effective first-line treatment for patulous Eustachian tube (PET) is paper patching of the tympanic membrane, which provides complete symptom relief in up to 87% of patients immediately after treatment and 65.2% at 3 months. 1

Understanding Patulous Eustachian Tube

Patulous Eustachian tube is a condition where the Eustachian tube remains abnormally open, causing symptoms that significantly impact quality of life:

• Autophony (abnormally loud hearing of one's own voice)
• Breath-synchronous tinnitus
• Pressure sensation in the ear
• Conductive hearing loss
• "Plugged ear" sensation

The condition has a bimodal age distribution with:

• A peak in females in their fourth decade
• A second peak in older male patients 2

Diagnostic Approach

Diagnosis requires:

1. Thorough patient history focusing on autophony and breath-synchronous symptoms
2. Physical examination with careful observation of tympanic membrane movements
3. Tympanometry with reflex-decay
4. Use of standardized assessment tools:
   • ETS-5 score for patients with perforated ear drums
   • ETS-7 score for patients with intact ear drums 3

Treatment Algorithm

First-Line Treatments:

1. Paper Patching of Tympanic Membrane

   • Placement of cigarette paper over the most mobile quadrants of the tympanic membrane
   • Success rates: 87% immediate complete remission, 65.2% at 3 months
   • Can be repeated as needed in the outpatient setting 1

2. Nasal Saline Irrigation

   • Effective in 63.5% of patients overall
   • More effective in:
     • Patients with shorter duration of symptoms (80% success in those with recent onset)
     • Male patients (81.8% success) versus females (50%) 2

Second-Line Treatments:

1. Pharmacological Options

   • Ipratropium bromide nasal spray (can be combined with saline irrigation) 1
   • Estrogen-containing nasal ointment 3
   • Specialized nasal medications designed to produce tube closure 4

2. Soft-Tissue Bulking Agent Injections

   • Transnasal endoscopic injection into the torus tubarius
   • Dosage: 0.8-2 mL per intervention
   • Success rate: 10 out of 15 patients (67%) reported satisfaction
   • May require multiple procedures (9 out of 20 patients needed more than one injection) 5

3. Craniocervical Manual Therapy 3

Treatment Selection Factors

• Duration of symptoms: Patients with shorter duration respond better to conservative treatments like saline irrigation 2
• Gender: Males tend to respond better to saline irrigation than females 2
• Severity of symptoms: More severe cases may require more invasive approaches like bulking agent injections
• Previous treatment failures: Consider escalating to next treatment option if first-line treatments fail

Important Considerations and Pitfalls

• PET is often misdiagnosed due to ambiguous symptoms that can mimic other ear conditions
• The combination of "plugged ear" sensation with autophony is highly suggestive of PET 4
• Persistent untreated PET combined with "sniffing" behavior can potentially lead to cholesteatoma development 5
• There is currently no universally accepted gold standard treatment for PET 5
• Multiple treatments may be necessary, as the condition can be persistent or recurrent

For patients with persistent symptoms despite conservative measures, referral to an otolaryngologist for consideration of more invasive options like soft-tissue bulking agent injections is appropriate.