What treatment options are available for a slender female patient with a history of recent weight loss or pregnancy, presenting with symptoms of patulous eustachian tube?

Patulous Eustachian Tube Management in Slender Females with Recent Weight Loss or Pregnancy

Initial Conservative Management

For slender female patients with patulous Eustachian tube following weight loss or pregnancy, nasal instillation of physiological saline should be the first-line treatment, as it is effective in approximately 63.5% of patients and shows particular benefit (80% effectiveness) in those with short disease duration. 1

First-Line Medical Therapy

• Nasal saline irrigation is the primary initial treatment, with demonstrated effectiveness in controlling or eliminating symptoms of autophony and breath-synchronous tinnitus 1, 2
• Instill physiological saline nasally and assess subjective improvement after 2-8 weeks 1
• Male patients show higher response rates (81.8%) compared to females (50.0%), though the treatment remains first-line regardless of sex 1

Additional Conservative Options

• Estrogen-containing nasal ointment may be beneficial, particularly in this demographic of reproductive-age females with hormonal changes from pregnancy or weight loss 2
• Craniocervical manual therapy has been evaluated as a causal treatment option 2
• Patients should be counseled to avoid "sniffing" maneuvers, as this can trigger cholesteatoma development in combination with patulous Eustachian tube 3

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis through:

• Direct observation of tympanic membrane movement synchronous with respiration and swallowing during otoscopy 3, 4
• Tympanometry with reflex-decay to document abnormal tube patency 3
• Assess for orthostatic symptoms, as spontaneous intracranial hypotension can present with patulous Eustachian tube in slender females and may require epidural blood patch treatment 4
• Use the Eustachian Tube Score-7 (ETS-7) for patients with intact tympanic membrane 2

Surgical Intervention for Refractory Cases

If conservative management fails after 2-8 weeks:

• Soft-tissue bulking agent injection into the torus tubarius via transnasal endoscopy is the primary surgical option 3
• Use 0.8 to 2 mL of injectable soft-tissue bulking agent per procedure 3
• Approximately 67% of patients (10 out of 15) report satisfaction with results at 12-month follow-up 3
• Multiple procedures may be necessary in 45% of patients (9 out of 20) 3
• The procedure is minimally invasive, fast, and easy to perform with low morbidity 3

Critical Clinical Pitfalls

• Do not confuse with obstructive Eustachian tube dysfunction, which presents with opposite pathophysiology and requires different treatment (steroid nasal sprays, Valsalva maneuver, balloon dilation) 2
• Do not miss spontaneous intracranial hypotension in slender females with recent weight loss presenting with patulous tube symptoms plus orthostatic headache, as this requires epidural blood patch rather than standard patulous tube treatment 4
• The diagnosis is frequently missed or delayed due to the ambiguous symptom of "plugged ear" - specifically ask about autophony (hearing one's own voice loudly) and amphoric sounds (hearing one's own breathing) 3, 5
• Recognize that patulous Eustachian tube represents the opposite end of the spectrum from the more common obstructive dysfunction, where the tube remains abnormally open rather than closed at rest 6

Follow-up Protocol

• Reassess at 2-8 weeks after initiating saline therapy 1
• For surgical patients, schedule follow-up at 6 weeks, 6 months, and 12 months post-procedure 3
• Monitor for quality of life improvement, as persistent symptoms cause enormous reduction in daily functioning 3