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PANEL ON EXPERIENCES WITH TESTING EUSTACHIAN TUBE FUNCTION

CURRENT CLINICAL METHODS, INDICATIONS AND INTERPRETATION OF EUSTACHIAN TUBE FUNCTION TESTS

CHARLE S

D .

BLUESTONE ,

M D

ERDE M

I.

CANTEKIN ,

PhD

 

PITTSBURGH.

PENNSYLVANIA

Eustachian tube (ET) dysfunction is the most important factor in the pathogenesis of otitis media and related conditions. The impor­ tance of the function of the E T in relation to the middle ear-mastoid air cell system is compared to the critical role that laryngeal function has in its relation to the tracheobronchial-pulmonary system. However, because of its obscure location, the E T is not as easily assessed by clinical or laboratory methods as is the larynx, and therefore, its function is not as well understood. Most clinicians do not include E T func­ tion testing as part of their evaluation of patients with middle ear (ME) disease. Pneumatic otoscopy, the Toynbee test, tympanometry, the 9-step inflation-deflation tympanometric test, and the patulous tube test can be performed when the tympanic membrane is intact. The modified inflation-deflation test employing the pump-manometer of the electroacoustic impedance bridge can assess the function of the E T when the tympanic membrane is not intact. These tests are helpful in the diagnosis of the presence or absence of abnormal E T function; if a dysfunction is present, these tests help to determine whether or not the tube is obstructed (mechanically or functionally) or abnormally pa­ tent, and in some instances, the degree of the malfunction. Even though testing of the function of the E T in the clinical setting has severe hmitations at present, and further research is needed, information can be gained which is useful in the diagnosis and management of ME disease. Failing to recognize and assess the function of the E T in relation to the M E and mastoid in selected patients is as irrational as ignor­ ing the function of the larynx in patients with disease of the lower respiratory tract.

INTRODUCTIO N

Abnormal function of the E T appears to be the most important factor in the pathogenesis of middle ear (ME) disease. This hypothesis was first sug­ gested more than 10 0 years ago by Politzer.' How­ ever, later studies^'* suggested that otitis media (OM) was a disease primarily of the ME mucous membrane, ie, due to infection or allergic reactions in this tissue, rather than related to dysfunction of the ET . Figure 1 is an attempt to incorporate these hypotheses and thus, to resolve the controversy.

The vast majority of patients with OM and re­ lated conditions have (or have had in the past) ab­ normal function of the E T that may cause secon­ dary mucosal disease of the ME, ie, inflammation.' Infection is secondary to reflux, aspiration, or insuf­ flation of nasopharyngeal bacteria up the E T and into the ME. ' Inflammation (infection or possibly allergy) may also cause intrinsic mechanical ob­ struction of the ET. ' Unrelated to the function of the ET , hematogenous spread of bacteria into the ME may also result in OM; the commonly postu­ lated example of this mechanism is meningitis as.sociated with OM in infants. A much smaller number of patients may have primary mucosal disease of the ME as a result of allergy (although this has not been proven), or, more rarely, an ab­ normality of the cilia, eg, Kartagener syndrome.'

Fig.

EUSTACHIAN

TUBE

DYSFUNCTION

INFECTION

ALLERGY

CILIARY OYSMOTILITY

•OTHER'"

1. Etiology and pathogenesis of otitis media.

Since abnormalities of E T function may result in ME disease, we need to review our current knowledge of the physiology and pathophysiology of the E T with regard to the pathogenesis of OM before selecting methods to test tubal function and interpreting the results of these tests for the purpose of selecting among management options. The func­ tion of the E T will be compared with the function of the larynx to put into perspective for the modern otorhinolaryngologist the importance of the ET.

O F

COMPARISO N

TH E EUSTACHIA N TUB E

O F TH E FUNCTION S

AN D

LARYN X

The physiologic functions of the E T cannot be isolated from the other components of the ME system: the nose, nasopharynx, and palate at the proximal end, and the ME and mastoid air cells at the distal end (Fig. 2). Likewise, the larynx is with­ in a system made up of the pharynx at the proximal

From the Department

grant from the National

Presented

REPRINTS — Charles D. Bluestone, MD , Department of Otolaryngology,

of Otolaryngology,

University

Otological

of Pittsburgh School

of

and Communicative

Society,

Inc.,

Medicine,

and Childrens

Hospital

of Pittsburgh.

1981.

125 DeSoto

Supported in part by a

15213.

Institute of Neurological

of the American

Disorders and Stroke,

lPOl-NS-16337.

May 9-10,

at the meeting

Vancouver,

British Columbia,

Children's Hospital of Pittsburgh,

Street, Pittsburgh, PA

552

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PANEL

ON EXPERIENCES

WITH

TESTING

EUSTACHIAN

TUBE

FUNCTION

MIDDLE EAR

MASTOID

\

EUSTACHIAN TUBE

553

PHYSIOLOGY

PATHOPHYSIOLOGY

PATHOLOGY

EUSTACHIAN

TUBE

HEARING

VENTILATIO N

 

PROTECTION

PUMP

DRAINAGE

 

OBSTRUCTION

MECHANICAL

FUNCTIONAL

ABNORMAL

PATENCY

ATELECTASIS

LARYNX

PHONATION

COUGH

RETRACTION

 

SEGMENTAL

POCKET

ATELECTASIS

EFFUSION

MIDDLE

EAR

PULMONARY

EFFUSION

 

EDEMA

INFECTION

REFLUX

OTITIS

ASPIRATION

MEDIA

 

PNEUMONIA

SUPPURATIVE

BACTERIAL

OTITIS

MEDIA

PNEUMONIA

TIS

Fig. 2. Nose-nasophar- ynx-eustachian tube-mid­ dle ear-mastoid system

compared to the pharynx-

larynx-tracheobronchial-

pulmonary system.

end, and the tracheobronchial-pulmonary system distally. Within their respective systems, the E T and the larynx play critical roles in the functions of the ME and lungs, respectively, in their connections to the aerodigestive tract. The tympanic membrane (TM) and malleus (which may be compared to a rib) and tensor tympani muscle (which may play a role similar to that of the intercostal muscles) could even be compared to the rib cage and diaphragm of the pulmonary system. The mastoid air cell system,

in its role as a reservoir for gas for the ME , can also be compared to the reserve volumes of the lungs. Physiologically, both the E T and the larynx have ventilatory, protective, and drainage functions. The E T ventilates the M E to regulate M E pressure, which maintains optimum hearing. The larynx ven­ tilates the lungs to provide respiration which, in man , has also evolved phylogenetically into phona­ tion. In order to perform these critical physiologic functions, the E T and larynx must protect the ME - mastoid and the tracheobronchial-pulmonary sys­ tems from unwanted secretions. In the absence of swallowing, the ME and mastoid are protected (also from nasopharyngeal sound pressures) by the func­

tional collapse of the normal ET ; however,

during

swallowing, the normal E T actively opens

due to

contraction of one muscle, the tensor veli palatini,'""'^ and the palate seals off the naso­ pharynx from the contents of, and extreme pressure developed in, the oropharyngeal cavity. The lar­ ynx, on the other hand, is open (by the activity of one paired muscle) when swallowing is not occurr­ ing but closes during swallowing activity. The epiglottis, although less important in humans, pro­ tects the glottis during swallowing much like

palatal closure protects the nasopharyngeal end of the ET .

Both systems have clearance (or drainage) func­ tions primarily provided by the mucociliary activity of their mucosal linings, but the larynx is integrally involved in coughing, acting to clear (and therefore

to protect) the lungs. Likewise, the E T is now thought to have a pump-like activity that actually "milks" secretions out of the ME and mastoid."

The pathophysiology of the E T can also be com­ pared to that of the larynx. Both can be obstructed mechanically (anatomically) or functionally. Clear­ ly, both structures can have intrinsic (due to inflam­ mation) or extrinsic (as from a tumor) mechanical obstructions. However, functional obstruction of the E T is much less easy to visualize conceptually than this type of obstruction of the larynx and tra­ cheobronchial tree. Functional obstruction of the larynx caused by bilateral vocal cord paralysis (in the median or paramedian position), or laryngo­ malacia, or, more distally, tracheobronchial mala- cia, is well known and understood. However, an abnormally compliant (floppy) E T or an abnormal tubal opening mechanism, even though it may have similarities to the pathophysiology of laryngeal dys­ function, is not as easily understood. This is because the larynx, trachea, and bronchi are more readily available for examination, and have been studied much more than the ET . Other instances in which laryngeal abnormalities may lead to disease include 1) aspiration pneumonia caused by an abnormally patent or incompetent glottis (eg, paralysis of the vocal cords in the lateral position); 2) reflux esopha­ gitis, which can also cause aspiration pneumonia, resulting from incompetence of the esophagogastric junction; and 3) cricopharyngeal achalasia re­ sulting in a similar condition. The analogies in the ME system include 1) "reflux otitis media" caused by the reflux of nasopharyngeal secretions through an abnormally patent (patulous or semipatulous) E T ; and 2) the aspiration through the E T of secre­ tions into a ME that has high negative pressure. Nasal obstruction may have an effect on both E T (Toynbee phenomenon)' and pulmonary function.

Some of the pathologic conditions found at the distal ends of the two systems are also comparable.

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554

BLUESTONE-CANTEKIN

Atelectasis of the TM, which is analogous to pul­ monary atelectasis, is the result of hypoaeration of the ME. A retraction pocket of the posterosuperior or pars flaccida areas of the TM could be likened to segmental pulmonary atelectasis, for instance, ate­ lectasis of the right middle lobe; both of these con­ ditions may result from the unique anatomies of the parts involved. A middle ear effusion (MEE) which is sterile may develop in a way similar to that in which pulmonary edema develops, and suppurative OM could be compared to bacterial pneumonia in their pathogenesis.

In conclusion, then, the larynx plays a well- recognized and critical role in the functioning of the pulmonary system, but while the E T plays a similar role in the ME system, this latter role is poorly un­ derstood. This is due to the obscure location of the E T and the limited methods available to assess its function. The larynx and tracheobronchial-pul- monary system have been extensively studied by many different methods, some of which are quite simple. For instance, laryngeal function can readily be assessed by indirect laryngoscopy, one of the simplest assessment techniques, although more so­ phisticated laryngeal and pulmonary function tests are available and used frequently in clinical prac­ tice as well as in the laboratory. Unfortunately, since the E T is not as accessible to the clinician or investigator, and therefore has not been studied as extensively as its counterpart, it is thus not as well understood. However, in spite of these disadvan­ tages, it is as important to assess the function of the ET of a patient with tympanic membrane-middle ear-mastoid disease as it is to assess the function of the larynx of a patient who has tracheobronchial or pulmonary disease. The various instruments avail­ able to the clinician and investigator, as well as the methods of assessment of E T function, have been described in detail elsewhere.'" In the following dis­ cussion only the instruments and assessment tech­ niques available to the clinician will be reviewed.

INSTRUMENTATION NEEDED TO ASSESS EUSTACHIAN TUBE FUNCTION IN THE CLINICAL SETTING

Prior to the examination of the patient, the pres­ ence of certain signs and symptoms may be helpful in determining if E T dysfunction is present. How­ ever, as in the assessment of laryngeal and pul­ monary function, the presence or absence of these signs and symptoms, eg, airway obstruction, stri­ dor, hoarseness, dyspnea, cough, may only help in determining if dysfunction is present and, when present, may not determine the type, location, or severity. Likewise, conductive hearing loss, otalgia, otorrhea, tinnitus, or vertigo may or may not be present with E T dysfunction.

Otoscopy. Visual inspection of the T M is one of the simplest (and oldest) ways to assess the function­ ing of the ET; however, like auscultation of the

chest to diagnose pulmonary disease, it has severe limitations. The appearance of a ME E or the pre­

sence of high negative ME pressure, or both, as de­ termined by the pneumatic otoscope," is presump­ tive evidence of E T dysfunction, but the type, ie, obstruction (functional vs mechanical), as well as the degree of abnormality, cannot be determined by this method. Moreover, a normal-appearing TM cannot be considered to be evidence of normal func­

semi-

patulous E T may

to be normal. In addition, the presence of one or more of the complications or sequelae of OM (such as a perforation or atelectasis, as observed through the otoscope) may not correlate with dysfunction of the E T at the time of the examination, since E T function may improve with growth and develop­ ment.

be present when the TM appears

tioning of the ET : for instance, a patulous or

Many otolaryngologists use the otomicroscope to improve the accuracy with which OM and related conditions are diagnosed. For assessment of TM mobility, the otomicroscope, when used with the Bruening pneumatic otoscope and a nonmagnifying lens, is superior to the conventional otoscopes.

Nasopharyngoscopy. Indirect mirror examina­ tion of the nasopharyngeal end of the E T is also an old but still important part of the clinical assess­ ment of a patient with ME disease. For instance, a neoplasm in the fossa of Rosenmuller may be diag­ nosed by this simple technique. The development of endoscopic instruments has greatly improved the accuracy of this type of examination but, unlike in­ direct and direct laryngoscopy (and bronchoscopy), the function of the E T cannot be determined with the aid of currently available instruments.

Tympanometry. The use of an electroacoustic impedance instrument to obtain a tympanogram is an excellent way of determining the status of the TM-ME system, and can be helpful in the assess­ ment of E T function." The presence of a MEE or high negative ME pressure as determined by this method usually indicates impaired E T function; however, unlike the otoscopic evaluation, the tympanogram is an objective way of determining the degree of negative pressure present in the ME. Unfortunately, assessing the abnormality of values of negative pressure is not so simple; high negative pressure may be present in some patients, especially children, who are asymptomatic and who have rel­ atively good hearing, while in others, symptoms such as hearing loss, otalgia, vertigo, and tinnitus may be associated with modest degrees of negative pressure or even with normal ME pressures. Alberti and Kristensen" have suggested that the limits of norma l M E pressur e fo r adult s ar e betwee n -i- 5 0 and - 50 mm H2O, while Brooks'* feels that the nor­ mal ME pressure in children may be as low as - 175 to -20 0 mm H2O. However, these values depend upon the time of day, season of the year, or the con-

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PANEL

ON EXPERIENCES

WITH

TESTING

EUSTACHIAN

TUBE

FUNCTION

555

(Oor+)

(Oor+/- )

 
 

Fig.

3.

Toynbee test of E T

function.

During closea-nose swallowing a positive pressure develops within the nasophar­ ynx, followed by a negative pressure phase. If the E T opens during the test, the M E pressure will change depending upon the timing of the tubalopening and pressure gradient.

POSITIVE PHASE

NEGATIVE PHASE

dition of the other parts of the system, such as the presence of an upper respiratory tract infection. For instance, a young child with a common cold may have transitory high negative pressure within the ME while he has the cold, but be otherwise otolog­ ically normal. The decision as to whether or not high negative pressure is abnormal or is only a physiologic variation should be made taking into consideration the presence or absence of signs and

If severe atelectasis or

adhesive otitis

symptoms of M E disease.

of the TM-M E system is present, the

tympanogram may not be a reliable indicator of the actual pressure within the ME.

Therefore, a resting pressure that is high negative is associated with some degree of E T obstruction, but the presence of normal M E pressure does not ne­ cessarily indicate normal E T function. An analogy can be made to the evaluation of pulmonary func­ tion employing chest x-ray films. Abnormal pul­ monary function is most likely associated with ra­ diographic evidence of severe disease of the lung, but the finding of a normal-appearing roentgeno­ graph of the chest does not necessarily indicate nor­ mal pulmonary function.

The pump-manomete r system of the

electroacoustic impedance bridge is usually ade­ quate to assess E T function clinically when the T M

is not intact. However, due to the limitations of the manometric systems of all of the commercially available instruments, a controlled syringe and manometer (a water manometer will suffice) should be available when these limitations are exceeded,

opening pressure is in excess of + 400 H^O.

eg, when E T to + 600 m m

Manometry.

METHOD S

O F

ASSESSIN G

EUSTACHIA N

TUB E

FUNCTIO N

Classical Tests of Tubal Patency. Valsalva an d Politzer have developed methods to assess patency

of the ET ; E T catheterization achieves the same re­ sults. When the TM is intact and the ME inflates following one of these tests, then the tube is not totally mechanically obstructed. Likewise, if the

would

TM is not intact, passage of air into the M E

indicate patency of the tube. The success of these tests can be determined subjectively by the use of the otoscope, a Toynbee tube, or a stethoscope at

the ME end of the system. The assessment is more objective when a tympanogram is obtained when the TM is intact, or when the manometer on the im­ pedance instrument is observed when the TM is not intact. However, inflation of the ET-ME from the nasopharynx end of the system by one of these clas­ sical methods only is an assessment of tubal patency and not function, and failure to inflate the M E does not necessarily indicate a lack of patency of the ET . Elner et al" reported that 86% of 100 otologically normal adults could perform the Valsalva test. In young children, the Valsalva test is usually more difficult to perform than the Politzer test. However, in a recent study by Bluestone and coworkers," 6 of 7 children who had a traumatic perforation but who were otherwise otologically "normal" could perform the Valsava test as compared to only 11 of 28 children who had a retraction pocket or a cholesteatoma. The Valsalva and Politzer maneu­ vers are more beneficial as management options in selected patients than they are as methods to assess tubal function.

Toynbee Test. One of the oldest and still one of the best tests of E T function is the Toynbee test (Fig. 3). The test is usually considered positive when an alteration in ME pressure results. More specifically, if negative pressure (even transitory in the absence of a patulous tube) develops in the ME during closed-nose swallowing, the E T function can be considered most likely to be normal. When the TM is intact, the presence of negative M E pressure must be determined by pneumatic otoscopy or, more accurately, by obtaining a tympanogram be­ fore and immediately following the test (Fig. 4). When the TM is not intact, the manometer of the impedance bridge can be observed to determine M E pressure. In the Elner et al study," the Toynbee test was positive in 79% of normal adults. Cantekin et aP' reported that only 7 of 106 ears (6.6%) of sub­ jects (mostly children) who had had tympanostomy tubes inserted for OM could perform a modification of the Toynbee test (closed-nose equilibration at­ tempt with applied negative ME pressure of 100 or 200 mm HjO). Likewise, in a series of patients, most of whom were older children and adults with chronic perforations of the TM , only 3 of 21 (14.3%) passed the test. However, in children with a traumatic perforation of the TM but who other-

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556

10

BLUESTONE-CANTEKIN

10

-40 0

AFTER

TOYNBEE

TEST

/ [^RESTIN G

mmHjO

PRESSURE

+

40 0

Fig. 4. Tympanogram obtained before and after Toyn­ bee test. Negative M E pressure is objectively demonstrated in the ME , which is considered to be associated with good E T function.

wise had a negative otologic history, three of ten (30%) could pass the test. In the Bluestone et al study^" of "normal" children with traumatic per­ forations, six of seven children could change the ME pressure as compared to none of the 21 ears of children who had a retraction pocket or a chol­ esteatoma. The test is of greater value in determin­ ing normal versus abnormal E T function in adults than in children. The test is still of considerable value since, regardless of age, if negative pressure develops in the ME during or following the test, the E T function is most likely normal, since the E T ac­ tively opens and is sufficiently stiff to withstand nasopharyngeal negative pressure, ie, it does not "lock." If positive pressure is noted or no change in pressure occurs, the function of the E T still may be normal and other tests of E T function should be performed.

Patulous Eustachian Tube Test. If a patulous E T is suspected, the diagnosis can be confirmed by oto­ scopy or objectively by tympanometry when the TM is intact." One tympanogram is obtained while the patient is breathing normally, and a second is obtained while the patient holds his breath. Fluctu­ ation of the tympanometric trace which coincides with breathing confirms the diagnosis of a patulous tube (Fig. 5). Fluctuation can be exaggerated by asking the patient to occlude one nostril with the mouth closed during forced inspiration and expira­ tion or by performing the Toynbee maneuver. When the TM is not intact, a patulous E T can be identified by the free flow of air into and out of the E T using the pump-manometer portion of the elec­ troacoustic impedance bridge. These tests should not be performed while the patient is in a reclining position since the patulous E T will close.

Nine-Step Inflation-Deflation Tympanometric Test. Another method of assessing the function of the E T when the TM is intact, developed by Blue- stone," is called the 9-step inflation-deflation tym­ panometric test, although the applied ME pressures are very limited in magnitude. The ME must be free of effusion. The 9-step tympanometry procedure may be summarized as follows (Fig. 6):

-

BREAT H

/HOLDIN G

/HOLDIN G

t

5

BREATHING

/

2

3

^

-40 0

7

]

L

mmHjO

+

'.

40 0

Fig. 5. Diagnosis of a patulous E T employing the tym­ panogram .

1.

The

tympanogram

records resting

ME pres­

sure.

2 .

Ea r cana l pressur e i s increase d t o

-i-

20

0

m m

H2O, with medial deflection of the TM and a cor­ responding increase in ME pressure. The subject

swallows to equilibrate ME overpressure.

3. While the subject refrains from swallowing,

ear canal pressure is returned to normal, thus estab­ lishing a slight negative ME pressure (as the TM moves outward). The tympanogram documents the established ME underpressure.

STE P

ACTIVIT Y

RESTIN G

PRESSUR E

INFLATIO N

AN D

SWALLOW

(x3 )

PRESSUR E

AFTE R

EQUILIBRATIO N

SWALLO W

( k 3 1

PRESSUR E

AFTE R

EQUILIBRATIO N

DEFLATIO N

SWALLO W

PRESSUR E

AN D

(x3 )

AFTE R

EQUILIBRATIO N

SWALLO W

(x3 1

PRESSUR E

AFTE R

EQUILIBRATIO N

MODE L

ft Τ VP

f

ME

(+)

(0)1

TYMMNOGRA M

Fig. 6. Nine-step inflation-deflation tympanometric test. TV ? - Tensor veli palatini muscle, E T - Eustachian tube, M E - Middle ear, T M - Tympanic membrane, E C - Ear canal.

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PANEL

ON EXPERIENCES

WITH

TESTING

EUSTACHIAN

TUBE

FUNCTION

NINE-STEP INFLATION-DEFLATION TYMPANOMETRI C TES T

FINDINGS

 

Function

Test Findings

(Ears)

557

Groups

of

subjects

All

Positive

Normal adults (N = 27)

39

Abnormal adults (N =

42)

18

Normal children (N = 44)

11

Abnormal children (N = 18)

7

Some

None

Total

% All

or

Positive

Posiifue

Ears

Some

Positive

10

5

54

90.7

26

36

80

55.0

19

58

88

34.1

8

61

76

19.7

in an attempt to equili­

brate negative ME pressure. If equilibration is suc­ cessful, airflow is from nasopharynx to ME.

5. The tympanogram records the extent of equil­

ibration.

6. Ear canal pressure is decreased to -20 0 mm

HjO, causing a lateral deflection of the TM and a corresponding decrease in ME pressure. The subject swallows to equilibrate negative ME pressure; air­

flow is from the nasopharynx to the ME.

4. The subject swallows

7. The subject refrains from swallowing while

external ear canal pressure is returned to normal, thus establishing a slight positive pressure in the M E as the TM moves medially. The tympanogram re­ cords the overpressure established.

8. The subject swallows to reduce overpressure.

If equilibration is successful, airflow is from the ME to the nasopharynx.

9. The final tympanogram documents the extent

of equilibration.

In an attempt to determine the usefulness of this

four groups of sub­

jects, all of whom had intact TM and no otoscopic or tympanometric evidence of MEE , were evalu­ ated:

method of testing E T function,

— history of otologic disease.

2. Abnormal adults — 42 adults with a prior his­

tory of otologic disease.

3. Normal children — 44 children between 2 and

15 years of age without a prior history of otologic disease.

4. Abnormal children — 48 children between 2

and 15 years of age, all of whom had otoscopic and tympanometric evidence of a ME E in the recent past.

a prior

27

1.

Normal

adults

adults without

The table shows the findings in these four groups of subjects. The ability to perform all or any one of the steps progressively increased with advancing age and the absence of a past history of otologic dis­ ease. Conversely, the percentage of ears in which no function was present progressively increased from the normal adult group (9.3%) to the abnormal children group (80.3%). Of the 46 ears in these children, regardless of past history, in whom a ME pressure of - 50 mm HjO or less was found, only 3

(7 %) could perform any of the tests. Likewise, of 13 ears with high negative pressure in the abnormal adult group, only two (15.3%) could pass any of the tests. These findings verify the presence of E T ob­ struction when high negative ME pressure is identi­ fied.

The test is simple to perform and can give useful information regarding E T function and should be

part of the clinical evaluation of patients with sus­

pected E T dysfunction. In general,

most normal adults

can perform all or some parts of this test, but even normal children have difficulty in performing this test.

Modified Inflation-Deflation Test (Nonintact Tympanic Membrane). When the TM is not intact, the pump-manometer system of the electroacoustic impedance bridge can be used to perform the mod­ ified inflation-deflation E T function test, which assesses passive as well as active functioning of the ET. " " The ME should be free of any drainage for an accurate assessment of E T function using this test. Figure 7 illustrates the procedures employed during the test. The ME is inflated, ie, positive pressure is applied, until the E T spontaneously opens. At this time, the pump is manually stopped and air is discharged through the E T until the tube closes passively. The pressure at which the E T is passively forced open is called the opening pressure, and the pressure at which it closes passively is called the closing pressure. The patient is then instructed to equilibrate the ME pressure actively by swallow­ ing. The residual pressure remaining in the ME after swallowing is recorded. The active function is also recorded by applying over- and underpressure to the ME , which the patient then attempts to equilibrate by swallowing. The residual pressure in the ME following equilibration of + 200 mm HjO or half of the passive opening pressure is recorded. The residual negative pressure which remains in the ME after the attempt to equilibrate applied nega­ tive pressure of — 200 mm HjO is also noted. This procedure is not performed in patients who cannot equilibrate applied overpressure. If the E T does not open following application of positive pressure us­ ing the electroacoustic impedance bridge, and no reduction in positive pressure occurs during swal­ lowing, then the E T must be assessed using a mano­ metric system other than the electroacoustic impe­ dance bridge manometric system. The opening pressure may be higher than 400 to 600 mm HjO pressure, or not present at all (severe mechanical

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558

g o
I

^

q:

3

+

+

400 F

200 h

-20 0

SWALLOW

+ 400

+200

7\

1

0

^

EXAMPLE

C—S—R P

A

BL

UESTONE-CANTEKIN

=»S—5

^^S-R P

Fig. 7. Procedure and symbols used in describing the modified inflation-deflation test employing the pump- manometer system of an electroacoustic bridge. The figure shows strip-chart recordings, but the results of the test can be read directly from the equipment readout and noted manually. RP - Residual pressure, Ο - Opening pressure, C - Closing pressure, · - Mark for swallow, S - Pressure after swallow.

-200 i

SWALLOW

···

\

>

···

S

RP

• · ·

EXAMPLE

obstruction). Example A in Figure 7 shows that fol­

brated by swallowing and applied negative pressure

lowing

passive opening and closing of the E T dur­

can

also be equilibrated completely, then the E T

ing the inflation phase of the study, the patient was

can

be considered to have normal function. How­

able completely to equilibrate the remaining posi­

ever, if the tube does not open to a pressure of 1000

tive pressure. Active swallowing also completely

 

mm

H2O, one can assume that total mechanical ob­

equilibrated applied negative pressure (deflation).

struction is present. This pressure is not hazardous

This is considered to be characteristic of normal E T

to

the ME or inner ear windows if the pressure is ap­

function. Example Β shows the E T passively opened and closed following inflation, but subsequent swallowing failed to equilibrate the residual posi­

plied slowly. An extremely high opening pressure (eg, greater than 500 to 600 m m H2O) may indicate partial obstruction, whereas a very low opening

tive pressure. In the deflation phase of the study,

pressure (eg, less than 100 m m H2O) would indicate

the patient was unable to equilibrate negative pres­

a

semipatulous

ET . Inability to maintain even a

sure. Inflation to a pressure below the opening pres­ sure but above the closing pressure could not be equilibrated by active swallowing. This type of re­ sult is considered to be abnormal but may be found in a few subjects who do not have any obvious oto­

modest positive pressure within the ME would be consistent with a patulous tube, ie, one which is open at rest. Complete equilibration by swallowing of applied negative pressure is usually associated with normal function, but partial equilibration, or

logic disease.

even failure to reduce any applied negative pressure

Failure to equilibrate the applied negative pres­ sure may indicate locking of the E T during the test. This type of tube is considered to have increased compliance or to be "floppy" in comparison to a tube with perfect function. The tensor veli palatini muscle is unable to open (dilate) the tube. The speed of application of the positive and negative pressures is an important variable in testing E T function with the inflation-deflation test. The faster the positive pressure is applied, the higher the open­ ing pressure. During the deflation phase of the study, the faster the negative pressure is applied, the more likely it is that the locking phenomenon will occur.

Even though the inflation-deflation test of E T function does not strictly duplicate physiologic functions of the tube, the results are helpful in dif­ ferentiating normal from abnormal function. The mean opening pressure for apparently normal sub­ jects with a traumatic perforation and negative oto­ logic history reported by Cantekin and coworkers" was 330 mm H2O (±7 0 mm H2O). If the test results reveal passive opening and closing within the nor­ mal range, residual positive pressure can be equili-

may or may not be considered abnormal since even

a normal E T will lock when negative pressure is

rapidly applied. Therefore, inability to equilibrate applied negative pressure may not indicate poor E T function, especially when it is the only abnormal parameter.

Elner et al" studied 102 adults with intact TM

and a negative otologic history. They used the mi-

croflow technique and pressure chamber to eval­

the results of this type of

testing are comparable to the results of the infla­ tion-deflation test when the TM is not intact. They

reported that only 5 % could not equilibrate to some degree an applied pressure of + 100 and 7% could not equilibrate -10 0 mm H2O. Bylander" com­ pared the E T functioning in 53 children with that

in 55 adults, all of whom had intact TM and who

uate E T function, but

were apparently otologically healthy. Employing a pressure chamber, she reported that 53% of the

children could not equilibrate applied negative in- tratympanic pressure (-10 0 mm H2O) by swal­ lowing, whereas only 9% of the adults were unable

to perform this function. Children between 3 and 6

years of age had worse function than those in the

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PANEL

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EUSTACHIAN

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FUNCTION

559

7-to-12-year age group. In addition, she also found that even normal children who had tympanometric evidence of high negative pressure within the ME had poor E T function. From these two studies, it can be concluded that even in apparently otolog­

ically normal children, E T function is not as good as in adults, which would contribute to the higher in­ cidence of ME disease in children compared to adults. In the Cantekin et al study," only 8 of 108 ears (7%) of subjects (primarily children) with tym­ panostomy tubes could equilibrate an applied pres­ sure of — 200 mm HjO to any degree and none of 67

ears

with chronic dry perforations, 4 of 30 ears (13%) could equilibrate -10 0 mm H2O, and none of 17 ears could equilibrate — 200 mm H2O. These results were compared to those obtained from a group of subjects with traumatic perforations of the TM; in this latter group 12 of the 27 (44%) ears equili­ brated a pressure of —200 mm H2O.

could equilibrate -10 0 mm H2O. In subjects

Other Methods Available for Laboratory Use. There are other methods available to test the func­ tioning of the ET , but they are limited to use in the laboratory for investigational purposes at present. When the TM is intact the microflow technique'* or an impedance method,'' both of which require a pressure chamber, or sonometry"" may be used. When the tympanic membrane is not intact the forced-response test" may be used. Sonometry and the forced-response test show great promise for fu­ ture use in the clinical setting.

CLINICA L

INDICATION S FO R

TESTIN G

EUSTACHIA N

TUB E

FUNCTIO N

Diagnosis. One of the most important reasons for

need to make a differen­

tial diagnosis in a patient who has an intact T M without evidence of OM but has symptoms that might be related to E T dysfunction (such as otalgia, snapping or popping in the ear, fluctuating hearing

loss, tinnitus, or vertigo). An example of such a case would be a patient who has a complaint of fullness in the ear without hearing loss at the time of the ex­ amination, a symptom which could be related to

to

inner ear pathology. A tympanogram that reveals a high negative pressure (-5 0 mm H2O or less) is presumptive evidence of tubal obstruction, whereas normal resting ME pressure is not diagnostically sig­ nificant. However, when the resting intratympanic pressure is within normal limits and the patient can develop negative ME pressure following Toynbee's test or can perform all or some of the functions in the 9-step inflation-deflation tympanometric test, the E T is probably functioning normally. Unfortun­ ately, failure to develop negative M E pressure dur­ ing the Toynbee test or inability to pass the 9-step test does not necessarily indicate poor E T function. Tympanometry is not only of value in determining if E T obstruction is present: it can also identify ab­

abnormal functioning of the E T or could be due

assessing E T function is the

normality at the other end of the spectrum of E T

dysfunction;

E T can be confirmed

metric patulous tube test.

by the results of the tympano­

the presence of an abnormally patent

Screening for the presence of high negative pres­ sure in certain high-risk populations (ie, children with known sensorineural hearing losses, develop- mentally delayed and mentally impaired children, children with cleft palates or other craniofacial anomalies, American Indian and Eskimo children, and children with Down syndrome) appears to be helpful in identifying those individuals who may need to be monitored closely for the occurrence of OM. "

Tympanometry appears to be a reliable method for detecting the presence of high negative pressure as well as of otitis media with effusion (OME) in children."" The identification of high negative pressure without effusion in children is indicative of some degree of E T obstruction. These children as well as those with ME E should have follow-up ser­ ial tympanograms since they may be at risk of de­ veloping OME.

However, the most direct method available to the clinician today for testing E T function is the infla­ tion-deflation test. A perforation of the TM or a tympanostomy tube must be present in order to per­ form this test. The test uses the simple apparatus described earlier, with or without the electroacous­ tic impedance bridge pump-manometer system. This test will aid in determining the presence or ab­ sence of a dysfunction, and the type of dysfunction (obstruction vs abnormal patency) and severity of dysfunction when one is present. No other test pro­ cedures may be needed if the patient has either functional obstruction of the E T tube or an abnor­ mally patent tube. However, if there is a mechan­ ical obstruction, especially if the tube appears to be totally blocked anatomically, then further testing may be indicated. In such instances, retrograde- prograde radiographic contrast studies of the ET- ME, which are used primarily for research pur­ poses, can be performed to determine the site and cause of the blockage.' In most cases in which mechanical obstruction of the tube is found inflam­ mation is present at the ME end of the E T (protym- panic or bony portion), which usually resolves with medical management or M E surgery. Serial infla­ tion-deflation studies show resolution of the mech­ anical obstruction. However, if no M E cause is ob­ vious, other studies should be performed to rule out the possibility of neoplasm in the nasopharynx.

Management. Patients with recurrent acute or chronic OM E should have E T function studies as part of their otolaryngologic workup. The manage­

ment of such patients may depend on the results of

these

studies, as mechanical obstruction of the E T

may indicate treatment different from that for functional obstruction. For instance, adenoidec-

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560

BLUESTONE-CANTEKIN

tomy may not be indicated in a child with a small adenoid mass and tubal function test results that in­ dicate functional obstruction; however, the opera­ tion may benefit the child with marked mechanical obstruction of the ET."^'

Patients in whom tympanostomy tubes have been inserted may benefit from serial E T function studies. Improvement in function as indicated by inflation-deflation tests might aid the clinician in determining the proper time to remove the tubes. Cleft palate repair,"" adenoidectomy,^*" elimin­ ation of nasal and nasopharyngeal inflammation,' treatment of a nasopharyngeal tumor, or growth and development of a child^' may be associated with improvement in ET function.

Studies of the E T function of the patient with a chronic perforation of the TM may be helpful in determining preoperatively the potential results of tympanoplasty surgery. Holmquist^' studied E T function in adults before and after tympanoplasty and reported that the operation had a high rate of

(ie, those

who could equilibrate applied negative pressure) but that in patients without good tubal function surgery frequently failed to close the perforation. Miller and Bilodeau"" and Siedentop"' reported sim­ ilar findings but Ekvall,"^ Lee and Schuknecht,"^ Andreasson and Harris,"" Cohn et al,"' and Vir­ tanen et al"' found no correlation between the results of the inflation-deflation tests and success or failure of tympanoplasty. Most of these studies fail­ ed to define the criteria for "success" and the postoperative follow-up period was too short. Blue- stone et al"' assessed children prior to tympan­ oplasty and found that of 51 ears of 45 children, 8 ears could equilibrate an applied negative pressure (-20 0 mm HjO) to some degree, and in 7 of these ears, the graft took, no ME E occurred, and no recurrence of the perforation developed during a follow-up period of between one and two years. However, like the studies in adults, failure to equilibrate an applied negative pressure did not predict failure of the tympanoplasty.

success in patients with good E T function

The conclusion to be drawn from these studies is that if the patient is able to equilibrate an applied negative pressure, regardless of age, the success of tympanoplasty is likely, but failure to perform this difficult test will not help the clinician in deciding not to operate. However, the value of testing a per­ son's ability to equilibrate negative pressure lies in the possibility of determining from the test results if a young child is a candidate for tympanoplasty when one might decide on the basis of other fin­ dings alone to withhold surgery until the child is older. These tests are also of value in the diagnosis of severe or total mechanical obstruction, condi­ tions which contraindicate the performing of a my­ ringoplasty; further evaluation and medical or

surgical management of such patients may be in­ dicated depending upon the condition of the ear. When a tympanoplasty is performed and the func­ tion of the E T is thought to be poor, a tympan­ ostomy tube should be inserted.

In children and adults, tympanoplasty frequently fails when performed on ears in which an acquired cholesteatoma is present. This has been attributed to poor E T function in these ears."' Bluestone et

gj2o,48 reported that, using the modified inflation-

E T function tests,

they have found that in almost all subjects the E T constricts during swallowing instead of dilating, as it does normally. This abnormality is one involving functional obstruction of the ET . However, pre­ operative testing of a patient with a cholesteatoma can be helpful in deciding whether a tympanoplasty should be performed and, if it is done, whether a tympanostomy tube should be inserted at the time

deflation and forced-response

of surgery. Eustachian tube function may be nor­ mal if the cholesteatoma is congenital,^" secondary to trauma (implantation), or present in an adult in whom tubal function has improved following the development of an acquired cholesteatoma in child­ hood.

Failure to obstruct the ME end of the E T sur­ gically at the time of radical mastoidectomy for the eradication of cholesteatoma may result in trou­ blesome postoperative otorrhea secondary to reflux of nasopharyngeal bacteria."' Assessment of E T function by the inflation-deflation manometric technique or by performing a Valsalva or Politzer test (observing the manometer) is helpful in deter­ mining if the E T is still patent following a radical mastoidectomy from which otorrhea is a postopera­ tive complication.

Failure to consider the function of the E T as a cri­ tical variable may be the reason why it is so difficult to interpret the results of clinical studies of various techniques advocated for surgical reconstruction of the ME and mastoid. Prospective clinical trials that include, among other important factors, controlling for E T function, are urgently needed.

CONCLUSIO N

Even though the testing of E T function is not an exact science and more research on such testing is needed, the methods presently available to the clin­ ician provide useful information related to the diag­ nosis and management of M E disease. Not to in­ clude E T function testing as part of the modern otorhinolaryngologist's diagnostic assessment of selected patients is as irrational as failing to perform laryngeal and pulmonary function tests in the diag­ nosis and management of patients with disease of the lower respiratory tract.

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ACKNOWLEDGMENTS — The authors would like to thank Sandi Arjona and Diana Mathis for assistance in preparation of the manuscript; Margaretha

of the artwork; and Vera Spector for technical

assistance.

Casselbrant,

MD,

PhD,

for

assistance in analysis of

portions of the

data; Jon Coulter for preparation

REFERENCES

des

Trommelfells.

Ohr-

trompete. Berlin: Springer Veriag,

Secretory otitis media. Laryngoscope 1952;

62:998-1027.

4. Senturia BH, Gessert DF , Carr CD , Caumann HS. Studies

concerned with tubotympanitis. Ann Otol Rhinol Laryngol 1958;

67:440-7.

5. Sad6 J. Pathology and pathogenesis of serous otitis media.

1. Politzer

2. ZoUner

3. Suehs

A.

R.

OW.

die

Weiner Med Halle Nr 1862;

Ueber

Willkurlichen

Physiologie

1942.

Bewegungen

der

18:103.

und

Klinik

Anatomie,

Arch Otolaryngol

6. Bluestone CD , Paradise JL, Beery QC . Physiology of the

eustachian tube in the pathogenesis and management of middle ear effusions. Laryngoscope 1972; 82:1654-70.

pathogenesis of

1966;

84:297-305.

7. Bluestone CD , Beery QC . Concepts on the

middle ear effusions.

Ann Otol

Rhinol

Laryngol 1976; 85 Suppl

25:182-6.

EI , Beery QC : Effect of inflam­

mation on the ventilatory function of the eustachian tube. Laryn­ goscope 1977; 87:493-507.

9. Fisher R, McManus J , Entis G, Cotton R, Ghory J , Avs-

den-Moore R. Middle ear ciliary defect in Kartagener's syndrome. Pediatrics 1978; 62:443-5.

study of eustachian tube and its re­

lated muscles. Bull Johns Hopkins Hosp 1920;

WJ, Reichert TJ , Phillips DC , Blue-

stimu­

lation of the mandibular nerve. Ann Otol Rhinol Laryngol 1979;

88:40-51.

12. Honjo I, Okazaki N, Kumazawa T. Experimental study of

with regard to its related muscles.

Acta Otolaryngol (Stockh) 1979;

13. Honjo I, Okazaki N, Nozoe T, Ushiro K, Kumazawa T.

Experimental study of the pumping function of the eustachian tube. Acta Otolaryngol (Stockh) 1981; 91:85-9.

stone

8. Bluestone CD , Cantekin

10. Rich A. Physiological

U .

Cantekin EI , Doyle

CD .

Dilation

31:206-14.

of the eustachian

tube by electrical

the eustachian tube function

87:84-9.

York: American Electromedics Corp,

23. Ingelstedt S, Ortegren U. Qualitative testing of the eusta­

chian tube function. Acta Otolaryngol (Stockh) 1963; Suppl

182:7-23.

24. Cantekin EI , Bluestone CD , Saez C , Doyle WJ, Philips D.

1975.

Rhinol

Laryngol

25. Bylander A. Comparison of eustachian tube function in

children and adults with normal ears. Ann Otol Rhinol Laryngol 1980; 89 Suppl 68:20-4.

26. Ingelstedt S, Ivarsson A, Jonson A. Mechanics of the hu­

man middle ear; pressure regulation in aviation and diving, a nontraumatic method. Acta Otolaryngol (Stockh) 1967; Suppl

228:1-57.

27. Virtanen H. Sonotubometry: an acoustical method for ob­

jective measurement of auditory tubal opening. Acta Otolaryngol (Stockh) 1978; 86:93-103.

28. Murti K, Stem R, Cantekin EI , Bluestone CD . Sonometric

using broadband stimuli.

Ann Otol Rhinol Laryngol 1980, 89 Suppl

Airflow

through

88:603-12.

Impedance

screening

York: Grime

1979;

evaluation of eustachian tube function

Normal and abnormal middle ear ventilation.

Ann Otol

1977; 86 Suppl 41:1-15.

68:178-84.

29. Cantekin EI , Saez CA, Bluestone CD , Bern SA.

30.

the eustachian

tube.

Ann

Otol

Rhinol

Laryngol

Harford E ,

Bess R,

Bluestone

CD ,

Klein

for middle ear disease in children.

New

J .

and Stratton, 1978.

31. Beery QC , Bluestone CD , Cantekin EI . Otologic

audiometry and tympanometry

school screening. Laryngoscope 1975; 85:1976-85.

as a case finding

history,

procedure for

32.

Brooks D .

An

objective

method

of detecting

fluid

in

the

middle ear. J Int Audiol

1968; 7:280-6.

 

33.

Brooks D.

Electroacoustic

impedance

bridge studies

on

normal ears of children. J Speech Hear Res 1971;

14:247-53.

34. Bluestone CD , Wittel R, Paradise JL , Felder H. Eusta­

as related to adenoidectomy for otitis media.

chian tube function

14.

Bluestone CD , Cantekin EI . Eustachian tube

dysfunction.

Trans Am Acad Ophthalmol

Otolaryngol

1972;

76:1325-39.

In: English GM , ed. Otolaryngology.

Hagerstown:

Harper and

35. Bluestone

CD , Cantekin EI , Beery QC . Certain effects of

Row,

1980.

adenoidectomy

on eustachian tube ventilatory

function.

Laryn­

15.

Bluestone CD , Shurin

P. Middle ear diseases in

children:

goscope 1975;

85:113-27.

pathogenesis,

diagnosis, and management.

Ped

Clin North

Am

36.

Bluestone CD , Paradise JL,

Beery QC , Wittel R. Certain

1974;

21:379-400.

effects

of cleft

palate repair on eustachian

tube function.

Cleft

16.

Bluestone CD . Assessment of eustachian tube function.

In:

Palate J 1972;

9:183-93.

Jerger J , Northern J , eds. Clinical impedance

audiometry.

New

37.

Paradise JL,

Bluestone CD .

Early treatment of

universal

York: American Electromedics Corp, 1980:83-108.

otitis media of infants with cleft palate. Pediatrics 1974; 53:48-54.

17.

Alberti

R,

Kristensen R.

The

clinical

application of

im­

38.

Holborow C. Eustachian tube function.

Arch Otolaryngol

pedance audiometry. Laryngoscope 1970;

80:735-46.

1970;

92:624-6.

18.

Brooks D.

Electroacoustic

impedance

bridge studies

on

39.

Holmquist J . The role of the eustachian tube in myringo­

normal ears of children. J Speech Hear Res 1971;

14:247.

plasty. Acta Otolaryngol

(Stockh) 1968;

66:289-95.

 

19.

Elner A, Ingelstedt S, Ivarsson A. The normal function

of

40.

Miller GF , Bilodeau R. Preoperative evaluation of eustach­

the eustachian tube. Acta Otolaryngol

(Stockh) 1971; 72:320-8.

ian tubal function

in tympanoplasty. South Med J 1967;

60:868.

CD , Casselbrant ML , Cantekin EI . Functional

eustachian tube obstruction in the pathogenesis of acquired cho­ lesteatoma in children. The Netherlands: Kugler Publications BV, 1981 (in press).

21. Cantekin EI , Bluestone CD , Parkin LP . Eustachian tube

ventilatory function in children. Ann Otol Rhinol Laryngol 1976; 85 Suppl 25:171-7.

In

New

Jerger J , ed. Handbook of clinical

20. Bluestone

22. Bluestone CD . Assessment of eustachian tube function.

impedance audiometry.

41. Siedentop KH. Eustachian tube dynamics, size of the mas­

toid air cell system, and results with tympanoplasty. Otolaryngol Clin North Am 1972; 5:33-44.

42. Ekvall L . Eustachian tube function in tympanoplasty. Ac­

ta Otolaryngol

43. Lee K, Schuknecht HF . Results of tympanoplasty and mas­

toidectomy at the Massachusetts Eye and Ear Infirmary. Laryn­ goscope 1971; 81:529-43.

(Stockh) 1970; Suppl

263:33-42.

44.

Andreasson L , Harris S. Middle ear mechanics and eusta-

Downloaded from aor.sagepub.com at Bobst Library, New York University on June 29, 2015

562

JAMES

L.

chian tube function in tympanoplasty. Acta Otolaryngol (Stockh) 1979; Suppl 360:141-7.

AM, Schwaber MK , Anthony LS , Jerger JF. Eus­

tachian tube function and tympanoplasty. Ann Otol Rhinol Lar­ yngol 1979; 88:339-47.

45. Cohn

46. Virtanen H , Palva T, Jauhiainen T. The prognostic value

of eustachian tube function measurements in tympanoplastic sur­ gery. Acta Otolaryngol (Stockh) 1980; 90:317-23.

47. Bluestone CD , Cantekin EI , Douglas GS. Eustachian tube

SHEEHY

related to the outcome of tympanoplasty in children.

Laryngoscope 1979; 89:450-8.

48. Bluestone CD , Cantekin EI , Beery QC , Douglas GS , Stool

SE, Doyle WJ. Functional eustachian tube obstruction in ac­ quired cholesteatoma and related conditions. In McCabe BF , Sad6 J , Abramson M, eds. Cholesteatoma, first international congress. Birmingham: Aesculapius, 1977.

function

49. Bluestone CD , Cantekin EI , Beery QC , Stool SE: Function

of the eustachian tube related to surgical management of acquired aural cholesteatoma in children. Laryngoscope 1978; 87:1155-63.

TESTING EUSTACHIAN TUBE FUNCTION

JAME S

L .

SHEEHY ,

M D

Los

ANGELES ,

CALIFORNIA

This paper reviews the concepts, attitudes and experience at the Otologic Medical Group (OMG) in regard to testing eustachian tube

function.

reasons for this are reviewed. The lack of significant incidence of serous otitis media in postoperative patients substantiates the conclusion that there is no rationale for preoperative eustachian tube function tests in patients who are to undergo reconstructive surgery for chronic otitis media.

At OM G eustachian tube function tests are not performed prior to reconstructive surgery in cases of chronic otitis media and the

At the Otologic Medical Group (OMG) eusta­ chian tube function tests are rarely performed prior to surgery for correction of chronic otitis media. Our concepts of the role of the eustachian tube and the lack of importance of preoperative tubal func­ tion testing have evolved over a number of years. These concepts are intimately related to, and have modified, our philosophy of surgery for chronic otitis media. The OMG publications on this subject will be reviewed to demonstrate how and why these concepts have evolved.

EARLY EXPERIENCES

In 1958, Compere,' when he was closely asso­ ciated with OMG, worked with W. House on tym­ panic clearance studies using water-soluble radi­ opaque media. Compere commented that a "tubal ear" may very well be a tubotympanic problem rather than a nasal or nasopharyngeal problem, that obstruction of the tube may be due to mucous membrane edema, granulations or inspissated mu­ cus in the tubotympanum. Despite the now obvious conclusion from this. House stated that if it could be determined preoperatively that fluid would not drain through the eustachian tube, then the middle ear should not be closed by grafting procedures.

In 1960 W. House^ commented on the need for elimination of mucous membrane edema and gran­ ulations preoperatively and the use of polyethylene

tubing in the eustachian tube at the time of surgery. He concluded that closure of the eustachian tube seriously limited the possibility of success in tym­ panoplasty.

By 1963 eustachian tube function tests were not being performed in most cases. The approach at OMG was to operate, if indicated, regardless of pos­ sible tubal malfunction. It was felt that if the func­ tion of the eustachian tube could not be reestablished the tympanoplasty would not be successful.^ The possibility of a two-stage procedure for gain in hearing was mentioned indicating that we had be­ gun to think of the apparent eustachian tube prob­ lem more in terms of adequacy of the mucous mem­ brane. But it was some time before this concept was crystallized.

The important word in the above paragraph is reestablished. We had learned that most of our pa­ tients whose eustachian tube function was nil using the Compere test, but who nonetheless required surgery for elimination of disease, did well follow­ ing tympanoplasty. This confirmed the concept stated in Compere's paper. As a result of this exper­ ience we began in the early 1960s to perform sur­ gery electively on patients generally thought to be poor risks in regard to eustachian tube function:

adults with a cleft palate repair or with a chronic si­ nusitis-bronchitis syndrome.

One of these cases demonstrated that our evolv-

From the Otologic

Medical Group, Inc., Los Angeles.

Supported by funds from the House Ea r Institute,

Los

Angeles.

Presented

at the meeting

of the American

Otological

Society,

Inc., Vancouver,

British Columbia,

May 9-10,

1981.

ilEPRlNTS -

James L . Sheehy,

MD ,

2122 West Third Street, Los Angeles,

C A

90057.

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