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The Eustachian TubeBryan D. Friedman, D.O.

Triple Board CertifiedENT, Facial Plastic & Cosmetic Surgery

Disclosures

• None

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Special thanks

• Jack Obadia, D.O

• OB/GYN, Cosmetic Surgery

• Mentor

• Colleague

• Friend

What is it?

• The Eustachian tube, a.k.a. auditory or pharyngotympanic tube links the nasopharynx to the middle ear

• At maturity 35 mm long and 3 mm in diameter

• Named after Bartolomeo Eustachi

• From childhood to adolescence the tube’s angulation from its early horizontal position increase

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Anatomy/structure

• Extends from anterior wall of middle ear to lateral wall of nasopharynx

• 1/3 proximal to ear is bony, 12 mm in length

• 2/3 cartilaginous, 24 mm in length, ends at the torus tubarius in the nasopharynx

• 4 muscles and nervous innervation• Levator veli palatini Vagus Nerve

• Salpingopharyngeus Vagus Nerve

• Tensor tympaniMandibular Branch of Trigeminal

• Tensor veli palatiniMandibular Branch of Trigeminal

Function

• Pressure Equalization: normally tube is closed, opens to allow small passage of air to allow equalization between the middle ear and the atmosphere

• Mucus Drainage: from build up in the middle ear

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Torus Tubarius

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When Things Go Astray

The hamulus

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Pediatrics C.O.M.E

1 set of tubes…2nd set, think adenoidectomy, as well

Eustachian tube angle as we mature….

Until Proven otherwise

• 72 Year Old Chinese Male with Unilateral Otitis Media………

• Fossa of Rossenmuller

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Normal

Eustachian TUBE Dysfunction

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Stay with me

Retracted TM to the extreme

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Is it starting to make sense?

• Everyone on board?

• Let’s proceed……..

Let’s all Participate

• An otherwise healthy 30 year old woman presents with vague symptoms, she describes “autophony” in her own words, she battled with this in her 20’s and it seemed to go away while pregnant with her four children

• Having been well educated in the Eustachian Tube’s anatomy and physiology by some cool dude at the most recent Arizona Osetopathic Annual Meeting, you ask the patient to put their head between their legs and ask them to elicit….

• They tell you, “wait a second…..where did my symptoms go?”

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Why?

• Someone have at it……..

Patulous Eustachian Tube

• Estrogen (Premarin) Drops 25 mg in 30 mL normal saline

• Nasal drops, 3 gtt’s TID

• Estrogen leads to congestion, hence pregnancy made her autophony go away

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Poiseuille’s Law

ETD

• Subjective complaints• Dizzy

• Muffled voice

• Can’t equalize pressure, feel like I’m on an air plane

• Won’t pop! (politzerization)

PE:

Ears: retracted TM’s, questionable serous effusions

Nose: Turbinate hypertrophy and rhinitis

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My Approach to TX ETD

• Least invasive to most invasive

• Earn a stranger’s trust through diligent, autonomous care and watch the relationship develop into a doctor patient bond

• Start with nasal hygiene and intranasal steroid spray

• Decrease smoking

• Eradicate Sinus Disease

Surgical Philosophy

• Mucosal Preservation

• Front Door/Back Door Approach a.k.a. “The 1,2, Joe Louis”

• Not just pressure equalization tubes, front door, but also treat the torus tubarius, back door

• Apply Poiseuille’s Law

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Eustachian Tube Dilation

Pressure Equalization TUBE

Posterior Inferior as opposed to Anterior Inferior

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T tube or U tube

Anchor in dry wall

Why Posterior Inferior?

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Still Dizzy? Thinking Menierre’s or Viral

• Dexamethasone drops weekly

• 40 mg/ml0.5 cc’s per ear

• Dizziness often subsides

Attestation: Dizzy s/p CVA

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Attestation: R/o Menierre’s

My Love

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To my colleagues..

• Thank you for allowing me to be part of this great organization……

• It is my honor and pleasure…….

• questions?.....

Works cited

• a b Keith L. Moore; Arthur F. Dalley; A. M. R. Agur (13 February 2013). Clinically Oriented Anatomy. Lippincott Williams & Wilkins. p. 970. ISBN 978-1-4511-1945-9.

• ^ http://www.medicinenet.com/eustachian_tube_problems/article.htm ^ Eustachian tube at Who Named It?

• ^ 'Ear - Dissector Answers at University of Michigan Medical School

• ^ Page 152 in:Rex S. Haberman (2004). Middle Ear and Mastoid Surgery. New York: Thieme Medical Pub. ISBN 1-58890-173-4.

• ^ Leunig, A.; Mees, K. (2008). "Mittelohrbelüftung mit dem Otovent®-Latexmembran- System". Laryngo-Rhino-Otologie 74 (6): 352–354. doi:10.1055/s-2007-997756. PMID 7662078.

• ^ "Middle Ear, Eustachian Tube, Inflammation/Infection Treatment & Management". Medscape. Retrieved 2014-08-06.

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Works cited

• ^ Eustachian Tube Function and Dysfunction at Baylor College of Medicine

• ^ "FAQs - Cranial Osteopathy". The Children's Clinic. Archived from the original on 2010-05-29. Retrieved 2008-12-23.

• ^ Dubin MG, Pollock HW, Ebert CS, Berg E, Buenting JE, Prazma JP (2002). "Eustachian tube dysfunction after tobacco smoke exposure". Otolaryngology - Head and Neck Surgery 126 (1): 14–19. doi:10.1067/mhn.2002.121320. PMID 11821759.

• ^ US Patent #3,982,545, "Middle ear aeration and implant", issued Aug 22, 1974 http://www.google.com/patents/US3982545 Accessed Feb 4, 2016

• ^ US Patent #4015607, "Eustachian tube prosthesis", issued Jan 23, 1976 http://www.google.com/patents/US4015607 Accessed Feb 4, 2016

• ^ J.W. Wright III et al. “The Eustachian tube prosthesis revisited”, Journal of Oto-Rhino-Laryngology, vol. 86, 1978, pp. 834-837

• ^ Microdebrider eustachian tuboplasty: A preliminary report. Otolaryngol Head Neck Surg. 2007 Mar;136(3):422-7. http://www.ncbi.nlm.nih.gov/pubmed/17321871