Rigid Eustachian Tuboplasty for the Treatment of Persistent EustRigid Eustachian Tuboplasty for the Treatment of Persistent Eustachain achain Tube Dysfunction in the Pediatric PopulationTube Dysfunction in the Pediatric Population

Nitin J. Patel, MD1; Rahul Shah, MD1,2

1George Washington University, Washington D.C., 2Children’s National Medical Center, Washington D.C.

INTRODUCTION DISCUSSIONRESULTS

Figure 4. Endoscopic view of left ET orifice post-dilation.

Figure 2. Urethral sound instruments (size 8-12mm).

Figure 1. Endoscopic view of left ET orifice pre-dilation.

Figure 3. Endoscopic view of rigid dilation of ET orifice with size 10 urethral sound (left).

ABSTRACT

METHODS AND MATERIALS

CONCLUSIONS

REFERENCES

CONTACT

Educational Objective: At the conclusion of this presentation, the participants should be able to demonstrate understanding of the endoscopic transnasal rigid eustachian tuboplasty approach employed to treat persistent eustachian tube dysfunction (ETD) in the pediatric population. Participants should be able to describe the unique treatment challenges presented by persistent ETD in the pediatric population.

Objectives: To describe a novel surgical technique in the pediatric population – endoscopic transnasal rigid eustachian tuboplasty –employed for the management of persistent eustachian tube dysfunction.

Study Design: Technical case report of a novel surgical technique.

Method: We describe an 11 year old female with a history of persistent ETD despite maximal medical management and repeated placement of ventilatory tympanostomy tubes who presented with chronic serous otitis media. We employed a transnasal approach to perform rigid eustachian tuboplasty using pediatric urethral sound instruments to dilate the eustachian tube orifices under endoscopic visualization. The transnasal endoscopic rigid eustachian tuboplasty by surgical terms is described in detail.

Results: The patient was followed with clinical and audiological examinations postoperatively without findings suggestive of ETD. She received no adjuvant treatment and experienced no complications.

Conclusion: Eustachian tube (ET) dysfunction is common in the pediatric population. In spite of this, eustachian tuboplasty has not been investigated in this population. Ours is the first report to demonstrate the successful management of persistent ET dysfunction in the pediatric population through eustachian tuboplasty, more specifically using a rigid method of dilation of the ET. In this report, we present the potential of rigid dilation of the ET in the treatment of pediatric persistent ET dysfunction.

The patient was followed with clinical examinations postoperatively without findings suggestive of ETD. She received no adjuvant treatment and experienced no complications. She is to have a repeat audiogram at her next visit.

At the present, eustachian tuboplasty has not been considered in the pediatric population. The introduction of rigid eustachian tuboplasty holds potential as a new, minimally invasive treatment for persistent eustachian tube dysfunction in the this population.

Under normal circumstances, the cartilaginous ET functions as a valve as it is closed at rest with mucosal surfaces in apposition. The cartilaginous ET dilates to the open position due to the action of the levator veli palatini muscle which rotates the torus tubarius medially and the tensor veli palatiniwhich distracts the anteriolateral wall laterally.4 Tubal dysfunction prevents dilation of the valve and subsequently causes insufficient ventilation of the middle ear.1 The pediatric ET is particularly unique compared to adults due to its smaller cross-sectional width and length and the more horizontal angle at which it courses through the middle ear space to the nasopharynx.

Widening of the cartilaginous tubal valve can be accomplished by balloon, or as in our case, rigid dilation. Although more investigation is needed to elucidate the similarities between the mechanism of rigid and balloon dilation, there is literature to support that balloon dilation causes fissuring of the mucosa and submucosa of the cartilaginous eustachian tube. This fissuring subsequently leads to fibrosis and contraction during healing which may improve the patency of the eustachain tube lumen.5 This irreversibly injured mucosa and submucosa may also induce regrowth with thinner and healthier layers and subsequently, cause permanent changes in the cartilaginous eustachian tube by widening the lumen and facilitating the dilatory action of the levator and tensor palatini muscles.4

This report demonstrates that rigid dilation of the ET is technically feasible and can be performed without significant adverse effect. Rigid dilation eustachian tuboplasty in the pediatric population provides a controlled dilation of the eustachian tube orifice. This rigid approach appeared to effectively dilate the mid-portion and orifice of the eustachian tube, which corresponds to dilation of the functional valve and subsequent, improved aeration of the middle ear. Thus, similar to balloon dilation in the adult population, we concludethat rigid dilation ET may provide a safe alternative treatment modality in the pediatric population.

Although preliminary, rigid dilation eustachian tuboplasty has shown potential in the treatment of persistent ET dysfunction in the pediatric population. We have presented a novel technique to perform minimally invasive surgery on the cartilaginous ET with improvement in ET dysfunction. This newly introduced method seems to be a feasible procedure to dilate the ET. Further studies and trials of rigid dilation will be necessary to determine long-term efficacy in the treatment of ET dysfunction.

Eustachian tube dysfunction is common in the pediatric population; it is reported that almost 40% of all children up tothe age of 10 develop temporary ETD.1 ETD in the pediatric population may result from allergy, chronic infection, mucosal disease, laryngopharyngeal reflux and anatomical obstruction such as adenoid hypertrophy.2 This dysfunction leads to symptoms and diseases, such as serous otitis media or chronic otitis media, each with well known sequele.3 Otolaryngologists attempt to ascertain the underlying etiology in each case and treat it with medical therapy as indicated. When tubal dysfunction is refractory to medical management, patients with persistent ETD may require placement of ventilation tympanostomy tubes. There are a subset of patients who often need repeated insertion, as these ventilation tubes are prone toobstruction, extrusion and infection.

In the 1960s, William House introduced eustachian tuboplasty as a means of dysfunction leads to different treatment for persistent ETD through a middle fossa approach; however, this method was soon discontinued due to invasiveness and morbidity of the procedure. The evolution of endoscopic transnasal surgery combined with the application of inflatable balloons in urologic, cardiac and vascular procedures, as well as more recently sinus surgery, has led to new treatment options for persistent ETD. In particular, balloon dilation of the Eustachian tube, has emerged as a successful alternative treatment for ETD in the adult population.1-5

In spite of this, eustachian tuboplasty has not been investigated in the pediatric population. We report the successful management of persistent ETD in the pediatric population with rigid dilation of the ET. In this report, we present the potential of rigid dilation of the ET in the treatment of pediatric persistent ET dysfunction.

1. Ockermann T, Reineke U, Upile T, Ebmeyer J, SudhoffHH. Balloon dilation eustachain tuboplasty: a clinical study. Laryngoscope 2010; 120:1411-1416.

2. Ockermann T, Reineke U, Upile T, Ebmeyer J, SudhoffHH. Balloon dilation eustachian tuboplasty: a feasibility study. Otol Neurotol 2010; 31:1100-1103.

3. Poe DS, Silvola J, Pyykko I. Balloon dilation of the cartilaginous Eustachian tube:. Otolaryngol Head Neck Surg 2011; 144:563-569.

4. Poe DS, Hanna BMN. Balloon dilation of the cartilaginous portion of the Eustachian tube: initial safety and feasibility analysis in a cadaver model. Am J Otolaryngol 2011; 32:115-123.

5. McCoul E, Singh A, Anand V, Tabaee A. Balloon dilation of the Eustachian tube in a cadaver model: technical considerations, learning curve, and potential barriers. Laryngoscope 2012; 122:718-723.

Nitin J. Patel, M.D.George Washington UniversityDivision of Otolaryngology njpatel@gwu.edu

CASE REPORT

Under general anesthesia, binocular microscopy was first performed to confirm clinical findings. Once this was completed,attention was then turned to transnasal rigid eustachian tuboplasty.

After nasal decongestion with Afrin pledgets, a 4mm 0 degree endoscope was placed in the left nare to allow visualization of the nasopharynx and eustachian tube orifice (Figure 1). Eustachian tube dilation was attempted with a balloon catheter system, which was unsuccessful with curving into the angle of the eustachian tube and was subsequently, abandoned.

Rigid urethral sound instruments (Figure 2) were then utilized successfully to sequentially dilate the orifice. Size 8 through 12mm urethral sounds were used. This dilation was done under direct visualization, as well as through palpation of proper placement into the cartilaginous portion of the orifice (Figure 3). The cartilaginous tube opened with each dilation. Care was taken to avoid placing the rigid instruments into the bony ET. The limit of dilation was 12mm; this was felt as the largest diameter the ET orifice would allow safely without causing irreversible damage based on visual and tactile cues. The same procedure with similar results was done on the right. Figure 4 shows post-dilation opening.

We present a case of an 11 year old female with a history of persistent ETD despite maximal medical management and repeated placement of ventilatory tympanostomy tubes who presented with chronic serous otitis media and otalgia. Persistent ETD was confirmed pre-operatively with physical exam revealing severely retracted tympanic membranes bilaterally and suggested by audiogram.

As a result of failure of medical management and repeated tympanostomy tube placement, the patient was taken to the operating room for transnasal rigid eustachian tuboplasty. The transnasal endoscopic rigid eustachian tuboplasty by surgical terms is described in detail below.