​Kembara Xtra - Medicine - Eustachian Tube Dysfunction

​Kembara Xtra - Medicine - Eustachian Tube Dysfunction 
Introduction 

The nasopharynx and the middle ear are connected by the eustachian tube (ET), also called the auditory or pharyngotympanic tube. The first two-thirds of the ET are formed of cartilage, whereas the final third that connects to the middle ear is comprised of bone. Its principal role is to adjust the pressure in the middle ear to that of the surrounding air. The middle ear is also protected from infection and debris by the ventilation and drainage provided by this method. ET dysfunction (ETD) occurs when the ET is abnormally dilated (patulous dysfunction) or blocked off (obstructive dysfunction).
A group of diseases characterized by dysfunctional ET valve
Patulous dysfunction, in which the ET is too wide open, and dilatory dysfunction, in which the tubes do not expand enough, are the two main types of ETD.
Pressure dysregulation, inadequate protection from irritant reflux into the middle ear, and subpar mucociliary clearance all contribute to the underlying pathophysiology.
Pressure changes (such those seen during scuba diving or air travel) and acute inflammation of the upper airway (like that seen in cases of allergy or infectious rhinosinusitis, or acute otitis media [OM]) are both possible triggers. 
Retracted tympanic membrane, repeated serous effusion, repeated OM, adhesive OM, chronic mastoiditis, and cholesteatoma are all possible complications of ETD.
Synonyms: ET disorder, blocked ET, patulous ET, and dysfunctional auditory tube.


Caution 

A misdiagnosis of ETD is possible in cases of sudden sensorineural hearing loss (SSNHL).
In SSNHL, the affected ear is lateralized with a simple 512-Hz tuning fork test, but in ETD with conductive hearing loss, the unaffected ear is lateralized.
An otolaryngologist should be consulted immediately for any suspected or confirmed case of SSNHL.

Epidemiology 

Acute rhinitis is the most prevalent co-occurring disorder among adults, who account for over two million annual medical visits. The median age is 48, and women outnumber men.

Causes and Mechanisms of Illness 

To maintain a constant pressure in the middle ear, the ET is normally closed, only opening to vent a tiny quantity of air.
When the eustachian tube (ET), palate, nasal cavities, and nasopharynx are unable to control middle ear and mastoid pressure, this condition is known as otitis media with effusion (OMI).
Safeguarding Against Nasopharyngeal Secretions
ET is closed when the body is at rest and opens during activities such as yawning, swallowing, and chewing.
Dysfunctional ET cycle due to structural or functional impediment - The middle ear develops a vacuum.
When the ET opens momentarily, the serous exudate is attracted to the middle ear by the negative pressure, or it can reflux into the middle ear.
Static fluid infection worsens the inflammatory and obstructive cycle by causing edema and the release of inflammatory mediators.
Children are more likely to have trouble with breathing and draining if their ET is horizontal and shorter.
The proximal aperture of the ET (the torus tubarius) might become obstructed in cases of adenoid hypertrophy.
The majority of afflicted adults experience paradoxical ET closure during swallowing.
Dysfunction can also be caused by tumors, which can either impede or obstruct the ET, or infiltrate the tensor veli palatini and disrupt normal swallow regulation.
Genetics
The research on twins have revealed a hereditary link. No clear genetic basis has been established.


Possible Dangers 
Allergic rhinitis, cigarette use, gastroesophageal reflux illness, chronic sinusitis, adenoid hypertrophy, nasopharyngeal mass, neuromuscular disease, and impaired immunity all affect both adults and children.
Causes of craniofacial anomalies (such as cleft palate and Down syndrome) include prematurity, low birth weight, infancy, daycare, overcrowding, poverty, prolonged bottle usage, and sleeping face down for long periods of time. Pregnancy Considerations
Pregnancy-related rhinitis can make ETD worse, although it usually goes away after the baby is born.

Care in General 
Reducing Inflammation in the Upper Airway: Allergies, Rhinitis, and GERD

Avoid exposure to environmental irritants including tobacco smoke and pollution during an acute allergy exacerbation or URI. Perform autoinsufflation of the middle ear (i.e., blow softly against pinched nose and closed mouth).

The following conditions are linked to OM: acute, chronic, and serous; hearing loss; chronic mastoiditis; cholesteatoma; allergic rhinitis; chronic sinusitis/URI; adenoid hypertrophy; gastroesophageal reflux disease; cleft palate; Down syndrome; obesity; and nasopharyngeal cancer or other tumor.

In the past, you may have experienced unilateral or bilateral ear pain, fullness, "plugging," hearing loss, tinnitus, popping or snapping noises, and vertigo. Adults with chronic, single-sided symptoms should be checked for a nasopharyngeal tumor.
Prior ear infections, surgeries, or head trauma; recent aviation or scuba experience; Difference between patulous dysfunction, in which the patient's own voice and breath sounds are amplified (autophony), and dilatory dysfunction, in which the patient complains more of ear pain, "plugged" ear, hearing loss, and tinnitus. - Change in voice (hypo- or hypernasal voice, consider NP mass or palatal dysfunction. - Differentiate between patulous and dilatory dysfunction.
The ETDQ-7 is a questionnaire designed to assess ETD severity in adults. The severity is graded on a scale from 1 to 7 based on the occurrence and intensity of symptoms over the preceding month. Patients with a sum score of >14.5 are classified as having ETD (1)[B],(2)[B].
Are you experiencing ear pressure?
Have you had ear pain in the last month?
What causes a sensation of being "under water" or with plugged ears?
A cold or sinus infection giving you ear pain?
Is there a popping or crackling sound in your ears?
Hearing loss?
A sensation that your ears are being plugged?


Medical Diagnosis 

Tympanic membrane retraction, effusion, and diminished drum movement on pneumatic otoscopy
The entire drum may retract and "lateralize" with insufflation in the Toynbee technique, in which the patient autoinsufflates against closed lips and pinched nostrils.
The posterior superior quadrant (pars flaccida) is a potential site for a retraction pocket to occur.

Conductive hearing loss can be diagnosed using a tuning fork test (Weber test) or a Rinne test (bone conduction > air conduction), wherein a 512-Hz fork put on the forehead is heard more clearly behind the ear on the mastoid than in front of the ear.
Adenoid hypertrophy or a nasopharyngeal mass, as seen on nasopharyngoscopy
Hypertrophy of the turbinates and the mucosa, polyps, and a deviated nasal septum can all be seen on an anterior rhinoscopy.

Differential Diagnosis Superior Semicircular Canal Dehiscence Superior Syringomyelia (a medical emergency) Tympanic Membrane Perforation Barotrauma Temporomandibular Joint Disorder Ménière's Disease 

Results from the Lab 
The First Round of Exams (Lab, Imaging)
If clinical signs and symptoms point to ETD, then standard radiologic investigations are not required.
Alterations associated with OM or middle ear/mastoid opacification may be visible on a CT scan (but this is not required).
Since the ET opening may be seen on a functional MRI during Valsalva, this technique may help diagnose ETD (in stubborn cases).

Tests and Other Methods of Diagnosis
Conductive hearing loss can be detected by an audiogram and confirmed by tympanometry. Tympanograms of type B or C represent fluid and retraction, respectively; tympanograms can be normal (type A) but nevertheless show abnormally low middle ear peak pressures


In terms of management, it is difficult to advocate for a specific treatment or intervention due to a lack of sufficient data.

Clearing OM with effusion with a "nasal balloon" has been demonstrated to be helpful; its usefulness for ETD remains questionable.
The overarching principle is to treat the underlying problem (infection, tumor, TM perforation, tensor palatini muscle restoration, etc.) to stop the cycle of infection and inflammation.
Although there is no proof, some people think that antibiotics for acute OM, decongestants, nasal steroids, antihistamines (in the case of allergic rhinitis), and surgery/procedures for chronic instances might be effective. 
In cases of chronic otitis media or significant progressive retraction, tympanostomy tubes and adenoidectomy may be recommended.

Medication 

There is limited evidence to support the use of pharmaceutical treatments for ETD, such as decongestants, nasal steroids, or antihistamines. Antibiotics are reserved for cases when an infection is thought to be the underlying cause.
Comorbid disorders can be managed with medication.
Oral and topical decongestants
Use with caution after 3 days; may develop drug-induced rhinitis
Acute ETD associated with a subsiding URI is best treated with decongestants.
– When it comes to relieving persistent ETD in children, decongestants are rarely used.
Oxymetazoline, Pseudoephedrine, and Phenylephrine
Those who suffer from allergic rhinitis may get the benefits of nasal steroids. (5)[A]
Fluticasone propionate (Flonase) Beclomethasone (Beconase, Vancenase) Budesonide (Rhinocort)
Methylprednisolone (Nasonex)
(Nasacort) triamcinolone
Antihistamines of the H1 class, the second generation (may help those with ETD and chronic rhinitis), Cetirizine (Zyrtec) (in pill, chewable tablet, and liquid form)
Tablets, RediTabs, and a liquid form of desloratadine (Clarinex)
Allegra (fexofenadine) tablets, RediTabs, and liquid.
Tablets and a liquid form of levocetirizine (Xyzal)
Topical antihistamine nasal sprays (which may help people with ETD and persistent rhinitis) Astelin (Azelastine) and Olopatadine (Patanase)

Supplemental Therapies 

Symptoms can be alleviated by opening the ET, which can be done through gum chewing, eating, or drinking.
Patients with ETD shouldn't take a flight if they have a stuffy nose or an ear infection. Patients who need to fly should be given decongestants both orally and intranasally one hour before takeoff.
Patients should not participate in scuba diving activities.


Methods of Surgery 

To prevent complications from a chronically retracted drum, a myringotomy and pressure equalization tube implantation are recommended.
Minimally invasive laser eustachian tuboplasty may help patients who experience ETD during pressure shifts.
There is scant evidence that balloon tuboplasty is effective, safe, or has lasting effects.
In youngsters, the first pair of tubes is often implanted without an adenoidectomy if hypertrophied tissue is present.
If the adenoidectomy fails again, a second pair of tubes will be inserted.
– Even if there isn't an obvious excess of tissue, some people still recommend adenoidectomy because it decreases the likelihood of future tube blockages. 

Medication Substitutes 
Treatment for ETD may include osteopathic manipulative therapy (OMT).
Both the Galbreath method and the modified Muncie method

In the case of children, check on their pressure equalization tubes every 6 to 8 months, and in the case of adults, check on them every 6 to 12 months.
In order to catch hearing loss, ossicular erosion, or cholesteatoma in their early stages, doctors recommend monitoring the tympanic membrane retraction pocket every 6-12 months.
HEALTHY DIET Breastfeeding has been linked to a decrease in the occurrence of both ETD and OM.

The prognosis for a patient with ETD is poorer if their symptoms have persisted for longer than 7 years.

Complications 

Hearing loss and the complications of chronic ear infections are major causes of morbidity.