Balloon Eustachian Tuboplasty (BET) in Children: A Retrospective Multicenter Analysis.

OBJECTIVE: Generation of pilot data for planning of prospective BET-studies for treatment of dilatory Eustachian tube (ET) dysfunction in children. STUDY DESIGN: Retrospective multicenter analysis. SETTING: Nine ENT departments at tertiary care teaching hospitals. PATIENTS: 4-12-year-old children with chronic otitis media with effusion (COME) for more than 3 months or more than 3 episodes of acute otitis media during the last year, having failed standard surgical therapy at least once. INTERVENTION: BET with or without paracentesis, ventilation tube insertion, or tympanoplasty. MAIN OUTCOME MEASURES: Tympanic membrane appearance, tympanometry, and hearing threshold. RESULTS: Two hundred ninety-nine ETs of 167 children were treated. Mean age was 9.1 years (95% confidence interval [95% CI]: 8.7-9.4 yr). In 249 ears (83.3%), COME and/or retraction of the tympanic membrane were the indication for BET. Median hearing threshold was 20 dB HL (95% CI: 0-46 dB). One hundred fifty-five ears (51.8%, 95% CI: 46.1-57.4%) showed a tympanogram type B. Treatment consisted of BET without other interventions ("BET-only") in 70 children, 128 ears. Median length of follow-up for 158 (94.6%) children was 2.6 months (95% CI: 0.3-16.1 mo). After treatment, the tympanic membrane appeared normal in 196 ears (65.6%, 95% CI: 60.0-70.8%, p < 0.001). Median hearing threshold improved to 10 dB HL (95% CI: 0-45 dB, p < 0.001). Tympanograms shifted toward type A and C (type A: 39.1%, 95% CI: 33.7-44.7, p < 0.001). These improvements were also observed in subgroup analyses of "BET-only" treatment and the indication of "COME" respectively. CONCLUSION: BET is improving a variety of dilatory ET dysfunction-related ear diseases in children. This study provides detailed data for design and planning of prospective studies on BET in children.

Intrathecal Application of a Fluorescent Dye for the Identification of Cerebrospinal Fluid Leaks in Cochlear Malformation.

In cases of cerebrospinal fluid (CSF) leaks, reliable detection of their origins is needed to seal the leak sufficiently and prevent complications, such as meningitis. A method is presented here using intrathecal administered fluorescein in a clinical case of bilateral congenital ear malformation. A fluorescent dye is administered intrathecally to achieve intraoperative visualization of CSF leaks. The dye is applied 20 min before surgery, and concentration of 5% is used. Per every 10 kg of body weight, 0.1 mL of the fluid is applied intrathecally. The fluorescein is visualized using a fully digital microscope. The origin of the fluid leak is identified in the stapes footplate. During primary surgery, it is sealed, and cochlea implantation is performed for hearing restoration. In this specific case, 6 weeks later, the implant was explanted due to acute meningitis, and the electrode array was left as a spacer. Postoperatively, in the aural smear, ß-transferrin was detected. During a revision mastoidectomy, dislocated coverage of the leak was found. The stapes was removed and oval window sealed. Five days after revision surgery, no ß-transferrin was detected in the aural smear. During the revision of cochlea implantation 6 months later, intact coverage of the oval niche was observed. Thus, intrathecal fluorescein application proves to be a reliable tool for the detection of CSF leaks. It facilitates the orientation in malformations and complicated or unknown surgical situs. In the literature, its use is described for CSF fistulas in endonasal surgery but is rarely described in skull base and mastoid surgeries. The method has been used successfully in several cases with CSF leaks, and the results confirm the feasibility of safely accessing the origin of the leak.

A novel diagnostic tool for chronic obstructive eustachian tube dysfunction­the eustachian tube score.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to introduce a new tool for the diagnosis of chronic obstructive eustachian tube dysfunction (ETD) and as a follow-up tool for eustachian tube therapy using objective and subjective elements. STUDY DESIGN: Combined, prospective, retrospective clinical study at a tertiary referral center. METHODS: Physical examination, history, tympanometry, audiometry, and tubomanometry as well as the seven-item Eustachian Tube Dysfunction Questionnaire (EDTQ-7) were included as diagnostic tests. After initiating the eustachian tube score (ETS), we compared our results of healthy subjects to our data of patients with chronic obstructive ETD. In addition to ETS, an extended test ETS-7 was evaluated, which incorporated two additional items. RESULTS: The test-retest reliability revealed a correlation of 0.82 for the ETS and 0.87 for the ETS-7. ETS-7 receiver operating characteristic analysis, with reference to the EDTQ-7 score, resulted in an area under the curve (AUC) of 0.64. Our analysis considered essential criteria of ETD as comparative tools, which were typical clinical complaints, and at least two of three conditions: a pathologic EDTQ-7, a type B/C tympanometry, and a positive independent expert evaluation. The corresponding AUC was 0.98. Chronic obstructive ETD was identified at a cutoff of 7, with a sensitivity of 96% and a specificity of 96%, using the novel ETS-7. CONCLUSIONS: ETS is a valid and reliable instrument in adult patients with chronic obstructive ETD. ETS-7, with a cutoff point of ≤7, should facilitate the diagnosis of ETD and might be valuable as a diagnostic follow-up tool.

Treatment of the patulous Eustachian tube with soft-tissue bulking agent injections.

OBJECTIVE: A patulous Eustachian tube ([ET] tuba aperta) may cause symptoms as autophony, breath synchronous tinnitus, pressure sensation, and conductive hearing loss and thus lead to an enormous cutback in quality of life. In combination with "sniffing," it can trigger the development of cholesteatoma. Because of the ambiguous symptoms, the diagnosis can be challenging. A patulous ET can only be diagnosed through a well-structured examination, including patient history, physical examination with thorough observation of the movements of the tympanic membrane, and tympanometry with reflex-decay. STUDY DESIGN AND METHODS: Transnasal endoscopic injection of injectable soft-tissue bulking agent into the torus tubarius was performed in 20 patients as a new treatment option for patulous ET. All patients were followed up 6 weeks and 6 and 12 months after treatment. For each intervention, 0.8 to 2 mL of injectable soft-tissue bulking agent was used. RESULTS: In nine patients, more than one procedure was necessary. On follow-up, 10 out of 15 patients were satisfied with the result. Only three out of 15 patients reported no improvement of their symptoms. The procedure was minimally invasive, fast, and easy to perform. CONCLUSION: There is no gold standard for the therapy of patulous ET. The injection of soft-tissue bulking agent in the torus tubarius is a new minimally invasive therapeutic approach, but much more clinical experience is needed.

Computed tomography before balloon Eustachian tuboplasty--a true necessity?

OBJECTIVE: Since the introduction of balloon Eustachian tuboplasty the necessity of preoperative high-resolution CT scans of the temporal bone has been a topic of debate. This study investigated the informative value of preoperative CT scanning in predicting intraoperative or postoperative difficulties and complications. Special focus was laid on the existence of carotid canal dehiscences for fear of intraprocedural injury. STUDY DESIGN: Retrospective. SETTING: Tertiary referral center. PATIENTS AND INTERVENTIONS: Approximately 284 patients (510 Eustachian tubes) with intractable Eustachian tube dysfunction undergoing unilateral or bilateral balloon Eustachian tuboplasty with preoperative high-resolution CT scans of the temporal bone from January 1, 2009, to December 31, 2012. RESULTS: Carotid canal dehiscences were found in 18 patients (6.3%). In 3 patients (4 Eustachian tubes, 1.1% of patients) balloon dilatation could not be performed because of difficulties advancing the balloon catheter. Of these 3 patients, one had bilateral carotid canal dehiscences, whereas the other two had unremarkable CT scans. Postoperative complications occurred in 3 patients (1.1%): 2 soft tissue emphysemas and 1 unilateral hypoglossal paresis. All 3 patients had unremarkable CT scans, and all complications resolved completely without further sequelae. CONCLUSION: Preoperative high-resolution CT scan of the temporal bone does not seem to be suitable to predict intraoperative or postoperative difficulties of balloon Eustachian tuboplasty. Being extremely cautious during balloon catheter insertion into the Eustachian tube and using a device that is designed with a built-in stop mechanism preventing too deep insertion, the data presented suggest that fear of injury to the internal carotid artery during balloon dilatation might be disproportionate. Nevertheless, for inexperienced surgeons, HR-CT scans of the temporal bone may help to understand the relation between internal carotid artery and the Eustachian tube.