Eustachian Tube And It’s Disorders Otalgia

1. Eustachian Tube And It’s Disorders Otalgia Dr Sheetal Rai Assistant Professor Dept of ENT Yenepoya Medical College

2. EUSTACHIAN TUBE Connects the middle ear to the nasopharynx

3. EUSTACHIAN TUBE • Named after Bartolomeus Eustachia – discovered it in 1562.

4. Anatomy Auditory tube or pharyngotympanic tube: • 36mm in length, • lateral 1/3 is bony, • medial 2/3 is cartilaginous part, with an isthmus in between

5. It opens into nasopharynx 1-1.25cm behind and a little below the posterior end of inferior turbinate where it forms tubal elevation. Opening is SLIT LIKE in shape • Endoscopic picture

6. Blood supply is by ascending pharyngeal and middle meningeal artery, • Venous drainage to pharyngeal plexus, • Lymph to retropharyngeal node, • Nerve supply – • for ostium - by pharyngeal branch of sphenopalatine ganglion, • for cartilage portion – by the nervus spinosus, • for bony part- tympanic plexus, • tympanic branch of IXn to tubal mucosa for sensation and secretion.

11. Tensor palati help to open the cartilaginous portion by acting on curve of tubal cartilage, levator palati helps in opening by supporting cartilage, pushing up and medially, • Closure is by the lateral fat pad of ostmann. The elastin hinge at the junction of the 2 lamina at the roof is rich in elastin and helps to close tube by recoil,

13. LINING EPITHELIUM • Lined by ciliated epithelium which is • in cartilaginous part - pseudostratified columnar, • in bony part - columnar

14. Eustachian Tube

15. FUNCTIONS OF EUSTACHIAN TUBE • Ventilation and regulation of middle ear pressure • Protective function - protects middle ear from loud sound pressure from nasopharynx and from reflux of nasopharyngeal secretions. • Clearance of middle ear secretions

16. ET PATENCY TESTS • Valsalva manoeuvre • Politzerisation • ET Catheterization • Toynbee manoeuvre • Impedance Audiometry • Radological test • Saccharin test • Sonotubometry • Frenzel’s manoeuvre • ET cannulation

17. Differences between infant and adult

18. DIFFERENCES B/W ADULT & INFANT ET

19. ET DYSFUNCTION Aetiology- • +congenital-cleft palate(submucous type), • +inflammation-URTI, • +DNS • +trauma-ET catheterisation, fracture maxilla • +neoplasm-benign,malignant- nasopharynx • +palatal paralysis, muscular dysfunction esp. TVP or LVP leads to dynamic dysfunction causing functional blocks • +post radiation • + Down’s syndrome +miscellaneous- poor feeding habits, malnutrition, ciliary motility disorder, mucosal abnormality, allergy, in 3rd trimester of pregnancy • mechanical- intrinsic-infection, allergy- extrinsic-adenoids, neoplasms of nasopharynx; serous otitis media .

20. When tube is blocked, oxygen is absorbed in middle ear, CO2 and nitrogen also diffuse out into blood. Create negative pressure in middle ear and retraction of TM. • If negative pressure still increases, leads to locking of tube with collection of transudate and later exudate and Haemorrhage.

21. Symptoms- otalgia, hearing loss, popping sensation, tinnitus, vertigo • Signs-vary based on acuteness and severity-retracted TM, congestion along handle of malleus and pars tensa, transudate behind TM, imparts amber colour, CHL • Can lead to Chronic OM

22. TREATMENT Identify and treat the cause; • reflux- avoid food causing acidity, PPI, H2 receptor blockers, sleep on an inclined bed, fundoplication. • Allergy- oral anti-histamines, nasal steroid spray, immunotherapy. • Nasopharyngeal ca- radiotherapy. • Adenoid- adenoidectomy. • Infections-antibiotics, • granulomatous disease- immunosuppressants.

23. Surgery- if medical line fails. • In serous otitis media, ventilation tubes. In persistent cases, repeated placement of tubes may be needed. • Laser tuboplasty- Laser de-bulking of posterior cushion luminal mucosa and submucosa down to the medial cartilaginous lamina

24. PATULOUS ET Patulous ET- the tubal orifice remains inappropriately abnormally patent • Aetiology- • atrophic rhinitis, • senility, • sudden loss of weight, • pt on OCP, pregnancy (3rd trim), • elderly pt on diuretics, • lower motor neuron disease, • mucosal atrophy, • muscular dysfunction, • multiple sclerosis,

25. SYMPTOMS Intermittent or fluctuating symptoms. • blocking sensation of the ear without hearing loss and disappears on lying down and alters with change of position of head or compression of ipsilateral IJV; • Autophony, • blowing sound, • awareness of breath sound sensation as if they are speaking within a barrel. • Worsen with nasal decongestants, better with URTI.

26. SIGNS • When tube is patent, pressure changes in nasopharynx are easily transmitted to middle ear and seen as movements of TM synchronous with respiration; • pts breathing can be heard through an auscultation tube inserted into EAC. • presence of autophony.

27. PATULOUS ET OPENING • Endoscopic evaluation of ET shows tissue loss longitudinally through the valve seen as concave or scaphoid defect along superior aspect of anterolateral wall.

28. INVESTIGATIONS • IMPEDANCE AUDIOGRAM- • needle moves with respiration……… fluctuation………enhanced by forced respiration through mouth with nose closed

29. TREATMENT • Reassurance Aim at thickening the mucus or restoring the bulk of ET valve. • Stop decongestants, weight gain, good hydration with nasal saline drops. • insertion of ventilation tube, • oral potassium iodide, • local application of pot iodide solution -used to thicken mucous secretions.

30. local application of conjugated oestrogen (oestrogen nasal drops 3 drops TIS for 6 weeks)- lead to localised hypertrophy around ET orifice. • Topical irritants like aspirin onto ET orifice- localised inflammatory oedema around the orifice. • Surgical- peritubal injection of Teflon paste into posterior cushion or floor of tubal lumen for cushion effect. • endoscopic approach- implants conchal cartilage or alloderm (alloplastic material) grafts into the concave anterolateral defect to create a normal convex shape to restore valve competency.

31. Right patulous ET reconstruction • 1-preop view shows concave defect seen in anterolateral wall of valve. • 2-post op shows repair of concave defect in anterolateral wall.

32. ACUTE SALPHINGITIS functional obstruction • After an URTI especially sinusitis or influenza- • epithelial lining of tube becomes congested and edematous leads to tubal blocking without involving middle ear. • Oedema of orifice, blockage of orifice with mucopurulent discharge, • ciliated cells reduce, mucous production increases, creates negative ME pressure

33. Symptom- History of blocking sensation of ear, ear ache- relieved temporarily on swallowing, tinnitus, mild hearing loss. • On examination- nasal obstruction with mucopurulent nasal discharge, TM retracted and intact but with few dilated surface vessels • Treatment- rest, nasal decongestant, anti-histamine, local steroid spray

34. CHRONIC SALPHINGITIS • chronic hypertrophic, hyperplastic, adhesive changes in the tubal lining • predisposed by adenoiditis, nasal allergy, allergic fungal sinusitis, chronic infection in nose & PNS • symptom- history of intermittent deafness with discomfort. blocking sensation in ear, occasional tinnitus

35. On examination- retracted TM which does not move on valsalva manoeuvre, tuning fork test show conductive hearing loss • Inv- PTA-mild to moderate conductive hearing loss, impedance shows Type C audiogram • Treatment- treat the cause, nasal decongestant and anti-histamine are given, ET catheterisation, myringotomy and grommet insertion, in children adenoidectomy

36. BARO-OTITIS MEDIA • Cause is rapid atmospheric pressure changes. • During decompression (ascent) – as ME pressure exceeds ambient pressure, passive ventilation of air thru ET to pharynx occurs as ET allows easy and passive egress of air from ME.

37. During descent, the ambient pressure increases.... Normally pressure is equalised by opening of the ET (voluntary action of TVP & LVP) • If ET remains blocked ……… pressure reflected onto the ME vasculature…. Congestion & edema of the mucosa…..transudation/ H’ge

38. The perception of requirement to equalise occurs at depth of 2.6ft reflecting a pressure change of 60mmHg. • Continued descent …….. ET locking when the atmospheric pressure exceeds the ME pressure by 90mmHg or at depth of 3.9 ft…….. at this pressure, the power of LVP is insufficient to overcome external closing pressures - barotrauma occurs.

39. ACUTE OTITIS MEDIA Predisposing factors- • ET in infants and children is shorter, wider and more horizontal • feeding in horizontal position may force fluid through the ET to ME, • swimming and diving. • upper respiratory tract infection. • Altered tubal function- muscular opening function. • Infection spreads through ET to ME, actively via the lumen of the tube or along subepithelial peritubal lymphatics or passively along ET with other nasopharyngeal secretions.

40. OTALGIA

41. OTALGIA CAUSES : • Local • Referred • Psychogenic

42. LOCAL CAUSES EXTERNAL EAR MIDDLE EAR ACUTE OTITIS MEDIA EUSTACHIAN TUBE OBSTRUCTION BARO-OTITIS MEDIA ACUTE MASTOIDITIS EXTRADURAL ABSCESS ME MALIGNANCY • FURUNCLE • ACUTE DIFFUSE OTITIS EXTERNA • OTOMYCOSIS • HERPES ZOSTER • MYRINGITIS BULLOSA • MALIGNANCY

43. REFERRED OTALGIA

44. Thank You