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1. EUSTACHIAN TUBE DISORDERS - NAME - DR. BANSARI AKBARI 1 ST YEAR ENT RESIDENT UNDER GUIDANCE OF DR VIRAL SIR AND DR VATSAL SIR

2. TUBAL BLOCKAGE - Normally, eustachian tube is closed. It opens intermittently during swallowing, yawning and sneezing through the active contraction of tensor veli palatini muscle. Air, composed of oxygen, carbon di-oxide, nitrogen and water vapour , normally fills the middle ear and mastoid. When tube is blocked, first oxygen is absorbed, but later other gases, CO2 and nitrogen also diffuse out into the blood. This results in negative pressure in the middle ear and retraction of tympanic membrane. If negative pressure is still further increased, it causes “locking” of the tube with collection of transudate and later exudate and even haemorrhage .  Eustachian tube obstruction can be mechanical, functional or both. Mechanical obstruction can result from
( i ) intrinsic causes such as inflammation or allergy or  (ii) extrinsic causes such as tumour in the nasopharynx or adenoids. Functional obstruction is caused by collapse of  the tube due to increased cartilage compliance, which resists opening of the tube or failure of active tubal-opening mechanism due to poor function of tensor veli palatini . 

3. 2. Adenoids and Eustachian Tube Function.  Adenoids cause tubal dysfunction by:
(a) Mechanical obstruction of the tubal opening.
(b) Acting as reservoir for pathogenic organisms.
(c) In cases of allergy, mast cells of the adenoid tissue release inflammatory mediators which cause tubal blockage.
Thus, adenoids can cause otitis media with effusion
or recurrent acute otitis media. Adenoidectomy can help
both these conditions.

4. AERO-OTITIS MEDIA (OTITIC BAROTRAUMA )-
It is a nonsuppurative condition resulting from failure of eustachian tube to maintain middle ear pressure at ambient atmospheric level. The usual cause is rapid descent during air flight, underwater diving or compression in pressure chamber. MECHANISM- Eustachian tube allows easy and passive egress of air from middle ear to the pharynx if middle ear pressure is high.
In the reverse situation, where nasopharyngeal air pressure is high, air cannot enter the middle ear unless tube is actively opened by the contraction of muscles as in swallowing, yawning or Valsalva manoeuvre . When atmospheric pressure is higher than that of middle ear by critical level of 90 mm Hg, eustachian tube gets “locked” . In the presence of eustachian tube oedema , even smaller pressure differentials cause “locking” of the tube. Sudden negative pressure in the middle ear causes retraction of tympanic membrane, hyperaemia and engorgement of vessels, transudation and haemorrhages .

5. CLINICAL FEATURES- Severe earache, hearing loss and tinnitus are common complaints. Tympanic membrane appears retracted and congested. It may get ruptured.Middle ear may show air bubbles or haemorrhagic effusion. Hearing loss is usually conductive. TREATMENT The aim is to restore middle ear aeration. This is done by catheterization or politzerization . In mild cases, decongestant nasal drops or with antihistaminics are helpful. In the presence of fluid or failure of the above methods, myringotomy may be performed to “unlock” the tube and aspirate the fluid. PREVENTION Aero-otitis can be prevented by the following measures:
1. Avoid air travel in the presence of upper respiratory
infection or allergy.
2. Swallow repeatedly during descent. Sucking sweets or
chewing gum is useful.
3. Do not permit sleep during descent as number of swallows normally decrease during sleep.

6. 4. Autoinflation of the tube by Valsalva should be performed intermittently during descent.
5. Use vasoconstrictor nasal spray and a tablet of antihistaminic and systemic decongestant, half an hour before descent in persons with previous history of this episode. 6. In recurrent barotrauma, attention should be paid to nasal polyps, septal deviation, nasal allergy and chronic sinus infections.

7. PATULOUS EUSTACHIAN TUBE :- -Patulous Eustachian tube is defined as abnormally patent Eustachian tube. Causes:- Atrophic rhinitis
Senility
Sudden loss of weight.
Patients on oral contraceptives
Pregnancy
Elderly patients on diuretics
Myasthenia gravis, lower motor neuron disease. Gasserian ganglion surger y

8. SYMPTOMS - Blocking sensation of the ear without hearing loss and disappears on lying down and alters with change of position of the head. Autophony Tympanic membrane is normal in appearance but moves with deep respiration. Investigations:- Impedance audiogram: The needle of the audiogram moves with respiration. Treatment:- Reassurance
Insertion of the ventilation tube
Injection of Teflon paste around the Eustachian tube (cushion effect)

9. ACUTE SALPINGITIS :- Definitions- Acute salpingitis is inflammation of the mucosal lining of the Eustachian tube usually following upper respiratory tract infection. Symptoms- Bilateral intermittent blocking sensation of the ear. Pain is experienced below the ear radiating between the mandible and the mastoid process. Pain during sneezing and coughing is common in Eustachian tube dysfunction in children.   Patient can hear his own voice louder ( autophony )   Tinnitus Mild hearing loss

10. SIGNS- Mild retraction of the tympanic membrane. TREATMENT – Decongestion with nasal drops thrice daily for 3-5 days Antihistamines if history of associated allergic rhinitis.  Analgesics like acetaminophen thrice daily for 3-5 days

11. CHRONIC SALPINGITIS : Chronic salphingitis is chronic inflammation of the mucosal lining of the Eastachian tube with associated hypertrophic, hyperplastic, adhesive changes in the tubal lining leading to obstruction of the tube due to chronic nasal disease or suppurative or nonsuppurative otitis media. Symptoms- Bilateral blocking sensation in the car, which may be constant Bilateral hearing loss. Bilateral ear discomfort or pain due to Eustachian tube block may be experienced. Signs : Mild retraction of the tympanic membrane with early sigen of otitis media with effusion.

12. Features of Retracted Tympanic Membrane- Dull appearance
Laser Cone of light distorted/absent
Apparent shortening of handie of malleus
Prominent ossicles Prominent malleolar folds - Treatment – Infection and allergy of nose and paranasal sinus to be controlled. Decongestant nasal drops , nasal douching followed by steroidal spray and Antihistaminic tablets
Exercises to ventilate the middle ear- Valsalva maneuver: Advised several times a day to unlock the Eustachian tube and hasten the clearance. To blow balloons and use of chewing guns to ventilate the middle car. Otoventilation sets available in the market which may be useful. Myringotomy and grommet insertion in case of failed conservative management with history of recurrent ear infection.
Presence of nasopharyngeal pathology to be taken care .

13. TUBOMANOMETRY- TMM is the tool to measure the opening of the ET tube and the transportation of gas into the middle car by registering pressure changes .
A stimulus of controlled gas bolus is applied to the nasopharynx during swallowing and recorded by a pressure sensor in the occluded external ear canal. If ET opening is registered, the time of opening in relation to pressure application can be measured. An R value of <1 indicates early opening of the ET, which is considered optimal and R>1 indicates delayed opening . TMM R values have used together with clinical symptoms to generate an ET score. The ET score can range from 0 =complete obstruction to 10 =normal tubal function).

14. Surgical anatomy of EUSTACHIAN tube - The eustachian tube runs posteriorly, laterally, and superiorly from the nasopharynx to the middle ear. The long axis of the eustachian tube on the axial plane corresponds to the line passing through the medial opening of the osseous part of the eustachian tube and the dorsal opening of the vidian canal . The eustachian tube runs almost parallel to the horizontal segment of the internal carotid artery toward the medial pterygoid plate. The cartilaginous part of the Eustachian tube run anteromedial to foramen ovale . In addition, the cartilaginous eustachian tube is not tubal and has a noncartilaginous gap located inferolaterally between the medial and lateral cartilaginous laminae ,which is covered by the tensor veli palatini , levator veli palatini , and the lateral fat pad.