Those patients might complain of aural fullness, but their primary problem is autophony of voice or breath. Sniffing inappropriately might also be a warning sign for patulous ETD.
Explore This IssueJune 2018
For those patients who complain of aural fullness but lack major warning signs—no barorestriction, autophony, or tympanic membrane excursion—otolaryngologists should look at alternatives to ETD such as TMJ dysfunction or inner ear hydrops.
Valsalva Pros and Cons
There is a fine line when it comes to how often a patient can Valsalva. “The dilatory dysfunction patient can try Valsalva-ing so frequently that they in fact give themselves patulous dysfunction,” Dr. Chandrasekhar said. “You can actually keep sniffing and keep Valsalva-ing and end up patulous.”
Eric Smouha, MD, a clinical professor of otolaryngology at Icahn School of Medicine at Mount Sinai in New York, also preaches the usefulness of the Valsalva maneuver to patients. “I spend a lot of time explaining this to patients because I think that in the end, we’re going to treat the majority of these people conservatively,” he said. “I think that the Valsalva maneuver … is really an essential part of the physical exam in these patients and helps determine the degree of severity.”
Many of Dr. Smouha’s patients struggle to properly Valsalva in the office, so, in addition to sending them home with nasal decongestants or steroids, he also makes sure to “instruct them on doing these procedures repeatedly at home,” he said. “They often say something like, ‘I tried and I tried and it doesn’t work.’ My instruction to them is to keep performing the maneuver. Once they’re able to persuade that valve to open, they’ll start to achieve some relief.”
Dr. Chandrasekhar said it’s worth otolaryngologists’ time to work with patients as much as necessary to teach the proper methods for the Valsalva maneuver, so that it’s done correctly and not to excess. “If you spend a few minutes in your office teaching people how to Valsalva, I think a lot of these problems can be ameliorated,” she said.
Dennis Poe, MD, PhD, associate professor of otology and laryngology at Harvard Medical School and Boston Children’s Hospital, both in Boston, said a modified version of the Valsalva maneuver could be helpful. The approach is to hold the nose and mouth closed, gently performing an auto-insufflation and simultaneously swallowing, which uses the dilatory muscles while the patient is generating some mild positive pressure.
That version helps protect patients, particularly those who might hurt themselves by trying too hard or improperly performing the maneuver. Dr. Poe disclosed consulting work for Acclarent Corp., and Otodyne Inc.