In the most commonly performed procedure, Dr. Poe threads a 14-gauge intravenous angio-catheter, pre-occluded with bone wax, through the mouth, and inserts it into the full length of the Eustachian tube. “It will wedge nicely into the boney-cartilaginous isthmus where the Eustachian tube narrows, holding it in place, but it usually won’t block it,” he said. Because it’s flexible, the catheter will lie in the longitudinal concavity in the wall of the Eustachian tube where the leak is occurring. “The procedure is done in the operating room because it is uncomfortable,” Dr. Poe said.
Explore This IssueJanuary 2016
Although the procedure’s immediate success rate is more than 90% and the catheter is well tolerated, that number drops over time because some catheters become displaced, extruding from the nose or mouth after months or years. If the catheter falls out, a scenario that occurs approximately 40% of the time, according to Dr. Poe, a patient’s symptoms may or may not return. This is because mucosa rejuvenates itself, stopping the air leak. To date, no one has ever aspirated or choked on one of the catheters.
For small defects in favorable locations, hydroxyapatite or collagen fillers can be injected into the submucosa of the Eustachian tube. Some surgeons are performing these procedures in an office setting.
For failures of the above procedures, a more definitive repair can be done by sub-total occlusion of the lumen with an Alloderm implant using a technique similar to the CSF obliteration, but leaving a mucosal strip inferiorly to prevent complete blockage. Cartilage grafts can also be placed in a submucosal pocket to narrow the lumen.
Patients first have a CT scan to ensure that the carotid artery is protected by bone. If there’s any chance of encountering the artery, Dr. Poe won’t perform the procedure. All of the materials placed into the Eustachian tube are currently off-label uses, as is the use of an intravenous catheter.
“Patulous Eustachian tube repair is much more successful than the alternative procedure of inserting a tympanostomy tube,” Dr. Poe said. “As opposed to completely obliterating the Eustachian tube, as was done in the past, it allows for reversible functional repair that is minimally invasive. Other procedures, such putting ointment or sticky tack on the eardrum so it doesn’t move as much while breathing, work in some but not all patients.”
Elias Michaelides, MD, associate professor of surgery in otolaryngology and director of the Yale Hearing and Balance Center at the Yale School of Medicine in New Haven, Conn., said, “We have found that we can be much more aggressive in narrowing the Eustachian tube and restoring normal function by using advanced techniques than we first thought.”