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Literature Reading

EUSTACHIAN TUBE
DYSFUNCTION
Desti Kusmardiani
Supervisor:
dr. Arif Dermawan M.Kes, Sp.T.H.T.K.L(K)
1

DEPARTMENT OF OTORHINOLARYNGOLOGY - HEAD&NECK


SURGERY
PADJADJARAN UNIVERSITY / HASAN SADIKIN GENERAL HOSPITAL
BANDUNG
2O16

DEFINITION
Eustachian tube dysfunction (ETD) means the
tube does not open properly.
The air pressure on the outer side of the eardrum
becomes grater than the air pressure in the
middle ear.
The eardrum is pushed inward, becomes tense,
and does not vibrate well. A healthy ear is one
that pops easily and feels immediately better.

A.G.M, Schilder et al. Eustachian tube dysfunction: consensus statement on definition, types,clinical presentation and diagnosis. 2015. Clin.
Otolaryngol., 40, 407411

ANATOMI

Bluestone, Charles D, Klein, Jerome. Otitis Media and Eustachian Tube Dysfunction In: Pediatric Otolaryngology. 4 th
Edition. Saunders, 2003
3
Bluestone, Charles D. Anatomy and Physiology of the Eustachian Tube System. In : Head and Neck Surgery-Otolaryngology.
Fourth Edition. Edited by: Bailey B.J. Lippincott Williams & Wilkin. 2006

4
Bluestone, Charles D, Klein, Jerome. Otitis Media and Eustachian Tube Dysfunction In: Pediatric Otolaryngology.
4 th
Edition. Saunders, 2003

Descriptive of anatomic Eustachian


tube

Children vs Adult

Long of eustachian tube


Lumen
Size of

Children < adult


smaller
10 vs 45

Large corner m. tensor veli palatini againts


cartilage
Density of cartilage cell
Cartilage Volume
Elastin composite of cartilage

Variable vs stabil

Ostmann lipid layer


Mucosa fold

Relatif more wide


Bigger

More bigger
Less
Less

VASCULARITATION OF EUSTACHIAN
TUBE
Artery:

a. palatine ascenden,
Faringeal brach of arteri maksilari interna,
a. canalis pterygoid,
a. faringeal ascenden and
a. meningeal media.

Venous drainage pleksus pterigoideus.


Limfatic drainageto the retrofaring and deep
servikal

INNERVATION OF EUSTACHIAN TUBE


Faringeal Orifisium from tuba eustakhius
Motoric Branch of otic ganglion , n. sphenopalatinus and
faringeal plexus.
Sensoric timpanicus and faringeal pleksus . N. glossofaringeal
suspend to having eustachian tube innervation.
Simpatic ganglion sphenopalatinus, otic ganglion, n.
glossofaringeal, n. petrosa and n. carticotympanicus

M. tensor veli palatine and m. tensor tympani part of


ventromedial nukleus motor trigeminal ipsilateral througt
trigeminus nerve.
Musculus levator veli palatine n. ambigus through n. vagus
Bluestone, Charles D, Klein, Jerome. Otitis Media and Eustachian Tube Dysfunction In: Pediatric Otolaryngology. 4 th
Edition. Saunders, 2003

THE FUNCTIONS OF THE


EUSTACHIAN TUBE ARE

A.G.M, Schilder et al. Eustachian tube dysfunction: consensus statement on definition, types,clinical presentation and diagnosis. 2015. Clin.
Otolaryngol., 40, 407411

Pressure in the middle ear is maintained through


two mechanisms:
middle

ear mucosal gas exchange


Opening of the Eustachian tube to equilibrate
pressure with that in the nasopharynx

A.G.M, Schilder et al. Eustachian tube dysfunction: consensus statement on definition, types,clinical presentation and diagnosis. 2015. Clin.
Otolaryngol., 40, 407411

3 SUBTYPES OF EUSTACHIAN TUBE DYSFUNCTION:

dilatory Eustachian tube


dysfunction,

baro-challenge-induced
Eustachian tube dysfunction

patulous Eustachian tube


dysfunction.

A.G.M, Schilder et al. Eustachian tube dysfunction: consensus statement on definition, types,clinical presentation and diagnosis. 2015. Clin.
Otolaryngol., 40, 407411

DILATORY EUSTACHIAN TUBE


DYSFUNCTION CAN BE BROKEN DOWN AS
FOLLOWS:

1 functional
obstruction,
2 dynamic dysfunction
(muscular failure),
3 anatomical
obstruction
A.G.M, Schilder et al. Eustachian tube dysfunction: consensus statement on definition, types,clinical presentation and diagnosis. 2015. Clin.
Otolaryngol., 40, 407411

CLINICAL HISTORY: SYMPTOMS OF


EUSTACHIAN TUBE DYSFUNCTION
aural fullness or popping or discomfort/pain
pressure, clogged or under water sensation,
crackling, ringing, autophony and muffled hearing

A.G.M, Schilder et al. Eustachian tube dysfunction: consensus statement on definition, types,clinical presentation and diagnosis. 2015. Clin.
Otolaryngol., 40, 407411

ACUTE DILATORY EUSTACHIAN


TUBE DYSFUNCTION

preceded by :
an

upper respiratory tract infection


an exacerbation of allergic rhinitis, which presumably
causes inflammation in the Eustachian tube orifice or
lumen.
a prior history of otitis media

A.G.M, Schilder et al. Eustachian tube dysfunction: consensus statement on definition, types,clinical presentation and diagnosis. 2015. Clin.
Otolaryngol., 40, 407411

BARO-CHALLENGE-INDUCED
EUSTACHIAN TUBE DYSFUNCTION
Symptoms :
aural fullness, popping or discomfort/pain
under conditions of alteration to the ambient
pressure.
manifest when scuba-diving or on descent from
altitude

A.G.M, Schilder et al. Eustachian tube dysfunction: consensus statement on definition, types,clinical presentation and diagnosis. 2015. Clin.
Otolaryngol., 40, 407411

PATULOUS EUSTACHIAN TUBE DYSFUNCTION

Symptoms :
aural

fullness and autophony


worsen during exercise
caused by an abnormally patent Eustachian tube; as
such, it may be precipitated by recent weight loss

A.G.M, Schilder et al. Eustachian tube dysfunction: consensus statement on definition, types,clinical presentation and diagnosis. 2015. Clin.
Otolaryngol., 40, 407411

SYMPTOMS AND SIGNS

A.G.M, Schilder et al. Eustachian tube dysfunction: consensus statement on definition, types,clinical presentation and diagnosis. 2015. Clin.
Otolaryngol., 40, 407411

CLINICAL ASSESSMENT: SIGNS OF EUSTACHIAN TUBE


DYSFUNCTION

Ideally assessment should include the following:


1

otoscopy or otomicroscopy,
2 tympanometry,
3 Rinnes and Webers tuning fork tests or pure tone
audiometry,
4 nasopharyngoscopy (to visualise the opening of the
Eustachian tube).

A.G.M, Schilder et al. Eustachian tube dysfunction: consensus statement on definition, types,clinical presentation and diagnosis. 2015. Clin.
Otolaryngol., 40, 407411

TESTS OF THE VENTILATORY


FUNCTION OF THE EUSTACHIAN
TUBE

The Eustachian Tube Score (ETS) and its


extension the ETS-77 combine subjective (clicking
sound when swallowing, Valsalva) and objective
(tubomanometry, tympanometry) measures of
Eustachian tube function.

A.G.M, Schilder et al. Eustachian tube dysfunction: consensus statement on definition, types,clinical presentation and diagnosis. 2015. Clin.
Otolaryngol., 40, 407411

19

Bluestone, Charles D, Klein, Jerome. Otitis Media and Eustachian Tube Dysfunction In: Pediatric Otolaryngology. 4 th

LR-JP

20

Bluestone, Charles D, Klein, Jerome. Otitis Media and Eustachian Tube Dysfunction In: Pediatric Otolaryngology. 4 th

MEP: middle ear pressure; SC: Static compliance; ECV: ear canal
volume

condition: ossicular dislocation or erosion, timpanosklerotik,


pseudomembran

21

condition : otosclerosis or middle ear effusi


on

Normal volume -> middle ear effusion, sclerosis


Small volume -> miss probe position or cerumen 22
Big volume -> MT perforation

Condition : negatif pressure in


eustachian tube eustachian tube
dysfunction

23

Tes
Politzer
Tes
Valsava

Tes Tuba
Patulous

Tes
Toynbee
24
Bluestone, Charles D, Klein, Jerome. Otitis Media and Eustachian
Tube Dysfunction In: Pediatric Otolaryngology. 4th Edition.
Saunders, 2003

DILATORY EUSTACHIAN TUBE DYSFUNCTION

patient-reported symptoms evidence of


negative pressure in the middle ear
As assessed by clinical assessment, either as
follows:

otoscopic

or otomicroscopic evidence of tympanic


membrane retraction and/or
tympanogram indicating negative middle ear
pressure

IN BARO-CHALLENGE-INDUCED EUSTACHIAN TUBE DYSFUNCTION

otoscopy and tympanometry normal, so


diagnosis relies on patient history.
In some cases of baro-challenge-induced
Eustachian tube dysfunction, middle ear effusion
or haemotympanum may be evident.

PATULOUS EUSTACHIAN TUBE


DYSFUNCTION

symptoms + evidence on otoscopy or


tympanometry of tympanic membrane excursion
with breathing

Pure tone audiometry A mild or moderate


conductive hearing loss may be found in some
patients with Eustachian tube dysfunction

NASOPHARYNGOSCOPY

Examination may reveal a cause for Eustachian


tube dysfunction, for example inflammation
adjacent to the Eustachian tube orifice, or
(rarely) neoplasms, scarring or other lesions.

DIFFERENTIAL DIAGNOSIS
ventilatory dysfunction of the Eustachian tube
may contribute to the onset or persistence of
these types of otitis media
cochlear hydrops
temporomandibular joint (TMJ) dysfunction

discomfort

in front of and around the ear, typically


unilateral, and in some cases associated with clicking
or popping noises and altered hearing or tinnitus.

A.G.M, Schilder et al. Eustachian tube dysfunction: consensus statement on definition, types,clinical presentation and diagnosis. 2015. Clin.
Otolaryngol., 40, 407411

MANAGEMENT
Force

air to flow into the Eustachian tube


Decongestant tablets (e.g. Sudafed) and
nasal sprays (e.g. Afrin, Neo-synephrine)
Antihistamines (e.g. Zyrtec, Benadryl)
Guaifenesin (e.g. plain Mucinex or
Robitussin).
Steroid nasal sprays

HIGHLIGHTS
There are three subtypes of Eustachian tube
dysfunction: dilatory, baro-challenge induced,
and patulous Eustachian tube dysfunction
presents with symptoms of pressure
disequilibrium in the affected ear
In dilatory dysfunction there are signs on
otoscopy or tympanometry of negative middle ear
pressure

In baro-challenge induced dysfunction, symptoms


occur only on changes to ambient pressure.
In patulous dysfunction there is otoscopic or
tympanometric evidence of excursion of the
tympanic membrane with breathing.

Thank You