The Laryngoscope
C 2014 The American Laryngological,
V
Rhinological and Otological Society, Inc.
How I Do It
Endoscopic Transnasal Shim Technique for Treatment of Patulous
Eustachian Tube
Brian Rotenberg, MD, MPH, FRCSC; Benjamin Davidson, BSc
INTRODUCTION
An abnormally patent Eustachian tube, known as a
patulous Eustachian tube (pET), can cause disabling
autophony as well as annoying transmitted sounds of
breathing and swallowing.1 The elegant work of Poe’s
group has shown that the anatomical defect is found in
the anterolateral tubal valve of the nasopharyngeal end
of the Eustachian tube (ET).2 To the frustration of both
patients and their caregivers, current medical and surgical treatments are relatively inconsistent in their ability
to eliminate the symptoms of pET. Numerous treatments
have been proposed, including silicone plugs,2 rolled
catheters,2 mass loading material on the tympanic membrane,3 silver nitrate cautery,2 conjugated estrogen
drops,4 electrocauterization,4 Teflon/fat injection,2 and
cartilaginous luminal reconstruction.5
In 2012, our group from Western University published the results of suture ligation of the torus tubaris
for treatment of pET.6 Over time, however, we found
that the sutures eventually worked themselves out of
place in several cases, presumably due to the strong
muscular forces acting on the ET during swallow. In
these cases, revision surgery via placement of a suturefixated shim filled with bone wax to block the ET lumen
in the resting position, thereby restoring the competency
of the closing mechanism, immediately improved the
pET symptoms—and did so both consistently and for the
long term. Herein we describe our shim technique and
its effectiveness in eliminating autophony.
SURGICAL METHOD
A CT scan of the temporal bones is performed in all
cases to rule out petrous carotid dehiscence, which
From the Department of Otolaryngology–Head & Neck Surgery,
University of Western Ontario, London, Ontario, Canada.
Editor’s Note: This Manuscript was accepted for publication April
26, 2014.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Brian Rotenberg, MD, Associate Professor,
Department of Otolaryngology–Head & Neck Surgery, St. Joseph’s
Health Centre, 268 Grosvenor Street, Rm E3-104, London, Ontario, N6A
4V2, Canada. E-mail: brian.rotenberg@sjhc.london.on.ca
DOI: 10.1002/lary.24751
Laryngoscope 124: November 2014
2466
would be a contraindication to shim placement. Endoscopic shim placement is performed under general anesthetic in all cases. The patient is placed supine and
prepared in standard fashion for endoscopic sinus surgery. The nasal cavity is decongested and visible landmarks
infiltrated
with
local
anesthesia
with
epinephrine, using a narrow-gauge spinal needle to
reach the nasopharynx and torus tubaris. The torus is
visualized with a 45-degree endoscope. The shim is constructed using an irrigation catheter (Med-Rx, Oakville,
Canada) that is comprised of semirigid rubberized plastic and measures 19-gauge in width. The catheter is
trimmed to 3.5 cm in length (to allow for transit up the
cartilaginous ET and wedging in the isthmus, with
5 mm still protruding into the nasopharynx), after
which melted bone wax is drawn up into the catheter
and then allowed to cool, which consequently turns the
catheter into a shim with a solid outside and semisolid
interior. As the first step in placing the suture ligation,
a 4-0 Ethibond Excel TF braided suture (Ethicon; Johnson & Johnson, Markham, Canada) is securely sutured
through-and-through the shim 5-mm along its length.
The shim is then grasped with an angled forceps, placed
into the nasopharynx, and gently inserted into the
lumen of the torus, after which it is advanced up the ET
lumen until it firmly wedges in the ET isthmus. The 3.5cm length is designed such that approximately 5-mm of
the shim protrudes into the nasopharynx to facilitate
future removal, if necessary. The needle end of the Ethibond suture is now endoscopically placed into the nasopharynx and sutured to the anterior cushion of the torus
using an endoscopic needle driver. This second suture
firmly secures the shim in place in an attempt to prevent dislodgement during cough, swallow, or sneeze, but
still allows freedom of removal by cutting the suture, if
necessary. Figure 1 and Figure 2 show illustrations of
shim placement in axial and coronal cuts, respectively,
with Figure 3 showing an endoscopic photograph taken
at 2 weeks postoperatively. Placement of nasal packing
is not necessary; placement of a myringotomy tube is not
routine. Postoperatively, patients are instructed to
gently irrigate their nose with a fine spray and if possible avoid nose blowing for several weeks. Patients are
followed up initially at 2 weeks after surgery to check
Rotenberg and Davidson: Shim Placement for Patulous Eustachian Tube
TABLE I.
Results of Shim Placement.
Patient
Number
Age
(years)
Sex
Duration of
Follow-up
(months)
Preoperative
Autophony
Postoperative
Autophony
1
27
F
21
5
1
2
3
36
43
F
F
18
9
3
4
1
1
4
21
M
12
5
1
5
6
39
42
F
F
14
18
4
4
2
1
7
41
M
6
3
1
surgical healing, and then at 3 to 6 months after surgery
to ascertain the success of repair by both history and
exam of ear and nose. For the purposes of this article,
patients were asked to go to the clinic to be assessed. If
this was not possible, they were surveyed over the
phone.
RESULTS AND REPRESENTATIVE CASES
From 2011 to 2013, the bone-wax shim technique
was employed in seven patients (five female; two male)
with pET who were suffering from moderate-to-disabling
autophony that had proven resistant to several previous
attempts at surgical repair. The mean age was 35.6
years old. No ear effusions were noted for any patient.
Should an effusion have been present, it would have
been drained by ventilating tube placement. No problematic crusting or infection was noted, despite the suture
being a braided one. Over the maximal duration of
follow-up, to date no catheters have spontaneously
extruded. Autophony severity was assessed preoperatively and postoperatively with the same self-reported
scale used in our previous publication6 and adapted
from Poe.5 The patient-reported symptoms were scored
as 1) no autophony, 2) mild autophony (not affecting
activities of daily living), 3) moderate autophony
Fig. 1. Axial illustration of shim placement.
Laryngoscope 124: November 2014
Fig. 2. Coronal illustration of shim placement.
(consistent throughout activities of daily living), 4)
severe autophony (affecting ability to perform activities
of daily living), and 5) disabling autophony (patient
unable to cope on a daily basis). At follow-up, all
patients reported complete resolution of autophony and
had no associated hearing loss or ear effusion from the
procedure. There were no observed surgical complications within this small series. Most patients reported
that they could not even feel the shim in place; however,
two (28.6% of the series) patients noted that in the
immediate postoperative period there was an ache,
described as “deep in the ear,” on the ipsilateral side. In
both cases, this resolved rapidly after surgery with only
routine pain medication. One patient’s catheter (Fig. 3)
was found to be a little bit too long in the clinic; it could
be felt touching the palate and was trimmed in the clinic
setting using a fine scissor. There was immediate resolution of the problem. No patients have noticed feeling the
sutures in their nose. At last recorded autophony check,
mean duration of follow-up was 14 months after surgery.
Table I lists the results of our cases to date. Three representative cases are described in more detail below.
Fig. 3. Photograph of suture ligated shim in situ. [Color figure
can be viewed in the online issue, which is available at
www.laryngoscope.com.]
Rotenberg and Davidson: Shim Placement for Patulous Eustachian Tube
2467
Patient 1 was a 30-year-old female who had suffered from autophony for several years. The patient was
first treated with ET augmentation using periumbilical
fat grafting, suction cauterization of the torus tubarius,
and purse string closure of the ET orifice. Although the
patient experienced diminished autophony, it was still
bothersome; therefore, the patient elected to have a
catheter bone-wax repair. Preoperatively, the patient
endorsed disabling (4/5) autophony. Postoperatively, the
patient reported mild (2/5) autophony with exertion,
which then resolved completely (1/5) by 3-month followup. There were no complications or hearing loss from
the procedure, and at 1 year the patient remains symptom-free.
Patient 2 was a 36-year-old female who had suffered from autophony and hyperacusis due to a rightsided pET for over 10 years. The patient had undergone
a course of estrogen drops and placement of a myringotomy tube to no effect. Endoscopic augmentation of the
ET orifice with an abdominal fat graft was performed.
Initially, the patient autophony decreased substantially
but soon returned sufficiently to be bothersome. The
patient had secondary and tertiary revision surgeries,
both of which followed a similar pattern of symptom
recurrence postoperatively. Following both of the revision procedures, sneezing out the sutures precipitated
symptom recurrence. Therefore, a bone wax-filled catheter was inserted, but ultimately forceful swallowing and
sneezing caused it to be dislodged. Finally, the patient
had a fifth surgery in which we inserted a bone-wax
stent and sutured it to the anterior cushion as per the
above technique. Prior to this last operation, the patient
endorsed moderate (3/5) autophony. Postoperatively, the
patient reported complete resolution of the autophony
(1/5), which was sustained. A repeat audiogram at 6
months after the shim placement demonstrated resolution of the conductive hearing loss, and the autophony
at the same visit was still graded at 1/5.
Patient 3 was a 64-year-old female who had suffered from recent onset autophony due to a left-sided
patulous Eustachian tube. Initially, the patient had an
endoscopic augmentation of the ET with an abdominal
fat graft with total symptom resolution. However, 3
weeks after surgery the patient felt a pop in the ear and
symptoms unfortunately returned. A bone-wax shim was
subsequently inserted without suture, but the patient
coughed it out. Finally we performed the bone-wax shim
suture placement, as described above. Preoperatively,
the patient endorsed severe (4/5) autophony. Postoperatively, autophony was completely gone (1/5). The patient
remains symptom-free at 6 months after surgery.
has written on mass loading of the tympanic membrane.3 Unfortunately, at present these techniques can
be time- and resource-intensive, demonstrate mixed
results in the literature, or may be straightforward but
only show temporary results. Although we acknowledge
that some form of luminal reconstruction will likely be
the ideal approach in the future, in this report we have
demonstrated a simple procedure to correct pET that is
both consistently effective and easily reversible. Conceivably, the simple technique we have described herein
could be used as a first-line surgical therapy (after failure of medical management), with some of the more
involved procedures being offered for salvage.
The first report of an occluded catheter used as a
shim to treat pET was published by Bluestone and Cantekin in an 1981 article.7 This, as well as a more recent
series from Kobayashi (the largest shim series to date)
both made use of a transtympanic approach—inserting
the shim through a myringotomy incision.7,8 Both
groups used a shim flared at one end to prevent it from
sliding through the ET into the nasopharynx. Kobayashi’s work resulted in consistent improvement, although
25% of patients required further treatment for some
residual autophony.8
There are several advantages to a transnasal
approach. Because 5 mm of the shim is left protruding
into the nasopharynx, the catheter’s position can be
readily assessed in clinic. The location also allows the
catheter to be sutured in place, decreasing the chance of
dislodgement but also affording the ability to remove the
catheter without a myringotomy incision. Finally, transnasal shim insertion avoids myringotomy and its complications. Recent work of Manes et al. used cadaveric
heads to demonstrate the technical feasibility of an
endoscopic transnasal approach to place a 16G-semirigid
catheter filled with bone wax in the ET as a shim.9 This
in-vitro conceptual study lends credence to our in-vivo
clinical work.
A potential limitation of the shim technique, or any
other that attempts to obliterate the ET, is the possibility of an OME—a complication dating back to the work
of Brookler and Pulec.10 Interestingly, the literature has
shown great variability in the incidence of these events.
In our previous study, as well as the current one, we
found a very low rate of effusion. This can be explained
by either a small lumen remaining sufficiently patent, or
the epithelial mucosa lining the middle ear being proficient enough in the role of gas and fluid exchange to prevent an effusion—a theory that has been put forward
previously.11,12
CONCLUSION
DISCUSSION
The concept of how to best repair a symptomatic
pET remains largely unresolved. Poe’s group out of Boston has demonstrated some success with a technical
patulous Eustachian tube reconstruction technique
designed to restore tubal competence using cartilage
grafts5; our group has described endoscopic suture ligation with fat packing6; and Bance’s group from Halifax
Laryngoscope 124: November 2014
2468
This endoscopic shim technique involves using an
irrigation catheter filled with bone wax to occlude a
symptomatically patent ET. Suturing the shim in place
prevents dislodgement, and it also allows for easy reversal of the surgery should that prove necessary. In our
series, the shim consistently eliminated intractable
moderate-to-severe autophony in all cases. In the future,
a method to consistently eliminate autophony through
Rotenberg and Davidson: Shim Placement for Patulous Eustachian Tube
restoration of the ET valve function would be ideal.
However, at present the endoscopic shim sutureplacement technique offers an efficient and reproducible
repair for patulous Eustachian tube.
4.
5.
6.
Acknowledgment
The authors would like to acknowledge the work of Mr.
Arvand Barghi, BSc, in preparing the fine illustrations
used in this article.
7.
8.
9.
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