To Balloon or Not to Balloon, The Current State of Management of Eustachian Tube Dysfunction

While otologic complaints are a common reason for patients to present to an otolaryngologist, Eustachian tube dysfunction (ETD) remains a poorly understood disease whose management is unclear. Among the general population in the United States, ETD has a prevalence of 4.6% among adults and 6.1% among children. Eustachian tube dysfunction is not just a common diagnosis for otolaryngologists, ETD accounted for 2 million visits for patients less than 20 years old to primary care providers and over 2 million visits for patients older than 20 years old between 2005 and 2012. Despite the commonality of ETD, opinions differ wildly among otolaryngologist on the management of these patients. One of the issues faced by otolaryngologists and primary care providers alike is the difficulty in clarifying the diagnosis ofETD. Patients will often present with aural fullness, popping, pain, pressure, clogging, andunderwater sensation. The first challenge faced after a clinician suspects a diagnosis of ETD is to determine what type of ETD the patient may be experiencing. The patient history is key as is an appropriately focused physical examination and workup which considers 3 categories of ETD: (1) dilatory ETD, (2) Baro-challenge-induced ETD, (3) Patulous ETD. Acute dilatory or obstructive ETD is commonly preceded by an upper respiratory infection or allergic rhinitis. Patients will report aural fullness and popping. There may be an associated otitis media. Chronic dilatory ETD is a long-standing presence of similar symptoms, typically not associated with an acute illness, though they may be exacerbated by one. Barochallenge-induced ETD is brought on by changes in the ambient pressure. The patients usually are asymptomatic until a change in ambient pressure occurs. Scuba divers and flight crews are not infrequently afflicted. Patulous ETD is often misdiagnosed as dilatory ETD or baro-trauma-induced ETD. The distinguishing symptom of patulous ETD versus the other types is the presence of autophony. This editorial will primarily focus on dilatory and baro-trauma-induced ETD. The diagnose of dilatory ETD is typically made based on the patients reported symptoms as well as negative pressure in the ear based on clinical assessment, whether it be by tympanometry, otoscopy, or otomicroscopy. Baro-challenge-induced ETD is a diagnosis made based on patient history. Abnormal physical examination findings will typically be absent. The diagnoses of patulous ETD will also largely depend on the patient’s history. Although, most commonly, the tympanic membrane and middle ear will appear normal, excursions of the tympanic membrane may be appreciated with ipsilateral nasal respiration performed while upright. A careful history is required to identify those patients who have or are suspected to have patulous ETD, as their treatment differs greatly from the others. The management of ETD may be as challenging as its diagnosis. The first approach generally is to address the underlying cause or causes of ETD. Mucosal edema at the Eustachian tube orifice has been noted in 83% of patients with ETD. There is a strong correlation between mucosal inflammation and laryngopharyngeal reflux and allergic rhinitis. Because of this association, it is common practice to prescribe nasal steroids as first-line treatment for ETD. A study by Wang et al in 2017 showed that otolaryngologists continue to prescribe nasal steroids for the treatment of otitis media with effusion, despite level I evidence that intranasal steroids are no more effective than placebo in the treatment of ETD. The decision to prescribe nasal steroids should be made to specifically treat an