The Medical Consumer's Advocate
Treatment options for Eustachian
tube dysfunction; risks of ventilation tube placement
Q: 
I have been diagnosed with ETD,
especially on the left side. It is a condition that I've
had ever since I can remember (about 25 years now).
Symptoms are a feeling of full ears, diminished hearing
and occasional pain. When I have been examined, there is
no outwardly visible sign that there is pressure in my
ear(s), though a CT scan does show considerable sinus
problems. My ENT suggested that we try either a FESS or
placement of tubes in the eardrum. I have my concerns
about both procedures.
As I understand the condition,
regardless of the etiology, ETD is the result of not
being able to equalize pressure between the ambient air
and the middle ear. My question is simple: is it possible
either to enlarge the ET or make a hole into the middle
ear without penetrating the eardrum itself?
A: Good questions. First of all, I would not
recommend a FESS unless (1) you have symptoms of chronic
sinusitis, i.e. facial pain or pressure, postnasal drainage;
and (2) your ENT has already tried to treat your sinusitis
with "maximal medical therapy." It seems obvious to
me that medical solutions should be tried prior to surgical
solutions, but not all ENTs (or other surgeons, for that
matter) see it that way. "Maximal medical therapy"
is tailored to your symptoms, and may include some
combination of the following: antibiotics, decongestants,
antihistamines (for my patients: usually azelastine, a spray), a nasal allergy spray (Nasalcrom), a nasal
steroid spray, guaifenesin (an expectorant), and
rarely, an oral steroid such as Prednisone. Again, I
emphasize: some subset of these, tailored to your specific
symptoms. Since your Eustachian tube dysfunction is most
likely (though not necessarily) due to your sinus problems,
it should respond to this treatment regimen, too. Thus, ear
tubes should be offered only after this medical intervention
has been attempted first (and failed).
Furthermore, if you make SOME progress on a medical
regimen but still have some symptoms, it would be reasonable
to continue medical treatment, perhaps with an alteration of
the regimen.
Having said all of this, I would encourage you to go
ahead and get the tubes, should medical therapy fail to help
you. Please note -- any single drug therapy you may have had
for this problem is irrelevant. Just because you had one
drug, be it a decongestant, nasal steroid spray, whatever --
and it failed -- does not mean that surgery is the only
option. Aggressive medical intervention is key.
The operation is usually fairly painless and
complications are uncommon. It will also relieve your symptoms,
assuming you have been correctly diagnosed with ETD. To
answer your questions, there are no operations which enlarge
the Eustachian tube or provide a hole into the middle ear
without penetrating the ear drum. While I can imagine ways of
doing such things, these operations would be about 1000 times
more dangerous than the operation to place the tubes. And
that's no exaggeration.
By the way, your understanding of ETD is exactly correct.
Q: Yes, we have tried
antibiotics, Flonase, oral steroids, decongestants,
antihistamines (most as part of a comprehensive regimen
over a few months at a time). Frankly, my frustration
level rises with each failed attempt to resolve the
issue. So, my real goal is to research long-term
solutions.
My concern on tube placement is
the possibility of permanent damage to the eardrum or the
necessity to repair the eardrum should damage be done.
This comes from the fact that, despite all my ET
problems, my hearing is superb and I wish to keep it that
way. I also understand that some patients find it
difficult to adjust to the reverberation of their own
voice. What has your experience been?
A: About the only medications that
you haven't tried are Guaifenesin, which is only effective at
prescription strength (2 in the AM, 2 in the PM), and
Nasalcrom, which is a nonprescription nasal spray (and will
only have a chance at helping IF your ETD is related to nasal
allergies.) Both are very safe medications so they are
probably worth trying, but I wouldn't get your hopes up, of
course.
Placement of a single, short-lived
tube in the ear drum causes little or no scarring (I have, on
several occasions, seen tubes come out without a trace of
scar.) The only thing to watch out for are the long-lasting
tubes ("T-tubes", so named for their shape.) Your
ENT may try to sell you on these precisely because they are
long lasting. Unfortunately, they are associated with a
fairly high perforation rate, i.e. when the tubes come out,
they leave a hole behind. I suspect you would find this an
unacceptable risk. Perforation is also a risk for the
short-lived tubes (which, in an adult, typically last 1 to 2
years), but this is very rare, probably less than 1%. Even if
they leave a scar behind when they come out, this usually
does not cause any hearing loss. For that matter, even if
there is a persistent perforation, it is always quite small
and has extremely little impact on hearing.
Regarding adjusting to "the
reverberation of their own voice," I have never heard
this complaint. Actually, there is a condition known as
"patulous
Eustachian tube" in
which the Eustachian tube is abnormally open. The person
hears their own voice slightly out of phase from two sources:
from within the oral cavity, up the open Eustachian tube,
straight to the middle ear; and the normal way, lips to
eardrums. These people do complain that they are
"hearing themselves speak," i.e. their
voice reverberates in their ears.
Realistically, here are the main
problems with tubes. If your ENT isn't gentle, tube insertion
can be painful. While the tubes are in, certain activities
are forbidden, e.g. diving, snorkeling, that sort of thing
(water under pressure). To some degree, you need to keep
water out of your ears as much as possible. If any water gets
down the tube, it could be uncomfortable for a while, and it
could start an infection. Finally, if you have NOT been
accurately diagnosed (i.e. you really don't have ETD) then
the tubes will not help you. (Much more uncommon
risks: persistent perforation after the tubes come out,
persistent fluid drainage from the tubes, dizziness with tube
placement, heavy bleeding, hearing loss).
DISCLAIMER: ask your ENT all of these questions,
too. At the very least, you can learn a lot from your doctor's willingness
to answer questions. Ultimately, he/she will be the one to hold the knife,
should you decide to have the tubes placed. You had better be satisfied with
his/her judgment, bedside manner,
technical ability, etc. I assume you have gotten a second or
third opinion; if not, do so.
Once you have finally made a
decision, should you decide to have the tubes, then take
responsibility for your decision. Boy am I tired of people
who say they understand the risks which I have explained to
them and are then unhappy with me when one of those risks
turns into a reality. "That could only happen to someone
else-- it could never happen to me."
Finally, always remember that there
is another option-- live with it. Do nothing. Many problems
resolve spontaneously, given TOT (tincture of time) and no
other treatment. I can't recall if you told me how long the
problem has been bothering you, but if it has only been a few
months, I would strongly consider doing nothing for a few
more months.