Materials and methods
This was a retrospective case series in which we assessed the
feasibility of Valsalva maneuvered computed tomography scanning in the
diagnosis of patulous Eustachian tube (PET). All patients assessed for
eligibility for inclusion in the study applied with complaints
suggestive of PET to the outpatient clinics of otolaryngology head and
neck surgery of a private university hospital. Recruited patients were
diagnosed with PET based on their symptoms and clinical tests. In these
patients, temporal bone computed tomography was performed while patients
were in the supine position and again when they were performing a
Valsalva maneuver.
Institutional Review Board of XXX University approved the study protocol
(2/2020.K-054).
Patients
In general, none of the patients had a structural ear abnormality or
prior ear surgical procedure. All patients underwent Eustachian function
tests, which revealed that all patients had functional and patent
Eustachian tubes. None of the patients had an obstructing nasal
pathology such as septum deviation, concha hypertrophy, nasal polyp, or
adenoids. During ear examination, special attention was paid to the
tympanic membrane movements. Middle ear pressures were measured by
tympanometry in the supine position with and without the Valsalva
maneuver. Middle ear pressures were found to be more than +10 daPA on
the right and the left ear.
Patient-1. Thirty-two-year-old female patient. The patient complained
hearing of her own eating or drinking sounds, ringing in the ears, and
autophony for the last 2 years. Ear physical examination revealed normal
ears. The patient reported an intentional weight loss of 12 kg during a
3-month period, after which her complaints had started. She was treated
for allergic rhinitis that did not alleviate her symptoms. We performed
tympanometric and audiologic tests which showed no pathology. The
patient underwent temporal bone computed tomography, the result of which
was compatible with the patulous Eustachian tube. We recommended that
the patient should gain weight.
Patient-2. Thirty-eight-year-old female patient. The patient applied
with complaints of hearing her own speaking sounds in an uncomfortable
way and intolerance of loud sounds. Ears were found normal in otoscopic
examination. The nasal exam was also normal. The patient stated that her
symptoms started after she gave birth one year earlier. Tympanometric
and audiologic tests revealed normal results. Temporal bone computed
tomography showed findings compatible with PET.
Patient-3. Forty-eight-year-old male patient. The main complaints of the
patient were hearing his own eating and drinking sounds, tinnitus, and
aerophony. The patient has been using a decongestant nasal spray for
about 10 years. He reported an increase in his symptoms for the last 6
months. Nasal physical examination showed rhinitis medicamentosa due to
continuous decongestant use. Ear examination was normal except for a
slightly flask tympanic membrane. Audiologic assessment did not show any
abnormalities. Temporal bone computed tomography was carried out.
Valsalva computed tomography procedure
While the patient was in the supine position in the CT machine, we first
obtained images (pre-Valsalva CT) in the neutral position. Then the
patient was asked to perform Valsalva maneuver as forceful exhalation
against a closed nose and images in the axial plane (Valsalva CT) were
obtained. Toshiba Aquilion One 320-detector row 640-slice dynamic volume
CT system (160×0.5 volume scanning mode) was used. We made multiplanar
reconstruction (MPR) of the images using the workstation to display the
whole axis of the Eustachian tube. In order to display the Eustachian
tube with its whole axis, we took the nasopharyngeal orifice of the ET
as the center of the rotation, and axial plane was tilted
antero-inferiorly while looking at the sagittal and coronal images until
the ET was shown throughout its axis.
We also demonstrated the air tract between the oropharynx and tympanic
cavity (patulous Eustachian tube) three-dimensionally by means of the 3D
Air Volume rendering method.
Results
Three patients (two females, one male) with a total of 6 ears with PET
were included in the study. The ages of the patients were 32, 38, and 46
years. All patients had symptoms suggestive of patulous Eustachian tube,
and clinical history, examination and tests confirmed the diagnosis. In
all patients, temporal bone CT showed that the distal one-third of the
Eustachian tube was closed while the patient was in the (a) supine
position (Figures 1a and 1b). In CT images taken during the Valsalva
maneuver (Valsalva CT), the Eustachian tube was visualized in its
entirety in all scanned ears (Figures 2a and 2b).