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).