Bernt Falk

Variability of Eustachian Tube Function: Comparison of Ears With Retraction Disease and Normal Middle Ears †

Objective To explore the short‐term and long‐term variability of tubal opening and closing in ears with advanced retractions and in healthy ears.

Evacuation of the Middle Ear by Sniffing: A Cause of High Negative Pressure and Development of Middle Ear Disease

Previous research on eustachian tube function has been devoted mainly to the study of the tubal opening ability and pressure equalization. This article summarizes a series of experimental studies focusing on the closing ability of the tube. Results support the belief that the purpose of the tube should be seen primarily as protecting the middle ear from the extensive pressure variations that physiologically take place in the nasopharynx. A number of studies of diseased ears have shown that tubal malfunction was characterized mainly by a reduced ability to withstand negative pressure in the nasopharynx. Sniffing can evacuate the middle ear, causing high negative intratympanic pressure. It seems likely that this mechanism is involved in the development of middle ear effusion and manifest retraction-type middle ear disease.

Variability of Eustachian tube function in children with secretory otitis media. Evaluations at tube insertion and at follow-up

OBJECTIVE Despite the variable clinical course of diseases related to Eustachian tube function, the variability of tubal function has been less focused than outcomes of single tests. This study aimed to compare the passive and active tubal function and its variability in children with secretory otitis media (SOM) at tube insertion and at follow-up. METHOD Thirty-eight ears in 19 children aged 4-10 years (mean 7.0 years) with long-standing SOM were examined 4-6 h after tube insertion, at 4 months and at 9 months. The pressure in the middle ear and the nasopharynx were recorded while performing (1) forced opening test, (2) equalization of +100 and -100 daPa, (3) Valsalva test, and (4) sniff test. The procedure was repeated after 30 min. Relationships were analyzed by uni- and multi-variate analysis of variance. RESULTS From tube insertion to 4 months, the mean forced opening pressure increased from 282+/-128 to 355+/-153 daPa (P<0.01), and the mean closing pressure from 91+/-51 to 126+/-82 daPa (P<0.01). There was no further change at 9 months. Female gender, serous effusion (in contrast to mucoid), and more than three previous episodes of acute otitis media were related to higher opening and closing pressures. At tube insertion, 60% and 16% equalized +100 and -100 daPa, respectively, and 28% succeeded in performing Valsalva inflation. The sniff test was positive in 32%, indicating a closing failure. These rates did not change significantly over time. For individual ears, outcomes of all tests varied considerably when retested after 30 min; P(o) changed by +/-12% and P(c) by +/-26%, and 9-29% of the ears changed from a positive to negative response, or vice versa, in the equalization, Valsalva, and sniff tests. CONCLUSIONS The unexpected finding of weaker closing forces at the day of tube insertion and increased tubal resistance at follow-up might be ascribed to changes in the muco-adhesive forces related to the disease and tube treatment. The pronounced intra-individual variability of test outcomes indicates that tubal function is dynamic and variable in ears prone to SOM, which emphasizes that results of single tubal function tests have very low prognostic value.

Eustachian Tube Function Varies over Time in Children with Secretory Otitis Media

Impaired opening and closing functions of the Eustachian tube are considered to be pathogenic factors in secretory otitis media (SOM). As the clinical course of SOM is variable, the variability of tubal function is of interest. We aimed to explore the short- and long-term variability of tubal opening and closing functions in SOM. The study comprised 42 ears in 21 children (13 males and 8 females) with tympanostomy tubes due to SOM. The middle ear pressure was recorded during repeated passive forced openings, equalization of + 100 daPa and - 100 daPa by swallowing, Valsalva inflation and forceful sniffing. Test sessions were performed twice (separated by 30 min) on each of 2 days, with a mean interval of 3.7 months in between. In the forced opening test there was a considerable intra-individual variability over time. Expressed as SD of the mean, the variability of the forced opening and closing pressures in individual ears was on average 15% and 23%, respectively, between sessions and 20% and 30% respectively, between test days. In the equalization, Valsalva and sniff tests the rates of responses that changed from positive to negative between sessions and test days ranged from 12% to 33%. Female gender and retraction pockets were related to poorer opening function in the forced opening test. Ears with serous effusion (in contrast to mucoid) showed a similar trend and also a lower occurrence of positive equalization, Valsalva and sniff tests. It was concluded that Eustachian tube opening and closing functions are highly variable in ears with SOM. Consequently, single tubal function tests have low value when used as a prognostic tool in individual ears.Impaired opening and closing functions of the Eustachian tube are considered to be pathogenic factors in secretory otitis media (SOM). As the clinical course of SOM is variable, the variability of tubal function is of interest. We aimed to explore the shortand long-term variability of tubal opening and closing functions in SOM. The study comprised 42 ears in 21 children (13 males and 8 females) with tympanostomy tubes due to SOM. The middle ear pressure was recorded during repeated passive forced openings, equalization of +100 daPa and −100 daPa by swallowing, Valsalva inflation and forceful sniffing. Test sessions were performed twice (separated by 30 min) on each of 2 days, with a mean interval of 3.7 months in between. In the forced opening test there was a considerable intra-individual variability over time. Expressed as SD of the mean, the variability of the forced opening and closing pressures in individual ears was on average 15% and 23%, respectively, between sessions and 20% and 30%, respectively, between test days. In the equalization, Valsalva and sniff tests the rates of responses that changed from positive to negative between sessions and test days ranged from 12% to 33%. Female gender and retraction pockets were related to poorer opening function in the forced opening test. Ears with serous effusion (in contrast to mucoid) showed a similar trend and also a lower occurrence of positive equalization, Valsalva and sniff tests. It was concluded that Eustachian tube opening and closing functions are highly variable in ears with SOM. Consequently, single tubal function tests have low value when used as a prognostic tool in individual ears.

Test-retest variability of eustachian tube responses in children with persistent middle ear effusion

SummaryIn our previous studies on eustachian tube function in children with middle ear effusion, we found that many ears were evacuated by the act of sniffing. When subjects were tested repeatedly, however, responses to sniffing were very variable. In order to study the spontaneous variability, a total of 51 subjects (81 ears) were retested. The results of the retest were very similar to those of the first test when all the ears were considered as a group. However, in individual ears pronounced variability was seen. In the sniff test, responses changed qualitatively in 30% of the ears, and in 27% of the ears there was a change in the ability to equalize pressure by swallowing. Thus, the results of the group were highly reproducible, while at the same time individual results were highly variable with time.

The character and consequences of disturbing sound sensations in retraction type middle ear disease

OBJECTIVE Transient sound disturbances are common but neglected symptoms in retraction type middle ear disease (R-MED). The aim of this study was to explore and describe their character, their individual consequences, and their role in the development of tympanic membrane retractions. METHODS Fifty-three subjects with manifest retractions and experiences of disturbing sound and ear sensations were interviewed. A qualitative method was used for analysis of the transcribed interviews. RESULTS Two different patterns emerged from the interviews. 1. Too weak sound was the least common and most tolerable disturbance. It occurred in 45% and was eliminated by Valsalvas inflation. 2. Sudden and transient sensations of too loud and piercing sound, and intermittent autophony frequently caused intense and intolerable discomfort, which might in turn cause loss of control of speech and conversation. These types occurred in 74% and 60%, respectively, and were eliminated by evacuating the middle ear, for example by sniffing. Subjects who described too loud sound or intermittent autophony commonly preferred a retracted tympanic membrane position. This may explain why pressure equalization by swallowing, and inflation by Valsalvas manoeuvre often elicited discomfort. CONCLUSIONS Transient experiences of too loud sound or intermittent autophony may indicate a shift of sound preference towards the sound experienced at negative middle ear pressure, and an unreliable tubal function in the sense that it fails to stay closed to protect the ear from sounds and pressure variations in the nasopharynx. Such experiences of altered sound may trigger evacuation of the middle ear, which eliminates the sound disturbance. It is crucial to identify, interpret, and explain the disturbances correctly in the therapy and prevention of retractions, since habitual evacuation exposes the tympanic membrane to strong negative pressure loads and a subsequent risk of developing retraction.