The Medical Consumer's Advocate
Tubes for Eustachian tube dysfunction: caveats
Q: 
I have
had Eustachian tube dysfunction for quite some time.
Both ears are blocked constantly.
About 5 years ago I went to an ENT
doctor and he put a ventilation tube in my right ear
which fell out after about a year or so. That ear has
been ok since then.
My left ear still blocks all the
time. I had to switch ENTs because of my medical
insurance. The one I went to in December said there
was nothing he could do. He gave me a prescription for Nasonex which I take every day. I just don't believe
there's nothing that can be done.
I am thinking about going to another
ENT for consultation. Is there any advice at all you
can give. It is a problem that just "drives me
up the wall." I know it's not life-threatening
but it really bothers me. I get a cracking in the ear
as well when the ear blocks. The doctor I saw in
December doesn't want to see me again until this
coming Dec 99.
Please let me ask your advice. I
just can't believe that there's nothing that can be
done. No medication that can be tried, etc. Pls.
advise. Thank you so much.
A: Why did you only
have a ventilation tube placed in the right ear, if you
were symptomatic in both ears?
Q: The doctor I
first went to about 5-6 yrs. ago put the ventilation
tube in the right ear. He did not want to put one in
the left ear. Whenever I asked him if it would help,
he would just keep putting me off, at times even
scaring me saying I might be "dizzy" but
long story short he didn't want to do it. When I
switched insurances and saw the new ENT he didn't
even want to deal with the problem I went to see him
with (the fact that my left ear is blocking all the
time).
He did order
the hearing test and another (I don't know the name
of it) and that indicated to him that it was a
dysfunctional Eustachian tube. He just gave me the
Nasonex to spray daily in both nostrils which I do
daily.
A: I am still very
perplexed as to why no one wants to put a tube in your
left ear. Here are the possibilities:
1. You do
have Eustachian tube dysfunction. Your doctor is lazy.
2. You don't
really have Eustachian tube dysfunction (in other words,
your physical exam and test results do not support a
diagnosis of Eustachian tube dysfunction) so your doctor
does not want to put a tube in, because a tube would not
help. But he has not bothered to explain this to you, or
explain to you what he thinks you DO have. Once again, your doctor is
lazy (i.e., unwilling to spend the time to explain things
to you).
I will often give a patient a
trial with a nasal steroid spray (such as Nasonex) with or without
Astelin (an antihistamine spray) before resorting to a ventilation tube. I think
that a 2 or 3 week trial of Nasonex is adequate-- you
should know, after 2 or 3 weeks, whether Nasonex is
helping. If you do have Eustachian tube dysfunction
(again, this is based on test results and your physical
exam), the only treatment options are (1) medical therapy to address the
underlying problem, be it allergy, sinusitis, or something else; (2)
surgical therapy (usually ventilation tube placement); or (3) tincture
of time. Yes, I have seen some of these improve without treatment.
The best option is
to figure out why you are having ETD and treat the
underlying problem. Are you having problems with nasal
allergy? chronic sinusitis? chronic pharyngitis? Some
people even believe reflux causes ETD (but I have yet to
make this diagnosis!) ETD can also be caused by a tumor
compressing the Eustachian tube. This is a rare, but
obviously very serious, cause of ETD.
The investigation
to determine the root cause of ETD can be very detailed.
It may involve fiberoptic nasopharyngoscopy (examining
the opening to your Eustachian tubes with a flexible
scope) and a radiologic study such as a CT or MRI. The
initial exam should certainly include an examination of
the ears (including pneumatic otoscopy, in which the ENT
blows air against your ear drums to observe how they
move) and an examination of the nose. An audiogram and
tympanogram are also very reasonable"early"
tests. I reserve the more detailed studies for
"suspicious" cases.
I hope this helps.
My specific advice: when you next see an ENT, come armed
with questions. Specifically, what do you think I have
(what's my diagnosis)? How did you come to that
conclusion? What are my treatment options? Don't let your
doctors rush you. Be persistent and stubborn. If you do
not come prepared to ask lots of questions, you will be
doomed to thinking of these questions AFTER the doc has
left the room. Good luck, and let me know how things turn
out.
Q: I want to
tell you about my visit to a Ear, Nose and Throat
doctor because you were so very kind to me.
I first gave
him a little back history, telling him I went to two
other ENTs and that one had put in a tube in my
right ear. I also said that both doctors told me I
had Eustachian Tube Dysfunction in my left ear as
well. I further explained things like going from hot
to cold temperature would block the ear. I told him
my throat felt funny on the left hand side and
wondered if saliva might be backing up into the canal
or eustachian tube. Also, I would hear better when
the tube was blocked.
He examined my
throat and nose. He also took out some wax from my
ear. I asked if it was a lot and he said, "quite
a bit". He asked me to take the test for
pressure and to find out if there was any fluid which
the technician did.
Incidentally,
my ear had blocked while I was in the waiting room
awaiting my turn.
The doctor
then got the results and though my ear still felt
blocked the test showed the eustachian tube was not.
I desperately kept asking for more information as you
had suggested to me. I asked him what his diagnosis
was. He said Eustachian Tube Dysfunction. I asked him
what my options were as far as treatment. He said he
would definitely NOT put in a tube.
I couldn't
understand why my ear felt like it was blocked if the
Eustachian tube was ok when the test was taken. I
kept asking and he avoided answering me. I asked if
there was something wrong in the canal and he said
because he took out the wax, that should be better.
He asked if I
liked the Nasonex. I told him yes. Although it
doesn't help me day to day, but if my ear is blocked
and it's time to use it, it will help unblock the ear
after a fashion.
I asked other
questions, can't remember now what they were but I
could see he was a little impatient so I thanked him
and left. I must say I'm still perplexed. Please
comment.
A: He's making the
diagnosis of ETD based on your symptoms, which suggest
ETD, but he's telling you your ET is open based on the
normal tympanogram. Occasionally I will see someone with
fullness/pressure who lacks objective findings (on exam
or tympanogram) to support the diagnosis of ETD. I think
these people may have inflammation of the ET, hence the
symptoms, but since it isn't bad enough to cause middle
ear problems, I also do not recommend tubes in this
circumstance (since they will probably not
relieve the symptoms).
So... he may not have
had the best bedside manner, but it sounds like he did
what I may have done.