A micro fibroscope coupled with a camera is introduced through a nostril until the entrance of the Eustachian tube. To ensure a totally comfortable exam, it is sometimes useful to anaesthetize nasal cavity for a moment, with Naphazoline or Xylocaïne 5%.
To improve the comfort of the patient, and by the same way, the success of the treatment, we place in front of his eyes video glasses Glasstron (Sony).
He can so move easily the head without losing the image of the Eustachian tube that he is working. This way to proceed is particularly appreciated by the childrens.
Location and action of the TVPM muscle.
Location and action of the LVPM muscle.
Left Eustachian tube in relaxed state and open.
TVP muscle, the main tubal muscle anterior (in dark pink), is covert by the anterior intra tubal mucosa (in dark blue), making together some physiological convexity of the anterior wall in relax state, as a mirror of the posterior cartilaginous concavity. Perfect contact of both of these walls ensure correct closure. This is the tubal.
When opening, the posterior wall (cartilage) is pushes back by contracting the LVP muscle. The anterior wall runs forward by contracting the TVP muscle, straightening the convex curve (dark blue), creating the channel and tubal aperture. It’s a complicated dynamic system, requiring perfect coordination of all structures. Any damage or muscular malfunction induces Eustachian tube dysfunction.
Obstructive Eustachian tube surgery
Patulous Eustachian tube (PET) surgery
The Eustachian tube orifice is like a cleft, bordered by the convexity of the Tensor Veli Palatini Muscle at the front, and the concavity of the cartilage at the back. When the opening is not sufficient, we modify original parameters of the posterior wall (cartilage).
We shape the posterior wall by treating the edematous or hypertrophied mucosa and the underlying cartilage through a laser-assisted, trans-nasal and oral endoscopic approach with a diode laser.
The reduction of the edematous mucosa and hypertrophied cartilage increases the concavity facing the TVP muscle, and restores the lumen of the tube which allows ventilation of middle ear during TVP muscle contraction. This allows TVP contraction to be more effective in opening the ET lumen.
Several surgical treatment have been described. Attempting to narrow the lumen by diathermy or silver nitrate cautery, extrinsic compression by paraffin, teflon, gelatine, sponge or collagen injection. Attempting to alter the function of palatal muscles. Occlusion of the bony Eustachian tube by an indwelling layered and occluding catheter. Myringotomy and insertion of a ventilating tube may provide temporary relief in some patients. None of these could show a relevant or permanent success rate.
In some early stages of light Patulous Eustachian tubes, we inject non-reabsobable solution (viscous gel of dextranomer microspheres, stabilized hyaluronic acid, collagen, ...) under the intra-tubal mucosa in anterior or posterior wall. This injection is provided under local/general anaesthesia with specific needles and may relieve the patient immediately.
Endoscopic view of a right
PET-posterior wall injection.
Atrophic posterior wall mucosa circled in red.
A : anterior tubal wall.
ENT SURGERY SOLUTIONS
PATULOUS EUSTACHIAN TUBE RECONSTRUCTION (PETR)
In cases of sever PET or previous injection’s failure,
we consider a real PET reconstruction surgery.
Reinforcement or remplacement of tubal cartilage with a free cartilaginous graft.