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\begin{document}

\title{Valsalva computed tomography in visualization of Eustachian tube in
patients with patulous Eustachian tube}



\author[1]{Suleyman Aksoy}%
\author[2]{Yavuz Selim Yıldırım}%
\author[3]{Işıl Yurdaışık}%
\affil[1]{Hisar Intercontinental Hospital}%
\affil[2]{Dogus Universitesi}%
\affil[3]{Istinye University}%


\vspace{-1em}



  
  \date{May 22, 2024}


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\selectlanguage{english}
\begin{abstract}
Abstract Objectives: There is no study in the literature that patients
with clinically-proven PET were evaluated by Valsalva CT. We aimed to
evaluate the merit of Valsalva computed tomography (CT) in patients who
had clinically-proven patulous Eustachian tube (PET). Design:
Case-series Setting and participants: We recruited patients with
clinically-proven PET. Participants: Main outcome measures: All
participants underwent temporal bone CTs while they were performing the
Valsalva maneuver in the supine position. Standard axial plane CT
images, along with multiplanar reconstruction and 3D Air volume
rendering, were used to visualize the ET in its entirety. Results: Three
patients (2 females, one male) with a total of 6 ears were included in
the study. All patients had suggestive symptoms of PET, including aural
fullness, aerophony, and autophony and underwent clinical examination
and audiologic tests. In all ears, the whole Eustachian tube could be
visualized with Valsalva CT. Conclusion: For the first time, we
demonstrated the merit of Valsalva CT in visualization of the Eustachian
tube in its entirety in patients with clinically diagnosed PET.%
\end{abstract}%



\sloppy


\textbf{Valsalva computed tomography in visualization of Eustachian tube
in patients with patulous Eustachian tube}

\textbf{Abstract}

\textbf{Objectives:} There is no study in the literature that patients
with clinically-proven PET were evaluated by Valsalva CT. We aimed to
evaluate the merit of Valsalva computed tomography (CT) in patients who
had clinically-proven patulous Eustachian tube (PET).

\textbf{Design:} Case-series

\textbf{Setting and participants:} We recruited patients with
clinically-proven PET.

\textbf{Participants:}

\textbf{Main outcome measures:} All participants underwent temporal bone
CTs while they were performing the Valsalva maneuver in the supine
position. Standard axial plane CT images, along with multiplanar
reconstruction and 3D Air volume rendering, were used to visualize the
ET in its entirety.

\textbf{Results:} Three patients (2 females, one male) with a total of 6
ears were included in the study. All patients had suggestive symptoms of
PET, including aural fullness, aerophony, and autophony and underwent
clinical examination and audiologic tests. In all ears, the whole
Eustachian tube could be visualized with Valsalva CT.

\textbf{Conclusion:} For the first time, we demonstrated the merit of
Valsalva CT in visualization of the Eustachian tube in its entirety in
patients with clinically diagnosed PET.

\textbf{Keywords} : Computed Tomography; Eustachian tube; Patulous
Eustachian tube; Valsalva maneuver

\textbf{Key points;}1. Patulous Tuba Eustachii is not clearly seen on
routine radiological imaging.

2. Valsalva CT is never performed to diagnose the patulous Tuba
Eustachii.

3. CT is commonly used in daily practice of the ENT.

4. Valsalva maneuver can easily be done by patients during CT
examination of the patients who have suspicion of patulous Tuba
Eustachii.

5. Patulous Tuba Eustachii can easily be seen on Valsalva CT.

\textbf{Introduction}

The Eustachian tube (ET) is an anatomical structure that extends from
the nasopharynx up to the middle ear and is composed of a bony and a
cartilaginous part. Its normal function is vital for healthy hearing
(1). This epithelial-lined tube has three main functions: (i)
equalization of the pressure in the middle ear to the atmospheric
pressure. This is important to curb the untoward effects of external
pressure fluctuations on the tympanic membrane. (i) clearance of middle
ear secretions, (iii) prevention of middle ear from nasopharyngeal
secretions containing microorganisms and precluding transmission of
one's own speech sounds back to their ear (2).

Eustachian tube dysfunction might be due to either obstruction of the
tube or persistent opening of it (3). ET, under physiologic conditions,
remains passively closed and only briefly opens in case of swallowing or
Valsalva maneuver. When the ET remains permanently open, this condition
is called patulous Eustachian tube (PET). Although its prevalence is
much less compared with the obstructive pathologies of the ET, PET is
associated with annoying symptoms that lower the quality of life of the
affected patients. Patients with PET mainly complaint about hearing
their own voice (autophony), their breathing (aerophony) or sound of
eating or drinking in a disturbing way. Inflicted patients can also
report other more nonspecific symptoms such as aural fullness, vertigo,
and tinnitus (4).

Due in part to its inaccessible nature, there is not a single reliable
test correctly diagnose ET dysfunction. Constellation of the
aforementioned symptoms in a patient suggests the presence of PET;
however, these symptoms can also be reported by patients with several
other disorders. Thus, more objective and reliable tests are needed.
Tympanometry is the commonly used office-based test to evaluate the ET
function indirectly. This test measures the one-time middle ear
pressure. Normal pressures measured with tympanometry does not exclude
obstructive ET dysfunction or PET. Breathing-synchronous tympanic
membrane movement is accepted as a specific finding of PET but, to
diagnose PET, various objective and subjective findings, such as medical
history, physical examination and ET function tests, are combined,
because there is no single test available to evaluate ET function
accurately. Clinical tympanic membrane movement can be carried out by
visual observation, continuous impedance recording, or sonotubometry (5,
6). However, these tests are not well standardized and limited in cases
of intermittent PET or patients who had low acoustic impedance.

Radiologic imaging of the ET is also without its own problems.
Currently, there is no single radiologic imaging modality that can
provide details of all related structures of the ET per se. The
collapsed nature of the ET at rest makes it more difficult to image the
entire tube. One can think that this cannot be a problem for a PET
patient. However, the ET temporarily closes when the patient lies
supine, which is the usual position in sectional imaging modalities (7).
Thus, several investigators tried to find some ways to overcome these
difficulties, such as CT imaging in a seated patient or positioning the
patient in 45 degrees in a standard CT scanner (8-10). However, these
modifications are not always technically feasible. One other solution to
the imaging problem of PET is performing a Valsalva maneuver during CT
scanning. Self-administered pressure increases force the ET to open even
in a patient who is lying supine.

\textbf{Aim and Purpose}

Valsalva CT of temporal bone has been performed in patients with nose
related complaints (11) and patients who would undergo surgery for
chronic ear disease (12). To the best of our knowledge, there is no
study in the literature that patients with clinically-proven PET were
evaluated by Valsalva CT. Thus, we aimed to evaluate the ability of
Valsalva CT in demonstrating patency of ET in its entirety in patients
with symptoms strongly suggestive of PET.

\textbf{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\selectlanguage{ngerman}×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).

\textbf{Discussion}

The main finding of this study was that Valsalva CT was effective in
demonstrating the whole length of Eustachian tube in patients with
suggestive symptoms of patulous Eustachian tube (PET). We could
visualize ET in its entirety in all six ears.

Patulous Eustachian tube is generally diagnosed based on suggestive
symptoms, physical examination, and audiologic findings. However, no
diagnostic gold standard is currently available. With an attempt to
reduce the subjectivity in the diagnosis of PET, several specialized
tests, including tubomanometry, sonotubometry, and
tubotympanoaerodynamography, have been devised (13, 14). However, these
methods provide indirect information and cannot provide the anatomic
nature of the ET. Computed tomography and magnetic resonance imaging
have been used to visualize ET in patients with ET dysfunction. Yoshida
et al. reported that standard CT visualized only 13 ETs entirely as open
out of 31 PET ears. A systematic review evaluating the value of the
imaging modalities in PET revealed that CT and MRI provided detailed
anatomic information about the ET; nevertheless no single test emerged
as a stand-alone diagnostic method in PET (15).

One inherent nature of the ET that is closure of the cartilaginous part
of the tube in the recumbent position makes these methods unreliable in
the evaluation of PET.

To be able to show the patency status of the ET with cross-sectional
imaging modalities, several groups attempted various methods. Yoshida et
al. (16) compared the air space lumen between the sitting and recumbent
positions in CT in two PET patients. The size of the airspace lumen was
larger during the sitting CT. Kikuchi and colleagues reported the
beneficial use of sitting position Valsalva CT in the diagnosis of PET
(17). Kawamura and coworkers showed the value of sitting position CT
relative to other diagnostic tests in Patients with PET (4). However,
sitting position CT is not feasible with standard CT machines. Thus,
methods to prevent the collapse of the ET in recumbent positions were
sought.

One such method that enables ET to open is the performance of Valsalva
maneuver during the CT when the patient is in the supine position.
Tarabichi et al. (11) performed Valsalva CT in 38 patients who had nose
pathologies but no ear disease. The authors concluded that Valsalva CT
could visualize the whole length of the ET tube in 35\% of the ears,
whereas in 94\% of the ears, distal one-third of ET could be visualized.
Poor Valsalva technique was associated with paradoxical closure of the
ET in this study. Another case-control study conducted by the same
authors and recruited patients who would undergo surgery for chronic ear
diseases found that Valsalva CT could visualize distal one-third of the
ears in 96\% of the ears (12). However, to the best of our knowledge,
the value of the Valsalva CT in visualization of the entire ET has not
been evaluated in patients who had clinically diagnosed PET or patients
who had suggestive symptoms for PET yet.

Our results showed that in all 6 ears studied; ET could be visualized
entirely by Valsalva CT. We also demonstrated 3D and air-reconstructed
images of patent ET. Our findings lend support to previous studies in
which Valsalva CT had merit in visualization of the ET in patients who
had ear or nose diseases other than PET. Our findings extend the prior
findings to patients with clinically-proven PET. In all ears, the
Valsalva maneuver could preclude the collapse of the distal part of the
ET.

Some limitations of the present study deserve mention. First, ours was a
preliminary study with only 6 ears. The number of the patients in this
study is relatively small however, all of the patients were selected to
represent clinical characteristics of PET. None of them had chronic ear
and/or nose disease other than aforementioned symptoms. Moreover,
patients with relatively severe PET visit our Hospital department to
seek treatment.

\textbf{Conclusion;}

As far as we know, this was the first report of the utilization of
supine Valsalva CT in patients with clinically diagnosed PET. It is a
clear research need to extend our findings in larger patient samples.

\textbf{Data availability statement;}

The data that support the findings of this study are available from the
corresponding author upon reasonable request.

\textbf{References:}

1. Bance M, Tysome JR, Smith ME. (2019) Patulous Eustachian tube (PET),
a practical overview. World J Otorhinolaryngol Head Neck Surg. 5:137-42.

2. Ars B, Dirckx J. (2016)Eustachian Tube Function. Otolaryngol Clin
North Am.49:1121-33.

3. Schilder AG, Bhutta MF, Butler CC, Holy C, Levine LH, Kvaerner KJ, et
al. (2015) Eustachian tube dysfunction: consensus statement on
definition, types, clinical presentation and diagnosis. Clin
Otolaryngol.40:407-11.

4. Kawamura Y, Ikeda R, Kikuchi T, Miyazaki H, Kawase T, Katori Y, et
al. (2019) The characteristic of patulous eustachian tube patients
diagnosed by the JOS diagnostic criteria. PLoS One.14):e0226908.

5. Schroder S, Lehmann M, Korbmacher D, Sauzet O, Sudhoff H, Ebmeyer J.
(2015) Evaluation of tubomanometry as a routine diagnostic tool for
chronic obstructive Eustachian tube dysfunction. Clin
Otolaryngol.40:691-7.

6. McGrath AP, Michaelides EM. (2011) Use of middle ear immittance
testing in the evaluation of patulous eustachian tube. J Am Acad
Audiol.22:201-7.

7. Brace MD, Horwich P, Kirkpatrick D, Bance M. (2014) Tympanic membrane
manipulation to treat symptoms of patulous eustachian tube. Otol
Neurotol.;35:1201-6.

8. Kikuchi T, Oshima T, Hori Y, Kawase T, Kobayashi T. (2009)
Three-dimensional computed tomography imaging of the eustachian tube
lumen in patients with patulous eustachian tube. ORL J Otorhinolaryngol
Relat Spec.71:312-6.

9. Yoshioka S, Naito K, Fujii N, Katada K. (2013) Movement of the
Eustachian tube during sniffing in patients with patulous Eustachian
tube: evaluation using a 320-row area detector CT scanner. Otol
Neurotol.34:877-83.

10. Ikeda R, Kikuchi T, Oshima H, Miyazaki H, Hidaka H, Kawase T, et al.
(2016) Relationship Between Clinical Test Results and Morphologic
Severity Demonstrated by Sitting 3-D CT in Patients With Patulous
Eustachian Tube. Otol Neurotol.37:908-13.

11. Tarabichi M, Najmi M. (2015) Visualization of the eustachian tube
lumen with Valsalva computed tomography. Laryngoscope.125:724-9.

12. Tarabichi M, Najmi M. (2015)Site of eustachian tube obstruction in
chronic ear disease. Laryngoscope.125:2572-5.

13. Smith ME, Takwoingi Y, Deeks J, Alper C, Bance ML, Bhutta MF, et al.
(2018) Eustachian tube dysfunction: A diagnostic accuracy study and
proposed diagnostic pathway. PLoS One.13:e0206946.

14. Sudhoff HH, Mueller S. (2018) Treatment of pharyngotympanic tube
dysfunction. Auris Nasus Larynx. 45:207-14.

15. Smith ME, Scoffings DJ, Tysome JR. (2016) Imaging of the Eustachian
tube and its function: a systematic review. Neuroradiology.58:543-56.

16. Yoshida H, Kobayashi T, Morikawa M, Hayashi K, Tsujii H, Sasaki Y.
(2003) CT imaging of the patulous eustachian tube--comparison between
sitting and recumbent positions. Auris Nasus Larynx.30:135-40.

17. Kikuchi T, Oshima T, Ogura M, Hori Y, Kawase T, Kobayashi T. (2007)
Three-dimensional computed tomography imaging in the sitting position
for the diagnosis of patulous eustachian tube. Otol Neurotol.28:199-203.

\textbf{Figure Legends}

Figure 1. Appearance of the cartilage part of the Eustachian tube in
temporal bone 3D air-reconstruction (1a) and CT with MPR (1b) when the
patient was in the supine position.

Figure 2. Appearance of the Eustachian tube in temporal bone CT with 3D
air-reconstruction (2a) and MPR (2b) when the patient was performing a
Valsalva maneuver in the supine position. Note that the Eustachian tube
can be seen from the nasopharynx up to the middle ear in its entirety.\selectlanguage{english}
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