Eustachian Tube Balloon Dilation to Treat Clogged Ears

by Dr. Christopher Chang, last modified on 6/11/21.

Introduction

Please note that our office is in the process of hopefully offering this procedure in the near future. Just not yet currently... So stay tuned!

Eustachian tube balloon dilation is a procedure to open up the tunnel that connects the middle ear with the back of the nose. Normally, this tunnel should open easily and quickly with the valsalva maneuver, whether by yawning, swallowing, or trying to blow air out the nose while keeping it pinched shut. Some patients even purchase devices to help pop their ears including the Otovent or EarPopper.

With such a manuever, a clogged ear should feel back to normal. If this normal transition does not happen easily if at all, than the eustachian tube may be swollen shut, a condition known as eustachian tube dysfunction.

Historically, if the condition does not resolve with time and medications, ear tubes can be placed with relief. Essentially, the ear tube prevents pressure from buidling up in the ear (similar to how a hole in a car tire would prevent air pressure from building up). However, ear tubes over time will come out and ear symptoms may recur requiriing repeated tube replacement.

Watch Video of How a Ear Pops Open Anatomically When Clogged.
A more simplified video explanation can be found here.

In years past, researchers have tried a number of different surgical procedures to open the eustachian tube, the "normal" pathway for pressure release, with limited success and in some cases, catastrophic complications. After all, it makes sense to open the normal eustachian tube pathway rather than create an alternative detour pathway through the eardrum using a tube.

It is only since 2011 that a safe and effective method to open the eustachian tube using a balloon was first described by Dr. Dennis Poe at Massachusetts Eye and Ear Infirmary (Boston, MA). FDA approval was granted in Sept 2016 after which Insurance coverage has slowly gained traction. Watch how this procedure is performed below or here.

Am I a Candidate?

Our office uses the AERA eustachian tube balloon dilation system made by Acclarent. This procedure is performed under under endoscopic guidance through the nose with the patient completely sedated and takes under 15 minutes. For a patient to be considered a candidate for this procedure, the following criteria must be met. Note that there are both subjective as well as objective criterias.

Objective Criterias

Older than 22 years old
Negative or flat pressure tympanogram with or without fluid in the middle ear
Retracted or non-adherent atelectasis of the eardrum
Mucosal inflammation in or around the eustachian tube opening on endoscopic visualization
CT temporal bone scan showing intact bone between the eustachian tube and internal carotid artery (see image below). CA is carotid artery, ET is eustachian tube, and EC is ear canal. Note the presence of a thin white bone between CA and ET.

No history of skull base surgery or extensive middle ear surgery
No history of cancer in the head / neck region
No clinically significant osteoporosis
Symptom improvement with ear tube placement **

Subjective Criterias

Clogged, muffled ear sensation
Inability to pop the ear easily
Absence of autophony
Hearing loss with pressure changes
Barochallenge problems - Difficulty with ear popping with elevation (flying or going up a mountain) or depth (swimming underwater)
NO urge to sniff the nose to try and alleviate ear symptoms

** This additional criteria our office uses include benefit from prior ear tube placement. Although some surgeons may be willing to perform this balloon dilation without prior myringotomy or ear tube placement, most surgeons will use this criteria as a "test" to increase the chance that balloon dilation will actually work. Keep in mind that the overall success rate of resolving eustachian tube dysfunction symptoms with balloon dilaton is only about 60% after 6 months.

Also, please keep in mind that sometimes in order for balloon dilation to even be technically possible, other surgical procedures may be required including septoplasty, turbinate reduction, adenoidectomy, and/or sinus surgery. At the very least, septoplasty may be required in order to allow enough room to allow passage of the balloon guide and endoscope thru the nose to get to where the eustachian tube opening is located.

Post-Operative Care

Do continue all medications to treat any underlying conditions that may have contributed to the development of eustachian tube dysfunction in the first place. That includes all allergy and reflux medications.

No nose-blowing for one week to prevent any soft tissue air emphysema.

Start modified valsalva after one week, hourly while awake. Plan to do this for 3-6 weeks until ear(s) start to (hopefully) feel normal.

Pinch nostrils shut
Begin to gently blow the nose in order to gently raise the pressue within the nose
Add strong swallow while gently blowing the nose

Keep nose moist with saline nasal spray to be used as frequently as needed to avoid any dry sensation within the nose as well as humidifier use in the bedroom while sleeping.

What's Actually Happening

Although much of the information presented thus far implies that improvement occurs through the physical widening of the eustachian tube via balloon inflation, that's actually not what helps with eustachian tube dysfunction.

Histologic evidence suggests that balloon dilation helps resolve eustachian tube dysfunction by stripping away the inflamed superficial mucosa lining the eustachian tube allowing for healthy regrowth of normal mucosa along with scar tissue.

Balloon dilation appears to be analogously doing the same thing as adenoid removal does for the chronically congested snotty nose.

Complications

A mild nosebleed not uncommonly occurs and resolves within a few days. Other complications include soft tissue air emphysema, eardrum perforation, infection, constant ear "crunching" sound, etc. A lack of improvement also occurs in up to 40% of patients.

Rarely, the procedure may cause a false passage and theoretically even rupture of the internal carotid artery which can lead to excessive bleeding, stroke, and even death. This is why it is imperative a CT scan of the temporal bone is performed showing intact wall of bone separating the eustachian tube from the internal carotid artery. However, even with the presence of an intact boney wall separation, it is theoretically possible that balloon inflation may fracture this wall and damage the internal carotid artery. However, this complication has not ever been reported with proper use of the AERA balloon device so far.

The other main complication of this procedure is that balloon dilation may induce a medical condtion known as Patulous Eustchian Tube which is just that... a eustachian tube that stays open all the time. Although a eustachian tube that stays open all the time may sound like a good thing, this situation also causes undesirable problems. People with Patulous Eustachian Tube suffer from symptoms including hearing themself breath in and out all the time as well as hearing themself talk in their head as if in a barrel (autophonia). Symptoms may temporarily improve when bending down for a few seconds, but return soon thereafter. Unfortunately for sufferers of Patulous Eustachian Tube, there is no treatment that works very well unlike for Eustachian Tube Dysfunction. SSKI, premarin drops, PatulEND, and reserpine are some not totally effective medications. Surgical treatment includes placing a catheter into the eustachian tube to deliberately try and plug it up as well as placing a weight of some kind over the eardrum with ointment or steri-strip.

References

Balloon Dilation of the Cartilaginous Eustachian Tube. Otolaryngol Head Neck Surg April 2011 vol. 144 no. 4 563-569

Balloon catheter dilatation of eustachian tube: a preliminary study. Otol Neurotol. 2012 Dec;33(9):1549-52. doi: 10.1097/MAO.0b013e31826a50c3.

Balloon Dilation of the Eustachian Tube Is Indeed a "Gizmo" Until Future Research Proves Safety and Efficacy. Otolaryngol Head Neck Surg. 2014 Jun 3. pii: 0194599814538232.

Balloon dilation of the eustachian tube for dilatory dysfunction: A randomized controlled trial. Laryngoscope. 2017 Sep 20. doi: 10.1002/lary.26827. [Epub ahead of print]

Balloon Dilation of the Cartilaginous Portion of the Eustachian Tube. Otolaryngol Head Neck Surg. 2014 Apr 4;151(1):125-130. [Epub ahead of print]

Balloon Eustachian Tuboplasty: A Systematic Review. Otolaryngol Head Neck Surg. 2015 Jan 20. pii: 0194599814567105. [Epub ahead of print]

Balloon dilation for eustachian tube dysfunction: systematic review. J Laryngol Otol. 2016 Jul;130 Suppl 4:S2-6. doi: 10.1017/S0022215116008252.

Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube. Otolaryngol Head Neck Surg. 2019 Jun 4:194599819848423. doi: 10.1177/0194599819848423. [Epub ahead of print]

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Eustachian Tube Balloon Dilation to Treat Clogged Ears

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