New Consensus Statement on Balloon Dilation of the Eustachian Tube

The American Academy of Otolaryngology–Head and Neck Surgery recently published a set of clinical statements on the indications for and appropriate use of balloon dilation of the Eustachian tube (BDET) for adult patients (aged 18 years and older) with obstructive Eustachian tube dysfunction (OETD). Published June 4, 2019 in Otolaryngology-Head and Neck Surgery, “Clinical Consensus Statements: Balloon Dilation of the Eustachian Tube” was compiled by a panel of experts in response to the increasing rates of use of this technology for treatment of OETD by otolaryngologists and the need for some guidance given evidence gaps regarding its use.

“Balloon dilation of the Eustachian tube holds promise for the management of OETD, but because it is new territory for most clinicians an official statement was deemed necessary to reduce variations in care and prevent misapplication of this technology,” said Edward D. McCoul, MD, MPH, associate professor and director of rhinology and sinus surgery in the department of otorhinolaryngology at the Ochsner Clinic in New Orleans and a coauthor of the statement. “This statement calls attention to the current state of the literature as interpreted by experts in the field.”

The consensus statement offers 28 specific points of guidance categorized into the areas of patient criteria, perioperative considerations, and outcomes. Dr. McCoul highlighted a number of key areas he thought may be new to otolaryngologists and therefore particularly useful.

Patient criteria: Accurate diagnosis of OETD prior to considering BDET is critical given the variable and nonspecific symptoms that patients may present with. Along with a careful history, the panel emphasized the need to identify any underlying extrinsic causes of OETC such as allergic rhinitis, rhinosinusitis, and laryngopharyngeal reflux for which targeted treatment could also improve OETC. If any of these comorbid conditions are found, the panel recommends treating them prior to offering BDET.

The panel also emphasized the need for nasal endoscopy prior to consideration of BDET. “Nasal endoscopy and tympanometry are important to include when evaluating a patient for the presence of OETD,” said Dr. McCoul, underscoring the need to rule out other causes of ear fullness, including patulous Eustachian tube dysfunction.

Perioperative considerations: The panel underscored that tympanostomy tube placement is not a mandatory prerequisite for performing BDET. In addition, the panel stated that BDET should be considered an alternative to tympanostomy tube placement for treating OETD.

Outcomes: To determine outcomes, the panel noted the most reliable outcome measure is a standardized questionnaire (the Eustachian Tube Dysfunction Questionnaire-7) to record patient-reported symptoms using.
The statement also discusses and highlights clinical areas for which no consensus could be reached. Dr. McCoul highlighted a few: the extent of optimal medical therapy prior to offering BDT remains unclear, and additional objective outcome measures are still needed.

Overall, the consensus statement offers clinicians a guide to what experts currently agree on regarding the role and implementation of BDET for OETD. The authors hope that application of the statements will reduce variation in how BDET is currently used for OETD and increase the quality of care.

ENT Today

Is Hearing Preserved Following Radiotherapy for Vestibular Schwannoma?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

A common question by patients with newly diagnosed vestibular schwannomas (VS) is, “Which treatment will best preserve my hearing?” Currently, management of this benign tumor arising from the eighth cranial nerve sheath includes three broad options: observation with serial imaging, microsurgery, and radiotherapy. There are no high-quality, prospective controlled trials comparing outcomes among these three treatment modalities. Therefore, treatment recommendations are largely based on data from single-institution case series. As outcomes of tumor control and facial nerve preservation have improved with modern surgical and radiotherapy techniques, the possibility of hearing preservation (HP) often plays a significant role for patients and physicians making treatment decisions.

The heterogeneity of data poses a major challenge to providing accurate estimates of hearing preservation rates with radiotherapy for VS. Indications for treatment and inclusion criteria vary widely by institution. Radiation may be delivered in a single dose or as many as 30. The radiation source may be cobalt (e.g., GammaKnife surgery [GKS]) or a linear accelerator (e.g., CyberKnife). The methods for reproducing localization differ between techniques as well. Moreover, hearing outcomes are not standardized. For example, some publications simply report the patient’s subjective ability to use the telephone at the first post-treatment visit, whereas other studies utilize audiograms to provide an objective measure of hearing in the treated ear. Traditionally, serviceable hearing has been defined as pure-tone audiometry (PTA) < 50 db with speech discrimination scores (SDS) > 50%, corresponding to American Academy of Otolaryngology–Head and Neck Surgery class A or B, or Garner-Robertson (GR) grade 1 or 2. These differences result in widely varied rates of hearing preservation (between 10% and 90%) after radiotherapy for VS.

Best Practice

The level of evidence of reviewed articles is low. Given that the field involves rapidly developing technology, this is not surprising. Moreover, synthesis of data from case series is vitally important, as controlled studies comparing radiotherapy against microsurgery or conservative management would logistically be very challenging. Evidence from modern, highly conformal, low-dose radiation techniques demonstrate that long-term hearing preservation rates are poor; an approximately 80% hearing preservation rate at two years posttreatment falls to approximately 23% at 10 years. Although radiation therapy provides patients with satisfactory short-term hearing preservation, this treatment modality does not reliably preserve hearing in the long term. It is important when assessing publications in this field to thoroughly scrutinize the methodology, systems of hearing classification, and time to follow-up to provide patients with the most accurate estimations of hearing preservation (Laryngoscope. 2019;129:775–776).

ENT Today