Eur Arch Otorhinolaryngol (2016) 273:607–613
DOI 10.1007/s00405-015-3602-0
OTOLOGY
First results of Endonasal dilatation of the Eustachian tube (EET)
in patients with chronic obstructive tube dysfunction
Carsten V. Dalchow1 • M. Loewenthal1 • N. Kappo1 • F. Jenckel1 • B. B. Loerincz1
R. Knecht1
Received: 20 November 2014 / Accepted: 8 March 2015 / Published online: 19 March 2015
Ó Springer-Verlag Berlin Heidelberg 2015
Abstract For years, several surgical and non-surgical
therapeutic strategies in Eustachian tube dysfunction have
been described. The Endonasal dilatation of the Eustachian
tube (EET) utilising a balloon catheter is a feasible option
in patients with symptoms of chronic obstructive Eus-
tachian tube dysfunction. However, long-term results in a
large series are missing. In a prospective case series, 217
patients (342 cases) with symptoms of chronic Eustachian
tube dysfunction underwent uni- or bilateral EET at the
ENT Department of the University of Hamburg, Germany,
between September 2010 and April 2013. A tube score
consisting of the type of tympanogram and the R value of
the tubomanometry was used to evaluate pre- and postop-
erative tube function. All patients underwent follow-up
with a post-operative interval of 3–12 months. The mean
value of the pre-treatment tube score was 2.23 ± 1.147 and
significantly improved to 2.68 ± 1.011 1 year after EET.
There was a significant increase in the tube score during
follow-up. The co-variables time period, tympanoplasty
and pressure range showed a significant impact on the tube
score. EET is a minimally invasive and effective treatment
of chronic obstructive tube dysfunction. It is a safe pro-
cedure without causing significant complications. Never-
theless, long-term results of larger, placebo-controlled
multicentre studies are needed to confirm its effectiveness.
Keywords Endonasal dilatation of the Eustaschian tube
(EET)
Balloon dilatation of the Eustachian tube (BET)

& Carsten V. Dalchow
c.dalchow@uke.de
1 8], transtympanic and transnasal endoscopy (photo-
Department of Otorhinolaryngology, University Medical
Centre Hamburg-Eppendorf (UKE), Martinistrasse 52,
20246 Hamburg, Germany
•
Chronic obstructive tube dysfunction
Tubomanometry

Ear-related symptoms
Introduction
The prevalence of Eustachian tube dysfunction in adults is
approximately 1 % [1]; this can cause considerable and
chronic discomfort with feeling of fullness in the ear,
snapping and clicking noise, otalgia, hearing loss, vertigo,
recurrent otitis media and even cholesteatoma. Patients
often report of problems performing a Valsalva manoeuvre
or difficulties with barometric changes. Nearly 40 % of the
children under the age of 10 years suffer from temporary
Eustachian tube dysfunction [1], predominantly caused by
adenoid hyperplasia and mucosal swelling due to infec-
tions. Other reasons for chronic dysfunction include upper
respiratory tract infections, chronic or allergic rhi-
nosinusitis, nasal obstruction, laryngopharyngeal reflux,
anatomic conditions and nasopharyngeal pathologies [2–4].
Although several diagnostic procedures and therapeutic
strategies have been described in the past [5], applicable and
effective methods are still missing. A detailed anamnesis and
an in-depth ENT examination with otoscopy is one of the
most important steps to gain information about the ventila-
tory function of the system. However, a tympanic membrane
that appears normal does not exclude a Eustachian tube
dysfunction. Furthermore, the otoscopy should be combined
with the Valsalva and Toynbee manoeuvre. The tympa-
nometry is another available instrument that is routinely used
in the clinical setting. Other methods like imaging of the
Eustachian tube with MRI and CT scans or fluoroscopy [6–
tubometry) and catheterisation of the tube [9–11], sono-
tubometry [12], inflation–deflation test [13] and the use of
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pressure chambers [14] are quite sophisticated techniques
with only a little additive informative value. A new and
practicable Eustachian function test is the modified tubo-
manometry by Estève, first described in 2001 [15]. In con-
trast to the other methods mentioned, it can give information
about the Eustachian tube function in either intact or defec-
tive tympanic membranes. Beside otoscopy and tympa-
nometry, tubomanometry by Estève is the currently routinely
used diagnostic tool before surgical intervention. Tube scores
including swallowing, Valsalva manoeuvre, otomicroscopy
and the results of tubomanometry [16, 17] as well as ques-
tionnaires like the ETDQ-7 [18] were developed to assess
Eustachian tube dysfunction value before and after treatment.
As for the different Eustachian tube function tests, the
range of treatment is wide and goes from observation to
pharmacological and surgical options. Poe and Gopen [19]
determined a mucosal oedema of the Eustachian tube ori-
fice in 83 % of patients with tube obstructive complaints,
but a recent randomised, placebo-controlled trial showed
that the use of steroid nose spray over 6 weeks could not
improve Eustachian tube function in patients with otitis
media with effusion or negative middle ear pressure com-
pared to placebo [20].
Several surgical attempts have been made to improve
Eustachian tube function. Myringotomy and tympanosto-
my tubes can equalise the negative middle ear pressure but
do not address the real cause of dysfunction. Repeated tube
insertion or long-acting tubes are often needed in chronic
dysfunction and present a persistent risk for inflammation,
permanent perforation, tympanosclerosis and even choles-
teatoma. Poe identified a 5-mm long segment of the tubal
lumen directly inferior to the bony cartilaginous isthmus as
the cause for obstructive Eustachian tube dysfunction [21].
The idea of temporarily dilating the cartilaginous portion of
the Eustachian tube through the nasopharyngeal orifice
using a flexible balloon catheter has emerged as a potential
therapeutic option in the clinical setting [17, 22]. In several
studies, improvements in dysfunction symptoms, perfor-
mance of Valsalva manoeuvre and tubomanometer scores
have already been observed [17, 18, 23, 24].
The purpose of this study was to present follow-up data
of patients with chronic Eustachian tube dysfunction
treated with balloon dilatation between September 2010
and April 2013 at the ENT Department of the University of
Hamburg, Hamburg-Eppendorf, Germany.
Materials and methods
Patient characteristics and preoperative data
In this prospective case series, 217 patients with symp-
toms of chronic obstructive Eustachian tube dysfunction
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Eur Arch Otorhinolaryngol (2016) 273:607–613
underwent uni- or bilateral Endonasal dilatation of the
Eustachian tube (EET) at the ENT Department of the
University of Hamburg, Hamburg-Eppendorf, Germany,
between September 2010 and April 2013. A total of 342
EETs (167 left and 175 right ears) were performed. Re-
vision surgery procedures were excluded. The patients’
informed consent has been obtained regarding their in-
clusion and evaluation of their results in this prospective
case series. In 124 cases, a tympanoplasty was performed
before or during EET. The patient cohort consisted of 98
women (45.2 %) and 119 men (54.8 %), with a median
age of 45.58 ± 19.67 years (range from 6 to 88 years).
Patients were questioned about subjective ear pressure
and feasibility of performing a Valsalva manoeuvre via a
visual analogue scale from 0 (minimum) to 10 (max-
imum). All patients underwent clinical ENT examination
including endoscopic nasopharyngoscopy with examina-
tion of the Eustachian tube orifice and otomicroscopy with
performance of the Valsalva and Toynbee manoeuvre.
Pure tone audiometry, tympanometry and the tubo-
manometry (TMM) by Estève completed diagnostic in-
vestigation. Tympanogram types were classified as
proposed by Jerger (type A, B and C). A special tube
score consisting of the type of tympanogram and the
R value of the TMM was used to evaluate pre- and
postoperative tube function (Table 1). Clinical and au-
diological examinations were repeated on the first post-
operative day, after 1 month and after 3, 6, 9 and
12 months at our department.
Before surgery, all patients received a digital volume
tomography (DVT) of the temporal bone once to recognise
anatomical pathologies of the Eustachian tube and cranial
base and to identify possible internal carotid artery canal
dehiscence close to the bony part of the Eustachian tube in
the tubal lumen. Prior to EET, all patients received con-
servative treatment such as detumescent nasal sprays with
or without cortisone, systemic cortisone treatment or tube
training without improving their symptoms.
Table 1 Eustachian tube score
R value Tympanogram type Score
0 B 0
C 1
A 2
\1 or1 B 2
C 3
A 4
[1 B 1
C 2
A 3
0 no tube opening, 4 regular tube opening
Eur Arch Otorhinolaryngol (2016) 273:607–613
Tubomanometry
The tubomanometry (TMM) by Estève is a non-invasive
method to determine the threshold pressure and the time
from nasal pressure application to the opening of the
Eustachian tube (Esteve 2001). Through a nasal adapter,
which occludes both nostrils, a pressure generator re-
leases controlled positive boluses of gas consisting of 30,
40 and 50 mbar. These pressure values correspond to a
change of atmospheric pressure of 300, 400 and 500
altitude difference. While the patient swallows a bolus of
water, another pressure sensor in the external auditory
canal registers the pressure change by movement of the
tympanic membrane through the gas transport from the
nasopharynx to the middle ear. Pressure curves measured
both in the nasopharynx and in the external auditory
canal are demonstrated on a pressure–time diagram
(Fig. 1).
The time until the Eustachian tube opens is defined as
the opening latency index or R value:
P1 C1
R = C2 C1 = 0.56
R \ 1: regular opening of the Eustachian tube
R [ 1: delayed opening of the Eustachian tube
R % 0: no opening of the Eustachian tube
Eustachian tube score
The score was calculated as the amount of the tym-
panogram type (A, B or C by Jerger) and the R value
Fig. 1 Pressure–time diagram of the tubomanometry with pressure
curves of the nasopharynx (lower curve) and the middle ear (upper
curve). C1–C2 pressure generation time in the nasopharynx, C2–C3
pressure plateau in the nasopharynx, C3–C4 nasopharyngeal decrease
609
ranging from 0 (no tube opening) to 4 (regular tube
opening). The scoring system was developed to compare
pre- and postoperative results by statistical analysis.
Endonasal dilatation of the Eustachian tube
Dilatation of the fibrocartilaginous part of the Eustachian
tube was performed under general anaesthesia. Initially,
nasal mucosa was ebbed away with privin-containing
tamponades. After removing the tamponades, the distal
part of the inflexible applicator containing the balloon
catheter (Spiegel & Theiss, Overath, Germany) was placed
in the pharyngeal orifice of the Eustachian tube under vi-
sual control with a 45° microendoscope. The catheter was
then carefully and slowly moved forward into the tube until
an automatic attachment point. Insertion had to run easily
without any resistance. The balloon was blocked with
0.9 % saline solution to a length of 20 mm and a width of
3.28 mm, to a maximum pressure of 10 bars for 2 min.
When correctly positioned, a fasciculation of the velum
could be observed. The procedure was finished by re-
moving the catheter after pumping down the balloon.
After surgery, the patients received cefuroxim
2 9 500 mg (Cefuroxim SandozÒ, Sandoz Pharmaceuti-
cals GmbH, Holzkirchen, Germany) prophylactically for
5 days and on the first postoperative day a single shot of
250 mg prednisolone (Solu-DecortinÒ H 250 mg, Merck
Serono, Darmstadt, Germany) to reduce peri- and in-
tratubal mucosal swelling.
in pressure and relaxation of the velum, P1–P2 pressure generation
time in the middle ear, P2–P3 pressure plateau in the middle ear with
maximal tympanic membrane movement, Eustachian tube is open,
P3–P4 middle ear decrease in pressure
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Statistical analysis The co-variables time period [6 months: p = 0.008; CI

Results were documented in Excel (MS Office 2003) and
analysed using SPSS (SPSS Version 21, Inc., Chicago,
Illinois, USA). A mixed model containing pressure range,
availability of tympanoplasty and the time period as fixed
effects as well as patients as a random effect was used to
compare the results of the tube score pre- and postop-
eratively. Significance level was defined as p \ 0.05 and
confidence interval (CI) as 95 %. The tube score showed a
normal distribution.
Results
(0.30; 1.97), 12 months: p = 0.003; CI (0.34; 1.66)] and
tympanoplasty [p = 0.001; CI (0.64; 1.84)], as well as the
factor pressure range [p = 0.001; CI (0.93; 0.19)], had a
significant impact on the tube score (Table 3). Patients who
underwent a tympanoplasty showed lower tube scores than
patients without (Table 4). The tube score increased with
higher applied pressure during tubomanometry.
Patients who did not show any improvement of symp-
toms or tube score underwent revision surgery. Revision
surgery was performed in 38 of 342 cases and was not
included in statistical evaluation.
Preoperative CT scans did not show any internal carotid
canal dehiscence or tubal abnormality.

Uni- or bilateral EET was performed in 380 cases (n = 217

patients, 98 females and 119 males) at the ENT department Discussion
of the University of Hamburg, Germany, between
September 2010 and April 2013. There were no peri- or A proper function of the Eustachian tube is necessary to
postoperative complications registered. None of the pa- equalise pressure between the middle ear and the atmo-
tients showed postoperative bleeding, emphysema, tinnitus, sphere. Otherwise, negative pressure in the middle ear can
vertigo or pain. In the follow-up period, no patulous Eus-
tachian tube could be observed.
The tube score was measured preoperatively (n = 202)
and postoperatively after 1 month (n = 175), 3 (n = 92), 6
(n = 43), 9 (n = 29) and 12 months (n = 19). The mean
value of the tube score was 2.23 (±1.147 SD) preoperatively
and significantly improved to 2.68 (±1.011 SD) 12 months
after surgery (Table 2). The tube score 1 month after surgery
(2.23 ± 1.147 SD) decreased under the pre-treatment tube
score (2.68 ± 1.011 SD), but then showed a significant in-
crease (p \ 0.05) during follow-up (Fig. 2). The highest tube
score (‘‘4’’) was mostly registered 12 months after surgery
(26.8 %; R \ 1 = 55.6 %) and fewest after 1 month
(13.4 %) (Table 2). The lowest tube score (‘‘0’’) was mostly
measured 3 months after surgery (8.8 %) and never appeared
after 12 months (R [ 1 = 28.4 %). R = 0 mostly appeared
preoperatively (24.3 %). We did not find any impact of the
values ‘‘ear’’ or ‘‘patient’’ on the outcomes.
Fig. 2 Median value (MV) of the tube score measured pre- and
Table 2 Frequency of different tube scores (%) pre- and postoperatively (1 = preoperative, 2 = 1 month, 3 = 3 months,
postoperatively 4 = 6 months, 5 = 9 months, 6 = 12 months postoperatively)

Time period (month) Score (%) MV SD

Table 3 Impact of the co-variables time period, tympanoplasty and
0 1 2 3 4 pressure range on the tube score
Preoperative 5.5 21.3 36.5 17.8 18.9 2.23 1147 Rating p value 95 % CI
1 7.8 24.9 33.2 20.7 13.4 2.07 1142 Min. Max.
3 8.8 16.2 32.4 20.2 22.4 2.31 1234
6 8.2 19.7 27.0 22.1 23.0 2.32 1255 6 months 1.134584 0.008 0.297712 1.971456
9 5.0 30.0 18.8 20.0 26.3 2.33 1290 12 months 1.000397 0.003 0.338063 1.662731
12 0.0 12.2 34.1 26.8 26.8 2.68 1011 TPL 1.240937 0.000 0.638713 1.843161
Pressure 0.141496 0.000 0.092761 0.190230
MV median value, SD standard deviation

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Table 4 Tube score in TMM mbar (p = 001)
dependency of the
tympanoplasty status and the 1 (30 mbar)
pressure range of the
tubomanometry (TMM) TPL (p \ 001) 1.47582732 (1.10, 1.85)
No TPL 2.240221 (1.62, 2.86)
lead to hearing loss by decreased motion of the tympanic
membrane and the ossicular chain, otalgia and discomfort
and is often the basis for chronic middle ear diseases like
otitis media with effusion or even cholesteatoma. Pau et al.
[25] demonstrated the importance of an efficient ventilation
system in a self-model. The Endonasal dilatation of the
Eustachian tube (EET), established first in 2009 [26], is a
feasible alternative to common therapy of tympanostomy
tubes. The detailed mechanism of tube dilatation has not
yet been established. In cadaver studies the effect of the
EET was explained by causing microfractures of the car-
tilaginous part of the Eustachian tube [24, 27], Moreover,
the corresponding tissue is altered and post-inflammable
adhesions are loosened, thus decreasing the need for high
pressure to open the Eustachian tube. Tisch et al. [28]
performed an MRI scan directly pre- and postoperatively
and could not find any oedema or bleeding as a result of
fracturing. A change in sensitivity of the proprioreceptors
of the peritubal musculature or a squeezing mechanism
more than an effect on the tubal wall could be another
explanation.
In our study, the tube score improved after EET from
2.23 (±1.147 SD) preoperatively to 2.68 (±1.011 SD)
12 months after surgery. No complications had been ob-
served. EET was technically easy to perform without any
intraoperative difficulties. EET presented itself as a safe
and successful procedure. In particular, patients after
tympanoplasty showed lower score levels and benefited
from tube dilatation shown by higher post-treatment tube
scores. After completion of treatment with EET in our
centre, there has been a significant loss to follow-up over
time. The reasons for this may include the high proportion
of long-distance patients, lacking travel refunds in their
health insurance, as well as the presumably generally good
outcomes, as far as our study centre was able to reach the
patients or their local doctors via emails and phone calls to
confirm this assumption. Another study of Eustachian tube
function before and after tympanoplasty early confirmed
that the operation has a higher rate of success with good
Eustachian tube function and frequently failed to close
perforations in patients without sufficient tubal function
[29]. To improve long-term surgical outcome, EET should
be performed several months before tympanoplasty.
Schröder et al. [24] registered a postoperative im-
provement of dysfunction symptoms in 80 % of 66 patients
2 months and in 90 % of 12 patients 12 months after
611
2 (40 mbar) 3 (50 mbar)
1.61141817 (1.15, 2.07) 1.74700903 (1.21, 2.29)
2.3758119 (1.68, 3.08) 2.51140275 (1.73, 3.29)
surgery. In two patients, the pre-existing tinnitus got worse
during the first 2 weeks after EET and in some patients,
few and self-limiting nasal bleeding occurred. The latter
was attributed to perioperative anti-coagulative medication
(ASS, Clopidogrel, Cumarin). In eight patients, EET was
combined with tympanoplasty and in six patients this was
with sinus surgery. In both settings, Eustachian tube
function improved postoperatively. In comparison with
EET alone, EET combined with sinus surgery showed less
improvement. Thus, sinus surgery should be initially per-
formed before EET. A score consisting of clicking during
swallowing, Valsalva manoeuvre and R value of the dif-
ferent TMM pressure steps was used to examine postop-
erative success.
Tisch et al. [28] reported a subjective improvement of
symptoms in 71.4 % and a postoperative ability to perform
a Valsalva manoeuvre in 90 % of the 210 patients exam-
ined. One of the patients developed postoperative, self-
limiting emphysema up to the mediastinum after forced
Valsalva manoeuvre. To clarify the question of whether
more than one EET can be performed, 27 patients with a
history of multiple middle ear effusion and surgeries un-
derwent 3–5 EETs every 12 weeks. A complete regression
of symptoms was reached in 18 patients without any
complications. This underlines the EET to be a safe and
micro-invasive procedure. However, in our study, tube
ventilation did not improve until 3 months and was highest
after 12 months. Therefore, revision surgery should not be
performed within the first 3–6 months.
Poe et al. [23] described an improvement of Valsalva
manoeuvre in all 11 patients after 6 months. Multiple other
studies showed similar successful results [16, 17, 22, 30].
Nearly all of these studies declare an accomplished
indication finding. Regarding the wide range of Eustachian
tube dysfunctions, not all seem to be eligible for EET. A
practicable classification may help to identify suitable pa-
tients. Also, postoperative results may show even better
results. Diagnostic tools and postoperative success cur-
rently lean on different tube scoring systems [16, 24]. The
problem of these systems is that they are mostly non-
validated tests and do not give clear evidence of tubal
dysfunction. Tympanograms, TMM and performance of
Valsalva manoeuvre should, therefore, be more or less
helpful to decide whether the EET is necessary or not.
Also, examination and test results often just give infor-
mation about momentary conditions. Recently, a tube score
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consisting of usual criteria (otomicroscopy, tympanogram
and Valsalva manoeuvre) was completed by mucosal in-
flammation score (1 = normal, 2 = mild, 3 = moderate
with compromise and 4 = severe inflammation with
complete failure of tubal opening) [16]. Postoperatively,
the score improved significantly, supporting the hypothesis
that inflammation within the Eustachian tube plays an
important role in tubal dysfunction. The authors suppose
that the reduction of inflammation may be due to crushing
of irreversibly injured mucosa and that healthy tissue can
re-grow after intervention.
The ETDQ-7 questionnaire is a recently developed
symptom score tested for validity and reliability in 50 pa-
tients and 25 controls [31], including 7 questions con-
cerning tubal dysfunction symptoms from 1 (no problem)
to 7 (severe problem), but it is not used as standard. The
absence of standardised assessment, the wide variations of
inclusion criteria and the heterogeneous pool of patients
make it difficult to compare results [32]. There is an out-
standing need for consensus on the diagnostic criteria as
suggested in the novel ETS-7 questionnaire that includes
two additional items [33]. Furthermore, a long-term rela-
tionship between a good tube score and a good middle ear
pressure in chronic otitis media must be shown. With our
present data and the scoring used in our study, it remained
difficult to prove successful treatment, especially in pre-
viously operated ears with tympanoplasty.
Beside the EET, several other surgical treatment op-
tions exist. Inserting silk threads, polyethylene tubes or
drilling the bony part of the Eustachian tube are all at-
tempts that have been made to improve tubal function [34,
35], but are obviously quite invasive procedures, leading
to various complications. Poe et al. [36] described laser
Eustachian tuboplasty (LETP) as a safe and efficacious
procedure. Microdebrider Eustachian tuboplasty should
remove inflamed soft tissue from the tubal orifice and
make it wider [37]. Both interventions are also more in-
vasive than the EET and postoperative development of
scar and synechiae formation with occlusion of the tubal
orifice; strictures and other complications are to be
awaited in long-term results.
However, the surgical technique of EET also differs in
balloon diameter, dilatation time and dilatation pressure.
The best combination should be determined for each
indication and subpopulation [38]. Catalano et al. stated
that if an ear failed to respond to an initial dilatation, it also
failed to respond to any subsequent dilatation using the
same balloon diameter. On the other hand, the use of a
larger balloon catheter and higher dilatation pressures
could increase the risk of surgical complications. Silvola
et al. [16] suggest that the length of the cartilaginous part of
the Eustachian tube correlates with the surgical success rate
and that EET performance more often fails in shorter tubes.
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Eur Arch Otorhinolaryngol (2016) 273:607–613
The risk of injuring peritubal structures like the internal
carotid artery has been described in tubal injections and
treatments of patulous Eustachian tubes [39]. Preoperative
CT scan should exclude carotid canal dehiscence and the
risk of fracturing the bony canal, leading to bleeding and
rupture during EET. A retrospective clinical trial of 284
patients undergoing EET examined the relationship be-
tween the Eustachian tube and the internal carotid artery
[40]. Carotid canal dehiscence next to the Eustachian tube
was diagnosed in 18 patients (6.3 %). One patient had bi-
lateral carotid canal dehiscence. Postoperative complica-
tions occurred in three patients: unilateral soft tissue
emphysema in two patients and a unilateral hypoglossal
paresis in one patient. All of the patients had a normal CT
scan. No complication occurred in the group of ra-
diologically diagnosed carotid canal dehiscence. In the
author’s opinion, EET can be performed despite carotid
canal dehiscence as long as dilatation is restricted to the
cartilaginous part of the Eustachian tube. Temporal bone
CT scan seems not to be predictive of postoperative com-
plications and should not be used routinely before EET.
Only when EET performance fails will a postoperative CT
be useful in recognising tubal pathologies. The DVT used
in our study presents a good, fast and feasible alternative,
producing three-dimensional voxels of anatomical data
with generally lower total radiation doses compared to
conventional CT.
EET is a safe and effective treatment procedure in pa-
tients with chronic Eustachian tube function and it can also
be applied in children. Nevertheless, long-term results of
larger, placebo-controlled multicentre studies have to be
acquired to fully confirm the effectiveness of EET. A
validated, standardised instrument is needed to select
indication criteria and a questionnaire to assess quality of
life before and after EET has to be established.
Conflict of interest This research was funded by the Department of
ORL, University Medical Centre, Hamburg-Eppendorf (UKE),
Germany.
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