Ann 0 ( 0 / 9 0 : 1 9 8 1

PANEL ON EXPERIENCES WITH TESTING

EUSTACHIAN TUBE FUNCTION

CURRENT CLINICAL METHODS, INDICATIONS AND INTERPRETATION

OF EUSTACHIAN TUBE FUNCTION TESTS

CHARLES D. BLUESTONE, MD E R D E M I. CANTEKIN, PhD

P I T T S B U R G H . PENNSYLVANIA

Eustachian tube ( E T ) dysfunction is the most important factor in the pathogenesis of otitis media and related conditions. T h e impor­
tance of the function of the E T in relation to the middle ear-mastoid air cell system is c o m p a r e d to the critical role that laryngeal function
has in its relation to the tracheobronchial-pulmonary system. However, because of its obscure location, the E T is not as easily assessed by
clinical or laboratory methods as is the larynx, and therefore, its function is not as well understood. Most clinicians do not include E T func­
tion testing as part of their evaluation of patients with middle ear (ME) disease. Pneumatic otoscopy, the T o y n b e e test, tympanometry, the
9-step inflation-deflation tympanometric test, and the patulous tube test can be performed when the tympanic m e m b r a n e is intact. T h e
modified inflation-deflation test employing the p u m p - m a n o m e t e r of the electroacoustic impedance bridge can assess the function of the E T
when the tympanic m e m b r a n e is not intact. These tests are helpful in the diagnosis of the presence or absence of a b n o r m a l E T function; if a
dysfunction is present, these tests help to determine whether or not the tube is obstructed (mechanically or functionally) or abnormally pa­
tent, and in some instances, the degree of the malfunction. Even though testing of the function of the E T in the clinical setting has severe
hmitations at present, and further research is needed, information can be gained which is useful in the diagnosis and m a n a g e m e n t of M E
disease. Failing to recognize and assess the function of the E T in relation to the M E and mastoid in selected patients is as irrational as ignor­
ing the function of the larynx in patients with disease of the lower respiratory tract.

INTRODUCTION

Abnormal function of the E T appears to be the EUSTACHIAN

TUBE INFECTION
most important factor in the pathogenesis of middle DYSFUNCTION
ear (ME) disease. This hypothesis was first sug­
gested more than 1 0 0 years ago by Politzer.' How­
ever, later studies^'* suggested that otitis media ALLERGY
CILIARY OYSMOTILITY
(OM) was a disease primarily of the M E mucous •OTHER'"
membrane, ie, due to infection or allergic reactions Fig. 1. Etiology and pathogenesis of otitis m e d i a .
in this tissue, rather than related to dysfunction of
the E T . Figure 1 is an attempt to incorporate these Since abnormalities of E T function may result in
hypotheses and thus, to resolve the controversy. M E disease, we need to review our current
knowledge of the physiology and pathophysiology
The vast majority of patients with OM and re­
of the E T with regard to the pathogenesis of OM
lated conditions have (or have had in the past) ab­
before selecting methods to test tubal function and
normal function of the E T that may cause secon­
interpreting the results of these tests for the purpose
dary mucosal disease of the M E , ie, inflammation.'
of selecting among management options. The func­
Infection is secondary to reflux, aspiration, or insuf­
tion of the E T will be compared with the function
flation of nasopharyngeal bacteria up the E T and
of the larynx to put into perspective for the modern
into the M E . ' Inflammation (infection or possibly
otorhinolaryngologist the importance of the E T .
allergy) may also cause intrinsic mechanical ob­
struction of the E T . ' Unrelated to the function of
COMPARISON OF T H E FUNCTIONS
the E T , hematogenous spread of bacteria into the OF T H E EUSTACHIAN TUBE AND LARYNX
M E may also result in OM; the commonly postu­
lated example of this mechanism is meningitis The physiologic functions of the E T cannot be
as.sociated with OM in infants. A much smaller isolated from the other components of the M E
number of patients may have primary mucosal system: the nose, nasopharynx, and palate at the
disease of the M E as a result of allergy (although proximal end, and the M E and mastoid air cells at
this has not been proven), or, more rarely, an ab­ the distal end (Fig. 2). Likewise, the larynx is with­
normality of the cilia, eg, Kartagener syndrome.' in a system m a d e up of the pharynx at the proximal
F r o m the D e p a r t m e n t of O t o l a r y n g o l o g y , University of Pittsburgh School of Medicine, a n d C h i l d r e n s Hospital of Pittsburgh. S u p p o r t e d in part by a
grant from the N a t i o n a l Institute of Neurological a n d C o m m u n i c a t i v e Disorders a n d Stroke, l P O l - N S - 1 6 3 3 7 .
Presented at the meeting of the American Otological Society, I n c . , V a n c o u v e r , British C o l u m b i a , M a y 9-10, 1 9 8 1 .
R E P R I N T S — C h a r l e s D . Bluestone, M D , D e p a r t m e n t of O t o l a r y n g o l o g y , Children's Hospital of Pittsburgh, 125 D e S o t o Street, P i t t s b u r g h , PA 15213.

552

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 PANEL ON EXPERIENCES WITH TESTING
EUSTACHIAN
TUBE
HEARING — VENTILATION
PHYSIOLOGY PROTECTION
PUMP — DRAINAGE
OBSTRUCTION
MECHANICAL
PATHOPHYSIOLOGY FUNCTIONAL
ABNORMAL PATENCY
ATELECTASIS
RETRACTION
POCKET
EFFUSION
MIDDLE EAR
PATHOLOGY EFFUSION
INFECTION
REFLUX OTITIS
MEDIA
SUPPURATIVE
OTITIS MEDIA
end, and the tracheobronchial-pulmonary system
distally. Within their respective systems, the E T
and the larynx play critical roles in the functions of
the M E and lungs, respectively, in their connections
to the aerodigestive tract. The tympanic m e m b r a n e
(TM) and malleus (which m a y be compared to a
rib) and tensor tympani muscle (which may play a
role similar to that of the intercostal muscles) could
even be compared to the rib c a g e and d i a p h r a g m of
the pulmonary system. The mastoid air cell system,
in its role as a reservoir for gas for the M E , can also
be compared to the reserve volumes of the lungs.
Physiologically, both the E T and the larynx have
ventilatory, protective, and drainage functions.
The E T ventilates the M E to regulate M E pressure,
which maintains optimum hearing. The larynx ven­
tilates the lungs to provide respiration which, in
m a n , has also evolved phylogenetically into phona­
tion. In order to perform these critical physiologic
functions, the E T and larynx must protect the M E -
mastoid and the tracheobronchial-pulmonary sys­
tems from unwanted secretions. In the absence of
swallowing, the M E and mastoid are protected (also
from nasopharyngeal sound pressures) by the func­
tional collapse of the normal E T ; however, during
swallowing, the normal E T actively opens due to
contraction of one muscle, the tensor veli
palatini,'""'^ and the palate seals off the naso­
pharynx from the contents of, and extreme pressure
developed in, the oropharyngeal cavity. The lar­
ynx, on the other h a n d , is open (by the activity of
one paired muscle) when swallowing is not occurr­
ing but closes during swallowing activity. The
epiglottis, although less important in humans, pro­
tects the glottis during swallowing much like
palatal closure protects the nasopharyngeal end of
the E T .
Both systems have clearance (or drainage) func­
tions primarily provided by the mucociliary activity
of their mucosal linings, but the larynx is integrally
involved in coughing, acting to clear (and therefore
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EUSTACHIAN TUBE FUNCTION 553
MIDDLE EAR
MASTOID \ EUSTACHIAN TUBE
LARYNX
PHONATION
COUGH TIS
F i g . 2. Nose-nasophar-
ynx-eustachian tube-mid­
dle e a r - m a s t o i d system
compared to the pharynx-
larynx-tracheobronchial-
p u l m o n a r y system.
SEGMENTAL
ATELECTASIS
PULMONARY
EDEMA
ASPIRATION
PNEUMONIA
BACTERIAL
PNEUMONIA
to protect) the lungs. Likewise, the E T is now
thought to have a pump-like activity that actually
"milks" secretions out of the M E and m a s t o i d . "
T h e pathophysiology of the E T can also be com­
pared to that of the larynx. Both can be obstructed
mechanically (anatomically) or functionally. Clear­
ly, both structures can have intrinsic (due to inflam­
mation) or extrinsic (as from a tumor) mechanical
obstructions. However, functional obstruction of
the E T is much less easy to visualize conceptually
than this type of obstruction of the larynx and tra­
cheobronchial tree. Functional obstruction of the
larynx caused by bilateral vocal cord paralysis (in
the median or p a r a m e d i a n position), or laryngo­
m a l a c i a , or, more distally, tracheobronchial mala-
cia, is well known and understood. However, an
abnormally compliant (floppy) E T or an abnormal
tubal opening mechanism, even though it m a y have
similarities to the pathophysiology of laryngeal dys­
function, is not as easily understood. This is because
the larynx, trachea, and bronchi are more readily
available for examination, and have been studied
much more than the E T . Other instances in which
laryngeal abnormalities m a y lead to disease include
1) aspiration pneumonia caused by an abnormally
patent or incompetent glottis (eg, paralysis of the
vocal cords in the lateral position); 2) reflux esopha­
gitis, which can also cause aspiration pneumonia,
resulting from incompetence of the esophagogastric
junction; and 3) cricopharyngeal achalasia re­
sulting in a similar condition. The analogies in the
M E system include 1) "reflux otitis media" caused
by the reflux of nasopharyngeal secretions through
an abnormally patent (patulous or semipatulous)
E T ; and 2) the aspiration through the E T of secre­
tions into a M E that has high negative pressure.
Nasal obstruction may have an effect on both E T
(Toynbee phenomenon)' and pulmonary function.
Some of the pathologic conditions found at the
distal ends of the two systems are also comparable.
554
Atelectasis of the T M , which is analogous to pul­
monary atelectasis, is the result of hypoaeration of
the M E . A retraction pocket of the posterosuperior
or pars flaccida areas of the T M could be likened to
segmental pulmonary atelectasis, for instance, ate­
lectasis of the right middle lobe; both of these con­
ditions may result from the unique anatomies of the
parts involved. A middle ear effusion ( M E E ) which
is sterile may develop in a way similar to that in
which pulmonary edema develops, and suppurative
OM could be compared to bacterial pneumonia in
their pathogenesis.
In conclusion, then, the larynx plays a well-
recognized and critical role in the functioning of the
pulmonary system, but while the E T plays a similar
role in the M E system, this latter role is poorly un­
derstood. This is due to the obscure location of the
E T and the limited methods available to assess its
function. The larynx and tracheobronchial-pul-
monary system have been extensively studied by
many different methods, some of which are quite
simple. For instance, laryngeal function can readily
be assessed by indirect laryngoscopy, one of the
simplest assessment techniques, although more so­
phisticated laryngeal and pulmonary function tests
are available and used frequently in clinical prac­
tice as well as in the laboratory. Unfortunately,
since the E T is not as accessible to the clinician or
investigator, and therefore has not been studied as
extensively as its counterpart, it is thus not as well
understood. However, in spite of these disadvan­
tages, it is as important to assess the function of the
E T of a patient with tympanic membrane-middle
ear-mastoid disease as it is to assess the function of
the larynx of a patient who has tracheobronchial or
pulmonary disease. The various instruments avail­
able to the clinician and investigator, as well as the
methods of assessment of E T function, have been
described in detail elsewhere.'" In the following dis­
cussion only the instruments and assessment tech­
niques available to the clinician will be reviewed.
INSTRUMENTATION NEEDED TO ASSESS
EUSTACHIAN TUBE FUNCTION
IN THE CLINICAL SETTING
Prior to the examination of the patient, the pres­
ence of certain signs and symptoms may be helpful
in determining if E T dysfunction is present. How­
ever, as in the assessment of laryngeal and pul­
monary function, the presence or absence of these
signs and symptoms, eg, airway obstruction, stri­
dor, hoarseness, dyspnea, cough, may only help in
determining if dysfunction is present and, when
present, may not determine the type, location, or
severity. Likewise, conductive hearing loss, otalgia,
otorrhea, tinnitus, or vertigo may or may not be
present with E T dysfunction.
Otoscopy. Visual inspection of the T M is one of
the simplest (and oldest) ways to assess the function­
ing of the E T ; however, like auscultation of the
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BLUESTONE-CANTEKIN
chest to diagnose pulmonary disease, it has severe
limitations. The a p p e a r a n c e of a M E E or the pre­
sence of high negative M E pressure, or both, as de­
termined by the pneumatic otoscope," is presump­
tive evidence of E T dysfunction, but the type, ie,
obstruction (functional vs mechanical), as well as
the degree of abnormality, cannot be determined
by this method. Moreover, a normal-appearing T M
cannot be considered to be evidence of normal func­
tioning of the E T : for instance, a patulous or semi-
patulous E T may be present when the T M appears
to be normal. In addition, the presence of one or
more of the complications or sequelae of OM (such
as a perforation or atelectasis, as observed through
the otoscope) may not correlate with dysfunction of
the E T at the time of the examination, since E T
function may improve with growth and develop­
ment.
Many otolaryngologists use the otomicroscope to
improve the accuracy with which OM and related
conditions are diagnosed. For assessment of T M
mobility, the otomicroscope, when used with the
Bruening pneumatic otoscope and a nonmagnifying
lens, is superior to the conventional otoscopes.
Nasopharyngoscopy. Indirect mirror examina­
tion of the nasopharyngeal end of the E T is also an
old but still important part of the clinical assess­
ment of a patient with M E disease. For instance, a
neoplasm in the fossa of Rosenmuller may be diag­
nosed by this simple technique. The development of
endoscopic instruments has greatly improved the
accuracy of this type of examination but, unlike in­
direct and direct laryngoscopy (and bronchoscopy),
the function of the E T cannot be determined with
the aid of currently available instruments.
Tympanometry. The use of an electroacoustic
impedance instrument to obtain a tympanogram is
an excellent way of determining the status of the
T M - M E system, and can be helpful in the assess­
ment of E T function." The presence of a M E E or
high negative M E pressure as determined by this
method usually indicates impaired E T function;
however, unlike the otoscopic evaluation, the
tympanogram is an objective way of determining
the degree of negative pressure present in the M E .
Unfortunately, assessing the abnormality of values
of negative pressure is not so simple; high negative
pressure may be present in some patients, especially
children, who are asymptomatic and who have rel­
atively good hearing, while in others, symptoms
such as hearing loss, otalgia, vertigo, and tinnitus
may be associated with modest degrees of negative
pressure or even with normal M E pressures. Alberti
and Kristensen" have suggested that the limits of
normal M E pressure for adults are between -i- 50
and - 50 mm H2O, while Brooks'* feels that the nor­
mal M E pressure in children may be as low as - 175
to - 2 0 0 mm H2O. However, these values depend
upon the time of day, season of the year, or the con-
 PANEL ON EXPERIENCES
(Oor+) (Oor+/-)
POSITIVE PHASE
dition of the other parts of the system, such as the
presence of an upper respiratory tract infection. For
instance, a young child with a common cold m a y
have transitory high negative pressure within the
M E while he has the cold, but be otherwise otolog­
ically normal. The decision as to whether or not
high negative pressure is abnormal or is only a
physiologic variation should be m a d e taking into
consideration the presence or absence of signs and
symptoms of M E disease. If severe atelectasis or
adhesive otitis of the T M - M E system is present, the
tympanogram may not be a reliable indicator of the
actual pressure within the M E .
Therefore, a resting pressure that is high negative
is associated with some degree of E T obstruction,
but the presence of normal M E pressure does not ne­
cessarily indicate normal E T function. An analogy
can be m a d e to the evaluation of pulmonary func­
tion employing chest x-ray films. Abnormal pul­
monary function is most likely associated with ra­
diographic evidence of severe disease of the lung,
but the finding of a normal-appearing roentgeno­
graph of the chest does not necessarily indicate nor­
mal pulmonary function.
Manometry. The pump-manometer system of the
electroacoustic impedance bridge is usually ade­
quate to assess E T function clinically when the T M
is not intact. However, due to the limitations of the
manometric systems of all of the commercially
available instruments, a controlled syringe and
manometer (a water manometer will suffice) should
be available when these limitations are exceeded,
eg, when E T opening pressure is in excess of + 400
to + 600 mm H^O.
METHODS O F ASSESSING
EUSTACHIAN TUBE FUNCTION
Classical Tests of Tubal Patency. Valsalva and
Politzer have developed methods to assess patency
of the E T ; E T catheterization achieves the same re­
sults. When the T M is intact and the M E inflates
following one of these tests, then the tube is not
totally mechanically obstructed. Likewise, if the
TM is not intact, passage of air into the M E would
indicate patency of the tube. The success of these
tests can be determined subjectively by the use of
the otoscope, a Toynbee tube, or a stethoscope at
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WITH TESTING EUSTACHIAN TUBE FUNCTION 555
F i g . 3. T o y n b e e test of E T function.
D u r i n g closea-nose swallowing a positive
pressure develops within the nasophar­
ynx, followed by a negative pressure
phase. If the E T opens during the test,
the M E pressure will change depending
upon the timing of the t u b a l o p e n i n g and
pressure gradient.
NEGATIVE PHASE
the M E end of the system. T h e assessment is more
objective when a t y m p a n o g r a m is obtained when
the T M is intact, or when the manometer on the im­
pedance instrument is observed when the T M is not
intact. However, inflation of the E T - M E from the
nasopharynx end of the system by one of these clas­
sical methods only is an assessment of tubal patency
and not function, a n d failure to inflate the M E does
not necessarily indicate a lack of patency of the E T .
Elner et a l " reported that 86% of 100 otologically
normal adults could perform the Valsalva test. In
young children, the Valsalva test is usually more
difficult to perform than the Politzer test. However,
in a recent study by Bluestone and coworkers," 6 of
7 children who had a traumatic perforation but
who were otherwise otologically "normal" could
perform the Valsava test as compared to only 11 of
28 children who had a retraction pocket or a
cholesteatoma. The Valsalva and Politzer maneu­
vers are more beneficial as management options in
selected patients than they are as methods to assess
tubal function.
Toynbee Test. One of the oldest and still one of
the best tests of E T function is the Toynbee test
(Fig. 3). The test is usually considered positive
when an alteration in M E pressure results. More
specifically, if negative pressure (even transitory in
the absence of a patulous tube) develops in the M E
during closed-nose swallowing, the E T function can
be considered most likely to be normal. When the
T M is intact, the presence of negative M E pressure
must be determined by pneumatic otoscopy or,
more accurately, by obtaining a tympanogram be­
fore and immediately following the test (Fig. 4).
When the T M is not intact, the manometer of the
i m p e d a n c e bridge can b e observed to determine M E
pressure. In the Elner et al s t u d y , " the Toynbee test
was positive in 79% of normal adults. Cantekin et
aP' reported that only 7 of 106 ears (6.6%) of sub­
jects (mostly children) who had had tympanostomy
tubes inserted for O M could perform a modification
of the Toynbee test (closed-nose equilibration at­
tempt with applied negative M E pressure of 100 or
200 mm H j O ) . Likewise, in a series of patients,
most of whom were older children and adults with
chronic perforations of the T M , only 3 of 21
(14.3%) passed the test. However, in children with
a traumatic perforation of the T M but who other-
556 BLUESTONE-CANTEKIN

10 10

AFTER TOYNBEE TEST -

BREATH '.
/ [^RESTING /HOLDING
PRESSURE BREATHING /
t 5
2
3

^ ] L

-400 + 400 -400 + 400

mmHjO mmHjO

Fig. 4. T y m p a n o g r a m obtained before and after Toyn­ F i g . 5. Diagnosis of a patulous E T employing the tym­
bee test. Negative M E pressure is objectively demonstrated panogram .
in the M E , which is considered to be associated with good
E T function.
1. The tympanogram records resting M E pres­
sure.
wise had a negative otologic history, three of ten
(30%) could pass the test. In the Bluestone et al 2. E a r canal pressure is increased to -i- 200 mm
study^" of "normal" children with traumatic per­ H2O, with medial deflection of the T M and a cor­
forations, six of seven children could change the M E responding increase in M E pressure. The subject
pressure as compared to none of the 21 ears of swallows to equilibrate M E overpressure.
children who had a retraction pocket or a chol­
3. While the subject refrains from swallowing,
esteatoma. The test is of greater value in determin­
ear canal pressure is returned to normal, thus estab­
ing normal versus abnormal E T function in adults
lishing a slight negative M E pressure (as the T M
than in children. The test is still of considerable
moves outward). The tympanogram documents the
value since, regardless of age, if negative pressure
established M E underpressure.
develops in the M E during or following the test, the
E T function is most likely normal, since the E T ac­
tively opens and is sufficiently stiff to withstand STEP ACTIVITY MODEL TYMMNOGRAM

nasopharyngeal negative pressure, ie, it does not ft Τ VP ME

RESTING
"lock." If positive pressure is noted or no change in
PRESSURE
pressure occurs, the function of the E T still may be
normal and other tests of E T function should be
performed. INFLATION AND

Patulous Eustachian Tube Test. If a patulous E T

SWALLOW ( x 3 )
f
is suspected, the diagnosis can be confirmed by oto­
PRESSURE AFTER
scopy or objectively by tympanometry when the
EQUILIBRATION
T M is intact." One tympanogram is obtained while
the patient is breathing normally, and a second is
SWALLOW
obtained while the patient holds his breath. Fluctu­
(k31
ation of the tympanometric trace which coincides
with breathing confirms the diagnosis of a patulous
tube (Fig. 5). Fluctuation can be exaggerated by PRESSURE AFTER
asking the patient to occlude one nostril with the EQUILIBRATION

mouth closed during forced inspiration and expira­

tion or by performing the Toynbee maneuver. DEFLATION AND
When the TM is not intact, a patulous E T can be SWALLOW ( x 3 )

identified by the free flow of air into and out of the

E T using the pump-manometer portion of the elec­
PRESSURE AFTER
troacoustic impedance bridge. These tests should (+)
EQUILIBRATION
not be performed while the patient is in a reclining
position since the patulous E T will close.
SWALLOW
Nine-Step Inflation-Deflation Tympanometric (x31

Test. Another method of assessing the function of

the E T when the T M is intact, developed by Blue- PRESSURE AFTER (0)1
stone," is called the 9-step inflation-deflation tym­ EQUILIBRATION

panometric test, although the applied M E pressures

are very limited in magnitude. The M E must be free F i g . 6. Nine-step inflation-deflation tympanometric
test. T V ? - Tensor veli palatini muscle, E T - Eustachian
of effusion. The 9-step tympanometry procedure tube, M E - Middle ear, T M - T y m p a n i c m e m b r a n e , E C -
may be summarized as follows (Fig. 6): E a r canal.

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 PANEL ON EXPERIENCES WITH TESTING
NINE-STEP INFLATION-DEFLATION TYMPANOMETRIC TEST FINDINGS
All Some
Groups of subjects Positive Positive
Normal adults (N = 27) 39 10
Abnormal adults (N = 42) 18 26
Normal children (N = 44) 11 19
Abnormal children (N = 18) 7 8
4. The subject swallows in an attempt to equili­
brate negative M E pressure. If equilibration is suc­
cessful, airflow is from nasopharynx to M E .
5. The tympanogram records the extent of equil­
ibration.
6. E a r canal pressure is decreased to - 2 0 0 m m
H j O , causing a lateral deflection of the T M and a
corresponding decrease in M E pressure. The subject
swallows to equilibrate negative M E pressure; air­
flow is from the nasopharynx to the M E .
7. The subject refrains from swallowing while
external ear canal pressure is returned to normal,
thus establishing a slight positive pressure in the M E
as the T M moves medially. The tympanogram re­
cords the overpressure established.
8. The subject swallows to reduce overpressure.
If equilibration is successful, airflow is from the M E
to the nasopharynx.
9. The final tympanogram documents the extent
of equilibration.
In an attempt to determine the usefulness of this
method of testing E T function, four groups of sub­
jects, all of whom had intact T M and no otoscopic
or tympanometric evidence of M E E , were evalu­
ated:
1. Normal adults — 27 adults without a prior
history of otologic disease.
2. Abnormal adults — 42 adults with a prior his­
tory of otologic disease.
3. Normal children — 44 children between 2 and
15 years of age without a prior history of otologic
disease.
4. Abnormal children — 48 children between 2
and 15 years of age, all of whom had otoscopic and
tympanometric evidence of a M E E in the recent
past.
The table shows the findings in these four groups
of subjects. The ability to perform all or any one of
the steps progressively increased with advancing
age and the absence of a past history of otologic dis­
ease. Conversely, the percentage of ears in which no
function was present progressively increased from
the normal adult group (9.3%) to the abnormal
children group (80.3%). Of the 46 ears in these
children, regardless of past history, in whom a M E
pressure of - 50 mm HjO or less was found, only 3
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EUSTACHIAN TUBE FUNCTION 557
Function Test Findings (Ears)
None Total % All or
Posiifue Ears Some Positive
5 54 90.7
36 80 55.0
58 88 34.1
61 76 19.7
(7 %) could perform any of the tests. Likewise, of 13
ears with high negative pressure in the abnormal
adult group, only two (15.3%) could pass any of the
tests. These findings verify the presence of E T ob­
struction when high negative M E pressure is identi­
fied.
T h e test is simple to perform and can give useful
information regarding E T function and should be
part of the clinical evaluation of patients with sus­
pected E T dysfunction. In general, most normal adults
can perform all or some parts of this test, but even
normal children have difficulty in performing this
test.
Modified Inflation-Deflation Test (Nonintact
T y m p a n i c Membrane). When the T M is not intact,
the pump-manometer system of the electroacoustic
impedance bridge can be used to perform the mod­
ified inflation-deflation E T function test, which
assesses passive as well as active functioning of the
E T . " " The M E should be free of any drainage for
an accurate assessment of E T function using this
test. Figure 7 illustrates the procedures employed
during the test. The M E is inflated, ie, positive
pressure is applied, until the E T spontaneously
opens. At this time, the p u m p is manually stopped
and air is discharged through the E T until the tube
closes passively. The pressure at which the E T is
passively forced open is called the opening pressure,
and the pressure at which it closes passively is called
the closing pressure. The patient is then instructed
to equilibrate the M E pressure actively by swallow­
ing. The residual pressure remaining in the M E
after swallowing is recorded. The active function is
also recorded by applying over- and underpressure
to the M E , which the patient then attempts to
equilibrate by swallowing. T h e residual pressure in
the M E following equilibration of + 200 mm HjO
or half of the passive opening pressure is recorded.
T h e residual negative pressure which remains in the
M E after the attempt to equilibrate applied nega­
tive pressure of — 200 mm H j O is also noted. This
procedure is not performed in patients who cannot
equilibrate applied overpressure. If the E T does not
open following application of positive pressure us­
ing the electroacoustic impedance bridge, and no
reduction in positive pressure occurs during swal­
lowing, then the E T must be assessed using a mano­
metric system other than the electroacoustic impe­
dance bridge manometric system. The opening
pressure m a y be higher than 400 to 600 mm H j O
pressure, or not present at all (severe mechanical
558 BL
+ 4 0 0 F
+ 200h 7\
go
I
^
-200
SWALLOW
EXAMPLE A figure shows strip-chart recordings, but the results of
q:
3 + 400
0 readout and noted manually. RP - Residual pressure, Ο
+200
1 ^ C—S—RP
\
-200i
SWALLOW
··· EXAMPLE Β
>
···
obstruction). Example A in Figure 7 shows that fol­
lowing passive opening and closing of the E T dur­
ing the inflation phase of the study, the patient was
able completely to equilibrate the remaining posi­
tive pressure. Active swallowing also completely
equilibrated applied negative pressure (deflation).
This is considered to be characteristic of normal E T
function. Example Β shows the E T passively opened
and closed following inflation, but subsequent
swallowing failed to equilibrate the residual posi­
tive pressure. In the deflation phase of the study,
the patient was unable to equilibrate negative pres­
sure. Inflation to a pressure below the opening pres­
sure but above the closing pressure could not be
equilibrated by active swallowing. This type of re­
sult is considered to be abnormal but may be found
in a few subjects who do not have any obvious oto­
logic disease.
Failure to equilibrate the applied negative pres­
sure may indicate locking of the E T during the test.
This type of tube is considered to have increased
compliance or to be "floppy" in comparison to a
tube with perfect function. The tensor veli palatini
muscle is unable to open (dilate) the tube. The
speed of application of the positive and negative
pressures is an important variable in testing E T
function with the inflation-deflation test. The faster
the positive pressure is applied, the higher the open­
ing pressure. During the deflation phase of the
study, the faster the negative pressure is applied,
the more likely it is that the locking phenomenon
will occur.
Even though the inflation-deflation test of E T
function does not strictly duplicate physiologic
functions of the tube, the results are helpful in dif­
ferentiating normal from abnormal function. The
mean opening pressure for apparently normal sub­
jects with a traumatic perforation and negative oto­
logic history reported by Cantekin and coworkers"
was 330 mm H2O ( ± 7 0 mm H2O). If the test results
reveal passive opening and closing within the nor­
mal range, residual positive pressure can be equili-
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UESTONE-CANTEKIN
=»S—5
F i g . 7. Procedure and symbols used in describing the
modified inflation-deflation test employing the p u m p -
manometer system of an electroacoustic bridge. T h e
the test can be read directly from the equipment
- Opening pressure, C - Closing pressure, · - Mark for
^ ^ S - R P swallow, S - Pressure after swallow.
S RP
•··
brated by swallowing and applied negative pressure
can also be equilibrated completely, then the E T
can be considered to have normal function. How­
ever, if the tube does not open to a pressure of 1000
mm H2O, one can assume that total mechanical ob­
struction is present. This pressure is not hazardous
to the M E or inner ear windows if the pressure is ap­
plied slowly. An extremely high opening pressure
(eg, greater than 500 to 600 m m H2O) may indicate
partial obstruction, whereas a very low opening
pressure (eg, less than 100 m m H2O) would indicate
a semipatulous E T . Inability to maintain even a
modest positive pressure within the M E would be
consistent with a patulous tube, ie, one which is
open at rest. Complete equilibration by swallowing
of applied negative pressure is usually associated
with normal function, but partial equilibration, or
even failure to reduce any applied negative pressure
may or may not be considered abnormal since even
a normal E T will lock when negative pressure is
rapidly applied. Therefore, inability to equilibrate
applied negative pressure may not indicate poor E T
function, especially when it is the only abnormal
parameter.
Elner et a l " studied 102 adults with intact T M
and a negative otologic history. They used the mi-
croflow technique and pressure chamber to eval­
uate E T function, but the results of this type of
testing are comparable to the results of the infla­
tion-deflation test when the T M is not intact. They
reported that only 5 % could not equilibrate to some
degree an applied pressure of + 100 and 7% could
not equilibrate - 1 0 0 mm H2O. Bylander" com­
pared the E T functioning in 53 children with that
in 55 adults, all of whom had intact T M and who
were apparently otologically healthy. Employing a
pressure chamber, she reported that 53% of the
children could not equilibrate applied negative in-
tratympanic pressure ( - 1 0 0 mm H2O) by swal­
lowing, whereas only 9% of the adults were unable
to perform this function. Children between 3 and 6
years of age had worse function than those in the
 PANEL ON EXPERIENCES
7-to-12-year age group. In addition, she also found
that even normal children who had tympanometric
evidence of high negative pressure within the M E
had poor E T function. From these two studies, it
can be concluded that even in apparently otolog­
ically normal children, E T function is not as good as
in adults, which would contribute to the higher in­
cidence of M E disease in children compared to
adults. In the Cantekin et al s t u d y , " only 8 of 108
ears (7%) of subjects (primarily children) with tym­
panostomy tubes could equilibrate an applied pres­
sure of — 200 mm H j O to any degree and none of 67
ears could equilibrate - 1 0 0 mm H2O. In subjects
with chronic dry perforations, 4 of 30 ears (13%)
could equilibrate - 1 0 0 mm H2O, and none of 17
ears could equilibrate — 200 mm H2O. These results
were compared to those obtained from a group of
subjects with traumatic perforations of the T M ; in
this latter group 12 of the 27 (44%) ears equili­
brated a pressure of —200 mm H2O.
Other Methods Available for Laboratory Use.
There are other methods available to test the func­
tioning of the E T , but they are limited to use in the
laboratory for investigational purposes at present.
When the T M is intact the microflow technique'* or
an impedance method,'' both of which require a
pressure chamber, or s o n o m e t r y " " may be used.
When the tympanic m e m b r a n e is not intact the
forced-response test" may be used. Sonometry and
the forced-response test show great promise for fu­
ture use in the clinical setting.
CLINICAL INDICATIONSFOR TESTING
EUSTACHIAN TUBE FUNCTION
Diagnosis. One of the most important reasons for
assessing E T function is the need to make a differen­
tial diagnosis in a patient who has an intact T M
without evidence of OM but has symptoms that
might be related to E T dysfunction (such as otalgia,
snapping or popping in the ear, fluctuating hearing
loss, tinnitus, or vertigo). An example of such a case
would be a patient who has a complaint of fullness
in the ear without hearing loss at the time of the ex­
amination, a symptom which could be related to
abnormal functioning of the E T or could be due to
inner ear pathology. A tympanogram that reveals a
high negative pressure ( - 5 0 mm H2O or less) is
presumptive evidence of tubal obstruction, whereas
normal resting M E pressure is not diagnostically sig­
nificant. However, when the resting intratympanic
pressure is within normal limits and the patient can
develop negative M E pressure following Toynbee's
test or can perform all or some of the functions in
the 9-step inflation-deflation tympanometric test,
the E T is probably functioning normally. Unfortun­
ately, failure to develop negative M E pressure dur­
ing the Toynbee test or inability to pass the 9-step
test does not necessarily indicate poor E T function.
Tympanometry is not only of value in determining
if E T obstruction is present: it can also identify ab­
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WITH TESTING EUSTACHIAN TUBE FUNCTION 559
normality at the other end of the spectrum of E T
dysfunction; the presence of an abnormally patent
E T can be confirmed by the results of the tympano­
metric patulous tube test.
Screening for the presence of high negative pres­
sure in certain high-risk populations (ie, children
with known sensorineural hearing losses, develop-
mentally delayed and mentally impaired children,
children with cleft palates or other craniofacial
anomalies, American Indian and Eskimo children,
and children with Down syndrome) appears to be
helpful in identifying those individuals who may
need to be monitored closely for the occurrence of
OM."
Tympanometry appears to be a reliable method
for detecting the presence of high negative pressure
as well as of otitis media with effusion (OME) in
c h i l d r e n . " " T h e identification of high negative
pressure without effusion in children is indicative of
some degree of E T obstruction. These children as
well as those with M E E should have follow-up ser­
ial t y m p a n o g r a m s since they m a y be at risk of de­
veloping O M E .
However, the most direct method available to the
clinician today for testing E T function is the infla­
tion-deflation test. A perforation of the T M or a
tympanostomy tube must be present in order to per­
form this test. The test uses the simple apparatus
described earlier, with or without the electroacous­
tic impedance bridge pump-manometer system.
This test will aid in determining the presence or ab­
sence of a dysfunction, and the type of dysfunction
(obstruction vs abnormal patency) and severity of
dysfunction when one is present. No other test pro­
cedures may be needed if the patient has either
functional obstruction of the E T tube or an abnor­
mally patent tube. However, if there is a mechan­
ical obstruction, especially if the tube appears to be
totally blocked anatomically, then further testing
m a y be indicated. In such instances, retrograde-
prograde radiographic contrast studies of the E T -
M E , which are used primarily for research pur­
poses, can be performed to determine the site and
cause of the b l o c k a g e . ' In most cases in which
mechanical obstruction of the tube is found inflam­
mation is present at the M E end of the E T (protym-
panic or bony portion), which usually resolves with
medical management or M E surgery. Serial infla­
tion-deflation studies show resolution of the mech­
anical obstruction. However, if no M E cause is ob­
vious, other studies should be performed to rule out
the possibility of neoplasm in the nasopharynx.
Management. Patients with recurrent acute or
chronic O M E should have E T function studies as
part of their otolaryngologic workup. T h e manage­
ment of such patients may depend on the results of
these studies, as mechanical obstruction of the E T
may indicate treatment different from that for
functional obstruction. For instance, adenoidec-
560
tomy may not be indicated in a child with a small
adenoid mass and tubal function test results that in­
dicate functional obstruction; however, the opera­
tion may benefit the child with marked mechanical
obstruction of the E T . " ^ '
Patients in whom tympanostomy tubes have been
inserted may benefit from serial E T function
studies. Improvement in function as indicated by
inflation-deflation tests might aid the clinician in
determining the proper time to remove the tubes.
Cleft palate r e p a i r , " " adenoidectomy,^*" elimin­
ation of nasal and nasopharyngeal inflammation,'
treatment of a nasopharyngeal tumor, or growth
and development of a child^' may be associated
with improvement in E T function.
Studies of the E T function of the patient with a
chronic perforation of the T M may be helpful in
determining preoperatively the potential results of
tympanoplasty surgery. Holmquist^' studied E T
function in adults before and after tympanoplasty
and reported that the operation had a high rate of
success in patients with good E T function (ie, those
who could equilibrate applied negative pressure)
but that in patients without good tubal function
surgery frequently failed to close the perforation.
Miller and Bilodeau"" and Siedentop"' reported sim­
ilar findings but Ekvall,"^ L e e and Schuknecht,"^
Andreasson and Harris,"" Cohn et al,"' and Vir­
tanen et al"' found no correlation between the
results of the inflation-deflation tests and success or
failure of tympanoplasty. Most of these studies fail­
ed to define the criteria for "success" and the
postoperative follow-up period was too short. Blue-
stone et al"' assessed children prior to tympan­
oplasty and found that of 51 ears of 45 children, 8
ears could equilibrate an applied negative pressure
( - 2 0 0 mm HjO) to some degree, and in 7 of these
ears, the graft took, no M E E occurred, and no
recurrence of the perforation developed during a
follow-up period of between one and two years.
However, like the studies in adults, failure to
equilibrate an applied negative pressure did not
predict failure of the tympanoplasty.
The conclusion to be drawn from these studies is
that if the patient is able to equilibrate an applied
negative pressure, regardless of age, the success of
tympanoplasty is likely, but failure to perform this
difficult test will not help the clinician in deciding
not to operate. However, the value of testing a per­
son's ability to equilibrate negative pressure lies in
the possibility of determining from the test results if
a young child is a candidate for tympanoplasty
when one might decide on the basis of other fin­
dings alone to withhold surgery until the child is
older. These tests are also of value in the diagnosis
of severe or total mechanical obstruction, condi­
tions which contraindicate the performing of a my­
ringoplasty; further evaluation and medical or
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BLUESTONE-CANTEKIN
surgical management of such patients may be in­
dicated depending upon the condition of the ear.
When a tympanoplasty is performed and the func­
tion of the E T is thought to be poor, a tympan­
ostomy tube should be inserted.
In children and adults, tympanoplasty frequently
fails when performed on ears in which an acquired
cholesteatoma is present. This has been attributed
to poor E T function in these ears."' Bluestone et
g j 2 o , 4 8 reported that, using the modified inflation-
deflation and forced-response E T function tests,
they have found that in almost all subjects the E T
constricts during swallowing instead of dilating, as
it does normally. This abnormality is one involving
functional obstruction of the E T . However, pre­
operative testing of a patient with a cholesteatoma
can be helpful in deciding whether a tympanoplasty
should be performed and, if it is done, whether a
tympanostomy tube should be inserted at the time
of surgery. Eustachian tube function may be nor­
mal if the cholesteatoma is congenital,^" secondary
to t r a u m a (implantation), or present in an adult in
whom tubal function has improved following the
development of an acquired cholesteatoma in child­
hood.
Failure to obstruct the M E end of the E T sur­
gically at the time of radical mastoidectomy for the
eradication of cholesteatoma may result in trou­
blesome postoperative otorrhea secondary to reflux
of nasopharyngeal bacteria."' Assessment of E T
function by the inflation-deflation manometric
technique or by performing a Valsalva or Politzer
test (observing the manometer) is helpful in deter­
mining if the E T is still patent following a radical
mastoidectomy from which otorrhea is a postopera­
tive complication.
Failure to consider the function of the E T as a cri­
tical variable may be the reason why it is so difficult
to interpret the results of clinical studies of various
techniques advocated for surgical reconstruction of
the M E and mastoid. Prospective clinical trials that
include, among other important factors, controlling
for E T function, are urgently needed.
CONCLUSION
Even though the testing of E T function is not an
exact science and more research on such testing is
needed, the methods presently available to the clin­
ician provide useful information related to the diag­
nosis and management of M E disease. Not to in­
clude E T function testing as part of the modern
otorhinolaryngologist's diagnostic assessment of
selected patients is as irrational as failing to perform
laryngeal and pulmonary function tests in the diag­
nosis and management of patients with disease of
the lower respiratory tract.
 PANEL ON EXPERIENCES
A C K N O W L E D G M E N T S — T h e authors w o u l d like to thank S a n d i A r j o n a a n d D i a n a Mathis for assistance in p r e p a r a t i o n of the m a n u s c r i p t ; M a r g a r e t h a
C a s s e l b r a n t , M D , P h D , for assistance in analysis of portions of the d a t a ; J o n C o u l t e r for p r e p a r a t i o n of the a r t w o r k ; a n d V e r a Spector for technical
assistance.
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562 JAMES L. SHEEHY

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TESTING EUSTACHIAN TUBE FUNCTION

JAMES L. SHEEHY, MD

Los ANGELES, CALIFORNIA

This paper reviews the concepts, attitudes and experience at the Otologic Medical G r o u p ( O M G ) in regard to testing eustachian tube
function. At O M G eustachian tube function tests are not performed prior to reconstructive surgery in cases of chronic otitis m e d i a a n d the
reasons for this are reviewed. T h e lack of significant incidence of serous otitis m e d i a in postoperative patients substantiates the conclusion
that there is no rationale for preoperative eustachian tube function tests in patients who are to undergo reconstructive surgery for chronic
otitis media.

At the Otologic Medical Group (OMG) eusta­ tubing in the eustachian tube at the time of surgery.
chian tube function tests are rarely performed prior He concluded that closure of the eustachian tube
to surgery for correction of chronic otitis media. seriously limited the possibility of success in tym­
Our concepts of the role of the eustachian tube and panoplasty.
the lack of importance of preoperative tubal func­ By 1963 eustachian tube function tests were not
tion testing have evolved over a number of years. being performed in most cases. The approach at
These concepts are intimately related to, and have O M G was to operate, if indicated, regardless of pos­
modified, our philosophy of surgery for chronic sible tubal malfunction. It was felt that if the func­
otitis media. The O M G publications on this subject tion of the eustachian tube could not be reestablished
will be reviewed to demonstrate how and why these the tympanoplasty would not be successful.^ The
concepts have evolved. possibility of a two-stage procedure for gain in
hearing was mentioned indicating that we had be­
EARLY EXPERIENCES gun to think of the apparent eustachian tube prob­
lem more in terms of adequacy of the mucous mem­
In 1958, C o m p e r e , ' when he was closely asso­
brane. But it was some time before this concept was
ciated with O M G , worked with W. House on tym­
crystallized.
panic clearance studies using water-soluble radi­
opaque media. Compere commented that a "tubal The important word in the above p a r a g r a p h is
ear" m a y very well be a tubotympanic problem reestablished. We had learned that most of our pa­
rather than a nasal or nasopharyngeal problem, tients whose eustachian tube function was nil using
that obstruction of the tube may be due to mucous the C o m p e r e test, but who nonetheless required
membrane edema, granulations or inspissated mu­ surgery for elimination of disease, did well follow­
cus in the tubotympanum. Despite the now obvious ing tympanoplasty. This confirmed the concept
conclusion from this. House stated that if it could be stated in Compere's paper. As a result of this exper­
determined preoperatively that fluid would not ience we began in the early 1960s to perform sur­
drain through the eustachian tube, then the middle gery electively on patients generally thought to be
ear should not be closed by grafting procedures. poor risks in regard to eustachian tube function:
adults with a cleft palate repair or with a chronic si­
In 1960 W. House^ commented on the need for nusitis-bronchitis syndrome.
elimination of mucous membrane edema and gran­
ulations preoperatively and the use of polyethylene One of these cases demonstrated that our evolv-
F r o m the Otologic Medical G r o u p , I n c . , L o s Angeles. S u p p o r t e d by funds from the H o u s e E a r Institute, L o s Angeles.
Presented at the meeting of the A m e r i c a n Otological Society, I n c . , V a n c o u v e r , British C o l u m b i a , M a y 9-10, 1 9 8 1 .
ilEPRlNTS - J a m e s L . Sheehy, M D , 2122 West T h i r d Street, L o s Angeles, C A 9 0 0 5 7 .

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