By Dr Holly McGuigan (Specialty Doctor in Palliative Medicine, Strathcarron Hospice) and Dr Ruth Isherwood (Consultant in Palliative Medicine, Cornhill Macmillan Centre, Perth)
Twitter: @cloudy_lemonade
“I’m sorry, what?”
“Patulous Eustachian Tube”, came the reply from my prospective Masters supervisor.
“I’m sorry but I have no idea what you’re talking about…”
And so began an obsession with a part of the body I hadn’t thought about since medical school.
What’s a Eustachian tube and how does it become Patulous?
Thanks for asking!
The Eustachian tube is the small passageway that connects your throat to your middle ear. Under normal resting conditions it is held closed by the pressure of surrounding tissues and opens when you sneeze, swallow, or yawn.
A Patulous Eustachian Tube (PET) is one that stays open all the time. This causes external sounds to seem muffled and causes an abnormal awareness of ‘internal sounds’ such as your own breathing and speech [1].
How common is it?
More common than you’d think!
Rapid weight loss causes the fatty tissues holding the Eustachian tube closed to shrink leading to PET. Because of this association we thought that PET would be more common in patients with advanced cancer so we did a study to find out.
We recruited 36 participants with cancer (24 women and 12 men). Participants were aged between 52 and 92 years (mean=70.7). The participants had a range of primary cancers and most (25 of the 36) had metastatic disease.
Patients with PET were identified using the Eustachian Tube Dysfunction Questionnaire (ETDQ-7), otoscopy and tympanometry.
A diagnosis of PET was made in seven (19.4%) of the 36 participants in the study. This is much higher than the general population prevalence of 0.3-6.6% [2,3,4]
What did the patients have to say about it?
We conducted interviews with five participants and identified several themes.
Theme 1: Patient Experience of Symptoms
Participants described hearing loss as the initial symptom.
“Sometimes it’s like talking through a fog, ken. Just like it’s like a vacuum. It’s weird I can’t explain it.” (Participant 5)
Two participants described feeling as though their ears were closed or blocked.
“I feel as though somebody’s stuck a bit of cotton wool in there and not taken it out. It’s just dulled your hearing a bit.” (Participant 4)
Theme 2: Communication
All participants spoke about adaptations that their families or friends made to aid communication.
“I’ve got to try to be face to face… I’m picking up the wrong thing that they are saying if they are not directly beside me” (Participant 1)
Participants described the emotional impact of their communication difficulties. The majority of participants expressed a fear of missing parts of conversations and spoke of this making them feel dissociated from their loved ones.
Theme 3: Understanding
Most participants spoke about wanting to understand the cause of their symptoms rather than simply being offered aids to manage hearing loss.
Two participants expressed concern that the underlying cause of hearing impairment was brain metastases.
Theme 4: Acceptance and Stigma
Significant stigma was identified regarding hearing loss.
“I wouldn’t like to be deaf, I really wouldn’t like to be deaf. Honestly, I wouldn’t like to be deaf….” (Participant 3)
Theme 5: Hearing Aid Experiences and Perceived Futility
There were several comments related to body image and stigma associated with hearing aids. Participants who had tried hearing aids didn’t find them useful.
“Well I did get a hearing aid but it doesn’t work properly so I don’t bother with it” (Participant 5)
Why should it matter to me?
In palliative medicine we spend a lot of time paying careful attention to the words we say but it’s equally important that patients can hear our carefully chosen words!
Patients with PET may struggle in discussions held in a large group e.g. discharge planning meetings. Patients may also struggle to understand what is being said to them in noisy ward environments. It is important that these issues are considered, and that adaptations are made to allow effective communication.
Now that I know what you’re talking about what changes can I make to my practice?
- A history of weight loss should prompt you to ask about symptoms of PET. The main symptoms are muffled hearing and the patient’s own voice or breathing seeming loud.
- Your suspicion can be confirmed with otoscopy. The typical finding is the tympanic membrane moving with respiration.
- Unfortunately, there is no standard treatment for PET and hearing aids don’t typically help but that doesn’t mean there is nothing you can do:
- Explaining the condition to patients can be reassuring especially if they are worried that the condition is related to brain metastases.
- Adapt your communication style e.g. have conversations in smaller groups or in quieter environments, clarifying understanding and providing written information when possible.
References
- Schilder AGM, Bhutta MF, Butler, et al. Eustachian tube dysfunction: consensus statement on definition, types, clinical presentation and diagnosis. Clin Otolaryngol 2015;40:407–11.
- Henry DF, Dibartolomeo JR. Patulous Eustachian Tube Identification Using Tympanometry. J Am Acad Audiol 1993;4:53–7.
- Bunne M, Falk B, Magnuson B. Variability of Eustachian Tube Function: Comparison of Ears With Retraction Disease and Normal Middle Ears. Laryngoscope 2000;110:1389–95. doi:10.1097/00005537-200008000-00032
- Schilder AGM, Bhutta MF, Butler, et al. Eustachian tube dysfunction: consensus statement on definition, types, clinical presentation and diagnosis. Clin Otolaryngol 2015;40:407–11.