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KAREN H.CALHOUNMDRONALD B.KUPPERSMITHMDNot Available
To serve and protect—the motto of many police departments—summarizes the functions of the eustachian tube. The timely review by Cliff A. Mergerian, MD, well presents the pros and cons of eustachian tube testing for pediatric tympanoplasty candidates.
N. Wendell Todd, MD
Eustachian tube services include ventilation (the maintenance of near-atmospheric middle ear pressure) and mucociliary clearance (the surface sweeping from middle ear into nasopharynx). The normal eustachian tube protects against reflux into the middle ear and from sniff-induced high negative middle ear pressure. Qualitative notions about service and protection, regarding both the eustachian tube and the police, are more readily available than are rigorous quantitative data.
Eustachian tube functions, at least qualitatively, are bilaterally symmetrical, even in patients with unilateral aural atresia.1 Knowledge of a patient's interear qualitative eustachian tube status is invaluable. That is, if the patient's better ear is clinically normal, then tympanoplasty in the contralateral ear will probably be successful. Conversely, if the patient's better ear is clinically abnormal, then tympanoplasty in the other ear will probably not yield good results. This idea is not new.2
Only the age of the patient was found, in the recent meta-analysis, to significantly correlate with successful pediatric tympanoplasty.3 Since age presumably correlates better with skeletal growth than with either changing immune status or mucosal health, and since skeletal growth (as measured by the child's growth along his/her height chart) presumably correlates with cranial base and eustachian tube growth, the idea has been offered that the likelihood of successful tympanoplasty reaches a plateau when the child stops growing.
In the child with bilateral tympanic membrane perforations, when tympanoplasty is being considered, are eustachian tube tests helpful? A successful tympanoplasty, some argue, is itself an indicator of adequate eustachian tube status. More stringently, others argue that a clinically normal middle ear, able to withstand the barotrauma challenges of aircraft travel and scuba diving, is the "gold standard" of eustachian tube adequacy. Many clinicians wisely hesitate to recommend tympanoplasty for a child, worrying that the long-term result does not justify the costs and hope lost. A comparative success (for example, attaining serviceable hearing, though a small perforation persists) may justify tympanoplasty for some patients. Of course, bilateral traumatic, or iatrogenic perforations of the tympanic membranes in the child without clinically significant prior otitis (that is, the child with good eustachian tube status) are satisfactory for surgery at a young age; normal temporal bone pneumatization seems to help identify these few patients.
The usefulness of a test depends on both the consistency and accuracy of the test, ie, getting the same result and the correct result, respectively, time after time. The precision and accuracy of "time to taste saccharin" in pediatric tympanoplasty candidates are unknown. Indeed, presently available tests of eustachian tube function are incomplete; they are inadequate to facilitate clinical care of patients with tympanic membrane perforation.
Todd NW. There Are No Accurate Tests for Eustachian Tube Function. Arch Otolaryngol Head Neck Surg. 2000;126(8):1041–1042. doi:10.1001/archotol.126.8.1041
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