Patulous Eustachian Tube: Part 2
Most clinical descriptions of Patulous Eustachian Tube (PET) report a variety of complaints.1 The complaints range from a minor, occasional clicking or popping of the eustachian tube that may occur several times in a year, as is the case with a nurse in our office; to a constant, overwhelming complex of symptoms including a dis-equilibrium, that can make the accomplishment of basic life responsibilities difficult or impossible for the patient. This case report describes a patient who used a cervical traction device that may likely have initiated Patulous Eustachian Tube and as well as several craniofacial conditions that occurred at the same time.
A female patient, approximately fifty years of age, presented for examination and assessment for left-sided head and face pain and ear symptoms of six months duration. She also presented with signs and symptoms of an accessory nerve deficit of the left side, characterized by significant atrophy of the left trapezius and left sternocleidomastoid muscles. Neurologic assessment and imaging studies suggested idiopathic etiology.
The patient connected the onset of her present symptoms with the utilization of a mechanical cervical traction device that utilized hydraulic pressure as the means of applied leverage. The device was strapped to the base of the cranium and to the posterior margins of the ascending rami of the mandible bilaterally (gonial angle). When distraction relieved discomfort in the cervical region, it created a lot of pressure on the lower jaw resulting in a new set of symptoms. The patient described the new symptoms as being unrelated to the original cervical complaints.
The patient listed her new complaints as pain in the head, lower jaw, teeth, lip, nose, and throat, and ear—all mostly on the left side. The pain was constant, aching, shooting, burning at times, along with pressure and pain at the ear with lots of clicking and popping sounds.
My examination revealed left-sided pain at the lateral and medial temporal tendon insertions, pain at the soft palate, and pain at the insertion of the left stylomandibular ligament at the rear of the mandible. At the time, I had no idea why the patient suffered the ear complaints and assumed that the ear complaints may be secondary to the temporal tendon and stylomandibular ligament (SML) injury. However, the ear complaints became more defined once the temporal tendon and SML symptoms were resolved.
Local anesthetic blockade of the lateral and medial temporal tendons alleviated the headache and facial pain of the left side, but did not stop the ear pain and pressure, nor the popping or clicking at the ear. A separate infiltration of the stylomandibular ligament insertion stopped the gonial angle pain but did not affect the ear pain, pressure or popping. At the time, I did not give much attention to the popping since I had no answer for it. However, the patient continued to be concerned about the popping and clicking and the bother that it caused her.
Repeated local anesthetic infiltration of the left temporal tendons and the stylomandibular ligament insertion temporarily stopped the painful symptoms of headache, facial pain, ear pain, and retro-orbital pain. The patient elected to have radiofrequency thermoneurolysis (RFTN) of the temporal tendon insertions with the result being elimination of headache, facial pain, and eye pain. The gonial angle pain was still a present complaint and after several weeks of palliative treatment the patient requested a more permanent solution using RFTN for the stylomandibular ligament pain.
After several weeks of follow-up to evaluate the results of RFTN, the patient called and said that she had discovered what was wrong with her ear and her swallowing. She indicated that she had found information on the internet that helped to explain her ear and swallowing symptoms. She had read about Patulous Eustachian Tube and thought it described her ear problem. It seems that the elimination of the pain symptoms associated with temporal tendonitis and stylomandibular ligament injury (Ernest Syndrome) helped her to identify and define her ear and swallowing complaints. She returned to our office and the eustachian tube was examined. With each swallow she had a loud clicking sound that also occurred when she turned her head.
Note that the average person swallows about two thousand times a day. This patient was hearing the click or pop sound every time that she swallowed or turned her head. Additionally, now that the RFTN procedures had eliminated musculoskeletal symptoms, she was able to better describe a pain referral pattern that occurred with her swallowing. When awakening in the mornings, she had no pain in the ear, palate or throat, but as the day’s clicking and popping progressed, around two or three in the afternoon, pain—often with a slight burning quality—would start in her ear, soft palate and lateral throat wall and would increase into the evening until she retired for sleep. She had noted a pattern where the clicking or popping “seemed” to locate in the roof of mouth, then as the roof of mouth started burning, the sound “seemed” to move to the nose, rear of head, and then to the angle of the jaw at submandibular area. The patient also has sensations at times of an air bubble in the eustachian tube that seemed to travel upward to the ear. She had been evaluated neurologically as a result of falling at home but there had been no answer for the episodes. She thought the dis-equilibrium was also caused by the Patulous Eustachian Tube.
“I want to emphasize that, with this patient, the clicking or popping was very audible externally to me as the examiner and to the nurse who assisted me. The intensity of the various sounds bouncing off the eardrum is very loud and distracting to the patient.”
Again, I want to emphasize that, with this patient, the clicking or popping was very audible externally to me as the examiner and to the nurse who assisted me. The intensity of the various sounds bouncing off the eardrum is very loud and distracting to the patient. This patient has bilateral pops or clicks, one side first, then the other side, but not at the same time. She describes the left side as by far the worst and the most distressing.
The pattern of pain was consistent throughout the week and weekends. Pain would start in the early afternoon and increase until sleep. Placing her head between her legs would stop the clicking and the pain as well. It is my opinion that the onset of progressive ear and palatal pain starting about two or three in the afternoon was a result of progressive fatigue of the tensor levi palatini and the levator veli palatini muscles, and possibly the tensor tympani muscle. During the sleep period, the rate of swallowing is greatly reduced—approximately one fourth to one fifth of the day time rate—and the clicking or popping often stops while lying down, perhaps giving rest to the eustachian tube muscles.