Does Removing the Adenoids Decrease Risk of Ear Infections? Yes...

A recent meta-analysis has determined that risk of recurrent ear infections is significantly reduced if adenoidectomy is performed in combination with ear tube placement as opposed to ear tube placement alone. When stratified by age, removing the adenoids was found particularly helpful in children older than 4 years of age.

Combining results from over 15 studies containing over 71,000 children, the estimated rate of repeat ear tube placement for recurrent ear infections in children who also had adenoidectomy was only 17.2% vs 31.8% for children undergoing ear tubes alone. However this significance faded under the age of 4 years.

Why would adenoid removal influence ear infections?

First a little anatomy lesson...

In the back of the nose, there is an opening called the eustachian tube that goes up into the ear. That's why one is able to pop the ears when blowing into a pinched nose.

Image by Chittka and Brockmann from Wikipedia

The adenoids are located in the back of the nose immediately behind the eustachian tube opening. The adenoids can potentially lead to ear problems via two mechanisms. First, the adenoids could be very enlarged causing physical obstruction of the eustachian tube which can make it impossible to pop the ears. Second, the adenoids could be a reservoir of germs which can lead to ear infections given proximity to the eustachian tube.

As such, removal of the adenoids would allow the eustachian tube to function better as well as eliminate a potential reservoir of infection.

However, recommendation for adenoid removal typically occurs if a child requires a 2nd set of tubes which usually occurs around age 4. Adenoidectomy may be recommended with the initial set of ear tubes (after taking into consideration age) if other symptoms are present including nasal obstruction and a snotty nose.


Reference:
Adenoidectomy as an Adjuvant to Primary Tympanostomy Tube Placement: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. 2013 Nov 28. doi: 10.1001/jamaoto.2013.5842. [Epub ahead of print]

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Why Is Eustachian Tube Balloon Dilation to Treat Eustachian Tube Dysfunction Slow to Catch On?

Eustachian tube dysfunction is a phenomenon whereby a person is unable to pop their ears to relieve symptoms of ear pressure, clogging, or fullness. It is much akin to the ear pressure a person experiences when flying, but at ground level. Traditionally, treatment of this condition involved medications like steroid nasal sprays and prednisone along with active valsalva (watch video below). Once medical treatment has failed, ear tube placement has been the step of last resort.

However, a promising new treatment called eustachian tube balloon dilation has been described in March 2011 to address eustachian tube dysfunction at the source (the eustachian tube) surgically rather than indirectly with tube placement across the eardrum. In essence, a balloon is inserted into the eustachian tube and than inflated thereby opening it up (the balloon is "popping" the ear for you). The balloon is than deflated and removed.

Dr. Dennis Poe in Boston, MA is the researcher who first described this technique in March 2011 and at this time, is offered only in a few centers.

Why has something so simple with equipment so readily available been so slow to gain acceptance by ENTs?

Well, there are several reasons, not the least of which is the fact that this procedure is still considered "experimental" and in the research stage only.

However, there is the cost of the balloon itself which is typically not covered by insurance even if a patient wishes to proceed with an unproven treatment. The material cost of the balloon is around $2000 or more. Compare this to the cost of a tube which is around $30 or less. In other words, hospitals would lose money by offering this procedure with current fee schedules.

Furthermore, there are potentially huge, albeit rare risks associated with balloon dilation of the eustachian tube. These risks are clearly reported by Dr. Dennis Poe who "invented" this procedure in his landmark paper.

The internal carotid artery supplies blood to the brain and can be found right next to the eustachian tube. Take a look at this CT scan of the ear:

ET is the eustachian tube and ICA is the (internal) carotid artery. These structures are found right next to each other!

The balloon catheters used for eustachian tube dilation have a fairly pointy tip (though not sharp), but when placed in a directed fashion inside of small diameter tunnel like the eustachian tube, there is the chance that the catheter tip may puncture or injure the carotid artery leading to risk of:

1) horrible bleeding
2) stroke
3) arterial wall dissection or aneurysm formation
4) death

In most individuals, there is a thin layer of bone that separates the carotid artery from the eustachian tube that does proffer some protection. But, this bone is not always present and therefore can not be counted on to protect the artery from any unintentional injury.

So to summarize, given ear tube placement has profoundly less risk, much cheaper, and long history of effectiveness compared to balloon dilation of the eustachian tube which has significant risks, expensive, and unproven long-term results, it is actually no wonder that the balloon method has been slow to gain acceptance.

Indeed, in another published article, it specifically states balloon sinuplasty to be a "gizmo" of uncertain safety and efficacy... in fact, the title of the article says it all "Balloon Dilation of the Eustachian Tube Is Indeed a 'Gizmo' Until Future Research Proves Safety and Efficacy."


Reference:
Balloon Dilation of the Cartilaginous Eustachian Tube. Otolaryngol Head Neck Surg April 2011 vol. 144 no. 4 563-569

Balloon catheter dilatation of eustachian tube: a preliminary study. Otol Neurotol. 2012 Dec;33(9):1549-52. doi: 10.1097/MAO.0b013e31826a50c3.

Balloon Dilation of the Eustachian Tube Is Indeed a "Gizmo" Until Future Research Proves Safety and Efficacy.Otolaryngol Head Neck Surg. 2014 Jun 3. pii: 0194599814538232.

Balloon Dilation of the Cartilaginous Portion of the Eustachian Tube. Otolaryngol Head Neck Surg. 2014 Apr 4;151(1):125-130. [Epub ahead of print]

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How Can Nasal Obstruction CAUSE Clogged Ears?

It is not uncommon that patients who suffer from a clogged nose also develop clogged ears.

Why??? There are 2 major and 1 minor reasons.

First a little anatomy lesson.

In the back of the nose, there is an opening that leads into a tunnel (eustachian tube) that goes up into the ear. When the ears get clogged, a person can get the pressure out by "popping the ears." This can be accomplished by yawn, swallow, or trying to blow out the nose that is pinched shut. When the ear pops, what happens is that the tunnel opens up allowing pressure to come out the ear. Watch video:



Mucosal Swelling

Now when the patient's nose gets obstructed, it may mean the nasal lining has become swollen making it difficult to breath. It also means the tunnel that goes up into the ear may be swollen shut as well. As such, it may become difficult if not impossible to pop the ears. This is known as eustachian tube dysfunction.

Negative Pressure Inside the Nose

However, there is a more active process that may lead to ear clogging beyond just mucosal swelling of the eustachian tube.

When the nose is obstructed, every time the patient tries to breath in thru the nose, negative pressure is built up in the back of the nose where the eustachian tube opening is located. As such, this negative pressure inside the nose can get transmitted up into the ear resulting in negative pressure to slowly build up in the ear as well which can ultimately cause a clogged ear sensation. This is just like sucking on a straw to draw fluid out of a cup, though in this case, the straw is analogous to the eustachian tube, the fluid is air, cup is the ear, and the mouth is the nose.

Bernoulli's Principle

In fluid dynamics, Bernoulli's principle states that for an inviscid flow, an increase in the speed of the fluid occurs simultaneously with a decrease in pressure.

To use an example, if you are driving a car with the window down, the fast-moving air outside the car creates a negative pressure inside the car causing things to not just blow around, but does cause some suction effect to things within the car (paper inside the car potentially getting "sucked" to the outside).

When the nose becomes clogged, airflow increases in the back of the nose (think garden hose where you have the same amount of water flow, but by changing the nozzle diameter, flow can be increased by making diameter smaller or decreased by making diameter larger). Due to Bernoulli's principle, negative pressure builds up inside the ear due to this increased nasal airflow.

This negative pressure can be transmitted into the ear causing it to become clogged.

So there you have it... 3 reasons why a clogged nose can lead to clogged ears!

That also means that often, if you just treat the clogged nose... the clogged ears will get better as well!

Reference:
Upper airway obstructions and chronic otitis media: A clinical study. American Journal of Otolaryngology - Head and Neck Medicine and Surgery. Volume 35, Issue 3 , Pages 329-331, May 2014

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Devices That Help Fix Clogged Ears

Clogged ears due to eustachian tube dysfunction or fluid in the ears is one of the most common complaints seen in an ENT clinic. Beyond medications like steroids & nasal sprays or even surgery (ear tubes) to resolve this complaint, a fundamental physical maneuver the patient MUST also be doing is called "valsalva". Valsalva is the attempt to "pop" the ears by yawn, swallow, or attempting to gently blow air out the nose that is pinched shut.

The yawn and swallow are passive maneuvers to pop the ear whereby trying to gently blow air out the nose while keeping it pinched shut to create intra-nasal pressure is an active maneuver.

The key concept is that medications do not pop the ears for you... YOU have to pop the ears yourself. Medications just help accomplish this task.

Typically, when things are truly clogged and it is very difficult if not impossible to pop the ears open, actively trying to pop the ears open is key. Yawning and swallowing typically is ineffective.

However, there are patients who can't quite grasp the idea of HOW to pop the ears by nose pinching. OR, they are too scared that they might rupture their eardrums (which could happen if the nose-blowing is too aggressive).

Furthermore, what about the 2 years old who doesn't even understand how to nose-blow let alone valsalva?

As such, there are two main devices to perform the active valsalva for such individuals. Please note, I have no financial ties to either companies to disclose.

Otovent

The first is a simple balloon called Otovent (can be purchased on Amazon). In essence, you snug the balloon up against the nose and try to inflate the balloon up. The balloon itself provides the necessary and sufficient back-pressure into the nose resulting in an active valsalva. This is mainly used by children who can appreciate the visual feedback.

EarPopper

The second is an electronic device, EarPopper (also can be purchased on Amazon), that pushes air into the nose. So, rather than having the lungs "push" air into the nose to create intra-nasal air pressure, this device replaces the lungs and pushes air into the nose from the front. This device comes in two flavors: Home and Pro versions.

Please keep in mind that there's another electronic device which supposedly helps with ear popping called EarDoc which is not recommended as it uses an unproven concept.

So there you have it...

Read more about this condition here.

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Video of Eustachian Tube Popping Open with Valsalva

Ever wonder what the eustachian tube looks like when the ear pops open with valsalva maneuver? Valsalva is accomplished by trying to blow air out a nose that is pinched closed. The eustachian tube is a tunnel that goes from the back of the nose to the ear.

Well, here you go! Video provided courtesy of Dr. Vijay Anand.

Watch this video to see where this eustachian tube is exactly located.

Read more about ear popping and when one is NOT able to pop the ears, a condition called eustachian tube dysfunction!

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Video on Ear Clogging and What Happens When They Pop Open (or Don't)

A new video has been created describing anatomically how a person pops the ear open when it feels clogged or under pressure. Also explained is what happens anatomically when the clogged ear is very difficult if not impossible to pop open; a condition called eustachian tube dysfunction.

Check the video out here!

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Laryngospasm and Vocal Cord Dysfunction Video

A new video has been uploaded showing what happens inside the throat when a patient suffering from laryngospasm or vocal cord dysfunction suffers from a breathing attack.

For more information on this condition, click here.

If you are unable to watch the video below, click here to watch it on YouTube.

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