Original Study
Transtympanic Tripod-shaped Angiocatheter Insertion for Patients
With Intractable Patulous Eustachian Tube
yJung Mee Park, yJae Sang Han, zSo Young Park, and yShi Nae Park
Department of Otorhinolaryngology-Head and Neck Surgery, Gangneung Asan Hospital, College of Medicine University of Ulsan,
Gangneung; yDepartment of Otolaryngology-Head and Neck Surgery, Seoul St. Mary’s Hospital; and zDepartment of
Otolaryngology-Head and Neck Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Republic of Korea
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Objective: Despite the efforts to treat patients with patulous
Eustachian tube (PET), intractable symptoms of PET may
require surgical intervention. In this study, we introduce our
surgical technique of ‘‘transtympanic tripod-shaped angio-
catheter’’ (TTA) insertion and evaluate the safety and
efficacy of the procedure in patients with intractable PET.
Study design: Retrospective chart review.
Setting: Tertiary referral center.
Patients: Thirty-two cases (26 patients) diagnosed with
intractable PET between the years 2011 and 2019 were
included in this study.
Intervention: All cases were surgically treated with TTA
insertion.
Main outcome measures: The clinical characteristics, surgi-
cal results, complication rates, and the level of satisfaction
by questionnaires were analyzed for evaluation.
Results: The mean age of enrolled patients was
40.9  19.5 years, with slight male gender predominance
INTRODUCTION
The Eustachian tube (ET) is an anatomic osseocarti-
laginous structure surrounded by muscles and fat,
ascribed by Antonio Valsalva in 1704 (1). One of the
main functions of the ET is the regulation of pressure in
the middle ear cavity via dynamic tubal opening and
closing. The patulous Eustachian tube (PET) is defined as
abnormal patency of the tube and is thought to be caused
by a longitudinal concave defect in the mucosal valve at
Address correspondence and reprint requests to Shi Nae Park, M.D.,
Ph.D., Department of Otolaryngology-Head and Neck Surgery, Seoul
St. Mary’s Hospital, College of Medicine, The Catholic University of
Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea;
E-mail: snparkmd@catholic.ac.kr
The design of this retrospective study was reviewed and approved by
the institutional review board of the associated institution (IRB No.
KC16RISI0544 of Seoul St. Mary’s Hospital, the Catholic University of
Korea).
The authors disclose no conflicts of interest.
Supplemental digital content is available in the text.
DOI: 10.1097/MAO.0000000000003254
ß 2021, Otology & Neurotology, Inc.
Copyright © 2021 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
(59.4% vs. 40.6%). Both ears were operated in six patients,
simultaneously in three. All patients successfully received
the insertion of TTA, with no immediate complication.
Eleven cases were re-inserted after the first insertion due to
the recurrence of symptoms or spontaneous extrusion of
TTA. No major complications were observed during the
follow-up period of 1 to 115 months (mean 37.7 mo). The
average Visual Analogue Scale score of PET symptoms was
significantly decreased ( p < 0.05), along with 92% of
patients with relief from autophony symptoms.
Conclusions: TTA insertion is a relatively simple procedure
that can be performed in a short period under local
anesthesia. Surgical intervention of TTA insertion for
patients with intractable PET symptoms seems promising
with a high success rate. Key Words: Intervention—
Patulous eustachian tube—Transtympanic.
Otol Neurotol 42:e1273–e1278, 2021.
the superior aspect of the anterolateral wall due to loss or
atrophy of adipose tissue surrounding ET (2). Such
conditions may be related to environmental allergy,
weight loss, laryngopharyngeal reflux, neurological dis-
order, pregnancy, and hormone replacement therapy (3).
Patients with PET experience troublesome symptoms
such as autophony, ear fullness, humming tinnitus, and
hearing one’s breathing sounds known as tympanophonia
that is synchronous with respiration (2,3). The continuous
symptoms of PET may lead to anxiety, depression, and
social isolation. Conservative treatments that include
lifestyle changes, as well as some medications, were
reported to be somewhat effective in controlling the
symptoms, and various surgical procedures that manipu-
late the tympanic membrane or occludes the lumen of the
ET by several materials have been introduced in the
literature for severe cases (4,5). Despite the efforts, there
is no consensus on the management of intractable PET
since published literature depends on small case series
studies with various intervention techniques (5).
In this study, we introduce ‘‘transtympanic tripod-
shaped angiocatheter’’ (TTA) insertion for intractable
e1274 J. M. PARK ET AL.
PET patients in a long-term follow-up study by analyzing
its safety and efficacy, as well as complications following
this procedure.
MATERIALS AND METHODS
Enrolled Subjects and Assessments
A total of 32 PET cases from 26 patients who received TTA
insertion between the years 2011 and 2019 at a tertiary hospital
were enrolled for a retrospective analysis after obtaining
approval from the institutional review board. The CARE Case
Report Guidelines (https://www.equator-network.org/repor-
tingguidelines/care/) were followed for this study.
Patients were diagnosed with definite PET if they satisfied
all of the following inclusion criteria: 1) observation of syn-
chronous to and fro movement of the tympanic membrane
during ipsilateral forced nasal breathing under oto-endoscopic
examination (Appendix 1 [the to and fro movement of the
tympanic membrane during forced nasal breathing of PET
patient demonstrated under oto-endoscopic examination],
http://links.lww.com/MAO/B292); 2) perturbation of imped-
ance tympanogram during breathing (Fig. 1A); 3) ringing of
‘‘m’’ and ‘‘n’’ vocal sounds auscultated through the Toynbee
tube by the examiner. Preoperative CT scans and audiometry
were also performed to evaluate any abnormalities in the middle
ear and the Eustachian tube, as well as for the superior semi-
circular canal dehiscence which can present with similar symp-
toms (Fig. 1B). All enrolled patients were definite and
‘‘intractable’’ PET patients, who were nonresponders to con-
servative treatments that included behavior therapy such as
drinking sufficient water and inducing weight gain, use of
anticholinergic nasal spray, and minor surgical intervention
that included paper patching or myringotomy with/without
ventilation tube insertion for at least 3 months. Outcomes of
TTA insertion were assessed by Poe’s autophony scoring
system (Appendix 2, http://links.lww.com/MAO/B326) (2)
and 5-item questionnaires with Visual Analogue Scale
(VAS) (Appendix 3, http://links.lww.com/MAO/B326) modi-
fied from the Cambridge ETD Assessment (6) 2 weeks after the
FIG. 1. (A) Impedance tympanogram assessed during respiration in a PET patient. Severe sawtooth-like perturbations are shown. (B)
Preoperative temporal bone CT scan showing a relatively wide bony portion of the Eustachian tube. (Red box) Anatomical variations of air
cells adjacent to the Eustachian tube may interfere with the smooth insertion of TTA and should be checked preoperatively. PET, patulous
Eustachian tube. TTA, transtympanic tripod-shaped angiocatheter.
Otology & Neurotology, Vol. 42, No. 9, 2021
Copyright © 2021 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
final surgery. Clinical characteristics of the enrolled patients
and clinical courses after TTA insertion were evaluated retro-
spectively.
Design of TTA and Surgical Technique
Angiocatheters of 16, 18, and 20 gauges were aseptically
prepared previous to surgery. The inner space of each angio-
catheter was filled with liquified bone wax through a syringe.
After bone wax was solidified, the catheter was tapered accord-
ing to the approximated length of the patient’s ET determined
by the preoperative CT. To prevent spontaneous extrusion of
angiocatheter into the nasopharynx, the tapered, lateral end of
the catheter was cut into a tripod shape to work as an anchor.
Therefore, the final length of the catheter was the distance from
the isthmus to the bony orifice of the ET, with 2.5 mm added for
the tripod shape (Fig. 2). This specially designed catheter was
named ‘‘TTA,’’ as described in our previous case report in the
year 2014 (7). The surgery was performed under local anesthe-
sia. After making a small linear incision on an anterosuperior
portion of the tympanic membrane, the inner diameter of the ET
was approximated by inserting three different sizes of blunt-
ended lacrimal probes into the tympanic orifice of ET that
matched 16, 18, and 20 gauge angiocatheters. The most tightly
fitting gauge was chosen for the patient. The selected gauge
TTA was then slightly bent for the natural curvature of ET and
was slowly inserted into the tympanic orifice. Finally, the
myringotomy site was covered using a paper patch.
Ethical Considerations
All enrolled patients were fully informed of the surgical
techniques and provided written informed consent at the time of
surgery. The design of this retrospective study was reviewed
and approved by the institutional review board of the associated
institution.
Data Availability Statement
An anonymized data that support the findings of this study
are available from the corresponding author upon request.
 TRANSTYMPANIC ANGIOCATHETER INSERTION FOR PATULOUS EUSTACHIAN TUBE
FIG. 2. (A) A schematic illustration of inserted TTA in a Eustachian
tube. (B) A picture of an actual 18-gauge angiocatheter filled with
bone wax. The tip is cut into a shape of a tripod for firm anchoring.
(C) An inserted TTA in a Eustachian tube is demonstrated in the
axial view of the temporal bone CT scan postoperatively (white
arrows). TTA, transtympanic tripod-shaped angiocatheter.
RESULTS
The mean age of 26 enrolled patients was 43.2 years
(range, 20–75 yrs). The age distribution showed that
53.8% of the patients were in their 20s to 30s, with the
remaining patients (46.2%) in their 50s or older (Fig. 3).
The male to female ratio was 17 to 9 (59.4% vs. 40.6%),
and the right to left ear ratio was 12 to 20. Six patients were
operated bilaterally, simultaneously in three patients. All
patients complained of aural fullness and autophony, as
92.3% of the patients experienced tympanophonia, fol-
lowed by pulsatile ‘‘crackling’’ tinnitus in 76.9%. Possible
etiologies of PET included weight loss (53.8%), allergy
(23.1%), laryngopharyngeal reflux (11.5%), and autoim-
mune disease (3.8%). Three patients (11.5%) developed
PET symptoms with unknown etiology. The mean conser-
vative treatment period before TTA surgery, which
included lifestyle modification, medication, and minor
surgical intervention, was 7.2  13.2 months (range, 3–
72 mo). Enrolled patients were followed up for 37.7 
36.2 months on average (range, 1–115 mo).
FIG. 3. The age distribution of enrolled patients shows 2 clusters;
the first cluster in the 20s to 30s, the second cluster in the 50s and
above.
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e1275
The size of the inserted angiocatheter ranged from 16 to
20 gauges. Out of 32 cases, 20 cases were inserted with
16 gauge angiocatheter, 10 cases were inserted with 18
gauge angiocatheter, and two cases were inserted with 20
gauge angiocatheter at the time of their final surgery. The
length of angiocatheter determined by the preoperative
CT varied from 20 to 28 mm. There was no statistically
significant correlation between the size of the selected
TTA and the diameter of the bony ET estimated from the
temporal bone CT ( p ¼ 0.542). The size of TTA did not
correlate with the gender of the patients either
( p ¼ 0.467). However, male patients were tended to be
inserted with the thicker TTA, as 68.4% of male patients
were inserted with the thickest, 16-gauge, angiocatheter
compared to 58.3% in females. The size and length of the
TTA did not affect the patient’s final satisfaction score
( p ¼ 0.119 and p ¼ 0.152, respectively).
The symptoms of PET were resolved entirely with a
single insertion of TTA in 21 cases out of 32 operated
cases (66%), whereas 11 cases were re-operated due to
recurrence of symptoms (nine cases) and spontaneous
extrusion of TTA into the nasopharynx (two cases). The
recurrent PET symptoms of the re-operated patients
occurred as short as within 3 days, up to 18 months
postoperatively. Although the majority of enrolled
patients were inserted with TTA once or two times
(90.6%), three cases were re-inserted with TTA up to
four times with a larger size angiocatheter than previous
surgery. The replacement was proceeded with the same
surgical technique as the first insertion, as the previously
inserted TTA could be easily removed with microforceps
through the myringotomy site. One patient who continu-
ously complained PET symptoms was re-inserted with
TTA for the 4th time with the thickest, 16 gauge,
angiocatheter wrapped up with a tragal perichondrium
to nearly close the ET passage. The final diameter of
angiocatheter wrapped up with a tragal perichondrium
was approximately 2 mm. The patient showed no signs of
recurrence or complication during the 8-year follow-up
period after the final surgery.
The most common complication after TTA insertion
was otitis media with effusion (OME) (n ¼ 10, 31.3%),
followed by tympanic membrane (TM) perforation (n ¼ 3,
9.4%), and TM retraction (n ¼ 1, 3.1%). Seven patients out
of 10 patients who developed OME during the follow-up
period were resolved of their symptoms spontaneously
within 3 months; the remaining three patients eventually
underwent ventilation tube insertion. All three patients
with TM perforation received a paper patch at the perfo-
ration site as soon as it was confirmed. All TM perforation
cases were resolved within 6 months. One patient com-
plained of severe foreign body sensation after severe acute
sinusitis and showed recurrent otitis media with intermit-
tent otorrhea. The patient’s TTA was removed 3 years after
the insertion. No patient showed major complications
intra-operatively or postoperatively, such as foreign body
reaction. The incidence of complications was not statisti-
cally related to the gender of the patients ( p ¼ 0.474) nor
the gauge of inserted TTA ( p ¼ 0.417).
Otology & Neurotology, Vol. 42, No. 9, 2021
e1276 J. M. PARK ET AL.
FIG. 4. The autophony scores after TTA shows improvement in
92% of the enrolled patients. TTA, transtympanic tripod-shaped
angiocatheter.
At their final follow-up visit, 92% of the 27 cases
followed up for more than 6 months showed relief from
autophony after TTA insertion, according to Poe’s
autophony scoring system (Fig. 4). Mean PET distress
scores assessed by 5-item questionnaires decreased sig-
nificantly from 28.84  10.02 points preoperatively to
10.95  8.22 points postoperatively ( p ¼ 0.004) in 19
patients who completed the questionnaires (Fig. 5A).
The individual trend lines of the average PET distress
scores of each patient are illustrated in Figure 5B.
DISCUSSION
The PET was first described by Schwartze in 1864, and
the incidence has been known to be about 6% of the
population (2,8,9). The possible etiologies of PET are
atrophy of peritubal fat tissue, loss of the pterygoid
venous plexus, and peritubal musculature dysfunction
associated with aging, chronic inflammation, weight loss,
and pregnancy. Strenuous exercise is an important factor
for the worsening of the symptoms, and resting in the
supine position may improve PET symptoms. Children
and teenagers may show spontaneous improvement of
FIG. 5. (A) Mean PET distress scores assessed by the 5-item
questionnaires decreased significantly from 28.84  10.02 points
preoperatively to 10.95  8.22 points postoperatively. (B) The
individual trend lines of the average PET distress scores show
the alleviation of PET symptoms in most of the patients. PET,
patulous Eustachian tube.
Otology & Neurotology, Vol. 42, No. 9, 2021
Copyright © 2021 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
PET symptoms due to the anatomical changes in the
structure or function of the Eustachian tube secondary to
rapid growth and development.
An interesting clinical feature of this study is that more
than half of the enrolled patients were in their 20s to early
30s. The possible etiology of PET in most of these young
patients was weight loss. It is well known that elderly
patients can develop PET symptoms after progressive
weight loss and soft tissue sagging due to chronic dis-
eases or the aging process. The weight loss in these
younger patients was mostly self-induced with a strict
diet and vigorous exercise routine for better body shape.
Various therapeutic methods have been suggested for
patients with PET. Conservative methods include reassur-
ance, lifestyle guidance such as Valsalva’s maneuver with/
without weight gain, and discontinuation of decongestant
and/or nasal steroid sprays. Several medications such as
topical estrogen, saline, or anticholinergic nasal sprays,
and insufflation with boric or salicylic acid have been
reported to alleviate symptoms of PET (8–10). As for the
intractable PET cases that do not respond to either conserva-
tive treatment of medication, simple procedures such as
placing a paper patch on the tympanic membrane to prevent
tympanophonia due to vibration (11,12), or inserting venti-
lation tube insertion to suppress the sense of pressure (13)
may be effective to control troublesome symptoms.
More invasive procedures include tensor veli palatini
muscle modulation and the ET occlusion using various
methods or materials. Irreversible modifications of the
ET by the transposition of the tensor veli palatini muscle,
surgical ligation of the tubal orifice, and cauterization of
the tubal orifice using 20% silver nitrate or diathermy
were reported to be effective but are no longer recom-
mended due to the possibility of complications (4).
Several injection materials to narrow the lumen of the
ET have been introduced to substitute such invasive
procedures, such as fat, collagen, Teflon (polytetra-
fluoroethylene), calcium hydroxyapatite, etc. (14–16).
Although injection techniques were assumed to be more
accessible and safer than more invasive surgical techni-
ques, complications due to foreign body reactions
occurred with nonabsorbable materials, and the effects
were temporary with absorbable materials (4).
As for the insertion technique to occlude the ET,
Ogawa et al. infused gelatin sponge into the ET through
a transnasal approach and showed 73% symptom resolu-
tion in 16 patients with PET back in 1976 (17). More
recently, Poe reported the use of autologous cartilage
grafts via endoscopic transnasal or transoral approach
with a 93% success rate in 11 intractable PET patients
(2). The first transtympanic approach to restore tubal
competency was reported by Bluestone and Cantekin in
which the ET was occluded with a catheter-like plug
known as a ‘‘shim’’ (18). Kobayashi et al. designed a new
silicone plug, a ‘‘Kobayashi plug’’ for its transtympanic
insertion to the bony orifice of the ET, and reported an
83% success rate in a large cases series of 252 patients
(19). In order to substitute commercially unavailable
Kobayashi plug, we have designed our bone wax filled
 TRANSTYMPANIC ANGIOCATHETER INSERTION FOR PATULOUS EUSTACHIAN TUBE
angiocatheter and reported it previously as a case study in
2014 (7). Kong et al. have also reported a success rate of
83% using similarly formed ‘‘Y-shaped’’ or ‘‘folded tip’’
angiocatheters with relatively few complications (8).
Our specially shaped TTA has several advantages: 1)
The main material of TTA is a typical plastic angiocath-
eter, which is readily available in medical institutions
where the commercially made Kobayashi plugs are
unavailable. It is also cost-friendly and biocompatible.
The modern angiocatheter consists of synthetic polymers
such as polytetrafluoroethylene or fluorinated ethylene
propylene, which are the main property of permanent
stents and implants that are used in various parts of the
body, particularly for vessel reconstruction. Also, bone
wax used to fill the lumen of the angiocatheter is strongly
hydrophobic and minimally resorbable (20). Therefore,
the inserted TTA can be considered semi-permanent and
does not need to be removed or replaced unless there is a
complication. 2) TTA can be easily modified in size or
length for each individual. Angles of the catheter can also
be adjusted during the operation to fit the curvature of the
ET lumen. 3) The tripod shape enables a strong fixation at
the tympanic orifice with a low rate of spontaneous
extrusion. No additional material is needed for anchoring.
4) No serious intra-operative complication is expected
with the procedure, as long as there is no bony dehiscence
of the carotid plate.
With our TTA, only two patients (6.3%) experienced
an extrusion of the implant, which was a low rate
compared to previous studies. A habit of sniffing or
blowing one’s nose with force could be related to the
spontaneous extrusion of the TTA through the nasophar-
ynx. Only minor complications were observed during the
average follow-up period of 37.7 months, which included
OMEs possibly due to the ET irritation by TTA, residual
TM perforation due to anterior myringotomy during the
surgical procedure, and TM retraction probably due to
decreased air ventilation through the ET. Although the
majority of patients were relieved of their PET symptoms
with a single insertion, some of the patients were re-
inserted with a thicker catheter due to a recurrence. The
outcome of the patients using Poe’s autophony scoring
system showed only two cases that reported unchanged
or worsened symptoms after TTA insertion, which indi-
cates a 92% improvement rate in intractable PET cases.
The overall average scores of PET distress VAS scores,
however, showed a decreasing trend line in all of the
patients, indicating a significant relief from PET symp-
toms. As the enrolled patients were intractable patients
who did not respond to any conservative therapy, major-
ity of the patients clearly benefited from the TTA inser-
tion. Only one patient had TTA removed due to recurrent
OME 3 years after the insertion, but this patient was also
satisfied with TTA during the first 3 years after insertion.
From these results, it can be concluded that TTA inser-
tion is a safe and effective procedure for an intractable
PET patient.
The limitation of this study is that it was a single-
institution study with a relatively small sample size due
Copyright © 2021 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
e1277
to the rarity of the disease. Moreover, although the
longest follow-up was up to 115 months, 5 of the 32
enrolled cases were followed up under 6 months after the
TTA insertion. Lastly, the 5-item questionnaire PET
distress instrument that was used to assess the changes
in PET symptoms was not officially validated. Future
studies are in progress to validate the PET questionnaire
used in this study.
CONCLUSION
TTA insertion is a relatively simple procedure that can
be performed in a short period under local anesthesia.
Surgical intervention of TTA insertion for patients with
intractable PET symptoms seems promising, with a high
success rate and a low rate of complications even in a
long-term follow-up period.
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