the next thing I'll be talking about is your station tube dysfunction. Um This is something probably is the most common thing that I see in my practice. It's it's um maybe not the most exciting thing, but it frustrates a lot of patients, especially when it becomes chronic. And so I think it's important to kind of give you guys a spiel about that and what we kind of try to do for them. Um So I'll talk about the anatomy and the function of the station to the path of physiology of the station tube dysfunction, uh potential causes of the station tube dysfunction. Um What we do in terms of clinical clinical evaluation and diagnosis. Um And then importantly I think we'll talk about the differential diagnosis. I think there's a few things that can kind of mimic you. Station tube dysfunction. And so it's important to, you know, ask the right questions to rule that out. Um And then we'll talk about the treatment of you station tube dysfunction. And then we'll talk about an entity that I think is a little bit underdiagnosed, which is a spatula, City station tube. So um the station tube is a funnel shaped tube connecting the middle ear to the nasopharynx of this. So this is the use station tube here. Um it passes superior early posterior lee and laterally from the nasopharynx up into the middle ear. Uh The adult you station tube is um 36 to 38 millimeters. Um Children tend to have a shorter and more horizontal. You station tube, so it'll kind of go in this direction. Um And they're more floppy. And because it's horizontal and shorter, that's why Children they tend to have more backup of fluid and more infections and more pressure. Um So the lateral part of the station tube, the lateral 1/3, this area is bony and then the medial two thirds of it is cartilaginous. And the junction between the cartilaginous and bony portion is called the Isthmus which is the narrowest part. And so this cartilaginous portion is the only part that's dynamic dynamic so it opens and closes and there's you know there's four muscles that kind of attached to the cartilaginous portion. Um The most important of which is the tensor valley palatine, which is this one. So the three main roles of the of the station tube. Um Equalization of pressure within the middle ear. They protect, it protects the middle ear from infection and uh and reflux. And it clears out natural middle ear secretions and all three of these functions are mediated by the opening and closing of the cartilaginous portion of the station tube. So the station tube is usually at rest at rest. It's closed and then it opens with things like swallowing or yawning or the val salva maneuver. And like I mentioned, the tensor valley palatine which is this muscle here is the main dilator of the station tube. So when this contracts it causes the U. Station tube to open and that pressure to equalize and that fluid to be released. Uh This is just uh you know an an atomic view of that in the nasal flaring. So um this is the tensor valley Palestinian kind of contracting and opening up the station tube which is this this is the opening of it there. So path of physiology of the station tube dysfunction. Um First of all it's pressure dis regulation um negative pressure is continually accumulating in the middle ear due to natural absorption of middle ear gasses. Um But if the U. Station tube cannot open to ventilate adequately, negative pressure will build up in the middle ear. So patients will feel this pressure or fullness pain, hearing loss. They can have some crackling sounds as they try to open up their use station tube. Um The other part of the path of physiology is is an impaired protective function. So if if there's reflux into the station tube you can get nasal pharyngeal pathogens, allergens, gastric secretions into the station tube that can cause inflammation and like I mentioned, it's more common in Children due to their short and floppy station tubes. So causes um you know the most common causes of you station tube are are inflammation related. So allergies being the most common reason in that category. Um There's there's definitely infections that can cause um you station tube dysfunction whether it's adenoid itis nasal syringe itis or sinusitis. Um when acid reflux or lowering differential reflux is really severe. It can also come up into the nasal pharynx and cause you station tube dysfunction hormonal changes in pregnancy, especially in the in the third trimester. Sometimes we see with those hormonal changes, patients will have um swelling of their use station tube. Um Other ideologies, sudden changes in pressure. We call this here barrel trauma, you know quick descent from air travel, scuba diving. Those things can cause you station tube dysfunction especially if the patient already has some pre existing allergies or they're flying with a sinus infection that they're gonna have some issues with this. Uh Then there's also acquired an atomic abnormalities. These are a little bit less common but you can get nasal pharyngeal masses like nasopharyngeal carcinomas which are rare in the population we treat but really technically in any adult with the unilateral middle ear effusion um You know we should be probably scoping them and taking a look at their nasopharynx to make sure they don't have any mass in that area. Um Cleft palate is a very um very common reason to have you station tube dysfunction. Um In these patients, their tensor Veli Palestinians not as well developed and does not have the normal midline insertion into the palette and so it can't contract to open up the station tube as effectively. So cleft palate, kids are so prone to middle ear infections and infusions that we almost universally. Um put tubes in them when they're getting their cleft lip or palate repaired um And then adenoid hypertrophy which is something that we see commonly in kids. So when when we see these patients, you know, history is the most important to try to decipher what what they're experiencing and what the diagnosis is. I think so. The most common symptoms that patients will complain about is cheerfulness or pressure. They say their ear feels plugged up. They they wanna they wanna pop their ear but they can't. Those are those are like the words that I'm looking for when, when when they come in, some patients will have some ear pain. They'll have some subjective hearing loss. Um Sometimes they'll even have tinnitus on that side. And this can include not only just high tone or high pitches but also popping and crackling sounds that they hear. In more severe cases. They might be a little off balance, they might get some vertigo. Um I'll ask them about recent air travel or scuba diving. Um You know, allergy symptoms, sneezing, refineria, sinusitis symptoms and symptoms of acid reflux are also important to ask about. So on physical examination this is a normal tim panic membrane. Um You know, you have the Malia's here that you can see but in your station tube dysfunction. Sometimes what you'll see is a retraction of the titanic membrane where the titanic membrane is kind of sunken in word. And sometimes you'll see this short process of the malley's kind of bulging forward. That can be an indication of you station tube dysfunction. Sometimes we'll see um middle ear effusions. Especially more severe cases cases of you station tube dysfunction. And that's what you see in this picture here with these little bubbles, McCoy diffusion behind the tim panic membrane. Um But I will say you know, a normal otis coptic exam doesn't necessarily mean the patient doesn't have you stationed tube dysfunction. I would say in the majority of patients that um that I see with you station tube dysfunction, their ear drum kind of that kind of looks pretty normal if if it's available. I think pneumatic Aw tosca p is important. Um A normal drum will move inward with positive pressure when you're pressing on the bulb and then outward with negative pressure as you're releasing it in a fluid filled middle ear. There's gonna be limited movement. The ear drum is not gonna move much at all because it's restricted by that by that fluid. Um When the ear drum is retracted. What you'll actually see is more movement outward with the negative pressure as you're releasing the the pneumatic. Um the little bulb, the jungle kind of pop out to you more. Um And a tuning fork exam I think is important if you have it available to you and we'll talk about that in a second. Um Audio metric evaluation. This is something that we have available in our office which which is great to have. And so I think the temple geometry is really important. This measures the compliance of the eardrum when pressure is applied to the external ear canal, it's kind of an indirect measure of the middle ear pressure. So if we a normal ear drum will have a kind of a nice little timpano graham that looks like this with a nice peak. But sometimes you'll get a flat timpano graham, which is a type B tim pentagram, which is kind of just flat. The eardrum doesn't move at all and that's a sign of the middle ear effusion or it can be a sign of a perforation. Um And then type C is when there's a negative pressure and that's what we see with you. Station tube dysfunction, we'll also get pure tone average is when we do our hearing tests and what you'll see. Um Sometimes you'll see a mild to moderate conductive hearing loss and that's usually in very severe. Station tube dysfunction or definitely if they have a middle ear effusion but oftentimes the pure tone average is will be will be normal with patients with you. Station tube dysfunction. Um Just going over the differential diagnosis, you know, I think there are a few things that can mimic you. Station tube dysfunction. I think probably the most common thing is is TMJ disorder. Um You know, these patients especially who grind their teeth and clench their jaw and they don't wear a night guard, they can get these ear blockage symptoms that are often misdiagnosed as you station tube dysfunction. They'll get kind of a deep ear pain or pressure in their ear. Uh Sometimes they'll have some pre pre auricular tenderness and pain. Sometimes you'll even feel some prejudice or over over the TMJ joints. So I think it's important to ask these patients about a history of grinding or clenching at night because like I said, it can very much mimic you Station tube dysfunction. Another thing is sudden hearing loss, sudden sensory neural hearing loss. Especially you know if you have a patient with unilateral U. Station tube dysfunction or it seems like that. Um This is something to try to figure out if it you know, rule it out. Um So they can often present with unilateral ear fullness and tinnitus on one side. Typically their main complaint is hearing loss. So if hearing loss is the main complaint I think um definitely think of sudden hearing loss. Whereas if it's mostly this this pressure or fullness um that might be most likely you station tube dysfunction but this is where a tuning fork exam I think is important if you have one in your office and um what I typically do especially if its unilateral is I'll do the weber exam where you put the tuning fork either on the forehead. Sometimes you can put it on there on their front top front teeth and and you station tube dysfunction. Um The sound will be heard either in the middle or it'll or it'll lateral eyes to the ear that's affected, whereas in sudden sensory neural hearing loss, um the patient will hear the sound louder on the opposite side. And so if they're hearing the sound on the opposite side, it might be an indication that they have sudden sensory neural hearing loss and that might be a good reason to send them to us urgently. So we can do a hearing test and kind of confirm that because um sudden sensory neural hearing loss needs to be treated as soon as possible with oral steroids. Um Another thing that can cause some ear fullness is Meniere's disease and cheerfulness is one of the, or pressure is one of the, you know, the four main symptoms of Meniere's disease, but they also have hearing loss that's usually low frequency and sensory neural in nature. They'll have tinnitus on that side and then typically they'll have some imbalance or vertigo. Um and then finally, patch list the station to which I'll talk about at the end, but they can also have some ear blockage or fullness symptoms. I think the differentiating thing is the symptom called oughta funny. So in terms of the treatment of you station tube dysfunction. Um Randomized trials for this condition are limited and study outcomes vary widely between studies. Um definitely the treatment should be directed at the underlying ideology if it is known. So if the patient has sinusitis allergies or LPR you know treat that appropriately because that might solve, you know the condition but if the ideology is unclear um you know, consider a referral for an audio graham to rule out other issues. Um There's not much evidence to support for pharmacologic therapy for isolated you station tube dysfunction without any cause. But I would tell you most patients will have some some allergy component that they that they have. So because of that our treatment is kind of geared mostly towards allergies, especially if they don't have symptoms of sinusitis or or LPR so my basic regimen is for the patient to start Flonase once a day um Afrin twice a day but only for three days just to avoid that rebound congestion and then um Sudafed and I like the fact that you you know, you have to ask the pharmacist for. Uh so the 12 hour 1 to 2 times daily, you know, as long as they don't have any heart problems, cardiac issues or or blood pressure issues. Um You know, oral steroids are always a question. I think again they've shown some benefit in animal models but this hasn't been realized in human studies. Um I do use them, especially in patients who have already tried the above three things that I mentioned um kind of as a last resort from medical management standpoint, I will offer them like a medical dose pack um I do think auto inflation is okay for them to do you know occasionally throughout the day. Um As long as they don't have the middle of your infusion um patients often come in you know with the station tube dysfunction and they're going on a flight or their scuba diving. You know I think ideally they can put that off but I do think it's safe to fly if it's just the station tube dysfunction and they don't have any middle ear effusion. I do tell them to take a Sudafed and spray Afrin in their nose before takeoff. Um I also tell them to spray Afrin in their nose on descent. Um And then I asked them to start Flonase at least a week before the flight if possible. Um airplanes are these you know, I don't think there's any, I haven't found any research that actually supports this but there are these little earplugs that you can wear in your ear and they have a filter in them that slows this shift of air pressure that enters your ear canal. And I think you know these are low risk and anecdotally a lot of patients say that they seem to be helpful. So I also mentioned that to patients who are flying soon. Um But yeah, you know if if the medical management fails then we have more interventional options. Um The most common thing that we offer is a merengue gotta me with or without tube and in this procedure the pressure is equalized through the temple Nossa me to rather than than the station tube. So it's kind of like a band aid for the issue if if the tubal pathology persists and the U. Station tube symptoms will likely recur once the either the tube falls out or the whole heals up. Um And you always have to warn patients that there is a small risk of a permanent perforation when we do this procedure. More recently there's there's another procedure that's become available called the station to balloon dilation. And this procedure basically what we do is we take a balloon catheter um And we thread it you know it goes through the nose. We guided endoscopic lee and we thread it into the station tube. Um And then we blow up the balloon um for about for a couple of minutes and then we take it out. Um And the hope is that it kind of keeps the U. Station tube dilated and allows that pressure to be equal equalized more effectively. Um You know it I said usually requires general anesthesia but I will say more and more. Uh now it's being done under local anesthesia. I don't know. See this is just a quick video of that if it plays, yeah this is just a quick video this is the balloon going down the nasal cavity. Um Then we take them make a little turn into the nasopharynx into the station tube. And we basically thread the balloon catheter in there. Um And then the balloon is inflated for a couple of minutes like that. And uh and then it's taken out And that's that's the whole procedure. It's pretty quick. Um and you know there is some data to support it. Um there's a there's a randomized trial of 60 adult patients with chronic use station tube dysfunction. And uh in one group they gave them medical therapy alone which is just nasal steroids. And in the second group they did balloon dilation plus medical therapy. And what they found in this study was that the station tube symptom scores improved significantly more at six weeks in the in the balloon dilation group compared to the control group. In addition the patients that had abnormal timpano grams at baseline whether it was type B or type C, 57% of them showed normalization in the balloon dilation group and only 10% in the control arm. And that was statistically significant. Um and they did have a follow up study that showed that results were sustained at 52 weeks as well. Um so the results are overall good. I usually tell my patients, you know, if we're gonna go down this route. Um you know, I'd like to set the the expectations good. And so I usually say maybe 60-70% chance that it'll give you some benefit. Um So the last part of the talk. I just want to talk about an entirely different condition called Patch list. You station tube, which is essentially the opposite of you station tube dysfunction. You station tube dysfunction is when the when the station tube is um kind of inflamed and narrow and shut off. And Patchouli station tube is a chronic patton C. Of the U. Station tube where it's too open. So again, the symptoms, they can be similar in that they will complain of this plug full sensation in their ear. But the differentiating thing that I see is oughta funny, which basically means they kind of hear the echo of their own voice in their ear. Uh they kind of hear this resonance of their own voice in the ear or they'll they'll hear their own breathing in there ear. Um A lot of times symptoms are, are improved when the head is in a dependent position, like when they're lying down or when they have a upper respiratory infection, just because that causes more edema within the station tube and kind of fixes this condition in a way and it may worsen with exercise or prolonged speaking. Um Both of these things can dehydrate the mucosa. Uh and then there's a, you know, a decongestant effect from the epinephrine like hormones released with exercise. Um So, you know, sometimes I'll ask them, you know, is it worse when you're exercising a lot of them will say, yeah, I feel that only at the gym when I'm when I'm working out or when I'm running. Um similar, you know, similar things can cause pathological station tube allergies. You know, especially chronic allergies can cause me coastal and sub mucosal atrophy within the U. Station tube. Very quick weight loss can lead to tissue atrophy within the station tube. Uh You know, reflux can also similarly cause mucosal atrophy. Like I mentioned dehydration, uh neuro muscular disorders. Um Any you know, decongestant use intranasal cocaine use Afrin overuse can cause that you station to to become to open. So the treatment um you know this is a relatively rare condition. So there isn't that much research, oops. Um So there isn't that much research there. But you know, first things we usually try is just hydrating the mucosa with saline. Obviously if they're really underweight try to get them to gain weight but then there's certain drops. And one of them is the estrogen drops and then the other one is the patch alone drops. And what these do is basically they induce inflammation within the station tube. So a lot of times when they're you know, putting these drops into their nose they'll actually feel like this burning sensation um in their nose as it kind of travels back and then they'll sometimes even feel a little burning in their ear and I usually tell them that just means it's working. Um there's even surgical management for this, especially when it becomes chronic and is unresponsive to that medical therapy. Um for whatever reason to monogamy to placement which seems counterintuitive can be beneficial in about 50% of patients. But typically what we're doing is some type of direct therapy to the youth station tube orifice here. Um Some people will place a catheter filled with bone wax into the station tube to partially obstruct the station tube. And then there's certain injections that we can do kind of around the station tube orifice. Sometimes it's gel foam filler, autologous fat injection around this area to kind of bulk up that area and close off the station tube. So um in conclusion the use asian tube helps to equalize pressure between the middle ear and atmosphere. And it also protects the middle ear from infection and reflux, inflammation and anna topic obstruction. Or the new station tube are the main causes common symptoms, cheerfulness. I want to pop my ear but I can't hearing loss, pain. Tinnitus. On physical exam you might see a normal ear drum, you might see a retracted eardrum. Um Pneumatic Aw. Tosca P if it's available and again if its unilateral I definitely think a tuning fork exam would be important. Um An audio graham with temp Anoma tree if it's available to you. Obviously you can send them to us for that. We have that available on every day. Um And then the treatment, you know treat the cause if it's known but otherwise it's Flonase Afrin for three days. Sudafed and I do think an anti histamine is reasonable if they do have symptoms of allergies and if that fails, you have a merengue gotta me with or without tube. And then the newer procedure of you station to balloon dilation. And I think just to reiterate, just be aware of naturalistic station tube. Um you know, I usually do ask my patients whether they hear the echo of their own voice, in their ear, breathing in their own ear. And if they if they look at me funny then I usually know that they don't know what that means. But if they if they really resonate with that then then I'm like, okay, maybe maybe we're treating the wrong thing here. Okay, that's it. Thank you. Any questions with that one, The remote and pentagram. Do you feel like the procedure you station tube dilation is as effective compared to those patients who have a retracted TM or an infusion? Yeah, definitely. If they have a normal timpano graham, um I probably wouldn't take them for you station tube dilation. Um because I think the patients that have an abnormal to pentagram, they definitely have better results. Um and if the pentagram is normal, I'm very hesitant to do any procedure and I really like to rule out those other causes that we mentioned, especially TMJ disorder. That was excellent. No, being your, your first decade of practice and some of the senior people, we have dealt with this problem and now there is a a solution. I used to have a cadre of patients. I'd be putting tubes in T tubes in and now with the station tube violation rabel. Actually, it's almost like a scar contraction of the station tube. And then that opens it. And those patients can be offered, you know, the next set of tubes when they fall out. E. T. Tube dilation and then Americana me. So it's I've had a great success with this procedure and those patients are are really happy after this procedure. So it's a it's a new innovative option for for those people. So, Great, thank you.