I am an 18-year-old female. I have had multiple surgeries on my right ear because my eustachian tube fails to open and a vacuum is created in my middle ear, pulling the drum inward. I am dissatisfied with the repeated insertion of ventilation tubes. I cannot participate in swimming, and as a hopeful triathlete, this poses a problem for me. I am also experiencing gradual hearing loss due to the scarring of my eardrum. If my eustachian tube is such a problem, is there any procedure that will help it open?

N.

Air within the middle ear gradually dissolves into tiny blood vessels in the walls of the middle ear. The air that is lost in this way is periodically replenished with the opening of the eustachian tubes, which connect the middle ear to the upper throat. When eustachian-tube dysfunction is long-standing, this air is not replaced, and the air pressure in the middle ear becomes lower and lower. The only flexible "wall" of the middle ear is the eardrum. As the air pressure drops, the eardrum is sucked inward.

Ventilation tubes are certainly an appropriate "first step" to solving this problem. When you place a tiny plastic tube into the eardrum, the air pressure difference is eliminated, and the eardrum USUALLY returns to its normal position. However, if the eardrum is stuck in the "sucked-in" state for very long, it may develop chronic, possibly irreversible changes.

Similarly, scar tissue is created each time a ventilation tube is placed, and scar tissue may cause inappropriate stiffening of the eardrum. While this is fairly insignificant when only one ventilation tube has been placed, people who have had several tubes develop more and more scar tissue with the placement of each tube. This can adversely affect hearing.

One option, which may or may not be appropriate in your situation, is a tympanoplasty. In this operation, the eardrum is replaced with tissue from another source. One common source is the dense tissue ("fascia") that wraps the chewing muscle located just above and behind the ear. This fascia is thin and tough, which makes it an ideal replacement for the eardrum. During the tympanoplasty, the surgeon will also check the three tiny middle-ear bones that conduct sound from the eardrum to the inner ear. If there is a problem with these bones, the surgeon may be able to fix it. Finally, the surgeon will probably place a so-called "permanent" ventilation tube in the graft. (Such tubes usually last for several years, but are not truly permanent.)

Tympanoplasty would do nothing to correct your eustachian-tube dysfunction (ETD), though it could help your hearing. Your ETD may be something that you were born with, or it may be caused by tissue inflammation. The problem may or may not be correctable. A diligent ear, nose and throat specialist (ENT) could take a number of approaches to try to correct the problem, but there are no guarantees of success.

Stenting the eustachian tube open, while theoretically possible, is NOT the answer. There is a condition known as "patulous eustachian-tube dysfunction," in which the eustachian tubes remain open all of the time. Folks with this problem note a very disconcerting echo whenever they talk. That's because the sound of their voice reaches the inner ear via the usual pathway AND via the open eustachian tubes. This can be a maddening problem, and it is arguably worse than "simple" ETD.

How can you find someone who will offer you more than just another tube? You could try talking to your ENT about this. I would take a direct approach by asking, "Isn't there anything ELSE that can be done to fix this problem?"

Alternatively, you could see an otologist. Otologists are otolaryngologists (ENTs) who have had an extra year or two of training (beyond the ENT training) doing nothing but ears. You may be able to find an otologist in practice at your nearest medical school. Alternatively, call your state's medical society and ask for the names of surgeons in your state who have been certified by the American Board of Otology.