Bariatric surgery is an increasingly widespread and accepted treatment for morbid obesity, a multifactorial chronic disease genetically related to an excessive overstock of body fat. This condition is intimately related to medical, psychological, physical, and economic comorbidities. As the prevalence of obesity rises worldwide, so does the number of bariatric surgeries performed. While bariatric surgery offers significant benefits for weight loss and related health improvements, it can also lead to unique clinical conditions, including ear problems. This article aims to provide a comprehensive overview of ear problems that may arise after bariatric surgery, with a focus on eustachian tube dysfunction (ETD).
The Eustachian Tube and Its Role
The eustachian tube is a vital structure responsible for maintaining functional balance in the middle ear. In adults, it typically measures around 35 to 38 mm in length, with approximately 26 mm consisting of fibrocartilaginous tissue. This tube connects the middle ear to the nasopharynx, equalizing pressure and draining secretions.
Eustachian Tube Dysfunction (ETD)
Some clinical conditions associated with tubal malfunction can cause extremely unpleasant symptoms. ETD occurs when the eustachian tube doesn't open or close properly, leading to pressure imbalances and fluid buildup in the middle ear.
Patulous Eustachian Tube (PET)
Patulous eustachian tube (PET) dysfunction is a rare complication of weight loss, which can be easily misdiagnosed. PET is defined as a eustachian tube remaining persistently open. Common PET symptoms include autophony, aural fullness, and hearing one’s own breathing (aerophony).
Studies Linking Bariatric Surgery to ETD
Several studies have investigated the relationship between bariatric surgery and ETD. A prospective cohort study conducted with adult patients (≥18 years) with body mass index (BMI) > 40 or > 35 and presenting comorbidities related to their weight, showed that tube dysfunction after bariatric surgery might originate from the lack of fat tissue that involves and supports the eustachian tube.
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Study Design and Methodology
In the aforementioned study, all patients underwent bariatric surgery by production of gastric bypass (Fobi-Capella technique) at the same hospital, by the same surgeon. Prior to surgery, all patients had a hearing evaluation (otoscopy, tonal and vocal audiometry, and impedanceometry) and a standardized hearing questionnaire. Three to four months (first postoperative evaluation) and 5 to 6 months (second postoperative evaluation) after the surgery, all patients were reevaluated with the same questionnaire. Twenty-one patients were selected for the study, but only 19 were included. Two were lost during follow-up.
Study Results
Postsurgical results showed that 5 (26.3%) patients presented symptoms related to dysfunction of the eustachian tube at the first postoperative evaluation. The prevalence of tube dysfunction in the preoperative period was 0%. In the postoperative evaluations, 5 (26.3%) patients presented symptoms related to tube dysfunction at the first evaluation, and 9 (47.3%) presented symptoms at the second evaluation. Average onset of symptoms was 2.33 weeks (range: 1 to 20 weeks).
Proposed Mechanisms for ETD After Bariatric Surgery
The abrupt decrease of adipocytes in this region caused by the acute loss of weight might lead to a failure of tubal support and to a relaxation in this covering tissue, ultimately leading to eustachian tube dysfunction symptoms. It is believed that the rapid weight loss associated with bariatric surgery predisposes these patients to developing eustachian tube dysfunction. The mechanism is thought to be due to loss of adipose tissue, or “Ostmann’s fat”, in the peritubal region. This allows the Eustachain tube to remain patent.
Letti, in 1977, evaluated eight patients with complaints of patent tube; they all had a restrictive diet, with average weight loss of 15 kg in 45 to 65 days.
Ostmann's Fat Pads
PET may be caused by rapid weight loss and the consequent wasting of adipose tissue that surrounds the cartilaginous part of the ET, the Ostmann fat pads.
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Symptoms of ETD and PET After Bariatric Surgery
Patients can present to their primary care providers with multiple vague symptoms, which can be challenging to diagnose; therefore, a detailed past medical and surgical history is required.
Common Symptoms
The resulting clinical symptoms include autophony, hearing one’s own breathing, and a sensation of aural fullness in the setting of normal audiometry and tympanostomy findings. Symptoms can vary from autophony, aural fullness, aerophony, foreign body sensation, and tinnitus to severe anxiety and insomnia. Symptoms can increase in frequency and duration with time and can be exacerbated with exercise. Symptoms can be relieved with posture (placing the head in a dependent position), upper respiratory infection, or ipsilateral internal jugular vein compression.
Diagnosis of ETD and PET
Unfortunately, objective diagnosis of tubal dysfunction is still difficult, as the symptoms are not always present at the examination time (e.g. tympanometry).
Diagnostic Tools
At the otolaryngology visit, otoscopy revealed clear ear canals. Pure tone testing revealed normal hearing, bilaterally. Word Recognition scores were excellent for each ear. Tympanometry revealed normal middle ear pressure and compliance, bilaterally. PET testing was positive for the right ear; changes to the immittance were synchronous with breathing and most pronounced in the occluded-nostril condition. Normal hearing with evidence of PET was noted for the right ear.
Differential Diagnoses
Certain diseases such as multiple sclerosis, anorexia, or motor neuron disease can be associated with PET. It is important to consider all the possible differentials including psychiatric illnesses. Stress and anxiety were identified as novel risk factors and may heighten the awareness of internal auditory sounds. According to the literature, auditory verbal hallucinations or hearing voices (multiple voices or sounds such as whispering or murmuring) are the most common symptoms, particularly in schizophrenia
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Treatment Options for ETD and PET
Treatment options for PET can be minimally invasive, medical, and surgical depending on the severity of symptoms.
Medical and Minimally Invasive Treatments
Medical options and minimally invasive options include topical estrogen or insufflation with salicylic or boric acid into the ET pharyngeal orifice. Adequate hydration, nasal saline drops, and saline irrigations can be effective options for symptom management. Decongestants or nasal steroids can, on the contrary, worsen the symptoms.
Surgical Interventions
Surgical options are reserved for patients with severe symptoms and include tympanostomy tube insertion, ligation of the orifice, intraluminal catheter placement, cartilage grafting, complete occlusion of the ET, and hamulotomy.
Other Ear-Related Complications After Bariatric Surgery
Hearing impairments, however, is rarely reported after LSG. In one case report, a woman suffered from positional vertigo and unilateral gradual hearing loss plus continues tinnitus after LSG.
Potential Mechanisms
One possible mechanism might involve the relaxation of ear muscles due to the loss of surrounding adipose tissues. In adult humans, the eustachian tube contains a 24-26 millimeters fibrocartilaginous part. Due to the elastic nature of the fibrocartilaginous part, it is closed most of the time. It only allows the air to pass through during activities such as sneezing, yawning, or swallowing.