AUCTORES
Globalize your Research
Case Report
*Corresponding Author: Sven-Eric Stangerup, Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
Citation: Sven- Eric Stangerup., Mads Klokker., Søren Vesterhauge., Peter Rea., and Jonathan Harcourt., (2021) Methods to Improve the Efficacy of Autoinflation Procedures and to Classify Eustachian Tube Patency. J. Archives of Medical Case Reports and Case Study. 4(1); DOI:10.31579/2692-9392/025
Copyright: © 2021 Sven-Eric Stangerup, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 22 January 2021 | Accepted: 17 February 2021 | Published: 23 February 2021
Keywords: valsalva’s maneuver; extended valsalva’s maneuver; nasal balloon autoinflation, middle ear ventilation; eustachian tube patency classification
We describe three methods to improve the efficacy of autoinflation procedures. The subjects were examined after flight with otoscopy and tympanometry. If the middle ear pressures after flight were negative, the passengers were asked to perform a Valsalva maneuver after which tympanometry was repeated. If still negative, the passengers were instructed to perform an extended Valsalva maneuver. If middle ear pressure was still negative, the passenger then was instructed to perform autoinflation using a nasal balloon. Among the ears with initial negative middle ear pressure, 14% normalized the middle ear pressure after Valsalva’s maneuver. In the passengers with a remaining negative pressure, the pressure was equalized to zero or positive pressure in 46% following an extended Valsalva maneuvre. In the ears with remaining negative middle ear pressure after both Valsalva and extended Valsalva maneuver, 69% could normalize the middle ear pressure after nasal balloon inflation.
As described by Feldman [1] and Black [2] the first anatomical description of the nasopharynx-middle ear tube was done by Eustachio (1520-74) in 1563. He regarded the tube, which was named after him, only as a pathway for draining pathological material from the tympanic cavity. Du Verney (1648-1730) [3] in 1683 realized that an important function of the tube was replacing and adjusting the pressure of the air in the tympanic cavity. He thought that the tube is permanently open, thus offering a vent to the middle ear, when the tympanic membrane moves inwards and outwards. Valsalva (1666-1723) [1,2] in 1704 discovered a muscle for opening the tube and presumed that in the process of hearing this muscle would come into action. Valsalva described the maneuver that is named after him as a method to expel pus from the tympanic cavity into the external auditory canal. Now the Valsalva’s maneuver is widely known as a method to equalize or “clear” the middle ear in the case of negative pressure. It has been shown that long-lasting negative middle ear pressure predisposes to chronic ear disease including cholesteatoma [4].
Today the three known functions of the Eustachian tube are pressure regulation, protection and drainage of the middle ear. The pressure regulation and protection are accomplished by active and passive functions of the Eustachian tube. The active function is tubal opening after active inferior -lateral traction of the tensor veli palatini muscle. If there is a pressure difference between the nasopharynx and the middle ear this will equalize when the tube opens. Closing the tube after termination of muscle tensor veli palatini activity is a passive event due to the elasticity of the surrounding tissue and if the pressure exceeds the closing forces around the lumen, the tube may open passively and the gas will flow through the tube.
The Valsalva maneuver is recommended in cases of Eustachian tube dysfunction: In children with glue ear, as a method to avoid barotrauma in aviation and in SCUBA diving. In patients who have undergone middle ear surgery, the procedure is advised in as a method to ventilate the middle ear, and hereby to prevent retractions and adhesions of the tympanic membrane or the graft to the promontory. Furthermore, satisfactory autoinflation is essential in professional aviation in obtaining safe flight. Disregarding this is a serious hazard leading to pilot incapacitation and to compromise aviation safety [5,6].
From clinical experience with Valsalva’s maneuver, we have described a method, by which it is possible to improve the effectiveness of Valsalva’s maneuver [7]. We call the method the extended Valsalva maneuver. In this report we also include the nasal balloon inflation method, which has shown to be an effective tool, to improve middle ear ventilation in the treatment of otitis media with effusion (OME) and as a treatment and as a prevention of barotitis during and after flight. [8,9]. We also like to describe the different steps of autoinflation, as a method to classify the Eustachian tube patency. In a study on balloon dilatation of the Eustachian tube, our proposed classification of the Eustachian tube patency was evaluated [10].
The subjects of the study comprise 134 adult passengers, with a negative middle ear pressure in at least one ear after air-flight at the arrival gate in Copenhagen airport [9]. The passengers were examined with an otoscopy and tympanometry at the gate in Heathrow airport before departure, and after arrival at the airport gate in Copenhagen airport. At the examination all subjects with negative middle ear pressures after air-flight, were asked to perform a Valsalva’s maneuver, after which tympanometry was repeated. In case of residual negative middle ear pressure after Valsalva, the extended Valsalva’s maneuver was performed, and tympanometry was repeated. In cases of continued negative middle ear pressure after the extended Valsalva’s maneuver, nasal balloon autoinflation was performed again after which tympanometry was repeated.
Valsalva’s maneuver:
The Valsalva’s maneuver is performed by pressing air into the nasopharynx, with the mouth closed and the nostrils compressed with the fingers (Figure. 1).
Extended Valsalva’s maneuver:
The maneuver is performed as the ordinary Valsalva’s maneuver, but first the neck is stretched maximally by forward flexion, and then the head is turned, positioning the ear to be inflated upwards. In this position the Valsalva maneuver is performed, increasing the chance of inflation in the uppermost ear. When the opposite ear is to be inflated, the head is turned in the opposite position (Figure. 2).
Nasal balloon inflation:
The (Otovent®) set, developed by one of the authors (Stangerup SE), consists of a nose tube mounted with a special membrane. The nose tube is held airtight to one nostril, the opposite nostril is compressed with a finger, and with the mouth closed, the balloon is inflated through the nose. During the inflation phase, a positive pressure of 600 dPa. is created in the nose and nasopharynx, which can equalize the middle ear pressure through the eustachian tube, the normal opening pressure of which is approximately 400 dPa.(Figure. 3).
Results:
Middle ear pressure after Valsalva’s maneuver:
Among the 134 ears with initial negative middle ear pressure, ranging from –5 dPa. to –210 dPa., 19 ears (14%) normalized the pressure (to zero or positive), after Valsalva’s msaneuver (Table 1).
Middle ear pressure after extended Valsalva’s maneuver:
In the 114 ears with remaining negative pressure after Valsalva’s maneuver, 52 passengers (46%), could equalize the pressure by
performing the extended Valsalva’s maneuver. In 62 ears the pressure was still negative (Table 1).
Middle ear pressure after nasal balloon inflation:
In the 62 ears with remaining negative pressure after extended Valsalva’s maneuver, 43 passengers (69%), could equalize the pressure by performing nasal balloon inflation using the Otovent set. In 19 ears the pressure was still negative (Table 1).
Efficacy of the autoinflation procedures:
Of the 134 ears with negative middle ear pressure after flight, the combination of the different autoinflation procedures,
115 passengers (86%) could equalize their middle ear pressures (Table 1).
Proposed classification of the Eustachian tube patency (Table 2).
Class 1: 0 or positive pressure after Valsalva.
Class 2: Negative pressure after Valsalva, but 0 or positive after extended Valsalva.
Class 3: Negative pressure after extended Valsalva, but 0 or positive after balloon inflation.
Class 4: Still negative pressure after balloon inflation.
Only few subjects in this study had significant negative pressure of clinical relevance. The majority of ears with negative pressure had pressures ranging from –10 to –80 dPa. If the Eustachian tube is normally functioning and passable, the subjects should be able to equalize this to zero or positive pressure, by performing the Valsalva’s maneuver. It is a surprise that only 14% of this adult age group were able to equalize the middle ear pressure in this way.
We cannot explain why stretching the neck and turning the head improves the effectiveness of Valsalva’s maneuver. But it is possible that during this maneuver, the parapharyngeal muscles stretches, and thereby improves the opening of the tubal orifice. Another point of interest with the extended Valsalva’s maneuver is that it is possible to “direct” the ventilation to the one ear in focus and to avoid the ventilation of the contralateral ear. This may be of clinical importance since many children, especially children with unilateral adhesions in the middle ear, where the opposite ear needs no ventilation, are afraid to perform autoinflation because of ear pain during the procedure. If this direction effect is due to improved opening of the tube to the ear in focus or is due to “blockage” of the contralateral tube, we do not know. Why nasal balloon inflations are so much more effective compared to Valsalva maneuvers could be explained by the fact that many patients are not aware of how the procedure is correctly performed or might be afraid of discomfort during the maneuver and may even perform a Toynbee maneuver (applying a negative pressure) by mistake. Inflating a balloon ensures that the procedure is performed correctly because of the visual feedback of the growing size of the balloon.
In cases of significant negative pressure the sequential steps of autoinflation should be used. Valsalva, extended Valsalva and nasal balloon inflation. We also advocate these steps as a method to classify the Eustachian tube patency.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
