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CT Imaging of the Cartilaginous Eustachian Tube

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CT Imaging of the Cartilaginous Eustachian Tube CT imaging of the cartilaginous Eustachian tube Benedicte Falkenberg-Jensen Thesis for the degree of Philosophiae Doctor Faculty of Medicine, University of Oslo Division of Radiology and Nuclear Medicine Oslo University Hospital, Rikshospitalet Norway 2018 © Benedicte Falkenberg-Jensen, 2019 Series of dissertations submitted to the Faculty of Medicine, University of Oslo ISBN 978-82-8377-469-6 All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without permission. Cover: Hanne Baadsgaard Utigard. Photo cover: Ine Eriksen Print production: Reprosentralen, University of Oslo. To Emil and Marius “Neither blame or praise yourself” Plutarch 3 4 1 Table of contents 2 Abstract of the thesis .......................................................................................................... 7 3 Acknowledgements ............................................................................................................ 9 4 Abbreviations ................................................................................................................... 13 5 List of papers .................................................................................................................... 15 6 Introduction ...................................................................................................................... 17 6.1 History ....................................................................................................................... 17 6.1.1 Early descriptions and publications.................................................................... 17 6.1.2 History of Eustachian tube catheterisation. ........................................................ 18 6.1.3 Historical development of x-ray methods and of views on radiation................. 19 6.1.4 Historical and current use iodinated of contrast media ...................................... 21 6.1.5 Historical radiologic imaging of the Eustachian tube ........................................ 21 6.2 Eustachian tube anatomy, physiology and function .................................................. 22 6.3 Middle ear disease and Eustachian tube dysfunction ................................................ 25 6.4 Eustachian tube dysfunction ...................................................................................... 28 6.5 Balloon dilation and its effects .................................................................................. 29 6.6 Computed Tomography ............................................................................................. 31 7 Aims of the thesis ............................................................................................................. 34 7.1 General aims .............................................................................................................. 34 7.2 Specific aims.............................................................................................................. 34 8 Summary of papers........................................................................................................... 35 8.1 Paper I ...................................................................................................................... 35 8.1.1 Title and status ................................................................................................... 35 8.1.2 Purpose ............................................................................................................... 35 8.1.3 Material and Methods: ....................................................................................... 35 5 8.1.4 Results paper I .................................................................................................... 37 8.1.5 Correction paper I............................................................................................... 39 8.2 Paper II ..................................................................................................................... 40 8.2.1 Title and status ................................................................................................... 40 8.2.2 Purpose ............................................................................................................... 40 8.2.3 Material and methods ......................................................................................... 40 8.2.4 Results paper II................................................................................................... 41 8.3 Paper III ................................................................................................................... 43 8.3.1 Title and status ................................................................................................... 43 8.3.2 Purpose ............................................................................................................... 43 8.3.3 Material and methods ......................................................................................... 43 8.3.4 Results paper III ................................................................................................. 46 9 Ethical considerations ...................................................................................................... 50 10 Discussion ........................................................................................................................ 51 10.1 Contrast media and ototoxicity .................................................................................. 51 10.2 Discussion Paper I ..................................................................................................... 53 10.3 Discussion Paper II .................................................................................................... 53 10.4 Discussion Paper III................................................................................................... 54 10.5 General discussion ..................................................................................................... 55 11 Conclusions and future aspects ........................................................................................ 56 12 Reference List .................................................................................................................. 58 13 PAPERS I-III.................................................................................................................... 63 6 2 Abstract of the thesis Middle ear disease is common. Chronic otitis media has a prevalence of 4.1% in the adult population (1) which gives an estimated 180.000 Norwegian adult patients with chronic middle ear disease. In many, the problem is bilateral. Although silent and invisible to the observer, middle ear disease induces hearing loss, pressure sensations, pain, sound phenomena such as popping, crackling or ringing, and recurrent infections. Over time, scaring, atelectasis and cholesteatoma and may develop, sometimes leading to extensive surgery. As the Eustachian tube (ET) is the only macroscopic channel of ventilation of the middle ear, dysfunction of the ET is a major contributor to middle ear disease. Tympanic tubes were up until recent years the best treatment option and have provided a relief of symptoms without addressing the cause. Over the past few years, balloon Eustachian tuboplasty (BET) has emerged as a treatment option, addressing dysfunction in the cartilaginous portion of the ET. Indications for BET can be otitis media with effusion, recurrent pressure equalizing problems after pressure changes or chronic symptoms believed to be caused by ET dysfunction, such as muffled hearing, popping sounds and pressure sensations. The ET serves not only as a pressure equaliser, but is lined with ciliated epithelium, transporting mucus and contaminations such as microorganisms and pollution out from the middle ear to the epipharynx. In this thesis, we tested the feasibility and safety of letting diluted contrast medium (iodixanol) pass through the ET from the tympanic cavity to the epipharynx and visualising it with CT imaging, both in an animal model and in humans. In addition, we determined the level of contrast medium passage in the human study. We also described a new method to measure the length of the cartilaginous ET, and tested the accuracy of the measurements. Finally, we tested whether the length of the cartilaginous ET predicts disease development and treatment outcome after BET. Our results demonstrate that the use of the contrast medium iodixanol in the middle ear and ET is safe, and that it fills the ET after approximately 10 minutes in an animal model. Furthermore, the technique can be used in humans, but larger studies are needed to determine 7 if it has diagnostic value. The measurement study showed excellent inter and intra observer correlation and good correlation to endoscopic measurements. The length of the cartilaginous ET does not seem to have prognostic value. However, females have shorter cartilaginous ETs than men do. 8 3 Acknowledgements This thesis is based on work and research carried out in the Department of Radiology and Nuclear Medicine, Rikshospitalet, Oslo University Hospital between the years 2013 and 2017, with great involvement of the Department of Otorhinolaryngology & Head and Neck Surgery. I would like to thank my main supervisor Einar Hopp. You took my request for a small science project so seriously it turned into a PhD. Due to your guidance, positive thinking and endless enthusiasm, I can look back on
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