Eustachian Tube Dysfunction Questionnaire Score Changes at 6 and 12 Weeks: Follow‐Up Implications

Abstract

Eustachian tube dysfunction (ETD) can cause symptoms such as aural fullness, hearing loss, and tinnitus, and the Eustachian Tube Dysfunction Questionnaire (ETDQ‐7) is used to assess symptom burden. Balloon dilation of the eustachian tube (BDET) is a treatment for chronic obstructive ETD (OETD) in patients who fail medical therapy, yet optimal postoperative follow‐up timing remains unclear. We conducted a cross‐sectional study of 28 patients who underwent BDET between 2017 and 2024, analyzing ETDQ‐7 scores at baseline, 6 weeks, and 12 weeks. Repeated measures ANOVA showed a significant improvement from baseline to 6 weeks (P < .001), with no additional benefit from 6 to 12 weeks (P = .625). These findings suggest early symptom improvement is sustained, and a single 6‐week follow‐up visit may suffice for monitoring outcomes. This could reduce patient burden and optimize healthcare resource utilization. Further studies are warranted to confirm these findings in larger, more diverse populations across different clinical settings.

Eustachian tube dysfunction (ETD) is characterized by the failure of the eustachian tube to adequately perform its functions of protecting the middle ear, ventilating to equalize pressure, and draining secretions. ¹ Symptoms of ETD can include aural fullness, hearing loss, otalgia, and tinnitus. ¹ , ² Common treatments include intranasal corticosteroids, decongestants, antihistamines, mechanical devices, and surgery. ¹ , ³ The seven‐item Eustachian Tube Dysfunction Questionnaire (ETDQ‐7) is a validated patient‐reported outcome measure assessing symptom burden and guiding treatment plans. ¹

Balloon dilation of the eustachian tube (BDET) is an established intervention for chronic obstructive eustachian tube dysfunction (OETD), in patients not responsive to medical therapy. Clinical evidence supports its efficacy in improving symptoms and middle ear function, with normalization of tympanograms and improved ETDQ‐7 scores. ¹ , ⁴ However, the timing of follow‐up care for patients following BDET has not been clearly established in the literature, and postoperative ETDQ‐7 scores may change over time with patients. Findings suggest that there are improvements by 6 weeks, but there is limited evidence confirming long term stabilization. ⁴ We analyzed ETDQ‐7 scores before surgery and at 6 and 12 weeks postoperatively to clarify follow‐up recommendations, demonstrate efficacy of BDET, and reduce unnecessary visits.

Methods

We conducted a cross‐sectional study with a single surgeon panel (DBK) to analyze ETDQ‐7 scores at baseline, 6 weeks, and 12 weeks, for patients who underwent BDET from January 2017 to December 2024. Patients were included if they had complete data on ETDQ‐7 scores with clinical and demographic characteristics. Chi‐square and independent t‐tests examined differences of clinical and demographic characteristics by sex; paired t‐tests and repeated measures ANOVA assessed difference of ETDQ‐7 score over time. Analysis was performed on IBM SPSS Version 30.0. The Kaiser Permanente Southern California Institutional Review Board approved this study.

Results

Twenty‐eight patients who underwent endoscopic BDET were included, with equal sex representation. All patients tried medical management before BDET and 7 (25.0%) patients had previously undergone myringotomy with pressure‐equalizing tube. The overall cohort mean was 50.5, and most patients identified as White (82.1%). Baseline demographic and clinical characteristics did not significantly differ by sex (Table 1). There was a significant main effect of follow‐up time on ETDQ‐7 scores, F(2,80) = 17.5, P < .001. Post hoc tests revealed statistically significant difference in mean scores at baseline (32.3) versus 6 weeks (21.4; P < .001) and baseline versus 12 weeks (20.6; P < .001), but no significant difference between scores at 6 versus 12 weeks (P = .625) (Table 2). The mean improvement in ETDQ‐7 from baseline to 6 weeks was 10.9 points and from baseline to 12 weeks was 11.7 points, above the Minimal Clinically Important Difference (MCID) of 3.5 (Table 2).

Table 1.

Characteristic of Patients Undergoing Balloon Dilation for Eustachian Tube Dysfunction by Sex

Characteristic	Overall (N = 28)	Female (N = 14)	Male (N = 14)	P‐value
Agea, mean (SD), in years	50.5 (17.6)	51.4 (18.9)	49.6 (16.8)	.786
BMI, mean (SD), kg/m2	27.6 (6.1)	26.9 (5.76)	28.4 (6.48)	.530
Race/ethnicity, No. (%)
White	23 (82.1)	10 (71.4)	13 (92.9)	.335
Hispanic	2 (7.1)	2 (14.3)	0 (0.0)
Asian	2 (7.1)	1 (7.1)	1 (7.1)
Black or African American	1 (3.6)	1 (7.1)	0 (0.0)
Smoking status, No. (%)
Never	27 (96.4)	14 (100)	13 (92.9)	.309
Current	1 (3.6)	0 (0.0)	1 (7.1)
History of, No. (%)
Sinusitis	4 (14.3)	3 (21.4)	1 (7.1)	.280
Diabetes mellitus type 2	3 (10.7)	1 (7.1)	2 (14.3)	.541
Allergic rhinitis	8 (28.6)	6 (42.9)	2 (14.3)	.094
Laterality of surgery
Bilateral	21 (75.0)	11 (78.6)	10 (71.4)	.501
Left	4 (14.3)	1 (7.1)	3 (21.4)
Right	3 (10.7)	2 (14.3)	1 (7.1)
History of prior myringotomy with pressure equalizing tube, No. (%)	7 (25.0)	4 (28.6)	3 (21.4)	.663

^a Age was obtained from preoperative visit when the baseline ETDQ7 was performed.

Table 2.

Comparison of ETDQ‐7 Total Scores

Comparison	Mean difference, (SD)	95% CI	P‐value
Baseline vs 6 weeksa (Total score b , c )	10.9 (9.97)	7.06‐14.8	<.001
Baseline vs 12 weeks b , c (Total score)	11.7 (9.57)	8.06‐15.5	<.001
6 weeks vs 12 weeks (Total score)	0.84 (8.98)	−2.64‐4.32	.625

^a 6 weeks (42 days) had a mean of 41.6 days and a standard deviation of 11.9.

^b 12‐weeks (98 days) had a mean of 109.2 days and a standard deviation of 23.7.

^c ETDQ‐7 evaluates on a Likert scale from 1 (no problem) to 7 (severe problem), resulting in a total score range of 7 to 49. The total ETDQ‐7 score is calculated by summing the responses to all 7 items.

Discussion

The significant improvement in ETDQ‐7 scores at 6 weeks aligns with prior literature supporting the efficacy of BDET in alleviating OETD. ¹ , ⁵ Our findings align with prior studies demonstrating BDET leads to early and durable symptomatic improvement measured by ETDQ‐7. ⁴ In addition to corroborating previous study findings, our results compare 6‐ and 12‐week patient‐reported outcomes to inform follow‐up strategies. The observed mean improvement in ETDQ‐7 scores at 6 and 12 weeks exceeded the MCID of >3.5 points, indicating not only statistically but clinically meaningful symptomatic improvement. ⁶ This suggests that the value of an additional 12‐week visit may be limited. Previous studies have suggested that the recommended follow‐up for an endoscopic BDET is generally conducted at 1 week, 1 month, 3 months, 6 months, and 12 months. ¹ , ⁷ A systemic review in 2020, displayed that there were no significant differences in improved tympanograms at 6 weeks compared to long‐term, where long‐term was defined as 3 to 12 months. ⁵ Our findings suggest that early symptomatic gains are sustained long‐term. As a result, a 6‐week postoperative assessment should be sufficient to determine long‐term minimum outcome. In addition, eliminating low‐value appointments can reduce patient treatment burden and healthcare resource utilization without compromising outcomes.

Despite the strengths of our study, including the structured analysis of ETDQ‐7 scores over time, there are limitations to consider. Our study was conducted using a single physician panel with a limited sample size, which may affect the generalizability of our findings. We recognize that our study used only ETDQ‐7 as the sole outcome and did not include other objective measures. Our goal was to provide patient‐centered data to optimize follow‐up timelines rather than re‐establish the physiologic efficacy of BDET, which has been well documented. ¹ , ² , ³ , ⁴ Future studies with larger, more diverse populations and extended follow‐up periods may help refine follow‐up recommendations further beyond the first 3 months. In conclusion, our findings suggest that a single follow‐up visit at 6 weeks may suffice for monitoring early postoperative symptom improvement following endoscopic BDET, informing follow‐up care protocols.

Author Contributions

Alexander R. Gomez‐Lara, conceptualization, methodology, manuscript production; Emilie O'Banion, formal analysis, manuscript production; Jagatkumar Patel, conceptualization, methodology, manuscript review and edits; David B. Keschner, conceptualization, methodology, manuscript production, supervision.

Disclosures

Competing interests

None.

Funding source

None.

Data Availability Statement

The data supporting this study's findings are available on request from the corresponding author. The data is not publicly available due to privacy or ethical restrictions.