Extensive Turbinate Surgery: A Potential Risk Factor for a Patulous Eustachian Tube

Abstract

Objective

To describe a series of patients who developed a patulous Eustachian tube (PET) after turbinate surgery and to explore potential anatomical and clinical factors contributing to its development.

Methods

This retrospective case series examines three patients who presented with PET symptoms after turbinate surgery at a single tertiary care institution in Saudi Arabia. It reviews their clinical presentation, tympanic membrane mobility, nasal endoscopic findings, surgical history, and weight loss history.

Results

All three patients developed autophony within weeks to months following turbinate surgery. Positional symptom relief and characteristic tympanic membrane mobility were observed in all cases. Nasal endoscopy demonstrated postoperative fibrosis or adhesions involving the posterior inferior turbinate with mechanical traction on the Eustachian tube orifice, resulting in abnormal patency. One patient presented with a history of significant weight loss, but it was temporally remote. One patient experienced symptomatic improvement following Eustachian tube shim insertion.

Conclusions

This case series suggests that turbinate surgery may contribute to PET development, particularly when fibrosis develops postoperatively near the Eustachian tube orifice. While weight loss may represent a permissive factor in certain patients, local postoperative anatomical changes appear to play a critical role. Careful surgical technique and increased awareness of this potential complication may help reduce the risk of iatrogenic PET.

Introduction

Patulous Eustachian tube (PET) is a challenging condition in otolaryngology clinical practice, with autophony among its most characteristic and distressing symptoms. ¹ Significant weight loss has been independently associated with PET. ² However, the development of PET-related autophony following turbinate surgery has not been adequately described in prior studies, case reports, or case series.

In this case series, two of the three patients had no history of significant weight loss or other recognized risk factors for PET. In contrast, the third patient reported intentional weight loss approximately 17 years before symptom onset, making a direct causal relationship unlikely. In contrast, all patients demonstrated a clear temporal association between turbinate surgery and the subsequent development of autophony, suggesting a potential role of surgical alteration of the nasal and nasopharyngeal environment in PET pathophysiology.

The uniqueness of this case series is the consistent time-based relationship between turbinate surgery and symptom onset, particularly in patients without traditional predisposing factors. These observations raise the possibility that turbinate surgery itself may act as a precipitating or permissive factor in PET development through mechanisms such as altered nasal airflow dynamics, mucosal dehydration, or changes in peritubal pressure regulation.

These findings offer new pathophysiological insights and support the need for broader preoperative risk assessment that extends beyond weight loss alone when counseling patients indicated for turbinate surgery.

Methods

This retrospective case series examines three patients who presented with a PET following turbinate surgery at a single tertiary institution in Saudi Arabia between June 2023 and November 2025. It reviews their clinical presentation, tympanic membrane mobility, nasal endoscopic findings, surgical history, and weight loss history.

Inclusion Criteria: Patients Presenting With Patulous Eustachian Tube (PET) Symptoms Following Turbinate Surgery

Exclusion criteria: Patients with PET unrelated to prior nasal surgery or with incomplete clinical data.

All patients had undergone turbinate surgery prior to the onset of symptoms. No experimental intervention was applied as part of this study; management was individualized per clinical indication.

Results

Case 1

A 56-year-old Saudi male presented to our clinic with autophony and ear fullness following inferior turbinoplasty performed at another institution for nasal obstruction, mouth breathing, and snoring. The patient reported an initially uncomplicated postoperative course; however, three months postoperatively, he developed bothersome autophony associated with a sensation of ear fullness. His symptoms improved in gravity-dependent positions, consistent with a PET.

Otoscopic examination demonstrated movement of the right tympanic membrane synchronous with nasal respiration (Type VI). On the left side, the tympanic membrane showed immediate retraction following the Valsalva maneuver (Type IV), Tympanic membrane mobility was assessed using an institutional classification system developed based on the methodology described by Alamry et al , ³ with further categorization into six mobility patterns as detailed in Table 1 (Table 1).

Table 1.

The Classification System of Tympanic Membrane Mobility Used at Our Institution

Type	Mobility of the tympanic membrane	Interpretation
I	No mobility with the modified Valsalva maneuver	Obstructive Eustachian tube dysfunction
II	Delayed recoil of more than 3 seconds after the Valsalva maneuver	Obstructive Eustachian tube dysfunction
III	Fair recoil less than 3 seconds after the Valsalva maneuver	Normal Eustachian tube function
IV	Immediate recoil after the Valsalva maneuver	Mild PET
V	Mobile with breathing through the ipsilateral nostril	Moderate PET
VI	Mobile with normal breathing through the nose	Severe PET

Nasal endoscopy revealed postoperative scarring extending from the posterior aspect of the inferior turbinate toward the nasopharynx, exerting traction on the Eustachian tube orifice and resulting in persistent abnormal patency. The nasal septum was midline with no evidence of septal deviation. Computed tomography (CT) scan of the temporal bone was done to rule out other causes, but it was unremarkable.

Case 2

A 45-year-old Yemeni male presented to our clinic with complaints of left-sided clicking sounds and autophony following endoscopic sinus surgery with septoturbinoplasty performed for nasal obstruction in 2021. The patient reported that symptoms developed approximately one month postoperatively. Autophony was associated with increased perception of his own breathing and improved in the supine position, findings consistent with a PET.

Otoscopic examination revealed intact tympanic membranes bilaterally with no evidence of middle ear effusion. On the right side, the tympanic membrane demonstrated normal recoil following the Valsalva maneuver within three seconds (Type III). On the left side, the tympanic membrane showed synchronous movement with respiration through the ipsilateral nostril (Type VI).

Nasal endoscopy demonstrated postoperative changes consistent with prior sinus surgery, in addition to fibrotic scarring extending from the posterior aspect of the inferior turbinate to the left Eustachian tube orifice. The scar tissue exerted mechanical traction on the Eustachian tube opening, resulting in persistent abnormal patency (Figure 1). The nasal septum was centrally aligned with no residual deviation. CT scan of the temporal bone was done to rule out other causes, but it was unremarkable.

Figure 1.

Endoscopic view blue arrow showing a fibrous band formed following turbinate surgery, which exerts lateral traction on the torus tubarius and maintains the Eustachian tube orifice in an abnormally patent position

Case 3

A 35-year-old male presented to our clinic with left-sided autophony that developed approximately four months after bilateral inferior turbinate surgery. The patient reported that symptoms improved in the supine position and during forward bending, findings consistent with a PET.

The patient’s medical history was otherwise unremarkable. He reported a history of significant intentional weight loss of 29 kg (from 117 kg to 88 kg) approximately 17 years prior, achieved through dietary restriction and intensive exercise. Importantly, he did not experience autophony or other symptoms suggestive of PET during the intervening 17 years, with symptoms developing only after undergoing inferior turbinate surgery. Otoscopic examination revealed an intact right tympanic membrane with immediate recoil following the Valsalva maneuver (Type IV). On the left side, the tympanic membrane demonstrated synchronous movement with ipsilateral nasal respiration (Type V). Nasal endoscopy demonstrated expected postoperative changes on the right side, without evidence of fibrous band formation or peritubal scarring. On the left side, a fibrous band extending from the posterior aspect of the inferior turbinate to the anterior wall of the Eustachian tube orifice was identified (Figure 2), exerting mechanical traction and exacerbating abnormal tubal patency. CT scan of the temporal bone was done to rule out other causes, but it was unremarkable.

Figure 2.

Endoscopic view of a fibrous band formed following turbinate surgery showing in blue arrow, which extends from the posterior aspect of the inferior turbinate to the anterior wall of the Eustachian tube orifice

Discussion

PET is an uncommon but clinically significant condition that presents diagnostic and therapeutic challenges in otolaryngology practice. Although PET has been traditionally associated with systemic factors, most notably significant weight loss, the role of local anatomical and iatrogenic factors remains incompletely understood. In this case series, we described patients who developed PET symptoms following turbinoplasty, with consistent temporal proximity to surgery and direct endoscopic evidence of peritubal structural alteration, suggesting a potential contributory role of nasal surgery in PET pathophysiology.

At our tertiary referral institution, where a dedicated clinic for Eustachian tube disorders is held regularly, PET is encountered infrequently relative to other forms of Eustachian tube dysfunction. At our clinic, we routinely use an endoscopic grading system of Eustachian tube patency based on tympanic membrane mobility during respiration (Table 1), which has proven helpful for both diagnostic assessment and post-treatment follow-up. In this classification system, Types I and II correspond to obstructive Eustachian tube dysfunction, Type III to normal Eustachian tube function, Type IV to mild PET, Type V to moderate PET, and Type VI to severe PET. The cases presented in this series are notable for their atypical clinical pattern, in which PET symptoms developed soon after turbinate surgery, rather than in association with systemic or metabolic factors alone. In addition to the cases presented in this series, we have encountered a similar instance of PET following aggressive adenoidectomy in our clinical practice (Figure 3). Turbinate surgery has not been discussed as a potential contributing factor in the literature. This observation further supports the concept that surgical alteration of the peritubal soft tissue environment—whether through fibrosis, traction, or disruption of normal anatomical support—may contribute to abnormal tubal patency. The presence of postoperative fibrosis extending from the posterior inferior turbinate to the Eustachian tube orifice in our cases highlights the anatomical vulnerability of the peritubal region to surgical manipulation and subsequent scarring.

Figure 3.

Endoscopic view of a fibrous band formed following adenoidectomy in a separate case shown in blue arrow, which exerts medial traction on the Eustachian tube orifice and results in persistent abnormal patency

One case in particular provides important mechanistic insight. Although bilateral Eustachian tube patency was likely influenced by a temporally remote history of significant weight loss, symptomatic PET manifested only after unilateral turbinoplasty, and only on the side where postoperative fibrosis and adhesions were identified endoscopically. Despite appearing patent, the contralateral Eustachian tube remained asymptomatic in the absence of postoperative scarring. This asymmetry supports the hypothesis that local mechanical factors, such as fibrotic traction on the Eustachian tube orifice, may act as a precipitating or amplifying factor, shifting a subclinical or compensated state into symptomatic PET.

The pathophysiology of PET is widely regarded as multifactorial. Significant weight loss is a well-documented risk factor,^3,4 particularly after bariatric surgery or rapid pharmacologically induced weight reduction, when depletion of peritubal adipose tissue compromises normal Eustachian tube closure mechanisms. The adipose tissue surrounding the Eustachian tube plays an important role in maintaining physiological tubal closure, and its loss may predispose to patency.^5-7 However, in this case series, weight loss was either absent or temporally remote in most patients, suggesting that weight loss alone is insufficient to explain symptom onset in our cases.

Other mechanisms proposed in the literature include neurological factors, such as trigeminal nerve dysfunction,^8,9 and rare associations with systemic diseases, including Graves’ disease ¹⁰ and oculopharyngeal muscular dystrophy. ¹¹ While these mechanisms were not evident in our cases, their existence emphasizes the complexity of PET pathogenesis and supports a model in which multiple predisposing and precipitating factors interact.

The Eustachian tube’s sensitivity to surgical manipulation has also been demonstrated in other contexts. Although balloon Eustachian tuboplasty is therapeutically intended to treat obstructive dysfunction, it has been reported to cause PET when excessive dilation disrupts normal tubal function. ¹² While mechanistically distinct from turbinoplasty, these reports reinforce the concept that alterations to the peritubal environment—whether intraluminal or extraluminal—can significantly impact Eustachian tube physiology.

Clinically, this case series highlights the importance of meticulous surgical technique during turbinoplasty, particularly in the posterior inferior turbinate region adjacent to the Eustachian tube orifice. Conservative tissue handling, avoidance of excessive posterior resection, and minimization of mucosal trauma may reduce the risk of postoperative fibrosis and subsequent PET, especially in patients with known or suspected Eustachian tube susceptibility.

The strengths of this case series include the clear temporal relationship between turbinate surgery and the onset of PET symptoms, detailed weight loss histories, and direct endoscopic visualization of postoperative anatomical changes. Its limitations include a small sample size, a lack of long-term follow-up, and an inability to definitively establish causation rather than association. The objective quantification of Eustachian tube patency was also limited. Therefore, future studies incorporating standardized functional assessments would be valuable.

Overall, this case series supports the notion that PET should not be viewed solely as a metabolic or systemic disorder, but rather as a condition in which local anatomical and iatrogenic factors may play a critical and underrecognized role.

Conclusions

This case series suggests a potential association between turbinate surgery and the development of patulous Eustachian tube (PET), likely related to postoperative peritubal fibrosis and mechanical traction on the Eustachian tube orifice. While weight loss may contribute in selected cases, local anatomical changes appear to play a more direct role. Awareness of this potential complication and careful surgical technique, particularly in the posterior inferior turbinate region, may help reduce the risk of iatrogenic PET.

Limitations

This study is subject to several limitations. All post-turbinoplasty cases were performed outside our institution, and operative reports were unavailable for most patients; consequently, the specific surgical techniques employed could not be determined or evaluated. Additionally, the number of images included in this manuscript is restricted in accordance with the journal’s guidelines on figure limitations.

Supplemental Material

Supplemental Material - Extensive Turbinate Surgery: A Potential Risk Factor for a Patulous Eustachian Tube

Supplemental Material for Extensive Turbinate Surgery: A Potential Risk Factor for a Patulous Eustachian Tube by Saleh Alamry, Homood M. Almutairi and Naif Abdulaziz M. Alqarni in Ear, Nose & Throat Journal.