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Consensus on Treatment of Obstructive Eustachian Tube Dysfunction With Balloon Eustachian Tuboplasty
Consenso sobre el tratamiento de la disfunción tubárica obstructiva mediante dilatación con balón
Guillermo Plazaa,
Corresponding author
gplaza.hflr@salud.madrid.org

Corresponding author.
, Juan José Navarrob, Jorge Alfaroc, Marta Sandovald, Jaime Marcoe
a Servicio de Otorrinolaringología, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, Madrid, Spain
b Servicio de Otorrinolaringología, Hospital Universitario Donostia, San Sebastián, Spain
c Servicio de Otorrinolaringología, Hospital Quirón Salud, Zaragoza, Spain
d Servicio de Otorrinolaringología, Hospital Sant Joan Despi-Moisés Broggi, Barcelona, Spain
e Servicio de Otorrinolaringología, Hospital Clínico de Valencia. Universidad de Valencia, Valencia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">For many years&#44; once medical treatments had failed&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> surgical treatment of obstructive Eustachian tube &#40;ET&#41; had been the insertion of transtympanic drains&#44; with repeated treatment on successive occasions in the same ear&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">However&#44; from 2009 onwards&#44; a further therapeutic option appeared to resolve tube obstruction&#44; thanks to the works of Sudhoff et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> This option is balloon Eustachian tuboplasty &#40;BET&#41;&#46; This procedure treats chronic obstructive Eustachian tube dysfunction using a minimally invasive&#44; easy&#44; safe and reliable system&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Unlike other ablative procedures of the ET&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> BET consists of the transnasal introduction of a catheter with a balloon to be dilated in the ET aimed at dilating its cartilaginous section&#46; It is recommended when the patient does not respond to other conservative treatments and chronic Eustachian tube obstruction persists&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There is actually great variability in the diagnosis and treatment of chronic Eustachian tube dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Recently several international consensual documents have been published on the diagnosis of this disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> However&#44; none of them totally clarify the recommendations to be followed regarding treatment for chronic Eustachian tube obstruction through BET&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study was to present a summary of the consensual recommendations reached by a group of experts on the indication&#44; contraindications&#44; methodology&#44; complications and results of the BET&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Method</span><p id="par0030" class="elsevierStylePara elsevierViewall">For this consensual study a group of 5 experts were selected from Spain &#40;the authors&#41; with proven experience in BET &#40;minimum of 30 cases per specialist&#41;&#44; whose combined experience amounted to over 250 cases&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This group carried out a systematic review of the literature published from 1966 until 10th November 2018&#44; on the terms MESH <span class="elsevierStyleItalic">Eustachian tube and &#40;dilation or dysfunction</span>&#44; collecting a total of 1943 articles in Spanish&#44; English&#44; German and French which were reviewed by authors in relation to the evidence of each suggestion made&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In fact&#44; out of the total articles reviewed 139 were selected where the abstract was relevant&#46; Of these&#44; to reach a consensus the following were included&#58; 2 consensus on the diagnosis of tube dysfunction&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> 7 systematic reviews&#44;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;19</span></a> 4 non systematic reviews&#44; 2 randomised clinical trials on BET<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a> and 2 non randomised comparative studies on BET&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> In addition to many studies on anatomy&#44; physiopathology of tube dysfunction or the diagnosis of it there are highly numerous series of BET cases&#44; both in adults<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;8&#44;13&#8211;19&#44;24&#8211;28</span></a> and children<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">During the face-to-face meetings the selected articles were reviewed&#44; assessing their level of evidence &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#41;&#44; and the results were presented&#46; As a result the creation of a proposal for a consensual document on BET was reached&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Finally&#44; this proposal was presented at the SEORL Congress in October 2018&#44; where it was discussed and sent to the Otology Committee of SEORL for improvement and endorsement as a final document&#44; the abbreviated version of which is present in this study &#40;the complete version is available as supplementary material&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In this consensual document current BET indications are shown&#44; both for children and adults&#44; together with absolute and relative contraindications&#44; tips on surgical procedure and postoperative care&#46; The most common and most relevant complications were also reviewed together with expectations of BET results according to the disease which caused it&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Concept of Eustachian Tube Dysfunction</span><p id="par0060" class="elsevierStylePara elsevierViewall">ET dysfunction consists in the failure of the ventilator function of the ET on the middle ear&#46; Causes of Eustachian tube dysfunction may be obstructive&#44; patulous and from barotrauma&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;10&#8211;12</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Both obstructive Eustachian tube dysfunction and barotrauma dysfunction lead to symptoms and signs relating to the poor ventilation of the middle ear&#46; Their symptoms include&#44; among others&#44; the feeling of a stuffed up ear&#44; tinnitus&#44; blocking or inability to balance pressure at middle ear level&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Patients with obstructive Eustachian tube dysfunction present with symptoms which are compatible with negative pressures in the middle ear&#44; such as tympanic retraction or chronic otitis media images in the otoscopy&#44; negative Valsalva manoeuvres and&#47;or negative pressure in tympannometry&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;10&#8211;12&#44;31&#8211;33</span></a> Different findings have therefore been proposed to define this disease&#44; which may or may not be coincidental &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12&#44;31&#8211;33</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Obstructive Eustachian tube dysfunction may lead to chronic otitis media&#44; tympanic atelectasis and even the appearance of a cholesteatoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;17</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Indications for Balloon Eustachian Tuboplasty</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Indications for Adult Patients<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;13&#44;16</span></a></span><p id="par0080" class="elsevierStylePara elsevierViewall">In patients who suffer from symptoms derived from obstructive ET dysfunction&#44; either uni or bilateral&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">o</span><p id="par0085" class="elsevierStylePara elsevierViewall">Chronic serous otitis media&#58; after appropriate medical treatment from the failure of the second tympanic drainage in the same ear BET should be considered&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">o</span><p id="par0090" class="elsevierStylePara elsevierViewall">Mild to moderate adhesive otitis media&#58; Sad&#233; grade <span class="elsevierStyleSmallCaps">i</span> and <span class="elsevierStyleSmallCaps">ii</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">o</span><p id="par0095" class="elsevierStylePara elsevierViewall">Mild to moderate atelectasis&#58; Sad&#233; grade <span class="elsevierStyleSmallCaps">i</span> and <span class="elsevierStyleSmallCaps">ii</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">o</span><p id="par0100" class="elsevierStylePara elsevierViewall">Tympanoplasty failure&#58; after failure of a myringoplasty&#44; when there is re-perforation of the tympanic membrane or the start of tympanic retraction with suspicion of ET dysfunction&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">o</span><p id="par0105" class="elsevierStylePara elsevierViewall">Barotrauma &#40;aviation and diving&#41;&#58; sensation of discomfort and pain from pressure in the ears&#44; particularly with changes in atmospheric pressure &#40;dysbarism&#41;&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Indications for Paediatric Patients<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a></span><p id="par0110" class="elsevierStylePara elsevierViewall">From 4 years of age&#44; in children with obstructive ET dysfunction ET&#44; either uni or bilateral&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">o</span><p id="par0115" class="elsevierStylePara elsevierViewall">Chronic serous otitis media without tympanic retraction&#58; from the failure of the second tympanic drainage in the same ear&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">o</span><p id="par0120" class="elsevierStylePara elsevierViewall">Serous otitis media with suspicion of chronic ET dysfunction&#58; from the failure of the first&#44; second or third tympanic drainage &#40;to be assessed by the ENT depending on the evolution of the atelctasis&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">o</span><p id="par0125" class="elsevierStylePara elsevierViewall">Tympanic perforation in one ear and serous or adhesive otitis media in the other ear&#58; assess bilateral BET depending on the evolution of the ET dysfunction in each ear&#46;</p></li></ul></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Contraindications of Balloon Eustachian Tuboplasty</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Absolute</span><p id="par0130" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045"><p id="par0135" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">o</span><p id="par0140" class="elsevierStylePara elsevierViewall">Previous treatment with radiation in the area&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">o</span><p id="par0145" class="elsevierStylePara elsevierViewall">Previous head trauma with anatomical changes to the area&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">o</span><p id="par0150" class="elsevierStylePara elsevierViewall">Cleft lip&#47;palate&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">o</span><p id="par0155" class="elsevierStylePara elsevierViewall">Open or patulous ET&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">o</span><p id="par0160" class="elsevierStylePara elsevierViewall">Down&#8217;s syndrome&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">o</span><p id="par0165" class="elsevierStylePara elsevierViewall">Large quantity of scar tissue in the area due to previous surgery&#46;</p></li></ul></p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Relative</span><p id="par0170" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">o</span><p id="par0175" class="elsevierStylePara elsevierViewall">Craneofacial malformation with anatomical changes in the area&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">o</span><p id="par0180" class="elsevierStylePara elsevierViewall">Adhesive otitis media&#58; Sad&#233; grades <span class="elsevierStyleSmallCaps">iii</span> and <span class="elsevierStyleSmallCaps">iv</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">o</span><p id="par0185" class="elsevierStylePara elsevierViewall">Atelectasis&#58; Sad&#233; grades <span class="elsevierStyleSmallCaps">iii</span> and <span class="elsevierStyleSmallCaps">iv</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">o</span><p id="par0190" class="elsevierStylePara elsevierViewall">Cystic fibrosis and dyskinesias&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">o</span><p id="par0195" class="elsevierStylePara elsevierViewall">Previous ET surgery &#40;excluding previous BET&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">o</span><p id="par0200" class="elsevierStylePara elsevierViewall">Obstructive nasal disease&#58; septal deviation&#44; sinonasal polyposis &#40;it is recommended to treat this disease first&#46; Only when ET dysfunction persists is it advisable to treat with BET&#41;&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Necessary Pre-operative Tests for Balloon Eustachian Tuboplasty</span><p id="par0205" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">1&#41;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Complete anamnesis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">2&#41;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Questionnaires for ET dysfunction &#40;ETDQ-7&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#8211;39</span></a> validated into Spanish &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">3&#41;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Otoscopy&#47;microscopy&#58; description of the status of the tympanum&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">4&#41;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Valsalva and Toynbee manoeuvre during otoscopy &#40;with patient seated&#41;&#58; recommended to record on video&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">5&#41;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Tympanometry&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">6&#41;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Tonal audiometry&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">7&#41;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Nasal endoscopy&#58; to rule out nasal and cavum disease&#44; and assess good access to the torus tubarius&#58; recommended to record on video&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">8&#41;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Tubanometry&#58; this is not essential it is only an aid&#44; but leads to obtaining the Eustachian Tube Score &#40;ETS&#41;&#44; which is of prognostic interest and the ETS-7 when combined with a typanogram&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#8211;43</span></a></p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">9&#41;</span><p id="par0250" class="elsevierStylePara elsevierViewall">Computerised tomography&#58; this is not essential in all cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">44&#44;45</span></a> it would be indicated if after examination there is any suspicion of an acute or previous disease of the temporal bone&#46;</p></li></ul></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Advice During Balloon Eustachian Tuboplasty</span><p id="par0255" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">1&#41;</span><p id="par0260" class="elsevierStylePara elsevierViewall">Prior preparation to BET&#58;</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">-</span><p id="par0265" class="elsevierStylePara elsevierViewall">The specific informed consent of the patient must be obtained&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall">The application of a topical nasal vasoconstrictor just before starting the intervention&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">2&#41;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Recommendations during BET&#58;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">-</span><p id="par0280" class="elsevierStylePara elsevierViewall">The procedure is generally performed under general anaesthesia or deep sedation with the patient in a supine position&#44; although some authors perform surgery under local anaesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall">There are different balloons available in the market for BET&#58; Tubavent&#174; &#40;Spiggle &#38; Theis&#44; Germany&#41;&#44; Area&#174; &#40;Accelerant&#44; U&#46;S&#46;A&#46;&#41; and XprESSTM &#40;Entellus Medical&#44; U&#46;S&#46;A&#46;&#41;&#44; which are very similar to one another&#46; One study compares them&#44; without any significant differences between them being observed&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">-</span><p id="par0290" class="elsevierStylePara elsevierViewall">In adult patients the use of optics of 0 or 30 is recommended&#44; performing the BET through the same nostril and using inserters with a 45&#8211;60 angulation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">-</span><p id="par0295" class="elsevierStylePara elsevierViewall">In paediatric patients&#44; due to their anatomy&#44; the use of optics of 0 or 30 is recommended&#44; performing the BET through the contralateral nostril and using inserters with a 60&#8211;70 angulation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">-</span><p id="par0300" class="elsevierStylePara elsevierViewall">During the procedure the nostril mucosa should not be damaged with the optics or instruments used for ET insertion&#44; to avoid bleeding&#46;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">-</span><p id="par0305" class="elsevierStylePara elsevierViewall">When placing the balloon in the inserter the catheter should be positioned in a straight line without turning it and should be introduced smoothly to prevent it folding&#46; We recommend positioning the balloon in the inserter prior to inserting the system into the nostril&#46;</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">-</span><p id="par0310" class="elsevierStylePara elsevierViewall">Once inserted in the Eustachian tube&#44; the catheter is displaced through the canal of the inserter and is fitted carefully onto it&#44; avoiding any resistance&#46;</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">-</span><p id="par0315" class="elsevierStylePara elsevierViewall">Ensure appropriate introduction of the inserter in the ET&#44; to ensure that the balloon is positioned inside it&#46;</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">-</span><p id="par0320" class="elsevierStylePara elsevierViewall">Once the catheter has been correctly positioned inside the tube&#44; the manometer is used to inflate the balloon to a pressure of 10&#8239;bar&#46; This pressure is maintained for 2&#8239;min&#46;</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">-</span><p id="par0325" class="elsevierStylePara elsevierViewall">If a vibration is felt when the balloon is to be inserted in the ET&#44; this indicates that torsion of the torus has occurred and the catheter is not where it should be&#46; However&#44; once correctly inserted&#44; during inflation&#44; it is common to observe a minor vibration of the ET cartilage which indicates that the procedure is correct&#46;</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">-</span><p id="par0330" class="elsevierStylePara elsevierViewall">Once inflation has terminated&#44; the deflated or inflated balloon may be extracted &#40;producing a suction effect on drawing out mucus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">-</span><p id="par0335" class="elsevierStylePara elsevierViewall">If tympanoplasty is performed during the same surgical procedure it is recommended that the balloon be extracted in a deflated state to avoid a suction effect in the tympanic cavity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">-</span><p id="par0340" class="elsevierStylePara elsevierViewall">Tuboplasty of the same tube twice may be made if there is doubt that the initial tuboplasty was effective&#46;</p></li></ul></p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Procedures Associated With Balloon Eustachian Tuboplasty</span><p id="par0345" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">-</span><p id="par0350" class="elsevierStylePara elsevierViewall">When it is considered necessary to recommend the performing of BET and a myringotomy in the same procedure&#44; but it is not recommended to place a tympanic drainage tube at the same time as the BET&#44; except in children with adhesive otitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47&#44;48</span></a></p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">-</span><p id="par0355" class="elsevierStylePara elsevierViewall">When combining BET with tuboplasty or a tonsillarectomy&#44; it is recommended to first perform the BET&#44; and then the remainder of the surgery&#44; to avoid any possible bleeding hindering observation of the torus tubarius&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p></li><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">-</span><p id="par0360" class="elsevierStylePara elsevierViewall">On occasions it may be beneficial to combine the BET with middle ear surgery&#44; such as myringoplasties or tympanoplasties with mastoidectory&#44; if there is a clinical suspicion of obstructive ET dysfunction that requires BET&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Postoperative Recommendations</span><p id="par0365" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">1&#41;</span><p id="par0370" class="elsevierStylePara elsevierViewall">Medical treatment&#46;<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">-</span><p id="par0375" class="elsevierStylePara elsevierViewall">Similar to a nasal surgery&#46; It is recommended to administer analgesics on demand&#44; non steroid oral anti inflmmatories and occasionally topical corticoids&#46;</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">-</span><p id="par0380" class="elsevierStylePara elsevierViewall">In contrast&#44; the use of oral antibiotics and oral corticosteroids is not recommended during the postoperative period&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">2&#41;</span><p id="par0385" class="elsevierStylePara elsevierViewall">Recommendations for the patient&#46;<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">-</span><p id="par0390" class="elsevierStylePara elsevierViewall">During the first 24&#8239;h after the intervention&#58; <ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">o</span><p id="par0395" class="elsevierStylePara elsevierViewall">Patients are recommended not to blow the nose or sneeze with the mouth shut&#46;</p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">o</span><p id="par0400" class="elsevierStylePara elsevierViewall">Patients are recommended to carry out frequent nasal washes for 2 weeks&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">-</span><p id="par0405" class="elsevierStylePara elsevierViewall">After the first 24&#8239;h following surgery the patients are recommended to&#58;<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">o</span><p id="par0410" class="elsevierStylePara elsevierViewall">Carry out repeated Valsalva manoeuvres for at least 4 weeks &#40;pinch the nostrils and then&#44; whilst keeping the mouth shut and tensing the stomach muscles&#44; exhale as if you were blowing through the nose&#46; This manoeuvre works equally on ear pressure&#44; whilst also opening the Eustachian tubes&#41;&#46; Experience suggests repetition of this manoeuvre 3&#8211;5 times per day&#46;</p></li><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">o</span><p id="par0415" class="elsevierStylePara elsevierViewall">If surgery to the middle ear was performed&#44; including myringotomy&#44; combined with BET&#44; the Valsalva manoeuvre is not recommended until one month after surgery&#44; and the guidelines for middle ear surgery are recommended&#46;</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">o</span><p id="par0420" class="elsevierStylePara elsevierViewall">Patients should be warned that pre-existing tinnitus could increase&#44; together with a buzzing sensation&#44; but that this is a good sign of balloon efficacy&#46;</p></li></ul></p></li></ul></p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Complications From Balloon Eustachian Tuboplasty</span><p id="par0425" class="elsevierStylePara elsevierViewall">Few&#44; generally mild complications have been described&#58; <ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">-</span><p id="par0430" class="elsevierStylePara elsevierViewall">Mild or moderate pain</p></li><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">-</span><p id="par0435" class="elsevierStylePara elsevierViewall">Mild haemorrhaging or bleeding</p></li><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">-</span><p id="par0440" class="elsevierStylePara elsevierViewall">Temporary hemotympanum</p></li><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">-</span><p id="par0445" class="elsevierStylePara elsevierViewall">Acute otitis media</p></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">-</span><p id="par0450" class="elsevierStylePara elsevierViewall">Changes to taste sensation</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">-</span><p id="par0455" class="elsevierStylePara elsevierViewall">Temporary peritubaric emphysema&#44; although on very few occasions this may extend through the neck to the mediastinum &#40;incidence of &#46;003&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a></p></li></ul></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Postoperative Tests After Balloon Eustachian Tuboplasty</span><p id="par0460" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">-</span><p id="par0465" class="elsevierStylePara elsevierViewall">These are usually the same as in preoperative&#44; aimed at proving the resolution of the Eustachian tube dysfunction &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">-</span><p id="par0470" class="elsevierStylePara elsevierViewall">The most common is to assess its efficacy using otoscopy&#47;microscopy&#44; Valsalva and Toynbee manoeuvres&#44; tonal audiometry&#44; tympanogram and postoperative ETDQ-7&#46;</p></li><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">-</span><p id="par0475" class="elsevierStylePara elsevierViewall">The tubomanometry may be a more objective tool for assessing tube opening after BET&#46;</p></li></ul></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Follow-up After Balloon Eustachian Tuboplasty</span><p id="par0480" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">-</span><p id="par0485" class="elsevierStylePara elsevierViewall">For accurate follow-up check-ups with patients after one month&#44; 3 months&#44; 6 months and one year are to be made&#46;</p></li><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">-</span><p id="par0490" class="elsevierStylePara elsevierViewall">If there is an associated myringotomy patients must be seen after 15 days&#46;</p></li><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">-</span><p id="par0495" class="elsevierStylePara elsevierViewall">For assessment of efficacy the results are considered to be short term &#40;4&#8211;6 weeks&#41;&#44; medium term &#40;6 months&#41; and long term &#40;&#62;12&#8239;months&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p></li><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">-</span><p id="par0500" class="elsevierStylePara elsevierViewall">It is important to know that effectiveness cannot be assessed until 3 months have passed&#44; and that stability may be obtained from 12 months onwards &#40;the patient has experienced all season of the year and climate changes associated with the changing of the seasons&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">53&#44;54</span></a></p></li></ul></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Definition of the Results of Balloon Eustachian Tuboplasty</span><p id="par0505" class="elsevierStylePara elsevierViewall">The consensus is that 6 months after surgery a good result is considered to be when&#58; <ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">1&#41;</span><p id="par0510" class="elsevierStylePara elsevierViewall">Serous otitis media&#58; when it is not necessary to insert another tympanic drainage&#46;</p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">2&#41;</span><p id="par0515" class="elsevierStylePara elsevierViewall">Adhesive otitis media &#40;grades <span class="elsevierStyleSmallCaps">i</span> and <span class="elsevierStyleSmallCaps">ii</span>&#41;&#58; recovery of tubaric ventilation &#40;not audition&#41; with positive Valsalva manoeuvres and&#47;or improvement in typanogram&#46;</p></li><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">3&#41;</span><p id="par0520" class="elsevierStylePara elsevierViewall">Atelectasis &#40;grades <span class="elsevierStyleSmallCaps">i</span> and <span class="elsevierStyleSmallCaps">ii</span>&#41;&#58; recovery of tubaric ventilation &#40;not audition&#41; with positive Valsalva manoeuvres and&#47;or improvement in typanogram&#46;</p></li><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">4&#41;</span><p id="par0525" class="elsevierStylePara elsevierViewall">Failure of tympanoplasty&#58; closure of the tympanic perforation &#40;if there was perforation&#41;&#44; improvement and&#47;or stabilization of typanic retraction &#40;if there was retraction&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">5&#41;</span><p id="par0530" class="elsevierStylePara elsevierViewall">Barotrauma &#40;aviation and diving&#41;&#58; improvement of symptoms&#44; positive Valsalva manoeuvres and&#47;or improvement in typanogram&#46;</p></li></ul></p><p id="par0535" class="elsevierStylePara elsevierViewall">Regarding the effectiveness of the BET&#44; the studies published offer the best result when the baseline disease is barotrauma &#40;aviation and diving&#41;&#44; followed by serous otitis media &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In the other indications the results are more uneven&#46; For some authors BET has not even yet presented valid results&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a></p><p id="par0540" class="elsevierStylePara elsevierViewall">Numerous studies have been published on the BET&#44; the good results of which have been maintained or even improved long term&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7&#44;13&#8211;19&#44;24&#8211;30</span></a> On the other hand&#44; recently 2 randomised clinical trials have been published<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a> in which the efficacy of BET has been confirmed compared with medical treatment &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0545" class="elsevierStylePara elsevierViewall">For Poe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> improvement after treatment was interpreted as a ETDQ-7&#8239;&#60;&#8239;3&#44; a positive Valsalva manoeuvre &#40;when it was initially negative&#41; and normalisation of the tympanogram to a type A &#40;when it was previously type B&#47;C&#41;&#46; These were all more common after BET than after medical treatment&#44; with all 3 being statistically significant&#46; Recently Anand et al&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> published the results of this same trial&#44; with 52 weeks of follow-up&#44; showing how the improvements after BET remained over time&#46;</p><p id="par0550" class="elsevierStylePara elsevierViewall">For Meyer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> improvement after BET became an improvement of the ETDQ-7&#44; to a positive Valsalva manoeuvre &#40;when it was initially negative&#41; and normalisation of the tympanogram to a type A &#40;when it was previously type B&#47;C&#41;&#46; These were all more common after BET than after medical treatment&#44; with those of the ETDQ and the tympanogram being statistically significant&#46;</p><p id="par0555" class="elsevierStylePara elsevierViewall">Without a doubt the BET is a technique which will be increasingly used more by all ENT specialists as shown by the survey conducted by Miccuci et al&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a></p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclusions</span><p id="par0560" class="elsevierStylePara elsevierViewall">BET is a minimally invasive surgical procedure which has demonstrated its effectiveness and safely in the treatment of chronic Eustachian tube dysfunction in adults and children&#46; It is a treatment which is aimed at improving the aetiology of Eustachian tube disease and not to alleviate its symptoms&#46; The indications for which BET is most effective are barotrauma and serous otitis media&#46; BET is a safe procedure with minimal complications&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Financing</span><p id="par0565" class="elsevierStylePara elsevierViewall">This research received specific finance from the company <span class="elsevierStyleGrantSponsor" id="gs0005">SH Medical Group</span> for the development of this consensus&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conflict of Interests</span><p id="par0570" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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              "titulo" => "Indications for Paediatric Patients"
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          "titulo" => "Advice During Balloon Eustachian Tuboplasty"
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            2 => "Tympanometry"
            3 => "Balloon Eustachian tuboplasty"
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            0 => "Disfunci&#243;n tub&#225;rica cr&#243;nica"
            1 => "Valsalva"
            2 => "Timpanometr&#237;a"
            3 => "Dilataci&#243;n tub&#225;rica"
            4 => "Bal&#243;n tub&#225;rico"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">There is a great variability in diagnosis of obstructive Eustachian tube dysfunction and its treatment by balloon Eustachian tuboplasty &#40;BET&#41;&#46; The aim of this paper was to present a consensus on indications&#44; contraindications&#44; methodology&#44; complications and results after BET&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material &#38; Methods</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">We obtained a consensus on BET&#44; after a systematic review of the literature on BET from 1966 to November 2018&#44; using MESH terms &#8220;Eustachian tube and &#40;dilation or dysfunction&#41;&#8221;&#44; including a total of 1&#46;943 papers in Spanish&#44; English&#44; German and French&#46; We selected 139 papers with a relevant abstract&#44; including two international consensuses&#44; seven systematic revisions&#44; and two randomised control trials on BET&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The indications for BT are barotrauma&#44; serous otitis media&#44; adhesive otitis&#44; atelectatic middle ear and failure after tympanoplasty&#44; once obstructive Eustachian tube dysfunction is confirmed&#46; BET is more effective in barotrauma and serous otitis media&#46; There are high-evidence reports on BET showing good results that persist long-term&#44; as compared to conservative medical treatment&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">BET is a surgical&#44; minimally invasive treatment that has shown its effectiveness and safety in obstructive Eustachian tube dysfunction in adults and children&#46; It is most effective in barotrauma and serous otitis media&#46;</p></span>"
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          0 => array:2 [
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            "titulo" => "Objective"
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            "titulo" => "Material &#38; Methods"
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          2 => array:2 [
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            "titulo" => "Results"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Existe una gran variabilidad en el diagn&#243;stico de la disfunci&#243;n tub&#225;rica obstructiva y su tratamiento mediante la dilataci&#243;n tub&#225;rica con bal&#243;n &#40;DTB&#41;&#46; El objetivo de este trabajo es presentar unas recomendaciones de consenso sobre las indicaciones&#44; contraindicaciones&#44; metodolog&#237;a&#44; complicaciones y resultados de la DTB&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Presentamos un consenso sobre la DTB&#44; mediante revisi&#243;n sistem&#225;tica de la literatura desde 1966 hasta noviembre de 2018&#44; t&#233;rminos MESH &#8220;Eustachian tube and &#40;dilation or dysfunction&#41;&#8221;&#44; recogiendo un total de 1&#46;943 art&#237;culos en espa&#241;ol&#44; ingl&#233;s&#44; alem&#225;n y franc&#233;s&#46; Del total de art&#237;culos revisados&#44; se seleccionaron 139 cuyo abstract era relevante&#44; incluyendo dos consensos internaciones sobre diagn&#243;stico&#44; siete revisiones sistem&#225;ticas y dos ensayos cl&#237;nicos aleatorizados sobre la DTB&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Las indicaciones de la DTB son el barotrauma&#44; la otitis media secretora&#44; la otitis media adhesiva&#44; la atelectasia y el fracaso de una timpanoplastia&#44; siempre que se haya podido demostrar una disfunci&#243;n tub&#225;rica obstructiva cr&#243;nica&#46; La efectividad de la DTB es mayor en el barotrauma y la otitis media secretora&#46; Hay estudios publicados de elevada evidencia sobre la DTB&#44; cuyos buenos resultados se mantienen a largo plazo&#44; frente a tratamiento m&#233;dico conservador&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La DTB es un procedimiento quir&#250;rgico m&#237;nimamente invasivo que ha demostrado su efectividad y seguridad en el tratamiento de la disfunci&#243;n tub&#225;rica cr&#243;nica en adultos y en ni&#241;os&#46; Las indicaciones en las que es m&#225;s efectiva son el barotrauma y la otitis media secretora&#46;</p></span>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of Patients &#40;Ballooning&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean Follow-up &#40;Months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Symptoms&#58; ETS&#44; ETDQ-7 or Improvement in Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Positive Valsalva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Modified Tympanogram &#40;B&#8211;C&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Poe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> &#40;2011&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;6&#8211;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#37; pre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#37; pre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#37; post&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#37; post&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">McCoul et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> &#40;2012&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;&#191;&#63;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;5 pre 2&#46;8 post&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#37; pre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Epystaxis with hemotympanum after turbinectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#37; post&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Schr&#246;der et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> &#40;2013&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Improvement of symptoms in 83&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Always&#8239;&#43; 45&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#47;15 ears 40&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">At times&#8239;&#43; 45&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Silvola et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> &#40;2014&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;18&#8211;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#37; pre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#37; pre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">80&#37; post&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;0001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Schr&#246;der et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> &#40;2015&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;188&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;15 pre vs&#46; 5&#46;75 post&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">73&#37; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;65 pre vs&#46; 6&#46;26 post 82&#37; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Dalchow et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> &#40;2016&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#40;43&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;23 pre 2&#46;68 post&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">Xiong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> &#40;2016&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">40 &#40;58&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Stuffiness <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No complications&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">earache <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">98&#37; pos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#37; pos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Tinnitus <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;005&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dulled hearing <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;005&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bowles et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> &#40;2017&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">39 &#40;55&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&#46;9 pre 2&#46;0 post <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#37; pre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">49&#37; pre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#37; post&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#37; post<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leichtle et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> &#40;2017&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52 &#40;97&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#37; pre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&#37; pre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">One hemotympanum 3 mild nosebleeds&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&#37; post&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#37; post&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Luukkainen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> &#40;2017&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#40;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Improvement in symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#37;Valsalva&#8239;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of Patients &#40;Easrs&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ETDQ-7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Positive Valsalva &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Normal Type A Tympanogram&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Meyer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> &#40;2018&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;2&#46;9 &#40;SD 1&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#47;17 &#40;47&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#47;14 &#40;57&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Controls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&#46;6 &#40;SD 1&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#47;14 &#40;14&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#47;10 &#40;10&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Poe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> &#40;2018&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">162 &#40;234&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&#47;137 &#40;56&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&#47;139 &#40;51&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Controls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80 &#40;117&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#47;71 &#40;8&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&#47;72 &#40;13&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">During the Last Month&#44; What Discomfort Have the Following Symptoms Caused You&#63;</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t">Pressure in the ear&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 4 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Pain in the ear&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">3 4 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6 7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Blockage of ears&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 4 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6 7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Symptoms of catarrh in the ear&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 4 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">6 7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Clicking on opening in the ear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 4 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6 7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Buzzing in the ear&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 4 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6 7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Reduced hearing&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 4 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6 7&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">EDTQ-7&#58; Eustachian Tube Dysfunction Questionnaire of McCoul et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Validated Into Spanish by Herrera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p>"
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                    0 => array:2 [
                      "titulo" => "Eustachian tube&#58; Structure&#44; function&#44; role in middle-ear disease"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
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                            1 => "M&#46;B&#46; Bluestone"
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                        "fecha" => "2017"
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                        "editorialLocalizacion" => "Raleigh&#44; NorthCarolina"
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                          "etal" => false
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                            0 => "H&#46; Sudhoff"
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            2 => array:3 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Balloon dilation Eustachian tuboplasty"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "T&#46; Ockermann"
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                            2 => "T&#46; Upile"
                            3 => "J&#46; Ebmeyer"
                            4 => "H&#46;H&#46; Sudhoff"
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                      ]
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                    0 => array:2 [
                      "doi" => "10.1097/MAO.0b013e3181e8cc6d"
                      "Revista" => array:6 [
                        "tituloSerie" => "Otol Neurotol"
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                        "link" => array:1 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Balloon dilatation Eustachian tuboplasty&#58; A clinical study"
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                      "doi" => "10.1016/j.amjoto.2009.11.008"
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                          "etal" => false
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                            0 => "P&#46;J&#46; Catalano"
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                            3 => "A&#46; Tabaee"
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                      "doi" => "10.1002/lary.23181"
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Article information
ISSN: 21735735
Original language: English
DOI:10.1016/j.otoeng.2019.01.005
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