Tympanometry, Valsalva and Toynbee …

The Effect of Valsalva and Toynbee Maneuvers on Tympanometry Parameters in Normal and Retracted Tympanic Membrane https://juniperpublishers.com/gjo/pdf/GJO.MS.ID.555896.pdf
Tympanometry* is a test that measures the tympanic membrane impedance. It’s helpful in diagnosing middle ear pathologies along with Eustachian tube diseases [4]. Valsalva maneuver is a maneuver which is done by blowing against pinched nostrils and a closed mouth. It increases the middle ear pressure, pushing the tympanic membranes laterally. Toynbee is the exact opposite, it’s done by closing the mouth and nostrils and swallowing, which creates negative pressure in the middle ear, retracting the tympanic membranes medially. Kumazawa, et al. [5] used tympanometry combined with the aforementioned maneuvers to diagnose Eustachian tube diseases.

More on pressure:

Study of Toynbee Phenomenon by Combined Intranasopharyngeal and Tympanometric Measurements – https://journals.sagepub.com/doi/abs/10.1177/000348948809700220?journalCode=aora
” In 1971 Elner et al” found that in normal subjects the Toynbee maneuver resulted in negative middle ear pressure in 64%, alternately positive and negative pressure in 24 %, and positive pressure in 12%”

Abstract: The Toynbee maneuver, swallowing when the nose is obstructed, leads in most cases to pressure changes in one or both middle ears, resulting in a sensation of fullness. Since first described, many varying and contradictory comments have been reported in the literature concerning the type and amount of pressure changes both in the nasopharynx and in the middle ear. In our study, the pressure changes were determined by catheters placed into the nasopharynx and repeated tympanometric measurements. New information concerning the rapid pressure variations in the nasopharynx and middle ear during deglutition with an obstructed nose was obtained. Typical individual nasopharyngeal pressure change patterns were recorded, ranging from a maximal positive pressure of + 450 to a negative pressure as low as −320 mm H2O.

What causes positive ear pressure? As you ascend, the cabin air pressure drops and a relative positive pressure builds up in the middle ears. For most people, this pressure easily escapes out through the Eustachian tube. Thus, the pressure of the middle ear equilibrates with that of the cabin air pressure (about 6000 feet above sea level). https://med.stanford.edu/ohns/OHNS-healthcare/earinstitute/conditions-and-services/conditions/eustachian-tube-dysfunction.html

What is negative pressure in ear? When the eustachian tube does not open to allow the middle ear space to ventilate for a prolonged period of time, negative pressure is generated in the middle ear space as the mucous membranes absorb the air from the middle ear. http://www.idahoear.com/condition-eustachian-tube-problems.html

The Effect of Valsalva and Toynbee Maneuvers on Tympanometry Parameters in Normal and Retracted Tympanic Membrane https://juniperpublishers.com/gjo/pdf/GJO.MS.ID.555896.pdf
Tympanometry is a test that measures the tympanic membrane impedance. It’s helpful in diagnosing middle ear pathologies along with Eustachian tube diseases [4]. Valsalva maneuver is a maneuver which is done by blowing against pinched nostrils and a closed mouth. It increases the middle ear pressure, pushing the tympanic membranes laterally. Toynbee is the exact opposite, it’s done by closing the mouth and nostrils and swallowing, which creates negative pressure in the middle ear, retracting the tympanic membranes medially. Kumazawa, et al. [5] used tympanometry combined with the aforementioned maneuvers to diagnose Eustachian tube diseases. 

About consequences of obstruction in the nostrils. Based on the Toynbee phenomenon, even minor obstacles can obviously cause negative pressure in the middle ear, which in turn can have several consequential effects. Although there are many different systems/functions close by and that even (chronic) infections/inflammations can interact, it can be difficult to investigate and identify critical possible (synergy?) dysfunctions, but pressure (and possibly hypoxia involvement) can be an initiating mechanism. Extremely complex, but perhaps one may be able to do, as we do in psychophysiological behavioral medicine, precisely focus on critical central systems/functions (in our case, e.g. autonomic nervous system oscillation).

 

* Tympanometry https://www.aafp.org/afp/2004/1101/p1713.html ”Tympanogram tracings are classified as type A (normal), type B (flat, clearly abnormal), and type C (indicating a significantly negative pressure in the middle ear, possibly indicative of pathology)”

 

 

 

 

Figure 1 – Type A tympanogram. Type AD has a high peak height. The middle curve is normal. Type AS has a reduced peak height.

 

 

 

 

 

 

 

Fig. 2A is a flattened, or type B tracing, with a low static admittance. The ear canal volume is normal. The most common cause of this pattern is decreased mobility of the tympanic membrane secondary to middle ear fluid (OME). Other causes are increased stiffness of the eardrum (from scarring), tympanosclerosis (the formation of dense connective tissue around the auditory ossicles), cholesteatoma, or middle ear tumor.26,31 When evaluating the efficacy and clinical usefulness of tympanometry, many studies consider only a type B tracing as definitely abnormal

Fig 2B depicts a completely flat tracing with low ear canal volume, indicating partial ear canal occlusion with cerumen or improper placement of the probe.

Figure 2C depicts a type B curve with a high measured volume. In the presence of a perforation of the tympanic membrane or a patent tympanostomy tube, acoustic energy also will be absorbed by air in the middle ear and possibly mastoid air cells, resulting in a higher than normal volume detected.32 Mastoidectomy also increases the measured volume.

Fig 2D is qualitatively somewhere between the preceding examples—the peak height falls within the normal range, but the tympanogram is too wide. Although this finding has been reported to be sensitive to middle ear disease when the static admittance is normal,33 most authorities do not consider its presence to be reliably diagnostic for middle ear pathology. It may occur with oncoming or resolving OME, or tympanosclerosis.

Fig 2E (or type C tracing) demonstrates a highly negative pressure in the middle ear, correlating to a retracted tympanic membrane. A viral upper respiratory infection may impair the ventilatory function of the eustachian tube. Negative middle ear pressure develops and nasopharyngeal contents are aspirated into the middle ear, resulting in AOM.4,34 This type of curve may indicate a transition between a normal ear and an ear that is full of fluid.35 The presence of a highly negative tympanic peak pressure observed during upper respiratory infection with no evidence of AOM may be a significant marker for increased risk for development of AOM.36 A type C curve may be clinically useful when correlated with other findings, but by itself is an imprecise estimate of middle ear pressure and does not have high sensitivity or specificity for middle ear disorders.17,37 Some authorities will subdivide C curves and distinguish C1 curves (moderately negative pressure) as normal and C2 curves (highly negative pressure) as abnormal or indefinite

Fig 2F indicates a highly positive peak pressure consistent with the bulging tympanic membrane that sometimes occurs with AOM.

Abstract: Tympanometry provides useful quantitative information about the presence of fluid in the middle ear, mobility of the middle ear system, and ear canal volume. Its use has been recommended in conjunction with more qualitative information (e.g., history, appearance, and mobility of the tympanic membrane) in the evaluation of otitis media with effusion and to a lesser extent in acute otitis media. It also can provide useful information about the patency of tympanostomy tubes. Tympanometry is not reliable in infants younger than seven months because of the highly compliant ear canals of infants. Tympanogram tracings are classified as type A (normal), type B (flat, clearly abnormal), and type C (indicating a significantly negative pressure in the middle ear, possibly indicative of pathology). According to the Agency for Healthcare Research and Quality guidelines on otitis media with effusion, the positive predictive value of an abnormal (flat, type B) tympanogram is between 49 and 99 percent. A type C curve may be useful when correlated with other findings, but by itself it is an imprecise estimate of middle ear pressure and does not have high sensitivity or specificity for middle ear disorders.”  

More is to come ..