Revisiting the Diagnostic Performance of the Modified Nine-Step Test for Obstructive and Patulous Eustachian Tube Dysfunction

Abstract

The nine-step test is a classical method for evaluating Eustachian tube function. It directly assesses the patient’s capacity to equilibrate middle ear pressure by swallowing. However, there are insufficient studies to appraise its diagnostic performance. The purpose of this study is to evaluate the sensitivity, specificity, and cut-off value of the nine-step test in patients with obstructive Eustachian tube dysfunction (oETD) and patulous Eustachian tube (PET). Enrolled subjects were divided into three groups. Control (50 ears of healthy volunteers), oETD (19 ears with oETD), and PET (29 ears with PET). Receiver operating characteristics curve analysis was conducted to evaluate the diagnostic performance of maximal peak pressure difference (ETTmd) in the nine-step test. Both the oETD group and the PET group showed decreased ETTmd. The nine-step test showed moderate accuracy when used to diagnose oETD (area under the curve = 0.875) and PET (area under the curve = 0.769). The highest diagnostic performance was observed when the cut-off value was 13 daPa for both the oETD group (sensitivity = 73.7%, specificity = 90.0%) and the PET group (sensitivity = 58.6%, specificity = 90.0%). The nine-step test has moderate diagnostic performance for oETD and PET.

Balloon Dilation Eustachian Tuboplasty for Dilatory Dysfunction With and Without Effusion: A Comprehensive Outcome Analysis

“…ETF tests with manometric approaches have been reasonably accurate and are widely used in many medical institutions. 11,27,28 They reflect the status of ETF more straightforwardly than tympanometry, regardless of the tympanic membrane integrity. Hence, they were introduced as the assessment tools to present the treatment outcomes.…”

“…But, the VTI or myringotomy treatment made the postoperative tympanometry inapplicable to the population with ETD and concurrent MEE. ETF tests with manometric approaches have been reasonably accurate and are widely used in many medical institutions 11,27,28 . They reflect the status of ETF more straightforwardly than tympanometry, regardless of the tympanic membrane integrity.…”

Results of Eustachian tube balloon dilation measured using the nine-step test

“…The exclusion criteria were as follows: (1) no distinguishable peak in tympanometry (not type A or C), (2) MPD in the nine-step test higher than 13 daPa, (3) lack of 1-month follow-up evaluation with the nine-step test, and (4) craniofacial anomaly. We selected patients with abnormal MPD (≤ 13 daPa) in whom opening of the Eustachian tube failed upon swallowing 23 .…”

Interpretation of the nine‐step test for Eustachian tube function should consider mastoid cavity volume

“…However, as with other Eustachian tube function tests (ETFT), the diagnostic performance of the nine-step test is not satisfactory. [3][4][5][6] Although sensitivity and specificity vary according to different cut-off values and different definitions of Eustachian tube dysfunction (ETD), the reported sensitivity and specificity of the nine-step test do not exceed 75% and 90%, respectively. 4,5,7 Furthermore, alternative ETFTs, including sonotubometry, tubo-tympano-aerodynamic-graphy and tubomanometry, have been developed for the diagnosis of ETD.…”

“…[3][4][5][6] Although sensitivity and specificity vary according to different cut-off values and different definitions of Eustachian tube dysfunction (ETD), the reported sensitivity and specificity of the nine-step test do not exceed 75% and 90%, respectively. 4,5,7 Furthermore, alternative ETFTs, including sonotubometry, tubo-tympano-aerodynamic-graphy and tubomanometry, have been developed for the diagnosis of ETD. 3,6,[8][9][10] The critical disadvantage of the nine-step test is that can only be applied to a normal tympanic membrane, indicating an intact tympanic membrane with aerated middle ear cavity.…”