The most important  thing about a patent E tube is to diagnose it so that a coherent explanation can be given to the patient.  The diagnosis ought to be clear from the history, but it may be useful to show breathing movements on the baseline acoustic impedance trace, getting the patient to stand up if not at first seen .

I think there is only one short and easy answer (if he/she is in a real trouble with it, indeed): VT!

You may put a VT to provide a better comfort if they accept. But, they have to know how to protect the ear with VT in bathroom, and in particular during swimming. This will be new trouble of those subjects!

And there are some medical recommendations (I have never seen that they work) and more surgical techniques (collagen injection, grafting, paper oatching and endoscopic ligation, etc). 

"I think there is only one short and easy answer..... VT"

In pat ET, the problems are caused by hyperaeration of the middle ear, so I do not see a priori why grommets should help.  There is a suggestion that some PET symptoms arise from a secondary endolymphatic hydrops (audiosensitivity, feeling of blockage or pressure in the ear, etc).  A likely explanation is that the middle ear gets dehydrated, perilymph pressure drops, hydrops forms.   There is accumulating evidence that grommets in childhood predispose to pat ET in adults.

Yes, it is true that grommets and previous ear surgeries are not rarely identified in those cases. Because, first ET abnormalities are main underlying causes of the otitis media (OM) with effusion in which VT insertion could be indicated; second either VT insertions or OM disturbs structure of the tympanic membrane (TM), known as pseudomembrane mostly lost fibrous layer of the TM. Thus, we may find out history of OM in many subjects with patulous ET. (And further forms OM are a very common diseases during childhood: acute OM is the 2nd most common infection disease after common cold, and OM with effusion is present in about 1/5 of the children under 8 years of age during winter season.)

What VT do in the subjects with patulous ET:  If the subject is complaining a sound or movement of TM while breathing and if you clearly observe TM movement while breathing and/or swallowing, VT works to subside these symptoms because when VT is inserted, breathing can not change the pressure in the middle ear cavity, hence TM movement which occurs in parallel to pressure changes related with inspiration and expiration, and also swallowing, etc. in the subjects with patulous ET stop. The problem of patulous ET still continues, but symptoms subside. The patient stop suffering TM movement or sound accompanying the breathing. It works in many cases. However, as I pointed out before, new problems such as protection of the ear from water, etc replace!

Or you do prefer ET surgery which is out of my experience.

I also do not have any background information related with relation of  hydrops with ET function. 

On the other hand, if the patient suffers from sound (tinnitus) while breathing but no movement of the TM is seen by otoscopy, and even during Valsalva, and further tympanometry  disclose no abnormality, ET function tests should be done. If these are also normal, I think other causes of objective tinnitus should be taken account first. 

"Yes, it is true that grommets and previous ear surgeries are not rarely identified in those cases"

I suspect that grommets are disproportionally common with PET, and hence a likely cause.  Since grommets have been used so widely in OM, this is probably a major link.  A simple explanation is that grommets have altered lymphatic drainage routes in and out of the middle ear, taking up less of the ET lumen.

"Because, first ET abnormalities are main underlying causes of the otitis media (OM) with effusion"

I know this is widely believed, but I think it is not true.  I think the main cause, as Hippocrates said, is a widespread developmental abnormality of cranial lymph circulation, either excessive input from the CSF, or restricted drainage channels, with ET blockage mainly secondary to this, though once the ET has swollen up, this will restrict fluid drainage and cause fluid accumulation in the middle ear.  Most children with OM have perfectly normal ETs, at least betwen bouts.

"I also do not have any background information related with relation of hydrops with ET function"

Like PET, this is a clinical diagnosis.  The following may accompany PET: vertigo, dizziness, tinnitus, slight cochlear deafness, distorted hearing, audiosensitivity.  Taken together, these are all totally consistent with hydrops.  The clincher is the blocked ear feeling, in my opinion pathognomonic of hydrops, and which can surely, contrary to popular belief, indicate an open ET.

Division of tensor palati has been helpful some cases.

Thanks Ranjit for your sharing. Would you mention any published article which supports your opinion.

Sorry I failed to publish my results.

I don't beleive VT may play an important role in the mangement of these patients. Because, after insertion of VT, the problem is there, and that is hyper-areation of middle ear and connection with pharynx leading to autophony and patients symptoms. In the literature, VT have efficacy of about 50% in management of PET.

what i do in these patients, is assuarance, that play an important role, and recommend swimming! The chloride in the water and air leads to some degree of inflammation of eustachian tube and therefore decreases symptoms significantly. My patients are very well with this recommendtation.

Thanks Ali for your sharing. I hope you add any publication which support your recommendation.

I got idea from this paper:

THE AMERICAN JOURNAL OF OTOLOGY/VOLUME 13, NUMBER 4 July 1992

A NEW MEDICATION TO CONTROL PATULOUS EUSTACHIAN TUBE DISORDERS

Joseph R. DiBartolomeo, and David F. Henry

In general the only therapy that I have had success with is ventilation tube placement.  My experience is that about 75% of patients who have this diagnosis report imporved tolerance of the problem with ventilation.  The mechanism for the improvement is the lack of pressure fluctuation in the tympanic space as the tube allows the airway pressure variation to be dissipated at least to some degree with each ventilation cycle.  The other problem that I have encountered is the severely atrophic flaccid TM that can be the result of longstanding cyclic pressure variation in the middle ear.  This has responded well to tympanoplasty with cartialge grafting to stabilize the TM. 

Thanks Michael for your sharing. I hope you support your therapeutic trend with  published articles.

I agree with above mentioned managements; reassurance, VT insertion, and cartilage myringoplasty. Some doctors had tried E-tube stents. How about silastic stent insertion?

Thanks Sun O Chang for your sharing but would you inform when you choose either VT insertion or cartilage myringoplasty.

 see this article

Otolaryngology Head and Neck Surgery 04/2011; 145(3):446-51. DOI:10.1177/0194599811406347

and you could  get more answer !

also you could follow Carlos Yanez to get more

https://www.researchgate.net/profile/Carlos_Yanez/publications

An experienced Otolaryngologist that has recently retired, told me he would fracture the hook of the hamulus to release the tension in the tensor timpani, and found that quite successful.

A few papers I have found informative are:

1.             Schilder, A.G.M., Bhutta, M.F., Butler, C.C., Holy, C., Levine, L.H., Kvaerner, K.J., Norma, G., Pennings, R.J., Poe, D., Silvola, J.T., Sudhoff, H. and Lund, V.J.

Eustachian tube dysfunction: consensus statement on definition, types, clinical presentation and diagnosis

Accepted for publication 3 June 2015 Clin. Otolaryngol. 2015, 40, 407-411

2.This is one I base my assessment of Patulous Eustachian Tubes on. I contacted McGrath and he said that breath synchronous compliance using reflex decay = a patulous eustachian tube 100% of the time. Then with history, it will tell you the degree of discomfort caused to the patient. I myself have breath synchronous compliance using reflex decay, but no symptoms so history is obviously an indicator of severity. 

J Am Acad Audiol. 2011 Apr;22(4):201-7. doi: 10.3766/jaaa.22.4.2.

Use of middle ear immittance testing in the evaluation of patulous eustachian tube.

McGrath AP1, Michaelides EM.

3.Poe DS. Diagnosis and management of the patulous Eustachian tube. Otol Neurotol 2007; 28:668–677. Ovid Full Text [Context Link]

"I myself have breath synchronous compliance using reflex decay, but no symptoms so history is obviously an indicator of severity."

Have you looked for typical compliance changes in various head/body positions?  My guess is that your E tube is only slightly open in certain positions, especially on standing,  so that you do not get bothersome symptoms.

See:

Treatment Effectiveness for Symptoms of Patulous Eustachian Tube: A Systematic Review.

Luu K1, Remillard A, Fandino M, Saxby A, Westerberg BD....

OBJECTIVES:

To determine the effectiveness of currently available medical and surgical interventions for treating symptoms of Patulous Eustachian Tube (PET).

DATA SOURCES:

A comprehensive search of MEDLINE (January 1948 to July 8, 2015), EMBASE (January 1974 to July 8, 2015), gray literature, hand searches, and cross-reference checking.

STUDY SELECTION:

Original published reports evaluating an intervention to treat the symptoms of patulous eustachian tube in patients 18 years and older.

DATA EXTRACTION:

Quality-of-case reviews were assessed with the National Institute of Health (NIH) Quality Assessment Tool for Case Series Studies.

DATA SYNTHESIS:

The search strategy identified 1,104 unique titles; 39 articles with 533 patients are included. The available evidence consists of small case series and case reports. The most common medical treatment was nasal instillation of normal saline. Surgical treatments were categorized as mass loading of the tympanic membrane, eustachian tube plugging, and manipulation of eustachian tube musculature.

CONCLUSIONS:

The available evidence for management of patients with PET is poor in quality and consists predominantly of small case series. Further research is needed to determine the comparative efficacy of the current treatments.

The best for PET diagnostic is a french device called "tubomanometry". It gives the level of ET operture (in mbar) and it can record diferences of pressure during forced breath.

The research that was the basis for my M.S.(1968) was looking to see the ideal place for injection of polytetrafluoroethylene (PTFE) to treat patulous Eustachian tubes. 

I developed a method for measuring ET patency in anesthetized dogs using an air flow system through a myringotomy. The back flow in a manometer would show the opening pressure of the ET. There were two possible places for the injection. 1. behind the torus tubarius  2.in front into the tensor veli palatini. The tensor injection reduced the patency without causing serous otitis media. The behind the torus injection did not change the patency as expected but produced serous otitis media in all dogs. The latter revealed that ET obstruction was not a necessary etiology for serous otitis media.

Clinically the PTFE injection was effective, but its exact placement in the human was difficult and lead to at least two deaths and was subsequently abandoned.

Clinically, now when expected, the diagnosis is confirmed with the ET insufflation of a boric acid/salicylic acid powder. If confirmed the patient can be instructed in self ET catheterization with insufflation of the powder as necessary. In some instances presumably by producing some chronic inflammation of the ET mucosa the symptom disappears.

Dennis Poe has been performing the leading edge endonasal contemporary surgical management.