{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T16:13:13Z","timestamp":1787069593222,"version":"build-2736575974"},"reference-count":9,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2024,5,10]],"date-time":"2024-05-10T00:00:00Z","timestamp":1715299200000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Ear Nose Throat J"],"abstract":"<jats:p>Objective: In this retrospective case series, we reported 4 patients presenting with a patulous Eustachian tube (PET) to highlight our institutional management approach to PET with shim insertion and a modified shim with hydroxyapatite injection. Methods: A single institution retrospective review. Results: One case was complicated by otitis media effusion; thus, the shim was downsized under local anesthesia with an immediately improved effusion. Another patient managed with a bilateral shim of the same size but is still symptomatic on one side; therefore, we upsized it, and the symptoms disappeared. The last one developed biofilm formation and thick secretion even after downsizing. Hydroxyapatite injection was performed under local anesthesia using the same shim insertion protocol. Conclusion: Shim insertion for the treatment of PET is considered a safe, reversible, and adjustable technique, giving satisfactory results while avoiding middle ear effusion. It can be performed under local or topical anesthesia in the clinic, and size adjustment can be considered to get maximum relief without middle ear effusion. This case series highlights that adjusting the size of the shim is a suggested method to eliminate symptoms and avoid complications of shim without the need for myringotomy and ventilation tube.<\/jats:p>","DOI":"10.1177\/01455613241253215","type":"journal-article","created":{"date-parts":[[2024,5,10]],"date-time":"2024-05-10T08:21:35Z","timestamp":1715329295000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":2,"title":["Optimized Management of Patulous Eustachian Tube: Shim Size Modifications to Minimize Middle Ear Effusion and Enhancing Treatment Outcomes"],"prefix":"10.1177","author":[{"given":"Saleh","family":"AlAmry","sequence":"first","affiliation":[{"name":"Department of Otolaryngology\u2014Head and Neck Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6552-9341","authenticated-orcid":false,"given":"Homood M.","family":"Almutairi","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology\u2014Head and Neck Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thamer M.","family":"AlBilasi","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology\u2014Head and Neck Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8981-411X","authenticated-orcid":false,"given":"Firas K.","family":"Almarri","sequence":"additional","affiliation":[{"name":"Department of Otorhinolaryngology\u2014Head and Neck Surgery, Ad Diriyah Hospital, Riyadh Third Health Cluster, Ministry of Health, Riyadh, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2024,5,10]]},"reference":[{"issue":"12","key":"bibr1-01455613241253215","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0226908","volume":"14","author":"Kawamura Y","year":"2019","journal-title":"PLoS One"},{"issue":"3","key":"bibr2-01455613241253215","doi-asserted-by":"crossref","first-page":"253","DOI":"10.1080\/00016489.2016.1231420","volume":"137","author":"Kikuchi T","year":"2017","journal-title":"Acta Otolaryngol"},{"issue":"3","key":"bibr3-01455613241253215","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1016\/j.wjorl.2019.08.003","volume":"5","author":"Bance M","year":"2019","journal-title":"World J Otorhinolaryngol Head Neck Surg"},{"issue":"1","key":"bibr4-01455613241253215","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1002\/lary.27443","volume":"129","author":"Ward BK","year":"2019","journal-title":"Laryngoscope"},{"issue":"4","key":"bibr5-01455613241253215","first-page":"272","volume":"11","author":"Chen DA","year":"1990","journal-title":"Am J Otol"},{"issue":"1","key":"bibr6-01455613241253215","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1097\/MOO.0000000000000020","volume":"22","author":"Adil E","year":"2014","journal-title":"Curr Opin Otolaryngol Head Neck Surg"},{"issue":"2","key":"bibr7-01455613241253215","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1016\/S0385-8146(03)00006-3","volume":"30","author":"Yoshida H","year":"2003","journal-title":"Auris Nasus Larynx"},{"issue":"5","key":"bibr8-01455613241253215","doi-asserted-by":"crossref","first-page":"103581","DOI":"10.1016\/j.amjoto.2022.103581","volume":"43","author":"Wu SS","year":"2022","journal-title":"Am J Otolaryngol"},{"issue":"1","key":"bibr9-01455613241253215","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1002\/lary.24250","volume":"124","author":"Vaezeafshar R","year":"2014","journal-title":"Laryngoscope"}],"container-title":["Ear, Nose &amp; 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