Eustachian tube dysfunction

Eustachian tube dysfunction (ETD) is when the eustachian tube (ET) fails to perform its normal middle ear functions. It is a common problem affecting up to 20% of children and ∼ 5% of adults. Two main subtypes exist: obstructive ETD, where occlusion of the ET leads to the inability to effectively dilate, and patulous ETD, where the tube remains chronically patent. Both conditions can cause a sensation of fullness in the ear, ear pain, and muffled hearing. Patients with patulous ETD may also complain that their voice and/or breathing are excessively loud. A clinical diagnosis is made based on history and otoscopy findings. Specialists may perform additional diagnostic studies if needed. Management differs between obstructive and patulous ETD and is usually conservative. Surgery is reserved for severe or refractory cases.

• Eustachian tube dysfunction: failure of the eustachian tube to perform its normal middle ear functions. ^[1][2]
  • Pressure equalization and ventilation
  • Clearance of secretions and pathogens
  • Sound protection
• Obstructive, or dilatory, ETD: the obstruction or ineffective dilation of the eustachian tube (closed) ^[1][2]
• Patulous ETD: a eustachian tube that is chronically patent (open) ^[2]

• Children: Prevalence is ∼ 4–20%. ^[3]
• Adults ^[4]
  • Prevalence is 4.6%.
  • More common in men and older adults

Epidemiological data refers to the US, unless otherwise specified.

Causes of obstructive ETD ^[3]

• Inflammation and edema of the nasopharyngeal mucosa, e.g. from:
  • Allergic rhinitis
  • Reflux (e.g., laryngopharyngeal reflux, gastroesophageal reflux)
  • Recurrent infections (e.g., rhinosinusitis, common colds)
• Anatomic conditions
  • Adenoid hypertrophy with nasal obstruction
  • Eustachian tube abnormalities, e.g., immature ET in young children, small diameter ET
  • Craniofacial abnormalities
  • Nasopharyngeal tumors or growths ^[5]

Causes of patulous ETD ^[3]

• Etiology frequently unclear
• Atrophy around the ET from chronic inflammation, e.g., from:
  • Allergic rhinitis
  • Reflux (e.g., laryngopharyngeal reflux, gastroesophageal reflux)
• Rapid or severe weight loss, e.g., from bariatric surgery
• Sustained contraction of the tensor veli palatini, e.g., from stress or anxiety

Common symptoms ^[2][3]

• Aural fullness
• Popping or clicking sensations in the ear
• Ear discomfort and/or pain ^[6]
• Changes in hearing
• Tinnitus

Obstructive vs patulous ETD ^[1][2][7]

ETD is typically divided into obstructive or patulous based on symptoms and clinical findings. Symptoms may overlap and patients may convert from one type to another or alternate between them. ^[1][3][8]

Baro-challenge-induced ETD ^[2]

• Symptoms of ETD occur only with changes in ambient pressure (e.g., scuba diving, on airplanes).
• Patients are usually asymptomatic at ground level.
• Diagnosis is usually based on history. ^[3]
• Examination findings are typically normal; middle ear effusion or hemotympanum may be present in severe cases.
• For treatment, see “Management of obstructive ETD.”

Clinical diagnosis ^[1][2][3]

A presumptive clinical diagnosis is made based on

• Clinical features of ETD ^[2]
• Hearing assessment : Obstructive ETD with a middle ear effusion may cause conductive hearing loss.

Advanced diagnostics ^[1][2][7]

For diagnostic uncertainty or persistent symptoms despite appropriate management, otolaryngology may obtain additional studies, e.g.: ^[2]

• Tympanometry ^[2][3]
  • Obstructive ETD: negative middle ear pressure, i.e., Type C curve ^[1][8]
  • Patulous ETD: TM movement that is synchronous with respiration ^[8]
• Nasopharyngoscopy ^[2][3]
  • Obstructive: cause of the obstruction, findings of comorbidities
  • Patulous: continuously patent eustachian tube or defect in the tubal valve, findings of comorbidities ^[8]
• Imaging (e.g., CT or MRI): reserved for suspected underlying etiologies that cannot be visualized on endoscopy ^[2][3][11]

• Otitis media
• Temporomandibular disorders
• Other causes of hearing loss
• Cochlear hydrops
• Inner ear fistula, e.g., semicircular canal dehiscence

The differential diagnoses listed here are not exhaustive.

Approach ^[1][3][7]

• Treat any contributing causes of ETD (e.g., allergic rhinitis, GERD) and complications of ETD.
• Recommend smoking cessation.
• Initiate general measures and pharmacotherapy based on the type of ETD (i.e., obstructive or patulous).
• Consider using validated questionnaires to assess symptoms and follow outcomes, e.g., ^[2][3]
  • The Eustachian tube dysfunction questionnaire (ETDQ-7) ^[12][13]
  • Extended eustachian tube score (ETS-7) ^[14]
• Refer to otolaryngology for: ^[2]
  • Severe symptoms (e.g., significant pain, hearing loss)
  • Chronic ETD > 3 months
  • Symptoms refractory to nonsurgical interventions

The ETS-7 and ETDQ-7 are used to assess symptom severity and treatment response and are not diagnostic. ^[13][15][16]

Management of obstructive ETD ^[1][3][7]

• General measures: Mechanical interventions may alleviate symptoms.
  • Nasal balloon autoinflation
  • Middle ear inflation devices
  • Modified Valsalva maneuvers ^[10]
• Pharmacotherapy ^[3][17]
  • Nasal glucocorticoids
  • Antihistamines
  • Decongestants
• Surgical interventions (if refractory)
  • Balloon dilation of the ET ^[1]
  • Laser tuboplasty
  • Adenoidectomy if adenoid hypertrophy is causing obstruction
  • Tympanostomy tube placement (adjunctive) if a middle ear effusion is present

In children, symptoms often improve as the ET grows and matures. ^[3]

Management of patulous ETD ^[3][8]

• General measures
  • Provide reassurance that the condition is benign.
  • Identify contributing medications and adjust if possible.
  • Encourage hydration and limit alcohol and caffeine intake.
• Pharmacotherapy: The goal is to cause irritation and edema of the nasal mucosa. ^[8]
  • Nasal saline or hypertonic saline drops
  • Nasal ascorbic acid solution
  • Nasal estrogen
  • Oral potassium iodide ^[3][8]
• Surgical interventions (if refractory)
  • Interventions to build up or occlude the ET, or reconstruct the ET valve ^[18]
  • Tympanostomy tube placement (adjunctive) ^[8]

Although weight loss may cause patulous ETD, weight gain is generally ineffective at reversing the condition and is not recommended. ^[3]

• Hearing loss
• Acute otitis media ^[3]
• Tympanic membrane retraction, possibly with an acquired cholesteatoma ^[3][9]
• Ear barotrauma

We list the most important complications. The selection is not exhaustive.