Eustachian Tube Dysfunction (ETD)

1. What is the Eustachian tube?

Each ear connects to the back of the nose through a small passage called the Eustachian tube. Its job is to let air into the middle ear, match the pressure on both sides of the eardrum and let fluid drain out. If it works well the eardrum moves freely and hearing feels normal.

2. What is Eustachian tube dysfunction?

Eustachian tube dysfunction happens when that tube does not open properly, or stays blocked, so the middle ear cannot equalise pressure. This can cause a feeling of blockage, popping, crackling or hearing that sounds “under water”. In some people it contributes to otitis media with effusion (fluid behind the eardrum).

3. Common symptoms

• Fullness or pressure in one or both ears
• Muffled hearing or fluctuating hearing
• Needing to swallow or yawn to “clear” the ear
• Clicking or popping sounds
• Ear discomfort when flying or changing altitude
• Sometimes fluid behind the eardrum on examination
• These symptoms can overlap with other ear problems, so careful diagnosis is important.

4. Why does it happen?

ETD is usually multifactorial. Swelling in the nose or nasopharynx can narrow the opening of the tube. Typical contributors include:

• Allergic rhinitis or nasal allergy, which inflames the same airway that the tube drains into.
• Viral or bacterial upper respiratory infections.
• Chronic nasal disease such as chronic rhinosinusitis or turbinate enlargement.
• Structural narrowing such as a deviated nasal septum. Treating the nasal obstruction can improve ETD in selected patients.
• Reflux, adenoids or less commonly masses around the opening of the tube.
• The ear and nose form one functional airway, so inflammation in the nose can show up as symptoms in the ear.

Differential diagnosis (what else it could be)

Symptoms like ear fullness, popping and muffled hearing are not unique to Eustachian tube dysfunction. Your ENT will think through other causes, especially if symptoms are one sided, sudden, painful or not responding.

Middle ear and eardrum problems

• Otitis media with effusion (glue ear in children, effusion in adults), fluid sits behind an intact eardrum and causes fullness and hearing loss. ETD can cause it, but it can also persist on its own and may need separate treatment.
• Acute or recurrent otitis media, usually painful, often with fever or discharge.
• Chronic otitis media or retraction pockets, including early cholesteatoma, especially if there is unilateral fullness, hearing loss or crusting. These need otoscopy and sometimes imaging.

Patulous Eustachian tube

This is the opposite problem. The tube stays too open, patients hear their own breathing or voice loudly (autophony). Balloon dilation is not used here so separating this from obstructive ETD is important.

External or conductive causes

• Impacted wax
• Otitis externa with canal swelling
• Ossicular chain or eardrum scarring
• These can all give a blocked sensation without Eustachian tube pathology.

Inner ear or pressure related disorders

• Early Ménière disease can present with fullness before vertigo and tinnitus are obvious.
• Sudden sensorineural hearing loss can start with aural fullness before the hearing drop is noticed. This is an emergency and needs prompt ENT review.
• Superior semicircular canal dehiscence can give a sense of pressure, noise sensitivity and autophony, usually diagnosed with specific tests.

Nasal and nasopharyngeal causes

If there is a mass, adenoidal enlargement in adults or significant septal deviation around the Eustachian tube opening, it can mimic ETD on that side. Nasal endoscopy is useful here.

Temporomandibular joint (TMJ) and neck related causes

TMJ dysfunction and some cervical myalgias can give referred pressure or fullness to the ear despite a normal Eustachian tube. The ear exam is usually normal.

Headache or migraine related aural pressure

Some patients with migraine variants describe intermittent ear pressure that looks like ETD but tympanometry and otoscopy are normal.

Serious conditions such as brain fluid leak can present with a blocked ear feeling.

5. How ETD is assessed

A good assessment separates obstructive ETD (tube does not open) from patulous ETD (tube stays too open), since treatments differ. A typical workup may include:

• History of ear pressure, barochallenge problems (flying, diving) and nasal disease
• Otoscopy to look for eardrum retraction or fluid
• Tympanometry to measure middle ear pressure, often the first objective test in clinic.
• Validated symptom scoring such as ETDQ-7 in persistent cases.
• Nasal endoscopy to look for allergy, septal deviation or chronic rhinosinusitis that could be addressed at the same time.

International reviews note that there is no single perfect test, so ENT specialists combine symptoms, examination and simple investigations to reach a diagnosis.

6. Treatment options

Treatment is guided by the cause and by how troublesome the symptoms are.

a. General and home measures

• Manage colds and allergies promptly.
• Try gentle auto inflation techniques if advised (eg pinching the nose and swallowing) provided the eardrum is intact.
• Avoid smoking and treat reflux if present. These help the whole upper airway.

b. Treat the nose and allergy

Because many patients with ETD have coexistent rhinitis or nasal obstruction, treating the nose is often the first step. This can include saline rinses and a trial of intranasal corticosteroid sprays. Evidence shows sprays can help some subgroups, especially where nasal inflammation is present, although high quality trials are still limited.

When a deviated septum or turbinate hypertrophy is clearly linked to symptoms, nasal surgery has been shown to improve ETD scores and middle ear ventilation. This is considered in selected adults.

c. Treat the middle ear

If ETD has led to persistent fluid or retraction, myringotomy with or without a ventilation tube (grommet) can bypass the tube and restore hearing. Your surgeon will advise if this is appropriate.

d. Balloon dilation of the Eustachian tube (BDET)

For adults with chronic obstructive ETD who have not responded to medical and nasal treatment, balloon dilation is a minimally invasive option. A small balloon is passed endonasally into the cartilaginous part of the tube and inflated for a short period to remodel the lumen. Studies and national guidance report symptom improvement and better middle ear pressure in well selected patients.

Selection is important. Balloon dilation is not used for patulous ETD because widening the tube would worsen autophony. A structured diagnostic pathway that first confirms obstructive ETD and considers nasal pathology is therefore recommended.

Published safety data show generally low complication rates when performed by experienced ENT surgeons, and NICE guidance is available to support indications.

7. When to seek review

• Symptoms lasting longer than three months
• Recurrent ear infections or fluid
• Difficulty equalising when flying that affects work or travel
• Known nasal allergy or chronic sinus disease with new ear symptoms
• Any sudden hearing drop, severe pain, discharge or dizziness should be assessed promptly, since these may indicate another condition.

8. How ETD is approached at our clinic

Our aim is to identify and treat the nasal or allergy component, give the middle ear time to normalise, and reserve procedures such as grommets or balloon dilation for patients who continue to have objective dysfunction or significant symptoms despite appropriate medical therapy. This follows contemporary ENT literature that views ETD as part of a unified airway problem in many patients.

If you would like an appointment to discuss Eustachian tube symptoms, or have ongoing blocked ears with nasal issues, please contact our clinic to arrange a consultation.