Symptoms

When atmospheric pressure rises or falls without change in the middle ear, the tympanic membrane cannot vibrate normally. This can result in temporary hearing problems and ear discomfort.2 Typical presenting complaints include aural fullness, hearing loss, tinnitus, dysequilibrium, intermittent sharp pain, a sensation of fluid in the ear, sustained pain (if blockage results in an ear infection), and difficulty popping the ears.6 Symptoms, which can last from a few hours to several months, typically are intermittent and can be temporarily relieved by swallowing, yawning, or chewing.

Causes of dysfunction

In many children, eustachian-tube ventilation is less efficient because of anatomic variances, making these patients susceptible to such middle-ear conditions as otitis media and otitis media with effusion.2,4,6 In addition, multiple upper respiratory infections (URIs) and enlarged adenoids and tonsils can further contribute to the increased incidence of middle-ear diseases in children.2,5 ETD may follow URI or exacerbations of allergic rhinitis.2 The nasal blockage and/or thickened mucus that develops during URI can cause significant inflammation of the eustachian tube. With growth, the eustachian-tube function of children usually improves, as demonstrated by the reduced frequency of otitis media from infancy through maturity.2

Habitual sniffing creates negative pressure within the middle ear.4 Air travel or scuba diving can cause ear pain secondary to negative middle-ear pressure as well. These activities may “lock” the ETD, leading to stasis of secretions and effusion secondary to barotraumas.2 For most patients, normal swallowing and chewing gum can equalize the pressure by helping air to travel up the eustachian tube.

An abnormally open tube is described as “patulous.” Patients with this condition will complain of echo when speaking (autophony) as well as ear fullness.2 They may also note that they can hear themselves breathe. Rapid weight loss may result in reduction in size of the Ostmann fat pad, decreasing its effect on closing and protecting the eustachian tube and middle ear and leading to symptoms of ETD.1

Physical findings

While otoscopic findings of ETD are usually normal, examination in chronic ETD may demonstrate retraction pockets of the tympanic membrane.6 Rhinoscopy may reveal a deviated septum with or without inferior turbinate hypertrophy. Peritubal inflammation or mass may appear on nasopharyngoscopy.1 In acute otitis media, the tympanic membrane may be erythematous and bulging, while in chronic otitis media, the membrane may appear dull. In both instances, the membrane will demonstrate a sluggish response to pneumatic otoscopy.6

Treatment

ETD is frequently mild and lasts only a few days. This is typically the case with the common cold, and no particular treatment is necessary. As previously noted, simple acts of swallowing, chewing, or yawning can be effective at alleviating symptoms. Inflation of the eustachian tube via the Valsalva maneuver can further break the negative pressure.2

If symptoms do not go away within a few days, other treatment may be necessary. Decongestants (oral or nasal), steroids (oral or nasal), antihistamines, or leukotriene antagonists can be used to relieve congestion and enable the eustachian tube to open.3,5 To improve compliance, tell the patient that these medications can take time to build to their full effect.

ETD is usually treated with a combination of time, auto-insufflation, and medications. As stated, decongestants are helpful for acute symptoms but not chronic ETD. Be mindful of the cardiovascular effects of oral decongestants. Further consideration should be given to the early tachyphylaxis observed with the use of nasal decongestants as well.5 No provider wants to be responsible for the development of comorbid rhinitis medicamentosa. Always limit the use of nasal decongestants to three days.

In patients with uncontrolled laryngopharyngeal reflux, use of a proton-pump inhibitor is often helpful. Instruct patients with ETD to use a topical or oral decongestant 30 minutes before flying or diving (i.e., snorkeling or scuba).6

Conclusion

If symptoms persist or if the cause of the ETD is unclear, referral to an otolaryngologist may be necessary. He or she can perform tympanometry to further assess eustachian-tube function.2,6 Tympanography, which measures middle-ear pressure, tympanic membrane movement, ear-canal volume, and acoustic reflexes, may detect the presence of effusions. Other tests include an audiogram and telescopic examination of the nose.2,6 Posterior rhinoscopic examination with a mirror or fiberoptic endoscopy helps visualize any mass obstructing the pharyngeal end of the eustachian tube.2 CT or MRI may be obtained to assess for temporal bone tumors.2,6

Occasionally, patients whose severe symptoms of ETD do not respond to traditional treatment may require myringotomy with or without pressure-equalization tubes. Other treatment approaches will depend on underlying causes that may be identified through further testing.

Ms. Lisano Valentino is a nurse practitioner at Ear, Nose & Throat Specialists of Upstate New York in Auburn and Syracuse.

References

1. Silverstein H, Light JP, Jackson LE, et al. Direct application of dexamethasone for the treatment of chronic eustachian tube dysfunction. Ear Nose Throat J. 2003;82:28-32.
2. Massoud E, Singh H, Tewfik L. Eustachian tube function. Available at
emedicine.medscape.com/article/874348-overview.
3. Hain TC. Eustachian tube dysfunction. Available at www.dizziness-and-balance.com/disorders/symptoms/etdysfunction.htm.
4. Bluestone CD. Anatomy and physiology of the eustachian tube system. In: Bailey BJ, Johnson JT, Newlands SD. Head & Neck Surgery–Otolaryngology. 4th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins;2005:1253-1263.
5. Gulya AJ, Glasscock ME. Glasscock-Shambaugh Surgery of the Ear. 5th ed. Hamilton, Ont., Canada: BC Decker Inc.; 2003:154;422-423.
6. Meek RB. Middle ear, eustachian tube, inflammation/infection. Emedicine. Available at www.emedicine.com/ent/Topic207.HTM.

All electronic documents accessed April 6, 2009.