EUSTACHIAN TUBE DYSFUNCTION

Adam W. Kowalski, MD • Vernon Wheeler, MD, FAAFP

 BASICS

DESCRIPTION

•  Eustachian tube dysfunction (ETD) represents a spectrum of disorders involving an impairment in the functional valve of the eustachian tube of the middle ear.

•  ETD can be classified as patulous dysfunction, in which the eustachian tube is excessively open, or dilatory dysfunction, in which there is failure of the tubes to dilate (i.e., open) appropriately.

•  Pathophysiology is thought to be related to pressure dysregulation, impaired protection secondary to reflux of irritating material into the middle ear, or impaired clearance by the mucociliary system.

•  May occur in the setting of pressure changes (e.g., scuba diving or air travel) or acute upper airway inflammation (e.g., allergic or infectious rhinosinusitis, acute otitis media)

•  Chronic ETD may lead to a retracted tympanic membrane, recurrent serous effusion, recurrent otitis media (OM), adhesive OM, chronic mastoiditis, or cholesteatoma.

•  System(s) affected: auditory

•  Synonym(s): auditory tube dysfunction; eustachian tube disorder; blocked eustachian tube; patulous eustachian tube

ALERT

•  Sudden sensorineural hearing loss (SSNHL) can be misdiagnosed as ETD.

•  A simple 512-Hz tuning fork test lateralizes to the opposite ear in SSNHL and to the affected ear in ETD with conductive hearing loss.

•  Any SSNHL is a medical emergency and should be referred to an otolaryngologist immediately.

EPIDEMIOLOGY

•  Limited quality studies on epidemiology of ETD

•  Most common in children <5 years of age, thought to be related to anatomical differences (see “Etiology and Pathophysiology” section)

•  Usually decreases with age

Incidence

70% of children by age 7 years have experienced ETD.

Prevalence

•  1% of the adult population

•  Males > females

•  Highest prevalence among Native Americans, Inuits, Australian Aborigines, Hispanics, Africans

ETIOLOGY AND PATHOPHYSIOLOGY

•  Under normal circumstances, the eustachian tube (ET) is closed but can open to release a small amount of air to equalize pressure between the middle ear and the surrounding atmosphere.

•  ETD is failure of the ET, palate, nasal cavities, and nasopharynx to regulate middle ear and mastoid pressure.

•  ET functions

–  Ventilation/regulation of middle ear pressure

–  Protection from nasopharyngeal secretions

–  Drainage of middle ear fluid

–  ET is closed at rest and opens with yawning, swallowing, and chewing.

•  Cycle of dysfunction: Structural or functional obstruction of the ET compromises three functions

–  Negative pressure develops in middle ear.

–  Serous exudate is drawn from the middle ear by negative pressure or refluxed into the middle ear if the ET opens momentarily.

–  Infection of static fluid causes edema and release of inflammatory mediators, which exacerbates cycle of inflammation and obstruction.

•  In children, a horizontal and shorter ET predisposes to difficulties with ventilation and drainage.

•  Adenoid hypertrophy can block the torus tubarius (proximal opening of the ET).

•  In adults, paradoxical closing with swallowing has been noted in a majority of affected patients.

•  Tumors that impair/occlude the ET proximally or distally, or that invade the tensor veli palatini and impair normal swallow regulation, can also lead to dysfunction.

Genetics

Twin studies show a genetic component. Specific genetic cause is still undefined.

RISK FACTORS

•  Adult and pediatric

–  Allergic rhinitis, tobacco exposure, GERD, chronic sinusitis, adenoid hypertrophy or nasopharyngeal mass, neuromuscular disease, altered immunity

•  Pediatric

–  In addition to the earlier mentioned, prematurity and low birth weight, young age, daycare, crowded living conditions, low socioeconomic status, prone sleeping position, prolonged bottle use, craniofacial abnormalities (e.g., cleft palate, Down syndrome)

Pregnancy Considerations

ETD may be exacerbated by rhinitis of pregnancy; symptoms resolve postpartum.

GENERAL PREVENTION

•  Control sources of upper airway inflammation: allergies, infectious rhinosinusitis, GERD

•  Autoinsufflation of middle ear (i.e., blow gently against pinched nostril and closed mouth)

•  Avoid atmospheric pressure changes (e.g., plane flight, scuba diving) in the setting of acute allergy exacerbation or URI.

•  Avoid exposure to environmental irritants: tobacco smoke and pollutants.

COMMONLY ASSOCIATED CONDITIONS

•  Hearing loss

•  OM: acute, chronic, and serous

•  Chronic mastoiditis

•  Cholesteatoma

•  Allergic rhinitis

•  Chronic sinusitis/URI

•  Adenoid hypertrophy

•  GERD

•  Cleft palate

•  Down syndrome

•  Obesity

•  Nasopharyngeal carcinoma or other tumor

 DIAGNOSIS

HISTORY

•  Symptoms of ear pain, fullness, “plugging,” hearing loss, tinnitus, popping or snapping noises, and vertigo are commonly seen with ETD.

•  Other historical elements

–  Unilateral or bilateral. Adults presenting with persistent unilateral symptoms should be evaluated for nasopharyngeal process (tumor).

–  History of previous ear infections, surgeries, head trauma, recent flying or diving

–  Voice change (hypo- or hypernasal voice, consider NP mass or palatal dysfunction)

–  Differentiate patulous dysfunction, in which patient’s own voice and breath sounds are amplified (autophony), from dilatory dysfunction, in which patient complains more of ear pain, “plugged” ear, hearing loss, and tinnitus.

•  ETDQ-7 is a new questionnaire to attempt to quantify ETD in adult patients. Based on presence and intensity of symptoms in past 1 month, severity is rated on 1 to 7 scale, with 1 indicating no problem and 7 indicating severe problems. A total score cutoff >14.5 categorizes patient as having diagnosis of ETD (1,2)[B]. Data is limited but promising. Questions:

–  Pressure in ears in past 1 month?

–  Pain in ears in past 1 month?

–  A feeling that ears are clogged or “under water”?

–  Ear symptoms when you have cold or sinusitis?

–  Crackling or popping sounds in the ears?

–  Ringing in ears?

–  A feeling that your hearing is muffled?

PHYSICAL EXAM

•  Pneumatic otoscopy: retracted tympanic membrane, effusion, decreased drum movement

•  Toynbee maneuver: view changes of the drum while patient autoinsufflates against closed lips and pinched nostrils; may show various degrees of retraction

–  Entire drum may be retracted and “lateralize” with insufflation.

–  Posterosuperior quadrant (pars flaccida) may form a retraction pocket.

•  Tuning fork tests: 512-Hz fork placed on the forehead lateralizes to affected ear (Weber test); the fork will be louder behind the ear on the mastoid than in front of the ear (bone conduction > air conduction, Rinne test) in conductive hearing loss.

•  Nasopharyngoscopy: adenoid hypertrophy or nasopharyngeal mass

•  Anterior rhinoscopy: deviated nasal septum, polyps, mucosal hypertrophy, turbinate hypertrophy

DIFFERENTIAL DIAGNOSIS

•  SSNHL (a medical emergency)

•  Tympanic membrane perforation

•  Barotrauma

•  Temporomandibular joint disorder

•  Ménière disease

•  Superior semicircular canal dehiscence

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

•  Radiologic studies are not performed routinely if clinical signs/symptoms suggest ETD.

•  CT scan (not necessary) may show changes related to OM or middle ear/mastoid opacification.

•  Functional MRI might determine cause of ETD (in recalcitrant cases), as the ET opening can be visualized during Valsalva.

Diagnostic Procedures/Other

•  Audiogram may show conductive hearing loss.

•  Tympanometry: type B or C tympanograms indicate fluid or retraction, respectively. Negative middle ear peak pressures seen even with normal (type A) tympanograms.

 TREATMENT

•  Due to limited high-quality evidence, it is difficult to recommend any one treatment option/intervention as superior (3)[C].

•  Use of a “nasal balloon” shown effective for clearing OM with effusion; unclear of benefit for ETD

•  Generally, principle of treatment is to remove or fix the underlying cause (e.g., infection, tumor, perforation of TM, restore tensor palitini muscle, etc.) and hopefully end or at least reduce cycle of infection/inflammation.

•  Although no evidence exists, some consider antibiotics for AOM; decongestants, nasal steroids, antihistamines (if allergic rhinitis is present), and surgery/procedures for recalcitrant cases

•  Tympanostomy tubes ± adenoidectomy when indicated for recurrent ear infections or severe progressive retractions

MEDICATION

•  Only when infection such as AOM is suspected as driving cause of ETD should antibiotics be given; large study giving antibiotics to children with OM with effusion showed no benefit (4)[A].

•  Few data support pharmacologic treatments such as decongestants, nasal steroids, or antihistamines for ETD.

•  Medication options are for treatment of comorbid conditions.

•  Decongestants, topical, oral

–  Avoid prolonged use (>3 days); can cause rhinitis medicamentosa.

–  Decongestants are most useful for acute ETD related to a resolving URI.

–  Decongestants are not typically used for relief of chronic ETD in children.

  Phenylephrine: adults and children ≥12 years of age, 1 tablet (10 mg) q4h PRN; children 6 to 11 years of age, 5 mg q4h PRN; children 4 to 5 years of age, 2.5 mg q4h PRN

  Pseudoephedrine: adults, 60 mg q4–6h PRN; children 6 to 12 years of age, 30 mg q4–6h PRN; children 4 to 5 years of age, 15 mg q4–6h PRN

  Oxymetazoline: adults and children ≥6 years of age, 1 to 2 sprays each nostril q12h PRN. Limit use to ≤3 days.

  Phenylephrine: adults, 1 to 2 sprays each nostril q4h PRN. Limit use to ≤3 days.

•  Nasal steroids (may be beneficial for those with allergic rhinitis) (5)[A]

–  Beclomethasone (Beconase, Vancenase): adults and children ≥12 years of age, 1 to 2 sprays each nostril BID; children 6 to 11 years of age, 1 spray each nostril BID. Not recommended for children <6 years of age

–  Budesonide (Rhinocort): adults and children ≥6 years of age, 1 spray each nostril daily

–  Ciclesonide (Omnaris) (a prodrug activated on nasal mucosa): adults and children ≥6 years of age, 2 sprays each nostril daily

–  Flunisolide (Nasarel, Nasalide): adults and children ≥6 years of age, 2 sprays each nostril BID

–  Fluticasone furoate (Veramyst): adults and children ≥12 years of age, 2 sprays each nostril daily; children 2 to 11 years of age, 1 spray each nostril daily

–  Fluticasone propionate (Flonase): adults 1 to 2 sprays each nostril daily; children ≥4 years of age, 1 spray each nostril daily

–  Mometasone (Nasonex): adults and children ≥12 years of age, 2 sprays each nostril daily; children 2 to 12 years of age, 1 spray each nostril daily

–  Triamcinolone (Nasacort): adults and children ≥6 years of age, 1 to 2 sprays each nostril daily; children 2 to 5 years of age, 1 spray each nostril daily

•  2nd-generation H₁ antihistamines (may be beneficial for those with ETD and chronic rhinitis)

–  Cetirizine (Zyrtec) (tablets, chewable tablets, liquid): adults and children ≥6 years of age, 5 to 10 mg/day PO; children 12 months to 5 years of age: 2.5 mg/day PO, may increase to BID; children 6 to <12 months of age: 2.5 mg/day PO

–  Desloratadine (Clarinex) (tablets, Reditabs, liquid): adults and children ≥12 years of age, 5 mg/day PO; children 6 to 11 years of age, 2.5 mg/day PO; children 12 months to 5 years of age, 1.25 mg/day PO; children 6 to 11 months of age, 1 mg/day PO

–  Fexofenadine (Allegra) (tablets, Reditabs, liquid): adults and children ≥12 years of age, 60 mg PO BID or 180 mg/day PO; children 2 to 11 years of age, 30 mg PO BID

–  Levocetirizine (Xyzal) (tablets, liquid): adults and children ≥12 years of age, 2.5 to 5 mg PO every evening; children 6 to 11 years of age, 2.5 mg PO every evening; children 6 months to 5 years of age, 1.25 mg PO every evening

•  Antihistamine nasal sprays (may be beneficial for those with ETD and chronic rhinitis)

–  Azelastine (Astepro or Astelin): adults and children ≥12 years of age, 1 to 2 sprays each nostril BID; children 6 to 11 years of age, 1 spray each nostril BID

–  Olopatadine (Patanase): adults and children ≥12 years of age, 2 sprays each nostril BID; children 6 to 11 years of age, 1 spray each nostril BID

SURGERY/OTHER PROCEDURES

•  Myringotomy and pressure equalization tube placement to ventilate middle ear, relieve pressure, and prevent sequelae of chronically retracted drum

•  Patients with ETD during pressure changes may benefit from minimally invasive laser eustachian tuboplasty.

•  New studies are emerging regarding balloon tuboplasty, but to date are very limited in terms of efficacy, safety, and long-term outcomes (6)[B].

•  Adenoidectomy if hypertrophied tissue is present.

–  In children, first set of tubes are typically placed alone. Adenoidectomy is performed with second set of tubes if problems recur.

–  Some advocate adenoidectomy even in absence of excess tissue; reduces frequency and number of subsequent tubes

 ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

•  Monitor pressure equalization tubes every 6 to 8 months in children and every 6 to 12 months in adults.

•  Monitor tympanic membrane retraction pocket for progression every 6 to 12 months to allow for early intervention for progression in hearing loss, obvious ossicular erosion, or cholesteatoma.

DIET

Breastfeeding is associated with lower incidence of ETD and OM.

PROGNOSIS

If symptoms of ETD persist beyond age 7 years, patient is more likely to have long-term problems and require regular monitoring.

COMPLICATIONS

Morbidity related to hearing compromise or associated sequela of chronic ear infections

REFERENCES

1.  McCoul ED, Anand VK, Christos PJ. Validating the clinical assessment of eustachian tube dysfunction: the Eustachian Tube Dysfunction Questionnaire (ETDQ-7). Laryngoscope. 2012;122(5):1137–1141.

2.  Van Roeyen S, Van de Heyning P, Van Rompaey V. Value and discriminative power of the seven-item Eustachian tube dysfunction questionnaire. Laryngoscope. 2015;125(11):2553–2556.

3.  Norman G, Llewellyn A, Harden M, et al. Systematic review of the limited evidence base for treatments of Eustachian tube dysfunction: a healthy technology assessment. Clin Otolaryngol. 2014;39(1):6–21.

4.  van Zon A, van der Heijden GJ, van Dongen TM, et al. Antibiotics for otitis media with effusion in children. Cochrane Database Syst Rev. 2012;(9): CD009163.

5.  Simpson SA, Lewis R, van der Voort J, et al. Oral or topical nasal steroids for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev. 2011;(5):CD001935.

6.  Gürtler N, Husner A, Flurin H. Balloon dilation of the Eustachian tube: early outcome analysis. Otol Neurotol. 2015;36(3):437–443.

ADDITIONAL READING

•  Bluestone CD. Studies in otitis media: Children’s Hospital of Pittsburgh-University of Pittsburgh progress report—2004. Laryngoscope. 2004;114(11, Pt 3 Suppl 105):1–26.

•  Gluth MB, McDonald DR, Weaver AL, et al. Management of Eustachian tube dysfunction with nasal steroid spray: a prospective, randomized, placebo-controlled trial. Arch Otolaryngol Head Neck Surg. 2011;137(5):449–455.

•  Seibert JW, Danner CJ. Eustachian tube function and the middle ear. Otolaryngol Clin North Am. 2006;39(6):1221–1235.

•  Williamson I, Vennik J, Harnden A, et al. Effect of nasal balloon autoinflation in children with otitis media with effusion in primary care: an open randomized controlled trial. CMAJ. 2015;187(13):961–969.

 SEE ALSO

Algorithm: Ear Pain

 CODES

ICD10

•  H69.90 Unspecified Eustachian tube disorder, unspecified ear

•  H69.00 Patulous Eustachian tube, unspecified ear

•  H68.109 Unspecified obstruction of Eustachian tube, unspecified ear

CLINICAL PEARLS

•  ETD can be acute or chronic. Treatment is based on the underlying etiology.

•  Weber test: 512-Hz fork placed on the forehead lateralizes to affected ear in ETD and opposite ear in SSNHL

•  SSNHL (medical emergency) can be misdiagnosed as ETD and should always be ruled out, especially in patients with unilateral symptoms.