Eustachian tube dysfunction in adults

Authors: Anushka Pradhan, Allan Vescan, Jong Wook Lee

Eustachian tube dysfunction leads to inadequate ventilation of the middle ear

It is caused by inflammation or narrowing of the eustachian tube, which leads to aural fullness and muffled hearing (obstructive dysfunction) or, less commonly, hearing one’s own voice amplified (patulous dysfunction). 1 Affecting roughly 5% of adults, eustachian tube dysfunction often follows an upper respiratory tract infection, allergies, or barotrauma (when engaging in aviation or diving) but can also occur spontaneously.1,2

Other conditions and modifiable risk factors influence severity and outcomes

Allergic rhinitis, chronic rhinosinusitis, gastroesophageal reflux disease (GERD), and smoking increase risk and severity.2 Temporomandibular joint (TMJ) dysfunction can have overlapping symptoms, such as ear fullness, tinnitus, and otalgia. History of jaw clenching or pain on TMJ palpation may indicate TMJ, rather than eustachian tube, dysfunction. Unilateral middle ear effusion, persistent otalgia, or cranial nerve deficits warrant urgent otolaryngology referral to rule out nasopharyngeal pathology.3

Diagnosis can be confirmed using clinical findings and audiologic testing

Otoscopy may reveal tympanic membrane retraction or middle ear effusion. An audiologist should conduct objective hearing testing and assessment of middle ear pressures using tympanometry.3 Type B (fluid) or C (negative pressure) curves on tympanometry suggest eustachian tube dysfunction.4 Type A (normal) curves do not exclude the diagnosis, particularly when symptoms are induced by barotrauma.3

Initial management should target the underlying cause

In addition to treatment of GERD and smoking cessation, where applicable, first-line treatments should target inflammation and include intranasal corticosteroids (e.g., mometasone 200 μg/d) and second-generation antihistamines (e.g., loratadine 10 mg/d). These improve symptoms in 30% to 64% of people with subacute symptoms and 11% to 50% of people with chronic symptoms.5 When dysfunction is caused by barotrauma, an oral decongestant (e.g., pseudoephedrine 30 mg/d) may be taken 30 to 60 minutes before descent.2

Clinicians should consider surgical referrals for patients with refractory symptoms

Patients with persistent symptoms beyond 3 months, recurrent effusions, or treatment-resistant barotrauma may benefit from ventilation tubes for temporary relief or eustachian tube balloon dilation.6