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with Rod Moser, PA, PhD

Stories from behind the examining room door, as told by Rod Moser, PA, a primary care physician assistant with more than 35 years of clinical experience.

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Friday, July 17, 2009

Eustachian Tube Dysfunction (ETD)

If you talk to someone with chronic ETD, I think they would rather have an STD. At least an STD is curable in most cases. How can something so small cause so much angst? Eustachian tube issues are clearly at the top of the list for postings on WebMD Ear, Nose, and Throat Board. This is an unusual long Blog posting, but this was required in order to cover the full gamete of this disorder.

Dysfunctional Eustachian tubes can cause a variety of annoying symptoms, depending on the type. If the normally-closed tubes will not open normally, the patient will experience ear fullness, popping/crackling, hearing loss (mild), and even temporary tinnitus (ringing). Another less-common type of Eustachian tube dysfunction is where the e-tubes are locked in the “open” position, called a Patulous Eustachian Tube (PET). People with PET often hear their own voices (autophony) or echoes, and of course, they also complain of annoying ear fullness.

The function of the Eustachian Tubes

The two e-tubes (one for each ear) are only about 35mm (1.3 inches) long and runs from the middle ear space (the area on the other side of the eardrum that houses those three tiny ear bones) to the back of the throat (nasopharynx). Adult e-tubes are not only short, but they are tiny, less than a 1/10 of an inch, with a triangular lumen of only about 2-3 mm. The e-tubes of an infant or young child are about half as long, less efficient, and much more capable of becoming dysfunctional. Some people are just born with unusually small Eustachian tubes and have recurrent trouble most of their lives.

There are three main functions of the Eustachian tubes: (1) ventilation (aeration) and air pressure regulation in the middle ear space, (2) Drainage of normal middle ear fluids, and (3) preventing fluids form the nose/throat area from entering the middle ear.

The e-tubes are normally closed (collapsed) but they are required to have repeated openings in order to regulate middle ear pressure. The e-tubes will open when you swallow, yawn, or talk/vocalize. In children, the e-tubes open and equalize pressure with crying. When you come down the mountains in a car or descend in an airplane, you may feel your ears clog and then “pop” (hopefully). These are your Eustachian tubes properly working. Sudden loud noises are capable of causing severe pressure in the ears, an open Eustachian tubes help limit potential ear damage.

The tiny bones in the middle ear space are bathed and lubricated by special bodily fluids which are supposed to drain through the Eustachian tubes into the back of the throat. The cilliary action, special muscles, and gravity-drainage help keep nose and throat secretions from going back up into the middle ear.

Causes of ETD

Perhaps the most common cause of a blocked or compromised Eustachian tube would be the upper respiratory infection (the common cold). The lining of the e-tubes is really the same tissue as the inside of your nose. If your nose swells and gets stuffy with a cold, then your e-tubes can have a similar swelling response. Additionally, when you blow your nose forcibly, you can inadvertently cause air to go up the e-tubes into the middle ear space, resulting in some instant ear fullness. A common complication of colds is post-nasal drainage, occasionally the result of sinusitis. When you are supine, this drainage will flow down the back of the throat where the e-tubes exit, causing inflammation and swelling. In children, the e-tubes exit near the location of the adenoids. The adenoids are lymph tissue that often enlarges when infected or inflamed causing the e-tubes to clog. Chronically enlarged adenoids, especially in children, can cause mouth-breathing, snoring, or a nasal quality to the voice.

Dysfunctional Eustachian tubes (and enlarged adenoids) are a major contributing factor for middle ear infections in children. In younger children, the e-tubes are more horizontal making drainage more challenging. By age six, the neck will sufficiently elongate, improving the “plumbing and ventilation”. Additionally, children are more prone to catching colds, averaging about six to nine per year. Children in day-care tend to get even more.

Another cause of ETD can be allergies. Like colds, allergies can cause tissue swelling that can compromise the normal function of the e-tubes. Colds typically last a week or so, but allergies can last year-round in some people.

People who smoke, or are exposed to secondary smoke are more prone to ETD. Smoking can damage the cilia in the e-tubes and interfere with the normal drainage of middle ear fluid.

E-tubes can also become compromised with altitude changes, such as driving in the mountains or even fast moving elevators in tall buildings, scuba diving/snorkeling/diving deep in pools, or with air travel. These events can be especially contributory when the person has a cold or allergies.

How ETD is diagnosed

ETD is diagnosed based on the usual symptoms and certain physical examination findings. During an otoscopic examination, a medical provider may notice that the eardrums are sucked inward (retracted) because the Eustachian tubes are not equalizing pressure. Using a small bulb syringe attached to the otoscope, the clinician can observe movements of the eardrum when positive air pressure is applied. A normal eardrum with air in the middle ear space will move in and out easily. If there is middle ear fluid (effusion) or increased/decreased pressure in the middle ear space, the eardrum will remain immobile. An electronic device used in many offices called a tympanogram can measure eardrum movement and these pressure variations. There are other special tests that the ENT can perform to further evaluate the e-tube appearance or function, if the diagnosis is in question.

How ETD is medically treated

Leave it alone. Most cases of simple ETD caused by a cold, or changes in altitude will self-resolve in time without any specific treatments, however, it is rarely possible to predict when full recovery might happen. Since colds typically last about a week, most people are back to normal in a week or so. So, it could be a few days…a few weeks…or, unfortunately, it could be months or years in severe cases, depending on the underlying causes.

Swallow and chew. ETD is improved by swallowing, chewing gum, drinking, or yawning. (Reading an extensive blog article about ETD can be boring, causing you to yawn, and thus improve your symptoms!).

Self-Inflation. Doing a gentle Valsalva maneuver – Take a deep breath, hold your nose and mouth closed, and try to force air up the Eustachian tubes by blowing. If you feel a “pop”, then it worked. Don’t blow too forcibly or you can make it worse, however.

Decongestants. Although controversial, many clinicians will recommend decongestants, either orally or nasally, to help open the e-tubes. This may or may not help. Assuming you can medically-use this type of medication, it is worth a try for a few days.

Nasal Corticosteroids. Steroids (No, not the bad types) relieve tissue inflammation, one of the major causes of ETD. There are several types, available only by prescription, they can be tried if
ETD persists. They may be especially helpful if you have allergies.

Antihistamines. If you have middle ear fluid (effusion), antihistamines are not usually recommended. However, if you do have allergies, antihistamines may reduce the amount of rhinorrhea (runny nose) and post-nasal drainage that may be contributory to ETD.

A few words about Airplane Ears. In children, have them suck on a bottle or pacifier. If babies are crying, this can actually help the ears to clear. For older kids, have them suck on a juice box – squeeze on those little juice box straws and make them work a bit to get the juice out. It is not a good idea to fly when you or your children are very congested with a bad cold, if this can be avoided.

Surgical Treatment of ETD – for Chronic or Severe Cases

In cases where ETD does not self-resolve or respond to medical interventions, the person is usually referred to a good ENT. Once the diagnosis is confirmed, either by diagnostic tests or direct visualization of the structure with a rhinoscopy (a fiberoptic, video device), various treatments may be suggested, including these two surgical approaches:

Myringotomy. A tiny slit can be made in the eardrum to aspirate any middle ear fluid and to allow a temporary ventilation portal into the middle ear space. This little slit will usually heal in only a few days, but the fluid and pressure may re-accumulate.

Pressure Equalization Tubes. Instead of allowing the myringotomy to heal, a tiny plastic or metal tube can be inserted into the slit to keep the portal open. This usually will provide relief for 6-12 months, even longer. Both the myringotomy and PET can be done in the office with topical anesthesia (in adults), but children require a brief general anesthesia.

Treating Patulous Eustachian Tubes (PET)

PET occurs when the Eustachian tubes remain open most of the time, creating some annoying symptoms as hearing one’s own voice, breathing, or echoes. This condition is more common in women, and rarely seen in children. The exact cause of PET is not always clear, but there is an odd association between PET and rapid weight changes, either from rapid dieting to the weight gain of pregnancy. TMJ disorders, and the use of certain medications (like birth control pills) have also been associated with PET.

One unusual treatment of PET (for men or women) is with the use of a special-formulated estrogen nasal spray, to induce swelling and hopefully close the Eustachian tubes. There are many other ENT surgical technique that can be used for severe or persistent cases.

Posted by: Rod Moser, PA, PhD at 6:30 am

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