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Eustachian Tube Dysfunction

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  • Eustachian tube dysfunction (ETD) is a functional or structural obstruction of the eustachian tube. It occurs due to improper opening in response to atmospheric pressure changes and negative pressure in the middle ear.
  • May occur in the setting of pressure changes (e.g., scuba diving or plane travel) or acute upper airway inflammation (e.g., allergic or infectious rhinosinusitis)
  • Chronic ETD may lead to a retracted tympanic membrane, recurrent serous effusions, recurrent otitis media (OM), adhesive OM, chronic mastoiditis, or cholesteatoma.
  • 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 appropriately.
  • System(s) affected: Auditory
  • Synonym(s): Auditory tube dysfunction; Eustachian tube disorder; Blocked eustachian tube; Patulous eustachian tube
  • Sudden single-sided deafness (SSNHL) can be misdiagnosed as ETD.
  • A simple 512-Hz tuning fork test lateralizes to the opposite ear in sudden sensorineural hearing loss and to the affected ear in ETD with conductive hearing loss.
  • Any sudden sensorineural hearing loss is a medical emergency and should be referred to an otolaryngologist immediately.


  • Most common in children <5 years (1)
  • Usually decreases with age

70% of children by age 7 have experienced ETD.

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

Etiology and Pathophysiology

  • Under normal circumstances, the eustachian tube is closed, but it can open to let a small amount of air through to equalize pressure between the middle ear and the atmosphere.
  • ETD is failure of the system at the proximal end (ET, palate, nasal cavities, and nasopharynx) to regulate the middle ear and mastoid.
  • Eustachian tube 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, chewing.
  • Cycle of dysfunction: Structural or functional obstruction of the ET compromises 3 functions of this system:
    • Negative pressure develops in middle ear.
    • Serous exudate is drawn from the middle ear mucosa 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 (1).
  • Adenoid hypertrophy can block the torus tubarius (proximal opening of the ET) (1).
  • In adults, paradoxical closing with swallowing has been noted in a majority of patients (1).

Twin studies show a genetic component (1). 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 those listed above, prematurity and low birth weight, young age, daycare, exposure to many other children, 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, pollutants.

Commonly Associated Conditions

  • Hearing loss
  • Middle ear effusion
  • Recurrent OM
  • Chronic mastoiditis
  • Cholesteatoma
  • Allergic rhinitis
  • Chronic sinusitis/URI
  • Adenoid hypertrophy
  • GERD
  • Cleft palate
  • Down syndrome
  • Obesity
  • Nasopharyngeal carcinoma or other tumor

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