5-Minute Clinical Consult

Eustachian Tube Dysfunction

Eustachian Tube Dysfunction is a topic covered in the 5-Minute Clinical Consult.

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  • 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
  • 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.


  • 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

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

  • 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.

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

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