BLOCKED EARS - EUSTACHIAN TUBE DYSFUNCTION (ETD)

One of the most common reasons patients come to see me is because their ears feel blocked. Most people reasonably assume that is because their ears are blocked with wax. This is often the case, however many of the patients I see have already been to see their GP who has examined their ears and told them it ‘looks normal’. There are many reasons why ears can feel blocked, but this article focusses on one of the most common causes of blocked ears - Eustachian tube dysfunction - and what can be done about it.

What is the Eustachian tube, and what does it do?

On the inside of the eardrum there is a small pocket of air. The air is continuously absorbed by the lining, generating a negative pressure. The way that the body deals with this is via the Eustachian tube. The Eustachian tube is, yes, a tube, that connects the air pocket to the very back of the nose. The Eustachian tube is usually closed, but each time you swallow or yawn, it temporarily opens and sends a little puff of air into the ear, keeping the pressures on each side of the eardrum the same. 

The ear drum has a very rich nerve supply and is incredibly sensitive (one of the reasons why ear infections are so painful), so it can detect very small pressure changes, giving rise to a feeling of blockage (and other symptoms) if the Eustachian tube isn't working perfectly. It only takes some thick mucus, or a little bit of inflammation, to upset the delicate mechanism of the Eustachian tube.

What are the symptoms of Eustachian tube dysfunction?

ETD can give rise to a number of different symptoms, that can occur together or in isolation. The feeling of a blocked ear is probably the most common symptom. Some people describe it as being a feeling of water in the ear, or a pressure sensation. It is sometimes, but not always, made worse by changes in air pressure, such as going up a hill in a car, through a tunnel in a train, or being on a plane (most commonly when the plane descends to land). Other symptoms include:

• A pulsing or ringing noise in the ear (tinnitus)
• Earache,
• Poor or muffled hearing
• Popping or crackling noises in the ear
• Poor balance or vague feelings of dizziness
• A vague sense of disorientation, or feeling ‘as if I’m not all there’

How is Eustachian tube dysfunction diagnosed?

The diagnosis is often obvious from the history, but making a diagnosis of ETD is not always straightforward. In addition to hearing about the symptoms a patient is experiencing, an examination of the ear, nose, mouth and neck can be helpful. Examination of the back of the nose with a small flexible telescope (flexible nasendoscopy) is sometimes required to ensure there are no growths or blockages around the opening of the Eustachian tube. Hearing tests are usually required to establish if any hearing loss is present and a pressure test (tympanogram) can determine if there is a negative pressure or fluid on the inside of the ear drum. Sometimes a scan of the head is required.

What causes Eustachian tube dysfunction?

The cause of ETD is not always identified. It is much more common in young children, in whom it can lead to problems of glue ear, but it can occur at any age. People who have nasal problems such as allergic rhinitis or chronic sinusitis commonly have problems with ETD, as the inflammation in the nose often includes the Eustachian tube. Another common cause of ETD is a cough or cold. Frequently people report having had a cold that got better, but left them with a blocked ear (or ears). It usually gets better in a week or two, but can last for months afterwards.

Swellings at the back of the nose (the nasopharynx) can cause the Eustachian tubes to become blocked. Enlarged adenoids can lead to Eustachian tube problems in children, and less commonly in adults. Rarely tumours in the nasopharynx can give be the cause of ETD. If you have had a blocked ear or ears for more than six weeks, you should seek medical advice.

What can I do about it?

Unfortunately there aren’t any 100% reliable treatments, however there are a number of potential treatments. The good news is that it often gets better by itself without any treatment, although it can take many months to do so.

• Nasal salt water washes - there are many different varieties of salt water washes and sprays that can be bought over the counter, or if you prefer, you can make your own at home. These sprays can help clear thick mucus from the back of the nose in and around the opening of the Eustachian tubes.
• Steam inhalations - these work in a similar way to salt water washes
• Steroid nasal sprays or drops - these are effective at reducing inflammation in the nose and are often a good treatment for blocked nose. They can also reduce inflammation around the opening of the Eustachian tube and improve its function, although this isn't a reliable treatment.
• Antihistamines - if you have an allergy, antihistamines sometimes help.
• Gently pop the ears several times a day
• Smoking causes inflammation in the upper airways, and can lead to ETD. Stopping smoking often helps.

Are there any operations to treat Eustachian tube dysfunction?

The two main operations available treat ETD are grommet insertion and/or balloon Eustachian tube dilation

Grommets/ventilation tubes - these are small plastic tubes with a hole in the middle that can be inserted into the eardrum under a local or general anaesthetic. Air can pass directly through the grommet, bypassing the Eustachian tube. Grommets can be a very effective treatment for ETD. They usually stay in place for about 6-9 months, and the symptoms sometimes recur when the grommet falls out. In a small percentage of cases, grommets can actually make the symptoms worse. This usually occurs when an incorrect diagnosis has been made, and the symptoms are not due to ETD. The disadvantage of grommet insertion is that the ears need to be kept dry whilst the grommets are in place. There is also the risk of infection, or a hole (perforation) in the eardrum, which occurs in about one in fifty grommets that are inserted.

Eustachian tube balloon dilation (balloon tuboplasty) - this is a relatively new procedure that has been around for the last five years or so. It involves gently inserting a deflated balloon through the nose and into the opening of the Eustachian tube. The balloon is then inflated for a minute or so, gently stretching open the Eustachian tube, before it is deflated and removed. A number of research studies have been conducted looking at this treatment, almost all of which have found it is an effective treatment. However, the numbers of patients in the studies have not always been large, and the quality variable. This does mean it is difficult to say with absolute certainty that it is an effective treatment, however the early indicators are that it is a helpful treatment in about 70-80% of patients. The studies have also shown that it is a safe, treatment, and the risk of serious complications following this procedure is extremely low. Balloon tuboplasty can also be performed at the same time as grommet insertion if required.