What is the eustachian tube?

The eustachian tube is a narrow channel which connects the middle ear with the nasopharynx (the upper throat area just above the palate and behind the nose). The eustachian tube is approximately 1-½ inches in length. The narrowest portion is the area near the middle ear space.

The eustachian tube functions as a pressure equalizing valve for the middle ear, which is normally filled with air. Under normal circumstances, the eustachian tube opens for a fraction of a second in response to swallowing or yawning. In so doing, it allows air into the middle ear to replace air that has been absorbed by the middle ear lining (mucous membrane), or to equalize pressure changes occurring with altitude changes. Anything that interferes with this periodic opening and closing of the eustachian tube may result in a hearing impairment or other ear symptoms.

Eustachian Tube Dysfunction

Obstruction or blockage of the eustachian tube results in a vacuum in the middle ear (negative middle ear pressure), with resultant retraction (sucking in) of the eardrum. In an adult, this is usually accompanied by some discomfort, such as a fullness or pressure feeling, and may result in a mild hearing impairment and head noise (tinnitus). In children, there may be no symptoms. If the obstruction is prolonged, fluid may be sucked into the middle ear from the lining mucous membranes. If the fluid is unable to drain into the throat due to obstruction of the eustachian tube, a condition called serous otitis media (fluid in the middle ear) may develop. Serous otitis media is very common in young children due to immaturity of the eustachian tube, but can also occur in older children and adults. It occurs frequently in connection with upper respiratory infections or allergies. The limitation of mobility of the eardrum due to the presence of a vacuum or fluid in the middle ear accounts for the hearing impairment associated with eustachian tube dysfunction.

Patulous Eustachian Tube

On occasion, the opposite of blockage occurs, and the eustachian tube remains excessively open for a prolonged period. This is called abnormal patency of the eustachian tube (patulous eustachian tube). This is less common than eustachian tube dysfunction and serous otitis media, and it occurs primarily in adults. It sometimes begins after a significant weight loss. Because the tube is constantly open, the patient may hear himself breath, and his voice may reverberate in the affected ear. Fullness and a blocked feeling are common sensations experienced by the patient. Abnormal patency of the eustachian tube can be extremely annoying but does not produce a hearing impairment.

Treatment of an Abnormally Functioning Eustachian Tube

There are many alternatives to treat a poorly functioning eustachian tube.

1. An abnormally narrow eustachian tube can sometimes be enlarged with medicines. Nasal steroid sprays are frequently tried, and in adults nasal and oral decongestants may be recommended.
2. If an infection is thought to be present (otitis media), then antibiotics are appropriate. However, if middle ear fluid persists after more than one course of antibiotics, additional trials of antibiotics are much less efficacious in relieving the problem.
3. If allergies are thought to be contributing to the eustachian tube dysfunction, allergy testing (which can be performed through our office) and allergy treatment may be indicated.

When eustachian tube dysfunction persists despite maximal medical therapy, surgical procedures can be utilized.

                                                                Picture courtesy of Acclarent Inc.

1. Last September the FDA approved a new procedure to treat eustachian tube dysfunction it is the Acclarent Aera.  The procedure involves threading a catheter with a small balloon into the opening of the eustachian tube in the back of the nose under endoscopic guidance.  The balloon is then expanded for 2 minutes.  The procedure dilates the eustachian tube, allowing it to remain open long term. After the procedure, the recovery is very quick.  The procedure has demonstrated a high success rate for symptomatic relief, with resolution of muffled hearing, ear pressure, and/or ear pain.
2. Tube placement into the eardrum is indicated for persistent or frequently recurrent ear infections. For most adults and older children, the procedure can be performed in the office with the use of topical or local anesthetic. Younger children require the assistance of an anesthesiologist so that the delicate surgery can be safely completed. The procedure takes roughly 10 minutes, and most children resume normal activities and diet several hours after the operation, once the effects of the anesthetic have had a chance to wear off. Pain is minimal to none. The tubes in the eardrum are designed to be temporary, and typically fall out 6 months to 3 years after placement (depending on type of tube selected). The hope is that the eustachian tube will have a chance to heal and resume normal function once the tube extrudes.
3. At the Ear Institute of Texas, we are also performing a new procedure for treatment of chronic eustachian tube dysfunction in patients who have required more than one trial of tube placements in the eardrum. This procedure involves placing a tube in the eardrum overlying the opening to the eustachian tube, after the eustachian tube and middle ear have been visualized and inspected with an oto-endoscope (a small thin scope that allows the physician to visualize the middle ear structures with magnification and high resolution). A MicroWick is threaded through the tube and into the eustachian tube opening. The patient is then instructed to apply steroid drops to the ear canal, which allows delivery of a high concentration of steroids to the eustachian tube in a near-continuous fashion. The technique can be performed in the office or out-patient surgery center. Many patients have been found to respond to the treatment, with lasting improvement in their eustachian tube function and symptoms.

Eustachian Tube Problems Related to Flying

Individuals with an eustachian tube problem may experience difficulty equalizing middle ear pressure when flying. When an aircraft ascends, the atmospheric pressure decreases. This results in a relative increase in the middle ear air pressure compared to the surrounding cabin pressure. When the aircraft descends, just the opposite occurs: atmospheric pressure increases in the cabin of the aircraft, and there is a relative decrease in the middle ear pressure compared to the surrounding cabin pressure. Either situation may result in discomfort in the ear due to pressure and stretching of the eardrum, when the eustachian tube is not functioning properly to equalize the pressure between middle ear and cabin pressure. Usually, this discomfort is experienced during descent of the aircraft. To avoid middle ear problems associated with flying, you should not fly if you have an acute upper respiratory problem such as a common cold, allergy attack, or sinus infection.

Should you have such a problem, or a history of chronic eustachian tube problems, and must fly, you may help avoid ear difficulty by observing the following recommendations (if your physician agrees you can tolerate this therapy):

1. Obtain from your drug store the following over the counter items: Sudafed tablets and a plastic squeeze bottle of NeoSynephrine or Afrin decongestant nasal spray. One must be careful using these medications if you are not otherwise healthy and have conditions such as hypertension or heart rhythm disturbances. If you do have other medical conditions, you may discuss these recommendations with your primary care physician.
2. Following the container directions, begin taking Sudafed tablets the day before your air flight. If you have experienced any problems equalizing your middle ear pressure during the flight, continue the medication for 24 hours after the flight.
3. Following the container directions, use the nasal spray shortly before boarding the aircraft. Should your ears “plug up” upon ascent, hold your nose and swallow while attempting to force air up the back of the throat. This will help suck excess air pressure out of the middle ear.
4. Forty-five minutes before the aircraft is due to land, use the nasal spray every five minutes for fifteen minutes. Chew gum to stimulate swallowing. Should your ears “plug up” despite this, hold your nose and blow gently toward the back of the throat, while swallowing. This will blow air up the eustachian tube into the middle ear (termed Valsalva maneuver).

***None of these recommendations or precautions need to be followed if you have a tube in your eardrum.