The Eustachian tube is a narrow passage between the back of the nose and the middle ear (the air containing space behind the eardrum). Its function is to help equalise the pressure on either side of the eardrum and drain any fluid or congestion from the middle ear. If the pressure on either side of the eardrum is equal, the eardrum works efficiently. If there is excesive negative or positive pressure across the eardrum, the normal vibrations of the ear drum due to sound are reduced and the hearing is reduced. This may also be accompanied by a sensation of blockage. Eustachian tube dysfunction describes a condition characterised by a sensation of blockage in the ears. Traditionally these symptoms of “blockage in the ears” have been thought to result from a problem with the Eustachian tube function. This is usually due to blockage of the Eustachian tube but in some cases a sensation of blockage or pressure can exist even when the eustachian tube appears to be working adequately on tests.
Eustachian tube connected nose to middle ear
Problems with the Eustachian tube can occur after a cold or sinusitis when the lining of the nose and the opening to the Eustachian tube at the back of the nose becomes congested/blocked. This can result in a sensation of blockage/pressure in the ear. Occasionally the congestion/infection may be particularly severe and cause fluid to build up in the middle ear behind the eardrum (glue ear). This results in a significant hearing loss.
Other conditions such as allergy in the lining of the nose, nasal polyps or adenoids can also cause problems with the function of the eustachian tube. On very rare occasions potentially serious problems such as cancer or lymphomas of the back of nose can also cause congestion/fluid buildup in the middle ear.
In the conditions listed above there is usually some objective evidence of a problem (hearing loss on audiometry, negative pressure on tympanometry or an abnormal ear drum on otoscopy). The pressures behind the eardrum can be measured and if these are abnormally negative it would suggest that there is a problem with the Eustachian tube. In addition if there is a buildup of fluid behind the eardrum this would also be apparent on testing (tympanogram). Occasionally the eardrum can be pulled inwards (retraction) due to the negative pressure. This would be apparent on inspection of the eardrum. In such cases the treatment would address the underlying cause if apparent. Conditions such as allergy and adenoids can be treated with medical or surgical intervention. In the case of nasal allergy this would usually involve treatment with an antihistamines taken by mouth and a steroid nasal spray/drops. Adenoids are usually removed surgically. In cases where there is a buildup of fluid which does not resolve with medical treatment, surgery may be appropriate. Options include insertion of a grommets in the eardrum. This would allow equalisation of pressure on either side of the eardrum. Grommets do occasionally cause problems such as infections or perforation of the eardrum. Grommets are also not a permanent solution. Long term grommets can be inserted but they will also usually eventually either become blocked, infected or fall out.
Recently a new device (Eustachian tube catheter) incorporating a balloon has been used to dilate the Eustachian tube dysfunction. This technique involves insertion of a catheter tube through the nose under general anaesthetic (see video below). The catheter tube is inserted into the eustachian tube opening at the back of the nose. At the end of the catheter tube is a balloon which is inflated with saline while inside the eustachian tube. This stretches the eustachian tube. In theory there is a risk of damaging the carotid artery which takes blood to the brain. This has not been reported in thousands of cases performed in Europe. It is not a likely complication if the carotid artery is in its normal place. Other potential problems are damage to the eustachian tube or excessive dilatation the tube resulting in a patulous eustachian tube. A patulous eustachian tube results in air entering into the middle ear easily which may result in a patient’s own voice being heard excessively in the ear.
It is apparent that besides the patients with clear evidence of Eustachian tube dysfunction there are a group of patients (possibly the majority with a blocked sensation in the ear) with symptoms of blockage in their ears in whom the eardrum, hearing and pressures behind the eardrum are all normal. Some of these patient can even equalise the pressures behind their eardrum easily by blowing into the nose without any relief from the symptoms. This group of patients may not have a actual localised problem with the Eustachian tube as traditionally thought. Many have other symptoms of discomfort, dizziness, headaches etc. The problem of blockage may therefore represent a type of sensitisation (similar to a chronic migraine) which is accompanied by subtle congestion of the lining of the nose, Eustachian tube and ear causing the sensation of blockage. It is known that certain types of headache/migraine can cause some congestion in the lining of the nose. It would still seem reasonable to initially treat this group of patients with antihistamines/steroid sprays etc., but the benefit is unpredictable. Grommets can also be tried but again in my experience the results are unpredictable with some patients benefiting while others find their problem worsens.
I have performed a trial of Balloon Eustachian Tuboplasty / Dilatation. The finding of the trial has recently been accepted for publication in the Journal of Laryngology and Otology. I found that dilatation of the eustachian tube with a balloon catheter improves the sensation of blockage in most patient but glue ear and retractions of the ear drum often persisted. The sensation of the blockage and glue ear may therefore, represent two separate problems which can exacerbate each other. If patients do have symptoms suggestive of a migraine type of problem it would be reasonable to try migraine treatments (click here).