Blocked Ear

A sensation of “blocked ear” is a common reason for patients to attend an ENT (ear nose and throat) clinic. The reasons for this symptom can be obvious. For example earwax occlusion, infections of the ear canal (otitis externa), problems with the eardrum (perforation or cholesteatoma), middle ear fluid (glue ear/otitis media with effusion) and hearing loss (conductive or sensorineural).

Other reasons for a blocked sensation in the ear can include more obscure problems. Traditionally eustachian tube dysfunction has been considered a common reason for the ears to feel blocked. Although intuitively this would seem logical it is known that 1 in 20 in the general population who have no ear symptoms people have a eustachian tube that is almost permanently blocked and yet have no problems (except possibly when flying). Nevertheless, patients with a eustachian tube that does not work normally and have symptoms may improve when treated for eustachian tube problems (for example with nasal steroid sprays, antihistamines, Otovent® or EarPopper® device (see video below), grommet insertion or balloon eustachian tube dilatation). There are other conditions such as Ménière’s disease which can cause a sensation of blockage in the ear. Meniere’s disease is usually associated with bouts of spinning dizziness (vertigo), hearing loss and tinnitus.

There are a significant proportion of people with a sensation of blocked ear who seem to have no abnormality which neatly fits with any of the above. Although I have used the term “blocked ear” many patients would use different words to explain their problem for example “pressure in ear”, “pain”, “popping”, “crackling”, “sensation of fluid in ear” and “numbness in ear”. Some patients may have multiple symptoms. Other symptoms patients may experience (not necessarily at the same time as the ear pressure) include fluctuating hearing loss, pain, tinnitus, unsteadiness or pressure in other parts of the head or neck and visual disturbance. Recent research has revealed that a significant proportion of this group of patients are likely to have a disorder linked to or part of a type of  atypical migraine. Although migraine typically causes bouts of headache it is well recognised that patients with migraine are prone to a number of other symptoms including ear symptoms. My own experience is that if one is prepared to be a little flexible regarding the definition of migraine then the vast majority of patients with a blocked ear who have no other explanation do have or have had evidence of migraine. The other possibility is that this group of patients have a Ménière’s disease variant (i.e.without the spinning dizziness/vertigo, hearing loss or tinnitus). Interestingly a significant proportion of people with Ménière’s disease also have migraine. It is, of course, possible that blocked ear is a standalone disorder.

In my opinion, having seen 1000’s of patients with similar problems, it is likely that a significant proportion of the patients with a sensation of blockage in the ears without any other obvious cause have a migraine/Ménière’s disease variant. Treatments for these conditions can, therefore, be considered. It is still also a reasonable option to consider “conventional” treatment for eustachian tube problems. This could include nasal steroid sprays/drops, antihistamines, EarPopper®, Otovent® (see video below), grommet insertion and balloon dietician of the eustachian tube. In my own experience, however, these treatments are not entirely reliable, and some can involve potential risks and complications.

Unfortunately, there is a lack of clear scientific knowledge in this area. This has resulted in a varied approach to this type of problem and on occasions unsatisfactory outcomes for patients. A further problem is the propensity of patients with these types of disorders (including migraine and Meniere’s disease) to respond to placebo treatment. There is also a potential surgical effect which may be more than placebo but non-specific. For example, I operated on a patient who had popping etc in both ears equally but I was not confident surgery would help. We agreed to operate on only one side. 2 weeks after surgery both ears had improved equally! How can this be? Most surgeons may be little coy regarding this issue but it is well recognised. On the positive side, the rate of improvement in some types of surgery (this includes certain back and migraine operations) is a little too high to be pure placebo. The placebo effect is usually considered to be approximately 30%. This is recognised with placebo medications. With certain operations, a benefit of 60% is obtained even in the “sham surgery” (placebo surgery) group. I suspect that what is considered placebo surgery (which still involved cutting skin and tissue) does something not fully recognised. What I call the non-specific effect of surgery. It may be simply due to natural endorphin release or possibly an effect on the neural system from injury. Unfortunately, occasionally the opposite can also occur i.e. surgery causes increased symptoms in the area. Surgery must therefore always be considered very carefully and as a last resort.

 

Otovent device to ventilate the middle ear ear.