Eustachian Tube Dysfunction (ETD)

This is a common cause of acute morbidity but one in which the scientific literature is wanting.¹ In the setting of Upper Respiratory Tract Infection (URTI), with associated rhinosinusitis, otitis or not, the patient can present with a complaint of giddiness or a feeling of fullness in their ears.

Pharyngeal or sinus swelling will be transmitted across to the middle ear and, if the middle ear pressure fails to equilibrate with atmosphere because of inflammatory oedema of the eustachian tube, high middle ear pressures result in ear pain, a feeling of fullness about the ears and dampened hearing, and often disequilibrium with unsteadiness, giddiness, and occasionally vertigo. (Of course, more serious causes of dizziness should be excluded.)

The Eustachian tube connects the middle ear chamber with the posterior pharynx, helping to re-equilibrate pressures to atmosphere.

Functions of the Eustachian tube

1. pressure equalisation and ventilation of middle ear – middle ear mucosal gas exchange and periodic opening of the Eustachian tube to restore middle ear towards atmospheric pressure
2. mucociliary clearance of secretions from middle ear – both muscular (levator veli palatini, tensor veli palatini) and mucociliary mechanisms
3. protection of the middle ear from sounds, and from nasopharyngeal pathogens and secretions (including gastric acid)¹

The problem is particularly acute during the descent phase of a flight, as I recently discovered. Having had a recent URTI, I diligently “popped” my ears as the plane gave away altitude to find, nonetheless, upon alighting, that I could no more walk straight than a publican in the early hours of a Saturday.

My impression is that disequilibrium is greater in adults than children, but it may be that children simply do not readily think to complain of it.

Types of ETD

A consensus statement recently issued by an international forum of experts identified three major types of eustachian tube dysfunction (and three subtypes of the dilatory type):

Patients with frank otitis media (bulging, inflamed drum) or sinusitis (facial tenderness with purulent nasal discharge) need antibiotics. But ALL patients should be advised to commence salt-water gargles. Salt-water gargles are the simple and easy fix for the dreadful unsteadiness and ear fullness that manifests from this problem. Take 1/2 teaspoon of regular salt and mix in a full glass of warm water and gargle. Try to hold the gargle for as long as you can. Discard. Repeat twice. Do that three times a day and enjoy clear sounds and steady gait once more.

ETD can also complicate allergic rhinitis. Supplement salt-water gargles with nasal glucocorticoids and oral antihistamines, as necessary, and expect eustachian tube function to improve as nasal symptoms subside.

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References

1. Llewellyn A, Norman G, Harden M, Coatesworth A, Kimberling D, Schilder A, et al. Interventions for adult Eustachian tube dysfunction: a systematic review. Health Technol Assess 2014;18(46).
2. Ma, Y., Liang, M., Tian, P. et al. Eustachian tube dysfunction in patients with house dust mite-allergic rhinitis. Clin Transl Allergy 10, 30 (2020). https://doi.org/10.1186/s13601-020-00328-9.
3. Smith ME, Takwoingi Y, Deeks J, Alper C, Bance ML, Bhutta MF, et al. (2018) Eustachian tube dysfunction: A diagnostic accuracy study and
   proposed diagnostic pathway. PLoS ONE 13(11): e0206946. https://doi.org/10.1371/journal.pone.0206946.
4. A.G.M. Schilder, M.F. Bhutta, C.C. Butler, C. Holy, L.H. Levine, K.J. Kvaerner, G. Norman, R.J. Pennings, D. Poe, J.T. Silvola, H. Sudhoff, V.J. Lund. Eustachian tube dysfunction: consensus statement on definition, types, clinical presentation and diagnosis. Sep 7, 2015. https://doi.org/10.1111/coa.12475.