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Eustachian Tube Dysfunction

Eustachian Tube Dysfunction is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • A spectrum of disorders involving impairment of the functional valve of the eustachian tube (ET)
  • ETD can be classified as patulous dysfunction, in which the ET is excessively open, or dilatory dysfunction, in which there is failure of the tubes to dilate (i.e., open) appropriately.
  • Pathophysiology related to pressure dysregulation, impaired protection secondary to reflux of irritating material into the middle ear, or impaired clearance by the mucociliary system
  • May occur in the setting of pressure changes (e.g., scuba diving or air travel) or acute upper airway inflammation (e.g., allergic or infectious rhinosinusitis, acute otitis media [OM])
  • Chronic ETD may lead to a retracted tympanic membrane, recurrent serous effusion, recurrent OM, adhesive OM, chronic mastoiditis, or cholesteatoma.
  • System(s) affected: auditory
  • Synonym(s): auditory tube dysfunction; ET disorder; blocked ET; patulous ET
ALERT
  • Sudden sensorineural hearing loss (SSNHL) can be misdiagnosed as ETD.
  • A simple 512-Hz tuning fork test lateralizes to the opposite ear in SSNHL and to the affected ear in ETD with conductive hearing loss.
  • Any SSNHL is a medical emergency and should be referred to an otolaryngologist immediately.

Epidemiology

  • Most common in children <5 years of age, thought to be related to anatomical differences (see “Etiology and Pathophysiology” section)
  • Usually decreases with age

Incidence
70% of children by age 7 years have experienced ETD.

Prevalence
  • 1% of the adult population
  • Males > females
  • Highest prevalence among Native Americans, Inuits, Australian Aborigines, Hispanics, Africans

Etiology and Pathophysiology

  • Under normal circumstances, the ET is closed, opening to release a small amount of air to equilibrate middle ear pressure with surrounding atmospheric pressure.
  • ETD is failure of the ET, palate, nasal cavities, and nasopharynx to regulate middle ear and mastoid pressure.
  • ET functions
    • Ventilation/regulation of middle ear pressure
    • Protection from nasopharyngeal secretions
    • Drainage of middle ear fluid
    • ET is closed at rest and opens with yawning, swallowing, and chewing.
  • Cycle of dysfunction: structural or functional obstruction of the ET:
    • Negative pressure develops in middle ear.
    • Serous exudate is drawn to the middle ear by negative pressure or refluxed into the middle ear if the ET opens momentarily.
    • Infection of static fluid causes edema and release of inflammatory mediators, exacerbating the cycle of inflammation and obstruction.
  • In children, a horizontal and shorter ET predisposes to difficulties with ventilation and drainage.
  • Adenoid hypertrophy can block the torus tubarius (proximal opening of the ET).
  • In adults, paradoxical closing of the ET with swallowing occurs in a majority of affected patients.
  • Tumors that impair/occlude the ET or that invade the tensor veli palatini to impair normal swallow regulation, can also lead to dysfunction.

Genetics
Twin studies show a genetic component. Specific genetic cause is undefined.

Risk Factors

Adult and pediatric

  • Allergic rhinitis, tobacco exposure, GERD, chronic sinusitis, adenoid hypertrophy or nasopharyngeal mass, neuromuscular disease, altered immunity
  • Prematurity and low birth weight, young age, daycare, crowded living conditions, low socioeconomic status, prone sleeping position, prolonged bottle use, craniofacial abnormalities (e.g., cleft palate, Down syndrome)

Pregnancy Considerations
ETD may be exacerbated by rhinitis of pregnancy; symptoms resolve postpartum.

General Prevention

  • Control of upper airway inflammation: allergies, infectious rhinosinusitis, GERD
  • Autoinsufflation of middle ear (i.e., blow gently against pinched nostril and closed mouth)
  • Avoid atmospheric pressure changes (e.g., plane flight, scuba diving) in the setting of acute allergy exacerbation or URI.
  • Avoid exposure to environmental irritants: tobacco smoke and pollutants.

Commonly Associated Conditions

  • Hearing loss
  • OM: acute, chronic, and serous
  • Chronic mastoiditis
  • Cholesteatoma
  • Allergic rhinitis
  • Chronic sinusitis/URI
  • Adenoid hypertrophy
  • GERD
  • Cleft palate
  • Down syndrome
  • Obesity
  • Nasopharyngeal carcinoma or other tumor

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Citation

Stephens, Mark B., et al., editors. "Eustachian Tube Dysfunction." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116831/all/Eustachian_Tube_Dysfunction.
Eustachian Tube Dysfunction. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116831/all/Eustachian_Tube_Dysfunction. Accessed April 19, 2019.
Eustachian Tube Dysfunction. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116831/all/Eustachian_Tube_Dysfunction
Eustachian Tube Dysfunction [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 19]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116831/all/Eustachian_Tube_Dysfunction.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Eustachian Tube Dysfunction ID - 116831 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116831/all/Eustachian_Tube_Dysfunction PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -