Assessment and Treatment of Eustachian Tube Dysfunction
Assessment
Clinical Diagnosis
Eustachian tube dysfunction (ETD) should be diagnosed based on clinical assessment and objective tests of Eustachian tube opening, not solely on patient-reported symptoms, as symptoms alone have very poor specificity and no diagnostic value. 1
Diagnostic Approach
Tympanometry is the cornerstone diagnostic test and should be performed in all suspected cases 2, 1:
- Type B (flat) tympanogram indicates middle ear effusion or severely impaired tympanic membrane mobility, commonly seen with obstructive ETD 2
- Type C tympanogram shows negative middle ear pressure, reflecting incomplete or intermittent ETD 2
- Type A (normal) tympanogram can occur between episodes or when dysfunction temporarily resolves 2
Pneumatic otoscopy should be the primary diagnostic method, with tympanometry used for confirmation and monitoring 2
Serial tympanometry over 3-6 month intervals is more informative than a single measurement, as it captures the fluctuating nature of dysfunction 2
Otomicroscopy and otoendoscopy should be performed to assess tympanic membrane appearance, retraction pockets, ossicular erosion, and areas of atelectasis 3, 4
Trans-nasal videoendoscopy can identify specific endotypes including muscular weakness (ETD-M), inflammation (ETD-I), adenoid restriction (ETD-R), and patulous dysfunction (ETD-P) 4
Audiologic Assessment
Hearing evaluation is mandatory when ETD is associated with middle ear effusion, structural tympanic membrane changes, or in at-risk children 3
Repeat hearing testing in 3-6 months should be performed if otitis media with effusion persists during watchful waiting 3
For at-risk children (Down syndrome, cleft palate, developmental delays), hearing assessments should be performed every 6 months starting at birth until age 3-4 years, then annually 3
Common Diagnostic Pitfalls
A single normal tympanogram does not exclude ETD, as testing during temporary resolution may miss intermittent dysfunction 2
Patient-reported outcome measures (PROMs) have very poor specificity and should not be used alone for diagnosis 1
The absence of middle ear effusion at assessment suggests favorable Eustachian tube function, even in patients with recurrent acute otitis media 2
Treatment
Medical Management
Medical therapy is the first-line approach for obstructive ETD, though evidence for effectiveness is limited. 5, 6
Pharmacologic Options
Nasal corticosteroids are commonly used but showed no improvement in symptoms or middle ear function in a single RCT for patients with otitis media with effusion 5
Topical decongestants (directly applied) showed very short-term improvements in middle ear function 5
Antihistamine-ephedrine combinations demonstrated short-term improvements in middle ear function 5
Regular Valsalva maneuver is recommended for obstructive dysfunction 6
For Patulous ETD
- Saline nasal irrigation, estrogen nasal ointment, and craniocervical manual therapy are treatment options for patulous Eustachian tube 6
Surgical Management
Surgical intervention should be considered when medical management fails and objective evidence of persistent dysfunction exists.
Tympanostomy Tube Insertion
For children with chronic OME (≥3 months) and bilateral mild hearing loss (16-40 dB HL), bilateral tympanostomy tube insertion should be offered 3
Tympanostomy tubes should NOT be performed in children with recurrent AOM who do not have middle ear effusion at assessment 3
For at-risk children (Down syndrome, cleft palate, developmental disabilities) with unilateral or bilateral OME likely to persist (Type B tympanogram or documented effusion ≥3 months), tympanostomy tube insertion may be performed 3
Indications for tube insertion regardless of OME duration include posterosuperior retraction pockets, ossicular erosion, and adhesive atelectasis 3
Advanced Surgical Techniques
Balloon dilation (Eustachian tuboplasty) is a feasible option for refractory dilatory dysfunction as an alternative to tympanostomy tubes 7, 6
Microdebrider Eustachian tuboplasty showed positive results in case series for refractory obstructive ETD 5, 7
For patulous ETD, insertion of a shim or fat graft reconstruction within the Eustachian tube orifice may be effective 7
Special Populations
Children with Cleft Palate
Children with cleft palate should be managed by a multidisciplinary team including otolaryngologists, audiologists, speech-language pathologists, and plastic surgeons 3, 8
Continued monitoring for OME and hearing loss throughout childhood is essential, even after palate repair, due to persistent high prevalence of effusion 3, 9
Tympanostomy tube insertion may be performed in children with cleft palate who have OME likely to persist 9
Children with Down Syndrome
Otolaryngologic evaluation with otologic microscope every 3-6 months is recommended to remove cerumen and assess for OME 3
Multiple tympanostomy tube placements may be required throughout childhood due to persistent poor Eustachian tube function 3
Monitoring Strategy
Reevaluation at 3-6 month intervals is recommended for children with chronic OME who don't receive tympanostomy tubes, continuing until effusion resolves, significant hearing loss is detected, or structural abnormalities develop 2
Tympanometry can document resolution by showing conversion from Type B to normal Type A, though this occurs in only 20% of preschool children after 3 months and 28% after 6 months with chronic effusion 2