How is Eustachian tube dysfunction diagnosed and treated?

How to Check for Eustachian Tube Dysfunction

Pneumatic otoscopy is the gold standard diagnostic test for Eustachian tube dysfunction, with 94% sensitivity and 80% specificity when performed correctly, and should be the primary method used to assess tympanic membrane mobility. 1, 2

Primary Diagnostic Approach

Step 1: Pneumatic Otoscopy

• Perform pneumatic otoscopy first to assess tympanic membrane mobility and document the presence of middle ear effusion 1, 2
• Distinctly impaired mobility has the highest diagnostic accuracy with approximately 95% sensitivity and 85% specificity 1
• Normal tympanic membrane movement occurs with positive and negative pressure, especially in the superior posterior quadrant 1
• When the tympanic membrane doesn't move perceptibly with gentle positive or negative pressure, middle ear effusion is likely present 1

Key findings on pneumatic otoscopy indicating ETD: 3, 2

• Retracted tympanic membrane with prominent short process of malleus
• Restricted or absent inward motion with positive pressure
• Opaque, amber, or gray tympanic membrane appearance
• Loss of normal landmarks (light reflex, malleus handle)
• Visible air bubbles or fluid levels behind the tympanic membrane

Step 2: Tympanometry for Confirmation

• Obtain tympanometry when the diagnosis is uncertain after performing pneumatic otoscopy 1
• Use standard 226 Hz probe tone for adults and children over 6 months; use 1000 Hz probe tone for infants under 6 months 2

Tympanometry interpretation: 3, 2

• Type B (flat) tympanogram: Indicates middle ear effusion or severely impaired tympanic membrane mobility—this is the hallmark of obstructive ETD
• Type C tympanogram: Shows negative middle ear pressure, reflecting incomplete or intermittent ETD
• Type A (normal) tympanogram: Can occur between episodes or when dysfunction temporarily resolves

Step 3: Otomicroscopy/Otoendoscopy

• Examine the tympanic membrane with otomicroscopy or otoendoscopy to identify structural changes 3

Critical findings to document: 3

• Posterosuperior retraction pockets (indicate chronic negative middle ear pressure)
• Ossicular erosion visible through the tympanic membrane
• Adhesive atelectasis or generalized atelectasis
• Areas of tympanic membrane atrophy
• Early cholesteatoma formation in chronic cases

Audiologic Assessment

When to Obtain Hearing Testing

• Perform age-appropriate hearing testing if OME persists for ≥3 months 1
• Mandatory when ETD is associated with middle ear effusion or structural tympanic membrane changes 3
• For at-risk children (Down syndrome, cleft palate, developmental delays), perform hearing assessments every 6 months starting at birth until age 3-4 years, then annually 3

Expected audiologic findings: 3

• Conductive hearing loss is most common, typically mild (16-40 dB HL)
• Repeat hearing testing in 3-6 months if OME persists during watchful waiting 3

Clinical History Elements

Document the following: 2

• Pattern, chronicity, and triggers of symptoms (especially association with upper respiratory infections)
• Whether symptoms are unilateral or bilateral
• Quality of life impacts: fatigue, sleep disturbances, learning problems, work/school absenteeism
• Accompanying conditions: otitis media, sinusitis, nasal polyps, allergic rhinitis

Serial Monitoring Strategy

For chronic cases, serial tympanometry over 3-6 month intervals is more informative than a single measurement because it captures the fluctuating nature of dysfunction 3. Reevaluate at 3-6 month intervals until effusion resolves, significant hearing loss is detected, or structural abnormalities develop 1, 3.

Common Pitfalls to Avoid

• Never rely solely on non-pneumatic otoscopy for primary diagnosis—this misses the critical assessment of tympanic membrane mobility 2
• Don't misinterpret tympanometry results due to improper technique or equipment calibration 2
• Avoid confusing ETD with acute otitis media, which presents with acute signs of middle ear inflammation and bulging tympanic membrane 2
• Don't skip hearing testing before considering surgical intervention—it's essential for appropriate decision-making 4
• Patient-reported outcome measures (PROMs) have very poor specificity and no diagnostic value; diagnosis must be based on clinical assessment and tests of ET opening 5