What are the treatment options for a patient with Eustachian Tube Dysfunction (ETD)?

Treatment of Eustachian Tube Dysfunction

Initial Management: Watchful Waiting with Auto-Inflation

For most patients with ETD, begin with a 3-month period of watchful waiting combined with nasal balloon auto-inflation, as the majority of cases resolve spontaneously without intervention. 1, 2

• Nasal balloon auto-inflation should be performed regularly during the observation period because it effectively clears middle ear effusion and improves symptoms at 3 months with a number needed to treat of 9, has no adverse effects, and costs very little 1, 2, 3
• Reevaluate patients every 3-6 months with otologic examination until effusion resolves, significant hearing loss develops, or structural abnormalities appear 1, 2
• Obtain age-appropriate hearing testing at 3 months if effusion persists, as ETD typically causes mild conductive hearing loss averaging 25 dB HL, with 20% of patients exceeding 35 dB HL 1

Medical Therapies: What NOT to Use

Do not prescribe intranasal corticosteroids, oral steroids, antihistamines, decongestants, or systemic antibiotics for ETD, as these have been proven ineffective or may cause harm without benefit. 1, 2

• Intranasal corticosteroids show no improvement in symptoms or middle ear function and may cause adverse effects without clear benefit 1, 2, 3
• Oral/systemic steroids are ineffective and not recommended 1
• Antihistamines and decongestants may provide very short-term improvements but a Cochrane meta-analysis found no significant benefit (RR 0.99,95% CI 0.92-1.05) and they should not be used for long-term management 1, 2, 3
• Systemic antibiotics are not effective for treating OME/ETD 1
• Topical nasal decongestants (oxymetazoline or xylometazoline) may be used for acute, short-term management (maximum 3 days only) to avoid rhinitis medicamentosa, which can occur as early as day 3-4 of regular use 1

Exception: Allergy Management

If ETD is secondary to allergic rhinitis, treat the underlying allergic rhinitis with intranasal corticosteroids as first-line therapy, with second-generation antihistamines for sneezing and itching. 1, 2, 3

• Specific allergy therapy improves fullness, allergy symptoms, and overall well-being in patients with allergy-mediated ETD 2, 3
• This is the only scenario where intranasal corticosteroids have a role—treating the allergic rhinitis itself, not the ETD directly 1

Surgical Intervention: Timing and Indications

Do not perform surgery until ETD has persisted for at least 3 months, as there is no evidence of benefit before this timeframe and it exposes patients to unnecessary surgical risks. 1, 2

Tympanostomy Tube Insertion (First-Line Surgery)

Tympanostomy tube insertion is the preferred initial surgical procedure for persistent ETD with effusion lasting ≥3 months. 1, 2, 3

• Offer bilateral tympanostomy tubes for bilateral effusions lasting ≥3 months with mild hearing loss (16-40 dB HL) 1
• Tubes provide high-level evidence of benefit for hearing and quality of life for up to 9 months, clear middle ear effusion for up to 2 years, and improve hearing by 6-12 dB while patent 1, 3
• Contraindication: Do not insert tubes in patients with recurrent acute otitis media who do not have middle ear effusion present at assessment 1

Age-Specific Surgical Algorithms

For children <4 years old:

• Recommend tympanostomy tubes alone 1
• Do not perform adenoidectomy unless a distinct indication exists other than OME (such as nasal obstruction or chronic adenoiditis) 1

For children ≥4 years old and adults:

• Consider tympanostomy tubes, adenoidectomy, or both 1
• For repeat surgery, recommend adenoidectomy plus myringotomy (with or without tubes) unless cleft palate is present, as this confers a 50% reduction in need for future operations and reduces ventilation tube re-insertions by ~10% 1, 3

For children <2 years with recurrent acute otitis media:

• Adenoidectomy as standalone or adjunct to tube insertion provides modest benefit 1

Management of Complications After Tube Insertion

For ear infections with tympanostomy tubes in place, use antibiotic ear drops (ofloxacin or ciprofloxacin-dexamethasone) applied twice daily for up to 10 days—not oral antibiotics. 1, 2

• Quinolone ear drops have not shown ototoxicity and are preferred over systemic antibiotics 1, 2
• Oral antibiotics are generally unnecessary unless the child is very ill or the infection doesn't respond to ear drops 1
• Do not use antibiotic eardrops frequently or for more than 10 days at a time to avoid yeast infections of the ear canal 1

Post-Surgical Monitoring

• Evaluate children within 3 months after tympanostomy tube placement, then periodically while tubes remain in place 1, 2, 3
• Water precautions may be necessary, particularly for swimming in non-chlorinated water or dunking head during bathing 1, 2

Emerging Surgical Option: Balloon Dilatation

Balloon dilatation of the Eustachian tube may provide clinically meaningful improvement in ETD symptoms at up to 3 months compared to non-surgical treatment, though the evidence is low to very low certainty. 1, 4

• A 2025 Cochrane review found low-certainty evidence that balloon dilatation may reduce ETDQ-7 scores (MD -1.66,95% CI -2.16 to -1.16) and improve tympanometry (RR 2.51,95% CI 1.82 to 3.48) at up to 3 months 4
• Effects beyond 3 months are very uncertain 4
• Studies were underpowered to detect adverse events and performed by highly experienced investigators, which may underestimate real-world complication rates 4

Special Populations Requiring Closer Monitoring

At-risk children (Down syndrome, cleft palate, craniofacial syndromes, developmental disabilities) may receive tympanostomy tubes earlier than the standard 3-month threshold. 1

• Children with Down syndrome require hearing assessments every 6 months starting at birth due to poor Eustachian tube function 1, 2
• Children with cleft palate require management by a multidisciplinary team and continued monitoring for OME and hearing loss throughout childhood, even after palate repair 1
• Children with developmental disabilities require closer monitoring as they may lack communication skills to express pain or discomfort 1, 2

Critical Pitfalls to Avoid

• Never insert tympanostomy tubes before 3 months of documented ETD—there is no evidence of benefit and it exposes patients to unnecessary surgical risks 1
• Never skip hearing testing before considering surgery—it is essential for appropriate decision-making 1
• Never use prolonged or repetitive courses of antimicrobials or steroids for long-term resolution of OME, as this is strongly not recommended 1
• Never assume OME severity is unrelated to behavioral problems or developmental delays, as OME severity correlates with lower IQ, hyperactive behavior, and reading defects 1