Eustachian tube dysfunction in primary care: Diagnosis,management and when to refer

ETD overview and prevalence

Eustachian tube dysfunction (ETD) is a common yet under-recognised presentation in UK general practice. A UK primary care cohort study found ETD symptoms affected approximately 0.9% of adults, with transient dysfunction affecting up to 40% of children (Schilder et al., 2015; Alper et al., 2019). Patients typically report non-specific aural pressure, muffled hearing or popping sensations, comprising symptoms that overlap with rhinosinusitis, allergic rhinitis or upper-airway infection (Schröder et al., 2015; Tangbumrungtham et al., 2018).

The eustachian tube (ET) connects the middle ear to the nasopharynx and opens intermittently to equalise pressure, drain secretions and protect the tympanic cavity (Seibert & Danner, 2006). Obstruction or inflammation (whether infective, allergic or anatomical) leads to ETD and consequent discomfort, conductive hearing loss or tinnitus (Schilder et al., 2015).

Although most cases are self-limiting, persistent or unilateral symptoms should trigger concern for more serious pathology, including nasopharyngeal carcinoma (Smith et al., 2016). This article offers a pragmatic, evidence-based guide for general practice: how to recognise ETD, initiate management, and identify red flags for ear, nose and throat (ENT) referral.

Classification and pathophysiology

An international consensus recognised three phenotypes for ETD (Schilder et al., 2015). To treat the patient correctly, the type of ETD must be discerned:

History: listening for clues

Taking a detailed history is essential. Many patients attribute their symptoms to seasonal allergy or post-viral congestion and will not mention ear symptoms unless prompted. Useful questions include whether they feel pressure, fullness or muffled hearing, whether symptoms vary with altitude change, and whether they hear crackling or popping sounds. Some report autophony, an uncomfortable awareness of their own voice, which suggests a patulous (abnormally open) tube (Ballenger and Snow, 2003).

Key points to cover

The consultation should also explore functional impact. Disturbed sleep, difficulty at work or school, or parental concerns about speech or behaviour can signal clinically important disease.

Examination: seeing beyond the drum

Clinical examination plays a central role in the evaluation of suspected ETD. Otoscopy may reveal a retracted tympanic membrane, visible air-fluid levels or a dull, opacified appearance suggestive of negative middle ear pressure. However, it is important to note that normal otoscopic findings do not rule out intermittent dysfunction (Smith et al., 2018).

Pneumatic otoscopy, though rarely used in primary or secondary care, can offer additional value by assessing tympanic membrane mobility. Reduced movement typically reflects fluid or pressure changes. Asking the patient to attempt a Valsalva manoeuvre may provoke symptoms or transiently relieve them, thereby aiding diagnosis and offering symptomatic insight (Bal and Deshmukh, 2022).

In children, anterior rhinoscopy may demonstrate turbinate hypertrophy or adenoidal enlargement, which are common contributors to ETD in the paediatric population (Manno et al., 2021). Identifying these anatomical factors is crucial as they often underlie recurrent or persistent symptoms and may warrant further evaluation or referral for consideration of medical or surgical intervention.

Even without specialist equipment, suspected ETD may be explored with the Eustachian Tube Dysfunction Questionnaire-7 Items (ETDQ-7). This questionnaire is a validated clinical tool used to assess symptoms of ETD in adults, which can quantify the severity of a patient's ETD symptoms and monitor treatment response over time. Seven domains are assessed in the questionnaire: pressure in the ears, pain in the ears, sensation of clogged ears, ear symptoms when having a cold or sinusitis, popping or cracking sounds in ears, ringing in ears (tinnitus), and hearing loss or muffled hearing. Each item is scored on a Likert scale from 1 to 7, where ‘1’ corresponds to no problem, while ‘7’ indicates a severe problem The total score then divided by 7 to give the mean of the seven items. A total score of 14.5 or more is considered abnormal and suggestive of ETD (McCoul et al., 2012). Surgical intervention for obstructive symptoms in the form of eustachian tube balloon tuboplasty is typically considered in patients with a mean score of greater than 4 or 5.

Differentials: considering the context

ETD is often a diagnosis of exclusion. Its symptoms frequently overlap with other conditions, and so a careful evaluation is essential. A thorough history and focused examination, assessing nasal patency, tympanic membrane mobility and associated allergic or infective features, can help differentiate ETD from alternative causes such as otitis media, allergic rhinitis or temporomandibular joint dysfunction

The most common differential is otitis media with effusion (OME). Both ETD and OME may present with hearing loss, ear fullness and reduced tympanic membrane mobility. Although OME often results from ETD in children, it can also occur independently due to upper respiratory infections, allergy or inflammation (Iwano et al., 1993).

Other potential causes to consider include:

A detailed history and examination, supported by targeted investigations where available, can help distinguish ETD from other diagnoses (Schilder et al., 2015). Securing an ETD diagnosis can help expedite further management and allow for the patient to be triaged to the correct management pathway.

Investigations in primary care

Initial assessment and simple investigations can be performed in general practice to support a diagnosis of ETD and determine whether referral is warranted. These may include otoscopy, tympanometry and assessment of nasal function, with referral advised for persistent, atypical or unilateral symptoms, or when red flags such as otorrhoea, cranial neuropathies or nasopharyngeal masses are suspected.

A short trial of intranasal corticosteroids can be both diagnostic and therapeutic in cases where allergic rhinitis is suspected. Recording the patient's symptoms and treatment response over a few weeks helps establish a clearer clinical picture (Sproat et al., 2014).

Managing ETD: knowing when to escalate

Not all cases of ETD necessitate specialist referral because management should be tailored to the specific subtype. For dilatory ETD, initial treatment involves optimisation of underlying nasal pathology using intranasal corticosteroids, with or without oral antihistamines, alongside a trial of auto-inflation for 4–6 weeks. In baro-challenge ETD, symptomatic relief may be achieved by using pre-flight intranasal decongestants (e.g. oxymetazoline), instruction in timed Valsalva manoeuvres and education on pressure-equalising techniques during diving or altitude changes. Management of patulous ETD includes measures to enhance mucosal hydration such as increased fluid intake, topical saline or oestrogen nasal drops and the avoidance of decongestants, which may worsen symptoms (Bal et al., 2012).

One example of a primary care intervention for ETD is autoinflation, a mechanical technique in which positive pressure is generated in the nasopharynx, typically by blowing against resistance (such as a nasal balloon device), to force the ET open, thereby ventilating the middle ear. In the context of ETD, autoinflation is considered a safe, low-cost and effective option, particularly during the watchful waiting period before considering surgical interventions such as tympanostomy tubes or balloon eustachian tuboplasty (Webster et al., 2023; Williamson et al., 2015).

Despite primary care being able to manage the aforementioned, the following cases should prompt consideration of an ENT input and thus a secondary care referral:

Urgent referrals may be needed if there are red flags such as unilateral serous otitis media in an older adult, persistent epistaxis or cranial nerve involvement. These symptoms would be suspect of potential malignancy and therefore would be subject to national referral pathways (e.g. the 2WW suspected cancer route).

In cases where ETD is persistent and unresponsive to conservative measures, referral for surgical intervention may be warranted. One option is insertion of a tympanostomy tube, also referred to as a ventilation tube or grommet, through a myringotomy provides a temporary route for middle ear aeration. Another is balloon eustachian tuboplasty (BET) which is the introduction of a balloon catheter into the cartilaginous portion of the ET via the nasal passage with subsequent inflation to achieve mucosal and submucosal remodelling. This intervention is warranted when the intended therapeutic effect is mechanical dilatation of the ET lumen, thereby enhancing tubal patency and promoting long-term functional improvement [National Institute for Health and Care Excellence (NICE), 2019]. One randomised control trial in 2018 found that BET could improve the mean ETDQ-7 score at 6 weeks post-intervention by −2.9, thus highlighting it as a safe and effective treatment for persistent ETD (Meyer et al., 2018). While this intervention is beneficial, according to a survey-study in 2020, most UK ENT consultants do not perform BET and therefore its availability would vary from region to region (Koumpa et al., 2020).

Conclusions

ETD in primary care is often benign but can be indicative of more serious pathology. The primary care clinician must not only be able to recognise typical cases, but also understand when to further investigate and escalate the case to an ENT specialist. With a focused history and careful examination, many cases can be effectively treated within general practice. By gaining an understanding of identification and treatment of ETD, primary care clinicians can reduce unnecessary referrals, improve the management of the condition, and aid in early detection when necessary.