What the tube does
The Eustachian tube connects the middle ear to the back of the nose. It is normally closed and opens briefly when you swallow or yawn, letting in a little air so that the pressure behind the eardrum matches the pressure outside. It also drains mucus from the middle ear.
When it fails to open, the middle ear lining absorbs the trapped air, the pressure falls and the eardrum is drawn inwards. The ear feels blocked; if this goes on, fluid can collect behind the drum and hearing becomes muffled.
Three different problems
An international consensus group describes three types. The distinction matters, because the treatment for one can make another worse.
- Obstructive (dilatory) dysfunction. The tube does not open well enough. It often follows a cold or comes with hay fever and is usually temporary; beyond three months it is called chronic.
- Baro-challenge dysfunction. The ear is normal on the ground but cannot keep up with rapid pressure changes, typically on descent in an aircraft or when diving.
- Patulous dysfunction. The tube stays open when it should be closed, and people hear their own voice and breathing loudly in the ear.
Symptoms and diagnosis
Fullness or pressure, a clogged or “underwater” feeling, popping and crackling, discomfort, muffled hearing and sometimes tinnitus. The commonest story is a blocked ear that won’t pop for days or weeks after a cold; most of these settle without treatment.
There is no single test; the diagnosis rests on history and examination together. The eardrum may be pulled inwards or have fluid behind it. Tympanometry, a painless probe test of eardrum movement, gives a flat trace with fluid and a negative-pressure peak when the tube is not ventilating the ear (interpreting hearing tests); in baro-challenge dysfunction it is often normal. A hearing test may show a mild conductive hearing loss, and nasal endoscopy shows the opening of the tube. Being able to pop the ear does not rule the condition out.
The ETDQ-7 is a seven-question form about the past month, each item scored from 1 (no problem) to 7 (severe problem). In the original validation study, a total of 14.5 or more (about 2.1 per question) separated 50 patients with Eustachian tube dysfunction from 25 people without ear complaints. It measures how troublesome the symptoms are and whether treatment has helped, but it does not make the diagnosis: it cannot tell an obstructed tube from a patulous one, or from other causes of a full ear.
Assessment: what the tests can and cannot do
In the 2015 consensus, dilatory dysfunction requires symptoms plus otoscopic retraction and/or a negative-pressure tympanogram, patulous dysfunction requires drum excursion with respiration, and baro-challenge dysfunction rests on the history. Tubomanometry, sonotubometry and the nine-step test remain research tools; imaging is reserved for suspected other pathology. The ETDQ-7 cut-off of 14.5 achieved 100% sensitivity and specificity only against controls without ear complaints, and will discriminate less well in a clinic population.
Treatment without surgery
Time. Most dysfunction after a cold resolves within weeks.
Autoinflation. Gently pushing air up the tube: a soft Valsalva (mouth closed, nose pinched, blowing gently) or a nasal balloon inflated through one nostril. Done gently, these are safe and worth trying, although the evidence for balloon autoinflation comes mainly from children with glue ear. After ear surgery your surgeon’s advice comes first; after stapedotomy, forced equalisation is usually discouraged in the first weeks.
Steroid nasal sprays. Widely prescribed, but in a randomised placebo-controlled trial of 91 patients, six weeks of a steroid spray did no better than placebo at returning tympanometry or symptoms to normal. They remain useful when the nose itself is the problem.
Treating the nose. Allergic rhinitis, chronic sinusitis, nasal polyps, adenoid tissue and smoking can all affect the tube. Treating them comes first, and is sometimes enough. Decongestant sprays help over a flight but should not be used for more than a few days, because the nose rebounds.
Balloon dilation
Balloon dilation of the Eustachian tube (balloon Eustachian tuboplasty) is considered when obstructive dysfunction has lasted more than three months despite treatment of the nose. Under endoscopic view, a catheter is passed through the nostril and a small balloon is placed in the cartilaginous part of the tube, inflated briefly and removed. Nothing is left behind. It can be done under general or local anaesthesia; in one trial, 72% of procedures were done in the clinic under local anaesthesia.
Results. In the larger randomised trial (Poe et al., 2018), in adults whose symptoms had not responded to medical treatment, the tympanogram was normal six weeks later in 51.8% after balloon dilation plus medical treatment against 13.9% with medical treatment alone, and the ETDQ-7 score in 56.2% against 8.5%. In a second trial of 60 participants (Meyer et al., 2018), the average ETDQ-7 score (on the 1-to-7 scale) fell by 2.9 points against 0.6, and the improvement was maintained at 12 months.
A 2025 Cochrane review of nine trials (684 participants) concluded that balloon dilation may give a clinically meaningful improvement in symptoms for up to three months, but rated the evidence as low to very low certainty and the effect beyond three months as very uncertain. Most trials were unblinded; the single sham-controlled trial had 17 participants and showed no clear difference.
In short: a reasonable option for carefully selected adults with persistent obstructive dysfunction. Many improve; not everyone does.
Risks. The trials reported no serious complications, but they were too small to detect uncommon events. Problems described in practice include nosebleeds, temporary ear discomfort and, occasionally, air escaping into the tissues of the face or neck, which usually settles. The internal carotid artery lies close to the bony part of the tube, one reason the balloon is kept to the cartilaginous part.
Reading the balloon dilation trials
Poe et al. randomised 2:1 (primary endpoint tympanogram normalisation at six weeks, 72/139 versus 10/72). Meyer et al. randomised 1:1 on mean ETDQ-7 change; controls could cross over after six weeks, so the 12-month data are uncontrolled. Both trials were unblinded and included authors affiliated with the device manufacturers. The Cochrane review found a mean ETDQ-7 difference of −1.66 (95% CI −2.16 to −1.16; four trials, 362 participants) up to three months, with no trial at overall low risk of bias. Selection criteria used in practice are pragmatic, not validated.
Grommets
A grommet (ventilation tube) through the eardrum bypasses the Eustachian tube rather than treating it. It works at once, for fluid and for a drum being pulled inwards. Most grommets fall out after some months, and the problem can return. Drawbacks include discharge and, in a small proportion, a hole that does not close (see eardrum perforation). For fluid in the middle ear a grommet is often the simpler choice; the two treatments are sometimes combined. See grommets in adults.
The patulous Eustachian tube
Here the tube stays open. The main symptom is autophony: hearing your own voice and breathing loudly in the ear. It is typically better lying down and worse after exercise, and can follow weight loss; often no cause is found. Some people habitually sniff to close the tube, which can pull the eardrum inwards and lead to a retraction pocket. The eardrum may be seen moving with breathing.
Treatment starts with explanation and simple measures, such as stopping habitual sniffing. Surgical options include plugging or narrowing the tube and placing a grommet, but a systematic review found only small, low-level studies (14 studies, 226 patients) reporting improvement anywhere from 22% to 100%. Balloon dilation would be expected to make a patulous tube worse.
Autophony can also come from superior canal dehiscence, a thin area in the bone over a balance canal of the inner ear, which is treated quite differently.
When it may be something else
- Fluid behind one eardrum in an adult, without a recent cold, needs an examination of the back of the nose. Rarely, a growth there, including nasopharyngeal cancer, blocks the tube on one side, and persistent one-sided fluid can be its first sign.
- A muffled ear that came on suddenly, with a normal-looking eardrum, may be a sudden hearing loss of the inner ear. Be seen the same day.
- Fullness with fluctuating hearing, tinnitus and attacks of vertigo suggests raised inner-ear fluid pressure (hydrops).
- Pain in front of the ear, worse with chewing, points to the jaw joint.
- A long-standing retracted eardrum can progress to a retraction pocket or cholesteatoma, forms of chronic middle-ear disease that need monitoring or surgery.
Flying and diving
For baro-challenge dysfunction: be awake for the descent, swallow and yawn often, equalise gently, and consider a decongestant spray before descent. Divers who repeatedly cannot equalise should stop diving until assessed. A 2022 systematic review of balloon dilation for this problem found only 81 patients in 11 small studies, most reporting improvement. After an operation, see flying after ear surgery.
Sources
- Schilder AGM, Bhutta MF, Butler CC, et al. Eustachian tube dysfunction: consensus statement on definition, types, clinical presentation and diagnosis. Clin Otolaryngol. 2015;40(5):407-411. PubMed
- McCoul ED, Anand VK, Christos PJ. Validating the clinical assessment of eustachian tube dysfunction: the Eustachian Tube Dysfunction Questionnaire (ETDQ-7). Laryngoscope. 2012;122(5):1137-1141. PubMed
- Gluth MB, McDonald DR, Weaver AL, et al. Management of eustachian tube dysfunction with nasal steroid spray: a prospective, randomized, placebo-controlled trial. Arch Otolaryngol Head Neck Surg. 2011;137(5):449-455. PubMed
- Poe D, Anand V, Dean M, et al. Balloon dilation of the eustachian tube for dilatory dysfunction: a randomized controlled trial. Laryngoscope. 2018;128(5):1200-1206. PubMed
- Meyer TA, O’Malley EM, Schlosser RJ, et al. A randomized controlled trial of balloon dilation as a treatment for persistent Eustachian tube dysfunction with 1-year follow-up. Otol Neurotol. 2018;39(7):894-902. PubMed
- Swords C, Smith ME, Patel A, et al. Balloon dilatation of the Eustachian tube for obstructive Eustachian tube dysfunction in adults. Cochrane Database Syst Rev. 2025;2(2):CD013429. PubMed
- Raymond MJ, Shih MC, Elvis PR, et al. A systematic review of Eustachian tube procedures for baro-challenge Eustachian tube dysfunction. Laryngoscope. 2022;132(12):2473-2483. PubMed
- Hussein AA, Adams AS, Turner JH. Surgical management of patulous Eustachian tube: a systematic review. Laryngoscope. 2015;125(9):2193-2198. PubMed
Common questions
Why won't my ear pop?
The Eustachian tube, which lets air into the middle ear when you swallow or yawn, is not opening properly. The commonest reason is swelling of its lining after a cold or during hay fever, and this usually settles within a few weeks. If the ear stays blocked for more than three months, or only one ear is affected for a long time, it is worth having the ear and the back of the nose examined.
Does Eustachian tube balloon dilation work?
For adults with long-standing obstructive dysfunction that has not responded to treatment of the nose, randomised trials show better symptom scores and tympanograms six weeks after balloon dilation than with continued medical treatment alone. A 2025 Cochrane review judged the evidence to be of low certainty, and the benefit beyond three months is uncertain. It helps many people but not everyone, and it does not help a patulous tube.
What is the ETDQ-7?
A seven-question form about the past month: pressure, pain, a clogged or underwater feeling, ear symptoms with colds, crackling or popping, ringing, and muffled hearing. Each is scored from 1 (no problem) to 7 (severe). In the original study a total of 14.5 or more, an average of about 2.1 per question, separated people with Eustachian tube dysfunction from people without ear complaints. It measures how troublesome symptoms are; it does not make the diagnosis on its own.
Do nasal steroid sprays help a blocked ear?
On their own, probably not much. A randomised placebo-controlled trial found that six weeks of a steroid nasal spray did no better than placebo at clearing the signs and symptoms of Eustachian tube dysfunction. They are still worth using when there is a nasal cause, such as allergic rhinitis or chronic sinusitis, because treating the nose is the first step in treating the tube.
Why can I hear my own voice and breathing loudly in one ear?
This is called autophony. The commonest cause is a patulous Eustachian tube, one that stays open when it should be closed. It is typically better lying down and worse after exercise, and can follow weight loss. A less common cause is superior canal dehiscence, a thin area in the bone over one of the balance canals. The two are treated differently, so the cause needs to be established.
Can I fly with Eustachian tube dysfunction?
Usually yes, with precautions. Be awake for the descent, swallow and yawn often, and equalise gently. A decongestant nasal spray shortly before descent helps some people; check it suits you. Avoid flying with a heavily blocked nose if you can. If you have had ear surgery, follow the advice given for your own operation.
This page provides general educational information. It cannot replace an individual assessment, which depends on a full history, examination, audiometry and, where relevant, imaging. If you have sudden hearing loss, severe pain, facial weakness, severe dizziness or discharge with fever, seek medical care promptly.