When a “Blocked Ear” Isn’t Obstructive ETD

For otolaryngologists, the phrase “blocked ear” can be deceptively imprecise. Because obstructive and patulous Eustachian tube dysfunction (ETD) can overlap in how patients describe their symptoms, careful differentiation is essential before treatment—particularly before balloon dilation, which may help selected patients with obstructive ETD but can worsen patulous disease.

Among the two main types of ETD, the most common is obstructive dysfunction, in which the valve regulating airflow into the ear does not stay open adequately. A temporary form of this, called baro-challenge, occurs with sudden barometric pressure changes, which occur in situations such as flying or scuba diving. The other main type is patulous dysfunction, in which the opposite occurs: The valve gets stuck and remains open.

At the 2026 Combined Otolaryngology Spring Meetings (COSM), Tina C. T. Huang, MD, MS, a neurotologist and associate professor in the department of otolaryngology–head and neck surgery at the University of Minnesota Medical School in Minneapolis, moderated a panel of experts who shared practical insights on how to manage ETD, including differentiating between and appropriately treating the types of dysfunctions.

Dennis S. Poe, MD, PhD, professor of otolaryngology in the department of otolaryngology at Boston Children’s Hospital and Harvard Medical School, who specializes in otology/neurotology and skull base surgery, runs the International Eustachian Tube Study Group and is the principal investigator for two multicenter clinical trials of balloon Eustachian tuboplasty. Dr. Poe discussed patulous ETD and emphasized both its underrecognized frequency and the critical need to distinguish it from obstructive ETD.

Dr. Huang presented data on obstructive ETD in adults, with a focus on indications and evidence for balloon dilation in eligible patients, provided by Seilesh C. Babu, MD, who was unable to attend the panel. Dr. Babu is an assistant professor and director of the division of otolaryngology at Michigan State University in Farmington Hills, Mich., specializing in neurology, otology, and skull base surgery in both adults and children.

Judith E. C. Lieu, MD, MSPH, professor of otolaryngology–head and neck surgery at Washington University Medicine in St. Louis, Mo., spoke on pediatric ETD and questioned the current utility of balloon dilation in children based on limited pediatric data and unanswered questions, including how to determine which children are the best candidates for the procedure.

Differentiating the Types of Obstructive ETD in Adults: Patulous ETD More Common Than Recognized

One of the key takeaways from the panel discussion was the critical importance of differentiating obstructive from patulous ETD in adults. Although most adults and children will experience obstructive ETD at times, patulous ETD is far more prevalent than commonly suspected. Table 1 lists differences in symptoms.

Dr. Poe underscored the lack of recognition and underdiagnosis of patulous ETD, and the deleterious effect this can have when making treatment decisions.

“Textbooks say that patulous ETD is rare, but it is not,” Dr. Poe said. “It is very common, but people don’t readily recognize it.”

Unlike obstructive ETD, in which the Eustachian tube valve does not open properly, patulous dysfunction occurs when the Eustachian tube valve does not close properly and creates symptoms that include autophony, when a person can hear their own voice or their own breathing amplified inside their head. “It’s like taking a rubber hose from your mouth to your ear and talking and breathing loudly into it,” he said, adding that talking loudly and breathing into the diaphragm of a stethoscope creates a high-fidelity simulation of patulous autophony.

Often called “runner’s ear” because it occurs commonly in people who are dehydrated or exercising at the time, it usually goes away when the person cools down.

Dr. Poe said it becomes a problem when the symptoms do not go away. In this chronic form, ETD can be extremely disturbing, particularly for people who rely heavily on their voices, such as singers, performers, teachers, or basically anyone who talks a lot. Patients describe the sound as “Darth Vader breathing in their ear,” Dr. Poe said.

Differentiating patulous ETD from obstructive ETD is critical because treatment differs widely. Otolaryngologists want to avoid a misdiagnosis of obstructive ETD and treatment with balloon dilation, as that could exacerbate a patulous ETD condition, he said.

Teasing out the type of blocked ear relies on a careful history and objective findings. While symptoms and findings of obstructive ETD are well known among otolaryngologists, many may not be aware of how to recognize patulous ETD.

The hallmark of patulous ETD, Dr. Poe said, is that patients complain of autophony and ear popping and clicking. They commonly report that their ear is “blocked,” and often use the word “muffled” to refer to hearing (instead of the hearing loss that is seen in obstructive ETD). Most commonly, audiogram reveals normal hearing, but the “muffled sensation is due to alteration in the resonance of their middle ear from the added air volume through the patent ET that opens into the nasopharynx.

Physical examination shows patients’ eardrums moving during active symptoms, which can be accentuated by having them breathe through the same side nostril. “I call it ipsilateral nasal breathing,” Dr. Poe said.

He said that changes in the pressure of the ear can be seen with more sensitivity when using tympanometry in the reflux decay mode. “That is our patulous test,” he said. “We look at the Eustachian tube and can see the valve not closing.” He noted that endoscopic view does not see the full length of the ET, so observing excursions of the tympanic membrane with breathing or a positive patulous test are diagnostic.

He underscored that a common problem is that many patients start with obstructive ETD with chronic inflammation, which then causes patches of burned-out mucous membrane where the secretory glands dry up from being overstimulated with subsequent atrophy of the tissue. With this atrophy, the valve of the Eustachian tube gets stuck open.

“Patients keep saying, ‘I have a blocked ear,’ so the otolaryngologist is thinking they still have obstructive ETD, without questioning whether it may have turned patulous,” Dr. Poe said. “It is a very common condition, and we miss it all the time.”

Dr. Poe said that many patients with patulous ETD have learned that strong sniffing relieves their symptoms, at least temporarily, so it’s good to ask patients whether they are sniffing more than usual. “They may be sniffing throughout the day, as sniffing generates negative pressure in their ear by temporarily pulling the Eustachian valve closed, even to the point of causing middle ear fluid, and thus can present as appearing like obstructive ETD and mistakenly be diagnosed as obstructive ETD,” he said.

He called frequent sniffing a “red flag” for patulous ETD. Formerly called “habitual sniffing,” it is usually a behavior that patients exhibit in attempts to control patulous symptoms, he explained. “When asking patients why they are sniffing, the reply is often that it ‘unblocks’ their ear,” he said, adding that this again uses misleading language since the sniff temporarily closes the valve of the Eustachian tube.

To avoid misdiagnosis, Dr. Poe said all patients who present with symptoms of blocked ears should be asked about autophony, frequent sniffing, and unusual ear popping and clicking. “There is a common association between chronic allergic rhinitis and patulous ETD, so suspicion should be heightened for the possibility in allergic patients,” he said.

Before Balloon Dilation: Key Questions to Ask

• Does the patient describe autophony, including hearing their own voice or their own breathing amplified inside their head?
• Do symptoms improve temporarily with sniffing?
• Is there objective evidence of negative middle ear pressure, such as tympanic membrane retraction or abnormal tympanometry?
• Has inflammatory disease, allergy, reflux, or another contributing condition been treated first?
• Are alternative diagnoses—such as temporomandibular disorder, hydrops, superior canal dehiscence syndrome, migraine, or patulous physiology—more likely?

Treatment of ETD in Adults

For patients with ETD, regardless of whether it’s obstructive or patulous, treatment is highly dependent on the root cause, which a careful history can tease out. Table 2 lists key comorbidities associated with obstructive and patulous ETD and first-line approaches to treatment.

For patients with obstructive ETD, first-line treatment is medical management if an underlying etiology is suspected. In that case, treatment consists of antihistamines, nasal steroid sprays, reflux measures, and other measures. For patients with persistent significant adenoid or tubal tonsil hypertrophy, surgery may be indicated. Adenoidectomy can be done endoscopically to remove the lateral portion away from the torus tubarius and fossa of Rosenmüller. Tubal tonsil tissue on the medial one-half of the torus tubarius can be trimmed carefully, avoiding injury to the underlying cartilage and staying clear of the tubal orifice.

For patients with patulous ETD, the first step is maintaining good hydration, and if there are no restrictions for water intake, two liters per day can be very helpful.  Medications that may be drying out the mucous membrane in the ETs should be minimized or discontinued if indicated. Chronic allergic rhinitis is the most common condition associated with patulous ETD, and many patients are on drying agents such as antihistamines, nasal steroid sprays, and decongestants. 

“We try to get them off these or minimize use of them, then switch to nasal saline irrigations and, if needed, supplemented with cromolyn sodium,” Dr. Poe said, adding that environmental measures, allergy testing, and immunotherapy are recommended when appropriate. “These measures typically get the allergy under control, and patients get better,” he said.

Diuretics also can dry people out, he said, and noted the significant rate of patulous ETD in women who take birth control pills that contain the diuretic spironolactone. Spironolactone is also often used to treat acne. The use of substitute medications is often effective in relieving patulous symptoms. 

Given the increased use of GLP-1 agents, bariatric surgery, and other weight loss measures, Dr. Poe said he is seeing an increase in patulous ETD associated with rapid significant weight loss. He recommended against telling patients to gain weight unless they are medically underweight, because weight gain typically occurs in all the wrong places, like the waistline.

Topical nasal drops can be very helpful in controlling symptoms, he said. The optimal position for application is to lie supine, hang the head 15 to 30 degrees, apply three to four or more drops to one nostril, and turn 45 degrees to the same side, awaiting a twinge that will radiate to the ipsilateral ear as a referred symptom indicating contact of the drops with the orifice of the ET.

Drops can be applied as often as desired, with the goal of stopping airflow through the ET valve, which dries out the mucosa and perpetuates the condition. “With adequate control of symptoms, the mucosa may be able to rehabilitate and restore competency to the valve,” Dr. Poe said.

If plain saline does not help, hypertonic saline—purchased or prepared at home with four teaspoons of table salt in one cup of water—may be more irritating and more effective, he said. For an even more effective irritant drop, he said, lemon juice mixed with water can be used, starting with equal amounts and diluting with more water as needed for tolerance. For patients with chronic patulous symptoms, use of drops two to three times daily for two months can often yield lasting benefit.

For patients with patulous ETD caused by tension in the jaw (mastication) muscles (TMD), he recommends referral to a dentist specializing in oral medicine to manage underlying causes, including teaching the patient to stop clenching or mitigate the effects of grinding their teeth. Oral medicine dentists offer a program that involves specially trained physical therapists and may offer other services such as counseling for relaxation techniques and behavioral management. Dr. Poe explained that the TMD connection to ETD is that the medial pterygoid muscle is an axillary dilator of the valve of the Eustachian tube, so when that muscle is tense, it can create chronic opening of the tube. “Otolaryngologists are trained to look at the jaw joint and abnormalities of the jaw (temporomandibular joint [TMJ] dysfunction), but only a small percentage of TMD patients have TMJ dysfunction,” he said. “Otolaryngologists need to become more familiar with examination of the muscles to make the diagnosis and refer patients appropriately.”

If these conservative measures do not work, Dr. Poe also touched on surgical procedures that help some patients, especially pediatric patients—such as a paper patch or tympanostomy tube to mass load the tympanic membrane. Off-label procedures are done with insertion of a plastic shim into the lumen of the ET or by injection of fillers or implantation of cartilage to bulk up the walls of the ET valve. 

Who Is—and Isn’t—a Candidate for Balloon Dilation?

While balloon dilation is not indicated for patients with patulous ETD, the indications and evidence do support balloon dilation in adults with obstructive ETD. Dr. Babu’s research describes best candidates for balloon dilation, the evidence for it, and, importantly, how to improve coverage through proper documentation and coding.

His research underscores that a normal otologic exam, normal tympanogram, and aural fullness with or without hearing loss should be used to make the differential diagnosis, but you shouldn’t automatically treat with balloon dilation.

When obstructive ETD is confirmed as the differential diagnosis, he said the best candidate for balloon dilation fulfills three criteria: clinical indications (symptoms), objective findings (see Table 1), and failure to respond to appropriate directed medical therapy.

Dr. Babu’s research also cited a number of red flags that indicate contraindications to balloon dilation, including patulous ETD symptoms, nasopharyngeal mass/extrinsic obstruction, active mucosal/systemic inflammatory disease that affects the Eustachian tube or nasopharynx until the inflammation is medically stabilized, and craniofacial syndromes.

Like Dr. Poe, he emphasized the importance of screening for patulous ETD, with emphasis on carefully listening to how the patient describes their symptoms, as data show that about 7% of patients can develop patulous symptoms after balloon dilation and, although most cases are mild or self-limiting, some are not. He said a repeat dilation and severe pre-operative inflammation may increase the risk of post-dilation patulous symptoms.

Poor candidates for balloon dilation include those with a normal exam and tympanogram and nonspecific fullness. He emphasized that TMJ dysfunction, hydrops, superior canal dehiscence, migraine, or patulous physiology are better indications of poor candidates.

In support of balloon dilation, Dr. Babu’s research provided evidence from four trials, three of which had follow-up of one year and one with a longer-term cohort of nearly 30 months (Laryngoscope. https://doi.org/10.1002/lary.26827; Otol Neurotol. https://doi.org/10.1097/MAO.0000000000001853; Otolaryngol Head Neck Surg. https://doi.org/10.1177/0194599818821938; Otol Neurotol. https://doi.org/10.1097/MAO.0000000000002396.)

The trials showed improvement in quality of life based on the Eustachian Tube Dysfunction Questionnaire (ETDQ-7), with the longest follow-up trial of 30 months showing a 94% improvement in ETDQ-7 and 83% satisfaction (Otol Neurotol. https://doi.org/10.1097/MAO.0000000000002396). He noted that the most frequently cited study showing efficacy of balloon dilation in adults in the U.S. reported that balloon dilation was associated with an improvement in ETDQ-7 by -2.9 versus -0.6 with medical management, and also reported objective improvements in tympanogram/tympanic membrane. (Otol Neurotol. https://doi.org/10.1097/MAO.0000000000001853).

Evidence from systematic reviews also showed positive support of balloon dilation in appropriately selected patients, but most of the trials were small with limited follow-up and heterogeneous patient populations.

Dr. Babu’s research also touched on complications of balloon dilation, noting that serious adverse events are not reported in the major adult trials and that minor and transient events are more common. Of the potential rare complications repeatedly reported, he cited subcutaneous/cervicofacial emphysema and pneumomediastinum with subcutaneous emphysema as the most commonly reported.

For otolaryngologists who wish to use balloon dilation in their practices, documentation and coding are essential for reimbursement as the procedure is not uniformly reimbursed. Dr. Babu’s research showed that the main reasons for denials are that coverage varies by plan and often specifies age thresholds, chronic symptom duration, objective findings, and prior directed medical therapy. He underscored that payers want explicit documentation.

To this end, Dr. Babu suggested bundling documentation into five categories: 1) symptom duration and severity that includes baro-challenge history if relevant, 2) objective findings that include tympanogram, otoscopy, audiogram, and endoscopy summary, 3) directed medical therapy already tried, and outcome, 4) why differential diagnoses are less likely (i.e., TMJ, hydrops, SCDS, patulous ETD, mass lesion), and 5) whether prior tympanostomy tubes improved symptoms while patent.

He said the coding guidance from the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) is to use CPT 69705 for unilateral and CPT 69706 for bilateral nasopharyngoscopy with balloon dilation of the Eustachian tube.

He cited national averages for physician non-facility dilations based on industry guides as $2,571.00 (CPT 69705) and $2,662 (CPT 69706) and for ambulatory surgical centers as $4,190 and $4,319, respectively.

Pediatric Balloon Dilation: FDA-Cleared, but Evidence-Limited

Dr. Lieu emphasized that the jury is out when considering balloon dilation in children. In fact, she said the data is so thin, and the differences in what causes ETD in children compared to adults are so substantial, that a lot more research is needed to know which children may be the best candidates.

“Trying to determine the standard criteria for when to consider balloon dilation in kids is still not determined, and a lot more work is needed to see if this will be a positive and effective treatment for kids,” she said.

She underscored that the leading cause of ETD in young children is repeated upper respiratory viral or bacterial infections, unlike chronic obstructive or patulous ETD in adults. She also said ETD is much more multifactorial in kids, and it often gets better as they get older and their anatomy and immune status become more adult-like. “So the idea that you can use balloon dilation once and make all the ear infections go away or keep them from getting fluid in the ear seems very simplistic,” she said.

She also pointed out the challenges of balloon dilation in children, including the need for anesthesia that makes it a longer procedure with higher cost compared to tubes because of the need for nasal endoscopy and a single-use balloon dilator that can cost thousands of dollars.

The bulk of her talk was describing five studies that included pediatric patients in whom balloon dilation was used for ETD compared to control patients. She highlighted the difficulty of parsing out the benefit of balloon dilation in children based on this evidence, given their limitations of small sample size (in total, the studies included only 126 pediatric patients who underwent balloon dilation and 127 controls who received tubes of less than 12 months), and that the comparison between the balloon dilation patients and controls was dissimilar in age, indication for treatment, prior treatment, comorbidities, and measurement of outcomes.

Emphasizing that balloon dilation could be of some benefit in kids, she underscored that the data do not yet support this. “We have a lot of outstanding questions,” she said. “I’m not saying it doesn’t or does work; I’m saying we really don’t know yet because the data is not there yet.”

She highlighted three main concerns she has that have not yet been answered by the evidence: 1) Do children treated with balloon dilation alone do better than those with ventilation tubes, or do ventilation tubes always need to accompany dilation?, 2) How does balloon dilation compare with tubes that are in place longer than 12 months?, and 3) Is the cost worth it when comparing about $40.00 for tubes versus $1600 for a balloon catheter (based on cost data from her hospital), given that the child would still require anesthesia?

To fill some of the evidence gap, she is working with Yi-Chun Carol Liu, MD, a pediatric otolaryngologist at Texas Children’s Hospital in Houston, who is among pediatric otolaryngologists doing the most balloon dilations in children, to validate an ETD quality-of-life survey for kids, given the lack of one to date. “We’re trying to validate a survey for kids to fill out, not their parents,” she said.

Currently, she and many of her colleagues think about the possibility of balloon dilation for their patients only after other, more traditional, methods are exhausted. Tubes are the first line in children with fluid in their ears and at least three months of hearing dysfunction related to the fluid or negative pressure. If the child has problems with the tubes staying in, or when they have recurrent problems after the tubes come out, she uses evidence-based guidelines for chronic ear effusions to make sure they’ve had adenoidectomy, and then they have ear tubes placed again. “If that fails, and we are thinking of maybe a third or fourth set of tubes, then we consider the potential benefit of dilation,” she said.

The 2016 approval by the Food and Drug Administration for Eustachian tube balloon dilation for adults aged 18 and older was expanded to include children and adolescents aged 8 to 17 in 2023. Still, the panelists emphasized that expanded availability should not be mistaken for a one-size-fits-all solution. In adults, balloon dilation requires careful confirmation of obstructive ETD, attention to patulous symptoms, and clear documentation; in children, patient selection remains more uncertain, and the evidence base continues to evolve.

Mary Beth Nierengarten is a freelance medical writer based in Minnesota.