Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – monitoring and supportive care

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ACUTE
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all patients
1st line – 

monitoring and supportive care

ETD symptoms are often mild and do not persist beyond a few days. In patients whose symptoms continue without an obvious underlying cause (e.g., allergic rhinitis), further investigations and management of Eustachian tube obstruction, trauma, and chronic otologic complications can be initiated. There is insufficient evidence to recommend a trial of any particular intervention, and continued research is necessary.[29]

Advice to swallow, yawn, or chew can equalize the pressure in the middle ear, and is especially appropriate on aircraft.

Hearing impairment caused by patulous Eustachian tubes may improve with supine position or leaning the head forward. There is no medical treatment. Several surgical therapies have been proposed for the management of patulous Eustachian tube, but none are reliably effective.[34][35]

Plus – intranasal corticosteroid

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ACUTE
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all patients
|
with persistent ETD
Plus – 

intranasal corticosteroid

Treatment recommended for ALL patients in selected patient group

Corticosteroids are given intranasally to minimize edema and inflammation at the Eustachian tube orifice. The treatment may be given at any time after clinical presentation.

The risks or significant complications associated with intranasal corticosteroid use are epistaxis and septal perforation.

Corticosteroids have not been experimentally proven to improve ETD in the absence of coexisting inflammatory disease states. However, given the favorable safety profile of these medications, an empiric trial may be considered.

Primary options

fluticasone propionate nasal: (50 micrograms/spray) 100 micrograms (2 sprays) in each nostril once daily

OR

budesonide nasal: (32 micrograms/spray) 64 micrograms (2 sprays) in each nostril once daily

OR

mometasone nasal: (50 micrograms/spray) 100 micrograms (2 sprays) in each nostril once daily

Plus – surgery

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ACUTE
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all patients
|
with Eustachian orifice obstruction or trauma
Plus – 

surgery

Treatment recommended for ALL patients in selected patient group

Surgical treatment is given once pathology is identified, to relieve obstruction of the Eustachian tube orifice or to repair trauma.

Adenoidectomy is given for patients with adenoid hypertrophy and serous effusion.

Surgery for an obstructing nasopharyngeal neoplasm will depend on concurrent radiation therapy and chemotherapy, and the patient's response to those treatments.

Risks of surgery in the area include bleeding, scarring of the nasopharynx, and persistent ETD.

Plus – pressure equalization tubes

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ACUTE
|
all patients
|
with chronic otologic complications
Plus – 

pressure equalization tubes

Treatment recommended for ALL patients in selected patient group

This option is most often utilized in patients with chronic otologic complications of ETD, including chronic otitis media, serous otitis media, and retraction of the tympanic membrane.

The tubes are designed to alleviate the negative pressure differential between the middle ear space and the atmosphere.

There is no set time course for placement of pressure equalization tubes, although usually a trial of medical therapy - such as antibiotics, and perhaps intranasal corticosteroids - will have occurred first.

The risks associated with tube placement include infection, persistent tympanic membrane perforation, and hearing loss. Tubes typically extrude after 3 to 6 months. There are tubes designed to be utilized for longer durations, but these are associated with their own set of potential problems, including granulation tissue and clogging.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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