Blocked ears during or after a flu? It may be due to a Eustachian Tube Dysfunction (ETD)!
Dr Gan saw Mr A, who had a sudden onset of ear blockage (both sides) while recovering from a common cold. He has been wearing hearing aids for a few years for age-related hearing loss. However, he was worried when his hearing level deteriorated further during his cold. He did not have any ear pain or fluid coming out of his ears.
On examination, there was fluid noted behind his right and left eardrums (Figures 1a-c). There were no palpable neck lumps. A nasoendoscopy (scope through the nose) was performed. It showed signs of a recent cold with thick mucous and swollen mucous membranes (lining of the nose)(Figures 2a-b). There was no mass blocking the opening of the Eustachian tube at the postnasal space (PNS or "back of the nose"). A hearing test showed mixed hearing loss and a "stiff" ear drum, suggesting fluid buildup behind the ear drum.
Figure 1a – Fluid behind left eardrum (dark yellowish tinge seen)
Figure 1b – Fluid behind right eardrum (dark yellow tinge and bulge seen on eardrum)
Figure 1c – Picture of a normal left ear canal and eardrum
Figure 2a – Endoscopic view of the back of the nose showing the left eustachian tube opening (indicated by blue arrow)
Figure 2b – Endoscopic view of the back of the nose showing the right eustachian tube opening (blue arrow) and thick mucous (blue asterisks)
As Mr A's nasal symptoms were only 5 days and he was feeling better, it was likely that he was suffering from a viral cold (which does not need oral antibitoics). However, in view of the fluid behind the ear drum, he was given a course of oral antibiotics to fasten the resolution of the fluid. Typically, most fluid behind the ear drum resolves on its own (absorbed by body or drained through the Eustachian tube) between 1 to 3 months. Mr A was also advised to perform maneuvers to open the Eustachian tube regularly which may fasten the resolution of the collection of fluid. These include Valsalva maneuver (blowing out against a closed mouth and nose to "pop" your ear), chewing on a gum and swallowing. Mr A was also given medications to reduce inflammation and congestion in his nose. On review in the clinic 6 weeks later, Mr A's hearing is back to his usual level. A clinical examination and hearing test showed complete resolution of the fluid behind his ear drums.
Mr A's ear condition is known as Otitis Media with Effusion ("Fluid behind the eardrum" aka "glue ear"). This is a as a result of his cold which resulted in inflammation of the lining of the nose. The middle ear (the space behind the ear drum) is connected to the back of the nose by the Eustachian tube (Figures 3a-b). The Eustachian tube opens and closes during changes in environmental pressure (E.g. when one goes up the elevator, during air flight or diving) to equalize the pressure in the middle ear with that of the outside environment. However, when one has problems with the nose (E.g. sinusitis, allergic rhinitis or cold/flu), the tube may not be functioning properly, resulting in negative pressure in the middle ear and subsequent buildup of fluid behind the eardrum. A Eustachian Tube that fails to open or close to equilize the middle ear pressure is known as Eustachian Tube Dysfunction (ETD). It is always good to have a scope to screen the back part of the nose (PNS or postnasal space) as one of the early presentation of cancer of the nose is fluid behind the eardrum due to blockage of the Eustachian tube. Fortunately for Mr A, he did not have nose cancer!
Figure 3a – The Eustachian Tube connects the middle ear to the back of the nose
Figure 3b – Eustachian Tube opening in the nasal cavity