Chronic Ear Pain: It’s Not All in Your Head, Part I

Chronic ear pressure, pain, or discomfort can be extremely frustrating.  This is especially true when there is no clear cause found by your doctor.  Usually this will result in treatment for an ear infection (otitis media or otitis externa) inappropriately and unsuccessfully.

One of the most common causes of ear pressure is eustachian tube dysfunction (ETD).  The middle ear is a closed-off space in the temporal bone behind the ear drum.  It has a single air vent, the “eustachian tube” that acts more like a pop-off valve than a true open vent.  The eustachian tube is typically in a closed position, however certain throat movements will cause it to open allow for the pressure to equalize.

Classic otitis media is due to a swelling of the eustachian tube that causes the ear pressure to never vent and never normalize.  After a few hours or so the middle ear will actually fill with fluid drained from the tissues and then may become secondarily infected.  This is a super-common problem and is the reason for ear tube placement in children and some adults.  Basically the ear tube allows for the middle ear to stay permanently ventilated, effectively bypassing the faulty eustachian tube.

A much more frustrating problem is the symptom of a mildly dysfunctioning eustachian tube coupled with an apparent heightened sensitivity to ear pressure differences.  In these cases no fluid builds up in the middle ear, and no true infection occurs.  In fact there is often no abnormality found at all.  Tympanometry, or middle ear pressure analysis, may be done and it may even reveal “normal” middle ear pressures.  This is a disorder not found in mainstream textbooks however I have been convinced it certainly exists.

Patients with what I call “subjective eustachian tube dysfunction” basically have an abnormal sensitivity to mildly altered pressures in the middle ear.  Patients will often get relief temporarily by “popping” their ear.  After evaluating for infection and other causes of ear pain, finally a tiny diagnostic myringotomy (hole placed in the eardrum) may be performed to see if this helps.  Sometimes patients with ETD will find the “new” normalized pressure almost as odd a sensation as as the previous pressure.  However I now have a regular following of patients who have had semi-permanent ear tubes placed and are quite happy with the results, even in the absence of ever having had fluid or infection in the ear.  These same patients will often be the first to notice a small plug of wax occluding their ear tube or other minor abnormality that our “regular” tube patients would never detect.

If you are not getting answers about your ear pain, I recommend you seek out a competent otolaryngologist who will take the time to evaluate the different causes and work on a treatment plan.  An evaluation may involve hearing and pressure testing, a microscope examination, and nasopharyngoscopy (to see the eustachian tubes).  Referral for allergy testing and even jaw joint mechanical evaluation may also be considered.