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Cited by 33Ear Surgery and Otitis MediaSinusitis and nasal conditionsVestibular and auditory disorders

Medical Management for Eustachian Tube Dysfunction in Adults: A Systematic Review and Meta‐Analysis

Open access
Mehta, Neil K., Ma, Cheng, Nguyen, Shaun A., McRackan, Theodore R., Meyer, Ted A., Lambert, Paul R.·2022·The Laryngoscope
DOI 10.1002/lary.29878
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Abstract

Objective: Medical treatment for eustachian tube dysfunction (ETD) is varied, with physician preference driving treatment choice and limited guidance for these options. An evaluation of the efficacy of medical management (MM) for ETD is warranted. Methods: A systematic review of three databases (PubMed, Scopus, and Embase) was performed through December 2020. Adults treated nonsurgically for ETD were included. Exclusion criteria were as follows: patulous ETD, ETD deriving from craniofacial anomalies, or surgical treatment. Data were extracted independently by two reviewers according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. A meta‐analysis of continuous measures, proportions, and risk ratio was conducted. Results: Twelve articles were identified by systematic review, with either level 2 or 3 evidence. A meta‐analysis of available data was performed on nine studies. A pooled cohort found 50.3% (95% confidence interval [CI], 41.7–59.0) of patients experienced symptomatic improvement with MM. ETDQ‐7 scores improved in a clinically nonsignificant manner by −0.88 (95% CI, −1.12 to −0.64) following medical treatment. Further, MM benefited from subacute and chronic symptoms in 30% to 64% and 11% to 50% of cases, respectively. Intranasal corticosteroids (INCS) were not efficacious, improving only 11% to 18% of chronic cases. Therapies such as Politzer devices and Valsalva therapy had minimally beneficial results. Conclusion: Our review did not find any level 1 evidence for MM of ETD in adults. Available evidence indicates INCS are ineffective for chronic symptoms and the efficacy of nonsurgical options for subacute ETD has yet to be determined. Further randomized controlled trials are needed to discern efficacy of single‐agent medical therapies. Laryngoscope , 132:849–856, 2022

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review and meta-analysis found only level 2 to 3 evidence for medical management of adult obstructive eustachian tube dysfunction (ETD), with no level 1 evidence and no RCTs meeting the primary meta-analysis criteria. Pooled data showed modest symptomatic improvement but clinically nonsignificant ETDQ-7 change, and intranasal corticosteroids were ineffective for chronic ETD.

Key findings

  • Twelve articles were included, covering 625 patients and 802 ears (mean age 46.5 years, range 16-90); nine studies with 527 patients were meta-analyzed. Symptomatic improvement with medical management occurred in 50.3% (95% CI 41.7-59.0) at ≤2 weeks follow-up.
  • ETDQ-7 scores improved by -0.88 (95% CI -1.12 to -0.64), which was considered clinically nonsignificant. Medical management improved 30% to 64% of subacute cases and 11% to 50% of chronic cases.
  • Intranasal corticosteroids improved only 11% to 18% of chronic ETD cases. In one RCT of 27 patients, INCS plus Buteyko breathing was more efficacious than INCS alone (P = 0.046), with complete symptom resolution in 50% and Type C tympanogram normalization in 54%.
  • Post-treatment tympanograms were less likely to be Type B (RR 0.67, 95% CI 0.53-0.85) or Type C (RR 0.73, 95% CI 0.61-0.87). Positive Valsalva maneuver rose from 31.6% at baseline to 39.3% at 6 weeks and 49.6% at 12 weeks.

Methods

  • PRISMA systematic review of PubMed, Scopus, and Embase through December 2020 per the abstract (the methods section states September 2020). Adults ≥16 years treated nonsurgically for ETD were included; exclusions were patulous ETD, ETD from craniofacial anomalies, surgical treatment, non-English articles, nonhuman studies, reviews, case reports/series with <10 patients, inaccessible articles, and incomplete/missing statistical data.
  • Twelve articles were included: four RCTs, five prospective cohort trials, and three retrospective cohort trials, with level 2 or 3 evidence. Because no RCTs compared medical management to controls among chronic ETD patients, the primary meta-analysis criteria were not met; a secondary meta-analysis was conducted on nine studies with 527 patients.
  • Meta-analysis of continuous measures, proportions, and risk ratios used Cochrane Review Manager 5.4 and MedCalc 19.5.3, with fixed- and random-effects models. Publication bias was assessed with Sterne and Egger tests and funnel plots.

Limitations

  • Stated in the paper: the review relies on secondhand data from published articles and is vulnerable to bias within the original articles; the meta-analysis pooled patients with different ETD durations, symptom severity, and etiologies; and few studies examined single-agent therapy, with many reporting combined medical therapies.
  • Evident from the text: no RCTs comparing medical management to controls among chronic ETD patients were available, so the primary meta-analysis could not be performed and the secondary analysis included non-RCTs; some analyses had small samples (e.g., 27 patients in the combination-therapy RCT) and substantial heterogeneity (Valsalva analyses I² 74.20%-85.04%).

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1002/lary.29878

Cites

40 of 40 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 33 cited sources checked · 0 supported · 0 flagged

  • Findingcitation

    Politzer device studies found moderate subjective improvements in patient-reported symptoms.

    “These studies found moderate subjective improvements in patient-reported symptoms.”
    Quote in the paperNot a substantial claim
  • Findingcitation

    In two studies, the Politzer device was analyzed among 63 patients with subacute or duration-unspecified ETD and improved symptoms in 30% of cases.

    “In two studies, the Politzer device was analyzed among 63 patients with subacute or duration-unspecified ETD and improved symptoms in 30% of cases.29,33”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [29]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [33]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Findingown data

    ETDQ-7 scores improved by -0.88 (95% CI -1.12 to -0.64) following medical treatment.

    “ETDQ-7 scores improved in a clinically nonsignificant manner by À0.88 (95% CI, À1.12 to À0.64) following medical treatment.”
    • Also stated in: § Meta-Analysis Results · plain
      “Meta-analysis of continuous measures for ETDQ-7 resulted in À0.88 (95% CI, À1.12 to À0.64), favoring improvement of patient-reported scores.”
    Quote in the paperSubstantial claim
  • Findingcitation

    Combination therapy of intranasal corticosteroids and Buteyko breathing was more efficacious compared to intranasal corticosteroids alone (P = 0.046) in a single RCT of 27 patients.

    “Of interest, combination therapy of INCS and Buteyko breathing, assessed in a single RCT of 27 patients, was more efficacious compared to INCS alone (P = 0.046).36”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Findingcitation

    Baseline measurements of air-bone gap and tubomanometry were predictive of responsiveness to pharmacological treatment.

    “Furthermore, baseline measurements of ABG and TMM were found to be predictive in determining responsiveness to pharmacological treatment.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 22
  • Classified as probably not a substantial claim. 12

  • May combine two claims.

    Findingcitation

    Politzer device studies identified absolute improvements in air-bone gap and tympanometric peak pressure, but only tympanometric peak pressure was statistically significant (P = .004) from the control group.

    “Absolute improvements in ABG and tympanometric peak pressure were identified, however, only tympanometric peak pressure was considered statistically significant (P = .004)from the control group.33”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [33]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Findingown data

    The systematic review identified 12 articles providing level 2 or 3 evidence, with two RCTs representing level 2 evidence and the remaining articles level 3 evidence.

    “Twelve articles were identified by systematic review, with either level 2 or 3 evidence.”
    • Also stated in: § Study Characteristics · plain
      “Two of the RCTs represented level 2 evidence, and the remaining articles represented level 3 evidence (Table I).”
    • Also stated in: § CONCLUSION · plain
      “Our study identified level 2 to 3 evidence for the MM of adults with ETD.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Among Valsalva therapy patients, 43% to 64% experienced symptomatic improvement, with conflicting statistical significance in two studies.

    “Among these patients, 43% to 64% experienced symptomatic improvement, however, with conflicting statistical significance in two studies.28,29”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [28]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [29]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Findingreasoning

    Higher tubomanometry had a more profound impact on response to medical management (OR 1.43 [95% CI 1.17-1.75]) compared to air-bone gaps <17 dB (OR 0.93 [95% CI 0.88-0.98]).

    “Higher TMM had a more profound impact on response to MM (odds ratio [OR] 1.43 [95% CI, 1.17-1.75])compared to ABGs <17 dB (OR 0.93 [95% CI, 0.88-0.98])”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    In the combination therapy trial, complete resolution of symptoms occurred in 50% of patients with chronic ETD and 54% had normalization of Type C tympanograms by study endpoint.

    “In this trial, combination therapy led to complete resolution of symptoms in 50% of patients with chronic ETD and 54% normalization of Type C tympanograms by study endpoint.36”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [36]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Valsalva therapy was assessed among 67 patients with subacute ETD.

    “Valsalva therapy was assessed among 67 patients with subacute ETD.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Responders to medical management had smaller air-bone gaps (<17 dB) and greater tubomanometry values (>2, theoretical range 0-6).

    “Responders to MM were found to have smaller ABG's (<17 dB) and greater TMM (>2, theoretical range 0-6).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Medical management led to symptomatic improvement in 30% to 64% of subacute cases and 11% to 50% of chronic cases.

    “Further, MM benefited from subacute and chronic symptoms in 30% to 64% and 11% to 50% of cases, respectively.”
    • Also stated in: § Medical Therapy Results · plain
      “MM for ETD led to improvement of symptoms in 30% to 64% of subacute cases and 11% to 50% of chronic cases.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Post-treatment patient tympanograms were less likely to be Type B (RR 0.67 [95% CI 0.53-0.85]) or Type C (RR 0.73 [95% CI 0.61-0.87]).

    “Post-treatment patient tympanograms were less likely to be Type B (RR 0.67 [95% CI, 0.53-0.85])or Type C (RR 0.73 [95% CI, 0.61-0.87])”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The literature search yielded 939 articles after deduplication.

    “The literature search yielded 939 articles after deduplication.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    A total of 625 patients were examined, involving 802 ears.

    “A total of 625 patients were examined, involving 802 ears.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The 12 included studies were published between 1993 and 2020 and included four RCTs, five prospective cohort trials, and three retrospective cohort trials.

    “The 12 studies included were published between 1993 and 2020 and included four RCTs, five prospective cohort trials, and three retrospective cohort trials.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The therapies evaluated included INCS, oral decongestants, antihistamines, Valsalva therapy, Politzer devices, Buteyko breathing techniques, nitric oxide gas, or a combination of multiple therapies.

    “The therapies evaluated included INCS, oral decongestants, antihistamines, Valsalva therapy, Politzer devices, Buteyko breathing techniques, nitric oxide gas, or a combination of multiple therapies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Five studies examined subacute ETD, five examined chronic ETD, and two studies did not specify symptom duration.

    “Five studies examined subacute ETD (<6 weeks), five examined chronic ETD (>12 weeks), and two studies did not specify symptom duration.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    INCS appeared to be more efficacious when combined with Buteyko breathing techniques, but these results are from a single, small nonrandomized trial and need to be evaluated further.

    “INCS did appear to be more efficacious when combined with Buteyko breathing techniques, but these results are from a single, small nonrandomized trial and need to be evaluated further.36”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Data extraction was performed by two reviewers independently.

    “Data extraction was performed by two reviewers (N.K.M. and C.M.) independently.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The secondary meta-analysis included non-RCTs and found unconvincing evidence for clinical improvement of ETD with medical management.

    “Our secondary meta-analysis included non-RCTs and found unconvincing evidence for clinical improvement of ETD with MM.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Abstracts were independently assessed by two reviewers and conflicts were resolved by a third reviewer.

    “Abstracts were independently assessed by two reviewers (N.K.M. and C.M.) and conflicts were resolved by a third reviewer (S.A.N.).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Only half of patients had improved outcomes, indicating that subacute ETD might or might not be responsive to treatment.

    “In addition, only half of patients had improved outcomes, indicating that subacute ETD might or might not be responsive to treatment.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    A majority of patients with chronic ETD fail INCS, but INCS may be more effective as combination therapy.

    “A majority of patients with chronic ETD fail INCS, but INCS may be more effective as combination therapy.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    A limited number of studies examined single-agent therapy, with many studies reporting results from all medical therapies combined, limiting the ability to determine efficacy between single treatments.

    “Last, a limited number of studies examined single-agent therapy, with many studies reporting results from all medical therapies combined.This limited our ability to determine efficacy between single treatments.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    The systematic review relies on data collected secondhand from published articles, making the results vulnerable to bias within the original articles.

    “This systematic review relies on data collected secondhand from published articles.Thus, our results are vulnerable to bias within the original article.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Neither symptomatic improvement nor ETDQ-7 scores improved in a clinically significant manner among pooled patients.

    “Neither symptomatic improvement nor ETDQ-7 scores improved in a clinically significant manner among pooled patients.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationcitation

    The etiology of subacute ETD might explain these results as allergic or infectious factors causing subacute symptoms might improve on their own with or without pharmacologic treatment.

    “Here, the etiology of subacute ETD might explain these results as allergic or infectious factors causing subacute symptoms might improve on their own with or without pharmacologic treatment.2,4”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [2]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [4]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The Sterne and Egger tests with funnel plots were performed to further assess risk of publication bias.

    “In addition, the Sterne and Egger tests with funnel plots were performed to further assess risk of publication bias.24,25”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [24]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [25]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Risk of bias was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions version 6.1.

    “The risk of bias was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions (version 6.1).16”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [16]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationown data

    Nontraditional therapies such as Politzer devices, Valsalva therapy, and Buteyko breathing may be beneficial but require more evidence.

    “Nontraditional therapies such as Politzer devices, Valsalva therapy, and Buteyko breathing may be beneficial but require more evidence.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    Included articles were critically appraised to assess level of evidence using the Oxford Center for Evidence-Based Medicine criteria.

    “Included articles were critically appraised to assess level of evidence using the Oxford Center for Evidence-Based Medicine criteria.15”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [15]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The study was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

    “This study was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.14”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    In chronic ETD, patients may have local remodeling of the eustachian tube that local steroids cannot ameliorate.

    “Further, for chronic ETD symptoms patients may have local remodeling of the ET to which local steroids cannot ameliorate symptoms.”
    Quote in the paperNot a substantial claim
30 of 30

  • The paper relies on this without support.

    There is a lack of clear recommendations and a wide variation in patient response, leaving the decision of treatment modality up to physician preference.

    “In addition, a lack of clear recommendations and a wide variation in patient response has left the decision of treatment modality up to physician preference.”

  • The paper relies on this without support.

    Otitis media with effusion commonly results from ETD.

    “While the present study focuses on adult patients, OME commonly results from ETD and it stands that INCS would be similarly ineffective for ETD in adults.”
2 of 2

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Zhang female percentage uses the wrong denominator

    Minor

    The table lists 16 female patients among 41 patients, which is 39.0%, not 30%. The reported percentage is approximately 16 out of 53 affected ears.

    Reported 30 · recomputed 39.02439

  • Zhong female percentage uses the wrong denominator

    Minor

    The table lists 57 female patients among 107 patients, which is 53.3%, not 42%. The reported percentage is approximately 57 out of 135 affected ears.

    Reported 42 · recomputed 53.271028

  • Teklu female percentage uses the wrong denominator

    Minor

    The table lists 21 female patients among 34 patients, which is 61.8%, not 43%. The reported percentage is approximately 21 out of 49 affected ears.

    Reported 43 · recomputed 61.764706

  • Buteyko combination trial called both randomized and nonrandomized

    Minor

    The results describe the INCS-plus-Buteyko study as an RCT, but the discussion calls the same cited trial nonrandomized.

  • Gas treatment named nitric oxide instead of nitrous oxide

    Minor

    The study summary names nitric oxide gas as a therapy, whereas the table's abbreviation key identifies the gas used as nitrous oxide.

  • Conflicting literature-search end dates

    Minor

    The abstract says the database search ran through December 2020, while the Search Strategy section says it ran through September 2020.

  • Politzer cohort described as subacute or unspecified despite a chronic study

    Minor

    The results characterize both Politzer studies as involving subacute or duration-unspecified ETD, but Table I classifies Silman's Politzer study as chronic.

7 of 7

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. Table of Evidence Working Group JH ICJLL PaulGlasziou TrishGreenhalgh CarlHeneghan AlessandroLiberati IvanMoschetti BobPhillips HazelThornton OliveGoddardandMaryHodgkinson.The Oxford 2011 levels of evidence. Available at:http://www.cebm.net/index.aspx?o¼5653. Accessed October 30 2020.
  2. 10.1016/s0194-59989770017-2 · DOI

Cited by

Sorted by citations

Related

Authors
Mehta, N. K., Ma, C., Nguyen, S. A., McRackan, T. R., Meyer, T. A., & Lambert, P. R.
Affiliations
Medical University of South Carolina (US)
Corresponding author
Mehta, Neil K.
ORCID
Venue
The Laryngoscope
Publisher
Wiley
Published
2021-10-04
Volume
132
Issue
4
Pages
849-856
ISSN
  • 0023-852X (ISSN-L)
  • 1531-4995
DOI
10.1002/lary.29878
OpenAlex
W3201908040
Semantic Scholar
99df19632082d52d522733829f4ba19352236412
Cited by
33
References
40
Citations by year
2026: 9 · 2025: 6 · 2024: 9 · 2023: 5 · 2022: 2 · 2021: 2
FWCI
1.35
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • The Laryngoscope (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Otorhinolaryngology › Ear Surgery and Otitis Media
  • Health Sciences › Medicine › Otorhinolaryngology › Sinusitis and nasal conditions
  • Life Sciences › Neuroscience › Neurology › Vestibular and auditory disorders
Keywords
Eustachian tube dysfunction, medical management, intranasal corticosteroids, Valsalva maneuver, ETDQ-7, symptomatic improvement, adults
MeSH terms
Adult, Ear Diseases, Eustachian Tube, Humans

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Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-23.

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