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Introduction (Click here to skip to nasal spray use)

Before going into an explanation of why there are occasions when the ear doesn't feel right (ear fullness, clogged ears) or makes unusual noises (ear crackling/popping), one must understand the anatomy of how the ear works when things are normal. If your ears hurt, click here.

To the right is a diagram of a normal ear with structures labelled. The middle ear space (colored in with yellow) is an air-filled region of the ear that is cut-off from the outside world except for one passage called the eustachian tube which opens into the back of the nose (see picture or video). If the eustachian tube doesn't open normally, the middle ear space becomes isolated.

When the eustachian tube functions normally, every single time you swallow, yawn, blow your nose, etc, your ear "pops". This popping is when the eustachian tube opens transiently allowing air to pass from the middle ear to the back of the nose which is open to the environment.

Image is a modification of that found in Wikipedia under GNU Free Documentation License.

Images are a modification of that found in Wikipedia under GNU Free Documentation License.

Images are a modification of that found in Wikipedia under GNU Free Documentation License.

Normally, by popping your ears, the pressure difference will normalize (ie, no pressure can build up in a balloon if there is a hole) and the eardrum will go back into a neutral position. If the pressure difference is severe, the eardrum can bulge to the point it can pop like a balloon, a situation known as a perforated eardrum. Of note, people suffering predominantly from negative ear pressure are at risk of developing fluid in the middle ear which may lead to middle ear infections (otitis media) and hearing loss.

So, what would cause the eustachian tube to not open up properly? Well, something could be physically blocking the opening of the eustachian tube in the nose, most notably large adenoids. In rare cases, it could even be a tumor. Endoscopy is required to evaluate for these possibilities. More commonly, the eustachian tube does not open properly due to inflammatory conditions, especially allergies, resulting in the tube becoming inflamed and swollen. That's why when people get a cold or allergies are bad, their ears also becomes affected. This condition is known as Eustachian Tube Dysfunction.

Treatment

Treatment is based on the underlying condition. If due to large adenoids, adenoidectomy is the treatment. If due to Eustachian Tube Dysfunction, than treatment is with steroid nasal sprays for about 6 weeks along with Afrin for 3 days (do NOT use Afrin or any other nasal decongestant spray for more than 5 days due to rhinitis medicamentosa risk). These sprays are used differently than normal and instructions on the correct use can be found here. Throughout this time period, one must try to pop the ears 15-20 times per day (hourly) and also immediately after nasal spray use. Ear popping is done by pinching the nose and blowing gently (about the same amount of pressure as if one has mild constipation). Popping the ears in this manner, esp after nasal spray use helps to squeeze some of the medication into the eustachian tube.

Occasionally, systemic steroids, singulair, and anti-histamine nasal sprays are also prescribed. If these medications don't work, than placement of a tube across the eardrum often helps resolve the symptoms. Tube placement is generally recommended if a patient with eustachian tube dysfunction is about to fly, otherwise he/she may experience a very painful ear squeeze.

If a patient has allergies or a sinus infection, these need to be addressed as well. Rarely, severe laryngopharyngeal reflux causes Eustachian Tube Dysfunction.

Obviously, ear drops would not work since such drops would remain in the ear canal as it can't cross the eardrum to reach the eustachian tube which is the culprit for the cause of the symptoms.

BEWARE!!! There are other reasons for ear fullness which is not as common including sudden sensorineural hearing loss, serous otitis media, Meniere's Disease, cochlear hydrops, endolymphatic hydrops, large tympanic membrane perforation, TMJ, acoustic neuroma, etc. As such, one of the tests that needs to be performed before treatment is an audiogram. In some patients, this may be followed up with an ABR and/or even an MRI scan of the brain.

So why does my ear sometimes make funny crackling & popping noises?

Can't the eustachian tube be kept open to prevent Eustachian Tube Dysfunction?

As a matter of fact, there actually is a medical condtion known as Patulous Eustchian Tube which is just that... a eustachian tube that stays open all the time. However, this situation causes problems as well. People with Patulous Eustachian Tube suffer from symptoms including hearing themself breath in and out all the time as well as hearing themself talk in their head as if in a barrel. Symptoms may temporarily improve when bending down for a few seconds, but return soon thereafter. Unfortunately for sufferers of Patulous Eustachian Tube, there is no treatment that works very well unlike for Eustachian Tube Dysfunction. SSKI, premarin drops, and reserpine are some not totally effective treatments.

Perhaps the best treatment I've seen for Patulous Eustachian Tube is that provided by Dr. Dennis Poe at Massachusetts Eye and Ear Infirmary in Boston, MA. He performs a minimally invasive endoscopic insertion of a tiny catheter into the eustachian tube. The catheter is just the right size that one can still pop ears easily to prevent eustachian tube dysfunction, but large enough so that one does not suffer the symptoms of patulous eustachian tube.

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