Ear fullness and blocked ear sensation

Ear fullness is a sensation of pressure, plugging or blockage in the ear, with or without hearing loss. Most cases are due to wax, Eustachian tube dysfunction or middle ear effusion.

Anatomy and physiology. The Eustachian tube opens during swallowing to equalise middle ear pressure with the nasopharynx. Failure to open (obstructive dysfunction) causes negative pressure, retraction and effusion. Failure to close (patulous) causes autophony and fullness.

Classification. Outer ear (wax, foreign body, otitis externa), middle ear (Eustachian tube dysfunction, effusion, acute otitis media, barotrauma), inner ear (Meniere disease, sudden loss, labyrinthitis), referred (temporomandibular, cervical, nasopharyngeal), and functional.

Key distinctions. Fullness with fluctuating low frequency loss, tinnitus and vertigo suggests Meniere disease. Fullness with autophony and sound of own breathing suggests patulous Eustachian tube. Unilateral persistent effusion in an adult needs the nasopharynx examined.

History. Onset, duration, laterality, hearing loss, tinnitus, vertigo, otalgia, discharge, autophony, relation to flying, diving, altitude or upper respiratory infection, nasal obstruction, allergy, reflux, jaw clicking or pain, neck pain, weight change (patulous tube), and previous ear surgery. Ask about facial pain, epistaxis, neck mass and weight loss.

Drug history. Oral contraceptives and diuretics (patulous tube association), intranasal decongestants (rebound), ototoxic drugs.

Examination. Otoscopy (wax, effusion with air bubbles or fluid level, retraction, perforation), pneumatic otoscopy for drum mobility, tuning forks, nasal examination, oropharynx and palate, nasopharyngolaryngoscopy for unilateral persistent effusion in adults, neck nodes, temporomandibular joint, cranial nerves.

Red flags

• Unilateral persistent effusion in an adult, especially with epistaxis, neck mass, cranial nerve palsy or weight loss
• Sudden hearing loss
• Vertigo, facial weakness or neurological signs
• Fever, post-auricular swelling or severe pain
• Head injury with blood or fluid from the ear

Special groups. Children: otitis media with effusion and adenoidal hypertrophy. Pregnancy: rhinitis and patulous tube. Region specific: nasopharyngeal carcinoma is more frequent in parts of South East Asia, southern China and North Africa.

Outer ear

• Cerumen impaction, foreign body, otitis externa

Middle ear

• Eustachian tube dysfunction (rhinitis, sinusitis, adenoids, reflux, barotrauma)
• Otitis media with effusion, acute otitis media, chronic otitis media
• Patulous Eustachian tube
• Nasopharyngeal carcinoma and other nasopharyngeal mass, skull base tumour
• Otosclerosis, tympanosclerosis, cholesteatoma

Inner ear and neurological

• Meniere disease, sudden sensorineural hearing loss, labyrinthitis, vestibular schwannoma
• Superior semicircular canal dehiscence, perilymph fistula
• Multiple sclerosis, migraine

Referred and functional

• Temporomandibular disorder, cervical spine disease, dental disease
• Anxiety and somatic symptom disorder

Reasoning. Examine after wax removal, test hearing, and measure middle ear pressure. Exclude sensorineural loss and a nasopharyngeal cause.

First line. Otoscopy, tuning forks, pure tone audiometry and tympanometry (type B flat: effusion; type C: negative pressure; normal in patulous tube or inner ear causes).

Targeted tests. Nasopharyngolaryngoscopy and biopsy of any nasopharyngeal mass. MRI of the internal acoustic meatus for asymmetric sensorineural loss (15 dB or more at two or more adjacent frequencies). CT temporal bone for suspected dehiscence or cholesteatoma. Epstein Barr virus serology as an adjunct in suspected nasopharyngeal carcinoma. Allergy testing and nasal assessment for chronic rhinitis. Tympanometry during breathing and sniffing for patulous tube.

Limitations. Tympanometry is unreliable in infants under 6 months. A normal examination does not exclude Eustachian tube dysfunction.

Wax. Sodium bicarbonate 5 percent ear drops or olive oil 3 to 4 drops two or three times daily for 5 to 7 days, then microsuction or irrigation (not with perforation, grommet or previous ear surgery).

Eustachian tube dysfunction. Autoinflation (Valsalva or Toynbee manoeuvres) several times daily, intranasal corticosteroid (mometasone 50 micrograms, 2 sprays to each nostril once daily, for 4 to 6 weeks), treatment of allergic rhinitis with a non-sedating antihistamine (loratadine 10 mg orally once daily), and oxymetazoline 0.05 percent nasal spray, 2 sprays to each nostril twice daily for no more than 3 days. Avoid flying or diving until resolved.

Otitis media with effusion. Watchful waiting for 3 months. Grommet insertion for persistent effusion with hearing loss of 25 to 30 dB or more. Examine the nasopharynx in every adult with unilateral effusion.

Acute otitis media. Amoxicillin 500 mg orally three times daily for 5 to 7 days in adults (maximum 3 g daily; clarithromycin 500 mg orally twice daily in penicillin allergy).

Sudden sensorineural loss. Prednisolone 1 mg/kg orally each morning (maximum 60 mg) for 7 to 14 days, started within 72 hours, with same day ENT review.

Meniere disease. Low salt diet, betahistine 16 mg orally three times daily (evidence is limited), and specialist care.

Patulous Eustachian tube. Reassurance, hydration, avoidance of diuretics and decongestants, and nasal saline drops; ENT referral for procedures.

Temporomandibular disorder. Ibuprofen 400 mg orally three times daily with food for up to 2 weeks (maximum 2.4 g daily), soft diet, jaw rest and dental review.

Nasopharyngeal carcinoma. Urgent oncology referral with biopsy and staging.

Monitoring. Repeat audiometry and tympanometry at 4 to 6 weeks and 3 months.

Referral and escalation. Same day for sudden loss. ENT within 2 weeks for unilateral persistent effusion, nasopharyngeal mass or asymmetric loss. Audiology for persistent fullness with hearing loss.

Admission criteria. Suspected stroke, intracranial complication, or severe vertigo with vomiting.

Discharge and safety netting. Review at 4 to 6 weeks. Return for sudden hearing loss, vertigo, facial weakness, ear pain with fever, swelling behind the ear or persistent unilateral blockage.