An overly patent auditory tube is a relatively uncommon problem that may be quite distressing. Typical complaints include fullness in the ear and autophony, an exaggerated ability to hear oneself breath and speak. A patulous auditory tube may develop during rapid weight loss, or it may commence without a discernible cause. In contrast to a hypofunctioning auditory tube, the aural pressure is often made worse by exertion and may diminish during an upper respiratory tract infection. Although physical examination is usually normal, respiratory excursions of the tympanic membrane may occasionally be detected during vigorous breathing. Treatment includes avoidance of decongestant products, insertion of a ventilating tube to reduce the outward stretch of the ear drum during phonation, and surgical narrowing of the auditory tube (rarely).

When the auditory tube remains blocked for a prolonged period, the resultant negative pressure will result in transudation of fluid. This condition, known as serous otitis media, is especially common in children because their auditory tubes are narrower and more horizontal in orientation than adults. It is less common in adults, in whom it usually follows an upper respiratory tract infection or barotrauma. In an adult with persistent unilateral serous otitis media, nasopharyngeal carcinoma must be excluded. The tympanic membrane in serous otitis media is dull and hypomobile, occasionally accompanied by air bubbles in the middle ear and conductive hearing loss. The treatment of serous otitis media is similar to that for auditory tube dysfunction. A short course of oral corticosteroids (eg, prednisone, 40 mg/d for 7 days) has been advocated by some in the management of serous otitis media, as have oral antibiotics (eg, amoxicillin, 250 mg orally three times daily for 7 days)—or even a combination of the two. The role of these regimens remains controversial, but they are probably of little lasting benefit.

When medication fails to bring relief after several months, a ventilating tube placed through the tympanic membrane may restore hearing and alleviate the sense of aural fullness.

Individuals with auditory tube dysfunction due either to congenital narrowness or to acquired mucosal edema may be unable to equalize the barometric stress exerted on the middle ear by air travel, rapid altitudinal change, or underwater diving. The problem is generally most acute during airplane descent, since the negative middle ear pressure tends to collapse and lock the auditory tube. Several measures are useful to enhance auditory tube function and avoid otic barotrauma. The patient should be advised to swallow, yawn, and autoinflate frequently during descent, which may be painful if the auditory tube collapses. Systemic decongestants (eg, pseudoephedrine, 30–60 mg) should be taken several hours before anticipated arrival time so that they will be maximally effective during descent. Topical decongestants such as 1% phenylephrine nasal spray should be administered 1 hour before arrival.

The treatment of acute negative middle ear pressure that persists on the ground is with decongestants and attempts at autoinflation. Myringotomy provides immediate relief and is appropriate in the setting of severe otalgia and hearing loss. Repeated episodes of barotrauma in persons who must fly frequently may be alleviated by insertion of ventilating tubes.

Underwater diving represents even a greater barometric stress to the ear than flying. The problem occurs most commonly during the descent phase, when pain develops within the first 15 feet if inflation of the middle ear via the auditory tube has not occurred. Divers must descend slowly and equilibrate in stages to avoid the development of severely negative pressures in the tympanum that may result in hemorrhage (hemotympanum) or perilymphatic fistulization. In the latter, the oval or round window ruptures, resulting in sensory hearing loss and acute vertigo. Emesis due to acute labyrinthine dysfunction can be very dangerous during an underwater dive. Sensory hearing loss or vertigo, which develops during the ascent phase of a saturation dive, may be the first (or only) symptom of decompression sickness. Immediate recompression will return intravascular gas bubbles to solution and restore the inner ear microcirculation. Patients should be warned to avoid diving when they have upper respiratory infections or episodes of nasal allergy. Tympanic membrane perforation is an absolute contraindication to diving, as the patient will experience an unbalanced thermal stimulus to the semicircular canals and may experience vertigo, disorientation, and even emesis. Finally, individuals with only one hearing ear should be discouraged from diving because of the significant risk of otologic injury.