A patulous Eustachian tube is a disorder where the Eustachian tube, which is normally a closed valve, instead remains intermittently or persistently open. To understand why this causes such unusual symptoms, it is essential to first understand the normal function of this structure.

The Eustachian tube is a narrow, tissue-lined channel that connects the middle ear space (the air-filled area behind the eardrum) to the nasopharynx (the upper part of the throat, at the back of the nose).

• In a healthy ear, this tube is normally closed.
• It only opens for a fraction of a second when we swallow, yawn, or chew. This brief opening allows air to flow in or out to equalize the air pressure in the middle ear with the pressure of the outside world. This is the “pop” you feel in your ears when you are on an airplane.

A helpful analogy is to think of your middle ear as a small, sealed, sound-proofed room.

• The Eustachian tube is like a specially designed pressure-release window that connects this quiet room to the large, noisy “hallway” at the back of your nose and throat.
• In a normal ear, this window is spring-loaded and remains tightly shut, keeping the room quiet and maintaining its own air pressure. It only pops open for a split second when needed to equalize pressure.
• In Patulous Eustachian Tube, the spring on this window is broken. The window is now stuck open or flaps open and closed when it should not.
• This open channel allows all the sounds from the hallway, the sound of your own breathing, the vibrations of your own voice, and even your heartbeat to travel directly up into the sealed room and vibrate against your eardrum from the inside.

This direct transmission of internal body sounds to the eardrum is what causes the hallmark symptom of PET, known as autophony.

In my experience, patients often describe the bizarre sensation of hearing their own voice or breathing unusually loud, this “echo effect” typically points to a patulous Eustachian tube.

The direct cause of PET is a loss of the supportive tissue that keeps the Eustachian tube valve closed. The opening of the tube in the nasopharynx is surrounded by a natural pad of fatty tissue. When this tissue shrinks or is lost, the tube can lose its support and collapse into an open position.

Several conditions and factors can lead to this loss of supportive tissue:

• Significant Weight Loss: This is a major and common cause. Rapid or substantial weight loss from any cause, including bariatric surgery, chronic illness, or an eating disorder, can cause the fat pads throughout the body, including the one around the Eustachian tube, to shrink.
• Hormonal Changes:
  • Pregnancy: High levels of estrogen and progesterone during pregnancy can affect the tissues and surface tension in the Eustachian tube, sometimes causing it to stay open.
  • Oral Contraceptives: Some women may develop symptoms after starting birth control pills.
• Medications: The chronic use of decongestant nasal sprays can dry out and thin the mucosal tissues in the back of the nose, which can contribute to the development of PET.
• Neurological Conditions: Diseases that affect muscle control, such as multiple sclerosis, stroke, or post-polio syndrome, can sometimes impair the function of the small muscles that help to control the Eustachian tube.
• Scarring: Scar tissue from previous surgery (like an adenoidectomy) or from radiation therapy to the head and neck can pull the tube into an open position.
• Idiopathic: In many cases, a specific cause cannot be identified, and the condition is considered idiopathic.

In my experience, I also see it in association with neurological conditions, hormonal changes (like pregnancy), or as a postoperative effect from nasal or sinus surgeries.

A person develops PET as a consequence of one of the underlying conditions or risk factors described above. It is not contagious and is not considered a directly inherited disorder, although the underlying anatomy that might predispose someone to it can be. The primary risk factors are those that can lead to changes in the tissues at the back of the throat, most notably significant weight loss.

Clinically, some patients may have anatomical predispositions like thinner Eustachian tube walls or develop it secondary to chronic allergies or mucosal thinning.

The symptoms of PET can be extremely bothersome and can significantly impact a person’s quality of life, often leading to anxiety and depression.

The Hallmark Symptom: Autophony

The most specific and distressing symptom of PET is autophony. This is the experience of hearing your own internal body sounds with an unnerving, amplified loudness in the affected ear. This includes:

• Hearing your own voice as excessively loud, booming, or echoing inside your head. This often causes people to speak very quietly to avoid the uncomfortable sensation.
• Hearing the sound of your own breathing. This can be a constant roaring or “wind-in-a-tunnel” sound that is synchronized with your every breath.
• Hearing other internal sounds, like your heartbeat or chewing.

Other Common Symptoms:

• A feeling of fullness or pressure in the ear, often described as feeling like the ear is clogged or underwater.
• A perception of muffled hearing.
• Tinnitus, or ringing in the ear.

The Key Diagnostic Clue: Positional Changes

A critical feature of the symptoms of PET is that they are often positional.

• The symptoms are typically worse when upright, sitting or standing, and during physical exercise.
• The symptoms are often temporarily relieved by lying down or by putting your head down between your knees. This is because these positions increase blood flow to the head, which causes the tissues around the Eustachian tube to swell slightly and temporarily close the opening. This positional relief is a major clue to the diagnosis.

Clinically, I look for positional variation in symptoms. Lying down often improves PET along with the absence of ear pain, which helps differentiate it from middle ear infections.

The diagnostic journey for PET can be long and frustrating because the condition is rare and often misdiagnosed. The symptoms of aural fullness are frequently mistaken for the much more common problem of obstructive Eustachian tube dysfunction (a blocked tube). A patient may be incorrectly treated with decongestants, which can actually worsen the symptoms of PET.

A correct diagnosis requires a thorough evaluation by an otolaryngologist (an ENT specialist) who is familiar with the condition.

1. Patient History: The diagnosis is often strongly suspected based on the patient’s very characteristic story, especially the complaint of autophony that is relieved by postural changes like lying down.
2. Otoscopy (Examination of the Eardrum): This is a key part of the physical exam. The ENT will use a microscope to look at the eardrum while the patient performs breathing maneuvers. The definitive physical sign of PET is observing the eardrum physically moving in and out in time with the patient’s breathing.
3. Tympanometry: This is an objective test that measures the movement and pressure of the middle ear system. In PET, the tracing on the tympanogram will often show small fluctuations that are perfectly synchronized with the patient’s nasal breathing, confirming an open connection.
4. Audiogram: A formal hearing test will be performed to rule out other causes of hearing loss or tinnitus.

In my experience, I may use nasal endoscopy or imaging in persistent cases to rule out other structural issues or to confirm dynamic tube patency.

The goal of treatment is to relieve the distressing symptoms of autophony. Treatment is typically stepwise, starting with the least invasive options.

1. Conservative and Behavioral Measures

• Reassurance and Education: The first step is a definitive diagnosis and reassurance that the condition is physical, not psychological.
• Hydration: Staying well-hydrated is important to keep the mucosal tissues at the back of the nose healthy.
• Avoiding Decongestants: It is critical to stop using any nasal or oral decongestants, as these will make the condition worse.
• Weight Gain: If the condition was triggered by significant weight loss, regaining weight can sometimes resolve the symptoms completely.
• Postural Maneuvers: Lying down or putting the head down can provide temporary relief during severe episodes. A quick “sniffing” maneuver can also sometimes temporarily close the tube.

2. Medical Treatments

The goal of medical therapy is to create mild inflammation or swelling of the tissues around the Eustachian tube opening to help it close.

• Saline Nasal Spray: Using a hypertonic saline spray can help to hydrate the tissues.
• Ipratropium Bromide Nasal Spray: This prescription anticholinergic spray can sometimes be helpful.
• Compounded Nasal Drops: In some cases, an ENT may prescribe specially formulated drops containing irritating substances (like benzyl alcohol or potassium iodide) to be carefully applied to the opening of the tube.

3. Surgical and Procedural Options

These are reserved for severe, persistent cases that do not respond to conservative measures.

• Myringotomy with Ventilation Tube (Ear Tube): Placing a pressure-equalizing tube in the eardrum is sometimes performed. It does not close the Eustachian tube, but by aerating the middle ear, it can sometimes reduce the severity of the autophony symptoms, although the results are mixed.
• Injectable Fillers: An experienced surgeon can inject a bulking agent, such as hyaluronic acid, into the tissues surrounding the Eustachian tube opening to help it close.
• Surgical Obliteration: For the most severe and refractory cases, more invasive surgical techniques can be performed to partially or completely plug the Eustachian tube using cartilage or other materials.

Clinically, severe or persistent cases may require surgical interventions like gel or fat injections around the Eustachian tube to help it close properly.

Patulous Eustachian Tube is a rare and often misunderstood physical disorder that can cause the profoundly distressing symptom of autophony, the experience of hearing your own voice, breath, and heartbeat inside your head. While the symptoms are bizarre, they are real and have a clear anatomical cause. The diagnostic journey is often challenging, as the condition is frequently mistaken for a simple blocked ear. However, a correct diagnosis from a knowledgeable ENT specialist is the key to ending this frustration. In my experience, educating patients about the benign nature of PET helps reduce anxiety especially when symptoms are unusual but not dangerous.

The American Academy of Otolaryngology, Head and Neck Surgery. (n.d.). Eustachian Tubes: Blocked vs. Patulous. Retrieved from https://www.enthealth.org/conditions/eustachian-tubes-blocked-vs-patulous/

National Organization for Rare Disorders (NORD). (2022). Patulous Eustachian Tube. Retrieved from https://rarediseases.org/rare-diseases/patulous-eustachian-tube/

The Cleveland Clinic. (2023). Patulous Eustachian Tube. Retrieved from https://my.clevelandclinic.org/health/diseases/24647-patulous-eustachian-tube