Patulous Eustachian tube

What is Patulous Eustachian Tube?

Patulous Eustachian tube (PET) is a condition where the Eustachian tube—the narrow canal connecting the middle ear to the upper throat behind the nose—remains abnormally open. Normally, this tube stays closed and opens only for brief moments when we swallow, yawn, or chew, which helps balance ear pressure.

When the tube stays open, it creates a direct passageway for sound and air movement from the nose and throat to reach the middle ear. This causes a range of symptoms like hearing one's own breathing or voice echoing unnaturally.

Céline Dion's Experience

In 2018, singer Céline Dion canceled her Las Vegas shows due to severe PET symptoms. She described difficulties singing and hearing herself properly—symptoms that disrupted her ability to perform. Her story has helped many others recognize and seek help for this condition. Céline Dion’s story demonstrates an important risk factor for PET: low body weight. When a person has a slender build, there is less protective fat around the Eustachian tube valve. This lack of support can cause the valve to function improperly, leading to persistent symptoms. Her struggle underscores how PET can disrupt even high-profile careers, with symptoms including distorted hearing and ear fullness that made performing impossible.

Why Does Patulous Eustachian tube Happen? Anatomy and Pathophysiology

Quick Anatomy Lesson

For a more detailed review of the anatomy and role of the Eustachian tube, please read this article. The Eustachian tube is about 3.5 to 4 cm long in adults and consists of two parts:

• A bony part near the middle ear
• A cartilaginous (flexible) part near the nasopharynx

Its main roles are to:

• Equalize air pressure between the middle ear and outside environment
• Drain mucus from the middle ear
• Protect the ear from backflow of secretions and loud sounds

In healthy individuals, the Eustachian tube is typically closed and only opens briefly during activities like swallowing or yawning. This valve relies on surrounding tissues (like fat and muscles) to stay sealed. In PET, the tube fails to remain closed due to thinning of surrounding tissues, loss of fat, or poor muscle control, creating an abnormally open passage. This allows air movement and sound to flow continuously from the nose to the middle ear, disrupting normal hearing.

Symptoms: How Patulous Eustachian Tube Feels and Presents 

People with PET often describe their symptoms as strange and distressing. Common symptoms include:

• Hearing your own breathing: It basically feels like you are breathing through your ear (you hear the wind whooshing through your ear). It feels like your head is an echo chamber. This is one of the most common presenting symptom.

• Autophony: Your voice echoes or booms in your ear, making conversations exhausting. This is also very common.

• A feeling of ear fullness or pressure: A constant "plugged ear" sensation without actual blockage. As if the ear is “too open” or hollow

• Hearing fluctuations: Hearing may feel muffled or distorted depending on posture or physical activity.

• Improvement when lying down: Symptoms tend to improve when the head is lower than the heart, due to increased blood flow thickening surrounding tissues. Gravity also helps close the tube. This detail is very important to ask about, as very few other conditions share this specific feature. It helps me make an accurate diagnosis.

• Worsening of symptoms with: Exercise, stress, or dehydration. This feature is also particular to PET.

Risk Factors and Associated Conditions

Risk factors that can trigger PET include:

• Significant weight loss: Rapid or major weight loss (due to dieting, illness, or surgery) can reduce fat around the Eustachian tube, leading to poor closure

• Dehydration: Low body fluid levels can dry out tissues, making them thinner.

• Radiation therapy: Especially to the head or neck, can damage or scar tissue. Radiation will also lead to thinning of the fat pad that helps close the Eustachian tube. 

• Prolonged use of nasal sprays: Nasal steroid sprays (Nasonex, Avamys, etc.) and nasal decongestants (Otrivin for example) can thin mucosal tissues and worsen PET

• Chronic nasal or sinus inflammation: May alter pressure dynamics in the nasal cavity, or lead to changes in the structure of the mucosa. Patients with chronic sinusitis also tend to use more nasal sprays such as steroids (see above).

• Medications: Diuretics ("water pills") evacuate excess body water and can lead to thinning of the mucosa of the Eustachian tube opening. 
  

Linked Medical Conditions

PET may also coexist with other disorders, which can complicate diagnosis and treatment. The most common ones are:

• Temporomandibular joint (TMJ) disorders (Jaw joint): This is because the Eustachian tube runs very close to the jaw joint and shares some surrounding muscles. The chewing muscles also help open the Eustachian tube (they are secondary dilators). If you grind your teeth often (disorder called bruxism), these chewing muscles will keep the tube open longer than normal, which may contribute to developing PET. For some people, TMJ issues can worsen PET symptoms like ear fullness or internal echoing sounds, and managing both conditions together can help improve relief.

• Chronic nasal allergies: Chronic nasal allergies can dry out or inflame the lining of the nose and the Eustachian tube. Over time, this inflammation may weaken the tissues that normally help the Eustachian tube stay closed. In some cases, prolonged use of nasal sprays or decongestants for allergy relief can further thin the tissue around the Eustachian tube, making it more likely to stay abnormally open. People with long-standing allergies are often at higher risk of developing PET symptoms like autophony or ear pressure changes.

• Acid reflux disease: Acid reflux (also known as GERD) doesn’t just affect the stomach and throat—it can sometimes irritate the back of the nose and the opening of the Eustachian tube. Stomach acid or digestive enzymes that reach the upper throat (laryngopharyngeal reflux) may inflame or damage the delicate tissue around the Eustachian tube opening. This can reduce the natural tone and support of the tube, allowing it to remain open more often than normal. Managing reflux through diet, medication, and lifestyle changes may help improve or reduce PET symptoms in some patients.

• Neurological conditions (e.g., stroke, multiple sclerosis): Affect muscle control around the Eustachian tube

Clinical Evaluation: History and Physical Exam

A detailed clinical history is the first step in diagnosing PET. Important clues include:

• Presence of autophony or hearing your own breath

• Symptom relief when lying down, bending forward, or during nasal congestion. Worsening of symptoms with exercise and stress.

• History of recent weight loss or overuse of nasal sprays

During the physical exam, the ENT will:

• Use a microscope or otoscope to observe the eardrum. Other ear conditions are eliminated at this step.
  
  

• You’ll breathe deeply or sniff while the doctor looks into your ear. In PET, the eardrum visibly moves with each breath. This movement in sync with breathing strongly suggests PET. Sometimes, it’s hard to trigger PET symptoms during a doctor’s visit. If your symptoms aren’t present at the appointment, it doesn’t rule out the diagnosis. I often ask my patients to try to bring on their symptoms—like by climbing stairs or doing jumping jacks in my office! —so I can examine them again when the PET is active.

• Perform maneuvers like lying down or tilting the head to see how posture affects symptoms

• Use a fiberoptic camera (called nasolaryngoscope, or "scope") to examine your nasal passages and more specifically the opening of the Eustachian tube

Medical Work-Up

PET is primarily a clinical diagnosis, but certain tests may help confirm it or rule out other conditions:

• Tympanometry: Can detect the eardrum motion in sync with every breath.

• Hearing test (audiogram): A hearing test is usually normal in PET or showing mild changes.

• CT imaging: Rare needed. May be used to check for structural issues or other middle ear diseases

It’s essential to differentiate PET from conditions with similar symptoms, like:

• Obstructive Eustachian tube dysfunction (which causes a clogged or blocked sensation)

• Superior canal dehiscence (an inner ear bone problem)

• Temporomandibular joint disorders (jaw joint)

Treatment Options for PET

Treating PET can be hard. No treatment is universally effective. We often need to adopt a trial and error approach, which can feel slow and frustrating for patients. Treatment often begins with the least invasive approach.

Lifestyle modifications and conservative measures:

• Increase hydration: Drink fluids regularly to keep tissues moist and "plump".

• Weight gain: If PET began after weight loss, modest weight gain may help. However, the added weight rarely goes where we need it so this approach is not very efficient.

• Avoid nasal decongestants and steroids: These may worsen symptoms by thinning tissues

• Avoid triggers: Cut caffeine, decongestants, and diuretics.

Medical treatments:

• Regular nasal saline sprays or drops: Keep nasal passages moist and reduce symptoms

• Nasal estrogen drops: These thicken tissues to help close the Eustachian tube. It mimics the congested nose seen in pregnancy. However, this treatment approach is less often used these days.

• Nasal hypertonic saline drops:  A more concentrated salt solution (3% or 7%) can cause slight irritation and swelling of the Eustachian tube lining, helping it stay closed over time.  You need to apply the drops in the nose (on the affected side, or both sides) while lying down with the head hanging and turned towards the affected ear.
  
  

• PatulEND: A non-prescription nasal drop formulated specifically for PET, which uses natural ingredients such as liquid Vitamin C (ascorbic acid) to thicken mucosa and narrow the Eustachian tube opening. Many patients report significant benefit, and this has become the most commonly recommended first line of treatment for patients with PET. We usually recommend a trial of 2-3 months on PatulEND before evaluating its efficacy. *It is currently not available for direct purchase in Canada. To get it, patients must order from the manufacturer's website, which can leads to higher costs due to shipping and duties. 

Surgical options:

• Eustachian tube "filler" injections: A small amount of filler material is injected near the tube’s opening to increase tissue thickness and support tube closure. This is often the first surgical intervention suggested once the diagnosis in confirmed and medical treatment failed to improve, or patients want a more long-term solution. We usually start with a temporary filler (hyaluronic acid) that lasts 6-12 months. If the response is favorable, we can proceed with a more permanent filler material (hydroxyapatite) that can last many years. Injection of the Eustachian tube is done under local anesthesia as outpatient (clinic or office).
  
  

• Tympanostomy tubes (ear tubes): Provide pressure relief and can sometimes resolve the autophony sensation. However, a tube can sometimes worsen symptoms. It is very hard to predict which patient will respond well to the tube, so appropriate discussion with the patient is needed before trying. Removing a tube too prematurely (if the patient does not tolerate it well) can lead to a perforated eardrum, so caution is necessary. Ear tubes are done under local anesthesia in the office.

• Eustachian tube surgery (shim or closure): In severe, unmanageable cases, the tube can be closed off. This is usually reserved for extreme, persistent PET and requires the patient to rely on ear tubes for pressure regulation. These are performed under general anesthesia in the operating room. Very few centers in Canada currently offer this procedure, as the outcomes are still being studied. I do not perform this surgery at this time.

Living with Patulous Eustachian Tube

PET can affect daily life in unexpected ways. Hearing your own voice or breathing constantly can cause emotional distress, fatigue, and even anxiety. Many patients report frustration with delayed diagnosis or being misunderstood.

Tips for managing life with PET:

• Stay hydrated: Dehydration worsens symptoms

• Practice positional strategies: Lying down or bending forward may offer temporary relief

• Use earplugs or white noise: Helps reduce the perceived loudness of internal sounds

• Join support groups or online forums: Sharing experiences can provide comfort and coping strategies

If symptoms are interfering with daily functioning, a consultation with an ENT specialist can provide individualized care. Most importantly, you are not alone—help and treatment options are available.

Conclusion

Patulous Eustachian tube is a rare but impactful condition that can affect how you hear your own body. While it may be unsettling at first, understanding the condition and seeking expert care can go a long way in helping you manage symptoms. Thanks to growing awareness—both in the medical field and among the public—more patients are finding accurate diagnoses and effective relief.