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Month: October 2023

Eustachian Tube Dysfunction

The Eustachian tube is a small canal that connects the middle ear to the back of the nose and upper throat.  It is normally closed but opens when we swallow, yawn, or chew.

Normal functions of the Eustachian tube:

  1. Ventilation of the middle ear – Helps keep the air pressure equal on either side of the eardrum (i.e., tympanic membrane), enabling the eardrum to work and vibrate correctly.
  2. Drainage of secretions from the middle ear cleft.
  3. Protection of the middle ear from pathogens (e.g., bacteria, viruses, fungi)

Dysfunction of the Eustachian tube or Eustachian tube dysfunction (ETD) may occur when the mucosal lining of the tube is swollen or does not open or close appropriately.


  1. 1. Allergic rhinitis (i.e., hay fever) – Seasonal or perennial in nature
  2. Upper respiratory tract infections (URI’s) – Single or recurrent episodes
  3. Nasal septal deviation (i.e., deviated septum)
  4. Cleft palate
  5. Enlarged adenoids and/or tonsils – Especially in children
  6. Nasal polyps

Risk Factors:

  1. Tobacco smoke
  2. Acid reflux [i.e., gastroesophageal reflux disease (GERD)]
  3. Radiation exposure


  1. Feeling of clogging, fullness or pressure in the ear(s)
  2. Pain or discomfort in the ear(s)
  3. Muffled or decreased hearing
  4. Ringing sensation in the ear(s)
  5. Dizziness, vertigo, or feeling of imbalance


  1. Otitis media with effusion (i.e., glue ear)
  2. Middle ear atelectasis (i.e., retraction of the eardrum)
  3. Chronic otitis media


The inability to “clear” or “pop” the ear with changes in barometric pressure, together with other patient-reported symptoms (e.g., aural fullness, pain, muffled hearing) is consistent with Eustachian tube dysfunction.


  1. Otoscopy
  2. Tympanometry
  3. Nasal endoscopy



  1. Supportive care – Includes advice about self-management such as to swallow, yawn, or chew.  These measures are especially useful while flying as sudden changes in barometric pressures aggravate Eustachian tube dysfunction.
  2. Pressure equalization methods – A technique where the Eustachian tube is reopened by raising the pressure in the nose.  This can be accomplished by forced exhalation against a closed mouth and nose which is referred to as the Valsalva maneuver.  Blowing balloons is also helpful in relieving the pressure in the middle ear by forcing air into the Eustachian tubes and keeping them patent.
  3. Nasal douching – The nasal cavity is washed with a saline solution in order to flush out excess mucus and debris from the nose and sinuses.
  4. Decongestants, antihistamines, nasal or oral corticosteroids – These medications are aimed at reducing nasal congestion and/or inflammation of the lining of the Eustachian tube.
  5. Antibiotics – Used for the treatment of rhinosinusitis (i.e., sinus infections)
  6. Simethicone – This is currently being investigated in adults to assess whether or not it can help to break up bubbles that may block the opening of the Eustachian tube in the back of the nose during an upper respiratory infection.  As a result, air should be able to pass between the nose and middle ear easier.


  1. Insertion of a pressure equalizing tube into the eardrum – Also known as a tympanostomy tube, ventilation tube, or grommet.  Pressure equalizing tubes typically fall out of the ears after 6-9 months.
  2. Eustachian tuboplasty – Balloon dilatation of the Eustachian tube

Of note:  The opposite condition of Eustachian tube dysfunction is called patulous Eustachian tube.  In this malady, there is an abnormal patency of the Eustachian tube.  Instead of being in the normal closed position, the Eustachian tube stays intermittently open, causing an echoing sound of the person’s own heartbeat, breathing, and/or speech.  These sounds will then vibrate directly onto the eardrum causing a “bucket on the head” sound effect.  This condition can usually be managed by nasal sprays.  Rarely, surgical intervention is warranted.

The board certified allergists at Black & Kletz Allergy has 3 locations in the Washington, Northern Virginia, and Maryland metropolitan area.  We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All 3 of our offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible.  The McLean office has a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line.  The allergy specialists of Black & Kletz Allergy diagnose and treat both adult and pediatric patients.  For an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy specialists at Black & Kletz Allergy have been helping patients with Eustachian tube dysfunction, allergic rhinitis (i.e., hay fever), asthma, sinus disease, eczema (i.e., atopic dermatitis), hives (i.e., urticaria), insect sting allergies, immunological disorders, medication allergies, and food allergies for more than 50 years.  If you suffer from allergies, it is our mission to improve your quality of life by reducing or preventing your undesirable and annoying allergy symptoms.

Chronic Sinusitis Update

The term “chronic sinusitis” is defined as an inflammation of the sinus or sinuses lasting more than 12 weeks in duration. The inflammation can be of any etiology however it is implied and commonly agreed upon that infection is the primary cause of chronic sinusitis. In order to understand chronic sinusitis, it is important to know the anatomy of a sinus. A sinus is a cavity in any organ or tissue, but in reference to allergies, it is a cavity in the skull and often referred to a “paranasal sinuses.” There are 4 paired sinuses in the cranial bones. They are named for their location with regards to the head and face. The names of the sinuses include the frontal, ethmoid, sphenoid, and maxillary sinuses. The frontal sinuses are located in the forehead region above the eyes. The ethmoid sinuses are situated between the eyes on each side of the upper nose. The sphenoid sinuses are positioned behind the eyes and bridge of the nose and lie in the deeper areas of the cranium. The maxillary sinuses are located on either side of the nostrils in the cheekbone areas.

The symptoms of inflammation of the sinuses or a chronic sinus infection may include a sinus headache, facial pressure or pain, post-nasal drip, discolored nasal secretions, cough and/or fatigue. It should be noted that it is not uncommon for an individual to present with just a chronic cough without many additional sinus symptoms. The diagnosis of chronic sinusitis requires a comprehensive and physical examination. There is often a history of onset of the infection as well as a progression of specific symptoms which may help diagnose the sinus infection. In some instances, sinus X-rays and/or CT scans of the sinuses may be helpful in the diagnosis.

The treatment of chronic sinusitis varies depending upon how severe the symptoms are in each individual patient. Oral antibiotics are the most common treatment however a longer course of antibiotics is usually prescribed due to the chronicity of the infection. It is not uncommon to treat these patients with 30 days of continuous oral antibiotics. Topical corticosteroids [e.g., Flonase (fluticasone), Nasonex (mometasone), Nasacort AQ (triamcinolone), Rhinocort (budesonide), Qnasl (beclomethasone), Nasarel (flunisolide), Zetonna (ciclesonide), (Xhance (fluticasone)] are sometimes useful in the local treatment of bacterial infections.  The effects are usually short-lived however. The nasal corticosteroids are not currently recommended for routine use; however, they offer the potential for improved directed treatment of the sinuses. Saline irrigation or saline nasal strays are useful in the mechanical clearance of allergens, irritants, and microorganisms (i.e., bacteria, viruses) from the nasal and sinus cavities.  Saline irrigation is an inexpensive and easy to use method of “cleaning” the nasal and sinus cavities. It is often used in conjunction with other treatments such as nasal corticosteroids and oral antibiotics to treat chronic sinusitis. It should be noted that some individuals do not like saline irrigation as it may cause some discomfort in the nasal or sinus passages. Topical antibiotics are sometimes useful in the local treatment of bacterial infections. As with nasal corticosteroids, the effects are usually short-lived and topical antibiotics are not currently recommended for routine use; however, they offer the potential for improved directed treatment of the sinuses.

Occasionally, a more aggressive treatment regimen for chronic sinusitis is necessary and other medications are then utilized. Oral corticosteroids are implemented in more severe or recalcitrant cases. Oral corticosteroids reduce inflammation and are particularly useful for shrinking nasal polyps, though they also may result in the multisystem improvement of symptoms.  Nasal polyps (i.e., nasal polyposis) are soft, benign growths that develop from the lining of the sinuses and nasal cavity. Approximately 4-5% of the general population has nasal polyps.  Nasal polyps cause increased nasal congestion and may block the normal drainage pattern of the sinuses. As a result, sinus infections are more likely to develop in these individuals. It should be pointed out that oral corticosteroids carry a risk for significant systemic side effects such as weight gain, peptic ulcers, cataract formation, thinning of one’s bones, depression, and/or endocrine dysfunction. They should be used judiciously and only for brief periods of time. In addition to oral corticosteroids, biological medications [i.e., Dupixent (dupilumab)] are being used more often to treat chronic sinusitis with nasal polyps. Biological medications can offer targeted and more effective treatment than other therapies.  The potential advantages of biological medications include the reduced need for oral or topical corticosteroids as well as the need for sinus surgery. A few of these biological agents [i.e., Xolair (omalizumab), Fasenra (benralizumab), Nucala (mepolizumab), Dupixent (dupilumab)] are currently being used for the control of asthma but only one of them, Dupixent (dupilumab) has been approved for chronic sinusitis with nasal polyps.

Prevention is always the goal in any malady if at all possible. For chronic sinusitis, preventive measures include the identification of specific allergen sensitivities and the subsequent avoidance or preventive treatment for these allergies. Allergy testing should be done by skin testing or blood testing. Aggressive treatment of any seasonal or perennial allergic rhinitis (i.e., hay fever) promotes proper sinus drainage and as a result improves upper airway function. Allergy immunotherapy (i.e., allergy shots, allergy injections, allergy desensitization, allergy hyposensitization) is a very effective tool to treat allergies and asthma as it works in 80-85% of patients that take them. The average treatment length of allergy shots is typically 3-5 years.

The board certified allergists at Black & Kletz Allergy treat both pediatric and adult patients. We diagnose and treat chronic sinusitis as well as other types of sinus disease, allergic rhinitis (hay fever), allergic conjunctivitis (i.e., eye allergies, asthma, allergic shin disorders [i.e., eczema (i.e., atopic dermatitis), hives (i.e., urticaria), generalized itching (i.e., pruritus), swelling episodes (i.e., angioedema), poison ivy, poison sumac, poison oak], anaphylaxis, food allergies, medication allergies, insect sting allergies, eosinophilic esophagitis, mast cell disorders, and immunological disorders. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking. The Washington, DC and McLean, VA offices are Metro accessible and the McLean, VA office has a free shuttle that runs between our office and the Spring Hill metro station on the silver line. You may also click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy has been a fixture in the greater Washington, DC, Northern Virginia, and Maryland metropolitan area for over 50 years for our outstanding services for the diagnosis and management of allergic, asthmatic, and immunological conditions.