Understanding Eustachian Tube Dysfunction: Why Your Ears Feel "Underwater"

• How is ETD treated?

  • Medical Therapy
  • Eustachian Tube Catheterisation (ETC)
  • Balloon Eustachian Tuboplasty (BET)
  • Tympanostomy (Ventilation) Tubes

• Managing Eustachian Tube Dysfunction at Home

  • Equalisation Manoeuvres
  • Supportive Care
  • Saline Nasal Sprays and Rinses
  • Auto-inflation Devices

• Stay Tuned Hearing Clinic

• FAQ – Frequently Asked Question

That familiar sensation — like your ears are stuffed with cotton, or you’ve just surfaced from a pool but the muffled feeling won’t go away — is one of the most common reasons people visit an audiologist. If that sounds like you, there’s a good chance your Eustachian tube is involved.

Eustachian tube dysfunction (ETD) occurs when this small but essential tube can’t do its job of ventilating your middle ear properly. After a cold, an allergy flare, or a bout of sinusitis, the tube can stay blocked or inflamed, creating negative pressure that stiffens your eardrum or allows fluid to build up behind it. The result is that muffled, pressured, “underwater” feeling — sometimes with popping, ringing, or even some discomfort.

Many people who experience this kind of muffled, full feeling assume it must be earwax. It’s an understandable first thought, and earwax buildup can certainly cause similar symptoms. But if you’ve already tried clearing your ears and nothing has changed, or if your symptoms reliably flare with colds, allergies, or altitude changes, Eustachian tube dysfunction is much more likely to be the culprit. A proper assessment at Stay Tuned Hearing will tell you quickly whether earwax is the problem, and if so, have it cleared safely. But, if not, we have the expertise to find and treat the actual cause, like ETD.

The good news is that ETD is very treatable, and understanding what’s happening in your ear is the first step to feeling better. Read on to find out what the Eustachian tube actually does, which type of ETD might apply to you, and what your options are.

Drainage — The middle ear naturally produces small amounts of mucus and fluid. The Eustachian tube clears this away by opening periodically and channelling secretions down into the back of the nose, where they’re swallowed harmlessly.
When the tube can’t open properly, this fluid has nowhere to go. It accumulates behind the eardrum — a condition called middle ear effusion (or “glue ear” in children) — which adds weight to the eardrum and further dampens your hearing.

When the tube can’t open or close the way it should, one or more of these functions breaks down — and that’s when symptoms start.

ETD affects hearing in a few distinct ways depending on what’s happening in the middle ear. Understanding the mechanism can help explain why the hearing changes you experience feel the way they do.

The Mass Effect

When ETD persists long enough for fluid to accumulate behind the eardrum, that fluid adds mass to the eardrum and ossicles. A heavier system moves more slowly, and this “mass effect” tends to affect higher-frequency sounds first. Consonants start to blur, voices sound distant, and the whole world sounds like you’re listening through a wall — even when there’s no pain at all.
You might notice it most with TV — turning the volume up more than usual, or struggling to follow speech even though you can hear the sound. These fluctuations, especially during colds or allergy season, are a hallmark of ETD-related fluid buildup. An otoscopy and tympanometry can confirm whether fluid is present, and treating the underlying nasal inflammation usually clears the hearing along with the fluid.

Sensorineural Impact

In cases of chronic or severe ETD, the effects can go beyond the middle ear. Sustained negative pressure can alter the movement of the round and oval windows — the membranes that connect the middle ear to the inner ear — disrupting the fluid dynamics of the cochlea. Over time, this mechanical strain may cause temporary threshold shifts, and in prolonged cases, it can contribute to sensorineural hearing loss through hair-cell stress.
Impaired blood flow to the cochlea and heightened inflammation around the inner ear are also possible in long-standing cases. New tinnitus alongside muffled hearing is worth taking seriously and getting assessed promptly — early care gives the best chance of a full recovery.
A word of caution: avoid forceful Valsalva manoeuvres (bearing down hard against pinched nostrils) when you suspect inner ear involvement, as this can worsen pressure dynamics. Seek an audiology and ENT evaluation for proper baseline testing and targeted treatment.

Mixed Hearing Loss

In some cases of chronic ETD, both the conductive system (the middle ear) and the sensorineural system (the inner ear) are affected at the same time — this is called mixed hearing loss. The conductive component comes from negative pressure or fluid reducing eardrum and ossicle movement, while the sensorineural component reflects inner ear strain from prolonged pressure imbalance or inflammation.

Mixed hearing loss related to ETD is one of the reasons timely treatment matters. Audiometry with air–bone gap measurement can distinguish how much of the loss is conductive versus sensorineural, and guide whether the focus should be on clearing middle ear fluid, reducing inflammation, or addressing both. Addressing contributing factors like reflux, allergy, and sinusitis early helps prevent the conductive element from developing a permanent sensorineural overlay. Monitoring dizziness, tinnitus, and any return of symptoms over time is also important.

ETD isn’t one-size-fits-all. There are three recognised types, and knowing which one you have matters a great deal for how it’s treated.

Dilatory (Obstructive) ETD

This is the most common type. In dilatory ETD, the Eustachian tube doesn’t open adequately when you swallow or yawn, so the middle ear can’t ventilate and pressurise normally. The result is that familiar build-up of negative pressure — persistent fullness, muffled “underwater” hearing, popping, occasional mild pain, and sometimes fluid collecting behind the eardrum.
The usual culprits are inflammation from colds, allergies, sinus disease, acid reflux (GORD), or enlarged adenoids, all of which can narrow the tube’s opening near the back of the nose. A clinician can confirm it with otoscopy and tympanometry, and treatment typically starts with addressing the underlying inflammation: saline nasal rinses, intranasal corticosteroid sprays, antihistamines for allergy-driven cases, and gentle autoinflation exercises.
If symptoms persist for several months or complications develop, an ENT may discuss procedures such as balloon Eustachian tuboplasty (BET) or ventilation tubes.

Baro-challenge-induced ETD

This type is triggered specifically by rapid changes in ambient pressure — most commonly flying, scuba diving, or driving through mountains. In normal circumstances, the Eustachian tube equalises middle ear pressure continuously as the environment changes around you. In baro-challenge-induced ETD, the tube is slow to respond or fails to open at the critical moment, leaving you with sharp ear pain, pressure, or a sudden drop in hearing as the cabin depressurises on descent or as you ascend from a dive.
It’s particularly common to experience this when you’re flying with a cold or active nasal congestion, because the tube’s opening is already swollen and less responsive. You may find your ears clear eventually — but the process is uncomfortable and sometimes takes hours or days.
The best approach is prevention: treat nasal allergies and congestion before travel, use saline rinses and a nasal steroid spray before flying, and use gentle equalisation manoeuvres — swallowing, yawning, chewing gum, or a careful Valsalva — early and often during ascent and especially descent. Avoid flying or diving when you have a significant cold or active ear symptoms. If you still have notable pressure, pain, or muffled hearing days after travel, get it assessed to rule out effusion or barotrauma.

Patulous ETD

Patulous ETD is essentially the opposite problem: instead of failing to open, the Eustachian tube stays abnormally open at rest. With a normally functioning tube, the closed resting state protects the middle ear from the sounds of your own body. When the tube is patulous (persistently open), sound and airflow from your nose and throat transmit directly into the middle ear.
The most distinctive symptom is autophony — your own voice, breathing, or even chewing sounds unnaturally loud and echoey inside your own head. It can feel like you’re talking into a bucket. You might also notice it fluctuates: symptoms often ease when you lie down or lower your head, and worsen when you’re upright, dehydrated, or after significant weight loss.
Common contributing factors include weight loss (which reduces the soft tissue supporting the tube), dehydration, pregnancy, and some nasal sprays. A clinician can confirm patulous ETD by observing eardrum movement in sync with breathing, or by tympanometry. Treatment targets the triggers: improving hydration, reviewing medications, and in persistent cases, procedures to add bulk or narrowing to the tube.

Common contributing factors include weight loss (which reduces the soft tissue supporting the tube), dehydration, pregnancy, and some nasal sprays. A clinician can confirm patulous ETD by observing eardrum movement in sync with breathing, or by tympanometry. Treatment targets the triggers: improving hydration, reviewing medications, and in persistent cases, procedures to add bulk or narrowing to the tube.

The symptoms of ETD overlap quite a bit with earwax buildup — both can cause muffled hearing, a sense of fullness, and the feeling that your ear needs to “pop.” The key difference is in the pattern. Earwax-related symptoms tend to be constant and unrelated to what’s happening in your nose or sinuses. ETD symptoms, on the other hand, tend to fluctuate — worsening with colds, allergies, sinus congestion, or altitude changes, and sometimes easing temporarily when you swallow or yawn. If you’ve tried addressing earwax and nothing has changed, or if your symptoms move in sync with congestion and pressure, ETD is worth looking into. Here’s what to look for.

Fullness or Pressure in the Ears

The feeling that your ear won’t “clear” — like it needs to pop but won’t — is usually the first sign of ETD. When the tube isn’t opening properly, air can’t enter the middle ear to equalise pressure, and negative pressure gradually builds behind the eardrum. In some cases this pulls the eardrum inward slightly; in others it promotes fluid formation.
You might notice this fullness comes and goes with colds, allergy seasons, or altitude changes, sometimes accompanied by a pop when you swallow. Gentle equalisation manoeuvres — swallowing, yawning, or a careful Valsalva — may temporarily relieve it. Stop immediately if you feel sharp pain. If the pressure persists for more than a week, keeps coming back, or is accompanied by fever, drainage, or significant pain, an Audiologist visit is warranted to rule out infection or persistent effusion.

Muffled or Distorted Hearing

When the Eustachian tube isn’t ventilating the middle ear, the resulting pressure imbalance stiffens the eardrum and ossicles, and sound transmission drops — especially for lower-pitched sounds. If fluid has also collected behind the eardrum, higher frequencies are dampened too. The overall effect is that voices sound distant, indistinct, or as if someone has turned the volume down and added a blanket over the speaker.
You might find yourself straining to follow conversations, missing parts of words, or feeling like you’re hearing through cotton wool. Your own voice may sound strange or uneven between ears. If muffled hearing lasts more than a week, keeps recurring with colds or allergies, or comes with fever, drainage, or a sudden one-sided change, seek an assessment.

Popping, Clicking, or Snapping Sounds When Swallowing

These sounds happen because the Eustachian tube normally opens briefly with each swallow to equalise middle ear pressure and clear mucus. When swelling from a cold, allergies, or reflux narrows the tube, it opens unevenly or with a delay — and you hear (and sometimes feel) the result as a pop, click, or snap. A brief change in pressure or muffling may come with it as the eardrum shifts.
In patulous ETD, where the tube stays too open, airflow can cause the eardrum to move with each swallow, producing a frequent soft click. Track your triggers, stay well hydrated, and use gentle swallowing or yawning rather than forceful blowing. If these sounds persist beyond a few weeks, worsen, or come with significant pain or fever, get it assessed.

Tinnitus

Tinnitus — a ringing, buzzing, hissing, or “whooshing” sound that seems to come from inside the ear rather than the outside world — can accompany ETD when pressure imbalance or middle ear fluid changes how the eardrum and ossicles vibrate. You might also notice ear fullness and muffled hearing alongside it, particularly with colds, allergies, or after altitude changes.
The reassuring news is that ETD-related tinnitus usually fluctuates rather than being constant, and it tends to improve as ventilation is restored and nasal inflammation settles. That said, it’s worth tracking when it starts, what seems to trigger it, and whether it’s in one ear or both. Prompt assessment is important if tinnitus is accompanied by sudden hearing loss, significant pain, fever, or one-sided symptoms. In the meantime, treating nasal inflammation, using saline rinses, and practising gentle equalisation manoeuvres can support recovery.

Autophony

Autophony is the sensation of hearing your own voice, breathing, or chewing with an unnaturally loud or echoey quality inside the affected ear. It can make everyday conversation feel exhausting and distracting — as though you’re wearing hearing protection that amplifies your own sounds while muffling the world.
This symptom most often points toward patulous ETD, where the tube remains too open at rest rather than failing to open. It’s typically position-sensitive: worse when you’re upright, better when you lie down or lower your head between your knees. It can also worsen with dehydration or after significant weight loss. Because autophony has a distinct pattern from other ETD symptoms, documenting when it happens and what changes it — and sharing that with your audiologist or GP — will really help them reach the right diagnosis. An ear exam and tympanometry can confirm it and rule out other causes.

Pain or a Ticklish Feeling in the Ear

When the Eustachian tube can’t equalise pressure, the eardrum can retract and the lining of the middle ear can become irritated and inflamed — producing a dull ache, mild pain, or an odd ticklish or itching sensation in the ear. It’s not usually dangerous, but it’s uncomfortable, and it can signal that fluid is building up or that a mild infection is brewing.
This discomfort often worsens during colds, allergy flares, flying, or after swimming. Gentle equalisation manoeuvres (swallowing, yawning, or a careful Valsalva) and treating nasal inflammation as advised by your clinician can help settle it. Seek urgent review if you develop fever, discharge from the ear, severe one-sided pain, facial weakness, or symptoms that persist for more than a few weeks.

ETD usually develops when inflammation narrows the Eustachian tube’s opening — most commonly from allergies, viral respiratory infections, or chronic sinusitis. Acid reflux, anatomy, and lifestyle factors can also play a significant role.

Gastro-oesophageal Reflux Disease (GORD)

This one surprises many people: acid reflux can affect your ears. When stomach acid and pepsin reflux up into the throat — a pattern called laryngopharyngeal reflux — they can inflame the tissue right around the Eustachian tube’s opening. Repeated exposure drives chronic inflammation, excess mucus, and pressure changes that make the ears feel blocked or “underwater.”
You might notice your ear symptoms are worse after late meals, alcohol, spicy foods, or lying flat, and may improve if you manage your reflux. Other signs that reflux may be a factor include a persistent hoarse voice in the mornings, a chronic cough, or a sensation of something stuck in your throat. Keeping a symptom diary and discussing it with your clinician — who may recommend proton pump inhibitors, alginates, or dietary adjustments — can make a real difference.

Anatomical Factors

Sometimes the issue isn’t inflammation but anatomy. Enlarged adenoids (particularly in children) can press directly on the Eustachian tube’s opening in the nasopharynx, restricting ventilation and trapping mucus. In adults, a deviated nasal septum, enlarged turbinates, or nasal polyps can redirect airflow and increase local congestion around the tube’s opening, making each swallow less effective at equalising pressure.
In less common cases, variations in craniofacial anatomy can change the angle or stiffness of the tube itself. If your ETD doesn’t respond to the usual treatments, or if you’ve had ear problems all your life, an ENT assessment — which may include endoscopy or imaging — can identify whether an anatomical factor is at play. Many of these are correctable.

Other Risk Factors

Several additional factors can increase your susceptibility to ETD or make existing symptoms harder to shift. Smoking impairs the cilia (tiny hair-like structures) that help clear mucus from the Eustachian tube, so secretions linger longer. Obesity may increase fatty tissue around the tube, reducing its patency. In children, craniofacial conditions such as cleft palate can weaken the muscles that open the tube, making obstructive ETD much more common.
Flying and diving with active nasal congestion is also a significant risk factor for acute ETD — particularly barotrauma — so it’s worth deferring travel if your ears and nose are already symptomatic.

The right treatment for ETD depends on what type you have and what’s driving it. For most people, a combination of managing the underlying cause and some targeted self-care is enough to resolve things. For persistent or more complicated cases, there are well-established procedures that can help.

Medical Therapy

For dilatory (obstructive) ETD, the first step is almost always addressing the inflammation that’s preventing the tube from opening normally. Intranasal corticosteroid sprays, used consistently for several weeks, are often the cornerstone of treatment — particularly when allergic rhinitis or chronic sinus disease is driving the symptoms. If allergy is prominent, an antihistamine can help reduce sneezing, itch, and the excess mucus that blocks the tube’s opening.
Short courses of decongestants can provide relief during an acute cold, but topical nasal decongestant sprays shouldn’t be used for more than three days due to the risk of rebound congestion. Saline nasal irrigation supports mucosal clearance and is gentle enough to use long-term. If acid reflux is a contributing factor, addressing that — through dietary changes or medication — is also part of the treatment picture. See your clinician or audiologist if pain, fever, or hearing changes persist for two weeks or more.

Eustachian Tube Catheterisation (ETC)

When symptoms persist despite optimised medical therapy, Eustachian tube catheterisation may be recommended. Using a nasal endoscope, a clinician guides a soft catheter to the Eustachian tube’s nasopharyngeal opening and delivers controlled air pulses or suction to re-establish ventilation and drainage. Some catheter systems include a small stabilising balloon cuff at the tip to assist positioning — this is distinct from the dilating balloon used in balloon Eustachian tuboplasty.
The procedure is typically performed under local anaesthetic and is done as a day procedure. Evidence supports its use in selected cases of obstructive ETD, particularly when nasal inflammation has been well-controlled. Side effects are usually mild — nasal irritation, brief ear discomfort, or occasional minor nosebleed. Follow-up tympanometry helps confirm whether the treatment has achieved meaningful pressure improvement.

Balloon Eustachian Tuboplasty (BET)

Balloon Eustachian tuboplasty is a minimally invasive procedure for chronic dilatory ETD that hasn’t responded to medical management. Under endoscopic guidance, a small balloon catheter is positioned within the cartilaginous portion of the Eustachian tube and briefly inflated to remodel the lumen and improve its ability to open. It’s a day procedure performed under general or local anaesthesia.
Many people report a meaningful reduction in pressure symptoms and fewer “underwater” episodes over the months following the procedure. The evidence base for BET is strongest in carefully selected adults where symptoms and objective testing align. It’s worth noting that BET improves the tube’s mechanical function but doesn’t remove the underlying cause of inflammation — so ongoing management of rhinitis, sinus disease, or reflux remains important to maintain the benefit. Complications are uncommon but can include nasal bleeding or temporary ear soreness.

Tympanostomy (Ventilation) Tubes

If you have persistent middle ear fluid or pressure that hasn’t responded to other approaches, a small ventilation tube (also called a grommet) can be placed through the eardrum to bypass the dysfunctional Eustachian tube and ventilate the middle ear directly. The procedure is usually performed under brief local or general anaesthesia and is done as a day procedure.
Ventilation tubes provide rapid relief from the conductive hearing loss, pressure, and fullness that come with persistent effusion. It’s important to understand that they don’t fix the underlying Eustachian tube problem — they simply hold the middle ear open while the inflammation causing ETD is treated. Water precautions may or may not be required depending on your clinician’s advice. Most tubes extrude naturally within 6–18 months, and regular hearing checks during that period help ensure things are tracking well.

For mild or short-lived ETD, there’s quite a bit you can do yourself to support recovery and make symptoms more manageable day-to-day.

A Note of Caution Before You Try Equalisation Manoeuvres

Before diving into the specific techniques, it’s worth emphasising: gentle is the operative word with all of these manoeuvres. Forceful Valsalva — blowing too hard against a blocked nose — can drive bacteria from the nasopharynx into the middle ear, worsen inner ear pressure, or in rare cases cause barotrauma. If a manoeuvre causes sharp pain, dizziness, or makes symptoms noticeably worse, stop immediately and seek assessment. Never attempt these manoeuvres if you have a current ear infection, are experiencing severe pain, or have been told to avoid them by an audiologist or clinician.

Toynbee Manoeuvre

The Toynbee manoeuvre is a gentler alternative. Pinch your nostrils closed, close your mouth, and swallow. The act of swallowing while the nose is blocked generates a small pressure change that can coax the Eustachian tube open. It’s less forceful than the Valsalva and is a good option to try first, especially if you’re prone to discomfort with the Valsalva. Repeat once or twice as needed, and combine with a yawn if helpful.

Supportive Care

Sometimes the simplest measures make the biggest difference. When your ears feel blocked, try swallowing, yawning, or chewing gum — these activate the same muscles that open the Eustachian tube. Staying well hydrated keeps mucus thinner and easier for the tube to clear. Resting when you’re unwell and avoiding smoke or vaping — both of which irritate the nasal and tubal lining and slow recovery — also helps.
During flights, use your equalisation techniques early and often, not just when you feel pressure building. Staying awake during descent means you’re actively swallowing and yawning rather than sleeping through the pressure change. If you have children with persistent symptoms, clinician-guided autoinflation devices can support ventilation and reduce the risk of glue ear. Seek assessment if symptoms last more than two to three weeks, or if fever or discharge develops.

Saline Nasal Sprays and Rinses

Saline nasal irrigation is one of the simplest and most consistently supported self-care measures for ETD. Rinsing or spraying the nose with sterile isotonic saline thins mucus, flushes out allergens and irritants, improves nasal airflow, and reduces swelling around the Eustachian tube’s opening — all of which make pressure equalisation easier.
A simple saline spray works well for quick moisture and mild congestion. A squeeze bottle or neti pot–style rinse provides a deeper cleanse and is especially useful during colds or high-pollen periods. Aim for once or twice daily when symptoms are active. Choose isotonic products to minimise any stinging; hypertonic solutions are more concentrated and are best used only on clinician advice. If you’re mixing saline solution from sachets at home, always use distilled or previously boiled water, and ensure your device is thoroughly cleaned and air-dried between uses to prevent any infection risk.

Auto-inflation Devices

Auto-inflation devices — the most widely known being the Otovent — offer a structured way to gently increase pressure in the nasopharynx and encourage the Eustachian tube to open. The Auto-inflation device involves closing one nostril, placing the nozzle at the other nostril, and using your nose (not your mouth) to inflate a small balloon to approximately the size of a grapefruit. Inflating it this way directs positive pressure toward the Eustachian tube opening. Follow the instructions provided with your device, as technique matters.
Studies in children with middle ear effusion and in adults with dilatory ETD have shown improved symptoms and tympanometry results with regular use over several weeks. Use slow, controlled pressure — if you feel pain, vertigo, or notice any bleeding, stop and seek advice. Auto-inflation works best as part of a broader approach that includes treating the underlying nasal inflammation, rather than in isolation.

At Stay Tuned Hearing your wellbeing is our highest priority, so let our Audiologist bring you some peace of mind if you are suffering from Eustachian Tube Dysfunction or showing symptoms, but unsure what it means. We’d love to hear from you and help you on your journey to recovery.

If you would like to book an appointment at our Mount Eliza Clinic or book a home visit, please follow this link to see the ways you can contact us.

Robin brings with him over 20 years of experience in audiology education, so you can be rest assured that you are in capable hands.