Article Text

The use of breathing techniques for the management of Eustachian tube dysfunction
  1. Jonathan BT Herron
  1. Correspondence to Lt Jonathan BT Herron, Room 5 Doctors residence, MDHU North, Friarage Hospital, Northallerton DL6 1JG, UK; herronjonny{at}


Introduction Eustachian tube dysfunction (ETD) is a common condition faced by primary care physicians with a variety of available treatments, none of which are particularly efficacious.

Case report A 28 year old male soldier presented with ETD following swimming at depth which did not resolve with initial therapies. His condition resolved rapidly after implementation of the Modified Butyenko Breathing technique.

Discussion The breathing technique offers a series of methods that can be used to treat patients who are refractory to conventional treatments and can add to the range of non-surgical treatments for this common condition.

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Key messages

  • Modified Buteyko Breathing increases nitric oxide and carbon dioxide in the middle ear.

  • This technique can be used as an adjunct to the treatment of ETD.

  • It is free at the point of use once learnt and can be used when other medicines are unavailable.


Eustachian tube dysfunction (ETD) is an issue commonly faced by clinicians. If left untreated, it can result in negative middle-ear pressure and can further complicate more serious conditions, such as hearing loss and cholesteatoma formation.1 ETD is the failure of the body to perform one or all of the three functions of the eustachian tube namely to prevent disease progression in the middle ear, to assist with ventilation/equalisation of the middle ear and to evacuate excretion from the middle ear.2 This is important to the military, due to its frequency of occurrence and the nature of the work which can be a risk factor for occurrence, such as flying, barotrauma or diving.3 It is common in the military with approximately 7% of all ear, nose and throat (ENT) cases presenting as ETD.4 There is no single, reliable diagnostic test for ETD that could be used in soldiers as diagnosis involves the use of many tests which is not efficient for screening.5

Case report

A previously fit and well 28-year-old male soldier who smoked 20 cigarettes per day presented with a 6–8 months history suggestive of ETD appearing gradually in the right ear. The symptoms presented as pain in both ears after swimming at depth which initially appeared to resolve itself afterwards. Since then he reported reduced hearing and muffed sound. After frequent attempts to equalise his ears, he was given olive oil, beclomethasone aqueous nasal spray (50 μg, two sprays two times per day) and pseudoephedrine hydrochloride (60 mg) for a 12-day course. Smoking cessation advice was also given. Two weeks later, he reported little benefit from these treatments—the complaint of ongoing ear fullness had not yet dissipated and the ears had not equalised. He denied all URTI symptoms and continued to smoke for this period. An examination of the patient's ear, nose and throat was normal, while hearing remained H1H1. Minimal improvement was reported with a lessened ‘bubbling’ sensation in the right ear; however, a marked difference between the sides remained.

The patient was instructed on breathing techniques to ease the remaining symptoms in line with the ‘Buteyko Breathing Technique’ with some modification. It concentrated on reduced tidal volume all through the nose, breath-holding on the ‘out’ breath; and implementation of maximal tolerable exercise with recovery exclusively through the nose. Initial relief was immediately reported and he noted a continued improvement over the 2-week period in which he practised these exercises. Despite some residual ear fullness, he can now equalise the ears and believes this to be as a result of practising the breathing technique.


The current practice for the treatment of ETD entails observation over time, autoinsufflation (such as the Valsalva manoeuvre or a device such as Otovent) and oral/intranasal steroids. However, there is some evidence that nasal steroids alone do not always resolve ETD and there are no clear guidelines.6 Another treatment that can be considered is decongestant therapy, but this should only be employed for short-term symptomatic relief, due to the cardiac side-effect profile of oral decongestants and tachyphylaxis with nasal usage.7 It has also been noted that patients who have undergone balloon dilation of the eustachian tube have reported significant symptomatic improvement—however, there is little evidence to support this, and further evaluation is required due to a potential risk association from the surgery involved with the treatment.8 The modified Buteyko breathing technique aims to correct the breathing pattern of the patient, and there is evidence that this can reduce both asthma and nasal symptoms.9–11 This type of breathing is known to increase both CO212 and nitric oxide13 levels. The effectiveness of the Buteyko method in this particular case may be due to the fact that nitric oxide can then lead to an increase in the middle-ear pressure resulting in the easier opening of the eustachian tube and thus resolving the initial problem.14 There is substantial documentation that hypoxia and hypercapnia lower opening pressures of the eustachian tube, subsequently reducing the passive and active resistance. This makes it easier for the patient to equalise the ear performing autoinsufflation as the middle-ear pressure increases.15

The ‘Body Oxygen Level Test’ is a measurement used to determine the progress/compliance of the individual with the exercises. It consists of measuring the length of time the patient can hold their breath on the ‘out’ breath, until the first urge to breathe ‘in’ occurs. The times recorded will increase with tolerance. Another exercise that increases with tolerance is ‘Steps’, which focuses on inhalation and exhalation through the nose, while holding the breath and closing the nostrils. The patient walks in a straight line, taking as many steps as possible to the point that full recovery can be achieved within three breaths through the nose. This is repeated with extra steps added each time until the exercise has been completed six times; this forms one set. A set of ‘steps’ is done two times per day. Additionally, the exercise ‘mouse breathing’ is undertaken, whereby the patient is breathing nasally with the smallest tidal volume possible, with the aim of having breaths so small they cannot be felt on a finger held under the nose.9


The modified Buteyko breathing technique can be used to treat patients who are refractory to conventional treatments. The exercises can add to conservative management before subjecting the patient to the risks associated with surgical intervention. This technique, after the initial cost of training, is free to implement, however, further study in this area is needed.

  • Received September 23, 2015.
  • Revision received November 23, 2015.
  • Accepted November 27, 2015.


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  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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