Clinical Manifestations of Aural Fullness

Many patients complain of "ear pressure" or a "clogging sensation" of the ear, both of which suggest aural fullness. The underlying mechanisms of this widely overlooked symptom may involve any part of the peripheral hearing organ, from the external auditory canal to the inner ear. For instance, ear fullness is often reported in the early stages of Menière's disease1 and idiopathic sudden sensorineural hearing loss.2 Despite countless descriptions of ear diseases, only a few reports have attempted to unravel the clinical meaning of ear fullness as a chief complaint. Consequently, an objective diagnostic approach or treatment protocol for managing patients with aural fullness has yet to be developed. As a result, treatment tends to depend on a doctor's personal experience. In this study, patients in whom ear fullness was reported as a chief complaint were thoroughly investigated. Retrospective analysis was performed to investigate 1) the prevalence of aural fullness in an otolaryngology outpatient population, 2) symptoms associated with ear fullness, 3) audiological findings in individuals complaining of ear fullness and 4) identified final diagnoses.

Although many studies on patients with hearing loss and tinnitus have focused on aspects of pathophysiology and treatment, there have been no studies to date on the clinical manifestations of ear fullness, despite similarities between these audiological symptoms. Ear fullness has been regarded as an associated symptom of Menière's disease and otitis media with effusion. In this study, 1.44% of outpatients at the otolaryngology clinic complained of ear fullness as a primary symptom.

Ear fullness was more prevalent in females than in males, perhaps due to do hormonal changes accompanying menstrual cycles, and was especially prevalent in patients in their early forties.3 We also assessed the associations between aural fullness and diseases such as diabetes, hypertension, hepatitis, head and neck cancer, malignancies throughout the body, migraines, thyroid disease, chronic renal failure, depressive disorder, and allergic rhinitis, all of which might have some influence on hearing. For example, diabetes is frequently accompanied by sensorineuronal hearing loss, which may hinder both hearing and cognitive functioning.4, 5 In addition, a study based of DPOAE and PTA found that hypertension was a high risk factor for hearing loss.6 Other studies also showed a possible association between aural fullness and other diseases, such as delayed neural conduction of the auditory pathway during chronic renal failure and numerous cases of hearing loss among phonophobia patients with migraines.7, 8 Depression has also been linked to hearing loss and vision impairments.9, 10 In contrast with these reported associations, we found no relationship between aural fullness and any of these diseases.

In this study, symptoms significantly associated with ear fullness included hearing disturbances (43.0%), tinnitus (28.3%), autophony (26.3%), nasal obstruction (17.7%), and sore throat (5.4%), suggesting that outpatients complaining of ear fullness should be examined for these symptoms in order to arrive at a final diagnosis. Physical examination should include the Valsalva test; nasal examinations should include endoscopy; and audiological tests should include PTA. The highest incidence of hearing disturbances was due to the subjective similarity between hearing loss and ear fullness, making it important to determine whether these symptoms are due only to "ear fullness". The results of audiological tests showed that the A type was most prevalent in patients with aural fullness, followed by the B and C types. This result was not surprising, since 69.0% of these patients had normal functioning eardrums. About 20% of patients suffered from severe or profoundly severe hearing loss, indicating that subjective hearing loss can coexist with ear fullness, regardless of hearing capacity.

Patients who present with ear fullness should undergo basic hearing threshold evaluations, such as PTA. This is more important in assessing the possibility of Menière's disease and dysfunction of the inner ear in the early stages, when ear fullness may present.

The most prevalent final diagnoses in patients complaining chiefly of ear fullness were Eustachian tube dysfunction, followed by otitis media with effusion and chronic otitis media. Eustachian tube dysfunction may be accompanied by ear fullness due to the failure of pressure control. Ear fullness in patients with otitis media with effusion or disorders of sound transmission or resonance may be due to fluid filling the middle ear.

Eustachian tube dysfunction may be triggered by many causes, the most common being viral infection, chronic sinusitis, allergic rhinitis, adenoid hypertrophy, tobacco smoke, reflux, cleft palate, reduced mastoid air cell system, and nitrous oxide.11 There may also be an association between Eustachian tube dysfunction and allergic rhinitis.12 In general, there is no single test that can precisely evaluate the functioning of the Eustachian tube.13 Therefore, in order to accurately diagnose Eustachian tube dysfunction, it is necessary to examine nasal and Eustachian tube conditions by taking a detailed history and by performing otoscopic and nasal endoscopic examinations. Moreover, the Toynbee and Valsalva maneuver, while frequently used for examination, cannot be used in quantitative analyses. To compensate, sonotubometry has been introduced for the evaluation of Eustachian tube function, regardless of eardrum conditions. This test, however, remains unpopular.14

Finally, clinicians should not overlook the possibility of nasopharyngeal carcinoma. Although usually occurring in fewer than 1 per 100000 persons, its incidence is 30-times higher in Chinese individuals. It is also well-known that low socioeconomic status, Epstein Barr virus infection, and exposure to croton and tung oil increase the risk of nasopharyngeal carcinoma; an association between HLA-A2 and HLA-B17 has also been shown.15-18 In addition, 3.2% of patients with ear fullness in this study were diagnosed with nasopharyngeal cancer, a higher rate than that for the total rate of nasopharyngeal cancer.15 This can be explained by the fact that many patients are referred from either a primary or a secondary hospital for more accurate diagnosis and suspicious cancer treatment. After analyzing patients with nasopharyngeal cancer, many complained of otologic symptoms upon visitation to the outpatient clinic, among which ear fullness was most frequently reported, followed by sinonasal symptoms and head and neck symptoms.

Of particular importance, patients that first complained of otologic symptoms only took longer to be finally diagnosed with nasopharyngeal cancer. Since ear fullness was only considered as a simple otologic symptom, the lack of endoscopic and histological examination may have delayed the diagnosis for nasopharyngeal cancer. Thus, ear fullness should not be considered as a simple otologic symptom, and should be carefully examined along with other accompanying symptoms. In conclusion, in examining outpatients whose main complaint was ear fullness, we found that the predominant final diagnosis was Eustachian tube dysfunction, followed by otitis media with effusion and chronic otitis media. These patients should be examined by otoscopy, nasal endoscopy, the Valsalva maneuver, and additional audiological tests. Since many of our patients could not be initially diagnosed, it is necessary to take a detailed history, as well as perform thorough examinations and sustained observations of patients in order to arrive at a final diagnosis.