Specialist article: ear
Ear pressure and pressure equalisationWhy swallowing ventilates your ear
Pressure in your ears, your ear feels blocked, and equalising just won’t work? Here you will find out how the Eustachian tube opens when you swallow, what helps when flying and diving, what Eustachian tube dysfunction is and why, in our view, pressure equalisation is a pattern of breathing, swallowing and head balance.
Does this sound familiar?
Your ear is blocked, and swallowing doesn’t help?
What applies to you?
Tap whatever applies to you.
If several points apply, it is worth taking a closer look at how your middle ear is ventilated. The Eustachian tube is opened by muscles that work during swallowing. How well they do this depends, in our view, on the interplay of breathing, swallowing and head balance, and this can be trained.
What happens in the ear when you swallowWhat helps with acute pressureThe key points at a glance
- Ear pressure arises when the air pressure in the middle ear differs from that of the surroundings. It is equalised via the Eustachian tube, a narrow passage to the nasopharynx.
- At rest, the Eustachian tube is closed. It opens for a fraction of a second when you swallow and yawn, pulled by the muscles of the soft palate.
- If pressure equalisation repeatedly fails, this is called Eustachian tube dysfunction. Disturbed muscle work is one of its routes. Merely bridging the pressure does not resolve it. In our view, the approach lies in the swallowing sequence, and that can be trained.
Video
Pressure in the ears: how pressure equalisation works
Das Video lädt erst nach dem Klick. Dann werden Daten an YouTube (Google) übertragen.
Physics
How ear pressure arises
Almost everyone knows pressure in the ears, on a plane, in a lift or on a mountain pass road. Behind it lies a simple physical principle.
Behind the eardrum lies the middle ear, a small, air-filled space containing the three ossicles. In front of the eardrum is the ear canal and thus the outside air. The eardrum can only vibrate freely when the pressure on both sides is the same. If the air pressure outside changes faster than the middle ear can follow, the eardrum bulges. You feel this as pressure, as muffled hearing or as a feeling that your ear is blocked.
Like a bag of crisps on a plane
Take a sealed bag of crisps on board. At cruising altitude it puffs up, and during the landing approach it collapses again. The air in the bag stays the same; only the pressure outside changes. The middle ear behaves similarly, with one difference. It has a valve through which it can equalise the pressure: the Eustachian tube.
Ascent
The pressure outside falls, and in the middle ear it is comparatively too high. The excess air usually escapes easily via the Eustachian tube. Often a single swallow is enough, and there is a brief click.
Descent and landing
The pressure outside rises, and negative pressure develops in the middle ear. Now air has to be actively let in, and for this the Eustachian tube has to be opened. This is why the ears cause problems mainly during descent.
Descending underwater
Underwater, the pressure rises sharply within the first few metres. Equalisation has to happen early and often, before a large difference develops.
The ear canal plays no role in pressure equalisation. Air reaches the middle ear exclusively via the nasopharynx.
When your ear feels blocked, many people reach for the ear without thinking. But pulling on the earlobe or pressing into the ear canal does not reach the middle ear, because the pressure sits behind the eardrum.
Anatomy
The Eustachian tube: a valve to the nasopharynx
The middle ear is connected to the outside world by only a single passage. It ends where the nose and throat merge.
The Eustachian tube, in Latin tuba auditiva, runs at a downward angle from the middle ear into the nasopharynx, the space behind the nose. At rest, its walls lie against each other. This keeps the middle ear protected from secretions from the nasopharynx and from the sound of your own voice.
The Eustachian tube is opened by muscles of the soft palate. The tensor of the soft palate originates at the base of the skull and at the cartilage wall of the Eustachian tube. When it contracts, it tightens the soft palate and in doing so pulls the wall of the tube open. The levator of the soft palate also originates at the Eustachian tube and lifts the soft palate against the back wall of the throat.
Both muscles work when you swallow or yawn. The soft palate then seals off the nasal cavity, and in the same movement the path to the middle ear opens for a moment. That is why your ear sometimes clicks when you swallow.
Swallowing is also a ventilation process for the middle ear.Swallowing, the soft palate and the middle ear are mechanically linked. Anyone who wants to understand pressure equalisation therefore has to look at swallowing.
Mechanics
What happens in the ear when you swallow
You swallow many hundreds to a thousand times a day, usually without noticing. With many of these swallows, your middle ear is ventilated along the way.
The tongue rests against the palate
The tip of the tongue lies at the reference point behind the upper front teeth, and the teeth touch briefly. The back of the tongue pushes the swallow backwards.
The soft palate rises
The levator pulls the soft palate backwards and upwards and closes off the nasal cavity so that nothing gets into the nose.
The tensor pulls the tube open
It tightens the soft palate and pulls on the cartilage wall of the Eustachian tube. The passage opens.
Air equalises the pressure
For a fraction of a second, air flows between the nasopharynx and the middle ear, in the direction of the lower pressure.
The tube closes again
The muscles relax and the walls lie against each other again. The middle ear is sealed off once more.
were measured during swallowing in Pittsburgh, with needle electrodes in both soft palate muscles on one side and a microphone in the ear canal1
was how long an opening of the Eustachian tube lasted, measured as a median of 196 milliseconds1
worked together. The levator started first, and the widest opening coincided with the activity of the tensor1
Not every swallow opens the tube measurably. A research group in Madison tracked swallowing in rapid image series in a CT scanner. In the five healthy people, they saw a small portion of air travel through the Eustachian tube, but not in the examined person with a functional disorder2. The number of cases is small, and the finding is a hypothesis.
An animal study showed how strongly the muscles determine the mechanics. After the tensor had been paralysed with botulinum toxin in twelve cynomolgus monkeys, the opening pressure and compliance of the Eustachian tube changed markedly3. This does not represent a disease in humans, but it does show that the passage is partly shaped by muscle tension.
3D film
The swallow as an exercise
The animation from the FaceFormer instructions shows the sequence in question in a side section: lips on the FaceFormer, bite briefly, swallow once. The soft palate and Eustachian tube are not drawn in it.
Eustachian tube dysfunction
When pressure equalisation does not work
If pressure equalisation repeatedly fails, ENT doctors speak of Eustachian tube dysfunction or a tubal ventilation disorder.
In 2015, an international expert group described what is meant by Eustachian tube dysfunction. Its characteristics are complaints caused by unequal pressure in the ear, such as a feeling of fullness, clicking or pain. These are often accompanied by a feeling of being under water, crackling, ear noises, muffled hearing or your own voice sounding loud4. According to an American study group, the form in which the tube opens too little affects up to 5 % of adults5.
If ventilation of the middle ear remains disturbed for a long time, fluid can collect behind the eardrum, and hearing becomes more muffled. In our view, pressure equalisation that has been disturbed for years can also be a link in the chain at the end of which stand sensitivity to noise or ear noises. This chain as a whole has not been tested; it is our model. More on this in the article Tinnitus.
Opens too little
The tube does not open sufficiently when you swallow. The consensus paper distinguishes three ways this can happen: swelling of the mucous membrane, for example with an infection or allergy, a structural narrowing, and impaired muscle function4.
Gets stuck with pressure changes
In everyday life everything is fine, but when diving or during a descent in an aircraft, equalisation does not succeed. Back on the ground, the symptoms usually subside4.
Stays open
The tube does not close properly. Your own voice and your own breathing boom in the ear, and lying down often makes it better. This is called a patulous Eustachian tube4.
With a patulous Eustachian tube, the tube does not close completely after swallowing. The conspicuously loud hearing of your own voice and your own breathing is technically called autophony4. In our view, closing the tube is part of the same swallowing sequence as opening it. However, this connection has not been studied for the patulous Eustachian tube.
Injection at the ENT practice
- Filler material, such as hyaluronic acid or silicone, is injected in the area of the tube opening
- Narrows the open passage, while muscle function remains unchanged
- Resorbable material is broken down over time, after which a repeat may be necessary
Training the basic functions
- Addresses the swallowing sequence, which in our view includes the opening and closing of the tube
- Trains breathing, swallowing and head balance in the same sequence
- Requires your participation over several months
- Targets the control pattern, not the tissue
The two approaches are not mutually exclusive. Whether an injection is an option is decided by the ENT practice on a case-by-case basis. The training can be combined with it, and you do not stop any treatment started by a doctor on your own for it.
The acute form often follows an infection of the upper airways or an allergy flare-up. According to the consensus paper, it is unclear whether the chronic form has the same cause4. It is notable that the expert group names impaired muscle function as a separate pathway. That is exactly where our view comes in.
The triad
Pressure equalisation is a muscle function
The Eustachian tube does not open by itself. It is opened, namely by muscles that are part of the swallowing sequence.
In Rome, a research group used a surface electrode to record the activity of the tensor muscle during swallowing in 20 people with middle ear infection and 10 healthy people. In 78.5% of those affected, the signal on the affected side was shorter or weaker6. After tubal rehabilitation, the authors found higher activity. The group was small, and the measurement shows a correlation, not a cause.
Breathing
The Eustachian tube opens into the nasopharynx. With nasal breathing and closed lips, air flows through it. With mouth breathing, the tongue drops, and swallowing changes along with it.
Swallowing
Swallowing opens the tube. The tongue rests against the palate, the teeth touch briefly, and the soft palate lifts firmly. The starting point is the tongue reference position.
Head balance
If the head moves forward, in our view the tensions around the jaw, hyoid bone and throat shift, right up to the soft palate.
One special feature links the ear to the jaw. The tensor muscle of the soft palate is supplied by the same nerve branch as the jaw-closing muscles, the muscles of the floor of the mouth and the small muscle in the middle ear that pulls on the malleus.
If you constantly clench or use your lower jaw differently, in our view you also change the working conditions of this nerve branch.
Swallow once consciously. What are your tongue and teeth doing?
The mouth is open
It often begins with mouth breathing, in childhood, with a blocked nose or out of habit.
The tongue drops
It lacks its reference point on the palate. Swallowing happens with the tongue against the teeth, without brief tooth contact.
The soft palate works less strongly
What is not integrated into the function is not used and loses its tension.
The tube does not open sufficiently
The middle ear is ventilated less often, and it gets stuck when pressure changes.
The ear feels blocked
The end result is the feeling of pressure, often with a diagnosis of Eustachian tube dysfunction.
This chain is our model, not a diagnosis for the individual case. If the ear repeatedly feels blocked even without an infection, in our view the cause usually lies in the interplay of breathing, swallowing and head balance, not in the tube alone.
Acute ear pressure
Pressure in your ears: what helps now
With acute pressure, for example during the landing approach or in a lift, it is best to use the mechanism your body has provided for this.
Swallow consciously
Several times in a row, with closed lips and brief tooth contact. Each swallow gives the Eustachian tube an opportunity to open.
Drink or chew
A sip of water, a sweet or chewing gum help because they produce saliva, which makes you swallow more often.
Yawn
When you yawn, the soft palate tenses firmly, and the tube often opens along with it.
Gentle pressing (Valsalva)
Pinch your nose, close your mouth and breathe out gently against your closed nose. Only with little pressure, and not if you have pain or inflammation in the ear.
Swallowing with your nose pinched
The Toynbee manoeuvre: pinch your nose and swallow; the swallow opens the tube.
Tongue as a piston (Frenzel)
Hold your nose, hold the air in your throat and form the sound “k”. The base of the tongue presses backwards and upwards and pushes the air in the throat into the Eustachian tube, without straining via the chest. This is specifically practised in diving training.
Start early
On a plane, start equalising at the beginning of the descent, not only at touchdown. If you sleep through the landing approach, you don’t equalise.
of air travellers showed signs of pressure damage to the eardrum after landing, in a study of 134 passengers7
of ears with negative pressure after the flight could be equalised with the Valsalva manoeuvre in the same study7
of the remainder were equalised with a nasal balloon, which you inflate with your nose7
See a doctor if the pressure comes with severe ear pain, fever or discharge, if your hearing suddenly gets worse, if dizziness or new ear noises appear, or if pain persists after a dive.
Flying and diving
Ear pressure when flying and diving
Both situations put the Eustachian tube to the test. The difference lies in the speed and size of the pressure change.
On a plane, cabin pressure is lowered during the flight, to roughly the level found on a high mountain. During descent, it rises again over many minutes. Under water, things happen faster. Just a few metres of depth bring a greater pressure change than an entire descent. That is why divers need to equalise earlier and more often.
- Before the flight
Nose clear?
If you have a bad cold, ask at a pharmacy or doctor’s practice whether a decongestant nasal spray makes sense.
- Cruising
Stay awake
The pressure is stable. If your ear clicked during the climb, it has already equalised.
- Start of descent
Start early
Swallow, drink, chew, yawn. The smaller the difference stays, the more easily the tube opens.
- Landing approach
Keep going
Keep swallowing regularly. If it gets stuck, gently use the Valsalva manoeuvre.
- After landing
Equalise again
If a feeling of pressure remains, keep swallowing and yawning. If it persists for days, have it examined.
The same principle applies to diving, only more strictly. Equalise early and at short intervals before you feel any pressure, descend slowly and ascend a little if it gets stuck. Do not dive with a blocked nose. When diving, ear pain is a signal to turn back, not an obstacle you should push through.
Research
What ENT medicine offers
For persistent Eustachian tube dysfunction, several options are available at an ENT practice. They target the mucous membrane and the width of the passage.
Decongestant nasal sprays reduce swelling of the mucous membrane in the short term and are intended for a few days only. For a cortisone nasal spray, a Mayo Clinic study with 91 affected individuals found no advantage over a placebo after six weeks, either in the test results or in the symptoms8. If fluid collects in the middle ear, a tympanostomy tube (grommet) in the eardrum can take over ventilation.
of those treated had a normal middle ear pressure reading six weeks after balloon dilation of the Eustachian tube. The study examined adults whom medication had not helped9
was the figure in the comparison group of the same study, which continued to receive medication only9
In balloon dilation, the cartilaginous part of the Eustachian tube is widened with a small balloon inserted through the nose. The study shows a clear advantage over medication. It was conducted with the manufacturer’s involvement, and just under half of those treated did not have a normal reading afterwards. All of these procedures target the mucous membrane and the width of the tube. None of them trains the muscles that open the tube during swallowing.
In our view, simply accepting the pressure or bridging it on every flight with nasal spray and manoeuvres is not a therapeutic approach. It does not clarify why the Eustachian tube does not open reliably. In our view, the answer lies in the swallowing sequence, right down to the tensor muscle of the soft palate, which pulls the tube open during swallowing. That is where the training starts, creating the conditions under which pressure equalisation can improve.
If you use a nasal spray, have a tympanostomy tube or have a procedure planned, do not stop anything on your own and discuss any changes with your practice. Training the basic functions can be combined with ENT treatment.
Training
Practising pressure equalisation: training the swallowing sequence
If you follow this logic, recurring ear pressure can be addressed most deeply where the Eustachian tube is opened, in the interplay of swallowing, soft palate and nasal breathing. Anyone who simply swallows more often when there is pressure repeats the very sequence that is not sufficient. A swallowing pattern is a stored sequence, and it changes through precise repetition. That requires consistent training over weeks and months, not individual exercises on the plane.
Das Video lädt erst nach dem Klick. Dann werden Daten an YouTube (Google) übertragen.
Video: Dr. Berndsen explains how the tongue and soft palate open the Eustachian tube during swallowing and why the swallow needs to be strong and coordinated enough to do this. The channel title from 2021 is deliberately pointed. What it means is: if equalising by swallowing does not work, you practise the movements that matter in swallowing, regularly and over a longer period.
In FaceFormer training, the FaceFormer sits in the oral vestibule, behind the lips and in front of the teeth. The tip of your tongue rests on the small ridge behind your upper front teeth, you breathe through your nose, and your head is balanced upright.
In the basic exercise, you press the lip wedge together with your lips, bite down briefly on your back teeth and swallow once. The negative pressure draws the tongue to the palate, and the swallow takes place with tooth contact and a closed mouth.
For ventilation of the middle ear, there is also the AirFlip, module 11. You hold the lip wedge firmly, close your nose and create short alternations of negative pressure and counter-pressure in the throat. These engage the opening mechanism of the Eustachian tube.
The AirFlip is added to the basic exercise, ideally in consultation with a practice. Pause it if you have a cold or earache.
- From day 1
Basic exercise
A few minutes three times a day with the FaceFormer ZERO; you increase the repetitions week by week.
- From around week 3
Pull exercise and night
The pull exercise is added. At night you wear the FaceFormer ZERO as soon as you have mastered the basic exercise.
- After a few weeks
Switching to the ONE
During the day, you train with the FaceFormer ONE. It is the same size and shape as the ZERO, just made of firmer material.
- Once you have mastered the basic exercise
Add the AirFlip
As an addition for ventilation of the middle ear, three times a day in short cycles.
- Over months
The pattern runs by itself
The exercise manual allows six to twelve months until the new sequences run without thinking.
The free FaceFormer app guides you through the basic exercises, and you can find all modules on the exercise pages. The AirFlip is only available on its module page, not in the app. There is a separate exercise plan for children; find out more under FaceFormer for children.
Questions
Frequently asked
What helps quickly with pressure in the ears?
Swallowing, drinking, chewing or yawning, because this opens the Eustachian tube. If that is not enough, the gentle Valsalva manoeuvre often helps, that is, breathing out gently against your pinched nose, never with force. If you have pain, fever or suddenly worse hearing, have your ear examined.
Why won’t my ear pop, even though I don’t have a cold?
Without swollen mucous membranes, the explanation often lies in the mechanism itself. The Eustachian tube is not opened wide enough or long enough during swallowing. In our view, a weak or poorly coordinated swallowing sequence usually plays a role here, often together with mouth breathing and a tongue that does not rest against the palate. This sequence can be trained.
What is Eustachian tube dysfunction?
A disorder of the Eustachian tube in which pressure equalisation between the middle ear and the nasopharynx does not work properly. The tube opens too little, fails only during pressure changes or stays open. Typical signs are a feeling of pressure and fullness, clicking, muffled hearing and your own voice sounding loud. Tubal ventilation disorder means the same thing.
What is a patulous Eustachian tube and how does it show itself?
With a patulous tube, the Eustachian tube no longer closes completely after swallowing. Autophony is typical: your own voice and your own breathing sound conspicuously loud in the affected ear, and it often improves when lying down. If symptoms persist, an ENT practice can inject filler material around the passage. In our view, closing the tube is also part of the swallowing sequence that you practise in training the basic functions.
What helps with ear pressure when diving?
Equalise early and at short intervals, descend slowly and ascend a little if you feel pressure. You should not dive with a blocked nose. Techniques such as Valsalva, Toynbee or Frenzel are best learned during dive training.
Can pressure equalisation be trained?
In our view, yes, because the Eustachian tube is opened by muscles that are part of the swallowing sequence. In FaceFormer training you practise breathing, swallowing and head balance in one sequence, and for ventilating the middle ear the AirFlip from module 11 is added. How quickly something changes varies from person to person.
Can I train with grommets or after a middle ear infection?
The basic exercise is a training of lips, tongue, swallowing and breathing and not a pressure exercise. The AirFlip, on the other hand, works with pressure changes. If you have grommets, after procedures on the eardrum or with acute symptoms, discuss it with your ENT practice beforehand.
More articles from the knowledge section
Experiences on this topic
Where to go next
Sources
- Alper CM, Swarts JD, Singla A, Banks J, Doyle WJ (2012). Relationship between the electromyographic activity of the paratubal muscles and eustachian tube opening assessed by sonotubometry and videoendoscopy. Archives of Otolaryngology Head and Neck Surgery 138(8):741-746. PMID 22801708. Source
- McDonald MH, Hoffman MR, Gentry LR, Jiang JJ (2012). New insights into mechanism of Eustachian tube ventilation based on cine computed tomography images. European Archives of Oto-Rhino-Laryngology 269(8):1901-1907. PMID 22120826. Source
- Ghadiali SN, Swarts JD, Doyle WJ (2003). Effect of tensor veli palatini muscle paralysis on eustachian tube mechanics. Annals of Otology, Rhinology and Laryngology 112(8):704-711. PMID 12940669. Source
- Schilder AG, Bhutta MF, Butler CC, Holy C, Levine LH, Kvaerner KJ, Norman G, Pennings RJ, Poe D, Silvola JT, Sudhoff H, Lund VJ (2015). Eustachian tube dysfunction: consensus statement on definition, types, clinical presentation and diagnosis. Clinical Otolaryngology 40(5):407-411. PMID 26347263. Source
- Anand V, Poe D, Dean M et al. (2019). Balloon Dilation of the Eustachian Tube: 12-Month Follow-up of the Randomized Controlled Trial Treatment Group. Otolaryngology Head and Neck Surgery 160(4):687-694. PMID 30620688. Source
- Picciotti PM, Della Marca G, D’Alatri L, Lucidi D, Rigante M, Scarano E (2017). Tensor veli palatini electromyography for monitoring Eustachian tube rehabilitation in otitis media. Journal of Laryngology and Otology 131(5):411-416. PMID 28294083. Source
- Stangerup SE, Klokker M, Vesterhauge S, Jayaraj S, Rea P, Harcourt J (2004). Point prevalence of barotitis and its prevention and treatment with nasal balloon inflation: a prospective, controlled study. Otology and Neurotology 25(2):89-94. PMID 15021764. Source
- Gluth MB, McDonald DR, Weaver AL, Bauch CD, Beatty CW, Orvidas LJ (2011). Management of eustachian tube dysfunction with nasal steroid spray: a prospective, randomized, placebo-controlled trial. Archives of Otolaryngology Head and Neck Surgery 137(5):449-455. PMID 21576556. Source
- Poe D, Anand V, Dean M et al. (2018). Balloon dilation of the eustachian tube for dilatory dysfunction: A randomized controlled trial. Laryngoscope 128(5):1200-1206. PMID 28940574. Source
Get started
Ready for the training?
The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
