Conservative management of functional middle ear disorders: a systematic review with narrative synthesis and conceptual clinical framework.

OBJECTIVE

To systematically evaluate the efficacy and safety of conservative (non-surgical) interventions for functional middle ear disorders (FMEDs), including tinnitus, auditory tube dysfunction, middle ear myoclonus, and related functional auditory syndromes.

DATA SOURCES: PubMed/MEDLINE, Scopus, Embase, and Web of Science were searched through June 21, 2025, using PRISMA 2020 guidelines.

REVIEW

METHODS

Eligible studies included adults or children diagnosed with FMEDs managed with pharmacologic, behavioral, or minimally invasive conservative therapies. Data on study design, interventions, outcomes, and adverse events were extracted. Methodological quality was assessed using the Cochrane RoB-2 tool and the Methodological Index for Non-Randomized Studies (MINORS).

RESULTS

Twenty-four studies (n = 986 patients) were included: 3 systematic reviews, 12 prospective, 8 retrospective, and 1 cross-sectional. Tinnitus (n = 11 studies) auditory tube dysfunction (n = 11) were most common, followed by myoclonus (n = 2). Intratympanic steroids and auditory stimulation showed partial or complete tinnitus relief. Nasal saline instillation, paper patching, and topical agents achieved significant improvement in patulous auditory tube. Pharmacologic management of myoclonus (e.g., carbamazepine, clonazepam, baclofen) also yielded symptomatic benefit. Most interventions were well tolerated with minor, transient adverse effects.

CONCLUSIONS

Conservative management offers potential symptomatic benefit with generally favorable safety profiles for FMEDs, particularly in pediatric and mild-to-moderate adult cases. FMEDs often present concomitantly and might be pathophysiologically interconnected. Thus, therapies targeting one disorder may confer improvement in others. Structured, stepwise treatment, beginning with education, counseling, and simple topical agents, and progressing to targeted pharmacologic or minimally invasive measures, may be used prior to surgical intervention, although comparative effectiveness per se was not assessed.