Overview
The eustachian tube (pharyngotympanic tube) connects the middle ear cavity with the nasopharynx. It aerates the middle ear system and clears mucus from the middle ear into the nasopharynx. Opening and closing functions of the eustachian tube are physiologically and pathologically important. Normal opening of the eustachian tube equalizes atmospheric pressure in the middle ear; closing of the eustachian tube protects the middle ear from unwanted pressure fluctuations and loud sounds. Mucociliary clearance drains mucus away from the middle ear into the nasopharynx, thus preventing infection from ascending to the middle ear.
Abnormal or impaired eustachian tube functions (ie, impaired opening or closing, defective mucociliary clearance) may cause pathological changes in the middle ear. This in turn can lead to hearing loss and other complications of otitis media. These pathological changes include recurrent acute otitis media and otitis media with effusion. Chronic retraction of the tympanic membrane may also lead to middle ear atelectasis and subsequent adhesive otitis media. A retraction pocket of the tympanic membrane secondary to chronic eustachian tube dysfunction may eventually evolve into cholesteatoma and potentially serious complications.
The cartilage and muscles of the eustachian tube develop from the surrounding mesoderm during the ensuing weeks. The levator veli palatini and the tensor veli palatini muscles seem to develop earlier than the cartilage and glandular tissue. The cartilaginous portion of the tube elongates during the middle and third trimester until it reaches approximately 13 mm in length at term. Other morphologic changes also occur during that time with further development of the glandular structures and folding of the epithelium. As the skull base grows down, the angle of the eustachian tube changes gradually from horizontal to oblique. This process continues after birth and well into adulthood.
The muscles of the eustachian tube system help open and close the tube, thus allowing it to perform its function. These muscles are the (1) tensor veli palatini, (2) levator veli palatini, (3) salpingopharyngeus, and (4) tensor tympani. The tensor veli palatini muscle originates from the bony wall of the scaphoid fossa and from the whole length of the short cartilaginous flange that forms the upper portion of the front wall of the cartilaginous tube. The muscle runs downward, converging into a short tendon that turns medially around the pterygoid hamulus. It then fans out within the soft palate and mingles with the fibers from the opposite side in the midline raphe. The tensor veli palatini separates the eustachian tube from the otic ganglion, the mandibular nerve and its branches, the chorda tympani, and the middle meningeal artery. The salpingopharyngeus is a delicate muscle that is attached to the pharyngeal end of the eustachian tube and blends with the palatopharyngeus muscle downward. The levator veli palatini has 2 origins: the lower surface of the cartilaginous tube and the lower surface of the petrous bone. At first, the levator is inferior to the tube; it then crosses to the medial side and merges into the soft palate.
Blood vessels
The arterial supply of the eustachian tube is derived from the ascending pharyngeal and middle meningeal arteries. The venous drainage is carried to the pharyngeal and pterygoid plexus of veins. The lymphatics drain into the retropharyngeal lymph nodes.
Nerves
The pharyngeal branch of the sphenopalatine ganglion derived from the maxillary nerve (V2) supplies the ostium. The nervus spinosus derived from the mandibular nerve (V3) supplies the cartilaginous part, and the tympanic plexus derived from the glossopharyngeal nerve supplies the bony portion of the eustachian tube.
Protection
The eustachian tube is closed at rest. Sudden loud sounds are thus dampened before reaching the middle ear through the nasopharynx.
Patulous eustachian tube is an abnormal but not uncommon condition in which the tube is abnormally patent. The patient often complains about echoing when he or she talks (autophony), as well as ear fullness. Rapid weight loss may lead to decreased size of the Ostmann fat pad, which is thought to contribute to this condition. The eustachian tube drains normal secretions of the middle ear by the mucociliary transport system and by repeated active tubal opening and closing, which allows secretions to drain into the nasopharynx. A derangement in the closed middle ear system, such as tympanic membrane perforation or after mastoid surgery, sometimes results in reflux of nasopharyngeal secretions into the tube and can cause otorrhea. Similarly, forceful nose blowing creates high nasopharyngeal pressure and may force nasopharyngeal secretions into the middle ear. Laryngopharyngeal reflux (LPR) was recently implicated in the etiology of otitis media with effusion (OME). Al-Saab et al (2008) demonstrated the presence of pepsinogen in 84% of middle ear effusions (MEEs) at concentrations 1.86 to 12.5 times higher than that of serum. [2] Conversely, a relative negative middle ear pressure, as occurs in aircraft or scuba diving descent, may lock the eustachian tube. This leads to stagnation of secretions, and effusion collects in the middle ear as otitic barotrauma evolves. Inflation of the eustachian tube by the Valsalva maneuver or by politzerization can break the negative pressure in the middle ear and clears the effusion. The middle ear is also protected by the local immunologic defense of the respiratory epithelium of the eustachian tube, as well as its mucociliary defense (clearance). A pulmonary immunoreactive surfactant protein has been isolated from the middle ears of animals and humans. It is thought to have the same protective function in the middle ear.
Clearance or drainage
Drainage of secretions and occasional foreign material from the middle ear is achieved by the mucociliary system of the eustachian tube and the middle-ear mucosa and muscular clearance of the eustachian tube, as well as surface tension within the tube lumen. The flask model proposed by Bluestone and his colleagues helps to better explain the role of the anatomic configuration of the eustachian tube in the protection and drainage of the middle ear. [3] In this model, the eustachian tube and middle ear system is likened to a flask with a long narrow neck. The mouth of the flask represents the nasopharyngeal end, the narrow neck represents the isthmus, and the middle ear and mastoid gas cell system represents the body of the flask. Fluid flow through the neck depends on the pressure at either end, the radius and length of the neck, and the viscosity of the liquid. When a small amount of liquid is instilled into the mouth of the flask, the liquid flow stops somewhere in the narrow neck due to the narrow diameter of the neck and the relative positive air pressure in the chamber of the flask. However, this does not take into consideration the dynamic role of the tensor veli palatini muscle in actively opening the nasopharyngeal orifice of the eustachian tube.
Pneumatic otoscopy
Permeatal examination of the tympanic membrane assesses the patency and perhaps the function of the tube. A normal appearing tympanic membrane usually indicates a normally functioning eustachian tube, although this does not preclude the possibility of a patulous tube. Otoscopic evidence of tympanic membrane retraction or fluid in the middle ear indicates eustachian tube dysfunction but cannot be used to differentiate between functional impairment and mechanical obstruction of the tube. Normal tympanic membrane mobility on pneumatic otoscopy (siegalization) indicates good patency of the eustachian tube.
Nasopharyngoscopy
Nasopharyngoscopy by posterior rhinoscopic mirror examination or more accurately by fiberoptic endoscope helps visualization of any mass (eg, adenoids, soft tissue growth in the nasopharynx) that may be obstructing the pharyngeal end of the eustachian tube. Attempts have been made to assess eustachian tube function with the help of nasopharyngoscopy. Yagi and colleagues evaluated the patency of the eustachian tube using a fiberoptic endoscope and a photoelectric device (phototubometry).[4]Using videoendoscopy of the ear, Poe and colleagues assessed tubal function in adults and observed various disease processes such as inflammation of the tube and patulous dysfunction. This method has been gaining popularity in the assessment of patients suspected to have eustachian tube dysfunction.
Tympanometry
Measuring middle ear pressure with an electroacoustic impedance meter helps to assess eustachian tube function. High negative middle ear pressure (>-100 daPa) indicates eustachian tube dysfunction. High negative pressures may be seen in individuals with normal hearing; however, a nearly normal middle ear pressure may be associated with hearing loss. In the presence of tympanic membrane perforation, the air passes into the middle ear resulting in a large canal volume on tympanometry.
Imaging
With the recent development of advanced imaging technology, studies have been used to better define the anatomy and pathology of the eustachian tube. MRI has been used to visualize the eustachian tube and to assess its anatomy and pathology in patients with nasopharyngeal carcinoma. Moreover, MRI has been used in experimental animal models to evaluate middle ear inflammation. It has more accurately been also used to assess the effect of experimentally induced functional obstruction of the eustachian tube by botulinum toxin A on the middle ear. CT has also been used to assess the tube in normal individuals, in patients with patulous eustachian tube, and in otitis media. It has also been used in studying eustachian tube clearance. Fluoroscopy with contrast provides dynamic evaluation of mucociliary clearance.
observed by otoscopy as a bulging tympanic membrane. When the tympanic membrane is perforated, the sound of the air escaping from the middle ear can be heard with a stethoscope or with the Toynbee tube. The Politzer test is similar to the Valsalva test, but instead of positive nasopharyngeal pressure being generated by the patient, the nasopharynx is passively inflated. This is achieved by compressing one nostril into which the end of a rubber tube attached to an air bag has been inserted while compressing the opposite nostril by finger pressure. The subject is asked to swallow or to elevate the soft palate by repeating the letter "k." Both the Valsalva and Politzer tests are outdated and rarely used clinically for assessment of eustachian tube function. These maneuvers may be more beneficial in the management of some patients. Nevertheless, the efficacy of these procedures for treatment of middle ear effusion is controversial, and they are not without potential risks. The author has encountered a case of meningitis following Politzerization for the treatment of otitis media with effusion in an otherwise healthy elderly man.
Toynbee test
This test is considered more reliable than the previous 2 in the assessment of eustachian tube function. On closed nose swallowing, negative middle ear pressure develops in healthy persons. In an intact tympanic membrane, pneumatic otoscopy or tympanography can be used to measure changes in middle ear compliance. In a perforated tympanic membrane, the manometer of the impedance bridge can be used to measure middle ear pressure changes.