Anatomy of the Eustachian

Tu b e
Rudolf Leuwer,

MD

KEYWORDS 
Eustachian tube cartilage  Ru¨dinger safety canal  Auxiliary gap  Ostmann fat pad 
Tubal supensory ligaments  Tensor veli palatini muscle  Medial pterygoid muscle 
Salpingopharyngeal muscle
KEY POINTS 
The opening of the eustachian tube, provided by the contraction of the tensor veli palatini
muscle, is limited to Ru¨dinger safety canal. 
The contraction of the tensor veli palatini muscle is almost completely isometric; it depends on hypomochlia, which modulate the muscular force vectors. 
Due to their fibromuscular interconnections on both sides of the Weber-Liel fascia, tensor
veli palatini muscle and medial pterygoid muscle form a functional unit.

The eustachian tube consists of 2 different portions: an osseous posterolateral and a
fibrocartilaginous anteromedial portion. The osseous portion is grossly formed by the
petrous part of the temporal bone, the flexible fibrocartilaginous portion by the tubal
cartilage, and its surrounding tissue. The active eustachian tube function is located
in the fibrocartilaginous portion. This portion is connected to the skull base by suspensory ligaments.
SPATIAL ORIENTATION

The longitudinal axis of the tube forms an angle with the mediosagittal plane as well as
with the horizontal plane.1 The angle between the longitudinal axis of the cartilaginous
part of the eustachian tube and the mediosagittal plane in adults is about 45 on
average. In infants, it is only about 10 .2 The average angle between the Frankfurt horizontal plane (orbitomeatal plane) and the tubal longitudinal axis in adults is about 35 .1
LENGTH

The total length of the eustachian tube ranges between 31 and 44 cm3,4 in adults. Its
length in newborns measures only about one-half of the adult’s.5 The length of the

Declaration of Conflicts: There are no commercial or financial conflicts of interest. There are no
funding sources for the underlying scientific work.
ENT-department, HELIOS Hospital Krefeld, Lutherplatz 40, Krefeld 47805, Germany
E-mail address: rudolf.leuwer@helios-kliniken.de
Otolaryngol Clin N Am 49 (2016) 1097–1106
http://dx.doi.org/10.1016/j.otc.2016.05.002
0030-6665/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.

oto.theclinics.com

which is the narrowest point in the tubal lumen. Ru¨dinger7 observed a fibrocartilaginous mass connecting the bone and the hyaline cartilage.1 mm. Pahnke even observed cartilage reaching the tympanic orifice of the tube.6 The tubal cartilage ends posterolaterally to the isthmus. becomes thinner toward both orifices. its shape resembles a shepherd’s crook. this is the reason why there is a difference between the length of the cartilage.9 consisting of a dome with a short lateral lamina and a long medial lamina. The size and shape of the lateral lamina are much more constant than that of the medial lamina.” This space is situated between the lateral and the medial lamina of the cartilage and is filled with mucus or air. which he found in an anatomic specimen.1 COMPARTMENTS On a frontal 2-dimensional view. the length of the fibrocartilaginous part is about twothirds of its total length. Oshima and colleagues8 could demonstrate a wide individual variety especially of the medial lamina.9 the elasticity of the tubal cartilage is comparable to that of the pinna and the nasal cartilage. There is no sharp borderline between the osseous and the fibrocartilaginous portion for the cartilage extends into the roof of the osseous part. This elasticity. and it is found in about 85% of the adults.1098 Leuwer osseous part is about one-third. Ru¨dinger distinguishes between 2 zones of the tubal lumen:  A cranial half-cylindrical space. which is about 26 mm. The lateral lamina has a mean height of 1. Lumen Fig. the lower end of the medial lamina formed a hook around the lower portion of the eustachian tube lumen. and the fibrocartilaginous portion of the eustachian tube. Its diameter is about 0.8 Both structures form the cartilaginous and the muscular wall of the eustachian tube. Most probably this space is always open.4 the distance between the pharyngeal orifice and the isthmus measures 24 to 28 mm. This maximum height of both laminae can be found at about 6. however. In about 25% of his specimen. which is higher in adults than in infants.11 is crucial for the reset forces after the contraction of tensor veli palatini muscle.6 mm behind the pharyngeal orifice.7 Cartilage With respect to the eustachian tube function. there is a gap that is mainly surrounded by the muscular or membranous wall of the eustachian tube and partly by the medial lamina of the .10 According to Bluestone. By means of MRI studies of the eustachian tube.5 mm. and the medial lamina has a mean maximum height of 5. because it forms the luminal frame of the tube. the lateral lamina. 1 depicts the main structures contributing to the functional eustachian tube anatomy. The fibrocartilaginous portion of the eustachian tube is almost completely surrounded by the tubal cartilage and by the tensor veli palatini muscle. In comparison to the medial lamina. The thickness of the medial and lateral lamina in the middle portion is approximately equal.12  Under the safety canal.8 mm at its largest extension.7 It shows his cross-sectional view of the tubal lumen. which is about 31. According to Zo¨llner.10 The safety canal probably warrants pressure equalization and ventilation function of the eustachian tube. the cartilage is a very important structure.2 mm. Fig. Pahnke10 also described this variety.8 Looking at the cross-section of the eustachian tube cartilage. They concluded that this could have potential implications for eustachian tube surgery. which today is called the “Ru¨dinger safety canal. 2 is a copy of an original illustration by Ru¨dinger.

tensor veli palatini muscle.9 1099 . levator veli palatini muscle.Anatomy of the Eustachian Tube Fig. ofm. The height of the lumen widely differs: in the petrous portion of the temporal bone.5 mm. ofl. bursa. Frontal view of the eustachian tube. lateral lamina. lateral tubal suspensory ligament. it is about 3. tubal cartilage. tensor veli palatini muscle. 1.” The figure shows mucosal folds in the lower medial wall of the auxiliary gap. tvpm. tcl. cartilage. b.1. lvp. rsc. medial lamina. medial pterygoid muscle. medial Ostmann fat pad. tubal cartilage.14 These so-called microturbinates seem to contribute to the mucociliary clearance and to the protection function of the eustachian tube. tslm. lateral layer. medial layer. pterygoid hamulus. mpm. tcm. lateral Ostmann fat pad. Ru¨dinger7 called this gap the “auxiliary gap. tsll. ph. 6 to 7 mm proximally to the pharyngeal orifice it is 6 to 10 mm. Ru¨dinger’s safety canal. These inconstant folds were also described by Sando and colleagues13 and by Ozturk and colleagues. medial tubal suspensory ligament. tvpl.

In a 3-dimensional (3D) view. 2. which are divided by a thin layer of fat tissue. on the other hand. Vergleichende Anatomie und Histologie der Ohrtrompete.4 There are 2 fasciae that cover the medial and the lateral surface of the tensor veli palatini muscle. these ligaments resemble a fibrous plate rather than a ligament. which is also called the von Tro¨ltsch fascia. Medially. Ru¨dinger’s illustration of the human eustachian tube (1870). the so-called medial Ostmann fat pad. (Adapted from Ru¨dinger N.4 These ligaments are tangentially connected to the medial and the lateral lamina of the cartilage.15 Lymphatic tissue of the nasopharynx.17 It consists of the medial and the lateral tubal suspensory ligament. there is a fascia that runs from the lateral lamina of the tubal cartilage along the lateral surface of the so-called lateral Ostmann fat pad to the salpingopharyngeal fascia.16 Ligaments and Fasciae Between the tubal cartilage and the skull base there is a system of superior tubal ligaments. . 1870.1100 Leuwer tsll tslm ofm rsc tcl tcm ofl Fig. Laterally. which separates the tensor veli palatine muscle from the medial pterygoid muscle. This lateral suspensory ligament partially connects to the tendinous fibers of the lateral layer of the tensor veli palatini muscle. They arise from the temporal as well as the sphenoid bone. Mu¨nchen (Germany): JJ Lentner’sche Buchhandlung. The most constant structure is the lateral suspensory ligament that is connected to the lateral lamina. there is mucosa-associated lymphatic tissue. there is the Weber-Liel fascia.) Within the cartilaginous portion of the eustachian tube. does not extend into the tube.

the thickness of Ostmann fat pad corresponds to its thickness in adults. consisting of its mucous membrane and the Ostmann fat pad. the muscles need to be depicted separately. According to Ru¨dinger. this fat pad does not correlate to the body weight. This wall mainly consists of the tensor veli palatini muscle and of the levator veli palatini muscle. there is the so-called membranous wall of the eustachian tube. Its motoric innervation belongs to the mandibular nerve. the lateral Ostmann fat pad limits the eustachian tube opening to the Ru¨dinger safety canal. which is located in a skull base niche. Additional to the constant “lateral Ostmann fat pad” between the lateral lamina and the lateral wall of the eustachian tube. the lateral suspensory ligaments. the medial pterygoid muscle. the posterior half of the membranous tubal wall. Ru¨dinger7 estimated the average thickness of the lateral tubal wall. of which the medial Ostmann fat pad between the tubal suspensory ligaments is the most important. Fig. the Ostmann fat pad gradually decreases toward both orifices. there is a third anatomic compartment. 3 shows a methanal-fixated anatomic specimen of the muscles surrounding the eustachian tube. causing a growth in volume. the lateral lamina of the cartilage.4 This closing effect helps to prevent the ascension of fluids and acoustic noise from the nasopharynx toward the middle ear.22 The tensor consists of a 1101 .22 Tensor veli palatini muscle Today most investigators consider the tensor veli palatini muscle the essential eustachian tube muscle. to be 2 mm. Its fibers originate from the sphenoid spine. the fat pad serves as a hypomochlion for the lateral layer of the tensor veli palatini muscle. and the salpingopharyngeal muscle.21 It transfers the pressure of the almost isometric contraction of the muscle to the lower portion of the eustachian tube. and the salpingopharyngeal fascia. Hence.10 It is activated by swallowing and by yawning.20  Second. Muscles Although both the tensor and the levator veli palatini muscles are a part of the membranous wall of the eustachian tube. other fatty tissue is found in characteristic locations. This effect is nondirectional: at the same time the fat pad may prevent the evacuation of the middle ear due to a rapid decrease of nasopharyngeal pressure as postulated by the sniff theory.16.23 The muscle forms an inverse triangle. as well as the Ostmann fat pad constitute a common functional unit.Anatomy of the Eustachian Tube Thus. Membranous Wall Opposite to the tubal cartilage. Ru¨dinger called it “muscular wall.19 This physiologic decrease does not necessarily cause a patulous eustachian tube. There are 2 different roles of the lateral Ostmann fat pad:  First.4 mm. Four muscles around the eustachian tube contribute to its function: the tensor and levator veli palatini muscles. the scaphoid fossa. The position of this maximum is found about 20 mm proximal to the pharyngeal orifice. That is why the term “membranous wall” is more common.18 However.”7 Nevertheless. the static pressure of the fat pad supports the passive closure of the eustachian tube after contraction of the tensor veli palatini muscle. During childhood and adolescence. From this point. which contributes to the muscular function: the lateral Ostmann fat pad. This volume decreases again with advanced age. and the lateral lamina of the tubal cartilage. albeit its respective impact still is a matter of discussion. its height increases during postnatal life. The maximum average thickness of the lateral Ostmann fat pad is 2.

M. its innervation arises from the mandibular nerve. tubal cartilage. 4 shows the force vectors influencing the tensor veli palatini muscle and the tubal cartilage. 3. Muscles contributing to the eustachian tube function. S. and the lateral layer supports drainage and protection. tensor veli palatini muscle. levator veli palatini muscle. Like the tensor veli palatini muscle. increasing the tubal opening . the lateral layer compresses the lower portion of the tube.1102 Leuwer Fig. PH.24 for the 2 following reasons:  Apart from the bursa at the pterygoid hamulus. 4. lateral layer originating from the skull base and a medial layer arising from the lateral lamina of the tubal cartilage.22 the medial pterygoid muscle is an elastic hypomochlion of the tensor. Fig. There are 3 hypomochlia influencing the tensor veli palatini muscle:  The pterygoid hamulus25  The lateral Ostmann fat pad21 (see Fig. which influence its force vectors. pterygoid hamulus. skull base. salpingopharyngeal muscle. Both layers can be partly but not entirely separated by fatty tissue. TC. the membranous wall. meaning that the muscular function depends on hypomochlia. The medial layer of the tensor is situated between the lateral lamina of the tubal cartilage and the medial lamina of the pterygoid process. Its contraction causes a posteromedial movement of the tensor toward the cartilage. medial pterygoid muscle. which closes the mouth and helps in protruding the mandibula. the medial layer supports ventilation. carotid artery. the contraction of both layers is completely isometric.  Both layers have dissimilar effects on eustachian tube function: whereas contraction of the medial layer opens the eustachian tube by lateralization of the lateral lamina of the cartilage (see Fig. T.4 Between the tendon and the hamulus there is a small bursa. According to Leuwer and colleagues. SB. Thus. CA.10 The lateral layer pulls from the skull base to a small tendon going around the pterygoid hamulus and spreading into the aponeurosis of the soft palate. L. The function of the tensor veli palatini muscle is complex22. 4: force vector 2)  The medial pterygoid muscle22 Medial pterygoid muscle The medial pterygoid muscle is a chewing muscle. force vector 3).

Wenzel26 found fibromuscular interconnections. As described earlier. between the tensor veli palatini muscle and the medial pterygoid muscle there is the Weber-Liel fascia. On both sides of this fascia. the opening of the eustachian tube is facilitated by the relaxation of the medial pterygoid due to an anterolateral movement of the tensor while opening the mouth (see Fig.Anatomy of the Eustachian Tube Fig. Thus. Inversely. Pseudo-3D illustration of the eustachian tube showing the force vectors influencing the eustachian tube function. force vector 1). (1) Anterolateral rotation of the medial pterygoid muscle during relaxation. (4) Mediocranial rotation of the medial lamina of the tubal cartilage. 4. decreasing the tubal opening pressure. (3) Laterocaudal traction of the lateral lamina of the tubal cartilage and tubal suspensory ligaments. 4. (2) Pressure of the lateral layer of the tensor veli palatini muscle on Ostmann fat pad and auxiliary gap. both 1103 . pressure.

thus assisting to a pumping action of the eustachian tube toward the pharyngeal orifice. adapted for sustained contraction. its action is antagonistic to the tensor and levator veli palatini muscles. according to Bylander28 and Magnuson. The muscle is a red muscle of slow contraction speed. actively regulated by the medial pterygoid muscle. may change the muscular compliance of the eustachian tube.29 the eustachian tube opening can be facilitated by opening the mouth alone. the function of the tensor muscle can be understood as a passive diaphragm. Morphological or functional alterations of the medial pterygoid muscle. 4 shows that there is a rolling force vector from the medial lamina of the eustachian tube cartilage (see Fig. 1991. the salpingopharyngeal muscle gives the impression of an anchor chain controlling the position of the medial lamina and keeping the pharyngeal orifice of the eustachian tube in position. the muscle as well as the elastic fibers assist in the closure of the anterior tube. It relaxes during deglutition and is active at rest with the mouth shut. palatopharyngeal muscle. for example. This force vector is caused by the contraction of the medial layer of the tensor veli palatini muscle. and salpingopharyngeal muscle). such as the landing of an airplane (“Eppendorf manoeuver”27). there are bundles of muscle fibers as well as groups of elastic fibers. in craniomandibular disorders. posteriorly to the pterygoid hamulus. Its motoric innervation is provided by each branch of the glossopharyngeal as well as of the vagal nerve.33 which are the elevators of the pharynx. crossing the longitudinal axis of the eustachian tube at the so-called tubal incisure. Pahnke J.1 The levator originates at the lower surface of the petrous part of the temporal bone and spreads out into the soft palate. Hence. force vector 4). On the other hand.34 It originates from the inferior edge of the medial lamina of the eustachian tube cartilage and inserts into the longitudinal fibers of the pharynx. Beitra¨ge zur Klinischen Anatomie der Tuba Auditiva. Simultaneous relaxation of the medial pterygoid muscle as well as contraction of the tensor veli palatini muscle by yawning can be used as a maneuver for the physiologic active tubal opening during external pressure changes. According to Finkelstein and colleagues32 and based on clinical data. Levator veli palatini muscle The levator veli palatini muscle is located inferolateral to the inferior margin of the medial lamina of the eustachian tube cartilage. REFERENCES 1. 4.30 Although it is close to the medial lamina. Considering this force vector. Also.16 there is no direct attachment to the cartilage. These fibromuscular interconnections can give an explanation for this observation. Fig.35 Within the muscle.1104 Leuwer muscles at the medial third of the eustachian tube do not only passively shift against each other but represent a mechanical functional unit. .31 Bryant23 described a fascial attachment to the inferior edge of the medial lamina preventing the muscle from slipping off the cartilage. Salpingopharyngeal muscle The salpingopharyngeal muscle belongs to the 3 internal longitudinal pharyngeal muscles (stylopharyngeal muscle. Wu¨rzburg (Germany): Medizinische Habilitationsschrift. Thus. The levator causes a superior-medial rotation of the anterior tubal cartilage. These elastic fibers are also attached to the floor of the eustachian tube. the main function of the levator muscle is restricted to the competence of the soft palate.

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