ANATOMY AND PHYSIOLOGY OF EUSTACHIAN TUBE

EUSTACHIAN TUBE
The first description of Eustachian tube was attributed to Almacean of Sparta in 400bc.It was
his belief that the Eustachian tube allows the goats to breathe through their ears as well as
their noses.
In 1562, Barolomeus Eustachian published the first detailed description in his thesis ‘Epistola
de Auditas Organis’ accurately describing their structure, course and relations of ET.
Other names: Auditory tube or Pharyngotympanic tube
ANATOMY OF THE EUSTACHIAN TUBE
Eustachian tube provides a communication between the nasopharynx and the middle ear.
Because of the communication air passes into the tympanic cavity. As a result air pressure on
both sides of the tympanic membrane is same. This is important for proper vibration of the
tympanic membrane.
The middle ear and the ET are located deep in the temporal bone. It is approximately 35-
38mm long and is directed downward, forward and medially and form an angle of 45 degree
with the horizontal where as in infants it is only 10.The tube exit into the nasopharynx via a
prominence called the torus tubarius.
THE ET HAS THREE PORTIONS:
1. The osseous/bony part
2. The cartilaginous part
3. The junction (isthmus)
1. THE OSSEUS PORTION
The osseous portion is also called as protympanum or bony tube. It’s an open cavity forming
direct anterior continuation of the middle ear cavity (mesotympanum). It is approximately 10-
12mm long. It lies under the canal for the tensor tympani. The mucosa membrane in the
osseous portion of the tube is firmly adherent to the bony walls and consists of columnar
ciliated epithelium. The tympanic opening of the auditory tube is about 3 mm above the floor
of the tympanic cavity. The bony portion is widest at its tympanic end (3mm). And narrows
gradually to the velum. The lumen is normally open and varies from 3-6mm in diameter.
The osseous portion is divided into semi canals by a thin lamina of bone with tensor tympani
muscle lying above it. An extremely thin bony plate covering the carotid artery constitutes
the medial wall.
2. THE CARTILAGINOUS PORTION
The cartilaginous portion varies in length from about 18 to 24 mm and lies at an angle of
45degree whereas in the child the tube is shorter and lies at an angle of approximately 10
degree. It begins as a rounded shelf located above the lumen of the tube and gradually widens
to form an incomplete ring whose upper edge is curled upon itself laterally so as to present
the appearance of a hook when seen in transverse section. It is enclosed by the cartilage and

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the soft tissue. It inclines downwards slightly more than the bony part. (The increase in angle
is formed when the hard palate drops away from the skull during the childhood)
The tube is lined with pseudo-stratified, columnar epithelium with ciliated and goblet cells. A
thin film of mucous is propelled by the ciliary action from the middle ear through the ET to
the nasopharynx, protecting the middle ear from the ascending infection. The cartilaginous
tube has a crook shape which is completed laterally by the elastic fibrous cartilage. This
serves as the site for attachment of the fibres of Tensor veli palitini. There is no open lumen
within the cartilaginous tube but like a valve it is felt to protect the middle ear from strong
sounds and pressure variations evoked by phonation and respiration. The cartilage protrudes
somewhat into the nasopharynx at the torus tubarius. The tube takes a gentle slow curving
inverted s pathway to the nasopharynx. The tubal cartilage fits into a sulcus at the skull base
called the sphenoid sulcus (sulcus tuberous)
3. THE ISTHMUS
The junction of the osseous and cartilaginous portions is called isthmus.

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The elastin hinge: The cartilage, at the junction of medial, and lateral lamina at the roof, is
rich in elastin fibres which form a hinge. By its recoil it helps to keep the tube closed when
no longer acted upon by dilator tubae muscle.

Ostmann’s pad of fat: It is a mass of fatty tissues related laterally to the membranous part of
the cartilaginous tube and is thought to be an important contributing factor in closing the
tube. It is also quite likely to contribute in the protection of the eustachian tube and the
middle ear from retrograde flow of nasopharyngeal secretions.

MUSCLES OF EUSTACHIAN TUBE

1. TENSOR VELI PALITINI
Origin: from an attachment on the cranial base at the scaphoid fossa
Course: Runs lateral to the tube and inferiorly rounds the Hamulus before its insertion to the
anterior velum and onto the posterior margin of hard palate.
It’s divided into two bundles, the lateral TVP and the medial dilator tube (DT) because of
which it is known as dilator tube. This muscle is activated by swallowing and yawning and
sometimes by mandibular movement.
2. LEVATOR VELI PALITINI
Origin: from the medial surface of the petrous part of the temporal bone
Course: runs inferior and parallel to the cartilaginous tube from a superior skull base
attachment to an inferior attaches into the nasal surface of the velum or soft palate.
Innervated by the pharyngeal branch of the vagus nerve (cranial nerve 10)
The primary function is to elevate the soft palate in speech and deglutition and its function in
ET opening is not clear. It is believed that LVP has a minor role in the dilation of the
nasopharyngeal orifice of ET.
3. TENSOR TYMPANI
It originates from the fibres common to the tensor veli palatine. It is attached to the neck.
Origin: (1) from the cartilaginous portion of the tube,
(2) from the adjoining part of the sphenoid,
(3) from its own bony canal.
The muscle is contained in a bony canal situated above the osseous part of the tube.
The innervation to the muscle arises from the nerve to tensor tympani, which arises from
the mandibular (V3) division of the trigeminal nerve (cranial nerve 5).

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Course: Its head passes posteriorly, forming a tendon which turns at a right angle at the
process cochleariformis, and after crossing the tympanic cavity, is inserted in the neck of the
malleus.
4. SALPHINGOPHARYNGEOUS
Origin: Superior-lateral border of the tubal cartilage.
Course: It descends downward and forward to blend with the palatopharyngeous muscle
downward. This muscle is involved in opening and closing of the Eustachian tube.
It is innervated by the vagus nerve via the pharyngeal plexus.

BLOOD SUPPLY:
 Ascending pharyngeal artery(from external carotid)
 Middle meningeal artery(frim maxillary artery)
 Artery of pterygoid canal(from maxillary artery)

NERVE SUPPLY
 Tympanic branch of CN IX supplies sensory as well as parasympathetic secretory
motor fibers.
 Tenser velipalatini-mandibular branch of trigeminal nerve
 Levatorpalatine and salphingopharyngeous supply through pharyngeal plexus.

What happens to Eustachian tube while swallowing?

 The tensor veli palatine tenses the soft palate and by doing so, assists the levator veli
palatini in elevating the palate.

 To occlude and prevent entry of food into the naso pharynx during swallowing.

 Since it is also attached to the lateral cartilaginous lamina of the auditory tube

It assists in its opening during swallowing or yawning to allow air pressure to equalize
between the tympanic cavity and outside air.

FEATURES INFANTS ADULT

1.DIAMETER OF THE 4-5 mm 8-9mm

ORIFICE

2.LENGTH 13 -18 mm AT BIRTH 36mm ( 31-38mm)

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3.DIRECTION AT BIRTH 10 DEGREE WITH FORMS AN ANGLE OF 45

THE HORIZONTAL.
IT’S MORE HORIZONTAL
THAN ADULTS.

4.TUBAL CARTILAGE FLACCID COMPARITIVELY RIGID.

5.BONY VS BONY PART IS LONGER ANTERIOR TWO-THIRD IS

CARTILAGINOUS PART AND RELATIVELY WIDER CARTILAGINOUS AND
POSTERIOR ONE THIRD IS
BONY

6. DENSITY OF ELASTIN AT LESS DENSE; TUBE DOES MORE DENSE; HELPS TO

THE HINGE NOT EFFICIENTLY CLOSE KEEP THE TUBE CLOSED
BY RECOIL BY RECOIL OF CARTILAGE

7. OSTMANN’S PAD OF FAT LESS IN VOLUME LARGE AND HELPS TO

KEEP THE TUBE CLOSED

DIFFERENCES BETWEEN THE INFANT AND ADULT EUSTACHIAN TUBE

PHYSIOLOGY OF EUSTACHIAN TUBE

Physiologically, eustachian tube performs three main functions:
1. Ventilation and thus regulation of middle ear pressure.
2. Protection against
(i) nasopharyngeal sound pressure and
(ii) reflux of nasopharyngeal secretions.
3. Clearance of middle ear secretions.

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Ventilation and regulation of middle ear pressure. For normal hearing, it is essential that
pressure on two sides of the tympanic membrane should be equal. Negative or positive
pressure in the middle ear affects hearing. Thus, eustachian tube should open periodically to
equilibrate the air pressure in the middle ear with the ambient pressure.
Normally, the eustachian tube remains closed and opens intermittently during swallowing,
yawning and sneezing. Posture also affects the function; tubal opening is less efficient in
recumbent position and during sleep due to venous engorgement. Tubal function is also poor
in infants and young children and thus responsible for more ear problems in that age group. It
usually normalizes by the age of 7–10 years.
Protective functions. Abnormally, high sound pressures from the nasopharynx can be
transmitted to the middle ear if the tube is open thus interfering with normal hearing.
Normally, the eustachian tube remains closed and protects the middle ear against these
sounds. A normal eustachian tube also protects the middle ear from reflux of nasopharyngeal
secretions into the middle ear. This reflux occurs more readily if the tube is wide in diameter
(patulous tube), short in length (as in babies) or the tympanic membrane is perforated (cause
for persistence of middle ear infections in cases of tympanic membrane perforations).
High pressures in the nasopharynx can also force nasopharyngeal secretions into the middle
ear, e.g. forceful nose blowing, closed-nose swallowing as in the presence of adenoids or
bilateral nasal obstruction.
Clearance of middle ear secretions. Mucous membrane of the eustachian tube and anterior
part of the middle ear is lined by ciliated columnar cells. The cilia beat in the direction of
nasopharynx. This helps to clear the secretions and debris in the middle ear towards the
nasopharynx. The clearance function is further augmented by active opening and closing of
the tube.
TUBAL CLOSURE AND OPENING MECHANISM
TUBAL OPENING:
As a result of muscular activity the cartilaginous part of the tube will open. The Tensor
Palatine is considered as the main dilator while the levator veli palatine muscle forming the
part of the bottom of the tube supports the opening. The Tensor Tympani may also play a role
in the tube opening mechanism. As stated above, the Tensor Tympani is attached to the neck
of the malleus and contraction of the muscle slightly increases the middle ear pressure by the
medial placement of the tympanic membrane. The origin of this muscle from the cartilage of
the tube as well as the adjoining bone may well influence the opening of the tube at this
point. This is also supported by the fact that the tube begins to open from the middle ear end.
The contraction of the tensor tympani may facilitate tubal opening.
Another mechanism for the opening of the tube must be taken into account. If the
intratympanic pressure for some reason exceeds 100-150mm of H2O above the ambient
pressure, the ET may open spontaneously without any muscular activity involved. This holds
for an increases in air pressure applied from the pharyngeal end of the tube, exemplified in
tube or applying +ve pressure in the nasopharynx as in Valsalva’s maneuver.
TUBAL CLOSING MECHANISM:

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In contrast to the opening of tube, closure is exclusively a passive phenomenon. When the
muscles relax or when a static pressure no longer keeps the tubal walls separated, the tubal
lumen collapses. Aschan showed that the closure of the tube starts at the nasopharyngeal end.
In this way it is possible that small air volume are forced into the middle ear during the
closing of the tube. This explains the presence of a slight positive pressure under normal
condition (Hotlmquist et.al)
FLASK MODEL
The flask model proposed by Bluestone and his colleagues helps to better explain the role of
the anatomic configuration of the ET in the protection and drainage of the middle ear. In this
model, the ET and the middle ear is likened to be a flask with a long narrow neck. The mouth
of the flask represents the nasopharyngeal end, the narrowneck represents the isthmus and the
middle ear and the mastoid gas cell system represents the body of the flask. Fluid flow
through the neck depends on the pressure at either end, the radius or the 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 diameter of the neck
and due to the +ve pressure in the chamber of the flask. However, this does not take into
consideration the dynamic role of the TVPin actively opening the nasopharyngeal orifice of
the ET.

Recent studies

1. Physiology, Eustachian Tube Function

Jarett Casale; Karlie R. Shumway; Jason D. Hatcher.
(NATIONAL LIBRARY OF MEDICINE)
The anatomy of the Eustachian tube in infants and young children differs from that of adults
in that the ET runs horizontally rather than sloping downward from the middle ear. Because
of this anatomical difference, bottle-feeding of infants should be performed with the head

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elevated to decrease the risk of reflux into the middle ear space. The horizontal course of an
infant's ET makes it more difficult for fluid to drain out of the ear and creates a more
accessible avenue for bacteria to travel from the mouth to the middle ear space, both of which
can culminate in an ear infection. After the age of six, the frequency of ear infections
substantially decreases.
As previously discussed, Eustachian tube dysfunction often manifests in the setting of an
inflammatory process such as otitis media or rhinosinusitis. Symptoms include tinnitus,
distorted or diminished hearing, and pressure in the ear. These symptoms are typically mild
and respond to actions that facilitate the normal opening of the tube, such as swallowing or
yawning. Theoretically, medications aimed at reducing inflammation, whi
ch include corticosteroids, antihistamines, and antibiotics in the setting of an infectious
process, may temporarily improve Eustachian tube function; however, the research and
evidence for this are underwhelming.

2. STUDY OF EUSTACHIAN TUBE FUNCTION IN NORMAL ADULTS AND

THOSE WITH MIDDLE EAR DISEASE
In most patients with healed central perforation and in post operative patients who were
successfully treated by surgery, the Eustachian tube function was found to be normal. ET
function was found to be partially or grossly impaired in most patients with recurrent or
residual CP. In most of the CSOM patients and patients with retracted ear drum also the
impairment of Eustachian tube function was found to be statistically significant. Chronic
sinusitis, allergic rhinitis and smoking were the important causes of ET dysfunction

Reference
 Casale J, Shumway KR, Hatcher JD. Physiology, Eustachian Tube Function.
[Updated 2023 Mar 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK532284/
 Hearing- Anatomy, Physiology, and Disorders of the Auditory system
 Clinical Audiology by Jack katz

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 Speech and Hearing Science: Anatomy and Physiology by Willard R. Zemlin

 Ear, Nose, Throat by PL Dhingra

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