The ears

Anatomy and physiology of eustachian tube

and middle ear related to otitis media

Charles D. Bluestone, MD, and William J. Doyle, PhD Pittsburgh, 8%.

The middle ear is part of a functional system composed of the nusopharynr and the eustachiatl
tube (anteriorly) and the mastoid air cells (posteriorly). The only uctive muscle that operls the
eustachian tube is the tensor veli palatini, which promotes ventilation of the middle ear. The
eustachian tube also functions to protect the middle ear ,from excessive sound pressure. unti
nasopharyngeal secretions. The eustachian tube helps drain the middle ear during openin,y
and closing by pumping secretions from the middle ear; clearance of secretions also occur,~ An
understanding of the anatomy and physiology of the system can aid the cliniciutr in
understanding the role of eustachian tube dysfunction in the cause and pathogenesis of middle
eur disease and the possible contribution of allergy to this disease. (J ALLERGY CLLV IMMWI?I
1988;81:997-1003.)

The middle ear is part of a functional system com-
posed of the nasopharynx and eustachian tube ante-
riorly and the mastoid air cells posteriorly (Fig. 1).
An understanding of the anatomy and physiology of
this system aids the clinician in understanding the role
of tubal dysfunction in the cause and pathogenesis of
middle ear disease and the possible contribution of
allergy to this disease.
NASOPHARYNX
The nasopharynx is continually patent, communi-
cating with the nasal cavities anteriorly through paired
choanae. Communication with the oral cavity is by
means of the velopharyngeal port. On each lateral wall
is a prominence, the torus tubarius, which protrudes
into the nasopharynx. Within this prominence is the
triangular nasophqngeal orifice of the tube. From
the torus a raised ridge of mucous membrane, the
salpingopharyngeal fold, descends vertically. On the
posterior wall lie the adenoids, or pharyngeal tonsil,
composed of abundant lymphoid tissue. Above the
tonsil is a variable depression within the mucous mem-
brane called the pharyngeal bursa. Behind the torus
lies a deep pocket, extending the nasopharynx pos-
teriorly along the medial border of the eustachian tube.
From the Otitis Media Research Center, Children’s Hospital of
Pittsburgh.
Reprint requests: Charles D. Bluestone, MD, Department of Pe-
diatric Otolaryngology, One Children’s Place, 3705 Fifth Ave.
at DeSoto St., Pittsburgh, PA 15213.
This pocket, the fossa of Rosenmiiiler, vanes in height
from 8 to 10 mm, and in depth from 3 to lO mm.’
EUSTACHIAN TUBE
In adults the eustachian tube lies at an angle of 45
degrees to the horizontal plane, but at only IO degrees
in infants.’ The tube is longer in the adult than in the
infant and young child, and its length varies with
race; it has been reported to be as short as 30 mm and
as long as 40 mm, but the usual range is 31 to 38
mm.‘-’
The bony portion of the eustachian tube ties com-
pletely within the petrous portion of the temporal bone
and is directly continuous with the anterior wall of
the superior portion of the middle ear. The juncture
of the osseous portion of the tube and the epitym-
panum lies 4 mm above the floor of the tympanic
cavity.4 The lumen is roughly triangular. measuring 2
to 3 mm vertically and 3 to 4 mm along the horizontal
base. When healthy, the osseous portion is open at
all times, in contrast to the fibrocartitaginous portion,
which is closed at rest and opens during swallowing
or when forced open, such as during the Valsalva
maneuver. The osseous and cartilaginous portions of
the eustachian tube meet at an irregular bony surface
and form an angle of about 160 degrees with each
other.
The fibrocartilaginous eustachian tuhe courses an-
teromedially and inferiorly, angled in most cases 30
to 40 degrees to the transverse plane and 45 degrees
to the sagittal plane.4 The tube is closely applied to
997
 J. ALLERGY CLIN. IMMUNOL.
998 Bluestone and Doyle
MAY 1988

FIG. 1. Eustachian tube, middle ear, mastoid air cells, and nasopharynx as system. (From Blue-
stone CD, Klein JO. Otitis media in infants and children. Philadelphia: WB Saunders, 1988.)

end it is attached to a tubercle on the posterior edge

Tensor veli
palatini - - Dilatator tubae
’ Q-
ik
Hamulus
FIG. 2. Representation of tube in cross section, and rela-
tion between superficial and deep bundles of tensor veli
palatini muscle. (From Bluestone CD, Stool SE, eds.
Pediatric otolaryngology. Philadelphia: WB Saunders,
1983.)
the basal aspect of the skull and is fitted to a sulcus
(sulcus tubae) between the greater wing of the sphe-
noid bone and the petrous portion of the temporal
bone. The fibrocartilaginous tube is firmly attached at
its posterior end to the osseous orifice by fibrous
bands, and usually extends some distance (3 mm) into
the osseous portion of the tube. At its inferomedial
of the medial pterygoid lamma.*-’
The fibrocartilaginous tube has a crook-shaped me-
diolateral superior wall. It is completed laterally and
inferiorly by a veiled membrane,‘, 6V’ which serves as
the site for the attachment of the fibers of the dilator
tubae, or tensor veli palatini muscle’ (Fig. 2). The
tubal lumen is shaped like two cones joined at their
apices. The juncture of the cones is the narrowest point
of the lumen, and has been called the “isthmus,” and
its position is usually described as at or near the junc-
ture of the osseous and cartilaginous portions of the
tube. The lumen at this point is approximately 2 mm
high and 1 mm wide.’ From the isthmus the lumen
expands to approximately 8 to 10 mm in height and
1 to 2 mm in diameter at the pharyngeal orifice. Tubal
cartilage increases in mass from birth to puberty, and
this development may have physiologic implications.g
The cartilaginous eustachian tube does not follow
a straight course in the adult, but extends along a curve
from the junction of the osseous and cartilaginous
portions to the medial pterygoid plate, approximating
the cranial base for the greater part of its course. The
eustachian tube crosses the superior border of the su-
perior constrictor muscle immediately posterior to its
terminus with the nasopharynx. The thickened ante-
rior fibrous investment of the medial cartilage of the
tube presses against the pharyngeal wall to form a
prominent fold, the torus tubarius, which is 10 to 15
mm thick.’ The torus is the site of origin of the sal-
pingopharyngeal muscle, which lies within the infer-
oposteriorly directed salpingopharyngeal fold. lo
The mucosal lining of the eustachian tube is con-
VOLUME f?l
NUMBER i. PART 2
TENSORTYMPANI
FIG. 3. Representation of relationship between tensor veli
palatini and tensor tympani muscles. (From Bluestone CD,
Stool SE, eds. Pediatric otolaryngology. Philadelphia: WB
Saunders, 1983.)
tinuous with that of the nasopharynx and middle ear
and is characterized as modified respiratory epithe-
lium. Structural differentiation of this mucosal lining
is evident; mucous glands predominate at the naso-
pharyngeal orifice, and there is a gradual change to a
mixture of goblet, columnar, and ciliated cells near
the tympanum . 1’
Traditionally four muscles are associated with the
eustachian tube: the tensor veli palatini, levator veli
palatini, salpingopharyngeus , and tensor tympani.
Each has at one time or another been directly or in-
directly implicated in tubal function.
Usually the eustachian tube is closed; it opens dur-
ing such actions as swallowing, yawning, or sneezing,
and thereby permits equalization of middle ear and
atmospheric pressures. Active dilation is induced
solely by the tensor veli palatini muscle.‘29 I3 Closure
of the tube has been attributed to passive reapproxi-
mation of tubal walls by extrinsic forces exerted either
by the surrounding tissues or by the recoil of elastic
fibers within the tubal wall or by both. More recent
experimental and clinical data suggest that, at least
for certain abnormal populations, the closely applied
internal pterygoid muscle may assist tubal closure by
PRESSURE
FIG. 4. Three physiologic functions of eustachian tube.
(From Bluestone CD. Pediatr Clin North Am fS81;28:727-
55.)
an increase in its mass within the pterygoid fossa; this
increase applies medial pressure to the tensor veli
palatini muscle and consequently to the lateral mm-
branous wall of the eustachian tube.‘*, I4 I5
The tensor veli palatini is composed of two fairly
distinct bundles of muscle fibers divided by a layer
of fibroelastic tissue (Fig. 3). The bundles lie medi-
olateral to the tube. The more lateral bundle (the tensor
veli palatini proper) is of an inverted triangular design,
taking its origin from the scaphoid fossa and entire
lateral osseous ridge of the sulcus tubarius for the
course of the eustachian tube. The bundles descend
anteriorly, laterally, and inferiorly to converge in a
tendon that rounds the hamular process of the medial
pterygoid lamina about an interposed bursa. This fiber
group then inserts into the posterior border of the
horizontal process of the palatine bone and into the
palatine aponeurosis of the anterior portion of the
velum. The more posteroinferior muscle fibers lack
an osseous origin, extending instead into the semi-
canal of the tensor tympani muscle. Here the latter
group of muscle fibers receives a second muscle slip,
which originates from the tubal cartilage and sphenoid
bone. These muscle masses converge to a tendon that
rounds the cochleariform process and inserts into the
manubrium of the malleus (Fig. 3). This arrangement
imposes a bipennate form to the tensor tympanni mus-
cle. 8, I6 The tensor tympani does not appear to be
involved in the function of the eustachian tube.“’
The medial bundle of the tensor veli palatini muscle
 J. ALLERGY CLIN. IMMUNOL.
1000 Bluestone and Doyle
MAY 1988

PRESSURE
--VISCOSITY

COMPLIANC
II
I ------- RADIUS

CHILD

ADULT
FIG. 6. Flask model showing how shorter length of eusta-
chian tube can adversely affect protective function in
child, as compared with adult. (From Bluestone CD, Klein
FIG. 5. Eustachian tube, middle ear, and mastoid air cell JO. Otitis media in infants and children. Philadelphia: WB
system compared to flask. Mouth of flask represents na- Saunders, 1988.)
sopharvngeal end of eustachian tube; neck is cartilagi-
nous portion of tube; and bulbous portion is middle ear
and mastoid air cells. (From Bluestone CD, Klein JO. Otitis PHYSIOLOGY OF EUSTACHIAN TUBE AND
media in infants and children, Philadelphia: WB Saunders, MIDDLE EAR
1988.)
The eustachian tube has at least three physiologic
functions with respect to the middle ear: protection
lies immediately adjacent to the lateral membranous from nasopharyngeal sound pressure and secretions,
wall of the eustachian tube and is called the dilator drainage into the nasopharynx of secretions produced
tubae muscle.8~ I8 It takes its superior origin from the within the middle ear, and ventilation of the middle
posterior third of the lateral membranous wall of the ear with atmospheric pressure to replenish gases that
eustachian tube. The fibers descend sharply to enter have been absorbed (Fig. 4).
and blend with the fibers of the lateral bundle of the
tensor veli palatini muscle. This inner bundle is re- Protective and drainage functions
sponsible for active dilation of the tube by inferolateral The protective and drainage functions of the eusta-
displacement of the membranous wall.‘. “2 I9 chian tube and middle ear have been studied in chil-
The levator veli palatini muscle arises from the in- dren by using radiographic techniques.2’-24 Under-
ferior aspect of the petrous apex. Some fibers may standing of these radiographic studies can be best
attach to the lower border of the medial lamina of the shown by a model of the system.25 The eustachian
tubal cartilage. The fibers pass inferomedially, par- tube, middle ear, and mastoid air cell system can be
alleling the tubal cartilage and lying within the vault likened to a flask with a long, narrow neck (Fig. 5).
of the tubal floor. They fan out and blend with the The mouth of the flask represents the nasopharyngeal
dorsal surface of the soft palate.4sI9 Most investigators end, the narrow neck the isthmus of the eustachian
deny a tubal origin for this muscle and believe that it tube, and the bulbous portion the middle ear and mas-
is related to the tube only by loose connective tissue. toid air chamber. Fluid flow through the neck is de-
The levator is not an active opener of the tube, but pendent on the pressure at either end, the radius and
probably adds support inferiorly.” length of the neck, and the viscosity of the liquid.
The salpingopharyngeal muscle arises from the me- When a small amount of liquid is instilled into the
dial and inferior borders of the tubal cartilage through mouth of the flask, liquid flow stops somewhere in
slips of muscular and tendinous fibers. The muscle the narrow neck because of capillarity within the neck
then courses inferoposteriorly to blend with the mass and the relative positive air pressure that develops in
of the palatopharyngeal muscle.4 Rosen” reported that the chamber of the flask. This basic geometric design
in humans this muscle is poorly developed and prob- is considered to be critical for the protective function
ably nonfunctional. of the eustachian tube-middle ear system. Reflux of
VOLUME 81
NUMBER 5 P9AT 2
FIG. 7. Flask model showing how reflux can occur when
middle ear air cushion is lost because of hole. (From Blue-
stone CD, Klein JO. Otitis media in infants and children.
Philadelphia: WB Saunders, 1988.)
liquid into the body of the flask occurs if the neck is
excessively wide. This is analagous to an abnormally
patent human eustachian tube, in which there is not
only free flow of air from the nasopharynx into the
middle ear but also free flow of nasopharyngeal se-
cretions, which can result in reflux otitis media.
Fig. 6 shows that a flask with a short neck would not
be as protective as a flask with a long neck. Inasmuch
as infants have a shorter eustachian tube than adults
do, reflux is more likely in the baby. The position of
the flask in relation to the liquid is another important
factor. In humans the supine position enhances flow
of liquid into the middle ear; thus infants might be at
particular risk for reflux otitis media because they are
frequently supine.
Fig. 7 shows that reflux of a liquid into the vessel
can also occur if a hole is made in the bulbous portion
of the flask, because this prevents the creation of the
slight positive pressure in the bottom of the flask that
deters reflux; that is, the middle ear and mastoid phys-
iologic cushion of air is lost. This hole is analogous
to a perforation of the tympanic membrane or the
Eustachian tube, middle ear, am! H&I<; >.rcrile ?0ol
\
ACTIVE DILATION
OF TUBE
FIG. 8. Representation of active dilation of eustachian tube
by tensor veli palatini muscle (TVf). (From Bluestone CD.
Pediatr Clin North Am 1981;28:727-55.)
presence of a tympanostomy tube that could allow
reflux of nasopharyngeal secretions as a result of the
loss of the middle ear mastoid air cushion. Similarly,
after radical mastoidectomy a patent eustachian tube
could cause troublesome otorrhea.”
If negative pressure is applied to the bottom of the
flask, the liquid is aspirated into the vessel. In the
clinical situation represented by the model, high neg-
ative middle ear pressure could lead to aspiration of
nasopharyngeal secretions into the middle ear. If pos-
itive pressure is applied to the mouth of the flask, the
liquid is insufflated into the vessel. Nose blowing,
crying, closed nose swallowing, diving, or ascent in
an airplane could create high positive nasopharyngeal
pressure and result in a similar condition in the human
system.
One of the major differences between a flask with
a rigid neck and a biologic tube such as the eustachian
tube is that the isthmus (neck) of the human tube is
compliant. Application of positive pressure at the
mouth of a flask with a comphant neck distends the
neck, enhancing fluid flow into the vessel. Thus less
positive pressure is required to ins&late liquid into
the vessel. In humans, insufflation of nasopharyngeal
secretions into the middle ear occurs more readily if
the eustachian tube is abnormally distensible (has in-
creased compliance). The speed with which the neg-
ative pressure is applied and the compliance in such
a system appear to be critical factors. Clinically, as-
piration of gas into the middle ear is possible because
 1992Bluestone
andDoyle
negative middle ear pressure develops slowly as gas
is absorbed by the middle ear mucous membrane. On
the other hand, sudden application of negative middle
ear pressure such as occurs with rapid alterations in
atmospheric pressure (as in descent in an airplane or
diving or during an. attempt to test the ventilatory
function of the eustachian tube) could lock the tube,
preventing the flow of air.
Certain aspects of fluid flow from the middle ear
into the nasopharynx can be demonstrated by inverting
the flask of the model. The liquid trapped in the bul-
bous portion of the flask does not flow out of the
vessel because of the relative negative pressure that
develops inside the chamber. However, if a hole is
made in the vessel, the liquid drains out of the flask
because the suction is broken. Clinically these con-
ditions occur in middle ear effusion; pressure is re-
lieved by spontaneous rupture of the tympanic mem-
brane or by myringotomy. Inflation of air into the flask
could also relieve the pressure, which may explain the
frequent success of the Politzer or Valsalva method in
clearing middle ear effusion.
These examples of fluid flow through a flask present
some of the mechanical aspects of the physiology of
the human middle ear system. Other factors that prob-
ably affect flow of liquid and air through the middle
ear include (1) the mucociliary transport system of the
eustachian tube and middle ear (i.e., clearance); (2)
active tubal opening and closing, acting to pump liquid
out of the middle ea?‘; and (3) surface tension.
Ventilatory function
The normal eustachian tube is functionally ob-
structed or collapsed at rest; there is probably slight
negative pressure in the middle ear (Fig. 8). When
the eustachian tube functions ideally, intermittent ac-
tive dilation (opening) of the tube maintains near am-
bient pressure in the middle ear. It is suspected that
when active function is inefficient in opening the eu-
stachian tube, functional collapse of the tube persists,
resulting in negative pressure in the middle ear. When
tubal opening does occur, a large bolus of air could
enter the middle ear, which could eventually result in
even higher negative pressure.28 This type of venti-
lation appears to be quite common in children: mod-
erate to high negative middle ear pressures have been
identified by tympanometry in many children who
have no apparent ear disease.29
In an effort to describe normal eustachian tube func-
tion by using a microflow technique inside of a pres-
sure chamber, Elner et a130 studied 102 adults with
intact tympanic membranes and apparently no history
of otologic disorders. The patients were divided into
four groups according to their ability to equilibrate
J. ALLERGY CLIN. IMMUNOL.
MAV1488
static relative positive and negative pressures of 100
mm H,O in the middle ear. The patients in group 1
were able to equilibrate pressure differences across
the tympanic membrane completely; those in group 2
equilibrated positive pressure, but a small residual
negative pressure remained in the middle ear; patients
in group 3 were capable of equilibrating only relative
positive pressure, with a small residual remaining, but
not negative pressure; and those in group 4 were in-
capable of equilibrating any pressure. These data
probably indicate decreased stiffness of the eustachian
tube in the patients in groups 2, 3, and 4 compared
with those in group 1. This study also showed that
93% could equilibrate applied negative pressure to
some extent by active swallowing. However, 28% of
the patients could not completely equilibrate either
applied positive or negative pressure or both.
Children have less efficient eustachian tube venti-
latory function than adults do. Bylander?’ compared
eustachian tube function in 53 children with that in
55 adults, all of whom had intact tympanic membranes
and who were apparently otologically healthy. Using
a pressure chamber, Bylander reported that 35.8% of
the children could not equilibrate applied negative
intratympanic pressure ( - 100 mm H,O) by swallow-
ing, whereas only 5% of the adults were unable to
perform this function. Children between 3 and 6 years
of age had worse function than did those aged 7 to
12 years. In this study and a subsequent study con-
ducted by the same research group,32 children who
had tympanometric evidence of negative pressure
within the middle ear had poor eustachian tube func-
tion. Eustachian tube function improves with age,
which is consistent with the decreasing incidence of
otitis media from infancy to adolescence.33
From these studies it can be concluded that even in
apparently otologically normal children, eustachian
tube function is not as good as in adults, which could
explain the higher incidence of middle ear disease in
children.
In a study by Cantekin et al. ,** serial tympanograms
were obtained in rhesus monkeys to determine the
nature of gas absorption. During 4 hours of obser-
vation, middle ear pressure was approximately normal
in alert animals, whereas when the animals were an-
esthetized and swallowing was absent, middle ear
pressure dropped to - 60 mm H,O and remained at
that level. The experiment indicated that middle ear
pressure normally is in equilibrium with the mucosal
blood-tissue gases or inner ear gas pressures. Under
these circumstances the gas absorption rate is small
because the partial pressure gradients are not great.
In the normally functioning eustachian tube the fre-
quent openings of the tube readily equilibrate the pres-
VOLUME 81 Eustachian tubt-, middle ear, and otitis media 1003
NUMBER 5, PART 2

sure differences between the middle ear and the na- 16. Lupin AJ. The relationship of the tensor tympani and tensor
palati muscles. Ann Otorhinolaryngol 1969;78:792-6.
sopharynx, with a small volume of air (1 to 5 ml)
17. Honjo I, Ushiro K, Majo T, Nozoe T, Matsui H. Role of tensor
entering the middle ear. However, an abnormally func- tympani muscle in eustachian tube function. Acta Otolaryngol
tioning eustachian tube may alter this mechanism, 1983;95:329-32.
allowing the development of significant negative 18. GOSS C, ed. Gray’s anatomy of the human body. Philadelphia:
pressure. Lea & Febiger, 19(;7: 1087.
19. Rood SR. Morphology of m. tensor veli palatini in the tive-
Another explanation for the finding of high negative
month human fetux Am J knat 1973;138:191-6.
middle ear pressure in children is the possibility that 20. Cantekin EI, Doyle WJ, Bluestone CD. Effect of lavator veli
some individuals who are habitual “sniffers” actually palatini muscle excision on eustachian tube function. Arch
create underpressure within the middle ear by this Otolaryngol 1983; 109:281-4.
act.j“ The rate of gas absorption from the middle ear 21. Bluestone CD. Eustachian tube obstruction m the infant with
cleft palate. Ann Otorhinoldryngol 197 1;80: l-30.
has been reported by several investigators to be ap-
22. Bluestone CD, Paradise JL, Beery QC. Physiology of the eu-
proximately 1 ml over 24 hours.35-38However, because stachian tube in the pathogenesis and management of middle-
values taken over a short period were extrapolated to ear effusion% Laryngoscopc 1972;82: 1654-70.
arrive at this figure, the true rate of gas absorption 23. Bluestone CD, Wittel R, Paradise JL, Felder H. Eustachian
over 24 hours has yet to be determined in humans. tube function as related tc adenoidectomy for otitis media.
Trans AA00 1972;76:132!-39.
24. Honjo I, Ushiro R, Okazbki N, Kumazawa T. Evaluation of
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