EUSTACHIAN TUBE
DYSFUNCTION:
DR HAMEEZA ASIF
RESIDENT OTOLARYNGOLOGY
THE INDUS HOSPITAL
CONTENTS:
INTRODUCTION AND HISTORY
EMBRYOLOGY, ANATOMY AND PHYSIOLOGY
FUNCTIONS
TESTS FOR EUSTACHIAN TUBE FUNCTION
EUSTACHIAN TUBE DYSFUNCTION
TREATMENT OPTIONS
INTRODUCTION:
EUSTACHIAN TUBE – Narrow channel connecting the
tympanic cavity and nasopharynx
Eustachian tube is a complex organ consisting of a
dynamic, mucosal lined canal, cartilage surrounding
soft tissue, peri-tubal muscles, superior bony support
and the sphenoid sulcus.
HISTORY:
The first anatomical description of the tube was
given by Eustachius (1563).
Valsalva (1704) discovered a muscle for opening the
tube.
EMBRYOLOGY:
ANATOMY:
Cont..
OSTMANN’S PAD:
Lateral to the membranous part of cartilaginous tube
Helps in keeping the tube close
CONT..
TYMPANIC END – 5*2mm situated in the anterior wall od middle ear
PHARYNGHEAL END – slit like vertical. Makes an elevation on lateral
wall of nasopharynx called Torus Tubarius which is 1.25cm behind the
posterior end of inferior turbinate.
RELATIONS WITH IMPORTANT
STRUCTURES:
OSSEOUS PART: TM joint (laterally),
middle cranial fossa (superiorly),
internal carotid artery ( medially)
FIBROCARTILAGENOUS: skull base,
nasopharynx & fossa of
rosenmuller.
Muscles related to Eustachian tube:
There are 3 muscles related to the tube
1. Tensor veli palatine
2. Levator veli palatine
3. Salpingopharyngeus
BLOOD SUPPLY:
BONY PART – Tubal artery from accessory meningeal
a. & caroticotympanic artery from internal carotid
artery.
CARTILAGENOUS PART – Internal maxillary, ascending
palatine & ascending pharyngeal artery
NERVE SUPPLY:
Sensory supply with parasympathetic secretomotor
fibres – tympanic branch of cranial nerve IX
Tensor veli palatine – V3
Levator veli palatine & salpingopharyngeus –
pharyngeal plexus
HISTOLOGY:
BONT PART – Low cuboidal
ciliated
CARTILAGENOUS PART –
pseudostratified ciliated
columnar & goblet cells
INFANT VS ADULT ET:
FUNCTIONS:
1. Ventilation and regulation of middle ear pressure
2. Protection against
• Nasopharyngeal sound pressure
• Reflux
3. clearance of middle ear
CONT..
Eustachian tube opens periodically to equilibrate the
air pressure in the middle ear as –ve or +ve pressure
in the middle ear affects hearing.
Abnormal high pressure from the nasopharynx can
be transmitted to the middle ear if the tube is open.
Cilia beat in the direction of nasopharynx thus clear
the secretions and debri from the middle ear into
nasopharynx.
Eustachian tube dysfunction ETD:
Impairment of ET function and leads to a variety of
symptoms and findings.
Can be acute or chronic
Acute ETD occur during nasal congestion or allergic
rhinitis
ETD lasting longer than 3 months is termed as
chronic.
SYMPTOMS:
Aural fullness
Impaired pressure equilibration
Altered middle ear aeration
Hearing loss
Autophony
Associated with :
Nasopharyngeal reflux
Adenoidal hypertrophy
Cleft palate
Granulomatous diseases
Cystic fibrosis
• Almost 40% of all children up to
the age of 10 years develop
temporary ETD
EVALUATION OF EUSTACHIAN TUBE
DYSFUNCTION:
Pneumatic otoscopic
examination
Valsalva test
Politzer test
Toynbee’s test
Eustachian tube
catheterization
CONT..
Saccharine/methylene
blue test
Endoscopic
examination
Tympanometry
(inflation-deflation test)
sonotubometry
Pneumatic otoscopic
examination:
This movement indicates
that the Eustachian tube is
allowing air to enter and
exit the middle ear space,
equalizing pressure.
Valsalva Test:
Nose is
Take a deep Tries to blow
pinched with
breath & close air into the
the thumb &
his mouth ears
index finger
If air enters the middle ear the tympanic
membrane will move outwards & visualized
using otoscope
Cont..
Tympanic membrane perforation - hissing sound
Discharge in the middle ear – cracking sound
Whistling sound – partial obstruction
No sound – complete obstruction
CONTRAINDICATIONS:
Atrophic scar of tympanic membrane which can rupture
Infection of nose or nasopharynx leads to otitis media
Politzer Test:
Done in children who cant perform
Valsalva test.
By using an auscultation tube A hissing
sound is heard if the tube is patent.
Also used therapeutically to ventilate
middle ear.
Toynbee’s Test:
Unlike other tests it caused negative
pressure.
Patient is asked to swallow while nose
is pinched.
This draws the tympanic membrane
inward , verified by otoscope.
Eustachian tube catheterization:
After insertion of catheter
over the tubal opening,
politzers bag is attached & air
is insufflated.
Air entry is verified by
auscultation.
Cont...
COMPLICATIONS:
Injury & scarring of the tube
Bleeding from nose
Transmission of infections into the middle ear
Rupture of tympanic membrane if too much pressure
Tympanometry:
Diagnostic for certain
middle ear pathologies.
A negative and positive
pressure is created and
patient is asked to swallow
5 times in 20 sec. the
ability to equilibrate the
pressure indicated normal
tubal function.
Saccharine/methylene blue test:
This test is done in pre-existing perforation.
Saccharine/ methylene blue dye is instilled into the
EAC , time taken by it to reach the pharynx & imparts
a sweet/bitter taste is a measure of normal clearance
function.
Sonotubometry:
Also tells the duration of tube
opening.
Tone is heard louder when the
tube is patent.
Accessory sounds produced in
the nasopharynx may
interfere with the test results.
Tubotympanometry:
Time of opening in relation to pressure application
can be measured as opening latency index ‘R’. <1 is
considered optimal.
Dysfunction of Eustachian tube
system:
Disorders of Eustachian tube:
Tubal blockage:
o Intrinsic due to inflammation
o Extrinsic due to tumors or adenoids
Adenoids:
o Mechanical obstruction
o Acts as reservoir for pathogens
o Release inflammatory mediators
Cont..
Cleft palate:
o Abnormalities of torus tubaris, high elastic density
makes tube difficult to open.
o TVP muscles does not insert into the torus tubaris in
40% of cases.
Down syndrome:
o Poor tone of Eustachian tube & abnormal shape of
nasopharynx.
Patulous Eustachian tube:
Eustachian tube is abnormally
patent.
Could be due to rapid weight
loss, pregnancy especially 3rd
trimester or multiple sclerosis.
Patient’s chief complaints are
autophony.
Medical management:
Pharmacological intervention includes nasal
steroids , anti-histamine, inhaled and systemic
decongestants.
Politzerization/ otovent/ ear popper
Myringotomy & grommet insertion decreases the
symptoms but are not definitive therapy.
Laser tuboplasty:
It seems feasible, safe and effective treatment of
chronic obstructive ETD.
Reported successful in almost 70% after 1 year.
Balloon Dilation Eustachian
Tuboplasty:
Can be performed in adult patients & children from
the age of 7 years.
Indications:
• Symptomatic patients with an ET score of <5 and
the presence of at least one of the following.
Cont..
Limitations:
Cleft palate patients don’t get benefit from BET as
they have muscular dysfunction rather than
obstruction.
In a series of 400 patients 80% reported
improvements in ET score.
