7. Anatomy
• 36 mm long in adults.
• Directed anteriorly, inferiorly & medially from anterior
wall of M.E., forming angle of 450 with horizontal
• Enters naso-pharynx 1.25 cm behind posterior end of
inferior turbinate.
7
13. Anatomy
Muscle attachments:
1. tensor veli palatini or dilator tubae
2. levator veli palatini
3. salpingopharyngeus
13
14. Nerve supply
• Tubal mucosa – tympanic branch of cranial
nerve IX
• Tensor veli palatini - Mandibular branch of
trigeminal
14
• Levator veli palatini
Pharyngeal plexus
• Salpingo pharygeus
15. Endoscopic Anatomy
• Medial end forms tubal
elevation / torus tubarius
• Lymphoid collection over
torus is called Gerlach’s tubal
tonsil.
• Postero-superior to torus is
fossa of Rosenmüller.
15
17. Adult vs INFANT
ADULT INFANT
Length 36 mm 18 mm
Angle with horizontal 45 0 10 0
Lumen Narrower Wider
Angulation at isthmus Present Absent
Cartilage Rigid Flaccid
Elastic recoil Effective Ineffective
Ostmann’s fat More Less
17
18. Infant E. tube
• wider shorter and more horizontal
So secretions even milk can regurgitate from
nasopharynx to middle ear if infant not fed in head
up position
18
19. Physiology
• Bony part is always open.
• Fibro-cartilaginous part is closed at rest.
• Opens on:
1. swallowing
2. yawning
3. sneezing
4. forceful inflation
19
20. Physiology
• Opens actively by contraction of tensor veli palatini &
passively by contraction of levator veli palatini (it
releases the tension on tubal cartilage).
• Closes by elastic recoil of elastin hinge + deforming
force of Ostmann’s fat pad.
20
22. Functions
1. Ventilation & maintenance of atmospheric
pressure in middle ear for normal hearing
2. Drainage of middle ear secretions into
nasopharynx by muco-ciliary clearance,
pumping action of Eustachian tube &
presence of intra-luminal surface tension
22
23. Functions
3. Protection of middle ear from:
– Ascending nasopharyngeal secretions due to
narrow isthmus & angulation between 2 parts of
E.T. at isthmus
– Pressure fluctuations
– Loud sound coming through pharynx
23
27. ET Function Tests
• VALSALVA TEST
– Principle: positive pressure in the nasopharynx causes air
to enter the Eustachian tube
27
28. – Tympanic membrane perforation- a hissing sound
– Discharge in the middle ear- cracking sound
– Only 65% of persons can do this test.
– Contraindications:
• Atrophic scar of tympanic membrane which can rupture
• Infection of nose & nasopharynx
28
29. • Politzer test
– Done in children who are unable to perform valsalva
test.
– Olive shaped tip of the politzer’s bag is introduced
into the patient’s nostril on the side of which the tubal
function is desired to be tested
– Other nostril closed & the bag compressed while at
the same time the patient swallows or says “ik,ik,ik”
29
30. – By means of an auscultation tube a hissing sound
is heard.
– Compressed air can also be used instead of
politzer’s bag
– Test is also therapeutically used to ventilate the
middle ear.
30
32. • Procedure for Catheterisation
32
•Nose is anaesthetised
•E Tube catheter passed along the floor of nose till it
reaches naso pharynx
•Rotated 90deg medially
•Pulled back till posterior border of nasal septum
engaged
•Rotated 180 deg laterally – tip lies against tubular
opening
• Politzer’s bag connected
• Air insufflated
• Entry of air to middle ear verified (lateral bulging of
t.m)
33. 6. E.T. catheterization
Air pushed into E.T. catheter by squeezing Politzer bag.
Examiner hears by Toynbee auscultation tube put in
pt's ear.
Blowing sound = normal E.T. patency
Bubbling sound = middle ear fluid
Whistling sound = partial E.T. obstruction
No sound = complete obstruction of E.T.
33
34. – Complications:
• Injury to Eustachian tube opening
• Bleeding from nose
• Transmission of nasal & nasopharyngeal infection into
middle ear
• Rupture of atrophic area of tympanic membrane
34
35. • Toynbee’s test
– Uses negative pressure
– Ask the patient to swallow while nose is pinched
– Draws air from middle ear to nasopharynx – inward
movement of t.m.
35
36. • Tympanometry (inflation-deflation test)
– +Ve & -ve pressures are created in the external ear
and the patient swallows repeatedly
– in patients with perforated or intact tympanic
membrane
• Radiological Test
• Saccharine/ Methylene blue Test
– Saccharine solution
– Methylene blue dye
– Ear drops into ear with TM perforation
• Sonotubometry
36
38. Tubal Blockage
ACUTE TUBAL BLOCKAGE
ABSORPTION OF ME GASES
-VE PRESSURE IN ME
RETRACTION OF TM
TRANSUDATE IN ME/HAEMORRHAGE PROLONGED TUBAL BLOCKAGE/DYSFUNCTION
OME(THIN WATERY OR MUCOID DISCHARGE)
ATELECTATIC EAR/PERFORATION
RETRACTION POCKET/CHOLESTEATOMA
EROSION OF INCUDOSTAPEDIAL JOINT
38
40. • Symptoms of tubal occlusion
– Otalgia
– Hearing loss
– Popping sensation
– Tinnitus
– Disturbances of equilibrium
• Signs of tubal occlusion
– Retracted TM
– Congestion along the handle
of malleus and pars tensa
– Transudate behind TM
40
41. • Clinical causes of ET obstruction
– Upper respiratory tract infection
– Allergy
– Sinusitis
– Nasal polypi
– DNS
– Hypertrophic adenoids
– Nasopharyngeal tumour/ mass
– Cleft palate
– Submucous cleft palate
– Down’s syndrome
41
42. Adenoids
• Adenoids cause tubal dysfunction by:
– Mechanical obstruction of the tubal opening
– Acting as reservoir for pathogenic organisms
– Inflammatory mediators in allergy cause tubal
blockage
• Adenoids can cause otitis media with effusion or
recurrent acute otitis media
• Adenoidectomy
42
45. Cleft palate
• Tubal dysfunction due to:
– Abnormalities of torus tubaris
– Tensor veli palatini doe not insert into the torus
tubaris
• Otitis media with effusion is common in these
patients
45
46. Down’s syndrome
• Dysfunction due to:
– Poor tone of tensor veli palatini
– Abnormal shape of nasopharynx
46
47. Barotrauma
• Non suppurative condition resulting from failure
of E Tube to maintain M Ear pressure at ambient
atmospheric level
• Cause:
– Rapid descent during air flight
– Under water diving
– Compression in pressure chamber
• When atm pressure > M E pressure by critical
pressure of 90mm Hg E T gets locked – Negative
pressure in ME
• T M retraction - transudation/ h’ge
47
49. • Any obstruction in the ventilation pathway
retraction pockets or atelectasis of tympanic
membrane
– Obstruction of Eustachian tube total atelectasis of tm
– Obstruction at additus cholesterol granuloma &
collection of mucoid discharge in mastoid air cells
49
50. • Other changes
– Thin atrophic TM
– Cholesteatoma
– Ossicular necrosis
– Tympanosclerotic changes
• Management
– Repair of irreversible pathologic processes
– Establishment of ventilation
50
51. Patulous Eustachian Tube
• ET is abnormally patent
• Causes:
– Idiopathic, rapid weight loss, pregnancy (esp 3rd
trim) & multiple sclerosis
• Chief complaints
– Autophony, hearing his own breath sounds
• Pressure changes in the nasopharynx are easily
transmitted to the ME
• Movements of the TM can be seen with
inspiration & expiration
51
52. • Management
– Acute cases Usually self-limiting
– Weight gain & oral administration of KI
– Long standing cases = cauterisation/ insertion of grommet
52
53. EXAMINATION OF EUSTACHIAN TUBE
Pharyngeal end of eustachian tube :posterior
rhinoscopy, rigid nasal endoscope or flexible
nasopharyngoscope
Tympanic end :microscope or endoscope
Simple examination of TM may reveal retraction
pockets or fluid in the me
Movements of TM with respiration point to
patulous eustachian tube
53
54. • Aetiologic causes of eustachian tube
dysfunction assessed through:
– Nasal examination
– Endoscopy
– Tests of allergy
– CT scan of temporal bones
– MRI to exclude multiple sclerosis
54
