Eustachian tube function: physiology,

pathophysiology, and role of allergy in

pathogenesis of otitis media

Charles D. Bluestone, M.D. Pittsburgh, Pa.

Otitis media may be the result of Eustachian tube dysfunction or inJlammation of the middle ear,
or both. The Eustachian tube may be either abnormally patent (patulous or semipatulous) or,
more commonly, obstructed. Functional obstruction is most likely due to either lack of tubal
stiflness or an abnormal active opening mechanism, e.g., inefficient tensor veli palatini muscle.
Mechanical obstruction may be secondary to extrinsic causes such as a nasophatyngeal tumor
or possibly an adenoid mass. Intrinsic obstruction can result from an upper respiratory tract
infection. Even though proof that allergy is causally related to otitis media is lacking, recent
studies indicate that the Eustachian tube can become partially obstructed when upper
respiratory allergy is present. In addition, there is now some evidence that in a small
percentage of children with upper respiratory allergy, the middle ear may be a “shock organ.”
Future studies are needed to define the role of allergy in the pathophysiology of the Eustachian
tube and the pathogenesis of otitis media. Randomized clinical trials will be required to
determine the ef3cacy of the currently popular forms of immunotherapy and allergy control in
the prevention ofotitis media. (/ALLERGYCLINIUMUNOL72:242-251, 1983.)

Otitis media may be secondary to reflux, aspira-
tion, or insufflation of nasopharyngeal bacteria up the
Eustachian tube and into the middle ear.’ Inflamma-
tion (infection or allergy) may also cause intrinsic
mechanical obstruction of the Eustachian tube.*’ 3
However, hematogenous spread of bacteria into the
middle ear may also result in otitis media that is unre-
lated to the function of the Eustachian tube. The com-
monly postulated example of this mechanism is men-
ingitis associated with, but not caused by, otitis media
in young infants. A much smaller number of patients
may have primary mucosal disease of the middle ear
Dr. Bluestone is Director, Department of Otolaryngology, Chil-
dren’s Hospitaal of Pittsburgh; Professor of Otolaryngology, Uni-
versity of Pittsburgh School of Medicine, Pittsburgh, Pa.
From the Otitis Media Research Center, University of Pittsburgh
School of Medicine and Children’s Hospital of Pittsburgh
(NINCDS, 5POl NS16337). Supported in part by the Bureau of
Community and Health Services, Maternal and Child Health Re-
search Grants Program (MC-J-420434) and the Cleft Palate Cen-
ter, University of Pittsburgh School of Medicine (NINDR, 5POl
DEO1697).
Presented in part at the American Academy of Allergy, Post-
graduate Course, Hollywood, Ffa., March 1983.
Reprint requests: Charles D. Bluestone, M.D., Department of
Otolaryngology, Children’s Hospital of Pittsburgh, 125 De Soto
St., Pittsburgh, PA. 15213.
242
as a result of allergy4 or, more rarely, an abnormality
of the cilia, e.g., Kartagener syndrome.”
PHYSIOLOGY
The Eustachian tube has at least three physiologic
functions with respect to the middle ear (Fig. 1): (1)
protection from nasopharyngeal sound pressures and
secretions, (2) cIearance into the nasopharynx of se-
cretions produced within the middle ear, and (3) ven-
tilation of the middle ear to equilibrate air pressure in
the middle ear with atmospheric pressure. In ideal
tubal function, intermittent active opening of the eu-
stachian tube, due only to contraction of the tensor
veli palatini muscle during swallowing, maintains
nearly ambient pressures in the middle ear.6-R As-
sessment of these functions has been helpful in un-
derstanding the physiology and pathophysiology of
the Eustachian tube, as well as in the diagnosis and
management of children with middle ear disease.
Protective and clearance functions
The clearance or drainage function of the Eusta-
chian tube has been assessedby a variety of methods
in the past. By means of radiographic techniques, the
flow of contrast media from the middle ear (tympanic
membrane not intact) into the nasopharynx has been
VOLUME 72 Eustachian
NUMBER 3
FIG. 1. Eustachian tube-middle ear system, showing the three physiologic
Eustachian tube related to the middle ear. The active dilation of the tube is by contraction of the
tensor veli palatini muscle. NP, Nasopharynx;
muscle; ME, middle ear; TM, tympanic membrane; EC, external canal; MAST, mastoid air cells.
assessed by Aschan,s* lo Compere,“* I2 Bluestone,13
and Bluestone and associates.14’ l5 Rogers et al.16 in-
stilled a solution of fluorescein into the middle ear and
assessed the clearance function by subsequently
examining the pharynx with an ultraviolet light.
LaFaye et a1.17utilized a radioisotope technique to
monitor the flow of saline solution down the Eusta-
chian tube. Bauerls assessed clearance by observing
methylene blue in the pharynx after it had been in-
stilled into the middle ear. Elbrond and Larsenlg as-
sessed middle ear-Eustachian tube mucociliary flow
by determining the time that elapsed after saccharin
had been placed on the mucous membrane of the
middle ear until the subject reported tasting it. Unfor-
tunately, all these methods are qualitative and actually
test Eustachian tube patency rather than measure the
clearance function of the tube quantitatively.
Even though abnormalities of the protective func-
tion are directly related to the pathogenesis of otitis
media, this function has been assessedonly by radio-
graphic techniques and only by Bluestone and cowork-
ers 13-15employing a test that was a modification of
a tubal patency test described by Wittenborg and
Neuhauser .20
The protective and clearance functions of the Eusta-
chian tube have been assessed by a combined radio-
graphic technique. 14, I5 Radiopaque material was in-
stilled through the nose of children so that the retro-
grade flow of the medium from the nasopharynx into
the Eustachian tube could be observed. Patients were
considered to have normal protective function when
radiopaque material entered only the nasopharyngeal
tube function: role in pathogenesis of otitis media 243
FUNCTIONS OF THE EUSTACHIAN TUBE:
VENTILATION
PROTECTION
DRAINAGE
functions of the
ET, Eustachian tube; TVP, tensor veli palatini
or isthmic portion of the tube and did not enter the
bony portion of the tube or middle ear cavity during
swallowing. The normal Eustachian tube protected the
middle ear from the contrast material even when the
liquid was under increased nasopharyngeal pressure
during closed-nose swallowing. If, during the retro-
grade study, contrast medium traversed the entire Eu-
stachian tube and refluxed into the middle ear during
swallowing, the tube was considered to have in-
creased distensibility and poor protective function.
The effectiveness of the Eustachian tube in clearing
the radiopaque medium instilled into the middle ear
was taken as an indication of the effectiveness of the
Eustachian tube in the clearance of secretions. Rapid
and complete clearance of the medium into the
nasopharynx was considered to indicate normal drain-
age function, whereas failure of the contrast material
to drain from the middle ear into the nasopharynx
indicated mechanical obstruction of the Eustachian
tube, especially when contrast material also failed to
enter the nasopharyngeal portion of the tube during
the retrograde study. These abnormal functions of the
tube were found in patients with otitis media and were
not found in a small group of normal children.
Ventilatory function
From studies in children, the ventilatory function of
the Eustachian tube has been postulated.’ The normal
Eustachiantube is functionally obstructed or collapsed
at rest; there is probably a slight negative pressure in
the middle ear (Fig. 2). When the Eustachian tube
functions ideally, intermittent active dilation (open-
244 Bluestone
FIG. 2. Physiologic ventilation of the middle ear during active opening of the Eustachian tube by
the tensor veli palatini muscle. Symbols as in Fig. 1. A, Normal function of the Eustachian tube.
B, Ideal function to maintain near-ambient
the tube. D, Gradient-assisted opening of tube
ing) of the tube maintains near-ambient pressures in
the middle ear. It is suspected that when active func-
tion is inefficient in opening the Eustachian tube,
functional collapse of the tube persists. The interval
between openings then depends on the establishment
of a pressure gradient between the middle ear cavity
and the nasopharynx, which passively assists tubal
function. Physiologically, this gradient is achieved by
the absorption of middle ear gas, which results in the
creation of progressive negative middle ear pressure.
This type of ventilation appears to be quite common
in children, since moderate-to-high negative middle
ear pressures have been identified by tympanometry
in many children who have no apparent ear disease.21
In an effort to describe normal Eustachian tube
function by using the microflow technique inside a
pressure chamber, Elner et a1.22 studied 102 adults
with intact tympanic membranes and apparently neg-
ative otologic histories. The patients were divided
into four groups according to their abilities to equili-
brate static relative positive and negative pressures of
100 mm H20 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. The
subjects in group 3 were capable of equilibrating only
relative positive pressure with a small residual re-
maining, but not negative pressure, and those in
group 4 were incapable of equilibrating any pressure.
Toynbee’s test was negative and Valsalva’s test was
positive in all patients in groups 3 and 4. These data
probably indicate decreased stiffness of theiEustachian
tube in the subjects in groups 2 to 4 when compared
with those in group 1. This study also showed that
95% of normal adults could equilibrate an applied
J ALLERGY CLIN. IMMUNOL.
SEPTEMBER 1983
middle ear pressure. C, Partial functional collapse of
positive pressure and that 93% could equilibrate
applied negative pressure by active swallowing to
some extent. However, 28% of the subjects could not
completely equilibrate applied positive or negative
pressure, or both.
Bylandef3 compared the Eustachian tube function
of 53 children with 55 adults, all of whom had intact
tympanic membranes and who were apparently oto-
logically healthy. Employing a pressure chamber, she
reported that 35.8% of the children could not equilib-
rate applied negative intratympanic pressure (- 100
mm H20) by swallowing whereas only 5% of the
adults were unable to perform this function (Table I).
Children between 3 and 6 yr of age had worse func-
tion than the 7 to 12 yr age group. In addition, she
found that children who had tympanometric evidence
of negative pressure within the middle ear had poor
Eustachian tube function.
From these two studies, it can be concluded that
even in apparently otologically normal children, Eu-
stachian tube function is not as good as in adults. This
may contribute to the higher incidence of middle ear
disease in children as compared to adults.
In studying the parameters of middle ear pressure,
Brooks24 determined the resting middle ear pressure
by tympanometry in a large group of apparently nor-
mal children as being between 0 and - 175 mm H,O.
However, pressures outside this range have been re-
ported as normal for large populations of apparently
asymptomatic children who were measured for this
parameter by screening. 2s High negative middle ear
pressure does not necessarily indicate disease; it may
indicate only physiologic tubal obstruction. Ventila-
tion occurs, but only after the nasopharynx-middle ear
pressure gradient reaches an opening pressure. It has
been suggested that these children probably should be
VOLUME 72
Eustachian
NUMBER 3
TABLE I. Active Eustachian tube opening function
3 4 5 6
Active function:
Good 0 2 3 4
Poor 3 4 4 3
Total ears 3 6 7 7
*Adapted from Bylander A: Ann Otol Rhino1 Laryngol 89(Suppl. 68):20, 1980.
considered at risk for middle ear problems until more
is learned about the normal and abnormal physiology
of the Eustachian tube.26 In normal adults, Alberti and
Kristensen” obtained resting middle ear pressures of
between 50 and -50 mm H,O. Again, a pressure
outside this range does not necessarily mean the pa-
tient has ear disease.
The rate of gas absorption from the middle ear has
been reported to be approximately 1 ml in a 24 hr
period by several investigators.2”-31 However, since
values taken over a short period were extrapolated to
arrive at this figure, the true rate of gas absorption
over 24 hr has yet to be determined in humans.
In a study by Cantekin et al.,32 serial tympano-
grams were obtained in rhesus monkeys to determine
the gas absorption process. During a 4 hr observation
period, the middle ear pressure was approximately
normal in alert animals, whereas when the animals
were anesthetized and swallowing was absent, the
middle ear pressure dropped to -60 mm HZ0 and
remained at that level. The experiment indicated that,
normally, middle ear gases are nearly in equilibrium
with the mucosal blood-tissue gases or inner ear gas
pressures. Under these circumstances, the gas ab-
sorption rate is smali because the partial pressure
gradients are not great. In the normally functioning
Eustachian tube, the frequent openings of the tube
readily equilibrate the pressure differences between
the middle ear and the nasopharynx, with a small
volume of air (1 to 5 ~1) entering into the middle ear.
However, an abnormally functioning Eustachian tube
may alter this physiologic mechanism.
The physiological role of the mastoid air cell sys-
tem in relation to the middle ear is not fully under-
stood, but the current concept is that it acts as a surge
tank of gas (air) available to the relatively smaller
middle ear cavity. During intervals of Eustachian tube
obstruction the compliance of the tympanic mem-
brane and ossicular chain (which would affect hear-
ing) would not be decreased due to reduced middle
ear gas pressure, since there is a reservoir of gas in the
mastoid air cells. If this concept is correct, then a
tube function: role in pathogenesis of otitis media 245
related to age in 53 children with normal ears*
Age (yr)
7 8 9 10 11 12 Total ears
6 6 3 4 3 3 34 (64.2%)
3 0 I 1 I 0 19 (35.8%)
9 6 4 5 4 3 53
small mastoid air cell system could be detrimental to
the middle ear if abnormal Eustachian tube function is
present.
Posture appears to have an effect on the function of
the Eustachian tube. The mean volume of air passing
through the Eustachian tube was found to be reduced
by one third when the body was elevated 20” to the
horizontal and by two thirds when in the horizontal
position. 33 This reduction in function with change in
body position was found to be the result of venous
engorgement of the Eustachian tube.34
A seasonal variation in Eustachian tube function
was reported by Beery et a1.35In children who had
had tympanostomy tubes inserted for recurrent or
chronic otitis media with effusion, serial inflation-
deflation studies revealed better Eustachian tube
function in the summer and fall than in the winter and
spring.
Unfortunately, the true physiology of the Eusta-
chian tube-middle ear system still remains to be
defined.
PATHOPHYSIOLOGY
The major types of abnormal function of the Eusta-
chian tube that can cause otitis media appear to be
obstruction, abnormal patency, or both (Fig. 3). Eu-
stachian tube obstruction can be functional or me-
chanical, or both. Functional obstruction results from
persistent collapse of the Eustachian tube due to in-
creased tubal compliance, an abnormal active opening
mechanism, or both. Functional Eustachian tube
obstruction is common in infants and younger chil-
dren, since there appear to be marked age differences
in the cranial base that render the tensor veli palatini
muscle less efficient prior to puberty. Mechanical
obstruction of the Eustachian tube may be intrinsic or
extrinsic. Intrinsic obstruction could be the result of
abnormal geometry or intraluminal or mural factors
that could compromise the lumen of the Eustachian
tube; the most common of these is inflammation due
to infection or possibly to allergy. Extrinsic obstruc-
tion could be the result of increased extramural pres-
246 Bluestone
FIG. 3. Eustachian tube dysfunction. The tube may be either abnormally
When obstruction is present, it may be functional or mechanical, or both (see text).
sure, such as occurs when the subject is supine or
when there is peritubal compression secondary to a
tumor or, possibly, an adenoid mass.
In extreme cases of abnormal patency of the Eusta-
chian tube, the tube is open even at rest, i.e., patu-
lous. Lesser degrees of abnormal patency result in a
semipatulous Eustachian tube that is closed at rest but
has low resistance in comparison to the normal tube.
Increased patency of the tube may be due to abnormal
tube geometry or to a decrease in the extramural pres-
sure, such as occurs as a result of weight loss or
possibly as a result of mural or intraluminal factors.
EUSTACHIAN TUBE DYSFUNCTION AS
RELATED TO PATHOGENESIS OF OTITIS
MEDIA AND ATELECTASIS
Fig. 4 depicts the chain of events in the pathogene-
sis of otitis media with effusion and atelectasis. Func-
tional obstruction may result in persistent high nega-
tive middle ear pressure, and when associated with
marked collapse or retraction of the tympanic mem-
brane, it has been termed atelectasis. This condition
has been demonstrated in an experimental animal
model.:j6 After transection of the tensor veli palatini
muscle posterior to the hamulus of the pterygoid bone
in the rhesus monkey, temporary high negative mid-
dle ear pressure and severe retraction of the tympanic
membrane were noted to occur and persisted until the
muscle healed. If ventilation occurs when there is
high negative middle ear pressure, nasopharyngeal
secretions can be aspirated into the middle ear and
result in an acute bacterial otitis media with effusion.
To test this hypothesis, Cantekin et al.% unilaterally
transected the tensor muscle in the rhesus monkey.
The result was persistent high negative middle ear
pressure without effusion while in the unoperated
side, middle ear pressure remained normal. Forty-
eight hours after instillation of pneumococcus into the
nasopharynx of the monkey, acute otitis media with
effusion developed in the ear with the high negative
J. ALLERGY CLIN. IMMUNOL.
SEPTEMBER 1983
patent or obstructed.
middle ear pressure but not in the unoperated side.
If ventilation does not occur, persistent functional
Eustachian tube obstruction could result in sterile
otitis media with effusion. Cantekin et a1.“6 also re-
produced this condition in the rhesus monkey by ex-
cision of the tensor muscle, which resulted in severe
functional Eustachian tube obstruction and the devel-
opment of sterile otitis media with effusion shortly
after the procedure. Development of otitis media with
effusion at this stage might be dependent on the de-
gree and duration of the negative pressure as well as
middle ear hypoxia or hypercapnia. Since tubal open-
ing is possible in a middle ear with an effusion, aspi-
ration of nasopharyngeal secretions might occur, thus
creating the clinical condition in which persistent
otitis media with effusion and recurrent acute bacte-
rial otitis media with effusion occur together. All in-
fants with unrepaired palatal clefts and many children
with repaired cleft palates have otitis media with ef-
fusion as a result of functional obstruction of the Eu-
stachian tube. I3
Intrinsic mechanical obstruction of the Eustachian
tube is most commonly the result of inflammation.
Obstruction within the bony or protympanic portion
of the tube is usually due to acute or chronic in-
flammation of the mucosal lining, which may also be
associated with polyps or a cholesteatoma. Total
obstruction may be present at the middle ear end of
the tube. However, these conditions are the result of
Eustachian tube dysfunction and not the initial cause.
Stenosis of the Eustachian tube has also been de-
scribed, but is a rare finding.
Most ears at risk for developing atelectasis or otitis
media with effusion when inflammation is present
probably have a significant degree of functional
obstruction. An upper respiratory tract infection in
children with this condition has been shown to sig-
nificantly decrease Eustachian tube function.* Peri-
ods of upper respiratory tract infection may then result
in either atelectasis of the tympanic membrane-
VOLUME 72
Eustachian
NUMBER 3
PATHOPHYS IOLOGY PATHOGENESIS
FIG. 4. Pathogenesis of otitis media with effusion
text).
middle ear, bacterial otitis media with effusion, or a
sterile otitis media with effusion due to swelling of the
Eustachian tube lumen. The mechanisms are similar
to those described for functional Eustachian tube ob-
struction. Allergy as a cause of intrinsic mechanical
Eustachian tube obstruction has not been demon-
strated in children.37 However, in adult volunteers,
Eustachian tube obstruction has been produced by a
challenge with antigen insufflated into the nasal
cavity.”
Extrinsic mechanical obstruction of the Eustachian
tube may be the result of extrinsic compression by a
nasopharyngeal tumor or adenoids. In an attempt to
improve criteria for the preoperative selection of
children for adenoidectomy to prevent otitis media
with effusion, Bluestone et al.‘j conducted radio-
graphic studies of the nasopharynx and Eustachian
tube before and after adenoidectomy. The ventilatory
function of the Eustachian tube has also been studied
by the inflation-deflation manometric technique, both
before and after adenoidectomy, in a group of chil-
dren with recurrent or chronic otitis media with effu-
sion in whom tympanostomy tubes had been in-
serted.% The results of these studies indicated that
after adenoidectomy, Eustachian tube function im-
proved in some, remained the same in others, and in a
few children worsened. Improvement was related to a
reduction of extrinsic mechanical obstruction of the
Eustachian tube.
Partial tube obstruction may result only in atelec-
tube function: role in pathogenesis of otitis media 247
PATHOLOGY
and atelectasis of the tympanic membrane (see
tasis of the tympanic membrane-middle ear or a bac-
terial otitis media with effusion, but more severe
obstruction could result in a sterile otitis media with
effusion. Otitis media with effusion has been pro-
duced in animal models when the Eustachian tube was
mechanically obstructed.3g
Fig. 4 also depicts the possible sequence of events
that can cause an otitis media with effusion when the
Eustachian tube is abnormally patent. A patulous Eu-
stachian tube usually permits air to flow readily from
the nasopharynx into the middle ear, which thus re-
mains well ventilated; however, unwanted nasopha-
ryngeal secretions can also traverse the tube and result
in reflux otitis media. A semipatulous Eustachian tube
may be obstructed functionally as the result of in-
creased tubal compliance, and the middle ear may
even have negative pressure, or an effusion, or both.
Since the tubal walls are abnormally distensible,
nasopharyngeal secretions may readily be insufflated
into the middle ear even with modest positive naso-
pharyngeal pressures, e.g., as a result of noseblow-
ing, sneezing, crying, or closed-nose swallowing. If
active tubal opening (tensor veli palatini contraction)
occurs, resulting in an abnormally patent tube, reflux
or insufflation of nasopharyngeal secretions is also
likely.
If the Eustachian tube has lower resistance than
normal but remains functionally obstructed even dur-
ing attempts at active tubal opening, it is conceivable
that nasopharyngeal secretions would enter the middle
248 Bluestone
POSlflYB
Phase
FIG. 5. Toynbee phenomenon
ear more readily than would air. American Indians
have been shown to have tubal resistancesthat are
lower than those of the averagewhite person.40They
seem to have an increased incidence of reflux of
nasopharyngealsecretion into the middle ear and fre-
quently suffer from recurrent acuteotitis media that is
often associated with perforation and discharge.
However, American Indians have a low incidence of
cholesteatoma.This type of Eustachiantube function
and middle ear diseaseis different from the types of
diseaseseenin individuals who have a cleft palate.
Nasal obstruction related to Eustachian
tube function
Nasal obstruction may also be involved in the
pathogenesisof otitis media with effusion. Swallow-
ing when the nose is obstructed (due to inflammation
or obstructed adenoids) results in an initial positive
nasopharyngealair pressure, followed by a negative
pressure phase. When the tube is pliant, positive
nasopharyngealpressuremight insufflate infected se-
cretions into the middle ear, especially when the
middle ear has a high negative pressure(Fig. 5); with
negative nasopharyngealpressure, such a tube could
be prevented from opening and be further obstructed
functionally floynbee phenomenon).38*41
Allergy and Eustachian tube function
Allergy is thought to be one of the etiologic factors
in otitis media with effusion, since otitis media with
effusion occurs frequently in allergic individuals .42,43
The mechanism by which allergy might cause otitis
media with effusion remains hypothetical and con-
troversial, but there is now somesupport that mucosal
swelling associatedwith nasal allergy extends to the
Eustachian tube and causes intrinsic mechanical
obstruction.3 The role of allergy in the etiology and
pathogenesisof acute and chronic otitis media with
effusion may be one or more of the following mecha-
nisms: (1) middle ear functioning as a “shock or-
gan,” (2) inflammatory swelling of the Eustachian
J. ALLERGY CLIN. IMMUNOL.
SEPTEMBER 1983
Negative Phase
(see text).
tube, (3) inflammatory obstruction of the nose, or (4)
aspiration of bacteria-laden allergic nasopharyngeal
secretionsinto the middle ear cavity. The latter three
mechanisms would be associated with abnormal
function of the Eustachian tube. In studies by Bem-
stein et al. ,4 15% of children with proven allergy did
have some evidence that the middle ear may be a
target organ, but they consideredthis condition to be
rare. It seemsreasonablethat children with signs and
symptomsof upper respiratory allergy may have otitis
media as a result of the allergic condition.
Eustachian tube function related
to cleft palate
Otitis media with effusion is universally present in
infants with an unrepaired cleft of the palate.44,45
Palaterepair appearsto improve middle ear status,but
middle ear diseasenonethelessoften continues or re-
curs even after palate repair.46Radiographic assess-
ment has shown that infants and children with both
repaired and unrepaired cleft palate have abnormal
Eustachian tube function, which suggestsan abnor-
mal opening mechanism in the infants with an unre-
paired cleft palate,I3347plus a persistentfailure of the
Eustachian tube to open actively or increaseddisten-
sibility of the Eustachiantube, or both, after repair of
the soft palate.I3
Inflation-deflation manometric Eustachian tube
function testshave shown that infants with unrepaired
cleft palates have variable degrees of difficulty in
equilibrating increased middle ear pressure and are
unable to equilibrate negative pressure by active
function (swallowing). 48Children with repaired pal-
ates either had the sametype of test results as those
with unrepaired palates or had lower opening pres-
sures. Doyle et al. ,4yemploying the forced-response
Eustachian tube function test, found that the Eusta-
chian tubes of infants and children with cleft palates
constrictedinsteadof dilating during swallowing. An-
imal models in which the palate was surgically split
have developed otitis media with effusion.50z51
VOLUME 72
Eustachian
NUMBER 3
All these studies indicated that the Eustachian tube
is functionally obstructed in children with cleft pal-
ates, which results in middle ear disease characterized
by persistent or recurrent high negative middle ear
pressure, effusion, or both. Cholesteatoma is a fre-
quent sequela in such children; this is not the case in
American Indians, in whom the Eustachian tube has
been shown to be abnormally patent, i.e., to have low
tubal resistance.
Patients with a submucous cleft of the palate appear
to have the same risk of developing middle ear disease
as those with an overt cleft. In addition, the presence
of a bifid uvula has also been associated with a high
incidence of otitis media.“* Both of these conditions
are probably associated with the same pathogenic
mechanism for otitis media as is found in patients
with overt cleft palates, i.e., functional obstruction of
the Eustachian tube.
OTHER CAUSES OF EUSTACHIAN
TUBE DYSFUNCTION
There are many other etiologic factors responsible
for abnormal function of the Eustachian tube. In-
flammation of the nose-nasopharynx-Eustachian
tube- middle ear system has been presented as a major
factor in the pathogenesis of otitis media, but there are
congenital, traumatic, neoplastic, degenerative, met-
abolic, and idiopathic conditions that also can result
in tubal abnormalities.
Since a cleft of the palate results in functional
obstruction of the Eustachian tube, any child with a
craniofacial malformation that has an associated cleft
of the palate will have otitis media or a related
condition-one of the more common examples being
Pierre-Robin syndrome. However, children with cra-
niofacial anomalies that do not include an overt cleft
of the palate also have an increased incidence of mid-
dle ear disease. These anomalies include, among oth-
ers, syndromes such as the Down, Crouzon, Apert,
and Turner. Even though there have been no reports
of formal Eustachian tube function studies in indi-
viduals with these and other anomalies, dysfunction
of the Eustachian tube is the most likely cause of such
ear disease. Presumably, a defect related to the ab-
normal craniofacial complex influences the relation
between the Eustachian tube and the tensor veli pala-
tini muscle.
Even in the absence of an obvious craniofacial mal-
formation that is associated with otitis media, there is
some evidence that children and adults with middle
ear disease have a congenital defect that results in a
dysfunction of the tube. Such a dysfunction could be
abnormal patency or functional obstruction of the tube
tube function: role in pathogenesis of otitis media 249
that is the result of an abnormal relation between the
Eustachian tube and the tensor veli palatini muscle.
Such an assumption is supported by apparent racial
differences in the prevalence and incidence of otitis
media: Eskimos and American Indians have a higher
incidence of otitis media which is half that in whites.
There is also some evidence that otitis media is more
prevalent in certain families. In the Boston collabora-
tive study a familial tendency to otitis media has been
found (W. J . Doyle, personal communication).
It has also been observed that patients with dento-
facial abnormalities may have otitis media or develop
middle ear disease as a result of these abnormalities.
Correction of the defect to relieve the Eustachian tube
dysfunction would appear to be indicated.
In certain patients with a deviated nasal septum,
impaired Eustachian tube function has been reported.
This dysfunction is especially apparent during at-
tempts to equilibrate middle ear pressure by the Val-
salva maneuver during periods of wide fluctuations in
barometric pressure, e.g., flying in an airplane or div-
ing. In such cases, successful inflation of the middle
ear by the Valsalva maneuver has been reported after
repair of the deviated nasal septum.“”
Trauma to the palate, the pterygoid bone, the tensor
veli palatini muscle, or the Eustachian tube itself can
also result in abnormal Eustachian tube function. In-
jury to the trigeminal nerve, or more specifically to
the mandibular branch of this nerve, can result in
either functional obstruction of the Eustachian tube or
a patulous tube, since the innervation of the tensor
veli palatini is from this nerve. 7. j4 The trauma may be
associated with surgical procedures such as palatal or
maxillary resection for tumors.
Neoplastic disease, either benign or malignant, that
invades the palate and pterygoid bone can interfere
with tensor veli palatini muscle function and result
in functional obstruction of the tube. Functional ob-
struction or abnormal patency of the tube can also
occur from involvement of the innervation of the ten-
sor veli palatini muscle. Mechanical obstruction of
the Eustachian tube can result from direct invasion by
neoplasm. Degenerative and metabolic diseases such
as myasthenia gravis can alter the Eustachian tube by
affecting the tubal musculature or by changing the
extramural or mural pressures in such a way as would
occur with major shifts of extracellular fluids.
Finally, whenever Eustachian tube dysfunction is
diagnosed and the etiology is obscure, the dysfunction
is usually considered to be idiopathic. Most patients
with otitis media have been found to have functional
obstruction of the Eustachian tube with an idiopathic
etiology. It should not be forgotten, however, that the
250 Bluestone
cause may be a variation in the anatomy of the base of
the skull.
I thank Sandra K. Arjona for editorial assistance and
preparation of the manuscript.
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