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Dr. Maue-Dickson Is Associate Professor of Pediat- Rics, University of Miami, Mailman Center for Child Development, University

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Dr. Maue-Dickson Is Associate Professor of Pediat- Rics, University of Miami, Mailman Center for Child Development, University Section II. Anatomy and Physiology WILMA MAUE-DICKSON, Ph.D. (CHAIRMAN) Introduction Middle Ear Musculature, The Auditory Tube, and The Velopharyngeal This Section has been prepared for the Mechanism purpose of updating the previous report, "Status of Research in Cleft Palate: Anat- 1. Tur Mippour® Ear omy and Physiology," published in two parts in the Cleft Palate Journal, Volume 11, The authors of the previous report 1974, and Volume 12, 1975. questioned the validity of the concept that As indicated in the previous two-part the tensor tympani and the stapedius mus- report, it is imperative to consider not only cles provide protection to the inner ear the palate but all of the oral-facial-pharyn- from loud sounds, except perhaps for geal system, both in normal and abnormal minimal protection (less than 10 dB) at low conditions, and both in the adult and in frequencies. They also cited research the developing child. Thus, this review in- which indicated that stapedius contraction cludes normal, abnormal, and develop- is more closely associated with voicing and mental studies on middle ear musculature, coughing than with acoustic stimuli, and the auditory tube, the velopharyngeal that the middle ear muscles might be in- mechanism, the tongue, the larynx, the volved in auditory tube opening. face and mandible, and blood supply and The literature reviewed for this report innervation relevant to cleft lip and palate. does not resolve all of these questions, but Though the relevance of embryology of it does add some focus for future research. the orofacial complex is obvious, it has Greisen and Neergaard (1975) used extra- been reviewed in a recently published re- tympanic phonometry to study middle ear port (Dickson, 1975) and will not be in- reflex activity and were able to demon- cluded as a separate topic in this review strate a tensor tympani reflex in response because of space limitations. Maxillary to acoustic stimuli only when a generalized growth and development, included in the startle response was provoked. They also previous report, will be covered in the cur- demonstrated that stapedius did not con- rent report under Section III, "Orofacial tract during the startle response. Like the Growth and Dentistry." data of Klockhoff (1959), Moller (1961), An effort has been made in the current Feldman (1967) and Solomon and Starr report to indicate areas in which signifi- (1963), their data indicated a close relation- cant contributions have been made during ship between stapedial contractions and the period reviewed as well as areas which acoustic stimuli. Greisen and Neergaard are still seriously in need of further defini- observed that during the startle response, tive research. As in the previous report, both tensor tympani and the auditory tube literature which largely reflects opinion muscles (especially tensor vel palatini) rather than data-based conclusions has not contract and give rise to small volume dis- been included. ' placements and subsequently to small changes in the pressure of the middle ear. They suggested that the muscles which open the auditory tube (they included lev- Dr. Maue-Dickson is Associate Professor of Pediat- rics, University of Miami, Mailman Center for Child ator veli palatini) may act synergistically Development, University of Miami, P.O. Box 52006, with the tensor tympani muscle during Biscayne Annex, Miami, Florida 33152 swallowing. A similar hypothesis, i.e., that 270 Maue-Dickson, STATE-OF-ART (ANATOMY) 271 the middle ear muscles and tensor veli pal- widened by the tensor veli palatini muscle atini may act together in auditory tube and that maximal tubal dilation occurs to- clearance, was suggested in the previous ward the middle part of the canal, with less report (Dickson, et al. 1974, 1975) and still intense dilation at the pharyngeal ostium seems tenable since both the tensor veli and at the isthmus. Misurya's study of the palatini and tensor tympani muscles are in- levator muscles indicated that dilation of nervated by the fifth cranial nerve. the isthmus lumen occurs with simultane- In summary, the consensus among the ous narrowing of the pharyngeal ostium authors reviewed here is that tensor tym- lumen. He was careful to emphasize, how- pani responds primarily and probably ex- ever, that the levator muscle cannot be clusively to non-acoustic stimuli and that considered to be an active lumen dilator stapedius responds primarily and probably since its fibers have no direct attachment to exclusively to acoustic stimuli. None of the the tube. He also demonstrated that the authors reviewed presented data in sup- concavity produced by the elevation of the port of a functional relationship between floor of the pharyngeal ostium is produced stapedius and non-acoustic stimuli or be- by contraction of the belly of the levator tween tensor tympani and acoustic stimuli. muscle. Misurya also successfully recorded Finally, while the question of the role of pressure changes from anterior and poste- the muscle(s) of the middle ear in auditory rior parts of the tube and found them to tube clearance has still not been resolved, differ but also learned that the net result the data reviewed suggest that both tensor was no change. tympani and tensor veli palatini play an The probably universal occurrence of important role in auditory tube clearance. middle ear effusion and hearing loss in As indicated in the previous review babies born with cleft palate continues to (Dickson, et al. 1974, 1975), the literature is be a source of concern. Glasscock (1971) replete with references to the very high has indicated that prolonged middle ear and probably universal incidence of mid- effusion may cause permanent damage to dle ear disease and hearing loss in infants the middle ear mechanism and may result born with cleft palate. While substantial in sensorineural as well as conductive loss. efforts have been made to determine the Bluestone, et al. (1972-a, 1972-b) have pro- possible role of the auditory tube in this vided further data on infants and children regard, the role of the middle ear muscu- with middle ear disease which again indi- lature still has not been investigated ade- cates that middle ear disease is often asso- quately. ciated with abnormalities in retrograde flow patterns through the auditory tube. 2. T'nmr AupIrorRry TUBE -His studies also suggest abnormal auditory A number of studies on auditory tube tube distensibility associated with cleft pal- anatomy and physiology in normal and ate. The research of Gerwat (1975) and cleft palate subjects have been published Bluestone and Cantekin (1975) further during the period of the current review. suggests that adenoidectomy will improve Lim (1973) published a comprehensive re- auditory tube function if mechanical ob- view of the functional morphology of the struction of the tube is present and chronic lining membrane of the middle ear and inflammation is absent (Bluestone and auditory tube. Koch (1963) published an Cantekin) or is the degree of adenoid en- excellent review of qualitative testing of largement, though insufficient to produce auditory tube function. Misurya (1975) total tubal obstruction, if sufficient to conducted an elegant study on the func- cause increased linear velocity of air flow tional anatomy of the tensor palatt and with a resultant intermittent negative pres- levator palati muscles in two dogs. Mis- sure around the pharyngeal orifice of the urya's study, which essentially replicated tube (Gerwat). the landmark studies of Rich (1920), dem- The question of the role of growth in the onstrated that the auditory tube canal is alleviation of middle ear disease associated 272 Cleft Palate Journal, October 1977, Vol. 14 No. 4 with cleft palate has still not been an- suggested that this could result in an alter- swered. However, several studies have ation of the biomechanics operating on the been published recently which bear on the auditory tube and that growth of the crani- question. Cole and Cole (1974) found that ofacial complex may play an important poor auditory tube function is not charac- role in the decreasing incidence of audi- teristic of cleft palate in the young adult tory tube malfunction in children with age group. Their research also indicated a cleft palate during the first few years of positive correlation between the level of life. observed pharyngeal wall activity and It is apparent that most of the data re- the adequacy of auditory tube function. ported recently on auditory tube function Brooks (1975) found the incidence of mid- still comes from indirect measures such as dle ear effusion to be no greater in se- the electro-acoustic bridge, and that very verely hearing-impaired individuals than little research has been done on the possi- in normal subjects at the age of 5 years. In ble anatomical, developmental, and bio- a study of newborn infants, Keith (1975) mechanical factors responsible for audi- discovered that all infants tested exhibited tory tube malfunction associated with cleft normal middle ear pressure and mobile palate. middle ear systems; they appeared to have well-aerated middle ears and showed no 3. T'ur® VELOPHARYNGEAL MECHANISM evidence of mucous or other fluid behind As indicated in the previous State of the the tympanic membrane. Art Report, there is a critical need for These studies thus support the view- further anatomical and physiological re- point that middle ear fluid is not charac- search in the areas of normal and cleft teristic of normal newborn babies and that palate to resolve questions regarding nor- it is no more common in cleft palate or mal patterns of velopharyngeal motion, hearing-impaired groups after the age of 5 the level of motion relative to the torus than it is in non-cleft palate groups. Yet, as tuberius, the role of specific muscles of the already indicated, there is ample evidence velum and pharynx in velopharyngeal that middle ear effusion is practically uni- anatomy and physiology, developmental versal in the newborn cleft palate group.
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