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We present the first anatomical reconstruction of the Neanderthal cartilaginous Eustachian tube (CET), a vital component of the upper respiratory tract and nexus for the middle ear and postnasal airway. The Eustachian (auditory, pharyngotympanic) tube, comprised of a bony and cartilaginous (CET) portion, is integral to normal physiological functions such as middle ear aeration and pressure equilibration. Findings indicate that Neanderthal tubal morphology may have predisposed them to high rates of middle ear disease (otitis media [OM]). In living humans, mechanical CET dysfunction underlies OM in infants and young children, with sequelae including hearing loss, meningitis, and pneumonia. Despite proven linkage of CET malfunction with OM, the role of CET morphology in Neanderthal health and disease remains unstudied. We reconstructed Neanderthal CET morphology, comparing their crania to a modern human growth series. Methods included geometric morphometrics and univariate measures among Procrustes\u2010fitted coordinates. Results showed Neanderthal adults exhibiting primitively tall and narrow nasopharynges with infant\u2010like horizontal CET and choanal orientation. As horizontal CET orientation is associated with increased OM incidence in infants and children until around age six, its appearance in Neanderthal adults strongly indicates persistence of high OM susceptibility at this time. This could have compromised fitness and disease load relative to sympatric modern humans, affecting Neanderthals' ability to compete within their ecological niche, and potentially contributing to their rapid extinction. Anat Rec, 302:2109\u20132125, 2019. \u00a9 2019 American Association for Anatomy<\/jats:p>","DOI":"10.1002\/ar.24248","type":"journal-article","created":{"date-parts":[[2019,8,31]],"date-time":"2019-08-31T10:48:56Z","timestamp":1567248536000},"page":"2109-2125","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Reconstructing the Neanderthal Eustachian Tube: New Insights on Disease Susceptibility, Fitness Cost, and Extinction"],"prefix":"10.1002","volume":"302","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2323-5561","authenticated-orcid":false,"given":"Anthony Santino","family":"Pagano","sequence":"first","affiliation":[{"name":"Department of Medical Sciences Hackensack Meridian School of Medicine at Seton Hall University  Nutley New Jersey"},{"name":"NYCEP Morphometrics Group"},{"name":"Center for Anatomy and Functional Morphology Icahn School of Medicine at Mount Sinai  New York New York"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9764-1597","authenticated-orcid":false,"given":"Samuel","family":"M\u00e1rquez","sequence":"additional","affiliation":[{"name":"Department of Cell Biology SUNY Downstate College of Medicine  New York New York"},{"name":"Department of Otolaryngology SUNY Downstate College of Medicine  New York New York"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jeffrey T.","family":"Laitman","sequence":"additional","affiliation":[{"name":"Center for Anatomy and Functional Morphology Icahn School of Medicine at Mount Sinai  New York New York"},{"name":"Department of Otolaryngology Icahn School of Medicine  New York New York"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2019,9,30]]},"reference":[{"key":"e_1_2_6_2_1","doi-asserted-by":"publisher","DOI":"10.1002\/(SICI)1099-1212(199603)6:2<185::AID-OA254>3.0.CO;2-W"},{"key":"e_1_2_6_3_1","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1111\/j.1096-3642.1957.tb00280.x","article-title":"Age changes in the basicranial axis of the anthropoidea","volume":"129","author":"Ashton EH","year":"1957","journal-title":"Proc Zool Soc Lond"},{"key":"e_1_2_6_4_1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0003972"},{"key":"e_1_2_6_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/0091-6749(83)90027-1"},{"volume-title":"Eustachian tube: structure, function, role in otitis media","year":"2005","author":"Bluestone CD","key":"e_1_2_6_6_1"},{"key":"e_1_2_6_7_1","doi-asserted-by":"publisher","DOI":"10.1097\/MLG.0b013e31815ddaa0"},{"key":"e_1_2_6_8_1","doi-asserted-by":"publisher","DOI":"10.1177\/0194599812461892"},{"key":"e_1_2_6_9_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.otohns.2010.08.015"},{"key":"e_1_2_6_10_1","doi-asserted-by":"publisher","DOI":"10.1017\/S0952836903003522"},{"key":"e_1_2_6_11_1","doi-asserted-by":"publisher","DOI":"10.1002\/ar.23065"},{"key":"e_1_2_6_12_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijporl.2016.03.032"},{"key":"e_1_2_6_13_1","doi-asserted-by":"publisher","DOI":"10.1159\/000156196"},{"key":"e_1_2_6_14_1","doi-asserted-by":"crossref","first-page":"e0216742","DOI":"10.1371\/journal.pone.0216742","article-title":"Living on the edge: was demographic weakness the cause of Neanderthal demise?","volume":"14","author":"Degeoanni A","year":"2019","journal-title":"PLoS One"},{"key":"e_1_2_6_15_1","doi-asserted-by":"publisher","DOI":"10.1177\/000348940010900602"},{"key":"e_1_2_6_16_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.tree.2007.02.001"},{"key":"e_1_2_6_17_1","doi-asserted-by":"publisher","DOI":"10.1001\/archotol.1994.01880360076014"},{"key":"e_1_2_6_18_1","unstructured":"HarvatiK.2001.The Neanderthal problem: 3\u2010D Geometric morphometric models of cranial shape variation within and among species. 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