ANATOMY OF

A N
EXTERNAL
M &
A H
MIDDLE EAR
L R
SA
AI
. F Dr. A.T.M Faisal Rahman

DR DLO Trainee
DEPARTMENT OF OTOLARYNGOLOGY-
HEAD AND NECK SURGERY
CMH DHAKA
INTRODUCTION
A N
 Anatomical unit serving both hearing and equilibrium
 In the embryo
H M
1. the external ear
2. the middle ear RA
3. the inner ear
A L
IS
FA
R.
D
The External Ear

 Involved in N
hearing only A
 Structures of H M
the external RA
ear
A L
 Pinna IS
(auricle)
FA
 ExternalR.
D canal
auditory
 A N
H M
RA
A L
IS
FA
R.
D
 PINNA
• Around 6 t h week of IUL

pharyngeal cleft . A N
•Develops from six hillocks or TUBERCLES OF HIS around 1st

•1STubercle- 1st branchial arch

H M
•REST
T – 2 nd branchial arch
RA
A L
IS
FA
R.
D
 ANOMALIES OF PINNA
 PRE-AURICULAR SINUS- Preauricular sinuses and cysts result from
developmental defects of the first and second pharyngeal arches.
 ANOTIA – Failure of development of hillocks .
A N
tubercle causing absence of antihelix .
H M
 BAT EAR DEFORMITY – abnormally protruding human ear due to Defective development of 4 t h

RA
A L
IS
FA
R.
D
 A N
H M
RA
A L
IS
FA
R.
D
 PINNA
 Single sheet of yellow elastic fibrocartilage

N
 2 surfaces- medial(cranial) , lateral.
 Medial surface- convex
A
 Lateral surface- concave with folds &
H M
hollows.
RA
A L
IS
FA
R.
D
 Lateral surface
 HELIX – most prominent outer fold.
 ANTIHELIX- fold infront of helix.
A N
M
 CONCHA – infront of antihelix , hollow space

H
divided by crus of helix – Cymba conchae &
Cavum conchae.
 TRAGUS- cartilaginous projection anterior to
RA
cavum concha.

A
 SCAPHOID FOSSA – boat shaped space b/w L
upper part of helix & antihelix .
IS
FA
 INCISURA TERMINALIS- space b/w crus of helix
& tragus.
R.
conchae ,
infront of antihelix .
D
 FOSSA TRIANGULARIS- in upper part of cavum
 2 LIGAMENTS –
- Anterior ligament
- Posterior ligament

 MUSCLES –
A
-EXTRINSIC – Auricularis anterior ,posterior, superior
N (connect

- INTRINSIC - connect the different partsH

M
the auricle to the skull and scalp and move the auricle as a whole)
of the auricle

R A
A L
I S
F A
R .
D
 IMPORTANCE
 INCISURA TERMINALIS- This area is devoid of cartilage ,
can be used for giving incision for procedures in ear to avoid
A N
post- op perichondritis .

H M
 LATERAL SURFACE – Skin is firmly adherent to
RA
perichondrium ; so more prone for frost bite.
A L
 MEDIAL SURFACE – More of subcutaneous I S tissue , skin
F A
is loosely adherent to underlying cartilage ; so cysts like
sebaceous cyst are common .
R .
D
IMPORTANCE
Stripping the perichondrium from the
cartilage, as occurs following injuries
A N
that cause haematoma, can lead to
cartilage necrosis with crumpled up H M
'boxer's ears'.
RA
A L
IS
FA
R.
D
 BLOOD SUPPLY

N
 ARTERIAL SUPPLY – External carotid artery
 Posterior auricular artery
A
 Anterior auricular branches of superficial
temporal artery
H M
 Superior auricular artery
RA
 VENOUS DRAINAGE-
A
Auricular veins L
IS
correspond to the arteries of the auricle.

A
Arteriovenous anastomoses are numerous in the
F
.
skin of the auricle and are thought to be

R
important in the regulation of core temperature

D
 NERVE SUPPLY

A N
H M
RA
A L
IS
FA
R.
D
 A N
H M
RA
A L
IS
FA
R.
D
 LYMPHATIC DRAINAGE
 The posterior aspect of the pinna
A N
drains to nodes at the mastoid tip.
H M
 The tragus and upper part of the pinna
drain into pre- auricular nodes RA
A
 The remainder of the pinna drains L
IS
to upper deep cervical lymph
nodes.
FA
R.
D
EXTERNAL
AUDITORY CANAL
A N
• Dimensions: EAC measures about 24 mm

H M
A
• Extends from the concha to the tympanic membrane
• Its anterior wall & floor are 6 mm longer than the
posterior wall & roof
• EAC is usually divided into 2 parts:
Its outer one-third (8
L R
A
• mm) is cartilaginous and its inner two-third (16

S
mm) is bony.

• Direction: EAC is ‘S’ shaped

AI
. F
• Outer one-third is directed upwards, backwards &
medially

medially
R
• Inner two-third is directed downwards, forwards &

D
• Anatomically divided into – pars externa, pars media
& pars interna
RELATIONS OF BONY
EAC
A N
H M
•

•
Superior: Middle cranial fossa
Inferior: Parotid gland
RA
• Posterior: Mastoid antrum and air cells
A L
S
and the facial nerve
•

AI
Anterior: Temporomandibular joint

F
(TMJ)
•
•
Medial: Tympanic membrane
Lateral: Cartilaginous EAC
R.
D
CARTILAGENOUS
EAC
A N
• Fissures of Santorini: Transverse slits in the
H M
floor of cartilaginous EAC, provide passages
for infections and neoplasms to and from the
surrounding soft tissue (parotid & mastoid)
RA
• Hair follicles are present only in the
outer cartilaginous canal and therefore
A L
furuncles are seen only here in
IS
A
Cartilagenous EAC
•

. F
The skin of the cartilaginous canal is thick and
contains ceruminous and pilosebaceous glands

DR
that secrete wax. The hydrophobic, slightly
acidic (pH 6.0–6.5) cerumen is formed in this
part of EAC.
BONY EAC
A N
• It is mainly formed by the tympanic portion of
temporal bone but roof is formed by the
H M
•
squamous part of the temporal bone
In the anterosuperior region,
RA
squamous part articulates with
tympanic bone
A L
•
(tympanosquamous suture).

IS
Inferiorly and medially squamous part joins

A
with the lateral superior portion of the petrous

F
.
bone (petrosquamous suture).

R
• Skin of the bony EAC is thin and

D
continuous over the tympanic membrane &
skin is devoid of subcutaneous layer, hair
follicles and ceruminous glands.
 A N
• Isthmus: Approximately 6 mm
H M
lateral to tympanic membrane, bony
EAC has a narrowing called the
isthmus. Foreign body impacted RA
medial to bony isthmus of EAC are
A L
S
difficult to remove.
•

AI
Foramen of Huschke: In children and

F
occasionally in adults, anteroinferior

R.
bony EAC may have a deficiency that
is called foramen of Huschke. It

D
permits spread of infections to and from
EAC and parotid.
NERVE
SUPPLY • Auriculotemporal nerve (CN V3): It is a

A N
branch of mandibular division of trigeminal
nerve and supplies antero-superior wall of

•
EAC.
H M
CN X (vagus nerve): Its auricular branch

RA
(Arnold’s nerve) supplies to infero-
posterior wall of EAC.
•

A L
CN VII (facial nerve): It innervates the

IS skin of the mastoid and posterior of

EAC.

FA
R.
D
CLINICAL IMPORTANCE OF N/S OF EAC

N
 Hitzelberger’s sign: The hypoesthesia of posterior
meatal wall occurs due to the pressure on facial nerve
(sensory fibers are affected early) in patients with A
acoustic neuroma.
H M
A
Vasovagal reflex: While cleaning the EAC, patient may


L R
develop coughing, bradycardia, syncope and even
cardiac arrest. They can occur because of Arnold’s

A
branch of vagus nerve.
S


AI
Appetite: Because of vagal innervation, instilling spirit in
EAC before meal can stimulate appetite.

. F
Ramsay Hunt syndrome: Vesicles of herpes zoster

DR
oticus occur on mastoid and posterior meatal wall
which indicate that this part of external ear has facial
nerve innervation.
TYMPANIC MEMBRANE

A N
H M
• Dimensions: Its dimensions are: 9–10 mm
height
RA
• and 8–9 mm width. It is 0.1 mm thick.

A
• „Position: Tympanic membrane (TM) is a L
IS
partition wall between the EAC and the

angle of 55° with deep EAC. Its

FA
middle ear. It is positioned obliquely. It forms

anteroinferior part.
R.
posterosuperior part is more lateral than its

D
 • Structure: Tympanic membrane consists of the
following three layers

A N
• Outer epithelial layer (Cuticular Stratum): It is
continuous with the EAC skin. Keratinised,
stratified squamous type. 10 cells thick.
M
• * The cells have a propensity for lateral migration
H
RA
• Middle fibrous layer (Fibrous Stratum): It encloses
the handle of malleus and consists of three types of

L
fibers: radial, circular and parabolic. In comparison
to pars tensa, this layer is very thin in pars flaccida

SA (consists of loose conn. tissue) and not organized into

AI various fibers.

F
• Inner mucosal layer (Mucous Stratum): It is

R. continuous with the middle ear mucosa. Single layer

of flat cells. Cilliated collumnar cells are absent over

D medial aspect of TM.

 „Parts: Tympanic membrane consists of two parts:
 Pars tensa: It forms most of tympanic membrane
 Annulus tympanicus: TM is thickened in the periphery and

that fits in the tympanic sulcus.

A N
forms a fibrocartilaginous ring called the annulus tympanicus

M
 Umbo: The central part of TM near the tip of malleus is tended

H
inwards and is called the umbo.

A
 Cone of light: A bright cone of light radiating from the tip of

usually seen during otoscopy.

L R
malleus to the periphery in the anteroinferior quadrant is

SA
Pars flaccida (Shrapnell’s membrane): It is situated

AI
above the lateral process of malleus between the notch
of Rivinus and the anterior and posterior malleal folds.

. F
It is not as tense as pars tensa and may appear

R
little pinkish.

D
 A N
H M
RA
A L
IS
FA
R.
D
NERVE SUPPLY:
A N
• Auriculotemporal nerve (CN V3): It is
a branch of mandibular division of
H M
trigeminal nerve and supplies anterior
half of lateral surface of TM.
RA
• CN X (vagus nerve): Its auricular
A L
IS
branch (Arnold’s nerve) supplies to
posterior half of lateral surface of
TM.
FA
•

R.
CN IX (glossopharyngeal nerve):

D
Its tympanic branch (Jacobson’s
nerve) supplies to medial surface
of tympanic membrane.
MIDDLE EAR
TYMPANIC CAVITY AND AUDITORY
A N
MEATUS
H M
 1st pharyngeal pouch
RA
 Contact with 1st pharyngeal cleft

A L
 Distal part – primitive tympanic cavity

IS
 Proximal part – auditory tube

FA
R.
D
Ossicles
 Malleus and incus - 1st pharyngeal pouch
A N
 Stapes - 2nd pharyngeal pouch
H M
month RA
 Remain embedded in the mesenchyme until 8th

A L
 Tympanic cavity becomes twice its original size

IS
 Endoderm epithelium connects ossicles to the wall

FA
of the cavity in mesentary like fashion.

R.
 Supporting ligaments of ossicles develop later.
D
Ossicles
A N
 During late fetal life, by vacuolization of surrounding
tissue form tymapnic antrum.
H M
 After birth – pneumatization
RA
 Later, most of the mastoid air sinus come in contact
L
with the antrum and tympanic cavity – middle ear
A
infection.
IS
FA
R.
D
 MIDDLE EAR

 The middle ear cleft is lined by mucous membrane

and filled with air
 Consists of the middle ear,
A N
eustachian tube,
H M
aditus ad antrum,
mastoid antrum and
RA
mastoid air cells.
A L
IS
 Middle ear is a 1 to 2 cm3 air filled cavity that

A
houses ossicles, stapedius and tensor tympani
F
plexus. R.
muscles and chorda tympani nerve and tympanic

D
RELATIONS OF MIDDLE EAR CLEFT
Roof: Tegmen plate separates it from middle
N


A
cranial fossa and its contents like meninges and
temporal lobe of cerebrum.
 „Floor: Jugular bulb
H M
RA
 Medial: Labyrinth & the Lateral semicircular
canal
A L
S
lies posterosuperior to facial nerve.
I
A
 „Posterior: Sigmoid venous sinus

F
R.
 Anterior: Petrous part of internal carotid artery
lying in carotid canal
D
 Posteromedial: Posteromedial to mastoid air cells
is situated cerebellum in the posterior cranial
fossa
 A N
H M
RA
A L
IS
FA
R.
D
PARTS OF MIDDLE EAR
Mesotympanum: This is the portion of middle ear
N

that lies at the level of pars tensa.
A
H M
 Epitympanum (attic): This is the portion of middle
ear that lies above the level of pars tensa and

RA
medial to Shrapnell’s membrane and the bony
lateral attic wall.
A L
IS
 Hypotympanum: This is the portion of middle ear
that lies below the level of pars tensa.
FA
.
 Protympanum: The portion of middle ear around

DR
the eustachian tube opening is termed as
protympanum. Presence of more goblet cells near
the orifice of E. Tube
MIDDLE EAR

A N
H M
RA
A L
IS
FA
R.
D
 BOUNDARIES OF
MIDDLE EAR
A N
• Middle ear has six boundaries: roof, floor, and medial,
• lateral, anterior and posterior walls.
H M
• Roof (Tegmental wall): It is formed by tegmen
tympani (a thin plate of bone), which extends
RA
L
posteriorly to form the roof of the aditus and antrum

A
(tegmen antri). Tegmen tympani separates middle ear

S
from the middle cranial fossa.

AI
Floor (Jugular wall): The floor, a thin plate of bone,

F
• separates tympanic cavity from the jugular bulb.
• 
.
The floor of middle ear may be

R
congenitally dehiscent. In such cases, jugular bulb

D
projects into the middle ear and is at greater risk
of injury during surgery because it is only covered
by middle ear mucosa.
3. Anterior (carotid wall): The anterior wall, a thin
plate of bone, which separates the middle ear
cavity from internal carotid artery, has following
features: A N
 Eustachian tube: It connects the middle ear with
H M
nasopharynx. It aerates and drains the middle ear.

RA
Malfunctioning of eustachian tube is common cause of


ear infections especially in children.

A L
Canal of tensor tympani muscle: It is situated in the
roof of eustachian tube.
IS

FA
Canal for chorda tympani nerve (Canal of Huguier)


R.
Attachment of anterior malleolar ligament.

D
Canal for Lesser Petrosal Nr

 Canal for branch from Int. Carotid Plexus to
tympanic
plexus (Caroticotympanic Nr)
4. Posterior (mastoid wall): It lies close to the mastoid
air cells and presents following structures:
 Pyramid: It is a bony projection through the summit of
which appears the tendon of the stapedius muscle that
is inserted to the neck of stapes.
A N
 Aditus ad antrum: It is an opening through which
H M
mastoid antrum opens into the attic. It lies above the
pyramid. Its relations are following:

RA
Medial: Bony prominence of the horizontal semicircular
canal.

A L
 Lateral: Fossa incudis, to which is attached the short process

of incus.
IS
A
 Inferior: Fallopian canal for facial nerve.


. F
Facial nerve: The vertical mastoid part of the fallopian
canal for facial nerve runs in the posterior wall just

DR
behind the pyramid.
 Facial (suprapyramidal) recess: This recess is a
depression in the posterior wall lateral to the pyramid.
Its boundaries are following:

A N
 Medial: Vertical part of CN VII.
 Lateral: Chorda tympani (branch of 7th CN) and tympanic

H M
annulus.

RA
 Superior: Fossa incudis, in which lies short process of incus.

A L

lies medial to the pyramid. IS
Sinus (infrapyramidal) tympani: This deep recess

FA
R.
D
 A N
H M
RA
A L
IS
FA
R.
D
5. Medial (labyrinthine wall): It is formed by the
lateral wall of labyrinth. It presents following
structures:
 Promontory: It is a bony bulge which is due to the
A N
basal coil of cochlea. Tympanic plexus present over it.
Anteriorly – rel to apex of cochlea
Posteriorly – rel to sinus tympani
H M


RA
Oval window (fenestra vestibuli/ovalis): Kidney
shaped opening. Situated above and behind

A L
promontory. The footplate of stapes is placed over this
window guarded by anular ligament.

IS
Round window (fenestra cochleae/rotunda): lies
A
below & behind F.Ovalis. It is covered by the secondary
F
mucosa
R.
tympanic membrane, having 3 layers : External – tymp

D
Intermediate – fibrous layer
Internal – cochlear lining membrane.
FACIAL NERVE COURSE IN RELATION TO
MIDDLE EAR (LATERAL VIEW)

A N
H M
RA
A L
IS
FA
R.
D
 FACIAL NERVE COURSE IN RELATION TO
MIDDLE EAR (MEDIAL VIEW)

A N
H M
RA
A L
IS
FA
R.
D
 A N
H M
RA
A L
IS
FA
R .
FACIALD
NERVE COURSE IN THE MEDIAL WALL OF
MIDDLE EAR
 Horizontal tympanic part of fallopian canal for facial
nerve: It lies above the oval window.
A N
M
The tympanic segment of facial nerve canal may be


H
congenitally dehiscent and the exposed facial nerve becomes

A
vulnerable to injuries or infection.

canal, facial nerve.
L R
Lateral semicircular canal: It lies above the fallopian


SA
Processus cochleariformis: It is a hook-like

AI
projection, which lies anterior to the oval window. The
tendon of tensor tympani takes a turn on this

. F
process and then is inserted on the neck of malleus.


DR
Processus cochleariformis is an important surgical landmark
for the level of the genu of the facial nerve.
6. Lateral (membranous wall)

A N
Tympanic membrane: Lateral wall is formed mainly by

H M
the tympanic membrane. Some structures of the middle
ear (such as long process of incus, incudostapedial

RA
joint, round window and eustachian tube) can be seen
through the normal semitransparent tympanic
membrane.
A L


IS
Scutum: An upper part of epitympanum is formed by
outer bony attic wall called scutum.

FA
R.
D
 Eustachian tube Anatomy
• 36 mm long in adults.

A N
M
• Directed anteriorly, inferiorly & medially from anterior wall of
H
M.E., forming angle
A
of 450 with horizontal
R
•
A L
Enters naso-pharynx 1.25 cm behind posterior end of inferior

I S
turbinate.
F A
•
R .
Channel connecting tympanic cavity and nasopharynx

• D
lumen of the Eustachian tube is roughly triangular,
measuring
2-3 mm vertically and 3-4 mm horizontally.
 Pharyngeal opening
49

A N
H M
RA
A L
IS
FA
R.
D
50 Parts
• Lateral 1/3 is bony
A N
• Medial 2/3 is fibro-
H M
cartilaginous.
RA
• Junction b/w 2 parts is
A L
I S
A
isthmus, narrowest part
F
R .
of Eustachian Tube.
D
51

• Bony part :
A N
•
•
12mm long
H M
•
widest at tympanic end
RA
L
gradually narrows towards isthmus (2mm)
A
•
S
Thin plate of separating from tensor
I
A
tympani superiorly
F
.
• Plate of bone separating from internal
R
D
carotid medially
52

• Cartilaginous part
• 24mm long A N
M
• Cartilage forms posteromedial wall and a small
H
portion anterolaterally
RA
• sits in a groove between petrous temporal bone
L
and greater wing of sphenoid
A
S
• nasopharyngeal opening surrounded by tubal
I
A
elevation above and behind
F
.
• Fossa of Rosen Muller lying behind this tubal
R
D
elevation
53
Anatomy

N
• Lining epithelium: pseudo stratified ciliated columnar
A
• Arterial supply: ascending pharyngeal &
H M
A
middle meningealRarteries
A L
•
I S
Venous drainage: pharyngeal & pterygoid
F A
R . venous plexus
D
• Lymphatic drainage: retropharyngeal node
 Anatomy
Muscle attachments:
Muscles attached to ET
A N
Levaor palati – lower surface of petrous bone and cartilage
and fascia of upper carotid sheath
H M
RA
A
cartilaginous flange L
Tensor palati- bony wall of scaphoid and whole length of short

IS
FA
R.
Salphingo pharyngeus – inferior part of cartilage near its
pharyngeal end
D
Tensor tympani – cartilage of ET, surrounding bony canal and
14
greater wing of sphenoid
55 Nerve supply

• Tubal mucosa – tympanic branch of cranial

A N
nerve IX
H M
• R A
Tensor veli palatini - Mandibular branch of
A L
trigeminal
IS
• F A
Levator veli .palatini
• Salpingo
R
Dpharygeus Pharyngeal plexus
56 Endoscopic Anatomy

• Medial end forms tubal

A N
elevation / torus tubarius
H M
• Lymphoid collection over
RA
A
torus is called Gerlach’s tubal L
IS
tonsil.
F A
Postero-superior. to torus is
•
D R
fossa of Rosenmüller.
Adult vs. Child (< 7 yr)

A N
H M
RA
A L
IS
FA
R.
D
17
 Adult vs INFANT
ADULT INFANT
Length 36 mm
A N
18 mm
Angle with horizontal 45 0
H M 10 0
Lumen RA
Narrower Wider

A L
IS
Angulation at isthmus Present Absent
Cartilage A
. F Rigid Flaccid

D R
Elastic recoil Effective Ineffective
Ostmann’s fat More Less
18
59

Infant E. tube
A N
• wider shorter and more horizontal
secretions even milk canH
M
So
nasopharynx
R A
regurgitate to middle ear if infant
from
not fed in head
up position
A L
I S
FA
R .
D
 OSSICLES
 The ossicles conduct sound energy from the tympanic
membrane to the oval window. There are three middle
ear ossicles.
A N
1. Malleus (Hammer): It consists of a head, neck,
handle (manubrium), a lateral and an anterior H M
process. It is the largest ossicle and measures 8
RA

mm in length.
A
Head and Neck: They lie in the attic. L

IS
Manubrium(handle): It is embedded in the fibrous layer
of the tympanic membrane.
FA
.
Anterior process: bony spicule connected to


fibres
DR
petrotympanic fissure by ligamentous

 Lateral process: It appears as a knob-like projection on

the outer surface of the tympanic membrane and
provides attachments to the anterior and posterior
2. Incus (Anvil): It consists of following parts:
 Body and Short process: They lie in the attic. Short pr.
Is connected to fossa incudis by lig. fibres in
epitympanic recess A N
 Long process: It hangs vertically and medial & parallel
H M
to malleus handle and forms incudostapedial joint
with the head of stapes by its lenticular process.
RA
3. Stapes (Stirrup):
A L

mm. IS
This smallest bone of body measures about 3.5

FA
It consists of head, neck, anterior and posterior crura
.


R
and footplate.

annular ligament D
The footplate is positioned in the oval window by
 A N
H M
RA
A L
IS
FA
R.
D
LIGAMENTS OF
OSSICLES
Malleus
N


A
 Anterior ligament of Malleus: neck of malleus to ant wall of
tympanic cavity

externus mallei
H M
Contains muscle fibers called as Laxator tympani/ Musculus

A
 Lateral ligament of Malleus: triangular band, from post

R
border of tympanic inscisure to head of malleus
 Superior ligament of Malleus: head of malleus to roof of
epitympanic recess
A L
S
 Incus

fossa incudis
AI
Posterior ligament of Incus: from end of short process to

. F
Superior ligament of Incus: body to roof of epitympanic
recess
 Stapes
 DR
Vestibular surf & rim of stapedial base covered with hyaline
cartilage, which is attached to margin of fen. vestibuli by
annular ligament
MUSCLES OF TYMPANIC CAVITY
Tensor tympani: It runs above the eustachian tube
N

in a bony tunnel. Its tendon turns round the
A
processus cochleariformis and passes laterally.
H M
Origin: from the bony tunnel, the cart. part of E.Tube &
A


R
the adjoining part of greater wing of Sphenoid.

L
Insertion: Just below the neck of malleus.



SA
N/S: It develops from the 1st branchial arch and is

AI
supplied by a branch of the nerve to medial pterygoid,
a br of mandibular division of trigeminal nerve (CN V3).

. F
B/S: sup. tympanic br of middle meningeal artery


DR
Action : It tenses the tympanic membrane by drawing
the handle of malleus medially.
 Stapedius: On contraction it dampens the loud
sounds and prevents noise trauma to the inner ear.

A N
Origin: Conical cavity and canal within pyramid (on post.
tymp wall).
 Insertion: It inserts to the neck stapes.
H M


RA
N/S: It is developed from the 2nd branchial arch and is
supplied by a branch of CN VII (nerve to stapedius of
facial nerve)
A L
S
B/S: branches of Posterior auricular, anterior tympanic &


I
middle meningeal arteries
A


. F
Action: damp down excessive sound vibrations.
Opposes action of tensor tympani which pushes the

DR
stapes more tightly into fenestra vestibuli
ACOUSTIC REFLEX
When noises are loud, there occurs reflex
N

contraction of stapedius and tensor tympani which
A
before vibrations reach the internal ear. H M
helps to dampen the movement of ossicular chain


RA
Afferent pathway: auditory component of 8th Cr Nr


A L
Efferent Pathway: Facial Nerve – Stapedius &
Mandibular Nerve – Tensor tympani

IS
FA
R.
D
INTRATYMPANIC NERVES
Tympanic plexus (Nerve supply of middle ear): The
N

tympanic nerve plexus, which lies on the promontory,
supplies to the medial surface of the tympanic A
membrane, tympanic cavity, mastoid air cells and the
bony eustachian tube. It is formed by following nerves:
H M


RA
Tympanic branch of glossopharyngeal (Jacobson’s
Nerve) : It carries secretomotor fibers to the parotid gland.

L
 The pathway of secretomotor fibers to the parotid gland consists
of

SA
Inferior salivary nucleus  CN IX 

AI
Jacobson’s tympanic branch  Tympanic plexus 
Lesser petrosal nerve  Otic ganglion 


. F Auriculotemporal nerve  Parotid gland.
Section of Jacobson’s nerve is carried out in cases of Frey’s

 R
syndrome.

D
Sympathetic fibers: Caroticotympanic nerves come from the
sympathetic plexus, which is present round the internal
carotid artery
 Chorda tympani nerve: This branch of the facial
N

nerve enters the middle ear through posterior
A
canaliculus.
H
It runs on the medial surface of the tympanic
M
A


R
membrane.

L
It lies between the malleus and long process of incus,


A
above the insertion of tensor tympani.
S
AI
F
It carries gustatory fibers from the anterior two-third of


R.
tongue and parasympathetic secretomotor fibers to the
submaxillary and sublingual salivary glands.
D
 A N
H M
RA
AL
IS
FA
R .
D IN RELATION WITH THE MIDDLE
NERVES
EAR
 MASTOID ANTRUM
•  This air-containing space (9 mm height, 14 mm width
and 7 mm

N
• depth) is situated in the upper part of mastoid. Vol – 1ml

A
• BOUNDARIES -

• Roof: It is formed by the tegmen, which separates

M
mastoid antrum from the middle cranial fossa.

H
• „Lateral wall: It is formed by a 15mm thick plate of squamous
part of temporal bone which is marked on the lateral surface of
mastoid by suprameatal (Macewen’s) triangle. It is covered by
postaural skin.
• Boundaries of Macewen’s triangle
RA
• Linea temporalis (temporal line): A ridge of bone

A
extending posteriorly from the zygomatic process L
S
(marking the lower margin of temporalis muscle and

AI
approximating the floor of middle cranial fossa)
EAC: Posterosuperior margin of EAC.

F
• Tangent: A tangent to the posterior margin of EAC

.
• At birth its 2mm thick and increases at rate of 1 mm/yr to

R
attain
• full thickness of 12-15mm

D
 Medial wall: It is formed by the petrous bone and
related to the
 Posterior semicircular canal


Endolymphatic sac
Dura of posterior cranial fossa A N
H M


RA
„Anterior: Anteriorly mastoid antrum communicates
with the attic through the aditus ad antrum. Medial
to lateral relations are following:
A L

IS
Facial nerve canal


FA
Aditus ad antrum and facial recess lie between

.
tympanum and mastoid antrum


DR
Deep bony external auditory canal (EAC)
 Posterior wall: It is formed by mastoid bone and
communicates with mastoid air cells.
 Sigmoid sinus curves downwards.
A N
 „Floor: It is formed by mastoid bone and
H M
RA
communicates with mastoid air cells. Other deeper
relations from medial to lateral sides are

A L
Jugular bulb medial to facial canal.

IS
Digastric ridge which gives origin of posterior belly of

A
digastric muscle.

F
.
 Origin of sternocleidomastoid muscle.

DR
TYPES OF MASTOID
The mastoid consists of “honeycomb” air cells,
N

which lie underneath the bony cortex. Depending
A
described: cellular, diploeic and acellular.H M
on its development, three types of mastoid are


RA
Cellular (Well-pneumatized): Mastoid cells are well


A L
developed with thin intervening septa.
Diploeic: Mainly there are marrow spaces with few air
cells.
IS

FA
Acellular (Sclerotic): There are neither cells nor

.
marrow spaces.
R
D
 A N
H M
RA
A L
IS
FA
R.
D
3 TYPES OF MASTOID AIR CELLS
 MASTOID AIR CELLS
The mastoid air cells are traditionally divided into several groups, which
include:
1.

2.
Zygomatic cells: In the root of zygoma.
Tegmen cells: In the tegmen tympani.
A N
3. Perisinus cells: Present over the sinus plate.
Retrofacial cells: Present round the fallopian canal of facial nerve. H M
A
4.

5. Perilabyrinthine cells: They are located above, below and behind the
 labyrinth.

L R


SA
The cells, which are present in the arch of superior semicircular canal, may communicate with the petrous apex.

6.

AI
Peritubal cells: They are present around the eustachian tube. These and the hypotympanic cells
communicate with the petrous apex.
7.
. F
Tip cells: These large cells lie in the tip of mastoid medial and lateral to
 the digastric ridge.
8. DR
Marginal cells: These cells, which lie behind the sinus plate, may extend into the occipital
bone.
9. Squamous cells: They lie in the squamous part of temporal bone.
 A N
H M
RA
A L
IS
FA
R.
D
AIR CELLS OF TEMPORAL BONE
 COMPARTMENTS & FOLDS OF MIDDLE EAR
 Ossicles and their mucosal folds separate
mesotympanum from epitympanum (attic).
A N
 Compartments of Epitympanum

1. Prussak’s space: Its boundaries, which limit H M

spread of infection to other compartments,
RA
are following:
A L
S
 Lateral: Membrana flaccida (Shrapnell’s
membrane)
AI
 Medial: Neck of malleus
. F
Floor: Lateral process of malleus
R


D
Roof: Fibers of lateral malleolar ligament arising from
neck of malleus and inserting along the rim of notch of
Rivinus
 Importance- PotentialSpace which May 1st be involved
 A N
H M
RA
A L
IS
FA
R.
D
 2. Attic compartments:
 Transversely placed superior malleolar fold divides
attic into two compartments – smaller anterior and
A N

larger posterior.
The space between the lateral malleolar fold and
H M
lateral incudal fold provides communication with
Prussak’s space. RA
 2 compartments
A L
 Anterior attic compartment
IS
FA
 Posterior attic compartment: Superior incudal fold divides

this space into following two divisions:

 Medial space

R.
D
 Lateral space
 Compartments of Mesotympanum:
In the upper part of mesotympanum there are following

1.
three compartments.
Inferior incudal space: Its boundaries are A N
following
H M
a.
b.
Superior: Lateral incudal fold
Medial: Medial incudal fold
RA
c.
A L
Lateral: Posterior malleolar fold extending from neck

sulcus.
IS
of malleus to posterosuperior margin of tympanic

d.
FA
Anterior: Interossicular fold that lies between long
.
process of incus and upper two-third of handle of
R
D
malleus.
 2. Anterior pouch of von Troeltsch: It lies between the
following boundaries:
 Medial: Anterior malleolar fold extending from neck of
A N

malleus to anterosuperior margin of tympanic sulcus
Lateral: Portion of the tympanic membrane anterior to
H M
handle of malleus
R
Posterior pouch of von Troeltsch: It is situated
A
L
3.
between the following boundaries:
S A


A I
Medial: Posterior malleolar fold extending from neck of
malleus to posterosuperior margin of tympanic sulcus.

. F
Lateral: Portion of the tympanic membrane posterior to
handle of malleus.
D R
 A N
H M
RA
A L
IS
FA
R.
D
SPACES & FOLDS IN MIDDLE EAR
 • Mastoid develops from the squamous
KORNER’S SEPTUM and petrous part of temporal bone.

• In some cases Petrosquamosal suture

A N
persists as a bony plate called Korner’s
septum, which separates superficial

H
cells.M
squamosal cells from the deep petrosal

R A
During the mastoid surgery,
L Korner’s septum causes difficulty
•

SA in locating the antrum and the

AI deeper cells.

. F
DR • If not recognized, Korner’s septum
leads to incomplete removal of disease
during mastoidectomy. Mastoid
antrum can be entered into only after the
removal of Korner’s septum
 BLOOD SUPPLY
ARTERIAL SUPPLY
 Following branches of external and internal carotid
arteries supply blood to middle ear:

A N
1.

External Carotid Artery
Maxillary artery
H M
Anterior tympanic artery: Major contributor
A


R
 Middle meningeal artery

L
 Petrosal branch

A
 Superior tympanic artery: It traverses along the canal

S
for tensor tympanic muscle.
eustachian tube.
A I
 Artery of pterygoid canal: Branch that runs along

 Posterior auricular artery

. F
Stylomastoid artery: Major contributor
Ascending pharyngealR

 artery

2.
 Tympanic branch D
Internal Carotid Artery: petrous part
 Caroticotympanic branches.
 VENOUS DRAINAGE
Veins from the middle ear cleft
N


A
drain into pterygoid venous
plexus, superior petrosal sinus and
sigmoid sinus.
H M
 LYMPHATIC DRAINAGE RA

A
The lymphatics of middle ear drain into L
S
retropharyngeal and parotid nodes.
I
A
Eustachian tube lymphatics drain into

. F
retropharyngeal group of lymph nodes .
Internal ear does not have any
lymphatics
DR
References

 Scott Brown’s
A
otorhinolarynology , head &N
neck surgery
H M
Dhingra
RA
 Diseases of ENT & HNS – PL Dhingra, Shruti

L
 Textbook of ENT & HNS -P Hazarika,
A
IS
D.R.Nayak, R. Balakrishnan
A
 Textbook of Anatomy by Vishram Singh
F
R.
D
 THANK YOU…
A N
H M
RA
A L
IS
FA
R.
D