TEMPORAL

BONE,PARANASAL
SINUSUSES, HEARING
APPARATUS AND
COMMON ENT DISEASES
DR NWOSU OBIOHA
OUTLINE
• INTRODUCTION
• ANATOMY
• Temporal bone
• Paranasal sinuses
• Ear
• Common ENT Diseases
• CONCLUSION
 Anatomy of Temporal bone
• Temporal bone is one of the most
complex bones in the body
• Situated on the sides and base of
cranium and lateral to the temporal
lobe of cerebrum
• Each forms the middle and posterior
cranial fossae
Anatomy of Temporal bone
• Each bone is consist of
the following:
• Squama
• Lateral to middle cranial
fossa
• Mastoid
• Mastoid air cells
• Petrous
• Encloses labyrinth
• Tympanic
• Forms the bony EAC
Anatomy of Temporal bone
• The temporal bone
articulates with
• Sphenoid bone
• Parietal bone
• Occipital bone
• Zygomatic bone
Squamous part
• Forms the lateral wall of middle
cranial fossa
• Interfaces with parietal bone
superiorly, with zygomatic and
sphenoid anteriorly
 Mastoid bone
• Mastoid portion of temporal bone is the
inferiorly extending projection seen on lateral
surface
• Mastoid foramen is located posteriorly on the
mastoid process
• Contains the mastoid antrum which
communicates with tympanic cavity via aditus
ad antrum
• The antrum is surrounded by smaller variable-
sized mastoid air cells
Tympanic part
• Tympanic bone forms anterior, inferior and
parts of posterior wall of EAC
• It constitutes the posterior wall of the
glenoid fossa for TMJ
• Chorda tympani, anterior process of
malleus and anterior tympanic artery
traverse the petro-tympanic fissure
Petrous part
• Petrous pyramid contains otic labyrinth
• Superiorly forms the middle cranial fossa
• Lateral wall of petrous is the medial wall of the middle ear
• At petrous apex is a canal called Meckel’s cave which transmits
trigeminal nerve
• Sixth cranial nerve runs on top of articulation of petrous and sphenoid
bones (Dorello’s canal)
 Temporal bone contd
• Internal auditory canal • Carotid canal
• Bony conduit within the petrous • Enters the base of skull and
portion of the temporal bone ascends towards the petrous apex
• Transmits VII (facial) and VIII • Separated from the middle ear
(vestibulocochlear) from the cavity by a thin bony plate
pontomedullary junction of the
brainstem to the inner ear
• Jugular fossa
• The floor of tympanic cavity normally
forms the roof of the jugular fossa
• Jugular foramen contains vital
structures
Facial Nerve
• The facial nerve runs from
pontomedullary junction
through internal acoustic meatus
(Meatal segment)
• Formation of Labyrinthine
segment
• Tympanic segment (horizontal)
• Mastoid segment (vertical)
THE EAR
Anatomy of the Ear
• The ear is divided into:
• External
• Middle
• Inner
 External Ear
• The external ear consists of :
• Pinna (auricle)
• External auditory canal (EAC)
• Tympanic membrane(TM)
• EAC -Extends from concha to TM
• Approx. 2.4cm
• Divided into
• Cartilaginous part(lat 1/3rd)
• Bony part(med 2/3rd)
• Cartilaginous part
• 8mm
• Contains hairs and glands
• Bony part
• 16mm
• EAC has 2 constrictions
 Middle ear
• Air space within the petrous portion of the temporal bone
• Middle ear contains
• Ossicles (malleus, incus and stapes)
• Stapedius muscle
• Chorda tympani and tympanic plexus
• Blood vessels
• Lines by columnar epithelium
• Middle ear cleft contains
• Middle ear cavity(tympanic cavity)
• Eustachian tube
• mastoid air cells
• Aditus ad antrum
• Lining of middle ear cavity
• Ciliated columnar epithelium
Middle ear – Eustachian tube

• Connects tympanic cavity with nasopharynx

• In adults is 3.7cm long
• Runs forwards, downwards & medially
• Divided into
• Lateral bony portion (1cm)
• Medial cartilage(2cm)
• Closed at rest but open when yawning or
chewing
• More horizontal and wider in infants
 Inner ear
• Petrous part of the temporal bone
• Consist
• Bony and membranous labyrinth
• Bony labyrinth
• Semicircular canals
• Cochlea
• vestibule
• Bony labyrinth encapsulates the
membranous labyrinth which is filled
with endolymph
• Space between membranous and bony
labyrinths is filled with perilymph
Cochlea
• Coiled tube making 2 1/2 to 2
¾ turns round a pyramid of bone
called modiolus
• Base of the modiolus is directed
towards Internal acoustic
meatus
• Bulge in the medial wall of
middle ear is due to basal turn of
cochlea
Anatomy of Nose and Paranasal Sinuses
Sinus Anatomy Overview
• Paranasal sinuses are air containing
cavities in certain bones of the skull
• Clinically divide into
• Anterior group: maxillary, frontal, anterior
an middle ethmoidal air cell.the all open
into the middle meatus
• Posterior group: posterior ethmoidal
sinuses which open in the superior
meatus, and the sphenoid sinus which
open in the sphenoethmoidal recess.

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Pediatric Sinus Anatomy
Development and growth of PNS
 Sinus Drainage Schema

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The Lateral Wall of the Nasal Cavity
• Marked by 3 projections
• Superior concha
• Middle concha
• Inferior concha
• The space below each concha is
called a meatus
 Frontal Sinus
• Paired sinuses situated deep to the
inner and outer table of the frontal
bone
• It drains through the frontal recess to
the middle meatus via ostiomeatal
complex
• Related Structures
• Frontal recess

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 Maxillary Sinus
• Also known as antrum of Highmore(1651)
• Largest paranasal sinus occupying the
maxilla
• Structure
• Volume = 15ml (average) ,pyramidal in shape
• Walls, floor, roof

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 Ethmoid Sinus
• Thin-walled air cavities in the
lateral masses of the ethmoid bone
• Clinically divided into:-
• Anterior ethmoidal cells
• Middle ethmoidal air cells
• Posterior ethmoidal air cells

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Sphenoidal Sinus
• Occupies the body of sphenoid.
• The two right and left sinuses are rarely symmetrical and are
separated by a thin bony septum.
• Drains into sphenoethmoidal recess

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 The Onodi Cell
• Also called Sphenoethmoidal air cell
• An anatomical variant of the paranasal
sinuses
• It’s the posteriormost ethmoidal air
cell, that extends posteriorly to lie
superolateral to the sphenoid sinus
• Is in close proximity to optic nerve and
internal carotid artery

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 Ostiomeatal complex (OMC)
• OMC is a common channel that links
the frontal sinus, anterior and middle
ethmoid sinuses and the maxillary
sinus to the middle meatus.
• The ostiomeatal complex is
composed of five structures:
• Maxillary ostium
• Infundibulum
• Ethmoidal bulla
• Uncinate process
• Hiatus semilunaris
 Microscopic Anatomy
• Mucosa
• Cilliated columnar epithelial cells
• Anatomy
• Beat frequency
• Inhibitory effects of contact
• Noncilliated columnar cells
• Distribution
• Function
• Basal cells

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 Microscopic Anatomy—Cont’d
• Goblet Cells
• Glycoproteins—viscosity and elasticity
• Innervation (para=thick, symp=thin)
• Basement membrane
• Submucosal glands
• Distribution

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Common ENT pathologies
• Ear
• Otitis media (acute and chronic)
• Otitis externa
• Nose and paranasal sinuses
• Rhinosinusitis
• Nasopharyngeal carcinoma
• Larynx
• Laryngeal carcinoma
Ear – otitis media
• Otitis media is the inflammation of • Predisposing factors
the mucosal lining of the middle ear • Upper respiratory tract infection
cleft. • Adenoids
• Nasopharyngeal tumors
• Classification • Cleft palate
• Acute otitis media • Nasal allergy
• Otitis media with effusion(secretory • Infections of tonsils and adenoids
otitis media)
• Pathology
• Chronic otitis media
• Tubal occlusion
• Routes of infection • Pre-suppuration stage
• Eustachian tube • Suppuration stage
• External ear • Resolution stage
• Hematogenous (rare) • Complication
Otitis media
• Duration • Causative organisms for chronic
• <4 weeks-Acute • Pseudomonas aeruginosa
• >12 weeks- chronic • Proteus
• Causative organisms for Acute • E. coli
• Strep pneumonia (30%) • Staph aureus
• H. influenza(20%) • Bacteroides fragilis
• Moraxella catarrhalis(12%)
• Strep pyogenes
• Staph aureus
• P. aeruginosa
Otitis media
• Clinical features • Investigation
• Otalgia • Pure tone audiometry
• Otorrhoea • Swab m/c/s
• Fever, nausea and vomiting • X-ray temporal bone –schuller,
(children) owen views
• Otoscopy – bulging TM, perforated • CT scan of temporal bone
TM, mucopurulent secretion
• Treatment –Medical or surgical
• Antibiotics
• Decongestants
• Analgesics
• Aural toileting
 Otitis media
• Indications for surgery • Surgical options
• Complicated otitis media • Canal wall up mastoidectomies
• Facial nerve palsy • Cortical mastoidectomy
• Mastoiditis • Intact canal wall mastoidectomy
• Petrositis • Canal wall down mastoidectomies
• Modified radical mastoidectomy
• Labyrinthitis
• Radical mastoidectomy
• Cholesteatoma
 Otitis externa
• Inflammation of external ear • Infective
• Classified based on aetiological • Bacterial
basis • Localized otitis externa (Furuncle)
1. Infective group: Bacterial, Fungal or • Diffuse otitis externa
Viral • Malignant otitis externa
2. Reactive group : Eczematous,
Seborrheic or Neurodermatitis
• Fungal
• Otomycosis
• Viral
• Herpes zoster oticus
• Otitis externa haemorrhagica
 Otitis externa
• Furuncle : A staphylococcal infection of the
hair follicle
• CF: Otalgia, tragal tenderness
• Rx : antibiotics, analgesics and local heat
• Diffuse otitis externa (Swimmer’s ear):
• Inflammation of the meatal skin and pinna
• Aetiology : trauma to meatal skin &
invasion by pathogenic organisms
• CF: Otalgia, swollen pinna, otorrhoea
• Rx: antibiotics, analgesics, medicated
wicks
• Otomycosis
• Fungal infection of ear canal
• Due to Aspergillus spp.
• CF: otalgia, ear itching, watery otorrhoea
• Rx : Ear mopping, syringing, analgesics,
antifungal ointments
• Herpes Zoster Oticus
• Varicella zoster infection of geniculate
gangion
• Characterized by formation of vesicles on
TM, meatal skin, concha and postauricular
groove
• Involves cranial nerves VII and VIII
• Common in Diabetics
• Rx : Acyclovir
Otitis externa
• Malignant Otitis Externa
• Inflammatory condition caused by pseudomonas infection usually in elderly
and diabetics or immunosuppresive drugs
• Facial paralysis is common
• Causes erosion of bones
• Infection may spread to skull base and jugular foramen causing multiple
cranial nerve palsies
• Rx:
• Control blood sugar
• Ciprofloxacin for 3 months
• Aural mopping and toileting
 Rhinosinusitis
• Inflammation of the mucosal lining • Predisposing factors
of the nose and paranasal sinuses • Mechanical obstruction
• Duration • Focal infection
• Acute vs Subacute vs Chronic • Allergy
• Immunodeficiency state
• Depending on site
• Decreased mucociliary function
• Frontal sinusitis
• Iatrogenic
• Maxillary sinusitis
• Idiopathic
• Sphenoidal
• Ethmoidal
• Pansinusitis
Rhinosinusitis- Bacteriology

Acute Chronic
• Streptococcus pnuemoniae • Bacteroides fragilis
• Haemophilus influenza • Streptococcus viridans
• Moraxella catarrhalis
• Streptococcus pyogenes
• Staphylococcus aureus
• Klebsiella pyogenes
Rhinosinusitis –clinical features
• Depends on the site and • Ethmoidal sinusitis
duration • Pain between the eyes, frontal
• Frontal sinusitis headache, postnasal drip, nasal
discharge, tenderness in
• Headache, swelling of upper intercanthal region
eyelid, nasal obstruction, nasal
discharge, anosmia/hyposmia • Sphenoidal sinusitis
• Headache-frontal, occipital or
• Maxillary sinusitis
central
• Pain over cheek, swollen cheek,
nasal discharge and obstruction,
hyposmia
 Rhinosinusitis
• Investigation • Frontal sinusitis
• CT scan of paranasal sinuses will
show extent of the disease • Rx -Acute=
• Nasoendoscopy • Medical treatment is the main stay
• X-ray • If medical treatment fails=surgery
• Frontal sinus trephination
• Treatment • Endoscopic clearance
• Acute – Medical treatment
• Chronic – Medical / surgical (when • Chronic = treatment of choice is
medical treatment fails)
Functional Endoscopic Sinus Surgery
(FESS)
Rhinosinusitis
• Maxillary sinusitis • Ethmoidal sinusitis
• Rx- Acute • Rx-Acute
• Medical treatment = mainstay • Medical treatment
• Surgery if medical Rx fails • Chronic
• Chronic • FESS
• Treatment of choice= Endoscopic • Sphenoidal sinusitis
middle meatal antrostomy
• Rx= Acute=Medical
• Antral lavage
• Chronic
• Intranasal antrostomy • FESS
 Nasopharyngeal Carcinoma(NPC)
• NPC is a multifactorial disease • Aetiology
• Incidence and geographical • Genetic
distribution depends on several • Viral
• Ebstein-Barr virus
factors
• Environmental
• Most common in Southern China • Nitrosamines from dry salted fish
• Seen more in males than females 3:1 • Tobacco Smoke
• Smoke from opium
• Age
• 1st peak -15-20 years
• 2nd peak - 50-70 years
NPC
• Pathology • Spread
• WHO classification • Local spread
• Keratinizing carcinoma • Lymphatic spread
• Nonkeratinizing differentiated • Distant metastasis
carcinoma
• Nonkeratinizing undifferentiated
carcinoma
• Grossly
• Proliferative
• Ulcerative
• Infiltrative
 NPC – clinical features
• Nasal – Nasal blockage, nasal • Distant metastasis
discharge, hyponasal speech and • Investigations
epistaxis
• Nasoendoscopy
• Otologic –hearing loss, Aural fullness, • CT scan of nasopharynx
tinnitus, otalgia • X-ray chest/ Abdomen
• Ophthalmic – squint, diplopia, • Biopsy
ophthalmoplegia, exophphthalomos • Tympanometry
• Neurologic • Treatment
• All cranial nerves could be affected
depending on the stage
• Radiotherapy
• Chemotherapy
• Cervical node metastasis (commonest
symptom in > 50% of patients)
THANK YOU