Jaypee Brothers 

Textbook
of
Ear,
Nose
and
Throat
SECTION 1
Amandeep
Singh,
DISEASES OF EAR
BS
Tuli,
Isha
Preet
Tuli,
Navneet
Kaur
Tuli
1. Surgical Anatomy of Ear
 2. Physiology of Hearing and Equilibrium
3. History Taking and Physical Examination of Ear
4. Functional Assessment of Hearing and Vestibular Function Tests
5. Diseases of External Ear
6. Acute Otitis Media
7. Chronic Suppurative Otitis Media
8. Complications of Suppurative Otitis Media
 9. Nonsuppurative Otitis Media
10. Otospongiosis
11. Facial Nerve Disorders
 12. Tumors of Ear
13. Vertigo and Ménière's Disease
14. Deafness and Various Rehabilitative Measures
15. Tinnitus 2

 Surgical Anatomy Of Ear CHAPTER

CHAPTER 11

What Students Must Know!

❖ Development
Development of
of Ear
Ear

❖ Anatomy
Anatomy of
of Ear
Ear
• External Auditory Meatus

• Tympanic Membrane with Diagram

• Walls of Middle Ear Cavity with Diagram

❖ Facial
Facial Recess
Recess and
and Sinus
Sinus Tympani
Tympani
• Anatomy of Eustachian Tube

❖ Anatomy
Anatomy of
of Internal
Internal Ear
Ear
• Bony Labyrinth

• Membranous Labyrinth

❖ Scala
Scala Media
Media with
with Diagram
Diagram
• Prussak ‘s Space

INTRODUCTION
INTRODUCTION

Basic knowledge of the anatomy of ear is necessary for a better understanding of the
diseases of this magic box concerned with hearing and equilibrium.

DEVELOPMENT
DEVELOPMENT OF
OF EAR
EAR

EXTERNAL
EXTERNAL EAR
EAR

The pinna develops from a series of six ectodermal tubercles (Hillocks of His) that
appear on Arst and second pharyngeal arches in the 6th week of intrauterine life (IUL)
and it is completely formed by 20th week.
Tragus develops from the tubercle of Arst arch, while rest of the pinna develops from
remaining Ave tubercles of second arch.
Preauricular sinus results from failure of fusion of these tubercles of Arst and second
branchial arches (Figure 1.1A).
External auditory meatus development starts by 8th week and by about 16th week
there occurs invagination of dorsal end of Arst branchial cleft or groove by the process
of canalization starting from near the tympanic membrane outwards and it is well
formed by 28 weeks (Figure 1.1B).

MIDDLE
MIDDLE EAR
EAR

Middle ear develops from endoderm of tubotympanic recess arising mainly as a

diverticulum of the Arst and partly from second pharyngeal pouches in the 3rd week of
IUL and development is complete by 30 weeks.

Figure 1.1A: Development of external ear (1-6 tubercles)

Proximal part of the tubotympanic recess forms the auditory tube and distal part gives
rise to middle ear cavity
Tympanic membrane develops from all three germinal layers in the 28th week of IUL.
Malleus (except handle) and incus (except lenticular process) develop from
mesoderm of Arst arch (Meckel cartilage) between 6 to 8 weeks.
Stapes along with styloid process and hyoid bone are formed from second arch
cartilage between 5 and 28 weeks.
Footplate of stapes develops from otic capsule.
Ossicular chain appears at 4th week and by 15 weeks attains the adult size. 4

Figure 1.1B: Development of external auditory meatus (EAM) and middle ear

According to some, chorda tympani is a dividing line; parts of the ossicles above it
develop from Arst branchial arch and below it from second arch
At birth mastoid antrum size approximates that of an adult whereas mastoid process
develops after the Arst year of life (by the pull of sternomastoid due to proper head
holding).

INNER
INNER EAR
EAR

Otic placode is an ectodermal thickening, which invaginates to form otic pit, its mouth
gets narrowed to form otocyst, which differentiates into various parts of inner ear.
Bony labyrinth develops from mesoderm around otocyst.
Membranous labyrinth develops from ectoderm around otocyst in the 3rd week of
fetal life and is complete by 16th week of IUL.
Between 6 and 8 weeks semicircular canals and utricle are fully formed.
Cochlea is well developed by 20 weeks of gestation (Figure 1.1C).

Labyrinth is the Arst organ, which develops before other organs has yet started
forming in the embryo. Vestibular apparatus develops before cochlea. Summary of
development of ear is given in Table 1.1.

ANATOMY
ANATOMY OF
OF EAR
EAR

Ear can be divided into three parts:

1. External ear
2. Middle ear
3. Inner ear.

EXTERNAL
EXTERNAL EAR
EAR

External ear consists of pinna and the external auditory meatus.

Figure 1.1C: Development of membranous labyrinth

PINNA
PINNA

Pinna is made up of Abroelastic cartilage covered by skin and connected to the

surrounding parts by ligaments and muscles. The cartilage of pinna is continuous with
the cartilage of external auditory meatus, but it is absent in lobule of the pinna.
Various landmarks on the pinna are helix, antihelix, lobule, tragus, concha, scaphoid
fossa and triangular fossa (Figure 1.2A).
Pinna has two surfaces, i.e. medial or cranial surface and a lateral surface which is
concave and shows the above said landmarks.
Cymba concha lies between crus helix and crus antihelix. It is an important surface
landmark for mastoid antrum.
Bat-ear is the most common congenital anomaly of pinna in which antihelix has not
developed and excessive conchal cartilage is present.
Corrections of pinna defects are done at 6 years of age as graft from the costal
cartilage can be easily obtained by then.

LIGAMENTS
LIGAMENTS AND
AND MUSCLES
MUSCLES OF
OF PINNA
PINNA

There are both extrinsic and intrinsic ligaments and muscles:

Extrinsic muscles are anterior, posterior and superior auricularis

Intrinsic muscles are helicis major and helicis minor, tragus and antitragus
Both groups of muscles are supplied by branches of facial nerve.

SENSORY
SENSORY NERVE
NERVE SUPPLY
SUPPLY OF
OF PINNA
PINNA

LATERAL
LATERAL SURFACE
SURFACE

Upper two-thirds is supplied by auriculotemporal nerve (branch of Afth nerve)

Lower one-third by greater auricular nerve (C2, C3) (Figures 1.2B and C). 5

Table 1.1 Summary of schedule of development of ear

Parts Of Ear Period Of Development Derivative Of

Start Complete

1. External ear
6 weeks 20 weeks First and second branchial arch
1. Pinna 8 weeks 28 weeks Dorsal end of Arst branchial arch
2. EAC* 3–4 weeks 30 weeks Dorsal end of Arst and second branchial
28 weeks pouch
2. Middle ear
6–8 weeks 15–20 All three germinal layers
1. TM† 5–28 weeks First and second branchial arch derivatives
2. Malleus and incus weeks Develops from otic capsule

3. Stapes — —
3–4 weeks 25 weeks
Footplate
3–4 weeks 6–8 weeks
3. Inner ear 3 weeks 20 weeks Otic capsule

1. SCC†† and utricle 3–4 weeks 16 weeks

4–6 weeks 20–25
2. Cochlea
weeks
3. Membranous
labyrinth

Organ of Corti

*EAC = External auditory canal

†TM = Tympanic membrane

††SCC = Semicircular canal

Figure 1.2A: Various landmarks on the lateral surface of pinna

MEDIAL
MEDIAL OR
OR CRANIAL
CRANIAL SURFACE
SURFACE OF
OF THE
THE PINNA
PINNA

Lower two-thirds is supplied by greater auricular nerve

Upper one-third by the lesser occipital nerve.
Arnold's nerve (a branch of vagus nerve) also called Alderman's nerve and another
nerve branch of facial nerve supplies concha on the lateral surface of pinna.

BLOOD
BLOOD SUPPLY
SUPPLY OF
OF PINNA
PINNA

Posterior auricular branch of external carotid

Anterior auricular branch of superAcial temporal
A branch of occipital artery.

Veins corresponding to the arteries drain into external jugular and common facial
vein.

Figures 1.2B and C: Cutaneous innervations of pinna. (B) Lateral surface; (C) Cranial surface

LYMPHATIC
LYMPHATIC DRAINAGE
DRAINAGE

They drain into parotid group, upper deep cervical and preauricular and postauricular
lymph nodes (Figure 1.3A). 6

Figure 1.3A: Lymphatic drainage of pinna

Figure 1.3B: Nerve supply of external auditory canal (EAC) and tympanic membrane (TM)

EXTERNAL
EXTERNAL ACOUSTIC
ACOUSTIC MEATUS
MEATUS

At birth only cartilaginous meatus is present because the bony part develops from
tympanic ring, which is incompletely formed at that time, i.e. bony part of meatus is
absent in newborn.
Its length is 24 mm, outer one-third (8 mm) being cartil-aginous and inner two-thirds
(16 mm) bony. The canal forms a mild S-shaped curve directed medially, upwards and
forwards and then medially, backward and downward.
The canal has two constrictions in the external auditory canal (EAC); one, near the
medial end of cartilaginous part and the other 5 mm short of tympanic membrane in
the osseous part called isthmus.
Floor and anterior wall of meatus are longer than the roof and posterior part due to
oblique position of tympanic membrane (TM).
Anterior, inferior and posterior bony walls of meatus are formed by tympanic part of
temporal bone. Roof and part of posterior wall are formed by squamous part of
temporal bone.
A meatal recess is present in relation to the inferior wall of the meatus and is a
common site for lodgement of debris and foreign bodies.
Foramen of Luschka is a deAciency in anteroinferior part of bony meatus. It closes
around 4 years of age.
Fissures of Santorini are deAciencies seen in cartilaginous portion of EAC through
which infection of mastoid and parotid gland can spread to the meatus.
Skin is very thin and Armly attached to the bone and cartilage of meatus, therefore,
indammation is very painful due to increased tension in these tissues. Ceruminous
glands and hair are present mostly in the subcutaneous tissue of cartilaginous part.
Important relations include:
Condyloid process of mandible is in close relation to anterior wall
Middle cranial fossa lies above the osseous meatus
Mastoid air cells are posterior to it.

NERVE
NERVE SUPPLY
SUPPLY OF
OF MEATUS
MEATUS

The nerve supply of EAC and TM are shown in Figure 1.3B.

Anterior and superior walls by auriculotemporal branch of mandibular nerve

Posterior and inferior walls are supplied by auricular branch of vagus (Arnold's nerve)
A sensory branch of the facial nerve (nerve of Wrisberg) may supply a part of the
posterior wall of meatus.

INTERNAL
INTERNAL ACOUSTIC
ACOUSTIC MEATUS
MEATUS

Internal acoustic meatus is approximately 1 cm long and has a vertical diameter of 2

to 8 mm, which is symmetrical on both sides and the difference between the two
sides is not more than 1 mm. It is roughly parallel to the EAC.
It has three parts:
Porus (inlet of internal acoustic meatus [IAM])
Canal
Fundus (applied to labyrinth).

Bill's bar is a vertical crest of bone, which divides superior compartment of canal into
anterior compartment for facial nerve and posterior compartment for superior
vestibular nerve (Figure 1.3C).
Contents:
Meninges
Facial nerve
Nervus intermedius
Cochlear and vestibular nerve
Blood vessels.

MIDDLE
MIDDLE EAR
EAR CAVITY
CAVITY (TYMPANUM)
(TYMPANUM)

Middle ear cleft consists of middle ear proper, eustachian tube and mastoid antrum
(Figure 1.3D). 7

Figure 1.3C: Fundus of internal acoustic meatus

Figure 1.3D: Middle ear cleft

Figure 1.3E: Dimensions of middle ear space

It is a biconcave irregular space contained in the petrous part of temporal bone, which
is fully developed to adult size at birth.
Middle ear resembles a six-sided box (like a matchbox)
It measures 15 mm each both vertically and antero-posteriorly, while transverse
diameter will be 6 mm above, 4 mm below and 2 mm opposite umbo (Figure 1.3E).
Contents of middle ear is only air. Ossicles and tendons of stapedius and tensor
tympani lie outside the mucous membrane.
It communicates with nasopharynx through eustachian tube and with the mastoid
antrum posteriorly through aditus opening.
Middle ear cavity is further subdivided into:
Epitympanum
Mesotympanum
Protympanum (area of tympanum around eustachian tube)
Hypotympanum.

Part of middle ear extending above the tympanic membrane is known as epitympanic
recess or attic.

WALLS
WALLS OF
OF TYMPANIC
TYMPANIC CAVITY
CAVITY ((Figures
Figures 1.4A
1.4A AND
AND BB))

ROOF
ROOF

Roof is formed by tegmen tympani, a part of petrous and squamous bone forming
petrosquamous suture through which veins communicate with the meninges or
superior petrosal sinus
Roof of middle ear is also pierced by greater and lesser petrosal nerves.

FLOOR
FLOOR

Floor is a thin convex plate of bone, which separates the door from superior bulb of
internal jugular vein
An aperture for the passage of Jacobson's nerve (tympanic branch of
glossopharyngeal nerve) lies in the door close to the medial wall of tympanic cavity.

LATERAL
LATERAL WALL
WALL

This wall of a tympanic cavity is shown in Figures 1.4A and B.

Upper most part of lateral wall is formed by lateral attic wall called scutum (Shield of
Liedy).
Tympanic membrane, which forms the major part of lateral wall of middle ear and
separates it from external acoustic meatus (Figures 1.5A To D).
Tympanic membrane is a semitransparent, pearly, gray trilaminar membrane that
weighs nearly 12 to 14 mg. Its thickness varies from 0.1 to 0.15 mm.
Anteroposteriorly, it is 8 to 9 mm and vertically it is 9 to 10 mm.
Total surface area is 85 sq mm, while vibrating surface area is nearly 55 sq mm.
Tympanic membrane of an infant is thicker than that of an adult and is placed almost
horizontal in infants. In adults it is placed at an angle of 55o with the door.
Posterosuperior part of TM is nearest to the observer while anteroinferior part is
farthest.
The membrane is convex towards the middle ear cavity and the tense part is called
pars tensa.
Peripheral part of tympanic membrane (pars tensa) is thickened to form
Abrocartilaginous ring attached to tympanic sulcus. This sulcus is deAcient superiorly
(notch of Rivinus). This notch of Rivinus lies medial to pars daccida. Lamina propria
of Pars tensa has a predominance of Collagen Type II making this part of membrane
tense. 8

Figure 1.4A: Walls of middle ear cavity with lateral wall opened up

Figure 1.4B: Walls of middle ear cavity

Figures 1.5A to D: Various landmarks of normal tympanic membrane. (A) Right tympanic membrane; (B) Left tympanic
membrane; (C) Left tympanic membrane; (D) Right tympanic membrane showing quadrants (PS: Posterosuperior, AS:
Anterosuperior, PI: Posteroinferior, AI: Anteroinferior) 9

Flaccid part above the malleolar folds is called pars daccida (Shrapnel membrane),
which is approximately 2 to 3 mm only. Flaccidity is due to random and loose
arrangement of Abers in middle Abrous layer and absence of an annulus to keep the
Abrous layer taut, and this allows free movements of the head of malleus.
Cone of light is always seen in anteroinferior quadrant of pars tensa as this is the only
part that is nearly at right angle to the meatus and therefore in a position to redect
back light of the mirror. The light redex may be absent or its position may be altered, if
the curvature of drum changes.
The tympanic membrane has three layers:
Outer cuticular
Middle Abrous layer which consists of inner circular and outer radiating Abers
Inner mucosal layer.

Umbo is the most reliable landmark in otoscopy.

Retraction of tympanic membrane is indicated by:
Absent cone of light
Anterior and posterior malleolar folds become prominent
Lateral process of malleus becomes prominent
Handle of malleus becomes fore shortened and assumes a horizontal position
Drum looses its normal luster
Mobility is restricted.

Arterial supply:
Deep auricular branch of maxillary artery to cuticular layer
Stylomastoid branch of occipital or posterior auricular artery
Tympanic branch of maxillary artery to middle and mucosal layer.

Veins drain to external jugular vein and transverse sinus.

Nerve supply:
Auriculotemporal branch of mandibular nerve
Auricular branch of vagus (Arnold's nerve)
Tympanic branch of glossopharyngeal nerve (Jaco-bson's nerve) through tympanic
plexus.

MEDIAL
MEDIAL WALL
WALL

Also called the surgical door of middle ear and this labyrinthine wall separates middle
ear from inner ear.

The main features on medial wall are (Figures 1.6A and B):

Promontory formed by basal turn of cochlea.

Fenestra vestibuli (oval window) lies posterosuperior to the promontory and opens
into scala vestibuli. It measures 3.25 × 1.75 mm. It is occupied by footplate of stapes
 Axed by annular ligament.
Fenestra cochleae (round window) lies posteroinferior to promontory, opens into door
of scala tympani of cochlea, measures 1.5 × 1.3 mm and is closed by secondary
tympanic membrane. The round window is closest to ampulla of posterior
semicircular canal.
Horizontal part of facial nerve is enclosed in a bony canal (Fallopius canal), which lies
above the fenestra vestibuli curving downwards into posterior wall of middle ear
(Figure 1.7). The facial nerve here separates epitympanic region above from
mesotympanic region below.
Anterior to oval window is a hook-like projection called the processus cochleariformis
for tendon of tensor tympani. It marks the level of genu of facial nerve. Ponticulus is a
bony spicule which runs from promontory to pyramid below the oval window.
Subiculum is just posterior extension of promontory lying above the round window.
Tympanic plexus is formed by tympanic branch of glossopharyngeal nerve and the
superior and inferior branches of sympathetic plexus around internal carotid artery.
Tympanic plexus in front of oval window is highly sensitive and painful on surgical
manipulation.

Figure 1.6A: Various structures on the medial wall of middle ear

Figure 1.6B: Inside view of middle ear 10

Figure 1.7: Sensory hair cells of vestibular organ

POSTERIOR
POSTERIOR WALL
WALL

Posterior wall has the following main features:

Aditus ad antrum is an irregular aperture leading back from epitympanic recess into
upper part of mastoid antrum. Aditus word in Latin means access.
Pyramidal eminence lies just behind fenestra vestibuli and contains stapedius
muscle.
Fossa incudis lies in epitympanic recess and contains short process of the incus.
An opening below and lateral to pyramid is for entry of chorda tympani nerve into the
middle ear.

FACIAL
FACIAL RECESS
RECESS

Also called suprapyramidal recess, is a groove or depression on the posterior wall, which
lies between pyramid and facial nerve and annulus of the tympanic membrane. It is a
collection of air cells lying lateral to facial nerve.

The term was coined by House and Sheehy

It is bounded:
Medially by external genu of facial nerve
Laterally by chorda tympani
Superiorly by fossa incudis
Anterolaterally by tympanic membrane.

Facial recess is superAcial to sinus tympani and is separated from it by descending

part of facial nerve.
Importance of this recess is that one can approach the middle ear from behind
without disturbing posterior meatal wall. This is one of the hidden areas where
cholesteatoma can reoccur after surgery, so a surgeon should be extra cautious in
clearing this area. Ear may continue discharging if this area is not cleaned during
mastoid surgery.

SINUS
SINUS TYMPANI
TYMPANI

Also called infrapyramidal recess or medial facial recess.

It is a depression behind promontory deep to the pyramid, continuous with the

hypotympanum and its position is opposite to ampulla of posterior SCC.
It starts at oval window and occupies a space deep to descending part of the facial
nerve and pyramid and passes behind round window niche to hypotympanum.
Sinus tympani is the most inaccessible area in the middle ear and mastoid. Approach
to this area is not possible via mastoid (retrofacial approach) because posterior SCC
comes in the way. It cannot be visualized directly in the surgery of cholesteatoma, so
can be a site of recurrence.
It is also described as a triangular space between ponticulus above and subiculum
below. These are two bony spicules extending from the promontory on to the posterior
wall superiorly and inferiorly, respectively.
Sinus tympani is bounded laterally by vertical segment of facial nerve and medially by
medial wall of tympanum.

ANTERIOR
ANTERIOR WALL
WALL (CAROTID
(CAROTID WALL)
WALL)

Anterior wall has the following openings (Figure 1.8):

Above is the canal for tensor tympani extending to medial wall to form a pulley called
processus cochleariformis
Below is osseous opening of eustachian tube.
Anteriorly the plate of bone, separates middle ear from internal carotid artery. It is
perforated by superior and inferior carotico-tympanic nerves and tympanic branches
of internal carotid artery.
Canal of Huguier for passage of chorda tympani nerve out of temporal bone anteriorly
through the medial end of petrotympanic Assure to join the lingual nerve in the
infratemporal fossa. It carries taste from anterior two-thirds of tongue and
secretomotor Abers to submaxillary and sublingual gland.
Glasserian Sssure below canal of Huguier transmits tympanic artery and anterior
ligament of malleus.

Remember anterior wall of middle ear is closely related to internal carotid artery;
posterior wall is occupied by facial nerve and door is mainly venous occupied by internal
jugular vein.

SURGICAL
SURGICAL ANATOMY
ANATOMY OF
OF MASTOID
MASTOID ANTRUM
ANTRUM

It is an air sinus in the petrous temporal bone, with a capacity of 1 cc. It is the largest
and the most consistent mastoid air cell present.
It is of the same size (10 mm) in adults and children and it is always present.
Its upper anterior wall has the opening of aditus.
Medial wall is related to posterior and lateral semicircular canal.
Posteriorly lies the sigmoid sinus.
The roof is formed by tegmen antri separating it from middle cranial fossa and
temporal lobe of brain.
Anteroinferiorly is the descending part of facial nerve canal (or fallopian canal).
Lateral wall is formed by squamous temporal bone and in adult is 12 to 15 mm thick.
Mastoid process develops after 1st year of life and Cymba concha is the soft tissue
landmark of mastoid antrum. 11

Figure 1.8: Anterior wall and door of middle ear cavity

MACEWEN'S
MACEWEN'S TRIANGLE
TRIANGLE OR
OR SUPRAMEATAL
SUPRAMEATAL TRIANGLE
TRIANGLE

Macewen's triangle is used to locate the mastoid antrum which lies about 1.5 cm deep
to it.

It can be felt under cymba concha (Figures 1.9A and B). It is bounded:

Above by supramastoid crest (base)

Anteroinferiorly by posterosuperior margin of external auditory canal
Posteriorly by a tangent drawn from supramastoid crest to spine of Henle.
Spine of Henle lies in the triangle
Mastoid antrum lies 15 mm deep
Korner's septum is persistence of petrosquamous suture. Its presence leads to
formation of false bottom of mastoid antrum. This may lead to incomplete
exenteration of mastoid cells in mastoidectomy operation and if the surgeon mistakes
it for the true mastoid antrum and drills anteriorly, he may damage the facial nerve.

Trautmann's Triangle

It is bounded by:

Sigmoid sinus posteriorly

Bony labyrinth anteriorly

Superior petrosal sinus superiorly.

The triangle identiAes the location of posterior cranial fossa. Infection into the
posterior cranial fossa can spread through this triangle and this can be approached
by removing the bone in between the triangle.

ANTRUM
ANTRUM THRESHOLD
THRESHOLD ANGLE
ANGLE

Antrum threshold angle is bounded:

Above by horizontal semicircular canal (HSCC) and fossa incudis

Figure 1.9A: Boundaries of Macewen's triangle

Figure 1.9B: Parts of temporal bone

Medially by descending part of nerve VII

Laterally by chorda tympani nerve.

By drilling it, surgeon enters the facial recess from the antrum side.

SOLID
SOLID ANGLE
ANGLE

Formed by solid bone in the angle formed by three SCCs.

SINODURAL
SINODURAL ANGLE
ANGLE

The angle between tegmen antri and sigmoid sinus.

TYPES
TYPES OF
OF MASTOID
MASTOID ANTRUM
ANTRUM

Pneumatized (80%)—there are present many groups of cells like tip cells, dural cells,
perisinus cells, sinodural angle cells, retrofacial cells and zygomatic cells.
Pneumatization starts in 1st year of life and is complete by 4 to 6 years.
Sclerotic (20%)—there are present few or no cells. In this type, cells are absent and are
replaced by dense bone.
Mixed (Diploeic)—there are small air cells and bone marrow spaces (Figure 1.10). 12

EXTENT
EXTENT OF
OF PNEUMATIZATION
PNEUMATIZATION DEPENDS
DEPENDS ON
ON THE
THE FOLLOWING
FOLLOWING
FACTORS
FACTORS

Eustachian tube function (Tumarkin's theory)

Environment
Heredity (Diamant's theory)
Infantile otitis media (Wittmark's theory).

EUSTACHIAN
EUSTACHIAN TUBE
TUBE

Named after Bartholomeus Eustachius (1520–1574 AD).

It is also called pharyngotympanic tube and helps to equalize pressure on either sides
of TM (Figure 1.11). It is trumpet like in shape.
In infants, the auditory tube is short and wide and is placed horizontally.
Eustachian tube measures 17 mm at birth and about 36 mm long in adults and
descends at an angle of 45 degree with sagittal plane and 30 degree with horizontal
plane.
In resting state, tubal end in nasopharynx lies collapsed, opening during yawning and
deglutition.
Osseous part (12 mm long) starts from anterior tympanic wall and lies 4 mm above
the level of door of middle ear, which narrows to end at squamous and petrous part of
temporal bone to become continuous with cartilaginous tube.
Cartilaginous part (24 mm long) opens into the naso-pharynx between the petrous
part of temporal bone and greater wing of sphenoid bone, 1.25 cm behind the
posterior end of inferior turbinate.
Ostmann's pad of fat is adipose tissue found between lateral aspect of eustachian
tube and tensor palati muscle and it helps to keep the tube closed thus preventing
redux of secretions in middle ear.
During Valsalva maneuver handle of malleus moves outwards with TM but incus does
not, due to unlocking of incudomalleolar joint and this prevents stapes being torn
away from fenestra vestibuli. Valsalva maneuver generates 20 to 40 mm Hg of
pressure.
Muscles of eustachian tube
Tensor palati opening the cartilaginous part of eustachian tube (dilator tubae is a
part of it) supplied by branch of mandibular nerve.
Levator palati supplied by pharyngeal plexus through cranial nerve XI.
Tensor palati separates the eustachian tube from otic ganglion, mandibular nerve,
chorda tympani nerve and middle meningeal artery (Figure 1.12).

Arterial supply is through branches from ascending pharyngeal, middle meningeal and
artery of pterygoid canal (both branches of maxillary artery). Venous drainage is to the
pterygoid and pharyngeal venous plexus.
Nerve supply is by tympanic plexus and pharyngeal branches of pterygopalatine
ganglion.

Figure 1.10: Various groups of air cells in the temporal bone

Figure 1.11: Right eustachian tube

Figure 1.12: Tensor palati and eustachian tube

Lymphatics drain into retropharyngeal lymph nodes.

Lymphoid tissue related to eustachian tube has been called tonsil of Gerlach.

AUDITORY
AUDITORY OSSICLES
OSSICLES

Vesalius (1543) described malleus and incus

Ingrassia (1546) described stapes oval window (OW) and round window (RW)
Malleus, incus and stapes (Figure 1.13) are connected to each other by synovial joints
forming ball and socket and saddle joint respectively
Malleus and incus develops from mesoderm of Arst branchial arch, while stapes from
second branchial arch. Footplate of stapes develops from otic capsule. 13

Figure 1.13: Ear ossicles and their parts

MALLEUS
MALLEUS

It is the largest ossicle shaped like a mallet and is 8 to 9 mm long and weighs 23 to 25
mg
It has head, neck, manubrium (handle), anterior and lateral processes
Head lies in epitympanic recess and articulates with the incus
Neck lies against pars daccida and related to chorda tympani nerve
Handle of malleus extend downward, backward and medially.

INCUS
INCUS

It is shaped like an anvil, weighs 25 to 30 mg and has a body and two processes
Long process descends parallel to the malleus and ends in a lenticular process which
articulates with stapes capitulum
Short process lies in the fossa incudis of epitympanic recess, i.e. attic
Pneumatization of long process of incus may occur.

STAPES
STAPES

It is the shortest bone of the body and weighs 2.5 to 3 mg

It has a head, neck, two crurae and a base, which Ats into the oval window
Neck provides insertion to tendon of stapedius
Stapes moves in a rocking fashion
Stapes footplate area is 1.65 to 3.75 mm2.

All these ossicles are supplied by branches of anterior, inferior and posterior
tympanic arteries.

MUSCLES
MUSCLES OF
OF THE
THE TYMPANIC
TYMPANIC CAVITY
CAVITY

TENSOR
TENSOR TYMPANI
TYMPANI

First branchial arch muscle

It arises from walls of cartilaginous part of the eustachian tube and adjoining region
of greater wing of sphenoid and its tendon is attached to the handle of malleus near
the neck
It is supplied by a branch of mandibular nerve through otic ganglion
Normally, the pulley action of tensor tympani muscle is opposed by elasticity of pars
propria of TM.

STAPEDIUS
STAPEDIUS

Second branchial arch muscle

It arises from interior of pyramidal eminence and emerges from its apex and is
attached to the back of neck of stapes
It is supplied by branch of facial nerve.

ACTIONS
ACTIONS

Both muscles contract in response to loud sounds exerting a protective, dampening

effect before vibrations reach the internal ear.

Paralysis of stapedius results in hyperacusis. Action of stapedius is opposite to the

action of tensor, which tends to push in the footplate deep into fenestra vestibuli.

COMPARTMENTS AND SPACES OF MIDDLE EAR

Epitympanum (3 mm) communicates with mesotympanum (7–8 mm) through

isthmus tympani anticus and posticus.
Upper part of mesotympanum has three compartments:
Inferior incudal space
Anterior and posterior pouch of von Troltsch (Figure 1.14)
Epitympanum is divided by superior malleolar fold into a smaller upper
compartment and lower large compartment further subdivided by superior incudal
fold into medial incudal and superior incudal space.

PRUSSAK'S SPACE

1. Also called superior recess of TM. It lies between neck of malleus (internally) and pars
daccida (externally). It is bounded above by Abers of lateral malleolar fold and below
by lateral process of malleus.
2. Importance of this space: It is most common site of cholesteatoma. The
cholesteatoma may extend to posterior mesotympanum under lateral incudal fold and
infection here does not drain easily and causes attic pathology.

FACIAL RECESS AND SINUS TYMPANI (DESCRIBED ABOVE Figures

1.15A And B
B):
):

Facial recess also called suprapyramidal recess

Sinus tympani also called infrapyramidal recess.

Figure 1.14: Middle ear spaces (diagrammatic view) 14

Figures 1.15A and B: (A) Facial recess and sinus tympani; (B) Diagrammatic view of sinus tympani in relation to oval
and round windows

MUCOUS MEMBRANE OF MIDDLE EAR

Tympanic mucosa is pale, thin and slightly vascular ciliated columnar epithelium except
on posterior wall where it is non-ciliated like that of the mastoid antrum.

BLOOD SUPPLY OF TYMPANIC CAVITY

ARTERIAL SUPPLY

Anterior tympanic branch of maxillary

Posterior tympanic branch of stylomastoid (which is a branch of posterior auricular)
Superior tympanic branch of middle meningeal artery
Inferior tympanic branch of ascending pharyngeal
Deep auricular branch of maxillary.

VEINS
VEINS DRAINAGE
DRAINAGE

Drain into pterygoid venous plexus and superior petrosal sinus.

LYMPHATICS
LYMPHATICS DRAINAGE
DRAINAGE

Drain to parotid and upper deep cervical lymph nodes.

NERVES
NERVES

Tympanic plexus formed by union of tympanic branch of glossopharyngeal nerve and

caroticotympanic nerves of sympathetic plexus around internal carotid artery
Mastoid antrum is supplied by meningeal branch of mandibular nerve.

Figures 1.16A and B: Internal ear. (A) View of bony labyrinth; (B) Membranous labyrinth

INTERNAL
INTERNAL EAR
EAR

Internal ear consists of a bony labyrinth contained within the petrous temporal bone
along with the membranous labyrinth (Figures 1.16A And B). It serves the most
important function of hearing and equilibrium.

Otic capsule develops from 14 centers.

BONY
BONY LABYRINTH
LABYRINTH

It consists of (Figure 1.16A):

1. Vestibule
2. Semicircular canals
3. Cochlea.

VESTIBULE
VESTIBULE

Ovoid in shape measuring 5 mm × 3 mm and forms the central part of bony labyrinth
It has a spherical recess containing saccule, a cochlear recess for cochlear duct and
an elliptical recess for utricle. Opening of vestibular aqueduct lies below elliptical
recess
Posterior part of vestibule has Ave openings of three semicircular canals
Lateral wall has the fenestra vestibuli or oval window. Its medial wall is related to 15
internal acoustic meatus.

SEMICIRCULAR
SEMICIRCULAR CANALS
CANALS

There are three SCCs, i.e. superior, posterior and lateral. These are all about 0.8 mm in
diameter and have a terminal swelling called ampulla (2 mm)
These open into vestibule by Ave openings, the one common between anterior and
posterior is called the crus commune
Their lengths are: Posterior SCC is 18 to 22 mm, superior SCC is 15 to 20 mm and
lateral SCC is 12 to 15 mm long
The three canals lie at 90° to each other. Superior SCC is placed transverse to the long
axis of petrous temporal and its upward convexity forms the arcuate eminence.
Posterior SCC runs parallel to posterior surface of petrous bone
Lateral SCC lies at 30° to the horizontal plane. After 30° dexion of head, the lateral
canal becomes horizontal.

Remember that the two horizontal SCCs lie in the same plane, while superior SCC of
one side is parallel with the posterior SCC of other side.
 COCHLEA
COCHLEA

Fallopius (1561) described cochlea and labyrinth.

It is shaped like a conical snail shell, measures 35 mm (long) × 5 mm (base to apex)
and 9 mm across its base.
Cochlea has a central conical axis called modiolus with a spiral canal of 2.5 to 2.75
turns around it.
Apex of cochlea points towards anterosuperior part of medial wall of middle ear cavity
and the base is towards the fundus of internal acoustic meatus.
An osseous spiral lamina projects from the modiolus and divides the cochlear canal
into upper scala vestibuli and lower scala tympani.
Both the scalae are continuous with each other through helicotrema at the apex of
cochlea.
Cochlea has three openings at its base, i.e.
Fenestra vestibuli
Fenestra cochleae
Cochlear canaliculus, which transmits a small vein to inferior petrosal sinus.

The cochlear aqueduct is a bony channel connecting scala tympani with a

subarachnoid space in posterior cranial fossa and vestibular aqueduct extends from
vestibule to the posterior cranial fossa.
Bony labyrinth contains perilymph, which resembles cerebrospinal duid (CSF) in its
composition and is rich in sodium and poor in potassium.

MEMBRANOUS
MEMBRANOUS LABYRINTH
LABYRINTH

It lies within the osseous labyrinth and is Alled with endolymphatic duid (Figure 1.16B).

Vestibulocochlear nerve Abers are distributed in the walls of membranous labyrinth.

The membranous labyrinth is separated from the bony labyrinth by perilymphatic duid.

It has the following parts:

1. Utricle
2. Saccule
3. Semicircular ducts.

UTRICLE
UTRICLE

It is an irregular oblong structure 2 to 5 mm in diameter

It occupies elliptical recess of the vestibule
The lateral wall and adjoining door have a thickened area of 3 mm × 2 mm called
utricular macula
It is innervated by utricular Abers of vestibular nerve
The semicircular ducts open into the utricle through 5 ampullary ends.

SACCULE
SACCULE

It is globular in shape of 1 to 1.5 mm in diameter and occupies the spherical recess

near the opening of scala vestibuli
Its anterior wall has the macula set at right angle to the utricular macula
Saccule is connected to the utricle through a Y-shaped tube, to the endolymphatic
duct and sac
The sac lies under the dura mater on posterior surface of petrous bone
Ductus reuniens passes inferior from lower part of saccule into the basal end of
cochlear duct
Donaldson's line is a landmark for endolymphatic sac and this line passes through
HSSC and bisects posterior SCC. The endolymphatic sac lies below this line.

SEMICIRCULAR
SEMICIRCULAR DUCTS
DUCTS

These open into the utricle by Ave oriAces, one being common to the medial end of
superior and posterior duct
In the ampullary end of each duct, there is a transverse elevation shaped like an
hourglass called septum transversum
Its most prominent part is ampullary cristae, which are the sensitive organs to the
movements of endolymph
These cristae respond to pressure changes of endolymph, while maculae respond to
gravitational changes.

STRUCTURE
STRUCTURE OF
OF UTRICLE,
UTRICLE, SACCULE
SACCULE AND
AND SEMICIRCULAR
SEMICIRCULAR DUCTS
DUCTS

Each has three layers:

1. External layer is Abrous and vascular.

2. Middle layer is vascular connective tissue.
3. Internal layer is simple epithelium varying from squamous to cuboidal with a
basement membrane having light and dark cells.

In ampullary crests, the epithelium contains sensory hair cells of type I and type II
and supporting cells of Hensen (Figure 1.17). 16

Figure 1.17: Sensory hair cells of vestibular organ

Type I cell is pyriform in shape and type II cell is cylindrical. Apical surface of both
these cells carry 40 to 100 stereocilia or modiAed microvilli.
A long kinocilium is also attached to each cell. These stereocilia and kinocilium are
inserted into a gelatinous mass-like membrane called otolithic membrane
containing many otoliths or statoconia (Figure 1.18).
Macula is the organ for static balance, while ampullary crest is the organ for kinetic
balance (or responds to angular acceleration).
Endolymph resembles intracellular duid being rich in potassium and poor in sodium
ions.

COCHLEAR
COCHLEAR DUCT
DUCT (SCALA
(SCALA MEDIA)
MEDIA)

1. The canal enclosed between scala vestibuli and scala tympani is the cochlear duct (or
scala media).

Figure 1.18: Structure of macula

2. It lies within the bony cochlea and has the sensory area called organ of Corti which is
triangular in cross-section (Figures 1.19A and B).
3. The basilar membrane forms the horizontal limb of scala media, the Reissner's
membrane forms the superior limb and the vertical limb of the triangle is formed by
the stria vascularis and the spiral ligament.
4. Basilar membrane stretches from the osseous spiral lamina to spiral ligament.
5. Its total length is 35 mm and width is between 0.21 mm and 0.36 mm. It consists of
two zones, i.e.

Zona arcuata, which supports organ of Corti

Zona pectinata, which is thicker and has three layers.

q. Vestibular membrane also called Reissner's membrane lies well over the basilar
membrane below the scala vestibuli.

Figure 1.19A: Section of the cochlea to show scala media 17

Figure 1.19B: MagniAed view of hair cells

7. Cochlear duct is Alled with a duid called endolymph and the scala vestibuli and
tympani are Alled with perilymph.
r. Organ of Corti consists of two rows of cells (Described in 1851 by Corti)

External rod cells (4000)

Internal rod cells (6000).

9. Inner-to-inner rods are inner hair cells (3500) in one row, while external-to-outer rods
are three to four layers of outer hair cells (12000).
10. Organ of Corti is covered by tectorial membrane.
11. Supporting cells of Deiters’ are situated between the outer hair cells. Cells of Hensen
lie outside the Deiters’ cells.
12. In addition to tunnel of Corti (between outer and inner rod cells), there is also an outer
tunnel and space of Nuel (medial tunnel). These spaces are Alled with cortilymph
which resembles perilymph in composition.
13. Remember, the organ of Corti has no direct blood supply and depends for its
metabolic activity from diffusion of oxygen from stria vascularis. This arrangement
provides acoustic insulation of hair cells.

VESTIBULOCOCHLEAR
VESTIBULOCOCHLEAR NERVE
NERVE

Gallen (200 AD) described the VIII cranial nerve (Vestibulocochlear nerve).
The nerve VIII divides deep in the internal acoustic meatus into anterior cochlear and
posterior vestibular nerve.
Oort's anastomosis is, in fact, a vestibulocochlear anastomosis.

COCHLEAR
COCHLEAR NERVE
NERVE

It divides into many Alaments at the modiolar base and ultimately ends in inner hair cells
(95%) and outer hair cells (5%). A vestibular branch of cochlear nerve supplies the
vestibular end of cochlear duct.

VESTIBULAR
VESTIBULAR NERVE
NERVE

It supplies maculae of utricle, saccule and ampulla of SC ducts. Scarpa's ganglion, from
where these Abers arise, lies in the internal acoustic meatus. Distal to the ganglion, it
divides into superior, inferior and posterior vestibular branches.

Superior branch supplies utricular macula and ampullary crest of anterior and lateral
SC ducts
Inferior branch supplies saccular macula
Posterior supplies ampulla of posterior SC duct.

ARTERIES
ARTERIES OF
OF LABYRINTH
LABYRINTH

Internal auditory artery is a branch of anterior inferior cerebellar artery, which itself
arises from basilar artery
Internal auditory artery (labyrinthine artery) divides into a cochlear and a vestibular
branch
Stylomastoid branch of occipital artery and posterior auricular artery also contribute.

VEINS
VEINS

Cochlear vein and vestibular vein join to form the labyrinthine vein, which ends in
superior petrosal sinus or in transverse sinus
A small vein from basal turn of cochlea also joins the internal jugular vein. 18

Table 1.2 Measurement of ear

Name Measurement Name Measurement
(Mm) (Mm)

24 (8C + 16B) 12–15

EAC Length of HSCC

15 × 15 × 6 – 2 – 4 15–20
Middle ear Length of anterior
SCC

10 × 9 × 0.1 18–22
Tympanic membrane Length of posterior
SCC

36 (24C + 12B) 5 × 9 × 35
Eustachian tube Cochlea

1.5 × 1.3 35 × 0.3

Fenestra cochleae Basilar membrane

3.25 × 1.75 2–3

Fenestra vestibuli Pars daccida

15 × 12 3×2
Mastoid antrum Utricular macula

5×3 1–1.5
Vestibule Saccular macula

0.8 55 (mm2)
Semicircular canal Vibrating surface
diameter

Key Points

1. Preauricular sinus results due to failure of fusion of tubercles of Arst and second
branchial arches.

2. Important measurements of ear are given in Table 1.2.

3. Boundaries of facial recess are facial nerve (medially), chorda tympani (laterally) and
fossa incudis (above).

4. Sinus tympani or infrapyramidal recess lies between oval and round window, below
ponticulus and above subiculum process of bone on medial wall.

5. Trautmann triangle is bounded by superior petrosal sinus (superiorly), sigmoid sinus

(posteriorly) and bony labyrinth (anteriorly).

q. Eddy currents in the external auditory meatus do not allow water to reach tympanic
membrane while swimming.

7. Glasserian =ssure in the middle ear transmits anterior tympanic branch of maxillary
artery, anterior ligament of malleus and chorda tympani nerve through canal of
Huguier.

r. Prussak space is bounded by: lateral malleolar fold on anterior, posterior and
superior side, lateral process of malleus on inferior side, neck of malleus medially
and pars daccida laterally.

9. Cochlear aqueduct is a bony channel of 6.2 mm length which connects scala

tympani with subarachnoid space of posterior cranial fossa.

10. Meckel cave on the superior part of temporal bone houses the Gasserian ganglion (V
nerve).

11. Eustachian tube is opened by tensor palati; levator palati and salpingopharyngeus
muscles.

12. Bill's bar in internal acoustic meatus separates facial nerve from superior vestibular
nerve.

13. Mastoid process develops at Arst year of age.

14. Sensory supply of middle ear and posterior wall of pharynx is by glossopharyngeal
nerve.

15. Superiorly roof of external auditory meatus is related to middle cranial fossa.

1q. Caroticotympanic artery is a branch of internal carotid artery which anastamose with
branches of external carotid in the middle ear.

17. Hyrtl's =ssure also called tympanomeatal hiatus which connects cerebrospinal duid
(CSF) space to middle ear just anterior and inferior to round window. Normally, it gets
obliterated but if it persists may become a source of CSF otorrhea or meningitis from
middle ear infection.

1r. Structures of ear fully formed at birth are middle ear, ossicles, labyrinth and cochlea.

19. Cartilage derivatives of 1st pharyngeal arch (mandibular)—remember mneumonic:

I'M A Super Sexy Guy: Incus-Malleus-Anterior ligament of malleus; Spine of sphenoid;
Sphenomandibular ligament; Genial tubercle of mandible.