II. 15.

Exterior and middle ear

The ear is the organ of hearing and plays an important role in maintaining the balance (equilibrium) of
the body. The ear is divided into three parts (Fig. 18.1), viz.
1. External ear.
2. Middle ear.
3. Internal ear.
The external ear consists of the auricle or pinna and external auditory meatus at the medial end of
which lies the tympanic membrane or ear drum, separating the external ear from the middle ear. The
middle ear or tympanic cavity is a small air-filled space within the petrous part of the temporal bone
containing the auditory ossicles. It communicates with the nasopharynx through auditory tube. By its
medial wall, the middle ear adjoins the internal ear. The internal ear consists of a bony labyrinth, a
complicated space, also in the petrous part of the temporal bone containing fluid-filled membranous
labyrinth. The membranous labyrinth contains sensory receptors for hearing and balancing.
The sensations of hearing and balancing from these receptors are carried by vestibulocochlear nerve to
the cerebral cortex for interpretation.
EXTERNAL EAR
The external ear consists of
(a) pinna or auricle and
(b) external auditory meatus, which are concerned with collection and transmission of sound waves to
the tympanic membrane, respectively.

AURICLE/PINNA
The auricle is trumpet-like undulating projection on the side of the head (Fig. 18.2). The entire pinna
except its lobule is made up of a single piece of crumpled yellow elastic cartilage covered with skin (Fig.
18.2B). The lobule of pinna is made of fibrofatty tissue covered with skin. The auricular cartilage is
continuous with the cartilage of the external auditory meatus.
Features
The auricle presents two surfaces: lateral and medial.
The lateral surface of auricle (Fig. 18.2A) displays following elevations and depressions:
1. Concha, a large depression that leads into the external auditory meatus. It is guarded in front by a
triangular flap of cartilage, the tragus.
2. Helix forms a prominent peripheral rim of the pinna. It consists of two limbs—anterior and posterior.
An anterior limb ends as crus of helix, which divides the concha into smaller upper and larger lower
parts. The posterior limb ends below as flabby ear lobe and its upper end sometimes presents a small
elevation called
Darwin’s tubercle. It is probably erroneously thought to represent the vestige of the pointed part of the
quadruped ear.
3. Antihelix is another prominent ridge present in front and parallel to the posterior part of helix, partly
encircling the concha. Its upper end divides into two crura enclosing a triangular depression called
triangular fossa. The narrow gutter between the helix and antihelix is called scaphoid fossa.
4. Tragus is a small triangular flap in front of concha.
5. Antitragus is a small elevation opposite to tragus from which it is separated by an intertragic notch.
6. Cymba conchae is a small area of concha above the crus of helix. Clinically it is important as it
corresponds to the suprameatal triangle (McEwen’s triangle).
7. Lobule of the ear hangs below the antitragus as a large skin covered flap of fibrofatty tissue.

N.B.
• There is no cartilage between tragus and crus and the gap between the two is called incisura
terminalis.
• The thick hair on pinna particularly on tragus in male represents Y-linked inheritance.
• The pinna collects and directs the sound waves to the external auditory meatus.

The medial/cranial surface of (pinna) presents the following features:

1. Eminentia concha, which corresponds to the depression of the concha.
2. Eminentia triangularis, which corresponds to the triangular fossa between the crura of the antihelix.

Clinical correlation
• Pinna is a source of several graft materials for the surgeons.
• The lobule of ear is commonly pierced for wearing earrings.
• For surgery of external auditory meatus, the incision is made in the region of incisura terminalis as it
will not cut through the cartilage.

Muscles
The muscles of the auricle are divided into two groups: extrinsic and intrinsic. They are rudimentary in
humans.
The extrinsic muscles pass from scalp or skull to the auricle. They are as follows:
1. Auricularis anterior.
2. Auricularis superior.
3. Auricularis posterior.
The anterior and superior muscles arise from epicranial aponeurosis and are inserted into the upper part
of the helix and upper part of the cranial surface of the auricle, respectively. The auricularis posterior
arises from the mastoid process and gets inserted into eminentia concha.
The intrinsic muscles are small muscular slips, which pass between the cartilaginous parts of the auricle.
Actions
The extrinsic muscles may play a role in positioning of the auricle to catch the sound, while intrinsic
muscles may change the shape of the auricle. Such movements are rarely seen in human beings.
However in animals they modify the shape of the pinna.

Skin
The skin covering the auricle is closely adherent to the underlying cartilage and fibrofatty tissue.
Sometimes coarse hair projects out of the tragus, antitragus, intertragic notch, and helix in elderly
males. The hairy pinna is an expression of Y-linked genes.

Arterial Supply
1. The cranial surface and posterior part of the lateral surface is supplied by the posterior auricular
branch of the external carotid artery.
2. The anterior part of the lateral surface is supplied by the superficial temporal artery.

N.B. Few branches of occipital artery supply the upper part of the cranial surface.

Venous Drainage
The veins accompany the arteries and drain into superficial temporal and external jugular veins.

Lymphatic Drainage
The lymph from auricle drains into:
1. Preauricular (parotid) lymph nodes.
2. Mastoid lymph nodes.
3. Upper group of deep cervical lymph nodes.

Nerve Supply
Motor supply: All the extrinsic and intrinsic muscles of the auricle are supplied by the facial nerve. The
auricularis anterior and auricularis superior are supplied by the temporal branch of the facial nerve,
while auricularis posterior is supplied by the posterior auricular branch of the facial nerve.
Sensory supply (Fig. 18.3)
1. Lateral (facial) surface (Fig. 18.3A)
(a) Lower one-third, by great auricular nerve (C2, C3).
(b) Upper two-third, by auriculotemporal nerve [(a branch of mandibular division of the trigeminal nerve
(CNV)].
(c) Concha, by auricular branch of the vagus (Alderman’s nerve) nerve (CNX).
2. Medial (cranial) surface (Fig. 18.3B)
(a) Lower one-third, by great auricular nerve (C2, C3).
(b) Upper two-third, by lesser occipital nerve (C2).
(c) Eminentia conchae, by auricular branch of the vagus.

CLINICAL CORRELATION
Involvement of pinna in herpes zoster of geniculate ganglion (Ramsay Hunt syndrome): Clinically, it is
acknowledged that a few fibres of the facial nerve accompany the auricular branch of vagus and supply
the skin in the region of concha and eminentia conchae, as vesicles are seen in these regions during
involvement of the geniculate ganglion of the facial nerve by herpes zoster virus. The communication
between the auricular branch of vagus and facial nerves takes place within the petrous temporal bone.
Clinical correlation
EXTERNAL AUDITORY MEATUS
The external auditory meatus (syn. external acoustic meatus) extends from the bottom of the concha to
the tympanic membrane and measures about 24 mm along its posterior wall. Note that it is not a
straight tube but it has a typical S-shaped course. Its outer part is directed upwards, backwards, and
medially (UBM), whereas its inner part is directed downwards, forwards, and medially (DFM).
Therefore, to examine the tympanic membrane the pinna has to be pulled upwards, backwards, and
laterally, to bring the two parts in alignment.
Parts
The external auditory meatus is divided into two parts: Cartilaginous and bony.
The cartilaginous part forms the outer one-third (8 mm) of the meatus. The cartilage is the continuation
of the cartilage of the auricle. The skin covering the cartilaginous part is thick, and contains hair and
ceruminous (pilosebaceous) glands, which secrete ear wax.

CLINICAL CORRELATION

Since the hairs are confined to the outer part of the meatus, the furuncles (infection of hair follicles)
develop only in this part.
• To examine external auditory meatus and tympanic membrane, the pinna is pulled upwards,
backwards, and laterally (vide supra) in adults, while in infants it is pulled downwards and backwards.
This is because in infants the bony part of external auditory meatus is not developed and tympanic
membrane is directed mainly downwards.
The bony part forms the inner two-third (16 mm) of the external auditory meatus. The skin lining the
bony part of meatus is thin and continuous with the cuticular layer of the tympanic membrane. It is
devoid of hair and ceruminous glands. About 4 mm lateral to the tympanic membrane (about 20 mm
deep to concha), the bony meatus presents a narrowing called isthmus. The foreign body lodged medial
to isthmus gets impacted and are difficult to remove.
Sometimes the anterior wall of bony part presents a foramen (foramen of Huschke), permitting
infection back and forth from parotid gland. This foramen is normally present in children up to the age
of 4 years.
In the newborn, the bony canal is not developed and is represented by a tympanic ring of bone.
Consequently the external auditory meatus is shorter in children, and therefore, deep insertion of ear
speculum may damage the tympanic membrane.

Arterial Supply
The external auditory meatus is supplied by the following arteries:
1. Posterior auricular artery, a branch of the external carotid artery.
2. Deep auricular artery, a branch of first part of the maxillary artery.
3. Anterior tympanic artery, a branch of first part of the maxillary artery.

Nerve Supply
1. Roof and anterior wall are supplied by the auriculotemporal nerve.
2. Floor and posterior wall are supplied by the auricular branch of vagus (note that it is the only
cutaneous branch of the vagus nerve).
CLINICAL CORRELATION

• The infection and boils of the external auditory meatus cause very little swelling but are very painful
because the skin lining is firmly adhered to the underlying cartilage and bone.
• Ear wax: It prevents the injury of the lining epithelium of the external auditory meatus from water and
the damage of tympanic membrane by trapping the insects. The excess of ear wax interfering with
hearing is removed by syringing.
The irritation of auricular branch of vagus during syringing may reflexly produce persistent cough called
ear cough, vomiting, and even death due to sudden cardiac inhibition.
• The Aldermen were the individuals in ancient Rome, who were very fond of excessive eating and used
to stimulate their jaded appetite by dropping cold water or spirit behind the ear as this could reflexly
stimulate gastric peristalsis due to supply of this area by the vagus nerve which also supplies motor
innervation to the GIT.
Clinical correlation
Development
The external auditory meatus develops as an ectodermal invagination of first pharyngeal cleft. It
becomes filled with ectodermal cells forming a solid mass called meatal plug, which is canalized before
birth. The auricle develops from six mesodermal tubercles around the external opening of the first
pharyngeal cleft. The failure of canalization of meatal plug results in atresia of the external auditory
meatus, while failure of fusion of tubercles will give rise to accessory auricles.

TYMPANIC MEMBRANE
The tympanic membrane (or ear drum) is a thin (0.1 mm thick) semitransparent membrane, which forms
the partition between external acoustic meatus and middle ear. It is oval, measuring 9–10 mm in length,
and 8–9 mm in width. It is placed obliquely making an angle of about 55° with the floor of the external
acoustic meatus. The tympanic membrane faces downwards, forwards, and laterally as though to catch
the sounds reflected from the ground. Consequently the anterior wall and the floor of external auditory
meatus are longer than the posterior wall and the roof.
Structure
The tympanic membrane is made of three layers (Fig. 18.4); from lateral to medial these are as follows:
1. Outer cuticular layer of stratified squamous epithelium,
which is continuous with the skin lining the external auditory, meatus.
2. Middle fibrous layer, which encloses the handle of the malleus. It contains outer radiating and inner
circular fibres.
3. Innermucosal layer is lined by low columnar epithelium, which is continuous with the mucous lining
of the middle, ear.

Parts
The tympanic membrane is divided into two parts: pars tensa and pars flaccida.
Pars tensa forms most of the tympanic membrane. Its periphery is thickened to form a
fibrocartilaginous rim called annulus tympanicus, which fits into the tympanic sulcus. The
fibrocartilaginous rim presents a notch above. From the margins of the notch the anterior and posterior
malleolar folds in mucous membrane of tympanic cavity pass to gain attachment to the lateral process
of the malleus.
The handle of the malleus is firmly attached to the inner surface of the pars tensa. This part is rendered
tough by the inward pull of the tensor tympani muscle, attached to the root of handle of the malleus
and radial fibres.
Pars flaccida (Shrapnell’s membrane) is a small triangular area above the lateral process of malleus
between anterior and posterior malleolar folds (now called malleal folds). This part is thin and lax
because intermediate fibrous layer here is replaced by loose areolar tissue. It appears slightly pinkish.
Surfaces
Lateral surface of the tympanic membrane is concave towards the meatus and directed downwards,
forwards, and laterally.
Medial surface is convex and bulges towards the middle ear. The point of maximum convexity is called
umbo (Fig. 18.5). When the tympanic membrane is illuminated for inspection, the concavity of the
membrane produces a ‘cone of light’ radiating from the umbo over the anteroinferior quadrant. This
surface receives the attachment of malleus up to the center of the membrane. Here the handle of the
malleus is crossed medially by chorda tympani nerve, which runs forwards between the fibrous and
mucosal layer at the junction of pars flaccida and pars tensa.

Arterial Supply
1. The outer surface is supplied by deep auricular artery, a branch from first part of maxillary artery.
2. The inner surface is supplied by
(a) anterior tympanic artery, a branch from first part of maxillary artery, and
(b) posterior tympanic artery, a branch from stylomastoid artery arising from posterior auricular artery.
Venous Drainage
1. Veins from outer surface drain into external jugular vein.
2. Veins from inner surface drain into transverse sinus and pterygoid venous plexus.

Nerve Supply
1. Anterior half of the lateral surface is supplied by the auriculotemporal nerve (V3).
2. Posterior half of the lateral surface by the auricular branch of vagus (CNX).
3. Medial surface by tympanic branch of the glossopharyngeal (CNIX) through tympanic plexus.

CLINICAL CORRELATION

Perforation of the tympanic membrane: It may result from an external injury or middle ear infection
(otitis media).
• Examination of tympanic membrane: Inspection of the tympanic membrane with an otoscope
provides significant information about the condition of the middle ear. The color, curvature, presence of
lesions, and position of malleus are features of special importance. When tympanic membrane is
illuminated for examination, a cone of light is reflected in the anteroinferior quadrant of the membrane
from umbo, the point of maximum concavity, which marks the attachment of the handle of the malleus.
Since the membrane is semitranslucent, the following structures lying deep to it can be seen (Fig. 18.6):
– Handle of Malleus, as a yellow streak extending from umbo upwards and forwards.
– Lateral process of malleus, as a white prominence in the upper part of the streak of handle of malleus.
– Long processes of incus, as white streaks behind and parallel to the upper part of the handle of
malleus.
– A cone of light at 5 o’clock position in anteroinferior quadrant.
Clinical correlation
Clinically, the tympanic membrane is divided into four quadrants by means of two imaginary lines
passing through the umbo. One is drawn along the handle of the malleus and the other at right angle to
it through the umbo.

N.B. On illumination the normal membrane looks pearly grey. Sometimes an incision is given in the
tympanic membrane (myringotomy) to drain the pus from the middle ear. The incision is usually given in
the posteroinferior quadrant to avoid injury to the chorda tympani nerve, which crosses the inner aspect
of the membrane in the upper part.

Development
The tympanic membrane develops from first pharyngeal membrane consisting, from superficial to deep,
of three layers: ectoderm, mesoderm, and endoderm.
Therefore, the tympanic membrane also consists of three layers from superficial to deep these are:
1. Cuticular layer, derived from ectoderm.
2. Intermediate layer, derived from mesoderm.
3. Mucous layer, derived from endoderm.
The three layers of tympanic membrane are likened to the three layers of trilaminar embryonic disc.
MIDDLE EAR
The middle ear (syn. tympanum, tympanic cavity) is a narrow slit-like air-filled cavity within the petrous
part of the temporal bone. The middle ear is sandwiched between the external and internal ear. It
contains three auditory ossicles, which transmit sound vibrations from tympanic membrane in its lateral
wall to the internal ear via its medial wall. The tympanic cavity is really the intermediate portion of a
blind diverticulum from the respiratory mucous membrane of the nasopharynx. From front to back, the
diverticulum consists of pharyngotympanic tube, tympanic cavity, and mastoid antrum.
In a section through long axis of petromastoid bone, the outline of tympanic cavity together with
mastoid antrum and pharyngotympanic tube resembles a pistol, the nozzle being represented by the
tube, the body by tympanic cavity, and handle by mastoid antrum (Fig. 18.7).

Size and Shape

The middle ear is shaped like a cube, compressed from side to side. In coronal section, it resembles a
biconcave disc, like a red blood cell (Fig. 18.8).
Measurements
_ Vertical diameter: 15 mm.
_ Anteroposterior diameter: 15 mm.

Transverse diameters
(a) At roof: 6 mm.
(b) In the center: 2 mm.
(c) At the floor: 4 mm.
Communication
The middle ear communicates:
Anteriorly with nasopharynx through pharyngotympanic tube.
Posteriorly with mastoid antrum and mastoid air cells through aditus to antrum called aditus ad antrum.

Contents of the Middle Ear

Inside the mucous lining:
1. Air.
Outside the mucous lining:
1. Three small bones called ear ossicles: malleus, incus, and stapes.
2. Two muscles: tensor tympani and stapedius.
3. Two nerves: chorda tympani and tympanic plexus.
4. Vessels supplying and draining the middle ear.
5. Ligaments of the ear ossicles.

N.B. The mucous membrane lining of the middle ear invests all the structures within it and forms several
folds, which project into the cavity giving it a honey-comb appearance.
Thus strictly speaking, the middle ear contains only air.

Subdivisions of the Middle Ear (Fig. 18.9)

The tympanic cavity extends much beyond the limits of tympanic membrane, which forms its lateral
boundary. It is divided into three parts, viz.
1. Epitympanum (attic), a part above the tympanic membrane containing head of malleus, body, and
short process of incus.
2. Mesotympanum, a part opposite to tympanic membrane containing handle of malleus, long process
of incus, and stapes. It is the narrowest part of the middle ear.
3. Hypotympanum, a part below the tympanic membrane.
Boundaries (Fig. 18.10)
The middle ear is likened to a six-sided box and thus presents six walls, namely,
1. Roof.
2. Floor.
3. Anterior wall.
4. Posterior wall.
5. Medial wall.
6. Lateral wall.

Roof: It is formed by a thin plate of bone called tegmen tympani. It separates the tympanic cavity from
the middle cranial fossa. The tegmen tympani also extend posteriorly to form the roof of aditus ad
antrum.
Floor: The floor is also formed by a thin plate of bone, which separates the tympanic cavity from the
jugular bulb.
Sometimes it is congenitally deficient and the jugular bulb then projects into the middle ear, being
separated from cavity only by mucosa.
The tympanic branch of glossopharyngeal nerve pierces the floor between the jugular fossa and lower
opening of the carotid canal and enters the tympanic cavity to take part in the formation of tympanic
plexus.
Anterior wall: It is formed by a thin plate of bone. In the lower part it separates the cavity from internal
carotid artery.
The upper part of anterior wall presents two openings or canals, the upper one for the tensor tympani
muscle and the lower one for the auditory tube.
The bony partition between the two canals extends backwards along the medial wall in the tympanic
cavity as a curved lamina called processus cochleariformis.
Posterior wall: The posterior wall separates the tympanic cavity from mastoid antrum and mastoid air
cells, and presents the following features:
1. Aditus ad antrum, an opening in the upper part through which tympanic cavity communicates with
the mastoid antrum.
2. Fossa incudis, a small depression close to the aditus, lodging the short process of the incus.
3. Pyramid, a hollow conical bony projection below the aditus containing stapedius muscle whose
tendon appears through its summit, passes forwards to be attached to the neck of the stapes.
4. Vertical part of facial canal runs in the posterior wall just behind the pyramid and descends up to the
stylomastoid foramen.
5. Posterior canaliculus for chorda tympani, a small aperture for emergence of this nerve.

Medial wall: It separates the tympanic cavity from the internal ear; thus it is actually formed by the bony
lateral wall of the internal ear. The medial wall presents the following features:
1. Promontory, a rounded prominence in the centre produced by first (basal) turn of the cochlea. The
tympanic branch of the glossopharyngeal nerve ramifies on it to form tympanic plexus.

2. Oval window (fenestra vestibuli), a reniform aperture located above and behind the promontory. It is
closed by the base of stapes and annular ligament.

3. Round window (fenestra cochleae), a small round opening below and behind the promontory which
in life, is closed by fibrous secondary tympanic membrane.
The secondary tympanic membrane separates the middle ear from the scala tympani.

4. Sinus tympani, a depression behind the promontory between fenestra vestibuli and fenestra
cochleae, which indicates the position of ampulla of the posterior semicircular canal.

5. Prominence of oblique part of the facial canal that extends backwards and downwards above the
oval window until it joins the vertical part of the facial canal in the posterior wall of the tympanic cavity.
Sometimes the bony covering of the facial nerve may be absent, thus exposing the nerve for injuries and
infection.
6. Prominence of lateral semicircular canal of the internal ear, which is seen as a small ridge high up in
the angle between the medial and posterior walls.

Lateral wall: Most of the lateral wall is formed by tympanic membrane, which separates the tympanic
cavity from the external auditory meatus .
The chorda tympani nerve, a branch of facial nerve passes across the tympanic membrane lying lateral
to the long process of the incus and medial to the handle of the malleus. It enters the tympanic cavity
through the posterior canaliculus in the posterior wall and leaves through the anterior canaliculus
medial to the petrotympanic fissure.

CLINICAL CORRELATION

Infection of the middle ear (otitis media): It is common especially in infants and children. Infective
agents reach the middle ear from the upper respiratory tract through pharyngotympanic tube. The long-
standing infection leads to chronic suppurative otitis media (CSOM), which clinically presents as ear
discharge and perforation of tympanic membrane. The spread of infection from the middle ear may give
rise to the following clinical conditions:
– Acute mastoiditis and mastoid abscess, when infection spreads into mastoid antrum and mastoid air
cells through aditus ad antrum in the posterior wall.
– Meningitis and temporal lobe abscess may occur, if infection spreads upwards through the thin roof
(tegmen tympani).
– Lower motor neuron type of facial palsy, when infection erodes the papery thin bony wall of facial
canal.
– Transverse and sigmoid sinus thrombosis, when infection spreads through the floor.
– Labyrinthitis, when infection spreads deep into medial wall. The labyrinthitis causes vomiting and
vertigo.
– Cerebellar abscess, when infection spreads too far posteromedially.

Ear Ossicles
The three ear ossicles (malleus, incus, and stapes) within the middle ear are connected to one another
by synovial joints and form a bony chain that extend across the tympanic cavity from the tympanic
membrane to the oval window (Fig. 18.11). They conduct sound vibrations from tympanic membrane to
the oval window and subsequently to the inner ear fluid.
Malleus
It resembles a hammer and, therefore, known as malleus. It has head, neck, handle (manubrium), a
lateral process, and an anterior process. The head and neck lie in the epitympanum, whereas the handle
is embedded in the fibrous layer of tympanic membrane. The lateral process forms a knob-like
projection on the outer surface of the tympanic membrane and provides attachment to the anterior and
posterior malleolar folds. The head of malleus articulates with the body of the incus forming the
incudomalleolar joint (saddle type of synovial joint).

Incus
It resembles an anvil or a premolar tooth in shape. It consists of a relatively large body and two slender
processes: a short process and a long process. The body and short process lie in the attic, whereas its
long process hangs vertically behind and parallel with the handle of the malleus. Its bulbous tip
(lentiform nodule) is directed medially to articulate with the head of the stapes, forming the
incudostapedial joint (ball and socket type of synovial joint).

Stapes
It resembles a stirrup. It consists of head, neck, anterior and posterior crura, and footplate. The
footplate closes the oval window and is attached to its margin by annular ligament. The features of ear
ossicles are summarized in Table 18.1.
Intratympanic Muscles
There are two intratympanic muscles: tensor tympani and stapedius.
The features of these muscles are enumerated in Table 18.2.

CLINICAL CORRELATION

Hyperacusis: Both, tensor tympani and stapedius contrac reflexly and simultaneously to dampen very
loud sounds, thus preventing noise trauma to the internal ear. The paralysis of stapedius results in
hyperacusis (an abnormally increased power of hearing) where even whisper appears as noise.

Otosclerosis: Abnormal ossification of annular ligament, which anchors the footplate of stapes to the
oval window is called otosclerosis. This impedes the movements of stapes and causes deafness. The
otosclerosis is the most common cause of conductive deafness in adults.

Arterial Supply
The middle ear is supplied by six arteries, viz.
1. Anterior tympanic branch of the maxillary artery.
2. Stylomastoid branch of the posterior auricular artery.
3. Petrosal branch of the middle meningeal artery, running along the greater petrosal nerve.
4. Superior tympanic branch of the middle meningeal artery, running along the canal for tensor tympani.
5. Branch from the artery of pterygoid canal.
6. Tympanic branch of the internal carotid artery.
N.B. Out of the six arteries, first two—anterior tympanic branch of the maxillary and stylomastoid
branch of the posterior auricular artery are the main source of the blood supply.

Venous Drainage
The veins from middle ear drain into:
1. Pterygoid venous plexus, via squamotympanic fissure.
2. Superior petrosal sinus, through subarcuate fossa.

Lymphatic Drainage
The lymphatics from middle ear drain into:
1. Retropharyngeal lymph nodes.
2. Parotid lymph nodes.
3. Upper deep cervical lymph nodes.

Nerve Supply
1. Tympanic branch of glossopharyngeal nerve: It enters the middle ear through a canaliculus in the
floor of the tympanic cavity and takes part in the formation of tympanic plexus.
It provides sensory supply to the lining of middle ear, antrum, and auditory tube.
Its preganglionic parasympathetic fibres supply the secretomotor fibres to the parotid gland.

2. Superior and inferior caroticotympanic nerves: They are vasomotor and derived from sympathetic
plexus around the internal carotid artery.
3. Facial nerve: It runs in the bony canal along the medial and posterior walls of tympanic cavity and
gives rise to three branches, viz.
(a) Chorda tympanic nerve, which
(i) carries taste sensations from anterior two-third of the tongue except vallate papillae, and
(ii) provides secretomotor fibres to submandibular and sublingual salivary glands.
(b) Greater petrosal nerve, which provides secretomotor fibres to lacrimal, nasal, and palatal mucous
glands.
(c) Nerve to stapedius muscle.

4. Mandibular nerve: It provides motor fibres to tensor tympani muscle.

Tympanic Plexus
It is a plexus of nerves on the promontory in the medial wall of the middle ear. It is formed by:
(a) tympanic branch of the glossopharyngeal nerve (Jacobson’s nerve).
(b) superior and inferior caroticotympanic nerves derived from sympathetic plexus around the internal
carotid artery, and
(c) branch from facial ganglion (geniculate ganglion).
The tympanic plexus supplies mucous membrane of the middle ear, mastoid air cells, and bony
eustachian tube. The lesser petrosal nerve derived from it contains secretomotor fibres of
glossopharyngeal nerve to supply the parotid gland via otic ganglion.

CLINICAL CORRELATION

Referred pain of ear: Since the middle ear and external ear are supplied by the branches of trigeminal
(CNV), glossopharyngeal (CNIX) and vagus (CNX) nerves, the pain in the ear (otalgia) is often referred to
other areas supplied by these nerves, e.g., tongue, teeth, tonsil, and pharynx.

Mastoid Antrum
It is a large air-containing space in the upper part of the mastoid process. It communicates anteriorly
with tympanic cavity through aditus ad antrum. Its roof is formed by tegmen antri, which is the
backward continuation of tegmen tympani. It separates the antrum from middle cranial fossa.
The lateral wall of the antrum is formed by a plate of bone, which is on an average 1.5 cm thick in the
adult. (It is only 2 mm thick in a newborn.) It is marked on the surface of mastoid by suprameatal
triangle (McEwen’s triangle). The floor of antrum receives the openings of mastoid air cells. Its posterior
wall is related to sigmoid sinus whereas its medial wall presents bulging of the lateral semicircular canal.

Development
Mastoid antrum develops as a backward extension of tympanic cavity and assumes the full adult size at
birth. The mastoid abscess is a common condition. The antrum is approached surgically through its
lateral wall. Thus it is important to assess the limits of suprameatal triangle. This triangle is bounded
above by supramastoid crest, anteroinferiorly by posterosuperior segment of bony external auditory
meatus and posteriorly by a line drawn as a tangent to the posterior margin of the bony meatal opening.
Clinical correlation
Pharyngotympanic Tube (Fig. 18.12)
The pharyngotympanic tube (auditory tube) is an osseocartilaginous tube, which connects the
nasopharynx with tympanic cavity (middle ear). It is directed downwards, forwards, and medially from
the tympanic cavity to the nasopharynx.
The auditory tube maintains equilibrium of air pressure on either side of the tympanic membrane for its
proper vibration.

Development of the Middle Ear

The auditory tube and middle ear develop from endodermal tubotympanic recess, which arises from
the first pharyngeal pouch (and partly from second pharyngeal pouch). The mastoid antrum develops as
an extension of the middle ear cavity into the mastoid process.
The malleus and incus develop from mesoderm of the first arch. The stapes develops from mesoderm
of the second arch except its foot palate and annular ligament, which are derived from otic capsule.

INTERNAL EAR
The internal ear consists of a closed system of fluid filled intercommunicating membranous sacs and
ducts called membranous labyrinth. The fluid filled in the membranous labyrinth is called endolymph.
The membranous labyrinth lies within the complex intercommunicating bony cavities and canals (bony
labyrinth) in the petrous part of the temporal bone. The space between the membranous and bony
labyrinth is filled with fluid called perilymph. The sensory receptors within the membranous labyrinth
are responsible for hearing and balancing (equilibrium).
Components of the Internal Ear
The internal ear consists of two components, viz.
1. Membranous labyrinth.
2. Bony labyrinth.

MEMBRANOUS LABYRINTH (Fig. 18.13)

The membranous labyrinth consists of the following four parts (Fig. 18.12A):
1. Cochlear duct.
2. Saccule.
3. Utricle.
4. Semicircular ducts (three).
The cochlear duct lies within the bony cochlea, the saccule, and utricle lie within the bony vestibule, and
three semicircular ducts lie within the three bony semicircular canals.

These four parts are interconnected as follows:

1. The cochlear duct (basal turn) is connected to saccule by ductus reuniens.
2. The saccule and utricle are connected to each other by Y-shaped utriculo-saccular duct, which
expands to form ductus and saccus endolymphaticus.
3. The utricle is connected to three semicircular ducts through five openings.

N.B.
• The sensory receptor within cochlear duct is spiral organ of Corti. It is concerned with hearing.
• The sensory receptors within saccule and utricle are maculae. They are concerned with static balance.
• The sensory receptors within the semicircular ducts are cristae ampullaris. They are concerned with
kinetic balance.
The sensations from cristae (kinetic balance) and maculae (static balance) are carried by vestibular
nerve, while sensations of hearing from spiral organ are carried by the cochlear nerve (Fig. 18.14).

Cochlear Duct (Scala Media)

The cochlear duct is a spiral anterior part of the membranous labyrinth having two- and three-fourth
turns. It lies in the middle part of the cochlear canal between scala vestibuli and scala tympani. The
cochlear duct contains spiral organ of Corti, which is sensory receptor for hearing.

Structure
The structure of cochlear duct is best studied in cross section of the cochlear canal. In cross section, the
cochlear duct is triangular in shape (Fig. 18.15).
Boundaries
Base: Formed by the osseous spiral lamina (medially) and basilar membrane (laterally).
Roof: Formed by the vestibular membrane (Reissner’s membrane), which passes from upper surface of
spiral lamina to the wall of cochlea.
Laterally: It is bounded by the outer wall of cochlear canal.

Spiral Organ of Corti

It is the peripheral organ of hearing in the cochlear duct and is situated on the basilar membrane. The
important components of the organ of Corti are as follows:
1. Tunnel of Corti: It is formed by the inner and outer rod cells. It contains a fluid called corticolymph.
The exact function of rods and corticolymph is not known.
2. Hair cells: These are receptor cells of hearing located on basilar membrane and their apices possess
stereocilia (hair), which are overlaid by tectorial membrane. The inner cells are flask shaped and
arranged in a single row while outer cells are cylindrical and arranged in 3 or 4 rows.
When sound vibrations (in fact fluid waves) pass from perilymph of scala vestibuli to the perilymph of
scala tympani, the basilar membrane bulge and the overlying hair cells are stimulated. The inner hair
cells are richly supplied by the cochlear nerve fibres and are responsible for transmission of auditory
impulses. The outer hair cells are innervated by efferent fibres from the olivary complex and are
concerned with modulation function of inner hair cells.
3. Supporting cells (Deiter’s and Hansen’s Cells): The Deiter’s cells are situated between the outer hair
cells and provide support to the latter. The Hansen’s cells lie outside the hair cells.
4. Membrana tectoria: It is made up of gelatinous substance and overlies the hair cells. Medially it is
attached to osseous spiral lamina. The shearing force between the hair cells and tectorial membrane
stimulate the hair cells.
N.B. The scala vestibuli and scala tympani containing perilymph lie above and below basilar membrane
respectively. Therefore cochlea duct (containing endolymph) is bathed above and below by the
perilymph within the two scalae. The two scala are continuous with each other through a narrow
opening at the apex of cochlear duct called helicotrema .

Innervation of Hair Cells of Organ of Corti

Ninety-five percent of afferent fibres (peripheral processes of bipolar neurons of spiral ganglion) supply
the inner hair cells while only 5% supply the outer hair cells. The spiral ganglion is located in the spiral
canal within the modiolus near the base of the spiral lamina. The central processes of ganglion cells form
the cochlear nerve.
Efferent fibres to the outer hair cells come from olivocochlear bundle. Their cell bodies are located in
the superior olivary complex.

Saccule and Utricle

The saccule, a small globular membranous sac, lies in the anteroinferior part of the vestibule. The utricle
is an oblong membranous sac and is larger than the saccule. It lies in the posterosuperior part of the
vestibule.
The saccule is connected in front to the basal turn of cochlear duct by the ductus reuniens and behind
with the utricle by a Y-shaped utriculo-saccular duct. The vertical limb of ‘Y’ continues as endolymphatic
duct (ductus endolymphaticus) and its dilated blind terminal end is called saccus endolymphaticus. The
endolymphatic duct passes through a bony canal (aqueduct of vestibule) in the posterior
part of petrous temporal bone and its dilated terminal end projects on the posterior surface of petrous
temporal bone beneath the dura mater of the posterior cranial fossa. The endolymph is absorbed by the
epithelial cells lining the saccus and drains into extradural vascular plexus.
The utricle receives the three semicircular ducts posteriorly through five openings.

Semicircular Ducts
The three semicircular ducts—anterior, posterior, and lateral lie within the corresponding semicircular
canals. They open into the utricle by five openings.
Each duct has one dilated end called ampulla. It corresponds to the ampulla of the corresponding
semicircular canal. The ampullary end of each duct bears a raised crest (crista ampullaris), which
projects into its lumen. Peripheral receptors in saccule, utricle, and semicircular ducts (vestibular
system) are as follows:
1. Maculae: These are sensory receptors located in the medial walls of saccule and utricle. They sense
position of head in response to gravity and linear acceleration, i.e., static balance.
2. Cristae: These are sensory receptors located in the ampullated ends of the three semicircular ducts.
They respond to angular acceleration, i.e., kinetic balance.

Innervation of Peripheral Receptors of Vestibular System

The vestibular or Scarpa’s ganglion is situated in the lateral part of the internal acoustic meatus. It
consists of bipolar neurons. The peripheral processes of these cells innervate hair cells of cristae and
maculae, while their central processes aggregate to form the vestibular nerve.

BONY LABYRINTH
The bony labyrinth consists of a series of intercommunicating bony cavities and canals within the
petrous part of the temporal bone.

Parts
The bony labyrinth presents three parts ; from before backwards these are as follows:
1. Cochlea.
2. Vestibule.
3. Semicircular canals (three).

Cochlea
The cochlea resembles the shell of a common snail. Its apex (cupula) is directed towards the medial wall
of the tympanic cavity, while its base is directed towards the bottom of the internal acoustic meatus.
The cochlea consists of a central pillar called modiolus, and a bony cochlear canal:

1. Modiolus is the axial bony stem around which the cochlear canal spirals. It is like an elongated cone.
The base of modiolus lies at the fundus of the internal acoustic meatus and apex points towards the
middle ear. The apex of the modiolus is overlaid by the apical turn of the cochlear canal. The modiolus is
perforated spirally at its base in the internal acoustic meatus by the fibres of the cochlear nerve.

2. Cochlear canal is arranged spirally around the modiolus and makes two and three-fourth turns. Its
basal turn bulges into tympanic cavity as the promontory. A spiral ridge of bone called spiral lamina
projects from the surface of the modiolus into the cochlear canal like a thread of a screw. The free edge
of lamina splits into the upper and lower lips. The vestibular membrane extends from the upper lip of
lamina to the outer wall of the cochlea, while basilar membrane extends from the lower lip of the
lamina to the outer wall of the cochlea. The triangular area thus enclosed by the vestibular and basilar
membranes, and the outer wall of the cochlear canal forms the cochlear duct (scala media).
The spiral lamina partly divides the cochlear canal into scala vestibuli above and scala tympani below.
The scala vestibuli and scala tympani communicate with each other at the apex of the cochlea by a small
opening called helicotrema
At the basal turn of cochlea, the scala vestibuli communicates with the anterior wall of the vestibule.
Close to the basal turn of cochlea the scala tympani presents two features—fenestra cochleae and
beginning of the aqueduct of cochlea:

1. The fenestra cochleae open into the tympanic cavity below and behind the promontory. It is closed
by secondary tympanic membrane in life.

2. The aqueduct of cochlea is a narrow tubular canal through which perilymph within the cochlea
communicates with the cerebrospinal fluid (CSF) of the subarachnoid space through cochlear
canaliculus.

Vestibule
The vestibule is a central ovoid cavity of bony labyrinth between cochlea in front and three semicircular
canals behind. It lies medial to the middle ear cavity.
The lateral wall of the vestibule communicates with the middle ear cavity by fenestra vestibuli, which in
life is closed by footplate of stapes and annular ligament.
The medial wall of the vestibule presents two recesses : a spherical recess in front and an elliptical
recess behind. The two recesses are separated by the vestibular crest, which splits inferiorly to enclose
the cochlear recess. The spherical recess lodges saccule and is perforated by foramina for the passage of
lower division of the vestibular nerve. The elliptical recess lodges the utricle, and is perforated by
foramina for the passage of the upper division of the vestibular nerve.
Just below the elliptical recess, there is an opening of a bony canal called aqueduct of vestibule, which
reaches the epidural space on the posterior surface of the petrous temporal bone. The aqueduct of
vestibule transmits the tubular prolongation of membranous labyrinth, the saccus and ductus
endolymphaticus. The anterior wall of the vestibule bears an opening, which communicates with scala
vestibuli of the cochlear canal. The posterior wall of the vestibule bears five openings of three
semicircular canals.

Semicircular canals
There are three bony semicircular canals: anterior (superior), posterior, and lateral. They lie in three
planes at right angles to each other. Each canal is about two-third of a circle and is dilated at one end to
form the ampulla:

1. The anterior semicircular canal lies in a vertical plane at right angle to the long axis of the petrous
temporal bone. It is convex upwards and its position is indicated on the anterior surface of the petrous
temporal bone as arcuate eminence. Its anterior ampullated end communicates with vestibule
anterolaterally. Its posterior non-ampullated end unites with the upper non-ampullated end of the
posterior semicircular canal to form crus commune, which opens into vestibule.

2. The posterior semicircular canal also lies in a vertical plane parallel to the long axis of petrous
temporal bone. Its convexity is directed backwards. Its lower ampullated end communicates with the
vestibule and is innervated separately by a branch of vestibular nerve, which passes through foramen
singulare in the fundus of internal acoustic meatus.

3. The lateral semicircular canal lies in the horizontal plane. Its convexity is directed posterolaterally. Its
anterolateral end is ampullated and lies close to the ampullated end of the anterior semicircular canal.
Both the ends of this canal open directly into the vestibule.
Thus three semicircular canals open in the vestibule by five openings.

N.B.
• The lateral semicircular canals of two sides lie in the same plane.
• The anterior semicircular canal of one side lies parallel to the posterior semicircular canal of the other
side.
• The anterior and posterior semicircular canals, lying across and along the long axis of the petrous
temporal bone, are each at 45º with the sagittal plane.