Objectives

• To describe the external ear

• To define otoscopic appearance of tympanic membrane

• To illustrate shape & contents of the middle ear

• To Define auditory tube & its importance

• To list important structures in the 3 parts of the pharynx

• To describe NV supply of these areas

• To relate to clinical practice


External ear
- Mechanical & chemical defense
- Sound collection
- Sound transmission
Inner ear
- Conversion of mechanical waves to
nerve impulse
- Linear & angular equilibrium
Middle ear
- Conversion of sound waves to mechanical
waves
- Amplification of sound
- Protects inner ear from acoustic injuries by
the acoustic reflex
The external ear:
The auricle ..
Elastic artilage
•Vessels from ECA;
•Posterior auricular
•Superficial temporal
•Nerves;
1- Great auricular
2- Lesser occipital
3- Auricular branch of vagus
4- Auriculotemporal
The external acoustic meatus..
In ear syringing,
•Is 2.5 cm long
Angulated posterior superiory the nozzle should
•The floor is 5 mm longer than the be directed
roof due to the obliquity of the postero-superiorly
eardrum
•Lies between the TM joint
anteriorly the mastoid process
posteriorly
•Vessels; like the auricle
•Nerves;
o Auriculotemporal
o Auricular branch of X
o Facial nerves
Fissure of Santorini:
- In the floor of EAM between the
cartilagenous & bony parts
- Transmit diseases from adjacent
organs like the parotid &
mastoid process to the external
ear
Auricle should be pulled
postero-superiorly & outward
to straighten the EAM & view
the eardrum
The tympanic membrane:
Placed obliquely
•Oval, 8X10 mm

•Semitransparent, shiny gray

•Set as a cone with its

concavity outward & its
center is called “umbo”

•The handle of the malleus is

fused with its upper part

•The upper 1/6 is called pars

flaccida & the remaining 5/6
is called pars tensa
Normal ear drum in otoscopic exam:
1- Handle of malleus
2- Cone of light
3- Pars flaccida
4- Pars tensa
5- Short process of incus
Innervation:
- Auricular branch of X
- VII nerve
 Applied notes on the nerve
supply of eardrum
Vagus nerve:
1- Vasovagal reflex results from cleaning of the ear:
- Cough
- Hypotension & bradycardia
- Syncope
2- Spirit installation in the EAM stimulates appetite
 Applied notes on the nerve
supply of eardrum
Facial nerve:
Ramsay-Hunt syndrome:
Herpes zoster vesicles appear in the auricle, posterior meatal wall & part
of eardrum with LMN facial palsy
The Middle ear:

•A six-walled cavity in the

temporal bone

•15 X 15 X 2-4 mm (Looks like a

biconcave lens)

•Communicates anteriorly with

the nasopharynx through the
auditory tube

•Communicates posteriorly with

the mastoid air cells through the
aditus •Pneumatizations within the mastoid process
•The first cell is the largest & called mastoid antrum
•The lining mucosa is respiratory
Parts:
a)Epitympanum “attic”
b)Mesotympanum
c)Hypotympanum

c
Contents:
a)ONE nerve; chorda tympani
b)TWO muscles; tensor tympani & stapedius
c)THREE bones; incus, malleus & stapes

m i

s
The auditory tube:

•It is 3.5 cm long

•Directed downward, forward

& medially

•Tympanic 1/3 is osseous &

pharyngeal 2/3 is
cartilagenous Bone

•Equalizes the middle ear

pressure with atmospheric
pressure
Pressure equalizer
Drain
Auditory tube is SHORTER – WIDER – MORE HORIZONTAL in infants
Otitis media is more common in infants!
The auditory ossicles:

•Three bones, the incus, I

malleus & stapes S
M
•They are united by true
synovial joints

•They convert the vibrations of

the tympanic membrane into
movement of the footplate of
stapes on the oval window

•Fixed by their attachments to

the 4 walls of the middle ear
Functions of the middle ear:
1- Transmits sound waves striking the
TM to the oval window of the inner ear
through the ossicular chain.
2- Converts these waves into
mechanical force applied on the oval
window & hence fluids of the inner ear.
3- Increases sound intensity by:
A) Surface area mechanism; TM is 17
times the area of the oval window.
B) Lever mechanism; Mallear handle is
1.3 times the length of the long
process of incus

17X1.3 = 22
Acoustic reflex:

Reflex contraction of stapedius & TT on

exposure to sudden loud noise
The arterial supply:

1- The anterior tympanic branch

of maxillary artery

2- The stylomastoid branch of

posterior auricular artery

3- Ascending pharyngeal &

middle meningeal arteries

The veins:

-Are parallel to arteries & drain

to:

1)Superior petrosal sinus

2)Pterygoid plexus
Nerve supply of the middle ear:

Tympanic plexus:

1)The tympanic branch of

glossopharyngeal nerve (referred)

2)Coraticotympanic branches of the

carotid sympathetic plexus

Nerves in the middle ear:

1)Facial nerve; in the medial &

posterior walls

2)Chorda tympani; in the cavity

 ETD

tympanic membrane becomes otitis media

weakened and is pulled inwards with effusion
by the negative pressure within
eustachian tube dysfunction the middle ear
The External Nose: C
A
Skeleton: General shape

1-The bony part: B A

A) Nasal bones B

B) Frontal process of maxilla

C) Frontal bone

2-The cartilagenous part:

A) Lateral nasal cartilage; attached to lower

border of nasal bone

B) Alar cartilage; from rounded part of the

nostril
Alar crura: Tip shape

- Lateral
- Middle
- Medial
Arterial supply:
1- Facial artery (ECA).
2- Infraorbital artery (maxillary artery).
Veins:
Accompany arteries.
Nerves:
1- Midline; Infratrochlear & external
nasal (Va)
2- Lateral side; infraorbital (Vb)
Nasal cavity:

1- Floor:

-Formed by the hard palate.

-Fixes the septum by the maxillary crest

2- Roof:

-Is formed by the cribriform plate

-Communicates with anterior cranial

fossa

-Lined with olfactory neuro-epithelium

-Olfactory nerves leave the roof through

the cribriform plate to the brain

-Olfaction takes place in the roof

3- Lateral wall:
-Sphenoid
-Palatine
-Ethmoid E
-Maxilla M
-Inferior concha S
IC
P
4-Medial wall (septum):

-Perpendicular plate of ethmoid

E
-Vomer
SC
-Septal cartilage
V
-Maxillary crest
•The conchae (Turbinates):
-Three scroll-like projections in the lateral wall of the nose
-The upper two are parts of the ethmoid while the lower is a separate bone
-Their covering mucosa is highly vascular & contain erectile tissue so their
size is not fixed
-Functions; increase mucosal area & protect the meatuses
•Meatuses:

-Each concha overlies a meatus

-Consequently we have superior,

middle & inferior meatuses

-Inferior meatus receives the

nasolacrimal duct from the orbit

-Other meatuses receive

openings of the paranasal
sinuses

-Spheno-ethmoidal recess is the

space between the superior
concha & nasal roof
Osteomeatal complex (OMC):
• A common channel that links
the frontal, anterior and
middle ethmoid, & the
maxillary sinuses to the
middle meatus
• Allows sinus air flow and
mucociliary drainage
• Its obliteration is associated
with chronic sinusitis
OMC is composed of five structures:
1. Maxillary ostium
2. Infundibulum: common channel that drains maxillary and ethmoid sinuses to
the hiatus semilunaris
3. Ethmoidal bulla: A single air cell that projects over the hiatus semilunaris
4. Uncinate process: hook-like process that forms the anterior boundary of the
hiatus semilunaris
5. Hiatus semilunaris: a region between the ethmoid bulla superiorly and free-
edge of the uncinate process
Nerve supply:

Lateral wall: (in quadrants)

1- Anterior ethmoidal n.

2- Anterior superior alveolar n.

3- Posterior superior lateral nasal n.

4- Greater & lesser palatine n.

1 3
•(1) is ophthalmic branch 2 4
•(2) is maxillary branch

•Others are pterygopalatine

ganglion branches
The septum: (in halves)

1- Nasopalatine nerve:

-Branch of pterygopalatine ganglion

-Supplies postero-inferior half

2- Anterior ethmoidal nerve:

-Branch of ophthalmic nerve

-Supplies anterosuperior quadrant

Arterial supply:

Like nerve supply

Venous drainage:

*Anterior ½; anterior facial vein

*Posterior ½; pterygoid v. plexus

Epistaxis
“Little’s area”
The paranasal sinuses:

•Pneumatic areas in the frontal,

ethmoidal, sphenoidal & maxillary
bones.

•Their mucosa is continuous with that

of the nasal cavity through the
meatuses

•The maxillary sinus is well developed

at birth, the frontal & sphenoidal
develop at the 7th year of life while the
ethmoidal develop at puberty.

•Supplied by regional vessels & nerves

•Function !??
The frontal sinuses:
•2 pyramidal sinuses within the frontal bone, rarely symmetrical
•Drain to the anterior part of the hiatus semilunaris
•Supplied by supraorbital & supratrochlear vessels & nerves.
The ethmoidal sinuses:
•3 sinuses in each lateral mass of the ethmoid; anterior, middle & posterior
•They are trabeculated forming air cells
•Anterior & middle drain to the middle meatus
•The posterior drains to the superior meatus
•Anterior & posterior vessels & nerves supply them

ACF

Orb

NC
Mx
The sphenoidal sinuses:
•2 sinuses in the body of sphenoid
•Closely related to cvernous sinuses & hypophyseal fossa
•Opens in the spheno-ethmoidal recess.
•Supplied by the posterior ethmoidal vessels & nerves
The maxillary sinuses:
•2 sinuses, one occupies each maxillary body
•They are pyramidal cavities with their bases directed to the lateral nasal wall
•The big openings in the lateral nasal wall are blocked by the inferior conchae
•Drain in the posterior part of hiatus semilunaris
•Roots of some teeth may project in its floor
•Supplied by superior alveolar, infraorbital & zygomaticofacial vessels & nerves
The pharynx:

•Is a funnel-shape muscular tube 12 cm long

•Diameter above 5 cm & below 1.5 cm

•Base of the skull - cricoid cartilage (C6 vertebra)

•Opens anteriorly into three openings, the nasal

cavity, the oral cavity & the larynx
The nasopharynx:

•Is completely respiratory

•Its wall is strengthened by the

pharyngobasilar fascia

•Supplied by pharyngeal br. of PPG

•Structures in this part are:

-Pharyngeal tonsils, adenoids

Pharyngeal recess
(of Rosenmuller)
-The tubal tonsils (Torus tubarius)

-Auditory tube

-Salpingopharyngeal fold
The oropharynx:
•Limited anteriorly by the palatoglossal fold
•Supplied by pharyngeal br. of IX
•Structures in this part are:
-Palatoglossal fold
-Palatopharyngeal fold
-Lingual tonsils
The palatine tonsils:

•Between the 2 pillars

•Occupies the lower part of tonsillar fossa

leaving a (supratonsillar recess)

•Tonsillar crypts

•Tonsillar capsule

•Blood supply
The laryngopharynx:

•Supplied by internal laryngeal nerve

•Its anterior wall is characterized by:

1- ONE median glosso-epiglottic fold

2- TWO lateral glosso-epiglottic folds

3- The valleculae: between the 3 folds

4- The pyriform recess