Anatomy and Physiology of the EAR

The ear is divided into 3 parts: The external ear, the middle ear, and the inner ear.

THE EXTERNAL EAR Consists of 3 parts:

A- The auricle: a thin plate of elastic cartilage, firmly attached to the covering skin (perichondritis
results in severe pain).

N.B. The cartilage at deficient at the ear lobule.

B- The external canal

C- The tympanic membrane (outer layer)

The external auditory canal (meatus): 24 mm from the auricle to the tympanic membrane, formed of 2
parts:

1- Cartilaginous part: the lateral 1/3 (8mm), Continuous with the cartilage of the auricle, the skin is
thick, adherent, contains hairs (furuncle occurs here) sebaceous and ceruminous (modified sweat)
gland.

The mixed secretion of these two glands forms the ear wax (cerumen).

2- Bony part: Form the inner 2/3 (16mm).

The skin is thin, adherent, and contains no hairs nor glands, it is continuous with the outer layer of the
tympanic membrane.

N.B. the Ext Aud Canal is related anteriorly to the TMJ, posteriorly to the mastoid process, and
superiorly to the middle cranial fossa.

(C) The tympanic membrane (ear drum)

• Separate the ext. auditory meatus from the middle ear.

• Placed obliquely so that the posterior wall and roof of the meatus

are shorter than the anterior wall and floor.

• Formed of 3 layers: The lateral epithelial (skin) layer, Middle fibrous layer, and Inner mucosal layer
Cone of light: light directed on the T.M (from otoscope or headlight) forming a cone anteroinferiorly
– at the apex of the cone of light a point called the umbo.

Nerve supply of the ear drum:

• Medially : Tympanic plexus (IX).

• Laterally : Auriculotemporal(V).

• Auricular branch of vagus (X).

The middle ear cleft consists of:

1. The tympanic cavity

2. The Eustachian tube

3. The mastoid air cells

The tympanic cavity is a 6-wall, within the temporal bone between the external auditory canal and the
inner ear.

Contents: Air, 3 ossicles (malleus, incus and stapes), 2 muscles (tensor tympani and stapedius) and 2
nerves (the chorda tympani and the tympanic plexus).

The Eustachian tube (36 mm): It connects the middle ear (anterior wall) with the nasopharynx. The
ET is closed at rest.

In children, the tube is shorter, wider, and more horizontal than in adults (facilitating infection of the
middle ear).

• Its lateral (tympanic) 1/3 is bony while its medial 2/3 is cartilaginous (close to the nasopharynx)

The mastoid air cells: are variable in number and size, arranged in groups.

The mastoid antrum: the most fixed and biggest air cell communicating anteriorly with the middle ear
cavity through the aditus.

2- Its lateral wall corresponds to the suprameatal triangle (Macewen’s triangle) which forms its bony
surface marking on the skull. It lies 1.5 cm deep to this triangle in adults.

Mastoid pneumatization:
• Cellular : air cells are large and numerous (most common 80%).

• Diploic : air cells are small and less numerous (10%).

• Sclerotic : no air cells (10%).

Nerve supply of the ear:

Sensory:

1. Auricle

• Lateral aspect: Great auricular (C2,3), Auriculo-temporal (V).

• Medial aspect: Laser occipital (C2), Great auricular (C2,3)

• Concha: facial nerve (VII)

2. External auditory canal

• a- Anteriorly: Auriculo-temporal (V).

• b- Posteriorly: Auricular branch (X); facial nerve (VII)

3. Tympanic membrane

• a- Medial aspect : Tympanic plexus (IX).

• b- Lateral aspect : Auriculotemporal (V). - Auricular branch (X)

4. Tympanic cavity: Tympanic plexus (IX).

Motor:

• Tensor tympani : Mandibular br. of the trigeminal nerve (V).

• Stapedius : Facial nerve (VII)

The inner ear:

Functionally, it consists of 2 parts: The cochlea (anteriorly) and the vestibular labyrinth posteriorly.

Anatomically, it is divided into the bony labyrinth and the membranous labyrinth.
The bony labyrinth consists of: The cochlea, the vestibule, and 3 semicircular canals: superior,
posterior, and lateral.

The membranous labyrinth consists of: the cochlear duct (organ of hearing), the membranous SCCs
(angular acceleration), and the utricle/saccule (linear acceleration).

N.B. The membranous cochlear duct is located within the bony cochlea and contains the sensory
hearing organ (organ of Corti);

Terminal fibers from the inner ear form the vestibule-cochlear nerve (VIII) towards the central nuclei
in the brain stem

The ear is the organ of hearing and Equilibrium.

The hearing is provided via: Conductive and Perceptive systems.

The conductive system is: the ext ear, middle ear (TM and ossicles), and the Eust tube (equalize
middle ear pressure and drainage of secretions).

The perceptive system is the cochlea and the cochlear nerve.

The vestibular system is responsible for: angular acceleration (the membranous SCCs) , and the linear
acceleration (utricle/saccule).
 DISEASES OF THE EXTERNAL EAR

A) Auricle

Congenital anomalies:

1. Anotia/Mirotia: For plastic surgery and reconstruction

2. Preauricular sinus:

• No treatment for asymptomatic cases.

• Simple sinectomy
• Extended pre-auricular incision and sinectomy
• Drainage of the abscess followed by excision of the tract.
Trauma
A. Lacerations: with or without the involvement of the cartilage (infection)….avulsed auricle.
For antibiotics and immediate plastic repair.
B- Hematoma of the auricle:
• Sub-perichondrial collection of blood, due to trauma (boxers) or spontaneous (blood
diseases)
• Cystic swelling which is red and tender.
• Infection which results in perichondritis.
• Treatment:
Antibiotics.
Aspiration (early) or incision and evacuation (in late) followed by pressure bandage to
prevent recollection of blood.
N.B. in perichondritis: Infection → ischemia + pus → cartilage necrosis → fibrosis → cauliflower
ear.

Treatment…Antibiotics, drainage with necrotic tissue/cartilage removal

B) External auditory canal:

Congenital aural atresia
• Failure of canalization of the external canal; Unilateral or bilateral
 • May be associated with congenital anomalies of the auricle, middle ear. and rare inner ear
• Investigations:
Radiological (CT scan), and Audiological (ABR)
• Treatment:
Unilateral cases: plastic surgery after puberty.
Bilateral cases:
Hearing aid at 6 months of age to help speech development
Reconstructing surgery at the age of 6 years
Bilateral dead ear: lip reading and cosmetic surgery
Traumatic rupture of the ear drum
Etiology:
Indirect trauma: Due to rapid and marked pressure changes in the external canal: (Hand
slap, Otitic barotraumas, Explosion.
Direct trauma: (Foreign body, Self-inflicted e.g by a hairpin, Unskilled ear
wash/instrumentation)
Treatment: the perforation usually heals within a few weeks
A) Conservative: Avoid water in the ear, ear drops and nose blowing
prophylactic antibiotics.
B) Surgery:
Myringoplasty if the perforations fail to heal after 3-6 months.

Inflammation of the external canal (Otitis externa)

• Infective:
Bacterial: Diffuse otitis externa;
Localized otitis externa (furuncle)
Malignant otitis externa
Fungal: Otomycosis.
Viral: Bullous myringitis, Herpes zoster oticus
• Non-infective (Reactive):
 Eczematous otitis externa
Seborrhaeic otitis externa
Localized otitis externa (furuncle)
• Localized suppurative infection of a hair follicle in the skin lining of the external canal,
caused by Staphylococcus aureus.
• Earache: severe (why??) throbbing and increases on moving the jaw e.g during
mastication (Why???).
• Hearing loss: when the furuncle is large and occludes the external canal.
• Treatment: Antibiotics, Analgesics.
Packing the canal with a gauze strip soaked with antibiotics/ steroids ear drops or
glycerin ichthyol 10%.
N.B.: -No General symptoms: because the area of suppuration is very small.
-Recurrent furuncle…..check for DM
Diffuse otitis externa
• Diffuse infection of the skin lining of the external canal, caused by streptococcus.
• Earache: severe (why??), increases on moving the jaw e.g during mastication (Why???).
• Hearing loss: when the edema occludes the external canal.
• Treatment: Antibiotics, Analgesics.
Packing the canal with a gauze strip soaked with antibiotics/ steroids ear drops
Malignant otitis externa
• Severe otitis externa, caused by Pseudomonas aeruginosa, occurs in
immunocompromised patients and usually affects old diabetics (Uncontrolled).
• Starts as otitis externa (but with severe pain) which does not respond to usual treatment.
Granulation tissues at the junction of bony and cartilaginous parts.
• Spread of infection to Skull base (osteomyelitis) → facial n. paralysis and Jugular
foramen syndrome (9, 10 and 11 cranial nerves), Big vessels of the neck, and Intracranial
spread.
• Treatment:
Hospitalization; Control of diabetes.
Massive anti-pseudomonal antibiotic therapy e.g quinolones or 3rd generation
cephalosporines should be continued till a complete cure (usually several weeks).
 Analgesics, Aural toilet, and antibiotics ear drops.
Surgical treatment: removal of granulations and debridement of necrotic tissues.
Viral otitis externa:
A) Bullous myringitis:
Viral infection (Herpes simplex virus) of the tympanic membrane.
Severe earache, Yellowish or sanguineous watery discharge after rupture of the bullae.
Analgesics are needed.
B) Herpes zoster oticus:
Viral infection (Herpes zoster virus) of the skin covering of the auricle and the skin lining of the
external canal.
Severe earache, Sero-sanguinous otorrhoea after rupture of the bullae.
Reddish bullae on the auricle and in the external canal.
Treatment Analgesics; Anti-viral therapy as acyclovir (oral and local).
Corticosteroids (in severe cases)
N.B. The triad of (a) herpes zoster oticus, (b) facial nerve palsy and (c) sensorineural hearing
loss and vertigo is called Ramsay-Hunt syndrome

Ear wax
• Ear wax (cerumen) consists of a mixture of secretions of both sebaceous and ceruminous
(modified sweat) glands (in the outer cartilaginous part) and desquamated skin cells.
• It protects the skin by its acidic reaction and its lysozyme enzymes.
• Normally it is expelled outside the canal by normal outward migration of the skin of the
external canal and by the movement of the tempro-mandibular joint.
• Causes of impaction: Stenosis of the canal, or Improper cleaning
• The patient has deafness and tinnitus (usually after swimming or bathing) with a yellow
or dark brown mass in the ext. canal. No pain
• Treatment:
Removal by ear wash or instruments.
If the wax is hard, soften it by glycerin bicarbonate 10% before removal
Ear wash
Indications:
• Impacted wax.
• Foreign body: Animate (after it is killed by oil); Inanimate (small, non-vegetable)
Contraindications:
• Impacted F.B.
• Big vegetable F.B.
• Tympanic membrane perforation.
• Otitis externa/Otitis media
Complication:
• Injury of the canal skin or tympanic membrane; Scalding of the ext. canal skin
• Irritation of the Inner ear by very hot or very cold water leading to vertigo and nystagmus
(vestibular stimulation), or the Auricular branch of vagus nerve leading to reflex cough
and vasovagal attack (vagal stimulation).
• Otitis externa (fungal), Otitis media