ANATOMY OF

EXTERNAL AND
MIDDLE EAR
PRESENTED BY
DR PUSHKAR
Introduction

 Ear is divided into three parts -External ,Middle ,Internal ear.

 The ear funtions as an early warning system by detecting and locating potentially
threatening environmental sounds (hearing).

 The ear also plays a major part in the balance system.

 Ear also forms a major part of communication system.

EMBRYOLOGY
 The blastocyst from the time of implantation of fertilized egg and throughout the 9 months
is divided into 3 imp stages:
-pre-embryonic – 21 days
-embryonic -35 days
-foetal-210 days(longest phase)

-Majority of growth occurs in foetal period and formation of germ layers occurs in embryonic
period.
 PHARYNGEAL OR BRANCHIAL ARCHES
 Most distinctive feature in development of head and neck is presence of pharyngeal
arches(old term:branchial arches).

 They appear in 4th &5th wk of development.

 Initially they consist of bars of mesenchymal tissue separated by deep clefts –PHARYNGEAL
CLEFTS

 Simultaneously with the development of arches and clefts,a number of outpocketings,the

pharyngeal pouches appear along lateral walls of pharynx.

 They contribute to formation of neck and face.

 Each pharyngeal arch consist of a core of mesenchymal tissue covered on outside by
surface ectoderm and inside by endoderm
Derivatives of pharyngeal arches

Each pharyngeal arch contains a skeletal element

(cartilage that may later form bone),striated muscle
supplied by the nerve of the arch and artery of arch
The second,third and
fourth pharyngeal
grooves become
obliterated by
caudal outgrowth of
the 2nd pharyngeal
arch,which provides
a smooth contour to
the neck
 EXTERNAL AUDITORY MEATUS
 The external auditory canal is derived from the dorsal part of the
1st ectodermal cleft
 At the beginning of 3rd month,epithelial cells at the bottom of
meatus proliferate,forming a solid epithelial plate,the meatal
plug.
 In the 7th month meatal plug dissolves and the epithelium
undergoes canalization starting from near TM outwards forming
definitive external auditory canal by 28 weeks.
AURICLE
 Around 6th week of IUL six hillocks or “tubercles of His” appear around 1st&2nd branchial
arches.These swellings fuse and form definitive auricle.
 Initially the external ears are in lower neck region,but growth of mandible posteriorly
and cranially ,moves the external ears to the side of head at the level of eyes.
 Since the hillocks are derived from neural crest cells ,external ear defects are often
associated with malformations in other organs derived from neural crest like
face,skull,heart.
 The tympanic membrane is formed by the apposition of the tubotympanic recess
and the first ectodermal cleft ,these two forms the inner (endodermal ) and outer
(ectodermal) epithelial linings of the membrane
 Intervening mesoderm forms the connective tissue basis.
*During late foetal life,tympanic cavity expands dorsally by vacuolization
of surrounding tissue to form tympanic antrum.After birth epithelium of
tympanic cavity invades the bone of developing mastoid process and
epithelium lined air sacs are formed(pneumatization)

*Antrum is about 3mm thickness at birth and it increases 1 mm every year

till it reaches the adult size of 15mm thickness.
 OSSICLES
 Malleus & Incus cartilage of 1st pharyngeal arch(Meckel’s
cartilage). Its muscle tensor tympani is innervated by mandibular branch of
trigeminal nerve.

 Stapes 2nd pharyngeal arch .The stapedius muscle ,attached to stapes ,is
innervated by facial nerve.

 The ossicles of the ear fully ossifies in the 4th month of IUL ;they are the 1st on
the body to do so.
The ossicles are at 1st outside the mucous membrane of the developing middle ear
,they invaginate the mucous membrane ,which cover them throughout life.The
endodermal epithelium connects them in a mesentry like fashion to the wall of
cavity.Supporting ligaments of ossicles develop later.
EMBRYOLOGY OF MASTOID
 Mastoid process appears at 29th week of gestation d/t fusion of periosteal layers of otic
capsule & tympanic process of squamous bone.
 At birth-mastoid process is underdeveloped
 2 years-becomes prominent & continues to grow until 6 yrs of age.
 Expansion is an active process & is secondary to pneumatization taking place inside it.
 Mastoid process continues to grow until puberty and even beyond.
Mastoid antrum
 Starts development b/w 22nd & 24th wk of fetal life.
 Reaches adult size on 35th wk.
 Antrum develops at the center of mastoid process on both sides of petrosquamous fissure.
 Medial part(petrous )-develops from saccus medius.
Lateral part(squamous)-develops from saccus superior.
Fusion plane b/w medial & lateral part gives rise to petrosquamous fissure

***Failure of complete fusion b/w the 2 sacci sepatation by a bony partition—Korner’s

septum.
Antrum is well developed at birth(SA=1sqcm) & its size doesn’t change after birth.
EXTERNAL EAR
THE AURICLE
 Projects at variable angle from the side of the head and collects sound.
 Lateral surface of auricle has characteristic prominences and depressions ,which are
different in every individual even in identical twins . It compares to fingerprints as
identification of person on physiognomy of their auricle.
 The skin is covered with fine hairs which are furnished with sebaceous glands ,it is firmly
adherent on the anterior surface , loosely on the posterior surface and there fore in any
infection , the swelling is more noticeable in the lax tissues behind the auricle
 Auricle has a prominent outer rim –HELIX, at its upper end there is a small tubercle called
darwin’s tubercle .
 2nd prominence lying inside and parallel to helix -ANTIHELIX
 Superiorly antihelix divides into 2 ridges bounding the TRIANGULAR FOSSA.
 The curved depression between helix & antihelix is SCAPHOID FOSSA.
 Within and partly encircled by antihelix is a deep cavity- CONCHA, into which dips the
helix (crus of helix) which divides it into
a)CYMBA CONCHA-direct relation to suprameatal triangle
b)CAVUM CONCHA-larger inferior portion
 Opening of external auditory meatus is bounded infront by projection-TRAGUS.
 Opposite to tragus at the inferior limit of antihelix lies-ANTITRAGUS.
 INTERTRAGIC NOTCH –separates tragus and antitragus.
 LOBULE-lies below the antitragus and contains fatty areolar tissue and no cartilage.
 Medial surface of auricle consists of elevations corresponding to depressions on lateral
surface eg:eminentia conchae.
Cartilage framework of auricle
 Single thin plate of elastic cartilage (yellow elastic cartilage )
 It is continuous with the cartilage of EAC.
 No cartilage in lobule and between tragus and crus of the helix –
INCISURA TERMINALIS .
 The cartilage extends about 8mm down the ear canal to form its
lateral third and is covered by perichondrium and gets its blood
supply from perichondrium .
 Applied anatomy
 Incisura terminalis is devoid of cartilage --Endaural incision can
be safely given in this areas to avoid postoperative perichondritis.

-Frost bite:little depth b/w skin &cartilage vessel lie exposed

--BOXER’S EAR /CAULIFLOWER EAR-Stripping of perichondrium

from cartilage as occurs in injuries that cause haematoma can
cause cartilage necrosis , crumpling up of ear.
LIGAMENTS

 Cartilage of auricle is connected to the temporal bone by two

extrinsic ligaments .
 Anterior ligament-runs from the tragus and crus of helix to the root of
zygomatic arch .
 Posterior ligament -runs from the medial surface of the concha to
the lateral surface of the mastoid prominence .
 Intrinsic ligaments connect various parts of the cartilaginous auricle
, between helix and tragus and another from the antihelix to the
postero inferior portion of the helix .
SENSORY INNERVATION OF AURICLE

NERVE DERIVATION REGION SUPPLIED

GREATER AURICULAR CERVICAL PLEXUS C2,3 MEDIAL SURFACE AND

POSTERIOR PORTION OF
LATERAL SURFACE
LESSER OCCIPITAL CERVICAL PLEXUS C2,3 SUPERIOR PORTION OF
MEDIAL SURFACE
AURICULAR VAGUS X CONCHA AND ANTIHELIX

AURICULOTEMPORAL Vc MANDIBULAR TRAGUS,CRUS OF HELIX

AND ADJACENT HELIX
FACIAL (7TH) SMALL REGION IN ROOT
OF
CONCHA,RETROAURICUL
AR GROOVE
Auriculotemporal nerve block-
anaesthesia to helix & tragus
BLOOD SUPPLY & VENOUS
DRAINAGE OF PINNA
LYMPHATIC DRAINAGE OF PINNA
CONGENITAL DEFORMITIES OF
AURICLE
MICROTIA
LOW SET EAR
WILDERMUTH EAR
DARWIN’S
TUBERCLE
STAHL’S EAR
BAT EAR
Congenital deformities of auricle
 MICROTIA-Characterized by either severe underdevelopment or absence of pinna.
 ANOTIA-Complete absence of pinna.
 MOZART’S EAR-deformity of pinna where the two crurae of antihelix and crus of helix are fused
,giving a bulging appearance of superior part of pinna.
 LOW SET EARS-Ears with depressed positioning of pinna two or more standard deviations below the
population average.It may be associated with Downs syndrome,Turner syndrome,Noonan syndrome.
 PREAURICULAR SINUS-Results d/t defective fusion between 1st & 2nd arch,hence it is situated between
tragus and rest of pinna.Opening of sinus is found in front of ascending limb of helix.
 LOP EAR-The external ear stands away from the head at a greater angle (Normal angle of the
auricle to the median plane averages 25 degrees in boys and 18 degrees in girls). Lop ears are
usually larger than normal ears.
 MALOTIA-Ear located on the cheek
 BAT EAR-Absent antihelix
 WILDERMUTH EAR-A congenital defect characterized by prominence of antihelix and
underdevelopment of helix.
 STAHL’S EAR-Pointy ear shape with an extra cartilage fold in scapha portion of ear.
 DARWIN’S TUBERCLES-Thickening on helix at the j/n of upper and middle third.
 SKIN TAGS/PREAURICULAR APPENDAGES
EXTERNAL AUDITORY CANAL
 The external auditory canal extends from the concha of the auricle to the tympanic
membrane and is approximately 2.5 cm long.
 The supporting framework of the canal wall is cartilage in the lateral one third and bone in
the medial two thirds.

 The diameter of the canal varies greatly between individuals and between different races .

 In adults ,the cartilaginous portions run inwards slightly downward & forwards ;canal is
straightened therefore by gently moving the auricle upwards, backwards to counteract the
direction of the cartilaginous portions .
 In neonate ,there is virtually no bony external meatus as the
tympanic bone is not developed and tympanic membrane is more
horizontally placed so that auricle must be gently drawn downwards
and backwards for the best view of TM.
 Lateral cartilaginous portion -8 mm(outer 1/3rd) long and is continuous with the
auricular cartilage and it is deficient superiorly.

 Medial bony canal wall, about 16 mm long, and is narrower than the cartilaginous
portion and becomes smaller closer to the tympanic membrane.

 the tympanic bone forms the greater part of the bony canal; The squamous bone
forms the roof.

 The medial end of the bony canal is marked by a groove, the tympanic sulcus, which
is absent superiorly.
 EAC has two deficiencies –1. fissures of Santorini (in cartilagenous part)
2. foramen of Huschke(in bony part)

 1)Cartilagenous part of the EAC-Defects in the floor(ant-inf.) ,the fissures of santorini are
notorious routes of infection for necrotizing otitis externa OR TUMOURS spreading to the
parotid gland and skull base.
 2)bony part of EAC-Anteroinferior part of tympanic ring has a deficiency known as
foramen of huschke(persists till age of 4).Its persistence may predispose the person for
spread of infection /tumor from EAC to infratemporal fossa and vice versa.
 3)deeper in the bony canal are two longitudinal sutures
a)Tympanosquamous -anteriorly
b)Tympanomastoid -posteriorly
,these closely adherent to skin so its a challenge to any surgeon in raising an intact
tympanomeatal flap.
 There are two constrictions in the canal:
 At the j/n of the cartilaginous and bony portions &
 The isthmus, 5 mm from the tympanic membrane where a prominence
of the anterior canal wall reduces the diameter. (FB gets lodged in it &
are difficult to remove)
 Deep to the isthmus, the anteroinferior portion of the canal dips forward forming a
wedge-shaped anterior recess between the tympanic membrane and the canal.
 Clinical significance –this recess can be a difficult spot for access either in the clinic
or at the surgery.
 “EAC is the only skin lined cul-de-sac in the human body.”

 Skin in outer 1/3– thicker,1-1.5mm,closely adherent to cartilage & provided with hairs,
sebaceous & ceruminous glands.

 Skin in bony part-thinner,0.1mm,firmly adherent to periosteum & sutures,no glands /hairs.

 Self cleaning of ear canal is effected by migration of skin covering TM & deep external
canal,usual pattern is centrifugal,@ of 0.05 mm/day.
ANATOMICAL RELATIONS OF EAC
 Anteriorly-Glenoid fossa of TMJ(this is a useful landmark in entering middle ear cavity in congenital
atresia of external auditory meatus with middle ear deformities.)& inner 2/3rd of head of mandible.
superficially-superficial temporal vessels,auriculotemporal nerve,upper part of parotid
gland& preauricular lymph glands.
-Posteriorly-Mastoid air cells & deeply to vertical portion of facial nerve.
-Posteromedial & Superomedial-Mastoid antrum.
-Above-Middle cranial fossa.
-Below-Parotid gland.
 Arterial Supply: Derived from branches of the external carotid artery

 Auricular branches of the superficial temporal artery :- supply the roof and
anterior portion of the canal.

 Deep auricular branch of the first part of the maxillary artery :- Anterior meatal
wall & outer epithelial layer of tympanic membrane.

 Auricular branches of the posterior auricular artery (ECA) :-posterior portions of

the canal.

 Venous Drainage :- external jugular vein, the maxillary veins and the pterygoid
plexus.

 The lymphatic drainage follows that of the auricle

NERVE SUPPLY OF EAC
 Anterior wall & roof :- Auriculo temporal Nerve

 Posterior wall & floor :- Auricular branch of vagus(ARNOLD’S nerve)

 Posterior wall also receive fibres from facial (fibres of wriesberg ) through auricular
branch of vagus : loss of which produce hypoesthesia k/a Hitselberger’s sign.
 Clinical importance of nerve supply of EAC –

 Hitzelberger’s sign: The hypoaesthesia of posterior meatal wall occurs due the
pressure on facial nerve (sensory fibres are affected early ) in patients with
acoustic neuroma

 Vasovagal reflex :While cleaning the EAC , patients may develop coughing ,
bradycardia , syncope and even cardiac arrest .they can occur because of
Arnold’s branch of vagus nerve

 Ramsay Hunt Syndrome-Vesicles of herpes zoster oticus occurs on mastoid and

posterior meatal wall which indicates that this part of external ear has facial nerve
innervation.
Lymphatic drainage of EAC

 Anterior wall:Preauricular lymph nodes

 Posterior wall:Lymphnodes at mastoid tip

 Rest:Superficial cervical lymph nodes.

TYMPANIC MEMBRANE
 The tympanic membrane lies at the medial end of the external auditory meatus
and forms the majority of the lateral wall of the tympanic cavity.

 It is pearly grey coloured,slightly oval in shape, being broader above than below,
forming an angle of about 55° with the floor of the meatus.

 It is approx. 8mm wide,9-10mm high and 0.1mm thick.

 Surface area 90 mm2

 TM is divided into 2 parts:

-PARS TENSA :Bigger ,lower part,thickened peripherally into annulus &
inserted into tympanic sulcus.It is concave towards ear canal.
-PARS FLACCIDA :SHARPENELL’S MEMBRANE ,Lax,occupies
Notch of Rivinus,and directly attached to scutum.
 Most of the circumference is thickened to form a fibrocartilaginous ring, the
tympanic annulus or Gerlach’s ligament, which sits in a groove in the tympanic
bone, the tympanic sulcus.
 Annulus- sulcus combination act as a ligament stabilizing the insertion of TM to
surrounding bone.
 Annulus is absent superiorly at the level of notch of Rivinus .
 Depth of sulcus reflects the stability of insertion of annulus.This depth is not
uniform:shallowest area is at the PSQ of TM.In this area annulus is not totally inserted
into sulcus and is merely supported.Hence PSQ is weak,lax and more prone to
retractions.
 From the superior limits of the sulcus, the annulus becomes a fibrous band which runs
centrally as anterior and posterior malleolar folds to the lateral process of the
malleus.
 Tympanic membrane consists of three layers
–
1)Outer epithelial layer which is continuous with
the skin lining the meatus .
2)Inner mucosal layer which is continuous with
the mucosa of the middle ear
3)Middle fibrous layer/lamina propria which
enclose the handle of malleus and has three
types of fibres:-
a)The radial
b)Circular (*myringotomy given in curvilinear
fashion inorder not to damage these fibres)
c)The parabolic
 Epidermal layer of TM has no glands/hair follicles.It has a potential of
lateral migration not encountered in any epidermis elsewhere.This
accounts for self cleaning ability of ear canal .
 Lamina propria is situated b/w epithelial & fibrous layer and it marks the
main difference between PT &PF.
 Collagen type 2 &4 are the major constituents of lamina propria of PT.
 Posterosuperior part of PT is prone to retraction in c/o middle ear –ve
pressure d/t
- lacks well developed circular fibrous layer.
- has weak insertion of annulus.
- more vascularised prone to inflammation.
-Distinct arrangement of lamina propria fibers are absent in PF.
 Arterial supply of Tympanic membrane
 The arterial supply of the tympanic membrane arises from branches supplying both the external auditory
meatus and the middle ear.
 The epidermal vessels originate from the deep auricular branch of the maxillary artery coming from
the external auditory meatus,
 The mucosal /medial surface is supplied by:
 anterior tympanic branches of the maxillary artery,
 stylomastoid branch of the posterior auricular artery,
 middle meningeal artery.
 Clinical significance:
- Cartwheel appearance of TM is seen in ASOM stage of
Of presuppuration.
- Arterial supply reaches from periphery to centre (again comes back to periphery)hence
umbo has poor blood supply and is in danger of perforation in inflame
diseases of middle ear thrombosed artery at periphery.==kidney shaped perforation is the most common type
of perforation.
Nerve Supply
 Branches of the auriculotemporal nerve (Vc)(anterior half of the lateral surface ),
 the auricular branch of the vagus(posterior half of the lateral surface )(ARNOLD’S NERVE) and
 the tympanic branch of the glossopharyngeal nerve(JACOBSON nerve) supply medial surface of the
tympanic membrane

 Lymphatic drainage
-Drains into preauricular and retroauricular lymphnodes.
 Important points-
 1)the pearly grey membrane of the pars tensa will show a light Reflex unless inflamed but
is too opaque to allow clear view of ossicles other than handle of malleus
 2)retraction of the drum can produce foreshortened appearance to the handle .
 3)the joint between the incus and the stapes lies deep to the posterosuperior segment
but is rarely evident unless the drum is thinned or retracted on to it
 4)again in the same quadrant the chorda tympani nerve passes posteriorly lateral to
the long process of the incus and medial to the neck of malleus.
 Applied anatomy of TM
-Myringotomy incision:curvilinear incision( placed b/w handle of malleus and
annulus ) in PIQ c/o ASOM & AIQ in serous otitis media(glue ear).

-Grommet insertion:small tube inserted in AIQ to keep ME aerated for prolon-

ged period of time & to prevent accumulation of fluid in ME.

-Red TM: Acute otitis media/Glomus jugulare.Red reflex seen in Glomus jugulare is called
Rising sun appearance
-Light house sign-Extruding discharge from small perforation in PT in ASOM.
-Blue TM: Seen in Secretory otitis media,High jugular bulb
-Schwartz sign-pink reflex seen through TM indicating active otosclerosis especially
in pregnancy.
PRUSSAK’S SPACE
 Shallow recess within the posterior part of pars flaccida.
 Boundaries:lateral-pars flaccida ,medial-neck of malleus , floor –lateral process of malleus
and roof –fibres of lateral malleolar ligament arising from neck of the malleus and inserting
along the rim of the notch of the rivinus

 Importance-This space can play an important role in the retention of keratin and
subsequent development of cholesteatoma
MIDDLE EAR
 Middle ear resembles six sided box
(match box) with
roof,floor,medial,lateral,anterior&
posterior walls.
 Biconcave ,irregular space in petrous part of
temporal bone.
 fully developed to adult size at birth.
 The cavity extends vertically and A-P for
about 15mm in adults.
 Transverse diameter :
-in epitympanic recess=6mm
-opposite the level of convex part of
tympanic membrane =2mm
-lower part =4mm
-It communicates with nasopharynx through
eustachian tube and mastoid posteriorly
through aditus.
 Further divided into compartments
 1)epitympanum (upper)
 2)mesotympanum (middle )
 3)Protympanum(area of tympanum
around ET)
 4)hypotympanum(lower)
THE ROOF
 The roof of the tympanic cavity is formed by tegmen tympani.
 Formed by both petrous and squamous part of the temporal bone.
 It is thin bony plate which separates middle ear space from middle
cranial fossa.
 It forms the petrosquamous suture line through which veins
communicate with meninges or superior petrosal sinus. ------- infection
into the extradural space in children.
 (It also forms a roof for tensor tympani muscle.)
 COG-Bony septum extending
inferiorly from tegmen .

 Divides anterior attic into anterior

epitympanic recess and anterior
malleal space.
The floor
 The floor of the tympanic cavity may consist of
compact or pneumatized bone and separates
the hypotympanum from the dome of the jugular
bulb.

 Floor is formed by meeting of tympanic plate &

jugular plate of petrous temporal bone.

 At the junction of the floor and the

medial wall of the cavity there is small
opening that allows the entry of the
tympanic branch of the
glossopharyngeal nerve(Jacobson’s
nerve-secretomotor fibres to parotid)
into the middle ear from its origin
below the base of the skull .


 LATERAL wall
 The lateral wall of the tympanic cavity is formed by the
 bony lateral wall of the epitympanum superiorly,
 tympanic membrane centrally and
 bony lateral wall of the hypotympanum inferiorly.
 The lateral epitympanic wall is wedge-shaped in section and its sharp
inferior portion is also called the outer attic wall or scutum
(Latin: 'shield').
 It is thin and easily eroded by cholesteatoma, leaving a telltale sign on a high
resolution coronal CT scan
 The petrotympanic fissure is 2 mm long which opens anteriorly just above the attachment
of the tympanic membrane. It receives the anterior malleolar ligament and transmits the
anterior tympanic branch of the maxillary artery to the tympanic cavity.

 The chorda tympani nerve a branch of facial nerve enter the cavity through posterior
canaliculus.The nerve then then pass superficial to long process of incus and deep to
handle of malleus lying outside the epithelial lining of cavity. The nerve leaves the cavity
through anterior canaliculus (canal of Huguier) which lies in the medial end of
petrotympanic fissure to join the lingual nerve in infratemporal fossa.

 Chorda tympani carries taste sensation from ant 2/3rd from same side of tongue &
secretomotor fibres to submandibular gland
MEDIAL WALL
 Medial wall is formed by lateral wall of vestibule and first turn of cochlea &
separates middle ear from inner ear.

Main features are:

-Promontory –rounded projection formed
by basal turn of cochlea.occupies central
portion of medial wall.Has small grooves
on its surface containing nerves which
form tympanic plexus
-Fenestra vestibuli(oval window)-lies
posterosuperior to promontory and
opens into scala vestibuli.measures
3.25x1.75mm.occupied by footplate
of stapes fixed by annular ligament.

-Fenestrae cochlea(round window)

:lies posteroinferior to promontory
,opens into scala tympani of
cochlea.measures 1.5x1.3mm and is
closed by secondary tympanic
membrane .RW is closest to ampulla
of posterior semicircular canal.
 -Horizontal part of facial nerve-enclosed in a bony canal called fallopian canal
, which lies above the OW curving downwards into the posterior wall of
ME.Facial nerve here separates epitympanum region above from
mesotympanum region below.
 The facial nerve canal (or Fallopian canal) runs above the promontory and
oval window in an anteroposterior direction.
 It has a smooth rounded lateral surface that often has microdehiscences.
 When the bone is thin or the nerve exposed by disease, there are two or three
straight blood vessels clearly visible along this line of nerve. These are the only
straight blood vessels in the middle ear and indicate that the facial nerve is very
close by.
 -Process cochleariformis –Anterior to OW is a
hook like projection for tendon of tensor
tympani.It marks the level of genu of facial
nerve.
 -Tympanic plexus-formed by tympanic branch
of glossopharyngeal nerve and superior &
inferior branches of sympathetic plexus
around internal carotid artery.Tympanic plexus
infront of OW is highly sensitive and painful on
surgical manipulation.
 Ponticulus is a bony spicule which
runs from promontory to pyramid
below OW.
 Subiculum is just posterior
extension of promontory lying
above RW.
ANTERIOR WALL
 Anterior wall of the tympanic
cavity is rather narrow as the
medial and lateral wall converge .
 The lower third of the anterior wall
consists of a thin plate of bone
covering the carotid artery as it
enters the skull and before it turns
anteriorly.
 This plate if perforated by the
superior and inferior carotico
tympanic nerves carrying
sympathetic fibres to the
tympanic plexus and by the
tympanic branches of the
external carotid artery
 The middle third comprises the tympanic orifice
of the eustachian tube which is oval in shape.
 Just above this is a canal containing the tensor
tympani muscle that subsequently runs along
the medial wall of the tympanic cavity
enclosed in a thin bony sheath
 The upper third is usually pneumatized and may
house the anterior epitympanic sinus , a small
niche anterior to the ossicular heads , which
can hide residual cholesteatoma in canal wall
up surgery .
POSTERIOR WALL
 Its close to mastoid air cells has following structures:
 1)aditus
 2)fossa incudes
 3)pyramid
 4)facial recess
1-The posterior wall is wider above than below and has in its upper part a
large irregular opening –the ADITUS ad antrum – that leads back from the
posterior epitympanium into the mastoid antrum.(Aditus in latin=access)
2-Below aditus , is a small depression ,the FOSSA INCUDES which houses the short
process of incus and its suspensory ligaments .
3-below the fossa incudis and medial to the opening of the chorda tympani nerve is
the PROCESSES PYRAMIDALIS a small hollow conical projection with its apex pointing
anteriorly ;this houses the stapedius muscle and tendon which inserts into the
posterior aspect of the head of stapes
FACIAL RECESS
 A/K/A Suprameatal recess is a groove /depression in posterior wall which lies b/w pyramid
&facial nerve & annulus of TM.
 Facial recess is superficial to sinus tympani and separated from it by descending part of
facial nerve.
Boundaries:
-medially-external genu of facial nerve.
-laterally-chorda tympani.
-superiorly-fossa incudes.
-anterolaterally-tympanic membrane.

Importance: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 surgeon should be
extracautious in clearing this area .Ear
may continue to discharge if this area is
not cleaned during mastoid surgery.
SINUS TYMPANI
 Also k/a infrapyramidal recess/medial
facial recess.
 It is a depression behind the
promontory deep to
pyramid,continuous with
hypotympanum and its position is
opposite to ampulla of posterior SCC.
 It starts at OW and occupies a space
deep to descending part of facial
nerve and pyramid and passes
behind RW niche to hypotympanum.
 Sinus tympani is the most inaccessible
area in ME & mastoid.Approach to
this area is not possible via
mastoid(retrofacial approach) as
posterior SCC comes in way.
 It cannot be visualized directly in surgery
of cholesteatoma hence it can be site of
recurrence.

 Boundaries:
-Superior :Ponticulus
-Inferior :Subiculum
-Lateral :Mastoid segment of facial nerve
-Medial :Posterior semicircular canal
MIDDLE EAR CLEFT
MIDDLE EAR CLEFT
Middle ear together with eustachian tube,aditus,antrum and mastoid air
cells is called middle ear cleft.
 The cavity is lined with a modified respiratory mucosa that undergoes a
transition passing posteriorly
 Applied anatomy-the relationships of the cleft are best considered for
their clinical relevance .
-Superiorly lies the temporal bone in the middle cranial fossa .
Complications-1)CSF leak otorrhea & CSF rhinorrhea
2)Temporal lobe abscess
3)Sigmoid sinus thrombophlebitis
-Inferiorly, internal jugular vein .
-More anteriorly , the carotid passes anteromedially , deep to the
cochlea.
EAR OSSICLES

 3 Tiny bones that conduct the sound from ear drum to oval window-
-MALLEUS
-INCUS
-STAPES
-Ear ossicles are almost adult size & shape at birth & has poor
reparative capacity in respose to #s.
-Suspended by numerous suspensory ligaments & covered by mucous
membrane of ME cavity.
-Transmit sound induced vibrations of TM to OW.
 MALLEUS
 It consists of a head, neck, handle(manubrium) a L &
A process.
 largest ossicle- 8 mm
 Head and neck-they lie in the attic
 Manubrium(handle)-it is embedded in the fibrous
layer of the tympanic membrane.
 Lateral process : knob like projections on the outer
surface of the TM & provides attachments to the A &
P malleal folds.
 Anterior process: bony spicule
connected to petrotympanic
fissure by ligamentous fibres.

 The head of the malleus has a saddle

–shaped facet on its posteromedial
surface to articulate with the body of
the incus by a synovial joint .
INCUS
 Consists of :
 Body & short process :they lie on
the attic . Short process is
connected to fossa incudes by
lig.fibres in the epitympanic
recess.
 Long process :it hangs vertically
and medial and parallel to
malleus handle and forms incudo
stapedial joint with the head of
stapes by it lenticular process.
 Lenticular process has sometimes
been called as 4th ossicle d/t its
incomplete fusion with long
process.
 STAPES

 smallest bone of the body

- 3.5 mm
 WT-2.5 MG
 It consists of head , neck ,
anterior and posterior
crura and footplate
 The foot plate is positioned
in the oval window by
annular ligament
The incudomalleolar joint is saddle-shaped, the
incudostapedial is a ball and socket articulation. Their
articular surfaces are covered with articular cartilage and
each joint is enveloped by a capsule containing much
elastic tissue and lined by synovial membrane.
MUSCLES OF TYMPANIC
cavity
TENSOR TYMPANI
 It runs above the eustachian tube in a bony
tunnel .its tendon turns round the processus
cochleariformis and passes laterally .
 Origin-from the bonny tunnel, the
cartilaginous part of eustachian tube and
the adjoining part of greater wing of
sphenoid
 Insertion-just below the neck of
malleus
 Nerve supply- mandibular
division of trigeminal nerve
(CNV3)
 Blood supply-superior tympanic
branch of middle meningeal
artery
 Action-it tenses the tympanic
membrane.
 STAPEDIUS
 Origin-conical cavity and canal within pyramid
on posterior tympanic wall.
 Insertion –it inserts to the neck of stapes .
 Nerve supply-nerve to stapedius
 Blood supply-branches of posterior auricular
,anterior tympanic and middle meningeal
arteries .
 Action-damp down excessive sound vibrations
opposes action of tensor tympani which pushes
the stapes more tightly into fenestrae vestibuli.
 Paralysis leads to hyperacusis
MASTOID ANTRUM

 It is an air sinus in petrous part of temporal bone.

 It is the largest and most consistent mastoid air cell present.

 Mastoid antrum,but not air cells is well developed at birth and

by adult life has a volume of 2ml. 9mm height , 14 mm width
and 7 mm depth) .
 BOUNDARIES
 Roof-it is formed by the tegmen antri
 Lateral wall -it is formed by a 15 mm thick plate
of squamous part of temporal bone which is
marked on the lateral surface of mastoid by
suprameatal (mac Ewen’s )triangle.
 Medial wall-it is formed by the petrous bone
and related to the
 1)Posterior semicircular canal
2)Endolymphatic sac
3)Dura of posterior cranial fossa
Anterior- anteriorly mastoid antrum
communicates with the attic through the
aditus ad antrum
Inferior wall-Is perforated and has holes
through which antrum communicates with
mastoid air cells.
Posterior wall –separates antrum from sigmoid
venous sinus and cerebellum.
 .medial to lateral relations are following:
1) Facial nerve canal
2) Aditus ad antrum and facial recess lie between tympanum and mastoid antrum
3) Deep bony external canal
-Cymba concha is the soft tissue land mark of mastoid antrum.
 McEwen's triangle
 McEwen’s triangle is used to locate mastoid antrum which lies 1.5 cm deep
to it.
 It can be felt under cymba concha.
 Boundaries:
-Superiorly-supramastoid crest
-AI-Posterosuperior margin of external auditory canal.
-Posteriorly-tangent drawn from supramastoid crest to spine of henle.
Korner’s septum:
 It is persistence of petrosquamous suture.Its presence leads to false bottom of
mastoid antrum.
 This may lead to incomplete exenteration of mastoid cells in mastoidectomy
operation and if the surgeon mistake it for true mastoid antrum and drills anteriorly he
might damage facial nerve.
TRAUTMANN’S TRIANGLE

 Pathway to posterior cranial fossa from mastoid cavity.

 Bounded:
- Superiorly-superior petrosal sinus
- Posteriorly-Sigmoid sinus
- Anteriorly-semi-circular canals
Sinodural angle Or Citelle’s angle
 Angle b/w tegmen antrum & sigmoid sinus.
 MASTOID AIR CELLS

-Mastoid air cell system-it is considered to be an important contributor

to the physiology of middle ear function.
 The mean volume of air in the mastoid air cell system could be
about 5-8 ml.
 CT scan evaluation of temporal bone is considered to be the best
modality to asses the mastoid air cell system.
 Not present at birth
 Development starts at the end of infancy
 Reach adult size at 5 years of age
 Full maturation at 15-20 years of age
 Honeycomb air cells
 Depending on development 3 types are described:
 1)cellular /well aerated pneumatized(80%): mastoid cells are well
developed within intervening septa
 2)mixed/diploeic: Mainly there are marrow spaces with few air cells
 3)acellular /sclerosed(20%): there are neither cells nor marrow
spaces .
 Mastoid air cells
 The mastoid air cells are traditionally divided into the
several group, which include :
1) Zygomatic cells
2) Tegment cells
3) Perisinus cells
4) Retrofacial cells
5) Perilabyrinthine cells
6) Peritubal cells
7) Tip cells
8) Marginal cells
9) Squamosal cells
 Clinical points –patients with poor pneumatization of mastoid air cells
are more prone to develop adhesive otitis media following the middle
ear infections as the normal buffering system of the mastoid
pneumatization is not adequate in them
 Treatment of secretory otitis media with effusion is more effective in a
patient with well developed mastoid air cell system when compared to
that of patients with sclerosed one .
 EUSTACHIAN TUBE
 The Eustachian tube a/k/a the auditory tube or pharyngotympanic tube,[ links
the nasopharynx to the middle ear. It is a part of the middle ear.
 Helps to equalize pressure on either sides of TM.
 ET is 17mm at birth and 36mm in adults.
 It descends at an angle of 45 degree with sagittal plane and 30 degree with horizontal
plane.
 In resting state tubal end of nasopharynx lies collapsed opening during yawning and
deglutition.
 Osseous part(12mm) starts from
anterior tympanic wall and lies
4mm above the floor of middle
ear,which narrows to squamous
and petrous part of temporal
bone to become continuous with
cartilaginous tube.
 Cartilaginous part(24mm ) opens
into the nasopharynx b/w petrous
part of temporal bone & greater
wing of sphenoid,1.25 cm behind
the posterior end of inferior
turbinate.
-The whole tube is directed upwards,backwards and laterally from opening in
pharynx.Tube is narrowest at isthmus(j/n of the two parts)
- It is the reverse of the external ear canal , being one third bony and two thirds
cartilaginous .
 Pharyngeal opening is triangular in outline and is surrounded
posterosuperiorly by tubal elevation or torus tubarius.From the lower
part of torus salpingopharyngeal fold passes downwards to lateral wall
of pharynx.Behind the torus is lateral pharyngeal recess of fossa of
rosenmuller.Cartilagenous opening is deficient below ,gap being closed
by fibrous tissue.
 MUCOSA OF ET
-Mucous membrane lining the ET is
continuous with pharynx and middle ear.
Covered by ciliated columnar epithelium in
bony part,whereas in cartilaginous part
non ciliated stratified squamous epithelium
and contains number of mucous glands.
 In neonates and 1 year old child , tube is more horizontally placed throughout its entire
length.Tube is shorter than in adults
 Also, there is no torus present at opening which is reduced to narrow slit,and is found at
a lower level than in adult,being almost posterior to soft palate.
MUSCLES ASSOCIATED WITH ET
 There are four muscles associated with the function of the Eustachian tube:
 Levator veli palatini (innervated by the vagus nerve)
 Salpingopharyngeus (innervated by the vagus nerve)
 Tensor tympani (innervated by the mandibular nerve of CN V)
 Tensor veli palatini (innervated by the mandibular nerve of CN V)
 The tube is opened during swallowing by contraction of the tensor veli palatini and levator
veli palatini, muscles of the soft palate.
 funtions-3 main functions :
-Equalizes air pressure between the middle and nasopharynx .
-Protects the middle ear from nasopharyngeal secretions and loud sounds
-Ventilation and drainage of the middle ear
BLOOD SUPPLY:
-Ascending pharyngeal branch from ECA,branches of Middle meningeal
artery,Artery of pterygoid canal.
-Venous drainage:Pterygoid plexus and pharyngeal venous plexus.
NERVE SUPPLY:
Tympanic plexus and pharyngeal branch of sphenopalatine ganglion.
LYMPHATIC DRAINAGE:
Drain into retropharyngeal lymphnodes upper deep cervical glands.
Lympahoid tissue related to Et is called tubal tonsil of Gerlach.
MIDDLE EAR MUCOSAL FOLDS

 Mucous membrane is thrown into series of fold by intratympanic

structures.
 They are of surgical importance as they divide middle ear into
compartments & carry blood vessels to ossicular chains.
 Mucosal remnants and folds are considered as residues of
inflammation or adhesion.
 Superior malleolar fold:
Divides attic into smaller A malleolar space&
larger P compartment which include superior
and medial incudal space.
 In the upper part of mesotympanum there
are 3 compartments:
-Inferior incudal space
-Anterior pouch of Von Troltsch
-Posterior pouch of Von Troltsch
IIS is limited superiorly by LIMF
medially by MIF
laterally by PMF
Anteriorly by IOF
 Anterior pouch of Von Troltsch-b/w AMF &
portion of TM A to HOM.
 Posterior pouch of Von Troltsch –b/w PMF
& portion of TM P to HOM.

 **Chorda tympani usually lies in the free

margin of PMF
 Prussacks space:
 Small space b/w neck of malleus
& pars flaccida
 MIDDLE EAR VENTILATION
 From ventilatory point of view tympanic
diaphragm divides physically middle ear
into AI &PS COMPARTMENTS
 AI part comprises
of:pro,meso,hypotympanum and inferior
part of retrotympanum
 AI part is widely open to ET which ensures
direct aeration to meso&hypotympanic
spaces.
 PS part consist of attic and mastoid air
cell system it is aerated through an
opening in tympanic diapragm called
tympanic isthmus.
 BLOOD SUPPLY OF MIDDLE EAR
BRANCH PARENT ARTERY REGION SUPPLIED

ANTERIOR TYMPANIC MAXILLARY ARTERY TYMPANIC MEMBRANE;MALLEUS

&INCUS;ANTERIOR PART OF
TYMPANIC CAVITY
STYLOMASTOID POSTERIOR AURICULAR POSTERIOR PART OF TYMPANIC
CAVITY;STAPEDIUS MUSCLE
MASTOID STYLOMASTOID MASTOID AIR CELLS

PETROSAL MIDDLE MENINGEAL ROOF OF MASTOID;ROOF OF

EPITYMPANUM
SUPERIOR TYMPANIC MIDDLE MENINGEAL MALLEUS &INCUS;TENSOR TYMPANI

INFERIOR TYMPANIC ASCENDING PHARYNGEAL MESOTYMPANUM

BRANCH FROM ARTERY ARTERY OF PTERYGOID CANAL MESO & HYPOTYMPANUM

TYMPANIC ARCHES INTERNAL CAROTID MESO & HYPOTYMPANUM

 Venous drainage –veins from the middle ear cleft drain into the
pterygoid venous plexus , superior petrosal sinus and sigmoid sinus
.
 Lymphatic drainage –the lymphatics of the middle ear drain into
the retropharyngeal and parotid nodes .Eustachian tube
lymphatics drain in the retropharyngeal group of lymph nodes
.Internal ear does not have any lymphatics.
FACIAL NERVE AND MIDDLE EAR
 The nerve first enters IAM and runs
laterally above the vestibule to reach
the medial wall of epitympanic
recess.Here it turns abruptly backwards
at genu and lies above promontory.A
reddish swelling ,ganglion of facial nerve
is formed at this point.

 Processus cochleariformis demarcates

the geniculate ganglion which lies just
ant to it.Tympanic segment of nerve
starts here.
 The third part ,intrapetrous portion of
facial nerve ,traverses facial canal and
arches downwards along medial wall of
tympanic cavity.Here nerve lies above
OW(stapes) and below horizontal SCC.
 The fourth part descends
vertically,anterior to medial
border of aditus to
tympanic antrum ,to reach
stylomastoid foramen.
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