ANATOMY OF EAR

BY:DR.ISHA GOYAL MODERATOR : DR.BALDEV SINGH, PROF. &HEAD,DEPT OF ENT

EXTERNAL EAR
AURICLE/PINNA EXTERNAL AUDITORY CANAL TYMPANIC MEMBRANE

AURICLE

 Localisation of sound Yellow elastic cartilage frame except lobule. Continous plate except for narrow gap b/w tragus and crus of helix-INCISURA TERMINALIS LATERAL SURFACE MEDIAL/CRANIAL SURFACE

LATERAL SURFACE Irregularly concave, predominated by concavities

MEDIAL SURAFCE Conxexities , contain subcutaneous tissue

Skin thin and tightly bound to perichondrium

Loosely attached to perichondrium

Frost bite

Sebacous cyst or furuncle

 Cartilage extends 8mm into EAC Avascular, nutrients from perichondrium

In case of trauma,Stripping of perichondrium cause haematoma formation cartilage necrosis- BOXERS EARS.

LIGAMENTS
EXTRINSIC LIGAMENTS (connect cartilage to temporal bone) 1. Anterior ligament from tragus and spine of helix to zygomatic process of temporal bone. 2. Posterior ligament from medial surface of concha to lateral surface of mastoid process. INTRINSIC LIGAMENTS (connect individual auricular cartilages )

AURICULAR MUSCLES
EXTRINSIC MUSCLES : Auricularis anterior Auricularis superior Auricularis posterior Posterior Auricular artery A.posterior : Post. Auricular nerve A.superior and anterior : temporal branch of facial nerve

INTRINSIC MUSCLES Post. Auricular artery, superficial temporal A. Nerve supply Lateral: temporal br.(7thN) Medial: post. Auricular br.

BLOOD SUPPLY OF PINNA

Posterior auricular Artery:medial surface (except lobule) , concha , middle and lower portions of helix , lower part of antihelix. Anterior auricular br. of Superficial temporal artery: upper part of helix , antihelix , tragus and lobule. Superior auricular artery:connect superior temporal A. with post. Auricular network. Small auricular br of occipital Artery

NERVE SUPPLY

External auditory canal

 Only cul-de-sac in body lined by skin 2.4cm , S-shaped Lateral 1/3rd: cartilaginous ; FORAMEN OF SANTORINI Medial 2/3rd : bony; FORAMEN OF HUSCHKE (persist till age of four), narrower , medial end form TYMPANIC SULCUS

 TYMPANIC BONE : Greater part of canal. SQUAMOUS BONE : Roof. Two constrictions:1. Junction of cartilaginous and bony part. 2. Isthmus (narrowest)-5mm from TM,just medial to junc. Of cartilage and bony part.

 Anterior recess-deep to isthmus anteroinfiorly Skin : outward and oblique growth of epidermis,migrate towards EAC opening. Normal rate of migration : .1mm / day Skin of pars tensa: outward migration Cartilaginous part : epidermis & dermis,short hairs project towards EAC opening. Bony part : only epidermis , thin skin

 Ceruminous glands: modifies apocrine sweat glands,watery secretions Sebacous glands : oily secretions(sebum) Mixture of desquamated cells , cerumen and sebum WAX Mendelian trait ; dry wax and wet wax. Dry wax- lack cerumen , yellow/grey,brittle Wet wax-brownish , sticky , dominant.

RELATIONS OF MEATUS
Anteriorly : TM joint Superiorly : middle cranial fossa Posteriorly : mastoid air cells and facial nerve Inferiorly : parotid gland

BLOOD SUPPLY
Auricular br. of superficial temporal artery : roof and anterior wall Deep auricular br. Of Ist part of maxillary artery : anterior meatal wall skin Auricular br. Of post. Auricular artery : post. Potion of canal Veins drain into EJV,maxillary veins and pterygoid plexus.

NERVE SUPPLY
Anterior wall & roof : Auriculotemporal Nerve Posterior wall and floor : Arnolds Nerve Posterior wall also receive sensory fibres of CN VII through auricular branch of vagus.

Lymphatic drainage
AREA NODES CONCHA,TRAGUS,TRIANGULAR PREAURICULAR AND PAROTID FOSSA & EAC NODES

LOBULE & ANTITRAGUS HELIX AND ANTIHELIX

INFRA-AURICULAR NODES POSTERIOR AURICULAR,DEEP JUGLAR & SPINAL ACCESSORY NODES

Tympanic Membrane

 Thin, semi-transparent, pearly- grey, Oval, broader above than below, 550 Longest diameter from postsup. To anteroinf 9-10mm Shortest diameter 8-9 mm .1mm thick Circumfernce thickened to form tympanic annulus, fits in tympanic sulcus.

 Notch of Rivinus : at roof ,lack sulcus,formed by squama. Anterior and posterior malleolar folds : arise from sup. Limit of sulcus to attach to lateral process of malleus. Irregular cone,apex attached to umbo. Firmly attached to malleus at lateral process and umbo,in b/w loosely attached by flimsy fold called PLICA MALLERIS

Pars Flaccida(Shrappnels membrane)

Triangular , pinkish Within notch of rivinus and above folds. Thin , lax Lack fibrous layer Replaced by loose connective tissue.

Pars Tensa
Taut Outer epithelial layer Middle fibrous layer radially oriented fibres in outer layers and circular, parabolic and transverse layers in deep layers. Inner mucosal layer From umbo, bright area emanates called cone of light

BLOOD SUPPLY
Epidermal vessels: deep auricular br. Of maxillary artery coming from EAC Mucosal vessels: 1. Anterior tympanic br.of maxillary artery. 2. Posterior tympanic br. of stylomastoid artery(post. Auricular artery). 3. Inferior tympanic artery,br. From ascending pharyngeal artery. 4. Middle meningeal artery

NERVE SUPLY
OUTER SURFACE : auriculotemporal nerve, auricular br. Of vagus nerve

INNER SURFACE : tympanic br. Of glossopharyngeal nerve.

MIDDLE EAR CLEFT

Middle ear Eustachian tube Mastoid antrum Mastoid air cells

MIDDLE EAR
EPITYMPANUM/ATTIC MESOTYMPANUM HYPOTYMPANUM PROTYMPANUM POSTERIOR TYMPANIC CAVITY

 Irregular, laterally compressed space in the petrous part of the temporal bone BICONCAVE DISC 1. AP &VERTICAL DIAMETER- 15mm 2. Tranverse diameter : upper part-6mm centre 2mm lower part 4mm

WALLS OF MIDDLE EAR

LATERAL WALL
Superior: bony lateral wall of epiytmpanum Centre : tympanic membrane Inferior : bony lateral wall of hypotympanum

Lateral Epitympanic Walll

Wedge shaped Sharp inferior portion : SCUTUM Eroded by cholesteatoma,HRCT

THREE HOLES ON MEDIAL SURFACE OF LATERAL WALL

1. PETROTYMPANIC FISSURE 2mm long slit Open ant. Just above attachment of TM Transmit Ant. Tympanic br of maxillary artey to tympanic cavity. Contain anterior process and anterior ligament of malleus.

2. ITER CHORDAE ANTERIUS(Canal of Huguier) Chorda Tympani Nerve exit tympanic cavity after crossing lateral to long process of incus and medial to malleus 3. ITER CHORDAE POSTERIUS Situated in angle b/w post. And lat. Walls of tympanic cavity. Chorda enters through this

ROOF
TEGMEN TYMAPNI-thin bony plate Extend posteriorly - form roof of aditus and mastoid antrum. Separate middle ear from middle cranial fosssa PETROUS AND SQUAMOUS PORTION In youth, the unossified petrosquamosal suture allow spread of infection from tympanic cavity to meninges.

FLOOR
Compact or pneumatised bone Separate hypotympanum from dome of INTERNAL JUGLAR VEIN. If deficient,juglar bulb covered only by fibrous tissue and mucous membrane. Junc of floor and medial wall,small opening (anterior tympanic canaliculus) for passage of JACOBSONS NERVE and inferior tymapnic artery.

ANTERIOR WALL

 Inferior, larger area narrowed by approximation of the medial and lateral walls. Lower third thin plate of bone covering internal carotid artery. perforated by the superior and inferior caroticotympanic nerves(carry symapthetic fibres to tympanic plexus) and the tympanic branches of the internal carotid artery.

 Middle third : 5x2mm,oval ,tympanic orifice of eustachain tube. Just above, canal for tensor tympani, runs along medial wall enclosed in thin bony sheath. Both canals incline downwards and anteromedially, to open in the angle between the squamous and petrous parts of the temporal bone, and separated by a thin, osseous septum.

 Upper third : pneumatised House anterior epitympanic sinus

POSTERIOR WALL
Wider above than below Aditus ad antrum : irregular opening in upper part,lead back from Post. Epitympanum/ Epitympanic Recess to upper part of mastoid antrum.

FOSSA INCUDIS
Small depression in the lower and posterior part of the epitympanic recess. Contain short process of incus and its suspensory ligament.

Pyramid
Lies below fossa incudis and medial to opening of chorda tympani nerve. Small conical projection, apex pointing towards fenestra vestibuli. Hollow and contain Stapedius muscle and tendon The cavity is prolonged down and back in front of the facial nerve canal; communicates by an aperture through which a small branch of the facial nerve passes to stapedius.

FACIAL RECESS
Posterior sinus Lies lateral to pyramid Medially vertical part of seventh nerve Laterally tympanic annulus with chorda tympani ruuning obliquely through wall b/w two. Superiorly fossa incudis.

 Surgically, direct access can be made through this into middle ear without disturbing posterior canal wall. (INTACT CANAL WALL MASTOIDECTOMY)

MASTOID ANTRUM
Air sinus in the petrous part of the temporal bone. Communicates with the attic through the aditus. Well develpoed at birth Adult capacity - 1ml

Relations of mastoid antrum

 Medial wall posterior SCC Roof tegmen antri Lateral wall postmeatal process of the squamous part of the temporal bone, only 2 mm thick at birth,increases at average rate of 1 mm a year, final thickness of 1215 mm. Corresponds to the suprameatal triangle (Macewen's triangle) on the outer surface of the skull

Macewans triangle
palpable through the cymba conchae It is bounded by (a) temporal line , (b)posterosuperior segment of bony external auditory canal (c) line drawn as a tangent to the external canal. important landmark to locate the mastoid antrum in mastoid surgery

Aditus ad antrum
Medially : lateral SCC Laterally : fossa incudis Anteroinferior: descending part of facial nerve

Mastoid air cell system

Mastoid consist of mastoid cortex with underneath air cells. Three types of mastoid : (i) Well-pneumatised or cellular. Mastoid cells are well developed and intervening septa are thin. (ii) Diploetic. Mastoid consists of marrow spaces and a few air cells. (iii) Sclerotic or acellular. There are no cells or marrow spaces. Mastoid antrum is always present

Mastoid air cells

(i) zygomatic cells (ii) tegmen cells (iii) perisinus cells (iv ) retrofacial cells (v) perilabyrinthine cells. (vi) peritubal (vii) tip cells (viii) marginal cells (ix) squamosal cells

MEDIAL WALL

Surgical floor of middle ear PROMOMTORY FENESTRA VESTIBULI(OVAL WINDOW) FENERSTRA COCHLEAE(ROUND WINDOW) FACIAL NERVE CANAL PROCESSUS COCHLEAFORMIS SINUS TYMPANI

PROMONTORY
Rounded elevation , lying over lateral projection of basal coil of cochlea. Small grooves- lodge nerves of tympanic plexus. Spicule of bone connect it to pyramid. Apex of cochlea lies anteriorly. Incline forward to merge with anterior wall of tympanic cavity.

OVAL WINDOW
Kidney shaped, connect cavity with vestibule. Above and behind promontory Closed by footplate of stapes and its surrounding annular ligament. Size varies with size of footplate, avg. 3.25mm long and 1.75mm wide. Site of Perilymphatic fistula.

Endoscopic view of the posterior medial wall of the tympanic cavity showing the relationship between the oval window niche (OWN). round window niche (RWN). promontory(P),facial nerve (VII) and facial recess (FR). The sinus tympani (ST) lies medial to the facial nerve between the ponticuluS (PONT) and subiculum (SUB)

Round window
Situated below and a little behind oval window, separated by posterior extension of the promontory, called subiculum. Lies completely under the overhanging edge of the promontory in a deep hollow or niche RWN triangular,with ant.,postsup.& postinf. Walls.latter two meet & lead to sinus tymapani. Ponticulus leaves promontory above subiculum and runs to pyramid.

 Covered by secondary TM. Oval, 2.3x1.9mm Right angle to staps footplate , curve toward scala tympani of basal coil of cochlea. Concave towards the tympanic cavity and convex towards the cochlea. External layer - tympanic mucosa Internal layer - cochlear lining membrane Intermediate layer fibrous tissue.

FACIAL NERVE CANAL

Fallopian canal Above promomtory and oval window in anteroposterior direction Dehiscent, two or three straight blood vessels visible along line of nerve. Above it lies projection of lateral semicircular canal.

PROCESSUS COCHLEAFORMIS
Hook like projection ,concave anteriorly. Houses tendon of tensor tympani muscle. Landmark for first genu of facial nerve The canal crosses the medial tympanic wall from the cochleariform process anteriorly, runs just above the fenestra vestibuli, and then curves down into the posterior wall of the cavity.

SINUS TYMPANI
Deep recess, medial to pyramid, behind promontory Posterior extension of mesotympanum Superior - Ponticulus Inferior Subiculum Lateral Mastoid part of facial nerve Medial Posterior SCC Shallow or deep,extend as far as 9mm into mastoid bone

Clinical importance: Cholesteatoma extended here from mesotympanum is extremely difficult to remove.

CONTENTS OF MIDDLE EAR

OSSICLES TWO MUSCLES CHORDA TYMPANI TYMPANIC PLEXUS AIR

OSSICLES OF MIDDLE EAR

Ear bones Form a chain across middle ear From TM to oval window Consists of: 1] MALLEUS 2] INCUS 3] STAPES

MALLEUS
Largest,upto 9mm in length, shaped like mallet 1] Head rounded superior part lies in epitympanic recess articulates w/ incus(saddle shape facet) 2] Neck chorda tympani crosses handle on medial surface above insertion of tensor tympani tendon& below neck.

3]Handle- runs downwards, medially, backwards b/w mucosal & fibrous layers of TM. Upper end on medial surface,slight projection where tendon of tensor tympani is attached. 4]Lateral process prominent projection, anterior & posterior malleolar folds attach. 5]Anterior process-anterior ligament arise here to insert in petrotympanic fissure.

INCUS
Shaped like anvil Body and three processes 1]BODY-articulate with malleus,lies in epitympanum. suspended by superior incudal ligament attached to tensor tymapni.

2]Short process lie in fossa incudis,attached buy posterior incudal ligament. 3]Long process descend in mesotympanum, behind and medial to handle of malleus. 4]Lenticular process articulate with head of stapes(fourth ossicle)

STAPES
Shaped like stirrup Smallest Head, neck, two limbs (processes or crura) and a base (footplate) 1]Head- point laterally, articulate with incus. 2]Neck- constricted,tendon of stapedius attached to its posterior surface and posterior crus

3]Processes arise from neck,anterior thinner and less curved,both join footplate. 4]Footplate 3mm long and 1.4mm wide Sits in oval window surrounded by stapediovestibular ligament.

TENSOR TYMAPNI MUSCLE

ORIGIN - cartilaginous part of ET, greater wing of the sphenoid, walls of its semicanal. Tendon sweeps around processus cochleaformis & across tympanic cavity. INSERTION- medial aspect of upper end of malleus handle .

 BLOOD SUPPLY - superior tympanic branch of the middle meningeal artery NERVE SUPPLY medial pterygoid nerve (a ramus of mandibular division of the trigeminal nerve) ACTIONS - draws the handle of the malleus medially, and so tenses the tympanic membrane, pushes the base of the stapes more tightly into the fenestra vestibuli.

STAPEDIUS MUSCLE
Arise from pyramid and inserts into posterior surface of neck of stapes and posterior crus. BLOOD SUPPLY -branches of the posterior auricular, anterior tympanic and middle meningeal arteries

 NERVE SUPPLY nerve to stapedius (branch of facial nerve) ACTIONS - damp down excessive sound vibrations,opposes the action of tensor tympani (which pushes the stapes more tightly into the fenestra vestibuli). Paralysis of stapedius results in hyperacusis.

CHORDA TYMPANI NERVE

Branch of facial nerve. Separate from main trunk 4mm proximal to stylaomastoid foramen. Enters tympanic cavity from Post. Canaliculus at junc to lateral and posterior walls.

 Runs across medial suface of TM above tendon of tensor tympani,medial to handle malleus and lateral to long process of incus. Leaves cavity by way of Ant. Canaliculus which subsequently join petrotympanic fissure. Carries taste from ant 2/3rd of tongue and supply secrotomotor fibres to submandibular and sublingual glands.

TYMPANIC PLEXUS
Tympanic br of glossopharyngeal nerve (JACOBSONS NERVE)- inferior ganglion, reaches the tympanic cavity via inf. tympanic canaliculus Caroticotympanic nerves- superiorand inferior,arise from sympathetic plexus around ICA, traverse the wall of carotid canal to join plexus Nerves ramify on surface of promontory.

 Innervate : medial surface of tympanic membrane,mucosa of tympanic cavity, mastoid air cells and eustachian tube. Secretomotor fibres to parotid gland Course of secretomotor fibres to the parotid: Inferior salivary nucleus ---+ CN IX ---+ Tympanic branch ---+ Tympanic plexus ---+ Lesser petrosal nerve ---+Otic ganglion ---+ Auriculotemporal nerve ---+ Parotid gland.

MUCOSA OF MIDDLE EAR

pale, thin and slightly vascular. mucus-secreting respiratory mucosa bearing cilia on its surface. continuous with that of the pharynx, via the pharyngotympanic tube. wraps the ossicles, muscles,tendons and nerves in the cavity to form the inner layer of the tympanic membrane and the outer layer of the secondary tympanic membrane. spreads into the mastoid antrum and air cells .

 Three distinct mucociliary pathways: 1. Epitympanic 2. Promontorial 3. Hypotympanic( largest) Coalesces at the tympanic orifice of the pharyngotympanic tube

Histologically , ET pseudostratified ciliated columnar epithelium in cartilaginous part,columnar in bony part with mucous glands in submucosa. Tympanic cavity ciliated columnar in ant and inf part,changes to cuboidal in post part Epitympanum and mastoid air cells -flat cuboidal epithelium

 Mucosal folds SEPARATE middle ear space into compartments giving it honeycomb appearance. The only route for ventilation of epitympanic space from mesotympanum - via two small openings between mucosal folds - the anterior and posterior isthmus tympani.

PRUSSAKS SPACE
Medially : pars flaccida Laterally : neck of malleus Inferiorly : lateral process of malleus Anteriorly , posteriorly and superiorly : lateral malleal ligament Posterior gap communicates with epitympanum. Important role in the retention of keratin and development of cholesteatoma.

BLOOD SUPPLY
TWO MAIN ARTERIES:(i) Anterior tympanic branch of maxillary artery- tympanic membrane,malleus,incus,anterior part of tympanic cavity. (ii) Stylomastoid branch of posterior auricular artery - posterior part of tympanic cavity and stapedius muscle.

Minor vessels are: (i) Petrosal branch of middle meningeal artery (runs along greater petrosal nerve). (ii) Superior tympanic branch of middle meningeal artery traversing along the canal for tensor tympani muscle. (iii) Branch of artery of pterygoid canal (runs along eustachian tube). (iv) Tympanic branch of internal carotid artery. (v) Mastoid branch of stylomastoid artey. (vi) Inferior tymapnic branch of ascending pharyngeal A.

LYMPHATIC DRAINAGE
Middle ear : Retropharyngeal and Parotid nodes Eustachian tube : Retropharyngeal nodes. VEINS DRAIN INTO PTERYGOID VENOUS PLEXUS AND SUPERIOR PETROSAL SINUS.