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
PHARYNGEAL OR BRANCHIAL BRANCHES
• 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.
1ST AND 2ND BRANCHIAL ARCHES GIVES RISE
TO 6 MESODERMAL
THICKENINGS(AURICULAR TUBERCLES)
KNOWN AS “HILLOCKS OF HIS” WHICH
FUSE TO FORM PINNA.

1ST HILLOCK ARISES FROM 1ST ARCH $

REMAINING 5 HILLOCKS ARISE FROM 2ND
ARCH.

TAKES DEFINITE FORM BY END OF 3

MONTH OF IUL.
• EXTERNAL AUDITORY MEATUS
• Dorsal part of the 1st ectodermal cleft (OR 1ST BRANCHIAL GROOVE GROWS
MEDIALLY AND FORMS THE EAC.AT BIRTH ONLY CARTILAGENOUS PART FULLY
DEVELOPED .BONY PART CONTINUES TO GROW AFTER BIRTH
• OSSICLES
• Malleus & Incus cartilage of 1st pharyngeal arch(Meckel’s cartilage). Tensor
tympani muscle attached to it. 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.
• 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.
• Mastoid process continues to grow until puberty and even beyond.
Mastoid antrum
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 .
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,RETROAURICULAR
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
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.
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.
• cartilage in the lateral one third and bone in the medial two thirds.
• The diameter varies b/w different individuals and races .
• In adults ,the cartilaginous portions run inwards slightly downward & forwards
;canal is straightened 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.
cartilaginous portion -8 mm(outer 1/3rd) long and is continuous with the auricular
cartilage and it is deficient superiorly.
bony canal, about 16 mm long, and is narrower than the cartilaginous portion.
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(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(ANTERO SUP.) :- Auriculo temporal Nerve
 Posterior wall & floor(POSTERO INF.) :- 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:DEEP cervical lymph nodes.
TYMPANIC MEMBRANE
The tympanic membrane lies at the medial end of the EAC and forms the
majority of the lateral wall of the TM.
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 ->continuous with the
skin lining the meatus .
2)Inner mucosal layer ->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 .
• 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.
 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
 Arterial supply of Tympanic membrane
• Arises from branches supplying both the EAC and the middle ear.
• The epidermal vessels -> deep auricular branch of the maxillary artery (comes from the
EAC)
 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 inflammatory
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) -> 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 in 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.
MIDDLE EAR
• Middle ear -> six sided cavity
• Roof-separated from MCF by
tegmen tympani
• Floor-separated from IJV BY
THIN PLATE OF BONE
• Medial wall
• Lateral wall
• Anterior wall
• posterior walls.
• Biconcave ,irregular space in
petrous part of temporal bone.
• fully developed to adult size at
birth.
-It communicates with nasopharynx
through eustachian tube and
mastoid posteriorly through aditus.
• Further divided into
compartments
• 1)epitympanum (upper)-above
malleolar fold of tm.
• 2)mesotympanum (middle )-
medial to pars tensa of tm.
• 3)Protympanum(area of
tympanum around ET)
• 4)hypotympanum(lower)-below
the level of tm.
THE ROOF
• The roof of the tympanic cavity is formed by tegmen tympani.
• Formed by both petrous and squamous part of the temporal bone.
• Tegmen tympani separates middle ear space from MCF.
• 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 $
hypotympanum inferiorly.
 tympanic membrane centrally and

 The lateral epitympanic wall is wedge-shaped in section and its sharp

inferior portion is also called the outer attic wall or scutum.
 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 -> formed by lateral wall of vestibule and first turn of
cochlea & separates middle ear from inner ear.

-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)- opens
into scala vestibuli.occupied by
footplate of stapes fixed by annular
ligament.
-Fenestrae cochlea(round window)
->opens into scala tympani of cochlea
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
-seperates ME from ICA
• structures passing are-
• Canal for chorda tympani n.
• Canal for tensor tympani ms.
• Eustachian tube
• Ant. Malleolar ligament
• Ant. Tympanic artery(br. ECA)
• 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 .
• Post. wall close to mastoid air cells has following structures:
• 1)aditus- leads to mastoid antrum

• 2)fossa incudes POSTERIOR WALL

• 3)pyramid
• 4)facial recess-suprameatal/suprapyramidal recess
1-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 ;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 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, 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 .
-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 Lat & Ant 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 malleolar folds.
posteromedial surface of the head of malleus
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 also k/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
 Incudomalleolar joint

Incudostapedial joint

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.
• 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 br. Of 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) .
• Roof-it is formed by the tegmen tympani
• Lateral wall -it is formed by 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-post.semi circular canals

Sinodural angle or citellis 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. 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-> squamous and petrous
part of temporal bone -> 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.
• In neonates and 1 year old child , tube is more horizontal $ shorter than in
adults.
• Also, there is no torus present at opening which is reduced to narrow slit.
 MIDDLE EAR VENTILATION
• tympanic diaphragm divides
physical AI &PS
COMPARTMENTS
• 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.
THANK YOU