ANATOMY OF

EXTERNAL AND
MIDDLE EAR
Dr Aarogya Karki
First year resident
ENT department , PAHS
 ANATOMY OF EAR
•External ear
•Middle ear
•Inner ear
(the labyrinth)
 Development of External
Ear
Pinna
Within 2 weeks, six ridges (Hillocks of His), arise from tissue condensations 1 st and 2nd
arch which fuse to form auricle.
Tragus develops from tubercle of the first arch while rest of the pinna develops from
remaining five tubercles of second arch.
Faulty fusion : pre-auricular sinus or cyst.MC in root of helix
External auditory meatus

Develops from dorsal end of the first branchial cleft.

Bony part develops later than cartilaginous part
Persistence of cleft = Callaural fistula with external
opening between angle of mandible and
sterocleidomastoid and internal opening in the floor
of EAC.
Tympanic Membrane

Epidermal layer : formed from the deepest ectodermal cells of ectodermal 1 st cleft

Fibrous layer : from the mesenchyme between meatal plate and endodermal floor
of tubo-tympanic recess. mesodermal

Mucosal layer : from the epithelial lining of first pharyngeal pouch endodermal.
 Development of Middle Ear
Develops from 1st pouch .that grows laterally towards EAC to form Tubotympanic
recess, lying between the first and second pharyngeal arches.
Lateral part of the recess eventually comes in contact with the first pharyngeal cleft
and widens to develop the eustachian tube tympanic cavity and mastoid antrum.
Middle ear ossicles : Malleus and incus develop from
first arch while stapes suprastructure from the second
arch. Foot plate of stapes from otic capsule.
 THE EXTERNAL EAR
Made up of :
•Auricle (Pinna)
•External acoustic(auditory) canal
•Tympanic membrane
(the drumhead).
Auricle(Pinna)
•Single piece of yellow elastic cartilage covered
with perichondrium and skin.

•2 surfaces
Lateral surface - skin closely adherent to
perichondrium, has characteristic prominences
and depressions.
Medial(Cranial) surface -skin loosely
adherent to perichondrium, has
elevations corresponding to the depression on the
lateral surface.
Incisura terminalis
 No cartilage between the tragus
and crus of helix
No cartilage in lobule
 For end aural(through EAC) approach in surgery. Can
avoid infection and cartilage necrosis.
Site of insicion : Lempert endaural incision
Clinical significance – as a source of several graft
materials
 Reconstructive surgery of middle ear.
 Correct depressed nasal bridge and defects of nasal ala.
Lobule= fat graft
CYMBA CONCHA
Cartilaginous landmark for mastoid antrum
Bony landmark is macewen’s triangle
Ligaments
1. Extrinsic: Connects cartilage of auricle to temporal bone.
 Anterior ligament - from the tragus and crus of the helix to the root of
zygomatic arch.
 Posterior ligament - from the medial surface of concha to the lateral surface of
mastoid prominence.

2. Intrinsic: Connects various parts of cartilaginous auricle.

Muscles
1. Extrinsic : Auricularis anterior, superior and posterior.
Gives rise to postauricular myogenic response.

2. Intrinsic : Small, inconsistent and without useful function.

 Nerve supply of Pinna
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
Some supply medial surface (eminetia
concha)

Auriculotemporal Vc mandibular Tragus, crus of helix and adjacent helix

Facial VII Probably supplies small region in the root of
concha
Arterial supply
From Branches of External carotid artery
1. Posterior auricular : Supplies medial surface
(except lobule), concha, middle and lower portions
of helix and lower part of antihelix.

2. Anterior auricular(branch of superficial temporal

artery): Supplies upper portion of helix, antihelix,
triangular fossa, tragus and lobule.

3. Superior auricular artery: connects superior

temporal artery and posterior auricular artery
network.

4. Small auricular branch of occipital artery: medial

surface.
Lymphatic drainage

1. From posterior surface: lymph nodes at the mastoid tip

2. From tragus and upper part of anterior surface: pre-auricular nodes

3. Remaining auricle: upper deep cervical nodes.

 External Auditory Canal
• Extends from concha of the auricle to tympanic membrane.
• 24 mm long, S shaped
• Lined by keratinizing stratified squamous epithelium
Two parts:
 Lateral 1/3rd : Cartilaginous , directed upwards, backwards and medially.8mm
 Medial 2/3rd : Bony , directed downwards, forwards and medially.16mm

To see tympanic membrane, pinna has to be pulled upwards, backwards and

outward.

In the neonate there is virtually no bony external meatus as the tympanic bone is not
yet developed , tympanic membrane is more horizontally placed so that the auricle
must be gently drawn downwards and backwards for the best view of tympanic
membrane.
Cartilaginous part (8mm)
Continuous with the auricular cartilage.

Skin covering – thick

Fissures of Santorini: 2 horizontal fissures that lie antero-inferiorly

 increases the flexibility but allows the passage of infection or tumour into the parotid
gland and base of skull and vice versa.

Contains:
1. Ceruminous glands
2. Sebaceous glands
3. Hair : furuncles seen only in the outer 1/3rd of the canal.
Bony part(16mm)
Skin covering – thin and continuous over the tympanic membrane.

Devoid of hair and appendages.

Foramen of hushke communicated with parotid gland

Medial end :Marked by a groove(tympanic sulcus) which is absent superiorly.

Two suture lines in the canal wall: landmarks for the “vascular strip” incisions.
-Tympano-squamous anteriorly
-Tympano-mastoid posteriorly
2 constrictions
1. At the junction of cartilaginous and bony portions
2. Isthmus : 6mm lateral to tympanic membrane. Narrowest part of
TM
 Foreign bodies lodged medial to it gets impacted and are difficult to remove

Anterior recess: Wedge shaped ; in the anteroinferior portion of the

canal deep to the isthmus.
 Acts as a cesspool for discharge and debris in cases of external and middle
ear infections

Foramen of Huschke: deficiency at the antero-inferior part,

permitting infections to and from the parotid.
Relationships of External Auditory Canal
Arterial supply
From branches of external carotid artery
 Auricular branches of superficial temporal artery: Supplies roof and anterior portion
of the canal.
 Deep auricular branch of first part of maxillary artery: anterior meatal wall skin and
the epithelium of the outer surface of the tympanic membrane.
 Auricular branches of posterior auricular artery: posterior portion of the canal.

Veins drain into the external jugular vein, maxillary veins and pterygoid plexus.

Lymphatic drainage follows that of auricle.

Nerve supply
Auriculotemporal nerve (V3): anterior wall and roof.
Auricular branch of vagus (X): posterior wall and floor. Known as Arnolds nerve.
Stimulation can cause cough reflex during syringing or probing and vasovagal
syncope.
Posterior wall of auditory canal also receives sensory fibers of CN VII through
auricular branch of vagus.

Referred otalgia
 TYMPANIC MEMBRANE
Lies at the medial end of the external auditory meatus
Forms majority of the lateral wall of the tympanic cavity
Slightly oval in shape
Forms an angle of about 55° with the floor of the meatus
9-10 mm tall
8-9 mm wide
0.1 mm thick
TSA - 90mm sq
Effective Vibrating area: 45 to
50mm sq
As surface attached to malleus
Doesn’t vibrate
 Most of the circumference is thickened to form a fibro-
cartilaginous ring, the tympanic annulus in pars tensa.

Tympanic annulus sits in a groove in the tympanic bone ,the

tympanic sulcus.

From the superior limits of the sulcus, annulus becomes a

fibrous band which runs centrally as anterior(shoerter) and
posterior(posterior) malleolar folds to the lateral process of
malleus.
2 parts:

1. Pars Flaccida
 Pinkish, small triangular region above the malleolar
folds within the notch of rivinus.
 More mobile
 Retraction pocket common here.

2. Pars Tensa
 Below the malleolar folds.
 Tense due to fibrous layer
 Central part tented inwards at the level of the tip of
malleus called umbo.
 Bright cone of light seen radiating from the tip of
malleus to periphery in antero-inferior quadrant.
QUADRANTS OF TYMPANIC MEMBRANE AND CLINICAL SIGNIFICANCE:
Nerve supply
Auriculotemporal nerve (V3): Anterior half of lateral surface.
Auricular branch of vagus nerve (X): Posterior half of lateral surface.
Tympanic branch of CN IX ( Jacobson’s nerve) : Medial surface.

Arterial supply
From branches supplying both external auditory meatus and the middle ear.
Epidermal vessel: Deep auricular branch of the maxillary artery
coming from external auditory meatus
Mucosal vessel: Anterior tympanic branches of the maxillary artery,
stylomastoid branch of posterior auricular artery, middle meningeal
artery.
MIDDLE EAR
Middle Ear Cleft
Consists of:
1.Tympanic cavity
2.Eustachian tube
3.Mastoid air cell system
Largest air cell being antrum
Tympanic Cavity (for ventilation)
Parts:
Epitympanum : above the level of the malleolar
folds, lies against pars flaccida
Mesotympanum : opposite of pars tensa
Hypotympanum : below the level of inferior part of
tympanic sulcus
Protympanum : anterior to the promontory has
ET opening
Retrotympanum : posterior to mesotympanum
Roof
Tegmen tympani:
 Thin plate of bone formed by Petrous and Squamous
portions of temporal bone.
 Separates the tympanic cavity from middle cranial
fossa.

Cog:
 a bony crest projecting from tegmen tympani.
 Landmark for geniculate ganglion
 Divides the posterior epitympanic space from anterior
epitympanic space.
 Site of residual cholesteatoma.
Floor
Compact or pneumatized bone with spines and trabeculae.

Separates hypotympanum from dome of jugular bulb.

Inferior tympanic canaliculus(junction of floor and medial

wall):
 allows entry of tympanic branch of glossopharyngeal or jacobson’s nerve into
the middle ear
 carries preganglionic parasympathetic fibers from the inferior salivary nucleus
on their course to otic ganglion
 Referred otalgia from oropharynx
Lateral wall
Superiorly: Bony lateral wall of
epitympanum.

Centrally: Tympanic membrane.

Inferiorly: Bony lateral wall of

hypotympanum.
 Lateral epitympanic wall: wedge shaped, its sharp
inferior portion is called the outer attic wall or scutum.

Petrotympanic fissure: Slit about 2mm long , opens

anteriorly just above the attachment of the tympanic
membrane.

Chorda tympani : Across the upper part of the handle

of the malleus
 Medial Wall
Formed by the labyrinth
Promontory – impression by the basal coil of cochlea
Oval window – closed by footplate of stapes
Round window(fenestra cochleae) – covered by the
secondary tympanic membrane
Canal for facial nerve – above the oval window
Prominence of lateral semicircular canal – above the
canal for facial nerve
Processus cochleariformis
 hook like projection just anterior to oval window.
 Tendon of tensor tympani takes a turn here to get attachment
to the neck of malleus.
 landmark for level of genu of facial nerve.
Promontary
Has small grooves on its surface containing nerves which form the tympanic
plexus.
Oval window: Behind and above the
promontary. Connects the tympanic cavity
with the vestibule. 3.25mm long and
1.75mm wide.
Round window: Below and a little behind
the oval window separated from it by a
bony ridge called the subiculum
Another bony ridge, ponticulus leaves the
promontary above the subiculum and runs
to the pyramid on the posterior wall of the
cavity.
Posterior wall

Upper part – Aditus – connects attic and mastoid antrum.

Fossa incudes : Small depression below the aditus which houses the short
process of the incus and its suspensory ligament.

Pyramid: Small hollow conical projection below the fossa incudes and
medial to opening of chorda tympani, houses the stapedius muscle and
tendon which inserts into the posterior aspect of the head of stapes.
Facial recess:
Groove which lies between the facial nerve
and the chorda tympani.it is suprapyramidal.
To approach middle ear for posterior
tympanotomy from mastoid

Medially:
Facial nerve

Laterally:
Chorda tympani

Above:
Fossa incudes
Sinus tympani:
Posterior extension of the
mesotympanum into the posterior
wall.Infrapyramidal
Medial wall: Continuous with the
posterior portion of the medial wall of
the tympanic cavity in the
retrotympanum
Laterally: Mastoid segment of the
Facial nerve
Superiorly: Ponticulus
Inferiorly: Subiculum


Importance : cholesteatoma extremely
difficult to eradicate
Anterior wall
Lower third: Plate of bone covering the carotid artery
wafer thin or upto 3mm thick, perforated by superior and inferior
caroticotympanic nerves carrying sympathetic fibers to the tympanic plexus and by
the tympanic branches of the internal carotid artery

Middle third: Tympanic orifice of the eustachian tube

Canal containing tensor tympani muscle

Upper third: Is usually pneumatised and may house the supratubal recess,
 Supratubal recess: A small niche that can be separated from the anterior
epitympanic space by the tensor fold.
Contents of middle ear cavity

Air
3 ossicles – malleus, incus and stapes
2 muscles- tensor tympani and stapedius
2 nerves
Mucosal folds and ligaments
Blood vessels
Ossicles
Muscles of middle ear
Stapedius:
Develops from 2nd pharyngeal arch.
Insertion: inserts into the stapes.
Nerve supply : branch of facial nerve.
Tensor tympani:
Origin: walls of bony canal lying above
the eustachian tube, cartilaginous portion
of the eustachian tube and greater wing of
sphenoid . Develop from 1st arch
Insertion : Medial aspect of upper end of
the malleus handle.
Nerve supply: mandibular nerve by way
of a branch from medial pterygoid nerve.
 Chorda tympani nerve
• Enters medial surface of
petrotympanic fissure through a
separate anterior canaliculus (Canal
of Huguier)
• Runs between the fibrous and
mucosal layers of the tympanic
membrane
• Across the upper part of the handle
of the malleus
• Enters the posterior canaliculus
• Reaches the facial nerve
 During cortical mastoidectomy the
fibrous strands of the tympanomastoid
suture line can often be confused with the
chorda tympani
Tympanic Plexus
FORMED BY:
 Tympanic branch of glossopharyngeal ( jacobson’s nerve)
 caroticotympanic nerves , Sympathetic fibres from the nerve plexus around
internal carotid artery
Nerves form the plexus on the promontory
SUPPLIES INNERVATION TO:
 Medial surface of tympanic membrane
 Tympanic cavity
 Mastoid air cells
 Bony eustachian tube
The plexus also provides branches to join the greater superficial nerve and lesser
superficial petrosal nerve that contains all the parasympathetic fibers of the
glossopharyngeal nerve
Mucosa of the tympanic cavity

Mucus secreting respiratory mucosa.

Three distinct mucociliary pathway can be identified-
epitympanic, promontorial and hypotympanic
Mucus membrane lines the bony walls of the tympanic cavity,
and it extends to cover the ossicles and their supporting
ligaments
The mucosal folds also cover the tendons of the two middle ear
muscles and carry blood supply to and from the contents of the
tympanic cavity.
These folds separate the middle ear
space into compartments.
As a result the only route for ventilation
of the epitympanic space from
mesotympanum is via two small openings
between the various mucosal folds-the
anterior and posterior isthmus tympani

Prussak space : found between the

pars flaccida and neck of malleus,
bounded by the lateral malleolar
process.
 Importance: the retention of keratin and
subsequent development of
cholesteatoma.
Blood supply of middle ear
Eustachian tube
Links middle ear with
nasopharynx
36mm in length
Runs downwards at 45◦ and
turned forwards and medially.
2 unequal cones, connected at
their apices.
Lined by respiratory mucosa
Cartilaginous part
Medial 2/3rd

Posteromedially : Cartilage plate,

consists of medial and lateral lamina
separated by elastic hinge.

Anterolaterally : Fibrous tissue and

ostmann’s fat pad

Upper border: Resemble inverted J

Fixed to base of the skull in a groove

between the petrous part of temporal
bone and greater wing of sphenoid
Medial end: protrudes into nasopharynx,
forms torus tubarius and opens 1 -
1.25cm behind and little below the end
of inferior turbinate.

Behind the torus is the pharyngeal

recess or fossa of rosenmuller.
Bony Part
Lateral 1/3rd

Roof: Thin plate of bone

Medially: Carotid canal
Cross section: Triangular or
Rectangular
Muscles attached to eustachian tube
1.Tensor veli palati: Supplied
by mandibular nerve.
2.Salpingopharyngeus
3.Levator palati

Both salpingopharyngeus and

levator palati are supplied
from the pharyngeal plexus.
Arterial supply: Ascending pharyngeal and middle
meningeal artery

Venous drainage: Pharyngeal plexus

Lymphatic: Retropharyngeal nodes.

Nerve supply: Pharyngeal branch of the sphenopalatine

ganglion(Vb) for the ostium, nervus spinosus(Vc) for the
cartilaginous portion and the tympanic plexus(IX) for the
bony part.
DIFFERENCES BETWEEN THE INFANT AND
ADULT
EUSTACHIAN TUBE
Mastoid air cell system
Mastoid antrum: air filled sinus within the petrous part of the temporal bone
 It comunicates with the middle ear by way of the aditus and has mastoid air cells
arising from its walls
 The antrum but not the air cells, is well developed at birth and by adult life has a
volume of about 2ml
Roof: floor of middle cranial fossa
Medial wall:
 relates to posterior semicircular canal .
 More deeply and inferiorly is the dura of posterior cranial fossa and the
endolymphatic sac
 Sigmoid sinus: Posterior to the endolymphatic system
 The posterior belly of digastric muscle forms a groove in the base of mastoid bone
Outer wall: lies just below the skin and is easily palpable behind the pinna
Pneumatization
Five recognized regions

Middle ear : epitympanic, hypotympanic, mesotympanic,

protympanic, and posterior tympanic areas
Mastoid : mastoid antrum, central mastoid, and peripheral
mastoid
Perilabyrinthine : supralabyrinthine and infralabyrinthine areas
Petrous Apex : apical and peritubal area
Accessory : zygomatic, squamous, occipital, and styloid areas
Air Cell Tracts

5 tracts
Posterosuperior tract : between posterior and middle fossa aspects
of the temporal bone
Posteromedial cell tract : parallels and runs inferior to it
Subarcuate tract : through the arch of the superior semicircular
canal
Perilabyrinthine tracts : superior and inferior to the bony
labyrinth,
Peritubal tract : surrounds the eustachian tube
Macewen’s triangle
Superior: temporal line
Anterior: postero superior margin
of bony external auditory canal
opening
Posterior: tangent drawn to mid
point of posterior of external
auditory canal.

Mastoid antrum lies 12-15 mm

deep to the triangle.
 References
Scott-Brown’s Otorhinolaryngology 8th edition
PL Dhingra 7th edition
Thank You