Middle ear anatomy

Middle ear cleft consists of:

1. tympanic cavity: (Irregular, air filled space within the temporal bone between the
tympanic membrane laterally & the osseous labyrinth medially)
a. Auditory ossicles
b. Tendons of ossicles which attach them to the
muscles of the middle ear
c. Tympanic segment of the Facial Nerve
2. Eustachian tube
3. Mastoid air cell system
Tympanic membrane
 Lies at the medial end of the external auditory canal.
 Forms the majority of lateral wall of the tympanic cavity
 Shape: Oval; Broader above than below
 Orientation:
o forming an angle 55° with the floor
o placed obliquely forming acute angle with
meatus anteriorly and obtuse one posteriorly
 Diameters:
o Its longest diameter (posterosuperior to
anteroinferior)= 9-10mm, Perpendicular to
this the shortest diameter= 8-9mm
o So tympanic membrane is 9*9 mm in size
o 0.1mm in thickness
o Surface area 85 mm3; Effective vibrating
area: 55 mm3
 Color:
o Pearly white-gray, shiny, The light reflex is
due to the concave position of the membrane
o Red Tympanic membrane may be seen in:
OM, crying child, sneezing, nasal blowing
o Blue tympanic membrane may be seen in:
Glue ear, Hemotympanum, High jugular
bulb, Choleasterol granuloma
 Tympanic membrane layers:
1. Outer- stratified squamous Epithelial layer -ectoderm
2. Middle- Fibrous layer: -mesoderm
Lamina propria which is made of:
a- Outer Radiating fibrous layer
b- Inner Circular fibrous layer
3. Inner- Mucosa layer.-endoderm
Embryology of Tympanic membrane Layers:
1. 1ST Branchial Pouch/ tubotympanic recess (Endoderm)forms:
 eustachian tube
 middle ear space
 inner mucosal layer of the tympanic membrane
2. Mesoderm of the 1st & 2nd brachial arch:
 Arise from the neural crest mesenchyme
 Forms middle fibrous layer of the tympanic membrane
3. 1ST Pharyngeal Groove/meatal plug (Ectoderm) forms:
 EAC and the outer epidermal layer of the tympanic membrane
 It is adult sized at birth but due in part to incomplete ossification of the external auditory canal, lies in a nearly
horizontal position, impairing its visualization on neonatal ear examination.
 The final vertical orientation of the eardrum is achieved with completion of canal ossification by approximately age
of 2 years
 Umbo is the center point which divides the tympanic membrane
 Its most prominent land mark is the handle of malleus (directed in anterio-superior direction)
Tympanic Membrane Relation to the Temporal Bone:
 Most of the circumference is thickened to form fibrocartilaginous ring = tympanic annulus
 Which sits in Tympanic sulcus (groove in the temporal bone)
 sulcus does not extend into the Notch of Rivinus
Notch of Rivinus (tympanic incisura):
 Superior part of tympanic ring (roof of the canal) is made of the squamous part of the
temporal bone
 where the pars flaccida is attached to squamous part
 deficient in the annulus ring
Anterior & Posterior malleolar folds:
 From the superior limits of the sulcus, the annulus ring becomes fibrous band which
runs centrally to handle of malleous So it is a continuation of the annular ring & sets
the border between pars flaccida & tensa
Paras flacida (shrapnel's membrane):
 Part of Tympanic membrane above the malleolar folds
 Does not have annular ring
 Triangular in shape, small in size
 Lamina propria has radially oriented fibers in the outer layers; circular, parabolic and transverse fibers in deep layers
Paras Tensa:
 Forms the rest of the tympanic membrane (below the malleolar folds)
 Lamina propria is less marked and orientation of fibers is random
 Concave toward the ear canal except between:
1. the lateral attachment of the annulus
2. center of the membrane where the tip of the malleus handle is attached at the umbo
Paras flacida Paras Tensa
Above the malleolar folds Below the malleolar folds
Does not have annular ring has annular ring
Triangular in shape Concave toward the ear canal
Non vibratory vibratory part
Made of 3 layers but the lamia propria fibers are less organized Made of 3 layers
More innervated Less innervated
Note:
 Induostapedial joint, stapedius muscle, chora tympani could be seen through normal Tympanic membrane
 The Tympanic membrane is lined with cuboidal & respiratory epithelium
 Tympanic Cavity
Embryology: Middle ear cavity: 1st + 2nd pharyngeal pouch
Compartments of the tympanic cavity
1. epitympanum (attic): above the level of malleolar folds
2. mesotympanum
3. Hypotympanum: area below the tympanic sulcus
Dimensions of the Tympanic cavity:
 Anterio-posterior (width): 15 mm
 Vertical (height): 15 mm
 Transverse (depth):
Epitympanum: 6mm
Mesotympanum: 2mm
Hypotympanum: 4mm
Note: the narrowest area is the mesotympanum due to the medial
orientation of handle of the malleus
 Epitympanum is separated from the mesotympanum +
hypotympanum by series of mucosal folds
 Mesotympanum + hypotympanum are continuous with each other
Borders of the epitympanum/attic:
Superiorly Tegmen
Laterally squamosa (scutum)
Medially lateral semicircular canal and VII nerve
Posteriorly Aditus
Inferiorly fossa incudis
Anteriorly zygomatic arch
Protympanum: anterior to Tympanic membrane
retrotympanum: - posterior to Tympanic membrane,
- contains facial recess + sinus stympani
Content of the epitympanum:
1- head & neck of the malleus
2- body & short process of the incus
3- lateral semicircular canal
4- tympanic part of the fallopian canal of facial nerve
5- aditus

Hyrtl's triangle/fissure
 Embryological connection between the subarachnoid space & hypotympanum
 Located anterior–inferior to the round window near the inferior ganglion of the (IX) glossopharyngeal nerve
 Closes as the infant grows
 If persists it will afford a rout for direct extension of the middle ear infection into the subarachnoid space
Content of the Mesotympanum:
1. handle of the malleus
2. long process of the incus
3. stapes
4. round, oval windows
 Walls of tympanic cavity
1- Lateral wall (Membranous wall):
Divisions:
 Superiorly: bony lateral wall of the epitympanum= outer attic wall/scutum = Squamous bone
o It is wedge shape in section (shield-like)
o With sharp inferior portion
o Thin & easily eroded by cholesteatoma leaving a telltale sign on the CT scan
 Centrally: Tympanic membrane
 Inferiorly: bony lateral wall of the Hypotympanum = tympanic bone
Holes:
a- Petrotympanic fissure (Glaserian fissure): is a slit about 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.
b- iter chordæ anterius (canal of Huguier) (ant canaliculus): see nerve course of chorda tympani
c- iter chordæ posterius: see nerve course of
chorda tympani
Chorda Tympani:
see nerve course of chorda tympani
2- Roof of the tympanic cavity (tegmen tympani):
 Roof of epitympanum = tegmen tympani
 Thin bony plate that separates the middle ear from the middle cranial fossa (temporal lobe)
 It is made up of petrous and squamous portions of temporal bone
 It is continuous with tegmen antri
 It contains the petrosquamous fissure
 The fissure contains superior tympanic canaliculus through which the superior petrosal nerve passes
 Veins from the tympanic cavity running to the superior petrosal sinuses through this suture line
 Petrosquamous suture line does not close until adult life so can provide a route of infection into the
extradural space in children
3- Floor of tympanic cavity (jugular wall)
 It is made of tympanic plate + part of the petrous bone (??)
 may consists of compact or pneumonized bone
 Separates the Hypotympanum from the Jugular fossa
 Occasionally, the floor is deficient & the jugular bulb lies in the mesotympanum is covered only by fibrous
tissue & mucous membrane (May be at risk during myringotomy)
 At the junction of the floor & medial wall there is inferior tympanic canaliculus through which tympanic branch
of glossopharyngeal nerve enters the tympanic cavity
 IX, X, XI are nerve that emerge through jugular foramen, so they are found beneath the floor of the middle ear
4- Anterior wall (Carotid wall)
 Anterior wall narrows as the medial & lateral walls converge
 Elements:
o The petrous portion of the bony Internal Carotid artery canal
o Eustachian tube
o Tensor tympani muscle & its semi-canal
1. Lower 1/3 of the Anterior wall:
o Consists of thin plate of bone covering the carotid artery as it enters the skull before it turns anteriorly
o This plate is perforated by (through the opening of the carotid canal “Glasserian fissure”)
- superior & inferior caroticotympanic nerves carring sympathetic fibers to tympanic plexus
- tympanic branch of the internal carotid artery
2. Middle 1/3 of the Anterior wall:
o Comprises the tympanic orifice of the Eustachian tube, which is oval &is 5x2 mm in size.
o Just above it is a canal that contains the tensor tympani muscle that subsequently runs along the medial
wall of the tympanic cavity, enclosed in a thin bony sheath
3. Upper 1/3 of the anterior wall:
o Usually pneumonized, may house the epitympanic sinus
o Epitympanic sinus: is a small niche anterior to the ossicular heads, which can hide residual cholesteatoma in
canal wall up surgery
5- Medial wall (labyrinthine wall):
- The medial wall separates the middle from the inner ear, Composed of:
A- promontory: see page 475 netter
 The most prominent portion in the medial wall
 Occupying most of the central portion of the medial wall of the middle ear
 It covers part of the basal coil of the cochlea.
 it inclines gently forward to merge with the anterior wall, but is more steeply sloped posteriorly
 Grooved because of branches of the tympanic plexus which lie under its mucous membrane
 Sometimes the groove that contains the tympanic branch of the glossopharyngeal nerve may be covered
with bone which forms a small canal
B- two fossa:
The oval vestibular window (fenestra vestibule):
 Lie above & behind the promontory, in the
bottom of a depression which varies in depth
depending on the position of the Facial nerve
superiorly and the promontory inferiorly
 Connect the tympanic cavity with the vestibule
 The opening is closed in life by the footplate
stapes and its surrounding annular ligament.
 Kidney shape
 The long axis of the fenestra vestibuli is horizontal
 The size of the oval window varies according to the
size of footplate but on an average it is 3.25mm
long & 1.75 mm wide
The round window (fenestra cochlea):
Round window niche:
 Vestibule that leads to the round window.
 Below and a little behind the oval window niche
from which it is separated by a posterior extension of the
promontory called the subiculum.
 The entrance to this vestibule (the round window
niche) is usually triangular in shape, with
anterior, posteriosuperior and posterioinferior
walls, The later 2 meet Posteriorly and lead to the
sinus tympani
Bounderies of the vestibule:
 The medial lip (subiculum of the promontory):
posterior extension of the promontory which
separates it from the oval window.
 occasionally, another ridge of bone (the
ponticulus) runs above the subiculum & runs to
the pyramid on the post wall of the cavity
 The lateral lip is created by the posterior margin
of the promontory.
The round window membrane :
 The round window is closed in life by round
window membrane (secondary tympanic
membrane).
 Out of sight, obscured by the overhanging edge
of the promontory forming the niche and the
mucosal folds within it
 almost oval in shape, lies in right angle to the
plane of the stapes footplate, its dimensions=
1.9*2.3 mm
 it curves toward the scala tympani of the basal
coil of cochlea= concave when viewed from
middle ear
 appears to be divided by transverse thickening into anterior & posterior portions
 The ampulla of the posterior semicircular canal is the closest vestibular structure to this
membrane.
 The nerve supplying the ampulla of the posterior semicirular canal (singular nerve) lies close to it.
So The secondary tympanic membrane forms a landmark for the position of the singular nerve.
This is useful during surgical procedures like singular neurectomy for treatment of intractable
vertigo.
 Oval window Round window
Plane Sagittal Transverse
Orientation Facing inferior post lateral
Relation to the promontory Posterior superior Poaterio-inferior
Relation to perilymphatic duct Sacla vestibule Sacla tympani
C- Two prominences in the medial wall:
1. the lateral semicircular canal:
 The most superior in the medial wall
 Major feature of the posterior portion of the
epitympanum.
 Land Mark: It is used as a land mark of the
epitympanum from which you start reading the CT
temporal
 The dome of the lateral semicircular canal above,
posterior & extends a little lateral to the facial canal
 In well pneumatized mastoid bone the labyrinthine
over the superior canal can be very prominent,
running in Right angle to the lateral semicircular canal
& joining it anteriorly at a swelling which houses the
ampullae of the two canals
 In front and a little below this, above the
cochleariformis process, may be a slight swelling
corresponding to the geniculate ganglion with the
bony canal of the greater superficial petrosal nerve running for short distance anteriorly
In cortical mastoidectomy the triangular relationship between the facial canal, lateral semicircular
canal & short process of the incus is very helpful
2. The facial canal (fallopian canal):
 Lies above the promontory and oval window in an anteroposterior direction
 Behind the fenestra vestibuli, the facial nerve turns inferiorly to begin its descent in the
posterior wall of the tympani cavity, also superior petrosal artery travels in it
 Region above the level of the facial nerve canal forms the medial wall of the epitympanum/
attic.
Medial wall outline:
A- promontory
B- widows: oval + round
C- Canals: lateral semicircular canal + tympanic/horizontal segment
of the facial nerve
D- cochleariformis process +/- sup semicircular canal, ampulla of the
superior & lateral canal geniculate gangilion, greater petrosal
The sequence of medial prominence from superior to inferior:
 prominence of the lateral semicircular canal
 prominence of the facial canal
 promontory
The most anterior structure in the medial wall is:
 cochleariformis process
The oval window & round window niche relation to the
promontory:
 oval window lies posterior superior to the promontory
 round window lies posterior inferior to the promontory
6- Posterior wall
 Wider above than below
1. aditus ad antrum:
o large irregular opening
o in the upper part of the medial wall
o leads back from the posterior epitympanum into the mastoid antrum
o lateral semicircular canal form the floor of the antrum
o Mastoid antrum lies above the middle ear cavity & about 2 mm deep
2. Fossa incudis:
o Small depression below the aditus
o Houses the short process of the incus and its suspensory ligament
o Forms a land mark for:
1- lateral semicircular canal which lies medial to it
2- facial nerve which lies inferiomedial to it
3. Opening of the chorda tympani nerve
4. Pyramid:
o Small hollow conical projections
o Lays below the fossa incudis & medial to the opening of the chorda tympani
nerve
o It’s apex pointing anteriorly
o Houses the stapidus muscle and tendon, which inserts into the posterior
aspect of the head of stapes
o The canal within the pyramid curves downward & backwards to join the
descending portion of the facial nerve canal
o The vertical part of the facial nerve divides the posterior wall of the tympanic
cavity into 2 recesses:
a- facial recess (suprapyramidal recess) (lateral to facial nerve):
Aerated extension posterior superior portion of the middle ear
cavity
 Boundaries:
o Posterio-Medial: Facial nerve + pyramid
o Anterio-Lateral: tympanic annulus + chorda tympani
o Superior: fossa incudis (near the short process of incus)
 It is shallower lower down where the facial canal forms only
slight prominence over the posterior wall
 chorda tympani nerve Runs obliquely through the wall between
the facial nerve and the annulus. Chorda tympani always run
medial to the tympanic membrane.
 Drilling in this area between the facial nerve and annulus in the
angle formed by the chorda tympani nerve leads into the middle
ear cavity with ability to keep the tympanic membrane intact.
This surgical approach to the middle ear cavity is known as facial
recess approach.
 This approach can be used for posterior tympanotomy
 site for hidden choleasteatoma
b- sinus tympani (medial to facial nerve)
 The largest sinus, Inferiomedial, Infrapyramidal
 deep to facial nerve & promontary
 posterior extension of the mesotympanum
 extension of the mesotympanuum can be very extensive making it the most inaccessible part of
the middle ear cavity & mastoid, choleasteatoma in this region is very difficult to eradicate
 The extension into the mastoid may reach 9mm when measured from the pyramidal process
 The medial wall of the sinus is continuous with the posterior part of the medial wall of the tympanic
cavity in which it is related to the oval window, round window, promontory, subiculum
 Sinus tympani lies between the ponticulus (superiorly) and subiculum (inferior)
 Subiculum: ridge of bone originating from the promontory that separates the round window niche
(which is inferior to it) from the sinus tympani.
 Ponticulus: bony ridge originating from the promontory, connecting the promontory to the pyramid
which separates the oval window (which is superior to it) from the sinus tympani.
 So subiculum & ponticulus forms 3 depressions in the posterior part of the medial wall
 Round window lies inferior to subiculum & inferio-posterior to the promontory
 Superior inferior: oval window ponticulus sinus tympani subiculumround window
 The sinus tympani is the worst way for access because:
1- medial to facial nerve
2- below the pyramid
3- posterior to intact stapes
 Retro-facial approach is impossible as the posterior semicircular canal obstructs the view
 Facial recess is superficial to the sinus tympani and separated from it by:
1- vertical part of facial canal
2- pyramidal process

Facial recess 2 nd genu of facial nerve

Superior lateral
Above pyramide Pyramid
Sinus tympani
Descending part of the facial Nerve Inferior medial
Below the pyramid
 Facial recess Sinus tympani
Relation to facial nerve Lateral medial
Relation to the pyramid Superior inferior
Posterior extension location Superior lateral Inferio-medial
Borders Post medial: facial nerve Between subiculum & ponticulus
Ant-lateral: chordytympani
Superior: fossa incudis (near the short process of incus)
The middle ear cavity is entered during combined approach tympanoplasty & cochlear implant via facial recess

Summary of Boundaries of the tympanic cavity:

o Roof: tegmen
o Floor: jugular wall and styloid prominence
o Posteriorly: mastoid, stapedius, pyramidal prominence
o Anteriorly: carotid wall, eustachian tube, canal for tensor
tympani
o Medially: labyrinthine wall
o Laterally: tympanic membrane, scutum (latero-superior).
Connections of the middle ear:
o Nasopharynx via: Eustachian tube
o Mastoid antrum via: aditus ad antrum
o Vestibule via: oval window
o Cochlea via: the round window
Summary of bone components of the ear:
o Anterior + floor + posterior wall of the external auditory canal =
tympanic plate
o Superior wall of external auditory canal = squamous part
o Tegmen tympani = squamous + petrous part
o Hypotympanum = tympanic plate
o Lateral wall = squamous + tympanic plate
o Anterior wall = petrous portion of internal carotid canal + ET + Tensor tympani muscle semi canal
Trautmann’s triangle
Triangle between:
 Anteriorly: ottic capsule (posterior semi-circular canal)
 Posteriorly: sigmoid sinus
 Superiorly: dura containg superficial petrosal vein
Or it is the triangle between:
 Solid angle
 Sigmoidal sinus
 Sinuodural angle
This triangle is important in mastoidectomy
Part of the bony plate of the posterior cranial fossa
Clinical application:
1. Potential weak spot through which infections of temporal
bone may traverse and affect cerebellum.
2. Extra dural abscess involving the posterior cranial fossa is
also possible when thin bone (post semi-circular canal) in
this triangle gets breached in infections /cholesteatoma
involving mastoid cavity.
3. Land mark for entry into the posterior cranial fossa: Since
bone in this area is rather thin it can be drilled out to enter
into the posterior cranial fossa. This can be used as an
approach to posterior cranial fossa lesions.
Citelli's angle (sinodural angle) 8:

 It is located between the dura of the sigmoid sinus

and the middle fossa dura plate.
 Important landmark in the mastoidectomy
 Others consider the superior side of Trautmann's
triangle to be Citelli's angle.
Solid angle:
It is the place where the three semicirculat canals meet.
 The contents of the tympanic cavity

1- Ossicles: Malleus, Incus, Stapes (See ossicle page)

2- muscles: tensor tympani muscle, Stapedius muscle
3- Nerves: chorda tympani, Tympanic plexus
Stapedius muscle:
o Origin: the wall of the conical cavity within the
pyramid + downward curved continuation of the
canal in front of the descending part of the facial
nerve
o A slender tendon emerges from the apex of the
pyramid
o Insertion: posterior neck of the stapes
o Innervation: small branch of the facial nerve
o Action: pulls stapes posterior to the direction of the movement of the ossicular chain, attenuating low frequency
sounds
Tensor tympani muscle:
o Long slender muscle (2 cm long)
o Origin: the walls of the bony canal lying above the Eustachian tube, Greater wing of the sphenoid, Cartilaginous
portion of the Eustachian tube
o From its origin, the muscle passes backwards into the tympanic cavity where it lies on the medial wall, a little below
the level of the 1 st genu of facial nerve
o The bony coverage of the canal is often deficient in its tympanic segment where the muscle is replaced by slender
tendon
o Insertion: The tendon enters cochlearformis process, where it is held down by transverse tendon as it turns
through a right angle (90°) to pass laterally and inserts into the medial aspect of upper part of the handle of the
Malleus
o Innervation: trigeminal Nerve madibular branch medial pterygoid Nerve
o Action: display the handle of the malleus medially to decrease the compliance of tympanic membrane & stiffening
the ossicular chain attenuating the low frequency high intensity sounds
o Its contraction could be audible causing tinnitus
o Note: Cochearformis process is located in the anterior wall of the tympanic cavity
o Note: it is an Important land mark for the 1 st genu of the facial nerve
o The tensor tympani muscles fibers are continuous with fibers of tensor veli muscles
o the tensor tympani muscle is above the Eustachian tube
Tensor tympani muscle & Stapedius muscle decrease the dampen down the movement of the ossicles
Tensor tympani muscle: Medial pterygoid muscle
Stapedius muscle: Facial nerve
THE MUCOSA OF THE TYMPANIC CAVITY
o The middle ear mucosa is essentially mucus -secreting respiratory mucosa bearing cilia on its surface.
o mucociliary epithelium varies in normal middle ears, being more widespread in the young.
o Three distinct mucocilary pathways can be identified - epitympanic, promontorial and hypotympanic,
the latter being the largest. Each of these pathways coalesces at the tympanic orifice of the Eustachian
tube.
o The mucous membrane lines the bony walls of the tympanic cavity, and it extends to cover the ossicles
and their supporting ligaments.
o The mucosal folds also cover the tendons of the two middle ear muscles and carry the blood supply to
and from the contents of the tympanic cavity.
o These folds separate the middle ear space into compartments. As a result, the only route for ventilation
of the epitympanic space from the mesotympanum is via two small openings between the various
mucosal folds -the anterior and posterior isthmus tympani. Likewise, Prussak's space is found between
the pars flaccida and the neck of the malleus, bounded by the lateral malleolar fold.
Prussak's space:
Boundaries
o Anteriorly + Superiorly+ Posteriorly: by the lateral malleolar fold
o Medially: neck of malleus
o Laterally: pars flaccida (Shrapnell's membrane) (epitympanum area)
o Inferiorly: lateral process of malleus
Clinical application: can play an important role in the retention of keratin and subsequent development of cholesteatoma
Koerner's line/false bottom:
o Persistent petrosquamous suture line which separates The superfecial squamous air cells from the deep petrousal
air cells by the Korner septum
o This line separates the mastoid air cells into medial & lateral air cells
o The mastoid antrum lies deep to it
o The antrum cannot be located unless this septum is removed during mastoid exploration
 Temporal bone pneumonization
Only 9 % of the population has pneumonized petrous
portion of temporal bone (baily q p250)
The mastoid is completely pneumatized at the age of 2
years

Mucosal folds of middle ear

Located mainly in the attic area (most of them are related to the neck of the malleus)- May limit infection
1) Anterior malleal fold & Posterior malleal fold:
Both connected to:
1. Neck of the malleus
2. superior margin of the tympanic sulcus:
A. anterior malleal fold: anteriosuperior margin
B. posterior malleal fold: posteriosuperior margin

Note: Anterior & Posterior folds are the borders between:

1. epitympanum & mesotypanum: this is why they are attached to the superior margin of the tympanic sulcus
2. paras flaccida & paras tensa: because they are attached to the superior margin of the tympanic sulcus to
which paras tensa attaches.
3. 1st arch & 2nd arch derivatives: They are attached to the malleur neck which is the 1st arch derivative while
the manubrium is 2nd arch derivative

Pouch of von Tröltsch: lies between the malleal fold & segment of tympanic membrane anterio/post the handle of
malleus:
a- Anterior pouch of von Tröltsch:
Lies between the anterior malleal fold & the portion of the tympanic membrane anterior to the handle of the
malleus.
b- Posterior pouch of von Tröltsch:
Lies between the posterior malleal fold and the portion of the tympanic membrane posterior to the handle of the
malleus
2) Lateral medial mallear fold:
neck to neck in an arch form and to Shrapnell's membrane.

Ligaments
Malleus ligaments:
Stabilization direction Name of the ligament Site of insertion over the malleus Insertion on the bone
Superiorly Superior malleal ligament Head of the malleus Tegmen tympani
Anteriorly Anterior malleal ligament Neck of the malleus near the anterior process Sphenoid bone via
petrotympanic fissure
Medial Tensor tympani muscle tendon Upper part of manibrium cochleariformis
Lateral Lateral malleal ligament Neck of the malleus Tympanic notch
Incus:
superior incudal ligament: body to tegmen
posterior incudal ligament: short process to the floor of incudal fossa
stapes:
stapedial tendon: apex of the pyramidal process to the posterior aspect of the stapedial neck
annular ligament: footplate to the margin of vestibular fenestrum
How does the composition of gas in the middle ear differ from that of room air?
 Lower oxygen level and higher carbon dioxide and nitrogen levels.
 Ossicles
Forms semi-rigid bony chain for conducting sound
Embryology:
1. First Branchial Arch (Meckel’s cartilage):
 Malleus( head and neck ,anterior malleal ligament, short process)
 incus (body and short process)
2. Second Branchial Arch (Reichert’s cartilage):
 manubrium of the malleus
 long process and lenticular process of the incus
 stapes suprastructures* (except vestibular part of footplate)
3. process of folius (mesenchyme bone):
 anterior process of the malleus (so develops from the membranous bone)
4. otic capsule: the vestibular part of the foot plate ; the annular ligament of the
footplate
footplate supra-structure: head+ neck+ both cura + tympanic part of the foot plate
note: stapes footplate has dual origin (2nd arch + otic capsule)
Development of the incus & malleus:
 4th wk: the process of ossicles formation starts
 6th wk: malleus & incus forms a single mass
 8th wk: they are separated by the malleoinsudal Joint
 16thwk:
 adult size
 ossification starts:
 1st part to ossify :begins at the long process of the incus
 the following ossicular components never completely ossifies:
o manubrium of the malleus
o vestibular portion of the foot plate
 at 25 wk: the ossicles are adult size (endochondrial ossification is complete)
TH

Development of The muscles attached to the ossicles:

Tensor tempani muscle Stapedius muscle
Attachment site Upper part of the malleus handle Post surface of the stapes neck
Arch 1st arch 2nd arch
Nerve supply V3 Facial nerve
Malleus
 The most lateral ossicle
 Largest of the 3 ossicles (9mm)
Made of:
1- Head: It has a saddle shaped facet over the posteriomedial surface to articulate
with body of the incus by synovial joint
2- Neck of malleus:
 Connects the handle with the malleus
 Below the neck of malleus, the bone broadens to form anterior & lateral processes and the hadle of malleus
3- Lateral /short process:
 Create the malleolar prominence (Prominent landmark on Tympanic membrane)
 Attach to Pars Tensa of Tympanic membrane
4- Handle of Malleus (manubrium):
 Runs downward, medially and slightly backward
 Between the mucosal & fibrous layers of Tympanic membrane
1- Lower end: very closely attached to the membrane
2- Upper end: there is a fine web of mucosa separating the membrane from the
handle before it becomes adherent again at the lateral process.
 Tendon of tensor tympani muscle (V3) is inserted into the small projection over
the upper part of the handle of malleus
 Chorda tympani Nerve crosses theupper part medial surface of the malleus
handle, above the insertion of the tensor tympani muscle but below the neck of
malleus
 So amuptation of the head by cutting through the neck will leave the chorda tympani nerve & tensor
tympani muscle intact
 All parts of the ossicles are situated in the Mesotympanic except:
Incus:  Body & short process of the malleus
Made of:  Head & neck of the incus
1- Body:
 Has cartilage covered facet corresponding that on the head of Malleus
 Suspended by superior incudal ligament that is attached to the tegmen tympani
2- Short process:
 Project posteriorly from the body to lie in fossa incudius to which it is attached
by short suspensory ligament (posterior ligament)
 Land mark for: lateral semicircular canal (medially), facial nerve (inferiomedially)
3- Long process (crus):
 descends into the mesotympanum Behind and medial to handle of the Malleus (parallel)
4- Lenticular process: (is sometimes called the 4th ossicles because of its incomplete fusion with the long process)
 located at the tip of the long process, Medially directed
 Articulates with the head of the stapes via diarthrodial joints (ball and socket articulation)
Stapes: shortest bone of the body
1) Head
 points laterally, Has small cartilage covered depression (fovea) for articulation wi th lenticular process of Incus
 Stapedius muscle (VII) is inserted into the posterior part of the neck and the upper portion of the posterior Crus
2) Crura (anterior and posterior):
 Anterior Crus is thinner, shorter & less curved than posterior Crus (great variation in the shape of the 2 crura)
 Hollowed on its concave surface (for optimal strength and lightness)
3) Footplate (base):
 convex superior surface; Almost straight inferior surface; Curved anterior + posterior ends
 Average dimensions= 2.99 mm long + 1.41 mm wide
 Kidney shape (reniform)
 attaches to the bony margins of the oval window by the annular ligament forming a joint (syndesmosis)
 The long axis is almost horizontal with the posterior end being slightly lower than the anterior end
Footplate movement:
 Most movement at the footplate occurs at anterio-superior portion
 The safest site to create an opening in the footplate is the central portion
 The minimal distance between the central portion and: Utricle: 1.2mm, Saccule:1.4mm
Ossicular joints types:
 Malleal-insudal joint: diarthrodial joint Ossicle part Orientation
 Incudo-stapedial joint: diarthrodial joint Head of malleus Medioposterior
 Stapedial-labyrinthin joint: synodesmotic joint Manubrium Inferior-medial-posterior
Diarthrodial: Short process of incus Posterior
 freely mobile joint Long process of incus Inferior
 surrounded by capsule Lentiform process of incus Medial
 as knee joint Head of stapes Lateral
 slightly mobile joint
 Eustachian Tube
Embryology:
 Originatates from medial part of the tubotympanic
recess (ventral part of the 1st pharyngeal pouch)
 The length of the ET doubles from birth to adulthood
 Dynamic channel that connects the middle ear with the
Nasopharynx
 Directed:
 Runs downward from middle ear at 45 degree and is
turned forward and medially from the bony part in
the petrous portion of temporal bone
Adult length: 36 mm long
Consists of 2 unequal cones connected at their apices:
Bony portion (intratemporal):
 Upper posteriolateral 1/3 (12 mm)
 This portion is inactive and is always open
 Arise from the anterior wall of the tympanic cavity 4 mm
above the most inferior part of the floor of the cavity
 The diameter of the Ostium is 3-5 mm
 Widest at its oval tympanic end & tapes down to its junction with cartilaginous part of the tube
 In cross section the tube is triangular or rectangular with the horizontal diameter being greater
 It passes through the squamous and petrous portions of the temporal bone
 A thin plate of the bone forms the roof of ET, separating the tube from tensor tympani muscle
 The carotid canal lies medially and can impinge on the bony ET
The Isthmus :
 The Narrowest part of the tube (diameter =<0.5mm), Connect
the bony part to cartilaginous part of the Eustachian
 Lies just medial to the spine of the sphenoid bone
fibrocartilaginous portion:
 The attachment site for peritubal muscles
 lower anteriomedial 2/3 (24 mm) of the tube
 the active part of the Eustachian part (opens only during
swallowing/yawning/ forceful inflation)
 The apex of the cartilage is attached to the isthmus , where it overhangs
by the spine of the sphenoid.
 Attached to the skull base in scaphoid fossa a groove between the petrous part of the temporal bone and the greater wing of the
sphenoid) so it Lies:
 medial to: the foramen ovale and spinosum (which lie in line with the lateral pterygoid plate)
 lateral to: foramen lacerum and carotid canal
The Eustachian tube is an important land mark in the base of the skull anatomy
Along its lateral aspect, a straight line passes from the lateral pterygoid plate along the medial lip of the foramen ovale
to the foramen spinosum and into petrotympanic plate
It is a land mark for petrous Internal carotid artery
 Attached to the back of the medial pterygoid plate just above the pharyngobasilar fascia so it Opens:
 At the root of medial pterygoid plate, Ant to foramen ovale
 At its upper border, the cartilage is bent over to form an inverted J , thereby forming a longer medial cartilaginous lamina
 Thus, the back (posteriomedial) wall is composed of cartilage
 The front (anteriolateral) wall is composed of cartilage and fibrous tissue (due to deficiency in the cartilage that is bridge
by fibrous Connective tissue)

The tube opens in the Nasopharynx about 1.25 cm behind and slightly below the posterior end of the inferior turbinate

 The wider medial end protrudes into the Nasopharynx lying directly under the mucosa; it raises the mucosa to
form the tubal elevation (torus tubarius).
 The opening is almost triangular in shape, measuring 2-3 mm vertically and 3-4 mm horizontally and is
surrounded above and behind by the torus
 Just behind this elevation is a recess called the fossa of Rosenmüller, which is a common site of origin for
nasopharyngeal carcinoma and occult primary tumors.
 Pharyngobasilar fascia is attached to the undersurface of the Eustachian tube
 The lymphoid tissue is present around the tubal orifice & in the fossa of rosenmuller and may be prominent
during childhood
 Muscles attached to the Eustachian tube:
 Muscle arising from the posterior lower margin of the tubal orifice:
 Salpingopharyngeal muscle ( see pharyngeal wall: inner longitudinal muscle) –supplied by pharyngeal plexus
 Muscles arising from the undersurface of the Eustachian tube (para-tubal muscles):
 Levator palati muscle: arise medially (within the pharynx) –supplied by pharyngeal plexus
 Tensor palati muscle : arises laterally (outside the pharynx) – seperates the tube from the otic ganglion, the
mandibular nerve, the chorda tympani nerve and the middle meningeal artery
 Tensor tympani muscle
 Both Para-Tubal muscles are partly attached to the tube
 All muscles helps in opening the ET during the act of swallowing
 Tensor palati muscle (predominate dilator, the medial bundle of tensor veli palatine forms the dilator tubae)
Note:
 opening of the Eustachian tube is an active process that is done mainly by the tensor palate muscles
 Closing of the Eustachian tube is a passive process
Nerve supply Blood supply
Bony part Inferior tympanic plexus of glossopharyngeal Inferior tympanic branch of ascending pharyngeal artery
nerve (IX)
Cartilaginous part Nervous spinosum of Vc Middle menigeal artery
Ostium Pharyngeal branch of Pterygopalatine ganglion
Venous drainage: pharyngeal plexus
Lymphatic drainage: retropharyngeal LNs
Mucosal lining of the Eustachian tube:
The cartilaginous part of the tube is lined by respiratory mucosa containing goblet cells and mucous glands, with ciliated
epithelium on its floor (less towards ear): pseudostratified columnar ciliated, but toward the tympanic orifice it is lined
by ciliated cuboidal epithelium.
Lymphoid tissue within the tube: Tonsil of Gerlach
Functions:
 Ventilation: equalization of the pressure between the nasopharynx & middle ear
 Clearance: drainage of middle ear secretions
 Protection: from nasopharynx sound and secretion
The eustachian tube features in infants
 Length in infants is 1/2 of the adult's length = 18 mm.
 more horizontal
 Less angulated.
 The bony portion is relatively longer and wider in diameter, the nasopharyngeal end of the cartilaginous portion
lies more inferiorly.
 The adult length is reached at the age of 7 years
 Congenital absence of the Eustachian tube is associated with 1st arch syndrome especially treacher Collin
syndrome
 It opens by the action of the tensor palati (innervated by the third division of the V nerve) acting synergistically with
the levator veli palatini (innervated by the vagus).
 In children, the only muscle that works is the tensor palati because the levator palati is separated from the
eustachian tube cartilage by a considerable distance. Therefore, a cleft palate child with poor tensor palati function
is expected to have eustachian tube problems until the levator palati starts to function.
 In a normal individual, a pressure difference of 200 to 300 mm H2O is needed to produce airflow.
 It is easier to expel air from the middle ear than to get it into the middle ear (reason for more tubal problems when
descending in an airplane).
 A pressure of–30 mm Hg or lower for 15 minutes can produce a transudate in the middle ear. A pressure differential
of 90 mm Hg or greater may “lock” the Eustachian tube, preventing opening of the tube by the tensor palati muscle.
It is called the critical pressure difference.
 If the pressure differential exceeds 100 mm Hg, the tympanic membrane may rupture.
 A Valsalva maneuver generates about 20 to 40 mm Hg of pressure.
 The tympanis ostium of the tube is at the anterior wall of the tympanic cavity about 4mm above the most inferior
part of the floor of the cavity. The diameter of the ostium is 3 to 5 mm. The size of the pharyngeal ostium varies
from 3 to 10 mm in its vertical diameter and 2 to 5 mm in its horizontal diameter.