Ear Anatomy

Dr.Haytham ijla
Edited by : Ali Alhabash
ENT consultant
Jordanian board
Arab board
External ear : composed of auricle , external canal and the lateral wall of the
tympanic membrane.
Middle ear : Eustachian tube , middle ear cavity and mastoid ear cells.
Inner ear : cochlea and vestibular system (vestibule and semi-circular canal).
General compartments
• External
• Middle
• Inner
Function of the ear :
- Hearing
- Equilibrium.
External ear Function :
- Collection of the sound.
- Orientation of it.
- Cosmotic.
• Pinna (auricle) - Play a role in acoustic resonance.

• External auditory canal

- Auricle composed of hyaline cartilage.
- Lobe lack of cartilage : in case of
chondritis or peri-chondritis , all the auricle
will be involved except the lobe.
- But in case of cellulitis , all the auricle
will be involved including the lobe.
Auricle nerve supply
• Anterior part: Auriculotemporal
branch of mandibular branch of
trigeminal (V)
• Posterior and central part:
auricular branch of Vagus Nerve
(X), Facial nerve (VII)
• Posterior and inferior part: cervical
C2, C3

• Understanding innervation is
important to understand referred
ear pain - The most organ recieve
referred pain is the ear.
- The most common
source of referred pain is
the teeth and TMJ.
Hellix , anti-hellix and the other surface markers arise from
the 2nd brachial arch.
Tragus from 1st brachial arch.

Pinna embryology
• Condensation of the mesoderm of
the 1st and 2nd
pharyngeal/brachial arches occurs
to give rise to 6 hillocks of His
• 20th week: It has reached adult
shape ‫ ﺳﻧوات ﻋﺷﺎن ﻣﺎ ﯾﺻﯾر ﺗﻧﻣر ﻋﻠﻰ اﻟطﻔل‬6 ‫ﺑﻌض اﻟﺟراﺣﯾن ﺑﯾﺣﻛوا اﻧﮫ ﺗﻧﻌﻣل اﻟﻌﻣﻠﯾﺔ ﻋﻠﻰ‬
• 9 years: reach adult size (this is the
age of performing plastic surgery)
• Pre-auricular tag
• Remnant of one of the hillocks.
• Uncertain risk factor for hearing loss.
Pre-auricular sinus Sinus : external opening + blind ended
cavity (covered by epithelial line)
The difference between sinus and fistula
is that the fistula has 2 openings.

• Results from improper fusion of

the 1st & 2nd brachial arches
• May be associated with
branchio-oto-renal syndrome
• Surgery is only indicated when it is
complicated by recurrent infection or
abscesses Most patients come with no problems.
Life-long sinus.
 Hearing assessment :
For adults : pure tone audiogram or
Microtia Most common on
the right side.
tympanogram (assess middle ear
compliance).
Most common type of Microtia For children : auditory brain stem
response (ABR).

What i do for patient

with microtia or anortia :
- First , check if the
affected ear functioning or
not.
- Second , CT scan to
determine if the canal
completely or
incompletely absent.
- Third , check if the other
ear good functioning or
not.
Prominent ear deformity (bat ear)
Anti-hellix be flat (absent) in this anomaly.

• The most common auricular

deformity with an estimated
incidence of 0.5% to 15% in
newborns
• Management:
• Adult: Surgical correction
• Infant: Molding ranging from 2-12
weeks
 Pinna anatomy
• The skin
• Is adherent to the perichondrium anteriorly;
The auricle connected to the
Posteriorly the skin is less adherent external canal by lateral 1/3
• Thin: prone to frost bite cartilagenous part.
• Firmly attached to the yellow elastic cartilage:
auricular hematoma & chondritis is painful
• All pinna cartilage:
• Made of fibroelastic cartilage except the lobule & the
ant incisura (groove between the tragus & helix)
• The cartilage of the auricle is covered with
perichondrium from which it derives its supply of
nutrients, as cartilage itself is avascular. Clinical significance of
• Stripping the perichondrium from the cartilage, as incisura :
occurs following injuries that cause hematoma, can When i want to perform surgey in
the middle ear , one of the
lead to cartilage necrosis with crumpled up 'boxer's approaches is to make incision in
ears'. the incisura (end-aural)
• The lobule is made of fatty and fibrous tissue Another approaches :
- Post-auricular.
- From ear canal itself.
 Relapsing Polychondritis
• Auto-immune disease
• Pathophysiology: Chronic multi-systemic Inflammation of
types of cartilage and may involve other proteoglycan-rich
structures, such as the eyes and the cardiovascular
system. Recurrent attacks and bilateral
• Presentation:
• Acute phase: fever
• Sudden sever painful uniform swelling and erythema of the
auricle
• Chondritis rapidly develops and resolves in 5-10 days
• Spares: external auditory canal, lobule
• McAdam's signs: (diagnostic)
• Recurrent Auricular chondritis of both auricles (50%)
• Non-erosive polyarthritis (50%): hands and knees
• Nasal chondritis (15%)
• Inflammation of ocular structures(15%): conjunctivitis,
keratitis, scleritis/episcleritis and/or uveitis
• Chondritis of respiratory tract involving laryngeal and/ or
tracheal cartilage (15%)
• Cochlear and vestibular damage manifested by SNHL , tinnitus
and/or vertigo.
 Infections of the auricle Erysipelas :
• Erysipelas: Early systemic manifestation
Well-demarcated
• infection of the overlying skin Involve the epidermis
• Caused by group A beta hemolytic strep. Pinna not involved

• Rapid treatment with oral or IV antibiotic

• Cellulitis (infection of the soft tissue)
• Cellulitis of the ear typically results from a spreading otitis externa
or a penetrating injury.
• It is distinguished from peri-chondritis by the lack of induration
• Rapid treatment with Anti-staph oral or IV antibiotic
• Peri-chondiritis to chondritis :
• Represent infections of the auricular perichondrium or cartilage
• Infection involving the cartilage itself of the auricle & external
auditory canal.
• The lobule, which contains no cartilage, is spared
• Most common cause is Pseudomonas aeruginosa
Eczema
 External clue to OE (atopic, contact and sebrrheoic)
dermatitis
 Usual symptom is itching.
 On examination : erythaema, edema, flaking and
crusting.
 Metal sensitivity is the most common form of chronic
dermatitis involving the ear.
 Nickel is the most common offending metal.
 Women are affected more than men.
 Ear piercing is an important cause of primary
sensitization to nickel.
 Treatment :
- Local cleansing.
- Usage of corticosteroid and drying agents.
External auditory canal anatomy
• It is tortuous S shaped to protects • Auditory canal constrictions:
the Tympanic membrane • at the junction of the cartilaginous and
bony portions
• Dimensions: 24 mm in length from
• the isthmus
the concha to the Tympanic
membrane • The isthmus:
• The narrowest point of the EAC , 5 mm
• Bony part: 2/3 of the canal = 16 from the tympanic membrane, which is
mm taller more than wider (important note
• Cartilaginous part: 1/3 of the canal for foreign body retrieval)
= 8 mm For adults : posterior and superior displacement of
the auricle.
• Made of yellow elastic fibrocartilage For pediatric : posterior and inferior up to 3 years
because complete ossification for canal will happen
 In the pediatrics , otitis
media with effusion

Cerumen
• Consists of desquamated epithelium
mixed with the sebum produced from
sebaceous glands and the watery
secretions of modified apocrine sweat
glands (apopilo-sebaceous unit)
• Acidic: bacteriostatic + fungostatic
• Contains lysozymes which are
bactericidal
The outer 1/3 of the canal contain hair
appendages while the medial part doesn't
contain.

This waxy impaction can be and bad hyagiene

removed from the ear alone by
lateral migration (related to
chewing)
 Furunculosis
Any patient present to the clinic
One type of otitis externa.
Arises from the lateral 1/3
of skin appendages.
with a pain , disease of the external
ear should be on the top of the list.
• Furuncle is a localized abscess of
the apopilo-sebaceous unit
• Most common organism: S. aureus
• Treatment:
• Analgesia
• Anti-staphylococcal oral and topical
antibiotics should be administered.
• A fluctuant lesion should be incised
and drained under local anesthetic.
 Herpes Zoster Oticus
• Prodrome of otalgia, which may be severe.
• A vesicular eruption is seen in the canal and concha.
• Ultimately, these vesicles rupture and form crusts.
• Etiology:
• After primary infection (chickenpox), varicella-zoster virus is harbored in a latent state in sensory ganglia,
and reactivates with infection spreading along dermatomes.
• Harbored in the facial nerve VII and the vestibular ganglia of VIII
• A subgroup of patients manifest Ramsay Hunt syndrome: SNHL, tinnitus or vertigo or both, Palsy: lower motor
neuron palsy of the ipsilateral facial nerve
• 2nd commonest cause of lower facial nerve palsy after bell's palsy (9%)
• Prognosis for facial nerve recovery worse than Bell’s palsy (only 60% regain normal function, where as up 90%
regain normal function in bell’s palsy).
• Symptoms:
• Auricular pain: the 1st symptom to appear
• Vesicular Rash: location: concha, EAC, mucosa of the palate, anterior 2/3 of the tongue
• Treatment: Anatomy of facial nerve :
• acyclovir or valacyclovir Cerpellopontine angle to internal acoustic meatus to
medial wall of middle ear and give the 1st branch to
• High-dose steroids
greater petrosal and then geniculate ganglion and give
• Corneal protection the 2nd branch stapius muscle and the 3rd branch is
chorda tympani.
Otitis externa
• Acute otitis externa affects approximately 4-
8/1000 per year.
• Approximately 10% of the population during
their lifetime.
• Approximately 80% of cases occur in the
summer, particularly in warm, humid
environments.
• Other predisposing factors include anatomic
obstructions of the ear canal (e.g., stenosis,
impacted cerumen), hearing aid or ear plug
use, self-induced trauma (e.g., by cotton
swabs), and swimming.
• Systemic: Immune compromise, DM.
• Bacterial > Fungal (only 2%)
 Due to :
- Swimmers ear - sensory innervation.

Otitis externa - Main precursor

is trauma
- skin adherent to the canal
- no subcutaneous fat

• Most common micro-organism: Pseudomonus aeruginosa

• Second most common: Staph species (epidermidis + aureus)
• Presentation:
• Pain: due to high innervation, closely adherent skin
• May be severe and is exacerbated by manipulation of the auricle or the
Tragus sign tragus (due to cartilage continuity) Wet newspaper present
• Discharge: scanty, purulent. in fungal infection
• Aural fullness: due edema, discharge.
 Treatment :
1. Frequent aural toileting
2. Local antibiotic
3. Analgesics
4. Avoid water contact
• Causes of Treatment failure: Bacterial vs Fungal infection :
- Pain more severe in bacterial
• Skipping aural toilet infection.
• Inappropriate ear drops - In both , scanty discharge.
- Itching present in fungal infection
• Allergy to the ear drops more than bacterial.
• Underlying CSOM - Ear fullness more in fungal
• Superimposed fungal infection infection.
Fungal otitis externa (otomycosis)
Aspergillus
• Aspergillus accounts for 80-90 % of
cases with Candida being responsible
for the remaining 10-20%.
• Presentation: Itchiness, Pain, aural
fullness.
• In cases of resistant otomycosis, it is
essential to exclude fungal infection
elsewhere, including athelete's foot.
 Treatment :
Candida
1. Frequent aural toileting
2. Local antifungal
3. Avoid water contact
 High mortality rate > 30%

Malignant (Necrotizing) otitis externa

• Malignant Otitis Externa: otitis externa + osteomyelitis of
the tympanic plate of the temporal bone which may
extend to involve skull base
• Clinical Presentation:
• Persistent Otalgia more than 1 month
• Persistent Otorrhea with granulation tissue
• Persistent Otorrhea in the immunocompromised patients
(Diabetics with microangiopathy and cellular immune
dysfunction), HIV.
• Deep-seated aural pain (pain out of proportion to examination
findings). at night
• Most cases are caused by P. aeruginosa followed by S.
aureus
• Diagnostic:
• CT scan with IV contrast
• MRI
• Technetium-99m bone scanning
Malignant (Necrotizing) otitis externa
Treatment:
• Regular aural toilet
• Blood sugar control
• Correct immunodeficiency if possible
• Pain killer
• Infectious disease consult
• IV antibiotic for 6 weeks, with anti-
pseudomonal coverage
Prognosis:
• Mortality is 5-20%
 The Tympanic Membrane anatomy
• Height: 9-10 mm. Width: 8-9 mm.
Thickness: 0.1 mm.
• At the medial end of the EAC
• Forms the majority of the lateral wall of
the tympanic cavity.
• Slightly oval in shape
• 55 degrees angle with the floor of the
meatus
• The tympanic annulus: a
fibrocartilagenous ring on the
circumference of the TM. Lies in the
tympanic sulcus.
• Pars flaccida & pars tensa
Nerve supply
• Auriculotemporal nerve; V3 (Mandibular division); anterior half of
lateral surface
• Vagus nerve (CN X); Auricular branch [Arnold’s nerve] posterior half of
lateral surface.
• Glossopharyngeal nerve (CN IX); Tympanic branch [Jackobson’s nerve];
medial surface.
 Middle ear Anatomy
Fallopian canal
• Air containing cavity
• Lined with mucous membrane
• Containing auditory ossicles
• Lies in the petrous part of the temporal bone.
Surfaces:
• Roof: tegmen tympani (tegmental roof).
• Floor: jugular floor.
• Anterior wall (carotid wall): auditory tube & tube
for tensor tympani muscle.
• Posterior wall (mastoid wall): aditus to mastoid
antrum. pyramid : stapedius muscle
• Lateral wall (membranous wall): tympanic
membrane.
• Medial wall: facial nerve, promontory, fenestra
vestibuli, fenestra cochleae.
Middle ear Anatomy
Middle ear cleft contains:
1. Middle ear cavity
2. Attic
3. Eustachian tube
4. Aditus to mastoid antrum
5. Mastoid antrum
6. Mastoid air cells
 THE TYMPANIC CAVITY
Secutum : upper part of
the lateral wall of the
middle ear.

 Divided into three

compartments:
 Epitympanum (upper)
 Mesotympanum
(middle)
 Hypotympanum
(lower).
THE CONTENTS OF THE TYMPANIC CAVITY
 The tympanic cavity contains the
– Ossicles Mandibular nerve
– two muscles (tensor tympani,
Hyperacusia stapedius)

– the chorda tympani (facial nerve

branch)
– the tympanic plexus.
 Chorda tympani: branch of the facial nerve,
Carries taste sensation from the anterior
2/3 of the tongue & sends secretomotor
fibers to the submandibular gland
• Tensor tympani : is supplied by mandibular
nerve
• Stapedius muscle: is supplied by facial nerve
 Amplify the sound waves by : the

The ossicles difference in the surface area between the

tympanic membrane and the ossicles
(about 17-20 times)
Lever effect : amplify the sound about 1.3

• The ossicles are the

malleus, incus and stapes
that form a semi-rigid bony
chain for conducting sound.
• The malleus is the most
lateral and is attached to
the tympanic membrane,
whereas the stapes is
attached to the oval
window.
 The area where it opens in the

THE EUSTACHIAN TUBE Function of eustachian tube :

- equalize the pressure
nasopharynx called : fossa of
rosenmullar (most common area
where hidden tumor exist)
- drainage
 It links the middle ear with the nasopharynx. - protection
adult patient present with ear fullness
and with tympanogram , we find
Its the precursor of most there's otitis media with effusion , the
 Length = 36 mm (reached by the age of 7). middle ear diseases. next step is endoscope.

 It runs downwards from the middle ear at 45° and is

turned forwards and medially.
 Medial two-thirds cartilaginous part.
 Lateral one-third bony.
 Its narrowest portion is called the isthmus, where
the diameter is only 0.5 mm or less.
 It ventilates the middle ear and equalizes air
pressure on both sides of tympanic membrane
Inner ear anatomy
Osseous labyrinth:
• Located in the petrous portion of the temporal
bone
• Surrounds the membranous labyrinth
• Contains perilymph
• Connects to the middle ear via fenestra vestibule
& fenestra cochleae
• Divided into 3 parts:
• Vestibule
• Cochlea
• Semicircular canal
Membranous labyrinth:
• Located within the bony labyrinth
Utricle
Saccule
Semicircular ducts
Cochlear duct
• Contains endolymph
 Cochlea
The cochlea is coiled around the modiolus
The Modiolus: central axis of the cochlea
Contains:
• cochlear nerve
• Blood vessels
The cochlear coil extends “up” from its base to (2¾
X)
High frequency at the base, low frequency at the
tip.
The cochlea is divided by Reissner’s membrane and
the basilar membrane into 3 scalae(chambers):
• Scala vestibule Scala vestibule and scala
tympani communicated at
• Scala media (cochlear duct) helicotrema.
• Scala tympani
Organ of Corti/ spiral organ

Components of the organ

of Corti:
1. hair cells: inner + outer Connected to tentorial
membrane

2. support cells
(phalangeal cells
3. tectorial membrane –
acellular avascular
4. reticular lamina
Thanks