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 labrynith medially)

a-Auditory ossicles
b-Tendons of ossicles which attach them 2 muscles of middle ear
c-Tympanic segment of the Facial Nerve

2-Eustachian tube

3-Mastoid air cell system

Tympanic membrane

General description of the T.M

-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:

-forming an angle 55 with the floor

-placed obliquely forming acute angle with meatus anteriorly and obtuse one
posteriorly

Diameters:

Its longest diameter (posterior-superior: anterio-inferior) = 9-10 mm

Perpendicular to this is the shortest diameter = 8-9 mm

So TM is 9mm*9mm in size

1mm in thickness
DDX of blue tympanic membrane:
Surface area 85mm3
1. Glue ear
Effective vibrating area: 55mm3
2. Hemptympanum

3. High jugular bulb

4. Choleasterol granuloma

5.
Color:

Pearly white-gray,shiny, The light reflex is due to the concave position of the membrane
Red T.M may be seen in:
1-OM.
2-crying child
3-sneezing
4-nasal blowing
T.M layers:

The tympanic membrane has 3 layers:

1. Epithelial layer: squamous
2. Fibrous layer = lamina propria which is made of
a- Radiating fibrous layer
b- Circular fibrous layer
3. Mucosa layer.
Embryology of T.M 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 forms:

Arise from the neural crest mesenchyme

middle fibrous layer of the tympanic membrane

3. 1ST Pharyngeal Groove/meatal plug (Ectoderm) forms:

EAC and the outer epidermal layer of the T.M

The tympanic membrane 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 2 years of age

Umbo is the center point which divides T.M

The most prominent land mark of T.M is the handle of malleus (
directed in ant sup 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)

made of the squamous part of the temporal bone

where the paras falccida is attached to squamous part

deficient in the annulus ring

Ant & Post 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 continuation of the annular ring & set the border between paras flacida &tensa

-Paras flacida(shrapnel's membrane):

-Part of TM above the malleolar folds

-Does not have annular ring

-Triangular in shape

-small in size

-Paras Tensa :

Forms the rest of the T.M (below the malleolar folds)

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

P 3108+3109
 Paras flacida Paras Tensa

Above the malleolar folds Below it

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 probria is less Made of 3 layers

organized & orientation of collagen fibers less
organized.

More innervated Less innervated

Note:
Induostapedial joint, stapedius muscle, chora tympani could be seen through normal T.M

The T.M is lined with cuboidal & respiratory epithelium

Blood supply of the TM:

See blood supply of the middle ear

Nerve supply of the T.M

See nerve supply of the ear

Note:

Both the vascular supply & innervation are relatively spares in the middle part of the posterior half of
T.M
 Tympanic Cavity

Outline:

1-embryology

2-compartments of tympanic cavity

3-wall of the tympanic cavity

Embryology:
st nd
Middle ear cavity : 1 +2 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:

Anterioposterior (width): 15 mm
Vertical (Ht) : 15 mm
Transverse (depth):
Epitympanum : 6mm
Mesotympanum: 2mm
Hypotympanum: 4mm

In summary 15*15*5 mm in which 5mm represent the depth

Note:
-the narrowest area is the mesotympanum due to the medial orientation of handle of the malleus

-Epitympanum is separated from the meso + hypo tympanum By series of mucosal folds (see mucosal fold file)
-Meso+hypotympanum is continuous with each others

Borders of the epitympanum/attic:

Content of the epitympanum:
Superiorly Tegmen 1- head & neck of the malleus

Laterally squamosa (scutum) 2-body & short process of the incus

Medially lateral semicircular canal and VII nerve
3-lateral semicircular canal
Posteriorly Aditus
4-tympanic part of the fallopian
Inferiorly fossa incudis canal of facial nerve
Anteriorly zygomatic arch 5-aditus

Protympanum: ant to T.M retrotympanum: post to T.M contains facial recess+sinus stympani
Walls of tympanic cavity:
1-Lateral wall ( Membranous wall ):
Out line:

1-divisions of lateral wall

2-The 3 holes:

a-petrotympanic fissure

b-iter chordæ anterius (canal of Huguier ( ant canaliculus)

c-iter chordæ posterius

3- course of chorda tympani

1-divisions:

-Sup: bony lateral wall of the epitympanum= outer attic wall/scutum = Squamous bone

It is wedge shape in section

With sharp inf portion

Thin & easily eroded by cholesteatoma leaving a telltale sign on the CT scan

-Centrally: T.M

-INF: bony lateral wall of the Hypotympanum = tympanic bone

2-Holes:

a- Petrotympanic fissure ( Glaserian fissure ):

See temporal bone: tympanic plate+ lateral surface

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

3-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

It is continuous with tegmen antri

It contains the petrosquamous fissure

The fissure contains superior tympanic canaliculus through which the sup 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 z inferior tympanic canaliculus through which
tympanic branch of glossopharyngeal nerve gets into the tympanic cavity
 IX,X,XI are nerve that emerge through jugular foramen, so they are found beneath the floor of
the middle ear

Course of tympanic nerve;

See temporal bone: middle fossa surface of temporal bone: superior tympanic canaliculus
4-Anterior wall (Carotid wall)

-Ant wall is narrow as the medial & ant wall converge

- Elements:

The petrous portion of the bony Internal Carotid artery canal

Eustachian tube

Tensor tympani muscle & its semi-canal

1-Lower 1/3 of the Ant wall:

Consists of thin plate of bone that covering the carotid artery as it enters
the skull before it turns anteriorly

This plate is perforated by

-sup & inf caroticotympanic nerves carring sympathetic fibers to

tympanic plexus

- tympanic branch of the internal carotid artery

2-Middle 1/3 of the Ant wall:

Comprises the tympanic orifice of the Eustachian tube, which is oval & 5x2 mm in size.

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 ant wall:

Usually pneumonized, may house the epitympanic sinus

Epitympanic sinus: small niche ant to the ossicular heads, which can hide residual cholesteatoma in canal up surgery
5-Medial wall (labyrinthine wall):

The medial wall separates the middle ear from the inner ear and 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.
 Ant it inclines gently forward to merge with the ant wall, but is more
steeply sloped anteriorly
 Grooved because of branches of the tympanic plexus which lie under its
mucous membrane
 Sometimes the groove that z containing the tympanic branch of the
glossopharyngeal nerve is covered with canal which forming small canal

B-two fossa:

1- The oval vestibular window (fenestra vestibule):

 Lie above & behind the promontory, in the

bottom of depression which varies in depth
depending on the position of the Facial nerve
superiorly and the promontory inf
 Connect the tympanic cavity with the vestibule
 The opening is closed in life by the footplate
stapes and its surrounding annular ligament.
 Kideny 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

2- The round window( fenestra cochlea):

Round window niche:

 vestibule that leads to the round window.

 Below and behind the promontory and oval window, it faces inferiorly and a little posteriorly
 The entrance to this vestibule 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): post extension of the promontory which separates it from
the oval window.
 occationally, another ridge of bone( the ponticulus) runs above the subiculum & runs 2 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
 in right angle to the plane of the stapes footplate
 The diameter of the round window membrane is between 1.8 to 2.3 mm
 it curves toward the scala tympani of the basal coil of cochlea= concave when viewd from middle ear
 appears to divide by transverse thickening into ant & post thickening

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 Saggital transverse

orientation Facing inferior post lateral

Relation to the promontory Posterior superior Poaterio-inferior

Relation to perilymphatic duct Sacla vestibule Sacla tympani

 C- 2 prominences in the medial wall:

1-
the lateral semicircular canal:

 The most superior in the medial wall

 Major feature of the post portion of the epitympanum.
 Land Mark: It is used as a land mark of the epitympanum
from which u start reading the CT temporal
 The dome of the lateral semicircular canal above ,post &
extends a little lateral to the facial canal
 In well pneumatised mastoid bone the labyrinthine over the
sup canal can be very prominent, running in Rt angle to the
lateral semicircular canal & joining it ant 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 corresbonding
to the geniculate ganglion with the bony canal of the greater superficial petrosal nerve running for short
distance ant

In cortical mastoidectomy the triangular relationship

between the facial canal, lateral semicircular canal
& short process of the incus is very helpful

The facial canal:

 Lies above the promontory and vestibular window in an

anteroposterior direction
 Behind the fenestra vestibuli, the facial nerve turns inf to
begin its descent in the post wall of the tympani cavity
 The region above the level of the facial nerve canal
forms the medial wall of the epitympanum or attic.
 For more detail facial nerve; tympanic segment
Medial wall outline:
1-promontory

2-widows: oval + round

3-Canals: lateral semicircular canal+tympanic/horizantal segment of the facial nerve

4-cochleariformis process

+/- sup semicircular canal,ampulla of the sup & lateral canal geniculate gangilion, greater petrosal

 The sequence of medial prominence from superior to inferior:

1. prominence of the lateral semicircular canal

2. promience of the facial canal
3. 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

cochleariformis process: tensor tympani muscle

pyramidal process: stapedius muscle

Posterior wall

Wider above than below

1-aditus ad antrum:

large irregular opening

in the upper part of the medial wall

leads back from the post epitympanum into the mastoid antrum

lateral semicircular canal form the floor of the antrum

Mastoid antrum lies above the middle ear cavity & about 2mm deep

2-Fossa incudis:

Small depression below the aditus

House the short process of the incus and its suspensory

ligament

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:

Small hollow conical projections

Lays below the fossa incudis & medial to the opening

of the chorda tympani nerve

It’s apex pointing ant

House the stapidus muscle and tendon

The canal within the pyramid curves downward & post 2 join the descending portion of the facial
nerve canal

The vertical part of the facial nerve divid the post wall of the tympanic cavity into 2 recess:

a-facial recess ( lateral to facial nerve):

aerated extension posterior superior portion of the middle ear cavity

Boundaries:
 Posterio-Medial: Facial nerve + pyramid

Anterio-Lateral: chorda tympani nerve

Superior: fossa incudis (near the short process of incus)

It is shallower lower down where the facial canal forms only slight prominence over the post tympanic
wall

Running through the wall between these two structures with varying degrees of obliquity is the chorda
tympani nerve. Chorda tympani nerve 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 T.M intact. This surgical approach to the
middle ear cavity is known as facial recess approach.

This approach can be used for post tympanotomy

site for hidden choleasteatoma

6-sinus tympani (medial to facial nerve)

The largest sinus

Inferiomedial

Infrapyramidal

deep to facial nerve & promontary

posterior extension of the mesotympanum

this extension of the mesotympanuum can be very extensive making it the most inaccessiable 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 post part of the medial wall of tympanic cavity in
which it is related to the oval window, round window, promontory, subiculum

sinus tympani lies between the ponticulusly (superiorly) and subiculum (inferior)

subiculum: ridge of bone originating from the promontory that separates the round window niche
(which is inf 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 post part of the medial wall

Round window lies inferior to subiculum & inferio-posterior to the promontory

the sinus tympani is The worst way 4 access:

1-medial 2 facial nerve

2-below the pyramid

3-post to intact stapes

Retro-facial approach is impossible as the post 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 2nd genu of facial nerve

Superior lateral

Above pyramide
Pyramid

Sinus tympani

Inferior medial
Descending part of the facial N
Below the pyramid
 Facial recess Sinus tympani

Relation to facial nerve Lateral medial

Relation to the Superior inferior

pyramid
Post extension location Superior lateral Inferio-medial

Borders Post medial: facial nerve Between subiculum &

Ant-lateral: chordytympani ponticulus
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:

Roof: tegmen
Floor: jugular wall and styloid prominence
Posteriorly: mastoid, stapedius, pyramidal prominence
Anteriorly: carotid wall, eustachian tube, canal for tensor tympani
Medially: labyrinthine wall
Laterally: tympanic membrane, scutum (latero-superior).

Connections of the middle ear:

Nasopharynx via: Eustachian tube

Mastoid antrum via: aditus ad antrum

Vestibule via: oval window

 Cochlea via: the round window

Summary of bone components of the ear:

Ant+ floor + post wall of the external auditory canal = tympanic plate

Sup wall of external auditory canal = squamous part

Tegmen tympani = squamous + petrous part

Hypotympanum = tympanic plate

Lateral wall = squamous +tympanic plate

Ant wall = petrous portion of internal carotid canal + ET+ Tensotympani muscle semi canal

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:
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

A slender tendon emerges from the apex of the pyramid

Insertion: post neck of the stapes

Innervation: small branch of the facial nerve

Action: pulls the stapes post to the direction of the movement of the ossicular
chain, attenuating low frequency sounds

Tensor tympani muscle:

Long slender muscle (2 cm long)

Origin: the wall of the bony canal above the Eustachian tube

Greater wings of the sphenoid

Cartilaginous portion of the Eustachian tube

From its origin, the muscle passes backwards into the tympanic membrane where
it lies on the medial wall, a little below the level of the 1st genu of facial nerve

The bony coverage of the canal is often deficient in its tympanic segment where
the muscle is replaced by slender tendon

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

Innervation: trigeminal N : madibular branch: medial

pterygoid N

Action: display the handle of the malleus medially to decrease the compliance of T.M & stiffining the ossicular
chain attenuating the low frequency high intensity sounds

Its contraction could be audiable causing tinnitus

Note:
 Cochearformis process is located in the ant wall of the tympanic cavity

Important land mark for the 1st genu of the facial nerve

The tensor tympani muscles fibers are continuous with fibers of tensor veli muscles

he 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

Prussak's space:

Boundaries

 Medially: neck of malleus

 Laterally: pars flaccida

 Inferiorly: lateral process of malleus

 Superiorly: lateral mallear fold

Clinical application: site of choleastetoma formation

Koerner's line/false bottom:

Persistent petrosquamous suture line which seperates The

squamous air cells from the petrous air cells by the Koerner
septum

This line separates the mastoid air cells into medial & lateral
air cells

The mastoid antrum lies deep to it

The antrum can not 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 pneumotized at the age of 2 yr