Dissector Answers - Ear & Nasal Cavity

Learning Objectives:
Upon completion of this session, the student will be able to:
1. Define the three parts of the ear and the function of each part.
2. Describe each of the four walls of the middle ear cavity and identify deeper structures responsible for certain of their
features.
3. Describe the structure and actions of the tympanic membrane, the auditory ossicles, and the muscles of the middle ear.
4. Trace the course of the facial nerve through the temporal bone and give the origin, course, and functional components of
each of its intracranial branches.
5. Identify the auditory tube and explain its function.
6. Describe the maxillary nerve, its distribution and functional significance.
7. Describe the nasal cavity, its general morphology including walls, openings, nasal septum, conchae, meatuses, and its
general neurovascular supply.
8. List the paranasal sinuses and where each opens into the nasal cavity.
9. Describe the hard and soft palate.

Learning Objectives and Explanations:

1. Define the three parts of the ear, and the function of each part. (W&B pp 302-307; N92, N93, N94A, N94B, TG7-65, TG7-68A, TG768B, TG7-70)
The three parts of the ear are: external ear, middle ear and internal ear.
Functions:
External ear: is comprised of the oval auricle and the external acoustic meatus. The external acoustic meatus is a canal, approximately
2.5cm long, which leads from the auricle to the tympanic membrane. The auricle is the cartilaginous portion of the outer ear, attached to
the skull by ligaments and muscles, and covered by skin.
Middle ear: includes the tympanic cavity proper, the space directly internal to the tympanic membrane, and the epitympanic recess, the
space above it. The middle ear is a narrow cavity in the temporal bone where the energy of sound waves is converted into mechanical
energy through a chain of ossicles.
Internal ear: consists of the cochlea, for auditory sense, and a series of intercommunicating channels, the semicircular ducts, the utricle
and the saccule, for the sense of balance and position. The internal ear provides the essential organs of hearing and of equilibrium.

2. Describe each of the four walls of the middle ear cavity and identify the deeper structures responsible for certain of their features.
(N92, N94A, N94B, TG7-65, TG7-68A, TG7-68B)
Lateral wall: formed by the tympanic membrane which is set obliquely into the external acoustic meatus and faces outward, downward
and forward. The tympanic membrane has three layers: 1) the outer surface is the modified skin of the external meatus 2) the
intermediate layer is composed of radial and circular fibers which provide strength for the membrane and 3) the internal layer is
composed of mucous membrane. The tympanic membrane is one cm in diameter and has a fibrocartilaginous ring at the greater part of
its circumference which fixes it into the tympanic sulcus at the inner end of the external acoustic meatus. Where the membrane lacks
this ring, at its upper limit, the membrane is termed the membrana flaccida. Membrana flaccida is one sixth the area of the total
membrane and lacks the fibrous stratum which provides rigidity. The other five-sixths of the membrane, called the membrana tensa,
has this strengthening fibrous layer. The head of the malleus is attached to the fibrous layer on the inner surface of the membrane and
extends to a little below the center of the membrane. On N93, TG7-69A, TG7-69B, TG7-69C, TG7-69D, the head/handle of the malleus
appears to make a projection into the membrane along its course. The most indrawn point of the tympanic membrane is termed the
umbo. Additionally, the radial fibers which compose part of the intermediate layer of the tympanic membrane, diverge from the handle
of the malleus. The circular fibers are more at the edge of the membrane.
Medial wall: composed mainly of the promontory which is a bony eminence formed by the cochlea. The promontory is grooved because
of branches of the tympanic plexus which lie under its mucous membrane. There are two fossa in the medial wall, formed by the oval
vestibular window and the round cochlear window. The fenestra vestibuli (vestibular window or oval window) lies above the promontory,
and is an opening in the medial wall which is actually closed in life by the stapes. The fenestra cochlea, or round window, is below and
behind the promontory and is another opening which is closed in life, only this time by a membrane. This membrane yields to the surge
of fluid in the closed system of canals of the inner ear produced by the piston-like action of the footplate of the stapes at the vestibular
window. (WB 305) There are two prominences in the medial wall. One is the prominence of the facial canal and lies above the
vestibular window. This carries the facial nerve and sometimes the bone over the facial nerve is quite thin. The other prominence is the
prominence of the lateral semicircular canal and is the most superior in the lateral wall.
Anterior wall: divides the tympanic cavity and the carotid canal. The caroticotympanic nerves from the sympathetic plexus on the
internal carotid artery perforate the anterior wall and join up with the tympanic plexus. The anterior wall is incomplete because at its
superior edge are the openings for both the auditory tube and the semicanal for the tensor tympani muscle. These openings are
separated by the septum canalis musculotubarii, a very long name for a very thin shelf of bone.
Posterior wall: at the top of the posterior wall is the aditus ad antrum, the entrance to the mastoid antrum, which is the common cavity in
the mastoid bone into which the mastoid air cells open. Below the entrance of the mastoid antrum is the fossa incudis, the part of the
posterior wall which receives the short process of the incus. Also below the aditus ad antrum is the pyramidal eminence, a conical
elevation of bone which juts forward from the posterior wall in front of the vertical portion of the facial canal. The eminence is hollow and
its walls give rise to the stapedius muscle. A small branch of the facial nerve goes through the stapedius muscle at the base of the
pyramidal eminence.
[WB 305-306]
3. Describe the structure and actions of a) the tympanic membrane, b) the auditory ossicles, and c) the muscles of the middle ear.
(N93,N94A, N94B, N96, TG7-68, TG7-69A, TG7-69B, TG7-69C, TG7-69D)

a) Tympanic membrane: The structure of the tympanic membrane is described in some detail in the description of the lateral wall of the
middle ear cavity in Objective 2 above. Sound waves travel through the external acoustic meatus and set the tympanic membrane into
vibration.
b) Auditory ossicles: The auditory ossicles are three small bones, the malleus, the incus and the stapes. The three bones are united by
true joints and form a lever system which converts the vibrations in air impinging on the tympanic membrane into mechanical energy to
oscillate the footplate of the stapes in the vestibular window. This lever system causes a decrease in amplitude but an increase in
power of the piston-like action of the stapes. Their fixation in space depends on the attachments of the malleus to the tympanic
membrane and of the stapes in the oval window and on ligaments which suspend the bones from the walls of the cavity.
Malleus: Supposedly shaped like a hammer. Its handle, or manubrium, is attached firmly to the upper half of the tympanic membrane.
Its anterior process arises from the neck of the malleus and projects forward toward the petrotympanic fissure, to which it is connected
by ligamentous fibers. Its head projects upward into the epitympanic recess. The posterior aspect of its head receives the incus.
Incus: Supposedly resembles an anvil. Body of incus articulates with head of malleus. Short process of incus extends backward into
fossa incudis and is attached there by posterior incudal ligament. The long process of incus descends vertically, parallel to handle of
malleus and articulates with the stapes.
Stapes: Is supposed to and actually does kind of look like a stirrup. Its head is hollow and receives the end of the long process of the
incus. The neck of the stapes is where the stapedius muscle (described next) inserts. Two crura diverge from the neck (which continues
from the head) and then the crura are connected by a flattened oval plate, the base of the stirrup. The base of the stirrup is attached to
the margin of the vestibular window ( or oval window) by ligamentous fibers. Additionally, the articulation between the malleus and incus
is a synovial joint, a saddle-shaped articulation more specifically. And the articulation between the incus and the stapes is a synovial
joint and more specifically, a ball and socket joint.
c) Muscles of the middle ear: The tensor tympani muscle arises from the septum canalis musculotubarii (that very thin shelf of bone in
the anterior wall), the cartilaginous part of the auditory tube and part of the greater wing of the sphenoid bone. The muscle is 2 cm in
length and seems to lie on the septum. Its tendon wraps around the end of the septum (at the processus cochleariformis) to enter the
tympanic cavity. It inserts into the handle of the malleus at its root and acts to draw the handle of the malleus and the tympanic
membrane toward the medial wall. This action increases the tension and dampens the vibrations of the membrane. The tensor tympani
muscle is innervated by a twig of the medial pterygoid branch of the mandibular nerve. The fibers of the stapedius muscle arise from
the hollow pyramidal eminence (part of the posterior wall.) The central tendon of the stapedius muscle inserts in the posterior surface of
the neck of the stapes. The contraction of the stapedius muscle tilts the footplate of the stapes which tends to dampen its vibrations. It
therefore seems to serve a protective function. Remember from the description of the posterior wall that a small branch of the facial
nerve travels to the stapedius muscle at the base of the pyramidal eminence.
[Woodburne & Burkel 305 to 306]
4. Trace the course of the facial nerve through the temporal bone and give the origin, course, and functional components of each of its
intracranial branches. (N86, N94A, N94B, N97, N123, TG7-67, TG7-68A, TG7-68B, TG7-87)
The facial nerve is composed of two unequal roots; the larger motor root supplies all the muscles of facial expression, the smaller
root, the nervus intermedius, contains taste fibers from the anterior 2/3 of the tongue, fibers of general sensation from the external
acoustic meatus, parasympathetic and visceral afferent fibers for the submandibular, sublingual, lacrimal, nasal and palatine glands.

The two roots enter the internal acoustic meatus with the vestibulocochlear nerve (CN VIII), and divide into branches. Facial roots
pass lateralward in the meatus between the cochlea and semicircular canals and at the lateral end of the meatus they fuse and form the
geniculate ganglion. The geniculate ganglion is the sensory ganglion of the facial nerve. It is located at the abrupt bend taken by the
nerve as it turns from the acoustic meatus into the posteriorly directed facial canal.
Intracranial branches of the facial nerve: greater petrosal nerve, geniculotympanic nerve, and chorda tympani.
The greater petrosal nerve arises adjacent to the geniculate ganglion, it passes a short course in the bone, and emerges at the
hiatus of the canal for the greater petrosal nerve, into the middle cranial fossa. After passing forward between the dura mater and the
trigeminal ganglion, crossing the foramen lacerum lateral to the internal carotid artery, the greater petrosal nerve unites with the deep
petrosal nerve (a sympathetic branch of the internal carotid plexus) to form the nerve of the pterygoid canal. Function: the greater
petrosal nerve provides parasympathetic innervation of the lacrimal, nasal and palatine glands, and sensory from the soft palate.
The geniculotympanic branch passes from the ganglion to the lesser petrosal nerve (lesser petrosal nerve is a continuation of the
tympanic nerve, which is a branch of the glossopharyngeal).
The facial nerve then enters the bony facial canal distal to the geniculate ganglion, which passes posteriorly in the medial wall of
the tympanic cavity above the vestibular window, and then behind the window, turns nearly vertically downward along the posterior wall
of the cavity. The facial nerve emerges from the skull at the stylomastoid foramen. In its downward course along the posterior wall of
the cavity, the facial nerve gives off a branch to the stapedius muscle, a branch to the auricular branch of the vagus nerve, and the
chorda tympani.
The chorda tympani arises 5 mm proximal to the stylomastoid foramen, turns sharply upward and enters a canal in the bone which
takes it into the tympanic cavity. The chorda passes forward over the medial surface of the tympanic membrane and under its mucous
membrane, and leaves the tympanic cavity near the anterior border of the membrane. This anterior opening leads to the petrotympanic
fissure, which is how the chorda exits the skull. Function of chorda tympani: taste from the anterior 2/3 of the tongue, parasympathetic
innervation to the submandibular and sublingual glands. (W&B 309, 240, 287)
5. Identify the auditory tube and explain its function. (N55, N65, N67, N92, N94A, N94B, TG7-24, TG7-65, TG7-68A, TG7-68B)
The auditory (eustachian) tube is a communication between the nasal portion of the pharynx and the tympanic cavity that allows
for equalization of pressure on either side of the tympanic membrane. It is located in the anterior wall of the middle ear, and is
comprised of bone (1/3 of the length) at the tympanic end, and cartilage (2/3 of it) on the pharyngeal end. Through the mucous
membrane of the tube the pharyngeal mucosa is continuous with that lining the tympanic cavity and mastoid air cells, which allows
passage of infectious material to the middle ear and mastoid area (otitis media).
6. Describe the maxillary nerve, its distribution and functional significance. (N49, N122, TG7-81, TG7-83A, TG7-83B, TG7-83C)
The maxillary division of the trigeminal nerve (Cranial Nerve V 2) is entirely sensory. It supplies cutaneous innervation to the midface,
from lower eyelid to upper lip, via its infraorbital nerve and branches of its zygomatic nerve, the zygomaticofacial and

zygomaticotemporal. The zygomatic nerve and its zygomaticotemporal branch also relay the postganglionic parasympathetic fibers
from the pterygopalatine ganglion to the lacrimal gland. The maxillary division also supplies sensory innervation to the nasal cavity and
palate via the nasopalatine nerve (to nasal septum), posterior superior lateral nasal branches, posterior inferior lateral nasal branches
(from greater palatine), and the greater and lesser palatine nerves (to hard and soft palate respectively). These nerves also carry
postganglionic parasympathetic fibers from the pterygopalatine ganglion to the nasal and oral mucous glands. A small pharyngeal
branch of the maxillary division reaches the nasopharynx and sphenoid sinus. The maxillary division reaches all of the upper teeth and
gingiva via its posterior superior alveolar nerve (to molars) and its middle superior alveolar (premolars) and anterior superior alveolar
(canine and incisors) branches of the infraorbital nerve.
7. Describe the nasal cavity, its general morphology including walls, openings, nasal septum, conchae, meatuses, and its general
neurovascular supply. (N37A, N37B, N37C,N42A, N42B, N43, N44, N45, N46, N47, TG7-41, TG7-42, TG7-43A, TG7-43B, TG745AB, TG7-45CD)
Walls of the nasal cavity:

Roof - primarily the cribriform plate of the ethmoid bone.

Floor - hard palate formed by palatine processes of the maxillae and the horizontal processes of the palatine bones
Medial wall - nasal septum
Lateral wall - inferior, middle, and superior concha project from the lateral wall. Beneath each is a space or meatus inferior meatus, middle meatus, and superior meatus. Above and behind the superior concha is a sphenoethmoidal
recess.

Openings: nostrils or nares open onto the face, and choanae open posteriorly into the nasopharynx.
Nasal septum: anteriorly, the septum is cartilagenous; posteriorly, it is bony. The upper bony septum is formed by the perpendicular
plate of the ethmoid, which articulates below with the vomer.
Meatuses:

inferior meatus - receives the nasolacrimal duct (conducting tears from the orbit) anteriorly
middle meatus - the bulla ethmoidalis projects medially beneath the middle concha, with middle ethmoidal air cells
opening on its surface. Below the bulla, a curved groove, the hiatus semilunaris, receives the frontonasal duct from the
frontal sinus anterosuperiorly. Posteroinferiorly, it receives the maxillary sinus. Between these openings the anterior
ethmoidal air cells empty into the hiatus.
superior meatus - receives the posterior ethmoid air cells
sphenoethmoidal recess - receives the sphenoid sinus

Nerve supply: Olfactory epithelium, containing olfactory nerves, is found in and near the roof. Anteriorly, branches of the anterior
ethmoidal nerve from ophthalmic division of trigeminal nerve (CN V 1) distribute. Lateral wall - posterior superior and inferior lateral nasal
branches. Nasal septum - nasopalatine nerve.

Blood vessels: Sphenopalatine artery supplies most of the nasal cavity via its posterior lateral nasal branches and its septal branches.
Branches of the anterior and posterior ethmoidal arteries also reach the anterior and superior portions of the nasal cavity.
8. List the paranasal sinuses and where each opens into the nasal cavity. (N41A, N41B, N41C, N52, N53, TG7-43A, TG7-43B, TG744A, TG7-44BC)
Frontal sinus: middle meatus via hiatus semilunaris
Maxillary sinus: middle meatus via hiatus semilunaris
Ethmoid air cells (small air spaces within the ethmoid bone):

anterior ethmoid air cells - middle meatus via hiatus semilunaris

middle ethmoid air cells - middle meatus via bulla ethmoidalis
posterior ethmoid air cells - superior meatus

Sphenoid sinus: sphenoethmoidal recess

9. Describe the hard and soft palate. (N63, N64A, N64B, TG7-23, TG7-24)
The hard palate is formed primarily by the palatine processes of the maxillary bones, with the horizontal processes of the palatine
bones forming the posterior third. The soft palate stretches posteriorly. It is a fibromuscular septum that can be moved to close off the
nasopharynx.

Questions and Answers:

10. Consider the structure and functions of conchae. (N37A, N37B, N37C, N70, TG7-22, TG7-43A, TG7-43B)
The concha are scroll-like in shape. Also called turbinates, they cause inspired air to be turbulent so as to facilitate the warming and
humidifying action of the mucous membrane, whose surface area is increased by the conchae.
11. Consider drainage of sinuses and air cells. (N37A, N37B, N37C, N52, N53, TG7-43B, TG7-44A, TG7-44BC)
See above.
12. What is the primary function of the tensor veli palatini? (N68, N69, N72, TG7-24, TG7-65)
The most important function of tensor veli palatini is to open the auditory tube by pulling its lateral wall inferiorly. This flushes the middle
ear cavity with fresh air, thereby equalizing pressure within the middle ear.

Clinical Cases - Ear & Nasal Cavity

An eight year-old boy presents to his physician with a chief complaint of an earache, fever and some degree of hearing loss. The
patient's case history indicates a recent viral upper respiratory tract infection. During physical exam,
the physician examines the
patient with an otoscope and notes an inflamed tympanic membrane that is bulging and opacified. Pneumatic otoscopy confirms the
presence of fluid in the middle ear. The patient is diagnosed with acute otitis media,
an infection of the mucoperiosteal lining of
the middle ear which has a relatively sudden onset and short duration.
Questions to consider:
1. A major factor in the pathogenesis of otitis media is dysfunction of the auditory (Eustachian) tubes. What is the function of the
auditory tubes?
The normal function of the auditory (old term: eustachian) tubes is to regulate pressure within the middle ear (ventilation), protect
the middle ear by preventing nasopharyngeal aspiration (protection), and allow clearance of secretions from the middle ear
(drainage).
2. If the ventilatory function of the auditory (eustachian) tubes is compromised, air is resorbed by the middle ear and a negative
pressure, anaerobic environment is created in the middle ear. The negative pressure may result in aspiration of nasopharyngeal
contents, including bacteria, into the middle ear that then proliferate to cause otitis media. Which muscle opens the auditory
(Eustachian) tube?
The tensor veli palatini muscle opens the auditory tube during swallowing by pulling on the cartilage of its lateral wall.
3. What surgical procedures may be used to treat the fluid build-up in the middle ear?
Surgical alleviation of fluid build-up includes myringotomy. This procedure involves making a curvilinear incision
in the
inferior portion of the tympanic membrane below the malleus handle. The incision should be long enough to allow good drainage,
the fluid may be gently suctioned. Post-operationally, cotton should be inserted into the patient's ear to absorb the drainage.
In the case of the patient with recurrent or chronic (fluid build-up lasting for more than 2 or 3 months) otitis media, the patient
may have a tympanostomy tube
inserted. In the long-run, the tube equalizes middle ear pressure by preventing the early
closure of the initial myringotomy opening thus artificially maintaining proper middle ear ventilation.
4. What are possible complications to otitis media?

Possible intratemporal complications due to otitis media include mastoiditis, an invasive infection of the mastoid air cells which is
frequently accompanied by abscess formation and invasion into surrounding bone. It is generally associated with otitis media.
Possible intracranial complications to otitis media include brain abscess, extradural abscess, subdural abscess, and meningitis.
5. What would an infection of the outer ear be called? What anatomical features/structures protect the ear from injury?
An infection of the outer ear is called otitis externa. Features and structures that protect the ear include: a small opening to the
auditory canal, the narrow isthmus and upward orientation of the auditory canal, hair in the auditory canal, and the presence of
sebaceous and apocrine glands that produce the water-repellent cerumen (ear wax).

A 5-year-old girl was taken to the primary health care physician because she was having sore throat, high temperature and runny nose.
Symptoms started a couple of days ago and her mother reported that she also complained of pain in the right ear at night. The doctor
examined her tonsils and found them enlarged, and checked her ears with the otoscope and saw that both eardrums were congested
and looked reddish especially on the right. He recommended decongestant medication and analgesics and requested to see the girl
again a week later.
Questions to consider:
1. How would you explain the congestion of both eardrums?
The auditory (Eustachian) tube provides a passage for organisms to reach the middle ear from the nasal cavity. In
children the tube is more horizontal and shorter than in adults, and therefore the possibility of spread is higher. One of the
earliest signs of otitis media is congestion of the eardrum that may be seen easily with otoscope.
2. If the ear infection was not treated properly, what important anatomical structures are likely to be affected in the middle
ear?
Neglected otitis media may lead to rupture of the tympanic membrane and loss of hearing. Ossicles may be involved, and
that may lead to further deterioration of hearing. Infection may spread posteriorly to the mastoid air
cells causing mastoiditis, with possible spread to the posterior cranial fossa and infection of meninges.

A 12-year-old boy was admitted to the hospital complaining of a severe sore throat and bilateral earache. He had a history of
frequent infections of the palatine tonsils, which had all been treated successfully with antibiotics; however, the infections had become
progressively more severe and he had missed a considerable amount of school. This bout of tonsillitis was also treated with antibiotics
successfully, but the boy's physician suggested that a tonsillectomy be performed to eliminate the problem once and for all. The boy

was readmitted to the hospital for surgery two weeks after his most recent infection had cleared up. The surgery was proceeding well
when suddenly there was a massive amount of bleeding. After a short period, the surgeon was able to locate the bleeder and ligate it,
following which the wound was closed and the patient's recovery was uneventful.
Questions to consider:
1. Where is the palatine tonsil located? The lingual tonsil? The pharyngeal tonsil?
The palatine tonsil is a collection of lymphatic tissue found beneath the mucous membrane between the palatoglossal and
palatopharyngeal arches. The lingual and pharyngeal tonsils are also lymphatic tissue; the lingual tonsil is located on the
posterior aspect of the tongue and the pharyngeal tonsil, or adenoid, is found on the upper part of the posterior
pharyngeal wall.
2. What blood vessels are found near the palatine tonsil and may have been responsible for the bleeding?
The palatine tonsil is supplied by five arterial branches: the ascending palatine and tonsillar branches of the facial artery,
the palatine branch of the ascending pharyngeal artery, the dorsal lingual branch of the lingual artery, and the descending
palatine branch of the maxillary artery. The primary source of hemorrhage, however, is usually the external palatine vein.
The internal carotid artery is usually safe during tonsillectomy, but may be damaged if it is located unusually close to the
lateral side of the tonsil.
3. What nerves are at risk during a tonsillectomy?
The glossopharyngeal nerve accompanies the tonsillar artery on the lateral wall of the pharynx and is particularly
vulnerable during a tonsillectomy. In addition, a careless surgeon may damage the lingual nerve, which passes lateral to
the pharyngeal wall, just anterior to the tonsil.
4. What lymphatic structures are often secondarily affected in tonsillitis?
Tonsillitis of the palatine tonsil may spread to the lingual and pharyngeal tonsils, which are associated in a grouping
designated the tonsillar (Waldeyer's) ring. The tonsillar ring is assumed to have protective significance during ingestion.
The tonsils drain through the superior deep cervical lymph nodes, and thus these may also be affected. The
jugulodigastric (tonsillar) node, into which most tonsillar lymphatic vessels drain, is particularly vulnerable.
5. How do you explain the patient's complaint about pain in both ears?
The earache was due to spread of the infection causing swelling of the torus tubarius and subsequent closing of the
auditory tube. This forces the tympanic membrane to compensate for pressure changes due to altitude or temperature,

which may cause severe pain or even deafness. This condition, as well as otitis media, is commonly associated with
infection of the pharyngeal tonsil.
6. What is a quinsy?
A quinsy is a peritonsillar abscess in the loose connective tissue outside the capsule of the tonsil. It occurs when
microorganisms manage to escape from the capsule and infiltrate the infratonsillar cleft.
References:
Moore, Clinically Oriented Anatomy p. 1158-72; 1194, 1199.
W&B p. 235-41; 280-1.

Practice Quiz - Ear & Nasal Cavity

Below are written questions from previous quizzes and exams. Click here for a Practical Quiz - old format or Practical Quiz - new
format.
1. The entry of bacteria through which space could lead to an infection in the mastoid air cells:
Auditory (nasopharyngeal) tube
Cochlea
External acoustic meatus
Internal acoustic meatus
Sacculus
The correct answer is:

Auditory (nasopharyngeal) tube

The auditory (nasopharyngeal) tube is a connection between the nasal portion of the pharynx and the tympanic cavity that allows
pressure to equalize on either side of the tympanic membrane. It is located in the anterior wall of the middle ear and is comprised
of bone at the tympanic end and cartilage on the pharyngeal end. The pharyngeal mucosa is continuous with the lining of the
tympanic cavity and mastoid air cells. This allows infectious material to pass to the middle ear and mastoid area.
The cochlea is the organ of hearing that receives, interprets, and transmits sound via the vestibulocochlear nerve (CN VIII). The
external acoustic meatus is the opening in the temporal bone that allows sound waves to reach the tympanic membrane. The
internal acoustic meatus is the foramen in the temporal bone that allows the vestibulocochlear nerve and the facial nerve to pass
into the skull at the base of the brain. Finally, the sacculus is a fluid filled sac that is part of the balancing apparatus of the ear - it
is located in the vestibule of the ear.

2. Which structure is attached to the center of the tympanic membrane?

Foot plate of the stapes
Handle (manubrium) of the malleus
Long process of the incus
Tragus
Utricle

The correct answer is:

handle (manubrium) of the malleus

The handle of the malleus is attached to the center of the tympanic membrane. The head of the malleus then articulates with the
body of incus, and the long process of incus articulates with the head of stapes. The foot plate of stapes sits in the oval window. Take a
look at Netter Plate 88 for a better idea of how these ossicles connect!
The tragus is a cartilagenous structure of the external ear, located anterior to the external auditory meatus. It is hard to describe
the tragus; it is labeled in the upper left picture of Netter Plate 88. The utricle is a part of the balancing apparatus of the ear--like the
saccule, it is a fluid filled sac in the vestibule.
3. A 45-year old woman with recurrent left middle ear infection (otitis media) complained of partial dryness of her mouth to her ENT
surgeon. Taste sensation and hearing were normal. After a thorough clinical examination at the hospital, the doctor concluded
that the infection must have spread to a component of the glossopharyngeal nerve (CN IX) that supplies the parotid gland. On
which of the following walls of the middle ear is this nerve component located?
Anterior
Lateral
Medial
Posterior
Roof

The correct answer is:

Medial

To answer this question, you first need to identify the component of the glossopharyngeal nerve that innervates parotid gland.
Remember--preganglionic parasympathetic fibers from CN IX are arriving at the otic ganglion via the lesser petrosal nerve and
synapsing in the ganglion; the postganglionic fibers then travel on the auriculotemporal nerve (V 3) and innervate the parotid gland. So,
the lesser petrosal nerve, or fibers that create the lesser petrosal nerve, must have been injured. Now, you just need to think about
where these fibers are in the ear.
These fibers from the glossopharyngeal nerve are covering the promontory on the medial wall of the ear. The tympanic nerve is a
branch of the glossopharyngeal nerve that carries the preganglionic parasympathetic fibers that will eventually travel to the otic
ganglion. The tympanic nerve lies on the promontory and creates the tympanic plexus, which gives rise to the lesser petrosal nerve.
Given the clinical presentation, the patient must have an infection in the tympanic nerve, tympanic plexus or lesser petrosal nerve. And,
all of these nerves are associated with the medial wall of the middle ear.
What are the important associations with the other walls of the ear? The lateral wall is formed by the tympanic membrane, and the
chorda tympani courses across this membrane. The anterior wall contains the opening of the auditory tube and a semicanal for tensor
tympani. The posterior wall of the ear has the aditus ad antrum, which is the entrance to the mastoid antrum and air cells. The facial
nerve (VII) and a small branch of the facial nerve which innervates stapedius are found on the posterior wall.
4. A 3-year-old girl ruptured her eardrum when she inserted a pencil into her ear. Her mother took her to the emergency
department after noticing that the child was crying and complaining of pain in her ear with a few drops of blood in the external
auditory meatus. The attending doctor examined the child for possible injury to a nerve that runs across the eardrum. The most
likely nerve to be injured is the:
Auricular branch of the vagus
Chorda tympani
Glossopharyngeal (CN IX)
Lesser petrosal
Trigeminal (CN V)

The correct answer is:

chorda tympani

When this girl ruptured her eardrum, she damaged the tympanic membrane. So, you need to think about the nerve and structures
that are associated with the tympanic membrane (ie, on the lateral wall of the middle ear). Chorda tympani lies across the tympanic
membrane, so it's possible that this nerve was injured by the pencil.
The auricular branch of the vagus nerve is a small branch of the vagus that supplies afferent sensory innervation to the external
acoustic meatus. This nerve is not close to the tympanic membrane The glossopharyngeal nerve and lesser petrosal nerve are
associated with the promontory of the ear, which is on the medial wall of the middle ear. The trigeminal nerve is not close to the ear and
would not be damaged by the injury.
What might happen if chorda tympani was injured? No taste sensation to the anterior 2/3 of the tongue and no secretomotor
innervation to the sublingual and submandibular glands!
5. An elderly patient with chronic otitis media (middle ear infection) might have all the following complications EXCEPT:
Inabilty to chew food due to injury to the mandibular division of the trigeminal nerve (CN V)
Loss of taste in the anterior part of the tongue due to injury to the chorda tympani nerve
Mastoiditis
Paralysis of facial muscles due an injury to the facial nerve (CN VII)
Some degree of deafness due to damage to the ossicles

The correct answer is:

Inability to chew food due to injury to the mandibular division of the trigeminal nerve (CN V3)

The mandibular division of the trigeminal nerve is not associated with the middle ear. So, chronic ear infections should have no
effect on this structure. All of the other answers refer to structures that are closely associated with the middle ear--a chronic infection in
this area could cause any of the other listed complications. The chorda tympani nerve travels along the lateral wall of the middle ear,
running across the tympanic membrane. It could be damaged by chronic infection and inflammation. Remember--chorda tympani
provides secretomotor innervation to the submandibular and sublingual glands and taste sensation to the anterior 2/3 of the tongue.
Mastoiditis is an infection of the mastoid air cells. Since these air cells connect to the middle ear through the aditus ad antrum on the
posterior wall, an infection in the middle ear could easily spread to the mastoid air cells. The facial nerve is also located on the posterior
wall of the middle ear, so it could also be damaged by the chronic infection. Finally, a chronic infection can damage the three ossicles
and lead to deafness.

6. A patient with a facial nerve paralysis suffers from inability to dampen loud noises (hyperacusis) due to denervation of which
muscle?
Posterior belly of digastric
Stapedius
Tensor tympani
Stylohyoid muscle

The correct answer is:

Stapedius

Stapedius is a small muscle in the ear innervated by the facial nerve. It dampens large vibrations of the stapes and the tympanic
membrane; this allows the ear to diminish loud noises. If the facial nerve is paralyzed (as seen with Bell's palsy), the nerve to stapedius
is lost, and the ear cannot lessen the vibrations of stapedius. This causes hyperacusis.
The digastric muscle elevates the hyoid bone and depresses the mandible. Its posterior belly is innervated by the facial nerve, so
this muscle would be paralyzed if the facial nerve was damaged. However, the posterior belly of the digastric is not involved with the
ear. Tensor tympani is a muscle in the ear with a similar function to stapedius--it dampens vibrations of the tympanic membrane. This
muscle is innervated by the mandibular branch of the trigeminal nerve (V3)--not the facial nerve. Stylohyoid elevates and retracts the
hyoid bone. It's innervated by the facial nerve, but it does not have any effect on the ear.
7. All of the following are true about the middle ear EXCEPT:
The joints between ossicles are synovial
The chorda tympani nerve is related to the lateral wall
The facial nerve passes in a canal situated in the medial and anterior walls
The auditory tube connects the nasopharynx with the anterior wall
Its mucous membrane is supplied by the glossopharyngeal nerve (CN IX)

The correct answer is:

The facial nerve passes in a canal situated in the medial and anterior wall.

The facial nerve passes in a canal situated in the posterior and medial walls of the middle ear. It is not associated with the anterior
wall. The other 4 statements are true. The ossicles articulate with each other at synovial joints. The chorda tympani is a branch of the
facial nerve that is related to the lateral wall of the middle ear, near the tympanic membrane. It passes between the malleus and incus.
The auditory tube is found in the anterior wall--it is a path of communication between the nasal portion of the pharynx and the tympanic
cavity that allows pressure to equalize on either side of the tympanic membrane. Finally, the mucous membrane of the middle ear is
supplied by branches of the tympanic plexus, which is formed by the tympanic branch of the glossopharyngeal nerve.
8. A patient has sustained a fracture to the base of the skull. Thorough examination concluded that the right greater petrosal nerve,
among other structures, has been injured. This conclusion was based on which of the patient's signs:
Partial dryness of the mouth due to lack of salivary secretions from the submandibular and sublingual glands
Partial dryness of the mouth due to lack of salivary secretions from the parotid gland
Dryness of the right cornea due to lack of lacrimal secretion
Loss of taste sensation from the right anterior 2/3rd of the tongue
Loss of general sensation from the right anterior 2/3rd of the tongue

The correct answer is:

Dryness of the right cornea due to lack of lacrimal secretion.

The greater petrosal nerve is a branch of the facial nerve that arises adjacent to the geniculate ganglion. It carries preganglionic
parasympathetic fibers to the pterygopalatine ganglion. The fibers synapse in this ganglion, and the postsynaptic parasympathetic
fibers go on to innervate the lacrimal gland, mucous glands of the palate, and the mucous glands of the nasal cavity. So, if the greater
petrosal nerve was damaged, the presynaptic parasympathetic fibers would be lost, and the lacrimal gland would not function properly.
The sublingual and submandibular glands are innervated by the chorda tympani, which brings preganglionic parasympathetic
fibers to the submandibular ganglion. The chorda tympani also provides taste sensation to the anterior 2/3 of the tongue. Although the
chorda tympani, like the greater petrosal nerve, is a branch of the facial nerve, the chorda tympani never runs with the greater petrosal
nerve. So, injuring the greater petrosal nerve would not harm the chorda tympani. The parotid gland is innervated by the lesser petrosal
nerve, a branch of the glossopharyngeal nerve (CN IX). The fibers from this nerve go to the otic ganglion, synapse there, and then
continue on to the parotid gland via the auriculotemporal nerve. Finally, general sensation to the anterior 2/3 of the tongue is carried by
the lingual nerve, a branch of V3.

9. The location of the otic ganglion is in the:

Pterygopalatine fossa
Internal ear
Infratemporal fossa
Middle cranial fossa
None of the above

The correct answer is:

Infratemporal fossa

The otic ganglion is in the infratemporal fossa, just inferior to the foramen ovale, medial to the mandibular nerve and posterior to
the medial pterygoid muscle. It is the ganglion where fibers from the lesser petrosal nerve synape. The postsynaptic parasympathetic
fibers from the otic ganglion are secretory to the parotid gland--they reach the parotid gland by the auriculotemporal nerve. The
pterygopalatine fossa is a small pyramidal space inferior to the apex of the orbit. It lies between the pterygoid process of the sphenoid
bone posteriorly and the posterior aspect of the maxilla anteriorly. It contains the terminal part of the maxillary artery, the maxillary
nerve, and the pterygopalatine ganglion. The internal ear is buried in the petrous part of the temporal bone--it contains the
vestibulocochlear organ which allows for the reception of sound and maintaining balance.
Finally, the middle cranial fossa is the large depression in the cranial base, formed by the greater wings of the sphenoid and
squamous parts of the temporal bones laterally and the petrous parts of the temporal bones posteriorly. It contains four important
foramina: the superior orbital fissure, which transmits the ophthalmic veins and the nerves entering the orbit (CN III, CN IV, CN V1 and
CN VI); the foramen rotundum which transmits CN V2; the foramen ovale, which transmits CN V3, and the foramen spinosum, which
transmits the middle meningeal vessels.

10. A patient complains of loss of hearing in the right ear. Examination reveals ankylosis (otosclerosis) of the footplate of the stapes
to the surrounding bone. Which part of the bony labyrinth is involved?
Aditus ad antrum
Cochlear (round) window
Cochlear duct
Internal acoustic meatus
Vestibular (oval) window

The correct answer is:

Vestibular (Oval) Window

The oval window is a fossa in the medial wall of the middle ear--it is found just above the promontory. It leads into the vestibule of
the bony labyrinth. In life, this fossa is completely covered by the footplate of the stapes. So, if there was otosclerosis of the stapes to
the surrounding bone, there would be damage to the oval window. The round window is also a fossa in the medial wall of the middle
ear, but it is located below the promontory. The round window is covered by a thin membrane.
The aditus ad antrum is an opening on the posterior wall of the middle ear. It is the opening to the mastoid antrum and mastoid air
cells. The cochlear duct is the spiral tube suspended in the cochlear canal--it is part of the membranous labyrinth. Finally, the internal
acoustic meatus is a foramen in the base of the skull. The facial nerve (CN VII) and the vestibulocochlear nerve (CN VIII) enter the
petrous temporal bone through this foramen.
11. The geniculate ganglion is the sensory ganglion of which nerve:
Facial
Glossopharyngeal
Trigeminal
Vagus
Vestibulocochlear

The correct answer is:

Facial nerve

The geniculate ganglion is the sensory ganglion of the facial nerve. These fibers travel as part of the chorda tympani to provide
taste sensation to the anterior 2/3 of the tongue. The glossopharyngeal nerve has superior and inferior ganglia, located near the jugular
foramen. These ganglia contain the cell bodies for the afferent components of this nerve. The trigeminal nerve has a trigeminal ganglion
which contains the cell bodies of neurons composing the sensory root of this nerve. The vagus nerve also has a superior and inferior
ganglion, which are located near the ganglia of the glossopharyngeal nerve. The superior ganglion is concerned with the general
sensory component of the nerve, and the inferior ganglion is concerned with the visceral sensory component of the nerve. Finally, the
vestibulocochlear nerve has a vestibular ganglion, which houses the neurons for balance, and the cochlear ganglion, which houses the
neurons concerned with hearing.
12. Repeated middle ear infections have destroyed the tympanic plexus in the middle ear cavity. The loss of preganglionic
parasympathetic fibers that pass through the plexus diminish production of:
Mucus in the nasal cavity
Mucus on the soft palate
Saliva by the parotid gland
Saliva by the submandibular and sublingual glands
Tears by the lacrimal gland

The correct answer is:

Saliva by the parotid gland

The tympanic plexus is formed by the tympanic nerve, a branch of the glossopharyngeal nerve (CN IX). The tympanic plexus
provides sensory innervation to the mucosal lining of the middle ear. The lesser petrosal nerve also comes out of the tympanic plexus.
This nerve carries preganglionic parasympathetic fibers from the tympanic plexus - these fibers eventually synapse in the otic ganglion.
The postsynaptic fibers that leave the otic ganglion provide parasympathetic secretomotor innervation to the parotid gland. So, if the
tympanic plexus was destroyed, the lesser petrosal nerve would be destroyed and the parotid gland would not secrete saliva.
Mucosal secretions in the nasal cavity and the soft palate and tear secretions by the lacrimal gland are all mediated by the
postganglionic fibers of the pterygopalatine ganglion. This ganglion receives preganglionic fibers from the greater petrosal nerve, a
branch of the facial nerve (CN VII). The submandibular and sublingual glands receive their preganglionic fibers from the chorda tympani
- another branch of the facial nerve.

13. The soft palate is active in all of the following except:

Breathing
Chewing
Coughing
Swallowing
Yawning

The correct answer is:

Breathing

The soft palate is the movable posterior 1/3 of the palate, which is suspended from the posterior border of the hard palate. When a
person swallows, the soft palate is initially tensed to allow the tongue to press against it, squeezing the bolus of food to the back of the
mouth. The soft palate is elevated posteriorly and superiorly against the wall of the pharynx, thereby preventing the passage of food
into the nasal cavity. The soft palate functions similarly to prevent the bolus of food from passing into the nasal cavity while chewing
and to prevent expectorated material from entering the nasal cavity while coughing. The soft palate also elevates when yawning. The
soft palate does not elevate during breathing--if it did rise during breathing, the air inspired through the nose might be blocked from
entering the trachea.
14. Most paranasal sinuses and/or air cells drain, directly or indirectly, into the:
Inferior meatus
Middle meatus
Superior meatus
Nasal vestibule
Sphenoethmoidal recess

The correct answer is:

middle meatus

The middle meatus contains the semilunar hiatus, which receives drainage from the frontonasal duct (draining the frontal sinus),
the anterior ethmoidal air cells, and the maxillary sinus. So, it's draining most of the paranasal sinuses. The inferior meatus receives the
nasolacrimal duct which conducts tears from the orbit. The superior meatus receives drainage from the posterior ethmoidal air cells.
The nasal vestibule is the opening of the nose--none of the sinuses drain directly into this area. The sphenoethmoidal recess is the
opening for the sphenoethmoidal sinus.
15. Irrigation of the maxillary sinus through its opening is a supportive measure to accelerate the resolution of a maxillary sinus
infection. Which of the following nasal spaces is the most likely approach to the sinus opening?
choana
inferior meatus
middle meatus
sphenoethmoidal recess
superior meatus

The correct answer is:

middle meatus

The middle meatus contains the semilunar hiatus, which receives drainage from the maxillary sinus, the frontonasal duct (draining
the frontal sinus), and the anterior ethmoidal air cells. The maxillary sinus is draining into the middle meatus, so it would be easiest to
approach the maxillary sinus through this space. The choana is the space where the nasal cavity opens into the nasopharynx--it is
found at the very posterior border of the nasal cavity. The inferior meatus receives the nasolacrimal duct which conducts tears from the
orbit. The sphenoethmoidal recess is the opening for the sphenoethmoidal sinus. Finally, the superior meatus receives drainage from
the posterior ethmoidal air cells.

16. In assessing a deep laceration of the right side of the nose, the attending physician determines that the cartilage on the lateral
side of the nostril has been cut. What cartilage was injured?
Accessory
Alar
Lateral
Septal
None of the above

The correct answer is:

alar cartilage

The alar cartilage is found on the inferolateral side of the nose. This is probably the cartilage that was injured in this laceration.
The septal cartilage creates the septum of the nose. The lateral cartilage is a specialization of the septal cartilage that is superior to the
alar cartilage, also on the lateral side of the nose. The accessory cartilage is a small piece of cartilage between the alar cartilage and
the lateral cartilage
17. The nasolacrimal duct empties into which part of the nasal cavity?
Hiatus semilunaris
Inferior meatus
Middle meatus
Sphenoethmoidal recess
Vestibule

The correct answer is:

inferior meatus

The inferior meatus receives the nasolacrimal duct which conducts tears from the orbit. The semilunar hiatus is found in the
middle meatus--it receives drainage from the frontonasal duct (draining the frontal sinus), the anterior ethmoidal air cells, and the

maxillary sinus. The sphenoethmoid recess is the opening for the sphenoethmoidal sinus. The vestibule of the nose is the opening of
the nose that is covered with skin and stiff hairs.
18. The pharyngeal tonsils, or adenoids, may become inflamed and in serious cases need to be removed. Where would the
physician search for them?
In the tonsillar fossa
In the pharyngeal recess
In the piriform recess
In the roof of the nasopharynx
Upon the dorsal surface of the tongue

The correct answer is:

In the roof of the nasopharynx

The pharyngeal tonsil is located on the roof of the nasopharynx. The pharyngeal recess is a space located posterior to the torus
tubarius in nasopharynx. The tonsillar fossa is the space where the palatine tonsil is located--it is found between the palatoglossal fold
and the palatopharyngeal fold. The piriform recess is a shallow depression located lateral to the aryepiglottic fold in the laryngopharynx.
This is a common place where food can get stuck. The piriform recess is also significant because the internal branch of the superior
laryngeal nerve is located immediately deep to the mucosa of this region--so, an injury here may damage this nerve! Finally, the lingual
tonsil is found on the dorsal surface of the tongue.
19. The middle nasal concha is part of what bone?
Ethmoid bone
Maxilla
Palatine bone
Sphenoid bone
Vomer

The correct answer is:

ethmoid

The superior and middle nasal conchae are part of the ethmoid bone. The maxillary bone is the bone that forms the midface. It
forms the inferior orbital margin and contains the teeth and maxillary sinus. The palatine bone forms the posterior part of the hard
palate. The sphenoid bone is an irregularly shaped bone forming the central portion of the skull. It has many parts, including a body,
greater wing, lesser wing and pterygoid plates. The vomer is a thin plate of bone forming the posteroinferior part of the nasal septum.
20. A 23-year-old man comes to you complaining that he can't stop crying, i.e. tears regularly run down the right side of his face. You
suspect that one of the lacrimal ducts on the right side of the face is blocked. You look into an endoscope to see if the
nasolacrimal duct is blocked. Into which part of the nasal cavity would you look to see the opening of the duct?
Hiatus semilunaris
Inferior meatus
Middle meatus
Sphenoethmoidal recess
Superior meatus

The correct answer is:

Inferior meatus

The inferior meatus receives the nasolacrimal duct which conducts tears from the orbit. So, this is the place where you should be
looking to see the opening of the nasolacrimal duct. The semilunar hiatus is found in the middle meatus--it receives drainage from the
frontonasal duct (draining the frontal sinus), the anterior ethmoidal air cells, and the maxillary sinus. The sphenoethmoid recess is the
opening for the sphenoethmoidal sinus. The superior meatus is the opening for the posterior ethmoidal air cells.

21. Which structure forms a border of the tonsillar fossa?

Torus tubarius
Palatopharyngeal fold
Salpingopharyngeal fold
Lateral glossoepiglottic fold
Medial pterygoid plate

The correct answer is:

Palatopharyngeal fold

The tonsillar fossa is the place where you find the palatine tonsil - it is a space found between the palatoglossal and
palatopharyngeal folds. Torus tubaris is a mucosal fold covering the anteromedial end of the auditory tube cartilage - it projects toward
the midline from the lateral wall of the nasopharynx. The salpingopharyngeal fold is a vertical fold of mucous membrane that extends
from the medial end of the auditory tube - it covers the salpingopharyngeus muscle. The lateral glossoepiglottic fold is a small fold
extending from the tongue to the epiglottis - it is found posterior to the tonsillar fossa. Finally, the medial pterygoid plate is a part of the
sphenoid bone in the skull - it is the attachment of the superior pharyngeal constrictor muscle and the pharyngobasilar fascia.
22. The communication between the pharynx and the nasal cavity is known as the:
Aditus
Auditory tube
Choanae
Fauces
Piriform recess

The correct answer is:

choanae

The choanae are the opening at the posterior border of the nasal cavity that allow the nasal cavity to communicate with the
nasopharynx. The aditus is the laryngeal inlet - this is the space that is covered by the epiglottis when swallowing. The auditory tube is

a tube that connects the nasopharynx with the middle ear, allowing for pressure to equalize on both sides of the tympanic membrane.
The fauces is the passage from the mouth to the oropharynx, including the lumen and its boundaries. Finally, the piriform recess is a
shallow depression located lateral to the aryepiglottic fold in the laryngopharynx. This is a place where food is commonly lodged.