Anatomy of the Ear

Pinna
 The posterior auricular nerve (CN VII), innervates the intrinsic muscles

External Auditory Canal

Innervation
Sensory innervation of the pinna and EAC
The auriculotemporal (V3)
Lesser occipital nerve (V2 and V3 derivation)
Auricular branch of the vagus nerve (Arnold’s nerve)
Facial nerve

Vascular Supply
Two branches of the ECA are the sources of arterial blood supply to the pinna and
EAC
Posterior auricular artery (its stylomastoid branch enters the fallopian canal to supply
the inferior segment of the facial nerve)
Superficial temporal artery
TEMPORAL BONE
Consist of the tympanic bone, mastoid process, squama “squamous portion” and
petrosal

Tympanic + squama  tympanosquamous suture

Traversed by Arnold’s nerve

Tympanic + mastoid  tympanomastoid suture

Tympanic + petrosa  petrotympanic fissure (posterior wall of the glenoid fossa for
the TMJ)
Traversed by chorda tympani nerve, anterior process of the malleus, and anterior
tympanic artery

The tympanosquamous and tympanomastoid sutures are landmarks for the “vascular
strip” incisions used in tympanomastoid surgery
The annular sulcus houses the annulus of the TM except superiorly, where it is
deficient; at this point, known as the notch of Rivinus, the TM attaches directly to
the squama

The mastoid portion of the temporal bone is the inferiorly extending projection seen
on the lateral surface of the temporal bone. It is composed of a squamous portion
(laterally) and a petrous portion (medially) separated by Körner’s (petrosquamous)
septum.

The fossa mastoidea (Macewen’s triangle) is defined by the linea temporalis

(temporal line), a ridge of bone extending posteriorly from the zygomatic process
(marking the lower margin of the temporalis muscle and approximating the inferior
descent of the middle cranial fossa dura), the posterosuperior margin of the EAC,
and a tangent to the posterior margin of the EAC. The fossa mastoidea, a cribrose
(cribriform) area, is identified by its numerous, perforating small blood vessels
The fossa mastoidea is an important surgical landmark as it laterally overlies the
mastoid antrum.

The mastoid foramen, located posteriorly on the mastoid process, is traversed by

the mastoid emissary vein and one or two mastoid arteries. Inferiorly, the SCM
muscle attaches to the mastoid tip

The petrosa
Important landmarks seen on a superior view are the arcuate eminence (roughly
corresponding to the superior SCC), meatal plane (indicative of the IAC), foramen
spinosum for the middle meningeal artery, and facial hiatus (marking the departure
of the greater petrosal nerve from the anterior aspect of the geniculate ganglion)
The lesser petrosal nerve, accompanied by the superior tympanic artery occupies the
superior tympanic canaliculus

The petrous apex points anteromedially and is marked by the transition of the
intrapetrous to the intracranial internal carotid artery, orifice of the bony eustachian
tube, and, anterolaterally, ganglion of the trigeminal nerve in Meckel’s cave

The medial view of the temporal bone features the porus of the IAC
The foramen seen at the petrous apex is the internal carotid foramen, by which the
ICA exits the temporal bone
The sigmoid portion of the lateral venous sinus runs in the deep sulcus seen
posteriorly, whereas the superior petrosal sinus runs in the sulcus located at the
junction of the posterior and middle fossa faces of the temporal bone

The posterior view of the temporal bone as it delimits the anterolateral aspect of the
posterior cranial fossa and lies between the superior and inferior petrosal sinuses.
The porus of the IAC, operculum, endolymphatic fossette cradling the endolymphatic
sac, and subarcuate fossa are the key anatomic features on this surface
The inferior surface of the temporal bone interfaces with the sphenoid and occipital
bones
The jugular fossa, housing the jugular bulb, is separated from the internal carotid
artery by the jugulocarotid crest
The inferior tympanic canaliculus, traversed by the inferior tympanic artery and the
tympanic branch of the glossopharyngeal nerve (Jacobson’s nerve), is sited in the
jugulocarotid crest, whereas the cranial aperture of the cochlear aqueduct is located
anteromedial to the jugular fossa
The cochlear aqueduct, is an important landmark for the neurootologist. As the
cochlear aqueduct runs from the medial aspect of the scala tympani of the basal
cochlear turn to terminate anteromedial to the jugular bulb, it parallels, and lies
inferior to, the IAC
From the transmastoid perspective, the aqueduct is encountered when drilling medial
to the jugular bulb; opening the aqueduct results in the flow of CSF into the mastoid,
a useful maneuver in translabyrinthine cerebellopontine angle tumor surgery as it
decompresses CSF pressure. In addition, cranial nerve IX, the inferior petrosal sinus,
and, in some cases, cranial nerves X and XI can be found immediately inferior to the
lateral terminus of the cochlear aqueduct. Therefore, the cochlear aqueduct can be
used as a guide to the lower limits of IAC dissection in, for example, the
translabyrinthine approach as it allows full exposure of the IAC without risking the
lower cranial nerves
Tympanic Membrane
The adult tympanic membrane is about 9 mm in diameter and subtends an acute
angle with respect to the inferior wall of the EAC
The fibrous annulus of the TM anchors it in the tympanic sulcus
In addition, the TM firmly attaches to the malleus at the lateral process and at the
umbo; between these two points, only a flimsy mucosal fold, the plica mallearis,
connects the tympanic membrane to the malleus
The TM is separated into a superior pars flaccida (Shrapnell’s membrane) and a pars
inferior by the anterior and posterior tympanic stria, which run from the lateral
process of the malleus to the anterior and posterior tympanic spines,
respectively
Shrapnell’s membrane serves as the lateral wall of Prussak’s space (the superior
recess of the TM); the head and neck of the malleus, the lateral malleal ligament,
and anterior and posterior malleal folds form the medial, anterosuperior, and inferior
limits of Prussak’s space.
The TM is a trilaminar structure. The lateral surface is formed by squamous
epithelium, whereas the medial layer is a continuation of the mucosal epithelium of
the middle ear. Between these layers is a fibrous layer, known as the pars propria.
The pars propria at the umbo splits to envelop the distal tip of the manubrium

Ossicles
The anterior ligament of the malleus, extending from the anterior process, passes
through the petrotympanic fissure and, with the posterior incudal ligament, creates
the axis of ossicular rotation
The short process of the incus is anchored in the incudal fossa by the posterior
incudal ligament
Stapes footplate sits in the oval window, surrounded by the stapediovestibular
ligament
Middle Ear Muscles
The tensor tympani muscle, innervated by the V3, originates from the walls of its
semicanal, greater wing of the sphenoid, and cartilage of the ET. The tendon of the
tensor tympani muscle sweeps around the cochleariform process and across the
tympanic cavity to attach to the medial aspect of the neck and manubrium of the
malleus
The facial nerve is seen in its vertical and tympanic segments. Anterosuperiorly, the
facial nerve passes superior to the tensor tympani tendon, which is seen sectioned
just after it exits the cochleariform process

The cochleariform process is a landmark to the anterior aspect of the tympanic

segment of the facial nerve as the nerve runs immediately superior to this process

The stapedius muscle runs in a vertical sulcus in the posterior wall of the tympanic
cavity adjacent to the facial nerve, from which it receives its innervation. Its tendon
traverses the pyramidal eminence to attach to the posterior crus, and occasionally
the head, of the stapes

Middle Ear Spaces

Planes extended from the tympanic annulus subdivide the tympanic cavity into a
mesotympanum, hypotympanum, protympanum, and posterior tympanic cavity. The
epitympanum lies above the plane of the anterior and posterior tympanic spines

Anteriorly, the mesotympanum is dominated by

Semicanal of the tensor tympani muscle
Tympanic orifice of the eustachian tube is immediately inferior to this bulge
Posteriorly
Pyramidal eminence and, lateral to it, the chordal eminence
The chordal eminence houses the iter chordae posterius by which the chorda
tympani nerve enters the tympanic cavity
The medial wall (the surgical “floor” of the middle ear) features three depressions:
the sinus tympani, oval window niche, and round window niche. The sinus tympani is
defined by the ponticulus superiorly, the subiculum inferiorly, the mastoid segment
of the facial nerve laterally, and the posterior semicircular canal medially
There is substantial variability in the posterior extension (surgical “depth”) of the
sinus tympani, ranging from “shallow” to “deep.”
The oval window niche, occupied by the stapes footplate, is located anterosuperior to
the ponticulus. The round window niche can be found posteroinferior to the
promontory, the bulge created by the basal turn of the cochlea. The sinus tympani
evades direct surgical visualization, which is particularly worrisome in cholesteatoma
surgery as it can harbor the nidus of recurrence.
The true round window membrane is obscured by some kind of mucosal veil (Figure
2–16); most often, the veil is perforated, giving the false impression of seeing a
defect in the round window membrane