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ANATOMY OF THE

OUTER & MIDDLE EAR


By dr Risman Rais Sp THT-KL

Dept. Of Ear, Nose, and Throat Head & Neck Surgery


Gatot Soebroto Military Hospital
Jakarta
2006

Outer Ear

Auricle (pinna)

External Auditory C
anal

The Auricle

Cartilage of Auricle
(cranial aspect)

Sensory Innervation of the Auricle


Nerve

Derivation

Region Supplied

Greater
auricular

Cervical plexus
C2.3

Medial surface and


posterior portion of lateral
surface

Lesser
occipital

Cervical plexus
C2.3

Superior portion of medial


surface

Auricular

Vagus

Concha , antihelix, some


eminentia concha (medial
surface)

Auriculotemp
oral

Mandibular (N.
V3)

Tragus, crus of helix,


adjacent helix

Facial (N. VII)

Probably supplies small


region in the root of concha

Blood Supply of The Auricle


Branches of external carotid artery:
Posterior auricular artery
Anterior auricular branches of the
superficial temporal artery
Auricular branch of occipital artery

Lymphatic Drainage of The


Auricle

From posterior mastoid tip nodes


From the tragus & upper part anterior
surface preauricular nodes
From the rest of the auricle upper
deep cervical nodes

The External Auditory Canal

Approximately 2,5 cm long


1/3 lateral cartilage, 2/3 medial bone
Ended in tympanic sulcus
(tympanomastoid & tympanosquamous)
Covered with skin :

Outer portion : hairs & glands


Glands: ceruminous (modified apocrine
sweat gland) & sebaceous

External Ear Canal Relationship


SUPERIOR

Middle cranial
TMJ
fossa

MEDIAL

ANTERIOR
Superficial temporal A & V
Auriculotemporal nerve
Parotid gland
Preauricular lymph node

Middle ear

Outside world

LATERAL

Mastoid

POSTERIOR

Parotid Gland
Digastric muscle
Jugular Bulb Facial nerve
Styloid process
Carotid

INFERIOR
Adapted from: Wright, Scott-Browns Otolaryngology,1992

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Innervation of External Auditory


Canal & Tympanic Membrane
VII

C3

Blood supply & Lymphatics of the External


Ear Canal
Branch

Parent Artery

Superficial
temporal artery
Maxillary artery

Deep
auricular

Region Supplied
Roof & anterior portion
of the canal
Anterior meatal wall
skin, epithelium of the
outer surface of the
tympanic membrane

Auricular

Posterior
Posterior portion of the
auricular artery canal
Veins : drains into the external jugular veins,
maxillary veins, and
Pterygoid Plexus
Lymphatics same as the auricle

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Telinga Luar

Auricula:

mengumpulkan suara
lokalisasi suara

CAE:

menghantarkan suara
ke membran timpani
berbentuk huruf S

Telinga Tengah

Membran Timpani

Ossicles

Menerima getaran suara


Menggerakkan ossicles
Ikut dlm proses transformasi
Menghantarkan getaran
Ikut dlm proses transformasi

Cavum Timpani

Resonator

The Middle Ear

Tympanic Cavity, Eustachian tube,


Mastoid Air cell system
Within the temporal bone
Cube-like shaped
Contents :

Ossicles
Muscles : Tensor tympani & Stapedius muscle

Related to adjacent organs

Right Middle Ear Relationship


SUPERIOR
ANTERIOR
Middle Cranial Fossa

Tensor tympani
Eustachian tube

MEDIAL
External auditoryLATERAL
meatus

Inner Ear
Aditus to
mastoid

POSTERIOR

Mastoid

Carotid

Jugular bulb

INFERIOR

Adapted from: Wright, Scott-Browns Otolaryngology1992

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The Tympanic Membrane

Tympanic Membrane Vascularization


OUTER SURFACE
Manubrial artery

Deep Auricular branch


(maxillary artery)

INNER SURFACE

Anterior Tympanic Artery (Maxil


Stylomastoid artery (Posterior A

Tympanic Cavity (see from lateral)


Long process of Incus
Manubrium
mallei
Round Window

Promontory

The Ossicles

Mastoid Antrum Relationship


SUPERIOR
Middle Cranial
Fossa

ANTERIOR
Middle Ear
External Auditory Meatus
Facial Nerve

MEDIAL
Post Aural SkinLATERAL

Posterior
Cranial Fossa

Sigmoid Sinus

POSTERIOR

Sternocleidomastoid
Digastric Muscle
Jugular Bulb

INFERIOR

Adapted from: Wright, Scott-Browns O

Blood Supply to the Middle Ear


Branch

Parent Artery

Region Supplied

Anterior
Tympanic

Maxillary Artery

Tympanic membrane,
malleus and incus,
anterior part of tympanic
cavity

Stylomastoid

Posterior
Auricular

Posteroid part of tympanic


cavity, stapedius muscle

Mastoid

Stylomastoid

Mastoid air cells

Petrosal

Middle Meningeal

Roof of mastoid, roof of


epitympanum

Superior
Tympanic

Middle Meningeal

Malleus and incus, tensor


tympani

Inferior
Tympanic

Ascending
Pharyngeal

Mesotympanum

Branch from

Artery of
Pterygoid Canal

Meso- and hypotympanum

Tympanic

Internal Carotid

Meso- and hypotympanum

Innervation, Veins, & Lymphatics


of The Middle Ear

Innervation of the middle ear,


mastoid, & eustachian tube:

Tympanic plexus (n. IX) sensory &


sympathetic (caroticotimpani nerve)
Probably from Facial Nerve

Veins parallel to the arteries


Lymphatics drains to retropharyngeal
& parotid lymph nodes

The Facial Nerve

Hearing Process
Outer

Middle

Inner

Transmission
Sound localization
Sound Collection

Transformation
Protection

Transduction

Telinga Tengah Transformasi

Luas Membran
timpani (A1) lebih
besar dari luas
footplate
stapes
P= F/A
(A2)
maka
P2 > P1

Gaya yg sama pada MT akan memberikan energi hidrolik


yg lebih besar pada footplate stapes 18 kali

Telinga Tengah Transformasi

Panjang malleus 1,3


kali panjang incus
Gaya tuas pada
sendi incudomalleal

Pembesaran Energi
sebanyak 1,3 kali

Transduksi

Beda potensial
antara endolimf
dan intrasel

Fisiologi pendengaran

Suara Auricula CAE MT Getar


Ossicles ( M ,I,S ) Foramen ovale
Perilimf (scalavestibuli) Scala Media
(endolimf) M.Basalis Scala Timpani
(perilimf)Beda Na, K N VIII
Pusat sensorik pendengaran (area 34
40)
L Temporalis

sigmoid
sinus

anterior canal

endolymphatic
sac

cupula

brain

operculum
dura mater

horizontal canal

macula
endolymphatic
duct

cupula
utriculus

cochlear
aquaduct

posterior canal
sacculus
cupula

organ of
Corti

stapes

middle ear

scala media
round window

scala vestibulum
scala tympani

ductus reuniens

Audiologi Dasar

- Fisiologik 20 - 18.000Hz.
- Pendengaran sehari-hari 500 - 2.000Hz

Kualitatif :garpu tala


- Rinne : membandingkan AC & BC
- Weber : membandingkan BC ke-2 telinga
- Schwabach : membandingkan BC antara
pemeriksa
& pasien
- Bing ( Oklusi ) = weber :(+) tragus ditutup
- Stenger: simulasi/ pura2 tuli

Macam : 128, 256, 512, 1024, 2048.

Cara Pemeriksaan :
- Rinne : Penala digetarkan tangkai di
prosessus mastoid bunyi(-)
letakkan 2,5cm didepan telinga
suara (+) Rinne (+)
suara (-) Rinnie (-)
- Weber : penala getar tangkai digaris
tengah kepala ( vertex, dahi,
pangkal, hidung, dagu, tengah2 gigi seri
Lateralisasi : bunyi terdengar > keras
pada salah satu telinga

Schwabach :
Penala getar prosessus mastoid bunyi
(-)
pindah prosessus mastoid pemeriksa
pemeriksa dengar (+) schwabach
memendek ulang mulai pemeriksa
bunyi (-)pindah ke pasien bunyi (+)
schwabach memanjang

Test Berbisik : Semi Kuantitatif


- Ruang tenang
- 6 meter
- Normal 5/6 6/6
Audiometri Nada Murni :
- Audiogram
- Audiometer
- Nada murni (pure tone ) : bunyi dengan 1
frekuensi ( getaran/detik )
- Bising : bunyi banyak frekuensi
- Frekuensi : nada murni ok getaran suatu
benda ( Hertz = Hz )
- Intensitas : dB ( decibel ): bunyi nada
murni terlemah, frekuensi
tertentu yang masih terdengar

Ambang Dengar :

- AC ( Air Conduction ) konduksi udara


- BC ( Bone Conduction )konduksi tulang
Hubungkan => Audiogram

Nilai Nol Audiometrik : intensitas nada murni terkecil


frekuensi tertentu yang masih
dapat di dengar
- Manusia sensitif 1000 Hz( besar 0,0002 dyne/cm 2)
- Kenaikan Logaritmik
cont : 20 dB100X > 10dB bukan 2X
- Notasi Audiogram
Grafik AC ( 125 Hz s/d 8000 Hz ) : garis lurus
BC ( 250 4000 Hz ): garis putus 2
AD : warna merah
AS : warna biru

Jenis dan derajat ketulian :


Derajat ketulian : indek Fletcher :
Ambang Dengar :
500 Hz + 1000 Hz + 2000 Hz
3
Interpretasi :
- Letak telinga
- Jenis Ketulian
- Derajat Ketulian
Dihitung : AC

Derajat :
0 25 dB : normal
26 40 dB : ringan
41 60 db : sedang
60 90 dB : berat
Gap : apabila antara AC & BC terdapat perbedaan
>10 dB minimal pada 2 frekuensi berdekatan
Bila beda >=45 dB antara telinga kanan & kirimasking
Macam Tuli :
- konduktif : telinga luar s/d tengah
- sensorineural : telinga dalam
- campuran

Tuli koklea & Tuli retrokoklea


Recruitment : peningkatan sensitifitas pendengaran yg berlebihan
diatas
ambang dengar
Decay /Fatigue : adaptasi abnormal. Saraf pendengaran cepat lelah
bila
dirangsang terus menerus. Bila istirahat akan kembali
normal
Pemeriksaan :
- SISI ( Short Increment Sensitivity Index )
- Kelainan koklea
- Fenomena Recruitment
- ABLB ( Alternate Binaural Loudness Balance )
- membandingkan persepsi intensitas antara ke2 telinga pada
frekuensi konstan
- Tone Decay ( Tes Kelelehaan )
rangsangan terus menerus kelelehan
- TTD ( Threshold Tone Decay )
- STAT ( Supra Threshold Adaptation Test )

- Audiometri Tutur ( Speech Audiometry )


- Monosilabus
- Bisilabus
- Menilai kemampuan pasien dalam
pembicaraan & penilaian untuk pemberian
hearing aid
- Audiometri Bekessy. ( Bekessy Audiometry )
Audiometry Objektif :
- Audiometry Impedans
- Timpanometry : mengetahui keadaan kavum timpani
- Fungsi Tuba Eustachius : terbuka / tertutup
- Refleks stapedius : muncul pada rangsangan 70 80
dB diatas ambang dengar
- Elektrokokleografi
- Pemeriksaan Koklea
- Elektrode jarum

Evoke Response Audiometry


- gel I s/d gel V
Pemeriksaan Tuli anorganik : pura 2 tuli
- stenger
- audiometri secara berulang selama 1 minggu
- impedans
Audiologi Anak
- Neometer : bunyi suara lihat reaksi
- Free Field Test : Anak bermain rangsang bunyi
reaksi
- Screening : AC 500 Hz, 1000 Hz, 2000 Hz