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Ear anatomy& Physiology and Embryology of the ear +congenital anomalies Dr. Manal Bukhari King Saud University Otolaryngology Assistant professor consultant Phonosurgeon King Abdulaziz University Embryology Six visceral arches Auricle :first and second branchial arch EAC: first phayrngeal groove Ossicles : first branchial arch (meckel’s cartilage) malleus head and neck incus body and short process . Second branchial arch(reichert;s cartilage) manubrium of malleus ,long and lenticular process of incus ,stapes Anatomy of the ear External ear: 1. Auricle : Arise from the first and second branchial cleft. Cartilage +perichondrium +skin (close adherent together) except the lobule. 2-External auditory canal: First pharyngeal cleft Length:2.5 cm Cartilaginous EAC: lateral 1/3 fibrocartilage contains apopilosebaceous units Osseous EAC: • medial 2/3periosteum • Post sup squama • The remainder tympanic plate • Squmotympanic &tympanomastoid sutures • • Two constriction : At the medial end of the cartilaginous portion and 5 mm from the TM Relations of external auditory meatus Sensory nerve supply: Greater auricular -(C2,C3) Auricular –vagus X Auriculotemporal -Vc mandibular Vascular supply: Front: TMJ Behind :Mastoid air cell Above :middle cranial fossa Front and below parotid gland Auriculotemporal branch of superficial temporal artery ,anteriorly Branches of postauricular division of external carotid artery postriorly. Lymphatic drainage: Preauricular Postauricular Ext jugular lymph node Middle ear cleft Tympanic membrane: Outer epithelial layer Middle fibrous layer Inner mucosal layer Parsa Flaccida Parsa Tensa Annulus Fibrosus Notch of Rivinus Tympanic cavity: Bioconcave disc shaped cavity 13mm ant post ,15 mm in height . Eustachain tube: Post 1/3 osseous portion open in the ant wall of the tympanic cavity Ant membranous cartilaginous portion 2/3 end in the nasopharynx Length :3.7 cm ------45 degree from horizontal Closed at rest but opened on yawing and swallowing (tensor paltai muscle) Ossicles: Transmit sound energy from the TM to the oval window Malleus head,neck ant and lat processes and the handle (tensor tympani muscles). Incus : body ,short processes ,long process Stapes : : head ,neck ,ant and post crura and foot plate (stapedius) Medial wall: The promontory : Oval window : separates the middle ear from scala tympani Facial nerve : occupied by the footplate of the stapes ,closes the middle ear from the scala vestibuli Round window : bony projection covering the basal turn of the cochlea. the horizontal portion lies above the oval window . The horizontal semicircular canal : above the second genu of the facial nerve. Roof (tegmen tympani) Separate the cavity from middle cranial fossa Anterior wall: Canal Huguier ,chorda tympani Canal of tensor tympani ms Tympanic orifice of ET Canal of carotid artery Posterior wall Aditus :which lead backwards from the epitympanum into mastoid antrum Pyramid (stapedius tendon) vertical portion of facial nerve Floor jugular bulb Mastoid antrum: Situated in the post portion of petrous temporal bone Ant :opening of the aditus Medial :post and horizontal semicircular mcanals Roof (tegmen antri) Lat :squama and macewen’s triangle Nerve supply of middle ear : Sensory : • IX (tympanic plexus) +VII Motor : • V3 to tensor tympani ms • VII to stapedial ms Vascular supply : Branches of both internal and external carotid artery Inner ear Inner ear (labyrinth) Osseous labyrinth vestibule: • lie between the medial wall of the middle ear and lateral end of internal auditory canal . • Oval window in the lateral wall Bony semicircular canal • Sup ,post, horizontal Bony cochlea; • in front the vestibule ,snail shell in shape ,2 1/2 turns, central axis (mediolus )inner wall of the canal Contain perilymph =extracellular fluids Membranous labyrinth communicating sacs and ducts within the bony cavities Saccule &utricle (vestibule) Membranous semicircular ducts Cochlear duct (scala media) Membranous labyrinth contain endolymph =intracelluar fluids ↑K,↓Na Organ of corti; Scala vestibuli --oval window Scala tympani -–round window Both contain perilymph Scala media --endolymph Physiology of hearing Sound energy →air → external canal → TM → Ossicles → cochlear fluid wave → stimulation of basal membrane → shearing of hair cell with tectorial membrane → rapid depolarization → impulse carried along the auditory nerve . Area advantage :TM 55 mm the stapes 3.2mm =17:1 Lever effect : 1.3:1 Transformer ratio 22:1 25-30 dB gain Central connection of cochlear nerve The vestibular labyrinth Semicircular canals =hair cell ►gelatinous cupula ► sheared (angular movements ) ►vestibular nerve . Utricle and saccule= hair cell ► otoconial membrane ► (linear acceleration&pull of the gravity) ► vestibular nerve The major connection of the vestibular system are: spinal cord ,cerebellum, external ocular muscle Disease of external ear and acute otitis media Congenital anomalies of external ear Protruding ear (bat ear): otoplasty Preauricular sinus: surgical excision Microtia : Atrasia Accessory auricles RX: plastic reconstruction Bone anchored hearing aid Perichondritis of pinna: it may follow: infection of the auricular cartilage-----necrosis ---deformity. Haematoma Surgery RX: ABX Incision & drainage Removal of necrotic tissue Otitis externa Acute otitis externa: Pathophysiology: pseudomonas aeruginosa, staphlococcus (furuncle) SSx: aggressive washing the wax or retention water Microtruma (cotton swabs,fingernails ) Pathogens; Bacterial infection involving the skin of the external canal pain ,tragal tendreness otalgia ,pruritus, edematous erythematous EAC, conductive hearing loss. RX: suction cleaning Ear drop Analgesia Antibiotic Eczematous otitis externa: SSx; Allergic dermatitis pruritis ,redness oedema , mild pain,dry scaly skin RX: recognize the allergen Hydrocortisone cream Antihistamin Coal tar ointment ,silver nitrate ,canalplasty (chronic stage) Seborrhoeic otitis externa : Cause: abn sebum and wax SSx: Greasy, scaling and crusting condition Greasy yellow scales itching RX: Shampoo selenium sulphide and ketoconazole Ointment; salicylic acid and sulpher 2% Herpetic Herpes simplex (acyclovir in severe cases ) herpes zoster oticus • • • • • lesions: Sever pain Vesication Cranial nerve lesion deafness SNHL Vertigo Facial nerve palsies Ramsay hunt syndrom RX: • oral and topical acyclovir early Otomycosis : SSX: Aspergillus ,candida moist tissue –paper dotted gray membran, prurtic RX : suction cleaning Fungicides : • nystatin ,econazol Otitis externa malignans (osteomyelitis of skull base): SSX: Granulation tissue in EAC at the bony cartilagenous junction Persist otalgia, otorrhea Crainal nerve involvement VII, IX ,X XI ,XII,V,VI DX ; Pseudomonas infection occurring in elderly diabetic patients . CT scan, bone scan ,culture RX: diabetic control Prolonged parentral anti- pseudomonus abx Ear drop Debridement Hyperbaric oxygen Acute otitis media Inflammation of the middle ear cavity (<3 weeks) Pathophysiology : ET dysfunction ,spread of the infection via submucosal lymphatic or direct spread Pathogens; S,pneumonia, H, influnza.Moraxella Risks: Craniofacial abn Rec URTI Day care Bottle feeding smoking immunological disorders IgA ,IgG deficiencies Ciliary dysfunction Adenoid hypertrophy GERD NGT SSX: Otalgia,aural fullness, hearing loss, tinnitus ,fever Hyperemic TM ,non mobile bulgingTM ,air fluid level RX; oral ABX for 10 days Antipyretics , analgsia oral and nasal decongestants Acute mastoditis Management of recurrent acute otitis media : Myringotomy with pressure equalization tube; Secretory otitis media (otitis media with effusion) SSX: nonmobile TM, airfluid levels, aural fullness, hearing loss, DX: Persistence of fluid in the middle ear space without evidence of infection. tympanometry RX: ABx, Myringotomy with pressure equalization tube.