966 Chapter 7 • Head

EAR The elevated margin of the auricle is the helix. The other
depressions and elevations are identified in Figure 7.110. The
non-cartilaginous lobule (lobe) consists of fibrous tissue, fat,
The ear—the organ of hearing and equilibrium (balance)—is
and blood vessels. It is easily pierced for taking small blood
divided into the external, middle, and internal ear (Fig. 7.109).
samples and inserting earrings. The tragus (G. tragos, goat;
The external ear and middle ear are mainly concerned with
alluding to the hairs that tend to grow from this formation,
the transfer of sound to the internal ear, which contains the
like a goat’s beard) is a tongue-like projection overlapping
organ for equilibrium as well as for hearing. The tympanic
the opening of the external acoustic meatus. The arterial
membrane separates the external ear from the middle ear.
supply to the auricle is derived mainly from the posterior
The pharyngotympanic tube joins the middle ear to the
auricular and superficial temporal arteries (Fig. 7.111A).
nasopharynx.
The main nerves to the skin of the auricle are the great
auricular and auriculotemporal nerves. The great auricu-
External Ear lar nerve supplies the cranial (medial) surface (commonly
The external ear is composed of the shell-like auricle called the “back of the ear”) and the posterior part (helix,
(pinna), which collects sound, and the external acoustic antihelix, and lobule) of the lateral surface (“front”). The
meatus (ear canal), which conducts sound to the tympanic auriculotemporal nerve, a branch of CN V3, supplies the
membrane. skin of the auricle anterior to the external acoustic meatus
(Figs. 7.109 and 7.111A). Minor contributions of embryo-
logical significance are made to the skin of the concha and its
AURICLE
eminence by the vagus and facial nerves.
The auricle (L. auris, ear) is composed of an irregularly The lymphatic drainage of the auricle is as follows: the
shaped plate of elastic cartilage that is covered by thin skin lateral surface of the superior half of the auricle drains to
(Fig. 7.110). The auricle has several depressions and eleva- the superficial parotid lymph nodes (Fig. 7.111B); the cra-
tions. The concha of the auricle is the deepest depression. nial surface of the superior half of the auricle drains to the

Incus Epitympanic
recess
Malleus
Temporalis Tympanic
membrane Semicircular canals
muscle
Stapes Vestibular nerve
Facial nerve (CN VII)
Auricle
Cochlear nerve
Vestibulocochlear
External nerve (CN VIII)
acoustic
meatus Internal acoustic
meatus

Opening of external Cochlea

acoustic meatus

Parts of the ear:

External ear
Tragus
Middle ear
Internal ear

Lobule of auricle

Superior parotid Tympanic cavity

lymph nodes
Pharyngotympanic
tube
Auriculotemporal Parotid gland
nerve
Anterior view

FIGURE 7.109. Parts of ear. A coronal section of the ear, with accompanying orientation figure, demonstrates that the ear has three parts: external,
middle, and internal. The external ear consists of the auricle and external acoustic meatus. The middle ear is an air space in which the auditory ossicles
are located. The internal ear contains the membranous labyrinth; its chief divisions are the cochlear labyrinth and the vestibular labyrinth.

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 Chapter 7 • Head 967

Helix
The tympanic membrane moves in response to air vibra-
tions that pass to it through the external acoustic meatus.
Triangular fossa
of antihelix
Movements of the membrane are transmitted by the audi-
Crura of antihelix
tory ossicles through the middle ear to the internal ear
Scapha (Fig. 7.109). The external surface of the tympanic mem-
Cy Concha of auricle: brane is supplied mainly by the auriculotemporal nerve (Fig.
Antihelix Cymba (Cy)
Cavity (Ca) 7.111A), a branch of CN V3. Some innervation is supplied by
a small auricular branch of the vagus (CN X). The internal
Opening of Tragus
external Ca surface of the tympanic membrane is supplied by the glos-
acoustic meatus Intertragic notch sopharyngeal nerve (CN IX).
Lobule of auricle
Antitragus Middle Ear
FIGURE 7.110. External ear. The parts of the auricle commonly used in The tympanic cavity or cavity of the middle ear is
clinical descriptions are labeled. The external ear includes the auricle and the narrow air-filled chamber in the petrous part of the
external acoustic meatus. temporal bone (Fig. 7.109 and 7.113). The cavity has two
parts: the tympanic cavity proper, the space directly
mastoid lymph nodes and deep cervical lymph nodes; and internal to the tympanic membrane, and the epitym-
the remainder of the auricle, including the lobule, drains into panic recess, the space superior to the membrane. The
the superficial cervical lymph nodes. tympanic cavity is connected anteromedially with the
nasopharynx by the pharyngotympanic tube and postero-
superiorly with the mastoid cells through the mastoid
EXTERNAL ACOUSTIC MEATUS
antrum (Figs. 7.113A and 7.114). The tympanic cavity
The external acoustic meatus is an ear canal that leads is lined with mucous membrane that is continuous with
inward through the tympanic part of the temporal bone from the lining of the pharyngotympanic tube, mastoid cells,
the auricle to the tympanic membrane, a distance of 2–3 cm and mastoid antrum.
in adults (Fig. 7.109). The lateral third of this slightly S-shaped The contents of the middle ear are the:
canal is cartilaginous and is lined with skin that is continuous
• Auditory ossicles (malleus, incus, and stapes).
with the auricular skin. The medial two thirds of the meatus
• Stapedius and tensor tympani muscles.
is bony and lined with thin skin that is continuous with the
• Chorda tympani nerve, a branch of CN VII (Fig. 7.114).
external layer of the tympanic membrane. The ceruminous
• Tympanic plexus of nerves.
and sebaceous glands in the subcutaneous tissue of the carti-
laginous part of the meatus produce cerumen (earwax).
The tympanic membrane, approximately 1 cm in diameter, WALLS OF TYMPANIC CAVITY
is a thin, oval semitransparent membrane at the medial end of
The middle ear is shaped like a lozenge or narrow box with
the external acoustic meatus (Figs. 7.109 and 7.112). This mem-
concave sides. It has six walls (Fig. 7.114B).
brane forms a partition between the external acoustic meatus
and the tympanic cavity of the middle ear. The tympanic mem- 1. The tegmental wall (roof) is formed by a thin plate of
brane is covered with thin skin externally and mucous mem- bone, the tegmen tympani, which separates the tympanic
brane of the middle ear internally. Viewed through an otoscope, cavity from the dura mater on the floor of the middle cra-
the tympanic membrane has a concavity toward the external nial fossa.
acoustic meatus with a shallow, cone-like central depression, 2. The jugular wall (floor) is formed by a layer of bone that
the peak of which is the umbo (Fig. 7.112A) (see the blue box separates the tympanic cavity from the superior bulb of
“Otoscopic Examination,” p. 977). The central axis of the tym- the internal jugular vein.
panic membrane passes perpendicularly through the umbo like 3. The membranous (lateral) wall is formed almost
the handle of an umbrella, running anteriorly and inferiorly as it entirely by the peaked convexity of the tympanic mem-
runs laterally. Thus, the tympanic membrane is oriented like a brane; superiorly it is formed by the lateral bony wall
mini radar or satellite dish positioned to receive signals coming of the epitympanic recess. The handle of the malleus is
from the ground in front and to the side of the head. attached to the tympanic membrane, and its head extends
Superior to the lateral process of the malleus (one of the into the epitympanic recess.
small ear bones, or auditory ossicles, of the middle ear), the 4. The labyrinthine (medial) wall (medial wall) separates
membrane is thin and is called the pars flaccida (flaccid the tympanic cavity from the internal ear. It also features
part. It lacks the radial and circular fibers present in the the promontory of the labyrinthine wall, formed by the
remainder of the membrane, called the pars tensa (tense initial part (basal turn) of the cochlea, and the oval and
part). The flaccid part forms the lateral wall of the superior round windows, which, in a dry cranium, communicate
recess of the tympanic cavity. with the internal ear.

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 968 Chapter 7 • Head

Superficial temporal artery

Auriculotemporal
nerve (CN V3)

Branches of facial nerve

(CN VII) emerging from
parotid plexus

Muscle
Vein Branches of facial nerve
Posterior Nerve (CN VII) emerging form
auricular Lymph node parotid plexus
Artery
Parotid duct
Parotid gland

Parotid lymph nodes

Masseter
Great auricular nerve

External jugular vein

(A) Lateral view

Lymph node groups:

Occipital Submental
Mastoid Superfical cervical
Parotid Deep cervical
Buccal *Retropharyngeal
Infrahyoid *Jugulo-digastric
Submandibular *Jugulo-omohyoid

*Part of deep cervical group of lymph nodes

Facial vein

Anterior
Jugular veins
External
Internal
jugular vein

(B)

FIGURE 7.111. Dissection of face and lymphatic drainage of head. A. The posterior auricular and superficial temporal arteries and veins and the great
auricular and auriculotemporal nerves provide the circulation and innervation of the external ear. B. Lymphatic drainage is to the parotid lymph nodes and
the mastoid and superficial cervical lymph nodes, all which drain to the deep cervical nodes.

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 Chapter 7 • Head 969

Epitympanic Tegmen
recess tympani

Incus: Malleus:
Short limb
Head
Body
Posterior Pars flaccida Lateral
Long limb
mallear fold process
Anterior mallear Chorda
fold tympani Handle
Long limb
(manubrium
of incus
Lateral Base (footplate)
process of of stapes in
malleolus vestibular
Handle (oval) window
Pars Tendon
Umbo Pyramidal of tensor
tensa
eminence tympani

Cone of light Tendon of

stapedius muscle Tympanic
Tympanic (reflected) membrane
sulcus of Cochlear (round) (made
temporal bone Fibrocartilaginous ring window transparent)

(A) Otoscopic view of right tympanic membrane (B) Ossicles of ear seen through tympanic membrane
FIGURE 7.112. Tympanic membrane and lateral approach to tympanic cavity. A. An otoscopic view of the right tympanic membrane is demonstrated.
The cone of light is a reflection of the light of the otoscope. B. The tympanic membrane has been rendered semitransparent and the lateral wall of the
epitympanic recess has been removed to demonstrate the ossicles of the middle ear in situ.

LATERAL POSTERIOR

Auditory Stapes Squamous Part of

ossicles Incus temporal
Malleus Petrous bone
Tympanic cavity Semicircular canals

External acoustic
meatus Endolymphatic duct
Anterolateral (and
inferior) direction of Oval window
axes of tympanic
membrane and cochlea Cochlear aqueduct
Tympanic membrane
Internal acoustic
meatus
Tensor tympani
Bony part
Cochlea
Pharyngotympanic Cartilaginous
tube part

Levator veli
palatini

ANTERIOR MEDIAL
(A) Superomedial view
FIGURE 7.113. General scheme and orientation of components of ear. A. The ear is shown in situ. The external acoustic meatus runs lateral to medial;
the axis of the tympanic membrane and the axis about which the cochlea winds runs inferiorly and anteriorly as it proceeds laterally. The long axes of the
bony and membranous labyrinths and of the pharyngotympanic tube and parallel tensor tympani and levator palatini muscles lie perpendicular to those of
the tympanic membrane and cochlea (i.e., they run inferiorly and anteriorly as they proceed medially).

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 970 Chapter 7 • Head
Dura mater
Endolymphatic sac
Semicircular duct
and canal Vestibular aqueduct containing
Base of stapes in endolymphatic duct
oval window
Cochlear aqueduct
Stapes
Duct of cochlea
Incus
Malleus
Temporal bone
External acoustic
meatus
Tympanic membrane

Tympanic cavity Tympanic cavity

Bony labyrinth Pharyngotympanic tube
Membranous labyrinth Vestibule of bony labyrinth
Round window
(B) Oblique section of petrous temporal bone
FIGURE 7.113. (Continued) B. The middle and internal parts of the ear are shown. The middle ear lies between the tympanic membrane and the internal
ear. Three auditory ossicles stretch from the lateral to the medial wall of the tympanic cavity. The pharyngotympanic tube is a communication between the
anterior wall of the tympanic cavity and the lateral wall of the nasopharynx. The internal ear is composed of a closed system of membranous tubes and
bulbs, the membranous labyrinth, which is filled with a fluid called endolymph (orange) and bathed in surrounding fluid called perilymph (purple).

5. The mastoid wall (posterior wall) features an opening By allowing air to enter and leave the tympanic cavity, this
in its superior part, the aditus (L. access) to the mastoid tube balances the pressure on both sides of the membrane.
antrum, connecting the tympanic cavity to the mastoid Because the walls of the cartilaginous part of the tube are
cells; the canal for the facial nerve descends between the normally in apposition, the tube must be actively opened.
posterior wall and the antrum, medial to the aditus. The tube is opened by the expanding girth of the belly of
6. The anterior carotid wall separates the tympanic cav- the levator veli palatini as it contracts longitudinally, push-
ity from the carotid canal; superiorly, it has the opening ing against one wall while the tensor veli palatini pulls on the
of the pharyngotympanic tube and the canal for the other. Because these are muscles of the soft palate, equaliz-
tensor tympani. ing pressure (“popping the eardrums”) is commonly associ-
ated with activities such as yawning and swallowing.
The mastoid antrum is a cavity in the mastoid process of the
The arteries of the pharyngotympanic tube are derived
temporal bone (Fig. 7.114A). The antrum (L. from G., cave),
from the ascending pharyngeal artery, a branch of the exter-
like the tympanic cavity, is separated from the middle cranial
nal carotid artery, and the middle meningeal artery and
fossa by a thin plate of the temporal bone, called the tegmen
artery of the pterygoid canal, branches of the maxillary artery
tympani. This structure forms the tegmental wall (roof) for
(Fig. 7.115; Table 7.12).
the ear cavities and is also part of the floor of the lateral part
The veins of the pharyngotympanic tube drain into the
of the middle cranial fossa. The mastoid antrum is the com-
pterygoid venous plexus. Lymphatic drainage of the tube
mon cavity into which the mastoid cells open. The antrum
is to the deep cervical lymph nodes (Fig. 7.111B).
and mastoid cells are lined by mucous membrane that is con-
The nerves of the pharyngotympanic tube arise from
tinuous with the lining of the middle ear. Antero-inferiorly,
the tympanic plexus (Fig. 7.114B), which is formed by fibers of
the antrum is related to the canal for the facial nerve.
the glossopharyngeal nerve (CN IX). Anteriorly, the tube also
receives fibers from the pterygopalatine ganglion (Fig. 7.106A).
PHARYNGOTYMPANIC TUBE
The pharyngotympanic tube (auditory tube) connects the
AUDITORY OSSICLES
tympanic cavity to the nasopharynx, where it opens posterior
to the inferior nasal meatus (Fig. 7.113). The posterolateral The auditory ossicles form a mobile chain of small bones
third of the tube is bony, and the remainder is cartilaginous. across the tympanic cavity from the tympanic membrane to
The pharyngotympanic tube is lined by mucous membrane the oval window (L. fenestra vestibuli), an oval opening on
that is continuous posteriorly with that of the tympanic cavity the labyrinthine wall of the tympanic cavity leading to the
and anteriorly with that of the nasopharynx. vestibule of the bony labyrinth (Figs. 7.113B and 7.116A).
The function of the pharyngotympanic tube is to equalize These ossicles are the first bones to be fully ossified during
pressure in the middle ear with the atmospheric pressure, development and are essentially mature at birth. The bone
thereby allowing free movement of the tympanic membrane. from which they are formed is exceptionally dense (hard).

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 Chapter 7 • Head 971

Tegmen tympani [tegmental wall

(roof) of tympanic cavity]
Chorda tympani
Epitympanic recess
Tensor tympani Mastoid antrum
Aditus
*Opening of pharyngotympanic tube
in carotid (anterior) wall
*
Facial nerve
Internal carotid artery
Jugular wall (floor)
of tympanic cavity

Anterior Posterior

Tympanic membrane Sigmoid sinus

forming membranous
(lateral) wall

(A) Superomedial view Superior bulb of internal jugular vein

Epitympanic recess Lesser petrosal nerve

Prominence of lateral
Malleus semicircular canal
Incus
Stapes Facial nerve
Aditus to mastoid antrum
Chorda tympani (forming posterior wall)
Walls of tympanic cavity:
Prominence of canal
Tensor tympani for facial nerve Tegmental wall (roof)
Jugular wall (floor)
Tympanic Tympanic plexus on
Membranous (lateral) wall
membrane promontory of
labyrinthine wall Labyrinthine (medial) wall
Mastoid (posterior) wall
Stapedius
Carotid (anterior) wall was
Pyramidal eminence
removed to provide this view

(B) Anterior view Tympanic nerve (from CN IX)

FIGURE 7.114. Walls of tympanic cavity. A. This specimen was dissected with a drill from the medial aspect. The tegmen tympani, forming the roof of
the tympanic cavity and the mastoid antrum, is fairly thick in this specimen; usually it is extremely thin. The internal carotid artery is the main relation of
the anterior wall, the internal jugular vein is the main relation of the floor, and the facial nerve (CN VII) is a main feature of the posterior wall. The chorda
tympani passes between the malleus and the incus. B. In this view of the middle ear, the carotid (anterior) wall of the tympanic cavity has been removed. The
tympanic membrane forms most of the membranous (lateral) wall; superior to it is the epitympanic recess, in which are housed the larger parts of the mal-
leus and incus. Branches of the tympanic plexus provide innervation to the mucosa of the middle ear and adjacent pharyngotympanic tube; but one branch,
the lesser petrosal nerve, is conveying presynaptic parasympathetic fibers to the otic ganglion for secretomotor innervation of the parotid gland.

The ossicles are covered with the mucous membrane lining malleus moves with the membrane. The head of the malleus
the tympanic cavity; but unlike other bones, they lack a sur- articulates with the incus; the tendon of the tensor tympani
rounding layer of osteogenic periosteum. inserts into its handle near the neck. The chorda tympani
Malleus. The malleus (L. a hammer) attaches to the tym- crosses the medial surface of the neck of the malleus. The
panic membrane. The rounded superior head of the mal- malleus functions as a lever, with the longer of its two pro-
leus lies in the epitympanic recess (Fig. 7.116B). The neck cesses and its handle attached to the tympanic membrane.
of the malleus lies against the flaccid part of the tympanic Incus. The incus (L. an anvil) is located between the malleus
membrane, and the handle of the malleus is embedded in and the stapes and articulates with them. It has a body and two
the tympanic membrane, with its tip at the umbo; thus the limbs. Its large body lies in the epitympanic recess (Fig. 7.116A),

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 972 Chapter 7 • Head

External acoustic meatus

Auricular branch of
vagus nerve Auriculotemporal
nerve
Facial nerve Secretory branches
(CN VII)
Maxillary artery
Mastoid process
External carotid artery
Posterior belly
of digastric
Occipital artery

Accessory meningeal a.
Area shown in (A) Glossopharyngeal
Middle meningeal a. nerve (CN IX)
Anterior
tympanic a. Ascending
Spinal accessory
nerve (CN XI) pharyngeal artery
Deep
External carotid
auricular a. Vagus nerve artery
(CN X)
Superficial Hypoglossal nerve
temporal a. (CN XII)
Pterygoid a. Internal
Masseter a. jugular vein Internal
Maxillary artery (a.)
carotid artery
External carotid a. (A) Lateral view
Inferior alveolar a.

(B) Lateral view

FIGURE 7.115. Neurovascular structures in vicinity of external and middle ear. A. In this dissection of structures deep to parotid bed, the facial nerve
(CN VII), the posterior belly of the digastric muscle, and the nerve to it are retracted. The deeply placed ascending pharyngeal artery is the only medial
branch of the external carotid artery. It supplies the pharynx, palatine tonsil, pharyngotympanic tube, and the medial wall of the tympanic cavity before it
terminates by sending meningeal branches to the cranial cavity. B. Maxillary artery and its branches. The branches of the first (mandibular) part supply the
external acoustic meatus and tympanic membrane. The middle meningeal artery sends branches to the pharyngotympanic tube before entering the cranium
through the foramen spinosum.

where it articulates with the head of the malleus (Fig. 7.116C). Muscles Associated with Auditory Ossicles. Two
The long limb lies parallel to the handle of the malleus, and its muscles dampen or resist movements of the auditory ossicles;
interior end articulates with the stapes by way of the lenticular one also dampens movements (vibration) of the tympanic
process, a medially directed projection. The short limb is con- membrane. The tensor tympani is a short muscle that arises
nected by a ligament to the posterior wall of the tympanic cavity. from the superior surface of the cartilaginous part of the pha-
Stapes. The stapes (L. stirrup) is the smallest ossicle. It ryngotympanic tube, the greater wing of the sphenoid, and the
has a head, two limbs, and a base (Fig. 7.116D). Its head, petrous part of the temporal bone (Figs. 7.113A and 7.114).
directed laterally, articulates with the incus (Fig. 7.116A). The The muscle inserts into the handle of the malleus. The ten-
base (footplate) of the stapes fits into the oval window on the sor tympani pulls the handle medially, tensing the tympanic
medial wall of the tympanic cavity. The oval base is attached membrane and reducing the amplitude of its oscillations.
to the margins of the oval window. The base of the stapes is This action tends to prevent damage to the internal ear when
considerably smaller than the tympanic membrane; as a result, one is exposed to loud sounds. The tensor tympani is sup-
the vibratory force of the stapes is increased approximately 10 plied by the mandibular nerve (CN V3).
times over that of the tympanic membrane. Consequently, the The stapedius is a tiny muscle inside the pyramidal
auditory ossicles increase the force but decrease the amplitude eminence (pyramid), a hollow, cone-shaped prominence on
of the vibrations transmitted from the tympanic membrane the posterior wall of the tympanic cavity (Figs. 7.112B and
through the ossicles to the internal ear (see Fig. 7.120). 7.114B). Its tendon enters the tympanic cavity by emerging

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 Chapter 7 • Head 973

Epitympanic recess
Incus
Base of stapes occupying
oval window
Malleus
Stapes

External
acoustic Tympanic cavity
meatus

Tympanic Pharyngotympanic tube

membrane

(A) Anterior view of coronal section through middle ear

Head Anterior Head

Body
limb
Posterior
Neck Short limb limb
Lateral Long limb Superior view Base
process
Lenticular
Handle process
Posteromedial views Medial view

Head “Cog”
Body Head
Anterior
process Short Neck
limb
Posterior
Neck Long limb Anterior limb
limb
Handle Lenticular Base
process (footplate)
Medial views
Superolateral view

(B) MALLEUS (C) INCUS (D) STAPES

FIGURE 7.116. Auditory ossicles. A. The ossicles in situ are shown. B–E. The isolated ossicles are shown.

from a pinpoint foramen in the apex of the eminence and labyrinth, containing endolymph, is suspended within the
inserts on the neck of the stapes. The stapedius pulls the sta- perilymph-filled bony labyrinth, either by delicate filaments
pes posteriorly and tilts its base in the oval window, thereby similar to the filaments of arachnoid mater that traverse the
tightening the anular ligament and reducing the oscillatory subarachnoid space or by the substantial spiral ligament. It
range. It also prevents excessive movement of the stapes. The does not float. These fluids are involved in stimulating the
nerve to the stapedius arises from the facial nerve (CN VII). end organs for balance and hearing, respectively.

Internal Ear BONY LABYRINTH

The internal ear contains the vestibulocochlear organ The bony labyrinth is a series of cavities (cochlea, vestibule,
concerned with the reception of sound and the maintenance and semicircular canals) contained within the otic capsule
of balance. Buried in the petrous part of the temporal bone of the petrous part of the temporal bone (Figs. 7.113A and
(Figs. 7.113 and 7.117A), the internal ear consists of the sacs 7.117B). The otic capsule is made of bone that is denser
and ducts of the membranous labyrinth. The membranous than the remainder of the petrous temporal bone and can

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 974 Chapter 7 • Head

Direction of view for

parts B–D
Squamous part
of temporal bone
Cochlea Petrosquamous fissure
Anterior
Semicircular
Lateral
canals Petrous part Of temporal
Posterior
Mastoid part bone
Vestibule
Vestibular aqueduct Internal acoustic meatus
Foramen magnum
(A) Superior view of internal surface of cranial base

Anterior semicircular canal

and bony ampulla
Lateral semicircular
Facial canal, opened canal and bony ampulla
(canal for facial
nerve)
Cupula Posterior
semicircular
Cochlea 2nd turn canal and
bony ampulla
1st turn
Round window Vestibule and oval window
(B) Anterolateral view of left otic capsule

Lateral semicircular duct

Anterior semicircular duct
and membranous Common crus
ampulla
Posterior
Cochlear duct semicircular
duct
Saccule Utricle
Secondary tympanic
Ductus membrane
reuniens
Endolymphatic sac
(C) Anterolateral view of left membranous labyrinth
(through transparent otic capsule)

Anterior semicircular
duct and membranous
ampulla (with ampulla crest)
Cochlear duct Maculae
Saccule
Utriculosaccular
duct
Ductus reuniens

Endolymphatic duct
Lateral semicircular duct Endolymphatic sac
Posterior semicircular duct
(D) Anterolateral view of left membranous labyrinth
FIGURE 7.117. Bony and membranous labyrinths of internal ear. A. This view of the interior of the base of the cranium shows the temporal bone and
the location of the bony labyrinth. B. The walls of the bony labyrinth have been carved out of the petrous temporal bone. C. A similar view of the bony
labyrinth occupied by perilymph and the membranous labyrinth is shown. D. The membranous labyrinth, shown after removal from the bony labyrinth, is a
closed system of ducts and chambers filled with endolymph and bathed by perilymph. It has three parts: the cochlear duct, which occupies the cochlea; the
saccule and utricle, which occupy the vestibule; and the three semicircular ducts, which occupy the semicircular canals. The utricle communicates with the
saccule through the utriculosaccular duct. The lateral semicircular duct lies in the horizontal plane and is more horizontal than it appears in this drawing.

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 Chapter 7 • Head 975

be isolated (carved) from it using a dental drill. The otic cap- differing in composition from the surrounding perilymph
sule is often erroneously illustrated and identified as being (which is like extracellular fluid) that fills the remainder of the
the bony labyrinth. However, the bony labyrinth is the fluid- bony labyrinth. The membranous labyrinth—composed of
filled space, which is surrounded by the otic capsule, and is two divisions, the vestibular labyrinth and the cochlear laby-
most accurately represented by a cast of the otic capsule after rinth—consists of more parts than does the bony labyrinth:
removal of the surrounding bone.
• Vestibular labyrinth: utricle and saccule, two small
Cochlea. The cochlea is the shell-shaped part of the
communicating sacs in the vestibule of the bony labyrinth.
bony labyrinth that contains the cochlear duct (Fig. 7.117C),
• Three semicircular ducts in the semicircular canals.
the part of the internal ear concerned with hearing. The spi-
• Cochlear labyrinth: cochlear duct in the cochlea.
ral canal of the cochlea begins at the vestibule and makes
2.5 turns around a bony core, the modiolus (Fig. 7.118), the The spiral ligament, a spiral thickening of the periosteal
cone-shaped core of spongy bone about which the spiral canal lining of the cochlear canal, secures the cochlear duct to the
of the cochlea turns. The modiolus contains canals for blood spiral canal of the cochlea (Fig. 7.118). The remainder of
vessels and for distribution of the branches of the cochlear the membranous labyrinth is suspended by delicate filaments
nerve. The apex of the cone-shaped modiolus, like the axis of that traverse the perilymph.
the tympanic membrane, is directed laterally, anteriorly, and The semicircular ducts open into the utricle through
inferiorly. The large basal turn of the cochlea produces the five openings, reflective of the way the surrounding semicir-
promontory of the labyrinthine wall of the tympanic cavity cular canals open into the vestibule. The utricle communi-
(Fig. 7.114B). At the basal turn, the bony labyrinth communi- cates with the saccule through the utriculosaccular duct,
cates with the subarachnoid space superior to the jugular fora- from which the endolymphatic duct arises (Fig. 7.117D).
men through the cochlear aqueduct (Fig. 7.113B). It also The saccule is continuous with the cochlear duct through
features the round window (L. fenestra cochleae), closed by the ductus reuniens, a uniting duct. The utricle and saccule
the secondary tympanic membrane (Fig. 7.117B & C). have specialized areas of sensory epithelium called maculae.
Vestibule of Bony Labyrinth. The vestibule of the The macula of the utricle (L. macula utriculi) is in the floor
bony labyrinth is a small oval chamber (approximately 5 of the utricle, parallel with the base of the cranium, whereas
mm long) that contains the utricle and saccule (Fig. 7.117C) the macula of the saccule (L. macula sacculi) is vertically
and parts of the balancing apparatus (vestibular labyrinth). placed on the medial wall of the saccule. The hair cells in
The vestibule features the oval window on its lateral wall, the maculae are innervated by fibers of the vestibular divi-
occupied by the base of the stapes. The vestibule is continu- sion of the vestibulocochlear nerve. The primary sensory
ous with the bony cochlea anteriorly, the semicircular canals neurons are in the vestibular ganglia (Fig. 7.119), which
posteriorly, and the posterior cranial fossa by the vestibu- are in the internal acoustic meatus.
lar aqueduct (Fig. 7.113B). The aqueduct extends to the The endolymphatic duct traverses the vestibular aqueduct
posterior surface of the petrous part of the temporal bone, (Fig. 7.113B) and emerges through the bone of the posterior
where it opens posterolateral to the internal acoustic meatus cranial fossa, where it expands into a blind pouch called the
(Fig. 7.117A). The vestibular aqueduct transmits the endo- endolymphatic sac (Figs. 7.113B, 7.117C and 7.119). The
lymphatic duct (Figs. 7.113B and 7.117D) and two small endolymphatic sac is located under the dura mater on the
blood vessels. posterior surface of the petrous part of the temporal bone.
Semicircular Canals. The semicircular canals (ante- The sac is a storage reservoir for excess endolymph, formed
rior, posterior, and lateral) communicate with the ves- by the blood capillaries in the membranous labyrinth.
tibule of the bony labyrinth (Fig. 7.117B). The canals lie Semicircular Ducts. Each semicircular duct has an
posterosuperior to the vestibule into which they open; they ampulla at one end containing a sensory area, the ampul-
are set at right angles to each other. The canals occupy three lary crest (L. crista ampullari) (Fig. 7.119). The crests are
planes in space. Each semicircular canal forms approxi- sensors for recording movements of the endolymph in the
mately two thirds of a circle, and is approximately 1.5 mm ampulla resulting from rotation of the head in the plane of
in diameter, except at one end where there is a swelling, the the duct. The hair cells of the crests, like those of the mac-
bony ampulla. The canals have only five openings into the ulae, stimulate primary sensory neurons, whose cell bodies
vestibule because the anterior and posterior canals have one are in the vestibular ganglia.
limb common to both. Lodged within the canals are the semi- Cochlear Duct. The cochlear duct is a spiral tube,
circular ducts (Fig. 7.117C & D). closed at one end and triangular in cross section. The duct is
firmly suspended across the cochlear canal between the spiral
ligament on the external wall of the cochlear canal (Fig. 7.118)
MEMBRANOUS LABYRINTH
and the osseous spiral lamina of the modiolus. Spanning the
The membranous labyrinth consists of a series of commu- spiral canal in this manner, the endolymph-filled cochlear duct
nicating sacs and ducts that are suspended in the bony laby- divides the perilymph-filled spiral canal into two channels that
rinth (Fig. 7.117C). The labyrinth contains endolymph, a are continuous at the apex of the cochlea at the helicotrema,
watery fluid similar in composition to intracellular fluid, thus a semilunar communication at the apex of the cochlea.

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 976 Chapter 7 • Head

Osseous
spiral lamina

Cochlear nerve
Modiolus

Spiral (cochlear) Scala vestibuli

ganglion with cut edge
Otic capsule Spiral ganglion Cochlear duct

Vestibular membrane Spiral organ

Osseous Tectorial membrane
spiral lamina Vascular stria
Cochlear Internal spiral sulcus
duct Border cells Cells of Hensen
Cochlear nerve
(enters modiolus) Spiral ligament
Scalae Osseous
communicating spiral lamina Basilar membrane
via helicotrema
(arrow) Cochlear nerve Outer hair cells

Spiral ganglion Inner hair cells Scala tympani

Section of cochlea

Spiral ganglion

FIGURE 7.118. Structure of cochlea. The cochlea has been sectioned along the axis about which the cochlea winds (see orientation figure). An isolated,
cone-like, bony core of the cochlea, the modiolus, is shown after the turns of the cochlea are removed, leaving only the spiral lamina winding around it like
the thread of a screw. Details of the area enclosed in the rectangle are also shown.

Waves of hydraulic pressure created in the perilymph The roof of the cochlear duct is formed by the vestibular
of the vestibule by the vibrations of the base of the stapes membrane. The floor of the duct is also formed by part of the
ascend to the apex of the cochlea by one channel, the scala duct, the basilar membrane, plus the outer edge of the osse-
vestibuli (Fig. 7.120). The pressure waves then pass through ous spiral lamina. The receptor of auditory stimuli is the spiral
the helicotrema and descend back to the basal turn of the organ (of Corti), situated on the basilar membrane (Fig. 7.118).
cochlea by the other channel, the scala tympani. Here, the It is overlaid by the gelatinous tectorial membrane.
pressure waves again become vibrations, this time of the sec- The spiral organ contains hair cells, the tips of which
ondary tympanic membrane in the round window, and the are embedded in the tectorial membrane. The organ is
energy initially received by the (primary) tympanic mem- stimulated to respond by deformation of the cochlear duct
brane is finally dissipated into the air of the tympanic cavity. induced by the hydraulic pressure waves in the perilymph,

Internal Spiral Cochlear Maculae Utricle Semicircular duct

acoustic (cochlear) duct
Midbrain
meatus ganglion Ampullae of
Cochlear semicircular
Cochlear
nerve Pons ducts (containing
CN VIII nerve
ampullary crests)
Vestibular
nerve

Medulla Vestibulocochlear Vestibular

oblongata nerve (CN VIII) nerve
Vestibular Saccule Endolymphatic sac
ganglion

FIGURE 7.119. Vestibulocochlear nerve. CN VIII has two parts: the cochlear nerve (the nerve of hearing) and the vestibular nerve (the nerve of balance).
The cell bodies of the scensory fibers that make up the two parts of this nerve constitute the spiral and vestibular ganglia.

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 Chapter 7 • Head 977

Incus Stapes

Base plate Helicotrema Cochlear nerve

of stapes in (CN VIII)
oval window
Malleus
3

Tympanic Scala vestibuli

membrane 2 4 Contain
6 perilymph
5 Scala tympani
5
External
acoustic Tectorial
meatus 1 membrane
7
6

Secondary Cochlear duct (contains

tympanic spiral organ and
membrane endolymph)
in round
window Pharyngotympanic tube

FIGURE 7.120. Sound transmission through the ear. The cochlea is depicted schematically as if consisting of a single coil to demonstrate the transmis-
sion of sound stimuli through the ear. 1, Sound waves entering the external ear strike the tympanic membrane, causing it to vibrate. 2, Vibrations initiated
at the tympanic membrane are transmitted through the ossicles of the middle ear and their articulations. 3, The base of the stapes vibrates with increased
strength and decreased amplitude in the oval window. 4, Vibrations of the base of the stapes create pressure waves in the perilymph of the scala vestibuli.
5, Pressure waves in the scala vestibuli cause displacement of the basilar membrane of the cochlear duct. Short waves (high pitch) cause displacement near
the oval window; longer waves (low pitch) cause more distant displacement, nearer to the helicotrema at the apex of the cochlea. Movement of the basilar
membrane bends the hair cells of the spiral organ. Neurotransmitter is released, stimulating action potentials conveyed by the cochlear nerve to the brain. 6,
Vibrations are transferred across the cochlear duct to the perilymph of the scala tympani. 7, Pressure waves in the perilymph are dissipated (dampened) by
the secondary tympanic membrane at the round window into the air of the tympanic cavity.

which ascend and descend in the surrounding scalae ves- opening is in the posteromedial part of this bone, in line with
tibuli and tympani. the external acoustic meatus. The internal acoustic meatus is
closed laterally by a thin, perforated plate of bone that sepa-
rates it from the internal ear. Through this plate pass the facial
INTERNAL ACOUSTIC MEATUS
nerve (CN VII), the vestibulocochlear nerve (CN VIII) and
The internal acoustic meatus is a narrow canal that runs its divisions, and blood vessels. The vestibulocochlear nerve
laterally for approximately 1 cm within the petrous part of the divides near the lateral end of the internal acoustic meatus into
temporal bone (Fig. 7.117A). The internal acoustic meatus two parts: a cochlear nerve and a vestibular nerve (Fig. 7.119).

EAR Otoscopic Examination

External Ear Injury Examination of the external acoustic meatus and tym-
panic membrane begins by straightening the meatus.
Bleeding within the auricle resulting from trauma In adults, the helix is grasped and pulled posterosupe-
may produce an auricular hematoma. A localized riorly (up, out, and back). These movements reduce the curva-
collection of blood forms between the perichon- ture of the external acoustic meatus, facilitating insertion of the
drium and auricular cartilage, causing distortion of the con- otoscope (Fig. B7.42A). The meatus is relatively short in infants;
tours of the auricle. As the hematoma enlarges, it compromises therefore, extra care must be exercised to prevent injury to the
the blood supply to the cartilage. If untreated (e.g., by aspira- tympanic membrane. The meatus is straightened in infants by
tion of blood), fibrosis (formation of fibrous tissue) develops pulling the auricle inferoposteriorly (down and back). The
in the overlying skin, forming a deformed auricle (e.g., the examination also provides a clue to tenderness, which can indi-
cauliflower or boxer’s ear of some professional boxers and cate inflammation of the auricle and/or the meatus.
wrestlers).

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 978 Chapter 7 • Head

5
4
2

(A) (B)

FIGURE B7.42. A. Otoscopic examination. B. Normal tympanic membrane. 1, cone of light; 2, handle of malleus; 3, umbo; 4, long limb of incus;
5, posterior limb of stapes.

The tympanic membrane is normally translucent and ear is often secondary to upper respiratory infections.
pearly gray (Fig. B7.42B). The handle of the malleus is usu- Inflammation and swelling of the mucous membrane lining the
ally visible near the center of the membrane (the umbo). tympanic cavity may cause partial or complete blockage of the
From the inferior end of the handle, a bright cone of light is pharyngotympanic tube (Fig. 7.109). The tympanic membrane
reflected from the otoscope’s illuminator. This light reflex is becomes red and bulges, and the person may complain of “ear
visible radiating antero-inferiorly in the healthy ear. popping.” An amber-colored bloody fluid may be observed
through the tympanic membrane. If untreated, otitis media
Acute Otitis Externa may produce impaired hearing owing to scarring of the audi-
tory ossicles, limiting their ability to move in response to sound.
Otitis externa is an inflammation of the external
acoustic meatus. The infection often develops in Perforation of Tympanic Membrane
swimmers who do not dry their meatus (ear canals)
after swimming and/or use ear drops. The inflammation may Perforation of the tympanic membrane (“ruptured
also be the result of a bacterial infection of the skin lining the eardrum”) may result from otitis media and is one
meatus. The affected individual complains of itching and of several causes of middle ear deafness. Perforation
pain in the external ear. Pulling the auricle or applying pres- may also result from foreign bodies in the external acoustic
sure on the tragus increases the pain. meatus, trauma, or excessive pressure (e.g., during scuba div-
ing). Minor ruptures of the tympanic membrane often heal
spontaneously. Large ruptures usually require surgical repair.
Otitis Media Because the superior half of the tympanic membrane is
An earache and a bulging red tympanic membrane much more vascular than the inferior half, incisions to release
may indicate pus or fluid in the middle ear, a sign of pus from a middle ear abscess (myringotomy), for example,
otitis media (Fig. B7.43A). Infection of the middle are made postero-inferiorly through the membrane

Manubrium Manubrium
of Malleus of Malleus
Manubrium
Air-fluid of Malleus
Meniscus

Air-fluid Levels

Umbo
Myringotomy

Pope Tympanostomy Tube

Light Reflex

(A) Otitis media (B) Myringotomy incision (C) Tympanostomy tube inserted

FIGURE B7.43.

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 Chapter 7 • Head 979

(Fig. B7.43B). This incision also avoids injury to the chorda Paralysis of Stapedius
tympani nerve and auditory ossicles. In persons with chronic
middle ear infections, myringotomy may be followed by The tympanic muscles have a protective action in
insertion of tympanostomy or pressure-equalization (PE) that they dampen large vibrations of the tympanic
tubes in the incision to enable drainage of effusion and ven- membrane resulting from loud noises. Paralysis of
tilation of pressure (Fig. B7.43C). the stapedius (e.g., resulting from a lesion of the facial nerve)
is associated with excessive acuteness of hearing, called
hyperacusis or hyperacusia. This condition results from
Mastoiditis uninhibited movements of the stapes.
Infections of the mastoid antrum and mastoid
cells (mastoiditis) result from a middle ear infec- Motion Sickness
tion that causes inflammation of the mastoid pro-
cess (Fig. B7.44). Infections may spread superiorly into The maculae of the membranous labyrinth are pri-
the middle cranial fossa through the petrosquamous fis- marily static organs, which have small dense parti-
sure in children and cause osteomyelitis (bone infection) cles (otoliths) embedded among hair cells. Under
of the tegmen tympani. Since the advent of antibiotics, the influence of gravity, the otoliths cause bending of the hair
mastoiditis is uncommon. During operations for mastoid- cells, which stimulate the vestibular nerve, and provide
itis, surgeons are conscious of the course of the facial awareness of the position of the head in space; the hairs also
nerve to avoid injuring it. One point of access to the tym- respond to quick tilting movements and to linear accelera-
panic cavity is through the mastoid antrum. In children, tion and deceleration. Motion sickness results from discor-
only a thin plate of bone must be removed from the lat- dance between vestibular and visual stimulation.
eral wall of the antrum to expose the tympanic cavity. In
adults, bone must be penetrated for 15 mm or more. At Dizziness and Hearing Loss
present, most mastoidectomies are endaural (i.e., per-
formed through the posterior wall of the external acoustic Injuries of the peripheral auditory system cause three
meatus). major symptoms: hearing loss (usually conductive hear-
ing loss), vertigo (dizziness) when the injury involves
the semicircular ducts, and tinnitus (buzzing or ringing) when the
injury is localized in the cochlear duct. Tinnitus and hearing loss
may result from lesions anywhere in the peripheral or central
auditory pathways. The two types of hearing loss are as follows:
• Conductive hearing loss: resulting from anything in the
external or middle ear that interferes with conduction of
sound or movement of the oval or round windows. Peo-
ple with this type of hearing loss often speak with a soft
voice because, to them, their own voices sound louder
than background sounds. This type of hearing loss may be
improved surgically or by use of a hearing aid device.
FIGURE B7.44. Mastoiditis (ruptured retro-auricular abscess).
• Sensorineural hearing loss: resulting from defects in the
pathway from cochlea to brain: defects of the cochlea,
cochlear nerve, brainstem, or cortical connections. Cochlear
implants are one approach employed to restore sound per-
Blockage of ception when the hair cells of the spiral organ have been
damaged (Fig. B7.45). Sound received by a small exter-
Pharyngotympanic Tube
nal microphone are transmitted to an implanted receiver
The pharyngotympanic tube forms a route for an that sends electrical impulses to the cochlea, stimulating
infection to pass from the nasopharynx to the tym- the cochlear nerve. Hearing remains relatively crude but
panic cavity. This tube is easily blocked by swelling enables perception of rhythm and intensity of sounds.
of its mucous membrane, even as a result of mild infections
(e.g., a cold), because the walls of its cartilaginous part are
normally already in apposition. When the pharyngotympanic
Ménière Syndrome
tube is occluded, residual air in the tympanic cavity is usually Ménière syndrome is related to excess endolymph
absorbed into the mucosal blood vessels, resulting in lower production or blockage of the endolymphatic duct
pressure in the tympanic cavity, retraction of the tympanic (Fig. 7.113B) and is characterized by recurrent attacks
membrane, and interference with its free movement. Finally, of tinnitus, hearing loss, and vertigo. These symptoms are
hearing is affected. accompanied by a sense of pressure in the ear, distortion of

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 980 Chapter 7 • Head
sounds, and sensitivity to noises (Storper, 2010). A characteristic
External coil Internal coil sign is ballooning of the cochlear duct, utricle, and saccule
caused by an increase in endolymphatic volume.
Ground electrode in
epitympanic recess
Cochlear
nerve High Tone Deafness
Persistent exposure to excessively loud sounds
causes degenerative changes in the spiral organ,
resulting in high tone deafness. This type of hearing
Cochlea loss commonly occurs in workers who are exposed to loud
Active
noises and do not wear protective earmuffs (e.g., individuals
Microphone
electrode working for long periods around jet engines).
Tympanic membrane
Stimulator wire from Otic Barotrauma
microphone to speech
processor Pharyngotympanic Injury caused to the ear by an imbalance in pressure
tube
Stimulator wire from speech between ambient (surrounding) air and the air in the
processor to external coil middle ear is called otic barotrauma. This type of
FIGURE B7.45. Cochlear implant. injury usually occurs in fliers and divers.

The Bottom Line

The ear is divided into external, middle, and internal parts. suspended within a bony cave otherwise occupied by extracel-
¨ All three parts are concerned with the sense of hearing, but lular fluid (perilymph). ¨ Although much larger and slightly less
the internal ear also has a vestibular function. ¨ The external complex, the architecture of the bony labyrinth is a reflection of
ear is a funnel-like conduit for airborne sound waves to reach that of the membranous labyrinth. ¨ The posterior portion of
the middle ear. ¨ The protruding auricle and lateral part of the bony labyrinth takes the form of three semicircular canals
the external acoustic meatus have an elastic cartilage skeleton and ducts; the ampulla of each of the ducts contains an ampul-
that allows flexibility. ¨ The primary sensory innervation of the lary crest that is sensitive to motion of the head. ¨ The central
external ear is provided by CN V and CN X. ¨ The tympanic bony vestibule contains a membranous utricle and saccule, each
membrane responds to airborne sound waves, converting them provided with a macula to monitor the position of the head
to vibrations transmitted by the solid medium of the ossicles of relative to the line of gravitational pull. ¨ The neuroepithelial
the middle ear. ¨ Because its entire lateral wall is formed by a crests and maculae are innervated by the vestibular portion of
thin membrane, the middle ear (tympanic cavity) is a pressure- CN VIII. ¨ The anterior portion of the internal ear contains a
sensitive space, ventilated by means of the pharyngotympanic membranous cochlear duct, suspended between two limbs of
tube. ¨ The mucosa lining both the cavity and tube is inner- continuous pathway for the sonar waves that are conducted
vated by CN IX. ¨ At the oval window, between the middle by the perilymph; the duct and perilymphatic channels spiral
and internal ears, the solid medium vibrations of the ossicles through the 2.5 turns of the bony cochlea. ¨ Deformation of
are converted to fluid-borne sonar waves. ¨ The internal ear the spiral organ within the cochlear duct by the sonar waves
consists of a delicate and complex membranous labyrinth stimulates impulses conducted by the cochlear part of CN VIII
filled with fluid that resembles intracellular fluid (endolymph), for the sense of hearing.

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