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1st and 2nd brachial arch ectoderm: external year

1st and 2nd brachial arch endoderm: middle aero

Otic capsule: inner ear

Anterior: x. Infra temporal fossa

Posterior: x. Mastoid

Roof : tegmen tympani. Middle cranial fossa

Lateral : tympanic membrane. External ear

Medial: Promontory. Inner ear

Floor : x. Jugular bulb

Middle ear is at the junction of

pp fossa and infra temporal fossa

Epi tympanum, widest

Meso tympanum, narrowest

Hypo tympanum

Division Based on ear ossicles

Attachment of malleus

malleus has two attachments

Anterior malleolar fold

Posterior malleolar fold

Pars flaccida: sharpnels membrane, 30

Pars tensa: functional tympanic membrane, 60

Total area: 90 mm square

Diameter: 1 cm

Thickness: 0.1 cm

Cone of light: anterior inferior area

This is where the incision is given

Malleus shadow is seen on tympanic membrane

Most common/ earliest dysfunction is Eustachian tube dysfunction

Retraction pocket formation: most accepted hypothesis for any pathology

Retraction can be in flaccida or tensa

TOSS classification is for flaccida

SADE classification is for tensa

Stapes attaches at oval window

Below is the round window, function is to maintain phase dierence

Extra pressure is released by it


handle of the malleus:

Reliable marker of middle ear

Lenticular process of incus: long process of incus

Earliest site for necrosis because it has a tortuous

blood supply

Most common site for otosclerosis: foot plate of stapes

Malleus and incus from 1st brachial arch

Stapes from 2nd brachial arch

Medial surface of stapes coming from Otic capsule(neuro ectoderm)

Handle of malleus: manubrium

Below flaccida, above malleus is the area where cholestoma first formed

ka Prussack space

Tympanic plexus: 9th and 10th nerve form it

Fibre of 9th nerve: jacobsons fibers

Fibre of 10th nerve: these are sympathetic fibers of vagus

These are not Arnold fibers as given in some books

Divide middle ear in two parts: anterior to ossicle and posterior to ossicle

Two muscles: tensor tympani

Pyramid is on posterior wall

Processus cochlearformis on the promontory

We label the structure in middle ear depending on the important

structure in the vicinity

Mnemonic for anterior wall

Tensor tympani

Eustachian tube

carotid Artery

Rectangle formation




a small track or sinus in the

middle ear

Sinus tympani

Behind the oval window

Behind the processus cochlearformis

It can only be felt, not seen

Dicult to clean

Therefore this is the most common area where

we leave the disease

That is why, magnification increased during surgery

Two attachments

Upper: ponticulus

Lower: subiculum

Mastoid is posterior to middle ear

Mastoid cavity: Antrum

Epi tympanum: attic

Aditus: duct or communication between attic and Antrum

Thickness of mastoid lateral wall in newborn: 1 mm

Adult : 15 mm

Rate Of growth: 1mm per year

Age at which child attains full thickness: 15 years

korner septum is similar to mastoid cavity

It is in the lateral wall of mastoid

Therefore when we reach the septum, we feel that we have entered the
mastoid cavity

It dierentiates the superficial air cells and deep air cells

It is a Petrosquamous suture at the depth of 5 mm

External auditory canal


In front is ante

Outer rim of pinna is ka helix

Second rim is anti helix

Groove between these is called scaphoid fossa

Lobule is lower end and is fibro fatty tissue

Above this is cartilaginous tragus

Triangular fossa in upper one third

One mm below this

is another fossa

This is lateral wall

of mastoid


Cymba concha


Point in


Incisura terminalis

Lempert end aural incision

Above tragus and below helix

lobule is the last structure to devlop in intrauterine life

Tragus from 1st brachial arch

Rest of pinna from second

Congenital anamolies of ear

Bat ear: no anti helix

Mozaic ear: mixing of helix and anti helix

Wilder smith ear: no helix

Hillock of His

Preauricular sinus: incomplete fusion between the hillocks

Mostly in 1st branchial arch

Symptom: discharge

Mx: Sx

Symptom : discharge

Mx: Sx

Lower opening in neck

It is in between mandible and sternocleidomastoid muscle

Upper opening in floor of EAC


inner ear is divided anterior to posterior

inner ear is a ball in a ball or a box in a box

Membranous in bony

Membranous has endo lymph, rich in potassium

Bony has peri lymph, rich in sodium

Cochlea is snail shaped

Turns are 2 and 3/4

Peri lymph is ultra filtered CSF/ serum

Aquaduct advantage: secretion of CSF

Disadvantage: infection

infection to brain from inner ear

Goes from aquaduct

Cochlear duct is defined as membranous part of cochlea that is the scala


Vestibular duct is defined as membranous part of vestibule

Both have endo lymph

Endo lymphatic sac

Blind sac

Formed by joining of membranous part

Endo lymphatic sac is aected in menier's disease

Hydrops of endo lymphatic sac

Back pressure aects cochlea leading to deafness

And vestibule leads to nystagmus and ataxia

Endo lymphatic sac is located in a pouch formed by the duramater in

epidural space

Although given as subdural in books

Sound is equal to:
Frequency(tone): type of sound, hertz(cochlea responds to 20-20000)

Intensity: volume of sound, decibel

Both are independent

Base of cochlea: high frequency

Apex of cochlea: low frequency

500, 1000, 2000 hz are the speech frequency that are measured

Above 25 decibel is cut o mark for hearing loss

Audiometry depends on the will of the patient

It is a subjective investigation

Objective Audiometry is needed

Single frequency at one time: pure tone Audiometry

Pure tone audio gram

deafness is patient responding to sound at more than 25 decibel

While if no sound heard: dead cochlea

In any type of deafness, one compartment abnormal, rest 3 normal

bone conduction is always normal

Masking done by white sound which is non specific given by Barany

noise box

Masking is equal to non specific sound= white sound= Barany noise box=
unwanted sound

We get a total of four graphs: two ( air and bone) for right and two for left

Subjective Audiometry always evaluates the pathway coz the microphone

is outside. It does not evaluate the compartments


Tympanic membrane is 21 times the oval window

Tense part is 14 times

Malleus is 1.3 times the stapes( lever action of middle ear)

Therefore amplify by 14* 1.3= 18 times

This is equal to 5-10 decibels

No air bone gap, no hearing loss: normal person

Air bone gap, mild hearing loss: conductive hearing loss

No air bone gap, severe hearing loss: sensory hearing loss

No air bone gap, very severe hearing loss: neural hearing loss

Therefore, no amplification in conductive hearing loss

Air bone gap is more than 15 decibels

Maximum hearing loss at 2000 hz, otosclerosis, car hart notch

Max hearing loss at 4000 hz, noise induced hearing loss

High frequency hearing loss, high age, presbycusis

menier's has low frequency hearing loss

Early hearing loss as well

Capacity of pure tone Audiometry: 250 to 8000

High frequency Audiometry= ototoxic drugs, 8000- 20000 hz

Tuning fork tests

256,512,1024 hz

512 is best heard, used in ENT

128-256 better felt, used by neuro medicine


Air conduction> bone conduction, normal/ sensory/ neural

B> A, conductive deafness

Unilateral severe sensorineural : false negative REINNE's

Trans cranial transmission of sound

Weber is centralized in normal person

Lateralized to normal ear in sensorineural deafness

Weber Lateralized to diseased ear in conductive deafness because there

is no disturbance of air conduction in diseased ear

Speech Audiometry

Decibel vs percentage of words

Decibel on x axis here

Words used here are very basic words

When the person repeats all the words, a plateau is reached

Anything on the right, deafness

Plateau will be touched at higher decibels

Patient of neural deafness is not able to sustain the plateau: roll over
phenomena, due to fatiguability of 8th cranial nerve

Decay test is used for fatiguability

Speech reception threshold( SRT) is the intensity at which the pt repeats

50% of the words

Unit is decibel

Add 20 decibel to the SRT and calculate the percentage of the word
repeated. This is known as Speech discrimination score(SDS)

Unit is %

Therefore it will always be more than the SRT

VERY poor SDS score is hallmark feature of neural deafness

Good SDS score for conductive deafness

Roll over phenomena= neural deafness= very poor SDS score

Objective speech Audiometry

X: conductive

Y: sensory

Z: neural

Maximum movement when pressure

is equal at both sides of the TM

TM hyper mobile


Ossicular dysfunction

TM thin

TM hypo mobile

Tympano fibrosis or sclerosis


Ossicular fibrosis or sclerosis


Normal is A, most commonly found

Ad is ossicular disruption

As is otosclerosis

Perforated: B

Fluid: flat

Eustachian tube dysfunction: C, therefore it is the most common

abnormal tympanograms

According to few books, B and flat tympanograms are same

Stapedial reflex

Reaction to very loud sound

Normal 8th nerve(aerent), 7th nerve(eerent), and normal middle ear is


Therefore it is a marker for middle ear

Tympanometry and Stapedial reflex done together by the electrode. This

is ka IMPEDENCE AUDIOMETRY denoted as the X above (x,y,z)

Electrocochleography is the Y

Electrode kept at the promontory

Less than 0.3 is normal

More than 0.45 is abnormal

Trans tympanic route is used which is invasive

Between 0.3 and 0.45 is borderline

Brain stem evoked response Audiometry

3 electrodes, 5 milestones, 7 waves

E: eighth nerve, (1,2 waves)

C: cochlear nucleus, (3)

O: olivary nucleus, (4)

L: lateral leminiscus, (5)

I: inferior colliculus, (6,7)

The stimulus fades down as it reaches the inferior colliculus

Therefore Cortical evoked response Audiometry is done

Non invasive

Fifth wave is the largest wave

If we use four electrodes, both the ears can be assessed

Menier's disease


Endo lymphatic hydrops

Increased secretion and decreased absorption

Treatment of menier's

Labyrinthine sedatives

Symptomatic treatment

If does not respond

Meniete device

Positive pressure therapy

Symptomatic treatment

Kept on pinna, not an internal device

Intra tympanic injection of gentamicin

To destroy the nerves to the vestibule

Most accepted Sx: decompression surgery

Shunt surgery to jugular vein if surgery can not be done

Chromosome 14>6>12

Important symptoms



Sensory deafness


If symptoms appear in a reverse order: Lermoyez syndrome

Tulio's phenomena: vertigo precipitated on exposure to loud sound in


TVS plus drop attacks: tumarkin's phenomena

Diplacusis: perceiving a single sound in two dierent ways

Menier's is always unilateral while otosclerosis is bilateral

Over sensitivity to small increase in intensity( one decibel) is ka

Recruitment phenomena

This is tested by Short increment sensitivity index( SISI) for cochlear





Pregnancy predisposes


Measles asso with otosclerosis

Mumps : most imp infection of sensorineural deafness

Otosclerosis with blue sclera with osteogenisis I perfecta: vonder hoeve


Most common site : foot plate of stapes, 99% of times

1% in cochlea ka cochlear otosclerosis

Anterior part of footplate of stapes

Conductive deafness

Treatment of choice: stapedectomy

Sodium fluoride given before stapedectomy

Increase osteoblast, decrease Osteoclast

New surgery: stapedotomy

After stapedectomy, we get Ad graph on tympanometry ( originally As)

Car hart notch will also disappear

Early stage of disease

Reddish TM membrane on otoscopy due to inflammation of foot stapes:

Shwartz sign/ flamingo pink sign

Never operate if this is positive, manage with sodium fluoride

Bluish stapes on histopathology, late sign: blue mantle sign

Cochlear otosclerosis

No carhart notch

W shaped graph is seen, cookie bite audio gram , hallmark feature

U shaped audio gram seen in congenital deafness

Acoustic neuroma

Most common cerebropontine angle tumor

Inferior vestibular nerve is most commonly involved


Radiological IOC is gladolinium enhanced MRI

Treatment of choice: Sx

If Sx can't be done: gamma knife radiotherapy

Causes pressure on all cranial nerve except first

Earliest is fifth

Therefore, loss of corneal reflex is the earliest sign

Seventh nerve is resistant to pressure therefore it is not involved initially

And then also, only sensory fibers are involved

Postero superior part of canal supplied by nerve of Wrisberg ( facial)

Loss of sensation is histelberger sign

Retraction of pars flaccida: toss

Tensa: Sade

Antoni classification: acoustic neuroma

Fisch classification: glomus tumors

Nelson classification: CSOM

HSEA classification: menier's

Ishika classification: thyroplasty

Wullestin : tympanoplasty

Menkerey classification: Congenital stenosis/ web

Nerve supply of auricle

Most common site for CSF otorrhea: tegmen tympani

Chorda tympani nerve goes in between malleus and incus

Facial recess is an area on the posterior wall bounded by

Posterior tympanotomy is done through this recess

Mc ewens triangle used for mastoid surgery

Trautmans triangle: posterior cranial fossa

Donaldson fossa: endo lymphatic sac

Glomus tumor
Para ganglioma
Aka chemodectoma: benign tumor of chemo receptive cells

Can occur anywhere in body

Glomus carotid

Glomus jugulare

Glomus tympanum

Nail bed is the most common site

Most common vascular tumor of the middle ear

Tympanum in promontory

Jugulare in the floor

Most common symptom: deafness

Treatment : Sx

Rising sun sign

Increase pressure, blanching seen: brown sign

Phelp sign: loss of bony partition seen in glomus jugulare

Infection of ear

Malignant otitis externa/ osteomyelitis of the skull base


Doc: third gen cephalosporins

Alternatives are penicillin, ciprofloxacin

Toc is debridement Sx

MOE = perichondritis=generalized otitis externa= pseudomonas

Furunculosis: staph

Epiglotitis= pharyngitis=sinusitis= otitis media= pneumococcus strep

One week child

Allergic OM

Due to milk

10 degree angle of ET

Upright feeding

6-24 months

Bulging TM

Serous/ glue

Small radial anterograde inferior incision to remove the mucus

Antibiotics, analgesics and anti allergics

Myringotomy with grommet


2 years

Mucus with pus

Circumferential incision

High grade fever

Bulging with congestion of TM

No grommet, foreign body granuloma

gets formed


Ear discharge and perforation

Safe and unsafe CSOM

Safe: tubotympanic

Unsafe: atticoantral ( attic, Antrum, aditus, pars flaccida)


Blood stained discharge, foul smelling, polyp, granulation

Therefore lower part safe and upper part unsafe



Clean cut perforation, damage to ossicles, basic anatomy preserved

Management of choice is tympanoplasty


Tympanic tags visible

Ossicles fully eroded

Basic anatomy is fully distorted

Modified radical mastoidectomy

PORT: partial ossicular replacement therapy: type 3

TORT: Total ossicular replacement therapy: type 5

Management of unsafe

Modified radical mastoidectomy

Remnants preserved

Never closed ET

Main reason was due to obstruction due to cholestatoma

Main purpose is to keep the ear dry

Aditus is usually narrow in these patients, so aditus is widened by

sacrificing the posterior wall but look for the facial nerve

Therefore, if only unsafe mentioned: don't damage post wall: canal wall
up MRM

If unsafe with complications: canal wall down MRM

Radical done

Extra cranial complications


Most common extra cranial complication

Most common overall complication

Most common symptom : discharge

Sign: tenderness on cymba concha

Ironing of mastoid : earliest sign

Retroauricular sinus gets obliterated, also the first sign

Pathognomonic sign: sagging of the canal

bezold abscess: pus along sternocleidomastoid

Digastric muscle: citelli abscess

Luc's abscess: within the canal

Post auric ulnar abscess : behind the pinna, most common abscess

Gradinego triad: fifth and sixth nerve palsy with persistent discharge

Facial palsy: tympanic part is involved

Labyrinthitis: inner ear involvement, lateral semi circular canal

Temp of water used is 37 degrees

No response at 40 ml, fully dead vestibule

Bithermic caloric test

Thirty and fourth four degrees


Lateral semi circular canal is maximally stimulated in caloric test

Benign paroxysmal positional vertigo

Posterior canal involved

Loose otoconia hit at particular position, made up of calcium carbonate

Applaise exercise is the treatment

Tinnitus test

All causes of tinnitus are subjective except AV malformation and

myoclonus of middle ear muscle which are objective

Pulsatile in glomus

Fistula test, press the tragus, negative in normal, positive in unsafe

False negative in dead labyrinth, extensive cholestoma

False positive in hyper mobile ossicles( congenital syphilis and menier's)

Sign seen in congenital syphilis: Hennebert sign