The mastoid bone surrounds the middle ear. The external ear collects sound waves. The ear canal carries sound waves to the eardrum. The eardrum vibrates from sound waves, setting the middle ear bones in motion. The middle ear bones (ossicles) vibrate, transmitting sound waves to the inner ear. When the ear is healthy, air pressure remains balanced in the middle ear. The eustachian tube helps control air pressure in the middle ear. The semicircular canals help maintain balance. The vestibular nerve carries balance signals to the brain. The auditory nerve carries sound signals to the brain. The cochlea picks up sound waves and makes nerve signals. 

Structure

Parts of the External Ear

The external ear can be divided functionally and structurally into two parts; the auricle (or pinna), and the external acoustic meatus – which ends at the tympanic membrane.

Auricle

The auricle is a paired structure found on either side of the head. It functions to capture and direct sound waves towards the external acoustic meatus.

It is a mostly cartilaginous structure, with the lobule being the only part not supported by cartilage. The cartilaginous part of the auricle forms an outer curvature, known as the helix. A second innermost curvature runs in parallel with the helix – the antihelix. The antihelix divides into two cura; the inferoanterior crus, and the superoposterior crus.

In the middle of the auricle is a hollow depression, called the concha. It continues into the skull as the external acoustic meatus. The concha acts to direct sound into the external acoustic meatus. Immediately anterior to the beginning of the external acoustic meatus is an elevation of cartilaginous tissue – the tragus. Opposite the tragus is the antitragus.

External Acoustic Meatus

The external acoustic meatus is a sigmoid shaped tube that extends from the deep part of the concha to the tympanic membrane. The walls of the external 1/3 are formed by cartilage, whereas the inner 2/3 are formed by the temporal bone.

The external acoustic meatus does not have a straight path, and instead travels in an S-shaped curve as follows:

• Initially it travels in a superoanterior direction.
• In then turns slightly to move superoposteriorly.
• It ends by running in an inferoanterior direction.

Tympanic Membrane

The tympanic membrane lies at the distal end of the external acoustic meatus. It is a connective tissue structure, covered with skin on the outside and a mucous membrane on the inside. The membrane is connected to the surrounding temporal bone by a fibrocartilaginous ring.

The translucency of the tympanic membrane allows the structures within the middle ear to be observed during otoscopy. On the inner surface of the membrane, the handle of malleus attaches to the tympanic membrane, at a point called the umbo of tympanic membrane.

The handle of malleus continues superiorly, and at its highest point, a small projection called the lateral process of the malleus can be seen. The parts of the tympanic membrane moving away from the lateral process are called the anterior and posterior malleolar folds.

Vasculature

The external ear is supplied by branches of the external carotid artery:

• Posterior auricular artery
• Superficial temporal artery
• Occipital artery
• Maxillary artery (deep auricular branch) – supplies the deep aspect of the external acoustic meatus and tympanic membrane only.

Venous drainage is via veins following the arteries listed above.

Innervation

The sensory innervation to the skin of the auricle comes from numerous nerves:

• Greater auricular nerve (branch of the cervical plexus) – innervates the skin of the auricle
• Lesser occipital nerve (branch of the cervical plexus) – innervates the skin of the auricle
• Auriculotemporal nerve (branch of the mandibular nerve) – innervates the skin of the auricle and external auditory meatus.
• Branches of the facial and vagus nerves – innervates the deeper aspect of the auricle and external auditory meatus

Some individuals can complain of an involuntary cough when cleaning their ears – this is due to stimulation of the auricular branch of the vagus nerve (the vagus nerve is also responsible for the cough reflex).

Parts of the Middle Ear

The middle ear can be divided into two parts:

• Tympanic cavity – located medially to the tympanic membrane. It contains three small bones known as the auditory ossicles: the malleus, incus and stapes. They transmit sound vibrations through the middle ear.
• Epitympanic recess – a space superior to the tympanic cavity, which lies next to the mastoid air cells. The malleus and incus partially extend upwards into the epitympanic recess.

Borders

The middle ear can be visualised as a rectangular box, with a roof and floor, medial and lateral walls and anterior and posterior walls.

• Roof – formed by a thin bone from the petrous part of the temporal bone. It separates the middle ear from the middle cranial fossa.
• Floor – known as the jugular wall, it consists of a thin layer of bone, which separates the middle ear from the internal jugular vein
• Lateral wall – made up of the tympanic membrane and the lateral wall of the epitympanic recess.
• Medial wall – formed by the lateral wall of the internal ear. It contains a prominent bulge, produced by the facial nerve as it travels nearby.
• Anterior wall – a thin bony plate with two openings; for the auditory tube and the tensor tympani muscle. It separates the middle ear from the internal carotid artery.
• Posterior wall (mastoid wall) – it consists of a bony partition between the tympanic cavity and the mastoid air cells.
  • Superiorly, there is a hole in this partition, allowing the two areas to communicate. This hole is known as the aditus to the mastoid antrum.

Bones

The bones of the middle ear are the auditory ossicles – the malleus, incus and stapes. They are connected in a chain-like manner, linking the tympanic membrane to the oval window of the internal ear.

Sound vibrations cause a movement in the tympanic membrane which then creates movement, or oscillation, in the auditory ossicles. This movement helps to transmit the sound waves from the tympanic membrane of external ear to the oval window of the internal ear.

The malleus is the largest and most lateral of the ear bones, attaching to the tympanic membrane, via the handle of malleus. The head of the malleus lies in the epitympanic recess, where it articulates with the next auditory ossicle, the incus.

The next bone – the incus – consists of a body and two limbs. The body articulates with the malleus, the short limb attaches to the posterior wall of the middle, and the long limb joins the last of the ossicles; the stapes.

The stapes is the smallest bone in the human body. It joins the incus to the oval window of the inner ear. It is stirrup-shaped, with a head, two limbs, and a base. The head articulates with the incus, and the base joins the oval window.

Mastoid Air Cells

The mastoid air cells are located posterior to epitympanic recess. They are a collection of air-filled spaces in the mastoid process of the temporal bone. The air cells are contained within a cavity called the mastoid antrum. The mastoid antrum communicates with the middle ear via the aditus to mastoid antrum.

The mastoid air cells act as a ‘buffer system‘ of air –  releasing air into the tympanic cavity when the pressure is too low.

Muscles

There are two muscles which serve a protective function in the middle ear; the tensor tympani and stapedius. They contract in response to loud noise, inhibiting the vibrations of the malleus, incus and stapes, and reducing the transmission of sound to the inner ear. This action is known as the acoustic reflex.

The tensor tympani originates from the auditory tube and attaches to the handle of malleus, pulling it medially when contracting. It is innervated by the tensor tympani nerve, a branch of the mandibular nerve. The stapedius muscle attaches to the stapes, and is innervated by the facial nerve.

Auditory Tube

The auditory tube (eustachian tube) is a cartilaginous and bony tube that connects the middle ear to the nasopharynx. It acts to equalise the pressure of the middle ear to that of the external auditory meatus.

It extends from the anterior wall of the middle ear, in an anterior, medioinferior direction, opening onto the lateral wall of the nasopharynx. In joining the two structures, it is a pathway by which an upper respiratory infection can spread into the middle ear.

The tube is shorter and straighter in children, therefore middle ear infections tend to be more common in children than adults.

Structure of the Inner Ear

The inner ear is located within the petrous part of the temporal bone. It lies between the middle ear and the internal acoustic meatus, which lie laterally and medially respectively. The inner ear has two main components – the bony labyrinth and membranous labyrinth.

• Bony labyrinth – consists of a series of bony cavities within the petrous part of the temporal bone. It is composed of the cochlea, vestibule and three semi-circular canals. All these structures are lined internally with periosteum and contain a fluid called perilymph.
• Membranous labyrinth – lies within the bony labyrinth. It consists of the cochlear duct, semi-circular ducts, utricle and the saccule. The membranous labyrinth is filled with fluid called endolymph.

The inner ear has two openings into the middle ear, both covered by membranes. The oval window lies between the middle ear and the vestibule, whilst the round window separates the middle ear from the scala tympani (part of the cochlear duct).

Bony Labyrinth

The bony labyrinth is a series of bony cavities within the petrous part of the temporal bone. It consists of three parts – the cochlea, vestibule and the three semi-circular canals.

Vestibule

The vestibule is the central part of the bony labyrinth. It is separated from the middle ear by the oval window, and communicates anteriorly with the cochlea and posterioly with the semi-circular canals. Two parts of the membranous labyrinth; the saccule and utricle, are located within the vestibule.

Cochlea

The cochlea houses the cochlea duct of the membranous labyrinth – the auditory part of the inner ear. It twists upon itself around a central portion of bone called the modiolus, producing a cone shape which points in an anterolateral direction. Branches from the cochlear portion of the vestibulocochlear (VIII) nerve are found at the base of the modiolus.

Extending outwards from the modiolus is a ledge of bone known as spiral lamina, which attaches to the cochlear duct, holding it in position. The presence of the cochlear duct creates two perilymph-filled chambers above and below:

• Scala vestibuli: Located superiorly to the cochlear duct. As its name suggests, it is continuous with the vestibule.
• Scala tympani: Located inferiorly to the cochlear duct. It terminates at the round window.

Semi-circular Canals

There are three semi-circular canals; anterior, lateral and posterior. They contain the semi-circular ducts, which are responsible for balance (along with the utricle and saccule).

The canals are situated superoposterior to the vestibule, at right angles to each other. They have a swelling at one end, known as the ampulla.

Membranous Labyrinth

The membranous labyrinth is a continuous system of ducts filled with endolymph. It lies within the bony labyrinth, surrounded by perilymph. It is composed of the cochlear duct, three semi-circular ducts, saccule and the utricle.

The cochlear duct is situated within the cochlea and is the organ of hearing. The semi-circular ducts, saccule and utricle are the organs of balance (also known as the vestibular apparatus).

Cochlear Duct

The cochlear duct is located within the bony scaffolding of the cochlea. It is held in place by the spiral lamina. The presence of the duct creates two canals above and below it –  the scala vestibuli and scala tympani respectively. The cochlear duct can be described as having a triangular shape:

• Lateral wall – Formed by thickened periosteum, known as the spiral ligament.
• Roof – Formed by a membrane which separates the cochlear duct from the scala vestibuli, known as the Reissner’s membrane.
• Floor – Formed by a membrane which separates the cochlear duct from the scala tympani, known as the basilar membrane.

The basilar membrane houses the epithelial cells of hearing – the Organ of Corti. A more detailed description of the Organ of Corti is beyond the scope of this article.

Saccule and Utricle

The saccule and utricle are two membranous sacs located in the vestibule. They are organs of balance which detect movement or acceleration of the head in the vertical and horizontal planes, respectively.

The utricle is the larger of the two, receiving the three semi-circular ducts. The saccule is globular in shape and receives the cochlear duct.

Endolymph drains from the saccule and utricle into the endolymphatic duct. The duct travels through the vestibular aqueduct to the posterior aspect of the petrous part of the temporal bone. Here, the duct expands to a sac where endolymph can be secreted and absorbed.

Semi-circular Ducts

The semi-circular ducts are located within the semi-circular canals, and share their orientation. Upon movement of the head, the flow of endolymph within the ducts changes speed and/or direction. Sensory receptors in the ampullae of the semi-circular canals detect this change, and send signals to the brain, allowing for the processing of balance.

Vasculature

The bony labyrinth and membranous labyrinth have different arterial supplies. The bony labyrinth receives its blood supply from three arteries, which also supply the surrounding temporal bone:

• Anterior tympanic branch (from maxillary artery).
• Petrosal branch (from middle meningeal artery).
• Stylomastoid branch (from posterior auricular artery).

The membranous labyrinth is supplied by the labyrinthine artery, a branch of the inferior cerebellar artery (or, occasionally, the basilar artery). It divides into three branches:

• Cochlear branch – supplies the cochlear duct.
• Vestibular branches (x2) – supply the vestibular apparatus.

Venous drainage of the inner ear is through the labyrinthine vein, which empties into the sigmoid sinus or inferior petrosal sinus.

Innervation

The inner ear is innervated by the vestibulocochlear nerve (CN VIII). It enters the inner ear via the internal acoustic meatus, where it divides into the vestibular nerve (responsible for balance) and the cochlear nerve (responsible for hearing):

• Vestibular nerve – enlarges to form the vestibular ganglion, which then splits into superior and inferior parts to supply the utricle, saccule and three semi-circular ducts.
• Cochlear nerve – enters at the base of the modiolus and its branches pass through the lamina to supply the receptors of the Organ of Corti.

The facial nerve, CN VII, also passes through the inner ear, but does not innervate any of the structures present.

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