03 Anatomy and Physiology1

Anatomy and Physiology of the ear
Data Management Hearing assessment Fitting & Testing Balance assessment
Helping you make the right decision

The Principles of Hearing
•Sound waves (air pressure waves) are transformed

through mechanical energy to nerve signals that are
recognised as sound by the brain.
•The outer ear catch sound waves, leads them through

the ear canal to set the ear drum into vibration.
•Located in the air filled middle ear inside the ear drum,
are the three small bones, the hammer (malleus), the
anvil (incus) and the stirrup (stapes).
•These are jointed together, and serve to transfer the ear

drum vibrations to the oval window, via the foot plate of
the stirrup, located in the wall between the middle ear
cavity and the fluid filled inner ear - the cochlear.

The Principles of Hearing
The piston like movement in the stirrup give rise to

pressure waves in the inner ear fluids, pressure waves
that in turn puts hair like sensor cells in the inner ear
cochlea into movement.
•In the cochlea, the mechanical energy of movement –

the movement of the hairs – is translated into the
electrochemical signals communicated by the nerve
system.
•Nerve signals are lead through the hearing nerves to the

hearing area in the cortex, and we hear sound.

The Peripheral and the Central Parts
Auditory
Cortex
Central
Peripheral Peripheral

The Middle ear
Tympanic Membrane
Eustachian tube
The middle ear cavity

and the ossicular chain: MalleusIncus Stapes

Getting sound into a different medium

The acoustic reflex
2
Stapedius Muscle
1
Tensor Muscle
•Stabilises the mechanical system and protects the cochlea from

excessive low frequency vibration
•Very loud sounds make the stapedius muscle contract. This makes
the middle ear system stiffer and less low frequency sound can get
through the middle ear

The Eustachian tube
Air pressure must be near equal

on both sides of the ear drum in
order to optimise mobility
Air
Air
The Eustachian tube (ET) ventilates the middle

ear and allows pressure equalisation
The ET opens when swallowing or gasping

The Inner ear
Cochlea
• Approx. 2 1/2 turns
• 35 mm long when uncoiled
• three fluid filled channels
o = oval window
r = round window

The Hair cells (in organ of Corti)
Outer hair cells

• About 12.000 in each ear
• Organised in three rows along the cochlea
• Actively sort out waves of specific frequencies (decomposition)
• Actively amplify the specific waves
Inner hair cells

• About 3.500 in each ear
• Organised in one row along the cochlea
• Send the decomposed signal to the brain

Outer Hair Cell hairs

Inner Hair Cell hairs

Inner and outer hair cells
Outer
Inner
Tectorial membrane removed

Organ of Corti
Cross section
TM
BM
Sound waves make the Basilar Membrane (BM)

move up and down skewing motion against the
Tectorial Membrane (TM) the hairs of the hair cells bend
and create neural signal

Outer hair cell function
The outer hair cells actively enhance
the movement
Each outer hair cell responds to“its own” frequency.

The “echo” of this additional movement
can be measured in the ear canal.
Otoacoustic emission - OAE


Pure Tone and Speech
Audiometry

The Main Audiometric Tests
ENG/ VNG Balance/Vestibular
Brain Stem
Thresholds Impedance OAE Evoked potential
Data Management Hearing assessment Fitting & Testing Balance assessment Audiometry
Pure Tone Audiogram Threshold - Bone conduction
Normal
Hearing
Should be
better than
(below) 20dB
Threshold Air
Conduction
Uncomfortable
level

Audiogram Characteristics
Normal Hearing
20dB or better
Threshold
Dynamic
Uncomfortable
range
level

Types of Hearing Loss
• Conductive Loss
• Sensorineural Loss
• Mixed Hearing Loss

The Middle ear - Typical causes
Conductive hearing loss
• Wax or foreign body
• Bony narrowing
• Perforated eardrum
• Fluid in the middle ear (effusion)
• Fixated middle ear ossicles (otosclerosis)
• Interrupted ossicle chain (ossicular discontinuity)

Conductive hearing loss can be cured
•Non surgical
•Syringing with water
•Drug treatment
•Surgical treatment
•Seal perforations
•Repair / replace ossicles

The Middle ear - Pure tone audiometry
Conductive hearing loss in right ear
Bone conduction
thresholds
- tones pass Air conduction

directly to the thresholds
inner ear
- tones pass
through the
middle ear
The difference is the “air-bone gap”


The Inner ear - Typical causes
Sensorineural hearing loss (Cochlear)
Hair cell damage owing to

• Increased intracochlear pressure (Mb Ménière)
disease)
• Noise exposure
• Drugs (e.g. ototoxic antibiotics and cytotoxins)
• Age
• Genetics
Sensorineural hearing loss CANNOT be cured

The Inner ear - Associated problems
• Altered loudness
– Poorer sensitivity to soft and intermediate sounds
– Some times increased sensibility to loud sounds
• Distortion (missing frequencies)
• Poor discrimination (especially in noisy environment)
• Tinnitus

The Inner ear - Pure tone audiometry
Bone
conduction
thresholds
- tones pass Air conduction

directly to the thresholds
inner ear
- tones pass
through the
middle ear
No air-bone gap rules out

conductive hearing loss

Noise induced hearing loss


Age related hearing loss


Sensorineural + Conductive
+
hearing loss
Mixed loss

• Threshold - the level at which the patient can
correctly repeat 50% of test materials (phoneme,
balanced words (PB), syntetic sentences, etc.).
• Intelligibility- by convention, the percentage of
words or sentences a patient can correctly repeat
when presented at supra-threshold levels.
– Provides information about hearing handicap.
– Problem may be worse than indicated by pure
tone average for the speech frequencies.
Useful to determine candidacy for hearing aid.
– Very poor results, out of proportion to pure
tone average, suggests probable retrocochlear
cause of hearing loss.

Equipment used in speech audiometry
• Audiometers are rarely stand alone instruments
• Any audiometer with separate speech channels
• Separate amplifiers (internal or external)
• Speakers (internal or external)
• Internal CD (PC hard drive) or external tape or
CD
• Multimedia
• Free field (normal room)
• Sound booth
• Talk over / talk back patient communications
• Sound level meter

Speech Audiometry – Graphical Mode

The Middle Ear

The Main Audiometric Tests
ENG/ VNG Balance/Vestibular
Brain Stem
Thresholds Impedance OAE Evoked potential
Data Management Hearing assessment Fitting & Testing Balance assessment Audiometry
The Middle ear - Tests
IMMITTANCE TESTS
• Tympanometry
• Acoustic reflexes
• EFT – I
• EFT - P

The Middle ear - Tympanometry
Air pressure sweep with

simultaneous recording of how much
sound is admitted into the ear
Admittance
-200 daPa 0 200 daPa

Ear canal pressure

Theoretically, the tympanometric peak tells where the

air pressure is equal on both sides of the ear drum
Admittance
-200 daPa 0 200 daPa

Ear canal pressure

Classifications of tympanometric
patterns according to Jerger
-200 0 200 -200 0 200
Type A: Normal Type Ad: Ossicular discontinuity
or age related hypermobility
-200 0 200 -200 0 200

Type As: Possible effusion Type B: “Flat” -Effusion or perforated
ear drum
-200 0 200
Type C: Abnormal negative pressure

Normal tymp with 1000 Hz

The Inner ear - Tests
• IMMITTANCE TESTS
- Acoustic reflexes

The Middle ear - Reflex thresholds
The middle ear admittance change is
measured during loud stimulations
80 dB HL 85 dB HL
0.00 0.00
0.02
Deflection criterion
0.02 ?!
90 dB HL 95 dB HL
0.00 0.00
0.02 0.02
Stapedius reflex deflections are intensity

dependent - It is useful to study the growth
with intensity to confirm a reflex threshold

• Stapedius muscle controlled by facial nerve (CN

VII)
• Network in brainstem consists of ipsilateral and
contralateral paths
• Reflex activated on both ears, even when
stimulation only occurs in one ear
• Comparison of ipsilateral vs. contralateral
acoustic reflexes helps to determine site of lesion

Contralateral Ipsilateral
Stimulus Measure Stimulus
R L Measure
Audiogram notation example, probe in Left ear

Symbol color indicates stimulus ear!

Acoustic Reflex Decay
Threshold+10 dB, 10 seconds stimulus time
0
Admittance
5 10
seconds
change
No reflex decay present
0 HLT
Admittance
5 10
seconds
change
Max
50 % of Max Reflex decay present!
Half-Life Time (HLT), the time after stimulus onset

when the admittance deflection has decreased by 50%.
A half-life time value <5 seconds is indicative of tumour

EFT-I test
• Tympanogram shows normal tymp

• Then ask the patient to do the Valsalva's
Maneuver (Blowing) and the Tympanogram will
move to the left.
• Then ask the patient to do the Toynbee's
Maneuver swallowing and the tymp will move to
the right.
• See example


ETF-P test (Estucian tube function
• Normal ear with normal estucian tube testing,

you will build up an pressure, and the ear will
hold the pressure.
• Perforated ear will build up a pressure, but will
then loose the pressure. See example


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Anatomy and Physiology of the ear

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

•Sound waves (air pressure waves) are transformed

•The outer ear catch sound waves, leads them through

•These are jointed together, and serve to transfer the ear

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

The piston like movement in the stirrup give rise to

•In the cochlea, the mechanical energy of movement –

•Nerve signals are lead through the hearing nerves to the

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

The middle ear cavity

Helping you make the right decision

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

•Stabilises the mechanical system and protects the cochlea from

Helping you make the right decision

Air pressure must be near equal

The Eustachian tube (ET) ventilates the middle

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

• Approx. 2 1/2 turns

• 35 mm long when uncoiled

• three fluid filled channels

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

Outer hair cells

Inner hair cells

Helping you make the right decision

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

Tectorial membrane removed

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

Sound waves make the Basilar Membrane (BM)

Helping you make the right decision

Each outer hair cell responds to“its own” frequency.

Otoacoustic emission - OAE

Helping you make the right decision

Data Management Hearing assessment Fitting & Testing Balance assessment

ENG/ VNG Balance/Vestibular

Thresholds Impedance OAE Evoked potential

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

• Mixed Hearing Loss

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

Data Management Hearing assessment Fitting & Testing Balance assessment

Helping you make the right decision

- tones pass Air conduction

The difference is the “air-bone gap”

Helping you make the right decision

Hair cell damage owing to

Sensorineural hearing loss CANNOT be cured