EARS

EMBRYOLOGY
• External ear canal – ectodermal first
branchial cleft
• Tympanic membrane – closing of the
membrane of the first branchial cleft
• Pinna – margins of the first branchial
cleft and the first and second
branchial arches
• Middle ear – endodermal first
branchial cleft
• Ossicles – cartilage of the branchial
arches
• Malleus – cartilage of the first
branchial arch (Meckels)
• Incus and stapes – cartilage of the
second branchial arch (Reicerts
cartilage)
 EMBRYOLOGY
• Tensor tympani – first arch
• Stapedius muscle – second
branch
• Otic vesicle – otic placode
• Bony external ear canal –
tympanic ring
• Styloid process – second
branchial cartilage
• Squamous portion - cartilage
• Petrous portion –
cartilaginous capsule of otic
vesicle
• Mastoid process – not present
at birth
ANATOMY
 EXTERNAL EAR
• External ear or pinna
is covered of
cartilage.
• It is cartilaginous
laterally but bony
medially.
• Cartilage: one of the
surgical landmarks to
locate facial nerve
 TYMPANIC MEMBRANE
• Tympanic membrane is a conical structure
with the umbo directed medially.
• Tympanic membrane is composed of outer
epidermal layer, middle fibrous layer (handle
of the malleus) and inner mucosal layer
 MIDDLE EAR
• Impedance-matching device between air and
liquid
• Contains malleus, incus and stapes
 EUSTACHIAN TUBE
• Connects the middle ear cavity to the nasopharynx
• Lateral part is bony while medial two thirds is
cartilaginous
• Servevs to equalize the air pressure on both sides of
the tympanic membrane
 INNER EAR
• Has a convoluted shape
referred to as the labyrinth
• Membranous labyrinth is filled
with endolymph (high in
potassium, low in sodium)
surrounded by perilymph (high
in sodium, low in potassium)
• Pars superior: balance
• Pars inferior: organ of hearing
• Cochlea is coiled for two and
one-half turns
• Axis of the spiral is called the
modiolus which contains nerve
bundles
• Organ of Corti: contains essential organelles of
the peripheral neural mechanism of hearing
– One row of inner hair (3,000)
– Three rows of outer hair cells (12,000)
• Stereocilia are attached to tectorial membrane
supported by limbus
• Vestibular part: saccule, utricle, semicircular
canals
• Otoliths: calcium-containing
 FUNCTION
• Pinna: “collector of sound”
• External auditory canal: amplifies the region
to 10-15 dB
VESTIBULAR SYSTEM
 PHYSIOLOGY
• Sensory signals from the inner ear 
integrated in the CNS  control position and
movement of the body
• Receptors: hair cells in the cristae of the
semicircular canal and maculae of the otolith
organs
– Semicircular canal: sensitive to rotation
– Otolith: linear motion
 Hair cells
• Structural polarization defined by position of
the stereocilia relative to the kinocilium
• Movement  stereocilia bent TOWARD
kinocilium  excitied hair cells
• Movement  stereocilia bent AWAY from
kinocilium  hair cells are inhibited
 Semicircular canal
• Left horizontal – right horizontal
• Left anterior – right posterior
• Left posterior – right anterior
• During a rotation, one canal gets excited and
the other one gets inhibited
 Otolith organs
• Utriculus: horizontal plane of the head
• Sacculus: vertical plane
• Do not all have the same polarization
• In the utricular macula, kinocilium is located
on the side of the hair cell closest to the
central region, the striola.
 Vestibular Reflexes
• Afferents  CNS – synapse  neurons in
vestibular nuclei in brain stem  project to other
parts of the brain
• Vestibulo-ocular reflex (VOR): direct connections
between vestibular nuclei and extraocular
– Slow component opposite to the head rotation and
stabilizes image on the retina
– Fast component in the same direction as head
rotation and redirects gaze to another part of the
visual field
– Normal nystagmus
 DIAGNOSIS
• Spontaneous eye movements in the light and
dark
• Caloric stimulation: CoWs
– Reduced stimulation is an evidence of peripheral
deficit on that side
• Rotation
• Positional Testing
• Posturography
DISEASES OF THE EXTERNAL EAR
 KERATOSIS OBTURANS
• Presents as keratin plug occluding the external
auditory canal
• Keratosis obturans – bilateral, associated with
bronchiectasis and chronic sinusitis
– Pain and hearing loss
– Widening of external canal
– Hyperplasia and inflammation of epithelium and
subepithelium
• CAUSE: overproduction of
squamous epithelium and squamous
plug; faulty migration of the
epithelium
 CHOLESTEATOMA
• Presents as keratin plug occluding the external
auditory canal
• Unilateral
• Dull pain, intermittent
otorrhea
• CAUSE: circumscribed
periostitis and faulty
epithelial migration
• TREATMENT: debridement of bone, canalplasty,
tympanomastoidectomy
 EXTERNAL OTITIS
• INFECTIOUS: bacterial, fungal, viral
• NONINFECTIOUS: dermatoses, some
conditions directly involving external ear
• CAUSE: change of pH, environmental changes,
mild trauma
• MANAGEMENT:
– Careful cleaning of canal by suction or wipes
 FURUNCULOSIS
• Otitis Externa Circumscripta
• Confined to the
fibrocartilaginous portion of
the external auditory meatus
• Begins in pilosebaceous follicle
• CAUSE: Staphylococcus aureus
or S. Albus
• Abscess and “point” formation
• TREATMENT: topical
medications, heat, analgesics
 DIFFUSE OTITIS MEDIA
• Swimmer’s ear
• CAUSE: Pseudomonas group, S. albus, E. coli,
Enterobacter aerogenes
• Tragal tenderness, severe pain, canal wall
swelling, scanty discharge, slight diminished
hearing, no fungal particles, +/- tender
regional adenopathy
• TREATMENT: Otic drops (Cortisporin, Coli-
Mycin S, Pyocidin, VoSol HC, Chloromycetin)
 OTOMYCOSIS
• CAUSE: Pityrosporum and Aspergillus
• Superficial scaling
• Sense of blockage or inflamed epithelium or
drumhead
• TREATMENT: cleansing of the canal by wiping,
suctioning or gentle irrigation then drying; otic
drops (VoSol, Cresylate, Otic domeboro)
 HERPES ZOSTER OTICUS
• Ramsay Hunt Disease
• Onset of facial paralysis, otalgia, herpetic eruptions
in the external ear
• CAUSE: viral infection in the genticulate ganglion
• TREATMENT: mainly symptomatic
 PERICHONDRITIS
• Trauma or inflammation
causes an effusion of serum
or pus between
perichondrium and
cartilage of external ear
• Involved part of auricle is
inflamed and is very tender
upon palpation
• TREATMENT: Incision and
drainage
 LACERATION
• Most common cause is
digging the ear with finger
or using an instrument
using a hairpin or
paperclip
• Transient bleeding
• No treatment needed
• Advised to keep ear dry
 HEMATOMA
• Commonly seen in
wrestlers and boxers
• May result to
cauliflower ear
• TREATMENT: Incision
and drainage of
collected blood
• PREVENTION:
protective headgear
 MALFORMATION
• MOST COMMON: Lop ear deformity
• Macrotia and microtia
• Rudimentary ear appendages
• Total absence of ear
• Partial or complete stenosis of the canal
• First branchial cleft abnormalities: cysts or sinus
tract involving pinna or external auditory canal
– Type I: ectodermal tissue only, cartilage-free, first cleft
origin only
– Type II: epithelium of first cleft, cartilage from first and
second
 NEOPLASM
• Osteoma: benign tumor, single firm, rounded
growth attached by smaller bony pedicle to the
inner third of canal
• Exostosis: rounded protuberance of hypertrophic
canal bone, frequently seen in swimming in cold
water
• Squamous cell CA: most common malignancy of
external auditory canal, chronic serosanguinous
discharge, free bleeding, pain, canal swelling
DISEASES OF THE MIDDLE EAR AND
MASTOID
 DISEASES OF THE TYMPANIC
MEMBRANE
• Tympanosclerosis: TM may contain white thick
patches or become entirely white due to
deposition of hyalinized collagen in its middle
layer
• Eustachian tube ventilation dysfunction: allows
air to move in the middle ear with respiration 
ischemia and necrosis
• Perforation: tubal, central, marginal, pars flaccida
• Myringitis: inflammation of TM
 DISORDERS OF EUSTACHIAN TUBE
• PE: Toynbee maneuver, Valsalva maneuver,
Politzerization
• Abnormally patent ET: open all the time so air
enters middle ear with respiration
– Autophony, sensation of fullness, plugged up feeling
– PE: patient is asked to breath heavily while mouth
closed
– Tympanic membrane is atrophic and thin
– Women taking OCPs or men taking estrogen
• Palatal myoclonus: palatal muscles undergo
periodic rhythmic contractions
– Clicking sound
– May be associate with vascular lesions, MS,
aneurysm, tumor
• Eustachian Tube Obstruction
– May result from inflammation, nasopharyngitis or
adenoiditis
• Cleft Palate: lack of anchorage of the tensor
palatini muscle
– Prevents muscle from exerting sufficient
contraction on eustachian tube orifice upon
swallowing  inadequate ventilation to the
middle ear  inflammation
 MIDDLE EAR TRAUMA
• May be caused by sudden changes in
pressure, blast injuries, foreign body
• Contaminated perforation: fall from skiing
• Perforation due to hot slag in welders
• Perforations resulting to injury in the ossicular
chain
– Significant hearing loss (>25 dB), vertigo  TRUE
OTOLOGIC EMERGENCY
 ACUTE PURULENT OTITIS MEDIA
• Disruption in the action of cilia and mucus
secreting enzymes
• Obstruction of the eustachian tube
• CAUSE: S. pneumoniae, H. influenzae, beta-
hemolytic streptococci
• Pain, fever, malaise, anorexia, nausea, vomiting
• Tympanic membrane is red and bulging
• Abscess in the middle ear
 SEROUS OTITIS MEDIA
• Transudation of plasma from the blood vessels
into the middle ear due to hydrostatic pressure
differences
• MUCOID OM: active secretion from glands and
cysts lining the middle ear
• Eustachian tube dysfunction is a major underlying
factor
• Most common cause of hearing loss in school-age
children
• Plugged up feeling, decreased hearing acuity,
tinnitus
 CHRONIC INFECTION OF THE MIDDLE
EAR AND MASTOID
• Active: presence of infection with drainage
from the ear or otorrhea
– Foul smelling, putrid discharge of grayish yellow in
color
• Inactive: sequelae from previously active
infection that has “burnt out”, no otorrhea
– Hearing loss, vertigo, tinnitus, sense of fullness
 MIDDLE EAR COMPLICATIONS
• Facial nerve paralysis
• Lateral sinus thrombophlebitis: infectious
invasion of the sigmoid sinus
• Extradural abscess: collection of pus between
dura and bone over the mastoid cavity
• Subdural abscess: direct extension of
extradural abscess or extension of
thrombophlebitis through venous channels
 CNS COMPLICATIONS
• Meningitis: most common complication due
to suppurative otitis media
• Brain abscess: consequence of the direct
extension of otologic infection or
thrombophlebitis
• Otitic hydrocephalus: increased ICP with
normal CSF findings
 MYRINGOTOMY
• Incision of tympanic membrane to provide
ventilation to the middle ear and allow
drainage of middle ear fluid
• Not used in the presence of external otitis
• For treatment of complications of otitis media
such as mastoiditis or facial nerve paralysis
INDICATIONS FOR MYRINGOTOMY
• Persistent pain after 48 hours of antibiotic
treatment
• Acute mastoiditis or facial nerve paralysis
• Development of acute otitis media while on
systemic antibiotic
• Development of otitis media in
immunosuppressed patient
TUMORS OF THE MIDDLE EAR AND
MASTOID
 PRIMARY TUMOR
• Glomus jugulare or glomus
tympanicum
• Originates from glomus bodies
to the jugular bulb in the floor
of the middle ear
• Bulging purplish mass in the
floor of the middle ear
• Brown’s sign: blanching by the
pressure of otoscope
• MOST USEFUL DIAGNOSTIC: CT
Scan with contrast
 PRIMARY TUMOR
• Rhabdomyosarcoma: young children
– Combined radiotherapy and chemotherapy
• Squamous cell carcinoma
• Persistent external otitis warrants biopsy
• MOST COMMON MALIGNANT TUMORS OF
THE MIDDLE EAR: adenoid cystic carcinoma
and adenocarcinoma
 SECONDARY TUMOR
• Arise from distant primary foci and
metastasize to middle ear and temporal bone
(Adenocarcinoma of the prostate, renal
carcinoma, bronchogenic carcinoma)
• Invasion of middle ear and mastoid
(meningioma, acoustic neuroma, glioma)
• Hematologic malignancies (lymphoma,
leukemia)
DISEASES OF THE INNER EAR
 CLINICAL
• History
• Tinnitus
• Dizziness

• Electronystamography (ENG) – visual tracking,

rapid deviation of eye movement, caloric
testing
 CONGENITAL DEAFNESS OF GENETIC
IN ORIGIN
• Without associated anomalies
– Michel’s deafness – total lack of development of
inner ear
– Mondini’s deafness – partial aplasia of bony and
membranous labyrinth  flattened cochlea
– Scheibes deafness – pars inferior is represented by
mounds of undifferentiated cell
 CONGENITAL DEAFNESS OF GENETIC
IN ORIGIN
• With other abnormalities
– Waardenburg’s disease – lateral displacement of the
medial canthi and lacrimal points, flat nasal root,
hyperplasia of the eyebrows, partial or total
hetrochromia of the irides, partial albinism
– Albinism
– Hyperpigmentation
– Onychodystrophy
– Pendred’s (Nonendemic goiter)
– Jervell’s
– Usher’s disease
 CONGENITAL DEAFNESS OF GENETIC
IN ORIGIN
• Chromosomal abnormalities
– Trisomy 13-15: absence of external auditory canal
or middle ear
– Trisomy 18: low set of ears, malformed pinna
 CONGENITAL DEAFNESS OF
NONGENETIC IN ORIGIN
• Rubella: aplasia of Organ of Corti and saccule
(pars inferior)
• Erythroblastosis Fetalis: high-tone
sensorineural deafness
• Cretinism: hearing loss, both sensorineural
and conductive
 DEAFNESS ASSOCIATED WITH OTHER
ABNORMALITIES
• Alport’s disease: bilateral, symmetric and
greater in higher frequency,
• Von Recklinghausen: bilateral acoustic tumors
• Paget’s:
 INECTIOUS CAUSES
• Metabolic products  middle ear 
cochlea/vestibule
• Mumps: leading cause of unilateral hearing
loss
• Measles: leading cause of bilateral hearing
loss
• Meningitis
• Syphilis
OTOTOXIC DRUGS
 ACOUSTIC TUMOR
• Acoustic neuroma: most common inner ear
tumor
– Benign tumors of the Schwann cells covering 8th
nerve
• Any unilateral or asymmetric hearing loss is an
acoustic neuroma until proved otherwise
 TRAUMA
• Through acoustic or mechanical energy
• Temporal bone fractures can cause loss of
consciousness, subdural or epidural
hematoma or concussion
– Longitudinal: 80%
• Begins at foramen magnum and ends at EAC
– Transverse: 20%
• Injuries to the labyrinth and facial nerve
 PRESBYCUSIS
• Loss of hearing due to aging
• Sensory presbycusis: hair cells are lost first
leading to cochlear neuron loss
• Neuropresbycusis: primary loss of cochlear
nueorons with preservation of hair cells
• Strial presbycusis: stria vascularis degenerates
and shrink
• Cochlear-conductive: limitation to the
movement in the basilar membrane
 IDIOPATHIC CAUSE
• Meniere’s disease: swelling of endolymphatic
space
– Fluctuation in hearing loss with low tone tinnitus
• Multiple sclerosis
– Structural location of hearing loss not explained
well
 NONVESTIBULAR CAUSES OF
DIZZINESS
• Hyperventilation: lightheadedness,
paresthesia in distal extremities with rapid
ventilation
• Hypoglycemia: unsteadiness, lightheadedness,
severe sweating and pallor
• Vascular: long-term disequilibrium,
unsteadiness
• Cervical vertigo
DISORDERS OF THE FACIAL NERVE
 DIAGNOSTICS
• Schirmer test
• Measurement of taste
and salivation are a
reliable indicator of
the interruption of the
chorda tympani nerve
• Electromyography
• Electroneuronography
FACIAL PAIN, HEADACHE, OTALGIA
 Vascular headaches of migraine type
• Classic migraine: sharply defined, transient visual,
sensory and motor prodromes
• Common migraine: without striking prodromes,
maybe due to environmental, occupational or
menstrual
• Cluster: unilateral, with flushing, sweating,
rhinorrhea and increased lacrimation
• Hemiplegic: sensory and motor phenomenon
during and after headache
• Lower half: occur in lower face
 Muscle Contraction
• Ache or sensation of tightness, pressure or
contraction
• Commonly suboccipital
• Commonly during stressful events
 Combined headache
• Vascular and muscle contraction
 Nasal Vasomotor Reaction
• Headache + nasal obstruction, rhinorrhea,
tightness or burning
• Resulting from congestion and edema of
paranasal sinuses
• Anterior in location
• Also called vasomotor rhinitis
 Delusional, Conversion or
Hypochondriacal States
• May also be called psychogenic headaches
Nonmigranous Vascular Headahce
• Systemic infection with fever
• Miscellaneous disorders
 Traction headache
• Mainly vascular, by masses
– Primary or metastatic tumors of meninges
– Hematomas
– Abscess
– Postlumbar puncture
– Pseudotumor cerebri
 Headache due to Overt Cranial
Inflammation
• Intracranial: infections, chemical, allergic
meningitis, subarachnoid hemorrhage
• Extracranial: arteritis, cellulitis
 OTALGIA
• Ear pain due to primary or secondary causes
 TMJ Joint Dysfunction
• Common cause of secondary otalgia
• Deep, boring pain mimicking otitis media
• Temporalis, masseter, medial and lateral
pterygoid, trapezius, suboccipital, frontal and
occipital
• Presents as malposition of the maxilla or
mandible
 Trigeminal neuralgia
• Primary type (Tic douloureux)
– Sudden onset of headache, sharp and lancinating
– At trigger zones about the face which react to light
physical contact or drafts of air
– Ophthalmic division is frequently affected
• Secondary type
– Longer episodes of pain and less severe attacks
– Uncommon trigger zones
– May be caused by lesions in the nerve roots
 Glossopharyngeal neuralgia
• Primary
• Stabbing pain in the ear
• Trigger zones in the tonsillar area + salivation
• Secondary
– Ear pain following tonsillectomy