Anatomy of Temporal Bone and Surgical Implications

Gulya and Schuknecht’s
Anatomy of the
Temporal Bone with
Surgical Implications
Gulya and Schuknecht’s
Anatomy of the
Temporal Bone with
Surgical Implications
Third Edition
Aina Julianna Gulya

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Library of Congress Cataloging-in-Publication Data
Gulya, Aina J.
Anatomy of the temporal bone with surgical
implications / Aina Julianna Gulya. — 3rd ed.
p. ; cm.
Rev. ed. of: Anatomy of the temporal bone with surgical implications /
A. Julianna Gulya, Harold F. Schuknecht. 2nd ed. 1995.
Includes bibliographical references and index.
ISBN-13: 978-0-8493-7597-2 (hb : alk. paper)
ISBN-10: 0-8493-7597-5 (hb : alk. paper)
1. Temporal bone—Anatomy. 2. Temporal bone—Anatomy—Atlases. I.
Gulya, Aina J. Anatomy of the temporal bone with surgical implications.
II. Title. III. Title: Anatomy of the temporal bone with surgical
implications.
[DNLM: 1. Ear—surgery. 2. Temporal Bone—anatomy & histology. 3.
Ear—anatomy & histology. WV 201 G973g 2007]
QM507.S38 2007
611'.85—dc22 2007024541
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To the memory of my mentor, colleague, and friend—
Harold Frederick Schuknecht, M.D.
February 10, 1917–October 19, 1996
Portrait reprinted with the kind permission of Bachrach Photography, Boston, Massachusetts.
Preface to the Third Edition
More than 20 years have passed since the publication of the first edition and
over 10 years since the publication of the second edition of Anatomy of the
Temporal Bone with Surgical Implications. In that time there has been some
evolution in our understanding of the normal and anomalous anatomy of
the human temporal bone, most notably the recognition of the anomaly
referred to as dehiscence of the superior semicircular canal. However, and
more relevant to the decision to publish this third edition, are the remarkable
changes in information acquisition, storage, and retrieval propelled by
modern technology.
Accordingly, although there is little substantive change in the text, this
edition strives to take advantage of digitization of information to make it a
more useful teaching tool. In particular, the teaching slide set that was created
as a companion to the first edition is included in a digital version in the accom-
panying CD-ROM. Similarly, the somewhat cumbersome three-dimensional
reels have been supplanted by digital image pairs intended to be visualized on
a monitor. With a little practice, most individuals can “see” the depth of the
images.
This book has been designed as a companion volume to Pathology of the
Ear, second edition (Schuknecht, 1993) and Surgery of the Ear and Temporal
Bone, third edition (Nadol and McKenna, 2005).
As stated in the preface to the preceding editions of this book, the
goal of the authors was to assist in the acquisition of a sophisticated, three-
dimensional understanding of the intricate anatomy of the human temporal
bone by providing a practical compendium on basic surgical anatomy writ-
ten for clinicians by clinicians. Sadly, the senior author is now deceased.
Nonetheless, the goal remains the same, and I believe that were he here,
Dr. Schuknecht would agree that this third edition continues to achieve
our goal.
Aina Julianna Gulya
v
Preface from the Second Edition
The human temporal bone collection at the Massachusetts Eye and Ear
Infirmary, comprising 1518 specimens from 862 individuals, most of whom
had otologic disorders, served as the primary resource for the material
contained in this book. The senior author, in the course of a 30-year career of
correlating pathological findings with clinical manifestations through light
microscopic study of serially sectioned temporal bones, systematically
accumulated photomicrographs depicting various aspects of normal
anatomy. As an otolaryngology resident in training, the junior author, frus-
trated with available anatomy texts, sought to develop a resident teaching
manual. With the encouragement and collaboration of the senior author, the
manual grew to the current text, which includes some 350 selected photomi-
crographs as well as sets of horizontally and vertically serially sectioned
specimens, depicting normal and variant anatomy of the human temporal
bone. Chapter 9 includes 40 photomicrographs of fetal (from two months’
gestation) and newborn temporal bones and is designed to review develop-
ment in an easily assimilated manner. Recognizing that modern otologic/
neurotologic surgery demands a three-dimensional conceptualization of the
temporal bone, three-dimensional stereo reels are included. Through these
stereo reels, each with an accompanying labeled, two-dimensional photo-
graph, the reader can explore the celloidin-embedded temporal bone under-
going horizontal serial sectioning, study a variety of pathological conditions,
view surgical cases, and complete a temporal bone dissection.
New to this second edition are color photographs of the macroscopic
human temporal bone, and an expansion of the descriptive text accompanying
the temporal bone dissection series.
This book is meant to serve as a companion to the books Pathology of the
Ear, second edition (Schuknecht, 1993) and Surgery of the Ear and Temporal
Bone (Nadol and Schuknecht, 1993). Expansion of the frontiers of temporal
bone surgery, as manifested in the growth of neurotologic skull base surgery,
has increased the importance of acquiring a sophisticated understanding
of the intricate anatomy of the temporal bone to anyone contemplating
invasive therapeutic procedures. We believe that this book, as a practical
compendium on basic surgical anatomy written for clinicians by clinicians,
will facilitate the acquisition of such knowledge.
Aina Julianna Gulya

Harold F. Schuknecht
vii
Preface from the First Edition
The principal source of material for this book is the human temporal bone
collection housed at the Massachusetts Eye and Ear Infirmary. The collection
consists of 1500 temporal bones from 850 subjects, most of whom had
otologic disorders. The specimens were prepared for light microscopic study
by fixation, decalcification, embedding in celloidin, and serial sectioning at a
thickness of 20 , with every tenth section stained and mounted on glass
slides. The primary purpose for collecting these temporal bones was to study
the pathologic basis of ear disease. The extent to which this objective was real-
ized is evidenced in a book entitled Pathology of the Ear (Schuknecht, 1974).
The temporal bone collection also provides numerous examples of normal
anatomy and its variations, which provides the basis for this book
on anatomy and its surgical implications. It is meant to be a practical com-
pendium written by clinicians for clinicians. As such, it contains a minimum
of cellular and ultrastructural detail, which would have little relevance to the
practicing otologist. It is meant to complement the excellent books Surgical
and Microscopic Anatomy of the Temporal Bone (Wolff, Bellucci, and Eggston,
1971) and Surgical Anatomy of the Temporal Bone (Anson and Donaldson, 1981).
The sequence of presentation of the material begins with Chapter 1
showing low-power photomicrographs of serial sections in horizontal and
vertical planes. Chapters 2 through 7 present selected views in the following
sequence: pinna and external canal, middle ear, pneumatization, inner ear,
neuroanatomy and vascular anatomy.
Photomicrographs present a two-dimensional display of anatomy in a
single plane which leads to an appreciation, although somewhat imperfect,
of the size and spatial relationships of these structures. Realizing that we
live in a three-dimensional world and that the temporal bone is a three-
dimensional structure, part of Chapter 1 and all of Chapter 8 have been
devoted to stereoscopic anatomy. The photographs were made with a
Donaldson camera (designed by Dr. David Donaldson, ophthalmologist at
the Massachusetts Eye and Ear Infirmary and Harvard Medical School).
These color stereoscopic transparencies are mounted into View-Master®
reels (Sawyer’s Inc., Portland, Oregon) and can be viewed with the View-
Master three-dimensional viewer that can be purchased at department and
toy stores. To assist in orientation of anatomic structures, the book contains
labeled photographs matching each of the stereo views.
Chapter 1 features two reels (14 views) of partially sectioned temporal
bones in celloidin blocks that expose to view the intimate anatomy of the
middle and inner ears. Chapter 8 provides a set of four reels (28 views)
showing a method of progressive dissection of the fresh temporal bone,
as well as one (seven views) of pathologic anatomy, and two (14 views) of
otologic surgery.
Congenital anomalies of the ear are often the result of faulty or arrested
development and present in recurring patterns of dysplasia which are best
ix
understood by a knowledge of the normal embryologic process. With this in
mind we present in Chapter 9 a series of photomicrographs from three
embryos of progressive gestational ages.
The appendices present a glossary of terms and a history of anatomic
discoveries of the ear. We had originally hoped that the history section could
be brought up-to-date. However, the recent contributors to ear morphology
have been so numerous and the assessment of relative importance to new
knowledge so difficult to judge that we are limiting the presentation to those
who are deceased, leaving to subsequent generations the task of pinpointing
the principal contributors of our time.
Finally, we are making available a set of 163 selected color, 35-mm
paper-mounted transparencies, each of which matches a photomicrograph
in the book. This teaching set should be useful in augmenting lectures in
both the basic and clinical sciences.
We are grateful to the histologic technicians, especially Diane DeLeo
Jones, Barbara Burgess, Richard Cortese, and Clarinda Northrop DuBois,
who have provided such technically excellent temporal bone sections. We
appreciate the superb quality of the photomicrographs prepared by Arthur
Bowden. To Carol Ota and Linda Joyce we are especially grateful for prepa-
ration and editing of the manuscript as well as mounting and labeling of
photomicrographs. Others who contributed significantly to editing and
preparation were Eileen Nims, Cheryl Hurley, Anne Schuknecht, and
Tomomi Kimura; we thank them. Finally, we are indebted to the publishing
house of Lea & Febiger, and especially to R. Kenneth Bussy, for their willing-
ness to publish a book with so many illustrations as well as View-Master
reels and slide sets.
Otology is both a medical and surgical specialty. The anatomy is com-
plex with many important structures sequestered deeply in bone. A sophisti-
cated knowledge of anatomy is necessary if invasive therapeutic procedures
are to be performed safely. We believe this book will serve that end.
Harold F. Schuknecht
Aina Julianna Gulya
x ■ PREFACE
Acknowledgments
Many thanks to Joseph B. Nadol, Carol Y. Ota, and Bob Galla who helped
resurrect this phoenix from its ashes. Also much gratitude to those who con-
tributed their talents to the previous editions, including Anne Schuknecht,
Eileen Nims, Linda Joyce, Diane DeLeo Jones, Barbara Burgess, Richard
Cortese, Clarinda Northrop Dubois, Arthur Bowden, Cheryl Hurley, and
Tomomi Kimura. R. Kenneth Bussey (Lea & Febiger) and Nat Russo (The
Parthenon Publishing Group) played important roles in the publication of
the previous editions of the book, and a debt of gratitude is owed them, as
well as Geoffrey Greenwood, Alyssa Fried, and Sherri Niziolek (Informa
Healthcare, USA) who worked on this third edition. Many loving thanks
to my parents, Sylvia and Aladar Gulya, for all their encouragement and
support. And last, but certainly not least, words cannot adequately describe
all I owe my husband, William R. Wilson, for his many years of faithful love
and support.
This book represents the accumulated experience and observations of the

authors (and their clinical and research associates) in a single volume. As a
result, numerous illustrations were previously published in several journals
and books.
The authors are grateful to these publishers for permission to use illus-
trations that have appeared previously as indicated below. (The correspon-
ding figure number in this book is set in parentheses, double-numbered with
chapter and figure number.)
alan r. liss for the march of dimes birth defects foundation

Morphogenesis and Malformation of the Ear, Gorlin, 1980
Figure 1, page 48 (Figure 5.39)
american journal of otology (Thieme Stratton)

5:262, 1984—Figure in “Letter to the Editor” (Figure 7.34)
annals of otology, rhinology, laryngology (Annals Publishing Company)

72:689, 1963—Figure 1 (Figure 5.39)
78:794, 1969—Figure 2 (Figure 3.78)
79:109, 1970—Figure 4 (Figure 5.24)
Supplement 11, 83:13, 1974—Figure 8 (Figure 3.110)
83:49–53, 1974—Figure 1 (Figure 3.60)
Figure 2 (Figure 3.65)
xi
88:317, 1979—Figure 2 (Figure 5.45)
Supplement 78, 90:7, 1981—Figure 6 (Figure 7.36)
Figure 7A (Figure 7.37)
archives of otolaryngology (American Medical Association)

86:499, 1967—Figure 2 (Figure 4.20)
91:599, 601, 1970—Figure 1 (Figure 6.19)
110:479, 1984—Figure 6 (Figure 5.23)
111:120, 1985—Figure 3 (Figure 5.41)
auris nasus larynx

12 (suppl. 1): 521, 1985 (Figure 3.109)
harvard university press

Pathology of the Ear, Schuknecht, 1974
Figure 2.5, page 24 (Figure 3.62)
Figures 2.14–2.16, pages 31–32 (Figures 7.26–7.28)
Figures 2.99–2.118, pages 85–92 (Figures 1.1–1.20)
xii ■ ACKNOWLEDGMENTS
Figures 8.12–8.14, page 328 (Figures 7.3–7.5)
Figure 11.11, page 422 (Figures 3.115 & 3.116)
Table 2.1, page 79 Table, page 111
Teaching slide set
journal of laryngology and otology

87:281, 1973—Figure 1 (Figure 3.80)
89:987–995, 1975–Figure 1 (Figure 5.18)
Figure 10 (Figures 9.1–9.4)
laryngoscope
69:629, 1959—Figure 9B (Figure 2.9)
79:641, 1969—Figure 1 (Figure 9.5)
85:1730, 1975—Figure 4 (Figure 3.113)
86:1166, 1976—Figure 1 (Figure 2.5)
little, brown and company

Stapedectomy, Schuknecht, 1971
otolaryngology clinics of north america (W.B. Saunders Company)

1:298, 1968—Figure 26B (Figure 5.28)
ACKNOWLEDGMENTS ■ xiii
Contents
Preface to the Third Edition ....................................... v
Preface from the Second Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Preface from the First Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
1 ■ Serial Photographs of Sections of the

Temporal Bone ................................................ 1
Osteology of the Temporal Bone ■ 2
Horizontal Two-Dimensional Serial Photographs ■ 6
Vertical Two-Dimensional Serial Photographs ■ 14
Horizontal Three-Dimensional Photographs of Celloidin-Impregnated
Temporal Bones ■ 23
2 ■ The Pinna and External Auditory Canal . . . . . . . . . . . . . . . . . . . . . . . 31

The Pinna ■ 31
The External Auditory Canal ■ 33
Normal Anatomy ■ 33
Exostoses ■ 39
3 ■ The Middle Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

The Tympanic Membrane ■ 41
The Ossicles ■ 46
The Malleus ■ 46
The Incus ■ 61
The Stapes ■ 66
The Ossicular Articulations (Joints) ■ 70
The Incudomalleal Articulation ■ 70
The Incudostapedial Articulation ■ 74
The Stapediovestibular Articulation ■ 75
Changes of Aging in the Articulations ■ 75
The Muscles ■ 80
The Stapedius Muscle ■ 80
The Tensor Tympani Muscle ■ 82
Ectopic and Anomalous Muscles ■ 84
The Middle Ear Spaces ■ 85
The Anterior Epitympanic Recess ■ 88
The Oval Window Niche ■ 90
The Round Window Niche ■ 90
The Sinus Tympani ■ 93
The Facial Recess ■ 94
The Eustachian Tube ■ 96
The Bony Eustachian Tube ■ 96
The Fibrocartilaginous Eustachian Tube ■ 96
The Lining Membrane ■ 97
xv
The Palatal Muscles ■ 104
The Middle Ear Mucosa ■ 106
Histology ■ 106
The Mucociliary Transport System ■ 107
The Immune System of the Middle Ear ■ 108
The Mucosal Folds ■ 108
The Middle Ear Corpuscles ■ 110
Glomus Bodies ■ 112
4 ■ Pneumatization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
The Middle Ear Region ■ 116
The Mastoid Region ■ 116
The Perilabyrinthine Region ■ 124
The Petrous Apex Region ■ 124
The Accessory Regions ■ 129
The Tracts of Pneumatization ■ 129
Pacchionian Bodies ■ 133
The Subarcuate Fossa and the Petromastoid Canal ■ 136
5 ■ The Inner Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

The Bony Labyrinth ■ 137
The Vestibule ■ 137
The Cochlea ■ 137
The Canals ■ 139
Microfissures ■ 141
The Tympanomeningeal Fissure ■ 142
The Fissures of the Vestibule ■ 142
The Membranous Labyrinth ■ 144
The Cochlear Duct ■ 145
The Utricle ■ 149
The Saccule ■ 151
Macular Orientation ■ 151
The Semicircular Ducts ■ 152
The Crista Neglecta ■ 153
The Endolymphatic Duct and Sac ■ 154
The Utriculo-Endolymphatic Valve ■ 154
The Endolymphatic Duct ■ 155
The Endolymphatic Sac ■ 157
The Paravestibular Canaliculi (Aqueducts) ■ 161
The Perilymphatic System ■ 162
The Perilymphatic Labyrinth ■ 162
The Cochlear Aqueduct and Periotic Duct ■ 163
The Internal Auditory Canal ■ 166
6 ■ Neuroanatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
The Facial Nerve ■ 171
The Functional Components ■ 171
The Normal Course in the Temporal Bone ■ 172
Abnormal Courses in the Temporal Bone ■ 175
Dehiscences of the Facial Nerve ■ 179
The Facial Hiatus ■ 184
Branches of the Facial Nerve ■ 185
The Nervus Intermedius ■ 187
The Vascular Supply of the Facial Nerve ■ 189
The Sensory Nerves of the Middle Ear ■ 189
The Vestibular Nerves ■ 193
The Cochlear Nerve ■ 195
xvi ■ CONTENTS
7 ■ Vascular Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
The Vascular Supply of the External Auditory Canal and Pinna ■ 197
The Major Arteries ■ 197
The Major Veins ■ 202
The Vascular Supply to the Middle Ear ■ 210
The Vascular Supply to the Inner Ear ■ 216
Arteries ■ 216
Veins ■ 219
8 ■ Stereoscopic Views of the Temporal Bone . . . . . . . . . . . . . . . . . . . . . . 223

Surgical Dissection of the Temporal Bone ■ 223
Pathologic Conditions of the Temporal Bone ■ 238
Operative Views ■ 246
9 ■ Phylogeny and Embryology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

Phylogeny ■ 251
Embryology ■ 256
Development to Four Weeks ■ 256
The Membranous Labyrinth (0–4 Weeks) ■ 256
The Semicircular Ducts (0–4 Weeks) ■ 257
The VIIIth Cranial Nerve and Ganglion (0–4 Weeks) ■ 257
The Otic Capsule (0–4 Weeks) ■ 257
The Facial Nerve (0–4 Weeks) ■ 258
The Pinna (0–4 Weeks) ■ 258
The Tympanomastoid Compartment (0–4 Weeks) ■ 258
The Malleus and Incus (0–4 Weeks) ■ 259
The Stapes (0–4 Weeks) ■ 259
The Arteries (0–4 Weeks) ■ 259
The Veins (0–4 Weeks) ■ 261
Development to Eight Weeks ■ 261
The Cochlear Duct (0–8 Weeks) ■ 262
The Utricle and Saccule (0–8 Weeks) ■ 262
The Endolymphatic Duct (0–8 Weeks) ■ 263
The VIIIth Cranial Nerve and Ganglion (4–8 Weeks) ■ 263
The Perilymphatic Spaces (0–8 Weeks) ■ 264
The Capsular Channels (0–8 Weeks) ■ 264
The Facial Canal (0–8 Weeks) ■ 265
The Pinna (4–8 Weeks) ■ 265
The External Auditory Canal, Tympanic Membrane, and Tympanic Ring
(0–8 Weeks) ■ 267
Temporal Bone (0–8 Weeks) ■ 272
Development to 16 Weeks ■ 272
The Cochlear Duct (8–16 Weeks) ■ 272
The Utricle and Saccule (8–16 Weeks) ■ 273
The Perilymphatic Space (8–16 Weeks) ■ 275
The Capsular Channels (8–16 Weeks) ■ 275
The Fissula Ante Fenestram (0–16 Weeks) ■ 275
CONTENTS ■ xvii
The Fossula Post Fenestram (0–16 Weeks) ■ 275
The External Auditory Canal, Tympanic Membrane, and
Tympanic Ring (8–16 Weeks) ■ 276
The Ossicular Muscles (0–16 Weeks) ■ 278
The Temporal Bone (8–16 Weeks) ■ 278
Development After 16 Weeks ■ 278
The Cochlear Duct (16 Weeks) ■ 279
The Semicircular Ducts (16 Weeks) ■ 279
The Endolymphatic Duct (16 Weeks) ■ 279
The Otic Capsule (16 Weeks) ■ 279
The Perilymphatic Spaces (16 Weeks) ■ 281
The Capsular Channels (16 Weeks) ■ 282
The Facial Nerve (16 Weeks) ■ 282
The Facial Canal (8–16 Weeks) ■ 282
The Pinna (16 Weeks) ■ 282
The External Auditory Canal, Tympanic Membrane, and Tympanic
Ring (16 Weeks) ■ 282
The Tympanomastoid Compartment (16 Weeks) ■ 283
The Malleus and Incus (16 Weeks) ■ 284
The Stapes (16 Weeks) ■ 285
The Ossicular Muscles (16 Weeks) ■ 285
The Veins (16 Weeks) ■ 286
The Temporal Bone (16 Weeks) ■ 286
Ossification ■ 287
The Genesis and Growth of Bone ■ 287
Ossification of the Otic Capsule ■ 288
Serial Embryologic Sections ■ 291
Fetus A (8 Weeks) ■ 292
Fetus B (12 Weeks) ■ 297
Fetus C (16 Weeks) ■ 301
Infant (5 Months) ■ 307
■ References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
■ Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
■ Historical Bibliography of Ear Anatomy . . . . . . . . . . . . . . . . . . . . . . . 335
■ Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
xviii ■ CONTENTS
Chapter 1
Serial Photographs of Sections

of the Temporal Bone
The temporal bone is made up of the squamous, mastoid, petrous, and

tympanic parts. It articulates with the occipital, parietal, sphenoid, and zygo-
matic bones. It contributes to the lateral wall and base of the skull and forms
part of the middle and posterior cranial fossae. For study of the osteology of
the temporal bone, the reader is referred to Figures A to E.
The squama is a vertical plate of bone which forms the lateral wall of
the middle cranial fossa. It articulates with the sphenoid bone anteriorly and
with the parietal bone superiorly. The anteriorly projecting zygomatic
process articulates with the zygoma of the maxillary bone. The lateral
surface of the squama provides an anchor for the temporalis muscle, while
the masseter muscle attaches to the zygomatic process. On its lateral surface
is the sulcus for the middle temporal artery and on the medial surface is
the sulcus for the middle meningeal artery.
The mastoid part of the temporal bone is made up of the inferior
protrusions of the squamous and petrous bones. The sternocleidomastoid,
posterior auricular, and occipital muscles attach to the lateral aspect of the
mastoid, while the posterior belly of the digastric muscle attaches to a
groove medial to the mastoid process. The mastoid branch of the occipital
artery and mastoid emissary vein pierce its lateral surface. The mastoid fossa
is a cribriform area immediately posterior to the suprameatal spine of Henle.
The latter projection is located at the posterosuperior margin of the external
auditory canal. Medially, the mastoid is indented by a deep furrow for the
sigmoid portion of the lateral venous sinus.
The petrous part of the temporal bone is pyramidally shaped and
contains the inner ear structures. It extends from the mastoid part posteri-
orly to the angle between the occipital and sphenoid bones anteriorly. Its
anterosuperior surface contributes to the floor of the middle cranial fossa
and is marked by the arcuate eminence denoting the location of the superior
semicircular canal, the tympanic tegmen overlying the tympanic cavity, and
the trigeminal impression for the fifth cranial nerve. Anterior to the arcuate
eminence is the facial hiatus, an opening that leads to the geniculate gan-
glion and genu of the facial nerve and from which emerges the greater
superficial petrosal nerve. The posterior surface of the petrous pyramid lies
in a vertical plane and forms the anterolateral wall of the posterior cranial
fossa. It is bounded above by the sulcus for the superior petrosal sinus and
bounded below by the sulcus for the inferior petrosal sinus. The meatus of
the internal auditory canal is located on the posterior surface at the midpoint
between the base and apex of the petrous pyramid. Other structures on the
posterior surface of the petrous bone are the subarcuate fossa leading into
the petromastoid canal and the cranial orifice of the vestibular aqueduct.
Located at the apex of the petrous pyramid are the internal carotid artery, the
1
OSTEOLOGY OF THE TEMPORAL BONE
Figures A through E are photographs of a dry temporal bone specimen

viewed from the lateral, medial, superior, inferior, and posterior aspects. The
reader is encouraged to study dry temporal bone specimens in conjunction
with viewing the photographs as there is substantial variability in the
topography of the temporal bone and each individual specimen displays the
various features to differing degrees.
Figure A
Lateral view, left temporal bone. The
temporal line, extending posteriorly
from the root of the zygoma, approxi-
mates the inferior descent of the dura
medially as well as the inferior attach-
ment of the temporalis muscle laterally.
1 – Squama, 2 – temporal line, 3 – mas-
toid fossa, 4 – Henle’s spine, 5 – tympa-
nosquamosal suture, 6 – mastoid fora-
men, 7 – mastoid process, 8 – external
auditory canal, 9 – zygoma, 10 –
petrotympanic fissure, 11 – tympanic
bone, 12 – mandibular fossa, 13 –
styloid process.
Figure B
Medial view, left temporal bone. The
meeting of the posterior and middle
fossa faces of the temporal bone occurs
at the sulcus for the superior petrosal
sinus. 1 – Superior petrosal sulcus,
2 – arcuate eminence, 3 – squama,
4 – sigmoid sulcus, 5 – petromastoid
canal, 6 – middle meningeal artery
sulcus, 7 – internal auditory canal,
8 – petrous apex, 9 – styloid process,
10 – internal carotid artery foramen.
2 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS

Figure C
Superior view, left temporal bone. The pyrami-
dal shape of the petrous bone is well shown in
this view. 1 – Zygoma, 2 – tegmen, 3 – arcuate
eminence, 4 – lesser superficial petrosal canal, 5 –
internal carotid artery foramen, 6 – internal audi-
tory canal, 7 – facial hiatus, 8 – petrous apex.
Figure D
Inferior view, left temporal bone. This view
shows the topographically intricate inferior sur-
face of the temporal bone. 1 – Inferior petrosal
sulcus, 2 – cochlear aqueduct, 3 – inferior
tympanic canaliculus, 4 – jugulocarotid crest,
5 – internal carotid artery foramen, 6 – jugular
fossa, 7 – sigmoid sulcus, 8 – mandibular fossa,
9 – temporal groove, 10 – mastoid incisure,
11 – mastoid tip, 12 – stylomastoid foramen,
13 – styloid process.
Figure E
Posterior view, left temporal bone. In this
specimen the endolymphatic fossette is particu-
larly well developed. 1 – Squama, 2 – arcuate
eminence, 3 – petromastoid canal, 4 – internal
auditory canal, 5 – endolymphatic fossette,
6 – petrous apex, 7 – sigmoid sulcus.
CHAPTER 1: SERIAL PHOTOGRAPHS OF SECTIONS OF THE TEMPORAL BONE ■ 3

hiatus for the lesser superficial petrosal nerve, and the semicanal for the ten-
sor tympani muscle. The inferior aspect of the petrous pyramid is irregular
and provides attachment for several deep neck muscles. A ridge of bone sep-
arates the jugular bulb from the more anteriorly located canal for the inter-
nal carotid artery. The inferior aperture of the inferior tympanic canaliculus
(containing Jacobson’s nerve and the tympanic branch of the ascending pha-
ryngeal artery) is located medially in this ridge as is the cranial orifice of the
cochlear aqueduct. The styloid process arises just lateral to the posterior
aspect of the jugular fossa. The stylomastoid foramen for the facial nerve lies
posterior to the styloid process.
The tympanic bone forms the inferior, anterior, and part of the posterior
wall of the bony external auditory canal. Its juncture with the mastoid forms
the tympanomastoid suture, while its anterior interface with the petrous bone
results in the petrotympanic fissure. Superiorly, the tympanosquamous fis-
sure represents the union of the tympanic bone with the squama. Its inferior
projection forms the sheath (vaginal process) of the styloid. At the medial end
of the tympanic bone is a narrow groove, the tympanic sulcus, which is
deficient superiorly and which harbors the tympanic annulus.

These line drawings are designed to complement the vertical and horizontal
two-dimensional serial photographs of the temporal bone (Figures 1 through
37 in Chapter 1). Each drawing depicts the bony labyrinth of a right tempo-
ral bone with a shaded rectangle indicating the approximate level of section-
ing in the referenced two-dimensional photograph (number in parentheses).

HORIZONTAL TWO-DIMENSIONAL SERIAL PHOTOGRAPHS
The following series of photomicrographs (Figs. 1–20) depict horizontal

sections of the right ear of a five-year-old boy. The temporal bone was
mounted on the cutting block in the standard method with the plane of
sectioning passing through the axis of the modiolus of the cochlea. Each
section was cut at a thickness of 20 ␮m, and sectioning proceeded from supe-
rior to inferior. Every 20th section was photographed for this series.
This temporal bone, like most of the others in the collection, was
removed with the bone plug cutter which is a circular oscillating saw blade
1.5 inches (38 mm) in diameter. After the brain has been removed at the time
of autopsy, the saw is centered on the arcuate eminence and advanced in an
inferior direction until it has passed through the skull base. This plug of bone
contains the bony part of the external auditory canal, the middle ear, the
bony labyrinth, the internal auditory canal, the petrous apex, part of the
eustachian tube, and most of the mastoid. After the completion of the decal-
cification and embedding process, the block is trimmed to a size that allows
each section to be accommodated on a 1 inch ⫻ 3 inch (25 mm ⫻ 76 mm)
glass slide. This routine procedure of horizontal sectioning at 20 ␮m thick-
ness generates about 500 sections; normally every 10th is stained and
mounted for study, resulting in a set of about 50 slides.
The posterior cranial fossa is located medially and posteriorly, while
the middle cranial fossa is situated anteriorly. The external auditory canal
and mandibular fossa are located laterally and the internal auditory canal
lies medially.
In preparation for the material that follows, the student of ear anatomy
would do well to pass sequentially back and forth through these serial
sections until he/she is thoroughly familiar with the anatomic relationships.
Figure 1
The petrosquamosal suture marks the
apposition of the petrous pyramid
and the squama. The head of the
malleus, the most superior component
of the ossicular system, is visible in the
epitympanum anterolateral to the body
of the incus. The facial nerve is evident
at the facial hiatus in the floor of the
middle cranial fossa. The lateral
(ampullated) and the medial (nonam-
pullated) limbs of the superior canal
are seen in cross section. The cranial
aperture of the petromastoid canal
which carries the subarcuate artery and
its venae comites is seen. This artery is
a branch of the labyrinthine artery (or
less frequently a branch of the anterior
inferior cerebellar artery) and distrib-
utes to the mastoid air cells. The aditus
ad antrum leads posteriorly from the
epitympanum to the mastoid antrum.

Figure 2
The greater superficial petrosal nerve
(GSPN) emerges from the geniculate
ganglion and passes anteriorly into the
intracranial cavity via the facial hiatus
en route to the foramen lacerum. The
anterior epitympanic recess, mastoid
antrum, and periantral cells are well
demonstrated.
Figure 3
There is an exceptionally wide petro-
tympanic (Glaserian) fissure. The facial
nerve is seen in its labyrinthine and
tympanic segments.
Figure 4
The incus extends toward the aditus as
the crus breve or short process.
The facial nerve is seen entering its
labyrinthine segment as it leaves the
internal auditory canal (IAC). The lat-
eral canal bulges prominently into the
mastoid antrum. The petrosquamosal
(Koerner’s) septum divides the mastoid
into squamous and petrous parts.

Figure 5
The external auditory canal (EAC) has
come into view. Tethering the short
process of the incus to the walls of the
incudal recess is the fan-shaped poste-
rior incudal ligament. Within the inter-
nal auditory canal are the facial nerve
and the superior division of the
vestibular nerve. The superior-most
aspect of the basal turn of the cochlea is
apparent. The ampullated end of the
lateral semicircular duct joins the
utricle. As the superior canal recedes
from view, the posterior semicircular
canal emerges.
Figure 6
The anterior malleal ligament envelopes
the anterior process of the malleus
(processus Folianus, also known as
processus gracilis). Fibers of the tensor
tympani muscle are visible in its semi-
canal and the cochleariform (spoon-
shaped) process is beginning to assume
its characteristic form. The facial nerve
courses in its bony canal on the medial
wall of the middle ear, accompanied in
this case by a large vein. The posterior
canal continues its emergence. The
macula of the utricle lies in its elliptical
recess.
Figure 7
The pars flaccida of the tympanic mem-
brane (Shrapnell’s membrane) forms
the lateral wall of Prussak’s recess. The
body of the incus narrows to its long
process. The chorda tympani nerve is
seen passing medial to the neck of the
malleus. The cochleariform process is
now distinct as are the bundles of the
tensor tympani muscle. The common
crus, formed by the junction of the
nonampullated limbs of the superior
and posterior canals, approaches the
utricle. The lesser superficial petrosal
nerve (LSPN) is located in the superior
tympanic canaliculus medial to the
tensor tympani muscle. The middle
turn of the cochlea is exposed.

Figure 8
The tensor tympani tendon bridges the
middle ear on its way to the malleus.
The macula of the utricle faces postero-
medially.
Figure 9
The lateral process of the malleus is
evident. The chorda tympani nerve
is seen lateral to the long process of the
incus. This nerve is also seen more
anteriorly in its iter chordae anterius.
More often than not, the tympanic
segment of the facial canal is dehiscent,
as shown here. The common crus com-
municates with the utricle. The bony
lateral canal joins the vestibule. All
three turns of the cochlea are visible.
The carotid canal is seen anteriorly.
Figure 10
The manubrium, long process of the
incus, and footplate are apparent.
Lateral to the facial nerve is the facial
recess. Within the internal auditory
canal, one can distinguish the cochlear
nerve as it passes to the cribrose area of
the cochlea. Posterior to it is the inferior
division of the vestibular nerve.
The saccule is visible in its spherical
recess. The endolymphatic duct
courses posterolaterally, paralleling the
common crus.

Figure 11
The manubrium continues its descent
separated from the pars tensa by a
mucosal fold. The stapes is now
evident in its characteristic stirrup
form. The facial nerve descends in its
mastoid segment. The protympanum
extends anteriorly from the
mesotympanum. The apical turn of the
cochlea is visible as well as the heli-
cotrema which marks the wide com-
munication of the scala tympani and
scala vestibuli. The nonampullated end
of the membranous lateral semicircular
duct enters the utricle.
Figure 12
Note the normal thinness of the skin lin-
ing the anterior wall of the bony exter-
nal auditory canal. The fibrous annulus
of the tympanic membrane is seated
within its bony sulcus. The manubrium
narrows as it extends downward. The
incudostapedial articulation is seen. The
bone that overlies the facial nerve pro-
trudes toward the oval window niche,
forming the pyramidal eminence which
houses the stapedius tendon. The ten-
don attaches to the head of the stapes.
The saccule is seen at the anteromedial
aspect of the perilymphatic cistern of
the vestibule. The glial-Schwann sheath
junctions of the cochlear and vestibular
nerve trunks are seen in the internal
auditory canal.
Figure 13
The manubrium and inferior tip of
the long process of the incus are seen.
The facial nerve continues its descent
in its fallopian canal. The posterior
semicircular canal remains visible. The
utricle narrows as the nonampullated
end of the lateral duct enters at the
utricular crest. The saccular nerve trav-
erses the cribrose area to the saccular
macula. The carotid artery is sur-
rounded by a connective tissue sheath
in which the pericarotid venous plexus
and pericarotid sympathetic nerve
plexus are embedded. The sigmoid sul-
cus is visible posteriorly.

Figure 14
The tympanic membrane is circum-
ferentially fixed by the tympanic
annulus to the walls of the tympanic
sulcus. The singular canal carries the
posterior ampullary nerve, a branch of
the inferior division of the vestibular
nerve, to the ampulla of the posterior
canal. The vestibular aqueduct contain-
ing the endolymphatic (otic) duct
approaches the dura. Shielding its exit
is a thin scale of bone, the operculum.
Figure 15
The umbo marks the approximate
center of the tympanic membrane and
corresponds to the end of the
manubrium which at this level is
completely enveloped by the pars
propria of the tympanic membrane.
The basal turn of the cochlea turns into
the vestibule. The ductus reuniens
links the cochlear duct and saccule. The
singular canal is seen traveling toward
the ampullated end of the posterior
canal.
Figure 16
The internal auditory canal gradually
recedes from view as does the middle
turn of the cochlea. The bony wall of
the basal turn forms the promontory on
the medial wall of the middle ear.

Figure 17
The facial nerve continues its descent
in the mastoid segment of the fallopian
canal. Only the basal turn of the
cochlea remains visible. The scala tym-
pani of the basal turn lies adjacent to
the round window membrane. The
endolymphatic sac lies between
two layers of dura in its foveate fossa,
paralleling the posterior wall of the
temporal bone.
Figure 18
The round window niche lies inferior
to the promontory. The tympanic
ostium of the cochlear aqueduct is
situated at the posteromedial aspect
of the basal turn of the cochlea. The
subiculum is a ridge of bone that
defines the inferior limit of the sinus
tympani. The lumen of the bony
posterior semicircular canal is
seen with the ampullated and
nonampullated ends of the
membranous duct. Anteriorly lies
the petrous apex containing, in this
case, highly cellular marrow.
Figure 19
The pericarotid venous plexus is visible
on both the anterior and posterior
aspects of the internal carotid artery.
The peritubal air cells comprise the lat-
eral components of pneumatization of
the petrous apex region.

Figure 20
The anatomic juxtaposition of the
stapedius muscle and the facial nerve is
evident. The bony posterior semicircular
canal recedes from view. The cochlear
aqueduct proceeds posteroinferiorly
toward the subarachnoid space.

VERTICAL TWO-DIMENSIONAL SERIAL PHOTOGRAPHS
The following series of photomicrographs (Figs. 21–37) show the right tempo-
ral bone of a 32-year-old female as it appears in vertical cross section, cut
perpendicular to the long axis of the petrous bone. Vertical sections are smaller
than horizontal sections but there are more of them. The trimmed specimen
cut at 20 ␮m generates about 800 sections and every 10th is stained and
mounted on glass slides. In this case, two vertical sections can be mounted on
each 1 inch ⫻ 3 inch slide, resulting in a final series of about 40 such slides.
Vertical sections are particularly useful for the study of pathologic conditions
located in the most superior and inferior parts of the temporal bone.
The sections are arranged sequentially from posterolateral to antero-
medial; approximately every 50th section has been selected for this series.
The tegmen lies superiorly separating the mastoid and middle ear from the
temporal lobe. The posterior cranial fossa is located posteriorly. The carotid
canal and jugular vein are seen inferiorly, the external auditory canal later-
ally, and the middle ear space medially. The inner ear structures begin with
the canals, then the vestibule, and finally the cochlea.
Figure 21
The external auditory canal (EAC) is seen in
cross section. The chorda tympani nerve heads
anteriorly and laterally toward the tympanic
cavity. The bony posterior canal is opened and
its enclosed duct is seen. The break in the
tegmen of the mastoid is an artifact of prepara-
tion.

Figure 22
The facial nerve descends in its mastoid segment and the
chorda tympani nerve approaches the iter chordae posterius.
The short process of the incus is tethered in the incudal fossa by
the posterior incudal ligament. The lateral canal is now evident;
an extension through its long axis bisects the posterior canal.
Cells of the supralabyrinthine area are visible posterosuperi-
orly. Posteriorly, the endolymphatic sac is capped by the oper-
culum. The retrofacial group of mastoid air cells is seen.
Figure 23
Progressing anteromedially, the tympanic membrane, tympanic
sulcus, and fibrous annulus come into view. The stapedius mus-
cle is inferior and posterior to the facial nerve.

Figure 24
The incus is now visible in the epitympanum. The chorda
tympani nerve crosses the tympanic cavity suspended in a
mucosal fold. The tympanic segment of the facial nerve lies
inferior to the lateral canal.
Figure 25
The division of the tympanic membrane into a pars flaccida
superiorly and a pars tensa inferiorly can be seen. The space
superior to the lateral process of the malleus, medial to the pars
flaccida, is Prussak’s recess. The incus articulates with
the malleus in a cog wheel fashion.

Figure 26
The chorda tympani nerve now is closely applied to the medial
aspect of the neck of the malleus. Extending laterally from the
neck of the malleus is the lateral malleal ligament. The lenticu-
lar process of the incus articulates with the head of the stapes.
Within the perimeter of the superior semicircular canal one can
see the petromastoid canal with its subarcuate vessels. The
opening in the canal is an artifact.
Figure 27
The ampulla and crista of the superior canal are visible. Inferior
to the oval window niche is the bulge of the promontory.

Figure 28
Superior to the external auditory canal (EAC) is the petrotym-
panic fissure. Lateral to the facial nerve, the tendon of the tensor
tympani muscle lies in the concavity of the cochleariform
process. The round window niche and membrance are
emerging.
Figure 29
The facial nerve is located just superior to the tendon of the ten-
sor tympani muscle. The utricle and saccule now come into
view. The scala vestibuli opens into the vestibule. The peaked
configuration at the posterior aspect of the scala tympani is the
tympanic orifice of the cochlear aqueduct. The singular canal
contains the posterior ampullary nerve.

Figure 30
The external auditory canal dwindles. Running medially from
the scala tympani is the cochlear aqueduct. There is extensive
infralabyrinthine pneumatization.
Figure 31
The facial nerve is seen in its labyrinthine segment as well as
at its genu.

Figure 32
The middle and apical turns of the cochlea are emerging as the
middle ear space narrows. The falciform crest and its
relationship to the cochlear and facial nerves are seen, as well
as the labyrinthine segment of the facial nerve.
Figure 33
The facial nerve and its geniculate ganglion lie beneath the
dura of the middle cranial fossa. The facial, vestibular, and
cochlear nerve trunks are seen in the internal auditory canal.

Figure 34
The protympanum diminishes in size anteriorly. The lesser
superficial petrosal nerve (LSPN) in its superior tympanic
canaliculus lies just superior to the tensor tympani muscle. All
three turns of the cochlea and the helicotrema are seen.
Figure 35
The tensor tympani muscle lies in its semicanal just medial
to the osseous part of the eustachian tube.

Figure 36
Progressing anteromedially, only the anterior aspect of the basal
turn of the cochlea remains.
Figure 37
The internal auditory canal opens to the posterior cranial fossa.
The pericarotid and peritubal areas are well pneumatized.

HORIZONTAL THREE-DIMENSIONAL PHOTOGRAPHS
OF CELLOIDIN-IMPREGNATED TEMPORAL BONES
The paired images appearing in Figures 38 to 51 are stereoscopic counter-

parts of the accompanying, labeled photograph. The photograph is
presented only to aid in identifying the anatomic structures featured in the
stereo views. The stereo photographs were made with a Donaldson camera
from celloidin blocks during the process of sectioning. They show the three-
dimensional anatomy of the temporal bone in the horizontal plane. Figures
38 to 44 show a sequence of views from superior to inferior; Figures 45 to 51
show selected views of particular anatomic interest.
In order to appreciate the three-dimensional effect, it is important to
concentrate on the paired images and have them fully occupy your field of
vision. In addition, the plane of your eyes must remain parallel to the plane
of the page. Then “defocus” your eyes and allow the images to fuse.
Alternatively, looking “through” or “beyond” the images without focusing
on them enables perception of the three-dimensional effect. We believe that
these stereo views will facilitate the comprehension of ear anatomy in its
three-dimensional aspect, and aid in understanding of the two-dimensional
photographs in this book.

Figure 38
There is a large anterior epitympanic recess
which opens into the mesotympanum inferiorly.
The epitympanum narrows posteriorly to the
aditus which in turn communicates with the
mastoid air cell system. The crista is seen on the
lateral wall of the ampulla of the superior canal
(female, age 72 yr). (Comparable to Fig. 2 on p. 6.)
Figure 39
At a deeper level, we see the genu of the facial
nerve. It is an important landmark in the middle
cranial fossa approach to the internal auditory
canal. The vertical crest (also known as “Bill’s
bar”) separates the facial nerve anteriorly from
the superior vestibular nerve posteriorly. The
lateral and posterior canals are both visible. The
lateral part of the internal auditory canal is
narrower than the midportion, with the cochlea
located anteriorly and the ampulla of the supe-
rior canal located posteriorly. The short process
of the incus is tethered to the walls of the incu-
dal fossa by the posterior incudal ligament.
(Comparable to Fig. 4 on p. 7.)

Figure 40
Prussak’s recess is seen lateral to the head and
neck of the malleus. The incus articulates with
the stapes by means of the lenticular process. The
facial nerve is seen in its tympanic (horizontal)
segment. The basal turn of the cochlea is
exposed. The superior division of the vestibular
nerve and its utricular branch are evident. The
otoconial surface of the macula of the utricle
faces medially and posteriorly. (Comparable to
Fig. 5 on p. 7.)
Figure 41
The external auditory canal (EAC) is widely
opened and lies in the same plane as the internal
auditory canal. The posterior pouch of von Tröltsch
occupies the interval between the posterior malleal
fold and the tympanic membrane. The facial nerve
is seen in the beginning of its mastoid (vertical) seg-
ment. Normally, the anterior crus of the stapes is
straight and the posterior crus is curved, as seen
here. All three turns of the cochlea are seen. Note
that the apex of the cochlea points laterally, anteri-
orly, and inferiorly, and lies medial to the cochlear-
iform process. The saccular branch of the inferior
vestibular nerve passes to the cribrose area. The
tensor tympani muscle and tendon are fully
exposed. (Comparable to Fig. 11 on p. 9.)

Figure 42
The conical shape of the pars tensa is evident.
The stapedius tendon attaches to the head of the
stapes. The promontory of the cochlea lies fully
exposed. The posterior ampullary nerve traverses
the singular canal on its way to the ampulla of the
posterior canal. There is a small arachnoid cyst
causing slight displacement but no atrophy of the
cochlear nerve bundles in the internal auditory
canal. (Comparable to Fig. 14 on p. 10.)
Figure 43
The manubrium of the malleus is visible in the
region of the umbo. The protympanum and hypo-
tympanum are seen. The facial recess lies lateral and
the sinus tympani lies medial to the facial nerve.
The hook portion of the cochlea is located near the
ampulla of the posterior canal. Note the crista of the
posterior canal. (Comparable to Fig. 15 on p. 11.)

Figure 44
The basal turn of the cochlea and round window
are seen. The protympanum leads to the tym-
panic orifice of the bony part of the eustachian
tube. (Comparable to Fig. 19 on p. 12.)
Figure 45
There is extensive pneumatization of the tempo-
ral bone. The posterosuperior cell tract leads to
the pneumatized petrous apex. The subarcuate
tract passes through the arch of the superior
canal, also leading to the petrous apex. Note that
the semicircular duct hugs the outer wall of the
bony canal (female, age 67 yr).

Figure 46
This view shows Koerner’s (petrosquamosal)
septum which marks the junction of the lateral
or squamous part and the medial or petrous part
of the mastoid. The crista of the lateral canal and
the ampullated end of the superior canal are
visualized (male, age 67 yr).
Figure 47
The anterior inferior cerebellar artery loops
deeply into the internal auditory canal. The facial
nerve is seen in the internal auditory canal and in
its tympanic segment. The superior division of
the vestibular nerve and its utricular branch, as
well as the utricular macula are seen (male, age
87 yr).

Figure 48
The cochlear nerve and the inferior division of
the vestibular nerve with its two branches, the
posterior ampullary and saccular nerves, are
seen. The inferior utricular crest marks the
boundary between the nonampullated end of
the lateral semicircular duct and the utricle. The
modiolus, osseous spiral lamina, limbus, organ
of Corti, and spiral ligament can be seen. The
saccule narrows inferiorly to the ductus
reuniens (female, age 68 yr).
Figure 49
This is the right ear of a 62-yr-old man who
underwent stapedectomy for otosclerosis 2 yr
before death. A gelfoam-wire prosthesis was
implanted and attached to the incus. Hearing
was improved. The prosthesis is partially
enveloped in fibrous tissue. The ductus reuniens
is seen passing from the saccule to the cochlear
duct.

Figure 50
This photograph shows the sinus tympani as
it lies medial to the facial nerve, separated from
the round window niche by the subiculum.
Medially lies the ampullated end of the poste-
rior canal. The carotid canal is located close to
the basal turn of the cochlea (male, age 69 yr).
Figure 51
The protympanum is that portion of the middle
ear space anterior to a coronal plane passing
through the anterior margin of the tympanic
annulus. It leads into the eustachian tube. Note
the hook end of the cochlear duct and the utric-
ular opening into the ampulla of the posterior
canal (female, age 68 yr).

Chapter 2
The Pinna and External Auditory Canal
THE PINNA
In vernacular parlance, the term “ear” evokes an image of that bilaterally

symmetric, cartilage-framed, cranial appendage known as the pinna or
auricle. This structure acts to focus and localize sound; otoplasty (surgical
correction of lop ears), if not properly done, can increase the error in the lat-
ter function from 4° to 20° (1). The pinna normally rests at an angle of 30° to
the sagittal plane of the head, while the concha lies at an angle of 90° (⫾15°)
to the bony cortex of the mastoid (2). The pinna’s growth parallels overall
body growth until approximately nine years of age; in general, the left ear is
smaller than the right (2). This text is not concerned with auricular congeni-
tal deformities and diseases. Suffice it to say that, due to the multi-component
nature of its embryologic development, the pinna manifests a wide variety of
configurations. Despite this variability, there are certain relatively constant
features that can be recognized in the human ear.
The topography of the visualized pinna is determined almost solely by
the contour of its underlying cartilaginous frame. The flange-like pinna has
a convex medial surface which attaches to the head at its medial one-third;
the lateral surface is concave. The major concavity of the lateral aspect of the
pinna is the concha (Fig. 1). Anteriorly, the tragus delimits the concha as it
extends over the orifice of the external auditory canal. Superiorly and poste-
riorly the concha is bounded by the anthelix and its anterior crus. The infe-
rior extent of the concha is determined by the antitragus, which is separated
from the anthelix posteriorly by the posterior auricular sulcus, and from the
tragus anteriorly by the intertragic incisura. The concha is partitioned at the
crus of the helix into a superior cymba concha and an inferior cavum concha;
the latter depression points to the meatus of the external auditory canal.
Anteroinferiorly, the crus of the helix is separated from the tragus by the
anterior incisure. The helix, with its furled edge, sweeps superiorly and pos-
teriorly from the crus of the helix to end at the lobule; a projection, the
Darwinian or auricular tubercle, occasionally exists at its posterosuperior
aspect. There are two additional depressions of note. As it curves antero-
superiorly, the anthelix bifurcates into two crura, between which lies a
depression known as the triangular fossa. The scaphoid fossa is a trench-like
groove separating the helix from the anthelix. Lop ears lack an anthelix, with
the consequence that the helix assumes an outstanding position; therefore in
a surgical correction an anthelix must be created.
The medial aspect of the pinna is a negative relief model of the lateral
aspect. The scaphoid, conchal, and triangular eminences correspond to the
respective fossae on the lateral surface. Similarly, depressions of the medial
aspect (i.e., the transverse sulcus of the anthelix, the sulcus of the crus of the
31
Figure 1
The right auricle (pinna) of the co-author
(AJG) showing the principal anatomic
features of its lateral surface.
helix, and the fossa of the anthelix) correspond to elevations of the lateral
surface of the pinna and are hidden by the cranial attachment of the pinna.
The framework of the pinna consists of elastic cartilage, the contours of
which determine its topography; the cartilage measures 0.5 to 2 mm in thick-
ness (3). It consists of two furled plates of cartilage separated by the termi-
nal incisure. The larger plate supports the major bulk of the pinna; the lesser
underlies the tragus and is connected to the larger by a narrow isthmus.
While the cartilage features much the same topography as the surface of the
pinna, there are additional elements which are obscured by its mantle of skin
and subcutaneous tissue. Anteriorly, from that portion of the helix just supe-
rior to the crus, arises the spine of the helix. Inferiorly, the antitragohelicine
fissure separates the tail of the helix (cauda helicis), the posteroinferior ter-
minus of the helix, from the antitragus.

The pinna is attached to the cranium by its skin, cartilage, and a com-
plex of muscles and ligaments. There are three extrinsic ligaments and three
extrinsic muscles, both sets referred to as superior, anterior, and posterior.
The superior ligament links the superior aspect of the bony external auditory
canal to the spine of the cartilaginous helix, the anterior ligament connects
the zygoma to the helix and the tragus, and the posterior ligament attaches
the eminence of the concha to the mastoid process.
The three extrinsic muscles originate from the galea aponeurotica of
the scalp. The superior auricular muscle inserts upon the eminence of the tri-
angular fossa, the anterior auricular muscle inserts upon the spine of the
helix, and the posterior auricular muscle inserts upon the eminence of the
cavum concha.
The six intrinsic auricular muscles show great individual variability in
their extent of development and are poorly represented in man; four are
found on the lateral surface and two on the medial surface. On the lateral
surface, the helicis major extends from the spine of the helix to attach tangen-
tially to the anterosuperior curve of the helix. The helicis minor hugs the crus
of the helix. The tragicus overlies the tragus, and the antitragicus spans the
antitragohelicine fissure between the tail of the helix and the inferior aspect
of the antitragus. On the medial surface, the transverse auricular muscle
links the eminence of the scaphoid fossa and the cavum concha. The oblique
auricular muscle connects the eminence of the triangular fossa and the cymba
concha.
The skin and subcutaneous tissue reproduce the irregular contours of
the cartilaginous frame; the skin of the medial aspect is only loosely attached,
while on the lateral surface it is snugly secured by subcutaneous areolar tis-
sue. The usual skin adnexal structures are present, including sebaceous and
sudoriferous (sweat) glands, and hair. The sebaceous glands are distributed
both medially and laterally, especially in the regions of the concha and trian-
gular fossa (4). Sudoriferous glands are sparse. A rudimentary type of hair is
in abundance over the entirety of the pinna; in elderly male persons, the hairs
may be long and large, especially over the tragus and antitragus.
The lobule, the inferior appendage of the pinna, is essentially a fibro-
fatty nodule. While the lobule has no known physiologic function, its adi-
pose tissue serves as a reservoir for autogenous tissue grafts and its conven-
ient anatomical site serves admirably as a tethering base for ornamentation.
THE EXTERNAL AUDITORY CANAL
Normal Anatomy
The external auditory canal is approximately 2.5 cm in length and serves as a

channel for sound transmission to the middle ear. It also functions to protect
the middle and inner ears from foreign bodies and fluctuations in environ-
mental temperature (1). Its lateral one-third is bolstered by elastic cartilage
oriented in an upward and backward fashion; its anterior aspect is pierced by
two or three variably present vertical fissures known as the fissures of
Santorini (Fig. 6); these fissures are a potential route for spread of infections
or neoplasms between the external auditory canal and the parotid gland.
The medial two-thirds of the external auditory canal is osseous and is
oriented in a downward and forward direction. Because of the different
angulations of the fibrocartilaginous and bony canal walls, the adult auricle
CHAPTER 2: THE PINNA AND EXTERNAL AUDITORY CANAL ■ 33

Figure 2
This horizontal section demonstrates
the anatomy of the normal osseous
external auditory canal (EAC). The ante-
rior wall of the canal forms an acute
angle with the tympanic membrane.
An excessive convexity of the anterior
wall can impair otoscopic visualization
of the anterior part of the tympanic
membrane. Surgically created dehis-
cences of the anterior canal wall can
result in herniation of the contents of the
mandibular fossa into the EAC (female,
age 32 yr).
must be pulled upward and posteriorly to achieve alignment during

otoscopic examination.
The narrowest portion of the external auditory canal or isthmus is
located just medial to the junction of the bony and fibrocartilaginous canals.
The inferior tympanic recess is a depression in the inferior aspect of the
osseous canal. Because of the angulation of the tympanic membrane, the canal
is approximately 6 mm longer anteroinferiorly than posterosuperiorly, thus
creating an acute angle between the tympanic membrane and anteroinferior
Figure 3
In our collection of temporal bones
there are several examples of pneumati-
zation of the tympanic bone (male, age
70 yr).

bony canal wall (Fig. 2). Although the condition is unusual, our collection con-
tains several examples of pneumatization of the anterior wall of the external
auditory canal (Fig. 3).
The skin of the osseous canal is much thinner than that of the fibrocarti-
laginous portion (Fig. 4), measuring about 0.2 mm in thickness (3), and is
continuous with the skin of the tympanic membrane. The subcutaneous layer
has no glands or hair follicles. The bony posterior wall of the external auditory
canal, which overlies the mastoid air cells, may be extremely thin (Fig. 4).
The thinness of the skin of the bony external auditory canal has the fol-
lowing clinical implications: (1) it is easily traumatized during manipula-
tions such as removing cerumen, (2) it is easily torn in the course of surgical
procedures such as tympanotomy, and (3) it permits thermal irritation of the
periosteum and consequently the formation of exostoses caused by swim-
ming in cold water.
The skin of the fibrocartilaginous part of the canal averages 0.5 to 1 mm
in thickness (3), with an epidermis of four layers (basal, squamous, granular,
and cornified) blanketing a true subcutaneous layer. The lateral one-third of
the fibrocartilaginous canal is replete with hair follicles, but they are less
numerous in the medial part. Both sebaceous and modified apocrine (ceru-
minous) glands (Figs. 5–7) develop from the outer root sheath of hair folli-
cles; hence their numerical distribution follows a pattern similar to that of
the hair follicles. In addition, the modified apocrine glands are found mainly
on the superior and inferior walls of the canal. Arrector pili muscles are not
found in association with the hair follicles in any portion of the external
auditory canal.
The apocrine glands are the ceruminous glands of the ear canal (Fig. 7).
They are located in the dermis deep to the sebaceous glands and have three
major components (3): (1) a coiled secretory portion, (2) a secretory duct
within the dermis, and (3) a terminal funnel. A myoepithelial cell layer is
associated with the coiled secretory portion.
Main and Lim (5) detected both apocrine and eccrine modes of secre-
tion in these glands. Moreover, they found that these modified apocrine
Figure 4
Surgical enlargement of the external
auditory canal (EAC) (canalplasty) is
necessarily limited by the thinness of
its bony walls, both anteriorly and
posteriorly (female, age 67 yr).

Figure 5
This schematic drawing illustrates the
adnexae and secretory system of the
skin of the external auditory canal.
Source: Courtesy of Main and Lim (5).
glands secreted a heterogeneous population of granules as well as secretory

vesicles. The exact nature of their secreted product is unclear. They are
easily differentiated from the parotid glands which consist principally of
serous cells (Fig. 8). The sebaceous glands (Fig. 9) expel the combined prod-
ucts of several acini into the hair follicles via short excretory ducts. These
sebaceous glands manifest the holocrine mode of secretion; they contain
only one type of secretory granule, presumed to consist of squalene and sat-
urated fatty acids (5).
Acute circumscribed external otitis is a bacterial infection of a seba-
ceous or apocrine gland. It is an extremely painful disorder requiring aggres-
sive antibiotic and pain therapy. A common cause is swimming in bacterially
contaminated water.

Figure 6
This photomicrograph shows the
anterior wall of the fibrocartilaginous
part of the external auditory canal (EAC)
of a 3-mo-old infant. The sebaceous
(lipid-producing) and apocrine (cerumi-
nous) glands are histologically distinct
from the glandular tissue of the adjacent
parotid gland. The fissures of Santorini
in the anterior fibrocartilaginous wall
facilitate the spread of bacterial and neo-
plastic diseases between the EAC and
the parotid gland. Outlined areas A and
B are shown in higher magnification in
Figures 7 and 8, respectively.
Chronic external otitis is a low-grade inflammatory disorder of the skin

of the external auditory canal, characterized symptomatically by itching and
weeping and also by being exceptionally recalcitrant to treatment. Fibrous
tissue proliferation in the subepidermal tissue may lead to stenosis requiring
surgical correction.
The ear wax (cerumen) of humans, to a large extent, is the combined
product of the sebaceous (lipid-producing) and apocrine (ceruminous)
Figure 7
A higher magnification of the outlined
area A in Figure 6 showing the cross-
sectioned, coiled, secretory portion of
apocrine (ceruminous) glands. These
are modified sweat glands.

Figure 8
A higher magnification of outlined area
B in Figure 6 shows the serous cells of
the parotid gland.
Figure 9
This photomicrograph of the skin of the
fibrocartilaginous part of the external
auditory canal (EAC) demonstrates the
sebaceous glands. These glands, as well
as hair follicles, are most numerous at
the meatus of the canal.

glands; there is also a variable component of desquamated epithelial cells.
Impacted cerumen is a common cause of conductive hearing loss.
There are genetically and racially determined differences in the physi-
cal characteristics of ear wax; Caucasians and blacks tend to secrete a wet,
brown wax, and Orientals a dry, gray wax (6). These differences in appear-
ance and consistency seem to be associated with differences in immuno-
globulin and lysozyme content (7). The implications of these differences in
relation to the role of the external auditory canal in immunocompetence are
unknown and possibly irrelevant.
Exostoses
Exostoses are benign bony excrescences of the external auditory canal usually
caused by refrigeration periostitis from swimming in cold water (Fig. 10).
Histologically, they demonstrate a laminated structure (Figs. 11 and 12)
consistent with a periodic growth pattern.
Exostoses remain clinically silent until they become large enough to
impair the egress of epithelial debris and water from the canal, in which case
there may be an associated external otitis and fluctuating hearing loss. They
may also cause a hearing loss by impinging upon the tympanic membrane
and/or manubrium. Symptomatic relief is attained by surgical removal
and skin grafting of the epithelially denuded areas of the bony walls of the
external auditory canal.
Figure 10
This view shows occult (asympto-
matic) exostoses of the anterior and
posterior walls of the external auditory
canal (male, age 75 yr).

Figure 11
Here we see the interesting condition in
which a second exostosis appears
to have formed on the surface of a
pre-existing exostosis (male, age 60 yr).
Figure 12
This high power magnification shows
the usual lamellar structure of a typical
exostosis punctuated by the normal
process of focal remodeling (male, age
61 yr). The number of laminations may
correlate with the number of cold water
insults to the external auditory canal.

Chapter 3
The Middle Ear
THE TYMPANIC MEMBRANE
The tympanic membrane is irregularly round and slightly conical in shape;

the apex of the cone is located at the umbo, which marks the tip of the
manubrium. In the adult, it is angulated approximately 140° with respect to
the superior wall of the external auditory canal. The vertical diameter of the
tympanic membrane as determined along the axis of the manubrium ranges
from 8.5 to 10 mm, while the horizontal diameter varies from 8 to 9 mm (8).
The malleal prominence (Fig. 1), a projection formed by the lateral process of
the malleus, is located at the superior end of the manubrium. The manubrium
is firmly attached to the tympanic membrane at the umbo and lateral process
and is clearly visible throughout its length (the stria mallearis). The anterior
and posterior tympanic striae extend from the lateral process of the malleus
to the anterior and posterior tympanic spines, respectively. These striae
divide the tympanic membrane into larger pars tensa below, and smaller tri-
angular pars flaccida (or Shrapnell’s membrane) above.
The superior recess of the tympanic membrane is eponymically known
as Prussak’s space (9). The pars flaccida forms the lateral border of this space
as it attaches superiorly to the bony margins of the notch of Rivinus or tym-
panic incisura. The lateral malleal ligament limits this space anterosuperi-
orly as it extends from the union of the head and neck of the malleus to the
periphery of the notch of Rivinus. Posteriorly, Prussak’s space opens into the
epitympanum. The anterior and posterior malleal folds mark the inferior
limit of Prussak’s space.
The thickened periphery of the pars tensa, the tympanic annulus (lim-
bus) (Fig. 2), anchors the tympanic membrane in a groove known as the tym-
panic sulcus. The tympanic annulus and sulcus are absent superiorly in the
area of the notch of Rivinus. The surgeon, when exposing the middle ear via
a tympanomeatal flap approach, must elevate the tympanic annulus from the
tympanic sulcus if perforation of the tympanic membrane is to be avoided.
The pars tensa and pars flaccida differ in structure. The pars tensa, as its
name suggests, is taut and consists of three layers: (1) a lateral epidermal layer,
(2) a medial mucosal layer, and (3) an intermediate fibrous layer, the pars pro-
pria. The epidermal layer is contiguous with the skin of the external auditory
canal (see chap. 2, p. 33) and the mucosal layer is contiguous with the mucous
membrane of the middle ear. The intermediate layer consists of fibrous tissue
arranged in inner circular and outer radial strata. Elastic fibers are rare in the
pars tensa (10).
With acute infections of the middle ear, the tympanic membrane
becomes acutely inflamed. It is not unusual for blebs or bullae to form at the
interface between the pars propria and epidermal layers. The surgeon
41
Figure 1
This diagrammatic sketch illustrates the
superior, anterior, and inferior bound-
aries of Prussak’s space. Shrapnell’s
membrane (not illustrated) constitutes
the lateral wall as it extends from the
anterior and posterior tympanic striae
to attach to the margins of the notch of
Rivinus. Source: After Proctor (76).
performing therapeutic myringotomy (incision of the ear drum) must not be

misled by such a bleb and fail to incise all three layers of the membrane.
The pars flaccida, although lax, is actually thicker than the pars tensa
(10). First described by Shrapnell (11), it also consists of epidermal, fibrous,
and mucosal layers. The epidermis is composed of 5 to 10 layers of epithe-
lial cells, the fibrous layer consists of irregularly arranged collagen and
elastic fibers, and the mucosal layer is composed of simple squamous cells,
as in the pars tensa.
When the tympanic membrane is perforated by either trauma or
infection, the extent of fibrous tissue proliferation determines the thickness
of the healing membrane. The replacement membrane may develop a dense
intermediate fibrous layer or alternately may fail to develop a fibrous layer,
Figure 2
In the region of the umbo, the manub-
rium is enveloped by the lamina propria
of the tympanic membrane (see Fig. 19
on p. 50). The tympanic (fibrous) annu-
lus is seen lodged within the tympanic
sulcus. The nerves of the tympanic
plexus ascend the promontory region in
grooves (male, age 63 yr).

Figure 3
This tympanic membrane shows histo-
logic alterations caused by chronic
otitis media. Although intact, there is
an anterior marginal area of fibrous
thickening and a large area of replace-
ment membrane (neomembrane). The
latter area represents a site of previous
perforation and is characterized by
the absence of the lamina propria
(the fibrous layer of the tympanic
membrane). The inset shows a higher
magnification of the outlined area
(male, age 54 yr). Thin replacement
membranes are frequently seen during
routine otoscopic examination and,
unless very large, have no effect on
hearing.
resulting in a thin membrane composed only of epidermal and mucosal

layers (Fig. 3). It may vary in thickness in different areas and may have areas
of hyalinization (Fig. 4). The replacement membrane when invaginated into
the middle ear space forms a retraction pocket (Figs. 5 and 6). These pockets
may be fixed by adhesions to structures in the middle ear. If not adherent,
positive middle ear pressures can cause them to evert into the external
auditory canal (Fig. 7).
For a successful functional result in myringoplasty operations (closure
of perforations of the tympanic membrane), it is important to avoid postop-
erative fibrous obliteration (blunting) of the anterior tympanomeatal angle.
Figures 8 and 9 show examples of malleus fixation caused by fibrous prolif-
eration in this angle following myringoplasty.
Figure 4
A tympanosclerotic (hyalin) plaque
is seen in the anterior part of the
tympanic membrane. Otoscopically such
plaques have a whitish appearance and
are often erroneously termed “calcium
plaques.” They are the consequence of
otitis media (male, age 45 yr). These
plaques cause no hearing loss unless they
are large enough to stiffen the tympanic
membrane or fix the manubrium.
CHAPTER 3: THE MIDDLE EAR ■ 43

Figure 5
The tympanic membrane shows a
posterior retraction pocket and an
anterior replacement membrane. The
long process of the incus has been
resorbed. Additionally, there is a
healed fistulous tract leading from the
mastoid to the external auditory canal.
These alterations are the result of
chronic otitis media and mastoiditis
(female, age 48 yr).
Figure 6
There is a deep retraction pocket in the
posterior part of the tympanic mem-
brane. The long process of the incus has
been resorbed and the central mastoid
tract is surrounded by sclerotic bone.
These changes are the result of previ-
ous otitis media and mastoiditis (male,
age 67 yr).

Figure 7
Retraction pockets, if not fixed to
middle ear structures by adhesions,
may evert or invert depending upon
the state of middle ear pressure
Figure 8
There is fibrous fixation of the malleus
and hearing loss following surgical clo-
sure (myringoplasty) of an anterior
perforation of the tympanic membrane
with fascia from the temporalis muscle
(male, age 19 yr; see Fig. 9 below).
Figure 9
The opposite ear of the subject shown
in Figure 8 demonstrates fibrous thick-
ening of the entire tympanic membrane
with hearing loss following myringo-
plasty for an anterior perforation
(male, age 19 yr). Such untoward
results can be avoided by the proper
use of skin grafts.

THE OSSICLES
The ossicles serve to transmit sound energy from the tympanic membrane to
the inner ear. The general size, shape, and configuration of the malleus,
incus, and stapes are shown in Figure 10.
The Malleus
The most lateral of the ossicles is the malleus. It has a head, neck, lateral
process, anterior process, and manubrium. The anterior process (processus
gracilis or processus Folianus) is a thin projection of bone which extends from
the neck of the malleus into the petrotympanic (Glaserian) fissure, accompa-
nied by the chorda tympani nerve (Figs. 11–13). It seems doubtful that the
anterior process of the malleus has any important function, for in adult ears
it is often found to be fractured (Fig. 14) or partially resorbed (Fig. 15) with-
out causing hearing loss. It is held to the walls of the petrotympanic fissure
by the anterior malleal ligament which, with the posterior incudal ligament,
serves to establish the axis of rotation of the ossicles (Fig. 16). The anterior
malleal ligament must not be confused with the anterior suspensory ligament
of the malleus.
The dense fibrous tissue of the anterior malleal ligament is in contigu-
ity with the periosteum of the malleus (12) and traverses the petrotympanic
fissure to reach as far as the angular spine of the sphenoid bone. On its
thinner, medial aspect runs the chorda tympani nerve as it passes anteriorly
to enter the iter chordae anterius at the Glaserian fissure.
Figure 10
This sketch shows the articulated
ossicles and the form and dimensions
of the stapes. Source: After Anson and
Donaldson (77).

Figure 11
Mesenchyme is still present in the
middle ear cavity. The long anterior
process of the malleus (processus gra-
cilis or Folianus) is demonstrated in its
normal configuration (male, age 5 mo).
Figure 12
The anterior process of the malleus is
believed to develop in membrane bone
and to fuse secondarily with the
enchondral bone of the remainder of
the malleus (male, age 39 yr).
Figure 13
The anterior process of the malleus and
the anterior malleal ligament constitute
the anterior pole of the axis of ossicular
rotation. The anterior malleal ligament
may reach as far as the angular spine of
the sphenoid bone (male, age 65 yr).

Figure 14
In the adult temporal bone, the anterior
process of the malleus frequently
shows fractures (female, age 85 yr).
The lateral process of the malleus contains a cartilaginous cap attached

to the pars tensa of the tympanic membrane (Figs. 17 and 18). The inferior
end of the manubrium is firmly attached to the tympanic membrane as the
pars propria splits to envelop it (the umbo) (Fig. 19). In surgical procedures,
the tympanic membrane can be readily separated from the malleus except at
the umbo.
Midway between the lateral process and umbo, the manubrium,
because of its gentle medial curvature, may separate slightly from the pars
propria so that its only attachment is a fold of mucous membrane, the plica
mallearis (Fig. 20). Prostheses clamped to the manubrium in the region
midway between the lateral process and umbo therefore may have little or
no contact with the pars propria of a normal tympanic membrane.
Figure 15
In this ear, the anterior process of the
malleus has undergone partial resorp-
tion. The chorda tympani nerve fre-
quently lies in a groove on the medial
surface of the malleus near the base of
the anterior process (female, age 85 yr).

Figure 16
The anterior suspensory ligament,
shown here, lies superior to the ante-
rior malleal ligament seen in Figures 13
to 15. Apparently, the suspensory liga-
ments do not interfere with the process
of sound transmission even though
they are outside the axis of rotation
(male, age 47 yr).
Usually the manubrium lies midway between the anterior and poste-
rior borders of the tympanic membrane (Fig. 21), but may occupy a more
anterior position (Fig. 22). The surgical significance of an anteriorly located
manubrium is the difficulty it may cause in the repair of an anterior perfora-
tion of the tympanic membrane, as well as in the removal of exostoses and
stenoses of the external auditory canal. Surgical procedures on the tympanic
membrane and exter nal auditory canal are especially difficult when an ante-
riorly located malleus is associated with convexity of the anterior canal wall.
The cross-sectional ovoid configuration of the manubrium (Figs. 23
and 24) is an important determinant in the design of prostheses that attach
to it (Figs. 25 and 26).
Figure 17
Although the lateral process of the
malleus is firmly adherent to the tym-
panic membrane, surgical separation
without perforation is readily accom-
plished (male, age 28 yr).

Figure 18
The lateral process of the malleus has a
cartilaginous cap which facilitates sep-
aration of the malleus from the tym-
panic membrane in this region (male,
age 72 yr).
Figure 19
At the umbo, the lamina propria splits to
envelop the manubrium of the malleus,
making it difficult to separate the
malleus from the tympanic membrane
without perforation (male, age 28 yr).

Figure 20
At its mid-portion, the manubrium is
normally separated from the tympanic
membrane by a mucosal fold (the
manubrial fold or plica mallearis)
(male, age 63 yr).
Figure 21
In the anteroposterior dimension, the
manubrium is normally located near
the middle of the tympanic membrane
(male, age 87 yr).

Figure 22
In this ear, the manubrium is positioned
anteriorly in the tympanic membrane.
While this anatomical variant is compat-
ible with normal hearing, it increases
the risk of fibrous fixation of the malleus
following myringoplasty (male, age
79 yr; see Figs. 8 and 9 on p. 45).
Figure 23
Except at the umbo, the manubrium is
oval-shaped, an anatomical feature that
must be considered in the design of
prostheses that attach to it (male, age
28 yr).
Figure 24
Midway between the lateral process
and umbo, the manubrium is separated
from the tympanic membrane with
only the manubrial fold of mucous
membrane joining them. This is the
ideal location for attachment of pros-
theses (female, age 60 yr).

Figure 25
Attachment of a prosthesis (e.g., teflon
wire piston) to the oval-shaped manub-
rium requires a longer loop than is
needed for the circular-shaped long
process of the incus. The fabrication of
such a loop is illustrated in this figure.
The black semicircles represent the
jaws of a small forceps (78).
Figure 26
The metallic prosthesis is firmly attached
to the manubrium in a wrap-around
manner. A loose attachment invariably
results in traumatic osteitis and extru-
sion of the prosthesis (78).

Figure 27
The anterior and lateral suspensory lig-
aments of the malleus are shown. The
notch in the short process of the incus,
originally described by Lempert and
Wolff (79), is well visualized; its deriva-
tion and function (if any) is not known
(male, age 77 yr).
The malleus is held in place by five ligaments, one articulation, the tensor
tympani tendon, and the tympanic membrane. Three of the five ligaments
are well outside the axis of rotation and have a suspensory function; they
are: (1) the anterior suspensory ligament which lies superior to the anterior
malleal ligament and attaches the head of the malleus to the anterior wall of
the epitympanum (Fig. 16), (2) the lateral suspensory ligament (Figs. 27
and 28) which attaches the neck of the malleus to the bony margins of the
tympanic notch (the notch of Rivinus), and (3) the superior suspensory
Figure 28
The lateral suspensory ligament of the
malleus extends from the neck of the
malleus to the bony margin of the
notch of Rivinus (male, age 65 yr).

Figure 29
The thickened, inferior portion of the
posterior malleal fold forms the poste-
rior malleal ligament. It stretches from
the neck of the malleus to the pretym-
panic spine (female, age 64 yr).
ligament which bridges the gap between the head of the malleus and the
tegmen of the epitympanum.
These ligaments apparently do not interfere with sound transmission
because of the small movement of the ossicles. They may be useful in damp-
ing the response of the ossicles to low frequency stimuli of high intensity and
in resisting ossicular displacement with large changes in middle ear pres-
sures. The anterior malleal ligament, in concert with the anterior process of
the malleus, is in the axis of ossicular rotation. The posterior malleal liga-
ment (Fig. 29) is the thickened inferior margin of the posterior malleal fold
and stretches from the neck of the malleus to the pretympanic spine. The
tympanic membrane attaches the manubrium to the tympanic sulcus.
Additionally, the malleus is tethered by the capsule of the incudomal-
leal articulation which features two thickenings known as the medial and
lateral incudomalleal ligaments and by the capsule of the incudostapedial
articulation.
The tendon of the tensor tympani muscle extends laterally from the
cochleariform process to attach to the neck and manubrium of the malleus.
Often some of its fibers pass anterior to the manubrium to reach the tym-
panic membrane (Figs. 30–32). The function of the tensor tympani muscle is
to pull the manubrium medially and thus exert tension on the tympanic
membrane.
Normally, the pull of the tensor tendon is opposed by the elasticity of
the pars propria. With a large perforation of the tympanic membrane,
the unopposed pull of the tensor tendon causes a medial displacement of
the inferior end of the manubrium (Figs. 33 and 34). In some cases, the
manubrium may eventually reach the promontory. In surgical reconstruc-
tive procedures, such as myringoplasty, it may be prudent to section the
tensor tendon prior to manipulating the manubrium back into its normal
position.

Figure 30
In this ear, the tensor tympani tendon
attaches to the tympanic bone as well
as to the neck of the malleus (male, age
81 yr).
Figure 31
In addition to inserting into its normal
position on the posterior aspect of the
neck of the malleus, a small slip of the
tensor tendon extends laterally to
the tympanic membrane. Anteriorly,
the canal of Huguier transmits the
chorda tympani nerve as it leaves the
petrotympanic (Glaserian) fissure.
A stapedectomy for otosclerosis had
been performed (male, age 72 yr;
see Fig. 32 on p. 57).

Figure 32
High-power view of outlined area of
Figure 31 on p. 56.
Figure 33
This subject had a long history of recur-
rent otorrhea. There is a perforation of
the tympanic membrane and displace-
ment of the manubrium toward the
promontory (male, age 35 yr).

Figure 34
With a large perforation of the tym-
panic membrane, the tensor tympani
muscle acts with diminished opposi-
tion which eventually results in medial
displacement of the manubrium
Frequently, there are projections of bone from the anterior and superior
walls of the epitympanum which approximate the head of the malleus. In
some instances, only a thin layer of loose fibrous tissue separates them
(Figs. 35–40). Davies (13) reasoned that developmental failure of the normal
epitympanic expansion and inadequate absorption of bony spicules by
the tympanic epithelium might result in restricted epitympanic clearance
for the head of the malleus. Fusion of the malleus to the epitympanic wall
is normally seen in a number of mammals, such as the flying fox or the fruit
bat (1).
Figure 35
A bony spur extends from the lateral
wall of the epitympanum to approxi-
mate the lateral aspect of the head of
the malleus, causing no apparent
hearing loss (female, age 22 yr).

Figure 36
A vertical section through the epitym-
panum illustrates a close proximity of
the head of the malleus to the squa-
mous part of the temporal bone. Note
the normal thinness of the tegmen
tympani (female, age 55 yr).
Figure 37
There is a fibrous attachment of the
head of the malleus with a bony spur
extending from the anterior wall of the
epitympanum (squamous temporal).
There was no documented hearing loss
(male, age 77 yr).

Figure 38
There is a fibrous attachment of the
head of the malleus to a bony spur aris-
ing from the lateral wall of the epitym-
panum causing no effect on hearing
Figure 39
A bony spur projects from the lateral
epitympanic wall to make a fibrous
attachment to the lateral aspect of the
head of the malleus. We propose that
these fibrous attachments may, in some
instances, lead to bony ankylosis and
fixation of the malleus (male, age 36 yr).
Figure 40
A vertical section illustrates that the
superior aspect of the head of
the malleus is in fibrous union with the
tegmen tympani. There was no docu-
mented hearing loss. There is an excep-
tionally large vein in the fallopian
canal, an anatomical variant probably
representing a persistent lateral capital
vein (female, age 87 yr).

Figure 41
In this ear with chronic otitis media,
there is bony fixation of the malleus to
the anterolateral wall of the epitympa-
num. There was a mild conductive
We have found ankylosis of the head of the malleus in 15 of 1200

temporal bones which had no other evidence of middle ear abnormality or
disease. Malleus ankylosis can be diagnosed clinically by pneumatic
otoscopy or by palpation and is thus differentiated from stapes fixation
which it mimics functionally (Figs. 41–43) (14–17).
The Incus
The incus, the largest of the auditory ossicles, consists of a body, short
process, long process, and lenticular process. The body of the incus rests in
the epitympanum in association with the head of the malleus. Movement of
the incus is closely geared to that of the malleus by virtue of their cog-type,
saddle articulation (see p. 70); this gearing is responsible for the “secondary
Figure 42
This horizontal section through the
epitympanum of the left ear of a
60-yr-old female with otosclerosis and
conductive hearing loss shows the head
of the malleus fixed by a trabeculum of
lamellar (not otosclerotic) bone which
reaches from the anterior epitympanic
wall to the anterior aspect of the head
of the malleus.

Figure 43
There is ankylosis of the head of the
malleus to the lateral epitympanic wall
by lamellar (not otosclerotic) bone.
Otosclerosis was also present and
stapedectomy 13 yr before death had
resulted in excellent hearing improve-
ment (female, age 82 yr).
incus effect” (14, 15) in which malleal fixation also interferes with the trans-
fer of sound energy through the incus.
The short process of the incus extends posteriorly, occupying the poste-
rior incudal recess (fossa incudis) (Fig. 27); in some cases, the short process may
be long and slender (Fig. 44). The long process reaches inferiorly, paralleling the
manubrium, to end in the lenticular process; the convex surface of this process
articulates with the concave surface of the head of the stapes in the diarthrodial
incudostapedial articulation (Fig. 45). The horizontal, cross-sectional configura-
tion of the long process of the incus is circular (Figs. 46 and 47), in contradis-
tinction to the ovoid shape of the manubrium of the malleus. These differing
shapes are taken into consideration in the design of prostheses (Fig. 48).
Figure 44
This view is through the axis of rota-
tion. The long and slender short
process of the incus as seen in this ear
makes the name seem somewhat incon-
gruous (female, age 82 yr).

Figure 45
The head of the stapes articulates with
the lenticular process of the incus and
also acts as a site of attachment for the
stapedius tendon. There is partial
resorption of the long process of the
incus presumably caused by osteoporo-
sis (male, age 71 yr).
Figure 46
The anatomic relationships of the long
process of the incus, the lenticular
process, and the head of the stapes are
shown (male, age 63 yr).

Figure 47
The long process of the incus is roughly
circular in cross section. There are
numerous nutrient vessels within the
bone as well as in the surface mucosa
Figure 48
The round cross-sectional configura-
tion of the long process of the incus
permits a simple, crimp-on prosthesis
as is schematically illustrated (78).

Figure 49
The embryologic derivation and pur-
pose of the consistently present notch in
the short process of the incus, first
described by Lempert and Wolff (79), is
not known. In this ear, the chorda tym-
pani nerve lies in a groove on the
medial aspect of the base of the anterior
process of the malleus (female, age
53 yr).
Three ligaments anchor the incus in place. The posterior incudal liga-
ment secures the short process in the posterior incudal recess. Anteriorly, the
medial and lateral incudomalleal ligaments secure the body of the incus to
the head of the malleus (Figs. 27 and 49).
Calcification of the posterior incudal ligament has been noted on
histopathological examination of the temporal bone; however, its effect on
sound conduction is unknown. A superior incudal ligament has been men-
tioned (4); however, we have not been able to identify such a structure.
The long process of the incus is highly susceptible to osteitic resorption
caused by chronic otitis media (Fig. 45).
In newborn infants, both the malleus and incus have large marrow
spaces (Fig. 50) which may persist into adulthood.
Figure 50
In infancy, the malleus and incus
normally contain a central core of bone
marrow (female, age 25 days).

Figure 51
There is a pneumatized pit in the long
process of the incus. These excavations
in the incus are seen in the course of
otologic surgery. Fluid with proteina-
ceous precipitate (arrows) occupies the
pneumatized spaces. Fluid collections
in the tympanomastoid compartment
sometimes occur as a terminal event in
patients in coma and/or circulatory
failure (male, age 77 yr).
It is common for the long process to show slight pneumatization in the

form of a pit (Fig. 51). Highly pneumatized incudes are rare (Figs. 52 and 53),
but in such cases the long process would be vulnerable to fracture during
surgical manipulation.
The Stapes
The stapes is the smallest and the most medial link of the ossicular chain; it
consists of a head, footplate (the basis stapedis), and two crura or legs (4).
The anterior crus is straighter and more delicate than the posterior (Figs. 10
and 54). There is an irregular area near the superior aspect of the posterior
Figure 52
There is extensive pneumatization
of the bony long process and body
(see Fig. 53 on p. 67) of the incus. The
ostium (left view) is located on its
anteromedial aspect approximately
2 mm from its inferior tip. As the pneu-
matized area extends superiorly (right
view), only a shell of bone remains

Figure 53
Same ear as Figure 52 showing the
pneumatization extending into the
body of the incus (female, age 44 yr).
crus to which the stapedius tendon variably attaches. The area delimited by
the concave arches of the crura is the obturator foramen, sometimes bridged
by a veil of mucous membrane.
The footplate, in association with the annular ligament, seals the oval
window (Figs. 55 and 56). The shape, thickness, and curvature of the foot-
plate are inconstant. On its lateral surface, it has a variably present longitudi-
nal ridge known as the crista stapedis. The vestibular surface may be flat,
slightly convex, or slightly concave. The head articulates with the lenticular
process of the incus at its fovea (see the sections on articulations on p. 74), and
it may have a muscular process for the attachment of the stapedius tendon.
The relative thickness and curvature of the crura vary among individ-
uals, as does the locale for attachment of the stapedius tendon. Both the
external configuration and the degree of internal excavation may vary in the
head and crura.
Figure 54
This cross-sectional view of the stapes
shows the crura and head; the
stapes has no neck. An expanding
otosclerotic focus at the anterior
margin of the footplate has caused jam-
ming of the posterior edge of the foot-
plate against the margins of the oval
window, resulting in mild conductive

Figure 55
The normal stapes are seen in relation
to the adjacent anatomic structures. The
posterior crus is normally more curved
than the anterior one. Posterior tilting is
caused by the unopposed pull of the
stapedius muscle and is routinely
observed in postmortem specimens
(male, age 45 yr). Abbreviations: IAC,
internal auditory canal; EAC, external
auditory canal.
The depth of the fovea for the lenticular process of the incus and the
presence of a muscular process on the head are variable. The obturator fora-
men is embryologically related to the stapedial artery which at one time
passes through the blastema of the stapes (see chap. 9). Presumably, failure
of normal interaction between these two structures causes occasional col-
umellar formation of the stapes (Fig. 57). In cretins, the stapes show a consis-
tent anomaly (Fig. 58). The Mondini anomaly may be associated with defects
in the footplate, leading to cerebrospinal fluid otorrhea and meningitis (18).
The most dependable method for removing the stapes without fractur-
ing it is to cut its tendon and rock it forward by gentle pressure on the
posterior surface of its head, keeping the stress in the plane of the crura.
Figure 56
An infrequent finding is that of a
sesamoid bone in the anterior aspect
of the stapediovestibular articulation
(male, age 78 yr).

Figure 57
The left ear of this 30-yr-old man with
conductive hearing loss demonstrates
congenitally malformed crura. The
capitulum is well developed, but the
crural arch is replaced by a single thick
columella making fibrous contact with
the promontory immediately inferior to
the oval window. The footplate was
also deformed and fixed.
Figure 58
This right ear of a 43-yr-old congeni-
tally deaf female shows the classical
middle ear anomalies of cretinism. The
stapedius muscle and tendon are
absent, as are the pyramidal eminence
and facial recess. The head of the stapes
and the lenticular process of the incus
rest against the posterior wall of the
tympanic cavity. The facial nerve is
widely dehiscent.

THE OSSICULAR ARTICULATIONS (JOINTS)
The ossicular articulations are true articulations in the sense of uniting two
bones. The articulating surfaces are lined by cartilage and there may or may
not be an interarticular disc. Each articulation has a true capsule composed
of ligamentous fibers originating from the periosteum of the linked bones
and lined by a synovial membrane.
While the ossicular articulations are sufficiently strong to withstand
physiologic stresses, they are easily torn by direct trauma to the middle ear,
fracture of the temporal bone, or surgical manipulation (Fig. 59). The ossicles
may be partially luxated in which case only part of the capsule is torn and
ossicular displacement is partial, or luxated in which case the entire capsule
is torn and total disarticulation occurs.
The Incudomalleal Articulation
The incudomalleal articulation is a nonweight-bearing, synovial, diarthro-

dial articulation linking the malleus and incus (Fig. 60). It is generally
described as saddle-shaped, although Wolff and Bellucci (12) point out that
in vertical sections the opposing joint surfaces appear to present interlocking
jaw-like surfaces (Fig. 61). A capsule of elastic tissue surrounds the articular
margin and there is an interarticular disc. The capsule is trilaminar with: (1)
the synovial membrane lining the cavity, (2) the mucous membrane of the
middle ear, and (3) an intervening fibrous layer. The capsule is not uniform
in structure. At superior levels, the medial aspect of the capsule shows
greater length and density of the fibrous layer and is known as the medial
incudomalleal ligament (Figs. 62–64). At inferior levels, the lateral part of the
capsule is thicker and is known as the lateral incudomalleal ligament. These
regional variations in fiber length, density, and thickness all interact to
control the interdigitation of the two ossicles.
The articular cartilage is bilaminar. The deep layer, adjacent to ossicular
bone, demonstrates enchondral bone formation as well as direct osseous
transformation of its cartilaginous matrix. This latter process is characteristic
Figure 59
Here is shown a surgically induced
inward subluxation of the posterior
margin of the footplate of the stapes. A
modified radical mastoidectomy had
been performed 14 yr before death. The
membranous labyrinth appears normal
and there was no postoperative
sensorineural hearing loss (female, age
60 yr).

Figure 60
The normal incudomalleal articulation
is shown here (male, age 10 wk).

Figure 61
Both the incudomalleal and incudostapedial
articulations (joints) are seen in this vertical sec-
tion. The space inferior to the lateral malleal liga-
ment is Prussak’s space (male, age unknown).
Figure 62
The capsule of the incudomalleal artic-
ulation is thickened on its medial side
to form the medial incudomalleal liga-
ment (male, age 9 yr).

Figure 63
At a level slightly inferior to that of
Figure 62 the capsule is thickened to
form the lateral incudomalleal liga-
ment (male, age 9 yr).
Figure 64
The anterior suspensory ligament of
the malleus is located superior to the
anterior malleal ligament. Mucosal
folds from the lateral epitympanic wall
transmit the vascular supply for the
ossicles (male, age 81 yr).

of secondary or chondroid cartilage which derives from membrane bone (19).
The superficial layer is of primitive cartilage, a product of and maintained by
the synovial membrane; it is considered analogous to epiphyseal cartilage.
The Incudostapedial Articulation
The incudostapedial articulation (Fig. 65), also a nonweight-bearing,

synovial, diarthrodial articulation, joins the convex lenticular process of the
incus (Fig. 66) and the concave surface of the head of the stapes. The lentic-
ular process may exist as an accessory bone. There is a joint space, but an
interarticular cartilage is not usually present. The fibers of the capsule are
longer than those of the incudomalleal articulation, but are of similar
thickness and variability of thickness (12). At the inferior aspect of the artic-
ulation, the posterior capsular fibers sometimes merge with those of the ten-
don of the stapedius muscle with the effect that contraction of the stapedius
muscle, in addition to pulling the head of the stapes posteriorly, also draws
the long process of the incus posteriorly.
In surgical procedures for otosclerosis, the head and crura of the stapes
are usually removed preparatory to fenestrating the fixed footplate. The
Figure 65
The incudostapedial articulation of a 10-wk-old
male infant is shown here. The articular facet of
the lenticular process is convex and that of the
head of stapes is concave. The lenticular process
normally contains islands of fibrous tissue; per-
haps this fibrous component underlies the sus-
ceptibility of the lenticular process to resorption
in chronic otitis media.

Figure 66
The lenticular process of the incus is
shown as it rests in the concavity of the
head of the stapes. The facial recess is
located directly posterior to the incud-
ostapedial articulation (male, age
58 yr).
incudostapedial articulation is fragile enough that downward pressure on

the head in the direction of the promontory causes separation of the joint
without luxating the incus; thus fracture-dislocation of the head and crura is
easily performed.
The Stapediovestibular Articulation
The stapediovestibular articulation is the junction between the stapes

footplate and the oval window. This articulation is one of the sites of
predilection for otosclerosis and has been the focus of detailed study. It has
been variously labeled as a syndesmosis, an amphiarthrosis, and a
“half-joint.” The annular ligament holds the footplate of the stapes in the
oval window; peripherally, its connective tissue fibers fuse with periosteum
and endosteum. Wolff and Bellucci (12) have identified fibers which span the
entire distance from the endosteal surface of the footplate to the periosteum
of the tympanic aspect of the bony labyrinth; moreover, they have docu-
mented that “posteroinferiorly, . . . endosteal ligamentous fibers are contin-
uous with those of the spiral ligament of the basal turn of the cochlea.”
Spaces within the stapediovestibular articulation (Fig. 67) were recognized
as long ago as 1873 (327) but later were attributed to artifact (329). In a more
recent study of morphology of the stapediovestibular articulation, Bolz and Lim
(20) found such spaces in 70% of adult temporal bones, usually in the posterior
pole of the articulation (Fig. 67). Because no such spaces were found in the
temporal bones of children, they hypothesized that these spaces represent
adventitious bursae developing in response to friction, pressure, or trauma.
Changes of Aging in the Articulations
Both the incudomalleal and incudostapedial joints show pathologic changes of

aging in which chondroid cartilage undergoes a change to a chondro–osseous
matrix (19).

Figure 67
Small spaces (bursae) are found in the
posterior part of the stapediovestibular
articulation in 70% of adult temporal
bones (female, age 61 yr).
Figure 68
The incudomalleal articulation of a 16-yr-old
female illustrates grade I changes of aging.

Etholm and Belal (21) describe three grades of degenerative change.
Grade I shows fraying (Fig. 68), vacuolization, and fibrillation of the articu-
lar cartilage. Grade II changes show narrowing of the joint space, rarefaction
and calcification of the articular cartilage, and hyaline deposition in the
capsule and disc (Figs. 69 and 70). Grade III changes include obliteration of
the joint space, as well as calcification of the articular cartilage, capsule, and
disc (Figs. 71–73).
Fibrous fixation or bony ankylosis of the incudomalleal and/or incud-
ostapedial articulations appears to have little or no effect on hearing (21),
and therefore is of minor pathologic significance.
Figure 69
The incudomalleal articulation of this
34-yr-old female shows narrowing of
the joint space, hyalinization of carti-
lage, and deposition of hyalin within
the articular cartilage characteristic of
grade II changes of aging.

Figure 70
The incudostapedial articulation of this
59-yr-old man shows grade II changes
consisting of hyalinization of the joint
capsule, as well as hyalinized deposits
and narrowing of the joint space.
Figure 71
The incudomalleal articulation of this 60-yr-old
female demonstrates grade II changes with nar-
rowing of the joint space, calcification, and
hyalinization.

Figure 72
The incudomalleal articulation of this
65-yr-old male shows severe (grade III)
arthritic changes. The joint space is
obliterated laterally, while medially
there are scattered calcium deposits.
There is irregular thinning and calcifi-
cation of the articular cartilage. The
joint capsule shows atrophic changes.

Figure 73
The incudostapedial articulation shows fusion
of the articular surfaces (grade III changes).
Audiometric tests showed no conductive
THE MUSCLES
The Stapedius Muscle
The stapedius muscle, the smallest of the skeletal muscles, lies in a bony
sulcus adjacent to the facial canal in the posterior wall of the tympanic
cavity. This penniform muscle is a mixture of striated and nonstriated fibers
that converge into a tendon which emerges from the orifice of the pyramidal
eminence into the tympanic cavity. It variably attaches to the head and/or
posterior crus of the stapes (4) (Figs. 74–76). The stapedius muscle receives
its innervation from the facial nerve. Its contraction draws the anterior
border of the footplate laterally and the posterior border medially. This
tilting of the stapes stretches the annular ligament, thus fixing the footplate
and damping its response to acoustic stimulation.

Figure 74
The stapedius tendon normally attaches
to the head of the stapes and to the
capsule of the incudostapedial articula-
tion (female, age 5 yr).
Figure 75
The stapedius tendon emerges from the
pyramidal eminence to attach to the
head of the stapes (male, age 44 yr).

Figure 76
In this case, the stapedius tendon
attaches to the posterior crus of the
stapes (female, age 73 yr).
The Tensor Tympani Muscle
The tensor tympani muscle, in concert with the stapedius muscle, acts to
modify the movements of the ossicular chain. The tensor tympani muscle
(Fig. 77) arises from the cartilage of the eustachian tube, the walls of its
enveloping semicanal, and the adjacent portion of the greater wing of the
sphenoid bone. A bony sheath, the semicanal, houses the muscle for the
majority of its 2 cm length. The fibers converge to form a central fibrous core
which, proceeding posteriorly, forms the tendon of the muscle. The most
medial fibers of the tendon attach to the concave surface of the cochleariform
(spoon-shaped) process, at which point the main body of the tendon turns
laterally to attach to the medial and anterior surfaces of the neck and the
manubrium of the malleus. It should be observed that the cochleariform
process does not function mechanically in the same fashion as a pulley.
Lupin (22), on the basis of anatomic dissections, suggests that the
tensor tympani muscle represents a continuation of the muscle fibers of the
tensor veli palatini muscle (Fig. 78). Its innervation is from the trigeminal
nerve via the nerve to the medial pterygoid muscle. Histologically, striated
as well as nonstriated muscle fibers can be observed. The muscle bundles
and tendinous fibers are surrounded by varying amounts of adipose tissue
(Fig. 79). This tissue may facilitate their adaptation to the confines of the
bony semicanal upon contraction. The action of the tensor tympani muscle
is to draw the manubrium medially, thus tensing the tympanic membrane.
Spontaneous contractions of this muscle may cause a clicking or
fluttering tinnitus in the ear and/or vertigo. Cutting the tendon has been
advocated for the relief of these symptoms (23).

Figure 77
The tensor tympani tendon makes a
nearly right-angled turn at the
cochleariform (spoon-shaped) process
on its way to the neck of the malleus
(male, age 45 yr).
Figure 78
This illustration shows the probable
derivation of the tensor tympani mus-
cle from the tensor palatini muscle.
Source: Courtesy of Lupin (22).

Figure 79
Normally, there is adipose tissue sur-
rounding the bundles of the tensor
tympani muscle. Presumably, this
yielding tissue facilitates contraction of
the muscle within its bony semicanal.
The muscle consists predominantly of
striated fibers (inset) (male, age 66 yr).
Ectopic and Anomalous Muscles
Wright and Etholm (24) found a total of 28 ectopic or anomalous muscles in

a study of 500 temporal bone specimens (Fig. 80). In no case was the muscle
anomaly bilateral and in three ears there were two separate anomalies.
Ectopic muscle was most frequent along the course of the facial nerve, either
within or close to the fallopian canal. They attributed this anomaly to the
persistence of mesenchymal rests along the hyostapedial ligament
(interhyale—see chap. 9) which in the seven-week embryo connects the
primordial stapes to the laterohyale of Reichert’s cartilage origin.
In three temporal bones, they found the tensor tympani muscles split
into medial and lateral bundles. The lateral bundles followed the normal
path of the tensor tympani muscle to the cochleariform process. In two of
three cases, the medial bundles pursued aberrant courses within the fallop-
Figure 80
The black dots in this sketch show the
location of ectopic muscle bundles in
25 of 500 ears studied by Wright and
Etholm (24). Abbreviations: OW, oval
window; RW, round window.

Figure 81
This photomicrograph shows ectopic
muscle in the tympanic segment of the
fallopian canal (male, age 30 yr).
ian canals and terminated by joining with the stapedius muscles. In certain
mammals, the tensor tympani may show a double origin—one from the
semicanal and one from the medial wall of the middle ear (1).
Wright and Etholm (24) observed anomalies of the stapedius muscle in
six ears. In two cases, the stapedius tendons, muscles, and pyramidal emi-
nences were rudimentary; in two, the stapedius tendons were absent; and in
two, there was duplication of the muscles. In one of the latter cases, the
duplicate muscle bundle was located superior to the normal muscle (Fig. 81)
and the associated tendon failed to gain access into the tympanic cavity. The
authors suggested that premature separation of the interhyale from the
stapes due to an aberration of development was responsible for these anom-
alies. They noted that anomalies of the stapes bone were frequently associ-
ated with muscle anomalies. Hoshino and Paparella (25) found absent
stapedius muscles, unassociated with any other congenital anomaly, in
approximately 1% of ears undergoing surgical procedures. The presence of
ectopic muscle in the middle ear appears to be of no clinical importance.
THE MIDDLE EAR SPACES
The tympanic cavity is a cleft in the sagittal plane measuring about 15 mm in

the vertical and anteroposterior dimensions; in its transverse dimension, it
expands superiorly to 6 mm and inferiorly to 4 mm from a central constric-
tion of 2 mm (Fig. 82). It is pneumatized via the eustachian tube which links
it with the nasopharynx; posteriorly, the mastoid antrum connects the tym-
panic cavity with the mastoid air cells. It is traversed by the ossicular system
and is lined by mucous membrane.
The floor of the tympanic cavity (jugular wall) is composed principally
of the jugular bulb, the surface of which may show irregularities due to

Figure 82
Schematic view of the middle ear cleft.
Source: After Deaver (80) and Brodel (81).
overlying pneumatized cells (Fig. 83). In the posterior part of the floor is the
root of the styloid process which gives rise to the styloid eminence.
The posterior wall (mastoid wall) of the tympanic cavity narrows
inferiorly and features numerous anatomic structures. At its inferior aspect,
tympanic air cells are surmounted by the pyramidal eminence from which the
tendon of the stapedius muscle emerges. The chordal eminence is lateral to the
pyramidal eminence and medial to the posterior rim of the tympanic mem-
brane; there is a foramen in this eminence, known as the iter chordae
posterius (or the apertura tympanica canaliculi chordae tympani), through
which the chorda tympani nerve gains access to the middle ear. The facial
recess is interposed between the chordal eminence laterally and the pyram-
idal eminence medially. Acting as the superior limit of the facial recess is the
incudal fossa, in which the short process of the incus is held in place by the
posterior incudal ligament. More superiorly, the epitympanic recess opens
into the mastoid antrum. There are three ridges connecting the three
eminences of the posterior tympanic wall: the chordal ridge links the chordal
eminence to the pyramidal eminence, the styloid ridge connects the styloid
prominence to the chordal eminence, and the pyramidal ridge joins the styloid
prominence to the pyramidal eminence (26).
The anterior wall of the middle ear (carotid wall) narrows inferiorly
where it is formed by the thin bony shell of the carotid canal which is often
covered by pneumatized cells. Located more superiorly in the anterior wall
is the orifice of the eustachian tube and above it the tensor tympani muscle
lies in its semicanal.
The roof (tegmental wall, tegmen tympani) separates the tympanic
cavity from the cranial cavity. In an autopsy series, 6% of cases showed
dehiscences in this wall (27).
The lateral boundary (membranous wall) is composed of the tympanic
membrane, the bony tympanic ring, and a layer of bone from the squama—
the scutum or shield of Leidy (28). Erosion of the scutum is a classical radi-
ologic sign of cholesteatoma of the epitympanum.
The medial wall (labyrinthine wall) of the tympanic cavity is marked by
three main depressions—the sinus tympani, the round window niche, and the

Figure 83
This vertical section depicts the relative posi-
tions of the oval and round windows. The facial
nerve runs in the medial wall of the middle ear
at the boundary of the mesotympanum and epi-
tympanum. The hypotympanum is normally
studded with trabeculations. The infra-
labyrinthine cell tract can be the site of extension
for cholesteatomas and neoplasms (male, age
unknown).
oval window niche (Fig. 84). The sinus tympani lies between the ponticulus
which bridges the gap between the pyramidal eminence and the promontory
superiorly, and the subiculum (subiculum promontorii), a ridge stretching infe-
riorly between the styloid eminence to the posterior lip of the round window
niche (29). The round window niche is located anteroinferior to the subiculum
and posteroinferior to the promontory; the latter structure is the bulge of the
bone overlying the basal turn of the cochlea. The oval window niche is antero-
superior to the ponticulus and the cochleariform process of the tensor tympani
muscle is even more anteriorly and superiorly located. Located posterosuperi-
orly is the prominence of the facial canal as it traverses the medial wall and then
descends along the mastoid wall of the tympanic cavity.
It is useful in descriptions of disease or surgery to divide the middle
ear space into four regions: (1) The mesotympanum (middle ear proper) is that
area located medial to the tympanic membrane and the bony tympanic
annulus. (2) The epitympanum is that area that lies superior to a horizontal
plane drawn through the most superior level of the tympanic membrane (4).

Figure 84
The tympanic sinus is one of the three
major depressions of the medial wall of
the tympanic cavity. The ponticulus
limits this space superiorly, while the
subiculum limits it inferiorly. Its exten-
sion posteriorly is variable and may
amount to several millimeters. Source:
After Donaldson et al. (82).
It is approximately one-third the vertical dimension of the entire tympanic

cavity, and houses the head of the malleus as well as the body and short
process of the incus. (3) The protympanum lies anterior to a frontal plane
drawn through to the anterior margin of the tympanic annulus. It leads to
the tympanic orifice of the eustachian tube. (4) The hypotympanum is that part
of the middle ear located inferior to a horizontal plane through the most
inferior part of the tympanic annulus.
Otologic surgeons are aware of variability in the depth of the hypotym-
panum. This variability may be ascribed to its tripartite origin (30) from the
tympanic bone, the otic capsule, and the petrosa. A shallow hypotympanum
is usually associated with a superiorly located jugular bulb and can be an
undesirable anatomic feature in tympanoplasty surgery where one of the
objectives is to preserve or attain a pneumatized hypotympanic space.
Otologic surgeons are required to have an intimate knowledge of the normal
and variant anatomy of the middle ear if removal of disease (granulations,
cholesteatoma, etc.) and preservation of function are to be realized.
The Anterior Epitympanic Recess
The anterior epitympanic recess is located anterior to the head of the

malleus. Its boundaries include the middle cranial fossa superiorly, the
petrous apex and middle cranial fossa anteriorly, the tympanic bone laterally
and inferiorly, and the facial nerve and geniculate ganglion medially.
Posteriorly, it communicates with the epitympanum (Figs. 85–87). Also
known as the “sinus epitympani” (31), this recess varies greatly in size; it
may be quite large, in which case it may be partly walled off from the
epitympanum by a perforate septum.

Figure 85
In this ear, the anterior epitympanic
recess bulges into the middle cranial
fossa. This configuration renders it sus-
ceptible to perforation during surgical
procedures in the middle cranial fossa
(male, age 46 yr).
Figure 86
The anterior epitympanic recess may
be partly isolated from the epitym-
panum by a bony septum (female, age
75 yr).
Figure 87
In this ear, the genu of the facial nerve
lies immediately beneath the dura of
the middle cranial fossa (male, age
50 yr).

It is common for cholesteatoma of the epitympanic space to extend into
the anterior epitympanic recess. Surgeons must be aware that the facial
nerve and geniculate ganglion may be dehiscent in its medial wall.
The Oval Window Niche
The oval window niche is located in the medial wall of the posterior part of
the mesotympanum and harbors the stapes (Figs. 84 and 88). It is bounded
superiorly by the facial nerve and inferiorly by the promontory. Located
anteriorly is the cochleariform process and posteriorly the ponticulus, sinus
tympani, and pyramidal eminence.
With the advent of tympanoplasty surgery for chronic infections, stapes
operations for otosclerosis, labyrinth operations for Ménière’s disease, and
reconstructive surgery for congenital anomalies of the middle ear, the oval
window area has become an important anatomic site. The stapes is vulnera-
ble to fracture or subluxation, and the facial nerve, which may be dehiscent
and bulging from its canal, can be injured. Some of the spatial relationships
concerning the middle ear and oval window are seen in Figure 89.
The Round Window Niche
The round window niche (fossula fenestra cochleae) is a depression of vari-

able depth located in the posteroinferior aspect of the medial wall of the
tympanic cavity (Figs. 84 and 90). A bony ridge of bone, the subiculum, sep-
arates the round window niche from the sinus tympani posterosuperiorly.
The round window niche is delimited anterosuperiorly by the promontory
and inferiorly by the hypotympanum (Fig. 91).
Figure 88
This vertical section depicts the
anatomical relationships of inner and
middle ear structures (male, age 47 yr).
Abbreviations: EAC, external auditory
canal; TM, tympanic membrane.

Figure 89
The measurements shown here are
average normal for the adult ear (4).
Figure 90
The subiculum is shown in relation to
the round window niche and sinus
tympani. The microfissure extending
from the round window niche to the
ampulla of the posterior canal is nor-
mally present in adult temporal bones.
The posterior part of the tympanic
membrane is pathologically thin and
retracted medially, probably as a conse-
quence of previous otitis media (male,
age 83 yr).

Figure 91
The tympanic ostium of the cochlear
aqueduct is located just medial to the
semilunar crest of the round window.
The inferior cochlear vein provides the
principal venous drainage for the inner
ear (male, age 68 yr).
Ultrastructural studies of the round window membrane in guinea pigs

(32–34) reveal that it is composed of three layers. In the external layer, facing the
tympanic cavity, there are four distinct types of cells: osmiophilic, osmiophobic,
dark granulated, and goblet. Numerous microvilli stud the free epithelial sur-
face, the cells of which are flat and mostly nonciliated. The internal layer, fac-
ing the scala tympani, consists of a single layer of thin cells having long, thin,
cytoplasmic extensions into the scala tympani, a cytoarchitectural pattern very
similar to that of the perilymphatic surface of Reissner’s membrane. An inter-
mediate layer consists of a dense latticework of fibrocytes interspersed with
large intercellular spaces containing collagen and elastic fibers, blood
vessels, and myelinated as well as unmyelinated nerve fibers.
The round window membrane functions as a yielding area of the bony
labyrinth, permitting movement of the inner ear fluids associated with
movement of the stapedial footplate. Conductive hearing loss associated
with congenital absence of the round window has been successfully treated
by surgical fenestration (35). The round window membrane is believed to be
a route by which toxic substances (bacterial exotoxins, chemical solutions)
may enter the inner ear to cause sensorineural hearing loss.
The round window niche is angulated posteroinferiorly with respect to
the external auditory canal. The membrane lies mostly in the horizontal
plane, but assumes a more vertical orientation as it curves anteriorly toward
the scala tympani. It frequently lies partly hidden behind an incomplete
curtain of mucosa which bridges the mouth of the niche (Fig. 91).
Goodhill et al. (36) have implicated rupture (fistulization) of the round
window membrane as a cause of sudden sensorineural hearing loss occur-
ring in association with barotrauma or head injury. When a surgical explo-
ration is done for a suspected round window fistula, the mucous membrane
fold must not be mistaken for the round window membrane. The bony lip of
the round window niche will usually have to be removed if the round
window membrane is to be visualized. Patency of the niche is essential for
efficient acoustic transmission. In tympanoplasty surgery, the objective is to
achieve a pneumatized round window niche behind a protective tympanic
membrane.
Section of the posterior ampullary nerve has been advocated for relief of
benign paroxysmal positional vertigo (37). The singular canal that contains this

Figure 92
Located lateral to the facial nerve is the
facial recess and medial to it is the
sinus tympani. The subiculum sepa-
rates the round window niche from the
sinus tympani. The operculum is a
scale of bone that partly overlies the
endolymphatic sac (male, age 47 yr).
nerve lies immediately inferior to the posterior attachment of the round

window membrane. This membrane and the ampulla of the posterior canal are
vulnerable to injury in the surgical approach to the posterior ampullary nerve.
The Sinus Tympani
The sinus tympani is one of the three depressions in the medial wall of the
posterior part of the mesotympanum (Fig. 92), the other two are the round
and oval windows. Superiorly, it is bounded by the ponticulus and lateral
semicircular canal, posteriorly by the posterior semicircular canal, and
inferiorly by the subiculum, styloid eminence, and jugular wall (38). It is
bounded medially by the bony labyrinth and laterally by the pyramidal
eminence and facial nerve. It extends for variable distances in posterior
direction, medial to the facial nerve (Figs. 93–95).
Figure 93
The sinus tympani may extend for sev-
eral millimeters medial and posterior to
the facial nerve as seen in this ear.
Invariably, there is a bony partition
between the sinus tympani and mastoid
air cells due to their different routes of
pneumatization (male, age 49 yr).

Figure 94
The ponticulus (little bridge), which
forms the superior boundary of
the sinus tympani, stretches from
the pyramidal eminence to the
promontory. The facial recess lies
lateral to the facial nerve and is used by
otologic surgeons as a route from the
mastoid to the middle ear (the
posterior tympanotomy approach)
(male, age 9 yr).
The sinus tympani may harbor diseased tissue such as cholesteatoma,

and is not directly visible by the usual surgical approaches to this area
(39–41). Visualization may be facilitated by the use of mirrors, and access to
its depths may be afforded by 3- or 4-mm right-angled picks and small,
curved, metal suction tubes. Partial removal of the bony tympanic annulus
is often necessary to gain access to the sinus tympani.
The Facial Recess
The facial recess is a depression of variable depth in the posterior wall of the
middle ear. It is bounded medially by the facial canal and styloid complex
and laterally by the tympanic bone (Fig. 96). The styloid complex (26) is the
Figure 95
The sinus tympani and round window
niche are seen in relationship to the
subiculum. The posterior ampullary
nerve, located in the singular canal, is
surgically accessible by an approach
through the middle ear (male, age
40 yr).

Figure 96
This photomicrograph shows the anato-
mical relationships of several middle ear
structures (female, age 60 yr).
term used to describe the derivatives of the superior portion of the second
branchial arch; once ossified, it gives rise to three projections present in all
adult temporal bones—the pyramidal, styloid, and chordal eminences. The
facial recess, like the sinus tympani, is a potential site for the sequestration
of disease, such as cholesteatoma.
The surgeon will find that the facial nerve is occasionally dehiscent in
the medial wall of the facial recess, making it vulnerable to surgical injury
(Fig. 97). In intact-canal-wall tympanoplasty, the route from the mastoid to
the middle ear is via the facial recess, a surgical maneuver commonly known
as posterior tympanotomy.
Figure 97
In this ear, the mastoid segment of the
facial nerve bulges into the facial recess
(male, age 61 yr).

THE EUSTACHIAN TUBE
The eustachian tube, a mucosally lined pathway between the nasopharynx

and the middle ear, permits ventilation of the pneumatized spaces of the
temporal bone while safeguarding against bacterial contamination of these
spaces. The posterolateral one-third is bony while the anteromedial
two-thirds is fibrocartilaginous; these two sections are joined at the tubal
isthmus. The overall length of the eustachian tube in the adult varies from
31 to 38 mm (42, 43).
The Bony Eustachian Tube
The bony part of the eustachian tube lies lateral to the internal carotid artery
(Fig. 98); the thin bone separating these structures has dehiscences permit-
ting the passage of the caroticotympanic arteries. The tubal isthmus marks a
region of structural transition, with cartilage forming its anterolateral and
superior walls and bone forming its posteromedial and inferior limits
(Fig. 99). The lining mucosa is a low columnar ciliated epithelium with abun-
dant goblet cells on a tunica propria of basement membrane and loose
connective tissue. The tympanic ostium of the eustachian tube is in the ante-
rior wall of the middle ear cavity, about 4 to 6 mm superior to the inferior
wall of the hypotympanum. Here, the lumen is triangular, measuring 3 to
5 mm in diameter. As the osseous part of the tube heads anteriorly and
inferiorly to the isthmus, its vertical diameter shrinks to 2 to 3 mm and its
horizontal diameter to 1 to 1.5 mm.
The Fibrocartilaginous Eustachian Tube
This part of the tube in cross section resembles a shepherd’s crook. The
lumen is maintained by a larger medial cartilaginous lamella and a smaller
Figure 98
The next four photomicrographs are
from vertical sections in the coronal
plane of the eustachian tube of a one-
month-old infant presented serially
from posterior to anterior. This section
at the tympanic orifice shows the thin
bony shell separating the internal
carotid artery from the cartilage of the
eustachian tube. Source: Courtesy of
Drs. Doyle and Rood, University of
Pittsburgh.

Figure 99
This section shows the eustachian tube
at the junction of the cartilaginous and
bony portions (the isthmus tubae).
Source: Courtesy of Drs. Doyle and
Rood, University of Pittsburgh.
lateral one (Fig. 100). The salpingopharyngeal fascia stretches between the
inferior edge of the medial lamella and the free edge of the lateral lamella.
The tubal incisura is a groove in the middle one-third of the inferior margin
of the medial lamella which accommodates the levator veli palatini muscle.
The histology of the tubal cartilage varies with age; in the newborn it is
entirely hyaline, while in the adult an elastic component can be found concen-
trated at the inner aspect of the junction of the medial and lateral lamellae.
In the adult, the nasopharyngeal orifice lies some 15 mm inferior to the
tympanic ostium (Fig. 101). At rest the orifice is a vertical slit measuring
about 8 mm ⫻ 4 mm. The posterior lip of the pharyngeal orifice is the mobile
portion which forms the torus tubarius. The fossa of Rosenmüller is located
posterior to the torus.
A series of photomicrographs showing the anatomical features of the
eustachian tube of an adult is seen in Figures 102 to 105.
The Lining Membrane
The lining (mucosal) membrane is composed of a pseudostratified, ciliated

columnar epithelium interspersed with goblet cells that are most abundant
at the pharyngeal orifice (Figs. 106–108). The supporting lamina propria is of
variable thickness and can be divided into three layers: (1) a basement mem-
brane directly beneath the epithelium, (2) a sheet of lymphoid tissue, the
thickness of which varies inversely with the age of the individual, and (3) a
layer of compound tubuloalveolar glands. The mucosa of the eustachian
tube consists of pseudostratified ciliated columnar cells mixed with a
cuboidal ciliated epithelium and goblet cells (44). Some authors (45, 46)
believe that lymphatic tissue of the nasopharynx never reaches up to, or into,
the pharyngeal orifice of the eustachian tube but occurs as a distinct extra-
tubal lymphoid mass (the so-called Gerlach’s tubal tonsil).

Figure 100
This section shows the classical shep-
herd’s crook (Hirtenstabkrümmung)
configuration of a cross section of the
cartilage of the eustachian tube. The
anatomic relationships of the levator
veli palatini, tensor veli palatini, and
medial pterygoid muscles are shown.
Figure 101
The nasopharyngeal orifice of the
eustachian tube is seen in this section.

Figure 102
The next four photomicrographs are
from vertical sections in the coronal
plane of the eustachian tube of an adult
presented serially from posterior to
anterior. A thin bony partition sepa-
rates the bony eustachian tube from the
internal carotid artery. Source: Courtesy
of Dr. Sando, University of Pittsburgh.

Figure 103
This section of the eustachian tube,
taken at its isthmus, shows its lumen
and cartilage as well as adjacent struc-
tures. Source: Courtesy of Dr. Sando,
University of Pittsburgh.

Figure 104
The relationship of the cartilaginous
part of the eustachian tube to the tensor
and levator veli palatini muscles is
shown. Source: Courtesy of Dr. Sando,

Figure 105
The pharyngeal orifice of the
eustachian tube is seen in this view.
Also shown are Rosenmüller’s fossa
and the levator veli palatini muscle.
Source: Courtesy of Dr. Sando,

Figure 106
This photomicrograph and the follow-
ing two magnified views from the out-
lined areas A and B are from horizontal
sections of a newborn infant.
Figure 107
This magnified view of area A in Figure
106 shows the respiratory epithelium of
the fibrocartilaginous part of the
eustachian tube.

Figure 108
This magnified view of area B in Figure
106 shows the mucous glands and
lymphoid tissue at the nasopharyngeal
orifice of the eustachian tube.
The Palatal Muscles
The tensor veli palatini muscle arises from the spine of the sphenoid bone,
the scaphoid fossa, the lateral lamina of the tubal cartilage, and the salpin-
gopharyngeal fascia (47) to run a course nearly parallel to the slit-like lumen
of the tube. Anteroinferiorly, it forms a tendon that sweeps around the
hamulus of the medial pterygoid plate and inserts medially into the soft
palate. Its crucial role in tubal opening is to draw the lateral lamella of the
tubal cartilage inferiorly. Some of its fibers are thought to be continuous with
those of the tensor tympani muscle (see p. 82 and Fig. 78 on p. 83) (22). Its
innervation is derived from the mandibular division of the trigeminal nerve.
The levator veli palatini muscle arises from the inferior aspect of the
petrous bone anterior to the carotid canal, as well as from the medial
cartilaginous lamina of the eustachian tube. The belly of this muscle
descends parallel to the tube to insert into the soft palate. Upon stimulation
through the pharyngeal plexus of the vagus, the levator veli palatini muscle
shortens and thickens, thus elevating the eustachian tube and widening its
lumen (Fig. 100).
The salpingopharyngeus muscle originates from the inferior aspect of
the medial cartilaginous lamella of the eustachian tube and divides inferi-
orly to insert into the posterior wall of the pharynx and onto the superior
horn of the thyroid cartilage. It also is innervated by the vagus nerve.
In its resting position, the eustachian tube is closed due to a combina-
tion of passive mechanisms including the elasticity of the cartilage, pressure
from surrounding tissues, and the capillary force of apposed moist mucous
membranes (46). With deglutition or yawning, the tensor veli palatini, the
levator veli palatini, and the salpingopharyngeus muscles act in concert to
open the tube (42, 43, 46).
Dysfunctions of the mechanisms controlling tubal function cause: (1)
serous otitis (otitis media with effusion) when the tube fails to open on swal-
lowing and (2) the patulous tube syndrome (autophony) when it fails to
close. Another dysfunction of this mechanism is palatal myoclonus in which

clonic spasms of the levator palatini and/or tensor tympani muscles cause
an annoying clicking sensation in the ear. The function of the eustachian tube
is affected by the amount of peritubal adiposity [fat pad of Ostmann (48);
Fig. 109]. Obesity may lead to eustachian tube obstruction, while loss of
body weight may cause tubal patency.
Figure 109
This photo shows the mid-portion of
the eustachian tube and adjacent
anatomic structures. Source: Courtesy
of Sando et al. (336).

THE MIDDLE EAR MUCOSA
Histology
A knowledge of the structure of the normal mucosa of the human middle

ear, mastoid, and eustachian tube will help in understanding the
mechanisms involved in otitis media and middle ear effusions (Fig. 110).
In electron microscopic observations, Hentzer (49) distinguished five
types of cells in the middle ear mucosa: (1) nonciliated without secretory gran-
ules, (2) nonciliated with secretory granules, (3) ciliated, (4) intermediate, and
(5) basal. He analyzed the distribution of these five types of cells within the
middle ear, mastoid, and eustachian tube and divided them into seven
regions: (1) The mastoid contained ciliated cells and nonciliated cells without
secretory granules. (2) The posterior part of the middle ear had a thicker
epithelium with two additional types of cells—nonciliated cells with secretory
granules and basal cells. Simple squamous epithelium without cilia could
also be found. (3) The epitympanic recess was lined with epithelium similar to
Figure 110
This schematic drawing illustrates the
cell types in the middle ear mucosa.
Abbreviations: BM, basement mem-
brane; CAP, capillary. Source: Courtesy
of Lim (44).

that of the posterior part of the middle ear; however, simple nonciliated squa-
mous epithelium could also be found. (4) In the area of the promontory, pseu-
dostratified ciliated columnar epithelium predominated over ciliated cuboidal
epithelium. Goblet cells as well as intraepithelial and submucosal glands were
seen. Simple nonciliated squamous epithelium no longer appeared. (5) At the
tympanic orifice of the eustachian tube, the epithelium was similar to that of
the promontory, save for less frequent glands and more nonciliated cells with
secretory granules. (6) The pars flaccida possessed a simple nonciliated epithe-
lium. (7) The epithelium of the pars tensa varied in height from pseudostrati-
fied, ciliated columnar to simple, nonciliated cuboidal. Mature goblet cells
were not found on the tympanic membrane.
Hentzer (49) concluded that the mucosa of the middle ear represents a
modified respiratory mucosa. He proposed that the nonciliated cell was its
sole secretory structure which, in its most active secretory phase, resembled
a goblet cell.
The Mucociliary Transport System
The secretions produced by the glands and goblet cells produce a mucous
blanket and the ciliated cells mobilize this blanket to create the mucociliary
transport system. Studies by Shimada and Lim (50), Lim et al. (51), and Lim
(44, 52) have demonstrated that the distribution of the ciliated cells corresponds
to that of the secretory cells. Metachronal motion (coordinated beating) of the
cilia is responsible for propelling the mucous blanket. By using six power or
higher magnification, ciliary activity can frequently be observed in the anterior
part of the hypotympanum through a perforation of the tympanic membrane.
Light reflections in the mucous sheath will be observed to be shimmering.
Lim (52) describes three distinct mucociliary tracts in the tympanic
cavity: (1) a hypotympanic tract commencing in the hypotympanum and
leading into the eustachian tube, (2) an epitympanic tract from the epitym-
panum to the eustachian tube, and (3) a promontory tract leading from the
promontory to the eustachian tube (52). The eustachian tube likewise
possesses a mucociliary transport system; its lining cells are believed to
secrete a surface-active agent (like a surfactant) which reduces surface
tension, thus facilitating tubal opening (53). The mastoid air cells do not
appear to have a mucociliary transport system.
Blockage of the eustachian tube in children characteristically results in
a seromucinous fluid in the tympanomastoid compartment, whereas in
adults the fluid is serous. The difference is probably related to an associated
inflammatory reaction in children, causing hyperactivity of the mucous pro-
ducing goblet cells and glands.
A perforation of the tympanic membrane in association with a blocked
eustachian tube may cause a mucoid otorrhea, especially in children.

THE IMMUNE SYSTEM OF THE MIDDLE EAR
Another defense mechanism in the middle ear involves the secretion of

immunoglobulin-A (IgA) and the antibacterial enzyme, lysozyme, by the
mucosal epithelium (54). Tissue macrophages are also seen in normal human
middle ear mucosa (44). Acid phosphatase, a cytochemical marker for
lysosomes (55), has been found in the epithelium of normal mucosa,
although its exact cellular location is undetermined (56, 57). Possibly some
of the lysosomal enzymes are integrated into the enzymatic defense of the
middle ear by the mucosal secretory cells. Tracer studies (58) have
documented pinocytosis of tracer particles by the surface epithelium; these
particles then either enter the blood or lymphatic circulation or are acted
upon by the tissue macrophages of the submucosa.
Thus, the submucosa also participates in middle ear defense. This thin
connective tissue layer consists of fibroblasts and fibrocytes with their asso-
ciated collagen fibers. Scattered wandering tissue phagocytes, occasional
plasma cells and lymphocytes, as well as sporadic clumps of mast cells are
also present in the submucosa; it is permeated by a multitude of blood and
lymph capillaries, and there is an abundance of nerve fibers. Plasma cells
producing immunoglobulins A, E, G, and M have been detected in the sub-
mucosa by immunohistochemical methods; in contrast, only IgA staining
has been observed in the epithelial cells of the mucosa [by immunofluores-
cence techniques (59)]. These immunoglobulins are believed to play a role in
local immunocompetency (60).
The Mucosal Folds
The middle ear is completely lined by a mucous membrane that is continu-

ous with the mucosa of the eustachian tube and the mastoid antrum (see the
section on Histology, see p. 106). It also extends from the walls of the
tympanic cavity to envelop the middle ear structures such as the ossicles
with their various ligaments and the tendons of the intratympanic muscles.
In doing so, the mucosa forms several folds and pouches. As the mucosa
drapes over the anterior process and anterior ligament of the malleus, as
well as the closely associated chorda tympani nerve, it forms the anterior mal-
leal fold. This fold extends from the notch of Rivinus to the head and neck of
the malleus and, in conjunction with the anterior tympanic stria (see the sec-
tion on Tympanic Membrane, p. 41), encloses a blind pouch, the anterior
pouch of von Tröltsch. The posterior malleal fold envelops the posterior seg-
ment of the chorda tympani nerve as the latter stretches from the pretym-
panic spine to the neck of the malleus. The posterior pouch of von Tröltsch
lies between the posterior malleal fold and the posterior tympanic stria. In
Figure 111, Prussak’s space communicates with the posterior pouch of von
Tröltsch. As the mucosa descends from the roof of the tympanic cavity to
cover the body and short process of the incus, it forms the incudal fold. The
stapes, including the obturator foramen, is sheathed by an extension of
mucosa from the posterior tympanic wall referred to as the stapedial fold.
Proctor (61) produced an exhaustive description of the genesis of these
folds as well as detailed diagrams of their anatomy. Their constancy is
related to the development of the tubotympanic recess as an outpouching of
the nasopharynx (see chap. 9). By approximately 28 weeks’ gestation, four

Figure 111
This view shows the tympanic mem-
brane and ossicular anatomy at the
level of the lateral process of the
malleus. The posterior pouch of von
Tröltsch is bounded medially by the
posterior malleal fold (male, age 63 yr).
buds known as primary sacs or pouches invade the middle ear cavity: (1)
The saccus anticus, the smallest of the four, forms the anterior pouch of von
Tröltsch as it extends superiorly, anterior to the tendon of the tensor tympani
muscle. (2) The saccus medius also reaches superiorly, forming the attic; it
then sprouts three saccules. The anterior saccule gives rise to the anterior
compartment of the attic, while the medial saccule develops into the
superior incudal recess. The posterior saccule is responsible for the pneuma-
tization of the petrous part of the mastoid air cell system. (3) The saccus
superioris forms the posterior pouch of von Tröltsch and the inferior incudal
recess as it expands posterolaterally between the manubrium and the distal
aspect of the long process of the incus. With continued posterior expansion,
the saccus superioris also extends medially, entering the antrum and eventu-
ally pneumatizing the pars squamosa of the temporal bone. (4) The saccus
posticus courses in the hypotympanum and forms the round window niche,
the sinus tympani, and the majority of the oval window niche. Mucosal
folds, carrying the vessels which supply the ossicles (much like the abdom-
inal mesentery), develop where these four major sacs come into contact with
each other.
According to Proctor (61), the various compartments of the ear defined
by these folds limit, at least in early stages, the extent of disease processes
such as cholesteatoma, and also designate probable routes of extension of
disease. Proctor believes that as long as the mucosal folds are intact, it is pos-
sible to remove a cholesteatoma and its lining epithelium and still preserve
the integrity of the particular middle ear compartment involved and the
blood supply of the ossicles. Clinical observations indicate, however, that
these folds have minimal influence on the location or magnitude of
advanced disease in the tympanomastoid compartment.

The Middle Ear Corpuscles
The presence of a small “oval body” near the tympanic membrane was first
noted in 1859 by von Tröltsch (337), he considered it a pathologic entity, hav-
ing seen it in the ear of an elderly woman with hearing loss. Politzer (63) and
Kessel (62) described similar structures tethered by connective tissue in the
middle ear, antrum, and mastoid; they thought that these structures
were physiologic rather than pathologic (Fig. 112).
Gussen (64) studied 77 adult human temporal bones, all without
evidence of infection, and found “pacinian corpuscles” (her terminology) in
the middle ears of all specimens examined. She emphasized that their
suspension from mucosal-mesentery folds was consistently in relation to
either of the three ossicles or the stapedius or tensor tympani tendons. She
hypothesized that they have a kinesthetic receptor capacity of maintenance
and coordination of the movements of the ossicles.
Lim et al. (65) disputed these findings. They studied 124 temporal
bones by light microscopy and an additional 27 temporal bones with
the electron microscope. While the middle ear corpuscles are most
commonly located in the mastoid antrum and epitympanic recess, they
also occur throughout the mastoid cavity (Fig. 113). There was great varia-
bility in size, ranging from 0.8 to 10 mm in length and 0.4 to 2.5 mm in
diameter.
Histologic study showed these round or elliptical bodies (Fig. 114) to
consist of an encircling mucous membrane, an outer capsule of concentrically
laminated collagen fibers and fibrocytes, and a central core. Electron
microscopic study of the central core failed to reveal any nerve fibers—only
homogeneous ground substance was found. These bodies were not found in
specimens from patients less than six years old or from those with a history
Figure 112
Middle ear corpuscles may be of
variable size and are found scattered
throughout the middle ear and
mastoid. They have not been found in
ears having previous otitis media or in
children less than 6 yr of age (male, age
65 yr). Their function, if any, is
unknown.

Figure 113
In this sketch each black dot represents
the location of a middle ear corpuscle
as found in 151 temporal bones by Lim
et al. (65).
of chronic otitis media, otitis media with effusion, or mastoiditis. Although

this study did not reveal the functional nature of these middle ear corpuscles,
it provided evidence that invalidates the concept of their being Pacinian cor-
puscles. While they have no known physiologic function, they may be
viewed with some curiosity by the otologic microsurgeon seeing them for the
first time.
Figure 114
This cross section of a middle ear
corpuscle shows its multilaminar struc-
ture. There is a distinct central core
surrounded by a laminated capsule, all
enveloped in a surface lining of mucous
membrane (male, age 47 yr).

Figure 115
There is a normal glomus body on the
promontory of the cochlea in associa-
tion with the tympanic branch of the
glossopharyngeal nerve (female, age
68 yr) (Fig. 116).
Glomus Bodies
Glomus bodies occurring in the middle ear were first described by Guild (66)
as glomus jugulare (glomus jugularis) formations. Glomus formations may
be found anywhere along the course of Arnold’s nerve (tympanic branch of
the vagus) as far distally as the intersection with the descending portion of
the facial nerve, and also along Jacobson’s nerve (the tympanic branch of the
glossopharyngeal nerve) (Figs. 115 and 116). Guild (67) determined that just
over 50% of the glomus formations were situated in the region of the
Figure 116
Here is a higher magnification of the
outlined area in Figure 115 showing
details of the glomus body (female, age
68 yr).

jugular fossa accompanying either of the above-mentioned nerves or in the
adventitia of the jugular bulb. Less frequently they are found in the tym-
panic canaliculus or in the mastoid segment of the facial canal.
The glomus body tumor is the most commonly found neoplasm in the
middle ear (68). This relatively benign neoplasm is also known as carotid
body-like tumor (69), glomus jugulare tumor (70), nonchromaffin paragan-
glioma (71), chemodectoma (72), receptoma (73), and glomerocytoma (74).
The most commonly recognized appellation is that of glomus tumor. The
term “glomus tympanicum” is reserved for those tumors arising in the
mesotympanum, while those arising in the hypotympanum are designated
as glomus jugulare (75).
Glomus jugulare neoplasms tend to extend into the infralabyrinthine
cells, an area that is demonstrated in Figure 83. In well-pneumatized temporal
bones, the growth will then extend anteriorly into the petrous apex and
pericarotid areas (Fig. 1 on p. 116) and occasionally into the mastoid and
jugular vein. Surgical removal requires careful planning of the surgical
approach to prevent or minimize hearing loss.

Chapter 4
Pneumatization
The extent of pneumatization of the normal human temporal bone is

variable (83–87). The growth pattern is thought to be controlled by heredity,
environment, nutrition, bacterial infections, and the adequacy of ventilation
as determined by eustachian tube function.
Hug and Pfaltz (88) conducted a planimetric study of temporal bone
pneumatization by X-ray examination in 73 children, evaluating normal ears
as well as those with middle ear disease. They found that both otitis media
with effusion and recurrent suppurative otitis media had an inhibitory effect
upon the pneumatization process. They also presented data indicating that
after infection is controlled, pneumatization again proceeds. They noted,
however, that in no case could they observe a normal sized air cell system
once the pneumatization process had been inhibited.
The reader’s understanding of the three-dimensional anatomy of the
pneumatization of the temporal bone will be enhanced by the study of stereo
views of celloidin blocks (chap. 1, Figs. 38 to 51) as well as stereo views of
surgical dissection (chap. 8, Figs. 1 to 28).
The pneumatized spaces of the temporal bone may be divided into five
regions which are further subdivided into areas. A diagrammatic sketch
showing most of the regions, areas, and tracts is seen in Figure 1, and the
complete classification appears below (89).
Pneumatized Spaces of the Temporal Bone

A. Middle ear region D. Petrous apex region
1. Mesotympanic area 1. Peritubal area
2. Epitympanic area 2. Apical area
3. Hypotympanic area E. Accessory region
4. Protympanic area 1. Zygomatic area
5. Posterior tympanic area 2. Squamous area
B. Mastoid region 3. Occipital area
1. Mastoid antrum area 4. Styloid area
2. Central mastoid tract F. Tracts of pneumatization
3. Peripheral mastoid areas 1. Posterosuperior tract
(a) Tegmental cells 2. Posteromedial tract
(b) Sinodural cells 3. Subarcuate tract
(c) Sinal cells 4. Perilabyrinthine tracts
(d) Facial cells 5. Peritubal tracts
(e) Tip cells
C. Perilabyrinthine region
1. Supralabyrinthine area
2. Infralabyrinthine area
115
THE MIDDLE EAR REGION
The middle ear region may be divided into five areas: (1) a mesotympanic
area that lies medial to the pars tensa, (2) an epitympanic area that lies
superior to a horizontal plane passing through the anterior and posterior
tympanic striae, (3) a hypotympanic area located inferior to a horizontal
plane passing through the most inferior level of the tympanic annulus, (4) a
protympanic area, occupying that space anterior to a frontal plane passing
through the anterior margin of the tympanic annulus, and (5) a posterior
tympanic area located posterior to a frontal plane passing through the pos-
terior margin of the tympanic annulus and including the sinus tympani and
facial recess. For detailed anatomy see middle ear spaces (chap. 3, p. 85).
Figure 1
Two vertical planes, one passing
through the plane of the superior canal
and another through the axis of the
modiolus, serve to demarcate the
mastoid, perilabyrinthine, and petrous
apex regions of pneumatization of the
temporal bone. The perilabyrinthine
region can be further subdivided into
infralabyrinthine and supralabyrinthine
areas; in the petrous apex, peritubal and
apical areas are recognized.
THE MASTOID REGION
At birth the mastoid has a single cavity consisting of the antrum and small
adjacent mastoid. It occupies a superficial position and is surrounded by
diploic bone (Figs. 2–4).
In adult life, the normal mastoid may be fully pneumatized, diploic, or
sclerotic. In the diploic and sclerotic types, pneumatization is limited mainly
to the antra and central mastoid tracts. The diploic type contains soft
tissue in the form of bone marrow, whereas the sclerotic type consists
predominantly of dense bone (Figs. 5–8). Even narrow mastoids may be

Figure 2
The following three photos are from the
same temporal bone of a 41-day-old
female infant. This view of a superior
level shows the pneumatization of the
epitympanum and aditus for this age.
Occasionally mesenchyme will persist
in the epitympanum and mastoid for
some months after birth. The periantral
cells have not yet appeared. The subar-
cuate fossa leads to the petromastoid
canal, which in turn passes between the
limbs of the superior canal.
Figure 3
At the level of the oval window there is
pneumatization of the middle ear and
central mastoid tract which is appropri-
ate for this age (41 days). The cortical
bone of the mastoid is normally thin.
CHAPTER 4: PNEUMATIZATION ■ 117

Figure 4
At a more inferior level, the hypotym-
panum is seen to be fully pneumatized.
The mastoid consists of solid bone. As
the embryo nears term, the resolution
of mesenchyme proceeds from the
hypotympanum and mesotympanum
to the epitympanum and mastoid
(female, age 41 days).
Figure 5
This section shows a lack of mastoid air
cell development without evidence of
inflammatory disease. The small
mastoid is associated with an anterior
and lateral location of the sigmoid
sinus (male, age 79 yr).
Figure 6
The mastoid is markedly sclerotic in
this specimen. Pathologic changes in
the tympanic membrane document the
previous occurrence of otitis media.
The petrous apex contains bone marrow

Figure 7
A narrow mastoid is seen in association
with a laterally situated sigmoid (lat-
eral venous) sinus. The operculum
overlying the endolymphatic sac is
demonstrated. An otosclerotic focus is
present anterior to the oval window.
There is no evidence of previous otitis
media (female, age 80 yr).
well-pneumatized (Figs. 9 and 10). Surgical access to the middle ear via the
facial recess (posterior tympanotomy approach) is difficult or impossible in
narrow mastoids such as those shown in Figures 5, 7, and 9.
In an examination of 250 adult human temporal bones, Zuckerkandl
(90) found 36.8% to be completely pneumatized, 43.2% to be partially pneu-
matized and partially diploic, and 20% to be completely diploic or sclerotic.
In temporal bones with inhibited pneumatization of the perilabyrinthine
areas, the posterior canal may form a prominence on the posterior surface of
the petrous bone (Fig. 11). The arcuate eminence, which marks the location of
the superior canal in the floor of the middle cranial fossa, is also emphasized
by inhibited pneumatization of this area of the temporal bone.
Figure 8
The middle ear and upper portion of
the central mastoid tract are well-
pneumatized in this 9-wk-old infant.
Sclerotic bone surrounds the central mas-
toid tract. The bone of the mastoid cortex
is normally thin.

Figure 9
In contrast to the large external
auditory canal (EAC), the mastoid is
narrow, although well-pneumatized.
The large tip cell abuts the bony EAC
(male, age 73 yr).
The anterolateral portion of the mastoid arises from the squamous part
of the temporal bone; the posteromedial portion, including the mastoid tip,
arises from the petrous part. The delineation of these areas is indicated on
the outer surface by the petromastoid fissure, which is usually obliterated in
early adult life. In most mastoids, the plane of junction of these two parts is
marked internally by an incomplete plate of bone, the petrosquamosal
septum, also known as Koerner’s septum (91). This bony partition is of vari-
able thickness and descends to variable depths; in extensively pneumatized
bones it may be missing altogether. Proctor (61) proposes that Koerner’s
septum is the consequence of the “persistence and further development of
the mucosal fold between saccus superior and saccus medius in the antrum
and mastoid of the adult.”
Figure 10
This temporal bone shows a well-pneu-
matized narrow mastoid. The peritubal
area is well-pneumatized. The bony
dehiscence of the anterior wall of
the external auditory canal is an
occasionally occurring anatomic variant
(male, age 22 yr).

Figure 11
The temporal bone of this 8-mo-old
infant shows advanced pneumatiza-
tion of the mastoid but inhibited
perilabyrinthine pneumatization; thus,
the internal auditory canal is short and
wide and the posterior canal bulges
into the posterior fossa. Anteriorly, the
pars tensa has been artifactually sepa-
rated from the tympanic annulus.
When encountered during surgical procedures, Koerner’s septum may

be confused with the medial wall of the antrum (Figs. 12–14). The identity of
Koerner’s septum becomes obvious when it is realized that the usual
anatomic landmarks such as the tegmen of the mastoid, the prominence of
the lateral canal, the lateral venous sinus, and the antrum are not in view.
The mastoid region can be divided into three areas (Fig. 15): (1) The
mastoid antrum area is a large superior central space which communicates
with the epitympanic space of the middle ear via the aditus. The lateral wall
is formed by the squamous part of the temporal bone. (2) The central
mastoid tract area extends inferiorly from the mastoid antrum (Fig. 16). It
may consist of a single space of varying size or of a series of cells and may
Figure 12
The division of the mastoid into an
anterolateral squamous portion and
a posteromedial petrous portion by
Koerner’s septum is demonstrated in
this photograph (female, age 65 yr).

Figure 13
Koerner’s septum delineates a normally
smaller squamous part from the larger
petrous part of the mastoid. In this
specimen, the anterior epitympanic
recess protrudes into the middle cranial
fossa (male, age 76 yr).
be partly divided by the petrosquamosal (Koerner’s) septum. (3) The periph-

eral mastoid area has five cell groups consisting of (i) the tegmental cells
bordering the tegmen and lying superiorly in the mastoid bone, (ii) the
sinodural cells occupying the posterosuperior angle of the mastoid bone and
bounded superiorly by the dural plate of bone as well as posteroinferiorly by
the sinus plate of bone, (iii) the sinal cells lying lateral, medial, and posterior
to the sigmoid sinus, (iv) the facial cells lying in relation to the mastoid
segment of the facial nerve, and (v) the tip cells occupying the inferior pro-
jection of the mastoid bone and divided by the digastric ridge into medial
and lateral groups.
Figure 14
This more inferior view of the same ear
shown in Figure 12 demonstrates the
smaller size of the anterolateral squa-
mous part when compared to
the larger posteromedial part of the
mastoid. Because of the differing
origins of their pneumatization, the
facial recess and mastoid are always
separated by a bony partition (female,
age 65 yr).

Figure 15
This diagrammatic sketch illustrates
the areas of pneumatization of the mas-
toid region and accessory regions of the
temporal bone.
Figure 16
The central mastoid tract extends
inferiorly from the antrum and is
surrounded by smaller air cells, some
of which may extend into the cortex
of the posterior wall of the external
auditory canal (female, age 58 yr).

THE PERILABYRINTHINE REGION
The perilabyrinthine region is subdivided into: (1) the supralabyrinthine

area (Fig. 24) and (2) the infralabyrinthine area (Fig. 17) which lie superior
and inferior to the labyrinth, respectively.
THE PETROUS APEX REGION
The petrous apex region is divided into: (1) the peritubal area (Figs. 18 and 19)
which surrounds the osseous portion of the eustachian tube and lies antero-
lateral to the carotid canal, and (2) the apical area (Figs. 20–24) which lies
anteromedial to the carotid canal. Peritubal pneumatization is common;
however, the apical area is not usually pneumatized (Fig. 25).
To the surgeon, the apical area is the most remote part of the temporal
bone. It may be pneumatized by the peritubal, perilabyrinthine, posterosu-
perior, posteromedial, and subarcuate cell tracts. Surgical access for drainage
of purulent accumulations (petrous apicitis) can usually be accomplished by
following one of these routes (92–95). An alternative route, proposed by
Ramadier (96), is to drill through the bony labyrinth between the cochlea
and carotid canal; most otologic surgeons, however, consider this approach
to be too difficult to be practical. The limited space available between the
cochlea posteriorly and the facial nerve and carotid artery anteriorly is
demonstrated in Figures 20, 21, and 22. Infections of the petrous apex have
become a rarity in most parts of the world.
Figure 17
This photomicrograph shows extensive
pneumatization of the infralabyrinthine
area (female, age 16 yr).

Figure 18
In this ear, peritubal air cells are located
both medial and lateral to the
eustachian tube. The internal carotid
artery is separated from the bony part
of the eustachian tube by a thin plate of
bone (male, age 74 yr).
Figure 19
There is a dehiscence of the anterior
wall of the external auditory canal. This
anatomic variant is of significance in
surgical procedures in this area (male,
age 53 yr).

Figure 20
This temporal bone shows extensive
pneumatization of the peritubal and
apical areas of the petrous apex region.
Peritubal cells frequently serve as a
route of pneumatization to the apical
area (female, age 89 yr).
Figure 21
The petrous apex is narrow but
extensively pneumatized. The aditus is
that constricted region posteromedial
and superior to the body and short
process of the incus leading from the
epitympanum to the mastoid antrum

Figure 22
In this ear, the petrous apex area is
highly pneumatized. Serial sections
show continuity with the peritubal
and posterosuperior cell tracts (female,
age 49 yr).
Figure 23
This temporal bone shows a single
large apical air cell (male, age 40 yr).

Figure 24
Two common pathways to the petrous
apex from the mastoid are the postero-
superior tract and the subarcuate tract
Figure 25
This temporal bone shows the usual
state of nonpneumatization of the
petrous apex. The carotid canal with its
vascular and neural plexuses is also
found in the petrous apex (male,
age 60 yr).

THE ACCESSORY REGIONS
Occasionally, pneumatization extends beyond the middle ear, mastoid, peri-

labyrinthine, and petrous apex regions to involve adjacent portions of the
temporal bone and even the adjacent cranial bones, thus forming the acces-
sory cell areas (Fig. 15): (1) a zygomatic area that is an anterior extension
from either the epitympanic or tegmental cell areas and occupies the root
and sometimes the arch of the zygoma, (2) a squamous area which lies in the
squamous portion of the temporal bone above the level of the infratemporal
line as a superior extension from the tegmental cells, (3) an occipital area that
lies within the occipital bone as a posterior extension from the sinal cells, and
(4) a styloid area consisting of a rare accessory pneumatization occurring as
an extension of the tip cells into the base of the styloid process.
THE TRACTS OF PNEUMATIZATION
Pneumatization of the temporal bone is the result of a hollowing-out process

in which mesenchyme is resolved to leave spaces. Each space becomes air-
containing and is in free communication with all other pneumatized spaces.
The tracts of pneumatization are well-known to the otologic surgeon, for
they serve as routes which can be followed to approach diseased areas of the
temporal bone (86,97–99).
These tracts are as follows: (1) The posterosuperior cell tract extends
anteromedially from the superior part of the mastoid and lies in the angle
between the dural plates of bone of the middle and posterior cranial fossae
and the superior canal. This tract usually terminates near the internal audi-
tory canal, but may pass superior to the internal auditory canal to reach the
supralabyrinthine and apical areas (Figs. 26 and 27). (2) The posteromedial
cell tract extends anteromedially from the mastoid along the posterior sur-
face of the petrous bone at a level inferior to the posterosuperior cell tract
(Figs. 28 and 29). On one side it is bordered by the endolymphatic duct and
sac, and on the other by the bony wall of the posterior cranial fossa. It may
lead to the supralabyrinthine and infralabyrinthine areas. (3) The subarcuate
cell tract, occurring in 3% of temporal bones (100), extends from the mastoid
in an anteromedial direction through the arc of the superior semicircular
canal adjacent to the petromastoid canal. It may reach the apical area
(Figs. 30 and 31). (4) The perilabyrinthine tracts extend from the epitympanic
and hypotympanic areas of the middle ear into the supralabyrinthine and
infralabyrinthine areas, respectively. (5) The peritubal tract arises from the
protympanum or eustachian tube and takes a course anterior to the internal
carotid artery to reach the apical area (Fig. 20).

Figure 26
posterosuperior cell tract as it extends
anteromedially from the mastoid
toward the internal auditory canal
in a course parallel to the posterior sur-
face of the temporal bone. It lies
in close anatomic relationship to the
nonampullated limb of the superior
Figure 27
In this case, a large posterosuperior cell
tract leads directly to a pneumatized
apical area (female, age 16 yr).

Figure 28
This temporal bone has a well-
developed posteromedial cell tract
(male, age 57 yr). Abbreviations: AICA,
anterior inferior cerebellar artery; EAC,
external auditory canal.
Figure 29
The posteromedial cell tract of this
79-yr-old female is composed of large
cells which bulge into the posterior cra-
nial fossa.

Figure 30
The subarcuate tract is seen passing
between the ampullated and nonam-
pullated limbs of the superior canal as
it extends anteromedially from the
mastoid. The petromastoid canal is also
seen, passing posterolaterally from the
posterior cranial fossa (male, age 44 yr).
Figure 31
The subarcuate tract extends anteriorly
through the arc of the superior canal.
The posterosuperior tract parallels the
posterior border of the temporal bone
(male, age 80 yr). The subarcuate
tract is one of the several surgical
routes to the petrous apex (see also
Fig. 45 on p. 27).

PACCHIONIAN BODIES
Pacchionian bodies, also known as arachnoid granulations, are pseudopodial

projections of the pia-arachnoid which normally extend through the dura
into venous sinuses or venous lacunae. There is variability in the number and
location of these bodies. The largest number can generally be found adjacent
to the superior sagittal sinus, but they may also be found bordering the trans-
verse, cavernous, and superior petrosal sinuses. With age, there is a tendency
for the bodies to increase in size and number, and to undergo calcification.
Each of these pacchionian bodies is composed of several arachnoid villi; each
of the villi consists of bundles of collagenous fibers interspersed with pia-
arachnoid-like cells surrounded by a thin, outer membrane with small, oval
epithelial cells on the surface. The space contained by the villi is a continua-
tion of the subarachnoid space. The bodies are believed to serve principally
as one-way, pressure-dependent valves between the relatively high pressure
cerebrospinal fluid system to the low pressure venous sinus system.
Pacchionian bodies are also found extending from the arachnoid of the
middle cranial fossa (Figs. 32 and 33) and from the posterior fossa into the
adjacent mastoid cells (Figs. 34–36). In these locations, the bodies may be
encountered by the surgeon, particularly in noninfected ears. Exposing them
does not result in a cerebrospinal fluid leak. The function of these bodies in
areas not related to venous channels is not known.
Figure 32
This section shows a large pacchionian
body in the subdural area of the middle
cranial fossa (male, age 50 yr) (see Fig. 33
on p. 134).

Figure 33
This photomicrograph shows a high-
power view of the outlined area of
Figure 32 (male, age 50 yr).
Figure 34
In this case, there is a large pacchionian
body arising from the meninges of the
posterior cranial fossa. There is soft tis-
sue continuity (osseous dehiscence)
between the cranial cavity and the mas-
toid at the site of this body. It has not
been demonstrated, however, that such
sites provide pathways for bacterial
spread or cerebrospinal fluid leak.
Figures 35 and 36 on p. 135 are high-
power views of areas A and B respec-
tively (female, age 74 yr).

Figure 35
Shown is a high-power view of area
A in Figure 34 (female, age 74 yr).
Figure 36
Shown is a high-power view of area
B in Figure 34 (female, age 74 yr).

THE SUBARCUATE FOSSA AND THE PETROMASTOID CANAL
In the adult, the subarcuate fossa is usually a small shallow depression on the
posterior surface of the petrous pyramid, posterosuperior to the meatus of
the internal auditory canal. In the fetus and the newborn, the fossa is
relatively larger than in the adult (100) (Figs. 2 and 37). It leads into the petro-
mastoid canal, a channel for the subarcuate artery and its accompanying vein
as they course posteriorly through the arc of the superior canal (Figs. 23 and
30) (101). The mastoid aperture of the petromastoid canal is usually found in
a periantral cell anterior to the nonampullated end of the superior canal;
however, in 5% of cases it opens directly into the antrum (100).
Figure 37
This ear demonstrates a persisting sub-
arcuate fossa. If such an ear also had a
well-pneumatized subarcuate tract,
mastoidectomy could readily be com-
plicated by a cerebrospinal fluid leak
(male, age 1 yr, 9 mo).

Chapter 5
The Inner Ear
THE BONY LABYRINTH
The bony labyrinth develops from the otic capsule. Its matrix is trilamellar,
consisting of the internal periosteal (or endosteal) layer, the middle mixed
layer of intrachondrial and enchondral bone, and the external periosteal layer.
The internal and external periosteal layers are derived, respectively, from the
embryonic internal and external perichondrium (see the section on ossifica-
tion, chap. 9, p. 287). Scattered within the middle layer is intrachondrial bone
(globuli interossei) (Figs. 1 and 2) which consists of islands of cartilage, the
lacunae of which develop a thin layer of bone from invading osteoblasts. The
amount of intrachondrial bone decreases with the age of the individual (102).
Following fracture, this middle layer of bone fails to heal by osteoid or callus
formation. The endosteal (inner periosteal) layer also demonstrates poor
reparative capability. Fractures of the temporal bone heal predominantly with
fibrous tissue and some bone from the external periosteal layer.
The long axis of the bony labyrinth, measuring 20 mm in length (4),
roughly parallels the posterior surface of the petrous pyramid. Its compo-
nents are the vestibule, the semicircular canals, and the cochlea (Fig. 3).
The Vestibule
The vestibule is the central chamber, measuring 4 mm in diameter; the irregular

topography of its walls corresponds to the contained elements of the
membranous labyrinth. At the posterosuperior aspect of its medial wall is a
depression known as the elliptical recess which accommodates part of the utric-
ular macula. The spherical recess is a similar depression for the saccular macula,
located anteroinferiorly. The vestibular crest, an oblique elevation between these
two recesses, bifurcates posteriorly into two wings which delimit the cochlear
recess for the vestibular cecum (basal end) of the cochlear duct.
There are discrete openings in the bony walls of the vestibule. The open-
ing for the cochlea lies anteriorly, while the openings for the semicircular
canals are located posteriorly. The cribriform (or cribrose) areas are clustered
tiny openings through which the vestibular and cochlear nerve bundles gain
access to the inner ear. The oval window is an opening on the lateral wall,
adjoining the tympanic cavity. The vestibular aqueduct with its contained
endolymphatic duct opens into the posteroinferior aspect of the vestibule.
The Cochlea
The osseous cochlea (Figs. 4–6) derives its name from its resemblance to a
snail shell; it consists of a 32-mm spiral canal which winds two and one-half
137
Figure 1
The three layers of the adult bony
labyrinth are shown. The globuli
interossei (intrachondrial bone) are
islands of modified cartilage in the
enchondral layer of bone. Grenzscheiden
are to be distinguished from the blue
mantles of Manasse (male, age 59 yr).
turns about a central bony axis, the modiolus. The base of the spiral is
located at the anterolateral aspect of the internal auditory canal, correspon-
ding to the cochlear cribrose area for the transmission of nerves supplying
the cochlea; the apex points inferiorly, laterally, and anteriorly. The height of
the cochlea is 5 mm. The osseous spiral lamina is a slender bony projection
which circles the modiolus to partially subdivide the cochlear canal into the
scala vestibuli anteriorly and the scala tympani posteriorly; it terminates
apically at the hamulus. The helicotrema is the apical communication of the
two scalae. The secondary osseous spiral lamina is a thin, narrow, curved
shelf of bone located on the external wall of the basal end of the cochlea,
hugging the posterior surface of the spiral ligament. Defects in the
Figure 2
Shown here are the three layers of
the bony labyrinth of a newborn infant
with osteogenesis imperfecta. The
endosteal layer of bone is normal. The
enchondral layer shows an increase in
the fibrous tissue component. The deli-
cate trabeculae of the enchondral layer
are separated by moderately cellular
fibrous tissue with some blood vessels.
The periosteal bone is denser than the
enchondral layer, and is also composed
of thin trabeculae separated by fibrous
tissue.

Figure 3
This sketch of the bony labyrinth
in effect shows the configuration of the
endosteal layer of bone. Source: After
Sobotta (186).
interscalar septum between the middle and apical turns (scala communis)
are common and of no functional significance (Fig. 7).
The Canals
The osseous semicircular canals (here referred to as the lateral, posterior, and
superior canals) are situated posteriorly relative to the vestibule. Each canal
Figure 4
This photograph shows the microscopic
anatomy of a normal cochlea. Note that
from base to apex there is progressive
narrowing of the spiral ligament and
widening of the basilar membrane
(female, age 63 yr). Same ear as in
Figures 5 and 6.
CHAPTER 5: THE INNER EAR ■ 139

Figure 5
This view shows the normal cochlear
duct. Compare with sketch in Figure 15.
The areas of acellularity in the spiral
ligament are normal for age. The protein
precipitate is a normal consequence of
histologic preparation (female, age
63 yr). Same ear as in Figures 4 and 6.
is orthogonally related to the others, describing a 240° arc, and measuring

1 mm in diameter. Each canal expands to double its diameter at its osseous
ampulla where it communicates with the vestibule. The nonampullated ends
of the posterior and superior canals fuse, forming the common crus, while
the nonampullated end of the lateral canal remains independent. Thus, the
vestibule has five apertures for the semicircular canals.
In 1998, Minor and colleagues (103) described a syndrome comprising
vestibular symptoms, occasionally accompanied by chronic disequilibrium,
that was provoked by sound or by alterations in middle ear/intracranial
pressure. They linked this symptom complex to a dehiscence in the bone
overlying the superior semicircular canal. A subsequent microscopic study
Figure 6
This is a normal organ of Corti. Ciliary
tufts are often visualized in well-
preserved specimens. Note that the
OHC nuclei and Deiters’ cell nuclei are
located in distinct rows (female, age
63 yr). Same ear as in Figures 4 and 5.
Compare with sketch in Figure 15.
Abbreviations: IHC, inner hair cell;
OHC, outer hair cell.

Figure 7
A partially missing interscalar septum
(scala communis) is a common devel-
opmental defect and is compatible with
normal cochlear function (female, age
63 yr).
(104) of 1000 vertically-sectioned temporal bones revealed a complete dehis-

cence of the superior semicircular canal in 0.5% and markedly thin (</ = 0.1
mm) bone in an additional 1.4%. The dehiscences/thinning, which were
identified most commonly at the middle cranial fossa floor and in the region
of superior semicircular canal in contact with the superior petrosal sinus,
generally occurred bilaterally. Moreover, the bone overlying the superior
semicircular canal invariably was found to be thin at birth, gradually thick-
ening over the first three years of life.
Microfissures
Microfissures, commonly occurring disruptions in the endosteal and

enchondral layers of the bony labyrinth, are of no pathologic or functional
significance. They contain a combination of fibrous tissue and an osteoid-
like acellular matrix. Temporal bone fractures caused by trauma create
wider, longer fissures which also involve the periosteal layer and may
extend through the entire transverse dimension of the temporal bone.
Increased numbers of microfissures may be seen in association with tempo-
ral bone fractures and in Paget’s disease, in which case the more appropriate
terminology would be microfractures. While the endosteal and enchondral
layers of the bony labyrinth manifest minimal osseous reparative powers,
the external periosteal layer is capable of osseous repair.
A constant microfissure is located between the round window niche
and the ampulla of the posterior canal (Fig. 8) (105, 106). Okano, Harada,
and colleagues (106–108) related this microfissure to an embryologic
communication between the round window niche and the ampulla of the
posterior canal seen in 10- to 15-week fetuses. With further gestational age,
mesenchymal tissue originally present in the channel is replaced by carti-
lage, so that no communication is discernible at term. After one year of age,
the microfissure is observed with increasing incidence as a function of age.
By the age of six years, it is seen in all ears.

Figure 8
The microfissure between the ampulla
of the posterior canal and round win-
dow niche occurs in all adult temporal
bones (male, age 84 yr) (106–108). The
crest of the cochlear fenestra (round
window) is also known as the semilu-
nar crest.
Mayer (109, 110) was the first to describe alternate sites of temporal
bone microfissures. Harada et al. (106) found microfissures in the oval
window region in 25% of 331 temporal bone specimens, with an increased
incidence after the age of 40 years. In two-thirds of the cases, the microfis-
sure extended in a vertical plane both superior and inferior to the oval
window but it did not penetrate the footplate.
The etiology of these microfissures is unclear, but a popular hypothesis
contends that they are stress fractures generated by ossification and remod-
eling processes occurring within the bony labyrinth (106, 109, 110). Another
proposal (111) suggests that they are caused by constant stresses transferred
to the bony labyrinth by the act of mastication.
Because of firm fibrous healing and blockage of the fissure, it seems
improbable that it could act as a conduit for the spread of middle ear inflam-
matory processes and ototoxic medications into the inner ear as suggested
by Harada et al. (106). The role that these microfissures may play as sites for
spontaneous perilymph fistulae is a matter for speculation.
The Tympanomeningeal Fissure
The tympanomeningeal fissure, which apparently is open in early embry-

onic life, parallels the cochlear aqueduct extending from the area inferior to
the round window to the meninges of the posterior fossa (Figs. 9 and 10).
This fissure is a rare site for spontaneous cerebrospinal fluid otorrhea. It has
been termed Hyrtl’s fissure (45, 112); search of the literature, however, has
failed to reveal a description of this fissure by Hyrtl.
The Fissures of the Vestibule
The fissula ante fenestram is considered to be an appendage of the perilym-

phatic space (Fig. 11). It is a transcapsular channel formed by resorption of
precartilage. In adult life, it contains cartilage and/or fibrous tissue. It

Figure 9
The cochlea of this newborn infant
shows the area of the tympanomeningeal
(Hyrtl’s) fissure. Rarely, this fissure
may persist into adulthood to become
the site of cerebrospinal fluid otorrhea.
Reichert’s bar is seen as the cartilagi-
nous precursor of the styloid process
which ossifies only after birth.
courses from the vestibule anterior to the oval window through an irregular
slit-like space to the periosteum of the tympanic cavity near the cochleari-
form process (4).
The fossula post fenestram is an invagination of the periotic tissue into
the otic capsule posterior to the oval window (Fig. 12) and extends about
one-third of the way to the nonampullated end of the lateral canal. It occurs
inconsistently, contains fibrous tissue (4), and when present is likely to com-
municate only with the vestibule.
Figure 10
The tympanomeningeal fissure runs
parallel to the cochlear aqueduct (male,
age 44 yr).

Figure 11
This view shows the fissula ante fenes-
tram and stapediovestibular articulation
in a newborn infant. This area is the site
of predilection for otosclerosis.
Figure 12
The normal histologic appearance of
the fossula and fissula is demonstrated.
The apparent overlapping of the
footplate onto the anterosuperior
margin of the oval window is the
normal consequence of the angle of
sectioning (female, age 34 yr).
THE MEMBRANOUS LABYRINTH
The membranous labyrinth is encased within the bony labyrinth and is

surrounded by the perilymphatic space with its fluid, blood vessels, and
supporting connective tissue. The constituents of the membranous labyrinth
are the cochlear duct, the three semicircular ducts and their ampullae,
the otolithic organs (the utricle and saccule), and the endolymphatic (otic)
duct and sac (Fig. 13). This system of epithelially lined channels and spaces
is filled with endolymph (Scarpa’s fluid); the utricular duct, the saccular
duct, and the ductus reuniens interconnect the major structures.

Figure 13
This sketch shows the membranous
labyrinth as viewed from medially.
Note the “Y” configuration of the utric-
ular and saccular ducts as they join to
form the sinus of the endolymphatic
duct. The endolymphatic duct parallels
the common crus and posterior semi-
circular duct on its way to the posterior
surface of the temporal bone. Source:
After Anson and Donaldson (4).
Vesiculations, which may be seen in the walls of the membranous

canals, were described by Rüdinger approximately a century ago. Lempert
et al. (113) theorized that these vesiculations were the result of viral infection
of the labyrinth and that their rupture was responsible for the symptoms of
Ménière’s disease. Today they are considered to be of no pathologic signifi-
cance; it is not known whether they are premortem alterations of aging, post-
mortem changes, or artifacts of preparation (114).
The Cochlear Duct
The cochlear duct (scala media) is the spiral epithelial duct coursing between
the osseous spiral lamina internally and the bony wall of the cochlea exter-
nally (Fig. 14). It begins in the vestibule (vestibular cecum) as a blind pouch
connected to the saccule via the ductus reuniens (Fig. 13). Mimicking the bony
cochlea, the cochlear duct forms a 32-mm spiral around two and one-half
turns (a basal, a middle, and an incomplete apical turn) to end immediately
distal to the hamulus of the osseous spiral lamina in another cul-de-sac, the
cupular cecum. With the osseous spiral lamina, this duct completes the subdi-
vision of the bony cochlear canal into the scala vestibuli and scala tympani.
In a shallow sulcus in the outer wall of the bony, cochlear canal lies a
specialized layer of thickened periosteum, the spiral ligament (Fig. 15). This
ligament is an intricate arrangement of connective tissue cells (fibrocytes),
intercellular substance, and blood vessels. On its inner surface, it is lined by
the stria vascularis, the spiral prominence, the basilar crest, and the external
sulcus cells. The spiral prominence consists of a single layer of small
cuboidal cells interposed between the external sulcus cells and the stria vas-
cularis (vascular stripe). The outer sulcus cells lie posterior to the spiral
prominence, and are external to and distinct from the cells of Claudius.
Duvall (115), in an electron microscopic study of guinea pig cochleae,

Figure 14
This photomicrograph shows a
cross-sectional view of the basal turn
(male, age 28 yr).
Figure 15
This sketch shows most of the
structures of the cochlear duct. Source:
After Davis (187).

confirmed Shambaugh’s (116) finding that these external sulcus cells are
arranged as a “continuous band” for the entire length of the cochlear duct.
He noted that they form peg-like projections into the spiral ligament exter-
nal to the stria vascularis and are surrounded by the capillary network of the
stria vascularis and the spiral prominence. In the basal and middle turns,
these external sulcus cells are beneath both the Claudius’ cells and the cells
of the spiral prominence, but in the apical turn, they insinuate themselves
between these two cell types and border the endolymphatic surface.
The stria vascularis is a band of specialized tissues which lie on the spi-
ral ligament between the spiral prominence and the attachment of Reissner’s
membrane. It is composed of three cell types (Fig. 16): (1) marginal cells
located on the endolymphatic surface, (2) intermediate cells, and (3) basal
cells which border the spiral ligament (117). A rich capillary network lies
within the stria vascularis. The floor (posterior wall) of the cochlear duct is
composed of the thickened periosteum of the osseous spiral lamina and a
fibrous tissue continuation, the basilar membrane, which stretches from the
tympanic lip of the osseous spiral lamina to the basilar crest of the spiral lig-
ament. Reissner’s membrane forms the roof (anterior wall) of the cochlear
duct. It bridges from its site of attachment at the spiral ligament (the vesti-
bular crest) to the spiral limbus, and consists of an epithelial layer at its
endolymphatic surface and a mesothelial layer at its perilymphatic surface.
The limbus is a specialized mound of thickened periosteum of the osseous
spiral lamina; its surface can be divided into three zones: (1) facing the scala
media, (2) facing the inner spiral sulcus, and (3) facing the scala vestibuli.
The epithelium of the floor of the cochlear duct is highly specialized and
is dominated by the organ of Corti (the spiral organ). Huschke (118, 119) termed
this organ the basilar papilla. Corti (120) was the first to provide a detailed
description of the cytoarchitecture of this structure, subsequently known as the
organ of Corti. The light microscopic details have since been further described
by Boettcher (121), Retzius (122), Held (123), and Kolmer (124). Transmission
Figure 16
Shown are the cellular details of the
three layers of the normal stria vascu-
laris and the adjacent part of the spiral
ligament.

electron microscopy (115, 117, 125–131) and scanning electron microscopy
(132, 133) have revealed a whole order of magnitude of greater detail.
The basilar membrane which supports the organ of Corti consists of
connective tissue layers and extracellular matrix (131). In man, it is about
32 mm in length and measures 104 ␮m in width at its basal end and 504 ␮m
at the apical end (122). The basilar membrane is divided into two portions
(Fig. 15): (1) the zona arcuata which is located under the tunnel of Corti and
extends to the outer pillars, and (2) the zona pectinata which extends from
the outer pillars to the basilar crest of the spiral ligament. This membrane
separates the bases of the supporting cells, which rest on a thin basement
membrane, from the perilymph of the scala tympani. It consists of three
main elements: a fibrous portion, a homogeneous ground substance, and
mesothelial cells (134). The tympanic border cells (mesothelial cells) form a
layer on the posterior surface of the basilar membrane; there is a general
increase in their number proceeding apically (134). The basilar membrane
permits nearly unimpeded passage of small particles (horseradish peroxi-
dase, thorium dioxide) to the extracellular fluid of the organ of Corti; hence
that fluid should very closely approximate perilymph (135). Engström (136)
believes that this fluid is a separate entity and calls it “cortilymph.”
The primary cytologic elements of the organ of Corti are Deiters’ cells,
Hensen’s cells, hair cells, internal and external sulcus cells, and pillar cells.
According to Retzius (122), there are 3500 inner hair cells and 12,000 outer
hair cells in the human cochlea. The term “hair cells” stems from the tufts of
stereocilia which protrude from their apices. The outer hair cells, cylindrical
in shape, are supported by the reticular membrane apically and by concavi-
ties of Deiters’ cells basally. The inner hair cells are flask-shaped and are
completely surrounded, except apically, by internal pillar cells, inner pha-
langeal cells, and border cells. The inner and outer hair cells are the primary
auditory receptors; their cell bodies are partially enveloped by the synaptic
terminations of the cochlear nerve fibers.
Several types of supporting cells are associated with the inner and
outer hair cells (Fig. 15). Proceeding radially outward from the inner sulcus
cells, they are: the inner border cells, inner phalangeal cells, inner and outer
pillar cells, Deiters’ cells (outer phalangeal cells), Hensen’s cells, and
Claudius’ cells. Save for the pillar cells, all of the supporting cells possess
numerous microvilli at their free surfaces, hypothesized to function either in
endolymph ion exchange or in attachment to the tectorial membrane.
The inner border cells stretch from the basilar membrane to the surface,
forming a thin band of cells internal to the inner hair cells; they are rich in
mitochondria and microvilli and are believed to act in a nutritional role for
the inner hair cells (135).
The inner phalangeal cells are arranged in a single row with a single
phalanx stretching between two inner hair cells. They are tall, slender cells,
extending from the basilar membrane to the surface; it is unclear whether
they possess fibrils as do Deiters’ cells and the outer phalangeal cells.
There are 5600 inner pillar cells and 3850 outer pillar cells (or rods)
(135). These cells also rest on the basilar membrane. By electron microscopy
it has been shown that they contain an abundance of fibrillar structures;
hence, their function is presumed to be supportive. Along with Deiters’ cells,
they form the reticular membrane, which supports and surrounds the apices
of all the hair cells.
Deiters’ cells (outer phalangeal cells) reach from the basilar membrane
to the bases of the outer hair cells for which they provide supporting cups.
These large, filament-containing cells also provide slender processes which
extend to, and are integrated into, the reticular membrane.

Hensen’s cells are tall, columnar cells. The extent of their contact with
the tectorial membrane has been a matter of some dispute and it is felt that
after birth this contact is very tenuous, consisting only of small strands (135).
Claudius’ cells are shorter than Hensen’s cells and have no intracellu-
lar filaments (131).
The inner sulcus cells, along with Hensen’s cells, are the least differen-
tiated of the epithelial cells of the organ of Corti. They lie internal to the inner
border cells. Boettcher’s (Böttcher’s) cells form a layer between the basilar
membrane and Claudius’ cells.
The organ of Corti contains constant intercellular spaces including the
tunnel of Corti, the spaces of Nuel (the outer tunnel), and the spaces between
the outer hair cells. All of these spaces communicate with each other. Iurato
(131) describes the “lacuna of Corti” which is bounded superiorly by the
reticular lamina, inferiorly by the upper surface of Deiters’ cells, radially out-
ward by Hensen’s cells, and radially inward by the inner pillar cells.
The tectorial membrane is a gelatinous leaf that stretches out from its
attachment at the vestibular lip of the limbus and ends in the border net
(Randfasernetz). It is divided into three zones (137, 138): (1) the inner limbal
zone, which inserts into the interdental cells, (2) the middle zone which over-
lies the organ of Corti, and (3) the outer marginal zone or border net (123,
124, 139, 140) which overlies Hensen’s cells. Hardesty’s membrane is that
part of the marginal zone in which the cilia of the outer hair cells are embed-
ded (138). Hensen’s stripe marks the area at which the tectorial membrane is
attached to the inner phalangeal and border cells.
The Utricle
The utricle (Fig. 17) is an irregular, elliptical tube, the superior part of which
occupies the elliptical recess of the posterosuperior aspect of the medial wall
of the vestibule; here it is held in place by filaments of the utricular nerve
and strands of fibrous tissue. The utricular sense organ (the macula) is an
ovoid, thickened area that lies predominantly in the horizontal plane at the
Figure 17
The utricular nerve is a branch of the
superior division of the vestibular
nerve. All nerve fibers to the sense
organs of the inner ear pass through
tiny channels in the wall of the bony
labyrinth known as the cribrose or
cribriform areas (male, age 24 yr).

Figure 18
This photomicrograph illustrates the
utriculo-endolymphatic (UE) valve.
The outer wall is formed by the utricu-
lar wall. The inset shows the composi-
tion of the inner lip which consists of a
connective tissue core and a lining sur-
face epithelium (infant, age 41 days).
dilated anterior portion of the utricle (the utricular recess). The maculae of
both the utricle and the saccule are divided into two regions by the striola, a
narrow curvilinear area extending through their middle regions. The macu-
lae contain the sensory hair cells of the otolithic organs with their retinue of
supporting cells (see also the section on semicircular ducts, p. 152). The
otolithic membrane is the gelatinous blanket into which the stereocilia of the
macular hair cells project. This membrane is studded with otoconia, which
are calcium carbonate concretions in calcite crystalline structure with a spe-
cific gravity of approximately 2.71. Extending from the inferior aspect of the
utricle is the utricular duct, skirting the utricular wall to open into the sinus
of the endolymphatic duct. The utriculo-endolymphatic valve is a thicken-
ing found at the utricular aspect of the cleft-shaped opening into the
endolymphatic duct (Figs. 18 and 19) (122, 141). The semicircular ducts open
into the utricle via its posterior wall, while the anteriorly located utricular
and saccular ducts provide a route of communication with the saccule.
Figure 19
This diagram illustrates the interrela-
tionships of the endolymphatic sinus,
duct, and sac. Illustrated, but not labeled,
are the intraosseous and intradural
segments of the endolymphatic sac.
Source: After Anson and Donaldson (4).

Figure 20
In both ears of this subject, the utricle
and saccule are widely confluent and
communicate directly with the
endolymphatic sinus. The condition
may represent a phylogenetically
based failure of development of the
utriculo-endolymphatic valve (see
chap. 9, p. 272). The clinical history
revealed no evidence of auditory or
vestibular dysfunction (male, age
55 yr).
The Saccule
The saccule is an elliptical, flattened sac, the macula of which is located in

the spherical recess of the medial and anterior wall of the vestibule, inferior
to the utricle; it is held in position by connective tissue fibers and filaments
of the saccular nerve. The hook-like macula of the saccule is oriented prima-
rily in the vertical plane. The reinforced area is a discrete thickening of the
saccular wall located at its anterolateral part where it is adjacent to the
vestibular wall (142). Superiorly, the wall of the saccule abuts and adheres to
the membranous wall of the utricle; however, the only communication with
the utricle is indirectly through the saccular and utricular ducts. Inferiorly,
the saccule narrows into the ductus reuniens through which communication
with the cochlear duct is maintained. Occasionally, the saccule and utricle
are widely confluent (Fig. 20).
Macular Orientation
The otolithic surface of the macula of the utricle faces posteromedially, while
the otolithic surface of the macula of the saccule faces posterolaterally (Fig. 21).
Thus, when the utricle is viewed through an open oval window, the dull white
surface of the utricular nerve will be seen; in contrast, the saccule will present
a more glistening, slightly granular surface because of the reflective properties
of the otoconia.

Figure 21
When viewed through the oval window
during surgical procedures, the utricular
macula has a dull, white appearance
due to its neural presenting surface. In
contrast, the saccular macula has a
slightly granular, more brilliant, whitish
appearance because its presenting
surface is its otolithic membrane viewed
through the almost transparent saccular
wall (female, age 68 yr).
The Semicircular Ducts
The three semicircular membranous ducts course along the external walls of
the bony semicircular canals (Figs. 22 and 23). Like their bony channels, each
of the ducts is orthogonally related to the other. The lateral canal in man
forms a 30° angle with respect to the horizontal plane. Near its utricular ori-
fice, each duct enlarges to form the membranous ampulla, which is attached
to bone at its base. The walls of the semicircular ducts are trilaminar. A loose
connective tissue layer lies adjacent to the perilymphatic space and contains
blood vessels and pigment cells. The internal lining is a simple low epithe-
lium. Interposed between these layers is a basement membrane. The cristae
are mound-like elevations which cross the bases of the ampullae; they are
representative of a thickening of the three layers of the membranous wall and
consist of connective tissue, blood vessels, nerve fibers, and sensory neuro-
epithelium, all capped by a gelatinous cupula. The cupula extends diametri-
cally from the neuroepithelium to the opposing wall of the ampulla. The
semilunar planes are half-moon-shaped zones of cuboidal or cylindrical cells
which are located on the ampullary walls at either end of each crista.
Transitional epithelium occupies a zone along the sides of the crista; adjacent
to it is a zone of dark cells (143, 144). The dark cells are thought to have a
secretory capacity (143). The sensory epithelium of the maculae of the otolithic
organs has the same general morphological structure as the cristae (145).
Like the organ of Corti, the maculae of the otolithic organs and the
cristae of the semicircular ducts contain two types of ciliated hair cells,
type I and type II (146). The type I hair cell is analogous to the inner hair cell
of the organ of Corti, with a flask-like configuration and a surrounding chal-
ice of vestibular nerve endings. The type II hair cell is the vestibular counter-
part of the outer hair cell and has a cylindrical shape. Like the cochlear hair
cells, the vestibular hair cells are studded with stereocilia at their free
surface; however, the vestibular hair cells are distinguished by the presence

Figure 22
The semicircular ducts invariably pass
along the outer walls of their bony
canals, as seen in the nonampullated
end of this posterior canal (female, age
77 yr).
of a true kinocilium (147) in addition to the stereocilia. The stereocilia of the

cristae are embedded in a gelatinous cupula, while those of the maculae
project into the gelatinous otolithic membrane.
The Crista Neglecta
The crista neglecta is a small vestigial endorgan located in the vestibular

labyrinth. Its prevalence in man has been reported as 7.6% by Okano et al.
Figure 23
The bony wall of the posterior canal
shows a scalloped appearance. This is an
unusual but not pathologic finding in the
semicircular canals (female, age 22 yr).

(148) and 0.9% by Montandon et al. (149). In the former study, every section
of the serial set was stained and studied; therefore it probably represents the
more accurate figure. The crista neglecta is found on the anterolateral wall of
the ampulla of the posterior canal (148). It possesses all the morphologic
attributes of a true crista ampullaris, including a cupula, types I and II sen-
sory cells, and transitional epithelium, as well as efferent and afferent nerve
fibers (Fig. 24) (148, 149). Its size averages 70.3 ␮m in height, 17.5 ␮m in
width, and 228.2 ␮m in length in the 17 cases studied by Okano et al. (148);
however, there was a large range of values for each of these parameters. The
nerve supply is derived from the posterior ampullary nerve, either by the
main trunk or by a discrete branch that runs in its own bony canal. Although
the clinical significance of the crista neglecta is not established, it is closely
related to the posterior canal crista and, perhaps, as suggested by
Montandon et al. (149), is normally incorporated into the posterior canal
crista in man.
THE ENDOLYMPHATIC DUCT AND SAC
The Utriculo-Endolymphatic Valve
In the anteroinferior wall of the utricle at the orifice of the utricular duct is a
slit-shaped opening (Fig. 18) known as the utriculo-endolymphatic valve.
This structure was first described by Bast (150) and more recently has been
evaluated regarding its functional significance in man (151). The utricular
wall, in continuity with the utricular duct, forms its outer wall. The inner lip
is specially constructed to function as a valve. It has a central core of loosely
knit fibrocytes and capillaries and a surface layer of large cuboidal cells. As
endolymphatic pressure increases in the utricle, the outer membranous wall
Figure 24
The crista neglecta is a small accessory
crista, occurring regularly in felines
and certain other species and occasion-
ally in man. It has an ampulla, sensory
epithelium, cupula, and nerve fibers,
and is located in the anterior wall of
the ampullated end of the posterior

is displaced from the more rigid inner lip, permitting the escape of
endolymph into the utricular duct (Fig. 25). As the utricular endolymphatic
pressure is lowered, the valve again closes to prevent excess loss of
endolymphatic fluid. In view of the absence of any neural or muscular com-
ponents in its structure, the action of this valve probably is entirely passive.
Phylogenetically, this valve develops coincidentally with the appearance of
the auditory pars inferior (cochlea and saccule). Its purpose may be to pre-
vent collapse of the walls of the pars superior (utricle and semicircular
ducts) in the event of a rupture of the pars inferior. Absence of the utriculo-
endolymphatic valve may occur as an anatomical variant (Fig. 26).
The Endolymphatic Duct
The sinus of the endolymphatic duct is located in a groove on the postero-

lateral wall of the vestibule (Fig. 20) and terminates at the mouth of the
vestibular aqueduct. The vestibular aqueduct is a bony channel coursing pos-
teriorly and then laterally; it houses the intermediate segment of the endolym-
phatic duct as it passes from the vestibule to the posterior surface of the
petrous pyramid (Figs. 19 and 27). In embryologic development, the vestibu-
lar aqueduct initially pursues a straight course paralleling the common crus to
reach the endolymphatic sac in the posterior cranial fossa. While the otic
capsule has attained its final adult dimensions by 20 weeks of gestation, the
posterior cranial fossa continues to grow. This distal part of the endolymphatic
system is pulled inferiorly by the migrating sigmoid sinus and dura of the
posterior cranial fossa (Fig. 19). Thus, in the adult configuration the vestibular
aqueduct, and consequently the endolymphatic duct, are curved laterally and
inferiorly. From such developmental considerations, one can expect the
anatomic relationships of the first part of the vestibular aqueduct to be quite
constant and the course of the second portion to be highly variable.
Figure 25
Sketch to demonstrate the probable
mechanical action of the utriculo-
endolymphatic valve. Its apparent
purpose is to maintain the fluid
volume and preserve the membranous
contours of the pars superior (utricle
and canals) (151).

Figure 26
In this ear, the utriculo-endolymphatic
(UE) valve is missing. The medical
records of this patient made no mention
of a vestibular disorder (male, age
3.5 mo). E—endolymphatic.
The isthmus (narrowest part) of the endolymphatic duct is about 1 mm

from the vestibular orifice and averages 0.3 mm in diameter (152). The total
length of the vestibular aqueduct is determined by the degree of peri-
labyrinthine and infralabyrinthine pneumatization (153).
The dimensions of the vestibular aqueduct render visualization of this
structure by radiologic methods technically feasible. In Ménière’s disease, there
is an increased incidence of nonvisualization of the vestibular aqueduct (154,
155). Arenberg et al. (153) believe that such nonvisualization is not caused by
anatomic obliteration of the vestibular aqueduct, but by technical or morpho-
logic factors. They found that ears with Ménière’s disease showed reduced peri-
aqueductal pneumatization and a higher incidence of a shortened vestibular
Figure 27
Between the endolymphatic duct
and the bony walls of the vestibular
aqueduct is a layer of loose fibrous
tissue. The epithelial lining varies from
simple squamous to low columnar. The
paravestibular canaliculi carry blood
vessels which supply the endolym-
phatic duct and sac (female, age 40 yr).

aqueduct, which ran straighter and closer to the posterior canal than in ears
without Ménière’s disease. In association with the reduced periaqueductal
pneumatization, they also noted an increased incidence of an anteriorly located
sigmoid sinus and a superiorly located jugular bulb. The surgeon performing
drainage procedures on the endolymphatic sac should keep in mind that it may
be more inferiorly located in ears with Ménière’s disease than in normal ears.
The lining epithelium of the endolymphatic duct, as well as that of the
saccular and utricular ducts, is either simple squamous or low cuboidal;
subepithelially, there is a continuous basement membrane and loose connec-
tive tissue with sparse capillaries. From electron microscopic observations
(156) in both guinea pig and man, the morphologic characteristics of the cells
lining the endolymphatic duct suggest a functional role in water and solute
absorption from endolymph.
The Endolymphatic Sac
Externally, approximately 10 mm posterolateral to the porus of the internal

auditory canal and 10 mm inferior to the superior petrosal sulcus, the vestibu-
lar aqueduct expands to accommodate the terminal enlargement of the
endolymphatic duct, the endolymphatic sac. The sac lies on the posterior sur-
face of the petrous pyramid in a slight depression termed the foveate impres-
sion (77) or the endolymphatic fossette (157); here it is partially covered by a
scale of bone, the operculum. It is not simply an epithelially lined pocket, but
a network of interconnected ducts and sacs (Fig. 28). It is closely related to the
Figure 28
A graphic reconstruction of the endolymphatic
sac shows it to consist of a series of intercon-
nected saccules and channels. Source: Courtesy
of Anson et al. (188).

Figure 29
Shown here is the proximal part of the
endolymphatic sac. The paravestibular
canaliculus carries its nutrient vascular
supply (male, age 50 yr). Figure 30
shows a high-power view of the
outlined area.
lateral venous sinus and the posteromedial cell tract. In an electron micro-
scopic study, Lundquist (158) divided the endolymphatic sac into three parts:
(1) a proximal part located within the vestibular aqueduct and lined by
cuboidal epithelium on a loose connective tissue with numerous
capillaries,
(2) an intermediate or rugose part located partially within the vestibular
aqueduct and partially between layers of dura mater outside the
vestibular aqueduct, and
(3) a distal part adjacent to the sigmoid sinus, resting completely within
layers of dura mater (Figs. 29–34).
Figure 30
This high-power view of the outlined
area in Figure 29 shows the cuboidal,
epithelial lining of the proximal part of
the endolymphatic sac (male, age 50 yr).

Figure 31
In the rugose portion of the endolym-
phatic sac, the lining epithelium is
irregularly folded into papillae and
crypts, which probably reflects an
increased metabolic activity of this
region (male, age 50 yr). See Figure 32
for a high-power view of the outlined
area.
The intermediate portion of the endolymphatic sac has a highly differ-

entiated epithelium consisting of tall cylindrical cells irregularly dispersed
into papillae and crypts, which uniformly possess microvilli and pinocytotic
vesicles; it seems to be primarily engaged in pinocytotic activity (159, 160).
The subepithelial connective tissue is areolar with a rich capillary supply;
deep to the epithelium the connective tissue assumes a more fibrous charac-
ter as it merges with the endosteum of the surrounding bone or with the
dura. In the distal portion, the epithelial cell height decreases, so that at its
distal extreme only duct-like cuboidal cells are found, and the walls are
Figure 32
This high-power view of the outlined
area in Figure 31 shows the convoluted
architecture of the lining epithelium of
the rugose portion of the endolym-
phatic sac (male, age 50 yr).

Figure 33
The lining epithelium of the rugose
portion of the endolymphatic sac. Its
papillary projections result in islands
of epithelium surrounding connective
tissue cores (female, age 50 yr).
approximated. In this area, the subepithelial connective tissue has an

extensive capillary meshwork, and as the sigmoid sinus is approached, the
connective tissue gradually merges with that surrounding the sinus.
Anson and Donaldson (4) divide the sac into a proximal portion
(segments 1 and 2 of Lundquist) and a distal portion.
The portion of the sac that extends beyond the operculum is variable
and is determined by the degree of pneumatization of the petrous bone. A
long subosteal and a short intradural apportionment is associated with rich
pneumatization, and conversely (155).
Figure 34
The irregular contour of the rugose
portion of the endolymphatic sac is
seen in this photomicrograph (female,
age 16 yr).

The lumen of the endolymphatic sac normally contains a mixture of
cellular debris, free-floating macrophages, and a variety of blood cells,
predominantly leukocytes. Thus, one function of the sac appears to be
phagocytosis, acting as an arm of local immunodefense (156).
The arterial supply of the vestibular aqueduct and its contents is from
a branch of the posterior meningeal artery and a branch of the internal audi-
tory artery. Venous drainage is supplied by the vein of the vestibular aque-
duct (see below). Lymphatics in the perisaccular connective tissue were first
described by Arnvig (161). Rask-Andersen et al. (156) also identified lym-
phatic channels in association with the endolymphatic duct, and they
believed that these vessels, which seemed to drain directly into the vein of
the vestibular aqueduct, played a role in the resorptive function of the
endolymphatic duct.
The Paravestibular Canaliculi (Aqueducts)
The vestibular aqueduct is accompanied by the paravestibular canaliculi

(Fig. 35), of which there are usually two. The main channel, first described
by Cotunnius (Cotugno) in 1761, originates in the vestibule superior and
medial to the aperture of the vestibular aqueduct; it houses an important
vein as well as a small artery and loose connective tissue. In its intracranial
appearance, the vein of the vestibular aqueduct is found adjacent to the infe-
rior aspect of the cranial orifice of the vestibular aqueduct. In this position,
it is well removed from the site of surgical procedures on the endolymphatic
sac and internal auditory canal.
According to Mazzoni (162), the course of this vein, which drains much
of the vestibular labyrinth and part of the basal turn of the cochlea, may be
divided into three segments: (1) The first segment begins as the vein enters the
bony paravestibular canaliculus to travel dorsally. In this segment, it parallels
the vestibule and is cranial to the vestibular aqueduct. (2) The second segment
sweeps dorsally and inferiorly, leaving the labyrinthine capsule and coursing
through the retrolabyrinthine cell tract, first superior, then inferomedial, and
Figure 35
This view shows the vestibular aque-
duct and its contained endolymphatic
duct, as well as the accompanying
paravestibular canaliculi (female,
age 78 yr).

finally anteromedial to the aqueduct. (3) The third segment lies within the
dura mater, where it ramifies in proximity to the endolymphatic sac and ter-
minates either in the inferior petrosal sinus or in the jugular bulb. The
canaliculus enlarges as it runs from the vestibular aperture to the posterior cra-
nial fossa, with average diameters increasing from 0.095 mm (163) to 0.3 mm
(164) as it receives tributaries from the bone, dura, and the endolymphatic sac
(162). There is some controversy as to the course of this paravestibular aque-
duct. Sando et al. (163) found that in 80% of the temporal bones there were two
vestibular orifices instead of one as reported by Mazzoni (162). Ogura and
Clemis (164) and Stahle and Wilbrand (165) found that in 70% of cases the
paravestibular canaliculus merged with the vestibular aqueduct before
reaching the posterior cranial fossa.
THE PERILYMPHATIC SYSTEM
The Perilymphatic Labyrinth
The perilymphatic labyrinth consists of fluid-filled spaces interposed

between the membranous labyrinth and the bony labyrinth. Its components
include the vestibule (periotic cistern), the scalae tympani and vestibuli, the
perilymphatic spaces of the semicircular canals, the periotic duct contained
within the cochlear aqueduct, the cul-de-sac of the scala tympani, and the
space around the proximal portion of the endolymphatic sinus and duct.
The remnants of the primordial reticulum are represented by scattered
strands of fine connective tissue which traverse the perilymphatic spaces to
the membranous walls of the utricle, saccule, semicircular ducts, and to a
lesser extent the cochlear duct, often in association with small blood vessels.
The scala vestibuli is an extension of the vestibule along the anterior
surface of the cochlear duct (Fig. 36). It is bordered by a mesenchymal
Figure 36
This view demonstrates the normal
relationship of the vestibule with the
scala vestibuli of the basal turn (male,
age 3 days).

epithelium which, with the epithelium of the anterior wall of the cochlear
duct, forms Reissner’s membrane. The scala vestibuli communicates with
the scala tympani at the helicotrema.
The scala tympani is identical to the scala vestibuli in structure, but
rests on the posterior side of the cochlear duct and osseous spiral lamina.
From its union with the scala vestibuli at the helicotrema, it coils basalward
to the round window. The anterior wall of the scala tympani contributes to
the formation of the basilar membrane. The perilymph of the scala tympani
communicates directly with the fluid surrounding the organ of Corti
through small openings in the osseous spiral lamina known as canaliculae
perforantes (17).
At the opening of the vestibular aqueduct, the contained endolym-
phatic duct is sheathed by a short extension of the periotic labyrinth.
The Cochlear Aqueduct and Periotic Duct
The cochlear aqueduct (or canaliculus) traverses the petrous pyramid from
the scala tympani of the basal turn of the cochlea, close to the round window
membrane (Figs. 37 and 38), to an external, funnel-shaped aperture on the
inferior surface of the petrous pyramid at the anterior division of the jugular
foramen. Specialized, loose connective tissue and fluid, constituting the peri-
otic duct, fill the aqueduct and connect the scala tympani with the subarach-
noid space. The length of the aqueduct varies considerably, ranging from 6.2
to 12.9 mm in different studies, mainly because of variance in choice of meas-
urement points (166–170). Its narrowest point, or isthmus, generally is
located in the otic capsule.
The tissue of the periotic duct, as studied in the guinea pig by transmis-
sion electron microscopy, consists of two primary types of cells (171): (1) The
lining cells are spindle-shaped and extend from the tympanic ostium to the
external infundibulum as a continuous layer up to three strata in thickness.
Figure 37
This ear has a large patent cochlear
aqueduct. The contralateral cochlear
aqueduct is also widely patent. The
singular canal transmits the posterior
ampullary nerve (female, age 85 yr).

Figure 38
The inferior cochlear vein runs in the
canal of Cotugno, or the first accessory
canal (179). It is formed by the union of
the vestibulocochlear and common
modiolar veins and empties into the
inferior petrosal sinus (female, age
76 yr).
(2) The reticular cells form a loose, cellular network throughout the entirety
of the ductal lumen, and possess numerous pores as well as interdigitating
cytoplasmic processes which increase their surface area and equip them for
a fluid exchange function. Macrophages and erythrocytes are found among
the reticular cells. The cellular elements are supported in a meshwork of con-
nective tissue fibers. At the tympanic ostium, the reticular cells of the aque-
duct extend to the round window membrane, while the lining cells merge
imperceptibly with the endosteum of the scala tympani.
Waltner (172) described a “barrier membrane” occluding the cochlear
opening of the aqueduct, but subsequent studies (169, 173–175) have refuted
this claim. The lumen of the aqueduct is irregular, with bony excrescences
(176) as well as corpora amylacea. These latter structures were first described
by Waltner (177), who felt that they presented an impedance to cerebrospinal
fluid flow. Later studies (169, 176) documented that corpora amylacea could
be found throughout the lumen of the cochlear aqueduct, especially at its
cranial end. Palva and Dammert in 1969 demonstrated that the preponder-
ance of corpora amylacea were composed of degenerated and contracted
arachnoid cells and fibers impregnated with calcium salts and precipitates.
There was no evidence, however, to indicate that these structures impeded
fluid exchange between perilymph and cerebrospinal fluid.
The cranial aperture of the cochlear aqueduct is a flattened funnel that
is anatomically adjacent to the trunk of the glossopharyngeal nerve.
Extending into the aperture are dura and arachnoid membranes contiguous
with the cranial meninges.
The patency and the function of the cochlear aqueduct have been the
focus of multiple investigations (Figs. 39 and 40). Palva and Dammert (169),
in a histologic study of human temporal bones, concluded that it serves as a
channel for exchange of fluids between the perilymphatic and subarachnoid
spaces. The adaptation of the reticular cells for fluid exchange would facili-
tate such a flow. Moreover, the meshwork of the lumen could also serve to

Figure 39
A large patent cochlear aqueduct, as
the one shown here, is unusual (male,
age 67 yr). The condition is probably
responsible for the outflow of perilym-
phatic fluid (and cerebrospinal fluid)
which occasionally occurs upon fenes-
trating the footplate of the stapes dur-
ing surgical procedures. The clinical
vernacular is “perilymph oozer.”
dampen sudden pressure variations between the cerebrospinal fluid and

perilymph. Foreign particle transport studies (173), in conjunction with the
microscopic visualization of macrophages and erythrocytes within the con-
nective tissue meshwork, support the concept that the duct passes particu-
late matter as well as fluid between the perilymph and cerebrospinal fluid.
It has been conjectured by surgeons that the outflow of cerebrospinal
fluid that occasionally occurs when the oval window is opened, particularly
in ears with congenital hearing losses, is the result of large patent cochlear
aqueducts. This explanation seems reasonable for mild outflows, commonly
Figure 40
The cranial end of the cochlear aqueduct
may show a flared enlargement (male,
age 69 yr).

Figure 41
The cochlea of this 2.5-yr-old child
with congenital conductive hearing
loss shows a developmental defect in
the modiolus of the basal turn resulting
in a wide confluence between the sub-
arachnoid space of the internal audi-
tory canal and the scala vestibuli of the
basal turn. The stapes is fixed. In such
cases, fenestrating the footplate of the
stapes during surgical procedures
results in a voluminous outpouring of
perilymph and cerebrospinal fluid.
The clinical vernacular is “perilymph
gusher.”
referred to as “perilymph oozers.” It is doubtful, however, that voluminous

outflows, known as “perilymph gushers,” could be accounted for on this
basis. Defects in the modiolus have been suspected as the basis for this phe-
nomenon (18) and such defects have been demonstrated (Fig. 41) (178).
There are two accessory canals (179) which course in close association
with the cochlear aqueduct. The first accessory canal shelters the inferior
cochlear vein and exits the scala tympani adjacent to the cochlear aqueduct.
The vein empties into either the inferior petrosal sinus or the jugular bulb.
This bony canal is eponymically referred to as the “canal of Cotugno” (or
Cotunnio), named for the Neapolitan anatomist who originally described it
in 1761. Less constant is the second accessory canal which transmits a vein
from the tympanic cavity and eventually joins the canal of Cotugno (175).
THE INTERNAL AUDITORY CANAL
The internal auditory canal is a bony, neurovascular channel providing a

tunnel for the facial, cochlear and vestibular nerves, the nervus intermedius,
and the labyrinthine artery and vein from the posterior cranial fossa into the
petrous bone. It has three distinguishable regions: (1) the porus (meatus) or
inlet, located on the posterior surface of the temporal bone, (2) the canal
proper, and (3) the fundus, abutting upon the medial aspect of the labyrinth.
The dura and arachnoid membranes of the internal auditory canal extend to
the lamina cribrosa which marks the lateral boundary of the fundus. The fal-
ciform (transverse) crest, a transverse ridge of bone, divides the lamina
cribrosa into upper and lower compartments and provides an attachment
site for the dura. The upper compartment is further divided into anterior
(containing the facial nerve and nervus intermedius) and posterior (contain-
ing the superior vestibular nerve) quadrants by the vertical crest. In the

Figure 42
The fundus of the internal auditory
canal is compartmentalized by the
vertical and transverse crests. Source:
After Anson and Donaldson (4).
lower compartment, the cochlear nerve courses in the anterior quadrant,

while the inferior vestibular nerve occupies the posterior quadrant (Fig. 42).
The term “semilunar lip” is used clinically to denote the combined infe-
rior, superior, and posterior margins of the porus. Neoplasms arising within
the internal auditory canal often erode this lip, thus widening the porus and
canal as well as shortening the length of the floor, roof, and posterior wall.
Embryologically, the ossification of the fundus and the adjacent walls
of the internal auditory canal are intimately related with that of the otic cap-
sule; this establishes the constant relationship of structures of the inner ear
to the internal auditory canal.
Variations in size and degree of pneumatization of the encasing
petrous bone have an impact upon the size, shape, and orientation of the
internal auditory canal. X-ray studies by Carnelis, as cited by Portmann et al.
(180), show that the axis of the internal auditory canal makes an 80° to 90°
angle with the sagittal plane in 58% of ears, and 91° to 100° in 37% of ears.
There is great variability in both the vertical and horizontal diameters of the
internal auditory canal. A study by Pérez Olivares and Schuknecht (181)
showed horizontal diameter measurements ranging from 2.5 to 5.26 mm,
with a mean of 3.68 mm, and vertical diameter measurements of 2.0 to
5.8 mm, with an average of 3.72 mm. The average length of the internal audi-
tory canal is 8 mm (180), but large variations occur (Fig. 43). In each individ-
ual, there is relative constancy in the diameter of the paired internal auditory
canals; differences of more than 2 mm are considered to be abnormal.
However, there may be interaural differences in internal auditory canal
length of some 6 mm. Portmann et al. (180) believe that this relative con-
stancy of the diameter of the canal reflects the constancy of the volume of the
contained neurovascular bundle for a particular individual. The variable
length of the internal auditory canal is in great part determined by the
degree of pneumatization of the temporal bone. The internal auditory canal
is usually uniformly cylindrical, although variations of 1 to 2 mm in the hori-
zontal and vertical dimensions can occur. Thus, one may see funnel-shaped
canals with a smaller diameter at either the medial or lateral aspects of the
canal, or canals presenting a central hourglass-like narrowing.

Figure 43
The internal auditory canal in this ear
measures 12 mm in length (normal:
8 mm), which is considered to be a
normal anatomic variant (female, age
90 yr).
A common anatomic variant is a localized area of widening (cupping)

in the anterior wall of the canal (Figs. 44 and 45).
The exposure of the internal auditory canal and its contents by way of a
middle cranial fossa approach, popularized by House (182), has been success-
fully used for removal of small vestibular schwannomata, for vestibular
and/or cochlear nerve section, and for facial nerve decompression. This
approach to the internal auditory canal demands a thorough knowledge of the
normal anatomy as well as of the typical variations one may encounter. In the
House (182) approach, once the squamosal craniotomy has been performed,
the middle meningeal artery entering the cranium via the foramen spinosum
is the first intracranial landmark to be identified; it forms the anterior limit of
dissection. Further dural elevation is carried out to expose the arcuate emi-
nence posteriorly and the superior petrosal sinus medially. The greater super-
ficial petrosal nerve, a crucial landmark in the localization of the internal audi-
tory canal, is next identified and dural elevation proceeds posteriorly, parallel
to its course. The geniculate ganglion serves as a reference point for further
dissection. The facial nerve is medial to the geniculate ganglion, while the
superior canal is posteromedial to it. The exposure of the internal auditory
canal is achieved by drilling in the area between the superior canal and the
basal turn of the cochlea just medial to the geniculate ganglion. Medial dissec-
tion follows the facial nerve up to the ridge of the superior petrosal sinus
corresponding to the superior lip of the porus acousticus. This dissection is
facilitated by the anteromedial divergence of the internal auditory canal from
the superior canal, which widens the surgical field.
Suggestions have appeared in the literature that a narrow internal
auditory canal may cause sensorineural hearing loss and vertigo, and that
surgical decompression of the canal is an appropriate therapy (183). Pérez
Olivares and Schuknecht (181) studied 144 temporal bone specimens from
subjects with a history of slowly progressive sensorineural hearing loss and
found a distribution of canal dimensions similar to that of normals; they also

Figure 44
The internal auditory canal measures
7.5 mm in length, which is considered
to be normal. The cupping at its ante-
rior aspect is an occasional occurrence
that may create a diagnostic dilemma
on imaging studies. The pathologically
thin replacement membrane is the
result of a healed perforation. As a
result, the manubrium is medially dis-
placed because of lessened opposition
to the traction of the tensor tympani
muscle (male, age 46 yr).
reported the absence of any soft tissue lesions which could have caused a
canal narrowing. Hence, they believe that radiologic documentation of a
small internal auditory canal is merely coincidental to, and not causative of,
cochlear and/or vestibular peripheral symptomatology.
Parisier (184) conducted a temporal bone study, utilizing both dis-
sected and serially sectioned specimens, to examine the variations in
anatomic landmarks used in the middle cranial fossa approach. He found
that those structures which were of otic placode derivation and encased in
Figure 45
The temporal bone of a 66-yr-old man
shows anterior cupping of the middle
portion of the internal auditory canal
(IAC) occurring as an anatomic variant.

enchondral bone (for instance, the cochlea, superior canal, and facial nerve
at the area nervi facialis) demonstrated relatively little variability in
anatomic relationships. In contrast, neural and vascular structures showed a
considerable degree of variability, both with respect to each other as well as
to inner ear landmarks.
Fisch (185) has modified the House (182) approach to the internal audi-
tory canal, using the arcuate eminence as his primary reference point; how-
ever, as noted by Parisier (184), the prominence as well as its relationship to
the superior canal is quite variable, depending upon the pattern and degree
of temporal bone pneumatization. According to Fisch, the superior canal
forms a 60° angle with respect to the superior vestibular nerve; he uses this
fact to locate the posterior margin of the internal auditory canal. Parisier
noted considerable variability in this relationship.

Chapter 6
Neuroanatomy
THE FACIAL NERVE
The Functional Components
The facial nerve is the nerve of the second branchial arch, and as such
innervates structures derived from Reichert’s cartilage (see “Embryology,”
chap. 9). Five populations of fibers contribute to the facial nerve trunk (189,
190): (1) special visceral efferent fibers, which supply the striated muscles of
facial expression, the stapedius muscle, the stylohyoid muscle, and the
posterior belly of the digastric muscle; (2) general visceral efferent fibers (pre-
ganglionic secretory fibers) which are distributed to the lacrimal and sero-
mucinous glands of the nasal cavity via the greater superficial petrosal nerve
(see also Nervus Intermedius, p. 187) and to the submaxillary and sublingual
glands through the chorda tympani nerve; (3) special sensory fibers for taste
from the anterior two-thirds of the tongue through the chorda tympani
nerve and from the tonsillar fossae and palate via the greater superficial
petrosal nerve; (4) somatic sensory fibers supplying the external auditory canal
and adjacent conchal region, as well as conveying proprioceptive informa-
tion from the facial muscles; and (5) visceral afferent fibers serving the mucosa
of the nose, pharynx, and palate. Three nuclei supply the fibers to the facial
nerve: (1) The motor nucleus is located in the caudal aspect of the pons. Its
superior part, which supplies the frontal and orbicularis oculi muscles,
receives both crossed and uncrossed fibers from the precentral gyrus (motor
cortex). The inferior part of the facial motor nucleus receives only homolat-
eral, uncrossed cortical information to innervate the remainder of the facial
musculature, save for the levator palpebrae superioris. The blink reflex and
stapedius reflex are mediated through internuclear connections in the
medulla oblongata (191). (2) The superior salivatory nucleus is situated dorsal
to the motor nucleus and carries parasympathetic secretory stimuli to the
submaxillary, sublingual, lacrimal, nasal, and palatine glands. (3) The
nucleus of the solitary tract which is located in the medulla oblongata receives
the taste, proprioceptive, and cutaneous sensory fibers of the facial nerve.
The origins of the motor roots and sensory roots (nervus intermedius)
are located at the inferior border of the pons; there, in a recess between the
inferior cerebellar penduncle and the olive, the motor root lies medially with
respect to the nervus intermedius and the acoustic nerve lies laterally. A
schema of the distribution of the motor, taste, and parasympathetic fibers is
seen in Figure 1.
171
Figure 1
Schematic diagram of the facial
nerve illustrating the distri-
bution of motor ( ), taste
( ) and parasympathetic
( ) fibers (255).
THE NORMAL COURSE IN THE TEMPORAL BONE
The combined sensory and autonomic components of the facial nerve are
separated from the motor component distally as far as the geniculate gan-
glion into the nervus intermedius (see p. 187) and motor trunk. Distal to the
geniculate ganglion, the sensory component is segregated into a discrete
bundle within the trunks of the facial nerve. The question as to whether
there is a topographical organization in the facial nerve has been argued pos-
itively (192–194) and negatively (195, 196), but the issue appears finally to
have been resolved by Gacek and Radpour (197). Using an anterograde
degeneration technique in combination with selective lesions of the facial
nerve in cats, they could find no topographic segregation of the motor fibers.
The course of the facial nerve may be divided anatomically into five
segments:
(1) The first or intracranial segment of the facial nerve spans the 23 to 24 mm
between its origin at the pons and the internal auditory canal, cradled in a
groove on the superior surface of the cochlear nerve. The nervus inter-
medius parallels the facial nerve and joins it in a spiraling fashion in the
fundus of the internal auditory canal (198).
(2) The second or internal auditory canal segment is 7 to 8 mm in length. The
facial nerve maintains its superior position relative to the cochlear nerve and
passes above the transverse (falciform) crest to enter the fallopian canal at
the area nervi facialis.
(3) The third, labyrinthine (intratemporal) segment (Fig. 2), is the shortest at only
3 to 4 mm. It begins at the area nervi facialis and heads anteriorly
and laterally, running superior to the cochlea and vestibule and nearly perpen-
dicular to the petrous pyramid, until it reaches the geniculate ganglion. The
geniculate ganglion houses the cell bodies serving both the sensory (taste)

Figure 2
This vertical section shows the labyrinthine
segment of the facial nerve. In this region the
nerve is susceptible to injury by transverse
fractures of the temporal bone (male, age 71 yr).
fibers of the chorda tympani nerve and the greater superficial petrosal nerve,
and the preganglionic secretory fibers for the sphenopalatine ganglion.
Ganglion cells serving pain reception are also believed to be within the genicu-
late ganglion (199) and are held responsible for the pain of petrosal neuralgia.
In a topographic study, Dobozi (200) consistently found that the geniculate gan-
glion, which appears triangular in the horizontal plane of sectioning, averaged
1.09 mm in length, 0.76 mm in width, and 0.6 to 0.8 mm in height, showing
little variability among the specimens examined. Ultrastructural studies of the
guinea pig geniculate ganglion (201) have demonstrated two types of ganglion
cells: light cells and smaller dark cells. However, the exact functional signifi-
cance of these two types of cells remains obscure. The anterior limit of the
geniculate ganglion lies in close relation to the middle cranial fossa, from which
it is usually separated by a bony plate; however, it may lie free in a bony dehis-
cence in the floor of the middle cranial fossa (see the section on The Facial
Hiatus, p. 184). Distal to the geniculate ganglion, the facial nerve turns abruptly
posteriorly, forming the first genu of the facial nerve (Figs. 3–5). The bony
CHAPTER 6: NEUROANATOMY ■ 173

Figure 3
In approximately 5% of cases (230), the
genu of the facial nerve lies dehiscent
in the middle cranial fossa (female, age
16 yr).
fallopian canal, dubbed with a misnomer of “aqueductus” by Gabriele

Falloppio [cited by Politzer (202)] because it reminded him of a water pipe,
courses about 30 mm from the area nervi facialis to the stylomastoid foramen.
Not only is this bony canal riddled with multiple deficiencies in its walls (see
the section on Dehiscences of the Facial Nerve, p. 179), but also it can act as a
strangulating tunnel in the presence of facial nerve edema and facial palsy.
(4) The fourth or tympanic segment parallels the longitudinal axis of the
petrous pyramid, running posteriorly and laterally on the medial wall of the
Figure 4
In this ear the germ of the facial nerve
lies deeply buried in the petrous bone
far from the dura of the middle cranial
fossa. The greater superficial petrosal
nerve channels anteriorly through bone
to emerge from a small facial hiatus

Figure 5
The genu of the facial nerve normally
lies in the medial wall of the epitympa-
num and is protected by a bony cover-
ing. There is an otosclerotic focus
partly surrounding the labyrinthine
segment of the nerve (male, age 62 yr).
tympanic cavity between the lateral canal superiorly and the oval window
inferiorly for 12 to 13 mm. At the sinus tympani the nerve turns inferiorly.
This second genu marks the beginning of the mastoid segment.
(5) The fifth or mastoid segment carries the nerve vertically downward in the
posterior wall of the tympanic cavity and the anterior wall of the mastoid,
a distance of 15 to 20 mm, to the nerve’s egress from the skull at the stylo-
mastoid foramen.
Ogawa and Sando (203) studied the relative cross-sectional area of the
facial nerve with respect to its canal in histologic preparations of 18 normal
temporal bone specimens. They found that in its labyrinthine and tympanic
segments the nerve occupied, on the average, somewhat more than 45% of
the canal, whereas in the mastoid segment the figure was 32%.
ABNORMAL COURSES IN THE TEMPORAL BONE
The otologic surgeon must be aware of the various anomalous courses of the
facial nerve. Working in bone with a high-speed cutting bur, the surgeon
must develop a technique which will allow for an unexpected encounter
with the nerve without injury to it.
There are numerous examples of cases in which the facial nerve
pursues an anomalous course through the petrous bone (191, 204–212). The
most common example is that in which the main nerve trunk runs anterior
and inferior to the oval window (213, 214). Rarely, the nerve pursues a
course anterior to both the oval window and the round window (215, 216).
The infant lacks a true mastoid process and possesses only a rudimen-
tary tympanic ring, leaving the facial nerve vulnerable to injury at the stylo-
mastoid foramen. In subsequent development, the nerve becomes more
secluded by the medial migration of the stylomastoid foramen dictated by
the growth of the tympanic ring and mastoid.

Figure 6
The sketch shows the second genu of
the facial nerve more posteriorly
located than usual. After Miehlke (256).
Dehiscences in the bony canal also render the facial nerve potentially
vulnerable to surgical injury. The mastoid segment of the nerve may be
displaced several millimeters posteriorly and/or laterally (Fig. 6). There are
cases of bi- or even tri-partition of the nerve in which the individual
branches course to their separate points of exit from the skull, each in its own
canal (Figs. 7–9). The nerve may pass anterosuperiorly to the cochlea rather
than posterosuperiorly as it normally does (Figs. 10 and 11). In its mastoid
segment it may swerve more posteriorly than normal (Fig. 12).
Figure 7
The mastoid segment of the facial
nerve in this ear has divided into three
separate bundles, each of which exits
separately from the temporal bone

Figure 8
The sketch demonstrates tripartition of
the facial nerve distal to the second
genu. Compare to Figure 7. Source:
After Miehlke (256).
Figure 9
The sketch demonstrates bifurcation of
the facial nerve. Source: After Miehlke
(256).

Figure 10
The facial nerve may pass anterior to
the cochlea as shown here. The nerve
may also course between the oval and
round windows or over the promon-
tory just anterior to both windows.
Source: After Miehlke (256).
Figure 11
In this ear the facial nerve in its
labyrinthine segment takes an aberrant
course anterosuperior to the cochlea
(male, age 56 yr).

Figure 12
The sketch demonstrates the facial
nerve coursing in the mastoid far
posterior to its normal location. Source:
After Miehlke (256).
Other anomalous courses are more generally associated with aural

malformations, such as an hypoplastic facial nerve passing through the
obturator foramen of the stapes (217).
Litton et al. (218) studied the anatomic relationship of the facial nerve
in adults with respect to the tympanic annulus and noted great variability in
the course of the facial nerve through its tympanic and mastoid segments. It
is to be remembered that the tympanic annulus in the adult is not in the
sagittal plane, but rather is directed anteriorly and inferiorly. The usual
location of the facial nerve is 1.4 mm posterior and 2.3 mm medial to the
posterosuperior part of the tympanic annulus. The descending segment of
the facial nerve is consistently located posterior to the posteroinferior
margin of the tympanic annulus. The facial canal, as it heads laterally and
inferiorly, crosses the plane of the tympanic annulus in its lower one-half.
DEHISCENCES OF THE FACIAL NERVE
The facial nerve passes through the temporal bone, protected throughout
most of its course by the bony sheath of the fallopian canal. Politzer (219)
described “congenital gaps in the facial canal.” As documented by Baxter
(220), it is not unusual for gaps to exist in the continuity of this bony sheath;
he found dehiscences of the fallopian canal, defined as non-pathologic gaps
of 0.4 mm or greater in diameter, in either the tympanic or mastoid segments
of the facial nerve in 55% of the temporal bones studied. Moreover, more than
one dehiscence was found in 22% of the ears examined. The most common
site of dehiscence of the bony canal involved the tympanic segment adjacent
to the oval window (Figs. 13–15), where the facial nerve normally overhangs
the oval window niche. The average width of the dehiscences was 0.92 mm
in the oval window region and 0.73 mm in the mastoid segment. Other

Figure 13
The most common area for dehiscence
of the facial nerve is in the region of the
oval window. In this case, the facial
nerve protrudes from the fallopian
canal and overlies part of the stapes
footplate (male, age 51 yr).
Figure 14
The facial nerve in its tympanic
segment is seen protruding from its
canal and encroaching on the oval win-
dow. This ear also shows the patho-
logic condition of endolymphatic
hydrops (female, age 68 yr).

Figure 15
The facial nerve protrudes from its
canal to overlie the footplate partially
and nearly abut a posteriorly located
cochleariform process (male, age 82 yr).
histologic studies of the temporal bone (221, 222) and other observations
(213, 223–226) also confirm that the oval window area of the canal is the most
common site for dehiscence. Dehiscences of the facial nerve may also be
found adjacent to the tensor tympani tendon, in the facial recess (Fig. 16), and
in the medial wall of the anterior epitympanic recess (Figs. 17 and 18).
Dehiscences in the bony covering of the facial nerve provide areas of
vulnerability to surgical injury. This risk is increased when the nerve bulges
out of the dehiscence, as sometimes occurs in the oval window area (Figs. 19
and 20) (227). It is possible that dehiscences predispose the facial nerve
to inflammatory disease of the middle ear. Facial palsy may occur as a
complication of acute otitis media.
Figure 16
In this ear there is a bony dehiscence of
the fallopian canal in the medial wall of
the facial recess (female, age 50 yr).

Figure 17
The anterior epitympanic recess
appears as a single large cell with the
facial nerve dehiscent of bone in its
medial wall. In many cases, as shown
here, the facial nerve trunk in both its
tympanic and labyrinthine segments is
composed of several bundles (female,
age 65 yr).
Figure 18
There is a bony dehiscence of the facial
nerve canal in the medial wall of the
anterior epitympanic recess. The nerve
bulges slightly into the recess (female,
age 72 yr).

Figure 19
This photograph of a partially
dissected temporal bone shows a
tumor-like herniation of the facial
nerve from the fallopian canal just
superior to the oval window (see
Fig. 20). Source: Courtesy of Johnsson
and Kingsley (227).
Figure 20
Same specimen as Figure 19, showing a
histologic cross section of the nerve
after it has been removed from the
facial canal. The entire nerve trunk
takes an omega-shaped course out of
its canal. Source: Courtesy of Johnsson
and Kingsley (227).

THE FACIAL HIATUS
The facial hiatus (hiatus canalis nervi petrosi majoris) is a dehiscence of

variable size present in the petrous part of the temporal bone in the floor of
the middle cranial fossa; it marks the entrance of the greater superficial
petrosal nerve into the middle cranial fossa. This nerve originates from the
geniculate ganglion, located on the anterior aspect of the genu of the facial
nerve. Usually the geniculate ganglion lies deep to the hiatus, in which case
the greater superficial petrosal nerve passes through a bony canal to reach
the hiatus. In some cases the geniculate ganglion lies under the dura (Fig. 21)
within the hiatus (228). According to Ge and Spector (229), at 15 weeks’
gestation the geniculate ganglion lies in a dural condensation superior to the
anterior part of the epitympanum, and the “primitive facial hiatus” provides
a route of communication between the middle cranial fossa and the middle
ear cavity. As the squamous part of the temporal bone develops, it separates
the geniculate ganglion from the epitympanic space. The superior surface of
the geniculate ganglion, however, is still dehiscent in the 35-week-old
embryo, and its perineural tissues are directly attached to the dura and
middle cranial fossa. This dehiscence may persist to a variable extent even
into adulthood. House and Crabtree (230) found that the geniculate ganglion
was exposed to the middle cranial fossa without a bony covering in 5% of
cases. Hall et al. (228) found a 15% incidence of partial or total exposure of
the geniculate ganglion to the middle cranial fossa in a study of 100 adult
temporal bones. Saito et al. (231) reviewed 400 temporal bones in the collec-
tion of the Massachusetts Eye and Ear Infirmary and found that in 9% of the
cases the facial hiatus measured more than 1.5 mm in its greatest dimension,
leaving the geniculate ganglion open to the middle cranial fossa.
Figure 21
The genu of the facial nerve lies under
the dura of the middle cranial fossa.
This ear does not have an anterior
epitympanic recess (female, age 79 yr).

Variations in the anatomy of the facial hiatus are of significance for two
reasons: (1) when the geniculate ganglion and facial nerve lie within the hiatus,
they are vulnerable to injury during surgical procedures involving the floor of
the middle cranial fossa, and (2) the facial hiatus is used as an anatomic land-
mark in the middle fossa approach to the internal auditory canal.
BRANCHES OF THE FACIAL NERVE
The facial nerve gives off three major branches in its course through the
temporal bone: (1) The first is the greater superficial petrosal nerve (Fig. 4),
which originates from the anterior aspect of the geniculate ganglion. It sur-
faces at the facial hiatus and enters the middle cranial fossa, from which this
mixed nerve of parasympathetic and sensory fibers courses anteriorly
toward the foramen lacerum. It unites with the sympathetic fibers of the
deep petrosal nerve to form the vidian nerve (nerve of the pterygoid canal).
Leaving its canal anteriorly, the vidian nerve passes through the ptery-
gopalatine fossa to enter the sphenopalatine ganglion. (2) The second branch
is the nerve to the stapedius muscle. It arises from the mastoid segment of the
facial nerve in the region of the pyramidal eminence. (3) The fibers of the
third branch, the chorda tympani nerve, are located in the sensory bundle of
the facial nerve trunk which occupies approximately 10% of its total cross-
sectional area (Fig. 22) (231). The sensory bundle (chorda tympani fibers)
occupies an anterolateral position in the tympanic segment and postero-
lateral position in the mastoid segment of the facial nerve before separating
from the facial nerve trunk. The nerve usually arises about 4 mm superior to
the stylomastoid foramen, although it may arise distal to the stylomastoid
foramen. The nerve follows a course which is phylogenetically determined;
it is the pretrematic branch of the second branchial arch, and connects the
Figure 22
In the mastoid segment the sensory
component of the facial nerve is located
in the posterolateral part of the nerve
trunk (male, age 62 yr).

Vth cranial nerve (the nerve of the first branchial arch) with the nerve of the
second branchial arch (the facial nerve). Thus it runs with the facial nerve in
the area derived from the second branchial arch and with the trigeminal
nerve (mandibular division) in the region derived from the first arch.
It follows a recurrent route superiorly in its own canal (the canaliculus
chordae tympani), and enters the tympanic cavity through an opening in the
posterior wall, the iter chordae posterius, at the horizontal level of the round
window and the cochlear aqueduct. Here it is accompanied by the posterior
tympanic artery. The iter chordae posterius generally lies between the pyram-
idal eminence and the tympanic annulus in the vertical plane. In its transtym-
panic course the chorda tympani nerve is housed in a fibrous sheath and
shrouded in a layer of mucous membrane. As it heads anteriorly, it lies
medial to the posterior malleal ligament (Fig. 23) and then passes lateral to
the long process of the incus and medial to the neck of the malleus,
suspended between these two ossicles. The chorda tympani nerve passes
from the neck of the malleus, in which it may occupy a groove (Fig. 24), thus
paralleling the anterior process of the malleus. The chorda tympani
nerve takes a direct route from the iter posterius to the iter anterius; stretch-
ing of this nerve by disease processes or surgical manipulation causes tempo-
rary loss of secretion of the submandibular gland and loss of taste on the
ipsilateral anterior two-thirds of the tongue (232, 233). The iter chordae
anterius (canal of Huguier) marks the exit of the chorda tympani nerve from
the tympanic cavity as it enters the petrotympanic (Glaserian) fissure; here
the nerve is accompanied by the anterior tympanic artery. The nerve then
exits the skull at the medial surface of the spina angularis of the sphenoid
bone; occasionally it occupies a groove in this spine—the groove of Lucas—
as it travels anteriorly to join the lingual nerve.
Figure 23
This photomicrograph illustrates the pre-
tympanic spine and its relationship to
the chorda tympani nerve. The posterior
malleal ligament is the thickened inferior
margin of the posterior malleal (mucosal)
fold. The posterior pouch of von Tröltsch
is located between the posterior
tympanic stria and the posterior malleal
ligament (female, age 72 yr).

Figure 24
The chorda tympani nerve frequently
passes in a sulcus on the medial surface
of the neck of the malleus at the base of
the anterior process. Prussak’s space is
located medial to Shrapnell’s mem-
brane (female, age 55 yr).
Variations in the anatomy of the chorda tympani nerve may also occur.
The chorda of the infant normally separates from the facial nerve beyond the
skull which it re-enters by its own canal, anterior to the stylomastoid
foramen. This separate canal may persist into adulthood (189). At the other
extreme, the chorda tympani nerve may exit from the facial nerve at the level
of the lateral canal (234). The chorda tympani nerve varies in size and, like
the facial nerve, it may be bipartite (206, 213). The chorda tympani nerve’s
point of entry into the middle ear cavity may be as much as 1 to 2 mm lateral
to the rim of the external auditory canal, and the nerve may pass laterally,
instead of medially, to the neck of the malleus (206, 213).
Variations in the location of the chorda tympani nerve are of signifi-
cance in transcanal surgery. In these procedures the posterior part of the
tympanic membrane is elevated and the adjacent bony tympanic annulus is
removed to expose the posterior mesotympanum. Section of the chorda
tympani nerve in some patients may cause symptoms of partial ageusia or
dysgeusia and dry mouth. Stretching of the nerve may also cause these
symptoms with partial recovery after some months (233).
THE NERVUS INTERMEDIUS
The sensory component of the facial nerve, known variously as the nervus
intermedius, the nerve of Wrisberg, or the glossopalatine nerve (189), con-
tains visceral afferent (taste) fibers and general visceral efferent (secretory)
fibers (Figs. 1 and 25).
Its efferent neurons lie in the superior salivatory nucleus, located
dorsomedial to the motor nucleus of the facial nerve. The chorda tympani
nerve and the greater superficial petrosal nerve, both branches of the nervus

Figure 25
The nervus intermedius is seen in the
posterior portion of the facial nerve
trunk in the internal auditory canal.
Part of this nerve continues beyond the
genu as the sensory bundle where it
assumes a lateral position within the
tympanic segment of the nerve trunk
(female, age 5 yr).
intermedius, carry these secretory fibers to the submaxillary and spheno-

palatine ganglia, respectively. The fibers from the submaxillary ganglion
innervate the submaxillary and sublingual glands, while those fibers from
the sphenopalatine ganglion supply the lacrimal gland and mucosal glands
of the nose and palate.
The neurons serving the sensory function of taste lie in the geniculate
ganglion; their fibers, which travel with the fibers of the tractus solitarius,
end in the nucleus of this tract. These fibers from the ipsilateral palatal and
pharyngeal mucosa travel in the greater superficial petrosal nerve, while
those from the ipsilateral anterior two-thirds of the tongue travel in the
chorda tympani nerve.
There also appears to be a somatic sensory component, serving the skin
of the external auditory canal by fibers which travel with the auricular
branch of the vagus (Arnold’s nerve); the facial nerve is linked to Arnold’s
nerve via branches which pass between the two nerves just before the facial
nerve leaves the stylomastoid foramen. The cell bodies are located in the
geniculate ganglion, and centrally their fibers end in the spinal tract of the
Vth cranial nerve (189).
Through histologic study of the temporal bones of two patients with
facial nerve lesions, Saito et al. (231) traced the course and the position of the
sensory nerve bundle within the facial nerve trunk. In the internal auditory
canal the nervus intermedius courses between the superior division of the
vestibular nerve and the facial nerve (Fig. 25). In the tympanic segment of
the facial nerve the sensory bundle is located dorsally, while in the vertical
segment it assumes a more lateral and posterior position. It finally exits ante-
riorly as the chorda tympani nerve.

THE VASCULAR SUPPLY OF THE FACIAL NERVE
The arterial supply of the facial nerve is derived from a variety of vessels as
it courses from the pons to the stylomastoid foramen. In its intracranial
segment it is supplied by the anterior inferior cerebellar artery and in its
internal auditory canal segment by the labyrinthine artery. The geniculate
ganglion is richly supplied by the superficial petrosal artery, a branch of the
middle meningeal artery. For the remainder of its course in the fallopian
canal, the nerve is supplied by the anastomosing branches of the superficial
petrosal and stylomastoid arteries (235).
The vascular supply of the facial nerve is not uniform throughout the
course of the nerve, nor does it occupy a constant proportion of the fallopian
canal. Ogawa and Sando (203) found that in the labyrinthine segment of the
facial nerve canal the vascular channels occupied 12% of the cross-sectional
area, while in the tympanic segment the figure was 63% and in the mastoid
segment 54%. A large vein is frequently present in the fallopian canal (Fig. 26).
The Sensory Nerves of the Middle Ear
Jacobson’s nerve is the eponymic name for the inferior tympanic nerve; it
arises from the inferior ganglion of the IX nerve which is located in the
petrosal fossula at the caroticotympanic spine. Referred pain in the ear
caused by pharyngeal disorders is mediated by this nerve. Like the chorda
tympani nerve, this is a pretrematic nerve, and serves to interconnect the
VIIth (facial) and IXth (glossopharyngeal) nerves of the second and third
branchial arches, respectively. Having gained access into the middle ear via
Figure 26
Occasionally a large vein accompanies
the facial nerve in the fallopian canal.
This vein may cause troublesome
bleeding during surgical procedures on
the facial nerve. A fibrous partition sep-
arates the fallopian canal from the com-
partment for the stapedius muscle
(male, age 40 yr).

Figure 27
Jacobson’s nerve (the inferior tympanic
nerve) emerges from the inferior tym-
panic canaliculus and then ascends the
promontory in a groove or tunnel to exit
into the superior tympanic canaliculus
in the region of the cochleariform
process (male, age 83 yr). (See Fig. 28.)
the inferior tympanic canaliculus, the tympanic nerve scales the medial wall
of the tympanic cavity and the promontory partly in a bony canal and partly
in a groove (Figs. 27 and 28). It innervates the eustachian tube as well as the
middle ear mucosa. At the level of the round window, the tympanic nerve is
joined by the caroticotympanic nerves (usually two) from the pericarotid
sympathetic plexus (236, 237). This union forms the lesser superficial pet-
rosal nerve (236, 238) which enters the superior tympanic canaliculus
beneath the cochleariform process; as it courses toward the middle cranial
fossa, it runs parallel to, and sometimes within, the semicanal for the tensor
tympani muscle (Figs. 29 and 30) (102).
Figure 28
This photomicrograph is a high power
view of the outlined area in Figure 27
(male, age 83 yr).

Figure 29
The internal carotid artery is
accompanied by both veins and
sympathetic nerves. Also seen is the
lesser superficial petrosal nerve (LSPN)
(male, age 5 yr). (See Fig. 30.)
Figure 30
This photomicrograph is a high power
view of the outlined area of Figure 29
showing a cluster of ganglion cells in
association with the lesser superficial
petrosal nerve (male, age 5 yr).

Immediately after its union with the caroticotympanic nerve, the
tympanic nerve may send a twig to a more superior level of the carotid canal
(Fig. 31). According to Montandon (personal communication), this branch is
synonymous with the lesser deeper petrosal nerve of Arnold (236) and the
superior caroticotympanic nerve (239, 240).
As the lesser superficial petrosal nerve passes by the geniculate
ganglion, it is joined by a small twig from the facial nerve (241) and sends
branches to the greater superficial petrosal nerve. The lesser superficial
petrosal nerve leaves the middle cranial fossa either through the foramen
ovale or through a channel of its own. It carries preganglionic parasympa-
thetic and postganglionic sympathetic fibers to the otic ganglion, where it
terminates.
The auricular branch of the vagus nerve is also known as Arnold’s
nerve. It is a composite of a large branch from the superior ganglion of the
vagus nerve and a small branch from the inferior ganglion of the glosso-
pharyngeal nerve (Fig. 31) (236). From its origin in the jugular foramen it
passes over the dome of the jugular bulb to the fallopian canal by way of
either the mastoid canaliculus or a groove in the inferior aspect of the
Figure 31
This sketch shows the nerves that are
anatomically related to the middle ear:
(1) vestibular nerve, (2) vestibular
(Scarpa’s) ganglion, (3) facial nerve, (4)
vestibulofacial anastomosis, (5) exten-
sion of the geniculate ganglion within
the labyrinthine segment of the facial
nerve, (6) geniculate ganglion and
genu of the facial nerve, (7) greater
superficial petrosal nerve, (8) branch
from the facial nerve to the lesser
superficial petrosal nerve, (9) tympanic
segment of the facial nerve, (10) area of
the second genu and beginning of the
mastoid segment of the facial nerve,
(11) nerve to the stapedius muscle, (12)
cutaneous branch from the facial nerve,
(13) chorda tympani nerve, (14) inferior
ganglion of the glossopharyngeal
nerve in the jugular foramen, (15) tym-
panic (Jacobson’s) nerve, (15b) junction
of caroticotympanic and tympanic
(Jacobson’s) nerve, (16) branch of the
tympanic nerve to the eustachian tube,
(17) caroticotympanic nerve, (18) external branch of the internal carotid nerve, (19) lesser superficial petrosal nerve, (20) branch
of the lesser superficial petrosal nerve to the facial canal, (21a) tympanic ganglia, (21b) ganglion associated with the lesser super-
ficial nerve, (21c) ganglion with sensory fibers of the facial canal, (22) branch of the tympanic plexus, (23) variably present twig
of the tympanic nerve to a superior level of the carotid canal (also known as the superior caroticotympanic nerve or the lesser
deeper petrosal nerve), (24) superior ganglion (nodosa) of the vagus (Xth cranial) nerve, (25) large vagus twig to Arnold’s nerve,
(26) small glossopharyngeal twig to Arnold’s nerve, (27) auricular branch of the vagus (Arnold’s) nerve, (28) inferior branch of
Arnold’s nerve for cutaneous innervation of the external auditory canal, (29) superior branch of Arnold’s nerve, (30) fibers from
the superior branch of Arnold’s nerve entering the facial nerve trunk, (31) fibers from the superior branch of Arnold’s nerve
ending in the sheath of the facial nerve, (32) nerve twig arising in the facial nerve and ending in the facial canal, (33) twig of
Arnold’s nerve ending in the facial recess of the middle ear (257).

temporal bone (67); in this passage the nerve divides into two branches. Its
superior branch emits multiple twigs which course superiorly and inferiorly
in the facial nerve sheath in which they appear to terminate. The inferior
branch of Arnold’s nerve receives a small slip from the facial nerve (the cuta-
neous branch) and traverses the tympanomastoid fissure to distribute its
somatic afferent fibers to the posterior surface of the external auditory canal
and adjacent conchal area (242). These fibers provide the pathway for the
herpetic involvement of the skin of the external auditory canal in herpes
zoster oticus (243). Also, the tickling sensation in the throat and the cough-
ing that is sometimes elicited by touching the skin of the ear canal is medi-
ated by Arnold’s nerve (the Alderman’s nerve).
Clusters of ganglion cells, as opposed to a distinct ganglion, may be
found scattered along the course of many of the nerves of the middle ear.
Ganglion cells in small groups of 2 to 10 cells are also frequently seen within
the trunk of the facial nerve central to the geniculate ganglion (Montandon,
personal communication) (244).
The ganglion cells which are located along the course of the tympanic
nerve on the promontory are collectively referred to as the tympanic plexus
(239, 240). The role of these ganglion cells is not known. The area of the
tympanic plexus, particularly anterior to the oval window, is highly sensi-
tive and painful to surgical manipulation.
There are also scattered ganglion cells along the course of the lesser
superficial petrosal nerve, a clustering of which forms a distinct ganglion at
the site of departure of the branch that courses to the facial nerve (Figs.
29–31) (245). At the point where this branch joins the facial nerve (horizontal
segment) there is another cluster of ganglion cells. Goycoolea et al. (246)
reported finding ganglion cells rot only in the medial portion of the tensor
tympani muscle, but also immediately proximal and lateral to the muscle
fibers.
The Vestibular Nerves
There are three major interneural connections worthy of emphasis: (1) Voit’s
anastomosis is a small branch which leaves the superior vestibular nerve to
supply the superior part of the macula of the saccule. (2) The vestibulofacial
anastomosis is a bundle of fibers uniting the superior division of the vestibu-
lar nerve and facial nerve (Fig. 32) (244). It has been suggested that these
fibers may be motor fibers of the facial nerve which have traveled with the
vestibular nerve for some distance and are returning to the facial nerve
trunk. This anastomosis may also transmit unmyelinated sympathetic fibers
to the vestibular ganglion from the periphery (247). (3) Oort’s anastomosis
(the vestibulocochlear anastomosis) is composed of efferent fibers (248)
reaching from the saccular branch of the inferior division of the vestibular
nerve to the cochlear nerve.
The innervation of the superior canal crista and the lateral canal crista
is derived, respectively, from the superior and lateral ampullary nerves,
which are branches of the superior division of the vestibular nerve. The
posterior ampullary nerve is a branch from the inferior division of the
vestibular nerve. It passes through the singular canal and may itself be
subdivided (Fig. 33).
Gacek (249) described a small accessory branch of the posterior
ampullary nerve located posterosuperior to the main nerve trunk which
innervates only the most posterior aspect of the crista of the posterior canal.

Figure 32
This view shows the vestibulofacial
anastomosis (male, age 70 yr).
Figure 33
In this case the posterior ampullary
nerve is comprised of three discrete
bundles. The pattern of division can be
quite variable (female, age 5 yr).

Subsequent reports (149, 250) have confirmed this finding. Okano et al. (251)
reviewed 223 human temporal bones for the purpose of mapping the
intratemporal path of this accessory branch of the posterior ampullary
nerve. In 87% of specimens examined, this accessory branch was present.
While it usually joins the main posterior ampullary nerve after a short dis-
tance, in 5.8% of the cases it pursued a solitary course all the way to the
ampulla of the posterior canal. Montandon et al. (149) proposed that this
accessory branch innervates the crista neglecta when that organ is present
(0.9% of human ears). When the crista neglecta is not present, the accessory
nerve innervates the crista of the posterior canal which has incorporated the
crista neglecta into its structure. Surgical attempts to achieve total denerva-
tion of the crista of the posterior canal by sectioning the posterior ampullary
nerve in the singular canal, as proposed by Gacek (37) for the treatment of
benign paroxysmal positional vertigo, would not be successful in cases
where the accessory nerve pursued a solitary course all the way to the crista.
The macula of the utricle is innervated by the utricular branch of the
superior division of the vestibular nerve. The innervation of the macula of
the saccule is of dual origin. The superior division of the vestibular nerve
gives off a small branch to the macula of the saccule (the anastomosis of
Voit); the majority of the macula of the saccule is innervated by the main
branch of the inferior division of the vestibular nerve.
The Cochlear Nerve
Only those aspects of cochlear and vestibular neuroanatomy which are

of practical consequence to the surgeon will be discussed in this section.
For details of light and electron microscopic neuroanatomy see Pathology of
the Ear (17).
The afferent cochlear nerve fibers all arise about the receptor hair cells
as unmyelinated nerve fibers which then pass through the osseous spiral lam-
ina to the modiolus where they acquire a myelin sheath and attain their orig-
inating cell body located in the spiral ganglion. The ganglion cells of the spi-
ral ganglion are bipolar neurons, the central processes of which, having
aggregated at the fundus of the internal auditory canal, traverse the internal
auditory canal in close relationship to the vestibular and facial nerves. The
VIIIth cranial nerve enters the brain stem caudal (approximately 5 mm) to the
Vth cranial nerve (198) and cephalad to the IXth, Xth, XIth root entry zone.
The efferent or descending cochlear pathways parallel those of the afferent.
The anatomic interrelationships of the cochlear nerve with the vestibular
nerve as they gradually merge, and with the facial nerve as the VIIth/VIIIth
nerve complex undergoes a 90° rotation in its journey through the internal
auditory canal, have attained new significance in the light of the popularization
of the retrolabyrinthine approach to these nerves. At the fundus of the internal
auditory canal (Fig. 42 in chap. 5) the superior vestibular and facial nerves
occupy the superior hemisphere, separated by the vertical crest; the cochlear
nerve and inferior vestibular nerve are located in the inferior hemisphere as
discrete entities. The superior vestibular and inferior vestibular nerves fuse just
proximal to the transverse crest (252). As one traces the VIIth/VIIIth nerve
complex medially in the internal auditory canal, the cochlear nerve migrates
posteriorly (as viewed from the postauricular approach) and unites with the
superior vestibular/inferior vestibular nerve trunk; conversely, the facial nerve
migrates anteriorly (Fig. 34). By the time the nerves have reached the porus of
the internal auditory canal, they have completed a 90° rotation; the cochlear

Figure 34
This highly diagrammatic sketch
shows the most common relationships
of the nerve trunks in the right cerebel-
lopontine angle and the internal
auditory canal (IAC) as viewed from
posteroinferiorly. The cleavage plane
between the Cochlear and vestibular
nerve trunks is evident at the porus of
the IAC in about 70% of dissected spec-
imens. At the brain stem the facial
nerve lies anterior to the cochlear and
vestibular nerves, but as it passes
peripherally it becomes intimately
related to the superior division of the
vestibular nerve. The close anatomic
relationship of the posterior canal and
the cochlea limits surgical access to the
internal auditory canal. Source: After
Silverstein (252).
nerve, however, always remains in a relatively inferior location with respect to

the facial and vestibular nerves (252).
In addition to the previously described rotation, the cochlear and
vestibular nerves, which exist as multiple discrete bundles at the fundus of
the internal auditory canal, gradually merge to form two major branches (the
cochlear and vestibular nerve trunks) which are separated by a septum at the
porus of the internal auditory canal. Histologic examination of this merger
(252, 253) shows great variability in the completeness of this divisional
septum, with some 20% of the cases lacking a discrete septal cleavage plane
(252). In such cases selective vestibular nerve section would seem to be
precluded; however, other features may be used to determine the
cochlear–vestibular nerve trunk interface. Firstly, the vestibular nerve trunk
appears gray when compared to the cochlear, due to differing amounts of
myelin in the two trunks; secondly, a small vessel which courses longitudi-
nally along the lateral aspect of the cochlear–vestibular nerve trunk interface
may be useful in selective sectioning (252, 254). In some specimens
[Brackmann, cited by Silverstein (252)], a cleavage plane may be more read-
ily detected at the medial, rather than the lateral, aspect of the nerve trunks;
additionally, the nervus intermedius frequently can be found coursing
adjacent to the cochlear-vestibular cleavage plane at its medial aspect. The
facial nerve, at the point where selective vestibular nerve section is carried
out, is located anteriorly and often is separated from the cochleovestibular
nerve by the lateral branch of the anterior inferior cerebellar artery; hence,
selective preservation of the facial nerve is readily accomplished.

Chapter 7
Vascular Anatomy
THE VASCULAR SUPPLY OF THE EXTERNAL AUDITORY CANAL AND PINNA
The blood supply to the auricle derives from branches of the external carotid
artery: the posterior auricular artery from the external carotid artery, the
anterior auricular artery from the superficial temporal artery, and the mas-
toid branch from the occipital artery. The supply of the external auditory
canal comes from the posterior auricular artery, the internal maxillary artery,
and the superficial temporal artery. The veins accompany the corresponding
arteries.
THE MAJOR ARTERIES
There are several major vessels which are intimately related to the temporal
bone and consequently of significance in otologic surgery. Prime among
these is the internal carotid artery. This vessel gains access to the petrous
bone through the carotid canal which is located medial to the styloid
process. It courses upward anterior to the middle ear and cochlea and then
turns abruptly forward and medially (the “knee” segment) (258) to pass
beneath the eustachian tube (Figs. 1 and 2). It then again ascends, leaving its
canal to enter the cranial cavity between the lingula and the petrosal process
of the sphenoid.
Throughout its petrous course, the internal carotid artery is housed in
a bony canal, the wall of which often measures less than 0.5 mm in thickness
(259), and which in approximately 1% of the cases (260) shows dehiscent
areas. The artery is surrounded in its canal by a venous plexus and by the
pericarotid sympathetic plexus derived from the ascending branch of the
superior cervical ganglion of the sympathetic trunk. As with major arteries
elsewhere, it may undergo atherosclerotic changes with consequent weaken-
ing of its arterial wall (Fig. 3).
Atherosclerotic change of the internal carotid artery with dilation and
thinning of the wall is a common occurrence in aged subjects. In some cases,
the arterial wall appears to be totally atrophied and its function replaced by
the bony wall of the carotid canal (Figs. 4 and 5). The surgical importance of
this observation is clear: opening the carotid canal of an aged patient could
lead to rupture of the artery.
Major anomalies of the petrous segment of the internal carotid artery
are rare. Absence or hypoplasia may occur infrequently (261). Lapayowker
et al. (262) reported aberrant positioning of an otherwise normal artery; in
his cases, as well as those reported by Goodman and Cohen (263), Glasscock
et al. (264), and Glasgold and Horrigan (265), the anomalous internal carotid
197
Figure 1
The relationship between the internal
carotid artery, eustachian tube, and
peritubal cells is shown. The carotid
canal bulges slightly into the protym-
panum (female, age 89 yr).
artery was located lateral and posterior to the “vestibular line” (on antero-
posterior radiographic projection, a vertical line passing through the lateral
aspect of the vestibule). The carotid normally is found medial to this line.
An anomalous location of the internal carotid artery or an aneurysm of
the artery may appear clinically as a pulsating mass behind the anterior part
of the tympanic membrane. A common symptom is pulsatile tinnitus. The
obvious clinical implication is that the mass should not be biopsied. The
diagnosis is readily made by angiography.
Figure 2
The transition from bony to cartilagi-
nous eustachian tube is seen here. In
this case the carotid canal bulges into
the protympanum (female, age 48 yr).

Figure 3
This internal carotid artery shows
severe atheromatous degeneration
with partial luminal occlusion. The
pericarotid sympathetic nerve plexus
and venous system travel in the carotid
canal with the artery (female, age
70 yr).
Aneurysms of congenital origin are believed to arise in areas where the

tunica media is occasionally deficient, such as at the site of obliterated
embryonic arteries or at points of bifurcation (261).
The middle meningeal and the accessory meningeal arteries which
arise from the internal maxillary branch of the external carotid artery are
occasionally seen in temporal bone specimens. They lie lateral to the facial
hiatus and the petrous apex (Fig. 6).
The anterior inferior cerebellar artery is frequently encountered in tem-
poral bone sections. Mazzoni (266) found that there was often an arterial loop
Figure 4
A common finding in older subjects is
stretching and dilation of the internal
carotid artery, bringing the arterial wall
into contact with the bone of the
carotid canal. In the areas of contact
there is severe atrophy of the arterial
wall (female, age 72 yr) (see Fig. 5 on
p. 200).
CHAPTER 7: VASCULAR ANATOMY ■ 199

Figure 5
A higher magnification of Figure 4
shows the atrophic changes in the wall
of the internal carotid artery (female,
age 72 yr).
within or near the internal auditory canal. In his review of 100 human tempo-
ral bone specimens, this arterial loop was either the main trunk or a branch
of the anterior inferior cerebellar artery in 80%, the accessory anterior cerebel-
lar artery in 17%, and a branch of the posterior inferior cerebellar artery in 3%.
In 40% the loop was located within the internal auditory canal, in 27% it was
at the meatus, and in 33% in the cerebellopontine angle (Figs. 7–11).
Figure 6
An accessory meningeal artery may
occasionally be seen in horizontal tem-
poral bone sections. It occupies a bony
canal lateral to the facial hiatus (female,
age 49 yr).

Figure 7
The anterior inferior cerebellar artery
(AICA) frequently loops deeply into
the internal auditory canal as shown
here (male, age 87 yr).
Blockage of the anterior inferior cerebellar artery causes necrosis of

labyrinthine and brain stem structures, but is rarely fatal. Disruption of the
anterior inferior cerebellar artery during surgical procedures in the internal
auditory canal or cerebellopontine angle may result in uncontrollable
bleeding.
Figure 8
The anterior inferior cerebellar artery is
seen in the internal auditory canal
(IAC) (female, age 96 yr).

THE MAJOR VEINS
The venous sinuses of the dura mater are low-pressure, valveless venous
channels which drain the temporal bone, orbit, and brain. They are located
between the two layers of the dura mater and are lined with an endothelium
which is a continuation of that which lines the tributary veins. Of special
relevance to temporal bone anatomy are the lateral sinus, the superior
petrosal sinus, and the inferior petrosal sinus.
The lateral sinuses provide the major venous drainage from the head to
the neck and are appropriately the largest of the sinuses. They begin at the
Figure 9
Here is another example of the anterior
inferior cerebellar artery (AICA) loop-
ing deeply into the internal auditory
canal (IAC). An incidental feature is an
otosclerotic focus at the anterior mar-
gin of the oval window (female, age
75 yr).
Figure 10
In this case the anterior inferior cerebel-
lar artery lies in a groove on the poste-
rior wall of the petrous bone and enters
the internal auditory canal (IAC) to
form a tortuous loop (male, age
unknown).

Figure 11
The anterior inferior cerebellar artery
extends deeply into the internal audi-
tory canal (IAC) (male, age 83 yr).
internal occipital protuberance as continuations of either the superior sagittal

sinus (usually on the right side) or of the straight sinus, and then course in the
attached margin of the tentorium cerebelli to the bases of the petrous bones.
Each lateral sinus heads medially and inferiorly in an S-shaped sulcus in the
mastoid bone (the sigmoid sulcus) to end in the internal jugular vein (Fig. 12).
The sigmoid part of the lateral venous sinus may bulge anteriorly into the
mastoid air cell system where it is vulnerable to surgical injury (Fig. 13). The
Figure 12
The relationship of the sigmoid part of
the lateral venous sinus to the mastoid
air cell system is shown. The posterior
canal produces a slight prominence on
the posterior wall of the petrous bone
(male, age 72 yr).

Figure 13
The sigmoid sinus is that portion of the
lateral venous sinus which occupies the
sigmoid sulcus. It may protrude deeply
into the posterior part of the mastoid
air cell system. The operculum overlies
the endolymphatic sac (female, age
75 yr).
intimate relationship of the lateral venous sinus to the mastoid also makes it
susceptible to thrombosis in severe mastoid infections. The position of the
sigmoid sinus in relation to the labyrinth is variable (Figs. 14–18) and, accord-
ing to Montgomery (267), anterior positioning of the sinus usually indicates
underdevelopment of the mastoid air cell system.
The superior petrosal sinus occupies the superior petrosal sulcus which
runs along the petrous ridge enveloped in the attached margin of the tento-
rium cerebelli. It links the cavernous sinus with the lateral sinus; among its
tributaries are veins from the tympanic cavity, cerebellar veins, and inferior
cerebral veins.
Figure 14
In this case the lateral venous sinus
heads toward the jugular bulb without
forming a sigmoid segment. It forms a
membranous party wall with the poste-
rior canal (male, age 54 yr) (see Fig. 15 on
p. 205).

Figure 15
High power view from Figure 14 show-
ing the membranous party wall
between the lateral venous sinus and
the posterior canal (male, age 54 yr).
The inferior petrosal sinus runs in the inferior petrosal sulcus at the
petro-occipital suture line and connects the cavernous sinus with the jugular
bulb. Its tributaries consist of the internal auditory veins and veins from the
pons, medulla, and inferior aspect of the cerebellum.
The petrosquamous sinus is variably present; it occupies the petros-
quamous junction and drains into the lateral sinus.
Emissary veins connect the extracranial veins with the cranial sinuses.
The mastoid emissary vein traverses the mastoid foramen and carries blood
from the occipital or posterior auricular vein to the lateral sinus. It may be
large and can be transected, causing troublesome bleeding during mastoid
surgical procedures as when soft tissues are elevated to expose the cortical
bone of the mastoid.
Figure 16
In this case the lateral sinus passes
directly to the jugular bulb without
forming a sigmoid segment. The
endolymphatic sac lies in close proxi-
mity to the sinus (male, age 56 yr).

Figure 17
The jugular bulb may fail to reach the
level of the hypotympanum (female,
age 78 yr).
Occasionally a large vein is seen within the fallopian canal, a condition

which may cause bleeding during explorative procedures on the facial nerve
(Fig. 19).
The internal jugular vein is a direct continuation of the lateral sinus. It
begins at the base of the skull in the jugular foramen where it is dilated and
is referred to as the jugular bulb; there is great variability in the dimensions
of the jugular bulb, but it averages 15 mm in width and 20 mm in height
(268). The right jugular bulb is usually somewhat larger than the left. In
Figure 18
In this ear the lateral venous sinus is
located in an anterior position near the
posterior canal and endolymphatic sac.
An unrelated finding is obliteration of
the round window niche by otosclero-
sis (female, age 82 yr).

Figure 19
The head of the malleus is in fibrous
contact with the tegmen tympani but is
not ankylosed to it. A large vein accom-
panies the facial nerve in the tympanic
segment of the fallopian canal (male,
age 70 yr).
keeping with the inconstancy of venous structures, it may appear high in the
middle ear, encroaching upon the tympanic annulus and round window
niche, in which case it may cause conductive hearing loss (269) (Figs. 20–22).
The bony shell may be variably dehiscent (Figs. 23–25), with reported
incidences of between 6% and 7% (268, 270).
Figure 20
The jugular bulb lies in its normal posi-
tion in the floor of the hypotympanum
with its bony wall intact (female, age
77 yr).

Figure 21
In this ear the jugular bulb extends
superiorly into the mesotympanum. It
rests against the tympanic membrane
and obliterates the round window
niche. No tests of auditory function are
available; however, a conductive hear-
ing loss would be expected (female,
age 68 yr).
A high jugular bulb is susceptible to injury during surgical procedures

in which the tympanic membrane is elevated from its sulcus. A high jugular
bulb diminishes the depth of the hypotympanic space, which may increase
the difficulty of establishing an aerated hypotympanum in tympanoplasty
surgery. On otoscopic examination a high jugular bulb may be mistaken for
a glomus body tumor.
Figure 22
In this ear the lateral venous sinus
and the jugular bulb are located
anteriorly. The mastoid is narrow

Figure 23
This case shows small dehiscences in
the bony wall of the jugular bulb (male,
age 45 yr).
Figure 24
This section depicts a superiorly located
jugular bulb impinging on the tympanic
annulus. A jugular bulb in this location
can be inadvertently opened during
surgical elevation of a tympanomeatal
flap (female, age 75 yr) (see Fig. 25 on
p. 210).

THE VASCULAR SUPPLY TO THE MIDDLE EAR
Nager and Nager (271), in an exhaustive study of serially sectioned human

temporal bones, elucidated the arterial supply of the middle ear and
mastoid. On the whole their findings corroborated those of other investiga-
tors who had used dye perfusion techniques (272–274).
The blood supply of the middle ear stems from: (1) the external carotid
artery by way of the ascending pharyngeal artery, the occipital artery
(directly and via its posterior auricular branch), and the internal maxillary
Figure 25
Here is a higher magnification of
Figure 24 showing the juxtaposition
of the jugular bulb to the tympanic
annulus (female, age 75 yr).
Figure 26
The branches and distribution of the
anterior tympanic artery are shown in
this sketch. Source: After Nager and
Nager (271).

Figure 27
This sketch shows the usual arterial
supply of the middle ear and mastoid
exclusive of the anterior tympanic and
deep auricular arteries. Source: After
Nager and Nager (271).
artery and its branches (the middle meningeal artery and accessory
meningeal artery), (2) the internal carotid artery, and (3) the basilar artery via
the subarcuate branch of the labyrinthine (internal auditory) artery.
From these three major sources stem the arteries which provide an
extensively anastomotic vascular network for the middle ear and mastoid
(Figs. 26 and 27). Those vessels which originate from the external carotid
artery are: (1) the anterior tympanic artery, (2) the deep auricular artery, (3)
the inferior tympanic artery, (4) the mastoid artery, (5) the stylomastoid
artery, (6) the superficial petrosal artery, (7) the superior tympanic artery,
and (8) the tubal artery.
The anterior tympanic artery (Fig. 26) arises from the mandibular seg-
ment of the internal maxillary artery and enters the petrotympanic
(Glaserian) fissure, where it divides into three major branches: (1) The supe-
rior branch gains access to the middle ear through a short canal on the
petrous side of the petrotympanic fissure; it supplies the mucosa and bone of
the anterior and lateral epitympanic wall and the anterolateral aspect of the
tegmen, as well as anastomosing with the superior tympanic artery through
a branch which traverses the petrosquamosal fissure. (2) The posterior branch
channels through the bone of the tympanic side of the petrotympanic fissure.
It supplies the bone and mucosa of the posterolateral epitympanic wall, the
lateral aspect of the tegmen tympani, and all but the medial wall of the adi-
tus; it also provides the arterial network of the long process of the incus,
lenticular process, incudostapedial articulation, and head of the stapes
(Fig. 28). Through anastomotic linkages, the posterior branch contributes to
the peripheral vascular ring of the tympanic membrane. With a branch from
the stylomastoid artery, it forms the descending artery in the mucosa on the
medial aspect of the manubrium and supplies the medial surface of the tym-
panic membrane. The posterior and superior branches of the anterior tym-
panic artery anastomose to form the vascular network of the mucosa of the
malleus and incus. (3) The ossicular branch (Fig. 26) enters the middle ear,
either with the chorda tympani nerve or through its own canal, and divides
to provide the two vessels which are the major blood supply for both the

Figure 28
The usual arterial distribution to the
lenticular process, incudostapedial
articulation, and stapes is depicted.
Source: After Anson et al. (290) and
Alberti (291).
malleus and the incus. The malleal branch travels in the mucosa of the lateral
malleal ligament and enters the malleus at the nutrient foramen, located in
the anterolateral region of its neck. It also supplies a twig to the lateral process
of the malleus and, variably, may anastomose with the incudal branch. Either
the ossicular artery or its malleal branch, depending upon the site of branch-
ing, sends a few twigs to nourish the anterior process of the malleus. The
incudal branch pursues a less constant course, but usually runs across the lat-
eral epitympanic wall in a mucosal fold to enter the incudal nutrient foramen,
located laterally on the body of the incus. Having traversed their respective
nutrient foramina, the malleal and incudal branches form complex vascular
networks which ramify throughout their respective ossicles.
The deep auricular artery also arises from the mandibular branch of the
internal maxillary artery, enters the temporal bone at the inferior aspect of
the bony external auditory canal, and there divides into an anterior and a
posterior branch. The anterior branch supplies the bone and skin of the ante-
rior part of the external auditory canal, the peripheral vascular ring of the
tympanic membrane, and the mucosa of the floor of the middle ear. The pos-
terior branch supplies the bone and skin of the posterior part of the external
auditory canal and the peripheral vascular ring of the tympanic membrane;
it variably forms a vascular loop above the umbo which supplies the inferior
part of the tympanic membrane.
The inferior tympanic artery (Fig. 27) stems from the ascending pharyn-
geal artery and traverses the inferior tympanic canaliculus in accompaniment
with Jacobson’s nerve to reach the anterior part of the floor of the middle ear.
It scales the promontory in a bony groove or canal, remaining anterior to the
round window. While on the promontory, it links with the caroticotympanic
arteries and then with the superior tympanic artery anterior to the oval
window. In conjunction with these vessels, it supplies the floor of the middle
ear, the promontory, the tympanic orifice of the eustachian tube, the antero-
inferior wall of the middle ear and the anterior part of the stapes.
The inferior tympanic artery plays a prominent role in providing blood
supply for glomus body tumors of the middle ear. Other arteries which may

supply this richly vascular neoplasm are branches of the stylomastoid artery,
the caroticotympanic arteries, and branches of the occipital artery. Carotid
arteriography not only shows the size and location of the neoplasm, but also
reveals the major feeding arteries.
The mastoid artery is a branch of the occipital artery and supplies the
vascular network of the posterior part of the mastoid bone.
The stylomastoid artery arises from the posterior auricular artery and
joins the facial nerve at the stylomastoid foramen to travel superiorly in the
fallopian canal; in its upward journey it gives off vessels which supply the
bone and mucosa of the mastoid region, the floor and inferoposterior wall of
the tympanic cavity, facial nerve fibers, the medial floor of the aditus,
and part of the peripheral tympanic vascular ring. The posterior tympanic
arteries are branches of the stylomastoid artery which supply the chorda
tympani nerve as far as the iter chordae posterius, at which point they
diverge to supply the posterior part of the vascular ring of the tympanic
membrane. The largest branch of the stylomastoid artery supplies the
stapedius muscle. The stylomastoid artery has anastomotic connections with
branches of the posterior meningeal artery at the area of the intersection of
Arnold’s nerve and the facial nerve; it also sends branches which pass in the
posterior malleal fold and join the posterior branch of the anterior tympanic
artery to form a descending artery. The stylomastoid artery terminates by
connecting with vessels from the superficial petrosal artery.
The superficial petrosal artery stems from the middle meningeal artery,
just superior to the latter’s entry into the cranial cavity via the foramen spin-
osum. It courses posterolaterally, sharing a groove in the middle cranial
fossa with the greater superficial petrosal nerve, and supplies vessels to the
dura as well as branches which anastomose with the subarcuate artery near
the subarcuate fossa. Just before reaching the facial hiatus the superficial pet-
rosal artery gives off an anastomotic branch to the adjacent superior tym-
panic artery and subsequently bifurcates. One of the resulting branches joins
the facial nerve at the geniculate ganglion and then also bifurcates. One of
these vessels supplies the facial nerve, the other heads medially to link with
the facial branch of the labyrinthine (internal auditory) artery. The other
major branch of the superficial petrosal artery skips the geniculate ganglion
and descends between the facial nerve and the bony wall of its canal, sup-
plying the bony labyrinth, the mucosa overlying the facial canal, and the
posterior part of the stapes; its termination is marked by its anastomosis
with the stylomastoid artery at the level of the oval window.
The superior tympanic artery also arises from the middle meningeal
artery immediately superior to the foramen spinosum, and passes postero-
laterally to enter the tympanic cavity with the lesser superficial petrosal
nerve via the superior tympanic canaliculus. While in its canalicular course,
the superior tympanic artery supplies the tensor tympani muscle, the medial
part of the roof and wall of the epitympanum, and occasionally the posterior
part of the stapes; it also anastomoses with the superior branch of the ante-
rior tympanic artery, the superficial petrosal artery, and the stylomastoid
artery. Emerging from its canaliculus, the superior tympanic artery descends
with the lesser superficial petrosal nerve in a sulcus on the promontory and
joins the inferior tympanic artery near the oval window; in this segment it
sends a vessel to the anterior part of the stapes.
The tubal artery is a branch of the accessory meningeal artery. It
courses in the wall of the eustachian tube and supplies the walls of the
tube in its tympanic segment as well as the mucosa of the anterior part of the
tympanic cavity and promontory. It terminates by anastomosing with
branches of the caroticotympanic arteries.

The caroticotympanic arteries, usually two in number, arise from the
internal carotid artery and are remnants of the embryonic hyoid artery (275).
They traverse the bone surrounding the carotid canal in separate canals and,
in the middle ear, travel in the mucosa of the promontory. Before joining the
inferior tympanic artery, the two caroticotympanic arteries supply the
anteromedial wall of the middle ear from the floor to the tubal orifice.
The subarcuate artery usually is a branch of the labyrinthine (internal
auditory) artery, but may originate from the anterior inferior cerebellar
artery or as multiple branches from one or both of these vessels (101). It
enters the petromastoid canal and almost immediately sends off a branch
which passes above the internal auditory canal to the petrous apex. As it
courses posterolaterally, it sends vessels which supply the canalicular region
of the bony labyrinth and the posterosuperior part of the wall of the
vestibule. The subarcuate artery anastomoses with the superficial petrosal
artery and the posterior meningeal artery; it terminates in the anteromedial
wall of the mastoid antrum, dividing into two branches. One of these
branches supplies the bone and mucosa of the anterior region of the mastoid
as it descends to anastomose with vessels from the stylomastoid artery.
The second terminal branch supplies the superomedial part of the mas-
toid antrum and the wall of the superior petrosal sinus; it occasionally anas-
tomoses with vessels from the mastoid branch of the occipital artery.
The persistent stapedial artery, first described by Hyrtl in 1836, repre-
sents the residua of the normal embryonic hyoid artery (see embryology of
the stapedial artery, chap. 9). Its incidence has been reported to be between
1 in 5000 and 1 in 10,000 ears (261, 276). The persistent stapedial artery inter-
feres with access to the oval window in reconstructive middle ear surgery
(277). It arises from the internal carotid artery and passes through the floor
of the middle ear to reach the posterior part of the promontory, where it
ascends in a bony canal. It then passes through the obturator foramen of the
stapes (Figs. 29 and 30) to enter the fallopian canal via a dehiscence near the
cochleariform process. The artery soon leaves the fallopian canal by its own
Figure 29
The persistent stapedial artery is seen
as it ascends through the intercrural
space (the obturator foramen) (female,
age 75 yr).

Figure 30
This view shows the histologic detail of
a persistent stapedial artery (male, age
84 yr) (see Fig. 31).
opening to pass anteriorly and superiorly in the middle cranial fossa (278)
(Fig. 31). The small artery that is frequently seen crossing the footplate in the
vertical direction is not a persistent stapedial artery, but a branch from the
adjacent tympanic or facial nerve arterial plexuses.
Aberrant branching of the stapedial artery may result in a stapedial
anomaly. Steffen (261) described a three-legged stapes which he suggests may
be due to the stapedial artery giving rise to its supraorbital division
(see embryology, chap. 9, p. 270), or another branch at the site of the stapes. This
supposition is based on the idea that the stapedial obturator foramen is a result
of the passage of the stapedial artery through the embryonic, solid stapes.
Figure 31
The persistent stapedial artery passes
superiorly and anteriorly within the
tympanic segment of the fallopian
canal (male, age 84 yr). Same case as
shown in Figure 30.

THE VASCULAR SUPPLY TO THE INNER EAR
Arteries
The blood supply of the membranous labyrinth (Fig. 32) is predominantly

derived from the labyrinthine (internal auditory) artery. This vessel usually
arises as a branch of the anterior inferior cerebellar artery within the cranial
cavity, but may stem as an independent branch of the basilar artery. Thus,
the membranous labyrinth derives its arterial supply primarily from
intracranial sources. It may not be entirely separated from the vasculature of
the bony labyrinth and middle ear, however, for anastomotic branches
which penetrate the endosteal layer of the bony labyrinth have been
reported (271). The labyrinthine artery first supplies the nerves and dura of
the internal auditory canal, the bone contiguous to the internal auditory
canal, and the medial region of the inner ear. It then divides into two major
branches, the common cochlear artery and the anterior vestibular artery
(279). The common cochlear artery divides to form the main cochlear and
vestibulocochlear branches. Division of the vestibulocochlear artery results
in the posterior vestibular artery and the cochlear ramus (280–285).
The main cochlear artery supplies the superior three-fourths of the
cochlea and modiolus. As it enters the modiolus it sends out numerous pri-
mary and secondary arteries (Fig. 33). Further arborization of the cochlear
artery gives rise to two sets of radiating arterioles; one set supplies the struc-
tures of the outer wall of the cochlea, the other supplies the inner wall (286).
The external radiating arterioles curl about the scala vestibuli in the
intracochlear partition and distribute vessels to the walls of the scala
vestibuli. Upon entering the apex of the spiral ligament, these vessels form
four capillary networks: (1) the spiraling vessels located in that region of the
spiral ligament which faces the scala vestibuli (vessels at Reissner’s
membrane, vessels of the scala vestibuli), (2) the capillary network of the
Figure 32
The arterial system of the human mem-
branous labyrinth is shown.

Figure 33
The arterial supply and venous
drainage of the cochlea are shown.
Source: After Smith (286, 292).
stria vascularis, (3) the vessel of the spiral prominence, and (4) the vessels
within the spiral ligament on the scala tympani side of the basilar crest.
These latter vessels possess the morphologic characteristics of capillaries but
function as collecting venules.
Although the capillary network of the stria vascularis is a tortuous
anastomotic network traveling in a spiral path, its boundaries are relatively
straight and parallel (117). An abnormally large artery in the stria vascularis
of a subject who complained of pulsatile tinnitus is shown in Figure 34 (287).
The vessel of the spiral prominence generally receives a branch
from each radiating arteriole and, although this vessel follows a spiral path
Figure 34
There is a large artery in the stria vascu-
laris of the apical turn of the left cochlea.
In both apical and basal directions this
artery bifurcates and progressively
dwindles to fuse with the capillary bed
of the stria vascularis. The patient com-
plained of pulsatile tinnitus in this ear
(male, age 77 yr) (287).

paralleling that of the network of the stria vascularis, there are no intercon-
nections between the two.
The internal radiating arterioles of the cochlear artery remain within
the modiolus, supplying branches to the spiral ganglion as they course
toward the base of the cochlea. They enter the vestibular lamina of the
osseous spiral lamina, giving rise to the limbus vessels and the marginal
vessels (288). The marginal vessels constitute two groups of independent
arcades which serve as both arterial and venous channels—one group forms
the vessel of the basilar membrane while the other comprises the vessel of
the tympanic lip. Occasionally a vessel traverses a scala (Fig. 35).
The cochlear ramus of the vestibulocochlear artery supplies the basal
one-fourth of the cochlea and adjacent modiolus, while the posterior
vestibular branch supplies the macula of the saccule, the crista and membra-
nous canal of the posterior canal, and the inferior walls of the utricle and
saccule The artenolar ramifications are identical to those of the anterior
vestibular artery.
The anterior vestibular artery supplies the entirety of the macula of the
utricle, a small portion of the macula of the saccule, and the superior walls of
both the utricle and saccule. The arterioles enter the stroma of the maculae
along with the myelinated nerve fibers, and establish an extensive capillary
network below the hair cell areas. The anterior vestibular artery also sends
arterioles to the cristae and membranous ducts of the superior and lateral
canals (Figs. 36 and 37). These arterioles enter the ampullae via osseous
channels distinct from those of the nerve fibers. The capillary networks of
the ampullary cristae and ampullary walls are supplied by several aerioles.
Arteriolar ramification establishes capillary networks between the sensory
epithelium and nerve fibers near the midline of each crista. Each canal is tra-
versed throughout its length by one or two arterioles which sustain a system
of loosely connected capillaries.
Figure 35
In this cochlea an arteriole traverses
the mid-portion of the scala tympani of
the basal turn (male, age 8 mo).

Figure 36
The ampulla, crista, nerve, and vessel
of the lateral canal are demonstrated.
The artery is the ampullary branch of
the anterior vestibular artery. The out-
lined area is enlarged in Figure 37
Veins
The primary venous drainage of the cochlea is afforded by the anterior and
posterior spiral veins (Figs. 38 and 39). The anterior spiral vein receives trib-
utaries from the spiral lamina and scala vestibuli. The posterior spiral vein
collects venous blood from the scala tympani, the outer wall of the scala
media, and the spiral ganglion. There are several shunts from the anterior to
the posterior spiral vein as they pass to the basal end of the cochlea where
they join to form the common modiolar vein.
Figure 37
The outlined area in Figure 36 is
magnified to show the ampullary
branch of the anterior vestibular artery

Figure 38
This schematic drawing shows the
venous drainage of the human mem-
branous labyrinth.
The utricle as well as the ampullae of the superior and lateral canals are
drained by the anterior vestibular vein (289). The posterior vestibular vein
receives blood from the saccule, the ampulla of the posterior canal, and the
basal end of the cochlea. The vein of the round window joins with the con-
fluence of the anterior and posterior vestibular veins to form the vestibulo-
cochlear vein. The latter vessel unites with the common modiolar vein to
become the inferior cochlear vein; it then traverses the bony canal of
Cotugno (Cotunnio), located near the cochlear aqueduct, to empty into the
inferior petrosal sinus. The membranous ducts are drained by channels
Figure 39
The venous drainage of the cochlea is
provided by the anterior and posterior
spiral veins which join near the basal
end to form the common modiolar vein

which course toward their nonampullated ends to form the vein of the
vestibular aqueduct; this vessel travels within the vestibular aqueduct or a
paravestibular canaliculus to drain into the lateral venous sinus. A variably
present vessel is the internal auditory vein (274). When present, it collects
blood from the apical and middle turns of the cochlea and drains into the
inferior petrosal sinus via the internal auditory canal.

Chapter 8
Stereoscopic Views of the Temporal Bone
SURGICAL DISSECTION OF THE TEMPORAL BONE
Familiarity with the macroscopic anatomy of the temporal bone can be

acquired by dissection of the fresh cadaver specimen with the aid of the
operating microscope and appropriate surgical instruments. The following
photographs (Figs. 1–28) present a logical approach to the step-by-step
dissection of a right temporal bone. The sequence of dissection has relevancy
for transmastoid surgical procedures only. It does not apply to transcanal
procedures such as exploratory tympanotomy, stapedotomy, transcanal
labyrinthectomy, ossiculoplasty, myringoplasty, etc. An organized sequence
of dissection enables the maximum educational yield to be obtained from
each specimen. The views are presented in surgical orientation with the
anterior aspect of the ear located superiorly in the photographs.
In order to appreciate the three-dimensional effect, it is important to
concentrate on the paired images and have them fully your field of
vision. In addition, the plane of your eyes must remain parallel to the plane
of the page. Then “defocus” your eyes and allow the images to fuse.
Alternatively, looking “through” or “beyond” the images without focusing
on them enables perception of the three-dimensional effect. We believe that
these stereo views will facilitate the comprehension of ear anatomy in its
three-dimensional aspect, and aid in understanding of the two-dimensional
photographs in this book.
223
Figure 1
After the postauricular incision has been made,
the muscle and periosteum are elevated to
expose the mastoid cortex. The mastoid fossa
and spine of Henle are identified. The latter
landmark limits the anterior dissection in an
intact canal wall procedure.
Figure 2
Initial drilling is done in the mastoid fossa
which overlies the mastoid antrum. Large cut-
ting burs are preferable at this stage, where bone
removal is carried superiorly to identify the
mastoid tegman and posteriorly to identify the
eminence of the sigmoid sinus.

Figure 3
Koerner’s septum, when present, is a plate of
bone that extends downward from the mastoid
tegmen for a variable distance. It represents the
junction of the petrous and squamous portions
of the mastoid. In this specimen it hides the
lateral canal.
Figure 4
Once Koerner’s septum has been removed, the
prominence of the lateral canal is visualized. It is
important to saucerize the edges to avoid
obscuring the view by the bony margins of the
mastoid cavity.
CHAPTER 8: STEREOSCOPIC VIEWS OF THE TEMPORAL BONE ■ 225

Figure 5
The mastoid tip is divided into medial and
lateral compartments by the digastric ridge. The
anterior portion of this ridge is located near the
mastoid segment of the facial nerve.
Figure 6
The bony wall of the lateral venous sinus
(sigmoid sinus) is seen as a protuberance of the
posterior wall of the mastoid cavity, passing
anteroinferiorly towards the jugular bulb. The
sinodural angle represents the junction of the
tegmen (roof) of the mastoid and the lateral
venous sinus.

Figure 7
As bone is exenterated superiorly and anteriorly
from the antrum toward the epitympanum, the
incus comes into view. If one places a small
amount of fluid in the epitympanum, light
refraction will often reveal the position of the
incus before it is exposed to direct view. It is
important to avoid striking the ossicles with the
rotating bur, to prevent acoustic trauma.
Figure 8
With diamond burs, the posterior fossa dura and
endolymphatic sac have been decorticated. The
endolymphatic sac has been opened and a tube
placed within its lumen. Note the anatomic rela-
tionship of the endolymphatic sac and the lateral
venous (sigmoid) sinus. Surgical procedures to
drain the endolymphatic sac into either the sub-
arachnoid space or mastoid cavity are known as
endolymphatic sacotomy operations. Donaldson’s
line is a posterior extension of the plane of the
lateral canal bisecting the posterior canal; the
endolymphatic sac lies inferior to this line.

Figure 9
The bone of the posterior canal has been thinned
to create a blue line. The blueness is the result of
light resorption (instead of reflection) at the site
of the thinned bony wall.
Figure 10
The extent of the mastoid exenteration shown
here is known as a simple mastoidectomy. The bone
of the lateral canal has been thinned to create a
blue line.

Figure 11
The facial nerve has been partly uncovered by removing
bone with the largest diamond bur that can comfortably
be accommodated to avoid the risk of impaling the
facial nerve. Drilling is done parallel, not perpendicular,
to the expected course of the facial nerve, and liberal
irrigation is used. Exposing the trunk of the facial nerve
throughout its course is known as facial nerve exploration.
The facial recess, lateral to the facial nerve, is opened by
drilling with a small diamond bur, inferior to the short
process of the incus and lateral to the plane of the facial
nerve. The chorda tympani nerve is lateral and inferior
to the facial recess. This surgical approach to the middle
ear is known as a posterior tympanotomy and is frequently
used with intact canal wall procedures.
Figure 12
Removal of epitympanic bone exposes the body of
the incus and head of the malleus. This surgical
approach is known as posterior atticotomy. The epi-
tympanum is divided into medial and lateral
compartments by these ossicles. The posterior incu-
dal ligament is seen.

Figure 13
The posterior tympanotomy has been extended
by sacrifice of the chorda tympani nerve
to expose the round window niche and
hypotympanum. This approach is also used for
insertion of cochlear implants. While creating the
cochleostomy (the opening into the cochlea), the
bur should be held at such an angle as to avoid
contact with the facial nerve lying medially.
Figure 14
A blue line has been made on the superior canal.
Making blue lines is not part of any surgical
procedure, but as a dissection exercise it
improves drilling skills and knowledge of the
anatomic relationships of the canals to adjacent
structures.

Figure 15
This overall view shows the anatomic relation-
ships between the semicircular canals, facial
nerve, ossicles, mastoid cavity, and middle ear.
The exenteration, approximately as shown, is
known as intact-canal-wall tympanomastoidectomy.
Figure 16
The posterior wall of the external auditory canal
(EAC) has been removed, exposing the tym-
panic membrane and the anterior wall of the
EAC. The subarcuate cell tract is evident, and
the posterosuperior cell tract has been opened.
The jugular bulb will be found medial to the
facial nerve, and may rise as high as the level of
the posterior canal.

Figure 17
The skin of the external auditory canal (EAC)
has been elevated as a laterally based, pedicled
flap in preparation for thinning the anterior wall
to reduce its convexity. Overzealous bone
removal can allow posterior prolapse of the soft
tissue contents of the temporomandibular joint.
Figure 18
The convexity of the anterior wall of the external
auditory canal has been removed to afford easy
surgical access to the anterior aspect of the mid-
dle ear. The dissection shown here, exclusive of
the facial nerve exposure, is the approximate
extent of a modified radical (Bondy) mastoidectomy
in which diseased tissue is removed from the
mastoid and middle ear but the ossicles and
tympanic membrane, or what remains of them,
are left undisturbed.

Figure 19
This is a high power view of the middle ear area
seen in Figure 18.
Figure 20
The tympanic membrane, including its annulus,
has been removed to expose the anterior part of
the mesotympanum, the protympanum, and the
tympanic orifice of the eustachian tube.

Figure 21
This view is the same as that shown in Figure 20,
but at a lower magnification.
Figure 22
The tensor tympani tendon is severed with scis-
sors preparatory to removal of the malleus. The
tympanic sulcus can be seen.

Figure 23
The malleus and incus have been removed,
revealing the cochleariform process and tensor
tympani tendon. The anterior part of the lateral
epitympanic wall and adjacent canal wall have
been drilled away, opening the anterior epitym-
panum widely into the mesotympanum. The
exenteration to this stage (exclusive of the facial
nerve exposure) is approximately that of a radical
mastoidectomy.
Figure 24
The facial nerve has been lifted from its canal.
During the surgical removal of extensive
cholesteatomas or neoplasms, it may be neces-
sary to remove the nerve from its canal either
temporarily or permanently, a procedure known
as transposition of the facial nerve. The greater
superficial petrosal nerve is visible as it exits
anteriorly from the geniculate ganglion.

Figure 25
The internal carotid artery has been exposed by
removing overlying bone with a diamond bur.
The jugular bulb is seen in the hypotympanum.
Figure 26
The semicircular canals have been opened.
Mid-size diamond burs work well here, and
have less of a tendency to “skip” than do cutting
burs.

Figure 27
Surgical removal of the semicircular canals leads
to the vestibule and internal auditory canal
(IAC). This procedure is known as the
translabyrinthine approach to the internal auditory
canal and is used for removal of neoplasms of
the canal and cerebellopontine angle. Sectioning
of the greater superficial petrosal nerve allows
for posterior displacement of the facial nerve
along with removal of the cochlea, as in the
transcochlear approach to lesions located anterior
to the internal auditory canal.
Figure 28
The tensor tympani muscle and cochleariform
process have been removed. The underlying
basal and middle turns of the cochlea have been
opened to expose the scalae and osseous spiral
lamina.

PATHOLOGIC CONDITIONS OF THE TEMPORAL BONE
With few exceptions, this text is limited to the presentation of normal

anatomy and its variants. However, one of the reasons for learning normal
anatomy is to develop the ability to recognize the abnormal. The photographs
(Figs. 29–35) which accompany several different pathologic entities. The
photographs were taken from horizontal sections of celloidin-embedded
temporal bones.
Figure 29
Vestibular schwannoma (acoustic neurinoma).
This person had an 18-yr history of left-sided
hearing loss and tinnitis; there was no history of
vertigo or dysequilibrium. In the left ear there is
a large vestibular schwannoma fully occupying
the widened internal auditory canal. The
cochlear and vestibular nerves are displaced
inferiorly. There is a fibrinous precipitate in the
endolymphatic and perilymphatic spaces (male,
age 81 yr).

Figure 30
Sarcoma of the temporal bone. At age 24 the patient
developed right serous otitis and was treated by a
ventilation tube in the tympanic membrane. At age 26
she experienced multiple cranial nerve palsies and
right hemiparesis. Physical examination showed a
tumor mass in the inferior part of the middle ear
which biopsy proved to be a chondromyxosarcoma.
She died 12 days after attempted surgical removal.
The petrous apex was destroyed by the neoplasm;
the tumor infiltrated the mesotympanum, hypotym-
panum, and infralabyrinthine regions. Compression
of the eustachian tube caused serous otitis media and
pressure occlusion of the internal carotid artery for
the hemiparesis (female, age 27 yr).
Figure 31
Perforation of the tympanic membrane. There is a
large posteroinferior perforation of the tympanic
membrane with fibrous thickening of the anterior
and inferior margins. The manubrium is medially
displaced, presumably by the unopposed pull of
the tensor tympani muscle. The inferior part of
the external auditory canal (EAC) contains a
plug of dried exudate and epithelial debris (male,
age 69 yr).

Figure 32
Radical mastoidectomy cavity. A surgical proce-
dure including right modified radical mastoidec-
tomy was performed for squamous cell
carcinoma at age 71 yr. The mastoid bowl con-
tains desquamated keratin on a lining of squa-
mous epithelium. The patient died of unrelated
causes 9 yr after surgery (male, age 80 yr).
Figure 33
Purulent otitis media, meningitis, and labyrinthi-
tis. This infant had repeated bouts of pneumonia
and succumbed to acute pneumococcal meningi-
tis at the age of 17 mo. The precipitate in the mid-
dle ear is purulent fluid (otitis media). The cloudy
fluid in all three turns of the perilymphatic scalae
as well as in the vestibule and canals is character-
istic of bacterial labyrinthitis; the precipitate
around the nerve trunks in the internal auditory
canal is the purulent cerebrospinal fluid of
meningitis (male, age 17 mo).

Figure 34
Stapedectomy for otosclerosis. At the age of 45
this woman underwent right total stapedectomy
followed by the implantation of a “fat-wire”
prosthesis. She had an excellent hearing gain
which persisted to the time of death 13 yr later.
There is a large vascular otosclerotic focus
anterior to the oval window. The hook of the
prosthesis is well attached to the long process of
the incus. Its medial end extends to the posterior
margin of the oval window instead of to the
ideal central location (female, age 58 yr).
Figure 35
Exostoses. These bony excrescences of the
external auditory canal (EAC) are usually caused
by refrigeration periostitis associated with swim-
ming in cold water (male, age 80 yr).

OPERATIVE VIEWS
Surgery epitomizes applied anatomy. These operative views (Figs. 36–49)

accompany disease entities encountered at various stages of surgery. All
photographs are taken from the surgeon’s view, thus the anterior aspect of
the ear is located superiorly in the photographs.
Figure 36
This photograph shows the operative field dur-
ing a simple mastoidectomy on the right ear. In
this procedure the mastoid is exenterated but
the external auditory canal and middle ear are
not entered (male, age 7 yr).

Figure 37
This photograph was taken during the course of
a tympanomastoidectomy on the right ear for
chronic otitis media and cholesteatoma. The
incus has been resorbed and the head of the
malleus is surrounded by cholesteatoma. There
is a perforation of the posterior half of the tym-
panic membrane (male, age 29 yr).
Figure 38
Same case as Figure 44. A cholesteatoma is seen
in the middle ear and mastoid of this right ear.
The incus and crural arch are absent and the
malleus is enveloped by the cholesteatoma. As
the operation proceeds, the posterior wall of the
external auditory canal will be completely
removed to gain access to the middle ear. The
epitympanum has yet to be fully exteriorized
(male, age 16 yr).

Figure 39
The photograph shows the tympanomastoid
compartment of the left ear after surgical exen-
teration and removal of diseased tissues prior to
reconstructive procedures (female, age 55 yr).
TM–tympanic membrane. (See Fig. 40.)
Figure 40
Same ear as Figure 39. A temporalis fascia graft
has been introduced to bridge the tympanic
space. The graft is placed in contact with
the head of the stapes (female, age 55 yr). This
operation is a type III tympanoplasty.

Figure 41
This photograph was taken during tympa-
nomastoidectomy on the right ear. The mastoid
has been exenterated of diseased tissue and the
posterior wall of the external auditory canal has
been partially removed. Thick granular mucous
membrane can be seen in the epitympanum
surrounding the ossicles. An aural polyp
protrudes from a hidden perforation in the tym-
panic membrane (male, age 39 yr).
Figure 42
This photograph was taken during an intact-
canal-wall tympanoplasty on the left ear. The
skin of the posterior wall of the external audi-
tory canal (EAC) has been elevated from the
bony canal wall and displaced anteriorly along
with the tympanic membrane to provide access
to the middle ear (male, age 24 yr).

Figure 43
This view shows an extensive surgical exentera-
tion of the tympanomastoid compartment of the
left ear for removal of an acquired cholesteatoma.
The cholesteatoma had extended through the
supralabyrinthine tract to the petrous apex
Figure 44
Same case as Figure 38. Here we see the tympano-
mastoid compartment of the right ear after diseased
tissues (cholesteatoma and granulations) have been
removed preparatory to reconstructive procedures
(male, age 16 yr).

Figure 45
This photograph taken during a surgical procedure
shows a congenital cholesteatoma of the petrous apex
of the left ear. The apex has been reached by drilling
away the cochlear part of the bony labyrinth. The
cholesteatoma cavity was permanently exteriorized to
the external auditory canal (male, age 49 yr).
Figure 46
The tympanomastoid compartment of the left ear
has been thoroughly exenterated for the
management of chronic otitis media and mas-
toiditis with cholesteatoma. In this case, since the
ear was profoundly deaf, the entire compartment
was obliterated with pedicled and free auto-
genous tissue grafts (female, age 52 yr).

Figure 47
This view shows a late stage of a tympanomas-
toidectomy on the right ear. A packing, consisting
of silk cloth strips and cotton, holds in place the
tissue grafts used in reconstruction. Dual pedi-
cled grafts composed of muscle, fascia, and
periosteum are used to obliterate the mastoid
cavity (female, age 58 yr).
Figure 48
This photograph taken during a surgical proce-
dure on a right ear shows a glomus jugulare
tumor occupying the mesotympanum and
hypotympanum (female, age 63 yr).

Figure 49
This surgical view of the right ear shows the
opened endolymphatic sac. A plastic tube was
placed in the opening to drain the sac into the
mastoid cavity for the alleviation of vertigo
caused by Ménière’s disease (male, age 32 yr).

Chapter 9
Phylogeny and Embryology
Throughout this book, we have presented photographic examples of variant

anatomy that are clinically significant, particularly to the otologic surgeon.
These variants (e.g., wide cochlear aqueduct, aberrant facial nerve, high
jugular bulb, pneumatized incus) are not considered to be anomalies
because of the frequency of their occurrence. However, they must be reck-
oned with and identified if the surgeon is to avoid complications.
Congenital malformations, on the other hand, are more severe but less
frequent deviations in morphology and usually cause functional disorders.
An anatomy book for clinicians would not be complete without a review of
embryology which is essential to understanding the morphogenesis of most
anomalies.
The understanding of anomalies of the ear is based on a knowledge of
embryologic events such as the genesis of the pinna from the hillocks of His,
the formation of the external auditory canal from the first branchial groove,
the derivation of the ossicles from the first and second branchial arches, the
formation of the ectodermal part of the membranous labyrinth from the
primitive otic cyst, the genesis and maturing of the fissures and aqueducts
of the otic capsule, etc. With the advent of microscopic reconstructive sur-
gery some anomalies of the external and middle ears can now be corrected.
Kalter and Warkany (293, 294) have evolved a classification for the
causes of malformation as follows: (1) simple genetic origin (caused by sin-
gle major mutant genes), (2) interactions between hereditary tendencies and
nongenetic, undefined factors, (3) chromosomal aberrations, (4) discrete
environmental factors, and (5) all others (those with no identifiable cause).
The clinical manifestations of genetic and metabolic deafness, both
isolated and in syndromes, may be found in a book by Konigsmark and
Gorlin (295). The morphogenesis of normal and malformed ears are
described in a book edited by Gorlin (296) and a chapter on histopathology of
developmental defects of the ear can be found in a book by Schuknecht (17).
PHYLOGENY
The auditory and vestibular systems of the mammalian ear represent phylo-
genetic salvage and modification of the branchial apparatus which serves pri-
marily a respiratory function in aquatic and amphibious organisms. On the
flanks of fish a water-motion sensing system, the lateral line, consists of a series
of fluid-filled pits (ampullae) called neuromasts which are distributed from the
head to the tail. These neuromasts are derived from epidermal placodes and are
composed of hair cells bathed in fluid, encompassed by supporting cells, and
innervated by cranial nerves VII, IX, and X. The head portion of the lateral line
system gives rise to the first semicircular canal by a simple closing-over of the
251
lateral line groove; this development, first seen in the hagfish, represents the
establishment of the first true vestibular mechanism (151, 297).
The evolution of the membranous labyrinth to the form seen in man
can be appreciated by comparing the following vertebrate series. In the
Myxinoidea (hagfish, Fig. 1) of the vertebrate class cyclostomata, one finds
the simplest ear comparable to that of man; it is analogous to the utricle and
the superior and posterior semicircular ducts. There are two ampullae with
cristae, as well as a macula communis which is recapitulated in the ontogeny
of man. A primitive endolymphatic duct extends dorsally toward the skin.
In Petromyzontia (river lamprey, Fig. 2), also of the class cyclostomata,
the situation is more intricate with a ventral saccule partially separated from
the utricle. However, none of the cyclostomes develop a lateral canal.
The vestibular system of elasmobranchs (sharks, Fig. 3) has all three
semicircular ducts. In addition, the saccule becomes distinct from the utricle
and develops an outgrowth, the lagena. The endolymphatic spaces of the
elasmobranchs communicate with the environment via an invagination
canal (not depicted in the diagram), so that sea water freely passes into and
out of the endolymphatic chambers. For the first time, the membranous
labyrinth is enclosed in a cartilaginous capsule fused to the cranium.
In the lungfish (dipnoi), the invagination canal lies lateral to the
endolymphatic duct which grows out from the saccule as an independent
structure. Communication with the outside is maintained through the
invagination canal; until this canal degenerates in the teleosts, the vestibular
system is filled with sea water, not endolymph.
In the course of further evolution, the lagena gives rise to the cochlear
duct (Fig. 4). With these evolutionary modifications, the former neuromast of
the lateral line becomes the membranous labyrinth encased within the skull
and, instead of abutting the fluid of the external environment, the sensory
Figure 1
Schema of the labyrinth of Myxi-
noidea (hagfish). This labyrinth is
comparable to the mammalian utri-
cle and the superior and posterior
semicircular canals. Source: After
Guggenheim (297).

Figure 2
Schema of the labyrinth of Petro-
myzontia (river lamprey). In this
species, the inner ear is still a purely
vestibular organ with a utricle
and two semicircular canals, but a
saccule has appeared. Source: After
Guggenheim (297).
Figure 3
Schema of the labyrinth of Elasmo-
branchii (spine shark). A third (lateral)
semicircular canal is now present as
well as a distinct saccule and lagena.
Source: After Guggenheim (297).
CHAPTER 9: PHYLOGENY AND EMBRYOLOGY ■ 253

Figure 4
Schema of the mammalian labyrinth.
Note the presence of the utriculo-
endolymphatic valve and the devel-
opment of the pars inferior (saccule
and cochlear duct). Source: After
Guggenheim (297).
hair cells abut a fluid of the internal environment, endolymph. This enclosed
system retains its function of detecting the motion of the organism for pur-
poses of equilibrium.
A prerequisite to the development of auditory function is the ability to
transduce sound pressure waves to fluid displacement through a sound
transformer and impedance matching mechanism; these functions are pro-
vided by the external auditory canal, eustachian tube, and middle ear. The
eusthenopteron, a crossopterygian fish, employed a specialized spiracular
diverticulum to compensate for the acoustic impedance of air—the earliest
middle ear (298). The precursor of the mammalian tympanic membrane is
hypothesized to be represented by a bilaminar membrane formed by the
spiracular diverticulum. The inner layer of this membrane was derived from
the endoderm of the diverticulum, while the outer layer originated from
an ectodermal ligament which originally connected the diverticulum to
the skull.
The phylogenetic origin of the mammalian ossicular system is complex
and differs from that of all other vertebrates. According to the
Reichert–Gaupp theory (1), the mammalian stapes finds its ancestry in the
columella auris of reptiles, the incus is derived from the quadrate of the
upper jaw, and the malleus is derived from the articular of the lower jaw of
ancestral vertebrates (Fig. 5). The mandible (dentary) evolved a new articu-
lation with the squamosa, which in man is a part of the temporal bone. The
gradual modification of the reptilian jaw is hypothesized to have occurred in
the therapsids, mammal-like reptiles of the Triassic period. Through evolu-
tionary transformation, the first mandibular arch gave rise to the jaws of all

Figure 5
The stapes finds its ancestry in the col-
umella auris of reptiles, the incus in the
quadrate of the upper jaw, and the
malleus in the articular of the lower
jaw of ancestral vertebrates. The mam-
malian ossicular system derives from
the evolutionary transformation of the
first mandibular arch. Source: Courtesy
of Taylor (301).
vertebrates and to the mammalian ossicles. The jaws of the early vertebrates
had ligamentous attachments to the cranium. As the hyoid (second
branchial) arch moved forward, it established the attachment of the otic cap-
sular region to the jaw joint where it is known as the hyomandibular.
Consequent to the anterior migration of the hyoid, the first gill slit (branchial
cleft) migrated superior to the jaw joint and, as the spiracle, evolved into the
eustachian tube. The outer surface of the spiracle was sealed by the tympanic
membrane. With further migration the hyomandibular occupied the spiracle
and developed into the stapes to provide its relationship with the oval win-
dow and inner ear. In the therapsids, however, the stapes lay in a deep recess
sequestrated from the environment. Thus, a mechanism for the conduction
of sound to the stapes was needed.

Four bones comprised the lower jaw of amphibians and early reptiles
(299): the dentary, the quadrate, the articular, and the angular (Fig. 5). The
dentary (mandible) is the tooth-bearing component. The articular forms a
joint with the quadrate and abuts the angular. With refinements in the mas-
ticatory apparatus which reduced the stresses on the jaw joint, the posterior
elements of the jaw dwindled. As the lower jaw utilized an upper extension
of the dentary to articulate with the skull (the future temporomandibular
joint), the articular and quadrate bones became superfluous and were incor-
porated into the middle ear. The articular evolved into the malleus and the
quadrate into the incus to provide the necessary connection of the stapes
with the tympanic membrane (300, 301).
EMBRYOLOGY
The development of the human ear has been the subject of numerous stud-
ies (302–308), yet many students of otology find it difficult to comprehend
the developmental process and its time sequence. In an attempt to alleviate
this difficulty, the material is presented in four time periods in fetal develop-
ment as determined by availability of suitable specimens. These time peri-
ods are: 0 to 4, 4 to 8, 8 to 16, and 16 weeks and beyond. Within each period,
the developmental changes occurring within the various structures are pre-
sented. The reader has the option of following the sequential changes in one
structure or of focusing on one particular time period.
The accompanying photomicrographs are arranged in developmental
ages of approximately 8, 12, 16 weeks, and beyond (postnatal). Also pre-
sented is a summary of the unique ossification process of the otic capsule
and a brief review of the steps in ossification. When integrating the reports
of others, we noted some differences in opinion as to the fetal ages at which
certain developments occur. For this reason, we emphasize that the given
fetal ages are approximations.
Development to Four Weeks
The Membranous Labyrinth (0–4 Weeks) The membranous labyrinth

includes the cochlear duct with its organ of Corti, the utricle and saccule
with their maculae, the semicircular ducts with their cristae ampullares, and
the endolymphatic duct and sac. This interconnected system of epithelially
lined ducts and chambers contains endolymph and is encased in the otic
capsule. The otic labyrinth begins its development from surface ectoderm
(Fig. 6) at the end of the third week of gestation (118, 119). A plaque-like
thickening appears on the lateral aspect of the neural fold dorsal to the first
branchial groove, in close relation to the hindbrain. The lining basement
membrane of the primordial auditory placode is continuous with that of the
rhombencephalic neural groove. In the course of the next few days, the cells
in the placode elongate and begin to demonstrate a ciliary brush-border. The
placode develops in close conjunction with the “acousticofacial ganglion.”
These ganglion cells, of neural crest origin, delaminate from the wall of the
neural groove and migrate ventrally and laterally. Just before the fourth
week (Fig. 6), the placode invaginates into the underlying mesenchyme to
form the auditory pit. With dilation of the auditory pit a sac is formed; fusion
of tissue at the mouth of this sac separates it from the surface, creating a

Figure 6
The otic vesicle forms as an imagina-
tion of neural ectoderm (A, B). The
first projection to appear is that of
the endolymphatic appendage with
the semicircular canals developing as
flange-like outcroppings (C, D).
Progression of development results in
central obliteration of the canals and
spiral lengthening of the cochlea (E,
F). A ⫽ 22 days’ gestation, B ⫽ 4 wk,
C ⫽ 4.5 wk, D ⫽ 5.5 wk, E ⫽ 6 wk,
and F ⫽ 8⫹ wk. Source: After Streeter
(302).
structure called the otocyst (otic vesicle). Even as early as the fourth week of
gestation, the endolymphatic appendage can be discerned on the dorsome-
dial aspect of the otocyst (Fig. 6). Concomitant with this development of the
otocyst is the differentiation of mesenchymal tissue forming the cartilagi-
nous capsule of the otocyst.
The Semicircular Ducts (0–4 Weeks) By the fourth week of gestation the
future semicircular ducts are two flange-like outcroppings of the utricular
(dorsal) aspect of the auditory vesicle. They constitute the canalicular divi-
sion of the otic capsule.
The VIIIth Cranial Nerve and Ganglion (0–4 Weeks) The so-called “acousti-
cofacial primordium” is of neural crest origin and begins to develop during
the third week of gestation in close conjunction with the otic placode lateral
to the hindbrain. The acousticofacial primordium was originally credited
with giving rise to the geniculate ganglion of the Vllth nerve and the
ganglion of the VIIIth nerve via a dorsoventral division. Current evidence
(309, 310) supports the proposition, however, that only fibers of the Vllth
nerve derive from this complex.
The statoacoustic nerve arises instead from cells of the anteromedial
aspect of the otic placode; these cells migrate during the fourth week of ges-
tation between the epithelium of the otic vesicle and its basement membrane.
They then penetrate the basement membrane through minute defects to reach
the region in which the VIIIth nerve ganglion forms (308, 309) (Fig. 7).
The cells of the acousticofacial primordium extend ventrally to the
hyoid epibranchial placode (Fig. 7) where they give rise to the special visceral
afferent (taste) fibers of the facial nerve. It is currently thought (308, 309) that
cells of otic vesicle derivation are the anlage for the VIIIth cranial nerve gan-
glia. It now seems clear that these two ganglia, the VIIIth nerve and the genic-
ulate ganglion, have independent and discrete identities (309).
The Otic Capsule (0–4 Weeks) The otic capsule lies above the lateral extrem-
ity of the tubotympanic recess and consists of the cartilaginous mass which
encompasses the inner ear. Eventually it forms the petrous portion of the

Figure 7
This drawing of a 6-wk embryo
shows the relationship of the otic
vesicle to the acousticofacial pri-
mordium as well as the position of
the epibranchial placode. Source:
After Gasser (312).
temporal bone. The otic capsule develops in precartilage and by the end of
the fourth week it can be discerned as an increase in cell density of the mes-
enchyme surrounding the otic vesicle.
The Facial Nerve (0–4 Weeks) Early investigations suggested that the facial
nerve shared a common origin with VIIIth nerve (Fig. 7). In the four-week
embryo, the so-called “acousticofacial primordium” (or acousticofacial crest)
can be seen attaching to the metencephalon rostral to the otic vesicle. More
recent data (311) label the “acousticofacial primordium” as purely facial and
restrict it to giving rise only to general somatic sensory fibers and perhaps
motor fibers of the facial nerve (308, 312).
The Pinna (0–4 Weeks) The first signs of auricular development occur as tis-
sue condensations of the mandibular and hyoid arches at the distal portion
of the first branchial groove in the fourth week of gestation. The specific con-
tribution of the arches to the formation of the auricle is not definitely known,
but some (313) believe that the entire auricle except the tragus develops from
the hyoid (second branchial) arch and the anterior portion of the external
acoustic meatus and the tragus are the sole contributions of the mandibular
arch. Alternate theories (see The Pinna (4–8 Weeks), p. 265) favor a more or
less equal contribution of both the mandibular and hyoid arches to the
development of the auricle.
The Tympanomastoid Compartment (0–4 Weeks) The middle ear communi-

cates with the mastoid air cells through the aditus ad antrum and with the
pharynx by the auditory tube. The eustachian tube and middle ear cavity
derive from the endodermal tissue of the dorsal end of the first pharyngeal
pouch. This outpouching of the foregut is readily discernible in the three-week
embryo. The second pharyngeal pouch may also play a role in development of

the eustachian tube by merging with this evagination of the foregut. Most of the
remainder of the middle ear structures (ossicles, muscles, tendons, etc.) arise
from the mesoderm of the first and second branchial arches.
By the fourth week, the dorsoventrally flattened terminal end of the
first pharyngeal pouch has come into apposition with the infolding of the
first branchial groove. This contact is short-lived because the mesoderm,
which is destined to form the manubrium as well as a portion of the tym-
panic membrane (the tunica propria), grows in between these endodermal
(first pharyngeal pouch) and ectodermal (first branchial groove) layers. The
eustachian tube at this point is merely a slit-like tunnel.
The Malleus and Incus (0–4 Weeks) The anlage of the ossicles has been the
subject of much discussion. The consensus now holds that the ossicles have
multiple origins. It is believed that the manubrium of the malleus and the long
process of the incus derive from the hyoid visceral bar, while the head of the
malleus and body of the incus differentiate from the mandibular visceral bar.
The anterior process of the malleus, however, emerges from intramembranous
ossification distinct from the visceral bars. In this context, it is useful to draw a
distinction between the mandibular and hyoid visceral bars as opposed to
Meckel’s and Reichert’s cartilages (308). Lying within the branchial arches is a
condensation of mesenchymal tissue. With maturation it differentiates into car-
tilage and eventually becomes bone in some, although not all, regions. Visceral
bar is the term used to describe the entire masses of condensed mesenchymal
tissue, whereas the terms Meckel’s and Reichert’s cartilages refer only to the
cartilage formed from the ventromedial portions of these mandibular and
hyoid visceral bars, respectively.
At approximately four weeks of gestation (Fig. 8), areas of condensation
of the mesenchyme appear at the dorsolateral ends of the mandibular and
hyoid bars. An interbranchial bridge is formed which connects the upper end
of the mandibular visceral bar to the central region of the hyoid visceral bar;
it is this bridge that gives rise to the blastemae of the malleus and incus.
The Stapes (0–4 Weeks) The stapes, like the malleus and incus, has a dual ori-
gin first described by Gradenigo in 1887 (314). A stapedial “ring,” which arises
from mesenchyme of the hyoid visceral bar, gives rise to the capitulum, crura,
and tympanic (lateral) surface of the footplate. The lamina stapedialis, which
gives rise to the annular ligament and the labyrinthine (medial) surface of the
footplate, develops from the otic capsule and retains some of its cartilaginous
structure throughout life. A blastemal mass is all that is recognizable of the
future stapes at the fourth week of gestation (Fig. 8). This blastema is com-
posed of the condensed mesenchymal cells of the dorsolateral end of the hyoid
visceral bar, adjacent to the facial nerve, and the nascent stapedial artery.
The Arteries (0–4 Weeks) In the third week of gestation, small vascular
islands in the mesenchyme of the pharyngeal arches coalesce to form the six
aortic arch arteries. These arch arteries originate ventrally from the unpaired
aortic sac, course through the visceral arches, and terminate in the ipsilateral
dorsal aorta. These arteries are never all co-existent. The first and second
arteries dwindle and vanish even before the third and more caudally posi-
tioned arch arteries are completely developed. The paired dorsal aortae
course cranially to supply the embryonic forebrain and midbrain as well as
the inner ear. The auditory vesicle initially receives its blood supply from
one or more dorsal branches of these aortae and later from the otic arteries
which are branches of the primitive carotid artery.

Figure 8
At 4.5 to 6 wk, the chorda tympani
nerve appears to progressively
detach the malleus and incus from
the hyoid visceral bar. The facial
nerve deepens a groove on the
blastemal mass of the stapes which
eventually separates the blastema
into a stapes primordium and latero-
hyale. The rotation of the structures
of the stapes blastema with the lat-
erohyale is the result of a combina-
tion of anterior (superior) growth of
the stapes primordium with poste-
rior (inferior) growth of the latero-
hyale. A ⫽ 4.5 wk, B ⫽ 5.5 wk, and
C ⫽ 6 wk. Source: After Pearson
(308).
Between three to four weeks the primitive carotid artery, derived as a

cranial extension of the dorsal aorta, courses toward the optic vesicle to reach
the first aortic arch where it fuses with its twin from the opposite side to form
the basilar artery. The blood supply of the labyrinth becomes dependent
upon the longitudinal neural arteries, which later fuse to form the basilar
artery as the primitive otic artery fades away during the fourth week.
The first and second arch arteries disappear in fetal life, although the
dorsal segment of the second arch artery may remain even into adulthood (see
persistent stapedial artery on p. 214), passing between the stapedial crura.
The third arch artery gives rise to the carotid arterial system; an offshoot
from its ventral aspect gives rise to the external carotid artery. The common
carotid artery develops from that portion of the third arch artery proximal to
the origin of the external carotid artery. The internal carotid artery has dual
origins; its proximal portion develops from the distal third arch artery while
the remainder, encompassing its intracranial portion, develops from the dor-
sal aorta cranial to the third arch artery.

The Veins (0–4 Weeks) Bordering the developing brain of the human embryo
are simple channels which develop into the primary head sinus by the third
week of gestation. By the fourth week it has surrounded the Xth cranial
nerve. The dorsolateral segments of the brain drain into this primary head
sinus through the anterior, middle, and posterior dural plexuses. The latter
two channels drain the auditory vesicle. The vascular ring around the Xth
cranial nerve is only transient and by the end of the fourth week its medial
aspect shrinks. The cranial aspect persists, however, and in part develops into
the primitive myelencephalic vein, which in turn gives rise to the inferior pet-
rosal sinus and the inferior cochlear vein. Meanwhile, the posterior and mid-
dle dural plexuses form anastomotic connections near the auditory vesicle.
Development to Eight Weeks
The Membranous Labyrinth (4–8 Weeks) As late as the fifth week of gesta-
tion, a small stalk may persist as the sole communication of the otocyst with
the surface ectoderm. At four to five weeks of gestation, the otic vesicle ini-
tiates dorsoventral elongation. Three folds begin to form which divide the
vesicle into three major subdivisions: the endolymphatic duct and sac, the
saccule and its cochlear duct, and the utricle with its semicircular ducts.
The first fold develops at the five-week stage, as an inferiorly directed
infolding which demarcates the future endolymphatic duct and sac as a dor-
somedial projection from the utricular part of the vesicle (utriculosaccular
chambers) (Fig. 9). A ventromedial projection is the precursor of the cochlear
duct. At the same time, nerve fibers begin to extend from the statoacoustic
ganglion to the subdivisions of the otic vesicle. A thickening of the medial wall
of the otic vesicle forms the primordium of a common macula (macula com-
munis). This common macula soon divides into a superior segment which
gives rise to the macula of the utricle and the ampullary crests of the superior
and lateral semicircular ducts, and an inferior segment which forms the
Figure 9
Drawing of the developing otic labyrinth at 6 to 8 wk. The nas-
cent folds I, II, and III indent the otic vesicle to initiate the forma-
tion of the utricle, saccule, and endolymphatic duct. Source: After
Bast and Anson (274).

macula of the saccule and the ampullary crest of the posterior semicircular
duct. By six weeks, the primordial semicircular ducts (the canalicular division
of the otic capsule) materialize as two flattened sacs; the lateral duct arises
from a horizontal protuberance, while the superior and posterior semicircular
ducts arise from a common outpouching.
The second of the three divisional infoldings appears on the medial
aspect of the otic vesicle and is horizontally oriented at the junction of the
saccule and ostium of the primordial endolymphatic duct.
The third fold is also horizontally oriented and is located on the lateral
aspect of the utriculosaccular chamber. This infolding was called the utricu-
losaccular partition (cloison interutriculosacculaire) by Chatellier (315) and
Anson (303), and is the fold primarily responsible for the separation of the
utricle from the saccule. Initially, the medial and lateral horizontal infoldings
are diametrically opposed, but by eight weeks the medial shelf assumes a
more caudal position with respect to the lateral ledge. The resultant structure
has a Y-shaped configuration which connects the utriculosaccular division
with the endolymphatic duct.
The Cochlear Duct (0–8 Weeks) In the six-week embryo, the cochlear duct
forms as a tubular diverticulum from the saccular portion of the otic vesicle
(Fig. 6). This ventral projection coils with medial growth, completing one
turn by the sixth week and its entire two and one-half turns by the eighth
week. At this stage, the communication of the cochlear duct with the saccule
narrows to form the ductus reuniens. Even as the cochlear duct first appears,
the organ of Corti can be seen as a placode of stratified epithelial cells in the
wall of the cochlear duct (Figs. 30, 33, 40, and 43). Like the maculae and
cristae, the organ of Corti appears early in gestation and attains maximum
size by midterm. At the region of the nascent organ of Corti, from base to
apex, the epithelial cells of the cochlear duct differentiate into two ridges of
tall, columnar cells. The cells of these ridges secrete the gelatinous cushion
which forms the tectorial membrane. The smaller outer ridge differentiates
into the organ of Corti, while the inner larger ridge gives rise to the spiral
limbus. This metamorphosis spreads as a wave from the basal to the apical
aspect of the cochlea. By the eighth week differentiation of the epithelium
and subjacent mesenchyme at the outer wall of the cochlear duct initiates the
development of the stria vascularis (Fig. 43). The modiolus, the tympanic
and vestibular scalae, and the enveloping otic capsule begin to differentiate
at about the eighth week.
The Utricle and Saccule (0–8 Weeks) The utricle in association with the
semicircular ducts makes up the pars superior of the membranous labyrinth.
This phylogenetically older segment of the membranous labyrinth develops
earlier in the ontogeny of the fetus (Figs. 29 and 34). The saccule in associa-
tion with the cochlear duct makes up the phylogenetically younger pars
inferior (Figs. 30 and 35).
During the seventh week of gestation, the constriction between the
saccule and the cochlear duct forms the ductus reuniens and in the ensuing
week the three infoldings of the otic vesicle deepen to create the adult forms
of the utricle, saccule, and endolymphatic duct (Fig. 9). The macula of
the utricle, like the other sense organs, differentiates from the simple
epithelium of the wall of the membranous labyrinth at those areas
where the sensory nerves enter. Between the seventh and eighth weeks of
development, the simple epithelium is transformed into a complex pseudo-
stratified type.

The Semicircular Ducts (4–8 Weeks) At the six-week stage the two arching
flanges undergo partial obliteration of their cavities through fusion and dis-
integration of opposing epithelial walls (Fig. 6). The void is filled by mes-
enchymal tissue. The peripheral aspect of each flange retains its lumen,
thereby creating the semicircular duct. This process occurs first in the supe-
rior semicircular canal and soon after in the posterior and the lateral canals.
The ampullae are the dilated ends of the three semicircular ducts which open
into the utricle; those of the superior and lateral canals are located on their
anterior limbs (crura) while that of the posterior canal is found on its inferior
limb (crus). By the seventh week of gestation, a ridge-like structure formed
by neuroepithelial cells appears within the ampullae at a point where the
vestibular nerve fibers enter (Figs. 29, 32, and 36). These future cristae
ampullares are oriented perpendicularly to the direction of endolymph flow.
The nonampullated ends of the semicircular ducts also empty into the utri-
cle. Because the posterior and superior ducts fuse to form a common duct
(crus commune), a total of five crura (rather than six) enter the utricle.
The Endolymphatic Duct (0–8 Weeks) The endolymphatic duct is first seen
as a dorsomedial projection from the otic vesicle, known as the endolym-
phatic appendage, at approximately the sixth week of gestation (Fig. 9).
Although it is a narrow tube at its vestibular end, it widens out distally into
a sac-like configuration. With lateral development of the otic vesicle, the dis-
tal end of the endolymphatic appendage assumes a relatively more medial
position and by the eighth week it is a large fusiform sac with a thin epithe-
lial lining, rippled by low rugae.
The VIIIth Cranial Nerve and Ganglion (4–8 Weeks) Between the fourth and
fifth weeks, the statoacoustic ganglion divides into superior and inferior seg-
ments sending nerve fibers to the various areas of the otic vesicle. The supe-
rior division supplies the utricular macula and the cristae of the superior and
lateral semicircular ducts. At five to six weeks, the inferior segment further
subdivides into upper and lower portions; the upper segment innervates the
saccular macula and the crista of the posterior semicircular duct and the
lower segment supplies the organ of Corti.
At approximately six weeks, the nerve fibers to the posterior ampulla
are splayed out, but later appear as one compact nerve. Streeter (302)
hypothesized that the streamlining may be related to the incorporation or
atrophy of temporary fibers to sensory structures found in this area in lower
forms (e.g., crista neglecta).
By the end of seven weeks, the pars superior has enlarged greatly and
its nerve supply has become defined as discrete branches. By the end of eight
weeks, the nerves approximate the adult condition. The vestibular nerve, a
derivative of the upper part of the statoacoustic ganglion, now consists of a
superior and inferior division with its ganglion on its trunk. The cochlear
nerve likewise resembles that of the adult with its compactly arranged spi-
raling fibers.
Differentiation into sensory neuroepithelium and supporting cells
occurs where neural contact is established. In a review of organogenesis of the
ear, Van de Water and Ruben (310) suggest, however, that neuronal contact
may not be required for the initial differentiation of the sensory structures of
the internal ear but may be of importance in maintenance of sensory struc-
tures, once differentiated. Hilding (316) found that hair cells were differenti-
ated before the appearance of synapses; he was unsure as to whether nerve
fibers influenced differentiation.

The Otic Capsule (4–8 Weeks) In the fifth week, the condensation of mes-
enchyme occurs everywhere except in the region of the developing endolym-
phatic duct. It envelops the membranous labyrinth in the sixth week and
begins to assume a cartilaginous character. A small area on the medial wall
fails to be included in the mesenchymal condensation; it marks the future loca-
tion of the internal acoustic meatus. The condensed mesenchyme, except for
its lack of blood vessels, is identical to embryonic connective tissue elsewhere
in the developing embryo. As the sixth week closes, precartilage (compacted
mesenchyme which is assuming the character of embryonic cartilage) differ-
entiates into the first true cartilage of the otic capsule. This process is not com-
pleted until approximately the eighth week. At this time the membranous
labyrinth has attained its adult shape, although adult size is not reached until
approximately midterm. Even as the outer zone of precartilage is becoming
true cartilage, dedifferentiation of already formed cartilage is taking place,
forming a loose, vascular reticulum of mesenchyme immediately adjacent to
the epithelium of the otic vesicle.
The Perilymphatic Spaces (0–8 Weeks) The perilymphatic (periotic) labyrinth

occupies the space between the membranous labyrinth and the inner
periosteal layer of the otic capsule. The development of this composite tissue
and tissue–fluid space from the mesodermal tissue surrounding the membra-
nous labyrinth occurs rapidly between the 8th and 24th weeks of develop-
ment. The same general scheme is followed in the cochlear, canalicular, and
vestibular portions of the labyrinth. As with development of the otic capsule,
a process of retrogressive change in precartilage is involved; instead of differ-
entiating to mature cartilage, it dedifferentiates into a loose, vascular reticu-
lum. This process begins at approximately the eighth week with rarefaction of
the precartilage surrounding the membranous ampullae of the semicircular
ducts (Fig. 32). Also during the eighth week, a loose vascular reticulum is seen
lining the utricle, saccule, and proximal part of the cochlear duct (Fig. 34); it is
the first evidence of the development of the perilymphatic (periotic) cistern of
the vestibule (Fig. 31). An area of rarefaction in precartilage just under the
round window initiates the beginning of the scala tympani.
The Capsular Channels (0–8 Weeks) In the seven-week embryo, a rarefac-

tion of the otic capsular precartilage in the region of the medial wall of the
basal turn of the cochlea, just medial to the developing round window and
extending to the posterior cranial fossa, is the primordial cochlear aqueduct.
With further development its contained periotic duct will provide a route of
communication between the scala tympani and the subarachnoid space.
The reticular tissue contained by the cochlear aqueduct is continuous
with that encompassing the IXth cranial nerve, the dura, and the inferior pet-
rosal sinus. Hence, the round window niche, occupied by loose mesenchy-
mal connective tissue and vessels, is also continuous with posterior fossa
dura via the cochlear aqueduct.
The Facial Nerve (4–8 Weeks) At four to five weeks, the cells of the “acousti-
cofacial primordium” at the level of the epibranchial placode begin to trans-
form into the neuroblasts of the geniculate ganglion (312). This ganglion
which develops independently of the motor fibers [Fisch as quoted by
Jahrsdoerfer (317)] is well defined by six weeks.
The facial division of the “acousticofacial primordium” undergoes a
division at four to five weeks into a caudal portion which gives rise to the
main trunk of the facial nerve and a rostral portion which passes ventral to

the first pharyngeal pouch to enter the mandibular arch. This rostral portion
is the chorda tympani nerve which at this time is comparable in size to the
main trunk of the facial nerve (312). The distal termination of the chorda
tympani nerve is in the same region as the termination of a branch of the
mandibular nerve (the lingual nerve) and coincides with the area in which
the submandibular ganglion develops at about six and half weeks. By the
seventh week, a definite union has been established between the lingual and
chorda tympani nerves just proximal to the ganglion (312).
The nervus intermedius (nerve of Wrisberg) develops from the genicu-
late ganglion and is present as a discrete entity by approximately seven
weeks. It courses as one or two bundles of fibers between the VIIth and
VIIIth nerves to the brain stem and even at this stage is much smaller than
the main trunk of the VIIth nerve (312).
The greater superficial petrosal nerve, which is the second branch of
the facial nerve to develop (318), stems from the most ventral aspect of the
geniculate ganglion; it is present at five weeks and is well developed by six
and half weeks.
The Facial Canal (0–8 Weeks) In the eight-week fetus, the facial canal is a sul-
cus located on the tympanic wall of the posterior part of the otic capsule. The
future canal, like the rest of the otic capsule, is still cartilaginous and houses
the developing stapedius muscle, facial nerve, and vascular channels.
The Pinna (4–8 Weeks) During the fifth and sixth weeks, the condensations
seen at the four-week stage now form six ridges, known as the hillocks of His
(319) (Figs. 10–12). Controversy surrounds the significance of these hillocks
Figure 10
The auricle develops from hillocks
1 to 3 of the first branchial arch and
hillocks 4 to 6 of the second branchial
arch at approximately 6 wk (see Figs.
11 and 12). Source: After Levine (332).

Figure 11
The original six hillocks of His are further developed
at approximately 7 wk (see Figs. 10 and 12.). Source: After
Levine (332).
in the development of the pinna. Some authors believe that they are coinci-
dental rather than integral to the process. Most authorities believe, however,
that these six hillocks do bear upon the final configuration of the pinna.
Hillocks 1, 2, and 3, of mandibular arch origin, are innervated by the
auriculotemporal branch of the Vth cranial nerve. Hillocks 4, 5, and 6 are of
hyoid arch origin and are innervated by the small cutaneous branch of the
VIIth nerve as well as the branches of the cervical plexus, in particular the
greater auricular and lesser occipital nerves.
The adult homologues of these hillocks as described by Anson and
Donaldson (1980), His (319), and Arey (320) are depicted in Figure 12.
Streeter (321) and Pearson (308) suggest a different scheme. They propose
that the first hillock forms the tragal region, the second establishes the crus
of the helix, and the third is responsible for the major part of the helix. They
suggest that hillock 4 gives rise to the anthelix, hillock 5 to the antitragus,
and hillock 6 to both the future lobule and most of the inferior aspect of the
helix. In a total departure from these theories, Wood-Jones and Wen (313)
propose that only the tragus is derived from the mandibular arch and that
the remainder of the auricle is of hyoid arch origin.
Initially these ridges are closely situated along the first branchial
groove but are separated as the groove develops to eventuate in the forma-
tion of the cymba conchae, the cavum conchae, and the incisura intertragica.
As the end of the sixth week approaches, the hillocks give rise to the
two folds of the pinna, those of mandibular arch origin forming the anterior
fold and those of the hyoid arch forming the posterior fold. These folds then

Figure 12
The adult auricle is shown with derived parts from the six
hillocks of His indicated by numbers 1 to 6 (see Figs. 10 and
11). Source: After Levine (332).
fuse at the upper end of the first branchial groove. During the second month
of development, because of mandibular and facial growth, the pinna is dis-
placed dorsolaterally from its original ventromedial position. After the sev-
enth week, cartilage develops from the mesenchyme of the folds.
The External Auditory Canal, Tympanic Membrane, and Tympanic Ring (0–8
Weeks) The external auditory canal is derived from the dorsal part of the
first branchial groove which deepens during the second month of gestation
and forms a funnel-shaped depression located between the mandibular and
hyoid arches. Between the fourth and fifth weeks, the ectoderm of the first
branchial groove transiently impinges upon the endodermal lining of the
tubotympanic recess. By the sixth week, ingrowth of mesoderm breaks this
contact (Fig. 32). At eight weeks, with extension of the inferior portion of the
first branchial groove toward the middle ear, a narrow tunnel is established,
the primary (primitive) canal. This primary canal corresponds to the future
fibrocartilaginous portion of the adult canal.

The Tympanomastoid Compartment (4–8 Weeks) Between the fourth and
sixth weeks, the tympanic cavity undergoes progressive expansion to keep
pace with the developing cartilaginous otic capsule. Beginning at seven
weeks, the tubotympanic recess becomes constricted at its midpoint due to
the rapid growth of the second branchial arch. Hammar [cited by Proctor
(42)] defined the region of the tubotympanic recess lateral to this constriction
as the primary tympanic cavity and the region lying medially as the primor-
dial eustachian tube.
By the end of eight weeks, the approximation of the lateral aspect of the
tympanic cavity to the first branchial groove (the future external auditory
canal) is broken by the ingrowth of mesodermal tissue destined to form the
pars propria of the tympanic membrane as well as the manubrium of the
malleus (Fig. 13). Concomitantly the mesenchyme surrounding the middle
ear thins out, allowing for progressive expansion of the middle ear space.
The process of cavitation is present initially only in the inferior half of the
middle ear cavity and attains completion only late in fetal life.
The superior periotic process develops as a projection of the otic cap-
sule, and as it stretches forward over the ossicles it forms the lateral portion
of the tegmen tympani; at this time, a plate of mesenchymal tissue is the sole
component of the medial aspect of the tegmen.
Also, at this time, growth of the fetal head has contributed to the nar-
rowing and elongation of the medial aspect of the tubotympanic recess so
that it now forms the eustachian tube.
The Malleus and Incus (4–8 Weeks) Between four and eight weeks, cartilagi-
nous models of the incus and malleus derive from the aggregated
mesenchyme of the interbranchial bridge. The development of the chorda
tympani nerve is closely involved in the steps of differentiation of these ossi-
cles; this nerve forms a fixed point for growth of the ossicles as it sweeps
around the ventral aspect of the combined incudal and malleal primordia
(the interbranchial bridge) (Fig. 8).
Figure 13
By 9 wk the ectoderm of the first
branchial groove extends toward the
middle ear, forming the primitive
external auditory canal. The meatal
plate is the result of surface ectoder-
mal ingrowth, and extends from
the external auditory canal (EAC) to
the inferior wall of the tympanic
cavity. Source: After Anson and
Donaldson (4).

Between the fifth and sixth weeks, the primordial malleus and incus
grow rapidly in size; however, the chorda tympani nerve lags behind and at
six weeks seems to separate the incudal and malleal blastemae from the
hyoid visceral bar. During the sixth week, precartilage forms in the future
ossicles as well as in Meckel’s and Reichert’s cartilages. Rapid transforma-
tion into true cartilage occurs during the seventh week and the short process
of the incus establishes contact with the otic capsule (Fig. 31). By the end of
the eighth week, the form of the cartilaginous malleus closely approximates
that of the adult; however, there is still continuity between the malleus and
Meckel’s cartilage at a time when the incus is already separated from
Reichert’s cartilage. Different from the malleus, which has no continuity
with hyoid arch derivatives in the adult, the incudal articulation with the
stapes represents a persistent link to the hyoid arch structure. The re-estab-
lishment of this continuity is theorized to occur by proliferation of blastemal
cells of the long process of the incus toward the stapes as the chorda tympani
nerve is severing the link between the incus and the hyoid visceral bar
(Fig. 8). The primordium of the long process has nearly reached the head of
the stapes by the time this primary link has been broken. Fusion occurs at the
site of future joint development. At the junction of Meckel’s cartilage with
the malleus, there is an area of membranous bone formation which marks
the future anterior process of the malleus (processus Folianus). Meanwhile,
dense mesenchyme separates the malleus and incus at the area of their
future articulation (Fig. 30).
The Stapes (4–8 Weeks) During the fifth and sixth weeks, the solid blastemal
mass of the stapes develops a ring-like configuration about the stapedial artery.
The first step in this transformation is the creation of a groove in the stapes
blastema at its area of contact with the stapedial artery during the fifth week.
In the following week the grooved stapedial mass fuses around the artery,
forming the stapedial ring; the central defect housing the stapedial artery is the
obturator foramen. During the same period, the facial nerve tunnels another
groove which divides the primordium of the stapes into the stapes proper and
the laterohyale, bridged by the interhyale (Fig. 8). With posteroinferior expan-
sion of the primordium of the laterohyale and the anterosuperior expansion of
the stapes, these structures seem to rotate about the facial nerve so that the lat-
erohyale eventually comes to rest posterior to the stapes (Fig. 8).
During the seventh week, several events occur in stapedial evolution.
The laterohyale extends to meet the otic capsule as cells of the interhyale
condense at the proximal end of the hyoid bar. The stapedial ring enlarges to
approach the otic capsule at the region of the future oval window, and the
long process of the incus impinges upon the head of the stapes. As is true for
the incus and the malleus, blastemal tissue now differentiates into cartilage.
For the stapes this process is coordinated with that of the adjacent otic cap-
sule. There is a depression at the point where the stapes abuts the otic cap-
sule. During the eighth week, while the remainder of the otic capsule is
undergoing cartilaginous differentiation, the tissue at this junction (future
bases of crura and footplate) changes to dense fibrous tissue (the lamina
stapedialis of the otic capsule) (Fig. 31). This tissue gives rise to the vestibu-
lar (medial) surface of the stapes footplate. The tissue at the rim of the foot-
plate condenses to form the annular ligament, but this does not occur until
the footplate has reached its final size.
The Arteries (4–8 Weeks) At four to five weeks, the cranial nerve roots and
the aortic arch arteries correspond to each pharyngeal bar and pouch; this

relationship is known as the “branchial” phase of development. The first and
second aortic arch arteries have diminished, save for a dorsal fragment of the
first arch artery (the mandibular artery). In their places are the hyoid artery,
representative of the dorsal end of the second arch artery, and the ventral
pharyngeal artery which ends at the mandibular nerve root.
Beginning in the fifth week, the stapedial artery develops from the
proximal portion of the hyoid artery and courses through the primordial
stapes into the mandibular bar (Fig. 14). The distal remnant of the ventral
pharyngeal artery has become separated from its proximal portion. By the
end of the sixth week, the stapedial artery, as the major branch of the hyoid
artery, has reached the peak of its development; however, the distal end of
the hyoid artery shrinks to a small twig coursing in a caudal direction along
with the tympanic branch of the glossopharyngeal nerve. This hyoid twig
along with the stem of the stapedial artery gives rise to the caroticotympanic
branches of the adult internal carotid artery.
Immediately beyond the stapes, the stapedial artery (Fig. 14) sends off
a cranial branch which forms its supraorbital division accompanying the
ophthalmic branch of the Vth cranial nerve. The remainder of the stapedial
artery runs ventrally with the mandibular division of the Vth cranial nerve
to join the plexiform distal remnants of the ventral pharyngeal artery at the
region of the mandibular root of the chorda tympani nerve; this anastomosis
becomes the maxillomandibular division of the stapedial artery.
In this embryologic discussion we will use the term “internal auditory
artery” as is customary. We have elsewhere preferred to use the term
“labyrinthine artery” for the reason that it supplies the vestibular as well as
the auditory part of the labyrinth.
In the four- to six-week period of development, the internal auditory
artery and anterior inferior cerebellar artery extend laterally from the basilar
artery; as they are connected by a vessel running parallel to the basilar artery,
Figure 14
These drawings show the
sequence of the developmental
changes in the stapedial artery in
human embryos of 6 wk (A),
7 wk (B), and 7⫹ wk (C). Source:
After Altmann, 1947 and Davies,
1967.

a vascular ring is formed around the abducens nerve. Atrophy of part of this
ring determines the origin of the internal auditory artery with respect to the
anterior inferior cerebellar artery (Fig. 15). If the lateral aspect of the ring
degenerates, the internal auditory artery and anterior inferior cerebellar
artery arise separately from the basilar artery; however, if the cranial aspect
of the ring is interrupted, the internal auditory artery develops as a branch
of the anterior inferior cerebellar artery.
In the seven-week embryo, the stapedial artery through its supraor-
bital division is the primary blood supply to the orbit (except the globe);
this division branches into supraorbital, frontal, anterior ethmoid, and
lacrimal arteries. An anastomosis now begins to develop between the
supraorbital division of the stapedial artery and the primitive ophthalmic
artery; this anastomosis forms proximal to the division of the ophthalmic
artery into its three optic branches and dorsal to the optic nerve.
Meanwhile, an anastomotic linkage forms between the external carotid
artery and the maxillomandibular branch of the stapedial artery which will
give rise to the internal maxillary artery and middle meningeal arteries, as
well as the inferior alveolar and infraorbital arteries. The stem of the stape-
dial artery, located between the internal carotid artery and the origin of the
supraorbital division, undergoes atrophy and the external carotid artery
system takes over the area previously supplied by the supraorbital and
maxillomandibular divisions of the stapedial artery. Tandler (322) sug-
gested that the anterior tympanic artery, a branch of the internal maxillary
artery, represents the remains of the withered stem of the stapedial artery.
Altmann (278) proposed that the superior petrosal artery is another rem-
nant of the stem of the stapedial artery.
By the end of the eighth week, the subarcuate artery develops as a
branch of either the internal auditory artery or the anterior inferior cerebel-
lar artery and supplies part of the developing mastoid and labyrinthine
capsule. It traverses the subarcuate fossa.
Figure 15
Two different developmental seque-
nces determine the origin of the
labyrinthine artery. If vascular atro-
phy occurs at point A, it will arise
from the anterior inferior cerebellar
artery (AICA) or if atrophy occurs at
point B, it will arise from the basilar
artery. (After Altmann.)

The Veins (4–8 Weeks) In the fifth week, the bilaterally symmetrical cardinal
system of veins drains into the sinus venosus (the caudal chamber of the
heart). The anterior cardinal veins on either side drain caudally from the
head and join the posterior cardinal veins carrying blood from the caudal
portion of the embryo. This union results in bilaterally symmetrical venous
channels known as the ducts of Cuvier or the common cardinal veins which
empty into the lateral horns of the sinus venosus. At this stage, the anterior
cardinal veins penetrate the skull at an opening which will become the jugu-
lar foramen. The segment of the anterior cardinal vein superior to this open-
ing contributes to the sigmoid portion of the lateral venous sinus and the
segment inferior to the opening becomes the internal jugular vein (268).
Meanwhile, the primary head sinus assumes a position lateral to the Xth cra-
nial nerve.
Although the stem of the anterior dural plexus disappears, the portion
which has an anastomosis with the middle dural sinus forms the transverse
sinus. One of its tributaries is the primitive metencephalic vein which later
becomes the superior petrosal sinus. The stem of the middle dural plexus
persists as the pro-otic sinus. During the eighth week of development, a
medial extension of the pro-otic sinus joins the myelencephalic vein, form-
ing a plexiform cranial extension known as the inferior petrosal sinus.
Temporal Bone (0–8 Weeks) The adult temporal bone is made up of five
major components, namely the squamous part (squama), the petrous part
(petrosa), the tympanic bone, the mastoid process, and the styloid process.
However, of these five components, the mastoid and styloid processes do not
fully develop until after birth. Both the squama and the tympanic bone are
products of membranous bone development. The petrous portion is repre-
sented by the cartilaginous otic capsule until 20 weeks of gestation during
which ossification proceeds; the styloid process also is preformed in cartilage.
It is not until the eight-week stage that one can first discern develop-
ment of the squama of the temporal bone as commencing from an ossifica-
tion center which extends into the zygomatic process.
Development to 16 Weeks
The Membranous Labyrinth (8–16 Weeks) Between eight and nine weeks,
migration of the vertical shelf downward initially brings it into contact with
the medial fold (Fig. 16), and later it veers laterally to overlap the ridge from
the lateral wall. As a result, the utricle now connects only indirectly to the sac-
cule through the utricular and saccular ducts. Further migration of the medial
horizontal shelf in a ventral direction delineates the saccule from the utricu-
losaccular duct. The free edge of the dorsal vertically oriented infolding per-
sists as the utriculo-endolymphatic valve of Bast.
Also, in this time period, rugosities develop in the proximal portion of
the endolymphatic duct. Between 10 and 12 weeks, the adult configuration
of the membranous labyrinth is completely achieved.
The Cochlear Duct (8–16 Weeks) Having completed its requisite two and
one-half turns by the 8- to 10-week stage, further growth of the cochlear duct
occurs in caliber only and is essentially completed by midterm. The caliber
of the cochlear duct is less than that of the neighboring scala tympani and
scala vestibuli. The osseous spiral lamina stretches from the modiolus
between the scalae to the inner margin of the cochlear duct (Figs. 44 and 51).
The original round shape of the cochlear duct (Fig. 30) changes to oval by

Figure 16
Drawing of the developing otic labyrinth in a human
embryo at 9 wk. The progressive deepening of folds I, II,
and III transforms the original primitive utricular sac into
the adult utricle, saccule, and endolymphatic duct (see
Fig. 9 on p. 261). This embryologic process mimics that
of the phylogenetic development of the otic labyrinth (see
p. 251). Fold I gives rise to the utriculo-endolymphatic
valve. Source: After Bast and Anson, 1949.
11 weeks (Fig. 44) and to triangular by 16 weeks (Fig. 48). Three walls are
thus defined: the anterior wall forms the vestibular (Reissner’s) membrane
by fusion with the wall of the scala vestibuli, the posterior wall forms the
basilar membrane through union with the wall of the scala tympani, and the
spiral ligament constitutes the outer wall. In the 11-week fetus, at the region
of the future basilar membrane, the stratified epithelium of the cochlear duct
flattens into a simple columnar epithelium. Further development results in
a pseudostratified mound of cells and a vaguely discernible tectorial mem-
brane along its free edge. By 14 weeks, the epithelium of the anterior wall
has progressed to a cuboidal architecture. At the basal end of the cochlear
duct, the epithelium of the future organ of Corti shows swelling and disjunc-
tion of the cells at the area of the outer hair cells. In the 16-week fetus, the
cochlear duct has attained its final triangular configuration (Fig. 51). The
epithelium of the posterior wall (basilar membrane) continues its differenti-
ation into the organ of Corti and the tectorial membrane. The epithelium of
the outer wall undergoes differentiation into the stria vascularis with the spi-
ral ligament acting as a foundation. Meanwhile, the cellular differentiation
of the organ of Corti spreads apically. The cochlear nerve traverses tissue
which will become the osseous spiral lamina, the outer free margin of which
acts as an anchor for the inner angle of the cochlear duct (Fig. 44).
The Utricle and Saccule (8–16 Weeks) With further progression of the infold-
ings of the membranous labyrinth, the vertically oriented fold (Fig. 16) forms
the utriculo-endolymphatic valve. In the 10- to 12-week stage, the maculae
show sensory cells with tufted free margins and supporting cells (Fig. 44). The
now forming otolithic membrane appears as a gelatinous cushion overlying the
epithelium of the maculae and is superficially studded with rhombic crystals of
calcium carbonate, the otoconia. By the 14- to 16-week stage, the individual
components of the maculae are almost fully differentiated to resemble the adult
structure, yet the surrounding otic capsule is still largely cartilaginous.

The Semicircular Ducts (8–16 Weeks) Progressive growth in ductal diameter
and arch of curvature occurs throughout this period. The simple squamous
epithelium of the cristae, now pseudostratified, progressively differentiates
into the sensory hair cell and supporting cell populations of the adult cristae
by the 10th to 12th weeks of gestation; the hair cells have cilia at their free
margin. By the 15th week, the cristae are sickle-shaped in structure and there
is a well-developed cupula in which are embedded the bristle-like projec-
tions of the sensory hair cells (Figs. 36 and 54).
The Otic Capsule (8–16 Weeks) At nine weeks, the precartilage bordering
the developing membranous labyrinth dedifferentiates into loose reticular
mesenchyme, permitting growth of the labyrinth (Fig. 17). As precartilage
dedifferentiates to reticulum, adjacent cartilage dedifferentiates to precarti-
lage in preparation for yet further expansion. On the outer (advancing)
aspect of the enlarging semicircular canals, cartilage dedifferentiates to pre-
cartilage and precartilage dedifferentiates into a mesenchymal reticulum. On
the inner (trailing) edge of the canal, mesenchymal reticulum once more dif-
ferentiates to precartilage which in turn redifferentiates into cartilage. The
formation of the periotic space surrounding the otic labyrinth also involves
the dedifferentiation of the immediately adjacent precartilage.
In the first phase of growth of the otic labyrinth, the inner zone of pre-
cartilage gradually forms three layers: an inner zone of dense areolar tissue
which envelops the epithelium of the otic labyrinth (the membrana propria),
a center zone of loose, arachnoid-like tissue which is the fluid-filled (periotic)
space, and an outer zone of dense tissue which forms the perichondrium of the
otic capsule. The dedifferentiation of precartilage to a reticulum first appears
in the tissue between the stapes and utricle. In the second phase, between 9
Figure 17
The semicircular canals undergo
growth in the arc of curvature and in
cross-sectional diameter. Source:
After Pearson (308).

and 10 weeks, the latticework of the reticulum of the center zone coalesces to
form the first periotic space proper. The third and final stage begins with for-
mation of perichondrium in the 12th week and proceeds to the beginning of
ossification of the cartilage surrounding the membranous labyrinth by the
16th week (Figs. 46 and 51). Despite the small size of the otic capsule, ossifica-
tion involves 14 centers which appear in succession and enlarge to fuse with
other centers (see p. 288). The first such ossification center appears at approx-
imately 16 weeks on the outer aspect of the capsule at the origin of the basal
turn of the cochlea. Ossification is completed only shortly before birth.
The Perilymphatic Space (8–16 Weeks) Vacuole formation in the reticulum

(periotic mesenchyme) is the next step in the hollowing-out of space for the
perilymphatic system. By the 10th week, this process is relatively advanced,
especially at the lateral region of the saccule and utricle, resulting in a
mesothelially lined cavity separating the saccule and adjacent utricle from the
stapedial footplate (Fig. 40). The periotic tissue immediately begins to
develop fibers for the support of the saccular and utricular walls and their
vascular and neural supply. The development of the periotic spaces in the
canalicular region lags behind. By the 12th week, the primitive reticulum sur-
rounding the cochlear duct and nascent spiral lamina is extensively vac-
uolized with the interfibrillar spaces coalescing to form the scalae. However,
the first periotic space to clearly develop is the perilymphatic cistern of the
vestibule, adjacent to the oval window; this step occurs by late in the 12th
week. The scala tympani differentiates soon thereafter in the region of the
round window with the scala vestibuli forming slightly later as an outpouch-
ing of the perilymphatic cistern near the oval window (the area of the basal
coil of the cochlea). The central boundaries of the developing scalae are
smooth, but their peripheries are irregular, growing to keep up with the over-
all expansion of the cochlea. The osseous spiral lamina develops as mem-
brane bone within the connective tissue between the periotic scala tympani
and scala vestibuli, lengthening to meet the separately formed modiolus (also
membrane bone). By 16 weeks, the primordial reticulum surrounding the
canalicular part of the periotic labyrinth also becomes highly vacuolated. At
this same stage, fibrils appear within the reticulum to support the passage of
blood vessels and nerves entering from the internal auditory canal.
The Capsular Channels (8–16 Weeks) By the ninth week, the inferior
cochlear vein (vein at the cochlear aqueduct) becomes apparent in the
cochlear aqueductal syncytium. Also, a cartilaginous bar begins to stretch
from the area of the round window niche and ampulla of the posterior canal
toward the gap of the cochlear aqueduct which eventually forms the floor
and medial rim of the round window.
The Fissula Ante Fenestram (0–16 Weeks) In the ninth week, the fissula ante
fenestram is first noticed as a strip of precartilage in the lateral wall of the
still cartilaginous otic capsule. Gradually it enlarges and by the 14-week
stage its mesenchyme which consists of perilymphatic connective tissue is in
continuity with the connective tissue of the middle ear, the stapediovestibu-
lar joint, and the vestibule. The fissula ante fenestram connects the inner and
middle ear spaces as it traverses the bony partition of the otic capsule.
Vascular channels enter the fissula from the middle ear.
The Fossula Post Fenestram (0–16 Weeks) The fossula post fenestram is
an evagination of vestibular periotic tissue into the lateral wall of the otic

capsule at the posterior aspect of the oval window. The fossula develops in
about two-thirds of embryos and usually is without a communication with
the middle ear.
The Facial Nerve (8–16 Weeks) In the eighth week, a branch of the facial
nerve to the stapedius muscle is evident as the stapedius muscle becomes
distinctly separated from the facial nerve (Figs. 30 and 31).
Between 12 and 13 weeks, the nervus intermedius develops communi-
cations with the motor root of the facial nerve and the cochlear nerve.
Originating from the dorsomedial aspect of the facial nerve are two branches
which fuse and then connect with the superior ganglia of the vagus and glos-
sopharyngeal nerves; this connection results in a nerve which passes
through the primitive tympanomastoid fissure to innervate the subcuta-
neous tissue of the external auditory canal (312). By the 15th week, the genic-
ulate ganglion is developed to the form present at birth.

(8–16 Weeks) During the ninth week, a solid cord of epithelial cells called the
meatal plate or plug, which represents an ingrowth from the fundus of the
primitive external auditory canal, extends toward the lower wall of the tym-
panic cavity (Fig. 13); at its terminus this ectodermal plate forms a disc-like
swelling. The mesenchyme between the meatal plate and the epithelial cells
of the tympanic cavity forms the fibrous layer of the lamina propria of the
tympanic membrane. The inner mucosal layer of the tympanic membrane is
derived from the endodermal tissue of the tympanic cavity (the tubotym-
panic recess). The first of four small ossification centers of the membrane
bone of the tympanic ring appears at approximately nine weeks. There is con-
tinued expansion of the solid external auditory canal with cranial growth
until approximately the 12th week, at which point the bony tympanic ring
has formed at the periphery of the tympanic membrane. Once the four ossi-
fication centers have fused, there is rapid growth so that the tympanic ring is
almost fully developed by the 16th week. A fault known as the notch of
Rivinus remains at the superior cranial aspect of the ring. While the tympanic
membrane elsewhere inserts into a sulcus in the tympanic ring, superior to
the notch of Rivinus it attaches directly to the petrous bone.
The Tympanomastoid Compartment (8–16 Weeks) The tympanic cavity

gradually expands so that by the 12th week it extends over the medial sur-
face of the inferior two-thirds of the tympanic membrane as well as the lat-
eral wall of the middle ear. Dissolution of the mesenchyme of the middle ear
progresses to eventually reach the epitympanic recess. With the differentia-
tion of the ossicles and their associated muscles, there is dissolution of much
residual mesenchyme, facilitating the expansion of the tympanic cavity. In
the process the middle ear structures become ensheathed in a lining mucosa
similar to the development of the abdominal visceral peritoneum.
By 16 weeks, growth of the tympanic process of the squamous part of
the temporal bone has defined the anterior wall of the epitympanic cavity
and contributed to the lateral wall of the tympanic cavity proper. A major
component of the floor of the middle ear is formed by a bony lamella devel-
oping either as an offshoot from the petrous pyramid or as a separate bone
between the pyramid and tympanic ring. The tympanic membrane and the
osseous tympanic ring determine the lateral boundary of the middle ear.
Frazer [cited by Proctor (42)] suggests an alternative concept as to the
origin of the middle ear cavity. Frazer’s scheme involves forward growth of

the third branchial arch to form the primitive tympanic cavity. The third arch
then contacts the first arch at the anterior wall of the recess, which results in
the formation of the anterior and medial walls of the tympanic cavity. In this
concept, the second branchial arch and second branchial groove form the
floor of the tympanic cavity.
The Malleus and Incus (8–16 Weeks) Between the 8th and 10th weeks, the
ossicles and Meckel’s cartilage keep pace with overall embryonic growth,
dwarfing the anterior malleal process which grows more slowly. These pro-
gressive and prodigious ossicular growths occur as cartilaginous models
until approximately the 15th week of gestation, at which point maximal chon-
dral size is attained and the adult morphology is fully manifest (Fig. 49). The
incus initiates the ossification process at this time, being the first to lay down
a thin layer of perichondrial bone. This first ossification center is located on
the anterior surface of its long process and extends up the body of the incus.
Soon thereafter the malleus shows its first signs of ossification—vacuoliza-
tion of cartilage in the area of continuity with Meckel’s cartilage. Bone forma-
tion in the malleus begins during the 16th week with the development of a
plaque of perichondrial bone on the medial aspect of the neck of the malleus.
Meanwhile, a complete perichondrial bony shell forms around the long
process of the incus and vascular buds enter the calcifying cartilage. In both
the malleus and incus, ossification progresses through the formation of peri-
chondrial, endochondral, and intrachondrial bone. Meckel’s cartilage,
although it continues to grow in size, shows early signs of degeneration on its
surface, which results in the formation of the anterior ligament of the malleus.
The Stapes (8–16 Weeks) In the nine-week fetus, a condensation of tissue has
formed in the mesenchyme at the interhyale—the future stapedius muscle
(Fig. 18). The tendon of the stapedius muscle is derived from the remainder
of the interhyale, which maintains its connection with the head of the stapes.
Figure 18
This is a left lateral view of the deriva-
tion of the ossicles from their respective
branchial arches at 8 to 9 wk. The
malleus is still in continuity with
Meckel’s cartilage. The interhyale,
which develops from Reichert’s carti-
lage, attaches to the stapes at the region
of the incudostapedial articulation and
establishes the site of the insertion of
the stapedius tendon. An aggregation
of cells adjacent to the medial and
proximal aspect of Reichert’s cartilage
gives rise to the stapedius muscle.
Source: After Hanson et al. (330).

The laterohyale fuses to the otic capsule and participates in the development
of the anterior wall of the facial nerve canal as well as the bone of the stape-
dial pyramid (pyramidal eminence). That portion of the anterior wall of the
facial nerve canal which lies distal to the laterohyale is formed by Reichert’s
cartilage. However, in later development, intramembranous ossification
forms a wall separating Reichert’s cartilage from the contents of the facial
nerve canal, which terminates its brief role in the structure of the facial canal
wall (323). By the ninth week, the stapes, like the malleus and incus (Fig. 41),
is composed of cartilage and continued growth as a cartilaginous model
occurs until approximately 15 weeks of gestation. Beginning in the 16th
week, histologic differentiation and separation of the stapes from the otic
capsule becomes apparent with an oval-shaped zone indicating the future
annular ligament. Blood vessels appear in this region, coursing from the pri-
mordial facial nerve canal to both the footplate and the head of the stapes. In
some specimens the first stapedial ossification center may be seen, although
this does not usually occur until nearly the 18th week.
The Ossicular Muscles (0–16 Weeks) The tensor tympani muscle is a deriva-
tive of the first branchial arch and therefore is innervated by the trigeminal
(Vth cranial) nerve. The stapedius muscle is a derivative of the second
branchial arch and is innervated by the facial (VIIth cranial) nerve. In the
eighth week, the primordial tensor tympani muscle is seen in the mesenchyme
destined to become submucosal connective tissue lateral to the cochlea and the
stapedius muscle has developed from tissue of the interhyale.
The Arteries (8–16 Weeks) By the 10th week, the site of origin of most of the
vascular supply to the inner as well as external ear is readily discernible. The
occipital artery branches into the posterior auricular branch and the stylo-
mastoid artery, while it also supplies the endolymphatic sac. The inferior
tympanic artery is recognizable as a branch of the ascending pharyngeal
artery, as are the deep auricular and anterior tympanic arteries.
The Veins (8–16 Weeks) In the 10-week fetus both the inferior petrosal sinus
and the cavernous sinus are well developed. The superior petrosal sinus into
which the internal auditory veins of the internal auditory canal drain is the
last of the dural sinuses to appear. It is usually not until postnatal stages that
its drainage into the cavernous sinus is established. By the 12th week, the
terminal segment of the superior petrosal sinus has evolved from the persist-
ing proximal portion of the pro-otic sinus.
The Temporal Bone (8–16 Weeks) The tympanic part of the temporal bone
begins its development at about 9 to 10 weeks of gestation.
In the ninth week, the squama and zygomatic process begin membrane
bone formation. By the end of the ninth week, the superior wall of the mid-
dle ear emerges as a projection of the otic capsule; it is known as the supe-
rior periotic process. It grows forward over the ossicles forming the lateral
aspect of the tegmen tympani. The medial part of the tegmen tympani con-
sists of a fibrous tissue plate.
Development After 16 Weeks
By the 20th week, the membranous labyrinth is of maximum size and is

housed within a bony capsule. By 25 weeks, the inner ear displays an essen-
tially adult configuration.

The Cochlear Duct (16⫹ Weeks) During the 16th to 20th weeks, the organ of
Corti differentiates into its cellular components. At this time, the inner ear
has attained maximum size and the otic capsule forms a bony shell.
Beginning at approximately the 19th week, the vascular supply of the
cochlea is established by branches of the labyrinthine artery. The vessels pass
through the cochlear modiolus, osseous spiral lamina, and walls of the scalae
to form an end-vessel complex without anastomotic arborization.
The blood supply of the membranous labyrinth remains discrete from
that of the otic capsule, for although branches from the tympanic plexus pen-
etrate the outer periosteal layer of the otic capsule, they do not pass through
the inner periosteal layer. The stria vascularis is fully developed by the 20th
week of gestation and the tunnel of Corti is present in all turns by the 21st
week. By the 22nd week, the inner and outer ridges of the primordial organ
of Corti have differentiated from base to apex into recognizable inner and
outer sensory cells, pillar cells, and cells of Hensen. Developing peripheral
nerve fibers of the spiral ganglion have reached the sensory hair cells. In a
scanning electron microscopic study of the development of the organ of
Corti in fetuses between 18 and 20 weeks of gestation, Tanaka et al. (324)
found that afferent nerve endings were formed earlier than efferent ones.
This observation suggests that the differentiation of the sensory cells of the
organ of Corti is independent of efferent innervation. Deiters’ cells with their
tonofibril-rich cytoplasm also develop at this time. In the 24-week fetus, a
cellular reorganization occurs in the spiral limbus at the region of the inser-
tion of the tectorial membrane; this reorganization accentuates an existing
groove at the inner margin of the organ of Corti, the inner tunnel or inner
spiral sulcus. The inner and outer pillar cells soon develop with their sup-
portive tonofibrils. Cellular resorption is the mechanism of formation for
both the outer tunnel and the space between the inner hair cells and outer
hair cells. Gradual widening of the spaces between the outer phalangeal cells
(so-called because of their resemblance to the bony phalanges of the hand)
and the outer hair cells results in the formation of the spaces of Nuel.
The Semicircular Ducts (16⫹ Weeks) The superior semicircular duct reaches
its adult size by approximately 20 weeks of gestation. The posterior and then
the lateral semicircular ducts follow closely in accordance with the order in
which they were first created phylogenetically. Having already attained
nearly adult structure, the cristae are fully developed at this time (Fig. 62).
The Endolymphatic Duct (16⫹ Weeks) Originally a straight, tubal structure,

by midterm the endolymphatic duct bends in a caudal direction. The
endolymphatic duct originates from the junction of the saccular and utricu-
lar ducts and runs in the vestibular aqueduct parallel to the posteromedial
aspect of the common crus. Its distal termination, the endolymphatic sac,
shows its adult relationships as it lies adjacent to the lateral aspect of the sig-
moid sinus into which its accompanying venous plexus empties. The
endolymphatic sac is exceptional in that it continues to grow as the posterior
cranial fossa expands; it may triple or even quadruple the size it was at
midterm.
The Otic Capsule (16⫹ Weeks) The ossification process of both the canalicu-
lar and cochlear regions of the otic capsule intensifies when the membranous
labyrinth achieves full adult size. Between 16 and 20 weeks, the cochlear part
of the otic capsule completes growth. Even as early as the end of 16 weeks in
some specimens, there may be fusion of the first three ossification centers

superior to the round window (see p. 288). At this time successive ossification
centers appear, 14 in all. Each ossification center and the otic capsule as a
whole, is trilaminar in structure. The external and internal periosteal layers
are derived from the external and internal perichondrial membranes, respec-
tively. They undergo transformation to periosteum with the deposition of cal-
careous material by osteoblasts and vascular bud invasion (Figs. 19 and 20).
These layers develop Haversian systems exactly as in long bones elsewhere
in the body. The enchondral (middle) layer is composed of both intrachondr-
ial and endochondral bone. Intrachondrial bone represents persistent islands
of calcified hyaline cartilage which house osteocytes in the originally carti-
laginous lacunae and is the foundation upon which deposition of endochon-
dral bone takes place. The initial step of the ossification process entails the
invasion of chondral tissue by osteogenic buds which causes devitalization of
the calcified cartilage. Vascular buds remove much of the calcified cartilage
and the spaces created are soon occupied by bone. By 21 weeks, the remain-
ing islands of calcified cartilage become populated by osteoblasts to form
intrachondrial bone. On the outer surfaces of such islands osteoblasts deposit
enchondral bone. Meanwhile, the modiolus begins to develop as membrane
bone at the 20th to 21st week (Fig. 51). By the 21st week, the final ossification
center has appeared and fusion begins. There is no epiphyseal growth
between the centers which fuse directly. Ossification lags in the canalicular
region, allowing for continued growth of the semicircular ducts which is
nearly completed by 24 weeks. The cartilage surrounding the semicircular
canals then undergoes invasion and resorption by vascular buds from the
vessels coursing beneath the arch of the superior semicircular canal in the
subarcuate fossa. This process is soon followed by retreat of the vascular buds
and trilaminar ossification similar to that seen in the cochlear region. The
outer periosteal layer expands by internal and external lamellar bony deposi-
tion and in the central layer endochondral bone is laid down on the spicules
of intrachondrial bone.
Figure 19
The inferior cochlear vein empties into
the inferior petrosal sinus. The devel-
oping stapedius muscle is in close
proximity to the stapes. The outlined
area is enlarged in Figure 20 (fetus, age
17 wk).

Figure 20
This higher power magnification of the
outlined area in Figure 19 shows endo-
chondral (enchondral) bone formation.
Proceeding from right to left, notice that
the cartilage cells sequentially multiply,
hypertrophy, and undergo calcification;
their lacunae are invaded by osteoblasts
which lay down bone. Islands of carti-
lage that are not removed are known as
globuli interossei or intrachondrial
bone (fetus, age 17 wk).
The modiolus is the central conical support for the coils of the cochlear
canal and is unique in the otic capsule for its formation as membranous
bone. Although its ossification is independent of the remainder of the otic
capsule, it is attached to the outer cochlear wall by interscalar septa. It is tra-
versed by the longitudinal and spiral modiolar canals which transmit both
vessels and nerves. Beginning about the 23rd week, the spiral lamina ossifies
in the basal turn of the cochlea. By the 25th week, the modiolus has become
nearly completely ossified and the interscalar septa secure it to the cochlear
wall. By 26 weeks, the deposition of endochondral bone on the bars of intra-
chondrial bone diminishes the intervening marrow spaces to scattered, tiny
vascular channels (somewhat like Volkmann’s canals). This process acceler-
ates to completion just before birth. Once formed, there is no further remod-
eling in either the intrachondrial or endochondral bone layers.
Several unique features in the development of the otic capsule deserve
emphasis (325): (1) rapidity of growth, occurring primarily in the 15- to
21-week stages, (2) large number of ossification centers (14) despite the small
size of the otic capsule, (3) fusion of ossification centers without intervening
epiphyseal bone, (4) trilaminar histologic architecture of the otic capsule, (5)
persistence of fetal architecture in the periosteal and endochondral bone
areas without remodeling, and (6) independent appearance and ossification
of each of the separate ossification centers and of each of the layers of their
trilaminar structure.
The Perilymphatic Spaces (16⫹ Weeks) Development of the perilymphatic

space in the semicircular canal region lags behind that of the vestibule and
cochlear scalae. The perilymphatic space of the semicircular canals achieves
communication with the perilymphatic cistern of the vestibule by the 17th
week (Fig. 48) and full development of the space is achieved by the 20th
week. The final thinning of reticulum leaves an uninterrupted space, except

for scattered trabeculae which stretch between the membranous labyrinth
and the periosteum to provide support and conduits for vascular supply.
The Capsular Channels (16⫹ Weeks) The term “cochlear aqueduct” refers to
the channel in the otic capsule whereas the term “periotic duct” refers to its
enclosed membranous duct which provides communication between the per-
ilymphatic and subarachnoid spaces.
According to Spector et al. (112), the primitive cochlear aqueduct in the
16- to 18-week embryo contains three structures: the tympanomeningeal fis-
sure, the periotic duct, and the inferior cochlear vein. Their analysis of the
16- to 40-week period of development of these structures included four
developmental stages: (1) at 20 weeks growth and ossification of the petrous
apex relegates the inferior cochlear vein to a separate compartment (canal of
Cotugno), (2) at 24 weeks the promontory and rim of the round window fuse
with the capsule of the semicircular canals, obliterating the tympa-
nomeningeal fissure (Figs. 9 and 10 in chap. 5), (3) at 32 weeks progressive
elongation of the cochlear aqueduct and its contained periotic duct occurs by
a process of bone deposition on the medial aspect of the otic capsule at the
petrous apex, and (4) by the 40th week arachnoid tissue has grown into the
cochlear aqueduct to form a lining membrane and meshwork.
Between 32 and 40 weeks of gestation, there is widening of the cranial
opening of the cochlear aqueduct and periotic duct, which completes the
development of these structures.
The Facial Nerve (16⫹ Weeks) By the 17th week of gestation, all of the neu-
ral connections of the facial nerve have been established.
The Facial Canal (8–16⫹ Weeks) The geniculate ganglion area of the canal
is ossified partially in the membranous bone of the middle fossa plate and
the squama of the temporal bone. In the 26-week fetus, as progressive ossi-
fication of the otic capsule takes place, a preliminary sulcus is gradually
transformed into a true facial canal. Growth of periosteal bone is completed
at the deep surface of the facial canal while the anterior superficial surface
still is only partially closed. At 35 weeks, the geniculate ganglion lies upon a
bony plate which separates it from the epitympanum. Bone formation pro-
gresses along with continued morphogenesis of the contained structures so
that the facial canal at full-term closely approximates that of the adult. The
facial canal does not completely close at its cranial surface (facial hiatus) so
that the perineural tissue of the geniculate ganglion maintains direct contact
with the dura, a condition which may persist in adulthood.
The Pinna (16⫹ Weeks) The pinna (auricle) has attained adult configuration
by the 20th week of gestation (growth continues, however, to age nine years)
(Fig. 21). First evident in about the 25th week of development is a tubercle
occasionally appearing on the free margin of the helix known as the
Darwinian tubercle; this structure is the homologue of the tip of the auricle
in lower mammals. The six extrinsic and three intrinsic muscles of the auri-
cle develop from the mesoderm of the hyoid arch and, like other facial mus-
cles, they are innervated by the VIIth cranial nerve.

(16⫹ Weeks) At approximately the 21st week, the solid meatal plate begins
to form a lumen beginning in its deepest portion. By the 28th week, a canal
is formed by disintegration of the central cells of the ectodermal plate. The

Figure 21
The developing pinna and scalp are
shown. Skin appendages are present.
The auricular cartilage is in an
early stage of differentiation (fetus, age
17 wk).
remaining cells establish the epithelial lining of the bony external auditory
canal. The ectodermal plate becomes the inner bony part of the external
auditory canal; the most medial part of the plate also forms the superficial
layer of the tympanic membrane. At approximately the 34th week, the tym-
panic ring becomes fixed to the otic capsule commencing at its posterior
aspect. The walls of the outer cartilaginous part of the meatus are formed by
an extension of auricular cartilage; slit-like defects (fissures of Santorini) are
present in that portion of the cartilage adjacent to the parotid gland and are
of importance as channels of communication between the parotid gland and
the external auditory canal. A gap between the bony and cartilaginous canals
in their anterosuperior aspect is bridged by a fibrous membrane. Fusion of
the tympanic ring to the otic capsule is not complete until birth. Up to three
years after birth, progressive bone formation occurs in the remaining fibrous
portion of the plate resulting in complete ossification of both the anterior
and inferior walls of the external auditory canal. The superior wall of the
external auditory canal is formed solely by the horizontal plate of the tem-
poral squama while the floor grows in from the tympanic ring during early
postnatal life. During early life, the tympanic membrane lies superficially in
a nearly horizontal plane compared to the adult angulation of 50° to 60° from
the horizontal plane. The tympanic ring also contributes to the formation of
the mandibular fossa and the sheath of the styloid process. Atresia or steno-
sis of the external auditory canal is caused by failure of development of the
first branchial groove, either from lack of epithelial ingrowth or failure of
canalization of the meatal plate.
The Tympanomastoid Compartment (16⫹ Weeks) During the period of 16

to 20 weeks of gestation, the eustachian tube lengthens and areas of chondri-
fication arise in the surrounding mesoderm to form the fibrocartilaginous
part of the eustachian tube (Fig. 22).
At 21 weeks, lateral growth of the loose connective tissue of the epi-
tympanic recess marks the future antrum. As early as 24 weeks, there is air

Figure 22
The eustachian tube is patent, lined by
respiratory epithelium, and richly sup-
plied with seromucinous glands (male,
age 5 mo).
cell formation in the petrous pyramid (apical cells) shortly after ossification
of the otic capsule. Other air cell groups that form at about the same time are
the pericarotid and peritubal cells, supracochlear cells (anterosuperior to the
geniculate ganglion), and those of the wall of the tympanic cavity.
Ossification begins in the lateral and medial portions of the tegmen
of the middle ear by 23 weeks; it is not complete until nearly the end of
gestation.
At 29 weeks, the periosteal layer of the otic capsule extends around the
loose connective tissue of the antrum and fuses with the tympanic process of
the squamous bone to form the mastoid process. By the next week, posteri-
orly directed evagination of the epitympanic space begins formation of the
antrum which is well developed by the 35th week. As early as 33 weeks, cav-
itation extends to the mastoid.
By 30 weeks, the tympanic cavity has virtually completed its expan-
sion; the epitympanum follows suit approximately four weeks later. The
antrum of the infant is nearly as large as that of an adult, but the mastoid
continues to grow for 5 to 10 years postnatally.
The Malleus and Incus (16⫹ Weeks) By the end of the 17th week, the origi-
nal plaque of perichondrial bone has extended to the lateral aspect of the
malleus so that the neck is completely encircled. Cartilaginous vacuolization
by lacunar enlargement progresses rapidly beneath the perichondrial shell
and endochondral ossification in the interior of the malleus results in areas
of calcified cartilage. The center of the malleus is invaded by vascular buds
during the next week and the calcifying cartilage is resorbed. The process
permits the formation of bone marrow and trabeculae of intrachondrial bone
(Fig. 49). This casing progressively envelops the head and proximal part of
the manubrium during the 19th week and eventually sheaths the entire ossi-
cle, leaving bare only ligamentous attachment sites on the articular surfaces
and distal end of the manubrium.

Similarly, the perichondrial shell of the incus envelops both the short
and long processes. Endochondral bone forms a layer lining the inner sur-
face of the perichondrial shell. Meanwhile, Meckel’s cartilage regresses by
dedifferentiation of cartilage cells to fibroblasts forming the anterior liga-
ment of the malleus.
By the 20th week, the ossicles have assumed their adult configuration.
The membrane bone of the anterior process of the malleus fuses with the
neck at about the 21st week (Fig. 55). Between the 21st and 24th weeks, the
ossification process extends to the tip of the manubrium by endochondral
ossification. Also by endochondral ossification, the marrow cavities of the
malleus and incus are gradually obliterated and by 26 weeks begin to
undergo the lifelong remodeling process in which areas of bone are resorbed
to be replaced by new bone. The degree to which primary bone is replaced
by new bone is highly variable and does not seem age dependent. At this
stage, as regression of Meckel’s cartilage continues, the only cartilage which
remains is found in the area between the tympanic ring and the petrous por-
tion of the temporal bone.
Nearly adult in structure by the 27th week and free from extraneous
mesenchyme, the ossicles have become enveloped by mucous membrane
which connects each to the walls of the tympanic cavity like the abdominal
mesentery. The supporting ligaments and blood supply of the ossicles are
located in these folds.
At 28 weeks, endosteal bone with the periosteal shell render the ossi-
cles bilaminar in structure. Deposition of endosteal bone occurs rapidly so
that the histologic architecture of the malleus and incus in the early postna-
tal period closely mimics that of the adult (Figs. 55 and 57).
The Stapes (16⫹ Weeks) Generally, ossification is initiated at the 18-week

stage on the tympanic surface of the footplate and spreads to the adjacent
surfaces of the crura and finally to the head. The perichondrial “shell” which
occurs in the early stages of ossification of the other ossicles is incomplete in
the stapes with numerous gaps on the obturator surface. At 20 weeks, disso-
lution of the perichondrial bone and underlying calcified cartilage continues
on the obturator surfaces of the crura in association with deposition of
endosteal bone on the inner regions of the head and the footplate.
Endochondral bone forms a thin layer adherent to the permanently cartilagi-
nous lamina stapedialis of the stapes footplate. As the footplate widens, the
cartilaginous rim of the oval window dedifferentiates from cartilage to mes-
enchyme. This cartilage is continuous with that of the vestibular surface of
the footplate and that of the fissula ante fenestram (Fig. 23). When adult size
has been attained, the mesenchyme at the fenestral rim transforms to fibrous
tissue to create the annular ligament which encircles the stapedial footplate
and anchors it to the rim of the oval window.
During the 32nd week, the mucous membrane of the expanding tym-
panic cavity penetrates the intercrural space as perichondrial bone is
resorbed to create the obturator foramen. Unlike long bones which thicken
and lengthen with body growth, the stapes lose substance in achieving its
adult form and unlike the malleus and incus, the stapes does not enter into
the remodeling process—the fetal bone persists throughout life.
The Ossicular Muscles (16⫹ Weeks) With ossification of the otic capsule, the
semicanal of the tensor tympani muscle gradually encases the muscle in a
bony shell which remains incompletely formed at term and throughout
adult life (Fig. 56).

Figure 23
development of the annular ligament
of the stapediovestibular articulation
which involves the dedifferentiation of
cartilage to precartilage and mes-
enchyme. Mesenchyme is the basis of
the fibrous tissue of the adult annular
ligament (fetus, near term).
The Veins (16⫹ Weeks) In late fetal life, the distal segment of the pro-otic sinus
joins the petrosquamous sinus. Even at birth, part or all of the pro-otic sinus
may persist. Those segments which do remain are transformed postnatally into
diploic channels and the cranial remnant is converted into the lateral wing of
the cavernous sinus.
The Temporal Bone (16⫹ Weeks) After 16 weeks, the postauditory process of
the squama extends posterior to the tympanic ring forming the anterosupe-
rior portion of the mastoid process. During the 20th to 24th week,
the petrous bone, composed of the cartilaginous otic capsule, begins rapid
ossification from multiple centers (see p. 288). At this point, the tympanic
cavity and labyrinth have attained full size; however, the temporal bone,
especially the mastoid process, continues to grow. At 25 weeks, the floor of
the middle ear develops, either as an independent bone located between the
pyramid and the tympanic ring or as a bony lamellar projection of the
petrous pyramid.
By the 29th week, the tympanic process of the squama joins the antral
segment of the periosteal otic capsule to form the lateral wall of the antrum.
At term an ossification center forms at the dorsal aspect of Reichert’s carti-
lage which fuses with the otic capsule to create the styloid eminence in the
floor of the tympanic cavity and also part of the distal segment of the bony
fallopian canal.
The external petrosquamous fissure demarcates the border between
that part of the mastoid derived from the squama and the portion which
arises from the petrosa. This fissure is visible in the newborn, but generally
disappears by the second year of life.
At birth the mastoid antrum is large with a thin shell of bone. The mas-
toid process develops as a prominence on the outer aspect of the petrous
pyramid during the first year of life. As the mastoid grows, the antrum
shrinks in relative size and assumes a more medial position, as does the

facial nerve. The mastoid, although well developed by three years of age,
does not achieve adult configuration for several more years.
Postnatally, the styloid process forms as an ossification center in the
upper portion of Reichert’s cartilage; concurrently, at its ventral aspect
another ossification center appears which will become the lesser horn of the
hyoid and the superior part of the body of the hyoid. The stylohyoid liga-
ment represents the atrophied remnant of the intervening stylohyale. The
fusion of the separate components of the temporal bone then becomes the
major process in its further development.
OSSIFICATION
The Genesis and Growth of Bone
Bone is a connective tissue, the intercellular matrix of which becomes modi-

fied through the deposition of calcareous material. Two types of bone devel-
opment are recognized, depending upon the type of connective tissue in
which it occurs; intramembranous ossification occurs in mesenchyme and
intracartilaginous ossification in a previously established cartilaginous
model.
Intramembranous ossification is a method by which the flat bones of
the skull, the clavicle, and the mandible ossify. The first step consists of mes-
enchymal condensation and increase in vascularity in the region where bone
development is to occur. Certain cells of the connective tissue differentiate
into osteoblasts and lay down osteoid, a blend of collagenous fibers and
homogeneous matrix. Upon calcification, the osteoid becomes bone. Initially,
osteoblasts form a lining membrane on the surface of this bone, the
osteogenic layer; it is at the inner surface of this layer that calcareous depo-
sition occurs. Some of the cells of this osteogenic or cambium layer become
trapped by the bony matrix, later to be recognized as osteocytes which
occupy lacunae. The remainder of the osteogenic layer moves from the epi-
center with the deposition of each successive layer of bone. The bone formed
is insinuated between the vascular channels of the parent mesenchyme and
consists of spicules of bone traversed by multiple blood vessels with their
perivascular tissues. This bone is extant but a short time, for with growth of
the individual, membrane bones also must shift and grow by selective
resorption and deposition of bone.
There are three types of intracartilaginous bone: (1) perichondrial, (2)
enchondral (synonymous with endochondral), and (3) intrachondrial.
The first two types are found in the majority of the long bones of the skele-
ton; however, intrachondrial bone is unique to the otic capsule and ossicles.
Intracartilaginous bone formation differs from intramembranous bone
formation in that it occurs in a pre-existing model of embryonic hyaline
cartilage.
In the initial steps of enchondral bone development, the embryonic
mesenchyme differentiates first into precartilage and then into a true hyaline
cartilage model which mimics the final adult configuration. Growth in size,
as exemplified in the ossicles and otic capsule, takes place primarily in such
cartilage models; only after they attain adult size does ossification com-
mence. The cartilage cells hypertrophy and calcareous salts are deposited on
their intracellular matrix forming calcified cartilage.

At the same time, the connective tissue (perichondrium) which sur-
rounds the cartilaginous model gradually blends with the cartilage cells of
the chondral layer. As ossification begins, the deep layer of the perichon-
drium differentiates into a layer of osteoblasts that deposit perichondrial
bone on the subjacent ossifying cartilage. With the appearance of the peri-
chondrial bone, the perichondrium is then more properly referred to as
periosteum. The periosteal bone envelops the ossifying otic capsule.
At the time that perichondrial bone is being formed, highly cellular
and vascular osteogenic buds enter the otic capsule to gain access to the car-
tilage lacunae which they enlarge and from which they remove the cartilage
cells. Some of the cells of the osteogenic bud differentiate into osteoblasts
which lay down bone in the enlarged cartilage lacunae. They remove some,
but not all, of the calcified cartilage. The islands of calcified cartilage that
remain are referred to as intrachondrial bone (cartilage islands, globuli
interossei).
Osteoblasts form an enveloping membrane around the islands of calci-
fied cartilage and deposit a bone known as enchondral or replacement bone.
The thin layer of periosteal bone that forms on the inner surface of the
otic capsule is commonly known as the endosteal layer of bone. It develops
after the cartilaginous otic capsule has been largely replaced by the
osteogenic buds and intrachondrial bone has formed.
Ossification of the Otic Capsule
There are 14 centers of ossification of the otic capsule which comprises the
petrous portion of the temporal bone. According to Bast (326), ossification
centers arise in relation to nerve terminations, the internal auditory canal,
and the semicircular canals; moreover, “ossification of a particular region of
the otic capsule begins only after the part of the inner ear which it envelops
has attained maximum size” (326). Initially, calcification of cartilage occurs,
then osteogenic buds with their rich vascular supply invade the future ossi-
fication centers. The first three ossification centers appear at approximately
15 weeks’ gestation (Fig. 24).
The first center appears at the outer aspect of the otic capsule as the
basal turn of the cochlear duct sweeps over the round window. This center
later joins with the eighth ossification center. The second center also appears
on the outer aspect of the otic capsule inferior to the entrance of the poste-
rior ampullary nerve to its crista. This center may appear concurrently with
the first or may lag behind it. The third center also develops on the outer
aspect of the otic capsule at the entrance of the superior division of the
vestibular nerve. This center progressively enlarges, and by late in the 18th
week, practically encircles the VIIth cranial nerve, forming the initial facial
canal.
The fourth center generally appears at about 16 weeks (Fig. 24).
Located superior to the round window, it serves to connect the first and sec-
ond centers. The 5th through the 10th ossification centers all begin to form at
about 17 weeks. The fifth center appears on the outer aspect of the otic cap-
sule as well as on the lateral wall of the internal auditory canal. It not only
forms part of the roof of the internal auditory canal, but also fuses with the
posterior aspect of the third center, completing a bony arch over the vestibu-
lar nerve. The sixth center is formed on the inner aspect of the otic capsule
superior to the entry of the cochlear nerve branches to the cochlea; it also
shields the cochlear nerve as it enters the superomedial aspect of the basal

Figure 24
Drawing showing ossification of the
otic capsule at 16.5 wk. Source: After
Anson and Donaldson (4).
turn. This center also contributes in part to the medial wall of the internal
auditory canal. The seventh center appears in the upper medial wall of
the internal auditory canal in the outer part of the otic capsule. As this
center fuses with the fifth center, the roof of the internal auditory canal is
completed. Fusion with the sixth center completes the superomedial wall of
the internal auditory canal. Thus, the fifth, sixth, and seventh centers all con-
tribute to the formation of the bony walls of the internal auditory canal. The
eighth center develops nearly concomitantly with the seventh center on the
outer aspect of the otic capsule (Fig. 25).
Toward the end of the 17th week, the 9th and 10th centers appear in
close succession. The ninth center is situated at the outer aspect of the otic
capsule at the inferomedial rim of the internal auditory canal. The 10th cen-
ter develops at the posterior curve of the superior semicircular canal. The
11th, 12th, and 13th centers appear at 18 weeks in close proximity and there-
fore may not always arise as separate centers. The 11th center develops in
that portion of the otic capsule which lies superolateral to the cochlea, while
the 12th center arises between the cochlea and the superior division of the
vestibular nerve. The 13th center appears just inferior to the 12th center and,
with an inferior extension, partly surrounds the vestibular nerve. Eventually
fusion occurs with the second center.
The 14th and final ossification center appears at 20 to 21 weeks on the
outer aspect of the otic capsule (Fig. 26), overlying a portion of the postero-
lateral part of the posterior semicircular canal. With the appearance of this
center, the ossification of the otic capsule is completed, save for the area of the
fissula ante fenestram and an area covering the posterior and lateral semicir-
cular canals. This latter area allows for the continuing growth of the canals
and eventually ossifies to form the lateral aspect of the superior semicircular
canal only when growth is completed at about 23 weeks. The area of the fis-
sula ante fenestram usually starts its ossification in the 22nd or 23rd week.

Figure 25
Drawing showing ossification of the otic
capsule at 18 wk. Source: After Anson
and Donaldson (4).
Figure 26
Drawing showing ossification of the otic
capsule at 21 wk. Source: After Anson
and Donaldson (4).

Serial Embryologic Sections
The following photomicrographs (Figs. 27–62) show four developmental

stages of the human ear. The first three series are from fetuses of approxi-
mately 8, 12, and 16 weeks of gestation, respectively. The ages of the fetal
specimens were determined by crown-rump length correlated with gesta-
tional ages. These figures are compiled from averages and serve as approxi-
mations; therefore there may be individual variations. The fourth series is
from an infant of approximately five months of age with retarded postnatal
development caused by cerebrohepatorenal (Zellweger’s) syndrome.
The first photomicrograph in each of the fetal series is a cranial
overview, placing the ear perspective with the rest of the head. Then five
horizontal serial sections of the temporal bone are presented, progressing
from superior to inferior levels. To the extent possible, sections are presented
at comparable levels. The higher power photomicrographs show in
sequence the cochleae, utricles and saccules, and cristae ampullares.

FETUS A (8 WEEKS)
Figure 27
This photomicrograph is an overview
of a horizontal section of the head. The
outlined area indicates the regions
shown in Figures 28 to 32, passing
sequentially from superior to inferior.

Figure 28
The future middle ear cavity contains
mesenchyme. The facial and vestibular
nerves are seen passing from the brain
stem to the internal auditory canal.
Figure 29
This view shows the developing carti-
laginous otic capsule and membranous
labyrinth. The primitive cochlear duct
and spiral ganglion are visible.

Figure 30
The cochlear duct has its full two and
one-half turns. The perilymphatic
space of the vestibule is developing as
reticulum is resorbed. (See Fig. 33.)
Figure 31
The malleus and incus are seen. The
normally massive cartilaginous foot-
plate rests in the oval window.
Figure 32
The tubotympanic recess is invading
the mesenchyme of the middle ear. The
ectoderm of the first branchial groove
is approaching the mesodermal con-
densation of the future tympanic
membrane.

Figure 33
This photomicrograph is a higher mag-
nification of the cochlea appearing in
Figure 31.
Figure 34
The utricle is seen in high magnifica-
tion. The sensory epithelium, otolithic
membrane, and vestibular nerve bun-
dles are visualized.

Figure 35
This high magnification of the saccule
shows an already well-formed sensory
epithelium.
Figure 36
The sensory epithelium and the cupula
of the lateral canal are well developed.
The endolymphatic space is fully
developed and the perilymphatic space
is forming by dissolution of reticulum.

FETUS B (12 WEEKS)
Figure 37
Shown here is an overview of a hori-
zontal section of the head. The outlined
area indicates the regions included in
Figures 38 to 42.
Figure 38
The internal auditory canal is well devel-
oped. Ossification has not yet begun.
Facial nerve fibers are located in a sulcus
in the middle ear.

Figure 39
The cochlear scalae are developing and
the cochlear duct has assumed its char-
acteristic triangular shape in the basal
turn. The outlined area is magnified in
Figure 43.
Figure 40
The spiral ganglion is visible in the
basal turn of the cochlea. The vestibule
has expanded.

Figure 41
Note that the cochlear duct in the basal
turn already is nearly triangular in out-
line while the cochlear duct in the apex
still possesses the more immature oval
configuration.
Figure 42
The primitive cochlear aqueduct is
seen extending from the scala tympani
of the basal turn to the posterior cranial
fossa near the inferior petrosal sinus.

Figure 43
This is a higher magnification of the
cochlear duct and adjacent structures
shown in the outlined area of Figure 39.
The periotic reticulum shows greater
resolution in the scala vestibuli than in
the scala tympani. The spiral ganglion
is well developed.
Figure 44
At this stage the vestibular sense
organs show greater differentiation
than the cochlear duct.

FETUS C (16 WEEKS)
Figure 45
Shown is an overview of a horizontal
section of the head. The outlined area
indicates the regions included in
Figures 46 to 50.

Figure 46
The otic capsule is partly ossified.
Figure 47
Resolution of periotic reticulum pro-
ceeds toward development of the peri-
lymphatic spaces.

Figure 48
The stapes footplate is still cartilagi-
nous. The periosteal, endochondral
(enchondral), and endosteal layers of
bone are seen in the cochlear capsule.
The posterior part of the otic capsule is
still largely cartilaginous, allowing for
continued growth and expansion of the
semicircular canals.
Figure 49
The mesenchyme of the middle ear is
undergoing resolution. The incus and
malleus are partly ossified. At this
stage the stapedial crura are larger than
in the adult. Fibers of the tensor tym-
pani muscle are seen. The fissula ante
fenestram and fossula post fenestram
are both visible.

Figure 50
The cochlear aqueduct is clearly
defined. The stapedius muscle and its
tendon have reached the cartilaginous
head of the stapes.
Figure 51
The three layers of bone of the otic cap-
sule are clearly visible. Structures of the
cochlear duct (Reissner’s membrane,
stria vascularis, organ of Corti) are well
developed. There is a fibrillar precipi-
tate in the perilymphatic spaces
which will disappear in later stages of
development.

Figure 52
The cytoarchitecture of the utricular
macula is nearly mature. The perilym-
phatic reticulum has not yet completely
resolved.
Figure 53
The cribrose area for the saccular nerve
bundles has not yet formed. There is a
precipitate in the perilymphatic and
endolymphatic compartments which
indicates a high protein content.

Figure 54
The ampulla of the lateral canal and its
crista show advance toward maturity.
Perilymphatic reticulum remains.

INFANT (5 MONTHS)
Figure 55
The anterior process of the malleus
extends into the petrotympanic fissure.
Thin mesenchyme remains in the epi-
tympanum and mastoid antrum.
Figure 56
The superior part of the mesotympa-
num still contains mesenchyme but is
partially pneumatized. The external
auditory canal contains ceruminous
and keratin debris.

Figure 57
The middle part of the mesotympanum
is fully pneumatized. The obturator
foramen of the stapes still contains
mesenchyme. The mastoid consists of
bone trabeculae and marrow.
Figure 58
The periosteal and endochondral
(enchondral) layers of bone are well
demarcated. The internal auditory
canal is normal but flares at its ostium.

Figure 59
The carotid artery is small at this age.
The facial nerve and stapedius muscle
occupy a common intraosseous space.
Figure 60
The trilaminar structure of the bony
labyrinth is well demonstrated. The
membranous labyrinth appears nor-
mal. The attachment of the posterosu-
perior wall of the saccule to the
anteroinferior wall of the utricle is a
normal condition.

Figure 61
The saccular branch of the inferior
vestibular nerve, as it passes anteriorly
through the cribrose area, normally
tends to bypass the saccular macula; it
then bends abruptly posteriorly to
innervate it. The reinforced area of the
saccular wall probably serves the func-
tion of protection against eddy currents
in the perilymph which are generated
by movements of the footplate.
Figure 62
This high power view shows the crista
of the lateral canal. The sensory epithe-
lium has undergone moderate post-
mortem autolysis. The rarefaction of
the perilymphatic reticulum and the
formation of the bony latticework of
the cribrose area are evident.

References
1. Pye A, Hinchcliffe R. Comparative anatomy of the ear. 19. Gussen R. The human incudomalleal joint. Chondroid
In: Hinchcliffe R, Harrison D, eds. Scientific articular cartilage and degenerative arthritis. Arth
Foundations of Otolaryngology, ch. 13. London: Rheum 1971; 14:465.
William Heinemann Medical Books Publications, 1976. 20. Bolz EA, Lim DJ. Morphology of the stapediovestibu-
2. Rogers BD. Anatomy, embryology, and classification of lar joint. Acta Otolaryngol (Stockh) 1972; 73:10.
auricular deformities. In: Tanzer RC, Edgerton MT, 21. Etholm B, Belal A Jr. Senile changes in the middle ear
eds. Symposium on Reconstruction of the Auricle. Vol. joints. Ann Otol Rhinol Laryngol 1974; 83:49.
10. St. Louis: CV Mosby Co., 1974. 22. Lupin AJ. The relationship of the tensor tympani and
3. Senturia BH, Marcus MD, Lucente FE. Diseases of the tensor palati muscles. Ann Otol Rhinol Laryngol 1969;
External Ear. An Otologic-dermatologic Manual. New 78:792.
York: Grune & Stratton, 1980. 23. Epley JM. Reflexogenic vertigo treated by tensor tym-
4. Anson BJ, Donaldson JA. Surgical Anatomy of the pani transection. Otolaryngol Head Neck Surg 1981;
Temporal Bone. 3rd ed. Philadelphia: WB Saunders 89:849.
Co., 1981. 24. Wright JLW, Etholm B. Anomalies of the middle-ear
5. Main T, Lim D. The human external auditory canal muscles. J Laryngol Otol 1973; 87:281.
secretory system—an ultrastructural study. 25. Hoshino T, Paparella MM. Middle ear muscle anom-
Laryngoscope 1976; 86:1164. alies. Arch Otolaryngol 1971; 94:235.
6. Matsunaga E. The dimorphism in human normal ceru- 26. Proctor B. Surgical anatomy of the posterior tympa-
men. Ann Hum Genet 1962; 25:273. num. Ann Otol Rhinol Laryngol 1969; 78:1026.
7. Petrakis NL, Doherty M, Lee RE, Smith SC, Page NL. 27. Jahrsdoerfer RA, Richtsmeier WJ, Cantrell RW.
Demonstration and implications of lysozyme and Spontaneous CSF otorrhea. Arch Otolaryngol 1981;
immunoglobulins in human ear wax. Nature 1971; 107:257.
229:119. 28. Proctor B, Nielsen E, Proctor C. Petrosquamosal suture
8. Wever EG, Lawrence M. Physiological Acoustics. and lamina. Otolaryngol Head Neck Surg 1981; 89:482.
Princeton: Princeton University Press, 1954. 29. Platzer W. Zur Anatomie der Eminentia pyramidalis
9. Prussak A. Zur Anatomie des menschlichen und des M. Stapedius. Monatschr Ohrenheilk
Trommelfells. Arch Ohrenheilk 1867; 3:255. Laryngorhinol 1961; 95:553.
10. Lim DJ. Human tympanic membrane. An ultrastruc- 30. Spector GJ, Ge X.-X. Development of the hypotympa-
tural observation. Acta Otolaryngol (Stockh) 1970; num in the human fetus and neonate. Ann Otol Rhinol
70:176. Laryngol 1981; 90(suppl 88):1.
11. Shrapnell HJ. On the form and structure of membrana 31. Wigand ME, Trillsch K. Surgical anatomy of the sinus
tympani. Lond M Gaz 1832; 10:120. epitympani. Ann Otol Rhinol Laryngol 1973; 82:378.
12. Wolff D, Bellucci RJ. The human ossicular ligaments. 32. Kawabata I, Paparella MM. Fine structure of the round
Ann Otol Rhinol Laryngol 1956; 65:895. window membrane. Ann Otol Rhinol Laryngol 1971;
13. Davies DG. Malleus fixation. J Laryngol Otol 1968; 80:13.
82:331. 33. Richardson TL, Ishiyama E, Keels EW. Submicroscopic
14. Goodhill V. External conductive hypacusis and the studies of the round window membrane. Acta
fixed malleus syndrome. Acta Otolaryngol (Stockh) Otolaryngol (Stockh) 1971; 71:9.
1966; 217(suppl):1. 34. Schachern PA, Paparella MM, Duvall AJ III, Choo YB.
15. Goodhill V. The fixed malleus syndrome. Trans Am The human round window membrane. Arch
Acad Ophthalmol Otolaryngol 1966; 70:370. Otolaryngol 1984; 110:15.
16. Guilford FR, Anson BJ. Osseous fixation of the malleus. 35. Ombredanne M. Absence congénitale de fenêtre ronde
Trans Am Acad Ophthalmol Otolaryngol 1967; 71:398. dans certaines aplasies mineures. Ann Otolaryngol
17. Schuknecht HF. Pathology of the Ear. Cambridge: Chir Cervicofac 1968; 85:369.
Harvard University Press, 1974. 36. Goodhill V, Harris I, Brockman SJ, Hantz O. Sudden
18. Schuknecht HF. Mondini dysplasia. A clinical and deafness and labyrinthine window ruptures. Audio-
pathological study. Ann Otol Rhinol Laryngol, 1980; vestibular observations. Ann Otol Rhinol Laryngol
89(suppl 65):1. 1973; 82:2.
311
37. Gacek RR. Transection of the posterior ampullary 59. Sainte-Marie G. A paraffin-embedding technique for
nerve for the relief of benign paroxysmal positional studies employing immunofluorescence. J Histochem
vertigo. Ann Otol Rhinol Laryngol 1974; 83:596. Cytochem 1962; 10:250.
38. Saito R, Igarashi M, Alford BR, Guilford FR. 60. Tomasi TB Jr. The Immune System of Secretions.
Anatomical measurement of the sinus tympani. Arch Englewood Cliffs, NJ: Prentice-Hall, 1976.
Otolaryngol 1971; 94:418. 61. Proctor B. The development of the middle ear spaces
39. Cheatle AH. Some Points in the Surgical Anatomy of and their surgical significance. J Laryngol Otol 1964;
the Temporal Bone from Birth to Adult Life. London: J 78:631.
& A Churchill Ltd., 1907. 62. Kessel J. Ueber Form- und Lagererhältnisse eigenthüm-
40. Ballance C. Essays on the Surgery of the Temporal licher an der Schleimhaut des menschlichen Mittelohres
Bone. London: MacMillan Company, 1919. vorkommender Organe. Arch Ohrenheilk 1870; 5:254.
41. Dworacek H. Die anatomischen verhältnisse des 63. Politzer A. Ueber gestielte Gebilde im Mittelohre des
Mittelohres unter operationsmikroskopischer menschlichen Gehörorganes. Wien Med Wchnschr,
Betrachtung. Acta Otolaryngol (Stockh) 1960; 51:15. November 20, 1869.
42. Proctor B. Embryology and anatomy of the eustachian 64. Gussen R. Pacinian corpuscles in the middle ear. J
tube. Arch Otolaryngol 1967; 86:503. Laryngol Otol 1970; 84:71.
43. Proctor B. Anatomy of the eustachian tube. Arch 65. Lim DJ, Jackson D, Bennett J. Human middle ear
Otolaryngol 1973; 97:2. corpuscles—a light and electron microscopic study.
44. Lim DJ. Functional morphology of the lining mem- Laryngoscope 1975; 85:1725.
brane of the middle ear and eustachian tube. An 66. Guild SR. A hitherto unrecognized structure, the glo-
overview. Ann Otol Rhinol Laryngol 1974; 83(suppl mus jugularis, in man. Anat Rec 1941; 79(suppl 2):28.
11):5. 67. Guild SR. The glomus jugulare, a nonchromaffin para-
45. Eggston AA, Wolff D. Histopathology of the Ear, Nose ganglion, in man. Ann Otol Rhinol Laryngol 1953;
and Throat. Baltimore: Williams & Wilkins, 1947. 62:1045.
46. Aschan G. The anatomy of the eustachian tube with 68. Spector GJ, Maisel RH, Ogura JH. Glomus tumors in the
regard to its function. Acta Soc Med Upsal 1955; 60:131. middle ear. I. An analysis of 46 patients. Laryngoscope
47. Graves GO, Edwards LF. The eustachian tube: a 1973; 83:1652.
review of its descriptive, microscopic, topographic and 69. Rosenwasser H. Carotid body tumor of the middle ear
clinical anatomy. Arch Otolaryngol 1944; 39:359. and mastoid. Arch Otolaryngol 1945; 41:64.
48. Ostmann P. Die Würdigung des Fettpolsters der lat- 70. Winship T, Klopp CT, Jenkins WH. Glomus-jugularis
eralen Tubenwand. Ein Beitrag zur Frage der tumors. Cancer 1948; 1:441.
Autophonie. Arch Ohrenheilk 1893; 34:170. 71. Lattes R, Waltner JG. Nonchromaffin paraganglioma
49. Hentzer E. Ultrastructure of the normal mucosa in the of the middle ear (carotid-body-like tumor; glomus-
human middle ear, mastoid cavities, and eustachian jugulare tumor). Cancer 1949; 2:447.
tube. Ann Otol Rhinol Laryngol 1970; 79:1143. 72. Mulligan RM. Chemodectoma in the dog. Am J Pathol
50. Shimada T, Lim DJ. Distribution of ciliated cells in the 1950; 26:680.
human middle ear: electron and light microscopic 73. Gaffney JG. Carotid-body-like tumors of the jugular
observations. Ann Otol Rhinol Laryngol 1972; 81:203. bulb and middle ear. J Pathol Bacteriol 1953; 66:157.
51. Lim DJ, Shimada T, Yoder M. Distribution of 74. Zettergren L, Lindstrom J. Glomus tympanicum, its
mucus-secreting cells in normal middle ear mucosa. occurrence in man and its relation to middle ear
Arch Otolaryngol 1973; 98:2. tumors of carotid body type. Acta Pathol Microbiol
52. Lim DJ. Normal and pathological mucosa of the mid- Scand 1951; 28:157.
dle ear and eustachian tube. Clin Otolaryngol 1979; 75. Alford BR, Guilford FR. A comprehensive study of the
4:213. tumors of the glomus jugulare. Laryngoscope 1962;
53. Birken EA, Brookler KH. Surface tension lowering 72:765.
substance of the eustachian tube in non suppurative 76. Proctor B. Alexander Prussak. Ann Otol Rhinol
otitis media: an experiment with dogs. Laryngoscope Laryngol 1968; 77:344.
1973; 83:255. 77. Anson BJ, Donaldson JA. The Surgical Anatomy of the
54. Liu YS, Lim DJ, Lang RW, Birck HG. Chronic middle Temporal Bone and Ear. Philadelphia: WB Saunders
ear effusions. Immunochemical and bacteriological Co., 1967.
investigations. Arch Otolaryngol 1975; 101:278. 78. Schuknecht HF. Stapedectomy. Boston, Little: Brown &
55. Novikoff AB, Essner E. Pathological changes in cyto- Co., 1971.
plasmic organelles. Fed Proc Suppl 1962; 21:1130. 79. Lempert J, Wolff D. Histopathology of the incus and
56. Hiraide F, Paparella MM. Histochemical characteris- the head of the malleus in cases of stapedial ankylosis.
tics of normal middle ear mucosa. Acta Otolaryngol Arch Otolaryngol 1945; 42:339.
(Stockh) 1972; 74:45. 80. Deaver JB. Surgical Anatomy: A Treatise on Human
57. Lim DJ, Viall J, Birck H, St. Pierre R. Symposium on Anatomy in Its Application to the Practice of Medicine
prophylaxis and treatment of middle ear effusions. and Surgery. Vol. 3. No. 8. Philadelphia: F Blakiston’s
Laryngoscope 1972; 82:1625. Sons & Co., 1901–1903.
58. Lim DJ, Hussl B. Macromolecular transport by the 81. Brödel M. Three Unpublished Drawings of the
middle ear and its lymphatic system. Acta Otolaryngol Anatomy of the Human Ear. Philadelphia: WB
(Stockh) 1975; 80:19. Saunders Co., 1946.

82. Donaldson JA, Anson BJ, Warpeha RL, Rensink MJ. 106. Harada T, Sando I, Myers EN. Microfissure in the oval
The perils of the sinus tympani. Trans Pac Coast Oto- window area. Ann Otol Rhinol Laryngol 1981; 90:174.
Ophthalmol Soc 1968; 49:93. 107. Okano Y, Myers EN. Herniation of the singular nerve
83. Hagens EW. Anatomy and pathology of the petrous into the round window niche. Arch Otolaryngol 1976;
bone: based on a study of fifty temporal bones. Arch 102:478.
Otolaryngol 1934; 19:556. 108. Okano Y, Myers EN, Dickson DR. Microfissure
84. Meltzer PE. The mastoid cells: their arrangement in between the round window niche and posterior canal
relation to the sigmoid portion of the transverse sinus. ampulla. Ann Otol Rhinol Laryngol 1977; 86:49.
Arch Otolaryngol 1934; 19:326. 109. Mayer O. Über die Entstehung der Spontanfrakturen
85. Tremble GE. Pneumatization of the temporal bone. der Labyrinthkapsel und ihre Bedeutung für die
Arch Otolaryngol 1934; 19:172. Otosklerose. Z Hals Nas Ohrenheilk 1930; 26:261.
86. Lindsay JR. Petrous pyramid of temporal bone. 110. Mayer O. Die Ursache der Knochenneubildung bei der
Pneumatization and roentgenologic appearance. Arch Otosklerose. Acta Otolaryngol (Stockh) 1931; 15:35.
Otolaryngol 1940; 31:231. 111. Proops DW, Hawke M, Berger G, Mackay A. The ante-
87. Lindsay JR. Pneumatization of the petrous pyramid. rior process of the malleus. In: Lim DJ, ed. Abstr
Ann Otol Rhinol Laryngol 1941; 50:1109. Seventh Midwinter Res Meet Assn Res Otolaryngol.
88. Hug JE, Pfaltz CR. Temporal bone pneumatization. A Columbus: Offset Print, 1984.
planimetric study. Arch Otorhinolaryngol 1981; 112. Spector GJ, Lee D, Carr C, et al. Later stages of
233:145. development of the periotic duct and its adjacent area
89. Allam AF. Pneumatization of the temporal bone. Ann in the human fetus. Laryngoscope 1980; 90(suppl 20):1.
Otol Rhinol Laryngol 1969; 78:49. 113. Lempert J, Wolff D, Rambo JHT, Wever EG, Lawrence
90. Zuckerkandl E. Zur Anatomie des Warzenfortsatzes. M. New theory for the correlation of the pathology and
Monatschr Ohrenheilk 1879; 13:49. the symptomatology of Ménière’s disease. A research
91. Möller J. Le septum de Körner. Acta Otolaryngol study of the vestibular endolymphatic labyrinth. Ann
(Stockh) 1930; 14:213. Otol Rhinol Laryngol 1952; 61:717.
92. Jones MF. Pathways of approach to the petrous pyra- 114. Altmann F. Discussion. Otolaryngol Clin N Am 1968;
mid. Ann Otol Rhinol Laryngol 1935; 44:458. 1:352.
93. Mayer O. Die Pyramidenzelleneiterungen. Z Hals Nas 115. Duvall AJ III. The ultrastructure of the external sulcus
Ohrenheilk 1937; 42:1. in the guinea pig cochlear duct. Laryngoscope 1969;
94. Lindsay JR. Suppuration in the petrous pyramid. Ann 79:1.
Otol Rhinol Laryngol 1938; 47:3. 116. Shambaugh G. On the structure and function of the
95. Lindsay JR. Osteomyelitis of petrous pyramid of tem- epithelium in the sulcus spiralis externus. Arch
poral bone. Ann Surg 1945; 122:1060. Otolaryngol 1908; 37:538.
96. Ramadier J. Les osteites petreuses profondes (pet- 117. Smith CA. Structure of the stria vascularis and the spi-
rosites). Otorhinolaryngol Int 1933; 17:816. ral prominence. Ann Otol Rhinol Laryngol 1957;
97. Ziegelman EF. The cellular character of one hundred 66:521.
temporal bones: clinical and surgical significance. Ann 118. Huschke E. Über die Hörwerkzeuge. Beitr Physiol
Otol Rhinol Laryngol 1935; 44:3. 1824; 35.
98. Diamant M. Otitis and pneumatisation of the mastoid 119. Huschke E. Ueber die Sinne. Beitr Physiol Naturgesch.
bone. A clinical–statistical analysis. Acta Otolaryngol Vol. 1. Weimar: GHS pr Landes-Industrie-Compoirs,
(Stockh) 1940; 41(suppl):1. 1824.
99. Williams HL. Latent or dormant disease in the pneu- 120. Corti A. Recherches sur l’organe de l’ouie des mam-
matic cell tracts of the temporal bone. Trans Am Acad mifères. Z Wiss Zool 1851; 3:109.
Ophthalmol Otolaryngol 1966; 70:545. 121. Boettcher A. Über entwickelung und Bau des
100. Proctor B. The petromastoid canal. Ann Otol Rhinol Gehörlabyrinthes nach Untersuchungen an
Laryngol 1983; 92:640. Säugethieren. Nova Acta Acad Cesariae 1869; 35:1.
101. Mazzoni A. The subarcuate artery in man. 122. Retzius G. Das Gehörorgan der Wirbeltiere. II. Das
Laryngoscope 1970; 80:69. Gehörorgan der Reptilien, der Vögel, und der
102. Wolff D, Bellucci RJ, Eggston AA. Microscopic Saugetiere. Stockholm: Samson & Wallin, 1884.
Anatomy of the Temporal Bone. Baltimore: Williams & 123. Held H. Die cochlea der Säuger und der Vögel, ihre
Wilkins, 1957. Entwicklung und ihr Bau. In: Bethe A, ed. Handbuch
103. Minor LB, Solomon D, Zinreich JS, Zee DS. Sound- der normalen und pathologischen physiologie. Vol. II.
and/or pressure-induced vertigo due to bone dehis- Berlin: J Springer, 1926.
cence of the superior semicircular canal. Arch 124. Kolmer W. Gehörorgan. I. Das aüssere Ohr. In: von
Otolaryngol Head Neck Surg 1998; 124:249. Mollendorff W, ed. Handbuch Der Mikroskopischen
104. Carey JP, Minor LB, Nager GT. Dehiscence or thinning Anatomie des Menschen. Berlin: J Springer, 1927.
of bone overlying the superior semicircular canal in a 125. Engström H, Wersäll J. Structure and innervation of
temporal bone survey. Arch Otolaryngol Head Neck the inner ear sensory epithelia. Int Rev Cytol 1958;
Surg 2000; 126:137. 7:535.
105. Keleman U. Über die Fissuren im knochernen 126. Engström H, Wersäll J. The ultrastructural organiza-
innenohr. Arch Klin Exp Ohr Nas Kehlkopfheilk 1933; tion of the organ of Corti and of the vestibular sensory
137:36. epithelia. Exp Cell Res 1958; 5:460.
REFERENCES ■ 313
127. Friedmann I. Electron microscope observations on in 149. Montandon P, Gacek RR, Kimura RS. Crista neglecta in
vitro cultures of the isolated fowl embryo otocyst. the cat and human. Ann Otol Rhinol Laryngol 1970;
J Biophys Biochem Cytol 1959; 5:263. 79:105.
128. Flock Å. Electron microscopic and electrophysiological 150. Bast TH. The utriculo-endolymphatic valve. Anat Rec
studies on the lateral line canal organ. Acta 1928; 40:61.
Otolaryngol (Stockh) 1965; 199(suppl):1. 151. Schuknecht HF, Belal AA. The utriculo-endolymphatic
129. Kimura RS. Hairs of the cochlear sensory cells and valve: its functional significance. J Laryngol Otol 1975;
their attachment to the tectorial membrane. Acta 89:985.
Otolaryngol (Stockh) 1966; 61:55. 152. Valvassori GE, Clemis JD. The large vestibular aque-
130. Spoendlin H. The organization of the cochlear recep- duct syndrome. Laryngoscope 1978; 88:723.
tor. Adv Otorhinolaryngol 1966; 13:1. 153. Arenberg IK, Rask-Andersen H, Wilbrand H, Stahle J.
131. Iurato S. Submicroscopic Structure of the Inner Ear. The surgical anatomy of the endolymphatic sac. Arch
Long Island City: Pergamon Press, 1967. Otolaryngol 1977; 103:1.
132. Lim DJ. Three dimensional observation of the inner ear 154. Clemis JD, Valvassori GE. Recent radiographic and
with the scanning electron microscope. Acta clinical observations on the vestibular aqueduct. A pre-
Otolaryngol (Stockh) 1969; 255(suppl):1. liminary report. Otolaryngol Clin N Am 1968; 1:339.
133. Bredberg G, Lindeman H, Ades H, West R, Engström 155. Stahle J, Wilbrand H. The vestibular aqueduct in
H. Scanning electron microscopy of the organ of Corti. patients with Ménière’s disease. A tomographic and
Science 1970; 170:861. clinical investigation. Acta Otolaryngol (Stockh) 1974;
134. Cabezudo LM. The ultrastructure of the basilar mem- 78:36.
brane in the cat. Acta Otolaryngol (Stockh) 1978; 156. Rask-Andersen H, Bredberg G, Stahle J. Structure and
86:160. function of the endolymphatic duct. In: Vosteen K-H,
135. Angelborg C, Engström H. The normal organ of Corti. Schuknecht HF, Pfaltz CR, et al., eds. Ménière’s
In: Møller AR, ed. Basic Mechanisms in Hearing. New Disease. New York: Thieme-Stratton Inc., 1981.
York: Academic Press, 1973. 157. Portmann G. Vertigo. Surgical treatment by opening the
136. Engström H. The cortilymph, the third lymph of the saccus endolymphaticus. Arch Otolaryngol 1927; 6:309.
inner ear. Acta Morphol Neerl Scand 1960; 3:195. 158. Lundquist P.-G. The endolymphatic duct and sac in
137. Iurato S. Submicroscopic structure of the membranous the guinea pig. An electron microscopic and experi-
labyrinth. I. The tectorial membrane. Z Zellforsch 1960; mental investigation. Acta Otolaryngol (Stockh) 1965;
52:105. 201(suppl):1.
138. Lim DJ. Fine morphology of the tectorial membrane: 159. Lundquist P.-G, Kimura R, Wersäll J. Ultrastructural
its relationship to the organ of Corti. Arch Otolaryngol organization of the epithelial lining in the endolym-
1972; 96:199. phatic duct and sac in the guinea pig. Acta
139. de Vries H. Struktur und Lage de Tektorialmembran in Otolaryngol (Stockh) 1964; 57:65.
der Schnecke, untersucht mit neueren Hilfsmitteln. 160. Adlington P. The ultrastructure and the functions of
Acta Otolaryngol (Stockh) 1949; 37:334. the saccus endolymphaticus and its decompression in
140. Lawrence M. Hair cell–tectorial membrane complex. Ménière’s disease. J Laryngol Otol 1967; 81:759.
Am J Otolaryngol 1981; 2:345. 161. Arnvig J. Lymph vessels in the wall of the endolym-
141. Werner C. Das Labyrinth. Bau, Funktion und phatic sac. Arch Otolaryngol 1951; 53:290.
Krankheiten des Innenohres vom Standpunkt einer 162. Mazzoni A. Vein of the vestibular aqueduct. Ann Otol
experimentellen und vergleichenden. Pathologie Rhinol Laryngol 1979; 88:759.
Leipzig: Verlag Georg Thieme, 1940. 163. Sando I, Egami T, Harada T. Course and contents of
142. Perlman HB. The saccule; observations on a differenti- the paravestibular canaliculus. Ann Otol Rhinol
ated reinforced area of the saccular wall in man. Arch Laryngol 1980; 89:147.
Otolaryngol 1940; 32:678. 164. Ogura Y, Clemis JD. A study of the gross anatomy of
143. Kimura RS. Distribution, structure, and function of the human vestibular aqueduct. Ann Otol Rhinol
dark cells in the vestibular labyrinth. Ann Otol Rhinol Laryngol 1971; 80:813.
Laryngol 1969; 78:542. 165. Stahle J, Wilbrand H. The para-vestibular canaliculus.
144. Mira E, dal Negro F. Die histochemischen und Can J Otolaryngol 1974; 3:262.
histoenzymologischen Eigenschaften des Epithels der 166. Meurman Y. Zur Anatomie des Aquaeductus cochleae
Übergangszone der Crista ampullaris. Arch Ohr Nas nebst einigen Bemerkurgen über dessen Physiologie.
Kehlkopfheilk 1969; 193:322. Acta Soc Med Fenn Duodecim (Ser B, Fasc No 1) 1930;
145. Smith CA. Microscopic structure of the utricle. Ann 13:1.
Otol Rhinol Laryngol 1956; 65:450. 167. Anson BJ, Donaldson JA, Warpeha RL, Winch TR. The
146. Wersäll J. Studies on the structure and innervation of vestibular and cochlear aqueducts: their variational
the sensory epithelium of the cristae ampullares in the anatomy in the adult human ear. Laryngoscope 1965;
guinea pig. A light and electron microscopic investiga- 75:1203.
tion. Acta Otolaryngol (Stockh) 1956; 126(suppl):1. 168. Ritter FN, Lawrence M. A histological and experimen-
147. Hamilton DW. The cilium on mammalian vestibular tal study of cochlear aqueduct patency in the adult
hair cells. Anat Rec 1969; 164:253. human. Laryngoscope 1965; 75:1224.
148. Okano Y, Sando I, Myers EN. Crista neglecta in man. 169. Palva T, Dammert K. Human cochlear aqueduct. Acta
Ann Otol Rhinol Laryngol 1978; 87:306. Otolaryngol (Stockh) 1969; 246(suppl):1.

170. Rask-Andersen H, Stahle J, Wilbrand H. Human 190. Carpenter MB. Core Text of Neuroanatomy. 1st ed.
cochlear aqueduct and its accessory canals. Ann Otol Baltimore: Williams & Wilkins, 1972.
Rhinol Laryngol 1977; 86(suppl 42):1. 191. Miehlke A. Normal and anomalous anatomy of the
171. Duckert L. The morphology of the cochlear aqueduct facial nerve and an embryological study of the thalido-
and periotic duct of the guinea pig—a light and elec- mide catastrophe in Germany. Trans Am Acad
tron microscopic study. Trans Am Acad Ophthalmol Otolaryngol 1964; 68:1030.
Otolaryngol 1974; 78:21. 192. May M. Anatomy of the facial nerve (spatial orienta-
172. Waltner JG. Barrier membrane of the cochlear aque- tion of fibers in the temporal bone). Laryngoscope
duct. Histologic studies on the patency of the cochlear 1973; 83:1311.
aqueduct. Arch Otolaryngol 1948; 47:656. 193. Crumley RL. Spatial anatomy of facial nerve fibers—a
173. Schuknecht HF, Seifi AE. Experimental observations preliminary report. Laryngoscope 1980; 90:274.
on the fluid physiology of the inner ear. Ann Otol 194. Kempe LF. Topical organization of the distal portion of
Rhinol Laryngol 1963; 72:687. the facial nerve. J Neurosurg 1980; 52:671.
174. Anson BJ, Donaldson JA, Warpeha RL, Winch TR. A 195. Harris WD. Topography of the facial nerve. Arch
critical appraisal of the anatomy of the perilymphatic Otolaryngol 1968; 88:264.
system in man. Laryngoscope 1964; 74:945. 196. Thomander L, Aldskogius H, Grant G. Motor fiber
175. Palva T. Cochlear aqueduct in infants. Acta organization in the intratemporal portion of the cat
Otolaryngol (Stockh) 1970; 70:83. and rat facial nerve studied with the horseradish per-
176. Kelemen G, La Fuente AD, Olivares FP. The cochlear oxidase technique. Abstr Uppsala Disert Fac Med No
aqueduct: structural considerations. Laryngoscope 404 iii, 1. Uppsala: Acta Universitatis Upsaliensis,
1979; 89:639. 1981.
177. Waltner JG. Histogenesis of corpora amylacea of the 197. Gacek RR, Radpour S. Fiber orientation of the facial
cochlear aqueduct, the internal auditory meatus and the nerve: an experimental study in the cat. Laryngoscope
associated cranial nerves. Arch Otolaryngol 1947; 45:619. 1982; 92:547.
178. Shi S.-R. Temporal bone findings in a case of otopala- 198. Guerrier Y. Surgical anatomy, particularly vascular
todigital syndrome. Arch Otolaryngol 1985; 111:119. supply of the facial nerve. In: Fisch U, ed. Facial Nerve
179. Siebenmann F. Die Korrosions-Anatomie des knocher- Surgery. Birmingham: Aesculapius Publishing
nen Labyrinthes des menschlichen Ohres. Wiesbaden: Company, 1977.
JF Bergmann, 1890. 199. Kuré K, Sano T. Faserarten im N. facialis und die
180. Portmann M, Sterkers JM, Charachon R, Chouard C. funktionelle Bedeutung der Ganglion geniculi.
The Internal Auditory Meatus: Anatomy, Pathology Z Zellforsch Mikroskop Anat 1936; 23:495.
and Surgery. New York: Churchill Livingstone, 1975. 200. Dobozi M. Surgical anatomy of the geniculate gan-
181. Pérez Olivares F, Schuknecht HF. Width of the internal glion. Acta Otolaryngol (Stockh) 1975; 80:116.
auditory canal. A histological study. Ann Otol Rhinol 201. Kitamura K, Kimura RS, Schuknecht HF. The ultra-
Laryngol 1979; 88:316. structure of the geniculate ganglion. Acta Otolaryngol
182. House WF. Surgical exposure of the internal auditory (Stockh) 1982; 93:175.
canal and its contents through the middle, cranial 202. Politzer A. Geschichte der Ohrenheilkunde. Vol. 1.
fossa. Laryngoscope 1961; 71:1363. Stuttgart: F Enke, 1907.
183. House WF, Brackmann DE. Dizziness due to stenosis 203. Ogawa A, Sando I. Spatial occupancy of vessels and
of the internal auditory canal. In: Silverstein H, Norrell facial nerve in the facial canal. Ann Otol Rhinol
H, eds. Neurological Surgery of the Ear. Birmingham: Laryngol 1982; 91:14.
Aesculapius Publishing Co., 1977. 204. Basek M. Anomalies of the facial nerve in normal tem-
184. Parisier SC. The middle cranial fossa approach to the poral bones. Ann Otol Rhinol Laryngol 1962; 71:382.
internal auditory canal—an anatomical study stressing 205. Miehlke A. Anatomy and clinical aspects of the facial
critical distances between surgical landmarks. nerve. Arch Otolaryngol 1965; 81:444.
Laryngoscope 1977; 87(suppl 4):1. 206. Durcan DJ, Shea JJ, Sleeckx JP. Bifurcation of the facial
185. Fisch U. Transtemporal surgery of the internal audi- nerve. Arch Otolaryngol 1967; 86:619.
tory canal. Report of 92 cases, technique, indications 207. Shambaugh GE Jr. Facial nerve decompression and
and results. Adv Otorhinolaryngol 1970; 17:203. repair. In: Surgery of the Ear. 2nd ed. Philadelphia: WB
186. Sobotta J. Atlas of Descriptive Human Anatomy. Saunders Co., 1967.
Vol. III. 7th English ed. Edited and translated by 208. Wright JW Jr, Taylor CC, McKay DC. Variations in the
E. Uhlenhuth. New York: Hafner Publishing Co., 1957. course of the facial nerve as illustrated by tomography.
187. Davis H. Advances in the neurophysiology and Laryngoscope 1967; 77:717.
neuroanatomy of the cochlea. J Acoust Soc Am 1962; 209. Greisen O. Aberrant course of the facial nerve. Arch
34:1377. Otolaryngol 1975; 101:327.
188. Anson BJ, Warpeha RL, Donaldson JA, Rensink MJ. 210. Gerhardt HJ, Otto H.-D. The intratemporal course of
The developmental and adult anatomy of the membra- the facial nerve and its influence on the development
nous and osseous labyrinths of the otic capsule. of the ossicular chain. Acta Otolaryngol (Stockh) 1981;
Otolaryngol Clin N Am 1968; 1:273. 91:567.
189. Gray H. Anatomy of the human body. In: Goss CM, ed. 211. Proctor B, Nager GT. The facial canal: normal anatomy,
Textbook of Human Anatomy. 27th ed. Philadelphia: variations and anomalies. Ann Otol Rhinol Laryngol
Lea & Febiger, 1959. 1982; 91(suppl 97):33.
REFERENCES ■ 315
212. Proctor B, Nager GT. The facial canal: normal anatomy, 235. Groves J. Facial nerve. In: Hinchcliffe R, Harrison D,
variations and anomalies. Trans Am Otol Soc 1982; eds. Chapter 30 in Scientific Foundations of
70:49. Otolaryngology. London: William Heinemann Medical
213. Hough JVD. Malformations and anatomical variations Books Publication, 1976.
seen in the middle ear during the operation for mobi- 236. Arnold F. Der Kopftheil des vegetativen
lization of the stapes. Laryngoscope 1958; 68:1337. Nervensystems beim Menschen. Heidelberg: Karl
214. Hough JVD. Ossicular malformations and their correc- Groos, 1831.
tion. In: Shambaugh GE, Shea J, eds. Proceedings of 237. Mitchell GAG. Cranial extremities of sympathetic
the Shambaugh 5th International Workshop on Middle trunks. Acta Anat 1953; 18:195.
Ear Microsurgery and Fluctuant Hearing Loss. 238. Rosen S. Tympanic plexus. Anatomic study. Arch
Huntsville: Strode Publishers, 1977. Otolaryngol 1950; 52:15.
215. Fowler EP Jr. Variations in the temporal bone course of 239. Portmann M. A propos de la topographie des nerfs de
the facial nerve. Laryngoscope 1961; 71:937. l’oreille moyenne. Rev Laryngol 1955; 76:273.
216. Dickinson JT, Srisomboon P, Kamerer DB. Congenital 240. Portmann M. Quelques observations sur la systémati-
anomaly of the facial nerve. Arch Otolaryngol 1968; sation des nerfs transpétreux. Rev Laryngol 1955;
88:357. 76:281.
217. Altmann F. Malformations of the eustachian tube, the 241. Vidić B, Young PA. Gross and microscopic observa-
middle ear and its appendages. A critical review. Arch tions on the communicating branch of the facial nerve
Otolaryngol 1951; 54:241. to the lesser petrosal nerve. Anat Rec 1967; 158:257.
218. Litton WB, Krause CJ, Anson BA, Cohen WN. The 242. Foley JO, DuBois FS. An experimental study of the
relationship of the facial canal to the annular sulcus. facial nerve. J Comp Neurol 1943; 79:79.
Laryngoscope 1969; 79:1584. 243. Hunt JR. The sensory field of the facial nerve: a further
219. Politzer A. Textbook of the Diseases of the Ear and contribution to the symptomatology of the geniculate
Adjacent Organs. For Students and Practitioners. ganglion. Brain 1915; 38:418.
Translated by O. Dodd, edited by W. Dalby. London, 244. Orzalesi F, Pellegrini E. Sui rapporti fra i nervi inter-
Bailliere: Tindall & Cox, 1894. medio e vestibolare e sulla struttura del ganglio e del
220. Baxter A. Dehiscence of the fallopian canal. An nervo vestibolare nell’uomó. Arch Ital Anat Embriol
anatomical study. J Laryngol Otol 1971; 85:587. 1933; 31:105.
221. Kikuchi J. Topographic anatomy of the temporal bone 245. Böttner V, Ancetti A. La istomortologia dei ganglia
of Japanese. Jpn J Otolaryngol 1907; 13:605. timpanici nell’uomo. Min Otorhinolaryngol 1956; 6:106.
222. Iida H. Topographic anatomy of the middle ear. Pract 246. Goycoolea MV, Carpenter A.-M, Paparella MM, Juhn
Otolaryngol (Kyoto) 1951; 44:420. SK. Ganglia and ganglion cells in the middle ear of the
223. Fowler EP Jr. Medicine of the Ear. 1st ed. New York: cat. Arch Otolaryngol 1980; 106:269.
Thomas Nelson & Sons, 1947. 247. Spoendlin H, Lichtensteiger W. The sympathetic nerve
224. Guild SR. Natural absence of part of the bony wall of supply to the inner ear. Arch Klin Exp Ohr Nas
the facial canal. Laryngoscope 1949; 59:668. Kehlkopfheilk 1967; 189:346.
225. Kaplan J. Congenital dehiscence of the fallopian canal 248. Rasmussen GL. The olivary peduncle and other fiber
in middle ear surgery. Arch Otolaryngol 1960; 72:197. projections of the superior olivary complex. J Comp
226. Beddard D, Saunders WH. Congenital defects in the Neurol 1946; 84:141.
fallopian canal. Laryngoscope 1962; 72:112. 249. Gacek RR. The macula neglecta in the feline species. J
227. Johnsson L.-G, Kingsley TC. Herniation of the facial Comp Neurol 1961; 116:317.
nerve in the middle ear. Arch Otolaryngol 1970; 91:598. 250. Bergström B. Morphology of the vestibular nerve. I.
228. Hall GM, Pulec JL, Rhoton AL Jr. Geniculate ganglion Anatomical studies of the vestibular nerve in man.
anatomy for the otologist. Arch Otolaryngol 1969; Acta Otolaryngol (Stockh) 1973; 76:162.
90:568. 251. Okano Y, Sando I, Myers EN. Branch of the singular
229. Ge X.-X, Spector GJ. Labyrinthine segment and genic- nerve (posterior ampullary nerve) in the otic capsule.
ulate ganglion of facial nerve in fetal and adult human Ann Otol Rhinol Laryngol 1980; 89:13.
temporal bones. Ann Otol Rhinol Laryngol 1981; 252. Silverstein H. Cochlear and vestibular gross and histo-
90(suppl 85):1. logic anatomy (as seen from postauricular approach).
230. House WF, Crabtree JA. Surgical exposure of petrous Otolaryngol Head Neck Surg 1984; 92:207.
portion of seventh nerve. Arch Otolaryngol 1965; 253. Rasmussen AT. Studies of the eighth cranial nerve of
81:506. man. Laryngoscope 1940; 50:67.
231. Saito H, Ruby RF, Schuknecht HF. Course of the sen- 254. House JW, Hitselberger WE, McElveen J, Brackmann
sory component of the nervus intermedius in the tem- DE. Retrolabyrinthine section of the vestibular nerve.
poral bone. Ann Otol Rhinol Laryngol 1970; 79:960. Otolaryngol Head Neck Surg 1984; 92:212.
232. Bull TR. Taste and the chorda tympani. J Laryngol Otol 255. Schuknecht HF, Shinozaki. Unpublished data.
1965; 79:479. 256. Miehlke A. Surgery of the Facial Nerve. 2nd ed.
233. Chilla R, Nicklatsch J, Arglebe C. Late sequelae of Philadelphia: WB Saunders Co., 1973.
iatrogenic damage to chorda tympani nerve. Acta 257. Montandon P. Unpublished data.
Otolaryngol (Stockh) 1982; 94:461. 258. Moniz E. L’encephalographie artérielle son importance
234. Haynes DR. The relations of the facial nerve in the dans la localization des tumeurs cérébrales. Rev
temporal bone. Ann Roy Col Surg England 1955; 16:175. Neurol 1927; 342:72.

259. Goldman NC, Singleton GT, Holly EH. Aberrant inter- 280. Siebenmann F. Die Blutgefässe im Labyrinthe des
nal carotid artery. Arch Otolaryngol 1971; 94:269. menscblichen Ohres. Wiesbaden: JF Bergmann, 1894.
260. Myerson MC, Rubin H, Gilbert JG. Anatomic studies 281. Shambaugh GE. Blood-vessels in the Labyrinth of the
of the petrous portion of the temporal bone. Arch Ear. Vol. X. Dicennial Publication. Chicago: University
Otolaryngol 1934; 20:195. of Chicago Press, 1903.
261. Steffen TN. Vascular anomalies of the middle ear. 282. Shambaugh GE. The distribution of blood-vessels in
Laryngoscope 1968; 78:171. the labyrinth of the ear of the sheep and the calf. Arch
262. Lapayowker MS, Liebman EP, Ronis ML, Safer JN. Otol 1905; 34:71.
Presentation of the internal carotid artery as a tumor of 283. Asai K. Die Blutgefässe des häutigen Labyrinthe der
the middle ear. Radiology 1971; 98:293. Ratte. Anat Hefte 1908; 36:711.
263. Goodman RS, Cohen NL. Aberrant internal carotid 284. Asai K. Die Blutgefässe im häutigen Labyrinthe des
artery in the middle ear. Ann Otol Rhinol Laryngol Hundes. Anat Hefte 1908; 36:369.
1981; 90:67. 285. Nabeya D. The blood vessels of the middle ear, in rela-
264. Glasscock ME III, Dickins JRE, Jackson CG, Wiet RJ. tion to the development of the small ear bones and
Vascular anomalies of the middle ear. Laryngoscope their muscles. (A preliminary report.) Folia Anat Jpn
1980; 90:77. 1923; 1:243.
265. Glasgold AI, Horrigan WD. The internal carotid artery 286. Smith CA. Capillary areas of the cochlea in the guinea
presenting as a middle ear tumor. Laryngoscope 1972; pig. Laryngoscope 1951; 61:1073.
82:2217. 287. Gulya AJ, Schuknecht HF. Letter to the editor. Am J
266. Mazzoni A. Internal auditory canal arterial relations at Otol 1984; 5:262.
the porus acusticus. Ann Otol Rhinol Laryngol 1969; 288. Axelsson A. The vascular anatomy of the cochlea in the
78:797. guinea pig and in man. Acta Otolaryngol (Stockh)
267. Montgomery WW. Surgery of the Upper Respiratory 1968; 243(suppl):1.
System. Vol. 1. 1st ed. Philadelphia: Lea & Febiger, 289. Smith CA. The capillaries of the vestibular membra-
1971. nous labyrinth in the guinea pig. Laryngoscope 1953;
268. Graham MD. The jugular bulb: its anatomic and clinical 63:87.
considerations in contemporary otology. Laryngoscope 290. Anson BJ, Harper DG, Hanson JR. Vascular anatomy of
1977; 87:105. the auditory ossicles and petrous part of the temporal
269. Moretti JA. Highly placed jugular bulb and conductive bone in man. Ann Otol Rhinol Laryngol 1962; 71:622.
deafness. Secondary to sinusojugular hypoplasia. Arch 291. Alberti PWRM. The blood supply of the incudostape-
Otolaryngol 1976; 102:430. dial joint and the lenticular process. Laryngoscope
270. Overton SB, Ritter FN. A high placed jugular bulb in 1963; 73:605.
the middle ear. A clinical and temporal bone study. 292. Smith CA. Capillary areas of the membranous
Laryngoscope 1973; 83:1986. labyrinth. Ann Otol Rhinol Laryngol 1954; 63:435.
271. Nager GT, Nager M. The arteries of the human middle 293. Kalter H, Warkany J. Medical progress. Congenital
ear, with particular regard to the blood supply of the malformations: etiologic factors and their role in pre-
auditory ossicles. Ann Otol Rhinol Laryngol 1953; vention (first of two parts). N Engl J Med 1983; 308:424.
62:923. 294. Kalter H, Warkany J. Congenital malformations (sec-
272. Hyrtl J. Neue Beobachtungen aus dem Gebiete der ond of two parts). N Engl J Med 1983; 308:491.
menschlichen und vergleichenden Anatomie. Med 295. Konigsmark BW, Gorlin RJ. Genetic and Metabolic
Jahrb K K Österreich Staates 1836; 10:446. Deafness. Philadelphia: WB Saunders Co., 1976.
273. Nabeya D. A study in the comparative anatomy of the 296. Gorlin RJ, ed. Morphogenesis and Malformation of the
blood-vascular system of the internal ear in Mammalia Ear. New York: Alan R. Liss, 1980.
and in Homo (Japanese). Acta Sch Med Univ Imperiales 297. Guggenheim L. Phylogenesis of the Ear. Culver City:
Kioto 1923; 6:1. Murray & Gee, 1948.
274. Bast TH, Anson BJ. The Temporal Bone and the Ear. 298. Van Bergeijk WA. Evolution of the sense of hearing in
Springfield: Charles C Thomas, 1949. vertebrates. Am Zoologist 1966; 6:371.
275. Fisch U. Carotid lesions at the skull base. In: 299. Van de Water TR, Maderson PF, Jaskoll TF. The
Brackmann DE, ed. Neurological Surgery of the Ear morphogenesis of the middle and external ear. Birth
and Skull Base. New York: Raven Press, 1982. Defects 1980; 16:147.
276. Davies DG. Persistent stapedial artery: a temporal 300. Tumarkin A. Evolution of the auditory conducting appa-
bone report. J Laryngol Otol 1967; 81:649. ratus in terrestrial vertebrates. In: Ciba Fdn Symp on
277. Baron SH. Persistent stapedial artery, necrosis of the Hearing Mechanisms in Vertebrates, ed. AVS de Reuck
incus, and other problems which have influenced the & J. Knight, JA Churchil, London p. 18, Boston: Little,
choice of technique in stapes replacement surgery in Brown & Co., 1968.
otosclerosis. Laryngoscope 1963; 73:769. 301. Taylor GD. Evolution of the ear. Laryngoscope 1969;
278. Altmann F. Anomalies of the internal carotid artery and 79:638.
its branches; their embryological and comparative 302. Streeter GL. On the development of the membranous
anatomical significance. Report of a new case of persist- labyrinth and the acoustic and facial nerves in the
ent stapedial artery in man. Laryngoscope 1947; 57:313. human embryo. Am J Anat 1906; 6:139.
279. Mazzoni A. Internal auditory artery supply to the 303. Anson BJ. The early development of the membranous
petrous bone. Ann Otol Rhinol Laryngol 1972; 81:13. labyrinth in mammalian embryos, with special reference
REFERENCES ■ 317
to the endolymphatic duct and utriculo-endolymphatic 322. Tandler J. Zur vergleichenden Anatomie der
duct. Anat Rec 1934; 59:15. Kopfarterien bei den Mammalia. Wien: C Gerold’s
304. Anson BJ. The labyrinths and their capsule in health Sohn, 1898.
and disease. Trans Am Acad Ophthalmol Otolaryngol 323. Bast TH, Anson BJ, Richany SF. The development of
1969; 73:17. the second branchial arch (Reichert’s cartilage), facial
305. Anson BJ. Developmental anatomy of the ear. In: canal, and associated structures in man. Northwest U
Paparella MM, Shumrick DA, eds. Otolaryngology. Med Sch Quart Bull 1956; 30:235.
Philadelphia: WB Saunders Co., 1973. 324. Tanaka K, Sakai N, Terayama Y. Organ of Corti in the
306. Bast TH. Development of the aquaeductus cochleae human fetus. Scanning and transmission electron micro-
and its contained periotic duct and cochlear vein in scope studies. Ann Otol Rhinol Laryngol 1979; 88:749.
human embryos. Ann Otol Rhinol Laryngol 1946; 325. Austin DF. Anatomy and embryology. In: Ballenger JJ,
55:278. ed. Diseases of the Nose, Throat, and Ear. 12th ed.
307. Davies J. Embryology and anatomy of the head and Philadelphia: Lea & Febiger, 1977.
neck. In: Paparella MM, Shumrick DA, eds. 326. Bast TH. Ossification of otic capsule in human fetuses.
Otolaryngology. Philadelphia: WB Saunders Co., 1973. Contrib Embryol 1930; 121:53.
308. Pearson AA. Developmental anatomy of the ear. In: 327. Brunner H. Die Verbindungen der Gehörknöchelchen.
English GM, ed. Otolaryngology, ch. 1. Hagerstown: Arch Augen Ohrenheilk 1873; 3:23.
Harper & Row, 1984. 328. Cotunnius D. De Aqueductibus Auris Humanae
309. Batten EH. The origin of the acoustic ganglion in Internae Anatomica Dissertatio. 4°. Neapoli, 1761.
sheep. J Embryol Exp Morphol 1958; 6:597. 329. Gussen R. The stapediovestibular joint: normal struc-
310. Van de Water TR, Ruben RJ. Organogenesis of the ear. ture and pathogenesis of otosclerosis. Acta
In: Hinchcliffe R, Harrison D, eds. Scientific Otolaryngol (Stockh) 1969; 248(suppl):1.
Foundations of Otolaryngology. Ch. 12. London: 330. Hanson JR, Anson BJ, Strickland EM. Branchial
William Heinemann Medical Books Publication, 1976. sources of the auditory ossicles in man. Part II.
311. O’Rahilly R. The early development of the otic vesicle Observations of embryonic stages from 7 mm to 28 mm
in staged human embryos. J Embryol Exp Morphol (CR length). Arch Otolaryngol 1962; 76:200.
1963; 11:741. 331. von Kölliker A. Entwicklungsgeschichte des Menschen
312. Gasser RF. The development of the facial nerve in man. und der Höheren Thiere. Leipzig: W Engelmann, 1861.
Ann Otol Rhinol Laryngol 1967; 76:37. 332. Levine H. Cutaneous carcinoma of the head and neck:
313. Wood-Jones F, Wen I.-C. The development of the exter- management of massive and previously uncontrolled
nal ear. J Anat 1934; 68:525. lesions. Laryngoscope 1983; 93:87.
314. Gradenigo G. Die embryonale Anlage des Mittelohres: 333. Morton LT. A Medical Bibliography (Garrison and
die morphologische Bedeutung der Gehörknöchelchen. Morton). An Annotated Check-list of Texts Illustrating
Med Jahrb 1887; 83:61, 219. the History of Medicine. 4th ed. London: Gower
315. Chatellier HP. Evolution embryologique del’appareil Publishing Company, 1983.
endolymphatique et du cloisonnement utriculo- 334. Politzer A. History of Otology. Vol. I. English transla-
sacculaire chez l’homme. Arch Anat Histol Embryol tion by S. Milstein, C. Portnoff, A. Coleman. Phoenix:
1926; 5:49. Columella Press, 1981.
316. Hilding DA. Electron microscopy of the developing 335. Sando I, Doyle W, Okuno H, Takahara T, Kitajiri M,
hearing organ. Laryngoscope 1969; 79:1691. Coury WJ III. How to remove, process, and study the
317. Jahrsdoerfer RA. The facial nerve in congenital middle temporal bone with the entire eustachian tube and its
ear malformations. Laryngoscope 1981; 91:1217. accessory structures: a method for histopathologic
318. Rabl K. Über das Gebiet des Nervus facialis. Anat Anz study. Auris Nasus Larynx Suppl, 1985; 12(suppl 1):521.
(Jena) 1887; 2:219. 336. Sultan AA. Histoire de l’otologie. Chapitre XVII. Acta
319. His W. Die Formentwicklung des ausseren Ohres. Otorhinolaryngol Belg 1981; 35(suppl IV):1141.
Anat Menschl Embr pt. 3, 1885. 337. von Tröltsch AF. Anatomische Beiträge zur
320. Arey LB. Developmental Anatomy: A Textbook and Ohrenheilkunde. Virchow’s Arch 1859; 17:1.
Laboratory Manual of Embryology. Philadelphia: WB 338. Garrison FH. History of Medicine. 4th ed. Philadelphia:
Saunders Co., 1974. WB Saunders Co., 1929.
321. Streeter GL. Development of the auricle in the human 339. Dobson J. Anatomical Eponyms. 2nd ed. Edinburgh:
embryo. Contrib Embryol 1922; 14:111. E & S Livingstone Ltd., 1962.

Glossary
Acoustic Greek akoustikos, sound or its perception.

AD Latin to or toward.
Aditus [plural: aditus; possessive: aditus] Latin: approach to, access.
Alderman’s Nerve The auricular branch of the vagus (Xth cranial nerve), so named
because of the reflex coughing caused by mechanical stimulation of the skin of the
external auditory canal. Synonym: Arnold’s nerve.
Ampulla [plural: ampullae; possessive: ampullae] Latin: diminutive of amp(h)ora;
little jar or jug. The normal dilated end of a semicircular canal or duct.
An(n)ulus [plural: an(n)uluses or an(n)uli; possessive: an(n)uli] Latin: diminutive of
anus; a ring-like structure.
a. tympanicus, the fibrous annulus, the peripheral fibrous margin of the
tympanic membrane. The term a. fibrocartilagineus membranae tympani is a
misnomer, as this structure contains no cartilage.
Ante Latin: in front of or before.
Anterior Vertical Canal The superior semicircular canal.
Antrum [plural: antra; possessive: antri] Latin: cave.
a. mastoideum, mastoid antrum.
Apertura [plural: aperturae; possessive: aperturae] Latin: the past participle of aperire,
to open; an orifice, hole, or other opening.
a. tympanica canaliculi chordae tympani, the aperture through which the
chorda tympani nerve gains access to the middle ear.
Aqu(a)eductus [plural: aqu(a)eductus; possessive: aqu(a)eductus] Latin: combination
of aqua (water) and ductus (duct); a conduit or a channel for fluid.
a. of Cotugno, canal for the inferior cochlear vein. Synonyms: canal of Cotugno,
first accessory canal of Siebenmann. a. fallopii, canal for the facial nerve.
Synonyms: aqueduct of Fallopius; fallopian canal. a. vestibuli, the vestibular
aqueduct.
Arnold, Tubal Branch of Derivative of the tympanic plexus that ramifies in the
anterolateral wall of the cartilage and mucosa of the eustachian tube.
Arnold’s Nerve The auricular branch of the vagus (Xth cranial nerve). Synonym:
Alderman’s nerve.
Articulatio [plural: articulationes; possessive: articulationis] Latin: articulatus, past
participle of articulare, to divide into joints. A joint between two bones.
Auditory Tube The eustachian tube. Synonym: pharyngotympanic tube.
Auricle or Auricula [plural: auricles or auriculae; possessive: auriculae] Latin: auric-
ula, diminutive of auris; the external part of the ear, the pinna.
Auricular Branch of the Vagus Nerve Synonyms: Arnold’s nerve, Alderman’s nerve.
Auris [plural: aures; possessive: auris] Latin: ear.
a. externa, the external ear. a. interna, the inner ear. a. media, the middle ear.
319
Basilar Papilla The organ of Corti. Synonyms: papilla of Huschke, spiral organ.
Basis [plural: basis; possessive: basis] Latin: pedestal or base.
b. stapedis, the footplate of the stapes.
Bast, Utriculo-Endolymphatic Valve of The utriculo-endolymphatic valve.
Bechterew, Ganglion of Ganglion in the vestibule for fibers going to the basal end
of the organ of Corti.
Bechterew, Nucleus of Superior vestibular nucleus.
Bill’s Bar Vertical crest of the fundus of the internal auditory canal used as an
anatomic landmark during translabyrinthine surgery. Named for William House.
Blue Mantles of Manasse Uniform, basophilic-staining bone deposit, particularly
in the perivascular resorption spaces, commonly seen with otosclerosis.
Bock, Pharyngeal Nerve of The pharyngeal branch of the sphenopalatine nerve.
Synonym: rami pharyngei nervi vagi.
Boettcher (Böttcher) Cells Cells that form a layer located between the basilar mem-
brane and the outer sulcus cells.
Branchial Arch Cartilage, First Synonyms: mandibular cartilage, Meckel’s cartilage.
Branchial Arch Cartilage, Second Synonyms: hyoid cartilage, Reichert’s cartilage.
Breschet’s Hiatus Synonyms: helicotrema, Scarpa’s hiatus.
Caecum [plural: caeca; possessive: caeci] Latin: blind pouch.
c. cupulare, the blind, pouch-like, apical end of the cochlear duct just beyond the
hamulus of the spiral lamina. c. vestibulare, the cul-de-sac basal end of the
cochlear duct that occupies the cochlear recess of the vestibule.
Cajal, Interstitial Nucleus of Nucleus of the medial longitudinal fasciculus.
Canaliculi Perforantes of Schuknecht Tiny openings in the tympanic shelf of the
osseous spiral lamina that connect the scala tympani with the intercellular fluid
spaces within and surrounding the organ of Corti. Synonym: perilymph canaliculi.
Canaliculus [plural: canaliculi; possessive: canaliculi] Latin: diminutive of canalis; a
conduit or channel.
c. cochleae, the cochlear aqueduct. c. tympanicus (superior), the innominate canal
for the lesser superficial petrosal nerve. c. tympanicus (inferior), the canal for
Jacobson’s nerve. c. perforantes, small openings in the tympanic shelf of the
osseous spiral lamina. subarcuate c., petromastoid canal. Synonym: antrocerebellar
canal of Chatellier.
Canalis [plural: canales; possessive: canalis] Latin: channel.
c. mastoideus, a channel from the lateral wall of the jugular fossa carrying
Arnold’s nerve to the tympanomastoid fissure. c. semicirculares ossei, the bony
semicircular canals. c. spiralis modioli (c. spiralis cochleae), Rosenthal’s canal.
Synonym: spiral canal of the modiolus.
Capitulum [plural: capitula; possessive: capituli] Latin: diminutive of caput (head).
c. mallei, the head of the malleus. c. stapedis, the head of the stapes.
Cauda [plural: caudae; possessive: caudae] Latin: tail.
c. helicis, the most inferior portion of the helix of the cartilage of the pinna.
Cavum [plural: cava; possessive: cavi] Latin: hole or cavity.
c. conchae, the inferior depression of the concha of the auricle that leads into the
external auditory canal. c. tympani, the tympanic cavity.
Cellula [plural: cellulae; possessive: cellulae] Latin: diminutive of cella; a small
chamber, a cell.
c. mastoideae, the aerated honeycomb of the mastoid bone. c. tympanicae, the
tympanic air cells.
Cerumen Latin: cera (wax).
Chatellier, Antrocerebellar Canal of The petromastoid canal. Synonym: subarcuate
canaliculus.

Chorda [plural: chordae; possessive: chordae] Latin: cord or sinew.
c. tympani, a sensory branch of the facial nerve that stretches across the middle ear.
Citelli, Sinodural Angle of The sinodural angle.
Claudius’ Cells Those supporting cells of the organ of Corti that line the outer
spiral sulcus.
Cochlea [plural: cochleae; possessive: cochleae] Latin: snail shell. The bony configu-
ration of the organ of hearing.
Cochleare [plural: cochleares; possessive: cochlearis] Latin: spoon.
As cochleariformis: processus c., the bony projection that cradles the tendon of the
tensor tympani muscle as it extends to the neck of malleus.
Collum [plural: colla; possessive: colli] Latin: neck.
c. mallei, the neck of the malleus.
Columella [plural: columellae; possessive: columellae] Latin: small column.
c. cochleae, the modiolus.
Common Cardinal Veins The ducts of Cuvier.
Concha [plural: conchae; possessive: conchae] Latin: a shell-like structure.
c. auriculae, the deepest depression of the auricular cartilage.
Condyloid Greek: kondylos; a rounded articulatory prominence at the end of the
bone, as in the condyloid process of the mandible. The anterior condyloid foramen
refers to the tunnel that transmits the XIIth cranial nerve in the condyloid process of
the occipital bone.
Corti, Hair Cells of Outer hair cells of the organ of Corti.
Corti, Membrane of Tectorial membrane.
Corti, Organ of Synonyms: basilar papilla, papilla of Huschke, spiral organ.
Corti, Pillars of Pillar cells. Synonym: pillars of Corti’s organ.
Corti, Tunnel of Triangular channel, also known as the inner tunnel, which is
formed by the articulation of the heads of the inner and outer pillar cells.
Cortilymph Name given by Engström to his proposed “third lymph” of the inner
ear. This fluid theoretically is found in the tunnel of Corti, the spaces of Nuel, the
outer tunnel, and the spaces around the hair cells. This fluid is now believed to be
perilymph, which reaches these spaces by penetrating the osseous spiral lamina
through channels known as the canaliculi perforantes of Schuknecht.
Cotugno, Canal of Canal for the inferior cochlear vein (vein at the cochlear aque-
duct). Synonym: aqueduct of Cotugno; first accessory canal of Siebenmann.
Cotugno, Fluid of Name originally given to perilymph. Breschet in 1836
adopted the name perilymph and used the term endolymph to describe Scarpa’s fluid.
Cribrose Latin: cribrum (sieve); used in the form cribrose or cribrosa.
macula c. inferior, the small cribrose area deep in the singular canal that transmits
the fibers of the posterior ampullary nerve. macula c. media, the perforated area
at the posteromedial aspect of the fundus of the internal auditory canal that trans-
mits the fibers of the saccular nerve. macula c. superior, the perforated area at the
posterosuperior aspect of the fundus of the internal auditory canal above the falci-
form (transverse) crest that transmits the fibers of the utricular and superior
ampullary nerves. Synonym: Mike’s dot. c. tractus spiralis, the one-and-one-half-
turn spiral perforated area in the anteroinferior part of the fundus of the internal
auditory canal for transmission of the cochlear nerve fibers.
Crista [plural: cristae; possessive: cristae] Latin: crest.
c. falciformis, the transverse crest of the internal auditory canal. c. stapedis, an
intercrural ridge occasionally found on the tympanic aspect of the footplate of the
stapes. c. vestibuli, the vertical crest that separates the spherical recess housing
the saccule from the elliptical recess housing the utricle. c. ampullaris, the neuro-
epithelial crest in an ampulla of a semicircular canal.
GLOSSARY ■ 321
Crus [plural: crura; possessive: cruris] Latin: leg.
c. anterius, the anterior leg of the stapes. c. breve, the short process of the incus.
c. commune, the common duct formed by the superior and posterior canals as
their nonampullated ends enter the vestibule. c. curvilineum, the posterior leg of
the stapes. c. helicis, the oblique ridge of the auricular cartilage that divides the
concha into a superior cymba conchae and an inferior cavum conchae. c. longum,
the long process of the incus. c. posterius, the posterior leg of the stapes. c. recti-
lineum, the anterior leg of the stapes.
Plural: c. anthelicis, divides the superior division of the anthelix into two
ridges between which is a shallow concavity named the triangular fossa.
Cul-de-sac Latin: culus (bottom); French: blind alley, bottom of the sac.
A sac-like cavity or tube that is open only at one end.
Cupula [plural: cupulae; possessive: cupulae] Latin: the diminutive of cupa; a tub or vat.
c. cristae ampullaris, the gelatinous cap of the crista of the ampulla of the semi-
circular duct. c. cochleae, the termination of the cochlear duct at the helicotrema
just distal to the hamulus of the spiral lamina.
Cuvier, Ducts of common cardinal veins.
Cymba [plural: cymbae; possessive: cymbae] Latin: a small boat.
c. conchae, the concave depression of the concha that lies superior to the crus of
the helix.
Deiters’ cells Supporting cells of the outer hair cells. Synonyms: outer phalangeal
cells; sustentacular cells.
Deiters’ Nucleus Lateral vestibular nucleus.
Dorello, Canal of Channel in the dura between the petrous tip and the sphenoid
bone through which the abducens nerve and inferior petrosal sinus enter the cav-
ernous sinus.
Ductus [plural: ductus; possessive: ductus] Latin: a drawing or row.
d. cochlearis, the cochlear duct (scala media). d. endolymphaticus, endolymphatic
duct. Synonym: otic duct. d. perilymphatici, the periotic duct (within the cochlear
aqueduct). d. reuniens, the duct that establishes a communication between the saccule
and the cochlear duct. Synonym: Reichert’s canal. d. semicirculares, the membranous
semicircular canals. d. utriculosaccularis, an alternate name for the utricular duct.
Dura Mater Latin: dura (hard) and mater (mother). The tough, fibrous layer
enveloping the leptomeninges, the brain, and the spinal cord.
Eminentia [plural: eminentiae; possessive: eminentiae] Latin: prominence.
e. arcuata, the arcuate eminence, which is the bulge of the superior semicircular
canal located in the floor of the middle cranial fossa. e. conchae, the bulge on the
medial aspect of the auricle that corresponds to the cavum conchae. e. fossae
triangularis, the bulge on the medial aspect of the auricle that corresponds to the
triangular fossa. e. pyramidalis, the pyramidal eminence from which the tendon
of the stapedius muscle emerges. e. scaphae, the medially located bulge of the
auricle created by the scapha of the concha.
Endolymph Greek: endon (within). The intramembranous inner ear fluid.
Synonyms: Scarpa’s fluid; otic fluid.
Endolymphatic Duct Synonym: otic duct.
Epitympanum Greek: epi-, prefix meaning upon; therefore. That portion of the mid-
dle ear cavity that lies above a horizontal plane drawn through the superior aspect of
the tympanic annulus.
Eustachian Tube Synonyms: auditory tube, pharyngotympanic tube.
Facial Recess (Sinus) Synonyms: posterior recess, suprapyramidal recess.
Fallopian canal Canal for the facial nerve. Synonyms: aqueduct of Fallopius,
aqu(a)eductus Fallopii.
Fenestra [plural: fenestrae; possessive: fenestrae] Latin: window or opening.

f. cochleae, the round window, f. rotunda, the round window, f. vestibuli, the oval
window.
Fissula [plural: fissulae; possessive: fissulae] Latin: fissus, the past participle of findo,
findere; a cleavage or splitting.
f. ante fenestram, the evagination of the perilymphatic space immediately anterior
to the oval window.
Fissura [plural: fissurae; possessive: fissurae] Latin: from fissus, the past participle
form of findere; to split or cleave.
f. antitragohelicina, the deep groove in the auricular cartilage that separates the
tail of the helix from the antitragus.
Fistula [plural: fistulae; possessive: fistulae] Latin: abnormal passage or communica-
tion, ulcer.
Folianus, Processus The anterior process of the malleus. Synonym: processus gra-
cilis mallei.
Foramen [plural: foramina; possessive: foraminis] Latin: a hole or opening.
jugular f., the opening at the base of the skull for the internal jugular vein.
f. magnum, the passageway at the base of the skull for the spinal cord.
f. mastoideum, opening posterior to the mastoid process for the mastoid emissary
vein and an artery. f. ovale, the passageway that transmits the third mandibular
division of the trigeminal (Vth cranial) nerve. f. rotundum, the opening that trans-
mits the second (maxillary) division of the trigeminal nerve. f. singulare, the orifice
of the singular canal for the posterior ampullary nerve located in the posteroinfe-
rior part of the internal auditory canal. Synonyms: foramen singular of Morgagni;
solitary canal; singular canal.
Fossa [plural: fossae; possessive: fossae] Latin: ditch or trench.
f. incudis, the notch in the epitympanum that houses the short process of the
incus. jugular f., the depression on the inferior aspect of the temporal bone that
houses the jugular bulb. mandibular f., the depression, also known as the glenoid
fossa, that accommodates the temporomandibular joint. f. mastoidea, the small
depression immediately posterior to the suprameatal spine of Henle, medial to
which lies the mastoid antrum. f. triangularis, the concavity between the crura of
the anthelix.
Fossula [plural: fossulae; possessive: fossulae] Latin: diminutive of fossa, a ditch.
f. fenestrae cochleae (f. cochlear fenestra), the round window niche, f. fenestrae
vestibuli (f. vestibular fenestra), the oval window niche. f. post fenestram, the
extension of the perilymphatic labyrinth posterior to the oval window. f. rotunda,
the round window niche. f. subarcuata, subarcuate fossa.
Fovea [plural: foveae; possessive: foveae] Latin: small pit.
f. saccus endolymphaticus, the shallow depression on the posterior wall of the
petrous bone (foveate fossa) that accommodates the intra-dural portion of the
endolymphatic sac.
Ganglion [plural: ganglia (or ganglions)] Greek: a cyst-like tumor, a clustering of
neurons generally outside the central nervous system.
Corti’s g., the acoustic ganglion. gasserian g., Synonyms: semilunar ganglion; tri-
geminal ganglion. g. geniculi, the geniculate ganglion of the facial nerve. Meckel’s
g., sphenopalatine ganglion. Scarpa’s g., the vestibular ganglion, g. spirale cochleae,
g. spirale nervi cochleae, g. spirale partis cochlearis nervi octavi, the spiral ganglion
of the cochlear nerve.
Geniculum [plural: genicula; possessive: geniculi] Latin: diminutive of genu; knee.
g. nervus facialis, the sharp bend in the course of the facial nerve at the geniculate
ganglion where the labyrinthine segment ends and the tympanic segment begins.
Gerlach, Tubal Tonsil of Lymphatic follicles in and about the pharyngeal aspect of
the auditory tube described by Gerlach.
Glandulae [plural: glandulae; possessive: glandulae] Latin: glandula; a glandular
swelling.
GLOSSARY ■ 323
g. mucosae, the mucous glands in the cartilaginous portion of the eustachian tube.
Glaserian Fissure Petrotympanic fissure (suture).
Glial-Schwann Sheath Junction Synonym: Obersteiner-Redlich zone.
Gracilis, Processus The anterior process of the malleus. Synonyms: processus
gracilis mallei, processus Folianus.
Gradenigo’s Syndrome Symptom complex consisting of abducens palsy, retro-
orbital facial pain, and suppurative disease of the middle ear indicative of involvement
of the abducens and trigeminal nerves in petrous apicitis.
Grenzscheiden German: thin, basophilic staining membranes that normally line the
inner surfaces of the bony lacunae and canaliculi, as well as the walls of the vascular
channels of the temporal bone.
Gruber’s Ligament Petroclinoid ligament.
Habenula [plural; habenulae; possessive: habenulae] Latin: diminutive of habena;
strip or rein.
h. arcuata, the inner portion of the cochlear basilar membrane. h. perforata, foram-
ina nervosa limbus laminae spiralis, the openings in the tympanic lip of the limbus
permitting passage of the cochlear nerve fibers.
Haller, Plexus of Plexus formed chiefly by fibers from branches of the vagus nerve
with a contribution of fibers from the glossopharyngeal nerve and sympathetic
trunks; this plexus supplies motor, general sensory, and sympathetic innervation to
the muscles and mucosa of the pharynx and soft palate, save for the tensor veli pala-
tini muscle. Synonym: pharyngeal plexus.
Hamulus [plural: hamuli; possessive: hamuli] Latin: little hook.
h. cochleae, h. laminae spiralis, the hooked apical end of the osseous spiral
lamina. h. pterygoideus, a hook-like process on the inferior extremity of the
medial pterygoid plate of the sphenoid bone, around which the tendon of the
tensor veli palatini muscle passes.
Haversian System Consists of a haversian canal and its concentrically arranged
lamellae, comprising the basic unit of structure (osteon) of compact bone. A haver-
sian system is directed primarily in the long axis of the bone.
Held, Randfasernetz of Synonyms: Randfasernetz, Randfadennetz.
Helicotrema Greek: helico, form of helix (snail or coil) and trema (hole). The passage
whereby the scala tympani communicates with the scala vestibuli at the apex of the
cochlea. Synonyms: Breschet’s hiatus; Scarpa’s hiatus.
Helix Greek: coil. The most peripheral arc of the free margin of the auricle.
Henle’s Suprameatal Spine Small spine at the posterosuperior margin of the exter-
nal auditory canal.
Hensen’s Cells Tall supporting cells located in the organ of Corti external to the
outer hair cells.
Hensen’s Stripe In histologic sections a basophilically staining band at the
middle of the undersurface of the tectorial membrane. In its normal position,
this stripe is located at and attached to the border cells just internal to the inner hair
cells.
Hiatus [plural: hiatus; possessive: hiatus] Latin: an opening.
h. canalis facialis, the dehiscence in the middle cranial fossa that transmits the
greater superficial petrosal nerve, occasionally leaving the geniculate ganglion
open at the floor of the middle cranial fossa.
Hillocks of His Six developmental hillocks of the auricle that are derived from the
first and second branchial arches.
Hitselberger’s Sign Anesthesia of the posterior wall of the external auditory canal
innervated by a sensory branch of the facial nerve.
Horizontal Canal The lateral semicircular canal.

Howship’s Lacunae Excavations produced by osteoclastic erosion of bone.
Huguier, Canal of Channel beginning in the petrotympanic fissure through which
the chorda tympani nerve passes as it exits the tympanic cavity anteriorly. Synonym:
iter chordae anterius.
Huschke, Foramen of The lower of the two openings created by the partitioning of
the tympanic annulus in the development of the tympanic ring; it is usually closed
by early childhood.
Huschke, Papilla of The organ of Corti. Synonyms: basilar papilla, spiral organ.
Huschke, Stria Vascularis of Synonym: stria vascularis.
Huschke’s Teeth Tall cells covering the limbus.
Hyoid Cartilage The second branchial arch cartilage. Synonym: Reichert’s cartilage.
Hyrtl’s Fissure Extends from the hypotympanum just inferior to the round window
niche to the posterior cranial fossa paralleling the cochlear aqueduct. (We have been
unable to find Hyrtl’s description of this fissure.) Synonym: tympanomeningeal hiatus.
Incisura [plural: incisurae; possessive: incisurae] Latin: incisum, the past participal of
incidere; to cut into or to cut open.
i. anterior, the concavity that separates the crus of the helix from the tragus of the
auricle. i. intertragica, the depression dividing the tragus from the antitragus.
i. mastoidea, the digastric groove. i. Rivini, notch of Rivinus. Synonym: incisura
tympanica. i. tympanica. Synonyms: incisura rivini; notch of Rivinus.
plural: i. cartilaginis meatus acustici externi, the two fissures located in the ante-
rior wall of the fibrocartilaginous part of the external auditory canal. Synonym:
Santorini’s fissures.
Incus [plural: incudes; possessive: incudis] Latin: anvil. The middle ossicle in the
sound transmission mechanism, so named because of its resemblance to an anvil.
Inferior Cochlear Vein Vein at the cochlear aqueduct. Synonym: vena aquaeductus
cochleae.
Infrapyramidal Recess The sinus tympani.
Interhyal(e) Latin: inter (between); Greek: hyoeides (U-shaped). During embryonic
growth, a small shaft of bone that facilitates the articulation of the cornu of the hyoid
with Meckel’s cartilage, connecting the hyomandibular and the remainder of the
hyoid in some vertebrates.
Internal Auditory Artery Labyrinthine artery.
Isthmus [plural: isthmi; possessive: isthmi] Latin: derived from the Greek isthmos,
narrow passage.
Iter [plural: itineres; possessive: itineris] Latin: a walk or a way.
i. chordae anterius, the opening by which the chorda tympani nerve leaves the
middle ear cavity. Synonym: canal of Huguier. i. chordae posterius, the opening by
which the chorda tympani nerve gains access to the middle ear cavity.
Jacobson’s Nerve Tympanic branch of the glossopharyngeal (IXth cranial) nerve.
Synonym: tympanic nerve.
Koerner’s (Körner’s) Flap Surgically created, laterally based, pedicled flap of skin
of the posterior wall of the external auditory canal.
Koerner’s (Körner’s) Septum The bony partition dividing the mastoid into a lateral
squamous and medial petrous portions. Synonym: petrosquamosal septum.
Labyrinthine Artery Synonym: internal auditory artery.
Labyrinthus [plural: labyrinthi; possessive: labyrinthi] Latin: a maze or labyrinth.
l. membranaceus, the membranous labyrinth of the inner ear. l. osseus, the bony
labyrinth.
Lacuna [plural: lacunae; possessive: lacunae] Latin: pool, a small pit or hollow cavity.
GLOSSARY ■ 325
Lamina [plural: laminae; possessive: laminae] Latin: a thin plate.
l. basilaris, the basilar membrane of the cochlea. l. lateralis, the lateral plate of car-
tilage of the eustachian tube. l. medialis, the medial plate of cartilage of the
eustachian tube. l. membranacea, the band of connective tissue that defines the
cartilaginous eustachian tube inferiorly and laterally. l. spiralis ossea, the osseous
spiral lamina, the spiral projection that winds about the modiolus to end in the
apex of the cochlea at the hamulus.
Lateral Semicircular Canal Synonym: horizontal canal.
Lateral Vestibular Nucleus Synonym: Deiters nucleus.
Leidy, Scutum of Bony lamina of the squama that comprises the lateral wall of the
epitympanic recess. Synonym: lateral epitympanic bony wall.
Lenticular Process of the Incus Synonyms: os orbiculare, Sylvian apophysis.
Levator [plural: levatores; possessive: levatoris] Latin: levare; to raise or lift.
l. veli palatini, the muscle that, in conjunction with the tensor veli palatini, opens the
eustachian tube at its pharyngeal orifice. Synonym: retrotubal muscle of Sebileau.
Ligamentum [plural: ligamenta; possessive: ligamenti] Latin: a bandage or bond.
l. anulare stapedis, the annular ligament of the stapes that anchors the footplate in
the oval window. l. auriculare anterius, the anterior extrinsic ligament of
the auricle. l. auriculare posterius, the posterior extrinsic ligament of the auricle.
l. auriculare superius, the superior extrinsic ligament of the auricle. l. incudis pos-
terius, the ligament that seats the short process of the incus in the incudal fossa to
form the posterior axis of ossicular rotation. l. mallei anterius, the anterior
ligament of the malleus that accompanies the anterior malleal process to form the
anterior axis of ossicular rotation. This ligament must be differentiated from the
anterior suspensory ligament of the malleus, which lies at a more superior level
and tethers the head of the malleus to the anterior wall of the epitympanum.
l. mallei laterale, the suspensory ligament that attaches the neck of the malleus to
the margins of the tympanic notch. l. mallei superius, the suspensory ligament
that connects the head of the malleus to the tegmen of the epitympanum. l. spirale
cochleae, the thickened periosteum of the outer wall of the bony cochlea that acts
as the outer supporting wall for the cochlear duct (spiral ligament).
Limbus [plural: limbi; possessive: limbi] Latin: border or fringe.
l. laminae spiralis osseae, the fibroepithelial mound to which the tectorial and
Reissner’s membranes attach. l. membranae tympani, the thickened rim of the
tympanic membrane.
Lobulus [plural: lobuli; possessive: lobuli] Latin: diminutive of lobus; lobe.
l. auriculae, the lobule of the auricle.
Lucas, Groove of Groove in the spina angularis of the sphenoid bone for the chorda
tympani nerve.
Luschka’s Tonsil Synonyms: nasopharyngeal lymphoid mass; pharyngeal tonsil.
Lympha [plural: lymphae; possessive: lymphae] Latin: water.
Macewen’s Triangle Triangle formed at the lateral-most surface of the temporal
bone by the posterior extension of the upper border of the root of the zygoma (the
temporal line), the posterior wall of the external canal, and a line that connects the
two; this triangle is lateral to the mastoid antrum. Synonym: suprameatal triangle.
Macula [plural: maculae; possessive: maculae] Latin: spot or mark.
m. acustica sacculi, the sense organ of the saccule. m. acustica utriculi, the sense
organ of the utricle. m. cribrosa inferior, the perforated area penetrated by fibers
of the posterior ampullary nerve. m. cribrosa media, the perforated area of the
spherical recess through which nerve fibers pass to the macula of the saccule. m.
cribrosa superior, the perforated area of the elliptical recess through which nerve
fibers pass to the utricle and ampullae of the superior and lateral canals. Synonym:
Mike’s dot. m, sacculi, the sense organ of the saccule. m. utriculi, the sense organ
of the utricle.

Malleus [plural: mallei; possessive: mallei] Latin: hammer or mallet. The most lateral
of the ossicles.
Malleus, Anterior Process of Synonyms: processus Folianus, processus gracilis mallei.
Manasse, Blue Mantles of Synonym: blue mantles.
Mandibular Cartilage Synonyms: first branchial arch cartilage, Meckel’s cartilage.
Manubrium [plural: manubria; possessive: manubrii] Latin: handle.
m. mallei, the descending shaft of the malleus.
Meatus [plural: meatus, meatuses; possessive: meatus] Latin: a passage.
m. acusticus externus, the external auditory canal. m. acusticus externus
cartilagineus, the fibrocartilaginous portion of the external auditory canal.
m. acusticus externus osseus, the bony portion of the external auditory canal.
m. acusticus interims, the internal auditory canal.
Meckel’s Cartilage First branchial arch cartilage. Synonym: mandibular cartilage.
Meckel’s Ganglion Synonym: sphenopalatine ganglion.
Membrana [plural: membranae; possessive: membranae] Latin: a thin film or
membrane.
m. obturatoria stapedis, the veil of mucous membrane that occasionally bridges
the obturator foramen. m. tympani, the tympanic membrane. m. tympani secun-
daria, the round window membrane. m. vestibularis, Reissner’s membrane.
Synonym: vestibular membrane.
Mike’s Dot Macula cribrosa superior that transmits nerve fibers to the utricle and
ampullae of the superior and lateral semicircular canals. It is used as a landmark for
the lateral end of the internal auditory canal in translabyrinthine surgery. Named for
Michael Glasscock.
Modiolus [plural: modioli; possessive: modioli] Latin: hub of a wheel. The tapered
pillar that constitutes the central support of the cochlea. Synonym: columella
cochleae.
Morgagni, Foramen Singular of Foramen for the posterior ampullary nerve.
Synonyms: foramen singulare; singular canal; solitary canal.
Morgagni, Sinus of Gap between the upper border of the superior pharyngeal
constrictor muscle and the base of the skull that transmits the levator veli palatini
muscle and the eustachian tube.
Moriat, Ganglion of Ganglion cells located medially in the perimysium of the
tensor tympani muscle.
Nasopharyngeal Lymphoid Mass Synonyms: Luschka’s tonsil, pharyngeal tonsil.
Nervus [plural: nervi; possessive: nervi] Latin: string or wire.
n. acusticus, the VIIIth cranial nerve, both cochlear and vestibular divisions.
n. ampullaris canalis lateralis, the nerve fibers supplying the ampulla of the lateral
canal. n. ampullaris canalis posterior, the nerve fibers supplying the ampulla of the
posterior canal. n. ampullaris canalis superior, the nerve fibers supplying the
ampulla of the superior canal. n. cochleae, the cochlear nerve. n. facialis, the VIIth
cranial nerve. n. intermedius, the nerve of Wrisberg. n. petrosus superficialis
major, the greater superficial petrosal nerve. n. saccularis, the saccular nerve.
n. stapedius, the nerve to the stapedius muscle. n. tensoris tympani, the nerve to
the tensor tympani muscle. n. utricularis, the utricular nerve. n. vestibularis, the
vestibular nerve (with either inferioris or superioris). n. vestibulocochlearis, the
VIIIth cranial nerve.
Nodulus [plural: noduli; possessive: noduli] Latin: diminutive of nodus; a knob. A
small knot, or irregular rounded lump.
n. lymphatici tubarii, the lymphatic tissue of the eustachian tube.
Nucleus, Lateral Vestibular Synonym: Deiters’ nucleus.
Nucleus of the Medial Longitudinal Fasciculus Synonym: interstitial nucleus of Cajal.
GLOSSARY ■ 327
Nuel, Spaces of Spaces between the processes of the phalangeal cells in the organ
of Corti.
Obersteiner-Redlich Zone Transition zone between peripheral myelin and central
oligodendrital myelin of the cranial nerves. Synonym: glial-Schwann sheath junction.
Olivocochlear Bundle Efferent nerve fibers passing from neurons in the region of
the olive to the cochlea. Synonym: Rasmussen’s bundle.
Oort’s Anastomosis Anastomosis between the saccular branch of the inferior vesti-
bular nerve and the cochlear nerve. Part of the olivocochlear (Rasmussen’s) bundle.
Synonym: vestibulocochlear anastomosis.
Organum [plural: organa; possessive: organi] Latin: instrument or organ.
o. spirale, the organ of Corti. Synonyms: basilar papilla; papilla of Huschke;
spiral organ. o. vestibulocochleare, the statoacoustic organ (embryologic
connotation).
Os Orbiculare Synonyms: lenticular process of the incus, Sylvian apophysis.
Ostium [plural: ostia; possessive: ostii] Latin: an opening.
o. pharyngeum tubae auditivae, the pharyngeal opening of the eustachian tube.
o. tympanicum tubae auditivae, the tympanic orifice of the eustachian tube.
Ostmann, Lateral Fat Pad (Body) of Body of adipose tissue interspersed between
the lateral aspect of the fibrocartilaginous eustachian tube and the tensor veli palatini
muscle (48).
Otic Duct The endolymphatic duct.
Otoconia Greek: ous, ot- (ear); konis (dust). The calcium carbonate crystals of the
otolithic organs.
Outer Hair Cells of the Organ of Corti Synonym: hair cells of Corti.
Papilla, Basilar The organ of Corti. Synonyms: papilla of Huschke, spiral organ.
Papilla of Huschke The organ of Corti. Synonyms: basilar papilla, spiral organ.
Paries [plural: parietes; possessive: parietis] Latin: wall (of a house).
p. caroticus, the carotid (anterior) wall of the middle ear. p. jugularis, the jugular
(inferior) wall of the middle ear. p. labyrinthicus, the labyrinthine (medial) wall of
the middle ear. p. mastoideus, the mastoid (posterior) wall of the middle ear.
p. membranaceus, the membranous (lateral) wall of the middle ear. p. tegmen-
talis, the roof of the middle ear. p. vestibularis ductus cochlearis, the membrane
that separates the scala media from the scala vesribuli. Synonyms: membrana
vestibularis; Reissner’s membrane; vestibular membrane.
Pars [plural: partes; possessive: partis] Latin: part or portion.
p. cartilaginae tubae auditivae, the cartilaginous portion of the eustachian tube.
p. flaccida, the flaccid portion of the tympanic membrane located superior to the
lateral process of the malleus. Synonym: Shrapnell’s membrane, p. mastoideae, the
mastoid part of the temporal bone. p. petrosa, the petrous portion of the temporal
bone. p. propria, the middle (fibrous) layer of the tympanic membrane. p. squamosa,
the squamous portion of the temporal bone. p. tensa, the tense vibrating part of the
tympanic membrane. p. tympanica, the tympanic portion of the temporal bone.
Perilymph Greek: peri (around). The inner ear fluid between the bony and membra-
nous labyrinths. Synonym: fluid of Cotugno.
Perilymph Canaliculi Synonym: canaliculi perforantes of Schuknecht.
Perilymphatic Duct Synonym: periotic duct.
Periotic Duct Membranous tube within the cochlear aqueduct. Synonym: perilym-
phatic duct.
Petroclinoid Ligament Synonym: Gruber’s ligament.
Petromastoid Canal Synonyms: antrocerebellar canal of Chatellier, subarcuate
canaliculus.

Petrosquamosal Fissure (Suture) Narrow hiatus extending from the floor of the
middle cranial fossa that corresponds to the union of the petrous and squamous
portions of the temporal bone.
Petrosquamosal Septum Synonym: Koerner’s (Körner’s) septum.
Petrotympanic Fissure (Suture) Glaserian fissure.
Petrous Latin: rock-like.
p. pyramid, the petrous portion of the temporal bone.
Phalangeal Cells, Outer Synonyms: Deiters’ cells, sustentacular cells.
Pharyngeal Nerve of Bock Pharyngeal branch of the sphenopalatine nerve that
supplies the superior wall of the pharyngeal orifice of the eustachian tube. Synonym:
rami pharyngei nervi vagi.
Pharyngeal Plexus Synonym: plexus of Haller.
Pharyngeal Recess Synonym: fossa of Rosenmüller.
Pharyngeal Tonsil Synonyms: Luschka’s tonsil, nasopharyngeal lymphoid mass.
Pharyngotympanic Tube Synonyms: auditory tube, eustachian tube.
Pillar Cells Supporting cells of the organ of Corti occurring in inner and outer rows
to form the inner tunnel (Corti’s tunnel). Synonyms: pillars of Corti, pillars of Corti’s
organ.
Pinna [plural: pinnae; possessive: pinnae] Latin: a feather or fin. The external part of
the ear, the auricle.
Plexus [plural: plexus; possessive: plexus] Latin: past participle of plectere, to plait or
braid; a network.
p. tympanicus, the tympanic plexus of nerves on the promontory of the middle ear.
Plica [plural: plicae; possessive; plicae] Latin: plicare, to fold; a fold.
p. incudis, the variably present fold of mucosa that extends from the body and
short crus of the incus to the tegmen of the tympanic cavity. p. mallearis anterior,
the variably present membranous fold that extends from the tympanic membrane
to cover the anterior process and anterior ligament of the malleus as well as the
adjacent chorda tympani nerve. p. mallearis posterior, the variably present mem-
brane that extends between the posterior wall of the tympanic cavity and the
manubrium of the malleus to surround the lateral ligament of the malleus and the
posterior aspect of the chorda tympani nerve. p. stapedis, the variably present
membranous fold that extends from the posterior wall of the middle ear to sur-
round the stapes.
Ponticulus [plural: ponticuli; possessive: ponticuli] Latin: diminutive of bridge. The bony
bridge that extends from the posterior wall of the middle ear near the base of the pyram-
idal eminence to the promontory and forms the superior limit of the sinus tympani.
Post Latin: behind.
Posterior Recess Facial Recess (Sinus). Synonym: suprapyramidal recess.
Posterior Vertical Canal Synonym: posterior semicircular canal.
Processus [plural: processus; possessive: processus] Latin: an advance.
p. anterior. Synonyms: anterior process of the malleus; processus Folianus; proces-
sus gracilis mallei. p. cochleariformis, the cochleariform process. p. lateralis
mallei, the lateral process of the malleus. p. lenticularis. Synonyms: lenticular
process of the incus; os orbiculare; Sylvian apophysis.
Prominentia [plural: prominentiae; possessive: prominentiae] Latin: prominens, a
projection or headland.
p. canalis facialis, the bulge of the facial nerve canal as it courses in its tympanic
segment. p. canalis semicircularis lateralis, the bulge of the lateral semicir-
cular canal on the medial aspect of the tympanic cavity and mastoid antrum.
p. mallearis, the lateral process of the malleus. p. styloidea, an eminence on the
floor of the tympanic cavity that represents the root of the styloid process.
GLOSSARY ■ 329
Prussak’s Space Superior recess of the tympanic membrane. The superior tympanic
recess is limited by the pars flaccida, the lateral malleal ligament, and the anterior and
posterior malleal folds. Synonyms: Prussak’s pouch; superior tympanic recess.
Rami Pharyngei Nervi Vagi The pharyngeal branch of the sphenopalatine nerve.
Synonym: pharyngeal nerve of Bock.
Randfasernetz of Held Refers to the portion of the tectorial membrane that blan-
kets the organ of Corti on the “slope of Hensen’s cells” and additionally an outer
sheet that passes as far as the base of Hensen’s cells. In some specimens this sheet
seems to cross the outer sulcus and to extend to the spiral prominence (140).
Synonym: Randfadennetz (124).
Rasmussen’s Bundle The olivocochlear bundle.
Recessus [plural: recessus; possessive: recessus] Latin: a secluded spot or inner room.
r. cochlearis, the concavity delimited by two limbs of the vestibular crest that
houses the blind end (vestibular cecum) of the cochlear duct. r. ellipticus, the
recess of the posterior and superior aspects of the medial wall of the vestibule that
houses the utricle. r. membranae tympani superior, Prussak’s pouch. Synonyms:
Prussak’s space; superior tympanic recess. r. membranae tympani anterior or pos-
terior, the anterior and posterior pouches of von Tröltsch (Troeltsch). r. sphericus,
the round depression on the medial wall of the vestibule that houses the saccular
macula.
Reichert’s Bar Cartilaginous and osseous remnant of Reichert’s cartilage that per-
sists at least until early infancy; located posteromedial to the facial nerve.
Reichert’s Canal The ductus reuniens.
Reichert’s Cartilage Second branchial arch cartilage. Synonym: hyoid cartilage.
Reissner’s Membrane Vestibular membrane that forms the anterior wall of the
cochlear duct, bridging the space from the anterior edge of the spiral ligament to the
inner margin of the limbus. Named by von Kölliker (331). Synonyms: membrana
vestibularis; paries vestibularis ductus cochlearis.
Reticulum [plural: reticula; possessive: reticuli] Latin: diminutive of rete, net.
Rivinus, Notch of Superior deficiency in the tympanic ring that acts as the superior
attachment of the pars flaccida of the tympanic membrane. Synonyms: incisura rivini;
tympanic incisura.
Rosenmüller, Fossa of Recess in the nasopharynx located posterior to the torus
tubarius, the prominence of the eustachian tube. Synonym: pharyngeal recess.
Rosenthal’s Canal Canal in the modiolus for the spiral ganglion. Synonyms: canalis
spiralis cochleae; canalis spiralis modioli; spiral canal of the modiolus.
Rüdinger’s Safety Tube A small potential space seen superiorly on transverse sec-
tion of the cartilaginous portion of the eustachian tube. Synonyms: security canal of
Rüdinger; Sicherheitsrohr.
Sacculus [plural: sacculi; possessive: sacculi] Latin: diminutive of saccus, a bag or
pouch. The saccule.
Saccus [plural: sacci; possessive: sacci] Latin: bag.
s. endolymphaticus, the endolymphatic sac.
Salpingopalatine Fold of Tortual Extension of the anterior lip of the eustachian
tube onto the lateral wall of the nasopharynx.
Scala [plural: scalae; possessive: scalae] Latin: staircase.
s. media, the middle compartment of the cochlea (cochlear duct). s. tympani,
the perilymphatic compartment of the cochlea located posterior to the scala media.
s. vestibuli, the perilymphatic compartment of the cochlea anterior to the scala
media.
Scapha [plural: scaphae; possessive: scaphae] Latin: a small boat. The scaphoid fossa
of the auricle. Synonym: fossa helicis.

Scarpa’s Fluid Breschet renamed it endolymph. Synonym: otic fluid.
Scarpa’s Ganglion Peripheral ganglion of the vestibular nerve.
Scarpa’s Hiatus The helicotrema. Synonym: Breschet’s hiatus.
Schuknecht, Canaliculi Perforantes of Synonyms: perilymph canaliculi, canaliculi
perforantes.
Scutum [plural: scuta; possessive: scuti] Latin: shield. The part of the squamous
portion of the temporal bone that forms the lateral wall of the epitympanic recess.
Sebileau, Retrotubal Muscle of Synonym: levator veli palatini.
Security Canal of Rüdinger Synonyms: Rüdinger’s safety tube, Sicherheitsrohr.
Semilunar Ganglion Synonyms: trigeminal ganglion, gasserian ganglion.
Septum [plural: septa; possessive: septi] Latin: a partition or barrier.
mucosal s., any of the multiple mucosal folds that subdivide the tympanic
cavity. s. canalis musculotubarii, the superiorly located septum in the osseous
portion of the eustachian tube that separates its lumen from the tensor tympani
muscle.
Shambaugh, Glands of The modified epithelium along the outer wall of the
cochlear duct in the region of the stria vascularis which, in fetal development, resem-
bles a glandular epithelium.
Shrapnell’s Membrane Pars flaccida of the tympanic membrane.
Sicherheitsrohr Synonyms: Rüdinger’s safety tube, security canal of Rüdinger.
Siebenmann, First Accessory Canal of Synonyms: aqueduct of Cotugno, canal of
Cotugno.
Singular Canal Canal for the posterior ampullary nerve. Synonyms: foramen singu-
lare; foramen singular of Morgagni; solitary canal.
Sinodural Angle of Citelli Angle between the middle cranial fossa superiorly and
the posterior cranial fossa and sigmoid sinus posteriorly. It marks the position of the
superior petrosal sinus at the juncture of the dura of the middle and posterior cranial
fossae. Synonym: sinodural angle.
Sinus [plural: sinus; possessive: sinus] Latin: a hollow or valley.
facial s., the facial recess. Synonyms: posterior recess; suprapyramidal recess.
s. posterior, a depression between the posterior iter of the chorda tympani nerve
and the pyramidal eminence. s. tympani (tympanic s.), the depression located in
the medial wall of the middle ear, posterior to the round and oval windows,
medial to the facial nerve, and bounded by the ponticulus superiorly and the
subiculum inferiorly. Synonym: infrapyramidal recess.
Solitary Canal Synonyms: foramen singulare, foramen singular of Morgagni, singu-
lar canal.
Sphenopalatine Ganglion Synonym: Meckel’s ganglion.
Spina [plural: spinae; possessive: spinae] Latin: thorn or spine.
s. helicis, a small projection of cartilage that extends anteriorly from the crus of the
helix of the ear. s. tympanica major, the anterior spine of the bony tympanic ring
at the notch of Rivinus. s. tympanica minor, the posterior spine of the bony
tympanic ring at the notch of Rivinus.
Spiral Canal of the Modiolus Rosenthal’s canal. Synonym: canalis spiralis cochleae.
Spiral Organ The organ of Corti. Synonyms: basilar papilla, papilla of Huschke.
Squama [plural: squamae; possessive: squamae] Latin: a scale or plate-like structure.
The portion of the temporal bone that partially forms the lateral bony wall of the
middle cranial fossa and part of the mastoid.
Stratum [plural: strata; possessive: strati] Latin: a covering or a pavement, a sheet-like
mass of nearly uniform thickness.
GLOSSARY ■ 331
s. cutaneum, the epidermal (outer) layer of the tympanic membrane. s. mucosum,
the mucosal (inner) layer of the tympanic membrane. s. radiatum, the fibrous
(middle) layer of the tympanic membrane.
Stria [plural: striae; possessive: striae] Latin: channel or groove.
s. mallearis, the pale white streak seen upon otoscopic visualization of the
tympanic membrane that represents the manubrium of the malleus. s. vascularis,
the highly specialized and vascularized spiral structure located on the internal sur-
face of the spiral ligament between the attachment of Reissner’s membrane and
the spiral prominence. Synonym: stria vascularis of Huschke.
Subarcuate Canaliculus Synonyms: antrocerebellar canal of Chatellier, petromas-
toid canal.
Subiculum [plural: subicula; possessive: subiculi] Latin: diminutive of subex, a support
or underlayer.
s. promontorii, the ridge of bone inferior and posterior to the round window that
defines the inferior limit of the sinus tympani.
Sulcus [plural: sulci; possessive: sulci] Latin: sulcus, a groove or furrow.
s. anthelicis transversus, the depression on the medial aspect of the auricle corre-
sponding to the anthelix. s. auriculae posterior, the depression that separates the
antitragus from the anthelix. s. cruris helicis, the depression of the medial aspect
of the auricle corresponding to the crus of the helix. s. tympanicus, the groove in
the tympanic bone to which the tympanic membrane is attached.
Superior Semicircular Canal Synonym: anterior vertical canal.
Superior Tympanic Recess Synonyms: Prussak’s pouch, Prussak’s space.
Superior Vestibular Nucleus Synonym: nucleus of Bechterew.
Suprameatal Spine Synonym: Henle’s suprameatal spine.
Suprameatal Triangle Synonym: Macewen’s triangle.
Suprapyramidal Recess Facial recess (sinus). Synonym: posterior recess.
Sustentacular Cells Deiters’ cells. Synonym: outer phalangeal cells.
Sylvian Apophysis Lenticular process of the incus. Synonyms: os orbiculare; proces-
sus lenticularis.
Syndesmosis [plural: syndesmoses; possessive: syndesmosis] Latin: from the Greek
syndesmos, ligament.
s. tympanostapedia, the stapediovestibular articulation.
Tectorial Membrane Synonym: membrane of Corti.
Tegmen [plural: tegmines; possessive: tegminis] Latin: a roof or cover.
t. mastoideum, the roof of the mastoid. t. tympani, the roof of the middle ear cavity.
Tensor Latin: tensio, tendere, to stretch.
t. tympani, the middle ear muscle that forms a tendinous attachment to the malleus.
Tentorium [plural: tentoria; possessive: tentorii] Latin: a tent.
t. cerebelli, the layer of dura mater that serves as a roof for the cerebellum and also
acts as a support for the occipital lobes. It encloses the transverse venous sinus pos-
teriorly.
Tortual, Salpingopalatine Fold of Extension of the anterior lip of the eustachian
tube onto the lateral wall of the nasopharynx.
Tractus [plural: tractus; possessive: tractus] Latin: a trail.
t. tegmentalis centralis, that area of the medial wall of the vestibule through which
nerves pass to the cochlea of the inner ear. Synonym: tractus spiralis foraminosus.
Tragus [plural: tragi; possessive: tragi] Latin: from the Greek tragos, goat (apparently
from the resemblance of the hairs of the tragus to a goat’s beard). The singular form
is used to refer to that projection of cartilage that is located at the anterior aspect of
the external auditory meatus. The plural form is used to refer to the hairs of the auri-
cle, especially those on the tragus.

Trautmann’s Triangle Area of the mastoid bounded posteriorly by the lateral
venous sinus, superiorly by the tegmen and superior petrosal sinus, and anteriorly
by the bony labyrinth.
Trigeminal Ganglion Synonyms: semilunar ganglion, gasserian ganglion.
Tuba [plural: tubae; possessive: tubae] Latin: Roman war trumpet.
t. auditiva, the eustachian tube. Synonyms: auditory tube; pharyngotympanic tube.
Tuberculum [plural: tubercula; possessive: tuberculi] Latin: diminutive of tuber, a
lump or swelling.
t. auriculae, the Darwinian tubercle, a variably present protrusion on the postero-
superior aspect of the free margin of the helix of the auricle representing the
homolog for the tip of the auricle of lower mammals. t. supratragicum, a small
protrusion of the anterior aspect of the auricle just superior to the tragus.
Tunica [plural: tunicae; possessive: tunicae] Latin: a sheath or tunic.
t. mucosa, the mucous membrane lining of the eustachian tube. t. mucosa cavi
tympani, the mucous membrane lining of the tympanic cavity.
Tympanic Incisura The notch of Rivinus.
Tympanic Nerve The tympanic branch of the glossopharyngeal nerve. Synonym:
Jacobson’s nerve.
Tympanomastoid Fissure The fissure at the posteroinferior aspect of the lateral
bony external auditory canal, separating the mastoid and tympanic portions of the
temporal bone and transmitting the auricular branch of the vagus (Arnold’s nerve).
Tympanomeningeal Hiatus Hyrtl’s fissure.
Tympanum [plural: tympana; possessive: tympani] Latin: a drum. The middle ear
cavity, which somewhat resembles a drum in structure.
Umbo [plural: umbones; possessive: umbonis] Latin: the center of a shield. The cen-
tral region of the tympanic membrane marking the location of the tip of the
manubrium.
u. membrane tympani, the umbo.
Utriculo-Endolymphatic Valve of Bast Valve characterized as a thickened portion
of the utricular wall that is located at the inferior part of the utricle and marks the
beginning of the utricular duct. Synonym: utriculo-endolymphatic valve.
Utriculus [plural: utriculi; possessive: utriculi] Latin: diminutive of uter, a leather bag
or bottle. The funnel-shaped sense organ of the vestibular part of the membranous
labyrinth. Synonym: utricle.
Vagina [plural: vaginae; possessive: vaginae] Latin: a sheath or scabbard.
v. processus styloidei, the sheath extending from the temporal bone that sur-
rounds the superior-most portion of the styloid process.
Vas [plural: vasa; possessive: vasis] Latin: vessel or receptacle.
v. spirale, the vessel located just posterior to the inner tunnel of the organ of Corti
on the scala tympani side of the basilar membrane.
Vein at the Cochlear Aqueduct The inferior cochlear vein. Synonym: vena aquae-
ductus cochleae.
Vena Aquaeductus Cochleae The inferior cochlear vein. Synonym: vein at the
cochlear aqueduct.
Vertical Canal, Anterior The superior semicircular canal.
Vestibular Membrane Reissner’s membrane. Synonym: membrana vestibularis.
Vestibulocochlear Anastomosis Synonym: Oort’s anastomosis.
Vestibulum [plural: vestibula; possessive: vestibuli] Latin: a courtyard or entrance to
a court. The vestibule of the inner ear.
Voit’s Anastomosis A small nerve branch that leaves the superior division of the
vestibular nerve to innervate part of the saccule.
GLOSSARY ■ 333
Volkmann’s Canals Channels, other than haversian canals, for the passage of blood
vessels through bone.
Von Tröltsch (Troeltsch), Anterior Pouch of Anterior recess of the tympanic membrane.
Von Tröltsch (Troeltsch), Posterior Pouch of Posterior recess of the tympanic
membrane.
Von Tröltsch (Troeltsch), Salpingopharyngeal Fascia of Aponeurosis of the
eustachian tube. The continuation of the sheath of the tensor veli palatini muscle
toward the pharyngeal opening of the eustachian tube, this sheath is attached to the
inferior and external edge of the tubal cartilage.
Weber-Leil, Fascia of Fascia on the external surface of the tensor palatini muscle.
Wrisberg, Anastomosis of Anastomotic branch between the facial nerve and the
nervus intermedius.
Wrisberg, Nerve of The nervus intermedius.
Zaufal, Salpingopharyngeal Fold of Continuation of the posterior lip of the
eustachian tube onto the lateral pharyngeal wall.
Zinn, Zona Cochleae of Membranous part of the spiral lamina.
Zona [plural: zonae; possessive: zonae] Latin: a zone.
z. arcuata, the inner one third of the basilar membrane (the pars tecta).
z. pectinata, the outer two thirds of the basilar membrane (the pars pectinata).
Zuckerkandl, Pharyngotubal Ligament of Elastic fibers between the pharyngopala-
tini and salpingopharyngeal (pharyngotubal) muscles.

Historical Bibliography of Ear Anatomy
The following historical bibliography of ear anatomy represents information

culled from a variety of primary and secondary sources. The secondary
sources to which the interested reader is referred, and which we found
particularly helpful in locating more detailed information, include writings
by Politzer (1907, English translation by Milstein et al., 1981), Garrison
(1929), Dobson (1962), Sultan (1981), and Morton (1983).
The historical persons cited have been selected on the basis of their
significant contribution to the understanding of the anatomy of the ear.
Inevitably in such an arbitrary listing there are omissions; we apologize for
any particularly egregious oversights.
We acknowledge the kind assistance of Mr. Charles Snyder, former direc-
tor of the Lucian Howe Library of the Massachusetts Eye and Ear Infirmary.
Alcmaeon, Greece (circa 500 B.C.)
Quoted by Politzer in Geschichte der Ohrenheilkunde (Vol I, Stuttgart, F Enke,
1907) and History of Otology (English translation by S Milstein, C Portnoff, and
A Coleman, Phoenix, Columella Press, 1981).
According to Aristotle (as mentioned by Plutarch in De Placitis Philosophorum.
Paris, v. Dübner, 1841), Alcmaeon made the observation that goats breathe through
their ears. However, Politzer (1981) does not feel that the assumption that Alcmaeon
knew of or discovered the eustachian tube, as credited by many authors, is warranted.
Empedocles, Greece (circa 495–435 B.C.)
As detailed by Plutarch (De Placitis Philosophorum. Paris, v. Dübner, 1841) and
quoted by Politzer (1907, English translation by Milstein et al., 1981), this Greek
philosopher discovered a “snail-shaped cartilage” in the ear. This discovery is
remarkable in that his knowledge of the ear was limited to the tympanic membrane
and tympanic cavity. He also was aware of the fact that vibrations in air produce
sound, and he felt that the “snail-shaped cartilage” produced a tone similar to that of
a bell when set in motion by air currents.
Hippocrates, Greece (460–377 B.C.)
De Carnibus. In Hippocrates’ Works. Edited by Littrés. Paris, 1839–1861.
According to Politzer, Hippocrates was the first to emphasize the fact that the
tympanic membrane was an integral part of the organ of hearing. He described the
symptoms of acute otitis media, chronic suppurative otitis media, and otitic menin-
gitis. Hippocrates was well aware of the consequences of auricular hematoma and
fractures of the cartilage of the auricle. He also included injury to the skull as a poten-
tial cause of deafness.
Aristotle, Greece (384–322 B.C.)
De Animalibus Historiae Libra I. St v Stein, Lit d Anat u Physiolog, 1890.
Aristotle knew only of the existence of the external auditory canal and the auricle
in the human, although some of his writings suggest that he had seen the eustachian
tube and cochlea in the course of animal dissection. He assumed the existence of an
inner “air” (“aer innatus” or “aer implantus”), separated from the external ear, which
he felt was the conductor of sound within the ear. This theory dominated the
thoughts of subsequent investigators for many centuries.
335
Galen, Greece (130–200 A.D.)
Comment de Placit. Hippocrat et Plat, Lib VI.
De Nervorum Dissectione. Hippocrat et Plat, Lib VI.
De usu Partium. Hippocrat et Plat, Lib VIII.
In the first listed work, Galen credits Erasistratus (circa 310–250 B.C.) with
accurate knowledge of the auditory nerve. In the second work Galen realized that the
acoustic and facial nerves are separate branches of the “Vth cranial nerve” as num-
bered by Galen’s teacher, Marinus. Apparently he was overwhelmed by the complex-
ity of the numerous apertures and canals of the dissected temporal bone, and likened
them to a labyrinth. In the third work, Galen included the first description of the
course of the facial nerve. He indicated that it entered the foramen caecum (the inter-
nal auditory canal) and traveled in a tortuous bony canal to exit at the end of the
styloid canal.
Jacopo Berengario Da Carpi, Italy (1470–1550)
Anatomi Carpi Isagogae breves perlucidae ac uberrimae in anatomiam humani corporis a
communi medicorum academia usitatam, etc. Bonon, 1514.
In this work, Da Carpi describes the auditory ossicles, but does not claim to be
the discoverer of them.
Niccolò (Nicolaus) Massa, Italy (1499–1569)
Anatomiae Liber Introductorius. Venetiis, F Bindoni ac M Pasini, 1536.
Massa described a dissection technique for demonstrating the tympanic mem-
brane and the auditory ossicles.
Guido Guidi (Vidus Vidius), Italy and France (1500–1569)
De Anatomica Corporis Humani. Lib VII. Venetiis, 1611 (Francof, 1611, 1626), 1645, 1677.
Guidi was the first to describe the vidian nerve and its stem of origin shared
with the palatine nerve.
Giovanni Filippo Ingrassia, Sicily (1510–1580)
In Galeni Librum de Ossibus Dectissima et Exspectatissima Commentaria. Panormi, edited
post mortem, 1603.
In 1546 Ingrassia, an osteologist, discovered the stapes. He also described the
oval and round windows and the chorda tympani nerve. He was the first to note the
sound-conductivity of the teeth.
Andreas Vesalius, Belgium and Italy (1514–1564)
De Fabrica Humani Corporis. Lib VII, first edition. Ex Off Joann Oporin, Basil, 1543.
Anatomicarum Gabrielis Falloppii observationum examen. Venetiis, 1564.
The 1543 work includes the first drawing of the malleus and incus and a
demonstration of the organ of hearing in cross section. (The illustrator was Joh.
Stephan von Calcar, a student of Titian.) The subsequent volume corrects many of the
errors found in the 1543 edition. It also includes further details of the anatomy of the
organ of hearing. Vesalius described for the first time the round window, oval
window, and the promontory; he referred to the latter structure as the tuberculum
inter fenestram.
Matteo Realdo Colombo, Italy (1516–1559)
De Re Anatomica. Lib XV. Venetiis, 1559.
Colombo was the first anatomist to remark upon the blood supply of the inner
ear. He also first described the lenticular process of the incus.
Gabriele Falloppio (Falloppius, Falloppia), Italy (1523–1562)

Observationes Anatomicae. Venetiis, MA Ulmus, 1561.
This work is the most complete treatise of the so-called “Founder of the Italian
School of Anatomy.” He studied the embryologic development of the organ of hear-
ing and determined that the components of the adult ear could be found at early
stages of development. He also realized that, although in the fetus the tympanic ring
is separated from the temporal bone, in later development these two structures fuse.
His was the first clear description of the tympanic membrane and its inclination with
respect to the horizontal plane. He described the tympanic cavity and was the first to

name it the “tympanum.” In 1561 he discovered the “canalis sive aqueductus,” which
houses the intratemporal part of the facial nerve. He recognized that the inner ear
consists of two parts: the secunda cavitas, composed of the semicircular canals and
the vestibule, which he named the labyrinth, and the tertia cavitas, which he named
the cochlea. His description of both the coiled tubular nature of the cochlea and of the
vestibular labyrinth surpassed all preceding descriptions and was superior to many
that followed. He also was the first to describe the spiral lamina and to detail the
anatomy of the auricular muscles. He discovered and described the chorda tympani
nerve, a finding that was recapitulated in the postmortem studies of Ingrassia.
Bartolomeo Eustachio (Bartolommeo Eustachi, Eustachius), Italy (1524–1574)

Epistula de auditus organis. In Opuscula Anatomica. Venetiis, 1563. Tabulae anatomi-
cae cl viri Bartholomaei Eustachii, quae a tenebris tandem vindicatas, et sanct. Dom
Clementis IV, Pont max munificentia dono acceptas, praefatione notisque illustravit
Jo Maria Lancisius, intimus cubicularius et archiater pontificis. Romae, 1714; in fol
editio 1728.
Independently of Ingrassia and Colombo, Eustachio also discovered the stapes.
He described the tensor tympani muscle precisely and was the first to establish that
the chorda tympani is a nerve; he documented that it joined with the mandibular
branch of the trigeminal nerve, i.e., the lingual nerve. He was the first to describe
precisely the configuration of the eustachian tube, supposedly first described by
Alcmaeon in 500 B.C. He is credited with the discovery of the modiolus and provided
superior descriptions of the cochlear osseous spiral lamina.
Hieronymus Mercurialis (Geronimo Mercuriali), Italy (1530– 1606)
De compositione medicamentorum tractatus, tres libros complectens, eiusdem de oculorum
et aurium affectionibus praelectiones seorsim. Francoforti, Apud J Wechelum, 1584.
Mercurialis recognized that deafness could be caused not only by pathologic
processes in the organ of hearing, but also by diseases of the brain. His therapeutic
treatise was the first clinical manual on diseases of the ear.
Volcher Koyter (Coiter, Coeiter, Koiter), Holland and Italy (1534–1600)
De auditus instrumento. In Externarum et Internarum Principalium Corporis Humani
Partium Tabulae Atque Anatomicae Exercitationes, etc. Norimbergae, in off T Gerlatzeni,
1573.
This work was the first monograph on the organ of hearing. Koyter was a
student of Falloppio and was one of the first scientists to publish a theory of hearing.
This theory included the concept of an inner ear, “aer implantatus,” implanted into
the ear by the Maker.
Fabricius Ab Aquapendente (Girolamo Fabrizio), Italy (1537–1619)
De Visione, Voce et Auditu. Venetiis, F Bolzettam, 1600.
De Formato Foetu. Venetiis, 1600.
This student of Falloppio did not add any new information of anatomic signif-
icance with regard to the ear. He did, however, present a theory of hearing that was
similar to that of Koyter. He believed that the “aer implantatus” was the carrier of
sound perception; however, he felt that the vestibule was the center for hearing and
that the other canals functioned to diminish the amplitude and echo of sound.
Salomon Alberti, Germany (1540–1600)
Historia Plerarumque Partium Humani Corporis, in Usum Tyronum Edita. Viteberg, 1585.
This work includes chapters that deal specifically with the organ of hearing.
Alberti is credited by Morgagni with recognizing that the vestibule (the vestibulum)
is a distinct part of the labyrinth.
Constantius Varolius (Constanzo Varolio), Italy (1543–1575)
Anatomia, s De Resolutione Corporis Humani. Lib IV. Francof, 1591.
Varolius was the first to describe the stapedius muscle.
Giulio Casserio (Casserius Placentinus), Italy (1561–1616)
De Vocis Auditusque Organis Historia Anatomicae Tractatibus II. Explicata.
Ferrariae, Victorius Baldinus, 1600–1601.
HISTORICAL BIBLIOGRAPHY OF EAR ANATOMY ■ 337

Pentaesthesion, H E de Quinque Sensibus Liber. Lib VI. Venetiis, 1609; Francofurti,
1610.
Tabulae Anatomicae LXXIX. Omnes novae nec ante hoc visae. Venetiis, 1627. Cum
Supplementis Dan Bucretii. S.i. et a.f. Francof, 1632.
Casserio’s major contribution to otology consisted of a careful comparative
anatomic study of the organ of hearing. This student of Fabrizio discovered
the incisurae in the cartilaginous part of the external auditory canal. He also was the
first to describe otoliths in fish. Although the membrana fenestrae cochleae (round
window membrane) had already been mentioned by Guido Guidi, Casserius was the
first to describe this structure precisely. He used the term “canalis facialis” for the
fallopian canal. Casserio noted that there were three semicircular canals, and distin-
guished three cochlear turns. Although the membranous portion of the spiral lamina
(septum spirale) had been mentioned by Eustachio, Casserio defined it more clearly.
He also studied the embryology of the human ear.
Claude Perrault, France (1613–1688)

Observations sur l’Organe de l’Ouie, Mémoires de I’Ac de Paris. Vol I.
Essais de Physique ou Recueil de Plusieurs Traitez Touchant les Choses
Naturelles. Edit JB Caignard, Paris, T I, II, III, 1680; T IV, 1688. Oeuvres Diverses.
Leiden, 1721.
Claude Perrault extended the work of Casserius in comparative anatomy. He
was the first to describe the bony lip overhanging the round window.
Caecilius Folius (Folio), Italy (1615–1650)

Nova Auris Internae Delineatio. Venetiis, 1645.
Folius is credited with the discovery of the processus longus spinosus s. Folii
(anterior process) of the malleus, although this structure was known to both Koyter
(Proc. primus) and Casserio (Proc. anterior elatior et exilior). Jac. Ravius described
it as seen in the newborn, hence the occasional term “processus Ravii.” Folius is
credited with describing the semicircular canals; he limited the number of their
communications with the vestibule to five.
Thomas Willis, England (1622–1675)

Cerebri Anatome, Cui Accessit Nervorum Descriptio et Usus. London, 1664.
De Anima Brutorum quae hominis vitalis ac sensitiva est, exercitationes duae, etc. London,
R Davis, 1672.
Willis was the first to observe the phenomenon in which certain individuals
with a hearing loss hear better when noise is present. This phenomenon now carries
the name paracusis Willisii. He discovered the helicotrema independently of Méry,
and he was the first to ascribe properly the role of hearing to the cochlea.
Ludovicus Bils (Jonker Longs de Bils), Holland (1624–1670)

Anatomisch Vertoon van het Gehoor. Brüghe, 1655.
Bils described the temporal bone as consisting of four parts delineated by
sutures.
Johann Heinrich Glaser, Switzerland (1629–1675)

Tractatus posthumus de cerebro, in quo hujus non fabrica tantum, sed actiones omnes
principes, sensus ac motus ex veterum et recentiorum placitis et observationibus perspicue ac
methodice explicantur. Basileae, 1680.
Glaser is given credit for the discovery of the petrotympanic fissure which bears
his name (Glaserian fissure). Politzer, however, was not able to find the pertinent
passage in his main work referenced above.
Fredrik Ruysch, Holland (1638–1731)

In resp ad Epist probl VIII. Thesauri anatomici decem. Amst, 1701–1716.
Ruysch was the first to ascribe a trilamellar structure to the tympanic
membrane. He also provided evidence that contradicted the thesis of Rivinius, which
suggested the presence of an opening in the normal tympanic membrane. Ruysch
showed that the ossicles possess a periosteal covering.

Niels Stensen (Nikolaus Steno), Denmark (1638–1682)
De glandulis oris et nuper observatis inde prodentibus vasi. Lugduni Batavorum,
J Chouet, 1661.
Steno was the first to describe the ceruminous glands of the external auditory
canal.
Jean Méry, France (1645–1722)

Description Exacte de l’oreille de I’Homme avec Explication Méchanique et Physique des
Fonctions de l’âme Sensitive. Paris, 1677, 1681, 1687.
Méry was the first to describe the spine of the helix (the spina s. processus acu-
tus helicis) and added further details to the description of the fissures in the cartilage
of the external auditory canal first observed by Casserius. Méry also was the first to
observe the synovial capsules of the ossicular articulations.
Johannes Munni(c)ks, The Netherlands (1652–1711)

De Re Anatomica liber. Utrecht, 1697.
Munniks was the first to describe the notch in the bone of the superior part of
the tympanic annulus (now known as the notch of Rivinus).
Joseph Guichard Duverney, France (1648–1730)

Traité de l’organe de l’ouie, contenant la structure, les usages et les maladies de toutes les
parties de l’orielle. Paris, E Michallet, 1683.
Duverney is heralded as the founder of the French school of anatomy of the
eighteenth century. His contributions to the field of otology are many, and among his
impressive list of firsts are included: description of the posterior auricular ligament,
illustration of the vascular and neural branches of the auricle, accurate description of
the bony external auditory canal as originating from the tympanic annulus, illustra-
tion of the route of communication between the tympanic cavity and the cells of the
mastoid process, description of the epitympanum, and relationship of the eusta-
chian tube to the medial wall of the tympanic cavity. His “Traité” is the first treatise
in which the anatomy and the pathology of the ear are presented in a coherent and
analytic manner. His theory of hearing, which he developed with the physicist
Mariotte (the Duverny-Mariotte theory of hearing), ascribed to the labyrinth a role in
the perception of different tones. He believed that the vibrations of the tympanic
membrane were transmitted to the labyrinth through the ossicular chain. This theory
of hearing was later expanded upon and eventually accredited to Helmholtz.
Augustus Quirinus Rivinus (Rivinius), Germany (1652–1723)

In 1689 the senior Rivinus believed that he had discovered an opening in the
tympanic membrane in its normal state. He relayed this finding in 1691 in a letter to
Anton Nuck, a Dutch anatomist. His son, Joh. Aug. Rivinus, reported the finding in
“De Auditus Vitiis” Dissertatio (Lipsiae, 1717). Rivinus located his opening, which he
thought also had a fibrous sphincter, near the head of the malleus in the tympanic
membrane of sheep and calves. In today’s terminology, the notch of Rivinus
describes a deficiency in the superior aspect of the tympanic ring, where Shrapnell’s
membrane (pars flaccida) attaches to the petrous bone.
Antonio Maria Valsalva, Italy (1666–1723)

Tractatus de Aure Humana. Bologna, Typ C Pisarii, 1704.
Valsalva was a pupil of Malpighi and was the teacher of Morgagni. He was
well known for his method of inflating the middle ear, i.e. Valsalva’s maneuver; he
also was the first to present an anatomic preparation of the complete organ of hear-
ing. He divided the ear into an external compartment, a middle compartment, and
an internal compartment. Valsalva was the first to describe clearly a muscular dilator
that widened the eustachian tube, and he named the auditory tube in Eustachius’
honor. Valsalva used the term “labyrinth” to denote the entire inner ear; moreover, in
1707 he was the first to observe that the entire labyrinth was filled with a watery
fluid. He named the scala vestibuli and the scala tympani. He noted ankylosis of the
stapes to the margin of the oval window in an autopsy of a deaf person.

Giovanni Domenico Santorini, Italy (1681–1737)
Observationes Anatomicae. Venetiis, 1724.
Santorini provided a more detailed description of the incisures of the external
auditory canal (incisurae Santorini) previously described by Méry and Duverney. He
noted that muscle fibers could occasionally be seen passing over the first (largest)
incisura (Santorian muscle), and he first described the major and minor musculus
helicis.
Giovanni Battista Morgagni, Italy (1682–1771)
Epistolae anatomicae. Appendix in Valsalva’s Tractatus de Aure Humana. Venice, 1740.
Morgagni was a pupil of Valsalva and Malpighi. His research was incorporated
into Valsalva’s treatise as an appendix; it was an extension of Valsalva’s research. He
described the vestibular segment of the vestibular aqueduct, as well as the spherical
recess (cavitas hemisphaerica) and the elliptical recess (cavitas semiovalis). He
contradicted the teaching of Valsalva by showing for the first time that intracranial
suppuration is the consequence of infection from the ear rather than conversely, as
Valsalva had hypothesized.
Johann Friedrich Cassebohm, Germany (1699–1743)
Tractatus Quatuor Anatomici de Aure Humana. Sumtibus Orphanotrophei, Halae
Magdeburgi, 1734.
Tractatus quintus anatomicus de aure humana cui accedit tractatus sextus de aure
monstri humani. Halae Magdeburgi, 1735.
Cassebohm made many original contributions to the field of otology. He was
the first to mention the notch at the tip of the short process of the anvil (incus) and
was the first to describe the concavity of the inner aspect of the stapedial crura.
He antedated Cotugno in his awareness of the presence of two recesses within the
vestibule. He was the first to describe in some detail the communication of
the two scalae in the apex of the cochlea; he first noted the falciform crest dividing
the internal auditory canal into the superior and inferior halves. Cassebohm also
studied the ossification process of the otic capsule and located the beginning of this
process in the periphery of the round window.
Johann Gottfried Zinn, Germany (1727–1759)
Observationes quaedam botanicae et anatomicae de vasis subtilioribus oculi et cochleae auris
internae. Goettingen, 1753.
Thorough microscopic examination enabled Zinn to provide the first precise
description of the cochlear (osseous) spiral lamina. Zinn traced the path of the cochlear
nerve, and described how it entered the cochlea as a spiral band. He also was the first
to describe in clear detail the vasculature of the cochlea, especially that of the apex.
Domenico Cotugno (Cottunni, Cotunni, Cotugni, Cotunnius), Italy (1736–1822)
De aquaeductibus auris humani internae anatomica dissertatio. Ex typ Naples, Simoniana,
1761.
Although Pyl had recognized the existence of fluid within the labyrinth,
Cotugno, a student of Morgagni, is often credited as one of the first to be aware of the
importance of these fluids, both in an anatomic and a physiologic sense. He was
the first to establish the fact that the labyrinth was filled completely by fluid and
contained no air. He incorporated the knowledge of the presence of a labyrinthine
fluid into a theory of hearing that established the foundation for modern theories of
hearing and finally laid to rest Aristotle’s ancient “aer innatus” concept of the phys-
iology of hearing. Cotugno felt that the impact of sound waves precipitated move-
ment of the stapes, which in turn set into motion the labyrinthine fluid in which the
nerves were suspended. He discovered the vestibular aqueduct and traced it to its
opening on the posterior aspect of the petrous pyramid. He also discovered the
intradural sac of the vestibular aqueduct (endolymphatic sac), which he called “cav-
itas aquaeductus membranacea” and correctly identified it as a prolongation of the
endolymphatic duct. Cotugno discovered the cochlear aqueduct, which he traced
from the scala tympani orifice (“orificium superius”) to its funnel-shaped terminus at
the “orificium inferius.” He believed that these two aqueducts drained off
labyrinthine fluid after medial movement of the stapes.

Antonio Scarpa, Italy (1747–1832)
De structura fenestrae rotundae auris et de tympanos secundario anatomicae observationes.
Apud soc typog. Mutinae, 1772.
Anatomicarum annotatianum liber primus de nervorum gangliis et plexibus. Mutinae, 1779.
Disquisitiones anatomicae de auditu et olfactu. Ticini et Mediolani, 1789.
Scarpa, probably one of the greatest anatomists of all time, possessed superb
dissection technique, and his “Disquisitiones” marks the end of the premicroscopic
era of otologic research. He complemented the visualization of his dissections by
using a magnifying glass and by means of injection. He contended that sound waves
entered the cochlea by both the round and oval windows. He also believed that the
round window membrane could function as a tympanic membrane. In support of this
contention, he presented the finding that a vibrating instrument held between the
teeth could still be heard even after the tympanic membrane, ossicular chain, and
the entire external ear had been destroyed. His treatise “De structura” deals with the
architecture of the round window and its membrane. Scarpa’s description of the
anatomy of the labyrinth far excelled that of his predecessors. He was the first to
demonstrate the existence of the saccule in the spheric vestibular recess and the
utricle in the elliptic vestibular recess; he discovered the existence of membranous
canals within the bony semicircular canals. He recognized the utricle as the common
reservoir of the semicircular ducts; moreover, he noted that, upon squeezing the
utricle, fluid could be forced into the semicircular ducts, but not into the saccule. He
expanded upon the knowledge of the labyrinthine fluid because, although Cotugno
had been aware of the existence of perilymph, knowledge of the membranous
labyrinth was a prerequisite for the discovery of endolymph. Scarpa identified
endolymph in the vestibular system but was unaware of the cochlear duct.
Theodor Pyl, (?) (1749–1794)
Dissertatio medica de auditu in genere et de illo qui fit per os in specie. Gryphiswald, 1742.
Pyl antedated Cotugno in recognizing the existence of fluid in the labyrinth.
His theory of hearing, presented in 1742, was the first to be founded totally on the
presence of a fluid medium in the inner ear.
Adolph Murray, (?) (1751–1803)
Anatomische Bemerkungen über die Durchbohrung der Apophysis mastoidea als
Heilmittel gegen verschiedene Arten von Taubheit. In K Schwed Akad d Wissenschaft
neuen Abhandlungen aus der Naturlehre, 1789. Abscessus auris interne observatio. Upsal,
1796.
Murray detailed the anatomy of the air cells of the mastoid process and
described the communication of these cells with each other and with the tympanic cav-
ity. He observed variability in the degree of pneumatization of the mastoid process.
Samuel Thomas Von Soemmerring, Western Prussia, Germany (1755–1830)
De corporis humani fabrica. Traj ad Moen, 1794.
Icones organi auditus humani. Frankfurt, 1806.
Abbildungen des menschlichen Hörorgans. Frankfurt am Main, Varrentrapp u Wenner,
1806.
Von Soemmerring was the first to describe the superior suspensory ligament of
the malleus. He also was the first to utilize a chemical preparation of the organ of
hearing to further his anatomic studies. Dilute nitric acid softened the bony shell,
which he then removed; in this way, he visualized the course of the nerves in the
modiolus and also in the osseous spiral lamina.
Floriano Caldani, Italy (?)
Osservazioni sulla membrana del tympano e nuove ricerche sulla elettricita animale. Padua,
1799.
Caldani was first to note that the fibrous layers of the tympanic membrane
were arranged in both a radial and a circular manner.
Sir Astley Paston Cooper, England (1768–1841)
Further observations on the effects which take place from the destruction of the
membrana tympani of the ear; with an account of an operation for the removal of a

particular species of deafness. Phil Trans, 91:435, 1801. Dictionary of Practical Surgery.
London, 1825.
Sir Astley was the first to employ paracentesis of the tympanic membrane
(myringotomy) on a rational basis. This operation was first performed in 1760 by Eli, a
wandering quack who used it for the relief of certain cases of deafness. In his 1801
publication, Sir Astley presents three cases of deafness associated with eustachian
tube obstruction that were relieved by myringotomy. He reasoned that the perforated
tympanic membrane provided a substitute for the blocked eustachian tube.
Jean Marie Gaspard Itard, France (1775–1838)
Traité des Maladies de l’Oreille et de l’Audition. Vols 1 and 2. Paris, Méquignon Marvis,
1821.
This surgeon did much to establish the field of otology and wrote the first
modern textbook describing diseases of the ear.
Friedrich Christian Rosenthal, Germany (1780–1829)
Ueber den Bau der Spindel im menschlichen Ohr. In Meckels Archiv, Bd VIII, 1823.
Rosenthal was the first to describe the “canalis spiralis modioli,” which now
bears his name (Rosenthal’s canal). It houses the spiral ganglion.
John Howship, England (1781–1841)
On the natural and diseased state of the bones. London, 1820.
Howship, a victim himself of tibial osteomyelitis, was especially interested in
bone disease. The excavation defects created in bone by osteoclastic activity are
called Howship’s lacunae.
Johann Friedrich Meckel, Germany (1781–1833)
Abhandlungen aus der vergleichenden und menschlichen Anatomie. Halle, 1805.
Johann Meckel originally described the cartilage of the first branchial arch.
Ludwig Levin Jacobson, Denmark (1783–1843)
Supplementa ad otoiatriam. Supplementum primum de anastomosi nervorum nova
in aure detecta. Acta Reg Soc Med Havnien, 5:293, 1818.
Jacobson described the tympanic branch of the glossopharyngeal nerve, its
canal, and its plexus, all of which now bear his name.
Gilbert Breschet, France (1784–1845)
Études anatomiques et physiologiques sur l’organe de l’ouie et sur l’audition, dans
l’homme et les animaux vertébrés. Presentés á l’académie royale des sciences, 27
Août 1832.
Recherches anatomiques et physiologiques sur l’organe de l’ouie des poissons. Paris, JP
Baillière, 1838.
Breschet named the individual labyrinthine components according to a uni-
form and rational system. He was the first to use the term “helicotrema” to describe
the communication of the scala tympani and scala vestibuli at the apex of the cochlea.
He distinguished otoliths (ear stones), which are the large enamel-like stones in fish,
from otoconia (ear dust), a term that describes the fine granules of higher animals. He
documented the relationships of the scala tympani and the vestibule, and first used
the terms “perilymph” and “endolymph” to denote Cotugno’s and Scarpa’s fluids,
respectively. He accurately delineated the arteries of the spiral lamina as part of his
description of the vascular arborizations within the labyrinth.
August Albrecht Meckel, Germany and Switzerland (1790–1829)
Bemerkungen über die Hohle des knöchernen Labyrinthes (mit Abbildungen).
Meckels Arch f Anat u Physiol, 1827.
August Meckel introduced the corrosion method of preparation of the bony
labyrinth in the macerated temporal bone.
Carl Ernst Von Baer, Russia (1792–1876)
Ueber Entwicklungsgeschichte der Thiere. Bd I, Königsberg, 1828–1834; Bd II, 1837.
Von Baer is often referred to as the “Father of the New Embryology” and
was the first to study the embryologic development of the organ of hearing on a
comparative basis.

Martin Heinrich Rathke, Poland and Germany (1793–1860)
Entwicklungsgeschichte der Menschen und der Thiere. Leipzig, 1832.
Rathke, in 1825, was the first to observe transverse fissures (gill slits), which he
found present in the cervical region of pig embryos. He determined that the exterior
part of the first gill slit became the external auditory canal in the course of
embryologic development. Rathke is better known for Rathke’s pouch, a diverticu-
lum from the embryonic buccal cavity from which the anterior lobe of the pituitary
is developed.
Marie Jean Pierre Flourens, France (1794–1867)
Memoires présentés à l’académie royale des sciences, 27 Decembre 1824.
Recherches experimentales sur les propriétés et les fonctions du système nerveux dans les
animaux vertébrés. Paris, Crevot, 1824.
Nouvelles experiences sur l’independance respective des fonctions cérébrales.
Compt Rend T LII, 1861.
Through animal experimentation, Flourens demonstrated that lesions of the
semicircular canals resulted in dysequilibrium and motor incoordination. His exper-
iments provided the foundation for the modern physiology of the semicircular canals
and vestibule. Although Friedrich Goltz (1834–1902) was the first to suspect that the
semicircular canals were the organs of balance, Flourens’ experiments showed that
the cochlea was the sole organ for the perception of sound and that the vestibular and
semicircular canal structures were not involved in sound perception.
Emil Huschke, Germany (1797–1858)
S Th Soemmerring, Lehr von den Eingeweiden und Sinnesorganen des menschlichen Körpers.
Revised and concluded by Emil Huschke, Leipzig, 1844.
Huschke was the discoverer of the sensory papilla of the cochlea, which later
came to bear Corti’s name. Huschke also gave a clear description of the stria vascularis,
the dentate zone of the cochlea, and the tall cells that cover the limbus (Huschke’s teeth).
Friedrich Cornelius, Estonia (1799–1848)
De membranae tympani usu. Dorpat, 1825.
Cornelius was the first to observe and illustrate the “internal fold of the tympanic
membrane” and the “posterior pocket of the tympanic membrane,” which it formed.
Thus, he anticipated von Tröltsch after whom this posterior pouch is now named.
Johannes Peter Müller, Germany (1801–1858)
Handbuch der Physiologie des Menschen. Koblenz, 1837.
This German physiologist was the first to recognize the differential acoustic
properties of air and water and the logical necessity of a transformer mechanism to
convert air vibrations to those of fluid.
Kaspar Theobald Tourtual, Prussia (1802–1865)
Neuen Untersuchungen über den Bau des menschlichen Schlund- und Kehlkopfes mit vergle-
ichend-anatomischen Bemerkungen. Leipzig, 1846.
Tourtual was the first to provide an accurate description of the origin and rela-
tionships of the tensor veli palatini muscle, with special attention to its relationship
to the eustachian tube. His description of the fossa of Rosenmüller excelled that of its
namesake. He also described the location and course of the fold that bears his name,
the plica salpingopalatina.
Friedrich Arnold, Germany and Switzerland (1803–1890)
Diss inaug med sist observationes nonnullas neurologicas de parte cephalica nervi sympathici
in homine. Heidelberg, 1826.
Ueber den Ohrknoten. Eine anatomisch-physiologische Abhandlung. Heildelberg, 1828.
Ueber den Canalis tympanicus u mastoideus. Tiedemanns Ztschr f physiol, Bd IV, 1832.
Arnold published his discovery of the otic ganglion in his 1826 inaugural dis-
sertation. He was the first to describe and name the nervus petrosus superficialis
minor (lesser superficial petrosal nerve) and the nervus petrosus profundus
minor (lesser deeper petrosal nerve). An additional contribution to the field of neuro-
anatomy was his discovery and description of the auricular branch of the vagus and
the canaliculus mastoideus, which it transverses.

Pierre Charles Huguier, France (1804–1874)
Bichats’ Anatomie descriptive. Paris, 1834.
Huguier is well known for his description of the canal near the petrotympanic
fissure that transmits the chorda tympani nerve (canal of Huguier). He also described
the sinus tympani (cavité sous-pyramidale).
Friedrich Gustav Jacob Henle, Germany (1809–1885)
Allgemeine Anatomie. Leipzig, 1841.
Handbuch der systematische Anatomie des Menschen. Brunswick, 1855–1872.
Henle was the first to describe the processus auditorius of the temporal bone,
otherwise known as the suprameatal spine of Henle.
Joseph Hyrtl, Hungary and Austria (1811–1894)
Vergleichend-anatomische Untersuchungen über das innere Gehörorgan des Menschen und
der Säugethiere. Prague, Friedrich Ehrlich, 1845.
Ueber spontane Dehiszenz des Tegmen tympani u d Cellulae mastoideae. Wien, 1858.
Die Korrosionsanatomie u ihre Ergebnisse. Wien, 1873.
In the first of these publications, Hyrtl expanded the knowledge of the compar-
ative anatomy of the organ of hearing, particularly with respect to the structure of the
inner ear. In 1858, Hyrtl wrote a short paper pointing out the frequent occurrence of
dehiscence of the tegmen tympani, which could not be explained by the changes of
aging or infection; he noted that these openings most frequently could be found
superior and posterior to the incudomalleal articulation. In the third of the listed
works, Hyrtl describes the results of his work in corrosion anatomy combined with
injection of the external auditory canal, the tympanic cavity, the mastoid air cell sys-
tem, and the eustachian tube. This study laid the foundation for the elucidation of the
topographic anatomy of these regions of the organ of hearing. We have studied
Hyrtl’s publications but have been unable to confirm that he ever described the
fissure that bears his name, Hyrtl’s or tympanomeningeal fissure.
Karl Bogislaus Reichert, East Prussia (1811–1883)
De embryonum arcubus sic dictis branchialibus. Berlin, 1836.
Ueber die Visceralbogen der Wirbelthiere. Berlin, Sittenfeld, 1837.
Reichert declared that the second (hyoid) visceral bar, which he first described,
gave rise to the entire stapes. It is now known, however, that the footplate of the
stapes (basis stapedis) derives from the otic capsule.
Henry John (Jones) Shrapnell, England (1814–1834)
On the form and structure of the membrana tympani. Lond Med Gaz, 10:120, 1832.
Shrapnell was the first to distinguish between the pars tensa and the pars flac-
cida (Shrapnell’s membrane) of the tympanic membrane.
Joseph Toynbee, England (1815–1866)
On the functions of the membrana tympani, the ossicles and muscles of the tympa-
num, and of the eustachian tube and their actions in different classes of animals.
Abstr Papers Commun Roy Soc Lond, 6:217, 1850–1854.
On the structure of the membrana tympani in the human ear. Phil Trans, 1851,
pp. 159–168.
The Diseases of the Ear: Their Nature, Diagnosis, and Treatment. London, J Churchill, 1860.
The tensor tympani muscle is known as Toynbee’s muscle because of his inves-
tigations. Knowledge of the existence of this muscle dated back to the time of
Eustachius (1524–1574). Bernhard Albinus (1697–1770), a surgeon and anatomist
at Leyden University, is credited with the appellation of the tensor tympani muscle.
The third work is a medical classic written by this “Father of British Otology.”
In this text he delineates his method for removal of the temporal bone (of which he
dissected 2000). He correlated the postmortem findings with symptoms manifested
during life, thus being the first to correlate pathology with the clinical presentation
of otologic disease.
Rudolf Albert Von Kölliker, Sweden (1817–1905)

Entwicklungsgeschichte des Menschen und der höhren Thiere. Leipzig, W Engelmann, 1861.

In 1861 Kölliker honored Reissner by being the first to call the vestibular
membrane by Reissner’s name.
Friedrich Matthias Cladius (Claudius), Germany (1822–1869)
Physiologische Bermerkung ueber das Gehörorgan. Kiel, 1858; Marburg, 1862.
Claudius is credited with the original description of the cells that line the outer
spiral sulcus of the cochlear duct; these cells are known as the cells of Claudius.
Alfonso Marchese Corti, Italy (1822–1888)

Recherches sur l’organe de l’ouie des mammifères. Z Wiss Zool, 3:109, 1851.
Corti gave a more detailed description of the structure of the auditory papilla
first discovered by Huschke. Hence, many of its structures bear his name—the organ
of Corti, the pillars of Corti, the tunnel of Corti, the outer hair cells of Corti, and the
(tectorial) membrane of Corti.
Ernst Reissner, Latvia (1824–1878)

De auris internae formatione. Dorpati Livonorum, H Laakmann, 1851.
In 1851 Reissner proved conclusively that there was a special canal in the
cochlea termed the “canalis cochlearis.” Three years later he described the embry-
ologic development of the otic vesicle and demonstrated how the vesicle was trans-
formed into its three derivatives: (1) the recessus labyrinthi, which up to that time was
called the aquaeductus vestibuli, and was incorrectly considered to be the aquaeduc-
tus cochlearis, (2) the vestibular region with the semicircular ducts, and (3) the scala
media or cochlear duct. He described the vestibular membrane that bears his name.
Maximilian Johann Sigismund Schultze, Germany (1825–1874)

Ueber die Endigungsweise der Hörnerven im Labyrinth. Arch f Anat Physiol u Wiss
Med, 1858, p. 343.
Schultze was an important figure in the development of the science of
histology. Among his monographs on the nerve endings of the sense organs is the
description of the nerve endings of the labyrinth.
Anton Friedrich Von Tröltsch (Troeltsch), Germany (1829–1890)

Anatomische Beiträge zur Ohrenheilkunde. Virchows Arch, 17:1, 1859.
Die Untersuchung des Gehörgangs und Trommelfells. Ihre Bedeutung.
Kritik der bisherigen Untersuchungsmethoden und Angabe einer neuen.
Dtsch Klinik, 12:113, 1860.
Ein Fall von Anbohrung des Warzenfortsatzes bei Otitis interna mit
Bemerkungen über diese Operation. Virchows Arch f Path Anat, 21:295, 1861.
Die Krankheiten des Ohres, ihre Erkenntniss und Behandlung. Würzburg, Stahel, 1862.
Lebrbuch der Ohrenheilkunde, mit Einschluss der Anatomie des Ohres. 7th ed. Leipzig,
FCW Vögel, 1881.
Von Tröltsch developed the first modern otoscope; he originated the modern
radical mastoidectomy. The anterior and posterior malleal folds of the tympanic
membrane, as well as the pouches they delimit, are named after von Tröltsch. He
believed that sclerotic changes in the middle ear mucosa were responsible for stapes
fixation and thus developed the term “otosclerosis.”
Arthur Böttcher (Boettcher), Estonia (1831–1889)
Observationes microscopicae de ratione qua nervus cochleae mammalium terminatur.
Dorpat, 1856.
Ueber Entwickelung und Bau des Gehörlabyrinthes nach Untersuchungen an Säugethieren.
1. Theil. 4°. E Blockmann u sohn, 1869.
In 1869, Böttcher was the first to use the term “cartilage islands” to refer to the
globuli interossei of the temporal bone. His name is applied to the cells on the basi-
lar membrane of the cochlea that lie medial and deep to the cells of Claudius as well
as to the saccular duct connecting the saccule and utricle. He also studied the termi-
nal endings of the cochlear nerve.
Moritz Ferdinand Trautmann, Germany (1832–1902)
Embolische Processe des Mtttelohrs. Berlin, 1886.

Trautmann was the professor of aural surgery at Berlin University in the 1870s.
His name is associated with the triangular area bounded by the superior petrosal
sinus, the sigmoid sinus, and the bony labyrinth (Trautmann’s triangle).
Otto Friedrich Carl Deiters, Germany (1834–1863)
Untersuchungen über die Lamina spiralis membranacea. Bonn, 1860.
In 1860, Deiters was the first to describe the inner hair cells of the organ of Corti
and their supporting cells. The outer phalangeal cells bear Deiters’ name in honor of
this discovery.
Viktor Hensen, Germany (1835–1924)
Zur Morphologie der Schnecke des Menschen und der Säugthiere. Ztschr Wiss Zool,
13:481, 1863.
In 1863, Hensen was the first to describe numerous structures of the inner ear,
including: (1) the ductus reuniens (known as Hensen’s canal), (2) a thickened band
on the inferior surface of the tectorial membrane now known as Hensen’s stripe, (3)
the supporting cells radially outside the outer hair cells, which are now known as
Hensen’s cells, and (4) the hairs (stereocilia) of the hair cells. He was the first to
demonstrate that the basilar membrane gradually widened from base to apex of the
cochlea. He believed that alterations in the consistency of the protoplasm of the
cells of the organ of Corti triggered off the nerve impulses. Moreover, he agreed
with Claudius in believing that sound impulses entered the cochlea through the
round window and that the scala tympani was stimulated through the basilar
membrane.
Adam Politzer, Hungary and Austria (1835–1920)
Ueber em neues Heilverfahren gegen Schwerhörigkeit in Folge von Unwegsamkeit
der Eustachischen Ohrtrompete. Wien Med Wschr, 13:84, 1863.
Die Beleuchtungsbilder des Trommelfells im gesunden und kranken Zustande. Wein, W
Braumüller, 1865.
Lehrbuch der Ohrenheilkunde. Vols 1 and 2. Stuttgart, F Enke, 1878–1882.
On a peculiar affection of the labyrinthine capsule as a frequent cause of deafness.
Trans 1st Panam Med Congr (1893), 1895.
Geschichte der Ohrenheilkunde. Stuttgart, F Enke, Vol 1, 1907; Vol 2, 1913.
History of Otology. English translation by S Milstein, C Portnoff, and A Coleman.
Phoenix, Columella Press, 1981.
While Politzer made no contributions to new knowledge of anatomy, his
contributions to otology were prolific.
In the first of the cited references, Politzer describes his method for achieving
patency of the eustachian tube. The second is an atlas of colored illustrations of the
tympanic membrane. The third is his textbook of otology, which for many years
served as the preeminent source book on the subject. In the fourth, he described for
the first time the clinical entity of otosclerosis as being distinct from chronic middle
ear disease. The fifth reference is his classic two-volume history of otology, which
recently (1981) was translated into English by Milstein et al.
Gustav Magnus Retzius, Sweden (1842–1919)

Das Gehörorgan der Wirbelthiere. Vols 1 and 2. Stockholm, Samson and Wallin,
1881–1884.
Die Endigungsweise des Gehörnerven. Biol Untersuch, 3:29, 1892.
Retzius was one of the foremost histologists of the recent past, and his dia-
grams of the organ of hearing in bony fish and vertebrates can scarcely be excelled,
even in modern times. He felt that the hair cells were the ultimate receptors of the
hearing organ and noted their innervation by auditory nerve fibers.
Friedrich Siebenmann, Switzerland (1852–1928)

Die Blutgefässe im Labyrinth des menschlichen Ohres nach eigenen Untersucbungen an
Celloiden-Korrosionen und an Schnitten. Weisbaden, JF Bergmann, 1894.
Demonstration mikroscopischer und macroscopisher Präparate von Otospongiosis
progressiva. Int Otol Congr Bost, 9:207, 1912.
Siebenmann used the corrosion method of preparation of the temporal bone in
his anatomic studies. His name is eponymically associated with the channels traveling

with the cochlear aqueduct (paravestibular canaliculi). He described the blood supply
of the inner ear.
Santiago Ramón y Cajal, Spain (1852–1934)
Manual de Anatomia Patologica General. Barcelona, 1890 (7th ed, Madrid, Moya, 1922).
This Nobel laureate studied and described the histology of the nervous system
including the cochlear nuclei.
Max Brödel, U.S.A. (1870–1941)
Three Unpublished Drawings of the Anatomy of the Human Ear. Philadelphia, WB
Saunders Co, 1946.
Brödel was a master artist who contributed elegant drawings of the anatomic
structures of the human body, including the ear.
Kenkichi Asai, Japan (1872–1945)
Die Blutgefässe des häutigen Labyrinthe der Ratte. Anat Hefte, 36:711, 1908.
Die Blutgefässe des häutigen Labyrinthe des Hundes. Anat Hefte, 36:369, 1908.
Asai described in detail the blood vessels of the inner ear.
Robert Bárány, Austria (1876–1936)
Ueber die vom Ohrlabyrinth ausgelöste Gegenrollung der Augen bei Normalhörenden.
Arch Ohrenheilk, 68:1, 1906.
Untersuchungen über den vom Vestibularapparat des Ohres reflektorisch ausgelösten
rhythmischen Nystagmus und seine Begleiterscheinungen. Mschr Ohrenheilk, 40:193,
1906; 41:477, 1907.
Bárány (Nobel laureate, 1914) made no important anatomic studies, but is
remembered for developing and popularizing the caloric test as an indicator of
vestibular function.
Karl Wittmaack, Germany (1876–1972)
Über sekundäre Degeneration im inneren Ohre nach Akustikustammuer-letzungen.
Verh Dtsch Otol Ges, 20:289, 1911.
Die Ortho- und Pathobiologie des Labyrinthes. Stuttgart, Georg Thieme Verlag, 1956.
Wittmaack was a pathologist and researcher known for his detailed studies of
human inner ear disease based on light microscopic studies.
Theodore Hieronymous Bast, U.S.A. (1890–1959)
With BJ Anson. The Temporal Bone and the Ear. Springfield, Charles C Thomas, 1949.
Bast contributed greatly to today’s knowledge of the anatomy of the temporal
bone, both adult and developmental. He is credited with the discovery of the
utriculo-endolymphatic valve.
Gosta Dohlman, Sweden (1890–1983)
The mechanism of secretion and absorption of endolymph in the vestibular appara-
tus. Acta Otolaryngol (Stockh), 59:275, 1965.
Dohlman described the physiologic behavior of the cupula. He was a strong
proponent of the theory that ruptures of the membranous labyrinth are responsible
for the acute vertiginous episodes in Ménière’s disease.
Stacy Rufus Guild, U.S.A. (1890–1966)
A hitherto unrecognized structure, the glomus jugularis, in man. Anat Rec, Suppl 2,
79:28, 1941.
The glomus jugulare, a non-chromaffin paraganglion in man. Ann Otol Rhinol
Laryngol, 62:1045, 1953.
A graphic reconstruction method for the study of the organ of Corti. Anat Rec,
22:141, 1921.
Guild was the first to describe the normally occurring “glomus body” in the
middle ear and first demonstrated the method of graphic reconstruction of the
cochlea from serial histologic sections.
Barry Joseph Anson, U.S.A. (1894–1974)
With TH Bast. The Temporal Bone and the Ear. Springfield, Charles C Thomas, 1949.
Anson made numerous anatomic descriptions of the temporal bone from light
microscopic preparations and gave the first detailed report on ossification centers.

Dorothy Wolff, U.S.A. (1895–1980)
Otosclerosis: hypothesis of its origin and progress. Arch Otolaryngol, 52:853, 1950.
With RJ Bellucci and AA Eggston. Surgical and Microscopic Anatomy of the Temporal
Bone. New York, Hafner Publishing Co, 1971.
Wolff was a meticulous anatomist who will be remembered for her teaching of
ear anatomy and for the excellent books on microscopic anatomy of the ear that she
co-authored.
John Ralston Lindsay, U.S.A. (1898–1981)
Suppuration in the petrous pyramid. Ann Otol Rhinol Laryngol, 47:3, 1938.
Petrous pyramid of temporal bone: pneumatization and roentgenologic appearance.
Arch Otolaryngol, 31:231, 1940.
Labyrinthine dropsy and Ménière’s disease. Arch Otolaryngol, 35:853, 1942.
Postural vertigo and positional nystagmus. Ann Otol Rhinol Laryngol, 60:1134, 1951.
Lindsay developed a systematic study of the pathologic conditions of the tem-
poral bone. His surgical approach to suppuration of the petrous apex was based on
painstaking studies of pneumatization. He felt that one should first attempt to find a
tract from the mastoid to the petrous apex; if that course failed, he suggested an
approach to the apex from the middle ear. His first case report of idiopathic endolym-
phatic hydrops, which appeared only a few years after the initial discovery by
Yamakawa and by Hallpike and Cairns, launched three decades of investigation into
the pathology and pathophysiology of Ménière’s disease. He ascribed the overaccu-
mulation of endolymph found in Ménière’s disease to a failure of the endolymphatic
sac to perform its resorptive function. His expertise in neuro-otology is exemplified
by his classic paper on positional vertigo and nystagmus. In this paper, he detailed
the classifications, diagnostic examination, pathogenesis, and treatment of this entity.
Georg Von Békésy, Hungary, Sweden and U.S.A. (1899–1972)
Zur Physik des Mittelohres und über das Hören bei fehlerhaftem Trommelfell. Akust
Ztschr, 1:13, 1936.
Über die Messung der Schwingungsamplitude der Gehörknöchelchen mittels einer
kapazitiven Sonde. Akust Ztschr, 6:1, 1941.
Über die mechanische Frequenzanalyse in der Schnecke verschiedener Tiere Akust
Ztschr, 9:3, 1944.
Békésy (Nobel laureate, 1961) contributed to our present understanding of the
process of sound conduction by the middle and inner ears. His visualization of
sound-induced displacements of the basilar membrane made possible by strobomi-
croscopy led to his formulation of the traveling wave theory of hearing. He hypoth-
esized that the movements of the stapes footplate established traveling waves in the
basilar membrane; the maximal amplitude for the waves of low-pitched tones was
located in the apex of the cochlea while higher pitched tones were associated with
waves whose peak amplitudes occurred more basally. He noted that, in the diseased
middle ear, the round window could act as a significant route of sound access to the
cochlea as well as effectively cancel the effect of sound entering via the oval window.
He described the resting endocochlear potential.
Heinrich F.G. Kobrak, U.S.A. (1905–1957)
Zur Physiologie der Binnenmuskeln des Ohres. Beitr Anat Physiol Path Therap
Ohres, 28:138, 1930.
The physiology of sound conduction. Ann Otol Rhinol Laryngol, 47:166, 1938.
The Middle Ear. Chicago, University of Chicago Press, 1959.
Through his cinematographic studies of the movements of the ossicular
system, Kobrak contributed to our understanding of the vibrating characteristics of
the ossicles. He also eluidated the functions of the intratympanic muscles.

Index
Numerals in boldface indicate illustrations; numerals followed by s indicate

stereoscopic view; numerals followed by T indicate table
Accessory canals to cochlear aqueduct, 166 Artery(ies), accessory meningeal (Cont.)

Accessory regions, 123, 129 inferior, 211, 212
Acoustic neuroma (schwannoma), 238s superior, 211, 213
Acousticofacial ganglion, 256 vestibular, anterior, 216, 218
Acousticofacial primordium, 257, 258, 264 posterior, 216, 216
Aditus ad antrum, 6, 116–118, 126 Articulation(s), changes of aging, 75, 76 –80
Ampulla(e) of semicircular ducts, 17, 30s, 139, 145, incudomalleal, 49, 54, 55, 55, 59, 62, 65, 70,
152. See also Crista ampullaris 71–73, 72–74
Aneurysm of internal carotid artery, 198 incudostapedial, 72, 74, 75, 74, 75
Ankylosis of malleus, 60–62 ossicular, 70, 71–76, 74, 75
Annular ligament, 285, 286. See also Articulation, stapediovestibular, 68, 75, 76
Stapediovestibular Atticotomy, posterior, surgical procedure, 229s
Annulus, tympanic, 11, 41, 42, 232s, 233s Auricle (pinna), 31–33, 32
Antrum, mastoid, 116, 126, 225s cartilage of, 32
Aqueduct, cochlear, 163–166, 163–165 ligaments of, 33
vestibular, 155–157, 161 lobule of, 32, 33
Arcuate eminence, 1, 2, 119 skin of, 33
Arterioles, capillary network of stria vascularis, vascular supply of, 197
216–218 Auricular tubercle (Darwinian), 31, 32, 282
radiating, external and internal, 216, 217, 218
Artery(ies), accessory meningeal, 199, 200 Basilar membrane of cochlea, 146, 148
ampullary, anterior, 219 Blue-lining of semicircular canal(s), 228s, 230s
auditory (labyrinthine), internal, 216, 216 Body(ies), corpora amylacea, 164
auricular, deep, 212 glomus, 112, 112–113
caroticotympanic, 211, 214 middle ear corpuscles, 110–111, 110, 111
carotid, internal, 22, 197–199, 198–200, 235s, 236s pacchionian, 113, 133–135
aneurysm of, 199 Boettcher (Böttcher) cells, cochlea, 146, 149
atheromatous degeneration of, 197–201 Bone, enchondral (endochondral), 137, 138, 280–281
cerebellar, anterior inferior, 28s, 199–201, endosteal, 138, 288
201–203, 216 genesis and growth of, 287–288
cochlear, main (common), 216, 217 globuli interossei, 137, 138, 279–280, 288
ramus of, 216, 216, 218 intracartilaginous, 287
labyrinthine (internal auditory), 216, 216 intrachondrial. See Bone, globuli interossei
of cochlea, 216–218, 216 membranous. See Embryology, of membranous bone
of endolymphatic sac, 160, 161, 161 perichondrial, 280, 286, 287
of external auditory canal and pinna, 197 periosteal, 138, 280, 288
of incudostapedial articulation, 211, 212 Bony bar to head of malleus, 60 –62
of inner ear, 216–218, 216 Bony labyrinth of inner ear, 137–143, 138, 139
of mastoid, 211, 213 microfissures of, 141–142, 142
of membranous labyrinth, 216 Bony spur(s), epitympanic, 58, 58–61
of middle ear, 210–215, 211 Border cell(s) of cochlea, 148
of spiral prominence, 217, 217 Bursa(e) in stapediovestibular articulation, 75, 76
of stria vascularis, abnormally large, 217
stapedial, persistent, 214–215, 215 Canal(s), accessory, to Cochlear aqueduct, 166
stylomastoid, 211, 213 carotid, 21
subarcuate, 211, 214 external auditory. See External auditory canal
superficial petrosal, 211, 213 fallopian (for facial nerve), 174. See also
tubal, 211, 213 Dehiscence(s) of fallopian canal;
tympanic, anterior, 210, 211 Embryology of facial canal
349
Canal(s), accessory, to Cochlear aqueduct (Cont.) Darwinian (auricular) tubercle, 31, 32, 282
internal auditory. See Internal auditory canal Dehiscence(s) of fallopian canal, 176, 179–181,
of Cotugno (for inferior cochlear vein), 163, 166 180–183
of Huguier (for chorda tympani nerve), 56 Deiters’ cells of cochlea, 146, 149
petromastoid, 6, 127, 132, 136 Digastric ridge, 122, 226s
Rosenthal’s, 139, 146 Dissection of temporal bone, surgical, 223,
semicircular, 16, 17, 139, 139–140, 236s, 237s 224s–238s
blue-lining of, 228s, 230s Duct(s), cochlear. See Cochlear duct
lateral, 7, 227s, 229s endolymphatic. See Endolymphatic duct
posterior, 8, 11, 227s, 228s periotic, 163–166
superior, 6, 230s, 231s saccular, 145, 150, 151
singular, for posterior ampullary nerve, 11, 92–93 semicircular, 152–154, 153
Canaliculi, paravestibular, 156, 160, 161–162, 161 utricular, 145, 150, 150
Canaliculi perforantes (of Schuknecht), 163 Ductus reuniens, 29s, 145
Capsular channels (aqueducts). See Embryology,
of capsular channels Eighth cranial nerve and ganglion. See Embryology,
Carotid artery, internal. See Artery(ies), carotid, internal of eighth cranial nerve and ganglion
Carotid canal, 21 Elliptical recess of vestibule, 137, 139
Cartilage, Meckel’s, 259, 260, 277, 277 Embryology, 256–310
of auricle (pinna), 33 development to 4 weeks, 256–261
of eustachian tube, 96–97, 97–105 development to 8 weeks, 261–272
Reichert’s, 259, 260, 277, 277 development to 16 weeks, 272–278
Cecum, cupular, 145 development 16⫹ weeks, 278–287
vestibular, 26s, 137 of annular ligament, 285, 286
Central mastoid tract, 116, 117, 119, 120, 121, of arteries, 259–260, 269–271, 278
122, 123 auditory (labyrinthine), internal, 270–271, 271
Cerumen, 37–38 stapedial, 270–271, 270
Channel(s), capsular. See Embryology, of capsular of capsular channels, 264, 275, 282
channels of cochlear aqueduct, 282
Cholesteatoma, 243s, 246s, 247s of cochlear duct, 262, 272–273, 279
congenital, of petrous apex, 247s of eighth cranial nerve and ganglion, 257, 263
Chordal eminence, 86, 95 of enchondral (endochondral) bone, 280,
Chordal ridge, 86 279–280, 287
Cistern, perilymphatic, of vestibule, 10, 18 of endolymphatic duct, 263, 279
Claudius’ cells of cochlea, 146, 149 of eustachian tube, 108–109, 268, 283
Cochlea, 25s, 29s, 137–139, 139, 140 of external auditory canal, tympanic membrane,
hook portion of, 26s, 30s and tympanic ring, 267, 276, 282–283
vascular supply of, 216–218, 217, 220 of facial canal, 265, 282
Cochlear aqueduct, 163–166, 164, 165, 282 of facial nerve, 258, 264–265, 276, 282
Cochlear duct, 140, 145–149, 146, 162 of fissula ante fenestram, 275
Cochlear nerve. See Nerve(s), cochlear of fossula post fenestram, 275–276
Cochleariform process, 82, 83, 235s, 236s of lamina stapedialis, 259, 285
Common crus (crus commune), 8 of malleus and incus, 259, 268–269, 277, 284–285
Corpora amylacea, 164 of Meckel’s cartilage, 259, 260, 277, 277
Corpuscles, middle ear, 110–111, 110, 111 of membranous bone, 287
Corti, organ of, 148–149 of membranous labyrinth, 256–257, 261–262, 272
Cortilymph, 148 of ossicular muscles, 278, 285
Cotugno, canal of, 164, 166 of otic capsule, 257–258, 264, 274–275, 279–280,
Crest, semilunar, of round window, 92 288–290
transverse (falciform), of fundus of internal of perichondrium, 280, 286, 288
auditory canal, 20, 166, 167 of perilymphatic spaces, 264, 275, 281–282
utricular, inferior, 17, 29s of pinna, 258, 265–266, 265–267, 282
vertical, of fundus of internal auditory canal, 24s, of scala(e) tympani and vestibuli, 262, 272–273
166, 167 of semicircular canal(s), 274, 274
vestibular, 137 of semicircular duct(s), 257, 263, 274, 279
Cribriform (cribrose) area(s), 137, 149, 167 of stapediovestibular articulation, 285, 286
Crista ampullaris, of lateral canal, 7, 24s, 28s of stapes, 259, 269, 277–278, 285
of posterior canal, 92, 93, 165, 26s, 30s of styloid process, 272
of semicircular ducts, 152 of temporal bone, 272, 278–287
of superior canal, 24s of tympanic membrane, 267, 276, 282–283
Crista neglecta, 153–154, 154 of tympanomastoid compartment, 258–259, 268,
Crista stapedis, 67 276–277, 283–284
Crus (crura), 46, 66–67, 67 of utricle and saccule, 262–263, 273
Cupping of internal auditory canal, 168, 169 of veins, 261, 272, 278, 286
Cupula(e) of semicircular ducts, 94, 152 cardinal, 272
Cupular cecum of cochlear duct, 145 ossification, 287–290
350 ■ INDEX
Embryology (Cont.) Ganglion, acousticofacial, 257
serial photomicrographs, 291, 292–310 geniculate, 172–174, 184, 236
fetus A, 8 weeks, 292–296 Scarpa’s, 149, 188, 192, 194
fetus B, 12 weeks, 297–300 spiral. See Nerve(s), cochlear
fetus C, 16 weeks, 301–306 Genu of facial nerve, first, 20, 24s, 175, 178
infant, 5 months, 307–310 second, 172
Eminence, arcuate, 1, 6 Gerlach’s tubal tonsil, 97
chordal, 86, 95 Gland(s), apocrine (ceruminous), 37, 38–39, 38
pyramidal, 80, 86, 94, 95, 95 parotid, 38, 39
styloid, 86, 95 sebaceous, 35–36, 36, 39
Enchondral (endochondral) bone, 137, 138, 279–280 Glaserian fissure (suture). See Petrotympanic suture
Endolymph, 144 Glial-Schwann sheath junction, 8
Endolymphatic duct, 18, 150, 155–157, 156, 161, 241 Globuli interossei, 137, 138, 281, 288
sinus of, 150, 150, 155, 156 Glomus bodies, 112–113, 112, 113
Endolymphatic sac, 16, 150, 157–161, 157–160, 227, 249 Glomus jugulare tumor, 112, 248s
epithelium of, 159–160, 159–160 Gracilis, processus. See Malleus, process of, anterior
Epitympanic area, pneumatization of, 130 Grenzscheiden, 138
Epitympanum, 86, 87, 227 Gusher, perilymph, 165–166, 166
anterior epitympanic recess, 7, 24s, 88, 89, 90
Eustachian tube, 21–22, 96–97, 96–105, 97–104, 106, 235 Hair cell(s), cochlear, 148
bony, 96, 96, 99 vestibular, 152
fibrocartilaginous, 96–97, 96–105 Hamulus, cochlear, 137–139, 145
lining (mucosal) membrane of, 97, 103, 104 Hardesty’s membrane of tectorial membrane, 145, 149
Exostoses, 39, 39, 40, 241 Helicotrema, 10, 138, 139
External auditory canal, 33–35, 33, 34, 35–39, 39 Henle, spine of, 224
pneumatization of bony walls, 34, 35 Hensen’s cells of cochlea, 149
skin of, 34–35, 36–39, 37–39 Hensen’s stripe of tectorial membrane, 140, 149
vascular supply of, 197 Herniations of facial nerve, 176, 179–181, 180–183
Hiatus, facial, 1, 89
Facial canal. See Dehiscence(s) of fallopian canal; Hillock(s) of His, 265, 266
Embryology, of facial canal; Fallopian canal Huguier, canal of, for chorda tympani nerve, 56
Facial cells of mastoid, including retrofacial, 15, 122, Hyalin plaque (tympanosclerosis) in tympanic
232, 242 membrane, 43
Facial hiatus, 1, 89, 174, 184–185 Hypotympanum, 27, 31s, 87, 89
Facial nerve. See Nerve, facial Hyrtl’s (tympanomeningeal) fissure, 140, 142
Facial recess, 10, 75, 93–95, 95
Falciform crest. See Crest, tranverse Immune system of middle ear, 108
Fallopian canal, 173. See also Dehiscence(s) of Incudal recess, 54, 62
fallopian canal; Embryology, of facial canal Incus, 47, 61, 63, 59–66
vein in, 60, 189, 189, 206, 207 articulation(s) of, 49, 54, 54, 59, 63, 65, 70–71,
Fat pad of Ostmann, 105, 105 71–74, 73
Fissula ante fenestram, 142–143, 144. See also ligament(s) of, medial and lateral incudomalleal,
Embryology, of fissula ante fenestram 47, 55, 55, 65, 65, 72, 73
Fissure(s), microfissures, 141–142, 142 posterior, 54, 65, 65, 67
of Santorini, 33, 37 pneumatization of, 66, 67, 67
of temporal bone. See Suture(s) process of, long, 63, 63, 65, 66, 67
of vestibule. See Fissula ante fenestram; short, 62, 62, 65, 67
Fossula post fenestram prosthesis for, 29, 64
tympanomeningeal (Hyrtl’s), 142, 142 Infralabyrinthine, area, pneumatization of, 18–20
Fold, incudal, 108 Inner ear, 137–170
malleal, anterior, 108 bony labyrinth of, 137–144, 138, 139
malleal, posterior, 55, 108, 108 measurements of, 91
manubrial (plica mallearis), 48, 51, 52 vascular supply of, 216–218, 217, 220, 221
stapedial, 108 Internal auditory canal, 166–170, 167–169
Folianus, processus. See Malleus, process of, anterior cupping of, 168, 169
Footplate of stapes, 46, 63, 66, 67, 237 nerve trunks in, 7, 10, 24s, 26s, 28s, 29s,
Fossa (impression), foveate, 155 195–196, 196
Fossa, jugular, 4 surgical approach to, 185, 196, 237s
mandibular, 12, 17 Intracartilaginous bone, 287
of Rosenmüller, 97, 102 Intrachrondrial bone. See Globuli interossei
subarcuate, 1, 136, 136 Iter chordae, anterius and posterius, 186–187
Fossula post fenestram, 142, 144. See also Embryology,
of fossula post fenestram Joint(s). See Articulation(s)
Foveate fossa (impression) for endolymphatic sac, 157
Fracture of bony labyrinth, 137 Koerner’s (petrosquamosal) septum, 7, 9, 28s, 120,
Fundus of internal auditory canal, 166, 167 121, 122, 225s
INDEX ■ 351
Labyrinth, bony, 137–142, 146, 145 Membranous bone. See Embryology, of
membranous, 144–170, 145 membranous bone
perilymphatic, 162–163 Membranous labyrinth, 144–161, 145
Labyrinthitis, 240s Mesenchyme in middle ear cavity, 47
Lamina, osseous spiral, 139, 140, 145, 146, 237s Mesotympanum, 17, 86, 87–88, 235s
secondary, 138 Microfissure(s), 141–142, 142
Lamina (pars) propria of tympanic membrane, Microfracture(s), 141
41, 50 Middle ear, 41–113
Lamina stapedialis. See Embryology, of lamina cleft, 86
stapedialis corpuscles, 110–111, 110, 111
Laterohyale, 260, 277, 278 measurements of, 91
Leidy, shield of (scutum), 86 mucociliary transport system of, 107
Lenticular process, 46, 62, 63, 74 mucosa, 106–109, 106
Ligament(s), annular. See Embryology, of annular immune system of, 108
ligament; Articulation(s), stapediovestibular mucosal folds of, 73, 108–109
auricular, extrinsic and intrinsic, 33 spaces, 85–93, 86, 94–97, 97–104, 233s
incudal, posterior, 54, 62, 65, 67 vascular supply of, 210–215, 212
incudomalleal, lateral, 49, 54, 55, 65, 73 walls of, 85–86
medial, 55, 65, 62, 72 Modiolus of cochlea, 10, 138, 139, 166
malleal, anterior, 46, 48, 55, 55 Motor nucleus of facial nerve, 171, 172
posterior, 55, 55, 186 Mucociliary transport system of middle ear, 107
spiral, of cochlea, 145–147, 146 Mucosa, of eustachian tube, 97, 104
suspensory, anterior, of malleus, 49, 54, 54, 73 of middle ear, 106–109, 106
lateral, of malleus, 17, 54–55, 54, 72 Mucosal fold(s), of middle ear, 73, 108–109
superior, of malleus, 55 of round window, 142
Limbus, spiral, of cochlea, 147 Muscle(s), auricular, extrinsic and intrinsic, 32
Lobule of auricle (pinna), 32, 33 ectopic, in middle ear, 84, 84, 87
Long process of incus, 62, 63, 63, 65, 66, levator veli palatini, 97, 100–102, 104
of auricle (pinna), 32
Macula(e), of saccule, 25s, 149, 151, 151 of middle ear, 80–85, 81–85
of utricle, 25s, 149, 149, 151 palatal, 104–105
orientation to oval window, 151, 152 salpingopharyngeus, 104
Malleus, 46, 43–69, 48, 49, 54–61 stapedius, 15, 80, 81, 82
ankylosis of, 60–61, 61 tensor tympani, 26s, 82, 83
articulation(s) of, 48, 54, 55, 59, 63, 65, 70, 74–75 tensor veli palatini, 82, 83, 98, 101, 104, 105
ligament of, anterior, 46, 47, 49, 55 Myringoplasty, 43, 45
posterior, 55, 55, 186
suspensory, anterior, 49, 54, 54, 73 Nerve(s), ampullary, to lateral and superior canals, 193
lateral, 17, 54–55, 54, 72 to posterior canal, 24s, 29s, 93, 193–195, 194
superior, 55 auricular branch of vagus (Arnold’s, Alderman’s),
process of, anterior, (p. gracilis, p. Folianus), 46, 47–48 192–193, 192
lateral, 48, 49 caroticotympanic, 192, 192
prosthesis for, 49, 53 chorda tympani, 65, 172, 185–187, 186, 187
Mandibular fossa, 12, 17 cochlear, 9, 25s, 194, 195–196
Manubrial fold (plica mallearis), 48, 51, 52 interrelationships in internal auditory canal,
Manubrium, 48, 49, 50, 51, 52, 53, 58 195, 196
Mastoid, 1, 224s–227s, 229s–231s facial, 15, 171–176, 172–185, 184–188
antrum, 116, 121–122, 225s abnormal course(s) of, 175–179, 176 –179
narrow configuration of, 119, 120 branches of, 172, 185–187
region, pneumatization of, 116, 116, 119–122 dehiscences and herniations of, 176, 179–181,
sclerotic, 118 180–183
tegmen of, 227s, 229s, 242s exploration (decompression) of, surgical, 229s
tract, central, 116, 117, 119, 121, 123 functional components of, 171, 172
Mastoidectomy, modified radical, 232s genu of, first, 20, 24s, 174, 178
radical, 235s, 240s second, 175
simple, 228s, 242s interrelationships in internal auditory
Measurements of middle ear and inner ear, 91 canal, 195, 196
Meckel’s cartilage, 259, 260, 277, 277 middle cranial fossa approach to, surgical, 24s,
Membrane, basilar, of cochlea, 146, 148 168–169
Hardesty’s, 149 normal course of, 172–175, 173, 174, 180–181
otolithic, of saccule and utricle, 149–151, 152 nuclei, 171–172, 172
Reissner’s, 147 transposition of, surgical procedure, 235s
round window, 18, 27s, 90–92, 90, 92, 93 vascular supply to, 189, 189
tectorial, 146, 149 greater superficial petrosal, 172, 185, 237s
tympanic. See Tympanic membrane inferior tympanic, 189–190, 190, 192
352 ■ INDEX
Nerve(s), (Cont.) Pars flaccida (Shrapnell’s membrane) of tympanic
Jacobson’s. See Nerve(s), inferior tympanic membrane, 8, 16, 42, 56, 187
lesser superficial petrosal, 8, 21, 190, 191, 191, 192 Pars inferior of membranous labyrinth, 262
Oort’s (vestibulocochlear) anastomosis, 193 Pars propria of tympanic membrane, 41
pericarotid sympathetic plexus, 12, 22, 191, 192 Pars superior of membranous labyrinth, 262
saccular, 25s, 29s Pars tensa of tympanic membrane, 41
sensory, of middle ear, 189–192. See also Nerve(s), Perforation(s) of tympanic membrane, 58, 169, 239s
tympanic Pericarotid sympathetic plexus, 11–12, 22, 191, 192
statoacoustic. See Embryology, of eighth cranial Perichondrium. See Embryology, of perichondrium
nerve and ganglion Perilabyrinthine region and tracts, pneumatization
tympanic, 189–192, 190, 192 of, 116, 124
tympanic plexus, 42, 192, 192 Perilymph, 164–165
utricular, 149–150 Perilymph “gusher(s)” and “oozer(s),” 166, 166
vestibular, 193–194, 194 Perilymphatic cistern of vestibule, 10, 18
inferior division of, 9, 29s, 193–195 Perilymphatic labyrinth, 162
interrelationships in internal auditory Perilymphatic system, 162
canal, 195–196, 196 Periosteal bone, 138, 279, 288
superior division of, 24s, 25s, 28s, 193–195 Periotic duct of cochlear aqueduct, 163–166
vestibulofacial anastomosis of, 193, 194 Peritubal area and tracts, pneumatization of, 12, 116,
Voit’s anastomosis of, 193 120, 125, 126, 129
Nervus intermedius (nerve of Wrisberg), Petromastoid canal, 6, 127, 132, 136
187–188, 188 Petrosal ridge, 20
Niche, round window, 30s, 90–92, 91–94 Petrosal sinus, inferior, 1, 205, 280
oval window, 90 superior, 1, 204
Notch in short process of incus, 54, 65 Petrosquamosal (Koerner’s) septum, 7, 8, 28s, 120,
Notch of Rivinus, 41, 42 121, 122, 225s
Nucleus, motor, of facial nerve, 171–172, 172 suture, 6
of solitary tract, 171, 172 Petrotympanic (glaserian) suture, 4, 6, 18, 127
superior salivatory, 171, 172 Petrous apex area, cholesteatoma of, 247s
Nuel, spaces of, cochlea, 149 pneumatization of, 116, 124, 126, 127–128, 130
Phalangeal cell(s) of cochlea, 148–149
Obturator foramen of stapes, 68, 67
Phylogenesis, Elasmobranchii (sharks), 251–252, 253
Occipital area and cells, Pneumatization of, 123, 129
lagena, 252, 253
Oort’s (vestibulocochlear) anastomosis, 193
Myxinoidea (hagfish), 252, 252
Oozers, perilymphatic, 166
of columella auris, 255
Operculum, 15, 157
of mammalian labyrinth, 254, 254
Organ of Corti, 140, 147–149
of membranous labyrinth, 252, 252–254
Ossicle(s), 46, 49, 55–61, 66–67, 70, 73, 75, 43–80
ossicles, 254–256, 255
articulated, sketch of, 46
Petromyzontia (river lamprey), 252, 253
articulation(s), 70, 74–75, 77, 68–80. See also
Phylogeny, 251–256, 252–255
Articulation(s)
Pillar cell(s) of cochlea, 148–149
derivation of, 277–278, 277. See also Incus; Malleus;
Pinna. See Auricle
Stapes
Plica mallearis (manubrial fold), 48, 51, 52
Ossification, 287–289
Pneumatization, 115–136, 115t
centers of, 288–289, 289, 290
area(s) of, 115, 115t, 116–136, 119–124, 129–133
of enchondral (endochondral) bone, 138, 280, 281,
of accessory region(s), 123, 129
287–288
of anterior epitympanic recess, 6–7, 24s, 88, 89
of endosteal bone, 138, 288
of anterior wall of the external auditory
of intracartilaginous bone, 287
canal, 33, 34
of intrachondrial bone. See Globuli inter-ossei
of central mastoid tract, 116, 117, 119, 120–121,
of (intra)membranous bone, 287
121, 123
of perichondrial bone, 287–288
of epitympanic area, 130
Ostmann, fat pad of, 105, 105
of hypotympanic area, 27s, 86, 88, 124
Otic capsule. See Embryology, of otic capsule
of incus, 65, 65, 66–67
ossification of, 279–281, 288–289
of infralabyrinthine area, 18–20, 116, 124, 124
unique features in development of, 281
of mastoid antrum area, 116,121–122, 226s
Otitis media, 240s
of mastoid region, 116, 116, 119–122
Otoconia, 150, 151
of mesotympanic area, 18, 30s, 86, 87, 112
Otocyst (otic vesicle). See Embryology, of
of middle ear region, 112
membranous labyrinth
of perilabyrinthine region and tracts, 116, 124
Otolithic membrane of utricle and Saccule, 150–152, 152
of peripheral mastoid area, 120–122
Oval window niche, 90
of peritubal area and tract, 116, 119–120,
Pacchionian body(ies), 133, 133, 134 125–126, 129
Paravestibular canaliculi, 156, 160, 161, 161–162 of petrous apex area and region, 116, 124, 126, 127,
Parotid gland, 38, 38 129, 130
INDEX ■ 353
Pneumatization (Cont.) Scala(e) tympani and vestibuli, 139, 139, 162–166
of posterior tympanic area, 116 Scarpa’s ganglion, 149, 188, 192, 194
of posteromedial tract, 116, 129 Scutum (shield of Leidy), 86
of posterosuperior tract, 27s, 116, 128, 129, 130, Sebaceous gland(s), 35–36, 36, 37, 38
132, 220s Semicanal for tensor tympani muscle, 82
of protympanic area, 26s, 116, 126 Semicircular canal(s). See Canal(s), semicircular
of subarcuate tract, 27s, 116, 128, 129, 132, 231s, 235 Semicircular duct(s). See Duct(s), semicircular
of supralabyrinthine area, 15, 18, 116, 124, 246s Semilunar crest of round window, 92, 142
of tympanic bone, 34, 34–35 Semilunar lip of internal auditory canal, 167
region(s) of, 115t, 116, 116, 119–122, 124, 129 Semilunar plane(s) of crista ampullaris, 152
table of regions, areas, and tracts, 115t Septum, interscalar, 139, 139, 141, 146
tract(s) of, 115t, 116, 129 petrosquamosal (Koerner’s), 7, 8, 28s, 120,
Polyp, aural, 245s 121, 122, 225s
Ponticulus, 88, 94 Serial photographs of sections of the temporal bone,
Porus acousticus of internal auditory canal, 166 2–3
Posterior tympanic area, pneumatization of, 116 Serial photomicrographs of temporal bone,
Posteromedial tract, pneumatization of, 116, 129, 131 embryologic, horizontal, 291, 292–310
Posterosuperior tract, pneumatization of, 27s, 116, horizontal, 6, 6–13
128, 129, 130, 132, 235s stereoscopic, horizontal, 23, 24s–30s
Pouch(es) of von Tröltsch, 255, 265, 108, 109 vertical, 14, 14–22
Pretympanic spine, 57, 186 Sesamoid bone in Stapediovestibular articulation, 68
Process, cochleariform, 82, 83, 235s, 236s Short process of incus, 62, 62, 65, 67
lenticular, 46, 62, 63, 74, 75 Shrapnell’s membrane (pars flaccida), 8, 16, 42,
malleal, anterior, (p. gracilis, p. Folianus), 46, 47–49 55, 187
lateral, 48, 49, 50 Sigmoid sinus, 226s. See also Sinus, venous, lateral
zygomatic, 1 Sigmoid sulcus, 10, 11
Promontory, 11, 90, 230s, 231s, 233s, 236s Sinal cells of mastoid, 124
Prosthesis for incus, 29s, 64, 241s Singular canal for posterior ampullary nerve, 11, 92–93
for manubrium of malleus, 49, 53 Sinodural angle, 230s, 242s, 243s
Protympanic area, pneumatization of, 26s, 116, 126 Sinodural cells of the mastoid, 122, 123
Protympanum, 19, 20, 26s, 88, 233s Sinus, of endolymphatic duct, 150, 150–151,
Prussak’s space (recess), 25s, 41, 42, 55 155, 155, 241s
Pyramidal eminence, 81, 86, 94, 95, 95 petrosal, inferior, 1, 205, 279
Pyramidal ridge, 86 superior, 1, 204
sigmoid, 203–204, 226s. See also sinus, venous, lateral
Randfasernetz of tectorial membrane, 149 venous, lateral, 202–204, 203–206, 226s, 228s,
Recess(es), elliptical and spherical, 137 242s, 249s
epitympanic, anterior, 7, 24s, 89, 89 anatomic variants of, 204, 205
facial, 10, 75, 93–95, 94–95 Sinus tympani, 12, 30s, 88, 93–94, 93, 94
incudal, 54, 62 Solitary tract, nucleus of, 171, 172
Reichert’s cartilage, 259, 260, 278, 277 Spherical recess of vestibule, 137, 139
Reissner’s membrane, 147 Spine(s), pretympanic, 52, 186
Retrofacial cell(s) (facial cells), 15, 122, 123, 232s, 242s tympanic, anterior and posterior, 50
Ridge, chordal, 86 Spine of Henle, 224s
digastric, 122, 226s Spiral ganglion. See Nerve(s), cochlear
petrosal, 20 Spiral lamina, osseous, 138, 139, 140, 146, 145, 237s
pyramidal, 86 secondary osseous, 138
styloid, 86 Spiral ligament, cochlea, 145–147
Rivinus, notch of, 41, 42 Spiral limbus, cochlea, 147
Rosenmüller, fossa of, 97, 102 Spiral prominence, cochlea, 147
Rosenthal’s canal, 139, 146 Spur(s), bony, epitympanic, 58, 58–60
Round window membrane, 18, 27s, 90–92, 90, 92, 93 Squamous area and cells, pneumatization of, 123, 129
Round window niche, 30s, 90–93, 91–94 Stapedectomy, 29s, 241s
Stapes, 44, 63, 66–68, 235s, 236s
Saccular duct, 145, 150, 150 articulation(s) of, 67, 70, 72, 74, 75, 75, 76
Saccule, 9, 18, 19, 151, 150–151, 152 columella auris. See Phylogenesis, of columella auris
macula of, 25s, 149, 151, 151 crista stapedis of, 67
macular orientation of, 151, 151 crus (crura), 63, 66, 66
Sacotomy, endolymphatic, surgical procedure, 227s, 249s footplate of, 46, 63, 67, 68, 237s
Salivatory nucleus, superior, 171, 172 head of, 62, 63, 63, 66, 74
Santorini, fissures of, 33, 37 lamina stapedialis. See Embryology, of lamina
Sarcoma (chondromyxo-) of temporal bone, 239s stapedialis
Scala communis, 139, 141 stapedial fold of, 108
Scala media. See Cochlear duct Serial photographs, directions for viewing, 23, 223
354 ■ INDEX
Stereoscopic views, of anatomic serial sections, 23, Temporal bone, parts of (cont.)
23s–30s slide preparation technique, for horizontal series, 6
of pathologic conditions, 238, 238s –241s for stereoscopic series, 23
of surgical dissection, 223, 224s–238s for vertical series, 14
of surgical pathology, 246, 246s –249s surgical dissection of, 223, 224s–237s
Stria(e), anterior and posterior tympanic, 42 surgical pathology of, stereoscopic views, 242,
Stria mallearis, 41 242s–249s
Stria vascularis, 147, 147 Temporal bone dissection, surgical, 223, 224s–237s
Styloid area and cells, pneumatization of, 123, 129 Tendon, Stapedius, 10, 26s, 63, 82, 81, 82
Styloid complex, 94 tensor tympani, 18, 25s, 55, 56, 56, 83, 234s
Styloid eminence, 86, 95 Tip cells of the mastoid, 122, 123, 226s
Styloid process. See Embryology, of styloid process Torus tubarius, 97
Styloid ridge, 86 Transverse (falciform) crest, fundus of internal
Stylomastoid foramen, 4, 175, 176–179 auditory canal, 20, 166, 167
Subarachnoid space, 164 Tröltsch, von, pouch(es) of, anterior and posterior,
Subarcuate fossa, 1, 136, 136, 136 25s, 108, 109
Subarcuate tract, pneumatization of, 27s, 116, 127, Tubercle, auricular (Darwinian), 31, 32, 282
129, 132, 231s, 235s Tympanic annulus, 11, 41, 42, 232s–233s
Subiculum, 12, 30s, 88, 90, 91, 93 Tympanic border (mesothelial) cells of cochlea, 148
Sulcus, sigmoid, 10 Tympanic cavity of middle ear, 85–88
tympanic, 10, 41, 233s Tympanic membrane, 16, 26s, 30s, 34, 41–43, 231s
Sulcus cells, outer and inner, of cochlea, 147, 149 hyalin plaque of, 43
Supporting cells of organ of Corti, 148 notch of Rivinus, 41, 42
Supralabyrinthine area, pneumatization of, 15, 18, pars flaccida (Shrapnell’s membrane) of, 8, 16,
124, 246s 42, 187
Surgical dissection of temporal bone, stereoscopic pars propria of, 41
views, 223, 224s–238s pars tensa of, 41
Surgical pathology of temporal bone, stereoscopic perforation(s), 57, 169, 239s
views, 242, 242s–249s replacement membrane (neomembrane) of, 43,
Surgical procedure(s), ampullary nerve section, 43, 169
posterior, 92 retraction pocket in, 43, 44, 45
atticotomy, posterior, 229s Tympanic ring. See Embryology, of external auditory
cholesteatoma of petrous apex, congenital, canal, tympanic membrane, and tympanic
exteriorization of, 247s ring
endolymphatic sacotomy, 227s, 249s Tympanic sinus. See Sinus tympani
facial nerve, exploration of, 229s Tympanic spine(s), anterior and posterior, 42
transposition of, 235s Tympanic stria(e), anterior and posterior, 42
glomus jugulare, removal of, 248s Tympanic sulcus, 11, 41, 233s
internal auditory canal, approach to, 185, 196 Tympanomastoid compartment, 244s
mastoidectomy, modified radical, 232s Tympanomastoid suture, 4
radical, 235s, 240s Tympanomastoidectomy, 244s–248s
simple, 228s, 242s intact-canal-wall, 231s, 245s
myringoplasty, 43, 45, 45 type III, 244s
stapedectomy, 29s, 241s Tympanomeatal angle, anterior, obliteration of, 45
tympanomastoidectomy, 245s–248s Tympanomeningeal (Hyrtl’s) fissure, 142, 143
for total obliteration, 248s Tympanosclerotic (hyalin) plaque, 43
intact-canal-wall, 231s, 245s Tympanosquamous suture (fissure), 4
type III, 244s Tympanotomy, posterior, surgical procedure, 119,
tympanotomy, posterior, 119, 229s –231s 229s–231s
Suture(s) (fissure), petrosquamosal, 6
petrotympanic (glaserian), 4, 6, 18, 127 Umbo, 11, 41, 42, 48, 50
tympanomastoid, 4 Utricular crest, inferior, 17, 29s
tympanosquamous, 4 Utricular duct, 145, 150, 151
Utricular opening into the posterior ampulla, 30s
Tectorial membrane of cochlea, 146, 149 Utricle, 149–150, 150
Hensen’s stripe of, 140, 149 macula of, 25s, 150, 149, 151
Randfasernetz of, 149 macular orientation, 151
Tegmen, mastoid, 227s, 229s, 242s Utriculo-endolymphatic valve (of Bast), 150, 150,
Tegmen tympani, 19, 86, 229s 154–155, 155
Tegmental cells of the mastoid, 121, 123
Temporal bone, parts of, 1–6 Vascular supply, of auricle (pinna), 197
pathologic conditions of, stereoscopic views, 238, of cochlea, 216–218, 217, 220
238s–241s of external auditory canal, 197
removal technique, 6 of incudostapedial articulation, 212
INDEX ■ 355
Vascular supply, of auricle (pinna) (cont.) Vesiculations of semicircular duct(s), 145
of inner ear, 216–218, 217, 220 Vestibular aqueduct, 155–156, 161
of middle ear, 210–215, 211 radiologic studies of, 156
of facial nerve, 189, 189 Vestibular cecum of cochlear duct, 26s, 137
Vein(s), cardinal. See Embryology, of veins, cardinal Vestibular crest, vestibule, 137
cochlear, inferior, 164–165, 220, 220 Vestibular nerve. See Nerve(s), vestibular
in fallopian canal, 60, 189, 189, 206, 207 Vestibule, 137–138
jugular, internal, 4, 20, 206, 236s measurements of, 90
superior location of bulb, 206–208, 207, 210 perilymphatic cistern of, 10, 18
mastoid emissary, 205 Vestibulocochlear (Oort’s) anastomosis, 193
of cochlea, 219, 220, 220 Vestibulofacial anastomosis, 193, 194
spiral, anterior and posterior, 217, 218, 219, 220, 220 Voit’s anastomosis, 193
Venous plexus, pericarotid, 10
Venous sinus, lateral, 202–203, 204–206, 226s, 228s, Wax, ear (cerumen), 37
242s, 249s
Venous supply, of endolymphatic sac, 161, 161 Zona(e) arcuata and pectinata, 146, 148
of membranous labyrinth, 220 Zygomatic area and cells, Pneumatization of,
Vertical crest, fundus of internal auditory 123, 129
canal, 24s, 166, 167 Zygomatic process, 1
Vertical sections of temporal bone, 14, 14–22
356 ■ INDEX

Anatomy of Temporal Bone and Surgical Implications

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Gulya and Schuknecht’s

Aina Julianna Gulya

© 2007 by Informa Healthcare USA, Inc.

No claim to original U.S. Government works

International Standard Book Number-10: 0-8493-7597-5 (Hardcover)

Library of Congress Cataloging-in-Publication Data

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Aina Julianna Gulya

Aina Julianna Gulya

Aina Julianna Gulya

This book represents the accumulated experience and observations of the

alan r. liss for the march of dimes birth defects foundation

american journal of otology (Thieme Stratton)

annals of otology, rhinology, laryngology (Annals Publishing Company)

archives of otolaryngology (American Medical Association)

auris nasus larynx

harvard university press

journal of laryngology and otology

little, brown and company

otolaryngology clinics of north america (W.B. Saunders Company)

Preface to the Third Edition ....................................... v

Preface from the Second Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Preface from the First Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

1 ■ Serial Photographs of Sections of the

2 ■ The Pinna and External Auditory Canal . . . . . . . . . . . . . . . . . . . . . . . 31

3 ■ The Middle Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

5 ■ The Inner Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

8 ■ Stereoscopic Views of the Temporal Bone . . . . . . . . . . . . . . . . . . . . . . 223

9 ■ Phylogeny and Embryology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

■ Historical Bibliography of Ear Anatomy . . . . . . . . . . . . . . . . . . . . . . . 335

Serial Photographs of Sections

The temporal bone is made up of the squamous, mastoid, petrous, and

Figures A through E are photographs of a dry temporal bone specimen

2 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS

CHAPTER 1: SERIAL PHOTOGRAPHS OF SECTIONS OF THE TEMPORAL BONE ■ 3

4 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS

CHAPTER 1: SERIAL PHOTOGRAPHS OF SECTIONS OF THE TEMPORAL BONE ■ 5

The following series of photomicrographs (Figs. 1–20) depict horizontal

6 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS

CHAPTER 1: SERIAL PHOTOGRAPHS OF SECTIONS OF THE TEMPORAL BONE ■ 7

8 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS

CHAPTER 1: SERIAL PHOTOGRAPHS OF SECTIONS OF THE TEMPORAL BONE ■ 9

10 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS

CHAPTER 1: SERIAL PHOTOGRAPHS OF SECTIONS OF THE TEMPORAL BONE ■ 11

12 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS

CHAPTER 1: SERIAL PHOTOGRAPHS OF SECTIONS OF THE TEMPORAL BONE ■ 13

14 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS

CHAPTER 1: SERIAL PHOTOGRAPHS OF SECTIONS OF THE TEMPORAL BONE ■ 15

16 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS

CHAPTER 1: SERIAL PHOTOGRAPHS OF SECTIONS OF THE TEMPORAL BONE ■ 17

18 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS

CHAPTER 1: SERIAL PHOTOGRAPHS OF SECTIONS OF THE TEMPORAL BONE ■ 19

20 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS

CHAPTER 1: SERIAL PHOTOGRAPHS OF SECTIONS OF THE TEMPORAL BONE ■ 21

22 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS

The paired images appearing in Figures 38 to 51 are stereoscopic counter-

CHAPTER 1: SERIAL PHOTOGRAPHS OF SECTIONS OF THE TEMPORAL BONE ■ 23

24 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS

CHAPTER 1: SERIAL PHOTOGRAPHS OF SECTIONS OF THE TEMPORAL BONE ■ 25

26 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS

CHAPTER 1: SERIAL PHOTOGRAPHS OF SECTIONS OF THE TEMPORAL BONE ■ 27

28 ■ ANATOMY OF THE TEMPORAL BONE WITH SURGICAL IMPLICATIONS