1. Auditory and balance apparatus
Morphology
and
embryology
Auris, is = Us, oton

2. Auditory and vestibular apparatus
External ear
(Auris externa)
Middle ear
(Auris media)
Inner ear
(Auris interna)
= Organum
vestibulo-
cochleare

3. External ear (Auris externa)
Earbolt (Auricula, Pinna)
elastic cartilage
External meatus
(Meatus acusticus externus)
Eardrum
(Membrana tympanica, Myrinx)

4. Boltec Helix Antihelix Scapha Concha auriculae Tragus Antitragus
crus, spina, cauda
(tuberculum auriculare Darwini, apex auriculae)
Antihelix
crura, fossa triangularis
Scapha
Concha auriculae
cymba, cavitas
Tragus
Antitragus
Incisura intertragica
Lobulus auriculae
Posterior facet = negative ventral image
Boltec

5. Ligaments: lig. auriculare ant., sup., post.
Earbolt muscles - innervation: n. facialis
External muscles = mimic
mm. auriculares (ant., sup., inf.)
m. temporoparietalis
Proper muscles: rudimentary
m. tragicus + antitragicus
m. helicis major+minor
m. obliquus + transversus auriculae, m. pyramidalis auriculae
Cartilage: Cartilago auriculae - elastic
Skin: back side free, ventrally firmly attached to perichondrium - othematom

6. Earbolt – supply
Arteries: rr. auriculares ant.  a. temporalis superficialis
a. auricularis post.  a. carotis externa
Veins: v. jugularis ext.
Lymph: n.l. parotidei, mastoidei
Nerves: sensitive
nn. auriculares ant. z
n. auriculotemporalis (upper ventral 2/3)
r. auricularis n. X. (concha)
n. occipitalis minor (posterior up)
n. auricularis magnus (down)
motoric: n. VII.

7. Auditory canal (Meatus acusticus externus)
porus acusticus externus  diagonally ventromed.  med.  again diagonally ventromed. (totally it converges forth 160º and it declines convex, length approx. 22 mm)
external 2/3 – hyaloid cartilage open forth and down (incisurae Santorini), lamina tragi (forth)
transition – narrowest place – foreign bodies !!!
inner 1/3 – bony – incisura tympanica Rivini
glandulae ceruminosae + sebaceae  ear wax (cerumen) – protection
tragi (after 30. years of age)
Skin attached to perichondrium – even small inflamation very painful !!!
Anterior wall: relation to gl. parotis and art. temporomandibularis

8. Auditory canal (Meatus acusticus externus) supply
Arteries: same as earboltc + a. auricularis prof.  a. maxillaris
veins: v. temporalis superf., v. auricularis post.
lymph: n.l. parotidei, mastoidei
nerves: r. auricularis n.X. (posterior caudal part), n. auriculotemporalis  r. meatus ac. externi

9. Eardrum (Membrana tympanica, Myrinx)

10. Eardrum - composition Sulcus tympanicus, incisura tympanica Rivini
9x10 mm, thickness 0,1 mm, area 55 mm2
Anulus fribrocartilagineus
External surface - weakened epidermis (ectoderm)
Layer of thick collagenous tissue (mesenchyme)
Inner surface – single layer cuboid epithelium (endoderm)

11. Eardrum Otoskopy umbo m.t. stria mallearis prominetia mallearis
plica mallearis ant. + post.
light reflex – trigonum Wilde
(= cone of light, light reflex, Politzer's luminous cone)
Bezold trias: prominentia + stria + reflex
pars flaccida Shrapnelli (5 mm2) x pars tensa
- Declination of eardrum (50º sagitally)
- Inclinationof eardrum (45 º transverzally)
Paracentesis: lower posterior quadrant

13. Eardrum - supply Arteries:
a. auricularis prof.  a. maxillaris (external surface)
aa. tympanicae (inner surface)
Lymph: n.l. mastoidei, parotidei
Nerves:
a. auricularis n.X.
n. auriculotemporalis  r. membranae tympani

14. Middle ear (Auris media)
Middle ear cavity (Cavitas tympani)
Middle ear ossicles (Ossicula aditus)
Middle ear joints (Articulationes ossiculorum auditus)
Middle ear muscles (Musculi ossiculorum auditus)
Auditory tube (Tuba auditiva Eustachii)

15. Middle ear cavity (Cavitas tympani)
paries tegmentalis
paries jugularis: prominetia styloidea
paries mastoideus: aditus ad antrum mastoideum, prominetia canalis semicircularis lat. + n. VII., eminetia pyramidalis, fossa incudis, apertura tympanica canaliculi chordae tympani, antrum mastoideum (cellulae m.)
paries caroticus
paries membranaceus
paries labyrinthicus

17. Middle ear cavity paries labyrinthicus
promontorium – first coil of cochlea
sulcus promontorii – plexus tympanicus
fenestra vestibuli (= ovalis) – basis of stapes + membrana stapedia
fenestra cochlae (= rotunda) – membrana tympani secundaria

18. Middle ear cavity - supply
Arteries: 4 aa. tympanicae, rr. caroticotympanici
Veins: do plexus pterygoideus + sinus petrosus sup.
Lymph: n.l. parotidei, mastoidei, cervicales profundi, retropharyngei
Nerves:
n. tympanicus (n.IX) – sensitive + parasympatic (ganglion tympanicum)
r. pharyngeus (n.V2) for cartilagenous part of auditory tube
nn. caroticotympanici (sympatic)

19. Middle ear ossicles (Ossicula aditus)
Malleus (Malleus, Hammer)
caput
collum
manubrium
processus lateralis
processus anterior

20. Middle ear ossicles (Ossicula aditus)
Incus (Incus, Anvil)
corpus
crus longum
processus lenticularis
crus breve
Stapes (Stapes, Stirrup)
caput
(collum)
crus ant. + post.
basis

21. Middle ear joints and ligaments (Articulationes ossiculorum auditus)
art. incudomallearis (seddle bag)
art. incudostapedia (ball shape like)
syndesmosis tympanostapedialis
otosclerosis – ossification
Sometimes both joints are replaced by syndesmosis

22. Middle ear ligaments (Ligg. ossiculorum auditus)
lig. mallei ant. (spina o.s.)+ sup.+ lat.
lig. incudis sup. (fossa i.) + post.
membrana stapedialis (fenestra vestibuli)
lig. anulare stapediale (fenestra vestibuli)
membrana tympani secundaria = secondary eardrum (fenestra cochleae)

23. Middle ear muscles m. tensor tympani m. stapedius semicanalis m.t.t.
processus cochleariformis
manubrium mallei
innervation: n.V3
m. stapedius
eminetia pyramidalis
collum stapedis
innervation: n.VII
n. stapedius from pars mastoidea canalis nervi facialis

24. Middle ear
Shape of sand clock – 2 mm narrow by eardrum (= mesotympanon)
recessus epitympanicus (= atticus, epitympanon, epitympanum) – 6 mm
recessus hypotympanicus (hypotympanon)– 4 mm
plicae malleares ant., post. recessus ant., sup., post. (= Prussak space)
plica chordae tympani, incudialis, stapedialis
mucosa – single layer cuboid epithelium (different height)
Cup cells only by opening of auditory tube !!!
No glands !!!

27. Mastoid cavity (Antrum mastoideum)
aditus ad antrum mastoideum
cellulae mastoideae
(development postnatally – 6th year)
Type pneumatic
Type diploic
Type sclerotic
cellulae tympanicae
Flat 1 layer epithelium
Close to sinus sigmoideus
mastoidectomy

28. Auditory tube (Tuba auditiva) Tuba auditoria, tuba pharyngotympanica, salpinx, tuba Eustachii
ostium tympanicum
pars ossea (= semicanalis t.a.) – cellulae pneumaticae
pars cartilaginea – cartilago (lamina med.+ lat., lamina membranacea) – under mucosa of tonsilla tubaria Gerlachi
When enlarged tonsilla – lesion of ventilation (especially in kids)  inflammation of midlle ear cavity
ostium pharyngeum (v úrovni meatus nasi inf.)

29. Auditory tube
(Tuba auditiva)

30. Auditory tube (Tuba auditiva) Tuba auditoria, tuba pharyngotympanica, salpinx, tuba Eustachii
Equilibrates pressure in pharynx and middle ear cavity
thickness 2 mm, length 40 mm
Transition of multilayer cylindrical epithelium in single layer cylindrical
glandulae tubariae, cup cells – in cartilagenous part
In kids more horizontal, shorter and wider
Catetrization via nasal cavity

31. Auditory tube (Tuba auditiva)
opening:
m. tensor tympani
m. salpingopharyngeus
? role of m. levator veli palatini not clear ?
Ostmann adipose body

32. Inner ear (Auris interna)
organum vestibulocochleare
Bony labyrint (labyrinhtus osseus)
forechamber (vestibulum)
Semicircular canals (canales semicirculares)
snail (cochlea)
Inner acustic meatus (meatus acusticus internus)
spatium perilymphaticum
Membranous labyrinth (labyrinthus membranaceus)
labyrinthus vestibularis
labyrinthus cochlearis
spatium endolymphaticum

35. Bony labyrinth (labyrinthus osseus) forechamber (vestibulum)
recessus ellipticus (utricularis)
apertura int. canaliculi vestibuli
macula cribrosa superior
crista vestibuli (pyramis vestibuli)
recessus sphericus (saccularis)
recessus cochlearis
macula cribrosa media
macula cribrosa inferior

36. Membranous labyrint (Labyrinthus membranaceus) Vestibular labyrinth (Labyrinhtus vestibularis)
Utriculus (Elipsoid sac)
Sacculus (Spherical sac)
Ductus semicirculares (ampullae, crura)
Ductus utriculosaccularis, reuniens
Macula utriculi, sacculi – membrana statoconiorum (statoconium, striola)
Crista ampullaris (sulcus, cupula)

37. Otolitic organs saculus et utriculus
macula
Hairy cells
Supportive cells
Gelatinous layer
otoconia - crystals CaCO3
(otoliths – term for crystals in reptiles)

38. Bony labyrint (Labyrinhtus osseus) Semicircular canals (Canales semicirculares)
Canalis semicircularis anterior (parallel to the pyramid axis) – eminentia arcuata
Canalis semicircularis posterior (vertical)
Canalis semicircularis lateralis (horizontal) – prominentia c.s.l.
ampulla ossea (3)
crus commune (ant. + post.), simplex (lat.)

40. Semicircular canals Membranous inside bony Receptors in ampulas
cristae ampullares
Crest 90° to canal axis
cupula – gelatinous substance
Hairy cells
Support cells

41. Hairy cells Two types On apical surface:
1 kinocilia
Several stereocilias
bazally - synapse with nerve fibers

42. Bony labyrint (Labyrinhtus osseus) Snail (Cochlea)
cupula, basis (2 a ¾ coil)
scala vestibuli  helicotrema  scala tympani
canalis spiralis cochleae
lamina spiralis ossea
lamella vestibularis + spiralis
hamulus l.s. (end in helicotrema)
lamina spiralis secundaria (only in first coil)
apertura interna canaliculi cochleae

43. Bony labyrint (Labyrinhtus osseus) Snail (Cochlea)
Spindle (Modiolus)
basis
lamina
canalis spiralis – ganglion cochleare
canales longitudinales – n. cochlearis

45. Bony labyrint (Labyrinhtus osseus) Inner acustic meatus (Meatus acusticus internus)
porus acusticus internus
fundus m.a.i.
crista transversa + verticalis
area n. VII.
area cochlearis – tractus spiralis foraminosus
area vestibularis sup. + inf.
foramen singulare

47. Membranous labyrint (labyrinthus membranaceus) Labyrinhtus cochlearis
scala media = ductus cochlearis
paries vestibularis: membrana vestibularis Reissneri
paries externus: stria vascularis, prominentia spiralis, vas prominens, lig. spirale
paries tympanicus (= membrana spiralis): crista basilaris, lamina basilaris, vas spirale
limbus spiralis: labium limbi tympanici, labium limbi vestibularis, (dentes acustici)
membrana tectoria
Organum spirale Corti
membrana reticularis, sulcus spiralis internus + externus

48. Snail (Cochlea)

49. Scala media Contain endolymph on lamina basilaris is Corti organ
Covered by membrana tectoria
Bony lamina spiralis
ligamentum spirale

50. Corti organ (Organum spirale)
Hairy cells
outer (3-4 rows) and inner (1 row)
On surface stereocilia
Apices sank inside membrana tectoria
Between them Nuele space
Supportive cells
pillars (Cortiho) – border inner tunnel
phalangeal (Deiters) – cover hairy cells
Outer supportive – cylindrical Hensen and cuboid Claudius

51. Endolymph and perilymph
Endolymph: similar to intracellular fluid
stria vascularis  scala media  ductus endolymphaticus  saccus endolymphaticus (blind)  veins
Perilymph: similar to CSF
canalicus cochleae connected with subarachnoid space

52. Inner ear – blood supply
Arteries: a. basilaris  a. inf. ant. cerebelli  a. labyrinthi
Veins:
vv. labyrinthi  sinus petrosus inf.
v. aqueductus vestibuli, v. aqueductus cochleae
Lymph: replaced by endolymph and perilymph

53. Inner ear - nerves Nervus vestibularis – ggl. vestibulare Scarpae
pars superior
n. utriculoampullaris
pars inferior
n. saccularis
n. ampullaris posterior
Nervus cochlearis – ggl. cochleare Corti
!!! Bipolar neurons !!!

55. VIII. - Nervus vestibulocochlearis examination
Tuning fork exams (Rinné, Weber, Schwabach)
Examination of nystagmus (9 directions acc to Hering)
Romberg – standing and close eyes
Hautant – sitting and arms rising forward
Unterberger – close eyes and walking on spot 30s

56. VIII. - Nervus vestibulocochlearis irritation / palsy
Lesion of hearing (= hypacusis  anacusis )
deafness (= surditas)
Ear lisps (= tinnitus) – humming, whistling, ringing…
giddiness (= vertigo)
By will not affectable eyeball movements (= nystagmus)
Slow component – stronger side pushes weaker side
Fast component – compensatory movement back – according to it is described direction of nystagmua
Defects of gait and walking (= ataxie)

57. Auditory path I. Projection → Ascending → Sensory 4 – neuronal
Crossed as well as not crossed
1. neuron:
Bipolar cell in ganglion cochleare Corti in shape of spiral  n. cochlearis  n. VIII  tract divides into 2 parts into nuclei cochleares ant. + post.

59. Auditory path II. 2. neuron: pons
Cells in nucleus cochlearis posterior (depth of tones) et anterior (intenzity of tones) – separated by pedunculus cerebellaris inferior  crossing  lemniscus lateralis  colliculus inferior
Side tract:
nucleus olivaris superior ( contralaterally is inhibited from ncl. v corpus trapezoideum)  estimation of space orientation of hearing

60. Auditory path

61. Auditory path III. 3. neuron: mesencephalon
cells in colliculus inferior  brachium coll.inf.
tonotopic organization
commissura colliculi inferioris
4. neuron: diencephalon - metathalamus
cells in corpus geniculatum mediale  lobus temporalis - gyrus temporalis transversus Heschli, area 41, 42

62. Auditory path – 3D

63. Vestibular path I. Projection → Ascending → Sensory
3-neuronal, crossed
1. neuron: bipolar cell ganglion vestibulare Scarpae  n. vestibularis  n. VIII
Part of fibers runs as tractus vestibulocerebellaris directus w/o interconnection into cerebellum
2. neuron: cells nuclei vestibulares pontis  axons into different structures

65. Vestibular path II. – where to?
Cerebral cortex
cerebellum
RF → facilitatory descending system
spine
Nuclei of eyeball moving muscles
Via paramedial pontine RF
reflex head-eyeball

66. Vestibular path III. – into cortex
3. neuron: cells nuclei ventrales thalami  cerebral cortex
lobus parietalis - gyrus postcentralis (area 2) – primary cortex
parieto-inzular cortex (gyrus insularis longus) + lobus temporalis - gyrus temporalis transversus Heschli (area 41,42)

67. Vestibular path III. – into cerebellum
Tractus vestibulocerebellaris directus
vestibulum  corpus juxtarestiforme (v PCI)  nodulus + uvula (ipsilat.)
Tractus vestibulocerebellaris indirectus
vestibulum  ncl. vestibulares  corpus juxtarestiforme (v PCI)  lobulus flocclulonodularis + vermis (bilat.)

68. Vestibular path III. – into spine
Ncl. fastigii cerebelli  ncl. vestibularis lat. Deitersi (bilat.)  tr. vestibulospinalis lateralis  alfa + gama-motoneurons of extensors
Ncl. vestibularis medialis + inferior  fasciculus longitudinalis medialis  interneurons (+ and -) in cervica spine
reflex head-eye

69. Examination otoscopy, otomicroscopy – tympanice membrane
paracentesis, gromets
Tuning fork examinations
Vestibuloocular reflex – nystagmus
vestibulospinal reflex (Romberg, Unterberger test)
X-ray (projection Stenvers – meatus acusticus intenrus, Schüller – proc. mastoideus), CT, angiography
audiometry
BER/BERA (ERA, AEP, ABR)
otoacustic emision (from external hairy cells)
nystagmus – ENG (PENG), calory test

70. Symptoms and ilnesses Eye pain = otalgia giddiness = vertigo
humming / whistling = tinnitus
nystagmus = fast synkinetic movements
Cloth ears - hypacusis
deafness = surditas
morbus Menière – ionic dysbalance
Aterosclerosis of a. lybyrinthi
meningitis – most common reason for acquired deafness
Treatment: vazodilatation

71. Development of auditory and vestibular system
3 sources + nerve fibers
1. branchial arch, cleft and membrane
Mezenchyme of 1st and 2nd branchial arch
Surface ectoderrm of the head
Fibers from mezencephalon

72. Development of external eae
meatus acusticus externus
1st branchial cleft
After delivery short (danger of lesion)
pinna
6 auricular tubercles (mezenchyme)
Mostly 2nd branchial arch (but also 1st)
appendices preauriculares

73. Development of external ear

74. Development of middle ear
1st branchial exagination
tuba auditiva et cavum tympani
1. branchial arch
malleus, incus
lig. mallei anterius
m. tensor tympani
2. branchial arch
stapes
m. stapedius

76. Development of middle ear
antrum mastoideum
Are not present cellulae mastoideae after delivery
Appears in 2nd year
Finished pneumatization cca in 6th year

77. Development of membrana tympani
Outer epithelium from 1st branchial cleft
Inner epithelium from 1st branchial exagination
mezenchyme of 1st and 2nd branchial arch

78. Development of inner ear
Start at 4th week - otic placode (ektoderm)
Auditory pit
Auditory sac (otocyst)
Extension for ductus + saccus endolymphaticus
Dorzal part utricular
Ventral part saccular

81. Development of inner ear
From utricular part
Discoid extensions - ductus semicirculares
Widening into ampula and origin of crests
From saccular part
divertikulum ductus cochlearis (convoluted)
Origin of ductus reuniens
Corti organ (from the wall of d. cochlearis)
Origin of ganglion spirale

83. Development of inner ear
Surrounding mezenchyme changes into cartillagenous capsula otica
There appears cavities and thus originate perilymphatic spaces
in week cartillagenous model ossifies

85. Casuistic 1 male, 28 years Returned from vacation in Egypt
otalgia 3 days
Pain during palpation
objective examination: palpatory sensitive tragus
otoscopy: oedematic and reddish auditory canal with white cellular detrite

86. Casuistic 1 - diagnosis otitis externa
Ilness of summer monthes and swimming
complications: especially in DM
 perichondritis or destruction of temporal bone

87. Casuistic 2 female, 3 years
In the night burning pain of right ear, crying, cannot ease, 2 days runny nose
In the waiting room vomiting
temperature 38,3°C
otoscopy: tympanic membrane reddish, smeared, protruding backside

88. Casuistic 2 - diagnosis otitis media acuta l. dx.
treatment: paracentesis
complications: perforation of tympanic membrane
mastoiditis  trombosis of sinus sigmoideus
labyrinthitis
(chronic otitis media)
grometa

89. Casuistic 3
female, 34 let
Pressure in left ear, sudden cloth ear, humming tinnitus, rotatory vertigo, vomitus
Vertigo disappeared, the rest is still there
Objective examination: harmonic vestibular events (= dominance of on labyrinthus)
audiometry: perceptive cloth ear apicocochlearly
treatment: vazodilatation

90. Cazuistic 3 - diagnosis Menièr ilness
hydrops of the labyrinth
Mont after patient returns with the same problems
dif.dg.: circulatory problems, aterosclerosis, sclerosis multiplex, neurinom of the n. VIII