Color Atlas of EndoOtoscopy Examination Diagnosis Treatment

Color At las of Endo-Ot oscopy
Exam inat ion–Diagnosis–Treat m ent

Mar io San n a, MD
Professor of Otolar yngology
Depart m en t of Head an d Neck Surger y
Un iversit y of Ch ieti
Ch ieti, Italy
Director
Gruppo Otologico
Piacen za an d Rom e, Italy
Alessan d ra Ru sso, MD
Otologist an d Skull Base Surgeon
Gruppo Otologico
Piacen za an d Rom e, Italy
An ton io Car u so, MD
Otologist an d Skull Base Surgeon
Gruppo Otologico
Piacen za an d Rom e, Italy
Abd elkad er Taibah , MD
Neurosurgeon , Otologist , an d Skull Base Surgeon
Gruppo Otologico
Piacen za an d Rom e, Italy
Gian lu ca Piras, MD
Otologist an d Skull Base Surgeon
Gruppo Otologico
Piacen za an d Rom e, Italy

Wit h t h e collaborat ion of
Fern an do Man cin i, Hirosh i Sun ose, En rico Piccirillo, Loren zo Lauda, An n alisa Gian n uzzi,
Sam path Ch an dra Prasad Rao

1007 illust ration s

Th iem e
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Cont ent s
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Cont ribut ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
1.

Met hods of Ot oscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2.

The Norm al Tym panic Mem brane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

2.1

Anat om y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.2

Hist ology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

3.

Diseases A ect ing t he Ext ernal Audit ory Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

3.1

Exost osis and Ost eom as . . . . . . . . . . . . . . . . . . . . . . . . . 14

3.1.1

Surger y for Exostosis an d Osteom a: Can alplast y . . . . . 21

3.2

Ext ernal Audit ory Canal Inflam m at ory Diseases 25

3.2.1
3.2.2
3.2.3
3.2.4
3.2.5
3.2.6

Eczem a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Otitis Extern a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Forun colosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Otom ycosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Myringit is an d Meatal Sten osis . . . . . . . . . . . . . . . . . . . . .
Surger y for Postin flam m ator y Sten osis of th e Extern al

Auditory Can al . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25
25
27
27
29
33

2.3

Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

3.4

Pat hologies Ext ending t o t he Ext ernal Audit ory
Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

3.4.1
3.4.2
3.4.3
3.4.4
3.4.5
3.4.6

Carcin oid Tum ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Histiocytosis X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Men ingiom as . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Facial Nerve Tum ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Low er Cran ial Nerves Schw an n om a . . . . . . . . . . . . . . . . .

Oth er Path ologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.5

Tem poral Bone Fract ures . . . . . . . . . . . . . . . . . . . . . . . . 49

3.6

Carcinom a of t he Ext ernal Audit ory Canal . . . . . . . 50

40
41
42
44
46
47

3.3

Cholest eat om a of t he Ext ernal Audit ory Canal . . 37

4.

Ot it is Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

4.1

Secret ory Ot it is Media (Ot it is Media
w it h E usion) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

4.2

Secretory Otitis Media Secondary t o Neoplasm . . 69

5.

Cholest erol Granulom a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

6.

At elect asis, Adhesive Ot it is Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

7.

Noncholest eat om at ous Chronic Ot it is Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

7.1

General Charact erist ics of Tym panic Mem brane
Perforat ions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

7.7

Perforat ions Com plicat ed or Associat ed
w it h Ot her Pat hologies . . . . . . . . . . . . . . . . . . . . . . . . . 104

7.2

Post erior Perforat ions . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

7.8

Tym panosclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

7.8.1
7.8.2

Tym pan osclerosis Associated w ith Tym pan ic
Mem bran e Perforation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Tym pan osclerosis w ith Intact Tym panic Mem brane . . 110

7.9

Principles of Myringoplast y . . . . . . . . . . . . . . . . . . . . 112

7.3

Ant erior Perforat ions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

4.3

Acut e Ot it is Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

7.4

Inferior Perforat ions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

7.5

Subt ot al and Tot al Perforat ions . . . . . . . . . . . . . . . . 100

7.6

Post t raum at ic Perforat ions . . . . . . . . . . . . . . . . . . . . . 102

8.

Chronic Suppurat ive Ot it is Media w it h Cholest eat om a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

8.1

Epit ym panic Ret ract ion Pocket . . . . . . . . . . . . . . . . . 118

8.2

Epit ym panic Cholest eat om a . . . . . . . . . . . . . . . . . . . . 120

v


Contents

8.3

Mesot ym panic Cholest eat om a . . . . . . . . . . . . . . . . . 129

8.6

Surgical Treat m ent of Cholest eat om a:
Individualized Technique . . . . . . . . . . . . . . . . . . . . . . . 139

8.4

Cholest eat om a Associat ed w it h At elect asis . . . . 134

8.6.1
8.6.2
8.6.3

Can al Wall Up (Closed) Tym pan oplast y . . . . . . . . . . . . . 139
Can al Wall Dow n (Closed) Tym pan oplast y . . . . . . . . . . 145
Modified Bon dy’s Techn ique . . . . . . . . . . . . . . . . . . . . . . 153

8.5

Cholest e at om a Associat ed w it h
Com plicat ions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

9.

Congenit al Cholest eat om a of t he Middle Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

10.

Pet rous Bone Cholest eat om a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

10.1

Surgical Managem ent . . . . . . . . . . . . . . . . . . . . . . . . . . 184

10.1.2 Problem s in Surger y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

10.1.1 Th e Tran sotic an d Modified Tran scoch lear
Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

11.

Tem poral Bone Paragangliom as . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195

11.1

Clinical Present at ion of Tym panic and
Tym panom ast oid Paragangliom as . . . . . . . . . . . . . . 197

11.5.1 Surgical Man agem en t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208

Clinical Present at ion of Tym panojugular
Paragangliom as . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

11.6.1 Surgical Man agem en t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

11.2

11.3

Im aging Charact erist ics . . . . . . . . . . . . . . . . . . . . . . . . . 197

11.6

11.7

Class B: Tym panom ast oid Paragangliom as . . . . . 213

Class C: Tym panojugular Paragangliom as . . . . . . 221

11.7.1 Surgical Man agem en t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

11.3.1 Tym pan ojugular Paragan gliom as . . . . . . . . . . . . . . . . . . 197

11.8

11.4

Classificat ion: The Modified Fisch Classificat ion
Syst em for TJP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

11.8.1 Surgical Techn ique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

11.5

Class A: Tym panic Paragangliom as . . . . . . . . . . . . . 205

12.

Rare Ret rot ym panic Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

12.1

Di erent ial Diagnosis of Ret rot ym panic
Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

12.2
12.3

Type A Infrat em poral Fossa Approach . . . . . . . . . . 237

12.5

Facial Nerve Tum ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250

12.6

Aberrant Carot id Art ery . . . . . . . . . . . . . . . . . . . . . . . . 260

12.7

Int ernal Carot id Art ery Aneurysm . . . . . . . . . . . . . . 261

12.8

High Jugular Bulb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

Meningiom a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
Low er Cranial Nerves Neurinom a . . . . . . . . . . . . . . . 247

12.4

Chondrosarcom a of t he Jugular Foram en . . . . . . 249

13.

Meningoencephalic Herniat ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

13.1

Surgical Managem ent . . . . . . . . . . . . . . . . . . . . . . . . . . 276

13.1.1 Tran sm astoid Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . 276

13.1.2 Tran sm astoid Approach w ith Min icran iotom y . . . . . . 278
13.1.3 Subtotal Petrosectom y . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

14.

Post surgical Condit ions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

14.1

Myringot om y and Insert ion of Vent ilat ion
Tube . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

14.2

St apes Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

14.3

Myringoplast y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

14.3.1 Failures an d Com plication s . . . . . . . . . . . . . . . . . . . . . . . . 297

14.4

Tym panoplast y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

14.4.1 Can al Wall Up (Closed) Tym pan oplast y . . . . . . . . . . . . . 301
14.4.2 Can al Wall Dow n (Open ) Tym pan oplast y . . . . . . . . . . . 316
14.4.3 Meatoplast y, Blin d-Sac Closure of th e Extern al
Auditory Can al . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327

14.5

Hearing Im plant s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337

vi


Preface
Despite advan ces in diagn ostic tech n iques an d im aging m odalit ies,
otoscopy rem ain s th e corn erston e in th e diagn osis of otologic
diseases. Ever y otolar yngologist, pediatrician , or even gen eral
practition er dealin g w ith ear diseases sh ould h ave a good kn ow ledge of otoscopy. Th is atlas is based on 30 years of experien ce in
Gruppo Otologico in th e t reatm en t of otologic an d n eurotologic
disorders, w ith m ore th an 32,000 surgical operation s an d 300,000
con sultation s. It presen ts a vast collect ion of otoscopic view s of a
variety of lesion s th at can affect th e ear an d tem poral bon e. Many
exam ples are given for each disease so th at th e reader becom es

acquain ted w ith th e variable presen tation s each path ology can
h ave.
W h ile otoscopy alon e can establish th e diagn osis in som e cases,
param eters such as h istory or audiological an d n euroradiological
evaluation are required in oth ers. An im portan t aspect of th is atlas
is th at it ju xtaposes, w h en appropriate, th e clin ical picture, radiological diagn osis, an d in t raoperative n din gs w ith th e otoscopic
n din gs of th e patien t. Needless to say, ever y patien t sh ould be
con sidered as a w h ole, an d in som e particular cases, th e otoscopic
n din gs m igh t on ly be th e “tip of th e iceberg.” Otalgia, otorrh ea,
an d gran ulation s in th e extern al auditory can al are m an ifestation s
of otit is extern a, but w h en th ey persist, particularly in th e elderly,
th ey sh ould arouse suspicion of m align an cy. Ot itis m edia w ith
effu sion can be a sim ple disease w h en seen in ch ildren , w h ereas
un ilateral persisten t otitis m edia w ith effusion in an adult m ay be
th e on ly sign of a n asoph ar yn geal carcin om a. A sm all att ic perforation in th e presen ce of facial n er ve paralysis an d sen sorin eural
h earin g loss m ay be all th at is seen in a gian t petrous bon e
ch olesteatom a. Th e m an ifestation of an aural polyp can var y from
a m ucosal polyp associated w ith ch ron ic suppurative otitis m edia
to th e m uch less com m on but m ore dan gerous tem poral bon e
paragangliom a. A sm all retrot ym pan ic m ass m ay represen t an

an om alous an atom y such as a h igh jugular bulb or an aberran t
carotid arter y. It m ay also represen t fran k path ology such as facial
n er ve n eurom a, con gen ital ch olesteatom a, or even en -plaque
m en in giom a.
In each ch apter, a surgical sum m ar y th at lists th e differen t
approaches for th e m an agem en t of th e path ology dealt w ith is
provided. Th rough out th e book, em ph asis is on h ow th e otoscopic
view an d th e clin ical pict ure m ay affect th e ch oice of treatm en t an d
th e surgical tech n ique.

At th e en d of th is atlas, a ch apter on postsurgical con dition s is
presen ted. Th e presen ce of previous surger y poses special dif culties because of th e distorted an atom y. Moreover, th e otologist
sh ould be able to distin guish bet w een w h at is con sidered to be
n orm al postsurgical h ealin g an d com plicat ion s th at n eed furth er
in ter ven t ion .
Our goal is to offer an easy-to-con sult book for residen ts,
specialists, an d gen eral pract ition ers. So, th is rst-step approach
to patien ts w ith otologic diseases can open a w ider view on
com plete kn ow ledge of otology, n eurotology, skull base path ology
an d surger y, an d n euroradiology.
Drs. Russo, Taibah , Caruso, an d Gian luca Piras, a n ew young
colleague w h o h as been w orkin g w ith us for th e past year, h elped to
accom plish th is w ork w ith th eir act ive an d en th usiastic participation . A special th an k goes to th e oth er m em bers of Gruppo
Otologico, for th eir con tribut ion in th e realization of th is book:
Drs. Piccirillo, Lauda, Gian n uzzi, an d Prasad.
Th e auth ors w ould like to th an k Mr. Steph an Kon n r y at Th iem e
Publish ers for h is excellen t cooperat ion an d h elp. Th an ks also go to
Paolo Piazza, n euroradiologist , for h is con t in uous cooperat ion an d
to Fern an do Man cin i for th e illustration s in cluded in th e book.
Ma r io Sa nna , MD

vii


Cont ribut ors
An t on io Car u so, MD
Otologist an d Skull Base Surgeon
Gruppo Otologico
Piacen za an d Rom e, Italy

Sam p at h Ch an d ra Prasad Rao, MS, DNB, FEB-ORLHNS
ENT an d Skull Base Surgeon
Gruppo Otologico
Piacen za an d Rom e, Italy

An n alisa Gian n u zzi, MD, Ph D
Otologist an d Skull Base Surgeon
Gruppo Otologico
Piacen za an d Rom e, Italy

Alessan d ra Ru sso, MD
Otologist an d Skull Base Surgeon
Gruppo Otologico
Piacen za an d Rom e, Italy

Loren zo Lau d a, MD
ENT an d Skull Base Surgeon
Gruppo Otologico
Piacen za an d Rom e, Italy

Mar io San n a, MD
Professor of Otolaryn gology
Depart m en t of Head an d Neck Surgery
Un iversit y of Ch ieti
Ch ieti, Italy
Director
Gruppo Otologico
Piacen za an d Rom e, Italy

Fer n an d o Man cin i, MD

ENT an d Skull Base Surgeon
Gruppo Otologico
Piacen za an d Rom e, Italy

viii

En r ico Piccir illo, MD
ENT an d Skull Base Surgeon
Gruppo Otologico
Piacen za an d Rom e, Italy

Hirosh i Su n ose
Depart m en t of Otolaryn gology
Medical Cen ter East
Tokyo Wom en’s Medical Un iversit y
Tokyo, Japan

Gian lu ca Piras, MD
Otologist an d Skull Base Surgeon
Gruppo Otologico
Piacen za an d Rom e, Italy

Abd elkad er Taibah , MD
Neurosurgeon , Otologist , an d Skull Base Surgeon
Gruppo Otologico
Piacen za an d Rom e, Italy


Chapt er 1
Met hods of Ot oscopy

Methods of Otoscopy

1 Met hods of Ot oscopy
Abst ract
Th is ch apter explains h ow w e routin ely perform otoscopy. With
th e h elp of a m icroscope an d en doscope, each clin ical con dit ion
can be easily st udied, recorded, an d prin ted for a deeper an alysis.
Perform in g a proper otoscopy is th e first step for th e correct
m an agem en t of th e w h ole path ology of th e tem poral bon e an d
skull base.

A prelim in ar y exam ination is perform ed usin g a h ead m irror or
an otoscope.
For proper otoscopy, th e extern al auditor y can al sh ould be
clean ed. Few in strum en ts are used for th is step, n am ely, aural
speculi of di eren t sizes, a Billeau ear loop, Hartm an auricular
forceps, an d suction tips ( Fig. 1.1). In cases w ith a h istory of
recurren t otitis, w e prefer to clean th e ear w ith th e aid of a
m icroscope ( Fig. 1.2).

Keywords: otoscopy, m icroscope, en doscope, in stan t ph otography

Fig. 1.1 Instrum ents used for cleaning the external auditory canal.

Fig. 1.2 Microscope used as an aid in cleaning the ear.

2

Methods of Otoscopy
Th e use of a rigid 0-degree 6-cm en doscope ( Fig. 1.3) con n ected to a video system en ables th e patien t to see th e pthology
involvin g h is/h er ear ( Fig. 1.4). Th e rigid 30-degree en doscope
allow s evaluation of attic retraction pockets, th e exten t of
w hich can n ot alw ays be determ in ed usin g th e m icroscope or th e
0-degree en doscope ( Fig. 1.5).
In stan t ph otography h as also been used in th e operatin g room .
A copy of th e im portan t steps of th e operation is given to th e
patien t w h ile an oth er copy is kept in th e patien t ’s ch art . Th e
patien t is also ph otograph ed durin g th e follow -up visit. Th us, for
each patien t pre-, in t ra-, an d postoperative ph otograph ic docum en tation is obtain ed.

Durin g th e past years, a cam era m oun ted to th e en doscope w as
used for obtain ing ph otos ( Fig. 1.6); n ow adays a digital custom ized system is used for collect in g pictures on a laptop storage,
w ith th e possibilit y of collect otoscopic im ages on a patien t’s
ch art . So, th e adven t of com puterized system s ( Fig. 1.7) allow s
virt ual storaging of all th e ph otos or videos, w ith th e advan tage
of reducin g tim es of acquisition , m odification , an d deletion . Furth erm ore, a deeper clin ical an alysis could be assessed.
In all th e cases, th e exam in er sits to th e side of th e patien t
w h ose h ead is sligh tly t ilted tow ard th e con tralateral side. Th e
exam iner h olds th e cam era attach ed to th e en doscope w ith h is
righ t h an d. W ith th e rin g an d m iddle fin ger of th e left h an d, th e

Fig. 1.3 A rigid 0-degree 6-cm endoscope.

Fig. 1.4 The endoscope can be connected to a
video system such as this.

3

Methods of Otoscopy
Fig. 1.5 A series of rigid endoscopes.

Fig. 1.6 A setup used in past years for photographing patients.

Fig. 1.7 A modern setup of computerized systems for digital collection
of patients’ photos.

4


Methods of Otoscopy
Fig. 1.8 Examination of a patient in progress.

exam iner pulls th e patien t’s auricle backw ard an d out w ards
to straigh ten th e extern al auditor y can al. Th e en doscope is
advan ced over th e in dex fin ger of th e exam iner’s left h an d in to
th e patien t’s extern al auditor y can al. In th is m an n er, any un due
injur y to th e extern al auditory can al is preven ted ( Fig. 1.8).

5



Chapt er 2
The Norm al Tym panic
Mem brane

2.1

Anatom y

8

2.2

Histology

11

2.3

Physiology

11


The Norm al Tym panic Mem brane

2 The Norm al Tym panic Mem brane
Abst ract
Th e n orm al t ym pan ic m em bran e is th in , sem i-t ran sparen t ,
pearly gray colored, an d con sists of th ree layers from th e outside
to th e in side (epith elial, fibrous, an d m ucosal). Th e t ym pan ic
m em bran e n ot on ly acts as a soun d w ave tran sducer to th e ossicular ch ain, but also h as a protect ive fun ct ion to th e m iddle ear
an d ser ves as a soun d am plifier. It is conven tion ally divided in to
four quadran ts from t w o perpen dicular lin es passin g th rough
th e um bo (an terosuperior, an teroin ferior, posterosuperior,

posteroin ferior).
Keywords: t ym pan ic m em bran e, t ym pan ic layers, ossicular ch ain ,
t ym pan ic quadran ts

2.1 Anat om y
Th e t ym pan ic m em bran e form s th e m ajor part of th e lateral w all
of th e m iddle ear (see Fig. 2.1, Fig. 2.2, Fig. 2.3). It is th in ,
resistan t , sem i-t ran sparen t, h as a pearly gray color, an d is con elike. Th e apex of th e m em bran e lies at th e um bo, w h ich correspon ds to th e low est part of th e h an dle of th e m alleus. Most of

Fig. 2.1 Right ear. Normal t ympanic mem brane.
1, pars flaccida; 2, short process of the malleus;
3, handle of the malleus; 4, umbo; 5, supratubal
recess; 6, tubal orifice; 7, hypot ympanic air cells;
8, stapedius tendon; c, chorda t ympani; I, incus;
P, prom ontory; o, oval window; R, round window; T, tensor t ympani; A, annulus.

1
2
5

C
O

3

I

T

8

4

6

R
P

7

8

th e m em bran e circum feren ce is th icken ed to form a fibrocart ilagin ous rin g, th e t ym pan ic an n ulus, w h ich sits in a groove in th e
t ym pan ic bon e called th e t ym pan ic sulcus. Th e fibrocartilagin ous
rin g is deficien t superiorly. Th is deficien cy is kn ow n as th e n otch
of Rivin us. Th e an terior an d posterior m alleolar folds exten d from
th e sh ort process of th e m alleus to th e t ym pan ic sulcus, th us
form in g th e in ferior lim it of th e pars flaccida of Sh rapn ell's
m em bran e.
Th e m em bran e form s an obt use an gle w ith th e posterior w all
of th e extern al auditor y can al. It also form s an acute angle w ith
th e an terior w all of th e can al. It is im portan t to respect th is acute
an gulat ion in th e m yrin goplast y operation to m ain tain as m uch
as possible th e vibratory m ech an ism of th e t ym pan ic m em bran e
an d h en ce en sure m axim um h earin g im provem en t (see
Fig. 2.4, Fig. 2.5, Fig. 2.6, Fig. 2.7, Fig. 2.8).
Th e extern al surface of th e t ym pan ic m em bran e is in n er vated
by th e auriculotem poral n er ve an d th e auricular bran ch of th e
vagus n er ve, w h ereas th e in n er surface is supplied by Jacobson 's
n er ve, a bran ch of th e glossoph ar yngeal n er ve.

Th e blood supply is derived from th e deep auricular an d an terior t ym pan ic arteries. Both are bran ch es of th e m axillar y arter y.

A


The Norm al Tym panic Mem brane
Fig. 2.2 Right ear. Structures of the middle ear
seen after removal of the t ympanic membrane.
9, pyramidal eminence; co, cochleariform process; f, facial nerve; j, incudostapedial joint. See
legend to Fig. 2.1 for other numbers and
abbreviations.

1

2
C
CO
f
9

8

3

I
j

O
T
R

5

4

P

6

P.S.

A.S.

P.I.

A.I.

Fig. 2.3 Right ear. Division of the t ympanic membrane into four
quadrants: AS, anterosuperior; AI, anteroinferior; PS, posterosuperior;
PI, posteroinferior. This division facilitates the description of different
pathologic affections of the t ympanic membrane.

Fig. 2.4 Left ear. Normal t ym panic mem brane. Note the acute angle
formed between the t ympanic mem brane and the anterior wall of the
external auditory canal. The pars tensa with the short process of the
handle of the m alleus, the umbo, the cone of light, the annulus, and
the pars flaccida are seen. Note also the presence of early exostosis in
the superior wall of the external auditory canal.

9

The Norm al Tym panic Mem brane

10

Fig. 2.5 Right ear. Normal t ympanic mem brane. In this case, the drum
is very thin and transparent. The handle and short process of the
malleus as well as the umbo and cone of light are well visualized.
Through the transparent t ympanic m embrane, the region of the oval
window, the long process of the incus, the posterior arc of the stapes,
the incudostapedial joint, the round window, and the promontory can
be distinguished. Anteriorly, at the region of the Eustachian tube, the
tensor t ympani canal and the supratubaric recess can be observed.

Fig. 2.6 Left ear. Normal t ympanic membrane. The handle of the
malleus and cone of light are well visualized through the t ym panic
membrane; the promontory, the area of the round window, and the
air cells in the hypot ym panum can be appreciated. The pars flaccida is
visualized superior to the short process of the m alleus.

Fig. 2.7 Right ear. Norm al t ympanic m embrane. The drum, however,
is slightly thickened with an accentuated capillary net work along the
handle of the m alleus. The increased thickness of the t ympanic
membrane obscures all the structures in the middle ear.

Fig. 2.8 Left ear. A norm al t ympanic membrane that is slightly thinned
in the anterior quadrant and moderately thickened posteriorly.

The Norm al Tym panic Mem brane

2.2 Hist ology
Th e t ym pan ic m em bran e con sists of th ree layers: an outer epith elial layer con tin uous w ith th e skin of th e extern al auditor y
can al, a m iddle fibrous layer or lam in a propria, an d an in n er
m ucosal layer con tin uous w ith th e lin in g of th e t ym pan ic cavit y.
Th e epiderm is or outer layer is divided in to th e stratum corn eum , th e stratum gran ulosum , th e stratum spin osum , an d th e
stratum basale, w h ich is th e deepest layer th at rests on th e basem en t m em bran e.
Th e lam in a propria is ch aracterized by th e presen ce of collagen
fibers. In th e pars ten sa, th ese fibers are arran ged in t w o basic
layers: an outer radial layer th at origin ates from th e in ferior part
of th e h an dle of th e m alleus an d in serts in th e an n ulus, an d an
in n er circular layer th at origin ates prim arily from th e sh or t process of th e m alleus. Such a dist in ct arran gem en t , h ow ever, is
absen t in th e pars flaccida.

Th e m ucosal layer is form ed m ain ly of a sim ple cuboidal or colum n ar epith elium . Th e free surface of th e cells possesses n um erous m icrovilli.

2.3 Physiology
Th e extern al ear h as a protect ive fun ct ion again st th e m iddle ear
an d ser ves as a soun d am plifier. Th e extern al ear n ot on ly
ch an ges th e perception of soun d am plifyin g som e frequen cies,
but also in creases th e direction alit y, due to th e di raction of th e
soun d w aves on th e en tire h ead an d extern al ear, in particular
th e ear pavilion . Th e m axim um am plification is ~20 dB for frequen cies bet w een 2 an d 3 kHz. Th e t ym pan ic m em bran e acts as a
soun d w ave tran sducer to th e ossicular ch ain .

11

Chapt er 3
Diseases A ect ing t he Ext ernal
Audit ory Canal

3.1

Exostosis and Osteom as

14

3.2

External Auditory Canal
Inflam m atory Diseases

25

Cholesteatom a of the External
Auditory Canal

37

Pathologies Extending to the
External Auditory Canal

40

3.5

Tem poral Bone Fractures

49

3.6

Carcinom a of the Ext ernal
Auditory Canal

50

3.3
3.4


Diseases A ecting the External Auditory Canal

3 Diseases A ect ing t he Ext ernal Audit ory Canal
Abst ract
Path ologies a ectin g th e extern al auditor y can al (EAC) are a w ide
spectrum of diseases th at in clude: bony n eoform ation s of th e
EAC (exostosis an d osteom as), in flam m ator y diseases (extern al
otit is, otom ycosis, an d in flam m ator y sten osis of th e EAC), ch olesteatom a of th e EAC, ben ign tum ors of th e ear an d skull base
exten din g to th e EAC (carcin oid tum or, m en in giom as, facial n er ve
tum ors, etc.), tem poral bon e fract ures, an d carcin om a of th e EAC.
Otoscopy is fu n dam en tal for th e recogn it ion of each clin ical con dition . An alysis of patien t clin ical h istory an d sym ptom s are also
of utm ost im portan ce to decide th e proper th erapeut ic m an agem en t, w h ich is di eren t depen din g on th e path ology. For exam ple, in case of exostosis an d osteom as occludin g th e EAC a
can alplast y is in dicated, as w ell as a surgical t reat m en t is th e
m ain stay for m ost of th e ben ign an d m align tum ors involving th e
EAC. Furth er radiological exam in ation s (CT an d MRI scan s) are
in dicated in th e suspect of a tum or.

Keywords: extern al auditor y can al, exostosis, osteom as, otit is
extern a, otom ycosis, ch olesteatom a, m en in giom a, facial n er ve
tum or, tem poral bon e fract ures, squam ous cell carcin om a

3.1 Exost osis and Ost eom as
Exostosis are d efin ed as n ew bon y grow th s in t h e osseou s
p or t ion of th e extern al au d itor y can al (EAC). Th ey are usu ally
m ult ip le, bilateral, an d are com m on ly sessile. Th ey var y in

sh ap e, bein g eit h er rou n d , ovoid , or oblon g. Th e con d it ion is
cau sed by p eriost it is secon d ar y to exp osu re to cold w ater. Th is
explain s th e h igh in cid en ce of exostoses am on g d ivers an d
cold -w ater bath ers. Histologically, th ey are form ed from p arallel layers of n ew ly form ed bon e. It is p ost u lated th at th e p eriosteu m st im u lates an osteogen ic react ion w ith each exposu re
to cold w ater, cau sin g th is st rat ificat ion . W h en exostoses are
sm all, th ey are asym ptom at ic. Large lesion s, h ow ever, can
occlu d e th e EAC an d lead to con du ct ive h earin g loss or reten t ion of w ax an d d ebris w ith su bsequen t ot it is extern a. In su ch
cases, an d in cases in w h ich a h earin g aid is to be fit ted , su rgical rem oval of exostoses is in d icated . In som e cases, su rger y
is tech n ically d i cu lt an d sp ecial care is taken to p reser ve t h e
skin of th e EAC. Oth er st ru ct u res at risk are t h e t ym p an ic
m em bran e an d ossicu lar ch ain m ed ially, th e tem p orom an d ib u lar join t an teriorly, an d t h e th ird segm en t of th e facial n er ve
p osteroin feriorly.
Osteom a is a true ben ign n eoplasm of th e bon e of th e EAC, usually un ilateral an d pedun culated. Histologically, it can be di eren tiated from exostosis by th e absen ce of th e lam in ated grow th
pattern .
According to th e exten t of both diseases, w e developed a classification for EAC sten osis, w h ich is based m ain ly on th e am oun t of
t ym pan ic m em bran e otoscopically visible ( Table 3.1; Fig. 3.1,
Fig. 3.2, Fig. 3.3, Fig. 3.4, Fig. 3.5, Fig. 3.6, Fig. 3.7,
Fig. 3.8, Fig. 3.9, Fig. 3.10, Fig. 3.11, Fig. 3.12, Fig. 3.13,
Fig. 3.14,
Fig. 3.15,
Fig. 3.16,

Fig. 3.17,
Fig. 3.18,
Fig. 3.19, Fig. 3.20).

Table 3.1 Grading of external auditory canal stenosis

14

Grade

Severit y

Ot oendoscopic finding

Radiological finding*

0

No stenosis

All four quadrants of the pars tensa are
perfectly visible.
100% of the pars tensa area is visible.

No narrowing of EAC

I

Mild stenosis

One or more quadrants is/are partially
visible.
≥ 75% of the pars tensa area is visible.

10–25% narrowing of EAC

Descript ive figures


Diseases A ecting the External Auditory Canal
Table 3.1 Grading of external auditory canal stenosis (continued)
Grade

Severit y

Otoendoscopic finding

Radiological finding*

II

Moderate
stenosis

One of the quadrants is com pletely
obscured.
50–75% of the pars tensa area is visible.

25–50% narrowing of EAC

III

Severe stenosis Two of the quadrants are completely
obscured.
25–50% of the pars tensa area is visible.

50–75% narrowing of EAC

IV

Near total
stenosis

Three of the quadrants are completely
obscured.
10–25% of the pars tensa area is visible.

75–90% narrowing of EAC

V

Total stenosis

None of the quadrants are visible.
0% of the pars tensa area is visible.

90–100% narrowing of EAC

Descript ive figures

*The degree of stenosis is calculated as a percentage of the maximum measurem ent available of the lesion against the maximum diameter of the EAC
in axial and coronal cuts.
Abbreviation: EAC, external auditory canal.

15