Auditory and balance apparatus

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Auditory and balance apparatus

• Morphology
• and
• embryology
• Auris, is Us, oton

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Auditory and vestibular apparatus

• External ear
• (Auris externa)
• Middle ear
• (Auris media)
• Inner ear
• (Auris interna)
• Organum
• vestibulo-
• cochleare

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External ear (Auris externa)

• Earbolt (Auricula, Pinna)
• elastic cartilage
• External meatus
• (Meatus acusticus externus)
• Eardrum
• (Membrana tympanica, Myrinx)

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• Helix
• 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
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• 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 majorminor
• m. obliquus transversus auriculae, m.
  pyramidalis auriculae
• Cartilage Cartilago auriculae - elastic
• Skin back side free, ventrally firmly attached
  to perichondrium - othematom

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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.

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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

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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

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Eardrum(Membrana tympanica, Myrinx)
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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)

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EardrumOtoskopy

• 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

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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

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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)

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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

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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

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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)

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Middle ear ossicles (Ossicula aditus)

• Malleus (Malleus, Hammer)
• caput
• collum
• manubrium
• processus lateralis
• processus anterior

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Middle ear ossicles (Ossicula aditus)

• Incus (Incus, Anvil)
• corpus
• crus longum
• processus lenticularis
• crus breve
• Stapes (Stapes, Stirrup)
• caput
• (collum)
• crus ant. post.
• basis

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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

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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)

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Middle ear muscles

• m. tensor tympani
• 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

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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 !!!

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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

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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.)

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Auditory tube (Tuba auditiva)
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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

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Auditory tube (Tuba auditiva)

• opening
• m. tensor tympani
• m. salpingopharyngeus
• ? role of m. levator veli palatini not clear ?
• Ostmann adipose body

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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

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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

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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)

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Otolitic organssaculus et utriculus

• macula
• Hairy cells
• Supportive cells
• Gelatinous layer
• otoconia - crystals CaCO3
• (otoliths term for crystals in reptiles)

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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.)

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Semicircular canals

• Membranous inside bony
• Receptors in ampulas
• cristae ampullares
• Crest 90 to canal axis
• cupula gelatinous substance
• Hairy cells
• Support cells

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Hairy cells

• Two types
• On apical surface
• 1 kinocilia
• Several stereocilias
• bazally - synapse with nerve fibers

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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

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Bony labyrint (Labyrinhtus osseus)Snail (Cochlea)

• Spindle (Modiolus)
• basis
• lamina
• canalis spiralis ganglion cochleare
• canales longitudinales n. cochlearis

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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

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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

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Snail (Cochlea)
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Scala media

• Contain endolymph
• on lamina basilaris is Corti organ
• Covered by membrana tectoria
• Bony lamina spiralis
• ligamentum spirale

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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

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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

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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

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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 !!!

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VIII. - Nervus vestibulocochlearisexamination

• 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

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VIII. - Nervus vestibulocochlearisirritation /
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)

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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.

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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

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Auditory path
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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

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Auditory path 3D
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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 vestibulocerebellar
  is directus w/o interconnection into cerebellum
• 2. neuron cells nuclei vestibulares pontis ?
  axons into different structures

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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

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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)

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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.)

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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

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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

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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

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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

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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

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Development of external ear
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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

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Development of middle ear

• antrum mastoideum
• Are not present cellulae mastoideae after
  delivery
• Appears in 2nd year
• Finished pneumatization cca in 6th year

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Development of membrana tympani

• Outer epithelium from 1st branchial cleft
• Inner epithelium from 1st branchial exagination
• mezenchyme of 1st and 2nd branchial arch

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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

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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

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Development of inner ear

• Surrounding mezenchyme changes into
  cartillagenous capsula otica
• There appears cavities and thus originate
  perilymphatic spaces
• in 20. - 22. week cartillagenous model ossifies

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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

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Casuistic 1 - diagnosis

• otitis externa
• Ilness of summer monthes and swimming
• complications especially in DM
• ? perichondritis or destruction of temporal
  bone

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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 38,3C
• otoscopy tympanic membrane reddish, smeared,
  protruding backside

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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
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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

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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