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SUMPh “Nicolae Testemitanu”

Department Otorhinolaryngology

Anatomy and physiology of the

middle ear

Associate Professor Diacova Svetlana

Tympanic membrane - TM, membrana tympani, myrinx

• Delimits middle and external ear, in sulcus tympanicus in

bottom of EAC
• In adults TM – a board of ovale shape, translucid, 11 x 9 mm
Position: oblique, in new-borns - horizontal.
• Layers: 1.extern - skin 2. intern - mucous 3. meddle - fibrous
(radial şi circular). 2
• Parts:
1. pars tensa (stretched part)
2. pars flaccida - relaxed,
- without fibrous layer
(membrana Shrapnelli)

Tympanic membrane - TM, membrana tympani, myrinx
Color - Gray – Perl 2
Reference points:
1 - hammer handle ;
2 - short apophyses ; 1
3 - creases –
anterior and posterior;
4 - umbo; 5
5 – light cone . 4
Tympanic membrane - TM, membrana tympani,

Four quadrans:
(line along hammer handle through umbo and perpendicular to

1 anterosuperior
2 posterosuperior
3 anteroinferior
4 posteroinferior 4

Middle ear

Common system of pneumatic cavities :

1. tympanic cavity (cavum tympani);
2. auditory tube (Eustache);
3. antrum and procesus mastoideus
Timpanic cavity (cavum tympani)
• Central position
• Ventilation through auditory tube and nasofarinx
• Communicates with antrum and mastoid cells
– through aditus ad antrum

• Lateral wall– tympanic membrane,

• Internal wall – labirintic (Promontorium)
• Anterior wall - tubar (auditory tube),
• Posterior wall - mastoidic, (aditus ad antrum)
• Superior wall - tegmen (tegmen tympani), fosa cranii
• Inferioar wall - jugular - (bulbus v. jugularis).
Timpanic cavity (cavum tympani)
3 parts
• Superior part – supratympanal (attic or epitympanum).
• Middle part - mezotympanum (mesotympanum).
• Inferior part – hipotympanum

Mucosa – cubic epithelium of one layer

3 ossicles:

2 muscles of tympanic cavity: m. Stapedius, m. Tenzor tympani.

Auditory tube (Eustachio)

• Communicates with timpanic cavity and

• In children: short, large, more horizontal,
easy opens, in small children is opened.
• Mucosa – voluminous respiratory ciliated
epithelium with unique Goblet cells,
that produce mucus
• Functions:
» aeration,
» protection
» drainage
Mastoidian process
Contains pneumatic cells with the biggest cell - antrum.
• Communicates with tympanic cavity - through aditus ad
• In newborns – only antrum
• Developing – during the first years of life
• Superior - temporalis line, continuation of zygomaticus
• Anterior –posterior wall of EAC, in postero-super.part - spina
suprameatum Henle, antrum’s proiection

Antrum – the biggest cell, contains air. Tegmen of antrum

delimits from dura mater of the middle cranian fossa
3 types of pneumatization of mastoidian apophyses :
pneumatic, diploic, sclerozant.
Mastoidian apophyses
• Behind the posterior wall- Sinus lateralis (sinus sigmoideus) –
venous sinus of the jugular vein system.
• Under inferior wall– bulbus v. jugularis int.
• In anterior wall – n. Facialis, EAC
• Behind superior wall – middle cranian fossa
• Behind middle wall –semicircular canal
inflammaion of middle ear
(which includes :
tympanic cavity,
auditory tube (Eustachio),
antrum and mastoid cells).
•80 - 90 % children – once in a life
•50 - 70 % - 3 and more episodes

•60 - 85 % children by 3 y.o.with bronchitis and

•35 - 40 % children of the first 7 years of life with
“respiratory infection”

•60 - 70 % children with hipertrophy of

palatine amigdals and adenoides
OTITIS MEDIA relations
between different forms

Acute OM
Recurrent OM

Chronic Suppurative OM

OM with effusion
Adhesive OM
OM classification

• Acute OM– acute inflammation of middle ear

• OM with effusion
- presence of liquid behind intact tympanic

• Recurrent OM
- Recidive of acute OM 3 times in 6 months or 4
times in 12 months
OM classification

• Adhesive OM – cicatrization of tympanic cavity ,

adherences formation

• Chronic Suppurative OM - inflamatory chronic

purulent procces in middle ear
OM Lack of diagnostic
and an adequate treatment

OM with effusion Chronic Supurative OM

Adhesive OM with risc
OME – otitis media with effusion

etiologic variabil procces

with presence of effusion (exudate, liquid)
behind tympanic membrane
relativly intact

are not caracteristic

Acute infection signs:
fever, intensive pain
EMO Middle ear containing
serous mucous purulent

Glue ear

OM serous OME sero-mucous OM

Mucous OM
1. High Incidence
•60 % children
2. cognitiv –intelectual consequences
•speech development retardation
•psihoemoţional retardation in child
Otologic consequences
•Recurrent OM
•Adhesive OM
•Chronic Suppurative OM
•OM with colesteatom
with risc of intracranial complications
•sensoro-neural hearing loss
OME Etiology

• Caused by microbian or viral flora in a

small quantity
• The most frequent:
• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarralis
OME Pathogenesis
Eustachian tube is opened
Eustachian tube Microbian toxins or
is closed Alergic antigens = in auditory tube
„The vacuum”theory, =in tympanic cavity=stimulates
Is based on a postulat •hiperplazia of epithelium,
Of nasal obstruction as •Goblet cells proliferation ,
Principal initiative •paralises ciliar motions,
moment •blocks evacuation
of exudate from TC
Mucous edema,
hipersecretion and dereglation
of exudate evacuation
Leads to auditory tube obstruction.
OME Favorable factors

•Early age
•Artificial alimentation of a child during first
year of life
•Genetic anomalies of cranium and face,
•Recurrent otitis media during first months
•Allergy changes
•Frequent viral infections
Anatomic and functional features in children

Auditory tube

Mucosa in nose and tympanic cavity

•More irritated by bacteria, viruses, alergens
•More easily develop cells, that produce mucous
OME Favorable factors
in adults and older children
Viral infection
Nasal septum deviation
nazopharingeal tumor proccesses
as a complication of
a hiperbarooxigenotherapy

In pacients of these age groups

exudative serous proccesses.
OME Clinical signs

In elder children In children af early age

•Sleep disturbances
•Inadecvate reaction
to parents’ calling
•Hearing loss •Speech development
•Sensation of liquid retardation
in the ear •psiho-emoţional retardation
•Ear noise
OME Diagnostics
Sleep disturbances
Inadecvate reaction to parents’ calling,
Speech development retardation
Otoscopy TM gray-pink, dull

Tragal reflex is not a semnificativ diagnostic sign

Pneumootoscopy TM gray-pink, dull,

Motional decrease of MT

Impedance type B of tympanogram

Audiometry & Stapedian Reflex absence
Audiometry Conductive hearing loss (30 - 50 dB)
Otoscopic OME signs
EMO Impedansmetry

•type B
•Stapedian reflex is absent

OM Impedansmetry


- 100mm H2O O

Types of tympanogram
1. Type A – norm
2. Type B - pathology (OM ?)
3. Type C - pathologz (auditorz tube disfunction)
OME Audiometry
Tonal audiometry
•Conductive hearing loss
•10 – 15 % mixt hearing loss
Play audiometry
•Inadecvate reaction to sounds
30 – 50 dB on the wholl frequence scale
BAER inregistration
•inregistration of curve on 35-40 dB
•prolonged of latency of peak I
Inregistration Absence of otoemission to 30 dB
and presence of that to 60 dB
OME Screening methods

•Impedance Audiometry

•OAE inregistration

•BERA inregistration
OME Treatament methods
antibacterial antialergic

OME, acute General treatment

OME, subacute Local treatment

OME Miringotomy
OME Timpanostomy