The following CBME core competencies are covered in this chapter. EN1.1: Describe the Anatomy of ear. AN40.2: Describe and demonstrate the boundaries, contents, relations and functional anatomy of middle ear and auditory tube.

Anatomy of the Middle Ear

The middle ear is a fascinating, air-filled chamber within the temporal bone, acting as a crucial bridge for sound transmission to the inner ear. Understanding its intricate anatomy is paramount for both MBBS and ENT PG students, as it forms the basis for diagnosing and managing a wide array of otological conditions. This comprehensive chapter, aligned with the CBME curriculum, offers a detailed yet student-friendly exploration of middle ear anatomy, ideal for university theory exams, viva questions, practical exams, and NEET PG MCQs.

Introduction to the Middle Ear Cleft

The middle ear, also known as the tympanic cavity, is an irregular, air-filled space in the petrous part of the temporal bone. A thin mucous membrane lines this cavity. It lies laterally to the tympanic membrane and medially to the lateral wall of the inner ear.

Importantly, the middle ear does not exist in isolation. It forms part of a larger interconnected system called the middle ear cleft. This cleft comprises:

• The Eustachian tube (anteriorly)
• The tympanic cavity (middle ear proper)
• The attic (epitympanum)
• The aditus ad antrum
• The mastoid antrum
• The mastoid air cells (posteriorly)

Within the tympanic cavity are several important structures:

• Ossicles (malleus, incus, stapes)
• Tensor tympani muscle
• Stapedius muscle
• Chorda tympani nerve
• Tympanic plexus

The primary function of the middle ear is to transmit vibrations from the tympanic membrane to the inner ear.

Middle Ear at a Glance

Feature	Key Point
Location	Petrous temporal bone
Type	Air-filled cavity lined by mucosa
Main function	Sound transmission (TM → ossicles → oval window)
Connected system	Middle ear cleft
Key clinical importance	Pathway for the spread of infection to the mastoid and the brain

Diagram Showing Divisions of the Middle Ear (Compartment-wise)

Divisions of the Middle Ear

The middle ear is traditionally divided into three parts: the epitympanum (upper compartment), the mesotympanum (middle compartment) and the hypotympanum (lower compartment).

• Epitympanum or the Attic – This is the upper compartment. It lies above the level of pars tensa and malleolar folds but medial to the pars flaccida and the bony lateral attic wall (also known as scutum). It is separated from the mesotympanum and hypotympanum by a series of mucosal membranes and folds.
• Mesotympanum or the tympanic cavity – This is the middle compartment, directly opposite the pars tensa of the tympanic membrane.
• Hypotympanum – This is the lower compartment, located below the level of the pars tensa and the tympanic sulcus. 

Additional important areas: Beyond these main divisions, we also recognise specific anterior and posterior areas:

• Protympanum: This area lies in the anterior wall of the tympanic cavity, close to the opening of the Eustachian tube.
• Retrotympanum: This area occupies the posterior wall of the tympanic cavity.

Diagram Showing Retrotympanum and Protympanum Area

Boundaries of the middle ear (Six-Walled Box Concept)

The middle ear can be visualised as a six-sided box having:

• Roof
• Floor
• Anterior wall
• Posterior wall
• Lateral wall
• Medial wall

This is one of the most important frameworks for understanding middle ear anatomy.

Contents of the Middle Ear (Core Structures)

The tympanic cavity contains:

1. Ossicles (malleus, incus, stapes)
2. Muscles (Stapedius, Tensor tympani)
3. Nerves (Chorda tympani, Tympanic plexus)

1. Ear Ossicles.

There are three ossicles in the middle ear – the malleus, incus and stapes. The ossicles form a semi-rigid osseous chain across the middle ear from the tympanic membrane to the oval window of the internal ear. The malleus is the most lateral ossicle, and it is attached to the tympanic membrane, whereas the stapes ossicle is attached to the oval window. The ossicles conduct sound energy from the tympanic membrane to the oval window. Muscles related to the auditory ossicles modulate movement during the transmission of vibrations from the tympanic membrane.

Malleus (hammer): The malleus is the largest ossicle. It measures 8-9 mm in length. Parts of the malleus include the head of the malleus, neck of the malleus, anterior and lateral processes, and handle of the malleus(manubrium).

• Head: The head of the malleus is the rounded upper part of the malleus, which lies in the attic region. It is suspended by the superior ligament, which runs upwards to the tegmen tympani.  Its saddle-shaped posterior surface articulates with the body of the incus by a synovial joint.
• Neck: Inferior to the head of the malleus is the constricted neck of the malleus, which also lies in the attic region. The chorda tympani and tendon of the tensor tympani lie below the neck of the malleus; hence, amputation of the head of the malleus by cutting through the neck leaves both chorda tympani and tensor tympani intact.
• Anterior process: Below the neck of the malleus, there are the anterior and lateral processes. The anterior process is attached to the anterior wall of the middle ear by a ligament.
• Lateral process: The lateral process forms a knob-like projection on the outer surface of the tympanic membrane is attached to the anterior and posterior malleolar folds of the tympanic membrane.
• Handle of malleus: Below the anterior and lateral processes is the handle of the malleus, which is embedded in the fibrous layer of the tympanic membrane. The tendon of the tensor tympani muscle inserts on the medial surface of the handle. Chorda tympani crosses the handle of the malleus just above the insertion of the tensor tympani muscle.

Incus (Anvil). It is the second bone in the series of ear ossicles. Parts of the incus include the body of the incus and the long and short process.

• Body. It articulates with the head of the malleus and lies in the attic. It is suspended by the superior incudal ligament coming from the tegmen tympani.
• Short process. The short process projects backwards to lie in the fossa incudis. It is attached by a short suspensory ligament to the upper posterior wall of the middle ear.
• Long process. It hangs vertically downward into the mesotympanum almost parallel to the handle of the malleus. The tip of the incus, also known as the lenticular process, has at times been called the fourth ossicle because of its incomplete fusion with the tip of the long process. The lenticular process articulates with the head of the stapes and forms the incudostapedial joint.

Stapes (stirrup): The stapes is the third and smallest bone in the ossicular chain. It measures about 3.5 mm.  It is attached to the oval window by the annular ligament. Parts of the stapes include the head, neck, anterior and posterior crura and footplate.

2. Muscles of the Middle Ear

There are two muscles:

• Stapedius
• Tensor tympani

Stapedius muscle. The stapedius arises from the apex of the pyramid, which is a small projection on the posterior (mastoid) wall of the middle ear and passes forward to attach to the posterior surface of the neck of the stapes. In response to loud sounds (80 dB and above), the stapedius muscle contracts, pulling the stapes posteriorly, thereby dampening the loud sounds and preventing noise trauma to the inner ear (acoustic reflex). Stapedius is a second arch muscle and is supplied by the nerve to stapedius, which is a branch of CN VII.

Tensor tympani muscle. This is a long, slender muscle arising from the bony canal present on the anterior wall of the middle ear. It is present above the opening of the eustachian tube. Its tendon turns through a right angle around the processus cochleariformis and passes laterally and inserts into the medial aspect of the upper end of the handle of the malleus.  It tenses the tympanic membrane. Contraction of the tensor tympani pulls the handle of the malleus medially. This tenses the tympanic membrane, reducing the force of vibrations in response to loud noises. The muscle develops from the first arch and is supplied by the medial pterygoid branch of the mandibular nerve (V3).

Diagram Showing Muscles Associated with the Ossicles

Nerves of the Middle Ear

There are two nerves:

• Chorda Tympani
• Tympanic Plexus

Chorda Tympani Nerve. It is a branch of the facial nerve. It enters the middle ear through the posterior canaliculus at the junction of the lateral and posterior walls of the middle ear. It runs on the medial surface of the tympanic membrane between its mucosal and fibrous layers. On the malleus, it runs medially just below the neck of the malleus and above the attachment of the tendon of the tensor tympani. It further continues forward and leaves the middle ear through the anterior canaliculus. It carries taste sensation from the anterior two-thirds of the tongue and supplies secretomotor fibres to the submaxillary and sublingual salivary glands.

Tympanic Plexus. The tympanic plexus innervates the medial surface of the tympanic membrane, tympanic cavity, mastoid air cells and the bony eustachian tube.

The tympanic plexus lies on the promontory and is formed by the

• Tympanic branch of the glossopharyngeal and
• Caroticotympanic nerves (sympathetic fibres) from the plexus around the internal carotid artery. 

The tympanic plexus also gives off a major branch (the lesser petrosal nerve), which supplies preganglionic parasympathetic fibres to the otic ganglion. The tympanic branch of the glossopharyngeal nerve carries secretomotor fibres for the parotid gland. Sectioning of the tympanic branch of the glossopharyngeal nerve can be carried out in the middle ear in cases of Frey’s syndrome.

Course of secretomotor fibres to the parotid:

Inferior salivary nucleus → CN IX → Tympanic branch → Tympanic plexus → Lesser petrosal nerve → Otic ganglion → Auriculotemporal nerve → Parotid gland.

Diagram Showing Tympanic Plexus

Middle Ear Cleft: Mastoid Antrum and Air Cell System

The mastoid is an integral part of the middle ear cleft, serving as a reservoir for air and a common site for ear infections to spread.

Diagram Showing Mastoid Antrum and its Air Cell System

1. Mastoid Antrum

The mastoid antrum is a relatively large, air-containing space located in the upper part of the mastoid process.

• Dimensions: It typically measures approximately 9 mm in height, 14 mm in width, and 7 mm in depth in adults.
• Communication: The antrum directly communicates with the epitympanum of the middle ear via the aditus ad antrum.
• Development: Unlike the mastoid air cells, the antrum is well-developed at birth. In adults, its average volume is about 2 ml.
• Mucosal Continuity: The mucous membrane lining the mastoid air cells is continuous with the mucous membrane throughout the entire middle ear cleft. Therefore, infections in the middle ear can easily spread into the mastoid area. 

Boundaries of the Mastoid Antrum

Boundaries of Mastoid Antrum

• Roof: It is formed by a thin layer of bone called the tegmen antri, which separates the mastoid antrum from the middle cranial fossa, where the brain’s temporal lobe resides. If an infection in the middle ear cleft breaches this thin wall, it can travel to the brain. This can result in serious complications such as extradural abscess, meningitis and temporal lobe abscess.
• Lateral wall: The lateral wall of the antrum is formed by a plate of bone, which is on average 1.5 cm thick in the adult. It is marked externally on the surface of the mastoid by the suprameatal (MacEwen’s) triangle. It is covered by postaural skin. 
• Medial wall: It is formed by the petrous bone and related to the Posterior semicircular canal, Endolymphatic sac and Dura of the posterior cranial fossa
• Anterior: Anteriorly, the mastoid antrum communicates with the attic through the aditus ad antrum.
• Posterior wall: It is primarily formed by the mastoid bone and has an important role in connecting the middle ear to the mastoid air cells. The posterior wall separates the mastoid antrum from the sigmoid sinus, a major venous channel that drains blood from the brain. If an infection in the middle ear cleft spreads and breaches the posterior wall, it can extend to the sigmoid sinus. This can lead to a severe condition known as sigmoid sinus thrombophlebitis. In this condition, the drainage of blood from the central nervous system becomes impaired, and infection may spread further into the cerebellum or the brainstem, leading to life-threatening issues.
• Floor: It is formed by the mastoid bone and communicates with the mastoid air cells.

2. MacEwen’s Triangle (Suprameatal Triangle)

MacEwen’s triangle is an important external landmark for the mastoid antrum. You can define its boundaries:

• Superiorly: The linea temporalis (temporal line), a ridge of bone extending posteriorly from the zygomatic process, which marks the lower border of the temporalis muscle and approximates the floor of the middle cranial fossa.
• Anteriorly: The posterosuperior margin of the external auditory canal (EAC).
• Posteriorly: A tangent to the posterior margin of the EAC.

Boundaries of Macewen’s triangle

3. Pneumatization of the Mastoid Air Cell System

The mastoid process itself contains a “honeycomb” of air cells beneath its bony cortex. The extent of this pneumatization varies significantly among individuals.

Types of Mastoid Pneumatization:

• Well-pneumatized (Cellular): Characterised by well-developed air cells with thin intervening bony septa. This is the most common type.
• Diploetic: Contains marrow spaces and only a few scattered air cells.
• Sclerotic (Acellular): Lacks both air cells and marrow spaces, appearing as dense bone. This type is often associated with chronic mastoid infections.

Regardless of the pneumatization type, the mastoid antrum is always present. In sclerotic mastoids, the antrum is usually small, and the sigmoid sinus may be anteposed (positioned more anteriorly), increasing surgical risk. Abscesses can form in relation to these air cells, sometimes far from the main mastoid region.

4. Classification of Mastoid Air Cells by Location

Mastoid air cells are named based on their anatomical location:

• Zygomatic cells are present in the root of zygoma.
• Tegmen cells are present in the tegmen tympani.
• Perisinus cells are present in the the sinus plate.
• Retrofacial cells are present around the facial nerve.
• Perilabyrinthine cells are present above, below and behind the labyrinth.
• Peritubal are present around the eustachian tube.
• Tip cells are present medial and lateral to the digastric ridge in the tip of mastoid.
• Marginal cells are present behind the sinus plate and may extend into the occipital bone.
• Squamosal cells are present in the squamous part of temporal bones.

5. Korner’s Septum (Petrosquamosal Suture)

The squamous and petrous parts of the temporal bone together form the mastoid.

• Description: In some individuals, the petrosquamosal suture persists as a distinct bony plate known as Korner’s septum. This septum separates superficial squamosal cells from deeper petrosal cells.
• Surgical Importance: Korner’s septum causes difficulty in locating the antrum and the deeper cells. Removal of Korner’s septum is a must in order to reach the mastoid antrum during surgery. Otherwise, it will lead to incomplete removal of the disease at mastoidectomy.

Diagram Showing Korner’s Septum

Middle Ear Cleft Mucosa

The middle ear mucosa is essentially mucus-secreting respiratory mucosa bearing cilia on its surface. Mucosa of the nasopharynx is continuous with that of the middle ear cleft. The mucosa wraps ossicles, muscles, ligaments and nerves in a similar way as peritoneum wraps various viscera in the abdomen, raising several mucosal folds and dividing the middle ear into various compartments. So, all the middle ear structures lie outside the mucous membrane. The middle ear contains nothing but air; all the structures lie outside the mucous membrane. The mucous membrane of the nasopharynx is continuous with that of the middle ear cleft.

Histologically, the eustachian tube is lined by ciliated epithelium, which is pseudostratified columnar in the cartilaginous part, columnar in the bony part, with several mucous glands in the submucosa. The tympanic cavity is lined by ciliated columnar epithelium in its anterior and inferior part, which changes to cuboidal type in the posterior part. Epitympanum and mastoid air cells are lined by flat, non-ciliated epithelium.

Compartments and Folds of the Middle Ear

Ossicles and their mucosal folds separate mesotympanum from epitympanum (attic).

1.	Compartments of Epitympanum	a. Prussak’s space: Its boundaries, which limit the spread of infection to other compartments, are following: – Lateral: Pars flaccida – Medial: Neck of malleus – Floor: Lateral process of malleus – Roof: Ligament arising from neck of malleus
		b. Attic compartments: Cog divides the attic into two compartments – a smaller anterior epitympanum and a larger posterior epitympanum. The space between the lateral malleolar fold and the lateral incudal fold provides communication with Prussak’s space.
2.	Compartments of Mesotympanum	Inferior incudal space: Its boundaries are following – Superior: Lateral incudal fold – Medial: Medial incudal fold – Lateral: Posterior malleolar fold – Anterior: Interossicular fold
		Anterior pouch of von Troeltsch: It lies between the following boundaries:  – Medial: Anterior malleolar fold – Lateral: Portion of the tympanic membrane anterior to the handle of malleus
		Posterior pouch of von Troeltsch: It is situated between the following boundaries: – Medial: Posterior malleolar fold – Lateral: Portion of the tympanic membrane posterior to the handle of malleus.

Blood Supply of Middle Ear

The middle ear is supplied by eight arteries, out of which two are the main, i.e.

1. Anterior tympanic branch of maxillary artery, which supplies the tympanic membrane, malleus, incus and anterior part of tympanic cavity.
2. Stylomastoid branch of the posterior auricular artery, which supplies the stapedius muscle and the posterior part of tympanic cavity.

Six minor vessels are:

1. Mastoid branch of stylomastoid artery which supplies mastoid air cells.
2. Petrosal branch of middle meningeal artery (runs along greater petrosal nerve) which supplies the roof of mastoid and epitympanum.
3. Superior tympanic branch of middle meningeal artery which supplies the canal for tensor tympani muscle, malleus and incus.
4. Inferior tympanic branch of ascending pharyngeal artery which supplies the mesotympanum.
5. Branch of artery of pterygoid canal (runs along eustachian tube) which supplies the mesotympanum and hypotympanum
6. Tympanic branch of internal carotid which supplies the mesotympanum and hypotympanum

Branch	Parent artery	Region supplied
Anterior tympanic	Maxillary artery	Tympanic membrane Malleus and incus Anterior part of tympanic cavity
Stylomastoid	Posterior auricular	Posterior part of tympanic cavity Stapedius muscle
Mastoid	Stylomastoid	Mastoid air cells
Petrosal	Middle meningeal	Roof of mastoid Roof of epitympanum
Superior tympanic	Middle meningeal	Malleus and incus Tensor tympani
Inferior tympanic	Ascending pharyngeal	Mesotympanum
Branch from artery	Artery of pterygoid canal	Meso- and hypotympanum
Tympanic arches	Internal carotid	Meso- and hypotympanum

Veins drain into pterygoid venous plexus and superior petrosal sinus.

Lymphatic Drainage of the Middle Ear

The lymphatics of the middle ear drain into the retropharyngeal and parotid nodes. Eustachian tube lymphatics drain into the retropharyngeal group of lymph nodes. The internal ear has no lymphatics.

Anatomy of the Auditory Tube.

Click on the link: https://www.entlecture.com/eustachian-tube-anatomy/

———— End of the chapter ————

High-Yield Points for NEET PG and University Exams

• Middle ear is part of the middle ear cleft extending from Eustachian tube to mastoid air cells.
• Middle ear is divided into epitympanum, mesotympanum, hypotympanum.
• The tegmen tympani separates middle ear from temporal lobe and is a route for intracranial spread.
• The jugular bulb lies beneath the floor and may be dehiscent.
• The carotid wall separates middle ear from internal carotid artery and contains openings for ET and tensor tympani.
• The posterior wall contains pyramid, facial nerve canal, facial recess, and leads to mastoid via aditus.
• Scutum erosion is typical of attic cholesteatoma.
• The medial wall contains promontory, oval window, round window, facial nerve canal, lateral SCC bulge.
• Sinus tympani is a common site for cholesteatoma remnants.
• Ossicles transmit sound: TM → malleus → incus → stapes → oval window.
• Stapedius is supplied by CN VII, tensor tympani by V3.
• Chorda tympani carries taste anterior 2/3 tongue and crosses handle of malleus.
• Tympanic plexus gives rise to lesser petrosal nerve → otic ganglion → parotid secretomotor pathway.
• Mastoid antrum is present at birth and communicates with attic via aditus.
• Korner’s septum may cause incomplete mastoidectomy.

MCQs

• Q1. A 10-year-old boy presents with a 2-month history of ear discharge and hearing loss. HRCT temporal bone reveals scutum erosion and a soft tissue mass in the attic. Which compartment is most likely involved? A. Hypotympanum B. Epitympanum C. Mesotympanum D. Protympanum
• Q2. During middle ear surgery for cholesteatoma, a surgeon carefully inspects the anterior epitympanum. What structure divides the attic into anterior and posterior compartments? A. Promontory B. Ponticulus C. Cog D. Processus cochleariformis
• Q3. A child presents with congenital dehiscence of the floor of the middle ear, exposing the jugular bulb. Which wall of middle ear is deficient? A. Roof (tegmental wall) B. Floor (jugular wall) C. Anterior wall (carotid wall) D. Medial wall (labyrinthine wall)
• Q4. The nerve that enters through the floor of the middle ear is: A. Chorda tympani B. Facial nerve C. Jacobson’s nerve D. Lesser petrosal nerve
• Q5. A cochlear implant surgeon accesses the middle ear through facial recess approach. The facial recess is bounded: A. Laterally by facial nerve, medially by chorda tympani B. Medially by facial nerve, laterally by chorda tympani C. Superiorly by oval window, inferiorly by pyramid D. Superiorly by eustachian tube, inferiorly by promontory
• Q6. A patient has taste disturbances and dry mouth following middle ear surgery. The likely injured structure is: A. Jacobson’s nerve B. Lesser petrosal nerve C. Chorda tympani nerve D. Greater petrosal nerve
• Q7. The stapedius muscle originates from which bony projection of the posterior wall? A. Pyramid B. Ponticulus C. Subiculum D. Fossa incudis
• Q8. In a child with recurrent acute otitis media, infection can spread directly to the brain due to thin bone separating middle ear from cranial cavity. This bone is called: A. Tegmen tympani B. Scutum C. Promontory D. Processus cochleariformis
• Q9. In a HRCT scan of the mastoid, a large, well-developed mastoid antrum is seen communicating with attic via: A. Sinus tympani B. Aditus ad antrum C. Facial recess D. Round window niche
• Q10. Which of the following is the smallest ossicle? A. Malleus B. Incus C. Stapes D. Lenticular process

Answers : 1: B. 2: C. 3: B. 4: C. 5: B. 6: C. 7: A. 8: A. 9: B. 10: C.

Clinical Case Scenarios (Practical + Viva Oriented)

1. Case 1: A 14-year-old boy presents with foul-smelling ear discharge and attic retraction pocket. Otoscopy shows scutum erosion. Most likely diagnosis: Attic cholesteatoma. Most likely site involved: Epitympanum (attic). Key surgical concern: Residual disease in sinus tympani and anterior epitympanic space.

2. Case 2: A 35-year-old patient undergoing tympanoplasty develops postoperative altered taste sensation. Most likely nerve injured: Chorda tympani. Function affected: Taste from the anterior two-thirds of the tongue.

3. Case 3: A patient with chronic otitis media develops facial weakness. HRCT shows a bony canal defect. Most likely explanation: Dehiscent fallopian canal with facial nerve exposure. Most vulnerable site: Posterior wall region.

4. Case 4: During middle ear surgery, profuse bleeding occurs from the floor of the middle ear. Most likely structure injured: High jugular bulb. Reason: Congenital dehiscence of the jugular wall.

FAQ in Viva

• Why is the tegmen tympani clinically important? It is thin, and infection can spread to the brain, causing meningitis or an abscess.
• What is the scutum? The scutum is the bony lateral wall of the attic, commonly eroded in cholesteatoma.
• What is Prussak’s space? It is a small epitympanic space bounded by the pars flaccida and the malleus neck and is important in cholesteatoma spread.
• What is sinus tympani? It is a deep recess in the posterior medial wall and is a common site for residual cholesteatoma.
• Which nerve carries taste through the middle ear? Chorda tympani carries taste from the anterior two-thirds of the tongue.
• Which muscle protects against loud sounds? Stapedius contracts during loud sounds and reduces stapes movement.

———— End ————

Download full PDF Link:

Anatomy of Middle Ear Walls Best Lecture Notes Dr Rahul Bagla ENT Textbook

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Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Glasscock-Shambaugh, Textbook of Surgery of the Ear.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Salah Mansour, Middle Ear Diseases – Advances in Diagnosis and Management.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Rob and smith, Textbook of Operative surgery.
• Anirban Biswas, Textbook of Clinical Audio-vestibulometry.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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