Anatomy, Head and Neck, Ear Tympanic Membrane


Article Author:
Alice Szymanski
Joseph Toth


Article Editor:
Zachary Geiger


Editors In Chief:
Jasleen Jhajj
Cliff Caudill


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
8/22/2019 3:22:18 PM

Introduction

The tympanic membrane (eardrum, myringa) is a thin, ovoid structure that separates the outer from the middle ear.[1][2]

Structure and Function

This structure has a role in sound transmission and amplification. Similar to the membrane on a drum, the tympanic membrane vibrates as it encounters sound. It then transmits these vibrations to the ossicles of the middle ear to be further passed on to the cochlea of the inner ear for transduction.

Embryology

The tympanic membrane is derived from the invagination and meeting of the one pharyngeal groove with the one pharyngeal pouch, and as such, it is comprised of all three germ layers (ectoderm, mesoderm, endoderm). The lateral (external) epithelium is ectodermal in origin and is formed from canalization of an ectodermal plug involved in the formation of the external auditory meatus in the first pharyngeal groove. The medial aspect of the tympanic membrane is a continuation of the lining of the inner ear, which is endodermal in origin from the one pharyngeal pouch. The fibrous middle layer is mesodermal, of neural crest origin, and encases both the handle of the malleus and chorda tympani, of the same origin. The chorda tympani is the pre-trematic (coursing in the caudal aspect of the pharyngeal groove) nerve of the one pharyngeal arch, while the mandibular nerve is the post-trematic nerve of the one pharyngeal arch.

Blood Supply and Lymphatics

The lateral side of the tympanic membrane is supplied by the deep auricular branch of the maxillary artery. The medial side is irrigated by the auricular branch of the occipital artery and the anterior tympanic artery off the maxillary artery.

Nerves

The lateral surface of the tympanic membrane receives sensory innervation from the auriculotemporal branch of the mandibular nerve, a branch of the trigeminal nerve (V3), the auricular branch of the facial nerve (CN VII), the auricular branch of the vagus nerve (CN X), and the glossopharyngeal nerve (CN IX). The medial surface of the tympanic membrane receives sensory innervation from the tympanic branch of the glossopharyngeal nerve (CN IX).[3]

Muscles

There are no direct muscle attachments to the tympanic membrane. However, the tensor tympani muscle can pull the malleus inward to increase the tension across the tympanic membrane, effectively stiffening it. This involuntary activity is part of the acoustic reflex, which protects the tympanic membrane and the cochlear apparatus from acoustic, vibrational trauma precipitated by very loud sounds including the sounds of chewing and talking. The stapedius muscle completes this reflex by retracting the stapes from the oval window to avoid damaging the cochlea with high-amplitude vibrations. The acoustic reflex requires approximately 40 milliseconds to take effect. Thus it is ineffective against very sudden loud sounds, for example, a gunshot.[4][5]

Surgical Considerations

Surface and Landmarks

The tympanic membrane is anchored circumferentially to the walls of the auditory canal in a slanted, posterosuperior to anteroinferior orientation. The handle (manubrium) of the malleus ossicle is embedded in the tympanic membrane and can be visualized as a ray. The tympanic membrane is ovoid in shape, conical in configuration, and comprised of two parts: the pars tensa antero-inferiorly and the pars flaccida superior posteriorly. The pars tensa is the sturdier of the two. Its fibrous framework is thickened at the edges to form an annulus, and it is covered by skin laterally (the external side) and mucosa medially (internal side). The pars tensa is under tension by a medial pull from the handle of the malleus at a central point of maximum depression called the umbo. The pars flaccida constitutes a small portion above the lateral process of the handle of the malleus and is delicate because it is devoid of a fibrous layer. When light is directed at the tympanic membrane during an otoscopic examination, a characteristic feature to be observed is the anterior cone of light, which radiates antero-inferiorly from the umbo. The tympanic membrane should be pearly-grey in color, translucent, shiny, and mobile on insufflation.

Clinical Significance

Rupture of the tympanic membrane may be caused by head trauma, loud blasts of sound, direct membrane trauma, barotrauma, and infection. The acoustic reflex provides some protection from loud sounds. Q-tips only should be used to clean the external ear and should not be inserted into the external auditory canal. Fliers and divers may avoid barotrauma by equalizing the pressure across the tympanic membrane. Equalization is done by allowing air entry into the Eustachian tube, which connects the middle ear to the nasopharynx; techniques include performing a Valsalva maneuver with pinched nostrils, yawning, and swallowing. In the case of tympanic membrane rupture, patients may complain of pain and bloody effusion from the external auditory canal and may experience some conductive hearing loss and tinnitus. If no infection persists, the damaged tympanic membrane heals on its own. Patients should be advised to minimize water entry into the ear while the membrane is perforated to avoid injury to middle ear structures. Interestingly, intentional rupture of the tympanic membrane has been found to have been a typical practice among aquatic hunters of the Bajau people in the Southeast Asian Pacific. This would have been done to allow diving to great depths as part of their hunts. As a result, many of these hunters experience hearing impairment.[1]

Otitis media is a middle ear infection, which can cause an accumulation of pus behind the tympanic membrane. This may lead to pain or discomfort. Otoscopic examination typically reveals an erythematous and bulging tympanic membrane with obscured surface landmarks from distortion, possibly with a fluid layer or pus behind it. Recurrent otitis media infections may warrant tympanostomy tube placement to facilitate the drainage of pus and equalize the pressure across the tympanic membrane. The tympanostomy tubes are left in place for several months and are either removed later or fall out on their own.[6]

Cholesteatoma is keratinization of squamous epithelium, often associated with the pars flaccida in the posterior and superior portion of the tympanic membrane. It is a destructive lesion that tends to expand, and it can engulf the ossicles and even erode the skull. Cholesteatoma must be fully excised to prevent further growth. Deafness, vertigo, abscess, and septicemia may result if left untreated.[7]


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Anatomy, Head and Neck, Ear Tympanic Membrane - Questions

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A 65-year-old male with a past medical history of allergic rhinitis, diabetes mellitus, and hypertension presents for evaluation of hearing loss. He states that over the past ten years, he has noticed a dramatic decline in his hearing, especially on the left side. The patient denies any otorrhea, vertigo, or gait alterations. He does report more difficulty engaging in conversations in loud settings and occasional tinnitus. He does not take any aspirin or diuretics. He is in a monogamous relationship and drinks socially. The patient denies any history of smoking but reports a history of frequenting loud concerts. On physical exam, his vital signs are stable, including his blood pressure and heart rate. During otoscopy, which ossicular component illustrates the most inferior aspect of an ossicle visualized on physical exam?



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A 6-year-old female with recurrent bouts of acute otitis media with effusion presents for evaluation. Her mother states that the episodes of ear infection are often more common in the winter but have been occurring more frequently. She reports at least six ear infections in the past year. The patient has no history of craniofacial abnormalities. Her mother has a history of ear infection, as does her sister. Her mother also states she is worried her daughter is having difficulty excelling in school due to some challenges with hearing. She says during her episodes of otitis media she has some purulent ear drainage, auricular pain, fever, irritation, and fatigue. She is requesting a solution to her daughter’s chronic infections. The child has no other pertinent medical history and has no allergies. On physical exam, the patient’s tympanic membranes are erythematous but without drainage or perforations. A decision is made for surgical intervention. During the placement of a tympanostomy tube for her chronic ear infections, which of the following would be affected first?

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A 65-year-old female with a past medical history of myocardial infarction, hypertension, and hypercholesterolemia presents for evaluation of altered mental status in the emergency department. Her daughter states the patient began to hallucinate and was having some difficulty with walking. She thinks her mother may have forgotten to take her medication for the past week. The patient is currently taking atenolol, aspirin, and atorvastatin. She has no allergies and admits to a 50-pack-year history of smoking tobacco. She drinks one alcoholic beverage per night and has been doing so since she was 22. The patient denies any chest pain, dyspnea, numbness, or tingling, but reports some weakness with walking. She can engage in an entire conversation without difficulty. On physical exam, there are no frank neurological deficits, but she does report some metallic taste in her mouth. A CT scan is obtained without evidence of a cerebral vascular accident. The patient is stable and discharged home with the diagnosis of a transient ischemic attack. Which cranial nerve would lead to an altered sensory supply to the medial surface of the tympanic membrane if its associated spinal nucleus of the trigeminal nerve were injured due to compromised blood supply?



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The patient is a 7-year-old female with a past medical history of Treacher-Collins syndrome who presents for evaluation of chronic right ear drainage. Her mother states she has also had some foul-smelling cerumen that has begun to accumulate. She reports some history of ear infections since she was a child in both ears with a predisposition for the right ear, especially. Her mother thinks the child’s hearing has also begun to decline. She takes no medications but has been treated with Amoxicillin in the past. She has no allergies. Her father does smoke in the home. The patient’s vital signs are stable. On physical exam, there is a possible retraction pocket in the right ear with some associated erythema and bulging of the tympanic membrane. A diagnosis of cholesteatoma with superimposed acute otitis media is made. The most likely region of the tympanic membrane affected by the cholesteatoma lacks which embryological layer?



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A 34-year-old male presents for the evaluation of hearing loss. The patient reports he had a sudden loss of hearing when he was out playing with a BB gun. He states he forgot to wear his hearing protection. The patient has a history of attention deficit hyperactivity disorder (ADHD) and generalized anxiety disorder. He had a recent episode of otitis media and was treated with a cephalosporin. The patient takes sertraline and atomoxetine. He has no known allergies. The patient has a past surgical history of an appendectomy, meniscus repair, tympanostomy tubes, tonsillectomy, and adenoidectomy. His mother is deaf, and his father wears hearing aids. The patient denies any otorrhea but admits to some vertigo and tinnitus. On physical exam, his vital signs are stable, but he is slightly tachycardic. His otoscopic review reveals no bulging of the tympanic membranes bilaterally, and they appear gray. Which muscle functions to pull the malleus inward during the acoustic reflex?



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A 14-month-old male child with a past medical history of eczema presents to the clinician for evaluation of a fever. His mother states he was born full-term via a normal vaginal delivery without complications, was breastfed and is now undergoing a change to formula feeding. He has seasonal allergies but takes no medications. There is no smoking in the home nor a history of intubations. His mother reports that the child has had a fever for the past few days, which has responded to alternating regimens of Ibuprofen and Acetaminophen. The mother also reveals that she has noticed the child tugging his right ear and some right ear discharge. Otherwise, she denies any changes in the child’s oral intake, vomiting, diarrhea, cough, or rhinorrhea. On physical examination, the left ear is unremarkable, but the right tympanic membrane is red and bulging with hypomobility on pneumatic otoscope. What is the underlying etiology for this child’s ear infection?

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A 22-year-old woman presents to the clinic to inquire about recommended vaccinations for an upcoming trip to South Africa with her fiance in 3 months. She confides that it will be her first time aboard an airplane. The patient is apprehensive about the effects of pressure changes on her ears while flying. She recalls experiencing 2 painful ear infections in childhood. She denies any cough, rhinorrhea, or nasal congestion. On otoscopic examination, the tympanic membranes are pearly gray, translucent, and intact bilaterally. There is no wax or erythema in the external auditory canal. The patient would like to learn how to equalize the pressure across her tympanic membranes. Which of the following techniques would not be effective?



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A 5-year-old girl is brought to the physician by her mother to address her teacher’s complaint of inattentiveness at school. The child was born at term and has had no past medical problems. The girl is very talkative, enunciates well, and vividly describes her classroom, where she sits off to the side near a window. She has many friends with whom she plays at recess and received A's and B's on her first-semester report card. The mother relates that the child participates during lessons, but the teacher is concerned that her daughter does not respond when her name is called during the quiet writing period. On physical exam, the child is well-developed and vital signs are within normal limits. Otoscopic examination reveals a unilateral destructive growth engulfing the tympanic membrane. The mother is appropriately counseled and informed that treatment requires surgery to prevent further growth. What is the presumed diagnosis?



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A 33-year-old man with a past medical history of obsessive-compulsive disorder presents to the clinic for an annual check-up. He generally feels well but complains of “getting old” as for the past couple of weeks, food has tasted bland, and his hearing has been muffled first in the left ear, now in both ears. He completed a course of cognitive-behavioral therapy eight months ago but, admits to having resumed some of his compulsive behaviors two months ago. He describes washing his hands 30 times daily with soap and water, chewing food ten times on each side before swallowing, cleaning his ears every morning and night by twisting the Q-tip 7 times inward, and blowing his nose three times daily, at dawn, noon, and dusk. On physical examination, the patient is a thin but well-developed male with dry and cracking skin on his hands. Oral examination reveals a full set of teeth without caries. His tongue appears to have a full range of motion and is devoid of excoriations, lesions, or white coating. The patient categorically refuses otoscopic examination because of “germs” on the otoscope, despite reassurance and emphasis on its importance. Weber test is non-lateralizing, while Rinne test is negative bilaterally. The rest of his examination is within normal limits. What is most likely causing this patient’s complaints?



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Anatomy, Head and Neck, Ear Tympanic Membrane - References

References

ONeill OJ,Frank AJ, Ear Barotrauma 2019 Jan;     [PubMed]
Searight FT,Singh R,Peterson DC, Otitis Media With Effusion 2019 Jan;     [PubMed]
Widemar L,Hellström S,Schultzberg M,Stenfors LE, Autonomic innervation of the tympanic membrane. An immunocytochemical and histofluorescence study. Acta oto-laryngologica. 1985 Jul-Aug;     [PubMed]
Oktay MF,Tansuker HD,Fukushima H,Paparella MM,Schachern PA,Cureoglu S, Histopathology of tympanic membranes from patients with ventilation tubes. Auris, nasus, larynx. 2018 Jun;     [PubMed]
Mizutari K, Blast-induced hearing loss. Journal of Zhejiang University. Science. B. 2019 Feb.;     [PubMed]
Dimitrov L,Jan A,Bhimji SS, Pediatric Hearing Loss 2019 Jan;     [PubMed]
Misale P,Lepcha A, Congenital Cholesteatoma in Adults-Interesting Presentations and Management. Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India. 2018 Dec;     [PubMed]

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