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UnitedVRG - Tahir99
 SATALOFF'S COMPREHENSIVE
TEXTBOOK OF OTOLARYNGOLOGY
HEAD AND NECK SURGERY
Series Editor: Robert T Sataloff MD DMA FACS

OTOLOGY/NEUROTOLOGY/
SKULL BASE SURGERY

UnitedVRG - Tahir99
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 UnitedVRG - Tahir99
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 SATALOFF'S COMPREHENSIVE
TEXTBOOK OF OTOLARYNGOLOGY
HEAD AND NECK SURGERY
Series Editor: Robert T Sataloff MD DMA FACS

OTOLOGY/NEUROTOLOGY/
SKULL BASE SURGERY
Vol. 1

Volume Editor
Anil K Lalwani MD
Professor and Vice Chair for Research
Director, Division of Otology, Neurotology and Skull Base Surgery
Director, Columbia Cochlear Implant Program
Department of Otolaryngology—Head and Neck Surgery
Columbia University College of Physicians and Surgeons
New York, New York, USA

The Health Sciences Publisher

New Delhi | London | Philadelphia | Panama

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 Jaypee Brothers Medical Publishers (P) Ltd

Headquarters
Jaypee Brothers Medical Publishers (P) Ltd.
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
E-mail: [email protected]

Overseas Offices Jaypee-Highlights Medical Publishers Inc.

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Jaypee Medical Inc. Jaypee Brothers Medical Publishers (P) Ltd.

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111 South Independence Mall East Mohammadpur, Dhaka-1207
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E-mail: [email protected] E-mail: [email protected]

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E-mail: [email protected]

Website: www.jaypeebrothers.com
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© 2016, Jaypee Brothers Medical Publishers
The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those
of editor(s) of the book.
All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording or otherwise, without the prior permission in writing of the publishers.
­
All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective
owners. The publisher is not associated with any product or vendor mentioned in this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter
in question. However, readers are advised to check the most current information available on procedures included and check information from
the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse
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Inquiries for bulk sales may be solicited at: [email protected]

Sataloff’s Comprehensive Textbook of Otolaryngology: Head and Neck Surgery: Otology/Neurotology/Skull Base Surgery (Vol. 1)

First Edition: 2016

ISBN: 978-93-5152-455-7
Printed at

UnitedVRG - Tahir99
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 Contributors

Robert A Adamson MD Gregory J Basura MD Kevin D Brown MD PhD

Assistant Professor Assistant Professor Associate Professor
School of Biomedical Engineering Department of Otolaryngology— Department of Otolaryngology—
Dalhousie University Head and Neck Surgery Head and Neck Surgery
Halifax, Nova Scotia, Canada Kresge Hearing Research Institute University of North Carolina at Chapel
Ann Arbor, Michigan, USA Hill School of Medicine
Sumit K Agrawal MD FRCSC Chapel Hill, North Carolina, USA
Associate Professor Carol Bauer MD
Department of Otolaryngology— Professor/Chair Roxanne Cano MD
Head and Neck Surgery Department of Surgery University of Texas Medical School
Western University Division of Otolaryngology Houston, Texas, USA
London, Ontario, Canada Southern Illinois University
School of Medicine Divya Chari MD
Yuri Agrawal MD Springfield, Illinois, USA Resident
Assistant Professor University of California, San Francisco
Department of Otolaryngology— Joan M Besing PhD CCC-A San Francisco, California, USA
Head and Neck Surgery Professor
Johns Hopkins University Department of Communication Daniel H Coelho MD FACS
School of Medicine Sciences and Disorders G Douglas Hayden Associate Professor
Baltimore, Maryland, USA Department of Otolaryngology—
Montclair State University
Head and Neck Surgery
Montclair, New Jersey, USA
Art Ambrosio MD Virginia Commonwealth
Head and Neck Surgeon at Marine Corps Jason A Beyea MD PhD FRCSC School of Medicine
Base Camp Lejeune Fellow Richmond, Virginia, USA
Jacksonville, North Carolina, USA Department of Otolaryngology—
C Eduardo Corrales MD
Head and Neck Surgery
Simon I Angeli MD Brigham and Women’s Instructor
The Ohio State University
Professor Associate Surgeon
Columbus, Ohio, USA
Department of Otolaryngology Department of Surgery
University of Miami Harvard Medical School
Dennis I Bojrab MD
Miami, Florida, USA Assistant Professor
CEO and Director of Research
Department of Otolaryngology
Maris Appelbaum AuD Michigan Ear Institute
Massachusetts Eye and Ear Infirmary
Clinical Preceptor Director of Skull Base Surgery
Harvard Medical School
Department of Communication Providence Hospital and
Boston, Massachusetts, USA
Sciences and Disorders Medical Centers
Montclair State University Clinical Professor Maura K Cosetti MD
Montclair, New Jersey, USA Wayne State University Assistant Professor
Farmington Hills, Michigan, USA Departments of Otolaryngology—
H Alexander Arts MD FACS Head and Neck Surgery and
Professor of Otolaryngology Derald E Brackmann MD Neurosurgery
University of Michigan Clinical Professor of Otolaryngology— Louisiana State University
Ann Arbor, Michigan, USA Head and Neck Surgery and Health Sciences Center—Shreveport
Neurological Surgery Shreveport, Louisiana, USA
Manohar Bance MB MSc FRCSC University of Southern California
Professor and Head School of Medicine Ryan A Crane MD
Division of Otolaryngology— Associate Resident Physician
Head and Neck Surgery House Ear Clinic Department of Otolaryngology—
Department of Surgery Board of Directors Head and Neck Surgery
Dalhousie University House Ear Institute University of Cincinnati Medical Center
Halifax, Nova Scotia, Canada Los Angeles, California, USA Cincinnati, Ohio, USA

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 vi Otology/Neurotology/Skull Base Surgery

Karen Jo Doyle MD PhD Selena E Heman-Ackah MD MBA Anil K Lalwani MD

Professor Director of Otology Professor and Vice Chair for Research
Otology and Neurotology Neurotology, and Audiology Director
University of California Division of Otolaryngology Division of Otology
Davis Health System Beth Israel Deaconess Medical Center Neurotology and Skull Base Surgery
Department of Otolaryngology Harvard Medical School Director
Sacramento, California, USA Boston, Massachusetts, USA Columbia Cochlear Implant Program
Department of Otolaryngology—
Robert W Eppsteiner MD Michael E Hoffer MD Head and Neck Surgery
University of Massachusetts Otolaryngology Columbia University College of
Medical School University of Miami Health System Physicians and Surgeons
Worcester, Massachusetts, USA Miami, Florida, USA New York, New York, USA

Deema Fattal MD Brandon Isaacson MD FACS Lawrence R Lustig MD

Associate Professor Associate Professor Howard W Smith Professor and Chair
Director of Balance Disorders Clinic Department of Otolaryngology— Department of Otolaryngology—
Department of Neurology Head and Neck Surgery Head and Neck Surgery
University of Iowa University of Texas— Columbia University
Iowa City, Iowa, USA Southwestern Medical Center Medical Center and New York
Dallas, Texas, USA Presbyterian Hospital
Alexander Filatov MD
New York, New York, USA
Department of Radiology Daniel Jethanamest MD
Stony Brook University Assistant Professor Dean M Mancuso AuD
Stony Brook, New York, USA Department of Otolaryngology
Assistant Professor of Audiology
New York University School of Medicine
Department of Otolaryngology—
Richard A Goldman MD New York, New York, USA
Head and Neck Surgery
Assistant Professor
Columbia University Medical Center
Department of Otolaryngology— Steven K Juhn MD
New York, New York, USA
Head and Neck Surgery Department of Otolaryngology—
University of Kentucky Head and Neck Surgery
Peter L Santa Maria MBBS PhD
College of Medicine University of Minnesota
Instructor
Lexington, Kentucky, USA Minneapolis, Minnesota, USA
Department of Otolaryngology—
Sachin Gupta MD Robert W Jyung MD Head and Neck Surgery
Neurotology Fellow Associate Professor Stanford University
Department of Otolaryngology— Department of Otolaryngology— Stanford, California, USA
Head and Neck Surgery, University of Head and Neck Surgery
Texas—Southwestern Medical Center Rutgers New Jersey Medical School Adam N Master MD
Dallas, Texas, USA Newark, New Jersey, USA Resident Physician
Department of Otolaryngology—
Mari Hagiwara MD Ruwan Kiringoda MD Head and Neck Surgery
Assistant Professor Resident Physician Louisiana State University
Department of Radiology Otolaryngology—Head and Neck Surgery Health Science Center Shreveport
New York University, School of Medicine University of California, San Francisco Shreveport, Louisiana, USA
New York, New York, USA San Francisco, California, USA
Michael J McKenna MD
Marlan R Hansen MD FACS Ilkka Kivekäs MD PhD Director
Professor Assistant Professor in Otolaryngology Division of Otology and Neurotology
Departments of Otolaryngology— Tampere University Hospital and Massachusetts Eye and Ear
Head and Neck Surgery and the University of Tampere Boston, Massachusetts, USA
Neurosurgery, University of Iowa Tampere, Finland
Iowa City, Iowa, USA Sean O McMenomey MD
Janet Koehnke PhD Professor of Otolaryngology and
Mary J Hawkshaw BSN RN CORLN Professor and Chair Neurosurgery—Vice Chair
Research Associate Professor Department of Communication Department of Otolaryngology
Department of Otolaryngology Sciences and Disorders New York University
Drexel College of Medicine Montclair State University Langone Medical Center
Philadelphia, Pennsylvania, USA Montclair, New Jersey, USA New York, New York, USA

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 Contributors vii
Cliff A Megerian MD FACS John S Oghalai MD David A Schessel PhD MD
Julius W McCall Associate Professor Associate Professor
Professor and Chairman Department of Otolaryngology— Department of Surgery
Otolaryngology—Head and Neck Surgery Head and Neck Surgery Stony Brook University
Case Western Reserve University Stanford University Stony Brook, New York, USA
School of Medicine Stanford, California, USA
Richard W and Patricia R Marc S Schwartz MD
Pogue Endowed Chair Steven R Otto Neurological Surgery
Director Ear, Nose and Throat Institute Chief Audiologist and Coordinator House Ear Clinic
University Hospitals Case Medical Center Auditory Brainstem Implant Los Angeles, California, USA
Cleveland, Ohio, USA Program House Clinic
Los Angeles, California, USA Samuel H Selesnick MD FACS
Myles Melton Professor and Vice-Chairman
Medical Student Lorne S Parnes MD FRCSC Department of Otolaryngology—
Weill Cornell Medical College Professor Head and Neck Surgery
New York, New York, USA Departments of Otolaryngology— Weill Cornell Medical College
Head and Neck Surgery and New York, New York, USA
Ted A Meyer MD PhD Clinical Neurological Sciences
Associate Professor Western University Maroun T Semaan MD
Department of Otolaryngology— London, Ontario, Canada Associate Professor
Head and Neck Surgery Ear Nose and Throat Institute
Medical University of South Carolina Dennis Poe MD PhD
University Hospitals
Charleston, South Carolina, USA Associate Professor in Otolaryngology
Case Medical Center
Boston Children’s Hospital
Case Western Reserve University
Alan G Micco MD FACS Boston, Massachusetts, USA
Cleveland, Ohio, USA
Associate Professor
Department of Otolaryngology Alicia M Quesnel MD
J Caleb Simmons MD
Northwestern University Instructor
Baylor College of Medicine
Feinberg School of Medicine Department of Otology and Laryngology
Houston, Texas, USA
Chicago, Illinois, USA Harvard Medical School
Attending Surgeon
Eric E Smouha MD
Faith M Mogila ScD Department of Otolaryngology
Associate Professor
Clinical Preceptor Massachusetts Eye and Ear Infirmary
Department of Otolaryngology—
Department of Communication Boston, Massachusetts, USA
Head and Neck Surgery
Sciences and Disorders
Habib Rizk MD Icahn School of Medicine at
Montclair State University
Montclair, New Jersey, USA Neurotology Fellow Mount Sinai
Otolaryngology Head and Neck Surgery New York, New York, USA
Joseph J Montano EdD Medical University of South Carolina
Associate Professor of Audiology Charleston, South Carolina, USA Jaclyn B Spitzer PhD
Department of Otolaryngology Professor
Weill Cornell Medical College Amy L Rutt DO Department of Otolaryngology—
New York, New York, USA Assistant Professor Head and Neck Surgery
Department of Otolaryngology— Columbia University
Marc-Elie Nader MD Head and Neck Surgery New York, New York, USA
Assistant Professor Mayo Clinic
Department of Otolaryngology Rochester, Minnesota, USA Shawn M Stevens MD
University of Montreal Resident Surgeon
Montreal, Quebec, Canada Robert T Sataloff MD Department of Otolaryngology—
Professor and Chairman Head and Neck Surgery
John K Niparko MD Department of Otolaryngology— Medical University of
Professor and Chair Head and Neck Surgery South Carolina
Department of Otolaryngology— Senior Associate Charleston, South Carolina, USA
Head and Neck Surgery Dean for Clinical
Keck School of Medicine of Academic Specialties Emily Z Stucken MD
University of Southern California Drexel University College of Medicine Michigan Ear Institute
Los Angeles, California, USA Philadelphia, Pennsylvania, USA Farmington, Hills, Michigan, USA

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 viii Otology/Neurotology/Skull Base Surgery

Daniel Q Sun MD Andrea Vambutas MD FACS Brent Wilkerson MD

Radiation Oncology Healthcare Professor of Otolaryngology and Resident
Towson, Maryland, USA Molecular Medicine Department of Otolaryngology
Hofstra North Shore— University of California
Maja Svrakic MD LIJ School of Medicine Davis Health System
Bellevue Hospital—Otolaryngology New Hyde Park, New York, USA Sacramento, California, USA
New York, New York, USA
Alejandro Vázquez MD Eric P Wilkinson MD
Alex D Sweeney MD Resident Surgeon and Partner, House Clinic
Department of Otolaryngology— Department of Otolaryngology— Los Angeles, California, USA
Head and Neck Surgery Head and Neck Surgery
Vanderbilt University Rutgers New Jersey Medical School Robert A Williamson MD
Nashville, Tennessee, USA Newark, New Jersey, USA Assistant Professor of Otolaryngology—
Head and Neck Surgery
Monica Tadros MD FACS Jeffrey T Vrabec MD Baylor College of Medicine
Assistant Professor of Otolaryngology— Professor of Otolaryngology— Houston, Texas, USA
Head and Neck Surgery Head and Neck Surgery
Director of Facial Plastic and Baylor College of Medicine Justin D Wilson AuD
Reconstructive Surgery Houston, Texas, USA Mayo Clinic Health System
Columbia University Medical Center LaCrosse, Wisconsin, USA
New York, New York, USA Cameron C Wick MD
Resident Qiu Zhong MD
Elizabeth H Toh MD FACS Department of Otolaryngology— Resident
Department of Otolaryngology— Head and Neck Surgery Department of Otolaryngology
Head and Neck Surgery Case Western Reserve University Northwestern University
Lahey Hospital and Medical Center School of Medicine Feinberg School of Medicine
Burlington, Massachusetts, USA Cleveland, Ohio, USA Chicago, Illinois, USA

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 Foreword
Sataloff’s Comprehensive Textbook of Otolaryngology: Head and Neck Surgery is a component of the most extensive
compilation of information in otolaryngology—head and neck surgery to date. The six volumes of the comprehensive
textbook are part of a 12-volume, encyclopedic compendium that also includes a six-volume set of detailed, extensively
illustrated atlases of otolaryngologic surgical techniques. The vision for the Comprehensive Textbook was realized with
the invaluable, expert collaboration of eight world-class volume editors. Chapter authors include many of the most
prominent otolaryngologists in the world, and coverage of each subspecialty is extensive, detailed and scholarly.
Anil K Lalwani, MD edited the volume on otology/neurotology/skull base surgery. Like all six of the volumes in
the Comprehensive Textbook, the otology/neurotology/skull base surgery volume is designed not only as part of the
multivolume book, but also to stand alone or in combination with the atlas of otological surgery. Dr Lalwani’s volume
covers anatomy and physiology of hearing and balance, temporal bone radiology, medical and surgical treatment of
common and rare disorders of the ear and related structures, occupational hearing loss, aural rehabilitation, cochlear
and brainstem implantation, disorders of the facial nerve, and other topics. Each chapter is not only replete with the
latest scientific information, but also accessible and practical for clinicians.
The rhinology/allergy and immunology volume by Marvin P Fried and Abtin Tabaee is the most elegant and
inclusive book on the topic to date. Drs Fried and Tabaee start with a history of rhinology beginning in ancient times.
The chapters on evolution of the nose and sinuses, embryology, sinonasal anatomy and physiology, and rhinological
assessment are exceptional. The volume includes discussions of virtually all sinonasal disorders and allergy, including
not only traditional medical and surgical therapy but also complementary and integrative medicine. The information is
state-of-the-art.
Anthony P Sclafani’s volume on facial plastic and reconstructive surgery is unique in its thoroughness and
practicality. The volume covers skin anatomy and physiology, principles of wound healing, physiology of grafts and
flaps, lasers in facial plastic surgery, aesthetic analysis of the face and other basic topics. There are extensive discussions
on essentially all problems and procedures in facial plastic and reconstructive surgery contributed by many of the most
respected experts in the field. The volume includes not only cosmetic and reconstructive surgery, but also information
on diagnosis and treatment of facial trauma.
The volume on laryngology edited by Dr Michael S Benninger incorporates the most current information on
virtually every aspect of laryngology. The authors constitute a who’s who of world experts in voice and swallowing. After
extensive and practical discussions of science and genetics, the volume reviews diagnosis and treatment (traditional
and complementary) of laryngological disorders. Chapters on laser physics and use, voice therapy, laryngeal dystonia,
cough, vocal aging and many other topics provide invaluable “pearls” for clinicians. The volume also includes extensive
discussion of surgery for airway disorders, office-based laryngeal surgery, laryngeal transplantation and other topics.
For the volume on head and neck surgery, Drs Patrick J Gullane and David P Goldstein have recruited an extra­
ordinary group of contributors who have compiled the latest information on molecular biology of head and neck cancer,
principles of radiation, immunobiology, medical oncology, common and rare head and neck malignancies, endocrine
neoplasms, lymphoma, deep neck space infections and other maladies. The surgical discussions are thorough and richly
illustrated, and they include definitive discussions of free flap surgery, facial transplantation and other subjects.
Dr Christopher J Hartnick’s vision for the volume on pediatric otolaryngology was expansive, elegantly scholarly
and invaluable clinically. The volume begins with information on embryology, anatomy, genetics, syndromes and other
complex topics. Dr Hartnick’s contributors include basic discussions of otolaryngologic examination in a pediatric
patient, imaging, hearing screening and aural rehabilitation, and diagnosis and treatment of diseases of the ear, nose,
larynx, oral cavity, neck and airway. Congenital, syndromic and acquired disorders are covered in detail, as are special,
particularly vexing problems such as chronic cough in pediatric patients, breathing and obstructive sleep apnea in
children, pediatric voice disorders, and many other subjects. This volume will be invaluable to any otolaryngologist who
treats children.

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 x Otology/Neurotology/Skull Base Surgery

All of us who have been involved with the creation of the six-volume Sataloff’s Comprehensive Textbook of
Otolaryngology: Head and Neck Surgery and its companion six-volume set of surgical atlases hope and believe that
our colleagues will find this new offering to be not only the most extensive and convenient compilation of information
in our field, but also the most clinically practical and up-to-date resource in otolaryngology. We are indebted to
Mr Jitendar P Vij (Group Chairman) and Mr Ankit Vij (Group President) of M/s Jaypee Brothers Medical Publishers (P)
Ltd., New Delhi, India, for their commitment to this project, and for their promise to keep this work available not only
online but also in print. We are indebted also to the many otolaryngologists who have contributed to this work not only
by editing volumes and writing chapters, but also by asking questions that inspired many of us to seek the answers found
on these pages. We also thank especially the great academic otolaryngologists who trained us and inspired us to spend
our nights, weekends and vacations writing chapters and books. We hope that our colleagues and their patients find
this book useful.

Robert T Sataloff MD DMA FACS

Professor and Chairman
Department of Otolaryngology—Head and Neck Surgery
Senior Associate Dean for Clinical Academic Specialties
Drexel University College of Medicine
Philadelphia, Pennsylvania, USA

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 Preface

Though a subspecialty within otolaryngology—head and neck surgery, otology/neurotology/skull base surgery is as
diverse as the field of medicine itself. And like medicine, it enthralls those who pursue it—whether as a generalist or a
specialist. This textbook endeavors to capture the dynamic nature of otology/neurotology/skull base surgery in its pages
while providing a broad foundation in its basic and clinical sciences. Written by experts, the chapters encompass the
basics such as anatomy and physiology of hearing loss, vestibular dysfunction, facial nerve disorders, and skull base
tumors. Radiology has its own chapter, and disease-specific imaging is reviewed in all relevant chapters. Building upon
the basics, cutting-edge topics such as cochlear implantation, auditory brainstem implants, and implantable hearing
aids are thoroughly covered in their own chapters. Ultimately, this textbook is distinguished by the expertise of its
contributors—all leaders in otology/neurotology/skull base surgery. It is the reader who will benefit from absorbing
their experience as articulated in this wonderful textbook.

Anil K Lalwani MD

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Prelims.indd 12 25-06-2015 12:31:59
 Acknowledgments

The editor would like to thank Joseph Rusko, Marco Ulloa, Carol Rogers Field, Bridget Meyer, Thomas Gibbons and the
rest of the Jaypee Brothers team. Without their perseverance and hard work, this volume would not have been possible.
Special thanks are offered to the authors, who have shared their expertise and experience in order to improve the care of
the otology/neurotology/skull base surgery patients.
I would also like to thank Mr Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President), Ms Chetna Malhotra
Vohra (Associate Director), Mr Umar Rashid (Development Editor) and Production team of Jaypee Brothers Medical
Publishers (P) Ltd., New Delhi, India.

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Prelims.indd 14 25-06-2015 12:31:59
 Contents
1. Anatomy and Physiology of the Auditory System 1
Peter L Santa Maria, John S Oghalai
2. Evaluation of Auditory Function 19
Janet Koehnke, Faith M Mogila, Maris Appelbaum, Joan Besing
3. Middle Ear Mechanics in Normal Hearing, in Diseased Ears, and in Hearing Reconstruction 37
Manohar Bance, Robert A Adamson
4. Anatomy and Physiology of the Vestibular System 57
Daniel Q Sun, Yuri Agrawal
5. Evaluation of Vestibular Disorders 75
Justin D Wilson, Art Ambrosio, Roxanne Cano, Michael E Hoffer
6. Anatomy and Physiology of the Eustachian Tube 83
Ilkka Kivekäs, Dennis Poe
7. Radiology of the Temporal Bone 99
Alexander Filatov, Mari Hagiwara
8. Diseases of the External Ear 119
Myles Melton, Kevin D Brown, Samuel H Selesnick
9. Malignant Tumors of the Temporal Bone 135
Amy L Rutt, Mary J Hawkshaw, Robert T Sataloff
10. Non-Squamous Cell Carcinoma Tumors of the Temporal Bone 149
Maroun T Semaan, Cameron C Wick, Cliff A Megerian
11. Cholesteatoma 179
Eric E Smouha, Emily Stucken, Dennis Bojrab
12. Tympanoplasty and Ossiculoplasty 197
Dennis I Bojrab, Emily Z Stucken, Eric E Smouha
13. Complications of Temporal Bone Infection 219
Daniel Jethanamest, Simon I Angeli
14. Otosclerosis 231
Alicia M Quesnel, Michael J McKenna
15. Tumors of the Middle Ear 243
Alan G Micco, Qiu Zhong
16. Sensorineural Hearing Loss 253
Andrea Vambutas
17. Presbycusis 267
Selena E Heman-Ackah, Steven K Juhn
18. Occupational Hearing Loss 283
Robert T Sataloff
19. Ototoxicity 307
Karen Jo Doyle, Brent Wilkerson
20. Tinnitus 317
Carol Bauer

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 xvi Otology/Neurotology/Skull Base Surgery

21. Meniere’s Disease 331

Daniel H Coelho, Richard A Goldman
22. Temporal Bone Trauma 345
J Caleb Simmons, Alex D Sweeney, Marc-Elie Nader, Robert A Williamson
23. Vestibular Schwannoma 361
Sean McMenomey, Maja Svrakic
24. Meningioma and Other Non-vestibular Schwannoma Tumors of the CPA 419
Adam A Master, Maura K Cosetti
25. Jugular Bulb and Jugular Foramen in Ear Diseases 435
C Eduardo Corrales, John S Oghalai
26. Encephalocele and CSF Leak 459
Shawn M Stevens, Habib Rizk, Ryan A Crane, Ted A Meyer
27. Presbystasis and Balance in the Elderly 477
David A Schessel
28. Inner Ear Dehiscence 491
Jason A Beyea, Lorne S Parnes, Sumit K Agrawal
29. Peripheral Vertigo 505
Jeffrey T Vrabec, Marc-Elie Nader
30. Central Vertigo 517
Robert W Eppsteiner, Deema Fattal, Marlan R Hansen
31. Aural Rehabilitation and Hearing Aids 529
Jaclyn B Spitzer, Dean M Mancuso, Joseph J Montano
32. Implantable Middle Ear and Bone Conduction Devices 545
Alejandro Vázquez, Robert W Jyung
33. Cochlear Implants 557
Maura K Cosetti, Divya Chari, Anil K Lalwani
34. Auditory Brainstem Implants 573
Eric P Wilkinson, Steven R Otto, Marc S Schwartz, Derald E Brackmann
35. Inner Ear Molecular Therapies 581
Manohar Bance, Anil K Lalwani
36. Anatomy and Physiology of the Facial Nerve 617
Ruwan Kiringoda, John K Niparko, Lawrence R Lustig
37. Facial Nerve Testing 627
Sachin Gupta, Brandon Isaacson
38. Facial Nerve Paralysis 635
Elizabeth H Toh
39. Facial Nerve Tumors 649
Gregory J Basura, H Alexander Arts
40. Facial Nerve Reanimation 663
Monica Tadros

Index 707

Prelims.indd 16 25-06-2015 12:32:00

 1 Otology/Neurotology/Skull Base Surgery

CHAPTER
Anatomy and Physiology of
the Auditory System
Peter L Santa Maria, John S Oghalai
1
PINNA (AURICLE) There are two intrinsic and three extrinsic ligaments.
There are six intrinsic and six extrinsic muscles. The major
The pinna is composed of fibroelastic cartilage covered by intrinsic ligaments attach from the crus helicis to the
skin. This cartilage is continuous with that of the external audi­
tragus and from the antihelix to the cauda helicis. The
tory canal (EAC). Anteriorly the cartilage is adherent to the
extrinsic ligaments are named anterior (from the tragus to
skin, but posteriorly there is a loose areolar layer in between.
the crus of helicis to the zygoma), superior (from the spine
The dimensions of characteristics of the pinna include
of the helix to the superior EAC), posterior medial (from
(Fig. 1.1)1,2 a height of 5–6 cm, width 55% of height, forms
the concha to the mastoid prominence). The muscles are
an angle that is 20° from the vertical plane, has an auricle
divided into intrinsic (helix major, helix minor, tragus,
that diverges from the occipital scalp at 21°–30°, forms an
antitragus, transverse, oblique) and extrinsic (auricularis
angle of < 90° at the conchal bowl to the mastoid and has
posterior, auricularis superior, auricularis anterior).
a distance of 1–2 cm from the helical rim to the mastoid.
The pinna and mastoid scalp area are supplied by
Clinical comment branches of the external carotid artery (Fig. 1.2). Veins
•• An end aural incision is placed between a fibrous also accompany the named arteries. The postauricular
band between the tragus and the crus helices where artery3 supplies the posterior surface of the pinna, except
the cartilage is absent. the lobule and the mastoid scalp. It has auricular, mastoid,
transverse nuchal artery4 branches. The occipital artery5
supplies part of the mastoid scalp (via a lateral branch) and
has a medial and a lateral branch. The superficial temporal
artery6 supplies the anterior pinna, the temporal scalp, and
the superficial temporalis fascia. Its branches are7 anterior
(or superior), the temporal artery (via the main trunk or
parietal branch), parietal, temporal, and middle temporal
(Fig. 1.3).
The pinna is formed from the sixth gestational week
from the six hillocks of His that originate from the first and
second branchial arches (Fig. 1.1). It is completely formed
by week 16. It reaches adult size by age five. Hillocks
one to three are supplied by the auriculotemporal nerve
and hillocks four to six are supplied by a branch from
facial nerve, greater auricular and lesser occipital nerves
Fig. 1.1: The anatomical landmarks of the pinna. (Figs. 1.4A and B).8,9
 2 Otology/Neurotology/Skull Base Surgery

Fig. 1.2: The arterial supply of the pinna and mastoid region.
Source: Adapted from Imanishi and Nakajima3 and Alvernia et al.5

The external ear is important for sound localization.10

The folds and crevices that create the shape of the pinna
facilitate sound localization in vertical space. This design
provides a 10 kHz dip with elevation of sound. In contrast,
sound localization in horizontal space is provided by
three mechanisms. The resonance gain of the near ear
provides the gain of the ear closest to the sound. The head
shadow effect attenuates frequencies <2 kHz so that there
is a 5–15 dB interaural difference. There is an interaural Fig. 1.3: The innervation of the pinna.
time difference of 0.6 ms between sounds that is detected
within the ascending brainstem nuclei.

EXTERNAL AUDITORY CANAL

The EAC is composed of cartilage in its lateral third (8 mm)
and bone in its medial two thirds (16 mm). The cartilagi­
nous EAC is deficient superiorly but there is a ligament
between the helix and tragus. The EAC runs inferiorly and
anteriorly in adults but more horizontally in neonates. The
anterior wall of the EAC is longer than the posterior wall
by 4 mm. It contains two sutures: the tympanosquamous
(anteriorly) and the tympanomastoid (posteriorly) with
the skin in the intervening area forming the “vascular
strip”. The EAC contains two constrictions, at the bony
cartilaginous junction and at the isthmus. The isthmus is A B
5 mm lateral to the tympanic membrane (TM) produced
Figs. 1.4A and B: The embryology of the pinna. The six hillocks
from the anterior canal overhang. The tympanic ring is of His form as follows: one (tragus), two (helix crus), three (helix),
deficient superiorly at the tympanic incisura.11 four (antihelix), five (antitragus), and six (lobule, inferior helix).
 Chapter 1: Anatomy and Physiology of the Auditory System 3

Clinical comment
•• The TM is visualized by pulling the pinna superiorly
and posteriorly in adults or just posteriorly in children.

The EAC is largely supplied by the deep auricular

artery, a branch from the internal maxillary artery that
passes through the parotid, running posterior to temporo­
mandibular joint (TMJ). The “vascular strip” is supplied by
the anterior/superior auricular artery, a branch from the
superficial temporal artery. The skin of the EAC is much
thinner in the bony canal and lacks appendages (ceru­
men, sweat glands, and hair follicles). The cartilaginous
EAC skin contains these appendages with cerumen glands
being most prominent in the superior and inferior walls.
The EAC is drained by the superficial temporal vein and Fig. 1.5: The surface anatomy of the left tympanic membrane.
postauricular vein.11 The lymph drains mainly to parotid
nodes and mastoid nodes.
The EAC is formed by ectoderm of the first pouch as anterior tympanic artery, stylomastoid artery (a branch
it contacts the endoderm of first pouch with intervening from the postauricular artery) and also by branches of the
mesoderm that forms the TM. The bony EAC is formed middle meningeal artery.16 The lateral surface of the TM
by four centers of ossification of the tympanic ring in the is supplied by the auriculotemporal nerve from cranial
ninth week. nerve (CN) V, auricular branch of CN X (Arnold’s nerve),
and branches from CN VII, IX, X. The medial surface is
Clinical comment
supplied by CN VII and CN IX branches from the tympanic
•• There are two routes of infection from the EAC in plexus.
malignant otitis externa.12 Fissures of Santorini run The TM is formed by ectoderm (epithelial layer) and
from anterior inferior in the cartilaginous canal to the endoderm (mucosal layer) with intervening mesoderm
parotid. The Foramen of Huschke is formed by ante­ between these two layers (connective tissue layer) of the
rior and posterior ossification centers that normally first branchial pouch.
obliterate in adolescence. In 5% of people, this fora­
men persists in the anteroinferior canal and forms a Clinical comment
connection to the TMJ. •• A myringotomy should be placed away from the
posterior-superior quadrant so as to avoid damage
TYMPANIC MEMBRANE to the chorda tympani and incudostapedial joint. It
should also be placed with awareness of a potential
The TM is a trilaminar structure composed of an outer
high riding jugular bulb in the posterior inferior
epidermal layer, middle connective tissue layer, and an
quadrant or a dehiscent internal carotid artery in the
inner mucosal layer. It forms an angle with the superior
anterior inferior quadrant.
EAC of 140° and the inferior EAC of 55°. Its dimensions are
•• TM perforations can lead to a conductive hearing
8 mm (horizontal) by 10 mm (vertical). It is composed of a
loss up to 30 dB. Small holes lead to more loss in
pars tensa and a pars flaccida that has a thicker connective
the low frequencies, whereas large holes lead to a
tissue layer. The epithelium of the TM migrates radially
wider frequency hearing loss. The resulting hearing
from the umbo at 1–2 mm per day.13 Upon perforation,
loss may be inversely proportional to the size of the
keratinocytes form from progenitor cells at the umbo and
mastoid.17 The maximum conductive hearing loss is
migrate across to close the perforation.14,15 The middle
approximately 55 dB. Therefore, a patient presenting
connective tissue layer contains collagen fibers arranged
with a perforation and conductive hearing loss of >30
in three patterns: radial, circular, and oblique (Fig. 1.5).
dB should alert the clinician to pathology beyond that
The lateral surface of the TM is supplied by the deep
of the perforation.
auricular artery. The medial surface is supplied by the
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